The Feasibility of Government Partnerships with NGOs in the Reproductive Health Field in Mexico

Abstract

In 1995 the Mexican government began to develop policies on establishing collaborative agreements with civil society organisations, and there is currently interest in Mexico in government and NGOs working together. This paper analyses whether the conditions exist in Mexico for successful partnerships between the public sector and NGOs in the reproductive health field. In-depth interviews were carried out with key informants in the public sector at national and state level and the NGO sector in six states in Mexico. Partnerships were found to be an option for the provision of reproductive health services in geographical areas where the population is under-served, and for services the government does not provide. While the contribution of NGOs to the reproductive health field is recognised, at least at federal level, there are still very few public agencies that collaborate with NGOs, and agreements are often limited to short-term financing of projects. The future of NGOs in Mexico will depend largely on their ability to obtain funding from within the country. More effective mechanisms are needed by government to generate resources for health care. Government must recognise the specific contribution of NGOs, including inputs of social capital and creation of community networks, and must share decision-making more equitably with NGO for partnerships to succeed.

Résumé

En 1995, le Gouvernement mexicain a commencé à réguler les accords de collaboration avec les organisations de la société civile, et le Mexique s'intéresse actuellement à la collaboration entre l'É tat et les ONG. Cet article se demande si le pays réunit les conditions pour des partenariats réussis entre le secteur public et les ONG dans le domaine de la santé génésique. Des entretiens ont été menés avec des informateurs clés dans le secteur public au niveau national et des É tats, et dans des ONG de six É tats mexicains. Les partenariats sont une option pour la prestation de services de santé génésique dans des régions où la population est sous-desservie et pour des services que l'É tat n'assure pas. Alors que la contribution des ONG à la santé génésique est reconnue, au moins au niveau fédéral, rares sont encore les organismes publics qui collaborent avec les ONG, et les accords sont souvent limités à un financement de projets à court terme. L'avenir des ONG au Mexique dépendra largement de leur capacité à obtenir un financement auprès de sources nationales. Il faut des mécanismes plus efficaces qui permettront au Gouvernement de créer des ressources pour les soins de santé. Afin que les partenariats ré ussissent, l'É tat doit reconnaı̂tre la contribution des ONG, notamment les apports de capital social et la création de réseaux communautaires, et il doit partager plus équitablement la prise de décisions avec les ONG.

Resumen

En 1995 el gobierno mexicano empezó a formular polı́ticas para colaboració n con las organizaciones de la sociedad civil. Actualmente, existe interés en Mé xico por que el gobierno y las ONG colaboren. En este artı́culo se analiza si existen las circunstancias en Mé xico para establecer alianzas exitosas entre el sector pú blico y las ONG en el campo de la salud reproductiva. Se llevaron a cabo entrevistas a profundidad con informantes clave del sector pú blico a nivel nacional y estatal y en el sector de las ONG en seis estados de Mé xico. Se encontró que las alianzas son una opció n parala prestació n de los servicios de salud reproductiva en las zonas con sectores desatendidos de la població n, y para brindar servicios que no son prestados por el gobierno. A pesar de que se reconocen los aportes de las ONG al campo de la salud reproductiva, por lo menos a nivel federal, aú n existen muy pocas instituciones pú blicas que colaboran con ellas, y los acuerdos con frecuencia se limitan al financiamiento de proyectos de corta duració n. El futuro de las ONG en Mé xico dependerá en gran parte de su capacidad de obtener fondos nacionales. El gobierno necesita mecanismos má s eficaces para generar recursos para la prestació n de servicios de salud. Ademá s, el Estado debe renocer la contribució n de capital social y la creació n de redes comunitarias de las ONG, y debe compartir la toma de decisiones de manera má s equitativa con las ONG a fin de que las alianzas tengan éxito.

Key Words:

• non-governmental organisations
• government–NGO partnerships
• public sector
• reproductive health services
• Mexico

The inability of the public and private sectors to provide adequate health care has led to the involvement of other sectors, including civil society. All three sectors have recognised that working separately can result in duplication of efforts and failure to accomplish goals, and in a number of countries the notion of partnership in the provision of public services, including health care, has been accepted. Nevertheless, the experience of collaborative work, despite significant successes, has also brought a number of problems to the surface.¹²³

