WHO Collaboration between NGOs, Ministries of Health and WHO in Drug Distribution and Supply

Publication date: 1998

WHO/DAP/98.12 Original: English Distribution: Limited ACTION PROGRAMME Collaboration between NGOs, ON Ministries of Health and WHO ESSENTIAL in Drug Distribution and Supply DRUGS Peter B. Iversen Consultant, Action Programme on Essential Drugs World Health Organization © World Health Organization 1998 This document is not issued to the general public, and all rights are reserved by the World Health Organization (WHO). This document may not be reviewed, abstracted, quoted, reproduced or translated, in part or in whole, without the prior written permission of WHO. No part of this document may be stored in a retrieval system or transmitted in any form or by any means¾electronic, mechanical or other¾without the prior permission of WHO. The views expressed in documents by named authors are solely the responsibility of those authors. Contents iii Contents Page Acknowledgements. iv Acronyms and abbreviations .v Executive summary.1 1. Introduction.5 1.1 Current relations between WHO/HQ programmes and NGOs .5 1.2 Changing relations between NGOs, MoHs and WHO at country level.6 2. Methods.9 2.1 An NGO typology .9 3. Results . 11 3.1 International study .11 3.2 WHO/HQ programme policies on collaboration with NGOs .17 3.3 NGO perspectives on collaboration with WHO/HQ programmes .18 3.4 Conclusions for WHO/HQ analysis.20 3.5 Recommendations to WHO/HQ programmes .22 4. Country studies. 24 4.1 NGOs and drug distribution and supply in the three countries .25 4.2 What WHO can offer NGOs at country level .26 4.3 Initiating collaboration between NGOs and WHO at country level.27 4.4 Conclusions of the country studies .28 4.5 Recommendations for WHO and NGOs at country level .28 5. Discussion . 30 Annex 1: Questions discussed with WHO/HQ programmes .concerning NGOs and drug distribution and supply . 32 Annex 2: Themes discussed with international NGOs. 34 Annex 3: Themes discussed with stakeholders in Kenya, Malawi and Uganda . 36 Annex 4: List of persons met . 38 Annex 5: Criteria to be met by NGOs when collaborating with UNICEF in Kenya . 42 References. 55 Acknowlegements iv Acknowledgements The preparation of this report would not have been possible without the support of and valuable contribution made by a number of individuals and organizations. Several nongovernmental organizations (NGOs), National Drug Programmes, the Ministry of Health in Kenya, the Ministry of Health and Population in Malawi, the Ministry of Health in Uganda, WHO country offices in Kenya, Malawi and Uganda, and WHO programmes generously shared their experience and data with the author. Within WHO, interviews with Dr P. Chaulet (GTB), Dr D.P.J. Daumerie (LEP), Dr D.E. Etya’ale (PBD), Dr P.M. Evans (GPV), Dr R.J. Guidotti (RHT), Dr H.O. King (NCD), Dr L.J. Martinez (EMC), Dr J.D. Quick (DAP), Dr J.H.F. Remme (CTD), Dr D.A. Robinson (CHD), Dr A. Tekle Haimanot (CTD), Dr T. Yasukawa (EHA), and Mr T. Yoshida (DMP), provided important information and comments. Collaboration between NGOs, Ministries of Health and WHO in drug distribution and supply has previously been dealt with on an ad hoc basis. The information provided in the report and annexes is therefore limited (albeit the best available). However, more information will doubtless become available following further research. This report should be seen as preparatory to more in- depth research in other countries and regions, which in turn will make a global comparative study possible. Acronyms and abbreviations v Acronyms and abbreviations AFRO WHO Regional Office for Africa AMDA Association of Medical Doctors of Asia AMREF African Medical and Research Foundation CHAM Christian Health Association of Malawi CHD Division of Child Health and Development CONGOMA Council for Nongovernmental Organizations in Malawi CTD Division of Control of Tropical Diseases DAP Action Programme on Essential Drugs DMP Division of Drug Management and Policies ECHO ECHO International Health Services Ltd EHA Division of Emergency and Humanitarian Action EMC Division of Emerging and Other Communicable Diseases Surveillance and Control GLAR German Leprosy Relief Association GPV Global Programme for Vaccines and Immunization GTB Global Tuberculosis Programme GTZ Gesellschaft für Technische Zusammenarbeit (German Development Agency) HQ Headquarters IDA International Dispensary Association JMS Joint Medical Stores, Uganda KNCV The Royal Netherlands Tuberculosis Association KNDPIP Kenya National Drug Policy Implementation Project LEP Action Programme for the Elimination of Leprosy MAC Management Advisory Committee MAL Malaria Control MEDP Malawi Essential Drugs Programme MEDS Mission for Essential Drugs and Supplies, Kenya MoH Ministry of Health MoH&P Ministry of Health and Population MSF Médecins Sans Frontières NCD/DIA Division of Noncommunicable Diseases/Diabetes NDA National Drug Authority NGO Nongovernmental organization OECD/DAC Organisation for Economic Cooperation and Development/Development Assistance Committee PBD/PBL Programme of the Prevention of Blindness and Deafness RHT Division of Reproductive Health TB tuberculosis UN United Nations UNICEF United Nations Children's Fund WHA World Health Assembly WHO World Health Organization Collaboration between NGOs, MoH and WHO in drug distribution and supply vi Executive summary 1 Executive summary Background This study is based on the recognition, by the Action Programme on Essential Drugs and the Special Programme for Research and Training in Tropical Diseases, of the increasing importance in a number of countries of nongovernmental organizations (NGOs) in drug distribution and supply. These NGOs distribute a substantial proportion of drugs (more than 20%) and play an important role in health provision in general. The increasing role of NGOs as distributors has also been recognized by the Organisation for Economic Cooperation and Development/Development Assistance Committee (OECD/DAC), the United Nations (UN), and by several donor countries involved in development assistance. Reform of the UN, changes in donor attitudes towards NGOs, and decentralization in many countries have further strengthened the role of NGOs in drug distribution and supply. The increasing importance of NGOs can be seen at country level, where several NGOs are participating more frequently in policy formulation and strategic definition of goals. This study focuses on: · the different World Health Organization headquarters (WHO/HQ) programmes involved in drug distribution and supply; · international NGOs involved in drug distribution and supply; · the drug distribution and supply situation in Central and East Africa, specifically, Kenya, Malawi and Uganda. Aim and objectives of the study The aim of the study was to analyse the importance of NGOs in drug distribution and supply from port to district, and to collect evidence to support the argument that a more proactive WHO policy on collaboration with NGOs working in drug distribution and supply is needed. The specific objectives were to: · develop a list of WHO programmes/divisions working in drug distribution and supply; · develop an inventory of NGOs involved in drug distribution and supply (including which countries they are working in and what they are doing); · analyse the collaborative experience of NGOs, Ministries of Health (MoHs) and WHO programmes in drug distribution and supply; · translate this experience into recommendations for future WHO policy and programme implementation in the field of drug distribution and supply. Collaboration between NGOs, MoH and WHO in drug distribution and supply 2 Findings The study showed that collaboration between WHO programmes and NGOs is strongest when issues such as norm-setting, formulation of treatment regimes, production of guidelines and coordination are addressed, and weaker when issues such as financing and procurement are the main focus. This accords with the finding that many WHO/HQ programmes perceive their job as primarily normative and their priorities as standard setting, regulation and coordination. Interaction is also relatively marked in the area of distribution and dispensing. This is related to the fact that WHO programmes see NGOs as effective in these areas (even though NGOs have been assessed as distributing less than 5% of all drugs globally). The study found too that attitudes towards NGOs are more positive when a programme is collaborating with numerous NGOs on an informal basis, as opposed to collaborating with only a few NGOs who are in official relations with WHO. The correlation between the number of NGOs in informal relations with a programme and a positive attitude towards NGOs can partly be explained by four factors: · that programme’s particular area of work or the medical treatment regime that it recommends; · the way in which programme activities are financed; · the presence of programme workers at country level; · the positive personal attitude of programme staff towards NGOs and a tradition within the programme of working with NGOs. Interviews with WHO/HQ programmes showed that collaboration with NGOs is based on the following four assumptions: · that agreements and knowledge accumulated at WHO/HQ level flow down to NGOs operating at the international, regional and national level; · that WHO/HQ programmes request involvement of NGOs at country level as required; · that WHO country offices involve NGOs in their work; · that NGOs and MoHs are interested in and have the capacity to undertake collaboration with WHO. However, these assumptions do not necessarily reflect reality. The main findings at WHO/HQ were that: · few programmes have an established overview of the NGOs with which they collaborate; · only one-third of the NGOs that collaborate with WHO programmes in drug distribution and supply are in official relations with WHO; · only a few WHO programmes¾including those working in countries and regions where NGOs are highly important¾have an established and explicit policy on collaboration with NGOs. Interaction between WHO and NGOs thus tends to be based on personal contacts and has a low degree of sustainability. These factors, and the absence of an Executive summary 3 officer addressing NGO work in the majority of programmes, somewhat contradicts the assumption that agreements and knowledge accumulated at WHO/HQ level flow down to NGOs at international, regional and national level, and that WHO/HQ programmes request the involvement of NGOs at country level. These assumptions would be more likely to reflect reality if programmes had an explicit programme policy on NGOs, a network overviewa of the NGOs with which they work and an officer responsible for addressing these issues. In fact, most NGOs questioned doubted whether a downflow of information occurs. They also questioned whether WHO programmes involve NGOs at country level. Information collected during the country studies conducted in Kenya, Malawi and Uganda indicated that agreements and knowledge accumulated at international level do not necessarily flow down to country level. Indeed, several NGOs have called for WHO to support the formation of coalitions at country level so that WHO can more effectively use what many NGOs see as WHO’s comparative advantage: good contact with governments and MoHs. This is in line with study findings indicating that WHO programmes and WHO country offices focus extensively on MoHs and only to a limited extent on NGOs. The study indicated that practical collaboration and involvement of NGOs in drug distribution and supply at country level are best handled by the relevant national WHO/country office, with minor responsibility assigned to WHO/HQ programmes. But it was found that WHO country offices do not necessarily involve NGOs in drug distribution and supply activities, and little effort has been made by WHO to initiate interaction between NGOs, MoHs and WHO in this area. The study showed that developing a list of specific WHO programmes working in drug distribution and supply would be possible. However, developing a complete inventory of the NGOs involved in drug distribution and supply would not be, since not all individual WHO programmes have an overview of the NGOs working in drug supply and distribution in their particular area. In each of the countries studied it is anticipated that NGOs will become even more important in terms of drug supply and distribution, due to ongoing decentralization, demands from donors to increase NGO involvement in drug distribution and supply, and financial constraints. In all three countries, national drug distribution systems and NGO distribution systems are dependent on external funding. This situation could exacerbate competition between the different stakeholders involved in drug distribution and supply. Recommendations Specific recommendations for WHO programmes, WHO country offices and NGOs are outlined below. a A network overview is a list of NGOs with which the programme has collaborated, either officially or informally, during the past two to three years. Collaboration between NGOs, MoH and WHO in drug distribution and supply 4 WHO/HQ programmes Based on the study and conclusions, it is recommended that each WHO programme: · establishes an evidence-based overview of the importance of NGOs in drug distribution and supply in its area of work; · establishes a network overview of the NGOs with which it interacts, thereby creating transparency inside the programme and between programmes; · develops an explicit policy on NGO collaboration including: guidelines for informal collaboration; information about what NGOs can expect from the programme; and a list of criteria