At a time when major discussions on the SDGs are ongoing at the high-level ministerial discussion on the SDGs taking place at the UN this week (as well as other global fora such as AIDS2016 and UNCTAD), researchers Julia Smith, Kent Buse and Case Gordon have published a valuable reflection on the role of civil society in achieving the global goals.
The authors acknowledge the ambitious nature of the goals – including goal three on health – and the need to engage with stakeholders, including civil society organizations, in achieving them. Those of us who have worked in civil society will recognize the facilitating roles that the authors set out for CSOs, including building coalitions, democratizing debates, acting as watchdogs and leading the transformation of health systems to make them more participatory and multisectoral. The authors in the paper highlight the role of CSOs and illustrate them with inspiring examples of change and good practice.
But how far can these effective examples line-up in the face of the scale of demands presented by the SDGs? And do the SDGs represent a good vision of the changes that NGOs should be lobbying for in the first place?
The Institute for Health Metrics and Evaluation’s annual tracking of health aid shows the large increase in the resources coming from and channeled through NGOs over the past twenty years. Yet analysis of the effectiveness of the new resources remains radically incomplete. An understanding of the role played by NGOs in meeting the MDGs would be a good place to start with if we are to make a blanket proposal for greater civil society involvement in the SDGs. But we cannot even identify how much deliberate policy intervention helped achieve the outcomes to the first wave of global goals, let alone the NGO contribution. The examples of good practices shared by the authors are interesting. But we need to know much more about why they came about and how they worked, to enhance replicability on the scale and breadth needed by the SDGs. My suspicion is that we would discover many of the positive examples were stimulated by increased interactions with government or intergovernmental agencies, meaning difficult (but ultimately helpful) compromises in CSO independence. This should also be remembered in a world becoming ever more skeptical of politicians and policymakers.
The authors note the breadth of SDG-3 as compared with the MDGs saying that it widens the focus from select diseases to a ‘holistic conception of health’. While there is some truth in the move from a narrow focus, the SDG target list remains disease and condition focused, and the 17 separate overall SDG goals arguably fragment an approach to addressing the social determinants of health. It is good that there is a universal health coverage target included in SDG-3 – but it is way down on the list and easy to miss, leaving the objective diluted or lost among the others.
One of the lessons from the MDG-era may lie in the fact that the way that goals are formulated concentrates money and organizational priorities. There is a danger that NGOs – incentivized by the SDG-3 target list – may gravitate towards a narrow disease-focus path, rather than take a broader health system or social determinants approach. Many NGOs are already institutionally focused on disease/conditions or population group areas, and find it hard to take a broader vision.
The capacity to analyse and influence health policy is often limited in civil society, so other options are not considered when formulating research, policy and advocacy priorities. I wonder – for example – if it could have been imagined whether the campaign focus on access to medicines should have been accompanied by a movement to build capacity to make medicines in Africa and other low-income parts of the world? We probably need much more interaction and debate on health policy priorities among NGOs so that global agendas – or those of Northern NGOs – are not followed to the letter.
Further examples include the difficulties in forming coalitions around health system improvements. Yet surely this is one of the key areas where civil society can make a difference. The lessons from the welfare states of the developed world are that organized citizens making claims to services can be a driver of broad health system improvement. These movements organized around claims to health care are desperately needed in the thinly regulated, highly commercialized health systems of many developing countries. This necessitates a change in focus of NGO campaigns and global goals. The SDGs promised national targets to go alongside the global goals, and while ending preventable child deaths is an inspiring global campaign slogan able to mobilise activity in many countries, there needs to be incentives somewhere to create more national, context-driven campaigns around health systems. Northern NGOs funding civil society organizations in the South may play a critical role here, but to enhance democratic legitimacy the lead has got to come from the South. And a focus on the national level is inevitable with the increasing role played by domestic financing in health systems.
As one of the co-creators of the MDGs Jan Vandemoortele has pointed out, the SDGs may be global but they are still not truly universal – applicable to both developed and developing countries. From a health perspective there are great opportunities here, not least in addressing the burden of non-communicable disease. There are common interests between Southern and Northern civil societies in jointly forming coalitions to address the key risk factors for NCDs: and one of the biggest ones – as Julia Smith and her co-authors point out – is ‘demanding action to address the commercial determinants of health’ which drive the obesity, alcohol and smoking epidemics. Here a worldwide voice to lift campaigns above national borders would help in the fight to regulate the marketing activities of transnational companies.
Finally, alongside more analysis of the contribution of NGOs and how they work with other actors to achieve change, a re-imagination of the NGO health policy agenda, as well as the need for more national working, combined – on selected issues of universal concern – with global networking, there is a general need for NGOs to be more accountable and to enhance their legitimacy. Writing a decade ago, Anderson and Reiff looked skeptically on the new ‘global’ civil society, noting that ‘Civil society organisations are … the glory of democratic societies, but they are not the electoral institutions of democracy’. Their role as ushers in of democracy at the level of the ‘unaccountable’ global institutions has nonetheless been highlighted by Smith and colleagues. But there is also a danger that in reality, a narrow range of voices will be heard from civil society at the global level – again pointing to the need for more debate, among a diversity of better resourced and networked civil society actors. The cacophony will be great – but the outcomes may just be better in the long run.