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?

 

Sources:

  • 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.

12 thoughts on “Partners in Health Creating Systems for Years to Come”

  1. Hey Richael,

    I enjoyed reading about your experience with the Uganda Village Project! It’s very inspiring that you were part of a movement to educate the community about sanitation and the repair of tippy taps so that they can be more independent.

    I do see the outside funding of NGOs to be a problem, since, like you said, the funding is not completely reliable, and donors have a large role in determining the NGO’s goals. I think an alternative to this is the funding system used by Bangladesh Rural Advancement Committee (BRAC), an NGO described in the documentary that we watched during class on Nov. 18th. BRAC obtains funding from commercial profits – the selling of local artist’s work, tuition from BRAC University, etc. Although such funding can also be unreliable in the long run, funding from commercial profits could be used alongside donations. In addition, Partners in Health has college chapters in the U.S. that fundraise for the organization, increasing the amount of funding.

    As for more sustainable solutions, I’m having trouble thinking of one, mainly because PIH is touted as one of the most sustainable health care delivery models. As described in Chapter 6 of the Farmer et al. textbook, the PIH model emphasizes the following points: increasing access to primary health care (through addressing structural barriers via nutrition/financial assistance and improvement of access to food, shelter, and clean water, for instance), providing health care and education for the poor, involving community members at all stages of the intervention (i.e., assessment, design, implementation, and evaluation), working with the government to improve the public sector (to make sure everyone can have access to health care, including the poor), utilizing technology in medicine (especially electronic medical records), and providing attention to the particular needs of women and children. The PIH model also emphasize the use of the diagonal approach to health care, rather than just a vertical/horizontal approach, which I am also in support of. I really like PIH, too, although I do see some pitfalls like you mentioned.

  2. Hi Shelly,

    Thank you for your post and for sharing with us your experience working in Uganda this past summer. I do also believe that education is the most valuable tool that can be offered to an at risk immunity.

    I also think it is important to address the lack of reliable funding seen with NGOs. A potential solution for the reliability of funding could be increasing funding from the universities partnered with PIH. I think more funding from the universities would give PIH more freedom in what the money is being used for because it is more likely that universities are less set on an issue than larger donors. I also think advertising to people like you and me rather than a large corporation could be beneficial.

    PIH is responsible for their sustainable healthcare models. Every model could always work on sustainability however, I do think it would be hard to fix just because PIH is known as the most stable models out there.

  3. Hi Richael! I really enjoyed hearing about your personal experiences in Uganda, and I think you captured some important points about sustainability in NGOs. In terms of PIH funding, because they are such a large NGO I think they have a relatively consistent amount of funding, but they cannot continue to fund every project, so individual projects do not necessarily receive stable, long-term funding. In a perfect world this would not be the case, but I think it is less a matter of finding consistent funding and more a matter of ensuring that the funding is being put towards projects that need continuing, or at least allocating to the top priorities. However, if the goal is to become less dependent on donors, they could start a for-profit sector to use as a source of income. This would mean a sustainable income, but they would still have to decide how to best allocate the funds.

  4. Hello Richael,
    As Yuki commented above, I think that as an organization engineered by an anthropologist PIH theoretically seeks to emphasize ideals (e.g. PHC, education, community involvement, government involvement, etc.) that most efficiently and sustainably achieve improved global health in a culturally sensitive manner. From your blog and other’s comments, I think the main issue we struggle with is how to finance these ideals. Foreign funding inherently creates a hierarchy of dependence, but in order to make health a global effort foreign funding is needed, especially when, as you said, countries cannot allocate money towards the health of their nation. So I propose that rather than focus on this fixed component of initial global health efforts, we (including PIH) need to focus on how to transfer financial ownership of health to its respective country. Perhaps that involves funneling commercial profits into global health as Yuki suggested. In this respect, my biggest concern is how would NGOs like PIH convince local governments to dividend GDP towards health systems? Does it involve charismatic leaders, foreign infiltration of government, or simple education of the government officials? I’d love to hear your thoughts on this.

    1. Hi Nikisha,

      Thank you for reading my blog! I think you bring up some really great points with funding health interventions. I agree that transferring financial ownership to local countries is key to a sustainable health system. My question for you is, do NGOs necessarily have to partner with local governments, or can they go straight to local businesses to allocate funds to health projects. The problem with governments is the bureaucracy that organizations have to go through to allocate funds. Local businesses may be willing to donate a portion of their profits to community health, as they have a personal investment in the health of their friends and neighbors.

  5. Richael, thank you for your thoughtful post, and for sharing your experiences with the Uganda Village Project – that is such a cool project, and it does a great job of illustrating your point. NGOs a valuable organizations which can have a huge impact on people’s lives, but they are inherently temporary aid structures, so if the work they do is not sustainable, then it can result in wasted effort and resources.

    And the issue of limited or ear-marked funding, which might be directed towards something a community does not need or want, is a serious issue. The whole process seems a bit hard to get right – you need to convince international donors that there is an issue and you have a solution, but then you enter a community and learn what the problem really is and work with that community to understand how best to help. If only there were more funders willing to give money for this assessment stage – or give donations with less specific attachments.

