1.1. Civil society, working with society and Health 2020

Working with society has become an important strategy for the WHO European Region. Health 2020, the new European policy for health and well-being for the 21st century, supported by several studies, is making the case for intersectoral, interdepartmental governance (McQueen et al., 2012; Kickbusch & Gleicher, 2012; WHO, 2012). Conceptually, this has been captured by the whole-of-government and the whole-of-society approach (Dubé et al., 2014).

When ministries of health are reaching out to other ministries and sectors in order to address the wider determinants of health outside their remit, they will need to build bridges between otherwise separated ministries and administration. They will need to establish dialogue and use intersectoral structures, such as public health ministers, parliamentary committees, cabinet committees, and interdepartmental committees for intersectoral actions (McQueen et al., 2012). But this whole-of government approach remains inside the government and administration and often does not reach civil society and the world of CSOs. To reach out to civil society and CSOs, the whole-of-society approach (WHO, 2012), which is at the centre of this scoping review, is needed.

Box 1.1

The whole-of-society approach in Health 2020 (WHO, 2012).

1.2. What is civil society?

Civil society is a concept with a long lineage in European social thought but it came into its own as a meaningful concept in politics in the 1980s (Gellner, 1994). That was the decade in which it gained recognition, and a very positive image, for a variety of reasons. It seemed to capture the promising nature of non-state organizations that were defying authoritarian regimes, especially in central and eastern Europe. It seemed also to form an alternative to the market-based world of the west, where the idea of non-commercial, volunteer activity offered political and policy options that were not thought to be available in market transactions. In both cases, the appeal of civil society was simple: it might allow politics and civil society to break out of simplistic frameworks, such as those of the state or the market and explore new possibilities.

Civil society therefore entered political conversation as a rather broad concept. It rapidly came to cover actors as diverse as trade unions in Communist Poland and Francoist Spain, the Lutheran Church in the German Democratic Republic and the participatory milieu of the 1980s left in the German Federal Republic. It was then expanded further as it went global, becoming both a key analytical tool for analysts of the decline of authoritarian regimes and a normative object of policy by governments and charities that sought to strengthen it worldwide. By the 1990s some had broadened it to include everything that was not formally part of the state, up to and including multinational corporations, while others had narrowed it down to a small set of designated organizations representing newer social movements born in the 1960s, and some others had narrowed it down still further into campaigning groups with little purchase on society. At the same time, efforts to promote civil society often fell afoul of its diversity. Trying to promote a confused and often very western concept (Gellner, 1994) in diverse societies as part of a broader mission of social change was a challenge for policy-makers and funders, and they did not always get what they wanted. The result was that civil society lost some of its popularity as a policy objective or a theoretical concept in the 21st century.

But the fact that civil society was a fad for policy-makers and professors alike does not mean that it is valueless. Far from it. It became such a popular concept because of its importance, variability and ubiquity in Europe.¹ It remains powerful – but it needs conceptual clarity, not another cycle of fashion.

Defining civil society is a large part of the problem of thinking about civil society.² We hoped to avoid many of the definitional disputes and normative arguments that bog down conversations about civil society. We started with a capacious definition, avoiding specific claims that are often too dependent on specific contexts or become tied up in philosophical issues removed from immediate policy concerns. As a result, we adopted an inclusive approach with weak exclusion criteria. We then divided civil society into rough categories of organizations and functions in order to highlight its diversity and contributions to different aspects of health, health care, and health policy. Not all kinds of organizations and not all kinds of functions are found in the civil society of any given country. We also tried to avoid overly specific categories, since civil society organizations within any given country or political system tend to have distinctive legal and practical roles that do not translate more broadly. The point is to outline a framework that highlights the diversity and importance of civil society, point to different roles and relationships, and create a basic framework for discussing its role and contribution.

The core of a definition of civil society is that it is the society we engage in as active citizens, neither part of the market nor part of the state nor part of the family. “Neither state nor market” captures an essence of civil society, but it is hard to proceed without some more specific definitional characteristics. The next section explores that basic definition, which is the thread running through the many competitive definitions of civil society. It then refines the definition by identifying positive and contextual factors that mark civil society.

