Partners in Health provides comprehensive health care to individuals in the developing world (mostly rural Haiti and Africa) by creating and managing hospitals, health centers, and a network of community health workers.
We have little formal evidence regarding the quality and outcomes of PIH's medical care, but feel it faces a lower burden of proof than most charities because of the nature of its activities, and are largely convinced that it is improving health outcomes. Its cost-effectiveness is somewhat unclear; its programs are not as cost-effective as those of the charities listed above, but still likely within a reasonable range for this cause.
Table of Contents
Note: many of the notes in this report reference our work on Partners in Health from our 2007-2008 report.
What do they do?
Partners in Health provides comprehensive health care to individuals in the developing world by creating and managing hospitals, health centers, and a network of community health workers.1 Operations in Haiti and sub-Saharan Africa (Rwanda, Lesotho, and Malawi) account for almost 70% of PIH's 2008 expenses.2
PIH treats patients for a variety of conditions including malaria, upper respiratory tract infections, AIDS, diarrhea, and intestinal parasites.3 (For more on symptoms and causes for each, see our page on common diseases and conditions in the developing world.) PIH also provides maternal care and deliveries for pregnant mothers.4
Does it work?
We have little formal evidence regarding the quality of PIH's care or the outcomes of its treatments.5
However, we feel that PIH's approach requires a lower burden of proof than that of other charities we've seen. It is primarily running hospitals and health centers aiming to deliver proven medical treatments, rather than (a) conducting interventions whose impact won't be apparent until far in the future; (b) conducting population-based projects beyond the scope of what can be easily observed.
We are relatively confident that PIH's services are replacing medical services of extremely poor quality.6 We also feel that for a relatively impartial, and medically trained, observer, the quality of its current care should be fairly evident (by contrast, we do not feel this is true of a large-scale condom distribution program, agricultural assistance program, etc.) We observe that there appear to be a large number of such medically trained outsiders who spend significant time at its sites.7
Ultimately, despite the absence of formal evaluations, we feel that PIH would be unable to maintain its high profile if it were not providing quality medical care, and that providing medical care – in this case – can reasonably be equated to changing lives.
PIH does include some programming that we are significantly less confident in, including HIV prevention education, housing support, coverage of clients' school fees, and even microfinance projects. From the information we have (a detailed budget for the Rwanda program in 2007),8 we believe that these programs are a relatively small part of PIH's overall expenses (programs that strike us as outside the core approach of providing medical care total about 7% of total expenses).
Possible negative/offsetting impact
Provision of basic health care is arguably the responsibility of the government. An unpublished report on PIH's Rwanda program outlines plans for the government to assume responsibility for expenses over time, but we note that startup costs are overwhelmingly borne by PIH and are skeptical of this plan.9 On the other hand, since PIH is providing high-quality care (likely beyond what a government would realistically pay for, as we argue in our 2007-2008 report on PIH) in a small number of areas, we see fairly little risk that PIH is "crowding out" much government spending.
Our larger concern regards diversion of skilled labor. As noted above, PIH hospitals involve significantly more spending than other hospitals in Rwanda are likely to, and are possibly drawing from a relatively thin supply of skilled medical professionals.
An unpublished report on PIH's Rwanda program indicates that it attempts to make as little use as possible of highly skilled labor,10 and we would guess that the superior resources (and, potentially, supervision) that PIH provides are adding value on net. However, the net impact on Rwanda may be less positive than one would gather simply from a visit to PIH's sites, as it may be diverting skilled labor from some parts of Rwanda to others.
What do you get for your dollar?
PIH provides highly cost-effective treatments, particularly tuberculosis treatment, and less cost-effective treatments, particularly antiretroviral therapy. We do not have enough information about either expenses (i.e., how many are attributable to different activities) or health outcomes to provide a reasonably direct cost-effectiveness estimate. An extremely rough estimate (even by cost-effectiveness standards) from our 2007-2008 reports puts PIH at a total of $3500 spent per death averted.
