Public Health In The 21st Century
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  • 1. PUBLIC HEALTH IN THE 21st CENTURY: towards a people's health paradigm THE FIRST DR. N. H. ANTIA MEMORIAL LECTURE (Indian Health Front and PHM Tamilnadu) Dr. Ravi Narayan Community Health Adviser Society for Community Health Awareness, Research and Action Bangalore 28 th February 2008
  • 2. Dr. N.H. Antia, FRCS, FACS (HON) 18 th Feb 1922 - 26 th June 2007
    • Surgeon
    • Plastic Surgeon
    • Leprosy Rehabilitation
    • Foundation for Medical Research
    • Foundation for Research in Community Health
    • Association for Rural Surgeons
    • Health for All activist ( PHM)
    • NRHM and Advisory group on Community Action.
    • People’s Health Sector Proponent.
  • 3. People’s Health in Peoples Hands A Tribute
    • 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….
    • source : Dr. N.H. Antia, 1993
  • 4. People’s Health in Peoples Hands A Tribute
    • “ I feel that appropriate science and technology in every form and of every system should be utilized to solve our country’s and its people’s problems: not to glorify western technology for its own sake while denigrating our own….. Elegance is trying to find simple solutions to complicated problems, not the reverse…..
    • source : Dr. N.H. Antia, 1998
  • 5. Alma Ata, 1978 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.
  • 6. 1978- Alma Ata Declaration-I .
    • Health for All
    • Primary Health Care
    • Health a Fundamental Human Right
    • Equity
    • Appropriate Technology
    • Inter-sectoral Development
    • Community Participation.
  • 7. 1981 - Health for All – An Alternative Strategy The Prescription of ICSSR and ICMR in India
    • “ A Mass movement to reduce poverty inequality and spread education.
    • Organize 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 …..”
    • - ( Dr. N.H.Antia was member secretary of this committee)
  • 8. 1984- Community Health Definition (CHC)
    • “ 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 involves increasing of the individual family and community autonomy over health and over the organizations, the means, the opportunities, the knowledge and the supportive structure that makes health possible”.
  • 9. “ From Alma Ata to the Millennium Declaration”
  • 10. “ From Alma Ata to the Millennium Declaration” Source: Community Health Cell, Bangalore (www.sochara.org) Accessibility ? Affordability
  • 11. THE PUBLIC HEALTH CHALLENGES IN INDIA
    • 1. The continuing disease burden
      • Malnutrition
      • Communicable diseases
      • Non-communicable diseases
      • Mental Health / psycho-social / conflicts
    • 2 . The continuing problem of access of large sectors of the population to the determinants of health
      • Food security
      • Safe water
      • Clean environment
      • Adequate wage, and
      • Healthy work environment etc
    • 3. The effects of globalization on Health and Health services
    • CHC (2008)
  • 12. Globalization and its health effects
    • 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,
  • 13. What are the people saying? Less Food No Jobs No water
  • 14. Increasing Poverty and inequality ….. The greatest obstacle to Health for All and the Millennium Development Goals Poverty / Inequality
  • 15.
    • “ 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
  • 16. Meeting the challenges of India today
    • Farmers Suicides
    • Childhood Malnutrition
    • The Virus of Communalism & Social Conflicts
    • Life style Diseases Epidemics
    • Resurgence / return of the vector borne diseases
    • Development related displacement & ill health
    • Pollution impacted communities And ……………………..
    • We need new paradigms and a new understanding!
  • 17. 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, 1992
    • The Strategy of Preventive Medicine
  • 18. Researching levels of analysis and solutions 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.
  • 19. What evidence?
    • Disease?
    • Ill-health?
    • Or social determinants like
    • Poverty?
    • Gender bias?
    • Conflict?
    • Stigma?
    • Social exclusion?
