The exact number of NGOs in India remains unknown. Still, in 2015 the Central Bureau of Investigation (CBI) attempted to prepare such a report, which revealed that there were a minimum of 31 lakh NGOs in the country. What does this mean?
The Dance of Dependence
How funding dictates healthcare for those who need it the most.
Put on Hold
Nearly six months after the first wave of the COVID-19 pandemic, The Foreign Contribution (Regulation) Amendment Bill 2020 was introduced in the Lok Sabha on September 20, 2020, and passed unanimously. The Foreign Contribution (Regulation) Act, first enacted in 2010, applies to all organizations which intend to receive foreign donations and ensures that such contributions are not utilized in a way that 'compromises national interest.'
The latest amendment to the law introduced critical changes in how organizations could accept foreign money. Among other things, receiving funds only in an account in the State Bank of India branch in New Delhi became mandatory. Non-governmental organizations (NGOs) were barred from transferring foreign grants to other NGOs in India, and a lower ceiling on administrative expenses was prescribed. The government could also suspend the use of funds merely on a reason to suspect misdoing. NGOs across the country, many of whom had their licenses expiring that year, were given time until December 31, 2021, to align themselves with these new regulations.
These new rules were a huge setback for NGOs, volunteer groups, and other associations and sent them scrambling into the lengthy process of renewing licenses. While the public and private healthcare infrastructure creaked and groaned under overwhelming cases, much of the population depended on such organizations to provide medical relief. According to a report in The Hindu, the uncertainty of violating the provisions of the FCRA prevented many large donors from donating critically necessary equipment, such as oxygen production plants and concentrators for hospitals and charities, adding stress to an already burdened health infrastructure. In India, more prominent NGOs such as CRY work with a network of smaller NGOs through sub-granting. SOUL, working with the education of tribal children in the Sunderbans, is one such NGO, but under the new FCRA rules, the more prominent NGOs it relies on are now restricted from sharing funds with them for carrying out their work, and SOUL fears being shut down. Such organizations are unable to raise money independently and are dependent on their larger networks. According to experts, one of the most significant consequences of this move will be the reduction of such grassroots-level work.
Earlier in May, Amitabh Kant, then CEO of NITI Aayog, had emailed NGOs registered at their Darpan portal, appealing to them to join hands with the government in this crisis. Later, in an article for the Indian Express, he wrote, "Civil society, and voluntary and non-governmental organizations constitute the backbone of collective articulation of citizen interest in a democracy. As facilitators, mediators, and advocates of this interest, they have put people before everything else during this pandemic crisis." and went on to iterate the importance of their work.
“There is nobody better placed than the NGOs, to understand the pulse at the grassroots and engage closely with communities, especially in rural India,”Amitabh Kant, CEO of NITI Aayog
In retrospect, perhaps he should have also copied the email to the Parliament.
While FCRA created roadblocks for relief work, activities unrelated to the pandemic faced suspension. In a survey on challenges faced by NGOs during the pandemic, researchers at Azim Premji University found that more than two-thirds of the organizations faced difficulty in mobilizing funds for other programs and were faced with a reduction in funding from their donors. Low funds halted an active program working for people with disabilities in one NGO and other NGOs had to scale-down activities that were non-COVID and, thus, did not attract the required funding from their usual CSR partners. A World Health Organization (WHO) survey in May 2020 confirmed half of the countries surveyed suffered from partially or wholly disrupted healthcare services for non-communicable diseases such as cancer and diabetes. The G-FINDER report tracking global health investments for 2021 showed a 6% decrease from 2019 in funding for medical research on neglected diseases, such as tuberculosis. As we will later see, even in non-pandemic times, these diseases do not command a more significant chunk of the funding pie, but focusing on the virus only exacerbated their neglect.
COVID, quite literally, took up all the oxygen in the room.
The lack of funding from domestic sources, donors' inability to fulfill commitments, and the new FCRA amendments making it harder than ever to access funds from abroad were potent ingredients that made essential work difficult in a time of need. They highlighted how sensitive volunteer work is to changes in government and donor priorities.
The pandemic also potentially pushed back years of work in other areas of healthcare and research. The two are not entirely unrelated. Money being offered for research on specific issues can sometimes create a ‘pull’ incentive, inviting more activity in that area. NGOs also play a key role in translating research findings into practical solutions that can be implemented at the community level. An adverse impact on one may later be felt in the other.
