Global Policy Forum

Another Role for an NGO:


Yves BEIGBEDER, Senior Fellow, UNITAR, Geneva

Transnational Associations

Most international NGOs associated with the operational activities of UN and other intergovernmental organizations (IGOs), and a number of national NGOs, are subsidized by governments and intergovernmental organizations, to varying degrees to carry out work on their behalf.

As noted by Gordenker and Weiss , "In 1994 over 10% of public development aid ($8 billion) was channelled through NGOs, surpassing the volume of the combined UN system ($6 billion) without the Washington-based financial institutions. About 25% of US assistance is channelled through NGOs ..."

For example, UNHCR establishes contractual relationships with NGOs: some contracts provide for full financing by the agency. All OECD countries have "cofinancing" agreements, under which the OECD government subsidizes, from 50 to 100%, of the costs of an approved NGO-run project, or allocates a yearly subsidy to one or several NGOs. Cofinancing is also practiced by the European Union: the Union cofinances aid and development projects in developing countries undertaken by NGOs jointly with local partners under certain conditions. The major part of the budget of the International Committee of the Red Cross is paid by the Swiss Government.

In a role reversal, Rotary International has appropriated in 1988 $5,331,000 from its PolioPlus fund to the WHO Programme of Eradication of Poliomyelitis. Its PolioPlus programme, initiated in 1985, has allocated $223 million in grants to national polio immunization and eradication programmes in 111 countries.

While this is not a unique example of an NGO financing, in part, an IGO programme, this paper will focus on this particular WHO Programme and Rotary's contribution to it.

1. WHO's relations with NGOs

On similar lines to Art. 71 of the UN Charter, the WHO Constitution (Art. 71) authorizes the Organization to "make suitable arrangements for consultation and cooperation with non-governmental organizations and, with the consent of the Government concerned, with national organizations, governmental or non-governmental". The Organization's early interest in this collaboration was shown by the vote of a resolution by the First World Health Assembly in 1948 defining the "Working Principles Governing the Admission of Non-Governmental Organizations into Official Relations with WHO". Its latest revision was approved in 1987.

In order to be admitted into official relations with WHO, the area of competence of the NGO should fall within the purview of WHO and centre on development work in health or health-related fields. The applicant NGO must be international in its structure and/or scope, and free from concerns which are primarily of a commercial or profit-making nature.

The applicant NGOs will have to be "loyalist": they must declare their allegiance to the spirit, purposes and principles of the WHO Constitution and promote the policies, strategies and programmes derived from the decisions of the Organization's governing bodies, and in particular the "Health for all" strategies.

In contrast with the three UN categories for NGOs (I, II and Roster), WHO recognizes only one category of formal relations, known as "official relations". However, first contacts with an NGO frequently take the informal form of exchanges of information and reciprocal participation in technical meetings. When specific joint activities have been identified, collaboration may be taken a stage further by proceeding to a period (usually two years) of working relations entered into by an exchange of letters. An NGO may then apply for admission into official relations with WHO by submitting a structured plan for collaborative activities for a three-year period, agreed upon by the NGO and WHO. The admission decision is taken by the WHO Executive Board, whose Standing Committee on NGOs will review collaboration every three years.

The privileges conferred on NGOs by their relationship with WHO are the following:

(i) the right to appoint a representative to participate, without right of vote, in WHO's meetings and committees, with the right to make a statement at the invitation or with the permission of the meeting chairman;

(ii) access to non-confidential information;

(iii) the right to submit a memorandum to the Director-General, who will determine the nature and scope of the circulation of this document.

As of April 1996, there were 181 NGOs in official relations with WHO. They represent emergency and humanitarian relief organizations, trade and consumer associations, parliamentary and professional medical societies, association of women, young people, the elderly, occupational health specialists and research organizations etc. They cooperate, for example, in emergency relief operations, in training of personnel, workshops on blood safety and epidemiology, as well as education programmes for young surgeons and midwives. Other activities include exchanges on bioethical issues and developments in medical law, the application of the results of research on such subjects as nutrition, human reproduction and the prevention and treatment of accidents. Some monitor the implementation of the International Code of Marketing of Breast-milk Substitutes, after taking an active partisan part in the debates and controversies surrounding the adoption of the Code. They may thus mobilize public support in support of WHO policies and programmes, apply pressure on WHO and governments in promoting their associations' interests, as well as provide operational assistance to WHO activities, expert advice, supervision of the implementation of norms and training. They represent the concerns and interests of their constituencies. Their advocacy role should apply to WHO's own objectives and programmes, but it also applies to their organization's own objectives.

