Partners in Health: a Sustainable Model for Decreasing Health Disparities

Sub-Saharan Africa is currently facing one of the highest global burdens of disease, while maintaining the world’s smallest percentage of healthcare workers. This statistic, illustrated by the graph released in the World Health Organization’s 2006 Report (Figure 2), highlights the endemic lack of health care workers across the Sub-Saharan landscape. The World Health Organization’s recommended ratio of 2.3 health professionals for every 1000 persons seems an impossibly far cry from the Sub-Saharan norm highlighted by Rwanda’s ration of 0.72 health professionals for every 1000 persons (Cancedda 2014). What has lead to this huge deficit of health workers in the developing world and what has been done to fix it? Current work has focused primarily on confronting the burden of disease that has swept through developing nations, but what about addressing the heart of the issue? Setting up a sustainable system to fight the problem in the future is just as if not more important than attacking current health issues. This disparity in health workers has been attributed in part to the “Brain Drain”, or the migration of graduates from higher education, specifically health workers, from developing nations to developed nations in order to seek better opportunities.

Paul Farmer and his organization Partners in Health have illustrated the great work that foreign aid groups can do in aiding nations during crises, however there is little these organizations can do in order to prevent crises. There must be a shift in global health thinking from responsive to preventative, and the best way to accomplish this is by making health care more readily available. The easiest way to create a sustainable system of preventative care is by increasing the number of native health workers. However, to increase local health workers, one must slow the “brain drain” that is pulling these workers away from their countries. Factors that cause this migration of workers have been organized into Push and Pull Factors. Push factors are characterized by strong reasons to leave a country of residence like; limited career opportunities and poor working conditions, whereas Pull factors are those that incentivize movement to another country like; recruitment and better wages (Kissick). This drive to leave Sub-Saharan Africa is best characterized in Figure 3, which shows the percentage of health workers intending to migrate for better opportunities. This statistic is higher than 50% in most nations, and the reason why is clear from Figure 4 which shows the average monthly wages for health workers in developing versus developed nations. Kissick points out that the United Nations Universal Declaration of Human Rights states “Everyone has the right to leave any country, including his own, and to return to his country.” Making the point that in order to stop this migration you cannot ban it, but rather incentivize staying so that health workers will not choose to migrate.

How can Developing Nations incentivize their health workers in order to make them want to stay? Higher wages are one idea, but because of the economic situation in many developing nations it is not a valid option. Creating a sense of national pride and the want to stay and help build up your nation is another idea, however one would think this already would have worked if it was ever going to. The responsibility for stopping this migration might not fall on the nations losing their workers at all, but rather on the nations that are recruiting them away. Whichever of these if any are the right answer is not yet known, but what is for certain is that this problem needs to be fixed, or else the health disparities already present around the world will just become more exaggerated.



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Discussion Questions:

  1. How would you incentivize health workers to keep them from migrating from developing nations?


  1. Create a policy that would still allow Health Workers to move internationally, but would keep developed nations from stealing these workers away from developing nations.



Cancedda, Corrado. “Enhancing Formal Educational and In-Service Training Programs in Rural Rwanda A Partnership Among the Public Sector, a Nongovernmental Organization, and Academia.” Academic medicine 89, no. 8 (August 2014): 1117-.


Fink, Sheri. “Pattern of Safety Lapses Where Group Worked to Battle Ebola Outbreak.” The New York Times (Apr 2015).


The “Brain Drain”: Migration of Healthcare Workers out of sub-Saharan Africa

Kasey Kissick


Figures Sources

Connell, J, P Zurn, B Stilwell, M Awases, and J Braichet. “Sub-Saharan Africa: beyond the health worker migration crisis?” Social Science & Medicine 64 (2007): 1876-91.


World Health Organization. “Working Together for Health: World Health Report 2006.” 2006.


Vujicic, M, P Zurn, K Diallo, O Adams, and MR Dal Poz. “The role of wages in the migration of health care professionals from developing countries.” Human Resources for Health 2 (2004).

Partners in Health and Promoting Community Development

Partners In Health has often been discussed as the NGO that has one of the most successful models, but by looking at its shortcomings it paints a more realistic picture of the challenges in delivering health to peoples in developing worlds. Seeing its development and its efforts to expand demonstrate the moral obligation many feel towards providing adequate healthcare to all people, despite the dangers and unanticipated consequences as seen in their intervention in Sierra Leone.
Drawing back to the three core principles of Belmont Report, PIH has been successful in giving back dignity to impoverished people. Instead of focusing solely on the “zoe,” which groups like MSF are only equipped to do, PIH attempts to make humanizing people a goal. This is why I found the events in Ebola particularly shocking in regards to the Sierra Leone health worker. Health workers contracting a disease is probably one of the most feared unanticipated consequences of global health interventions. Out of the two health workers who contracted ebola, the one from Sierra Leone faced the most difficulty in being transported to a proper facility. Shouldn’t there be a moral obligation to protect health workers whether or not they are the “white savior” or a member of the local population. This brings up a question of valuing one life over another. Is the life of a foreign NGO worker more valuable than a community volunteer?
PIH has been greatly successful in delivering AIDS and tuberculosis treatment in Haiti and Rwanda, which is by no means a small feat, so its understandable why many other NGO’s would follow their model. By focusing closely on partnerships with the community, PIH manages to develop more effective treatment plans that combat low retention rates produced by structural violence. Both Zanmi Lasante in Haiti and Inshuti Mu Buzima in Rwanda demonstrate PIH success at forging community partnerships and the effectiveness of adding horizontal measures to improve vertical approaches. By giving incentives like food and transportation they improve the quality of life for people while at the same time serving more people. By removing some barriers caused by structural violence more people are able to in treatment longer.
While it’s nice to think that Paul Farmer has all facets of global health figured out, when looking at PIH’s ebola intervention there are issues in their approach. It brings into question why their model works in some cases but not in others. It’s necessary to develop programs “that are appropriate to the needs of the population” (Farmer 217). What differences are there in treating HIV/tuberculosis and ebola? How should PIH adapt their model to successfully treat ebola safely? In Haiti, PIH was able to forge strong community partnerships and train local people to be health workers which is an approach that successfully integrates the community into their intervention and gets them invested in the future. It allows for some growth in the health care system. For example after the 2010 earthquake in Haiti, Haitian doctors and nurses that were supported by PIH were able to respond to the disaster (WGBH). Vanessa Kerry, the CEO of Seed Global Health tries to implement PIH’s model and seeks to train skilled doctors and nurses in Haiti. In an interview she describes how 42 Americans were able to train more than 4,000 medical professionals in Africa. The PIH model realizes the need for extensive follow-ups that go beyond the immediate crises that organizations like MSF deal with, however this seems problematic in areas in immediate crisis. How can PIH hope to make long lasting change in more dangerous situations like Sierra Leone?

