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Community Approaches for Health System Strengthening & addressing
the Social Determinants of Health
Dr. Thelma Narayan
Centre for Public Health & Equity, SOCHARA Bangalore
ITM Antwerp, 2008
Primary Health Care in the 21st Century
New Challenges & Opportunities for the First Line
Nutritional Status of Children under 3 years: shift from NFHS-2 to NFHS-3
20
43
51
23
4045
0
10
20
30
40
50
60
Stunted Underweight Wasted
NFHS-2 NFHS-3
Source: National Family Health Survey 3- 2005-06, NFHS2-1998-99
Anemia Prevalence Among Under 3’s in India
Anaemia Prevalence State
Anaemia prevalenceAnaemia prevalence
more than 70 percentmore than 70 percent
BiharBihar
Madhya PradeshMadhya Pradesh
Uttar PradeshUttar Pradesh
HaryanaHaryana
ChhattisgarhChhattisgarh
Andhra PradeshAndhra Pradesh
KarnatakaKarnataka
JharkhandJharkhand
Anaemia prevalenceAnaemia prevalence
Less than 50 percentLess than 50 percent
GoaGoa
ManipurManipur
MizoramMizoram
KeralaKerala
Source: National Family Health Survey 3- 2005-06
56% of married and 59% of pregnant women are anaemic.
617665
19
35
23
Total Urban Rural
Given or purchased IFA Consumed IFA for 90 days
Source: National Family Health Survey 3- 2005-06
Percent of Household Having no Toilet Facilities
24
87
70
19
81
64
17
74
55
Urban Rural Total
NFHS-1 NFHS-2 NFHS-3
Source: National Family Health Survey 3- 2005-06, NFHS2-1998-99, NFHS1 1991
Percentage of House Holds by Source of Drinking Water
33 35
26
39 39
19
42
12
43
Piped Hand pump Well water
NFHS-1 NFHS-2 NFHS-3
Source: National Family Health Survey 3- 2005-06, NFHS2-1998-99, NFHS1 1991
Common forms of Violence against married women
37 35
10
16
2724
21
711
40
Physical, sexual,or emotional
violence
Physical orsexual violence
Physical violence Sexual violence Emotionalviolence
Ever In the past 12 months
Source: National Family Health Survey 3- 2005-06, NFHS2-1998-99, NFHS1 1991
Multidisciplinary professional resource network in Public Health & Community Health
Works towards a social and community model of health with an equity, rights, gender, and social determinants perspective.
Works with governments, NGOs & Civil Society, health campaigns, social movements and international health agencies
Part of the People’s Health Movement, Global Health Watch, International People’s Health University, Right to Health Campaign, and PHM advocacy with WHO and WHO-CSDH.
Society for Community Health Awareness, Research and Action
(SOCHARA)www.sochara.org
Challenges at the first line for health system strengthening to address
SDHPlacing: the Community back into primary
health carethe Public back into Public health
and health researchthe People back into the health
policy process.
Challenges & Opportunities
Realizing health rights and entitlements within a time frame.
Achieving equity in health through public policy & action
Addressing inequalities in access to the distal determinants of health
Challenges – Contd….
First line is an integral part of the health system
First line functioning determined by political priorities to public health and health system
Action on inequalities in access to SDH dependent on politico- economic factors
Pro active civil society involvement to address SDH to be strengthened
Role of social movements
“Health is a social, economic and political issue and above all a fundamental human right.”
The People’s Charter for Health
HISTORYHealth Survey and Development Committee- India
Bhore Committee (1946)
• “No permanent improvement of public health can be achieved without active participation of people in local health programs….• 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 program 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)
•“Unless the conscience of citizens as a whole is stimulated to demand and accept better standards of health…..
• 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….”Source : CBHI 1985
•CHWs CRHP, Jamkhed• VHWs - Indo-Dutch project, Hyderabad• Lay First Aiders – VHS -Adyar, Chennai• Link workers – CLWS,tea plantations, Nilgiris• Health Aides – RUHSA, Vellore• MCH workers - CINI, Calcutta• Swasthya Mitras – BHU,Varanasi•Sanyojaks - Banavasi Seva Ashram, UP• CHW’s- St. John’s, Bangalore, • Rehbar-e-Sehat -teacher workers, Kashmir• CHVs - Sewa Rural, Jhagadia• Community Health Guides - other projects
OVERVIEW OF CHW’S IN INDIA 1970s & 1980s
“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.”
Village Health Worker JAMKHED,India, Washington, DC, May 1988
Doctors & Village Health Workers -
Muktabai Pol, a CHW speaks
The Quest for Alternatives pre Alma Ata – a Community Health Movement
Integrated health & development action Preventive & promotive services Appropriate technology Using local resources & healers Village health workers/ cadres Community participation & organization Local finances- cooperatives Education for health Conscientisation & political action
Small Scale Need for scaling up
Source: Narayan, 1985
ICMR Monograph 1976
Local Self Governance / Village Health Committee
Community asResource
For Health Care
COMMUNITY PARTICIPATION
Community Organization
Community Health Worker
Community Participation Policy Statements to System Development in India
(before Alma Ata - 1978)
WHO and UNICEF Study, 1977 - ICase Studies from all over the World
Cuba China Tanzania Venezuela Nigeria Ivanjica, Yugoslavia Savar, Bangladesh Jamkhed, India Maradi,Niger
WHO and UNICEF Study, 1977 - IIPrinciples to achieve Primary Health Care
Communities should be involved in designing, staffing, & functioning of local primary health care centres & in other forms of support.