Partnership occurs when two or more entities work together to achieve a common goal and agree to share both efforts and benefits.⁴ The existence of civil society organisations suggests that citizens play an active role in the production of public goods and services that have direct consequences for them.¹ The intention of collaboration between the State and civil society organisations is to strengthen state institutions and create an atmosphere in which civic commitment is viable. The main objectives of partnership between the public and private sectors and civil society organisations are to achieve greater efficiency; reduce duplication of services and achieve economies of scale; create civic commitment and engage the community in efforts to resolve problems; and strengthen institutional capacity across the board.^{2 35}

There are different forms of collaboration between the public sector and civil society organisations, such as NGOs.* These may consist of informal agreements to exchange information or share certain activities, training or know-how, or formal contractual agreements in which each partner contributes resources and takes on certain responsibilities. Others may involve the evaluation or supervision by one partner of the other.⁶

The ICPD Programme of Action asserted the need to establish effective partnerships between governments and NGOs to assist in the formulation, implementation, monitoring and evaluation of population and development activities. However, in a UNFPA field analysis in that same year, only 49 of 114 countries reported having taken significant measures to promote NGO participation in policy and programme implementation.¹⁰ Also in that year, a meeting of 200 representatives of NGOs that promote health and women's rights was held to evaluate their achievements.¹¹ In that meeting, “partnership” was defined as a collaborative association that requires “common goals, mutual respect, open access to information and decision-making processes, and the accountability of the partners to their constituencies”. A document was drafted that stated “collaboration will have to emphasise government activity, instead of replacing its responsibility, in order to assure proper health care”. It called on “…governments, international and financial agencies to provide support with long-term funding for the strengthening of the capacity of women's organisations and their ability to participate, in an effective way, in government decision-making and in the implementation and evaluation of programmes”.¹¹

In this article, partnership for reproductive health is defined as a formal agreement between government and NGOs to achieve common goals for the creation of social values and fulfill the goals established under the ICPD Programme of Action. Ideally, such a collaboration is intended to improve the performance of the actors involved and assumes that the conditions for a successful and sustainable collaboration exist. Is this always the case? What has the experience been in the health field? What factors have affected the sustainability of public–private partnerships?

Hogwood and Gunn¹² emphasise the importance of proper timing in introducing an issue to the political agenda and being able to design feasible policies to address it. At this moment in Mexico the public sector and the NGOs are interested in working together and there is therefore a window of opportunity to propose a partnership between both parties. For that reason it is pertinent to analyse whether the conditions exist in Mexico for the implementation of successful and sustainable partnerships between the public sector and NGOs in the reproductive health field.

Experiences of NGO–government collaboration in the health field

There is controversy over the advantages and disadvantages of collaboration between government and NGOs in the health field. According to Reich, a fundamental dilemma of these partnerships is how to succeed in improving the health of the poorest in developing countries and, at the same time, guarantee accountability without sacrificing influence, innovation, voluntary spirit and organisational capacity. Public–private agreements not only depend on the goodwill of the partners involved to produce something jointly, but also on their capacity to handle the organisational interaction.⁴ Nowland-Foreman¹³ argues that the main problems of collaboration in New Zealand were that the NGOs lost their autonomy, and the confidence and transparency within the relationship were reduced. On the other hand, however, he describes an increase in the quality and efficiency of the work of some NGOs and mentions the increasing role around the world of NGOs in providing social services.

According to the World Bank, among the most dynamic NGOs in sectors like health, education and micro-credit are those that directly serve individuals and communities. In developing countries, most of these NGOs are small and work in communities where the capacity for government intervention is limited or non-existent.¹⁴ Smith argues that governments interested in collaborating with NGOs look for those with local experience and organisational capacity. When a government wants to replicate the successful projects of an NGO on a much larger scale, however, a risk of failure has been documented.⁷

Documented experience of public sector–NGO contracts for providing primary health care in Latin America exists for Costa Rica, Colombia, Guatemala, Peru and the Dominican Republic. The main factor that led these governments to collaborate with NGOs was to increase coverage and improve quality of care.¹⁵ For the NGOs, this collaboration has made financial sustainability in implementing their social mission possible; however, they also recognise the risk of losing their independence and identity. Based on the experience in these five countries, Abramson emphasises five issues to be considered by the buyer and supplier of services, before a contractual agreement should be made:

• the desire on both sides to establish contractual relations,

• the political scenario and the legal framework,

• the level of organisational and institutional development required for both sides to succeed in their new functions,

• the level of complexity of the contract, and

• the level of risk involved for both sides.¹⁵

There are still cases in which ideological differences and institutional competition continue to feed mutual mistrust.¹⁶ According to Herrera, an equitable balance in what each actor contributes, e.g. in access to information, resources and the decision-making process, must all be taken into account. The autonomy of each organisation must also be respected and formal mechanisms of accountability employed that guarantee the sustainability of commitments.⁶

Financial restrictions, asymmetries in power and a lack of accountability are the three most common problems that arise in partnerships between NGOs and government. A large majority of NGOs who deliver services are financially dependent, and this may lead to competition for government resources between NGOs.⁵ Competition for resources may lead NGOs to sacrifice their goals and principles and can generate stress in their relationship with government, who in turn can use access to resources to exert power over the NGO that needs them.