Discussion Questions:
What approach should have Partners In Health should have taken in Sierra Leone? What are possible unanticipated consequences?
How can PIH form equal partnerships with governments and have effective leadership in their interventions?

Farmer, Infections and Inequalities, Ch. 8
Farmer et al textbook, Ch. 6
Fink, Sheri. “Pattern of Safety Lapses Where Group Worked to Battle Ebola Outbreak.” New York Times 12 Apr. 2015: n. pag. Print.
Ross, Elizabeth “Beyond Ebola: Boston Physicians Lead Global Effort To Prevent The Next Pandemic” WGBH News 28 Oct. 2015

Institutional Support?

Before looking more closely at the Partners in Health (PIH) model, we analyzed the impact of NGOs. While most NGOs are able to provide temporary relief to individuals in a population, they often fail at creating sustainable infrastructure to address broader issues affecting a whole population. One example of an NGO, however, that has been rather successful in creating structural-based changes has been PIH. Although we’ve mostly been following PIH’s work in Haiti, the organization’s involvement in Rwanda has also led to promising changes in healthcare delivery there (4). PIH can’t take all of the credit though. Rather, their partnership with the Rwandan Ministry of Health (5) as well as with their well-endowed affiliated institution, Harvard University, has been crucial to their continued success. Harvard Medical School, along with its affiliated medical centers like Brigham and Women’s Hospital, has especially been able to supply much of the initial resources and expertise necessary for this endeavor (4). Corrado Cancedda uses the work of Harvard as a guide for other U.S. institutions on how to “channel the innovation, creativity, resources, and expertise of academia toward the pursuit of global health inequity” (4). Institutions no doubt can play an important role, yet with the exception of other institutions in the Ivy League and perhaps Stanford, I wonder how reliably PIH’s institutional model applies to less-endowed U.S. institutions.

Many institutions have already been aiding in the Global Health effort. Brown’s Global Health Initiative, for example, provides scholarships to students seeking to conduct relevant projects or research in other countries, just as it encourages collaboration with institutions in other countries. The Alpert Medical School even has some collaboration with St. Damien Hospital in Tabarre, Haiti (2), yet there haven’t been updates regarding this collaboration since 2010 (1). For the most part, Brown’s position in the Global Health effort mainly takes the form of research, as do other institutions. Case in point, the most recent global health related article published by Brown discussed research done on HIV incidence in Nigeria (3). Harvard University certainly pioneered a different approach to institutional involvement, one that partnered with an NGO founded by two of its alumni and the Ministry of Health of Rwanda in attempt to change the way healthcare was delivered there. With one of the highest U.S. institutional endowments, some of the brightest educators and doctors, and some of the top medical and research centers in the world, Harvard is no doubt an institution that can afford to go to these great lengths and do so well. Its financial and research position allows it to wield great power and influence over systemic changes in other countries. In the case of other institutions that have fewer resources, money, and prestige, it seems they would be less likely to get past the “NGO state” when conducting global health projects, i.e. providing temporary fixes as opposed to broad, structural-based changes. This is not to discredit the global health work other institutions do and have been doing, but this is to question how replicable the PIH partnership model is for other institutions.

Discussion Questions:

1. How can the PIH partnership model apply to other less-endowed institutions?

2.  What are some other ways these institutions can create broad, structural-based changes in other countries?


  1. Brown University (2015) Global Health Initiative: Alpert Medical School in Haiti. Retrieved from
  2. Brown University (2015) Global Health Initiative: Medical Education and Leadership Development. Retrieved from
  3. Brown University (2015) News From Brown: HIV Spreads Faster as Violent Conflict Looms. Retrieved from
  4. Cancedda, C., Farmer, P.E., Kyamanywa, P. (2014). Enhancing Formal Education and In-Service Training Programs in Rural Rwanda: A Partnership Among the Public Sector, a Nongovernmental Organization, and Academia. Academic Medicine, 89 (8), 1117-1123.
  5. Farmer, P.E., Kim, J.Y., Kleinman, A. (2013). Reimagining Global Health: An Introduction. (172-182). Berkeley and Los Angeles: University of California Press.

Partners in Health Creating Systems for Years to Come

This will become very clear throughout this blog post, but I believe Partners In Health is a wonderful organization that has made a positive impact on the lives of millions of people across the world. Nongovernmental organizations, such as PIH, take responsibility for what many local governments either cannot or will not allocate time and money towards; the health of their nation. These organizations commit to a goal of improving the health of hundreds of thousands of people, with a genuine desire to help.

The focus of Partners in Health in the case of Rwanda was to develop a sustainable health system in a nation that desperately needed sanitary facilities to properly care for infectious diseases. This summer, I worked with the Uganda Village Project in rural Uganda to collect water and sanitation data, increase access to clean water sources and hygiene and sanitation workshops. During my time living and working with the villagers of Kasambiika, I learned that education was the most valuable tool we could offer them. For example, the team who lived and worked in Kasambiika the summer of 2014 built tippy taps, a hand-washing station made of household items, for the local primary school. However, less than a year later, the parts of these tippy taps were stolen or broken, and no one knew how to put them back together. This year we held a workshop to education the children and staff on how to build a tippy tap and the importance of sanitation. This enabled the community to repair or rebuild these structures if necessary.

