The role of non-governmental organisations in strengthening the South African health system: a commentary

The need to strengthen the South African health system (public and private) has long been acknowledged. South Africa’s failure to meet the health-related Millennium Development Goals (Byass et al., 2015) and the challenges to meet the Sustainable Development Goals, especially given the impact of COVID-19 on health outcomes, point to the need to strengthen the health system.

Various policies have been developed to address the challenges experienced by the system – the latest of which is National Health Insurance (NHI). Many Ministers of Health have recognised that government working alone will not be able to solve the many challenges that the health sector faces. In this commentary, we focus on non-governmental organisations and their roles in supporting government to strengthen the health system.

International non-governmental organisations (NGOs) have a long history of working in low- and middle-income countries. These range from missionaries and religious organisations, humanitarian groups, social rights-oriented NGOs, health and human rights groups, university-based organisations, and contactors (Birn et al., 2017). The roles played by these organisations and groups are diverse, ranging from research, humanitarian interventions, advocacy for human, social and health rights, health systems strengthening as well as the provision of direct health services, usually to the most vulnerable and marginalised.

Many authors have commented on the role of international organisations. These range from those that argue that such assistance is another form of colonialism or post-colonialism (Hanchey, 2018; Kim, 2021). The continuing impact of colonialism and racism has received recent attention in the context of global health and the role of universities from the global north. For example, Daffé et al. (2021) noted that,

. . . one way the ‘coloniality of knowledge’ shows up is in our norms and perceptions surrounding expertise (p. 558). By knowingly or unwittingly devaluing the expertise of local collaborators and indigenous populations – their lived experience or other ways of knowing – we reproduce colonial practices and miss critical opportunities for impact.

Birn et al. (ibid) provide a list of questions that individuals and organisations that implement global health programmes should consider – many of which can apply to local NGOs as well. Reflecting on what can be done to address colonialism in global health, Abimbola et al. (2021) argue that individual emancipation, the building of southern networks to take ownership of global health, and for global health organisations to decentralise their operations, finances and empower local organisations.

In 2008, a number of international NGOs published the NGO Code of Conduct for Health System Strengthening (Health Alliance International, 2008). This was in reaction of the large volume of donor funding flowing to these organisations for health systems strengthening. This Code is as relevant to international NGOs as it is to local NGOs. The Code has six articles which focus on how NGOs should partner with and strengthen the public health sector.

In the South African public health context, much of the funding used by NGOs (international and local organisations) comes from foreign donors. Currently, the largest donors are bilateral donors such as the US Presidential Emergency Fund for AIDS Response (PEPFAR) and the Global Fund. Other funders include the Bill and Melinda Gates Foundation, UNITAID, and ELMA Philanthropies.

Bilateral donors and philanthropies have begun to fund local NGOs directly – a process called localisation – although many issues remain such as ‘who is local’? (Baguios et al., 2021). For example, in 2018, PEPFAR decided to provide at least 40% of their funding – rising to 70% by 2020 – to local NGOs and governments (Rose & Silverman, 2018).

This commentary will focus on local health NGOs that work directly with the national and provincial Departments of Health and which focus directly and indirectly on health system strengthening initiatives.

What is health system strengthening?

The World Health Organization (WHO, 2007) described health systems as consisting of ‘. . . all organizations, people and actions whose primary intent is to promote, restore or maintain health’ with six building blocks comprising health systems (p. 2). These are service delivery; health workforce; information; medical products, vaccines, and technologies; financing; and leadership and governance (stewardship). This implies that attempts to strengthen a country’s health system should focus on one or all of these components. This definition and these components have been criticised as not specifically including the community component. Sacks et al. (2019) propose the inclusion of household production of health, social determinants of health, and the role of community-based organisations, including community health workers to the WHO building blocks. This means that in strengthening health systems, community systems should also be strengthened to produce acceptable health outcomes.

Who are the local health NGOs, what do they do, who funds them, and who are they accountable to?

Without trying to be exhaustive, the following are some of the largest local health NGOs that are currently supporting the public health system in South Africa: ANOVA Health Institute; Aquity Innovations; AURUM Institute; BroadReach Healthcare; Clinton Health Access Initiative (CHAI), South Africa; Center for Communication Impact; Doctors without Borders; Foundation for Professional Development; Health Systems Trust; JPS Africa; Kheth’Impilo; Right to Care; SEAD Consulting; TB HIV Care; The Health Foundation; and Wits RHI.

In 2020, the organisations mentioned above established a forum called the Health Implementing Partners Group (HIP-G). The terms of reference of HIP-G are ‘To continue to address the health system challenges and improve coordination, collaboration and to provide effective support to the DoH’. The group has met to discuss how to strengthen their support to the Department in strengthening the national health system and to improve health outcomes and has hosted a number of webinars to share their experiences.

