I’m interested in critiquing “the demonstration of success” that NGOs are forced to produce for donors as evaluation for their efforts. I also think that evaluating the success of global health projects using a business-like model can be problematic.
Fundraising for a specific epidemic is one way to mobilize resources for NGOs using a vertical model (Biehl & Petryna, 2013). Uniting behind one health issue is a benefit of the vertical approach but as we have seen with “magic bullet” case studies for malaria and guinea worm, these programs can fail. Vertically oriented programs have major drawbacks because they don’t consider the improvement of regional health in a holistic manner. NGOs are one way to tackle issues of global health but they are dependent on donor funding (Zaidi, 1999). There exists a patron-client relationship between donors and NGOs similar to something you would find in a business.
Donor investment fads are one issue in NGO funding because popular issues are prioritized over necessities (Zaidi, 1999). Donors also have the power to decide what specific objectives are being targeted (Biehl & Petryna, 2013) and what projects to create. This makes me wonder how often project choices are based on evidence of need in a particular region or just based on the opinion of the donor, which may or may not be the best way to spend the money. Communication with community leaders about health projects they view as most important in their region should play a major role in NGO program planning to have the most effective outcomes (Ooko, 2014).
NGOS have been known to fix data for donors so they see the outcomes they want to continue to invest in the projects (Zaidi, 1999). This information is incredibly troublesome because it doesn’t show real progress or improvements of a health effort. This is similar to the portrayal and understanding of a country’s GDP, or the size of their economy. While Mozambique’s GDP increased after structural adjustment showing economic growth, the wealth of the rich increased, the poor populations grew poorer and rates of child malnutrition haven’t improved (Biehl & Petryna, 2013). The rise in GDP did not necessarily indicate an increase in health.
Statistics are one way to illustrate the “success” of a global health program to donors and specific patient examples are another. Ugandan patients in ARV programs proselytize their programs and endorse the success of treatment with their voice and bodies (Biehl & Petryna, 2013). Brenda of the HBAC program is one example of a success story from USAID support. Her story of transition, once on the verge of death to currently enrolled in college, provides evidence of success to donors and patrons, which shows the NGOs accountability. Benton (2015) also discusses the idea of successful examples of health in the context of HIV in effort to erase the stigma associated with being HIV positive. While I think that in both cases the use of specific patient examples can be motivating for either the donor or other patients, the comparison that other patients make between themselves and the example can be damaging to their own morale. Everyone recovers differently and faces different obstacles in their lives and health so modeling after one “good example” may sometimes be unrealistic.
Using a business-like model, or donors investing money with the expectation of “success” in the form of fast-improved health statistics or case studies, forces NGOs to create quick fixes to health issues rather than investing in regional structural changes that are sustainable. I draw a parallel in the US education system as teacher salaries in Florida are dependent on their student’s test scores. Studies have shown that teaching quality is not related to test scores (O’Connor, 2014) and I think this follows similar lines with the expectations of NGOs. Sometimes health improvements are difficult to measure or there are lags in the results of efforts, but these reasons should not deter donor investing in important projects.
The effects of NGO global health projects should be measured and monitored in some way to evaluate community health improvement. I suggest this be done through continued data collection, effective communication between NGO leaders and community members a part of target populations, and the donor taking a more hands-off role in program planning. We might also think about the time frame for the outcome of these efforts and consider measuring success over longer intervals so that efforts of long-term sustainable projects have time to form (Sriskandarajah, 2015).
Discussion Questions
- How can success pressure be alleviated from NGO programs? Is this necessary, or are there any alternative ways to evaluate the effects of global health projects?
- What role should donors play in the planning of global health programs they invest in? Does this change based on individual donors vs. government donors or their respective experience levels?
Sources:
- J. Biehl & A. Petryna, eds. 2013. When People Come First: Critical Studies in Global Health. Princeton: Princeton University Press.
- Zaidi, S.Akbar. 1999. “NGO Failure and the Need to Bring Back the State.” Journal of International Development 11(2): 259.
- Ooko, Sarah. “NGOs and Development in Africa: Lessons for Donors.” Thomson Reuters Foundation. 3 Mar. 2014. Web. 13 Nov. 2015. <http://www.trust.org/item/20140303151017-208vf/>.
