Maverick Citizen

SPOTLIGHT ANALYSIS

Are NGOs doing the work of the state? Should they?

Are NGOs doing the work of the state? Should they?
A Xhora Mouth in the Eastern Cape a resident has to cross the river in flood to get to the nearest clinic. (Photo: Black Star / Spotlight)

People in South Africa are used to reports of organisations like Gift of the Givers stepping in during humanitarian emergencies, or service delivery NGOs helping with HIV or tuberculosis programmes. But is there not a risk of the state becoming overly dependent on NGOs, and might this not mask state failure and thereby undermine democratic accountability?

There are many NGOs working around the country to supplement the work of the state. Take, for example, Touws River, a town in the Central Karoo in the Western Cape, with a high rate of unemployment. Residents recently turned to Gift of the Givers to help with healthcare services.

In another example, in March 2020 the board of the DG Murray Trust (DGMT) convened to discuss the “gathering Covid-19 storm”. It was during these discussions that they asked themselves: who would most likely be at the back of the queue when the storm hit? As always, the answer was the same: the people, residents, including community care workers who provide healthcare and social services in rural areas and townships. Over the following two years the DGMT played an important role in South Africa’s response to Covid-19.

To put it less generously, these and other NGOs are stepping in where the state has failed. 

What to make of it?

Dr Imtiaz Sooliman. (Photo: Deon Ferreira)

Making a difference

As a starting point, one thing is clear: organisations like Gift of the Givers do make a real difference in people’s lives. The organisation sent a multidisciplinary medical team to Touws River after that plea for help from residents battling with poor healthcare services.

The town was once a major railway junction, but after the railways in South Africa collapsed, jobs dried up.

“When we first went there, the soup kitchen had 50 or 60 people. The next time was 300, and then it got to 1,500 people a day,” said Dr Imtiaz Sooliman, founder of Gift of the Givers. “Touws River has one clinic. A nurse and doctor come once in a while. The hospital is far away. There are no ambulances and not enough supplies. The people battle it out with such grace and dignity.”

Sooliman was addressing a packed venue at a recent Gift of the Givers event in Cape Town. While the NGO is known for its work on many fronts – disaster, hunger relief, water provision and education – this event was to report back only on its health interventions in the Western Cape.

“Our team went to the school to hand out stationery and noticed a child crying with toothache. The staff told us hundreds of kids have dental problems,” he said. “So we went back there with 16 healthcare professionals of all disciplines. We pulled out a lot of teeth. The kids weren’t scared. It was easier to take the tooth out than live with the pain.”

Preparing for Covid-19

Referring to the DGMT board’s meeting in March 2020, DGMT CEO David Harrison wrote in his book Harnessing the Thunder: “We quickly decided on national responses that wouldn’t be on other people’s radars.” 

In the book, he chronicles the remarkable role of civil society during the pandemic in South Africa. “We knew we had to get PPE to the community care workers who work at the frontline of healthcare,” he wrote. Harrison estimates there are about 64,000 of these workers around the country.

Dr Imtiaz Sooliman in the Freesia Covid-19 ward which Gift of the Givers renovated at the Mitchells Plain District Hospital. With him is Dr Tatum Aronson, head doctor at the ward, and Evan Swarts, chief executive at the hospital. (Photo: Supplied / Spotlight)

Another group “at the back of the queue”, the DGMT team realised, were people in rural areas and informal settlements who rely on radio for outside information. Within days, says Harrison, the DGMT was coordinating the procurement and distribution of PPE to thousands of community care workers around South Africa. They’d also contacted the communications head of the Health Department with a view to producing nearly 2,000 daily 10-minute radio inserts, in 12 languages, to be broadcast on 65 public and community radio stations to inform the public about the epidemic and tell them how to protect themselves.