that NGOs must meet in order to establish informal relations with the programme; · establishes mechanisms to collect and document experiences of working with NGOs; · addresses involvement of NGOs in country-level work as a part of programme policy; · helps countries to establish overviews of the NGOs involved in drug distribution and supply at national level. WHO country offices It is recommended that the WHO country offices in the African region: · establish policies on how to involve NGOs in drug distribution and supply; · use WHO as a link between MoHs, national drug programmes and NGOs; · support MoHs in involving NGOs in drug distribution and supply to a larger extent; · establish mechanisms together with MoHs to collect and document experiences of working with NGOs. NGOs The NGOs in countries should: · form coalitions of NGOs involved in drug distribution and supply in order to create partners for national drug programmes and WHO; · define their role in drug distribution and supply. Further research Further research is recommended to: · identify NGOs in Asia, Europe, South America and West Africa and initiate research on the work they undertake, for comparative purposes; · analyse the experiences of other UN agencies concerning collaboration with NGOs in drug distribution and supply. Introduction 5 1. Introduction This study is based on the recognition, by the Action Programme on Essential Drugs (DAP) and the Special Programme for Research and Training in Tropical Diseases, of the increasing importance of nongovernmental organizations (NGOs) in drug distribution and supply. In several countries, including Ghana, India, Kenya, Malawi, Nepal, Nigeria, Uganda, Zambia and Zimbabwe,1, 2 NGOs distribute more than 20% of the drugs available and are important in health provision in general. NGOs are rapidly growing in number and attracting increasing resources. Additionally, health sector reform in many countries is leading to greater emphasis on the role of both NGOs and the private sector in health care.3, 4 The aim of the study was to analyse the importance of NGOs in drug distribution and supply from port to district, and to collect evidence to support the argument that a more proactive WHO policy on collaborating with NGOs in drug distribution and supply is needed. Specific objectives were to: · develop a list of WHO programmes/divisions working in drug distribution and supply; · develop an inventory of the NGOs involved in drug distribution and supply (including which countries they are working in and what they are doing); · analyse the collaborative experience of NGOs, MoHs and WHO programmes in drug distribution and supply so that it can be incorporated into relevant WHO policy and programme implementation. The growing role of NGOs has also been recognized and considered by others. However, an OECD/DAC study on the impact of 240 different NGO projects concluded that factors underlying NGO success in different sectors and different areas have not been analysed sufficiently.5 Accordingly, this study of NGOs seeks to provide an overview of a specific sector (drug distribution and supply) in a specific region (East and Central Africa). The growing importance of NGOs and civil society can be illustrated in relation to both the United Nations (UN) and WHO. For example, NGOs have become more active in advocacy and operationally. They have held parallel conferences during the global UN summits; they undertake increasing surveillance activities and they are increasingly being subcontracted to carry out activities, particularly in the humanitarian field.6 Current reforms of the UN, including enhancement of relations between the UN and NGOs, have furthered these developments.7 NGOs have also grown in importance within specific countries. 1.1 Current relations between WHO/HQ programmes and NGOs The scope for greater involvement of NGOs in WHO’s programme activities was signalled at the World Health Assembly (WHA) by Resolution WHA 47.13. The Collaboration between NGOs, MoH and WHO in drug distribution and supply 6 Director-General of WHO was requested to “encourage contacts with bilateral and multilateral aid agencies, with organizations and bodies of the United Nations system, bilateral and multilateral agencies, with consumers, industry, nongovernmental organizations and other collaborators”.8 This created an opportunity for increased interaction between WHO and national and international NGOs, even those who are not in official relations with WHO. However, no general policy has yet been formulated that covers interaction between WHO programmes and NGOs in informal relations with WHO. Suggestions on collaboration and coordination of activities have been made, though, in individual programmes; for example, during the DAP Management Advisory Committee (MAC) meeting in 1995. During that meeting collaboration was defined as, “the agreement of two or more parties to work together. It may entail nothing more than an understanding regarding mutual communication or it may extend to formal agreements to share various aspects of support so as to obtain a common goal. Coordination is, on the other hand, a more structured and controlled integration of various inputs into planned and well-defined outputs.”9 The distinction between collaboration and coordination is important. Coordination implies some kind of control, while collaboration is rather a partnership between equal partners. Regarding the latter, the WHA called on WHO to provide “Conceptual leadership and advocacy in mobilizing and coordinating a global collaborative effort to improve the world drug situation.”10 However, the MAC had previously recognized that the most serious challenge facing countries today regarding collaboration and coordination is not a lack of cooperative activities, but rather that the scale of activities is insufficient to meet country needs.9 Finally, it is worth keeping in mind that collaboration, although frequently worthwhile, can be very difficult and requires substantial resources. 1.2 Changing relations between WHO, MoHs and NGOs at country level Changing relations can also be seen at country level. During the WHO consultation with NGOs in May 1997, in Geneva, Figures 1A and 1B were presented to illustrate the changing relations between WHO, MoHs and NGOs at country level. Figure 1A shows that in the past, polices and strategies were ideally established by the relevant government/MoH, with the support of WHO. The MoH then implemented the policies through programmes run by its government. As part of the implementation process, NGOs were guided as to where they could apply their resources and where to offer services. However, experience has shown that such a top-down approach is not necessarily entirely practical since the MoH may lack resources, and the goals of the MoHs and the NGOs may differ. Yet given the growth in NGO resources, the role of NGOs in health provision is becoming more important in many countries. Many now have the capacity to work more actively with MoHs on policy formulation and implementation (Figure 1B), becoming what Korten calls “third-generation NGOs.”11 In such cases, the government/MoH contintues to be supported by WHO and is perceived by WHO as the stakeholder responsible for securing drugs, while NGOs are seen as valuable partners in implementation and policy formulation. Introduction 7 Increasing interaction between MoHs and NGOs is thus supported directly by WHO, but WHO itself also interacts with NGOs at country and global level more than in the past. Figure 1. The changing relations between NGOs, MoHs and WHO Government N G O s Government WHO WHON G O s Policy regime Policy regime Service Service Finance Finance moved up N G O s 1B. The new NGO situation at country level If Figure 1B is accurate and more structured collaboration with NGOs in the countries is required, how can increased interaction with NGOs be managed? Green and Matthias12 describe seven tasks that ideally should be undertaken when developing collaboration with NGOs: · define what constitutes an NGO; · survey the NGO sector to gather baseline information on NGOs; · assess and categorize the different types of NGOs; · assess strengths and weaknesses of the NGO sector relative to other sectors; · identify and analyse relevant government policies; · examine the role of coordination bodies; · develop policies relating to the NGO sector. As necessary preconditions, Green assumes that the relevant government has previously recognized that NGOs have a role to play, that the government is responsible for enabling this to occur, and that NGOs are prepared to work with the government. Yet as highlighted in the three country studies described in Section 4, these three preconditions do not always apply owing to a lack of resources among the stakeholders involved in drug distribution and supply. 1A. The old NGO situation at country level Collaboration between NGOs, MoH and WHO in drug distribution and supply 8 Methods 9 2. Methods The study consisted of three parts: · Research into the involvement in drug distribution of the different WHO/HQ programmes (see Table 1). · Interviews with international NGOs involved in drug distribution and supply. The NGOs were selected on the basis of their degree of involvement in drug distribution and supply, and their degree of interaction with WHO. · Country studies of three East and Central African countries. The three countries, Kenya, Malawi and Uganda, were chosen on the basis of three main criteria. Namely, they each have a high level of NGO involvement in drug distribution and supply (i.e. more than 20% of the country’s drugs are distributed by NGOs); they differ in size, in terms of both population and land area; and they belong to the same region. By choosing countries from the same region, a foundation for further comparative research into the experiences of collaboration between NGOs, MoHs, and WHO in drug distribution and supply was created. Qualitative interviews were used to obtain information from WHO/HQ, international NGOs, and stakeholders in drug distribution and supply who were contacted during the country studies (see Annexes 1, 2 and 3 for themes discussed). A snowball approach was used to identify known stakeholders and they provided information that enabled further stakeholders to be identified. The analysis focused on collaboration between NGOs, MoHs and WHO on distribution from port to district. It might have been logical to have considered the districts, but the purpose of this analysis was more general. The district was therefore seen as a receiver, rather than as an active participant. Moreover, WHO normally orients itself towards MoHs and not NGOs. Collaboration and interaction between MoHs and NGOs at national level is thus relatively undeveloped and very little information is available on collaboration between NGOs, MoH and WHO at district level. The study concentrated on the supply and distribution aspects of the drug management cycle. Selection, procurement and use were considered only very briefly. For a full discussion of the drug management cycle, see Managing drug supply: the selection, procurement, distribution, and use of pharmaceuticals.2 2.1 An NGO typology When discussing MoH and WHO collaboration with NGOs, it is necessary to define what is understood as an NGO and to establish a typology of NGOs. Several commentators have discussed the issue of NGOs but none so far has established a clear, short definition. This is attributable to the fact that the NGO sector is very broad, ranging from small football clubs, to very large organizations Collaboration between NGOs, MoH and WHO in drug distribution and supply 10 employing thousands of people, to research institutes, churches, professional associations and advocacy groups. The commonly used definition of NGOs working in health, which focuses on the fact that NGOs work outside and beyond the government sector, and the definition used in this study have their roots in the groupings and typology devised by Green.13 Green generally defines NGOs as organizations that are non- profit-making and outside state control. More specifically, he identifies six different kinds of NGOs involved in the health sector: · religious organizations; · international social welfare NGOs; · local/country-based social welfare NGOs; · unions, trade and professional associations; · other non-profit-making organizations; · non-profit-making (but prepaid) health care NGOs. The different kinds of NGOs will not be discussed further here since other sources can be consulted. (See Mburu, for example.14) Suffice to say that NGOs are present and very much involved in health provision and drug delivery in many countries, and that the importance of NGOs in health provision has been increasing over the last two decades. What is now more important, is establishing policy and standards under which NGOs should work. The key questions are, how have MoHs and WHO responded to the need for policy development in drug distribution and supply, and what follow-up actions should now be undertaken? This analysis of collaboration between NGOs, MoHs and WHO provides some answers to the first question, while Green and Matthias (1995) have already provided some ideas in response to the second question.12 The discussion and effort devoted to the classification of the different kinds of NGOs were considered necessary since many stakeholders involved in drug distribution and supply were unclear on this issue. For example, they were unsure whether the Danish International Development Agency and Gesellschaft für Technische Zusammenarbeit (GTZ) should be classified as NGOs. When the value of NGO involvement in drug distribution and supply is discussed, two points of view emerge. One sees NGOs as innovative, able to identify new areas of potential activity, reliable, able to reach the poor, etc.11 The other sees NGOs as having little capacity, unsustainable and lacking in authority.14 In 1996, Matthias and Green reviewed the comparative advantages of NGOs in the health sector. They examined the available evidence and argued points of view for both sides.15 This indicates that no clear, single, overall conclusion may be possible. Instead, conclusions should be drawn only for specific situations and should therefore be context-based. This approach is in line with the conclusions of the OECD/DAC study on NGOs.5 Results 11 3. Results This analysis of collaboration between NGOs, MoHs and WHO in drug distribution and supply concentrated on: · international vs. country-level collaboration; · NGOs in official relations with WHO vs. NGOs in informal relations with WHO. All relations based on a written agreement between an international NGO and WHO and adopted by the Executive Board of WHO are defined as official relations. All other forms of WHO relations with NGOs are seen as informal.16 The regional level is considered only very briefly in this analysis. The focus is on WHO programmes at country level, and the interaction between these, MoHs and NGOs involved in drug distribution and supply. 