We do not have reason to believe that PIH's activities are as cost-effective as those of the strongest charities. We would guess that they are outside – though not necessarily far outside – what we consider to be a reasonable range (we specify this range at our discussion of cost-effectiveness).
Room for more funds?
We have seen no "funding gap" analysis from PIH. From its financials,11 it appears that its health programs in Haiti and Africa are its largest and most rapidly expanding programs.
Financials/other
All data comes from PIH's IRS form 990s for 2002-2008, available for download through the National Center for Charitable Statistics.12
Revenue and expense growth (about this metric): PIH's revenues and expenses have grown consistently over the past 7 years.
Assets-to-expenses ratio (about this metric): PIH maintains a reasonable assets:expenses ratio with approximately 1 year's worth of reserves.
Expenses by program area (about this metric): PIH spends the majority of its funds on its rural health clinics, the focus of our review.13
Expenses by IRS-reported category (about this metric): PIH maintains a reasonable "overhead ratio", spending approximately 90% of its budget on program expenses.
Unanswered questions
- Medical outcomes. Does PIH have aggregated data on the outcomes of its treatments?
- Expenses by intervention type. Expenses by country are available, but our only other expense breakdown comes from the Rwanda program in 2007. We would particularly like to see an attribution of PIH's expenses by type of medical intervention.
- Relationship with government. Are there any updates on PIH's hope of passing expenses for its Rwanda program to the government?
- Room for more funds? Does PIH have a breakdown of projected expenses and revenues and the resulting "funding gap"?
Sources
- Clinton Foundation. " An Evaluation of the Southern Kayonza, Rwanda Project (2005-2011)." 2006. This document is not publicly available.
- 1.
- 2.
- 3.
- 4.
- 5.
See http://givewell.net/files/Round2Apps/Cause1/Partners%20In%20Health/B/Rwa... for an example of the sort of information we do have –limited, small-sample-size statements about health outcomes. (We have more, similar information in an unpublished report that we have not been cleared to post.)
- 6.
More at our 2007-2008 review of PIH.
- 7.
See, for example, the large number of people who have spent significant time volunteering for PIH listed at http://www.brighamandwomens.org/dom_newsletter/june_july_05/interns.htm (accessed 6/30/09). The linked program is a PIH partner (see http://www.pih.org/who/partners.html - accessed 6/30/09).
- 8.
http://givewell.net/files/Round2Apps/Cause1/Partners%20In%20Health/B/Rwa...
- 9.
More discussion at our 2007-2008 report on PIH.
- 10.
"Aside from doctors and nurses and the most senior administrators, there are few hiring constraints. Rwanda is investing in training more medical professionals to build on the existing 450 trained physicians and 3,800 nurses currently working in the country (source: WHO). The PIH rural model uses doctors sparingly and invests heavily in training nurses to be able to handle most procedures. For example, in the whole process of testing, enrolment and ongoing consultation for an adult patient on ART, there is no necessity to see a doctor. Because pediatric ART requires more precise care to map the regimen to the weight of a child, it is typically administered by a doctor.
Of the five Rwandan doctors (who spend their time across the whole project, including Kirehe district), two were recruited locally by recommendation from the MOH at the start of the project; two were recruited by Michael Rich, the Project Director in Kigali; and one answered an advertisement.
Rwandan nurses are categorized according to their level of training:
- A0 – Bachelors degree – four years of training post-high school
- A1 – Half a degree – three years of training post-high school
- A2 – High school level only
Roughly 70% of PIH nurses are A2, 20%, A1 and 10% A0." Clinton Foundation 2006.
- 11.
Page 32 of http://pih.org/inforesources/annual/PIH2008_annualreport.pdf, accessed 6/30/09
- 12.
http://nccsdataweb.urban.org/PubApps/showVals.php?ft=bmf&ein=043567502, accessed 12/25/09.
- 13.
Data comes from PIH's annual reports. Available on their website at http://www.pih.org/inforesources/annual.html, accessed 12/25/09.