    I also wonder what role local governments could play in this situation. One thing that bothers me about the entire NGO model is the underlying assumption that the local government is unable or unwilling to solve the problem, so someone else needs to. It is certainly true that systematic inequalities already exist, and governmental structures might be disinclined to work against the grain when it comes to these inequalities. It is also a reality that bureaucracies move slower than organizations focused on a specific project, and also that corruption is a reality. But this assumption cannot be entirely true, and I wonder if donors directed money (even with specific expectations and modes of assessment) towards local governments working on similar projects as NGOs, if similar outcomes could not be achieved.

    1. Jacob,

      First, I agree that sustainability is key in nonprofit interventions. As much as I wish it was not the case, interventions are temporary and creating sustainable systems and behavior changes are the only way that any kind of meaningful change can be enacted.

      You bring up an excellent point, concerning the assumptions NGOs make about local governments. I believe it would be beneficial for NGOs to assume that local governments are willing and able to help promote the health of the nation. If, in fact, bureaucracy and corruption hinder this goal, then the NGO can focus its attention and resources elsewhere. Partnerships with local governments would help create sustainability, but is many times overlooked because NGOs assume the worst. Best case scenario, a strong partnership with the government is fostered and public funds are allocated towards, roads, clinics, medicine. If this does not work out, I believe that partnering with local business owners and other NGOs is a way allocate local funds to improving the health of the community.

  6. Hi Rachel, thank you for your insight and for sharing your experience in Uganda, I enjoyed reading about your experience!

    I would like to echo what my peers have said above and propose that a more consistent funding model would be for PIH to have a for-profit sector that is used to fund its own projects. A way in which PIH could generate profit could be through offering courses (at a fee) on best aid practices. Such courses would appeal to members of other, smaller NGOs and individuals who are about to go into the global health field.

    Although PIH’s work, such as the partnership with Harvard and the Rwandan Ministry of Health, is impressive, I do think that there are unforeseen consequences of their work. With the Rwandan Ministry of Health project, I worry that the Rwandan government will forge this idea that in order to implement structural change, they will always need capital from the West. I believe that PIH should look more towards initiating south to south collaborations which would ultimately allow governments in developing countries to be less reliant on western capital.

    1. Hi Pauline,

      You bring up a great point about depending on Western funds in order to improve overall health systems. However, I do believe that providing education and training, as seen in this model, is the best way to alleviate financial dependence. Foreign aid is necessary in times of political or economic turmoil, as seen in Rwanda, when the governments are not focused on allocating GDP to the country’s health systems. I believe that with rising GDP, as stated in McKeown hypothesis, and increased education, that dependence on Western aid will lessen with time.

  7. Hi Richael!

    Your work with the Uganda Village Project sounds great! To answer both of your questions in one statement, I think creating sustainability and constant funding comes through community empowerment. Empowering a community with the tools and knowledge they need to create a thriving and sustainable life is the only way that NGOs can be relied on less. Your example of the tippy taps is a great example. The intervention didn’t work at first because the community didn’t understand its importance, nor did they know how to fix it. In order to prevent an NGO from having to come in every time the tippy tap broke, community members learned about the importance of the tippy tap and also how to take care of it. Interventions like this and educating community members to be health care workers are all important in having the NGO create more sustainable change. Funding for the community health works should eventually come from the government or the community. A huge unintended consequence of this could be a brain drain. Educating community members could cause them to want to move to the cities or a different country to get more education or a great job. This could cause an intervention to fail, but one does not have the right to demand another person to stay. There has the be the right balance of education and community pride to make a person educated enough to help a community and empowered enough to stay in the community.

  8. Hey Richael! I really appreciated your blog post on Partners in Health, and the distinction you made in the beginning of your post regarding a ‘genuine desire to help’. I think it’s incredibly important to acknowledge the strong connection between having a true desire to make change, and being forced to help as part of some governmental program, etc. I additionally really appreciated the discussion of your time spent at the Uganda Village Project, which added considerable insight to an overall analysis on Partners in Health, and their approach in a rural area.

    Additionally, I think the partnerships you described are essential, especially between Harvard Medical School and Brigham and Women’s Hospital. In any global health project mindful of sustainability, lessening dependence on the NGO is definitely a strong move. Offering more opportunities at Universities and Medical Schools for individuals to get involved on an International level, without such a heavy research related component, could be something that’s helpful.

    I think, as seen in Idi’s story (I believe by Kleinman), I think it is a whole complex web of situations and encounters, perhaps a partnership between an NGO, a charismatic leader, and individuals from the community who truly believe in and understand the cause. In addition, I believe that strengthening relations between south-south partners is a fantastic way to, as Pauline said, “allow governments in developing countries to be less reliant on Western capital.”

  9. Hello Richael,

    Thank you for your post. I found your points to be quite interesting as you have personal experience with trying to alleviate some of the issues associated with solutions that perhaps are not working out to be as successful in the long run as they once were in the nascent stages of the implementation of a given intervention.

    Success of an effort is often measured in terms of financial sustainability, and for that reason I would like to address your first question. It is interesting how economics can play a role in the eventual outcome of a health program implemented by a nongovernmental organization, as the ability to secure funding from donors consistently is one way to ensure that processes that are successful in achieving a desirable outcome can continue to have an impact. Unfortunately, it often takes a great deal of funding before an intervention can reach the stage where it can signal its success rate to potential funders.

    One way to overcome this is through the establishment of a social enterprise. Outside funding sources could still contribute a large portion of funds towards a program, but establishing a social enterprise could instill a sense of commitment from a nation’s people because they are incentivized to ensure the success of a healthcare project.

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