Expert Panel: Strengthening Health Systems: The Role of NGOs - November 7-11 2011

This is a very interesting discussion and actually quite timely especially when many developing countries especially are re-focusing more on community health delivery systems and their health information systems.

I represent a small organization happy to be contributing to the greater healthcare needs in Haiti. I realize that being an independent NGO does nothing to aide the overall cause. I also realize coordination with the Ministry of Health is ideal. We all however realize this process is quite complicated: 1/whom do I contact; 2/getting registered in English; 3/recognizing inspections are needed but avoiding the less than honorable methods often used by inspectors; 4/having a referral center that knows who we are and what we are trying to do. Ideally partnering with an establish NGO/organization that has mastered these issues is my goal. Possibly a NGO registry/partnership that can be intercessor may be the way to go with needed standards and levels of service to be "members" of that partnership. Dr Joe

This is a very timely discussion.I am neither in the policy line of the ministry nor have I ever worked in an NGO. I am a clinician and most of the time all these institutions are a bit distant for my understanding.They tend to emphasise training,workshops,meetings,capacity building,advocacy,policy statements,etc.(and all drive big cars!)To be sincere,as a clinician at the front line, I sometimes find these words not only superflous but difficult to interpret for the good of my patients. All that said,NGOs run projects while Ministry runs programs. A project starts and ends. The program remains. That is why these two should cooperate in order for projects to support the programs to run.Lastly,NGOs have only helped to take away the limited human resource in the government,pay them highly, more than the goverment can pay and leave the whole system in shambles. Is there a way all NGOs can contribute to the salaries of goverment workers? Dr Kamara.Mbarara,Uganda.

I'am wondering what'is the size of contribution of NGOs in Rwanda Health system; in term of health expenditures.In which sector of Rwanda health system NGO had a greatest impact.
Thanks
Dr Alain YAO

With TA-NPI we drew on the PIH experience of multi-role community volunteers, and FHI's suggestions for networks in low resource settings and formed the Referral Wheel with the components that helped NGO in their service delivery roles. Reducing Stigma, reducing Time involved in accessing services, overcoming Inertia that the services don't apply to 'me', reducing Costs and combating lack of Knowledge. Breaking this STICK has really helped NGO delivering services to understand their role

To reduce the risk of reinventing the wheel, the Global Funds Community Systems Strengthening framework has operated for a couple of years and was formalised in mid-2010. The document has been shared with ICASO and in-country NGO represented at CCMs. The AIDSPAN supporting guidance can help all GHDOnline members see what is already there. GFTS 2.0 seeks a support resource and yet it largely exists with CSAT, regional branches of ICASO, and AIDSPAN

@Philip - the link for the CSS Framework yields a 404 error. The "Community Systems Strengthening Framework," May 2010, is available at www.theglobalfund.org/documents/civilsociety/CSS_Framework.pdf.

Can you provide another link?

Thanks.

Although lot of scope and opportunity exists for NGO to add value to health care, due to lack of motivation and leadership the things are not moving as per expectations as for the NGO role in health care

Apologies for the missing link for CSS Framework - Global Fund is revising it for release in October 2011. The GF link on other resources is here, including their proposals for a code of conduct for technical support providers. A key feature of TGF technical support is close collaboration between the providers.

I have been working as a microbiologist in National TB Control Program of Afghanistan since 2010.In my observation, eighty five percent of total health services is being provided here by the NGOs in good coordination with the government.This is quite a successful contribution of NGOs in delivering health services as well as strengthening health systems of Afghanistan.I think in a country where the government machinery is not well structured due to the internal conflict,war ,corruption, and lack of sufficient resources and good governance;the role of NGOs is more there.Successful partnership is prerequisite between government and NGO to ensure best delivering of health services as well as its strengthening in least developed and developing countries .

I am a physician and academic from Sri Lanka. I have three concerns about the partnership between NGOs and states, especially developing countries. Firstly, there is gross asymmetry of power and resources between the NGOs and Philanthropists on one hand, and developing countries on the other. For example, the Gates Foundation contributes to health more than the investment on health by the World Bank! Such a situation could lead to deviation of priorities. This is practically felt at the front-line in two ways: (1) Disease - based programmes (e.g. HIV, malaria, TB) could get more funding than health system strengthening. (2) Health workers leave the state sector to join more lucrative posts in NGOs leading to health worker migration and disruption of services.
The second issue is that the agendas of certain NGOs and state sponsored aid organizations, and the universal humanitarian agendas they are supposed to espouse should be identified. For example, faith-based organizations such as World Vision or state sponsored ones such as USAID would have their own agendas (as stated in their own websites) that need not necessarily correspond to the needs of the recipient state. In such instances, how would the partnership foster to achieve the ...

I am a physician and academic from Sri Lanka. I have three concerns about the partnership between NGOs and states, especially developing countries. Firstly, there is gross asymmetry of power and resources between the NGOs and Philanthropists on one hand, and developing countries on the other. For example, the Gates Foundation contributes to health more than the investment on health by the World Bank! Such a situation could lead to deviation of priorities. This is practically felt at the front-line in two ways: (1) Disease - based programmes (e.g. HIV, malaria, TB) could get more funding than health system strengthening. (2) Health workers leave the state sector to join more lucrative posts in NGOs leading to health worker migration and disruption of services.
The second issue is that the agendas of certain NGOs and state sponsored aid organizations, and the universal humanitarian agendas they are supposed to espouse should be identified. For example, faith-based organizations such as World Vision or state sponsored ones such as USAID would have their own agendas (as stated in their own websites) that need not necessarily correspond to the needs of the recipient state. In such instances, how would the partnership foster to achieve the humanitarian aims?
The third issue is in relation to the potential for NGOs to undermine health sector development. Would the partnership lead to a dependency culture and retard the growth of indigenous capacity?

Part of these problems could be tackled by increasing the transparency of NGOs and aid organizations. This could be achieved by having a Global Register of INGOs and aid organizations, a more explicit Code of Conduct, a template for regulation of the NGO sector to be adapted by states, and a suggested rules of engagement for partnerships.

I have developed on these themes further in the following articles:

1. Contracts to devolve health services in fragile states and developing countries: do ethics matter? Journal of Medical Ethics 2009; 35: 552-557

2. Faith-based NGOs and healthcare in poor countries: a preliminary exploration of ethical issues. Journal of Medical Ethics. 2007: 33:623-626

3. Erosion of trust in humanitarian agencies: what strategies might help? Global Health Action (Accepted for publication)

Saroj Jayasinghe
Professor in the Department of Clinical Medicine
Faculty of Medicine
University of Colombo
Sri Lanka

and

Hon. Consultant Physician
National Hospital of Sri Lanka
Colombo

I hope this will add to our knowledge and help to cement our understanding on issue of this kind in our developing countries.

i am working in msf , manipur a conflict area in India . msf is doing its operation very well .

some challenges are ngo's are sort of considered 2nd hand ,by the govt.

lack of communication between the 2 players (state and ngo)

poor qualification is also another constrain .

i strongly feel discussions and interactions on various levels would solve some of these issues .if we have RELATION (AS IN OUR FRIENDS LISTEN TO US ) , half of our problems would be solved .

empowering employers through various educative courses is also another tool for improvement .

kind regards

jeetesh , msf

Dear Dr. Saroj Jayasinghe: I run a small NGO based out of Portland, Oregon, currently doing projects in Kathmandu, Nepal. Your concerns regarding the imbalance in power relations are well taken. I appreciate your suggestions to tackle the hegemony of NGO-dom, "...by increasing the transparency of NGOs and aid organizations. This could be achieved by having a Global Register of INGOs and aid organizations, a more explicit Code of Conduct, a template for regulation of the NGO sector to be adapted by states, and a suggested rules of engagement for partnerships." While this sounds good, I am concerned about donor motivation. Who is going to bell the cat, and why would they bother? Have you had any progress in moving forward with any of these suggestions, if so, it would be helpful if you shared them with us. Thank you!

I am 100% agreement with Dr. Saroj Jayasinghe regarding the 3 concerns mentioned:
1.) In the world of NGO/philanthropy vs developing nations, the scale will almost always tilt towards the former, making the them the ones in power and the country in need the recipient rather than the participant.
2.) I have been concerned for a very long time of the out come various NGOs expect, because of their focus, be it faith based or government sponsored, because the parameters to gage success come into play and make me question their validity and actual effectiveness.
3.) I am just going to quote the Dr. now because i hope everyone can see we need to be cognicent of the following "...the potential for NGOs to undermine health sector development. Would the partnership lead to a dependency culture and retard the growth of indigenous capacity?"
This aspect should be frightening to all! Because it means the inbalance of global health will never right itself. To achieve a balance it will require teaching, mentoring, allowing failures and open minded cultural sensitivity only then will we see an equalizing the health care delivery system.

And...in my own words...I agree with the ...

I am 100% agreement with Dr. Saroj Jayasinghe regarding the 3 concerns mentioned:
1.) In the world of NGO/philanthropy vs developing nations, the scale will almost always tilt towards the former, making the them the ones in power and the country in need the recipient rather than the participant.
2.) I have been concerned for a very long time of the out come various NGOs expect, because of their focus, be it faith based or government sponsored, because the parameters to gage success come into play and make me question their validity and actual effectiveness.
3.) I am just going to quote the Dr. now because i hope everyone can see we need to be cognicent of the following "...the potential for NGOs to undermine health sector development. Would the partnership lead to a dependency culture and retard the growth of indigenous capacity?"
This aspect should be frightening to all! Because it means the inbalance of global health will never right itself. To achieve a balance it will require teaching, mentoring, allowing failures and open minded cultural sensitivity only then will we see an equalizing the health care delivery system.

And...in my own words...I agree with the Dr. on how we can resolve these issues. What I hope to see in my lifetime:
A universal set of parameters of aid offered by groups so that all concerned can understand the scope and reach of the project at hand before embarking.
A clear purpose and measurable standard by which to gage success by each organization stated within the mission guidelines if not in the mission statement.( why not?)
Greater sensitivity to cultures, aid workers working within the system of the developing nation, not from the outside looking in. NGOs and the rest need to allow the current systems room to develop and work with the players already involved.

Brook Courchaine
Carrizo Project
www.carrizoproject.org

Dear All,

Being a panel of expert I have the following questions:


- whether all will response to all questions for health
system strengthening or
- each will be responsible for specific ones to response and if it is
such then I will choice any one of the following two question


- What are some of the main challenges of administering joint programs?
- How can NGOs best support building local human resource capacity?

Look for your kind guidance to prepare myself.
Best regards,* *

Ferdousi

*
*

*
*

*Please note my email address has changed to
>
*
*Dr. Ferdousi Begum* *| Maternal and Child Health and Nutrition Specialist
and Country Manager, Bangladesh**|**Food and Nutrition Technical Assistance
Project (FANTA-2), Global Population Health and Nutrition*
*8 Gulshan Avenue, Gulshan-1, Dhaka-1212*
*Mobile:(+88) 01730011740*
<> | www.fhi360.org | *

[image: FHI360]
*Please note that my email address has changed. Please update your address
book. *
FHI 360 has acquired the programs, expertise, and assets of AED.

NGO's are are playing great part in providing mentor-ship and capacity building (Trainings)to the government workers so that they can sail in the same boat towards the agreed targets. But there have been challenges which faces these NGO's, when a government move a work who has trained by these NGO's to other activities away from the Joint Program this shakes the activities and affects the performance in delivering health care to the people.
On the side of the main challenges administering the joint programs is the loyalty.
The targets Jointed these programs are well technically known but loyalty is lacking in playing the parts, some organizations are not sincere to their roles, they don't put enough energy on the field, and they come back with cooked Data, and when the data are sent on the table for decision making, its obvious the decision will not be in rhythm with the reality the society faces,and the same society will end up being the victims of the circumstances.
There has been a good and successful partnership Tanzania

Hi, I am a physician and researcher in Pakistan and am looking forward to this discussion. I have worked with a number of health related NGOs in the past.
NGOs certainly have a role, especially in countries where the government is not doing enough. However it is difficult for NGOs to work on a scale large enough to bring about large changes. I see partnerships between the government and NGOs as a potential solution to this.
Another concern I have is (since NGOs need a constant source of income to mainain their organization) often times the work NGOs do is very donor driven and they end up working in an area where funding is readily available. Thus areas where there is large need but no international funding are neglected.

We run a 30 bed rural tribal goverment hospital in Gujarat india for last 8 years.employees are ours and salary is paid as grant thru us this is most sucessful ppp. Experiment. And I believe this the answer to rural healthcare. We are NGO

Dr haren Joshi

Sent from my iPhone

Hi, I am representing Operation ASHA, an Indian NGO that fights tuberculosis in slum areas. Our operating model is largely focused on a public-private mix, which has allowed our organization to quickly scale up. I am interested to discover ways that NGOs are departing from their dependency on donations.

I too work with Operation ASHA, India. It would be really good to understand the changing scenario in a resource-limited setting that's been around and also, how this is going to affect the future of NGO's. Is it going to bring out better results?

I hope to contribute and learn a great deal too.
Thanks.

I am wondering as a student how I can contribute to an organization remotely beyond just checks and signatures on petitions. Are these best ways to contribute?
Thank you very much!

Hi, I am working with an NGO,in South India in a PPP model-Public Private Partnership for PPTCT.I sincerely wish to learn for this discussion and also contribute to share my experiences and learning's from this project of three years.Vertical programs should be designed in a way that benefits are accrued for the health system at large.NGOs definitely play a critical role in this area by acting as advocacy agents with multiple stakeholders in creating momentum towards this goal of health system strengthening-in areas of systems development-Health Information Systems, Research, Capacity Building of the health workers, also awareness building for accessing available health services in the govt.sector etc.Looking forward for this panel discussion.

Dear all,
This is a good opportunity for an organization like mine working in the rural communities to share in their experience and possibly contribute to the discussion. Look forward to the D day.
warmest Regard,
Eucharia Samuel.

We must not forget the role of health professionals when strengthening health systems. We must also go even a step back and look at the education of these health professionals as well. Many NGOs are looking at this aspect of health systems strengthening through education and training.

The World Health Organization (WHO) also has an initiative in the area of health systems strengthening looking at health professional education. The Initiative aims to support and advance the performance of country health systems so as to meet the needs of individuals and populations in an equitable and efficient manner.

http://www.who.int/hrh/education/initiatives/en/index.html

Looking forward to the discussion.
Rodrigo Rodriguez-Fernandez

Where does oral health fit into the equation for those of us trying to help? Richard T. Reckmeyer, DDS, MBA, Executive Director, Rural Rwanda Dental, www.rrdental.org

I'm try to understand building local human resource capacity in two ways:1st way is to increase the knowledge of personnel of health providers through scholarships and different trainings as well as workshops;2nd is to improve the salary of health providers especially those of rural area,to maintain the personnel over-there,then,to improve their life.

I am interested in hearing thoughts on short-term medical mission trips (1 week or less in length) including their value, training that is needed, and ways to transition from a short-term focus to something sustainable in the long-run. Are there resources that can help fledgling groups get more organized with recruitment and training of medical personnel who volunteer for these trips (and come mainly from U.S. hospitals) but have no prior experience in working in a 3rd world country such as Haiti. Thank you!

This is a very useful subject for discussion. The issues with most NGO,s is that they go a very quick fix and always wanted immediate results. I think we all need to realise that change is a "transformations" that requires time. Please lets decide with the NGO's on sincerity of purpose. will participate in the discussions. Gidado Mustapha

First off, "developing nations" best describes the places we are trying to support, 3rd world implies 3rd place, which has always made me wonder who is first and second.

As far as short-term medical mission trips, in my experience, few have the language ability and even fewer understand the culture they visit. All too often it seems the mission is an adventure rather than a solution to a very real problem; access to health care..the key being health, which includes on-going education on healthy living and addressing chronic health and lifestyle issues.

I would love to hear from anyone in country who has seen the short-term, revolving staff of medical missions make a measurable difference. I can see value in visiting to share information teach a new techniques, and even simply add helping hands to a short term situation. But in the long run every bit of help given must work within the culture of the target country.

I worry about the message we send healthcare systems in developing nations and the message received by the patients themselves when medical missions come and go. It reminds me of the misuse of Emergency Rooms in the USA, where the patient ...

First off, "developing nations" best describes the places we are trying to support, 3rd world implies 3rd place, which has always made me wonder who is first and second.

As far as short-term medical mission trips, in my experience, few have the language ability and even fewer understand the culture they visit. All too often it seems the mission is an adventure rather than a solution to a very real problem; access to health care..the key being health, which includes on-going education on healthy living and addressing chronic health and lifestyle issues.

I would love to hear from anyone in country who has seen the short-term, revolving staff of medical missions make a measurable difference. I can see value in visiting to share information teach a new techniques, and even simply add helping hands to a short term situation. But in the long run every bit of help given must work within the culture of the target country.

I worry about the message we send healthcare systems in developing nations and the message received by the patients themselves when medical missions come and go. It reminds me of the misuse of Emergency Rooms in the USA, where the patient visits an ER and doesn't follow up with care.

Please, i honestly invite examples of the productiveness of short term missions. In what instances are they preferable, other than where there is absolutely no other option for care.

Brook Courchaine
Carrizo Project

This is very important topic for discussion,but issues of NGO is the bridge between government and community at large. The NGO realised the core mission to exits in the country where we are operating. NGO wanted quick results its not true but sometime the resistant from the government take action based on immediate results from community such case of TB, HIV, cholera and malaria.
The role of NGo sector is to advocates the isues that hind the community canot reach the government or the developement partners to solve theirs problem.
The NGO is mouth piece of the voiceless. in this health system are few players in advocates for government to consider more resources rather than any sector that mighty think. The chnage cannot happen at once but they have some circumstances that we need immediate impact that doesnt relate to behaviour change intervention. We as NGO we have suffering resources to strength health systems so that we complements government efforts.
The last recommendation is that the donors think much on how the increase aid to NGO who are currently implementing health system it will help the government the process of health workers, drugs supplies, decent houses, electricity, capacity building ...

This is very important topic for discussion,but issues of NGO is the bridge between government and community at large. The NGO realised the core mission to exits in the country where we are operating. NGO wanted quick results its not true but sometime the resistant from the government take action based on immediate results from community such case of TB, HIV, cholera and malaria.
The role of NGo sector is to advocates the isues that hind the community canot reach the government or the developement partners to solve theirs problem.
The NGO is mouth piece of the voiceless. in this health system are few players in advocates for government to consider more resources rather than any sector that mighty think. The chnage cannot happen at once but they have some circumstances that we need immediate impact that doesnt relate to behaviour change intervention. We as NGO we have suffering resources to strength health systems so that we complements government efforts.
The last recommendation is that the donors think much on how the increase aid to NGO who are currently implementing health system it will help the government the process of health workers, drugs supplies, decent houses, electricity, capacity building especially in rural areas.
OSSEDI Malawi is NGO currently implementing strength health system in rural health centers but very sorry if you try.
OSSEDI Malawi will recommadation on increase ofmoney on health system.
stanley chitukwi,
OSSEDI Malawi

lam try to understand the strength health system in two ways: 1 building capacity of health workers especialyl in the rural areas.2. Increase incentives and motivation to health workers especilly in rural settings.
The last focus is that government policies must be familiar with community at large.
My participation its like that.
stanley chitukwi

I'm curious to learn a little bit more about the need to strengthen the administrative side of the health facilities. It seems to me that there is a huge lack of focus on clerical staff in clinics. These staff are usually the first point of contact that patients have within the health facility and where one can find the longest delays due to lost folders, untrained staff, and poor understanding of roles and responsibilities. This results in many nurses having to do more clerical work.

Dear Claudine, Your observation "It seems to me that there is a huge lack of focus on clerical staff in clinics." is right on the mark. There should be a much greater focus on the clerical staff in clinics and hospitals where the patient presents, and where the patient data is first captured - in manual paper-based documents. This is where, as you point out, "These staff are usually the first point of contact that patients have within the health facility and where one can find the longest delays due to lost folders, untrained staff, and poor understanding of roles and responsibilities. This patient data should be captured in e-format at the point of contact/care - then distributed in e-format to all those who need such information to better treat the patient, and to manage the clinics and hospitals based on 'evidence' that is accurate and timely.

This also addresses your last point - "This results in many nurses having to do more clerical work." - which is unfortunate, as nurses are trained to look after patients, and should not be wasting their valuable skills on paperwork. In addition, it is LESS expensive overall to capture this patient data in e-format at the ...

Dear Claudine, Your observation "It seems to me that there is a huge lack of focus on clerical staff in clinics." is right on the mark. There should be a much greater focus on the clerical staff in clinics and hospitals where the patient presents, and where the patient data is first captured - in manual paper-based documents. This is where, as you point out, "These staff are usually the first point of contact that patients have within the health facility and where one can find the longest delays due to lost folders, untrained staff, and poor understanding of roles and responsibilities. This patient data should be captured in e-format at the point of contact/care - then distributed in e-format to all those who need such information to better treat the patient, and to manage the clinics and hospitals based on 'evidence' that is accurate and timely.

This also addresses your last point - "This results in many nurses having to do more clerical work." - which is unfortunate, as nurses are trained to look after patients, and should not be wasting their valuable skills on paperwork. In addition, it is LESS expensive overall to capture this patient data in e-format at the point-of-contact/care!

Sincerely Ron Hebert, Toronto, CANADA

Certainly I would agree with Claudine about the clerical work but contrarily if we leave the medical terminology to clerks then again it creates lot of problems, so what could be the way out

Greetings, all. Before I post my response to the first question, I have replied to most of your comments/questions thus far. See below:

1: Steven, your comment is appreciated. Looking forward to the discussion.

2: Joseph, Maybe what you propose can be the solution, but the best way is to sit down with Haitians and hear from them what the best way to make their registration is and how to make a coordination system work, and to help them with those processes.

3: Nicholas, The difference between a single clinician working to save lives of individual patients, and a Ministry which has to care about all citizens, is that you as a physician are concerned by your own education, your own capability and capacity to provide quality care. But the government has to plan, maintain, and innovate for the whole system – creating education systems that produce enough health providers for quality care, for example. For this, a government needs money – meaning advocacy. To make this happen, we need national strategies, policies, plans and protocols to make the money work in a coordinated manor where all patients will benefit. To have policies, strategies, plans, protocols that can work, they need ...

Greetings, all. Before I post my response to the first question, I have replied to most of your comments/questions thus far. See below:

1: Steven, your comment is appreciated. Looking forward to the discussion.

2: Joseph, Maybe what you propose can be the solution, but the best way is to sit down with Haitians and hear from them what the best way to make their registration is and how to make a coordination system work, and to help them with those processes.

3: Nicholas, The difference between a single clinician working to save lives of individual patients, and a Ministry which has to care about all citizens, is that you as a physician are concerned by your own education, your own capability and capacity to provide quality care. But the government has to plan, maintain, and innovate for the whole system – creating education systems that produce enough health providers for quality care, for example. For this, a government needs money – meaning advocacy. To make this happen, we need national strategies, policies, plans and protocols to make the money work in a coordinated manor where all patients will benefit. To have policies, strategies, plans, protocols that can work, they need to be made in a participatory process in meetings and forum. That’s why, all the words that you have stated have a meaning for the good of the population when they are targeting the health and the welfare of each individual citizen that practitioners are caring for. Of course, for the money to work most effectively, we need transparency and to fight corruption to be sure that what you raise actually reaches the targeted population and not the pockets/bank accounts of the people that are between the money and the population.

To your second point, NGOs can contribute to salaries but not forever. A government must have a strong economic plan to have enough money to pay their civil servants. That’s why whatever we do in the health sector in Rwanda must fit in the overall development plan of the country. If it doesn’t fit in the development plan of a country not, don’t be surprised if you cannot sustain it.

4: Alain, Information can be seen on our website www.moh.gov.rw for the size of NGOs. And the greatest impact is always where we don't have national capacities yet. And it is great if there is a transfer of capacity, in fact we require this by rule in Rwanda.

5: Philip, In order to sustain that we need formal education, real infrastructure, and economic development. This is the other part of Partner In Health’s experience, as important as the community volunteer point you bring up.

6: Philip, It’s always good to share experience.

8: Anantha, I am not sure what leadership and expectation you are referring to. But you are right, that NGOs add value to health care delivery especially when there is a lack of human resources.

10: Sarder, Thank you for sharing this very good comment. I would like to add that national ownership is the first prerequisite, good strategies policies and tools on which you anchor the work of NGOs is the second part. And when you have that, success is guaranteed.

11: Saroj, This is debated throughout the week – how to avoid brain drain. Also, if money comes in a vertical way in your country, let it come. Just turn it horizontally when it comes. This idea is linked to the 3 Ones principle of UNAIDS for HIV (One national authority: the government, one national plan, one M&E plan). A plan must be expanded to the entire health sector, meaning every single dollar coming in your country has to support the health system and provide quality care. That is what we did in Rwanda. It’s just a matter of synergizing your strategies and ensuring you stick to the national plan and coordinate your sector.

The second issue is that the agendas of certain NGOs and state-sponsored aid organizations, and the universal humanitarian agendas they are supposed to espouse should be identified. For example, faith-based organizations such as World Vision or state-sponsored ones such as USAID would have their own agendas (as stated in their own websites) that need not necessarily correspond to the needs of the recipient state. In such instances, how would the partnership be fostered to achieve the humanitarian aims?

Whatever agenda NGOs have, they have to leave it in their headquarters. When they enter in your country they jump into your national plan. And in any case, in doing so they can achieve far more. It’s a win-win situation. It’s not a matter of questioning the agenda and the plan of NGOs, it’s a matter of questioning your agenda and your plan. And have the leadership to make it happen.

Regarding the potential for NGOs to undermine health sector development. This should not happen if the first step is taken toward having a development plan in a given sector: having a vision, having policies, strategies and plans to guide the country in this vision, and ensuring the coordination of all stakeholders to implement it. For this you need to create a legal framework enforcing that all in your sector work within your plan.

Regarding transparency. In Rwanda we have applied double accountability – we are accountable for the money we receive and the way we implement, and partners are accountable for the way they raise money for us, and how they distribute and spend it. For this again we have created a framework for mutual accountability.

12: Thaddeus, Hope we all learn from each other throughout out the week.

13: Jeetesh, You should always find a way to collaborate with a government when you come to work for their people. Follow along the debate this week and you will see panel posts about that.

14: Xeno, There is a Code of Conduct in the resources on this site by James Pfeiffer. If you want a better resource could you read the existing one and propose amendment?

16: Ferdousi, People on and off the panel will answer questions where they believe that their answers will add value.

17: Thaddeus, The solution is a strong pre-service training so that all people have the capacity to do the job without a hands-on mentor. Pre-service training is what happens in the West and the North. Mentorship principle without bringing whom you mentor in pre-service, is a way to ensure that underdevelopment continues. So we need more formal education and pre-service training.

On partnership. Good partnership is not only in Tanzania, if you want people to do the work plan and not to slow down the process, then have good M&E. If you believe they cook data, do a good audit and expose the people who are tricking the system.

18: Nabeel, You are right; sustainability of programs in a country belongs to the government, which is capable to take charge of public services. To make this happen, we need to be not money-driven, to recognize the poison money that can shoot down your system, have plans that are nationally owned and community-needs-driven. For this, the government must have the courage to say no to some poison money.

20: Nicholas, You are right – national NGOs must be able to find finances nationally for their own sustainability. Some models exist; one example is the Aravind Eye Care System, which uses a cross-subsidization model for some patients who can afford to do so to pay for care, while the poorest receive care for free. (www.aravind.org). In Rwanda, we also have another model through our community health insurance program called mutuelle de santé, which uses a similar financing scheme to generate revenue and ensure both universal coverage and long-term sustainability with the support of the government to take into account the poor.

21: Prateek, Could you please explain further about the changing scenario you are referring to? Is it the transition to a middle-income country or something else?

22: Claire, You can help good NGOs to provide services locally, whether through the headquarters of international NGOs or volunteering in your own community. You can also contribute to the national political environment through advocacy that supports health and development – write newspaper articles and have conversations. Invest in your own learning through opportunities like this so that you can become a useful partner now and in the future – when you have time to go and help directly, this learning will pay off!

23: Sree, You are right, but all of these things must be cost-effective. This means that NGOs must reduce overhead and help to pursue sustainable development.

24: Eucharia, Yes, waiting for our dialogue together.

25: Rodrigo, Pursuing health systems strengthening through medical education is good, but only if we promote formal training in a sustainable manner to create critical masses of workforce suited to the country’s needs. Whatever we do should not be theoretical, but rather measured in the number of health professionals formally trained. Many organizations measure their activities by empty metrics such as simply the number of trips taken – so, good on paper but…

26: Richard, The mouth is a part of the body that needs prevention, care, and treatment just like other parts. So countries and NGOs need to include oral health in our comprehensive approach to basic care as well. But partners have to include themselves in a national plan; they just go into one small part of a country and start something that is not sustained – a comprehensive approach to health means not just an approach to the body but also to the geography of the country and the training of its human resources in a comprehensive and holistic manner to make NGO services part of the national plan.

27: Buregeya, For scholarships, it is better to train people in their home country by focusing on increasing the capacity of their teaching institute by giving the country the ability to create, in a sustainable manner, the necessary human resources for health.