- A. Benton. 2015. HIV Exceptionalism: Development Through Disease in Sierra Leone. Minneapolis: University of Minnesota Press.
- O’Connor, John. “Two New Studies Find Problems With Teacher Evaluations.” State Impact. NPR, 13 May 2014. Web. 13 Nov. 2015. <https://stateimpact.npr.org/florida/2014/05/13/two-new-studies-find-problems-with-teacher-evaluations/>.
- Sriskandarajah, Dhananjayan. “Five Reasons Donors Give for Not Funding Local NGOs Directly.” The Guardian. 9 Nov. 2015. Web. 13 Nov. 2015. <http://www.theguardian.com/global-development-professionals-network/2015/nov/09/five-reasons-donors-give-for-not-funding-local-ngos-directly>.
Hi Zelda,
Thank you for your response. ” I absolutely agree with you that “the demonstration of success” is a problem that must be addressed in order to create more sustainable global health projects. Maybe I can offer my two cents from another class, a development seminar, where we interviewed many people who lead NGOs and have to deal with these problems on a daily basis. One thing that I found surprising is that, apparently, the extent to which you can dictate your own agenda is often determined by your experience. That is, donors are more likely to hand over money to an NGO without any conditions, if that NGO has proven its success time and time again in past projects. In this way, once an NGO has demonstrated success as an entity, it no longer has to demonstrate success in individual trials.
Of course, this also means that an NGO must demonstrate its success in individual trials at some point to gain some sort of autonomy. And I’m not sure there are many ways around this. Even though managers of NGOs are more likely to have the training and education to understand how to best spend the money, donors have to be cautious about the money they give; otherwise, an NGO could just take the money and run. This is much more the case for governments than individual donors. Governments and representatives are answerable to constituents in the promises they make, so they must produce tangible results, regardless of whether they are the best ones. With individual donors, the demonstration of success they set is often influenced by what political beliefs they have and the issues dear to their heart. Because of this, I think they are more open to hear what NGOs think is the best strategy to make a positive impact.
Hi Zelda!
I think you bring up some very interesting points, and I like how you incorporate your own opinions into your post.
You and Leah asked very similar questions, and I think it is a difficult one to answer. It appears that there is a tradeoff between NGOs and donors. You either listen to your donor, which may or may not be helping the well-being of the people; or you don’t listen to your donor, and risk the chance of losing your donor, therefore possible discontinuation of your NGO (Zaidi). I thought Benjamin brought up an interesting point to create some distance between NGOs and donors by letting NGOs build a reputable name and hope that people will want to donate to them without any compensation. I think the hardest part would be getting starting and building that reputation with little funding, but I think this idea is plausible. I think instead of measuring success based on quantitative statistics, researchers should base success on qualitative statistics such as surveys that rate the overall effectiveness of the program.
I think that donors should understand that they are donating to help people that are in desperate need. They should allow researchers who have experience and knowledge about what needs to be done. Donors should understand that their restrictions could hinder an NGOs performance and this could lead to suboptimal results. Maybe if NGOs discussed their plans with donors with goals, dates, and possible future contracts, donors might be willing to listen and negotiate a deal where everyone can be happy. Do you think that laws need to be enforced to keep donors from placing harsh restriction son NGOs? What are your thoughts?
Hi Samantha,
I agree with your point about discussion between NGOs and their donors, this seems vital to the success of the project so that everyone is on the same page for the goals of the program. I imagine this is usually part of the process for funding in global heath which makes we wonder if most of the time NGOs have agreed and think that the goals they set are realistic but they actually require more time to attain. I think that after this point maybe a re-evaluation of the goals would be useful so that the NGOs aren’t penalized for not getting the data they said they could. I think that the community where the NGO will be working should be included in planning too. This was mentioned in a cool study I found (http://www.accaglobal.com/content/dam/acca/global/PDF-technical/sustainability-reporting/rr-110-001.pdf) that talks a lot about different aspects of the NGO-donor relationship and the issue of accountability. One thing it mentions is the idea of self-regulation within the organization or that people who work for the NGO have standards they need to uphold throughout the project.
Hi Zelda!
