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Global Public Health
An International Journal for Research, Policy and Practice
ISSN: 1744-1692 (Print) 1744-1706 (Online) Journal homepage: http://www.tandfonline.com/loi/rgph20
Linkages between public and non-government
sectors in healthcare: a case study from Uttar
Pradesh, India
Aradhana Srivastava, Sanghita Bhattacharyya, Meenakshi Gautham, Joanna
Schellenberg & Bilal I. Avan
To cite this article: Aradhana Srivastava, Sanghita Bhattacharyya, Meenakshi Gautham, Joanna
Schellenberg & Bilal I. Avan (2016): Linkages between public and non-government sectors in
healthcare: a case study from Uttar Pradesh, India, Global Public Health
To link to this article: http://dx.doi.org/10.1080/17441692.2016.1144777
Published online: 07 Mar 2016.
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Linkages between public and non-government sectors in
healthcare: a case study from Uttar Pradesh, India
Aradhana Srivastava
a
, Sanghita Bhattacharyya
a
, Meenakshi Gautham
b
,
Joanna Schellenberg
b
and Bilal I. Avan
b
a
Department of Research, Public Health Foundation of India, Gurgaon, India;
b
Faculty of Infectious and
Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK
ABSTRACT
Effective utilisation of collaborative non-governmental organisation
(NGO)-public health system linkages in pluralistic health systems of
developing countries can substantially improve equity and quality
of services. This study explores level and types of linkages
between public health sector and NGOs in Uttar Pradesh (UP), an
underprivileged state of India, using a social science model for the
first time. It also identifies gaps and challenges for effective
linkage. Two NGOs were selected as case studies. Data collection
included semi-structured in-depth interviews with senior staff and
review of records and reporting formats. Formal linkages of NGOs
with the public health system related to registration, participation
in district level meetings, workforce linkages and sharing
information on government-supported programmes. Challenges
included limited data sharing, participation in planning and
limited monitoring of regulatory compliances. Linkage between
public health system and NGOs in UP was moderate, marked by
frequent interaction and some reciprocity in information and
resource flows, but weak participation in policy and planning. The
type of linkage could be described as ‘complementarity’, entailing
information and resource sharing but not joint action. Stronger
linkage is required for sustained and systematic collaboration,
with joint planning, implementation and evaluation.
ARTICLE HISTORY
Received 23 May 2014
Accepted 10 July 2015
KEYWORDS
Non-governmental
organisations; public health
system; linkages;
engagement; India
Introduction
Implementation of maternal and child health (MCH) programmes in low resource settings
of developing countries typically involves multiple interventions by both government as
well as non-governmental organisations (NGOs) and intergovernmental organisations
(IGOs). While NGOs are nationally registered bodies, IGOs are multilateral organisations
established by treaties and working with national governments on areas of common inter-
est (Harvard Law School, 2012). In this study, we have used non-governmental organis-
ation (NGO) as a broad term for any non-governmental non-profit organisation,
including local, national and international NGOs as well as IGOs with service delivery
models. Within the pluralistic health systems in many developing countries, NGOs
have emerged as important providers of social services and key partners in development,
© 2016 Taylor & Francis
CONTACT Bilal I. Avan bilal.avan@lshtm.ac.uk
GLOBAL PUBLIC HEALTH, 2016
http://dx.doi.org/10.1080/17441692.2016.1144777
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complementing and supplementing the public sector by their flexibility, innovation and
access to the most vulnerable and marginalised communities in need of social services
(Agg, 2006; Haque, 2002). However, the effect of NGOs on MCH outcomes is generally
localised, while government efforts are large scale but may have limited impact
(Edwards & Hulme, 1995). In order to improve outcomes at scale, it is important that
NGOs develop and maintain appropriate linkages with the wider public health system
and align their activities with the overall national and regional goals (Edwards &
Hulme, 1995).
India is among the countries according very high priority to improving MCH outcomes
through programmes for improving availability and access to MCH care. India has a
policy encouraging NGOs towards such efforts, linking with the voluntary sector to
improve efficiency and reach of services (Government of India, Ministry of Health and
Family Welfare, 2012). The policy on NGOs, formulated in 2007, acknowledges them
as partners in development and specifies rules of engaging them and also making them
accountable without affecting their autonomy. The policy also encourages state govern-
ments to evolve multi-stakeholder models of development, involving NGOs particularly
at the grassroots level (Planning Commission, Government of India, 2012).