3.1 International study Determinants for collaboration between WHO/HQ programmes and NGOs Many WHO/HQ programmes perceive their task as primarily normative. In which case, their main priorities are standard setting, regulation, coordination and acting as a catalyst, via MoHs and, to some extent, international NGOs, to promote adherence to standards. The more practical aspects of collaboration and involvement of NGOs in drug distribution and supply at country level are then handled by the WHO country offices, since these are not perceived as a major responsibility of the WHO/HQ programme. The interviews with WHO programmes showed that such an approach was based on four assumptions, two of which related to WHO/HQ: · that agreements and knowledge accumulated at the WHO/HQ level flow down to NGOs at international, regional and national levels; · that WHO/HQ programmes request involvement of NGOs at country level as required; · that WHO country offices involve NGOs in their work; · that NGOs and MoHs are interested in collaboration and have the capacity to undertake collaboration. Programmes were asked to indicate their degree of involvement with NGOs (Figure 2), and to identify all international NGOs with which they collaborate (Table 1). Collaboration between NGOs, MoH and WHO in drug distribution and supply 12 Figure 2. View of importance of NGOs in the work of the programme 1 2 3 4 5 PBD/PBL DAP CHD GTB EHA GPV EMC MAL LEP NCD/DIA Figure 2 shows that some WHO programmes see NGOs as crucial to their work. The WHO Programme on the Prevention of Blindness and Deafness (PBD/PBL) in particular emphasized the importance of NGOs. But programmes such as Malaria Control (MAL), the Division of Child Health and Development (CHD), and the Global Programme for Vaccines and Immunization (GPV) did not emphasize the importance of NGOs in drug distribution and supply, and the Global Tuberculosis Programme (GTB) even indicated some doubt as to the usefulness of NGOs to their work. Table 1 is the best available list (but incomplete), of the NGOs in contact with WHO programmes, as indicated by the programmes themselves. As can be seen, only eight NGOs are in contact with more than one programme in relation to drug distribution and supply. Creating Table 1 was more difficult than anticipated. The absence of an overview of the NGOs with which the programmes collaborate, and the tendency for programme collaboration with NGOs to be based on personal relations rather than structured programme policies, accounted for this difficulty. Interestingly, only approximately one-third (13 out of 38) of the NGOs with which the programmes collaborated were in official relations with WHO. When asked for a list of the NGOs with which the programme collaborates, many programmes reacted somewhat doubtfully. Several programmes even saw disadvantages in having such a list, arguing that the existence of a list of NGOs in informal relations with WHO would limit their freedom to contact other NGOs involved in drug distribution and supply. It was also mentioned that NGOs not included on such a list might feel excluded. Such problems could be solved by establishing an explicit policy concerning collaboration with NGOs and an extensive network overviewa of the NGOs with which the programmes have collaborated during the last two years. Interestingly, there seems to be a positive correlation between programme attitude towards NGOs and the degree of contact with NGOs in informal relations with the programme (as indicated in Figure 2). Conversely, contact with NGOs appears to be less and to involve fewer NGOs when the NGOs concerned are in official relations with the relevant WHO programme. DAP, the Division of Emerging and Other Communicable Diseases Surveillance and Control (EMC), the Division of Emergency and Humanitarian Action (EHA), the Action Programme for the Elimination of Leprosy (LEP) and PBD/PBL are the clearest examples of such a positive correlation (see Table 1). Table 2 shows that these programmes, with the exception of EMC, are also the programmes that have developed a policy on NGO collaboration. a A network overview is a list of NGOs with whom the programme has collaborated, either officially or informally, over the past two to three years. 1 - very crucial 5 - unnecessary Results 13 Table 1. Contacts between WHO programmes and NGOs WHO programmes Þ NGOs ß CHD DAP EHA EMC GPV GTB LEP CTD/ MAL NCD/ DIA PBD/ PBL African Medical Research Foundation (1)* x* Africare (1) x AMDA (1) x Appropriate Health Resources and Technologies Action Group (1) x CARE (2) x x Christoffel Blindenmission e.V (1)* x* Churches’ Action for Health (1)* x* Consumers International (1) x ECHO (1) x GLAR (1) x Global 2000 River Blindness Programme (1) x Health Action International (1) x Helen Keller International Inc. (1)* x* Interchurch Medical Assistance,Inc. (1) x International Diabetes Federation (1)* x* International Dispensary Association (1) x International Eye Foundation (1)* x* International Federation of Anti-leprosy Associations (1)* x* International Federation of Pharmaceutical Manufacturers Associations (1) x International Network for Rational Use of Drugs (1) x International Union Against Tuberculosis and Lung Diseases (1)* x* John Snow International (1) x KNCV (1) x Lions Club International (1) x Manufacturers International (1) x Mectizanã Donation Program (1) x Médecin du Monde (2) x x Médecins Sans Frontières (5) x x x x x Merlin (2) x x Organisation pour la Prévention de la Cécité (OPC) (1) x OXFAM (3)* x* x* x* PLAN (1) x Red Cross and Red Crescent Societies (3)* x* x* x* River Blindness Foundation (1) x Rotary International (1)* x* Save the Children Fund (2)* x* x* Sight Savers International (1) x World Vision International (3)* x* x* x* Total number of NGOs in contact with programme in drug distribution and supply/number in official relations with WHO 8 / 4* 9 / 2* 5 / 1* 7 / 3* 3 / 2* 3/ 1* 1/ 1* 2/ 1* 2/1* 12/4* * In official relations with WHO; 13 of the 38 collaborating NGOs listed here account for 20 of 52 instances of collaboration (each indicated by an x) with programmes. ( ) NGO collaboration with (number of) WHO programmes in drug distribution and supply. Collaboration between NGOs, MoH and WHO in drug distribution and supply 14 PBD/PBL and LEP are examples of programmes with positive attitudes towards NGOs. They interact closely with NGOs on drug supply and distribution, and have regular and formal meetings with NGOs. NGOs themselves have a relatively strong influence on the programmes’ work. In the case of the Onchocerciasis Unit within the PBL/PBD programme, close interaction is in part attributable to the high level of financing received by the programme from NGOs. In LEP’s case, all formal and informal contacts with NGOs are guided and formalized through the International Federation of Anti-leprosy Associations, which explains the extensive interaction between LEP and NGOs. An interesting but difficult question concerns whether a positive programme attitude towards NGOs develops after the experience of collaborating with NGOs, or whether collaboration leads to development of a positive programme attitude towards NGOs. This analysis was unable to provide a definitive answer to this question. A comment from an international NGO was helpful, however. The NGO stated that an appointed contact person within WHO and mutual confidence are crucial to good collaboration. In other words, people are more important than formal structures. The same experience was reflected in the country studies where mutual confidence was observed to be founded on actual contact. Establishing which variable is the dependent variable, and which the independent is difficult. But these comments indicate that if programmes interact with and are knowledgeable about NGOs, a positive attitude towards NGOs is created in the programmes. Table 2. WHO programme policies on NGOs Programme Programme policy on international NGOs Programme policy on national NGOs and how to involve them in programme work CHD No (Plan to develop a policy) No (Plan to develop a policy) DAP Partly (A very general policy) Partly (A general policy but no plan for implementation) EHA Partly (In the process of developing a policy) Partly (In the process of developing a policy) EMC No (No explicit policy in this area) No (No explicit policy in this area) GPV Partly (No explicit formulated policy. Mainly collaborate with NGOs in emergencies) No (No explicit formulated policy) GTB No (No explicit formulated policy) Yes (See NGOs as supporting national TB programmes. Main aim is to strengthen MoH) LEP Partly (See NGOs as very important and collaborate with them to a high degree) Yes (Established policy and work with NGOs through WHO country offices) MAL No (No active programme policy) No (No active programme policy) NCD/ DIA No (No formulated policy¾trying to be opportunistic) No (Limited contacts with national NGOs) PBD/ PBL Yes (Has formulated an explicit policy together with international NGOs and established mechanisms for collaborating with them) Yes (Has direct contact with locally-based NGOs) Results 15 Collaboration from a programme perspective When analysing the collaboration between the different WHO programmes and NGOs, is it possible to find common denominators to describe those programmes that have a high degree of collaboration with NGOs? In addition to the correlation between actual interaction and attitude, four factors seem to be important: · the programme’s particular area of work or the medical treatment that the programme recommends; · the way in which programme activities are financed; · the presence of programme staff at country level; · the positive personal attitude of programme staff towards NGOs and a tradition within the programme of working with NGOs. The treatment regime promoted by a programme can account for some of the attitudes towards NGOs and the actual degree of collaboration with them. A programme such as GTB is generally doubtful regarding the involvement of NGOs in the distribution of drugs, partly because public health principles require ongoing treatment for a specified period for patients with tuberculosis (TB). Conversely, the treatment of onchocerciasis with ivermectin is much simpler and is carried out only once a year, making the involvement of NGOs much easier. The same holds true for leprosy. The importance of financing can be seen by comparing the PBD/PBL and LEP programmes with GTB and MAL. PBD/PBL and LEP obtain much of their funding from NGOs and foundations, while GTB and MAL receive only limited resources from NGOs. The PBD/PBL programme involves NGOs extensively in policy formulation and implementation. The impact of employing country workers is also important. Programmes such as PBD/PBL, CHD and DAP, all employ country workers and maintain a relatively positive attitude towards NGOs, seeing them as important contributors to their work. This is especially true for PBD/PBL, which has strong representation in Africa through its regional activities.17 Finally, personal and traditional attitudes seem to be important. Traditionally, the GTB programme, in common with other WHO programmes, argues mainly for collaboration through the state. Some GTB programme staff actually consider that NGOs weaken the state. Such a stand must inevitably lead to a negative attitude towards NGOs. (Factors that might have been expected to help create a more open and positive attitude within GTB towards NGOs include the relative importance of the International Union Against Tuberculosis and Lung Diseases in TB prevention and treatment, and the high involvement of NGOs in some countries.) Conversely, programmes such as DAP and LEP seize opportunities to work with NGOs and have a tradition of collaboration with NGOs. Comparing programme ratings for the above four factors with the findings presented in Figure 2 is useful. PBL/PBD, DAP, EHA and LEP get positive ratings on all four factors, while GTB gets the poorest rating. Likewise, for MAL, CHD, EMC and GPV the ratings for the four factors are middling, as is reflected in the findings presented for those programmes in Figure 2. Collaboration between NGOs, MoH and WHO in drug distribution and supply 16 Collaboration in formulating guidelines, financing, procurement, distribution, dispensing and provision The