1.2.1. Neither state nor market nor family

The core of most sensible discussions of civil society – the point on which public intellectuals as different as Jürgen Habermas and Jeanne Kirkpatrick agree – is that it is part of neither the state nor the market (Habermas, 1975; Kirkpatrick, 1979).³ It is obviously linked to both, for funding, legal status, and context, but it is also different, accountable neither to the state nor to the market.

Civil society is, like society, a blanket term for a much more concrete set of people and organizations. Civil society organizations (CSOs), rather than civil society, are the real locus of civil society and where it happens. To characterize the civil society of a country is to characterize its CSOs and their interactions with each other and broader society. To work with civil society is to work with CSOs. To complain of civil society, or try to change it, is to challenge, join, or create CSOs.

Box

Civil society: definition.

Being “neither state nor market” is an enormously diverse category – even more diverse than categories such as “business”. That is one reason for the rise and fall of the concept of civil society, and the difficulty of defining it. This definition encompasses the most corporatist of social partners, such as the unions and trades associations that govern so much of life in Austria, to the most specific advocacy groups for vulnerable populations such as the homeless. As a result, the real challenge is not to theorize the abstract relationship between civil society, the market, and the state. There is not much we can usefully say about the problems and potential of Austrian trade unions, Cypriot “social groceries” for the hungry, and Royal Colleges in the UK in the abstract. But then, there is not much we can abstractly say about the public administrations or economies of Austria, Cyprus, and the UK. The real challenge is to understand the civil society of a given place, its relationship to health, and its potential to further improve health. And that will require specificity, context, and a willingness to examine cases in detail. The rest of this chapter will identify issues that do fit with civil society in the abstract, but also highlight the diversity of its nature and its roles in society.

Box

Examples of civil society organizations.

1.2.2. Positive characteristics

“Neither state nor market nor family” encompasses much of human life, from chess players in the park to organized religion. How can we go beyond that to start identifying civil society organizations so that we know what we are discussing and how it fits in with policy?

We will start with positive characteristics to complement the negative definition of ‘neither state nor market’. It is worth noting again that the contexts and forms of civil society are so diverse as to make it hard to produce a useful definition that spans all the world’s societies, so we are here focusing on the situation in the European region. That allows us to specify with more precision what does and does not constitute a manifestation of civil society.

We start with autonomy: the extent to which the organization determines what it is for and whom it serves. Autonomy distinguishes a CSO from profit-making companies (e.g. public affairs consultancies) or arms of the government.⁴ Key questions that we may ask of organizations in order to determine whether they have the autonomy to be called CSOs include:

• Who has the power to shut down the organization?
  A CSO is not autonomous if somebody else can close it down.
• Who has the power to choose and dismiss its leader (e.g. chief executive)?
  A CSO is not autonomous if it cannot select and reject its leadership.
• Who has the power to stipulate its statutes and operating by-laws?
  A CSO is not autonomous if it cannot stipulate its own internal procedures, including issues such as determination of budget and priorities.
• What is its economic base?
  Ideally, members. It is quite possible to depend on philanthropists, governments, or others for resources, but insofar as an organization depends on them, it should expect as a matter of realism to have its autonomy questioned and should have a compelling answer to those questions, typically involving transparency and separation between funders and decision-making.
• Who has the power to determine its mandate?
  Finally, autonomy requires that an organization must not have its mandate determined for it, or that an externally defined mandate may be something at its foundation that it outgrows.

In some legal systems, organizations must make their answers clear and there are legal and regulatory mechanisms to constrain the nature of such organizations. Formality does not always make the real answers clear, but it is a place to start in determining whether an organization is a CSO or something else. If nothing else, identifying discrepancies between formal and real behaviour is a useful way to understand what really runs an organization. Likewise, informal CSOs exist and often do important work. Even if there is no equivalent to a formal mandate or set of bylaws, or even if the formal documentation is unenlightening, it is possible to ask for the informal equivalent – to ask what the organization is for, who leads it and why it does what it does. A definition that fits all the different organizations, contexts, societies and questions would be impossibly unwieldy, but these questions sketch the limits of what an organization can do, and direct our attention to the contextual factors of civil society.

Balancing autonomy against other desirables – such as funding, political engagement, credibility, and the institutionalization necessary to deliver complex projects and employ staff – is always a challenge.

