1

INTRODUCTION
Background
Purpose of the Study

The importance of Non-governmental Organizations (NGOs) in the delivery of services is

gaining increasing recognition not only to complement government programmes, but also
to provide people with a choice of service outlets and to create an effective voice in respect
of service needs and expectations. The World Health Organization (WHO) has recognized
the need for concerted inter-sectoral action with the participation of all actors in health
development. Accordingly an analysis of the current situation in regard to NGO
participation and partnership in health development is considered to be timely and
relevant to initiate strategies to promote and enable NGOs to engage meaningfully in
collective action for health development. Such collaboration could have a positive impact
on the form and substance of health governance.
The analysis commences with the legal and administrative framework within
which NGOs are required to function. It proceeds with an assessment of the selected
NGOs in terms of their capacity, potential and willingness to enter into partnership with
the government in health care.
The status of NGOs and their operational environment is first examined. Thereafter,
the NGOs are assessed on three different dimensions;
Their strengths and weaknesses in terms of their potential for partnering in health
related activities.
Their role and performance in the delivery of health care in the context of their
current operations and activities.
Their partnership at appropriate levels of the system of governance that functions
today.
These Sections while analyzing performance and potential also highlight the requirements
for NGOs to become constructive partners in health.

Scope

Study reviews the policy framework for NGO partnership in development in general and in the health sector
in particular. It examines the current status and performance of NGOs, reviewing their strengths, weaknesses,
and risks and opportunities as agents in health services delivery as well as opportunities for and constraints
to their effective participation in health development programmes. It assesses scope for partnership in the
governance of health development and for partnership in development cooperation with WHO.
A directory comprising profiles of hundred and fifty health related NGOs has been compiled
 2

Study Methodology
Data was gathered through
An in-depth field survey of fifty NGOs, who responded to a semi-structured questionnaire. The sample was
selected from a stratification of NGOs into four types, International, National Level Foreign Funded, Local
Funded, and Sub-national and Community-based. The numbers were distributed as shown in the chart below.
01 International NGO 12 Foreign Funded National NGOs
16 Local Funded NGOs, 21 Sub-national NGOs
A review of the macro policy and operating environment, was obtained through secondary sources.
In the absence of a reliable sampling frame, known NGOs were used as sources of information. The list was compiled
through a snowballing technique.

SECTION A

NATIONAL POLICY FRAMEWORK FOR NGOs

Organized non-governmental activities addressing Role of

Role of NGOs
NGOs
peoples needs are increasingly pervading the arena of
collective development action, whether delivering Government
development services or mediating in voicing their needs.
Institutionalizing their role as intermediate organizations NGOs as
linking government and people in a responsive manner is intermediary
a challenge in the effective governance of development. It
is in the efficient and effective performance of these twin People
roles, as an agent for delivering services and partnering in the management of
development, that Non-governmental Organizations (NGOs) can make a significant
contribution to sustainable human development.

Political and Social Context for NGO Activities:

A rapidly changing development management scenario is the context in which NGOs

must function. Notably, these include the adoption of a private sector led growth strategy,
a shift to decentralized modes of governance, and increasing regional disparities in access
to development services. The changes and challenges are inevitably affected by the
ongoing conflict, which imposes not only heavy economic and financial costs, but also
social costs on a development system that is under pressure to perform comprehensively
in order to ensure long-term economic, social and political stability. Thus the imperatives
 3
of good governance, poverty reduction, social harmony
NGOs Partner In Development
and political stability comprise the nexus of challenges
and opportunities for NGOs in becoming an efficient
As Agent for good Governance
agent for development services and an effective partner
in development. Poverty Reduction

Social Harmony
Political Stability

There are several implications arising from the above development scenario for the role and functions of NGOs.
The structure of devolved governance and the spheres and levels of NGO participation and
partnership.
The role of the private sector in service delivery and the area of NGOs.
The good governance imperative in public interest management and the need for
accountability, transparency and openness of NGO actions and activities.

Legal and Administrative framework

The Legal Framework:

The legal and administrative framework is established by two enactments and a set of
regulations gazetted by the Minister of Social Services that constitutes the overall
operational context for NGOs in Sri Lanka.

Voluntary Social Service Organizations (Registration and Supervision) Act, No. 31 of 1980;
Voluntary Social Service Organizations (Registration and Supervision) (Amendment) Act, No. 8 of 1998:
Regulations framed by the Minister of Social Services by the Gazette No. 1101/14 of October 15th,
1999.

The legal framework is concerned mainly with voluntary organizations. The purposes of
the law in respect of Voluntary Social Services Organizations (VSSOs) are set out in the
preamble to the Act No. 31 of 1980, which seeks to regularize VSSOs and regulate their
operations.
Provisions in the preamble to Act 31 of 1980.
provides for the registration with the Government of Voluntary Social Service Organizations;
provides for their inspection and supervision;
facilitates the coordination of the activities of such organizations;
gives governmental recognition to such organizations which are properly constituted;
enforces the accountability of such organizations in respect of financial and policy management under
the existing rules of such organizations to the members of such organizations, the general public and
the government;
prevents malpractices by persons purporting to be such organizations;
regularizes the constitution of voluntary social service groups which have not been legally recognized;
 4
The administrative execution of the Act is through the Registrar of Voluntary Social
Service Organizations which post is held by the Secretary to the Ministry of Social
Services. The procedure for registration has been laid down (see Box)
The Amending Act No. 8 of 1998 brought a fundamental change to the legal
framework in terms of Government-VSSO relations. It empowers the Minister to appoint
an Interim Board of Management where he is satisfied that fraud or misappropriation
inquired into by a Board of Inquiry is of such a nature as would affect the financial
management of the organization and that public interest will suffer if such organization is
continued to be carried on by its existing executive committee. While this legal provision
can be seen as an opportunity for interference by government, it also brings into the legal
framework the notion of public interest implications of the activities of VSSOs, thereby
making them partners in collective action for public policy agenda. This aspect in NGO
regulation is relevant to establishing effective partnerships with Government in
programmes that would be State funded.
The administrative definition thus brings within the framework of the law Non-
government, Community, and Donor organizations. In terms of organization these types of
non-government actions and initiatives include a wide spectrum of operational bases.
Some of them may have alternate forms of legal recognition, especially through
registration as a company. Accordingly their interests, involvements, and interactions and
the scope of activities can have wide variations

Procedure for NGO Registration

Application for the registration of VSSOs should be submitted in the prescribed form. The following categories of
information that should be furnished are noteworthy.
Type of VO Organization. A three-fold typology of VOs is proposed, comprising Community-based
Organizations (CBOs), Non-governmental Organizations (NGOs), and Donor Organizations (DOs).
Geographical coverage in terms of districts and divisions.
A classification of subject areas covered by the Organization.
(These are, Poverty Alleviation; Environment; Entrepreneur Development and Training; Training and
Education; Health and Sanitation; Rehabilitation and Reconstruction; Reproductive Health; Human
Rights; Disaster Management; Rural Development; Protection of Child Rights; Women and
Development; Gender Equity; Relief Work; Credit and Savings Mobilization; and any other.)
Main project titles
Expected annual budget for the current year.
In respect of International and Foreign Funded VSSOs/NGOs the amount of money to be brought into
the country.

The Administrative Framework:

The focal point for administrative overseeing of the implementation of the provisions of the
Act is the NGO Secretariat, located within the Ministry of Social Services. The NGO
Secretariat itself has no formal legal recognition being extablished by executive decision. It
 5
carries out the administrative activities arising out of the powers vested in the Minister for
Social Services under the law.
The specific functions of the NGO Secretariat are as follows.
Registration of Voluntary Social Service Organizations, comprising CBOs, NGOs, and Donor
Organizations.
Function as a focal point and a clearinghouse for all VSSO/NGO programmes.
Function as a referral point for VSSOs/NGOs who want to engage in a particular field of activity and for
individuals and agencies that have particular expertise and resources.
Provide a convenient central location for donor agencies to communicate with Government or other
VSSOs/NGOs.
Function as an information centre about VSSO/NGO activities in Sri Lanka.
Monitor all activities of VSSOs/NGOs.
Function as a resource base for VSSOs/NGOs and perform coordinating role.

