Health for all All – built up from below

The last decade has seen tremendous changes. In this period of economic globalization, expenditure on health, education, food, and in the social sector is seen as wasteful. Cuts in budgets have been recommended to cut fiscal deficit. The state has withdrawn from fulfilling its responsibility to its citizens in providing basic services and ensuring non-erosion of the basic determinants of health. Commitment to Comprehensive Primary Health Care becomes a faded memory for many, as it is increasingly replaced by market oriented neo-liberal policies, with vertical top down programs and a reductionist approach. Many of the trendy public private partnerships are planned and implemented within this context and framework and unfortunately not within the Comprehensive Primary Health Care approach. This is also precisely the time when many donors who have supported Comprehensive Primary Health Care in the past have chosen to support short-term projects within the newer paradigm.

Keep the Flame Burning

The most important contribution of local and national action for Health for All (HFA) today is to keep alive the concept of Alma Ata and to keep alive health programs based on the concept of Comprehensive Primary Health Care. This is often not easy as little or no financial and moral support for comprehensive primary health work is available. We have witnessed its systematic marginalization and an unprecedented shift to vertical programs. The areas in which public private partnership is encouraged are areas in which there are technological fixes. Deeper questioning and involvement in the roots of ill health is not encouraged, nor is diversity of approaches and flexibility. There is an increasing push for techno-managerial approaches which are an antithesis of programs involved in response to community needs.

Organizations which become partners in such policies and programs are no longer in a position to be unbiased in their assessment of the negative impact of national and international health policies, since for their own survival options are limited. The choice of programs reflects market orientation. Health action is voluntarily given up in order to avoid displeasure of the powerful partners and the risk of losing support.

Many smaller initiatives supported by communities, as they lived and functioned with voluntary austerity, are being asphyxiated out – and these were the heart and soul of the deeply internalized Health for All movement. To keep the flame burning is the most important health action, because the comprehensive primary health care is the only approach that can work to provide HFA. Market oriented partnership will only increase inequities.

National action is needed to keep alive those initiatives which have in the past primarily responded to the local community needs while pursuing health and development work, putting people before projects. To believe in Health for All requires reminding authorities about people's right to health, their right to essential drugs, their right to water by ensuring their availability and affordability. This action has taken place at local as well as national level. But in comparison to the highly funded, high tech, fully backed, financed and supported reductionist approaches, it is much weaker. The climate has dramatically changed over the last one to two decades as medicalization, pharmaceuticalization, privatization and commercialization of health have grown dramatically. The coming decade is bound to see the pace of this trend increase many fold. Preventing this trend at local, national and global level will take much more energy and engagement.

The Right to Basic Needs

Some examples from India show the switch from Comprehensive Primary Health Care to market or donor driven short-term projects and the erosion of Health for All.

Oral Rehydration: Experience of health groups has shown that a simple sugar salt solution (ORS) has been a life saver in the 70s and 80s in managing diarrhoeal disease. Nowadays the use of home made ORS is withdrawn from training and training modules, as the method is called to be “unscientific”. Access to ORS packets by those who need them most is not easy in peripheral areas. David Werner, author of “Where there is no doctor”, has clearly shown how the new cereal based ORS solutions were not encouraged until commercial cereal based packets were available in the market.

Privatisation of water: When 70 percent of the health problems are water-related, privatization of this basic need will undoubtedly have serious public health consequences: Increasing reproductive tract infections and water-borne diseases are bound to increase with the privatization of water.

Tuberculosis: International priorities influence international health programs. TB was declared a Global Emergency in 1995 only when it reappeared in persons afflicted with HIV in the West. TB is a disease of poverty. Access to anti-TB drugs has definitely improved under DOTS (Directly Observed Treatment Short Course), yet communities working in quarries and mines need more than anti-TB drugs to address the problem. The people working in the quarries are the more vulnerable and often belong to Scheduled Castes and Scheduled Tribes. Issues of malnutrition, indebtedness, bondage, early death, early widowhood and child labour are equally important. Those addressing the problem comprehensively must be encouraged and supported. Ironically, there are higher chances that a sexual behaviour study or an HIV program for such a community would be supported...

HIV/AIDS: It is in this context that we would like to look at HIV/AIDS as an international health priority. Most of the HIV/AIDS programs were target-oriented on high-risk groups such as truck drivers and women in red light areas. The focus was on condom use. Concerns about total dependence on condoms – with the known problems of manufacturing defects and storage in the tropical heat of 48º, as well as the ignorance and unwillingness of male partners to use condoms regularly in a deeply patriarchal society – fell on deaf years. What a missed opportunity to increase gender sensitivity and also to give powerful messages to avoid using the partner as a mere commodity!

