Keeping the
Promise: The People's Response to Health For All - The external
evaluation report of the People's Health Movement
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Executive Summary
A global People's Health Movement (PHM) began to emerge
in December 2000, when nearly 1500 people from over 90 countries met for
five days in Savar, Bangladesh to re-establish health and equitable
development as top priorities in local, national and international
policy-making. In the intervening four years from this initial People's
Health Assembly (PHA), the movement has stumbled, struggled, and become
stronger, and today is having an increasing impact on health policy and
practice.
An indicator of the impact that PHM is now having comes
from its interaction with the World Health Organisation. In December 2000,
despite being invited at the highest level to attend the PHA, no one was
officially representing the WHO. In January 2004, several representatives
from the WHO attended the PHM activities around the World Social Forum in
Mumbai, India and were requested by the Director-General's Office to explore
closer engagement with the PHM.
Strong and ongoing activities have been taking place in
Asia (particularly South Asia) and in Latin America. Within South-East Asia
and the Pacific and the Middle East, events connected to the 25th
anniversary of the AlmaAta declaration on primary health care were used
during 2003 to help mobilise further action. Communication processes within
the movement are improving and more attention is now being paid to building
and developing strong and effective alliances and working relationships with
other networks, movements and organisations.
The People's Charter for Health, elaborated through a
worldwide consultative process and finalised and endorsed at the PHA, has
been spontaneously translated into more than 40 local languages. This
indicates the degree to which the Charter and its demands for social,
political and economic change to improve health reflect and resonate with
the reality of the situation facing the millions of people living in
poverty.
Unique approach to social mobilisation
This People's Health Assembly - the first of its kind -
was a unique social mobilisation exercise. In country after country, it
involved people in village meetings, in district meetings, in national
events, in regional workshops to prepare for the global gathering in
Bangladesh.
Along the way, the voices of the people were heard:
-
articulating their demands for better health, justice,
peace and equity
-
reaffirming their rights and responsibilities to be
involved in the decisions that affect their lives and their health
-
confirming that the right to health is one of the basic
human rights to which they are entitled.
The five-day meeting in Bangladesh provided an
opportunity for people involved in health, development, human rights,
agriculture, trade and economics, the environment and many other fields to
converge, to share ideas and continue a process of building a coalition to
drive social change.
Anyone who took part in the PHA describes it as a
transformational process. It changed their lives. The challenge now is to
see if the inspiration, solidarity and linkages that occurred can be
sustained.
Evaluation and learning
This report is one output from a three-year participatory
evaluation exercise that has helped to engage the PHM leadership in an
analytical learning process based on ongoing experience. The evaluation has
looked into the preparation of the PHA, the Assembly itself, and follow-up
activities. Led by Exchange - a networking and learning programme on health
communication - it has assessed the current status of PHM activities,
explored ways to reinforce and enhance current accomplishments, and examined
approaches to strengthen and sustain monitoring mechanisms.
A key feature of the PHA is that there was no real model
for this type of exercise. There are many examples of international
meetings, but few that feature a focus on people's voices or that start from
local experience. There are countless examples of meetings where experts
deliver papers, but few where testimonies of the daily realities of the
impact of globalisation policies, poverty and illness drive the agenda and
the search for solutions. This was uncharted territory. A significant
outcome of the process is that it has begun to elaborate new models for
organising, new approaches to giving voice to the vulnerable, and new ways
to advocate for social change.
Planned achievements
The PHA process aimed to develop and endorse a People's
Charter for Health and to achieve a further seven outputs:
-
hearing the unheard
-
re-enforcing the principle of health as a broad
cross-cutting issue
-
sharing and enhancing knowledge, skills, motivation and
advocacy for change
-
improving communication between concerned groups and
institutions
-
developing enhanced cooperation between concerned actors
in the field
-
enhancing media interest in health/equity issues
-
increasing involvement of the poor in the dialogue
process.