The registration of NGOs was streamlined in 1999 under a policy directive of the
Presidential Secretariat. It was noted that VSSOs are registered under different laws and
by different institutions making it difficult to obtain information about their activities. All
VSSOs were accordingly required to re-register in order that proper records of work could
be maintained and Government VSSO activities can be better coordinated. The
VSSOs/NGOs on registration signs a Memorandum of Understanding with the respective
Ministry, executed by the NGO Secretariat.
However the administrative
Coordination of Administrative Overseeing:
arrangements for
The NGO Secretariat works through a set of Liaison Officers
appointed to coordinate NGO activities under the law in each of
performing the legal
the Ministries. Every application for the registration of a NGO is objectives of facilitating
referred to the relevant Line Ministry, and the Ministries of voluntary and non-
Defence, Foreign Affairs, and Plan Implementation for report on
governmental action are
their suitability for registration of the respective NGO. The Line
Ministry reports on the relevance of the activities of the NGO to
inadequate to bring about
its programme of work. the engagement of NGOs
An NGO Steering Committee is constituted at the as voluntary actors
Ministry of Social Services to advice and assist in policy and
addressing matters of
programme oversight of NGOs. The Steering Committee is
comprised of representatives of the Ministries of, Defence,
public interest and concern
Foreign Affairs, Plan Implementation, Public Administration. The in a coordinated and
Secretary to the Ministry of Social Services chairs the accountable manner. In
Committee. The Steering Committee has in its deliberations
effect the application of the
engaged in matters ranging from,
Considering Amendments to the existing Act;
legal purposes is confined
Reviewing and approving the Memorandum of to a formal registration, a
Understanding signed by the NGO with the Secretariat; legal requirement to
Noting specific administrative actions taken or to be
operate. Beyond
taken by the constituent ministries,
Noting a Status Report pertaining to the registration
enforcement of this legal
of VSSO at the NGO Secretariat. requirement nothing more
At the District Level a District Coordinating Committee is appears to happen. While
constituted, comprised of the District Secretary as Chairman,
on paper there exists a
Heads of District Planning, Provincial Secretary in charge of
Social Services, Social Services Officer for the district as
members.
 6
formal system for government engagement with NGOs through a NGO Secretariat that
coordinates with the public sector system through a Steering Committee and set of
Liaison Officers, in practice it is nothing more than a registration process for both the
government and the NGO. There is a serious lacuna in respect of promotive action on the
part of the Government in giving substance to the declared legal purposes. There is no
doubt that the institutional capacity of the NGO Secretariat requires significant
enhancement if it is to perform its declared role and responsibilities.
It would seem that a major issue in Government-NGO relations is that NGOs relate
to the Government on an individual rather than a collective or programmatic basis.
Accordingly organizational arrangements are necessary for Government to relate with
NGOs on a collective basis while allowing them to retain their individual identity. Then
while disclosure arrangements would be important, an important aspect of NGO
accountability should be participation and partnership on a programme basis and
accountability for public interest results produced.
Neither the NGO Secretariat nor the Ministry of Health would seem to be ready
and have moved on to such a level of engagement with NGOs. Indeed a significant issue of
NGO accountability would be the nature of their agency relationship vis a vis the people
for whom they work and the government with whom they would be seeking to participate
and partner. In the absence of clarity of accountability in this regard the orientation of the
Government remains one of supervision, monitoring and control rather than participation
and partnership.

Organizational Arrangements in the Health Sector

At the Ministry of Health a focal point for VSSOs/NGOs engaged in health related
activities has been constituted in the Office of the Additional Secretary, Medical Services.
The arrangements at the Ministry of Health as presently organized are simple and
straightforward. When applications for registration are received from the NGO Secretariat,
the objectives of the VSSO/NGO are scrutinized to ascertain their relevance to the
programme activities of the Ministry of Health. The Ministry of Health routinely requests
the NGO Secretariat to instruct the VSSO/NGO to liaise with the relevant Medical Officer
of Health. The Ministry of Health does not enter into a direct dialogue with the
VSSO/NGO.
 7
SECTION B
ANALYSIS OF FIELD DATA

Potential For NGOs As Partners In Health Care.

The NGO partnership in Health Services is considered primarily in recognition of their

capacity to provide the outreach in health care that would make health policy more
effectively operational at the periphery. The Health Ministry is, understandably, cautious
in entrusting key health programmes to NGOs without some assessment of their capacity
to undertake, execute and sustain the services entrusted to them.
The assessment carried out in the present study examines the track record of the
past work of selected NGOs with a view to establishing the efficiency, timeliness,
accountability and professional capacity they have displayed so far in their work. Their
weaknesses are highlighted as indications for external assistance that would render them
more effective as partners in health.
The assessment utilizes several key aspects of NGO organization and activity as
indicators. The analysis uses intensively the quantitative data from the field survey, while
key indicators that have emerged from this have been used in the assessment of NGOs.
As to their regulatory status the majority of NGOs (72%) have been registered under the
VSSOs Act. Significantly, 16% operate under special Acts of Parliament. About 10% are
registered under the Companies Ordinance. There was one NGO that had not yet been
registered.
It is significant that only thirteen NGOs (26%) have been operational
before 1980. There are seventeen NGOs (34%) that became operational between 1980-
1990, with the balance twenty (40%) having become operational after 1991.

Assessment of Strengths and Weaknesses of NGO Activity

Quantitative Analysis:

Coverage:
The reasons motivating
Felt health needs of the people
NGOs to work in the area of
33(66%)
health development are
Nutrition needs of the people 7(14%)
varied.
Inadequacy of facilities 6(12%) A broad concern for health
provided by the Government
problems of people as
Health needs arising from 3(06%)
social problems of the contributing to poverty and
Lack of safe drinking water 1(2%) as being an imperative for
economic well being
constitute the main reason
 8
for working in the health area for all types of NGOs across all the core objectives. For Sub-
national and Community-based NGOs other concerns especially related to nutrition
constitute compelling reasons for involvement in health care. It is significant to note that
for those NGOs working in the health area because of inadequate facilities provided by
government, the issue is not as much one of health development but of providing essential
services for general well being. Nutrition needs of the people is a recognized need for half

of the NGOs working for health

NGOs in the Health Sector
development.
Their objectives, however, are Alleviate Social Problems 11 (22%)
indicative of wide ranging
Assist Persons Affected by Conflict
concerns extending from directly
and Violence 5 (10%)
health, through health and
development, to mainly non Health, Social and Economic
health ones. Over one third of Development 15 (30%)
NGOs (38%) have given health Health Development 19 (38%)
development as their main
objective. (Table 1) These have
been summarized in the Box.
When the main activities of NGOs during the last five years were
examined it was evident that the major part of their activities were health only or mainly
in health related areas (Table 2). They spanned the more community based activities
related to water and sanitation to training in first aid and nursing at a clinical level.
Water and
Areas of Activity of Health Related NGOs
Sanitation and Food and
Nutrition that constitute the 12 10
main areas of involvement 48
are programmes of two
major community-based 32
development projects. There
Water and Sanitation 46
is no significant pattern of First Aid and Nursing
Food and Nutrition
involvement by type of NGO Drugs Addiction
as stratified in the sample in Family Planning
these activities. A fair
proportion of NGOs (30%)
were engaged in directly health related activities that included areas such as mental
health and social diseases. The specific areas and the number of NGOs is given in the Box
 9

Directly health related activities The picture that emerges is a mix of activities but
Family Planning and STD 7 within it there was a large proportion (72%) focussing
Mental Health 3
First Aid 2 only on health while a lesser proportion (28%) had a
Communicable Diseases 1
mix of health and non-health activities. Here too there
Family Planning and Drug Addiction 1
Social Diseases, Family Planning 1 is no significant pattern of involvement by type of NGO
and Mental Health
as stratified in the sample. Perhaps the only significant
feature is the involvement of a over half of foreign
funded NGOs (55%) in mainly health activities with a greater engagement in a single area
- in particular family planning and social diseases- than a mix of activities. Local Funded
and Sub-national NGOs were largely involved in a mix of activities, with a typical mix of
nutrition, family planning, water and sanitation, and social diseases in health and
development activities, while water and sanitation, leadership training and vocational
training was a typical combination of non-health and health activities. (Table 3 and 4).

Geographical Coverage :

Only 4% of NGOs operated with an

Location of NGO Activity in % of NGOs
island-wide coverage. Nearly 95% each District :
36%
were active in one or a few districts 2% All Island
32%
while Provincial coverage was
minimal. Jaffna 26%
The geographical 24%
area of operation does not appear to 18%
be significantly related to their Mannar
Vavuniya 12%
**Tmalee
activities. The only significant 10%
feature was the greater involvement 8%
of district level NGOs in health and Anuradhapura 6%
4%
development, as well as mainly non- *Pnnaruwa
Puttalam
health areas, viz., social and
Batticaloa
economic development and conflict Matale
Kurunegala
affected persons.
Kandy
Their geographical Gampaha
Badulla
coverage had not determined their Kgalle Ampara
center of administration. Nearly Half Colombo **NEliya
Mragala
of them operated from their head Kalutara Rathnapura
office situated in one location, while
about one third have between one Hambantota
Galle
and five branch offices. Only 16% Matara
have a network of branch offices. *Polonnaruwa **Trincomalee ***Nuwara-Eliya
 10
Activities of NGOs in Health Care:
Health Education and Clinic Services constitute the major areas of current
activity. Nearly half (42%) of the Foreign Funded NGOs were engaged in each of these.
Health Education constitutes the predominant area of activity for Local Funded National
Level NGOs with 60% of the number engaged in this area, while Health Education
engages the largest number of Sub-national and Community level NGOs (40%), who
constitute the major actors in nutrition and water and sanitation related activities. At the
same time these NGOs along with Local Funded National NGOs account for the greater
share of involvement in mainly non-health activities such as vocational training (75%) and
self-employment (70%).
The current activity pattern of NGOs was not consistent with their main objectives.
Out of twenty-three NGOs with health only objectives the majority were engaged in health
education (60%). Out of the fifteen NGOs whose objectives encompassed both health and
development a majority currently engaged in health activities only. The majority of NGOs
with mainly non-health objectives too (7 out of 12) engage in health related activities only.
Most NGOs with multiple objectives engaged in non-health activities such
as community development, vocational training and other similar concerns (see Box)

Target Groups:
Non Heath
Multiple objectives
Objectives NGOs had multiple target groups, as
Community Development 14 (28%)
Vocational Training 19 (38%) beneficiaries of the mix of activities but they
Family Rehabilitation 02 (04%) were activity specific..
Human Rights 07 (14%
Target Groups of NGO Activities
The poor and the general public
- 24
constitute the main target groups for Public
most of the NGOs. About 40% of the Poor - 27
Project Officers
Foreign Funded NGOs target the general - 07
ers
public in their activities. Among Local ant Moth
n
Preg rs
Youth
- 16
Funded National NGOs only 22% targeted -1 1
othe
the general public but 26% more M
ren&
specifically targeted the poor as their ild
Ch 1
main beneficiary. Among the Sub- -1
national Community Level NGOs nearly
half (42%) had targeted the poor as their
main beneficiaries. Mothers, youth and
general public (15% each) constituted the
next important target groups. (Table 5
and 6).

