Caught in Contradiction: The Inverse Relationship between Funding and Freedom

In a perfect world, every state would be able to equally serve, represent, and protect its people. However, as we know all too well, the world is far from perfect. The effectiveness of the state varies immensely across different countries, communities, and groups, leaving many individuals falling through the cracks of development in bureaucratic, impersonal systems. Non-Government Organizations (NGOs) are thought to repair some of the damage done by the state by taking more personal, community-based approaches, but they are short term fixes. As a recent Guardian article explained about NGOs in Malawi, “Many NGOs don’t work closely with local communities, so when they leave, projects collapse.” (Pensulo)

According to S. A. Zaidi, the only solution to the failures of the state is to strengthen the state itself. Zaidi argues that “NGOs are usually not in a position to address the causes of the problems their project has been designed to address.” (Zaidi, 268) While I agree that most NGOs have very limited impact on the sources of issues, I do not think the state is necessarily the solution. It is not an issue of a government versus nongovernment program, but rather the ability of a program to act without restraints and contextualize. Large scale interventions often have sufficient resources to create change, but fail to contextualize the interventions, while smaller programs have the adaptability needed to address individual needs and act without restraints, but often lack the resources to create large scale or sustainable change. The root of the problem is this: the more funding a program receives, the less ability it has to determine its own agenda.

Funding is a necessary part of any aid project, but the demands of donors can weaken the mobility and flexibility of a program. The more degrees of separation between the donors and the intended beneficiaries, the more barriers there are to the effective use of resources. Donors are often more focused on numbers than people, and statistical evidence is easier to gather for single diseases or vertical campaigns. While vertical campaigns can be effective, they attack specific problems in society without addressing the structural problems that give rise to the problem. Smaller NGOs are better able to understand underlying problems in a community, but may have difficulty gaining traction for funding. Name recognition is a barrier for small NGOs to draw in funds, so “already large INGOs are likely to further grow at the detriment of smaller and passive players.” (Greensmith) Even if a program is funded, it must produce desired results to continue to receive funding. In the case of HIV treatment in Sierra Leone as presented in HIV Exceptionalism, drugs were overprescribed because “staff members worried about if they would be perceived as ineffective bureaucratic managers of donor goods if they had an overstock of drugs.” (Benton, 126) When funding is the priority, the goal is shifted from assisting communities in need to pleasing donors.

We can continue with the example of HIV in Sierra Leone to show the importance of contextualization. Disclosure of one’s HIV status is a powerful tool – it can prevent transmission, reduce discrimination, and relieve the psychological burdens of diagnosis. With all these positive benefits, it is difficult to see why disclosure would not be encouraged and accepted, and perhaps programs would operate on the assumption that disclosure will happen between sexual partners and families, but this is often not the case. As Benton explains, decisions of disclosure must be “interpreted within local moral notions of secrecy and concealment that are linked to gender and class.” (Benton, 72) Understanding the social context of programs is so important for a program to be effective, and extremely difficult to achieve on a large scale since it varies from country to country, community to community, and person to person.

No matter the amount of funds, if the proper framework is not in place, it is a lost cause. This is not so much a matter of state versus NGO, but top-down versus bottom-up approaches. While there is no universal answer, we have seen time and time again resources lost to worthwhile causes by programs without an understanding of the target community. An example of this was PEPFAR funding in Mozambique, where “the result is an ART scale-up with millions of new dollars flowing into the health sector but little support for the building blocks of the health system that make the scale-up possible.” (Biehl & Petryna, 174) An approach that first focuses on establishing the framework at the ground level before introducing funding may be more effective. Once funding is received, the program still must have the freedom to make decisions based on the beneficiaries and not the donors. This will help ensure that the priority is where it needs to be to create change.

1. Is it possible for an NGO to create a sustainable structural change, or as Zaidi claims, does it have to come from the state?
2. Is the type of organization (state vs. NGO) the most important consideration in determining potential impact, or is the type of intervention (bottom-up vs. top-down) more important?
3. How do we address the problem that large programs that receive the most funding are the least in control of their agendas?