The second positive characteristic, after autonomy, is the link to a constituency. This can be a representative link, in which the organization engages in policy debates on behalf of that organization, or it can be a link to a community that it services with some kind of benefit or function. Many organizations are both in some measure: they both represent and provide services to the community. In less formal cases, it is often hard to distinguish the two activities. But organizations that neither represent nor provide services to an identifiable community are suspect.

In short, civil society is made up of organizations that are autonomous, that are not wholly of the state, market, or family, and that work with or for a given constituency that can be identified. Further elaboration of this definition, such as tighter exclusion or inclusion criteria, should be context-dependent since what works in one place might not work in another.

Civil society has to be defined in the context of government, market, and family. This naturally limits the specificity of a definition, since civil society’s roles, access to politics, ability to influence society, independence from commercial interests, and strength are all context-dependent. There is a European Union civil society because there is a European Union political system that can define and be influenced by civil society, and there is a French or Lithuanian civil society because there are French and Lithuanian states and societies that can define civil society and in which civil society can play a role. The importance of context means, though, that autonomy and constituency operate differently. Being neither state nor market nor family ultimately means that the shape of civil society depends on the nature of state, market, and family.

Apart from academic discussion, the important consequences of definitions of civil society and non-governmental organization can be demonstrated by the WHO framework of engagement with non-state actors (FENSA) (see Box 1.2.). FENSA defines NGOs and other non-state actors in order to clarify on the principles, benefits and risks of engagement. It also defines to what extent WHO can interact with the different non-state actors regarding participation, evidence, advocacy and technical collaboration.

Box 1.2

Non-governmental organizations and other non-state actors according to the WHO framework of engagement with non-state actors (FENSA).

1.3. What does civil society do for health?

The fundamental case for the role of civil society in health in Europe is that it is ubiquitous, diverse, and beneficial. States, markets and families do not do all the work that contributes to health, or might not do it especially well. States are financially constrained and good public administration will often, by design, emphasize equality, accountability, and deliberation over speed and experimentation. Markets, ultimately, demand that something be profitable if it is to attract resources. Families look after their own better than others. Much that contributes to health is therefore best done by neither state nor market nor family. Emblematically, neither advocacy nor services to rapidly changing distinct vulnerable populations are ways to make money or show public administrations at their best, and vulnerable populations frequently cannot rely on families. Nobody questions the ability of the French or German state to provide services to migrants, but civil society organizations could start to provide services much more quickly than the state when the Syrian refugee crisis began (see mini case study 6 after Chapter 9).

Even when the best eventual solution is the market or the state, the way to the solution is often shown by civil society organizations with their ability to experiment and focus on the job, rather than being constrained by the demands of formal politics or profit. The ancestors of most western health systems, for example, are to be found in various forms of civil society association that started to provide health benefits.

Chapter 2 discusses the diverse contributions of civil society to health and health policy. For health, civil society can deliver services that governments are unwilling or unable to deliver because of lack of political interest, inflexible public administrations, resource constraints or lack of trust in certain populations. It can often offer committed people, flexibility, and responsiveness in service delivery that public sector and private sector organizations alike fail to muster. It can also mediate problematic policies, whether through a role in implementation or through assisting populations in dealing with a problem. With its low cost of entry, it can also be innovative and responsive, with civil society organizations addressing new tasks quickly and sometimes developing the solutions that will eventually be adopted by bigger public and private organizations. Civil society can therefore compensate for policy failures, through quick responses and incubation of alternative organizational models. Finally, civil society organizations often play a key role in advocacy, trying to drive social change through direct campaigns on topics such as disease awareness or public health issues such as smoking and domestic violence (Chao, 2005).

For health policy, meanwhile, civil society can bring expertise, ideas, and diverse perspectives. It is unfair to ask civil society organizations to “represent” groups as if civil society were a parliament, but it is wholly legitimate to appreciate the expertise and views they bring, especially when they come from smaller segments of society that might not be heard in an electoral process or party politics. That is why a policy that has the approval of, or at least has been discussed with, relevant civil society organizations is often seen to be more credible. The most immediately affected interests have been asked for their views and information, which in general means the policy will be better thought-through, targeted, and perhaps implemented (Putnam, 1993). A policy that is pushed through in the face of opposition from affected civil society groups might be perfectly legitimate, but it will also be contentious and face difficulties.

