ß The Author 2006.

Published by Oxford University Press in association with The London School of Hygiene and Tropical Medicine. All rights reserved.
doi:10.1093/heapol/czj014 Advance Access publication 24 January 2006

Government–NGO collaboration: the case

of tuberculosis control in Bangladesh
A N ZAFAR ULLAH,1 JAMES N NEWELL,1 JALAL UDDIN AHMED,1 M K A HYDER2 AND
AKRAMUL ISLAM3

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1
Nuffield Centre for International Health and Development, Institute of Health Sciences
and Public Health Research, University of Leeds, UK, 2National TB Control Programme (NTP),
Bangladesh and 3Bangladesh Rural Advancement Committee (BRAC), Bangladesh

This study analyzes the basic concepts and key issues of existing collaboration between government
and non-governmental organizations (NGOs) in health care, using as an example the implementation
of the DOTS (formerly an abbreviation for directly observed treatment, short course) strategy for
tuberculosis (TB) control in Bangladesh. It also examines efforts by the Government of Bangladesh to
improve health services delivery, especially for the poor, through collaboration with NGOs. Data were
collected in 2001 and 2002 as a part of the process of developing a public-private partnership model for
TB care in Bangladesh. Analyses of existing collaboration models in TB control strongly suggest that
the government and NGO sectors can be complementary in controlling TB. We found an increasing
trend of government collaborating with NGOs in implementing TB control programmes. The study
indicates that government–NGO collaboration is an effective way of improving access to and quality of
TB and other health care services.

Key words: government–NGO collaboration, health care, NTP, tuberculosis, DOTS, Bangladesh

Introduction instance, the government and NGOs collaborate to

For many countries, it is the responsibility of the
government to assure health care provision for the
whole population. But the public health agenda has
become so large that the governments of these countries
have been unable to provide adequate health care
(Buse and Waxman 2001). This has led organizations
outside the government to assume part of that responsi-
bility. Moreover, there is a growing recognition by
government and international organizations that the
involvement of all stakeholders is needed if health services
are to reach the poor (Korten 1991; World Bank 1998;
WHO 2001a). Further, continued bilateral relationships
between donors and non-governmental organizations
(NGOs) have created a window of opportunity for
government–NGO collaboration (Begum 2000; WHO
2001a; Zafar Ullah 2002; Management Sciences for
Health 2004). Research evidence indicates that working
in isolation can result in duplication of efforts and failure
to accomplish health goals, whereas collaboration among
health care providers can generate synergy and facilitate
the flow of information (World Bank 1996; UNICEF
1999; Begum 2000; Barkat and Islam 2001; Thomas and
Curtis 2001; Hurtig et al. 2002; WHO 2003; Gomez-
Jauregui 2004; Mercer et al. 2004; Newell et al. 2004).
In some developing countries, non-government stake-
holders cover a major component of health care
(Green 1987; Magagula et al. 1997). In order to avoid
clashes, it is necessary for the health care providers
in these countries to collaborate. In Bangladesh, for
a certain degree to provide health care, especially to
vulnerable populations such as women, children and the
poor. Within such collaboration, the government retains
ownership in the areas of policy formulation and
implementation, human resource development and bud-
getary control. NGOs concentrate on facilitating the
activities within national policies and strategies (MOHFW
1998). NGOs provide quality services (NTP 2003; Guda
et al. 2004; Mercer et al. 2004) in accordance with the
national policy guidelines, but lack deliberate plans to
build the capacity of government services. Moreover,
there is no set process to encourage governments to move
from restrictive bureaucracy towards creating a facilitat-
ing policy environment for collaboration. In order to
develop consistent and workable policy, clear under-
standing of the nature, principles, strengths and weak-
nesses, and challenges of the existing government–NGO
collaboration is essential. This paper, therefore, attempts
to investigate different government–NGO collaborations
in the health sector in Bangladesh, more specifically
the case of the National TB Control Programme (NTP),
in the light of movement towards wider collaboration to
achieve national health goals.
The paper first examines the experiences of different
projects promoting government–NGO collaborations in
the health and population programme in Bangladesh,
to identify the policies within which these collaborative
projects are being implemented and the different mecha-
nisms by which providers of health care collaborate.
144 A N Zafar Ullah et al.
Assessments are made as to how certain factors such
as government–NGO relations, health sector strategy,
regulatory frameworks and institutional characteristics
have catalyzed or constrained collaboration. The mutual
benefits and contributions of collaborating partners are
then analyzed, noting that both government and NGOs
must contribute in order to sustain government–NGO
collaboration. This section finally identifies the key
considerations which are critical to any successful
collaboration.
To understand the impact and effectiveness of any
collaboration, it is helpful to analyze a specific example
of government–NGO collaboration. The second part of
the paper, therefore, looks at government–NGO collab-
oration in tuberculosis (TB) control, in order to focus on
specific modes of collaboration. Here, the ‘government’
is the NTP, which collaborates with a group of NGOs
to implement the DOTS (formerly an abbreviation for
directly observed treatment, short-course) strategy. We
review the existing evidence in TB control to distinguish
the respective roles of the NTP and NGOs, and outcomes
of collaboration between the NTP and NGOs in
implementing DOTS. This section further analyzes the
strengths, weaknesses and difficulties of collaboration,
before identifying opportunities and constraints for
collaboration in TB control, leading to the development
of principles for government–NGO collaboration. The
article concludes by arguing that government and NGOs
can be complementary in achieving national health goals.
Government, NGOs and collaboration: definitions
In order to analyze the collaboration between the
government and NGOs, it is important to define these
three terms in the context of broad health care activities.
The diversity of NGOs strains any simple definition.
In wider usage, the term NGO is applied to any organiza-
tion which is: (1) self-governing and independent from
government, (2) not explicitly created for profit, and
(3) has meaningful voluntary content (Green 1987;
Mburu 1989; Smith 1989; Asian Development Bank
1999; Gomez-Jauregui 2004). For the purpose of this
article, we conceive NGOs as those civil society organiza-
tions which basically accord with all the above criteria
and are providing health care in Bangladesh. The
‘government’ represents both central (e.g. Ministry of
Health, Directorate General of Health Services) and
local government (e.g. Districts, Municipalities) health
authorities.
In order to conceptualize ‘collaboration’, we delineate
different terms being used to express the relationship
between the government and NGOs. Green and Matthias
(1997) have argued that relationships between organiza-
tions form a continuum of increased structure, decreased
autonomy and intensified communication. The continuum
starts with competition, progresses through cooperation
to coordination and then on to collaboration, finally
ending in control (Figure 1).
Competition Coordination Control
Cooperation Collaboration
Source: Green and Matthias (1997).
Figure 1. The competition-control continuum
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‘Competition’ is perhaps the easiest to conceptualize.
Organizations compete with each other and there is
almost no functional linkage and communication between
them. ‘Cooperation’ can be seen as a one-off relationship
where organizations cooperate around certain issues or
at certain times; although the organizations communicate
with each other, they maintain almost complete autonomy
(Green and Matthias 1997). Another view is a deliberate
relationship between otherwise autonomous organizations
for joint accomplishment of individual operating goals
(Rogers and Whetten 1982). The World Health
Organization referred to ‘coordination’ as ‘keeping each
other informed’ to avoid duplication of efforts (WHO
1999). It also represents an on-going and structured
relationship between independent organizations for
mutual benefit (Green and Matthias 1997), or ‘a structure
or process of concerted decision making or action wherein
the decision or action of two or more organizations are
made simultaneously in part or in whole with the same
deliberate degree of adjustment to each other’ (Rogers
and Whetten 1982).
‘Collaboration’ is often described as ‘joint activity’
or ‘working together’, where two or more organizations
work closely together and share resources and responsi-
bility for common goals and purpose (Omondi et al.
1993; Green and Matthias 1997; Magagula et al. 1997;
WHO 1999). It implies temporal accomplishment
of jointly agreed tasks, where continued institutional
linkage is not important (Bhattacharya and Ahmed
1995). Collaboration can take place at different stages
and in different ways. It is increasingly recognized,
however, that collaboration should not mean
‘sub-contracting’, but a genuine partnership between
organizations based on mutual respect, and acceptance
of the independence of the collaborating organizations
concerning their vision and approaches (Korten
1988; UNFPA 1995; Magagula et al. 1997;
Begum 2000). For this study, we have used the term
‘collaboration’ broadly to encompass cooperation and
coordination.
Finally, ‘control’ is a relationship where one organization
gains control over others (Green and Matthias 1997;
Begum 2000).
Methods
The study was carried out as part of the process
of developing a locally appropriate public-private
 Government–NGO collaboration in TB control
partnership model in the NTP in Bangladesh. The specific
objectives of this research were to:

Review existing government–NGO collaboration
mechanisms, and the policy environment within which
the collaboration is being nurtured and developed;

Review the NTP as a case study for government–NGO
collaboration;

Analyze the pros and cons of government–NGO
collaboration in the Bangladesh health sector, taking
the TB control programme as an example;

Examine existing relationships between the government
and NGOs;

Identify opportunities for and constraints to
government–NGO collaboration.
Both primary and secondary data were collected to
address the research objectives. Secondary data were
collected through review of relevant literature, policy
papers, programme reports and registers, and other
related published or unpublished consultants’ reports.
Electronic searches were made of Medline, Popline,
PubMed, Web of Science, the University of Leeds library
databases, and the websites of international organizations,
using the specific key words: ‘‘government-NGO collab-
oration’’, ‘‘collaboration’’, ‘‘partnerships’’, ‘‘health
sector’’, ‘‘tuberculosis’’, ‘‘DOTS’’, ‘‘NTP’’, ‘‘NGO’’,
‘‘South Asia’’ and ‘‘Bangladesh’’.
Primary qualitative data were obtained through consulta-
tive meetings and interviews with government and NGO
programme managers of jointly implemented TB control
activities. Semi-structured questionnaires and guide-
lines were used for the interviews, and minutes of the
consultative meetings were kept for subsequent analysis.
Interviews were informal and interactive, which allowed
collection of in-depth information and personal insights.
Data were also gathered from proceedings of two review
meetings held in Dhaka and Chittagong, jointly organized
by the NTP, local government and NGOs.
Results
Government–NGO collaboration in Bangladesh
Background
With a population of 130 million, Bangladesh is divided
into six divisions, 64 districts and 497 upazilas (sub-
districts). More than 80% of the population live in rural
areas and 64% of the population are directly involved
with agriculture. Bangladesh is one of the poorest
countries, with enormous health and development chal-
lenges. Only 47% are literate, gross income per capita is
low (US$277) and more than half of all households live in
poverty. Key health indicators are less than satisfactory.
For instance, the maternal mortality ratio is in the range
of 320 to 400 per 100 000 live births, the infant mortality
rate is 728 per 100 000 live births, life expectancy is around
60 years, and less than 40% of the population has
access to basic health care. The main causes of death are
145
poverty-related infectious diseases, which are exacerbated
by and contribute to malnutrition (World Bank 1993;
Abedin 1997; MOHFW 1998; Bangladesh Bureau of
Statistics 1999; WHO 2003).
Constitutionally, the state is responsible for providing
basic health care to its population. The Government of
Bangladesh (GOB) therefore runs an extensive network
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of hospitals and dispensaries, but the services suffer from
shortages of resources and mismanagement, and lack of
accountability (Azad and Haque 1999; Barkat et al. 2000).
Furthermore, in hard-to-reach areas, health care services
are either absent or inaccessible. This situation has led
NGOs and other voluntary organizations to grow and
to take responsibility for providing much of the country’s
health and social welfare services. Current estimates
suggest that NGOs provide services to almost one-quarter
of the total population (Rahman 2003). Bangladesh
has probably the most active NGO sector in the world,
with over 6000 registered NGOs. Of that, about a quarter
is considered active. Two – the Bangladesh Rural
Advancement Committee (BRAC) and the Grameen
Bank – are very large with nationwide capacity and
coverage. Most NGOs pursue a dual strategy, addressing
poverty (through micro-credit schemes) as well as provid-
ing service delivery programmes, particularly for educa-
tion, agriculture, health and other related areas. These
organizations generally follow the target-group approach,
giving greater priority to the poor and other vulnerable
groups (Azad and Haque 1999; Begum 2000; MOHFW
2000).
There is growing recognition that NGOs have consider-
able power to improve health-seeking behaviour and the
capacity of the community. NGOs are considered to be in
a better position to impose user fees that can lead to cost
recovery and community participation. They are thought
to be closer to the people and more aware of community
needs. Their success in economic empowerment of the
poor, polio eradication, sanitation, environmental con-
servation and in non-formal education programmes have
strengthened both the government’s and community
beliefs that NGOs can effectively contribute to achieve
national targets (Hadi 2000; Westergaard 2000; Ahmad
2001, 2003; Rahman 2003; WHO 2003).
Government–NGO collaboration in the health sector
is not new in Bangladesh. Collaboration between
the government and NGOs in TB, maternal and child
health and family planning, Extended Programme
of Immunization, leprosy elimination and nutritional
programmes has been efficient and effective. CARE-
Bangladesh’s reproductive health project, BRAC’s health
and development programmes, and the leprosy control
programmes of Health, Education and Economic
Development (HEED) are among many outstanding
examples of successful government–NGO collaboration
(Perry 1999; Zafar Ullah 2001, 2002). Under the current
Health and Population Sector Programme, the govern-
ment and NGOs collaborate through a sector-wide
approach to deliver an Essential Services Package
146 A N Zafar Ullah et al.
(MOHFW 1998; World Bank 1998). It is envisaged that
the government and NGOs need to adhere to the guiding
