_Role of NGOs in Health Delivery AfiVca Health Policy Study_ _.5_ difficulty In providing adcequate services for the whole<sup>populadon have increasingly</sup> recognized the contributron of NGOs in the he. th sector<sup>In Africa, although the political</sup> acceptability of individuaI NGOs varies greatly.

10. The last decade has also seen changes within NGOs themselves<sup>because of the</sup> entry of a new cadre of trained technical people and professionals<sup>into NGOs, willing for</sup> ideaistic reasons to accept lower salaries and difficult<sup>working conditions. This new wave</sup> of well-trained staff injected into NGOs new capacity and authority.<sup>Many observers have</sup> perceived a new assertiveness on the part of national NGOs<sup>in their relations with their</sup> international associates (Drabek 1987; World Bank 1988).<sup>A likely positive effect is that</sup> thcy will no longer be content to follow policies dictated<sup>internationally, but will caL for</sup> more locally suitable approaches. NGOs are now seeking a<sup>louder voice in national policy</sup> making and, increasingly, in the international policy arena.<sup>3</sup> 11. However, as Cumper has said of NGOs in his chaacterizadon<sup>of their role as the</sup> "eunuch In the harem," NGOs may feel powerless<sup>to</sup> change<sup>the fundamental paametm</sup> within which they operate. In groping to find the appropriate<sup>roies In a new world</sup> political and economic context, many within NGOs are concerned<sup>about the implications</sup> for staffing and organizadonal structure of NGOs.

12. Africa has been on the forefront of the growing activities of<sup>NGOs, asitSfamines</sup> and economic cisis have drawn concern and attention internationally.<sup>Both the types and</sup> numbers of NGOs active In Africa have risen, paricularly over<sup>the last decade (Baldwin</sup> 1988). In the health fleld, this broadening NGO role seems<sup>to have been particularly</sup> pronounced. As the Impact on health of activides in other sectors<sup>drew increasing</sup> attention, the broad, ir ter-sectoral acdvities of NGOs at<sup>thie micro level presented an</sup> example for possible replication on a national sakle. Indeed<sup>the primary health care</sup> (PHC) movement was itself Inspired by the wmallkcale successes<sup>of NGOs in mobilzing</sup> community involvement and in takdng a broad perspective<sup>on health problems (Cumper</sup> 1986). The swift responsiveness and effective contribuaIons<sup>of NGOs in &mine situadons</sup> in 1984 also contributed to their Increased recognition ( tan 1989).

13. The combined momentum of such forces has helped to assign<sup>NGOs more and</sup> more to the role of conduit for resources. However, in the<sup>African setting, such optimnsm</sup> about the capacity of NGOs to absorb funds and make up for<sup>deficiencies in government</sup> health services is somewhat at odds with she dearth of informadon<sup>about NGO. There</sup> remains the threat that without more knowledge about the<sup>activides and capacity of</sup> 3. Structural adjustment has provided a clear entry point,<sup>and NGOs have often found</sup> themselves as spokesmen for those experiencing the adverse<sup>effects of economic decline.</sup> Internadonal non.govemmental organizations such as OXPAM have<sup>entered the</sup> international political discussion of such issues witI. their criticisms<sup>of donor policies in</sup> these areas. OXFAM's participation in the debate over esential<sup>drugs is another easmple</sup> (Cumper 1986).