28: Juliet, Everything is about cost-effectiveness. The most effective assistance is being in the country for a longer term (at least three to six months) and transferring capacity so that you add value for your investment in your air ticket and your time. Even young professionals have something to share and knowledge to transfer. But again, we need to see the most cost-effective part of that.

29: Gidado, You are right. Quick solutions may handicap sustainable solutions, if not written in the national health plan and if not part of the national development plan. But this is not because you spend so much time to think, strategize, plan, and implement that you do better – it is all a balance. It is up to the country to choose its own approach. Except, of course when there is a catastrophe or something that must be fixed in an emergency for saving lives – even the quick fix solutions have their place.

31: Stanley, I would argue that NGOs do not form a sector of their own; they are just intermediaries to serve communities. As part of civil society, they can be a bridge between communities and other sectors, but they must do this in a sustainable way. This means working today in order to not be needed tomorrow – NGO employees should envision working themselves out of a job.

The problem of many NGOs is that they are working without a focus on transferring capacity, and donors should not necessarily increase the aid to NGOs – they should increase both the amount of and proportion of aid to communities themselves, so that communities can determine their own destiny for a better life. I agree with you that we need to increase money for the health sector, but the money should go to the public sector in order to provide access to quality, affordable, accessible care for all.

In Europe and the United States, big health threats have not been solved by NGOs, but by good public service. So, that’s what we should look to build because only equitable public service responds to the right to health for all people. In the mid-term, some NGOs are doing a good job, but to believe that they are going stay is accepting that we will be forever under-developed.

32: Stanley, Again, capacity building should influence pre-service training. When you identify a gap in the capacity, you should train people in services but immediately reinforce the pre-service training. Otherwise, you will build capacity forever and never transfer it; you will remove people from work in order to train and re-train them, when they should have been trained in pre-service learning.

For your second comment, we should not talk solely about salaries, but rather about total income (salaries in addition to additional/bonus compensation). Salaries are a constitutional right and must be the same for the same service across the country in Rwanda. But performance-based financing (PBF) is allocated according to the remoteness and the level of discomfort for working. So, in Rwanda, we will start next month to implement three zones of PBF: cities, rural, and most remote.

33: Claudine, I agree with you. That’s why we are developing courses for hospital managers in Rwanda through our School of Public Health. It is even more important than this; bad management causes the health sector to lose a lot of money that could have been used to provide more and better services to people and to purchase more drugs and consumables. As I always say, health is too important to be left to doctors alone! So management is key.

Greetings all, I am very pleased to join you for this panel and look forward to a great conversation this week. These issues are crucial for all of us who seek to work together to provide high quality health care in the most equitable ways around the world. Thank you for inviting me. Here is my response to the first question:

1) What are the most crucial aspects that make for successful partnerships between NGOs and Ministries of Health?

First and foremost, the country in question needs a vision and a national plan. In
Rwanda, it was essential that this plan was part of the national development framework. Further, within that national plan, the health sector must have its own strategic plan. This allows for NGOs to work within the framework of a sector-wide approach like we have in Rwanda (we call it the SWAp, as it is focused on capacity transfer as well as harmonization of NGO and governmental activities). This means that all NGOs working in a country must be committed to the national vision and that the Ministry of Health does not allow NGO partners to diverge from its plan. This structure facilitates coordination within the health ...

Greetings all, I am very pleased to join you for this panel and look forward to a great conversation this week. These issues are crucial for all of us who seek to work together to provide high quality health care in the most equitable ways around the world. Thank you for inviting me. Here is my response to the first question:

1) What are the most crucial aspects that make for successful partnerships between NGOs and Ministries of Health?

First and foremost, the country in question needs a vision and a national plan. In
Rwanda, it was essential that this plan was part of the national development framework. Further, within that national plan, the health sector must have its own strategic plan. This allows for NGOs to work within the framework of a sector-wide approach like we have in Rwanda (we call it the SWAp, as it is focused on capacity transfer as well as harmonization of NGO and governmental activities). This means that all NGOs working in a country must be committed to the national vision and that the Ministry of Health does not allow NGO partners to diverge from its plan. This structure facilitates coordination within the health sector. However, in order to make this work for in the long run, the national strategic plan must be accompanied by plans for both implementation and monitoring and evaluation.

It is crucial that NGOs do not simply come to Rwanda to implement interventions that have proven effective in Geneva or New York or Washington. Instead, NGOs should implement what has been proven effective (or to work with us to determine what will be even more effective) in Rwanda and respond to the actual need of Rwandans. For this to work across the entire health sector, Rwanda ensures that all planning takes place in a decentralized and participatory process, involving stakeholders at all levels – from the community, all constituencies of civil society, and the local and central government. When the planning is complete, all actors must stick to the result.

Another key aspect for successful partnerships with NGOs is the equitable distribution of activities across the country in order to ensure that the entire population benefits from their presence. The Ministry of Health must ensure that NGOs do not concentrate themselves exclusively in only a few parts of the country. Ministries should make NGOs work together and capitalize on synergies between their areas of work. If they are involved in medical procurement, they should coordinate their activities together to take advantage of economies of scale. Such actions help to avoid duplication of efforts, and they maximize benefits for the population.

For NGOs, it is very important to support the government’s leadership of the national plan, but also to contribute to its design. If there is no comprehensive national plan yet, NGOs should be ready to assist with the planning and implementation of a national strategy that they can be a part of. Such a strategy is not simply a plan for the central government, but the expression of a vision of the entire nation. Collaboration is key – everybody must be brought on board for the inclusive and community-driven planning process in order than it can respond to community needs. Again, however, the government itself must lead, because it is the central agent of planning and implementation efforts. The NGOs and public implementing agencies should be there to buttress and assist in realizing the vision of the government.

As a brief illustration, let us examine the situation in Haiti right now. First and foremost, what should be done is to convince all NGOs operating in the country for the long-term reconstruction efforts to come together and resolve to assist the government in a comprehensive national development plan for the country’s future. A national consultation should be undertaken that identifies the various constituencies and lists all stakeholders in Haiti. The population should be asked directly what their vision for Haiti looks like. All should participate, but the lead voices in orienting the vision should be those of the Haitian population. Together, the government, the population, and Haiti’s many NGO partners could move forward with strategies and planning activities to pursue that common vision for the country. This may seem like a tiring process but it is the only way to assure a comprehensive, participatory plan that takes into account the needs of all.

Fighting corruption is also critical to making the maximum use of the money available. So it remains crucial for NGOs to be honest and transparent about their overhead costs, and for all actors to be accountable be in a framework of zero-tolerance for corruption. In the case of Haiti, the government and the NGOs together need to maintain the primary goal of rebuilding Haiti for all Haitians – never to use the suffering of the population to take advantage of them or gain financially.

In 2005, UNAIDS developed the “3 ONEs” concept for the fight against AIDS: One national authority (the government), one national plan, and one monitoring and evaluation plan. In Rwanda, we have applied the depth and breadth of our participatory approach to planning, implementation and tracking in order to leave no Rwandan outside of the benefits of our progress. And to that end, we always focus first on the most vulnerable to ensure that our entire population enjoys the advancements of our nation’s development.

* Please describe some of the aspects you consider crucial to NGOs and Ministries of Health working in partnership to strengthen local health care delivery.

MoH need to know who is working where (and have MoUs with them) - this mapping needs to be shared with others. NGOs need to be included in joint assessments and have a voice, they need to be included in health policy development, and health system review and health sector reform. NGOs are skilled at determining supply and demand side failures and calling for reforms to address these issues. Thet are also good at putting together pilots for operational research to improve health service delivery and health outcomes.

* What are some of the main challenges of administering joint programs?
Resources, many NGOs do not have strong national level presence, the numbers of NGOs and their different sizes make speaking with one voice hard however in the last few years many NGOs have shown how good they are in coming together for agreed priorities. Finally WHO and others do not regard or include NGOs in the field in a systematic way

* How can NGOs best support building local human resource capacity?

Through working in curiculum exspansion with nursing ...

* Please describe some of the aspects you consider crucial to NGOs and Ministries of Health working in partnership to strengthen local health care delivery.

MoH need to know who is working where (and have MoUs with them) - this mapping needs to be shared with others. NGOs need to be included in joint assessments and have a voice, they need to be included in health policy development, and health system review and health sector reform. NGOs are skilled at determining supply and demand side failures and calling for reforms to address these issues. Thet are also good at putting together pilots for operational research to improve health service delivery and health outcomes.

* What are some of the main challenges of administering joint programs?
Resources, many NGOs do not have strong national level presence, the numbers of NGOs and their different sizes make speaking with one voice hard however in the last few years many NGOs have shown how good they are in coming together for agreed priorities. Finally WHO and others do not regard or include NGOs in the field in a systematic way

* How can NGOs best support building local human resource capacity?

Through working in curiculum exspansion with nursing and midwivery schools, carrying out training for health workers based on a nationally agreed and competency based model, these workers need to remain part of the health system and NGOs can support the establishment or strengthening of a national ISS (integrated supportive supervision system). NGOs can also help to expand roles of health workers with increased training and on the job trainging and motivation exercises. Shadowing has also worked well in some countries and placing an experienced NGO person into a district or ministry of health position can be one way of strengthening management skills. Also carrrying out managerial, policy and financing training can also strengthen the performance of the staff.
* How should partnerships between NGOs and the public sector deal with infrastructure needs?

NGOs can be contracted in by governments or contracted out. Either way they should be supporting the development of national health system infrastructure. It must follow national priorities and plans. Communities need to be involved in the planning and monitoring of infrastructure development so they are aware that the government not the NGO is doing the work. Also NGOs will need to reduce their branding and use materials that can be made in country with resources available to them.
* Are there examples of current partnerships you think have been particularly successful at strengthening health systems?

Liberia has worked well with NGOs to strengthen systems (such as getting one NGO to oversee a district level HSS programme and ensuring joint evaluation meetings are attended regularly)as has malawi. Similarly in Afghanistan where NGO all utilise competency based standardised training modules to increase the number of competent community midwives.

My greetings to all, my names are Felix Kayigamba; an MD and a public health specialist currently working as a country director for the Access project in Rwanda. Please see below my contribution to on the critical aspects to NGOs and Ministries of Health working in partnership to strengthen local health care delivery:
1. NGOs should follow MOH’s lead — they should not impose new policies but rather contribute to the existing strategies. All interventions should be cleared by MOH and in fact, MOH should decide where partners intervene — assign the districts/regions of operation based on perceived levels of donor/NGO support.

2. Rwanda’s health sector has demonstrated a firm grip and commitment towards the principles of government ownership of health programs. For instance NGOs have the interest of working in Rwanda because they believe in Rwanda’s ability to see their interventions through; to adopt for scale-up; and to ultimately create a health system that serves all with minimum dependence on outside interventions overtime.
3. NGOs should not see themselves as permanent fixtures — in fact, all interventions should be tailored to reasonable periods (of course with some flexibility) of intervention beyond which local ownership and sustainability takes ...

My greetings to all, my names are Felix Kayigamba; an MD and a public health specialist currently working as a country director for the Access project in Rwanda. Please see below my contribution to on the critical aspects to NGOs and Ministries of Health working in partnership to strengthen local health care delivery:
1. NGOs should follow MOH’s lead — they should not impose new policies but rather contribute to the existing strategies. All interventions should be cleared by MOH and in fact, MOH should decide where partners intervene — assign the districts/regions of operation based on perceived levels of donor/NGO support.

2. Rwanda’s health sector has demonstrated a firm grip and commitment towards the principles of government ownership of health programs. For instance NGOs have the interest of working in Rwanda because they believe in Rwanda’s ability to see their interventions through; to adopt for scale-up; and to ultimately create a health system that serves all with minimum dependence on outside interventions overtime.
3. NGOs should not see themselves as permanent fixtures — in fact, all interventions should be tailored to reasonable periods (of course with some flexibility) of intervention beyond which local ownership and sustainability takes over. Definitely building a strong health system with effective management principles takes time. However obvious way to go and they should align towards this approach.

4. NGOs should work with the Government at all levels – from national to the local authorities; they should work with district and community planning officials, to shape their management work in accordance with government priorities around health systems strengthening. While intervening at health facilities NGOs should customize their objectives according the goals designed by the government in their areas of intervention; i.e. engage in an ever-collaborative process, as opposed to coming in as INGOs and push their own priorities.

Welcome to all participants. I'm honored to be part of this discussion and am looking forward to a rewarding conversation over the next five days
I am the Chief Operating Officer of Partners In Health (PIH) and Project Manager for the Programs in Global Health and Social Change at Harvard Medical School. I manage the operations of PIH’s activities worldwide and help to define and implement our strategic and programmatic goals. Fifteen thousand strong, we work in 12 countries and implement a $118 million budget. With our partners, we provide medical services for several million patients, train thousands of healthcare workers, conduct research projects to document and strengthen our community-based model of care, and advocate for global and national policy change.

1. I think there are three important elements for successful partnerships between NGOs and Ministries of Health. The first is communication; it’s 90% of the relationship. Sharing information from the beginning and throughout the engagement is essential for the partnership to succeed. It’s the responsibility of the NGO to meet the Ministry where it works at the local, district, and/or national level. For PIH, the primary focus is the district. In all the countries where we work, the districts have a governance structure and a process to prepare district goals that feed into national ones. In Rwanda, for example, all NGOs in the region are invited to district planning meetings. Being cognizant of this process and participating in these meetings has been a key part of our work. It has provided us with opportunities to listen and learn about the Ministry’s plans and policies, see how we can harmonize our work with that of the Ministry, and explain our plans and activities.

The second important element is to be fully transparent in dealing with Ministry officials. Being forthcoming about your aspirations, work plans and constraints, including budget and organizational capacity constraints, helps to foster understanding and ...

1. I think there are three important elements for successful partnerships between NGOs and Ministries of Health. The first is communication; it’s 90% of the relationship. Sharing information from the beginning and throughout the engagement is essential for the partnership to succeed. It’s the responsibility of the NGO to meet the Ministry where it works at the local, district, and/or national level. For PIH, the primary focus is the district. In all the countries where we work, the districts have a governance structure and a process to prepare district goals that feed into national ones. In Rwanda, for example, all NGOs in the region are invited to district planning meetings. Being cognizant of this process and participating in these meetings has been a key part of our work. It has provided us with opportunities to listen and learn about the Ministry’s plans and policies, see how we can harmonize our work with that of the Ministry, and explain our plans and activities.

The second important element is to be fully transparent in dealing with Ministry officials. Being forthcoming about your aspirations, work plans and constraints, including budget and organizational capacity constraints, helps to foster understanding and clarify Ministry expectations about what you can achieve.

Third, flexibility and nimbleness when planning and implementing programs and activities help the partnership to grow. For example, if in learning about district goals, we find that some of our activities are duplicating the Ministry’s, do not overlap with theirs, or impede the intentions of the Ministry, we try to reallocate the budget to those activities which are more in line with the Ministry’s goals. If the Ministry asks us to support particular strategic items or projects such as purchasing ambulances or renovating a clinic, we try to accommodate these. Our aim is to be responsive to the Ministry’s plans and policies and not work in isolation, or in opposition to them. Communication, transparency, and flexibility all help to breed trust and clarity in the partnership.

a.THE GOAL:This has to be clearly defined.The MOH and the NGO after identifying the problem of interest should set a target to achieve. That is the goal.The resources, manpower,funds and equipment with the goal in mind.Without a goal, the journey lacks purposeful direction.

b.MANPOWER:Appropriate manpower required for reaching the goal is necessary.Healthcare professionals are required in all aspects of the service - information,education and medical care, when the need arises as there may be in NGOs assisting in the service to HIV ans Cancer patients. Manpower therefore remains a very crucial issue.

c.Funds:This is very crucial to both the MOH and NGOs partnering in the delivery of care.Our governments do not fund NGOs, they fund political organizations at the grassroots instead. Even international Donations meant for assistance in Health Care Delivery are diverted. A lot get stollen, even within the Ministry of Health.

d.HEALTH INFRASTRUCTURE:Another very crucial aspect here. In my country Budgetary allocations for Health is usually below 5%.And this is never made available to the MOH for required services in providing Health infrastructure . The ones provided are usually along lines of Party Patronage ...

a.THE GOAL:This has to be clearly defined.The MOH and the NGO after identifying the problem of interest should set a target to achieve. That is the goal.The resources, manpower,funds and equipment with the goal in mind.Without a goal, the journey lacks purposeful direction.

b.MANPOWER:Appropriate manpower required for reaching the goal is necessary.Healthcare professionals are required in all aspects of the service - information,education and medical care, when the need arises as there may be in NGOs assisting in the service to HIV ans Cancer patients. Manpower therefore remains a very crucial issue.

c.Funds:This is very crucial to both the MOH and NGOs partnering in the delivery of care.Our governments do not fund NGOs, they fund political organizations at the grassroots instead. Even international Donations meant for assistance in Health Care Delivery are diverted. A lot get stollen, even within the Ministry of Health.

d.HEALTH INFRASTRUCTURE:Another very crucial aspect here. In my country Budgetary allocations for Health is usually below 5%.And this is never made available to the MOH for required services in providing Health infrastructure . The ones provided are usually along lines of Party Patronage and may have designs not related to any health care delivery equation. Health care infrastructure are completely absent in rural areas where more than 80% of Nigerians live.

Hi All,

From experience, I have noted 2 crucial components. In places where (1)the Government has a vision for the overall development of their country, and within that, are clear about the role of health in achieving this vision, delineate a plan, and are committed to leading the process, and (2) the NGO(s) primary commitment is to align its vision of success with that of the government and to implement within the government's plan, there is great potential for the partnership to produce results. Of course other things are needed, including strong M&E, frameworks for continual improvement and flexibility.

Greetings to everyone from Seattle, Washington! It is such an honor to be on this panel with Dr. Agnes Binagwaho, who is one of the great leaders in global health today and one of the most effective Ministers of Health in Africa. I am currently Director of Mozambique Projects for Health Alliance International (HAI) based in Seattle. HAI is a non-profit organization closely affiliated with the University of Washington School of Public Health and Department of Global Health. I am also an Associate Professor in the Department. HAI currently has health system strengthening projects in Mozambique, Ivory Coast, Sudan and East Timor. Over the past years we have focused on MCH services, community health, HIV care and treatment scale-up, nutrition programs, immunization, TB, and malaria services within public sector primary health care systems where we work. HAI has helped lead the development of the “NGO Code of Conduct” (together with PIH and others) which I will describe today in relationship to the first question.
HAI's mission is somewhat different from many other international NGOs. We focus our efforts on strengthening public sector health systems since we believe a strong adequately-funded public sector is the best way to deliver health ...

Greetings to everyone from Seattle, Washington! It is such an honor to be on this panel with Dr. Agnes Binagwaho, who is one of the great leaders in global health today and one of the most effective Ministers of Health in Africa. I am currently Director of Mozambique Projects for Health Alliance International (HAI) based in Seattle. HAI is a non-profit organization closely affiliated with the University of Washington School of Public Health and Department of Global Health. I am also an Associate Professor in the Department. HAI currently has health system strengthening projects in Mozambique, Ivory Coast, Sudan and East Timor. Over the past years we have focused on MCH services, community health, HIV care and treatment scale-up, nutrition programs, immunization, TB, and malaria services within public sector primary health care systems where we work. HAI has helped lead the development of the “NGO Code of Conduct” (together with PIH and others) which I will describe today in relationship to the first question.
HAI's mission is somewhat different from many other international NGOs. We focus our efforts on strengthening public sector health systems since we believe a strong adequately-funded public sector is the best way to deliver health services most effectively and equitably, especially to the poor and most vulnerable. This means that we not only collaborate closely with governments but we also only take on projects that either directly strengthen existing services or pilot interventions that, if successful, can be scaled up within the public sector system itself. We have been active as an NGO in Mozambique since 1987 and witnessed the deluge of NGOs that arrived in the country in the early 1990s at the end of Mozambique’s long conflict with apartheid South Africa. We became very concerned at what we witnessed. While the public sector health system needed all the support it could get, the arrival of so many NGOs to help out should have been a welcome sight. Instead, it seemed as if every NGO had their own agenda, separate budgets, massive administrative staff, and different marching orders from their donors. The result was disruptive fragmentation of health services, even while more resources poured in.
We also believe the background for this NGO explosion in Mozambique is important to understand. Since 1987 the country had been undergoing a “structural adjustment program”, or SAP, as part of World Bank/IMF efforts to restructure economies in many African countries to cut government expenditures and promote privatization ostensibly to help economies grow. (For those not familiar with SAPs, they are very similar to what is happening now in many European countries as they struggle with debt). This meant the radical defunding much of the public sector. In Mozambique, the salaries for doctors and nurses plunged and many were laid off. Funding for infrastructure was cut. Because of the new constraints imposed on government spending by the SAP, donors rechanneled much of their funding to NGOs instead of the public sector leading to rapid NGO proliferation. Ten years after the end of conflict in Mozambique, the health systems was still in tatters and the country was filled with hundreds of NGOs often conducting their own health services and projects with little or no connection to the public sector system. While many NGOs were well meaning we felt that they were in some ways being used as a way to push the privatization agenda more broadly. HAI, together with other like-minded organizations, decided that perhaps an NGO code of conduct might be helpful to push NGOs to work more closely and effectively to strengthen public sector systems. It would certainly not resolve the problem, but as long as NGOs are receiving so much of the foreign aid flowing into developing countries it would be one way to begin reining in the scattered, uncoordinated, and sometimes harmful NGO landscape we see in so many settings.
In another post later today I will discuss the implications of the Code of Conduct for the first question. I look forward to hearing what people think and joining this lively and stimulating discussion!

I'd like to thank our panelists for kicking things off today and sharing their thoughts on some of the necessary aspects of successful partnerships between NGOs and Ministries of Health.

I hope we'll continue to hear more from the panel on this issue, but I'd also like to invite those reading and following this discussion online to chime in and share their own thoughts or questions about successful partnerships with the panel.

What do you consider to be the most crucial elements of partnerships between NGOs and Ministries of Health seeking to strengthen health systems?

Could you please define "ministries of health". This is a new term for me. Thank you!

Thanks for your question, Juliet.

The term 'Ministries of Health' (or sometimes MOH), refers to the government department focused on health services in any given country. In the United States, this is the Department of Health and Human Services, but in many other countries this division of the government is called the Ministry of Health. Rwanda's Ministry of Health has a great website if you'd like to learn more about the kind of work they do: http://www.moh.gov.rw/

NGOs are becoming the back bones for ministeries of health, a major effort is contributed to build human capacity, but yet sustainability of the NGOs effort still a major challenge.

Hello participants! I’m writing to you from the Southeastern corner of Liberia where we’re anxiously awaiting our national runoff election for the presidency tomorrow. At Tiyatien Health we are working in partnership with the local Ministry of Health and Social Welfare to strengthen health care delivery – especially in rural areas where lack of basic infrastructure and human resource capacity and retention are daily challenges. Here in Grand Gedeh County, more than 2/3 of the population live more than an hour’s walk from any health facility. We’ve developed a community health worker model to help manage chronic disease in the community and are presently working to expand the geographic and technical coverage our CHWs can provide.

I agree with much of what has been said so far and the hazard of a late reply is to avoid repetition. However, I must echo Ted Constan’s remarks about the need for a deliberate focus on the actual relationship. Too often the interactions are reduced to a set of deliverables and reports and what is lost is the very sense of being partners in more than just name. Communication and coordination do not come naturally, fluidly or freely ...

Hello participants! I’m writing to you from the Southeastern corner of Liberia where we’re anxiously awaiting our national runoff election for the presidency tomorrow. At Tiyatien Health we are working in partnership with the local Ministry of Health and Social Welfare to strengthen health care delivery – especially in rural areas where lack of basic infrastructure and human resource capacity and retention are daily challenges. Here in Grand Gedeh County, more than 2/3 of the population live more than an hour’s walk from any health facility. We’ve developed a community health worker model to help manage chronic disease in the community and are presently working to expand the geographic and technical coverage our CHWs can provide.

I agree with much of what has been said so far and the hazard of a late reply is to avoid repetition. However, I must echo Ted Constan’s remarks about the need for a deliberate focus on the actual relationship. Too often the interactions are reduced to a set of deliverables and reports and what is lost is the very sense of being partners in more than just name. Communication and coordination do not come naturally, fluidly or freely. They require intention and investment but without them mutual undertakings will fall short of potential. Furthermore, since the government is acting at all levels (local, district, national) so too must NGOs seek to develop relationships at each point. And one important ingredient for these relationships to grow is time. While many health problems have a sense of tremendous urgency, if all efforts are put into doing, then something critical is lost. Quick impact projects can erect a building seemingly overnight, but as the cliché says, trust cannot be bought it must be earned. And in a post-conflict society like Liberia, putting the relationship at the center of the work is perhaps the most important step that NGOs and governments can take. At the onset of the recent influx of refugees from neighboring Cote d'Ivoire, our established relationships with the MoH County Health Team and other NGO partners meant that we were able to rapidly respond and coordinate our efforts to meet the needs of 75,000 newly arrived persons (who represented at 50% increase to the total population of the county).

A second component to successful partnership is for NGOs and governments to seek alignment of their visions in order to achieve co-advocacy. Much has been said already about the issue of donor priorities and the constraints that NGOs and Ministries face in implementing projects that carry a high technical burden (specific targets, checklists, timelines) yet fail to budget for flexibility and innovation. When NGOs and government are aligned in their understanding of the country’s priorities, they are better able to “push back” and demand greater autonomy over implementation. It seems the donor community is beginning to respond to countries’ stated priorities and pooled funding channeled through the Ministry of Health for co-implementation by governments and NGOs is increasingly seen as a preferred mechanism to achieve impact and build capacity.

Thus, I agree whole-heartedly with Dr. Agnes Binagwaho’s comments about the necessity of NGOs supporting and contributing to the government’s strategic planning and priority-setting exercises. At Tiyatien Health, for example, we have been implementing primarily at the local level but our Monrovia-based staff have been instrumental in sharing critical knowledge and ideas at key decision points for the national health plan such as payment of community health workers and user fees. With direct knowledge of the challenges of rural health care delivery and access to expertise from other community-based NGOs, Tiyatien has been able to serve both as partner and advocate in supporting the MoH in developing their national strategic plan. Now, we are directly partnered with the local MoH team to deliver services in the county as part of that national package that was developed collaboratively.

A key factor in the development of country-driven planning processes is leadership. In Liberia, key leaders in Ministry of Health have been able to translate their commitment to health for all Liberians from vision into action – so much so that ministers from other sectors are “crossing the aisle” to learn from the MoH’s success. Local leadership at every level of the health care system is critical and demonstrating respect not only for planning processes but also for skilled in-country leaders is an important way to support sustainability for the health sector. Furthermore, NGOs often enjoy close relationships with academia; connecting these leaders with opportunities for personal development is another way to strengthen local capacity.

Finally, rather than focusing on specific mechanisms for implementing accountability, I would like to briefly examine this concept within the framework of national priorities and vision. Too often when actors discuss accountability, the focus is on fiscal accountability and indicators that do not necessarily match to the needs and priorities of the communities that NGOs and governments hope to serve. Without strong national priorities, NGOs and donors have tremendous power to define a problem and its solution and then designate the appropriate tool to measure success. In that scenario, a NGO is all but guaranteed to “shine” in the eyes of its current and future donors and further disrupt attempts to channel resources towards less visible areas of the health system in need of development. To avoid this scenario, we must return again my first point – putting the relationship at the core of our work. To ensure true accountability, discussions must go deeper than deliverables and budgets and get at the heart of what it means to be truly beholden to one another. And perhaps the key ingredient for success in this regard is something that has yet to be mentioned: humility.

As its name implies, the “NGO Code of Conduct for Health System Strengthening” was developed in part to minimize the sometimes negative effects of NGO behaviors that are harmful to long term health system development. But it was also created to suggest positive ways for NGOs to support health systems as well. Below are the six basic areas (articles) that the Code emphasizes:

1.)NGOs will engage in hiring practices that ensure long-term health system sustainability.
2.)NGOs will enact employee compensation practices that strengthen the public sector.
3.)NGOs pledge to create and maintain human resources training and support systems that are good for the countries where they work.
4.)NGOs will minimize the NGO management burden for ministries.
5.)NGOs will support Ministries of Health as they engage with communities.
6.)NGOs will advocate for policies that promote and support the public sector.

Many of these areas emphasize human resources issues that will be the focus of the main question for the forum on Wednesday. However, the Code is based on the idea that there are several overarching key aspects that are crucial to strong working partnerships between NGOs and Ministries of Health. Many of those who have ...

As its name implies, the “NGO Code of Conduct for Health System Strengthening” was developed in part to minimize the sometimes negative effects of NGO behaviors that are harmful to long term health system development. But it was also created to suggest positive ways for NGOs to support health systems as well. Below are the six basic areas (articles) that the Code emphasizes:

1.)NGOs will engage in hiring practices that ensure long-term health system sustainability.
2.)NGOs will enact employee compensation practices that strengthen the public sector.
3.)NGOs pledge to create and maintain human resources training and support systems that are good for the countries where they work.
4.)NGOs will minimize the NGO management burden for ministries.
5.)NGOs will support Ministries of Health as they engage with communities.
6.)NGOs will advocate for policies that promote and support the public sector.

