_Role of NGOs in Health Dellvery Africa Health Policy Study_ 12seconded to mission facilities which were severely<sup>short of staff. Such an arrangement,</sup> however, is usually far from automatic. Movement<sup>of staff from missions to government</sup> services, for example, is often impossible because<sup>training given to missionaries does not</sup> conform to criteria and standards established<sup>by government (Akerele 1976). However,</sup> if these staff are expatriate, It is not clear that<sup>if they were not working for the missions,</sup> they would remain In the country. As another<sup>example, frequently mission services run</sup> separate drug procurement systems. Given<sup>the limited scale of NGO activides in</sup> comparison to govemment systems, this duplicadon<sup>is likely to be inefficient as the NGO</sup> systems are unlikely to achieve the economies<sup>of scale reached by government.</sup>

# _Lack of Skilled Personnel_

35. NGOs may also lack specialized technical personnel in<sup>health but may justify their</sup> role in health by their greater knowledge of community<sup>processesand constituents' needs.</sup> Nonetheless, where the perceived needs of the communities,<sup>especially in peripheral</sup> areas, may lie particularly in rendering medical<sup>services, this staff deflciency may be</sup> critical. Mburu commented that in Sudan, after<sup>the famine during which a number of</sup> international NGOs flooded into the country, many<sup>chose to stay in Sudan after the famine</sup> ended and moved into the health domain, whether<sup>or not they had the appropriate staff</sup> to do so. Mburu contends that in a country<sup>such as Sudan, which exports skilled</sup> personnel, it is arguable whether they were responding<sup>to a real need (Mburu 1989).</sup>

## _Community Participation_

36. Finally, NGOs may not be as participatory<sup>or bottom-up as they portray</sup> themselves. Particularly if staffed by expatriates,<sup>their relationship to the communities</sup> they serve may be problematic. NGOs are not<sup>always above being co-opted by local elites</sup> who may control the decision-making process. The projects an NGO chooses to undertake may be influenced more by their comparative<sup>advantage than the needs of the</sup> community. Where NGOs manage to achieve genuine<sup>community involvement and accep-</sup> tance, it may not be sustainable if labor turnover<sup>within NGOs is high, if their activities</sup> are not sufficiently long term or if no mechanism<sup>is developed to ensure continued local</sup> support were the expatriate staff to leave.

# _Vulnerability to Political and Economic Change_

37. In many cases, the ideological predisposition of many<sup>NGOs, such as religious</sup> missions for example, may make them particularly<sup>susceptible to political suppression by</sup> providing a pretext with which government may attack<sup>their activities. This has been the</sup> case in Kenya, where political declarations that<sup>missions had ulterior motives led to a</sup> period of tension in government-mission relationships,<sup>or in Ghana in June 1?89 when</sup> the missions of theJehovah's Witness and the Church<sup>of Latter-Day Saintswere closed and</sup>