by Katherine Marshall

Many religious approaches to health focus on the world's least
favored citizens, especially those who are desperately poor
or face exclusion, discrimination, and displacement.

Religion, health, and poverty are interlinked in complex ways. Health of the body and mind are inseparable in many faith traditions, an integral part of their teachings; so is the call to care for the sick and suffering. The imperative to minister to those most in need is imbued in scripture and teaching, philosophy and practice. Religion contributes in many ways to health norms and to behaviors that underlie health (from the highly practical, such as hand washing and diet, to the more esoteric, such as handling life's stress). Links between physical, mental, and spiritual health are the subject of active research and reflection today.

Formal health systems are an important part of the story. Religious communities own, run, or inspire substantial parts of health care systems in many countries and communities. Like religious faiths themselves, these systems vary widely in approach and organization. Religiously linked health facilities and approaches can be remarkably akin to secular practice, with some being among world leaders in quality of service and investigation. Others focus far more on spiritual health rooted in daily life and faith practice in communities. Religious links to traditional medicine add another strand to this complex story. Ties between religion and health may begin with caring for the sick, but they go well beyond formal health systems.

Many religious approaches to health focus, as do the traditions themselves, on the world's least favored citizens, especially those who are desperately poor or face exclusion, discrimination, and displacement. The burden of illness on those without means is greater, as is the suffering and loneliness that accompanies it. Faith communities and organizations provide relief, caring for those in urgent need through health interventions and facilities. After natural and man-made disasters, faith communities are often first on the scene. They are central players in humanitarian relief, a vital element in addressing poverty and suffering. Faith institutions train disproportionate numbers of nurses and doctors. They actively seek ways to raise health care standards among poor communities or, put differently, to address the egregious inequities in health outcomes and services that starkly divide rich and poor.

Many quite different initiatives at the global level recognize faith communities as essential partners in antipoverty programs; without their support the Millennium Development Goals (MDGs) defined by world leaders in 2000 at the United Nations (with a deadline of 2015 and elaborate monitoring mechanisms to assess progress and results) cannot be achieved. Of the eight goals that are the backbone of the MDGs, three center on health: goal 4, to reduce child mortality; goal 5, to improve maternal health; and goal 6, to combat HIV/AIDS, malaria, and other diseases. Other goals also have clear links to health, notably ending hunger, promoting gender equality, and working for environmental sustainability. The covenant of partnerships embodied in the eighth goal highlights the need for better and deeper understanding and cooperation among different actors. Increasingly, this global partnership is understood to include faith communities and institutions.

Faith-linked organizations such as Catholic Relief Services and Islamic Relief are engaged in several global initiatives that are the action face of the global commitments and goals. So are faith-run hospitals, clinics, and movements. But the potential for engagement in classic health services is far from fully exploited. What is least appreciated and explored is the engagement of community-level leaders and services.

Faith communities should thus be actively engaged in high-level and community reflections on health strategies and program implementation. However, significant obstacles stand in the way. Three among them stand out: (a) we know far too little about how faith health systems function, their coverage, their impact, and relative strengths and weaknesses; (b) faith approaches to health tend to bring out underlying ethical dimensions that can present important barriers (tense controversies around abortion, abstinence focus in HIV/AIDS programs, issues concerning cloning, end-of-life treatment, and research protocols among them), yet avenues for thoughtful and productive dialogue are lacking; and (c) broader societal policies and attitudes toward the role of religion keep secular and faith communities at arm's length when they need to work in tandem. This complicates underlying financial challenges and potential partnerships.

Ancient Roots

The intertwined histories of religion and medicine underscore the fallacy of viewing them as belonging to separate spheres. They also offer insights into potential ways to build dialogue and institutional partnerships that promise to enhance delivery of decent health care to poor people.

As early as 4000 BCE, religions identified certain deities with healing. The temples of Saturn, and later Asclepius in Asia Minor were seen as healing centers. Hindu Brahmanic hospitals operated in Sri Lanka as early as 431 BCE, and King Ashoka established a chain of hospitals in Hindustan about 230 BCE. Roman hospitals (valetudinaria) had religious ties, while state-supported, faith-inspired hospitals appeared in China during the first millennium CE. Monastic orders of different faiths and in widely different regions operated facilities for the sick.