Many of these areas emphasize human resources issues that will be the focus of the main question for the forum on Wednesday. However, the Code is based on the idea that there are several overarching key aspects that are crucial to strong working partnerships between NGOs and Ministries of Health. Many of those who have commented already have also touched on these themes:
1.)As Dr. Binagwaho has suggested, NGOs should tailor and adapt their projects to the national plans in the countries where they would like to work. The Ministry of Health should be in the driver’s seat and NGOs should join the national planning process with humility and a spirit of cooperation. As Ted Constans emphasizes in his post, continual coordination and sharing of information is essential. Flexibility is also key – and NGOs should be willing to change and adapt their projects midstream if necessary to meet the needs of the system or avoid overlapping with other projects.
2.)NGO projects should avoid duplicating services or programs already offered by the national health system, and should avoid establishing separate logistics or administrative systems (such as health information systems, drug supply chains, transport systems) that cause confusion or drain resources from Ministries of Health.
3.)The presence of multiple NGOs overlapping in the same geographical areas often causes enormous management burdens for already understaffed Ministries. NGOs should consider how they can support the health system’s capacity to cope. This could take the form of support for more accountants and managers within the system down to district level. In one province in Mozambique where HAI works, the Provincial Director pleaded with the NGOs in her region to supply her with accountants and planners since she could not keep up with the complexity and multitude of projects.
4.)As Christina Bethke pointed out human relationships are essential to successful partnerships and trust can be developed. Most valuable projects and interventions take a long time to become sustainable and effective. Whenever possible NGOs should plan for a long term engagement with health system counterparts to focus on building trust in professional relationships that can ensure that NGOs contributions are useful and effective.

I suspect that there is fairly broad agreement with these ideas among the participants in this discussion – but it seems that the way foreign aid is structured often provides incentives for poor NGO behavior. Donors often expect their NGOs to produce short-term results, sometimes at the expense of the public sector. Many donors do not reward NGOs they fund for good cooperation with the Ministry or with other NGOs. NGO managers are sometimes encouraged to engage in turf wars with other NGOs to ensure that they can deliver the results to their donors and continue to receive funding. As long as the development system is structured this way, can we succeed in making NGOs more responsible? The creators of the Code of Conduct hoped that the document could also be used to educate donors as well so that they might rethink how they fund NGOs and what they expect of them. If coordination, collaboration, and respect for Ministries of Health are more highly valued by donors perhaps NGO behavior would change.

Sorry I sent comment from Cameron's account - he is my research assistant.

Thanks to all for great discussion so far. I will respond to all post later this week. Please find response to second guiding question below.

2) What are some of the main challenges of administering joint programs (i.e. numerous implementing organizations with multiple agendas competing for funding and space)?

First and foremost in the health sector is the process of developing a national vision, one that all policies of the Ministry and its NGO partners follow from. It is important for the Ministry of Health to have zero tolerance for any plan other than the national strategic plan for the country. To my fellow public sector officials, you had better demonstrate that you can say no to some partners, because the time that you spend working towards their goals set up in a city very far from your city that are certainly not aligned with your country’s needs is time that you cannot get back. In Rwanda, we are always ready to kindly accompany NGOs to the airport when they are not willing to work with us towards our vision and our plan.

A second ...

Sorry I sent comment from Cameron's account - he is my research assistant.

Thanks to all for great discussion so far. I will respond to all post later this week. Please find response to second guiding question below.

2) What are some of the main challenges of administering joint programs (i.e. numerous implementing organizations with multiple agendas competing for funding and space)?

First and foremost in the health sector is the process of developing a national vision, one that all policies of the Ministry and its NGO partners follow from. It is important for the Ministry of Health to have zero tolerance for any plan other than the national strategic plan for the country. To my fellow public sector officials, you had better demonstrate that you can say no to some partners, because the time that you spend working towards their goals set up in a city very far from your city that are certainly not aligned with your country’s needs is time that you cannot get back. In Rwanda, we are always ready to kindly accompany NGOs to the airport when they are not willing to work with us towards our vision and our plan.

A second and significant challenge is convincing these various organizations that the program to implement is your program – the Ministry of Health’s program, the national program of the health sector. If the program of the Ministry is well done, meaning in a participatory manner involving all constituencies concerned and responding to the needs of the communities, people should understand that we should not compete over labels or ownership over success, because success is shared. This involves convincing everybody that it is a win-win situation for them to join in the Ministry’s program and work to implement it, as they have worked with their national counterparts to design it.

A third major challenge comes from the multiple planning processes we must undertake simultaneously to meet the requirements of our different donor partners. This makes us lose time, does not serve to increase the quality of our services, and decreases the amount of time that all actors dedicate to service delivery. These duplications result from having to report to donors according to different timeframes and different indicators, despite the fact that we have our own indicators that are adjusted to our own context. If all of our partners used one set of indicators, reporting and harmonization would be much easier, but it is very difficult to push others to use your own indicators.

What we have done in Rwanda is to prioritize our indicators and ask our partners to conform to them. This has not worked for all partners, and it is a continuous fight over definitions even with the best partners such as The Global Fund to Fight AIDS, Tuberculosis, and Malaria. For example, we wasted months two years ago in a struggle with TGFATM over the definition of good diagnosis and treatment for sexually transmitted infections; our national protocol wanted to follow the World Health Organization guidelines of using a syndromic approach. The Global Fund insisted on laboratory confirmation. So, they told us that we were using a bad practice, and were about to cut grant money for these activities, and we had to struggle for weeks to impose our national protocol.

A fourth challenge is to make evidence-based decisions and to convince partners to join in the implementation. This means that we need to promote operational research and to obtain the capacity to do fair and true assessment, analysis, and monitoring and evaluation. This requires the creation of a culture of discipline and entrepreneurship throughout the Ministry of Health and the entire health sector; once this culture is created, NGOs themselves need to be part of and strengthen it. The challenge here is also that partners do not have the same needs in the realm of research that we have; we simply want research that shows us where we stand and where we want to go – research that we have ownership over. Partners, however, often have their own research priorities that are generalizable and based in many countries so that they can compare their own work over time. If you are not careful, you can find your health sector spending time on research that does not benefit your programs or your population. Setting up your own national research agenda is important.

To return to the example of Haiti, we need NGOs and their leaders to have the moral and ethical foundation to commit to helping the government construct an inclusive national plan that respects national ownership. It is the duty of the government to articulate a vision using a participatory process with the population first of all, to design a national strategic plan, to coordinate its implementation – meaning the activities of all sectors: public, private, community, national, and international.

The final challenge has largely been untouched by many in global health – ministries of health and NGOs alike. We can have the vision, the strategic plan, a good M&E system, but we need to use rational ways of implementing our policies to make the money work. An area that very few people are focusing on but one that makes all the difference is in the details of how you implement – how you actually deliver the services most equitably and most effectively.

We need better NGOs, and we need the government to understand that it is its duty to design a strategic plan and to regulate the activities of their NGO partners so that they truly meet the needs of the population and implement in the best of our collective capacity.

I had the enormous pleasure of working closely with Dr. Agnès in Rwanda from 2007 to 2010 and can attest to that country's success in insisting that NGO's align to the national strategic plan for the health sector. However, I have always viewed Rwanda as a rather exceptional case. Not only has Rwanda benefitted from exemplary leadership within the MOH but it is clear that the MOH and the health sector more generally are top priorities for the national government and indeed the President himself.

So my question is, how can NGOs operate in the best interest of health system strengthening in countries where that leadership is lacking? In some countries the health and well being of the population is sadly nowhere among the highest priorities of national leaders who are more concerned with consolidating their own power or exploiting natural resources. In other countries, the will is there but capacity within the MOH for effective strategic planning and coordination is extremely limited. How do panellists suggest that NGOs approach working in these countries? How do we help support capacity building within government in a way that is supportive without being paternalistic?

Thank you.

My greetings to you all.
My name is KAMONYO Mugabo, I am a Java Developer working for the Rwandan Ministry of Health as a EMR Programmer (OpenMRS).
1. I would like to comment on Felicia's question: "How do we help support capacity building within government in a way that is supportive without being paternalistic?"
>> I can testify that my government did a lot in supporting capacity building. I, myself, benefited from the funds allocated to that purpose, and The Ministry of Health paid a considerable amount in order to help me doing my studies in Professional Computer Science at Maharishi University of Management (Iowa, US) where I came from to do my Curricular Practical Training at the sam Ministry of Health in order to contribute in EMR developement. Before I was hired by the MoH, I was trained in Java Programming through the partnership between Partners in Health (Inshuti mu Buzima) and Rwanda Development Board (RITA at that time). This program (E-health Software Development and Implementation: EHSDI) was targeting the e-Health improvement in Rwandan Health domain.
I can testify that we now own the Electronic Medical Record, in that sense we can develop different modules in OpenMRS considering the ...

My greetings to you all.
My name is KAMONYO Mugabo, I am a Java Developer working for the Rwandan Ministry of Health as a EMR Programmer (OpenMRS).
1. I would like to comment on Felicia's question: "How do we help support capacity building within government in a way that is supportive without being paternalistic?"
>> I can testify that my government did a lot in supporting capacity building. I, myself, benefited from the funds allocated to that purpose, and The Ministry of Health paid a considerable amount in order to help me doing my studies in Professional Computer Science at Maharishi University of Management (Iowa, US) where I came from to do my Curricular Practical Training at the sam Ministry of Health in order to contribute in EMR developement. Before I was hired by the MoH, I was trained in Java Programming through the partnership between Partners in Health (Inshuti mu Buzima) and Rwanda Development Board (RITA at that time). This program (E-health Software Development and Implementation: EHSDI) was targeting the e-Health improvement in Rwandan Health domain.
I can testify that we now own the Electronic Medical Record, in that sense we can develop different modules in OpenMRS considering the Rwandan Health Domain needs. Last month, the OpenMRS community decided the annual conference was to be held in Rwanda. It was a total success.
These few words above were to define and describe how a better partnership (non paternalistic) between Governments and NGOs can help support capacity building within government in a way that is supportive without being paternalistic, and of course achieve more in that sense the Local government is not depending on those NGOs 100% (partnership instead of depency).

Looking forward to hearing from more comments and suggestions.

Best Regards,

Kamonyo.

In response to today's question, I will note that joint programs between an NGO and the Ministry can be challenging. Lines can become blurred between each partner’s roles, and this lack of clarity can lead to misunderstandings. For example, PIH supports government-run health facilities, and PIH staff and MOH employees work side-by-side. In this situation, it is not uncommon for two health workers with technically different employers, PIH and MOH, to have the same level of responsibility and perform the same tasks. Problems can arise, if one staff receives comparably higher salaries than another. We offer a top-up—a performance-based salary increase—to MOH employees so that salaries are more equitable. In these cases of joint payroll support, it can be unclear to staff whose management structure they follow. Drawing clear lines of managerial roles and responsibilities for us and the Ministry and transitioning staff from PIH to MOH employment over time help to resolve some of this confusion. Frequent communication with staff is also important.

Competition between NGOs running joint programs is another challenge. In advance of the program, setting out specific agreements through Memoranda of Understandings (MOUs) can help demarcate responsibilities. We often implement joint programs ...

In response to today's question, I will note that joint programs between an NGO and the Ministry can be challenging. Lines can become blurred between each partner’s roles, and this lack of clarity can lead to misunderstandings. For example, PIH supports government-run health facilities, and PIH staff and MOH employees work side-by-side. In this situation, it is not uncommon for two health workers with technically different employers, PIH and MOH, to have the same level of responsibility and perform the same tasks. Problems can arise, if one staff receives comparably higher salaries than another. We offer a top-up—a performance-based salary increase—to MOH employees so that salaries are more equitable. In these cases of joint payroll support, it can be unclear to staff whose management structure they follow. Drawing clear lines of managerial roles and responsibilities for us and the Ministry and transitioning staff from PIH to MOH employment over time help to resolve some of this confusion. Frequent communication with staff is also important.

Competition between NGOs running joint programs is another challenge. In advance of the program, setting out specific agreements through Memoranda of Understandings (MOUs) can help demarcate responsibilities. We often implement joint programs with other NGOs who offer expertise that we don’t have, from specialized surgical interventions, to solar panel construction to microfinancing projects. However, even when the other NGO is working out of the health sphere, it has been important to us to write down each partner’s responsibilities in advance and to maintain an ongoing line of communication. Without this close attention to detail, the project may falter: this can occur especially in capital projects when the technical installation or construction has been done but follow-up maintenance and care has been left to a partner who lacks the know-how.

Very interesting topic. I am a member of a health NGO and we had experience of working in a project of our ministry of health about TB. Our role was to supervise the project. There were specific requirements, so we gathered a team of experts in the field, we applied and won the project. We worked in that project for about 5 years and it was great experience. I think that NGOs can have a great role and in Strengthening of the Health System. Their work can be in many fields and can start from small NGOs that can do volunteer work and up to more serious professional NGOs that can bring innovative ideas about many problems in the Health System. The main thing is that there should be a competition of ideas and projects and accountability for their work especially if their projects are financed by the government.

Hi -- I'd like to address Felicia Price's important question: what is an NGO to do if there are leadership gaps within the host government? PIH has experience with a wide range of governments, from high-functioning, progressive ones to callous dictatorships to, well, a form of anarchy. As all aid in the end has political ramifications, NGOs must decide first whether to engage in a country at all. But once the decision to work in a country is made, we believe partnership with the government is required.

A big part of the answer for us is that even the best run government is not monolithic. It is a collection of humans, with complex motivations and interrelations. Finding traction with leadership at a variety of levels-- facility, district, state, and national-- involves listening, understanding, compassion, and, most of all, time. Christina Bethke made this point quite eloquently.
It must be said that the process of recognition of weakness within the host government risks being patronizing, humiliating and even colonial. I have witnessed too many NGO and donor country employees spend long hours in capital city restaurants contemptuously bemoaning what they perceive as incompetence within the government. (Attacking this culture is ...

Hi -- I'd like to address Felicia Price's important question: what is an NGO to do if there are leadership gaps within the host government? PIH has experience with a wide range of governments, from high-functioning, progressive ones to callous dictatorships to, well, a form of anarchy. As all aid in the end has political ramifications, NGOs must decide first whether to engage in a country at all. But once the decision to work in a country is made, we believe partnership with the government is required.

A big part of the answer for us is that even the best run government is not monolithic. It is a collection of humans, with complex motivations and interrelations. Finding traction with leadership at a variety of levels-- facility, district, state, and national-- involves listening, understanding, compassion, and, most of all, time. Christina Bethke made this point quite eloquently.
It must be said that the process of recognition of weakness within the host government risks being patronizing, humiliating and even colonial. I have witnessed too many NGO and donor country employees spend long hours in capital city restaurants contemptuously bemoaning what they perceive as incompetence within the government. (Attacking this culture is significant goal of the NGO Code of Conduct.) So what to do when we see challenges? Of course try to help fix it, but with humility, meeting the government where it stands.

A quick example from Haiti: After the quake, dozens of NGOs descended on the General Hospital in PaP. The vast majority of these was well-meaning and indeed saved countless lives. In the first few days, however, we heard dozens of NGO employees criticize the Haitian employees for not being at work. Separate from the shocking lack of compassion this showed for citizens of PaP who lost so much, on study it turned out that there were a number of underlying technical problems. One specific one was that the military team who valiantly set up a security perimeter around the hospital was only allowing injured Haitians through. It turned out that there were General Hospital employees in the crowd of Haitians who couldn’t get through. What did PIH do? We quickly delivered a digital camera, a photo printer, and a laminator. We set this up on a desk outside of the hospital, and in cooperation with hospital leadership, issued ID badges to employees and received military recognition of those credentials. Hospital employee census immediately improved.

Obviously this is an extreme example, but I hope it demonstrates that too often we leap to conclusions about the intractability of challenges within the host governments, and that a bit of pragmatic solidarity in devising solutions can quickly inure to the benefit of the destitute sick.

What are some of the main challenges of administering joint programs?

For more than 15 months, Tiyatien Health has been co-implementing in Grand Gedeh County with the local Ministry of Health County Health Team and Merlin (an international NGO or iNGO) to deliver Liberia’s Essential Package of Health Services under the Pool Fund Project. This innovative project links the public sector with an iNGO and a local NGO in order to build capacity at the local level while keeping services responsive to the community. The project will run until June 2012 during which time the MoH is working to decentralize health planning as local capacity grows.

We are also working to scale up the community health worker model for patients living with HIV at 19 treatment sites in the country. This work is part of a larger project that is financed by the Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM) and aims to improve adherence to treatment and reduce the number of patients who are lost-to-follow-up (LTFU). The GFATM project is administered directly by a team of national staff who sit directly within the MoH and the National AIDS Control Program (NACP).

As the local NGO partner ...

What are some of the main challenges of administering joint programs?

For more than 15 months, Tiyatien Health has been co-implementing in Grand Gedeh County with the local Ministry of Health County Health Team and Merlin (an international NGO or iNGO) to deliver Liberia’s Essential Package of Health Services under the Pool Fund Project. This innovative project links the public sector with an iNGO and a local NGO in order to build capacity at the local level while keeping services responsive to the community. The project will run until June 2012 during which time the MoH is working to decentralize health planning as local capacity grows.

We are also working to scale up the community health worker model for patients living with HIV at 19 treatment sites in the country. This work is part of a larger project that is financed by the Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM) and aims to improve adherence to treatment and reduce the number of patients who are lost-to-follow-up (LTFU). The GFATM project is administered directly by a team of national staff who sit directly within the MoH and the National AIDS Control Program (NACP).

As the local NGO partner in the Pool Fund triad and also a national partner under GFATM, Tiyatien Health has enjoyed different perspectives on the complex dynamics of co-implementation. Four main challenges stand out:
1) COMMUNICATION & INFORMATION SHARING in a regular and fluid way is an ongoing challenge for joint programming. First, technological barriers like reliable phone & internet access can hinder real-time information sharing. Second, forums for actual discussion rather than formalities can be difficult to achieve. Actors may be over-stretched with competing meetings and trainings and, often, there is no budget support for travel or communication. Third, inter-agency communication between local and national counterparts is often poor for both NGOs and the government which leads to different cohorts operating under different sets of shared assumptions. Finally, developing a common language and understanding between partners can be a struggle when many of the terms we use in global health are vague and broad (for example “capacity-building”). Common understanding is further hampered by cultural and linguistic differences.

2) HUMAN RESOURCES can be subdivided into recruitment, retention and workload. First, finding qualified staff to implement projects is a struggle for NGOs and governments alike. Hiring for certain positions may be restricted to national/local staff (rather than expat) which is a helpful practice in principle but can lead to vacancies and/or under-qualified persons serving in key roles. Lack of money and/or capacity to provide appropriate on-the-job training means certain function are un-staffed or understaffed. Second, retention of staff plagues both governments and NGOs. In places where highly skilled persons are often providing for numerous family members, the opportunity to increase one’s monthly salary, even by a small amount, may be too compelling to overlook. NGOs may surely strive to align with or even top-off public sector wages but ensuring enforcement takes a high level of oversight– something many governments simply lack the capacity and resources to achieve. Furthermore, NGOs may be willing to invest heavily in staff who then take the training they’ve received and put it to work in higher paying jobs. Difficulties with retention can be exacerbated by flat-funding schemes that budget for 2 or more years at a constant salary without accounted for expected increases in cost-of-living. Third, donors and governments may trim budgets to a point where a project’s success or failure rests in the hands of one or two individuals. These persons will inevitably become overworked and overstressed and may leave out of frustration rather than money. Often budget trimming is done out of perceived necessity without examining the larger cost of unsuccessful programming that may result. Donors, governments and NGOs have an obligation to the staff they fund or employ to ensure that they are adequately supported and set up for success.

3) POWER BALANCE & CLARITY OF ROLES – Memorandums of Understanding (MOUs) and Terms of Reference (TORs) tend to proliferate in the negotiation process but are less frequently living documents that help provide daily definitions as to the role of each party and its obligations to others. If a government has a clear sense of its priorities, it can more easily define the roles it wants partners to play. However, as we’ve heard discussed already in this forum, many countries may be lacking a well-developed, specific set of national health priorities and a plan for implementation. Thus, when NGOs arrive on the ground with significant resources behind them, they are placed in a privileged role of being able to unduly influence government policy. The NGO code of conduct is a step forward in promoting a more balanced approach to work in place where government is still attempting to strengthen itself but there is still much to be done.

4) OVERSIGHT & ACCOUNTABILITY – where public systems are strong, this area is less of a challenge. However, in many settings, governments may be unequipped to exercise oversight and demand accountability. The success of these functions is under cut by the challenges raised above – poor communication, lack of qualified staff and poor clarity of roles. Yet, creating conditions and mechanisms for accountability is at the core of sustainable improvements in health. If NGOs don’t embrace the importance of adhering to their obligations then they become an embodiment of “do as I say, not as I do”.
I’m looking forward to the upcoming questions where we can discuss constructive approaches to addressing the challenges panelists and contributors have identified thus far in this forum and I wish to thank all of you as well as the GHDonline organizers for such a rich learning and sharing experience.

Hi everyone,

First, thanks so much to everyone for their wonderful insights thus far. It is a privilege to hear from our expert panelists and so many others with such robust experience from all over the world.

As Christina astutely said, I will avoid the error of repetition, and simply say that I am very glad to see the general consensus among this group that, indeed, aligning NGO work with MOH visions is of crucial importance to truly developing reliable and long-term health systems.

In regards to Felicia's point about working in countries with a lack of or weak central leadership, and in particular, in response to Ted's commentary about the nuances of working to develop those relationships, I would be very interested to hear from others who have experience working in remote areas of countries where the often capital-centric government officials do not have much presence. We (Nyaya Health) are working in an extremely remote area of western Nepal, where the MOH's infrastructure and presence are quite weak (as are the other public services such as roads, electricity, etc) and there are scant other NGOs present in the region to augment the lack of facilities and ...

Hi everyone,

First, thanks so much to everyone for their wonderful insights thus far. It is a privilege to hear from our expert panelists and so many others with such robust experience from all over the world.

As Christina astutely said, I will avoid the error of repetition, and simply say that I am very glad to see the general consensus among this group that, indeed, aligning NGO work with MOH visions is of crucial importance to truly developing reliable and long-term health systems.

In regards to Felicia's point about working in countries with a lack of or weak central leadership, and in particular, in response to Ted's commentary about the nuances of working to develop those relationships, I would be very interested to hear from others who have experience working in remote areas of countries where the often capital-centric government officials do not have much presence. We (Nyaya Health) are working in an extremely remote area of western Nepal, where the MOH's infrastructure and presence are quite weak (as are the other public services such as roads, electricity, etc) and there are scant other NGOs present in the region to augment the lack of facilities and infrastructure. Despite having a formal MoU with the MOH (a public private partnership) we have struggled with the balance of maintaining and strengthening our relationship with the MOH due to their lack of presence in the region. We find ourselves constantly needing to be present in the capital (nearly two days journey from our hospital), but as Ted eloquently states, we firmly believe that our proper place is to be in the communities that we serve, not in fancy capital city restaurants. Christina's point about the importance of developing long-term relationships over time is well-heard, and indeed, our relationship (three years old currently) has grown substantially on the district and regional level, but we still struggle deeply with our central government relationship, which necessarily causes us problems in terms of aligning ourselves with central funding mechanisms and work plans.

I would be interested to hear from others working in extremely remote areas about how they work to develop these relationships with government authorities at all levels (district, regional, national).

Thank you once again to everyone for their contributions thus far.

Cheers,
-Dan Schwarz

--
Dan Schwarz
Alpert Medical School | Brown University
Harvard School of Public Health

Chief Operating Officer
Nyaya Health | www.nyayahealth.org

p: +1.845.797.9902
e:

What are some of the main challenges of administering joint programs?

I will add just a few thoughts to those already provided. In our experience in Mozambique and Ivory Coast, one of the major challenges is to create a sense of solidarity and shared purpose between HAI staff and their government health workers counterparts. If an NGO project is seen as an add-on to the workload of already overburdened staff the relationship will not work well. We have tried to address this by ensuring that our projects closely match the governments' priorities to begin with. But on a more day-to-day level, HAI staff are trained to work closely with their counterparts, and all of our program staff have work space side-by-side with their counterparts in the government offices. We maintain separate administrative offices so we don't take up too much precious space, but HAI program staff are all based within the health system itself. This helps ensure that HAI staff become integrated with the government staff team and can build tight working relationships. HAI staff are trained to provide support to their counterparts for activities that may not fall directly within the project plan, in order to simply help ...

What are some of the main challenges of administering joint programs?

I will add just a few thoughts to those already provided. In our experience in Mozambique and Ivory Coast, one of the major challenges is to create a sense of solidarity and shared purpose between HAI staff and their government health workers counterparts. If an NGO project is seen as an add-on to the workload of already overburdened staff the relationship will not work well. We have tried to address this by ensuring that our projects closely match the governments' priorities to begin with. But on a more day-to-day level, HAI staff are trained to work closely with their counterparts, and all of our program staff have work space side-by-side with their counterparts in the government offices. We maintain separate administrative offices so we don't take up too much precious space, but HAI program staff are all based within the health system itself. This helps ensure that HAI staff become integrated with the government staff team and can build tight working relationships. HAI staff are trained to provide support to their counterparts for activities that may not fall directly within the project plan, in order to simply help their counterparts out and establish a sense of shared burden and objectives. For example our staff who support PMTCT scale-up also provide planning support for the overall ANC and MCH sector and lend a hand whenever they can for other activities in ANC if needed. The development of strong personal relationshsips, as others have noted, is essential.

Another challenge is coordinating and managing the financing of activities. Developing a mechanism to either provide funding directly to the government accounts themselves or to provide salary incentives, per diems, or funding for specific piecemeal activities can be very difficult. Government services are often uderstaffed in the financial management sectors and need support in managing or accounting for additional NGO funds that might be provided to them. This has been a huge challenge in Mozambique as large amounts of funding from PEPFAR and other sources have poured into the health sector. We have found that we have to put a tremendous amount of time into developing clear mechanisms (subagreements) for providing and accounting for significant levels of funding for government activities, and developing reporting processes that aren't overly burdensome. In many countries, even at provincial or district levels, a number of NGOs may all be providing funding for overlapping activites creating an accounting mess. NGOs can help by providing management and accounting support. We have seen many NGO projects founder and fail because these mechanism were not well developed.

And a quick word about per diems. As many others probably have seen, the provision of per diems to government health workers to support NGO projects has become a problem in many places. NGOs sometimes use different rates and don't manage them well creating further confusion and accounting problems. And once per diems are provided for an activity - and then removed (for example if an NGO project ends) - that activity will end. Per diems act almost like performance-based incentives that when removed work performance stops. We have found the per diem problem to be one of the most difficult to resolve in Mozambique.

What are the main problems of administering joint programmes?
I would like to leave the expert panelists to discuss the usual problems. These are some of the unusual ones:
i.Funds even after allocation has been made to fund Projects -Some senior administrative officers in Government belief that NGOs have funds. Therefore whatever the government or donor agencies provide is additional and in some cased excess.They therefore do their best to frustrate the efforts of the workers by denying them funds.Others ask for "something for themselves" and if not provided, can definitely frustrate joint programmes.I would have called this subheading "corruption" but I better leave us to name it.

ii. Political Differences:Persons that do not belong to the same Party Caucus do not trust each other. But it is difficult to get only persons from the same Political Party Caucus to come together to work on joint programmes.

iii.Religious Differences: In as much as there are Faith-base NGOs,religious differences still constitute a barrier to the success of joint programmes.Religious differences create mistrust not much unlike racial and ethnic differences.

iv. Ignorance especially on the part of benefiting communities is another problem. Health infrastructure ...

What are the main problems of administering joint programmes?
I would like to leave the expert panelists to discuss the usual problems. These are some of the unusual ones:
i.Funds even after allocation has been made to fund Projects -Some senior administrative officers in Government belief that NGOs have funds. Therefore whatever the government or donor agencies provide is additional and in some cased excess.They therefore do their best to frustrate the efforts of the workers by denying them funds.Others ask for "something for themselves" and if not provided, can definitely frustrate joint programmes.I would have called this subheading "corruption" but I better leave us to name it.

ii. Political Differences:Persons that do not belong to the same Party Caucus do not trust each other. But it is difficult to get only persons from the same Political Party Caucus to come together to work on joint programmes.

iii.Religious Differences: In as much as there are Faith-base NGOs,religious differences still constitute a barrier to the success of joint programmes.Religious differences create mistrust not much unlike racial and ethnic differences.

iv. Ignorance especially on the part of benefiting communities is another problem. Health infrastructure has been vandalized and in some cased wantonly destroyed, sometimes to settle political differences. Ignorance is the main reason behind such action. The government agency - the MOH will therefore not have the will to assist with any joint programmes in such communities.

Another complication occurs when an NGO is trying to implement a project across a number of countries. Especially for health-related interventions, it often transpires that for epidemiological reasons, implementation needs to be as closely matched as possible. Yet sometimes this is not feasible because of differing regulatory and program guidelines that vary substantially by country.

Is there therefore a role for NGOs to bring these differing standards to the attention of Ministry of Health officials or to other policy makers?

