International NGOs and primary health care in Mozambique: the need for a new model of collaboration
Introduction
The decision to award Doctors without Borders (Médecins Sans Frontières), the 1999 Nobel Peace Prize demonstrates the extent to which international non-governmental organizations (NGOs) and their expatriate aid workers have become key players in health promotion in the developing world. Over the last 20 yr, the major bilateral and multilateral actors in international health, including the United States Agency for International Development (USAID) and the World Bank, have increasingly channeled aid to the health sector in poor countries through NGOs (USAID, 1995; Buse & Walt (1993), World Bank (1997); Buse & Walt, 1997; Green & Matthias, 1997; De Beyer, Preker, & Feachem, 2000). The proportion of bank-financed projects that included NGOs rose from 20% in 1989 to 52% in 1999 (World Bank, 2000a). The ostensible rationale for this shift rests on the largely unexamined assumption that NGOs have a comparative advantage since they can often reach poor communities more effectively, compassionately, and efficiently than public services (Edwards & Hulme, 1996b; Green & Matthias, 1997; World Bank (2000a), World Bank (2000b); USAID, 1995; Zaidi, 1999; Turshen, 1999). However, this “New Policy Agenda” has been ideologically driven, intimately bound up with the neo-liberal emphasis on free markets, privatization, and the development of an imagined “civil society” necessary for “sustainable development” (Edwards & Hulme, 1996a; Chabal & Daloz, 1999; Powell & Seddon, 1997; Turshen, 1999; Stewart, 1997; Hanlon, 1996; Drabek, 1987). One USAID policy document states, “At all levels of development, a flourishing NGO community is essential to effective and efficient civil society….Civil society organizes political participation just as markets organize economic participation in the society…Sustainable development is likely to occur where both civil society and markets are free and open” (USAID, 1995, p. 2).
In this new climate of privatization, international NGOs have been promoted to fill the gaps in public services created by World Bank/International Monetary Fund-promoted structural adjustment programs (SAPs) that normally slash government health spending (Turshen, 1999; Gary, 1996; Edwards & Hulme, 1996b; Laurell & Arellano, 1996). In Africa, USAID and the World Bank have been the most aggressive proponents of SAPs and have recruited NGOs to provide the social safety nets for the poor as inequality has increased across the region (Anang, 1994; Chabot, Harnmeijer, & Streefland, 1995; Ndengwa, 1996; Okuonzi & Macrae, 1995; Mburu, 1989). However, based on findings from the following case study in central Mozambique, this paper argues that the inundation of the health sector by international NGOs since the late 1980s may have in fact damaged the PHC system. Rather than redistributing resources to promote greater equity and help alleviate poverty, the flood of NGOs and their expatriate personnel has fragmented the health system and contributed to intensifying social inequality in local communities with important consequences for primary health care delivery. The Mozambique experience described here, and certainly replicated in many other developing nations, indicates that a new model for collaboration between foreign technical experts, national providers, and local communities is urgently needed to maintain equity-oriented primary health care.
A familiar mix, or what some have called an “unruly melange” (Buse & Walt, 1997), of international donors (bilateral and multilateral) and the health agencies they support, such as Save the Children, Doctors without Borders, Africare, Care, World Vision, Oxfam, Concern, Food for the Hungry International, Family Health International, Pathfinder, Population Services International, and others can be found in many developing country capitals and provinces where they have become key players in financing and implementing primary health care programs. With the collapse of the socialist bloc as an alternative source of capital and technical support, Western agencies have become central fixtures across the neo-liberal socioeconomic landscape of the Third World.
A voluminous literature has developed over the past two decades on the NGO phenomenon, and foreign health aid specifically (Green & Matthias, 1997). It is now widely accepted that the flood of aid agencies into countries such as Mozambique has had a range of negative consequences for local health systems (Cliff, 1993; Pavignani & Colombo, 2001; Pavignani & Durão, 1999; Turshen, 1999; Buse & Walt, 1997). The literature cites the lack of aid coordination and the subsequent fragmentation of health activities in many developing countries. The multiplicity of competing organizations that duplicate program support, create parallel projects, pull health service workers away from routine duties, and disrupt planning processes has generated concern for both donors and recipients. Most of the research and commentary on the issue has focused on the dynamics of policy-making and management at high levels in Ministries of Health and within agencies themselves (Walt, Pavignani, Gilson, & Buse, 1999; Buse & Walt, 1996; Gilson, Sen, Mohammed, & Mujinja, 1994). However, this paper argues that an emphasis solely on the managerial aspects of aid coordination may mask the greater structural transformation in local communities generated by the arrival of NGOs and other foreign agencies within local settings where actual programs are implemented. As illustrated by the Mozambican experience, the fragmentation of primary health care systems is not only the product of difficulties in aid management, but also the consequence of intensified local social inequality produced by foreign aid channeled through NGOs at the expense of the public sector.
