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Accountability
December 2007
Vol. 25, No. 12
InterAction
Features
03 Inside this Issue
04 Making Accountability Work: A
Constructive Role for Donors
06 The HAP Standard: Triple Distilled for
Humanitarian Program Quality
09 New Reproductive Risk Index from
Population Action International
10 Listening to Improve Accountability
13 Program Evaluation Standards: Raising
the Accountability Bar
14 Self-Certification Plus: Accountability,
Transparency, Effectiveness
16 Child Sponsorship Certification: Getting
it Right
17 Post-Crisis Community Recovery and
Renewal: Accountability Invisibility
18 Member CEOs Discuss Accountability
Challenges
21 Well-Being in Emergencies: The IASC
Guidelines on Mental Health and
Psychosocial Support in Emergency
Settings
MONDAY DEVELOPMENTS
22 Building Safer Organizations and
Managing Editor Monday Developments is published Accountability to Disaster Survivors
Julie Montgomery 12 times a year by InterAction, the largest
alliance of U.S.-based international 24 Code Blue: Non-Governmental
development and humanitarian
Editor
nongovernmental organizations. With Organizations Uniting to Support Public
Kathy Ward more than 160 members operating in Sector Health Services
every developing country, we work to
Copy Editor overcome poverty, exclusion and suffering 28 Accountability in Fleet Management
Nia Davis by advancing social justice and basic
dignity for all. 29 NGO Downward Accountability to Their
Advertising & Sales
InterAction welcomes submissions of news Beneficiaries
Josh Kearns
articles, opinions and announcements.
Article submission does not guarantee
Communications Department inclusion in Monday Developments. We
Also in this Issue
Nasserie Carew, Public Relations reserve the right to reject submission for
Tony Fleming, New Media any reason. It is at the discretion of our
Josh Kearns, Publications editorial team as to which articles are
Julie Montgomery, Publications published in individual issues. 33 CAREER DEVELOPMENT
Turning Love Into Work
Editorial Committee All statements in articles are the sole
Taina Alexander
opinion and responsibility of the authors. 34 Inside Our Community
Andrea Barron
Luisa Cordoba
Articles may be reprinted with prior 36 Inside InterAction
permission and attribution. Letters to the
Barbara Wallace editor are encouraged.
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Inside this Issue: Tackling Accountability
T
housands of people in our community are engaged in the day-to-day work of reducing
the devastating impact of poverty, providing humanitarian relief and responding to
natural and man-made disasters in every country of the world. Their direct experience
of the wide variety of conditions and circumstances in which our work takes place
provides a valuable advantage in meeting the challenge of developing evolving standards of
accountability for our sector.
Our unique perspective from this direct engagement with local communities in the expansion
of opportunities for the poor, and supporting access to education, health care, livelihood,
economic opportunity and other areas gives us the opportunity and the responsibility to define
the parameters and raise the bar on accountability.
Since 1994, our members have certified their compliance with InterAction’s Private Voluntary
Organization (PVO) Standards. Over the years these standards have been expanded and
adjusted as the sector’s examination of what it means to be accountable to partners, local
populations and donors has evolved.
The U.S. public shows its support for advancing human dignity and peace in the world through
contributions to InterAction members totaling around $7 billion annually. And as a result
of the tsunami, the public gained significant understanding of the need to further advance
humanitarian accountability.
Sam Worthington
President and CEO, InterAction
I
n the final decade of the twen- nisms, evaluation techniques and mechanisms with high price-tags
tieth century, there seemed to audit mechanisms are proliferating act as barriers to entry. A required
be a broad-based consensus across the world. There is tremen- certification brand would make it
that non-governmental organi- dous competition in some fields difficult for fledgling organizations
zations (NGOs) were a good thing: amongst would be auditors and in to gain wider recognition amongst
as shepherds of development, as some countries between certifica- the public and donor organizations.
democratic agents and in making tion and rating regimes. From a de-
sense of globalization. NGOs were cidedly scarce array of options five In spite of these challenges, it is
seen as the core of active civil so- years ago, today the average NGO critical for NGOs to sort out their
cieties, supporting the delivery of is dizzy with the possible ways in accountability equations given the
public services and contributing to which to embrace accountability. importance of NGOs in address-
an ever-stronger wave of democra- ing some of our greatest collective
tization. By 2000, many NGOs were Sorting through the many mecha- challenges. Institutional donors can
no longer fledging organizations nisms and approaches on offer is a help. They have key roles to play
but multi-million dollar enterprises time-consuming process. Many of in encouraging NGOs to embrace
with increasing power and stature the accountability services on offer accountability, but it is not the role
affecting relationships between carry a hefty price tag. Some NGOs often foreseen for these donors.
states, shaping markets and busi- are reluctant to embrace those costs Would-be auditors and other ac-
ness practices. With this growing because they are not directly relat- countability service providers have
influence came increased scrutiny ed to the core missions of say, sav- gone straight to the donors who
and increased attention to ques- ing lives, educating children, de- have the power and the resources
tions of NGO accountability. fending rights or conserving nature. to create industry leaders and cut
They fear donors and the donor out the competition. Donors have
NGOs have responded to these public will count the accountability the opportunity to favor one mecha-
questions by examining their own regime as an administrative burden nism, to insist upon the use of one
practices, developing codes of or cost. This fear is not unfounded approach, and to increase the mar-
conduct, launching certification when some of the very transpar- ket for one service provider over
schemes, increasing independent ency measures publicize only the another. Donors should resist this
audits, developing sector-wide ratio of costs and not quality of ser- temptation.
standards for best practice and vice delivered. Even when the fi-
tightening management practices nances are available, accountability The growing field or market in
that improve performance. Univer- equations (the total accountability NGO accountability is very healthy.
sities and think-tanks are enhanc- practice embraced within an NGO), While it is tempting to “clean up
ing the field by researching how to when they are good, can and often the field” and make accountability
measure success in advocacy, com- do point to weaknesses in practice choices for NGOs through report-
munity empowerment, improving that need to be addressed. Change ing requirements, at this early stage
race relations and a wide variety of in practice is never easy to embrace of development it may be better to
social justice outcomes that count for any organization. The whole is- allow innovation to flourish and to
but are not easily countable. Be- sue can seem to be time consuming, seed many approaches.