In this line of work, nongovernmental organizations come out of nowhere to an established community and impose change. For the most part, good change. However, change, no matter how positive or negative it is, is sometimes hard to accept. At the end of it all, these organizations then pack up all their things and leave the community, wishing the best for them. What PIH does well in Rwanda is the educational program with Harvard Medical School and Brigham and Women’s Hospital. This partnership “helped the Rwanda MOH and academic institutions establish new or strengthen existing formal educational programs (conferring advanced degrees) and in-service training programs” (Cancedda) with local health workers. Training local community members presents new opportunities for individual and autonomy for the health of the community. This partnership lessens the dependence on the NGO in the long term and increases the overall health of the community, even after PIH leaves.

Again, this model of health work in nations with high rates of communicable diseases and other health burdens has contributed a lot of positive change in the world. That is not to say, however, that this is a flawless model. First, the level of dependency Partners in Health has on its donors is not sustainable or completely reliable. Further, the person or company that is donating the money will more or less have a say in where the funds are allocated. Speaking of sustainability, foreign NGOs, no matter now noble the cause, will always be foreign to the communities they are trying to help. This runs the risk of imposing foreign notions or practices without considering local cultures.




Discussion Questions:


What are some ways that nongovernmental organizations, such as Partners in Health, can find more stable, consistent funding and rely less on donations?


How could Partners in Health offer more sustainable interventions; further, what are some unforeseen consequences of their work?



  • Farmer, Infections and Inequalities, Ch. 8
  • Farmer et al textbook, Ch. 6
  • Cancedda, Corrado et al. 2014. “Enhancing Formal Educational and In-Service Training Programs in Rural Rwanda: A Partnership Among the Public Sector, a Nongovernmental Organization, and Academia” Academic Medicine 89(8): 1117-1124.

Fink, Sheri. 2015. “Pattern of Safety Lapses Where Group Worked to Battle Ebola Outbreak.” The New York Times April 12.

Treatment IS Prevention: How PIH Reconstructs What Is Good

A recurrent theme in this course has been that programs in international health need to address the root causes of disease, as well as the biosocial contexts in which these diseases arise, in order to achieve some success (Lecture 1). Paul Farmer and his model of Partners in Health support this idea, creating programs that take into account the poverty, structural barriers, and social norms that often determine who benefits from health care systems and who doesn’t (Farmer et al. 4). What I find interesting, however, is that Farmer argues that development efforts seeking to address these issues should not necessarily be prioritized over the treatment of patients in immediate need (Farmer 217). I would like to look at whether this argument is made on a fundamentally moral basis (as in we have “the moral responsibility” to treat suffering patients) or effectiveness basis (treatment is good in the long run and reinforces development goals).

I think that PIH programs directed at tuberculosis are a good place to start, as TB is a disease that is not only intertwined in the issues of poverty, but also in debates about non-compliance and cost-effectiveness. Furthermore, although cures exist, TB continues to exact an enormous toll on populations and is projected to be the cause of 30 million more deaths by 2020 (Farmer 212). Because there are so many people suffering now and so many people expected to be suffering in the future, I think there is already a contradiction in where the money should go: Should funds go towards antibiotics to cure the people suffering right now? Or would the funds be better served in long-term infrastructure improvements, such as clean water systems, that will improve overall health and prevent future TB cases?

I believe that Paul Farmer’s answer, by the way he structures PIH, is both-that there shouldn’t be an “either-or” scenario (Farmer 217). For one, the effectiveness of financial assistance, nutritional supplements, and follow-up visits (Farmer 219) may refute the idea of cost-effectiveness. The accompaniment method of PIH is far less expensive than paying for the hospitalization of the patients if they are unable to comply (Farmer 224), which is often the case if antibiotics are distributed without accompanying social programs.

In terms of whether money should be going to development or treatment interventions, I think that Farmer is correct in saying that treatment is often prevention. An effective biosocial approach will cure patients, halt the progress of MDR TB, and prevent transmission; furthermore, “individuals with active pulmonary disease are most likely to transmit the disease to others” (Farmer 225). In other words, the treatment of those who suffer most is also the most effective way to prevent transmission. In this way, I think the effectiveness rationale reinforces the moral responsibility. Farmers argument conveniently aligns the interest in patients suffering now with concerns in the future.

One of the things that has interested me throughout this course is how interventions are based on social constructions of good, more specifically the often opposing ideals of the common good versus the good of the individual. We have seen in many instances how treatments that save individuals do little to nothing to the population, and that interventions designed to significantly ameliorate health in the population may neglect the well-being of minorities (Lecture 2). I think that, while Farmer’s model of PIH does not solve this problem, the aligning of development in population with care for individuals does shed some important light on how we should create programs in trying to impact the most “good:” utilitarian notions of cost-effectiveness in affecting good are automatically limited by perceived limitations of what is possible. When we reconsider constructions of what is possible, and aspire to care of any kind for individuals in poor places, we are more than often surprised by what programs can do.

Discussion Questions:

  1. In Sierra Leone, there is an attempt by PIH to use the resources for the treatment of Ebola patients to build a sustainable health system (Fink). Yet this leads to unintended consequences, when the government of Sierra Leone, which is supposed to maintain the health clinics, fails to provide safe equipment and two PIH volunteers contract Ebola. Are there any other ways in which the alignment of vertical and horizontal, treatment and development, can have negative consequences?
  2. Although Farmer makes a convincing argument that both treatment and development are important, there is still a question as to how much resources should be devoted to one and how much to the other. Should building infrastructure and treating patients be valued equally, or is one ultimately more important than the other?
  3. How would you define and measure making “good”? Do the numbers matter?


