About this page
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
Table of Contents
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:
- Program update: Haiti, Mirebalais Solar Innovation, June 2012
- Program update: HPV vaccine in Haiti Summary, Nov 2011
- Program update: Achieving Treatment Success for Pediatric Multidrug-Resistant Tuberculosis in Lesotho, November 2011
- Program update: Strengthening and Studying Community-Based, Integrated Primary Health Care Systems in Rural Rwanda
- Program update: Rwanda - Community Health Worker Accompaniment Improves Retention of HIV Patients January 2012
- Cross-site, Recent Research and Evaluation, June 2012
- Good and Promising Practice – Geo-Monitoring and Evaluation – Partners In Health
- Good and Promising Practice - Integrating M&E and Quality Improvement
- Lesotho, Maternal Mortality Reduction Program Year Two Update, May 2012. PIH requested that we keep this document confidential.
- Malawi - Monitoring, Evaluation, and Quality Improvement - Data Collected and MEQ procedures. PIH requested that we keep this document confidential.
- Using Geographic Information Systems to support HIV Care in Rwanda
- Transformative Projects – Cholera
- Transformative Projects – Doris Duke Charitable Foundation
- Transformative Projects – Maternal Mortality Reduction Project
- Transformative Projects – Non-Communicable Disease
- 25th Anniversary Brochure
- NY Times - In Rwanda, Health Care Coverage That Eludes the U.S.
- PIH FY13 Budget
- PIH shared country budgets from Lesotho, Rwanda, Malawi and Haiti. PIH requested the we keep these documents confidential.
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.
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
In addition to its medical care program, PIH also runs projects that:5
- Provide food aid
- Build houses
- Pay for school fees
- Protect or filter water sources
- Run income generating projects
- Provide job training and small business loans
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
Does it work?
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.
- Malaria treatment: PIH provides both in-patient and out-patient treatment for malaria.10 Malaria was responsible for 62% of hospitalizations and 47% of clinic consultations in Rwanda in 2006.11 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.12 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.13 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.14 This program is a proven, cost-effective way to save live in the developing world. (See our full review of TB treatment.)
We have not seen information on the quality of PIH's non-medical programs or on PIH's success in targeting very poor individuals.
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 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 program area (about this metric): PIH spends the majority of its funds on its rural health clinics, the focus of our review.20
Expenses by IRS-reported category (about this metric): PIH maintains a reasonable "overhead ratio," spending approximately 94% of its budget on program expenses.
- 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.
- Quality of non-medical programs. Does PIH have information on the quality of its non-medical programs and on its success in targeting very poor individuals?
- 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"?
- Brigham and Women's Hospital. A match made at BWH. http://www.brighamandwomens.org/publicaffairs/publications/DisplayBulle… (accessed September 17, 2010). Archived by WebCite® at http://www.webcitation.org/5so4vx6ny.
- Brigham and Women's Hospital. Medicine's newest recruits: 2005-2006 intern class. Archived by WebCite® at http://www.webcitation.org/5p2QMAaTR.
- CBS News. Dr. Farmer's remedy for world health. http://www.cbsnews.com/stories/2008/05/01/60minutes/main4063191.shtml?t… (accessed September 17, 2010). Archived by WebCite® at http://www.webcitation.org/5so99krSe.
- Clinics for Haiti. The story. http://www.clinicsforhaiti.org/story.php (accessed September 17, 2010). Archived by WebCite® at http://www.webcitation.org/5snq2un4h.
- Clinton Foundation. 2006. An evaluation of the Southern Kayonza, Rwanda project (2005-2011). This document is not publicly available.
- Degree Confluence Project. 19Â°N 72Â°W. http://confluence.org/confluence.php?id=3088 (accessed September 17, 2010). Archived by WebCite® at http://www.webcitation.org/5snqUGWHU.
- English, Bella. April 13, 2008. "In Rwanda, visionary doctor is moving mountains again." http://www.boston.com/lifestyle/articles/2008/04/13/in_rwanda_visionary… (accessed September 17, 2010). Archived by WebCite® at http://www.webcitation.org/5snrqWgvF.
- English, Paul. Haiti. Paul English personal blog. Archived by WebCite® at http://www.webcitation.org/5snqweCZ1.
- GiveWell. Program report: Anti-retroviral therapy (ART) to prevent mother-to-child transmission of HIV
- GiveWell. Program report: Anti-retroviral therapy (ART) to treat HIV/AIDS
- GiveWell. Diseases
- GiveWell. Guide to cost-effectiveness analysis
- GiveWell. Guide to GiveWell's financial metrics
- GiveWell. Charity review: Partners in Health (2007-08)
- GiveWell. Program report: Treatment of malaria
- GiveWell. Program report: Tuberculosis case finding and treatment ("DOTS" approach)
- Kidder, Tracy. 2004. Mountains beyond mountains: The quest of Dr. Paul Farmer, a man who would cure the world. New York: Random House.
- Partners in Health. Annual reports:
- Partners in Health. Apzu / Malawi. http://www.pih.org/pages/malawi (accessed September 22, 2010). Archived by WebCite® at http://www.webcitation.org/5svoV2E2w.
- Partners in Health. Consolidated financial statements (2007) (PDF).
- Partners in Health. E-Bulletin (September 2008) (PDF).
- Partners in Health. Inshuti Mu Buzima / Rwanda. http://www.pih.org/pages/rwanda (accessed September 22, 2010). Archived by WebCite® at http://www.webcitation.org/5svo21hkr.