I would like to reply to Dan Schwarz’s question about working in a capital-centric setting. Indeed in Liberia, more than 1/3 of the total population lives in Monrovia and that density, combined with historical legacy, means the rural areas (or hinterlands) play second fiddle to the capital. During rainy season we are 14-16 hours drive from Monrovia (if accessible at all).

In the past we had sought to bridge this gap with a very capable part-time volunteer doctor, but his work schedule made it impossible for him to present at every meeting. In July, Tiyatien hired its first FULL TIME National Policy Advisor who is based in Monrovia. The addition of this full time staff member has made a tremendous difference for us – officials are seeing the same face at the meetings week after week, relationships are being built and the osmotic learning and information gathering that takes place before and after meetings means we are better able to keep our finger on the pulse of what’s happening at the national level, raise concerns quickly to the appropriate parties and strengthen our ability to respond to the needs of the community we serve. By necessity, the Grand ...

I would like to reply to Dan Schwarz’s question about working in a capital-centric setting. Indeed in Liberia, more than 1/3 of the total population lives in Monrovia and that density, combined with historical legacy, means the rural areas (or hinterlands) play second fiddle to the capital. During rainy season we are 14-16 hours drive from Monrovia (if accessible at all).

In the past we had sought to bridge this gap with a very capable part-time volunteer doctor, but his work schedule made it impossible for him to present at every meeting. In July, Tiyatien hired its first FULL TIME National Policy Advisor who is based in Monrovia. The addition of this full time staff member has made a tremendous difference for us – officials are seeing the same face at the meetings week after week, relationships are being built and the osmotic learning and information gathering that takes place before and after meetings means we are better able to keep our finger on the pulse of what’s happening at the national level, raise concerns quickly to the appropriate parties and strengthen our ability to respond to the needs of the community we serve. By necessity, the Grand Gedeh MoH County Health Team spend most of the their time on the ground in county, but that means they are as equally removed as we are from national level dialogue. Having a full time point person in the capital enables us to act in solidarity with our local MoH partners. For example, our staffer in Monrovia recently alerted our County Health Officer to an opportunity to solicit additional lab equipment. This opportunity was never advertised but upon a casual conversation about constraints the county hospital is facing, an official explained that in fact new equipment had just arrived in country and the CHO should send a request.

I acknowledge that, when the needs in the local community are so extensive, it can be hard to “stomach” the idea of spending precious resources so far from your service delivery area but 5 months into this experiment, I would say the value of this position has far exceeded what we have invested. However, the obvious next challenge before us as a local NGO is to recruit or train a Liberian to fill this role because, as a local NGO, we should be represented by local staff not expats. But filling this role is another challenge… tomorrow we’re poised to talk about human resource constraints.

Thanks to everybody for sharing so many experiences!

This in response to Jeff Meer's posting on multinational projects. There may be different ways of bringing differences and similarities to the attention of health officials in different countries. We are finishing a multinational training project for primary health care workers in underserved areas in Central America and the Caribbean. It is a cooperative agreement. The team implemented various activities to transition from a project that was being implemented separately in four countries, to a regional project, while at the same time respecting local policies and conditions. Some of the things we did were:

-- Groups of mentors from each country were selected. They were brought together on-site, and given training on HIV topics, and training/evaluation/mentorship topics. This created a team spirit that resulted in a Mentor Corps.
-- The mentors had multinational groups of students (comprising service and management personnel from the various national ministries of health) during the virtual phase of the training. This created multiple opportunities for cross-country learning and interaction.
-- During the on-site phase of the training, the cohorts were multinational.
-- During the project-intervention designing phase, the mentors were matched to students from their own country, to ...

Thanks to everybody for sharing so many experiences!

This in response to Jeff Meer's posting on multinational projects. There may be different ways of bringing differences and similarities to the attention of health officials in different countries. We are finishing a multinational training project for primary health care workers in underserved areas in Central America and the Caribbean. It is a cooperative agreement. The team implemented various activities to transition from a project that was being implemented separately in four countries, to a regional project, while at the same time respecting local policies and conditions. Some of the things we did were:

-- Groups of mentors from each country were selected. They were brought together on-site, and given training on HIV topics, and training/evaluation/mentorship topics. This created a team spirit that resulted in a Mentor Corps.
-- The mentors had multinational groups of students (comprising service and management personnel from the various national ministries of health) during the virtual phase of the training. This created multiple opportunities for cross-country learning and interaction.
-- During the on-site phase of the training, the cohorts were multinational.
-- During the project-intervention designing phase, the mentors were matched to students from their own country, to ensure that the projects would be consistent with local policies and conditions
-- Right after the presentation of the of projects by the students, a workshop of governmental and non-govermental participants from all of the Central American countries (not just the three that participated in the project), plus the one participating Caribbean country, to share the experiences of the project and discuss regional continuing health education issues.

I do not know the results of the workshop yet, but I am hoping that at a minimum, we facilitated the regional discussion. Two of the workshop's objectives were:

-- To characterize the regional strategies and development plans of health care personnel competencies to strengthen chronic care models in the context of primary health care; and
-- To open a Central American regional discussion on the development of health care personnel competencies in primary care and public health oriented toward the transformation of education, based on models of continuing education and virtual learning.

The multinational character of the project added many challenges to the implementation of the agreement, some of which we were able to solve, but some of which -- such as those related to national politics -- were beyond our influence, and had a definite impact on the project.

Also, to have had multiple organizations working together on this project, had its own strengths and challenges; but without their joining of forces, the project would never have been accomplished successfully.

Hi Christina --

Thanks so much for the thoughtful comments. We have, indeed, struggled to "stomach" the costs of investing in full-time staff based exclusively in the capital, but as you say, providing that consistent face helps to develop those relationships and nurture future ones as well, identifying opportunities that we are otherwise unaware of, and helping to align ourselves with the central authorities priorities.

We currently have one part-time Nepali staff member in the capital (who originally started as a volunteer for us), and will likely soon have to convert him to full-time. We do not, as of yet, have an office or any property in the capital, but as our operations expand, we are cognizant that it may eventually become worthwhile/necessary. TH's example is very insightful and helpful in thinking about this for us; thanks very much!

Hope you're well!
Best, -Dan

Dear All:

This is a great forum-- so many thoughtful posts! Clearly there are challenges no matter where we work as NGOs. We have the challenge of supporting the MOH strategies and goals, and we have the challenge of reaching the population we intend to serve. In countries like Rwanda, these are largely one and the same. As has been noted before, the leadership within the Ministry of Health is one of the best, and I know firsthand through my work there earlier this decade. They are responsive to results that are brought to them with evidence from the field, have strong belief in developing their human capacity, and are creative in how that is achieved. I found that if you are doing work they find useful for their population, they support you 100%, and you do it together.

However, as mentioned earlier, this is not the same in other countries. Sometimes it is circumstantial. Haiti, for example, recently experienced the deluge of NGOs after the earthquake of 2010 that was perhaps similar to what happened in Mozambique in the late '80's. At some point, there were more than 400 registered NGOs working in the area of health alone ...

Dear All:

This is a great forum-- so many thoughtful posts! Clearly there are challenges no matter where we work as NGOs. We have the challenge of supporting the MOH strategies and goals, and we have the challenge of reaching the population we intend to serve. In countries like Rwanda, these are largely one and the same. As has been noted before, the leadership within the Ministry of Health is one of the best, and I know firsthand through my work there earlier this decade. They are responsive to results that are brought to them with evidence from the field, have strong belief in developing their human capacity, and are creative in how that is achieved. I found that if you are doing work they find useful for their population, they support you 100%, and you do it together.

However, as mentioned earlier, this is not the same in other countries. Sometimes it is circumstantial. Haiti, for example, recently experienced the deluge of NGOs after the earthquake of 2010 that was perhaps similar to what happened in Mozambique in the late '80's. At some point, there were more than 400 registered NGOs working in the area of health alone (not to mention the other areas). The MOH was literally in shambles, having lost buildings and staff, leadership was lacking, and NGOs took their cue initially from WHO, then PAHO, and others. To complicate things, it was an election year, so NGOs found it difficult to know who to create relationships with for the long run. And yet, the sufferings of the people, the local Haitians, was not put on pause while NGOs and MOH figure out how to work together. That is the reality.

I believe it is important for NGOs to support MOH. But a precursor, and a requisite foundation is that the MOH is the biggest advocate for the health of their nation, that they understand the epidemiology of their constituents, as well as demographic variability; that they understand key weaknesses in their existing systems, and have a determination to make evidence-based improvements; that at the end of it all, they seek the pride that comes with knowing that your nation is more healthy than it was in previous years. NGOs that find a situation like that are lucky, and should, without fail, fall in line behind the strategic vision of the MOH.

Now I ask, NGOs that do not find this, do they then have a responsibility to support the MOH in creating this vision? What are the best ways they could do that?

In addition, many NGOs enter this business to do good. This usually means reaching the unreachable and improving their health status. I think the point has been made that if this is done in an uncordinated way, chaos is created. But on the other hand, particularly in countries where the MOH does not have the political power (often health is not a priority in the budget, for example), and sometimes not even the inspiration to envision a healthy population, how does an NGO strike the balance between providing life saving medicines to dying infants, for example, and nurturing the MOH's inspiration? There should not have to be a balance, as these things should be the same. But let's face it-- in some settings, that is the starting point.

One last question I have is what about the local NGOs? In recent years, there is some discussion about public/private partnerships, and the observation that engagement of the private sector in health could also help with systems strengthening. Is it possible to make improved health status for the population a common goal for the public and the private sector? In places like Nigeria, where the private sector (formal and informal) provide up to 70% of health services, this is clearly an important question.

I look forward to your insights!

Best,
Rachel

First and foremost, the PIH answer to today's question is working within the public sector itself, helping to build its capacity. Our programs are embedded in the public health system, and we work in government hospitals and health centers. Building capacity within the Ministry of Health sometimes means seconding staff from PIH to work directly in the Ministry’s offices. At other times, we provide direct investment in the form of tangible support to the Ministry, for example, to buy computers, or to rent space for meetings. With added human bandwidth, we help officials with planning exercises. As we are based in close proximity with the Ministry at the district level, we have many opportunities to work directly with them, listen to their concerns, and help them structure their plans so they best meet their needs.

In the context of working with the public sector, a further way to prevent NGOs from drawing healthcare workers away from the public sector is for the NGO to offer a top-up—a performance-based salary increase—to MOH employees. In offering a top-up, you need to be aware of the Ministry of Health’s compensation system and those of other NGOs in the ...

First and foremost, the PIH answer to today's question is working within the public sector itself, helping to build its capacity. Our programs are embedded in the public health system, and we work in government hospitals and health centers. Building capacity within the Ministry of Health sometimes means seconding staff from PIH to work directly in the Ministry’s offices. At other times, we provide direct investment in the form of tangible support to the Ministry, for example, to buy computers, or to rent space for meetings. With added human bandwidth, we help officials with planning exercises. As we are based in close proximity with the Ministry at the district level, we have many opportunities to work directly with them, listen to their concerns, and help them structure their plans so they best meet their needs.

In the context of working with the public sector, a further way to prevent NGOs from drawing healthcare workers away from the public sector is for the NGO to offer a top-up—a performance-based salary increase—to MOH employees. In offering a top-up, you need to be aware of the Ministry of Health’s compensation system and those of other NGOs in the area. It’s important to remember that top-ups are not simply a one-time decision, but a process that requires ongoing monitoring and open communication with both government employees and your staff.

Providing programs and services in underserved areas where few healthcare facilities existed before brings new opportunities for communities. Hiring local people not only helps to build local capacity, it is also an investment in the local health infrastructure and local economy. It builds trust in your organization. Hiring locally can help keep staff turnover rates low; offering career structures that allow for professional growth and providing access to the Internet and other learning resources create an environment in which staff can develop new skills.

High-quality training and mentoring programs are vital to keep talented staff at your programs. We run formal training and mentoring programs at the sites for clinicians, other healthcare professionals, and community health workers (CHWs), as well as informal day-to-day mentoring for medical staff. Developing long-term training programs in collaboration with Ministries of Health also builds capacity in the public sector. For example, the Mentoring and Enhanced Supervision at Health Centers program in Rwanda was integrated into the MOH district supervisory structures already in place, rather than creating a parallel system. The result has been an increase in the number of supervisors and mentors available to train nurses at health centers.

Facilitating opportunities for national medical students and residents to work with you is another way to provide them with training and at the same time increase the clinical capacity at your site. If you support a government-run health facility, making sure that healthcare staff have the tools they need—medicines, supplies and adequate facilities—will ultimately help to retain staff in the public sector, particularly in an area with limited resources.

Here is my answer to question number 3. Thank you for all of your lively discussion so far this week.

From the perspective of the government, there are several critical concepts to understand, develop according to context, implement and maintain on all levels with respect to supporting human resource capacity. Underlying these four steps is ensuring that the definition of the word “support” in a given country is understood in the same way by the government and the non-governmental entities. In Rwanda, to support does not mean to dictate or to take the lead and control a given initiative or partnership. Support is technical assistance with long-term capacity transfer components to ensure sustainability. Governments cannot complain about their development partners if they don’t take the lead to assure a shared understanding of the word support.

Before inviting technical assistance, a country should always have a human resource capacity vision that is articulated in a national human resources strategic plan and an annual implementation plan. If you do not know where you want to go – how many cardiologists and pediatricians you want – how can you know what assistance to invite to your country? And how many you have to train ...

Here is my answer to question number 3. Thank you for all of your lively discussion so far this week.

From the perspective of the government, there are several critical concepts to understand, develop according to context, implement and maintain on all levels with respect to supporting human resource capacity. Underlying these four steps is ensuring that the definition of the word “support” in a given country is understood in the same way by the government and the non-governmental entities. In Rwanda, to support does not mean to dictate or to take the lead and control a given initiative or partnership. Support is technical assistance with long-term capacity transfer components to ensure sustainability. Governments cannot complain about their development partners if they don’t take the lead to assure a shared understanding of the word support.

Before inviting technical assistance, a country should always have a human resource capacity vision that is articulated in a national human resources strategic plan and an annual implementation plan. If you do not know where you want to go – how many cardiologists and pediatricians you want – how can you know what assistance to invite to your country? And how many you have to train to replace these foreigners over time? It is impossible. When a country has a national human resources strategic plan, we should not allow NGOs to do something outside of that plan. Instead NGOs should strengthen the plan. Moreover, governments must maintain and stand by their definition of support and their vision for human resources. If there is any flexibility in the aforementioned, you risk allowing development partners to run your health sector strategy on human resources forever, as you will not have built the capacity to replace them over time.

The first mechanism to put in place after defining the word support and articulating a national vision is to ensure that incentives are in place to keep human resources in-country and in the public sector. It is essential to have similar salaries in the public sector and in the NGOs. In Rwanda, there are specific guidelines for all people employed by NGOs doing care delivery. For those with very specific specializations, these salaries need not match public sector salaries. However, Rwanda still enforces the rule that the NGO-employed specialized care provider transfers capacity to health professionals working in the public sector. This mitigates national brain drain from public service to NGOs.

This brings me to the second mechanism. All development partner-employed care providers are to be paired with national professionals in order to enhance the capacity of our public health system and to uphold Rwanda’s valuation of equity. In fact, in Rwanda, to be a technical assistant you must prove to the Ministry of Immigration and Emigration that you are paired with a Rwandan national to transfer capacity.

The bottom line is to ensure that financial incentives are in place to keep your “brains” in the public sector, and ensure that the assistance you are receiving is sustainable and aligned with your country’s vision.

As all medical training is done with public money out of multilateral and national support (including taxes), we ensure that the training that our physicians receive is paid back to the population over time. Even within the public sector, all Rwandan-trained physicians must sign a contract on completion of their MDs that they have to work for 2 years at the district level. For Rwandan-trained physicians who wish to specialize, each person must sign a contract that they will work for 4-5 years in the Rwandan public sector according to the specialization they receive. During these timeframes where physicians work in the public sector, they are fully paid. This assures an equitable distribution of expertise, and assures that after 2-5 years we can replace them with a newly trained physician if they wish to leave the public sector or leave Rwanda.

But, I must tell you that so far nobody leaves Rwanda, people are even coming back from their training in other places. In place of brain drain, we have a brain faucet. And I am one example of that! What I can achieve here is far more than I could have achieved in the West or North if I count my work in lives saved and improved. And all of my colleagues here have the same feeling because of the environment we are working in in Rwanda.

To make NGOs work, you need a national human resources strategic plan. To avoid brain drain, you need to harmonize salaries between those who provide services that are paid by the public sector and those who are providing services that are paid by NGOs. To avoid international brain drain, you must create an enabling environment for your health care practitioners, including those with specializations.

How can NGOs best support building local human resource capacity?

As many participants have already commented, working in a remote area presents added challenges to the human resources for health question. Thus my response will include a number of strategies which are particularly suited to rural settings.

1) DECENTRALIZE TRAINING: governments can increase the human resource pool in remote areas by decentralizing training opportunities. Too often, institutions for higher learning are located within urban areas. This creates disparity for remote areas in two ways – first, greater incentives are necessary to recruit staff away from the convenience and ease of city life and second, qualified students from underserved areas face higher costs in having to relocate for schooling which can be an entry barrier. In Liberia, the Ministry of Health, in partnership with the McBain foundation, embarked on a plan to construct a midwifery school for the southeastern counties – a region that has struggled to recruit and retain health care workers. Merlin, an international health NGO already working in the region, provided technical support and stewardship for the project. The school now graduates 50 midwives per year – all of whom are recruited from counties in the Southeast.

2) BUILD ON EXISTING ...

How can NGOs best support building local human resource capacity?

As many participants have already commented, working in a remote area presents added challenges to the human resources for health question. Thus my response will include a number of strategies which are particularly suited to rural settings.

1) DECENTRALIZE TRAINING: governments can increase the human resource pool in remote areas by decentralizing training opportunities. Too often, institutions for higher learning are located within urban areas. This creates disparity for remote areas in two ways – first, greater incentives are necessary to recruit staff away from the convenience and ease of city life and second, qualified students from underserved areas face higher costs in having to relocate for schooling which can be an entry barrier. In Liberia, the Ministry of Health, in partnership with the McBain foundation, embarked on a plan to construct a midwifery school for the southeastern counties – a region that has struggled to recruit and retain health care workers. Merlin, an international health NGO already working in the region, provided technical support and stewardship for the project. The school now graduates 50 midwives per year – all of whom are recruited from counties in the Southeast.

2) BUILD ON EXISTING HUMAN POTENTIAL: Communities themselves contain bright, capable persons who are eager to serve. In places where human resources are scarce, well-managed task-shifting coupled with expert training can bridge health worker gaps. After the civil war ended, Liberia had just 51 doctors in the whole country – the majority of which were located in Monrovia. The number and concentration of nurses mirrored that of physicians. In post-war Grand Gedeh County, young people were recruited and trained to be professional nurse aids at the county hospital. Their instructor was a veteran of the health system who provided strong oversight and support in order to serve the needs of citizens in the county. Now Tiyatien is working to close another gap in services that plagues rural villages. The majority of the county lives in excess of 1 hours’ walk from a health facility and the MoH County Health Team reports that the average walking time to clinic for a citizen of Grand Gedeh County is 5 hours. We know that simply building more clinics will not solve this problem therefore, Tiyatien is sharpening and expanding its community health worker model to provide care in places where access is limited or non-existent.

3) ON-THE-JOB-TRAINING & MENTORING: Training usually takes place off-site which means that for the duration of the workshop, the health facility is missing one or two staff members. Furthermore, because it’s so difficult to spare multiple staff for training, the learning is often concentrated with one or two individuals at each facility. If one of those persons leaves, they take their capacity with them and the training process must begin anew. To improve the impact of training resources, NGOs should couple workshops with longitudinal mentorship at the facility level to improve quality and target learning for health workers already in community. Some examples of where this has been done successfully are the MESH program in Rwanda and the Clinton HIV/AIDS Initiative’s (CHAI) mentorship of HIV clinicians in country.

4) ADVOCATE FOR INCREASED AND/OR GAP FUNDING FOR MOH: NGOs often enjoy strong external (outside of country) relationships with donors. They are therefore poised to advocate for increased funding for MoH salaries as well as coverage for workers whose funding support is inadequate, intermittent or on the verge of completion. In Liberia, USAID and the Global Fund have, on separate occasions, stepped into guarantee salary coverage while financial wrinkles were straightened out.

5) CREATIVE INCENTIVES: Researchers have delved into the question of human resource recruitment & retention and studies tell us that higher wages, training opportunities, having sufficient tools to do their job, reasonable workload are some of the factors that help improve worker retention. But this short list alone tells us that the human resource question intersects with other areas like supply chains and civil sector wage caps. Because each country has its own set of challenges, NGOs must work within the local context to help mitigate the forces that draw workers away from their jobs. Furthermore, they should be promoting flexibility and creativity in how benefits are awarded. For example, if wage caps are unmovable, what sort in-kind compensation could be considered (rice, staff housing, etc). In Grand Gedeh County for example, Merlin, in partnership with the MoH County Health Team, is working hard to construct comfortable, dignified staff housing adjacent to every health facility in the county. This approach has the immediate benefit of having workers nearby in case of emergency but also, in a place where many healthcare workers are supporting families back in Monrovia, they are not forced to bear the cost of maintaining two households.

In areas where there are severe shortages of clinically trained staff, task shifting to community health workers (CHWs) is a strategy to try to build capacity. When is this strategy appropriate -- and when is it not? Is there field experience regarding ways that technology-assisted workflows (e.g. guidelines on pre-printed paper forms or on mobile phones) can leverage CHWs to "free up" more highly trained resources and make better use of their specialised skills?

I encourage everyone to take a look at the NGO Code of Conduct, which is available through a link on this website. We would love to hear what you think. The Code focuses mainly on human resources issues. As all the participants know, the health sector workforce shortage is the single greatest barrier to improving the delivery of services, especially in Africa. The WHO 2006 report on workforce is also a great resource with excellent data that reveals the extreme inequality among countries in health workforce per capita. The creators of the Code of Conduct focus on human resources because the NGO explosion has created a new kind of internal workforce brain drain. As public sector salaries are kept low and new hiring capped by SAP austerity policies, the arrival of NGOs with deep pockets and jobs to fill has pulled many talented and experienced national staff out of the public sector into the NGO world. NGOs often pay 10 times as much as the public sector for doctors and nurses. As long as NGOs are receiving so much foreign aid, internal brain drain will be a major concern for public sectors, so the Code of Conduct was designed to ...

I encourage everyone to take a look at the NGO Code of Conduct, which is available through a link on this website. We would love to hear what you think. The Code focuses mainly on human resources issues. As all the participants know, the health sector workforce shortage is the single greatest barrier to improving the delivery of services, especially in Africa. The WHO 2006 report on workforce is also a great resource with excellent data that reveals the extreme inequality among countries in health workforce per capita. The creators of the Code of Conduct focus on human resources because the NGO explosion has created a new kind of internal workforce brain drain. As public sector salaries are kept low and new hiring capped by SAP austerity policies, the arrival of NGOs with deep pockets and jobs to fill has pulled many talented and experienced national staff out of the public sector into the NGO world. NGOs often pay 10 times as much as the public sector for doctors and nurses. As long as NGOs are receiving so much foreign aid, internal brain drain will be a major concern for public sectors, so the Code of Conduct was designed to suggest ways to lessen the damage done by NGOs who take personnel out of public sector systems. Rather than repeat the articles in the Code - I'll just mention some key issues here from the document:

1.) NGOs can find creative ways to fund workforce within the public sector. Christina, for example, mentions gap funding. In Mozambique, HAI has been able to cover "gap year" funding in two provinces for MCH nurses who complete their pre-service training but cannot be placed because of government budget shortages. NGOs can temporarily cover their salaries until the state budget can kick in. NGOs can advocate to their donors the vital importance of this kind of support.

2.) NGOs should refrain from hiring staff out of the public sector. If on rare occassions it is necessary, it should be done in close collaboration with the health system and with their approval. If there has been a close relationship in developing a project in the first place, the problems can be sorted out early on.

3.) NGOs should strive for salaries that are not substantially more generous than the public
sector while providing a fair and living wage to
their employees. Salary inflation caused by the multitudes of NGOs competing to hire limited workforce has had a harmful effect in the end on the public sector. And it has created greater inquality in local communities. NGOs can play a lead role in advocating for higher salaries and better benefits across the board for public sector workers. The inflation of salaries for expats has been even more extreme, and NGOs should resist these market pressures whenever possible.

4.) The Code also pressures NGOs to be more vocal advocates in policy debates at national and international level for governements to hire more workers and to pay them better. In many countries, especially in Africa, SAP austerity policies now repackaged as Poverty Reduction Strategy Papers by the IMF and World Bank continue to place caps and restrictions on public sector workforce hiring and salaries. NGOs can challenge these policies and engage in advocacy to change them. The organization ActionAid, based in Washington, D.C., is a great resource for finding out how to do this kind of advocacy.

Hello, everyone.

Thank you all for the opportunity to contribute to this important
discussion. I have learned much from the contributors, and found the
comments very insightful.

It seems to me that any discussion about a system as diverse,
interconnected, and rapidly changing as health could benefit from the complex,
adaptive system
perspective<http://www.futurehealthsystems.org/publications/category/complex-adaptive-system>,
and participants should recognize that strengthening health
systems<http://ghsia.wordpress.com/>is a messy, long-term (decades),
context and history-dependent, iterative
process that requires a shared vision of underlying
principles<http://www.plosmedicine.org/article/info:doi/10.1371/journal.pmed.1000385>
.

Best Regards,

Chad Swanson

--
R. Chad Swanson, DO, MPH

Adjunct Assistant Professor
Brigham Young University Department of Health Sciences

Emergency Physician
Utah Valley Regional Medical Center

Chair, APHA Systems Sciences Working Group

Blogs: Strengthening <http://goog_206744991>Health Systems
<http://Strengthening>
Health Systems Stewards <http://healthsystemsstewards.wordpress.com/>

Dr Binagwho has so eloquently communicated the principles of proper international development and the concrete steps NGOs must take to implement those principles, that is difficult to add anything else to her writings. Rwanda is the shining example of how government should take the lead in controlling the behavior of NGO guests. It is my experience that donors and partners will fall into line and adhere (for the most part) to government guidelines and mandates when leadership is in place. It is in those countries where the government has not taken the lead in directing NGO activities that we find partners setting up parallel systems, implementing salary structures that undermine the public health system, and disregarding national strategic plans. A lack of strong leadership within the government is no excuse for us to take it upon ourselves to decide what is best in a particular setting. We can and should police ourselves in those situations.

Rachel raises a good point about Haiti and other countries where the capacity to manage partners is not in place, I would say, yes, we have a responsibility to help our government partners to be more effective and productive (if they want our help). They ...

Dr Binagwho has so eloquently communicated the principles of proper international development and the concrete steps NGOs must take to implement those principles, that is difficult to add anything else to her writings. Rwanda is the shining example of how government should take the lead in controlling the behavior of NGO guests. It is my experience that donors and partners will fall into line and adhere (for the most part) to government guidelines and mandates when leadership is in place. It is in those countries where the government has not taken the lead in directing NGO activities that we find partners setting up parallel systems, implementing salary structures that undermine the public health system, and disregarding national strategic plans. A lack of strong leadership within the government is no excuse for us to take it upon ourselves to decide what is best in a particular setting. We can and should police ourselves in those situations.

Rachel raises a good point about Haiti and other countries where the capacity to manage partners is not in place, I would say, yes, we have a responsibility to help our government partners to be more effective and productive (if they want our help). They are often responsible for multiple programs, with little staff or resources. If asked, we can help fill the gaps, provide technical assistance, improve data collection and analysis, and do the leg work to enable them to carry out their mandates. This only works if we truly respect our colleagues and recognize their leadership. At CHAI we like to say "We know our place". It is in service to the government of the country in which we work.

Ideally, we would not have to choose between life-saving care and capacity building within the MoH. They should be done concurrently.


This is already the best on-line discussion I have ever read. Thank you so much for all of the thoughtful contributions.

Anne

Greetings from Boston and thanks to all for the incredible variety of thoughtful and really inspiring comments. A special thanks to the Honorable Minister of Health of Rwanda for her leadership and to GHD online for hosting this very important panel discussion.

The role of NGOs in building capacity of health care providers and strengthening health systems is obviously relevant to many initiatives currently implemented across sub-Saharan Africa. Rwanda, as many comments on this panel noted, has been highly successful in establishing a framework to maximize the positive impact of NGOs on the health system by improving their coordination and align their individual activities to national strategic plans. Country-led vision, political commitment, and governance represent the strongest possible foundation for any contribution provided by international development partners and one of the best examples of this comes from Rwanda.

On the NGO side, and looking back at the experience of PIH in many different countries, there are two basic principles that I believe are key to improving the operational effectiveness of NGOs, regardless of their specific area of expertise in the health sector. One is accompaniment and the other is commitment to the highest standard of care.

Many people have talked ...

Greetings from Boston and thanks to all for the incredible variety of thoughtful and really inspiring comments. A special thanks to the Honorable Minister of Health of Rwanda for her leadership and to GHD online for hosting this very important panel discussion.

