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Code of Conduct
- 1. NGO Code of Conduct for Health Systems Strengthening: How is it working? Emily deRiel, MPH Based on thesis project of Anjali Sakhuja, MPH October 30, 2009
- 2. Outline Why a code of conduct? NGO Code of Conduct contents Research into implementation of the Code Discussion How best to use this Code? Are voluntary codes of conduct good tools for changing practices?
- 3. Why a code of conduct? Development aid for health quadrupled since 1990, to $21.8 bn in 2007 About 25% now flows to NGOs Source: IHME/Ravishankar et al, 2009
- 4. Why a code of conduct?
- 5. Why a code of conduct? There are many factors contributing to weak public sector health systems – why focus on NGOs?
- 6. Why a code of conduct? Lots of them already exist …NGOs Responding to HIV/AIDS, Disaster Relief, International Philanthropy, general codes of ethics and conduct, etc. One World Trust CSO Project: http://www.oneworldtrust.org/csoproject/
- 7. Why a code of conduct? Specifically, codes have been used for health workforce and recruitment efforts WONCA’s “Melbourne Manifesto” (2002) Commonwealth Code of Practice (2003) Voluntary Code of Ethical Conduct for the Recruitment of Foreign-Educated Nurses to the U.S. (2008) WHO Code of Practice on the international recruitment of health personnel (draft 2008) UK’s Code of Practice (2004)
- 8. NGO Code of Conduct for HSS Coalition of organizations worked on drafting and consultations starting in 2007 Launched in May 2008
- 9. NGO Code of Conduct for HSS 6 articles: Hiringpractices Employee compensation practices Human resources training and support to systems Impact of management burden on ministries of health Support of MOH engagement with communities Policyadvocacy for strengthening public sector ngocodeofconduct.org
- 10. First 3 articles: Human resources
- 11. Implementation so far Thesis research by Anjali Sakhuja (MPH 2009) 39 signatories today 14 countries (Dec 08) Questions: How are signatories implementing the Code of Conduct? What are best practices? What are challenges to operationalizing the Code?
- 12. Study design Qualitative Descriptive study I. Interview with signatories Experiences with implementation of Code HR policies Some promising practices II. Interview with non-signatories Practices in hiring, compensation and capacity building Reasons for not signing on the Code III. Case study: HAI’s Mozambique program Interviews with staff and MOH
- 13. Respondents Imp = Implementing org Tr = Training org Adv = Advocacy org Res = Research org
- 14. Findings: Hiring Most respondents make efforts to avoid hiring from the MOH Have hired in the case of Person already resigned from MOH With permission from MOH In “after-hours” setting (also with permission) Challenges: Rural posts Project deadlines/pressure Ethics of refusing to hire due to MOH employment
- 15. Findings: Hiring “We needed a psychiatric doctor. It is very difficult to hire a full-time doctor in an NGO like ours. We have to hire from the government sector because only they have psychiatric doctor. But we have been working according to the government policy as the doctors can have part-time service outside.” -- Signatory respondent
- 16. Findings: Hiring Expatriates are hired when special expertise is needed; try to make it the exception rather than the rule Challenges Can’t hire from MOH (nationals), can’t hire expats – what if there isn’t anyone else? Bureaucracy to hire expats Expats from non-Western countries fleeing conditions in home countries
- 17. Findings: Hiring “In (this country), half of our health providers are Zimbabwean and this is working well. We realize that when they move out they leave a gap in their country. But they are moving out of Zimbabwe due to death threats, inability to work. Systems are being depleted by the repressive government. So not hiring expats in this situation is ideal but not practical.” -- Non-signatory respondent
- 18. Findings: Compensation NGO salaries can be 10x greater, or more Some signatories do match government or university salaries Challenges Low salaries make hiring and retention difficult Market pressures Finding an elusive balance
- 19. Findings: Compensation “I left my government job in 1991 and joined UN, and later an NGO. My two children went to private schools. I could not pay for their education if I was in the government job. I could not afford to pay even for the important daily supplies of food or even for gasoline. [In 1991] I was getting US$10 a month. In UN I got US$300. Today a medical officer in public health sector will get US$50 a month. An NGO would pay US$ 500-900. If you work with the public health sector, after seven to eight years of study you get so little that you cannot survive without additional income -- you know, under-the-table income.” -- Signatory respondent
- 20. Findings: Compensation Some countries have regulatory bodies that decide salaries including for NGOs Mali – collective bargaining court Kenya – NGO Council (Ministry of Labor) Working conditions can be as important as salary considerations
