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James Pfeiffer, PhD, MPH, Wendy Johnson, MD, MPH, Meredith Fort, MPH, Aaron Shakow, MA, Amy Hagopian, PhD, MPH, Steve Gloyd, MD, MPH and Kenneth Gimbel-Sherr, MPH

All authors are with Health Alliance International, Seattle, WA. James Pfeiffer, Wendy Johnson, Meredith Fort, Amy Hagopian, and Steve Gloyd are also with the Department of Health Services, School of Public Health and Community Medicine, University of Washington, Seattle. James Pfeiffer and Steve Gloyd are also with the Department of Global Health, School of Public Health and Community Medicine, University of Washington, Seattle. Kenneth Gimbel-Sherr is with the Department of Epidemiology, School of Public Health and Community Medicine, University of Washington, Seattle.

Correspondence: Requests for reprints should be sent to Dr James Pfeiffer, Associate Professor, Department of Health Services, Box 357660, School of Public Health and Community Medicine, University of Washington, Seattle, WA 98195-7660 (e-mail: jamespf{at}u.washington.edu).

The challenges facing efforts in Africa to increase access to antiretroviral HIV treatment underscore the urgent need to strengthen national health systems across the continent. However, donor aid to developing countries continues to be disproportionately channeled to international nongovernmental organizations (NGOs) rather than to ministries of health. The rapid proliferation of NGOs has provoked "brain drain" from the public sector by luring workers away with higher salaries, fragmentation of services, and increased management burdens for local authorities in many countries. Projects by NGOs sometimes can undermine the strengthening of public primary health care systems. We argue for a return to a public focus for donor aid, and for NGOs to adopt a code of conduct that establishes standards and best practices for NGO relationships with public sector health systems.

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