non-governmental organizations in the health field: collaboration, integration and contrasting aims

Sot. SC;. &fed. Vol. 29. No. 3, pp. 395402, 1989 Prindd in Great Britain. All rights reserved

0277-9536189 $3.00 + 0.00 Copyright c 1989 Pergamon Press plc

SECTION K

NON-GOVERNMENTAL ORGANIZATIONS IN THE HEALTH FIELD: COLLABORATION, INTEGRATION AND

CONTRASTING AIMS

KARL SMITH

Health Sciences Division, International Development Research Centre, P.O. Box 8500, Ottawa, Canada KlG 3H9

Abstract-Non-governmental organizations, from being voluntary agencies often with relief or religious mission orientations, have become very important players in the field of social development. In this paper something is given of their evolution, diversity, aims and activities; and of the important role they now play in many instances, as well as some of the obstacles to collaboration, co-ordination and integration at different levels of operation-internationally, nationally and locally.

INTRODUCTION

DeJnition of a non -governmental organization (NGO)

Although the meaning of the term may at first sight be self evident, a definition may not in fact be that easy. NGOs may be Seen as organs of voluntary action for the purpose of achieving social goals [l-3]. Implicit here are considerations of mutual assistance for survival and progress. In addition, in Western societies, these voluntary agencies function as policy advocates and educators [ 1,2].

According to Cumper [4] NGOs are, by definition, “organizations not mainly financed by individual governments, either directly or through a UN-type assessment system, though they may receive government subventions for specific purposes”. He also notes that their activities are not under the control of donor governments; although one which is nationally based might expect to be influenced by government policy.

According to yet another definition, three characteristics are implied: legal independence from government; a non-profit status; a voluntary decision-making structure. However, the term is loosely used to refer to community-based groups; larger, established voluntary agencies operating at local, regional or national level and functioning as intermediaries between community-based groups, govem- ments and funders; or international and donor country agencies funding or implementing development activities or carrying out educational or advocacy work in industrialized countries. They may thus be classified as primary, secondary and tertiary. In addition a dichotomy is suggested between those with a research and analysis focus and those that are action oriented [5].

In aggregate, NGOs are involved in the development process [2,4]. In their view, underdevelopment is caused by factors such as inadequate institutions and poor public policy, the powerlessness of those governed (BRAC) [7].

Social awareness and/or economic progress (land ownership jobs, etc.) are seen as prerequisites for national development, with the addition of social service to reinforce them. Improved health status is a consequence, becoming self-sustaining by the community’s efforts (health insurance schemes, the use of auxiliary health personnel, etc.).

However problems remain, related to the emphasis placed on components (such as curative vs preven- tive medicine, family planning) as the basis for the conduct of funds from external sources, not altogether congruent with the philosophy of local empowerment.

As will be seen later, given the diversity of aims and functions, the evolutionary nature of these, the variety of situations in which the NGOs operate, the complex nature of their financing, a definition of a role is virtually impossible. Whatever their aims and origins, and no matter what their sectoral interests, it is perhaps true to say that the ethos of today’s typical and viable NGO is development assistance.

There are literally tens of thousands of NGOs worldwide: internationally, nationally, locally; with at least several hundred operating wholly or partially in the health field. For the purposes of this paper, a major emphasis will be placed on those operating internationally, while not forgetting those operating locally. One recent directory [8] lists over 400 agencies, in the U.S.A. alone, involved in international health assistance. Most of them would fit the above definitions. In Canada alone, some 82 NGOs are listed as working internationally in the health field [9]. Many of these will also be operating nationally. Similar ranges of numbers could be obtained for Europe and Australia.

The remainder of this paper will look at the origins, aims and objectives of some NGOs with special reference to some operating internationally; at their diversity; at NGOs in the north; NGOs in the south; and the complex inter-relationships between and among them; as well as factors which might facilitate

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or impede their future development and effectiveness, their ability or inability to co-ordinate and integrate their efforts. Issues are raised to stimulate further discussion.

