The Changing Role of Civil Society Organizations in International Health Cooperation and Global Health

The president of MMS, René Stäheli, welcomed the audience by contextualizing the year that MMS was established by reminding the audience of the many globally influential events MMS’s founding year, 1973, contained: Richard Nixon was still US president, the oil crisis or oil shock targeting countries, who had supported Israel during the Yom Kippur war was in full swing at the end of 1973, Pinochet had coup d’état-ed his way into power in Chile, to name just these few. Before proceeding to the first part of the symposium entitled “Are we ready for decolonization?”, a trilingual video message in Italian, German, and French by Federal Councillor Ignazio Cassis officially opened the symposium.

Are we ready for decolonization?

Who produces what knowledge and how, was the main question Sulakshana Nandi of WHO Europe reflected upon in her speech. This question was supported by others: What knowledge informs our decisions? Who gathers it and how? Who do NGOs from the global North support why and how? The experiences globally active NGO workers highlight and use in their work are those experiences that guide how health programs are conceptualized and, ultimately, who will benefit from them on the ground. The point Nandi stressed was that anytime a global organization becomes active, thorough research of the space, where work will be conducted, is needed. Understanding the social organization of a society, the hierarchies, how communication functions, or the role and power of elites, is crucial to sustainable work and cooperation, she concluded.

Next, J. Carolyn Gomes, Vice Chair of the Global Fund, took up this thought in her speech, questioning the role civil society has or should have in working towards a more equal world. Because one prerequisite for health for all is a just, inclusive, equitable society. How can we know, Gomes asked, sitting in our silos, ruminating? This last sentence can be emphasized on the can or the know. Gomes stressed the interconnectivity of racism, white supremacy, and the colonial remnant in global health. This does not only perpetuate the inferior status of the people, but also penetrates our organizations and the work we do. Colonial structures in aid-giving pervade how funding institutions distribute grants. So, we need to be able to answer questions such as who represents whom? Who do we listen to? Who and what do we need to challenge? We must ask ourselves hard questions and we need to look at the unconscious biases, which still exist in ourselves and in our organizations. We need a paradigm shift in global health that no longer questions that developing countries can solve their own health problems.

International aid is indeed a complex undertaking. This was highlighted by a comment from the audience, calling for a reorientation of funding structures to prioritize (long term) movements instead of (terminal) projects. An understanding of local politics, civil society, and social organization is imperative for equitable partnerships to function, be this locally or among partners in international collaborations. The presentation by Medicus Mundi International representatives Labila Sumayah Musoke and Thomas Schwarz introduced a report based on their joint mandate from MMS titled “Swiss NGOs engaged in international health cooperation: How to respond to the call for decolonization?”. The report summarizes the votes of network members on how they have taken up the call for decolonization and what can be done to push this process much further. Key areas where action is needed as identified by Network members include concrete steps in the fields of communication, programme management, financing modalities, and the overall setup of partnerships and collaborations. The report concludes with the question: “What next steps to be done as a Network?” and most important “Walk the talk” and “Act locally”.

Keeping the big picture in mind seems to be an obvious prerequisite for NGOs work, but is not always lived up to by their representatives on-site. Maybe it is a question of not being able to see the forest for the trees. Classism within countries and/or internal corruption of elites is not a topic willingly spoken about or investigated in detail by international organizations when decisions about aid are made. These reflections were continued in the panel discussion closing the first part of the symposium. Here, professionals from three different Swiss NGOs came together. The discussants dealt with the question “Are we ready for decolonization?”; the “we” refers both to those bringing or giving aid – the NGOs – and to those receiving it. Here, Axelle Kabou’s book Et si l’Afrique refusait le développement?, published in 1991, on how Africa could refuse development as defined by the global North, animated the discussion. In her text, debated across disciplines then as well as now, the Cameroonian economist and development specialist criticized foreign aid concepts. But Kabou also took African elites to account for relying on this aid instead of deciding themselves what kind of “development” their countries were supposed to work towards.

Insights into the Process of Decolonization by MMS Members

During the half-hour coffee break that followed, colleagues took the opportunity for mellow networking and reactivating old connections. With renewed energy the audience as well as the speakers were ready to delve into the second part of the symposium, dedicated to insights into the process of decolonization by MMS members. This second part started with a joint talk on decolonization processes by Terre des hommes Switzerland’s (tdh CH) representatives Hafid Derbal, working from Basel, and his colleague Tayson Mudarikiri, based in Harare, tdh co-program coordinators for Zimbabwe, Mozambique, and South Africa. The main question they put to the audience was: How can we be drivers of change? Thinking about this, NGO workers need to keep their position within the organization in mind. Derbal and Mudarikiri offered several possibilities to work towards more equitable collaborations, their own co-running of a program being the best example. One important prerequisite, they suggested, is that programs be implemented by local partners, while Swiss partners help with fundraising. This ideally results in co-lead programs such as theirs. Knowledge Hubs in the partner country in the global South are responsible for the production and gathering of local knowledge, needed for projects to be adequately designed, implemented, and led.