Regarding accountability, experience suggests the importance of establishing formal contractual relationships, based on agreed rules and clear procedures,¹⁷ which create a basis for mutual respect and equality, thereby contributing to the sustainability of the partnership.¹⁸ The challenge is to ensure accountability without sacrificing the autonomy of the NGO.¹⁹

Reproductive health indicators and resources in Mexico

The government in Mexico has two important problems. The first is that health expenditure has been reduced in the last ten years and is below that of several other middle-income countries in Latin America. From 1994 to 1997, health expenditure decreased from 6.5% to 5.6% of GNP. Comparable figures for 1997 in Latin America were: Chile 6.1%, Colombia 9.3%, Costa Rica 8.7%, Argentina 8.2 % and Brazil 6.5%.²⁰ Low expenditure for health has also affected the level of resources available for reproductive health programmes; reproductive health expenditure was reduced by 33% between 1993 and 1996.²¹

The second problem is a consequence of the first, i.e. that even though health sector officials say they consider the improvement of reproductive health a high priority, Mexico still has worse indicators, e.g. for cervical cancer and maternal mortality, than other middle-income Latin American countries. Thus, cervical cancer rates fell slightly between 1995 and 2000, from 21.6 per 100,000 women aged 25+ years to 19.2,²² but the comparable figures were 9.9 in Costa Rica, 10.9 in Colombia and 8.4 in Argentina.²³ And even though maternal mortality has diminished in Mexico in the last ten years, in 1999 it was 55 per 100,000 births compared to 29 in Costa Rica.²⁴

Collaboration between the government and NGOs in reproductive health care could help to address some of these problems by generating more efficient use of resources and using the experience of NGOs in the field. Nevertheless, contradictory results when this was tried in other countries justify an analysis of whether conditions in Mexico are likely to facilitate or limit collaboration between government and NGOs in reproductive health care.

Methodology

This paper, based on a qualitative study, analyses whether or not the conditions exist in Mexico for successful and sustainable partnerships between the public sector and NGOs in the reproductive health field. Key informants in the public sector and NGOs in six Mexican states were interviewed in depth between February 2002 and April 2003. As a first step, 21 NGOs working in reproductive health were surveyed by telephone and e-mail. The six chosen for this study (see Table 1

short-legendTable 1

) were selected based on location, year of founding, main areas of work, previous collaboration with the government and involvement in networks.* The key informants from the public sector were chosen at a local level in the states where the selected NGOs were located. Due to resource limitations it was not possible to select a larger sample of NGOs or key informants from the public sector.

At local level, those interviewed included personnel from the office on reproductive health of the Ministry of Health in the states of Yucatan and Chihuahua and the Director General of Coordination and Supervision in the state of Morelos; and at federal level, the Director General of Reproductive Health (DGSR), the Director of Family Planning and the coordinator of the Women and Health Programme.

Interviews were with informed consent, and confidentiality was guaranteed if requested. All organisations formally agreed to provide information and participate in the study after receiving detailed information on the study objectives and motivations, funding sources and strategies of dissemination of findings. Internal documents of NGOs and government documents, activity reports and legal frameworks were reviewed. Information from documents and previously published studies was analysed through content analysis. Interviews were systematically analysed using grounded theory techniques²⁵ with the support of specialised software on qualitative analysis (ATLAS Ti).

National policy on partnerships to provide reproductive health care

At the moment, 1,051 civil associations carrying out health-related activities are registered with the Mexican Centre for Philanthropy.²⁶ Approximately one-fifth of them carry out activities related to reproductive health, e.g. sexual education, preventive health, antenatal care, support to victims of domestic and sexual violence, HIV/AIDS work and advocacy for sexual and reproductive rights. Most of these NGOs are small and have limited resources and infrastructure; they could not replace the state in the provision of health care services.

