1. Dr. Ravi Narayan, Community Health Advisor
Society for Community Health, Awareness, Research and Action,
Bangalore, India
( Affiliated to Global People’s Health Movement)
Countervailing Power: The role of Civil
Society and Social Movements in
Catalyzing “Health in All Policies”
HEALTH IN ALL POLICIES
8TH GLOBAL CONFERENCE ON HEALTH PROMOTION
Plenary : Social Change and Health
8 GCHP – Helsinki, Finland
12th June 2013

2. Health in All
Policies
Health Policy
Health Systems including
Health Promotion
Closing Health inequalities gap
Action on
Social Determinants
Of Health
Globalization and Economic – Social - Political
Priorities and Policies ( National / International)
Communitization: engagement with
Community ,Civil Society and Social
Movements,
Empowerment of communities
HEALTH FOR ALL
Role of
Political Will
Economics
and
Wellbeing
Policy making
for Health
Building
Capacity
Social Change
and Health
Closing Health
inequity gap
8 GCHP – THEME : HEALTH IN ALL POLICIES

3. 1978- Alma Ata Declaration-I.
• Health for All
• Primary Health Care
• Health a Fundamental
Human Right
• Equity
• Appropriate Technology
• Inter-sectoral
Development
• Community Participation.
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.
Alma Ata, 1978:

4. FACTORS INFLUENCING SOCIAL CHANGE :
A COMPLEX MOSAIC OF INTERACTIONS
INDIVIDUAL COMMUNITY
KNOWLEDGE
ATTITUDE
BELIEFS
MOTIVATION
PAST
EXPERIENCE
CAPACITIES
CONFIDENCE
PEER
PRESSURE
SOCIAL NORMS
FAMILY
INFLUENCE
KNOWLEDGE
EMPOWERMENT
CAPACITY
CRITICAL
CONSCIO
USNESS
AUTONOMY
COLLABORATION
CONFLICT
COOPERATION
MARGINALIZATION
ORGANISATION

5. 1978- Alma Ata Declaration-I.
Alma Ata, 1978:
SOCIAL CHANGE AND HEALTH
“The promotion and protection of
the health of the people is
essential to sustained economic
and social development and
contributes is a better quality of
life and to world peace. .. the
attainment of the highest
possible level of health is a most
important social goal whose
realization requires the action of
many other social and economic
sectors in addition to the health
sector ”

6. THE OTTAWA CHARTER FOR HEALTH PROMOTION-1986
SOCIAL CHANGE AND HEALTH
“Good health is a major resource for
social, economic, and personal development and an
important dimension of quality of life.
Political, economic, social, cultural, environmental, beh
avioral and biological factors can all favour health to
be harmful to it…… Health promotion works through
concrete and effective community action in setting
priorities making decisions, planning, strategies and
implementing them to achieve better health. At the
heart of this process is the empowerment of
communities- their ownership and control of their own
endeavors and destinies”

7. 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,

8. Less Food No jobNo
water
What are the people saying?
Health crisis

9. 1978- Alma Ata Declaration-I.
Alma Ata, 1978:
PEOPLES PARTICIPATION
“The people have the
right and duty to
participate
individually and
collectively in the
planning and
implementation of
their healthcare”

10. COUNTERVAILING MOVEMENT
“For too long the medical profession and
the medical education sector have been
directed by professional control and
debate. It is time to recognize the role of
the community, the consumer, the patient
and the people in the whole debate. ……
What is needed is a strong countervailing
movement initiated by health and
development activist, consumer and
people organizations that will bring
health care and medical education and
their right orientation high on the
political agenda of the country. All those
concerned about ‘peoples needs’ and
‘Peoples health’ will have to take on this
emerging challenges as we approach the
end of the millennium”
Report of the INDEPENDENT COMMISSION ON HEALTH IN INDIA, 1998 (ICHI)
(Contribution from SOCHARA in the Human Resource Development Chapter).

