Expanding the Role of CSOs in Primary Health Care: Opportunities and Strategies

Civil Society Organisations (CSOs) have quietly become one of the most important forces shaping primary health care. From running maternal health clinics in Mumbai’s informal settlements to training community health workers in tribal Gadchiroli, these organisations bridge the gap between formal health systems and the people who need them most. But their full potential remains underused. Expanding what CSOs can do in primary health care is not just about adding more NGOs to the field, it is about creating the right policies, funding mechanisms, and collaboration structures that let them work effectively alongside the public health system.

Why CSOs matter in primary health care 🔗

Primary health care is the first point of contact between people and the health system. It covers preventive services, maternal and child health, immunisation, basic curative care, and health promotion. While the government runs a vast network of sub-centres, Primary Health Centres (PHCs), and Health and Wellness Centres under the Ayushman Bharat programme, large gaps remain in coverage, quality, and last-mile delivery.

This is where CSOs step in. Research published in Frontiers in Public Health documents how civil society helps the health system connect with hard-to-reach populations, builds the capacity of frontline workers, and acts as a “gap-filler” and “data messenger” between communities and the state. The COVID-19 pandemic made this role visible at a national scale, with CSOs mobilising food, oxygen, awareness drives, and vaccination support when public infrastructure was stretched thin.

Creating an enabling environment for CSOs 🔗

The most fundamental requirement for expanding CSO participation in primary health care is a policy environment that treats them as genuine partners rather than peripheral contractors. The 1982 National Health Policy was the first formal acknowledgement of voluntary organisations as partners in healthcare delivery, marking a shift from viewing health as a purely state responsibility to a shared one with the community.

Policy frameworks that support partnership 🔗

An enabling environment goes beyond recognition. It requires legal clarity on registration, simplified Foreign Contribution Regulation Act (FCRA) compliance for legitimate organisations, tax incentives for donors, and structured public-private partnership (PPP) models. The National Health Mission (NHM) already provides one such framework. Each state has a State Health Mission and each district a District Health Mission, both of which are mandated to coordinate with NGOs and development partners on health planning and delivery.

Schemes like the Chiranjeevi Yojana in Gujarat, where private practitioners and NGOs deliver obstetric care to below-poverty-line families, and the Arogya Kendra model in Karnataka, where NGOs manage primary health centres in underserved areas, show what is possible when governments contract CSOs to run public health services. Scaling such models requires stable, multi-year contracts, transparent selection criteria, and outcome-based payments rather than ad hoc project grants.

Reducing bureaucratic friction 🔗

One of the biggest barriers CSOs face is administrative complexity. Long approval cycles, frequent compliance audits, and shifting documentation requirements can paralyse small grassroots organisations. An enabling environment streamlines these processes, offers a single-window clearance for health-sector grants, and protects the operational independence that allows CSOs to remain trusted by the communities they serve.

CSOs as catalysts for innovation 🔗

One of the strongest arguments for expanding the role of CSOs is their ability to innovate at the grassroots. Unlike large bureaucracies, CSOs can pilot small, low-cost interventions, learn quickly from failure, and adapt to cultural and linguistic contexts. Many of the practices that are now standard in Indian public health began as CSO experiments.

From village pilots to global guidelines 🔗

A landmark example is the work of SEARCH (Society for Education, Action and Research in Community Health) in the tribal district of Gadchiroli, Maharashtra. SEARCH researched neonatal mortality in rural communities and engaged women community health workers to deliver culturally sensitive, life-saving interventions for newborns, reducing infant mortality by 62 percent in a short period. The evidence generated by this small CSO eventually informed a World Health Organization resolution on training community health workers to manage childhood pneumonia.

Similarly, the Self-Employed Women’s Association (SEWA) developed the Shakti Kendra model, community-based empowerment centres run by trained local women leaders called “aagevans”. These centres help informal-sector women and their families access public health and social entitlements in a simple and transparent manner, an example of how a CSO can integrate health with broader social protection.

Technology-led innovation 🔗

CSOs are also driving digital health innovation. SEWA Rural, working with a software firm, developed the ImTeCHO (Innovative Mobile-phone Technology for Community Health Operations) application, a job aid that helps ASHAs and PHC staff improve coverage of maternal, newborn, and child health services. Such CSO-led technology pilots often run on small budgets but generate evidence that the public system can later adopt at scale.

Why grassroots innovation works 🔗

CSOs succeed at innovation for three reasons. First, they have deep community trust, which lets them test sensitive interventions, such as adolescent reproductive health programmes or mental health outreach, that would be difficult for outside actors. Second, they can adapt rapidly because their decision-making is local. Third, they often work in neglected areas like geriatric care, palliative care, sickle cell disease, and migrant health, where market incentives are weak and government attention is thin.