principle laid down in the Programme Implementation
Plan of the Health and Population Sector Programme, to
further strengthen mutually supportive and complemen-
tary relationships between government, NGOs and the
private sector (Perry 1999; Begum 2000).
Policy environment for government–NGO
collaboration in Bangladesh
A number of rules and regulations exist in Bangladesh
that are intended to control and regulate NGO activities.
These have provided the legal and regulatory framework
which allows NGOs to secure legal identity and seek
assistance from the government, and also regulate their
relationship with the government. The following four
laws and ordinances were found to have substantial
implications for government–NGO relationships:

The 1861 Societies Registration Act: This Act sets
out ways in which a voluntary organization should be
set up, managed and maintain control of its accounts.
Although its use has gradually decreased, some old
NGOs are registered under this Act.

The 1961 Voluntary Social Welfare Agencies
(Regulation and Control) Ordinance: This Ordinance
compels NGOs that intend to render voluntary services
in any specific areas to register with the government
(Department of Social Welfare). Many NGOs are
registered under this ordinance and the registration
process is relatively less cumbersome than for the 1861
Act above.

The 1978 Foreign Donations (Voluntary Activities
Regulation) Ordinance: This law regulates NGOs on
the receipt and expenditure of any foreign donations
or contributions for voluntary activities.

The 1982 Foreign Contribution (Regulation)
Ordinance: Promulgated in 1982, this ordinance
requires NGOs to seek prior government approval
each time they receive or intend to receive any foreign
contribution – either cash or in kind.
Two government agencies are responsible for the regis-
tration and monitoring of NGOs: the Bangladesh NGOs
Affairs Bureau (NGOAB) and the Department of Social
Welfare. NGOAB was created in 1990 to provide one-stop
services for NGOs for registration and processing project
approvals. In 1996, the GOB established a consultative
council known as the ‘Government–NGO Consultative
Council (GNCC)’ to provide a forum for open dialogue
between the government and NGOs. The council has
23 member positions consisting of nominated representa-
tives from the government and NGOs (World Bank
1996; Asian Development Bank 1999; UNICEF 1999;
Begum 2000).
In order to address the huge burden of poverty-related
infectious diseases, the GOB identified two major
strategies in its Health and Population Sector Strategy
introduced in 1998: higher allocation of public sector
resources to the Essential Services Package (ESP); and
reform of the health sector to lay the foundation for
greater involvement of NGOs and the private sector in
ESP service delivery. The recent Five-Year Health and
Population Sector Programme (which began in 1998) set
out the basic principles for government–NGO collabora-
tion, recognizing the importance of mutual respect, trust
and expertise within the overall framework of national
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development (MOHFW 1998; World Bank 1998;
UNICEF 1999; Begum 2000; Barkat and Islam 2001).
The National Health Policy also recognizes the need to
integrate effort between the government and NGOs in
carrying out health care services (Perry 1999; UNICEF
1999; MOHFW 2000).
Clearly, there is a paradigm shift regarding NGO and
private sector involvement in public sector health care
provision. For example, the GOB’s Fifth Five-Year Plan
(1997–2002) included several statements about the nature
of involvement of NGOs and the private sector in health:
‘Involvement of the private sector and NGOs will be
promoted with a view to achieving the spirit of partici-
pation and ownership in health development . . . . The
role of government will be limited to policy setting,
monitoring and control’ (p. 463); ‘The existing research
institutes . . . will be strengthened . . . collaboration of pri-
vate organizations/institutes and NGOs will be fostered’
(p. 471). One of the main features of the recent Health and
Population Sector Programme is to establish partnership
with NGOs in the provision of health care services.
Under the National Health Policy, NGOs and other
voluntary organizations are encouraged to work as
‘complementary forces’ to the government’s efforts
(Perry 1999; UNICEF 1999; MOHFW 2000; Barkat and
Islam 2001; Ahmad 2003).
Relationships between NGOs and the
Government of Bangladesh
The relationship between NGOs and the GOB has been
and is mixed, varying from having parallel or competitive
activities to cooperation and collaboration for social
sector programmes (Asian Development Bank 1999;
UNICEF 1999; Begum 2000; Zafar Ullah 2002). Table 1
shows the types of government–NGO relationships
existing in Bangladesh. Some of them correspond with
the types of relationships described in the ‘competition-
control continuum’ (Figure 1), but some are context
specific and have clear overlaps. In some cases, the
government considers NGOs as its opponents, hence
relationships often become hostile. However, there is
increasing cooperation and collaboration between the
government and NGOs, particularly in poverty allevia-
tion, health, education and other social welfare activities
(Asian Development Bank 1999; Begum 2000; Hadi 2000).
The government’s policies and legal frameworks within
which these relationships take place inevitably affect
its day-to-day relations with NGOs. Furthermore, local
government structures play an important role in main-
taining good relationships with NGOs in coordinating
health and other NGO-run activities at local levels
 Government–NGO collaboration in TB control 147

