Civil society and global health

The term ‘civil society' broadly refers to social relationships and organizations outside either state (government) functions, or market-based relations that define people simply as ‘consumers' rather than more collectively, for example, as citizens, neighbours or colleagues.

Civil society organizations constitute a broad grouping that incorporates formally organized non-governmental organizations (NGOs), including faith-based charities, health NGOs, philanthropic foundations, and academic and professional networks. These may be organized at national regional or global level. At the other end of the scale, community groups and organizations may be based in local communities, such as youth groups or women's groups, or they may be communities of interest based on common factors, such as religion, ethnicity or other interests. For the purposes of this glossary, organizations aimed at promoting private business interests are excluded.

Faith-based charities: These have played a leading role in health provision in low-income countries for a long time. In most of sub-Saharan Africa, faith-based hospitals provide 30 to 40 per cent of healthcare services, particularly in rural areas. Christian Aid, the Catholic Agency for Overseas Development (CAFOD), World Vision and the Aga Khan Development Fund are examples of NGOs in this field. It must also be acknowledge that a very high proportion of philanthropic giving from community to community is faith based. This is often channelled directly to specific community partnership projects through church, temple or mosque links.

Health NGOs: Health NGOs, such as the Red Cross and Red Crescent, Save the Children, CARE International and Oxfam, have grown considerably over the past two-and-a-half decades. They now constitute a dense network of actors, which plays an important role in the delivery of health services as well as in advocacy. A notable area of civil society involvement in service delivery is that of assistance in humanitarian crises and emergencies, including conflict situations, where organizations such as Medical Emergency Relief International (Merlin) and Médecins Sans Frontières (MSF) both contribute resources and technical expertise and also sometimes play an important advocacy role. The leading role of some large NGOs, like MSF and Oxfam, has increased their impact on public opinion. MSF has also demonstrated its strength with the creation of the Drugs for Neglected Diseases Initiative (DNDi) as a new form of developing research and development. The rise of human rights organizations has led to a link between advocacy for public health with fighting for a broader field of human development.

Foundations: Foundations also have a long history in support of global health, including the Rockefeller Foundation, which started work in 1913. In recent, years the Bill & Melinda Gates Foundation has become a major actor in global health. In 2007, the foundation distributed US$ 2.3 billion. To put this into context, the WHO 2008-2009 programme budget is US$ 4.23 billion. An increasing number of global health initiatives - also within WHO - are dependant on support from the Gates Foundation. These initiatives include research into health solutions. The Wellcome Trust is the world's largest medical research charity, providing about US$ 1 billion per year for medical research, including research and technology transfer projects relevant to global health. Other examples of European foundations working in global health include the Gulbenkian, the King Baudouin and the Volkswagen foundations.

Academic and professional networks: These are active in all fields of health, supporting the global communication of research and developments in knowledge. They are also active in developing professional standards for education and practice, for example the International Council of Nurses. Networks that cross health professions or academic disciplines are less common but are increasing; the best known is the Global Health Council, which is mainly active in the USA but which also has a global membership. National cross-disciplinary groups focusing on global health are developing in many countries, for example, the Irish Forum for Global Health. Many networks focus on the provision of health knowledge, for example, the Supercourse Series, while others focus on the exchange of knowledge, for example, the Health Information for All network.

Global community organizations: The current status of civil society involvement in global health results from a number of forces. Conservative economic policies have resulted in fiscal restraint and the substantial withdrawal of the state, in many countries, from healthcare provision. Consequently, local and international NGOs and civil society groups have assumed a more prominent role in both service delivery and advocacy.

The struggle of South African NGOs to obtain affordable anti-retroviral medicines provides an unusual example of collaboration between a local social movement (the Treatment Action Campaign (TAC)), international NGOs with a specific focus and expertise, and an alliance with a national government. In 1997, Nelson Mandela signed a law aimed at lowering drug prices through ‘parallel importing' - that is, importing drugs from countries where they are sold at lower prices - and ‘compulsory licensing', which allows local companies to manufacture certain drugs they do not hold patents for in exchange for royalties. Both provisions are legal under the TRIPS agreement as all sides agreed that HIV and AIDS present an emergency situation. This was confirmed during the WTO meeting in Doha in 2001. The US administration did not bring its case to the WTO but instead, acting in concert with the multinational pharmaceutical corporations, brought a number of pressures (for example, threats of trade sanctions and legal action) to bear on the South African government to rescind the legislation. This followed similar successful threats against Thailand and Bangladesh. However, an uncompromising South African government, together with a vigorous campaign mounted by the local non-governmental organization, TAC, international AIDS activists and various other health NGOs, forced the US government and the multinational pharmaceutical companies to withdraw their action.

International NGOs sometimes perceive their role as acting as a conduit to communicate the demands and needs of poor people in developing countries. A recent example is the Make Poverty History campaign. While such a role is important, tokenism must be avoided. International NGOs in developed countries need to work with and through Southern-based NGOs, and UN agencies and intergovernmental bodies must find ways to create a more prominent involvement of Southern-based NGOs, academics and health institutions in shaping the international health policy agenda. Thus, a set of strong new non-state players is defining international priorities and approaches. As global communication becomes easier and cheaper, the role of non-governmental organiZations has become much more prominent, both in setting agendas and in delivering services.

Globalization has increased the need to engage with actors and policies from beyond the local area: this poses a particular challenge for civil society. Social movements may need to bring together the concerns of multiple communities and then find ways to present collective views and concerns at the national or international level. This form of community involvement requires an advanced level of organization, capacity-building and civil society networking.

An example of a developing network at the global level is the People's Health Movement (PHM). The PHM is a large global civil society network of health activists supportive of the WHO's Health for All policy. It is organized to combat the economic and political causes of deepening inequalities in health worldwide, and to revitalize the implementation of WHO's primary healthcare strategy. PHM, formed in 2000 at a People's Health Assembly attended by 1,500 delegates from over 90 countries, now comprises a range of NGOs and community-based organizations, and is playing an increasingly active advocacy and educational role at both national and global level. It has already had some success, in alliance with selected country governments, in clarifying and strengthening WHO's position in revitalizing its commitment to the principles of primary healthcare.


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