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
Dr. N.H. Antia, FRCS, FACS (HON) 18 th Feb 1922 - 26 th June 2007
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….
“ 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
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.
“ 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”.
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,
What are the people saying? Less Food No Jobs No water
Increasing Poverty and inequality ….. The greatest obstacle to Health for All and the Millennium Development Goals Poverty / Inequality
“ 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 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.
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
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”
2000- Preparing Campaign Materials for Health Mobilization
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
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
The People’s Charter for Health “ Health is a social, economic and political issue and above all a fundamental human right.”
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.”
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
Countering Commercialization by Medical Ethics
CHC Advocacy with Health University to introduce ethics in undergraduate curriculum (1999)
“ 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”.
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
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.
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.
“ 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
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
People Rural Health Watch
ASHA Mentoring Group
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)
“ 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
Developing a research and advocacy agenda for Health
Developing a research and advocacy agenda for Health Translating research into policy, advocacy and action to strengthen accountability
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
“ 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, )
“ From Alma Ata to the Millennium Declaration” Recognizing the People’s Paradigm
Successful PHC services:
Encourage (community) participation
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 , )
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
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 .
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
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…..”