The importance of WHO's collaboration with NGOs was underscored by the former Director of the WHO Global Programme on AIDS, Dr. Jonathan Mann, in 1989: "There is an increasing recognition of the power and importance of community-based organizations. These community organizations have often been pioneers, leading the way for more timid or reluctant governments ... In AIDS programmes, there is a direct relationship between the strength, diversity and involvement of community-based and non-governmental organizations and the level of success which can be achieved"

The collaboration achieved by this programme has expanded to other WHO programmes, including the Eradication of Poliomyelitis Programme.

2. The WHO Poliomyelitis Eradication Programme

WHO created its Expanded Programme on Immunization (EPI) in 1974, to immunize the children of the world against diphtheria, measles, poliomyelitis, tetanus, tuberculosis, and whooping cough. EPI's objective was to reduce childhood morbidity and mortality through immunization, and by making the best vaccines available and using them in the most effective manner.

In 1974, coverage for children under one year of age in developing countries was well below five per cent. In 1987, for the first time in history, coverage exceeded 50 % for all vaccines except measles (at 46%). Still, in the same year, in the developing world, some 230,000 children contracted polio.

In 1985, the Pan American Health Organization (PAHO) passed a regional resolution to eradicate polio from the Americas by 1990. By 1991, the last clinical case of polio was reported from the region, and the Americas were certified polio-free in 1994. Thus PAHO served as a regional pioneer for global polio eradication by identifying and implementing effective strategies, and by mobilizing Member States and a coalition of donors.

In 1988, the World Health Assembly established the goal of eradicating polio by the year 2000. This goal was also endorsed in 1990 by the World Summit for Children, attended by leaders of more than 150 countries, UN agencies and NGOs.

In 1990, over 70% of the world's children under one year of age were covered by immunisation against vaccine-preventable diseases. Immunization reached 74% for a third dose of polio vaccine for children under one year of age. It was estimated that over 480 000 cases of polio were being prevented each year with current levels of coverage of polio vaccine.

In 1992, progress toward the eradication goal was significant. Areas with a zero or low incidence of polio now included countries in Northern and Southern Africa and the Arabian Gulf. No polio cases were reported from the Western Hemisphere, and no endemic areas were identified in Western Europe. Globally, however, the progressive decline in incidence from 1988 to 1991 did not continue in 1992, when reported incidence increased by 6% over the previous year. The source of the problem appeared to be in the South-East Asian Region where incidence increased by 40%, although improved surveillance and better reporting may have contributed to the increase; the other five WHO regions reported declines in 1992.

In 1993, the number of reported polio cases fell below 10 000 for the first time and 143 countries were reporting zero cases of polio. Six emerging polio free zones had been identified: the Americas, where eradication was certified in September 1994; Western and Central Europe; North Africa; the Middle East and the Arabian Peninsula; and the Western Pacific. Significant progress was achieved in China where more than 80 million children were immunized in the first National Immunization Day in the winter of 1993-1994. As a result, only 149 cases of Acute Flaccid Paralysis were reported from China for 1994 of which only one was laboratory confirmed.

The priorities for 1995 were: achieving eradication in the Western Pacific region in 1995; activating polio eradication strategies in the countries of the Indian subcontinent, which accounts for two thirds of the world's polio cases; coordinated, multinational National Immunization Days in contiguous countries of Central Asia, the Caucasus and the Middle East; and advocacy to improve political commitment and raise funds

3. WHO Strategies for Polio Eradication

Polio will be considered to have been eradicated when the transmission of wild poliovirus has been interrupted and no wild virus can be found, despite intensive efforts to do so. The virus can be imported and may spread. Polio can be certified as eradicated only when no cases have been reported worldwide for three years.

