UHC reforms are usually established by national legislation. Civil society has a vital role to play in monitoring the development, enforcement and impact of UHC laws. This is easier to do when such legislation is rights-based and inclusive, with mechanisms to address policy and human rights issues as well as funding for communities to work on advocacy and rights. In Thailand, a citizen-based movement ensured key provisions on accountability and voice were included in the National Health Security Act of 2002 (Learn more).
In many countries, legal barriers prevent many CSOs from providing health services. UHC legislation must therefore also be supportive of community service delivery, also known as ‘social contracting’. Above all, UHC law should meet the needs of the poorest and most vulnerable. In Ghana, the Planned Parenthood Association lobbied successfully to ensure the inclusion of free contraception in the National Insurance Act (Learn more).
Where health legislation is harmful, civil society can call for reform and even engage in strategic litigation. In 2011, the Center for Health, Human Rights and Development in Uganda took the Government to court over the preventable deaths of women in childbirth due to poor quality health services (Learn more).
Planning & Priority Setting
Each country must set out a national health plan based on national health priorities. To inform the evidence-base, civil society can provide up-to-date community-level data and insights from the ‘frontline’, which are often overlooked. An important example of participatory research is the People Living with HIV Stigma Index, an initiative of the Global Network of People Living with HIV (GNP+). Developed by the community, this standardized research tool collects evidence on how stigma and discrimination impacts the lives of people living with HIV. Another example is the Key Population Consortium in Kenya, which brings the voices of some of the most marginalized people in society into health policy priority-setting (Learn more).
Full civil society engagement in UHC operational planning ensures that plans are relevant, feasible, and legitimate. This means they are more likely to be trusted by society as a whole. Several countries, such as Botswana, are working towards this by setting up multi-stakeholder technical working groups on crucial UHC topics.
National CSO health networks can be excellent platforms for influence as they bring together a wide range of expertise and experience. The national Health CSOs Network in Myanmar is included in the social accountability framework that monitors the implementation of the National Health Strategy and provides specific expertise on the integration of health services (Learn more). In Kenya, the health NGO network HENNET has been a member of the National Health Benefits Advisory Panel since 2018.
In West Africa, there have been positive steps towards citizen ownership of, and trust in, health reforms at national and regional levels. For example, in Senegal, civil society provides direct input into regional health sector reviews, while in Burkina Faso, NGOs have directly influenced the National Health Financing Strategy.
Finally, once mainstream CSOs have secured a seat at the planning table, they are responsible for pushing for fully inclusive policy processes, ensuring that the voices and perspectives of under-represented groups, such as adolescents and young people, are included in policy planning. The Ready for UHC campaign by the Global Network of Young People Living with HIV is an excellent example of a youth movement pushing for their inclusion at a national level.
As a critical stakeholder, civil society’s involvement in good governance is crucial when it comes to health financing. This is necessary to ensure transparency, value-for-money, and accountability, although this is an area in which very few CSOs feel comfortable.
Budgets are essential policy tools—they communicate government priorities and strategies and are how governments deliver on their promises. Good policies and plans are not enough; they need to be supported by appropriate and efficient budgets.
Civil society can—and should—be engaged in budget advocacy at every stage of the budget cycle—from participating in national and local budget-setting processes, checking the rationale for health spending (see Burkina Faso example) and independently verifying drug prices, to analyzing budgets and expenditure from the perspective of underserved groups.
In Indonesia, for example, the Forum for Budget Transparency (Seknas FITRA) advocates for transparent, pro-poor and gender-responsive budgeting in cooperation with both local civil society and the Ministry of Finance. In 2014, its analysis of the regional implementation of Indonesia’s 2004 National Social Security System informed the national health insurance scheme launched.
Community-based networks can play a vital role in monitoring actual expenditure at the level of local health facilities and district health teams. In the Democratic Republic of the Congo, the Participatory Budgeting Project has enabled rural and urban citizens to participate in formulating and managing local budgets, strengthening health governance in the process.
Monitoring & Evaluation
Alongside budget monitoring, the community has a vital role to play in monitoring the performance of UHC policies and programmes, including pilot initiatives. Community-led accountability mechanisms at all levels of implementation are known to improve the accessibility, responsiveness and quality of services (see, for example, PEPFAR). The Regional Community Treatment Observatory in West Africa (RCTO-WA) led by ITPC empowers networks of people living with HIV in 11 countries to collect and analyse qualitative and quantitative data on barriers to HIV services in order to increase access to treatment. In Uganda, the Action Group for Health, Human Rights and HIV focuses on improving the quality of health systems using a human rights lens. At the global level, community groups submit shadow reports to the Committee on the Rights of Persons with Disabilities (CRPD) to ensure persons with disabilities and their representatives monitor the implementation of the rights of people with disabilities within their country.
The forthcoming 2023 UN High-Level Meeting on UHC will be a critical moment for civil society to present data and evidence on progress towards UHC implementation, ensuring data is fully disaggregated to identify those left behind. In the meantime, Voluntary National Reviews and shadow reports are a crucial way to participate at the UN level, while at the national level, communities can participate in Joint Assessment of National Health Strategy processes.
Advocacy & Community Mobilization
There are many layers to UHC advocacy—from endorsing the concept of UHC and pushing for true universal access to health for all—to calling for increased health budgets and holding governments to account for their promises. All too often, UHC is seen as a technical and abstract concept and not a grassroots movement.
Yet above all, UHC is a political cause. For that reason, mobilizing citizens to use the power of their vote at the ballot box should not be overlooked. Raising broad public awareness of government responsibility in this area after decades of health spending neglect must be a vital component of civil society action in this area. This can be achieved through broad coalitions of diverse movements in many social sectors.
The National Health Assembly (NHA) in Thailand demonstrates how civil society, researchers and Government (the triangle) can work together to address the challenges of UHC design and implementation (the mountain). Founded in 2008, the core principle of the NHA is...
Over the past few years, civil society in Burkina Faso has been increasingly vocal about the need for better social protection and the removal of user fees for the poorest and most vulnerable. In 2015, the Ministry of Health created a multi-stakeholder steering...