The role of NGOs in building capacity of health care providers and strengthening health systems is obviously relevant to many initiatives currently implemented across sub-Saharan Africa. Rwanda, as many comments on this panel noted, has been highly successful in establishing a framework to maximize the positive impact of NGOs on the health system by improving their coordination and align their individual activities to national strategic plans. Country-led vision, political commitment, and governance represent the strongest possible foundation for any contribution provided by international development partners and one of the best examples of this comes from Rwanda.

On the NGO side, and looking back at the experience of PIH in many different countries, there are two basic principles that I believe are key to improving the operational effectiveness of NGOs, regardless of their specific area of expertise in the health sector. One is accompaniment and the other is commitment to the highest standard of care.

Many people have talked about accompaniment better than I ever will, but I feel that commitment to the highest standard of care deserves a little more space. International NGOs should never advise local partners to pursue standards that would never be acceptable in their home country. It is OK for NGOs to think creatively with local leaders about how to best use limited resources, provided that the resources are not too limited to achieve valuable results. However, pragmatism should never limit the drive to secure additional resources if necessary or cloud the vision of strengthening the health system of the host country to world-class levels. In other words, the day to day work of NGOs has to be humble,respond to needs that are identified locally, and rooted in reality. However, the vision has to remain ambitious and bold.

The combination of creative thinking on optimizing health care spending and strong commitment to world-class care is an important universal concept, applicable to so called resource-rich and resource-poor settings. Many countries in Sub-Saharan Africa are experimenting very innovative approaches to health system strengthening and there is a lot of very valuable lessons that NGOs can bring back to their home countries in this regard. And hopefully this process will help shift the paradigm of international development from a dynamic with donor and recipient countries and organizations (that starts feeling outdated) to one with partnerships based on equity and mutual interests.

Again, the Government of Rwanda has set very ambitious goals to strengthen the country's health care system. This type of leadership is the best guarantee to prevent NGOs from under-performing, but ambitious goals should also be at the core of the mission of most NGOs.

HOW CAN NGOs BEST SUPPORT BUILDING LOCAL HUMAN RESOURCE CAPACITY?
The local human resource capacity required in any locality should be in relationship with the problems that require attention in that community.Where there are health workers already available, they should be encouraged to acquire education appropriate and relevant to the required purposes. Such encouragement could be in the form of Scholarships for training and other educational grants.
It is often best to have the indigenes in a particular community working in service of their fellowmen and women, for obvious reasons.
In the absence of seedlings of health workers to draw from for training, the attending NGOs should aim at assisting high school graduates with the necessary talents but who may not have the resources to get the necessary education to qualify and return to serve in the community. They should not forget to bond them however.
The level to begin may be as low as building or expanding schools in localities and assisting with the appropriate teaching personnel and equipment.
In time, such community will surely have sufficient local human resource capacity for service.
While waiting for these seedlings to grow, NGOs can import the required human resources with ...

HOW CAN NGOs BEST SUPPORT BUILDING LOCAL HUMAN RESOURCE CAPACITY?
The local human resource capacity required in any locality should be in relationship with the problems that require attention in that community.Where there are health workers already available, they should be encouraged to acquire education appropriate and relevant to the required purposes. Such encouragement could be in the form of Scholarships for training and other educational grants.
It is often best to have the indigenes in a particular community working in service of their fellowmen and women, for obvious reasons.
In the absence of seedlings of health workers to draw from for training, the attending NGOs should aim at assisting high school graduates with the necessary talents but who may not have the resources to get the necessary education to qualify and return to serve in the community. They should not forget to bond them however.
The level to begin may be as low as building or expanding schools in localities and assisting with the appropriate teaching personnel and equipment.
In time, such community will surely have sufficient local human resource capacity for service.
While waiting for these seedlings to grow, NGOs can import the required human resources with high incentives.

For question number 4: "How should partnerships between NGOs and the public sector deal with infrastructure needs?"

This is the weakest part of our partnerships so far. This doesn’t concern only buildings but also equipment and material, in addition to the national capacity to build infrastructure, and to choose and use and maintain equipment. So often in many countries, partners find it very easy to buy the pills to put in the mouths of the patient, but not to train practitioners to do it, not to buy equipment that can accurately measure effect of drug, and not to pay for infrastructure required for service delivery. Then, when support is finished, partners leave nothing behind. And there is no sustainability.

To overcome these challenges, we have set human resources development as our priority through our human resources for health strategic plan. We have included in this plan not only physicians and nurses, but also engineers because this technical expertise is a requisite for sustainability in service delivery. In Rwanda, we have set a policy on equipment and maintenance allowing and ensuring that the Ministry verifies all equipment, assures it can be maintained by our people and so on. But this ...

For question number 4: "How should partnerships between NGOs and the public sector deal with infrastructure needs?"

This is the weakest part of our partnerships so far. This doesn’t concern only buildings but also equipment and material, in addition to the national capacity to build infrastructure, and to choose and use and maintain equipment. So often in many countries, partners find it very easy to buy the pills to put in the mouths of the patient, but not to train practitioners to do it, not to buy equipment that can accurately measure effect of drug, and not to pay for infrastructure required for service delivery. Then, when support is finished, partners leave nothing behind. And there is no sustainability.

To overcome these challenges, we have set human resources development as our priority through our human resources for health strategic plan. We have included in this plan not only physicians and nurses, but also engineers because this technical expertise is a requisite for sustainability in service delivery. In Rwanda, we have set a policy on equipment and maintenance allowing and ensuring that the Ministry verifies all equipment, assures it can be maintained by our people and so on. But this was not the case before, which is why we receive a dialysis machine from an donor organization in a Western country. On it was written “NOT FOR HUMAN USE”. We don’t know what it was supposed to be used for, but it cost us a lot of money to destroy that. This is how the developing world sometimes turns into the filthiest garbage dump full of refuse from the Western world.

We also try to coordinate all the materials we purchase in order to assure that maintenance capacity exists either in Rwanda or in a neighboring country. If this is not in place, we can remain idle for months with a fantastic piece of equipment that is not working for us because we do not have the support to repair or maintain it.

For infrastructure and building, we have sought very special partnerships with those who can support valuable construction. We especially seek partnerships with those NGOs that are using national materials, ensuring infection control, and are also teaching our students of architecture and engineering how to construct valuable buildings. But I can count those partners on my left hand, unfortunately. We have very few, but we hope that there will be more because this is true sustainability and true development.

This is a great discussion. I have worked and consulted with NGO's and there is tremendous strength in their programs that can complement the GO's struggle. What I would like to see is the development of a crosswalk of all NGO's program/service location/manpower working for a particular country and use that to develop a national health program matching the GO's current state. In this way we are not wasting and duplicating services as often seen - hence not allowing us to best meet the nations needs.

My name is Laurien Nyabienda(MD), I am the Executive Director of ARBEF, a local NGO in Rwanda affiliated to International Planned Parenthood Federation(IPPF).
I have been following up this discussion with interest and I find it not only informative but also a forum for experience sharing.
The question by Dr Christopher : " HOW CAN NGO's BEST SUPPORT BUILDING LOCAL CAPACITIES"  needs more attention.
The ultimate purpose of any human resource capacity is to serve local communities by engaging with them to identify their needs and propose the best way to address them. This is best done - the Rwandan Minister of Health has well articulated it - through supporting the National Human Resource Strategic Plan. This ansuers the whole question of sustainability through skills and equipment transfer.
Capacity Building ensures sustainability and effective capacity building may be guaranteed by always working with local staffs who are part of the communities and know better what the needs of their communities are. Where local staffs need strengthening , that is where efforts should be focused. Thanks.
 
Laurien

Dear Tess,

The suggestion to develop a 'crosswalk' between all NGO programmes in a country is definitely a great suggestion, and should be started in a selected country to act as a 'pilot' that would demonstrate the significant efficiencies, and most importantly, the data accuracy and timeliness that would emanate from such an approach. For example, if there were say five NGOs in a country, each NGO would identify what data elements are required for their particular programme. At the patient point-of-contact/care the data elements required by ALL of the NGOs would be captured in e-format ONCE, and then distributed electronically - only the required data elements for that NGO - to each NGO in the format that they require. This would eliminate, for example, the patient's name being written down on five different paper-based forms, etc., etc., resulting in a reduction of over 90% of the effort to collect data elements for different NGOs. Also, such data collection should be connected to a central database, such as in a PAS (Patient Administration System), ensuring the accuracy of the data being collected (positive ID, demographics, GIS codes, valid medical codes, field range checks, etc.).

I close my comment with your ...

Dear Tess,

The suggestion to develop a 'crosswalk' between all NGO programmes in a country is definitely a great suggestion, and should be started in a selected country to act as a 'pilot' that would demonstrate the significant efficiencies, and most importantly, the data accuracy and timeliness that would emanate from such an approach. For example, if there were say five NGOs in a country, each NGO would identify what data elements are required for their particular programme. At the patient point-of-contact/care the data elements required by ALL of the NGOs would be captured in e-format ONCE, and then distributed electronically - only the required data elements for that NGO - to each NGO in the format that they require. This would eliminate, for example, the patient's name being written down on five different paper-based forms, etc., etc., resulting in a reduction of over 90% of the effort to collect data elements for different NGOs. Also, such data collection should be connected to a central database, such as in a PAS (Patient Administration System), ensuring the accuracy of the data being collected (positive ID, demographics, GIS codes, valid medical codes, field range checks, etc.).

I close my comment with your last line " In this way we are not wasting and duplicating services as often seen - hence not allowing us to best meet the nation's needs."

Respectfully submitted,

Ron Hebert, Canada

Hello All,
Am very much enjoying this discussion as well. An interesting concern came up today while I was in a discussion with Swaziland's Ministry of Health and Information, Communication and Technology team. Am currently in discussions with the Ministry of Health to help map out their information management strategy, much of which is centered upon building out an electronic medical record system, database, corresponding network infrastructure, and simple interfaces to aid in data collection. The purpose is a common one - to aid in reporting at the clinic level to help drive ownership and analysis of data to aid in performance assessment. This group has been very helpful in evaluating different strategies to consider and what's not worked in the developing world.

At the end of the meeting the director of ICT shared that his main issue is not having enough trained personnel to support Swaziland's IT, network infrastructure and computer support needs. He shared that previously they used volunteers with such experience to fill this gap and provide technical support and capacity-building for local staff. The government would often cover accomodation and potentially transport for such volunteers.

The program, whatever it was, appears to have fallen ...

Hello All,
Am very much enjoying this discussion as well. An interesting concern came up today while I was in a discussion with Swaziland's Ministry of Health and Information, Communication and Technology team. Am currently in discussions with the Ministry of Health to help map out their information management strategy, much of which is centered upon building out an electronic medical record system, database, corresponding network infrastructure, and simple interfaces to aid in data collection. The purpose is a common one - to aid in reporting at the clinic level to help drive ownership and analysis of data to aid in performance assessment. This group has been very helpful in evaluating different strategies to consider and what's not worked in the developing world.

At the end of the meeting the director of ICT shared that his main issue is not having enough trained personnel to support Swaziland's IT, network infrastructure and computer support needs. He shared that previously they used volunteers with such experience to fill this gap and provide technical support and capacity-building for local staff. The government would often cover accomodation and potentially transport for such volunteers.

The program, whatever it was, appears to have fallen off. Does this group know of any established organizations who help connect such IT/engineering/software skilled volunteers from abroad with countries in Africa? I am also going to follow up with other contacts but figured this group may have a few insights to share.
Thank you,
Anne Pao

My name is Daragh Fahey. I am a clinical director for Right to Sight (www.righttosight.com)

We are focused on economically sustainable quality eye care delivery, through innovation, hospital management, clinical and surgical training programmes in Africa.

We focus our efforts in two areas
Firstly we look at how eye units are being managed. We support new or existing unit to develop the right adminstration,management, finance and outreach processes and systems with a view to them maximising their activity and revenue. This includes cross subsidisation from those who can afford to pay with a view to leaving a sustainable system in place when we leave.

Secondly, we develop appropriate training for clinicians to maximise the quality and quantity of care for patients as well as providing incentives for them to continue working in the eye unit.

Where possible, we try to do this within the government setting. This requires us to work closely with the local and national government. If we don't get this part right our efforts can be underminded quickly as the government can easily undo anything we've introduced. If we do it right, then the government can be very supportive, adopting our our ...

My name is Daragh Fahey. I am a clinical director for Right to Sight (www.righttosight.com)

We are focused on economically sustainable quality eye care delivery, through innovation, hospital management, clinical and surgical training programmes in Africa.

We focus our efforts in two areas
Firstly we look at how eye units are being managed. We support new or existing unit to develop the right adminstration,management, finance and outreach processes and systems with a view to them maximising their activity and revenue. This includes cross subsidisation from those who can afford to pay with a view to leaving a sustainable system in place when we leave.

Secondly, we develop appropriate training for clinicians to maximise the quality and quantity of care for patients as well as providing incentives for them to continue working in the eye unit.

Where possible, we try to do this within the government setting. This requires us to work closely with the local and national government. If we don't get this part right our efforts can be underminded quickly as the government can easily undo anything we've introduced. If we do it right, then the government can be very supportive, adopting our our approach and rolling it out across multiple units.

It takes time to build the right relationships with the government and develop a true partnership. The challenge is to get the balance right between being a source of funds and a source of expertise. We are happy to provide short to medium term funding but only if they adopt some of the sustainability/human resource measures that we advocate.

By some measure, NGOs have been successful renovating and building infrastructure. Problems arise, however, when they see their engagement as over once the health facility has been built or the water supply increased. Problems can also occur the other way- as NGOs build and improve infrastructure, they become reluctant to give up control and pass on the reins to local leadership. Support is needed over the long term, but the support should be premised on the transfer of the skills and services to the local health system.

In terms of building infrastructure, we have learned the importance of listening to local community leaders about what they need and what is possible in the local environment. It has also been critical to find out about and follow national norms and standards for buildings from the Ministry of Health or the Ministry of Planning and whether there are official bidding and hiring processes for infrastructure projects. Hiring local people to work on infrastructure projects builds local skills and capacity.

Even if an NGO is not funded for major construction, creative ways can be found to contribute to public sector infrastructure. Donors are often supportive of rehabilitation of health facilities where projects are being implemented. In scaling up PMTCT and ART services in two provinces in Mozambique, we found that donors supported fairly substantial rehabilitation of existing government health units to accommodate the expansion of services. In health centers where PMTCT services were being added, we could justify not only rehab of the ANC services section but of the health center as a whole. In one province in Mozambique, we have our main office inside the provincial health directorate itself. This has allowed us to use all of our HAI office maintenance funding to actually help do rehabilitation and repair work throughout the entire provincial directorate, which was in desperate need of work. When we establish internet connections for HAI we can make sure that the government health facilities are included. Whenever possible (and of course compliant with donor regs) we try to use funds for our own recurrent costs, rehab, and repair to benefit our public sector counterparts. As others have emphasized in this discussion, this should all be ...

Even if an NGO is not funded for major construction, creative ways can be found to contribute to public sector infrastructure. Donors are often supportive of rehabilitation of health facilities where projects are being implemented. In scaling up PMTCT and ART services in two provinces in Mozambique, we found that donors supported fairly substantial rehabilitation of existing government health units to accommodate the expansion of services. In health centers where PMTCT services were being added, we could justify not only rehab of the ANC services section but of the health center as a whole. In one province in Mozambique, we have our main office inside the provincial health directorate itself. This has allowed us to use all of our HAI office maintenance funding to actually help do rehabilitation and repair work throughout the entire provincial directorate, which was in desperate need of work. When we establish internet connections for HAI we can make sure that the government health facilities are included. Whenever possible (and of course compliant with donor regs) we try to use funds for our own recurrent costs, rehab, and repair to benefit our public sector counterparts. As others have emphasized in this discussion, this should all be done as part of the planning process with the government.
We have found that it is best, whenever possible, to include as much rehab and repair funding in initial proposals as possible so that donors are on board from the beginning. We have seen far too many NGOs that bring just enough funding for themselves, and build their projects on the public sector system without contributing anything meaningful to the government infrastructure. Or, for example, an organization that is supporting a vertical approach to PMTCT scale-up provides just enough funding to rehab a section of the ANC section and leaves the rest of a health center dilapidated. In Mozambique, there are numerous health facility sites that have become a kind of patchwork of vertical programs funded by NGOs with new gleaming ART clinics or TB services side-by -side with crumbling basic outpatient services.
If NGOs could orient themselves to always contribute something substantial and lasting to public infrastructure it would go a long way toward redirecting at least some funding back to the public sector that has been diverted to NGOs.

Dear participants, please see below my contribution on the HR question;"How can NGOs best support building local human resource capacity?

I do agree with the experiences from the different participants; however I would like to share or underscore some specifics:
There is need for sustained on-the-job training for both high and low level health cadres; nurses and physicians so to say. With physicians it’s a bit complicated, in most cases their capacity building requires to be long-term since specialized medical training must take a while and there is no short-cut for this, although this does not rule out the relevancy of some targeted on-the-job skills transfers or mentorship. Conversely, sustained mentorship for lower cadres such as nurses and low level accountants which form the biggest percentage of the health-worker base for primary health care delivery can be provided by NGOs. For instance the Access Project with its management model uses district health advisors and specialized team to offer technical support in different domains such as basic accounting principles, pharmacy management, data management, IT maintenance……etc and this has proven to be impacting a positive change. Health center titulaires through the one-one mentorship have developed a fine grip on ...

Dear participants, please see below my contribution on the HR question;"How can NGOs best support building local human resource capacity?

I do agree with the experiences from the different participants; however I would like to share or underscore some specifics:
There is need for sustained on-the-job training for both high and low level health cadres; nurses and physicians so to say. With physicians it’s a bit complicated, in most cases their capacity building requires to be long-term since specialized medical training must take a while and there is no short-cut for this, although this does not rule out the relevancy of some targeted on-the-job skills transfers or mentorship. Conversely, sustained mentorship for lower cadres such as nurses and low level accountants which form the biggest percentage of the health-worker base for primary health care delivery can be provided by NGOs. For instance the Access Project with its management model uses district health advisors and specialized team to offer technical support in different domains such as basic accounting principles, pharmacy management, data management, IT maintenance……etc and this has proven to be impacting a positive change. Health center titulaires through the one-one mentorship have developed a fine grip on their action plans and their implementation.

Performance based financing has been a key strategy in Rwanda’s health sector for health care staff motivation. However retention of personnel remains a moving target where most of the experienced staff particularly in the facilities located in the very rural areas still have a high turn-over hence forth the need to sustain the trainings. My feeling is that there is no magic bullet for the high turnover at the moment and it will remain a challenge for us to sort out in the near future.

Please also see below some thoughts on the Question #4, "How should partnerships between NGOs and the public sector deal with infrastructure needs?"
Strong health infrastructure is essential, especially in health facilities where staff is trying to build management capacity – we need computers, electricity or solar power at these facilities. How can we ensure that we have adequate supply chain management without shelves to keep records and scales to weigh essential medicines? It is often the bricks and mortar of the building – and all that goes inside – that are central to ensuring that health facility can function at full capacity to provide quality health services to its patients and patrons. When we have state-of-the-art health centers, they can also take the pressure off of regional hospitals and other facilities by providing top-quality primary health care at the very local level.

Equipment is also an essential component of an effective health center, and equipment maintenance right alongside it should be provided. I have seen many pieces of expensive equipment arrive at these centers from large corporations or organizations, and all too often they are not accompanied with training or contingency plans for equipment failure – once the warranty expires after a year, they may get relegated to a box in a deep dark closet because the resources for maintenance simply are not there. It will be essential to expand and strengthen in-country capacity to maintain essential medical equipment in hospitals and health centers.

* How should partnerships between NGOs and the public sector deal with infrastructure needs?
This fourth question is probably one of the more challenging questions because we know infrastructure needs can range from roads to buildings to laboratories to IT equipment. Perhaps it’s easiest to group them into LARGE, MEDIUM and SMALL infrastructure needs rather than topic-based categories.

LARGE NEEDS (Examples: Roads, bridges, entire hospitals).
1)I will repeat of what’s been said before about the importance of NGOs working to directly support the capacity of the MoH. The stronger the Ministry, the better-able it is to raise the capital necessary for, say, a hospital or to persuade its counterparts at the Ministry of Finance, Planning or Public Works of the importance of mobilizing around a bridge that will create access for remote communities.
2)Let’s recognize that projects of this size require huge infusions of funds and donors are often concerned about the “absorption capacity” of a country or district when large scale projects are undertaken. Some donors have sought to overcome this gap by encouraging an intermediate phase for planning and strengthening of existing systems to ensure project success. NGOs are well-positioned to be active partners ...

* How should partnerships between NGOs and the public sector deal with infrastructure needs?
This fourth question is probably one of the more challenging questions because we know infrastructure needs can range from roads to buildings to laboratories to IT equipment. Perhaps it’s easiest to group them into LARGE, MEDIUM and SMALL infrastructure needs rather than topic-based categories.

LARGE NEEDS (Examples: Roads, bridges, entire hospitals).
1)I will repeat of what’s been said before about the importance of NGOs working to directly support the capacity of the MoH. The stronger the Ministry, the better-able it is to raise the capital necessary for, say, a hospital or to persuade its counterparts at the Ministry of Finance, Planning or Public Works of the importance of mobilizing around a bridge that will create access for remote communities.
2)Let’s recognize that projects of this size require huge infusions of funds and donors are often concerned about the “absorption capacity” of a country or district when large scale projects are undertaken. Some donors have sought to overcome this gap by encouraging an intermediate phase for planning and strengthening of existing systems to ensure project success. NGOs are well-positioned to be active partners in supporting governments to achieve a state of readiness. Additionally, joint appeals from NGOs and MoH can draw upon each party’s existing relationships and experience in dealing with multilateral donors and can help empower the MoH to formulate a strong proposal and advocate for its acceptance.
3)Tremendous cooperation between multiple parties is also essential to the success of a massive infrastructure project. NGOs can support by lending technical expertise, coordination and facilitation to the process while working earnestly to ensure that the skills which enable these contributions are also transferred to the public sector in the form of mentoring and capacity-building. In places where political allegiances constrain good working relationships between in-country groups, NGOs may be able to serve as neutral mediator to keep the project moving.
4)Civil society must be involved! NGOs and governments need to invite the community to have a seat at the table very early in the process rather than as a cursory gesture. Increasing attention has been paid to these groups in recent years and they are an important component of assuring accountability. We know that large pots of money tend to be subject to skimming in *any* setting. Engaging civil society in the process helps to ensure that a large infrastructure plans are sensitive & responsive to the needs of the community and that they are implemented with transparency and quality.

MEDIUM NEEDS (Examples: expansion or renovation of existing structures, installation of indoor plumbing, essential medical tools such as CT scanner, major IT systems)
1)While all infrastructure implementation, large or small, should be done in alignment with the MoH’s strategic plans and under their direction, it seems mid-size projects are frequently prone to taking on a life of their own – a donor becomes enamored with a certain community and runs ahead to build a new hospital wing for specialy care for example. Working directly within the public system as Ted Constan has mentioned is one way to ensure goals and visions are aligned with the government’s plan. Additionally, NGOs that are working on the ground for the long-term may be better-prepared to understand the complex and often competing priorities of any major infrastructure investment.
2)Another role that NGOs working in multiple countries or communities can play is to help governments identify other partners who are particular adept at implementing specialized projects based on past performance.
3)In projects of this size, the oversight and technical functions (financial, monitoring, planning) may exceed the local MoH’s capacity even if the project is clearly in line with the national or district level plan. In partnering together, NGOs can handle the burden of those project support functions while enabling the MoH to grow its capacity to manage projects and also exercise authority over the process.

SMALL NEEDS (Examples: medical tools like laboratory equipment, computers, software system like quickbooks)
1)While the relatively “small” price of these items means there is usually money available during grant applications, if governments are not communicating this needs systematically, they can become chronically overlooked or funds may be misallocated to cover urgent gaps. Thus, at every level, NGOs should be engaged in continuous conversations with government about their needs for infrastructure and quality improvement.

FINAL THOUGHTS:
1)Beware the tech fix: in broken or fractured systems, it’s tempting to view a piece of technology- be it a computer system or high tech diagnostic equipment- as the solution to all problems. This is rarely (if ever) the case and in fact the addition of another complicated system can often cause further disruption rather than curing ills. Therefore, NGOs and governments alike should ask critical questions when considering any new technological acquisition to ensure the right technology is actually being considered and that necessary systemic improvements are undertaken to actual capitalize on the new technology.
2)Don’t overlook and/or underestimate the need for training when budgeting and planning for new equipment or a new service delivery space. Intensive, on-the-job instruction and mentoring will be critical in the short term and regular refreshers and quality assurance activities must be ongoing. Initially outsiders may be involved in the initial phases of the set up process, but they should be paired with national staff who themselves can become expert trainers. That way subsequent scale-up of a new technology can happen at increasingly affordable cost. Logistics and supply chain support should also be included in training needs.
3)Don’t forget maintenance: I would guess everyone on this forum can cite an example of a piece of equipment that was hailed as the answer to a community’s prayers when it arrived and then, within a period of months (or a year if you’re lucky), it broke down or malfunctioned and was never used again because the expertise to repair it did not exist in-country and the cost to fly in a technician was prohibitive. This is one area where the development of public-private partnerships could have particular value.
4)Dream big: A colleague of mine is very fond of citing Dr. Paul Farmer’s diagnosis that global health and development is suffering from “catastrophic failure of imagination”. Indeed, in settings where resource scarcity is the norm, we become accustomed to thinking on the smaller scale and considering only how to acquire the bare essentials to help us get by. NGOs and governments alike should encourage innovative, imaginative solutions whenever aiming to address gaps in the system. With every program planning exercise we do at Tiyatien Health, we create 3 budgets: a dream version, a comfortable version and a bare essentials version. This not only helps us continue to push ourselves to think big but it also helps our folks working in development & fundraising to know what our larger aspirations are and to seek partners that can support the realization of those visions.

Dear all, thank you for the continued engaging discussion. I will take time over the weekend to respond to each and every comment, but for right now I will answer only the shortest ones due to time constraints.

#43: Rachel, you are right, this is the ideal situation. However, most times this is not the case and we must push the NGOs to be as close as possible to that ideal situation.

#48: Maysa, around the world, some NGOs are delivering services, but few of them are building capacity. This really needs to change to emphasize building capacity, so that one day NGOs are not needed where they are currently working because one day the people they train will be able to take their sector and run it. This new spirit will overcome the challenge you talked about.
#52: Dear Felicia, your criticism has the roots of the solution; NGOs have to support national programs in design and implementation - in a way that leads to appropriation, for ownership and sustainability through creating capacity. Maybe the solution should be that all together we design a metric to evaluate NGOs. A system of international audit with accountability, with financial sanctions related to ...

Dear all, thank you for the continued engaging discussion. I will take time over the weekend to respond to each and every comment, but for right now I will answer only the shortest ones due to time constraints.

#43: Rachel, you are right, this is the ideal situation. However, most times this is not the case and we must push the NGOs to be as close as possible to that ideal situation.

#48: Maysa, around the world, some NGOs are delivering services, but few of them are building capacity. This really needs to change to emphasize building capacity, so that one day NGOs are not needed where they are currently working because one day the people they train will be able to take their sector and run it. This new spirit will overcome the challenge you talked about.
#52: Dear Felicia, your criticism has the roots of the solution; NGOs have to support national programs in design and implementation - in a way that leads to appropriation, for ownership and sustainability through creating capacity. Maybe the solution should be that all together we design a metric to evaluate NGOs. A system of international audit with accountability, with financial sanctions related to reimbursement of salaries and overhead for those who do not perform – this could push the NGOs to perform. Perhaps we should create a new UN body to track NGOs. First of all, no NGO should work in a country where there is no strategic plan and no national plan to implement without first helping the country to design one. No NGO should implement things that are outside of the national plan. Such a plan must be inclusive and owned by the country. What do you think?

#55: Blerim, I agree with you, but all of the work we do must be part of health systems strengthening.

#61: Jeff, thank you for your comment, but I must point out that you cannot implement the same plan in different countries. You can solve the same problem in different countries, but the way you do so must be customized and focused on the realities of different countries. This means that you have to be ready to implement different strategies and different plans to solve that problem. This can only be done in a participatory process with the citizens by starting with the simple question: do you believe that this is a problem, and what are your views to solve it? Then follow their ideas with a culture of ownership and participation. All health plans must be country-customized and focused. Copy-pasting anything is the worst thing that you can do in building health sectors in countries.
#69: Dear Derek, Indeed, what you're saying does exist and has been assessed and evaluated: In Rwanda we have a very strong task-shifting paradigm in place. We have nurses who have been trained to provide antiretroviral therapy with the remote support of doctors. We have community health workers treating lower respiratory infections, fevers, malaria, gastroenteritis in addition to providing contraceptives at the village level. This paradigm has really liberated the time of everyone - for each level with more specialized care, they are able to provide care at the appropriate level of training they have. There are several articles on this in Rwanda.

#71: Robert, you are right, but if you begin with this principle it becomes common and usual to each and every one and not so difficult to implement. Am I right? It may be complex, but it is not so difficult to do if you have an inclusive approach where each complexity is taking care of by the people concerned. When it is a national policy, on principle, it doesn’t seem so difficult, and it’s what we have done in Rwanda over the last ten years that I’ve been working as a health policy maker and program manager.

