People Centered PHC: Empowering Communities, enhancing participation and advocating for and stewarding

intersectoral action

Dr. Ravi Narayan ,Community Health Advisor, Society for Community Health Awareness, Research and Action – Bangalore &

Global Steering Council of People’s Health Movement

International conference- 30th anniversary of the Alma- Ata Declaration on Primary Health care (WHO/UNICEF)

Almaty, Kazakhstan 15-16 October 2008

The Challenge in the new millennium: Towards a People- centred PHC

• The People back into the centre of primary health care

• The Public back into Public health systems

• The Community back into the health policy discourse.

Plan of Presentation

• People Centered Primary health care before Alma Ata-1978 (with a focus on India)

• People Centered Primary health care – since Alma Ata -1978• Globalization of health from above : the distortion of PHC and loss of

the community and the people-orientation since 1990’s• Globalization of health solidarity from below since 2000 : the revival

of PHC with a strong peoples movement, committed to equity, rights, gender, and the social determinants perspective of health

• Towards a People-centered PHC – forward beyond Almaty – 2008 : the core agenda of the future

Health Survey and Development Committee- IndiaBhore Committee (1946)

• “No permanent improvement of public health can be achieved without the active participation of the people in the local health program….• We consider that the development of local effort and the promotion of a spirit of self help in the community are as important to the success of the health programme as the specific services, which the health officials will be able to place at the disposal of the people • Formation of village health committees and Voluntary health workers are needed who will need suitable training..”

Source : CBHI 1985

People Centered Primary health care before Alma Ata-1978 - I

•CHWs - Jamkhed• VHWs - Indo-Dutch, project Hyderabad• Lay First Aiders – VHS -Adyar, Chennai• Link workers - CLWS tea plantations• Health Aides – RUHSA• MCH workers - CINI, Calcutta•Swasthya Mitras – BHU Varanasi•Sanyojaks - Banavasi Seva Ashram, UP• CHW’s- St. John’s Bangalore, • Rehbar-e-Sehat - Teacher workers of Kashmir• CHVs - Sewa Rural, Jhagadia

CHW’S IN INDIA – AN OVERVIEW 1970s & 1980s)

People Centered Primary health care before Alma Ata-1978 - II

• Predominantly women• Mostly voluntary or link workers with minimum support• Mostly mature, married volunteers • Care taken to prevent the cooption by village leaders • Care taken to encourage representation of all segments• The participation of the community in identifying CHWs and

their supervision• The training programme - innovative components and methods • Well trained and highly mobile, field and supervisory staff. • Many projects had women on local action / advisory committees• Many had local women groups supportive of the process.

Source : CHC, 1997

The CHW’s of the NGO Sector in India (1970s & 1980s) An Overview

People Centered Primary health care before Alma Ata-1978 - III

Alternative Approaches to Health care- an ICMR Study 1976

• Integrating Health with development activities

• Preventive and Promotive services

• Appropriate Technology• Utilization of local resources and

healers• Village based health cadres• Community participation• Community organization• Local finances through

cooperatives• Education for health• Conscientization and political

action

Source: Narayan, 1985

ICMR initiative and Monograph 1976

People Centered Primary health care before Alma Ata-1978 -IV

Local Self Governance / Village Health Committee

Community asResource

For Health Care including

Traditional Practitioners / TBA’s

People-centred Community health

(primary health care)

Community Organization:

•Women's organization’s

•Youth clubs•Farmers

Coperatives

Community Health Worker’s / Volunteers

People-centred Community health: an evolving understanding 1978

People Centered Primary health care before Alma Ata-1978 - V

WHO and UNICEF Study, 1977 -- ICase Studies from all over the World

• Cuba • China• Tanzania• Venezuela• Nigeria• Ivanjica, Yugoslavia• Savar, Bangladesh• Jamkhed, India• Maradi,Niger

People Centered Primary health care - Alma Ata -1978 - I

WHO and UNICEF Study, 1977 - IIPrinciples to achieve primary health care:

• Communities should be involved in the designing, staffing, and functioning of their local primary health care centres and in other forms of support.

• The primary health care workers should be selected when possible by the community itself or at least in consultation with the community

• Respect for the cultural patterns and felt needs in health and community development of the consumers…..