above analysis illustrates how WHO programmes perceive their interaction with NGOs in drug distribution and supply, and indicates the importance particular programmes assign to NGOs in terms of programme activities. But what determines actual collaboration in drug distribution and supply? To investigate this issue, five specific factors related to drug distribution and supply were considered: · treatment, and drug distribution and supply guidelines; · financing; · procurement; · distribution; · dispensing and provision. Collaboration between NGOs and WHO programmes in formulating treatment regimes, and drug distribution and supply guidelines, has been quite extensive. For example, the regime for treatment of leprosy was agreed between WHO and NGOs. The Division of Mental Health and Prevention of Substance Abuse has worked with NGOs to develop guidelines for drug distribution and supply in emergency situations. DAP, together with Médecins Sans Frontières (MSF), and other NGOs has developed guidelines for drug donations, while PBD/PBL interacts closely with NGOs in most fields. EMC is also collaborating with NGOs, in areas such as norm setting and development of guidelines. In other cases, NGOs have developed guidelines that have been adopted by WHO. Such close interaction between NGOs and WHO in this area is of course to be expected, given that tasks such as norm setting, production of guidelines, and coordination are regarded by WHO as priority areas in drug distribution and supply. Interaction between WHO programmes and NGOs also occurs in relation to financing and procurement, but less so than for formulation of treatment regimes and development of guidelines. Only a few programmes are financing projects in collaboration with NGOs, and even fewer programmes work with NGOs to procure drugs. However, interaction with NGOs is greater with respect to formulation of strategies and policies concerning financing and procurement. Once again, this accords with WHO’s normative function. Collaboration between WHO programmes and international NGOs on distribution, dispensing and provision of drugs is much greater than collaboration on either treatment, financing or procurement. This is in line with the findings that most programmes identify the comparative advantage of NGOs as consisting of good contacts at local level within countries. The problem for programmes, though, is that some NGOs create parallel structures that although efficient are not part of the normal drug distribution, dispensing and provision system. This can result in overlap and even cause confusion. In brief, most programmes, ranging from PBD/PBL to GTB, agree that NGOs work well within their own context, but not necessarily as part of the overall drug distribution and supply system. These views accord with the findings of several other researchers.11,14 Results 17 On the whole, perceptions of NGOs tend to be based on personal contact and specific experiences rather than analysis of how the whole NGO sector operates. Other studies of this field have drawn similar conclusions. 5,18 The importance of NGOs in distributing drugs can also be considered. Programmes such as CHD, GPV and LEP estimate that NGOs distribute less than 5% of global drugs in their area, while DAP, EMC and PBD/PBL estimate the percentage to be higher. This global picture aside, all programmes strongly emphasize that differences between countries are substantial, and that the contribution of NGOs to drug distribution is significant in some countries. 3.2 WHO/HQ programme policies on collaboration with NGOs This section argues for the formulation of programme policies that take into account relations between NGOs and WHO. Programmes tend to emphasize the global view, in which NGOs appear to be of less significance. Thus, few programme policies reflect the fact that in some countries and regions, NGOs are very important in drug distribution and supply. WHO programme policies on NGOs are therefore unclear (see Table 2). As can be seen in Table 2, a clear link exists between programme policies on involvement of NGOs at international level and programme policies on involvement of NGOs at national level. The information presented in Table 1, Table 2 and Figure 2 indicates a correlation between the attitudes towards NGOs (Figure 2), the actual number of NGOs in official or unofficial relations with WHO (Table 1), and formulated policy regarding NGOs (Table 2). Most programmes with a high rating in Figure 2 also collaborate with several NGOs (Table 1) and have a developed or partly developed policy on NGOs (Table 2). When discussing the need for programme policies on NGOs involved in drug distribution and supply, a link must be made between such policies and overall WHO policy regarding NGOs. WHO has a policy governing official relations between NGOs and WHO,16 but none to guide informal relations with NGOs such as ECHO International Health Services Ltd. (ECHO), the International Dispensary Association (IDA), and MSF. These NGOs are heavily involved in drug distribution and supply and interact with WHO to quite a significant extent. The the lack of guiding WHO principles on informal relations with NGOs is significant, given that 25 of the 38 the NGOs listed in Table 1 are in informal relations with programmes. Lack of overall programme policies on informal relations means that: · there is no overview of the NGOs with which programmes collaborate in drug distribution and supply; · no uniform policies exist on collaboration with NGOs either within programmes or between programmes; · contacts with NGOs tend to operate on a personal basis and are therefore not highly sustainable. These conditions, and the fact that none of the programmes has an officer who is responsible for NGO relations, means that interaction between programmes and NGOs tends to be ill-defined and uncertain. This undermines two major assumptions made concerning programme collaboration with NGOs: that Collaboration between NGOs, MoH and WHO in drug distribution and supply 18 agreements and knowledge accumulated at WHO/HQ level flow down to NGOs at international, regional and national levels, and that WHO/HQ programmes request involvement of NGOs at country level. The three country studies show, in fact, that WHO/HQ programmes rarely request NGO involvement and collaboration at national level. A programme policy on NGOs, including a definition of what NGOs can expect from the programmes working in drug distribution and supply, could solve several problems relating to programme interaction with NGOs. It could: · help ensure that agreements and knowledge accumulated at WHO/HQ level flow down to NGOs at international, regional and national levels; and encourage WHO/HQ programmes to request involvement of NGOs at country level; · define what NGOs can expect from working with WHO programmes, thereby promoting transparency; · provide guidelines on the establishment of a network overview of NGOs.a Additionally, if locally-based NGOs were also to be covered by such a policy they would be entitled to seek more direct contact with WHO/HQ programmes. WHO’s constitution would allow for such interaction.19 Programme policies, particularly if they incorporated an overview of NGOs involved in drug distribution and supply, could also be catalysts for closer interaction between NGOs and WHO at country level. Developing an overview of the NGOs involved in health in specific countries within the countries themselves, rather than establishing parallel lists within different HQ programmes might therefore be advisable. EHA argued for such an approach. Finally, a network overview of the NGOs with which the programme has collaborated over the last two years would create transparency within and between programmes. Programmes such as GPV and PBD/PBL oppose a more laissez-faire and transparent policy on NGOs, however, arguing that loosening control of drug distribution could be dangerous. Indeed, several attempts have been made by semi-NGOs (for example, groups claiming to be NGOs but who are actually working for profit or even within government) and NGOs with very low capacity to obtain the drugs distributed by WHO programmes. Evidently, a cautious attitude towards NGOs helps prevent abuse of WHO programmes. The programme policy on NGOs should therefore also define what criteria must be met by NGOs who wish to develop informal relations with WHO. 3.3 NGO perspectives on collaboration with WHO/HQ programmes NGOs’ experiences in collaborating with WHO clearly reflect the conclusions that can be drawn from the preceding tables and figures. Interaction at HQ and regional level between WHO programmes and NGOs is not inconsiderable. However, NGOs questioned the assumptions made about downflow of information and the involvement of WHO programmes with NGOs at country level. Meetings attended by the major NGOs and WHO in Ireland20 in June 1996 and in Geneva17 in May 1997 supported NGO views on this issue. On the other hand, several examples exist whereby international NGOs in official relations with a A network overview is a list of NGOs with which the programme has collaborated, either officially or informally, over the last two to three years. Results 19 WHO have enjoyed good collaboration with WHO/HQ in drug distribution and supply. During the consultation in Geneva, the NGOs in the working group on specific diseases and disabilities emphasized that collaboration between WHO/HQ programmes and NGOs was good in areas of high visibility, rapid output and strong empathy, and where funding was available. However, they indicated a need to also work in more difficult areas, such as prevention of disease and disability. This could include distributing drugs that prevent diseases and disability. The international NGOs also mentioned that WHO’s role should include forming coalitions at country level, thereby integrating NGOs into a general drug distribution and supply system, and working to improve linkages between NGO distribution systems and existing public distribution systems. In other words, NGOs would like to see WHO working more closely with NGOs at country level. WHO could use what many NGOs see as its comparative advantages¾namely, its independence and its capacity to act as a mediator between NGOs, governments and MoHs¾to enhance the work of NGOs at country level. Some NGOs, such as ECHO, stressed that broadening what is understood as “drugs” to include gloves, syringes and appropriate diagnostic tests, would be beneficial. ECHO mentioned, too, that closer contact with, or even possible distribution to NGOs of drugs from the Merck/WHO (ivermectin) or Janssen/WHO (antifungals) initiatives could be worthwhile since some NGOs such as ECHO work closely with rural and more isolated NGOs and are able to reach populations that are not well served by government health services. One of the criteria for successful collaboration in drug distribution and supply between NGOs and WHO programmes is willingness on the part of NGOs to work in a more tightly organized and regulated manner. In so doing they would be more likely to be able to exert some influence on WHO’s programme work and to become involved in programme implementation. Several researchers support such an argument, commenting that the increasing interaction between the UN system and NGOs demands some kind of regulation. 6,21 In fact, much discussion has already taken place concerning regulation of the activities of relief NGOs.22 Additionally, current thinking about promoting more development-oriented activities is making increasing reference to regulation of NGO activities. Thus the United Nations Children’s Fund (UNICEF) and other donors have argued for greater coordination.23 The focus on the state remains, but the more active involvement of other stakeholders is sought. The principal idea is that the state has to ensure but not necessarily provide certain services. This idea also underlies WHO’s renewed health-for-all policy for the 21st century.24 In the near future, a number of upcoming policy issues will demand stronger relations between NGOs and WHO programmes in drug distribution and supply if they are to be dealt with adequately. They are: · ensuring access to those new drugs and vaccines that will be 10 to 100 times more expensive than present vaccines and drugs; · addressing international regulations and conventions that reduce access to drugs and that hinder drug distribution and supply activities; Collaboration between NGOs, MoH and WHO in drug distribution and supply 20 · creating mechanisms to collect and document the knowledge and experience gained by NGOs during implementation of their diverse and innovative activities. 