The Rise of NGOs in Global Health Governance and Credibility Issues in the 21 Century

NGOs/ CBOs have emerged as an integral pillar of both global and national governance, and are recognized as such by the official institutions founded after World War II. This is evident from the important gaps they are called upon to fill, their formal partnerships with international organizations and national governments, and the funding they manage for this purpose. Global health is perhaps the area where NGO activity has made the biggest difference. Over the last two decades, however, issues of transparency, effectiveness and, in some cases, legitimacy of their activities have arisen. This policy brief examines the circumstances that have led to the consolidation of NGOs in the international stage, and the reasons why their existence is vital. Finally, a framework that will restore and strengthen their credibility is envisaged, which in turn could potentially enhance their effectiveness too.


Introduction
The rapid growth of Non-Governmental Organizations (NGOs) after the Second World War and their development into a major actor at the international level has triggered a particular interest in their study. Their unique characteristics and their ability to fill gaps left by Governments and International Organizations -sometimes successfully and sometimes less so -now make them an integral part of international governance, with a particularly important role in global health.
The term Non-Governmental Organization refers to non-state actors, voluntary Civil Society Organizations, associations and non-profit institutions (Hudson & Bielfeld, 1997;Tvedt, 2006), which promote issues in the public interest (Hall-Jones, 2006). The adoption of a fairly general definition, which nevertheless captures their unique status, is an unavoidable choice in order to avoid conflicts with various individual definitions that may arise on a case-by-case basis. As Malena (1995) vol. 2 | no. 2 | December 2021 279 notes, the term NGO can be used for any non-profit organization that is independent of government.
In this spirit, the World Bank defines NGOs as "...a wide variety of groups and institutions that are entirely or largely independent of government and are characterized primarily by humanitarian and cooperative, rather than commercial objectives. Setting aside terminological and name differences that vary from one country to another, the Bank's policy recognizes the nature of NGOs as private organizations that pursue activities to relieve suffering, promote the interests of the poor, protect the environment or undertake community development." (Cernea, 1988: 43).
The dynamic growth of NGOs in the second half of the 20th ου century has generated a lot of enthusiasm in the international literature about the potential they create. Clark (1991) refers to them as forces for democratizing development, while Farrington & Bebbington (1993) also recognize them as agents that increase citizen participation. Drabek (1987) noted the alternatives they create for global development. This enthusiasm may have waned in the last two decades, but NGOs still have a very important role in the international system, having redefined the concepts of development and security by giving them a strong humanitarian dimension (Davies, 2008). In the health sector, as Stachowiak (2010) points out, many of the major developments can also be attributed -directly or indirectly -to the actions of NGOs. Nevertheless, issues of transparency and effectiveness remain to be resolved. The aim of this policy brief is to seek a framework that will restore the credibility of NGOs in the health sector through enhanced transparency and effectiveness.

Methodology
This policy brief provides a brief, narrative review of the literature on the role of NGOs in the international system, and more specifically on their work in global health. It examines their rapid growth, their partnerships with the World Health Organization and other international organizations, and their characteristics that make their operations in health essential. For our study we used two literature databases, Google Scholar and PubMed, in which through the main keywords listed in our study we searched for the most relevant published studies in reputable journals (Green et al., 2006). Also, for our study we used material from the official websites of international organizations and global institutions that maintain data on the action of NGOs operating in the health sector (Ferrari, 2015).
The great growth of NGOs and their significant involvement in contemporary global governance is due both to the post-World War II international political environment and to the very characteristics of NGOs that made them necessary. Initially, as McGann and Johnstone (2006)  War -for which international NGOs are considered to have played an important role (Davies, 2008) -also prompted the creation of new international NGOs (Gordenker, 1995). Notably, the number of international NGOs increased from 6,000 in 1990 to 26,000 in 1996 (McGann andJohnstone, 2006;Young and Dhanda, 2013). Globalization and technological developments, which among other things make finding and sharing information faster than ever before, have strengthened civil society and the capacities of NGOs (McGann and Johnstone, 2006;Davies, 2008).
The creation of many NGOs worldwide in the last century has also created a social automatism, which has resulted in the growth of the number of civil society organizations in staggering numbers. At the global level, there is no yearbook of NGOs updated by national authorities to know the exact number of organizations worldwide. Moreover, the specificity of NGOs, which are part of different legal systems and whose legal status therefore varies greatly from country to country, creates additional problems in the overall mapping of organized civil society (Council on Foundations, n.d.). We have organized NGO list archives mainly in developed countries, either because of their policy to include them in a crisis management plan and national policies, or because of the need to fight tax evasiontax avoidance. The specificity of their main activities gives us the opportunity to map NGOs and categorize them. We can therefore see that in databases of accredited organizations or members, such as the database of the United Nations Economic and Social Council (csonet.org), but also in other broader NGO self-organization sites (congo, wango, etc.) NGOs that hold accreditation or membership in broader formations are defined or self-characterized as non-governmental organizations (NGOs), non-profit organization (NPO), social benefit organization (SBO), community based organizations (CBO), civil society organization (CSO), citizen sector organization (CSO), advocacy organization (AO), patient organization (PO), voluntary organization (VO), grassroots support organization (GSO), non-state actor (NSA), etc.α., but also depending on the scope of their activities into local, national, regional or international non-governmental organizations. Of course, this perpetual differentiation of NGOs and naming continues to this day as they are a cornerstone of social self-organization (Willetts, 2001).
Apart from the developments in the international political environment, the growth of NGOs is also due to their specific characteristics, which are absent from other institutions of international governance. One of the most important of these is their connection and proximity to the local communities they help and whose interests they promote (Gellert, 1996;McGann and Johnstone, 2006;Bagire et al., 2014). In health in particular, their ability to deliver care to the most remote or small communities is crucial (McGann and Johnstone, 2006), especially in cases where local government fails to intervene effectively (McGann and Johnstone, 2006;Smith, 2010). Particularly with the rise of neoliberalism and the imposition of the "Washington Consensus", NGOs have taken on the task of filling -to the extent possible -the huge gaps in welfare created by the deliberate withdrawal of the state (Berthoud, 2001). These close links between NGOs and local communities also enhance the participation of citizens as well as local groups and organizations (Gellert, 1996;WHO, 2002), giving civil society even greater momentum. Moreover, according to Stachowiak (2010), NGOs are often the first actors to bring new issues that arise in the communities in which they operate to the surface in an organized manner. This role of NGOs to provide some forms of welfare when the state has withdrawn or is unable to intervene and markets fail, at relatively low cost, has gained the support of formal institutions (Fowler, 1988;Meyer, 1992) and made them the preferred channel for the diffusion of international aid (Edwards and Hulme, 2013).

