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Dr Santa comes to town: why NGOs
are failing the developing world

March 2007

by Jon Entine

An increase in support for high-profile healthcare projects such as fighting HIV and malaria is failing the developing world in the long term, warns Jon Entine.

It is the curse of good intentions. Each day, 50,000 people, mostly women and children – 18 million people a year – die from poverty-related causes such as dysentery and malnutrition. Although the statistics are devastating, the prognosis should be heartening. The explosion in philanthropy spearheaded by the mind-boggling $60 billion that has begun flowing out of the Bill and Melinda Gates Foundation for healthcare has buoyed hopes in the developing world.

But here's the rub: while billions pour into high-profile drug-focused programs targeting malaria and Aids – in the US, 43% of foreign health assistance funds HIV efforts – less glamorous but more widespread problems such as maternal care and the public health infrastructure are overlooked.

As Laurie Garrett notes in January/February's Foreign Affairs, "there is a grave danger that the current age of generosity could not only fall short of expectations but actually make things worse on the ground."

Who's to blame?

The major culprit is well-meaning NGOs that have seen their financial pipelines swell to overflowing. What's the problem? James Pfeiffer, now at the University of Washington and previously an NGO administrator in Mozambique, has written eloquently about the "flood of NGOs" which has "fragmented the health system" by creating model projects focused on popular drugs that help a tiny fraction but which bleed resources from the basic day-to-day needs of the vast majority.

"It's a 'Santa Comes to Town' health system," agrees George Jagoe, who spent two years in Mozambique as part of the Clinton Foundation HIV/AIDS Initiative. "In their eagerness to 'nail the numbers' promised to their donors or provide "first world care" in rural districts, foreign NGOs import short-term healthcare workers, over-invest in narrow disease-specific programs, and demotivate local workers who don't get any of the funds."

Under the current system, most aid is "stovepiped," reflecting the interests of the donors, not the recipients. As Garrett notes, mothers may get HIV drugs but cannot obtain the most rudimentary gynaecological or paediatric care. While touted new discounts mean paediatric Aids drugs only cost $60/patient/year for the 660,000 kids living with HIV, the greater tragedy is two million children who die each year of diarrhoea could be saved with oral rehydration packets that cost pennies. Money is not the issue – it's the NGO bureaucracy that directs funds to donor pleasing projects while the pubic health system in these countries crumble.

Come-and-go careers

Revolving door aid workers contribute to the problem. "The Martians fly in with their army of drivers and guards," says Jagoe. "They live in secure compounds and draw underpaid local health workers away from needier backwaters." Often, like US Senator Dr Bill Frist or the young Scottish doctor in The Last King of Scotland, they come as what Pfeiffer calls "aid cowboys" or "aid mercenaries," moving from one outpost to another as they climb up the NGO bureaucratic ladder.

In many cases, after a two-year stint, a glowing report card is sent out to donors – "We inoculated two million people!" Then the spaceship takes off and the clinics they established flounder from understaffing, a lack of basic supplies, and failing electricity and plumbing – the unsexy, under funded end of the developing world's health needs. Money that could have trained local doctors and nurses – a delayed payoff a generation down the road that does not register on report cards – are ignored. It's the perverse consequence of "managing for results," the corporate-like demand for short-term metrics that has infected neo-liberal NGOs and the World Bank alike.

To be fair, many NGOs work selflessly for sustainable health care. But if the growing chorus of critics is right, the media-focused campaigns fronted by well meaning celebrities like Bono that focus on high-profile scourges and drug delivery has proven a disaster. Misguided expectations are driving the design, management, and execution of global health programs, bypassing the recipient country's public system, and often ignoring the needs of the poorest.

"The funding Agencies have put too much focus on assuring that their money would be strictly spent to the agreed purpose," says Dr Paulo Ivo Garrido, minister of health for the Republic of Mozambique. "Only robust and strengthened National Health Systems can properly deliver comprehensive and integrated health care."

Many mom and pop donors would be distraught if they knew what was happening on the ground in Africa and elsewhere. With no standards for professional conduct to guide behaviour or hold NGOs accountable, we face the prospect of squandering history's greatest trust fund. With no meaningful long-term investment in the local human capital, the cycle of aid-dependency and helplessness will only grow worse.

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