3.4 Conclusions for WHO/HQ analysis At WHO/HQ, programme work on collaboration with NGOs is based on four assumptions or premises. Two of these relate directly to WHO/HQ, but only infrequently do they reflect the actual circumstances in which collaboration with NGOs occurs within programmes. This is because few programmes have a fact- based overview of the NGOs with which they are in contact, and few programmes have formulated an explicit policy on working with NGOs. This conclusion is supported by the information presented in Tables 1 and 2. Table 1 lists the NGOs who are in contact with the programmes. Only one-third of these NGOs are in official relations with WHO. The low level of policy development on working with NGOs (Table 2) means that the remaining two-thirds are rarely covered by any explicit policy. Figure 2, together with Tables 1 and 2, shows a positive correlation between: · the importance assigned by programmes to NGOs in terms of programme work; · the number of NGOs in contact with the programme; · whether a policy on NGOs has been developed. The positive correlation and the rating in Figure 2 can be explained with reference to four factors: · the programme’s particular work area or the medical treatment regime that the programme recommends; · the way in which programme activities are financed; · the presence of programme staff at country level; · the positive personal attitude of programme staff towards NGOs and a tradition towards NGOs within the programme of working with NGOs. The medical treatment regime promoted by a programme influences the way in which that programme works. A complex or long treatment regime, for instance, would be harder to implement and more demanding of programme resources than a simple or short treatment regime. The issue of whether the programme has country staff in turn relates to the structure of programme work. The other two factors relate to the actual degree of interaction with NGOs. It is not clear from the above analysis whether interaction with NGOs is dependent on a positive attitude towards NGOs or vice versa. This analysis has merely shown that a relationship exists. Anecdotal evidence would seem to indicate, however, that it is interaction that creates a positive relationship between a programme and NGOs. These conclusions are further strengthened by the fact that few programmes have an evidence-based overview of the importance of NGOs in drug distribution and supply, and few programmes have an evidence-based overview of the number of NGOs involved in drug distribution and supply in their field. Results 21 Collaboration between NGOs, MoH and WHO in drug distribution and supply 22 3.5 Recommendations to WHO/HQ programmes On the basis of the above analysis and conclusions, it is recommended that each of the WHO programmes: · establishes an evidence-based overview of the importance of NGOs in drug distribution and supply; · creates a network overview of the NGOs with which it interacts, thereby creating transparency inside the programme and between programmes; · develops an explicit policy on NGO collaboration (including guidelines for informal collaboration, an indication of what NGOs can expect from the programme, and a list of criteria that NGOs must meet in order to establish informal relations with the programme); · establishes mechanisms whereby NGO experiences in drug distribution and supply can be collected and documented; · addresses involvement of NGOs in the countries as part of programme policy; · helps countries to establish overviews of the NGOs involved in drug distribution and supply at national level. Results 23 Collaboration between NGOs, MoH and WHO in drug distribution and supply 24 4. Country studies: Kenya, Malawi, Uganda Studies on collaboration between NGOs, MoHs and WHO were conducted in Kenya, Malawi and Uganda. The criteria for selecting the three countries were as follows: · in each country, NGOs are significantly involved in drug distribution and supply (more than 20% of total drugs distributed by NGOs); · the countries are in the same region, so that later comparative studies will be easier to implement; · the countries are of different size, in terms of both population and land area. As can be seen in Table 3, the countries chosen meet the above criteria. Table 3. Country information Kenya Malawi Uganda Estimated percentage of drugs distributed by NGOs • Estimated 40% • More than 20% (difficult to estimate due to conflicting figures) • Estimated 25% Country-data: • Size • Number of inhabitants • % urban population • 569 000 sq. km • 30 million • 20% urban population • 119 000 sq. km • 11 million • 15% urban population • 197 000 sq. km • 20 million • 11% urban population Source: Economist Intelligence Unit, country profiles, 1996 and 1997. Health expenditure in Kenya has been declining steadily in recent years. In 1996, annual per capita expenditure on health was approximately US$ 3.50. The country’s national health strategy incorporates all government ministries, the private sector and NGOs with activities related to health.25 The MoH is estimated to provide 60% of curative services, and NGOs and private organizations the remainder. Approximately the same proportions apply for provision of preventive services. Decentralization of the health sector has been taking place over recent years and the future structure of the health system, including the drug sector, is uncertain. In Malawi, multiparty democracy has taken root, to which the country is now adapting. Following this change, a number of donors have started working with Malawi again. For example, the World Bank and the Dutch Government supported the Malawi Essential Drugs Programme (MEDP) until the end of 1997. As of January 1998, the Ministry of Health and Planning (MoH&P) has taken full responsibility for drug distribution. The annual health budget in Malawi is about US$ 5 per capita, of which an estimated US$ 1.25 is spent on drugs. Even though the amount spent on drugs is in accordance with WHO recommendations, drug shortages have occasionally occurred in the public sector. An acute shortage of drugs in May 1996, for instance, forced the MoH&P to carry out an international emergency purchase. Country studies: Kenya, Malawi, Uganda 25 In Uganda, ongoing decentralization of the government system has been taking place. Thus with the country’s health system, more authority is now being assigned to districts. Additionally, liberalization and decentralization of the health sector have created more opportunities for NGOs and the private sector, a situation recognized by the MoH in its new policy formulation, as outlined in a paper on collaboration with external partners (unpublished). However, within the MoH, there is a general feeling that a more explicit and operational policy is still needed, since many of the existing problems relate to the MoH’s lack of resources. The government spends 4.8% of its budget on health care, which represents US$ 1.7 per capita. However, total health expenditure in Uganda, including that by NGOs and donor agencies, is estimated to be US$ 7.73 per capita. The proportion of health financing from external sources is estimated to be 70%. 26 4.1 NGOs and drug distribution and supply in the three countries In all three countries, NGOs play a major role in drug distribution and supply, especially in more rural areas. In these areas¾which tend to lack a strong private sector and where there is little MoH presence¾NGOs are the main suppliers of drugs and providers of health services. In each country, the NGOs involved in drug distribution and supply are mainly national mission-based NGOs. A few international NGOs, but of less significance, also operate. The Mission for Essential Drugs and Supplies (MEDS) in Kenya, the Christian Medical Association for Malawi (CHAM) in Malawi, and the Joint Medical Stores (JMS) in Uganda are all affiliated to international networks, but highly independent in their activities. NGOs are expected to become more important in drug distribution and supply in these countries, owing to: · ongoing decentralization of the public health systems; · difficult economic situations (especially in Kenya and Malawi); · demands from donorsa for more NGO involvement in drug distribution and supply. In the three countries studied, continued need for donor funding of public distribution systems and, to a lesser extent, for missionary-based systems underlines the issue of sustainability regarding NGO activities in drug distribution and supply. Both public systems and NGO systems depend on external funding. Therefore, none of them can claim to be financially sustainable, although JMS in Uganda is 75% self-financed, and similar figures apply to MEDS in Kenya and CHAM in Malawi. In all three countries, the lack of government resources is leading to competition between the different stakeholders involved in drug distribution and supply. In Malawi, the MoH&P is sceptical about NGOs. It believes they lack professional capacity and that they are unwilling to be regulated. Such an attitude understandably affects the collaboration between the ministry and NGOs. This sceptical attitude towards NGOs on the part of the MoH is also seen, to a degree, in Kenya. Moreover, in all three countries, policy in drug distribution and supply has been developed without much NGO involvement. a Donors are phasing out their funding of public distribution systems in Uganda and reducing their funding in Malawi. Collaboration between NGOs, MoH and WHO in drug distribution and supply 26 Yet country studies revealed that NGOs are interested in collaborating more closely with WHO and MoHs in drug distribution and supply. They showed too that NGOs are prepared to work under some kinds of regulations (even though these could restrict their activities), provided their autonomy could be guaranteed. In all three countries, NGOs would like the national drug programmes to adopt a more proactive approach towards working with them, and urged WHO to use its comparative advantages to create better links between NGOs and MoHs. A more proactive WHO approach towards NGOs would presumably cause MoHs to focus more on NGOs. 4.2 What WHO can offer NGOs at country level In Section 1, seven issues were enumerated for consideration when collaboration between NGOs, MoH and WHO is to be developed: a definition of what is understood as the NGO sector; surveillance of the NGO sector; assessment of roles; assessment of strengths and weaknesses; identification and analysis of relevant government policies; examination of the role of coordination bodies; and development of relevant policies for collaboration with NGOs.12 However, two preconditions must be met before starting collaboration: a government must recognize that NGOs have a role to play and that it is responsible for ensuring that NGOs can carry out their role, and NGOs must be willing to cooperate with governments. These two preconditions have been met in Kenya and Uganda, but only partly in Malawi. Discussion with NGOs in Malawi revealed that NGOs were interested in an increased interaction with MoH&P and MEDP, but that the attitude of MoH&P and MEDP towards NGOs was ambiguous, and related to personal attitude rather than a formulated policy. And in Kenya, although the Health Policy Framework26 from 1994 recognizes the increasing role of NGOs, development of an actual NGO policy involving NGOs has not occurred. Unlike Kenya, interaction in Uganda between MoH and NGOs has not been structured by an explicit policy developed by MoH or the National Drug Authority (NDA), but nevertheless seems to run smoothly. In Kenya, what is understood as the NGO sector has been defined, even though no real survey of the NGO sector has taken place. Admittedly, the MoH has begun to recognize the increasing role of NGOs, as seen in its 1994 Health Policy Framework. But structured collaboration was only initiated very recently, when the Kenya National Drug Policy Implementation Programme (KNDPIP) held two meetings with NGOs. In Malawi and Uganda, no clear definitions of what is understood as the NGO sector have been developed. However, in Uganda, the importance of NGOs is recognized and an understanding of the government and NGO system as complementary to each other has been established. The situation in Malawi is uncertain owing to restructuring of the national drug programme. No clear assessment of the roles of the public sector and the NGO sector in drug distribution and supply has been carried out. However, the Council of Non- Governmental Organizations in Malawi (CONGOMA) has defined what is understood as the NGO sector, surveyed the sector and drawn up a draft code of conduct for NGOs in Malawi. Country studies: Kenya, Malawi, Uganda 27 The seven issues listed in Section 1 can be seen as a progression of steps leading towards increasing interaction and trust. Unfortunately, in Malawi, this progression had not advanced very far. But potential for further development of collaboration between NGOs, MoH and WHO in Kenya and Uganda is good. Initiation of meetings by the national drug programmes during the country visits in Uganda and immediately after in Kenya showed that stakeholders are interested in interaction and collaboration. Indeed, they are keen to establish a forum for discussion and as a means of resolving common problems. 