Community Approaches for Health System Strengthening & addressing the Social Determinants of Health Dr. Thelma Narayan Centre for Public Health & Equity, SOCHARA Bangalore ITM Antwerp, 2008 Primary Health Care in the 21 st Century New Challenges & Opportunities for the First Line
Nutritional Status of Children under 3 years: shift from NFHS-2 to NFHS-3 Source: National Family Health Survey 3- 2005-06, NFHS2-1998-99
Anemia Prevalence Among Under 3’s in India Source: National Family Health Survey 3- 2005-06 Anaemia Prevalence State Anaemia prevalence more than 70 percent Bihar Madhya Pradesh Uttar Pradesh Haryana Chhattisgarh Andhra Pradesh Karnataka Jharkhand Anaemia prevalence Less than 50 percent Goa Manipur Mizoram Kerala
56% of married and 59% of pregnant women are anaemic. Source: National Family Health Survey 3- 2005-06
Percent of Household Having no Toilet Facilities Source: National Family Health Survey 3- 2005-06, NFHS2-1998-99, NFHS1 1991
Percentage of House Holds by Source of Drinking Water Source: National Family Health Survey 3- 2005-06, NFHS2-1998-99, NFHS1 1991
Common forms of Violence against married women Source: National Family Health Survey 3- 2005-06, NFHS2-1998-99, NFHS1 1991
First line is an integral part of the health system
First line functioning determined by political priorities to public health and health system
Action on inequalities in access to SDH dependent on politico- economic factors
Pro active civil society involvement to address SDH to be strengthened
Role of social movements
The People’s Charter for Health “ Health is a social, economic and political issue and above all a fundamental human right.”
HISTORY Health Survey and Development Committee- India Bhore Committee (1946)
“ No permanent improvement of public health can be
achieved without active participation of people in local health programs ….
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 program 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
Health Survey and Planning Committee- India Mudaliar Committee (1961)
“ Unless the conscience of citizens as a whole is stimulated to demand and accept better standards of health…..
through health education and other efforts , and ….
Unless government feels strengthened in taking positive measures to promote health , it will be difficult for health authorities alone to ensure that the measures contemplated are actually implemented….”
“ Doctors are like chandeliers, beautiful and exquisite, but expensive and inaccessible…
I am like a little lamp inexpensive and simple and I can transfer light from one lamp to another, lighting the lamp of better health……, easily unlike the chandeliers
Workers like me can light another and another and thus encircle the whole earth. This is Health for All.”
Village Health Worker JAMKHED,India, Washington, DC, May 1988
Doctors & Village Health Workers - Muktabai Pol, a CHW speaks
The Quest for Alternatives pre Alma Ata – a Community Health Movement
Integrated health & development action
Preventive & promotive services
Using local resources & healers
Village health workers/ cadres
Community participation & organization
Local finances- cooperatives
Education for health
Conscientisation & political action
Need for scaling up
Source: Narayan, 1985 ICMR Monograph 1976
Community Participation Policy Statements 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
WHO and UNICEF Study, 1977 - I Case Studies from all over the World
WHO and UNICEF Study, 1977 - II Principles to achieve Primary Health Care
Communities should be involved in designing, staffing, & functioning of local primary health care centres & in other forms of support.
Primary health care workers should be selected by the community itself or at least in consultation with the community
Respect for cultural patterns and felt needs in health and community development …..
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
“ 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”
Health for All – the Prescription of ICMR and ICSSR – 1981 For a mass movement post Alma Ata
“ Reduce poverty, inequality & spread education
Organise poor & 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”
“ 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, 1992
The Strategy of Preventive Medicine
An agenda for change p resented 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
New Paradigms of Community Health through civil society in India 1984-99
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 ………
Less Food, No water, No jobs!!! Listening to People!
The People’s Health Resource Books in India -2000AD “ These books are the best expressions 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 .
Jan Swasthya Sabha, (People’s Health Assembly India), Kolkata 2000
Over 2000 participants in 5 peoples health trains
Mobilization across 19
Adopted 20 point Indian
Launched the Jan
campaign for Health for All
Accepted health as a Fundamental Human Right
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
The First Global People’s Health Assembly December, 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.
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”
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 Bangkok 2004 “ HIV and AIDS is a development issue calling 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… rooted in internationally accepted human rights and humanitarian norms .”
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
Right to Health Movement : India 2003 Primary Health Care and Health for All
People’s Health Tribunals in India – 2004 Dialogue with policy makers on behalf of the movement
A Peoples Court or Civil Court
A panel of judges and experts set up by the National Human Rights Commission
Senior State health officials respond
Second National Health Assembly Bhopal- India 2006
Listening to voices of marginalized people
People’s Health Rural Watch
Community based monitoring of NRHM
Towards a people’s health plan
Campaign against coercive population policies
Realizing the right to essential drugs
Dialogue with health policy makers
Dialogue with other social movements
Redefining Community Participation by Civil Society in India 2000-2008
On Right to Health
Peoples Rural Health Watch PEOPLE’S HEALTH MOVEMENT, - INDIA : JAN SWASTHYA ABHIYAN
Right to health campaign
Right to Information
Right to Food & Right to Water campaigns Pre-election dialogue with Political parties: Health in the Manifestos Community Monitoring of National Rural Health Mission People’s Tribunal On World Bank Policies - India
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
Revival of Interest in State level Community Health Worker and Community participation Evaluated by Civil Society Researchers Jaa Swasthya Rakshaks (JSR) Madhya Pradesh 1991 Mitanin Programme, Chattisgarh -2001
National Rural Health Mission 2005-2012 - Evolving through the politics of engagement
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
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!
COMMUNITY PARTICIPATION THE PARADIGM SHIFT – 2000 & beyond Source: CHC 2008 Approach Biomedical, deterministic, techno managerial model Participatory social/ community model Link with community As passive client or beneficatory As active empowered participants 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
Recognition of Globalization of Solidarity for Health 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
Global Health Watch I & II Alternative World Health Report
Action points to address macro-policies and global structural determinants of health