Role of Civil Society in Health Care
Role of Civil Society in Health Care
REVIEWED BY
Nachiket Mor,
vulnerable communities of India
The Banyan Academy of Leadership in Mental
Health, India
*CORRESPONDENCE
Anuja Jayaraman* and Armida Fernandez
Anuja Jayaraman
Society for Nutrition, Education and Health Action, Mumbai, India
[email protected]
SPECIALTY SECTION
This article was submitted to
Public Health Policy,
The role of civil society as a partner in the delivery of primary health care is
a section of the journal well-established. The pandemic placed a great burden on the existing public
Frontiers in Public Health health system and civil society stepped forward not only to help the vulnerable
RECEIVED 08 November 2022 population to mitigate challenges that subsequently arose but also to fill the
ACCEPTED 31 January 2023 gaps the pandemic exposed in India’s health care system. The objective of
PUBLISHED 22 February 2023
this paper is to provide mechanisms for realizing universal health coverage by
CITATION
Jayaraman A and Fernandez A (2023) Role of
strengthening primary health care from the perspective of civil society. The paper
civil society in health care: Mechanisms for uses examples of efforts of SNEHA, a non-profit organization working on the
realizing universal health coverage in health of women and children in informal settlements of Mumbai and other civil
vulnerable communities of India.
Front. Public Health 11:1091533.
society organizations working with vulnerable or hard-to-reach populations. We
doi: 10.3389/fpubh.2023.1091533 use existing literature, field data, reports and published work over the years. We
COPYRIGHT
find that civil society helps the health system to connect with difficult-to-reach
© 2023 Jayaraman and Fernandez. This is an populations and achieve wider coverage. They can also build the capacity of
open-access article distributed under the terms frontline staff in the public systems in formal and informal ways. They can
of the Creative Commons Attribution License
(CC BY). The use, distribution or reproduction recommend ways to change the attitudes and motivations of these workers. Civil
in other forums is permitted, provided the society organizations with their close connection with the community can play
original author(s) and the copyright owner(s) the part of a “gap-filler” and data messenger. Finally, they can refer people to
are credited and that the original publication in
this journal is cited, in accordance with appropriate health facilities minimizing out-of-pocket expenditure on health.
accepted academic practice. No use,
distribution or reproduction is permitted which KEYWORDS
does not comply with these terms.
universal health coverage, civil society organizations, primary health care, community
participation, collaboration with health systems, gap-filler
Background
In many instances, ranging from financial inclusion to health care, last-mile connectivity
is the main challenge. Consider the case of financial inclusion. The Indian central bank, the
Reserve Bank of India, actively fostered the business correspondent model with the objective
of “increasing banking outreach and ensuring greater financial inclusion” (1). It is a journey
that started in January 2006 and it is still a work in progress. In March 2010, there were only
34,174 business correspondents in rural areas and by December 2021 this had increased to
1,844,732. In urban areas, the number of urban locations covered by business correspondents
increased from 447 to 1,412,529 during the same period (1). Business correspondents play
a crucial role in the progress toward universal financial inclusion by connecting banks
and households in geographically under-banked areas. Non-governmental organizations
(NGOs) play a similar role in a different context.
Recently, the pandemic placed a great burden on the existing public health system
and civil society stepped forward not only to help the vulnerable population to mitigate
challenges that subsequently arose but also to fill the gaps the pandemic exposed in India’s
health care system (2). The number of NGOs working in India has hard-to-reach populations. We use existing literature, field data,
grown significantly since the 1990s. The United Nations recognizes reports and published work over the years to draw learnings for
that civil society organizations have a crucial role to play in UHC by studying how civil society organizations integrate into the
delivering Sustainable Development Goals (SDGs). The third goal existing public health infrastructure and at the same time engage
(SDG 3) pertains to ensuring “healthy lives and promote wellbeing with the community.
for all at all ages.” This is probably among the most ambitious
goals in terms of breadth, scale and complexity. Within this, target
3.8 relates to “universal health coverage.” The goal of universal Realizing universal health coverage in
health coverage (UHC) is that everyone should receive the health
care they need without facing any financial hardships (3). The
vulnerable communities
Sustainable Development Goal 3 of good health and wellbeing
The Primary Health Care Performance Initiative framework
includes achieving UHC which is measured by the progress made
outlines the 5S-5M-5C schematic which describes a systematic
in indicator 3.8.1 which monitors the coverage of essential health
approach to using appropriate inputs (5S) along with delivery
services and 3.8.2 which captures the out-of-pocket payments
mechanisms (5M) with the aim to achieve set health outcomes
made for health services (4). As of 2019 on a scale of 0 to 100,
(5C) by strengthening primary health care for all (12). This paper
India ranks 61 in the UHC index of service coverage which is
uses this framework to explore what functions community-based
indicative of significant challenges remaining in the achievement
organizations are capable of performing even when government-
of the indicator (5).
run urban health systems are functioning well.
