A benefit or a threat?

Jessica Maltha

International Non Governmental Organizations (NGOs) have been active in primary health care for many years. The majority of these NGOs is based in Western countries and has local branches in developing countries. Most of them run their own projects, some fund and monitor local service-providing NGOs. With many national governments not being able to supply sufficient health care, NGOs are considered to be the best institution for reaching the poor and providing health care in an efficient and cost-effective way. Therefore, large amounts of official funds are being channeled to NGOs active in the health sector.However, there is a growing opinion that NGOs do not live up the expectations and might even make things worse. As Pfeiffer, who worked for an NGO in Mozambique for many years, states, the current NGO model is deteriorating the public primary health care programmes. Are NGOs indeed a burden to the health care systems in developing countries?

Reaching the poor

Many NGOs characterize themselves as working for the poorest of the poor. However, despite having good intentions, they seem to fail at this point. An example from Bangladesh described by Zaidi et al. shows that the largest NGOs in the country are reaching less than 20% of landless households and fail to address the actual needs of the people. NGOs are blamed for carrying out projects the way their donors require, instead of using the ideas and knowledge of the local people to fulfill their needs.

Cost-effectiveness and efficiency

When Western donors regard a government as bureaucratic or corrupt, they often prefer to give their money to international NGOs instead. However, there is no proof that international NGOs work more cost-effective and efficiently. On the contrary, they have very high expenses compared to governments and local NGOs, mainly due to the high administrative costs (overhead costs account usually for 30-40% of project funds). Research from East-Timor, India and Bangladesh shows that the work of international NGOs is associated with high costs and that more people will benefit against lower costs if work is handed over to the government or to local NGOs.

Working environment

Most international NGOs have their own Western staff working in local projects who get paid much more than the local health workers. Pfeiffer calculated that in Mozambique in one year, an expatriate earns the equivalent of twenty times the annual salary for a similar job in the national health care system. NGOs that do hire local staff, pay them much more than the national government would. This enhances brain drain within the country as locals prefer to work for NGOs instead of for the state.

Expatriates often receive funding for housing in private compounds, transport and personal vacations. As a consequence of this exclusion from the community, developing a relationship of trust is very difficult. Furthermore, this inequality discourages government health workers, which in turn causes frustration by the NGO workers who see the locals as obstacles to implement their projects. Moreover, it causes under-the-desk charging by local health workers. And above all it lures away the health workers from the national health system.

 

Coordinating aid to the health sector

Good coordination of health care and good regulation of aid is important to make sure that health care is provided to everybody at a standard level. Organizational effectiveness requires learning, communication, initiative and risk-taking. These elements are often absent in bureaucratic and highly formalized structures, which were thought to exist in governments mainly but appear to play a role in lots of international NGOs as well.

One of the major problems is that 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 programmes.

As a good example, in Bangladesh, the Bangladesh Population and Health Consortium (BPHC) receives money from international agencies and divides it among local NGOs. The BPHC coordinates the health services throughout the country, thus making sure that the same package of services is provided to everyone, instead of different standards depending on the different levels of performance of NGOs.

Sustainability

There are several things that undermine the sustainability of foreign aid. First and most important is the dependency of NGOs on their donors. Donors want to see value for money, demonstrated in measurable results. As NGOs depend on these donors to be able to continue their work, they often work with very   restricted projects on short-term basis which undermine the broader goals of the health system. A study in Bangladesh by Edwards et al. among four NGOs shows that success is more likely when organizations identify a clear long-term goal at the outset and stick to it over time. Agencies that change their goals too often or try to achieve too many goals often lose their way.

A second problem is the current trend of expatriates moving from contract to contract, trying to make promotion. This results in a high turnover of staff and aid workers letting their own interest prevail, which goes at the expense of establishing a sustainable national public health sector.

Conclusion

Although we can not generalize about all NGOs, it seems that they indeed deteriorate the primary health care system at some points. They create an atmosphere of inequality and exclusion in the community and lure away the health workers from the government health system. Besides, they do not live up the expectations of being more cost-effective and efficient compared to the governmental health system.

The main reason for the malfunctioning of international NGOs is the donor dependency, leading to short-term specific goals imposed by donors instead of meeting the needs of the people. This results in unsustainable aid, bureaucracy and high overhead costs. Besides, the current mentality of most expatriates (moving from contract to contract and looking for career options) leads to an instable situation. NGOs have money and knowledge, but at this moment they are not using it in the right way. To create a sustainable health care system they should cooperate with the state, creating a long-term plan of a national health care system and making the government the main responsible party after a few years. Aid should be channeled into the country through one national institution that should be able to divide it without being stuck to short-term direct measurable goals. NGOs should employ and train as many locals as possible instead of bringing their own expatriates, providing the same salary as the national health care system does. The example of East Timor shows that it is possible to reach a good functioning health care system in this way in certain countries. Although NGOs do not live up expectations, donors still have more confidence in NGOs than in governments. Donors want to avoid the corruption that takes place in some countries and it is easier for donors to influence NGOs than governments. On the other hand, the corruption in government health care is being worsened by the presence of NGOs, because of the huge inequality in income. Changing the situation will be difficult because of a lack of trust in governments and in the capability of local health workers. However, NGOs should use the experience of governments to establish a long-term plan.

About the author

Jessica Maltha is a fourth year medical student currently enrolled in her clinical rotations at Maastricht University (The Netherlands). She is enrolled in an International Health honors programme and spent six months working in Mozambique in 2008.

Further reading

• In 2008, several international NGOs developed guidance on how international NGOs should operate in developing countries with respect to the delivery of primary health care: the NGO Code of Conduct for Health Systems Strengthening. 

References

1. Allen T., Thomas A. Poverty & development into the 21st century. Oxford University Press 2nd ed. 2000. p. 210-213.
2. Townsend J.G, Porter G, Mawdsley E. The role of the transnational community of non-government organizations: governance or poverty reduction? Journal of International Development 2002; 14: 829-839.
3. Zaidi S.A. NGO failure and the need to bring back the state. Journal of International Development 1999; 11: 259-271.
4. Edwards M. & Hulme D. Too close for comfort? The impact of official aid on nongovernmental organizations. World Development 1996; 24(6): 961-973.
5. Pfeiffer J. International NGOs and primary health care in Mozambique: the need for a new model of collaboration. Social Science and Medicine 2003; 56: 725-738.
6. Gellart G.A. Non-governmental organizations in international health: past successes, future challenges. International Journal of Health Planning and Management 1996; 11: 19-31.
7. Edwards M. NGO Performance – What breeds Success? New evidence from South Asia. World Development 1999; 27(2): 361-374.
8. Alonso A. & Brugha R. Rehabilitating the health system after conflict in East Timor: a shift from NGO to government leadership. The Author 2006. Oxford University Press in association with The London School of Hygiene and Tropical Medicine.
9. Ahmad M.M. The ‘Partnership’ between international NGOs (Non-Governmental Organizations) and local NGOs in Bangladesh. Journal of International Development 2006; 18: 629-638.
10. Okello D.O, Lubanga R, Guwatudde D. et al. The challenge to restoring basic health care in Uganda. Social Science and Medicine 1998; 46(1): 13-21. 
11. Pavignani E. & Durão J.R. Managing external resources in Mozambique: building new aid relationships on shifting sands? Health Policy and Planning 1999;14(3): 243-253.
12. Mercer A, Khan M.H, Daulatuzzaman M. et al. Effectiveness of an NGO primary health care programme in rural Bangladesh: evidence from the management information system. Health Policy and Planning 2004; 19(4): 187-198

Photo by dbking, shared under Creative Common License