NGO areas of activity tended to relate to

critical needs of their target groups. The
 11
poor are the target group of water and sanitation, nutrition, communicable diseases, and
family planning activities, in that order. For the general public, the main activities
encompassed a larger area that included water and sanitation, nutrition, social diseases,
mental health and drug addiction which constitute the main activities, in that order. The
lead areas for youth were sexually transmitted diseases, family planning, drugs combined
with nutrition and water and sanitation. From the point of view of the target groups it
would then seem that NGO areas of activities were needs sensitive.

Administrative and Professional Capability:

Staff Structure:

The numbers employed by NGOs range from under five to more than hundred persons.
Only a small proportion of 4% had over a hundred.
The presence of females among NGO staff
Less than 5 Persons 16 (32%)
6 to 20 16 (32%) varied from one NGO with no females to 22
21 to 100 14 (28%) with over 50% of the staff being female. In
More than 100 04 (04%)
fact 20% of the sampled NGOs had a
predominantly female staff with females comprising over 75% of the staff.

Female staff predominated largely in National level

No Females 1 (2%)
NGOs both foreign funded (66%) and local funded
(50%). Proportions of male staff were higher in <25% Females 3 (6%)
sub-national and community based NGOs.
26%-50% Females 24 (48%)
However, the numbers employed by the latter
NGOs were relatively small. 51%-75% Females 12 (24%)
The work commitment in terms of time
76% & Over 10 (20%)
expended showed that by and large NGOs worked
with a mix of full time and part time workers
Females Males
(96%). Two NGOs had no full-time staff. All types of
NGOs had more full time than part-time workers.
Full-time workers They also operated with a mix of paid and voluntary
2 (4%) 0 workers. Nearly half (48%) had more paid than voluntary
03 (10%)
05 (6%) < 25% workers, with sixteen (32%) employing more than 75% of
08 (20%)
10 (16%) 26%-50%
their staff on a paid basis.
10 (20%)(20%) 51%-75%
23 (46%) > 75%
Paid workers Nearly half the NGOs, therefore, relied more on voluntary
13 (26%) < 25% than paid workers. Voluntary work was used totally in a
09 (18%) 26%-50%.
majority of the Local Funded National Level NGOs (62.5%).
12 (24%) 51- 74%
16 (32%) > 75%
This was seen in one third of Sub-national Community-
based NGOs and 40% of Foreign Funded National Level
NGOs.
 12
Management Level Staff:
In terms of magnitude the numbers in management ranged from less than ten persons to
more than 20 persons. Only eight NGOs (16%) had more than twenty-one positions at the
management level. Ten NGOs (20%) had between eleven and twenty positions at the
management level and thirty two NGOs had less than ten. Those with a large management
staff were mainly National level NGOs. (

Females in management. The large majority (92%) of NGOs had at least one female
33 (66%) < five
05 (10%) > ten. holding management positions. A small number did not
08 (16%) 5 - 10 employ females at
04 (08%) None. Education attainment
management level. The
21 (42%) Primary/secondary
gender mix is shown in Box.
16 (32%) secondary/degree
The educational attainments of persons in
13 (26%) graduate/post-graduate
management showed a range from primary
graduate, and post-graduate levels. A detailed
breakdown is given in BOX
The management staff of Sub-national and Community-based NGOs tended to be
at the lower end of educational attainment, with twelve (55%) at primary/secondary levels
and seven (35%) at secondary/graduate level. International and Foreign Funded NGOs
had management staff at the upper end of educational attainment, six Foreign Funded
NGOs (50%) at the top end and four (33%) at secondary/graduate levels. Educational
attainments at management level of Local Funded
National NGOs also tended to be at
primary/secondary (42%) and at
Accounts, Computer
secondary/graduate (30%) levels.
Engineering
- 15 (30%) - Professional qualifications and experience of
Health And Public management level staff is varied and included such
Physiology Administration unrelated areas as health, accounts and law.
-16 (32%) - - 13 (26%) -
Nevertheless there were 04 NGOs (08%) that
Law
- 02 (4%) - had persons at management level without any
specific prior professional experience. The mix of
health, accounts and public service experiences were standard for all types of NGOs.
Local Funded National NGOs had 50% of management staff from a health and physiology
background. Sub-national and Community-based NGOs had more of persons with
accounts (38%) and public service (28%) experience at the management level. Four NGOs
(08%) reported management level staff with no specific experience, with three (06%) of
these being Sub-national and Community-based.

Training:
All NGOs had some trained staff. The number of trained staff as a percentage of the total
staff varied across the NGOs, some with over 75% trained staff to others with less than a
quarter.
 13
Numbers Trained The highest proportion of trained staff was found in the
Numbers
02
08 (16%) Trained < 25 %
(4%)
02 (4%)
International NGO (over 75%). Over half (58%) of the Foreign
26 -50%
29 (58%) 50-75
> 50 % % Funded National NGOs (58%) had more than half of trained
17 (34%) > 75 %.
staff. The situation was varied in respect of National Local
International Level: < 75 %
National Level: Funded NGOs and Sub National Community Based NGOs.
National Level:
07 < 25%
07 25-50%
04 51-75%
10 > 75%
CBOs
Sub-national and
Community-based:
01 < -25%
06 25-50%
08 51-75%
47 % 30 %
06 > 75%

The major areas of staff training were 12 % 11%

the following.The predominant area of First Aid, Nursing, Human Resource Nutrition WaterSanitation
training at all levels of staff was the first Family Planning, Management

aid and nursing cluster. Indeed in respect Social Diseases

of the NGOs with over 75% of staff

trained the major area of training remained First Aid and nursing in 76% of them. These
NGOs were equally distributed across the three major types surveyed (excluding the
International NGOs).
There appeared to be somewhat of a mismatch between training and activities of
NGOs in general. This was evident in NGOs for whom first aid and nursing constitutes the
major area of trained staff but main areas of activities in which this staff gets engaged was
nutrition and water supply and sanitation (42%). Social diseases, communicable diseases,
family planning, mental health, clinic services, cancer and first aid account for 47% of
staff trained in the first aid and nursing cluster.
Their assessment of training indicated that over half (66%) considered the training
provided to their staff to be inadequate. Only 34% considered it adequate. By type, 66%
of Foreign Funded National NGOs, 75% of Local Funded National NGOs and 57% of Sub-
national and Community-based NGOs considered training received by their staff to be
inadequate.
Specific reasons were adduced for inadequacy. Absence of training in new
technology in their curriculum was a major deficiency cited (46%). For some the training
was not related to their work (12%) and for others (8%) it was not practical and too short a
period.
Use of new technology was as important for the health and development cluster
(75%) and for the health only cluster (78%) than for the health and non-health cluster
(55%). Not being trained in new technology was an important inadequacy was marginally
more important for Foreign Funded National NGOs (75%) than for Local Funded National
NGOs (66%) and Sub-national and Community-based NGOs (66%).
 14
The inadequacies in training and professionalism were met by some NGOs who had
resources, by engaging external consultants. In fact 47 NGOs (94%) engaged external
consultants as resource persons in their activities. The subject areas varied but appears
to cover all major areas of NGO activity in health.
A breakdown by type of NGO
Use of External Consultants shows that all types engaged
9 (18%) 6 (12%) consultants in health activities while in
the health and development cluster one
Food and Water and
Nutrition
out of fifteen NGOs opted not to use
Sanitation
external consultants. Out of the twelve
Health Education 22 (44%) NGOs in the health and non-health
and Awareness Raising
2 (4%) cluster using external consultants,
2 (4%) three NGOs opted not to engage
Vocational Drug Addiction
Training external consultants.
Eleven out of the twelve Foreign
Three NGOs (06%) did not engage Funded NGOs; fifteen out of sixteen
any external consultants Local Funded National Level NGOs and
twenty out of twenty-one Sub-national
and Community-based NGOs engaged external consultants. All NGO types engaged health
only external consultants.

