People's Health Assembly 2012: Global Health Initiatives, Civil Society and the Evolution of Accountability, Part 3: ART and Accountability in South Africa
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  • District government often sidelined in setting up of relationships


  • 1. NGOs, Antiretroviral therapy (ART) and Accountability in South AfricaEU-funded GHI INCO-DEV Project School of Public HealthAnnie Neo Parsons University of the Western CapeDr Johann CailholDr Thuba MatholeProf David Sanders
  • 2. ART in South Africa• Government ART service delivery problems: financing, human resources, access• Service delivery NGOs help provide cover where government struggles – Service delivery role (or ‘Operational’): provides tangible and in- tangible services – Advocacy role: “create and maintain political spaces in democratic discourse for often disadvantaged [communities].”• “NGOs are formally accountable to limited constitutents” – Who are an NGO’s constituents? – Does an NGO have clients or constituents?Doyle C. and Patel P. (2008) ‘Civil society organizations and global health initiatives: problems of legitimacy’ in Soc Sci Med66:1928-1938Evans B. and Shields J. (2006) Neoliberal restructuring and the Third Sector: Reshaping Governance, Civil Society and LocalRelations. Centre for Voluntary Sector Studies Working Paper Series: Ryerson University Faculty of BusinessKilby P. (2004) Accountability for Empowerment: Dilemmas facing non-governmental organizations. Asia Pacific School ofEconomics and Government Discussion Papers: The Australian National University
  • 3. ART funding and GHIsGFATM Board•Donor governments•Developing country governments•Civil and private sector U.S. Government•Non-voting members Global Fund to U.S. President’s fight AIDS, TB Emergency Plan and Malaria For AIDS Relief Service Country recipient delivery NGOs Community-level ART services
  • 4. Preliminary taxonomy• Local level findings (facility, district) and relation to provincial/national structures• Three basic types of NGOs providing ART services in public health facilities – HR-focused (trainings; clinicians, data capturers, CHWs)• Defining issues: – External resources (in SA, almost all PEPFAR) – Community involvement – Management localityOssewaarde R., Nijhof A., Heyse L. (2008) ‘Dynamics of NGO legitimacy: How organizing betrays core missions of INGOs’ inPublic Admin. Dev. 28:42-53
  • 5. Large NGO working locally• History – Shift of services to HIV-centred work – Directly approached facility to offer services, sometimes after going through province/national• Funding – External resources (mostly PEPFAR)• Operations – NGO clinical staff provide ART services – Management based at provincial not local level
  • 6. “Large NGO acting small”• History – Shift of services to HIV-centred work – Approached district, consultation with province• Funding – External resources (mostly PEPFAR)• Operations – ART services provided by NGO staff – Management based at local level (near district offices)Kilby P. (2004) Accountability for Empowerment: Dilemmas facing non-governmental organizations. Asia Pacific School ofEconomics and Government Discussion Papers: The Australian National University
  • 7. Local NGO• History – Community developed and managed• Funding – External resources (mostly small private funders)• Often aware of funding implications – In one case, refused direct PEPFAR funding• Operations – ART services provided by volunteer staff – Management based at community level
  • 8. An accountability gap• “There’s a big difference between spending money on a community and working with a community”• Accountability to constituents not required of NGOs – People cannot automatically hold an NGO to account, especially when they have limited alternatives to the offered service• However, accountability to stakeholders is required – Donor accountability usually financial/target-driven – Impacts on ability to be accountable ‘downwards’Lief W. (2006) ‘Accountability in International Development Aid’ Ethics and International Affairs 20:1-24
  • 9. To Conclude• NGOs should clarify if they work for or with communities• NGOs must clearly state who are their constituents – What is “the community”? (People within a geographic area, patients attending a facility, etc) – Is local government a proxy for communities? – Are Community Health Workers proxies for communities?• Ultimately: do NGOs determine a community’s needs, or do a community’s needs determine an NGO’s work?