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

SECTION A NATIONAL POLICY FRAMEWORK FOR NGOs

Organized non-governmental activities addressing

peoples’ needs are increasingly pervading the arena of collective development action, whether delivering development services or mediating in voicing their needs. Institutionalizing their role as intermediate organizations linking government and people in a responsive manner is a challenge in the effective governance of development. It is in the efficient and effective performance of these twin

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

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.

Role of NGOsRole of NGOs

Government

NGOs asintermediary

People

Role of NGOsRole of NGOs

Government

NGOs asintermediary

People

3of good governance, poverty reduction, social harmony and political stability comprise the nexus of challenges and opportunities for NGOs in becoming an efficient agent for development services and an effective partner in development. 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;

NGOs Partner In Development

As Agent for good Governance

Poverty Reduction

Social Harmony

Political Stability

NGOs Partner In Development

As Agent for good Governance

Poverty Reduction

Social Harmony

Political Stability

4The 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

5carries 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 arrangements for performing the legal objectives of facilitating voluntary and non-governmental action are inadequate to bring about the engagement of NGOs as voluntary actors addressing matters of public interest and concern in a coordinated and accountable manner. In effect the application of the legal purposes is confined to a formal registration, a legal requirement to operate. Beyond enforcement of this legal requirement nothing more appears to happen. While on paper there exists a

Coordination of Administrative Overseeing: The NGO Secretariat works through a set of Liaison Officers appointed to coordinate NGO activities under the law in each of the Ministries. Every application for the registration of a NGO is referred to the relevant “Line” Ministry, and the Ministries of Defence, Foreign Affairs, and Plan Implementation for report on their suitability for registration of the respective NGO. The Line Ministry reports on the relevance of the activities of the NGO to its programme of work.

An “NGO Steering Committee” is constituted at the Ministry of Social Services to advice and assist in policy and programme oversight of NGOs. The Steering Committee is comprised of representatives of the Ministries of, Defence, Foreign Affairs, Plan Implementation, Public Administration. The Secretary to the Ministry of Social Services chairs the Committee. The Steering Committee has in its deliberations engaged in matters ranging from,

Considering Amendments to the existing Act; Reviewing and approving the Memorandum of

Understanding signed by the NGO with the Secretariat; Noting specific administrative actions taken or to be

taken by the constituent ministries, Noting a “Status Report” pertaining to the registration

of VSSO at the NGO Secretariat. At the District Level a District Coordinating Committee is

constituted, comprised of the District Secretary as Chairman, Heads of District Planning, Provincial Secretary in charge of Social Services, Social Services Officer for the district as members.

6formal 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.

7SECTION 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 NGOs to work in the area of health development are varied. A broad concern for health problems of people as contributing to poverty and as being an imperative for economic well being constitute the main reason

Felt health needs of the people 33(66%)

Nutrition needs of the people 7(14%)

Inadequacy of facilities provided by the Government

6(12%)

Health needs arising fromsocial problems of the

3(06%)

1(2%)Lack of safe drinking water

Felt health needs of the people 33(66%)

Nutrition needs of the people 7(14%)

Inadequacy of facilities provided by the Government

6(12%)

Health needs arising fromsocial problems of the

3(06%)

1(2%)Lack of safe drinking water

8for 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 development. Their objectives, however, are indicative of wide ranging concerns extending from directly health, through health and development, to mainly non health ones. Over one third of NGOs (38%) have given health 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 Sanitation and Food and Nutrition that constitute the main areas of involvement are programmes of two major community-based development projects. There is no significant pattern of involvement by type of NGO as stratified in the sample in 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

NGOs in the Health Sector

Health Development 19 (38%)

Assist Persons Affected by Conflict and Violence 5 (10%)

Health, Social and Economic Development 15 (30%)

Alleviate Social Problems 11 (22%)