11. Solidarity
• Solidarity is extent to which people in a society
work together to define and achieve the
common good. …..
• It is manifested in national and local
government, in the formation of voluntary
organizations and labour unions, and other in
forms of citizen participation in civic life…
• Social solidarity is one means by which
collective action can overcome problems;
• Participation and accountability at all levels is
necessary not only to achieve solidarity, but also
to assure that it is maintain overtime
Source: Renewing PHC in the Americas – PAHO. 2007

12. Civil Society
“A sphere of
ideas, values, institutions, organizations, networks
and individuals located between the family, the state
and the market, and operating beyond the confines
of the national societies, polities and economies”.
Source: OUP- Global Change and Health,2005
“Associations of citizens (out side their
families, friends and businesses) entered into
voluntarily to advance their interests, ideas and
ideologies. The term does not include profit-making
activity (the private sector) or governing (the public
sector)” - UN,2004:
Source: The New Public Health, Fran Baum

13. ‘ A form of collective action aimed at social
reorganization……..not highly institutionalized but
arising from spontaneous social protest directed
at specific or widespread grievances’
Source: Dictionary of Sociology (16)
“A spontaneous reaction to a given social,
economic, or political situation and may acquire a
formal or quasi – formal organization structure”
Source : Jayaram.N (17)
SOCIAL MOVEMENTS

14. CIVIL SOCIETY, SOCIAL MOVEMENTS, DEMOCRACY AND POLICY
ENGAGEMENT:
COMPLEXITY OF DEFINTION AND ROLE
PARTICIPATION
REPRESENTATIVENESS
VALUES
ENGAGEMENT /
CONFRONTATION
ACCOUNTABLIITY
LINKS TO POLITICAL PROCESS
CAPACITY
TRANSPARENCY
SUSTAINABILITY
INCLUSIVENESS
CONCERNS IN THE
ONGOING DEBATE
Context /Country Specific Role and Potential !!

15. Roles of Civil Society in HiAP
• Representing the ‘voice of people’.
• Advocacy and lobbying
• Watchdog Role
• Research and policy analysis
• Communication
• Involvement in horizontal government
mechanism (Participatory Governance)
• Involvement in multilevel governance
( multisectoral planning)
• Horizontal and vertical networking
• Build capacity of civil society
• Campaigns , programmes and movements
on specific health problems.
Source: Global change and Health; OUP, 2005 (UNDERSTANDING PUBLIC HEALTH SERIES)

16. • Over 2000 participants in 5
peoples health trains
• Mobilization across 19
states
• Adopted 20 point Indian
People’s Charter
• Launched the Jan
Swasthya Abhiyan,
•Campaigning for Health for
All Now
•Health as a Fundamental
Human Right
Role: Representing the Voice of the People- (1)
National People’s Health Assembly, Kolkatta – Dec 2000

18. Role: Representing the Voice of the People (1)
The First Global People’s Health Assembly, Savar,
December, 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.

19. “Health is a
social, economic and
political issue and
above all a
fundamental human
right.”
The People’s Charter for Health
(1454 people from 75 countries) Dec 2000

20. The People’s Charter for Health, Dec 2000
(1454 people from 75 countries)
SOCIAL CHANGE AND HEALTH
“Health is a social , economic and
political issue and above all a
fundamental human right.
Inequality, poverty, exploitation, vi
olence and injustice are at the roots
of ill health and the deaths of poor
and marginalized people….. Health
is primarily determined by the
political, economic , social, and
physical environment and should
along with equity and sustainable
development be a top priority in
local, national, and international
policy making”.

21. The People’s Charter for Health, Dec 2000
(1454 people from 75 countries)
PEOPLES PARTICIPATION
“The participation of people
and people’s organization is
essential to the formulation
implementation and evaluation
of all health and social policies
and programmes. Strong
peoples organization and
movements are fundamental to
more democratic, transparent
and accountable decision
making processes”

22. Role: Advocacy and Lobbying (2)
Right to Health Movement - India

23. Role: Advocacy and Lobbying (2)
Making Health an Agenda for the Social Movements.
World Social Forum, Porto Allegre Brazil

24. Role: Watch Dog ( 3)
Global Health Watch – I II & III
Alternative World Health Report
(People’s Health Movement, Medact, Global Equity Guage Alliance Health
Action International, Medico International, Third World Network, Zed Books)

25. Role: Research and Policy Analysis ( 4)
EQUINET – East and Southern Africa
CONTENTS:
1. Policy , Political and Legal
Commitments, to equity in health.
2. Equity in health outcomes
3. House Hold access to the resources
for health and the economic and social
determinants of health
4. Economic opportunities and
challenges for health
5. Challenging inequities through
redistributive health systems
6. A more just returned from the global
economy
7. Conclusions.

