| Background: International non-governmental organizations (INGOs) have proliferated over the past several decades. As significant actors in global health and development, they can help strengthen health systems in the countries in which they operate. INGOs sometimes, however, engage in practices that weaken health systems, including creating additional management burdens and distorting labor markets, as well as exacerbating inequities by offering higher quality care to some segments of a population. Health systems strengthening (HSS) is an evolving concept and, while little agreement exists on effective HSS metrics, there is consensus in the global health community that strong health systems are essential to achieve global health goals. In May 2008, several INGOs developed the NGO Code of Conduct for HSS to address factors related to the potential negative impact of INGOs; the Code, however, has not garnered significant attention within the global health community.;Study design: This research seeks to understand how INGOs can best support HSS without unintentionally harming national health systems and explores factors preventing the NGO Code of Conduct from gaining momentum. The methodology consists of a comprehensive literature review identifying evolving concepts regarding HSS and INGOs, a review of the NGO Code of Conduct, and analysis of key informant interviews with representatives of 20 INGOs.;Findings: INGOs can mitigate potential negative impact of their work by engaging in more systems thinking and self-analysis to develop greater awareness of their effects on health systems, especially their work on projects that are disease-focused or implemented in selected districts and not nation-wide. Donor agencies can facilitate INGOs' work to mitigate potential negative impact by dedicating funding to HSS, especially--but not only--in vertically funded projects, and creating more flexible funding mechanisms that allow for systems investments. In countries where ministries of health have greater management capacity, the work of INGOs and all health sector partners contributes more efficiently and effectively to HSS. Nearly all key informants shared challenges related to the NGO Code of Conduct for Health Systems Strengthening; they believe the Code should be modified and updated, or replaced by a simpler list of principles to guide INGOs in HSS. |