Christian health care history and its contemporary profile tend to be the best documented but are not more significant than counterparts in other faiths. Muslim hospitals developed high standards of care between the eighth and twelfth centuries. Baghdad's hospitals in the ninth and tenth centuries were precursors of the modern hospital. Jewish institutions have led health policy and practice in many parts of the world. Buddhist practice has innumerable lessons for approach and practice. Historically, only faith institutions reached out to rural, marginalized populations, especially outside Europe. They were in the vanguard in caring for ethnic minorities--whom majorities, or those who held money and power, sadly often regarded as less than human.

What We Know and What We Do Not Know

The contemporary global role of faith-run health facilities is poorly known and understood, despite their omnipresence and deep historic roots. Knowledge gaps are accentuated by the way these systems operate and by historical church-state tensions. The emergence of secular medical practices has exacerbated discontinuities. In Africa, countries such as Mozambique abruptly nationalized church-run facilities, then renegotiated church-state arrangements several times. The result is that many countries evolved either quite separate systems or complex hybrid systems. Changes in religious profiles as well as interfaith or interdenominational tensions shape what are often highly decentralized and quite dynamic health systems. In short, there are many reasons for the complexities of faith-based health arrangements.

One observer aptly described contemporary faith-run health systems as a galaxy. Most are decentralized; day-to-day management--including fund-raising and financial administration--is centered in each institution. The largest single faith-run system--the Catholic Church-includes countless kinds of facilities, many run by religious orders, while others are initiated directly by bishops (who have ultimate responsibility within their diocese), Catholic NGOs (such as Caritas Internationalis, a confederation of relief, development, and social service groups), or movements (such as the Community of Saint Egidio, a lay Catholic group whose fundamental work is with the very poor).

Faith-run systems account for a significant part of health care facilities worldwide, but estimates of their share vary widely and lack specificity. There has been considerable recent focus on Africa, but the challenges of estimating the extent and share of faith-run systems at national, much less continental, levels illustrate the difficulty, with an extraordinarily wide range of estimates, from 30 to 70 percent of total health care provided. The Catholic Church publishes regular estimates of its health care system, with more than one hundred thousand different institutions worldwide, but even those estimates convey poorly how they fit within national or regional care networks. Information is often available only to those who know how to locate and read it, with no obvious single global repository. In conflict-prone areas, faith-run institutions are often virtually the only providers on the ground, but again the picture is patchy at best. Analyses of how these faith-based institutions work and interface with other health institutions is weak, particularly in developing countries.

The dearth of specific information is a major impediment to defining actual and potential roles for faith-based health institutions, and even to framing policy questions. Fortunately, several efforts to map the faith-based health care landscape are under way. One is the African Religious Health Assets Program--a joint venture of Emory University and the University of Cape Town--which is documenting health assets in several countries, with support from the World Health Organization. The Unions of Superiors General--composed of the heads of both male and female religious orders--is collecting information on HIV programs and services.

Apart from the raw statistics on access and service, the vital gap is evaluation and analysis. While individual studies assess efficiency and impact, they are partial and rare. Systematic evaluation has rarely been a central concern of faith-inspired systems, particularly those operating under stress in poor countries. A 2003 study by Ritva Reinikke and Jacob Svensson, "Working for God," comparing church-run and public health institutions in Uganda, stands out as an exception but also as an example of the kind of work that is needed. Its central finding--that church-run facilities are more efficient and effective by most measures--is hardly surprising to those who have observed these facilities in action, but the study barely scratches the surface of questions that need practical answers.

Faith institutions are powerful advocates for increased international support for health care, including through the MDGs. However, without clear agreement on how faith institutions can contribute to global efforts, disconnections between faith-based and secular institutions are as numerous as connections. The lack of analytic work impedes informed exploration of potential collaborative work. Most outside funders do not find anecdotal evidence on the wonderful work of faith-based institutions sufficiently convincing. Happily, recognition is growing within faith-based health circles that evaluation can help them provide care to those most in need more effectively.

Difficulties in the Path to Dialogue

Moral issues lie at the heart of many controversies about the health care roles of faith-inspired institutions, some provoking raging public exchange, others quieter concern. Contemporary questions about medical ethics, for example--including bioethics, stem cell research, and policy and practice at the beginning and end of life--are more acute when faith-run health care systems are involved.