48

46

32

12 10

Water and Sanitation Food and Nutrition First Aid and Nursing

Drugs AddictionFamily Planning

Areas of Activity of Health Related NGOs

48

46

32

12 1048

46

32

12 10

Water and Sanitation Food and Nutrition Water and Sanitation Food and Nutrition First Aid and Nursing

Drugs AddictionFamily Planning

First Aid and NursingDrugs AddictionFamily Planning

Areas of Activity of Health Related NGOs

9

The picture that emerges is a mix of activities but within it there was a large proportion (72%) focussing only on health while a lesser proportion (28%) had a mix of health and non-health activities. Here too there is no significant pattern of involvement by type of NGO 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 island-wide coverage. Nearly 95% were active in one or a few districts while Provincial coverage was minimal. The geographical area of operation does not appear to be significantly related to their activities. The only significant feature was the greater involvement of district level NGOs in health and development, as well as mainly non-health areas, viz., social and economic development and conflict affected persons. Their geographical coverage had not determined their center of administration. Nearly Half of them operated from their head office situated in one location, while about one third have between one and five branch offices. Only 16% have a network of branch offices.

Directly health related activitiesFamily Planning and STD 7Mental Health 3First Aid 2Communicable Diseases 1Family Planning and Drug Addiction 1 Social Diseases, Family Planning 1and Mental Health

Directly health related activitiesFamily Planning and STD 7Mental Health 3First Aid 2Communicable Diseases 1Family Planning and Drug Addiction 1 Social Diseases, Family Planning 1and Mental Health

2% All Island36%

32%

26%

24%

18%

12%

10%8%6%4%

Location of NGO Activity in each District :

Jaffna

Vavuniya

Anuradhapura

Mannar

Puttalam

Kurunegala

Gampaha

**T’malee

*P’nnaruwa

Ampara

Matale

Kandy

Badulla

M’ragala**N’Eliya

K’galle

Colombo

Kalutara

GalleHambantota

Rathnapura

Matara

% of NGOs

*Polonnaruwa

Batticaloa

***Nuwara-’Eliya**Trincomalee

2% All Island2% All Island36%

32%

26%

24%

18%

12%

10%8%6%4%

36%

32%

26%

24%

18%

12%

10%8%6%4%

Location of NGO Activity in each District :

Jaffna

Vavuniya

Anuradhapura

Mannar

Puttalam

Kurunegala

Gampaha

**T’malee

*P’nnaruwa

Ampara

Matale

Kandy

Badulla

M’ragala**N’Eliya

K’galle

Colombo

Kalutara

GalleHambantota

Rathnapura

Matara

% of NGOs

*Polonnaruwa

Batticaloa

***Nuwara-’Eliya**Trincomalee

10Activities 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: NGOs had multiple target groups, as beneficiaries of the mix of activities but they were activity specific..

The poor and the general public constitute the main target groups for most of the NGOs. About 40% of the Foreign Funded NGOs target the general public in their activities. Among Local Funded National NGOs only 22% targeted the general public but 26% more specifically targeted the poor as their main beneficiary. Among the Sub-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

Poor - 27Public - 24

Pregnant Mothers

- 11

Project Officers - 07

Youth - 16

Children & Mothers

- 11

Target Groups of NGO Activities

Poor - 27Public - 24

Pregnant Mothers

- 11

Project Officers - 07

Youth - 16

Children & Mothers

- 11

Poor - 27Public - 24

Pregnant Mothers

- 11

Project Officers - 07

Youth - 16

Children & Mothers

- 11

Target Groups of NGO Activities

Multiple objectives Community Development 14 (28%)Vocational Training 19 (38%)Family Rehabilitation 02 (04%)Human Rights 07 (14%

Non Heath ObjectivesCommunity Development 14 (28%)Vocational Training 19 (38%)Family Rehabilitation 02 (04%)Human Rights 07 (14%

Multiple objectives Community Development 14 (28%)Vocational Training 19 (38%)Family Rehabilitation 02 (04%)Human Rights 07 (14%

Non Heath ObjectivesCommunity Development 14 (28%)Vocational Training 19 (38%)Family Rehabilitation 02 (04%)Human Rights 07 (14%

11poor 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 varied from one NGO with no females to 22 with over 50% of the staff being female. In 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 NGOs both foreign funded (66%) and local funded (50%). Proportions of male staff were higher in sub-national and community based NGOs. However, the numbers employed by the latter NGOs were relatively small.