yond the university-based research, a deviation from mission, threaten-
After all, all NGOs are not created
an entire industry has developed to ing and expensive. For small NGOs
equal. All fields (education, emer-
service the call for greater NGO ac- relying predominantly on volunteer
gency relief, conservation, rights
countability. Certification and rat- power and budgets of less than
defense and poverty alleviation)
ing systems, transparency mecha- $5,000, some of the accountability
W
hile quality assurance terAction; and a process objection Although the Sphere Humanitarian
regimes have become expressed most often, but not exclu- Charter concludes with an under-
familiar components of sively by, Southern NGOs. taking “to develop systems for ac-
most commercial and countability within our respective
social markets, the international The normative issue raised by MSF agencies, consortia and federations”
humanitarian system has remained and the ICRC centered upon the and an acknowledgement “that our
largely unregulated either by it- threat that a technical standards fundamental accountability must
self or by statutory authorities. Of compliance scheme might pose to be to those we seek to assist,” no
course, effective statutory regula- the fundamental principles of the register has ever been created to
tion is more difficult when the sys- Red Cross movement. In a letter to record exactly who is making this
tem in question is a genuinely foot- the Sphere Management Commit- commitment. This has inevitably
loose, global enterprise played out tee, MSF argued that the essential prevented further progress on de-
across a multitude of jurisdictions. nature of humanitarian action is veloping a system for accountability
However, this merely emphasizes contained in the personal relation- to “those we seek to assist” within
the case for self-regulation and ship between the recipient and the the Sphere coalition, in large part
deepens the mystery surrounding helper, and because this is rooted because of the perceived juridical
the very slow progress in establish- in the spirit of voluntarism and the risks so entailed.
ing voluntary program quality as- ethos of human solidarity, it simply
surance as an accepted central part cannot be reduced to a contractual The critique of the process through
of the infrastructure of the inter- service delivery relationship gov- which Sphere developed the mini-
national humanitarian system. So erned by “industry standards.” Sec- mum standards was linked to the
what is the cause of this dawdling ond, the MSF letter suggested that project’s initial difficulty in engag-
in a system that normally prides it- states might attempt to manipulate ing Southern NGOs and disaster
self on its dynamism? a standards compliance verification survivors in the consultation pro-
system for political ends, thereby cess. Although a growing number
In 1998, while chairing the Sphere compromising the fundamental of Southern NGOs did participate
Project Management Commit- humanitarian principle of indepen- in Sphere’s “institutionalization”
tee, it became clear that the loose dence. phase, the project never did find
coalition of agencies involved in a satisfactory method of including
writing the minimum standards for The juridical critique, aired by Inter- disaster survivors in the standards
humanitarian response could not Action, concluded that the Sphere development process. Hence it was
hold together if the project were to Standards should only be aspira- possible without too much fear of
venture into the quality assurance tional, because to make any sort of contradiction to suggest, on behalf
or compliance verification domain, binding compliance commitment of disaster survivors, that a com-
as had been envisaged in the proj- would present an open invitation pliance monitoring or verification
ect proposal. The disquiet about to ne’er-do-wells and opportunis- scheme would be damaging to their
compliance mechanisms voiced tic lawyers to launch hostile litiga- interests.
at that time boiled down to three tion against NGOs. An interesting
major concerns expressed by three consequence of this fear is that As the Sphere Project did not de-
distinct constituencies: a normative the Sphere Humanitarian Charter velop a compliance verification
objection, as articulated by the In- concentrates, rather paradoxically, mechanism it is difficult to establish
ternational Committee of the Red upon the duties and responsibilities whether or not these various anxiet-
Cross (ICRC) and Médecins Sans of states, while studiously avoiding ies were justified. Even so, as MSF
Frontières International (MSF); a any reference to the “duty of care” and the ICRC were more concerned
juridical objection, as voiced by In- borne by humanitarian agencies. with their fears that technical stan-
dards might displace ethical prin- complaints handling and redress these agencies clearly appreciated,
ciples, it does seem that the process dimensions of the quality assurance a quality assurance scheme simul-
of standards compliance verifica- agenda outside the Sphere coalition taneously provides enhanced risk
tion per se was not the primary once it became clear back in 1988 management.
issue for these agencies. Rather, that these matters could not be tak-
their concerns were founded upon en forward inside Sphere. But as a Meanwhile in Geneva, the Human-
the perceived inadequacies of the London-based research initiative, itarian Accountability Project gave
substantive content of the Sphere the Humanitarian Ombudsman way to the Humanitarian Account-
standards, which were then further Project also encountered practical ability Partnership (known rather
provoked by the spectre of a com- difficulties in conducting consulta- confusingly as HAP-International).
pliance scheme. Thus, provided tions with disaster survivors; and in The Project’s action research in the
that a compliance verification or 2001 the initiative was superseded field had demonstrated that in most
quality assurance system actually by the Humanitarian Accountabil- humanitarian contexts self-regula-
encourages human solidarity and ity Project (HAP) hosted by the In- tion was the only realistic and af-
voluntary humanitarian action, and ternational Federation of Red Cross fordable option for humanitarian
that it is administered in a strictly and Red Crescent Societies. In an quality assurance. In late 2003, a
independent manner on an entirely attempt to address the challenge core group of eight agencies found-
elective basis, it should surely be of including disaster survivors in ed a new independent organization,
possible to allay their fears. consultations, HAP set up and ran set up inter alia to “monitor and re-
action research projects in Afghani- port on the implementation of HAP-
However, the nightmare scenario stan, Cambodia and Sierra Leone. International’s principles of ac-
of large NGOs being held legal- countability to beneficiaries and to
ly liable for millions of avoidable The need to strengthen account- accredit its members accordingly”
deaths in foreign public health di- ability practices within the humani- thereby establishing the humani-
sasters seems to have held the body tarian system was reaffirmed with tarian community’s first internation-
politic of U.S. NGOs in thrall and the exposure of sexual exploitation al self-regulatory body. However, in
to date humanitarian quality assur- and abuse of beneficiaries by aid early 2004, the new board of HAP-
ance has remained almost as dis- workers in west Africa. Such egre- International recognized that the
tant a prospect in the United States gious examples of an accountabil- task of monitoring compliance with
as it seemed back in 1998. This in ity deficit within the international the accountability principles that its
spite of President Clinton’s strongly humanitarian system spurred the members commit to upon entry was
worded proposition in 2006 that the Inter-Agency Standing Committee a sensitive, complex and potential-
system is actually very vulnerable to to develop and issue guidelines in- ly expensive matter. In response,
mistakes and thus also to legitimate tended to prevent further cases, and HAP-International embarked upon
claims for redress, while it continues to establish a new initiative called a consultation process to develop an
to operate without a robust volun- “Building Safer Organisations” accountability and quality manage-
tary quality assurance scheme able (BSO) hosted by the International ment standard that could be used
to confirm that its major actors are Council of Voluntary Agencies in assessing compliance with its ac-
operating their field programmes (ICVA). BSO’s aim was to develop countability principles in a fair and
with due diligence. capacity within the humanitarian consistent manner.
