Over the last decade, unprecedented political will has been focused on addressing the growing and multiple health crises affecting the developing world. Funding from bilateral aid programs such as the U.S. President’s Emergency Program for AIDS Relief (PEPFAR), multilateral agencies such as the Global Fund to Fight AIDS, Tuberculosis and Malaria, and private donors like the Gates Foundation has increased by tens of billions of dollars.

Sharp increases in available funding, primarily aimed at curbing the HIV epidemic, have led to tremendous growth in the NGO community and a multitude of different projects and approaches, many with limited and in some cases widespread success. For example, although the ambitious goals of the World Health Organization’s 3 by 5 campaign (three million on antiretroviral medicines by 2005) were not realized, the campaign galvanized diverse governments, organizations and institutions to dramatically expand treatment access so that now nearly two million people are on antiretrovirals worldwide.

Despite these advances, consensus is growing that gains in some areas, such as HIV treatment, are severely limited while in other areas, like maternal child health, ground is being lost due to weak public health systems and most critically, the severe shortage of qualified health workers in the poorest countries. Often donors pressure NGOs to produce short-term gains in a limited population, creating conflict with the longer-term and more difficult task of building strong, high-quality national health care systems able to provide comprehensive health services to an entire population for decades to come.

National health systems have degraded over the years because of a lack of basic investment, sometimes due to misplaced priorities or corruption, but often directly attributable to austerity measures or structural adjustment programs, the burden of high debt payments, and other conditions imposed by institutions like the International Monetary Fund designed to reduce public expenditure in social services including health. International NGOs work in a constrained environment, where governments’ ability to address their own health problems may be severely curtailed while NGOs have more flexibility. NGOs can quickly hire more staff at higher salaries or acquire specialized equipment to satisfy vertical funding demands or create an idealized project serving one limited population in a small geographic area. The result is a fragmented and inequitable health care delivery system, where viral load measurement may be available, but cesarean sections are not; where one district has a state of the art hospital while the next district has only an empty cement-block building without running water or electricity that serves as a makeshift health post. Recent attention has been focused on the NGO contribution to the human resource crisis, dubbed “internal brain drain,” which occurs when NGOs and other international institutions lure government workers away from front-line clinical, public health and managerial jobs into high-paid program administration positions, thereby exacerbating the very problems they are attempting to solve.

Some NGOs, aware of these pitfalls, are exploring and implementing innovative ways to strengthen health systems and build public human resource capacity. Clearly, NGOs can have a positive effect by providing innovative technical assistance, by directing funding to support the public system that might otherwise go elsewhere, by training the local health care workforce, and by supporting national strategic plans and monitoring and evaluation systems. Perhaps more difficult for NGOs is the challenge to “do no harm”: that is, limiting their own potentially negative effects on the public health system. The process requires NGOs to honestly assess their own practices and their unintended consequences and to recognize that working though the public system often takes longer and requires the NGO to share decision-making power.

As a guide for international NGOs working to limit their harmful effects and maximize their contributions to strengthening public health systems, several health-focused NGOs including ActionAid, Health GAP, Partners In Health, Physicians for Human Rights, Health Alliance International and others developed a code of conduct. The NGO Code of Conduct for Health Systems Strengthening defines and describes specific actions and practices to be encouraged or avoided for NGOs concerned about strengthening health systems in the countries where they work. Although other codes exist outlining ethical NGO practices, none that we are aware of clearly address NGO practices and their effect on human resources and national health systems. The Code addresses hiring and compensation practices, training health workers, the management burden created by multiple NGO projects, and the role of NGOs in advocacy, and in engaging communities to link them to formal health systems.

In recent years, program “sustainability” has become a byword of international health policy. And yet it is clear that without a well-funded and healthy state, sustainability will be a mirage. Through initiatives such as the NGO Code of Conduct for Health Systems Strengthening, we hope to ensure that “health for all” is not a thousand-year project or forever out of reach.