INGO Capstone Paper 2014 Sarah DeCloux 7/11/2014 Webster University Francois Rubio

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Introduction:

Many developing countries have reported that while NGO assistance may have

good intentions, often their efforts undermine and contribute to the unsuccessful

implementation of government run public health systems. Really the issue comes

down to what is best for the citizens of developing countries? Most NGOs’ projects are

designed for short term assistance (3 years or less), but developing country

governments are working towards sustainable health systems based on long term goals

and achievements. The focus of this capstone paper will be to analyze the complex

dynamics between donors, NGOs and developing Ministries of Health and to gain some

insights as to how these entities can cooperate in the future in order to make health

care more synergistic.

Relevance:

This topic is very relevant in light of the new efforts of the WHO and others to

ensure universal health coverage worldwide and the ever growing need for the

expansion of health services in developing countries. In addition, thousands of NGOs

primarily focus on projects which are aimed at specific illnesses (i.e. HIV/AIDS, TB,

malaria, diabetes, immunizations, etc.) and specific people groups such as women

and children to garner maximum funds for their projects. These tailored focuses

exclude a large quantity of the population and do not assist governments in

establishing sustainable programs to provide essential health care for the entire

population; for once the project is over, many times the NGO packs up leaving empty

gaps in health services of the community where they once worked. It is essential, at

this time, to develop a new conceptual framework for how NGOs interact with

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government authorities and what kind of long term impact they have on the people of

developing societies.

Research Question:

My research question is: how can NGOs and governments work together toward

the same goals to improve sustainable health systems and allow their combined

efforts to become synergistic? To accomplish this I will first discuss the literature that

has been written about this topic in order to get a well-rounded perspective.

Secondly, I will focus on three case studies which demonstrate the most pressing

issues faced by governments, NGOs, and aid donors; but also give an example of one

collaborative effort that has paid off for both the developing country and the NGO

involved in this case. Finally, I will conclude the result of my findings. I expect to find

that changes need to be made to the current framework, further collaboration should

be explored, and practical, realistic measures must be put into practice. For

clarification, the NGOs referred to in this paper are considered to be International

NGOs with humanitarian causes, not emergency relief NGOs.

Literature Review:

Throughout my research of the existing literature I have found three major

perspectives: those who feel the current framework of how NGOs, donors, and

governments interact needs to change; contributions that have been made to the

framework already, and the views of society members who receive foreign aid and

assistance.

3

In the first group of perspectives Kevin Sansom conducted qualitative, case

studies in three developing countries analyzing the roles and interaction between

NGOs and government officials. One of his main themes is the differences between

these two actors which complicates collaboration. Sansom states, “Reconciling such

difference has been difficult for many NGOs that work with local government, often

leading to tensions and non-productive engagement.”1 Through his research he also

found that trust is a large factor in whether governments and NGOs can work together

successfully. He insists that building relationships is integral to overcoming the barrier

of mistrust. Sansom also made a keen observation noting that in light of increasing

donor involvement with governments, NGOs must be prepared to change their ways of

working from small to larger programs which are monitored closer by donors and

governments.2

Erin Polich, an NGO Health Coordinator, has proposed a transition for NGOs

from sole humanitarian action to thinking about the concerns of developing countries.

It is no longer good enough to provide assistance, but to consider the consequences of

your actions. She emphasizes that the new roles for NGOs must, “align with

overarching MOH policies and goals.”3 She also underlines that NGOs need to have a

1 Kevin Sansom, "Complementary Roles? NGO-Government Relations for Community-Based Sanitation in

South Asia," Public Administration and Development 31 (2011), accessed July 8, 2014,

doi:10.1002/pad.609.

2 Kevin Sansom, "Complementary Roles? NGO-Government Relations for Community-Based Sanitation in

South Asia," Public Administration and Development 31 (2011), accessed July 8, 2014,

doi:10.1002/pad.609.

3 Erin Polich, "The Role of NGOs in a Changing Environment" (speech, Joint Donor Team Event, March

27th, 2013).

