Health Policy and Planning Advance Access originally published online on January 24, 2006
Health Policy and Planning 2006 21(2):143-155; doi:10.1093/heapol/czj014
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Original article |
Government–NGO collaboration: the case of tuberculosis control in Bangladesh
1 Nuffield Centre for International Health and Development, Institute of Health Sciences and Public Health Research, University of Leeds, UK, 2 National TB Control Programme (NTP), Bangladesh and 3 Bangladesh Rural Advancement Committee (BRAC), Bangladesh
Correspondence: A N Zafar Ullah, Nuffield Centre for International Health & Development, University of Leeds, 71–75 Clarendon Road, Leeds, LS2 9PL UK. Tel: +44 113 343 1680; Fax: +44 113 3436997; E-mail: hss1anuz{at}leeds.ac.uk
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Abstract |
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This study analyzes the basic concepts and key issues of existing collaboration between government and non-governmental organizations (NGOs) in health care, using as an example the implementation of the DOTS (formerly an abbreviation for directly observed treatment, short course) strategy for tuberculosis (TB) control in Bangladesh. It also examines efforts by the Government of Bangladesh to improve health services delivery, especially for the poor, through collaboration with NGOs. Data were collected in 2001 and 2002 as a part of the process of developing a public-private partnership model for TB care in Bangladesh. Analyses of existing collaboration models in TB control strongly suggest that the government and NGO sectors can be complementary in controlling TB. We found an increasing trend of government collaborating with NGOs in implementing TB control programmes. The study indicates that government–NGO collaboration is an effective way of improving access to and quality of TB and other health care services.
Key Words: government–NGO collaboration, health care, NTP, tuberculosis, DOTS, Bangladesh
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Introduction |
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For many countries, it is the responsibility of the government to assure health care provision for the whole population. But the public health agenda has become so large that the governments of these countries have been unable to provide adequate health care (Buse and Waxman 2001
). This has led organizations outside the government to assume part of that responsibility. Moreover, there is a growing recognition by government and international organizations that the involvement of all stakeholders is needed if health services are to reach the poor (Korten 1991; World Bank 1998; WHO 2001a). Further, continued bilateral relationships between donors and non-governmental organizations (NGOs) have created a window of opportunity for government–NGO collaboration (Begum 2000; WHO 2001a; Zafar Ullah 2002; Management Sciences for Health 2004). Research evidence indicates that working in isolation can result in duplication of efforts and failure to accomplish health goals, whereas collaboration among health care providers can generate synergy and facilitate the flow of information (World Bank 1996; UNICEF 1999; Begum 2000; Barkat and Islam 2001; Thomas and Curtis 2001; Hurtig et al. 2002; WHO 2003; Gomez-Jauregui 2004; Mercer et al. 2004; Newell et al. 2004).
In some developing countries, non-government stakeholders cover a major component of health care (Green 1987; Magagula et al. 1997). In order to avoid clashes, it is necessary for the health care providers in these countries to collaborate. In Bangladesh, for instance, the government and NGOs collaborate to a certain degree to provide health care, especially to vulnerable populations such as women, children and the poor. Within such collaboration, the government retains ownership in the areas of policy formulation and implementation, human resource development and budgetary control. NGOs concentrate on facilitating the activities within national policies and strategies (MOHFW 1998). NGOs provide quality services (NTP 2003; Guda et al. 2004; Mercer et al. 2004) in accordance with the national policy guidelines, but lack deliberate plans to build the capacity of government services. Moreover, there is no set process to encourage governments to move from restrictive bureaucracy towards creating a facilitating policy environment for collaboration. In order to develop consistent and workable policy, clear understanding of the nature, principles, strengths and weaknesses, and challenges of the existing government–NGO collaboration is essential. This paper, therefore, attempts to investigate different government–NGO collaborations in the health sector in Bangladesh, more specifically the case of the National TB Control Programme (NTP), in the light of movement towards wider collaboration to achieve national health goals.
The paper first examines the experiences of different projects promoting government–NGO collaborations in the health and population programme in Bangladesh, to identify the policies within which these collaborative projects are being implemented and the different mechanisms by which providers of health care collaborate. Assessments are made as to how certain factors such as government–NGO relations, health sector strategy, regulatory frameworks and institutional characteristics have catalyzed or constrained collaboration. The mutual benefits and contributions of collaborating partners are then analyzed, noting that both government and NGOs must contribute in order to sustain government–NGO collaboration. This section finally identifies the key considerations which are critical to any successful collaboration.