Health expenditure by NGOs in 2004–2005 was about 3.8% of total health expenditure
in India (Government of India, Ministry of Health and Family Welfare, 2009). External
flows to health sector NGOs constituted 21% of total health expenditure, about a fifth
of these funds flowing into MCH and family welfare (Government of India, Ministry of
Health and Family Welfare, 2009).
NGOs are greatly dependent on linkages with local administration, provincial govern-
ment, other NGOs and also private providers for their effective day-to-day functioning.
Strong linkages also enhance their participation in planning, decision-making and evalu-
ation of programmes. Informing policy on strengthening such linkages requires an under-
standing of the nature of existing NGO–public health system linkages and avenues of
interaction that can potentially serve to expand these linkages.
The relationship of NGOs with government has been analysed and classified in social
science research (Coston, 1998). In this paper, the analysis of linkages is based on adap-
tation of a typology for analysing Government–NGO linkages, defining five levels of
linkage: (1) Autonomy –no interaction or government control over local organisation
resources; (2) Low linkage with little interaction; (3) Moderate linkage with some but
regular interaction; (4) High linkage with much interaction and some reciprocity (some
control by local organisations over their resource flows); (5) Direction –heavy interaction
controlled by government (Coston, 1998). These levels of linkage correspond to eight
types of linkage –(i) repression, (ii) rivalry, (iii) competition, (iv) contracting, (v) third-
party government, (vi) cooperation; (vii) complementarity and (viii) collaboration
(Coston, 1998). This model was selected for our study as it classifies linkages into well-
defined categories and provides clear operational definitions of the concepts.
For the purpose of our study, this typology has been suitably adapted to make it more
representative of the health sector, more specifically linkages between the NGO and public
health system (Table 1). While Coston’s model was designed to reflect the extent of Gov-
ernment control over NGOs, our adaptation modifies the typology to explain the level of
linkages rather than the extent of control. The linkages have been classified into four levels
(no linkage, low, moderate and high) and six types (repression, rivalry, competition,
2A. SRIVASTAVA ET AL.
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cooperation, complementarity and collaboration). Here we explore the following research
questions: (1) what are the level and types of linkages between the public sector and
NGOs? (2) What are the gaps and challenges that exist for effective linkage between the
two sectors?
Methods
This study was carried out between July -and September 2012 in Uttar Pradesh (UP), the most
populous state of India with 199.5 million population as per the latest Census in 2011. UP is
also one of the most underprivileged states, with maternal mortality ratio (MMR) of 359 per
100,000 and infant mortality rate (IMR) of 61 per 1000 live births (Office of the Registrar
General and Census Commissioner, India, 2011a,2011b). The study was part of a larger
grant for evaluation of interventions supported by the funders in the state of UP.
We used a descriptive, cross-sectional design with mixed qualitative methods to trian-
gulate findings, including key informant interviews, participant observations and docu-
ment reviews of organisational records pertaining to process documentation,
monitoring and reporting.
Official permission and consultation
We met with senior state government officials of the state National Health Mission (NHM)
to explain the study significance and objectives and obtain their permission to conduct the
study. We also welcomed their suggestions on the study area and organisations that could be
analysed. The study plan was finalised on the basis of their inputs and approval.
District selection
We selected two districts –Sitapur and Unnao –in close consultation with the state Gov-
ernment officials, from a list of districts typically representative of the state and health
Table 1. Levels and types of government–NGO linkages.
Levels Types
1–No linkage Repression: Unfavourable policy (NGOs not permitted to work); No NGOs function
Rivalry: Few mandated supportive services by NGOs; unfavourable policy; linkages dominated by
regulatory checks
Competition: Unfavourable policy; NGOs seen as unwanted critics or competitors in service delivery &
also for foreign funds or local power; though competition may increase client responsiveness by
both parties, it may also lead to repression of NGOs
2–Low linkage Cooperation: Limited flow of information between the two sectors; Government policy is neutral
towards NGOs; possible resource sharing & joint action (NGOs as consultants, contractors, co-
financers and implementers)
3–Moderate
linkage
Complementarity: Less than optimal sharing of information & resources; Government policy
inconclusive; potential NGO participation in policy & planning; technical, financial and
geographical balance; relatively specialised role of NGOs as opposed to supplementary or
competitive; provision of qualitatively different services by both NGOs & Government
4–High linkage Collaboration: Optimal sharing of information & resources; joint action or coproduction resulting in
service networks consisting of multiple organisations; favourable Government policy; NGO
participation in policy, planning & implementation; mutual benefit strategy; NGO autonomy
(symmetrical power relationship)
Source: Adapted from model presented by Coston (1998).
