Saturday, August 26, 2006

Partners in Health: Doing Whatever It Takes to Provide a Preferential Option for the Poor


After working with struggling clinics and underresourced hospitals for the last 2 months, we finally had the opportunity to see things done right at the Partners in Health Rwinkwavu Hospital in Rwanda. Dr. Paul Farmer has been a champion for health and human rights for the poor and has changed the world's view on providing quality medical care in impoverished areas through his work in Haiti and Peru over the past 20 years. As he became renowned for his work in these areas, the Rwandan government challenged his organization to see if their model could work in sub-Saharan Africa. Rumor has it that the government suggested Dr. Farmer work in one of their marginally struggling areas and he refused, telling them he would prefer to work in the most impoverished area they could find for him, which is how PIH ended up in Rwinkwavu.

The center in Rwinkwavu is an oasis in a valley wrought with rural poverty. PIH has worked hand in hand with the Rwandan government to renovate the old rundown Rwinkwavu Hospital to establish a government facility run through the PIH model. The PIH model is to do whatever it takes to provide the poor with a preferential option with regards to health care. This mindset shows through in everything they do.

ARVs are just the beginning of their HIV program. Patients are tested and receive their ARVs and counseling in groups, in order to give them a source of support throughout their therapy. Each patient on chronic therapy is assigned an accompanateur, a community member paid by PIH to help them monitor and directly observe the adminsitration of their medication. Recognizing that proper nutrition is as important as ARVs or anti-TB drugs, and that one is worthless without the other, each patient receives food throughout their therapy. In some cases, this may be for life. Social workers make home visits to ensure that therapy is progressing effectively, as well as to assess the home and family situation. With HIV and TB, all family members are brought in to the center for testing. If home conditions are inadequate and contributing to their health problems, PIH will simply build them a new house. Recognizing that many patients weak with HIV cannot endure rigorous agricultural labor during therapy, which is often the only available source of income, PIH will hire patients to work at the facility. When you look around at the gardeners, maintenance crew, and food preparation staff you can see how PIH has enveloped their patients and community into their team.

Another problem that we had encountered so frequently and felt so helpless against was malnutrition amongst children. PIH attacks this problem directly by dedicating a special malnutrition program to those children who are failing to thrive. Those deemed severely malnourished receive intensive inpatient feeding, which may last weeks to months. Those with milder malnutrition, as well as those who have succeeded in the inpatient program, go through an outpatient program. Their parents receive education on proper nutrition, as well as instruction in the PIH gardens on how to grow more nutritious high protein crops, such as beans. Home visits ensure that the children are growing properly, and deliver food and formula where needed.

PIH sees no patient as noncompliant, sees no obstacle as unsolvable, and sees no task as insignificant scut work. If a patient is not receiving correct care, they will do anything and everything in their power to find a way to make it work. A good illustration of this is the registration of their paitents on the progressive Rwandan government medical insurance plan. It costs only ~$2/year and covers most medical care, yet the majority of their patients were not registered for it. Instead of looking from afar and calling the program a failure, PIH's on the ground approach went directly to the people to uncover the obstacles to their registration. What they found was that the requirement of a photo for identification was the barrier keeping most of their patients from receiving this service. A PIH-er, Luke, took it upon himself to spend his summer going from house to house in the area taking pictures of community members with a digital camera and walking them through the registration process. This simple intervention has greatly increased the number of insured patients in the Rwinkwavu area, and is a great illustration of PIHs relentless dedication to the poor they serve.

Through this Rwandan health center, Dr. Farmer has proven once again that the PIH model works. When people raise arguments of reproducibility or cost-effectiveness, PIH can fall back on the fact that they have done everything possible for every patient that walks through their door. And no one can argue with that.

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