    “ From Alma Ata to the Millennium Declaration”
  • 20. 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
  • 21. An Agenda for Change -1998 “ A need for strong countervailing movement initiated by health and development professionals and activists, consumer and people’s organizations to bring health care and medical education and their right orientation high on the political agenda of the country and to ensure that the health policy choices are led by people’s health needs, not market factors”
  • 22. 2000- Preparing Campaign Materials for Health Mobilization
  • 23. 2000- Jan Swasthya Sabha, Kolkata
    • Over 2000 participants in 5 peoples health trains
    • Mobilization across 19
    • states
    • Adopted 20 point Indian
    • People’s Charter
    • Launched the Jan
    • Swasthya Abhiyan,
    • campaigning for
    • Health for All Now
    • Health as a Fundamental
    • Human Right
  • 24. Indian People’s Health Charter … We reaffirm our inalienable right to and demand for comprehensive health care that includes food security; sustainable livelihood options including secure employment opportunities; access to housing, drinking water and sanitation; and appropriate medical care for all; in sum - the right to Health For All, Now! … … We declare health as a justiciable right and demand the provision of comprehensive health care as a fundamental constitutional right of every one of us. We assert our right to take control of our health in our own hands… … Ethical guidelines for research involving human subjects be drawn up and implemented after an open public debate… December 2000 Kolkota, India
  • 25. The First Global People’s Health Assembly In 2000 December 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
  • 26. The People’s Charter for Health “ Health is a social, economic and political issue and above all a fundamental human right.”
  • 27. The People’s Charter for Health “ Health for all means that powerful interests have to be challenged, that globalisation has to be opposed, and that political and economic priorities have to be drastically changed.”
  • 28. PEOPLE’S CHARTER FOR HEALTH PRINCIPLES HEALTH IS FUNDAMENTAL HUMAN RIGHT PRIMARY HEALTH CARE (1978 Alma Ata Declaration) BASIS FOR POLICY GOVERNMENTS FUNDAMENTAL RESPONSIBILITY TO ENSURE ACCESS AND QUALITY PEOPLE AND PEOPLES ORGANISATIONS ESSENTIAL TO FORMULATION, IMPLEMENTATION, EVALUATION OF HEALTH PROGRAMMES POLITICAL / ECONOMIC SOCIAL / ENVIRONMENT ARE PRIMARY DETERMINANTS OF HEALTH AND MUST GET TOP PRIORITY IN POLICY MAKING
    • ACTION AT ALL LEVELS TO TACKLE CRISIS
      • Individual
      • Community
      • National
      • Global
  • 29. PHC in the New Millennium New Challenges
    • Health as a human right
    • Tackling broader determinants of health – Economic, Social and Political challenges
    • Tackling environmental challenges and unsustainable developments
    • Countering war, violence, conflict and natural disasters.
    • Rediscovering Universal and Comprehensive Primary Health Care
    • People’s organisations, People’s Movements and Civil Society involvement in dialogue, analysis, action, monitoring and evaluation.
  • 30. Publications
  • 31. People’s Health Movement (Global) from 2000 AD:
    • People’s Charter for health
    • Global Health Watch
    • International People’s Health University
  • 32. Globalizing solidarity from over 80 countries at the Second People’s Health Assembly, Cuenca Ecuador
  • 33. Peoples voices at national level People’s health tribunals in India
  • 34. Peoples Health Tribunals 2004 “Jan Sunwais”
    • Objectives
    • Bring ‘Public’ back into ‘Public Health’
    • Evidence gathering on the denial of Right to Health Care and other discriminations.
    • Increase pressure on government to make health systems responsive to ethics and human rights paradigm.
  • 35. PHM India
    • Dialogue with political parties
    • State and national health policy Dialogue
    • Right to Health Care Campaign with National
    • Human Rights Commission
    • People’s Rural Health Watch
    • Support to Campaigns:
    • Right to Food; Against Water Privatization; Access to Essential Medicines- Patents/TRIPS; Environment issues; Gender; HIV / AIDS; Women’s Health
  • 36. The People’s Health Paradigm: some Challenges
    • Rights
    • Ethics
    • Political Economy
    • Medical Pluralism
    • People Oriented Professionals
    • Community Participation and Monitoring.
  • 37. Right to Health Movement
  • 38. Countering Commercialization by Medical Ethics
    • CHC Advocacy with Health University to introduce ethics in undergraduate curriculum (1999)
    • Ordinance
    • “ The Doctor should be trained to analyze the ethical problems as they arise and deal with them in an acceptable manner. It is therefore recommended that teaching of Medical Ethics be introduced n Phase I and continued throughout the course including the internship period”.
    • Syllabus
    • Includes Introduction, perspectives, ethics of individuals, ethics of human life, ethics of family and society, death and dying, professional ethics, research ethics and ethical case work
    • RGUHS (1997-98)
  • 39. THE POLITICAL ECONOMY CHALLENGE
    • Countering the market economy in health system development
    • Countering market needs that take over from people’s needs
    • Strengthening equity, gender and the rights paradigms in health policy.
  • 40. Medical Pluralism Challenge. (AYUSH in Public Health) “ Respect communities and its diversities…. Support, recognize and promote traditional and holistic healing systems and practioners and their integration into Primary Health Care “ Source: PCH- Dec 2000.
