NGO intervention in global health: a panacea or misguided donor-driven intervention?

While most NGO interventions in global health are well-intentioned, many fail to create meaningful and sustainable change. I will analyze reasons behind this phenomenon, primarily the issue of uninformed donors directing interventions, the exceptionalisation of certain diseases, the client-patron relationship that arises and finally the expectation that NGOs are a panacea to global health problems.

A fundamental issue with NGO intervention in global health is that interventions are often driven “by purse-strings” rather than actual on the ground needs (Zaidi, 270) This is seen in HIV care and in what Whyte et. al refer to as the ‘projectification’ of HIV care. This refers to the reality that the level of care a patient receives depends in large part on the program they decide or are able to join and who is funding it. “Whether clients also receive medicines for opportunistic infections and other health problems depends upon the program they have joined.” (Petryna, 155) In this chapter, Whyte et al. provide the example of some Ugandan programs providing CD4 counts but other programs to not provide this more costly test. Whether or not a program offers certain tests and services ultimately comes down to how much money they have, where this money is coming from, and how the donor wants it to be spent. So at Ministry of Health facilities funded by the Global Fund in Uganda, most clients have never had their CD4 counts measured.

The notion of patients becoming clients brought forward in Chapter 5 of Petryna and Biehl’s work is immediately unsettling as there’s a problematic power dynamic at play. “To put it bluntly, public health in this setting does not mean rights and equal opportunities for all citizens of Uganda. Rather, it means building on patron-client relationships locally, nationally, and internationally.” (145) ‘Clients’ are at the will of their patrons and the amount of money that the program they are enrolled in has from donors and NGOs. Moreover, there is a notion of reciprocity at work here as patients enter into this contractual relationship and are thus at the will of the restrictions and inconveniences imposed on them by their ‘patron’ health program.

Zaidi’s piece condemns NGOs as a band-aid fix to health care particularly in settings where the state has failed. “Because of their limited scope and reach, NGOs are no alterative to state failure.” (Zaidi, 270) Similarly, Pfeiffer also criticizes the prevailing notion in global health that NGOs are a “panacea”. This is an extremely important point to consider because most of the time, NGOs are not in a position to address the root causes of the problems that their specific intervention is designed to handle. (Zaidi, 268) Consequently, the expectation that NGOs will solve problems that a failed state is not able to address, is completely unrealistic and more importantly, unsustainable.

Chapter 6 of When People Come First, is slightly more optimistic in that Pfeiffer highlights that despite the misguided efforts of many NGO interventions in global health, we are in a state currently of “high agitation” in global health(Pfeiffer, 181). As such, there is great potential and a wide gap for innovation and major progress in the field. However, there are so many different NGO actors currently involved that reaching this potential is complicated. This concept is echoed in the Council on Foreign Relations blog post that appeared earlier this month about the WHO. Miles Kahler offers an interesting suggestion to this issue of harnessing the potential for innovation that the WHO should act as a norm-developing body. In this way, the WHO could set best practices, guidelines and norms that would significantly improve the effectiveness of many NGO interventions.

Ultimately, as is so often in discussions of global health interventions, the issue of NGO intervention comes down to a question of population versus individual. If the aim is to save a few individual lives, then perhaps NGO interventions in global health suffice as they exist. However, if the aim is to help a broader population, it’s evident from this week’s reading that NGOs are ineffective as they are expected to be a panacea and are too often constrained by misinformed donors. Global norms for the conduct of NGOs in global health interventions would help to address this shortcoming significantly.

Discussion Questions:

  1. With such strong criticism of NGO intervention in global health, would the better alternative be for NGOs to not intervene at all? Or is some intervention, even if it is misguided, better than none?
  2. Do you think the WHO could successfully assume the role of a norm-setting leader in global health to guide NGO practices and interventions?

Sources:

  • Benton, Adia. HIV Exceptionalism: Development through Disease in Sierra Leone. Minneapolis: U of Minnesota, 2015.
  • Biehl, João Guilherme and Adriana Petryna. “Evidence-Based Global Public Health.” When People Come First: Critical Studies in Global Health. Princeton: Princeton UP, 2013.
  • Patrick, Stuart, Global Health and the WHO: Revival or Marginalization? Council on Foreign Relations Blog: http://blogs.cfr.org/patrick/2015/11/06/global-health-and-the-who-revival-or-marginalization/
  • Zaidi, S. Akbar. “NGO Failure and the Need to Bring Back the State.”Journal of International Development J. Int. Dev.2 (1999): 259-71. Web

 

26 thoughts on “NGO intervention in global health: a panacea or misguided donor-driven intervention?”