The work commitment in terms of time expended showed that by and large NGOs worked with a mix of full time and part time workers (96%). Two NGOs had no full-time staff. All types of NGOs had more full time than part-time workers.

They also operated with a mix of paid and voluntary workers. Nearly half (48%) had more paid than voluntary workers, with sixteen (32%) employing more than 75% of their staff on a paid basis. Nearly half the NGOs, therefore, relied more on voluntary than paid workers. Voluntary work was used totally in a majority of the Local Funded National Level NGOs (62.5%). This was seen in one third of Sub-national Community-based NGOs and 40% of Foreign Funded National Level

NGOs.

Less than 5 Persons 16 (32%)6 to 20 16 (32%)21 to 100 14 (28%)More than 100 04 (04%)

Less than 5 Persons 16 (32%)6 to 20 16 (32%)21 to 100 14 (28%)More than 100 04 (04%)

76% & Over – 10 (20%)

Females Males

51%-75% Females – 12 (24%)

26%-50% Females – 24 (48%)

<25% Females – 3 (6%)

No Females – 1 (2%)

76% & Over – 10 (20%)76% & Over – 10 (20%)

Females Males

51%-75% Females – 12 (24%)

26%-50% Females – 24 (48%)

<25% Females – 3 (6%)<25% Females – 3 (6%)

No Females – 1 (2%)No Females – 1 (2%)

Full-time workers

23 (46%) > 75%

03 (6%) < 25%08 (16%) 26%-50% 10 (20%) 51%-75%

Paid workers

13 (26%) < 25%09 (18%) 26%-50%.

Full-time workers

23 (46%) > 75%

05 (10%) < 25%10 (20%) 26%-50% 10 (20%) 51%-75%

Paid workers

13 (26%) < 25%09 (18%) 26%-50%.

2 (4%) 0

16 (32%)

12 (24%) 51- 74%

> 75%

Full-time workers

23 (46%) > 75%

03 (6%) < 25%08 (16%) 26%-50% 10 (20%) 51%-75%

Paid workers

13 (26%) < 25%09 (18%) 26%-50%.

Full-time workers

23 (46%) > 75%

05 (10%) < 25%10 (20%) 26%-50% 10 (20%) 51%-75%

Paid workers

13 (26%) < 25%09 (18%) 26%-50%.

2 (4%) 0

16 (32%)

12 (24%) 51- 74%

> 75%

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. (

The large majority (92%) of NGOs had at least one female holding management positions. A small number did not employ females at management level. The

gender mix is shown in Box. The educational attainments of persons in 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 secondary/graduate (30%) levels. Professional qualifications and experience of management level staff is varied and included such unrelated areas as health, accounts and law.

Nevertheless there were 04 NGOs (08%) that 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.

Education attainment

21 (42%) Primary/secondary

16 (32%) secondary/degree

13 (26%) graduate/post-graduate

Education attainment

21 (42%) Primary/secondary

16 (32%) secondary/degree

13 (26%) graduate/post-graduate

Females in management.33 (66%) < five 05 (10%) > ten.

04 (08%) None.

Females in management.33 (66%) < five 05 (10%) > ten.

04 (08%) None.08 (16%) 5 - 10

Accounts, Computer Engineering

- 15 (30%) -Health AndPhysiology

-16 (32%) -

Public Administration - 13 (26%) -

Law - 02 (4%) -

Accounts, Computer Engineering

- 15 (30%) -Health AndPhysiology

-16 (32%) -

Public Administration - 13 (26%) -

Public Administration - 13 (26%) -

Law - 02 (4%) -

13 The highest proportion of trained staff was found in the International NGO (over 75%). Over half (58%) of the Foreign Funded National NGOs (58%) had more than half of trained staff. The situation was varied in respect of National Local Funded NGOs and Sub National Community Based NGOs.

