Dialogue on Health of the Urban Poor in Bangalore

Focusing on Persons with Mental Illness, Disabilities and Senior Citizens

18th December 2012SOCHARA – CHC – Madiwala, Bangalore

Thelma NarayanCentre for Public Health and Equity, SOCHARA,

Bangalore

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!

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 SPOTSAbsence of Space and of functional programs with dignity and respect for persons with mental illness, disability and senior citizens

• 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

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?

Health, Wellbeing & Development in an era of Globalisation

Inequalities, vulnerabilities, trends,

Underlying determinants

ContradictionsRights, responsibilities,Accountability systemsSystems, convergenceSociety wide

participatory , inclusive mechanisms

PATHWAYS‘Globalisation of

Solidarity from Below’ – eg the PHM/ other initiatives

Addressing the social determinants of health

Research for Health, Development and Equity

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”

Tracing the development of the ideaDo 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

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

The right to health: in-dissociable and inter-dependent right

The Universal Declaration of Human Rights (UDHR), UN 1948the 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.”

The Right to Health An individual inalienable right

The States parties to the International Covenant on Economic, Social and Cultural Rights ( ICESCR), 1966 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

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

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 …..

Health for All –A Prescription by the ICMR and ICSSR,Health for All –A Prescription by the 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 1983Drew 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

Placebo Policies – Be Aware and Beware!

Those with no intention of being implemented.Keeps people happy and hopeful.Masks the situationAllows for capture of policy space by eliteOccurs with a passive population,

disempowered.

What should be our response?

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

Tackling the Social Determinants of Healththrough 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, 2005 -2008

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.

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

Poverty, Inequality, Discrimination

Development Health

The National Rural Health Mission, India

And other policies

National Rural Health Mission 2005-2012 Evolving through the politics of engagement

Goal availability …access …quality health care,

rural poor, women and childrenPrinciples 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.

NRHM OBJECTIVESReduce 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.

Village Health and Sanitation Committee

(VHSC)

NRHMCOMMUNITISATION

COMPONENTS

Citizens Charter for PHC and CHC’s

NGO-Civil Society involvement

Village Health Plan

Accredited Social Health Activists (ASHA)

+ASHA support systems

Rogi Kalyan Samiti (RKS)

Patient Welfare Committee Arogya Raksha Samiti

PRI Role

COMMUNITISATION COMPONENTS

Community Monitoring & PlanningAdvisory 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

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 HealthSource: Manual on Community based Monitoring of

Health Services under NRHM, 2007. AGCA.

Community ActionA three way partnership

Health System

Community, Community Based Organisations

(CBOs) and NGOs

Panchayat Raj Institutions (PRI)

Source: Manual on Community based Monitoring of Health Services under NRHM, 2007. AGCA.

Right to EducationRight to InformationMGNREGADraft National Health Bill, 2009Draft Mental Health Bill, 2010Persons with Disability Act (Amended)Mental Health Policy and revised DMHP…

•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

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

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)

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.

Globalization of Solidarity for Health From Below

Jan Swasthya Sabha, Kolkata 2000Over 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

“Health is a social, economic and political issue and above all a fundamental human right.”

Challenges & Opportunities

Right to Health Movement : India 2001Right to Health Movement : India 2001

Primary Health Care and Health for AllPrimary Health Care and Health for All

People’s TribunalsOn Right to Health

Regional Urban

National

PeoplesRuralHealthWatch

PEOPLE’S HEALTH MOVEMENT -JAN SWASTHYA ABHIYAN

Right to health campaignRight EquityGenderRight to Information

Right to Food &

Right to Water campaigns

Pre-election dialogue with Political parties:

Health in the Manifestos

Community Monitoringof National RuralHealth Mission

People’s TribunalOn World BankPolicies - India

Asian Social Forum, January 2003, Hyderabad

JSA members organized workshopson:1. The Right to Health Care2. Environment and Health3. Tobacco and Health4. The People’s Health Movement

Asian Social ForumAsian Social ForumJanuary 2003, Hyderabad - INDIAJanuary 2003, Hyderabad - INDIA

World Social Forum, January 2004, MumbaiWorkshops on health rights & determinants by JSA

and PHM

Health Policy Dialogue and Action

Adopted by Karnataka State Cabinet in 2004

Interim Report in April 2000Final Report in April 2004

Accepted by Govt of KarnatakaHigher Level Implementation Committee setup

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

Second National Health Assembly

Bhopal- India 2007

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 .

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

Health for All, Now !

BE PART OF THE CHANGE PROCESS! THANK YOU