Some of the issues which will be implicit in the discussions will include development aid vs development co-operation; dependence vs self-help and self- reliance at the local recipient agency end; project funding vs institution building and human resource development; definition of roles in partnerships; short-term vs long-term collaboration.

These are all inter-related.

THE CURRENT WORLD OF NGOs: THEIR EVOLUTION, DIVERSITY AND COMPLEXITY

Many northern NGOs which operate overseas have had their genesis in a true conviction that something needs to be done-and that not enough is being done-to improve the life and dignity of individuals in the developing world; almost a ‘save a life’ or ‘feed a child’ philosophy. Although the motivation may be lauded, it could be argued that in some cases this betrays a rather simplistic view of things, the solution being the ‘quick fix’. Likewise it might Seem that there is a rather simplistic understanding of, and a parallel response to, a much more complex problem than is apparent, often with complicated antecedents.

In many instances these operations are financed by foundations situated in wealthy industrialized nations. Foundations usually originate as the result of profits from multinationals being harnessed for philanthropic work.

According to Cumper [4] the traditional (post World War II) role of NGOs has been to provide governments with support for locally-based projects, either too small or too experimental to attract more formal multilateral (UN) or bilateral (government to government) assistance. In this role the typical function has been to channel funds and resources from the developed to the developing countries in order to improve the health and welfare of the populations of the developing countries.

Some trace the creation of most NGOs as a response to the failure of government policies to serve the poor and their interests; other NGOs to the existence of difficult political or administrative conditions at the recipient end. Cases in point are cited in Latin America with respect to research-oriented NGOs. Yet other NGOs are said to have been set up to deliver development assistance, USAID and the Ford Foundation, as an example, setting up an umbrella organization named The Voluntary Agencies development Assistance (VADA) in Kenya to co-ordinate the activities of other NGOs. Finally, there are so-called NGOs set up by governments, but functioning only as arms of the public sector [5].

Many voluntary development agencies were, of course, in existence and active in the developing world before World War II. In the case of Canada, for example, Canadians were engaged in missionary work overseas since late last century [l, 21. The Rockefeller Foundation, a large donor agency in the U.S.A., was helping governments in the Third World in the 1930s and 1940s to combat such problems as

yellow fever and hookworm. The Ford Foundation has existed for years and has operated in many countries of the world at different periods, with changing goals and primary activities. Some aspect of health has always been part of its multifaceted programme.

Extreme diversity

According to one observer, one of the characteristics of NGOs is their extreme diversity; they may range from a single-purpose group (e.g. to fight a specific disease) to large organizations providing relief and development aid in a variety of countries and sectors (e.g.- Catholic Relief Services, Oxfam). Inputs into projects may range from a few hundred to several million dollars. In the OECD (Organiz- ation for Economic Co-operation and Development) countries, in the mid 1970s there were an estimated 900-3000 NGOs, depending on the definition used- from those strictly developmental to meet human needs, to those with other purposes which also are involved in development activities (religious missions, educational institutions, trade unions) [lo].

According to another observer, there is great diversity in orientation, resources and types of field orientation. Some have very specific scctoral interests (e.g. shelter); others support multisectoral, community development efforts. In size they may vary from memberships of one person to several tens of thousands [5].

Canadian NGOs working in the health field range from those with quite broad involvement, like CUSO (formerly Canadian University Services Overseas), the Canadian Catholic Organization for Develop- ment and Peace, UNICEF Canada, CARE Canada; to those more restricted in scope, for example the Relief Society of Tigre’s Relief Committee in Canada [9], in this case geographically circumscribed in its ultimate goal. Similarities exist for NGOs from other parts of the developed world [2].

