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

18 thoughts on “Partners in Health and Promoting Community Development”

  1. Hey Hacheming,

    I appreciate how you addressed the shortcomings of the Partners in Health (PIH) model in certain cases like its intervention in the Ebola outbreak in Sierra Leone, even though PIH is often cited as the leader in global health.

    Considering PIH had never responded to an emergency medical situation before the Ebola outbreak, I think that the organization should have spent more time in the assessment and design stages of their program before moving forward with their implementation of the program. They should have first assessed the safety equipment provided by the government of Sierra Leone to make sure that the health workers would be safe from infection. They should have clarified how the waste would be disposed of properly as well as how to wear (and remove) the protective equipment, so as to avoid transmission of disease. They should also have taken more time to structure the program so that the leadership was not ambiguous for the health workers. Although PIH supposedly worked with the government, health workers in the program asserted that there seemed to be a divide and that there seemed to be “two different systems” rather than a unified leadership, leading to a lack of consistency (Fink, 2015). This makes for muddy waters, since there is no clear coordination of efforts between PIH and the Sierra Leonean government.

    Of course, all of these assessment and evaluative stages would have delayed action to treat Ebola-infected patients and would probably have led to more infected persons and more mortality, but they are necessary steps. Considering Doctors Without Borders and other organizations were also there to help, I think PIH could have spent some more time taking the aforementioned precautions to make sure their intervention would run smoothly.

    I think that it was a good idea for PIH to partner with the Sierra Leonean government, but the leadership aspect could have been handled in a more organized fashion. One of the facets of the PIH model is to work with the government to improve the public sector, taking a more horizontal approach to increase health care for all socioeconomic classes. PIH probably intended to do this, but the shortcomings of not checking the equipment for safety hindered this from happening.

    I think there should have been more interaction between the organization and government. Ms. Sheila Davis, who lead the Ebola response for PIH, points out that the Ministry of Health decided whether or not the facility was open. Rather than leaving the situation completely up to the Ministry of Health, PIH could have negotiated with the ministry to decide in what situations the facility should be closed (e.g., when health risks of using the facility were identified). I think there could have been clearer delineation of responsibilities in the program by delegating separate tasks to the government and to PIH workers, while sharing the same overall goal of treating Ebola patients while protecting the safety of health workers, so that there is no confusion of leadership.

    1. Hi Yuki,
      Thank you for your thoughtful comment! You broought up some really good ways PIH could have improved their response to Ebola. I definietly agree with you on all points. PIH needed more time to correctly assess the situation especially because ublike groups like MSF aren’t known for working in zones in immediate crisis. More attention should have been taken on appropriate safety precautions and hopefully this doesn’t stop them from attempting another intervention.

  2. Hi Hacheming,
    I also posted a blog for this topic, and mine also raised this issue of whether the life of a foreign NGO worker is more valuable than that of a community health volunteer. What is obvious is that both players are critical for the success of PIH — so, as you asked, why did the foreign worker receive better care than the other?
    Well I’ve been thinking a lot about this issue, and I think it stems down to 1) An inherent hierarchical nature in NGO work and 2) The fact that work is being done in a generally resource-poor setting. Since I talk about the first point in my blog post, I’ll just focus on the second. I think the issue is that NGOs, at the end of the day, depend on resources — namely finances. Because these finances are limited and are being brought INTO the country that is receiving aid, I think that there is this difficult choice NGOs are FORCED to make in the face of a crisis (like contracting Ebola): Who should the limited resources go to, a foreign worker or a community health worker? I think ideally, PIH wants to provide equal care to both, but with limited resources, they have to make a choice — most often the former…
    How do you think we can fix this/Should it be fixed so that the resources are directed to the community health workers?

