1. INGO Capstone Paper 2014
Sarah DeCloux
7/11/2014
WebsterUniversity
FrancoisRubio

2. 1
Introduction:
Many developing countries have reported that while NGO assistance may have
good intentions, often their efforts undermine and contribute to the unsuccessful
implementation of government run public health systems. Really the issue comes
down to what is best for the citizens of developing countries? Most NGOs’ projects are
designed for short term assistance (3 years or less), but developing country
governments are working towards sustainable health systems based on long term goals
and achievements. The focus of this capstone paper will be to analyze the complex
dynamics between donors, NGOs and developing Ministries of Health and to gain some
insights as to how these entities can cooperate in the future in order to make health
care more synergistic.
Relevance:
This topic is very relevant in light of the new efforts of the WHO and others to
ensure universal health coverage worldwide and the ever growing need for the
expansion of health services in developing countries. In addition, thousands of NGOs
primarily focus on projects which are aimed at specific illnesses (i.e. HIV/AIDS, TB,
malaria, diabetes, immunizations, etc.) and specific people groups such as women
and children to garner maximum funds for their projects. These tailored focuses
exclude a large quantity of the population and do not assist governments in
establishing sustainable programs to provide essential health care for the entire
population; for once the project is over, many times the NGO packs up leaving empty
gaps in health services of the community where they once worked. It is essential, at
this time, to develop a new conceptual framework for how NGOs interact with

3. 2
government authorities and what kind of long term impact they have on the people of
developing societies.
Research Question:
My research question is: how can NGOs and governments work together toward
the same goals to improve sustainable health systems and allow their combined
efforts to become synergistic? To accomplish this I will first discuss the literature that
has been written about this topic in order to get a well-rounded perspective.
Secondly, I will focus on three case studies which demonstrate the most pressing
issues faced by governments, NGOs, and aid donors; but also give an example of one
collaborative effort that has paid off for both the developing country and the NGO
involved in this case. Finally, I will conclude the result of my findings. I expect to find
that changes need to be made to the current framework, further collaboration should
be explored, and practical, realistic measures must be put into practice. For
clarification, the NGOs referred to in this paper are considered to be International
NGOs with humanitarian causes, not emergency relief NGOs.
Literature Review:
Throughout my research of the existing literature I have found three major
perspectives: those who feel the current framework of how NGOs, donors, and
governments interact needs to change; contributions that have been made to the
framework already, and the views of society members who receive foreign aid and
assistance.

4. 3
In the first group of perspectives Kevin Sansom conducted qualitative, case
studies in three developing countries analyzing the roles and interaction between
NGOs and government officials. One of his main themes is the differences between
these two actors which complicates collaboration. Sansom states, “Reconciling such
difference has been difficult for many NGOs that work with local government, often
leading to tensions and non-productive engagement.”1 Through his research he also
found that trust is a large factor in whether governments and NGOs can work together
successfully. He insists that building relationships is integral to overcoming the barrier
of mistrust. Sansom also made a keen observation noting that in light of increasing
donor involvement with governments, NGOs must be prepared to change their ways of
working from small to larger programs which are monitored closer by donors and
governments.2
Erin Polich, an NGO Health Coordinator, has proposed a transition for NGOs
from sole humanitarian action to thinking about the concerns of developing countries.
It is no longer good enough to provide assistance, but to consider the consequences of
your actions. She emphasizes that the new roles for NGOs must, “align with
overarching MOH policies and goals.”3 She also underlines that NGOs need to have a
1
Kevin Sansom, "Complementary Roles? NGO-Government Relations for Community-Based Sanitation in
South Asia," Public Administration and Development 31 (2011), accessed July 8, 2014,
doi:10.1002/pad.609.
2
Kevin Sansom, "Complementary Roles? NGO-Government Relations for Community-Based Sanitation in
South Asia," Public Administration and Development 31 (2011), accessed July 8, 2014,
doi:10.1002/pad.609.
3
Erin Polich, "The Role of NGOs in a Changing Environment" (speech, Joint Donor Team Event, March
27th, 2013).

