Main concept number 1: Political issues
Changing managers in medical sciences universities is commonplace in Iran health system that affects the managers' view of the relationship with the NGOs.” The other problem is that changing the manager regularly [at the University of Medical Sciences] makes collaborations less and that's a lot” (p21). The effects of political issues on deployment of NGO varied in different presidential courses of Iran. This has affected the expansion or decrease of NGO s participation in various fields, including healthcare, which analyzed in the work of Aghababa et al. [13]. “a manager welcomes a donor, but tomorrow, another university manager fires the same donor. This happens a lot and makes the donor confused and uncertain” (P7, P20, P17). Government should remain the sole decision maker, not the operator, and people should take the lead of their own affairs[14] . For instance, “it can be said that Different political factions give different meaning to. Ups and downs of each government are different” (P9, P1, P6, P8).
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 trouble [requesting 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)
NGO s should be able to play their role as a social capital in different fields and based on legal conditions and social regulations[15] . Studies have emphasized on lack of certain rules and supervisions based on the founded law. Another issue about NGO s, which is similar with the reported results of Heydari and Nekoui Moghadam and Zareie, is existence of some problems related to charity organizations which caused by legal gaps [9, 16, 17]. “tax exemption should also include healthcare NGO s … 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).
Main concept number 2: Performance issues
In order to further their goals and fulfill their mission, the NGO s needs the support of the government, not only financial support, but also the confidence and relinquishment of their projects to the community. NGO s in Iran, especially in the field of health, needs to grow and flourish as well as maintain, which requires the government to advance its goals so that they can make the most of their participation. "... in Iran we expect NGO s to be different from other countries. It is very important that people say their health needs and their suggestions and where they can be present should be specified ... “ (p30).
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 difficult ... 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 NGO s and governmental organizations which leads to injustice for receiving services [18]. “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 field 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 [19] . “Hospitals have no specific pattern in relation to NGOs and are provided with insufficient information about the NGOs”. (P11, P12, P17).
“All the affairs should be carried out with a certain coordination. Awareness should be increased, especially awareness of Hospitals from their interactions with donors and NGOs” (P4, P11, P17). This solution is also referred to in Delislem et al.’s study [20]. Another problem which is highlighted by Lencucha is allocation of financial resources to healthcare system [21]. These organizations have been converted to an auxiliary lever for aggregation of income [14, 15]. “They say that NGO s [healthcare NGO s] should enter economics in a legal framework, but it is a big challenge for us” (P1, P11, P12).
Main concept number 3: Cultural issues
Lack of appropriate infra-structures with the aim of institutionalizing non-governmental organizations is another problem leading to weak performance of NGO s, which is also referred to in Musa’s study [22]. “Collaboration should be cultural and educational, and healthcare NGO s should initiate with the help of municipality.” (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 culture first, especially when it comes to health” (p19).
Thida et al. highlighted the importance of a specific law about the activities of NGO s, and also, the importance of an accurate supervision over these activities [23]. Attitudes in healthcare governmental sector should be modified, so that this sector should consider non-governmental sector as a collaborator in reaching developmental goals, not a competitor [24]. “our main challenge [healthcare NGO s] is that they think we work internationally and they do not cooperate with us” (P1, P4, P11). In some of organizations, the issues of individual and social freedoms , modification of laws, and also criticisms from the performance of governmental organizations, are taken into consideration [25]. So this leads to positioning of some of the governmental managers against NGO s and reduction of their collaboration.” Health Centers don't cooperate ... practically the public sector they just looking to see what we're going to do “(p14) It is recommended that this problem can be solved via counseling and holding meetings and memorandums of understanding. Some of the governmental healthcare managers believe that NGO s, who proceed to work in healthcare system with the aim of founding their organization, (for example for making money).” Unfortunately, there is a bad outlook in our society ... there is no place for our people to say, for example, that I want to do something good”(p29) However, Reddy does not consider the intention of non-governmental organizations to be exploitation [26]. Another challenge is lack of people’s awareness from charity organizations which causes some challenges for these organizations in Iran. “People should directly enter the field of charity, however there is a lack of awareness from donors and performances of social deputy…” (P3, P9, P11). “In Iran, what is referred to as non-governmental organization is not inferred similarly by all the people” (p25).