    1. Hi Nini, you brouht up some very good questions. I definietly think that equality is something to strive for even though in these low-resource settings it is definitely much harder to achieve. PIH has made community health workers a staple part of most of their intervention efforts and I definitely believe they should have the same access to treatment as non-local health workers. This would require more funding and resources but as was pointed out in lecture, Paul Farmer doesn’t seem to believe in cost-effectiveness. Thank you for your thoughful comment.

  3. Hi Hacheming,

    Thank you for your thoughtful post. I appreciate how you addressed the issues seen with PIH.

    For your first question, I believe that there should have been more assessment action taken before implementation of the program occurred. A major issue with the Sierra Leon case was the infection of health workers. More at ions should have been taken in checking the healthcare equipment and other factors that would keep the health care workers safe from infection. Actions for this could have been taken also with PIH’s relationship with the Sierra Leon government. It is vitally important to have a partnership with the government in place however, even if the relationship is a good one it is still important to really check all the supplies and process offered from the government. the supplies provided by the government should have been given a closer look. If this had happened, infection of the health care workers could have ben drastically decreased.

    Ideally I think that in the relationships with PIH and the government of the areas in need need to be more facilitated. There needs to be trust but there also must be a critical eye that can look point out potential issues with resources and policies that are in place during a time of crisis.

    1. Hi Sarah,
      Thank you for your comment, you definitely brought up some really interesting points. I agree that PIH should have taken more safety precautions regarding there equipment and that it would have made a difference in their intervention effort. PIH has prided itself on fostering community relationships and this has been greatly successful dring their other interventions. Developing a relationship with the government during the Ebola crisis definitely is important, but I do think that there needed to be organization to reduce confusion.

  4. Hi Hacheming! You did a good job addressing both the strengths and weaknesses of the PIH model. In class, we have viewed this as the ideal, but it is important to still be critical and look for ways in which it can be improved. For your first question, Ebola in Sierra Leone was a unique case because it was one of the most crisis-like situations addressed by PIH. This is not to say that their other work, such as AIDS and tuberculosis treatment in Haiti and Rwanda, is not urgent and needed. However, because of the nature and speed of the spread of Ebola, I think it is different from other global health problems that PIH has worked on, and this is likely why greater challenges were faced. However, it is disappointing that an organization that is driven to protect human life was not able to put an equal value on the lives of their workers. This problem goes deeper than the framework of PIH and ties back in with previous discussions we have had about the value of life. While clearly they were not intending for either worker to become ill, I think there is an obligation to value all workers and volunteers as high as possible and provide with the best care available, which was not done for the local volunteer. This is an area PIH should look into for improving future disease outbreak interventions.

    1. Hi Leah
      Thanks for your comment! I definitely agree with you that it is important o distinguish the difference between PIH’s intervention in crisis zones like Sierra Leone, and their interventions in Haiti and Rwanda where there wasn’t an immediate crisis-like situation. Prehaps this why PIH might need to adjust it’s model to be more apporiate in such a dfferent situation than it usually intervenes in.

  5. Hello Hacheming,
    I thought you brought a poignant point about this hierarchy of healthcare treatment. I find it particularly interesting that the PIH model of “preferential treatment for the poor” does not play out when we consider the treatment of healthcare workers. I think that perhaps this exceptional treatment of health workers is even more obvious in emergency situations (such as in Sierra Leone) where immediate attention is given to the most privileged health worker, which more often than not is the foreign aid worker. However, although morally dubious, I think preferential treatment is inherent in health work in general. Even in the U.S., there is a dichotomy not only between provider and patient, but also a hierarchy of health care workers—for instant physicians and nurse practitioners. So even if we argue that nurse practitioners are vital and valuable for an efficient and sustainable health care system, doctors will have inherent preferential authority. In the same way, even if community health works are valued as sustainable members in a developing health care setting, foreign medical professionals have inherent power. Conceivably, this is due to knowledge as power and the assumption that foreign workers/doctors are the “teachers” or “experts” in the health care setting.