system at large to investigate alle-
The Humanitarian Ombudsman gations of sexual exploitation and However, HAP-International’s stan-
Project was the brainchild of a abuse. This paralleled develop- dard development project soon en-
group of agencies (including the ments by leading child sponsorship countered the same challenges that
British Red Cross, Oxfam GB and agencies within InterAction to de- have so often hampered the involve-
Save the Children UK) determined velop a more rigorous self-regula- ment of disaster survivors in other
to follow through the compliance, tory scheme to protect children. As humanitarian standards setting
continued on next page
processes. However, not consulting 3. Which of the measurable prac- the BSO project was transferred
with humanitarian aid recipients tices of humanitarian quality man- from ICVA in April 2007, HAP-In-
was not an option and eventually a agement identified by this process ternational now has the skills and
diverse group of disaster survivors are, by general consensus, afford- experience to train investigators to
willing to participate in develop- able and practicable in the great examine allegations of sexual ex-
ing the HAP-International standard majority of circumstances? ploitation and abuse. The BSO proj-
were identified. While the people ect has greatly strengthened HAP-
selected were not demographically Drawing upon the collective wis- International’s complaints-handling
or democratically representative dom of aid workers, disaster survi- service, making it better equipped
of disaster populations as a whole, vors, academics and other stake- to deal with a broader range of is-
it was possible to ensure that the holders, the HAP Standard is their sues stemming from malfeasance,
group of disaster survivors was bal- answer to these questions. Like a negligence or improper conduct.
anced with regard to gender and good whisky, the HAP Standard is
geographical representation and, triple distilled: first, to isolate the es- As the HAP-International humani-
most crucially, they brought to the sential practices that determine the tarian quality assurance service is
process authentic experiences of di- quality of humanitarian work; sec- rolled out more widely, we expect to
saster survival and the work of hu- ond, to retain just those practices be able to tell of a growing number
manitarian agencies. that are verifiable and measurable; of HAP-certified agencies that can
and third, to produce an end distil- be expected to deliver consistently
Once underway, the HAP-Inter- late that is affordable and applica- high quality and cost-effective hu-
national standard development ble in all but the most exceptional manitarian work. We are sure this
process involved hundreds of aid situations. However, because such is information that will help inform
workers, specialists and disaster circumstances do prevail in human- important decisions made by disas-
survivors. Throughout 2006 an in- itarian theatres from time to time, ter survivors, aid workers, job seek-
tensive series of workshops and the HAP Standard also incorporates ers, volunteers, private donors and
field trials were conducted in Eu- a compliance exoneration facility officials.
rope, Africa and Asia, culminating for those special cases when the
in a final drafting workshop in Ge- Standard should not be applied. As in other sectors of human endea-
neva in December of that year. This vour with the potential to both help
elaborate consultation process fo- Of course the development of the and to harm intended beneficiaries,
cused upon three crucial questions: HAP Standard was just the first step we may soon find legal opinions
towards establishing a complete concluding that serious engage-
1. What matters most in an agen- humanitarian quality assurance ment with a self-regulatory body
cy’s management system with re- system. The Humanitarian Ac- is a sign of due diligence, making
gard to influencing humanitarian countability and Quality Manage- humanitarian organizations less,
outcomes? ment certification scheme is per- rather than more, vulnerable to the
haps the most prominent element predatory attentions of opportunis-
In other words, which factors con-
in the system, as it represents the tic claims seekers.
trolled by the agency have the
culmination of a process whereby
greatest potential impact upon the But more importantly, we believe
an independent audit of an agen-
well-being of disaster survivors, that the HAP-International humani-
cy’s programme quality manage-
with well-being defined as a func- tarian quality assurance scheme has
ment system has confirmed that it is
tion of mortality, morbidity and dig- greater potential to improve the im-
compliant with the HAP Standard.
nity? Together, these functions and pact and outcome of the humanitar-
However, HAP-International also
processes constitute an agency’s ian system than any other humani-
provides an organizational base-
humanitarian quality management tarian reform package currently on
line analysis service (to assess what
system. offer.
organizational development is re-
2. Which elements of the agency’s quired to achieve compliance with
humanitarian quality management the HAP Standard), and mid-term For more information on the HAP Standard,
improvement plan reviews (to con- baseline analysis, certification scheme and
system can be measured either di- complaints handling support, please visit
rectly or through proxy indicators firm that agreed organizational de- www.hapinternational.org or email the
velopment plans have actually been author at nstockton@hapinternational.org.
within reasonable parameters of
complexity and cost? implemented). In addition, since
W
hen a woman is health- The indicators of access to services
ier so are her family, and health outcomes reflect the di-
community, her coun- rect causes of vulnerability to death
try and our world. and injury for women around the
However, the bitter truth is that world. However, recognizing that
poor reproductive health threatens reproductive health outcomes are
the well-being and, in many cases, influenced by broader issues of in-
the very survival of women around equity in income distribution, ac-
the world. Indeed, more than half a cess to social services, and gender
million women (typically poor, un- relations, the study discusses the
educated and living in rural areas or linkages between these issues and
urban slums) die during pregnancy reproductive risk. have the highest unmet need for
and childbirth worldwide every contraception. Abortion policies are
year. Despite 20 years of campaign- A single reproductive risk index is restrictive, and infant and maternal
ing to improve the reproductive constructed from this range of in- mortality are high or very high. In
health status of women, the risk of dicators, and the 130 countries are Niger and Sierra Leone, a woman’s
dying in pregnancy or childbirth then ranked from highest to lowest lifetime risk of maternal death is
still shows the largest gap between risk and grouped into five risk cat- one in seven and one in eight, re-
the rich and the poor of all develop- egories. spectively.
ment statistics.
The report is an important advo- On the other hand, countries at low-
Working to improve these tragic cacy tool, showing that the risks est risk are industrialized countries
health outcomes and place women associated with childbearing vary with high incomes; China., Cuba
firmly at the center of development tremendously among countries and Singapore are the only devel-
initiatives, Population Action Inter- around the world. All of the 26 oping countries in this category.
national (PAI) has a long, success- countries at highest reproductive HIV/AIDS prevalence is low and
ful history of developing evidence- risk have low-incomes and all are early marriage is rare. Adolescent
based advocacy tools. In October in sub-Saharan Africa except Hai- fertility is generally low, although
2007, PAI released a new index that ti, Laos and Yemen – the poorest Cuba and the United States have
gauges the current status of repro- countries in their respective regions the highest adolescent fertility lev-
ductive health at the country-level – and Bangladesh. In the majority of els of countries in this category.
in 130 countries. these countries, levels of HIV infec- Skilled care during pregnancy and
tion range between moderate and childbirth is universal and contra-
The study, A Measure of Survival, high. Adolescent fertility is high ceptive use is high. Abortion is gen-
is organized around the concept of and very early marriage is common; erally not restricted, and infant and
a woman’s sexual and reproduc- in one-third of the countries, more maternal mortality are rare.
tive lifecycle, considered in terms than half of girls are married before
of four stages: sex, pregnancy, the age of 18. Skilled care during PAI has conducted three similar
childbirth and survival. Each stage pregnancy and childbirth is gener- indices of women’s reproductive
of a woman’s sexual and reproduc- ally limited, with Ethiopian women health status since 1995, all of which
tive lifecycle is measured in terms having the least access to such care unfortunately showed the same
of how healthy and how voluntary in the world. Contraceptive use is general clusterings of countries ac-
each is. generally low, at about 40 percent. cording to reproductive risk levels,
Yemen, Rwanda, Laos and Haiti particularly at the highest risk level.