GLOBAL PUBLIC HEALTH 3
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system. The criteria were as follows: (i) variability in governance, health and development
indicators; (ii) geographically non-contiguous, to minimise cross-influence, and (iii) con-
venience of access for ease of field research (Table 2).
Scoping visit
We conducted an initial scoping visit to UP, using a team of four researchers, to identify
potential NGO participants and key informants based on their role at state and district
(field) levels. The structure of the health system, linkages between Central, state and
local levels and the various schemes in operation were also identified.
Selection of NGO case studies
The two NGO case studies were selected on the following considerations –(a) they must
be active in field implementation of MCH programmes in both the selected districts;
(b) they must be of contrasting scale, one preferably an international and the other an
Indian NGO. A complete listing of NGOs working on MCH projects in the selected districts
was carried out. Based on our criteria two organisations –one multilateral (UNICEF) and
one national (Vatsalya) –were purposively selected as case studies for detailed analysis. In
the case of UNICEF, we focused on implementation of the Social Mobilisation Network or
SM-Net, a programme on intensifying polio and routine immunisation in designated ‘high-
risk areas’in districts, with rigorous coverage, follow-up and demand generation activities.
UNICEF’s role in this programme was like a service delivery organisation, training and
deploying a network of mobilisers at the district and sub-district levels, and following up
with close supervision and monitoring (Coates, Waisbord, Awale, Solomon, & Dey,
2013). For this reason, we included UNICEF as a case study, even though an IGO, and
just to maintain consistency we will henceforth refer to it as ‘NGO’.
In-depth interviews
We conducted four semi-structured in-depth interviews in the two NGOs with a senior
functionary at the state level and programme functionary at the district level, after
Table 2. Key health and development indicators –Sitapur and Unnao, UP.
Indicators Unnao Sitapur
Total population 3,110,595 4,474,446
Female literacy rate 63.0 53.4
Sex ratio at birth 937 994
Sex ratio (all ages) 888 881
Crude birth rate 21.2 28.0
Total fertility rate 3.3 4.4
Institutional deliveries (%) 52.8 42.4
No. of public health facilities 538 622
Percentage villages with public health centres 31 30
Infant mortality rate 58 80
Neonatal mortality rate 36 54
Under five mortality rate 83 116
Maternal mortality rate
a
346 346
Sources: Annual Health Survey, Uttar Pradesh Factsheet, 2011–2012, Office of the Registrar General & Census Commis-
sioner, India, Ministry of Home Affairs; http://www.nlrindia.org.
a
District level MMR figure is not available, therefore sub-regional estimate has been used.
4A. SRIVASTAVA ET AL.
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obtaining verbal consent. The interviews were conducted using topic guides to understand
the organisation’s structure and functions, activities, monitoring and supervision systems,
data available and linkages with the public health system.
Participant observation
Participant observation of field programme implementation was conducted at field sites of
both organisations. Detailed notes were taken on the observations pertaining to all activi-
ties and interactions between staff and public health system.
Record review
The team collected and reviewed records and reporting formats from the two NGOs, such
as annual reports, donor reports, field data collection formats and process documentation
to understand the nature, quality and utilisation of data collected by the NGOs.
Data analysis
Data were analysed manually using a framework approach, utilising both a priori and
emerging themes. Initially, a list of a priori themes was prepared based on the areas of
enquiry of the interview topic guides. The interview notes were accordingly tabulated
and any emerging themes were also added. In the synthesis, data from participant obser-
vations and document reviews was combined with the interview data in order to triangu-
late the findings. The combined data was finally categorised on the basis of Coston’s model
to identify the level and type of Government–NGO linkage observed in the case studies.
Ethics
Ethical approval for the study was obtained in the UK from the London School of Hygiene
and Tropical Medicine Observational/Interventions Ethics Committee and in India from
the independent review board of Society for the Promotion of Ethical Clinical Trials-ERB
and the Health Ministry Screening Committee.