To understand the impact and effectiveness of any collaboration, it is helpful to analyze a specific example of government–NGO collaboration. The second part of the paper, therefore, looks at government–NGO collaboration in tuberculosis (TB) control, in order to focus on specific modes of collaboration. Here, the ‘government’ is the NTP, which collaborates with a group of NGOs to implement the DOTS (formerly an abbreviation for directly observed treatment, short-course) strategy. We review the existing evidence in TB control to distinguish the respective roles of the NTP and NGOs, and outcomes of collaboration between the NTP and NGOs in implementing DOTS. This section further analyzes the strengths, weaknesses and difficulties of collaboration, before identifying opportunities and constraints for collaboration in TB control, leading to the development of principles for government–NGO collaboration. The article concludes by arguing that government and NGOs can be complementary in achieving national health goals.
Government, NGOs and collaboration: definitions
In order to analyze the collaboration between the government and NGOs, it is important to define these three terms in the context of broad health care activities. The diversity of NGOs strains any simple definition. In wider usage, the term NGO is applied to any organization which is: (1) self-governing and independent from government, (2) not explicitly created for profit, and (3) has meaningful voluntary content (Green 1987; Mburu 1989; Smith 1989; Asian Development Bank 1999; Gomez-Jauregui 2004). For the purpose of this article, we conceive NGOs as those civil society organizations which basically accord with all the above criteria and are providing health care in Bangladesh. The ‘government’ represents both central (e.g. Ministry of Health, Directorate General of Health Services) and local government (e.g. Districts, Municipalities) health authorities.
In order to conceptualize ‘collaboration’, we delineate different terms being used to express the relationship between the government and NGOs. Green and Matthias (1997) have argued that relationships between organizations form a continuum of increased structure, decreased autonomy and intensified communication. The continuum starts with competition, progresses through cooperation to coordination and then on to collaboration, finally ending in control (Figure 1).
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‘Competition’ is perhaps the easiest to conceptualize. Organizations compete with each other and there is almost no functional linkage and communication between them. ‘Cooperation’ can be seen as a one-off relationship where organizations cooperate around certain issues or at certain times; although the organizations communicate with each other, they maintain almost complete autonomy (Green and Matthias 1997
). Another view is a deliberate relationship between otherwise autonomous organizations for joint accomplishment of individual operating goals (Rogers and Whetten 1982). The World Health Organization referred to ‘coordination’ as ‘keeping each other informed’ to avoid duplication of efforts (WHO 1999). It also represents an on-going and structured relationship between independent organizations for mutual benefit (Green and Matthias 1997), or ‘a structure or process of concerted decision making or action wherein the decision or action of two or more organizations are made simultaneously in part or in whole with the same deliberate degree of adjustment to each other’ (Rogers and Whetten 1982).
‘Collaboration’ is often described as ‘joint activity’ or ‘working together’, where two or more organizations work closely together and share resources and responsibility for common goals and purpose (Omondi et al. 1993; Green and Matthias 1997; Magagula et al. 1997; WHO 1999). It implies temporal accomplishment of jointly agreed tasks, where continued institutional linkage is not important (Bhattacharya and Ahmed 1995). Collaboration can take place at different stages and in different ways. It is increasingly recognized, however, that collaboration should not mean ‘sub-contracting’, but a genuine partnership between organizations based on mutual respect, and acceptance of the independence of the collaborating organizations concerning their vision and approaches (Korten 1988; UNFPA 1995; Magagula et al. 1997; Begum 2000). For this study, we have used the term ‘collaboration’ broadly to encompass cooperation and coordination.
Finally, ‘control’ is a relationship where one organization gains control over others (Green and Matthias 1997; Begum 2000).
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Methods |
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The study was carried out as part of the process of developing a locally appropriate public-private partnership model in the NTP in Bangladesh. The specific objectives of this research were to:
- Review existing government–NGO collaboration mechanisms, and the policy environment within which the collaboration is being nurtured and developed;
- Review the NTP as a case study for government–NGO collaboration;
- Analyze the pros and cons of government–NGO collaboration in the Bangladesh health sector, taking the TB control programme as an example;
- Examine existing relationships between the government and NGOs;
- Identify opportunities for and constraints to government–NGO collaboration.
Both primary and secondary data were collected to address the research objectives. Secondary data were collected through review of relevant literature, policy papers, programme reports and registers, and other related published or unpublished consultants’ reports. Electronic searches were made of Medline, Popline, PubMed, Web of Science, the University of Leeds library databases, and the websites of international organizations, using the specific key words: "government-NGO collaboration", "collaboration", "partnerships", "health sector", "tuberculosis", "DOTS", "NTP", "NGO", "South Asia" and "Bangladesh".
