How NGOs Can Work With Governments to Build Partnerships That Will Scale

Dr. Agoro, regional health director, at an Integrate Health Community Health Worker training.

On the night before Integrate Health’s first Community Health Worker training in 2015, we got a startling call: "Please take the Ministry of Health logo off the training materials." Integrate Health had worked with the Ministry of Health’s District Health Director, from day one, to design the program. But she had gotten cold feet.

Gbeleou went to her office the next morning, and emerged after an hour, shaking his head. We had secured permission to proceed with the training and launch the program, with only the NGO logo on the training materials. The program that Integrate Health and the Ministry of Health were piloting together, the Integrated Primary Care Program, had acquired all of the necessary approvals and was even part of a joint study. But it was also different—Community Health Workers were being paid to work full-time, unlike the country's volunteer model—and different can be risky.

Since that initial rocky start in 2015, Integrate Health has made significant progress in strengthening our partnership with the Ministry of Health. In fact, Gbeleou and Dr. Sibabe Agoro, Regional Health Director for the Ministry of Health in Togo, had just returned from obtaining their UK visas in March of this year when they learned that the Skoll World Forum had been canceled due to COVID-19. Gbeleou and Dr. Agoro had planned to travel to Oxford to participate in a panel discussion on government and NGO partnership at scale. But as the novel coronavirus grew to a pandemic, the critical need for effective NGO and government collaboration rapidly accelerated.

Today, Gbeleou is a key participant in the coronavirus task force, convened by Dr. Agoro twice weekly. The two are in contact daily as the Ministry of Health mounts a rapid response and Integrate Health mobilizes technical and financial resources in support of the Ministry of Health to meet the country’s rapidly evolving needs. 

Why Partnership Is Critical for Scale

This partnership, seamless in a time of crisis, was not always this strong. NGOs and governments are different. We have different goals, different mandates, and different constraints. But we need one another: NGOs can be nimble and flexible and can try things that governments can't afford to do, whether financially or politically. And while NGOs can take risks and fail, NGOs need governments to scale, especially in fields like health care and education. Governments set national policies and funding, which provide scale and sustainability. And governments can leverage the support of NGOs to innovate and enhance accountability.

How can NGOs learn to work effectively with governments? At Integrate Health, we have learned a few key lessons, often the hard way, over the past five years of working to build real partnership with government.

1. Center the voice of government.

The literature on scale through public sector “adoption” tends to disproportionately focus on NGOs, positioning governments as the passive recipients of innovation. However, success stories illustrate that achieving impact through the public sector at scale requires building genuine, bi-directional partnership. Founding a genuine partnership requires putting government at the center from the earliest stages of designing a program or pilot.

For Integrate Health, our primary counterpart was the Togolese Ministry of Health’s District Health Director, since the health centers and communities where we hoped to work were under her jurisdiction. Our first step was to reach out to her, and to involve her from the initial design stage all the way through launch. She helped to identify challenges, provided input on the solutions, and selected the first intervention sites. Without her deep involvement we would have never gotten the pilot off the ground. But while this step was critical, it was just the beginning. The reality is that while the Director approved all of our decisions, she wasn’t fully convinced that the approach would work. She needed to see it to believe it.

2. Implement within existing government delivery and data systems.

If seeing is believing, then seeing a program work within the existing system is a prerequisite to scale with government. We worked with the District Health Director to ensure implementation was embedded in government systems, leveraging existing government infrastructure and personnel. The Integrated Primary Care Program launched in 2015 across four sites. The program was implemented directly in government clinics under the District Health Director’s supervision. The Director was able to observe the program as it operated and received feedback directly from her staff.

Effectively integrating the program’s impact data into the government’s data collection systems, however, proved more difficult, both logistically and politically. Ultimately the Ministry’s decision to transition to electronic data systems, namely DHIS2, created an opportunity for data from the Integrated Primary Care Program to be fed directly into the public sector system. This enabled outcomes to be routinely and consistently shared with government partners, such that the Integrated Primary Care Program data appear automatically in routine data that government actors see, analyze, and discuss each month in their regular review meetings. Critically, the District Health Director, and her superiors, could see the data and measure the impact from the activities happening in her District’s clinics and communities.