26. Role: Communications/Public Education (5)
The People’s Health Resource Books in India -2000AD
“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, DG Emeritus, WHO and
Architect of the Alma Ata Declaration.
1. Globalization and Health
2. Primary Health Care?
3. Inter-sectoral Action
4. Empowerment of the socially
Marginalised
5. Confronting Commercialization
of health care
1
2
5
3
4

27. Roles: Communications/Public Education: (5)
PHM: Promoting the politics of health

28. Roles: Communication /Public Education (6)
Websites and Media Effort
medico friend circle
Public Health Resource Network
Community Practice on
Accountability and Social
Action in Health -COPASAH
www.phmovement.org
www.mfcindia.org
www.copasah.net
www.sochara.org
www.phrnindia.org
www.communityhealth.in

29. National Rural Health Mission- India
2005-2012
MECHANISMS
OF ENGAGEMENT
Task forces
- India Public Health Standards
- ASHA Mentoring Group
- Medical Education and HRD
- Advisory Group for Community
Action
Partnerships
- Community Monitoring and
Community Action for Health
- ASHA Training
- Common Review Missions etc
Role : Participatory Governance by Civil Society (7)

30. Role : Involvement in Multisectoral dialogue (8)
WHO CSDH Report
• PHM and Civil Society
commissioners
• Dialogue with civil society
in different regions
• Civil Society report on
Social Determinants of
Health submitted to
commission
• Civil Society members
participated in various
knowledge hubs
• Civil society partnership in
advocacy

31. Role: Capacity Building (9)
The International People’s
Health University (IPHU)
The International People’s
Health University (IPHU)
is one of the major
programs of the
People’s Health
Movement (PHM) –
Global. IPHU is a global
university providing
short courses and other
resources for health
activists
Training young
professionals
in the politics of health

32. Role : Capacity Building (9)
Community Health Learning Program of SOCHARA
, India
FRAME WORK
 Development of Community Health
Practioners
Sharpen analytical skills and deeper
understanding social/ societal paradigm of
community health and public health
Engagement with state society, and
communities
Orientation and skills with focus on
equity, rights, gender, and social determinants
of health.
Capacities for community health
action, community action
research, educational strategies, and policy
dialogue and action

33. Role : Campaigns on Specific Health Challenges ( 10)
: Health effects of social and trade policies

34. Role : Campaigns on Specific Health Challenges ( 10)
Health in Conflicts

35. WATCHES
PEOPLE’S
TRIBUNALS
HEALTH
ASSEMBLIES
CAMPAIGN
INNOVATIONS
HEALTH
MANIFESTOS
HEALTH
POLICY
PROCESSES
INNOVATIVE
INSTRUMENTS OF
ENGAGEMENT
AND OTHERS …………………

36. INNOVATIVE INSTRUMENTS- 1
WATCHES
People’s Rural Health Watch, INDIA 2008
www.gapminder.org
Global equity guage alliance
http://www.gega.org.za/

37. INNOVATIVE INSTRUMENTS- 2
People’s health tribunals in India
(Jan Sunwais – Jan Samvad)

38. INNOVATIVE INSTRUMENTS- 3
Health Assemblies of Civil Society
PHM Health Forum at World Social Forum January 2004

39. INNOVATIVE INSTRUMENTS- 3
The Mumbai Declaration-2004
(1454 people from 75 countries)
•Implement comprehensive and
sustainable primary health care
involving marginal sectors in
decision
•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…..
•incorporate the needs of
marginalized population, the
unheard and unseen in health and
development strategies and social
policies in a rights context……

40. INNOVATIVE INSTRUMENTS- 3
Health Assemblies of Civil Society
Second People’s Health Assembly 2005, Cuenca - Ecuador

41. INNOVATIVE INSTRUMENTS- 3
The Cuenca Declaration Ecuador-2005
• “ struggle for comprehensive primary health
care and sustainable, quality local, and national
health systems.
• 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.
• gather within its movement positive
experiences of comprehensive PHC to build up
the evidence base ….. and to undertake
concerted advocacy for its revitalization”