Primary qualitative data were obtained through consultative meetings and interviews with government and NGO programme managers of jointly implemented TB control activities. Semi-structured questionnaires and guidelines were used for the interviews, and minutes of the consultative meetings were kept for subsequent analysis. Interviews were informal and interactive, which allowed collection of in-depth information and personal insights. Data were also gathered from proceedings of two review meetings held in Dhaka and Chittagong, jointly organized by the NTP, local government and NGOs.
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Results |
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Government–NGO collaboration in Bangladesh
Background
With a population of 130 million, Bangladesh is divided into six divisions, 64 districts and 497 upazilas (sub-districts). More than 80% of the population live in rural areas and 64% of the population are directly involved with agriculture. Bangladesh is one of the poorest countries, with enormous health and development challenges. Only 47% are literate, gross income per capita is low (US$277) and more than half of all households live in poverty. Key health indicators are less than satisfactory. For instance, the maternal mortality ratio is in the range of 320 to 400 per 100 000 live births, the infant mortality rate is 728 per 100 000 live births, life expectancy is around 60 years, and less than 40% of the population has access to basic health care. The main causes of death are poverty-related infectious diseases, which are exacerbated by and contribute to malnutrition (World Bank 1993; Abedin 1997; MOHFW 1998; Bangladesh Bureau of Statistics 1999; WHO 2003).
Constitutionally, the state is responsible for providing basic health care to its population. The Government of Bangladesh (GOB) therefore runs an extensive network of hospitals and dispensaries, but the services suffer from shortages of resources and mismanagement, and lack of accountability (Azad and Haque 1999; Barkat et al. 2000). Furthermore, in hard-to-reach areas, health care services are either absent or inaccessible. This situation has led NGOs and other voluntary organizations to grow and to take responsibility for providing much of the country's health and social welfare services. Current estimates suggest that NGOs provide services to almost one-quarter of the total population (Rahman 2003). Bangladesh has probably the most active NGO sector in the world, with over 6000 registered NGOs. Of that, about a quarter is considered active. Two – the Bangladesh Rural Advancement Committee (BRAC) and the Grameen Bank – are very large with nationwide capacity and coverage. Most NGOs pursue a dual strategy, addressing poverty (through micro-credit schemes) as well as providing service delivery programmes, particularly for education, agriculture, health and other related areas. These organizations generally follow the target-group approach, giving greater priority to the poor and other vulnerable groups (Azad and Haque 1999; Begum 2000; MOHFW 2000).
There is growing recognition that NGOs have considerable power to improve health-seeking behaviour and the capacity of the community. NGOs are considered to be in a better position to impose user fees that can lead to cost recovery and community participation. They are thought to be closer to the people and more aware of community needs. Their success in economic empowerment of the poor, polio eradication, sanitation, environmental conservation and in non-formal education programmes have strengthened both the government's and community beliefs that NGOs can effectively contribute to achieve national targets (Hadi 2000; Westergaard 2000; Ahmad 2001, 2003; Rahman 2003; WHO 2003).
Government–NGO collaboration in the health sector is not new in Bangladesh. Collaboration between the government and NGOs in TB, maternal and child health and family planning, Extended Programme of Immunization, leprosy elimination and nutritional programmes has been efficient and effective. CARE-Bangladesh's reproductive health project, BRAC's health and development programmes, and the leprosy control programmes of Health, Education and Economic Development (HEED) are among many outstanding examples of successful government–NGO collaboration (Perry 1999; Zafar Ullah 2001, 2002). Under the current Health and Population Sector Programme, the government and NGOs collaborate through a sector-wide approach to deliver an Essential Services Package (MOHFW 1998; World Bank 1998). It is envisaged that the government and NGOs need to adhere to the guiding principle laid down in the Programme Implementation Plan of the Health and Population Sector Programme, to further strengthen mutually supportive and complementary relationships between government, NGOs and the private sector (Perry 1999; Begum 2000).
Policy environment for government–NGO collaboration in Bangladesh
A number of rules and regulations exist in Bangladesh that are intended to control and regulate NGO activities. These have provided the legal and regulatory framework which allows NGOs to secure legal identity and seek assistance from the government, and also regulate their relationship with the government. The following four laws and ordinances were found to have substantial implications for government–NGO relationships:
- The 1861 Societies Registration Act: This Act sets out ways in which a voluntary organization should be set up, managed and maintain control of its accounts. Although its use has gradually decreased, some old NGOs are registered under this Act.