PHA participants surveyed feel strongly that the unheard
did have an opportunity to be heard; that health was reinforced as a cross
cutting issue and that skills and knowledge were shared during the Assembly
itself. There was a less strong sense that communication between different
groups and opportunities for enhanced cooperation happened. There was some
uncertainty as to whether media interest was enhanced or to what degree the
poor were really involved.
On balance, the overall impression of the Assembly itself
from participants was that it was a unique, transforming experience. It had
a profound impact on the 1500 people who attended, and nearly all of them
have communicated with others about the experience in some way.
As a judge from India who attended said, 'The biggest
achievement was making the world aware that the health of the common folk
had to be a matter of international concern'.
On balance, the process that was set in motion to develop
the PHA and get the event held was a positive one. It involved a number of
organisations and networks, consulted widely on content issues, and reached
out to a large audience to encourage involvement and participation. However,
there were also difficulties: not least the overwhelming burn out and
exhaustion of some of the organisers who faced severe stress in trying to
cope with growing and unexpected numbers of participants. The sheer volume
of people who attended meant that some of the carefully planned mechanisms
to deal with debate and arrive at clear positions on many issues were not
able to function. The issues were certainly raised and the problems
articulated; clear expressions of possible solutions were not always
reached. Many of the people involved in organising the event are highly
critical of the outcomes.
A major failing of the process was the lack of a plan
(and the resources - human and financial - to carry it out) about how to
follow up the Assembly and maintain the enthusiasm and solidarity that was
expressed. As a result, some of the dynamism of a new popular movement was
initially lost. It was nearly a year after the PHA that the ideas for
evolving a People's Health Movement that built on the first Assembly and
began to work towards implementation of the demands in the People's Charter
really began to develop.
In that sense, the words of a professor of medicine based
in the UK have some relevance: 'It was a remarkable and memorable
achievement, but now what?'. Those words are echoed by a representative from
a civil society organisation in India who said, 'The idea was good. The
implementation could have been better.'
Up until the beginning of 2003, any assessment of the
efforts to move the PHM forward would have had little positive to say.
Although a great deal of work was going on behind the scenes, little was
visible on the ground, and where it was, it appeared patchy, sporadic and
largely uncoordinated through 2001 and 2002. Through 2003 and into 2004,
greater coherence is beginning to emerge.
A large factor in the slow follow up to the PHA lay in
the lack of a clear strategic plan and a corresponding communication
strategy to reach out to different audiences. More recently, planning
processes have come into effect that are addressing this and beginning to
develop strategic approaches and concentrate on improving internal and
external communication.
Other issues that the PHM needs to address include:
-
maintaining and growing the movement (including the
dynamics of networking)
-
leadership and governance
-
strategic thinking and planning (including communication
and evaluation strategies).
Networking
There are enormous challenges in trying to maintain an
effective network that combines a broad range of organisations and
individuals. Networks, organisations, and individuals involved in the PHM
work on a wide range of issues - from the very specific to the very broad -
and at a number of levels - local, national, regional and international.
One of the strengths of the PHM was that it grew out of
associations and links between people and groups working in a range of
sectors - health, environment, education, agriculture, nutrition, trade,
economics. Another strength was that the movement was built from the bottom
up, building on community level concerns and the reality of poverty at the
grass roots. Can the PHM continue to relate across these sectors and build
strong links? Can it continue to link the grassroots reality with the
high-level advocacy aimed at transforming international policy? It will need
to if the movement is to remain relevant. A particular weak spot for the PHM
is Africa. Few African participants attended the PHA and the scope for
follow up has been limited.
Leadership and governance
Although there has been some discussion of possible
structures (a series of interacting 'circles' or associations of people and
organisations working on particular topics) to provide guidance and
leadership for the PHM, there are still many unresolved issues. This is to
be expected in what is a 'young movement'. However, an encouraging comment
that emerged in the evaluation process is that it is a young movement 'with
wisdom'. The PHM has its roots in a number of social movements in every part
of the world. