- + How is it possible that you can provide an open heart surgery in Iraq for less than $1,000? Is that the full cost?
The “less than $1k” numbers we routinely publish represent the amount in “program costs” (such as airfare and surgical labor) we spend from our international donor money. The figure does not account for every single management, overhead, or fundraising expense.
Our total expenditures in 2012 were $1,581,054. We performed 184 operations and provided 13,690 hours of training. The total cost per operation was $8,592.68.
However, our Remedy Mission partners—including the Iraqi government, medical companies that donate medicines and supplies, and local organizations—subsidize nearly 85% of the total cost of a single Remedy Mission. International donor support provides the final 15-20%.
- + Does my donation really make a difference? Especially if there is a large portion funded locally by those inside Iraq?
Yes, we absolutely depend on your donations. There is not a single site across Iraq for which our Remedy Missions are fully funded in advance of the mission. Even though “nearly 85%” is funded locally, without the final 15-20%, Remedy Missions fail; surgeons and nurses do not get trained regularly; on-site audits from our international medical teams do not occur; up to 20 children, per mission, are delayed from receiving surgery; and a few may even die or become inoperable.
Your role is critical. Each Remedy Mission requires funding for plane tickets, medical supplies, and other aspects necessary to proceed—and without enough, the mission cannot happen. Ultimately, our goal is for our local programs to no longer require international funding by 2015.
- + Are there any costs that are not tracked or reported?
Our numbers per Remedy Mission do not account for “indirect costs,” such as the cost (or value) of our volunteer medical staff from around the world, costs to local healthcare systems, the cost of a family to travel to the surgery site, the opportunity costs of lost income for families as they wait for surgery, etc. The reason we think it is important to note this here is because saving lives is actually quite difficult. Building a pediatric cardiac surgery system for the entire country of Iraq is laborious and full of complexities.
- + How can I be sure that Preemptive Love Coalition needs more funding, that I am not paying into some huge savings account, or “rainy day fund”?
For the record, we are skeptical of non-profits as well.
We celebrate the fact that the Iraqi government pays (on average) 85% of all the programmatic costs associated with our Remedy Missions.
However, our work is still 15-20% under-funded. Until we can successfully build in all programmatic costs into our contracts with Iraqi government, we will continue to require funding from international partners.
In addition to programmatic shortfalls, Iraqi law and the inevitably long repayment cycles in each of our provincial partnerships across the country require PLC to retain approximately six months of working capital to fulfill all of our programmatic and administrative obligations. As we continue to expand services, our target working capital is approximately $1.5 million to cover our daily cash flow needs.
Lastly, we have forgone multiple requests from around the country to expand the impact of our operations. Our inability to expand any further comes, in part, from the lack of dedicated growth capital with which to make enterprise-level investments.
For all these reasons, we are still hundreds of thousands of dollars under-funded.
Feel free to view our Financial Reports for more details.
- + What prevents more Remedy Missions—the lack of volunteer surgeons or the lack of funding?
The lack of funding. We have never failed to run a mission for lack of personnel. We have only cancelled or turned down a request for a future mission due to lack of funding.
Our model does not rely strictly on volunteers because the level of need in Iraq outstrips what we could reasonably supply through volunteer labor alone. Accordingly, we set our budgets so as to actually contract the international surgical and nursing staff we need to accomplish our mission. Sure, this increases the cost-per-mission (and thereby cost-per-child) over early “mission” models that idealized volunteerism and did not necessarily prioritize training. But our contract labor + volunteerism model is inarguably the only way to create a nationwide training program inside Iraq with international experts across multiple sites.
- + How much do you spend each year on “program” expenses and how much is spent on “overhead?”
As a rule, we do not adhere to the view that “overhead” is bad and “program” is good. There are very bad program expenses. There are overhead expenses that are excellent investments. We agree with Paul Brest, president of the Hewlett Foundation, who says, “Achieving a low overhead ratio drives many charities to behaviors that make them less effective and means more, not less, wasted dollars.”
Therefore, we spend as much on overhead as we need to accomplish our mission. The mission itself is our guide rather than arbitrary (even harmful) standards about overhead vs. program expenditures. For the record, however, a current pie chart of our expenditures is available (and, if you’re into that sort of thing, you’ll be very impressed!).
Charity Navigator, Better Business Bureau, and GuideStar released a letter on the myth of low overhead which can be viewed here.
- + How can I donate?
Click here to visit our donations page.
- + What is the major obstacle to establishing fully functioning pediatric heart hospitals across the country?
People often assume that the biggest need is more Iraqi heart surgeons. We could use a few more, but the real obstacle is skilled nurses, technicians, and non-surgical physicians. A surgeon is only as good as his support staff. One of our biggest challenges is training pediatric cardiac intensive care nurses.