Financial Capability:

The main sources of finances for the NGOs were the Government and International
Agencies.
The government The main sources of finances for the NGOs
22
constituted the main source
nt

of funding for the activities 40

e
rnm

undertaken by Foreign
ies al
enc ion
ve

l
Os iona
Go

Ag ernat

Funded National Level NGOs 30

NG ernat
Int

(58%). In respect of Local

Int

12
ed

Funded National Level NGOs

rat
ene

20
and Sub national and 10
lf-g

ns
Se

Community-based NGOs
Ins ional
t io
titu

sources of funding were

t
Na

10
05
more varied, with 01
government funding
accounting for 37% and 38%
respectively. Other important sources of funds for Foreign Funded National Level NGOs
were the International Institutions/Donors (16%) and Self-earned sources (16%). Indeed
funds from International NGOs accounted for only 10% of their funding. On the other
 15
hand Local Funded National Level NGOs depended more on foreign sources, with
International NGOs and International Institutions/Donors 31% each. For Sub-national
and Community-based NGOs too these were important sources of funds, with
International NGOs providing 19% and International Institutions/Donors providing 23%
of funding. Self-earned finances provided funding for 14%of these NGOs.
Meanwhile their expenditure during a normal year was mostly within a range of
Rs. One lakh and Rs. 2.5 million. While the International NGO operated in the high
spending category of more than 2.5 m, there were Five Foreign Funded National NGOs
(41%), Five Local Funded National Level NGOs (31%) and Three Sub-national Level and
Community-based NGOs (14%) who also belonged in that category. There were Six
Foreign Funded National Level NGOs (50%), Eleven Local Funded National Level NGOs
(68%) and Fourteen Sub-national and Community-based NGOs (66%) in the intermediate
spending level.
Only Ten NGOs (20%) were satisfied with the current levels of funding. As regards
those not satisfied with the current levels of funding, nineteen Sub-national Level and
Community-based NGOs (90%), Thirteen Local Funded National Level NGOs (81%) and
seven Foreign Funded National Level NGOs (58%) were not satisfied with the level of
funding.
Financial Management:
Forty-one NGOs (82%) stated that they were satisfied with the management of their
finances. Of the balance, Nine NGOs (18%), who expressed dissatisfaction the main
reasons given were ;
No proper control No annual accounts Inadequate
of finances published
finances

These NGOs suggested measures such as better project management (4%) special training
(10%) and improved management structures (4%),to improve the management of their
finances.

Administrative Capability:
Forty one NGOs (82%) responded positively to the way in which the administration was
conducted. Amongst the nine NGOs (18%) not satisfied with the conduct of their
administration were seven Sub-national and Community-based NGOs (33.3%). The major
reasons for dissatisfaction were cited as;.
Inadequate Administrative Knowledge and Skills 07 (14%)
Staff not being full-time 02 (04%)
 16
The identified weaknesses in their administration was predominated by the staff
shortages they experienced (70%), lack of appropriate qualifications and training (18%)
and deficiencies in general capability (2%).
Five NGOs (10%) perceived no specific weaknesses in their administration.
Inadequacy of staff numbers constituted the major reason for Seventeen Sub-national and
Community-based NGOs (90%), Nine Local Funded National Level NGOs (70%), and Nine
Foreign Funded National Level NGOs (90%) who found weaknesses in the conduct of their
administration.
Forty-five NGOs suggested several courses of action to counter these defects. Apart
from training and recruiting more staff , a close link with the government institutions and
partnering their programmes was perceived as a means of strengthening their
administrative capability. This was in recognition of the need to adhere to procedures and
government fiats that would exert the required discipline on NGOs. Other suggestions are
given in the Box below.
Performance of Activities:
NGO needs Nearly half the NGOs (48%) were
satisfied with the conduct of their
More trained staff 15 (30%)
Recruitment of qualified staff 14 (28%) projects.But close on one third (30%)
Provision of financial assistance 10 (20%)
Closer link with government institutions 03 (06%)
were not satisfied, while another quarter
Regular training on project activities 02 (04%) (22%) were not satisfied with the
Recruiting staff from project locations 01 (02%)
conduct of some of their project
activities.
When classified by type 50% of the Local Funded National Level NGOs, 47.5% of
the Sub-national and Community-based NGOs, and 41% of Foreign Funded National
Level NGOs were generally satisfied with their performance. Among those not satisfied,
29% were Sub-national and Community-based, 31% were Local Funded National Level
NGOs 33% were Foreign Funded National Level NGOs.
Explaining the reasons for satisfaction the Twenty-three NGOs stated the
following.
Able to direct patients for therapy 08.5%
Have been able to review projects and take appropriate action 48.0%
Committed implementation of projects 17.5%
Clear evidence of project successes 26.0%

The reasons for dis-satisfaction were the following.

Non-availability of finance 33%
Inadequacy of staff training 60%
Lack of necessary equipment 07%
 17
The reasons for dis-satisfaction with some of the project activities were the same as were
the reasons for dis-satisfaction with project activities in general.
Non-availability of financial facilities 20%
Inadequacy of staff training 40%
Lack of necessary equipment 40%
NGOs made the following proposals for improving the conduct of their project activities.
Provide training and equipment 19 (38%)
Provide financial assistance 16 (32%)
Provide Government sponsorship 07 (14%)
Develop NGO network 06 (12%)
Evaluate project activities 02 (04%)

Provision of training and equipment and financial assistance constituted the key
suggestions for improvement for all types of NGOs. Accordingly Fifteen Subnational and
Community-based NGOs (71.5%), twelve Local Funded National Level NGOs (75%), and
Eight Foreign Funded National Level NGOs (66.5%) found these to be the main
suggestions for improvement of their project activities.

NGO STRENGTHS AND WEAKNESSES

The foregoing analysis examined the current status of the NGO activities in the health
sector within a two-fold conceptual framework, one, the capacity to participate in delivery
of health care services and the other, the ability to partner health development action. The
focus of that section was on what NGOs want to do and are in fact doing; their ability to
undertake what they want to do; and their perception of performance, problems
encountered and what can be done about them. This component examines their strengths
and weaknesses on the basis of the foregoing analysis under four capability dimensions.

Scope and Coverage of NGO Health Activities:

The NGOs surveyed were classified into three broad categories according to the scope of
their objectives and main areas of activities, viz., health only, health and development,
and health and non-health.
A key point at issue in an assessment of strengths and weaknesses would be the
type and mix of objectives and activities that would enable them to engage in providing
complementary services. In general, objectives and activities that complement and
supplement national health objectives and service deliveries could be considered a
position of strength for an NGO-government partnership.
Another pertinent issue is the conditions that contributed to NGO engagement in a
mix of activities that often ranged from health through health development to non-health
subjects. Involvement in such a mix of activities in a well defined health care programme
 18
can imply both strengths and weaknesses depending on the mix of objectives in such a
programme
The key current activity of the NGOs is health education, and along with nutrition
and water supply and sanitation the mix of current activities appears to focus primarily
on the area of preventive health. It was found that Foreign Funded NGOs have a greater
presence in clinic services and a greater non-health involvement as one moves through
Local Funded national NGOs and on to Sub-national and Community-based NGOs.
Whether this pattern in the activity profile of the different types of NGOs conveys a sense
of their distinct competencies would be pertinent for considering their relative strengths
and weaknesses for participation in service deliveries.

Outreach of Health Care Activities:

The key target group of NGO activities is the poor, closely followed by the general public.
However the target group picture is one of inclusiveness than an exclusive target group. It
matches with the mixed activity profile of NGOs. However there is a pattern in the groups
targeted by the activities of the different types of NGOs. Activities of Foreign Funded NGOs
seem to target the general public, whereas Sub-national and Community-based NGOs
focus more on the poor with National Local Funded NGOs targeting a mix of poor and the
general public as their beneficiaries.
The relationship between target groups and activities of NGOs indicate that poor
constitute the target group for water and sanitation and nutrition and to a lesser extent
communicable diseases and family planning activities. At the same time water and
sanitation and nutrition constitute key activities for the general public too, combined with
social diseases, mental health and drugs. Youth are mainly targeted by activities in social
diseases, mental health and drugs.
Further there is a greater involvement of the NGOs with smaller target groups (less
than 100 and 101 1,000) with nutrition and water and sanitation, whereas the NGOs
with larger target groups have a wider mix of beneficiaries. The NGOs with smaller target
groups are the Sub-national and Community-based type that has a greater community
development orientation.
Accordingly there would seem to be a congruence between target groups, main
activities, and the size of target groups with the type of NGOs. The question that arises
then is whether this pattern of association between type of NGOs, main activities, and
target groups represent broad areas of expertise in service delivery and therefore distinct
competencies in terms of engaging with community groups, in which case they represent
NGO strengths.
Staffing, Knowledge, Skills and Attitudes:
NGO staffing is a mixed one, full-time and part-time on the one hand and paid and
voluntary on the other. Some NGOs have found the absence of a full-time cadre a
constraint to delivery of services. At the same time it is significant that approximately 42%
 19
of NGOs relied more on voluntary staff. As organizations directly engaged with the
community, a voluntary basis in service delivery operations can contribute to greater
sustainability of such engagement at the community level. The mix of paid and voluntary
staffing then constitutes a NGO strength.
Trained staff constituted more than half the total staffing for the majority of NGOs.
This is a strength. An issue here is as to whether the training has in fact been provided by
the NGO or has been acquired prior to joining that NGO. The extent to which NGOs train
their staff could be an important area of capability assessment that requires further
inquiry. More important is the relevance of training to the activities being undertaken. The
major area of staff training is the first aid and nursing cluster accounting for nearly half of
all NGO trained staff. Comparison of areas of training with the areas of main activities of
NGOs would seem to suggest a correlation between activities of nutrition and water
supply and sanitation and the first aid and nursing cluster. Whether this indicates a mis-
match between training and activities may need further probing before coming to any
conclusions.
In regard to the use of consultants, the main area in which such consultants have
been engaged is health education. A question that arises here is as to the capacity in
which consultants are engaged, whether as resource persons or as consultants
especially in relation to health education. It is then pertinent to ask as to what should be
the areas of core competencies of an NGO. The excessive use of consultants may
indicate a weakness in competence to undertake their prescribed activities. The
appropriate use of resource persons would no doubt be necessary and can strategically
enhance NGO acceptance in terms of professionalism in programme planning and
implementation.
The levels of educational attainments of NGO management level staff suggest an
association between the Sub-national and Community-based NGOs with the lower end of
educational attainment continuum. Obviously this cannot by itself suggest a weakness in
the management capabilities of these NGOs. This must be considered in association with
a bias towards public sector experience at the management level especially the Sub-
national and Communitybased NGOs. Overall then the public sector background can
constitute a strength as far as Sub-national and Community level NGOs are concerned in
managing relations with government.
Resource Availability and Accessibility
Finance emerges as a major issue as far as most NGOs are concerned. The
government is main source of finance for nearly half the NGOs, suggesting that they are
dependent upon the execution of government programmes for funding. The survey
findings in fact suggest that Foreign Funded National Level NGOs are more dependent
upon government sources than other types. However most of the NGOs appear to be
satisfied with the management of their finances. In the context of availability and
accessibility to sources of finances being an issue it is a significant strength that the
majority of NGOs are satisfied with the management of their finances.
 20

