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Analysis Accelerating Action on Sustainable Development Goals

Grassroots organisations and the sustainable development goals: no one left behind?

BMJ 2019; 365 doi: (Published 14 June 2019) Cite this as: BMJ 2019;365:l2269

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  1. Walter Flores, executive director1,
  2. Jeannie Samuel, assistant professor2
  1. 1Centro de Estudios para la Equidad y Gobernanza en los Sistemas de Salud-CEGSS, Guatemala
  2. 2Health and Society Program, York University, Toronto, Canada
  1. Correspondence to: W Flores wflores{at}

Walter Flores and Jeannie Samuel argue that grassroots organisations are essential to ensure improvements in the health of marginalised populations

A recent UN report indicates that local involvement with the sustainable development goals (SDGs) remains nascent at best in many countries.1 Grassroots organisations have a critical role in advancing progress towards the goals, especially at a subnational level.2 Nonetheless, these groups remain a largely untapped resource.

Ensuring that “no one is left behind” is a commitment of the 2030 SDG plan. The SDGs seek not only to achieve national outcomes but also to reduce inequalities within countries. This is no small task. Often these inequalities have become normalised in state institutions. Provision of lower quality social services to geographically, economically, and socially marginalised populations is often seen.3

However, the SDGs provide only “very tentative suggestions for review structures at the national, regional, and global level.” No mechanisms are provided for “independent civil society monitoring, data collection, and reporting.”4 Emerging research on the involvement of grassroots organisations (box 1) in social accountability interventions suggests that these organisations could bridge that gap.567 Data produced by users of services and collected by grassroots organisations may be useful for monitoring the SDGs. This information could be used to contrast with, and complement, the data collected by official sources.

Box 1

What are grassroots organisations?

Grassroots organisations are groups of people pursuing common interests, largely on a volunteer and not-for-profit basis. Often such organisations are formed by activists in social movements. Many are closely linked to communities and local concerns. The term often refers to voluntary associations through which “disadvantaged people organise themselves to improve the social, cultural, and economic wellbeing of their families, communities, and societies.”8 People have different conceptions of what constitutes the grassroots, but we apply the term to associations that draw their members from the communities that they aim to serve.


Since the early 2000s, many grassroots organisations around the globe have formed to deal with the problem of unresponsive governments. They seek to promote change by building citizen power and civic engagement. These interventions are particularly important for disadvantaged populations. They seek to tackle the needs of their neglected communities, such as indigenous people, sexual or ethnic minorities, or the urban poor. Organised civic action can also be important for broader segments of the population. For example, in Guatemala, active youth and middle class anti-corruption movements have emerged in recent years.9

Grassroots involvement in social accountability initiatives

The term “social accountability,” which became popular in the early 2000s, is used to describe initiatives designed to use new forms of civic engagement to promote reform.10 Pressure by citizens can help to stimulate government responsiveness. Social accountability is seen as a form of democracy building. It develops the ability of citizens to demand democratic change at the same time as enabling government institutions to respond to those demands.11 Social accountability is evolving and includes different types of intervention—for example, citizen monitoring of public services, social audits, and participatory budgeting.510

In general, social accountability initiatives are the product of alliances between grassroots organisations and intermediaries, such as non-governmental organisations, think tanks, professional associations, or other organisations. The grassroots organisation provides a connection to the population. The intermediaries provide structure and resources, such as training, organisational models, research, or assistance with advocacy, to help establish and maintain an initiative.

Grassroots organisations have unique strengths. Many have long been involved in struggles over structural inequality and the promotion of human rights. They can bring a distinct awareness of inequities that are, from other perspectives, either normalised or invisible. By providing details of their experience of inadequate services and by calling for accountability, they can challenge the marginalisation that their communities experience.

In addition, grassroots members are well positioned to communicate directly with local and regional governments. The 2016 report of the high level political forum on sustainable development noted that regional governments “have a front role to play in securing the safety, wellbeing, and livelihoods of communities, including by providing basic services.”12

Citizen monitoring and developing leverage for accountability

One model of social accountability relies on “citizen monitors” to deal with problems with the quality of healthcare and social services, particularly for disadvantaged populations. In this model, grassroots organisations mobilise volunteers, who gather information on service delivery through observation, community interviews, or collecting “report cards” through which users identify strengths and deficiencies.13 This collected information is then used to campaign for improvement. In some cases, volunteers take shifts to monitor specific healthcare delivery sites. In this way they record systemic problems and help deal with individual cases.

