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
Community participation before Alma Ata-1978 (focus on India)
Community participation after Alma Ata -1978(focus on India)
Globalization of health from above : the distortion of PHC and loss of the community
Globalization of health solidarity from below :
social movements including the people’s health movement and lessons from India
Back to Community participation and forward to Alma Aty – 2008 : the agenda of the future
Health Survey and Development Committee- India Bhore 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
Health Survey and Planning Committee- India Mudaliar Committee (1961) Source : CBHI 1985
“ Unless the conscience of the citizens has a whole is stimulated to demand and accept better standards of health…..
Unless the principles of sound hygiene are inculcated into the masses 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.
a Village Health Worker From JAMKHED India, Washington, DC, May 1988
Doctors and Village Health Workers :An Assessment by Muktabai Pol
The Quest for alternatives in 1970’s pre Alma Ata was primarily as a community health movement
Integrating Health with development activities
Preventive and Promotive services
Utilization of local resources and healers
Village based health cadres
Local finances through cooperatives
Education for health
Conscientization and political action
Source: Narayan, 1985 ICMR initiative and Monograph 1976
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
The Janata Rural Health Scheme (1977) Philosophy
“ The aim is to provide simple medical aid within the reach of every citizen by organising a cadre of medical and paramedical community health workers, of whom the trained practitioners of the indigenous systems of medicine will be a part”
The CHW will be ‘of the community’, ‘accountable to the community’ and the community in turn will supervise his work
As expression of community involvement and participation, the community should supplement the resources required for the continuation of this work and takeover the programme at a subsequent time”.
Source : CHC, 1997
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
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 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…..
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 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”
… ..Largescale transfer of knowledge, simple skills and technologies to health volunteers, selected by the communities and enjoying their confidence.
The Functioning of the front line of workers, selected by the community would require to be related to definitive action plans for the translation of medical and health knowledge into practical action,
The quality of training of these health guides/workers …… crucial to the success of this approach.
The success of the decentralized primary health care system would depend vitally on the organized building up of individual self reliance and effective community participation.
Health cannot be ‘delivered’ to the people…. Decentralized people’s based health care is desirable as well as feasible under the prevailing social and economic conditions and in a democratic set up..….
… ..the People’s sector can achieve both outreach and accountability, far more effectively and at much lower cost….. because health like education, lends itself best to people’s small scale action, which is in their own interest….
“ 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
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.
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
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)
“ Community health is a process of enabling people, to exercise collectively their responsibility to their own health and to demand health as their right
Community 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 .
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
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
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 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 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 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.”
“ 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 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 – I (2004) Dialogue with policy makers on behalf of the movement
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 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 - II Dialogue 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, 2008 Recommendations
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….
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
Links with Right to food and 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 (Programmes Evaluated by Civil Society Researchers) Jana 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!
Redefined Community Participation 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
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 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
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
The New Public Health Paradigm (The First Text Book from the Movement)
Chapter on Participation and Health Promotion
Psuedo – participation is a means
Participation as a means
Participation as a end
Participation as a power
Participation as a means
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
Global Health Watch - Alternative World Health Report: Strengthening the journey to health for all through renewed community participation
“ 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……”
ALMA ATA – 30 YEARS ON Community participation -The policy imperative of the future! Poverty / Inequality Building the bridge through community participation. Are we ready?
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”
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 )
Charter People IPHU Training Programme RTHC Social Movements WHO- CSDH/ other Engagements ( Policy Matters) GHW Academics & Research PHM
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….
IHI/ GPPI’s WHO IMF WTO IPR Trade/ Other UN Organistions MDG’s CHW’s and Health as a Social Movement
The Jan Swasthya Rakshak Scheme of Madhya Pradesh (1995) Source : CHC, 1997 Criteria JSR Scheme CHW Scheme Year 1995 1977 Training duration 6 months 3 months Goal One JSR / village One CHW / 1000 population Eligibility Upto 10 th std. Upto 6 th std. Training stipend during training Rs. 500 p/m Rs.200 p/m Honoraria Loan – subsidy from Jawahar Rozgar Yojana Rs. 50 per month Certification Panchayat certificate Informal certificate Content of manual (special)
Working with community
Anatomy / Physiology
Dengue / Filariasis / STD / Blindness
Minor ailment in Ayurveda/ Yoga/ Unani/ Siddha/ Homeopathy/ Naturopathy
Can the shift towards the People’s Health Paradigm become a power to counter the following ills of the existing
Neglect of public health
Distortions in primary health care
Lack of equity process
Need for ethical imperative
Human resource development neglected
Cultural gap and challenge of pluralism
Ignoring political economy
Exclusivism rather than partnerships
Inadequate policy research….
Source: Karnataka Task force on Health and Family Welfare - 2001
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
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
Globalization Of Health From Below Challenges ahead 5 Promoting Research and Action in the New Paradigm
Globalization Of Health From Below Challenges ahead 4 Dialogue with Academics and Researchers
CHW programmes are vulnerable unless driven, owned and embedded in communities
CHW programmes are successful if they are part of community mobilization efforts
CHW programmes are good investment but not cheap are easy
CHW programmes work with political will when integrated in the context of overall health sector and not separately
CHW programmes will work when the system efforts are supported by health movement from below.
Some Challenges in Promoting CHW’s as integral part of PHC
Political Economy (Dayrit/Khanum)
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”.
CHW’S IN INDIA – AN OVERVIEW The Global People’s Charter for Health of People’s Health Movement – December 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 …”
Source : CHC/PHM 2000
CHW’S IN INDIA – AN OVERVIEW The Indian People’s Health Charter of Jana Swasthya Abhiyan – December 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 …”
Source : CHC, 2000
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