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Partners in Health does not currently qualify for our highest ratings.
More information:
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Published: November 2010
Summary
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 at posted our
notes and photographs.
Previous reports on Partners in Health:
What do they do?
Medical care
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. Operations in Haiti and sub-Saharan Africa (Rwanda, Lesotho, and Malawi) account for about 73% of PIH's FY 2009 expenses.
PIH treats patients for a variety of conditions including malaria, upper respiratory tract infections, AIDS, diarrhea, and intestinal parasites. (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.
Other programs
In addition to its medical care program, PIH also runs projects that:
- 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.
Does it work?
Medical care
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. 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. 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.
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. Malaria was responsible for 62% of hospitalizations and 47% of clinic consultations in Rwanda in 2006. 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. 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. 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. This program is a proven, cost-effective way to save live in the developing world. (See our full review of TB treatment.)
Other programs
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. 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, 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).
We have requested, but have not received, "funding gap" analysis for PIH as a whole. From its financials, 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. We do not know which of its planned activities will not be funded if PIH does not receive all $40 million.
Financials/other
All data comes from Partner in Health, "IRS Form 990 (2002-2008)" and Partners in Health, "Annual Report (2009)" unless otherwise noted.
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.
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.
- 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"?
Sources
- Brigham and Women's Hospital. A match made at BWH. http://www.brighamandwomens.org/publicaffairs/publications/DisplayBulletin.aspx?articleid=4806 (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?tag=currentVideoInfo;segmentTitle (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. 19°N 72°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_doctor_is_moving_mountains_again/?page=full (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-financial-support-for-work-on-mdr-t/ (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/2010/03/12/partners-in-health. Archived by WebCite® at http://www.webcitation.org/5sns8hyAO.