    Nonetheless, I don’t think the exceptional treatment of health workers is the main problem; after all infection of the health workers was the consequence of a larger problem. The problem was inefficient regulation of personal protective equipment. In order to avoid a repeat of the case in Sierra Leone, PIH needs stronger protocols and standardized checks that ensure that the government health agencies are running according to PIH safety protocols before complete trust is given to that agency.

    1. Hi Nikisha,
      Thanks for you comment, you brught up some really good points about the hierarchy that exsists in systems of health. The comparison you brought up regarding doctors and nurse is a very interesting one. The training and qualifications of foreigner aid workers are usually higher than local health workers, I’m probably just being optimistic, but I would hope that an effort would made give equal care to both foreign and local health workers.

  6. Hi Hacheming, thank you for a thoughtful post! I really appreciated your critique of PIH as although it is often exemplified as the ideal NGO, this might not be the case. I think that ultimately the reason why the health worker from Sierra Leone received disparate treatment was because PIH falsely was under the impression that they weren’t as accountable to the Sierra Leonean as they were to the PIH worker. Prior to launching themselves into the crisis, PIH should have been very explicit with the Ministry of Health on what exactly this partnership would entail. As soon as there is a grey area, in a situation as dire as two health workers contracting Ebola, the one that isn’t directly the PIH worker is going to be seen as the responsibility of the Sierra Leonean government, even if this may not be the case. If PIH had explicitly stated that they were only accountable to its own health workers if they were to contract Ebola, perhaps prior to forming the partnership the Ministry of Health would have stated that a condition of the partnership would be that all health workers- directly PIH employed or not – are under the responsibility of PIH. Yet the Ministry of Health was never given the opportunity to leverage this very important aspect of the partnership in the first place.

    1. Hi Pauline,
      Thanks for your comment! I defineitely agreee with you, there needed to be more clarity between PIH and the Ministry of Health. The lack of organization between the two groups caused a lot of confusion and allowed an unsafe situation to occur and for these two health workers to contract Ebola.

  7. Hacheming, your post and follow-up questions are astute. I agree that the situation in Sierra Leone may have been unique, and requiring differing methods.

    One idea I have is that when it comes to responding and treating an acute and resource-intensive infectious disease like Ebola, efforts to respond to the disease and efforts to train healthcare workers and build infrastructure might need to be separate. While both are important, PIH has demonstrated that with limited manpower they have the capacity to train a significant amount of healthcare workers in a specialized manner, and I think this could have been incredibly helpful in Sierra Leone, and different from the treatment-based approach of MSF and other organizations. However, the acute treatment center that PIH oversaw might not have been the place to do that, or at least, a clearer organizational structure would have been needed.

    Perhaps, to answer both questions at once, PIH could have provided resources and providers to supplement the efforts being undergone by the local government and system in place already, but made it clear that management of the facility and treatment of the patients was under the local ordinances’ control. Then, PIH could have focused its efforts on what it does best – the training of healthcare workers and expanding of systematic capacity.

  8. Hey Hacheming,

    Thanks for your post! Like many others have pointed out it is interesting to see Partners in Health’s shortcoming being analyzed because it kinda goes with the idea that even when your intentions are very good you have well though out model there are going to be situations that arise that cause conflict.
    Your questions were also very thought-provoking. I believe that there was not enough involvement of the government, or at least not enough unity, and understanding between PIH and the government of Sierra Leone and that was in essence a large part of the problems that arose as there was not consensus onto who the responsibility should fall. I by no means believe this be an easy task however. I am well aware of the challenges, but there should have been more resources dedicated to trying to set up this equal partnership.

  9. Hey Hacheming! Thanks for your genuine and on-point response to the topic of Partner’s in Health, specifically coupled with the Sierra Leone example. The most poignant question, of course, is that of “Is the life of a foreign NGO worker more valuable than a health worker?” In the context of any International Organization, due to structural hierarchy and vast displacement of knowledge, I think they are perceived to be. Some may say that there is only one Paul Farmer, but many community health workers who can be trained by him — and not necessarily the other way around.

