The Struggle for Equity: An Examination of Surgical Services at Two NGO Hospitals in Rural Haiti

Alexi C. Matousek, Sarah B. Matousek, Stephen R. Addington, Rodolphe Jean‐Louis, Jean Hamiltong Pierre, Jacky Fils, Marguerite Hoyler, Paul E. Farmer, Robert Riviello

Health systems must deliver care equitably in order to serve the poor. Both L'Hôpital Albert Schweitzer (HAS) and L'Hôpital Bon Sauveur (HBS) have longstanding commitments to provide equitable surgical care in rural Haiti. HAS charges fees that demonstrate a preference for the rural population near the hospital, with free care available for the poorest. HBS does not charge fees. The two hospitals are otherwise similar in surgical capacity and rural location. We retrospectively reviewed operative case-logs at both hospitals from June 1 to Aug 31, 2012. The records were compared by total number of operations, geographic distribution of patients and number of elective operations. Using geography as a proxy for poverty, we analyzed the equity achieved under the financial systems at both hospitals. Patients from the rural service area received 86 % of operations at HAS compared to 38 % at HBS (p < 0.001). Only 5 % of all operations at HAS were performed on patients from outside the service area for elective conditions compared to 47 % at HBS (p < 0.001). Within its rural service area, HAS performed fewer operations on patients from the most destitute areas compared to other locations (40.3 vs. 101.3 operations/100,000 population, p < 0.001) to conform to international reporting standards of cases per 100,000 population rather than per 10,000 population. Using fees as part of an equity strategy will likely disadvantage the poorest patients, while providing care without fees may encourage patients to travel from urban areas that contain other hospitals. Health systems striving to serve the poor should continually evaluate and seek to improve equity, even within systems that provide free care.