In Guatemala a network of indigenous grassroots organisations is present in 35 rural municipalities. They collect information from service users about persistent and systemic problems with government provided health services relied upon by the rural indigenous population.14 Problems include the unavailability of vaccines, medicines, and medical supplies at healthcare facilities; discrimination by healthcare providers; lack of informed consent; absenteeism of personnel; and demands for illegal payments for services. This information is sent to health authorities and also fed to a virtual, open access platform. The platform tracks the level of response from authorities about complaints.14 A second grassroots network, which mobilises indigenous women volunteers in Guatemala, focuses specifically on the quality of healthcare provided to indigenous women. It uses similar strategies to collect information from local monitoring to examine the deficiencies in reproductive healthcare and other services.15

Monitoring initiatives typically attempt to advocate change by presenting their information at meetings with health officials, although this depends on persuading governments to participate.1415 Even so, making meetings effective remains a constant struggle. These initiatives depend on members of marginalised groups being able to hold officials to account. However, the nature of existing power relations makes this an uphill battle. Social accountability initiatives must find ways to build leverage.

Transparency as a lever of change

Citizen monitoring has developed different ways of responding to this problem. Grassroots groups in Maharashtra in India involve citizens in monitoring and planning in the health sector.13 To deliver this information, activists have developed a form of public hearing called Jan Sunwai as a kind of mass accountability event.

These hearings are planned well in advance. Evidence is marshalled and local organisations mobilise community members and local elected representatives to attend. The media are invited and prominent experts are convened to act as a panel of judges and mediate the discussions.

During the event, people are invited to present their experiences of health services. The relevant health authorities are required to attend and respond. The hearings enable people to witness any commitments made and to put pressure on health officials to deal with problems.13 Here, public transparency is used as a key source of leverage.

Using the law to effect change

Some social accountability initiatives use “legal empowerment” strategies.1014 This is the case in Puno in Peru. There groups of indigenous women have formed partnerships with non-governmental organisations, national health advocates, and human rights lawyers from the regional office of the national human rights ombudsman. They take part in an innovative monitoring programme called vigilancia ciudadana (citizen vigilance/surveillance). The programme was designed to deal with longstanding problems for indigenous communities of cultural insensitivity, poor quality care, and discrimination in healthcare delivery.

Volunteer monitors were convened in two districts of Puno by a national non-governmental organisation. They received training from partner organisations on human rights and the rules governing healthcare service delivery in local facilities. This included laws and policies guaranteeing freedom from discrimination, culturally sensitive care, and the right to carry out citizen monitoring. During their visits to health facilities the monitors were trained to observe and later report their findings. However, monitors have in many cases been able to move from observers to become informal on-site advocates. They use various sources of leverage (especially calls to lawyers at the regional human rights ombudsman’s office) to alter their subordinate social status in health facilities and intervene in problems as they occur. This enables the monitors to discuss the everyday injustices and petty abuses that may alienate many indigenous users.16 In this way, monitors help to extend the reach of the human rights ombudsman into matters that escape the influence of the courts. Also, monitors can refer particularly grave cases to human rights lawyers to seek a legal remedy when all else fails.16 As a result, discriminatory and abusive behaviour, illegal charges, and culturally insensitive care diminish when monitors are present.16

Citizen monitoring, where it exists, is made possible by legal reforms that authorise this form of public participation. In countries without these legal frameworks, monitoring may not be possible. The SDGs could have a role in promoting supportive frameworks for social accountability if this were to be made a greater priority.

Building leverage through strategic alliances

Grassroots organisations must deal with varied powerful authorities. Some work within authoritarian states, others must navigate the politics of racialised, gendered, and ethnic discrimination. As suggested by the Puno case, to deal with the challenges of highly asymmetrical power relations, grassroots organisations need the support of influential intermediary organisations. Through these alliances they can develop a variety of responses to different challenges.