Perceptions of NGOs Regarding Their Strengths and Weaknesses:

It is significant to note that most of the NGOs were satisfied with the conduct of
their administration and almost half were satisfied with the way their project activities
were carried out. These perceptions constitute an important strength in terms of how they
see themselves performing. At the same time these perceptions reflect strengths of their
confidence and commitment.
In this context suggestions for improvement were in areas which they recognized
as important for enhancing their capability and performance. Two major areas of concern
that emerge, therefore, are finance and staff skills.
The next two sections contain an assessment of NGO performance in two critical
areas that pertain to their potential to collaborate in national health policy. These are
their current performance in terms of impact and the other their proven ability to address
governance issues in health development. These aspects are now discussed.
ROLE PERFORMANCE OF NGOs IN THE DELIVERY OF HEALTH
CARE: Opportunities and Risks
As a distinct category of agents delivering services, NGOs become a partner in health
development. This is a role that cannot be performed by each NGO in isolation. They must
network with other NGOs and also collaborate with other agents in health development,
notably the government. This section will examine the current status of NGOs regarding
the performance of their partnership role in health development. This is carried out
through the use of several indicators.

Impact of Operations and Activities

Numbers of Beneficiaries Targeted:
The numbers of beneficiaries targeted in their projects was used to indicate the scale of

Numbers of Beneficiaries Targeted operations. They are given in the Box below.
28.3% 28.3%

25.5% The Poor constitute the key target group for all
categories except the more than 10,000 category. The
14.2% main target group of those NGOs that were not able
to estimate the numbers targeted were Youth,
3.8% Disabled and General Public. In the Less than 100
category, Poor and Youth constitute the main groups
Cannot Tell < 100 101 - 1000 1001
targeted. Mother, General Public and Project Officers
Over
10,000 10,001 constitute a second level of groups targeted. In the
101 1,000 category Poor continue to be the main
target group with General Public, Youth, Mothers and Children at the next level of
importance. In the 1,001 10,000 category the General Public take precedence over the
 21
Poor with Mothers and Children and Mothers at a lower level of importance. The General
Public constitute the main target group for the over 10,000 category (Table7).
The numbers targeted in terms of the main activities of NGOs reveal the following
pattern. (Table 8). In the group of NGOs unable to state the numbers targeted, Water and
Sanitation, Family Planning, Social Diseases and Drugs were the main activity areas. In
the under 100 category Nutrition and Water and Sanitation constitute the predominant
activity areas. In respect of the 101 1,000 Nutrition is the predominant activity with
Water and Sanitation, Family Planning and Social Diseases at the next level of
importance. For the 1,000 10,000 category Nutrition and Water and Sanitation are the
main activity areas with Family Planning, Social Diseases, Communicable Diseases at the
next level of importance.

Problems and Issues in the Conduct of NGO Affairs:

Their responses encompassed both internal and external problems of NGOs.
Finance, not surprisingly, was a primary concern for nearly half the NGOs. They identified
several others of a lesser importance such as lack of recognition, mistrust arising from
questions on accountability that have very often been highlighted publicly and political
influence that tended to erode the independence of NGOs, some of them becoming tools of
political interests. The box below quantifies these problems.
Problems and Issues in the Conduct of NGO Affairs
Finance was important for Nine Sub-
Finance 42%
national and Community-based NGOs (43%),
Recognition 22%
Nine Local Funded National Level NGOs (56%),
Mistrust
and Three Foreign Funded National Level NGOs
by people 20%
(25%).
Technical
equipment 8%
These general problems were expressed in more Political
influence 6%
specific terms as shown in the box below. They Communication
help to identify specific areas which require (language) 2%
attention.
The positive
Public misconception about NGO financial matters 13 (26%) feature about
Lack of Government sponsorship and political Interference 11 (22%)
Lack of Government sponsorship and financial Support 06 (12%) NGO self
Lack of acceptance by the public 03 (06%) assessment was
Inability to have a permanent staff 02 (04%)
Being subject to political influence in implementing projects 01 (02%) that they were
Financial problems 01 (02%)
able to follow it
Decisions and supply of material not getting done in a timely manner 01 (02%)
Wrong actions leading to virtual collapse 01 (02%) up with
Competitiveness amongst NGOs 01 (02%)
Fraudulant expectations of government officials 01 (02%) suggestions of
Uncertainty due to security situation 01 (02%) their own as
remedies for the
problems they identified. The suggestion for government sponsorship and financial
 22
support was made by nearly a quarter of the NGOs. The question that arises then is the
dependence on government that would inevitably lead to NGOs losing their character of
representing the interests of civil society. It could even lead to political interference that
they wish to eliminate from the NGO culture. There appears, therefore, be some
contradictions statements of their requirements. The detailed list is in the BOX below.

Government sponsorship 12 (24%) In a further step they identified

Arrangements for financial support 12 (24%)
the facilities needed to enable
Actions to gain trust and credibility 08 (16%)
Provide wider exposure to staff 03 (06%) them to work more efficiently.
Create consensus amongst NGOs 03 (06%)
Create public awareness 01 (02%) The NGOs considered the
Eliminate political interference 01 (02%) following;
Government sponsorship, publicity and removal
of political interference 01 (02%) The NGOs considered more important facilities needed.
Alternate organization to Ministry of Health for
decision making 01 (02%)
Remove public misconceptions 01 (02%)]

Partnering for Health Care : Organizational

Linkages of NGOs 34.5% 29.3% 28.4%
The inter-sectoral nature of health care
4.3% 3.4%
particularly in the key areas of current NGO activity
Trained Equipment Financial NGO Information
requires coordinated effort rather than individual staff Assistance Awareness
operations. One of the key indicators that would reflect Programmes

their capacity for partnering would be their current

ability to network with others. This aspect was examined through their membership in
associations that worked on common concerns.

Networking:

The majority of NGOs (90%) reported membership associations of NGOs. Only Five
Na t io n a l Le ve l NGOs (10%) did not belong to any
In s t it u t io n s
36%
association. The kinds of associations with
which NGOs networked are in the Box.
Go ve rn m e n t The associations they refer to seem
In s t it u t io n s
06% to suggest that the NGOs surveyed have
NGO Ne t wo rk in g
been establishing linear institutional
In t e rn a t io n a l
S u b -n a t io n a l Le ve l Org a n iz a t io n s
linkages than laterally networking with
Org a n iz a t io n s 26% associations of NGOs. This is significantly
22%
different from networking in common
programmes and issues.
Five NGOs (10%) reported that they
 23
do not belong to any associations. The reasons for their not belonging to any associations
were the following.
Cannot work independently 02 (04%) It appears therefore that NGOs would
Not necessary 02 (04%) generally be averse to sinking their
Lead to conflicts of opinion 01 (02%)
individuality in working with other civil
society organizations. Their desire to work with government would in fact reinforce their
tendency for linear rather than lateral linkages.

