I had the wonderful honor of meeting Deogratias, the founder of Village Health Works, at a global health equity training that I attended a few months ago. During the training, one of the audience members asked, “so what are your plans for expansion?” Currently, Village Health Works operates in one singular town, the town of Kitugu, in Burundi. And Deo responded with something along the lines of (not verbatim) “I have no intention of expanding, there is still work to be done here.” At first I was really disturbed and upset by his response, how could he, who is so intelligent and capable, not want to try and help other people when he has the capacity to? Why wasn’t he spreading across Burundi or trying to become Minister of Health? As I’ve thought more about his response, I’ve come to realize it is the best response I’ve ever heard, and one more international NGOs should take to heart.

Over $2 trillion has been given in aid and when I look around, I can’t figure out exactly what has been done. As I’ve thought about it more and more, I think I am beginning to see one of the major pitfalls in the way that INGOs work, and that is the desire to expand and “diversify.”

Many times INGOs want to see if their models can be replicated elsewhere, or they’ve come across funders who want them to work in a different area, or they see a need in another place similar to the need they are trying to address, or maybe they just want to go elsewhere, and they go. We’ve done a lot of going in international aid, and not much has changed, I think now it’s time to try something new, let’s all just stay put.

I know it’s not sexy or romantic, you don’t get to run around the world, you don’t get to say to your donors “we operate in 36 countries,” but maybe you can actually make more of a difference if you only work in one place at a time.

Right now, the INGOs model is focused on providing services (i.e. health, education, microfinance). I think that this is part of the reason very little is actually being accomplished. Instead of providing services, I think we need to start focusing on helping individuals and communities, one village at a time, one region at a time, one country at a time.

I’m going to use examples of two different organizations, both of which had books written about them by Tracy Kidder (I’m sure you already know what I’m going to say) Partners in Health and Village Health Works.

To start, I think that Partners in Health is amazing, they do great work, they have a great mission and from everything I’ve seen they are honest and dedicated to the work of providing preferential treatment for the poor. They are one of my favorite organizations and I have donated to them many times over the years. That being said, they started in Haiti, with Paul Farmer, who had a vision to provide access to great medical care to poor people in the poorest country on Earth. A very noble cause, and one that he achieved in the area of Cange in Haiti. The work he did in that community and for those people is phenomenal, but why not then move next door, to the next community, and then the next, all in Haiti, and slowly improve the collective health of the entire region, and maybe then the entire country? Why pick up and move to Peru when there is still so much to do in Haiti? Following that they also picked up and went to Rwanda, and Malawi, and to the handful of other countries that PIH now operates in. But why not focus just on Haiti, and provide preferential health care for people in other places there? (They have expanded throughout Haiti too, to 11 more sites, but anyone who knows anything about Haiti, knows that it still has a LONG way to go). Imagine what they could have done in Haiti if they poured all the resources they had into Haiti alone and not the many other countries they are now operating in. Maybe now Haiti’s health system would actually be descent instead of leaving so much to be desired.

Now, in the immediate areas that they provide services too, I am sure the quality of life has improved, whether it is in Haiti, Peru or Rwanda, and some might argue that it doesn’t exactly matter if the places are all next door to one another or on different continents, at the end of the day, the collective health of the world is improved (if only very slightly). For that, I say, I’m not sure that that segmented approach is what is really going to make an ultimate difference because if your next door neighbor is still living in undesirable conditions, how far can you really climb out of your situation? It’s like the broken window effect, if all of your neighbor’s windows are broken, even if all of your windows are not, you are still living in a neighborhood full of broken windows. But if you fix yours and your next door neighbors and everyone fixes their windows, the likelihood of falling back into that is much slimmer.

Then there is Village Health Works. Deo has a totally different approach that I mentioned at the beginning, which is, focus on the people you are trying to help until you’ve done everything you can, don’t try to expand. I agree, but would add my own caveat, which is, expand when you see you’ve achieved your goals, but expand to the neighboring town, don’t jump across the world. Instead of expanding, VHW invited people who are interested in adopting their model to come and learn how they function so that if they want, they can replicate it elsewhere.

I believe that the jumping from one country to another is partially selfish and self-serving for INGOs. It’s because there are high up people in the organization who want to travel and work in different places and it’s also so the organization can say “we work in 42 different countries,” but if none of the countries are doing measurably better, really, what does that mean?

What ends up happening is that you have all these isolated aid projects in all these different places where a few communities might be getting help, but there is nothing cohesive, nothing uniting. Not only that, the organization doesn’t get a chance to specialize in that particular country, or make a significant wide spanning change, because they are all over the map.

Now, I know people will argue, “well how do you chose who you help, which country to go to?” and they will also argue “there will be people getting left out” or “at the end of the day the collective whole is getting better, it doesn’t all need to be in one place at one time.” There are already people and countries getting left out, so those arguments apply now too. As for the “collective whole,” I’m not sure they are getting better enough to back up that argument either.

Aid is a slow process; right now it’s too slow. But maybe if we stay in one place, make sure what we are doing is good, and then take it from village A to village B to village C in the same country, eventually country X will do better on the whole. And while that work is going on in country X, another NGO will be working just focused on country Y, and another in country Z, and maybe then we can actually get something substantial done. Aid is done one person at a time, one community at a time, one country at a time. I don’t think we are helping anyone by being all over the place.

I know that there are a lot of hard working local and grassroots non-profits that do amazing work in just one country, I am working for one right now. But the habit is, as soon as they begin to gain recognition and funds, their first instinct is to spread. But this article in no way diminishes the incredible work that is being done on the local level, this is more of a critique on the large scale multinational INGOs.