4.3 Initiating collaboration between NGOs and WHO at country level In the above discussion on “collaboration between WHO/HQ programmes and NGOs”, four conditions were listed as essential if information and decisions made at the international level are to flow down to national level and strengthen collaboration between NGOs, MoHs and WHO in drug distribution. The country studies showed, however, that agreements and knowledge accumulated at international level do not necessarily flow down to country level. They also showed that WHO programmes focus extensively on MoHs and only to a limited extent on NGOs, even though NGOs are important in drug distribution and supply in all three countries. The clearest example of this approach was provided by the GTB programme, which focuses heavily on the MoH in Uganda, even though the German Leprosy Relief Association (GLAR) is heavily involved in distributing TB drugs in this country. GLAR funds leprosy activities in 33 districts and TB activities in 19 out of 39 districts. GLAR is satisfied with its role in providing services to the MoH, but closer interaction between GLAR, the GTB programme at HQ, and the WHO country office could have been expected. The GLAR example is typical of the lack of interaction between WHO country offices and NGOs. In Kenya, Malawi and Uganda the following two questions were raised concerning the role of WHO: · What can WHO offer NGOs? (Not many NGOs could answer this question.) · Could WHO use its strong links with MoHs in order to get NGOs and MoHs to work more closely together, thereby helping to focus the work of MoHs and NGOs in the same direction? The problems addressed by NGOs are recognized by WHO at country level. However, since there is no specific demand from programmes at HQ or from the African Regional Office (AFRO) to work with NGOs at country level, little is being done to encourage or initiate such collaboration. Interestingly, simply undertaking research in this area was seen to act as a catalyst for increased interaction between the stakeholders in drug distribution and supply. This was illustrated by the NDA in Uganda and KNDPIP in Kenya, who both used the research carried out for this analysis as a starting-point for activities of their own. In Kenya and Uganda, NGOs and MoHs showed a clear interest in and capacity to undertake collaboration. Such interest was less apparent in Malawi. In all three countries, NGOs see WHO as a mediator who could bring NGOs, national drug programmes and MoHs together, thereby acting as a clearing-house for and stimulus to interaction. Several NGOs emphasized that they prefer clear and Collaboration between NGOs, MoH and WHO in drug distribution and supply 28 explicit rules for interaction and would appreciate the MoH and the national drug programme taking a leading role in initiating collaboration with NGOs. The fora for collaboration between the stakeholders in the three countries are very diverse. They range from an actual meeting involving the stakeholders in Uganda, to the possibility of CONGOMA acting as a future catalyst for NGO involvement in Malawi, to the existence of structures for collaboration in Kenya which are currently unused. This diversity reflects the different attitudes displayed towards NGOs in the three countries. In Uganda, the MoH is open to NGOs. In Malawi, the MoH is more circumspect, while in Kenya, the MoH is generally positive towards NGOs. Furthermore, personal perceptions appeared to be a very important determinant of the degree of collaboration. The issue of whether NGOs were in official or informal relations did not seem to have any significance at country level. 4.4 Conclusions of the country studies NGOs were shown to be very important in drug distribution and supply in all three countries, distributing more than 20% of all drugs. The major NGOs involved in this activity were mission-based NGOs, and self-financed to a high degree (approximately 75%). NGOs, the MoH in Kenya, the MoH in Uganda, the MoH in Malawi and WHO country offices, are generally positive about the idea of greater interaction and collaboration in drug distribution and supply. Thus, one of the preconditions for collaboration has been fulfilled. In all three countries, the personal perception of NGOs, the MoH and the national drug programme proved to be a major factor in collaborative work, and even more important than the existence of an actual policy concerning NGOs. In Kenya and Uganda, regular coordination meetings between the different stakeholders involved in drug distribution and supply have been initiated, showing that the stakeholders, including NGOs, are interested in streamlining their activities. The country studies showed that the preconditions for involvement of NGOs at country level by HQ programmes and WHO country offices have not necessarily been met, and that agreements and knowledge accumulated at international level do not necessarily flow down to country level. Given that interaction between NGOs and WHO is currently non-existent or minimal, NGOs wanted to know how WHO could help them in their work. The research highlighted furthermore that it would be possible to initiate collaboration between stakeholders, and that NGOs are interested in closer interaction with the national drug programme of their country, the MoH and WHO. The analysis also highlighted the fact that, since an explicit programme policy for working with NGOs at WHO regional level is lacking, WHO country offices currently do little to promote collaboration with NGOs in their own country. 4.5 Recommendations for WHO and NGOs at country level On the basis of the country studies, it is recommended that the WHO country offices in the African Region: · establish policies on how to involve NGOs in drug distribution and supply; Country studies: Kenya, Malawi, Uganda 29 · use the comparative advantage of WHO to act as a link between MoHs, national drug programmes and NGOs; · support MoHs in increasing the involvement of NGOs in drug distribution and supply; · establish mechanisms together with MoHs whereby NGO experiences can be collected and documented. It is also recommended that NGOs in the countries: · form coalitions of NGOs involved in drug distribution and supply, to create partners for the national drug programmes and WHO; · define the role of NGOs in drug distribution and supply. Collaboration between NGOs, MoH and WHO in drug distribution and supply 30 5. Discussion The purpose of this study was to: · develop a list of specific WHO programmes/divisions working in drug distribution and supply; · develop an inventory of the NGOs involved in drug distribution and supply (including which countries they are working in and what they are doing); · analyse the experiences of NGOs, MoHs and WHO programmes when collaborating in drug distribution and supply; · suggest how WHO can translate these experiences into recommendations for future WHO policy and programme implementation. As the above analysis has shown, it was possible to develop a list of specific WHO programmes working in drug distribution and supply (Table 1), but not a complete inventory of the NGOs working in this area. This was because the individual programmes had not developed an overview of the relevant NGOs. The experiences of NGOs, MoHs and WHO in collaboration in drug distribution and supply are diverse. Much of the work in WHO programmes and at country level is based on false assumptions about the downflow of information, and about whether WHO/HQ programmes request the involvement of NGOs. Little effort has been made by WHO to establish interaction between NGOs, MoHs and WHO itself. It is therefore recommended that WHO programmes involved in drug distribution and supply develop explicit policies on NGO interaction that can be used within the programmes, and at international and country levels. This analysis can be seen within a broader WHO perspective. Meetings held in Ireland21 and Geneva17 included broader discussions on what the future role of NGOs should be within a WHO context. During the meeting in Geneva, the Director of AFRO invited NGOs to a regional meeting in Brazzaville. This was a signal to the NGOs and WHO representatives in the African Region, and to WHO/HQ, that NGOs working in the African Region could play a more central role in health care and provision. This invitation can be seen in the context of the changing roles and importance of NGOs, as already discussed, and as recognized by many stakeholders in health (see Figure 1). During the Geneva meeting, national and international NGOs requested WHO to act as the mediator between NGOs and MoHs, to combine the strengths of NGOs, MoHs and WHO. This same request was heard when the country studies were conducted. Other agencies such as the World Bank and UNICEF have explicitly recognized the new NGO situation and developed guidelines on how to establish contacts with NGOs at country level. Guidelines for NGOs working with UNICEF¾Operational Issues for UNICEF and NGO Staff, Guidelines for UNICEF Zambia Staff on working with NGOs, and Partnership in Action, are just some examples. Additionally, UNICEF in Kenya has established an NGO profile that Discussion 31 outlines specific criteria that must be met by NGOs collaborating with UNICEF (see Annex 5). A new WHO policy on NGOs to cover the two-thirds of NGOs who are involved in drug distribution and supply, and who are in informal relations with WHO, would thus be very timely. A crucial first step in developing such a policy would be to establish more extensive evidence based on WHO collaboration with NGOs than is presented here. Further research is recommended to: · identify countries and initiate research in Asia, Europe, South America and West Africa for comparative studies; · analyse the experience of NGO collaboration in drug distribution and supply of other UN agencies. Collaboration between NGOs, MoH and WHO in drug distribution and supply 32 Annex 1. Questions discussed with WHO/HQ programmes concerning NGOs and drug distribution and supply Programme policy on NGOs a) What is the programme policy on collaboration with NGOs? b) What is the programme’s role when collaborating with NGOs? c) Does the programme finance NGO activities? d) What are the main challenges that the programme and WHO must deal with when collaborating with NGOs? Importance of NGOs in programme work on drug distribution and supply a) How important are NGOs in programme work, and what percentage of a country’s drugs do NGOs distribute? b) Does the programme have a list of the NGOs with which it collaborates? c) With what kind of NGOs does the programme collaborate? Performance of NGOs in drug distribution and supply a) What are the general programme experiences with NGOs? b) What are the comparative advantages of NGOs? c) How well do NGOs perform in the different parts of the drug management cycle? d) How well do NGOs secure access to distributed drugs, and how efficient are NGOs? e) How well do NGOs coordinate their activities with other stakeholders? Annex 1 33 Collaboration between NGOs, MoH and WHO in drug distribution and supply 34 Annex 2. Themes discussed with international NGOs Collaboration between NGOs and WHO · Experiences of NGOs in collaboration with WHO in drug distribution and supply. · Comparative advantages of NGOs collaborating with WHO programmes in drug distribution and supply. · Efficiency of NGOs in drug distribution and supply. In-country distribution of drugs · Management of import, port clearance, transportation and distribution of drugs. Planning, building and management of storage and health facilities. · Securing regular flow, proper storage and provision of adequate stock. · Coordination with other agencies. · Percentage of drugs distributed by NGOs. Selection, procurement and management support · Management of information and human resources. · Financing of drugs and drug distribution. · Selection and buying of drugs. · Procurement: managing procurement, quantifying drug requirements, securing quality assurance and handling of drug donations. Impact of other stakeholders on WHO and NGO collaboration in drug distribution · Government and government institutions. · The UN system. · Other stakeholders. Annex 2 35 Collaboration between NGOs, MoH and WHO in drug distribution and supply 36 Annex 3. Themes discussed with stakeholders in Kenya, Malawi and Uganda · Areas of mutual interest for NGOs and MoHs, and experiences so far. · The present and possible future roles of the various stakeholders in drug distribution and supply. Comparative advantages of different stakeholders. · Coordination or collaboration. · Constraints on collaboration imposed by the various stakeholders. · Sustainability. · Experiences with WHO. · Experiences with other NGOs and other UN agencies. Annex 3 37 Collaboration between NGOs, MoH and WHO in drug distribution and supply 38 Annex 4. List of persons met The following persons have contributed to this study. Their advice and support are gratefully acknowledged. KENYA Crown Agents Mr B.O. Odenyo, Crown Agents Representative Mr M.Q. Watson, Senior Representative Medical Supply and Coordination Unit Dr Kandiie, Pharmacist Mr Kibera, DS – Officer-in-charge Ms Kioko, Pharm. Technician Mr E. Nduri, Pharm. Technologist Mrs I.A. Oduogi, Nursing Officer MoH Dr A. Gallacchi, Adviser, HESSP Dr K.C. Koskei, Chief Pharmacist Dr E. Larsson, Health Planning and Management Adviser, HESSP NGOs Mrs J.M.A. Adewa, Asst. General Manager, Mission for Essential Drugs and Supplies (MEDS) Dr J. Carter, Pharmacist, African Medical and Research Foundation (AMREF) Mr A. Chauhan, Coordinator, Pharmaciens Sans Frontières Mrs C. Chomilier, Medical Logistics Officer, MSF Mrs M.M. Kariuki, Policy Analyst, AMREF Mrs J. Masiga, Assistant General Manager Pharmacy, Mission for Essential Drugs and Supplies The Programme Director, Action Nord Sud Mr P.K. Patel, President, Lions Club; Director, Cosmos Pharmaceutical Manufacturers Mrs D. Wafula, Pharmacist, International Committee of the Red Cross Royal Dutch Embassy Mr J. Christiansen, First Secretary UNICEF Dr R. Goind, Country Representative Annex 4 39 WHO/Kenya Dr P.O. Chuke, WHO Representative, Kenya Mr P.J. Graff, Kenya Drug Policy Implementation Programme Coordinator Mr C. Ondari, Officer, Kenya Drug Policy Implementation Programme Coordinator WHO/Somalia Mr P. Hagen, WHO Representative, Somalia Dr R. Shoo, Professional Officer MALAWI Central Medical Stores Mr A. Churri, Acting Chief Pharmacist MoH Mr C. Ciwa, Programme Manager, Malaria Programme Professor P.R. Khonje, Controller of Health Mrs Maganga, Programme Manager, ARA Programme Mr Ninda, Programme Manager, CDD Programme NGOs Mr G.A. Banda, National Social Services Coordinator, CARITAS Mr P. Dil, Programme Coordinator, World Vision Mr D. Faiti, Executive Secretary, CONGOMA in Malawi Mr L. Mihowa, Programme Manager, Sue Ryder Foundation, Balaka Mr C. Mwale, Country Manager, Banja La Mtsogolo Ms N.S. Que, Chief Pharmacist, Christian Health Association of Malawi Mrs C. Thompson, Acting Programme Manager, STAFH Mrs C. Witte, Country Manager, International