People Centered Primary Health Care


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People Centered Primary Health Care

  1. 1. People Centered PHC: Empowering Communities, enhancing participation and advocating for and stewarding intersectoral action Dr. Ravi Narayan ,Community Health Advisor, Society for Community Health Awareness, Research and Action – Bangalore & Global Steering Council of People’s Health Movement International conference- 30 th anniversary of the Alma- Ata Declaration on Primary Health care (WHO/UNICEF) Almaty, Kazakhstan 15-16 October 2008
  2. 2. The Challenge in the new millennium: Towards a People- centred PHC <ul><li>The People back into the centre of primary health care </li></ul><ul><li>The Public back into Public health systems </li></ul><ul><li>The Community back into the health policy discourse. </li></ul>
  3. 3. Plan of Presentation <ul><li>People Centered Primary health care before Alma Ata-1978 (with a focus on India) </li></ul><ul><li>People Centered Primary health care – since Alma Ata -1978 </li></ul><ul><li>Globalization of health from above : the distortion of PHC and loss of the community and the people-orientation since 1990’s </li></ul><ul><li>Globalization of health solidarity from below since 2000 : the revival of PHC with a strong peoples movement, committed to equity, rights, gender, and the social determinants perspective of health </li></ul><ul><li>Towards a People-centered PHC – forward beyond Almaty – 2008 : the core agenda of the future </li></ul>
  4. 4. Health Survey and Development Committee- India Bhore Committee (1946) <ul><li>“ No permanent improvement of public health can be </li></ul><ul><li>achieved without the active participation of the </li></ul><ul><li>people in the local health program…. </li></ul><ul><li>We consider that the development of local effort </li></ul><ul><li>and the promotion of a spirit of self help in the </li></ul><ul><li>community are as important to the success of the </li></ul><ul><li>health programme as the specific services, which </li></ul><ul><li>the health officials will be able to place at the </li></ul><ul><li>disposal of the people </li></ul><ul><li>Formation of village health committees and </li></ul><ul><li>Voluntary health workers are needed who will </li></ul><ul><li>need suitable training..” </li></ul>Source : CBHI 1985 People Centered Primary health care before Alma Ata-1978 - I
  5. 5. <ul><li>CHWs - Jamkhed </li></ul><ul><li>VHWs - Indo-Dutch, </li></ul><ul><li>project Hyderabad </li></ul><ul><li>Lay First Aiders – VHS </li></ul><ul><li>-Adyar, Chennai </li></ul><ul><li>Link workers - CLWS </li></ul><ul><li>tea plantations </li></ul><ul><li>Health Aides – RUHSA </li></ul><ul><li>MCH workers - CINI, </li></ul><ul><li>Calcutta </li></ul><ul><li>Swasthya Mitras – BHU </li></ul><ul><li>Varanasi </li></ul><ul><li>Sanyojaks - Banavasi </li></ul><ul><li>Seva Ashram, UP </li></ul><ul><li>CHW’s - St. John’s </li></ul><ul><li>Bangalore, </li></ul><ul><li>Rehbar-e-Sehat - </li></ul><ul><li>Teacher workers of </li></ul><ul><li>Kashmir </li></ul><ul><li>CHVs - Sewa Rural, </li></ul><ul><li>Jhagadia </li></ul>CHW’S IN INDIA – AN OVERVIEW 1970s & 1980s) People Centered Primary health care before Alma Ata-1978 - II
  6. 6. <ul><li>Predominantly women </li></ul><ul><li>Mostly voluntary or link workers with minimum support </li></ul><ul><li>Mostly mature, married volunteers </li></ul><ul><li>Care taken to prevent the cooption by village leaders </li></ul><ul><li>Care taken to encourage representation of all segments </li></ul><ul><li>The participation of the community in identifying CHWs and their supervision </li></ul><ul><li>The training programme - innovative components and methods </li></ul><ul><li>Well trained and highly mobile, field and supervisory staff. </li></ul><ul><li>Many projects had women on local action / advisory committees </li></ul><ul><li>Many had local women groups supportive of the process. </li></ul><ul><li>Source : CHC, 1997 </li></ul>The CHW’s of the NGO Sector in India (1970s & 1980s) An Overview People Centered Primary health care before Alma Ata-1978 - III
  7. 7. Alternative Approaches to Health care - an ICMR Study 1976 <ul><li>Integrating Health with development activities </li></ul><ul><li>Preventive and Promotive services </li></ul><ul><li>Appropriate Technology </li></ul><ul><li>Utilization of local resources and healers </li></ul><ul><li>Village based health cadres </li></ul><ul><li>Community participation </li></ul><ul><li>Community organization </li></ul><ul><li>Local finances through cooperatives </li></ul><ul><li>Education for health </li></ul><ul><li>Conscientization and political action </li></ul>Source: Narayan, 1985 ICMR initiative and Monograph 1976 People Centered Primary health care before Alma Ata-1978 -IV