42. Innovative instruments - 4
CAMPAIGN INNOVATIONS
Campaign for Ethical Marketing of Drugs, Germany

43. Innovative instruments - 4
CAMPAIGN INNOVATIONS
Right to Primary Health Care Campaign- South India

44. Innovative instruments - 5
Peoples Health Manifesto India – 2009
( Dialogue with all political parties)
Suggested effective measures to achieve right to health
• Enactment of National Health ACT- to guarantee the basic
affordable quality health care services in all clinical
establishments including the private establishment
• Rural Infrastructure and the National Rural Health Mission-
Increased allocation and effective utilization of Funds and
strict action on corruption
• Drug Medicines and Patents- List of Essential and
Consumable drug s by the state. Ethical code of marketing
medicine and revival of public sector companies on medicine
and vaccines
• Gender and Health – Abolish coercive laws on policies and
practices that violate the reproductive and democratic rights
of women and Assure women of gender-specific health
entitlements
• Child Health and Nutrition – Urgency for a National policy on
Child health and nutrition. Universalization with quality IDCS

45. Innovative instruments - 6
DEVELOPMENTS IN PUBLIC HEALTH POLICY THROUGH
HEALTH POLICY PROCESSES INVOLVEMENT BY CIVIL SOCIETY
POLICY PROCESS ENGAGEMENT BY CIVIL
SOCIETY IN INDIA- 1998-2013
NATIONAL
KARNATAKA
NRHM
ORISSA

46. Some emerging concepts and paradigms
THE PARADIGM
SHIFT
GLOBALIZATION OF
HEALTH SOLIDARITY
FROM BELOW
SOCIAL VACCINE COMMUNITIZATION
CIVIL SOCIETY INVOLVEMENT
IN HFA
+SEPCE Analysis

47. CONCEPT / PARADIGM - 1
PEOPLE CENTRED HEALTH POLICY RECOGNISING THE
PARADIGM SHIFT
Approach Biomedical, deterministic,
techno managerial model
Participatory social/
community model
Link with
community
As passive client or
beneficatory
As active and empowered
participant
Dimensions
Explored
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
ends
People centred Empowerment
strategy as the central theme
Source: CHC 2008

48. CONCEPT / PARADIGM - 2
“Globalization of Health Solidarity from below”
(Academics describe civil society engagement process)
( 1)
(2)
(3)
(4)

49. CONCEPT / PARADIGM - 3
“Globalization of Health Solidarity from below”
(Academics describe civil society engagement process)
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.” (1)
The simultaneous rise of a global civil society movement pressing for
political actions to shift the rules of contemporary globalization is
significant (People’s health movement et al 2005 ) (2)
A strong voice in the global health debate for free primary health care is the
people’s health movement which in 2000, presented the Peoples Health Charter.
The charter argues strongly for a publicly financed health services and for
development policies that favours health…. (3)
Recognizes the movements 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 (4)

50. CONCEPT / PARADIGM - 3
Social Vaccine: A new metaphor
• Fran Baum, Ravi
Narayan, David
Sanders, Vikram Patel, and
Arturo Quizhpe,
• Social vaccines to resist and
change unhealthy social and
economic structures: a
useful metaphor for health
promotion,
• Health Promotion
International,2009 Vol. 24
No. 4, 428-433
“Social Vaccine would be
promoted as a means to
encourage popular moblization
and advocacy to change the
social and economic structural
conditions that render people
and communities vulnerable to
disease.
They would facilitate social and
political processes that develop
popular and political will to
protect and promote health
through action on the social and
economic determinants”

51. CONCEPT / PARADIGM – 4
Communitization
“ The institutionalization of community led action for health due to civil society and
ngo pressure and experimentation has been a significant feature of the NRHM in
India. Communitization now includes
 Village health and sanitation committees
 Selection and training of social health activists
 Involvement of local self government and
community based organization
 Community monitoring and planning for action in
health
 Periodic People’s hearings - Jan Sunwais or Jan
Samvad
 Untied funds for use at local discretion
 …. And other evolving initatives.