People Centered Primary health care - Alma Ata -1978 -II

The International Conference on Primary Health Care calls for urgent action by all governments, all health and development workers, and the world community to protect and promote the health of all the people of the world by the year 2000.

The Primary Health Care Movement towards Health for All The Primary Health Care Movement towards Health for All

by 2000AD by 2000AD Alma Ata, 1978

People Centered Primary health care - Alma Ata -1978 -III

The Alma Ata Declaration- 1978The Alma Ata Declaration- 1978

• “The People have the right and duty to participate individually and collectively in the planning and implementation of their health care…..

•Primary health care requires and promotes maximum community and individual self reliance and participation in the planning, organization, operation and control of primary health care, making fullest use of local, national and other available resources: and to this end develops through appropriate education the abilities of communities to participate”

People Centered Primary health care - Alma Ata -1978 -IV

People Centred Primary health care- evolving guidelines

People Centered Primary health care - Alma Ata -1978- V

Health for All – The Prescription of ICMR and ICSSRHealth for All – The Prescription of ICMR and ICSSR – 1981 – 1981

For a mass movement post Alma AtaFor a mass movement post Alma Ata

•Reduce Poverty inequality and spread education.

•Organise poor and underprivileged to fight for their basic rights

•Move away from the counter productive Western model of health care and replace it by an alternative based in the community …..”

• Provide community Health volunteers with special skills, readily available, who see health as …… a social function”

•“ A retreat from the goal of national health and drug policies as a part of an overall social policy;

•A lack of insight into the inter-sectoral nature of health problems and the failure to make health a priority in all sectors of society;

•The failure to promote participation and genuine involvement of communities in their own health development;

•Reduced state responsibilities at all levels as a consequence of wide spread - and usually inequitable - privatization of health policies;

•A narrow, top-down, technology - oriented view of health”

RECOGNISING THE CRISIS IN INDIA-1990’S RECOGNISING THE CRISIS IN INDIA-1990’S

The New Epidemiology

“ The primary determinants of disease are mainly economic and social and therefore its remedies must also be economic and social …

Medicine and politics cannot and should not be kept apart.”

- Prof. Geoffrey Rose, 1992The Strategy of Preventive Medicine

Researching levels of analysis and solutions:Addressing the societal determinants of health

(A SOCHARA Researcher)

Levels of analysis of tuberculosis

Casual understanding of tuberculosis

Solutions / Control strategies for tuberculosis

Surface phenomenon (medical and public health problem)

Infectious disease / germ theory

BCG, case finding and domiciliary chemotherapy

Immediate cause Under nutrition/ low resistance, poor housing, low income / poor purchasing capacity

Development and welfare – income generation / housing

Underlying cause (symptom of inequitable relations)

Poverty / deprivation, unequal access to resources

Land reforms, social movements towards a more egalitarian society

Basic cause (international problem)

Contraindications and inequalities in socio-economic and political systems at international, national and local levels

More just international relations, trade relations etc.

Source: Narayan T.,1998

An agenda for change pAn agenda for change presented to Independent Commission on Health in India by SOCHARA

•“ It is time to recognize the role of the community, the consumer, the patient and the people in the health policy debate …..

•What is needed is a strong countervailing movement initiated by health and development professionals and activists, consumer and people’s organizations that will bring health care and medical education and their right orientation high on the political agenda of the country

•MARKET or PEOPLE ? What will be our choice?” CHC - 1998

Towards a New Paradigm of Community Health and Community Participation through civil society initiative in

India – 1984-1999• Voluntary Health Association of India (1970)• Medico Friends Circle (1975)• Asian Community Health Action Network

( 1980)• Catholic Health Association of India (1983)• Community Health Cell (1984)• All India Drug Action Network ( 1989)• International People’s Health Council (1990’s)• Christian Medical Association of India

(1990’s)• National Alliance of People’s Movement

( 1996) • All India People’s Science Network - Health

Campaign (1998)• The Women’s movement and ………

“Community health is a process of enabling people, to exercise collectively their responsibility to their own health and to demand health as their rightCommunity health approach involves the increasing of the individual, family and community autonomy over health and over the organizations, the means, the opportunities, the knowledge and the supportive structures that make health possible…..” source: the CHC axioms – red book, 1986

The New Community Health Paradigm

Less Food, No water, No jobs!!!

Listening to the people!