5. 4
greater role in consultation in regards to human resources development, system
development, policy development, and advocacy. Polich points out several barriers to
this transition such as funding uncertainties, developing partnerships, low human
resource capacities, and physical infrastructure. In her assessment NGOs must,
“Continue to focus on humanitarian relief while and at the same time long term
development.”4 From her perspective the paradigm shift should focus on system
strengthening and advocacy for integrated service delivery. And in regards to NGO
exit strategy she stresses the importance of capacity building and supporting
sustainable government plans.5
Perhaps the most persuasive article for NGO transformation is a paper written
by Jessica Maltha. In her paper she explores the idea that NGOs do not live up to their
hype and that the, “Current NGO model is deteriorating the public primary health
care programs.”6 She strongly urges the reader that while many donors do not trust
developing governments because of their history of corruption, many NGOs’ cost-
effectiveness or efficiency is as bad if not worse than current developing
governments. Maltha underlines that those NGOs who hire local staff often over pay
them compared to local standards which causes immense brain drain in developing
countries and pulls national health professionals away from their roles in the public
4
Erin Polich, "The Role of NGOs in a Changing Environment" (speech, Joint Donor Team Event, March
27th, 2013).
5
Ibid
6
Jessica Maltha, "NGOs in Primary Health Care: A Benefit or a Threat?," Global Medicine, 2012,
accessed July 08, 2014, http%3A%2F%2Fglobalmedicine.nl%2Fissues%2Fissue-7%2Fngos-in-primary-
health-care-a-benefit-or-a-threat%2F.

6. 5
health system. She highlights a major problem with NGOs that often, “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 programs.”7 In the end all of these
issues undermine the public sector health system and promote unsustainable health
care. To this end she concludes that the current NGO model needs to change and sites
several potential solutions to these troubling issues.8
The second perspective is that of authors who point out contributions which
have already been made to transitioning the NGO model. The first of the authors,
Batley and Rose, produced a case study of three developing countries: Bangladesh,
India, and Pakistan; in which they discuss the how NGOs have changed their
approaches to collaboration with the governments in these countries and particularly
NNGO partnerships that make NGOs jobs easier and more in line with government
plans instead of devising parallel programs. They specifically address the importance
funding plays in NGO collaboration. They emphasize three main ways NGOs have built
key relationship by strategically planning their funding, “First, there is the type of
funding: some NGOs received untied funding from voluntary subscriptions, private
donors and endowments that enabled them to engage with government without any
financial exchange. Second, regardless of the type of funding, most NGOs had
7
Jessica Maltha, "NGOs in Primary Health Care: A Benefit or a Threat?," Global Medicine, 2012,
accessed July 08, 2014, http%3A%2F%2Fglobalmedicine.nl%2Fissues%2Fissue-7%2Fngos-in-primary-
health-care-a-benefit-or-a-threat%2F.
8
Ibid

7. 6
maintained a sufficient diversity of sources to reduce dependence on a particular
source. Third, rather than having their interests directed by the source of finance, as
Rose, find some NGOs were able to reverse this by seeking the funder that shared
their purpose.”9
From a more specific perspective, Mogedal writes an article encouraging
Norwegian Aid policy to conform to a plan wisely when distributing aid. This also
shows a contribution on the part of developed countries to acknowledge they are part
of the problem and must consider how best to distribute aid. In her article Mogedal
points out that perpetuating dependency on developed countries has a negative
impact on the solidarity and self-interest of developing countries. She stresses that
although the health challenges of today may be more than developing countries are
able to handle, those providing aid should be providing advice, shared alliance, and
cooperation. Mogedal insists, “There is a lack of association between, money,
knowledge and policy,”10 acknowledging a disconnect between developed countries’
financial contributions and their contributions of knowledge. She summarizes her
entire paper in one simple sentence, “Global health is more than health aid.”11
Possibly the largest contribution to rethinking the current model of NGOs is the
NGO Code of Conduct for Health Systems Strengthening. This code was drafted by
9
Richard Batley and Pauline Rose, "Analysing Collaboration Between Non-Governmental Service
Providers And Governments," Public Administration and Development 31, no. 4 (2011), accessed July 8,
2014, doi:10.1002/pad.613.
10
S. Mogedal, "Global Health Is the Objective - Is Health Aid the Answer?,"Tidsskr Nor Legenforen 133,
no. 1159 (June 11, 2013), accessed July 8, 2014, doi:10.405/tidsskr.13.0459.
11
Ibid

