Worldwide, the influence and activity of both national and international nongovernmental organizations (NGOs) continues to grow apace. NGOs hold parallel conferences during global summits, act as “watchdog” on many health issues, and are frequently contracted to implement activities, particularly in the humanitarian field. More specifically, they distribute 20% of the global supply of drugs and participate in drug policy formulation.
Concurrently, a number of upcoming drug policy issues are further increasing the need for collaboration between agencies such as WHO and NGOs. They include international regulations and conventions that threaten to further reduce access to drugs, and how to ensure access to new, more sophisticated but vastly more expensive generations of drugs and vaccines.
Scope for greater involvement
A recent WHO study1 concluded, however, that the Organization has yet to fully explore and define how best it can collaborate with NGOs in drug distribution and supply. The study points out that the 1994 World Health Assembly recognised the scope for greater involvement of those NGOs in formal relations with WHO in WHO programme activities. But it emphasises that a general policy covering informal interactions between the two sectors has still to be formulated.
Interestingly, the study found that contact between NGOs and WHO in drug distribution and supply is greater when NGOs are in informal relations with the Organization. In fact, two-thirds of the NGOs surveyed work with WHO on this informal basis. But by definition, informal relations tend to stem from personal contact and are not highly sustainable. Effective projects or initiatives therefore risk losing momentum when the staff involved start to work on other issues or leave the organizations in question.
But a number of simple measures could be applied to enhance working relationships with NGOs. Firstly, departments can define how and why NGOs are important partners in drug distribution and supply. This would increase departmental awareness of the potential for partnerships that NGOs represent. They could also list NGOs with whom they have collaborated during the past two or three years, to create transparency and raise awareness of the breadth and range of their past and present NGO partners. The study suggests too that each department develop an explicit policy on NGO collaboration. Ideally, such policies would include guidelines for informal collaboration, an indication of what NGOs can expect to gain from the collaboration, and a list of criteria that NGOs must meet in order to establish informal relations with the programme. Establishing mechanisms to collect and document the knowledge and experience gained by NGOs during implementation of their diverse and innovative activities could also be an important resource for departments.
At country level the study suggests that WHO country offices establish policies on how to involve NGOs in drug distribution and supply, and use WHO's comparative advantage to act as a link between ministries of health, national drug programmes and NGOs. It also recommends that WHO country offices encourage ministries of health to involve NGOs in drug distribution and supply at national level.
For their part, it is proposed that NGOs in countries define what they themselves consider their role in drug distribution and supply to be, and form coalitions of NGOs which could become partners for national drug programmes and WHO.
What do NGOs get in return?
If NGOs are open to cooperating with WHO on a more regularised basis, they can expect to be able to provide greater input to WHO's programme work and to even become involved in programme implementation. Within countries they might also be helped to develop a stronger partnership with their ministry of health. At the same time, agreements and knowledge accumulated at WHO headquarters level should flow more easily and frequently to international, regional and national NGOs.
People wait for their medicines in Ethiopia. NGOs’ role in drug distribution and supply is increasing (Photo: WHO)
1. WHO. Collaboration between NGOs, ministries of health and WHO in drug distribution and supply. Geneva: World Health Organization; 1999. WHO/DAP/98.12.
WHO sets priorities for 21st century
Increasing equity, making health systems more cost-effective and fighting the diseases which constitute the main burden of disease will be WHO's main priorities in the next decade, as outlined in the World Health Report 1999: Making a Difference1. Part summary of health achievements and challenges, and part strategy document for world health in the next 10 years, the Report charts the 20th century revolution in health, which has led to a drop in birth rates and significant increases in life expectancy.
But not everyone has benefited. The Report points out that over one billion people will begin the next century without having participated in the health revolution. Reducing inequality is a priority in international health. Yet the means already exist to achieve this. What are needed are vision, commitment and global leadership, the publication argues.
WHO believes that policy-makers in the early decades of the century will have to confront a double challenge. The first is emerging epidemics of non communicable disease and injuries, which are becoming more prevalent everywhere. And the second is the more complex “unfinished agenda” of infectious diseases, malnutrition and complications of childbirth, which disproportionately affect the poor.
The Report warns that non communicable diseases are likely to account for an increasing share of disease, rising from 55% in 1990 to 73% by the year 2020. Health systems will have to be adjusted to cope with this global shift which is expected to be particularly rapid in developing countries. In India, for example, deaths from non communicable diseases are expected to double from approximately four million to about eight million a year. In separate chapters, malaria and the prevention of tobacco deaths are singled out for concerted global action.
Need to increase health spending
According to the Report, the key to reducing disease is to improve health systems. The two major challenges confronting all countries are how to ensure efficiency and how to achieve and maintain universal coverage. The publication states that many countries need to increase overall health spending if they are to make even the most inexpensive and effective health measures available to the whole population.
One way of improving efficiency is through the extended use of integrated packages of interventions, such as immunization programmes. The least organized and most inequitable way of paying for health care is on an out-of-pocket basis, with people paying for services whenever they use them. The Report points out that the financing burden falls disproportionately on the poorest, and restricts their access to health services - despite their need being greater.
The Report suggests that governments must provide cost-effective services to prevent and treat their nation’s most pressing health problems, and so reduce the disproportionate burden of disease on the poor and aid economic growth. This marks a shift in WHO’s stance towards acceptance of the need to set priorities to make the best use of resources for all within society. What is proposed is a “new universalism”: that universal coverage means coverage for all not coverage of everything. Governments must ensure that good health care is accessible to everyone, but they should not attempt to provide all possible treatments. Priorities will have to be determined on the basis of resources available and the cost of top priority health interventions. The Report says that while governments may contract out services to private providers if necessary, they must take overall responsibility for leadership, regulation and ensuring solidarity in financing health care for all.
The publication identifies four main challenges for national governments and international agencies in the next decade:
• focusing health systems on delivering a limited number of interventions which have the greatest impact in reducing disease among the poor;
• enabling health systems to counter proactively the potential threats to health resulting from economic crises, unhealthy environments or risky behaviour;
• developing health systems that provide universal access to clinical services with no fees (or only small fees) at the point of delivery;
• encouraging health systems to invest in research and development.
WHO believes that meeting these challenges will make a major difference to the quality of life worldwide.
1. WHO. The world health report 1999: making a difference. Geneva: World Health Organization; 1999. Price: Sw.fr. 15. US$13.50, and in developing countries Sw.fr. 10.50.