Challenges in International Health for the New Millennium: NGOs & US Bilateral Assistance
BY CURTISS SWEZY
Nongovernmental organizations (NGOs) have long played a key role in providing health care in the US. Originally referred to as PVOs, or private voluntary organizations, these charitable hospitals and inner city resettlement homes provided some of the first health and social safety net care for remote and disenfranchised populations from the western frontier to inner-city ghettoes. Eventually this same idealistic approach to health care began to be exported to the poorest developing countries. Well-known health organizations surged into international work to address the carnage in the aftermath of World War II, including the American Red Cross, the International Rescue Committee and CARE.
In the immediate aftermath of World War II, in addition to the name brand NGOs working overseas, there were many small mom-and-pop operations assisting however they could in narrowly defined geographic areas. This effort has now blossomed into a major NGO health industry, complete with highly skilled managers, rigorous program evaluation, and creative innovations developed by a myriad of US-based NGOs.
The role of NGOs in international development can be cast into two broad categories: emergency relief and long-term development. Following the catastrophic 2004 tsunami, US relief NGOs sprang into action to provide emergency care in countries throughout the Pacific basin. Alternatively, development NGOs specialize in the creation and implementation of service programs within viable healthcare systems in countries that do not have the resources, training or local government commitment to provide health care to their citizenry. Such health development programs usually take place over a period of many years.
Momentum generated by NGOs to aid less affluent countries has also stimulated greater US government involvement in regards to healthcare and international development. President John Kennedy, by expanding on and renaming existing federal initiatives, created the Agency for International Development (USAID) in 1961, which became the major arm of US bilateral assistance to health and development in poorer countries around the world. The creation of USAID had a significant impact on NGOs working in the health field.
As more federal funds were made available for international development efforts, USAID first began issuing grants then directly contracting US-based NGOs to provide what the government deemed important health interventions around the world. This resulted in a host of innovative programs such as those related to family planning and birth spacing on which USAID took undisputed leadership in the 1960s and 1970s. As created by President Kennedy, USAID was a technical agency providing in-house leadership and technical management. This continued until the Reagan era, when USAID transitioned into a management agency employing generalists to monitor grantees and contractors.
As NGOs began relying more on USAID funds, some began to curtail their traditional fundraising efforts. Today, NGOs can be triaged into three groups: those that accept no US government funds and do all their own fundraising; those that have prescribed limits from government sources (e.g. 20 percent of their budget) and insist on raising all additional revenues; and those that obtain over 90 percent of their budget from USAID (what might unkindly be referred to as “whollyowned subsidiaries of USAID”).
The impact of expanded USAID funding of NGOs has been to upgrade management rigor and improve evaluation and measurable program impact. Twenty years ago, it was not uncommon for those of us in the NGO community to lament, “You cannot criticize us, we are doing good.” The firm reply was, “Doing good is no longer good enough; you must ‘do good’ well.” The NGO community has clearly responded.
Increased USAID funding of NGOs precipitated an interesting dynamic between the Agency and its implementing partners. USAID expected NGOs to be supportive of US government policies and willing participants to implement them under the management rubric of “he who funds, controls.” However USAID also requires support and funding from the US Congress for its own continuity. NGOs all have their own constituencies, principally through their members and fundraising networks, and sometimes have pushed back against USAID policy initiatives. Not infrequently, letters are generated to targeted Congresspersons to influence USAID policies and procedures.
One of the more dramatic examples was when the NGO community wanted increased funding – to be passed on to NGOs – for a basic package of maternal and child health (MCH) programs. This included immunization (EPI), diarrheal control (ORT), and pneumonia (ARI). The brilliant marketing strategy was employed to label MCH programs as “Child Survival” interventions and dared the most scrupulous of fiscal conservatives to oppose them. The outcome? A separate USAID account for Child Survival activities exists to the present day.
