Non-governmental organizations (NGOs) have increasingly been promoted as alternative health care providers to the state, furthering the same goals but less hampered by government inefficiencies and resource constraints. However, the reality of NGO health care provision is more complex. Not only is the distinction between government and NGO providers sometimes difficult to determine because of their operational integration, but NGOs may also suffer from resource constraionts and management inefficiencies similar to those of government providers. Some registered NGOs operate as for-profit providers in practice. Policy development must reflect the strengths and weaknesses of NGOs in particular settings and should be built on NGO advantages over government in terms of resource mobilization, efficiency and/or quality. Policy development will always require a strong government presence in co-ordinating and regulating health care provision, and an NGO sector responsive to the policy goals of government.
PIP: In 1993, the World Bank called for public policies which promote diversity and competition in health care provision, particularly through the use of nongovernmental organizations (NGOs). Despite the currently agreed definition of NGOs as nonprofit-maximizing, some NGOs in developing countries pursue profit with little regulation. Even nonprofit-maximizing NGOs do not always operate on strictly humanitarian principles and may consider proselytizing their faith to be their first concern. NGOs, therefore, are more heterogenous than is usually perceived, and they lack a direct accountability to government which exacerbates concerns about their true motives. 6 groups of NGOs have been identified as operating in the health sector: religious, international, locally-based, unions and trade and professional associations, other nonprofit organizations such as occupational health services, and pre-paid nonprofits such as health maintenance organizations. NGOs have 4 overall health sector functions: service provision, social welfare activities, support activities, and research and advocacy. In all of these roles, they make an important contribution to health care. Governments support NGOs overtly through financial grants, in-kind donations, and grants for specific health expenditures, particularly salaries. Covert support is provided through tax subsidies and exemptions. Government support is hampered by delays in disbursement, lack of flexibility, and economic constraints. International support also has problems: it is often project-specific, available for limited periods, and usually limited to start-up costs. Governments may also see international support as a threat to their sovereignty. Commercial activities and community resources have also become important funding sources for NGOs. While NGOs are perceived to be more efficient than other providers, there are weaknesses in the quality of provision including too few outreach activities, greater cold chain failures, and employment of untrained or inadequately trained staff. Management may be hampered by an elaborate organizational structure as the NGOs relate to their parent organization. Government regulation is important in light of evidence of NGO inefficiency, and several patterns of coordination with government agencies exist as well as 4 broad policy strategies: 1) to restrict their operations; 2) to maintain current levels of service and regulation; 3) to regulate, coordinate, and supervise them; and 4) to actively promote them. NGO umbrella organizations can greatly facilitate the coordination tasks of governments. Given the strengths and weaknesses of NGOs, policy formulation will be enhanced by research into 1) strategies for strengthening and developing Ministry of Health capacities for coordination and regulation, 2) structures/mechanisms for coordination among NGOs and with governments, 3) evaluation of relative NGO efficiency in provision and management, 4) evaluation of potential functions for NGOs in different circumstances, and 5) the development of quality monitoring procedures and tools. Policy development should build on the strengths of NGOs (their willingness to serve in remote areas, their flexible style of operation, and their close relationship with the community they serve) while recognizing their weaknesses, including their vulnerable financial base, isolated operation procedure, and reluctance to adopt national policy guidelines.