continued on page 20
O
ver years of organizing they reflected on and analyzed the does harm. Local people know that
collaborative learning impacts of international assistance agencies provide reports to donors,
projects (Do No Harm, for their societies, and provide the but many question why they do not
Reflecting on Peace evidence for the following initial get to see these reports and why do-
Practice, and others), questions findings. nors often do not check whether the
have arisen about the cumulative assistance they have provided has
effects of international assistance on The systems and structures of in- made a positive difference in recipi-
people, their communities and their ternational assistance limit oppor- ents’ lives.
societies. So, in 2005 we launched tunities and incentives for listening
the Listening Project to explore the in open-ended ways to people in Why is this important?
ideas and insights of people who recipient societies. If this evidence is borne out in future
live in societies on the recipient side conversations, the challenges to the
The evidence seems to show that international community cannot be
of international assistance efforts
international assistance agencies over-stated. It suggests the need
such as humanitarian assistance,
have developed often efficient de- for a fundamental rethinking of
development and peacebuilding.
livery systems that are often more the purposes and values of interna-
It is based on the belief that those
concerned with getting services and tional assistance and, subsequently,
who have intentionally crossed bor-
goods to people than with getting to a redesign of our systems to re-in-
ders to attempt to help other people
know and respect them. tegrate the importance of building
– and those who work with them
– must both listen carefully to the relationships (as well as delivering
In the places we visited, many
wise judgments of people in those goods and services).
people referred to international as-
societies about how these efforts sistance as “an industry” that is The systems of international assis-
have gone and be accountable to professionalized to meet delivery tance bias the ways that agencies
them. standards by employing certain and aid workers listen and do not
kinds of people, organizing needs listen, what they listen to, where
The Listening Project has facilitated
assessments, planning and proj- and when they listen, and to whom
listening exercises in Aceh (Indo-
ect activities according to specified they listen.
nesia), Angola, Bolivia, Bosnia and
systems, and reporting on pre-de-
Herzegovina, Cambodia, Ethiopia,
termined indicators (often related This is related to the first finding.
Kenya, Kosovo, New Orleans, Sri
to what is delivered at what cost). If the system is designed to deliver
Lanka, Thailand and Zimbabwe.
More and more, NGOs are using goods and services, the point of lis-
Over 225 staff members from more
the terminology of “customers” or tening to people in communities is
than 60 local and international
“clients” (i.e., “industry” language) to determine whether the goods and
NGOs have participated in the lis-
rather than “beneficiaries” to de- services have been delivered well:
tening exercises to date, holding
scribe those whom their efforts are Were they the right amount, of the
about 1,300 conversations with ap-
intended to help. Donors also focus right quality, delivered to the right
proximately 3,000 people. In each
on results-based management, a people and on time? Often the focus
location, teams listened to a broad
concept borrowed from the private is on gathering this information in
range of people, including those
sector. an “efficient” way to reduce costs of
who have directly received assis-
delivery and to ensure speed, leav-
tance, people who have not received People tell us that they do not get ing less and less time to listen to
assistance but have observed it, and to select the agencies that work in what people think about the effects
those who have been a part of the their communities, and that they of- of the assistance they received.
chain of delivery. The reports from ten have no way to hold the agen-
these listening exercises capture cies accountable when the work When aid agency staff are listen-
what we have heard from people as is badly done or, worse, when it ing for assessments of their service
There is an increasing demand for greater accountability atic evaluative strategies and practices, and create standards
in foreign assistance, and international non-governmental by which organizations can assess their work. Drawing upon
organizations (INGOs), along with other players in the provision InterAction member organizations’ diverse experience base
of foreign aid, are pressed to provide credible evidence in order to achieve broad relevance for the community, the
demonstrating achievement of program results. As part of EPEWG produced the “Position Statement on Demonstrating
InterAction’s effort to help its member organizations increase NGO Effectiveness,” which the InterAction board of directors
their accountability to a variety of stakeholders including approved on September 20, 2005. It is this position statement
program participants, partners and donors, InterAction’s that provided the foundation for the SCP’s revised program
Evaluation and Program Effectiveness Working Group (EPEWG) evaluation standards.
recently submitted evaluation standards to InterAction’s
Standards Committee. These standards are now part of both With the new SCP process evaluation standards now ap-
the Self-Certification Plus (SCP) process and InterAction’s proved, the EPEWG will provide further guidelines to clarify
Recommended Standards and Guidelines. (See separate article and illustrate the revised standards. Additionally, to help In-
by Barbara Wallace on page 14.) The standards are intended terAction member organizations respond to these new stan-
for all InterAction member organizations regardless of their dards, the working group will prepare presentations on major
scope and size of operations. The revised evaluation standards, topics related to demonstrating effectiveness and will compile
recently approved by InterAction’s board of directors for a list of resources for program effectiveness and accountability.
incorporation into the SCP process, are defined as follows: The EPEWG will also issue recommended program evaluation
standards to complement the revised SCP standards. All will be
1. The organization incorporates relevant monitoring available on InterAction’s website.
and evaluation practices in its policy, systems and cul-
ture. This standard aims to assess design, monitoring This effort revises InterAction’s evaluation standards and devel-
and evaluation standards and policies that are in place ops and highlights resources that can help InterAction mem-
for programs and projects. It also seeks to ensure adher- bers comply with those standards. In so doing, it responds to
ence to professional principles and standards to foster one of the EPEWG’s two objectives, namely, to build the ca-
program effectiveness. pacity of InterAction and its members to demonstrate effec-
tiveness by: (a) serving as a practical resource for InterAction
2. The organization conducts regular and deliberate members and InterAction itself in monitoring, evaluation, and
evaluative activities to examine progress toward its program effectiveness; and (b) acting as a platform and a think
goals and mission. Regardless of the size and scope of tank in which InterAction and its members can develop new,
operations, the member organization will show how it creative ideas for evaluation and program effectiveness. The
regularly assesses whether or not it is on the right track EPEWG’s second objective complements the first: to inform
for achieving its intended goals and overall mission. communications and advocacy initiatives to influence the U.S.
and global aid effectiveness discourse.
