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Nongovernmental organizations are a broad category of organizations that are neither for profit nor part of a government. The different definitions of NGOs have been contested, but there is some consensus that NGOs consist of durable, bounded, voluntary relationships among individuals to produce a particular product, using specific techniques. Weiss and Gordenker (1996: 18) argue that the term NGO has a host of alternative uses, such as the independent sector, the third sector or volunteer sector, civic society, grassroots organizations, private voluntary organizations, transnational social movement organizations, grassroots social change organizations, and nonstate actors.
There are key similarities between NGOs, which are outlined by Alan Fowler (1997: 39). He claims that NGOs differ from government and businesses in that
- they are not established for and cannot distribute any surplus they generate as a profit to owners or staff;
- they are not required or prevented from existing by law but result from people’s self-chosen voluntary initiative to pursue a shared interest or concern;
- formed by private initiative, they are independent, in that they are not part of government or controlled by a public body;
- within the terms of whatever legislation they choose to register themselves, they also govern themselves;
- registration means that the founders wish to have social recognition – this calls for some degree of formalization and acceptance of the principle of social accountability.
What has become clearly evident is that the number of NGOs has drastically increased since the 1980s. For example, the total development aid disbursed by International NGOs increased ten times between 1970 and 1985. By the middle of the 1990s, the Union of International Associations recognized over 15 000 International NGOs who operate in three or more countries and draw their finance from more than one country (Weiss and Gordenker, 1996: 11). Although there were comparatively low volumes of funding being funneled through NGOs in the 1960s and 1970s, the official funding of NGOs tripled in the 1980s and then doubled again in the 1990s. By the end of the twentieth century, an estimated $7 billion of official aid and foundation funding was being channeled through NGOs, surpassing the volume of the combined UN system of $6 billion (Reimann, 2005: 38). Although it is difficult to be specific about the exact number of NGOs in operation around the world, this sector is continuing to increase. NGOs are not the only organizations that fill this role in the field of health. There are many different types of information community-based organizations, civil society organizations, or self-help organizations that perform similar tasks to those of NGOs. These organizations serve a vital function, much like NGOs, but have chosen not to formalize and register themselves.
NGOs generally have a mission to work with vulnerable people, and the majority of NGO work is based in developing countries. They tend to be intermediary organizations that bridge donors and beneficiaries and are therefore responding to multiple constituencies (Hailey and James, 2004: 344). Within the international NGO sector, there are two types of NGOs involved in health: NGOs that have a specific focus on health issues, and international development or humanitarian NGOs that work on health as one of their key program areas. Following the relief/development continuum, these NGOs may work in arenas ranging from long-term development projects, such as building hospitals and developing immunization programs, to situations deemed as ‘humanitarian situations’ in which immediate care is required to save lives. NGOs involved in health are prevalent where there is a problem with state provision of services.
Health NGOs exist because there are needs that are not being met by government or international agencies. Health needs are being defined and redefined; emphases range from global health to primary health care to the Millennium Development Goals.
Global health has become a focus during the last few decades, marking a shift in the types and nature of perceived health threats and their ability to transcend national boundaries. The big health problems – primarily malaria, tuberculosis, and HIV/AIDS – are diseases that are not contained within state boundaries and therefore require globally based solutions. These three diseases kill more people than any other, and the idea behind global health as a concept is that these diseases do not contain themselves within state boundaries and require global solutions. Many examples of this exist, the most notable being the HIV/AIDS pandemic. Addressing HIV/AIDS may require state-run programs, but NGOs are vital in these, whereas developing a vaccine for HIV/AIDS cannot be done by one government or one agency but requires many partners internationally. An example frequently cited is the Global AIDS Vaccine Initiative (GAVI), which is based on private-public partnerships and a multi-actor approach across state boundaries. Chen et al. (2003: 70) argue that solutions must be based on
the transnational diffusion of knowledge, involving diverse global institutions and actor groups – government, industry, academia, non-profit institutions and the media. Local and national actions increasingly call for global reinforcement, engaging many actors beyond nations-states.
Health NGOs play a pivotal part in the global health approach. According to Chen et al. (2003: 78),
the emergence of multiple actors has necessitated more nuanced institutional arrangements in global health. After all, no single institution, however mandated or well intentioned can hope to fulfill all global health functions.