  • Mason, Katherine. “Lecture 1.” Providence. 09 Sept. 2015. Lecture.
  • Mason, Katherine. “Lecture 2.” Providence. 11 Sept. 2015. Lecture.
  • Farmer, Paul. Infections and Inequalities: The Modern Plagues. Berkeley: U of California, 1999. Print.
  • Farmer, Paul, Jim Yong Kim, Arthur Kleinman, and Matthew Basilico. Reimagining Global Health: An Introduction. N.p.: n.p., n.d. Print.
  • Fink, Sheri. “Pattern of Safety Lapses Where Group Worked to Battle Ebola Outbreak.” New York Times 12 Apr. 2015: n. pag. Print.

Exceptional Treatment of Global Health Workers

The outcomes of Partners in Health’s (PIH’s) previous interventions imply that partnerships with community health leaders play a critical role in the success of global health programs. While these leaders are invaluable, their lives are not treated as such, especially when compared to the lives of foreign aid workers. This discrepancy indicates a rooted hierarchical structure in foreign aid groups – even in ones like PIH that recognize the necessity of collaborating with individuals who belong to the communities that are receiving aid.

PIH’s health care delivery model factors in the requisite of fostering and relying on community partnerships. This component has proven to be a critical contributor to PIH’s global health programs, which focus on combining horizontal and vertical care by integrating aggressive infectious disease treatment and structural reformation. (1) For example, PIH’s ‘Proje Veye Sante’ largely relied on “accompagnateurs,” or paid community health workers, to “interface between the clinic and the community.” (2, 3) As shown by the project’s outcomes, the success of health interventions is contingent on decreasing structural barriers through various services (e.g. provision of food, transportation, etc.) and, accordingly, on the participation of community health leaders who conduct these services. (4)

In a sense, the community members’ roles in PIH’s efforts illustrate their resilience and leadership in the face of inequality and structural violence. Rather than the community depending exclusively on an NGO to work for them, the NGO instead relies on the community in order to make a sustainable impact. This interdependent relationship also draws attention to PIH necessarily collaborating with community members to augment its biosocial view and to better understand how to meet local needs. This is seen in the story of Haitian Catholic priest and psychologist Père Eddy, who has served as director of Zanmi Lasante’s (as PIH is known in Haiti) mental health program since 2005. (5) Zanmi Lasante’s HIV and tuberculosis program recruited Père Eddy, a past counselor for sexually abused teenagers and for victims of post-traumatic stress after 2004’s coup d’etat, in order to provide better assistance to patients who were dealing with depression, psychosis, social isolation, and stigma. (6) There, he “trained social workers how to meet their patients’ psychological needs.” (7) He understood so well his community/community-based work that his methods “were later used by PIH community health workers in settlements for displaced people and were adopted by the Haitian government to help mourners nationwide.” (8) Overall, Père Eddy’s background not only as a psychologist and pastor, but also as a Haitian citizen who has experienced social inequalities and violence first-hand, provides him with a more appropriate skill-set for delivering care to the population of interest and for educating PIH volunteers.

While local health workers ostensibly play just as valuable a role in PIH’s outcomes as PIH volunteers (professionals, logisticians, etc.) do, their lives are less valued than their foreign partners’. When an American PIH volunteer in Sierra Leone contracted Ebola, he was quickly transferred to the United States for treatment. (9) The same level of care was not provided for native community health leaders: Usman Mohamed Koroma, “a ministry employee who helped oversee infection prevention and control at the site,” contracted Ebola the same week but had to wait two days before being moved to Sierra Leone’s “British-run treatment unit set up for sick health workers.” (10) Thus, despite being colleagues both essential for PIH’s work, “one [received] arguably the best Ebola care in the world [while] the other [received] the best Ebola care available in one of the poorest countries in the world.” (11)

Why, in an organization like PIH that identifies the importance of community health advocates, is there preferential health treatment for foreigners? There are potentially several factors that contribute to this disparity. Nevertheless, this situation highlights the inherent hierarchial structure of foreign aid: the best treatment is reserved for those who hold the most power – for those who, driven by morality but under no obligation, have entered and brought resources to a foreign country. On the other hand, community health leaders, who belong to the population that is receiving aid, often derive the opportunity to showcase their agency from the foundation laid by global health organizations. They are therefore seen (and treated) as lower in the hierarchal configuration; their ability to help their communities necessitates the foreign aid organization being present — not because they have no agency, but because the structural inequalities they face obstruct their agency. Only when organizations like PIH are present to diminish fundamental inequalities — by providing financial assistance and resources — are community health leaders able to further help their fellow citizens. Perhaps, though, despite PIH’s attempts to decrease structural violence by meeting basic and financial needs, the underlying inequalities of the community they are attempting to improve pervades and is reflected by their work.


Hi Everyone,

This is an update to my blog post based on the discussions that were presented in the comment section. Before I address some of my new thoughts/conclusions, I want to clarify my opinion on PIH. I think that PIH executes great work; its model (described in the readings) is quite effective, and the administrators/members have designed effective methods in order to create large impacts on communities that need aid. Furthermore, I believe that PIH does work under the idea that all lives are equal; in fact, as we discussed in class, PIH is perhaps designed to provide a preferential option for the poor (i.e. they seek to act on inequality). My blog, therefore, was not meant to completely condemn PIH and render it hypocritical/discriminatory but rather to present a concern I have about PIH’s limitations. While PIH may want to provide equal care for all of its members (Fink’s article did indicate that PIH volunteers tried to negotiate and make several calls in order to get Usman Koroma the help he needed), they are sometimes unable to. Why is this? This is one of the questions I was trying to address, and I originally proposed the inherent hierarchal nature of NGO work as a potential answer.

