NON-GOVERNMENTAL ORGANIZATIONS AND HEALTH IN DEVELOPING COUNTRIES

Also by Andrew Green

AN INTRODUCTION TO HEALTH PLANNING IN DEVELOPING COUNTRIES

Non-Governmental Organizations and Health in Developing Countries

Andrew Green Senior Lecturer in Health Planning and Economics Nuffield Institute for Health University of Leeds

and

Ann Matthias Lecturer in Voluntary Sector Policy and Management Nuffield Institute for Health University of Leeds

First published in Great Britain 1997 by MACMILLAN PRESS LTD Houndmills, Basingstoke, Hampshire RG21 6XS and London Companies and representatives throughout the world

A catalogue record for this book is available from the British Library.

First published in the United States of America 1997 by ST. MARTIN'S PRESS, INC., Scholarly and Reference Division, 175 Fifth Avenue, New York, N.Y. 10010

Library of Congress Cataloging-in-Publication Data Green, Andrew, 1952-Non-govemmental organizations and health in developing countries I Andrew Green and Ann Matthias. p. em. Includes bibliographical references and index.

I. Medical care-Developing countries. 2. Non-governmental organizations. 3. Medicine, State-Developing countries. I. Matthias, Ann, I 950- . II. Title. RA395.D44G744 1996 362.1'09172'4--dc20 96-27850

CIP

© Andrew Green and Ann Matthias 1997 Softcover reprint of the hardcover 1st edition 1997 978-0-333-63874-3

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ISBN 978-0-333-68431-3 ISBN 978-0-230-37120-0 (eBook)DOI 10.1057/9780230371200

ISBN 978-0-312-16428-7

ISBN 978-0-312-16428-7 (cloth)

Contents

List of Figures and Tables viii Preface X

Acknowledgements xiv List of Abbreviations XV

1 NGOs: The Emerging Third Sector? 1 Health Sector Organizations 3 Health and Development Policy Trends 8 NGOs in the Health Sector 16 Summary 21

2 What are NGOs? 23 Some Definitions of NGOs 25 Primary Characteristics 25 Secondary Features 29 Types of NGO Operating in the Health Sector 32 Summary 37

3 Do NGOs have a Comparative Advantage in the Health Sector? 39 Introduction 39 Views and Attitudes to Health and Health Care 39 Health Sector Roles and Functions 41 Policy Setting and Service Objectives 46 Ability to Raise Revenue and Resources 51 Comparative Advantage in Service Provision 53 Quality Assurance and Regulation 57 Comparative Advantage of Individual Organizations

versus the Sector 59 The Way Forward 59 Summary 61

4 International NGOs: Doers or Donors? 62 Types of INGO 62 INGO Roles 65 INGO Issues 69 Summary 73

v

vi Contents

5 Country NGOs: Is There Strength in Diversity? 74 Cross-cultural Diversity 74 Diversity within Countries 74 Sub-groups within the CYNGO Sector 77 CYNGO Issues 84 Summary 86

6 NGOs and Health Sector Policy 87 Government Policy Concerning NGOs 88 Policies and Plans of NGOs 99 Role of NGOs in the Setting of Government Policy

and Plans 100 Policies of NGOs relating to Government 101 Policies of CYNGOs towards other NGOs 102 Policies of INGOs 103 Donor Policies related to NGOs 105 Summary 108

7 Zimbabwe: A Country Case-study 110 Background to the Research 110 The Health Sector in Zimbabwe 112 NGOs in the Health Sector 113 Summary 123

8 Resourcing NGOs 124 Sources of Resources 124 Funding Flows 133 Implications 146 Summary 150

9 External Accountability: A Neglected Dimension? 151 The Concept of Accountability 151 External Stakeholders 155 Mechanisms for Measuring Accountability 161 The Role of Governing Bodies in Maintaining

Accountability 163 Summary 164

10 How do NGOs Need Strengthening? 165 NGO Growth and Development 166 Basic Features of NGO Institutional Capacity 167 Operationalizing Institutional Strengthening 179 Summary 181

Contents vii

11 NGO Co-ordination: No Easy Answer 182 Introduction 182 Benefits of Co-ordination 185 Dimensions of Co-ordination 186 NGO Co-ordinating Bodies 187 Issues for NGO Co-ordinating Bodies 191 Operational Co-ordination 193 Summary 195