Currently, under the label of “transformational diplomacy,” the US government is shifting health service programs out of USAID and embedding them in the US State Department, which historically has not implemented health development initiatives. The long-term goal of this transition is to absorb USAID into the State Department. In the past, there have been mixed messages related to US government policy and direction. Until recently USAID generally functioned in parallel with the Department of State. This has been particularly true in the area of reproductive health. Proponents say that “transformational diplomacy” will provide consistency to policy and funded programs. Critics charge that long term development goals will be sacrificed for flavor-of-the month political objectives.
AUTONOMY
As NGO and government funds become more entwined, NGOs must carefully examine their mission and policy objectives. How autonomous can they remain in proportion to the percentage of their budget that comes from USAID and, increasingly, the Department of State? How loud can an NGO voice be when it strongly disagrees with specific government policy when the government funds over 90 percent of its programs?
THE ROLE OF THE EXPATRIATE AMERICAN
Those of us who work in international health love to be in the field and to drive programs. NGOs have spent the last 40 years training developing country staff to be managers, clinicians, epidemiologists and policy makers. What transition must our role go through in the next decade as host nationals take over these positions (and, inevitably, speak the local language better than we do)? We espouse country ownership of programs, but how badly do we really want to work ourselves out of a job?
ROLE OF THE HOST COUNTRY NATIONAL
If one mistake has repeated itself, it is putting country nationals into untenable positions where the cultural forces within their society preclude their performing at an expected western standard. Informal quid pro quo payments are a fact of life in many developing countries. We must provide insulation for our local staff against these harsh realities because, while eventually we leave, they must remain and work there for their entire careers.
ON-GOING INNOVATION
Many Child Survival NGOs have become very proficient and comfortable in programs related to MCH, reproductive health, HIV/AIDS, etc. There is inertia to continue along familiar paths and temper the pioneering spirit, which initially motivated those of us eager to affect change through working in international development. Many nutritional programs, born of emergency relief, still do not recognize the “nutritional transition” occurring in developing countries, i.e. that much malnutrition is an under-nutrient overcalorie diet (see Lisa Pawloski’s article on this topic). Similarly, Child Survival programs have been slow to acknowledge that mortality of one to five-year olds from vaccine preventable diseases, diarrhea, and pneumonia is being replaced by injury, most notably, drowning, as the leading cause of death.
UNINTENDED CONSEQUENCES
In our idealism (and haste) to be innovative and rapidly disseminate modern medical technology to the newly emerging nations of the world, we have an obligation to guard against the law of unintended consequences. One of the dramatic success stories of Child Survival has been the reduction of child deaths from contaminated water. Multiple organizations, including NGOs, were in the forefront of assisting villagers in digging wells with cement liner rings or drilled tube wells, to provide clean drinking water. This precipitated dramatic declines in infant and child deaths from diarrhea.
Years later, it was discovered that in eastern India and much of Bangladesh the groundwater is infused with high levels of arsenic. After drinking this water for a decade, many residents have come down with fatal cancers of the lungs, bladder and kidneys — outcomes that were totally unanticipated by the public healthy community. Notably, George Mason’s Dr. Abul Hussam has developed a very effective filter utilizing local materials that is currently being used to remove arsenic from the water in his native Bangladesh and for which he received a $1 million prize.
PROGNOSIS
NGOs will continue to play a vital role in professional training, service delivery and development of effective infrastructure to deliver health care in developing countries. The next decade will be particularly important as less developed nations strive to reach the economic and educational levels within their own countries to provide this vital service to its citizens. A conscious recognition by those of us in the NGO community of the challenges faced will both accelerate and smooth this transition to host county ownership and self-sufficiency, both universal goals of NGOs working in international health.
Curtiss Swezy (fswezy@gmu.edu) has directed, consulted, trained and evaluated health programs in over 40 countries and is an adjunct professor in the department of Global & Community Health in the College of Health and Human Services (http://www.gmu.edu/depts/chhs/gch). This article was first published in print and citations have been removed to space limitations, but are available from the author.