- The 1961 Voluntary Social Welfare Agencies (Regulation and Control) Ordinance: This Ordinance compels NGOs that intend to render voluntary services in any specific areas to register with the government (Department of Social Welfare). Many NGOs are registered under this ordinance and the registration process is relatively less cumbersome than for the 1861 Act above.
- The 1978 Foreign Donations (Voluntary Activities Regulation) Ordinance: This law regulates NGOs on the receipt and expenditure of any foreign donations or contributions for voluntary activities.
- The 1982 Foreign Contribution (Regulation) Ordinance: Promulgated in 1982, this ordinance requires NGOs to seek prior government approval each time they receive or intend to receive any foreign contribution – either cash or in kind.
Two government agencies are responsible for the registration and monitoring of NGOs: the Bangladesh NGOs Affairs Bureau (NGOAB) and the Department of Social Welfare. NGOAB was created in 1990 to provide one-stop services for NGOs for registration and processing project approvals. In 1996, the GOB established a consultative council known as the ‘Government–NGO Consultative Council (GNCC)’ to provide a forum for open dialogue between the government and NGOs. The council has 23 member positions consisting of nominated representatives from the government and NGOs (World Bank 1996; Asian Development Bank 1999; UNICEF 1999; Begum 2000).
In order to address the huge burden of poverty-related infectious diseases, the GOB identified two major strategies in its Health and Population Sector Strategy introduced in 1998: higher allocation of public sector resources to the Essential Services Package (ESP); and reform of the health sector to lay the foundation for greater involvement of NGOs and the private sector in ESP service delivery. The recent Five-Year Health and Population Sector Programme (which began in 1998) set out the basic principles for government–NGO collaboration, recognizing the importance of mutual respect, trust and expertise within the overall framework of national development (MOHFW 1998; World Bank 1998; UNICEF 1999; Begum 2000; Barkat and Islam 2001). The National Health Policy also recognizes the need to integrate effort between the government and NGOs in carrying out health care services (Perry 1999; UNICEF 1999; MOHFW 2000).
Clearly, there is a paradigm shift regarding NGO and private sector involvement in public sector health care provision. For example, the GOB's Fifth Five-Year Plan (1997–2002) included several statements about the nature of involvement of NGOs and the private sector in health: ‘Involvement of the private sector and NGOs will be promoted with a view to achieving the spirit of participation and ownership in health development ... . The role of government will be limited to policy setting, monitoring and control’ (p. 463); ‘The existing research institutes ... will be strengthened ... collaboration of private organizations/institutes and NGOs will be fostered’ (p. 471). One of the main features of the recent Health and Population Sector Programme is to establish partnership with NGOs in the provision of health care services. Under the National Health Policy, NGOs and other voluntary organizations are encouraged to work as ‘complementary forces’ to the government's efforts (Perry 1999; UNICEF 1999; MOHFW 2000; Barkat and Islam 2001; Ahmad 2003).
Relationships between NGOs and the Government of Bangladesh
The relationship between NGOs and the GOB has been and is mixed, varying from having parallel or competitive activities to cooperation and collaboration for social sector programmes (Asian Development Bank 1999; UNICEF 1999; Begum 2000; Zafar Ullah 2002). Table 1 shows the types of government–NGO relationships existing in Bangladesh. Some of them correspond with the types of relationships described in the ‘competition-control continuum’ (Figure 1), but some are context specific and have clear overlaps. In some cases, the government considers NGOs as its opponents, hence relationships often become hostile. However, there is increasing cooperation and collaboration between the government and NGOs, particularly in poverty alleviation, health, education and other social welfare activities (Asian Development Bank 1999; Begum 2000; Hadi 2000). The government's policies and legal frameworks within which these relationships take place inevitably affect its day-to-day relations with NGOs. Furthermore, local government structures play an important role in maintaining good relationships with NGOs in coordinating health and other NGO-run activities at local levels (World Bank 1998). In particular, local governments are collaborating with NGOs in selecting sites for Community Clinics, and in social mobilization and sanitation programmes (Asian Development Bank 1999; Hadi 2000). However, the level of commitment from local government varies widely, and is specific to the quality and motivation of individual leadership (Fernandez 1987; World Bank 1998; Asian Development Bank 1999).