Table 1. Types of government–NGO relationships existing in Bangladesh

Types of relationships Description of relationships

Competitive and parallel activities

Activities in the public and private sectors are run within the same geographic area, targeting the
same clients and competing for the same resources. This type of relationship is more applicable
to those NGOs which depend on service charges for their sustainability.

GOB and NGOs carry out activities without any mutual contact or acknowledgement
of each other’s work. For example, some local NGOs and voluntary organizations are

Coordination and complementary
service provision
Cooperation and collaboration
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providing general health care services without any linkages with government services or
programmes.

The nature and types of services complement each other either by design or by coincidence. For
example, community-based outreach and distribution of contraceptives carried out by NGOs
contributed significantly to the success of the national family planning programmes.
Coordination is through different committees and stakeholders meetings at various levels.

In the health sector, NGOs work together with GOB in planning and implementing health
programmes. Under the Health and Population Sector Programme, NGOs are assigned to
deliver ESP through an agreed contractual framework. For example, CARE-Bangladesh
is collaborating with GOB to improve reproductive health services in four districts, and
BRAC, DFB, HEED, NSDP and UPHCP are collaborating with the National TB Control
Programme to implement DOTS in 259 (56%) Upazilas and four metropolitan cities through
a Memorandum of Understanding signed in 1995.

Source: Based on data from World Bank (1998); Asian Development Bank (1999); Perry (1999); UNICEF (1999); NTP (2002); Zafar Ullah
(2002).
Notes: GOB ¼ Government of Bangladesh; ESP ¼ Essential Services Package; DFB ¼ Damien Foundation, Bangladesh; HEED ¼ Health,
Education and Economic Development; NSDP ¼ NGO Service Delivery Project; UPHCP ¼ Urban Primary Health Care Project.

(World Bank 1998). In particular, local governments are
collaborating with NGOs in selecting sites for Community
Clinics, and in social mobilization and sanitation pro-
grammes (Asian Development Bank 1999; Hadi 2000).
However, the level of commitment from local government
varies widely, and is specific to the quality and motivation
of individual leadership (Fernandez 1987; World Bank
1998; Asian Development Bank 1999).
Mechanisms to involve NGOs in health
sector programming
Within the perspective of government–NGO collabora-
tion, several mechanisms or frameworks have been tried
to involve NGOs in the health sector programmes. Due
to the diversity of NGOs and their differing relationships
with the government, these mechanisms have evolved
over time (MOHFW 1998; World Bank 1996, 1998; Perry
1999; Begum 2000; Barkat and Islam 2001; MOHFW
2001; NTP 2002):

Networks/consultation/representation: This is the
simplest form of collaboration. NGOs participate in
different taskforces and committees, especially under
the Health and Population Sector Programme. NGOs
also serve as effective linkages between the planners/
financiers of a project and its beneficiaries.

Contractual agreements: Under this mechanism,
government requests or assigns NGOs to undertake
a specific task on its behalf. Usually, this is achieved
through soliciting proposals or one-to-one negotiation.
This is the commonest form of collaboration mecha-
nism, and in general, GOB defines partnership as such.
Examples include the Bangladesh Integrated Nutrition
Project, and the Reproductive Health, Extended
Programme of Immunization and TB/Leprosy pro-
grammes of the ESP under the Health and Population
Sector Programme.

Patronage: This form of collaboration evolves when
one institution expresses interest in supporting another
institution to strengthen its institutional capacity. Here
they bind together to deliver some defined service, and
also share ideas about common vision. This form of
collaboration, though uncommon, has been practiced
to some extent by the Ministry of Health and Family
Welfare (MOHFW) in supporting NGOs for innova-
tive programmes during the Fourth Population and
Health Project (1992–98). Although it achieved high
levels of success, it was discontinued during the Health
and Population Sector Programme.

Partnering: This requires the perception that each
partner has something to contribute. Partnering implies
sharing both risks and benefits, and its guiding
principle is based on commitment to reciprocity,
sovereignty and equity. Although this is rare in the
Bangladesh health sector, some NGOs, such as BRAC,
CARE-Bangladesh, Oxfam and CONCERN-
Bangladesh, are promoting this type of partnership in
their health and family planning programmes.
Government–NGO collaboration – common
ground and differences
A number of studies have shown that the government
and NGOs have common goals and vision with respect
to social sector development, particularly in health and
nutrition, poverty alleviation, human resources develop-
ment, environmental protection, non-formal education
and women’s development (Perry 1999; Begum 2000;
148 A N Zafar Ullah et al.

