[afro-nets] NGO code of conduct your feedback welcome.

["Claudio Schuftan" <cschuftan@phmovement.org>]

This is a recently drafted NGO code of conduct designed to encourage NGOs to be sensitive to the needs of local health systems, especially the public sector. For example, it calls on NGOs to stop contributing to the internal brain drain from public to private ….

The NGO Code of Conduct for Health Systems Strengthening 

April 23, 2008

Preamble 

The purpose of this Code of Conduct for Health Systems Strengthening is to offer guidance on how international non-governmental organizations (NGOs) can work in host countries in a way that respects and supports the primacy of the government's responsibility for organizing health system delivery.

The last decade has ushered in tremendous growth in political will, funding support and organizational structures to improve international health. While gains have been achieved in some areas such as the HIV epidemic, ground has been lost in basic primary care and maternal child health. It is now becoming clearer that NGOs, if not careful and vigilant, can undermine the public sector and even the health system as a whole, by diverting health workers, managers and leaders into privatized operations that create parallel structures to government and that tend to worsen the isolation of communities from formal health systems.

This Health Systems Strengthening code is intended specifically to address international NGOs and their roles in training, securing and deploying human resources in the countries where they work. There are six areas where NGOs can do better: 1) hiring policies; 2) compensation schemes; 3) training and support; 4) minimizing the management burden on government due to multiple NGO projects in their countries; 5) helping governments connect communities to the formal health systems; and 6) providing better support to government systems through policy advocacy. This code offers sustainable practices in each of these areas of concern.

Signatories to this Code of Conduct recognize the role of voluntary ethical codes and country-based codes of conduct that have come before us. Those codes, such as the Code of Conduct for the International Red Cross and Red Crescent Movement and NGOs in Disaster Relief (1992), the Code of Good Practice for NGOs Responding to HIV/AIDS (2004), and the Paris Declaration on Aid Effectiveness (2005) offer practical ethical standards for NGOs and donors engaged in development work. These standards aim to improve the quality and impact of their work.

The original drafters of this code are representatives of international NGOs with implementation and advocacy experience in a variety of developing countries; we ourselves have made many of the mistakes that we address.

We hope that our Code of Conduct standards will prove useful for NGOs, governments, local institutions and donors by establishing principles to strengthen health systems. Our commitment helps ensure that "health for all" is not a thousand-year project, but well within our reach.

The code is intended to be clear, direct, succinct and action-oriented. (Please note that the term "NGO" in this document refers to international NGOs.)

Summary of NGO Code of Conduct for Health Systems Strengthening 

I. NGOs will engage in hiring practices that ensure long-term health system sustainability.

II. NGOs will enact employee compensation practices that strengthen the public sector.

III. NGOs pledge to create and maintain human resources training and support systems that are good for the countries where they work.

IV. NGOs will minimize the NGO management burden for ministries.

V. NGOs will support Ministries of Health as they engage with communities.

VI. NGOs will advocate for policies that promote and support the public sector.

Principles of the NGO Code of Conduct for Health Systems Strengthening 
ArticleI. NGOs will engage in hiring practices that ensure long-term health system sustainability. 

The role of international NGOs is to supplement — not supplant — the public policy role of host country governments and local institutions to strengthen and expand health systems. The NGO role is to provide research, support and expertise to strengthen civil society and local academic and research institutions in informing public health policy development. We, the signatories to this code, view our role as time-limited; that is, as communities, local institutions and Ministries of Health become stronger and build capacity, the role of the NGO should diminish or evolve.

1. In areas where trained personnel are scarce, NGOs will make every effort to refrain from hiring health or managerial professional staff away from the public sector, thus depleting ministries and their clinical operations of talent and expertise.

2. When hiring staff, NGOs will preferentially employ available national expertise outside public sector employment, recognizing that while the public sector is grossly understaffed, unemployment of highly qualified nationals also abounds. Where qualified nationals are available, volunteer labor will not be used as a substitute for paid staff.

3. In places of scarcity, on rare occasions when NGOs hire health staff already working in the public sector, NGOs pledge to do so in coordination and with the consent of local health authorities. This coordination will be accompanied by a commitment to expand overall human resource capacity in the public sector through pre-service training, salary support and/or other means. Governments and NGOs should work collaboratively to address the chronic underpayment of health workers in all sectors.

4. NGOs recognize that they have had a historical role in creating conditions that lead trained and skilled personnel to work abroad in wealthy countries. NGOs commit to avoid creating incentives for the health workforce to leave their developing countries for work in international organizations or locations. Instead, NGOs will provide incentives to stay in the public sector, including better working conditions, and good compensation and benefit packages.

Article II. NGOs will enact employee compensation practices that strengthen the public sector. NGOs recognize their collective history in creating inequitable pay structures that favor expatriates at the expense of national employees. The signatories to this code pledge that they will attempt to create pay structures that acknowledge differences in expertise and training, irrespective of the employee's nationality.

