_Role of NGOs in HeWlth Delivery Africa Heath Policy Study_ _.9._

# _Efflciency_

23. Within health service delivery, thete is some evidence that NGOs-both secular and religious-are more efficient in their operations than government services. Bradley found in his stuJy on Ghaiia, for example, that missions tended to have lower cost per visit and to be more efficient in pharmaceudcal procurement (Bradley 1989). However, as he, too, points out, such measures of efficiency are fraught with methodological difficulties, for inputs or the scale of activitdes may not be comparable. Missions, for example, often receive free donadlons of pharmaceuticals or other in-kind contribudons from constituents or their internadonal affiliates, or may call upon an network of volunteers. Moreover, NGOs are usually much smaller and often pay lower salaries than govemnment facilities.

24. Perhaps the greatest contribution of NGOs for the development of Sub.Saharan Africa where government capacity is typically weak is that they are alternative institudons providing some channel for popular participadon. In the health field, they fil a gap left by unresponsive apd often unaccountable public serces. They may provide a critical voice for social development and act as intermediaries between the public and government by putting public health issues on the polical agenda. Maay NG0s, however, are reluctant to exploit their potential influence on the public policy agenda. De Grafa among others, nas argued that now, more than ever, there is a need for NGOs to speak up In the policy arena, and that they should avail themselves of the necessary informadon and expertise In order to maximize their influence (de Graaf 1987). The questior, Is whether they can expand their role in such a way without lo:ng strengths unique to their type of organizatlon and approach.

25. It is arguable, however, that many of tht advantages of NGOs-their small sie and flexibility-could apply to public sector Irstitutions in a more decentralized organization of health care where the district level is the locus of accountability. Optimian about the capacity of decentralizaclon rests Inevitably on the ability of districts to gain some financial autonomy. Given that revenue-generating possibilities at the district 1-wd.1 are limited and that few governments are willilng to relinquish financial control, there are reasons for pessimism. Nevertheless, considerble Impetus is now evident in Africa to push for decentralization and NGOs do provide an example of responsiveness for possible emulation by the public sector.

26. From governments' point of view, however, sustaininS an NGO presence in the health sector maycarry distinct advantages. First, in manyAfrican countries, the aJditonal resources-particularly foreign exchange-which NGOs bring Into the country are invaluable. In Chad, for instance, government has little choice but to rely on NGOs in health delivery. Anheier has attributed the presence of NGOs In Togo to the need for resources as well (Anheier 1989). Governments may also, Ironically, recognize the flexibility which NGOs enjoy, and use them as innovators, particularly In politically rlsky areas or activities. NGOs may be free from the accountability constrants ficing governments (James 1989). Likewise, NGOs' penetradon into peripheral areas mayrelleve