Civil society in global health policymaking: a critical review

Non-government advocacy for health equity: evidence from Australia

The aim of this paper is to identify non-governmental organizations (NGOs) advocating for policy and practices to address rising health inequities in Australia. NGOs can play a critical role in shaping and influencing governance processes including public policy relating to the social and commercial determinants of health inequities. However, scholarship on who the NGOs are that are advocating to address health inequities in Australia and how they operate is sparse. Through desktop analysis in 2022, we searched NGO websites and documents for evidence of advocacy activities related to health inequities between 2017 and 2022. A database of the NGOs was compiled, noting the type of organization, function, advocacy activities and main issues their advocacy covered. A total of 137 NGOs were identified as engaging in activities advocating for change to address health inequities either directly (e.g. advocating directly to address health inequities) or indirectly (e.g. advocating on social determinants of health inequities such as housing and linking to their unequal health impacts). We noted the primary issues they advocated on, including topic categories: risk factor, disease-specific, broader health system, social determinants of health equity, and health workforce and service issues. The results indicate that Australian NGOs from multiple sectors are active in advocacy to address heath inequities on a variety of topics and through a variety of activities. This study provides a template for similar studies in other countries and suggests further research is needed to understand the role and impact of civil society advocacy to address growing health inequities.

Integrating animal welfare into the WHO pandemic treaty: a thematic analysis of civil society perspectives and comparison with treaty drafting

The COVID-19 pandemic has exposed critical weaknesses in the global health system, highlighting the urgent need for a coordinated international approach to pandemic prevention and management. As negotiations for a new WHO pandemic treaty progress, the effective integration of animal welfare is crucial. This paper aims to investigate the perspectives of key civil society organizations on the integration of animal welfare provisions into the pandemic treaty. Through a thematic analysis of documents prepared by FOUR PAWS, Wildlife Conservation Society, and Action for Animal Health between 2020-2023, five major themes are identified: prevention of zoonotic spillover, One Health approach, animal health systems and infrastructure, sustainable and ethical animal management practices, and policy coherence and governance. A comparative analysis of these themes against the April 2024 draft of the pandemic treaty reveals areas of alignment and divergence. Due to the ongoing controversies and the need for further improvements, the WHO's intergovernmental negotiating body was unable to finalize the treaty text for the 77th World Health Assembly in May 2024, leading to an extended mandate until 2025. Based on the findings, the paper proposes recommendations to strengthen the integration of animal welfare into the treaty, arguing that incorporating these recommendations is critical for developing a transformative, equitable, and effective treaty that addresses the systemic drivers of pandemic risk.

A framework of NGO inside and outside strategies in the commercial determinants of health: findings from a narrative review

BACKGROUND

Public health scholarship has uncovered a wide range of strategies used by industry actors to promote their products and influence government regulation. Less is known about the strategies used by non-government organisations to attempt to influence commercial practices. This narrative review applies a political science typology to identify a suite of 'inside' and 'outside' strategies used by NGOs to attempt to influence the commercial determinants of health.

METHODS

We conducted a systematic search in Web of Science, ProQuest and Scopus. Articles were eligible for inclusion if they comprised an empirical study, explicitly sought to examine 'NGOs', were in English, and identified at least one NGO strategy aimed at commercial and/or government policy and practice.

RESULTS

One hundred forty-four studies met the inclusion criteria. Eight industry sectors were identified: extractive, tobacco, food, alcohol, pharmaceuticals, weapons, textiles and asbestos, and a small number of general studies. We identified 18 types of NGO strategies, categorised according to the target (i.e. commercial actor or government actor) and type of interaction with the target (i.e. inside or outside). Of these, five NGO 'inside' strategies targeted commercial actors directly: 1) participation in partnerships and multistakeholder initiatives; 2) private meetings and roundtables; 3) engaging with company AGMs and shareholders; 4) collaborations other than partnerships; and 5) litigation. 'Outside' strategies targeting commercial actors through the mobilisation of public opinion included 1) monitoring and reporting; 2) protests at industry sites; 3) boycotts; 4) directly engaging the public; and 5) creative use of alternative spaces. Four NGO 'inside' strategies directly targeting government actors included: 1) lobbying; 2) drafting legislation, policies and standards; 3) providing technical support and training; and 4) litigation. NGO 'outside' strategies targeting government included 1) protests and public campaigns; 2) monitoring and reporting; 3) forum shifting; and 4) proposing and initiating alternative solutions. We identified three types of NGO impact: substantive, procedural, and normative.

CONCLUSION

The analysis presents a matrix of NGO strategies used to target commercial and government actors across a range of industry sectors. This framework can be used to guide examination of which NGO strategies are effective and appropriate, and which conditions enable NGO influence.