Many faith leaders see themselves as providing a moral compass for health care. A senior Catholic official objected to what he termed "moral conditionality." That is, urgently needed public funding often comes with conditions that run counter to church teachings and thus are considered immoral and unacceptable.

However, alternative perspectives on similar moral questions also draw deeply on tradition and ethics. Most significant is the view that faith-run approaches breach core human rights principles in their unwillingness to accept women's rights to reproductive health care.

Thus different parties contest fiercely for the moral high ground, with positions polarized, perceptions drowning out facts, and emotions running high. Dialogue is blocked because of the perceived force of the respective moral principles. The irony is that passionate advocates often share powerful concerns about the imperatives of care for poor people and communities. Debates over reproductive rights help explain why many public health experts are deeply reluctant to engage faith leaders, although those are not the only sources of tension. Health care presents ethical dilemmas at every step, with stalemate if participants are unwilling to engage in respectful dialogue. Encouraging dialogue has enormous importance.

Separation of Faith and Public Service, Toward Partnerships

Many faith communities see caring for the sick as a profound mission that is not open to question. They presume that health care is a continuing and fundamental part of their mission. This is rarely the perspective of public health professionals.

"The hospital is our cathedral," commented one prominent Catholic cardinal. Leaders from many faiths refer with pride to the long-term, sustainable nature of their engagement, integral parts of community life. They take issue with contemporary public health experts who might, if strongly secular in bent, tend to view faith-run facilities as something of an anachronism with limited relevance for their mission of developing public health systems.

Differences in perspective and medium- to long-term visions underlie the fractured and piecemeal engagement at a practical and policy level between faith-based and public institutions. The lack of literacy cuts both ways: public health and development officials often have scant or distorted understanding of religion, while many religious leaders who oversee health systems have little formal training in public health. Agreement on common ground, shared objectives, and respective roles is often needed. An underlying question is whether faith-run health systems are simply part of the not-for-profit sector or need or merit special consideration.

The MDG challenge calls these habits of separation into question. Faith communities need to be core partners in the global effort to fight poverty and disease. Engagement is increasing in many areas--childhood diarrhea, avian flu, and so on. The HIV/AIDS pandemic has profoundly challenged institutions to build new partnerships involving faith-run health institutions together with private companies, international organizations, and foundations. Humanitarian work is also seeing productive engagement between faith and secular institutions. The roles of Caritas Internationalis, World Vision, and Islamic Relief in responding to the Asian tsunami, the Pakistan earthquake, the Darfur conflict, and the Katrina catastrophe in New Orleans are contemporary cases. Faith traditions that place a high premium on meditation--notably Buddhism--are important to medical science. In Thailand, Ven. Dr. Mettanando Bhikkhu, a Buddhist leader, is a pioneer in health systems, advocating a deeply reformed, community-based national system that emphasizes elder and hospice care.

At the root of many challenges to faith-based health care systems and thus to new partnerships is money: How can they remain viable, especially when their core mission is to serve the poorest segments of the community? And who pays? Modern health care surely cannot, on a large scale, continue to run as a charity. Yet public funding for faith-based care is often provisional and precarious, with crises either occurring or looming. The theme of corruption arises constantly--on both sides. Faith institutions often view government systems as deeply corrupt and unreliable, while public officials often maintain that weak financial skills in faith-led institutions encourage waste and leakage.

Many faith providers would fiercely defend the premise that compassion and morality are integral to their approach, even as the issue of conversion sits uneasily. Others would argue, just as fiercely, that faith-run medicine is driven by a professional quest for excellence that cannot and should not be sharply distinguished from other health providers.

Looking Ahead

National, regional, and global health care projects and institutions have significant blind spots on roles of faith-inspired institutions. Gaps in awareness, knowledge, and collaborative work--stemming from lack of good data, habits of mind, and ethical concerns--have profound consequences. Commitment, openness to new perspectives, and goodwill can help overcome these barriers. Possible avenues for action include (a) supporting better information on faith-run health programs, assets, and policy, and integrating this information at community, national, regional, and global levels; (b) creating dialogue processes that lift barriers to common action; and (c) working from both development policy and faith leadership to enhance health delivery to poor countries and communities. With the enormous challenges facing both faith-run and national health systems, dialogue and engagement are urgent.