52. SEPCE Analysis
The scope and reach of epidemiology which is an integral
part of public health must be expanded to include the
study of the social, cultural, economic, ecological and
political determinants of health and constitute the key
stone for use of evidence for development of public
health policy…… Such an approach will help in moving
beyond health problems to per se to new complex social
and human development challenges such as the current
crisis and threat to public health, pose by the global
financial meltdown and climate change’
Source: WHO SEARO (46)

53. An emerging Tool Kit -1
Involving Community, Civil Society, and Social Movements in HiAP
1. Right and Duty ( Alma Ata)
2. Promote maximum community and individual self reliance and
participation ( Alma Ata)
3. Involve individuals, families, communities, professionals, and
social groups ( Ottawa)
4. Empower communities to enhance ownership and control (
Ottawa)
5. join forces in their commitment to public health alignment
(Adelaide)
6. Public health and ecological movements to develop strategies for
development and conservation ( Adelaide)
7. Encourage collaboration in peace, human rights, social justice,
ecology and sustainable development, ( Adelaide)
8. Broad alliance of advocates and activists for health environment
and social justice towards Health For All ( Sundsvall)

54. An emerging Tool Kit - 2
Involving Community, Civil Society, and Social Movements in HiAP
9. Make people centre of health promotion action and decision
making ( Jakarta)
10.Creation of new parternerships between different sectors of
governance and new and diverse networks created to achieve
intersectoral collaboration (Jakarta)
11.Active participation of all sectors and civil society in health
promoting action and partnerships for health ( Mexico)
12. Grass roots community projects, civil society groups and women’s
organizations can provide models for practice for others to follow.
( Bangkok)
13.Meaningful and equitable participation and control in decision
making of all groups including those experiencing social
, economic, or political exclusion (Nairobi)
14. Communities must share the power, resources and decisions
making to assure and sustain conditions for health equity
15. Building community capacity during
planning, implementation, monitoring and evaluation. (Nairobi)

55. An emerging Tool Kit - 3
Involving Community, Civil Society, and Social Movements in HiAP
Additional ideas taken from the evolving frame work for country
action being discussed in Helsinki.
16. Broader participation in discussions and exchanges
17. Civil Society and research community invited to give evidence in
broader hearings, seminars and consultations.
18. National Health Assembly established by an Act as in Thailand,
bringing together various actors and sectors in participatory policy
making
19. Citizens juries producing a report to an oversight panel that include
policy makers and interested parties
20. Alternative mechanisms to draw views from general public or
particular population groups through opinion survey ,focussed
group , e-cafes, open spaces and website commentaries.
(Many other ideas and components for the tool kit will emerge
in the discussions during this conference).

56. World Health Report 2008
Recognizing the role of civil society
• “The history of the politics of the PHC
reform in the countries that have made
major strides largely unwritten. It is clear
however where these reform have been
successful, the endorsement of the PHC by
health sector and by the political word has
invariably followed on rising demand and
pressure expressed by civil
society………..There is an important lesson
there; powerful allies for PHC reform are to
be found within civil society. They can make
difference between a well-intentioned but
short – lived attempt and successful and
sustained reform; and between a purely
technical initiative and one that is endorsed
by the political word and enjoys social
consensus.”
• Source: World Health Report, 2008 (45)

57. WHO Commission on Social Determinants in Health
Report – 2008
Recognizing Civil Society as champions of equity
“As community members, grassroot
advocates, service and programme
providers, and performance
monitors, civil society actors from the
global to local level constitute a vital
bridge between policies and plan and
reality of change and improvement in
the lives of all. Helping to organize
and promote diverse voices across
different community, civil society can
be a powerful champion of health
equity.”
Source: WHO Commission on Social
Determinants of Health, 2008, (46)

58. The Challenges for HiAP
• Are we ready to move from policy rhetoric to community
mobilization through the active participation and
engagement with civil society and social movements?
• Are we ready to engage with civil society and social
movements creating spaces for dialogue and engagement
that will enable them to play the different roles and use the
innovative methods of dialogue and engagement ?
• Are we ready , through this engagement for recognizing the
deeper social, economic, cultural, political, and ecological
determinants of health, that act as obstacles to our efforts
towards Health in All polices and Health For All?
The evidence is there – will policy action
and practice on the ground follow!

59. For further information visit
www.sochara.org
www.phmovement.org
www.ghwatch.org
www.phmovement.org/iphu
www.phm-india.org
www.mfcindia.org
www.communityhealth.in
http://www.phmovement.org/iphu/
http://mohfw.nic.in/NRHM.htm
THANK YOU