Category Archives: NGOs, Aid, and Infrastructure

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.

NGO-Donor Relationship and Pressure for Success

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

  1. 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?
  2. 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?



  • 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. <>.
  • 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. <>.
  • Sriskandarajah, Dhananjayan. “Five Reasons Donors Give for Not Funding Local NGOs Directly.” The Guardian. 9 Nov. 2015. Web. 13 Nov. 2015. <>.

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?


  • 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:
  • 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


A partnership between NGOs and the state: An Illusion

Given that many developing countries are exceedingly dependent on NGOs for health services (Zaidi, 264), it is important to examine this dependency and evaluate whether or not it emerges as a sustainable relationship.  I will argue that there are three fundamental issues with this relationship that prevent it from attaining sustainability. Firstly, as long as NGOs are present in developing countries, healthcare will never be accessible to all citizens. Secondly neither entity is ever held fully accountable to its citizens. Lastly, and perhaps most worryingly, over the years, the work of NGOs has been painted as altruistic, when in reality they are providing health services that all humans have a basic right to.

A poignant example that points to the limitations of NGO accessibility can be found in the approaches toward disclosure of HIV status. Benton recalls a skit that demonstrates how disclosure of one’s status to their family could turn out positively (Benton, 75). However, Benton notes that ‘successful disclosure…hinges upon whether the ‘disclosed-to’ have internalized NGO…messages delivered through NGO communication channels’ (Benton, 76). Consequently, while there may be a safe way to disclose one’s status and ultimately reduce the anguish that endures from suffering in silence, only a few have access to this possibility. Whyte et al. further paint this image of NGO networks by claiming that Saddam’s decision to join an AIDS program was through a ‘trusted social connection,’ (Biehl, 146). Saddam, as a citizen of Mozambique, is not guaranteed any health services. However, as long as he can locate an NGO through various networks, he is guaranteed health services. This dichotomy is disconcerting as it suggests that individuals living in more isolated areas (e.g. rural areas) are at a huge disadvantage to their urban counterparts where such a network of NGO knowledge exists. In this way, NGOs buttress already existing disparities by only being available to a select number.

One would hope that the NGOs are at least held fully accountable to the citizens that they do manage to serve.   Nonetheless, this does not seem to be the case – the donor’s priorities come first (Zaidi, 265). Insofar as donor power extends to such a degree, even Presidents of countries find themselves first appealing to international donors when speaking publicly about their nation’s progress (Benton, 119). The absurdity of this situation is made more explicit when making a comparison with the west. A western government’s success is not measured by its control of infectious disease (Benton 122), yet the culture of NGOs and their presence in developing countries over the years has engendered this double standard. Furthermore, NGO presence has lead governments to assume that they need not be held responsible for the welfare of all their citizens, as some of them are receiving healthcare from NGOs. Such a dangerous belief can be attributed to the well-known mystique associated with NGOs, in which they are seen as the ‘panacea for all the ills’ (Zaidi, 260). As a result of this aggrandized image, a President that is aware that x number of NGOs are present in their country would have a hard time arguing for the funneling of state funds into public health infrastructure. Additionally, this co-existence of NGOs and the state allows both entities to assert culpability to the other in times of crises. An unfortunate instance in which this cross-talk played out was in Sierra Leone at the height of the Ebola Crisis; a reporter recalls that “there was no coordination,” between NGOs and government officials (Inveen, 2015). If state-run institutions were the only existing entities, it would be much harder for them to disseminate the blame onto others and thus would be faced with no other option but to be held fully accountable to their citizens.

Along with problems of accountability, the excessive presence of NGOs corrupts the mentality the west has towards developing countries. As many NGO workers are volunteers, the work done by NGOs can be perceived as generous, and individuals who receive such aid need to ensure that they are deserving of it (Benton 133). If health services were provided by the state, its citizens would no longer be under this pressure and simply believe that they have a right to such services in virtue of being a citizen.

Despite my criticism of NGOs, I recognize that the solution cannot be to simply remove them from developing countries. Instead I think the solution would be to encourage donors to make investments in already existing state infrastructure as opposed to donations to NGOs and hope that overtime this shift in economic support leaves the state as the dominant provider. As it would be much harder to incentivize large donors to make investments into struggling state entities, perhaps more of an emphasis on obtaining multiple, smaller donations would allow for this shift in investment.

Discussion Questions:

  • How do you balance trying to elicit sympathy from donors with ensuring that you are not debilitating the image of the very people you are trying to help?
  • What is the best way to prepare state-run entities for an independence from NGOs? How do we solve problems such as government corruption?
  • Would citizens in developing countries resist to the removal of NGOs? If so, why and how could we alleviate their resistance?


Benton, Adia. HIV Exceptionalism: Development through Disease in Sierra Leone. Minneapolis: U of Minnesota, 2015. Print.

Biehl, João Guilherme., and Adriana Petryna. “Evidence-Based Global Public Health.” When People Come First: Critical Studies in Global Health. Princeton: Princeton UP, 2013. Print.

Inveen, Cooper. “Sierra Leone Officials Say Flawed Aid Strategies Hamper Ebola Recovery Efforts – Humanosphere.” Humanosphere. N.p., 02 Nov. 2015. Web. 11 Nov. 2015. <>.

Zaidi, S. Akbar. “NGO Failure and the Need to Bring Back the State.”Journal of International Development J. Int. Dev. 11.2 (1999): 259-71. Web.