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Mechanisms to involve NGOs in health sector programming
Within the perspective of government–NGO collaboration, several mechanisms or frameworks have been tried to involve NGOs in the health sector programmes. Due to the diversity of NGOs and their differing relationships with the government, these mechanisms have evolved over time (MOHFW 1998; World Bank 1996, 1998; Perry 1999; Begum 2000; Barkat and Islam 2001; MOHFW 2001; NTP 2002):
- Networks/consultation/representation: This is the simplest form of collaboration. NGOs participate in different taskforces and committees, especially under the Health and Population Sector Programme. NGOs also serve as effective linkages between the planners/financiers of a project and its beneficiaries.
- Contractual agreements: Under this mechanism, government requests or assigns NGOs to undertake a specific task on its behalf. Usually, this is achieved through soliciting proposals or one-to-one negotiation. This is the commonest form of collaboration mechanism, and in general, GOB defines partnership as such. Examples include the Bangladesh Integrated Nutrition Project, and the Reproductive Health, Extended Programme of Immunization and TB/Leprosy programmes of the ESP under the Health and Population Sector Programme.
- Patronage: This form of collaboration evolves when one institution expresses interest in supporting another institution to strengthen its institutional capacity. Here they bind together to deliver some defined service, and also share ideas about common vision. This form of collaboration, though uncommon, has been practiced to some extent by the Ministry of Health and Family Welfare (MOHFW) in supporting NGOs for innovative programmes during the Fourth Population and Health Project (1992–98). Although it achieved high levels of success, it was discontinued during the Health and Population Sector Programme.
- Partnering: This requires the perception that each partner has something to contribute. Partnering implies sharing both risks and benefits, and its guiding principle is based on commitment to reciprocity, sovereignty and equity. Although this is rare in the Bangladesh health sector, some NGOs, such as BRAC, CARE-Bangladesh, Oxfam and CONCERN-Bangladesh, are promoting this type of partnership in their health and family planning programmes.
Government–NGO collaboration – common ground and differences
A number of studies have shown that the government and NGOs have common goals and vision with respect to social sector development, particularly in health and nutrition, poverty alleviation, human resources development, environmental protection, non-formal education and women's development (Perry 1999; Begum 2000; Ahmad 2001). However, the basic institutional approach to addressing the social and health problems is different between government and NGOs (Table 2). An effective collaboration should therefore recognize the differences and build on the basis of the respective advantages of government and NGOs (Begum 2000; WHO 2001a).
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Benefits and contributions of collaborating partners
To develop and sustain a government–NGO collaboration, both government and NGOs must see considerable gain from it, and that if both stand to gain from the collaboration, they have much to contribute. Table 3 summarizes the benefits gained and the contributions offered by each sector in a government–NGO partnership.
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NGO involvement – risks and challenges
Despite the availability of evidence indicating government-NGO collaboration to be successful, there are still serious concerns over the continued involvement of NGOs in the health field. NGOs are not a homogeneous category. They differ from each other in terms of size, site, nature and characteristics, and their commitment towards the communities they serve. About 24 000 NGOs are registered with the Department of Social Services and about 1300 NGOs are registered with the NGO Affairs Bureau. This heterogeneity of the NGOs has made the task of developing workable policies and mechanisms difficult (Barkat et al. 2000; Begum 2000; Neaz 2004).
Under the Health and Population Sector Programme the government recognized that client-centred provision of the ESP would require an effective sector-wide partnership with NGOs, but no clearly defined framework for collaboration has so far been developed. Moreover, the lack of government capacity (including technical capacity and manpower) to adequately manage the process of NGO involvement poses a big challenge.
One of the most noteworthy trends in Bangladesh is the increasing role of NGOs in economic and social activities, including health. More schools, health and economic (mainly micro-credit) programmes, and environmental services are now being managed by NGOs, while the government's conventional role has shrunk considerably. While the advantages of this paradigm shift are widely recognized, there is also recognition of the risk of further weakening government health care delivery and thus increasing the health care system's vulnerability to the changing priorities of NGOs and their donors.
There are still cases in which ideological differences and lack of institutional openness continue to feed mistrust. In addition, the negative attitude of government officials about NGO involvement in health care activities clearly indicates a lack of understanding of NGOs’ vision and the nature of their work, whilst many NGOs have concerns about difficulties in accessing donor funds which are channelled through the government. The process of NGO selection was found to be cumbersome, full of bureaucracy and wasted time (World Bank 1996; Magagula et al. 1997; Barkat et al. 2000; Begum 2000; Gomez-Jauregui 2004).