3. The organization applies adequate financial and hu-
man resources for monitoring and evaluation. This stan- As the EPEWG begins taking on bigger tasks related to these
dard aims to ensure that the member organization not two objectives, it is eager to expand its membership to ensure
only allocates sufficient resources for program moni- that it represents the full range of InterAction members,
toring and evaluation activities, but also uses those re- drawing on InterAction members’ breadth of knowledge and
sources as planned/intended. experience and effectively responding to InterAction members’
needs related to evaluation and program effectiveness. To
These new SCP process evaluation standards emerge from join the EPEWG, please contact Hilary Nalven at HNalven@
three years of work that began when InterAction’s Board of Di- interaction.org.
rectors created the EPEWG to survey members’ evaluation ca-
pacities, support members’ needs for effectively using system-
I
nterAction members do not take a the broadening diversity The current Self-Certification Plus
lightly the trust placed in them amendments to include people process of validating compliance
by the American public through with disabilities in 2000; with the Standards became man-
direct donations, and, for some a the adoption of standards of- datory for all members in 2006. It
members, through government fering guidance in the pro- encourages organizational learning,
funding fueled by taxpayer dollars. tection of beneficiaries from advances best practices and helps
sexual exploitation and abuse ensure that InterAction members
Accountability is not only our re- and guiding NGOs in the ap- meet the highest standards of the
sponsibility, it is inherent in the mis- propriate use and movement international non-profit community.
sions and the core values that drive of pharmaceutical and medical The Standards further public trust
our organizations and the individu- resources in 2003; and confidence in InterAction mem-
als working in them who strive to a the adoption of standards bers. Indeed, in various aspects, the
save lives, alleviate suffering and covering whistleblower and InterAction PVO Standards exceed
support the world’s poor in devel- document destruction policies the prevailing standards of the Bet-
oping the capacity to thrive in self- in 2005; ter Business Bureau and the Nation-
sustaining communities around the a the inclusion of Minimum al Charities Information Bureau.
world. Because we are social profit, Operating Security Standards
rather than for-profit organizations, offering guidance on providing Through the Self-Certification Plus
the measure of our success is not staff security in 2006; and process, members explore their or-
measured by earnings, but by our a further refinement of standards ganizations’ compliance with each
accountability for the accomplish- for program monitoring and standard by examining organiza-
ment of our purposes and missions. evaluation in 2007. tional documents such as articles
Ultimately accountability to the of incorporation and by-laws, staff
public, our funders, our boards and Building on this tradition, all mem- and board of directors policies, and
staffs, and, perhaps most impor- bers and InterAction itself now un- operational practices. The organi-
tantly, to the people we serve is the dertake a rigorous self-certification zation then completes a checklist
foundation upon which all of our ef- called Self-Certification Plus every through which it certifies that it is in
forts are built. other year, using various types of compliance with each standard and
documented “evidence of compli- states the evidence used for its de-
Since 1994, each InterAction mem- ance,” to re-certify their compliance termination, or declares that it is not
ber organization has agreed to be with the Standards. in full compliance and provides its
bound by InterAction’s Private Vol- plan for achieving compliance with
untary Organization (PVO) Stan- Intended to ensure and strengthen the standard in question.
dards, a system of standards in the public confidence in the integrity,
areas of governance, finance, com- quality and effectiveness of mem- Any member that does not com-
munications with the U.S. public, ber organizations and their pro- plete the Self-Certification process
management practice, human re- grams, the Standards were created verifying compliance with the PVO
sources, program and public policy. when the overseas work of U.S. Standards is suspended from mem-
NGOs was dramatically increasing bership until it is completed. Any
The PVO Standards are continually in scope and significance. Defining member that identifies a standard
reviewed, added to and strength- the financial, operational, program- with which it is not in compliance
ened. Over the years, significant matic and ethical code of conduct and does not create and fulfill a
changes have been made such as: for InterAction and its member plan to satisfy the compliance re-
a the addition of gender and agencies, these high and objective quirement is also subject to suspen-
diversity amendments and standards set InterAction members sion from membership.
guidance for child sponsorship apart from many other charitable
programs in 1998; organizations.
InterAction’s work on standards, accountability and program ef- dence of compliance for each standard led to important self-as-
fectiveness directly influences how its member NGOs manage, sessments that have fostered on-going internal dialogue among
govern and evaluate their programs and their outcomes. It is their staff and boards about the standards and the way each
designed, in part, to help member agencies determine how best agency monitors the effectiveness of their programs. Each of the
to define success, how to design constructive strategies and agencies readily admitted that knowing that an external party
mechanisms for evaluating what they do, and how to improve was going to review their policies and procedures led them to
results reporting. complete a more thorough self-assessment than would have
otherwise been the case.
InterAction’s on-going child sponsorship certification project
demonstrates in tangible terms that sincere, constructive collab- As a direct result of observations made by the audit teams, plans
oration can take place and that NGOs can establish a community are now under way among these five agencies to meet shortly
of practice to improve transparency and program outcomes. to share their experiences and to make more uniform and com-
prehensive their program monitoring and evaluation systems
While they share common program goals and their member-
and their methods for tracking the benefits received by spon-
ship in InterAction, the five well-established member agencies
sored children.
that run child sponsorship programs are essentially competitors.
They compete in the same markets for the same donor public fi- Perhaps the most exciting evolution in this initiative has been
nancial support, as well as in many of the same countries for the the shared recognition among the five agencies that compli-
delivery of program services to essentially the same beneficiary ance with standards, while important, does not assure effective
communities. They also share the same skeptical media report- program delivery or guarantee positive outcomes. Each of the
ing that often questions the way child sponsorship programs agencies rightfully asked that if developing and implementing
operate. the systems and policies needed for standards compliance does
not lead ultimately to sustained, positive program outcomes,
Collectively, their common goal has become to strengthen their
then why have standards at all? This was a revelation and an
systems and program outcomes, and to develop a system of
evolution in thinking among these five agencies that never
externally verified compliance with established standards that
would have taken place before the process began in 1998. Only
could definitively assure a weary public and donor community
through sustained work examining their systems of operation
that, as service providers to children, they are indeed “delivering
and the meaning of the standards did these agencies come to
the goods” as promised.
understand and appreciate that accountability to an established
The process of developing a certification process that they all set of guidelines cannot and must not be the end in itself. Rather,
could agree to and feel comfortable with took over five years. having standards and subscribing to a more rigorous compli-
Among the first challenges was the need to tackle the often am- ance system must be part of a systemic commitment to trans-
biguous and un-auditable language contained in InterAction’s parency and to an ongoing, regular institutional self-examina-
standards. The certification project forced the first real, in-depth tion of the systems, policies and procedures needed for each
reading of the standards since their inception in 1992. In many agency to provide appropriate, consistent and effective services
instances the standards referred to other guidelines, merely sug- to the children and families being served.
gesting that InterAction members “should be guided by them”
All now agree that it is a wasted opportunity to limit audit teams
rather than requiring that they “shall” follow those guidelines.
to simply assessing compliance with standards. When audit
Through several years of countless meetings and conference teams are in the field visiting program sites and speaking to
calls with agency representatives and their attorneys, the stan- beneficiaries, child sponsorship agencies are increasingly asking
dards were rewritten in many places, substituting “shoulds” to them to also assess program effectiveness and share their ob-
“shalls” and defining the types of evidence that would be need- servations with them. At the end of each audit cycle, it has been
ed to demonstrate compliance with each standard to an inde- suggested that these assessments and observations be shared
pendent auditor. with the other agencies and the broader InterAction community
Sitting around the same table and working toward a common in order to assist child sponsorship programs and overall NGO
goal, led ultimately to collaboration among these five agencies. effectiveness.