Another framework that NGOs operate in is that of primary health care (PHC). PHC came onto the international scene in 1978 at a Conference in Alma Ata that was organized by the WHO and UNICEF. The Declaration of Alma Ata indicated that community participation was vital to health care for all and the Declaration stated that ‘‘primary health care requires and promotes maximum community and individual self-reliance and participation.. .making fullest use of local, national and other available resources’’ (Chen et al., 2003: 279). Underlying the concept is that primary health care must be universally accessible and available to all through community financing and management, as well as external funding, and NGOs have been seen again to play a vital role. This reflects the movement since the 1980s that developing countries participate in the planning, financing, organizing, and operating of health-care services in their own communities (Chen et al., 2003: 279). Since the conference in Alma Ata, PHC has been taken aboard by many governments as a way to obtain health care for all. However, Diskett and Nickson (1997: 37) argue that the costs of implementing PHC were grossly underestimated, as in most poorer countries, there would not be enough public money available to meet these demands.
The Millennium Development Goals (MDGs) have been a focal point for the international community since their inception in 2000. Three of the eight goals directly involve health, and if health was not firmly placed on the development industry’s agenda before, then it certainly is now. MDGs are important on a number of different levels – primarily in that they form a framework for donors to set priorities and channel funds into these areas. In broad terms, the MDGs can be said to have set or reinforced certain priorities in development – health being one of these. The three goals that are pertinent to health are the following:
- Goal 4 – by 2015 to reduce by two thirds the mortality rate among children under five;
- Goal 5 – by 2015 to reduce by three quarters the mortality rate;
- Goal 6 – by 2015 to halt and begin to reverse the incidence of HIV/AIDS and the incidence of malaria, and other diseases.
Goal 1 of the MDGs can also be said to be related to health in that it aims to eradicate extreme poverty, hunger, and malnutrition – something that cannot be done without adequate health provisions. Pivotal to the MDGs is that again one actor or group of actors cannot achieve these goals, and NGOs working on health issues are key to this process.
The Role Of Health NGOs
To speak of an exact role for health NGOs is difficult, as the term is used for a wide variety of organizations that have different historical trajectories, are fulfilling different identified needs, and have different institutional abilities and mandates. There are NGOs that are relief and welfare agencies, there are technical innovation organizations, organizations that are contracted to carry out public service contracts, development organizations with a health wing or a health focus, grassroots development organizations, and advocacy and lobbying groups advocating for change. However, as Farrington and Bebbington argue (1993: 3), part of the problem in discussing NGOs as a broad category is that these classifications do not fully differentiate between the function, ownership, and scale of the operation of such organizations. In addition, the number of NGOs in general, and more specifically the number of NGOs working in or around the field of health, is nearly impossible to specify. For example, medindia.com, which is a directory of NGOs working on health in India, has over 8000 entries (see Relevant Websites), yet even this figure is difficult to confirm.
Although it is difficult to categorize and quantify health NGOs, there are a number of broad categories that we can examine through the functional work of NGOs involved in health. Specifically, two key functional roles for NGOs are service delivery and advocacy. These are not the only functions of health NGOs, and more and more is expected of them. Lewis and Opoku-Mensah (2006: 666) best articulate this when they say that ‘‘alongside the more familiar roles of service delivery and campaigning.. . it has sometimes seemed that NGOs have been a tabula rasa onto which an ever-growing set of development expectations and anxieties have been projected.’’
The term ‘service delivery’ is broad and can comprise various tasks and functions taken on by NGOs, from building hospitals to providing training for local staff and health workers to vaccination programs to raising awareness around health-related issues. NGOs have frequently taken on the role of ‘filling the gap’ in providing services in health care. This can take many forms, but generally, NGOs work where health systems are insufficient and provide technical expertise, funds, and work to rebuild health structures. The ways in which this is done does depend on the particular NGO and the particular situation and location. NGOs might participate with a country’s own ministry of health, or NGOs could work independently of the government. According to recent studies (Loewenson, 2003: 8) there is significant evidence that NGO contributions of technical expertise through institutional and financial resources and health outreach have been effective, particularly in areas of advocacy and innovative and community responses to health problems, as well as in enhancing public accountability.