Government–NGO collaboration – key considerations
Based on the review and analyses of different government–NGO collaboration models in the health sector of Bangladesh, we identify certain essential pre-conditions which are critical to successful and sustainable collaboration between the government and NGOs (Begum 2000; WHO 2000; Barkat and Islam 2001). These are:
- mutual respect and trust;
- recognition of mutual strengths and values, and comparative advantages;
- favourable policies, laws and regulatory frameworks;
- effective mechanisms to monitor, measure and learn;
- transparency and accountability;
- involvement of all stakeholders at every step;
- continued commitment of collaborating partners.
Government–NGO collaboration for TB control in Bangladesh
In this section, we use the example of collaboration in TB control to highlight specific issues.
Background
In Bangladesh, the burden of communicable diseases including TB is high compared with other South Asian countries, and the HIV/AIDS epidemic is imminent. The incidence of TB in 2001 was estimated at 105 per 100 000 population, with a caseload of over 30 000. There were 70 000 deaths due to TB in 2001, and the death toll is expected to rise due to the HIV epidemic (World Bank 1998; UNICEF 1999; DHS 2000; NTP 2002; WHO 2004).
The overall aim of the NTP is to reduce the transmission of TB until it is no longer a public health problem (NTP 2002). The immediate objectives are to increase the cure rate of sputum smear-positive cases to 85%, and to increase case detection to 70% of the estimated incidence (MOHFW 2001). From its introduction in 1993, the internationally recognized DOTS strategy for TB control has suffered from limited capacity and quality. Shortages of physical infrastructure and appropriately trained health and laboratory personnel mean patients may need to travel considerable distances to health facilities, and have lengthy waits to be seen when they arrive. Furthermore, there is considerable stigma associated with TB. These factors combine to limit patients’ ability or desire to seek care from publicly provided TB services, but rather encourage them to seek initial diagnosis and treatment from private sector providers of any sort (Hussain 2001; WHO 2001b; Guda et al. 2004; Newell et al. 2004).
The treatment success rate rose to 84% for the 2001 cohort but could not quite reach the target level due to high (7%) default rates. Case notification rates, however, lag far behind the target level: although the DOTS population coverage was nominally 95%, the estimated case detection rate by the DOTS programme was only 32% in 2002 (WHO 2004). There remains a big gap between population coverage and the case detection rate. This is mainly because only about half of the population truly has access to the DOTS programme, and most TB patients prefer to seek care from the private sector. Moreover, a large number of self-reported cases remain undetected due to lack of adequate skilled personnel in the health facilities (NTP 2002, 2003; Newell 2002; Guda et al. 2004; WHO 2004; Zafar Ullah et al. 2004).
In line with international guidelines, the Bangladesh NTP is generally clinic-based, and there is only one bed available per 500 TB cases (Chowdhury et al. 1997). The lowest-level health facilities providing appropriate TB care are Upazila Health Complexes located in the upazila headquarters (one hospital per 250 000 population). Most of these facilities are short of skilled staff, equipment and drugs, especially in rural areas. There are few specialized institutions for TB, and those that exist are situated mostly in cities. In addition, frequent movements of staff as well as patients, inadequacy of the transport system, long distance to health facilities, and lack of clients’ trust in the health care system have adverse affects on access to and quality of TB care (Chowdhury et al. 1991; Chowdhury 1999; UNICEF 1999; MOHFW 2000). Given these constraints, it is essential to utilize the potential and resources of NGOs and the private sectors in order to ensure wider coverage and the planned expansion of DOTS. The government has the responsibility of determining policy guidelines and supplying logistics, while NGOs, through their extensive community networks, can help the NTP to tackle the huge unmet need for TB care (NTP 2002).
Government–NGO collaboration in implementing DOTS
Bangladesh presents a good example of government–NGO collaboration in the countrywide expansion of DOTS under the NTP. At present, NGOs and the private sector jointly cover more than half of the entire NTP activities, in both rural and urban areas (Hussain 2001; MOHFW 2001; NTP 2001, 2002; WHO 2004). This collaboration is based on a Memorandum of Understanding signed in 1995 between the government and six NGOs, namely, BRAC; the Damien Foundation; the Danish Bangladesh Leprosy Mission; Health, Education and Economic Development; Rangpur Dinajpur Rural Services; and Lutheran Aid to Medicine Bangladesh. The main purpose of the Memorandum is to outline specific tasks for the government and partner NGOs (see Table 4) in the delivery of DOTS in defined areas (MOHFW 2001; NTP 2002, 2003).