The main problem faced by these NGOs is lack of resources. The international agencies that have been the main financial support for NGOs since the 1980s believe that Mexico is more developed and that their financial support is no longer necessary. This reduction in resources has put the future of NGOs in jeopardy,²⁷ particularly those that are working with the same populations as the public sector, which wastes limited resources. Other NGOs are working with populations which have no access to public services or in activities that government handles in an inefficient way. However, it is impossible for public sector failure to be made up for by NGOs, which are struggling to survive financially.⁶²⁸

Since the ICPD in Cairo, a limited number of collaborative agreements between NGOs and various levels of government in Mexico have been carried out. In 1995 the federal government began to consider the possibility of establishing collaborative agreements with social organisations. The National Plan for Development 1995–2000 establishes that “the legal framework is not sufficient for the elaboration of the initiatives and the aims of the organised and independent civil society. The federal Government considers that it is of fundamental importance to promote the establishment of a new regulatory framework that recognises and encourages the social, civic and humanitarian activities of civil organisations”.²⁹

During Ernesto Zedillo's presidency (1994–2000) NGOs were invited to participate in the commissions in charge of designing specific health policies, including for reproductive health. The Reproductive Health and Family Planning Programme 1995–2000 was designed by the Inter-Agency Group on Reproductive Health, which included representatives of the Ministries of Health, Defence and Education, representatives of various government social security bodies and health services, as well as many NGOs and NGO networks, including those in family planning, the federation of private health associations, and advocacy groups for adolescent sexuality education, reproductive choice and safe motherhood.²⁴ There is a corresponding state-level inter-agency office in each state that is the link between the federal and local levels.

The government of Vicente Fox (2001– ), the first government formed by an opposition party in more than 70 years, also supports collaboration between government and civil society organisations in carrying out social and health policies, but from a different angle. Thus, the National Plan for Development 2001–2006 states that “to encourage the social wealth of Mexico, the social and human development policy…proposes actions and programmes which will diminish the presence of the State in areas where NGOs can make an effective contribution…”.³⁰

In the health field, the appointment of Julio Frenk as Minister of Health also helped to incorporate civil society into decision-making. In fact, one of the high priority programmes in Frenk's administration is the Women's Health Programme, which proposes the creation of a National Women's Health Consortium where different sectors, including civil society organisations, can be involved in the design and implementation of women's health policies. Another initiative by the Ministry of Health to collaborate with NGOs was the Community Health Programme. In both cases, NGOs were asked to submit projects for funding. The contractual relationships in these cases are very similar to those established between NGOs and international funding agencies: a multi-sectoral committee selects the projects to be funded and the work of funded NGOs is periodically evaluated. Another form of collaboration has consisted of NGO training of public sector personnel on reproductive health issues and gender perspective.³¹

In 1995, the Institute of Social Development (Indesol) was set up within the Ministry for Social Development specifically to establish links between the different levels of government and NGOs in order to support NGO anti-poverty programmes. This is the only public sector body that has institutionalised the relationship between the government and NGOs. Nevertheless, as with the Ministry of Health collaborative arrangements, the agreements made are mostly for the short term, i.e. one or two years.

Tax status of civil society organisations

A tax law passed in 1991 and further regulations in 1993, following an initiative of a coalition of NGOs, recognised civil society organisations as non-profit organisations and encouraged the expansion of the non-profit sector through tax exemptions.³²³³ There are two common forms of legal status in Mexico for social organisations: the “civil association” (AC) and the “private assistance institution” (IAP). Civil associations are mainly non-profit and their fiscal status varies according to their activities. Institutions of private assistance are charitable groups that deliver services. According to the tax law, both may apply for tax-exempt status and issue tax deductible receipts, as long as they are dedicated to charitable purposes, culture, wilderness conservation, education, or scientific and technological activities. However, the application process is complex and has limited the number of organisations that have achieved this status. Currently, only 43% of all philanthropic organisations have tax-exempt status. Some activities, such as the promotion of human rights and community development, are not eligible for tax benefits.³⁴

Policy on collaboration at state and local level

Herrera has identified four basic types of collaboration in Mexico:

• NGOs bringing successfully political pressure to bear on policy or programmes which, although not collaboration in a strict sense, is a step in the process of dialogue,

• the involvement of NGOs in government programmes and initiatives, e.g. as consultants, doing training or evaluations, lobbying for policies or preparing proposals,

• government support for activities that historically have been carried out by NGOs in the absence of relevant public policies, and

• mutual collaboration where both parties establish a formal agreement to undertake joint activities, the nearest to the idea of partnership.⁶

The NGO informants interviewed recognised partnership with government as one way to give continuity to their work, and several of their NGOs have been involved in such partnerships. However, interest in and experience of NGO–governmental collaboration have been different in the six states where the NGOs interviewed are located.