The People’s Health Resource Books in India -2000AD

“These books are the best expresssions of primary health care concepts and its politics that I have ever read. They are the bible of primary health care, a glorious milestone on the tortuous road to primary health care….”

Halfdan Mahler ,DG Emeritus, WHO and Architect of the

Alma Ata Declaration.

1. Globalization and Health 2. Primary Health Care?3. Inter-sectoral Action4. Empowerment of the socially Marginalised 5. Confronting Commercialization of health care

1

2

5

3

4

Jan Swasthya Sabha, (People’s Health Assembly India), Kolkata 2000

• Over 2000 participants in 5 peoples health trains

• Mobilization across 19 states• Adopted 20 point Indian People’s Charter• Launched the Jan Swasthya Abhiyan, campaign for Health for All Now• Accepted health as a

Fundamental Human Right JSA, 2000

INDIAN’S PEOPLE HEALTH CHARTER- DEC 2000

“ ….A Health Care system which is gender sensitive and responsive to the people’s needs and whose control is vested in people’s hands and not based on market defined concepts of health care…..”

“….. Village level health care based on village health care workers selected by the community and supported by the gram sabha / panchayat and the government health services which are given regulatory powers and adequate resource support”.

Towards a New Paradigm of Community Health and Community Participation through civil society Networks

and Initiatives globally Pre – 2000AD.

• Asian Community Health Action Network ( ACHAN)

• Consumer International (CI)• Dag Hammarskjold Foundation

(DHF) • Gonoshasthaya Kendra (GK) • Health Action International (HAI)• International People’s Health

Council ( IPHC)• Third World Network( TWN)• Women’s Global Network for

Reproductive Rights (WGNRR)

… towards a people’s health assembly in 2000AD

RECOGNISING HEALTH CRISIS- 1990’S by Global Civil Society -I

• ECONOMIC CHANGES AFFECTING PEOPLES HEALTH AND ACCESS TO HEALTH / SOCIAL SERVICES

• POVERTY AND HUNGER INCREASING

• GAPS BETWEEN RICH AND POOR NATIONS WIDENED; INEQUALITIES WITHIN COUNTRIES INCREASING

• LARGE PROPORTION LACK ACCESS TO BASIC NEEDS (FOOD, WATER, SANITATION, LAND, SHELTER, EDUCATION)

• PLANETARY RESOURCES BEING RAPIDLY DEPLETED

RECOGNISING HEALTH CRISIS- 1990’S by Global Civil Society -II

• UPSURGE OF CONFLICTS / VIOLENCE

• WORLDS RESOURCES INCREASINGLY CONCENTRATED IN HANDS OF FEW WHO STRIVE TO MAXIMISE THEIR PROFIT

• NEW ECONOMIC / POLITICAL POLICIES AFFECTING LIVES, LIVELIHOODS, HEALTH AND WELL BEING OF PEOPLES IN SOUTH AND NORTH

• PUBLIC SERVICES DETERIORATING, UNEVENLY DISTRIBUTED AND INAPPROPRIATE

• PRIVATIZATION UNDERMINING ACCESS AND EQUITY PRINCIPLES

Source-PHA 2000

The First Global People’s Health AssemblyDecember, 2000

• In 2000 Dec, 1454 health activists from 75 countries met in Savar, Bangladesh to discuss the challenge of attaining Health for All, Now!

• Over 250 Indian delegates attended.

“Promote, support and engage in actions that encourage people’s power and control in decision making in health at all levels including patients and consumer rights…… …..Build and strengthen people’s organizations to create a basis for analysis and action….”

The People’s Charter for Health (1454 people from 75 countries) Dec 2000

“Promote, support, and engage in actions that encourage people’s involvement in decision making in public services at all levels…..

……Demand that people’s organizations be represented in local/ national and international fora that are relevant to health”

The People’s Charter for Health(1454 people from 75 countries)

Dec 2000

The Mumbai Declaration-2004(1454 people from 75 countries)

•Implement comprehensive and sustainable primary health care involving marginal sectors in decision making regarding policies that affect them…..•Develop comprehensive primary health care oriented interventions for HIV/AIDS epidemic enhancing involvement of people affected communities and civil society in its planning through proactive dialogue…..•Make concerted efforts to incorporate the needs of marginalized population, the unheard and unseen in health and development strategies and social policies in a rights context……

People’s Charter on HIV/AIDS 2004released at Bangkok 2004

“HIV and AIDS is a development issue that calls for social and political action. It is also a public health issue that requires people-oriented health and medical interventions. Such responses require democracy, pro-people inter-sectoral policies, good governance, people’s participation and effective communication. They should be rooted in internationally accepted human rights and humanitarian norms.”