Table 2. Differences in basic institutional approach and structures between the government and NGOs in health

Area Government NGOs

Health, nutrition and
sanitation concerns
Resources
Within policies and strategies of overall health
development, for example, Health and Population
Sector Strategy, National Health Policy.
Capability to generate own resources plus donor
assistance.
Most NGOs focus on specific public health
problems, geographic area and targeted
population.
Mostly dependent on donations, contracts and
donor funding.

Management
Compliance and effectiveness
Guided by rules and regulations with limited scope
for flexibility in operations.
Currently, a centralized bureaucratic structure is in
place and the quality of services is dependent on
the nature of governance. Reform is in progress
under the Health and Population Sector
Programme.
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Guided by organizational constitution but
relatively simpler and more flexible.
Effectiveness determined by ability to mobilize
target groups at the grassroots level.

Source: Compiled from UNICEF (1999); Asian Development Bank (1999); Begum (2000); WHO (2000); WHO (2001a); Zafar Ullah (2002);
and key informant interviews.

Table 3. Benefits gained and contributions made by the agencies in a government–NGO collaboration

Government NGOs

Benefits
Better services to the people with higher coverage
leading to improved health;

Re-allocation of funds to other priorities, especially for
the poorest;

More opportunity and availability of tools and
techniques for service delivery and research;

Change of attitudes and management style, learning
from mutual strengths;

Programme efficiency improved;

Greater programme sustainability.
Contribution
Legitimacy/institutional support;

Facilitative regulatory mechanisms, less bureaucracy;

Resources channelling and resource allocation;

Grants and cash-flow mechanisms;

Best practices and global vision;

Access to public media networks.

Enhanced image to the community of responsiveness
towards social and health issues;

Team motivation (for socially engaged agencies);

Shared risks and results;

Influence in national development agenda;

Publicity received from government-run media;

Higher visibility and credibility;

Increased profit scope (for-profit NGOs);

Competitive advantage gained.

Management and marketing expertise;

Client-oriented services and product development;

Resources;

Helping sustainability and low-pricing of services;

Training facilities and expertise;

Community sensitization and awareness building.

Source: Based on information from UNICEF (1999); Begum (2000); Zafar Ullah (2002); and key informant interviews.

Ahmad 2001). However, the basic institutional approach
to addressing the social and health problems is different
between government and NGOs (Table 2). An effective
collaboration should therefore recognize the differences
and build on the basis of the respective advantages of
government and NGOs (Begum 2000; WHO 2001a).
Benefits and contributions of collaborating partners
To develop and sustain a government–NGO collabora-
tion, both government and NGOs must see considerable
gain from it, and that if both stand to gain from the
collaboration, they have much to contribute. Table 3
summarizes the benefits gained and the contributions
offered by each sector in a government–NGO partnership.
NGO involvement – risks and challenges
Despite the availability of evidence indicating government-
NGO collaboration to be successful, there are still serious
concerns over the continued involvement of NGOs in
the health field. NGOs are not a homogeneous
category. They differ from each other in terms of size,
site, nature and characteristics, and their commitment
towards the communities they serve. About 24 000
NGOs are registered with the Department of Social
Services and about 1300 NGOs are registered with the
NGO Affairs Bureau. This heterogeneity of the NGOs has
made the task of developing workable policies and
mechanisms difficult (Barkat et al. 2000; Begum 2000;
Neaz 2004).
Under the Health and Population Sector Programme
the government recognized that client-centred provision
of the ESP would require an effective sector-wide
partnership with NGOs, but no clearly defined framework
for collaboration has so far been developed. Moreover,
the lack of government capacity (including technical
capacity and manpower) to adequately manage the
process of NGO involvement poses a big challenge.
One of the most noteworthy trends in Bangladesh is the
increasing role of NGOs in economic and social activities,
including health. More schools, health and economic
 Government–NGO collaboration in TB control
(mainly micro-credit) programmes, and environmental
services are now being managed by NGOs, while the
government’s conventional role has shrunk considerably.
While the advantages of this paradigm shift are widely
recognized, there is also recognition of the risk of further
weakening government health care delivery and thus
increasing the health care system’s vulnerability to the
changing priorities of NGOs and their donors.
There are still cases in which ideological differences and
lack of institutional openness continue to feed mistrust.
In addition, the negative attitude of government officials
about NGO involvement in health care activities clearly
indicates a lack of understanding of NGOs’ vision and
the nature of their work, whilst many NGOs have
concerns about difficulties in accessing donor funds
which are channelled through the government. The
process of NGO selection was found to be cumbersome,
full of bureaucracy and wasted time (World Bank 1996;
Magagula et al. 1997; Barkat et al. 2000; Begum 2000;
Gomez-Jauregui 2004).
Government–NGO collaboration – key considerations
Based on the review and analyses of different
government–NGO collaboration models in the health
sector of Bangladesh, we identify certain essential pre-
conditions which are critical to successful and sustainable
collaboration between the government and NGOs (Begum
2000; WHO 2000; Barkat and Islam 2001). These are:

mutual respect and trust;

recognition of mutual strengths and values, and
comparative advantages;

favourable policies, laws and regulatory frameworks;

effective mechanisms to monitor, measure and learn;

transparency and accountability;

involvement of all stakeholders at every step;