1. A. Benton. 2015. HIV Exceptionalism: Development Through Disease in Sierra Leone. Minneapolis: University of Minnesota Press.
2. C. Pensulo. “NGOs in Malawi: What Happens When Donors Leave?”The Guardian. N.p., 28 Sept. 2015. Web. 13 Nov. 2015.
Link: network/2015/sep/28/ngos-in-malawi-what-happens-when-donors-leave
3. J. Biehl & A. Petryna, eds. 2013. When People Come First: Critical Studies in Global Health. Princeton: Princeton University Press.
4. J. Greensmith. “Global Policy Forum.” Trends in Fundraising and Giving by International NGOs. N.p., n.d. Web. 13 Nov. 2015.
5. S. Akbar Zaidi. 1999. “NGO Failure and the Need to Bring Back the State.” Journal of International Development 11(2): 259.

30 thoughts on “Caught in Contradiction: The Inverse Relationship between Funding and Freedom”

  1. Hi Leah!

    I thought you did a really nice job discussing the prominent issues in the readings. I liked how you also stated your opinion as well.

    Dr. Lindsey Reynolds explained how it is not uncommon that NGOs focus too much on quantitative data, and not enough on the well-being and interest of the population. I think that if NGOs were granted more separation from donors, this would allow more freedom for NGOs to create their own agendas. It’s very important that NGOs receive donations, but I think there comes a point where people must decide which is more important: the people or the economy. It was mentioned in the “NGO Failure” article that the public often hears of success stories from NGO, but neglects the missed opportunities by the thousands of other NGOs that go unnoticed (Zaidi).

    So in regards to your first question, I believe that NGOs should try to separate itself from the state in order to become less dependent on funds from donors. This would allow for a more flexible agenda. I think this would also allow NGOs to focus more on the needs and desires of the people (take a more horizontal approach) rather than abiding by the demands of people who may not know what’s ethical.
    I believe that the type of organization should be more important, but often this is not the case. Like I mentioned earlier, people are more focused on financial well-being as opposed to people’s well-being. NGOs need the funding, but suffer from restrictions that can hinder the organization’s performance. This is sad, but true. What do you think? Do you think there is a right or wrong answer?
    I thought a lot about your last question. This is a really big conflict, but I this issue can be resolved through negotiation or by setting some sort of laws that bans outside donors from restricting NGOs so much. However, this might result in less money, but it could be aiding more to a population’s interests. Overall, it appears that there is an unforgiving trade off here. What do you think?

    1. Hi Leah and Samantha!

      I really appreciated the contrast you drew, Leah, between the strengths and limitations of interventions of differing scale in terms of how forms of financial support can also confer problematic rubrics of success onto the interventions (demonstrable “success” in solving the problem to which the NGO was assigned) when the ultimate goal is to achieve a positive change in the overall and long term health of a population. I agree with your assertion that the needs and opinions of the population an NGO seeks to serve should ultimately be the voices that work in tandem with the healthcare workers in the NGO, rather than the voices or visions of donors influencing the intervention.

      Samantha, I appreciate your response to the questions because I agree – fluidity in agenda, especially when the workers delivering care may be more ethically and culturally aware of what is required of them as they navigate their goals and the goals of the people around them, is essential; it also is extremely difficult to achieve when donors fixated on a “vertical” health cause want to see the success they effect without seeing how rerouting the distribution of wealth and health infrastructure and resources more broadly might disentangle complicated health issues that keep these “vertical” calls health crises in philanthropic fashion.

      Leah, your last question touches on an extremely difficult problem to work around… do you – Leah, Samantha, or anyone else reading – think there’s a way to re-establish this type of donation/philanthropy on a cultural level, getting away from how it can become a sort of fad or philanthropic political/social “move,” in order for health interventions to accrue the monetary resources without accumulating donor expectations of “success” (on which further support are hinged) and restrictions on what NGO may do without fear of losing funding?