Resource allocation and transparency 🔗

For CSOs to expand their role, the way money flows to them must change. Currently, most CSO funding in the health sector comes from a mix of central and state government grants, corporate social responsibility (CSR) contributions, international donors, and individual giving. Each channel has its own rules, timelines, and reporting formats, which fragments the sector.

Transparent grant systems 🔗

Transparent resource allocation begins with publishing clear eligibility criteria, evaluation processes, and budget heads for every health-related government grant. It also means publicly disclosing which CSOs received how much money, for what work, and with what results. The Niti Aayog has begun to push in this direction through the NGO Darpan portal, but health-specific grant transparency is still patchy.

Predictable and outcome-linked funding 🔗

Grassroots CSOs often survive on short, project-based grants that make long-term planning impossible. A health worker hired for a one-year tuberculosis project loses her job when the grant ends, even if the community still needs her. Multi-year, outcome-linked contracts, where CSOs are paid for measurable health gains such as immunisation coverage or institutional deliveries, can stabilise the workforce and reward effective organisations. Models like development impact bonds in maternal and child health are already being piloted in this direction.

Accountability flowing both ways 🔗

Transparency is not only about CSOs being accountable to the government. It is also about the government being accountable to CSOs and communities on how decisions are made, why certain projects are funded, and how outcomes are measured. Joint review meetings, social audits, and community scorecards can institutionalise this two-way accountability.

Building a national CSO database 🔗

One of the most practical and underrated reforms is creating a robust, well-maintained national database of CSOs working in health. India already has the NGO Darpan portal, a centralised database developed by NITI Aayog in collaboration with the National Informatics Centre. Registered NGOs receive a Unique Identification Number that is required for accessing government grants and FCRA-related approvals.

What a strong database enables 🔗

A well-designed national CSO database does several things at once. It allows the health ministry to identify which organisations work in which districts and on which issues, making it easier to deploy them quickly during emergencies. It enables donors and CSR funders to find credible partners without relying on personal networks. It helps researchers map the civil society ecosystem and identify gaps. And it offers communities a way to verify whether an organisation working in their area is legitimate.

From listing to intelligence 🔗

The Darpan portal today is largely a registration tool. To truly support primary health care, it could evolve into a richer “CSO intelligence platform” that captures health-specific information such as service areas, types of interventions, target populations, partnerships with public health centres, and outcomes achieved. Linking this with the Ayushman Bharat Digital Mission could allow coordinated planning at the district level, where the public system, private providers, and CSOs see the same map of needs.

Protecting CSO autonomy 🔗

A national database must be designed carefully. Excessive disclosure requirements can make organisations vulnerable to political pressure or harassment, especially those working on rights-based advocacy in tribal health, gender, or mental health. The right balance is one where the database supports collaboration and accountability without becoming a tool for surveillance.

Strategies for the road ahead 🔗

Expanding the role of CSOs in primary health care will require a combined push on several fronts. Governments need to formalise CSOs as long-term partners through stable contracts and shared planning forums. Funders should move from short projects to outcome-based, multi-year commitments. CSOs themselves need to invest in measurement, governance, and professional development so they can absorb larger responsibilities. And the public must be brought in through participatory mechanisms like Village Health, Sanitation, and Nutrition Committees, which give communities a voice in how primary health care is delivered.

The goal is not to replace the public health system with civil society. It is to recognise that primary health care is too large, too diverse, and too socially complex for any single actor to deliver alone. A strong CSO ecosystem, working with a strong public system and an engaged community, is what universal health coverage in India will ultimately look like.

What do you think? Should the government allocate a fixed percentage of the National Health Mission budget specifically for CSO-led primary health care initiatives? And how can a national CSO database be designed so it strengthens collaboration without compromising the independence that makes civil society effective in the first place?

References

1. https://www.investindia.gov.in/blogs/national-health-mission-healthcare-all
2. https://pmc.ncbi.nlm.nih.gov/articles/PMC9992436/
3. https://ngo.management/health-care-management/government-ngo-partnerships-public-health-india/
4. https://www.cohred.org/civil-society-engagement/
5. https://journals.lww.com/wsep/fulltext/2020/09010/community_action_for_health_in_india__evolution,.14.aspx
6. https://nmji.in/high-uptake-of-an-innovative-mobile-phone-application-among-community-health-workers-in-rural-india-an-implementation-study/
7. https://ngodarpan.gov.in/