Ravi Narayan How Civil Society influences policies of Governments
Dr. Ravi Narayan, Community Health AdvisorSociety for Community Health, Awareness, Research and Action,Bangalore, India( Affiliated to Global People’s Health Movement)Countervailing Power: The role of CivilSociety and Social Movements inCatalyzing “Health in All Policies”HEALTH IN ALL POLICIES8TH GLOBAL CONFERENCE ON HEALTH PROMOTIONPlenary : Social Change and Health8 GCHP – Helsinki, Finland12th June 2013
Health in AllPoliciesHealth PolicyHealth Systems includingHealth PromotionClosing Health inequalities gapAction onSocial DeterminantsOf HealthGlobalization and Economic – Social - PoliticalPriorities and Policies ( National / International)Communitization: engagement withCommunity ,Civil Society and SocialMovements,Empowerment of communitiesHEALTH FOR ALLRole ofPolitical WillEconomicsandWellbeingPolicy makingfor HealthBuildingCapacitySocial Changeand HealthClosing Healthinequity gap8 GCHP – THEME : HEALTH IN ALL POLICIES
1978- Alma Ata Declaration-I.• Health for All• Primary Health Care• Health a FundamentalHuman Right• Equity• Appropriate Technology• Inter-sectoralDevelopment• Community Participation.The International Conference on Primary Health Care calls for urgent action by all governments, allhealth and development workers, and the world community to protect and promote the health of all thepeople of the world by the year 2000.Alma Ata, 1978:
FACTORS INFLUENCING SOCIAL CHANGE :A COMPLEX MOSAIC OF INTERACTIONSINDIVIDUAL COMMUNITYKNOWLEDGEATTITUDEBELIEFSMOTIVATIONPASTEXPERIENCECAPACITIESCONFIDENCEPEERPRESSURESOCIAL NORMSFAMILYINFLUENCEKNOWLEDGEEMPOWERMENTCAPACITYCRITICALCONSCIOUSNESSAUTONOMYCOLLABORATIONCONFLICTCOOPERATIONMARGINALIZATIONORGANISATION
1978- Alma Ata Declaration-I.Alma Ata, 1978:SOCIAL CHANGE AND HEALTH“The promotion and protection ofthe health of the people isessential to sustained economicand social development andcontributes is a better quality oflife and to world peace. .. theattainment of the highestpossible level of health is a mostimportant social goal whoserealization requires the action ofmany other social and economicsectors in addition to the healthsector ”
THE OTTAWA CHARTER FOR HEALTH PROMOTION-1986SOCIAL CHANGE AND HEALTH“Good health is a major resource forsocial, economic, and personal development and animportant dimension of quality of life.Political, economic, social, cultural, environmental, behavioral and biological factors can all favour health tobe harmful to it…… Health promotion works throughconcrete and effective community action in settingpriorities making decisions, planning, strategies andimplementing them to achieve better health. At theheart of this process is the empowerment ofcommunities- their ownership and control of their ownendeavors and destinies”
Corporate led globalization,Neo-liberal economic reforms,Negative macro-policiesAdversely affect thesocial majority,nationally & globallyLivelihoods,Incomes,Food security,Increased conflict,War and violence,Access to water,Access to health care,Environmental degradation,
Less Food No jobNowaterWhat are the people saying?Health crisis
1978- Alma Ata Declaration-I.Alma Ata, 1978:PEOPLES PARTICIPATION“The people have theright and duty toparticipateindividually andcollectively in theplanning andimplementation oftheir healthcare”
COUNTERVAILING MOVEMENT“For too long the medical profession andthe medical education sector have beendirected by professional control anddebate. It is time to recognize the role ofthe community, the consumer, the patientand the people in the whole debate. ……What is needed is a strong countervailingmovement initiated by health anddevelopment activist, consumer andpeople organizations that will bringhealth care and medical education andtheir right orientation high on thepolitical agenda of the country. All thoseconcerned about ‘peoples needs’ and‘Peoples health’ will have to take on thisemerging challenges as we approach theend of the millennium”Report of the INDEPENDENT COMMISSION ON HEALTH IN INDIA, 1998 (ICHI)(Contribution from SOCHARA in the Human Resource Development Chapter).