      1. Hi Emma!

        Thank you for including me in your comment. I think you have really good insights on this topic. I’m a little confused about your question, but I think you’re asking how we can change the incentives that philanthropists have-rather than focusing on quantitative data, they should focus on qualitative data?
        If that’s what you mean, I think NGOs should provide quarterly assessments to the people that are being treated. They could ask simple questions and rate them 1 to 5 (1 disagree 5-agree). They could ask questions like:
        1) I have seen improvements in my health or health in family members?
        2) Treatments easily accessible
        3) Treatments are fairly prices
        4) I have developed relationships with people in the NGO
        5) I would like to continue partnering with this NGO in the future
        Any additional comments or concerns: ________

        I think this would get a good sense of how villagers feel about NGOs and if they feel their mental, psychological, and physical needs are being met, and also how to further improve the organization.

        Sorry if this is totally irrelevant to your question, but I wanted to mention this before I forgot about it.

      2. Hey Samantha and Emma! I think you both brought up some really good points. Samantha, I definitely agree that more separation from donors allows for more horizontal approaches, which we have seen be more effective in many cases. The problem with this separation is that donors can choose not to donate, especially if they feel that they have no power over what is being done with their money. This is the same problem with trying to restrict donors from trying to regulate NGOs – they can choose not to donate. I think you brought up a really important point that maybe less money is worth having more power. The ideal solution is finding the right balance between enough funds to obtain needed resources, and enough funds to achieve the goal.

        Emma, your questions are tough but important things to consider. From a western standpoint, backing a vertical campaign has become a kind of trend, because it usually gets more attention. An example is the Carter Foundation with the guinea worm eradication campaign. If horizontal campaigns got this kind of backing, there would be much more potential. Instead of funding a specific disease campaign, maybe an NGO where donors fund a community would be an interesting idea. Community members would need to have most of the control over funds, but maybe this is a way to draw donors to horizontal efforts.

        1. Hi Leah,

          I agree, it will be much harder to get enough funding to support NGOs, however, I think that the money will be more useful. NGOs should promote its knowledge and research to gain trust in potential donors. They should also have goals, plans, and potential timelines to show to donors that they know what they’re doing. This can permit a more collaborative environment between donors and NGOs. Hopefully, they can compromise and produce more efficient results. (‘Two minds are better than one’)
          I just don’t see why donors aren’t willing to let NGOs do their job, especially considering that NGOs are ‘experts’ in this area.

          1. Samantha –

            Maybe an explanation for this is that while we hope that NGOs are ‘experts’ and know exactly how to accomplish their mission, this is often not the case. Any cases of failure could weaken the trust that donors have in the expertise of NGOs.

  2. Hey Leah!

    I think this question really gets to the fundamental issue for NGO intervention. I agree with Zaidi in that NGOs are too often a band-aid for larger structural problems arising from state failures. But I also agree with you in that this does not automatically mean that the state is the most able body to resolve issues. I think your question of focusing on the type of program as opposed to who is implementing it is crucial and super astute. The emphasis should be on bottom-up interventions that take into account a particular community’s needs and incorporate said community in the intervention.

    1. Hi Jessica, good point about NGOs being band-aids for state failures. While this doesn’t change the source of the problem, is it necessarily a bad thing? State failure clearly has detrimental effects on its people, so while a temporary fix is not ideal, it is better than nothing.

  3. Hi Leah,

    You hit the nail on the head when it comes to NGOs; a double-edged sword is presented because more funding is helpful in carrying out goals yet could lead to less flexibility since the NGO would be subject to donor demands. I think Samantha brought up some great example survey questions that could be asked to assess the impact of a particular NGO. I wonder how accepting donors would be to this sort of qualitative data. Is it perhaps the donors that need crash-course lessons on how to conduct effective philanthropy, i.e. being more lenient on how their money is spent by the NGO so that NGOs have greater flexibility? Do you think that this sort of method would lead to less donor funding because the philanthropists have less control over their money? Personally, I think potential donors should be taught the issues that NGOs face even if it may mean losing some donors. Of course, it should be emphasized that their funds are extremely helpful and important. However, these funders should be taught not to solely demand/rely on quantitative assessments and specific methods for carrying out programs because they may not play out so fluidly in the field.