But how did we get here? How did it come to be that external funds so heavily influence healthcare provision? What are the implications of this, and where do we go from here? To understand this, we must first examine how NGOs have evolved and how healthcare is funded in the country and worldwide.
Non-governmental organizations, if taken literally, would include the entire private sector, which would be misleading. Aside from not being under government control, three significant factors define what is commonly referred to as an NGO. For starters, they are registered as societies and public trusts, making their donors eligible for tax relief. Second, they primarily work in the 'development' sector, where their activities can range from promoting education, providing healthcare and housing, or carrying out relief work to advocacy and research. Finally, they are generally non-profit and do not generate their own funds, instead relying on external agencies and donors.
NGOs in India have evolved significantly from their ancestors; understanding them as they are now requires tracing some of that past.
How we got here
Before independence, three major groups were at the center of civil society activities in India. Firstly, encouraged by the British, Christian missionaries spread throughout the country, establishing institutions such as hospitals, schools, and universities. In response to their activities, the second type of civil society emerged out of Bengal (and later spread through the country), with religious underpinnings and a focus on topics such as widow remarriage, women's education, and other social issues. The final group, inspired by Gandhi's idea of voluntary action, believed in community upliftment by addressing poverty at its source. They worked in villages on health, education, handicrafts, and small industries. The landscape of the volunteer sector, as we know it now, was largely unformed. Following independence, most Gandhian and religious organizations remained and continued to work with the government in various roles. The atmosphere was optimistic, the vision of development was lofty, and the Indian government had promised to ensure the well-being of its people.
While the attitude was optimistic, the work cut out for them was sobering. The situation proved overwhelming, and nearly all indicators of health, education, economy, and welfare were down. But things were brought to a head in the 70s. With the war in Bangladesh and Indira Gandhi's imposition of the Emergency, this decade was a time of great turmoil in India. Deteriorating economic conditions prompted enormous political mobilization and nationwide strikes. The two-year suspension of democracy under an authoritarian regime resulted in it increasingly being felt that the government had failed to deliver its promises. A combination of these factors led to a renewed interest in the 'alternative' – organizations that worked outside government bureaucracy. A large part of this sector used this opportunity to transition from its Gandhian tone to something more businesslike and organized (interestingly, this was also around the time the term 'NGO' started becoming popular). Gradually, there was an increase in the number of professional NGOs who set to work in locations across the country and in fields such as community health, education, tribal development, women's rights, and the environment.
After Indira Gandhi's assassination, the state sought to improve relations with NGOs. By this time, the central and state governments recognized that NGOs did some things better than the government. In some cases, government agencies even transferred funds and administrative responsibility to NGOs to carry out essential government programs in such areas as health. In the Fifth Year Plan, the government acknowledged that to achieve their goals of welfare and upliftment, such organizations were necessary partners. In a report published in 1985, The Ministry of Health and Welfare emphasized the importance of their work, urging the government to create programs encouraging such efforts, but it was the Planning Commission's call for increased participation of voluntary organizations in the Seventh Five Year Plan that truly formalized the NGO-government partnership.
As conditions for running such groups improved and the government started lending more and more support to them, there was an increase in the number of professional non-governmental organisations (NGOs) who set to work in locations across the country and in fields such as community health, education, tribal development, women's rights, and the environment.
This change was not wholly organic and took place against the backdrop of the global economic crisis of the 70s and 80s. As countries, especially developing countries, underwent a wave of privatization in response to the recession, India, too, experienced a neoliberal transition of its institutions around this time. While these ideas were a part of existing discourse in the government anyway, much of this was accelerated by the conditions of the Structural Adjustment Programs (SAPs) led by the International Monetary Fund (IMF) and the World Bank, under which India accepted money to help it deal with the economic breakdown. India negotiated terms with these institutions and after much deliberation, accepted them.
In simple terms, the SAPs required the state to cut back its involvement in critical sectors and open them up to the free market. This included healthcare too. The National Health Policy of 1983 had already echoed this view by mandating a plan of “...[reducing] government expenditure” and “[encouraging] investment by nongovernmental agencies in establishing curative centers and by offering organized logistical, financial and technical support to voluntary agencies actIve in the health field.”
