Civil society organisations and global health initiatives Problems of legitimacy

Do Civil Society Organizations (CSOs) actually help global health?

Reda SadkiGlobal health

This summary analyzes two important articles examining the role of civil society organizations (CSOs) in global health: “Civil society organisations and global health initiatives: Problems of legitimacy” by Doyle and Patel (2008), and “Civil society in global health policymaking: a critical review” by Gómez (2018).

While both articles challenge dominant assumptions about CSOs in global health, Doyle and Patel focus more on issues of legitimacy, representation and effects on democracy. Gómez focuses more on the lack of theoretical and empirical evidence for CSOs’ influence across all stages of the policy process. 

Doyle and Patel (2008) challenge the assumption that CSOs automatically enhance representation and democracy in global health governance.

  • They argue that talk of ‘partnership’ obscures logistical and political obstacles to Southern CSO participation.
  • The authors also question the real agenda of many global health governance agencies and Western donor countries in the use of CSOs to deliver health interventions directly, bypassing government agencies where possible.
  • They suggest this CSO-led approach and the bypassing of government agencies has had a number of negative effects that either undermines claims of CSOs to be enhancing democracy or undermines the potential effectiveness of global health interventions.

Gómez (2018) similarly critiques the lack of evidence for CSOs’ assumed comparative advantage in health program delivery.

  • His review finds the literature “narrowly focused on the agenda-setting and policy implementation stages, failing to account for all stages of the policymaking process and civil society’s role in it.”
  • He argues that “very little effort has been made to test and develop theoretical and analytical policymaking frameworks, clearly and consistently defining and conceptualizing civil society’s role and influence in global health policymaking, provide methodological specificity and diversity, while emphasizing the importance of causal mechanisms.”

Doyle and Patel conclude that failure by advocates to respond to the sceptical arguments put forward here may weaken the legitimacy of CSO involvement in GHIs [global health initiatives].

They call for research to clarify how different CSOs operate in different contexts to help to identify those variables that promote or impede the success of health interventions in different settings globally.

Gómez, on the other hand, concludes by “encouraging scholars to address these lacuna in the literature and to explore the utility of political science theory and alternative policymaking models to better define and explain the complexity of civil society’s role and influence in global health policymaking processes.”

Together, these articles make a compelling case for more critical examination of the role of CSOs in global health, and for moving beyond broad assumptions to more nuanced, context-specific and empirically-grounded analysis. They provide a valuable counterpoint to the often unquestioning enthusiasm for CSO engagement in much of the global health field.

Dominant Assumption  Evidence Challenging Assumption 
CSOs enhance representation and democracy in global health governance  Questionable existence of a coherent “global civil society” (Doyle & Patel)
Lack of accountability and representation of populations claimed to be represented (Doyle & Patel)
Elevating CSOs can undermine democracy and state legitimacy in developing countries (Doyle & Patel) 
CSOs have a comparative advantage in delivering health interventions  Lack of evidence for comparative advantage (Gómez)
Short-term donor funding creates perverse incentives and unsustainable interventions (Doyle & Patel)
“Marketization” leads to duplication, inefficiencies, and focus on easy to measure outputs vs impact (Doyle & Patel)
Bypassing and competing with public health systems is detrimental (Doyle & Patel) 
CSOs play a significant role across all stages of the global health policy process  Literature narrowly focused on agenda-setting and implementation stages (Gómez)
Lack of theoretical and empirical analysis of CSO roles and influence across all policy stages (Gómez) 
Partnership rhetoric reflects genuine collaboration and equality between Northern and Southern CSOs  “Talk of ‘partnership” obscures logistical and political obstacles” to Southern CSO participation (Doyle & Patel)
Unequal power relations and Northern dominance in CSO partnerships (Doyle & Patel) 
CSO involvement improves the effectiveness of global health interventions  Lack of evidence for impact of CSO involvement on health outcomes (Gómez)
Focus on short-term, easily measurable outputs vs long-term impact and sustainability (Doyle & Patel)
Negative effects on health systems and government capacity (Doyle & Patel) 


Doyle, C., Patel, P., 2008. Civil society organisations and global health initiatives: Problems of legitimacy. Social Science & Medicine 66, 1928–1938.

Gómez, E.J., 2018. Civil society in global health policymaking: a critical review. Global Health 14, 73.