In how many ways is civil society integral to achieving the health-related Sustainable Development Goals (SDGs)? In a recent article in Globalization and Health, Julia Smith, Kent Buse, and Case Gordon identify eight ways. I will offer thoughts on several of them, and suggest that given the importance of civil society to the SDGs and to the right to health, health advocates must include among our top priorities pushing back against restrictions on civil society organizations in increasing numbers of countries.
First, the eight ways, detailed more in the article:
1. Transforming data into moral arguments
2. Building coalitions that reach beyond the traditional health sector
3. Democratizing policy debates and offering innovative options
The authors include the Framework Convention on Global Health, the proposed treaty based in the right to health and aimed at health equity, among these innovative possibilities. We see in the FCGH the dynamic between civil society and governments and other members of officialdom. Civil society advocates pressed for this proposed treaty for some six years before UN Secretary-General Ban Ki-moon stated in his report to this past June’s High-Level Meeting on Ending AIDS: “I further encourage the international community to consider and recognize the value of a comprehensive framework convention on global health” (para. 74). The Secretary-General’s call to action creates a powerful new argument for civil society to call upon states to take a close look at the FCGH, and for the next WHO Director-General to assume leadership on the FCGH.
We have seen such interplay before, such as with the Framework Convention on Tobacco Control, which took both the leadership of then-WHO Director-General Gro Harlem Brundtland and the Framework Convention Alliance, and the Global Fund to Fight AIDS, Tuberculosis and Malaria, whose origins are found both in civil society advocacy and in Kofi Annan’s vocal support.
The tobacco treaty and the Global Fund also hold lessons for the FCGH on the importance of civil society’s sustained support. Even after WHO adopted the tobacco treaty and most countries of the world ratified it, civil society advocacy has remained critical to pressing governments to implement their obligations. Similarly, from day one of the Global Fund, civil society has had to encourage governments to fund the Fund. If the dynamic between civil society, Ban Ki-moon, and — I hope — the next WHO Director-General and UN Secretary-General creates the environment that leads to more state support and enables the FCGH to come to fruition, civil society and communities will need to remain centrally involved so that states ratify and implement the treaty.
4. Enhancing the legitimacy of global health initiatives and institutions
The authors refer to civil society involvements in such global initiatives as the Global Fund and, through #WHO4ALL, the World Health Assembly, yet note that when it comes to participatory engagement in such initiatives, the role of civil society organizations “remains underappreciated, underutilized, and under-resourced.” Indeed.
The importance of civil society’s involvement comes in large part from the democracy deficit of global health initiatives and institutions, and thus shortcomings in how these initiatives represent the people whom they are supposed to serve and those to whom they ought to be accountable. This is an inherent feature of a world where many governments are either undemocratic or deeply flawed pseudo-democracies. If a global health initiative were comprised of only well-functioning democratic governments, many beneficiaries would be unrepresented because their governments, their countries, could not participate. By contrast, for global health institutions that are inclusive in their government membership – like the World Health Organization – the fact that so many of their member states are undemocratic, and thus cannot be considered genuine representatives of their populations, again leaves many people are unrepresented.
Civil society organizations can help overcome this deficit by bringing the voices and concerns of people, including those without effective representation through their own governments, into these institutions. This is particularly the case for community-based organizations and direct representatives of communities (for example, members of networks of people living with HIV/AIDS or disabilities).
This role of civil society points to the importance a system of more accountable community representation, so that community members or delegations to global health institutions are not representing only themselves or a handful of people or organizations, but communities more broadly. One of the Globalization and Health article’s authors, Case Gordon of the IMAXI Cooperative, is involved in trying to develop such a system.
5. Leading the transformation of systems for health fit for 2030 ambitions
6. Serving as watchdogs and advocates for accountability
7. Demanding action to address commercial determinants of (ill) health
8. Ensuring the right to health is universally enjoyed by all
Civil society’s role of advocating for marginalized populations is among its most vital. I noted the importance of civil society in helping to compensate for the undemocratic nature of many governments. Yet even better-functioning democracies are home to marginalized populations who lack power – and may even be subject to discriminatory laws or the legacy of discrimination rooted in legal structures – and who are therefore, again, not adequately represented, not only internationally but also domestically. Civil society can and must be their voice in national and international structures, while also working to empower them directly – uprooting barriers of discrimination that impede their ability to advocate for their own needs, educating them on their human rights and on the forums where they can assert their rights, and advocating for participation and accountability mechanisms where marginalized populations have real voice.
Civil society under threat
Given these critical civil society functions in achieving the promises of the SDGs, the pushback against NGOs in recent years should deeply concern all people and governments concerned about health. CIVICUS, an international alliance to strengthen civil society and citizen action around the world, observes that the three human rights that are the basis for civil society action – the rights to free association, peaceful assembly, and freedom of expression – “are under renewed and sustained assault,” with “[s]ix of seven people liv[ing] in countries where civic space has experienced serious recent challenges.” Detentions, lengthy jail sentences, violence against human rights defenders, restrictions on NGO registration, and crackdowns on press freedom are among the tools of civil society repression.
Restrictions on foreign funding are part of this assault. These may take a number of forms (p. 137-138). For example, NGOs, or NGOs working on certain issues, may be limited in how much foreign funding they receive, as in Ethiopia, where organizations that receive more than 10% of foreign funding may not engage in activities related to advancing human rights, among other activities. (Is this one place where it would be desirable if the highest attainable standard of health is not seen as a human right?) In Russia, NGOs receiving foreign funding are stigmatized with the label “foreign agents.”
Health rights organizations are not immune from these laws. To take one example, Lawyers Collective, a major health and human rights NGO in India whose director, Anand Grover, was the second UN special rapporteur on the right to health, has unjustly had its ability to receive foreign funding suspended under the country’s Foreign Contributions Regulation Act.
With civil society freedom vitally important to improving health equity, those of us who are part of civil society organizations focused primarily on the right to health need to bring civil society freedoms into our core concerns. Similarly, governments that are committed to improving global health, and the health of their own people, must fully incorporate support for civil society into their policies, including pushing back through all diplomatic tools at their disposal against these types of assaults on civil society. Anything less than total support for civil society freedom would not only be incoherent, inconsistent with support for advancing people’s health, but would also be a betrayal of the people whom global health efforts are meant to support.
A few quick initial steps you might take: Stay informed — sign up to the CIVICUS newsletter (archives; sign-up) and Civil Society Watch Bulletin (archives; sign-up). And take action through the CIVICUS Civil Society Behind Bars campaign.