A decade later, The World Bank, in their 1993 report, prescribed a policy that reinforced those ideas.
“Encourage greater…competition in the provision of health services by decentralizing government services, promoting competitive practices, fostering greater involvement by nongovernmental and other private organizations.”World Development Report: Investing in Healthcare
As the State liberalized healthcare systems, private corporations were pushed to supply healthcare services rather than the government. Foreign aid also began to pour into the country through the channel of private agencies and NGOs as donors saw the private sector as the fast-track to development and infused money into market-led, as opposed to state-led, activities.
Whether these changes were forced onto the country by the World Bank or the IMF is not what is important here but, given that they happened, understanding the transition of ideology that commercialisation brought about in the non-profit sector because of it. The Indian state, in keeping with the requirements of structural adjustment, withdrew funding from rural development, agriculture, energy, transport, and public health and with this abdication of its traditional role, NGOs moved in to work in these areas. They came to be seen as the de facto voice of the people and the link between them and the state, occupying greater roles in policy-making and public-private partnerships.
The funding that was being made available to them through global initiatives led to an obsession to access those resources. Over time, it appeared that more importance was being placed to reach those funds than whether that money reflected the requirement on the ground. With the increasing importance of private funding and donor agencies from abroad, their agendas started shaping national and local policy.
Getting a count
It is hard to say with any certainty exactly how many NGOs are there in India as there is no single, complete database of this information. NGO Darpan has 1,54,099 self-registered organisations. In a 1992 report, The Ford Foundation stated that there were about 100,000 NGOs registered with the government as private societies. One-eighth of them, or around 18,000, are development organisations, "ranging in size from such well-established groups as SEWA, which now counts 50,000 members across India, to two or three people working as activists in a village or an urban slum." A CBI census of NGOs arrived at a minimum of 31 lakh NGOs and other government reports contain different figures.
For every 1 lakh people, there are ...
Source: PIB, UNICEF, CBI Report 2017
Government hospitals are outnumbered by NGOs by a factor of at least 82.
There are almost 9 government doctors per lakh population, highest of 45 in Sikkim and lowest of 3 in Assam.
According to the Planning Commission's figures, there are almost 15 lakh schools in India, half of the number of NGOs.
There is almost 1 NGO for every 400 people. This makes them some of the most widespread institutions of social development. So what areas do they work in?
Of all these sources, NGO Darpan has the most data points, with information on the date of registration, the issues the organisation undertakes, self-disclosed sources and the amount of funding, among other things. Organisations often work in multiple sectors, and even a basic analysis of this distribution shows the sectors they tend to focus on most.
Healthcare, following education, is one of the most active fields of work, and now that we have an idea of how that came to be, it makes sense. However, the exact number of NGOs working specifically in healthcare is unknown; these numbers are probably exaggerated one way or the other because of errors in data entry. The poor data entry also prevents us from taking a more granular look at the data at this time; insights such as the amount of money received, who from, and where it was used could not be determined.
However, we can use what we have, and by combining that understanding with other published papers and reports, we may see where the money for these NGOs comes from.
Following the money
Foreign aid in India
As we have read, it was during the Emergency in 1976 that the FCRA was formed in response to concerns that foreign powers were intervening in Indian affairs by pumping money into the nation through independent organizations. The law aimed to limit foreign donations to persons and organizations so that they would not harm the national interest.
The map here shows the overall number of NGOs and those accepting foreign financing (working in healthcare and all sectors combined). Hover around to see the underlying data. When we switch it to show current FCRA registrations, we can clearly see a sharp divide in where this money goes. What could account for this?
According to a 2018 analysis by the Organisation for Economic Co-operation and Development (OECD), India received almost 1 billion USD between 2013 and 2015, with another estimate putting it at 1.4 billion USD; the greatest investment of any country. The Bill and Melinda Gates Foundation (BMGF), which has continually increased its donations to the country, has brought in a significant amount of international investment. BMGF funded 335 million USD to healthcare and other relevant programmes in 2017.
In data from NGO Darpan, 17% of healthcare-oriented NGOs have an active FCRA registration, with overseas donors making up the majority of their funding. With NGOs lacking an FCRA license, the converse is true; the greatest funders are central and state government agencies and programmes.Closer to home, domestic investments through corporate social responsibility (CSR) responsibilities make for a significant amount of money; the OECD estimates it to be just shy of 1.2 billion USD. This figure may be higher since, like NGOs, CSR investments are not adequately documented. Education and healthcare remain the top priorities domestically as well.