I think the article you posted was really interesting, and maybe a possible suggestion for Professor Mason for a class reading in the future. I think it is relative to what we have been talking about in class, and focuses more on the donor and NGO relationship. One of the suggestions made to increase the understanding the benefits of long-term programs to donors was to advise educational programs to demonstrate the effectiveness of long-term programs rather than short-term. Sometimes donors place too much of a time constraint on programs, which leads to sub optimal results. This could lead to problematic issues because it may increase the quantitative data, but not increase the qualitative data (or sometimes both). Quantitative data seems to neglect the well-being of individuals in the program.
I think this article highlights the importance of the relationships between donors and NGOs, which we fail to acknowledge today
Hey Benjamin,
Thank you for your comment. I totally understand that donors still need to hold the organizations they donate to accountable to make sure they are legitimate and aren’t corrupt. It’s interesting that this can be easier for NGOs when they have established their credibility somehow in the beginning. Besides different governments, and the popular organizations we hear about in the news and our class (Bill and Melinda Gates Foundation) I’m curious who these individual donors actually are and what sort of backgrounds they have. In looking this up I found a cool briefing paper on private funding for humanitarian projects (http://www.globalhumanitarianassistance.org/wp-content/uploads/2015/05/Private-Funding-2015_May2015.pdf) that has tables summarizing the types of funding in different countries. It says that some forms of giving can happen outside this bureaucratic system where a benefactor gives money directly to those who need it (10) which is a really interesting idea.
Hey Zelda,
I like that you analyzed the danger using patient success stories could bring. I agree, this qualitative method could be damaging because it could place unrealistic expectations on how recovery ought to look and feel like as well as the time frame of recovery, which differs between people. Similarly, I also agree that using quantitative data alone to measure health outcomes also has its problems. It is especially problematic when NGOs have to produce this data in a specific, short time frame to validate their effectiveness to donors. So what’s a good solution for NGOs to continue getting funding from donors while still being able to maintain flexibility in the field? Benjamin brought up a great point; NGOs need to gain their donors’ trust before they can be given this flexibility and autonomy.
On Lena’s post, there was discussion of using other qualitative metrics to evaluate health outcomes such as using surveys. Questions could revolve around what the people benefitting from the project think about the NGO, how effective it is, and how it has benefitted their individual lives. Although highly subjective, these perspectives are also important when it comes to evaluating project effectiveness and showing progress to donors. They tap into other determinants of a person’s wellbeing that quantitative data can’t show alone. You also brought up some good, possible solutions to the the NGO-donor relationship issue. I too think that there should be more effective communication between NGOs and donors on establishing reasonable time-frames.
Hey Jeannette,
Thank you for your thoughtful comment. To have those benefitting from the programs evaluate them in a way other than a reflection of their health status is a really interesting idea. Another idea that I hadn’t considered before was discussed in the link in response to Samantha, which is that the number of people the NGO trains in a community for a certain program can be a quantitative output. Before I thought that statistics could really only reflect those the prevalence of disease or literacy rates, but community building aspects are included too. This document also talks about “participatory reviews” which I think are essentially surveys of the NGO’s programs– one drawback with this can be the issue of translation between the community’s language and the donor’s.
Zelda,
Your post raises some truly concerning points in regard to the business-like model of evaluating success. I am equally saddened that these regimented indicators of success only encourage vertical programs instead of diagonal or horizontal ones. I commend you on your inquiry of whether the donor is the real decider of what a community needs instead of trained professionals, because I’m sure that often times, they certainly are. It’s certain that we need to change the culture of donorship by pushing donors to take a more active role in understanding the most important challenges facing the underserved population to whom they wish to donate.
In response to your second question, I do not think that this level of change should be based on individual donors vs. government donors, but rather we should keep in mind that their comprehension is increasingly important when their continued donations depend on their complacency with an NGO’s results.
I am very impressed by the comparison you made between NGO pressure to succeed and the common “teach to the test” method seen in American schools. This would be a great point to add when trying to explain to donors the importance of their full comprehension of the nuances involved in global health work, since it is something with which they are already familiar.
Hi Zelda,
I really enjoyed your post. I absolutely agree that vertical campaigns are limited in their effectiveness, as medical advances or short-term solutions will not solve the conditions that allow these diseases to emerge and to spread in the first place. I believe that “quick fixes” and improvements in numbers give the false pretense that overall health is improving, when it really isn’t, thus inhibiting real improvement.