GOALS, ACI’IVITIFS AND CATEGORIZATION OF NGOs IN HEALTH

It is instructive to look at some of the described for NGOs in international health, as plified in the listing of the U.S. based ones [8]. have no stated goals, other very broadly stated yet others quite specific ones:

goals exem- Some goals,

-technical assistance in specific areas (spelt out);

-consulting (with the subcontracting agencies detailed);

-clearing house on development communi- cation;

-promotion of grass roots economic development;

-development education; -enhancing quality of life and well being of

communities in the developing world: this is often the major goal for many of the NGOs;

-religious and missionary work, evangelism, ‘planting churches’, proselytizing; sometimes combined with charitable non-religious development activities;

NGOs in the health field 397

-supporting and/or conducting research; -promoting small business (with or without

charitable work); -supporting international development and

disaster relief activities; -improving the health care of women and

children, the aged, etc.; -implementing programmes of service, devel-

opment, justice and peace; -planning and management of health care insti-

tutions; -building self-reliance, dignity among poor

families; -assisting in the prevention, treatment, control

of specific diseases; -encouraging undergraduate and graduate

education, etc.

or some variation on one or more of the above. In many cases there is little difference between

goals and/or activities as stated. The following repre- sents a listing of some of the latter:

-religious (some strictly proselytizing, ‘church planting’, missionary);

-educational, training (general and/or specific); -disaster relief; -nutrition related; -family planning, fertility, adolescent fertility: -supplying needed equipment and supplies; -research (sometimes specific diseases like

leprosy, trachoma, onchocerciasis); -health policy, planning, management; -environmental services; -rehabilitation of the handicapped; -institution strengthening (capacity building); -supporting hospitals and other health facilities

(equipment, supplies, etc.); -promoting peace and justice.

In carrying out these activities the NGOs are sometimes geographically specific (regions, countries); occasionally even ethnically specific.

The listing categorizes the NGOs along the following lines (and others):

-universities/colleges; *onsulting/private businesses + charitable

work; -private voluntary organizations (by far the

largest category); -religious/church groups; -professional/trade associations; -private foundations.

Budgets are in many cases not available; on the other hand, those which are given range from as small as 50,000 to as large as several hundred million U.S. dollars.

One might pick out, for special mention, the following:

1. Catholic Relief Services. Although associated with a major religious denomination, it states in its goals that it “plans, promotes, organizes, etc.- directly or indirectly or in collaboration with others, whether such others be individuals or organizations

of any sort or nature-services and assistance to meet the religious, charitable, physical, educational and scientific needs of mankind related to or arising out of poverty and disasters, natural or man made, and the incidents and consequences thereof, no matter where found in the world, including the distribution of funds. food, clothing, medical, technical and educational services, supplies and equipment as well as all other services.”

2. Operations Crossroads Africa, Inc. has as its goal to “provide American medical and health care students a learning experience in community health in the third world and provide African health professional, attitudinal and technical support.” This has implications for another kind of collaboration, likely of lasting mutual benefit.

3. Private Agencies Collaborating Together (PACT). The goal of PACT is to “support initiatives of low income persons in developing countries to improve their social and economic conditions through the collaborative efforts of private development agencies throughout the world, particularly by fostering local organizations’ increased strength and self-sufficiency.”

This has implications not only for local sustainability, but also, depending on particular govem- ments, for either a most welcome or a hostile reception by local (national) authorities.

4. Salvation Arm) World Service Ofice. SAWS0 “promotes self-help development in less- developed nations. In Africa, Latin America, the Far East and South Asia, SAWS0 works to help communities improve, the quality of their lives through health care and income generation, agriculture and community development.” Implications would be similar to those immediately above.

For the sake of completeness, one might mention one unique Canadian organization:

5. Save the Children Federation. SCF “believes that the needs of children are best served through self-help participatory integrated development activities, aimed at helping impoverished people develop the skills and institutions necessary to ensure a better present and a more secure future.” In so doing SCF operates integrated multi-sectoral development projects in 42 countries and in the U.S. in the areas of health/nutrition, agriculture, small-scale enterprise development, appropriate technology, education and training as well as community organization techniques.

The International Development Research Centre is a Canadian agency which, although funded by the Canadian parliament, is by its mandate, structure and governance very much a development agency which can be viewed as a non-profit NGO. Almost 20 years old, it started out as an agency which would encourage research for development (including health), using the research project mode as its instru- ment. Over the years it has evolved not only in its philosophy but also in its mode, now espousing human resource development in the context of equity, sustainability and individual human dignity; and engaging in training, capacity building and institutional strengthening in order to meet these ends (the author is an employee).

