Collaboration Challenges of Non-Governmental Organizations in Healthcare system in Iran: a qualitative study

Objective Despite the strong emphasize of government on collaboration and application of non-governmental organizations in healthcare, there can be seen a research gap in this area in developing countries. The present study aims to investigate collaboration challenges of non-governmental organizations in healthcare from the viewpoint of healthcare managers and active managers of non-governmental organizations of Iran as an example of low-middle income country. Results The content analysis of qualitative data led to the emergence of ve main themes of collaboration challenges of non-governmental organizations in healthcare: political issues, operational issues, cultural issues, management issues, and communication issues. This study presents a clear framework for identication of collaboration challenges of non-governmental organizations in healthcare Especially for developing countries. This framework should be taken into consideration by authorities of Ministry of health in their policy makings.


Methods:
The present qualitative study is carried out in 2019-2020. The study sample consists of 54 individuals selected via purposive sampling and snowball method. The selection is done based on the following criteria: 1. managers of healthcare system who had at least one-year work experience in the eld of people's collaboration at national level (31 individuals). 2. Managers of NGOs who had at least one-year work experience in healthcare activities (23 individuals). The rst level of interviews was conducted on phone including an introduction on the research, title of the research, objectives, and con dentiality of the interviewee's name. Participants were informed that the researcher was interested in evaluating the collaboration challenges of NGOs in Healthcare system in Iran. Eventually, date and location of interviews were determined. The interviews consist of 48 in-person interviews, 4 interview on phone, and 2 interview by lling the required form via email. All the interviews were recorded and transcribed. Interviews were transcribed and transcripts returned to participants for review. Average duration of each interview was Interview guide questions were used for all the interviews. These questions were used based on extracted criteria from two Iranian papers published in the eld of healthcare [8,9]. During the interview, managers were required to identify collaboration challenges of NGOs from their own viewpoint in the framework of open questions. Validity of the questions was approved by experts. All the points were typed immediately after the interview. Data analysis was carried out via framework analysis consisting of ve steps of familiarity, identi cation of a thematic framework, indexing, drawing tables, drawing a map, and analysis [10]. The texts were reviewed several times for obtaining a general overview. Then, the texts were studied line by line in order to provide a comprehensive view of each line. At rst, data coded was done by two researchers which indicates analysis units. Analysis units are the answers for questions. Semantic units were extracted from the main concepts of analysis units and each of them was provided with a speci c code. The codes were compared with each other and an index of main and subsidiary codes was made. In coding of the second level, main and subsidiary codes were recited and those codes with similar meanings were categorized. In case of any dissimilarity, after discussion and reaching an agreement, the nal code was determined. Data framework analysis method in Atlas.T software is used for analysis of the interviews.

Results:
Interviews continued till there was no new code, and data saturation was done after 54 interviews. All of participants cooperated with our research. According to the results of Table 1, more than 60% of participants were male and with bachelor's degree. Also, about 55% of participants had 1-10 years work experience.  Table 2. These issues include 15 sub-concepts. The effects of political issues on deployment of NGO varied in different presidential courses of Iran. This has affected the expansion or decrease of NGOs participation in various elds, including healthcare, which analyzed in the work of Aghababa et al. [11]. "a manager welcomes a donor, but tomorrow, another university manager res the same donor. This happens a lot and makes the donor confused and uncertain" (P7, P20, P17).
The top-down view of the public sector towards NGOs has led to grammatical behaviors of public employees with NGOs, which has led to the discontent of NGOs and their diminished engagement with government areas "Sometimes when we [NGOs] had di culty, we request the help of the University of Medical Sciences. But we were worried about their collusion" (p28).
The lack of public sector Supervision of NGOs in the health sector causes some NGOs to fail to comply with the guidelines. "Government must monitoring of semen performance and their activities" (p16).
During the interviews, some participants stated that in addition to political abuses, the government is also abusing NGOs. "They want us to support the political work of government agencies, but we do not engage ourselves" (p21).
NGOs should be able to play their role as a social capital in different elds and based on legal conditions and social regulations [12]. Studies have emphasized on lack of certain rules and supervisions based on the founded law [8, 13,14]. "tax exemption should also include healthcare NGOs. Getting loans by a donor has its own challenges. It means that the government is unable to provide some facilities in order to give us some loans" (P3, P9, P13, P16, P17).

