Determinants for collaboration between WHO/HQ programmes and NGOs

Many WHO/HQ programmes perceive their task as primarily normative. In which case, their main priorities are standard setting, regulation, coordination and acting as a catalyst, via MoHs and, to some extent, international NGOs, to promote adherence to standards. The more practical aspects of collaboration and involvement of NGOs in drug distribution and supply at country level are then handled by the WHO country offices, since these are not perceived as a major responsibility of the WHO/HQ programme. The interviews with WHO programmes showed that such an approach was based on four assumptions, two of which related to WHO/HQ:

• that agreements and knowledge accumulated at the WHO/HQ level flow down to NGOs at international, regional and national levels;

• that WHO/HQ programmes request involvement of NGOs at country level as required;

• that WHO country offices involve NGOs in their work;

• that NGOs and MoHs are interested in collaboration and have the capacity to undertake collaboration.

Programmes were asked to indicate their degree of involvement with NGOs (Figure 2), and to identify all international NGOs with which they collaborate (Table 1).

Figure 2. View of importance of NGOs in the work of the programme

Figure 2 shows that some WHO programmes see NGOs as crucial to their work. The WHO Programme on the Prevention of Blindness and Deafness (PBD/PBL) in particular emphasized the importance of NGOs. But programmes such as Malaria Control (MAL), the Division of Child Health and Development (CHD), and the Global Programme for Vaccines and Immunization (GPV) did not emphasize the importance of NGOs in drug distribution and supply, and the Global Tuberculosis Programme (GTB) even indicated some doubt as to the usefulness of NGOs to their work.

Table 1 is the best available list (but incomplete), of the NGOs in contact with WHO programmes, as indicated by the programmes themselves. As can be seen, only eight NGOs are in contact with more than one programme in relation to drug distribution and supply. Creating Table 1 was more difficult than anticipated. The absence of an overview of the NGOs with which the programmes collaborate, and the tendency for programme collaboration with NGOs to be based on personal relations rather than structured programme policies, accounted for this difficulty. Interestingly, only approximately one-third (13 out of 38) of the NGOs with which the programmes collaborated were in official relations with WHO.

When asked for a list of the NGOs with which the programme collaborates, many programmes reacted somewhat doubtfully. Several programmes even saw disadvantages in having such a list, arguing that the existence of a list of NGOs in informal relations with WHO would limit their freedom to contact other NGOs involved in drug distribution and supply. It was also mentioned that NGOs not included on such a list might feel excluded. Such problems could be solved by establishing an explicit policy concerning collaboration with NGOs and an extensive network overview^a of the NGOs with which the programmes have collaborated during the last two years.

^a A network overview is a list of NGOs with whom the programme has collaborated, either officially or informally, over the past two to three years.

Interestingly, there seems to be a positive correlation between programme attitude towards NGOs and the degree of contact with NGOs in informal relations with the programme (as indicated in Figure 2). Conversely, contact with NGOs appears to be less and to involve fewer NGOs when the NGOs concerned are in official relations with the relevant WHO programme. DAP, the Division of Emerging and Other Communicable Diseases Surveillance and Control (EMC), the Division of Emergency and Humanitarian Action (EHA), the Action Programme for the Elimination of Leprosy (LEP) and PBD/PBL are the clearest examples of such a positive correlation (see Table 1). Table 2 shows that these programmes, with the exception of EMC, are also the programmes that have developed a policy on NGO collaboration.

Table 1. Contacts between WHO programmes and NGOs

* In official relations with WHO; 13 of the 38 collaborating NGOs listed here account for 20 of 52 instances of collaboration (each indicated by an x) with programmes.

() NGO collaboration with (number of) WHO programmes in drug distribution and supply.

PBD/PBL and LEP are examples of programmes with positive attitudes towards NGOs. They interact closely with NGOs on drug supply and distribution, and have regular and formal meetings with NGOs. NGOs themselves have a relatively strong influence on the programmes' work. In the case of the Onchocerciasis Unit within the PBL/PBD programme, close interaction is in part attributable to the high level of financing received by the programme from NGOs. In LEP's case, all formal and informal contacts with NGOs are guided and formalized through the International Federation of Anti-leprosy Associations, which explains the extensive interaction between LEP and NGOs.

An interesting but difficult question concerns whether a positive programme attitude towards NGOs develops after the experience of collaborating with NGOs, or whether collaboration leads to development of a positive programme attitude towards NGOs. This analysis was unable to provide a definitive answer to this question. A comment from an international NGO was helpful, however. The NGO stated that an appointed contact person within WHO and mutual confidence are crucial to good collaboration. In other words, people are more important than formal structures. The same experience was reflected in the country studies where mutual confidence was observed to be founded on actual contact. Establishing which variable is the dependent variable, and which the independent is difficult. But these comments indicate that if programmes interact with and are knowledgeable about NGOs, a positive attitude towards NGOs is created in the programmes.

