Partners in Health

By Sarah Fort and Rachel Leven

November 30, 2006

While still in medical school at Harvard University in 1987, Drs. Paul Farmer and Jim Yong Kim helped found Partners in Health (PIH) with real estate developer Thomas J. White, friend Todd McCormack, and current organization head Ophelia Dahl.

Kim and Farmer are well-known names in public health: They were independently awarded MacArthur Foundation Fellowships, nicknamed "genius grants." Kim recently returned to PIH after a stint as the director of the World Health Organization's HIV/AIDS Division.

PIH is based in Boston and has sister organizations in Haiti, Latin America, Russia and Africa. In addition to running programs, its Boston headquarters also raises money to support programs around the world. The organization has maintained longstanding alliances with Harvard Medical School and Brigham and Women's Hospital, one of the university's teaching hospitals.

Zanmi Lasante (Creole for "Partners in Health"), PIH's sister organization in Haiti, partners with other nongovernmental organizations (NGOs) and the Haitian Ministry of Health. Zanmi Lasante is the only provider of comprehensive primary health care for the Haiti's Central Plateau, an impoverished and largely rural state located a few hours from the capital city of Port-au-Prince.

According to Ted Constan, PIH vice president for program management, focusing on HIV and other infectious diseases such as tuberculosis, is the organization's way of addressing public health care for the poor.

"Health is just health, and then infectious disease is just our way into that fight," said Constan. "We will ride that battle horse into the fight against poverty, but our goal is poverty reduction and to bring communities out of despair into what we often call a virtuous social cycle where they can lift themselves up and take care of themselves."

Constan said the starting points for providing primary care in any community are testing and treatment for HIV and TB, as well as sexually transmitted disease and maternal health (prenatal and post-natal care) programs. Two of PIH's additional concerns in Africa since 2005 have been malaria and nutrition.

Finances

Early on, PIH was dependent upon White's personal wealth. As funding from White and a major grant from the Bill and Melinda Gates Foundation concluded, PIH diversified its sources. Small donations from individual donors increased, and PIH now receives about a third of its budget from government funding. In recent years, its annual funding has grown to about $20 million.

PIH's AIDS program is supported by the Global Fund to Fight AIDS, Tuberculosis and Malaria and the President's Emergency Plan for AIDS Relief (PEPFAR). The Global Fund grant, which started in 2002, has provided the organization with a little more than $2 million a year for its work in Rwanda and Haiti. In addition, PIH is receiving funding for its work in Rwanda and Lesotho from the Clinton Foundation.

According to Constan, PIH has received about $7 million from PEPFAR over the past three years for its work in Haiti through the Centers for Disease Control and Prevention. About 30 percent of PIH's total revenue in 2005 came from PEPFAR and the Global Fund.

Poverty

In 1988, PIH became the first organization in the world to provide antiretroviral treatment for HIV in resource-poor settings. The international community had feared that providing ART in such places would be inefficient and possibly dangerous because new strains of HIV resistant to the leading drugs could develop from inconsistent treatment.

However, PIH proved that its community-oriented approach could provide both consistent and efficient care. Zanmi Lasante's clinics even stayed open during the violence and chaos that followed the February 2004 coup that ousted Haitian President Jean-Bertrand Aristide. Part of the reason no AIDS patient went without medicine during that time was because of PIH's personal and localized system.

PIH's model of serving the poor includes using accompagnateurs (community health workers) as the backbone of the treatment and care programs. The accompagnateur is a neighbor or a community member who is respected, said Constan, and the person's primary responsibility is "to do what's referred to as 'DOT,' directly observed therapy."

"It's basically going house to house on a day-to-day basis with a bag of medicines and administering, helping, seeing the person take the dose," he said.

Treatment

Partners in Health's hospital in Cange provides some of the most advanced care and services in Haiti. Wealthy patients from Port-au-Prince often will make the drive of several hours in order to be treated there. (Photo by Guy-Claude Jean-Baptiste Jr.)

As a result of PEPFAR restrictions that all drugs purchased with its funding must first be approved by the U.S. Food and Drug Administration, Partners in Health takes PEPFAR money for only certain parts of its HIV programs, such as care, covering operating expenses and paying the salaries of doctors and accompagnateurs. PIH gets it treatment funding largely from the Global Fund, which does not bar the purchase of less-expensive generic drugs — thus allowing more people to be put on treatment more quickly.

"We just simply will not buy drugs that cost more money. We will not waste money [if] there is an acceptable cheaper alternative," Constan said. "How [the FDA restriction] impacts the average program out there in the world whose only source of money is PEPFAR, is probably very difficult, and they're treating fewer patients and doing less for those patients than they would like."

Dr. Cruff Renard, who works with PIH in the Haitian Central Plateau town of Thomonde, explained that PIH has bought generic drugs from different organizations through different alternative sources of funding. He said the PEPFAR restriction requiring drugs' FDA approval "was a big problem for us" in the beginning.

"You know, we are a poor country," Renard said.

Partners in Health's goal is to serve the most disadvantaged and to prove that those who live in poor communities should receive care equal to that of anyone, anywhere in the world.

"I think [PIH] is the best thing that has happened for the disadvantaged in the world, because I think it really gave them the respect that they deserved," said Ellen Powers, the executive director of a Haitian healthcare organization Project Medishare.

"For so many years people said, 'Well look, they're uneducated. They don't deserve access to that kind of expensive medicine,'" Powers said. "I think Paul [Farmer] obviously proved them wrong."