12 NGOs in the Next Millennium: Will the Bubble Burst? 196 Future Scenarios 196 Key Messages 198 Last Word 201

Notes and References 203 Bibliography 213 Index 222

List of Figures and Tables

Figures

1.1 Organizations providing health care 2 2.1 Examples of decisions required by NGOs 29 2.2 Primary features of NGOs and other organizations 30 3.1 Health sector functions 40 3.2 Situations in which NGOs may have a comparative

advantage over government 60 5.1 Framework of NGO-client relationships and activities 80 5.2 Skill-status framework 82 5.3 Task-skill-status framework 83 6.1 Policy relationships 89 6.2 Development of government policies towards NGOs 92 6.3 Strategic questions for NGOs 99 6.4 Key policy questions for INGOs 105 7.1 Zimbabwe health planning process 115 7.2 Comparisons between different health service providers 118 7.3 Govemment-NGO registration 121 8.1 Funding flows 134 8.2 Income levels for top 45 UK-based INGOs 137 8.3 Sources of funding for 15 major UK INGOs 140 8.4 Sources of internal tensions within NGOs around funding

and service provision 149 9.1 NGO external stakeholders 156 10.1 Interdependent components of institutional strengthening 168 10.2 The six phases of institutional strengthening 180 11.1 The competition-control continuum 182

Tables

1.1 Alternative characteristics of public and private providers 8 1.2 Indicators of inequity in resources and health needs 10 1.3 Growth in NGOs in Zimbabwe: dates of commencement 17 2.1 Strategies of development oriented NGOs: for generations 34 3.1 Alternative health sector models 42 5.1 NGOs in Zimbabwe reporting activities 76 6.1 Examples of policy tools available to government 96-7

viii

List of Figures and Tables ix

6.2 Alternative mechanisms for donor support to NGOs 106 8.1 Advantages and disadvantages of alternative sources

of resources 125 8.2 Sources of funding for health sector NGOs in Zimbabwe 135 8.3 Sources of funding for top 45 UK-based INGOs by band 138 8.4 Sources of funding for top 45 UK-based INGOs as a

percentage of total 138 8.5 Sources of funding for 15 major UK-based INGOs 139 8.6 Sources of funding for 15 major UK-based INGOs as a

percentage of total 141 8.7 Main categories of expenditure for top 45 UK-based

INGOs by band 143 8.8 Main categories of expenditure for 15 major UK-based

INGOs 144 8.9 The share of official aid going to NGOs: selected donors 145 8.10 The share of total NGO income derived from official

funds: selected donors 146 10.1 Differing operational opportunities and constraints 176 11.1 Inter-organizational relationships 184

Preface

Interest in non-governmental organizations (NGOs) operating in the health sector of developing countries is growing rapidly. This is for a variety of reasons. Whilst twenty years ago health development strategies focused on the public sector, there is now increasing recognition of the role that NGOs play in many countries. This acknowledgement of NGOs is coupled with and indeed fed by a growth itself in the numbers of NGOs. Second, the health sector itself in many developing countries is currently undergo­ing intense scrutiny. Its failure in the last twenty years to make significant sustainable inroads into the low levels of health, together with wider and frequently more ideological concerns and international pressures, has led to challenges to the previously broadly accepted State domination of the health sector. If Primary Health Care was the issue of the 1980s, Health Sector Reform has replaced it in the 1990s. This interest in the configura­tion of the health sector and the desire for a fresh look at the roles of all the potential actors has confirmed, if not accelerated, an interest in NGOs in the health sector. These previously neglected actors in the health scene are emerging and often being hailed by donors as the vanguard of the way forward.

This growing attention to NGOs is not confined to the health sector. Indeed to some degree interest in the health sector has lagged behind that applied to NGOs working in the more general community development fields. This is reflected in the publications that have arisen out of and indeed fed the growing concern with NGOs. There is now a number of journals which either specialize in the NGO sector or particularly encour­age contributions related to them. 1 There is also, as the bibliography at the end of the book demonstrates, an ever-expanding range of books on NG0s.2 However, there are two clear gaps in the literature. First there is still little written which focuses on the specific characteristics of NGOs operating in the health sector. Second, a significant section of the literature focuses primarily on the NGO sector or its individual constituent organ­izations in isolation from its wider place within the overall health sector.