In 1994 the local Congress of the state of Colima approved a state planning law which states that “…the law establishes procedures to promote and guarantee the plural and democratic participation of diverse social groups… in the design of the State Development Plan”. Unfortunately, another initiative, the Law of Promotion of Civil Agencies, which would have guaranteed public funds for NGOs, was not approved.³⁵

In Morelos, during a previous state administration, a private laboratory was contracted for the analysis of Pap smears. The current administration is involved in a much wider variety of collaborations with NGOs, ranging from an educational scholarship programme run by NGOs for youth and adults to the creation of a centre to support women's development, involving 27 NGOs. NGOs currently participate in the state Inter-Agency Group on Reproductive Health, and there is also a current collaboration with NGOs in advocacy and policy design on prevention and support for victims of domestic violence and the Committee for Promotion of Safe Motherhood. Finally, there have also been some agreements, mostly informal, with specific organisations; CIDHAL and public primary health care clinics have collaborated on cervical cancer screening and two other NGOs have coordinated efforts to provide training and residencies for midwives in the town of Tepoztlán.³⁶

In Yucatan, the State Development Plan for 2001–07³⁷ states that one of its main goals under social assistance is “to strengthen coordination efforts with non-governmental organisations to work jointly and avoid duplication”. In relation to health, it expresses interest in promoting the “participation of citizens in the decision-making bodies of the local health system” and “to carry out programmes and activities in coordination with NGOs and different institutions to benefit the health of youth”. NGOs also currently participate in the Inter-Agency Group on Reproductive Health at local level.

In Chihuahua, the executive board of the Women's Institute includes two NGO representatives. The state government has a list of 614 organisations working on social issues in the state, among them FEMAP.³⁸ The State Health Plan for 1999–2004 calls for the participation of local organisations in health promotion, but does not state what that participation consists of. One of the proposed solutions for the problem of coverage in the cervical cancer screening programme is to contract private providers to process smears.³⁹

In Veracruz there are a large number of NGOs registered, but there are few actual collaborative activities listed in the State Plan of Development or the Annual Government Reports. A Coordination for Human and Social Development Programmes was created in 2000 “to motivate and consolidate the linkage among different government levels, the private sector, academic institutions, non-governmental and international organisations, all committed to the reduction of poverty levels”. And in the Programme of Healthy Municipalities, the participation of NGOs with government authorities in health promotion activities is also mentioned.⁴⁰ However, all these programme documents only talk about government support for NGO work, not partnerships as such.

Jalisco is similar to Veracruz. The local government directory of civil society organisations now includes a total of 2,628 organisations. In 2002, the government gave advice on human development to 69 NGOs. The Jalisco Institute of Social Assistance gives training courses to the executives of NGOs on topics such as law, accounting and fiscal management of an NGO, as well as funding sources and trusteeships. In 2001 more than US$200,000 in infrastructure and equipment was given to NGOs by the government.⁴¹

Changing priorities for partnerships: government perspectives

The current perception of the government officials interviewed is that NGOs have an important role to play in monitoring the national reproductive health programme. Both the Director General of Reproductive Health and the coordinator of the Women and Health Programme, for example, recognise the contribution of NGOs in the expansion of reproductive health care coverage, not least because they can sometimes reach people the public sector has not been able to reach.

As regards establishing a formal partnership, in which the Ministry of Health would fund NGOs, the biggest constraint was said to be a shortage of resources, and external funding or a budget line would need to be devoted to that purpose. For example, several years ago the family planning programme received external funding from international organisations and part of those resources were utilised to support NGO service providers with supplies, financial resources and training. It was a successful initiative and the support was reciprocal; sometimes the public sector trained NGOs and sometimes vice versa. Nevertheless, the agreement was terminated by international organisations on the grounds that the situation of the population being served had improved and the funding was therefore no longer needed. These cuts had a negative impact on the financial sustainability of both the government and NGO programmes.

The interest in collaborating with and funding NGOs at the national level is now focused on research and assessment of public sector health care performance in order to plan future strategies. Negotiations were said to be taking place in the Congress to create a budget line for research on reproductive health, but it was not considered feasible to fund service delivery due to limited resources. At the local level there is now less interest in the work of NGOs. Although there are NGOs working on reproductive health in the three states where public sector officials were interviewed, not all high-level officials are aware of or interested in their activities. The lack of an effective regulatory framework for partnerships was mentioned as a problem, to define the rights and responsibilities of each party.