The major areas of staff training were the following.The predominant area of training at all levels of staff was the first aid and nursing cluster. Indeed in respect 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%).

Human Resource Management

First Aid, Nursing,

Family Planning,

Social Diseases

47 % 30 %

Nutrition

12 %

Water Sanitation

11%

Human Resource Management

First Aid, Nursing,

Family Planning,

Social Diseases

47 % 30 %

Nutrition

12 %

Nutrition

12 %

Water Sanitation

11%

Water Sanitation

11%

Numbers Trained

29 (58%) > 50 %17 (34%) > 75 %.

08 (16%) < 25 %

National Level:

Sub-national and Community-based:

Numbers Trained

29 (58%) > 50-75 %17 (34%) > 75 %.

02 (4%) < 25 %

National Level: 07 < 25%

-CBOs

< 75 %

02 (4%) 26 -50%

International Level:

07 25-50%04 51-75%10 > 75%

01 < 25%06 25-50%08 51-75%06 > 75%

Numbers Trained

29 (58%) > 50 %17 (34%) > 75 %.

08 (16%) < 25 %

National Level:

Sub-national and Community-based:

Numbers Trained

29 (58%) > 50-75 %17 (34%) > 75 %.

02 (4%) < 25 %

National Level: 07 < 25%

-CBOs

< 75 %

02 (4%) 26 -50%

International Level:

07 25-50%04 51-75%10 > 75%

01 < 25%06 25-50%08 51-75%06 > 75%

14The 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 shows that all types engaged consultants in health activities while in the health and development cluster one out of fifteen NGOs opted not to use external consultants. Out of the twelve NGOs in the health and non-health cluster using external consultants, three NGOs opted not to engage external consultants. Eleven out of the twelve Foreign Funded NGOs; fifteen out of sixteen 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 constituted the main source of funding for the activities undertaken by Foreign Funded National Level NGOs (58%). In respect of Local Funded National Level NGOs and Sub national and Community-based NGOs sources of funding were more varied, with 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

Three NGOs (06%) did not engage any external consultants

Health Education and Awareness Raising

6 (12%)

Drug AddictionVocational Training

9 (18%)

22 (44%)

2 (4%)

Food and Nutrition

Water and Sanitation

2 (4%)

Use of External Consultants

Three NGOs (06%) did not engage any external consultants

Health Education and Awareness Raising

6 (12%)

Drug AddictionVocational Training

9 (18%)

22 (44%)

2 (4%)

Food and Nutrition

Water and Sanitation

2 (4%)

Use of External Consultants

20

10

30

40

The main sources of finances for the NGOs

Gove

rnm

ent

22

12

10

0501

Inter

natio

nal

Agen

cies

Inter

natio

nal

NGOs

Self-

gene

rated

Nation

alIn

stitu

tions

20

10

30

40

The main sources of finances for the NGOs

Gove

rnm

ent

22

12

10

0501

Inter

natio

nal

Agen

cies

Inter

natio

nal

NGOs

Self-

gene

rated

Nation

alIn

stitu

tions

15hand 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 ;

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%)

No proper control of financesNo proper control of finances

No annual accounts published No annual accounts published

Inadequate finances Inadequate finances

16The 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: Nearly half the NGOs (48%) were satisfied with the conduct of their projects.But close on one third (30%) were not satisfied, while another quarter (22%) were not satisfied with the 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%

NGO needs

More trained staff 15 (30%)Recruitment of qualified staff 14 (28%)Provision of financial assistance 10 (20%)Closer link with government institutions 03 (06%)Regular training on project activities 02 (04%)Recruiting staff from project locations 01 (02%)

NGO needs

More trained staff 15 (30%)Recruitment of qualified staff 14 (28%)Provision of financial assistance 10 (20%)Closer link with government institutions 03 (06%)Regular training on project activities 02 (04%)Recruiting staff from project locations 01 (02%)

