Civil society is essential public health infrastructure that Europe cannot afford to lose

Civil society is fundamental to democracy—and to public health. Civil society organisations (CSOs) (https://eur-lex.europa.eu/EN/legal-content/glossary/civil-society-organisation.html) underpin democratic values; when they are eroded, good governance and vibrant democracy follow. Against a backdrop of geopolitical instability, workforce crises, and evolving health threats, CSOs act as change agents, holding governments and institutions accountable for the transformation of health systems and defending the public interest [1]. Yet, CSOs live a daily paradox: while expected to ensure resilience, equity, and sustainability of public health governance and delivery, they depend on fragile legal, financial, and human resources [2]. Recent global commitments recognize this contradiction. The Resolution on Social Participation adopted at the 77th World Health Assembly reaffirmed the central role of participatory governance in advancing global health, as set out in [3]. The WHO CSO Commission has since demonstrated how structured CSO engagement strengthens the legitimacy, quality, and effectiveness of health policies [4]. These commitments matter, but they stand in tension with an observable global reality in which civic space is shrinking, CSOs are increasingly defunded, and right-wing political forces openly contest their legitimacy. In European health governance, CSO presence in decision-making remains inadequate, which makes transparent and sustainable public funding all the more critical to the vibrancy—and resilience—of the public health sector [2]. In the absence of structured involvement, CSOs turn to multisectoral collaboration, scientific engagement, and health diplomacy to keep public health on the political agenda. Such engagement helps counter fragmented health governance and the influence of well-resourced commercial actors, while maintaining pressure to uphold health equity. The importance of this principle has been acknowledged at the EU level, including in the Council Conclusions of the Slovenian Presidency. Yet, in 2025, civic space for health civil society in Europe is moving in the opposite direction. The removal of operating grants under the EU4Health 2025 programme eliminated one of the last remaining structural funding lines for health CSOs at EU level, triggering staff lay-offs, programmes contraction, and the weakening of long-standing networks. Simultaneously, new political measures—from hyper-scrutiny of advocacy activities to delegitimization campaigns—are reshaping the operating environment for CSOs across Member States. These developments mirror what scholars and civil society observers describe as a systematic ‘playbook’ targeting public-interest organizations: delegitimize → defund → constrain → depend on them anyway [4]. The need for robust civil society engagement to confront the public health challenges posed by war, democratic backsliding, and rising misinformation has never been greater. Across Europe, CSOs contribute uniquely to strengthening resilience: countering misinformation, supporting communities most affected by crises, promoting evidence-based interventions, and amplifying the voices of those otherwise excluded from formal policy processes. Prevention remains underfunded, inequalities widen, economic pressures intensify, and misinformation erodes trust in institutions. Losing CSO capacity in this context does not simply reduce service provision; it weakens early warning signals, undermines accountability, and narrows the space for evidence-based policymaking. The erosion of the health workforce further compounds fragility [5]. The importance of addressing health determinants in reducing the burden of NCDs is well established; yet, when professional and scientific civil society voices are absent, the harmful influence of commercial determinants becomes even more pronounced. Without CSOs’ trusted role in communication, outreach, literacy, and equity-focused interventions, these pressures deepen—precisely as Europe becomes more reliant on civil society capacity to mitigate gaps in prevention, access, and public health preparedness. In such an era of uncertainty and precariousness, civil society must take an assertive stance in European health governance. CSOs can safeguard public health in ways that institutions alone cannot: by strengthening advocacy, addressing workforce challenges, enhancing community-based resilience, and preparing for future health emergencies. Collaboration between CSOs, policymakers, and the scientific and academic communities is essential if Europe is to emerge from this turmoil with a robust and equitable health system—and, in doing so, promote freedom and democracy. Europe now faces a choice: allow civil society capacity to erode further or reinvest in it as a strategic asset for public health resilience, accountability, and democratic health. Three actions are within reach. First, Europe should restore sustainable core funding for health civil society at EU and national levels. Second, participation must be measured, not presumed: health programmes should report systematically on CSO involvement in design, implementation, and evaluation, drawing inspiration from the WHA77 processes. Third, institutionalized mechanisms for structured CSO engagement should be embedded across the EU health architecture, with clear mandates, transparent agendas, and feedback loops. Civil society is essential public health infrastructure. Defunding or constraining it weakens Europe’s capacity to anticipate crises, protect communities, and uphold democratic values. Investing in civic space is therefore not charity—it is a strategic necessity for Europe’s health, resilience, and democracy. The authors gratefully acknowledge the colleagues who contributed to the early conceptual development of this work, including Prof. Henrique Barros, Jasmina Cunmulaj, Dr Elżbieta Czapka, Elisabeth Dupont, Dr Özden Gökdemir, Dr Peter van den Hazel, Dr Tadeusz Jedrzejczyk, Tatiana Paduraru, Dr Vesna Kerstin Petrič, Dr Laura Reali, Dr Roberto Romizi, George Sultana, Brian Ward, and Alice Chapman-Hatchett. The authors further thank the speakers and discussants of the 20 October 2025 roundtable Crises, Cuts and Civil Society for their insights, including Dr Hans Henri P. Kluge, Prof. Kjeld Hansen, Valentina Strammiello, Federica Margheri, Anne Stauffer, Dr Raman Bedi, Peter Agius, Michael van den Berg, and Dr Maria Neira. Responsibility for the final content rests solely with the authors. Conflict of interest: The authors declare no competing interests. The views expressed are those of the authors alone and do not necessarily represent the views of EPHA or EUPHA. No specific funding was received for the preparation of this editorial. The European Public Health Alliance (EPHA) and the European Public Health Association (EUPHA) are holders of Framework Partnership Agreements (2025–2026) with the European Commission; neither organization received operating-grant funding in 2025.