    In regards to your first question, I think that NGOs are still important just as the need for state reform. NGOs are the temporary fixes that are needed while large scale, structural changes take place. However, I do wonder if NGOs play a neutral part in this or if they are a distraction from state reform. In other words, do NGOs facilitate or slow state progress? What do you all think about this?

    1. Hi Jeannnette, really good questions. Ideally, NGOs would be the temporary fix while long term changes are made, but it is a very real possibility that a temporary fix could distract from any larger changes being made. However, if the state failed in the first place, I do not think we can count on it being able to make long term changes, so I still think it is better to do something than wait in the hopes that a long term change will happen.

  4. Hi Leah. Great Post. Yet a question that came to mind as I was reading your post was that should donors then only give their money to NGO’s instead of conducting their own researches and projects. This way, the pressure between the donor and the actor is avoided. But this also raises another question which is how reliable are NGO’s? as it can be more beneficial in some cases to avoid them, while in other cases, especially with well known NGO’s, they can very influential both locally and internationally.

    1. Hi Maen, these are some important considerations. I think that in regards to donors conducting their own research and projects to have the most control, they may not have the same background or be willing to invest the time and energy it would take. While this would, like you said, eliminate the gap between donors and actors, it also may decrease the ultimate reliability or usefulness of where the money goes if a donor does not have a complete grasp of the context of their intervention.

  5. Leah,

    Thanks for your insightful post! I agree that funder-based limitations on agendas are a great problem for NGOs. When we looked at the case study in section in which we were granted $5 million more after we had shown a statistical improvement, I myself was very tempted to implement vertical programs because they give the most short-term results.

    I’d like to address your third question, asking how we can solve this lack of control among large NGOs. Without a doubt, since NGOs are pressured to prove their efficacy through superficial numbers, an overhaul on the systems by which funders judge improvement in the targeted communities is quite necessary.

    As you illuminated in the example of contextualization in HIV Exceptionalism, we must understand the nuances of the local community to know which course of action is best, even on a person-to-person basis. A horizontal approach such as improving social environments enough so that every person feels comfortable disclosing is a long-lasting change and could be a more productive indicator of positive NGO work in a community.
    Perhaps, to be more specific, an indication such as the number of people who feel comfortable disclosing their HIV status to loved ones is a better measurement of sustainable success. Do you agree that changing the standards by which funders evaluate success is the most necessary way to combat this pressure?

    1. Hi Sarah, thanks for your comment. I really like the idea of changing the standards by which success of NGOs is evaluated, because it cannot always be captured in a few numbers and statistics. An idea for this would be to have community evaluation of an NGO as a more standard measure. This would make it easier to compare different approaches. For example, if a community feels that a vertical campaign is very effective for their situation, this would show that a horizontal approach might not be necessary in this instance. If a community is happy with the efforts being done, this is a reliable indicator for donors, so they can rely less heavily on other statistics.

  6. Hi Leah,
    Thank you for your insightful post. In response to your statement that NGO’s are primarily focused on “short-term fixes”, I do not believe that this is always the case. NGO’s facilitate community discourse and participation that enable the emergence of a new understanding of disease and treatment within the community. Community engagement is not necessarily a short-term solution, as it may pave the way for larger structural change over time and may therefore have lasting effects on the way disease is perceived and dealt with.
    Although I also believe that disclosure is necessary to curb the spread of disease, such disclosure may be problematic and even impossible in many cultural contexts. For example, Paul Farmer mentions how in Haiti, HIV-positive women are that forced into prostitution or that have contracted the disease due to other conditions of poverty and social instability are accused of being personally responsible for their disease. He describes how there is an overwhelmingly negative portrayal of women as transmitters of infection; in many communities, HIV is often associated with immorality and is even perceived as retribution for moral transgression. Disclosure thus often results in humiliation and societal exclusion; many HIV-positive individuals therefore feel as if they have no choice but to keep their illness a secret, thus foregoing treatment.
    In response to your first question, I believe that state involvement is essential to combat structural violence. The state is the only existing entity with the independent financial capability and political power to motivate significant structural change. Larger state involvement would also eliminate the issue of funding. The state is the only force that is equipped to address poverty and inequality, as these factors are under its jurisdiction; the state is, by definition, responsible for the wellbeing of its citizens.