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There is an increasing trend of government collaboration with NGOs in implementing DOTS. The NTP started implementing DOTS with BRAC in four upazilas in 1993 and within 5 years the NGO coverage had risen to 186 upazilas. In 2001, the government–NGO split for DOTS by upazilas was 50:50 (Figure 2), with BRAC providing the major portion of NGO support (23%). In 2003, NGOs provided services to 259 upazilas (56% of all upazilas; n = 460) and in four metropolitan cities in collaboration with the government, with remaining coverage provided by the government through its clinics and hospitals (Figure 3). NGOs play a vital role in assisting the NTP in TB service delivery, management support, operations research and social mobilization. The NTP provides treatment protocols, policy guidelines, logistic supplies (drugs, reagents and equipment) and training, while NGOs provide supervised treatment at the community level, promote active case finding and raise awareness about TB among the general population. Monitoring and supervision is done jointly by the NTP and NGOs (Hussain 2001
; MOHFW 2001; NTP 2002; Guda et al. 2004). The roles of each collaborating agency are summarized in Table 4.
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There have been gradual but steady improvements in the key areas of TB control (Figure 4): for instance, claimed DOTS population coverage rose from 90% in 1998 to 95% in 2002 (but see the earlier comments on the difference between population coverage and case detection rate). Over the same period, the case detection rate of new smear-positive cases under DOTS increased from 24% to 32%, and the treatment success rate rose closer to the target level (84% for the 2001 cohort) (MOHFW 2001
; NTP 2001, 2002; WHO 2004). There have been marked improvements in the technical capacity of staff providing DOTS. We found that the providers (both NGOs and the government staff) demonstrated average knowledge about DOTS and case management. About three-quarters of NGO doctors and four-fifths of lab technicians already received DOTS training. The quality of staining was found to meet NTP standards; on random testing, the examination slides fulfilled the criteria of the existing protocol. The NTP claims that collaboration between NGOs and the government are key to these successes (NTP 2001, 2002, 2003). An external review carried out in 2002 also affirmed this claim, and formed the basis of a revised 5-year strategic plan which emphasizes the need for continued collaboration with NGOs and the private sector (WHO 2004).
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Government–NGO collaboration in TB control: lessons learnt
Two external reviews of NTP activities have been carried out since the introduction of DOTS, one in 1997 and another in 2002 (MOHFW 2001; WHO 2004). Both the reviews acknowledged government–NGO collaboration in the Bangladesh NTP to be a major success. The reports suggest that the government has demonstrated its commitment to TB control, while NGOs have increased the coverage, quality and sustainability of their services by channelling their resources to provide standardized treatment to TB patients, particularly in remote, rural areas. The NTP and the partner NGOs have also carried out their own internal evaluations of the programme. The following are some commonly agreed lessons learnt from the government–NGO collaboration in implementing DOTS in Bangladesh (Hussain 2001; MOHFW 2001; WHO 2001b, 2004):
- The collaboration ensures greater coverage and access through NGO service facilities and community-based infrastructures.
- NGOs were able to increase awareness among the general population about TB, leading to increased numbers of TB suspects at different health facilities.
- Unified reporting systems enable a full account of the NTP's programmatic performance.
- Although NGOs are following NTP guidelines, they decide the operational strategy appropriate to their philosophy and thinking. This allows organizations to retain their independence while being accountable to the NTP.
The potential and constraints of government–NGO collaboration
Next we analyze the potential and constraints of government–NGO collaboration in TB control. During the analysis, we have focused on the strengths of collaboration in relation to access, efficiency, quality and coverage of the TB services. Table 5 summarizes the strengths and weaknesses of the government–NGO collaboration, and its future opportunities and potential threats.
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Evidence suggests that access to health services is increased through government–NGO collaboration by ensuring people's participation in the health and development programmes. NGOs have proven ability to improve people's capacity to seek and utilize health care (UNICEF 1999
; Begum 2000; MOHFW 2001; Newell 2002; Mercer et al. 2004). The vast majority of respondents (more than 80% of government officials and 100% of NGO representatives) believed that collaborative activities ensure people's participation, the mobilization of resources and increased coverage of services. In her research, Begum (2000) showed that the government and NGOs, while collaborating, share tasks among themselves based on their knowledge and skills, which in turn can free up resources for other social welfare activities, thus widening the spectrum of services for the poor and the disadvantaged. It is also widely acknowledged that concerted and collaborative efforts are needed to address priority public health problems, including TB. Without collaboration, the differing interests and ideologies of government and NGOs can lead to confusion and disparities (Bratton 1989; Honandle and Cooper 1989; Barkat and Islam 2001). Alter and Hage (1993) argue that organizational individualism has been seen as an inadequate response to the problems.
