Upload
cphe
View
6.154
Download
2
Embed Size (px)
Citation preview
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- 30th anniversary of the Alma- Ata Declaration on Primary Health care (WHO/UNICEF)
Almaty, Kazakhstan 15-16 October 2008
The Challenge in the new millennium: Towards a People- centred PHC
• The People back into the centre of primary health care
• The Public back into Public health systems
• The Community back into the health policy discourse.
Plan of Presentation
• People Centered Primary health care before Alma Ata-1978 (with a focus on India)
• People Centered Primary health care – since Alma Ata -1978• Globalization of health from above : the distortion of PHC and loss of
the community and the people-orientation since 1990’s• 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
• Towards a People-centered PHC – forward beyond Almaty – 2008 : the core agenda of the future
Health Survey and Development Committee- IndiaBhore Committee (1946)
• “No permanent improvement of public health can be achieved without the active participation of the people in the local health program….• 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 programme 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
People Centered Primary health care before Alma Ata-1978 - I
•CHWs - Jamkhed• VHWs - Indo-Dutch, project Hyderabad• Lay First Aiders – VHS -Adyar, Chennai• Link workers - CLWS tea plantations• Health Aides – RUHSA• MCH workers - CINI, Calcutta•Swasthya Mitras – BHU Varanasi•Sanyojaks - Banavasi Seva Ashram, UP• CHW’s- St. John’s Bangalore, • Rehbar-e-Sehat - Teacher workers of Kashmir• CHVs - Sewa Rural, Jhagadia
CHW’S IN INDIA – AN OVERVIEW 1970s & 1980s)
People Centered Primary health care before Alma Ata-1978 - II
• Predominantly women• Mostly voluntary or link workers with minimum support• Mostly mature, married volunteers • Care taken to prevent the cooption by village leaders • Care taken to encourage representation of all segments• The participation of the community in identifying CHWs and
their supervision• The training programme - innovative components and methods • Well trained and highly mobile, field and supervisory staff. • Many projects had women on local action / advisory committees• Many had local women groups supportive of the process.
Source : CHC, 1997
The CHW’s of the NGO Sector in India (1970s & 1980s) An Overview
People Centered Primary health care before Alma Ata-1978 - III
Alternative Approaches to Health care- an ICMR Study 1976
• Integrating Health with development activities
• Preventive and Promotive services
• Appropriate Technology• Utilization of local resources and
healers• Village based health cadres• Community participation• Community organization• Local finances through
cooperatives• Education for health• Conscientization and political
action
Source: Narayan, 1985
ICMR initiative and Monograph 1976
People Centered Primary health care before Alma Ata-1978 -IV
Local Self Governance / Village Health Committee
Community asResource
For Health Care including
Traditional Practitioners / TBA’s
People-centred Community health
(primary health care)
Community Organization:
•Women's organization’s
•Youth clubs•Farmers
Coperatives
Community Health Worker’s / Volunteers
People-centred Community health: an evolving understanding 1978
People Centered Primary health care before Alma Ata-1978 - V
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
People Centered Primary health care - Alma Ata -1978 - I
WHO and UNICEF Study, 1977 - IIPrinciples to achieve primary health care:
• Communities should be involved in the designing, staffing, and functioning of their local primary health care centres and in other forms of support.
• The primary health care workers should be selected when possible by the community itself or at least in consultation with the community
• Respect for the cultural patterns and felt needs in health and community development of the consumers…..
People Centered Primary health care - Alma Ata -1978 -II
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 2000AD by 2000AD Alma Ata, 1978
People Centered Primary health care - Alma Ata -1978 -III
The Alma Ata Declaration- 1978The Alma Ata Declaration- 1978
• “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”
People Centered Primary health care - Alma Ata -1978 -IV
People Centred Primary health care- evolving guidelines
People Centered Primary health care - Alma Ata -1978- V
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 and spread education.
•Organise 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 …..”
• Provide community Health volunteers with special skills, readily available, who see health as …… a social function”
•“ 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
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, 1992The Strategy of Preventive Medicine
Researching levels of analysis and solutions:Addressing the societal determinants of health
(A SOCHARA Researcher)
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.
Source: Narayan T.,1998
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
Towards a New Paradigm of Community Health and Community Participation through civil society initiative in
India – 1984-1999• 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 ………
“Community health is a process of enabling people, to exercise collectively their responsibility to their own health and to demand health as their rightCommunity 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…..” source: the CHC axioms – red book, 1986
The New Community Health Paradigm
Less Food, No water, No jobs!!!
Listening to the people!
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.
1. Globalization and Health 2. Primary Health Care?3. Inter-sectoral Action4. Empowerment of the socially Marginalised 5. Confronting Commercialization of health care
1
2
5
3
4
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
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”.
