Civil society is a potential mechanism to refocus healthcare systems according to health rights and social welfare goals through mobilization of citizen demand for accountability and relevant service provision (1). The right to health is generally perceived as the state's obligation to deliver affordable, accessible health services to all and is enshrined in Article 12 of the International Covenant on Economic, Social and Cultural Rights (2,3). The movement for people's participation in health is marked by the 1978 Alma-Ata declaration, which called for people's participation in local health systems and their active involvement in defining priorities for scarce resources (4). The World Bank, which promoted participation in all sectors with goals of decentralization and cost-cutting, further propelled this trend in the mid-1990s. Community participation is now widely expected to ensure that health systems are relevant, efficient, and sustainable, while public pressure is expected to improve quality, reduce inequity, and prevent corruption (2).
This analysis reviews the literature on civil society in Bangladesh. We briefly discuss the need for civil society's involvement in championing health equity and present the conflicting role of non-governmental organizations (NGOs) in promoting health equity. We recount examples of large-scale efforts to engage civil society in raising the quality of healthcare. These examples follow two main paths. First, an increased emphasis on decentralization as a means of localizing policy-making, bringing decision-making closer to disadvantaged groups, and encouraging local participation. A second mechanism is academic and professional monitoring and analysis. Although such professionals are unlikely to be members of the poor or excluded, they may speak on their behalf. Data produced may suggest ways in which health resources could be equitably distributed, correcting the elite capture often implicit in participatory decision-making. This analysis will examine examples of both of these intervention mechanisms as they have occurred in Bangladesh in relation to health. In the subsequent section, social exclusion theory provides a useful framework for revealing the complex economic, social, and political challenges to the success of civil society in holding the Government accountable.
Civil society in Bangladesh Civil society is currently being emphasized as central to the development process (5-7). Civil society is a broad concept that includes all voluntary organizations and associations that exist in the realm between, and are independent from, the state and the family (7,8). Mosque congregations, labour unions, professional associations, and NGOs are all factions of civil society, groups advocating for 'public interest' or at least to extend their own interests and values. Public interest is naturally a highly contested domain, and the essential heterogeneity of civil society means that there will often be contrary factions. For example, labour unions and the business community may hold different opinions about which policies are likely to contribute to the greater good but both are important contributors to a rich civil society. Still, the impact and meaning of an active and diverse civil society is under debate. Robert Putnam argues that weak civil society leads to a lack of civic engagement and social trust. However, active civil society can also be an indicator of state or political weaknesses (7).
Civil society's potential for positive change is theorized to occur by increasing social associations (contacts), trust, and increasing engagement with governance infrastructure to ensure that people's voices are heard and needs met. Ideally, civil society organizations (CSOs) provide transparency and accountability of government services through peoples' active scrutiny, advocacy, and monitoring to make service providers more responsive to the perceived needs of communities (9). …