Civil society is society’s ‘neuro-electric system’

“I have two lives – my DGMT work and then a nightlife, which is Department of Health work,” Harrison joked when interviewed by Spotlight. A medical doctor and expert on public health policy, he was seconded to the department to coordinate donor support to the national vaccine programme during Covid as well as manage elements of the programme. He also led the demand-acceleration task team, and ran the toll-free hotline at the national Covid contact centre.

“We hired 300 technical support staff around South Africa to assist with the roll-out of the vaccine programme,” he said. “Secondly, we requested 70 NGOs around South Africa to second their comms people into the Health Department to create a stronger bridge between the department and civil society organisations. Thirdly, we directed grant funding to 100 NGOs to help them with petrol and other costs to be able to get people to vaccination sites.

The DG Murray Trust (DGMT) was among many NGOs providing supplementary relief to people during the Covid pandemic. (Photo: Gauteng Health / Spotlight)

“We are currently trying to expand the function of the helpline, to include call centre services around the health of children and mothers related to TB and HIV. We’re also trying to pivot the communications campaign away from Covid to a health focus on young people,” he said.

Behind these interventions is an acute awareness of the unique social contribution that organised civil society can make. In his book, Harrison calls on the government to recognise organised civil society as equals of the government, trade unions and the private sector. 

“Our nation is one body and civil society is its neuro-electric system that can sense and signal changes in every cell. Without it, the government becomes less and less responsive to need, and communities more and more alienated. The whole body suffers.”

Social contract

On the role of NGOs in South Africa, Harrison was unequivocal about the need for an “effective social contract” between the government, civil society, the private sector and unions which “should recognise (and clearly define)” their respective roles and how they can work in synergy. 

“It should recognise them as having discrete, synergistic roles – but ensure that there are systems of financing and support and efficient collaboration across the sectors. Until we do that, we’ll have a big risk because the government will simply increasingly lean on the creaking infrastructure of civil society – and it’s creaking because it is hugely underfunded.

It is crucial that the non-profit sector is explicitly recognised, [or] else we’ll be in a situation where the market steps in to address the failings or to fill the space left by a failing state.

“When the Solidarity Fund was set up, President [Cyril] Ramaphosa had to find partners. He immediately went to the private sector to set up a new foundation, not to the existing foundations of civil society… but the Solidarity Fund quickly found it didn’t have the mechanisms for channels into these communities. It needed to rely on this incredibly rich network of civil society organisations.

“Next time, let’s prepare properly by ensuring we have the mechanisms; that we’ve got the institutional arrangements in place. That can only happen if the government gives due regard to civil society.”

‘Innovative partnerships’

“We have to move away from the idea that the government is necessarily both the financer and the provider of basic services in South Africa,” Harrison says. 

“There’s plenty of evidence that that system won’t work in the next 20 years. Government must be held to its constitutional mandate to ensure the provision of nutrition, health, education and other basic rights, but it has to start entering into far more structured and innovative partnerships with civil society players because the government has limited technical capacity and limited expertise. It doesn’t all reside with the government and we have to harness that capacity wherever it is.

“It is crucial,” says Harrison, “that the non-profit sector is explicitly recognised, [or] else we’ll be in a situation where the market steps in to address the failings or to fill the space left by a failing state. The consequence of that is that market forces and ability to pay will increasingly determine people’s access to basic services. 

“Until we understand and respect the role of civil society as a non-profit force in our society we will end up with this bipolar tussle between government and its failings and the market that is primed to take over in spaces where government fails to deliver, like Eskom.”

‘We can’t wait for government’

While a clear social contract and innovative partnerships are certainly worth considering, everything in this sphere is set against a backdrop of people needing help right now. As Sooliman told his audience in Cape Town: “People call me because they’ve lost hope. We can’t wait for the government. It’s us who have to make the change.”

On whether the state might become too dependent on NGOs, and whether the work of NGOs could mask state failure, Sooliman said in an interview: “It’s a fact that the state cannot manage delivering on health, or any other services, on its own. The budget is inadequate – there are only 7.4 million taxpayers. To be fair to the government, they do need partners. They, of course, have to be careful and frugal with their money. They can’t be allowing corruption to continue; they can’t give tenders that are way out of price. Everything should be within a system, conducted like a business to get the best value.