The strategies recommended by WHO include the following:

- routine immunization, with high levels of coverage in all countries.
- National Immunization Days in all polio endemic countries for a period of several years.
- intensive surveillance for acute flaccid paralysis using a global network of certified virology laboratories.
- mopping-up immunization in the final, localized reservoirs of wild poliovirus transmission.

According to WHO specialists, polio eradication is feasible because there is no natural animal reservoir or long term carrier state of poliovirus, and the virus cannot easily persist in tropical environments. In addition, there is an effective, low cost, oral polio vaccine that provides intestinal and humoral immunity, and can interrupt circulation of the virus. There are however two factors that make polio eradication challenging. First, there is a high inapparent infection rate: less than 1% of poliovirus infections result in paralysis. Secondly, this paralysis may be clinically indistinguishable from other infections. These factors make laboratory confirmation by virus isolation necessary for definitive diagnosis of polio.

Other obstacles include: shortage of funds for vaccine, laboratories, logistics and personnel; and, in some countries, insufficient political commitment, falling immunization coverage and the damaging effect of political unrest or civil war.

WHO asserts that the long term benefits of polio eradication far outweigh the short term costs. When the goal is achieved, no child will be paralyzed or killed by the crippling and painful disease. Another benefit is the reinforcement of health care delivery. The programme strengthens primary health care by expanding immunization and other preventive services, increasing public awareness of health services available, providing health education, better control of other diseases of public health importance and improving disease surveillance. The global laboratory network established by WHO to undertake the task of poliovirus surveillance can be used for other important diseases. The mass campaign provides an opportunity to provide other vaccines and micro-nutrients.

The principal donors to the EPI in the period 1988-1994 were the governments of Denmark, Netherlands, USA, Australia, Japan, Norway, Finland, Sweden, UK, Canada, United Arab Emirates, China, Italy, Malaysia and Austria, UNDP and UNICEF. Among the foundations, Rotary International provided the same amount in financial contributions as the US government, while the Rockefeller Foundation's contribution almost equalled that of Sweden.

Recognizing the remaining challenge, six global public health agencies and NGOs active in child immunization have recently joined together to form the Polio Eradication Network (PEN). It is composed of WHO, UNICEF, the Pan American Health Organization, the US Centers for Disease Control and Prevention (CDC), the Task Force for Child Survival and Development, and Rotary International.

WHO provides the global technical leadership. UNICEF is the major provider of vaccines and immunization equipment: it purchases the oral polio vaccine for Rotary's PolioPlus. UNICEF advocates globally for the programme, plays a key role in social mobilization, and provides operational support in countries. CDC, a US government agency, provides technical, laboratory and programmatic assistance, as well as funds.

Rotary International began its PolioPlus programme in 1985. By 1995, out of a fund of $248 million, the Rotary Foundation had allocated $223 million in PolioPlus grants to immunization and eradication efforts in 111 countries.

4. What is Rotary International

The first Rotary Club was created in Chicago on 23 February 1905. In 1995, Rotary International is a service club organization of close to 1,2 million business and professional men and women, associating more than 27,000 Rotary Clubs in 154 countries. Its budget for 1995-1996 is $93.7 million, of which $31.3 million is allocated for PolioPlus.

The organization is a non-political and non-sectarian international NGO. Rotarians give service on a voluntary basis. Each club determines its own service activities. Currently, Rotary International encourages clubs to focus community activities on fighting hunger, environmental concerns, illiteracy, drug abuse prevention, helping youth and the elderly, and childhood immunization.

One of its four "objects" or goals is "the advancement of international understanding, goodwill and peace through a world fellowship of business and professional persons united in the ideal of service". One of its four "avenues of service" concerns international service: "helping to fulfill educational and humanitarian needs beyond the boundaries of their own countries, usually by participating in the many international programs of Rotary International and the Rotary Foundation".