Healthcare Provider Advocacy for Primary Health Care Strengthening: A Call for Action

Primary Health Care (PHC) is the backbone of health systems and a cornerstone of Universal Health Coverage. In 2018, political commitment to PHC, including a comprehensive approach based on essential care throughout the lifespan, integrated public health functions, and community empowerment was reaffirmed by international stakeholders in Astana. As recent events exposed weaknesses of health care systems worldwide, growing attention has been paid to strengthening PHC. While the role of care providers as health advocates has been recognized, they may lack skills, opportunities, and resources to actively engage in advocacy. Particularly for PHC providers, guidance and tools on how to advocate to strengthen PHC are scarce. In this article, we review priority policy areas for PHC strengthening with relevance for several settings and health care systems and propose approaches to empower PHC providers-physician, non-physician, or informal PHC providers-to advocate for strengthening PHC in their countries by individual or collective action. We provide initial ideas for a stepwise advocacy strategy and recommendations for practical advocacy activities. Our aim is to initiate further discussion on how to strengthen health care provider driven advocacy for PHC and to encourage advocates in the field to reflect on their opportunities for local, national, and global action.

Assessing Health Data Security Risks in Global Health Partnerships: Development of a Conceptual Framework

Background

Health care databases contain a wealth of information that can be used to develop programs and mature health care systems. There is concern that the sensitive nature of health data (eg, ethnicity, reproductive health, sexually transmitted infections, and lifestyle information) can have significant impact on individuals if misused, particularly among vulnerable and marginalized populations. As academic institutions, nongovernmental organizations, and international agencies begin to collaborate with low- and middle-income countries to develop and deploy health information technology (HIT), it is important to understand the technical and practical security implications of these initiatives.

Objective

Our aim is to develop a conceptual framework for risk stratification of global health data partnerships and HIT projects. In addition to identifying key conceptual domains, we map each domain to a variety of publicly available indices that could be used to inform a quantitative model.

Methods

We conducted an overview of the literature to identify relevant publications, position statements, white papers, and reports. The research team reviewed all sources and used the framework method and conceptual framework analysis to name and categorize key concepts, integrate them into domains, and synthesize them into an overarching conceptual framework. Once key domains were identified, public international data sources were searched for relevant structured indices to generate quantitative counterparts.

Results

We identified 5 key domains to inform our conceptual framework: State of HIT, Economics of Health Care, Demographics and Equity, Societal Freedom and Safety, and Partnership and Trust. Each of these domains was mapped to a number of structured indices.

Conclusions

There is a complex relationship among the legal, economic, and social domains of health care, which affects the state of HIT in low- and middle-income countries and associated data security risks. The strength of partnership and trust among collaborating organizations is an important moderating factor. Additional work is needed to formalize the assessment of partnership and trust and to develop a quantitative model of the conceptual framework that can help support organizational decision-making.

Preventing and Controlling Pneumonia among Under-Five Children: A Qualitative Study of Civil Society Organizations’ Roles in West Java and East Nusa Tenggara

BACKGROUND: Pneumonia is the leading cause of under-five children mortality in the world, including in Indonesia. Various programs were developed both nationally and internationally to overcome this disease. One of the programs is cross-sectorial collaboration and community involvement as part of pneumonia prevention and control programs, including the involvement of civil society organizations (CSO). However, the limited research has explored through the role of CSO in this program. AIM: This study aimed to explore the roles of CSO in preventing and controlling the childhood pneumonia. METHODS: This qualitative descriptive study interviewed 15 participants who were representatives of CSO in West Java and East Nusa Tenggara. These CSO have focused on health activities programs. In-depth interviews were conducted using semi-structured interview guides. Data were analyzed using the comparative analysis technique for qualitative descriptive research. RESULTS: Three main themes have been found from the data analysis, including community empowerment and integrated actions to prevent childhood pneumonia, providing pneumonia services and advocacies to overcome childhood pneumonia, and the expectation versus challenges of CSO. The three themes showed that CSO have significant roles in various aspects of the prevention and control programs of under-five pneumonia. CONCLUSION: Various roles have been done by CSO. However, several functions were not performed optimally. Further research that was analyzing factors the influence CSO’s roles is needed as fundamental information to develop strategies in improving the functions of civil society organizations in childhood pneumonia.

Stakeholder engagement in the health policy process in a low income country: a qualitative study of stakeholder perceptions of the challenges to effective inclusion in Malawi

BACKGROUND

Inclusive engagement in healthcare policies and decision-making is essential to address the needs of patients and communities, reduce health inequities and increase the accountability of the government. In low income countries such as Malawi, with significant health challenges, stakeholder inclusion is particularly important to improve performance and service delivery. The 2017 National Health Plan II (NHP II) and accompanying Health Sector Strategic Plan II (HSSP II) aimed to improve the functioning of the healthcare system. The Ministry of Health for Malawi intended to involve all key health sector stakeholders in their development. This study explores the extent of stakeholder engagement in the health policy process through local level stakeholders' perceptions of their involvement in the NHP II and HSSP II.

METHODS

A qualitative study design was used. Interviews were conducted with 19 representatives of organisations operating at the local level, such as CSOs and local government. Open questions were asked about experiences and perceptions of the development of the NHP II and HSSP II. Inductive content analysis was performed.

