- Top charities
GiveWell aims to find the best giving opportunities we can and recommend them to donors. We tend to put a lot of investigation into the organizations we find most promising, and de-prioritize others based on limited information. When we decide not to prioritize an organization, we try to create a brief writeup of our thoughts on that charity because we want to be as transparent as possible about our reasoning.
The following write-up should be viewed in this context: it explains why we determined that (for the time being), we won't be prioritizing the organization in question as a potential top charity. This write-up should not be taken as a "negative rating" of the charity. Rather, it is our attempt to be as clear as possible about the process by which we came to our top recommendations.
Published: 2010; Updated: 2012
In October 2011, we visited PIH's program in Malawi and posted our notes and photographs.
In July 2012, we spoke with Partners in Health (PIH) and published notes from our conversation (DOC).
PIH also provided the following documents in response to our questions:
We have reviewed the documents and decided not to prioritize further analysis of PIH as of November 2012.
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. We would guess that it is improving health outcomes, but we have not seen recent information regarding (a) the proportion of PIH's expenditures that support its medical care program versus other programs; (b) PIH's ability to incorporate additional funding; or (c) the quality of PIH's care and the outcomes of its treatments. We therefore cannot confidently recommend PIH to donors.
We visited PIH's program in Malawi in October 2011 and posted our notes and photographs.
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 about 73% of PIH's FY 2009 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
In addition to its medical care program, PIH also runs projects that:5
We have requested information on what portion of PIH's expenses each of these programs accounts for, but have not received information on this. The only information we currently have on this question is from a detailed budget for the Rwanda program in 2007, which shows that programs that strike us as outside the core approach of providing medical care accounted for about 7% of total expenses for Rwanda at that time.6
We have little formal evidence regarding the quality of PIH's care or the outcomes of its treatments. When we first recommended PIH to donors in 2007, we had seen limited data about health outcomes from Rwanda.7 We have requested an update on this data, but have not received it. We have not seen health outcome data from the other countries in which PIH works.
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.8 We also feel that for a relatively impartial 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 outsiders who have spent time at its sites.9
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.
Independent evidence for PIH's programs
PIH's clinics and hospitals provide the following services, which have been shown to be effective by independent evidence. We have requested information from PIH on what proportion of PIH's total budget each accounts for, but have not received it.
We have not seen information on the quality of PIH's non-medical programs or on PIH's success in targeting very poor individuals.
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 start-up costs are overwhelmingly borne by PIH and we are skeptical of this plan.15 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,16 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.
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 report 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).
We have requested, but have not received, "funding gap" analysis for PIH as a whole. From its financials,17 it appears that its health programs in Haiti and Africa are its largest and most rapidly expanding programs.
As of June 2010, PIH was hoping to raise an additional $40 million for its activities in Haiti in 2010-2011.18 We do not know which of its planned activities will not be funded if PIH does not receive all $40 million.
All data comes from Partner in Health, "IRS Form 990 (2002-2008)" and Partners in Health, "Annual Report (2009)" unless otherwise noted.19
Revenue and expense growth (about this metric): PIH's revenues and expenses have grown consistently over the past 8 years.
Assets-to-expenses ratio (about this metric): PIH maintains a relatively low assets:expenses ratio with less than a half a year's worth of reserves in 2009.
Expenses by IRS-reported category (about this metric): PIH maintains a reasonable "overhead ratio," spending approximately 94% of its budget on program expenses.
PIH, "Annual Report (2009)," Pg 32.
See our 2007-2008 review of PIH.
See our 2007-2008 review of PIH.
HIV prevention education: $40,000
Housing support: $75,000
School fees: $107,500
Health insurance program: $150,000
Agriculture programs: $10,000
Vocational training: $30,000
Other social support: $50,000
Total Rwanda budget for non-core programs in 2007: $522,500
Total Rwanda budget for 2007: $7,439,192
Partners in Health, "Rwanda Budget."
See Partners in Health, "Inshuti Mu Buzima Summary Report (2006)" for an example of the sort of information we have. (We have more, similar information in an unpublished report that we have not been cleared to post.)
More at our 2007-2008 review of PIH.
"In the most serious cases, patients diagnosed with severe malaria are hospitalized and receive intensive inpatient treatment for at least two weeks. In the least serious cases, patients with simple malaria can be treated with a three-day drug regimen at home." Clinton Foundation 2006, Pg 32.
Treatment for uncomplicated cases is with the ACT drug Coartem (Clinton Foundation 2006, Pg 72). For more on ACT, see our full review of malaria treatment.
Clinton Foundation 2006, Pg 23.
"After the initiation of treatment, patients are visited each day by their accompagnateurs, once or twice dependent upon the workload and distances traveled, in order to receive their medications." Clinton Foundation 2006, Pg 27.
"All pregnant HIV-positive patients are prescribed an ARV regimen, regardless of their CD4 counts. For those with a CD4 count above 350, who would not normally receive ART, a regimen of AZT and nevirapine is prescribed to protect the fetus during the pregnancy and through delivery. After delivery, each child receives a single dose of nevirapine followed by a six-week course of AZT." Clinton Foundation 2006, Pg 30.
"Patients diagnosed with non-multi-drug resistant TB who are not infected with HIV are given a six-month regimen of medication, which is also administered every day by an accompagnateur." Clinton Foundation 2006, Pg 29.
More discussion at our 2007-2008 report on PIH.
"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:
Roughly 70% of PIH nurses are A2, 20%, A1 and 10% A0." Clinton Foundation 2006.
Partners in Health, "Annual Report (2008)," Pg 32.
"Individuals, organizations, and institutions who through June 30 had contributed a total of $85 million...of our planned $125 million fund over the next two years." Partners in Health, "Stand With Haiti Six-Month Report," Pg 2.
Note that in 2007, PIH changed from a calendar year end to a fiscal year ending June 30. Thus, figures for 2007 are shown as the figures for January to June 2007 doubled.
Data comes from Partners in Health, "Annual Reports (2003-2009)" and Partners in Health, "Consolidated Financial Statements (2007)."