As the largest funding for health became earmarked for HIV/AIDS work, including numerous research studies on sexual behaviour, the AIDS industry has grown; and so has the sex industry from brothels to dance bars, beauty parlours and massage parlours as a front for sex for money. We are witnessing an increased demand for vulnerable younger girls, as there is an increase in AIDS awareness. We are also witnessing an increase in sexual violence. The reality of slavery, abductions, trafficking, the links with drugs and crime and the control by pimps and brothel owners is overlooked as trade in girls and women has exponentially grown. Women in prostitution are exploited; they face a social stigma and are called and treated as “fallen” women. Ironically, the clients never fall, because in a patriarchal view of the world their right to pleasure is totally acceptable and unchallengeable, even if it destroys the lives of millions of young girls and women in the bargain. All women have a right to dignity, to real choices in their lives, to basic needs to education, to health care – whether they break stones in a quarry or work in a brothel. The conscious decision not to address the processes which force women into prostitution and to willingly accept the reality of millions of young girls and women being fed as fodder in this ever growing unscrupulous industry is cause of deep concern.

How good are the chances for international alliances and networks?

As comprehensive health care approaches are fading on a national level, what then are the chances for international alliances and networks of Primary Healthcare initiatives? They will depend very much on the role and responsibility that the recently created People’s Health Movement PHM takes on. These chances look good, if the People’s Health Movement fights for the rights of the communities at local level as well as at the national and global level;

• if it raises its collective voice against unjust policies and program, as well as against trade regimes that are destroying health;
• if it reaches out in solidarity to those who are struggling to protect their health, their resources, their rights and their shrinking, democratic, political spaces;
• if it can help document positive initiatives as well as violations of health rights; and also, if it is prepared to seek justice linking up with others working on the denial of rights such as water, food, education, livelihood, peace and justice;
• if it can highlight these concerns and project them as testimonies to sensitize the health community as well as policy makers;
• if it can reinterpret statistics dished out to legitimize national and global priorities which deeply influence resource allocation and the nature of research priorities, but sometimes negatively affect grass root work;
• if its demands focus on an increased health budget and its appropriate use for the real health priorities locally, nationally, regionally and globally.

To work towards the objectives the People’s Health Movement has set for itself is not going to be easy, especially in an economic and political climate where so much is loaded against those with little or no economic value, the poor marginalized communities as well as women and children. It is not going to be easy to stand up for them and to clearly articulate its position and work towards it.

But a collective voice like the People’s Health Movement is needed. Keeping the Movement alive is not a privilege, but a responsibility and duty of those who continue to believe in the Right to Health and Health for All.

The People’s Health Movement’s financial resources are negligible, but its human and intellectual resources made available for the Right to Health cause are significant. Many of those involved have been part of organizations and networks that know the struggle for health and have been in the health movement for one to three decades. Such organizations include Health Action International, International People's Health Council, Third World Network, Gonoswasthya Kendra, Dag Hammarskjold Foundation, Consumers International, and others. The movement has attempted to reach out to those working at the grass roots, those involved in people-oriented health research, participatory training, and advocacy for Right to Health and Health for All, linking up with other movements so that communities and practitioners of PHC feel supported. The People’s Health Movement believes in supporting local initiatives towards participatory democracy through the establishment of people-centred solidarity networks nationally and globally.

The People’s Health Movement believes that health is a social, economic and political issue and above all a fundamental human right. Inequality, poverty, exploitation, violence and injustice are at the root of ill health and the deaths of the poor and marginalized people. Health for All means that powerful interests have to be challenged, that globalization has to be opposed, and that political and economic priorities have to be drastically changed.

Much more will be needed in the future

The People’s Health Movement collectively expresses the concerns of many, at different levels. Action is now needed – not just of PHM but of many others, individuals and organizations who share a common vision. Equity, ecologically sustainable development and peace are at the heart of our vision of a better world – a world in which a healthy life for all is a reality, a world that respects, appreciates, celebrates all life in its full diversity, a world that enables the planning of people's talents and abilities to enrich each other, a world in which people's voices guide the decisions that shape our lives.

*Mira Shiva is a Community Health specialist and activist living in New Delhi, India; since 1979 working in various organisations and campaigns such as the Voluntary Health Association of India and the All India Drug Action. Her main issues of concern are Rational Drug Policy and Drug Use, Women’s Health and People's Education for Health. On the international level, she has been an active member of Health Action International lobbying for Access to Medicines at the World Health Organisation and she participated in the 1994 Cairo Population Conference. Today, she is a leading representative of the international People's Health Movement. Contact: vshiva@vsnl.com. People’s Health Movement and Cuenca Declaration: see www.phmovement.org for further information.