International NGOs and Global Health GH 101 February 2016 Stephen Gloyd, MD, MPH Professor, Departments of Global Health & Health Services University of Washington

Class case Study: Students will work in groups of 4-6 to create a role play exercise in a case study related to the lecture. All students should participate 2-3 students will play the roles of MOH workers (at national, regional, or local levels) 2-3 students will play the roles of donor or NGO workers. Be creative! 1-2 role plays will be selected for presentation in front of the class. In Zimbabwe, PEPFAR's largest NGO partner, called International AIDSCare (IAC), has just been funded to initiate a nationwide system, within the Ministry of Health (MOH) to provide mobile antenatal care to expand HIV testing (and other aspects of basic antenatal care) to hard to reach rural areas. The NGO has been granted plenty of resources to fund this new activity throughout the area where IAC is supporting the MOH. This activity will very likely improve the image of IAC in the view of the donors. The improved image will likely result in expanding their funding. The MOH - at a central level - is skeptical of this activity, since they are uncertain that the mobile antenatal care could be scaled up or sustained. However, the MOH staff at local levels are excited about the program since the mobile activities will provide opportunities for them to receive per diems. Per diem payments for just one day are equivalent to about days of salary for them. Furthermore, there are a few MOH officials at the central level who want to support the NGO partner since they may want a job with them in the future. How should the national level MOH respond, and how will the NGO respond to the MOH?

Agencies in International Health National Agencies – (usually recipients) Ministries: Health, Education, Planning etc. Universities: U Zimbabwe, Zambia, Nairobi, Makerere, AAU Churches Other agencies (KEMRI, AMREF, IFIKARI) Local NGOs (BRAC, Akwaba, Kubatsirana, Ariel) Private sector (multinationals Anglo-American, Bilateral Agencies USAID, CDC, DfID, SIDA, etc Foundations (Gates, Ford, Kellogg, Packard, Rockefeller, Aga Khan, Tata, Slim) International NGOs: (BINGOs) Non-Profits & Profits (CARE, Save The Children, World Vision, OXFAM, Chemonics, MSH, MSF, FHI, PATH, HAI) Often linked to Universities, Churches/Religion, Political Agencies Multilateral Agencies World Bank (IBRD), IMF Regional Development Banks OPEC Special Fund (Organization for Petroleum Exporting Countries) Arab Fund for Economic Development United Nations Agencies WHO (Geneva, regional & country offices) UNICEF, UNDP-UN Development Program (both New York, country offices) UNFPA (UN Fund for Population Activities) FAO, WFP

Which NGOs? Some NGO ACRONYMS NGO PVO BINGO CONGO DONGO MONGO NGI NGDO Non Governmental Organization (Profit &non-profit) Private Voluntary Organization (USAID) Big international NGO Commercial NGO – set up by businesses Donor NGO – to shift overhead costs outside My own NGO Non Governmental Individual Non Governmental Development Organization (Local/Southern/indigenous NGO)

Typical activities of NGOs  Service provision  Social welfare activities  Support activities  Research  Advocacy

Non Governmental Organizations – Typology (NGOs, PVOs, VOLAGs) Religious: World Vision, Hope Muslim world league Adventist Development and Relief International Caritas, Lifeline Lutheran world federation Local churches (Catholic, methodist, etc) Local social welfare BRAC (Bangladesh Rural Advancement Com) India Institute of Young Inspirers Center for Research and (Kenya) Community Devt Trust Fund (Tanzania) Kubutsirana (Mozambique AIDS support) FPAI (IPPA affiliate), COFAP (Ethiopia) RACHA (Cambodia), Monaso (Moz-donor createdl) Unions and professional associations Mozambique Medical Association Kenya Medical Association International social welfare CARE (USA, Australia, etc) Oxfam (UK, USA, Canada) Aga Khan Foundation Save the Children Alliance (USA, others) John Snow, Int, MSF, MDM Mgmt Sciences for Health (for profit) IPPA (Intl Planned Parenthood Assoc) Family Health International PATH (Seattle), Africare Center for Communications Programs (CCP) American Refugee Committee International Rescue Committee Engineers Eithout Borders Health Alliance International (Seattle-UW) Foundations Gates, Packard, Kellogg, Pew, Rockefeller, Ford, Handleman, Soros