4

greater role in consultation in regards to human resources development, system

development, policy development, and advocacy. Polich points out several barriers to

this transition such as funding uncertainties, developing partnerships, low human

resource capacities, and physical infrastructure. In her assessment NGOs must,

“Continue to focus on humanitarian relief while and at the same time long term

development.”4 From her perspective the paradigm shift should focus on system

strengthening and advocacy for integrated service delivery. And in regards to NGO

exit strategy she stresses the importance of capacity building and supporting

sustainable government plans.5

Perhaps the most persuasive article for NGO transformation is a paper written

by Jessica Maltha. In her paper she explores the idea that NGOs do not live up to their

hype and that the, “Current NGO model is deteriorating the public primary health

care programs.”6 She strongly urges the reader that while many donors do not trust

developing governments because of their history of corruption, many NGOs’ cost-

effectiveness or efficiency is as bad if not worse than current developing

governments. Maltha underlines that those NGOs who hire local staff often over pay

them compared to local standards which causes immense brain drain in developing

countries and pulls national health professionals away from their roles in the public

4Erin Polich, "The Role of NGOs in a Changing Environment" (speech, Joint Donor Team Event, March

27th, 2013).

5Ibid

6 Jessica Maltha, "NGOs in Primary Health Care: A Benefit or a Threat?," Global Medicine, 2012,

accessed July 08, 2014, http%3A%2F%2Fglobalmedicine.nl%2Fissues%2Fissue-7%2Fngos-in-primary-

health-care-a-benefit-or-a-threat%2F.

5

health system. She highlights a major problem with NGOs that often, “many foreign

agencies arrive with their own projects, approved by their donors or head offices,

with very specific objectives and targets that have to be met to ensure their funding.

This entails that NGOs often neglect the overall functioning of the health care system,

thus disregarding the impact of their implemented programs.”7 In the end all of these

issues undermine the public sector health system and promote unsustainable health

care. To this end she concludes that the current NGO model needs to change and sites

several potential solutions to these troubling issues.8

The second perspective is that of authors who point out contributions which

have already been made to transitioning the NGO model. The first of the authors,

Batley and Rose, produced a case study of three developing countries: Bangladesh,

India, and Pakistan; in which they discuss the how NGOs have changed their

approaches to collaboration with the governments in these countries and particularly

NNGO partnerships that make NGOs jobs easier and more in line with government

plans instead of devising parallel programs. They specifically address the importance

funding plays in NGO collaboration. They emphasize three main ways NGOs have built

key relationship by strategically planning their funding, “First, there is the type of

funding: some NGOs received untied funding from voluntary subscriptions, private

donors and endowments that enabled them to engage with government without any

financial exchange. Second, regardless of the type of funding, most NGOs had

7 Jessica Maltha, "NGOs in Primary Health Care: A Benefit or a Threat?," Global Medicine, 2012, accessed July 08, 2014, http%3A%2F%2Fglobalmedicine.nl%2Fissues%2Fissue-7%2Fngos-in-primary-

health-care-a-benefit-or-a-threat%2F. 8 Ibid

6

maintained a sufficient diversity of sources to reduce dependence on a particular

source. Third, rather than having their interests directed by the source of finance, as

Rose, find some NGOs were able to reverse this by seeking the funder that shared

their purpose.”9

From a more specific perspective, Mogedal writes an article encouraging

Norwegian Aid policy to conform to a plan wisely when distributing aid. This also

shows a contribution on the part of developed countries to acknowledge they are part

of the problem and must consider how best to distribute aid. In her article Mogedal

points out that perpetuating dependency on developed countries has a negative

impact on the solidarity and self-interest of developing countries. She stresses that

although the health challenges of today may be more than developing countries are

able to handle, those providing aid should be providing advice, shared alliance, and

cooperation. Mogedal insists, “There is a lack of association between, money,

knowledge and policy,”10 acknowledging a disconnect between developed countries’

financial contributions and their contributions of knowledge. She summarizes her

entire paper in one simple sentence, “Global health is more than health aid.”11

Possibly the largest contribution to rethinking the current model of NGOs is the

NGO Code of Conduct for Health Systems Strengthening. This code was drafted by

9 Richard Batley and Pauline Rose, "Analysing Collaboration Between Non-Governmental Service

Providers And Governments," Public Administration and Development 31, no. 4 (2011), accessed July 8,

2014, doi:10.1002/pad.613.

