How Civil Society Organizations Shape Health Care Systems

Across India, the public health system runs on an enormous network of primary health centres, sub-centres, and frontline workers. Yet, between policy on paper and care actually reaching a tribal hamlet in Odisha or a Mumbai slum lies a wide implementation gap. Civil Society Organisations (CSOs) – non-profits, community-based groups, faith networks, professional associations, and social movements – quietly fill this gap. They mobilise communities, train health workers, monitor service quality, and push the system to be more accountable. Understanding how CSOs shape health care is essential for anyone studying population and family health, because the strength of any health system today depends as much on its social partners as on its clinical staff.

Who counts as a civil society organisation in health 🔗

The term “civil society” is broad. It includes charities, development NGOs, community groups, faith-based organisations, professional associations, trade unions, social movements, and advocacy networks. In the health sector, these organisations take on three broad roles: policy work, service delivery, and governance or watchdog functions. Some operate clinics and mobile health units. Others train ASHAs (Accredited Social Health Activists), audit Primary Health Centres (PHCs), or campaign for the right to health.

What makes CSOs distinct from both the state and the market is their proximity to the community. They are usually trusted by the people they work with, can identify local needs faster than a district health office, and can experiment with models that a bureaucracy cannot easily pilot. The World Health Organization recognises this and treats active engagement with citizens, communities, and civil society as a guiding principle of health systems strengthening.

CSOs and primary health centres 🔗

Primary Health Centres are the backbone of rural health care in India, but they often struggle with staff shortages, medicine stock-outs, weak diagnostics, and low community trust. CSOs intervene at several points in this chain.

Filling service-delivery gaps 🔗

Many NGOs directly run clinics or partner with PHCs to deliver maternal care, child immunisation, and management of common illnesses. Mobile health units and satellite camps extend reach into hamlets and informal settlements that fall outside the PHC catchment in practice, if not on paper. The Society for Nutrition, Education and Health Action (SNEHA) in Mumbai is one such example, working inside informal settlements to improve maternal and child health by connecting families to the existing public system rather than building a parallel one.

Strengthening the workforce 🔗

Frontline workers – ASHAs, Anganwadi workers, and Auxiliary Nurse Midwives – are often overburdened and undertrained. CSOs supplement government training with refresher courses, mentoring, and supportive supervision. Skill-building workshops on counselling, danger-sign recognition, breastfeeding support, and digital reporting have a measurable effect on the quality of antenatal and newborn care delivered at sub-centre level.

Community-based monitoring 🔗

One of the most influential CSO contributions has been Community-Based Monitoring (CBM) of health services. Under the National Health Mission, CSOs are formally recognised as facilitators of CBM, serving as members of monitoring committees, resource groups for capacity building, and independent agencies that collect information on how services are actually being delivered.

In Maharashtra, CBM rounds carried out with NGO support produced striking results. A study of 220 villages found that ratings of “good” immunisation services rose from 69% in the first round to 90% in the third, and overall health services at primary health centres improved from 32% rated good in round one to 74% in round three. This shows that organised community feedback, when fed back into PHC management, can shift performance even without new infrastructure.

Challenges CSOs face at the PHC level 🔗

The work is not without friction. CSOs often run into asymmetry of information and power between health officials and community representatives, excessive bureaucracy, and weak decentralisation, which together limit the impact of village committees and Rogi Kalyan Samitis. Funding is another pressure point. A large share of CSO income comes from external grants and donations, which raises questions about sustainability and, after recent tightening of FCRA rules, about regulatory risk as well.

Strategies that tend to work include co-locating CSO staff with PHC teams, building long-term relationships with District Health Societies, using simple data tools like pictorial report cards, and investing in transparent financial audits to keep donor and government trust intact.

Role in preventive and promotive health care 🔗

If curative care is where the health system meets the patient, preventive and promotive care is where it meets the community. This is the natural habitat of CSOs.

Behaviour change and health literacy 🔗

Vaccination uptake, hand-washing, exclusive breastfeeding, antenatal check-ups, and timely TB diagnosis depend less on facilities and more on what people know, trust, and do. CSOs run door-to-door awareness drives, women’s group meetings, street plays, school sessions, and digital campaigns. They translate clinical advice into the local idiom and into the gendered realities of households.

Mahila Arogya Samitis and women’s collectives 🔗

The National Urban Health Mission relies on Mahila Arogya Samitis – small women’s groups that take collective action on neighbourhood health. SNEHA has been designated as a “Mother NGO” by the National Urban Health Mission, Maharashtra, to form Mahila Arogya Samitis in communities across the state. These groups identify pregnant women, malnourished children, and adolescents at risk, and link them to public services. The model shows how a CSO can act as a bridge between formal health structures and informal social networks.

Disease-specific prevention 🔗

CSOs have been central to India’s flagship disease control programmes. In tuberculosis control, NGOs work on case finding, supporting treatment adherence, and linking patients to social welfare schemes. They are positioned as a natural bridge to populations the formal system struggles to reach. A practical guide for community-based TB work notes that health expertise is not a requirement – just a willingness to learn the basics of TB and to link to government services. Similar partnerships have been crucial in HIV/AIDS prevention under the National AIDS Control Organisation, where community-led targeted interventions among high-risk groups would be nearly impossible for government staff to deliver alone.