It is undeniable that most governments find some aspects of civil society more attractive than others. Low-cost delivery is attractive to policy-makers with constrained budgets, but advocacy, new ideas, and efforts to shape the political agenda are all uncomfortable and can be regarded as beside the point if the government has already decided what it wants to do. Connection with less powerful and more vulnerable groups in society can lead to broad benefits but it can also empower them in ways that incumbent powers find uncomfortable. Consulting civil society organizations can provide some information, even if it is only information about opposition to the policy. Still, the reason to engage with civil society is that it might make health policy better and it is probably impossible to have the benefits of civil society without being critiqued by some of its members. If governments want civil servants, they can hire civil servants, but if they work with civil society, as they almost inevitably will, they must cope with criticism and an element of unpredictability that comes with commitment and flexibility.

The comfort and discomfort of working with civil society also varies by context. For example, in much of central and western Europe there is a long tradition of social partnership in which unions, employer associations, and the state are jointly involved in governing the economy (Chapter 9). Unions and employer associations in this context are civil society organizations that play a key role in making the government function, and their activity as repeat players in governance can feel quite different from smaller advocacy groups or international CSOs protesting policy from the outside. The relations between government and civil society are endlessly variable and can always be made more cooperative, more argumentative, more transparent or more trusting. The burden of doing so is often more on policy-makers than on civil society, for it is often the behaviour of policy-makers and governments that has undermined trust and perhaps even created the gaps that civil society fills. Nonetheless, better partnership is possible.

1.4. Benefits of civil society engagement

What are some of the benefits of civil society engagement that relationships should respect and enhance – or could impair? There are a few overarching themes: empowerment, service delivery, commitment, flexibility, participation in policy, and credibility.

Empowerment is a key benefit of a strong civil society both in general and in the health context. The Marmot Review defined empowerment as material, psycho-social, and political, the latter not necessarily or primarily meaning formal engagement in politics (Marmot & Bell, 2012; Marmot et al., 2010). Empowerment is strongly correlated with health and well-being, and its absence, whether due to poverty, illness, or stressful working conditions, is a cause of ill health, as Marmot has demonstrated (Marmot, 2004). Many conditions of modern life are in some way disempowering, and addressing disempowerment is important both to health and to a successful, sustainable, thriving society. It is here that civil society comes in.

In terms of social benefits, empowerment through civil society creates opportunities for people of many different kinds to empower themselves by acting together (a theme of many of the mini case studies in this book, which range from disability rights campaigns in Bosnia to Polish mothers seeking better obstetrical care). Effective participation in formal politics and policy in particular tends to be an expensive, specialist activity. Effective participation in civil society, and participation in politics through civil society, is often much easier and more attractive because of the diversity and entrepreneurialism of civil society organizations. Knowing about and participating in a consultation on local health services, for example, requires energy, optimism, and specialist skills that an individual citizen will often lack, but a group of citizens can jointly develop. The result is that a strong civil society, by empowering citizens, is a component of a strong democracy – a point first noted by de Tocqueville and scarcely put better since (de Tocqueville & Goldhammer, 2004).

Engagement with a strong civil society can also have specific benefits in the context of a health care system. Being a patient or having a chronic condition can often be a disempowering experience in all sorts of ways (Parsons, 1975; Pilnick & Dingwall, 2011), from financial costs to social isolation and physical pain. Patients and carers who organize to share information can reduce these burdens and empower themselves, whether to manage their disease better or to improve the quality and access of their care. If the health care system often deals with disempowered people and disempowers them still more, then patient, carer, and community groups in civil society can help to reverse that disempowerment.

Service delivery is perhaps the most common attraction for policy-makers. Civil society delivers things that state, market, and family cannot deliver – from well-run health care facilities to credible ethical determinations to outreach to vulnerable populations, social campaigns, and volunteers. Delivery, doing what others cannot, is a key part of the relationship between health systems and civil society almost everywhere (see, for example, Chapters 6 and 7 on how civil society responded to austerity in Cyprus and the refugee crisis in Turkey). This means that there are key kinds of relationships to be managed, with consequences of all sorts. First of all, how is a partnership to work? Is it to be in the form of grants or contracts? Who will determine the goals? How much oversight will the public sector expect, and how much should there be? What are the drawbacks for a CSO of becoming a contractor? Secondly, there are others who want delivery from CSOs, such as international donors and organizations. The same questions exist for them, but everybody involved in such a relationship must also balance multiple political arenas from local to global to the politics of donors in entirely different countries (whose interest in a given problem or country might be fleeting or based on some misapprehensions). Thirdly, the more a CSO is delivering according to government or other funder priorities, the more it risks its autonomy, which in turn might risk other virtues such as commitment, knowledge, and credibility.