10 S. Mogedal, "Global Health Is the Objective - Is Health Aid the Answer?,"Tidsskr Nor Legenforen 133,

no. 1159 (June 11, 2013), accessed July 8, 2014, doi:10.405/tidsskr.13.0459.

11 Ibid

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concerned NGOs who have themselves, made some of these same detrimental

mistakes and want to change future outcomes. The authors note that as this Code

becomes more widely adhered to, they hope that funders and host governments will

also see fit to observe these same six articles. The six fundamental articles of the

code are, “NGOs will engage in hiring practices that ensure long-term health system

sustainability. NGOs will enact employee compensation practices that strengthen the

public sector. NGOs pledge to create and maintain human resources training and

support systems that are good for the countries where they work. NGOs will minimize

the NGO management burden for ministries. NGOs will support Ministries of Health as

they engage with communities. NGOs will advocate for policies that promote and

support the public sector.”12 These articles seek to address some of the most

destructive habits of NGOs on developing countries. They reinforce government

solidarity and national self-determination and promote sound HRH and sustainable

practices. Currently there are 57 signatories to the Code, not much, but it’s a start.13

In addition Medicus Mundi has also contributed to NGO success by forming a collection

of thematic guides for NGOs to use as resource in staying informed and determining

their role in global health.14

12 "NGO Code of Conduct," World Health Organization, May 2008, accessed July 8, 2014,

http%3A%2F%2Fwww.who.int%2Fworkforcealliance%2Fnews%2FCode%2520booklet%2520lowres.pdf%3Fua

%3D1.

13 "NGO Code of Conduct," World Health Organization, May 2008, accessed July 8, 2014,

http%3A%2F%2Fwww.who.int%2Fworkforcealliance%2Fnews%2FCode%2520booklet%2520 lowres.pdf%3Fua%3D1.

14 "Thematic Guide: The Role of NGOs in National Health Systems and Global Health," Medicus Mundi,

2014, accessed July 8, 2014, http%3A%2F%2Fwww.medicusmundi.org%2Fen%2Ftopics%2Fstrategic-

positioning%2Fngos-strengthening-or-weakening-health-systems.

8

The third and final perspective comes from those who have experienced

receiving foreign aid. In her article Sabine Balk reviews several authors who argue

that microcredit and aid money has destroyed solidarity and community integration by

putting too much focus on individual welfare; dividing where it should be promoting

civil societies’ mutual success. Her article also endorses rejecting aid money in a

developing setting as the authors are collectively persuaded that aid money does

more harm than good. Her ultimate conclusion is that, “The overarching goal must be

to empower people to take their fate into their own hands, and that the current aid

architecture is not geared adequately to cooperation and solidarity.”15

In a review of the book Time to Listen: Hearing People on the Receiving End of

International Aid by Mary B. Anderson, this unnamed author selects several insights

sited by the book that people outside of the developing world would seldom realize.

She establishes that people, in general, are not against foreign aid, however, the

overall impact of aid is more negative than positive. Some of the insights include,

“People hate the sense of dependence and can feel it undermine their own sense of

agency and potential, tensions between the aided and the unaided, not focusing on

what resources and capacities local communities possess and can build on, and the

undermining of aid’s ability to listen, learn and adapt to local contexts.” She also

points out that while there are many negative feelings, one major positive reaction is

15 Sabine Balk, "Regaining Solidarity," Development and Cooperation, March 4, 2014, accessed July 8,

2014, http%3A%2F%2Fwww.dandc.eu%2Fen%2Farticle%2Fcritics -want-aid-be-re-designed-order-

promote-international-solidarity.