This book attempts to fill that gap, by focusing on NGOs operating in the health sector and on the relationships between health NGOs and the State. Whilst it deliberately avoids specific policy prescriptions, recogniz­ing that policy must be context-specific, it sets out and discusses the main issues that need consideration in the development of policies concerning the role of NGOs in the health sector. Such policies are, in many countries,

X

Preface XI

sadly lacking and yet are clearly critical in such a period of structural change. As such the book is an introductory text aimed at people either working in the government, NGOs or donor agencies who have, or should have, a policy development role. While the book is primarily written for those working in or studying the health sector, it is hoped that a number of the issues cross sectoral boundaries and may be of interest to policy­makers in other sectors.

A number of themes run through the book. First there is, perhaps self­evidently, a belief that although the NGO sector does have an important role to play in many countries its potential can only be maximized through a critical acceptance and understanding of this potential. There was a period in the mid-1980s when the international policy pendulum swung from disin­terest in the NGO sector to the other extreme of enthusiastic and unquestion­ing suggestions that NGOs provided a general panacea for all the problems of the health sector. We have already referred to the danger of policy blue­prints; linked to this is the need for a recognition that each of the many agents in the development of health policy brings a different set of issues and backgrounds to the process. One of the potential consequences of the interest in alternative health care providers advocated by Health Sector Reformers is the danger that the critical need for a cohesive health policy is lost. Within the overall policy development process, we make no apolo­gies for a stance that assumes the need for the development and regulation of such a cohesive policy. We believe that such an overarching framework needs to be set by government, and that in the absence of such a policy the efforts of individual agencies and organizations such as NGOs may not be maximized and indeed may be counter-productive.

There are, however, two important caveats to this. First, we recognize that in a number of countries the democratic processes are currently weak and that as a result government may not be accountable to the broader society. This causes difficulties for NGOs in terms of their view of the legitimacy of a government policy, and we recognize that in extreme cases of repressive authoritarian governments NGOs may need as a minimum to keep a distance from such a government. Indeed they may feel a respons­ibility to the broader public as a source of alternative perspectives which come close to oppositional politics. Whilst such positions are understand­able, it is also important that NGOs themselves recognize that their own accountability to the general public may itself be fragile. Indeed the ques­tion of NGO accountability is one of the themes of the book. Within the context of this book, we concentrate on situations where there is a degree of democratic accountability within government, albeit one which may require strengthening.

xii Preface

The second caveat is that government's role as a policy-setter should be built on a process that encourages inputs from non-State organizations including NGOs. Government policy-making in many countries is charac­terized by introspective and defensive attitudes which fail to recognize the potential importance of alternative views.

* * * The book draws on a number of sources. First of all, our own individual interests in the area stem from quite different professional backgrounds. The background of one of us (AG) has been predominantly work within the public health sector in the development of policy and planning sys­tems. This has led to a recognition of the failure of many governments to address the question of their relationship with the NGO sector. In contrast, the other author (AM) has spent a considerable part of her working life in health NGO settings. Second, both have been involved since joining the University of Leeds with teaching, consultancy and research in the area of NGOs. A recently completed research project into the role of NGOs forms part of the material for the book. We also continue to be involved in vari­ous projects involving NGOs which provides opportunities for practical experience of the issues we have attempted to cover. Lastly we teach a postgraduate course in the area of NGOs in the health sector. The experi­ence and insights of students from a variety of country and professional backgrounds on this course has been a continuing source of stimulus. It has also been one of the spurs to the production of this book as we realize the lack of suitable literature for students in this area. As such the book covers a broad spread of issues that are considered essential for an under­standing of NGOs and health in developing countries. Those interested in pursuing any of these in greater depth are referred to the bibliography at the end of the book.

* * * The book is broadly divided into two sections. The first (Chapters 1 to 7) looks at a number of issues facing the NGO health sector. It starts with a review of the history and development of the current situation facing the health sector in developing countries and the position of NGOs within it. Chapter 2 focuses on definitional issues of what is meant by the term NGO. The third chapter addresses the question as to whether NGOs have any comparative advantage over government in the health sector, a critical question for the development of policy. This is followed by two chapters

Preface xiii

that focus first on international NGOs and then on country-based NGOs. Chapter 6 examines various aspects in the formation of policy by dif­ferent organizations involved in the health sector including government, NGOs and donor agencies. The first section then concludes with a country case-study. We make no suggestion that Zimbabwe is (or indeed could be) representative of the situation in other countries. Indeed it would be im­possible to find any such single representative given the diversity of con­texts. However, the case-study is presented in order to illustrate a number of the issues which arise in the first set of chapters.