Commitment. Part of the reason civil society organizations can (and often do) work so well is a factor that state and market cannot tap: the commitment of people who are called to a mission, people who are working for a group or cause that they believe in. Commitment is part of the reason civil society organizations do things that state, market, and family will never do, and it is part of the reason why their autonomy is so important. Commitment demands that the organization is doing something that its donors and volunteers believe in, since otherwise they might demand market wages or public sector benefits. In other words, one of the most dangerous phases for a CSO is when its activities become so large-scale, so important to others, or so bureaucratized that its volunteers lose the sense that it belongs to them. Such an organization risks losing much of what makes it special.

Flexibility. The cost of entry to civil society is very low in most cases. If there is no special barrier put in the way, it is easy for a few people to form a local group and clean up a park or advocate that it have better playground equipment. This low cost of entry, which is further lowered in societies where there is high trust and extensive civil society engagement already (Putnam, 1993; Goldberg, 1996), means that it is often civil society that responds first to a crisis, as in the mini case study of refugee accommodation in this book (mini case study 6, after Chapter 9), or that responds to unexpected new needs, as in the austerity case study in this book (see Chapter 6). As the case study of austerity in Cyprus suggests, civil society organizations that are already entrenched in delivery and contracts with government might be more flexible than the public sector but they are still often less flexible than more spontaneous and less institutionalized organizations.

Participation in policy. One of the key benefits of a strong civil society is that it can bring new information to decision-makers, whether through research, through close contacts with particular populations, or through bringing opinions that are born neither in the state nor in the private sector. The benefits to policy-makers of civil society participation in policy-making are not just better information and better legitimacy, however. The benefits also include diverse ideas that their employees might not originate.

The ability of CSOs to bring any kind of information and ideas into policy-making, however, depends on the existence of mechanisms suited to their resources (see Chapter 5 on the European Medicines Agency’s engagement strategies, and mini case studies 3 and 4). There is an almost infinite variety of consultation mechanisms to involve civil society, including consultative forums and publication of government proposals for comment, and less formal mechanisms such as listening tours by officials. These need not be broad consultative forums. Sometimes the most effective participation is in narrow forums where civil society organizations can exchange ideas with policy-makers on specific topics such as food regulation, homelessness, or professional regulation (recalling that groups wholly composed of and accountable to business, with no broader accountability for social outcomes, are not part of civil society even when they share similar organizational features). Likewise, participation mechanisms make sense only in the context of the broader political system; the narrow forums for technical conversation in France make sense in that country’s policy-making just as the broad consultation documents of the European Union make sense in EU policy-making (Page, 2012). In particular, there is a distinction between civil society as a source of representatives, who can speak for a particular community, and experts, who can contribute a less or differently biased view.

Credibility. In political theory, a government has all the legitimacy it needs from its election, but in practice, many policies are challenged if they were made without the participation of affected interests, which are often best accessed through their organization in civil society (Greer, Wismar & Figueras, 2016). As a result, civil society’s credibility matters, and that comes from its participation and endorsement. Politicians are good at politics, by definition. They know how to empower interests to work after they move on. They also, therefore, know how to harness CSOs to make them do things and borrow the legitimacy of civil society. Creating opportunities for civil society to hold governments to account for their commitment is a basic technique used by ministers who want their innovations to persist after they move on (Greer & Lillvis, 2014).

In summary, the engagement of civil society with health policy and health is substantially dependent on the legal and political framework, which can affect both the benefits that civil society can bring and the ability of the political system and health system to hear and benefit from them. Civil society is often committed, diverse, and bottom-up, but the political, legal, and institutional context in both government and health system can lead to great variation in how it engages and whether the benefits of civil society engagement are realized.