I’ve thought a lot about this question since, and I have some new ideas that I’d like to share. I think that the resource-poor setting in which NGO takes place plays a large role in the preferential treatment to foreign aid workers. NGOs like PIH may emphasize this idea of ‘getting funds if you need them,’ but realistically, there are financial limitations that prevent everyone from getting access to equal care. (If there weren’t financial limitations, why wouldn’t PIH try to fly every sick person to a country with better health services?) These financial – and logistical – limitations become even more visible in the event of an emergency like the spread of ebola to volunteers. (I’m using the word ‘emergency’ in a specific way right now, but I do acknowledge that it’s difficult to define what exactly an ‘emergency’ is.) Therefore, NGOs have to make a decision about how to distribute their resources. And after more thought, I have identified three main factors that contribute to an NGO’s hierarchy and that influence an NGO’s decisions regarding allocation: 1) Place of Origin, 2) Academic Credentials/Expertise (I’m combining the two, though you identified them separately), and 3) Sphere of Influence (how much influence they have in a community — though this is hard to measure). Regarding the first point, I am assuming that foreigners are often the wealthier players in this situation; they are the people bringing resources into a country that lacks them. As for the second point, while all members (at all levels) are important to NGO work, I think it’s important to consider whether an NGO’s foundation in another country (infrastructure, health centers, logistics, etc.) would exist without the involvement of professionals.

Now that I’ve discussed more potential causes of preferential treatment, I want to focus on two of the questions I asked: Is it possible to eliminate the inherent hierarchical structure of global health organizations? Our classmates had varying opinions on this. Some argued that eliminating the hierarchy is possible. Yuki commented that NGO workers should place more value on the views of community members before doing their work to ensure that community health workers are valued as equal colleagues. Sara also shared a hope of eliminating the hierarchy. Methma, on the other hand, suggested that hierarchy is the nature of health care work and therefore cannot exactly be eliminated. I agreed with this but suggested that maybe some steps could be taken to reduce consequential inequalities of the hierarchy: perhaps instead of trying to completely dismantle the hierarchy, NGOs could give community health leaders higher positions within the hierarchy. By including them in decision-making processes and providing them with actual statuses, an NGO could possibly use its inherent hierarchy to further highlight the agency of the community. Another commenter, Niki, suggested that perhaps the problem we should focus on isn’t the hierarchy but rather safety regulations in general. After all, the lack of safety is what led to PIH’s volunteers contracting ebola in the first place. And I think Niki’s point raises yet another important idea to contemplate: as I stated in a comment, PIH strives to collaborate with governmental bodies/institutions (e.g. Sierra Leone health ministry) in an attempt to make health interventions more sustainable. This means that, unlike groups like Doctors Without Borders, PIH relies on the local government for protective gear and supplies. This obviously becomes a problem when safety lapses (e.g. faulty gear) occur because resources are less regulated. Although involving the government and making use of local resources may be critical to PIH creating self-sustaining health infrastructure, it seems like it also can be quite harmful (depending on the government’s capabilities).

Overall, maybe there is a way to abolish the hierarchy, but maybe there isn’t. Maybe we should direct our concern elsewhere. Clearly, this topic/debate is extremely multifaceted, but I hope that this blog and its comments have encouraged you to think about new ideas.


  1. Drobac, Peter, Matthew Basilico, Luke Messa, David Walton, and Paul Farmer. Reimagining Global Health. (Berkeley and Los Angeles: The Regents of the University of California, 2013), 133-183.
  2. Ibid, 160
  3. Farmer, Paul. Infections and Inequalities. (Berkeley: University of California Press, 1999), 211-227.
  4. Ibid
  5. “Père Eddy, Haiti’s Patron Saint of Mental Health.” Partners in Health. October 22, 2015.
  6. Ibid
  7. Ibid
  8. Ibid
  9. Fink, Sheri. “Pattern of Safety Lapses Where Group Worked to Battle Ebola Outbreak.” The New York Times, April 12, 2015.
  10. Ibid
  11. Huster, Karin, All Lives Matter, Slate, April 6, 2015.


Drobac, Peter, Matthew Basilico, Luke Messa, David Walton, and Paul Farmer. Reimagining Global Health. Berkeley and Los Angeles: The Regents of the University of California, 2013.

Farmer, Paul. Infections and Inequalities. Berkeley: University of California Press, 1999.

Fink, Sheri. “Pattern of Safety Lapses Where Group Worked to Battle Ebola Outbreak.” The New York Times. April 12, 2015.

Huster, Karin. “All Lives Matter.” Slate. April 6, 2015.

“Père Eddy, Haiti’s Patron Saint of Mental Health.” Partners in Health. October 22, 2015.


Discussion Questions

  • Who are more necessary, community health leaders or foreign volunteers/aid groups? Should both types of volunteers receive the same healthcare? If yes, should all members of the community also have equivalent access?
  • Is it possible to eliminate the inherent hierarchical structure of global health organizations? Is doing so necessary?
  • What factors contribute to the preferential treatment of foreign aid workers?

Edit 1: Spelling

Caught in Contradiction: The Inverse Relationship between Funding and Freedom

In a perfect world, every state would be able to equally serve, represent, and protect its people. However, as we know all too well, the world is far from perfect. The effectiveness of the state varies immensely across different countries, communities, and groups, leaving many individuals falling through the cracks of development in bureaucratic, impersonal systems. Non-Government Organizations (NGOs) are thought to repair some of the damage done by the state by taking more personal, community-based approaches, but they are short term fixes. As a recent Guardian article explained about NGOs in Malawi, “Many NGOs don’t work closely with local communities, so when they leave, projects collapse.” (Pensulo)

According to S. A. Zaidi, the only solution to the failures of the state is to strengthen the state itself. Zaidi argues that “NGOs are usually not in a position to address the causes of the problems their project has been designed to address.” (Zaidi, 268) While I agree that most NGOs have very limited impact on the sources of issues, I do not think the state is necessarily the solution. It is not an issue of a government versus nongovernment program, but rather the ability of a program to act without restraints and contextualize. Large scale interventions often have sufficient resources to create change, but fail to contextualize the interventions, while smaller programs have the adaptability needed to address individual needs and act without restraints, but often lack the resources to create large scale or sustainable change. The root of the problem is this: the more funding a program receives, the less ability it has to determine its own agenda.