Results
NGO efforts in MCH in UP
On account of its poverty and large population base, UP is a priority state for large inter-
national funding complementing state efforts on MCH. WHO and UNICEF have
implemented a number of MCH and reproductive health strategies and programmes in
the state since 1948, when they started functioning in India (World Health Organization
India, 2015). The US Agency for International Development (USAID) supported ‘The
Innovations in Family Planning Services’project in 1992 introduced innovative
approaches in family planning (Futures Group International, 2012). The World Bank-
assisted UP Health Systems Development Project (UPHSDP) from 2000 to 2005,
focused on improvements in physical infrastructure and human resources of public
GLOBAL PUBLIC HEALTH 5
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health facilities. The Bill and Melinda Gates Foundation (BMGF) (2015) is also investing
significantly in the state since the last decade, on programmes to expand demand for MCH
services, improve coverage and quality and assist implementation of the state’s reproduc-
tive, maternal, child and adolescent health strategy (BMGF, 2015).
Profile of NGOs selected as case studies
UNICEF is the largest United Nations organisation in India with offices in 13 states,
working towards strengthening public health delivery to achieve system-set targets
around maternal, newborn and child health goals (UNICEF, http://www.unicef.org/
india/overview_4299.htm). Within UP, UNICEF aims to support and strengthen the
state’s healthcare network. UNICEF’s newborn and child health activities include
support to the state’s immunisation coverage, diarrhoea management programme and
newborn intensive care units (The IDEAS Project, 2012). In maternal health, UNICEF
focuses on preventing maternal anaemia, early marriage and pregnancies among girls
and expansion of institutional delivery by strengthening the capacity of first referral
units in handling obstetric emergencies in five districts and supporting the incentive pro-
gramme for institutional deliveries called Janani Suraksha Yojana (Dhankani, 2010).
Vatsalya was established in Lucknow in 1995, primarily to work against female foeticide,
which remains its primary mission. Gradually its portfolio expanded to cover other health
services, particularly health and nutrition of adolescent girls. Currently, Vatsalya’s projects
focus on prevention offemale foeticide, child nutrition, community-based newborn care and
maternal and adolescent health. Specific to MCH, Vatsalya is implementing projects on
maternal and child nutrition, newborn care, job aids to help community health workers
in antenatal and postnatal counselling, and community education on MCH services includ-
ing pregnancy registration, antenatal care, immunisation and family planning. These pro-
jects are funded by multiple donors like Micronutrient Initiative, Catholic Relief Services
and Plan (http://vatsalya.org.in/). Its approach is a combination of advocacy, capacity build-
ing (of health workers and community-based NGOs), service delivery and research.
Their innovative district level model on addressing anaemia among adolescent girls, called
the Saloni programme, was later adopted and scaled up to the entire state by the State NHM.
Saloni targets 10–19-year-old girls with health education, nutritional counselling, deworm-
ing and iron supplementation (The IDEAS Project, 2012;http://vatsalya.org.in). Vatsalya
operates at a relatively small scale, in six districts of UP. It’s 2013–2014 budget was
around INR 7.3 million ($116,000) (Vatsalya, 2014). Vatsalya’s scope is limited to improving
behavioural practices in health and gender, especially curbing female foeticide and demon-
strating workable models addressing health imbalances in populations. Aligning with the
state’s priority, both organisations are mandated to work in the rural, particularly remote
blocks of the districts, and among poor and disadvantaged social groups.
Findings on levels and types of linkages between the public health and NGO
sector
Elements of NGO–public health system linkages
Regulation. NGOs in India can be of three types: (i) societies registered with the respective
State Office of Registrar of Societies as non-profit entities, governed by the Societies
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Registration Act of 1860 (a national Act with state-specific amendments); (ii) public chari-
table trusts, usually constituted around property, like land and buildings, governed by the
Indian Trusts Act 1882, and (iii) private non-profit company, governed by the Indian
Companies Act, 1956. Non-profit companies can be constituted to promote arts,
science, commerce and other such interests. However, any profits or other income
earned are to be used to promote objectives of the company and not paid as dividend
to its members. For registered societies, annual sharing of financial and managerial
reports is mandatory for renewal of registration (NGOs India, 2015). Vatsalya is a
society registered in UP and has to apply for renewal at the Registrar Office every five
years, when financial and operational reports are scrutinised. UNICEF, being a multilat-
eral entity and part of the United Nations, does not have to follow these regulations.
Joint planning and review. Both formal and non-formal forums are used for information
sharing and participation in planning and review, between NGOs and public health
system. Under a formal institutional mechanism, UNICEF’s annual plans are reviewed
and vetted by the national government. Similarly at the state level too annual work
plans are jointly prepared, approved and reviewed every quarter. This ensures aligning
of UNICEF activities with government priorities and implementation in close consultation
with the government. The UNICEF also on its part helps state governments develop state
plans of action in relevant areas.