  1. Hi Jessica!

    I really enjoyed reading your post as at it brought up many different readings that are relative to this topic. Your post was also very organized!

    To some extent I agree with your last paragraph, which states that NGOs are ineffective at a population level. Zaidi’s article explained that most stories that we hear about NGOs are the same overused success stories, but we often neglect to consider NGOs that have failed and why they have failed. It’s a shame that NGOs work hard to establish an organization for a good cause, but are left with no reward or encouragement by the end. I think we can relate these readings to the Idi article we read awhile ago. By understanding a population’s culture, needs, and desires, it is much easier to improve the well-being of fa population. However, donors do not acquire a basic understanding of the people, and therefore I don’t think they should be in charge of a region’s agenda. This results in quantitative statistics rather than qualitative statistics and lacks adequate measurement of a population’s well-being. What are your thoughts?

    I kept changing my mind to answer your first question, so I have decided to say that I’m unsure as to what NGOs should do. NGOs that provide interventions by a donor’s discretion may leave people in worse shape than before by implementing incomplete trials. However, some interventions that are short-term could be beneficial. If NGOs don’t intervene, this could create less risk to damaging people’s well-being, but could also deny people of short-term cares that interventions can provide. I’m kind of stuck in a never-ending circle on this question. I think the structure of NGOs can be improved in order to reduce the dependence on donors for funding even though this may result in helping smaller populations.
    I believe the WHO could successfully assume a role as a norm-setting leader, however, this may result in fewer donors. I think donors need to be more informed of interventions that NGOs plan to implement. There could be a lack of communication between donors and NGOs, which makes donors feel the need to enforce agendas (?)

  2. Hey Samantha!

    Thanks for a thoughtful reply! I totally agree with your point about qualitative versus quantitative NGO results. I also appreciate your reference to Kleinman’s chapter on Idi. Despite the tumultuous nature of her work, Idi’s constant seemed to be that she was constantly thinking about the individual rather than the population, as she didn’t think it feasible to try and change the system. A quote I have used in my audio response is that Idi mastered what Kleinman calls “the art of what is feasible.” I think this sums up really well the way Idi pragmatically navigated her work, focusing on the individual and how she acquired a unique understanding of the culture in which she was working, that so many donors lack.

    1. Hi Jessica!

      Thank you for your reply! Do you think that it would be more effective for people to live similar to those that NGOs are targeting? For my interview paper, my friend lived in a small building with no air conditioning, shared two showers between thirty people-sometimes the water didn’t work, and ate similar to the villagers. She was also expected to till a plot of land, and perform regular duties that people in her village did everyday. She said it was an experience she’ll never forget. She also stated that, “I hope I could impact their lives just as much as they did mine.” It was overall really inspiring to hear, and I think if policymakers could understand the needs of the people they were working with, it would be much more beneficial for them.

  3. Hey Samantha,

    I totally agree, it would be great if NGO workers could be able to experience in some way the lives of those they are trying to help. I think this would create much more effective work as activists would have a deeper and more nuanced understanding of the milieu in which they find themselves. Your interviewee sounds very interesting, what an experience! Thanks for sharing!

  4. Hey Jessica,

    I wasn’t quite sure what Akbar meant when he said most NGOs “fail.” Do they fail because they stopped getting funding, because they didn’t achieve what they originally set out to do, because they are not getting media attention even? What qualifies as being a success or failure? Is helping a few people considered a failure if an NGO sought to help more? I bring this up because it relates to your first question, the effectiveness of NGO intervention. Sure NGOs might not have as great a population effect, but can have an important impact at the individual level. I think when NGOs try to solve population-based issues they “fail” because they don’t or can’t address the larger structural/political/environmental climate contributing to the problem NGOs are trying to address. An example of this is an NGO we discussed in class that handed out mosquito nets to decease the incidence of Malaria; it led to the unintended consequence of people using them for other things like fishing nets, which polluted the water these nets were being used in. That being said, NGOs may end up doing more harm than good at times. However, NGOs like MSF, which focus on treating each individual that comes through its camp, “succeeds” at achieving its goal. Thus, if the WHO were to set guidelines for NGOs, I think this could be problematic because the WHO focuses more on population health, an area that NGOs should be wary of addressing.

