Children marching for Universal Health Coverage.

Squeezed Out: Shrinking civil society space threatens progress toward universal health coverage

109 countries have closed, repressed, or obstructed civic space, according to CIVICUS’s State of Civil Society Report 2018. This shrinking space for civil society impacts 82% of the world’s population. The CIVICUS report also found that globally, it was most common for protests related to socio-economic rights – where citizens are demanding their entitlements or questioning the quality of their services – to be met with excessive force.

This culture doesn’t bode well for global health governance. Strong and inclusive governance relies on informed citizens engaging in planning, budgeting and monitoring political processes to ensure that policy-makers prioritise people’s needs and that policies are implemented. This essential civic engagement becomes more and more challenging when space is restricted or non-existent and state responses to dissent foster a culture of disengagement and fear.

Informed and empowered civil society is the main driver of change in any country. Civil society organisations who represent the interests of their citizens are the best advocates for quality health services. They are vigilant watchdogs over policy formulation and implementation and ensure that the needs and interests of the most vulnerable – especially marginalised women and children – are at the heart of decision making processes.

To play this role, civil society organisations need to be strong and stable, with predictable funding, supported by an enabling political environment that guarantees their mandate and provides safe spaces for civic engagement. History has shown us that the stronger civil society becomes, the more it can strive for improved services and quality of life. It’s precisely because of this potential that institutions such as Gavi, the Vaccine Alliance and the Global Financing Facility (GFF) have a clear mandate to strengthen civil society in countries, while building and strengthening national systems – fully aware that government and social systems need to grow strong simultaneously to create robust and resilient national health systems.

The Universal Health Coverage (UHC) agenda requires policy-makers to reprioritise investment and commit to financing plans that deliver free-at-the-point-of-use healthcare to all, including the most marginalised and vulnerable people. The inclusion of UHC under Sustainable Development Goal 3 is a victory for civil society and an ongoing challenge to hold policy-makers to account. Civil society requires the support of the development community and international institutions to become strong, and for national civil society platforms to become drivers of policy change in their countries. Gavi and GFF should not give in to pressure from national governments that would scupper their plans to fortify national civil society platforms and to build citizens’ voice in helping improve health governance and accountability.

Save the Children is committed to strengthening national healthcare systems by building the capacity of civil society to engage in all aspects of health governance, from creating the demand for quality health services, to holding health planners to account, and engaging in planning, budgeting and monitoring processes. Save the Children will continue to engage with Gavi and GFF while ensuring they maintain a focus on strengthening civil society and strengthening health systems, especially where states have legally or illegally restricted space for civil society mobilisation.  This makes our work in countries such as Ethiopia, DRC, India, Bangladesh, Kenya, Liberia, Sierra Leone, Myanmar, Nigeria, and Senegal all the more important.

We urge Gavi and GFF to stay on track with their commitments to strengthening civil society – Save the Children believes in the capacity of people to set and control their own agendas, to claim their right to health and contribute to solutions in a meaningful way. This is the true pathway to achieving sustainable UHC in the countries we work in.



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  • Adetokunbo Diane Lawrence

    Way to go, Tara! This is a thoroughly inspiring and timely piece.

    In Lagos state, Nigeria, the Government just recently concluded Transparency in Primary Health Care Budgeting sensitisation meetings across its 20 LGAs, as part of its on boarding of the Saving One Million Lives Programme for Results (SOMLPforR), in the state. It was exciting to see CSOs (including the Lagos State Accountability Mechanism (LASAM) on Maternal and Newborn Health, the Lagos State Civil Society Partnership (LACSOP)), join Save the Children to call upon council officials and related actors to prioritise the allocation, release, utilization (and now, publication on the Ministry of Health’s website) of health budgets, particularly for procurement of consumables and equipment in primary health facilities.


  • Isyaku sabo tsafe

    I appreciate the contribution of SCI in Nigeria and other countries on capacity building for civil society on budget tracking