#76: Dear Tess, a compilation of NGO actions doesn't build a system, creating one action plan where each NGO takes a piece, this is building a system

#78: Ron, I agree that more coordination is crucial. But we will never meet the nation’s needs doing such a fragmented approach that just helps NGOs to remain with their differences and particularities. Instead, we should build a public sector with one electronic medical record with harmonized indicators set up in a participatory process with health care providers. Such a process reveals the true needs of the country to manage the health services delivery, which can be accomplished through one database run by the health workers at health centers – national or international or NGOs. When this data is aggregated nationally by the MOH, it allows extraction of epidemiologic and population data as well as costing data across the entire cycle of care for all patients. Countrywide, one set of data collection and one electronic medical record, not linked through any individual NGOs but rather with the national program that can then be used by the NGOs, is best. This brings economy of scale and efficiency. Efficiency = simplicity and cost-effectiveness.

HOW CAN NGO STRENGTH HEALTH SYSTEM

Dear All, First of all I would like first to apologize for my English but I need to give my contribution in this panel.
I am a civil servant currently heading the unit of care at the National Tuberculosis Control Program at the MOH in Senegal (West Africa).My work is to elaborate policies for care delivery for TB,TB/HIV, Pediatric TB and MDR/TB;

This question about the collaboration between the MOH and the NGO is a very interesting and important subject. And I am Happy to see that everybody agree that something is going wrong. I faced so many challenges in the collaboration with the NGO which are our principal Donors.

1. LEADERSHIP OF THE MOH :
 PROMOTE THE SYSTEM OF COACHING WITH THE TRAINING OF THE NEVRALGIC UNIT ( TO LEAD YOU MUST KNOW BETTER AND DO BETTER)
 BE RESPECTFUL OF THE AGENDA OF THE PROGRAM IF THERE IS NO AGENDA PROVIDE TECHNICHAL ASSISTANCE FOR A STRATEGIC PLAN ,
 BUILD A CULTURE OF INTERNAL CONTRIBUTION IN THE NATIONAL HEALTH SYSTEM

Is see the role of the NGO as a booster ,so the public sector must first to know which kind of help they ...

HOW CAN NGO STRENGTH HEALTH SYSTEM

Dear All, First of all I would like first to apologize for my English but I need to give my contribution in this panel.
I am a civil servant currently heading the unit of care at the National Tuberculosis Control Program at the MOH in Senegal (West Africa).My work is to elaborate policies for care delivery for TB,TB/HIV, Pediatric TB and MDR/TB;

This question about the collaboration between the MOH and the NGO is a very interesting and important subject. And I am Happy to see that everybody agree that something is going wrong. I faced so many challenges in the collaboration with the NGO which are our principal Donors.

1. LEADERSHIP OF THE MOH :
 PROMOTE THE SYSTEM OF COACHING WITH THE TRAINING OF THE NEVRALGIC UNIT ( TO LEAD YOU MUST KNOW BETTER AND DO BETTER)
 BE RESPECTFUL OF THE AGENDA OF THE PROGRAM IF THERE IS NO AGENDA PROVIDE TECHNICHAL ASSISTANCE FOR A STRATEGIC PLAN ,
 BUILD A CULTURE OF INTERNAL CONTRIBUTION IN THE NATIONAL HEALTH SYSTEM

Is see the role of the NGO as a booster ,so the public sector must first to know which kind of help they need. The role of the public sector is to have a strategic plan. The existence of a coherent strategic plan needs trained and qualified human resources. At this level countries often needs technical assistance. But wich kind of technical assistance can we wait from the NGO? In my experience in TB the few efficient assistance was provided by the WHO. The training of the member of the NTP with the members of the others NTP are the pretext to an exchange of experience an the organization of a regional response with individual country plan. Policies are shared, discussed and adapted at the national level and then the implementation can begin.
Usually what happen with the NGO is that they are often not following the recommendation of the WHO which is the reference in the public sector and unfortunately the technical assiatance have not this macroscopique view of the problem. I am not saying that everything that WHO is doing is good but they have the merit to be organized, to speak the same language and also to be operational.
Just to share with you an experience in our Round 7 for the global fund we proposed to start the care for MDR TB patients. It was very New for the staff . in the implamentation we saw that we missed the biological fellow up. The drugs where here, the teams were trained and the patients were identified but there was not a donor for this line . Each of them had their own agenda(always in MRD TB: we had 3 Technical assistance with the same goals for the lonely laboratory….) but not for this line. The chance that we had was that nephew of the head of the biology department was MDR TB ! And he agreed to reduce drastically the prices and finally and NGO agreed to pay so we could begin the treatment for the patients.
The leading rule of the MOH is not only in the management but we need also to look at our internal resources, financial but also managerial .
The “free fees services” in our countries can sound like a big joke. The service is supposed to be free , but in reality it leads to a “ no service system” with a lack of basic needs . Community contribute in his health in a way or another . if there is no services they will always use the tradipraticiens who are not free. The Bamako Initiative ( essential drugs in a low cost ) must be largely shared in poor settings countries
We can find so many internal resources: our government first, the emigrant Senegalese community, National NGOs , Community association etc..

For the MDR TB the Gap for the gap nutritional kit is assured by a small Senegalese NGO named “SOUTOURA” Which have been created by Senegalese emigrants and ordinary citizen who wants to do something for their country and each month they give a symbolic sum for the persons in difficulties.
The cost is 50 dollards per patients and it gives us unexpected results
. The global Fund and the other agencies are developing so many mechanisms to fight corruption and have transparency. And the procedures are completely different from one to another. What is our responsibility in all the scandal with the global Fund?

1. SHARE OUR AGENDA AND BUILD MUTUAL OWNERSHIP :

Often it seems that NGOs are somewhere searching for an “unexposed zone” (often rural area) to test their hypothesis an then to do a exposed an no exposed comparison. This research of originality often creates a cacophony in the country and at the end of the year even with 20 NGO in the area things we cannot say that something had changed. ; in this context of crisis the best thing to do is the rational use of the resources.
I fully agree that we need to share successful experience but do it with the MOH. NGO are rich of the experience of a multitude of countries, but the MOH is the only one who can scale up in a reasonable time these experiences. Communication is very important in this relation but also respect.
They must be associated at the conception of the project.
NGO have their own calendar , their own goals and their assumptions : "health problems are in the rural area". Like Dr Angéle said It is important for the Ministry of Health to have a strong national strategic plan and be aware of it.
Let’s seat together and have a frank discussion with “appreciation, good will and good intent” .What are your goals ? What can you bring me? Where our agenda do meets? We are all here for the benefit of the population. I often say that the difference between the NGO And the NTCP is the difference between the macroscopic and the microscopic view. Everybody is missing something when he wants to work alone. NGO get sick of any remark because they sacrifice the money of their country and their emotional capital .In the other hand the public sector is frustrated to hear that there is a lack of transparency and that the only thing that interest them are Cars, perdiums and training aboard. It is very frustrated to see that you are a civil servant , working for your country when it is so easy to go aboard where you can get the triple of your salary. This representation of the NGO giving over salary create a lot of problems at the operational level and everybody get suspicious: I do the hole work and they use it for other themselves.
2. COST EFFECTIVENESS BE REALISTIC

With NGO we are often facing some expensive and long initiatives that are often difficult to implement at the national level. If the conclusion of a mission is that we need 6 pharmacist in each of the 14 warehouse to effectively control supply chain when in the hole country there is less than 30 logistic pharmacist in the hole public sector , what can I do?
Do we really need to have the same standards as the US? May be ; But let’s priories and be realistic.


3. UNDESTAND THE ETHIC PROBLEM THAT CREAT THE “NGO ZONE”: WE ARE IN A SYSTEM

Most of time the part covered by an NGO never exceed more than 50 % of the population.
Do we have the right to creat surch disparities? What will happen if my patient ask me why do he needs to move to a region if he want to benefit for some care? Do a Program can answer that it’s because we have a partner in one region and not another? Can we in a country where in the urban area the rate of HIV is 7% be focus on the rural area where only 1% of the population is infected because an NGO come with the assumptions that Needs are in the remote area?
How can I explain to a pregnant woman that the blood cell count is free only for the HIV (+) patients? We are in a integrated system. In a poor health setting countries where we have poor access to health system we cannot afford to miss a contact with the patient or to select them; And we have as represent ant of the nation the regalia role to guaranty equity in health access as much as possible.

4. RELAY ON SUSTAINABILITY:
 HELP TO CREATE SUSTAINABLE VALUE “I UNDESTAND THE COST OF MY INACTIVITY” ,
 WHAT WILL HAPPEN WHEN NGO WILL NO LONGER BE THERE?

When we talk about sustainability it means that things must continue to go even when the NGO is no longer here. That means that we need to bet on a rock. And in the field of health the rock in a country is Health worker who is conscious of the impact of his action in his own community and who have to drive transformation for this community..The problem is less in quantity than in quality of the human resources First ,They need to be motivated. When we talk about motivation we often think about salaries.... A lot off them left the public sector and rush in the NGO because of the chasm between the salaries for the same work.
There is nothing less sustainable then money .We need to create new value. And the first one must be the satisfaction of a well done work. We Need Heath Workers to be leaders and a a leader must first take the time to understand the why of his action. If you don’t know why you do things there is a big chance that you will not do it for a long time. Training and coaching for a transformational leadership of the human resources is the key of a development. Show them that you can ad some value to their work; they often don’t know the cost of their inactivity.
If we talk about development we must first be aware that the rule of the NGO must be limited in time.
Foreign aid will soon be an old history and we are by our position accountable of the health of our population and our inactivity have a cost .At the end of the day looser will be our dad, brother, friend and us as evident part of the community...
Just ask that question: What will happen when you NGO will no longer be here? What will happen these days when the global crisis will reduce the foreign aid? What will happen when the Global Fund stops? A lot of NGO are build on the dream of one pioneer what will happen after Them?

For question number 5: "Are there examples of current partnerships you think have been particularly successful at strengthening health systems? Conversely, can you provide examples of 'partnerships' that aren’t working and explain why not?"

For the most helpful illustrations of such polar opposites, I find it best to think in general terms. Below I have outlined the characteristics of strong partnerships between governments and NGOs, and weak or harmful partnerships between governments and NGOs. While this outline is not exhaustive, it includes some of the key aspects of each pole that are of most concern in Rwanda.

An NGO seeking to work as a strong and useful partner to the Ministry of Health:
- Joins the country in designing a national plan for economic and social development
- Helps the health sector to develop a strategic plan as an integral piece of the overall national development plan, and help all subsectors (NGOs, disease-specific divisions of the Ministry, procurement agencies, etc.) to develop their own plans in a way that is well-aligned with the national health sector plan
- Goes where the biggest needs are (not the prettiest beaches!), and partners with the public sector to prioritize the most vulnerable first and foremost ...

For question number 5: "Are there examples of current partnerships you think have been particularly successful at strengthening health systems? Conversely, can you provide examples of 'partnerships' that aren’t working and explain why not?"

For the most helpful illustrations of such polar opposites, I find it best to think in general terms. Below I have outlined the characteristics of strong partnerships between governments and NGOs, and weak or harmful partnerships between governments and NGOs. While this outline is not exhaustive, it includes some of the key aspects of each pole that are of most concern in Rwanda.

An NGO seeking to work as a strong and useful partner to the Ministry of Health:
- Joins the country in designing a national plan for economic and social development
- Helps the health sector to develop a strategic plan as an integral piece of the overall national development plan, and help all subsectors (NGOs, disease-specific divisions of the Ministry, procurement agencies, etc.) to develop their own plans in a way that is well-aligned with the national health sector plan
- Goes where the biggest needs are (not the prettiest beaches!), and partners with the public sector to prioritize the most vulnerable first and foremost… when we focus on the most vulnerable, we bring everyone up
- Undertakes their work with the aim of “working themselves out of a job” – not staying forever with the intention of creating job opportunities for their own grandchildren at the same NGO

A self-serving NGO that can undermine the goals of the Ministry of Health:
- Moves about the country with an arrogance that says, “we love your people more than you… we know your needs better than you do… and we know how to implement programs better than you.”
- Undertakes activities with the primary aim of looking good in the eyes of others in the international community, prioritizing the image they see of themselves in the mirror instead of truly investing in national development
- Confuses the notion of working as partners for development with lounging at Club Med, simply researching good beaches and pay grades, not actual means of addressing the suffering they exploit from a distance
- Swallows more than 15% of the money they receive to work in your country for overhead… To put it simply, we are merely the pretext for the staff of such NGOs to have a good life
- Makes humanitarian work a systematic business for themselves, with outcomes measured in money for themselves – not health and wealth for our population
- Leaves the country in a worse state than before they arrived, because they didn’t work to create sustainable health systems but rather dependency… When such NGOs depart, the people don’t even know how to do what they knew before

Good afternoon all happy to participate in this forum on strengthening
health systems.


I'm from Ecuador Tec Systems at the Ministry of Public Health
We have been working for several years to implement an electronic health
system. It is a very important issue to improve service and streamline
processes to get to really information for decision-making.

we must continue working in the education of health professionals as
technology professionals to the important inclucar of medical informatics in
health.

To Christina Bethke’s excellent points about “small” infrastructure and maintenance: we are a nonprofit technology organization that equips hospitals to deliver anaesthesia safely, with a focus on facilities where unreliable electricity and medical gas shortages compromise the ability to provide surgery. We have learned a number of lessons working with hospitals, NGOs and Ministries of Health that we incorporate into the design of our equipment and the services that accompany it. When we install an anaesthesia machine we identify a technician on site that can take responsibility for preventative maintenance and be trained on basic service. The machine can be repaired by swapping out modules in the field using basic tools and simple instructions. We are creating regional spare parts depots to take time off transit, and if we ship a replacement part we include the tools required to install it. We are also working on a library of training materials specifically for preventative maintenance and service.



Adding appropriate technology to a hospital can provide great leverage in the delivery of care if individual equipment is evaluated in the larger context. An anaesthesia machine is only valuable if the hospital has the staff, training, procedures and physical infrastructure to ...

To Christina Bethke’s excellent points about “small” infrastructure and maintenance: we are a nonprofit technology organization that equips hospitals to deliver anaesthesia safely, with a focus on facilities where unreliable electricity and medical gas shortages compromise the ability to provide surgery. We have learned a number of lessons working with hospitals, NGOs and Ministries of Health that we incorporate into the design of our equipment and the services that accompany it. When we install an anaesthesia machine we identify a technician on site that can take responsibility for preventative maintenance and be trained on basic service. The machine can be repaired by swapping out modules in the field using basic tools and simple instructions. We are creating regional spare parts depots to take time off transit, and if we ship a replacement part we include the tools required to install it. We are also working on a library of training materials specifically for preventative maintenance and service.



Adding appropriate technology to a hospital can provide great leverage in the delivery of care if individual equipment is evaluated in the larger context. An anaesthesia machine is only valuable if the hospital has the staff, training, procedures and physical infrastructure to provide surgery. Maintenance costs can not be ignored. Those who provide equipment must take responsibility for its integration into the hospital and for maximizing its useful life. Placing medical technology anywhere without sufficient backend support is simply not ethical.


__________________

Stephen Rudy
Executive Director
UAM Global

Our partnership with the Rwandan Ministry of Health is a strong example of how an NGO can harmonize its program priorities and finances with those of the Ministry. When we first started working with the Ministry in Rwanda, together we developed HIV programs embedded in primary health care at a limited number of facilities in two districts. After a few years, the district level Ministry asked us to change focus. While they had appreciated our work with those specific health centers, they thought we should spread our existing support across all of the districts' health centers. As a result, we adjusted our strategy and did so, resulting in a more equitable distribution of services across the district. The same productive, consultative process occurred with community health workers. Initially, in our community health program, CHWs provided care primarily to those infected with HIV. The Ministry reorganized their community health program so that the CHWs now provide more generalized primary health care services at the village level. We adjusted our community health program and training priorities for CHW to fit with the new government strategy.

NGOs support to in-country governments in a bid to strengthen local health systems is much needed now than ever before. Those of us familiar with Africa health care systems know all too well how communicable diseases have overstretched the health care systems. More disturbing is the WHO prediction about the rising incidence of NCDs in SUb-Saharan Africa.WHO projects that NCDs will overtake infectious diseases by 2030 in terms of disease burden and mortality. Unless something is done, this will be catastrophic to our health care systems. Equipping our healthcare systems with tools to prevent and manage these cases is one of the fundamental things the NGO's must do. Nurses ought to be empowered much more on this. In the resource constrained environments, they are the primary health care providers responsible for initial screening, promoting wellness and offering health messages to clients. This tasks are the most effective in preventing NCDs and interestingly the least expensive in managing NCDs. However, nurses potential contribution is yet to be harnessed in the battle against NCD's. Whereas task shifting has been demonstrated effective in cases where nurses were empowered to manage HIV/AIDS, policy makers appear reluctant to let nurses do ...

NGOs support to in-country governments in a bid to strengthen local health systems is much needed now than ever before. Those of us familiar with Africa health care systems know all too well how communicable diseases have overstretched the health care systems. More disturbing is the WHO prediction about the rising incidence of NCDs in SUb-Saharan Africa.WHO projects that NCDs will overtake infectious diseases by 2030 in terms of disease burden and mortality. Unless something is done, this will be catastrophic to our health care systems. Equipping our healthcare systems with tools to prevent and manage these cases is one of the fundamental things the NGO's must do. Nurses ought to be empowered much more on this. In the resource constrained environments, they are the primary health care providers responsible for initial screening, promoting wellness and offering health messages to clients. This tasks are the most effective in preventing NCDs and interestingly the least expensive in managing NCDs. However, nurses potential contribution is yet to be harnessed in the battle against NCD's. Whereas task shifting has been demonstrated effective in cases where nurses were empowered to manage HIV/AIDS, policy makers appear reluctant to let nurses do what they can do best in managing NCD's. In many countries, there is minimal proactive strategy engaging nurses directly and deliberately either in screening or longtime management of chronic diseases. Their involvement is incidental, most often relying on directives of clinical officers (equivalent of physician assistants) and where possible physicians. This indirect involvement of this crucial team doesn't augur well with our health care systems. NGO's can employ their resources in advocacy, demonstrating to policy makers that empowering their nurses would be a major step in strengthening the health care systems. NGO's may also need to spearhead research that focus on country/region specific needs of the healthcare systems so as to identify the unique needs that ought to be addressed.

I’d like to thank all of our panelists and contributors for creating such an incredibly rich discussion this week. While we still have a bit of time left with our panelists, I’d like to take a moment to summarize a few of the key points from our discussion thus far, since newcomers to the conversation have quite a few comments to read through at this point!

We began the week by discussing the necessary elements of successful partnerships between NGOs and Ministries of Health. Dr. Agnes Binagwaho started things off by highlighting the particular importance of a national vision and strategic plan that sets priorities and creates a framework for NGOs to work within. From the NGO perspective, Ted Constan stressed the importance of communcation, saying “It’s 90% of the relationship. Sharing information from the beginning and throughout the engagement is essential for the partnership to succeed.” Many participants questioned how NGOs can best serve populations in countries that may not yet have the leadership to create the framework Dr. Agnes described. Please chime in if you have suggestions or insight to share with the panel on this topic.

Next, the conversation moved to the challenges of ...

I’d like to thank all of our panelists and contributors for creating such an incredibly rich discussion this week. While we still have a bit of time left with our panelists, I’d like to take a moment to summarize a few of the key points from our discussion thus far, since newcomers to the conversation have quite a few comments to read through at this point!

We began the week by discussing the necessary elements of successful partnerships between NGOs and Ministries of Health. Dr. Agnes Binagwaho started things off by highlighting the particular importance of a national vision and strategic plan that sets priorities and creates a framework for NGOs to work within. From the NGO perspective, Ted Constan stressed the importance of communcation, saying “It’s 90% of the relationship. Sharing information from the beginning and throughout the engagement is essential for the partnership to succeed.” Many participants questioned how NGOs can best serve populations in countries that may not yet have the leadership to create the framework Dr. Agnes described. Please chime in if you have suggestions or insight to share with the panel on this topic.

Next, the conversation moved to the challenges of administering joint programs. Some of the particularly burdensome challenges cited by our panel include: developing a national vision and convincing partners to implement it, creating a sense of solidarity between partners, managing finances, meeting requirements of multiple donors, making evidence-based decisions, and ultimately, delivering care equitably and effectively. The primary solution to these challenges again seems to be ongoing communication about priorities, responsibilities and roles.

On the third day of the panel, we tackled the question of building local human resource capacity. Panelists offered suggestions on providing salary top-ups or covering funding gaps for government counterparts and emphasized the importance of ongoing educational, training and mentorship opportunities to build local capacity. Dr. Felix Kayigamba challenged us to consider employee retention, particularly in rural areas, noting “There is no magic bullet for the high turnover at the moment and it will remain a challenge for us to sort out in the near future.”

Yesterday, we asked how partnerships should address infrastructure needs. Christina Bethke pointed out that “tremendous cooperation between multiple parties is also essential to the success of a massive infrastructure project. NGOs can support by lending technical expertise, coordination and facilitation to the process while working earnestly to ensure that the skills which enable these contributions are also transferred to the public sector in the form of mentoring and capacity-building.” For other projects James Pfeiffer noted, “Creative ways can be found to contribute to public sector infrastructure. Donors are often supportive of rehabilitation of health facilities where projects are being implemented.” Panelists and participants also raised questions about the value of technology and equipment that cannot be maintained with local resources, further emphasising the need for training and capacity building.

Today we are discussing examples of successful partnerships between NGOs and Ministries of Health. Of course, the government of Rwanda, as well as our panelists from Partners In Health, the Access Project, Tiyatien Health and Health Alliance International, are all strong examples of how these partnerships can truly strengthen health systems. We hope all of you following this discussion will also share examples of partnerships that you feel have been successful in this important work.

While we still have some time left with our expert panelists, what other questions would you like to discuss around the role of NGOs in health systems strengthening?

In our projects in Mozambique, HAI has strived to be a constructive partner with the Ministry of Health by always taking the Ministry lead and adapting projects to national health system priorities and plans. We have made our share of mistakes long the way - at least in part because of the way the aid and donor world work. But I will provide one example of a project that has worked particularly well. In the 1990s, together with the Ministry we identified syphilis testing and treatment as an important intervention in antenatal care that was not being properly conducted and prioritized throughout the country. The Ministry agreed and we obtained funding to focus efforts to increase the testing and treatment rates from about 10% in the early 1990s to over 90% now. Test and treat was the national policy at the time but for various reasons was not being done well. In two provinces, HAI piloted new registries, trained MCH nurses, and did trouble shooting of the lab services to streamline the system in the public sector. Over time the testing and treating rates gradually improved and HAI continued to provide training support and monitoring. Over this period, the streamlined approach ...

In our projects in Mozambique, HAI has strived to be a constructive partner with the Ministry of Health by always taking the Ministry lead and adapting projects to national health system priorities and plans. We have made our share of mistakes long the way - at least in part because of the way the aid and donor world work. But I will provide one example of a project that has worked particularly well. In the 1990s, together with the Ministry we identified syphilis testing and treatment as an important intervention in antenatal care that was not being properly conducted and prioritized throughout the country. The Ministry agreed and we obtained funding to focus efforts to increase the testing and treatment rates from about 10% in the early 1990s to over 90% now. Test and treat was the national policy at the time but for various reasons was not being done well. In two provinces, HAI piloted new registries, trained MCH nurses, and did trouble shooting of the lab services to streamline the system in the public sector. Over time the testing and treating rates gradually improved and HAI continued to provide training support and monitoring. Over this period, the streamlined approach became deeply routinized in the new MCH cadres and by the early to mid-2000s syphilis testing and treatment across all ANC sites in two provinces have sustained 80-90% plus coverage rates without HAI involvement. We believe this is a good example of a health system strengthening intervention designed to improve the public sector services across a large number of facilities based on the close partnership between an NGO and the government. The essential ingredients to success were close planning with the government services in response to their priorities, long term commitment to following through, a careful choice of an intervention that could realistically be scaled up within the health system without new unsustainable technologies, and very close day-to-day working relationships between HAI staff and health system staff. HAI's resources for data gathering, supplies of testing materials and medical supplies were channeled through the Ministry to help support those systems as well.
Our experience has indicated that health system strengthening projects in large complex systems must be realistic in scope and not try to achieve too much too quickly, must be based on Ministry priorities and shared planning with the Ministry in the driver's seat, and should focus on a long-term commitment. NGOs should avoid creating parallel data, logistics, transport, and supply systems, and should channel their support into the public sector systems they seek to strengthen. It is not always easy to do these things because of donor demands and timelines - but if NGOs orient themselves to the needs of the public system they can maximize positive impact and minimize the damage that NGOs can cause when they do not collaborate.

To me sustainability did not attract much attention yet it is key concept for a lasting development.
Sustainability requires not only financial and material support but also and perhaps more importantly a conducive environment.
Many developing countries do not lack natural resources to create a critical mass of required expertise but lack systems that can bring about sustainable development, which in turn guarantees quality health care delivery. Then how can NGOs contribute to creating a conducive environment where it is critically needed?
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I'm Corine Karema, the National Malaria Control Program Manager in Rwanda, I agree with Dr Nyabienda : sustainability is key and a strong established health system is the hearth of health care success, establishing a system given the context of a country is very crucial for service delivery, I will take the example of Rwanda which is decentralizing some basic care to the community while increasing the number and upgrading the level of nurses and MDs, the Rwanda MoH is using 4 CHWs per village
with a total of 60000 countrywide to treat malaria, pneumonia and diarrhea in children
As a result today 93% of children under five are treated within 24 hrs of symptom onset, this is possible thanks to the well established community health system which has became the 4th level of health care, in this context an NGO Will support the well established system, Will not implement activities out of this system and Will not duplicate and create system, the NGO Will support the improvement of this system and this is sustainability! Corine twitter:@ckarema

I am a family doc in Haiti now trying to represent my small NGO's mission to establish a community clinic and serve a section where no healthcare is available. Setting priorities, finding in country partners and understanding the system that you wish to integrate with is extremely difficult. There are NGO's who have become well established into the healthcare system here in a complementry manner. Templates to understand their method at a very high level is available, however when you get to the details a small organization like my group can easily get frustrated. I feel so strongly that those who have successfully learned to work w/i the system assist others to do the same to avoid misguided adventures in good meaning people. Mete Te Ansamn (in creole: put our heads together). Dr Joe

Dear all, I am now including all of my responses to the remaining comments that I have not already answered. Thanks again to all of you for a great discussion. The issues we have collectively explored are so important, and the conversation should not end with this panel.

#38: Regina, thank you for your response. All of this is true, but it is not specific to NGOs – it is also important to differentiate between national and international NGOs. Operational research at national or regional level much more influential than tiny pilots; how can we work together (NGOs and public sector) Priorities of NGOs should be aligned to government priorities; voices of NGOs should echo and amplify that of government. Could not agree more than NGO activities should be conducted in accordance with a national strategic plan proposed by the government, and that communities must be an integral part of devising and monitoring these plans – this last part is the most important for me, because communities are the end beneficiaries of all of our work. For sustainability, training of the workforce should be completed during pre-service education; if not, you will always take people out of work to train them because ...

Dear all, I am now including all of my responses to the remaining comments that I have not already answered. Thanks again to all of you for a great discussion. The issues we have collectively explored are so important, and the conversation should not end with this panel.

#38: Regina, thank you for your response. All of this is true, but it is not specific to NGOs – it is also important to differentiate between national and international NGOs. Operational research at national or regional level much more influential than tiny pilots; how can we work together (NGOs and public sector) Priorities of NGOs should be aligned to government priorities; voices of NGOs should echo and amplify that of government. Could not agree more than NGO activities should be conducted in accordance with a national strategic plan proposed by the government, and that communities must be an integral part of devising and monitoring these plans – this last part is the most important for me, because communities are the end beneficiaries of all of our work. For sustainability, training of the workforce should be completed during pre-service education; if not, you will always take people out of work to train them because you didn’t complete your job during their education, and you will harm their clinical practice, and waste money to continually bring people together. Of course, continuous medical education is out of the scope of this question but also very important; this question is about giving basic skills to health workers so that they can provide quality care. For the integrated supportive supervision system you mention, by principle NGOs can support the establishment of such a system – but it must be set and designed by the government if you are to respect national ownership. The only exception to this rule is when there is no state due to catastrophe or war – and then only for a short time.

#39: I agree, Felix; the MOH needs to provide a strong vision and structure in which NGOs can participate and align themselves. Partners should take their cues from the MOH on geographic distribution – the MOH knows best where the needs are and where services should be distributed. And I agree that partners should be aiming to work themselves out of jobs in the health sectors of other countries. But that also means providing the best quality services while in-country and transferring capacity.

#40: Thank you for your comments, Ted. Partners in Health has indeed been a partner who tries to live up to its professed values.

#41: Ted, I very much agree that from the Ministry’s perspective, inviting NGOs to join the planning process is essential. On the other hand, as you point out, transparency from NGOs is crucial to maintaining a productive relationship with the Ministry, as is flexibility in implementing shared goals that derive from the national strategic plan. All of the principles you talked about (transparency, flexibility, etc.) are key to the success of implementation.