- Partners in Health. Inshuti Mu Buzima Summary Report (2006) (DOC).
- Partners in Health. IRS form 990:
- Partners in Health. Partners are the key for Partners In Health. http://www.pih.org/pages/partners (accessed September 22, 2010). Archived by WebCite® at http://www.webcitation.org/5svpMCaCd.
- Partners in Health. PIH Lesotho / Bo-Mphato LitÅ¡ebeletsong Tsa Bophelo. http://www.pih.org/pages/lesotho (accessed September 22, 2010). Archived by WebCite® at http://www.webcitation.org/5svoKZNrS.
- Partners in Health. PIH Russia project earns top grades and financial support for work on MDR-TB. http://www.pih.org/news/entry/pih-russia-project-earns-top-grades-and-f… (accessed September 17, 2010). Archived by WebCite® at http://www.webcitation.org/5so5Wzkmj.
- Partners in Health. Rwanda Budget (XLS).
- Partners in Health. Socios En Salud / Peru. http://www.pih.org/pages/peru (accessed September 22, 2010). Archived by WebCite® at http://www.webcitation.org/5svodDyQO.
- Partners in Health. Stand With Haiti six-month report (PDF).
- Partners in Health. The PIH model of care. http://www.pih.org/pages/the-pih-model-of-care (accessed September 22, 2010). Archived by WebCite® at http://www.webcitation.org/5svpRMiiV.
- Skoll Foundation. Partners in Health. http://www.socialedge.org/blogs/alvins-guide-to-good-business/archive/2…. Archived by WebCite® at http://www.webcitation.org/5sns8hyAO.
- 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." Partners in Health, "The PIH Model of Care."
- In Rwanda: "PIH's intervention in Rwanda consciously replicates the model that has proven successful in central Haiti." Partners in Health, "Inshuti Mu Buzima / 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." Partners in Health, "PIH Lesotho / Bo-Mphato LitÅ¡ebeletsong Tsa Bophelo."
- 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." Partners in Health, "Apzu / Malawi."
PIH, "Annual Report (2009)," Pg 32.
See our 2007-2008 review of PIH.
See our 2007-2008 review of PIH.
- "Program on Social and Economic Rights (POSER)...addresses the social inequalities that put our patients at increased risk of disease by providing nutritional support, building houses, paying for school fees and installing well caps or filtering systems to ensure access to clean drinking water." Partners in Health, "Zanmi Lasante / Haiti."
- "IMB distributes food packages to the families of all patients being treated for HIV or tuberculosis, builds solid houses for patient families living in tumble-down shacks, pays school fees, and employs local people at a carpentry and metalworking shop." Partners in Health, "Inshuti Mu Buzima / Rwanda."
- "SES also provides food baskets, transportation, lodging and social support for impoverished patients whose needs have been confirmed by an extensive interview and evaluation. The project also provides opportunities for income generation projects, job skills training, and small loans to start businesses." Partners in Health, "Socios En Salud / Peru."
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.
- The journalist Tracy Kidder chronicles his time following PIH founder Paul Farmer to PIH sites around the world, including the hospital in Haiti in the book Mountains Beyond Mountains.
- The investigative news show 60 Minutes reported on PIH's hospital in Haiti in 2008: "Farmer invited 60 Minutes to central Haiti, where he discovered his life's work 25 years ago." CBS News, "Dr. Farmer's Remedy For World Health."
- 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 Partners in Health, "Partners Are the Key for Partners In Health."
- "Rodrigo Zepeda, MD, who graduated last year with his medical degree from Monterrey Tec in Monterrey, Mexico...spent one year training rural health outreach workers at the Partners In Health facility in Chiapas, a region of Mexico near the Guatemalan border." Brigham and Women's Hospital, "A Match Made at BWH."
- "Dr. Dillaha had recently read Mountains beyond Mountains by Tracy Kidder, a biography of Dr. Farmer. Dr. Dillaha had also visited Haiti in December and had a recent firsthand look at the needs of the Haitian people. He had developed a deep admiration for Dr. Farmer and his organization." Clinics for Haiti, "The Story."
- "Our time in Cange and at other Zanmi Lasante sites in the Central Plateau gave us a first-hand look at the primary health care system pioneered 20 years ago by PIH and its founder, Dr. Paul Farmer...It is a complex and expensive endeavor. But an effective one." Degree Confluence Project, "19Â°N 72Â°W."
- "Dr. Dumitru Laticevschi, Global Fund Portfolio Manager for Eastern Europe/Central Asia, visited the TB prison, hospital, TB drug dispensary, and Tomsk Red Cross. Dr. Laticevschi was impressed by the level of program performance and treatment results. He expressed interest in sharing the Tomsk experience with other TB grants administered through the Global Fund. Soon after Dr Laticevschi's visit, PIH received concrete confirmation of the Global Fund's continued support -- a $1 million installment that covers continuation of treatment and program improvement going forward for program quarters 10 and 11." Partners in Health, "PIH Russia Project Earns Top Grades and Financial Support for Work on MDR-TB."
- "On a visit to Haiti in March, Children's Hospital's Plastic Surgeon-in-Chief, Dr. John Meara..." Partners in Health, "E-Bulletin (September 2008)," Pg 6.
- "In September 2003 I visited Paul Farmer at Partners in Health in Haiti, and went back for my second trip in February 2004." English, "Haiti."
- English, April 13, 2008.
- See the video at Skoll Foundation, "Partners in Health."
"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:
- 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.
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)."