1.5. The limits of civil society engagement

CSOs are heterogeneous and so are the interests they represent. They may have conflicting ideas about policy development and agenda building; they may deal differently with systematic and anecdotal evidence; and some of them are just not compatible with mandated government policy. For example, with regards to vaccination CSOs have played ambiguous roles, some even sowing confusion and doubts, for example on measles or on HIVP (Laurent-Ledru, Thomson & Monsonego, 2011). Some organizations representing citizens and patients have been criticized for opacity regarding their funding sources and lines of accountability, raising suspicions that vested interests are using CSOs as a vehicle to undermine certain policies, such as tobacco control policies, or to push certain medicinal products into the market place. The uses and abuses of civil society will be dealt with as a cross-cutting theme throughout the chapters of this volume.

While most countries agree that participation and democracy have a value as such, and must be supported in all sectors and contexts, there is much less consensus on depth and breadth of public involvement. Some countries have implemented referendum procedures to ensure that citizens’ organizations can voice discontent and compel policy-makers to deal with the issues. There are plenty of other ways of informing, hearing or allowing citizens’ participation in policy development. Examples include citizens’ representatives’ participation in health services commissioning and decommissioning decisions, and formalized mediation procedures in environmental impact assessments. Some commentators have argued that civil society participation is a key strategy to revive western democracies (Crouch et al., 2001). Others have argued that participation is a key strategy to create ownership and ensure legitimacy of otherwise contentious decisions in highly diversified societies. But there are also doubts and dilemmas about the legitimacy of CSO influence.

A credible civil society comes from its autonomy from the state and market, even if it can gain from the endorsement and attention of government and the resources of businesses. Governments can influence civil society, through contracting relationships, legal regulation, and participatory mechanisms. But it is worth remembering that the benefits of civil society engagement come partly from its independence from the state. A credible civil society is necessary if its endorsement is to make policy more credible. If it is replaying policy-makers’ own messages, it will not be bringing new ideas; nor will it necessarily be credible as a messenger. Civil society organizations have to compete with others in society, above or below ground, to represent different voices. Once shielded from competition, they will often cease to represent anybody and will have little to contribute to policy debates. That means policy-makers should be attentive – if civil society organizations are saying inconvenient things, it might be for a good reason. By the same token, civil society organizations can often be infiltrated by private commercial interests. A legal framework that provides some clarity about their origins and membership will generally help to make such interests transparent.

Finally, there is little general reason to think that civil society is a panacea. The equivalence between a strong civil society and harmonious democracy, popularized by Putnam (Putnam, 1993), is facile. As Mann noted, German civil society in the 1930s was, “led by Nazis, a strong but evil civil society … Civil society may not be very civil!” (Mann, 2004; Satyanath, Voigtlaender & Voth, 2013). Put another way, “‘civil society’ and ‘uncivil society’ cannot be separated” (Pedahzur & Weinberg, 2001).

There are two key points to be made here. First, civil society can strengthen or undermine democracy and intergroup relations. A fruitful way to think about the difference is that civil society can bridge social cleavages (for example, by bringing together members of different religious groups in a shared sporting league) or can reinforce them (by, for example, having separate sporting leagues for each religious community)(Varshney, 2001). The latter is pernicious and endangers the stability of the political system, while the former lessens the risk of instability and ethnic conflict. Secondly, Putnam’s influential work, which found that the quality of government within Italy varied with the strength of civil society, was somewhat mistitled. The book was called Making Democracy Work, but on the evidence in it, which was largely about public administration, a better title would have been Making Public Administration Work (Putnam, 1993; Goldberg, 1996). For the purposes of this book, the fact that civil society contributes to better and more responsive public services, which Putnam’s book largely demonstrates, is the most important factor.

1.6. How does civil society engage with health?

No organization exists in a vacuum, and civil society occupies a vast space around the power centres of politics and the economy. That is why it is so hard to define; it is not just as protean as human life, it is also able to grow in very different social, political, and economic contexts.

The positive and contextual aspects of civil society that we listed earlier started to identify the mechanisms that connect civil society, health systems, health policy and health. Any sensible analysis of civil society in health must contend with all of these contextual factors, asking for each one what it does to give civil society its shape. In them often lies the key to a more productive relationship. Any sensible effort to work with civil society organizations involves understanding both their context and their positive characteristics. The context might not always enable all the positive characteristics that partners could want.