- 21. Findings: Compensation “Health care workers are leaving because the government doesn’t care. I know this surgeon in Uganda, gets a phone call at three in the morning that there is an emergency at a rural hospital. (…) Nobody can pick him up. He has a bicycle. So he goes to the local bus station from where one bus goes once every hour. He takes the bus, arrives in the village, walks to the hospital. By the time he gets there, the patient is dead. This happens in many, many countries. Everywhere! Everywhere! Over and over and over again! And this is something where the governments need to be held responsible as being unethical in not giving the health care providers the opportunity to save a person’s life.” -- Signatory respondent
- 22. Findings: Training and Support Most signatories do some kind of training, but majority do on-the-job trainings (in-service) A few do university/pre-service training support Challenges: In-service trainings are seen by some as perks MOH unable to pay salaries even if more workers graduate
- 23. Findings: Hiring “We recently trained 40 graduates just out of college in (this country) on M&E and seconded them in the Ministry [offices] across the country. We pay them [the same] salaries that the government pays.” -- Non-signatory respondent
- 24. Case study: HAI Staff familiar with Code, and value the principles Similar challenges to other signatories Tension of adhering to hiring and compensation policies while trying to recruit quality staff Dilemmas when MOH colleagues apply for posted HAI positions Attempt salary equity with MOH (including perks) “The principle of not hiring from the MOH is good but how can you do it? How can you stop people who want to leave?” -- MOH official
- 25. Suggestions and promising practices Visibility of Code Post in lobby, include in orientation Improve public sector opportunities Highlight value in setting policy, broader impact Invest in career path opportunities Second staff to the MOH
- 26. Suggestions and promising practices Build workforce capacity Share good practices in primary care and scaling up interventions “Adopt a medical student” Organize NGOs locally or regionally Form coalition or union Advocacy More aid/funding for pre-service training Example: http://www.theglobalhealthinitiative.org/ Donors should support/fund in line with Code
- 27. Summary Awareness, but few changes to HR policies Commitment to principles, challenges with hiring and compensation items Testing ideas in the field Importance of more pre-service training Some efforts to coordinate amongst NGOs
- 29. Is a voluntary Code a good tool for changing practices?
- 30. Other questions or thoughts?Thank you! Special thanks to Anjali Sakhuja, MPH whose work was presented here
Notes de l'éditeur
- Doubled between 2001 and 2007 alone. With that, proliferation of NGOs and other “private” actors, as well as increased support through bilateral and multilateral channels. Gates Foundation itself was about 4% in 2007.Development assistance for health (DAH)Financial and in-kind contributions from channels of assistance to improve health in low-income and middle-income countries. DAH aims to achieve either country-specific health improvements or to finance health-related global public goods such as research and development, disease surveillance, monitoring and evaluation, and data collection. DAH does not include support for allied fields such as humanitarian assistance, food aid, water and sanitation, education, and poverty alleviation that indirectly affect health. DAH includes loans on concessional terms, which charge below-market interest rates. We distinguish gross DAH, which is the actual outflow of resources in a specific year, from net DAH, which is the gross amount minus repayments for DAH loans in previous years. Results in this Article are for gross DAH only. Research funded by DAH channels of assistance is counted as DAH, whereas health research by other institutions whose primary purpose is not development assistance is not included.
- Why is this a problem? As James has just illustrated, directing aid to NGOs often results in fragmentation of the health system and services, management burden on MOH to track and coordinate what NGOs are doing, brain drain from MOH to NGOs (clinical and management staff), potential inefficient use of resources (many orgs in one area and for one disease, while other parts of country and other diseases are neglected) and undermining/loss of services when direct-service NGOs pull out of a region.
- Factors: Macroeconomic/lending policies that limit how much govts can invest in health and education, tied aid and other aid restrictions, Western/U.S. preference for private sector, and in-country conditions – limited number of health workers being produced, etc.A few reasons to focus on NGOs:We are an NGO, and this is our sphere of influence. NGOs aren’t the only players, but they are significant – 25-40K international NGOs. If a critical mass of NGOs were to change the way they worked, that could be an impetus for change in funding and other higher-level policies and practices.Start a conversation about it.
