Dr. Paul Farmer and Philanthropy for Global Health
Dr. Paul Farmer and Philanthropy for Global Health
By: Maria Nardell, 5/16/2007
Wherever Dr. Paul Farmer goes, he attracts followers – readers of Tracy Kidder’s bestselling Farmer biography Mountains Beyond Mountains, students aspiring to careers in international health, professionals inspired by the work of Partners in Health, and those interested in ending disease and poverty on a global scale.
Farmer’s recent appearance at the NYU Reynolds Program in Social Entrepreneurship was no exception. In a packed room, Farmer spoke of some of the challenges and opportunities facing public health in the developing world as he has experienced them through Partners in Health (PIH), the global health organization he co-founded with Dr. Jim Kim in 1987. In particular, Farmer addressed three key issues relevant to philanthropy: cost-effectiveness, vertical versus lateral funding, and the role of universities in international health and development efforts.
“Religion of cost-effectiveness”
Few would dispute the merit of ensuring that precious funds are used wisely, that donors see the outcomes of their investments, and that economists keep an eye on the overall economic health of developing countries.
Yet Farmer did not hide his frustrations with the prevalent emphasis on cost-effectiveness in the discourse on public health and international development. He described “jumping through hoops” at an international public health conference in order to justify the high price of funding for AIDS programs, referencing to economists, for instance, the significant economic cost of losing mothers to AIDS. He’s also tired of hearing that “there’s no market” to procure drugs for the poor, or that treating the poor with a long course of pills is not a sustainable solution.
“Knock yourself out if you start wars, but if you’re doing good, be cheap,” Farmer parodied some international advisors, criticizing what he calls the “religion of cost-effectiveness.” When PIH started operating in Rwanda in 2005, the organization had to defend the cost of its corps of “accompagnateurs,” local community health workers employed by PIH to serve as paid counselors, educators, treatment providers, and advocates for patients. Yet, as Farmer indicated, accompagnateurs account for only 9.3% of labor costs and 4.2% of overall operating costs. More importantly, he argued, they have proven to be indispensable to the success of PIH efforts around the world; with their local familiarity, they can get to know their patients well, ensuring that patients take a full course of treatment.
In many cases, the issue of cost-effectiveness boils down to immediate care versus long-term economic growth. Take the free distribution of vaccinations. Many economists despair that liberally distributing vaccines through international aid collapses the local markets for vaccine, creating aid dependency and other problems because there is often no local system in place to sustain such public health interventions. Other strategists, Farmer included, feel that while long-term local growth is critical, caring for the patient at hand with whatever means possible should come first.
The trick, of course, is balancing short-term and long-term goals, and Farmer is clearly committed to local sustainability. To that end, he understands the importance of working not only with foundations and nonprofits, but also with local governments to build up local public health capacity. As he sees it, local government is a natural ally in any complex health intervention. When NGOs attempt to solve major health problems outside of the public health infrastructure, they not only risk alienating potential allies, but also miss valuable opportunities to assure sustainability when the project ends.
Riding the “chwal batay”
With vertical funding, donors direct their money toward one narrowly-defined cause with the goal of achieving a deep impact in that area. With lateral funding, donors support a broad set of programs or projects.
Donors, particularly foundations, tend to favor vertical funding as a way of providing dollar-for-dollar measurements to prove the effectiveness of the money spent. Nonprofits, however, can find it challenging to create grant proposals that focus closely on one problem without attending to the inter-related nature of so many social issues.
The irony of the rigid requirements for vertical grants, Farmer pointed out, is that vertical money often has unintended lateral effects. With its AIDS treatment programs, for example, PIH has seen benefits across the social spectrum, from poverty reduction to women’s health to job creation (such as the hundreds of previously unemployed or underemployed community health workers who work for PIH). There have also been benefits to the environment in terms of reforestation around PIH clinics; higher employment means fewer individuals need to cut down trees to make a living.
In Haiti, the site of PIH’s flagship project, there is a term for this phenomenon. Treating HIV/AIDS is not the end of the fight itself but rather the “chwal batay,” the battle horse to ride into the war on poverty. For philanthropy, the implication is that while vertical funding can be useful, the reality is that few issues can be neatly compartmentalized for the purposes of proposals and measurements – and that isn’t necessarily a bad thing. After all, when the sick get well, Farmer remarked, the next “ailments” he hears about include problems with family members, the lack of jobs, and the need for better schools.
The role of universities
Universities have long been involved in international health and development efforts, though mostly through teaching and research, with service-related projects comprising a much smaller slice of the funding pie. This system may work for the United States, but for universities in developing countries, Farmer noted, university-sponsored or affiliated service programs have to play a bigger role to meet the pressing demand for public health development in their own communities. Without a robust nonprofit sector, it is universities themselves who are positioned to apply their knowledge of public health and development to those who need it.
Even in the U.S., there has been an explosion in the number of students at all levels interested in global health issues. Universities have responded not only through related classes and research opportunities, but also through scholarships, funds, and other programs that encourage students to apply their interests and desire to help outside the classroom.
Of course clinical research is critically important. But developing countries, Farmer reminded his audience, do not invite western health care workers, economists, academics, and others in order to be objects of study; they want to improve their situations.
Farmer ended his talk by touching on market applications in the developing world – specifically the argument that the poor should pay for health care services to the extent that they can, in the belief that they will be more invested in their care if there is a monetary value attached to it. While Farmer is not necessarily opposed to the strategy in principle, he has not seen it work in his experience with the poorest of the poor. “Without sounding too Marxist about it,” Farmer said, his views are nonetheless rooted in the realities of his patients, who often have to choose between food for their children and money for even a token co-payment.
As a 2003 New York Times article commented, “No program to treat people in the poorest countries has more intrigued experts than the one started in Haiti by Partners in Health.”1 The packed room at NYU stands as a testament to the enduring interest that surrounds Dr. Farmer and his organization.