1. The Role of Community Participation in Primary Health Care : A perspective from the People’s Health Movements in the South Dr. Ravi Narayan ,Community Health Advisor, SOCHARA - Bangalore People’s Health Movement Global Steering Council The Future of Primary Health Care : Alma Ata 30 Years On LSHTM/ THE LANCET/ DFID – ALMA SYMPOSIUM 11 September 2008, London
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11. Medical Education and Support Manpower Shrivastava Report (1974) “ What we need therefore, is the creation of large bands of part-time, semi-professional workers from the community itself who would be close to the people, live with them and in addition to promotive and preventive services (including those related to family planning) will also provide basic medical services needed in day to day common illnesses (which account for about eighty percent of all illnesses)”. “ These are essentially self employed people and therefore do not form part of the Government bureaucracy. They could be primary school teachers, housewives, practitioners of different systems of medicine and dais…” Source : CBHI, 1985
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13. Community participation : Policy rhetoric to System Development in India (before Alma Ata - 1978) Local Self Governance / Village Health Committee Community as Resource For Health Care COMMUNITY PARTICIPATION Community Organization Community Health Worker
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16. 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 by 2000AD Alma Ata, 1978
23. RECOGNISING THE CRISIS IN INDIA-1990’S Source: Community Health Cell, Bangalore (www.sochara.org) Accessibility ? Affordability?
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25. Researching levels of analysis and solutions: Addressing the societal determinants of health (A SOCHARA Researcher) Source: Narayan T.,1998 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.
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29. Less Food, No water, No jobs!!! Listening to the people!
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31. 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 .
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33. 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”.
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38. The People’s Charter for Health Dec 2000 “ 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….”
39. The People’s Charter for Health 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”
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41. People’s Charter on HIV/AIDS 2004 released 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.”
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43. 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 Community Participation in 2000 AD
44. Right to Health Movement : India 2003 Primary health care and Health for All
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50. Rediscovering Community Participation and Civil Society engagement , India NGO- CHW Experience 1980’s – Health Workers The Janata Experiences The JSR’s of Madhya Pradesh The Mitanins of Chattisgarh National Rural Health Mission ASHA’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 Jharkhand PHM India
51. Revival of Interest in State level Community Health Worker and Community participation (Programmes Evaluated by Civil Society Researchers) Jana Swasthya Rakshaks (JSR) Madhya Pradesh 1991 Mitanin Programme, Chattisgarh -2001
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53. 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”.
57. Redefining Community Participation – Experiences from the Global South Central American Networks Guatemala/ Nicaragua and Ecuador The Thai National Health Movement, Thailand HIV/AIDS Patients Networks ( TAC) and other initiatives South Africa Health Campaigns, Struggles, and Community mobilization efforts from many parts of the World Global PHM as learning Network India Brazil Philippines Nepal Middle East MENA Network Others
58. COMMUNITY PARTICIPATION – RECOGNISING THE PARADIGM SHIFT – 2000AD and beyond Source: CHC 2008 Approach Biomedical, deterministic, techno managerial model Participatory social/ community model Link with community As passive client or beneficatory As active and empowered participant Dimensions Explored Physical and technical Psycho- social, cultural, economic, political, ecological Focus of Participation Resources, Time/ Skills Leadership, Ownership, direction setting, Monitors. CHW Role Service provider, educator, organiser, data collector ( lackey ?) Mobilisor, activist, empowerer, social auditor, monitor. (Liberator) Research Community participation as means Community participation as ends
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60. 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
61. 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
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64. ALMA ATA – 30 YEARS ON Community participation -The policy imperative of the future! Poverty / Inequality Building the bridge through community participation. Are we ready?
66. For further information visit www.sochara.org www.phm-india.org www.phmovement.org www.ghwatch.org www.iphcglobal.org www.mohfw.nic.in/NRHM
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71. Globalization Of Health From Below System Engagement-6 Public Health Text Book - Sweden “ A strong voice in the global health debate for free primary health care is the people’s health movement which in 2000, presented the Peoples Health Charter. The charter argues strongly for a publicly financed health services and for development policies that favours health…. This network presently led from Bangalore in India is a leading representative for NGO’s in the Global health debate. This global network is itself a new aspect of globalisation”
72. System Engagement “ History suggests that such changes often demand radical forms of political mobilization and action, although history has not yet encountered such a demand on a global scale. No simple precedents exists but several forms of mobilization are already been pursued………. The simultaneous rise of a global civil society movement pressing for political actions to shift the rules of contemporary globalization (People’s health movement et al 2005 )
73. Charter People IPHU Training Programme RTHC Social Movements WHO- CSDH/ other Engagements ( Policy Matters) GHW Academics & Research PHM
74. PUBLIC HEALTH TEXT BOOK - UK The Peoples Health Movement is an international network of organization and individuals that came together in 2000 to reignite the call for the Health for All, Now. The goal of PHM is to reestablish the health and equitable development as top priorities at local, national and international policy making, with comprehensive primary health care as the strategy to achieve this priorities……. It is transnational network …… and a good example of an emerging player in global civil society… On a day today basis the secretariat in Bangalore …… puts forward strategic campaigning priorities….
75. IHI/ GPPI’s WHO IMF WTO IPR Trade/ Other UN Organistions MDG’s CHW’s and Health as a Social Movement
84. Case Study - Karnataka Task Force on Health and Family Welfare – 2001 (contd….) Karnataka State Integrated Health Policy 2003 (Drafted by SOCHARA) Incorporating many key recommendations of the task force and passed through several committee’s and cabinet so that recommendations become part of state policy unaffected by political changes and other influences
90. ARBO VIRUSES AGRICULTURAL DEVELOPMENT ANIMAL HUSBANDRY DEVELOPMENT PROJECTS FORE-STRY LABOUR MIGRATION URBANIZATION (including larger villages) INTERNATIONAL TRAVEL/ ECO TOURISM WILD LIFE SPORTS (Hunting, Hiking) CHANDIPURA WEST NILE CHIKUN GUNYA ALPHA VIRUSES ? KFD DENGUE JE New challenges of Globalization…. INEQUALITY MARGINALISATION NEW ECONOMIC POLICIES (Liberalization, Privatization, Globalization ) DISASTERS :NATURAL & MAN-MADE COMMERCIALIZATION OF HEALTH CARE DECREASED INVESTMENT IN SOCIAL SECTOR PRIVATIZATION OF HEALTH CARE AND SOCIAL SECURITY MORE TRAVELLERS/ MORE DESTINATIONS UNSUSTAINABLE DEVELOPMENT AND DISPLACEMENT
91. Globalization Of Health From Below Challenges ahead 5 Promoting Research and Action in the New Paradigm
92. Globalization Of Health From Below Challenges ahead 4 Dialogue with Academics and Researchers
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97. CHW’S IN INDIA – AN OVERVIEW The ASHA Training Programme of the National Rural Health Mission - 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”.
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100. CHW’S IN INDIA – AN OVERVIEW The CHW’s of the NGO Sector – III “ This is a beautiful hall and the shining chandeliers, are a treat to watch. One has to travel thousands of miles to come to see their beauty. The doctors are like these chandeliers, beautiful and exquisite, but expensive and inaccessible…” “ This lamp is inexpensive and simple but unlike the chandeliers it can transfer its light to another lamp. I am like this lamp lighting the lamp of better health. Workers like me can light another and another and thus encircle the whole earth. This is Health for All.” Muktabai Pol, a Village Health Worker From JAMKHED India, in Washington, DC, May 1988
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