8. 7
concerned NGOs who have themselves, made some of these same detrimental
mistakes and want to change future outcomes. The authors note that as this Code
becomes more widely adhered to, they hope that funders and host governments will
also see fit to observe these same six articles. The six fundamental articles of the
code are, “NGOs will engage in hiring practices that ensure long-term health system
sustainability. NGOs will enact employee compensation practices that strengthen the
public sector. NGOs pledge to create and maintain human resources training and
support systems that are good for the countries where they work. NGOs will minimize
the NGO management burden for ministries. NGOs will support Ministries of Health as
they engage with communities. NGOs will advocate for policies that promote and
support the public sector.”12 These articles seek to address some of the most
destructive habits of NGOs on developing countries. They reinforce government
solidarity and national self-determination and promote sound HRH and sustainable
practices. Currently there are 57 signatories to the Code, not much, but it’s a start.13
In addition Medicus Mundi has also contributed to NGO success by forming a collection
of thematic guides for NGOs to use as resource in staying informed and determining
their role in global health.14
12
"NGO Code of Conduct," World Health Organization, May 2008, accessed July 8, 2014,
http%3A%2F%2Fwww.who.int%2Fworkforcealliance%2Fnews%2FCode%2520booklet%2520lowres.pdf%3Fua
%3D1.
13
"NGO Code of Conduct," World Health Organization, May 2008, accessed July 8, 2014,
http%3A%2F%2Fwww.who.int%2Fworkforcealliance%2Fnews%2FCode%2520booklet%2520 lowres.pdf%3Fua
%3D1.
14
"Thematic Guide: The Role of NGOs in National Health Systems and Global Health," Medicus Mundi,
2014, accessed July 8, 2014, http%3A%2F%2Fwww.medicusmundi.org%2Fen%2Ftopics%2Fstrategic-
positioning%2Fngos-strengthening-or-weakening-health-systems.

9. 8
The third and final perspective comes from those who have experienced
receiving foreign aid. In her article Sabine Balk reviews several authors who argue
that microcredit and aid money has destroyed solidarity and community integration by
putting too much focus on individual welfare; dividing where it should be promoting
civilsocieties’ mutual success. Her article also endorses rejecting aid money in a
developing setting as the authors are collectively persuaded that aid money does
more harm than good. Her ultimate conclusion is that, “The overarching goal must be
to empower people to take their fate into their own hands, and that the current aid
architecture is not geared adequately to cooperation and solidarity.”15
In a review of the book Time to Listen: Hearing People on the Receiving End of
International Aid by Mary B. Anderson, this unnamed author selects several insights
sited by the book that people outside of the developing world would seldom realize.
She establishes that people, in general, are not against foreign aid, however, the
overall impact of aid is more negative than positive. Some of the insights include,
“People hate the sense of dependence and can feel it undermine their own sense of
agency and potential, tensions between the aided and the unaided, not focusing on
what resources and capacities local communities possess and can build on, and the
undermining of aid’s ability to listen, learn and adapt to local contexts.” She also
points out that while there are many negative feelings, one major positive reaction is
15
Sabine Balk, "Regaining Solidarity," Development and Cooperation, March 4, 2014, accessed July 8,
2014, http%3A%2F%2Fwww.dandc.eu%2Fen%2Farticle%2Fcritics-want-aid-be-re-designed-order-
promote-international-solidarity.