This is a lot of money, but it is distributed very unevenly. Across all sources of philanthropy, the geographic dispersion of philanthropic funding is concentrated in only a few states.
Maharashtra receives the most CSR cash, followed by Tamil Nadu and Karnataka, whereas other of the more populated and less developed states, such as Uttar Pradesh, Rajasthan, Bihar, Madhya Pradesh, and Odisha, receive far less. The distribution of resources is also lacking in the North East and Northern States, where development levels are lower than in the Southern States, receiving a very small portion of funds.
This is, of course, to be expected. The majority of CSR activity occurs in areas where firms have headquarters and factories, which are concentrated in these areas. The lucrative foreign financing is received by organisations that have the potential to carry out the needed tasks and are located in economically viable locations. Because there is no regulation, evaluation of needs, or duty associated with this type of donation, wealth is given depending on what becomes the donor's favour, the target of their gift.
So what happens when these decisions do not represent the needs and expectations of the people they seek to serve, or when funders decide to divert their attention elsewhere? Consider how HIV/AIDS has been addressed in India.
The Aid Epidemic
AIDS has claimed approximately 40 million lives worldwide since its discovery in 1981. It is an epidemic that has spread in several ways around the world, often impacting communities that are already socially and politically marginalized. The Western reaction to the epidemic was strong, and bolstered by the need of the hour, research was accelerated and antiretroviral therapy (ART) was introduced in 1996 at the International AIDS Conference in Vancouver, Canada – reported to reduce AIDS-related deaths by between 60% and 80%. AIDS was transformed from a horrific death sentence to a manageable disease in the West in under 20 years.
The ART treatments were efficient but expensive, and it would take another decade before they became generally accessible in low- and middle-income nations. At this time, help was difficult to come by because the issue appeared to be under control in North America. It doesn't, however, imply that it wasn't still widespread in other regions of the world, such as Africa and Latin America. The United Nations established UNAIDS in 1996 to coordinate the worldwide effort to battle AIDS, and it published a report in 1998 that showed the scope of the issue. It emphasized the need for more financing and the introduction of comprehensive programmes that addressed the disease's multifaceted difficulties, including mortality, stigmatization of those affected by it, and the diseases' economic and political repercussions.
The last argument is what really drove action towards the diseases. It was claimed that HIV/AIDS may obstruct democratic processes by impeding socioeconomic advancement and escalating the competition for resources. As potential recruits for terrorist and rebel organisations, AIDS orphans were also suggested to be a source of societal instability. And so it came to be that the alarm was raised again. According to a paper published by Copenhagen Consensus, a think-tank in Denmark, HIV/AIDS was ranked as the number one economic priority in terms of its cost-benefit analysis. When the Gates Foundation entered the arena towards the close of the millennium, AIDS became the biggest focus for the next decade and more.
In India, AIDS was first identified in 1986. With the ensuing panic about the disease across the ocean in Africa, the government also set itself to work to assess and contain the situation at home. An original report by the UN estimated the infection rate to be 0.9 percent, or 5.7 million people, across India. This survey was done by employing hundreds of monitoring sites to test the blood of expectant mothers and high-risk groups including injecting drug users and sex-workers over four months each year. It is easy to see why this number would be skewed, is it not? The sample that was surveyed did not fully reflect the general population. This was confirmed in another survey in 2007 when another population-based survey tested blood samples from 102,000 individuals for HIV in the general public rather than just certain categories. It revealed that number to be 0.36 percent (out of the 1.1 billion population). India's HIV caseload had been significantly overstated.
This does not imply that the sickness is not significant. Every life lost is important. But greater attention than ever before was paid to the exceptional help provided to AIDS and the disease-specific programmes that it inspired. The AIDS epidemic was the easiest topic to get funding for 20 years ago if you wanted to organize a medical conference. Numerous studies have examined how researchers and non-governmental organizations (NGOs) moved through the AIDS-focused environment, choosing to take on work merely because it was the only option to ensure financial security.
The thing is, it doesn't always work. If the funding does not reflect local needs and priorities, there will be no impact. In some cases, NGOs stopped receiving the same level of community participation once they became 'another one of those HIV/AIDS NGOs.'