Funding is a necessary part of any aid project, but the demands of donors can weaken the mobility and flexibility of a program. The more degrees of separation between the donors and the intended beneficiaries, the more barriers there are to the effective use of resources. Donors are often more focused on numbers than people, and statistical evidence is easier to gather for single diseases or vertical campaigns. While vertical campaigns can be effective, they attack specific problems in society without addressing the structural problems that give rise to the problem. Smaller NGOs are better able to understand underlying problems in a community, but may have difficulty gaining traction for funding. Name recognition is a barrier for small NGOs to draw in funds, so “already large INGOs are likely to further grow at the detriment of smaller and passive players.” (Greensmith) Even if a program is funded, it must produce desired results to continue to receive funding. In the case of HIV treatment in Sierra Leone as presented in HIV Exceptionalism, drugs were overprescribed because “staff members worried about if they would be perceived as ineffective bureaucratic managers of donor goods if they had an overstock of drugs.” (Benton, 126) When funding is the priority, the goal is shifted from assisting communities in need to pleasing donors.

We can continue with the example of HIV in Sierra Leone to show the importance of contextualization. Disclosure of one’s HIV status is a powerful tool – it can prevent transmission, reduce discrimination, and relieve the psychological burdens of diagnosis. With all these positive benefits, it is difficult to see why disclosure would not be encouraged and accepted, and perhaps programs would operate on the assumption that disclosure will happen between sexual partners and families, but this is often not the case. As Benton explains, decisions of disclosure must be “interpreted within local moral notions of secrecy and concealment that are linked to gender and class.” (Benton, 72) Understanding the social context of programs is so important for a program to be effective, and extremely difficult to achieve on a large scale since it varies from country to country, community to community, and person to person.

No matter the amount of funds, if the proper framework is not in place, it is a lost cause. This is not so much a matter of state versus NGO, but top-down versus bottom-up approaches. While there is no universal answer, we have seen time and time again resources lost to worthwhile causes by programs without an understanding of the target community. An example of this was PEPFAR funding in Mozambique, where “the result is an ART scale-up with millions of new dollars flowing into the health sector but little support for the building blocks of the health system that make the scale-up possible.” (Biehl & Petryna, 174) An approach that first focuses on establishing the framework at the ground level before introducing funding may be more effective. Once funding is received, the program still must have the freedom to make decisions based on the beneficiaries and not the donors. This will help ensure that the priority is where it needs to be to create change.

1. Is it possible for an NGO to create a sustainable structural change, or as Zaidi claims, does it have to come from the state?
2. Is the type of organization (state vs. NGO) the most important consideration in determining potential impact, or is the type of intervention (bottom-up vs. top-down) more important?
3. How do we address the problem that large programs that receive the most funding are the least in control of their agendas?

1. A. Benton. 2015. HIV Exceptionalism: Development Through Disease in Sierra Leone. Minneapolis: University of Minnesota Press.
2. C. Pensulo. “NGOs in Malawi: What Happens When Donors Leave?”The Guardian. N.p., 28 Sept. 2015. Web. 13 Nov. 2015.
Link: network/2015/sep/28/ngos-in-malawi-what-happens-when-donors-leave
3. J. Biehl & A. Petryna, eds. 2013. When People Come First: Critical Studies in Global Health. Princeton: Princeton University Press.
4. J. Greensmith. “Global Policy Forum.” Trends in Fundraising and Giving by International NGOs. N.p., n.d. Web. 13 Nov. 2015.
5. S. Akbar Zaidi. 1999. “NGO Failure and the Need to Bring Back the State.” Journal of International Development 11(2): 259.

NGO-Donor Relationship and Pressure for Success

I’m interested in critiquing “the demonstration of success” that NGOs are forced to produce for donors as evaluation for their efforts. I also think that evaluating the success of global health projects using a business-like model can be problematic.

Fundraising for a specific epidemic is one way to mobilize resources for NGOs using a vertical model (Biehl & Petryna, 2013). Uniting behind one health issue is a benefit of the vertical approach but as we have seen with “magic bullet” case studies for malaria and guinea worm, these programs can fail. Vertically oriented programs have major drawbacks because they don’t consider the improvement of regional health in a holistic manner. NGOs are one way to tackle issues of global health but they are dependent on donor funding (Zaidi, 1999). There exists a patron-client relationship between donors and NGOs similar to something you would find in a business.

Donor investment fads are one issue in NGO funding because popular issues are prioritized over necessities (Zaidi, 1999). Donors also have the power to decide what specific objectives are being targeted (Biehl & Petryna, 2013) and what projects to create. This makes me wonder how often project choices are based on evidence of need in a particular region or just based on the opinion of the donor, which may or may not be the best way to spend the money. Communication with community leaders about health projects they view as most important in their region should play a major role in NGO program planning to have the most effective outcomes (Ooko, 2014).

NGOS have been known to fix data for donors so they see the outcomes they want to continue to invest in the projects (Zaidi, 1999). This information is incredibly troublesome because it doesn’t show real progress or improvements of a health effort. This is similar to the portrayal and understanding of a country’s GDP, or the size of their economy. While Mozambique’s GDP increased after structural adjustment showing economic growth, the wealth of the rich increased, the poor populations grew poorer and rates of child malnutrition haven’t improved (Biehl & Petryna, 2013). The rise in GDP did not necessarily indicate an increase in health.

Statistics are one way to illustrate the “success” of a global health program to donors and specific patient examples are another. Ugandan patients in ARV programs proselytize their programs and endorse the success of treatment with their voice and bodies (Biehl & Petryna, 2013). Brenda of the HBAC program is one example of a success story from USAID support. Her story of transition, once on the verge of death to currently enrolled in college, provides evidence of success to donors and patrons, which shows the NGOs accountability. Benton (2015) also discusses the idea of successful examples of health in the context of HIV in effort to erase the stigma associated with being HIV positive. While I think that in both cases the use of specific patient examples can be motivating for either the donor or other patients, the comparison that other patients make between themselves and the example can be damaging to their own morale. Everyone recovers differently and faces different obstacles in their lives and health so modeling after one “good example” may sometimes be unrealistic.

