title: 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'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 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.
  
  
  RESULTS
  Patients from the rural service area received 306 operations (86·2%) at HAS compared with 149 (38·1%) at HBS (p<0·0001). Only 16 operations (4·5%) at HAS were performed on patients from outside the service area for elective conditions compared with 179 (47·0%) at HBS (p<0·0001). Within its rural service area, HAS performed fewer operations on patients from the most destitute areas compared with other locations (4·0 operations per 10 000 population vs 10·1 operations per 10 000 population; p<0·0001).
  
  
  CONCLUSIONS
  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.
  
  
  BACKGROUND
  None.
authors: The Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, MA, USA; The Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA, USA. Electronic address: amatousek@partners.org.
authors: Alexi C
authors: AC
authors: Matousek
authors: The Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, MA, USA.
authors: Stephen R
authors: SR
authors: Addington
authors: Hôpital Albert Schweitzer, Deschapelles, Haiti.
authors: Rodolphe R Eisenhower
authors: RR
authors: Jean-Louis
authors: Hôpital Bon Sauveur, Zanmi Lasante, Cange, Haiti.
authors: Jean Hamiltong
authors: JH
authors: Pierre
authors: The Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA, USA.
authors: Jacky
authors: J
authors: Fils
authors: The Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA, USA.
authors: Marguerite
authors: M
authors: Hoyler
authors: Boston University School of Public Health, Boston, MA, USA.
authors: Sarah B
authors: SB
authors: Matousek
authors: The Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA, USA.
authors: Jordan
authors: J
authors: Pyda
authors: The Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA, USA.
authors: Paul E
authors: PE
authors: Farmer
authors: The Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, MA, USA; The Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA, USA.
authors: Robert
authors: R
authors: Riviello