The dilemmas of civil society advocacy for health: challenging hegemonic capitalist neoliberalism and individualisation
Many of the dilemmas facing civil society advocacy for Health for All described by this group of long-term health activists reflect the impacts of the changing local and global political, economic and social dynamics over the last 50 years. The activists described these dilemmas as having to grapple with opposing viewpoints, such as whether to focus on single issue health policy reforms or to push for transformation of broader socioeconomic and political structures that condition and constrain health policy options. Such tensions between strategies are not unique to PHM activists, and are described in other literature on community development/mobilisation and social movement building [
31,
32]. Activities relating to health were positioned as having more urgency however, because of their direct impact on individuals.
The changes in social organisation during late modernity with increased individualisation and the dominance of capitalist neoliberal economic and political systems has contributed to unequal distributions of resources and power between and within countries [
33]. It is these inequities that motivate the activists to mobilise. Thus the strategies for building social movements and the capacity of civil society to advocate for health equity are deeply interlinked with challenges to the dominant neoliberal economic systems and the absence of effective global governance structures to regulate in the interests of the health of people and the planet.
In this section we introduce the concept of late modern individualisation and outline why a socio-political analysis of these global trends is important to understanding the challenges faced by groups mobilising collective action and building social movements for Health for All. The discussion then examines central dilemmas facing current civil society health activism raised by the activists and how they navigate these systemic challenges to work towards social change to improve health.
Individualisation theory suggests that two factors characterise our late modern era: ‘choice and reflexivity in identity and the privatisation of social and political problems to an individual level’ [
34]. Individualisation represents structural changes between the individual and society, in which the individual takes precedence over society or social communities [
35] and social reproduction is individually generated [
34]. For example, identity once tied to class, community, culture, or family tradition, has moved from a ‘given’ into a ‘task’, and a task in which individuals have more freedom to choose, but are also more responsible for enacting the set of tasks and norms associated with certain identities (e.g. gendered norms, such as boys don’t wear skirts, and women are responsible for domestic work) [
36]. This does not mean that these categories and identities are obsolete or that the influence of these structures on society has diminished, rather the relationship between them and the individual has shifted. Beck and Giddens view this freedom and the individual’s ability to act as central to late modernity. However, Bauman highlights the Western assumptions taken for granted in this position and argues while repression may have lessened, this freedom is to some extent illusionary and certainly not universally experienced [
37], referring to individualisation as the uneven ‘redistribution of freedoms’ [
36]. While individualisation may have created more freedoms of choice and identity for certain groups, in the current hegemonic neoliberal era only the very privileged have significantly benefited. Instead, for many, individual responsibility for basic necessities has increased, and the responsibility of the collective to the individual has decreased, as national and global elites have become disembedded from national and local responsibilities. This argument has been central to PHM’s HFA efforts, and as Rohit cautioned above, systems of power and discrimination while often less overt in global policy and advocacy settings can be just as, if not more, impactful on communities and individuals, while accountability is more difficult to trace back to global actors.
In rather stark (or dialectical) contrast, civil society groups such as the PHM are specifically concerned with building a social solidarity that has been weakened through neoliberal policies and discourses which encourage people to seek individual solutions to their problems [
19,
35]. The study findings illustrate how within the many local and global civil society communities in which the activists worked, they and their social movement comrades have been growing and nurturing alternative approaches to structuring society and improving health and wellbeing.
Individualisation of civil society: challenging the de-politicisation of civil society spaces
Our findings highlight growing concerns over the de-politicisation of individuals and groups in civil society. The activists positioned a progressive ideological foundation as being essential to the advocacy for health improvements and health equity, and felt this was lacking in many NGOs working in the field of health. NGOs have come to dominate the civil society space, receiving the majority of funding from government and international bodies, in particular to play technical roles or provide services [
38]. Edwards [
4], echoing the sentiments of the activists in this study, argues that post-1990 civil society has been co-opted by governments and aid agencies with ‘the replacement of civil society by a set of narrower concepts that are easier to operationalise such as the “third-sector”, the “non-profit sector”, and the “social economy”’ [
4]. Debates about the economic role of civil society dominate over their cultural and political significance, especially as states continue to retreat from their social obligations to provide essential services [
4]. Kapilashrami and McPake [
39] critique this funding environment which privileges business-like and large international NGOs, arguing it is impacting civil society more broadly through a loss of capacity, advocacy and movement building skills and thus the ability to respond effectively to health and equity issues at the local and global. In contrast informal and formal capacity building of individuals and groups was described as central to the work of the PHM and other activists’ groups in the activist narratives.