Filling the gap is increasingly pronounced in light of the MDGs, as well as with the primary health-care ideology, which promotes ‘health for all.’ The reality is that there are acute funding problems, poor-quality services, and low coverage, which according to Diskett and Nickson (1997: 37) led many governments to conclude that ‘free’ health care was not a viable option. Although poor people could potentially contribute to the cost of curative care, Diskett and Nickson (1997: 79) argue that it is unrealistic to expect them to share the burden of preventative activities. Therefore, at minimum, prevention and what has been called awareness-raising will continue to be heavily subsidized by donors and NGOs. Information and education about health issues, be they malaria nets, clean water, or HIV/ AIDS prevention, is a key function of many health NGOs working in developing countries.
Advocacy is an inherently political act promoting the causes of others. Keck and Sikkink (1998: 8) describe NGO advocacy networks as ‘‘plead[ing] the causes of others or defend[ing] a cause or proposition … [Advocacy groups] are organised to promote causes, principled ideas, and norms, and they often involve individuals advocating policy changes.’’ Advocacy goes beyond lobbying and influencing decision makers; it encompasses ‘development education,’ which is a form of educating the public on larger development issues. Jordan and Van Tuijl (1998: 6) have defined advocacy as action that attempts to rectify power imbalances.
The professionalization of lobbying is a relatively new aspect of NGO work, necessitated by the need for effective advocacy at the highest levels. Whereas the terms ‘lobby’ and ‘advocacy’ are sometimes used synonymously, lobbying is a narrowly defined process that describes the practice of influencing the formal political process (Jordan and Van Tuijl, 1998: 6). Thus, to lobby is to attempt to influence, or steer, formal decisions being made by government officials. The term has been extended to those who are outside of the formal political process but who have decision-making powers, such as staff, management, and board members of multilateral institutions.
There has been a long history of NGO participation in health. NGOs involved in health have been active at all different levels of decision making, and have been increasingly involved in advocating at the global policy level (Loewenson, 2003: 6). Loewenson (2003: 8–9) outlines some of the issues around state–NGO relations in health at the national level. She claims that even though state– NGO relations are a key determinant of health outcomes, the mechanisms for these relations
are poorly resourced and serviced and there is still sparse evidence on how best to formalize and support these mechanisms. In part this reflects the ambivalence and lack of consensus noted earlier on the relative roles of state and civil society within health systems. It also indicates that the matter goes beyond technical questions … these relations are a site of political struggle. (Loewenson, 2003: 9)
outlines a key concern for NGOs: whether their mission should be to be ‘‘increasingly efficient at interim strategies for ‘serving the poor’ or whether it should be building the political momentum for wider challenges and responses to poverty, even when this necessitates confronting the state.’’ At the global policy level, NGOs have had more access than ever before, particularly those from the North, having greater access to funding, technical support, and the ‘corridors of power,’ giving them greater political leverage. There is a bias for Northern NGOs given their access to funding, location, access to technology, and access to key organizations. Employing professional lobbyists or advocates is costly and their required skills and knowledge of the system are highly specialized, resulting in a built-in bias for Northern NGOs (Yanacopulos, 2005: 104).
Comparative Advantages Of NGOs
Health NGOs and NGOs involved in health issues are a very different type of organization from government institutions. Their differences result in advantages (and disadvantages) compared to governmental bodies. They are not bound by large bureaucracies and can be more fluid organizations. Institutionally, they are more open to experimentation without being bound by national political decision. However, the constraints of health-related NGOs is that they are constantly dependent on sometimes inconsistent funding from donors, thus affecting their longer-term planning, and can be subject to donor trends in development priorities.
Most certainly, NGOs have a comparative advantage in sharing of information and research – frequently across state boundaries. Diskett and Nickson (1997:79) argue that NGOs also play an important role in different models of cost-sharing and financing. They are also better able than government-run programs to monitor the effects of programs on beneficiaries, because they are better located ‘on the ground.’ Finally, they argue that NGOs are well placed to strengthen PHC structures and management at different levels, as well as promoting decentralization in a hostile economic climate.
Mercer et al. (2004) go one step further and argue that health-related NGOs not only fill a gap that governments and international agencies are unable to fulfill but they also serve even more specific and necessary functions. He uses the Bangladesh Population and Health Consortium (BPHC) in the following example.
Bangladesh Population and Health Consortium
An agency for funding small and medium-sized, locallevel NGOs to deliver maternal and child health and family planning services in rural areas was established by the British Overseas Development Administration (ODA) in 1988, under an agreement with the Government of Bangladesh. The agency became known as the Bangladesh Population and Health Consortium (BPHC). Initially, the main objectives were to fund NGOs and develop their capacity for managing health programmes, with the aim of improving MCH outcomes. Since 1988, BPHC has supported over 100 NGOs to provide doorstep and clinic services, and promote use of higher level services provided either by the NGO or by government at upazila level (sub-district).