The two tdh CH colleagues renewed the call for funding of movements (instead of projects) made earlier with a similar suggestion: Support advocacy! Young people have to be included in decision-making processes as well, they need to be able to participate in translating programs into action on the ground. Training them or creating opportunities and spaces for training can be a good place to start this process. Martin Gallard, responsible for partnership projects at the Foundation tdh in Lausanne, also emphasized how important a shift in power dynamics is in his presentation. Gallard seconded Derbal and Mudarikiri’s call for the localization of aid, this being a first step towards decolonizing aid. Now, we need to also look at funding, partnership, governance, and management. In other words, we need to look carefully at who makes the decisions. To conclude, Gallard stressed the importance of language. How we use language and which language we use are crucial; images matter, his two colleagues had mentioned as well.

Funding agencies are a tough terrain to break through or into, however. They are not interested in decolonization debates and continue to be structured in a very top-down way. This of course will not stop aid organizations and workers from internally debating these questions. We need to check our privileges and keep our eyes open to what we will and want to become in our international cooperation and partnerships. Challenging the structures of funding agencies is one more step towards this goal.

The Novartis Foundation was present at the symposium with the director of Population Health, Johannes Boch. He made a strong argument in favour of creating Health Tec Hubs in African partner countries, a thought along similar lines as tdh’s Knowledge Hubs mentioned above. Boch said local ownership of projects and intersectoral collaboration were a must if we wanted to truly work equitably. We need to keep asking what, exactly, the added value of Novartis Foundation – or an NGO from the global North – is to the local situation and reality. Local steering committees could be responsible to ensure these questions were asked and answered.

The Swiss Red Cross (SRC) colleagues Fortunat Büsch, based in Berne, and Atobian-Kouassi Kokouvi in Lomé, talked about the transformation process the SRC is presently implementing. They, too, stressed how central it was that people talked about the importance of language. In this vein, international cooperation partners can empower local communities by speaking of them as resilient instead of labelling them as vulnerable. The two colleagues presented the discussion presently going on between the SRC and the Benin Red Cross (BRC) and how the two organizations can become partners. Modelling their partnership on the well-established one between the Togo RC and the SRC, the BRC has a good example it can follow. By partnering with the SRC, the BRC can reposition itself with the Benin Ministry of Health and the government in general, striving towards a smoother running of their projects.

The second part of the symposium was concluded with a Q & A session. One question from the audience put to the panellists was how international aid donors could ensure the decolonization process was not misused as ethics washing. A delicate question that needs to be taken into consideration continuously by all parties involved. Now presenters and the audience put the extended lunch break to good use by eating and for animated discussions and networking.

Money is Power

The afternoon started off with a short quiz, testing the attention level of participants and making sure everybody was back on track. After this playful digestive wake-up, Cheikh Mbacke Gueye, director of the Medicor Foundation and trained philosopher, held a refreshingly different presentation. This last session was dedicated to the statement “Money is Power”. Gueye, based in Liechtenstein, presented without PowerPoint slides, which allowed the audience to fully concentrate on his words. Gueye elaborated on the question if cooperation at eye level was possible at all. For it to become possible, we need to continuously engage with our bubbles and reflect on our work and how we work. Participation, he continued, is about empowering those that are not heard. Here also Gueye stressed the point made earlier that we should not fund projects, but instead need to concentrate on institutions – and these we need to fund directly.

In order to attain this goal, we need to engage with what Gueye called cultural interpreters and translators. They are crucial to grasp the complexity of a society. Cultural sensitivity is at the heart of sustainable projects. And learning from one’s mistakes is crucial for an organization’s growth. Reports thus need to include also those things that went wrong so that mistakes could be learned from, Gueye concluded.

How will the International Health Cooperation Look Like in 15 Years?

The last panel concentrated on the questions “How does a meaningful and responsible international health cooperation look like in 2040?” and “What will be the role of western NGOs in global health in 2040?”

To summarise, it can be said that there was a visionary position and a somewhat sober view of the situation in 15 years. The majority would like to see international health cooperation based on partnership at eye level, solidarity, resource sharing, and exchange of knowledge.

They would like to establish a culture of listening in depth what the needs of the people in a certain context are. International NGOs should no longer disrespect the experience and knowledge of national NGOs or poach talented people from them. Overall, we should always keep the spirit of the Alma Ata Declaration in mind and not lose sight of the goal of “health for all”.

The somewhat sober view assumes that monetary support for the Global South will gradually decrease, as armed conflicts and climate change mean that countries increasingly need the money to deal with their own disasters. It is therefore more necessary than ever to empower people in the communities and give them the skills to take care of themselves.

From a global perspective, it is important that the global community does not give up the fight against poverty and social inequality, just as NGOs must do more than ever before at a political level to go for a change of the financial and economic world order.