Partners in Health - July 2009 review

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; we do not have reason to believe that PIH's activities are as cost-effective as those of the strongest charities, but still likely within a reasonable range for the cause of international aid. 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 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

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 have spent 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.

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 do not know, however, what proportion of PIH's total budget each accounts for.

• Malaria treatment: PIH provides both in-patient and out-patient treatment for malaria.8 Malaria was responsible for 62% of hospitalizations and 47% of clinic consultations in Rwanda in 2006.9 Malaria treatment is a costly but effective method of improving health in the developing world. (See our full review of malaria treatment.)
• HIV/AIDS treatment: PIH provides AIDS treatment through community health workers.10 Anti-retroviral therapy does effectively prolong life, but is much less cost effective than many other developing world health programs. (See our full review of HIV/AIDS treatment.)
• HIV/AIDS prevention: PIH provides drugs to pregnant women with HIV to lower the risk that they will pass HIV to their child.11 There is strong evidence that this is an effective and cost effective program. (See our full review of prevention of mother-to-child transmission of HIV/AIDS.)
• Tuberculosis treatment: PIH provides TB treatment through community health workers.12 This program is a proven, cost-effective way to save live in the developing world. (See our full review of TB treatment.)

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),13 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).14

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 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.

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 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).

Room for more funds?

We have seen no "funding gap" analysis from PIH. From its financials,17 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, "IRS Form 990 (2002-2008)" and PIH, "Annual Report (2009)" unless otherwise noted.18 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 reasonable assets:expenses ratio with approximately one 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.19 Expenses by IRS-reported category (about this metric): PIH maintains a reasonable "overhead ratio," spending approximately 94% 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

• Brigham and Women's Hospital. Medicine's newest recruits: 2005-2006 intern class. http://www.brighamandwomens.org/dom_newsletter/june_july_05/interns.htm (accessed April 12, 2010). Archived by WebCite® at http://www.webcitation.org/5p2QMAaTR.
• Clinton Foundation. 2006. An evaluation of the Southern Kayonza, Rwanda project (2005-2011). This document is not publicly available.
• GiveWell:
  • Program report: Anti-retroviral therapy (ART) to prevent mother-to-child transmission of HIV
  • Program report: Anti-retroviral therapy (ART) to treat HIV/AIDS
  • Diseases
  • Guide to cost-effectiveness analysis
  • Guide to GiveWell's financial metrics
  • Charity review: Partners in Health (2007-08)
  • Program report: Treatment of malaria
  • Program report: Tuberculosis case finding and treatment ("DOTS" approach)
• Partners in Health. Annual reports:
  • 2003 (PDF)
  • 2004 (PDF)
  • 2005 (PDF)
  • 2006 (PDF)
  • 2008 (PDF)
  • 2009 (PDF)
• Partners in Health. Consolidated financial statements (2007) (PDF).
• Partners in Health. Inshuti Mu Buzima Summary Report (2006) (DOC).
• Partners in Health. IRS form 990:
  • 2002 (PDF)
  • 2003 (PDF)
  • 2004 (PDF)
  • 2005 (PDF)
  • 2006 (PDF)
  • 2007 (PDF)
  • 2008 (PDF)
• Partners in Health. Organization website:
  • Lesotho. http://www.pih.org/where/Lesotho/Lesotho.html (accessed June 28, 2010). Archived by WebCite® at http://www.webcitation.org/5qpRrjBgo.
  • Malawi. http://www.pih.org/where/Malawi/Malawi.html (accessed June 28, 2010). Archived by WebCite® at http://www.webcitation.org/5qpRs1d7W.
  • Partners are the key for Partners In Health. http://www.pih.org/who/partners.html (accessed June 28, 2010). Archived by WebCite® at http://www.webcitation.org/5qpSBuemE.
  • Rwanda. http://www.pih.org/where/Rwanda/Rwanda.html (accessed June 28, 2010). Archived by WebCite® at http://www.webcitation.org/5qpSKQDLV.
  • The PIH model of care. http://www.pih.org/what/PIHmodel.html (accessed April 16, 2010). Archived by WebCite® at http://www.webcitation.org/5qpRt5KLj.
• Partners in Health. Rwanda Budget (XLS).

• 1.
  • In Haiti: "In each of our expansion sites, we have partnered with other nongovernmental organizations and the Haitian Ministry of Health to rebuild or refurbish existing clinics and hospitals, introduce essential drugs to the formulary, establish laboratories, train and pay community heath workers, and complement Ministry of Health personnel with PIH-trained staff." PIH, "The PIH Model of Care."
  • In Rwanda: "PIH's intervention in Rwanda consciously replicates the model that has proven successful in central Haiti." PIH, "Rwanda."
  • In Lesotho: "The PIH project in Lesotho was launched in 2006 following an invitation from the government of Lesotho and consultation with our partners in Rwanda, the Clinton HIV/AIDS Initiative (CHAI), about where to replicate that successful model elsewhere in Africa." PIH, "Lesotho."
  • In Malawi: "Like PIH's other projects, APZU combines treatment for HIV patients with comprehensive, community-based health care and programs to combat the conditions of extreme poverty in which disease takes root, including hunger and lack of access to clean water and decent housing, schools and livelihoods...By November 2007, more than 170 community health workers had received comprehensive training and had been hired to visit as many as six HIV and TB patients daily to ensure adherence to treatment, monitor side effects and socioeconomic needs, and accompany them to the clinic." PIH, "Malawi."
  For further discussion of these projects and PIH's other projects, see our 2007-2008 review of PIH.
• 2. PIH, "Annual Report (2009)," Pg 32.
• 3. See our 2007-2008 review of PIH.
• 4. See our 2007-2008 review of PIH.
• 5. See PIH, "Inshuti Mu Buzima Summary Report (2006)" 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, Brigham and Women's Hospital, "Medicine's Newest Recruits: 2005-2006 Intern Class." There are a number of people listed on this page who have spent significant time volunteering for PIH. The linked program is a PIH partner. See PIH, "Partners Are the Key for Partners In Health."
• 8. "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.
• 9. Clinton Foundation 2006, Pg 23.
• 10. "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.
• 11. "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.
• 12. "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.
• 13. PIH, "Rwanda Budget."
• 14. HIV prevention education: $40,000 Housing support: $75,000 School fees: $107,500 Microfinance: $60,000 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 PIH, "Rwanda Budget."
• 15. More discussion at our 2007-2008 report on PIH.
• 16. "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.
• 17. PIH, "Annual Report (2008)," Pg 32.
• 18. 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.
• 19. Data comes from PIH, "Annual Reports (2003-2009)" and PIH, "Consolidated Financial Statements (2007)."