  • 41. Community Orientation of Health Teams
    • Medico Friends Circle reflections (1991) recommends:
    • Community oriented, Socially conscious, primary health care provider
    • Multi-disciplinary health analysis and collective societal solution
    • Political economy, ethics and value orientation
    • Medical teachers – ethics and value orientation and learning facilitation
    • Links with peripheral hospitals and community projects
    • Institution part of community health/ people’s health network
  • 42. Political Will
    • “ We recognize health as an inalienable human right that every individual can justly claim.
    • So long as wide health inequalities exist in our country and access to essential health care is not universally assured, we would fall short in both economic planning and in our moral obligations to all citizens”
    • - Dr. Manmohan Singh at AIIMS recently
  • 43. New Challenges: National Rural Health Mission (NRHM) Civil Society Engagement.
    • Members of Task Force and Advisory Committee
    • Shifted the missions focus from Demography to Public Health
    • Community Monitoring
    • People Rural Health Watch
    • ASHA Mentoring Group
  • 44. Evolving Network of Schools of Public Health and MPH Courses
    • Public Health Foundation of India ( 4 Indian Institutes of Public Health)
    • ICMR Schools of Public Health ( 4 regional clusters including NIE,Chennai)
    • Existing Schools being strengthened – AIIPH, AMCHSS , IHMR, and JNU – CSMCH
    • Medical college based MPH courses or schools (CMC-Vellore, SJNAHS, MGR, PMC , MMC and KMC etc)
    • New initiatives – NICD, TISS, NIMHANS,CHE
  • 45. Engagement 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
  • 46. Promoting new types of research
    • Not only
    • Drug and vaccine trials
    • Epidemiological studies
    • Operations research
    • But also
    • Health policy studies
    • Health systems research
    • Research on social determinants
    • and political economy of health
    Developing a research and advocacy agenda for Health
  • 47. Developing a research and advocacy agenda for Health Translating research into policy, advocacy and action to strengthen accountability
  • 48. In Conclusion. THE NEED FOR A PARADIGM SHIFT ARE WE READY FOR THIS CHALLENGE ? Approach Biomedical Model Social Community Model Focus Individual Community Dimensions Physical / pathological Psycho- social, cultural, economic, political, ecological Technology Drugs / vaccines Education and social processes Type of service Providing/ Dependence creating / Social marketing Enabling / Empowering Autonomy Building Link with people Patient as passive beneficiary Community as active Participant Programmes and Campaigns Social Movements
  • 49. “ From Alma Ata to the Millennium Declaration” Recognizing the People’s Paradigm Why Renew PHC? For many in the region there is a feeling that, “health is a social, economic and political issue and, above all, a fundamental right, and inequality, poverty, exploitation, violence, and injustice are at the root ill-health and the death of poor and marginalized people” pp: (Quoting People’s Charter for Health in PAHO PHC document 2007, )
  • 50. “ From Alma Ata to the Millennium Declaration” Recognizing the People’s Paradigm
    • Successful PHC services:
    • Encourage (community) participation
    • Are accountable
    • Have appropriate level of investment to guarantee adequate services
    • Ensure services are accessible regardless of person’s ability to pay
    • (Quoting People’s Charter for Health Quoting People’s Charter for Health in PAHO PHC document 2007 , )
  • 51. Recognizing the People’s Paradigm 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…. Source: Public Health Text Book - UK
  • 52. Recognizing the People’s Paradigm “ 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 favors 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 globalization” Source: Public Health Text Book- Sweden .
  • 53. Can the shift towards the People’s Health Paradigm become a power to counter the following ills of the existing
    • Corruption
    • Neglect of public health
    • Distortions in primary health care
    • Lack of equity process
    • Implementation gap
    • 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
  • 54. People’s Health in Peoples Hands Dr. Antia’s Response
    • “ Decentralized people based health care
    • People operated health services
    • Demystification of Health to strengthen people’s involvement
    • Humane, cost effective and accessible health and medical care for all citizens
    • From unaccountable top-down system to an accountable bottom-up system
    • Small efficient people’s market not exploitative national or international market or distant centralized bureaucracy…..”
    What will be your contribution ?
  • 55. Shimoga - 2006
  • 56. Thank you www.phmovement.org
  • 57. Health for All, Now ! JOIN US THANK YOU
  • 58. For further information visit www.sochara.org www.phm-india.org www.phmovement.org www.ghwatch.org www.iphcglobal.org