  8. 8. People-centred Community health: an evolving understanding 1978 Local Self Governance / Village Health Committee Community as Resource For Health Care including Traditional Practitioners / TBA’s People-centred Community health (primary health care) <ul><li>Community </li></ul><ul><li>Organization: </li></ul><ul><li>Women's </li></ul><ul><li>organization’s </li></ul><ul><li>Youth clubs </li></ul><ul><li>Farmers </li></ul><ul><li>Coperatives </li></ul>Community Health Worker’s / Volunteers People Centered Primary health care before Alma Ata-1978 - V
  9. 9. WHO and UNICEF Study, 1977 -- I Case Studies from all over the World <ul><li>Cuba </li></ul><ul><li>China </li></ul><ul><li>Tanzania </li></ul><ul><li>Venezuela </li></ul><ul><li>Nigeria </li></ul><ul><li>Ivanjica, Yugoslavia </li></ul><ul><li>Savar, Bangladesh </li></ul><ul><li>Jamkhed, India </li></ul><ul><li>Maradi,Niger </li></ul>People Centered Primary health care - Alma Ata -1978 - I
  10. 10. WHO and UNICEF Study, 1977 - II Principles to achieve primary health care: <ul><li>Communities should be involved in the designing, staffing, and functioning of their local primary health care centres and in other forms of support. </li></ul><ul><li>The primary health care workers should be selected when possible by the community itself or at least in consultation with the community </li></ul><ul><li>Respect for the cultural patterns and felt needs in health and community development of the consumers….. </li></ul>People Centered Primary health care - Alma Ata -1978 -II
  11. 11. 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 People Centered Primary health care - Alma Ata -1978 -III
  12. 12. The Alma Ata Declaration- 1978 <ul><li>“ The People have the right and duty to participate individually and collectively in the planning and implementation of their health care….. </li></ul><ul><li>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” </li></ul>People Centered Primary health care - Alma Ata -1978 -IV
  13. 13. People Centred Primary health care- evolving guidelines People Centered Primary health care - Alma Ata -1978- V
  14. 14. Health for All – The Prescription of ICMR and ICSSR – 1981 For a mass movement post Alma Ata <ul><li>Reduce Poverty inequality and spread education. </li></ul><ul><li>Organise poor and underprivileged to fight for their basic rights </li></ul><ul><li>Move away from the counter productive Western model of health care and replace it by an alternative based in the community …..” </li></ul><ul><li>Provide community Health volunteers with special skills, readily available, who see health as …… a social function” </li></ul>
  15. 15. <ul><li>“ A retreat from the goal of national health and drug policies as a part of an overall social policy; </li></ul><ul><li>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; </li></ul><ul><li>The failure to promote participation and genuine involvement of communities in their own health development; </li></ul><ul><li>Reduced state responsibilities at all levels as a </li></ul><ul><li>consequence of wide spread - and usually </li></ul><ul><li>inequitable - privatization of health policies ; </li></ul><ul><li>A narrow, top-down, technology - oriented view of health” </li></ul>RECOGNISING THE CRISIS IN INDIA-1990’S
  16. 16. The New Epidemiology <ul><li>“ The primary determinants of disease are mainly economic and social and therefore its remedies must also be economic and social … </li></ul><ul><li>Medicine and politics cannot and should not be kept apart.” </li></ul><ul><li>Prof. Geoffrey Rose, 1992 </li></ul><ul><li>The Strategy of Preventive Medicine </li></ul>
  17. 17. 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.
  18. 18. An agenda for change p resented to Independent Commission on Health in India by SOCHARA <ul><li>“ It is time to recognize the role of the community, the consumer, the patient and the people in the health policy debate ….. </li></ul><ul><li>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 </li></ul><ul><li>MARKET or PEOPLE ? What will be our choice?” CHC - 1998 </li></ul>
  19. 19. Towards a New Paradigm of Community Health and Community Participation through civil society initiative in India – 1984-1999 <ul><li>Voluntary Health Association of India (1970) </li></ul><ul><li>Medico Friends Circle (1975) </li></ul><ul><li>Asian Community Health Action Network ( 1980) </li></ul><ul><li>Catholic Health Association of India (1983) </li></ul><ul><li>Community Health Cell (1984) </li></ul><ul><li>All India Drug Action Network ( 1989) </li></ul><ul><li>International People’s Health Council (1990’s) </li></ul><ul><li>Christian Medical Association of India (1990’s) </li></ul><ul><li>National Alliance of People’s Movement ( 1996) </li></ul><ul><li>All India People’s Science Network - Health Campaign (1998) </li></ul><ul><li>The Women’s movement and ……… </li></ul>
  20. 20. <ul><li>“ Community health is a process of enabling people, to exercise collectively their responsibility to their own health and to demand health as their right </li></ul><ul><li>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…..” </li></ul><ul><li>source: the CHC axioms – red book, 1986 </li></ul>The New Community Health Paradigm
  21. 21. Less Food, No water, No jobs!!! Listening to the people!