The activists in this study felt many employees of NGOs lack a political or ideological foundation, including of HFA, and are more often motivated by career advancement. Along with the reasons stated above, they highlighted how this is detrimental to the functioning of civil society, which without an ideological focus on challenging political and economic structures that lead to inequities is not only at risk of excluding citizens voice but reproducing and increasing inequities. These trends reflect a neoliberal individualisation of the civil society sector, in which workers are disembedded from the collective, organisations are encouraged to be competitive rather than collaborative, programmes and projects are siloed, and activities are tied primarily to an economic value.
This narrowing civil society environment affected the interviewees’ view of their own work. In the narratives there is a strong dialectical tension between campaigns which deal with specific issues (often cited was the campaign for affordable drugs which had introduced many of the interviewees to health activism) and working on the structural underpinnings of the single issues (e.g. neoliberalism, colonialism). The PHM’s niche is that it pays particular attention to campaigning on structural issues. Focusing on single issues risks ignoring inequitable underpinnings of national and global economies. Labonté [
40] questions whether it is possible to link issue-specific campaigning and organising to system-oriented change:
Health activists are left with a paradox. The simple message of a particular issue is good grist for campaigning. But without being anchored in a deeper yet simplified statement on societal structures of power, it lacks the ability to build a broad-based civil society movement for the type of society that might transform the escalations in wealth inequalities.
Under the theme on ‘Civil society organisations – building social movements or businesses?’, the activists described how this trend has impeded capacity building of civil society to grow social movements, including HFA. In response, some of the activities of PHM, and especially the International People’s Health University short courses, are designed to politicise NGO and other health and social service workers to encourage them to go beyond the provision of curative services to extend to prevention and advocacy for structural changes to economic and political systems.
We found this ongoing tension for health activists has been made more difficult by funding bodies and governments predominantly channelling funds to NGOs working on service provision or single-issue projects rather than broader projects critiquing the political and economic status quo and arguing for a fairer system that focuses on health.
Working at the global while representing the local
Linked to the concerns raised above is the centralisation of power in well-funded international NGOs engaging with global elites [
41]. This centralisation of power and decision making runs the risk of NGOs, specifically, and civil society social movements more generally, being disconnected from the populations they are often said to be representing and co-opted by vested interests. This is in direct conflict with the objectives of HFA which includes a commitment to citizen participation in decision making about individuals and their communities health to improve population health [
19,
21].
Kapilashrami and O’Brien [
41] highlight one consequence of this shift in power to international NGOs. They investigated the large AIDS NGO ‘industry’ and raised concerns that a ‘de-politicisation of critical voices’ has occurred and the increasing technical discourses of large NGOs have diverted attention away from advocacy work ‘in order to fit in with formalised models and frameworks of mainstream development’.
The interviewees were acutely aware of the need for a progressive social movement voice in global fora, but also of the tense balancing act involved, and the dangers of investing too heavily in either the global or local. Policy dialogue was seen to complement other forms of activism, such as working in community health clinics. There was, however, a caution raised of activists seeing community work as more ‘authentic’ than engaging in policy dialogue, especially at global scales. As Indra pointed out policy decisions are often made at the ‘global centres of power’ where the neoliberal economic agenda favours individual global elites over the majority of the world’s population. Bodini et al. [
21] argue ‘a critical priority for the HFA movement is therefore to develop the capacity to act as a global social movement’ including to provide a voice in global policy settings. A central goal of PHM efforts is to influence policy at the World Health Organisation (WHO), partly through its WHO Watch program that involves bringing new and younger activists to Geneva for policy analysis and lobbying purposes. Much of this work also formed the texts of the
Global Health Watches [
11‐
15].
The challenge in this global/local balancing act, as our larger study noted, lies in ‘addressing the local and immediate issues in ways which also contribute to redressing the larger scale and longer term dimensions’ [
21]. As argued by the activists and a previous study of community health activism [
42], the local and global are intrinsically connected in the current globalised era and thus, despite the challenges of globalisation, the struggle for health equity must work at all levels of society.
Navigating neoliberal individualisation and possibilities for social movement building
Since the 2000s reactions to hegemonic capitalist neoliberalism have brought a resurgence of interest in social issues campaigning and a continuing interest in the Health for All movement [
43]. As our larger research study found, there have been few progressive policies that have been implemented without the advocacy and mobilising efforts of civil society activists and organisations [
21]. In recent years civil society organisations have also come to play a more prominent role in global health governance [
41,
44,
45]. The narratives demonstrate some of the ways in which long-term health activists have negotiated and navigated late modernity and neoliberal individualisation processes to continue working with and against dominant systems to improve health.