Collaboration
The conclusion is in fact borne out when the current NGO government linkages
are examined. The majority have had linear links with the national health authority as
evident in the figure below.
Department of Health Services 27 (54%)
Ministry of Health 14 (28%)
NGO Federation 03 (06%)
Ministry of Education 02 (04%)
Human Rights Commission 01 (02%)
Ministry of Social Services 01 (02%)
Provincial Council 01 (02%)

(NGOs have differentiated between the Ministry of Health and the Department of Health,
as there were two separate institutions for some time.)
The inquiry proceeds to elicit the scope of collaboration that NGOs have had with the
Ministry of Health. It is seen that Forty-two NGOs (84%) have worked with the Ministry of
Health;
The International NGO
Foreign Funded National Level NGOs and
Fifteen (93.75%) out of the Sixteen Local Funded National Level NGOs.
Eight of the NGOs (16%) surveyed have not worked with the Ministry of
Health. Seven of these are Sub-national and Community-based NGOs constituting 33% of
this type. These would be probably be those NGOs whose main objective is mainly non-
health. The specific subject areas that the NGOs who have worked with the Ministry of
Health have collaborated in are;
Awareness programmes about common diseases 21 (42%)
Nutrition programmes for mothers and children 10 (20%)
Awareness programmes on family planning 09 (18%)
Immunization programmes 01 (02%)
As far as Foreign Funded National Level NGOs are concerned the main area of
collaboration with the Ministry of Health has been in awareness programmes about
 24
common diseases (75%). This area of collaboration is less important for Local Funded
national Level NGOs (53%) and for Sub-national Level Community-based NGOs
(28.5%) of those who collaborate with the Ministry of Health. The key area of
collaboration for the latter type has been in Nutrition (42.5%).

Willingness to Partner : Areas and Partnerships

The NGOs , it appeared, had a clear mandate for collaborative action. The institutions and
subject areas preferred indicate a high preference for government, international
institutions and the WHO. But there was also a high preference shown to work with other
NGOs which was a positive indication of a willingness to establish lateral links.
Prevention of diseases was the major area for all
NGOs as to their inclination to collaborate and network types of NGOs, seven Foreign Funded National
With Government 48(96%)
Institutions
Level NGOs (58%), twelve Local Funded National
NGOs (75%), and eighteen Sub-national
With International 50 (100%)
Institutions Community-based NGOs (86%).
National NGOs 48(96%)

World Health POTENTIAL FOR PARTNERING HEALTH

Organization 50 (100%)
DEVELOPMENT: OPPORTUNITIES AND
Prevention of Diseases 76%
Nutrition Action
RISKS
12%
Programmes
Resource Management 08%
and Development This main section in reviewing the current status
Vocational Training 04%
of NGO networking, collaboration and their
inclination to network and collaborate sought to focus on the available organizational
arrangements for the NGOs in health care to work as an organizational sector. The status
in this regard would then indicate the opportunities and risks for NGOs to function and
perform as an effective partner in health development. This is reviewed in the analysis
that follows.

Scope for Networking and Collaboration

Networking and collaboration would accordingly have three dimensions;
partnering among themselves as a group,
partnering with the government as a group, and
partnering with international organizations.
At present NGOs operate on an individual basis. The networking referred to by them
would seem to be more in the nature of resource support relations between international,
national and sub-national NGOs on the one hand and with the government on the other.
However the fact that there are several common areas of activity where NGOs provide
services suggest that there is scope for coming together in a partnership amongst
themselves to ensure better coverage of health care needs.The majority (98%) had in fact
expressed a preference to establish such networks. Further there is obviously a
 25
commonality of problems and needs as far as the NGOs are concerned that would create
the conditions for networking and collaboration. It would then seem that the necessary
conditions exist for formal or even informal networking and collaboration between NGOs
and with Government.

Levels of Networking and Collaboration

A question that arises then is as to at what level partnering should take place. The
survey findings suggest benefits of partnering in addressing problems faced by NGOs both
at the operational level, i.e., service delivery, as well as in addressing common problems
they face in engaging in their activities. These twin problems suggest partnership at the
service delivery level, i.e., a local level for better coordination of effort, as well as at a
higher level that would enable them to address their common problems. The latter should
be at a level where NGOs can engage with the Government at a policy/ programme level.
This aspect will be examined further in the next main section.

Risks in Partnering for Service Delivery:

The NGOs identified several problems they encounter in providing services to
people. Several of these are problems existing in the external-working environment of
NGOs. It is well to note them again as constraints to partnership in service delivery.
Recognition
Public Mis-trust and Misconceptions
Acceptance by People
Political Influence
Government Support and Sponsorship
The NGO culture of establishing an identity was reflected in their responses to factors that
had militated against their networking in their current operations. This too would be an
issue that would need to be addressed through practical measures to ensure collaboration
while maintaining their independence, since this feature of NGOs may be one that would
need to be preserved in the NGO culture. Effective role performance on the part of NGOs
calls for addressing these risks that can limit effective engagement with partners and
stakeholders of health development.

GOVERNANCE OF HEALTH DEVELOPMENT:

Scope For NGO Participation and Partnership

The efficient and effective participation of NGOs in terms of their role, responsibility and
functions in health development should be understood as being a primarily governance
issue. Governance of health development is about nature, scope, and arrangements for
collective actions, responsibilities and accountabilities in the deployment of resources,
delivery of services, and achievement of results. The NGOs working in the health sector
 26
constitute one of the players in promoting and undertaking development actions and
activities. The role, responsibility and functions of NGOs should then be delineated and
negotiated in the context of a partnership of collective action by the State, private sector
and non-government organizations. Accordingly the scope for NGO participation and
partnership in health development should be addressed in the governance context and
the ensuing policy and programme framework of the health sector.

Governance Context of the Health Sector

The framework for devolution of power provides the governance context for the
management of health development. A three-tiered structure of government establishes
three spheres of governance at national, provincial and local levels. Specific health
development powers and functions are assigned to these three levels by law. The
Thirteenth Amendment to the Constitution delineates the powers and functions of the
Central Government and Provincial Councils. The powers and functions of Municipal
Councils, Urban Councils and Pradeshiya Sabhas are set out in the respective Ordinances
and Acts.
The responsibility for provision of health development rests with these governance
institutions of the State. Ensuing therefrom would be a health delivery system at each of
the levels of governance. Effective complementarity and coordination of these delivery
systems would involve bringing together public, private and non-governmental
participation and partnership in service provision. The national and provincial delivery
systems constitute the core of the public health care system. Apart from a few Municipal
Councils, notably Colombo, Galle and Kandy, local authorities undertake at best some
public health functions. The regional delivery system operates at three health care
management levels;
provincial (Directors of Health),
district (Deputy Directors of Health), and
divisional (Divisional Directors/Medical Officers of Health).
These three levels of health development management provide the appropriate
participation and partnership linkages for NGO health activities. In this context it is
relevant to note that NGOs surveyed perceived themselves operating either at all-island or
district level. Only 04% of the NGOs considered themselves to be operating at the
provincial level. Indeed a crucial issue in NGO participation and partnership would be the
appropriate level of operational linkage with the governance system, keeping in view the
imperative of complementarity unless competing with public delivery systems.
The public sector, comprising the Ministry of Health, Provincial Councils, and the
Local Authorities, is the major provider of health care accounting for about 60% of the
population. The national and provincial health delivery systems cover the entire range of
preventive, curative and rehabilitative care. The private sector provides mainly curative
care, estimated at about 50% of the outpatient care of the population. Private sector
services are concentrated in the urban and sub-urban areas. (Ministry of Health -Annual
 27
Health Bulletin; 1998) According to National Health Accounts (Institute of Policy Studies ;
2001) the NGO sector accounts for about one per cent of total health expenditure. In fact
health reforms emphasize, inter alia, the strengthening of public-private linkages, and
optimizing resource use to enhance efficiency, effectiveness and equity. If it is argued that
the NGO sector is not for profit, then their service deliveries could efficiently and
effectively complement public sector service deliveries, in, especially rural areas, towards
ensuring greater equitability in distribution of services. Scope for NGO participation and
partnership will be examined later in this section.

Public Sector Programme Framework and Service Delivery Issues:

The public sector programme framework for health development consists of two core
service areas,
patient care and
public health.
Patient care provides curative services for in-patients and out-patients in both
general and specialized hospitals and clinics. In the absence of a referral system patients
by-pass the smaller institutions, especially in rural areas, resulting in their under -
utilization and conversely in overcrowding of the larger ones.
Public health services take care of the promotion of health and prevention of
diseases. Preventive services includes community health services consisting of family
health services, environmental health and sanitation, epidemiological surveillance, health
education and publicity; and specialized public health programmes that target malaria,
respiratory diseases, filariasis, STD/AIDS, leprosy, public health veterinary services.
The Six-Year Development Programme (1999-2004) noted that the hospital and
primary health care systems have come under increasing strain in recent years. The
major issues include the overcrowding of tertiary hospitals and insufficient community
outreach. Further the current epidemiological transition calls for fundamental re-
orientation and restructuring of the delivery system. The programme framework for health
development therefore takes note of the need to sustain current achievements and then
move on to prevention and control of communicable diseases, promotion and fostering of
healthy life styles, improvement of access to quality health services, human resources
development in the public and private sectors, and decentralization of health
administration.
The thrust areas for health development have been identified as the following.
Improvement of hospitals in order to provide more qualitative health care services.
Expansion of health services into most needy areas.
Strengthening health promotion and preventive programmes.
Strengthening institutional supportive services.
Improvement of resource mobilization and management in the health sector.
 28
The above programme framework for health development provides wide ranging
opportunities for NGO participation and partnership.