How is civil society connected to broad health and health policies? How, in other words, can policy-makers best work with civil society? This is one of the most important questions for civil society, for there are many different types of possible relationships, and they range from friendly to oppositional and positive to dysfunctional. We start here with the contextual factors:

Freedom of association. The underlying right that makes civil society possible is the right to associate in groups. This right is therefore often targeted by regimes seeking less democratic input and a less empowered citizenry (for example, Franco’s Spain required a permit for any non-religious gathering of more than twenty people, even including family events, which pushed civil society into the Catholic Church (Greer, 2016)).

Regulatory and legal issues shape the kinds of CSOs that exist, what they can do, and how flexible their relationships can be. What is the basic legal status of civil society organizations? How many different legal statuses are available to them and what are the implications? Are there policies designed to aid civil society activity, such as tax exemptions? Legal questions are often overlooked in high-level discussions of civil society, but they matter. They influence the ease of starting a CSO, the long-term governance and organizational stability of CSOs, the financial resources of CSOs, the advocacy and participation implications of CSOs, the scale of CSO dependence on smaller donors and members versus public, wealthy, or international funders, and the ability of CSOs to formulate and change their missions. It is worth distinguishing between legal – involving legislation, the legal profession, and the courts – and regulatory – involving government and regulatory instruments – because they often have different dynamics and pressure points. In general, trying to set a broad legal framework and letting diversity work is better than trying to micro-engineer civil society organizations and their work. Micro-engineering endangers much of what civil society brings in the first place, which includes diversity and responsiveness to diverse groups and people.

As a result, the first step is making the case for an effective, formal, transparent and efficient system for registering civil society organizations. Effective, meaning that it is responsive and has enough coverage and benefits to attract CSOs and reflect them; formal, meaning that it is based in law, can be understood by an intelligent outsider, and is not subject to private manipulation; transparent, meaning that decisions and their grounds are made clear; and efficient, meaning that it does not demand much resourcing or distort civil society activities. There are many such systems in operation, whether under specific charity laws, or company registration laws, or tax laws. Such a system can also allow them to gain benefits, such as tax benefits or access to youths doing civilian service. While making registration transparent, formal and efficient decreases the costs of registration, it is not useful to demand that every organization in civil society must register, since many of them go through what we might regard as a trial stage of informal organization, and not everybody wants to enter into formal contact with the state no matter what the benefits may be.

Once there is a system of some sort, we can then ask that it effectively ensures the autonomy of civil society. For example, we can ask that CSOs file bylaws, financial accounts, and a constitution, and even allow them to be challenged if they fail to abide by those rules. Even if an organization clearly “works for” somebody, at least the formal system can make that clearer.

Financing in its various forms is important. Civil society organizations are funded by a wide variety of mechanisms, including small donations, large donors, international organizations, their own endowments, membership fees, sales of products and services, contracts for service provision with the state or private actors, and grants for projects. CSOs can be adept at obtaining resources in kind, such as volunteer work, and likewise can have an impact at prices that private and public sector actors would find impossible, but ultimately much of civil society needs money, and areas like health care provision need a lot of it.

The problems of financing civil society are endless and, again, context-dependent. Maintaining intellectual and practical autonomy from rich donors, government contracts, and other revenue measures can be hard. Competition for funds can keep civil society streamlined, relevant, and evolving, but core funding can enable long-term investments and reduce dependence on donors’ fads. Likewise, accountability can be difficult to ensure for organizations that enjoy their own resource base (such as an endowment) or lucrative economic franchises (such as insurance sales or lotteries). The source of revenue can bias the effectiveness, views, and broad credibility of a CSO, but is also very difficult to ensure on a top-down basis. There will always be many CSOs who frustrate somebody with their dependence, and others that frustrate with their independence.

There are two kinds of problems in particular. One is the relationship of civil society with businesses. By definition, civil society organizations are not state actors, and people motivated by a cause will often have a different kind of credibility from businesses. As a result, it is a simple and often rewarding strategy for business interests to portray themselves as civil society – what Americans sometimes call “Astroturfing” (Astroturf is a brand name for artificial grass); in other words, creating an artificial grassroots base. Transparency about funding is an important part of establishing autonomy from the market. Long-term credibility is more important still. Funding sources can always be questioned, which is why a record of independence and clear accountability often matters more to the reputation and importance of a group. Strong civil societies will often police themselves, by extending or denying credibility to other organizations. Over time, it generally becomes quite clear what is grass and what is Astroturf.