Solidarity• Solidarity is extent to which people in a societywork together to define and achieve thecommon good. …..• It is manifested in national and localgovernment, in the formation of voluntaryorganizations and labour unions, and other informs of citizen participation in civic life…• Social solidarity is one means by whichcollective action can overcome problems;• Participation and accountability at all levels isnecessary not only to achieve solidarity, but alsoto assure that it is maintain overtimeSource: Renewing PHC in the Americas – PAHO. 2007
Civil Society“A sphere ofideas, values, institutions, organizations, networksand individuals located between the family, the stateand the market, and operating beyond the confinesof the national societies, polities and economies”.Source: OUP- Global Change and Health,2005“Associations of citizens (out side theirfamilies, friends and businesses) entered intovoluntarily to advance their interests, ideas andideologies. The term does not include profit-makingactivity (the private sector) or governing (the publicsector)” - UN,2004:Source: The New Public Health, Fran Baum
‘ A form of collective action aimed at socialreorganization……..not highly institutionalized butarising from spontaneous social protest directedat specific or widespread grievances’Source: Dictionary of Sociology (16)“A spontaneous reaction to a given social,economic, or political situation and may acquire aformal or quasi – formal organization structure”Source : Jayaram.N (17)SOCIAL MOVEMENTS
CIVIL SOCIETY, SOCIAL MOVEMENTS, DEMOCRACY AND POLICYENGAGEMENT:COMPLEXITY OF DEFINTION AND ROLEPARTICIPATIONREPRESENTATIVENESSVALUESENGAGEMENT /CONFRONTATIONACCOUNTABLIITYLINKS TO POLITICAL PROCESSCAPACITYTRANSPARENCYSUSTAINABILITYINCLUSIVENESSCONCERNS IN THEONGOING DEBATEContext /Country Specific Role and Potential !!
Roles of Civil Society in HiAP• Representing the ‘voice of people’.• Advocacy and lobbying• Watchdog Role• Research and policy analysis• Communication• Involvement in horizontal governmentmechanism (Participatory Governance)• Involvement in multilevel governance( multisectoral planning)• Horizontal and vertical networking• Build capacity of civil society• Campaigns , programmes and movementson specific health problems.Source: Global change and Health; OUP, 2005 (UNDERSTANDING PUBLIC HEALTH SERIES)
• Over 2000 participants in 5peoples health trains• Mobilization across 19states• Adopted 20 point IndianPeople’s Charter• Launched the JanSwasthya Abhiyan,•Campaigning for Health forAll Now•Health as a FundamentalHuman RightRole: Representing the Voice of the People- (1)National People’s Health Assembly, Kolkatta – Dec 2000
Role: Representing the Voice of the People (1)The First Global People’s Health Assembly, Savar,December, 2000• In 2000 Dec, 1454health activists from75 countries met inSavar, Bangladesh todiscuss the challengeof attaining Health forAll, Now!• Over 250 Indiandelegates attended.
“Health is asocial, economic andpolitical issue andabove all afundamental humanright.”The People’s Charter for Health(1454 people from 75 countries) Dec 2000
The People’s Charter for Health, Dec 2000(1454 people from 75 countries)SOCIAL CHANGE AND HEALTH“Health is a social , economic andpolitical issue and above all afundamental human right.Inequality, poverty, exploitation, violence and injustice are at the rootsof ill health and the deaths of poorand marginalized people….. Healthis primarily determined by thepolitical, economic , social, andphysical environment and shouldalong with equity and sustainabledevelopment be a top priority inlocal, national, and internationalpolicy making”.
The People’s Charter for Health, Dec 2000(1454 people from 75 countries)PEOPLES PARTICIPATION“The participation of peopleand people’s organization isessential to the formulationimplementation and evaluationof all health and social policiesand programmes. Strongpeoples organization andmovements are fundamental tomore democratic, transparentand accountable decisionmaking processes”
Role: Advocacy and Lobbying (2)Right to Health Movement - India
Role: Advocacy and Lobbying (2)Making Health an Agenda for the Social Movements.World Social Forum, Porto Allegre Brazil
Role: Watch Dog ( 3)Global Health Watch – I II & IIIAlternative World Health Report(People’s Health Movement, Medact, Global Equity Guage Alliance HealthAction International, Medico International, Third World Network, Zed Books)
Role: Research and Policy Analysis ( 4)EQUINET – East and Southern AfricaCONTENTS:1. Policy , Political and LegalCommitments, to equity in health.2. Equity in health outcomes3. House Hold access to the resourcesfor health and the economic and socialdeterminants of health4. Economic opportunities andchallenges for health5. Challenging inequities throughredistributive health systems6. A more just returned from the globaleconomy7. Conclusions.