Using a business-like model, or donors investing money with the expectation of “success” in the form of fast-improved health statistics or case studies, forces NGOs to create quick fixes to health issues rather than investing in regional structural changes that are sustainable. I draw a parallel in the US education system as teacher salaries in Florida are dependent on their student’s test scores. Studies have shown that teaching quality is not related to test scores (O’Connor, 2014) and I think this follows similar lines with the expectations of NGOs. Sometimes health improvements are difficult to measure or there are lags in the results of efforts, but these reasons should not deter donor investing in important projects.

The effects of NGO global health projects should be measured and monitored in some way to evaluate community health improvement. I suggest this be done through continued data collection, effective communication between NGO leaders and community members a part of target populations, and the donor taking a more hands-off role in program planning. We might also think about the time frame for the outcome of these efforts and consider measuring success over longer intervals so that efforts of long-term sustainable projects have time to form (Sriskandarajah, 2015).


Discussion Questions

  1. How can success pressure be alleviated from NGO programs? Is this necessary, or are there any alternative ways to evaluate the effects of global health projects?
  2. What role should donors play in the planning of global health programs they invest in? Does this change based on individual donors vs. government donors or their respective experience levels?



  • J. Biehl & A. Petryna, eds. 2013. When People Come First: Critical Studies in Global Health. Princeton: Princeton University Press.
  • Zaidi, S.Akbar. 1999. “NGO Failure and the Need to Bring Back the State.” Journal of International Development 11(2): 259.
  • Ooko, Sarah. “NGOs and Development in Africa: Lessons for Donors.” Thomson Reuters Foundation. 3 Mar. 2014. Web. 13 Nov. 2015. <>.
  • A. Benton. 2015. HIV Exceptionalism: Development Through Disease in Sierra Leone. Minneapolis: University of Minnesota Press.
  • O’Connor, John. “Two New Studies Find Problems With Teacher Evaluations.” State Impact. NPR, 13 May 2014. Web. 13 Nov. 2015. <>.
  • Sriskandarajah, Dhananjayan. “Five Reasons Donors Give for Not Funding Local NGOs Directly.” The Guardian. 9 Nov. 2015. Web. 13 Nov. 2015. <>.

NGO intervention in global health: a panacea or misguided donor-driven intervention?

While most NGO interventions in global health are well-intentioned, many fail to create meaningful and sustainable change. I will analyze reasons behind this phenomenon, primarily the issue of uninformed donors directing interventions, the exceptionalisation of certain diseases, the client-patron relationship that arises and finally the expectation that NGOs are a panacea to global health problems.

A fundamental issue with NGO intervention in global health is that interventions are often driven “by purse-strings” rather than actual on the ground needs (Zaidi, 270) This is seen in HIV care and in what Whyte et. al refer to as the ‘projectification’ of HIV care. This refers to the reality that the level of care a patient receives depends in large part on the program they decide or are able to join and who is funding it. “Whether clients also receive medicines for opportunistic infections and other health problems depends upon the program they have joined.” (Petryna, 155) In this chapter, Whyte et al. provide the example of some Ugandan programs providing CD4 counts but other programs to not provide this more costly test. Whether or not a program offers certain tests and services ultimately comes down to how much money they have, where this money is coming from, and how the donor wants it to be spent. So at Ministry of Health facilities funded by the Global Fund in Uganda, most clients have never had their CD4 counts measured.

The notion of patients becoming clients brought forward in Chapter 5 of Petryna and Biehl’s work is immediately unsettling as there’s a problematic power dynamic at play. “To put it bluntly, public health in this setting does not mean rights and equal opportunities for all citizens of Uganda. Rather, it means building on patron-client relationships locally, nationally, and internationally.” (145) ‘Clients’ are at the will of their patrons and the amount of money that the program they are enrolled in has from donors and NGOs. Moreover, there is a notion of reciprocity at work here as patients enter into this contractual relationship and are thus at the will of the restrictions and inconveniences imposed on them by their ‘patron’ health program.

Zaidi’s piece condemns NGOs as a band-aid fix to health care particularly in settings where the state has failed. “Because of their limited scope and reach, NGOs are no alterative to state failure.” (Zaidi, 270) Similarly, Pfeiffer also criticizes the prevailing notion in global health that NGOs are a “panacea”. This is an extremely important point to consider because most of the time, NGOs are not in a position to address the root causes of the problems that their specific intervention is designed to handle. (Zaidi, 268) Consequently, the expectation that NGOs will solve problems that a failed state is not able to address, is completely unrealistic and more importantly, unsustainable.

Chapter 6 of When People Come First, is slightly more optimistic in that Pfeiffer highlights that despite the misguided efforts of many NGO interventions in global health, we are in a state currently of “high agitation” in global health(Pfeiffer, 181). As such, there is great potential and a wide gap for innovation and major progress in the field. However, there are so many different NGO actors currently involved that reaching this potential is complicated. This concept is echoed in the Council on Foreign Relations blog post that appeared earlier this month about the WHO. Miles Kahler offers an interesting suggestion to this issue of harnessing the potential for innovation that the WHO should act as a norm-developing body. In this way, the WHO could set best practices, guidelines and norms that would significantly improve the effectiveness of many NGO interventions.

Ultimately, as is so often in discussions of global health interventions, the issue of NGO intervention comes down to a question of population versus individual. If the aim is to save a few individual lives, then perhaps NGO interventions in global health suffice as they exist. However, if the aim is to help a broader population, it’s evident from this week’s reading that NGOs are ineffective as they are expected to be a panacea and are too often constrained by misinformed donors. Global norms for the conduct of NGOs in global health interventions would help to address this shortcoming significantly.