1. NGOs commit to advocate for fair monetary compensation for work done by all employees, across the health care system, including salaries for community health workers.

2. NGOs that hire health workers, managers and other skilled personnel in the countries where they work will offer salaries that are "locally
competitive," striving for salaries that are not substantially more generous than the public sector while providing a fair and living wage to their employees.

3. NGOs sometimes pay "top-ups" (compensation payments that supplement public salaries) to public sector staff to secure their services for contract work.  In general, NGOs will avoid this practice, as it creates inequities, increases burdens on existing staff and fails to add new workforce to the health sector.

4. NGOs commit to limiting pay and benefits inequity between expatriate and national, rural and urban, and ministry and NGO workers. Compensation structures that provide incentives for rural service are encouraged and gender-related disparities are disallowed.

5. NGOs will establish benefit structures that are based on the needs of employees and, at a minimum, match public sector practices, including retirement plans. Where public sector benefits or pay structures are inadequate, NGOs will collaborate with the public sector to improve them.

6. Any privileges granted to expatriate employees will also be granted to national employees of similar qualification and responsibility, such as the opportunity to work from home or access to personal transportation.

Article III. NGOs pledge to create and maintain human resources training and support systems that are good for the countries where they work. NGOs embrace the goal of strengthening educational institutions that train health workers, while also providing on-the-job continuous education. Workshops and other short training programs for health workers already in service often divert health workers from their workday responsibilities, while providing minimal benefit to the system as a whole.

1. NGOs will preferentially invest in long-term commitments to pre-service education and training, particularly at the in-country university level where there can be lasting benefit.

2. In areas where health workers are scarce, international NGOs will adopt measures that increase the number and capacity of professionals in a country of operation over time.

3. NGOs will support training in a broad sense to support both the service and management capacity of Ministries of Health; the goal is to transfer skills to national workers and eventually build sufficient capacity to obviate the need for international NGOs.

Article IV. NGOs will minimize the NGO management burden for ministries. 

NGOs recognize the burden on governments that have insufficient resources to organize their own country's affairs, while having to juggle the management burden of multiple and sometimes-competing aid organizations from a variety of other countries.

1. In recognition of donor commitments at the 2005 Paris High-Level Forum on Aid Effectiveness and sector-wide approaches to planning, evaluation and coordination, NGOs commit to meaningful joint planning within the ministries' own planning cycles.

2. NGOs pledge to respect government and health ministry priorities, as well as labor and personnel policies. These policies include those relating to programmatic and geographic deployment of health resources, especially those that foster wider distribution of health workers and promote access to services.

3. NGOs recognize that management capacity in Ministries of Health is often limited. Rather than building parallel or circuitous structures around inadequate capacity, NGOs commit to strengthening governments' ability to operate effectively and efficiently. This practice may lead to NGOs seconding personnel to direct government service.

Article V. NGOs will support Ministries of Health as they engage with communities. 

NGOs can play an important role as a bridge between civil society organizations and government agencies, especially (but not exclusively) in nations where populations or sub-populations are actively oppressed by their governments.

1. NGOs will strengthen the capacity of communities to take responsibility for and ownership of their health development, and to become partners with government in the health system, while holding governments accountable for their human rights obligations.

2. NGOs shall document and share their work in and with communities to Inform  host government planning and priority setting. In sharing this information, NGOs will guard the privacy of individuals with whom they work, including staff and patients.

3. In places where NGOs are working with communities that are being oppressed, NGOs will work to protect populations.

Article VI. NGOs will advocate for policies which promote and support the public sector. 

NGOs will actively advocate with civil society, local institutions and donors for policies and programs that strengthen health systems overall. NGOs recognize that vertical programs and selective approaches exacerbate inequities in health systems and ignore underlying determinants of health. We also recognize that funding conditionalities can limit or distort government expenditures and priorities. These unnecessary limitations continue to create barriers to health and development and are unfair and inequitable.

1. NGOs will strengthen and support, not supplant, the role of government in making policy. NGOs will support efforts to involve indigenous civil society voices in the policy arena by encouraging their participation in developing policy and setting funding priorities.

2. NGOs pledge to advocate for removal of political, ideological and
Financial barriers to the expansion and improvement of public health systems, including unnecessarily restrictive fiscal and monetary policies, and wage bill caps imposed by the international financial institutions.

3. NGOs will work in solidarity with their Ministry of Health colleagues to oppose the detrimental policies of the International Monetary Fund, the World Bank and other lenders whose loan conditions limit government expenditures on health or education.

4. NGOs commit to designing their activities and programs so that they
Reinforce primary health care, foster equity and community involvement, and are generally replicable and financially sustainable over time.

5. NGOs will also advocate with donors to support general health systems strengthening in the service of comprehensive national priorities.

6. NGOs will follow national labor laws and pay all relevant taxes on their income and assets in the countries where they work, just as any business would.

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David Mccoy 
mailto:d.mccoy@ucl.ac.uk