- Code of Good Practice for NGOs Responding to HIV/AIDSCode of Conduct for the International Red Cross and Red Crescent Movement and Non-Governmental Organizations (NGOs) in Disaster ReliefPrinciples of Accountability for International Philanthropy - The Council on Foundations and the European Foundation Centre (EFC) created a Joint Working Group to develop a set of principles (integrity, understanding, respect, responsiveness, fairness, cooperation and collaboration and effectiveness) and good practice options of accountability for international philanthropy. They address accountability to mission, grantees, and partners and, ultimately, to the intended beneficiaries of transnational philanthropic activity.Code of Ethics and Conduct for NGOs - It includes issues such as human rights, transparency and accountability, good governance, human resources and public trust, among others.Definition of code of conduct:"Principles, values, standards, or rules of behavior that guide the decisions, procedures and systems of an organization in a way that (a) contributes to the welfare of its key stakeholders, and (b) respects the rights of all constituents affected by its operations.“ -- the International Federation of Accountants, Defining and Developing an Effective Code of Conduct for OrganizationsOne World Trust: database of self-regulatory initiatives, from codes of practice/conduct, to certification schemes, self-assessments, reporting frameworks, working groups, and information services/directories.Initiatives can be principles or standards based. Codes of ethics/conduct/practice tend to be principles-based, while standards-based ones have specific guidelines or rules to be adopted. Codes can including a compliance or monitoring component, or not.
- And resolutions:World Health Assembly (2004)World Federation of Public Health Associations (2005)American Public Health Association (2006)
- Started as a discussion at the APHA conference, around aid effectiveness, and sparked a discussion of how NGOs can better support the public sector
- First 3 articles: HR related4th – management burden, planning and coordination5th – engagement with communities; accountability and transparency6th - advocacy
- 1 Hiring:Avoid hiring from MOH and also avoid hiring expats (you can imagine tension there). Also, where there are qualified nationals, volunteer labor should not substitute for paid staff.Coordinate with MOH if there is a need to hire from the MOHAvoid where possible creating incentives for workers to migrate away / brain drainNOTE: we have to acknowledge the right of people to migrate and take up opportunities for themselves and their families. This is not contrary, rather saying we should all be focusing on improving the situations at home and in the public sector that “push” people to migrate, as well as being conscious of and limiting the “pull” factors.2 Compensation:Limit disparities btwn expat and national, rural and urban, ministry and NGO. Although incentives for rural work are encouraged.Offer salaries that are “locally competitive” and “not substantially more generous than the public sector while providing a fair and living wage to their employees.”Avoid top-upsEstablish benefits structures that meet the needs of employees, and attempt to match public sector practices, including retirement plans. Where public sector benefits are inadequate, NGOs will collaborate with the public sector to improve them.3 Training and support:Pre-service, rather than just short, one-off in-service trainingsIncrease the number and capacity of health professionals over timeBuild capacity in both service and management areas – goal is to transfer skills
- 45 signatories today
- Contacted via email and phone. Of the 39 signatories as of Dec 2008, we established contact with 32; the other 7 had invalid contact info or never responded. Six orgs that we contacted did not participate either because they didn’t know who had signed onto the Code or no one could speak about it, refused b/c they had little to share, or the contact was unavailable when Anjali called.The 26 signatories that participated work in diverse work, ranging from direct health care, food security, water, sanitation, housing, policy advocacy. The LNGOs were from Africa (6), followed by Asia (5) and one Latin American (1) country (Mexico – Universidad AutónomaMetropolitana). Different structures: NGOs, networks, consortia.“Other” = prepared health-related documents, and organized conferences; so sort of international but not operating in specific countries?For non-signatories, we targeted 5 orgs that had participated in consultations or discussions, but did not sign. Only 3 participated in the interview.
- Signatories and non-signatories make efforts to avoid hiring from MOHRespondents noted that donors and UN agencies hire personnel away too.Rural posts harder to fill/find qualified staff than urban areas.Some respondents said they would hire from govt when other efforts failed, and project deadlines necessitated filling the position quickly.Some respondents mentioned that they get MOH applicants to open position announcements, and those public-sector job seekers argue that it is not ethical to discriminate against public-sector workers who are looking to grow, learn, and fulfill their career ambitions.