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
RECOGNISING HEALTH CRISIS- 1990’S by Global Civil Society -I
• ECONOMIC CHANGES AFFECTING PEOPLES HEALTH AND ACCESS TO HEALTH / SOCIAL SERVICES
• POVERTY AND HUNGER INCREASING
• GAPS BETWEEN RICH AND POOR NATIONS WIDENED; INEQUALITIES WITHIN COUNTRIES INCREASING
• LARGE PROPORTION LACK ACCESS TO BASIC NEEDS (FOOD, WATER, SANITATION, LAND, SHELTER, EDUCATION)
• PLANETARY RESOURCES BEING RAPIDLY DEPLETED
RECOGNISING HEALTH CRISIS- 1990’S by Global Civil Society -II
• UPSURGE OF CONFLICTS / VIOLENCE
• WORLDS RESOURCES INCREASINGLY CONCENTRATED IN HANDS OF FEW WHO STRIVE TO MAXIMISE THEIR PROFIT
• NEW ECONOMIC / POLITICAL POLICIES AFFECTING LIVES, LIVELIHOODS, HEALTH AND WELL BEING OF PEOPLES IN SOUTH AND NORTH
• PUBLIC SERVICES DETERIORATING, UNEVENLY DISTRIBUTED AND INAPPROPRIATE
• PRIVATIZATION UNDERMINING ACCESS AND EQUITY PRINCIPLES
Source-PHA 2000
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 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….”
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”
The People’s Charter for Health(1454 people from 75 countries)
Dec 2000
The Mumbai Declaration-2004(1454 people from 75 countries)
•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 2004released 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.”
The Cuenca Declaration Ecuador-2005
• “PHM will struggle for comprehensive primary health care and sustainable, quality local, and national health systems.
• 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.
• 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”
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 People Centered PHC 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 is setup by the National Human Rights Commission
The senior-most State health officials act as respondents
People’s health tribunals in India – I (2004)Dialogue with policy makers on behalf of the movement
•People and activists present case studies and survey reports
•Proceedings are videotaped and documented
•Attended by members of the community / civil society
People’s health tribunals in India - IIDialogue with policy makers on behalf of the movement
Second National Health Assembly Bhopal- India 2006
Themes discussed included• Listening to voices of marginalized people
• People’s Health Rural Watch• Community based monitoring of NRHM
• Towards the people’s health plan • Campaign against coercive population policies
• Realizing right to essential drugs• Dialogue with health policy makers
• Dialogue with other social movements
People’s Rural Health Watch, 2008Recommendations
• ASHA’s to be chosen through a consultative village process
• Constitution and training of village health and sanitation committees before preparation of village and district health plans
• Community based monitoring to be integral part of public health system and not a stand alone component
• The communitzation option, with public people partnerships to replace the privatization options….
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
Links with Right to food and
right to water campaigns
Redefining People centered PHC 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 People-Centred PHC thru 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
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!
Redefined People centered PHC Training in NRHM/ PHRN -I
Panchayat Raj Institution and Health programmes Institutionalisation of community participation, village health committees and CBO’s Village health planning Involving NGO’s in community participation Peoples movements and campaigns for health Community monitoring.
Redefined Community Participation Training in NRHM/ PHRN -II
Understanding community participation
Community Health workers Selection of ASHA’s Training CHW’s in a large
scale programme Supporting the ASHA Community mobilisation,
social mobilisation Village level partners in
community participation
Redefining People centred PHC– Experiences from the Global South
Central AmericanNetworks
Guatemala/ Nicaragua and Ecuador
The ThaiNational Health
Movement, Thailand
HIV/AIDS PatientsNetworks ( TAC) and other initiativesSouth Africa
Health Campaigns,Struggles, and
Community mobilizationefforts from many parts
of the World
Global PHM as learning Network
India Brazil
Philippines
Nepal IRAN
Others
PEOPLE CENTRED PHC – RECOGNISING THE PARADIGM SHIFT – 2000AD and beyond
Approach Biomedical, deterministic, techno managerial model
Participatory social/ community model
Link with community
As passive client or beneficatory
As active and empowered participant
DimensionsExplored
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 endsPeople centred Empowerment strategy as the central theme
Source: CHC 2008
The New Public Health Paradigm (The First Text Book from the Movement)
Chapter on Participation and Health Promotion
Participation
Psuedo – participation is a means
Participation as a means
Participation as a end
Participation as a power
Continuum
Consultation
Participation as a means
Substantive participation
Structural participation
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
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
A WHO - SEARO Exhortation for mainstream Public Health to engage 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
• “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
• 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……”
GHW-I: First Alternative World Health Report: Released at Cuenca, Ecuador – July 2005
GHW-2: the second Alternative World Health Report to be released in London – October 2008
Inspiration, courage and resistance – a new understanding of people -centred PHC
1. Political and Social Action against theft of land and water
2. Right to health care campaigns 3. Movements for food sovereignty 4. Community Partnerships to improve water
and sanitation 5. Campaigns for Access to Essential
medicines 6. Campaigns for health and health care of
vulnerable groups
Primary Health Care as a Health for All Movement !
ALMA ATA – 30 YEARS ONALMA ATA – 30 YEARS ON
People - centred PHC -The policy imperative of the People - centred PHC -The policy imperative of the future!future!
Poverty / Inequality
Building the bridge through People-centredness: Are we ready?
For further information visitwww.sochara.org
www.phm-india.orgwww.phmovement.org
www.ghwatch.orghttp://www.phmovement.org/iphu/http://mohfw.nic.in/NRHM.htm