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Partners in Heath

November 2010"); ?>
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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.
Table of contents 
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.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

Other programs

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

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.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.

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.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.

Financials/other

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.

Unanswered questions

Sources

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