Through their global-local civil society networks the activists highlighted the possibilities that late modernity and globalisation offer to civil society organisations and advocacy for health, whilst remaining vigilant in resisting the forces discussed above. Knowledge generation and access, for example, were regarded by activists as powerful tools by which to connect and empower groups living in disadvantaged circumstances, potentially leading to social change that creates a ‘globalisation of norms’ [
46], and evidenced by changes in international rules, such as United Nations conventions and declarations [
47]. Wills and Pearce argue time-space distanciation defines globalisation and through various communication technologies social relationships are able to ‘stretch across the world, for people in distant places to link with each other in the here and now and for what happens in one space/place to impact on people in other places’ [
48]. Despite uncertainties in our activists’ narratives about the internet and social media, these modes of communication have assisted civil society groups and social movements to connect and share knowledge (e.g. linking marginalised LGBTIQ individuals to support groups and social movements [
49]). Social media has in recent times been crucial to making activism visual to audiences across the world (e.g. Black Lives Matter protests in the US) and catalysing real life social activism [
50]. Funnell’s [
50] argument is shared by many of the participants in this study, but with the
caveat that, while the internet and technology can enhance the effectiveness of activism, physical commitment and participation is needed to underpin its success.
Health for All has always consisted of an outward global looking approach to addressing health equity. However, since its origins the social landscape has changed dramatically, including increased globalisation and social connectedness which has resulted in health activists sharing common experiences in different settings across the world [
21]. As individuals can call on the knowledge of ‘expert systems’ [
51] to assist in understanding their localised and personal situations, there are more opportunities to build an inclusive global strategy and social movement for HFA.
Reflexivity was a key theme in the narratives for building the capacity of individuals and organisations in civil society. Beck, Giddens and Lash’s [
52] concept of ‘reflexive modernisation’ highlights how individuals have become reflexive agents, in which an individual is granted more agency, but also increased responsibility for their identity, actions and relations with other [
34]. Late modernity has been driven by a revaluation of modernisation, where the social cohesion of categories such as class and the family unit once dominated over individualism. As reflexive agents, individuals in late modernity are no longer embedded in industrial society’s predetermined social categories and identities, and it is during this process of removal that individuals become reflexive in their relationship to other individuals, social structures, and institutions [
53]. Giddens calls individualisation ‘the reflexive project of the self’ [
54] and Rasborg [
35] highlights how individualisation refers to the fact that individuals increasingly take themselves as a point of reference in late modernity and (neoliberal) capitalist structures. This points to individualisation being experienced as socio-culturally specific, and therefore experienced differently by different groups [
34].
This form of reflexivity is also evident in the narratives. It is discussed as a key tool for making sense of one’s own position in the social world, sharing those reflections with others, and encouraging others to also be reflexive, all with the intent of initiating social change. This process can act as a catalyst for personal and wider transformation:
… we are all engaged in producing the world. Reflexivity enables us to place ourselves actively within this process ... By actively and critically reflecting on the world and our place within it, we are more able to act in creative, constructive ways that challenge oppressive power relations rather than reinforce them [
55].
Maxey suggests reflexivity in activism is ‘something that can usefully be employed to help counter social exclusion at all levels’ [
55]. As the larger PHM study concluded:
A significant element of cultural development for activist organisations is the modelling of transgression. The norms of the establishment have a powerful hold on all of us, activists old and new. The act of transgression is part of shaping a collective identity which stands apart from those established norms, in aspiration if not always in practice [
21].
Reflexivity, then, is a tool for both transgression and social change in the current era of global capitalist neoliberalism. Individualisation creates spaces for reflexive practice, and is not necessarily opposed to community and collective identities but rather, and more dialectically, as Rasborg [
35] suggests expresses a new (reflexive) way of relating to communities. Individualisation has allowed disruption of traditional and sometimes oppressive social customs and norms to be replaced with newer forms [
53]. The examples of capacity building and formal learning in the narratives demonstrate how this is possible through building the knowledge of individuals that they can take back into their own worlds and workplaces, while also bringing them into contact with broader civil society circles and social movements. However, as noted above, while positive and transformational for some, in the current hegemonic capitalist neoliberal era, individualisation is so often deployed by elites and governments through a narrow agenda of ‘individual responsibility’, reinforcing inequities. Therefore, we do not argue that individualisation and reflexivity replace progressive social movements (such as trade unions) as a force for social change, rather that there may be benefits in exploring the new possibilities they offer to civil society activism and the goal of Health for All.