398 KARL S~~ITH

This brief review has served to show the diversity of origins, evolution, complexity, differing goals and activities of international NGOs in general.

In concluding, it might be said that nowadays the emphasis of international NGOs is more on long- term development projects than on relief. As an instance, in many African countries even today a substantial proportion of the health care available to rural people in many countries is provided by both external and indigenous, mainly church related, NGOs. Income generating activities are also on the increase, although very difficult to implement [lo].

COLLABORATION, CO-ORDINATION, INTEGRATION

In this discussion colluborntion will be taken to mean working jointly, acting together or associating for mutual benefit. Co-ordination will have a similar connotation. Integration will be used in the sense of uniting, or forming or blending into a whole. Collaboration and integration can be examined on a theoretical framework of several levels of linkage:

-the donor NGO and its national linkages, including those with other national NGOs and national authorities;

-the donor and the recipient NGOs; -the recipient NGO and other national link-

ages; -the recipient NGOs and national authorities.

In other words, co-operation among donor NGOs and with their national governments; between donor and recipient NGOs; among recipient NGOs and with their national authorities. Unfortunately, in real life things are not as clear cut. In the following discussion there is cutting across the several levels.

Opportunities for consultation, collaboration and co-ordination among NGOs do exist at various levels [2,3]. Apart from such ruses as ‘block grants’, there are examples in which developmental NGOs in donor countries are grouped in national councils where common problems are discussed, there is collective dealing with the public sector and with recipient NGOs (this is the case in Australia and Canada).

There are also international umbrella organizations which may be a mix of different types of agencies or of similar agencies, with similar aims. There is today much effort to promote the establish- ment of national councils of voluntary agencies in individual countries. It has also been demonstrated that the best opportunity for co-ordination among external voluntary agencies is by consultation at the individual national recipient level, providing the best possible match of resources to needs. An example is given of several different agencies effectively combining processes to help the Malawi government implement an immunization programme [lo].

As NGOs both in the north and in the south are seen to play a more prominent role in international development, they have attracted greater government attention, with changing trends in funding relationships. Major industrialized nations and the multilateral institutions under their control insist on policies lessening government controls, favouring a free market, as pre-requisites for Third World

economic growth, especially on the background of diminishing social sector resources in those countries, consequent on the ‘structural adjustment’ programmes. Appropriate funding mechanisms had to be worked out and tried [l I].

Until the 1980s it was simply donor government to southern government; or donor government to north- em NGO, the latter to southern NGO. Nowadays there is much more of northern government directly to southern NGO [2].

The most important form of collaboration is viewed by some as co-jnancing of development projects. Using different donor country criteria, governments contribute to the costs of NGO activities in developing countries, usually on a 50-50 basis. Some countries contract with NGOs to serve as executing agencies for official aid activities (thus U.S. Food Aid through CARE or CRS). In others, official funds for emergency aid go to NGOs (e.g. Sweden and the Red Cross). Sometimes there is pooling of NGO resources with those of official international organizations (e.g. with the UN High Commission for Refugees) or national fund-raising for an official agency (UNICEF via national committees). In many cases donor countries also contribute to co-financing of development education activities by the NGOs in the donor countries themselves [lo].

Advantages

Many governments are interested in supporting NGO development projects because the NGOs may have a long experience with sectors and approaches relevant to basic human needs and helping the poorest: education, health care, agriculture, rural development, community development. Donor governments are reasonably confident that projects co-financed with NGOs will reach the poor. The community participatory approach and the nurturing of local capacity are also appealing. NGOs are also seen as fostering respect for human rights. NGO projects are perceived as being highly cost effective as compared with official projects. Some NGOs are seen as having developed special expertise in specific fields (e.g. the Red Cross in emergency aid); and in sensitive areas such as family planning, humanitarian aid to liberation movements, emergency aid in conflict situations, governments may be more receptive to private rather than official channels. NGOs are seen also as playing important advocacy roles with respect to human rights. Above all, NGOs are courted by official agencies because of their potential for inno- vativeness; for example, NGOs are seen as having provided much of the experience on which the primary health care concept is based [12]; similarly community participation and non-formal education. Other strengths are seen in the development of appropriate technology, in support for projects promoting social change at the grass roots level.

