A.   Increased interest in NGOs

There is an increasing interest by governments and major donor agencies to work with non-governmental organizations (NGOs). While this is encouraging, we must recognize that greater collaboration may require compromises in development strategies. NGOs have their own development philosophies, and cannot simply be used as contractors to implement pre-designed and pre-packaged projects. At the same time, NGOs must be flexible in adopting development strategies which meet the local needs of the country and population which they are assisting.

The term NGO has not been well defined. NGO can refer to any non-governmental organization, but it is usually important to distinguish between national or indigenous NGOs and international NGOs (often referred to as Private Voluntary Organizations). Other propositions have been made by Carrol (in Intermediary NGOs) and by Brown & Korten (in NGOs and the World Bank):

Carrol in Intermediary NGOs:

• PVO = Northern-based International NGO
• GSO = Grassroots Support Organizations
• MSO = Membership Support Organizations
  
  Brown & Korten in NGOs and the World Bank:

• VO = Voluntary Organization (mission)
• PO = Peoples Organization (members)
• PSC= Public Service Contractors (nonprofit)

GONGO= NGO created by a government to implement governmental policyA conceptual framework, which I have found particularly appropriate for the health field, has been proposed by David Korten, in his book Getting to the 21st Century, and is based on four "generations" of NGO development strategies (see Table 1):

First generation strategies (Relief and Welfare) include relief efforts, feeding programs, hospital-based or dispensary-based curative care. A few fixed-based public health related activities may be included, e.g., well baby clinics and nutrition rehabilitation centers.

Second generation strategies (Community Development) generally move from a hospital or dispensary into the community, often with mobile teams and village health workers to promote community development work and perhaps to establish health huts/posts.

Third generation strategies (Sustainable Systems Development) require system wide policy changes and collaboration with between public and private institutions, e.g. the management by NGOs of components of a national integrated health system.

Fourth generation strategies (People's Movements) aim at creating loosely defined networks of people and organizations to develop self-managing development initiatives such as literacy movements.

B.  Three Generations of NGOs Development Strategies in Zaire

Zaire is a good example of a country which has demonstrated an evolution of NGO development strategies through second generation community development and third generation sustainable systems development.

At the community level church NGOs in Zaire are particularly effective in promoting community involvement that cares for the wholeness of individuals and families and not just medical ailments. Getting people at the community level to accept responsibility for their own health is often difficult. However, the church can be particularly effective in this "conscience raising" process at the community level.

The concept of NGO collaboration in developing sustainable health systems in Zaire was proposed in a 1974 national conference organized by the Catholic and Protestant churches. The development of health zones did not really take off, however, until 1982 when the national health plan called for the creation of 300 health zones, and USAID began the Basic Rural Health Project (SANRU) to finance the development of 50 health zones.

An inventory of existing hospitals at that time revealed a total of about 440 "hospitals" of which half were managed by the state and half by NGOs (both church and private enterprise). This meant that to establish 300 health zones around an existing hospital would require using the NGO infrastructure for at least 80 (25%) of the health zones. In fact of the first 85 health zones to become functional during the 1982-1984 period, 88% were managed by NGOs or received important NGO management assistance.

The first health zones in Zaire were "built" on the existing infrastructure of functional hospitals some of which were already making an effort to initiated primary health care activities. This meant that the health zone had immediate access to housing, office space, utilities, nursing schools and support services rather than starting from scratch. The NGO infrastructure and initiative provided a catalyst to both decentralization and creation of integrated health zones. This permitted the accelerated development of PHC and health zones during the 1980's, and resulted in more that 220 functional health zones by 1987.

C.  Need for an Assessment Methodology

Not surprisingly, an increased interest in NGOs has also resulted in the increase of NGOs seeking funding. In Zaire, when the Ministry of Plan, with World Bank encouragement, established a national office for coordination of funding to NGOs, an avalanche of NGOs suddenly appeared on the scene. As a result, the two major NGOs (the Protestant and catholic churches), which were already co-managing nearly half of the health zones in Zaire, were almost "lost" in the rush.

There is a need, therefore, to establish a methodology for identifying those NGOs with whom collaboration would be the most useful. I helped to develop such a methodology in Togo when the Office of the A.I.D. Representative wanted to assess options for using NGOs, both local and international, as avenues to channel humanitarian and development assistance. The four step methodology which was developed is as follows.

Step One: Compile an inventory of all NGOs.

In the case of Togo, 88 NGOs had already been identified by the national federation of NGOs (FONGTO). This was used as a starting point, with additional NGOs added as they were identified.

Step Two: Identify NGOs with health promotion activities.