  22. 22. 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 . <ul><li>Globalization and Health </li></ul><ul><li>Primary Health Care? </li></ul><ul><li>Inter-sectoral Action </li></ul><ul><li>Empowerment of the socially Marginalised </li></ul><ul><li>Confronting Commercialization of health care </li></ul>1 2 5 3 4
  23. 23. Jan Swasthya Sabha, (People’s Health Assembly India), Kolkata 2000 <ul><li>Over 2000 participants in 5 peoples health trains </li></ul><ul><li>Mobilization across 19 </li></ul><ul><li>states </li></ul><ul><li>Adopted 20 point Indian </li></ul><ul><li>People’s Charter </li></ul><ul><li>Launched the Jan </li></ul><ul><li>Swasthya Abhiyan, </li></ul><ul><li>campaign for Health for All </li></ul><ul><li>Now </li></ul><ul><li>Accepted health as a Fundamental Human Right </li></ul><ul><li>JSA, 2000 </li></ul>
  24. 24. 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”.
  25. 25. Towards a New Paradigm of Community Health and Community Participation through civil society Networks and Initiatives globally Pre – 2000AD. <ul><li>Asian Community Health Action Network ( ACHAN) </li></ul><ul><li>Consumer International (CI) </li></ul><ul><li>Dag Hammarskjold Foundation (DHF) </li></ul><ul><li>Gonoshasthaya Kendra (GK) </li></ul><ul><li>Health Action International (HAI) </li></ul><ul><li>International People’s Health Council ( IPHC) </li></ul><ul><li>Third World Network( TWN) </li></ul><ul><li>Women’s Global Network for Reproductive Rights (WGNRR) </li></ul>… towards a people’s health assembly in 2000AD
  28. 28. The First Global People’s Health Assembly December, 2000 <ul><li>In 2000 Dec, 1454 health activists from 75 countries met in Savar, Bangladesh to discuss the challenge of attaining Health for All, Now! </li></ul><ul><li>Over 250 Indian delegates attended. </li></ul>
  29. 29. The People’s Charter for Health (1454 people from 75 countries) 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….”
  30. 30. The People’s Charter for Health (1454 people from 75 countries) 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”
  31. 31. The Mumbai Declaration-2004 (1454 people from 75 countries) <ul><li>Implement comprehensive and sustainable primary health care involving marginal sectors in decision making regarding policies that affect them….. </li></ul><ul><li>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….. </li></ul><ul><li>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…… </li></ul>
  32. 32. 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.”
  33. 33. The Cuenca Declaration Ecuador-2005 <ul><li>“ PHM will struggle for comprehensive primary health care and sustainable, quality local, and national health systems. </li></ul><ul><li>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. </li></ul><ul><li>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” </li></ul>
  34. 34. 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 People Centered PHC in 2000 AD
  35. 35. Right to Health Movement : India 2003 Primary health care and Health for All
  36. 36. People’s health tribunals in India – I (2004) Dialogue with policy makers on behalf of the movement <ul><li>A Peoples Court or Civil Court </li></ul><ul><li>A panel of judges and experts is setup by the National Human Rights Commission </li></ul><ul><li>The senior-most State health officials act as respondents </li></ul>
  37. 37. <ul><li>People and activists present case studies and survey reports </li></ul><ul><li>Proceedings are videotaped and documented </li></ul><ul><li>Attended by members of the community / civil society </li></ul>People’s health tribunals in India - II Dialogue with policy makers on behalf of the movement
  38. 38. Second National Health Assembly Bhopal- India 2006 <ul><li>Themes discussed included </li></ul><ul><li>Listening to voices of marginalized people </li></ul><ul><li>People’s Health Rural Watch </li></ul><ul><li>Community based monitoring of NRHM </li></ul><ul><li>Towards the people’s health plan </li></ul><ul><li>Campaign against coercive population policies </li></ul><ul><li>Realizing right to essential drugs </li></ul><ul><li>Dialogue with health policy makers </li></ul><ul><li>Dialogue with other social movements </li></ul>
  39. 39. People’s Rural Health Watch, 2008 Recommendations <ul><li>ASHA’s to be chosen through a consultative village process </li></ul><ul><li>Constitution and training of village health and sanitation committees before preparation of village and district health plans </li></ul><ul><li>Community based monitoring to be integral part of public health system and not a stand alone component </li></ul><ul><li>The communitzation option, with public people partnerships to replace the privatization options…. </li></ul>
  40. 40. Redefining People centered PHC by Civil Society in India 2000-2008 <ul><li>People’s Tribunals </li></ul><ul><li>On Right to Health </li></ul><ul><li>Regional </li></ul><ul><li>Urban </li></ul><ul><li>National </li></ul>Peoples Rural Health Watch PEOPLE’S HEALTH MOVEMENT, - INDIA : JAN SWASTHYA ABHIYAN <ul><li>Right to health campaign </li></ul><ul><li>Right </li></ul><ul><li>Equity </li></ul><ul><li>Gender </li></ul><ul><li>Right to Information </li></ul>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
  41. 41. Rediscovering People-Centred PHC thru 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
  42. 42. National Rural Health Mission 2005-2012 - Evolving through the politics of engagement <ul><li>Goal: </li></ul><ul><li>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 </li></ul><ul><li>Principles: </li></ul><ul><li>It seeks to improve access to equitable, affordable, accountable, and effective primary health care. </li></ul><ul><li>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. </li></ul><ul><li>Train and enhance capacity of panchayathraj institution to own, control and manage public health service. </li></ul>
  43. 43. 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”.