10. 9
of that surrounding aid for women. Yet the overall message of this article is for NGOs
to quit trying to complete their project and slow down and listen to the people.
All three of these perspectives serve to unite the cause for remodeling the
current framework and ideologies behind NGOs “good intentions”. These perspectives
solidify that while some assistance has had a beneficial effect on some developing
countries, the majority of NGOs have yet to figure out that they are behind the times
and need to reevaluate how they plan and manage their projects for maximum
positivity and lasting, effective health systems.
Review and Analysis of Case Studies:
For this paper two case studies of specific countries were chosen: Mozambique
and Nepal. These two countries were selected because they are both developing
countries and they represent two different geographic locations; one in Africa and
one in Asia. These specific case studies were also selected because of the time
difference. There is a ten year time span from one case study to the other. This is
important to see if time has had any effect on the progress of NGOs working in
developing countries.
Prior to Mozambique’s civil war they had a thriving health system with plenty
of health posts, even in rural areas. As a result of the war the country’s entire
infrastructure was destroyed which is when hoards of NGOs came flooding into the
country and took over any opportunity the government might have had to rebuild
their once flourishing health system. At the same time, some of the workers from

11. 10
these NGOs brought with them attitudes of condescension and disinterest which led to
exclusion, demoralization, and bad habits of per diem for the local workers.16
Nepal was also engrossed in a civilwar that lasted ten years. Soon after the
end of the war they were inundated with NGOs in the same way Mozambique was.
Nepal began their rebuilding process by claiming health as a basic human right and
decided a new health plan along with External Development Partners (EDPs, i.e.
USAID, DFID, GiZ, WHO, UNICEF, World Bank, and others) which set up a management
mechanism between the Nepali government and the EDPs. This plan was set from
1997 till 2017. Both the government and the EDPs decided on policies together and it
was agreed that a pooled fund would be set up to be spent at the agreed discretion of
both parties.17
After thoroughly pouring through both case studies numerous times, I found
eleven similarities between these two cases which describe the greatest challenges
faced by NGOs, Donors, and Governments, and Health Workers in operating together
to produce equitable, efficient, accessible, and effective health care to civilsociety.
The first section of issues deals with the NGOs working Mozambique and Nepal.
One of the very first observations both cases reference is a lack of aid coordination.
As everyone hurriedly arrived in these countries without coordinating with one
16
James Pfeiffer, "International NGOs and Primary Health Care in Mozambique: The Need for a New
Model of Collaboration," Social Science & Medicine56, no. 4 (2003), accessed July 8, 2014,
doi:10.1016/S0277-9536(02)00068-0.
17
Aditi Giri et al., "Perceptions of Government Knowledge and Control over Contributions of Aid
Organizations and INGOs to Health in Nepal: A Qualitative Study," Globalization and Health 9, no. 1
(2013), accessed July 8, 2014, doi:10.1186/1744-8603-9-1.

12. 11
another or the government many projects were duplicated because insufficient
communication.18 Additionally, when NGOs did seek to coordinate with the
government they often sought to make under-the-table deals or special agreements
with the government. NGOs offered incentives to government officials if it meant
they received approval to work on a certain project or with particular people groups
(i.e. HIV/AIDS, Malaria, midwifery, maternal-child health, and people groups of
women and children). NGOs took this approach in order to gain access to more
funding, in competition with other rival NGOs wishing to do the same.19 In order to
meet their own criteria and priorities NGOs would pressure governments to approve
their project whether or not it was in alignment with existing governmental plans and
in actuality disrupt the planning process.20 Ultimately NGOs’ presence resulted in the
public health sector of these developing countries being completely undermined. A
good description of this scenario from Nepal’s case study looked at the differences
between the NGO and public health centers, “While it has a full time staff, a well-
stocked pharmacy and diagnostic equipment, its government counterpart is
continuously understaffed and disorganized. Locals say they prefer the NGO health
center over the government health post. The government health post doctor is
frequently absent for long periods of time.”21
18
First issue
19
Second issue
20
Third issue
21
Aditi Giri et al., "Perceptions of Government Knowledge and Control over Contributions of Aid
Organizations and INGOs to Health in Nepal: A Qualitative Study," Globalization and Health 9, no. 1
(2013), accessed July 8, 2014, doi:10.1186/1744-8603-9-1.