Russian Youth Organization – Mozambique, 1981

Comunidade Sant’ Egidio

Pakistan Eye Trust

Medical missions Has your church, organization, or institution ever sent out a short- term medical mission team? Or will you in the future? The best estimates tell us there are between 100 and 200 of these volunteer medical groups that leave the U.S. each month. However, few know the complexities of international credentialing for medical professionals, medication safety and customs clearance or the World Health Organization's (WHO) standards for practicing in developing countries. The purpose of this continuing education event is to provide tools, knowledge and strategies to help your church, school or mission program implement effective short-term healthcare missions. Topics include: *building effective cross cultural partnerships *international standards for healthcare in developing countries *best practices for global health missions Saturday March 12th 8AM to 5PM Hosted by First Presbyterian Church of Greenville 200 W Washington Street Greenville, South Carolina 29601

Health Alliance International

What is an International NGO?  Dependent on large donors (EU, USAID, The Global Fund, Gates, other bilateral donors)  Mission-driven  Need to connect mission and funding to grow  Generally accountable to donors based on outcomes and indicators  Generally less accountable to the country governments where they work

How do International NGOs fit in to the complicated global health context that we have discussed in class?

Why have NGOs grown so much?  Increasing exposure to global issues, charitable response  Ideology of anti-governmentalism Structural adjustment programs Weakened public sector health services  Agenda of foreign aid (support local agencies)  Effective lobbying by NGO groups

Investment in the public sector is in decline. as a % of GDP (constant 1995 prices) Source: Everhart and Sumlinski Public Investment in Developing Countries, From: Fiscal Space for Public Investment, UNDP, Sept 2006

Dramatic growth in DAH from

NGO Families and Revenues (adapted from Lindenberg & Bryant, 2001) NGO StartOfficesCountries With Projects Annual Revenues (2014/15 in US millions) Sources Save the Children % sponsors & private, 40% grants Plan International % sponsors Oxfam America ~2/3 private CARE ~3/4 govt World Vision ~3/4 private Medecins sans Fronteires % private

MOHDPSZ PEPFAR PMI State Department PCV

NGO characteristics  Agenda shaped by headquarters  Philosophy, religion  Training vs service  Methods of work (MSF nutrition in Zambezia)  Community based Romantic Less hassle with bureaucracy Support public sector, other local NGOs

NGO Benefits  Greater flexibility  Catalyze innovation, test new models  Bring experience gained in other settings  Access international technical expertise  Access to funds not directly available to governments  Can be more accountable to populations ignored by governments

Bilateral Donor Support to Tanzania, Source: Foreign Policy, Ranking the Rich 2004

Neo-colonization of Mozambique by donors 2002

Neocolonization by NGOs in Mozambique 2008

Foment disruptive turf wars NGO1 NGO2

How does US Aid Money Flow? Non Governmental Organizations (NGOs) Staff support (cars, housing, offices, etc) USA Funding Ministry of Health (MOH) Direct service delivery High Staff Salaries Local NGOs Indirect Costs Funds “Phantom aid:” Countries receive 20-40% of aid value

Phantom Aid The world's richest nations greatly exaggerate their aid to poor countries – with the US, the worst offender...some two-thirds of the money donated by the world’s wealthiest countries is in actuality “phantom aid” that is not genuinely available for poverty reduction in developing countries. This includes aid that is, among all G7 donations: · not targeted for poverty reduction, estimated to be worth US$4.9 billion · double counted as debt relief, totaling US$9.4 billion · overpriced and ineffective- Technical Assistance, estimated at US$13.8 billion · tied to goods and services from the donor country, estimated at US$2.7 billion · poorly coordinated and with high transaction costs, estimated at US$9 billion · too unpredictable to be useful to the recipient – lack of data prevents an estimate · spent on immigration-related costs in the donor country; totaling US$1.5 billion · spent on excess administration costs; totaling US$0.4 billion.

