Abstract
International nongovernmental organizations (INGOs) from the U.S. and Japan have a shared aim of improving women’s health yet implement very different programs in Cambodia. The author’s observations and interviews in Tokyo, Washington D.C., and Cambodia suggest that while NGO practitioners in Cambodia can adapt programming to better reflect the concerns of local stakeholders, they have less influence in defining what counts as success.
International nongovernmental organizations (INGOs) from the U.S. and Japan have a shared aim of improving women’s health yet implement very different programs in Cambodia. For example, a Japanese INGO, I give the pseudonym Health Services Asia (HSA) focuses on strengthening government provided high quality maternal and child health services. In contrast, a U.S. INGO I call Global Family Aid (GFA) funds Cambodian NGOs to promote women’s health empowerment. My observations and interviews in Tokyo, Washington D.C., and Cambodia suggest that while NGO practitioners in Cambodia can adapt programming to better reflect the concerns of local stakeholders, they have less influence in defining what counts as success.
Adjusting INGO Mandates
One day, I joined HSA staff traveling to a small, rural village to observe government health officials teach pregnant women and new mothers about nutrition based on community prenatal and maternal health education designed by HSA’s Cambodia office. I ask Sovann, the Khmer program manager, why the organization doesn’t just carry out the training itself, as many others in Cambodia’s expansive NGO sector do. He explains, “HSA has one goal: it helps the government to implement its policies and do its job.”
An expecting Cambodian mother sits still for a sonogram at her doctor’s appointment.
Chhor Sokunthea / World Bank, Flickr cc
HSA’s donors have a strict emphasis on biomedical solutions, and Sovann reports that they help Cambodian women become “modern Asian mothers” by “becoming close” to state officials and supporting government health efforts. As part of their mission, practitioners and public health staff must discuss with community members about how traditional practices like postpartum dieting can be harmful. However, practitioners are careful to delineate between what they see as harmful traditional practices and those that are not, such as drinking herbal tea. In this way, they reshape programming by balancing the aim and mission of the organization with careful consideration of everyday practices on the ground.
International nongovernmental organizations (INGOs) from the U.S. and Japan have a shared aim of improving women’s health yet implement very different programs in Cambodia.
In contrast, GFA funds the local NGO Khmer People United (KPU), which provides information to women from rural villages on family planning, maternal health, and nearby clinics. GFA’s director Channy explains that the program “works on the demand-side to create informed female consumers of healthcare… and improve communication between couples.”
Yet, KPU staff resist the demand to train couples because, to them, it is simply not practical. Sotheary, a Khmer KPU staff member, explains that men are typically working during the day when most trainings take place. Even if they are home, they often “run away” because “women’s topics” make them uncomfortable. Furthermore, many women who want to use medical birth control encounter resistance from their husbands, so KPU practitioners help women hide IUD insertion from husbands, and provide transportation to private clinics, while male partners are away from home—a practice in tension with GFA’s stated aim of promoting husbands’ involvement in family planning.
Constrained by Metrics
As the above examples suggest, when asked to implement a program designed by a donor or INGO in the Global North, local practitioners sometimes make adjustments they consider necessary or appropriate, given the context. However, Khmer practitioners in both settings are also constrained in their ability to adapt the metrics used in program evaluation, which proves highly consequential.
For example, HSA evaluates effectiveness by counting the number of government employees that participate in its various trainings. In order to encourage attendance at HSA events, as discussed above, staff members spend substantial time cultivating relationships with government officials, even when they are not sure this is a good investment. Some HSA practitioners complain that because the government is “slow to move” in helping mothers, and staff time would be better spent doing direct outreach to community members. Others suggest that if HSA wants to increase the capacity of the state, it should allocate more funding directly to public health clinics, instead of organizing events for government officials.
In contrast, one of the ways GFA assesses the effectiveness is by tracking the number of women who begin using medical birth control. While many beneficiaries welcome the opportunity to use new forms of family planning, this metric creates pressure on KPU staff to encourage the uptake of birth control among rural beneficiaries who may be more skeptical, particularly when staff have not met the quarterly quota they are expected to reach.” In extreme cases, staff may resort to misinformation, such as telling women the withdrawal method is “dangerous for your husband’s health,” or guilt tactics, like telling mothers they cannot take care of more children, to convince women to adopt birth control.
Creating Lasting Change
INGOs have particular missions and goals that are reflective of the priorities and experiences of their originating countries. Yet, whether their programs enact lasting change depends on whether INGO goals and metrics “match” local stakeholder concerns and local sociopolitical and cultural contexts. To ensure success, INGOs need to include local practitioners and stakeholders in decisions regarding, not just the content and implementation of programming, but also how to measure what constitutes success.
A smiling mother clutches her daughter.
Chhor Sokunthea / World Bank, Flickr cc
