Discuss the role of non-governmental organisations in health care in India.

Non-governmental Organisations in Health

• The types — international organisations working in India; national bodies such as the Indian Red Cross, the Indian Council for Child Welfare, the Hind Kusht Nivaran Sangh, the Tuberculosis Association of India, the Family Planning Association of India, the Central Social Welfare Board and the Bharat Sevak Samaj; faith-based organisations, including the Christian Medical Association of India, which runs a very large network of hospitals; community-based and grassroots organisations; professional bodies such as the Indian Medical Association and the Indian Public Health Association; and corporate social responsibility foundations
• Their roles — direct service delivery, particularly in areas the state does not reach; reaching marginalised groups — tribal populations, sex workers, people who inject drugs, sexual minorities, the homeless and people with disability — whom government services often cannot approach effectively; advocacy and holding the state to account; piloting and demonstrating innovative models; training and capacity building; research and documentation; community mobilisation and awareness; and disaster relief
• The marginalised-group function is their most distinctive contribution, and the reason should be given — groups engaged in stigmatised or criminalised activity will not approach a government service, and an NGO can build the trust that makes contact possible
• The clearest Indian example is the HIV programme, in which targeted interventions among sex workers, men who have sex with men and people who inject drugs were delivered almost entirely through NGOs and peer educators, and could not have been delivered by government staff directly
• The demonstration function is the other distinctive one — an NGO can try something on a small scale, with flexibility a government department does not have, and if it works the state can adopt it at scale
• The classical Indian examples deserve naming:
• Jamkhed (the Comprehensive Rural Health Project, Maharashtra) — which demonstrated that village women, many of them illiterate and from the poorest groups, could be trained as effective community health workers, and which directly influenced the Alma-Ata conception of primary health care and, later, the ASHA
• Search (Gadchiroli, Maharashtra) — whose trials of home-based newborn care by village health workers showed a large reduction in neonatal mortality, and which became the evidential basis of India’s national home-based newborn care programme
• These two examples make the strongest case for NGOs — each generated evidence that changed national policy, which no amount of service delivery at their own scale could have achieved
• Other examples — SEWA Rural, aravind eye care with its cross-subsidy model, the Christian Medical College tradition, and organisations working on disability, mental health and palliative care
• Their advantages over government services — flexibility and freedom from procedural constraint; ability to innovate and to fail without political cost; closeness to and trust of the community; committed and motivated staff; lower cost; and ability to work with groups the state cannot reach
• Their limitations, which an honest answer must give:
• Limited and patchy coverage — excellent work in a few blocks does not constitute a health system, and no NGO can achieve universality
• Dependence on external funding, with activity following donor priorities rather than local need
• Sustainability, since a project ends when its funding does
• Variable quality and, in some cases, absent accountability
• Duplication and poor coordination with government services
• Attracting good staff away from the public system by paying more
• Difficulty of scaling what worked in a small, intensively supervised project
• The scaling problem deserves emphasis, since it is the recurring disappointment — a model that depended on exceptional leadership, close supervision and high motivation frequently does not survive replication through a routine government system
• The principles of effective government-NGO partnership — complementary rather than substitutive roles, so that the NGO does not become an excuse for state withdrawal; clear terms of engagement and mutual accountability; NGOs given the roles they do best — reaching marginalised groups, piloting, community mobilisation and advocacy; government retaining responsibility for universal provision and regulation; shared information and joint planning at district level; and a plan for transition and sustainability from the outset
• The essential point — NGOs cannot and should not replace a public health system; their value is in reaching those it misses and in demonstrating what it should do next
• Their greatest contribution is usually evidence rather than service, since a small caseload changes nothing by itself
• Jamkhed showed illiterate women could be health workers, which influenced Alma-Ata and eventually the ASHA
• Gadchiroli proved home-based newborn care works, and became the evidential basis of the national programme
• Models built on exceptional leadership rarely scale, which is the recurring disappointment of successful pilots
• Stigmatised groups will not approach a government service, which is why NGOs reached them in the HIV programme
• They should complement, not substitute, or they become an excuse for the state to withdraw
• Funding ends and so does the project, which is why transition planning belongs at the start rather than the end
• They draw good staff from the public system by paying more, which is a cost rarely acknowledged