Monday, March 16, 2009

Swiss Pediatrician's Foundation Helps Cambodia's Chikdren While Alienating International Public Health Experts

The Financial Times recently profiled Swiss pediatrician, Beat Richner, who has built five hospitals through his Kantha Bopha Foundation to provide free care to 85% of Cambodia's children.  Richner plays two cello concerts a week to help raise the $25 million needed to run the foundation that supports the hospitals.  Richner operates under a donor-reliant model, which aims for excellence over affordability, and his stance on Cambodia’s medical priorities have put him on a collision course with WHO and the NGO community.  One development consultant who works for the WHO in Cambodia explains: “My main concern is the sustainability of his operation. Richner is nothing if not an excellent fundraiser – he’s got a lot of charisma – but what happens when he dies? Who will raise the money then?”

Richner’s critics accuse him of failing to provide value for money by not making enough use of cheaper, generic drugs and by relying on the most expensive medical supplies.  Some NGOs also worrry that his focus on child medicine could divert resources and attention from other severe health challenges, such as the high rate of maternal mortality and HIV AIDs.  People within Cambodia’s NGO community are reluctant to speak publicly against Richner, for fear of escalating the clash. They also want to avoid generating adverse publicity at a time when Cambodia’s Prime Minister, Hun Sen, is pushing ahead with a new NGO law that some feel is designed to restrict their ability to operate in the country. 

According to the article, the received wisdom among international public health experts is that development aid is best spent on education and the provision of basic rural clinics. But Richner argues that all people have the same fundamental right to good healthcare. He characterizes the other approach as “poor medicine for poor people.” “When I got my first CT machine in Cambodia 10 years ago, there was an outcry from the WHO and UNICEF  They said it was stupid to spend so much money on this machine. But you need a CT scan to diagnose and treat TB.”

Richner's open antagonism to the mainstream NGO community is unhelpful, his critics argue. “He’s merely building up a host of enemies so the fact that no one wants to work with him becomes a self-fulfilling prophecy,” says the WHO consultant. “But there’s always a tension between innovators doing good things on a small scale and the more sluggish public health systems.”  Richner’s insistence that the Kantha Bopha Foundation remain independent of the public health system and his refusal to bow to the prevailing corruption in Cambodia has even led to his receiving death threats.  In 1995, the Health Ministry tried to close the first Kantha Bopha hospital because health officials and their international advisers believed it was undermining attempts to build a national health system. Only the personal intervention of the king saved it. In 2002, Richner threatened to close the foundation himself unless the health minister stopped criticizing his work.  The king eventually brought about another truce.  Relations with the Health Ministry have improved since then but the small amount of funding Richner receives from the Cambodian government is still paid directly to his foundation, bypassing the ministry.

Notably, no one disagrees that many of the children in intensive care at Richner’s hospitals would die without the treatment they receive there.  One in three Cambodians lives on less than $1 a day and medical expenses remain one of the biggest causes of poverty.

Since 1991, the Kantha Bopha foundation has raised and spent more than $370 million, with the vast majority of its funding coming from private donors, many of whom live in Switzerland. All five of Richner's hospitals constantly operate at capacity, with around 300 admissions of seriously ill children every day.  Meanwhile, Richner’s drive to cut the rate of transmission between HIV-infected mothers and their newborn children has met with huge success: the normal mother-to-child HIV transmission rate in Cambodia is 40%, but at Jayavarman VII Hospital they have reduced it to less than 5% by performing caesarean sections, treating the mother and child with anti-retroviral drugs and insisting that they stop breast-feeding.

Richner employs 2,100 people but spends just 5% of his annual budget on administration (his 180 doctors take a central role in running the hospitals; they earn about $1,000 a month compared with the $40 they would get from a state hospital). Richner imports all his drugs and medical supplies directly from Thailand to avoid the counterfeit pharmaceutical products flooding Cambodia. The head nurses personally distribute the medicines every day to ensure no thefts.

However, Richner only has five months’ funding left in the kitty and, unlike many charitable foundations, he has no endowments other than a commitment from the Swiss and Cambodian governments to each cover 8% of his annual budget. He spends everything he gets on new buildings, machinery, and drugs, as well as day-to-day expenses. In the past three years he has spent $34 million on new construction projects.  “The hospitals are working well and everything can continue without me, but the ongoing nightmare is the money," says Richner "I can only start to think of my [succession] plan when I get the money – this $200 million I need to save Kantha Bopha for 20 years. Then I will be a free man.”

It is this attitude that disturbs Richner’s critics at the WHO and other international health organizations in Cambodia. They have seen countless maverick humanitarians fall by the wayside when the funding for their donor-heavy projects ran out.

While the future of Kantha Bopha Foundation in Cambodia is far from secure, Richner still hopes to take his model to other damaged nations, such as the Democratic Republic of Congo and Burma. He is launching a new academy to train young pediatricians from Asia and Africa in his methods, so they can recreate what he has achieved in their own countries.


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