NGOs, the United Nations and the World Health Organization
Non-governmental organizations have had an active relationship with the United Nations (UN) almost since their inception in 1945. Indeed, as Alger (2002)  Article 71 of the UN Charter, which was particularly pushed for by the civil society representatives (Willetts, 2000) and which established the Economic and Social Council (ECOSOC), defines the following: "The Economic and Social Council may make appropriate arrangements for consultations with non-governmental organizations (NGOs -CSOs) concerned with matters within its competence" (Charter of the United Nations, Chapter X, Article 71).
Regarding consultative status in ECOSOC, as stated in the standard operating procedures, Over time and with the growing influence of NGOs at the international level, their cooperation with the UN system has been strengthened. The 1990s brought major initiatives on the part of the UN to further enhance the role of NGOs in its processes (Willetts, 2000;Alger, 2002;WHO, 2002). As with the UN, so with the World Health Organization (WHO), institutional cooperation with NGOs was on the agenda from the beginning. In addition to the provisions in the constitution for consultation and cooperation with NGOs, the first World Health Assembly in 1948 adopted the first framework of rules for the development of formal WHO-NGO relations, which has been continuously updated and updated over time (WHO, 2002). In 2016, the 69th World Health Assembly adopted the

Examples of Active NGO Participation in Public Health
In the US, where the culture of limited state intervention in health has prevailed over time and with short-term exceptions, the contribution of NGOs in the field is vital. Over 40% of health insurance services are owned by NGOs. Community hospitals, nursing homes and health centers are for the most part run by NGOs. NGOs at the local level, in addition to operating and managing hospitals, are active in providing additional health benefits to members of local communities that are applicable to the health sector (health education and training programs, research support, reduced insurance premiums, etc.) (Metcalfe, 2002). In addition, we could not omit to mention the world-renowned NGOs that assist war veterans of the US military 6 , who receive personalized care from these organizations (Detert et al., 2019).
A notable example of an NGO with a long history and a significant contribution to public health is the case of the American Lung Association (ALA). The ALA was founded in 1904 due to the outbreak of tuberculosis in the United States, under the name "The National Association for the Study and Prevention of Tuberculosis" (Stachowiak, 2010). The ALA funded awareness campaigns as well as major research projects on TB. With the discovery of a cure in 1946 and its (near) elimination in the U.S. in the 1950s, the ALA turned its attention to the treatment and prevention of all diseases that strike the lungs (ALA, n.d.; Stachowiak, 2010). It was, in fact, one of the first to link smoking to lung cancer in 1960, and launched widespread awareness campaigns. When tuberculosis made its resurgence in the 1980s and became more resistant, ALA, in collaboration with the WHO and with funding from USAID, undertook international planning for its control (Stachowiak, 2010).
A different approach (due to different circumstances) but also crucial for public health was that of the NGOs ACT UP (AIDS Coalition to Unleash Power) and The NAMES Project, which were founded in the 1980s and aimed to raise awareness and inform about AIDS (Stachowiak, 2010). The more radical of the two, ACT UP, achieved this through powerful protests and marches, which addressed the high prices of available drugs and the stigma and indifference from society and relevant government agencies. As the organization says of its founding story, "Soon it found itself needing to fight corporate greed, lack of solidarity and various forms of stigma and discrimination at home and abroad" (ACT UP, n.d.). The NAMES Project, on the other hand, started a more symbolic movement where anyone who had lost a loved one to AIDS would write the person's name on a plaque and affix 6 It should be noted that the US Government itself has approved almost 45,000 NGOs whose main task is to support US war veterans, which provide support to their members, and the Government itself has created the NonProfit Program Office (NPPO) under the US Department of Veterans Affairs with the main objective of coordinating NPCs engaged in research and development activities that will ultimately benefit veterans.
vol. 2 | no. 2 | December 2021 284 it to the Federal Building in San Francisco. This action went viral and became internationally known, and was nominated for the Nobel Peace Prize in 1987 (Stackowiak, 2010).
The above examples were chosen because they show how decisive a contribution even individual NGOs can make to public health, and because they show the many ways in which an NGO can make a difference. Nevertheless, as mentioned above, NGOs are now institutional actors in global health governance and are constantly working with international organizations and governments to achieve goals. In countries such as Rwanda, Afghanistan, Mozambique and Liberia, collaborative programs have been developed between NGOs and governments to develop and strengthen health systems (Partners in Health) (Connelly, n.d).
An important example of international organizations, governments and NGOs working together on a large-scale project is the implementation of the World Health Organization's Framework Convention on Tobacco Control (FCTC). As Sparks (2010)  "Emphasizing the special contribution of nongovernmental organizations and other members of civil society not affiliated with the tobacco industry, including health professional bodies, women's, youth, environmental and consumer groups, and academic and health care institutions, to tobacco control efforts nationally and internationally and the vital importance of their participation in national and international tobacco control efforts" NGO activity covers the full range of practices necessary for treaty implementation, from awarenessraising campaigns to training government officials and developing legislative proposals (Sparks, 2010).