The second half of the book picks up and examines a number of themes. Chapter 8 looks at the question of resourcing NGOs. This is followed in Chapter 9 with an analysis of accountability, a theme to which we have already referred. Chapter 10 focuses on capacity-building in NGOs. The penultimate chapter addresses questions relating to the co-ordination of NGOs and mechanisms for this. The book concludes with a discussion of likely future trends in the area of NGOs and their role in the health sector.

Within the book we have attempted to avoid unnecessary jargon and acronyms. However, we have resorted to the use of three acronyms relat­ing to NGOs throughout the book. We use the term NGO to refer to all non-governmental organizations, the term INGO where we refer specific­ally to International NGOs and CYNGOs to refer to NGOs that operate either at the national or community level within a single country.

It is well recognized by both of us that the book raises far more ques­tions than it answers. This, however, is in the nature of the development of policy in new fields. It is hoped that readers will be encouraged them­selves to seek answers to these questions in a manner that results in greater cohesion and effectiveness in the health sector.

Notes

1. Examples are Development in Practice and Voluntas.

ANDREW GREEN

ANN MATTHIAS

2. In this book we have referred to a large range of publications, and provided a long bibliography. Some very recent publications in the broad area of NGOs include: Bennett (1995), Edwards and Hulme (eds) (1995), Fowler (1996) and Hulme and Edwards (eds) (1996).

Acknowledgements

We would like to acknowledge a number of people and organizations who have in one form or another contributed to the completion of this book. First of all, colleagues at the Nuffield Institute and particularly those in the International Division and Information Resource Centre have helped in a variety of ways including ideas, information and general support. Second, we would like to thank staff of the Ministry of Health and the University of Zimbabwe for their collaboration during the field research which forms a part of this book. This research was funded by the UK Government's Overseas Development Administration for which we are grateful, though of course the usual disclaimers concerning the views expressed here apply. Third, we have benefited from ideas and comments from individuals too numerous to mention by name including staff of NGOs and students at the University of Leeds and elsewhere. Five individuals do, however, need mentioning by name. Margaret Kaseje and Sidney Ndeki, both PhD stu­dents whose positive criticisms were welcome, and Mike Edwards, Head of Infmmation and Research at Save the Children Fund (SCF) whose comments on an earlier draft were invaluable. Mary Green, of Manchester University, and David Green, of Voluntary Service Overseas, both pro­vided many helpful insights.

Lastly we would like to thank both our families for their support dur­ing many long weekends and late hours of writing. It has been much appreciated.

xiv

List of Abbreviations

AMREF BRAC CAFOD CYNGO DDC DEC DHE DHT DRIC

DSW EC ESAP FP GAD GOBI-FFF

GoZ ICRC INGO IPPF JFS MCH MoH NAN GO NASCOH NGO ODA

ODI OECD PHT PMO PVO SAARC SCF

African Medical and Research Foundation Bangladesh Rural Advancement Committee Catholic Fund for Overseas Development Country Non Governmental Organisation District Development Committee Disasters Emergency Committee District Health Executive District Health Team Department of Regional and International Cooperation (of GOZ) Department of Social Welfare European Community Economic Structural Adjustment Programme Family Planning Gender and Development Growth monitoring, Oral rehydration, Breastfeeding, Immunisation-Family spacing, Female education, Food supplementation Government of Zimbabwe International Committee of the Red Cross International Non-Governmental Organisation International Planned Parenthood Federation Joint Funding Scheme Maternal and Child Health Ministry of Health National Association of Non-Governmental Organizations National Association for the Care of the Handicapped Non-Governmental Organisation Overseas Development Administration (of UK Government) Overseas Development Institute Organisation for Economic Cooperation and Development Provincial Health Team Provincial Medical Officer Private Voluntary Organisation South Asian Association for Regional Cooperation The Save the Children Fund (UK)

XV

xvi

SIDA UNICEF US AID VSA vso WHO WID

List of Abbreviations

Swedish International Development Authority United Nations Children's Fund United States Agency for International Development Volunteer-Sending Agency Voluntary Service Overseas World Health Organization Women in Developmen