Efficiency is another strength of collaboration. There is less duplication among government and NGO activities, especially in a context of resource constraints (Ross 1990; Begum 2000; Barkat and Islam 2001). Moreover, harmonization of both procedures and reporting mechanisms makes monitoring and evaluation easier (MOHFW 1998; World Bank 1998; Begum 2000; NTP 2002). Government–NGO collaboration enhances institutional strengthening of the collaborating agencies through the interaction and sharing of information, technology and expertise (Ross 1990; Begum 2000; Barkat and Islam 2001).
However, collaboration can affect organizational freedom to act independently as a result of prioritizing collaborative activities. It can expose one partner to others. In Bangladesh, NGOs are afraid of exposing themselves to government bureaucracy, and there is a mutual lack of trust. In addition, from the GOB side it is difficult to choose partners from the large number of NGOs available in the health sector.
A major potential threat to government–NGO collaboration is the slowness of implementation of health sector reform. The absence of simple, realistic collaborative mechanisms can pose a high hurdle in the pathway of collaboration. Over-controlling the flexibility of NGOs by the government, and lack of continuity of GOB's priorities, are other potential threats to collaboration.
Principles of NGOs involvement
This study has critically analyzed government–NGO collaboration models in the health sector in Bangladesh, including those existing in TB control programmes. As a result of our analysis, and building on the analyses presented in another paper (Zafar Ullah et al. 2004), we have identified the following four basic principles, which underline the best strategies for NGO involvement:
- Principle One: The government is responsible for the health care of its citizens. It must, therefore, take the lead in developing supportive policies and strategies for involving NGOs in health care programmes.
- Principle Two: The NGOs’ role is to build the capacity of individuals, communities and the government, and to facilitate and support community action.
- Principle Three: The involvement of NGOs should be based on mutual strengths, philosophies, objectives and the nature of the collaborating agencies.
- Principle Four: There is no ideal model for government–NGO collaboration in health care; the most suitable one should evolve from a transparent and iterative process.
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We can draw two conclusions relating to TB control and government–NGO collaboration. Access to TB care services is a key factor in achieving the objectives of DOTS. In Bangladesh, socioeconomic factors, shortages of skilled workers, irregular drug supplies and the absence of an effective referral system limit people's access to TB care, and encourage them to default from TB treatment. Taking treatment closer to patients and increasing the availability of TB treatment at every point of service delivery can improve accessibility. One way of achieving this is to involve NGOs in a wide range of TB control activities, from TB service provision to operational research. The health sectors of the South Asian countries, including the NTPs, have many examples of successful collaboration with NGOs. Lessons learnt from existing collaboration models reveal that government collaboration with NGOs in the delivery of TB services has enhanced case finding, treatment success, supervision and community participation. It is widely acknowledged that collaboration between the government and NGOs is the key to success in the TB control programme in Bangladesh.
More widely, NGOs play a significant role in providing health care and social welfare services in Bangladesh. There is compelling evidence that the government and NGOs are ‘complementary forces’ to each other in achieving national health goals. The role of NGOs, for example, in delivering the ESP, and more recently in the fight against TB, has been pivotal and effective. Therefore, although NGOs are diverse in their strategic vision and interests, there is great potential to develop collaborative approaches to improve access to and quality of TB and other health care. NGOs can be instrumental in establishing links between national programmes and patients. They can also have a crucial role in advocacy and in mobilizing policy makers and the community towards expansion of control programmes. Through building a powerful lobby with the government and the community, NGOs can raise awareness about causes of ill health, create demand for services and help provide those services.
Biographies
A N Zafar Ullah is a Teaching Fellow at the Nuffield Centre for International Health and Development, Institute of Health Sciences and Public Health Research, University of Leeds, UK.
James N Newell is a Senior Lecturer and Co-director of the communicable disease research programme at the Nuffield Centre for International Health and Development, Institute of Health Sciences and Public Health Research, University of Leeds, UK.
Jalal Uddin Ahmed is Programme Manager of the National TB Control Programme (NTP), Bangladesh.
M K A Hyder is a Junior Consultant with the National TB Control Programme (NTP), Bangladesh.
Akramul Islam is a Programme Manager with the Bangladesh Rural Advancement Committee (BRAC), Dhaka, Bangladesh.
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