The Rotary Foundation provides humanitarian awards and grants in conjunction with Rotary club and district international service activities. It is supported by voluntary contributions from Rotarians and friends of Rotary. All grants from the Foundation are international in nature: at least two different Rotary clubs or districts from different countries must participate in all Foundation endeavours. Total contributions for 1994-1995 were $61.7 million. In the 1993 ranking of the top US-based charitable organizations, the Rotary Foundation ranked as the 6th lowest in administrative costs as a percentage of total revenue.

6. Rotary's PolioPlus

Rotary International's involvement in polio eradication began modestly with support to the Philippines national immunization program, 1979-1980. The first project under the Rotary Foundation's new Health, Hunger and Humanity program was the provision of polio vaccine to some six million children in that country.

Following consultations with such experts as Dr. Albert Sabin, and officials at the Pan American Health Organization, WHO and UNICEF, Rotary's support evolved.

Since its early days, Rotary had worked to improve the quality of life for people with disabilities. It was the catalyst for the formation of national organizations for crippled children first in the US, then in numerous other countries . It was a natural extension of that tradition for Rotary to work to prevent disability by creating a world free of polio. It was also clear that this vision could not be endorsed without the political and technical endorsement of WHO, and without the collaboration of WHO and UNICEF.

In January 1985, Rotary was granted provisional consultative status with WHO. In February, the PolioPlus Program was announced. Beginning with a commitment to raise $120 million to help control polio, Rotarians raised the bulk of funds, $248 million, in a 1986-1988 fund-raising campaign. Contributions came from Rotarians, other individuals, firms, foundations and government grants.

The programme mobilized tens of thousands of volunteers to assist in massive immunization campaigns around the world. For instance, prior to the eradication of polio in the Americas, Rotarians in Peru served as home visitors, vaccinators, drivers, meal preparers, data analysts and publicists. Rotarians also secured some $440,000 worth in advertising, transportation, supplies, posters and print and broadcast messages for national immunization days. This included mobilizing 11,000 volunteers, 1,000 vehicles, generating mass media support and visiting 10,000 vaccination posts. In Chile, Rotarians printed and distributed 60,000 promotional posters, 2 million stickers with vaccination schedules and 1,500 manuals. They donated cold-chain equipment totalling $150,000 including 1,250 thermoses, 3,000 thermometers, 115 refrigerators, 19 freezers and 100 boxes of vaccine with ice packs.

Rotary claims that, to a large extent, the creation of PolioPlus was the catalyst for the World Health Assembly adoption of the goal of global polio eradication by the year 2000.

In November 1988, at WHO's request, the trustees of the Rotary Foundation agreed to provide funding for the immediate recruitment of six core professional staff for the period 1989-1994 who would help countries to develop and strengthen those technical capacities which would be required to achieve the eradication goal. Such personnel could provide more guidance to Rotarians in various countries on how they could focus their efforts and those of the rest of the private sector in the most effective ways. $5,331,000 was appropriated from the PolioPlus fund for this purpose.

In June 1991, a WHO meeting examined the possibilities for practical improvements in the oral polio vaccine. The meeting concluded that the best alternative was to increase the vaccine's heat stability, specifically to produce a vaccine which would maintain its potency for one week in temperatures of 45 degrees Celsius. It was anticipated that the laboratory research phase of this project would cost approximately $450,000. $200,000 were invested by the US government. In October 1991, the Rotary trustees made a PolioPlus grant of $250,000 for a one-year collaborative research project to produce a thermostable oral polio vaccine.

Rotary has met its original PolioPlus goal of providing the vaccine necessary for up to five consecutive years to any developing country requesting such assistance. Nearly 100 countries received such assistance. Funds currently allocated by the trustees will provide at least three doses of oral polio vaccine to some 500 million infants. Rotary resources will be focused in three main areas: limited vaccine grants, surveillance and advocacy for polio eradication.

7. An assessment

Rotary's collaboration with WHO and other IGOs and NGOs in the WHO Poliomyelitis Eradication Programme is not limited to its direct, limited financial support to WHO. Its main contribution is the support of this influential NGO to a global programme and its capacity to mobilize funds and volunteers in many countries. In view of the limited and shrinking resources of WHO and other UN organizations, and governments' fatigue, the resources provided by NGOs and by the private sector are more than welcome: they are necessary.