Role: Communications/Public Education (5)The People’s Health Resource Books in India -2000AD“These books are the best expressions of primary healthcare concepts and its politics that I have ever read. They arethe bible of primary health care, a glorious milestone on thetortuous road to primary health care….”Halfdan Mahler, DG Emeritus, WHO andArchitect of the Alma Ata Declaration.1. Globalization and Health2. Primary Health Care?3. Inter-sectoral Action4. Empowerment of the sociallyMarginalised5. Confronting Commercializationof health care12534
Roles: Communications/Public Education: (5)PHM: Promoting the politics of health
Roles: Communication /Public Education (6)Websites and Media Effortmedico friend circlePublic Health Resource NetworkCommunity Practice onAccountability and SocialAction in Health -COPASAHwww.phmovement.orgwww.mfcindia.orgwww.copasah.netwww.sochara.orgwww.phrnindia.orgwww.communityhealth.in
National Rural Health Mission- India2005-2012MECHANISMSOF ENGAGEMENTTask forces- India Public Health Standards- ASHA Mentoring Group- Medical Education and HRD- Advisory Group for CommunityActionPartnerships- Community Monitoring andCommunity Action for Health- ASHA Training- Common Review Missions etcRole : Participatory Governance by Civil Society (7)
Role : Involvement in Multisectoral dialogue (8)WHO CSDH Report• PHM and Civil Societycommissioners• Dialogue with civil societyin different regions• Civil Society report onSocial Determinants ofHealth submitted tocommission• Civil Society membersparticipated in variousknowledge hubs• Civil society partnership inadvocacy
Role: Capacity Building (9)The International People’sHealth University (IPHU)The International People’sHealth University (IPHU)is one of the majorprograms of thePeople’s HealthMovement (PHM) –Global. IPHU is a globaluniversity providingshort courses and otherresources for healthactivistsTraining youngprofessionalsin the politics of health
Role : Capacity Building (9)Community Health Learning Program of SOCHARA, IndiaFRAME WORK Development of Community HealthPractionersSharpen analytical skills and deeperunderstanding social/ societal paradigm ofcommunity health and public healthEngagement with state society, andcommunitiesOrientation and skills with focus onequity, rights, gender, and social determinantsof health.Capacities for community healthaction, community actionresearch, educational strategies, and policydialogue and action
Role : Campaigns on Specific Health Challenges ( 10): Health effects of social and trade policies
Role : Campaigns on Specific Health Challenges ( 10)Health in Conflicts
INNOVATIVE INSTRUMENTS- 1WATCHESPeople’s Rural Health Watch, INDIA 2008www.gapminder.orgGlobal equity guage alliancehttp://www.gega.org.za/
INNOVATIVE INSTRUMENTS- 2People’s health tribunals in India(Jan Sunwais – Jan Samvad)
INNOVATIVE INSTRUMENTS- 3Health Assemblies of Civil SocietyPHM Health Forum at World Social Forum January 2004
INNOVATIVE INSTRUMENTS- 3The Mumbai Declaration-2004(1454 people from 75 countries)•Implement comprehensive andsustainable primary health careinvolving marginal sectors indecision•Develop comprehensive primaryhealth care oriented interventionsfor HIV/AIDS epidemic enhancinginvolvement of people affectedcommunities and civil society in itsplanning through proactivedialogue…..•incorporate the needs ofmarginalized population, theunheard and unseen in health anddevelopment strategies and socialpolicies in a rights context……
INNOVATIVE INSTRUMENTS- 3Health Assemblies of Civil SocietySecond People’s Health Assembly 2005, Cuenca - Ecuador
INNOVATIVE INSTRUMENTS- 3The Cuenca Declaration Ecuador-2005• “ struggle for comprehensive primary healthcare and sustainable, quality local, and nationalhealth systems.• raise awareness among communities onpolicies, policy making process and financialissues to enable them to monitor governmentperformance increase accountability andaddress health equity issues.• gather within its movement positiveexperiences of comprehensive PHC to build upthe evidence base ….. and to undertakeconcerted advocacy for its revitalization”
Innovative instruments - 4CAMPAIGN INNOVATIONSCampaign for Ethical Marketing of Drugs, Germany
Innovative instruments - 4CAMPAIGN INNOVATIONSRight to Primary Health Care Campaign- South India
