1. “Towards Social Justice in Health”
Dialogue on Health of the Urban Poor in Bangalore
Focusing on Persons with Mental Illness,
Disabilities and Senior Citizens
18th December 2012
SOCHARA – CHC – Madiwala, Bangalore
Thelma Narayan
Centre for Public Health and Equity, SOCHARA,
Bangalore

2. With a review of health policy (NUHM + 12th Plan) and NGO initiatives, and engagement in practice, with a Comprehensive Primary Health Care approach …we can together make a difference to Equity in Health in Bengaluru!

3. Policy Process and the Politics of Health
Tracing the development of ideas and institutions that impact on the Health of Communities and on certain sections in particular
Local, National and Global interconnectedness
BLIND SPOTS
Absence of Space and of functional programs with dignity and respect for persons with mental illness, disability and senior citizens

4. Plan of Presentation
After an Introduction, the first set of slides trace the history of the idea about health and related rights and participation –
Together they highlight the nature of the challenges,
The second set of slides are a snapshot of responses by the community, civil society, governments and academics over the past decade indicating critical pathways and partnerships to address health inequalities

5. How do we engage with politics and policy?
From the 1970s and before there were stated efforts towards:
“Promoting sustainable, equitable, participatory development, community health and social justice.”
What drives the health and development agenda? LPG, science, technology, capital, management.
Do the social majority have a say?
Are there inclusive mechanisms?
How can we create them?

6. Health, Wellbeing & Development in an era of Globalisation
Inequalities, vulnerabilities, trends,
Underlying determinants
Contradictions
PATHWAYS
‘Globalisation of Solidarity from Below’ – eg the PHM/ other initiatives
Addressing the social determinants of health
Research for Health, Development and Equity
Rights, responsibilities,
Accountability systems
Systems, convergence
Society wide participatory , inclusive mechanisms

7. Inter-connected Rights and Pathways towards Social Justice and Equity in Health – Waves of Change…..
“A Globalisation of solidarity from Below”
Social mobilisation and a Peoples Health Movement with constructive, critical engagement between civil society and the State…. since 2000
Revitalising Health for ALL and comprehensive primary health care
Addressing health determinants – CSDH Knowledge Networks and Report, 2008; Rio Conference 2011
The Bamako Inter-Ministerial Conference on “Research for Health, Development and Equity”

8. Change in a Generation, WHO – Commission on Social Determinants of Health, 2008
Tracing the development of the idea
Do we believe it is possible?
How do we go about it?
What is our role – as individuals, organisation’s?
Can we join with larger collectives in today’s interconnected world

9. Right to Health: Is this new?
The World Health Organization (WHO) Constitution
“ Health is a state of complete physical, mental, and social wellbeing and not merely the absence of disease or infirmity.”
“ The enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being without distinction of race, political belief, economic or social condition”
Source: WHO 1946

10. The right to health: in-dissociable and inter-dependent right
The Universal Declaration of Human Rights (UDHR), UN 1948
the basis of all human rights and the primary human rights instrument in force, mentions the right to health in article 25, in connection with other economic, social and cultural rights:
“Every one has the right to a standard of living adequate for the health and well being of himself and of his family, including food, clothing, housing and medical care and necessary social services, and the right to security in the event of unemployment, sickness, disability, widowhood, old age or other lack of livelihood in circumstances beyond his control.”

11. The Right to Health An individual inalienable right
The States parties to the International Covenant on Economic, Social and Cultural Rights ( ICESCR), recognize:
“the right of everyone to the enjoyment of the highest attainable standard of physical and mental health” Article 12.1
For the committee on Economic, Social, and Cultural Rights (CESCR) the main body at the international level monitoring the realization of the right to health,
“Health is a fundamental human right indispensable for the exercise of other human rights. Every human being is entitled to the enjoyment of the highest attainable standard of health conducive to living a life in dignity” CESCR

12. Fostering Action…..in Solidarity
“ Since human development also means solidarity, the need to work with the family, neighbourhood and village and the practice of community medicine was considered necessary. Health personnel should “listen and learn” and should be “more concerned with fostering action than undertaking it themselves”.
Source: CBCI Memorandum, 1971

13. WHO and UNICEF Study, 1977 - II Principles 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 …..

14. For a mass movement post Alma Ata
Health for All –A Prescription by the ICMR and ICSSR, 1981
For 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”

15. National Health Policy 1983
Drew some inspiration from the HFA goal and approach
Large scale transfer of knowledge, simple skills and technologies to health volunteers, selected by the communities and enjoying their confidence.
The success of the decentralized primary health care system would depend on the organized building up of individual self reliance and effective community participation.
The NHP 2002 has a different perspective and approach

16. Placebo Policies – Be Aware and Beware!
Those with no intention of being implemented.
Keeps people happy and hopeful.
Masks the situation
Allows for capture of policy space by elite
Occurs with a passive population, disempowered.
What should be our response? 16

17. Social relevance and orientation of health efforts Is there need for a paradigm shift? Biomedical, old public health, to a societal approach built on human agency, participation, inclusiveness

18. Community Health
“ Increases individual, family and community autonomy over health and over the organisation’s, means, opportunities, knowledge and supportive structures that make health possible.”
Community Health Cell, 1987

19. Tackling the Social Determinants of Health through society wide action
“There is an urgent need to address the root cause of inequalities in disease, disability and health.
Social conditions in which people live and work or the social determinants of health.”
Source: WHO- CSDH,
This was followed up by the Rio Declaration in 2011 in which governments, civil society and academic and research organizations pledged to work together to bring about change …? in a generation.