I also agree that NGO program planning should be largely dependent on community leaders who are familiar with the specific conditions and needs of the community. In response to your second question, I don’t believe that donors should play a huge role in planning of global health programs. Not only are they probably unfamiliar with the real needs of the people who are receiving treatments from these funds, it is also likely that their involvement stems, at least in part, from a selfish motive, a desire to strengthen their own feelings of self-worth, accomplishment and global dominance (in the context of state funding). Significant donor involvement may challenge the cultural diversity of communities and promote the “Westernization” of these regions through the imposition of specific practices that are favored by the donor. In this sense, donor involvement may invoke a form hierarchy that may strengthen the divide between the donor and patient and thus engender feelings of superiority and inferiority.
I also agree that a rise in GDP is not an indication of health or levels of suffering, as growth is often centralized among the country’s most wealthy individuals and may even serve to benefit the wealthy at the expense of the poor through further exploitation, such as the promotion of terrible working conditions to foster economic growth. Furthermore, suffering cannot be measured in numbers or statistics, particularly on an individual level, as results exhibited at the population level may have no resonance for individuals.
Hey Zelda –
I think you did a really good job at highlighting the problem of success pressure within the NGO community, especially given the emphasis on EBM. One way that has been brought up before that I think can make some changes towards alleviating such pressure is a transition towards qualitative data collection paired with the system of quantitative data collection that is already in place. EBM often emphasizes quantitative data as the only form of evidence that is worthwhile, which can lead to some of the problems you brought up like modifying program data to secure more funding. I think that integrating qualitative data can help to reduce some of the pressure by assessing a more holistic picture of a programs impact, including the intangible benefits to aid recipients that wouldn’t otherwise be counted towards vaccines administered or houses built. While qualitative data may be harder to collect and not have as strong implications in terms of funding, I think it provides a valuable framework to look at public health interventions through, where the benefit comes from the comprehensive care offered, not just the individual interventions. Donors can help create this systemic change by asking for information about a program besides the hard numbers, including personal testimonies of its impacts and reflections on what has been done and what can be improved upon. If the people providing the money want to see a more holistic picture of the project they’re funding, I believe it is more likely to happen.
Hi Ruby,
The idea of including more qualitative data for the effectiveness of NGO involvement is a great idea. I hadn’t really thought of that before reading the aforementioned articles. This would definitely paint a better picture of the impact the NGO’s programs have had on the people they are working with.
Hi Zelda,
You did a great job of highlighting many of the difficulties NGOs have when forced to quantitatively demonstrate success to many of their donors. Dealing only with popular medical issues and having to show immediate impact sounds incredibly frustrating. I like the point you made about ensuring that everyone involved in the project has a realistic time frame for the project, and understands when success should be expected. As an example, in section we worked on a case study where infant mortality was a large problem, and the donor wanted to see immediate improvement. It would make sense in that situation to target newly pregnant women to get them to take prenatal vitamins and follow good maternity behaviors, and then measure our impacts several months after babies were born, so it would take over a year to have concrete data on our intervention because we are employing long-term preventative strategies.
I think to discuss your first question, on how exactly NGO projects can best be measured, the best response is to have equal amounts of qualitative feedback as quantitative, as no statistics make sense out of context. I still think it is critical from a donor perspective to ensure money is being used efficiently (as no one wants to waste their money), so form of evaluation/check-in is quite necessary.
Thanks Alana,
I hadn’t thought of using both qualitative and quantitative data for in order to understand the context of the statistics obtained but that really makes sense. Not only would obtaining the two make the information more legitimate but they could also be used to show people involved in the intervention as more than just numbers, by having their personal stories of how the NGO has effected their lives, both for donors and the general public interested in the issue.
Hi Zelda! Thanks for your informative post. I think you are very much right in your critique of the business-model NGO system. On the whole, it severely stunts the potential health promotion that NGOs could enact if they didn’t have to worry about having the correct stats, etc. It seems that by needing to show quick and cheap results, NGOs are often forced to use vertical campaigns that usually do not address what the patients/clients want or need. Although people may not be dying as much under this NGO system, they certainly aren’t living.