Secondly, there is the relationship between civil society and the state. Here, there are a number of problems. In particular, the state often has a great deal of power over civil society. Not only does it set and enforce the basic legal framework for civil society, it also sets the terms of political participation and often finances civil society organizations. The result is a constant stream of efforts by those with independent sources of finance (businesses, wealthy donors) or by the government itself to use contracts and grants to civil society organizations as ways to influence their work. Governments might give contracts to civil society organizations like universities because they want their commitment, knowledge, and credibility, but then find themselves funding their own critics. It is all too tempting to value the short-term and try to constrain civil society, with ill effects on policy decisions and the ability of civil society to deliver anything people or the state might ask of it.

Political contexts fall into two basic categories: what does the government want civil society to do and how well can it enforce its wishes; and how does civil society fit into the broader way of policy-making in a given country? The first question is a big one. Here it is worth noting that civil society of some description exists almost everywhere, and does something useful even if governments do not appreciate it. The second question, concerning how well civil society fits into policy development, is a question about politicization and the autonomy of civil society from political action. It is easy for CSOs to enter into what are basically clientelistic political relations, working for parties or individual politicians as conduits for money or support. Some societies that are organized by political party families have worked extremely well (for example, in postwar Austria), but it is not the norm. The problem is akin to the problem of politicizing the civil service and filling its posts with patronage appointees – there can be short-term benefits, but in the long run the risk is that neither the public service nor civil society will function well if they work for party politicians.

In particular, the closeness of the connection between civil society and the state involves a number of trade-offs and it is hard to say when the right trade-off has been made. On one hand, civil society organizations gain credibility when they are interlocutors of the state, but on the other hand they gain credibility from autonomy vis-à-vis the state. Civil society can be instrumentalized by political and partisan actors, but over time that endangers the commitment, flexibility, and low cost that make CSOs a desirable way to deliver services. It can be turned into an echo chamber for the government, or even shut down, but that diminishes the flow of ideas in society, makes government more fragile and error-prone, reduces the resilience of society by disempowering people and reducing the diversity of ideas, and leaves government less capable of engaging with or answering the range of needs and people in society.

Social contexts are multifarious, but in the context of relating to civil society there is one key point worth emphasizing: civil society can fill in important gaps, will frequently do so unbidden and can be a key partner if supported. For example, we can imagine a society in which some combination of strong family structures and a welfare state mean that most citizens enjoy appropriate access to health care. But what about the ones who are not fully integrated into the labour market, who are estranged from their families, or who suffer discrimination? Civil society organizations can represent them and work for them in ways that the surrounding society and political structures cannot or will not.

1.7. Summing up the background to the study on civil society and health

This book sets out to map the place of civil society in health. It uses a set of case studies and a broad framework to make three key points. First, it highlights the ubiquity and diversity of civil society. Civil society means many things, many kinds of organizations and many kinds of tasks. It does not mean the same thing in any two political systems, and so what it contributes and can contribute also varies. Secondly, it highlights the importance of context in understanding civil society’s diversity and contributions. What does civil society do in a given place, what has it traditionally done, what could it do, and why? These are all empirical questions. They also mean that it can be unwise to try to export a form or function of civil society from one country to another. Everybody likes to export their own institutions and ideas, but those institutions and ideas might be actively harmful, or at least have significant opportunity costs, in other settings. Thirdly, it highlights the broad value of civil society in many aspects of life, from social resilience to informed policy-making and good quality technical standard setting. Few countries are without civil society, and there are benefits to health in working with it.

In the subsequent chapters and mini case studies throughout the book, we highlight concrete cases of civil society at work, showing the diversity of civil society and its tasks, its broad value, and the importance of understanding context in understanding its work and potential. We do not aspire to cover every cell in the matrix from this chapter, and nor does Chapter 2 aspire to cover every kind of civil society action. Rather, the purpose is to show the ubiquity, diversity, and beneficial aspects of civil society in different health policy contexts.

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