At the state level, the ‘Health Partner’s Forum’(HPF), convened by the State Govern-
ment, brings all NGO partners working on public health to meet every quarter and share
good practices, get feedback and participate in developing district-specific action plans.
Both UNICEF and Vatsalya participate in HPF meetings to share their experiences and
learn from other partners (Table 3). Though initially envisaged by a senior bureaucrat,
the Forum lost priority amidst unearthing of financial irregularities in utilisation of
NHM funds in the state in 2010 and the investigation that followed (Sharda, 2012).
With a change of government in the state in 2013, the new Government took interest par-
ticularly to identify models that can be scaled up through the new NHM funds that arrived
Table 3. Formal contact opportunities between selected NGOs and the public health system.
Levels of
interaction
Formal contact opportunities
UNICEF VATSALYA
State level .Health Partner’s Forum
.Technical support for coordination, planning,
and policy-making
.Feedback to Government on routine
immunisation
.Health Partner’s Forum
.Regular meetings with senior State
Government officials
.Membership in state committees on health,
nutrition and child rights
District level .District Health Society/other district health
planning meetings
.District Health Society meeting
Sub-district
(block) level
.Monthly coordination meetings
.Task force meetings of MCH programmes
.Monitoring meetings between district and
block/community level field staff
.Field monitoring visits
.Support in planning ASHA meetings
.Advisory committee meeting for review
and planning
.Task force meetings of MCH programmes
.Support in planning ASHA meetings
GLOBAL PUBLIC HEALTH 7
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soon after. The Government is now actively using the HPF in monitoring NGO activities,
reviewing progress and identifying strategies that can be scaled up.
At the district level, the District Health Society has been constituted under the NHM for
joint planning, review and inter-sector coordination in implementation. Members include
district administration, senior health functionaries, NGOs, private for-profit providers and
other Government departments like women and child development, education and public
works. Both UNICEF and Vatsalya participate in District Health Society meetings as dis-
trict level NGO partners. The district administration requests their inputs on district
health issues as required. UNICEF supports the district NHM staff closely for preparing
the annual programme implementation plans under NHM.
Other forums for information sharing. Occasional one-to-one interactions are sought by
both NGOs at state and district levels to inform senior public health officials of progress
and seek resolution of any issues that may arise. Dissemination or advocacy events with
Government participation serve a similar purpose. These interactions are largely initiated
by the NGOs. The UNICEF Health Director meets with the State NHM Mission Director
occasionally to apprise him of any issues in UNICEF programmes that may require his
intervention. Similarly, the Vatsalya chief functionary meets senior health officials infor-
mally to maintain their acquaintance.
Workforce linkages. Both NGOs maintain workforce linkages with the public health
system, through capacity building, technical assistance, mentoring or field coordination.
Nodal staff from UNICEF is placed at the state health department for coordination and
day-to-day support as required. Consultants placed in state and divisional offices also
provide technical support to respective offices on a daily basis. At the district level,
UNICEF conducts occasional trainings of Medical Officers and Auxiliary Nurse and Mid-
wives and also mentors community health workers known as Accredited Social Health
Activists (ASHA) to improve their skills. Vatsalya also provides support to district
public health staff for programme implementation, including sharing field data or other
information, facilitating field visits or convening meetings with community health
workers. Table 3 summarises the contact opportunities that help maintain linkages
between UNICEF and Vatsalya and different levels of Government.
Implementation linkages. Direct support to MCH programme implementation is more
important at the field level, with day-to-day coordination tasks, as both NGOs were essen-
tially supporting Government programmes. Both UNICEF and Vatsalya work closely at
the field level with ASHAs and nutrition workers (Anganwadi worker) for beneficiary tar-
geting and programme implementation. UNICEF field staff holds weekly meetings with
ASHAs and Anganwadi Workers to coordinate immunisation sessions. NGOs also for-
mally approach the Chief Medical Officer of the district to resolve any issues that may
arise at the district level. At the state level, implementation linkages were mostly limited
to obtaining permissions or seeking any other facilitation of field implementation.
Monitoring and reporting/data sharing. Both UNICEF and Vatsalya record programme
data meticulously on a regular basis to meet monitoring and reporting requirements.