Innovative instruments - 5Peoples Health Manifesto India – 2009( Dialogue with all political parties)Suggested effective measures to achieve right to health• Enactment of National Health ACT- to guarantee the basicaffordable quality health care services in all clinicalestablishments including the private establishment• Rural Infrastructure and the National Rural Health Mission-Increased allocation and effective utilization of Funds andstrict action on corruption• Drug Medicines and Patents- List of Essential andConsumable drug s by the state. Ethical code of marketingmedicine and revival of public sector companies on medicineand vaccines• Gender and Health – Abolish coercive laws on policies andpractices that violate the reproductive and democratic rightsof women and Assure women of gender-specific healthentitlements• Child Health and Nutrition – Urgency for a National policy onChild health and nutrition. Universalization with quality IDCS
Innovative instruments - 6DEVELOPMENTS IN PUBLIC HEALTH POLICY THROUGHHEALTH POLICY PROCESSES INVOLVEMENT BY CIVIL SOCIETYPOLICY PROCESS ENGAGEMENT BY CIVILSOCIETY IN INDIA- 1998-2013NATIONALKARNATAKANRHMORISSA
Some emerging concepts and paradigmsTHE PARADIGMSHIFTGLOBALIZATION OFHEALTH SOLIDARITYFROM BELOWSOCIAL VACCINE COMMUNITIZATIONCIVIL SOCIETY INVOLVEMENTIN HFA+SEPCE Analysis
CONCEPT / PARADIGM - 1PEOPLE CENTRED HEALTH POLICY RECOGNISING THEPARADIGM SHIFTApproach Biomedical, deterministic,techno managerial modelParticipatory social/community modelLink withcommunityAs passive client orbeneficatoryAs active and empoweredparticipantDimensionsExploredPhysical and technical(Mostly Medical)Psycho- social, cultural,economic, political, ecological(intersectoral)Focus ofParticipationResources, Time/ Skills Leadership, Ownership,direction setting, Monitors.CHW Role Service provider, educator,organiser, data collectorMobilisor, activist, empowerer,social auditor, monitor.ResearchPolicyCommunity participation asmeansPatient Centredness andmarket /system orientationCommunity participation asendsPeople centred Empowermentstrategy as the central themeSource: CHC 2008
CONCEPT / PARADIGM - 2“Globalization of Health Solidarity from below”(Academics describe civil society engagement process)( 1)(2)(3)(4)
CONCEPT / PARADIGM - 3“Globalization of Health Solidarity from below”(Academics describe civil society engagement process)This movement is engaged in what amounts to ‘globalization frombelow’ as it builds support for its global ‘Health For All Now’ strategy,lobbies at the global level and mobilizes a grassroots based campaign torealize the vision and achieve the goals of the People’s Charter forHealth.” (1)The simultaneous rise of a global civil society movement pressing forpolitical actions to shift the rules of contemporary globalization issignificant (People’s health movement et al 2005 ) (2)A strong voice in the global health debate for free primary health care is thepeople’s health movement which in 2000, presented the Peoples Health Charter.The charter argues strongly for a publicly financed health services and fordevelopment policies that favours health…. (3)Recognizes the movements role in evolving the new health and human rightsapproach to Primary Health Care – with the necessity of tackling the broadersocial and political determinants of health (4)
CONCEPT / PARADIGM - 3Social Vaccine: A new metaphor• Fran Baum, RaviNarayan, DavidSanders, Vikram Patel, andArturo Quizhpe,• Social vaccines to resist andchange unhealthy social andeconomic structures: auseful metaphor for healthpromotion,• Health PromotionInternational,2009 Vol. 24No. 4, 428-433“Social Vaccine would bepromoted as a means toencourage popular moblizationand advocacy to change thesocial and economic structuralconditions that render peopleand communities vulnerable todisease.They would facilitate social andpolitical processes that developpopular and political will toprotect and promote healththrough action on the social andeconomic determinants”
CONCEPT / PARADIGM – 4Communitization“ The institutionalization of community led action for health due to civil society andngo pressure and experimentation has been a significant feature of the NRHM inIndia. Communitization now includes Village health and sanitation committees Selection and training of social health activists Involvement of local self government andcommunity based organization Community monitoring and planning for action inhealth Periodic People’s hearings - Jan Sunwais or JanSamvad Untied funds for use at local discretion …. And other evolving initatives.