Donor assistance and internal brain drain Non Governmental Organizations (NGOs) -high salaries, benefits -good work conditions Donor funding Ministry of Health (MOH) -low salaries Local in-country organizations -higher salaries Funds Trained technical staff flow Funds “white follows green” Nurses, Doctors, etc Nurses, Doctors, etc

Common problem in NGO-driven health economies: Divert aid funds from public sector services

Push pet projects of questionable value

Contribute to local inequality

Inequalities created by donors & NGOs  Expatriate staff become a highly visible local elite support luxury industry (luxury cars, hotels, etc) live in gated communities  Nationals working for NGOs & donors become relative elites  Large budgets and salaries push up prices for the poor  Resentment by MOH workers in other programs

Are NGOs the Velvet Glove of Privatization? James Pfeiffer, UW Anthropologist ____

NGO Risks  Vertical programming driven by donor- imposed outcomes (PEPFAR activists)  Waste/phantom aid  Internal Brain Drain/effect on HR  Lack of coordination  Sustainability/reliability  == Fragmented and inequitable health care system

Donors and NGOs usually leave when funding ends Manica Province, Mozambique NGOs present in 1994 Yellow shaded are those NGOs who left by 1998

What do NGOs typically leave behind when their projects end? Landscape of aid is littered with: Unemployed workers Community Health Workers Trained (but not supported) traditional birth attendants NGO managers Hardware (usually no longer functional) Laboratory and hospital equipment Water systems Tractors and agric equipment Vehicles that don’t work

NGOs and AIDS treatment  Most African countries received Global Fund resources for treatment  USA (PEPFAR) treatment resources mostly through NGOs  Countries divided up among NGOs  Separate drug procurement, medicines, systems  National MOHs have lost control in many places

Bush PEPFAR Initiative  $15B in 15 countries over 5 years  4 NGO recipients for HAART (CU, Harvard, CRS, Glazer $ m)  Requirements – preferences? Purchase of branded ARVs  $600 vs $140 per person per yr  No single 3-drug fixed dose combination Want rapid increase of people on treatment “Centers of Excellence” (NGO delivery)

“Centers of Excellence” “Centers of Excellence” HAART by NGOs & universities Justification……  Speed up access to ARV treatment  Provide quality care using experience of NGOs (staff, logistics, drug procurement) –but frequently with parallel systems  NGOs create innovative approaches to care – but often inconsistent with national norms  Idea is to work closely with (& strengthen) public sector – but contribute to workforce and management brain drain

Expansion of NGO role for clinical care Tanzania (Gilson, '92)  Greater perceived quality of services with NGOs  Some inherent structural inefficiencies  No outreach, increased cold chain failures, less preventive service by HWs  Often employ inadequately trained staff  Increased quality mostly related to increased resources

PHC System - for ARV treatment Starting curative care at referral site Provincial Health Center District Health Center Center District Health District Health Center ARV Care Sites - Health Post MOH support Drugs, Lab, M&E

PHC System: Expansion to District Centers Provincial Health Center District Health Center Center District Health District Health Center ARV Care Sites - Health Post MOH support Drugs, Lab, M&E

PHC System Expansion to some Health Posts Provincial Health Center District Health Center Center District Health District Health Center MOH support Drugs, Lab, M&E Care Sites - Health Post District Health Center

PHC System Expansion to most Health Posts Provincial Health Center District Health Center Center District Health District Health Center MOH support Drugs, Lab, M&E Care Sites - Health Post District Health Center

