_Role of NGOs in Health Delivery AM=R Health Policy Study_ _-_ 17.

48. Aseeminglysuccessful example of a health<sup>consortium comes from Ethiopiawhere</sup> the Christian Relief and Development Agency<sup>helps NGOs to obtain travel permits and</sup> customs clearance and has credibility with both<sup>the govemment and donors. Another</sup> successful example is the Private Health<sup>Association of Malawi described in the case</sup> studies. Such success is not easily achieved,<sup>for itrequires compromises among NGOs</sup> (which are reluctant to sacrifice their autonomy)<sup>and between govemments and NGOs</sup> if these associations are to wield any authority<sup>vis-a-vis govemment.</sup>

# _Decentralization_

49. Implementing policies such as those<sup>described here would be facilitated by</sup> decentralized organization and management of health<sup>care. The district level provides an</sup> entry point for involvement of NGOs and district committees<sup>are a forum for discussion</sup> of common problems. In Kenya, for example, since<sup>1983 the district committees have been</sup> charged with accepting or rejecting NGO<sup>proposals. In Zimbabwe, too, NGOs must get</sup> permission from the district to operate there<sup>(Bratton 1989). This is not to say that the</sup> district focus eliminates potential conflict<sup>between government and NGO agendas, but it</sup> relaxes somewhat the bureaucratic constraints<sup>to their increased coordination.</sup>

# Conclusion

50. This discussion has underscored the substantial<sup>contribution NGOs of various</sup> tv pes have made to health care delivery in Sub-Saharan<sup>Africa and noted that the current</sup> trend seems to be to channel more, not<sup>fewer, resources to them. In the past, such</sup> contributions have been made largely<sup>either with mild support from government, with</sup> benign neglect of government or even despite<sup>government; few countries seem to have</sup> clearly articulated policies towards NGOs<sup>or have expressed specific guidelines for their</sup> performance.

51. The greater visibility of NGOs today has implications<sup>both fbr government policies</sup> and for the internal structure of NGOs themselves,<sup>as well as for the wider role of NGOs</sup> within African societies. Two tentative conclusions emerge.<sup>First, from the point of view</sup> of govemments, while recognizing that the<sup>issue of government/non-governmental</sup> organization relations can be highly political,<sup>the question of howbest to optimize the use</sup> of all national resources should be addressed.<sup>Can governments afford to continue a</sup> laissez-faire policy with regard to NGOs?<sup>Or is, indeed, this a better policy than an</sup> interventionist one which may jeopardize<sup>the very qualities of NGOs which make them</sup> suitable in the health field? It seems<sup>clear that NGOs often provide essential services</sup> during certain periods (e.g., during emergencies<sup>or during a drought) or in areas,</sup> especially in the periphery, where government<sup>services have not successfully penetrated.</sup> On the other hand, such services may<sup>not conform to national policy guidelines and</sup> therefore maylimit the government'scapacityto<sup>implement acoherent, nationwide policy.</sup>