The combination of our quarterly Remedy Missions and the year-round training program we’ve forged with the International Children’s Heart Foundation is (in our opinion) one of the most robust training regimens imaginable for a country’s surgical development. Rather than exporting the nurses to Europe or the U.S. (whose medical systems barely resemble the Iraqi system) for training, we train them in their local environment. These in-country training programs will hopefully decrease this obstacle.
- + Many heart surgeries require follow-up treatment (including additional surgeries). Do you have a way of providing this treatment to patients?
Yes, we do. Our model assumes quarterly visits to each program site (a hospital inside a regional hub). Our reliance on local cardiologists ensures that the local team prioritizes and almost entirely sets the agenda for patient selection (within development curricula)—after all, Iraqi doctors are the ones who are most intimately connected to the patients and their daily progress.
When a local cardiologist sees a child who has either (1) deteriorated and requires another intervention or (2) advanced as expected to the next step of a complex, staged intervention, the cardiologist prioritizes the child for follow-up treatment.
- + How do you assess whether or not surgeries are completed competently?
Because PLC plays both an administrative and financial role in the coalition of partners working in Iraq to develop pediatric cardiac care, we stand in between the local surgical team and the international surgical team (whom we contract to train and perform surgeries in Iraq). The checks-and-balance between the two teams, which have their own political and philosophical concerns driving their decisions, helps create a healthy tension and balance, ensuring safety and competency for all surgeries.
When the local team or health directorate has suspected a poor judgement call or overly liberal approach to surgical risk, we have acted as go-between, advocating on behalf of the local healthcare providers with the international surgical team. Similarly, if the international surgical team feels pushed by the local surgical team to perform procedures with which they are uncomfortable or for which they think the local system is ill-prepared, the international medical team will simply refuse children for surgery and/or use PLC as an advance communicator regarding child selection and surgical risk.
- + How do you assess whether or not local surgeons are performing surgeries they would have been unable to perform without your training and funds?
In every location where we work, pediatric heart surgery is effectively non-existent. There are only two active programs—one in Erbil and one in Baghdad—for relatively simple surgeries. Local surgeons are unable to keep up against an annual increase of nearly 11,000 children born with congenital heart defects (of which roughly half are likely to require surgery). Therefore, every surgery performed at our program sites (both when we are present and when we are not) are surgeries they would not have had the skill to perform without the funding we employed to train them in their local environment.
- + How do you assess whether or not surgeons are charging their patients for the surgeries you fund?
This is not a problem. We work in public (government) hospitals—and because healthcare in Iraq is provided almost entirely free of charge—it is widely known that any cardiologist, surgeon, or administrator seeking compensation for services is acting outside of Iraqi law.
- + Do you follow up with the surgeons you have trained to assess whether or not they are correctly applying their training?
Yes—our international medical partners see them quarterly in their local environment and perform real-time audits of their skills, recollection of past training, and application of new techniques. Additionally, our international physicians remain on call at any time via phone, Skype, or email for consultation.
- + How do you measure success for both the surgical and the overall missions?
We gauge long-term success by the movement of local hospitals toward self- sufficiency—which brings us closer to our exit strategy. We measure short-term success by the increase in children receiving surgery, the increase of medical staff receiving training, and the increase in funding provided by local Iraqi groups. Reports are produced after each Remedy Mission detailing the trip, including data on the relative complexity of surgeries performed as well as annual mortality reports.
- + What information is available on the activities and competence of the surgeons who have been trained?
Due to the young age of our Remedy Mission and Fellowship programs, there is still relatively little independent practice to report, and therefore little data on the activities and competence of our surgeons and their teams. The majority of our surgeons have not yet completed their training, as it is multi-year in nature. Therefore, many programs still do not practice independent surgery without our assistance.
- + Where do surgeons work after completing training? Do they serve poor patients?
As of 2013, only one private hospital in Iraq (to our knowledge) provided pediatric heart surgery (and that hospital is actually only semi-private and provides surgeries that are on the lower end of the complexity scale). Our work does not necessarily mean to exclude private hospitals, as they continue to become viable options, but at present the public, government system has a better equipped foundation for training local surgical teams.
As we look to fully graduate our local surgical teams by 2020, we imagine most of them will stay in the public sector for all of the stability, pensions, and benefits of loyalty provided to those who stick with it. But, undoubtedly, some will seek positions at private hospitals (assuming private hospitals are willing to invest in the requisite capital purchases necessary to establish a credible program). In the public sector, rich and poor are served alike. In the private sector (which barely exists), poorer patients would be at an obvious disadvantage.