Scope for Participation

Scope for participation in the national programme for delivery of health care is not
only a question of the willingness and capability of NGOs to function as providers of
services. It is also a question of the services required and the relevance of what NGOs are
doing and are capable of doing. Accordingly participation of NGOs in health care should
take into account both dimensions of collective action. In this regard and important
aspect of the scope for participation will be the willingness and readiness of the
government to recognize and accept NGOs as agents for delivery of health care services.
Positive public pronouncements and statements by key health policy actors are
encouraging and augur well for greater involvement of NGOs in health services. However a
clearly structured role for NGOs in a framework for collective action is necessary for their
effective participation.
Then the health care programme framework and the devolved governance
structure provide institutional context for NGO participation in service delivery. At the
outset it should be noted that the national programme as currently organized does not
have any institutional arrangements for the participation of NGOs. It would be correct to
state that except where NGOs are partners in specific development programmes/projects
such as Community Water Supply and Sanitation (funded by the ADB) there is no
institutional arrangement in place for their involvement in the national programme for
health care. Therefore, institutional and organizational arrangements are necessary to
bring the NGOs into the national health care programme more effectively.
From a programme perspective much of what NGOs are doing now would fall into
the area of preventive activities of the national programme. Accordingly it is here that
their current strengths would lie and potential and scope is available. NGO experience
and expertise in engagement with the community would make them effective providers of
community health services. Such a role would fit well with their focus on service delivery
for the poor. At the same time it is important to note that what NGOs are doing now does
not necessarily reflect what they could be doing and doing competently within the
framework of a national programme. What NGOs are doing at present in the area of first
aid and nursing and in communicable diseases in the mainly health cluster of activities
suggest that they have the potential to move on to care giving activities in the curative
sphere as well. Indeed their concern for government sponsorship and support is probably
not only a question of finances but also opportunities for engagement in the national
programme. Accordingly NGO participation in collective action for health should be seen
as a dynamic relationship and not a static situation.
 29
Scope for Partnership
Assessment of the scope for partnership takes NGO participation on to the level of
governance. It would be concerned with the potential for NGOs to exercise voice on behalf
of their clientele and influence national programme decision- making. Here too the
institutional arrangements for engagement with the national programme (in governance)
become important. Partnership in collective action for health development is the
necessary basis for sustainability of a NGO role and function in the delivery of health care
services. Accordingly participation and partnership constitute complementary and
interacting facets of NGO capacity for collective action.
Findings of this study do not suggest that NGOs are ready for such an engagement
in the governance of the national programme. As noted earlier there is little or no
networking amongst NGOs to be able to partner and exercise voice. At present NGOs work
in isolation and perhaps with some negative competitive orientation. This may be due to
the fact that at present their relations with the government are on an individual basis.
This situation would need to change and NGOs brought into a programme of work linked
to community (preventive) or organizational (curative) service delivery networks.
An important aspect of partnering is the willingness of NGOs to ensure and
maintain the highest standards of service delivery. In the context of their non-
governmental nature this involves self-regulation and not external control. Networking
becomes critical in this regard by bringing about joint effort and shared commitment to
the objectives and standards of performance for which NGOs would take responsibility for
and in turn become accountable for. It is then and only then that they could become
effective partners. As evidenced by their willingness to collaborate there is no doubt that
most of the NGOs would want to move on to such a relationship
It is imperative that active partnership of NGOs requires that the national
programme moves on to a proactive mode in its operational orientation. Opportunities for
collective action in the governance of the national programme must be actively sought in
order to become more efficient and effective in service provision. It involves creating
partnerships at different levels with the different providers of health care services.
 30

CONCLUSION
THE WAY FORWARD: AN AGENDA FOR ACTION

The foregoing study of NGO activities in the health sector provides an overview of
their current status of involvement, operations and achievements. Indeed it is a preliminary
situation analysis rather than a record of NGO practice in health development. Despite this
limitation, the study adequately provides meaningful insights and suggests directions for
policy and programme follow up in promoting partnerships for health development in Sri
Lanka.

The role of NGOs in terms of quantity is a limited one. However for many NGOs their
beneficiary outreach is significant with at least a quarter providing services for more than a
1,000 persons. This is a substantial provider operation in terms of organization and
management. The activities undertaken by them while no doubt providing useful services for
their target groups, they also have potential for linking these sections of local (urban or
rural) communities with mainstream service deliveries.

Their role as providers of services then has potential to take on an added dimension as
outreach linkages in the delivery of health care. This progression from provider of services to
that of an outreach linkage can take place only as a partner in delivery of health care. It is
only in this role as an intermediate linking mainstream health care with people according to
their needs and preferences that NGOs can become a partner in health governance giving
voice to those who must remain with the public sector health care system. Then NGO
partnership has potential to make the public sector system more responsive.

Meaningful engagement of NGOs in collective action for health development then is a

challenge not only for the NGOs but also for the State health authorities at all levels. It is
more so for the national level health authorities who must give leadership and create the
enabling policy environment wherein opportunities are created for NGOs to come in to the
system as partner. How much, when and where are crucial governance decisions regarding
NGO role and responsibility for delivery of services and provision of outreach linkages.
There are no doubt attendant risks in collective action both for NGOs who must perform and
the State health authorities that must assure standards in services provided by them.

An agenda for promoting and enabling NGOs engage meaningfully in collective action for
health development would involve following areas of capacity building action.

Provide Opportunities for Participation:

Identify a clear role for NGOs in a framework for collective action in health
development. What does NGOs do, when and where constitute a crucial governance
condition for meaningful partnership and collective in health development. It is important
that NGO role be seen as an evolving one in the context of the specific health care delivery
imperatives in different local contexts. Their role as an intermediate and an outreach has
greatest potential in the local context.

Link NGOs in Service Delivery:

NGO service provision should then be effectively coordinated with the national
health care programme through programme-based networking. This would then mean that
NGOs would have to fit into the delivery system, whether curative or preventive. But it
need not and should not mean that NGOs lose their non-governmental context in
organization. What should be of importance as far as the health care delivery system is
 31
concerned would be the service delivery outputs rather than the style of management. In
fact the style of management constitutes a strength.

Create Mutual Accountabilities:

Partnership arrangements and collective action call for clear specification of
accountabilities. It is important to note that both NGOs and State health authorities would
be accountable to each other for the programme of collective action. It is an accountability
relationship in the nature of a performance contract agreed upon mutually.

Establish Regulatory Arrangements:

Performance accountability calls for regulatory mechanisms to ensure standards in
NGO service delivery. Consultative arrangements would be necessary for participatory
setting of service standards and review of service delivery activities. Such consultations
should be carried out collectively with the NGO network in a state health care jurisdiction,
rather than with individual NGOs.
Promote Associations of Health Care NGOs:
Organizations of NGOs in associations capable of engaging with the governance
structure especially at provincial and local levels are necessary to move on to collective
action. NGOs should be encouraged and promoted to act collectively in their partnerships
with the State health authorities. It is imperative that NGOs retain their civil society context
and exercise voice on behalf of their beneficiary whose needs and preferences they seek
to respond to and represent.

Support NGO Capacity and Capability Building:

Capacity and capability building of NGOs to perform task responsibilities assigned
would then constitute a critical item in the agenda for collective action. An NGO capacity and
capability building programme should in fact be the responsibility of the Ministry of Health.
Support in terms of resources and skills are critical but should not compromise the status of
NGOs as civil society organizations. Modalities for support could be accommodated under
donor funded programmes by way of matching assistance to services provided. The
Ministry of Health could perform a liaison role to link NGOs with sources of donor technical
support.

Participation and partnership of NGOs in health development poses challenges to

both the NGOs and the State health authorities. A re-orientation not only in their systems
and styles of management but also mind sets would be necessary for both parties to engage
in a mutually beneficial partnership. Benefits by way of more responsive service deliveries
that would accrue from such partnership constitutes adequate justification and motivation
for both players to set out on the path of collective action to provide better health care to
people.
 Table 1 Main Objective of NGOs by Geographical Distribution

Coverage
Main Objective All Island Provincial District Total
Level
No % No % No % No %
To Develop Health Conditions 7 46.7 - - 8 53.3 15 100.0
To Develop Health Social & Economic 6 40.0 - - 9 60.0 15 100.0
Conditions
Prevention of Social Diseases 2 50.0 1 25.0 1 25.0 04 100.0
To Help those affected by Violence & War 2 40.0 - - 3 60.0 05 100.0
To Solve Social Problems 6 54.5 - - 5 45.5 11 100.0
Total 23 46.0 1 2.0 26 52.0 50 100.0
 Table 2 Main Activities Undertaken During the Last Five years

