Background: the interview followed the EHFG2017 session on the role of civil society organisations (CSOs) for health. Here Matthias Wismar, who is the senior health policy analyst at the European Observatory on Health Systems and Policies, and a co-editor of the recent analytical study “Civil Society and Health: Contribution and Potential”, shares his reflections from the session and key highlights from the book.
You are a co-editor of the Observatory’s recent book on civil society and health, which is now available online. Could you tell us a bit more about the context in which the book was born?
MW: The book was commissioned by the WHO because major stakeholders today agree that we need civil society in health care – there are certain tasks only civil society can provide, whether it is service delivery or policy input. In some countries, civil society organizations (CSOs) are running hospitals, they provide services to the deprived, marginalized people. They have a lot of credibility and intimate knowledge of their constituencies, so it is clear that governments need to work with the civil society. But across Europe, there is no agreement on what the definition of civil society is and how to deal with it, nor what its contribution should be. The WHO has its own framework and definition, and the European Commission in the Health Policy Forum has a different one, tailored to their respective needs. So, the idea of this book was to do develop a relatively simple definition of civil society, and to map civil society organizations in health and their activities.
What kind of real-world examples did you look at to study these questions?
MW: We have developed a matrix of different types of civil society organizations and the types of activities they are engaged in. For example, we included a case of tobacco control in Russia, a whole-of-society approach in the Netherlands, HIV/AIDS prevention in Russia, trade unions in Austria, food banks in Cyprus, and plenty of other mini-case studies. Notably, our examples also included countries in which there are debates about limiting the activities of civil society. We took the perspective of governments and focused on the instruments of working together with civil society, and the contexts helping civil society to thrive.
What have you found?
MW: The most important contextual factor is the regulation of civil society. Today, most countries require transparency in civil society funding, and for good reasons. Namely, if you remember, some 10-15 years ago there were many patient organizations that were treated with suspicion because nobody knew where their money was coming from – probably from the industry. True, there are still a couple of suspicious organizations today, but most countries now require transparency. But the question is also how far should this transparency go? To what extent can you really ask a small organization that probably has a director and no-one else to be as transparent as a large, stock exchange listed company?
Sources of funding for civil society were also highly debated during the Gastein session on civil society in the health sector. Some people criticize the dependency of patient organizations on state or EU funding, while others see industry funding as a bigger threat. Has the book identified a healthy model of funding?
MW: It’s entirely wrong to discuss funding across the board for all civil society organizations. There are NGOs like the Cancer Leagues, but also professional organizations, which have very different sources of funding. Some have big players behind them – for instance, an NGO such as the European Health Management Association has teaching hospitals and sickness funds as its members. The European Public Health Association derives much of its funding from its annual conference. This means that they have a completely different budget structure from a patient organization. So, there are organizations that can be, and ought to be, independent, but there also organizations that cannot do that: patient organizations, organizations representing marginalized groups. We should be open to various models of funding CSOs and I doubt that one size fits all.
Your book takes the perspective of governments. To what extent do you think governments and civil society are working on the same goals?
MW: That’s a tough question, because it implies that the goals of governments are very clear, while very often they are not, and we see a lot of policy incoherence. This is not so much the case when it comes to health care; but when it comes to social determinants, we see governments that support the alcohol producing industry, and at the same time we have CSOs acting for responsible drinking, consumer protection, and so on. So, very often there are some conflicts, but not necessarily with ministries of health. Rather, the conflicts appear along the lines of the health policy and trade policy, health policy and agriculture, health policy and fiscal policy – the same tensions we have between the CSOs with different ministries and the industry. On the other hand, we could ask to what extent the CSOs contribute to policy coherence and make the trade of these conflicts, which are sometimes hidden in the machinery, more transparent. Take an example of the austerity policy – within governments, there was a very clear message that health sector had to put up with cuts, so it was civil society and academics who alerted us to the detrimental consequences of austerity policies for health.
How can civil servants become better health advocates and what should governments know about CSOs?
Very often, it looks as if these are two completely different organisational cultures. On one hand we have a measured and balanced public servant and administrator, and on the other, we have a self-starting, entrepreneurial civil society activist or leader. What we’ve seen in today’s discussion here in Gastein is that if civil servants adopt a positive attitude towards the CSOs and get engaged, it makes a big difference.
Secondly – and this is true for all intersectoral policies – the governments need to better understand the goals and objectives of other actors, including the CSOs. First, they need to know that the CSOs have their own constituency and their own goals, and even if these do not fully align with the government’s goals, it is not necessarily a problem. Second, governments need to know that the administrative burden put on CSOs can be quite devastating. We don’t want people to spend three months writing proposals to apply for grants, as some of them are so small that they don’t have the administrative capacity to do this.
Another thing that we have heard today is that policies need to be more supportive with regards to the CSOs, and their goals and funding instruments, which do not always align very well. Governments need to think about whether funding and control mechanisms make sense, or if it is better to give the CSOs more funds, leeway and more discretion on what they can do, because they have the local knowledge and know what needs to be done.
One last question: do you have an example of your favourite civil society action that made an impact on health?
MW: I like the example of tobacco control policy in Russia. It shows how important it is to have a CSO which has a constituency, autonomy, and is able to forge alliances. After the collapse of the Soviet Union, the Russian government was not really prepared to deal with big corporations, allowing their way into politics and gaining a very favourable political framework. It was really the contribution of civil society, which managed to, first of all, bundle the anti-tobacco activities, and then to increasingly raise awareness. For some time, they were despised by the politicians, but in the end, they contributed to make a change in perspective and policy, as the government agreed and collaborated on this. It may not have been a very stable collaboration, but it is a very nice example of various aspects which worked together very well. Also, these CSOs were reaching out for international expertise almost instantly, and setting up international advisory committees to help them, as Western European countries had much more experience on how to deal with tobacco industry.
Then there is this uplifting example of so called “social groceries” in Cyprus. Cyprus does not have a very strong welfare state, and as unemployment soared because of the economic and social crisis, people were left with very little means. But starting from, I think, two local initiatives, this idea of social groceries developed very quickly. It spread across the country and was supported by the Church. The government was also supportive and helpful in providing a platform for exchange of experience and made it easier for the CSOs to act. The Turkish example was very impressive as well, because I was originally unaware of what the civil society in Turkey actually is like. There were really many good examples in this book.
This interview was written by the Young Gasteiners Marina Karanikolos and Olga Löblova