The struggle for equity: an examination of surgical services at two NGO hospitals in rural Haiti.

Abstract Background Health systems must deliver care equitably to serve the poor. Both L'Hopital Albert Schweitzer (HAS) and L'Hopital Bon Sauveur (HBS) have longstanding commitments to provide equitable surgical care in rural Haiti. HAS charges fees that reflect 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. Using geography as a proxy for poverty, we analysed the equity achieved under the financial system at both hospitals. Methods We retrospectively reviewed operative case-logs for general surgery and orthopaedic cases 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. The service areas were defined as the governmental administrative units closest to both hospitals. For HAS, we analysed the number of operations performed on patients from the most poor and least poor regions within the service area; similarly detailed geographic information was not available from HBS. Rates were compared with χ 2 tests. The Ethics Committees at both hospitals and the Institutional Review Board at Partners Healthcare approved the study. Findings Patients from the rural service area received 306 operations (86·2%) at HAS compared with 149 (38·1%) at HBS (p vs 10·1 operations per 10 000 population; p Interpretation Use of fees as part of an equity strategy will likely disadvantage the poorest patients, while providing care without fees might 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. Funding None.