Helping Malawi, one tooth at a time
Reflections on the Scottish dental charity Smileawi, using the results of an undergraduate qualitative research project that explores the operations and sustainability of the organisation from multiple perspectives
As one of the poorest countries in the world, Malawi is no stranger to humanitarian aid, with over 700 registered Non-Governmental Organisations (NGOs) operating there in 2019/20[1, 2]. Scottish organisations contribute greatly, with strong links between the two countries co-ordinated by the Scotland-Malawi Partnership and the sister organisation based in Malawi. Smileawi is one such NGO, co-founded in 2012 by dentists Vicky and Nigel Milne, which provides dental care across the country, particularly in rural regions. The charity has evolved from a treatment model, consisting of volunteer trips that provide dental pain clinics, towards collaborative projects that have a view of longer lasting change in Malawi.
Final year dental student, Katie Read-Challen, travelled with Smileawi as part of a dental elective in June 2019 and went on to study an intercalated bachelor’s degree in Global Health at the University of Glasgow. The elective, a child oral health survey in rural Malawi, demonstrated one aspect of the charity’s transition towards long term impact which inspired the design of an undergraduate qualitative research project into the operations of Smileawi. The perspectives of eight participants with varying degrees of involvement in the charity were explored, to determine the perceived barriers and facilitators to sustainable practises. This article focuses on the identified successes of Smileawi, with their slogan ‘Helping Malawi one tooth at a time’ potentially underestimating the contributions that they could offer to Malawian dentistry. Collaborative partnerships and education were themes that appear integral to their work both within the undergraduate project and remits planned for the near future. This article hopes to demonstrate ways in which the charity has evolved towards more sustainable endeavours, whilst recognising the difficulties surrounding provision of healthcare aid overseas.
Critiques of short-term volunteer trips are common in the surrounding literature, with the term ‘voluntourism’ often used to describe situations where volunteer experience takes precedence over local benefits [5-7]. Sustainability is frequently questioned, with some authors arguing the term itself can be misrepresented by NGOs as longevity of the programme rather than lasting benefits for the host country infrastructure . Locals are often seen solely as recipients of aid rather than collaborative partners. Lowered ethical standards can therefore occur in charity work abroad where service provision alone is seen as good enough. In Judith Lasker’s book entitled ‘Hoping to help: The promises and pitfalls of global health volunteering’, the concepts of mutuality and continuity are suggested as ‘pillars of effective programmes’ . Here, mutuality is defined as equal respect between visitors and locals and continuity is the consistency in the operations of the charity (such as timing or location of the trips) . These terms are integral to the definition of sustainability used within the research, which aimed to analyse which remits of Smileawi have the potential to incur real lasting change in Malawi.
Eight participants, all based in the United Kingdom (UK), were recruited using purposive sampling. They included those with first-hand experience of the volunteer trips (covering trustees, volunteers and a member of Smileawi Spanners), representatives from collaborating organisations (Bridge2Aid, DentAid and funders Clyde Munro [10-12]) and a Malawian dental therapist. A semi-structured interview technique was used to guide questioning whilst giving flexibility for open discussions. Analysis of interviews identified common patterns and themes and was guided by a framework adapted from the literature review.
The chosen framework was taken from Matthew DeCamp’s paper, ‘Ethical Principles to Guide Global Short-Term Medical Volunteer Trips’ which proposes eight standards for health charities to ethically review their operations overseas . Strict ethical standards underpin healthcare in the UK, making it unacceptable for anything less when practising abroad. The literature highlights how ethics are central to sustainable practise, hence DeCamp’s paper seemed an appropriate tool to guide analysis of the operations of Smileawi [8,9].
Volunteer trips have been hosted by Smileawi biannually since 2012. Dental provision, mostly through extractions, has been given to thousands of people in rural areas of Malawi who could otherwise not access care. Founders Vicky and Nigel Milne were interviewed in Scottish Dental in 2016  where they spoke of a 10-year plan for the charity, after becoming independent from larger organisation The Raven Trust . Now at the halfway point, it is interesting to see how attitudes towards sustainability have since evolved. In the interview five years ago, Smileawi saw the treatment model as sustainable as extractions eliminate the source of pain and disease . However, when questioned along a similar route in the undergraduate study, no participants saw the treatment model as sustainable. Problems included difficulties surrounding follow up and referral of patients, as well as the continued finance required for such trips. As one participant described:
“The nearest referral centre might well be the capital city Lilongwe or it might even be Blantyre. So, you could be talking about several hundred kilometres. The patients can’t afford to make their way there and the hospital can’t afford to transport them there. So, very often what we do as a charity, at that stage, is we will actually pay for the transport of the patient, but that is not a very sustainable model”
Balancing the immediate dental needs with long term impact is certainly not a simple task. DeCamp advises to ultimately aim for ‘non-sustainability’ of the trips themselves, with the view that volunteers would no longer be needed in the host country if charities worked towards strengthening health systems . Two clear themes arose when exploring the facilitators to sustainability within such remits; education and collaboration.
The UN Sustainable Development Goals (SDGs) put health as a priority, recommending holistic approaches to care including capacity building and education [9, 15]. Smileawi demonstrates this through provision of financial aid for dental therapists during their education, with the promise they will work for a minimum of five years in a rural post. Unfilled posts, low pay and a sense of isolation were identified by participants as issues for professionals working in rural Malawi. Dental therapists, more commonly posted to these isolated regions than dentists, were also described as having to work way above their scope of practise. This brought interesting discussions surrounding the observed hierarchies within Malawian dentistry, with dental therapists often reported as feeling undervalued by dentists.