The experience of six NGOs in Mexico

Tarrés emphasises that the collaboration between NGOs dedicated to women's issues and government has particular manifestations. Women's NGOs interested in establishing a relationship with government do so through friends who are public employees or politicians, primarily women. On very few occasions does the relationship develop due to the interest of the politician in feminist theory or sympathy with the work of the NGO.²⁸ Furthermore, the many changes in personnel in the public sector in Mexico with each election make it difficult to maintain the relationships necessary for collaborative agreements to continue.

The relationships between the six NGOs listed in Table 1 and different parts of the government have had their ups and downs over the years. CREO is located in a region traditionally governed by the Partido Revolucionario Institucional (PRI), that governed Mexico for more that 70 years. The collaboration between local government and CREO has been limited. In the past, CREO provided training for nurses on issues in a public clinic in Santiago Tuxtla, and the Partido Acción Nacional (PAN) has also asked them for reproductive health training courses for some of its members. Recently, SEDESOL (the Ministry of Social Development) selected CREO to act as an external inspector of their resources management at local level. CREO and the Clinic for Cervical Dysplasia of the Ministry of Health of Xalapa, the capital of Veracruz, have had an agreement since 1996 that has contributed to the training of health promoters and to procedures for referring patients for secondary or tertiary care as needed. In 2002 CREO received funding from the Institute of Social Development to carry out a programme to advise and give support to women victims of domestic violence.

During the administration of Carillo Olea (1994–98), CIDHAL worked informally with some of the personnel of several public primary health care clinics in Morelos on prevention and screening for cervical cancer. Unfortunately, their proposal to create a Centre for Integrated Health Care was not taken seriously by the government. Since 1993, CIDHAL has been part of the national safe motherhood committee, which includes academic institutions, government agencies and NGOs. A funding requested by CIDHAL to the Programme for Healthy Communities, which is managed by the Ministry of Health at federal level, to train midwives in cervical cancer screening and promotion was rejected on the grounds that the Ministry of Health already had a cervical cancer screening programme in place.

CAM was originally created by the state government of Colima under Griselda Álvarez (1979–85) to undertake work on domestic violence, linked to the State Attorney General's Office. CAM later decided to become an independent civil society organisation, hoping to retain government financial support. However, once it became independent, the funding became unstable, as the local Congress now has to approve the amount annually, and each time the government administration changes funding must be re-negotiated. Only CAM among the six NGOs has received direct funding from the government on a regular basis.

CIAM initiated its work when Jalisco was still governed by the PRI. After a PAN candidate became governor, the relationship of CIAM with several government agencies improved dramatically as some of its professional members had connections with some of the new state government officials. Since then a number of joint activities have been established, such as training workshops for public officials. However, during the present PAN administration the relationship has declined, as the current governor has a limited interest in gender issues and human rights. CIAM has received funding from SEDESOL to carry out workshops on women's rights and domestic violence in marginalised zones of Guadalajara. Personnel from the Ministry of Health have attended workshops on domestic violence organised by CIAM, and the Ministry has invited CIAM to give training courses on gender issues to civil servants. However, these courses are not reimbursed; CIAM has to invest its own time and resources without public sector support.

Figure 1 Diego Garcia mural, Mexico City

FEMAP has had both formal and informal collaborative agreements with the government. There is an informal agreement to coordinate work on health promotion to avoid duplication of efforts by FEMAP's health promoters and those of the Ministry of Health and other government agencies. FEMAP has also established formal links with the reproductive health programme at national and state level; however, this only involves attendance at monthly meetings to discuss issues and few decisions are made. FEMAP also received funding from SEDESOL in 1998, and is one of the NGOs that has participated in the Inter-Agency Group on Reproductive Health of the Ministry of Health.

SHSSR has not to date established any formal or informal collaborative agreement with the government. They often organise training workshops on reproductive and sexual health to which public health sector personnel are invited, and some public sector personnel have accepted these invitations on several occasions. SHSSR believes this should be considered a form of government recognition of their activities.

Partnerships with government: the NGO perspective

All six NGO informants thought that the current administration is, apparently, more open to organised civil society and an interest in NGOs' points of view on policy. However, they also felt that increased interaction with government might decrease the level of NGO autonomy or shift them away from their missions.