Collaboration with government initiatives 🔗

The relationship between CSOs and the state has shifted from suspicion in the 1980s to formal partnership today. The 2007 National Policy for the Voluntary Sector recognised CSOs as development partners. The National Health Mission, Ayushman Bharat, and the rollout of Health and Wellness Centres all formally invite CSO engagement.

Resource mobilisation and last-mile delivery 🔗

CSOs help mobilise resources that government budgets alone cannot stretch to cover: CSR funding, philanthropic grants, technical assistance from international agencies, and volunteer time. They also bring last-mile reach. Under the National Health Mission, hundreds of NGOs hold formal partnerships with state governments to deliver components of national programmes, providing technical assistance, last-mile service delivery, innovation incubation, and independent monitoring.

Quality monitoring and accountability 🔗

Beyond delivering services, CSOs hold the system accountable. Watchdog activity – monitoring whether public and private providers comply with policy and ethics – is one of civil society’s defining contributions. In health, this takes the form of social audits, public hearings (jan sunwais), facility surveys, exit interviews with patients, and litigation when rights are violated. The People’s Health Movement in India has used such tools to push for the recognition of health as a right, not just a service.

Convergence across departments 🔗

Indian public health depends on coordination between the health department, the Integrated Child Development Services (ICDS) under Women and Child Development, water and sanitation departments, and local panchayats. These rarely speak to each other smoothly. CSOs often act as informal connectors. SNEHA’s work, for instance, has fostered convergence and cross-referrals between ASHAs appointed under the NHM and Anganwadi sevikas appointed by the WCD department, bringing both onto the same community platform to address child malnutrition together.

Case studies of successful CSO initiatives 🔗

The Jamkhed Comprehensive Rural Health Project 🔗

One of the earliest and most influential examples is the Comprehensive Rural Health Project in Jamkhed, Maharashtra, started by Rajanikant and Mabelle Arole in the 1970s. It trained village women as health workers long before ASHAs existed, and the model influenced WHO’s Alma Ata declaration on primary health care. It is still cited as proof that community-led primary care can deliver dramatic gains in maternal mortality, child survival, and disease control at a fraction of hospital costs.

SEWA’s health cooperatives in Gujarat 🔗

The Self-Employed Women’s Association runs health cooperatives that provide low-cost generic medicines, ante- and postnatal care, and health insurance to women in the informal sector. Its strength lies in combining livelihood support with health security, recognising that for poor women the two are inseparable.

The CORE Group Polio Project 🔗

India’s polio eradication is one of the great public health stories of this century, and CSOs were central to it. The CORE Group Polio Project built strong partnerships and coordination mechanisms among stakeholders, with learnings that can be adapted for other vaccine-preventable diseases, tuberculosis, and vector-borne diseases. NGOs reached migrant families, brick kiln workers, and underserved Muslim minority pockets that government teams alone could not consistently cover, and built community trust where rumours about the vaccine had taken root.

Karuna Trust in Karnataka 🔗

Karuna Trust took over the management of several Primary Health Centres in Karnataka under a public-private partnership model. The Indian country study for the People’s Health Movement noted that this experience showed success is variable and depends crucially on strong support from the local public health department. The model has both supporters, who see improved staffing and patient satisfaction, and critics, who view it as a step towards privatisation of public services. The debate itself is important – it forces clearer thinking about what role CSOs should and should not play inside the state system.

SNEHA in urban Mumbai 🔗

SNEHA’s integrated work in Mumbai’s informal settlements has scaled into a model adopted by the National Urban Health Mission. Its referral network for high-risk pregnancies, urban CMAM programme for malnourished children in Dharavi, and adolescent health platforms show how a single CSO can move from a pilot to a system-level intervention in partnership with municipal corporations.

Why this partnership matters for the future 🔗

India’s commitment to Universal Health Coverage and the Sustainable Development Goals cannot be met by the state alone. With out-of-pocket health spending still high and primary care facilities unevenly staffed, the role of civil society is more important, not less. The strongest CSOs are those that work with the public system, not parallel to it – strengthening accountability, generating evidence, and keeping the focus on the most vulnerable. The relationship will continue to evolve through tighter regulation, new funding rules, and digital tools that change how community monitoring is done.

What do you think? If you were designing a partnership between your district health office and a local NGO, which functions would you keep with the government and which would you trust the CSO to lead? And how would you ensure that CSO engagement strengthens public health services rather than quietly replacing them?

References

1. https://www.ncbi.nlm.nih.gov/books/NBK459034/
2. https://pmc.ncbi.nlm.nih.gov/articles/PMC9992436/
3. https://www.frontiersin.org/journals/public-health/articles/10.3389/fpubh.2023.1091533/full
4. https://nhm.gov.in/index1.php?lang=1&level=2&sublinkid=172&lid=246
5. https://pmc.ncbi.nlm.nih.gov/articles/PMC3287531/
6. https://www.snehamumbai.org/our-story/
7. https://coregroup.org/wp-content/uploads/media-backup/TB/Community-Based_TB.pdf
8. https://www.snehamumbai.org/
9. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6776101/
10. https://phmovement.org/wp-content/uploads/2018/06/19_IndiaReportFinal.pdf