continued commitment of collaborating partners.
Government–NGO collaboration for TB
control in Bangladesh
In this section, we use the example of collaboration in TB
control to highlight specific issues.
Background
In Bangladesh, the burden of communicable diseases
including TB is high compared with other South Asian
countries, and the HIV/AIDS epidemic is imminent. The
incidence of TB in 2001 was estimated at 105 per 100 000
population, with a caseload of over 30 000. There were
70 000 deaths due to TB in 2001, and the death toll is
expected to rise due to the HIV epidemic (World Bank
1998; UNICEF 1999; DHS 2000; NTP 2002; WHO 2004).
The overall aim of the NTP is to reduce the transmission
of TB until it is no longer a public health problem
(NTP 2002). The immediate objectives are to increase the
cure rate of sputum smear-positive cases to 85%, and to
increase case detection to 70% of the estimated incidence
149
(MOHFW 2001). From its introduction in 1993, the
internationally recognized DOTS strategy for TB control
has suffered from limited capacity and quality. Shortages
of physical infrastructure and appropriately trained health
and laboratory personnel mean patients may need to
travel considerable distances to health facilities, and have
lengthy waits to be seen when they arrive. Furthermore,
there is considerable stigma associated with TB. These
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factors combine to limit patients’ ability or desire to seek
care from publicly provided TB services, but rather
encourage them to seek initial diagnosis and treatment
from private sector providers of any sort (Hussain 2001;
WHO 2001b; Guda et al. 2004; Newell et al. 2004).
The treatment success rate rose to 84% for the 2001
cohort but could not quite reach the target level due to
high (7%) default rates. Case notification rates, however,
lag far behind the target level: although the DOTS
population coverage was nominally 95%, the estimated
case detection rate by the DOTS programme was only
32% in 2002 (WHO 2004). There remains a big gap
between population coverage and the case detection rate.
This is mainly because only about half of the population
truly has access to the DOTS programme, and most
TB patients prefer to seek care from the private sector.
Moreover, a large number of self-reported cases remain
undetected due to lack of adequate skilled personnel in
the health facilities (NTP 2002, 2003; Newell 2002; Guda
et al. 2004; WHO 2004; Zafar Ullah et al. 2004).
In line with international guidelines, the Bangladesh
NTP is generally clinic-based, and there is only one bed
available per 500 TB cases (Chowdhury et al. 1997). The
lowest-level health facilities providing appropriate TB
care are Upazila Health Complexes located in the upazila
headquarters (one hospital per 250 000 population). Most
of these facilities are short of skilled staff, equipment and
drugs, especially in rural areas. There are few specialized
institutions for TB, and those that exist are situated
mostly in cities. In addition, frequent movements of staff
as well as patients, inadequacy of the transport system,
long distance to health facilities, and lack of clients’
trust in the health care system have adverse affects on
access to and quality of TB care (Chowdhury et al.
1991; Chowdhury 1999; UNICEF 1999; MOHFW 2000).
Given these constraints, it is essential to utilize the
potential and resources of NGOs and the private sectors
in order to ensure wider coverage and the planned
expansion of DOTS. The government has the responsi-
bility of determining policy guidelines and supplying
logistics, while NGOs, through their extensive community
networks, can help the NTP to tackle the huge unmet need
for TB care (NTP 2002).
Government–NGO collaboration in implementing DOTS
Bangladesh presents a good example of government–
NGO collaboration in the countrywide expansion of
DOTS under the NTP. At present, NGOs and the
private sector jointly cover more than half of
the entire NTP activities, in both rural and urban areas
150 A N Zafar Ullah et al.

Table 4. Areas of government–NGO collaboration in TB control in Bangladesh

Area of collaboration Government NGOs

Policy
National policies and strategies supporting
Programme and management policies
collaboration based on national guidelines

National TB guidelines and protocols
Utilization of resources
Implementation
Equipment and lab supplies
Specific areas

Overall coordination

Case finding and case holding
Training
Drug supply
Monitoring and supervision
Behavioural change communication
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Referral centres
Diagnosis, treatment and follow-up

Reference laboratory
Late patient tracing

Training materials
Local training

Training of trainers (TOT)

Central procurement
Local storage and distribution

Distribution
Supply indent

Registers/forms
Registration/reporting

Overall monitoring and supervision
Local monitoring and supervision

National campaigns
Local campaigns

Source: Based on data from MOHFW (2001); Hussain (2001); NTP (2003); and key informant interviews.

RDRS LAMB
(Hussain 2001; MOHFW 2001; NTP 2001, 2002; WHO HEED
3%
5% 1%
2004). This collaboration is based on a Memorandum of
Understanding signed in 1995 between the government DBLM
and six NGOs, namely, BRAC; the Damien Foundation; 2%

the Danish Bangladesh Leprosy Mission; Health, Education

and Economic Development; Rangpur Dinajpur Rural DF
16%
Services; and Lutheran Aid to Medicine Bangladesh. The
GO
main purpose of the Memorandum is to outline specific 50%
tasks for the government and partner NGOs (see Table 4)
in the delivery of DOTS in defined areas (MOHFW 2001;
NTP 2002, 2003).

There is an increasing trend of government collaboration BRAC

with NGOs in implementing DOTS. The NTP started
implementing DOTS with BRAC in four upazilas in 1993
and within 5 years the NGO coverage had risen to 186
upazilas. In 2001, the government–NGO split for DOTS
by upazilas was 50:50 (Figure 2), with BRAC providing
the major portion of NGO support (23%). In 2003, NGOs
provided services to 259 upazilas (56% of all upazilas;
n ¼ 460) and in four metropolitan cities in collaboration
with the government, with remaining coverage provided
by the government through its clinics and hospitals
(Figure 3). NGOs play a vital role in assisting the NTP
23%
Figure 2. Government–NGO split for DOTS coverage by
upazilas in 2001 (n ¼ 460 upazilas)
Source: Hussain (2001)
Notes: GO ¼ goverment; BRAC ¼ Bangladesh Rural Advance-
ment Committee; DF ¼ Damien Foundation; DBLM ¼ Danish
Bangladesh Leprosy Mission; HEED ¼ Health, Education and
Economic Development; RDRS ¼ Rangpur Dinajpur Rural
Services; LAMB ¼ Lutheran Aid to Medicine Bangladesh
DOTS implementation by the GOB and NGOs GOB
Number of Upazilas (n = 460)