Regarding the possibility of the government funding specific NGO projects or the delivery of particular services, these NGOs saw both advantages and limitations. One advantage in having a reproductive health service provider other than the government is that it can prevent the manipulation of social policies for electoral purposes. Another is that funding gives financial sustainability to NGO projects. Still another is that such an agreement implies government recognition of its own limitations in the provision of services and its ability to maintain a certain level of quality of care or improve the health care status of the population. According to some of the NGOs, the national reproductive health programme has not fulfilled the Cairo conference agreements. They cite as examples the low participation of men in reproductive health programmes, the refusal to provide legal abortions, the lack of promotion and availability of family planning methods such as emergency contraception, and in some settings lack of respect for patient privacy. Hence, they feel partnership with NGOs would help to fulfill the Cairo agreements and have a positive impact on public sector performance.

An important challenge, in the opinion of these NGOs, is to establish formal mechanisms for supervising the process, to prevent those involved from taking advantage of their position. They feel the process for the selection of projects to be funded should be both rigorous and transparent, with projects selected according to their quality and potential impact and not for personal or political reasons. One of the six NGOs has participated in the project selection process with Indesol; another was on a committee that monitored the process. They point out that if the same NGOs who are applying for funding participate in the selection process, which has apparently occurred, any sense of impartiality will be totally undermined.

All NGO informants felt strongly that the State has the responsibility to assure education and health care provision for the whole population. NGO partnerships with government do not supplant the government's responsibilities; rather, the inability of the State to accomplish those goals has led civil society to assume part of that responsibility. Some of the NGO informants felt that NGOs should only take on certain activities, i.e. training, monitoring of government actions or the provision of very specialised services.

Discussion

NGO–government partnerships are an option in Mexico for the provision of reproductive health services in geographical areas where the population is under-served, and for advocacy and service delivery in areas that the government has not addressed. There are still rural areas in Mexico far from any public health services, where NGOs are working. Such is the case of CREO's work in several rural communities in the Tuxtlas region of Veracruz. Some of the issues ignored by the public health services but taken up by NGOs include support and care for victims of domestic violence, and provision of emergency contraception and legal abortions.

Partnership is also an option where the cost of providing government services is higher than if an NGO were contracted to do so, again mainly in rural areas. In each primary health care clinic, in most cases, there is one doctor who, as a requirement for completing training, is there on a social service basis and one nurse. The cost of hiring an additional general practitioner for such clinics would be very high. In areas where there is already an NGO providing reproductive health services, supporting it might be a less expensive option. According to a comparison of the cost of cervical cancer screening in one locale, the cost was 26% higher in the public clinic than in the clinic of CIDHAL.⁴²

Since 2001, the collaboration between the government and NGOs in reproductive health care has increased. However, the conditions for viable partnerships between reproductive health NGOs and the public sector in Mexico still remain to be met. Importantly, there is a tradition of distrust on the part of government and a tradition of lack of participation in decision-making by civil society that still influences behaviour on both sides, especially at state level. The influence of international agencies has been a crucial element in opening up this process, but it is difficult to determine to what extent current commitments are due to international pressure.

At the state level, the work done by NGOs is either not recognised or not considered relevant, and it is assumed that partnerships would benefit only the NGOs. At the federal level, the contribution of NGOs to the reproductive health field is now recognised. However, there are still very few public programmes that support collaboration with NGOs, and agreements are often limited to the financing of specific projects. Even where duplication of functions is a problem, implying waste of resources and lack of coordination among the actors involved, the government apparently does not see collaboration as a way to save resources. Therefore, even if in the official discourse there is interest shown in NGOs and partnerships, the political will to implement long-term agreements has not been forthcoming.

For the NGOs, partnership is considered an option as long as it does not contravene their mission nor imply that government is avoiding its responsibilities. Even when NGOs have the capacity to be good service providers, the responsibility to guarantee access to health services for the whole population should remain in the hands of the government, both as a service provider and as the regulator and coordinator of service provision, and with responsibility for guaranteeing that resources are sufficient for the provision of good quality services.

In fact, lack of resources is one of the main constraints for NGOs. In the collaborative agreements currently being implemented, NGOs are given a limited amount of resources which must be used in a specific period of time. Although the agreements are formal, there are no assurances that the partnership will be sustained in the long-term. Accountability mechanisms are limited to the same short period of time, which greatly restricts their worth. NGOs are forced to submit a “new” project proposal for ongoing work time and again, a procedure that increases the transaction costs for both sides and is a disincentive for future collaboration. And there is, of course, the constant threat of not receiving financing again.