  44. 44. Accredited Social Health Activist Training Manuals ASHA – Workers of Hope!
  45. 45. Redefined People centered PHC Training in NRHM/ PHRN -I <ul><li>Panchayat Raj Institution and Health programmes </li></ul><ul><li>Institutionalisation of community participation, village health committees and CBO’s </li></ul><ul><li>Village health planning </li></ul><ul><li>Involving NGO’s in community participation </li></ul><ul><li>Peoples movements and campaigns for health </li></ul><ul><li>Community monitoring. </li></ul>
  46. 46. Redefined Community Participation Training in NRHM/ PHRN -II <ul><li>Understanding community participation </li></ul><ul><li>Community Health workers </li></ul><ul><li>Selection of ASHA’s </li></ul><ul><li>Training CHW’s in a large scale programme </li></ul><ul><li>Supporting the ASHA </li></ul><ul><li>Community mobilisation, social mobilisation </li></ul><ul><li>Village level partners in community participation </li></ul>
  47. 47. Redefining People centred PHC– 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 IRAN Others
  48. 48. PEOPLE CENTRED PHC – 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 (Mostly Medical) Psycho- social, cultural, economic, political, ecological (intersectoral) Focus of Participation Resources, Time/ Skills Leadership, Ownership, direction setting, Monitors. CHW Role Service provider, educator, organiser, data collector Mobilisor, activist, empowerer, social auditor, monitor. Research Policy Community participation as means Patient Centredness and market /system orientation Community participation as ends People centred Empowerment strategy as the central theme
  49. 52. The New Public Health Paradigm (The First Text Book from the Movement) <ul><li>Chapter on Participation and Health Promotion </li></ul><ul><li>Participation </li></ul><ul><li>Psuedo – participation is a means </li></ul><ul><li>Participation as a means </li></ul><ul><li>Participation as a end </li></ul><ul><li>Participation as a power </li></ul><ul><li>Continuum </li></ul><ul><li>Consultation </li></ul><ul><li>Participation as a means </li></ul><ul><li>Substantive participation </li></ul><ul><li>Structural participation </li></ul>
  50. 53. 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
  51. 54. 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
  52. 55. A WHO - SEARO Exhortation for mainstream Public Health to engage with Alternative Sector. <ul><li>“ 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 &quot;. </li></ul>Source: South East Asia Public Health Initiative 2004-2008, WHO-SEARO
  53. 56. GHW-I: First Alternative World Health Report: Released at Cuenca, Ecuador – July 2005 <ul><li>“ 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 </li></ul><ul><li>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……” </li></ul>
  54. 57. GHW-2: the second Alternative World Health Report to be released in London – October 2008 <ul><li>Inspiration, courage and resistance – a new understanding of people -centred PHC </li></ul><ul><li>1. Political and Social Action against theft of land and water </li></ul><ul><li>2. Right to health care campaigns </li></ul><ul><li>3. Movements for food sovereignty </li></ul><ul><li>4. Community Partnerships to improve water and sanitation </li></ul><ul><li>5. Campaigns for Access to Essential medicines </li></ul><ul><li>6. Campaigns for health and health care of vulnerable groups </li></ul><ul><li>Primary Health Care as a Health for All Movement ! </li></ul>
  55. 58. ALMA ATA – 30 YEARS ON People - centred PHC -The policy imperative of the future! Poverty / Inequality Building the bridge through People-centredness: Are we ready?
  56. 59. Health for All, Now ! THANK YOU
  57. 60. For further information visit