For example, in Mozambique, the non-governmental organisation Namati is involved in a similar programme. It trains and deploys grassroots health advocates to raise awareness of health policy and resolve grievances in local healthcare facilities. The advocates aim to facilitate discussion between communities and clinics. They try to adopt a constructive, rather than a confrontational, approach to healthcare providers. Namati has had promising results in its first three years, including improvements in quality of care, access to services, infrastructure, and essential medicines. However, researchers find that health advocates need many connections with a larger team if they are to deal with hard cases. They may need to take these cases up through various levels of government and have connections with allies who can help with this.17

Similarly, in Guatemala, indigenous grassroots organisations working to improve healthcare accountability have had to call on external allies when Ministry of Health officials attempted to close down meetings with health authorities. They called on sympathetic parliamentarians to organise appointments with health authorities. By maintaining communication at different governance levels, indigenous organisations have negotiated a better allocation of public resources for healthcare services in their territories.18

These citizen monitoring initiatives can help to deal with facility or district level problems, such as discrimination and abuse, understaffing, absences, and illegal user fee charges. However, they may face considerable challenges in dealing with deficiencies in health facilities that are the product of broader problems in the health system. Increasingly, grassroots monitoring initiatives use their relationships with external allies to exert pressure on higher level authorities of the system.

Risks to accountability

Risks to grassroots organisations include their capture by government, domination by their advisers and allies, and domination of powerful subgroups within the organisations (men, high status community members, etc). These risks are well documented in reports on participatory or community driven development.1920 There is also a danger of tokenism, where grassroots involvement becomes more symbolic than substantive. For example, in some parts of Guatemala, municipal and other government authorities together with community representatives participate in decisions about the allocation of public resources. However, access to information is unequal, which often benefits authorities and may hamper community representatives. As information is controlled by authorities, they also control the debates and the decision making process. Community representation is sometimes reduced to a symbolic or procedural role.21

The use of volunteers has some limitations, which should also be acknowledged. In most cases, grassroots initiatives are attempting to fill gaps and perform functions that are the responsibility of the public health system.22 This is not without costs. For instance, opportunity costs (ie, attending public meetings instead of participating in paid work), travel time, and costs of transport are deterrents to participation.2122 Grassroots organisations should not be seen as free labour to replace the need for public data. Instead, the data and evidence they collect should complement any public information.


An accountability gap exists within the SDG framework. Grassroots organisations are one way in which that can be plugged, but this will not happen spontaneously. These organisations should be supported directly and through intermediary organisations. In this way they can establish innovative, sustainable mechanisms that allow them to interact with state institutions.

There is much still to be learnt. Some global networks, such as COPASAH (Community of Practitioners on Accountability and Social Action in Health;, are at the forefront of this endeavour. The practical experiences gained show how grassroots organisations can help the most marginalised people to play a central role in implementing the SDGs and promoting social and economic rights.

Key messages

  • Experience with grassroots involvement in social accountability strategies shows how these organisations can contribute to the sustainable development goals (SDGs), especially at the subnational level

  • Grassroots organisations face particular challenges when dealing with state authorities, including power asymmetry, organisational capture by elites, and some disadvantage of volunteerism

  • Grassroots organisations could be supported by intermediary organisations to establish mechanisms for the monitoring and accountability of the SDGs


  • See for other articles in this series.

  • Contributors and sources: WF works directly on social accountability in Guatemala and other countries and writes extensively on the topic. JS has studied and written on grassroots involvement in social accountability in Peru. The article was commissioned by Duncan Jarvis (a BMJ editor). Authorship: both authors conceived the article. WF developed the outline. JS wrote the first draft. Both authors contributed to the final version of the article. WF is guarantor.

  • Competing interests: We have read and understood BMJ policy on declaration of interests and have no interests to declare that WF is a member of the steering committee of Community of Practitioners on Accountability and Social Action in Health.

  • Provenance and peer review: Commissioned; externally peer reviewed.

  • This article is one of a series commissioned by The BMJ based on an idea by the International Development Research Centre, Canada. The BMJ retained full editorial control over the selection of authors, external peer review, editing, and publication.

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