The following text is an extended version of my inputs at a webinar on the topic “Is Space Closing for Civil Society in Global Health?” on 19 May 2020 organized by the Global Health Centre of the Graduate Insitute Geneva, with Medicus Mundi International and STOPAIDS as co-organizers. Find the recording of the webinar here.

My script below includes a section on NGOs being “too closely” involved in the governance of global health agencies that I prepared for the webinar but had to skip for time constraints, and I also added some links to key references. Find more background information on our Network’s engagement in WHO governance in the “global health governance” section of the MMI website.

Thomas Schwarz, Executive Secretary
Medicus Mundi International – Network Health for All

Question: What is the role of civil society in governance of global health governance agencies?

Let me first have a closer look at the term “global health governance agencies”, and allow me to distinguish between global health initiatives and multilateral insititutions.

Global Health Initiatives and Partnerships

There is a great number and variety of global health initiatives and partnerships. Some of them can show impressive results, and some are also extremely powerful, in particular the money distribution machines, such as the Global Fund, Unitaid or the Global Financing Facility (GFF). All these partnerships have different mechanisms, capacities and records of working with communities and civil society.

But first of all, we need to note that these global health initiatives are per se not democratic, but many of them organized as clubs, with a strong dominance by their powerful initiators and funders to whom they are accountable (and not to the public)  and with their financial power as main legitimacy. And the raise of all these partnersships is interrelated with side-lining, intentionally weakening and crowding out the WHO.

Good news for civil society: Most of the global partnership follow a “multi-stakeholder” approach, and, as part of the rules of the games of multi-stakeholderism, they need to have “civil society” – and the private sector – on Board. So they need us for their legitimacy.

I am not an expert in the governance of these global health initiatives. There is some sound academic research into the participation of civil society in global partnerships, such as a piece written two year ago by a team at the University of Oslo. And there are some civil society organizations closely watching and commenting on the governance of particular global health initiatives, e.g. the GFF.

The World Health Organization

However, when we talk about democratic global health governance, I mainly refer to the multilateral institutions.

Multilateralism is defined as countries’ membership in democratic international (UN) institutions that serve to negotiate and find common solutions to global issues, bind all and particularly the powerful nations though global agreements and treaties, discourage unilateralism, and give small nations a voice and influence that they could not otherwise exercise.

In this field, it is obvious to focus the World Health Organization, as directing and co-ordinating body in international health. When we engage with WHO, it is also to support all efforts to defend, reconfirm and strengthen WHO’s role as global health authority.

And this is where we suffer, as, despite some nice partnership rhetoric, we do not see civil society fully invited to engage with WHO. So those of us who care for the WHO are torn beteen requesting better access for civil society to the normative and political processes and to the WHO governing bodies, and defending WHO and its constitutional mandate as the  democratic “people’s health institution” against being sidelined in global health policy and against being underminded, in its political and normative work, by powerful commercial and political actors.

And we ask ourselves what WHO and what multilateralism we are exactly defending. How to deal with the uncontested participation of authoritarian regimes, the WHO engaging itself in all kind of partnerships with the private sector, and reducing the space of civil society etc.?

To get ourselves better organized, we have set up together with other civil society organizations, in 2016, the Geneva Global Health Hub, to strengthen the civil society space and voice in Geneva for more democratic global health. As G2H2 members, we have jointly assessed WHO governance and financing in a series of civil society workshops, e.g. in May 2019, on WHO, civil society and “non-State actors”: How to deal with a difficult relationship. And we have issued joint statements such as:

Unfortunately, we struggle with basics regarding financing and capacity. Civil society engagement in global health governance is not a “sexy” field for fundraising.

Question: Some people say that the NGOs on the boards or advising global health agencies are insiders who get a lot of funding but stay silent and uncritical.

Let me start with a story.

Last year, 12 leading global health agencies, including global health initiatives and multilateral institutions set up a “Global Action Plan” (GAP) to accelerate progress in achieving the health related SDGs, with a particular section on civil soicety and communities. In a “non-state actors” consultation in April 2019, as part of the GAP drafting process, this “boost” for communities and civil society was celebrated by the NGO audience, and there were strong voices to even “make funding to countries conditional on listening to beneficiaries needs and monitoring and reporting on engagement indicators.”

So what is wrong with this?

First, it looks as if some of the civil society colleagues having worked over years with/within the setting of Global Health Initiatives are tempted to see these actors and their money and power, by nature, good and helpful, not questioning their role, legitimacy and at times “unwanted” negative side effects. I wrote about this: “Such a naïve view of the global health initiatives as stewards of good governance and promoters of democracy ignores that these actors are more often rather part of governance and policy failures, distorting national policies and structures.”

