Strengthening Health Systems in Poor Countries: A Code of Conduct for Nongovernmental Organizations
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The challenges facing efforts in Africa to increase access to antiretroviral HIV treatment underscore the urgent need to strengthen national health systems across the continent. However, donor aid to developing countries continues to be disproportionately channeled to international nongovernmental organizations (NGOs) rather than to ministries of health. The rapid proliferation of NGOs has provoked "brain drain" from the public sector by luring workers away with higher salaries, fragmentation of services, and increased management burdens for local authorities in many countries. Projects by NGOs sometimes can undermine the strengthening of public primary health care systems. We argue for a return to a public focus for donor aid, and for NGOs to adopt a code of conduct that establishes standards and best practices for NGO relationships with public sector health systems.
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In other sub-Saharan African contexts, systems weaknesses, gaps in local capacity, and perceived lack of transparency have been found to contribute to the decision for external actors to implement parallel structures and vertical programmes that introduce health sector fragmentation.
“It has been noted in other sub-Saharan African contexts that systems weaknesses, gaps in local capacity, and perceived lack of transparency have been found to contribute to the decision for external actors to implement parallel structures and vertical programmes that introduce health sector fragmentation [1, 4, 29, 32, 38, 42].”
From Health sector fragmentation: three examples from Sierra Leone (2019) · cites this paper as [32]
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Kram, N., Yesufu, V. O., Lott, B. E., Palmer, K. N. B., Balogun, M. R., & Ehiri, J. E. (2021) · BMJ Open · doi:10.1136/bmjopen-2020-046263 · Cited by 13 · see citing works
Calling non-governmental organisations to strengthen primary health care: Lessons following Alma-Ata
Landes, M., Pfaff, C., Zerihun, M., Wondimagegn, D., Sodhi, S. K., Rouleau, K. D., & Kidd, M. R. (2019) · African Journal of Primary Health Care & Family Medicine · doi:10.4102/phcfm.v11i1.1945 · Cited by 10 · see citing works
Healthcare services for low-wage migrant workers: A systematic review
Rast, E., Lau, K. M., Lin, R. C.-Y., Loganathan, T., Hargreaves, S., & Zimmerman, C. (2025) · Social Science & Medicine · doi:10.1016/j.socscimed.2025.118176 · Cited by 9 · see citing works
O’Donovan, J., Namanda, A. S., & Hamala, R. (2021) · Global Public Health · doi:10.1080/17441692.2021.1969671 · Cited by 7 · see citing works
Children’s access to dental care during the COVID-19 pandemic: a multi-country survey
Elkhodary, H., Sabbagh, H. J., Meligy, O. E., Talaat, I. M., Abdellatif, E. B., Mostafa, M. H., Khader, Y. S., Al-Batayneh, O. B., Alhabli, S., Al‐Khanati, N. M., et al. (2022) · Children s Health Care · doi:10.1080/02739615.2022.2114478 · Cited by 8 · see citing works
‘Saving our people’: health workers, medical citizenship, and vernacular sovereignties in West Papua
Munro, J. (2020) · Journal of the Royal Anthropological Institute · doi:10.1111/1467-9655.13318 · Cited by 8 · see citing works
Leroi, I., Karanja, W., Adrion, E., Alladi, S., Custodio, N., Goswami, S. P., Guerchet, M., Gubner, J. M., Ibáñez, A. M., Ilinca, S., et al. (2022) · International Journal of Geriatric Psychiatry · doi:10.1002/gps.5762 · Cited by 7 · see citing works
Rudasingwa, M., Jahn, A., Uwitonze, A.-M., & Hennig, L. (2022) · Global Public Health · doi:10.1080/17441692.2022.2129726 · Cited by 7 · see citing works
Working Together in a Complex Environment: Collaborative Behaviors and Social Capital
Tsasis, P., Cooke-Lauder, J., & Evans, J. M. (2015) · International Journal of Public Administration · doi:10.1080/01900692.2014.949749 · Cited by 7 · see citing works
Political Violence, War and Medical Anthropology
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The Impact of NGO-Provided Aid on Government Capacity: Evidence from Uganda
Deserranno, E., Nansamba, A., & Qian, N. (2024) · Journal of the European Economic Association · doi:10.1093/jeea/jvae029 · Cited by 6 · see citing works
School Health Services and Millennium Development Goals
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Khalid, H., & FOX, A. M. (2019) · International Journal of Health Policy and Management · doi:10.15171/ijhpm.2018.131 · Cited by 6 · see citing works
Health non-governmental organizations (NGOs) amidst civil unrest: Lessons learned from Nicaragua
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Global Health Equity and Advocacy: The roles of international Non-Governmental Organizations
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Global telehealth and digital health
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Sousa, C., Akesson, B., & Badawi, D. (2020) · Global Public Health · doi:10.1080/17441692.2020.1775865 · Cited by 4 · see citing works
Abdalla, S. I. A., Weng, Y., Mehta, K. M., Mahapatra, T., Srikantiah, S., Shah, H., Ward, V. C., Pepper, K. T., Bentley, J., Carmichael, S. L., et al. (2020) · Europe PMC (PubMed Central) · doi:10.7189/jogh.10.021003 · Cited by 4 · see citing works
- Authors
- Pfeiffer, J., Johnson, W., Fort, M., Shakow, A., Hagopian, A., Gloyd, S., & Gimbel-Sherr, K.
- Affiliations
- University of Washington (US)
- Venue
- American Journal of Public Health
- Publisher
- American Public Health Association
- Published
- 2008-12
- Volume
- 98
- Issue
- 12
- Pages
- 2134-2140
- ISSN
- 0090-0036 (ISSN-L)
- 1541-0048
- PMC
- PMC2636539
- OpenAlex
- W2127281163
- Cited by
- 163
- References
- 35
- Citations by year
- 2026: 6 · 2025: 5 · 2024: 7 · 2023: 8 · 2022: 9 · 2021: 4 · 2020: 9 · 2019: 10 · 2018: 18 · 2017: 9 · 2016: 11 · 2015: 9 · 2014: 11 · 2013: 9 · 2012: 15
- FWCI
- 28.82
- Type
- journal article
- Language
- en
- Open access
- green
- www.ncbi.nlm.nih.gov
- Locations
- American Journal of Public Health (publishedVersion)
- PubMed Central (publishedVersion)
- PubMed (publishedVersion)
- RePEc: Research Papers in Economics (submittedVersion)
- Funders
- National Institute of Allergy and Infectious Diseases (P30AI027757)
- Topics
- Social Sciences › Development › International Development and Aid
- Social Sciences › Economics, Econometrics and Finance › Finance › Healthcare Systems and Reforms
- Social Sciences › Political Science and International Relations › Public health and occupational medicine
- Keywords
- non-governmental organizations, codes of conduct, health system strengthening, brain drain, primary care, Africa
- MeSH terms
- Africa, Delivery of Health Care, Developing Countries, Emigration and Immigration, Humans, International Agencies, International Cooperation, Organizations, Poverty, Global Health, HIV Infections, Public Health Practice, Guidelines as Topic, Anti-HIV Agents, Benchmarking, Codes of Ethics, Public-Private Sector Partnerships
About these checks
Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.
Statistics and arithmetic are recomputed, not judged.
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