The Current Insufficiency of Global Health NGOs

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Abraar Karan
Abraar Karan, MD MPH is a resident physician at the Brigham and Women's Hospital and Harvard Medical School. He is a member of the Hiatt Global Health Equity Residency Program. Abraar has worked in several countries in Latin America, Asia, and Africa on global health and human rights projects. His current interests include health systems improvement, medical ethics, political leadership in health, and anti-corruption. Abraar graduated from the Harvard TH Chan School of Public Health, the UCLA David Geffen School of Medicine, and Yale College. t: @AbraarKaran

In the global health arena, the 21st century has seen an unprecedented growth in the role of the non-governmental organization (NGO). High school, undergraduate and graduate students in the U.S. are increasingly volunteering and researching with international NGOs, particularly in developing countries, with some students even having created their own U.S. based NGOs that primarily function abroad.

Most international health NGOs tend to focus on very particular problems and diseases that are neglected or under-addressed by the larger health system. In this way, NGOs are serving as patchwork solutions to underlying problems with healthcare infrastructure. I have personally worked for several US-based and international NGOs providing services in Africa, India, and Latin America and continue to be struck by the dichotomy between NGOs and the local government with regards to development initiatives.

While it is true that NGOs are responsible for a large portion of healthcare provision that would otherwise be unaddressed, due to the limited interactions between governmental and non-governmental parties, the NGO response must be financially self-sustaining, which it is not. Many international NGOs depend on donor aid from developed country groups, such as wealthy individuals, large charities, or religious organizations, to fund their initiatives while others receive support from international governments. This was the case when I worked in Uganda in the HIV/AIDS sector. The U.S. PEPFAR program channeled money directly to NGOs in Uganda, avoiding any interaction with President Museveni’s cabinet. However, PEPFAR became subject to the global economic downturn as well as donor politics and the Obama administration’s new Global Health Initiative essentially refocused attention to maternal and child health, leaving HIV/AIDS NGOs with substantially less money than they had projected for 2011. This also meant that thousands of Ugandans suffered without antiretroviral treatment.

This engenders a question which I have been struggling with for quite some time: How do we better integrate non-governmental organizations into their own governmental healthcare infrastructure? By this, I don’t mean transference of control but growth of collaboration. Unfortunately, due to high levels of corruption in many developing country governments, several multilateral and bilateral organizations and programs have started attempting to work directly with NGOs and bypass the local government altogether, which is only further propelling this intranational division.

Even if NGOs had the financial resources to function independently, I am still quite weary of the answers to, “Who will watch the watchers?” Not all NGOs, especially ones in developing countries, are completely transparent and efficient with their money and the geographic divide between the Global North and South makes any sort of oversight by international donors largely unfeasible. Moreover, most NGOs are run by individuals who essentially have complete control over financial and resource allocation. I can assure you that most donors would rather not know how much money is actually allocated to the pockets of NGO Presidents and CEOs. In this regard, NGOs are vulnerable to the same type of fraud and corruption to which governments are subject, but they can more easily hide it.

Aside from their fragmented and isolated place in international healthcare systems, NGOs also rarely seem to be working in an evidence-based manner. With the shameful 10/90 gap (only 10% of health research worldwide is devoted to addressing 90% of the global disease burden), NGOs are laudable as they often address issues that are being ignored by governments and larger healthcare industries and corporations, but they rarely work with the top researchers or academic institutions in their fields. This is where the activist-academic divide becomes relevant. With regards to global health, NGOs must not only be incorporated into government health systems but also into university and research systems. While the NGOs are working on the ground and are familiar with the local culture and communities that are studied by many academics, they are usually not informed by up-to-date research in their initiatives. Contributing to this divide is the feeling that I’ve encountered from many activisits who are particularly disdainful of what they see as an elitism inherent in academic institutions. Bridging the divide between universities and NGOs will be a large step forward for global health as NGOs would be the ideal vehicle for delivery of healthcare research.

In this regard, I will say that students are essential to this collaborative effort. My own experiences have been working with activists in the field while being mentored by academics from my college. With this overlap of spheres, I have been much better equipped to address global health issues. Unite for Sight, the first NGO with which I conducted international research, has been a leader in this regard. It primarily takes volunteers from universities in the United States and places these students in developing countries to volunteer but has also started a research branch with several questions that students can aim to answer during their time abroad. I have spoken about my research and how one can go about the research process here.

With so many students now working for global health NGOs, I would encourage everyone to think about how we might help international NGOs better collaborate with both their home governments and academic institutions to improve health service quality and delivery. With regards to NGOs that are based in the U.S. or countries other than the one in which care is being provided, this may be more difficult to do. Nonetheless, the longer term goals should not be to address health issues in a vertical and isolated manner, but to perhaps begin this way if necessary with a continuous vision of how to eventually integrate into healthcare systems that include activists, academics, and politicians alike. It might sound utopian, but it is what we need.

Read a panel discussion of this topic by the Global Health Delivery Project here.

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