These include financial and management records, inputs and coverage data, and reports
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for all activities and research. For example, under the Saloni programme, Vatsalya main-
tains separate registers for recording data on number of adolescent girls covered under
awareness generation activities (such as education sessions by health workers with adoles-
cent girls at schools) and number of iron tablets distributed. It also records observations
during meetings with community members (such as in health camps or outreach visits) or
beneficiaries on a checklist. UNICEF, under its support to the Polio and Routine Immu-
nisation programmes, shares immunisation data with the State Government to strengthen
the public immunisation database and to enable review of progress in implementation. As
Government supplies are utilised in all programmes being implemented by the two organ-
isations, the Government also maintains records of commodities supplied to the NGOs,
such as vaccines, supplements or deworming tablets.
Data maintained by the NGOs, such as on eligible population, inputs and coverage, are
subject to strict monitoring, supervision and results based management (Table 4). Rigor-
ous training also ensures that community level workers are proficient in data collection
and maintenance, regularly validating and updating their records. Review of records
revealed that the records maintained by field staff at the district level of both NGOs
were more detailed and complete than routine data collected by field level public health
workers.
Challenges in effective linkage between government and NGOs
Limited data sharing
Some data is transferred to the public health system from the NGOs, while other data
sharing is negligible. Data relating to implementation of public health programmes,
such as the number of children immunised, or women given three antenatal check-ups,
are transferred to and utilised by the public health system. But similar data relating to
other donor-funded programmes is left out and not utilised for planning purposes. For
example, UNICEF data on immunisation performance is integrated with the public
health information system and is utilised for planning. Records of High Risk Areas are
shared with community health workers to help improve coverage of target populations.
However, there is no formal system of reciprocal data flow to help align NGO planning
Table 4. Supervision systems in NGO case studies.
Level of interaction
Supervisory activities
UNICEF VATSALYA
State level .Annual field observation visits
.Quarterly programme review meetings
.Technical support to district staff
.Daily monitoring during intensified
immunisation campaigns
.Quarterly progress reports to donor
.Quarterly programme review meetings
District level .Format -based reporting from district to state
level
.Fortnightly meetings between district, block &
field staff
.Monitoring visits by District Mobilisers
.Format -based reporting from district to
state level
.Field visits by District Coordinator
.Day-to-day contact with field staff
Sub-district (block)
level
Daily field supervision visits by Block Mobilisers Daily field supervision visits by Block
Coordinators
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with public health priorities. Vatsalya requests informal sharing of micro plans from dis-
trict level nutrition officers to integrate their own implementation plans with system-
defined targets. This exchange and utilisation of data between public and NGO sectors
is largely informal, dependent on the will of the health officials and donors.
Limited NGO participation in planning
While forums like HPF and District Health Society are reportedly being utilised for plan-
ning, it is not clear as to whether NGOs participate as equal stakeholders to the
government.
Limited monitoring regulatory compliance
A challenge in realising effective linkage is the lack of monitoring regulatory compliance.
Annual submission of financial and management reports by NGOs for regulatory compli-
ance are not being enforced. The common practice is of submitting these only at the time
of registration renewal, which is after every five years. Enforcing compliance is difficult in
the current setup on account of poor record maintenance and follow-up of NGOs by the
government.
Both case studies show that NGOs strive to maintain close links with the public sector;
the linkage is complementary in nature, being mutually beneficial to both parties, as the
NGO programmes are closely associated with ongoing public health programmes.
However, there are some differences in the way both the NGOs link with the public
health system, that are contingent upon their size, funding and scale of operations.
Being a multilateral agency, UNICEF does not need to be registered at the State level. Its
funding is independent, with no financial or management reporting to the State. It also has
the mandate to work closely with the government, with much more intensive interaction
and closer linkages with the State Government. Vatsalya on the other hand, is a national
NGO, and is registered with the State Government. It depends on donor-funded projects.
Institutional and financial processes are subject to scrutiny by donors as well as the State
Government. Linkages with the public health system are more limited, with the State
playing a dominant role.
Discussion
Through this study, Coston’s model of Government–NGO linkages is being adapted and
applied in MCH research for the first time. Findings from the case studies show that there
is moderate level of linkage between public health system and NGOs in UP, at both district
and state levels. The linkages are marked by frequent interaction and some level of reci-
procity in terms of information and resource flows. However, though there are forums
for interaction, NGO participation in policy and planning is weak, and there is no evidence
of joint action. Since NGOs in India are not registered with the Health department we did
not look into the extent of Government control in our analysis.
