Tuesday, October 26, 2010

Global Health ... NGOs and community level initiatives

Dear Colleagues

The problems of global health are substantial ... and the decision making process about the allocation of financial resources to fund health sector activities is pretty much dysfunctional. I think most observers would conclude that the available resources could be used considerably more effectively.

This issue came to the to the front of my TO DO list with the following e-mail:
[afro-nets] NGOs and health systems strengthening (or weakening)

What sounds to be obvious – nongovernmental organizations working in the field of international health cooperation support and strengthen health systems – is not taken for granted. NGOs, “if not careful and vigilant, can undermine the public sector and even the health system as a whole, by diverting health workers, managers and leaders into privatized operations that create parallel structures to government and that tend to worsen the isolation of communities from formal health systems (…)”

This assessment is, at least, the starting point of the “NGO Code of Conduct for Health Systems Strengthening” first published in May 2008. The code intends to offer guidance on how international non-governmental organizations can work in host countries in a way that respects and supports the primacy of the government’s responsibility for organizing health system delivery.

A matter of course? Well, you can test it yourself, right now, if you like: How many of the following statements taken from the NGO code correspond with your organization’s standard?

1. “In areas where trained personnel are scarce, we will make every effort to refrain from hiring health or managerial professional staff away from the public sector, thus depleting ministries and their clinical operations of talent and expertise.” (yes? no? not sure? not relevant for you?)

2. “We commit to limiting pay and benefits inequity between expatriate and national, rural and urban, and ministry and NGO workers. We encourage compensation structures that provide incentives for rural service and disallow gender-related disparities.” (yes? no? not sure? not relevant for you?)

3. “We recognize that management capacity in Ministries of Health is often limited. Rather than building parallel or circuitous structures around inadequate capacity, we commit to strengthening governments’ ability to operate effectively and efficiently.” (yes? no? not sure? not relevant for you?)

4. “We strengthen the capacity of communities to take responsibility for and ownership of their health development, and to become partners with government in the health system, while holding governments accountable for their human rights obligations.” (yes? no? not sure? not relevant for you?)

5. “We actively advocate with civil society, local institutions and donors for policies and programs that strengthen health systems overall.” (yes? no? not sure? not relevant for you?)

6. “We commit to designing their activities and programs so that they reinforce primary health care, foster equity and community involvement, and are generally replicable and financially sustainable over time.” (yes? no? not sure? not relevant for you?)

So, are you happy with your score? 6 out of 6? Congratulations! But nevertheless, you might be interested to further discuss the task of contributing to building public health systems and doing no harm. The members of the MMI Network members will meet on 5th November in Amsterdam in a workshop on "Health systems strengthening", reflecting about the role of NGOs and of their particular organization in health systems strengthening.

Join us, if you like!

Thomas Schwarz,
Medicus Mundi International Network
My interest was further stimulated with this additional e-mail.
There is room for reflection in this message.

I appreciate the concern of Medicus Mundi International that raised this sensitive point.

I would suggest to them to broaden their discussion when they'll meet in Amsterdam. A 'new' aspect of health care delivery in many poor countries is the role played by the *Private* *sector*. It is widespread, day by day,rapidly. A vivid example is here in Nyala where one can see plenty of private doctors,local healers, private clinics,private hospitals,private pharmacies,plenty of drugs and plumpynut....but still children do die from malnutrition and common diseases . A drug for any illness is not the correct approach,I think you agree.

We should be together to declare with one voice that : children under fives and pregnant women should receive FREE SERVICE. Under any circumstances, by the government clinics or by the non for profit clinics:always,always FREE! including medical consultation and drugs prescribed. As it is for vaccination.

Dr. Massimo Serventi
Nyala Pediatric Centre
Italian Hospital
I have added to the conversation with the following message:
Dear Colleagues

I am glad this subject has come up.

Work that I have been doing over the last five years to understand the progress and performance of the global health malaria control sub-sector suggests that way too much of the global health money is being consumed at the "top" of the sector and far too little funding is getting to strengthen community level healthcare. This is the same issue in many different parts of the health sector ... many different diseases ... and in both rich developed countries and poor developing countries. Most decision making about resource allocation is driven by the goals of management, whether it is a big NGO, pharmaceutical company, a health ministry, a hospital or a network of doctors.

The needs of beneficiaries are poorly represented in part because the prevailing systems of metrics do not include any metrics about the "value loss" associated with poor health status of a single individual and in aggregate for the community. This gets addressed in The Burgess Method of True Value Metrics.

The good news is that there are thousands of NGOs interested in health care activities ... but they are not delivering their services very effectively where they are most wanted. Bottom line, nobody knows where they are working and what they are doing. Nobody seems to know where they would be most needed and could be doing the most good. If there were metrics that showed at the community level what the needs are, and what health care services including government and NGOs are present ... and what they are doing ... and what still is left needing to be done, we might make some meaningful progress.

This should not be an idealogical argument about public or private sector ... free or paid ... but about needs, resources and how to get the best possible outcomes.

As it is ... there will be a meeting in Amsterdam of this network of NGOs. I hope that they enjoy themselves ... and look forward to learning of any steps forward to better performance that they are able to make!


Peter Burgess
There is a pervasive problem throughout the field of socio-economic development ... a widening gap between those that are at the "bottom" with very limited education and skills and those that are experts giving advice and planning solutions. Unless the people at the "bottom" are part of the solution ... and help to satisfy their own critical needs ... a welfare system of development assistance rapidly runs out of resources. This should be obvious ... but it is not the way assistance is being programmed!

Peter Burgess

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