Civil society organisations lack legitimacy to shape global health policy

Civil society organisations deliver health programmes and are key partners in new global health initiatives. But it is debatable to what extent they really represent their communities’ concerns. They need to earn the legitimacy to engage in global decision making that affects the health of millions of people.

Researchers from the London School of Hygiene and Tropical Medicine lookat the participation of civil society organisations (CSOs) in global healthpolicy. Health-related CSOs, including non-governmental organisations andcommunity-based organisations, either deliver health programmes or advocatepolicy change. They are increasingly involved in policy decisions byinternational organisations such as the World Health Organization, and GlobalHealth Initiatives (GHIs) such as the Global Fund to Fight HIV/AIDS,Tuberculosis and Malaria.

CSOs claim thatthey help to build a democratic culture where there is public debate at thegrassroots level, access to information on policy and transparency, andaccountability in decision making. International networks of health-relatedCSOs can form communities of citizens from different countries with sharedconcerns, supporting global policymaking. In addition, many donors prefer tochannel funds directly to CSOs, bypassing what they see as inefficient,ineffective and sometimes corrupt public sector agencies.

But do CSOs really enhance democracy anddeliver better health programmes? It is unwise to generalise about CSOs,particularly across developed and developing countries, as this obscures thecomplexities of their relationships with each other and with global agencies.The article surveys some of the key criticisms made of the role of CSOs in GHIs. These include:

• A lack of trust and solidarity means globalcommunities rarely exist; CSO involvement gives artificial legitimacy to theactions of international organisations and donors.
• Collaboration between CSOs and GHIs can underminegovernments’ ability to build up their own democratic legitimacy.
• CSOs’ lack of accountability (regarding theiroperations, funding sources, expenditures and ability to deliver services)harms their legitimacy.
• Smaller community-based organisations deliveringgrassroots health programmes are unlikely to connect with larger global CSOsand GHIs.
• Donors’ market mechanisms for contracting CSOs andtheir interest in quick results create incentives to downplay difficulties andexaggerate success, undermining the delivery of sustainable health benefits.
• Channelling donor funds through CSOs, which maycompete with each other or duplicate programmes, destabilises fragile healthinfrastructure and undermines local health authority control.

The paper identifies research priorities for evaluating the roles ofCSOs in global health initiatives. Key recommendations for CSOs wishing toimprove their credibility and legitimacy are:

• developing workable systems of accountability thatbalance demands from beneficiaries, donors, staff, partners, the media andothers
• increasing the transparency of processes forselecting CSOs to take part in GHIs
• demonstrating how beneficiaries of CSO health programmes are involved indecision-making.