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

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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).


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.

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Jordan Pyda provided a portion of the study data from HBS. The Swiss Bundner Partnershaft HAS Haiti provides funding for the Social Service program at HAS.


Partners Healthcare Center of Expertise in Patient Quality and Safety.

Potential and real Conflict of interest

Rodolphe Jean-Louis is a staff surgeon at Hôpital Albert Schweitzer. Hamiltong Pierre is a staff surgeon at Zanmi Lasante and worked at Hôpital Bon Sauveur during the study period. Paul Farmer is a co-founder of Partners In Health/Zanmi Lasante and the Hôpital Bon Sauveur.

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Correspondence to Alexi C. Matousek.

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Matousek, A.C., Matousek, S.B., Addington, S.R. et al. The Struggle for Equity: An Examination of Surgical Services at Two NGO Hospitals in Rural Haiti. World J Surg 39, 2191–2197 (2015).

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