From 1993–97, BPHC supported NGOs with funds provided by a consortium of international development agencies. From 1998–2003, the UK Department for International Development (DFID) funded BPHC to develop government–NGO collaboration in the sector and deliver ESP services through partner NGOs in a Public–NGO Partnership (PNP). This was to be an integral part of the sectoral programme, jointly managed by DFID and the Line Director for ESP-Reproductive Health in the Ministry of Health and Family Welfare (MOHFW). BPHC consists of a team of Bangladeshi staff led by an expatriate Technical Cooperation Officer employed by DFID. (Mercer et al., 2004: 188)
The BPHC NGO programme has been innovative in developing community participation, gender equity and local accountability. The NGOs’ role is not limited to ‘gap filling’ and provision of services in remote or underserved areas. NGOs offer an alternative for international agencies seeking to reach the poor, in Bangladesh and in other low-income countries. The degree of support they are willing to provide in different countries will depend to some extent on the capacity of the NGO sector for large-scale provision, the effectiveness of public services, the pace of government sectoral reforms, and other aspects of governance. Where there is a strong NGO sector and government lacks the capacity to provide universal coverage or to sub-contract on a large scale, it may be costeffective for international agencies to provide direct support to NGOs. Where there are acceptable standards of governance, regulatory mechanisms, systems for monitoring quality of care, and health sector reforms, governments in low-income countries can be given. Financial support to contract NGOs for PHC service delivery. (Mercer, 2004: 196)
As we see from the BPHC example, NGOs have varied competitive advantages. They are frequently more flexible than governments; they have high levels of commitment, and are seen to be more responsive to community needs, frequently working at the grassroots level. Whether these perceptions are justified is still open to discussion.
Criticisms Of NGOs
Along with the rapid increase in NGO numbers and presence, there has been an accompanying set of critiques of NGOs. These critiques can be grouped into different categories: performance and effectiveness, accountability, autonomy, commercialization, and, ideological critiques of their increasing influence (Reimann, 2005: 37). These general critiques of NGOs are also relevant to health NGOs.
NGO performance and effectiveness is increasingly being evaluated and monitored. During the 1990s, there were great expectations of NGOs, as they were seen as a way of working around inefficient states, as well as somehow being ‘closer to the ground.’ Although NGOs have delivered on some levels, they have not been the ‘magic bullet’ that many expected them to be. Successes such as mass immunizations, building of hospitals, education, and awareness-raising around HIV/AIDS have been successes, but the issue of effectiveness of NGOs is always in question.
There has been a great deal of discussion about the accountability of NGOs during the last decade (Edwards and Hulme, 1995; Fox and Brown, 1998), yet there is still little consensus as to whom and for what NGOs are accountable. There are different types of accountability, and whereas financial accountability to donor is straightforward and quantifiable, accountability for more abstract outcomes, such as ‘capacity building’ and ‘empowerment,’ are much more difficult to quantify. Indeed, in quantifying these outcomes, NGOs run the risk of oversimplifying what these outcomes actually represent.
Edwards and Hulme (1995: 9) originated the idea of ‘upward’ and ‘downward’ multidirectional accountability, stating that ‘‘weak accountability of NGOs relate to the difficulties they face in prioritising and reconciling’’ these forces. Although it is necessary to clarify to whom they are accountable, it is also necessary to ensure that these demands for accountability are realistic. Arguments around NGO accountability stem from these organizations’ increasing presence in service provision – that they are taking on more public sector duties, and NGOs should be more accountable. Ironically, it is when NGOs move away from public service provision that higher requirements on their accountability are demanded (Edwards et al., 1999). Edwards (2000: 19) outlines the challenge of accountability when he states that NGOs ‘‘require accountability mechanisms ‘downwards’ (to the poor) as well as ‘upwards’ to the donors who fund the NGO’s activities. This is a challenge that no NGO has addressed.’’ In addition, criticisms around autonomy stem from NGOs taking on roles that have been in the traditional domain of states.