Credibility and Legitimacy Crises in the 21st ο Century: The Need for an Enhanced Framework for Transparency and Efficiency
The growing power and involvement of NGOs in global governance has confronted them with a crisis of credibility and legitimacy of their action (McGann and Johnstone, 2006). This crisis has been encouraged for a number of reasons, including the involvement of some in terrorist activities, the staging of protests causing intense unrest and the scheduling of independent meetings alongside official meetings to challenge the legitimacy of official bodies. Thus, at the 1992 Earth Summit held vol. 2 | no. 2 | December 2021 285 in Rio, 17,000 NGO representatives organized an alternative forum, while only 1,400 attended the official meeting (McGann and Johnstone, 2006).
Funding is critical especially for achieving immediate results, which are often prioritized, strengthening health systems in the long term (Connelly, n.d.). However, compliance mechanisms are lacking (McGann and Johnstone, 2006). Bodies such as the World Bank and the UN, which work extensively with NGOs, would be useful to support the development of concrete practices to improve transparency and accountability. To a large extent, the problem for NGO activity in developing and transition economies comes from the fact that funding mainly flows from industrialized countries, and donors may dictate the NGO's action objectives. This suspicion can be exploited by authoritarian regimes and lead to the closure of NGOs. The political system of states is important particularly for organizations involved in health advocacy and activism (Getahun and Raviglione, 2011). It is understood that it is important to develop a state-specific approach. Communication on the delineation of priorities and action boundaries between NGOs and central authorities is useful to be provided by Memoranda of Understanding (MOUs), as well as outlined in a clear legal framework.
As McGann and Johnstone (2006) point out, monitoring the entire financial flow is probably impractical at present. In the developed world, NGOs are accountable to the state and the private sector through taxation and the publication of annual reports. The benefits of transparency are also evident in terms of communication and cooperation between NGOs and Ministries of Health (Connelly, n.d.). Specifically, transparency, flexibility and adaptability in implementing programs that align with government goals and the needs of each region, develops trust between parties and strengthens partnerships. At the local level, it is important to monitor skills and expertise received by Community Health Workers (CHWs). NGOs need to ensure that effective and equitable care is provided.
Public opinion questions the credibility of governments themselves given their poor performance and inefficient bureaucracy (McGann and Johnstone, 2006). NGOs come to cover up the inefficiencies of the state apparatus, yet they face similar questioning. Although there is a positive correlation between financial aid (channeled through NGOs) and progress to fighting diseases (Sidiropoulos et al., 2022), conditions such as local corruption appear to affect the performance of operations, especially in sub-Saharan African countries. It is important that NGOs are willing to undergo evaluation and achieve a greater degree of transparency in order to have more coherent and effective action, and ensure their independence by establishing reliable and verifiable criteria for action (Bagire et al., 2014).

Conclusion
It is apparent that NGOs are vital in global health governance, and the great increase in their numbers in the last decades is a result of this. Yet, there are important steps to be taken, to ensure their credibility and efficiency. As noted by McGann and Johnstone (2006), transparency will be achieved through a systematic dialogue on this issue within the NGO community with the aim of reaching agreement on the level of transparency and setting realistic targets. Private sector funders, national governments and international organizations should actively encourage the effort and provide the necessary resources. The importance of transparency in NGOs should then be promoted. The implementation of the principles must be coordinated and specific with no room for deviation and take into account the social and political environment in which they operate. It is therefore important to develop an international mindset of accountability and transparency within NGOs. Such a framework should be developed, implemented and overseen by international institutions, in cooperation with the NGOs.