Main Activities Number

1 Nutrition Programs & Water Sanitation 2

2 Communicable Diseases 1

3 Family Planning & Social Diseases 3

4 Water & Sanitation 2

5 Nutrition Programs & Clinical Services 1

6 Nutrition Programs Family Planning & Water Sanitation 2

7 Social Diseases 3

8 Nutrition Programs 5

9 Nutrition Programs & Communicable Diseases 1

10 Social Diseases, Family Planning & Mental Health 1

11 Social Diseases, Nutrition Programs & Communicable Diseases. 1

12 Water Sanitation & Communicable Diseases. 1

13 Nutrition Programs & Drugs Control. 1

14 Nutrition Programs, Communicable Diseases & Water Sanitation 1

15 Clinical Services, Education for Disabled & Vocational Training 1

16 Social Diseases, Nutrition Programs & Drugs Control 1

17 Drugs control, Mental Health & Vocational Training. 1

18 Mental Health 3

19 Cancer 1

20 First Aid 2

21 Water & Sanitation, Drugs Control & Social Diseases. 1

22 Nutrition Programs, Water & Sanitation & Vocational Training. 1

23 Social Diseases & Nutrition programs 1

24 Nutrition Programs & Vocational Training 2

25 Water & Sanitation & Self Employment 1

26 Water & Sanitation, Family Planning & Vocational Training 1

27 Nutrition Programs, Self Employment & Water Sanitation. 1

28 Drugs Control & Family Planning 1

29 Nutrition Programs & Education for Disabled. 1

30 Nutrition Programs, Water Sanitation & Human Rights. 1

31 Water & Sanitation & Drugs Control. 1

32 Water & Sanitation & Leadership Training. 1

33 Nutrition Programs, Elderly Care & Self Employment 1

34 Nutrition Programs, Self Employment & Human Rights. 1

35 Water & Sanitation, Leadership Training & Vocational Training. 1

Total. 50
 Table 4 Activities of NGOs in Last Five Years Showing Single Subject Areas

Type of NGO
Activities International National Local Sub- Total
NGOs Level Foreign Funded National &
Funded Community
Based
1. Nutrition Programs 0 3 7 14 24
2. Social Diseases 0 3 4 4 11
3. Water & Sanitation 1 3 4 11 19
4. Family Planning 0 3 5 2 10
5. Communicable Diseases 0 2 1 4 7
6. Mental Health 0 3 1 1 5
7. Clinical Services 0 0 1 1 2
8. Cancer 0 1 0 0 1
9. Drugs control 1 2 1 2 6
10. First Aid 0 2 0 0 2
11. Education for Disabled 0 0 1 1 2
12. Elderly Care 0 0 1 0 1
13. Leadership Training 0 0 0 2 2
14. Vocational Training 0 2 5 1 8
15. Self Employment 0 0 2 2 4
16. Human Rights 0 0 1 1 2
N = 1 12 16 21 50

Table 5 Main Target Group of NGO Activities

Type of NGO
Target Group International National Local Sub- Total
NGOs Level Foreign Funded National &
Funded (%) (%) Community
Based (%)

Children 0 1 0 3 4
Mothers 0 2 3 6 11
Patients 0 3 0 1 4
Poor 1 1 7 18 27
General Public 0 9 8 7 24
Children and mothers 0 1 3 1 5
Youth 1 4 4 7 16
Forces 0 0 2 0 2
Disabled 0 1 3 1 5
Project officers 0 2 4 1 7
N = 1 12 16 21 50
 Table 6 Target Group of NGOs by Main Area of Activity

Activity Children Mothers Patients Poor General Children Youth Armed Disabled Project Total
Public and Forces officers
mothers
Nutrition Programs 4 9 1 18 8 5 6 0 1 2 24
Social Diseases 1 3 0 2 7 0 8 2 0 2 11

Water & Sanitation 1 5 0 19 12 2 5 0 0 3 19

Family Planning 1 5 0 5 5 0 8 0 0 4 10

Communicable Diseases 1 1 4 9 4 0 0 0 0 0 7

Mental Health 0 0 0 0 7 0 1 0 0 1 5

Clinical Services 0 2 0 0 0 0 0 0 3 0 2

Cancer 0 0 1 0 0 0 0 0 0 0 1

Drugs control 1 0 0 2 5 0 6 0 0 1 6

First Aid 0 0 0 0 1 0 0 0 1 0 2

Education for Disabled 0 0 1 0 0 0 0 0 4 0 2

Elderly Care 0 0 0 1 1 1 0 0 0 0 1

Leadership Training 0 0 0 1 1 0 2 0 0 1 2

Vocational Training 0 2 0 5 2 0 6 0 3 5 8

Self Employment 0 1 0 5 2 2 1 0 0 0 4

Human Rights 0 0 0 4 0 1 0 0 0 0 2

N = 5 16 2 5 7 5 16 2 5 7 50
Table 7 Number of Beneficiaries Targeted

Target Group Cannot <100 101- 1,001- 10,000+ Total

Tell 1,000 10,000
Children 0 1 4 1 0 4
Mothers 3 8 9 7 1 11
Patients 0 4 2 0 1 4
Poor 3 27 22 19 0 27
General Public 9 8 12 22 4 24
Children and mothers 0 4 2 5 0 5
Youth 11 18 9 4 1 18
Forces 0 0 1 1 0 2
Disabled 10 0 2 0 0 10
Project officers 0 7 5 5 2 7
N = 15 30 30 27 4 50

Tatal 8 Numbers Targeted by Area of Activity

Number Targeted So far Total

Activity
Cannot <100 101- 1,001- 10,000+
Tell 1,000 10,000
Nutrition Programs 0 18 22 14 1 55
Social Disease 6 5 9 5 0 25
Water & Sanitation 7 16 11 13 1 48
Family Planning 6 9 6 6 1 28
Communicable Diseases 0 4 9 6 0 19
Mental Health 1 1 1 5 1 09
Clinical Services 3 0 0 2 0 05
Cancer 0 0 0 0 1 01
Drugs control 5 2 3 3 2 15
First Aid 2 0 0 0 0 02
Education for Disabled 3 0 2 0 0 05
Elderly Care 0 1 0 2 0 03
Leadership Training 0 4 1 0 0 05
Vocational Training 3 11 2 5 2 23
Self Employment 0 4 4 3 0 11
Human Rights 0 4 2 0 0 06
N = 30 30 30 27 4 50
 Table 3 Multiple Activities Undertaken by NGOs During the Last Five Years

Type of NGOs
Main Activities Total
International National Level Local Funded Sub-National &
NGOs Foreign Funded Community Based
No % No % No % No % N0 %
Nutrition Programs & Water Sanitation - - 1 8.3 1 6.3 - - 2 4.0
Communicable Diseases - - 1 8.3 - - - - 1 2.0
Family Planning & Social Diseases - - 1 8.3 2 12.5 - - 3 6.0
Water & Sanitation - - - - 1 6.3 1 4.8 2 4.0
Nutrition Programs & Clinical Services - - - - - - 1 4.8 1 2.0
Nutrition Programs Family Planning & Water Sanitation - - - - 2 9.5 2 4.0
Social Diseases - - - - 1 12.5 1 4.8 3 6.0
Nutrition Programs - - 1 8.3 1 6.3 3 14.3 5 10.0
Nutrition Programs & Communicable Diseases - - - - - - 1 4.8 1 2.0
Social Diseases, Family Planning & Mental Health - - 1 8.3 - - - - 1 2.0
Social Diseases, Nutrition Programs & Communicable Diseases. - - - - - - 1 4.8 1 2.0
Water Sanitation & Communicable Diseases. - - - - - - 1 4.8 1 2.0
Nutrition Programs & Drugs Control. - - - - - - 1 4.8 1 2.0
Nutrition Programs, Communicable Diseases & Water Sanitation - - - - 1 6.3 - - 1 2.0
Clinical Services, Education for Disabled & Vocational Training - - - - 1 6.3 - - 1 2.0
Social Diseases, Nutrition Programs & Drugs Control - - - - - - 1 4.8 1 2.0
Drugs control, Mental Health & Vocational Training. - - 1 8.3 - - - - 1 2.0
Mental Health - - 1 8.3 1 6.3 1 4.8 3 6.0
Cancer - - 1 8.3 - - - - 1 2.0
First Aid - - 2 16.7 - - - - 2 4.0
Water & Sanitation, Drugs Control & Social Diseases. - - 1 8.3 - - - - 1 2.0
Nutrition Programs, Water & Sanitation & Vocational Training. - - 1 8.3 - - - - 1 2.0
Social Diseases & Nutrition programs - - - - - - 1 4.8 1 2.0
Nutrition Programs & Vocational Training - - - - 2 12.5 - - 2 2.0
Water & Sanitation & Self Employment - - - - - - 1 4.8 1 2.0
Water & Sanitation, Family Planning & Vocational Training - - - - 1 6.3 - - 1 2.0
Nutrition Programs, Self Employment & Water Sanitation. - - - - - - 1 4.8 1 2.0
Drugs Control & Family Planning - - - - 1 63 - - 1 2.0
Nutrition Programs & Education for Disabled. - - - - - - 1 4.8 1 2.0
Nutrition Programs, Water Sanitation & Human Rights. 1 4.8 1 2.0
Water & Sanitation & Drugs Control. 1 100 - - - - - 1 2.0
Water & Sanitation & Leadership Training. - - - - - - 1 4.8 1 2.0
Nutrition Programs, Elderly Care & Self Employment - - - - 1 6.3 - - 1 2.0
Nutrition Programs, Self Employment & Human Rights. - - - - 1 6.3 - - 1 2.0
Water & Sanitation, Leadership Training & Vocational Training. - - - - - - 1 4.8 1 2.0
Total. 1 100 12 100 16 100 21 100 50 100