NGOs play an important role in helping provide antiretroviral therapy (ART) in South Africa where government services are limited. While NGOs are accountable to their donors for financial and service targets, their accountability to the communities they serve is less clear. The document examines different types of NGOs providing ART and finds gaps in how they define and engage with local constituents. It calls for NGOs to clarify who they are truly accountable to in order to better serve community needs.

1. NGOs,
Antiretroviral therapy (ART)
and Accountability
in South Africa
EU-funded GHI INCO-DEV Project School of Public Health
Annie Neo Parsons University of the Western Cape
Dr Johann Cailhol
Dr Thuba Mathole
Prof David Sanders

2. ART in South Africa
• Government ART service delivery problems: financing, human
resources, access
• Service delivery NGOs help provide cover where government
struggles
– Service delivery role (or ‘Operational’): provides tangible and in-
tangible services
– Advocacy role: “create and maintain political spaces in democratic
discourse for often disadvantaged [communities].”
• “NGOs are formally accountable to limited constitutents”
– Who are an NGO’s constituents?
– Does an NGO have clients or constituents?
Doyle C. and Patel P. (2008) ‘Civil society organizations and global health initiatives: problems of legitimacy’ in Soc Sci Med
66:1928-1938
Evans B. and Shields J. (2006) Neoliberal restructuring and the Third Sector: Reshaping Governance, Civil Society and Local
Relations. Centre for Voluntary Sector Studies Working Paper Series: Ryerson University Faculty of Business
Kilby P. (2004) Accountability for Empowerment: Dilemmas facing non-governmental organizations. Asia Pacific School of
Economics and Government Discussion Papers: The Australian National University

3. ART funding and GHIs
GFATM Board
•Donor governments
•Developing country governments
•Civil and private sector U.S. Government
•Non-voting members
Global Fund to U.S. President’s
fight AIDS, TB Emergency Plan
and Malaria For AIDS Relief
Service
Country recipient delivery
NGOs
Community-level ART services

4. Preliminary taxonomy
• Local level findings (facility, district) and relation
to provincial/national structures
• Three basic types of NGOs providing ART services in
public health facilities
– HR-focused (trainings; clinicians, data capturers, CHWs)
• Defining issues:
– External resources (in SA, almost all PEPFAR)
– Community involvement
– Management locality
Ossewaarde R., Nijhof A., Heyse L. (2008) ‘Dynamics of NGO legitimacy: How organizing betrays core missions of INGOs’ in
Public Admin. Dev. 28:42-53

5. Large NGO working locally
• History
– Shift of services to HIV-centred work
– Directly approached facility to offer services, sometimes
after going through province/national
• Funding
– External resources (mostly PEPFAR)
• Operations
– NGO clinical staff provide ART services
– Management based at provincial not local level

6. “Large NGO acting small”
• History
– Shift of services to HIV-centred work
– Approached district, consultation with province
• Funding
– External resources (mostly PEPFAR)
• Operations
– ART services provided by NGO staff
– Management based at local level (near district offices)
Kilby P. (2004) Accountability for Empowerment: Dilemmas facing non-governmental organizations. Asia Pacific School of
Economics and Government Discussion Papers: The Australian National University

7. Local NGO
• History
– Community developed and managed
• Funding
– External resources (mostly small private funders)
• Often aware of funding implications
– In one case, refused direct PEPFAR funding
• Operations
– ART services provided by volunteer staff
– Management based at community level

8. An accountability gap
• “There’s a big difference between spending money
on a community and working with a community”
• Accountability to constituents not required of NGOs
– People cannot automatically hold an NGO to account,
especially when they have limited alternatives to the
offered service
• However, accountability to stakeholders is required
– Donor accountability usually financial/target-driven
– Impacts on ability to be accountable ‘downwards’
Lief W. (2006) ‘Accountability in International Development Aid’ Ethics and International Affairs 20:1-24

9. To Conclude
• NGOs should clarify if they work for or with
communities
• NGOs must clearly state who are their constituents
– What is “the community”? (People within a geographic
area, patients attending a facility, etc)
– Is local government a proxy for communities?
– Are Community Health Workers proxies for communities?
• Ultimately: do NGOs determine a community’s
needs, or do a community’s needs determine an
NGO’s work?