RESULTS

Stakeholders perceived barriers to inclusive and meaningful engagement in the health policy process. Five categories were identified: tokenistic involvement; stakeholder hierarchy; mutual distrust; preferred stakeholders; no culture of engagement.

CONCLUSIONS

Serious challenges to the meaningful and equitable engagement of local level stakeholder groups in the health policy process were identified. Issues of trust, accountability and hierarchy in donor-citizen-government relations must be addressed to support stakeholder engagement. Engagement must go beyond tokenism to embed a range of stakeholders in the process with feedback mechanisms to ensure impact from their contributions. Local level stakeholders can be empowered to advocate for and participate in consultation exercises alongside greater top-down efforts to engage stakeholders via diverse and inclusive methods. These issues are not unique to Malawi or to health policy-making.

Collective forward-looking responsibility of patient advocacy organizations: conceptual and ethical analysis

Background

Patient advocacy organizations (PAOs) have an increasing influence on health policy and biomedical research, therefore, questions about the specific character of their responsibility arise: Can PAOs bear moral responsibility and, if so, to whom are they responsible, for what and on which normative basis? Although the concept of responsibility in healthcare is strongly discussed, PAOs particularly have rarely been systematically analyzed as morally responsible agents. The aim of the current paper is to analyze the character of PAOs’ responsibility to provide guidance to themselves and to other stakeholders in healthcare.

Methods

Responsibility is presented as a concept with four reference points: (1) The subject, (2) the object, (3) the addressee and (4) the underlying normative standard. This four-point relationship is applied to PAOs and the dimensions of collectivity and prospectivity are analyzed in each reference point.

Results

Understood as collectives, PAOs are, in principle, capable of intentionality and able to act and, thus, fulfill one prerequisite for the attribution of moral responsibility. Given their common mission to represent those affected, PAOs can be seen as responsible for patients’ representation and advocacy, primarily towards a certain group but secondarily in a broader social context. Various legal and political statements and the bioethical principles of justice, beneficence and empowerment can be used as a normative basis for attributing responsibility to PAOs.

Conclusions

The understanding of responsibility as a four-point relation incorporating collective and forward-looking dimensions helps one to understand the PAOs’ roles and responsibilities better. The analysis, thus, provides a basis for the debate about PAOs’ contribution and cooperation in the healthcare sector.

Addressing the double burden of the COVID-19 and noncommunicable disease pandemics: a new global governance challenge

Purpose

As the coronavirus disease 2019 (COVID-19) continues to spread across countries, it is becoming increasingly clear that the presence of pre-existing noncommunicable diseases (NCDs) dramatically increases the risk of aggravation in persons who contract the virus. The neglect in managing NCDs during emergencies may result in fatal consequences for individuals living with comorbidities. This paper aims to highlight the need for a paradigm shift in the governance of public health emergencies to simultaneously address NCD and noncommunicable disease (CD) pandemics while taking into account the needs of high-risk populations, underlying etiological factors, and the social, economic, and environmental determinants that are relevant for both CDs and NCDs.

Design/methodology/approach

The paper reviews the available global frameworks for pandemic preparedness to highlight the governance challenges of addressing the dual agenda of NCDs and CDs during a public health emergency. It proposes key strategies to strengthen multilevel governance in support of countries to better prepare for public health emergencies through the engagement of a wide range of stakeholders across sectors.

Findings

Addressing both CD and NCD pandemics during public health emergencies requires (1) a new framework that unites the narratives and overcomes service and system fragmentations; (2) a multisectoral and multistakeholder governance mechanism empowered and resourced to include stakeholders across sectors and (3) a prioritized research agenda to understand the political economy of pandemics, the role played by different political systems and actors and implementation challenges, and to identify combined strategies to address the converging agendas of CDs and NCDs.

Research limitations/implications

The article is based on the review of available published evidence.

Practical implications

The uptake of the strategies proposed will better prepare countries to respond to NCD and CD pandemics during public health emergencies.

Originality/value

The article is the first of its kind addressing the governance challenges of the dual pandemic of NCDs and CDs in emergencies.

Civil society demand for accountability to achieve the 90-90-90 targets: lessons from Eastern and Southern Africa

PURPOSE OF REVIEW

Civil society demand for accountability has long been a critical component of the AIDS response. In the age of 90-90-90 HIV treatment goals, civil society advocacy has continued, but often in new forms. In particular, civil society accountability at the intersection of national policy and global health financing has taken on increasing importance, but has not been well documented.

RECENT FINDINGS

Civil society demand for accountability is a key to addressing both the insufficient progress toward '90-90-90' HIV treatment goals and the gap in democracy in HIV policymaking particularly prevalent in the context of internationally financed HIV programming. Civil society can serve three vital functions for accountability: unlocking decision-making processes monopolized by powerful funders through North-South networks; challenging dominant ideas that justify status-quo policies; and 'venue shifting' to institutionalize new, more open spaces for policymaking.

SUMMARY

The functions of civil society demand for accountability have played key roles in improving the AIDS response in several countries in East and Southern Africa. Dramatically scaling-up capacity for civil society advocacy is necessary in the near term to achieve global HIV goals.