The most direct interaction/confrontation between expatriate NGO aid workers and their target communities occur “up-country”, in the provinces where foreign aid presumably arrives at its intended destination. In this unusual social interface between highly educated technicians from rich countries and communities in extreme poverty, relationships of power and inequality are enacted in ways that profoundly shape primary health care policies and programs. In this engagement, the exercise of power by wealthy donors over their target populations, including local health workers, is laid bare and the disempowerment of public sector services by international agencies is most visible. Expatriate health workers employed by international agencies can be found at all levels of many developing world health systems; from Ministry of Health offices in capital cities to remote villages where they are involved in health program implementation. These agencies’ activities may be integrated into Ministry programs, or conducted completely outside the public system. In addition to their expatriate staff, agencies usually employ small armies of “nationals”, from trained health professionals and office workers to drivers and guards. Usually these workers are paid far more than their counterparts in the public sector. And, as Chabol and Daloz (1999) have argued, many among the elite sectors in local populations have learned how to maneuver in the NGO world of the new “civil society” for personal benefit. They state, “The use of NGO resources can today serve the strategic interests of the classical entrepreneurial Big Man just as access to state coffers did in the past…[I]t is as well to recognize that there is an international “aid market” which Africans know how to play with great skill” (1999, p. 23).1
The Mozambique case suggests that the manner in which expatriate agency workers engaged both their Mozambican counterparts, and the larger communities where they resided, had an enormous and often negative impact on many PHC programs. These relationships were realized both within formal work settings and in the daily life of the community where expatriates resided, schooled their children, and conducted their social lives. As Uvin has shown in his important analysis of the development industry in Rwanda before the 1994 genocide, foreign aid can contribute to local processes of “exclusion” and “humiliation” that undermine equity-oriented efforts in development (Uvin, 1998). He writes:
[T]he development aid system contributes to processes of structural violence in many ways. It does so directly, through its own behavior, whether unintended (as in the case of growing income inequality and land concentration) or intended (as in its condescending attitude toward poor people). It also does so indirectly, by strengthening systems of exclusion and elite building through massive financial transfers, accompanied by self-imposed political and social blindness…The material advantages accorded to a small group of people and the lifestyles of the foreigners living in Rwanda contribute to greater economic inequality and the devaluation of the life of the majority (1998, p. 143).
Given how important these social dynamics are to the impact of foreign aid on primary health care in most of the developing world, there is a surprising dearth of research on these relationships. Social scientists, especially medical anthropologists, have contributed to the study of primary health care by examining the presumably problematic health-related behaviors of poor populations, the social world of national primary health care providers, and even the bureaucracies of international agencies (cf. Foster, 1977; Coreil & Mull, 1990; Justice, 1987; Nichter, 1996). However, little research on primary health care has examined the interface between expatriate foreign health agency workers in the field and the poor communities they are supposed to serve. Perhaps the inequalities of wealth and power are so obvious that they are taken for granted, or social scientists are afraid to bite the feeding hand. As Uvin states for Rwanda, “To the extent that some people at some point do realize the political and social stakes and abuses that surround development aid and its projects, they often choose not to react. This has various causes, including fear of rocking the boat, of making enemies, of losing jobs” (Uvin, 1998, p. 156). Publications by many of the major international NGOs themselves rarely if ever allude to the importance of these fieldwork dynamics.2
This paper provides a brief ethnographic sketch of these relationships in a central province of Mozambique during the period from 1993 to 1998. The vignette seeks to provide a case study of the social cost to primary health care, and the poor populations it serves, of donor policies that channel aid through foreign agencies at the expense of the public sector.
Section snippets
The health system in Mozambique
After independence from Portugal in 1975, Mozambique established a primary health care system that was eventually cited by the WHO as a model for other developing countries (Walt & Melamed, 1983). By 1978, over 90% of the population had been vaccinated, and by the early 1980s 1200 rural health posts had been constructed and staffed. Over 8000 health workers were trained and placed in service. During this period about 11% of the government budget was committed to health care (Gloyd, 1996). The
Research setting and the primary health care system
The majority of the population in the province is rural and very poor with an estimated annual per capita income under US$100 (at the time of this research). Basic health indicators reflect this severe impoverishment; cumulative under-five mortality is estimated at 200/1000 while maternal mortality may be as high as 1500/100,000 (Mozambique Ministry of Health, 1997). The primary health care system has been extended into isolated rural areas through construction of health posts and centers that
Discussion
Examples of harmful practices on the part of foreign aid agencies abound in Mozambique and elsewhere in Africa. The stark scenario depicted here emphasizes these negative aspects of NGO activity in the study community to underscore the extent and depth of the problem. To be sure, there are also NGOs and expatriate workers who have conducted exemplary work and contributed a great deal to sustainable improvement of primary health care in Mozambique. However, many readers will undoubtedly find
Acknowledgements
The author wishes to thank Julie Cliff, MD, Stephen Gloyd, MD, MPH, and Rachel Chapman, Ph.D. for their comments on early drafts of the manuscript.
References (56)
- et al.
Aid coordination for health sector reformA conceptual framework for analysis and assessment
Health Policy
(1996) - et al.
An unruly melange? Coordinating external resources to the health sectorA review
Social Science & Medicine
(1997) - et al.
The role of the World Bank in international healthRenewed commitment and partnership
Social Science & Medicine
(2000) Development alternativesThe challenge for NGOs—an overview of the issues
World Development
(1987)- et al.
Too close for comfort? The impact of official aid on non-governmental organizations
World Development
(1996) Medical anthropology and international health planning
Social Science & Medicine
(1977)The bureaucratic context of international healthA social scientist's view
Social Science & Medicine
(1987)Evaluating the role and impact of foreign NGOs in Ghana
- et al.
Stabilization and structural adjustment in MozambiqueAn appraisal
Journal of International Development
(2000) - BOCONGO (Botswana Council of Non-Governmental Organizations) (2001). NGO code of conduct. Botswana:...