    1. Hey Jeannette,

      I think you’re totally correct to highlight what the definition of success is in the case of NGO intervention. I think the reason NGO efforts are so often criticized is because they’re expected to be a cure-all fix to systemic problems. However, I agree with you in that this shouldn’t be the expectation and that often times, NGO work is ‘successful’ in that it greatly impacts individual lives. It seems we always come back to the population vs. individual discussion in this class!

  5. Jessica,
    Thank you for your thought-provoking post. I appreciate that you disproved the concept of NGOs being a panacea—this same thought came to mind for me when we looked at humanitarian aid. Many people critiqued Doctors Without Borders for their lack of a long-term plan for the countries in which they work, but their goal is specifically to sustain life in times of dire medical emergency, which is what they do. Many think that humanitarian aid and NGOs are meant to be a be-all end-all fix to global health issues, when the people that actually run the organizations have a much more sobered idea of what they care capable of accomplishing.

    You ask if it would be better for NGOs not to intervene at all, and as a result, leave the country and its government on its own, to which I would answer no. Without NGOs, there would be no signal of concern to the local government and consequently perhaps no push to improve it. By placing NGOs in these areas, we convey the message that we see something wrong and offer possible suggestions for improvement through action and example. Ultimately, yes. Some intervention is better than none.

    Even so, I do agree that government change is the only permanent fix. Even if the WHO aims to be a norm-setting organization, what can they do to actually influence action? This is the classic “no teeth” problem we see with the WHO and similar groups.

    1. Hi Sarah!

      I thought your comments were really interesting!

      I agree that NGOs still need to remain active in order to demonstrate that there is still a high demand for global health organizations worldwide. Without there existence, help may not be considered a pressing issue, and people may feel less obligated to donate. Any help is better than no help at all.

      As for governments, I think they can do a better job at connecting donor to NGOs to the community needs. People need to be on the same page for goals, plans, and time commitments. They can collaborate and compromise to one common goal. I’m learning about culture in my Micro Theory Organizational class, and it mentions how the most important aspect to building a strong culture is to create common goals and promote innovation. I think this directly correlates to the bonds between NGOs, donors, and the community since all players are being influenced by the outcomes of a program

      1. Hey Samantha!

        Thanks for sharing that interesting detail about the class you’re taking. I certainly agree that collaborating in terms of goals of the donors, the NGO and the community they’re serving would be hugely beneficial to creating effective impact.

  6. Hi Jessica,
    I really enjoyed your post. I thought it was very insightful and well-constructed, and you bring up some great points.
    I strongly agree with your conceptualization of donor involvement as a patron-client relationship in public health. Health is meant to be a right for all individuals, yet here we see that it is only a right for people who can afford it, even within programs meant to provide health for all patients in spite of this economic dynamic. Such a patron-client relationship invokes colonial dynamics and, like you mentioned, a sense of dependency on donors that may lead patients to internalize a communicated ‘inferiority’ . Many patients, as a result, may be unwilling to receive treatment or become involved in these programs due to lack of trust and feelings of oppression.
    Although I agree that NGO’s alone are incapable of solving structural issues, I do believe that they must at least try to address these issues, perhaps through public condemnation intended to raise public awareness and prompt more powerful governments to act. Otherwise, NGO’s risk prioritizing “bare life” at the expense of a needed recognition of the patients’ humanity, as simply living does not in any way constitute living well or happily.
    In response to your first question, I believe that NGO intervention is still necessary, as some sort of intervention is still better than none at all. Structural change is not something that can happen quickly, and a lack of intervention in the time undertaken to promote structural change would result in needless suffering and increased death rates. I believe that in spite of many of the NGOs’ shortcomings, any opportunity to save a life and relieve immediate suffering should always be utilized.

    1. Hey Alexandra,

      I think you bring up an important point that is often forgotten in the criticism of NGOs in that their abilities to place pressure on governments and institutions is significant and very important for impacting more long term change. Moreover, NGOs are often crucial in bringing issues to light and to the media which otherwise would’ve gone unreported. While there are certainly many issues with NGO intervention, I agree that these benefits should not be underestimated!

    2. Hey Alexandra,

      I think you bring up an important point that is often forgotten in the criticism of NGOs in that their abilities to place pressure on governments and institutions is significant and very important for impacting more long term change. Moreover, NGOs are often crucial in bringing issues to light and to the media which otherwise would’ve gone unreported. While there are certainly many issues with NGO intervention, I agree that these benefits should not be underestimated!