Even before the first certification audit was launched in October These five agencies continue to push the accountability enve-
2004, the agencies met, developed and shared a comprehensive lope, offering themselves up to increased scrutiny and external
set of child protection standards that each agreed to adopt and assessment. By their example they repeatedly demonstrate that
enforce. NGO community practice for accountability, transparency and
Following the audits, to an agency, they each found that the program effectiveness is not only possible but also necessary if
learning that took place as a result of their required self-stud- the sector is ever going to get it right.
ies that preceded the audits, as well as the observations made
about their programs by the audit teams was even greater than Kenneth Giunta is a private consultant and the former Senior
any benefit that might result from donor and public knowledge Director for Membership and Standards at InterAction. He staffed
of their certification. Indeed, the process of gathering the evi- this project for seven years from 2000-2007.
Natural disasters are typically times of great chaos and uncer- claims the unique role and value of CBOs in post-disaster sce-
tainty. Systems and infrastructure often fail under stress. Coor- narios, and instructs the funding and NGO community on better
dination, always a challenge, can sometimes collapse. In these practices for community recovery.
times, effective coordination and response are particularly
In some ways, the manifesto simply reiterated long-held tenets
difficult to tease out. Who is in charge? Who is answerable to
and principles elaborated on in other emergency and relief doc-
whom? Will people and communities be let down or will they
uments such as the Code of Conduct of the International Red
be effectively and equitably served as massive relief efforts un-
Cross and Red Crescent Movement and NGOs in Disaster Relief,
fold? And as individuals’ lives move forward, is there a defined,
and the Council on Foundation’s Disaster Grantmaking: A Prac-
accountable party or parties that meet their rebuilding needs or
tical Guide for Foundations and Corporations. The manifesto
are they faced with a bureaucratic, exasperating game of “pass
repeated the appeal for collaborative efforts and coordination
the buck?”
between civil society and government at both central and local
Following a natural disaster, community-based organizations levels. It also underscored the importance of meeting the needs
(CBOs) play a distinct and valuable role in a community’s recov- of women, children, and vulnerable populations as a central te-
ery and renewal. The CBO is often the first responder to offer net of relief, rebuilding, and recovery efforts, and attested to the
relief to its community in a disaster, but moreover, it is the last- importance of respect for and adaptation to local culture and
ing responder as community members move back into routines context of the affected community.
after emergency, relief and even rebuilding efforts have ended.
At first blush, the workshop and the manifesto may seem to have
In recognition of this critical role of re-knitting the fabric of com-
merely re-created a process typical of what is undertaken by the
munity life, The Global Fund for Children established dedicated
UN, multinationals and civil society at a global level and with
funding for community-based organizations in the recovery and
similar outcomes. Yet the workshop and the document have a
renewal process following disaster and crisis. Relatively new to
more subtle and implicit power. It is generated from the voice
funding relief and development work, The Global Fund for Chil-
and immediate witness of the community-based organizations
dren strategically established its grant criteria and has thus far
themselves. Further, the manifesto brings attention to the sec-
committed over $600,000 to 22 community-based organiza-
ondary, unintended effects of post-disaster programming and
tions affected by and supporting those affected by the 2004 In-
funding (such as mission diversion and funding skews). This
dian Ocean Tsunami, the 2005 Hurricanes Katrina and Rita in the
highlights the central importance of sustainable and integrat-
Gulf Coast and the 2005 Pakistan earthquake.
ed planning and funding for effective transitions from relief to
The learning from these organizations is not bounded by geog- recovery and, ultimately, to renewal of communities following
raphy, nor type of disaster. In response, The Global Fund for Chil- disaster.
dren convened twenty-two of its grantee partners from India,
The 22 CBOs that participated in the workshop were not timid in
Thailand, Indonesia, Sri Lanka, Pakistan, and the U.S. Gulf Coast in
demanding accountability of both governments and funders in
May 2007, in Mahabalipuram, India for a post-disaster recovery
supporting them in times of disaster. They declared that the im-
and renewal knowledge exchange workshop. While nearly two
plementers themselves are best qualified to make critical deci-
years had elapsed since the most recent tragedy (the Pakistan
sions on the use of funds. And they underscored the importance
earthquake in October 2005), emotions ran high, as participants
of fluid and flexible funding to adapt to changing needs. These
found both wonder and solace in common experiences. Today,
tenets require trust and transparency on the part of funders and
with the evocative third anniversary of the tsunami upon us, the
grantee partners.
fading memory of the Pakistan earthquake, and the failures of
emergency response in the Gulf Coast still readily apparent, we Perhaps, most importantly, the lessons from the workshop and
can examine with growing perspective the accountability chan- the manifesto remind us that particularly in times of disaster and
nels, or lack thereof, of each episode. distress, accountability is in itself a goal that must be integrated
in disaster prevention and preparedness. It is the mutually ac-
The four-day workshop focused on CBO experience and practice
countable relationships and partnerships established long be-
in implementing effective post-disaster programming. It culmi-
fore the chaos ensues that will carry those involved through
nated in the development of the participant-written Commu-
relief and rebuilding.
nity-Based Organization Post-Disaster Manifesto that powerfully
Perhaps, most importantly, the lessons from the workshop and the manifesto remind us that particularly
in times of disaster and distress, accountability is in itself a goal that must be integrated in disaster
prevention and preparedness. It is the mutually accountable relationships and partnerships established
long before the chaos ensues that will carry those involved through relief and rebuilding.
Too Many Standards Financial Accounting Standards policy-makers and the general pub-
The new outcry regarding Board has adopted a variety of stan- lic. We align our guidelines, suc-
accountability for results is, in dards for differing entities (colleges cess measures, resources and deci-
effect, “the other shoe dropping” and universities account for things sion-making to our ultimate goal of
in the wake of tightened financial differently from health care organi- ensuring that children in need are
accountability required by the zations or public welfare charities), safe, educated, healthy and better
partial adoption by the NGO standards appropriate to each type able to attain their rights.
sector of the Sarbanes-Oxley Act. of NGO should be developed and
agreed upon. When agreed upon, Currently, Save the Children is de-
Beneficiaries, donors, partners,
these standards should be consis- veloping an agency-wide account-
boards and other stakeholders are
tently implemented thus reducing ability framework for all program-
no longer content with being told
parallel and duplicative require- matic areas and operating contexts
by an organization that “we are
ments that negatively impact direct in which we work – emergency, tran-
doing good work here.” They also
and indirect costs. sition and development. This frame-
want verifiable evidence (parallel to
work will help us to assess program-
an independent audit for financial Daniel Pellegrom, President, matic and administrative strategies
purposes) that programmatic Pathfinder International
to achieve our goals with quality
progress (i.e. “impact”) which can
programs and determine whether
be linked to the organization’s
activities is demonstrable and
Building a Comprehensive we have sufficient quality assur-
measurable. This is a reasonable
Internal Framework for ance efforts in place. The develop-
requirement.