Additionally, there is an agreement that the primary health
care (PHC) approach shapes a viable health care system that
is effective, equitable and efficient leading to UHC and the
achievement of the Sustainable Development Goals (6). While Inputs (5S) needed for a strong primary
service coverage has improved in the last 20 years, the proportion health care
of people facing financial hardship due to out-of-pocket health
spending has increased. With rising poverty and shrinking incomes In the 5S-5M-5C framework, 5S refers to the inputs including
resulting from the current global economic recession and health the availability of health care providers, staff, adequate finances,
systems struggling to provide continuity of health services, the sufficient medical and other supplies and surveillance in terms
COVID-19 pandemic is likely to halt the progress made toward of responding to community needs (12). During the pandemic,
UHC, particularly among disadvantaged populations (2). One of SNEHA got involved in new activities which included the
the guiding principles to strengthening health systems is active distribution of food items in the community, dissemination
engagement with citizens, communities, civil society and the of information related to COVID-19 and coordination with
private sector (7). public systems for the continuity of routine services (13). As
Over the years, NGOs have filled the gaps in health care an organization that worked on issues related to the health and
provision by focussing on marginalized and vulnerable populations nutrition of women and children, SNEHA ended up distributing
(8–10). NGOs’ partnership with the government system is well fresh fruits and vegetables in informal settlements of Mumbai
established wherein the government relies on NGOs to provide during the pandemic between April and June 2020 when
universal coverage in health and education (11). A systematic communities were isolated due to strictly-imposed lockdown, an
review of the role of NGOs in progressing toward UHC activity that the organization had never undertaken. In the three-
concluded that NGOs could play an important role along with month period, 30,000 boxes of fresh fruits and vegetables were
the government and other key stakeholders (9). This review uses distributed to Dharavi residents (14). This was possible because of
the UHC cube dimension to explore the role of NGOs to identify SNEHA’s collaboration with another Mumbai-based philanthropic
themes and sub-themes wherein service coverage includes human organization, other NGOs, the Municipal Corporation of Greater
resources, equipment and public health; population coverage Mumbai (MCGM) and local community members and volunteers.
includes community participation and inclusion of poor and SNEHA could motivate community volunteers and private
vulnerable groups; and financial coverage encompasses insurance shopkeepers to arrange for food kits for needy and vulnerable
development, free charge and provision of loans. NGOs can assist populations including pregnant women and daily wage workers.
in the provision of PHC through the implementation of programs The philanthropic organization coordinated the procurement of
by providing information on health care schemes, ensuring the food supplies and SNEHA worked closely with MCGM to identify
participation of community members including disadvantaged individuals residing in the containment areas. Having worked in
and vulnerable populations, training health care workers, using Dharavi for over 20 years, SNEHA had the connections and grip
appropriate health technologies and applying a gender lens to on the pulse of the community to understand their immediate
health promotion while taking local context into account (8). needs at the start of the pandemic which brought an unanticipated
Given this context, the objective of this paper is to provide convergence of stakeholders (14).
mechanisms for realizing UHC by strengthening primary health Apart from surveillance and knowing community needs,
care from the perspective of civil society. The paper uses examples organizations have supported the public health system in
of efforts of SNEHA, a non-profit organization working on the strengthening primary health care by the provision of medical staff
health of women and children in informal settlements of Mumbai and training. As a not-for-profit and humanitarian organization,
and other civil society organizations working with vulnerable or Doctors For You (DFY) focuses on providing medical care and
services to vulnerable communities including disaster-hit zones indicators, application of data to make evidence-based decisions,
(15). Their key focus area is disaster response and recovery, and putting in place a well-functioning facility and population
public health and nutrition and community development initiatives health management systems (12). Working on the premise that
(16). Through their urban slum health centers, DFY provides timely obstetrics care is crucial in preventing both maternal and
basic primary and preventive health services which include child deaths, SNEHA has partnered with public health systems of
immunization, antenatal care and dental care. They also train and the Mumbai Metropolitan Region to initiate a formal maternity
build capacity for emergency preparedness and response (17). They referral network among health facilities. SNEHA’s role among
bring in the key resources needed for managing the health needs of other things is to establish referral linkages between sending and
the community. receiving facilities, manage referral data using the referral slips,
Some organizations use technology for last-mile connectivity. customize clinical protocols to decide types of cases that can be
The mission of the Digital Empowerment Foundation is to managed by the health facility, train staff and set up referral
“empower marginalized communities in information dark regions meetings among health facilities. Patient referral is not new to the
to access, consume and produce information online using digital medical field however, the need arose when a situational analysis
interventions and ICT tools” (18). This is done by providing conducted by SNEHA indicated gaps in the referral system. This
access to the internet, using digital tools to raise awareness project was piloted in two regions of the Municipal Corporation of
about government entitlements and opportunities including health, Greater Mumbai in 2004 and over the years scaled up to seven other
accessing critical information and creating a network of digital regions of MMR. Over the years, SNEHA has built the capacity of
practitioners to scale up and collaborate (19). the health facility to run this referral system independently. The
In 2016, SNEHA implemented “the community volunteer process of complete handover is on-going. Appropriate maternal
strategy” in vulnerable communities of Mumbai within referral widens the range of services provided to a pregnant
which they recruited and trained unpaid volunteers to help woman and adds to the depth of UHC. The aim here was
in implementing child health and nutrition programs. The idea to offer quality delivery services within the government health
was to initially motivate, handhold and support the volunteers care system.