NGOs
4

4
27

27

9
26

25

in TB service delivery, management support, operations

0
24
0
0
23
23

0
22

research and social mobilization. The NTP provides

8

20
19
6

6
18

18

treatment protocols, policy guidelines, logistic supplies

(drugs, reagents and equipment) and training, while
NGOs provide supervised treatment at the community
level, promote active case finding and raise awareness
about TB among the general population. Monitoring
and supervision is done jointly by the NTP and
NGOs (Hussain 2001; MOHFW 2001; NTP 2002; Guda
et al. 2004). The roles of each collaborating agency are
summarized in Table 4.
There have been gradual but steady improvements in
the key areas of TB control (Figure 4): for instance,
claimed DOTS population coverage rose from 90%
in 1998 to 95% in 2002 (but see the earlier comments
on the difference between population coverage and case
1998 1999 2000 2001 2002 2003
Year
Figure 3. Trend of government (GOB) and NGO coverage of
DOTS implementation by upazilas (n ¼ 460)
detection rate). Over the same period, the case detection
rate of new smear-positive cases under DOTS increased
from 24% to 32%, and the treatment success rate rose
closer to the target level (84% for the 2001 cohort)
(MOHFW 2001; NTP 2001, 2002; WHO 2004). There
have been marked improvements in the technical capacity
 Government–NGO collaboration in TB control
100
90 90
80
81
78
Percentage
60
40
20
24 24
0
19 19
98 99
Claimed DOTS pop
coverage %
Figure 4. Improvements in key areas of the National TB Control Programme, 1998–2002
of staff providing DOTS. We found that the providers
(both NGOs and the government staff) demonstrated
average knowledge about DOTS and case management.
About three-quarters of NGO doctors and four-fifths of
lab technicians already received DOTS training. The
quality of staining was found to meet NTP standards; on
random testing, the examination slides fulfilled the criteria
of the existing protocol. The NTP claims that collabora-
tion between NGOs and the government are key to these
successes (NTP 2001, 2002, 2003). An external review
carried out in 2002 also affirmed this claim, and formed
the basis of a revised 5-year strategic plan which
emphasizes the need for continued collaboration with
NGOs and the private sector (WHO 2004).
Government–NGO collaboration in TB control:
lessons learnt
Two external reviews of NTP activities have been carried
out since the introduction of DOTS, one in 1997 and
another in 2002 (MOHFW 2001; WHO 2004). Both the
reviews acknowledged government–NGO collaboration
in the Bangladesh NTP to be a major success. The reports
suggest that the government has demonstrated its
commitment to TB control, while NGOs have increased
the coverage, quality and sustainability of their services
by channelling their resources to provide standardized
treatment to TB patients, particularly in remote, rural
areas. The NTP and the partner NGOs have also carried
out their own internal evaluations of the programme.
The following are some commonly agreed lessons learnt
from the government–NGO collaboration in implement-
ing DOTS in Bangladesh (Hussain 2001; MOHFW 2001;
WHO 2001b, 2004):

The collaboration ensures greater coverage and access
through NGO service facilities and community-based
infrastructures.

NGOs were able to increase awareness among
the general population about TB, leading to
151
95 95
92
83 84
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32
25 27
20 20 20
00 01 02
Year
DOTS treatment DOTS detection of new
success % sputum positive cases %
increased numbers of TB suspects at different health
facilities.

Unified reporting systems enable a full account of the
NTP’s programmatic performance.

Although NGOs are following NTP guidelines, they
decide the operational strategy appropriate to their
philosophy and thinking. This allows organizations
to retain their independence while being accountable
to the NTP.
The potential and constraints of government–NGO
collaboration
Next we analyze the potential and constraints of
government–NGO collaboration in TB control. During
the analysis, we have focused on the strengths of
collaboration in relation to access, efficiency, quality
and coverage of the TB services. Table 5 summarizes the
strengths and weaknesses of the government–NGO
collaboration, and its future opportunities and potential
threats.
Evidence suggests that access to health services is
increased through government–NGO collaboration by
ensuring people’s participation in the health and devel-
opment programmes. NGOs have proven ability to
improve people’s capacity to seek and utilize health care
(UNICEF 1999; Begum 2000; MOHFW 2001; Newell
2002; Mercer et al. 2004). The vast majority of respon-
dents (more than 80% of government officials and 100%
of NGO representatives) believed that collaborative
activities ensure people’s participation, the mobilization
of resources and increased coverage of services. In her
research, Begum (2000) showed that the government and
NGOs, while collaborating, share tasks among themselves
based on their knowledge and skills, which in turn can free
up resources for other social welfare activities, thus
widening the spectrum of services for the poor and the
disadvantaged. It is also widely acknowledged that
concerted and collaborative efforts are needed to address

Table 5. SWOT analysis for government–NGO collaboration in TB control in Bangladesh
Strengths
Access related:

Increases people’s participation, and
enhances the accessibility of health
services to the poor;

Gives government and NGOs access to
each other’s expertise and resources;

Creates demand among the poor and
disadvantaged for health services.
Coverage related:

Joint implementation of health
programmes increases coverage;

Ensures utilization of knowledge and
abilities of collaborating agencies;

Provides opportunity for rapid
expansion of DOTS.
Efficiency related:

Improves institutional capacity of
government and NGOs from sharing
of technology and information;

Government learns flexible
management from NGOs;

Encourages cost-effectiveness.
Quality related:

Competence-based training and
technical assistance provided to the
government by NGOs;

Collaboration around areas of
excellence between government and
NGOs improves quality.
Weaknesses
Process related:

Difficult to choose partners because of
diversity and abundance of NGOs in
the health sector in Bangladesh;

NGOs’ dependency on external
funding;

Unwillingness of some NGOs to work
with the government;

NGOs are afraid of being exposed to
government;

Lack of mutual trust between the
government and NGOs;

Fear of losing philosophical
independence.
Capacity related:

Inadequate initiative on sharing lessons
from TB care approaches;

NGOs are mostly maternal and child
health/family planning focused: only a
few NGOs have experience of working
with the NTP;

Lack of uniformity of standards or
capacity for providing quality TB care
amongst health NGOs.
Opportunities
Policy related:

Paradigm shift for wider collaboration
among government, NGOs and private
sectors;

Current health sector reform
programme calls for greater
government–NGO collaboration.
Practice related:

Availability of global experiences on
successful collaborative approaches in
TB care;

Support from international
development partners for TB control;

Growing political awareness for
communicable disease control
programmes.
152
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Threats
Process related:

Resistance from some NGOs;

For contractual forms of collaboration,
there will be competition between
NGOs to ‘win’ the same pot of money;

Lack of sustained government focus on
public health issues.
Outcome related:

Slow progress of health sector reform;

Over-controlling of NGOs’ flexibility
A N Zafar Ullah et al.
by the government.
 Government–NGO collaboration in TB control
priority public health problems, including TB. Without
collaboration, the differing interests and ideologies of
government and NGOs can lead to confusion and
disparities (Bratton 1989; Honandle and Cooper 1989;
Barkat and Islam 2001). Alter and Hage (1993) argue
that organizational individualism has been seen as an
inadequate response to the problems.
Efficiency is another strength of collaboration. There is less
duplication among government and NGO activities,
especially in a context of resource constraints (Ross 1990;
Begum 2000; Barkat and Islam 2001). Moreover, harmo-
nization of both procedures and reporting mechanisms
makes monitoring and evaluation easier (MOHFW
1998; World Bank 1998; Begum 2000; NTP 2002).
Government–NGO collaboration enhances institutional
strengthening of the collaborating agencies through the
interaction and sharing of information, technology and
expertise (Ross 1990; Begum 2000; Barkat and Islam
2001).
However, collaboration can affect organizational freedom
to act independently as a result of prioritizing collabora-
tive activities. It can expose one partner to others.
In Bangladesh, NGOs are afraid of exposing themselves
to government bureaucracy, and there is a mutual lack
of trust. In addition, from the GOB side it is difficult
to choose partners from the large number of NGOs
available in the health sector.
A major potential threat to government–NGO collabora-
tion is the slowness of implementation of health sector
reform. The absence of simple, realistic collaborative
mechanisms can pose a high hurdle in the pathway of
collaboration. Over-controlling the flexibility of NGOs by
the government, and lack of continuity of GOB’s
priorities, are other potential threats to collaboration.
Principles of NGOs involvement
This study has critically analyzed government–NGO
collaboration models in the health sector in Bangladesh,
including those existing in TB control programmes.
As a result of our analysis, and building on the analyses
presented in another paper (Zafar Ullah et al. 2004), we
have identified the following four basic principles, which
underline the best strategies for NGO involvement:

Principle One: The government is responsible for the
health care of its citizens. It must, therefore, take the
lead in developing supportive policies and strategies
for involving NGOs in health care programmes.

Principle Two: The NGOs’ role is to build the capacity
of individuals, communities and the government, and
to facilitate and support community action.

Principle Three: The involvement of NGOs should
be based on mutual strengths, philosophies, objectives
and the nature of the collaborating agencies.

Principle Four: There is no ideal model for government–
NGO collaboration in health care; the most suitable one
should evolve from a transparent and iterative process.
153
Conclusions
We can draw two conclusions relating to TB control
and government–NGO collaboration. Access to TB care
services is a key factor in achieving the objectives of
DOTS. In Bangladesh, socioeconomic factors, shortages
of skilled workers, irregular drug supplies and the absence
of an effective referral system limit people’s access to TB
care, and encourage them to default from TB treatment.
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Taking treatment closer to patients and increasing the
availability of TB treatment at every point of service
delivery can improve accessibility. One way of achieving
this is to involve NGOs in a wide range of TB control
activities, from TB service provision to operational
research. The health sectors of the South Asian countries,
including the NTPs, have many examples of successful
collaboration with NGOs. Lessons learnt from existing
collaboration models reveal that government collabora-
tion with NGOs in the delivery of TB services has
enhanced case finding, treatment success, supervision
and community participation. It is widely acknowledged
that collaboration between the government and NGOs
is the key to success in the TB control programme in
Bangladesh.
More widely, NGOs play a significant role in providing
health care and social welfare services in Bangladesh.
There is compelling evidence that the government and
NGOs are ‘complementary forces’ to each other in
achieving national health goals. The role of NGOs, for
example, in delivering the ESP, and more recently in the
fight against TB, has been pivotal and effective.
Therefore, although NGOs are diverse in their strategic
vision and interests, there is great potential to develop
collaborative approaches to improve access to and quality
of TB and other health care. NGOs can be instrumental in
establishing links between national programmes and
patients. They can also have a crucial role in advocacy
and in mobilizing policy makers and the community
towards expansion of control programmes. Through
building a powerful lobby with the government and the
community, NGOs can raise awareness about causes of ill
health, create demand for services and help provide those
services.
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International Journal of Health Planning and Management
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Biographies
A N Zafar Ullah is a Teaching Fellow at the Nuffield Centre for
International Health and Development, Institute of Health Sciences
and Public Health Research, University of Leeds, UK.
James N Newell is a Senior Lecturer and Co-director of the
communicable disease research programme at the Nuffield Centre
for International Health and Development, Institute of Health
Sciences and Public Health Research, University of Leeds, UK.
Jalal Uddin Ahmed is Programme Manager of the National TB
Control Programme (NTP), Bangladesh.
M K A Hyder is a Junior Consultant with the National TB Control
Programme (NTP), Bangladesh.
Akramul Islam is a Programme Manager with the Bangladesh Rural
Advancement Committee (BRAC), Dhaka, Bangladesh.
Correspondence: A N Zafar Ullah, Nuffield Centre for International
Health & Development, University of Leeds, 71–75 Clarendon
Road, Leeds, LS2 9PL UK. Tel: þ44 113 343 1680; Fax: þ44 113
3436997; E-mail: hss1anuz@leeds.ac.uk