17The 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

18can 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%

19of 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 Community–based 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

operations. They are given in the Box below. The Poor constitute the key target group for all categories except the more than 10,000 category. The main target group of those NGOs that were not able to estimate the numbers targeted were Youth, Disabled and General Public. In the Less than 100 category, Poor and Youth constitute the main groups targeted. Mother, General Public and Project Officers 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

Numbers of Beneficiaries Targeted

Cannot Tell

14.2%

< 100

28.3%

101 - 1000 1001 –10,000

25.5%

Over 10,001

3.8%

28.3%Numbers of Beneficiaries Targeted

Cannot Tell

14.2%

< 100

28.3%

101 - 1000 1001 –10,000

25.5%

Over 10,001

3.8%

28.3%

21Poor 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.

Finance was important for Nine Sub-national and Community-based NGOs (43%), Nine Local Funded National Level NGOs (56%), and Three Foreign Funded National Level NGOs (25%).

These general problems were expressed in more specific terms as shown in the box below. They help to identify specific areas which require attention.

The positive feature about NGO self assessment was that they were able to follow it up with suggestions of their own as remedies for the

problems they identified. The suggestion for government sponsorship and financial

Communication (language)

Problems and Issues in the Conduct of NGO Affairs

Finance

Recognition

Mistrust by people

Technical equipment Political influence

42%

22%

20%

8%

6%

2%Communication (language)

Problems and Issues in the Conduct of NGO Affairs

Finance

Recognition

Mistrust by people

Technical equipment Political influence

42%

22%

20%

8%

6%

2%

Problems and Issues in the Conduct of NGO Affairs

Finance

Recognition

Mistrust by people

Technical equipment Political influence

42%

22%

20%

8%

6%

2%

Public misconception about NGO financial matters 13 (26%)Lack of Government sponsorship and political Interference 11 (22%)Lack of Government sponsorship and financial Support 06 (12%)Lack of acceptance by the public 03 (06%)Inability to have a permanent staff 02 (04%)Being subject to political influence in implementing projects 01 (02%)Financial problems 01 (02%)Decisions and supply of material not getting done in a timely manner 01 (02%)Wrong actions leading to virtual collapse 01 (02%)Competitiveness amongst NGOs 01 (02%)Fraudulant expectations of government officials 01 (02%)Uncertainty due to security situation 01 (02%)

Public misconception about NGO financial matters 13 (26%)Lack of Government sponsorship and political Interference 11 (22%)Lack of Government sponsorship and financial Support 06 (12%)Lack of acceptance by the public 03 (06%)Inability to have a permanent staff 02 (04%)Being subject to political influence in implementing projects 01 (02%)Financial problems 01 (02%)Decisions and supply of material not getting done in a timely manner 01 (02%)Wrong actions leading to virtual collapse 01 (02%)Competitiveness amongst NGOs 01 (02%)Fraudulant expectations of government officials 01 (02%)Uncertainty due to security situation 01 (02%)

22support 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.

In a further step they identified the facilities needed to enable them to work more efficiently. The NGOs considered the following;

Partnering for Health Care : Organizational Linkages of NGOs

The inter-sectoral nature of health care particularly in the key areas of current NGO activity requires coordinated effort rather than individual operations. One of the key indicators that would reflect 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 NGOs (10%) did not belong to any association. The kinds of associations with which NGOs networked are in the Box. The “associations” they refer to seem to suggest that the NGOs surveyed have been establishing linear institutional linkages than laterally networking with associations of NGOs. This is significantly different from networking in common programmes and issues.