SEPCE AnalysisThe scope and reach of epidemiology which is an integralpart of public health must be expanded to include thestudy of the social, cultural, economic, ecological andpolitical determinants of health and constitute the keystone for use of evidence for development of publichealth policy…… Such an approach will help in movingbeyond health problems to per se to new complex socialand human development challenges such as the currentcrisis and threat to public health, pose by the globalfinancial meltdown and climate change’Source: WHO SEARO (46)
An emerging Tool Kit -1Involving Community, Civil Society, and Social Movements in HiAP1. Right and Duty ( Alma Ata)2. Promote maximum community and individual self reliance andparticipation ( Alma Ata)3. Involve individuals, families, communities, professionals, andsocial groups ( Ottawa)4. Empower communities to enhance ownership and control (Ottawa)5. join forces in their commitment to public health alignment(Adelaide)6. Public health and ecological movements to develop strategies fordevelopment and conservation ( Adelaide)7. Encourage collaboration in peace, human rights, social justice,ecology and sustainable development, ( Adelaide)8. Broad alliance of advocates and activists for health environmentand social justice towards Health For All ( Sundsvall)
An emerging Tool Kit - 2Involving Community, Civil Society, and Social Movements in HiAP9. Make people centre of health promotion action and decisionmaking ( Jakarta)10.Creation of new parternerships between different sectors ofgovernance and new and diverse networks created to achieveintersectoral collaboration (Jakarta)11.Active participation of all sectors and civil society in healthpromoting action and partnerships for health ( Mexico)12. Grass roots community projects, civil society groups and women’sorganizations can provide models for practice for others to follow.( Bangkok)13.Meaningful and equitable participation and control in decisionmaking of all groups including those experiencing social, economic, or political exclusion (Nairobi)14. Communities must share the power, resources and decisionsmaking to assure and sustain conditions for health equity15. Building community capacity duringplanning, implementation, monitoring and evaluation. (Nairobi)
An emerging Tool Kit - 3Involving Community, Civil Society, and Social Movements in HiAPAdditional ideas taken from the evolving frame work for countryaction being discussed in Helsinki.16. Broader participation in discussions and exchanges17. Civil Society and research community invited to give evidence inbroader hearings, seminars and consultations.18. National Health Assembly established by an Act as in Thailand,bringing together various actors and sectors in participatory policymaking19. Citizens juries producing a report to an oversight panel that includepolicy makers and interested parties20. Alternative mechanisms to draw views from general public orparticular population groups through opinion survey ,focussedgroup , e-cafes, open spaces and website commentaries.(Many other ideas and components for the tool kit will emergein the discussions during this conference).
World Health Report 2008Recognizing the role of civil society• “The history of the politics of the PHCreform in the countries that have mademajor strides largely unwritten. It is clearhowever where these reform have beensuccessful, the endorsement of the PHC byhealth sector and by the political word hasinvariably followed on rising demand andpressure expressed by civilsociety………..There is an important lessonthere; powerful allies for PHC reform are tobe found within civil society. They can makedifference between a well-intentioned butshort – lived attempt and successful andsustained reform; and between a purelytechnical initiative and one that is endorsedby the political word and enjoys socialconsensus.”• Source: World Health Report, 2008 (45)
WHO Commission on Social Determinants in HealthReport – 2008Recognizing Civil Society as champions of equity“As community members, grassrootadvocates, service and programmeproviders, and performancemonitors, civil society actors from theglobal to local level constitute a vitalbridge between policies and plan andreality of change and improvement inthe lives of all. Helping to organizeand promote diverse voices acrossdifferent community, civil society canbe a powerful champion of healthequity.”Source: WHO Commission on SocialDeterminants of Health, 2008, (46)
The Challenges for HiAP• Are we ready to move from policy rhetoric to communitymobilization through the active participation andengagement with civil society and social movements?• Are we ready to engage with civil society and socialmovements creating spaces for dialogue and engagementthat will enable them to play the different roles and use theinnovative methods of dialogue and engagement ?• Are we ready , through this engagement for recognizing thedeeper social, economic, cultural, political, and ecologicaldeterminants of health, that act as obstacles to our effortstowards Health in All polices and Health For All?The evidence is there – will policy actionand practice on the ground follow!
For further information visitwww.sochara.orgwww.phmovement.orgwww.ghwatch.orgwww.phmovement.org/iphuwww.phm-india.orgwww.mfcindia.orgwww.communityhealth.inhttp://www.phmovement.org/iphu/http://mohfw.nic.in/NRHM.htmTHANK YOU