Performance issues
The NGOs Board of Trustee includes a number of people who sometimes do not share a common view of how to pursue a path to accomplish activities and achieve the goals. "Unfortunately, teamwork is di cult ... One of the problems in NGOs is the difference in taste causing them not to perform or to move elsewhere" (p27).
Another challenge is lack of a comprehensive system among NGOs and governmental organizations which leads to injustice for receiving services [15]. "An adroit person receives services from several sources, but another person who is unable in this regard will be deprived of services, and parallel processes intensify this problem" (P3, P5, P11, P12). "for receiving facilities from the governmental sector, there is a long process … if I [manager of NGOs] want to get help from someone in the eld of healthcare, no one is responsible and I should refer and have a long talk from early morning each time" (P12, P11, P1, P18). This challenge is also referred to in a study by NHA [16] . This challenge is also referred to in Delislem et al.'s study [17].
Another problem which is highlighted by Lencucha is allocation of nancial resources to healthcare system [18]. These organizations have been converted to an auxiliary lever for aggregation of income [14,15]. "They say that NGOs [healthcare NGOs] should enter economics in a legal framework, but it is a big challenge for us" (P1, P11, P12).

Cultural issues
Lack of cultural infra-structures with the aim of institutionalizing NGOs is another problem leading to weak performance of NGOs, which is also referred to in Musa's study [19]. "Collaboration should be cultural and educational" (P6, P18).
Another case mentioned in this section is the lack of recognition and culture for doing team work in the country. "In teamwork, we need to cultivate teamwork culture rst, especially when it comes to health" (p19).
Attitudes in healthcare governmental sector should be modi ed, so that this sector should consider nongovernmental sector as a collaborator in reaching developmental goals, not a competitor [20,21]. "our main challenge [healthcare NGOs] is that they think we work internationally and work for making money and they do not cooperate with us" (P1, P4, P11). Another challenge is lack of people's awareness from charity organizations which causes some challenges for these organizations in Iran. "In Iran, what is referred to as NGO is not inferred similarly by all the people" (p25).

Management issues
A challenge which is mostly stated with regard to management issues is weak support of governmental healthcare managers from NGOs. It is also referred to in the study of Anbazhagan and another study by Tucktuck [3,5]. "The manager should believe in NGOs … a reason for detachment of NGOs is lack of governmental supports" (P 2, P5, P7, P11, P18). Another challenge, which is referred to in the study of Abdallah is the need for support from using collective capacities [22]. Managers of NGOs need governmental supports for progress and ful llment of their goals. These supports are not only limited to nancial supports; providing appropriate infra-structures for foundation of NGOs, facilitating foundation of NGOs, educating the founders of these organizations, accurate and correct supervision of science with the aim of helping NGOs, trusting NGOs and introducing NGOs to the society are some other examples [23]. "The manager has to believe that the benefactors can help ... extend their hand to them" (p18).
Lack of scienti c management can be considered as a main cause of ine ciency in charity organizations [24]. "manager should be trustful, known, and honest; so that we do not think of deceiving him/her [healthcare NGOs and the donor] in order to take money and spend it in another eld" (P 1, P5, P6, P9).

Communication issues
Using media communications is the best way for interaction of NGOs who support patients with direct users in civil society [9]. One of the stated challenges in this group is lack of regular and systematic communications of governmental sector with healthcare NGOs which is also referred to in the study of Delisle [17]. "There is no regular communication with NGOs and the main problem is informing the hospitals about us" (P12, P11, P18).
Furthermore, another challenges, is unspeci c number of NGOs and their elds of activities in healthcare system for creation of appropriate communication. Lack of active and appropriate network communication between NGOs causes a lot of challenges in their collaboration with healthcare governmental sector [25]. "communication should be made between NGOs to provide guidelines and update their information" (p14).

Limitations:
The main limitation of our study is related to the inclusion criteria. Findings may have been different if the participants were changed. But the strong points of this study are semi-structured interviews with the specialist shows collaboration challenges of NGOs in healthcare system in Iran and other developing countries similar to Iran. Availability of data and materials: The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.