The other set of strong critiques surrounding NGOs has been ideological. By providing services that many think the state should be providing, they are part of the ‘rolling back the state’ or what has been termed the ‘neoliberal’ agenda. Critics such as Loewenson (2003: 7) argue that this undermines universal health-care coverage and does not resolve the critical weakness of the state. The criticism continues that NGOs are part of the very neoliberal system that they frequently criticize.
Fundamental tensions exist around two objectives of health NGOs – that of self-sufficiency and of primary health care. Health programs are more likely to succeed if there are decision making and contributions from the community; Oxfam’s experience working on health shows that some degree of self-financing to reduce dependency on donors and governments is necessary. However, Oxfam also found that total self-sufficiency was not possible or desirable. The higher charges that beneficiaries would need to pay would be too high, and this philosophy contradicts the aim of equality on which primary health care is based (Diskett and Nickson, 1997: 79).
NGOs are an integral element of health governance, particularly in developing countries. Dogson et al. (2002: 6) describe health governance as being ‘‘the actions and means adopted by a society to organize itself in the promotion and protection of the health of its population,’’ the governance mechanisms being situated at local, national, and international levels.
A number of the large issues in health transcend national boundaries and require more than one actor to address them. As a result, the language of partnerships has become more common, yet typically the term ‘partnership’ is used in an imprecise way meaning different things to different people. Because of this, what are frequently described as partnerships between northern and southern NGOs are not really partnerships but a way to transfer resources between the north and the south. In addition, many north/south partnerships are not active partnerships (those built through ongoing processes of negotiation, debate, occasional conflict, and learning through trial and error), but ‘dependent partnerships’ (Ahmad, 2006: 630).
One of the more recent developments among health NGOs is public-private partnerships (PPP). The UN General Assembly described PPPs as ‘‘relationships between various parties, both state and non-state, in which all participants agree to work together to achieve a common purpose or undertake a specific task and to share risks and responsibilities, resources and benefits.’’
PPPs exist in many forms, and health NGOs are key players in the PPP model that is prevailing in developing countries. For example, donors such as USAID have supported different models of PPPs in India. Advocates of PPPs include the WHO, the World Bank, and the Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM) (Prescott and Pellini, 2004). GFATM, also called The Global Fund, is a PPP set up to increase global financing to combat these three diseases, which kill over 6 million people a year.
The health NGO Merlin outlines some of the advantages and disadvantages of working in PPPs.
Public–private partnerships in the health sector: The case of Iraq
Public–private partnerships (PPPs) are fast becoming the dominant method of tackling large, complicated and expensive public health problems in post conflict and unstable settings such as Afghanistan and Iraq. They are seen as ‘win-win’ arrangements in which diverse actors – with often varied, sometimes conflicting, motivations – work together to contribute to health development.
In principle, there is no reason why a PPP should not be effective, provided it is established on the premise of a ‘partnership’. In the quest for a standard definition of partnership in a PPP, there are signs of convergence on common elements: the mutual recognition of comparative advantages; cooperation and coordinated planning; transparency; and cost-effectiveness. These general conditions are necessary for the existence of a partnership, regardless of its nature.
However, .. . private contractors will seek to make a profit. Are they really motivated to provide a culturally sensitive and appropriate health system to respond to Iraqis’ needs? Do these contractors intend to impose their idea of health reform, based on US healthcare models, bypassing the Ministry of Health and the general public’s will? An effective PPP should be based on mutual recognition of comparative advantages, transparency, costeffectiveness and coordinated planning. In addition, in occupied countries, the parties should operate within a framework of legality, legitimacy and sensitivity to contextual and cultural differences. Like it or not, PPPs have become established as a method of providing humanitarian and now development relief in Iraq. Yet, so far, they have had a chequered record in assisting and supporting the beneficiaries. (Prescott and Pellini, 2004)
Loewenson (2003: 8) claims that there are clear signs that the relationship between NGOs and the state produces better health action.
When legal, institutional and procedural mechanisms support the synergy between state and civil society, positive health outcomes are reported. These include better co-ordinated public financing and public mechanisms for joint action, and improved health equity. In contrast, parallel, competitive or poorly managed relations are reported to introduce inefficiencies into the actions of both state and civil society.
The international targets around the MDGs and the largescale transnational health issues such as infectious diseases are two examples of the inability of one health actor alone to address the problem. Despite criticisms, health NGOs are working on the ground, providing services, raising awareness around health, advocating for changes in policy, and working with other health actors in different forms of partnerships to address important health issues.
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