Table 2. WHO programme policies on NGOs

Collaboration from a programme perspective

When analysing the collaboration between the different WHO programmes and NGOs, is it possible to find common denominators to describe those programmes that have a high degree of collaboration with NGOs? In addition to the correlation between actual interaction and attitude, four factors seem to be important:

• the programme's particular area of work or the medical treatment that the programme recommends;

• the way in which programme activities are financed;

• the presence of programme staff at country level;

• the positive personal attitude of programme staff towards NGOs and a tradition within the programme of working with NGOs.

The treatment regime promoted by a programme can account for some of the attitudes towards NGOs and the actual degree of collaboration with them. A programme such as GTB is generally doubtful regarding the involvement of NGOs in the distribution of drugs, partly because public health principles require ongoing treatment for a specified period for patients with tuberculosis (TB). Conversely, the treatment of onchocerciasis with ivermectin is much simpler and is carried out only once a year, making the involvement of NGOs much easier. The same holds true for leprosy.

The importance of financing can be seen by comparing the PBD/PBL and LEP programmes with GTB and MAL. PBD/PBL and LEP obtain much of their funding from NGOs and foundations, while GTB and MAL receive only limited resources from NGOs. The PBD/PBL programme involves NGOs extensively in policy formulation and implementation.

The impact of employing country workers is also important. Programmes such as PBD/PBL, CHD and DAP, all employ country workers and maintain a relatively positive attitude towards NGOs, seeing them as important contributors to their work. This is especially true for PBD/PBL, which has strong representation in Africa through its regional activities.¹⁷

Finally, personal and traditional attitudes seem to be important. Traditionally, the GTB programme, in common with other WHO programmes, argues mainly for collaboration through the state. Some GTB programme staff actually consider that NGOs weaken the state. Such a stand must inevitably lead to a negative attitude towards NGOs. (Factors that might have been expected to help create a more open and positive attitude within GTB towards NGOs include the relative importance of the International Union Against Tuberculosis and Lung Diseases in TB prevention and treatment, and the high involvement of NGOs in some countries.) Conversely, programmes such as DAP and LEP seize opportunities to work with NGOs and have a tradition of collaboration with NGOs.

Comparing programme ratings for the above four factors with the findings presented in Figure 2 is useful. PBL/PBD, DAP, EHA and LEP get positive ratings on all four factors, while GTB gets the poorest rating. Likewise, for MAL, CHD, EMC and GPV the ratings for the four factors are middling, as is reflected in the findings presented for those programmes in Figure 2.

Collaboration in formulating guidelines, financing, procurement, distribution, dispensing and provision

The above analysis illustrates how WHO programmes perceive their interaction with NGOs in drug distribution and supply, and indicates the importance particular programmes assign to NGOs in terms of programme activities. But what determines actual collaboration in drug distribution and supply? To investigate this issue, five specific factors related to drug distribution and supply were considered:

• treatment, and drug distribution and supply guidelines;
• financing;
• procurement;
• distribution;
• dispensing and provision.

Collaboration between NGOs and WHO programmes in formulating treatment regimes, and drug distribution and supply guidelines, has been quite extensive. For example, the regime for treatment of leprosy was agreed between WHO and NGOs. The Division of Mental Health and Prevention of Substance Abuse has worked with NGOs to develop guidelines for drug distribution and supply in emergency situations. DAP, together with Médecins Sans Frontières (MSF), and other NGOs has developed guidelines for drug donations, while PBD/PBL interacts closely with NGOs in most fields. EMC is also collaborating with NGOs, in areas such as norm setting and development of guidelines. In other cases, NGOs have developed guidelines that have been adopted by WHO. Such close interaction between NGOs and WHO in this area is of course to be expected, given that tasks such as norm setting, production of guidelines, and coordination are regarded by WHO as priority areas in drug distribution and supply.

Interaction between WHO programmes and NGOs also occurs in relation to financing and procurement, but less so than for formulation of treatment regimes and development of guidelines. Only a few programmes are financing projects in collaboration with NGOs, and even fewer programmes work with NGOs to procure drugs. However, interaction with NGOs is greater with respect to formulation of strategies and policies concerning financing and procurement. Once again, this accords with WHO's normative function.

Collaboration between WHO programmes and international NGOs on distribution, dispensing and provision of drugs is much greater than collaboration on either treatment, financing or procurement. This is in line with the findings that most programmes identify the comparative advantage of NGOs as consisting of good contacts at local level within countries. The problem for programmes, though, is that some NGOs create parallel structures that although efficient are not part of the normal drug distribution, dispensing and provision system. This can result in overlap and even cause confusion. In brief, most programmes, ranging from PBD/PBL to GTB, agree that NGOs work well within their own context, but not necessarily as part of the overall drug distribution and supply system. These views accord with the findings of several other researchers.^11,14

On the whole, perceptions of NGOs tend to be based on personal contact and specific experiences rather than analysis of how the whole NGO sector operates. Other studies of this field have drawn similar conclusions.^5,18

The importance of NGOs in distributing drugs can also be considered. Programmes such as CHD, GPV and LEP estimate that NGOs distribute less than 5% of global drugs in their area, while DAP, EMC and PBD/PBL estimate the percentage to be higher. This global picture aside, all programmes strongly emphasize that differences between countries are substantial, and that the contribution of NGOs to drug distribution is significant in some countries.