#42: a) Christopher, I agree. All nations need a national development vision and plan; and to document their journey. And it has to be in a comprehensive and participatory process.

b) Human resources for health must be part of that national development vision and plan.

c) In Rwanda this is not the case, because we have created strong institutions that fight against corruption. And this ist he key to assure good management of funds that are meant for the population you need to have strong integrity and strong institutions like the auditor general and report the Parliament (which is elected and represents the interests of the population). To do that, there has to be a strong separation between legislative and executive power. If not, there is still risk of covering up corruption. 

d) You are right this is an issue, fair distribution of infrastructure across the country is key for social justice and breaking geographic barrier to accessing care. It is a priority that should never be neglected.

#44: Dear James, thank you for your thoughtful responses this past week. I have not had a chance to fully read through the NGO Code of Conduct, but based on your comments, I hope that it starts many more discussions among partners around the world. It is so important to understand the historical basis of the conditions where NGOs become part of the health system in African countries in order to understand why the goal of a country-owned health system is so important. When we understand this, we will know how to prevent and mitigate what we call the “NGO tsunami” – an incredible number of ineffective, uncoordinated NGOs rushing into a country to fill a gap that should be filled by the public sector and swallowing resources raised around the world for that country’s needs in an ineffective manner with a high transactional cost/overhead. I also agree that as a basis of development, strengthening the public sector to provide quality care is the key objective, and that this cannot be done when money is diverted into an NGO tsunami.

#46: Juliet, it seems that Marie has answered your question, but I appreciate your willingness to ask when unsure. For partners new and old, this is so important – if we do not know an answer, we must trust one another enough to ask before acting. As Marie suggested, you can have more information by visiting the website of our Ministry at www.moh.gov.rw.

#47: Marie, thank you for your moderation of the panel this week. Indeed, all who are interested in this panel’s topic should read the reports on our Ministry of Health’s website – we document all of our policies, and they are open for our citizens, donors, NGOs, and other countries to read. If one wants more information, we are always there to provide it.

#49: Dear Christina, thank you for your comments – I liked them very much. As you said, a focus on quick impacts can really undermine long-term and sustained solutions, and creating trust takes time. But believe me, when you come with good plans and good faith, it is always visible. Good faith, a willingness to align, and to support the development of the health sector in the respect of national and local leadership, and acting with humility, especially if you apply the principles of transparency and accountability, will take you far together with your partners. Never trying to replace the role of the communities themselves in identifying their own problems, as you state, is key in respecting them and creating trust.

#50: James, it seems that all governments and donor countries should customize the NGO Code of Conduct. This is an important document that addresses many, if not all, of the lessons we have learned in Rwanda about successful collaboration. Thank you very much.

#53: Dear Kamonyo, you are an example of successful investment in capacity building. We count on you to later train other Rwandans and to transfer knowledge – that’s the way that the Government of Rwanda plans to build the human resources for health that our country needs – with skilled and talented professionals as the backbone of our overall development plan. You will see – one day, Rwandans like you will be invited to teach and build capacity elsewhere in Africa or other continent overseas, even in the developed world, and will contribute to building health and wealth on Earth. Keep up the good work, and always remember what we are working for.

#54: Dear Ted, as I have discussed in my responses for the panel, compensation is certainly a crucial level for ensuring equitable distribution of human resources across the country and between NGO staff and Ministry of Health staff. In Rwanda, we have a national policy mandating salaries that are in line between sectors, with exceptions only for highly trained technical consultants (who must also transfer capacity like other non public sector employees). Equity in human resources is a key to successful partnerships between NGOs and the public sector. To put it simply, we should be seeking workers for the national health sector; salaries should be paid by one national entity, with the same salary paid for the same work, whether to NGO or public sector workers. This salary should be paid to all by one national authority to whom all NGOs and public sector employees report (NGOs should contribute their funding for worker salaries to this public entity, which would distribute it to NGO workers).

#56: Ted, I agree with you. If you decide to come and support a country in alleviating suffering and developing the health sector’s capacity for service delivery, you always need to customize your reaction to the real situation of the country, and always go for benefitting the community you have come to serve.

#57: Christina, thank you again for sharing your experience. But we should never forget that even when we respond to emergencies and crises, we need to build systems. MOUs are not the endpoints – it’s about the content of the MOUs and the sustainable outcomes that count.

#58: Dan, you bring together many important points from panelists on rural health care delivery with respect to NGO and MOH relationships. One of your key goals as an NGO – given the importance of your being in the communities and the difficulty the MOH may have in reaching all remote corners of the country at all times – should be to overcome these barriers to communication. There are always ways to innovate – maybe that means having weekly phone calls with the community health desk at the MOH to check in. Maybe that means local health professionals in these remote areas holding town meetings with community members in rural areas to hear directly from them what kind of support they wish to see strengthened from the MOH and communicating those messages directly to the MOH from the rural areas, thereby supporting the MOH in their efforts to reach rural areas. Maybe it’s to have the government to create a communication system to include all the country even in remote areas. As equity means the same services across the country, whatever area you are.
If your goal is to strengthen your relationship with the MOH there should be a systematic mechanism in place that is mutually devised to ensure and enhance communication between your NGO and the MOH.
Yes, this is the only way to create sustainable infrastructure and programmatic interventions in a developing country. We must work together to reach the nation’s goals – and those goals should be ambitious and in the framework of social justice and going in remote areas to serve the vulnerable should be a main focus of any NGO and for government building facilities for allowing access to care and treatment in those remote areas. This contributes to social justice.

#59: Dear James, you are right - one cannot divide the health sector between activities that fall into your plan or not. This is crucial for an integrated approach and for supporting local and national priorities. An NGO must support the government in addressing the needs that they face in the place where they work as far as health is in the mandate of the NGO and health service delivery is the outcome. I appreciate using the government channel for salaries and other initiatives. Doing so can help the government to also better manage this money that NGOs pool in as well as public funds. This is a way to sustain public finance, but also to decrease inequities in salaries and confusion around ownership, as everything belongs to local entities. For the per diem, we are against this in Rwanda – we just use this to allow people to have lunch outside of their home or capacity to pay hotel, but not for an activity. If this is not the case, you can create a vicious cycle of going to NGOs’ activities just to be paid via per diems, and this is very detrimental for the delivery of quality clinical services in the country.

#60: Christopher, principles of good administration for programs are based on ownership account and transition, so whatever you pay has to be the same across the country for the same work or services. The best practice is to base everything on the take-home (salary + incentive from performance-based financing or anything else) from whatever institution give it to you – the central/local government or NGOs – and this must be the same across the country for the same services rendered. Creating such an administrative system is the only way to avoid such frustration and to promote equity through salary equity. Politics should not be part of technical work and clinical service delivery; only technical skills should be considered, not the party you belong to or your religious orientation. Raising awareness about the right to quality services and increasing demand among the population fall within the role of both the government and NGOs.

#62: Christina, I agree – it is obvious from several decades of the NGO tsunami that James Pfeiffer referred to that, for most of them, the natural tendency is to coalesce around cities or areas with nice beaches and lots of SUVs. As I’ve said in other posts, Rwanda requires that NGOs are equitably distributed across the country, so we expect them to work where the needs are – not just the easiest access to a good life. Maintaining close dialogue with the Ministry of Health in Liberia is so important, and your innovation is one step in the process of becoming fully aligned and fully in touch. As you have said, it will be key to have your expatriate staff, including your Ministry liaison in the capital transfer capacity to local staff. If sustainability is the goal, this is the way.

#63: Carmen, your dialogue project sounds like an interesting workshop. Often in such events though, much talk and fancy meals do not translate into the tangible outcomes that truly matter: the health and wealth of the population. It is very important to have cross-border learning and exchange, but most important is the capacity-building element of international partnerships, as you identified.

#64: Dan, as Christina noted, it is absolutely fundamental to ensure alignment between NGOs, even in the most underserved rural areas, and the government at the central and local levels. Your work in Nepal will only be more effective as you link your efforts to the national government’s strategic plan for rural areas. If such a plan does not yet exist, join them in developing it using a participatory process.

#65: Dear Rachel, thank you for your kind words. The effectiveness of the Ministry comes directly from the goal of our government overall: to increase opportunities for our population by promoting their health and wealth in all that we do. We welcome NGOs who share this vision, as you know. While challenges of working together as Ministries and NGOs do exist everywhere and vary by context, there are many universal principles that apply to successful relationships. We have discussed them throughout the last week, but they are worth repeating: open and honest communication, alignment of NGO with Ministry goals and plans, and equitable distribution of services in a way that meets the true needs of the country. As I have said, emergencies and natural disasters can make conditions such that long-term alignment takes second priority to immediately redressing the needs of suffering populations, but in the case of Haiti it is now time to move towards rebuilding and this will require the kind of partnership we have been talking about, not temporary band-aids or arrogant externally-imposed solutions. As for NGOs having the responsibility to help craft a vision when there is none – of course this is the case, but always remember who must be in the driver’s seat. No matter how good their intentions, NGOs cannot guarantee health as a right; only the government can do that, and long-term progress depends on it.

#66: Dear Ted, thank you for your insightful comments. PIH has long been dedicated o these tenets in Rwanda, and we hope that more NGOs learn from their close collaboration with the Ministry of Health towards our shared goals. As has been discussed throughout the last week, the compensation scheme for both public sector and NGO workers is very important. We harmonize rates across both sectors, and we provide performance-based incentives to all from community health workers to specialists at the referral hospitals. Training for students and professionals is essential, which is why we emphasize capacity building in all partnerships. I do believe that, except for routine training updates and briefings on new developments in one’s field, most training should be targeted for the pre-service area so that we do not take public sector health professionals away from delivery.

#68: Yes, as you say Christina, geographic equity is important for education and training opportunities in addition to the delivery of services. Just as NGO distribution should be where there is most need, the training sites should be accessible to all those who need the training. For task-shifting in communities, you are right, Christina. In Rwanda we have devised a system whereby community health workers (4 per village, 60,000 in total) are elected by their community and serve their community providing basic health services, enabling visits to other health facilities or calling ambulances. Having health representatives at the community level is essential to a strong health system in a country where a large proportion of the population that lives in rural areas. Our community health workers treat pneumonia, gastroenteritis, malaria, among other symptoms and illnesses. They have decreased the number of transfers to health centers and they break down geographic barriers that often lead to delays in accessing treatment. Christina, you mention also examples where institutional knowledge can be lost when a trained employee leaves an NGO or a governmental entity – the way to tackle this is to ensure that incentive structures are in place to keep people within the system, as you mention. Just as we think about the whole patient when providing health services (i.e. wraparound services, geographic access, nutritional and social support, and so forth) we need to think about the whole health professional when providing opportunities – what are the incentives to stay in the system after receiving advanced training? How do we ensure that international NGOs do not inflate salaries to attract our best health professionals and ultimately remove them out from the public sector? These are questions we need to ask ourselves. But the solution is strong coordination and ensuring that NGOs align to ethics and appropriate behavior. Ministries of Health also sometimes need to be strong enough to tell them to kindly return to their home or go to another country if their behavior or actions disturb the national health sector. We have had to do this in Rwanda on several occasions. I also want to mention something that was only touched on briefly in your post: formal education. Formal medical education is the only sustainable way to building a health sector. The points you brought up mostly concern short term – which in many contexts become short cuts to – training and service delivery, but quality and sustainability go along with developing the formal health education sector.

#70: James, thank you for sharing details on the NGO Code of Conduct, and for your work in seeking to help NGOs be the best partners they can be to Ministries of Health. These lessons regarding internal brain drain are important to understand from the perspectives of both NGOs and the public sector. Effective policies must be put in place to ensure equity in payment structure and in geographic distribution, but NGO partners truly committed to the country’s development must also police themselves out of a desire to strengthen, not weaken, the government.

#72: When there isn’t proper government leadership it doesn't mean that NGO responsibilities decrease, and this is especially true for those NGOs that are international. They still must act in an ethical way to support the country to design a national strategic plan and a plan for monitoring and evaluation where everyone is accountable to each other. This is not easy but don’t start development work if you want easy things.

#73: Dear Corrado, thank you so much for your beautiful comments. Accompaniment is a very powerful concept – in the Ministry of Health we think of it as turning solidarity into policy. The question of standards of care is essential for both NGOs and governments to prioritize; as I mentioned with the example of the North American shipment we got including a dialysis machine labeled “NOT FOR HUMAN USE,” countries like Rwanda are often viewed as the dumping ground for the West. In research, protocols that would never pass ethical review in Europe or North America have been exported to Africa so that poor patients can be exploited for research that they will never benefit from. This is not acceptable, and both NGOs and governments must have policies and practices in place to prevent it. Access to high quality medical care should be the bare minimum of human rights, not something seen as unusual or special – no matter where a patient lives.

#74: Hi Christopher, Building human resources for health is crucial for service delivery to the population. This does not only mean physicians, but is applicable to all levels of human resource capacity including professionals who are program managers, engineers (to maintain and repair equipment) and so on. So, building a system that strengthens human resources for health in a sustainable way must include the assurance that community health workers are well-trained, but also that institutions for technical education in health (i.e. nurses) and institutions of higher education are supported so that the country can, with time, create its own workforce for health according to its needs at present. Unfortunately, this sustainable approach is generally refused to countries that propose it, and partners end up focusing on efforts like community health worker education and only very minor trainings for health professionals without building the capacity for the countries for formal education and quality training opportunities

#77: Dear Laurien, I could not agree more.

#79: Dear Anne, It should never be the case that a country tries to build a sustainable health system with volunteers from another country. Volunteers can help in emergencies or as additional support to established national workers who are well-educated, well-trained and appropriately retained. So if Swaziland wants to implement e-management of their health system (e.g. HMIS, EMR, Data Collection for infrastructure and HR management) you first need for the country to develop strong, dependable ICT infrastructure, and to create a formal training structure for ICT (especially for website developers). This is because your ICT / e-health system must be specific to Swaziland. To do that, those who develop and maintain the ICT system must have a solid grasp of the Swazi context for health care delivery. Also, all health facilities should be equipped with the same, necessary ICT equipment to ensure equity and also to effectively roll-out the e-health program. By Swazi, for Swazi. And to all volunteers across the world: Come to help Swazi do it, by Swazi, for Swazi. The people from Swaziland are the spine of their own e-health development. If this isn’t the case, failure may be expected because success by way of volunteers is linked to chance.

#80: Dear Daragh: The only way to do it right is to do it from the beginning with the government according to national needs. This is done as a partner, and not as an organization that comes and gives a pre-defined programmatic recommendations that have not been developed in a participatory process with national authorities (who are ultimately those who will sustain it over time). In the absence of a participatory process involving national authorities, NGO interventions cannot be sustained if the NGO leaves the country and the nation loses any investment in that intervention. Clinical services must also not be developed outside of the health system because this makes scaling up very difficult and there is inherently a lack of synergy with other health initiatives. More simply, your work is not efficient for building a health system. But when you are totally integrated, the funds you have for short/medium term become a catalyst to development programs. Hope this can help.

#81: Dear Ted, you raise a couple of important issues in your comment about NGOs that ultimately give up on communities they have worked with/in. That’s why countries should have very clear MOUs with NGOs to delineate who is doing what, for whom, how, and what is the end product meant for the population. And more than that – how NGOs can do their work, ethically, to develop the community in which they are working, and not do this type of work to gain power or promote their own image or simply to have property/goods. They are there to develop the community which means creating awareness, developing ownership, and creating an environment that sustains the future of those communities. Of course, listening to populations, following norms and standards of the country, and producing durable and quality infrastructure – designed with and for the people – is again a question of ethics. I like your comment.

#82: Dear James, you are right. And I appreciate that you are doing what you can in an integrated manner to support infrastructure development in Mozambique and not using a fragmented vertical approach. You must also know that integrating yourself into the national health plan as a partner is the optimal way to go. Unfortunately this sense of development is not always common sense among development partners! Often development partners focus on rehabilitating old and sometimes obsolete infrastructure instead of building fresh new infrastructures that are modern, durable and of good quality – infrastructure that can serve the population for years to come. Certainly old ones need to be rehabilitated, but the expansion of health services goes with expanding health infrastructure in countries where there is too little infrastructure to provide the needed services. This is what we fight for because it creates geographic equity, and increases access to health by breaking barriers. The poor don’t deserve to have camouflage placed over old infrastructure – the poor deserve all the same options as the rest of the world. Africa deserves more quality than they are given currently, and so much money is spent in futility that could be otherwise turned into real sustainable progress.

#83: Dear Felix, I totally agree with your comment. For the turn-over, there is only one solution: to create a critical mass of health professionals. This means expanding institutions for education, and expanding the capacity to produce the health workforce that is needed. In the mean time, we need to create an enabling environment for people to enjoy working in remote areas. This is not easy. In Rwanda, students are trained under the government support, and we ask them to pay back (as of now) two years working in remote areas with full salary and other advantages (i.e. Performance-based financing, PBF). After two years, many return to cities. But with time, and with the development of rural areas, the construction of schools for children, improving the roads, bringing water and electricity, creating internet connection for continuous education, this all makes the lives of health professionals more interesting and attractive in remote areas. We hope that this will increase the number of years that health professionals will remain in remote areas. Also, we have decided to apply different tiers of PBF according the area you are located. For the same services, the smallest PBF will be in the cities, the middle tier will be in rural, and the highest PBF will be in remote rural areas. This is simply a recognition of the fact that doing, for example, a good quality C-section by yourself in a remote area of Rwanda is a more difficult circumstance than doing the same service in the capital city where there are anesthetists and plenty of other support staff available, and many other things. We’ll see, with time if this strategy is paying back. But you can see that this is linked with economic development. In other words, we have to create a health sector but also we must promote the economic development of the country.

#84: Dear Christina, this is a very nice statement, but we have very few NGOs that are behaving as you describe. They are exceptions, not rules. I wonder if one could name 10 NGOs that are doing that without the crazy amount of money going into overhead instead of creating sustainable infrastructure in a participatory manner that responds to the need of the country. That’s why Paul Farmer (as you have cited in this comment) and his colleagues are exceptions.

#86: Ramatoulaye, tank you for sharing with us your experience. It shows us that when you do a plan, you need to think about each and every step without leaving any steps out – otherwise your program is in danger. This is what we could call the chain of service delivery – ensuring that each chain is linked to the next smoothly and durably. From identification of patient, to diagnose, to prognosis, to drug procurement, to follow side effects, etc………….. the care and support needed – this is the chain of service delivery. When you have this chain of service delivery, you need to assign to it a budget and a responsibility; that’s how that you have a big cake that is your plan and without any duplication you give a piece to each and every stakeholder, identify the gaps, mobilize to repair them, and start working. It avoids discovering when implementing that you miss a big part of the chain/cake. For sure, the role of the government is to help set the priorities, the strategies, and the ingredients of that cake, and to help to distribute the pieces to each and ever stakeholders. And sometimes in a mandatory way, to divert one stakeholder’s from non-effective useless work to come and take a piece of that cake for more cost effective interventions. All of this means that an NGO should not just come and start working like that. NGOs should have a dialogue with the MOH about where is best to go for the country according to the specific skillsets of the NGO. This is how you can have equitable access by equitably distributing opportunities. As for free care – we have experienced that this is not a solution except for the extremely poor. Others have to contribute according to their means and are supported in Rwanda through a three-tiered health insurance system, where the poorest pay nothing (this is 25% of the population), the middle pay a little, and the people who have means pay a bit more. And the government and our development partners contribute to this community-based insurance program, which is called mutuelles de santé. I agree with you that there is nothing less sustainable than money when the money is not yours, meaning again that economic development is crucial. Never expect to develop your health sector if you are not focusing as a country on economic development in parallel. That’s why in Rwanda everything is inspired by our overall development and our strategy to fight poverty; that’s where we extract our health sector strategy. That’s why all sectors work together – we are focused on economic growth and have over 8% annual growth so far. In Ministry of health, this growth is my best and most sustainable ally. Economic development and health are inextricably linked to each other.

#88: Hola Rodrigo, you are very correct that Ministries of Health must harness technology to strengthen health systems. In Rwanda, we have seen great progress in health care delivery through our usage of OpenMRS and FrontlineSMS systems. We have across the country 60,000 community health workers equipped with a telephone that alerts health professionals when their neighbors have a health problem and allows us to send advice or support for caring for the patient, or to send ambulances for transfer when necessary. This has helped us to reduce maternal mortality drastically – from more than 8 per day to less than 1 per day. Efficient and comprehensive medical informatics are essential for providing the best quality of care and for monitoring and evaluating your system over time. We learn best from rigorous data, not just from site visits or individual stories. We must always be ready to learn and adapt – to turn the best evidence into the best policies. More health workers, patients, and officials should keep themselves up to form by reading web-based follow-up through sites like GHDOnline. Of course, all of these technological innovations are only effective with continuous education and training.

#89: Stephen, thank you for the work that you do around the world to increase access to safe anesthesia. It is good to go around and help, but the best is to leave behind you the institutional capacity to make it for the long-term. This means in practice the effort to train people to maintain the equipment, to procure replacements with proper specifications, and to use it in the proper way. If not, those countries will always need people like – if not we do not prepare to grandchildren of the people you help today capable on their own, they will need your grandchildren to go and help them. You make good points that simply dropping off equipment will not do much to strengthen a health system. If you drop off a dialysis machine at a community health center in the United States but do not provide any training to use it safely or build the capacity (and supply chain) to repair it when it breaks down, it will sit unused, just as it would in rural Rwanda without these things. The idea of “culturally appropriate technology,” though, can be dangerous if approached the wrong way. If so-called cultural differences are used as excuses to not provide essential medical care to people too poor to afford it, we make a mockery of medicine and partnership. This does not mean that every village must have every service; for example, we plan to have four centers for cancer across the country providing chemotherapy and radiotherapy treatment (the other forty-one hospitals will transfer patients to these centers of excellence), but “cultural barriers” such as the arrogant lie that “Africans do not know what watches and clocks are” have been used in the past to argue against providing access to new medical technology like antiretroviral therapy. We face resistance from some parts of the world in our effort to build up cancer services, from those who say that this is not appropriate for poor people, as if Africans love their life less than others. Cost-effectiveness should be one important tool in policy, but it should not mean that where you live determines if your life has value. This is like how the WHO classifies an intervention that would save my life as more than ten times less cost-effective than the same intervention to save the life of my colleague in the US (http://www.who.int/choice/costs/CER_levels/en/index.html).

#90: Dear Ted, good to read your post. To quickly clarify, though, Rwanda’s public sector community health workers never focused on HIV – we just have worked to increase their knowledge over time, but they do not deliver antiretroviral DOT to patients’ homes. Also, we developed our HIV Care and Treatment program in 2001 (PIH started working here in 2005). It’s absolutely true that the Ministry of Health has and continues to highly appreciate PIH’s work and asked you to spread across the different health centers in the district and to expand to other districts. It is also true that the model of community health workers built in Haiti, where they are paid to provide HIV and TB care at the community level, was not suitable to our model where CHWs provide general primary care without direct payment – only performance-based financing through cooperatives. And after discussions, you aligned CHW financing with our national model – through PBF, as well. You’re always welcome to come back to Rwanda and see how things have developed. Thank you again for your continued great work alongside us here – we always appreciate PIH’s flexibility, community work, and orientation towards equitable and high-quality care for rural areas. We also have highly appreciated your comprehensive approach that progresses from building infrastructure, education, providing work forces, and service delivery in an integrated manner, etc.

#91: Jacob, you are correct that infectious diseases have once and for all exposed the consequences of having a weak health system gutted by colonialism and undermined by neocolonialism as well as the irresponsibility of many leaders in developing countries. You are also right that as our populations grow and life expectancies increase, we must address the rising burdens of cancer, heart disease, diabetes, and lung disease. I also have another sense of this rising incidence of NCDs – don’t you believe that the incidence is more important because the incidence of communicable diseases is decreases – in a world where we have more than 5 million people on ARVs and Roll Back Malaria talks of so much progress across the African continent, etc.? In Rwanda in 2004, we had a life expectancy of 34 years – with people dying before they got sick with heart disease, etc. – but now it is 53, and the expression of non-communicable diseases has started to be very visible. If this is a new burden, it’s an expression of the years that we have gained in life expectancy by successfully treating communicable diseases – let’s not be afraid of this expression of health sector success but let’s actively fight NCDs and try to win another fifteen years of life expectancy for our people and to reach 68 years! Can NGOs alone provide unified prevention and quality specialty care for all of these diseases in addition to basic primary care, care for other chronic diseases, safe birth and child health care, etc.? We all know the answer. As for task-shifting, we in Rwanda have shown the importance and potential, but we must be sure that we are emphasizing the right training, and using our health workers at the right level of their training for the best outcomes. Task-shifting cannot simply mean settling for less qualified people delivering worse care; it should be thought of as training the right people for the right tasks working together and using resources in the right way to get more health for less. In Rwanda, we still have no oncologists, but we will not solve this problem by asking community health workers to treat metastasized cancer – we need more oncologists plain and simple. At the same time, though, we address 80% of the burden of disease (especially diarrhea, malaria, etc.) at the household level through community health workers. This is task-shifting. Specialists are shifted to doctors, doctors to nurses, and nurses to community health workers – all freeing up time and resources for more specialized care.

#92: Dear Marie, I will of course write you personally but thank you for your facilitation of this conversation this week. We saw participation from around the world, from Ministries of Health and other policymaking bodies, from NGOs of many different kinds. I will post some final thoughts on the main topics and all of the questions that have been raised soon.

#93: James, once again you indicate the importance of collaborative planning with the Ministry of Health and of targeting programs to meet the true needs of the population rather than just the interests of donors. We have learned that health systems strengthening in practice means strengthening the Ministry, the health workers, the infrastructure, the management teams, etc. This can only be done, as you say, when we are aligned to national priorities with the Ministry of Health in the driver’s seat.

#94: Dear Laurien, sustainability is ultimately the most important marker of success once a quality program is in place that ensures equitable access. All of these discussions this past week relate to sustainability, for in the end it is not NGOs working alone and depending only on fickle donor money that can ensure a program lasts – only the government can guarantee this, but it takes work and vision. You are right that many developing countries do not resources – they just lack the goodwill to use these resources appropriately in a sustainable way to benefit their own population. And there can be no sustainable quality care without sustainable national economic development.

#95: Dear Dr. Corine, thank you so much for contributing your perspective to this online discussion. As you say, our most recent data show that our human resource strategy focused on breaking down geographic and financial barriers has resulted in great gains in health outcomes. Malaria is one of the best examples – integrating prevention, diagnosis, and treatment at the community level through the public sector with our partners. You should host one of these panels soon.

Dear Dr Agnes,

Please receive my sincere acknowledgement for the well thought and deeply educative responses you provided throughout the discussions; it requires substantial experience. There is no doubt that more of these panels will foster improvements across the health sectors globally through the shared experiences.

Dear All, I am on twitter every day @agnesbinagwaho and we can continue the conversation there. Twice a month I will also be hosting Mondays with the Minister (#MinisterMondays) on a particular health issue. Yesterday was the inaugural Minister Monday where we talked about family planning. I will host one on health system strengthening soon. Thank you all of you - organizers, facilitators, panelists and participants for the good discussion this week.

Hello Everyone, I would like to thank Dr. Binagwaho for her wonderful leadership for this panel. We will all continue to look to your leadership in the years ahead. It has been a great honor to participate with such an experienced and wise group of panelists. And thanks to Marie and PIH for organizing such an important discussion. The dialogue was very stimulating and I learned a great deal. If anyone would like more information about the NGO Code of Conduct please find the link to the site on this webpage or e-mail me directly. Good luck to all in your important work!

Congratulations to Marie and PIH for organizing a successful and important panel discussion.

Congrats to the team for this wonderful panel discussion which i missed due to a bad cough. I hope i will have time to read all what have been discussed.

Dear all,

I was one of the silent participants of this discussion. It was so encouraging to see hundreds of people committed to HSS. But the remaining issue now is: What have we learnt from this discussion?, How are we going to replicate good practices to our NGOs and partners? Do our objectives much match with ours? If not how can we fine tune them that we sail in the same boat?

Looking forward to the next topic.

My thanks, too, to the panelists and all the participants for a lively and enriching discussion. It’s been a great opportunity to share ideas and I hope this is the first of many more conversations. Thanks also to Marie for organizing it so well.

Thank you all once again for joining this discussion! We'd like to hear what you thought of this Expert Panel and have created a very short questionnaire to gather your feedback. You can submit your comments and suggestions by visiting: http://bit.ly/sKhycA

Your recommendations will help us improve the Expert Panel experience, and also let us know what topics we should focus on in the future, so we hope you'll take a few minutes to share your thoughts!

This video is the first part of the lecture "Non-Governmental Organizations and the Delivery of Health Care" taught by Salmaan Keshavjee on 9/29/11. It runs about one hour. It was given during the Fall 2011 "Case Studies in Global Health: Biosocial Perspectives" (SSCI-E125) course at Harvard University Extension School and is made available to all exclusively on GHDonline.org

Thank you in advance for your feedback.

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This video is the second part of the lecture "Non-Governmental Organizations and the Delivery of Health Care" taught by Salmaan Keshavjee on 9/29/11. It runs between 15-20 minutes.