  7. Jessica –
    You did a great job addressing and synthesizing a wide range of critiques of NGOs. In regards to your first question, I am wholeheartedly on the side of intervening, even if there is criticism. I find it troubling that critiques of NGOs have risen to the level that we would consider halting all attempts at providing assistance just because the aid we provide might not address every problem that afflicts a region. As long as we don’t assume that any given intervention will provide a complete fix to the issue, and we allow interventions to adapt and restructure according to initial results and problems I think that making some attempt will always be better than doing nothing.
    Regarding the WHO, I think that any agency like it that doesn’t have any inherent enforcement ability is going to struggle in terms of making substantive change. However, the function you propose, norm-setting, is one that is more likely to succeed than some of their other goals like reforming state-run health programs where they have no authority. That being said, I think there are a lot of examples of NGOs doing a better job at improving health incomes than the WHO, so rather than prescribing the role of leader to the WHO, I think it would make more sense for the organization to be focused on assessing public health interventions and encouraging others to follow those that are most effective.

    1. Hey Ruby,
      I think you make an important and nuanced point in that what needs to change more urgently are the assumptions and expectations surrounding NGOs and their interventions. I totally agree with this. If there weren’t the underlying assumption that NGOs are a ‘cure-all’ solution to more systemic failures of a state, then there would be less criticism of NGOs when it seems they haven’t solved all of the issues facing a specific place and they could focus on the very important work that they do carry out, perhaps at a more individual level.

  8. Hi Jessica,
    You brought up a lot of interesting points, and I agree with a lot of what you said in the post! Your argument on how the biggest health determinant in many situations is the particular intervention a person is enrolled in was particularly insightful.

    That being said, I disagree with the idea that “the expectation that NGOs will solve problems that a failed state is not able to address, is completely unrealistic and more importantly, unsustainable.” While Zaidi certainly presents a compelling argument that an NGO may never be able to address many of the broad systems that impact health in a country, I still believe that many NGOS perform tangible, necessary health benefits that do solve problems in a way some states cannot. NGOs are able to bring funding, and can often shed international attention on a problem that then creates pressure on a state to take more action. Additionally, there are examples of NGOs that are able to address issues that a state does not want to learn how to deal with, because of religious conflicts or certain political leadership. While many NGOs certainly have their flaws, I do believe that on the whole they do more good, and can create long-term sustainable health impacts.

    1. Hey Alana,

      I agree with you that NGOs certainly are important, especially in shedding light on serious issues and consequently pressuring governments to act. What I was trying to get across was more that NGOs shouldn’t be viewed or used as a ‘cure-all’ solution to more deeply structural issues associated with a failed state as they often are. This isn’t to say that NGOs can’t make meaningful impact, but simply that expecting NGO intervention to solve issues of a failed state is unsustainable.

  9. Hi Jessica! Thanks for your thoughts on NGOs. I like that within your critique of international aid, you provide some ideas for strategical change. Although we have seen the WHO as a catalyst for setting global health norms in the past (think cigarettes in developed countries), I wonder efficacy would translate when the goal is to guide NGO practices and interventions. Like we’ve often said in class about WHO, “They have no teeth.” How effective would WHO be as a leader in norm-setting when the entity they must regulate operates so independently and is funded privately?

    Still, I think that strategy has a lot of potential if WHO were to have a least some sort of teeth. If they can’t enforce anything, maybe they can at least have “baby” teeth and incentivize things. Although it’s a weaker sort of motivation than punishing or enforcing, I believe NGOs, as they operate in market economies, might fall under the sway of incentives. What do you think? What might be some effective incentive strategies? Or are there none?

    1. Hi Lilian,
      I like your reference to “baby teeth”! The criticisms of the WHO as having no teeth can’t be ignored but having baby teeth in enforcing norms could be an effective way to start. You bring up a good point in that an issue arises when considering who is funding the WHO.
      https://www.foreignaffairs.com/articles/2011-11-18/setting-record-straight-who-funding
      This is a really interesting read on who is funding the WHO. It comes primarily from government contributions as well as some private donations.

  10. I found your question about whether or not the World Health Organization could successfully assume the role of a norm-setting leader in guiding NGO interventions intriguing, especially since WHO has not always exhibited “best practices” in disseminating care to certain populations. As Farmer describes in Infections and Inequality, WHO utilized “cost-effective strategies” to justify withholding care from Peruvians suffering from multidrug resistant tuberculosis. More specifically, the World Health Organization was leading a campaign against tuberculosis but was resistant to Partners in Health’s petitions to advance care to MDTRB patients in Peru, because treatment required “aggressive…initiation of therapy” (Farmer 33). According to their calculations, it was economically unproductive to treat these patients. Farmer’s case study provides insight into how countries on the receiving end of international aid are subject to the political and economic motivations of wealthy international organizations.