The Cuenca Declaration Ecuador-2005

• “PHM will struggle for comprehensive primary health care and sustainable, quality local, and national health systems.

• PHM will continue to raise awareness among communities on policies, policy making process and financial issues to enable them to monitor government performance increase accountability and address health equity issues.

• PHM commits to gathering within its movement positive experiences of comprehensive PHC to build up the evidence base ….. and to undertake concerted advocacy for its revitalization”

Corporate led globalization, Neo-liberal economic reforms,

Negative macro-policies

Corporate led globalization, Neo-liberal economic reforms,

Negative macro-policies

Adversely affect the social majority,

nationally & globally

Livelihoods,Incomes,

Food security,Increased conflict,War and violence,Access to water,

Access to health care,Environmental degradation,

The New Challenge to Primary Health Care and People Centered PHC in 2000 AD

Right to Health Movement : India 2003Right to Health Movement : India 2003

Primary health care and Health for AllPrimary health care and Health for All

A Peoples Court or Civil Court

A panel of judges and experts is setup by the National Human Rights Commission

The senior-most State health officials act as respondents

People’s health tribunals in India – I (2004)Dialogue with policy makers on behalf of the movement

•People and activists present case studies and survey reports

•Proceedings are videotaped and documented

•Attended by members of the community / civil society

People’s health tribunals in India - IIDialogue with policy makers on behalf of the movement

Second National Health Assembly Bhopal- India 2006

Themes discussed included• Listening to voices of marginalized people

• People’s Health Rural Watch• Community based monitoring of NRHM

• Towards the people’s health plan • Campaign against coercive population policies

• Realizing right to essential drugs• Dialogue with health policy makers

• Dialogue with other social movements

People’s Rural Health Watch, 2008Recommendations

• ASHA’s to be chosen through a consultative village process

• Constitution and training of village health and sanitation committees before preparation of village and district health plans

• Community based monitoring to be integral part of public health system and not a stand alone component

• The communitzation option, with public people partnerships to replace the privatization options….

People’s TribunalsOn Right to Health

Regional Urban

National

PeoplesRuralHealthWatch

PEOPLE’S HEALTH MOVEMENT, - INDIA :

JAN SWASTHYA ABHIYAN

Right to health campaignRight EquityGenderRight to Information

Links with Right to food and

right to water campaigns

Redefining People centered PHC by Civil Society in India 2000-2008

Pre-election dialogue with Political parties:

Health in the Manifestos

Community Monitoringof National RuralHealth Mission

People’s TribunalOn World BankPolicies - India

Rediscovering People-Centred PHC thru Civil Society engagement , India

NGO- CHW Experience

1980’s – HealthWorkers

The JanataExperiences

The JSR’sof MadhyaPradesh

The Mitaninsof

Chattisgarh

National Rural Health MissionASHA’s ; VHSC’s; Community Monitoring

NGO- CHW Experience –

1990’s – Health Activists

Lessons in Community Participation through

Community Health Worker

Programmes in India The Sahiyas

JharkhandPHM India

National Rural Health Mission 2005-2012 - Evolving through the politics of engagement

Goal: • To improve the availability of and access to

quality health care by people, especially for those residing in rural areas, the poor, women and children

Principles: • It seeks to improve access to equitable,

affordable, accountable, and effective primary health care.

• It has as its they component provision of a female health activist in each village; a village health plan prepared through a local team headed by the village health and sanitation committee of the panchayath.

• Train and enhance capacity of panchayathraj institution to own, control and manage public health service.

The new Health Worker as Health Activist ASHA Training Programme of NRHM- India

2004

“A new band of community based functionaries named as

Accredited Social Health Activists (ASHA) who would

be a health activist and mobilize the community

towards local health planning and increase utilization and accountability of existing

health services”.

Accredited Social Health Activist Training Manuals ASHA – Workers of Hope!

Redefined People centered PHC Training in NRHM/ PHRN -I

Panchayat Raj Institution and Health programmes Institutionalisation of community participation, village health committees and CBO’s Village health planning Involving NGO’s in community participation Peoples movements and campaigns for health Community monitoring.