Accountability ment of this framework is a priority
Though Save the Children is ac- at Save the Children to strengthen
Unfortunately, unlike the account- countable to multiple stakeholders, our current efforts towards account-
ing side, there is no one body em- we recognize that our primary ac- ability to multiple stakeholders and
powered to determine the pro- countability is to produce positive to develop a culture of accountabil-
grammatic equivalent to GAAP and sustainable results for the chil- ity for quality results at all levels
(Generally Accepted Accounting dren we serve. In assessing the ef- within the Agency.
Principles), nor can independent fectiveness of our programs, we pri-
Charles F. MacCormack, President &
evaluators and impartial observers oritize listening to our beneficiaries
CEO, Save the Children
even agree upon the evidence each and measuring impact and outputs
will accept in making their indi- – especially for children – to help us
vidual determinations. As a result, understand not only whether our Accountability Through
organizations like Pathfinder are programs have achieved impact but Collaboration With
investing heavily and reluctantly whether we have done so in a man- Communities
in building multiple monitoring ner satisfactory to those we serve. Sometimes global conservation can
and evaluation frameworks, paral- be overwhelming: there is so much
Save the Children is committed to to do, the needs are so pressing,
lel systems of indicators and huge
accountability not only to our ben- and, to make it work, the needs of
databanks to hold the differently
eficiaries but to ourselves as an so many different individuals and
“sliced and diced” information re-
agency and to all of our external groups have to come into align-
quired by conflicting and confusing
stakeholders – donors, partners, ment. Rather than get discouraged
reporting requirements. Just as the
Traditionally, humanitarian interventions in emergencies fo- The heart of the Guidelines are 25 action sheets that cover top-
cused mostly on meeting basic physical needs and establishing ics such as coordination, assessment, social and legal protection,
security. In the past two decades, humanitarians have increas- care for humanitarian staff, community self-help, early child de-
ingly recognized that emergency affected people suffer signifi- velopment, mental health and psychosocial support in the pro-
cantly due to: the mental anguish of losses, deaths, attacks and vision of general health care, care for people with severe men-
displacement; the loss of social supports and familiar routines; tal disorders (including severe presentations of post-traumatic
and ongoing protection threats. As one conflict-affected elder stress disorder), harmful substance use, non-formal and formal
said, “the NGOs came and gave us food and shelter, but who education, and information dissemination. Overall, the bulk of
helped our spirits?” the guidance is on social interventions rather than clinical, indi-
vidual interventions. A distinctive feature is the view that all sec-
The sources of mental and psychosocial distress in emergencies
tors have a responsibility to promote mental health and psycho-
are diverse and reflect problems that arise before, during and af-
social well-being by virtue of the way in which basic needs are
ter an acute event such as a tsunami or an armed attack. Numer-
provided for. For example, how shelter is organized for displaced
ous individuals suffer from pre-existing psychological problems
people affects mental health and psychosocial well-being since
(such as severe mental disorders) or social problems (such as po-
people living in overcrowded camps may report that lack of pri-
litical discrimination and oppression). During emergencies, new
vacy is their greatest concern. This view contrasts with an older
problems arise due to losses, displacement, family separation,
view that mental health and psychosocial support is something
and protection threats such as recruitment and trafficking. After
to be done only after basic survival needs have been met.
emergencies, affected people suffer from social effects, includ-
ing being discriminated against as displaced people, being de- The Guidelines stand on six key principles: human rights and eq-
tained illegally, or being stigmatized as “rebels” or “rape victims.” uity, participation, Do No Harm, building on available resources
Moreover, many people experience psychological effects, such and capacities, integrated support systems, and multi-layered
as problems with anxiety and depression, which for many – but support systems. These reflect an empowerment model and
not for all – decreases with time. In addition, some issues arise emphasize that mental health and psychosocial support is to a
due to unintended side effects of humanitarian efforts. Harm large extent about what affected people do for themselves. A
may be caused by poorly coordinated humanitarian response, key point is that the Guidelines move beyond the tired debate
the labeling of everyone as “traumatized,” failure to inform all about which is more important: (a) clinical care, or (b) commu-
segments of the population about available aid, or harmful in- nity self-help and social support. These are two sides of a coin,
terventions. and multi-layered supports require attention to both.
The breadth of these issues challenges everyone to help orga- The Guidelines (available at http://www.humanitarianinfo.org/
nize a multifaceted, comprehensive response. This response iasc/content/products) are a useful resource both at the prac-
should go far beyond attention to traumatic stress, which is only tice and policy levels. For practitioners, they outline key steps
one aspect of a much wider set of issues. Unfortunately, there to be taken during the emergency. Coordination groups may
has, until recently, been no systematic, consensus guidance on use them as a checklist to identify gaps in multi-sectoral sup-
how to respond effectively and avoid harmful practices. port and to guide program development. They can also be used
as a lever in urging governments in emergency-affected coun-
This gap has been filled by the IASC Guidelines on Mental Health
tries to take an appropriate approach and to develop effective
and Psychosocial Support in Emergency Settings (IASC, 2007).
disaster response plans. For donors, the Guidelines offer a set of
These inter-agency, global guidelines, which were launched
benchmarks by which proposals can be judged. The important
in Geneva in September and on November 29 at InterAction,
task ahead is for all actors, whether practitioners or donors, to
define minimum recommended responses. These are the first
implement these Guidelines to protect the dignity and reduce
steps to be taken in emergencies and that lay the foundation
the suffering of people living through emergencies.
for subsequent supports. The Guidelines are the product of col-
laboration among 27 UN agencies, intergovernmental agencies
and international NGOs, including InterAction members such as The authors co-chaired the IASC Task Force that developed the
American Red Cross, CARE, Christian Children’s Fund, Interna- Guidelines.
tional Medical Corps, International Rescue Committee, Mercy
Corps and Save the Children.