Typical NGO Approach Coverage and system support Provincial Health Center District Health Center Center District Health District Health Center Care Sites - NGO 1 supportNGO 2 support MOH support Drugs, Lab, M&E Health Post

MOH NGO MOH NGO

Guro Tambara Chemba Maringue Macossa Sussundenga Machaze Machanga Muanza Cheringoma Chibabava HF Providing HAART (new) 7 (5) PLWHA Registered 18,600 Eligible in HAART 2,520 Eligible <15 y in HAART 150 All TB treatment sites in Sofala trained for testing for HIV (22) 26 facilities with pMTCT HIV Treatment Expansion 2005 CS HCB HR HPC HG

Guro Tambara Chemba Maringue Macossa Sussundenga Machaze Machanga Muanza Cheringoma Chibabava Facilities providing HAART 53 at end FY07 87 by FY 09 HIV+ Registered 180,000 Eligible in HAART 45,000 Children <15 y in HAART 5,000 All TB treatment sites in Sofala and Manica testing for HIV; improved TB diagnosis for PLWHA 202 facilities with pMTCT (2007) HIV Treatment Expansion Plan CS HCB HR HPC HG Pending

Ministry of Health characteristics  Slow, bureaucratic  Dependent on a few key people (who travel all the time)  Health workers frequently absent (due to training & per diems)  Workforce expansion is a principal bottleneck & limited by Ministries of Finance BUT:  Has broad health network – more capable of broad coverage for poor  Sometimes best option for sustainable systems & rapid access  Basket funding has been implemented to rationalize donor inputs

Public sector systems can work Rural Hospital in Mozambique Physician in Pharmacy

NGOs in developing countries (1) AdvantagesDisadvantages Don't need to work through governments (bureaucracy, inflexible, corruption, etc) Don't need to work through governments (less accountability, sustainability) Accountability is principally to funder Institutional memory can be limited ("re- learning") Higher quality, more efficient servicesOften less efficient – org structure, staff (studies) Inexpensive, salary flexibilityCan be expensive (expatriates, overhead rates) Salaries often paid by govt (for services) Inappropriate salary incentives (per diems, top- ups, high differentials & resentment)

NGOs in developing countries (2) AdvantagesDisadvantages Do not necessarily represent public or strategic interests Agendas shaped by headquarters -Philosophy: fit with environment? -Religion: Proselytizing Can work in countries where bilaterals, multilaterals do not work (Angola, Eritrea) Work mainly in countries where bilaterals, multilaterals fund (Mozambique vs Cuba) Tend to be community based, people centered -Advocacy work raises aspirations -Help organize people Tendency for direct action rather than institution building (often easier to attain results) Small size, scope of impact Training, procedures often at odds with govt norms Creation of parallel institutions Can bring new ideas to less agile bureaucracies -fast adoption of "best practices" -react quickly to developing needs Ideas usually represent "fashionable" ideas from bilaterals and multilateral funders, e.g., Cost recovery, privatization, CHWs, TBAs, vertical programs (EPI, VitA, ORT, EOC, etc)

NGOs in developing countries (3) AdvantagesDisadvantages Bring money to poor countriesMoney often goes more to home than host countries Tied aid from donors Bring expertise to countries with human resource weaknesses Expertise is often mixed (young hires, difficult to meet language, experience requirements) External (independent) management structure Management burden on national institutions -Different funding and planning cycles -Different geographic, program areas than in MOH -Turf wars, jealousies -Different styles (Methods of work, mgmt systems

Efforts to improve NGO/Donor effectiveness  The three ones: 1 plan 1 Monitoring and Evaluation system 1 Coordinating body  Paris Declaration Target on mutual accountability (mutual assessment reviews) 50% of TA flows are implemented through coordinated programs consistent with national development strategies. 85% of aid “on budget”  This signals a greater move towards accountability but…the target is not clear  Mutual accountability must result in meaningful change – not just tinkering