20. Poverty, Inequality, Discrimination Health Development
Health is a determinant of Development – UNDP 2005
Development is a determinant of Health
The deeper determinants of both need to be addressed as a priority at global, national and local levels

21. Healthy Public Policies
The National Rural Health Mission, India
And other policies

22. National Rural Health Mission 2005-2012 Evolving through the politics of engagement
Goal
availability …access …quality health care, rural poor, women and children
Principles
improve access to equitable, affordable, accountable, effective primary health care.
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 panchayat.
panchayati raj institutions to own, control and manage public health service.
COMMUNITIZATION
HUMAN RESOURCES
GOVERNANCE
FLEXIBLE FUNDING
MANAGEMENT

23. NRHM OBJECTIVES Reduce child and maternal mortality.
Universal access to public health care and public services for food, nutrition, sanitation.
Prevention and control of communicable and non communicable diseases.
Access to integrated comprehensive primary health care.
Stabilize population with gender and demographic balance.
Revitalize Local Health Traditions and mainstream AYUSH.
Health Promotion.

24. Accredited Social Health Patient Welfare Committee
COMMUNITISATION COMPONENTS
Village Health and
Sanitation Committee
(VHSC)
Citizens Charter for
PHC and CHC’s
NGO-Civil Society
involvement
Accredited Social Health
Activists (ASHA) +
ASHA support systems
NRHM
COMMUNITISATION
COMPONENTS
Village Health Plan
Rogi Kalyan Samiti
(RKS)
Patient Welfare Committee
Arogya Raksha Samiti
PRI Role

25. Community Monitoring & Planning
Advisory Group on Community Action for the NRHM (AGCA)
Pilot tested in 9 states
Expansion through Project Implementation Plans/ Central fund
Posters, pamphlets survey forms
Media fellowships

26. Community Planning & Monitoring of Health Services/Community Action for Health
Places people at the center of the process of regularly assessing the fulfillment of their health rights and needs
Is one of the three proposed accountability frameworks of NRHM
Seen as important to promote community led action in Health
Source: Manual on Community based Monitoring of Health Services under NRHM, AGCA.

27. Community Action A three way partnership
Health System
Panchayat Raj Institutions (PRI)
Community, Community Based Organisations (CBOs) and NGOs
Source: Manual on Community based Monitoring of Health Services under NRHM, AGCA.

28. Other Relevant Policies
Right to Education
Right to Information
MGNREGA
Draft National Health Bill, 2009
Draft Mental Health Bill, 2010
Persons with Disability Act (Amended)
Mental Health Policy and revised DMHP…

29. Pathways of Change Recognising the crises in India in the 1990’s
Retreat of the State
Lack of inter-sectoral action for health
Inadequate mechanisms for community participation in decision making …..etc

30. With people back into the centre of primary health care
Meeting Challenges in the New Millennium: with a Person Centric Approach together with a societal and policy perspective
With people back into the centre of primary health care
The public back into public health and health systems
and community voice and power back into health policy discourse & decisions,
As subjects & co-creators not objects

31. Towards the first PHA, 2000 AD. An alternative to the WHA
THE G 8 OF THE PHA
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)

32. The People’s Health Resource Books, India, 2000
“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, 2000,
DG Emeritus, WHO.

33. Globalization of Solidarity for Health From Below Jan Swasthya Sabha, 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
Health as a Fundamental
Human Right

34. The People’s Charter for Health
“Health is a social, economic and political issue and above all a fundamental human right.”

35. Challenges & Opportunities
Realizing health rights & entitlements within a time frame.
Achieving equity in health through public policy & action
Addressing inequalities in access to the distal determinants of health

36. Right to Health Movement : India 2001
Primary Health Care and Health for All

37. Redefining Community Participation by Civil Society in India 2000-2008
Right to health campaign
Right
Equity
Gender
Right to Information
People’s Tribunals
On Right to Health
Regional
Urban
National
Peoples
Rural
Health
Watch
PEOPLE’S HEALTH MOVEMENT
-JAN SWASTHYA ABHIYAN
Community Monitoring
of National Rural
Health Mission
Pre-election dialogue with
Political parties:
Health in the Manifestos
Right to Food
&
Right to Water campaigns
People’s Tribunal
On World Bank
Policies - India

38. Asian Social Forum, January 2003, Hyderabad
JSA members organized workshops
on:
The Right to Health Care
Environment and Health
Tobacco and Health
The People’s Health Movement

39. Asian Social Forum January 2003, Hyderabad - INDIA

40. World Social Forum, January 2004, Mumbai
Workshops on health rights & determinants by JSA and PHM

41. Health Policy Dialogue and Action
Adopted by Karnataka State
Cabinet in 2004
Interim Report in April 2000
Final Report in April 2004
Accepted by Govt of Karnataka
Higher Level Implementation Committee setup

42. MAINSTREAM DEVELOPMENTS IN PUBLIC HEALTH WITH ALTERNATIVE SECTOR PARTNERSHIPS – 1998-2008

43. Second National Health Assembly Bhopal- India 2007
People’s Health Rural Watch
Community based monitoring of NRHM
Dialogue with other social movements
Revitalising the Movement
Right to essential drugs
Dialogue with health policy makers
State unit strengthening
Towards a people’s health plan
Campaign against coercive population policies

44. Community Monitoring and Action for Health
Social audits and more regular forms of community driven monitoring of programs are essential, and should be universalized and integrated with community action for all programs.
Increasing citizen responsibility and capacity to addressing health determinants eg gender, caste, class, stigma and discrimination .

45. Together …we can make a difference to Health in Bengaluru!

46. BE PART OF THE CHANGE PROCESS! THANK YOU
Health for All, Now !
BE PART OF THE CHANGE PROCESS! THANK YOU