I think your suggestion to consider success over longer intervals is extremely fascinating and something I didn’t think about before. If NGOs were encouraged to take a longer, more careful amount of time in enacting health change, would they be further encouraged to use horizontal campaigns? In my opinion, I think they would. At least, NGOs would have less pressure to produce fast, unwieldy results. Still, I wonder who is going to regulate donors and push them to encourage the longer evaluation period? Despite the good intention behind the idea, NGOs are still operating in fast-paced market economy that prefers fast, cheap results. Could it then be the role of the WHO to push for such regulation? What are your ideas?
Hi Lilian,
I appreciate your comment comparing the vertical programs’ support as providing zoe but that they need to more horizontal to give the people more than bare life, or bios. The WHO might be able to regulate donors so that they understand the importance of encouraging longer time between evaluations but I also think it might come down to the area of expertise and education of the donor themselves. Maybe a donor who has a background in medicine would understand that it would take a while to assess the childhood health of a region, like Alana mentions above, and they would be more supportive of a longer time frame. Maybe the WHO could provide this information to donors or give them case studies that use longer time frames to show that it can be beneficial for programs to be evaluated in this way.
Zelda, thank you for your post! You brought up so many great points – the drawbacks of vertical NGO approaches, unrealistic examples of patient exceptionalism in interventions, and donor investment fads. I was particularly drawn to your thought on the extent to which “project choices are based on evidence of need in a particular region or just based on the opinion of the donor”. Based on class discussions, it is clear that many stakeholders fund programs or endorse health campaigns rooted in how relevant they perceive a given disease to be to certain populations.
In Improvising Medicine, Julie Livingston reveals that the emphasis on HIV/AIDS in Botswana, coupled with popular Euro-American notions that cancer is a “disease of civilization”, often obscures the prevalence of cancer among sub-Saharan African populations. In the Botswana context, it also appeared that there was initially little investigation into and insufficient infrastructure to address the “synergy” between antiretroviral therapies (ARVs) and cancer. ARVs suppress the immune system and create an environment for virus-associated cancers (Livingston 11). However, Livingston states that it was not until recently that epidemiologists “described cancer as a ‘common disease’ in Africa” (Livingston 8). While HIV is obviously a serious disease that global health workers should address, it is also important to incorporate illnesses related a disease of interest (in this case, cancer, an “anticipated byproduct” of intense, targeted HIV interventions) into discourse with donors so that they may more evenly distribute resources. In regards to your second question, I believe that the role donors play in planning global health programs must be in concert with local individuals, NGO workers, epidemiologists, and anthropologists. Only through discussions on funding holistic health, not simply one disease in isolation of factors that feed into it, can “NGO program planning (breakdown a hierarchy of disease funding) to have the most effective outcomes”.
Your discussion of patient success really resonated with something I’ve been thinking a lot about lately, this idea of what “health” looks like and what images of health we perpetuate and reproduce by validating them. I think this is inherently problematic and recalls for me Audre Lorde’s Cancer Journals, which discuss the pressure she felt to get prostheses after her mastsectomy in the eighties, as well as the more contemporary S. Lochlann Jain, who in her autoethnography, Malignant, implicates the “cancer industries” in perpetuating and profiting off cancer diagnosis through the affirmation of beauty based on ideas of traditional femininity, and I think these ideas tie in similarly to the NGO-as-business model that you discuss in your post, as well.
Thanks Dolma,
I hadn’t thought about the interpretation of the data obtained after NGOs have implemented their programs and that maybe assessments would differ between cultures. In a qualitative assessment about the effect one intervention has had in their lives, maybe the information read by an NGO worker or donor could be misinterpreted or the original cultural context would not be understood (relating to the social construction of reality). For this reason, maybe additional emphasis in having someone from the community or region involved in reviewing the feedback from the program would make the data analysis more accurate beyond the lens of western conceptions of health.
I think our discussion of vertical programs that later adopt horizontal measures is one solution to the questions you have posed. If an NGO can begin with a kind of vertical approach in order to get money from donors, perhaps after showing some results and gaining the trust of their donors, they can focus on more primary and preventative health measures. I also wonder about if NGO’s inviting their donors to the communities they are located within could be a positive part of relationship building, or if the separation of donor and NGO actually affords the NGO more freedom… increasing a donor’s knowledge of the context of where their money is going and the complexity of the problems facing the communities affected might be one way to increase their commitment to supporting that NGO, or it might lead to more pressure or the abandonment of it.