Participants noted how the annual Smileawi conference contributes to tackling this issue through better representation of dental therapists. The conference gives professionals the opportunity to reflect on their work and offers education through Continued Professional Development (CPD), delivered by respected Malawian and International speakers. This was seen as extremely valuable for connecting dental professionals as well as raising their profile at governmental level.
An important result described was the formation of Smile North, a group of dental professionals aiming to improve oral health in northern Malawi through prevention. Malawian experience of the conferences would certainly be interesting to explore. Reports from participants that dental personnel feel valued and connected through education shows promise for long term impact and mutuality with health professionals in Malawi.
DeCamp emphasises the need for education to occur in both directions, favouring the learning attainment of locals over volunteers . Smileawi Spanners, a branch of the charity set up following a volunteer trip in 2018, trains local mechanics to fix and maintain hospital vehicles .
Although this remit came about by chance, it offers educational gains for people in Malawi and a horizontal approach to care. Participants also reported that the programme builds rapport with the local hospitals and communities and highlighted how transferral of knowledge can help the charity to build connections in Malawi.
Forming collaborative partnerships appears to be central to the identity of Smileawi, with participants in the study celebrating the close relationships formed both in Scotland and Malawi. Dedication and passion of the founders was often described as creating a family atmosphere for everyone involved, with the relationships had with people in Malawi often described as friendships. This is something that Malawian health professionals deemed important in one anthropological study . Mutuality is certainly apparent according to interviewees, with one person describing the general feeling nicely:
“We’ve always believed that it was really important to remember that Malawi belongs to Malawians and we’ve always tried to ask our Malawian colleagues and friends what we can best offer. I think the partnerships we’ve built up in Malawi have been very important”
These genuine kinships have created advocates of Smileawi in health, government and local community settings. This includes the dedicated members of Tafika Youth Organisation in the north of the country, who help with translation and advocacy for Smileawi trips within local communities. As one participant described:
“That’s been a really valuable link. They identify areas where there’s real inequity and inequality”.
Collaborations have informed the design of Smileawi projects and exemplify the view of the World Health Organisation (WHO) who identify partnerships as key for global health equity . Collaborations with the Scottish Government funded MalDent project (www.themaldentproject.com) and the Malawian government also demonstrate this, with the design of the child oral health survey in June 2019 contributing to the formation of a national oral disease prevention policy . This was described by one participant as “possibly one of the most important things we’ve done so far”. The value of collaboration with governments was emphasised by interviewees as well as in the literature [6-9]. It is apparent that Smileawi have a good relationship with the Malawi Ministry of Health, who have facilitated the upgrading of dental practices and have spoken at the annual Smileawi conferences.
Looking at the sample of interviewees alone shows the collaborations Smileawi has with other organisations. Such partnerships were commonly credited as facilitating the growth of the charity as well as potentially mitigating the need for paid roles, of which there are currently none at organisational level. However, it was recognised that more structure, including salaried roles, may be required in the future to minimise the impact of any changes, such as new trustees, on the charity’s aims. This consideration is an important one for continuity of the charity, especially because participants frequently credited the personal attributes of the founders themselves to the successful collaborations seen. Partnerships have also contributed to the development of future projects which show promise of long-term impact in Malawi, as discussed by Vicky and Nigel below.
Looking to the Future
Since the project, Smileawi sought feedback from the therapists on a number of different aspects of their working life. It was interesting to see that 50 per cent had never visited rural clinics, 37.5 per cent occasionally ran a clinic on an ad hoc basis, 4.2 per cent ran a clinic once per month and 8.4 per cent ran a clinic once per week. That identified a continuing need for our own rural pain relief clinics. After discussion with Smile North we hope to continue running pain clinics but to work alongside our Malawian colleagues at these. We also plan to introduce a much more proactive preventive approach at the clinics.
In September we plan to run an online webinar with prevention being the main focus. We are seeking speakers from the UK and Malawi. We will continue supporting students, both dentists and therapists, and we will continue to support our dental colleagues in the north and central regions with equipment and materials where possible.
We are collaborating closely with Bridge2Aid and the Dental Association of Malawi and together have produced a series of twelve learning modules, designed to update the knowledge of the dental therapists in the north of the country and teach them how to cascade that information via health and community workers to the rural population. We are in discussions with other organisations to share the modules for use elsewhere in the world.
The qualitative research project engaged with multiple perspectives on the operations of Smileawi. The findings suggested collaboration and education as vital contributions to sustainable practice. These findings may appear unsurprising for dental personnel in the United Kingdom (UK), where lifelong learning and connecting with other professionals are integral to most healthcare careers. Indeed, partnerships and transferral of knowledge are commonly cited in the literature as key for successful charitable provision both overseas and in the UK. However, the impact of education and collaboration appears to be significantly important in a Malawian context, where there currently exists a large burden on dental personnel. Transparency and openness from all participants allowed an interesting view into the barriers and facilitators surrounding health provision abroad. The discussions here hope to inspire other organisations to consider ethical review and sustainability of their operations, in order to aim for lasting impact of their work.
This article is based on Katie Read-Challen’s dissertation written for her intercalated BSc in Global Health last academic session and for which she was awarded a First Class Honours BSc degree.
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