    The same issues of “cost-effective service delivery” are present in NGOs, which are a microcosm of greater issues within the global health community (Zahidi 262). Leading organizations often demonstrate a greater commitment to the perceived worthwhile of certain interventions, such as dumping drugs on populations, rather than to “replicability and sustainability” (Zahidi 266). In addition, donors to NGOs seek the most bang for their buck as measured in (often temporary) statistical improvements (Zaidi 267). Setting global health norms would take a critical analysis of how neoliberal values contribute to “band aid social welfare”.

    Despite the organization’s spotty record, I believe that WHO has the potential to establish norms – prioritizing treatment for patients rather than “purse strings” – but it begins with setting an international example. In answer to your first question, I believe that NGOs should intervene in health affairs. Given the tremendous amount of resources that the Global North can mobilize to aid millions, it is unethical for needs to go unmet. In the Peru-MDRTB case study, Farmer likens the way in which Western countries have allowed populations to languish in untreated disease to a “global Tuskegee experiment” (Farmer 34). Given the “immediacy of survival”, it is better for NGOs to be misguided than to promote suffering through inaction.

    1. Hey Alexis,
      Thanks for a thoughtful response! I certainly agree that one can’t deny the WHO’s dubious history in certain global health affairs. Focusing on alleviating the suffering of individuals as opposed to cost-effectiveness as you point out, would be a great first step and important norm that could be considered.

  11. I’m wondering what you think the best move is for NGO’s. How does one navigate the power of a misinformed donor, and is it up to the NGO to do that informing? I agree with Alexis that the WHO has the bargaining power (to cite Pogge) to establish norms, and I think they could also reasonably serve as this educating standard. It would be curious to see a “WHO approved” NGO list that could funnel donor funding towards NGOs that are considered “effective” in a potentially more holistic way than an effectiveness that is purely statistically derived.

    1. I think that you make a sort of WHO- approved list of NGOs could be an interesting place to start. I wonder what sort of criteria an NGO would have to meet to be included on the list? An important criterion that comes to mind is an NGO’s ability to achieve pragmatic solidarity and work with not for a community and thereby create more sustainable change as the local community can in time take the reigns of an intervention program.

  12. Hi Jessica,

    I found your post very interesting, not only in regard to NGOs but attempts intervene in general. In answer to your question, I think NGOs should intervene, even if their strategies are misguided. I think it is inevitable that interventions will cause unintended consequences and sometimes fail.

    I think it is important, however, to realize that you have no chance of success if you keep the discussion in the seminar room. Having anthropological training is useful in determining the social, political, and cultural factors that might influence the impact of a project. But the fact that an intervention can never be ideally fulfilled should not get in the way of trying to implement it. PIH doesn’t do everything right, but I still believe it does a lot of good.

  13. Hi Ben,
    I completely agree with your last point that ultimately action is better than nothing. We can talk forever, and we’ve discussed many of the pitfalls of NGO intervention, but I agree that even if an intervention cannot be fulfilled perfectly, this is not reason enough for it not to happen. Like so many of our discussions, it comes down to the individual vs. population issue – even if an intervention doesn’t change a population or greater system, it will still very likely positively impact certain individuals.

  14. Hi Jessica!

    Your first question is something I have been grappling with for much of this semester. While I appreciate Zaidi’s point of government responsibility and particular advantages to organizing health care, I don’t think we should get into the business of absolutes when discussing approaches to this problem. Consolidating the role of public health solely in the hands of the State, or else effectually absolving the State of its responsibility by shifting the burden onto NGOs – neither are great options for countries where governments refuse to order a fair and adequate health care system, or where the instability of the State and conflict interfere with State building efforts. While some NGOs may have misguided practices, the many organizations that successfully support communities are a testament to their special purposes. Halting the practices of NGOs in an attempt to pressure national governments to act puts a lot of lives at risk of government failure. I think there may be a way to network NGOs and consolidate many of them into organizations that can more comprehensively address the health of the places they are located.

  15. Hey Elena,

    Thanks for a thoughtful response! I thought the idea you brought up at the end about consolidating NGOs into some sort of network is interesting and a potentially very good solution. Encouraging NGOs to work together where appropriate could be an interesting way to avoid a sort of saturation of lots of programs in one place that may be more effective if they collaborated their resources and expertise all together.

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