    1. Hi Alexandra,

      While I agree that state involvement is a major priority in combating structural violence, this structural violence arises from state failure, so NGOs can be a big tool in picking up the slack of the state. Long term, hopefully states can address these failures, but I think help from NGOs is better than waiting for the state to repair itself. You made a good point about the potential for NGOs to create long-term changes, so in combining these ideas, they could make a long-term change in an area where the state has failed.

  7. Hi Leah –
    I thought you did a really great job synthesizing the various considerations regarding NGOs vs state structured interventions. In regards to your second question, about type of organization vs type of intervention, I think it can’t be reduced to one or the other. I mean that to say any combination of the options you provided has the potential to be effective, if it has the appropriate resources and can address the problem it is intended to solve. While I do agree with you that in an ideal world we would have state-run programs that effectively provided all of the necessary care, I think it is also feasible for NGOs to provide comprehensive care in the absence of an effective state. Likewise, I think that both bottom-up and top-down interventions can be effective if they are self-cognizant enough to adapt to local contexts and scale effectively. Rather than regarding certain types of interventions as wholly ineffective, I think we should instead focus on what aspects of certain interventions are most effective and which can be improved upon, given the contexts in which they are operating.

    1. Hi Ruby, I appreciate your point about taking into account specifics of individual interventions instead of ruling out a certain approach as wrong. I think that generalizations can be at least considered when designing an intervention based on the successes and failures of past interventions with similar goals, but the approach should focus more on the intended goal than adhering to a certain format. It will be different in different cases, so there is no right or wrong answer that can be definitely stated.

  8. Hi Leah,

    You did a great job synthesizing the struggles that NGOs face when designing health interventions while trying to please their donors. In response to your first question, on whether “sustainable structural change” has to come from the state as opposed to from a NGO, I agree with you that the strength of a program’s design, as opposed to who is running the program, is the most important factor when determining what effect an intervention will have. As we saw in the readings, often NGOs take action because the state is failing to do, so simply relying on the state or becoming involved in advocacy work is usually not the most productive solution. However, I do believe that an NGO ignoring the role that the state plays would be a huge mistake. This past week, we read about how Partners in Health tries its best to build sustainable relationships with the governments of any country that it operates inside, in order to ensure PIH can have long lasting relationships and impacts. I think that is the ideal situation, and all NGOs should be making proactive efforts to engage in collaborations with the local governments so that health interventions have long lasting effects.

    Going back to the point you were making about implementing effective interventions while being responsive to donors, I think the most obvious way to combat donor demands is to simultaneously release qualitative reports on the progress an NGO is making. You talk a lot about the importance of contextualization, and how crucial it is to understand that every community is different, so I think donors may understand that the data that is reported out on every community will be different too based on what specific community needs and problems are.

    1. Hi Alana, thanks for your comments. The example of PIH is something I had not thought of up until this point, but it is important to consider. I have been talking about state interventions and NGOs only as if they are mutually exclusive, but this is not the case and some of the most successful results we have seen are when the two have collaborated. NGOs are not limited to only trying to strengthen communities, but by working at higher levels can also create structural changes through the state.

  9. Hi Leah! Thanks for your great discussion. You make some really strong arguments about the relationship between funding and the ability to control the agenda of an NGO. I think we have definitely recognized the pattern in class: the larger an NGO and the more funding it receives, the more it has to play into what the donor wants and less into what the people they serve need or want. While you say that smaller NGOs don’t have, they don’t have the resources that allow them to achieve their goals. And if they did, they would just turn into a larger NGO with the same issues. And so, it seems like a rather negative cycle.

    I particularly liked how you shifted the focus of the issue from government vs NGO to top-down vs bottom-up in your attempt to explore solutions to the problems you discussed. I think this is a strong and valid point. If NGOs were allowed the freedom to use bottom-up approaches (and actually encouraged to do so), horizontal campaigns could be enacted with the all the funding that they needed to enact change. Still, in a market based economy and with NGOs and donors who operate within that structure, is this strategy feasible? At the end of the say, bottom-up approaches are not profitable for donors. It’s truly unfortunate that NGOs have to operate in such a system, and severely limiting. And so, I am wondering if there are any ways you might suggest of promoting bottom-up approaches in such a market-based economy? In my opinion, incentives might work really well. But again, smaller NGOs might run into the same problems of not being able to kick-start their campaigns.

    To explore your second question, I don’t think the government vs NGO question is necessarily unimportant. In my opinion, it seems dangerous to have an entire country’s health sector relying largely on NGOs that are easily collapsible under economic constraints. Ultimately, I believe state-based solutions might provide more sustainability than NGOs. Perhaps integrating the two might be the best, most resourceful solution.

    1. Hi Lilian! Your closing comment about integrating NGOs with state-based solutions is a great insight. This was the approach by PIH, and they are one of the most clear “success stories” we have heard in class, so there is definitely something to be said for this. You also made the point that bottom-up approaches are often not profitable for donors. While this may be true, I think donors are not necessarily looking to profit, but for concrete evidence that their money is being put to good use. To address this, community satisfaction could be used as an assessment of NGOs. This could make up for the lack of concrete statistics that many smaller NGOs may experience.

  10. Hi Leah! I appreciated your summary of issues with NGOs. You spoke to important deficits in NGO structure and function that Zaidi raised in the article.

    In answer to your third question, I believe that a possible solution to the problem (that large programs that receive the most funding are least in control of their agendas) is if donor funds are administered to the state, which then systematically distributes this money to NGOs. In other words, it could be effective if individual donors give grant money to a government that then gives these funds to the NGO. This could take shape as a block grant, which is a chunk of money that a government gives to local authorities to distribute across several areas of interest. By definition of the grant, a donor would have to recognize the need for funding “the building blocks of health” (as opposed to targeted, and often exclusionary, interventions as in the case with HIV in Sierra Leone) and accept that the emphasis would be less on data/measurable outcomes (that NGOs often fudge, according to Zaidi) but more so on broader program development. While the donor could specify a minimum requirement that money be directed towards areas, such as maternal health, the NGOs would, ultimately, determine how the funds are utilized.

    A block grant distribution system is one medium through which the United States federal government allocates state funds for Medicaid programs. With that being said, the U.S. generally has neither the best health measures nor an efficient health care system. As such, this model has several potential weaknesses, such as: 1) diffusion of monetary responsibility across programs as well as 2) NGOs’ reliance on states when NGOs are supposed to be detached from the government and apolitical. However, benefits of a block grant approach are that: 1) the donor would not have direct control of the NGOs’ agenda and 2) there would presumably be more collaboration between NGO administrators and local individuals with greater “freedom to make decisions based on the beneficiaries and not the donors”.

    1. Hi Alexis, thanks for your insightful comments. A block grant is something I have not considered (and do not really know much about), but it is an interesting possibility. It addresses the reliance of NGOs on donors, but moves to reliance on state funding, so this seems like a neutral point. A concern that comes to mind is that it would be easy for a corrupt state to abuse a system like this, and corrupts states are often the cause of the need for NGOs, so this is potentially dangerous. However, if done right, this could be a very effective solution. It is a good way to sway the focus from quantifiable date to strengthening the building blocks of health, as you said. The state would just need to be held accountable for distributing funding effectively.

  11. Hi Leah –

    I think you get at one of the key issues with this idea of the “beneficent actor” – that being financially free to good work and doing good work are fairly mutually exclusive, and that donor relationships are incredibly political and involve inherent power dynamics. I also appreciate your consideration of how measuring success of an ‘intervention’ is easier in a vertical approach than a horizontal one, and that monetary frugality is implicated in statistical analyses of “success.” I think your question of state vs. NGO or top-down vs. bottom-up is interesting, as we often set the two on the same dichotomous scale (NGO=bottom-up and state=top-down), and I wonder if this relationship is something that we should interrogate further. What would a bottom-up, state sponsored approach look like? Why is this not happening in the first place?