This audio podcast is the first part of the lecture "Non-Governmental Organizations and the Delivery of Health Care" taught by Salmaan Keshavjee on 9/29/11. It runs about one hour. It was given during the Fall 2011 "Case Studies in Global Health: Biosocial Perspectives" (SSCI-E125) course at Harvard University Extension School and is made available to all exclusively on GHDonline.org

Thank you in advance for your feedback.

This audio podcast is the second part of the lecture "Non-Governmental Organizations and the Delivery of Health Care" taught by Salmaan Keshavjee on 9/29/11. It runs about 15-20 minutes.

This video is the second part of the lecture "Delivery Struggles in Rwanda" taught by Paul Farmer on 10/13/11. It runs about 15-20 minutes.

This audio podcast is the second part of the lecture "Delivery Struggles in Rwanda" taught by Paul Farmer on 10/13/11. It runs about 15-20 minutes.

This audio podcast is the first part of the lecture “Delivery Struggles in Rwanda" taught by Paul Farmer on 10/13/11. It runs about one hour. It was given during the Fall 2011 "Case Studies in Global Health: Biosocial Perspectives" (SSCI-E125) course at Harvard University Extension School and is made available to all exclusively on GHDonline.org

Thank you in advance for your feedback.

This video is the second part of the lecture “Health System Strengthening" taught by Peter Drobac on 11/22/11. It runs about 15-20 min.

This audio podcast is the second part of the lecture “Health System Strengthening" taught by Peter Drobac on 11/22/11. It runs about 15-20 min.

This audio podcast is the first part of the lecture “Health System Strengthening" taught by Peter Drobac on 11/22/11. It runs about one hour. It was given during the Fall 2011 "Case Studies in Global Health: Biosocial Perspectives" (SSCI-E125) course at Harvard University Extension School and is made available to all exclusively on GHDonline.org

Thank you in advance for your feedback.

This video is the second part of the lecture “Global Health Policy and Advocacy" taught by Gregg Gonsalves on 11/29/11. It runs about 15-20 min.

This audio podcast is the second part of the lecture “Global Health Policy and Advocacy" taught by Gregg Gonsalves on 11/29/11. It runs about 15-20 min.

This video is the first part of the lecture “Global Health Policy and Advocacy" taught by Gregg Gonsalves on 11/29/11. It runs about one hour. It was given during the Fall 2011 "Case Studies in Global Health: Biosocial Perspectives" (SSCI-E125) course at Harvard University Extension School and is made available to all exclusively on GHDonline.org

Thank you in advance for your feedback.

Call for Candidates for Director of the Latin American and Caribbean Center on Health Sciences (BIREME)



Information available at: http://bit.ly/uJvvGs <http://bit.ly/uJvvGs>

The Pan American Health Organization (PAHO) <http://new.paho.org/hq/index.php?lang=en> is committed to strengthening regional and national information systems in health sciences as another bastion in its mission to promote equity in health, combat disease, and improve the quality and duration of life in the Americas.

BIREME <http://new.paho.org/bireme/> , based in San Paulo, Brazil since 1967, is a fundamental part of the Pan American and World Health Organization's technical cooperation efforts to achieve this mission. As one of the most important international organizations in management of technical and scientific information in health sciences, BIREME contributes to health development in the countries of Latin America and the Caribbean through the democratization of access, publication, and use of information, knowledge, and scientific evidence.

Over 40 years in existence, BIREME now faces new opportunities and challenges, not only in access to scientific information, but also in providing tools for the evidence-based development of such concepts as eHealth, a strategy adopted by the governments in 2011 at the ...

Call for Candidates for Director of the Latin American and Caribbean Center on Health Sciences (BIREME)



Information available at: http://bit.ly/uJvvGs <http://bit.ly/uJvvGs>

The Pan American Health Organization (PAHO) <http://new.paho.org/hq/index.php?lang=en> is committed to strengthening regional and national information systems in health sciences as another bastion in its mission to promote equity in health, combat disease, and improve the quality and duration of life in the Americas.

BIREME <http://new.paho.org/bireme/> , based in San Paulo, Brazil since 1967, is a fundamental part of the Pan American and World Health Organization's technical cooperation efforts to achieve this mission. As one of the most important international organizations in management of technical and scientific information in health sciences, BIREME contributes to health development in the countries of Latin America and the Caribbean through the democratization of access, publication, and use of information, knowledge, and scientific evidence.

Over 40 years in existence, BIREME now faces new opportunities and challenges, not only in access to scientific information, but also in providing tools for the evidence-based development of such concepts as eHealth, a strategy adopted by the governments in 2011 at the PAHO Directing Council. BIREME is perfectly positioned to take its place on the stage.

PAHO seeks a leader with ability, experience, and dedication to Public Health Service, with a strategic vision to ensure BIREME remains for the countries an essential reference in the sciences, in higher education, and in the development of public health policies. The new director will face the challenge of steering BIREME towards a more proactive and innovative relationship with countries and institutions, to ensure the democratization of knowledge and access to health information for all populations.

Below you will find the link to the call for candidates, and instructions on how to apply formally using the World Health Organization's recruiting system.

Vacancy notice: PAHO/11/FT397
Title: Center Director, Latin American and Caribbean Center on Health Sciences Information
Grade: P5
Duration of contract: Two years, first year probationary period
Duty station: Sao Paulo, Brazil
Organizational location / Area:KMC/BIREME
Closing date: 3 January 2012
Call for candidates (More information): http://bit.ly/sWq79Z



(Versión en español)



Llamado a concurso del cargo de la dirección del Centro Latinoamericano y del Caribe de Información en ciencias de la Salud (BIREME)



Información disponible en: http://bit.ly/tUhN2J

La Organización Panamericana de la Salud (OPS) <http://new.paho.org/hq/index.php?lang=es> está comprometida con el fortalecimiento de los sistemas regionales y nacionales de información en ciencias de la salud, como otro bastión de su misión de promover la equidad en salud, combatir la enfermedad, y mejorar la calidad de vida y prolongar su duración en las Américas.

BIREME <http://new.paho.org/bireme/> , instalada en San Pablo, Brasil desde 1967, es una pieza fundamental de la cooperación técnica de la Organización Panamericana y Mundial de la Salud para lograr esa misión. Como uno de los organismos internacionales más importantes en gestión de información técnico científica en ciencias de la salud, BIREME contribuye al desarrollo de la salud en los países de América Latina y el Caribe a través de la democratización del acceso, publicación y uso de la información, conocimiento y evidencia científica.

A más de 40 años de su creación, BIREME enfrenta hoy nuevas oportunidades y desafíos no sólo en el acceso a la información científica, sino también en proveer de herramientas para desarrollar desde la evidencia conceptos como eSalud, estrategia aprobada por los gobiernos en 2011 en el Consejo Directivo de la OPS. BIREME está en inmejorables condiciones para posicionarse en esos escenarios.

La OPS busca a un/a líder con capacidad, experiencia, y vocación de servicio en Salud Pública para que, con una visión estratégica a futuro, conduzca a BIREME como una referencia ineludible para los países en el área científica, en la educación superior y en el desarrollo de políticas públicas de salud. El nuevo director o directora tendrá el reto de guiar a BIREME hacia una interacción proactiva e innovadora con los países y sus instituciones, para así garantizar la democratización del saber y el acceso a la información en salud para todas las poblaciones.

Abajo encontrara el enlace al llamado a concurso, así como las instrucciones sobre cómo aplicar formalmente dentro del sistema de reclutamiento de la Organización Mundial de la Salud.

Anuncio de vacante: PAHO/11/FT397
Título: Director del Centro Latinoamericano y del Caribe de Información en Ciencias de la Salud
Grado: P5
Duración del contrato: dos años, el primer año probatorio
Lugar de destino: Sao Paulo, Brasil
Ubicación en la organización/Area: KMC / BIREME
Fecha de cierre: 3 de enero 2012
Llamado a concurso (Más información): http://bit.ly/sWq79Z <http://bit.ly/sWq79Z>





--

David Novillo-Ortiz
Advisor, Knowledge Management & Organizational learning

Knowledge Management and Communication Area - KMC
Pan American Health Organization, regional office for the Americas of the World Health Organization

Tel: 1-202-974-3060
Email:
Web: http://www.paho.org/







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Thank you.

Let me start by thanking all the members of the distinguished panel on this "panel-discussion" in the Strengthening Health Systems: The Role of NGOs

My contribution is seems belated but nonetheless necessary, since this online forum is still active. On this note let me recall that Dr Gro Harlem Brundtland, a former WHO chief in her paper "Towards a strategic agenda for the WHO secretariat", a Statement to the 105th session of the Executive Board, January 2000, specifically said and I quote “We are dealing with the prime public health concerns of our time. We are focusing on conditions with a major impact on the poor and disadvantaged […] and we are working alongside a broad range of partners, maximizing what we can achieve together”. This statement is very apt, since it states the NEED for all stakeholders to be part of a coalition of the willing to reverse the unacceptable trends in health indices of health systems, especially the low-income ones.

One particular fact that I noticed while reading the thread of discussions was that a lot of contributors rather unfocused the discussion by mixing up various bilateral bodies and Donor-Funded Projects (DFPs) with Non-Governmental Organisations (NGOs). In some cases ...

Let me start by thanking all the members of the distinguished panel on this "panel-discussion" in the Strengthening Health Systems: The Role of NGOs

My contribution is seems belated but nonetheless necessary, since this online forum is still active. On this note let me recall that Dr Gro Harlem Brundtland, a former WHO chief in her paper "Towards a strategic agenda for the WHO secretariat", a Statement to the 105th session of the Executive Board, January 2000, specifically said and I quote “We are dealing with the prime public health concerns of our time. We are focusing on conditions with a major impact on the poor and disadvantaged […] and we are working alongside a broad range of partners, maximizing what we can achieve together”. This statement is very apt, since it states the NEED for all stakeholders to be part of a coalition of the willing to reverse the unacceptable trends in health indices of health systems, especially the low-income ones.

One particular fact that I noticed while reading the thread of discussions was that a lot of contributors rather unfocused the discussion by mixing up various bilateral bodies and Donor-Funded Projects (DFPs) with Non-Governmental Organisations (NGOs). In some cases, some discussed these NGOs in abstracted reference or as purely foreign, thereby forgetting that there are also local NGOs (LNGOs) in most countries of the world working alongside the international NGOs (INGOs). For this reason can we have a handle on the discussion by defining NGOs and Health System?

What is an NGO?

I find this definition on http://www.ngo.org/ngoinfo/define.html very agreeable by virtue of the ambit of its reach; “A non-governmental organization (NGO) is any non-profit, voluntary citizens' group which is organized on a local, national or international level. Task-oriented and driven by people with a common interest, NGOs perform a variety of service and humanitarian functions, bring citizen concerns to Governments, advocate and monitor policies and encourage political participation through provision of information. Some are organized around specific issues, such as human rights, environment or health. They provide analysis and expertise, serve as early warning mechanisms and help monitor and implement international agreements. Their relationship with offices and agencies of the United Nations system differs depending on their goals, their venue and the mandate of a particular institution”. So in other words, we can view NGOs irrespective of their origin as having the vital role as primary participants in the health system, legitimizers of health system processes, and key watchdogs of health system policy and infrastructure, as well as key non-state collaborators in national health system development for better health outcomes.

What is health system strengthening?

What we have come to know as health system strengthening approach for addressing the recurrent challenges that have bedeviled health systems, especially in low-income countries, débuted as a turnaround system reform thinking in the late 1990s, but gained currency and attention when the World Health Organization published its 2000 report showing how to determine health systems performance. System strengthening methodology became even more practical and measurable later on when the concept of the Six Building Blocks of a Health System. This thus acted as a fulcrum towards designing more effective strategies for strengthening health systems, in order to meet the needs of the population especially at the bottom of the pyramid. Hence most times, I have found it more convenient to summarily define health systems strengthening as all activities that involve the identification of issues that interfere or impede the provision of services, and introducing changes that that are systemic so that the outcome is sustainable improvements it. The six building blocks of the health system are:

• 1: health service delivery

• 2: health workforce

• 3: health information systems

• 4: access to essential medicines

• 5: health systems financing

• 6: leadership and governance


A few things to note here is that the likes of USAID, UKaid, JICA, CIDA and so forth are NOT NGOs, but rather State instruments for development termed “Bilateral Bodies” , just like the UN agencies are wider global instruments , and as such referred to as “Multilateral Bodies”. These bodies may through their procurement policies and country-level cooperative agreement in one country decide to fund a project like USAID|COMPASS project in Nigeria. Usually, these projects are ‘implemented’ by NGOs that win the right to the fund through some form of bidding processes. The NGOs are thus referred to as “implementing partners” and can be either local or international NGOs or a consortium of such NGOs. We should not lose sight of the fact that some professional health bodies being Civil Society bodies too, have become more of NGOs in activities, classical examples are Medical and Nursing/Midwifery Associations. Please see :
1. http://maitlandli.academia.edu/FrancisOhanyido/Papers/482546/Ohanyido_FO._Sus...
2. NMA as a Potential Catalyst in Revitalisation of PHC; http://www.nigeriamedj.com/article.asp?issn=0300-1652;year=2010;volume=51;iss...

So what is the role of NGOs in Health System Strengthening?

I mentioned that there are six identified building blocks of the health system , as such the role of NGOs is actually dependent on their mandate or project charter which are in tandem with the overall programmes of the health system within which they operate. A few of these examples of roles of NGOs are summarized below:


• NGOs can work to ensure that the Health services are efficient, effective, and accessible.
• NGOs can work within the health system to ensure that the number of well-trained staff is available through capacity building or advocacy to government etc.
• NGOs can help ensure that the Health information systems is able to generate useful data on health determinants and health system performance and also avoid creating parallel systems
• NGOs can work with all stakeholders to ensure that there is access to medicines, vaccines, and medical technologies in an equitable fashion.
• NGOs can help strengthen Health financing systems by exploring funding sources and advocating to stakeholders to raise adequate funds for health, ensuring that people can access affordable services.
• NGOs can strengthen the system by ensuring that the Leadership must guarantee effective oversight, regulation, and accountability. They may also serve to ensure systematization of fund-tracking processes to hold government accountable etc



Francis Ohanyido FRSPH
Chief of Party| Team Leader Africa, Synergy PMP
Chair, International Public Health Forum (IPHF)
Country Representative, HIFA 2015- Nigeria
Consultant, WHO |AFRO

That was a detailed , clear definiton and relationship of NGOs and
Health Systems there has to be a clear well crafted stratergy to have
the pillars in place. This will ensure the livelihoods of individuals
in various resource limited settings. What still puzzlews me though is
there seems to be a disconnect with what is known as the ideal or
expected that needs to be done versus human want.
To ensure sustanability of service provision and ensure the pillars
remain intact there needs to be more transparency and accountability
on the part of NGOs. There is limited community mobilisation and
working together to address issues on the ground. The more we talk for
and think for or engage in any initiative without directly and
meaningfully involving people on the ground who are impacted by the
issues. We will continue to have knowledge and expertise that will not
be useful in utilising the pillars you indicated.
While its true that most but not all NGOs use community responsiveness
approach to address issues in the community more needs to be done.
This varies from one region ot the other .But having been a frontline
worker in the South and North I have ...

That was a detailed , clear definiton and relationship of NGOs and
Health Systems there has to be a clear well crafted stratergy to have
the pillars in place. This will ensure the livelihoods of individuals
in various resource limited settings. What still puzzlews me though is
there seems to be a disconnect with what is known as the ideal or
expected that needs to be done versus human want.
To ensure sustanability of service provision and ensure the pillars
remain intact there needs to be more transparency and accountability
on the part of NGOs. There is limited community mobilisation and
working together to address issues on the ground. The more we talk for
and think for or engage in any initiative without directly and
meaningfully involving people on the ground who are impacted by the
issues. We will continue to have knowledge and expertise that will not
be useful in utilising the pillars you indicated.
While its true that most but not all NGOs use community responsiveness
approach to address issues in the community more needs to be done.
This varies from one region ot the other .But having been a frontline
worker in the South and North I have come to realise that the same
pillars are consistently in trouble of collapsing or do not have the
right mixtures of stone and cement so that they bond strongly.
Funders should go beyond thier borders to support other countries who
are similarily addressing the same issues/challenges they face and or
even do more. The cooporate world weather we like it or not should
also play a pivotal role in ensuring health systems work and NGOs are
supported financially.
We are really living in global village where individuals irrespective
of where they are ,are faced with challenges in thier constituences.
If we have to strengthen the Health systems effectively lets train and
build capacity of those affected with issues to address them the best
way the know how this will be another way to sustain NGOs and Health
systems currently there is still a disconnect between those affected
or impacted with the issues and those in the driver's seat. How nice
it will be to get a girl child of someone living with AIDS to complete
school train them to be a medical Doctor or an epidemiologist
somewhere

--
*Believe Dhliwayo.*
*Skype:mabhindu145*
*Email:
"Those who want Change must be willing to be most Changed.." "Sri
Aurobindo "*

Hello,

after working for 8 years as a pilot project in Gujarat India I strongly
feel that if we want improve rural healthcare where few physician would
like to go ,only answer is public private partnership.
NGOs have problem with funding and government has enough resources. NGOs
has people with dedication so both combine result is excellent . we proved
this in our Shamlaji Hodspital. it was a defunct CHC ( community
healthcenter) we converted in Model hospital with all services and now
helping government to follow the same model for remaining 290 chcs

thanks

Dr Haren joshi

--
Drs.Haren Joshi and Pratima Tolat

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Greetings from Tanzania.The health system approach is a reminder to the world that we need to harmonise and strengthen synergies amongst actors.There are many lessons from the national responses to HIV over the last 20-30 years.NGOs were struggling to move quicky to bridge the service gaps where Ministries of Health could not suffice.Admitedly , scaling up responses (and successes) was appreciated. The challenge was on balancing Human Resource between NGO projects and government health facilities.We are now awakened by a simple message that we need to approach the delivery of the diversity of health services through a system approach instead of struggling with vertical programmes which do not necessarily coverge to provide the optimal benefit to service users.NGOs have therefore contributed to the lessons and continue to be a vital component of service provision not only to compliment government efforts but being partners.The key departure point would be to have a contextualised framework of action in which all actors fit while respecting the rules of partnerships.The government continues to the the overall co-ordinator and policy regulator guiding the service provision and creating space for dialogue with NGOs and even private sector providers on ...

Greetings from Tanzania.The health system approach is a reminder to the world that we need to harmonise and strengthen synergies amongst actors.There are many lessons from the national responses to HIV over the last 20-30 years.NGOs were struggling to move quicky to bridge the service gaps where Ministries of Health could not suffice.Admitedly , scaling up responses (and successes) was appreciated. The challenge was on balancing Human Resource between NGO projects and government health facilities.We are now awakened by a simple message that we need to approach the delivery of the diversity of health services through a system approach instead of struggling with vertical programmes which do not necessarily coverge to provide the optimal benefit to service users.NGOs have therefore contributed to the lessons and continue to be a vital component of service provision not only to compliment government efforts but being partners.The key departure point would be to have a contextualised framework of action in which all actors fit while respecting the rules of partnerships.The government continues to the the overall co-ordinator and policy regulator guiding the service provision and creating space for dialogue with NGOs and even private sector providers on how best to reach those who need the services effectively and efficiently.The health system approach is making huge differences in resource limited settings where neither government nor NGOs can meet the needs of communities without the other partner.

I am Noor Ahmad Baloch, a Public Health Professional having experience in research and development in the area of public-private Mix (PPM) and managing TB control programmes including PPM projects. My involvement in PPM was as a consultant, contributing in the first intervention study on General Practitioners, leading countrywide situation analysis, development of models, operational guideline and M&E mechanism for PPM Pakistan. As a National manager, TB Control Programme, I was involved in the management of PPM ventures. Therefore, I am going to share my hands on practical experience on PPM joint ventures of TB control and care in Pakistan.
Following were the main challenges which were observed at the initial stages i.e. before and early stages of implementation. The concerns were among two partners Private and public sector).
• Lack of confidence
• Lack of capacity with regard to resources, training, M&E
• Accepting national guidelines by the private partners
As mentioned earlier, there were various concerns on both the sides before and at the initial stages of the programme implementation but they proved to be of transient nature and disappeared with the time and both the parties are working with confidence by using each other’s strengths. With ...

I am Noor Ahmad Baloch, a Public Health Professional having experience in research and development in the area of public-private Mix (PPM) and managing TB control programmes including PPM projects. My involvement in PPM was as a consultant, contributing in the first intervention study on General Practitioners, leading countrywide situation analysis, development of models, operational guideline and M&E mechanism for PPM Pakistan. As a National manager, TB Control Programme, I was involved in the management of PPM ventures. Therefore, I am going to share my hands on practical experience on PPM joint ventures of TB control and care in Pakistan.
Following were the main challenges which were observed at the initial stages i.e. before and early stages of implementation. The concerns were among two partners Private and public sector).
• Lack of confidence
• Lack of capacity with regard to resources, training, M&E
• Accepting national guidelines by the private partners
As mentioned earlier, there were various concerns on both the sides before and at the initial stages of the programme implementation but they proved to be of transient nature and disappeared with the time and both the parties are working with confidence by using each other’s strengths. With the result the joint ventures showed significant progress and success. Following is the case study which I presented at 40st Union World Conference on Lung Health held in Cancun in December 2009 which was documented by Theo Smart, publish in Nam aidsman , HIV/AIDS- Sharing Knowledge changing lives-14 January 2010:
Public-private mix: engaging more providers in case finding and notification
Dr Noor Ahmad Baloch, the National TB Control Programme Manager in Pakistan described how diverse types of formal and informal providers can be engaged in TB case finding and management.
TB is a major public health problem in Pakistan. In a population of 170 million there are about new 300,000 cases (75% among people of reproductive age) and 15,000 new MDR TB cases each year. DOTS was introduced in 2001 and fully implemented at all public facilities by 2005. But around 40% of the total population lives in peri-urban low-income communities, with poor housing, inadequate water, sanitation and little or no access public health services.
Most of this population is dependent upon “a huge and diverse private sector providing health care to the population,” said Dr Baloch. “There are general practitioners, hospitals, for-profit, not-for-profits and non-governmental organizations — and one NGO has 108 outlets that exclusively provide TB services. There are also informal practitioners, many of whom are not qualified, not registered, not licensed, illegally practicing.”
A systematic approach was adopted to research and prepare for implementing the PPM. This started with a study assessing the knowledge of providers, conducted at sample sites in two large cities with 600 doctors providing TB services. Out of all of these doctors, only one knew that the first and the priority diagnostic tool for TB is sputum smear microscopy — most were instead relying on chest x-rays.
Once these doctors were trained and provided with free TB medications, an evaluation found that they readily adopted the DOTS strategy.
Next, a country-wide institutional analysis was conducted among all the stakeholders, assessing the capacity, gaps and needs of hospitals, NGOs and others providing TB care.
Based on this analysis, a national strategic framework was developed with six different models for delivery of TB services working with the different types of providers available in different areas (rural and urban). Operational guidelines and a mechanism for monitoring and evaluation were also developed.
The presentation focused on two models: social franchise marketing targeted to peri-urban low-income communities in very large cities; and a district led model, serving low income populations with poor access to TB services in both urban and rural areas.
In social franchising models, the private sector providers are trained and empowered to delivery branded and quality assured health services: in this case, TB diagnosis and treatment services.
In Pakistan, the social franchise marketing model provides active case finding through media marketing, ‘chest camps’ and interpersonal communication with community advocates who identify and refer suspects for diagnosis, with smear microscopy provided by a private laboratory.
The district-led model strengthens passive case finding — with diagnostic services being provided after the patient presents for care and smear microscopy is performed by either a public lab or NGO/ CBO supported lab.
In both models, the department of health provides free treatment, which is prescribed to the patient by a trained GP — though directly observed therapy may be provided by the practitioner, an outreach worker or lay health worker. The social franchisee is responsible for default tracing, reporting and quality assurance in the franchise social marketing model, while the district health sector provides these services for the district-led model.
Of course, before launching, materials, including the ACSM strategy and reporting and recording tools, were developed and resources mobilised (the Global Fund initially supported the Social Franchise Marketing). The target population had to be identified, surveyed and mapped. A training programme was developed and implemented and supply logistics worked out.
But in the space of just a few years, the social franchise marketing model engaged about one thousand GPs, large numbers of community workers and 54 private labs in five very large cities in Pakistan — covering a total population of 40 million. After 2005, the number of TB cases (smear-positive and all types) diagnosed and notified by GPs jumped dramatically (by around 12-20 fold). In the last couple years, the private sector has contributed 18-26% of the cases to national case notification.
While the model is feasible to provide TB services to the vulnerable population, “it needs evidence-based refinement for scale-up, keeping in mind sustainability,” said Dr Baloch, because there have recently been concerns about the sustainability of the project as Global Fund support for staff salaries has dried up.
I would like to conclude that the success of PPM joint ventures is subject to:
1. A resourceful and technically strong National Programme fully capable of stewardship:
2. A systematic approach to the PPM, starting with assessment of both the partners for resources, technical capability, willingness and potential to involve in PPM.
3. Based on the assessment, careful selection of private partners so they are willing to join and have potential to contribute in strengthening health system.
4. Availability of National Guidelines, training modules, resources to support private providers.
5. Presence of a strong coordination among partners through steering committees represented by both sectors and other relevant bodies including professional forums at different levels (policy and operations).
6. Public sector willing to facilitate/provide access to the private sector to use public sector facilities.
7. A strong monitoring and evaluation system need to be in place which can be used jointly
8. Starting joint ventures at a smaller scale and then gradually expanding to a larger scale
In my opinion, the key essentials of success of PPM TB Control in Pakistan are:
1. A country wide situation analysis was conducted to assess NTP, mapping of private providers and their assessment.
2. Based on the evidence, development of six PPM models with clear roles and role responsibilities for NTP and different categories of private sector with a geographical distribution (urban and rural)
3. Presence of Operational plans and M&E mechanisms
4. Selection of Private providers for partnership based on their willingness, area of interest and potentials.
5. Regular facilitation to private partners to implement programme at operational level.
6. Frequent coordination meetings at various levels i.e. Policy and operational. The meetings were used for validation of date, resolution of issues and dissemination of new developments in the programme.
7. Regular supply of resources committed by NTP (Medicines, lab consumables, stationery etc.) and technical support.

I’d like to invite everyone who joined us for this Expert Panel discussion, Health Systems Strengthening: The Role of NGOs, to participate in another upcoming Expert Panel discussion, Integrating M&E for Health Systems Strengthening, taking place April 2-6, 2012.

We are thrilled to have Drs. Pierre Barker, Paulin Basinga, Lisa Hirschhorn, Wesler Lambert and Kenny Sherr joining us as expert panelists for this discussion. To learn more about what our panelists will be addressing, and to sign up for the discussion, please visit: http://bit.ly/GWhRdQ and click the “Join this Expert Panel” button.

We're looking forward to a rich discussion!

In the public interest? The role of NGOs in national health systems and global health policy

The Medicus Mundi International Network and a number of member and partner organizations will contribute to the thirds People’s Health Assembly (PHA) in Cape Town, 6-11 July 2012, with a series of workshops on the role and the future of private not for profit health service providers and international NGOs: What does it need to make NGOs part of the solution and not the problem?
We will link the discussion on the integration of NGOs in national health systems with debates on the role of NGOs in global health governance and on the relations between NGOs and social movements such as the People’s Health Movement and many of its members. Let us define the common ground, share experiences and strengthen alliances.
We herewith invite interested organizations and individuals participating in the PHA to get involved in the planning of the workshop together with us. Let us know if you want to become part of the team! And get back to us if you have particular questions or suggestions.

Thomas Schwarz, Executive Secretary
Medicus Mundi International Network

This is an interesting subject. Looking forwarded to hear the solution
so that it can assist everyone involved.
Thank you
Regina Bhebhe

Hi Thomas
This indeed will be a very interesting and educative subject.I would love
to be part of the team , how are the logistics especially travel for those
outside S/A?
Thanks
Martha
Zambia

...many thanks for your interest. "Our NGO workshop" - http://bit.ly/pha3-ngo-workshop - is just one self-organized program element of the People's Health Assembly organized by the People's Health Movement. For all information regarding PHA, please refer to their website at http://www.phmovement.org/en/pha3. To get involved in the NGO workshop, please start with sending e-mail to specifying your interest and eventual input proposal. Best wishes from Thomas

Many thanks for this sharing


I am H. SEMLALI, Doctor

I would like to be part of the team ,
I am a Public Health specialist, I work for the Moroccan Ministry of
Health, as a responsible for the Division to the implementation of the
medical assistance program. As an activist in civil society for the right
to Health, I strongly believe of NGOs role in the work I am trying to lead
and I would like to attend the work of the PHM 3, I sent my application for
a sponsor of the logistics for such participation and I am still waiting
for an answer.

Best regards

*Dr SEMLALI Hassan MPH
Chef de la Division du suivi de la mise en oeuvre *
*du régime de l'assistance médicale (RAMED)
Direction de la Planification et des Ressources Financières
Ministère de la Santé
Tel: 212 537 69 78 29
Fax: 212 537 69 78 30*

* Please consider the environment before printing this e-mail*