Primary health care workers should be selected by the community itself or at least in consultation with the community
Respect for cultural patterns and felt needs in health and community development …..
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 The Primary Health Care Movement towards Health for All by 2000ADby 2000AD
Alma Ata, 1978
The Alma Ata DeclarationThe Alma Ata Declaration
19781978
• “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 ICSSRHealth for All – the Prescription of ICMR and ICSSR – 1981 – 1981
For a mass movement post Alma AtaFor a mass movement post Alma Ata
•“Reduce poverty, inequality & spread education
•Organise poor & 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”
National Health Policy 1983
• Large scale transfer of knowledge, simple skills and technologies to health volunteers, selected by the communities and enjoying their confidence.
• Functioning of front line of workers, selected by the community requires 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
• The success of the decentralized primary health care system would depend on the organized building up of individual self reliance and effective community participation.
•“ 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 RECOGNISING THE CRISIS IN INDIA-1990’S
RECOGNISING THE CRISIS IN INDIA-1990’SRECOGNISING THE CRISIS IN INDIA-1990’S
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
An agenda for change pAn agenda for change presented 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
New Paradigms of Community Health through civil society in India 1984-99
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) The Women’s Movement and ………
Less Food, No water, No jobs!!!
Listening to People!
The People’s Health Resource Books in India -2000AD
“These books are the best expressions 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.
Jan Swasthya Sabha, (People’s Health Assembly India), Kolkata
2000
Over 2000 participants in 5 peoples health trains
Mobilization across 19 states Adopted 20 point Indian People’s Charter Launched the Jan Swasthya Abhiyan, campaign for Health for All Now Accepted health as a
Fundamental Human Right JSA, 2000
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
The First Global People’s Health AssemblyDecember, 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.
“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”
The People’s Charter for Health Dec 2000
The Mumbai Declaration-2004
•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 Bangkok 2004
“HIV and AIDS is a development issue calling 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… rooted in internationally accepted human rights and humanitarian norms.”
Corporate led globalization, Neo-liberal economic reforms,
Negative macro-policies
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 2003Right to Health Movement : India 2003
Primary Health Care and Health for AllPrimary Health Care and Health for All
A Peoples Court or Civil Court
A panel of judges and experts set up by the National Human Rights Commission
Senior State health officials respond
People’s Health Tribunals in India – 2004Dialogue with policy makers on behalf of the movement
Second National Health Assembly Bhopal- India 2006
Themes Listening to voices of marginalized people
People’s Health Rural Watch Community based monitoring of NRHM
Towards a people’s health plan Campaign against coercive population policies
Realizing the right to essential drugs Dialogue with health policy makers
Dialogue with other social movements
People’s TribunalsOn Right to Health
Regional Urban
National
PeoplesRuralHealthWatch
PEOPLE’S HEALTH MOVEMENT, - INDIA :
JAN SWASTHYA ABHIYAN
Right to health campaignRight EquityGenderRight to Information
Right to Food &
Right to Water campaigns
Redefining Community Participation by Civil Society in India 2000-2008
Pre-election dialogue with Political parties:
Health in the Manifestos
Community Monitoringof National RuralHealth Mission
People’s TribunalOn World BankPolicies - India
Rediscovering Community Participation and Civil Society engagement , India
NGO- CHW Experience
1980’s – HealthWorkers
The JanataExperiences
The JSR’sof MadhyaPradesh
The Mitaninsof
Chattisgarh
National Rural Health MissionASHA’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
JharkhandPHM India
Revival of Interest in State level Community Health Worker and Community participation
Evaluated by Civil Society Researchers
Jaa Swasthya Rakshaks (JSR) Madhya Pradesh 1991
Mitanin Programme, Chattisgarh -2001
National Rural Health Mission 2005-2012 - Evolving through the politics of engagement
Goal: 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
Principles: 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!
COMMUNITY PARTICIPATION THE PARADIGM SHIFT – 2000 & beyond
Approach Biomedical, deterministic, techno managerial model
Participatory social/ community model
Link with community
As passive client or beneficatory
As active empowered participants
DimensionsExplored
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
Source: CHC 2008
Recognition of Globalization of Solidarity for Health 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
•Action points to address macro-policies and global structural determinants of health
Global Health Watch I & II Alternative World Health Report
Health for All, Now !
JOIN US THANK YOU
For further information visitwww.sochara.org
www.phm-india.orgwww.phmovement.org
www.ghwatch.orgwww.iphcglobal.org
www.mohfw.nic.in/NRHM