Five NGOs (10%) reported that they

Government sponsorship 12 (24%)Arrangements for financial support 12 (24%)Actions to gain trust and credibility 08 (16%)Provide wider exposure to staff 03 (06%)Create consensus amongst NGOs 03 (06%)Create public awareness 01 (02%)Eliminate political interference 01 (02%)Government sponsorship, publicity and removal of political interference 01 (02%)Alternate organization to Ministry of Health fordecision making 01 (02%)Remove public misconceptions 01 (02%)]

Government sponsorship 12 (24%)Arrangements for financial support 12 (24%)Actions to gain trust and credibility 08 (16%)Provide wider exposure to staff 03 (06%)Create consensus amongst NGOs 03 (06%)Create public awareness 01 (02%)Eliminate political interference 01 (02%)Government sponsorship, publicity and removal of political interference 01 (02%)Alternate organization to Ministry of Health fordecision making 01 (02%)Remove public misconceptions 01 (02%)]

The NGOs considered more important facilities needed.

Trained staff

34.5%

Equipment

29.3%

Financial Assistance

28.4%

NGO Awareness

Programmes

4.3%

Information

3.4%

The NGOs considered more important facilities needed.

Trained staff

34.5%

Equipment

29.3%

Financial Assistance

28.4%

NGO Awareness

Programmes

4.3%

Information

3.4%

NGO Ne t wo rkin g

Nat io n a l Le ve l

In s t it u t io n s

3 6 %

In t e rn a t io n a l

Org a n iza t io n s

2 6 %

S u b -n a t io n a l Le ve l

Org a n iza t io n s

2 2 %

Go ve rn m e n t In s t it u t io n s

0 6 %

NGO Ne t wo rkin g

Nat io n a l Le ve l

In s t it u t io n s

3 6 %

In t e rn a t io n a l

Org a n iza t io n s

2 6 %

S u b -n a t io n a l Le ve l

Org a n iza t io n s

2 2 %

Go ve rn m e n t In s t it u t io n s

0 6 %

23do not belong to any associations. The reasons for their not belonging to any associations

were the following. It appears therefore that NGOs would generally be averse to sinking their 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

Cannot work independently 02 (04%)Not necessary 02 (04%)Lead to conflicts of opinion 01 (02%)

Cannot work independently 02 (04%)Not necessary 02 (04%)Lead to conflicts of opinion 01 (02%)

24common 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 types of NGOs, seven Foreign Funded National Level NGOs (58%), twelve Local Funded National NGOs (75%), and eighteen Sub-national Community-based NGOs (86%). POTENTIAL FOR PARTNERING HEALTH DEVELOPMENT: OPPORTUNITIES AND RISKS

This main section in reviewing the current status

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

NGOs as to their inclination to collaborate and network With Government Institutions

With International Institutions National NGOs

World Health Organization

48(96%)

50 (100%)

48(96%)

50 (100%)

Prevention of Diseases 76%Nutrition Action ProgrammesResource Management and DevelopmentVocational Training

12%

08%

04%

NGOs as to their inclination to collaborate and network With Government Institutions

With International Institutions National NGOs

World Health Organization

48(96%)

50 (100%)

48(96%)

50 (100%)

Prevention of Diseases 76%Nutrition Action ProgrammesResource Management and DevelopmentVocational Training

12%

08%

04%

25commonality 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

26constitute 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

27Health 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.

28The 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.

29Scope 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

31concerned 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 All Island Provincial District

Level

Total

Main Objective

No % No % No % No %

To Develop Health Conditions 7 46.7 - - 8 53.3 15 100.0

To Develop Health Social & Economic Conditions

6 40.0 - - 9 60.0 15 100.0

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

NGOs National

Level Foreign Funded

Local Funded

Sub-National & Community

Based

Total

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

NGOs National

Level Foreign Funded (%)

Local Funded

(%)

Sub-National & Community Based (%)

Total

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 Public

Children and

mothers

Youth Armed Forces

Disabled Project officers

Total

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 Tell

<100 101-1,000

1,001-10,000

10,000+ Total

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 Activity

Cannot Tell

<100 101-1,000

1,001-10,000

10,000+

Total

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

International NGOs

National Level Foreign Funded

Local Funded Sub-National & Community Based

Total

Main Activities

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