9

of that surrounding aid for women. Yet the overall message of this article is for NGOs

to quit trying to complete their project and slow down and listen to the people.

All three of these perspectives serve to unite the cause for remodeling the

current framework and ideologies behind NGOs “good intentions”. These perspectives

solidify that while some assistance has had a beneficial effect on some developing

countries, the majority of NGOs have yet to figure out that they are behind the times

and need to reevaluate how they plan and manage their projects for maximum

positivity and lasting, effective health systems.

Review and Analysis of Case Studies:

For this paper two case studies of specific countries were chosen: Mozambique

and Nepal. These two countries were selected because they are both developing

countries and they represent two different geographic locations; one in Africa and

one in Asia. These specific case studies were also selected because of the time

difference. There is a ten year time span from one case study to the other. This is

important to see if time has had any effect on the progress of NGOs working in

developing countries.

Prior to Mozambique’s civil war they had a thriving health system with plenty

of health posts, even in rural areas. As a result of the war the country’s entire

infrastructure was destroyed which is when hoards of NGOs came flooding into the

country and took over any opportunity the government might have had to rebuild

their once flourishing health system. At the same time, some of the workers from

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these NGOs brought with them attitudes of condescension and disinterest which led to

exclusion, demoralization, and bad habits of per diem for the local workers.16

Nepal was also engrossed in a civil war that lasted ten years. Soon after the

end of the war they were inundated with NGOs in the same way Mozambique was.

Nepal began their rebuilding process by claiming health as a basic human right and

decided a new health plan along with External Development Partners (EDPs, i.e.

USAID, DFID, GiZ, WHO, UNICEF, World Bank, and others) which set up a management

mechanism between the Nepali government and the EDPs. This plan was set from

1997 till 2017. Both the government and the EDPs decided on policies together and it

was agreed that a pooled fund would be set up to be spent at the agreed discretion of

both parties.17

After thoroughly pouring through both case studies numerous times, I found

eleven similarities between these two cases which describe the greatest challenges

faced by NGOs, Donors, and Governments, and Health Workers in operating together

to produce equitable, efficient, accessible, and effective health care to civil society.

The first section of issues deals with the NGOs working Mozambique and Nepal.

One of the very first observations both cases reference is a lack of aid coordination.

As everyone hurriedly arrived in these countries without coordinating with one

16 James Pfeiffer, "International NGOs and Primary Health Care in Mozambique: The Need for a New

Model of Collaboration," Social Science & Medicine56, no. 4 (2003), accessed July 8, 2014,

doi:10.1016/S0277-9536(02)00068-0.

17 Aditi Giri et al., "Perceptions of Government Knowledge and Control over Contributions of Aid

Organizations and INGOs to Health in Nepal: A Qualitative Study," Globalization and Health 9, no. 1

(2013), accessed July 8, 2014, doi:10.1186/1744-8603-9-1.

11

another or the government many projects were duplicated because insufficient

communication.18 Additionally, when NGOs did seek to coordinate with the

government they often sought to make under-the-table deals or special agreements

with the government. NGOs offered incentives to government officials if it meant

they received approval to work on a certain project or with particular people groups

(i.e. HIV/AIDS, Malaria, midwifery, maternal-child health, and people groups of

women and children). NGOs took this approach in order to gain access to more

funding, in competition with other rival NGOs wishing to do the same.19 In order to

meet their own criteria and priorities NGOs would pressure governments to approve

their project whether or not it was in alignment with existing governmental plans and

in actuality disrupt the planning process.20 Ultimately NGOs’ presence resulted in the

public health sector of these developing countries being completely undermined. A

good description of this scenario from Nepal’s case study looked at the differences

between the NGO and public health centers, “While it has a full time staff, a well-

stocked pharmacy and diagnostic equipment, its government counterpart is

continuously understaffed and disorganized. Locals say they prefer the NGO health

center over the government health post. The government health post doctor is

frequently absent for long periods of time.”21

18 First issue 19 Second issue 20 Third issue 21 Aditi Giri et al., "Perceptions of Government Knowledge and Control over Contributions of Aid Organizations and INGOs to Health in Nepal: A Qualitative Study," Globalization and Health 9, no. 1

(2013), accessed July 8, 2014, doi:10.1186/1744-8603-9-1.