The type of linkage could be described as one of ‘complementarity’, which entails infor-
mation and resource sharing (including government grants and contracts) but not joint
action (Coston, 1998). UNICEF works with the public health system at all levels to
strengthen and support it, and Vatsalya aligns its planning and implementation with it
too. The public health system utilises their strengths of technical competency and
10 A. SRIVASTAVA ET AL.
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access to vulnerable groups in improving programme outreach and quality. Yet clearly, it
is the dominant partner, with the NGOs proactively striving to maintain formal and infor-
mal linkages as they cannot operate without State permission, and require the State Gov-
ernment’s intervention to resolve any implementation issues. Linkage with the public
health system also has potential positive effects for NGOs because of their need for (a)
resources and (b) cooperative implementation of programmes in alignment with public
health system (Coston, 1998). Complementarity entails potential NGO participation in
planning and policy-making. Both NGO case studies have different linkages in this
regard –while UNICEF is closely involved in supporting the State Government in
policy and planning, Vatsalya’s involvement is limited to participation in HPF and
some technical committees.
What drives these linkages between NGOs and public health system? In a relationship
where the government is in a dominant position, NGOs seek improved linkages with the
public health system for several reasons. They aspire to maintain positive relations with
the regulator and to facilitate permissions wherever required. Since their work is
aligned closely with public health system, better cooperation and coordination with
public health personnel at all levels is an essential requirement. Highlighting positive out-
comes to the Government also increases the possibility of scaling up of successful strat-
egies, winning future public contracts and participation in policy-making and planning.
In an evaluation of NGO-operated projects for vulnerable children in five African
countries, strong partnership with national and local Governments was identified as a
key factor for sustainability (Rosenberg, Hartwig, & Merson, 2008). Large-scale contract-
ing to NGOs is employed as a strategy by governments to capitalise on the resource effi-
ciency and quality advantages offered by NGOs (Gilson, Sen, Mohammad, & Mujinja,
1994; World Health Organization, 2000).
The public health system also maintains linkages with NGOs for different reasons. The
Government seeks periodic information from NGOs for regulatory compliance. This is
required by both Federal governments as lawmakers and regulators of foreign funding,
and state governments as law enforcers. Historically, access to remote and vulnerable
populations and foreign funding by NGOs has been of concern to federal Governments
(Gilson et al., 1994). In Africa, donor funding on HIV/AIDS was channelled largely
through NGOs, often at the cost of local health systems (World Health Organization,
2000). Governments increasingly push for closer scrutiny of NGO funding, geographical
reach and activities.
Close association of NGOs in programme implementation provides the advantages of
better access to vulnerable groups or difficult areas and innovative strategies to help accel-
erate progress towards public health goals. Engaging NGOs for improving programme
coverage, demand and quality is now a well-established strategy in several developing
countries, such as Tanzania, Bangladesh, South Africa, Pakistan and India (Ejaz,
Sheikh, & Rizvi, 2011; Haque, 2002; Heard, Awasthi, Ali, Shukla, & Forsberg, 2011;
Nxumalo, Goudge, & Thomas, 2013; Pfeiffer et al., 2008; Rosenberg et al., 2008). For
example, the Government of Bangladesh proactively engaged with NGOs in improving
the coverage of vulnerable groups under its tuberculosis control programme (Zafar
Ullah, Newell, Ahmed, Hyder, & Islam, 2006). Technical assistance by NGOs helps
improve productivity and skills of public health staff as well as facilitate implementation.
GLOBAL PUBLIC HEALTH 11
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Information sharing by NGOs helps in identification of different innovative strategies that
can be scaled up by the government for greater effect.
Limitations and recommendations
A more diverse exploration of NGO–public health system linkages in UP could have been
carried out. However, we feel that this typology of NGO–public health system linkages
could be used effectively to assess linkages and identify areas requiring modification
and improvement. Our approach could help government to identify areas, which need
more investment to improve NGO linkages.
Collaborative linkages with NGOs, if utilised effectively, can lead to improved equity
and quality of services leading to improved MCH outcomes (Baliga, Raghuveera,
Prabhu, Shenoy, & Rajeev, 2006; Ejaz et al., 2011). Research also advocates strong Govern-
ment coordination of NGOs for responsive services aligned with public health goals
(Gilson et al., 1994). It also corroborates WHO’s call for governments in pluralistic
health systems to fulfil their ‘stewardship’function by improving engagement and inclus-
ive planning with the diverse providers to enhance benefits to the community (World
Health Organization, 2000). NGO linkages can be best utilised for health system improve-
ment if there is horizontal and vertical integration of the NGOs with the public health
system and among themselves (Malena, 1997). However, our findings highlight the lack
of a structured engagement strategy with NGOs by the public health system that inhibits
the effective utilisation of existing linkages. In order to standardise the NGO–public health
system relationship, a statutory forum would improve interaction and collaborative func-
tioning. Also, the process would need complete mapping of the NGOs operating in the
state health sector. The UP Government commissioned an evaluation of NGOs in
health sector in the state, but there is no evidence of whether the data was utilised
(Heard et al., 2011).