3. Build relationships with government partners at all levels.

There are always risks associated with trying something new, but securing buy-in from multiple levels within a system or hierarchy can minimize those risks for individual actors.

For example, in the first year of the Integrated Primary Care Program it became clear that the program was working: utilization rates of health services were skyrocketing and deaths were dropping. But the idea became far less risky to embrace just in time for the District Health Director to be transferred to a new district. This kind of disruption is a reality of working with governments: personnel are not stable, and during a three-year pilot, we worked with three different District Health Directors. Fortunately, each was able to directly observe the impact of the program in their district, just as the first District Health Director had. As the pilot’s success continued, word spread. Other Directors began to ask for the program in their Districts. As a result, we were asked to meet with the Regional Health Director. Together, we began to think about expansion to multiple districts.

We’ll never forget the day the Regional Health Director sent the email instructing all of his District Health Directors to work with us. This was a paradigm shift: No longer would we have to plead our case, present the evidence, and ask each Director to take a risk on us. But it was by building relationships at multiple levels that we had streamlined our efforts and paved the way to program expansion.

4. Progressively transfer real ownership to government partners.

This should be a goal from the beginning. The process of transferring ownership from NGOs to governments requires a transition, of course. Given the risks associated with new or innovative ideas, it is understandable that government officials want to be convinced of the program’s feasibility and effectiveness before they are willing to take the reins. But ownership is absolutely critical to long-term success and sustainability. Effective government ownership ensures that a program will continue once the NGO is no longer leading implementation.

The expansion of the Integrated Primary Care Program launched in July 2018, three years after the initial pilot began. We had garnered strong buy-in from government partners but Integrate Health, as an NGO, was still leading the implementation. Why was this? “We’ve been implementing this program for three years,” Gbeleou reflected; “We know it works. Our government partners know it works. But now is the time to let them lead.”

With that proclamation our team shifted to position our government partners to take ownership of the program’s implementation. We began by embedding management staff on the Regional Health Team rather than employing them directly, and by having government representatives take over increasing responsibility, such as planning and running trainings, with our team playing a supporting role. These small steps have begun to shift both the perceived and actual ownership of the intervention from an NGO “program” to simply the government’s own system, positioning the program to continue over the long-term. A strong indication of progress; on the eve of the most recent Community Health Worker training in August, Gbeleou received a call from Dr. Agoro. He was calling to ensure that the Ministry of Health logo would appear on the cover of the training materials.

Genuine Partnership Can Unlock Opportunities to Scale

Our hope is that this effective transfer of ownership will be a springboard to national scale. Government representatives themselves are now actively and vocally advocating within the government hierarchy for the expansion of this approach. Having generated strong demand from the ground up, our team is now working with government and other partners at the national level to inform the policy and funding that will enable scale. Critically, the program is now playing a key role in both the current pandemic response and ensuring the continuity of primary health care delivery.

The Honorable Professor Moustafa Mijiyawa, Minister of Health for the Republic of Togo once asked us, in his jovial tone, if Integrate Health is a “non-governmental organization” or a “non-governable organization.” His point was well-taken: Not all NGOs commit, as Integrate Health has, to working within and in an effort to strengthen the government system. Many NGOs pursue their own agenda, contributing to fragmentation of the health system, creating an added management burden for Ministries of Health.

During our earliest meetings with Minister Mijiyawa, we explained that Integrate Health aims to reinforce the public system, rather than build a parallel solution. The Minister later told us that this was the most important thing we had said during that meeting, leaving more of an impression than our outstanding health outcomes, low-cost structure, or efficient delivery model.

At Integrate Health we are still on the journey to scale in partnership with government and we know we have a way to go. But we have learned so much, and so much of it the hard way, that we felt compelled to share some of our lessons learned. Let us know how they resonate with you, or better yet, try them and let us know if they work. We hope that by building on these lessons we can realize true partnerships between governments and NGOs and work together to strengthen health systems and save lives, both in times of crisis and long after.

Read more stories by Sesso Christophe Gbeleou & Jennifer Schechter.