13. 12
Local control was completely lost and the fragile public health systems could
not compete with the NGOs.22
There is a phrase that goes, “If you can’t beat ‘em, join ‘em.” That’s exactly
what the local health professionals did. There were many factors which worked
against public health professionals which included inadequate salaries,
pharmaceutical and material shortages, and equipment failures. With little motivation
and the demoralization of the local health workers, they gave up their posts and
joined the ranks of the elite health professionals working for the NGOs contributing to
major brain drain.23 The NGOs provided exemplary salary and a better working
environment, not to mention the all paid trips to other cities for training seminars
which essentially did not provide them with any added clinical knowledge. Even
public health workers took part in these training seminars while they were still
working in government facilities since the per diem pay was more than they could
make in a month normally. In addition this left their public clinic posts vacant while
they were away for weeks at a time.24 Per Diem and financial favors became a way of
life in these environments since the economies were in dire straits. They became so
common that soon none of the local health workers would show up or contribute
without receiving them. This incentive, turned bad habit, became so sought after that
the locals learned how to manipulate the NGO systems to get these positions.25
22
Fourth issue
23
Fifth issue
24
Sixth issue
25
Seventh issue

14. 13
The third section deals with the actions of donors or EDPs (as they are called in
the Nepal case study). From the start EDPs had a major disconnect with the central
governments with whom they worked closely. There was often a serious lack of
understanding on the donor part when insisting on working on specific projects.
Donors discussing a specific project with the Nepali government went like this, “When
it came to promoting home deliveries by SBAs (Skilled Birth Assistant), donors argued
that this would be counterproductive because the international community supports
hospital deliveries. The MoHP had to explain that for people in remote, rural areas
where accessibility and cultural beliefs pose problems, the best solution is to send
trained personnel to them. Donors then decided to fund this program instead of
promoting hospital deliveries.”26 27Perhaps a greater problem was that donors insisted
on channeling aid through NGOs instead of government programs. This was
detrimental to government budgets, but also went to support vertical projects instead
of being used equitably to fund horizontal program improvement.28 Part of the reason
donors chose to distribute aid this way was because they did not trust the Ministries
of Health to use the money efficiently.
In developing countries, governments are expected to have many issues and in
reality they do. Corruption was a serious issue for both the Mozambique and Nepali
governments. Furthermore they also had issues with transparency. Often times when
26
Aditi Giri et al., "Perceptions of Government Knowledge and Control over Contributions of Aid
Organizations and INGOs to Health in Nepal: A Qualitative Study," Globalization and Health 9, no. 1
(2013), accessed July 8, 2014, doi:10.1186/1744-8603-9-1.
27
Eighth issue
28
Ninth issue

15. 14
they would receive aid these resources were not filtered down to the local offices in a
timely fashion.29 Since the government had internal coordination issues, EDPs and
NGOs took total control of service delivery for the entire health sector which left
these governments paralyzed and weak. The government had no leverage to coerce
those in charge to conform to their rules or regulations and in return the EDPs and
NGOs did not report their actions or projects to the government, leaving them totally
in the dark.30
Conclusion:
After seeing the similarities between these two case studies even though these
studies were done ten years apart, it is easy to see that reliance on controlling NGOs
in developing countries has become a theme. A new approach to how all the
stakeholders involved in health provision is needed, including the NGOs, donors,
governments, and local health workers. In these two studies it was obvious that the
government and local health professions were starting the rebuilding process from a
weak position and instead of continuing to foster this position within the countries;
donors and NGOs should build up their weaker partners and listen to and
communicate with them more. Foreign partners must consider what the consequences
of their actions may be and listen to the internal governments and health
professionals insights in order to forge a synergistic health workforce and system that
can be sustainable for the developing country.
29
Tenth issue
30
Eleventh issue

16. 15
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17. 16
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