PARIS DECLARATION ON AID EFFECTIVENESS, March 2005 Reform the delivery and management of aid - five main principles:  Ownership: Partner countries exercise effective leadership over their development policies and strategies and co-ordinate development actions  Alignment: Donors base their overall support on partner countries’ national development strategies and procedures  Harmonisation: Donors’ actions are more harmonised, transparent and collectively effective  Managing for Development Results  Mutual accountability: Donors and partners are accountable for development results

Are there alternative models to support poor countries? Yes. Cancel debt of poor countries Reverse structural adjustment programs Fund the public sector, including recurrrent costs  Increase MOH workforce & pay living wage  Improve maintenance and rehabilitation of government health facilities  Support MOH management and procurement – workers, drugs, lab  Local governments and institutions should hire NGOs and expatriates to provide technical assistance

“NGOs would gain a great deal in credibility and sustainability if, instead of substituting the state, they opted to reinforce public institutions from the grassroots to fulfill their mission vis-a-vis the population and do the work for which they are intended.” Eys, 2002

An alternative model to donor assistance ‘Basket funding’ to the public sector, including recurrent costs  Increase government workforce (especially nurses and teachers) & pay living wage  Improve maintenance and rehabilitation of government health facilities  Support MOH management and procurement – workers, drugs, lab  MOH can hire NGOs and expatriates to provide technical assistance

David Damberger EWB TED talk

Aid as “Accompaniment” adapted from Farmer, et al, Chapter 10 Reimagining Global Health  Involve local systems  Buy and hire locals  Funding public systems/institutions that the poor identify with  Job creation  Base your work on evidence  Co invest with government to build strong public institutions  Regulate international groups

There are ways of improving NGO behaviors (2008)

NGO Code of Conduct (HAI, PIH, Oxfam, Action Aid) for Health System Strengthening (1) Hiring practices that ensure long-term health system sustainability (2) Compensation practices that strengthen the public sector - Limit pay inequity between the public and private sectors, and - Compensate community health workers. (3) Human resources support for local health systems - Support increases in the number and capacity of health professionals. (4) NGO management support for MOHs (5) Health system community support - Support communities’ linkages to health systems while promoting government accountability. (6) Advocacy to eliminate wage bill caps and limitations on health system investment promoted by IFIs.

NGO Code of Conduct (Detail)  Commitment to meaningful joint planning with Ministries of Health. From the earliest stages, before the NGO begins working in country Real collaboration as opposed to rubber stamp approval Includes joint planning of budgets, implementation and evaluation including indirect costs and other HQ costs related to projects  Joint Management of project implementation. Includes ongoing sharing of budgetary and financial information  Commitment to follow government and health ministry norms and procedures, especially as they affect geographic and programmatic administrative areas, labor and personnel policies. In areas where government norms are dictated or influenced by outside institutions and may themselves lead to weakened health systems, NGOs should commit to work with local stakeholders to advocate for change. This may include advocacy for living wages both in the national and international arena.

NGO Code of Conduct (detail)  Commitment to respect pay equity. Limits on inequities between expat and local and between NGO and MOH pay differences.  Commitment to limit hiring out of public systems. Permission to hire should be granted by the Ministry of Health and personnel hired by NGOs should have the option to return to the public system.  Support standardization of incentive policies across all NGOs, donors and international organizations. If they exist, follow ministry norms for such incentives.  Work to mitigate the deleterious effects of vertical funding programs. Commitment to build primary health care systems and use funding in ways which will most benefit comprehensive primary care. Advocate with donors for more flexibility in funding programs.  Commitment to fairly compensate for work done by all employees, including community health workers. Support standardization of policies to fairly compensate community health workers.

Code of Conduct questions?  Enforcement?  Advocacy tool?  Indicators for compliance?  Donor adoption?  Ministry of Health adoption?

What to do as expatriate health workers?  Understand (and reduce?) salary inequalities  Work within the national health system  Follow national systems and guidelines  Be sensitive to resentments that might be present  Observe and document what you see

Thank you!