Discussion Questions:

  1. With such strong criticism of NGO intervention in global health, would the better alternative be for NGOs to not intervene at all? Or is some intervention, even if it is misguided, better than none?
  2. Do you think the WHO could successfully assume the role of a norm-setting leader in global health to guide NGO practices and interventions?


  • Benton, Adia. HIV Exceptionalism: Development through Disease in Sierra Leone. Minneapolis: U of Minnesota, 2015.
  • Biehl, João Guilherme and Adriana Petryna. “Evidence-Based Global Public Health.” When People Come First: Critical Studies in Global Health. Princeton: Princeton UP, 2013.
  • Patrick, Stuart, Global Health and the WHO: Revival or Marginalization? Council on Foreign Relations Blog:
  • Zaidi, S. Akbar. “NGO Failure and the Need to Bring Back the State.”Journal of International Development J. Int. Dev.2 (1999): 259-71. Web


A partnership between NGOs and the state: An Illusion

Given that many developing countries are exceedingly dependent on NGOs for health services (Zaidi, 264), it is important to examine this dependency and evaluate whether or not it emerges as a sustainable relationship.  I will argue that there are three fundamental issues with this relationship that prevent it from attaining sustainability. Firstly, as long as NGOs are present in developing countries, healthcare will never be accessible to all citizens. Secondly neither entity is ever held fully accountable to its citizens. Lastly, and perhaps most worryingly, over the years, the work of NGOs has been painted as altruistic, when in reality they are providing health services that all humans have a basic right to.

A poignant example that points to the limitations of NGO accessibility can be found in the approaches toward disclosure of HIV status. Benton recalls a skit that demonstrates how disclosure of one’s status to their family could turn out positively (Benton, 75). However, Benton notes that ‘successful disclosure…hinges upon whether the ‘disclosed-to’ have internalized NGO…messages delivered through NGO communication channels’ (Benton, 76). Consequently, while there may be a safe way to disclose one’s status and ultimately reduce the anguish that endures from suffering in silence, only a few have access to this possibility. Whyte et al. further paint this image of NGO networks by claiming that Saddam’s decision to join an AIDS program was through a ‘trusted social connection,’ (Biehl, 146). Saddam, as a citizen of Mozambique, is not guaranteed any health services. However, as long as he can locate an NGO through various networks, he is guaranteed health services. This dichotomy is disconcerting as it suggests that individuals living in more isolated areas (e.g. rural areas) are at a huge disadvantage to their urban counterparts where such a network of NGO knowledge exists. In this way, NGOs buttress already existing disparities by only being available to a select number.

One would hope that the NGOs are at least held fully accountable to the citizens that they do manage to serve.   Nonetheless, this does not seem to be the case – the donor’s priorities come first (Zaidi, 265). Insofar as donor power extends to such a degree, even Presidents of countries find themselves first appealing to international donors when speaking publicly about their nation’s progress (Benton, 119). The absurdity of this situation is made more explicit when making a comparison with the west. A western government’s success is not measured by its control of infectious disease (Benton 122), yet the culture of NGOs and their presence in developing countries over the years has engendered this double standard. Furthermore, NGO presence has lead governments to assume that they need not be held responsible for the welfare of all their citizens, as some of them are receiving healthcare from NGOs. Such a dangerous belief can be attributed to the well-known mystique associated with NGOs, in which they are seen as the ‘panacea for all the ills’ (Zaidi, 260). As a result of this aggrandized image, a President that is aware that x number of NGOs are present in their country would have a hard time arguing for the funneling of state funds into public health infrastructure. Additionally, this co-existence of NGOs and the state allows both entities to assert culpability to the other in times of crises. An unfortunate instance in which this cross-talk played out was in Sierra Leone at the height of the Ebola Crisis; a reporter recalls that “there was no coordination,” between NGOs and government officials (Inveen, 2015). If state-run institutions were the only existing entities, it would be much harder for them to disseminate the blame onto others and thus would be faced with no other option but to be held fully accountable to their citizens.

Along with problems of accountability, the excessive presence of NGOs corrupts the mentality the west has towards developing countries. As many NGO workers are volunteers, the work done by NGOs can be perceived as generous, and individuals who receive such aid need to ensure that they are deserving of it (Benton 133). If health services were provided by the state, its citizens would no longer be under this pressure and simply believe that they have a right to such services in virtue of being a citizen.

Despite my criticism of NGOs, I recognize that the solution cannot be to simply remove them from developing countries. Instead I think the solution would be to encourage donors to make investments in already existing state infrastructure as opposed to donations to NGOs and hope that overtime this shift in economic support leaves the state as the dominant provider. As it would be much harder to incentivize large donors to make investments into struggling state entities, perhaps more of an emphasis on obtaining multiple, smaller donations would allow for this shift in investment.

Discussion Questions:

  • How do you balance trying to elicit sympathy from donors with ensuring that you are not debilitating the image of the very people you are trying to help?
  • What is the best way to prepare state-run entities for an independence from NGOs? How do we solve problems such as government corruption?
  • Would citizens in developing countries resist to the removal of NGOs? If so, why and how could we alleviate their resistance?


Benton, Adia. HIV Exceptionalism: Development through Disease in Sierra Leone. Minneapolis: U of Minnesota, 2015. Print.

Biehl, João Guilherme., and Adriana Petryna. “Evidence-Based Global Public Health.” When People Come First: Critical Studies in Global Health. Princeton: Princeton UP, 2013. Print.

Inveen, Cooper. “Sierra Leone Officials Say Flawed Aid Strategies Hamper Ebola Recovery Efforts – Humanosphere.” Humanosphere. N.p., 02 Nov. 2015. Web. 11 Nov. 2015. <>.

Zaidi, S. Akbar. “NGO Failure and the Need to Bring Back the State.”Journal of International Development J. Int. Dev. 11.2 (1999): 259-71. Web.