One of the reasons diseases like AIDS get more attention is because working on them can generate a profit in the long term. Pharmaceutical companies can recover the money spent into the R&D of a vaccine for AIDS in its distribution; in that way, it is seen as a highly technical problem with technical solutions. If it is clear that the population it is aimed for will not be able to pay for drugs or vaccines, such as TB, work is slower. The markets decide what is worth caring about.
Over the past few years, though, the funding pendulum has swung the other way, and funding for AIDS is now lower than for tuberculosis (TB). India has the highest population affected by TB globally, and yet the budget to work on it was difficult to come by. Now that ART is perceived to be available and the disease itself entirely preventable, the money has shifted spotlights. The recent change in donor interest can be attributed to linking TB with HIV; of the estimated 33.4 million people living with HIV in 2008, nearly 30% were estimated to have latent or active TB infection.
However, the dependence on external sources and the weak public infrastructure is becoming clear. Earlier this year, the National AIDS Control Organisation (NACO) faced a supply crisis, with thousands of patients in limbo. Just because the donors shifted goalposts does not mean people don’t suffer, but this exact over-reliance on the private sector created the situation we are in now. Healthcare should not be charged at a market rate.
We are not overspending on AIDS but underspending on the rest. These needed sums are paltry relative to military spending or bank bailouts. [...]. The choice is not between AIDS, health systems, and other Millennium Development Goals. We can and must support them all.Jeffrey D Sachs
Healthcare as a public good
The health systems in nations that offer high-quality healthcare to all of their citizens are effectively regulated by the government and supported by taxes and social insurance payments. These nations do not divide their populations according to employment status or income to receive health benefits, and their healthcare providers have cultivated a strong culture of ethics. Furthermore, these nations ensure that healthcare is maintained as a public benefit rather than subjecting it to market vagaries.
Healthcare is a fundamental human right that should be accessible to all individuals, regardless of their socio-economic status. States with a greater presence of the private sector in their healthcare systems tend to have higher healthcare costs and poorer health outcomes. In contrast, states with a stronger public healthcare sector have lower healthcare costs and better health outcomes. This is because the private sector is driven by profit, whereas the public sector is focused on providing necessary care to the community.
When healthcare is privatized, private companies often rely on funding from private donors in addition to government funding. This funding can come from a variety of sources, including individuals, foundations, and corporations.
However, the allocation of this private funding is not always based on objective criteria. Private donors may choose to fund specific types of healthcare services or research based on their own personal beliefs or interests. This can lead to a distorted allocation of resources within the private healthcare sector, where certain services or research areas are overfunded while others are underfunded.
Furthermore, private funding can also affect access to healthcare. Private donors may choose to fund services or research that is only available to certain groups of people, such as those who can afford to pay for care or those who live in a certain geographic area. This can create unequal access to healthcare within the private sector, with some individuals having access to a wider range of services and treatments than others.
Governments preach about providing universal access to healthcare, but their actions and policies reflect a fragmented and selective approach that results in extreme impoverishment and access to healthcare imbalances. If this is to change, healthcare must be made into a public benefit and separated from the market. There is no reason India should be any different from the other nations headed this way. In reality, certain states, like Mizoram, Sikkim, Goa, Pondicherry, and the Andaman Islands, are already on that path and spend more than Rs. 4000 per person on healthcare in their budgets. They do so because they lack a strong private sector and have an effective primary healthcare system. We must demand change and work toward removing healthcare from the market's grasp and turning it into a public good.
All illustrations were generated using DALL-E by OpenAI. Visualizations made using R, Layercake, D3 and Illustrator.
For data on the number of NGOs, a dataset was scraped from NGO Darpan and analysed. These numbers appear to be changing regularly and this essay uses data as it was downloaded on October 12th, 2022. The waffle chart showing per lakh population data was compiled using data from this article. Data on the number of government doctors was compiled from MoHFW National Health Profile, 2019. For funding allocated towards TB and HIV/AIDs, OECD’S CRS system was used. The intro features purpose statements from BMGF’s donation records.
For a full list of sources and bibliography, please refer to this document.
I would like to thank Amar Jesani and Sunil Kaul for taking the time to sit with me for and sharing their experience of working in the non-profit sector.