    1. Hi Dolma, this is a really good point to emphasize. I certainly associate the state with top-down approaches and NGOs with bottom-up approaches, but neither is confined to this. I am having a hard time processing the idea of a bottom-up state intervention because the state is less mobile and able to able to contextualize and a community level, but it is definitely an approach worth considering. PIH was successful because they worked to collaborate with the state, which helped to create lasting change, so perhaps the state collaborating with/funding smaller NGOs would be another effective integration.

  12. Hi Leah,

    Thank you for your thoughtful post. I completely agree with your comprehensive analysis of NGOs. One thing I mentioned in another post is that, while it may seem that NGOs are beholden to the agendas of their donors, this is not necessarily the case all the time. Especially, the more established NGOs have built up a “reputation” for succeeding in their aims, so donors are much more likely to give them money without setting benchmarks.

    In answer to your questions, I would agree with others that NGOs do still have a place in health projects. I think PIH does a good job of balancing its own interventions while respecting the responsibilities of the state: PIH works with the state to build sustainable health infrastructure so that at some point the state can take over health projects. At the same time, if there is cooperation, I think that the roles of the state and NGO must be clearly defined, as this can cause confusion and unintended consequences.

    1. Hi Benjamin! I definitely agree that certain NGOs are large enough and have their reputations built so donors have more trust in them, and they in turn have more freedom. The problem is for smaller NGOs who are not necessarily able to attain this freedom from donors. If this limits their ability to make decisions for the community instead of donors, it will likely also limit their impact, meaning they may not be able to build their reputation to the point of trust from donors. These are the instances where it is most critical that NGOs have freedom to do what they think is best, but it is certainly worth noting that some NGOs already have this freedom, even with strong donor connections.

  13. Hi Leah,

    In your post you emphasize that context (qualitative research) is imperative to a successful approach for tackling a health care problem or system. Thus, to answer your questions, it would seem that it matters less the type of intervention or type of organization than it does to always begin with an assessment of the problem particular to its region, community, and individuals. While it sometimes is tempting to argue that NGOs are not enough and they are a barrier to making governments responsible for ensuring adequate health care systems, it can also be easy to argue that government leaders are sometimes too corrupt and cannot be trusted with funds to better health care because there is no international accountability. Yet, I think both actors, governments and NGOs, are necessary in the equation for running a equitable and substantial health care system. Bottom-up and top-down approaches wielded by various groups can work symbiotically in an ideal situation. Though due to the un-ideal circumstances in many countries, I would agree with you that NGOs should be focusing on bottom-up interventions that depend on through needs assessments and consistent evaluation from the patients affected.

    To address your third question, one way to imagine a solution is if we can continue to press for a focus on primary care interventions. Currently, donors prefer quantitative research and analysis – they want to see programs that produce clear and fast results. Maybe we can shift this desire onto primary care initiatives because as Farmer made evident with PIH, you can get clear results with comprehensive and programs and integrated systems of care. While we discussed in class the ways vertical interventions can become diagonal by embracing horizontal measures, I think finding ways of attracting donors to primary care models can become a paradigmatic shift in the way global health is calculated.

    1. Hi Elena! Thanks for your comment, I especially agree with your point that the best case scenario is for top-down and bottom-up approaches to be working symbiotically. This means that structural changes are being made, but there are programs in place to help the people who may be falling through the cracks. In regards to the quantitative analysis, I think this can be useful but it can also be dangerous. If quantitative analysis is the only way an intervention is being assessed, it may miss important changes that are being made but more difficult to measure numerically. This could be harmful for interventions that have not had enough time to make a long term change but are in the process of producing positive results. That being said, quantitative data is definitely a good way to attract donors so it should be utilized when possible.

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