F
or many, the issue of sexual tion by humanitarian workers, with on investigating complaints and
exploitation and abuse by an absence of regulation, monitor- designing and implementing safe,
humanitarian workers is a ing and redress for victims creating accessible complaints mechanisms.
story beginning in West Af- practical impunity. The impression These learning program workshops
rica. In Sierra Leone, Liberia and of management inaction was com- were conducted in six different re-
Guinea, allegations against human- pounded by agency delays in re- gions around the world, where they
itarian workers and peacekeepers sponding and the dramatic media have been held on a rolling basis
scandalized the international com- coverage in 2002 that unleashed an ever since. The workshops have
munity in 2002 and prompted a ma- international furor. built skills, changed attitudes and
jor re-evaluation of organizational generated enthusiasm for a more
strategies to prevent and respond Unfortunately, when the UN sent effective organizational response.
to abuse. an investigative team to the refu- Yet many workshop participants re-
gee and displaced persons camps, ported challenges in implementing
Consultants engaged by Save the witnesses were unwilling to speak their new-found skills due to a lack
Children UK and the Office of the to them. As a result, the team could of understanding from management
UN High Commissioner for Refu- not substantiate the cases cited in and support in the field.
gees (UNHCR) went to West Africa the report. However, they did find
in 2001 and 2002 to report on the ex- other cases and gaps in organiza- BSO responded with a series of
periences of children living in situa- tions’ prevention and response ca- management workshops to con-
tions of armed conflict. During their pacities. vince managers of the risk of sex-
research, the consultants found al- ual exploitation and abuse by their
legations of widespread abuse by The exposure of abuses in West Af- staff. At the same time, BSO began
peacekeepers and humanitarian rica catapulted the problem of ex- providing expertise and financial
workers. These workers often used ploitation and abuse into the public support to field-based networks
the very humanitarian assistance realm. The first standardized inter- tackling sexual exploitation and
intended to help refugees as tools of national policy response was initi- abuse of disaster survivors. Manag-
exploitation, extorting sexual “fa- ated when a joint UN-NGO task ers and staff expressed support for
vors” for small amounts of money, force formulated six core principles further collaboration. Nevertheless,
food stuff, plastic sheeting, educa- guiding the behavior of humanitari- with some exceptions, the momen-
tion and the like. While the prin- an staff. These principles were later tum dissipated once participants
ciple targets were girls between 13 enshrined in a UN bulletin for UN were back in their organizations
and 18, the consultants also report- partners and staff. Furthermore, the and the networks were slow to get
ed cases of abuse against younger exposure led to activities to spread off the ground.
children and suspected unreported good practices in implementing
cases against boys. Further investi- these principles in different loca- There are a number of explanations
gations indicated that exploitation tions around the world. for the slow pace of organizational
of young women was endemic. change. Firstly, organizations are
In the aftermath of these events, the not easily persuaded to look past
Building Safer Organizations (BSO) West Africa as the source of the
Failure of management project was created as part of a problem. Similarly, analyses around
systems NGO global partnership to prevent solutions rarely look beyond stan-
Despite the large number of cases and respond to sexual exploitation dard gender-based violence pro-
documented by the consultants, no and abuse by encouraging NGOs gramming projects for solutions.
agency reported receiving com- to introduce safer and more acces- Secondly, there is a tendency to be
plaints from staff or refugees. It sible complaints mechanisms and overly optimistic in projecting the
was therefore not surprising that to improve the quality of investiga- pace of organizational change and
the consultants cited management tions when complaints are received. about how easily initial enthusiasm
practices as a clear contributing In 2004, BSO began training staff will be translated into transforma-
factor to the occurrence of exploita-
Over the last decade, unprecedented tribution to the human resource crisis,
political will has been focused on ad- dubbed “internal brain-drain,” which
dressing the growing and multiple occurs when NGOs and other inter-
health crises affecting the developing national institutions lure government
world. Funding from bilateral aid pro- workers away from front-line clinical,
grams like the U.S. President’s Emer- public health and managerial jobs into
gency Program for AIDS Relief (PEP- high-paid program administration po-
FAR), multilateral agencies such as the sitions, thereby exacerbating the very
Global Fund to Fight AIDS, Tuberculo- problems they are attempting to solve.
sis and Malaria, and private donors like
Some NGOs, aware of these pitfalls, are
the Gates Foundation has increased by
exploring and implementing innova-
tens of billions of dollars.
tive ways to strengthen health sys-
Sharp increases in available funding, Photo: courtesy of Jiro Ose. tems and build public human resource
primarily aimed at curbing the HIV capacity. Clearly, NGOs can have a
epidemic, have lead to tremendous positive effect by providing innovative
growth in the NGO community and a multitude of different technical assistance, by directing funding to support the public
projects and approaches, many with limited and in some cas- system that might otherwise go elsewhere, by training the lo-
es, wide-spread success. For example, although the ambitious cal health care workforce, and by supporting national strategic
goals of the World Health Organization’s 3 by 5 campaign (three plans and monitoring and evaluation systems. Perhaps more
million on antiretroviral medicines by 2005) were not realized, difficult for NGOs is the challenge to “do no harm”: that is, limit-
the campaign galvanized diverse governments, organizations ing their own potentially negative effects on the public health
and institutions to dramatically expand treatment access so that system. The process requires NGOs to honestly assess their own
now nearly two million people are on antiretrovirals worldwide. practices and their unintended consequences and to recognize
that working though the public system often takes longer and
Despite these advances, consensus is growing that gains in
requires the NGO to share decision-making power.
some areas, like HIV treatment, are severely limited while in oth-
er areas, like maternal child health, ground is being lost due to As a guide for international NGOs working to limit their harm-
weak public health systems and most critically, the severe short- ful effects and maximize their contributions to strengthening
age of qualified health workers in the poorest countries. Often public health systems, several health-focused NGOs including
donors pressure NGOs to produce short-term gains in a limited ActionAid, Health GAP, Partners in Health, Physicians for Human
population, creating conflict with the longer-term and more dif- Rights, Health Alliance International and others are developing
ficult task of building strong, high-quality national health care a code of conduct. The code will define and describe specific
systems able to provide comprehensive health services to an actions and practices to be encouraged or avoided for NGOs
entire population for decades to come. concerned about strengthening health systems in the countries
where they work. Although other codes exist outlining ethical
National health systems have degraded over the years because
NGO practices, none that we are aware of clearly address NGO
of a lack of basic investment, sometimes due to misplaced pri-
practices and their effect on human resources and national
orities or corruption, but often directly attributable to austerity
health systems. The draft, still in development, addresses hiring
measures or structural adjustment programs, the burden of high
and compensation practices, training health workers, the man-
debt payments, and other conditions imposed by institutions like
agement burden created by multiple NGO projects, and the role
the International Monetary Fund designed to reduce public ex-
of NGOs in advocacy and in engaging communities and linking
penditure in social services including health. International NGOs
them to formal health systems.
work in a constrained environment, where governments’ ability
to address their own health problems may be severely curtailed In recent years, program “sustainability” has become a byword
while NGOs have more flexibility. NGOs can quickly hire more of international health policy. And yet it is clear that without a
staff at higher salaries or acquire specialized equipment to sat- well-funded and healthy state, sustainability will be a mirage.
isfy vertical funding demands or create an idealized project serv- Through initiatives like the Code of Conduct, we hope to ensure
ing one limited population in a small geographic area. The result that “health for all” is not a thousand-year project or forever out
is a fragmented and inequitable health care delivery system, of reach.
where viral load measurement may be available, but cesarean
sections are not; where one district has a state of the art hospital For more information about the International NGO Code of Conduct
while the next district has only an empty cement-block building for Health System Strengthening in Developing Countries, or to
without running water or electricity that serves as a make-shift participate in the development and drafting of the Code, please
health post. Recent attention has been focused on the NGO con- contact the author at wjohns@u.washington.edu.
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