The future of NGOs in Mexico will depend largely on their ability to obtain funding and resources from within the country. Several NGOs have already put self-financing mechanisms (e.g. fees for services) in place. However, most of the activities of these NGOs are for low-income populations who cannot afford such fees. One alternative is government funding. On the other hand, it can also be argued that government funding for reproductive health care programmes is still very limited, and is not sufficient to fund or contract providers outside the public sector. To allow for longer-term partnerships, more effective mechanisms are required for the government to generate those resources.

Another possible option for NGOs is through national philanthropy. For NGOs to make the most of private donations, however, there should be institutional support from the government. The restrictions imposed by the tax law on the issuing of tax-deductible receipts and the limited tax benefits for NGOs are important barriers. An additional problem is that Mexican society has shown very little interest in philanthropy. According to Shepard this is a common phenomenon in Latin America, where many NGOs working on sexual and reproductive rights have been unable to convince the upper and middle classes, who have the capacity, to provide them with financial or political support.⁴³

In this respect, Mexico's citizens have a certain responsibility if they wish to secure universal access to social services. However, their main responsibility is to pay taxes. If a large number of citizens avoid paying taxes, the resources to finance government programmes are reduced. In this regard in Mexico, the percentage of the population working in the informal economy has increased considerably in the past 20 years, and the rate of tax evasion by those in the formal sector has also increased.^{44 45}

Saving money is not the only reason why government should work in partnership with NGOs. The creation of social capital by NGOs though work in the community is also a critical reason. CREO, FEMAP and CIDHAL have created large networks of health promoters and midwives who assist in the provision of reproductive health care and other services and bring these services closer to the community. The lack of government recognition of the experience and skills of NGOs, the information they provide and the community networks they have developed is difficult to justify. These are resources that, in most cases, only NGOs have to offer, and they are a valuable contribution to the success of health policy implementation.³

Unless the government recognises the specific contributions NGOs can make to any partnership, and unless there are formal mechanisms to ensure long-term accountability and commitment on the part of the government, it will be impossible to implement fair collaborative agreements. Thus, it is necessary to make changes to the legal framework that governs the recognition of civil society organisations and partnerships with government and, in particular, which will contribute to increased confidence.

Lastly, the current competition for resources generated by government among NGOs runs the risk that some NGOs will (re-)shape their aims and programmes to mirror those considered high priority by the government. The six NGOs interviewed for this study, all of which are highly commited to their work, have maintained their independence and the power to make their own decisions, but they also have fears for their financial sustainability, given the uncertainty as to how long the government will support them. Ironically, NGOs such as these may also feel very little trust in government, and may not even consider collaboration as an option.⁷

At the moment, the Mexican government has far greater decision-making power. It holds the decision in its hands of who to collaborate with, under what circumstances and with what resources. The only decision in the hands of NGOs is to accept or refuse those conditions. A more equitable distribution of power will be needed before the real meaning of partnership can be fulfilled.

Acknowledgements

Some of the information in this article was presented at the Society for Latin American Studies conference, Manchester, April 2003. That paper will be published with all the presentations of the panel on social policy. This article is taken from my PhD thesis in Public Health which was directed by Dr Mario Bronfman and funded by the Consejo Nacional de Ciencia y Technologia. My thanks to Blanca Rico and Laura Reichenbach for their comments and Laura for help with editing. I am grateful to all key informants interviewed and to Dr Michael Hirsch for this Patient support throughout the research. The research received financial support from the International Programme of Financial and Academic Support for Research from a Gender Perspective in Reproductive Health and Health Services, based at the National Institute of Public Health in Mexico City, financed by the Ford Foundation. Scholarship ID: CISS FF/DBSSC/PSYSR/BECA01/2002. The research was also funded by the Alliance for Health Policy and Systems Research, an initiative of the Global Forum for Health Research in collaboration with the World Health Organization.

Notes

* Non-governmental organisations (NGOs) are civil society organisations that are formally established; are private and independent from government (although they might receive its support or collaboration); are non-profit-making and self-governing (with internal decision-making structures); and have a meaningful voluntary content (income, labour or management).⁷⁸⁹

* FEMAP and CIDHAL were created in the 1970s, CAM in the 1980s, CREO and CIAM in the 1990s, and SHSSR in 2000. Although all of them have activities in reproductive health, some also carry out other activities. FEMAP and CREO work on general development issues; CAM, CIDHAL and CIAM focus on women's issues more broadly; while SHSSR works mostly in provision of reproductive health services. FEMAP is located in the north, CAM, CIAM and CIDHAL in the centre, and CREO and SHSSR in the south. CAM has collaborated with the government at local level and CIAM, CIDHAL, CREO and FEMAP at local and national level; SHSSR has not done so.