12

Local control was completely lost and the fragile public health systems could

not compete with the NGOs.22

There is a phrase that goes, “If you can’t beat ‘em, join ‘em.” That’s exactly

what the local health professionals did. There were many factors which worked

against public health professionals which included inadequate salaries,

pharmaceutical and material shortages, and equipment failures. With little motivation

and the demoralization of the local health workers, they gave up their posts and

joined the ranks of the elite health professionals working for the NGOs contributing to

major brain drain.23 The NGOs provided exemplary salary and a better working

environment, not to mention the all paid trips to other cities for training seminars

which essentially did not provide them with any added clinical knowledge. Even

public health workers took part in these training seminars while they were still

working in government facilities since the per diem pay was more than they could

make in a month normally. In addition this left their public clinic posts vacant while

they were away for weeks at a time.24 Per Diem and financial favors became a way of

life in these environments since the economies were in dire straits. They became so

common that soon none of the local health workers would show up or contribute

without receiving them. This incentive, turned bad habit, became so sought after that

the locals learned how to manipulate the NGO systems to get these positions.25

22 Fourth issue 23 Fifth issue 24 Sixth issue 25 Seventh issue

13

The third section deals with the actions of donors or EDPs (as they are called in

the Nepal case study). From the start EDPs had a major disconnect with the central

governments with whom they worked closely. There was often a serious lack of

understanding on the donor part when insisting on working on specific projects.

Donors discussing a specific project with the Nepali government went like this, “When

it came to promoting home deliveries by SBAs (Skilled Birth Assistant), donors argued

that this would be counterproductive because the international community supports

hospital deliveries. The MoHP had to explain that for people in remote, rural areas

where accessibility and cultural beliefs pose problems, the best solution is to send

trained personnel to them. Donors then decided to fund this program instead of

promoting hospital deliveries.”26 27Perhaps a greater problem was that donors insisted

on channeling aid through NGOs instead of government programs. This was

detrimental to government budgets, but also went to support vertical projects instead

of being used equitably to fund horizontal program improvement.28 Part of the reason

donors chose to distribute aid this way was because they did not trust the Ministries

of Health to use the money efficiently.

In developing countries, governments are expected to have many issues and in

reality they do. Corruption was a serious issue for both the Mozambique and Nepali

governments. Furthermore they also had issues with transparency. Often times when

26 Aditi Giri et al., "Perceptions of Government Knowledge and Control over Contributions of Aid

Organizations and INGOs to Health in Nepal: A Qualitative Study," Globalization and Health 9, no. 1 (2013), accessed July 8, 2014, doi:10.1186/1744-8603-9-1.

27 Eighth issue

28 Ninth issue

14

they would receive aid these resources were not filtered down to the local offices in a

timely fashion.29 Since the government had internal coordination issues, EDPs and

NGOs took total control of service delivery for the entire health sector which left

these governments paralyzed and weak. The government had no leverage to coerce

those in charge to conform to their rules or regulations and in return the EDPs and

NGOs did not report their actions or projects to the government, leaving them totally

in the dark.30

Conclusion:

After seeing the similarities between these two case studies even though these

studies were done ten years apart, it is easy to see that reliance on controlling NGOs

in developing countries has become a theme. A new approach to how all the

stakeholders involved in health provision is needed, including the NGOs, donors,

governments, and local health workers. In these two studies it was obvious that the

government and local health professions were starting the rebuilding process from a

weak position and instead of continuing to foster this position within the countries;

donors and NGOs should build up their weaker partners and listen to and

communicate with them more. Foreign partners must consider what the consequences

of their actions may be and listen to the internal governments and health

professionals insights in order to forge a synergistic health workforce and system that

can be sustainable for the developing country.

29 Tenth issue 30 Eleventh issue

15

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