Expertise, administrative capacity and local experience are the characteristics of NGOs which are appealing to official agencies [lo].

Many official agencies wish to strengthen voluntary groups in the Third World itself-through their own national NGOs or through international NGOs.

Governments have an interest in replicating, on a larger scale, successful projects and approaches tested


by NGOs. This may entail some risks of failure, however; factors and circumstances may be unique, not replicable [IO].

Problems

The major problems have to do with the rules and criteria for co-financing as between public and voluntary sectors when NGOs receive government funds for specific projects. This necessitates expan- sion of their professional and administrative capacity, the costs of which may not be allowable by the official aid agency. Furthermore, generous public funding of administrative costs may have the effect of dampen- ing the yield of fund-raising drives in the donor country. Continuity of public funding for sustainability when the donor funds are terminated in a co-funded project is another problem area. For an area such as primary health care, the time horizon has to be longer, rather than shorter.

A lack of flexibility in the use of funds for co- financing is another problem area; as are limitations on the minimum funding for a particular project. Block grants for simultaneous co-financing of many small projects is one way of circumventing this difficulty [lo].

It is unfortunately the case that in many instances the relationship between external agencies (official or non-governmental) and local NGOs or people is one of dependency of the latter on the former. This is the case made from a study by Oxfam of 20 ‘innovative’ health programme in rural Bangladesh, where foreign and local voluntary agencies are important health care providers. Although lip service is often paid to such phrases as ‘community-based’ and ‘community participation’, many projects are seen as offering neither responsibility nor opportunity for decision- making locally. In many instances decisions are made nationally (by elites) [7. 131 or internationally; and often foreign managers and their salaries absorb a large percentage of the available funds. An example quoted is the British Save the Children Fund in which 70-80% of resources regularly go towards the cost of foreign personnel [7]. The challenge is expressed in terms of socio-politico-economic structural reform (which has political risks for the local NGOs); and the fostering of local responsibility, initiative, decision- making and self-reliance based on human dignity-as expressed by David Werner [14]. However hope is expressed that, as in the case of some ‘hopeful’ projects in Bangladesh, large inputs of funds can be made into projects controlled and run by local NGOs. The Bangladesh Rural Advancement Committee (BRAC) is a case in point [7].

The relationship between official government agencies and NGOs has not always been a happy one. In Africa, for example, some governments are suspicious of their origins, their financial and political support, and sometimes of the conflicting objectives of government and the NGO. Often the empowerment given local people or the efforts fostered to bring about equity are contrary to government inclinations, challenging their power [ 15, 161.

A good example of co-ordination

One excellent example of an international NGO that has managed to demonstrate several areas of

co-ordination is the International Union Against Tuberculosis (IUAT). Almost 70 years old, it has evolved from an organizer of meetings in prestigious world capitals into an entity fighting tuberculosis and centralizing all experience with tuberculosis and, latterly other respiratory diseases and community health. The IUAT disseminates knowledge and information, focusing on applied research, action programmes, evaluation, training and public motivation. There are a quarterly publication, a journal, technical guides and manuals. It has seven scientific committees with experts from many countries. There is a Tuber- culosis Surveillance Research Unit which collabo- rates with WHO as well as several advanced countries in producing findings which have revolutionized approaches to control and eradication. There is also collaboration with several other governmental and non-governmental agencies.

Its structure makes it cost effective: a small control staff of about 10 people to carry out all activities approved by its Executive Committee and its Coun- cil. It has over 100 constituent (national) members, each with two representatives on the Council, ensur- ing democracy. All are entitled to become members of its different bodies. There are now six regions, each with its own secretariat. It is in a position to influence government policy, mould public opinion, reach to the grass roots [7].

Virtues and shortcomings of NGOs

In examining the role of voluntary agencies, particularly locally, one has to ask questions like: “Where do the responsibilities of governments end, and those of voluntary organizations begin?’ [13] and “what are the political and administrative implications of this?”