Read more in Daily Maverick: NGOs can’t tell stories as agents for change while fighting for a shrinking funding pool

“We’ve seen encouraging responses from the government where they want to improve systems,” said Sooliman. “When we put something down, they put something down from their side where it’s possible. So we keep supporting them in a positive, diplomatic manner. I’m sure in time we will get a corresponding response from them in a manner that is practical and beneficial for the country.”

Sooliman argued that, contrary to masking state failures, NGOs highlight them. 

“The public and the media are constantly asking why the government can’t do what NGOs are doing. They say, ‘the government collects taxes; NGOs don’t collect taxes. How come NGOs are more effective in getting things done?’ That puts pressure on the government and especially with the election coming on next year, they are more conscious about doing things right. The more the NGOs do, the more the media writes, and the more the citizens question, the more the government knows they cannot escape from their responsibility,” he said. “We have to do that collectively, all the time – to make them accountable. They need to know the country is watching.”

Partnership role

At times, the relationship between the government and NGOs can become fractious. For example, in 2018, Spotlight reported on the highly contentious closure of a successful NGO-run project in Limpopo. As in this case in the Free State, some feared a deterioration in services after the withdrawal of NGOs.

On the other hand, there are also remarkable examples of successful NGO projects working very well with the government. One of them, in the small, rural Nqileni village in the Eastern Cape, is the not-for-profit Bulungula Incubator.

Read more in Daily Maverick: Learning mission: The Bulungula Incubator ‘turns the light on’ in children’s eyes

When the founders arrived in 2004, there was no road, proper healthcare, schools, electricity or access to drinking water and sanitation. Today, Bulungula’s interventions span the spectrum of “cradle to career”, focusing on education, health and nutrition, sustainable livelihoods and vibrant villages. Their work informs government and corporate policy.

Bulungula Incubator director Réjane Woodroffe explained how the community health workers they trained constantly monitor the health of the community, because “not everyone can make it to a clinic”.

The Bulungula Health Point is often a saving grace for those in need of medicine in Xhora Mouth. (Photo: Black Star / Spotlight)

The Nomakhayas’ systematic cleaning programme proved to be the most successful intervention to halt the cycle of reinfection of scabies in the villages. (Photo: Bulungula Incubator / Spotlight)

These community workers check into the Bulungula Health Point, which is linked to the local clinic. “We started this system and the Department of Health helps us.”

The health point provides primary healthcare, including immunisations, ART and chronic medication refills using Central Chronic Medicines Dispensing and Distribution, as well as acute consultations and Covid-19 vaccinations.

“A few years ago, we had a big scabies epidemic… and the home-based carers went from door to door, helping households take everything out of the house, boil the clothes, etc. They solved the problem. We couldn’t have done that without these carers,” Woodroffe said. “We also wrote a manual for home-based healthcare workers on how to support people with disabilities, which didn’t exist before.”

Woodroffe said their strategy is clear. “[We] try to not crowd out, or do the work of government. The way we see it is there’s a role for NGOs and civil society to partner with government. People need education and healthcare today, not in the 10 years it takes government. The way we see our role is… we raise money through the private sector, then we train locals on how to provide that service and set it up. There’s a partnership role that civil society and NGOs should play, which is supporting government systems in various ways and providing a service with a clear view to how you spin it out of the NGO once it is set up, to provide excellent service. It should get to a point where it can be integrated into government systems and funded by government. It’s about strengthening processes for long-term sustainability.”

According to Woodroffe, they have a very good partnership with the Department of Health. “They partly fund the running costs of our programme and are also testing different models and systems that can work. The role of NGOs and [community-based organisations] will continue into the future. They keep the government service centres accountable to communities,” she said. DM/MC

This article was published by Spotlight – health journalism in the public interest.

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