This voluntary and generous assistance provided by a US-based NGO to a UN agency contrasts with the US Congress' continued delinquency in withholding payments of the US statutory contributions to the regular budgets of UN organizations. Rotary's financial and other support to a UN agency programme also contrasts with the generally negative assessment of US media of UN organizations' programmes and performance.

For WHO, the interest of the additional financial contribution is obvious. Although a relatively new development for the Organization, there is little risk that this contribution by a US-based NGO may be criticized by Member States as "politicized", in view of the general attitude of the US.

For Rotary, this campaign associates the NGO to a broad international effort of a humanitarian character. The campaign has a solid technical base, a well-defined strategy, a precise and reachable objective and a well-argued economic rationale, on lines similar to the successful smallpox eradication campaign. The illness is of global interest, as the populations of North and South countries are at risk. Rotary's contribution to the campaign is not only a "good deed" but also a public relations effort enhancing its public national and international image. Rotary benefits from its cooperation with WHO by the technical approval given to its polio eradication programme and, more generally, by the international legitimacy bestowed by the UN agency to the US Foundation.

In compensation for its contribution under its PolioPlus programme, Rotary demands public recognition from the governments concerned. In 1995, the Trustees agreed "that all PolioPlus grants shall be conditioned on an acceptable plan of government acknowledgement and public recognition to Rotary and no funds shall be released until a specific, detailed plan for government acknowledgement and public recognition of The Rotary Foundation of Rotary International as the donor of the grant is received and determined by the Chairman of the Trustees to be acceptable".

8. Other financial contributions by NGOs

The following foundations contributed to the WHO Voluntary Fund for Health Promotion, created in 1960, for the period from 1960 up to 31 December 1993:

- Carnegie Corporation on New York $ 3,630,900
- Damien Foundation, Belgium $ 2,353,331
- Edna McConnell Clark Foundation $ 2,242,500
- Ford Foundation $ 1,107,500
- John D. and Catherine T. Macarthur Foundation $ 5,920,000
- Rockefeller Foundation $11,316,217

NGOs contributed a total of $29.3 million for UNICEF-assisted programmes in 1994, of which Rotary International provided about one third. Other important financial contributors included NGO groups in Argentina, Brazil and Mexico, as well as the Bernard Van Leer Foundation, Kiwanis International and Redd Barna (Norwegian Save the Children).

9. Under what conditions ? What are the limits ?

WHO may accept financial contributions from NGOs under the same conditions which apply to the admission of NGOs into official relations with the Organization: allegiance to WHO's objectives and policies, acceptance of its role as "directing and coordinating authority" in international public health work, acceptance of its technical guidance and assessment. The NGO should have an international scope, a public health orientation and non-profit making activities.

While this is not specified in the WHO "Principles", it would be advisable that the NGO had a "neutral" profile in national and/or international politics, and an internationally-recognized humanitarian experience and prestige. WHO should reject offers of funds from organizations whose resources have attracted controversial and negative reports.

NGOs' financial contributions to IGOs could be the small beginning of a much needed "third resource" for UN organizations, besides the statutory and voluntary contributions of Member States. However, this would be essentially a symbolical contribution, rather than a significant one, to most IGOs budgets: WHO's regular budget for 1996-1997 amounts to more than $922 million.

The Director-General of WHO, Dr. H. Nakajima, has recently recognized the need for the Organization to diversify its alliances: "WHO must open itself up to all sectors of society, including nongovernmental organizations and the private sector. These new partners will bring new challenges, but by meeting them we can enhance significantly our ability to mobilize social, political and therefore financial support for health development and international health cooperation."

The main benefit of NGOs' involvement in WHO programmes is the participation of the ultimate clients of IGOs, the people, through their associations: a welcome involvement of the "civil society" into international humanitarian cooperation and assistance.

(*) This paper was first presented at the Ninth Annual Meeting of the Academic Council of the United Nations System, held in Turin, 24-26 June 1996.

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