Redefined Community Participation Training in NRHM/ PHRN -II

Understanding community participation

Community Health workers Selection of ASHA’s Training CHW’s in a large

scale programme Supporting the ASHA Community mobilisation,

social mobilisation Village level partners in

community participation

Redefining People centred PHC– Experiences from the Global South

Central AmericanNetworks

Guatemala/ Nicaragua and Ecuador

The ThaiNational Health

Movement, Thailand

HIV/AIDS PatientsNetworks ( TAC) and other initiativesSouth Africa

Health Campaigns,Struggles, and

Community mobilizationefforts from many parts

of the World

Global PHM as learning Network

India Brazil

Philippines

Nepal IRAN

Others

PEOPLE CENTRED PHC – RECOGNISING THE PARADIGM SHIFT – 2000AD and beyond

Approach Biomedical, deterministic, techno managerial model

Participatory social/ community model

Link with community

As passive client or beneficatory

As active and empowered participant

DimensionsExplored

Physical and technical (Mostly Medical)

Psycho- social, cultural, economic, political, ecological (intersectoral)

Focus of Participation

Resources, Time/ Skills Leadership, Ownership, direction setting, Monitors.

CHW Role Service provider, educator, organiser, data collector

Mobilisor, activist, empowerer, social auditor, monitor.

Research

Policy

Community participation as means Patient Centredness and market /system orientation

Community participation as endsPeople centred Empowerment strategy as the central theme

Source: CHC 2008

The New Public Health Paradigm (The First Text Book from the Movement)

Chapter on Participation and Health Promotion

Participation

Psuedo – participation is a means

Participation as a means

Participation as a end

Participation as a power

Continuum

Consultation

Participation as a means

Substantive participation

Structural participation

Recognition for a new form of community participation as globalization of health solidarity

from below

“This movement is engaged in what amounts to ‘globalization from below’ as it builds support for its global ‘Health For All Now’ strategy, lobbies at the global level and mobilizes a grassroots based campaign to realize the vision and achieve the goals of the People’s Charter for Health.”

Richard Harris and Melinda Seid, 2004, The Globalization of Health

Recognizes the PHM role in evolving the new health and human rights approach to Primary Health Care – with the necessity of tackling the broader social and political determinants of health

Recognition for a new approach to Primary Health Care with a human rights approach: New challenges

for community participation

PAHO paper on Primary Health Care

A WHO - SEARO Exhortation for mainstream Public Health to engage with Alternative Sector.

“A wave of community health NGO movements has taken place to try

alternative experiments and actions, and to build capacity from communities and grass

root workers….. These include PHM, SOCHARA, CEHAT and others….. Unless the

national apex institutions or schools of public health recognize these alternative sectors as strong resources and involve them in training and research , a large

portion of creative energy in public health will remain untapped".

Source: South East Asia Public Health Initiative 2004-2008, WHO-SEARO

• “The spectrum of appropriate community involvement includes community mobilisation to assert rights, challenge policy and present alternatives; monitoring of services of communities; involvement of in planning and decision making; an involvement in the implementation of PHC programmes and services

• Appropriate community involvement should also be enhanced by health care systems through effectively empowered community structures and forms, as well as by inculcating a culture of consultation and respect for lay people……”

GHW-I: First Alternative World Health Report: Released at Cuenca, Ecuador – July 2005

GHW-2: the second Alternative World Health Report to be released in London – October 2008

Inspiration, courage and resistance – a new understanding of people -centred PHC

1. Political and Social Action against theft of land and water

2. Right to health care campaigns 3. Movements for food sovereignty 4. Community Partnerships to improve water

and sanitation 5. Campaigns for Access to Essential

medicines 6. Campaigns for health and health care of

vulnerable groups

Primary Health Care as a Health for All Movement !

ALMA ATA – 30 YEARS ONALMA ATA – 30 YEARS ON

People - centred PHC -The policy imperative of the People - centred PHC -The policy imperative of the future!future!

Poverty / Inequality

Building the bridge through People-centredness: Are we ready?

Health for All, Now !

THANK YOU

For further information visitwww.sochara.org

www.phm-india.orgwww.phmovement.org

www.ghwatch.orghttp://www.phmovement.org/iphu/http://mohfw.nic.in/NRHM.htm