At a national level, all who are engaged in the struggle for better health and equity might ask themselves if a support by powerful external actors might rather strengthen their case, or if leads to a further “NGOization” or at least donor driven setup of what should be a social and political struggle for social and political rights.

In particular the existing national “multi-stakeholder engagement mechanisms” in the field of aid need to be carefully assessed. Often dominated by international NGOs, they are already now distorting or damaging the existing and often fragile democratic spaces and processes at a national level where people (organized in various ways) and governments are expected to “negotiate”, as right holders and duty bearers, the terms of their social contract for health.

At least the WHO has recently shown that it would be open to look at the matter in a more thoughtful way. The project of a “Handbook for social participation for UHC” undertaken with a series of partners and aiming at providing governments with some guidance on “what to do with civil society” is a valid one, and a series of webinars held in spring 2020 provided lots of great food for thought.

But we also see that temptation of being at the table. The current multistakeholderism exactly promotes a wrong assessment that, if you are at all these places all the time, you are important, and you are heard.

But this is not true.

And there are huge challenges regarding the good governance of civil society participation:

  • Who can participate, and who cannot?
  • The making of joint statements, in view of pretending to “speak with one voice”
  • To whom are the civil society representatives are accountable

I do not blame my colleagues who often do a great job in the civil society engagement mechanisms of global partnerships and health initiatives. I just think that, sometimes, if you are too close to something, you cannot see it properly anymore. So taking a bit of distance would help.

Question: Were NGOs able to engage effectively in 73rd World Health Assembly? 

Well, news are mixed, as usually. There was some successful civil society engagement in the negotiation ofthe Covid-19 resolution, with organizatons working in the field of access to medicines as a well organized lobby, but also with colleagues promoting particular language, e.g. on palliative care, doing a good and successful job.

All in all, despite the fact that they took place behind the closed doors of a member states process, I liked the intense negotiations on the COVID-19 resolution as a strong sign that WHO is alive.

Normally, civil society advocates follow the shaping of normative and political issues that are brought to the WHA for adoption throughout the year, with some clear entry points such as the EB meeting in January where you already see clearly what will be on the agenda of the WHA, and what are the positions of the Member States. And can engage.

You might compare this with the EU pledging conference to which civil society was not invited and that ended as a TV show with songs, celebrities and billionaires.

A special World Health Assembly

But this special session of the WHA on Covid-19 was really exceptional, in all senses, and we were already quite happy and relieved that it took place.

At the WHA itself, civil society organizations were not allowe not speak, but could post their statements on a dedicated website, as part of the WHA documentation. 83 organizations have done so. These statements are still accessible. Some of them provide sound technical input, others are rather used to promote the particular cause or the work of an organization.

In our own statement, we called WHO member states to deal, as caring governments and societies, with the pandemic together with the people in their  country and not against them; allowing real social participation and safeguarding civil and social rights;

And we asked them to actively engage in multilateralism, negotiated solutions, binding regulations and science based public health,

We ended by reiterating that this was a special WHA. While we criticized the reduction of civil society voices to written statements as exaggerated limitation, we recognized that our engagement in WHO governing bodies needs to be looked upon again in better times.

So let us quickly look ahead to these better times

We all know the shortcomings in the setup of the WHO governing body meetings: Limited instruments to manage a crowded agenda. Too many prefabricated statements, too little dialogue …and the same inequality in terms of power and access as anywhere. Reform is indeed needed.

But, in the middle of the Covid-19 crisis, I think that the reform of the WHO governing bodies is not the most urgent thing to be done. And I am confident that some silly old stories such as the proposal for a “World Health Forum” have, most probably, not survived the Covid-19 Pandemic.

When we have called – and will call again – for a more meaningful involvement of civil society in the WHO governing bodies, we do it in the sense of

  • Requesting the WHO and its member states not to replace democratic multilateralism with blurred multistakeholderism;
  • Claiming the civil society’s constitutional right to formally participate in WHO governance, and not to replace participation with informal playgrounds for which there is neither a clear need nor demand;
  • Asking the WHO secretariat and member states to reflect on what needs to be done “upstream”, beyond the governing body meetings, to protect and extend the space of civil society in national and global governance processes. And here we are not referring only to the small group of NGOs in “official relations” with the WHO.

In January, we ended the MMI statement to the WHO Executive Board with a call to civil society, and I think that this was the first civil society statement at an EB meeting that was addressed to civil society, and not to the WHO Secretariat or Member States. We stated:

“Let us not give up. There are good reasons for all of us being here. We are not just the ‘friends of the WHO’. We care for it. WHO is a people’s organization. It is ours. And we are part of it. But we also have to acknowledge that global health governance is a political arena and that the WHO is no exception to this. So let us reflect together, openly and constructively, how to contribute to making it better and stronger.”