In the view of some, it is the voluntary sector which, in its role over a period of two centuries, “spearheaded social change and opened up roads towards social progress, which governments have followed and provided legal sanction” [13]. In this view many governments in the Third World, auto- cratic and preoccupied with governing and perpetuat- ing their power, have little time or use little of the national resources for social welfare. Struck by social consciousness, individuals feel committed to bring about change. The action taken is local, decentral- ized, flexible, efficient in use of local resources, relevant to people’s needs.

The virtues of NGOs are seen as their close con- tacts at grass roots levels; their small size and simple administrative procedures; their low operating costs; their (in most cases) freedom from government restrictions (and, in the case of research-oriented NGOs, from strictly enforced academic disciplines). These make them relevant, flexible and quickly responsive [S] but there are, of course, individual and regional variations.

The shortcomings, on the other hand, are seen to be often weak and uncertain financial positions, especially in the case of research (and they may also have limited access to policy-makers), and an inability to develop human and national resources for research. Beyond that, many NGOs have an ambiva- lence to research and its place in development, being motivated to ‘action’. Their relative isolation from

400 KARL SMITH

each other is also cited [5, 13, IS]. Sometimes, due to the nature of the north-south relationship, the local umbrella NGO may be unable to deliver on promises, and lose credibility [S].

Furthermore, voluntary efforts may be handicapped by working in isolation, may be duplicative, competitive 113, 181. They do not exchange information and experiences. They are prone to ‘fads’-a warning in a particular instance is given against embracing ‘comprehensiveness’ and ‘integration’; on the basis that a particular target group in a particular place might need ‘specialized’ services. As voluntary organizations become large, they take on the characteristics of government bureaucracies: aloofness, politicization, perpetuation of power. Furthermore, organizations based on metropolises take on urban projects, with little relevance nationally [13].

The plea is made for international and national NGOs to come into real partnership, the former discarding the notion of benefaction [13] in re- assessed roles. On the part of the local agency, the great needs are seen as not only commitment, but competence [ 131.

Indeed the need for this sort of partnership reaches into the realm of health/medical research; Wyngaarden, from the National Institutes of Health of the U.S.A., in a recent paper which looks at the support of international co-operation in biomedical sciences, sees a place for private American funding [7]. This call was repeated, in slightly different form, by the recent U.S. Administration, in encouraging collaboration between the researchers of the National Institutes of Health and Industry [19]. This occa- sioned much fear over conflicts of interest as well as the weakening of some areas of research.

The NGO community sees areas such as information generated by research: organizational and institutional capacity of NGOs; integrated, non- sectoral approaches to problem solving; all these as desirable spheres of action to improve NGO effectiveness. This from both the donor and the recipient partners [S]. Consortium funding is a solution in the case of research NGOs which need to be strengthened. Likewise NGO coalitions are seen as an appropriate ‘vessel’ to receive donor funds [5].

A revolution of sorts is taking place in relations between donors and local voluntary associations in that some donors such as the United Nations Development Program (UNDP) are moving from programmes where policy decisions are driven internationally, to the ‘country programme’ model, in which the policies governing the aid given are decided at national level and implemented through national initiatives. In brief, aid will come in on national terms, at national request. The role of national voluntary agencies is likely to be enhanced [20].

Because of perceived low operating costs and flexibility, recipient NGOs have been the beneficiaries of donor government funding in many instances. The Canadian International Development Agency (CIDA) was one of the pioneer donor agencies in this regard, beginning in the 1960s; others followed, and by the 1980s the practice was commonplace. NGOs are now reported to receive some 1.5 billion USD annually from OECD governments and 3 billion from private sources. CIDA itself now gives about

200 million CAD per year to NGOs, Canadian (international) and overseas (local), representing more than 10% of Canada’s ODA [5].

In general, there has been an increase in levels of funding going directly to southern NGOs, rather than through northern intermediaries [5]. On the other hand, it has recently been recommended that CIDA assist southern NGOs through Canadian ones, the advantage being that thereby the routed funds attract less scrutiny by local officials [21].