Most of these NGOs are funded by the PEPFAR to support the government’s HIV programmes, including supporting adherence to treatment. Some are also funded by the United States Agency for International Development (USAID) to support the tuberculosis programme. In addition, organisations like CHAI, which has received funding from other organisations, have focussed on sustainable health financing, cancer, malaria, maternal and neonatal health, sexual and reproductive health, and increasing access to affordable medicines. During the COVID-19 pandemic, some of these NGOs also supported the Department of Health’s COVID-19 response.

In terms of accountability, the organisations that are part of HIP-G have local boards that they are accountable to. In addition, in compliance with South African law, these organisations are registered with the Companies and Intellectual Property Commission (CIPC). As these organisations are externally funded, they are also accountable to the donors to meet targets and to exercise proper financial management of the funds provided to them. Most of the organisations also have memoranda of understanding or agreement with the National and Provincial Departments of Health which set out the terms by which they will support the public health system.

Some examples of the roles played by local NGOs

The members of HIP-G have and continue to provide support in a range of areas to the Department of Health. These include as follows: direct support to the provision of clinical services by employing a range of health workers; provision of stipends to community health workers; training of health workers, including in the implementation of new clinical guidelines; training of community health workers, including in supporting patients’ to adhere to treatment; pharmaceutical demand forecasting support; strengthening supply chains, including pharmaceutical supply chains; strengthening laboratory systems; improving information systems and the use of information; and demand creation through the information, education, and communication (IEC) support.

NGOs typically can act with greater agility and are able to focus on innovation. These innovations, once supported by evidence, are shared with the Department of Health to consider taking them to scale. One example is antiretroviral therapy (ART) adherence clubs piloted by doctors without borders in Cape Town which was adopted by the Department of Health (MacGregor et al., 2018). A second example is the work done by ANOVA who trained health workers to better meet the needs of men who have sex with men – who have high rates of HIV (WHO, 2017). A third example is CHAI’s (2021) work in assisting the Department of Health since 2010 to save US$2 billion by working with the Department and global suppliers to reduce the prices of HIV, tuberculosis, malaria medicines, and childhood vaccines. A fourth example is the work of the Health Systems Trust which has for decades produced two value publications: the South African Health Review and the District Barometer. The annual review documents key policy and legislative changes as well as impact on the health system and on health outcomes. The barometer analyses the routinely collected health data from the District Health Information System (DHIS) and ranks districts against national average performance per indicator. The DHIS was developed by an NGO (Health Information System Program) in partnership with the Western Cape Department of Health and adopted by the National Department of Health. The DHIS is currently the only routinely available data in the public health system and used for both planning and monitoring public health sector activities.

South African NGOs are also involved in implementation research in the health sector. The publication lists of these NGOs are large and too numerous to list in this commentary. They cover a wide range of topics which can be accessed through their websites (e.g., https://www.righttocare.org/wp-content/uploads/2020/07/Resources/Conference%20Presentations%20and%20Publications/Publications%20List.pdf and https://www.hst.org.za/publications).

Discussion

NGOs working alongside the Department of Health have the potential to assist in the strengthening of the health system and improving service delivery. As note by Biermann et al. (2016), the work of NGOs ‘. . . need to be synergistic, complementary to public services, and rooted in community mobilization and collective action’ (p. 1).

NGO support to the Department of Health can only continue with donor funding. However, donor funding cannot be in perpetuity. This means that any support needs to be sustainable. Key factors to ensure sustainability of support to health facilities in the Western Cape by Right to Care included sufficient and stable resources (financial, human resources, technical expertise, equipment, and physical space); strong leadership at facility level; joint planning; formal mechanisms for skills transfer; the programme being valued by local health officials; and partnerships (Chiliza et al., 2021).

As South Africa moves towards implementation of the NHI, the role of NGOs may move from largely a focus on health programmes, such as HIV, to supporting various components of NHI. This support should go beyond strengthening financial coverage to also include improving service and population coverage (Sanadgol et al., 2021). A key concern raised about some of the NHI proposals is the possibility of increased corruption especially in a highly centralised system as envisaged in the draft NHI Bill (October, 2021). NGOs may also have an important role to play in ensuring good governance.

Conclusion

The need to strengthen the health system in South Africa has long been recognised. While the Department of Health at national and provincial levels must take the lead in strengthening the health system, there is a role for NGOs. However, NGOs must work closely with the Department to ensure that innovations that they may develop can be scaled and that they work within the policy framework set by the Department. An open and mutually respectful and collegial relationship between the Department and NGOs is needed to maximally benefit the health system.