Eye Foundation in Malawi WHO/Malawi Dr M.E. Chuwa, WHO Country Representative, Malawi Mr C. Forshaw, Programme Advisor, MEDP UGANDA MoH Mr M. Oteba, Principal Pharmacist, Acting CHS Pharmacy & H.S. National Drug Authority Mr G. Kisuule, Head of Drug Assessment and Registration Department Dr J.C. Lule, Head of Resource Land Training Department Dr C. Mwogia, Adviser Mr B. Osmond, Adviser Collaboration between NGOs, MoH and WHO in drug distribution and supply 40 National Medical Stores Mr Y. van Harparen, Programme Manager NGOs Dr. J. Kafulco, Health Programme Officer, UNICEF Mr A. Kilian, Consultant, GTZ Mr M. McGoldrich, Pharmacist, Hospice¾Uganda Dr A. Merriman, Medical Director, Hospice¾Uganda Dr R. Odelce, Zonal TB/Leprosy Supervisor Mr M. van der Poel, Manager, Joint Medical Stores Dr V. Riehl, GLAR Representative Mr P. Troisvallets, Country Coordinator, MSF-Switzerland Mr P.Victor, Pharmacist, Joint Medical Stores Mr L. Yves, Country Coordinator, MSF-France WHO/Uganda Dr S.O. Baine, Disease Prevention and Control Adviser Dr J. Namboze, WHO Professional Officer in Communicable Diseases Dr H. Nije, WHO Representative, Uganda Dr O. Setumbue, WHO Professional Officer in Maternal Health and Sexually Transmitted Diseases WHO headquarters Dr P. Chaulet, GTB Dr D.P.J. Daumerie, LEP Dr D.E. Etaya’ale, PBL Mr P.M. Evans, GPV Ms D.A Fresle, DAP Dr A. Tekle Haimanot, Division of Control of Tropical Diseases (CTD/MAL) Ms A.C. Hemsworth, DAP Dr H.V. Hogerzeil, DAP Dr H.O. King, Diabetes Mellitus (NCD/DIA) Dr L.H.C.M. Kuppens, EMC Mr C.L. Lissner, Division of Reproductive Health Dr S. Muziki, DAP Dr J.D. Quick, DAP Dr J.H.F. Remme, Special Programme for Research and Training in Tropical Diseases (CTD/TDF) Dr D.A. Robinson, CHD Dr H. Siem, EHA Dr T. Yasukawa, EHA International NGOs (headquarters) Dr V.D. Besten, IDA Ms C. Green, ECHO International Health Services Ltd. Ms M. Henkens, MSF Dr E.M.A. Ombaka, World Council of Churches Annex 4 41 Collaboration between NGOs, MoH and WHO in drug distribution and supply 42 Annex 5. Criteria to be met by NGOs when collaborating with UNICEF in Kenya Project Cooperation Agreement between UNICEF and Preamble Whereas the United Nations Children’s Fund (hereinafter referred to as “UNICEF”) and ________________, (hereinafter referred to as “the NGO”) have, on the basis of their respective mandate, as a common aim the well-being of children and women; Whereas UNICEF, on the basis of General Assembly Resolution 417 (V) of 1 December 1950 has been requested to obtain, from nongovernmental organizations having a special interest in child and family welfare the advice and technical assistance required for the implementation of its programmes; Whereas the Government and UNICEF have, in accordance with the Basic Cooperation Agreement between the Government and UNICEF entered into force on _____________ (only in countries where applicable) concluded a Master Plan of Operations which contains the programmes of cooperation between the Government and UNICEF and which provides the framework for the project, entitled here [name of the project] (hereinafter referred to as “the Project”); Whereas UNICEF has been entrusted by its donors with certain resources that can be allocated for cooperative programmes and projects with external organizations, and is accountable to its donors and the UNICEF Executive Board for the proper management of these funds and can, in accordance with the UNICEF Financial Regulations and Rules, make available such resources for the cooperation in the Project; Whereas the NGO, its status being in accordance with national regulations, is committed to the generally-accepted principles of participatory, sustainable development and development-oriented humanitarian assistance (for emergency situations); has demonstrated the capacity needed for the activities involved; is apolitical and not profit-oriented; Whereas the NGO and UNICEF agree that services shall be provided and material assistance be distributed impartially without discrimination, direct or indirect, because of race, creed, nationality status or political belief or any other such circumstances; Now, therefore, on the basis of mutual trust and in the spirit of friendly cooperation, the NGO and UNICEF have entered into the present Agreement. Annex 5 43 Article I. Definitions For the purpose of the present Agreement, the following definitions shall apply: a) “Parties” shall mean the NGO and UNICEF; b) “UNICEF” shall mean the United Nations Children's Fund, a subsidiary organ of the United Nations, established by the General Assembly of the United Nations by resolution 57 (I) of 11 December 1946; c) “The NGO” shall mean the nongovernmental organization which was established in, and incorporated under the laws of, [country] with the purpose of ____________; d) ”This Agreement” or “the present Agreement” shall mean the present Project Cooperation Agreement, the Project Plan (Annex A), the Project Budget (Annex B), the list of non-expendable property including vehicles (Annex C) and all other documents agreed upon between the Parties to be integral parts of this Agreement; e) ”Project” shall mean all the works and activities as described in the Project Plan; f) ”Government” shall mean the Government of _______________; g) ”UNICEF Representative” shall mean the UNICEF official in charge of the UNICEF Office in the country, or the person acting on his/her behalf; h) ”Person in charge of the Project” or “Project Manager” shall mean a person appointed by the NGO acting as the overall coordinator of the Project, assuming the primary responsibility for all aspects of it; i) “Expenditure” shall mean the sum of disbursements made and valid outstanding liabilities incurred in respect of goods and services rendered; j) “To advance” shall mean a transfer of assets including advances which shall be interpreted as meaning a payment of cash or a transfer of supplies, the accounting for which must be rendered by the NGO at a later date as herein agreed upon between the Parties; k) “Income” shall mean the interest on the Project Bank Account and all revenue derived from the use or sale of capital equipment, and from items purchased with funds provided by UNICEF; l) “Force Majeure” shall mean acts of nature, war (whether declared or not), invasion, revolution, insurrection or other acts of a similar nature or force; Article II. Objective and scope of this Agreement 1. This Agreement sets forth the general terms and conditions of the cooperation between the Parties in all aspects of achieving the Project objectives as set out in the Project Plan, Annex A. 2. The Parties agree to join efforts and to maintain close working relationships in order to achieve the objectives of the Project. Article III. Duration of the Project Agreement 1. The term of this Agreement shall commence on ____________ and terminate on ________. The Project shall commence and be completed in accordance with the schedule as set out in the Project Plan. Collaboration between NGOs, MoH and WHO in drug distribution and supply 44 2. Should it become evident to either Party during the implementation of the Project that an extension beyond the expiration date set out in paragraph 1 above will be necessary to achieve the objectives of this Project, the Party shall without delay inform the other with a view to entering into consultation to agree on a new termination date. Upon agreement on a termination date, the Parties shall conclude an amendment to this effect in accordance with Article XVI. 3. Should it become evident that the Project will not be completed during the approved current country programme agreed between UNICEF and the Government and should UNICEF decide that the extension of the Project will be appropriate within the framework of the new country programme, the Parties may agree to extend the Project for the period of the new country programme or whichever period of time may be seen fit within the new country programme. The procedure as outlined in Article XVI shall apply. Article IV. General responsibilities of the Parties 1. The Parties agree to carry out their respective responsibilities in accordance with the provisions of this Agreement. 2. Each Party shall determine and communicate to the other person (or unit) having the ultimate authority and responsibility for the Project on its behalf. The Person in charge of the Project or Project Manager shall be selected as mutually agreed upon between the Parties. 3. The Parties shall keep each other informed of all activities pertaining to the Project and shall consult once every three months or as circumstances arise which may have a bearing on the status of either Party in the country or may affect the achievement of the objectives of the Project, with a view to reviewing the workplan, budget and execution of the Project. 4. The Parties shall cooperate with each other to obtain and secure any licenses and permits required by national laws, where appropriate and necessary for the achievement of the objectives of the Project. 5. The NGO may only use the name and emblem of UNICEF in connection with the Project and subject to prior written consent of the UNICEF Representative in the country. 6. The UNICEF Representative will act as the principal channel for communicating with the Government regarding the Project. The Project Manager will be responsible for the day-to-day contacts with the relevant authorities on operational matters. 7. The UNICEF Representative will facilitate access to information, advisory services, technical and professional support available to UNICEF and assist the NGO to avail UNICEF of the advisory services of other United Nations organizations, whenever necessary. Article V. Personnel requirements Annex 5 45 1. The NGO shall be fully responsible for all work and services performed by its personnel, agents, employees, contractors or sub-contractors. 2. The NGO's personnel, its agents, employees, contractors or sub-contractors shall not be considered in any respect as being the employees or agents of UNICEF. The NGO shall ensure that all relevant national labour laws are observed. The NGO shall provide and maintain all salaries for its employees. It is understood that UNICEF is not liable for any claims for death, bodily injury, disability, damage to property or other hazards which may be suffered by employees of the NGO or of contractors hired by the NGO as a result of their employment or work pertaining to the Project. The NGO shall, therefore, take out and maintain all appropriate workmen's compensation and liability insurance to cover its employees in any such cases and any other insurance as may be agreed upon between the Parties. 3. The NGO shall ensure that its employees and any outside contractors, including technical experts and consultants, meet the highest standards of qualification and technical and professional competence necessary for the achievement of the objectives of the Project and that in decisions on employment related to the execution of the Project shall be free of discrimination on the basis of race, religion, sex handicapped status, ethnic groups or national origin, or other similar factors. Article VI. Supplies, vehicles and procurement 1. Each Party shall contribute to the Project the supplies, equipment and vehicles as indicated in the Project Budget (Annex B) and detailed in the list of non-expendable property (Annex C). 2. Technical and other equipment, non-expendable materials, supplies and other property furnished or financed by UNICEF shall remain the property of UNICEF and shall be returned to UNICEF upon completion of the project or upon termination of this Agreement unless otherwise agreed upon between the Parties. Prior to such return the NGO shall, for the protection of such equipment, materials and supplies, obtain appropriate insurance in such amounts as may be agreed upon between the Parties and incorporated in the Project Budget. 3. Vehicles made available to the NGO by UNICEF or purchased by the NGO with funds made available by UNICEF shall remain the property of UNICEF and shall be returned to UNICEF upon completion of the project or upon termination of the present Agreement unless otherwise agreed upon between the Parties. Separate loan agreements (UNICEF standard vehicle loan agreement, but review required) shall be concluded between the NGO and UNICEF pertaining to the use, insurance, maintenance, etc. of the vehicles, unless the Parties agree otherwise in writing. The NGO shall be responsible for the proper maintenance and care of the vehicles made available by UNICEF. The NGO shall not be liable for any normal wear and tear. Collaboration between NGOs, MoH and WHO in drug distribution and supply 46 4. UNICEF may place on the supplies, equipment and other materials it furnishes or finances, including vehicles, such markings as may be necessary to identify them as being provided by UNICEF. 5. In cases of total damage, theft or other losses of vehicles and other expendable property made available to the NGO, the NGO shall provide UNICEF with a comprehensive report, including a police report, where appropriate, and any other evidence giving full details of the event leading to the loss of the property. 