In recognizing that present trends to nationally determined ‘country programmes’ (see above) will enhance the role of local, Third World voluntary associations, Parvey [20] sets out, in an analytic framework, lists of relevant questions and factors associated which will help to address this possibility in a satisfactory way. Three major problems are posed:

-What are the structures and functions of voluntary associations within developing countries?

-How are international voluntary associations structured and how do they function in the international community?

-How might international voluntary associations become more effective in Third World development both on national and international levels?

Some of the suggested variables give us clues as to where integration or collaboration may or may not be possible.

In addressing the first major problem, variables are examined such as the classification of local voluntary associations: branches of international organizations vs organizations that function purely within one country or region; traditional or modem; indigenous or Western imports (e.g. Chamber of Com- merce, Lions, Kiwanis); grass roots, diffuse or not? Beyond that how do they work? What are their external dynamics? What kinds of influence within the country? Is it traditional, modern/reformist, revolutionary? Do they represent a contribution to contemporary development as for example socially, to help the poor adjust to urban survival, as vehicles for upward mobility, trainers for modern leadership roles, institutional agents of change? Politically do they represent self-determination through grass- participation? Do they influence the elite power structures? Do they have an influence in changing socio-economic-political structural inequalities? Do they contribute to the development of people in leadership roles?

Other variables examined include constraints on voluntary associations by governments depending on their degree of flexibility, tolerance of pluralism, of psychological and socio-cultural deviance by the associations’ members from the ‘norm’; concepts of leadership-whether monolithic, ‘top-down’, ‘demo- cratic’.

Regarding the second major problem, relevant variables include the basis of financial support and leadership-geographic, or particular ‘environ- ments’ of interest; whether concerns are geographic, ethnic, serving international policies; whether their purposes are narrow, specific or broad, diffuse;


whether they represent the combined policy of their member (donor) states or have their own aims and policies; who sets their goals and exerts influence; their relationship to other international voluntary organizations-whether they establish coalitions, minimally integrate or maintain self-identity; how the policies of the international organization affect the style of operation of member nations and organizations in terms of top-down movement of information, attitudes and policies or ‘bottom-up’, trans- mission of needs, pressures, etc. Furthermore, what are the constraints on voluntary associations relevant to issues of development: political, on member nation constituents from their own governments (e.g. South African and churches); from the power and pressure of UN and other international inter-governmental agencies; from member nations on the international association? Do international voluntary associations provide a forum for transnational mobilization?

Regarding the third major problem variables include the climate of receptivity for more short- and long-term activity; insights to be gained by the study of specific voluntary associations, international (IPPF, Red Cross, etc.) and national, with international implications (the National Association for the Advancement of Coloured People, NAACP); the role of voluntary associations in moderating social change, in the development of new intermediate groups (including women’s liberation); their role in providing primary social services, including basic community health services; their international political role in providing international institutions and interest groups to counter the private multinationals’ interests. Finally how international voluntary associations might provide support for strategic programmes in national development by discovering mutuality of interests, working with leadership training of educated sectors of the population, providing voluntary association trainingdevelopment education nationally and internationally.

Integration

Given the diversity of aims, activities, structures, funding sources and ways of operating, is integration of NGOs possible or feasible? It would appear that while collaboration and a certain degree of co- ordination are possible, true integration is more problematic. The diverse motivations, operational styles, sources of funding of NGOs would seem to make true integration difficult. While the influence of large funding sources such as say USAID or CIDA might force some northern NGOs to collaborate, integration would be rare, likely undesirable since autonomy is thereby lost. At the local level there are problems of at least two kinds: firstly administration/management, policy, planning the capacity for which are usually in short supply [7]. There is therefore a training implication.

Secondly often even the apparently more ‘progess- sive’ international NGOs place little of the resources locally. In construction programmes, for example, Oxfam and Concern have been cited as giving con- tracts to overseas (headquarters nation) contractors [7]. Because international NGOs may do this, there are difficulties in mobilizing resources for the necessary training of people locally.