with the expectation that over time they would be able to work In India, an organization like Haqdarshak seeks to leverage
independently in the communities in absence of SNEHA and technology with to ensure “last-mile” service delivery of
also support the health systems, particularly in accessing PHC. government welfare and financial services including health
An in-depth study of this strategy highlighted that volunteers insurance schemes (23). The idea is to bridge the information
were able to participate in events and training organized for gap and enable the common man to access health services and
them, mobilize community members, informally disseminate difficult-to-comprehend government schemes via agent-based
health information and help community members access health service delivery (training field cadres who provide services for a
services (20). Over the years, SNEHA has tried to foster capacities fee) or direct-to-beneficiary services (24).
within communities to actively participate in interventions that As an innovative way to address the problem of malnutrition
could improve health outcomes. There is also a high level of trust among children, SNEHA implemented the Community-based
that exists between SNEHA staff and the community. A study Management of Acute Malnutrition program between 2011 and
examining community perceptions of COVID-19 from informal 2016 which was part of a large-scale program conducted in
settlements in Mumbai found that over 90% of community partnership with national (Integrated Child Development Services)
members trusted information they received from health systems and municipal government (Municipal Corporation of Greater
and NGO staff during the pandemic (21). As part of a cluster- Mumbai) wherein wasting among children under age 3 decreased
randomized control trial, paid women health facilitators were by 28% in intervention areas and by only 5% in comparison
engaged by SNEHA to trigger health behavior change related to areas between November 2014 and December 2015 (25). To the
maternal and newborn health wherein their role was to create best of our knowledge, this was the only large-scale community-
strong community groups and encourage discussion on health based nutrition program to identify, treat, and prevent wasting
issues (22). The learning was that local recruitment helped in in urban informal settlements of India and this was possible
developing friendships, establishing relationships and negotiating as at each step efforts by the non-profit organization were
with community members which aided in contextualizing program taken to strengthen and work in collaboration with the public
strategies and eased implementation. A mechanism for ensuring systems (26).
the sustainability of health projects in vulnerable communities is
to develop a cadre of unpaid volunteers in the community to carry
out program activities and respond to community needs. Thereby
filling the gap to attain UHC.
Provision of high-quality primary health
care services (5C)
Mechanism (5M) for delivering primary 5C includes outcomes such as access to health care services,
health care long-term patient-provider relationships, effective transfer of
information within the system, ensuring proper promotive,
5M in the 5S-5M-5C schematic comprises a multidisciplinary preventive and curative services for all and offering person-
team, motivation to work, use of information systems to track centered care (12). During the second wave of the pandemic
They can ensure community mobilization and engagement. Finally, Both authors contributed to the article and approved the
they can refer community members to appropriate health facilities submitted version.
minimizing out-of-pocket expenditure on health. Attaining UHC
by 2030 seems like a distant dream but the “third sector” could
accelerate the rate at which “people have access to the health Conflict of interest
services they need, when and where they need them, without
financial hardship” in India. The authors declare that the research was conducted in the
absence of any commercial or financial relationships that could be
construed as a potential conflict of interest.
Data availability statement
The original contributions presented in the study are included
in the article/supplementary files, further inquiries can be directed Publisher’s note
to the corresponding author.
All claims expressed in this article are solely those of the
authors and do not necessarily represent those of their affiliated
Author contributions organizations, or those of the publisher, the editors and the
reviewers. Any product that may be evaluated in this article, or
AJ and AF have contributed to the conception, design of claim that may be made by its manufacturer, is not guaranteed or
the paper, and to the writing and review of the manuscript. endorsed by the publisher.
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