    Additionally, throughout your response, I couldn’t help but wonder if Merton had gotten it all right. In his article, “The Unanticipated Consequences of Purposive Social Action”, he warns readers of rigidity of habit, essentially not falling victim to our past successes, and basing all of our work off of that. Though PIH had serious successes in both Haiti and Rwanda (focusing on tuberculosis and AIDS), Ebola is a different kind of crisis — and I believe PIH needed to adapt their model to the current situation in a more effective way. Additionally, PIH was trying to do too much. A major focus needed to be, as others have stated, stronger protocols and equipment regulation checks that make sure agencies are up to par with PIH protocol.

  10. Hi Hacheming,

    Thank you for your post – it was very informative and insightful. You highlight many of the consequences and negative aspects of the Partners In Health model, which proved to be very interesting as we mostly studied the positive aspects of this model.
    To answer your question, I think it would be beneficial if PIH took a diagonal approach. By combining both horizontal and vertical approaches, PIH can aim to treat not only individuals, but also the society as a whole. It would’ve been beneficial if PIH examined potential unintended consequences that the health workers may face, and therefore prevent such issues from occurring.
    As part of your second question, I think it would be very effective if PIH formed equal partnerships with governments. On top of this, having a charismatic leader in places such as Haiti and Sierra Leone may prove to be effective (as we have seen in other parts of the world). They can form these partnerships by proposing potential plans for restructuring, and allowing those local governments to add input/ideas into policies and the plans.

  11. Hello Hacheming!

    Thank you for your insightful post. It goes to show that sometimes even seasoned organizations like PIH can get things wrong. Like the comments before mine suggest, I think the reason why PIH encountered problems in Sierra Leone was due to the lack of protocols and that with more planning they could have avoided the situation they found themselves in. Medical emergencies in the context of disease outbreaks present very unique circumstances that PIH was not necessarily geared for in Sierra Leone. Also, the situation called for a lot of adaptive measures and while the PIH model of collaboration with local governments is fantastic for creating sustainable institutions of healthcare, it isn’t the most effective in short term scenarios as the nature of bureaucracy necessities patient communication and a clear delineation of responsibilities. I remember discussing this case study in section and the group I was a part of felt that it might’ve been best for PIH, under those circumstances to mount an emergency response that was independent and once the emergency was over, bring the local governments and NGOs into the picture and lay the groundwork for a sustainable response system. The flipside to this argument of course, is that some emergencies last for a long time and that no local involvement can mean that in the case of a re-emergence, the situation proves to be novel for the first-responders and therefore repeats itself all over again.

    Perhaps another avenue could have been for PIH to dedicate most of its efforts towards working with the local governments and communities to develop a sustainable system to deal with Ebola and similar diseases while letting other emergency response organizations like MSF deal with the medical response. As we have seen countless times, unanticipated consequences follow any action and though we now have the privilege of hindsight, it is very difficult to say in the moment what might become of a certain plan of action.

  12. Hi Hacheming,
    You did a great job acknowledging how PIH is doing great work because of its attempt to acknowledge the “bios” of people, while simultaneously showing how PIH is prey to many of the same health intervention challenges we criticize other NGOs for. Like make other commenters have said, treating the Ebola outbreak in Sierra Leone was a very unique situation for PIH, but I think they did the right thing by beginning to provide treatment as soon as they could. I think PIH’s greatest flaw in that situation was not closely monitoring the unanticipated consequences that were arising from their health intervention. Like Stefanie brought up, PIH may have been too set in their ways of past success to question certain fundamental tenets of their intervention. They were then unable to take action on the issue that in this circumstance partnering with the local government was having the unanticipated consequence of putting their health workers in added jeopardy. On the whole though, I think they took the right initial approach and only took too long to modify their treatment plan based on local conditions.

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