The conclusion is that, despite the talk, Oxfam fosters dependency. It is the agency executive officers and the constituents in the donor countries who really control the resources and whose values (political, etc.) and judgements decide policy. In addition, U.K. law prohibits agencies such as Oxfam from engaging in political controversy and advocacy if they are to maintain their tax-exempt status. The end result is victim blaming! Some (like Briscoe) [7] feel that continued inappropriate aid by international voluntary agencies actually leads to and sustains underdevelopment!

Integration in the face of rules and a modus operandi such as exemplified by an internationally respected agency such as Oxfam, is at best difficult. At a strategy workshop for NGOs held in Washington, D.C. in 1982, some of the constraints on integration were identified as follows:

-overburdening projects with different donor funding, monitoring and reporting systems;

-not paying attention to sustainability; with costs of buildings, machinery, salaries so high as to make it impossible to have continuity when donor funds are withdrawn;

-problems of administration and account- ability;

-it is difficult to fit integrated (horizontal) NGO programmes with vertical government bureau- cratic structures. Problems of communi- cation and co-ordination result in fragmented decision-making;

-recipient governments are very sensitive to external criticism;

-government policies are often un-co- ordinated, are sectorial. Integration of co- ordinated programmes is difficult;

-personnel, governmental and voluntary, have different orientations, interests which make integration difficult;

-there is the constant fear of absorption of one group by the other;

-in order for high level administrators to see the benefits of integration, so obvious to people at the programme level, they have to be educated/re-educated-not an easy task;

-a lack of managerial skills is a pervasive problem;

-project staff usually lack the skills and time to document experiences, disseminate the findings;

-outside donors, not cognizant of local conditions, may set unrealistic goals and expec- tations;

-there is often a lack of the necessary infra- structure [22].

What challenges do these constraints hold for official agencies, northern NGOs, southern NGOs? How can such constraints best be overcome? A few suggestions may be mentioned which could, in particular circumstances, move efforts towards a measure of integration, especially locally:

-development of information sharing mechanisms and of consultative planning mechanisms among donors, at both technical and policy levels;

402 KARL SMITH

-donors might try to better inform and moti- vate policy and technical leadership; to support training; to support large scale research and demonstration efforts [23].

It may be that collaborative efforts will, for the most part, fall short of integration, rather achieving some sort of partnership [24]. Several kinds of partnerships of one sort or another have been discussed above in a theoretical way. Many examples could be given, especially at national level in the recipient countries. Two such examples are as follows.

-An inter-NGO Network for Participatory Development (Philippines); the title is self- explanatory [24].

-The association of Community Health Services in Guatemala (251 set up to provide technical assistance and consultation for the organization and administration of the services given by the members to improve community health, among other things.

In concluding, one could perhaps pose two questions which have not been addressed in this paper:

-To what extent, and by what means, can women be brought in more intimately as motive forces in the development process, as voluntary agents?

-To what extent will the tendency toward privatization in the developed Western world have an effect on the resources and ways of operation at the international, national and local levels?

Acknou~ledgements-My gratitude must be expressed to Professor R. Osbom, Department of Community Medicine, University of Toronto, who helped a great deal in suggesting areas to be covered in this paper; and to MS D. Grisdale, as well as MS M. Hawley and others at IDRC’s library for working hard to get reference material for my use in preparing it.

REFERENCES

I. Brodhead T. er al. Bridges of Hope, Canadian Voluntary Agencies, and rhe Third World. The North-South Institute, Ottawa, 1988.

2. Drabek A. G. (Ed.) Development Alternatives: The Challenge for NGOs. Pergamon Press, Oxford, 1987.

3. Badgley R. Commonwealth Collaboration in Heallh. International Development Research Centre, Ottawa, 1986.

4. Cumper G. E. The changing role of NGOs: no longer the eunuch in the harem? Hlrh Po1ic.v Plann. 1.335-444, 1986.

5. NGOs and the Social Sciences Division (IDRC): A Discussion Paper. 1987. International Development Research Centre, Ottawa, September 1987.

6. Turninp Private Voluntarv Oreanizarions in Dweloomenr Age&: Questions for ‘Evaluations. U.S. Agency for International Development. Washington, D.C.. April 1982.

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non-governmental organizations in the health field: collaboration, integration and contrasting aims

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