6. In its procedures for local procurement of supplies and equipment with funds made available by UNICEF as provided for in the Project Budget the NGO shall ensure that, when placing orders or awarding contracts for the purchase or hire of all supplies, goods and other equipment under the Project Agreement, it will safeguard the principles of highest quality, economy and efficiency and that the placing of will be based on an assessment of competitive quotations or bids, unless otherwise agreed to by UNICEF. The NGO shall purchase products only from those companies that comply with existing national labour laws and regulations with regard to their employment practices (minimum age of employment, wages, working conditions), including apprenticeships for children beyond the age of primary schooling, providing that those laws and regulations comply with the principles established in paragraph 1 of article 32 of the Convention on the Rights of the Child (subject to the country’s ratification of the Convention). 7. All international procurement using UNICEF funds shall be undertaken by UNICEF which is exempt by virtue of its privileges and immunities from the payment of direct taxes and customs duties. 8. The NGO shall maintain complete and accurate records of supplies, equipment and other property purchased with UNICEF funds and shall take periodic physical inventories of all equipment, property and non-expendable materials and supplies. The NGO shall provide UNICEF with records on such equipment, property and supplies at such time and in such form as UNICEF may reasonably request. Article VII. Financial and operational arrangements 1. In accordance with the Project Budget (Annex B), UNICEF has allocated and will make available to the NGO funds in the local currency up to the maximum amount of _______________. The first instalment of _____________ will be advanced to a project bank account designated by the NGO within five working days following the signature of this Agreement. The second and subsequent instalments will be advanced to the NGO as and when reports and accounts in the form of certified statements and/or other agreed upon documentation for the work completed have been submitted to and accepted by UNICEF showing satisfactory management and use of UNICEF's resources. 2. The NGO shall establish a separate bank account for the funds made available by UNICEF, unless UNICEF agrees otherwise and shall inform UNICEF of the opening of such bank account. The project bank account shall be maintained in the local currency. Annex 5 47 3. The NGO agrees to utilize the funds and any supplies and equipment provided by UNICEF in strict accordance with the Project Plan and Project Budget. The NGO shall be authorized to make variations not exceeding 10 percent on any one line item of the budget funded by UNICEF as shown in the Project Budget (Annex B), provided that the total budget allocated by UNICEF is not overspent. Whenever possible the NGO shall notify UNICEF about any expected variations at the occasion of the quarterly consultations and reviews as set forth in Article IV, paragraph 3. Any variations exceeding 10 percent on any one line item that may be necessary for the proper and successful implementation of the Project shall be subject to prior consultations with and approval in writing by UNICEF. 4. The NGO shall make available the personnel, supplies and other services as provided for in Annexes A and B. It is understood that UNICEF contributions to the Project Budget, in principle, do not cover overhead costs incurred by the NGO. In exceptional circumstances, personnel cost and other expenses which in the assessment of the Parties are essential to fulfil specific tasks or to reach specific purposes necessary for the effective and efficient implementation of the Project may be included in the Project Budget. 5. The NGO further agrees to return within two (2) weeks any unused supplies made available by UNICEF at the termination or end of this Agreement or the completion of the Project. Any unspent funds shall be returned within three months of the termination of this Agreement or the completion of the Project. 6. UNICEF shall not be liable for the payment of any expenses, fees, tolls or any other financial cost not outlined in the Project Plan or Project Budget, Annexes A and B, unless UNICEF has explicitly agreed in writing to do so prior to the expenditure by the NGO. Article VIII. Maintenance of records 1. The NGO shall keep accurate and up-to-date records and documents in respect of all expenditures incurred with funds made available by UNICEF to ensure that any obligations entered into and all disbursements made are in conformity with the provisions of the Project Plan (Annex A) and the Project Budget (Annex B). These records shall be kept separately from any other records of the NGO. For each payment, the documentation shall include the project designation, the payee, the amount, purpose and date of the disbursement. Original bills, invoices, receipts and any other supporting documentation pertinent to the transaction shall be attached. It is understood that any income as defined in Article I (i) arising from the management of the Project shall be promptly disclosed to UNICEF. The income shall be recorded as accrued income to UNICEF. 2. All vouchers, bills, invoices, and other financial statements shall be prepared by the NGO and submitted to UNICEF in the local currency. Collaboration between NGOs, MoH and WHO in drug distribution and supply 48 3. Upon completion of the Project/termination of this Agreement, the NGO shall maintain the records for a period of at least four years, unless otherwise agreed upon between the Parties. Article IX. Reporting requirements 1. The NGO shall submit to UNICEF every six months or as otherwise agreed upon between the Parties progress reports, if possible in June and December of each year. 2. The NGO shall submit to UNICEF annual financial reports on the funds provided by UNICEF and UNICEF stock reports no later than three months after the end of UNICEF's financial year. 3. Within three months of the completion of the Project or of the termination of the present Agreement, the NGO shall submit to UNICEF a final report on the outcome of the Project, and a final financial report on the use of UNICEF funds, supplies and other equipment. Article X. Access for UNICEF internal auditors UNICEF shall have the right, at its own expense, to have the records of the NGO pertaining to the execution of the Project reviewed and copied by the UNICEF Office of Internal Audit or the United Nations Board of Auditors. Article XI. Responsibility for claims 1. The NGO shall indemnify, hold and save harmless and defend, at its own expense, UNICEF, its officials and persons performing services for UNICEF, from and against all suits, claims, demands and liability of any nature and kind, including their cost and expenses, arising out of the acts or omissions of the NGO or its employees or persons hired for the execution of the present Agreement and the Project. 2. The NGO shall be responsible for, and deal with all claims brought against it by its personnel, employees, agents or contractors. Article XII. Early termination 1. Either Party shall have the right to terminate this Agreement within thirty days of a written notice to this effect, if the other Party is unable, unwilling or otherwise impeded to perform its obligations and meet its responsibilities under the present Agreement which would seriously endanger the achievement of the objectives of the Project, provided that consultations with a view to eliminating the impediment were unsuccessfully held. 2. Upon receipt of a notice of termination in accordance with the preceding paragraph, the Parties shall take immediate steps to terminate their activities under this Agreement in a prompt and orderly manner so as to minimize losses and further expenditures. No further disbursement of funds by UNICEF to the NGO will take place. The NGO shall undertake no forward commitments and Annex 5 49 shall return to UNICEF, within 30 days, all unspent funds, supplies and property provided by UNICEF, unless UNICEF agrees otherwise. Article XIII. Force majeure 1. In the event of and as soon as possible after the occurrence of any cause constituting Force Majeure as defined in Article I (j), the Party(ies) shall give the (each) other notice and, if possible, particulars in writing of such occurrence, if the Party(ies) is (are) rendered unable, wholly or in part, to perform its (their) obligations or meet its (their) responsibilities under the Project Agreement. The Parties shall consult on the appropriate action to be taken, which may include suspension of the Project or termination of this Agreement, in accordance with Article XII paragraph 1. 2. In the event that this Agreement is terminated due to causes constituting Force Majeure, the provisions of Article XII, paragraph 2 shall apply. Article XIV. Arbitration Any dispute, controversy or claim arising out of, or relating to the present Agreement, including breach and termination thereof shall, unless it is amicably settled by direct negotiations, be referred to arbitration in accordance with the UNCITRAL Arbitration Rules then obtaining. Such arbitration shall be conducted under the auspices of the International Chamber of Commerce which shall also serve as the Appointing Authority under the Rules. The Parties shall be bound by the arbitration award rendered in accordance with such arbitration, as the final adjudication of any such dispute, controversy or claim. Article XV. Privileges and immunities Nothing in or related to this Agreement shall be deemed a waiver, express or implied, of any of the privileges and immunities of the United Nations and UNICEF. Article XVI. Amendments This Agreement or its Annexes may be modified or amended only by written agreement between the Parties. IN WITNESS WHEREOF the undersigned, being duly authorized thereto, have on behalf of the Parties hereto signed this Agreement at the place and on the day below written. FOR the NGO: FOR UNICEF: Signature ______________ Signature ______________ Name ______________ Name ______________ Title ______________ Title ______________ Place ______________ Place ______________ Collaboration between NGOs, MoH and WHO in drug distribution and supply 50 Date ______________ Date ______________ Annex 5 51 Page 1 NGO Profile 1. Name of NGO_______________________________________________________ 2. Affiliate of _______________________________________________________ 3. Postal Address _________________________________________________ 4. Physical/Street Address ______________________________________________ 5. Telephone No. ___________________ Fax No. ____________________________ 6. Type of Organization ______________________ Not-for-Profit ______________________ Government ______________________ Quasi-Government 7. Post and Street Address of Parent Organization (if any) ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ 8. List of Board of Directors, term and address ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ 9. Authorized Person _________________ Designation ______________________ Direct Telephone No. _______________ Collaboration between NGOs, MoH and WHO in drug distribution and supply 52 Page 2 NGO’s Profile (continued) 10. NGO Registration details: A. Certificate of Inc. _______________ B. Date Organized ________________ C. Charitable Organization or NGO Reg. Number ________________________ D. PIN Number (if applicable) _________________________________________ E. Mandatory Filing Requirement up to date ____________________________ 11. Bank Information _________________________________________________ _________________________________________________ _________________________________________________ 12. Do you have sub-offices in the province, district or town? If yes, (attached list town, address, street address and telephone number) 13. Main activities of the Organization A __________________________________________________________________ B ___________________________________________________________________ C ___________________________________________________________________ D __________________________________________________________________ E ___________________________________________________________________ 14. Number of employees at HQ __________ Field ___________________________ 15. Copy last audited Statement __________________________________________ 16. Copy last annual report of the Organization _____________________________ 17. Membership (Professional/Organization Membership) ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ 18. Have you worked with other UN agencies or international organization before or currently? Yes ____ No _____ (if yes [attach] list the name of the organization, contact person and their telephone no., adddress, including the nature of work/service performed.) Annex 5 53 Page 3 Comment by UNICEF: New NGO Evaluation of NGO Capacity to Implement UNICEF Project (Project Officer) ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ _______________________________ Signature _______________ Name ______________________ Date _________________ Evaluation of the NGO’s Internal Control System and its Financial Positions as of _______________________ (Finance Officer and Operation Officer) ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________ Signature _______________ Name ______________________ Date _________________ Representative’s comments Date Collaboration between NGOs, MoH and WHO in drug distribution and supply 54 Page 4 Working experience with UNICEF (Comment by Project Officer) ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________ Signature _______________ Name ________________________ Date ______________ Evaluation of the NGO’s Internal Control and Financial Positions as of ___________________ (Finance Officer/Operation Officer) ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________ Signature _______________ Name ________________________ Date _________________ Representative’s comments Date References 55 References 1 WHO. 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