Based largely on reports and interviews at the national level, the list of NGOs was reduced to 28 which reported health as a major focus.

Step Three: Identify NGOs for an in-depth assessment for possible funding.

Of the 28 NGOs identified in Step Two, it was already known that some of the NGOs had only marginal work in health, and/or were too small to manage large inputs of direct USAID assistance (the possibility of indirect assistance was not excluded). Also several NGOs indicated that they were not interested in USAID funding for their programs. The following selection criteria were applied, therefore, to identify NGOs who might be the candidates for direct funding by USAID:

• Management of a primary health care or child survival program;
• Provision of family planning services;
• Provision of a support service of national scope, e.g. essential medicines;
• Provision of technical assistance to other NGOs. e.g. for family planning;
• Management of a hospital or similar sized infrastructure;
• Management of a population-based program of more than 20 villages;
• Links to a U.S. support base or funding source; and
• Management of an annual budget exceeding $100,000.

Step Four: Identify priority NGOs and priority programs for funding.

An in-depth assessment of the selected NGOs examined their geographical distribution, development strategies, management capability, relationships with government health services, and potential for expansion and sustainability. The assessment concluded that USAID/Togo had an excellent opportunity for collaboration through selected NGOs. Since NGOs are relatively more advanced than the government of Togo in cost recovery mechanisms and in managing integrated health services, they are a logical starting point to encourage decentralized integrated health districts and support systems. The assessment recommended interventions through NGOs to develop pilot health districts, to reinforce health areas, to strengthen the NGO drug supply system, and to increase family planning services.

Health Districts: Four NGO managed hospitals were identified as good candidates to establish pilot health districts which could improve access and utilization of PHC services and test the effectiveness of decentralized management systems.

Health Centers: The network of 70+ NGO managed health centers could be reinforced, through a catholic umbrella NGO (OCDI), to improve access/utilization of PHC and to develop population based planning/reporting systems.

Drug Distribution and Cost Recovery Systems: The catholic umbrella NGO (OCDI) is an important source of pharmaceuticals for many NGO health centers. USAID funding could help to improve depot facilities in Lomé; examine the need for decentralized depots; institute more effective procurement, distribution and inventory control; and increase cost recovery through better financial management procedures.

Family Planning/HIV: USAID buy-ins to four cooperating agencies (INTRAH, SEATS, Pathfinder & CARE) were assisting the Ministry of Public Health to develop technical and support activities for a national family planning program, to increase the number and quality of service sites, and to assure that all temporary modern methods are available. One national NGO, ATBEF (the Togolese IPPF affiliate), also played a large role in the program, particularly with regard to contraceptive distribution. Continuation and reinforcement of these efforts was recommended via buy-ins to the cooperating agencies.


D.  Key concepts When Working with NGOs

In conclusion, NGOs can make important contributions in developing and implementing integrated health systems, particularly in decentralization, district management, quality of care, cost recovery, and community empowerment. Here are some key concepts to keep in mind.

1) NGOs provide substantial health services in Africa. NGOs, especially national NGOs, should participate in all planning and implementation of a national health system.

2) Most NGOs operate health facilities on a not-for-profit basis. These NGOs should be considered public sector and carefully distinguished from private for-profit sector.

3) All NGOs should not be treated equally. A NGO assessment study can identify the select NGOs, especially "Third generation" NGOs, which could make the greatest contributions.

4) NGOs have their own development philosophy. They need the freedom to innovate new approaches. They should not be used to simply implement pre-designed projects.

5) NGO management of health districts can be a catalyst for decentralization. NGO managed health districts can establish precedents of management autonomy for a whole country.

6) NGOs can manage national and regional support services, e.g., regional supply depots managed by not-for-profit organizations.

7) Most NGOs have a keen interest in community empowerment and development. NGOs can help develop community-based services that interface with health centers.

8) NGOs often provide a high quality of care with limited staff and budget. This is usually linked to well supervised and motivated personnel (especially non-monetary motivation).

9) NGOs usually have well-developed cost recovery systems. NGO managed cost recovery can be used as a entry point to initiate a national cost recovery program.

10) NGOs often have a well maintained functional health infrastructure. "Building" on their existing infrastructure can represent a significant savings in investment cost and time.

11) NGOs have access to resources not available to governments. NGOs can sometimes obtain significant investments for NGO and government health centers and services.

12) National NGOs are an in-country permanent resource. Collaboration with these NGOs contributes to the long term sustainability of the health system.

13) Umbrella NGOs can make good "project of projects" managers. A umbrella NGO manager can streamline management and provide a buffer for the health service providers.