Main concept number 4: Management issues
A challenge which is mostly stated with regard to management issues is weak support of governmental healthcare managers from NGO s. It is also referred to in the study of Anbazhagan and another study by Tucktuck [3, 5]., “the manager should believe in NGO s … a reason for detachment of NGO s 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 [27]. Managers of non-governmental organizations need governmental supports for progress and fulfillment of their goals. These supports are not only limited to financial supports; providing appropriate infra-structures for foundation of NGO s, facilitating foundation of non-governmental organizations, educating the founders of these organizations, accurate and correct supervision of science with the aim of helping NGO s, trusting NGO s and introducing NGO s to the society are some other examples [28]. “The manager has to believe that the benefactors can help ... extend their hand to them.”(p18)
Lack of scientific management can be considered as a main cause of inefficiency in charity organizations [29]. “manager should be trustful, known, and honest; so that we do not think of deceiving him/her [healthcare NGO s and the donor] in order to take money and spend it in another field” (P 1, P5, P6, P9).
In addition to using NGO s to solve problems, managers also need to increase their impact on society "... the most important thing a manager can do is empower NGO s So they can be influential at the community level”(p24)
Some interviewees have emphasized on the presence of clinical specialists (benefactor) in board of directors of NGO s, the effects of manager’s reputation on continuity of the activities, and Managers incapacity of some NGO s managers as other challenges in this area. As an example, “due to the presence of some of the board members [NGO s] in some places, our credit is risen [healthcare NGO s] and we can achieve further credits [from governmental sector]” (P 11, P12, P14, P16). In order to continue the partnerships of NGO s or Benefactors with public health authorities, there should be managers who are well-known and trusted, not managers who do not have these capabilities.” "The person who is hired as a manager must be trustworthy ... must be known ... the most important characteristic of a manager ... must be honest.”(p27)
Main concept number 5: Communication issues
Using media communications is the best way for interaction of non-governmental organizations who support patients with direct users in civil society [11]. One of the stated challenges in this group is lack of regular and systematic communications of governmental sector with healthcare NGO s which is also referred to in the study of Delisle [20]. “There is no regular communication with NGO s … we should look after them, while they should look after us, and it is not good … the main problem is informing the hospitals about us” (P 12,P 11,P 18).
Furthermore, another challenges, is unspecific number of NGO s and their fields of activities in healthcare system for creation of appropriate communication. As we know, lack of active and appropriate network communication between non-governmental organizations [30]causes a lot of challenges in their collaboration with healthcare governmental sector. It is suggested to make some flowcharts for communication paths of healthcare NGO s in different meetings in order to overcome these challenges more optimally and increase their collaboration.
Lack of early communication between the public health authorities and active semen in this area was another major challenge "... communication should be made with this semen to provide guidelines and update their information."(p14)
Another challenge the researcher has encountered in the interview process is the inadequate knowledge of public sector staff about health NGO, s, as well as the lack of job recognition among health NGO ,s themselves” If we can figure out how to use health NGO s, we can be successful ... we must have at least a few meetings with them annually ... to make them more known.”(p30)
The study has some limitation. Inclusion criteria for interviewees were used, to find interviewees so some experts may have been missed. findings may have been different if the participants were changed. But the strong points of this study are: First semi-structured interviews with the specialist shows collaboration challenges of NGOs in healthcare system in Iran and other developing countries similar to Iran, Second, it Gives some recommendations to address those challenges based on literature review. This study presents a clear framework for identification of collaboration challenges of non-governmental organizations in healthcare in Iran. This framework provides the managers with a background from challenges before collaborating with healthcare NGOs. So, they can reduce these challenges and promote healthcare goals by holding more meetings with managers of NGOs and consulting other related organs for creation of better infrastructures for different activities of NGOs. It is recommended for further researches to investigate people’s collaboration in healthcare.