An under-utilised area of government engagement is with donor agencies, in order to
align donor-funded programmes with state priorities and help facilitate compliance with
the public sector’s data sharing requirements. Ideally, formalisation of an engagement
strategy and its piloting at a sample district level for a fixed duration would help demon-
strate the effectiveness of such a forum, its practicability and advantages at the ground
level.
Based on Coston’s model, a recommended engagement strategy of ‘high’level of linkage
between NGOs and public health system would include information and resource sharing,
joint action or implementation and participation in policy and planning, all within a
favourable policy environment. Information sharing in the health sector at both state
and district levels is critical for evaluating MCH programmes as well as designing effective
policies or interventions (Sood, Burger, Yoong, Kopf, & Spreng, 2011). Resource sharing is
largely from the government to NGOs as financial assistance for improved reach and
quality of MCH services (Sood et al., 2011). NGO participation in health policy and plan-
ning at the macro (state) and micro (district) levels is pivotal in enabling effective joint
action and alignment of health goals of the implementing partners (Wamai, 2008). Last
but not the least, a favourable health policy environment at the State level is needed to
realise this high level of linkage. Brazil gives a good example of health policy favouring
strong interactions and productive engagement of all stakeholders in terms of social
12 A. SRIVASTAVA ET AL.
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participation, regulation, auditing, monitoring, and evaluation (Victora et al., 2011). The
High Level Expert Group on Universal Health Coverage in India has also recommended
enhanced role of the private health sector, both for-profit and non-profit, in delivering
universal healthcare (Public Health Foundation of India, 2011). Its role is seen as comp-
lementary to the public health system primarily in fulfilling service guarantees through
innovations and ensuring competitive quality benchmarks (Public Health Foundation
of India, 2011). To achieve this, the Expert Group has recommended a broader engage-
ment model with the private sector (both for-profit and non-profit) through strong regu-
lation, accreditation, supervisory frameworks, and controlled input deployment along
with careful tracking of outcomes (Public Health Foundation of India, 2011).
Conclusion
The case studies highlight existing linkages between public and NGO sectors in UP. We
found a moderate level of collaborative NGO–public health system linkage, using an adap-
tation of Coston’s model. NGOs and health system are linked through regulation, joint
planning and review through forums like HPF, information sharing, workforce and
implementation linkages and data sharing. NGOs are significant partners of the Govern-
ment in the effort to improve MCH in pluralistic health systems of developing countries
like India. Strong linkages between NGOs and the Government would help improve
service coverage and outcomes through collaborative functioning. For joint planning,
implementation and evaluation, public health and NGO sectors need to be more strongly
integrated through a formal system for sustained and systematic collaboration. Both the
public health system and NGOs would gain from this. .In Bangladesh, for example, gov-
ernment–NGO collaboration in tuberculosis control was successful in improving the cov-
erage, quality and sustainability of the programme (Zafar Ullah et al., 2006). In UP itself, a
study successfully demonstrated that NGO facilitation of the government’s community-
based health programme improved the equity of maternal and newborn health in rural
areas (Baqui et al., 2008).
NGOs can thus be valuable partners of the public health system in achieving its MCH
goals. Understanding the extent of NGO–government linkages is crucial to identify areas
that need strengthening to increase collaboration and coordinated efforts. Towards this
end, a study is currently underway in a state of India to create a platform to bring the
public and private sectors together for formal data sharing and enabling utilisation of
data for decision-making.
Acknowledgements
The authors would like to thank the Uttar Pradesh State Health department staff at the state and
district levels, as well as the participating NGOs for their cooperation in the study as key informants
and for sharing relevant material for analysis.
Disclosure statement
No potential conflict of interest was reported by the authors.
GLOBAL PUBLIC HEALTH 13
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Funding
This work was supported by the Bill and Melinda Gates Foundation BMGF under the IDEAS
(Informed Decisions for Actions) project, a measurement, learning and evaluation grant to
assess the scalability and coverage of innovations on maternal and newborn health [number
OPP1017031].
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