“Towards Social Justice in Health”

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 • Rights, responsibilities, • Accountability systems • Systems, convergence • Society 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

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), 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

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 - 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 …..

14. 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?

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 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.

20. Poverty, Inequality, Discrimination 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 Health Development

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

22. National Rural Health Mission 2005-2012Evolving 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.

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. 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 RogiKalyanSamiti (RKS) Patient Welfare Committee ArogyaRakshaSamiti 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, 2007. AGCA.

27. Community ActionA 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, 2007. AGCA.

28. Other Relevant Policies Rightto 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. 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 publicback 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 SwasthyaSabha, 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. “Health is a social, economic and political issue and above all a fundamental human right.”

35. Challenges & Opportunities

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 ForumJanuary 2003, Hyderabad - INDIA

40. World Social Forum, January2004, 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

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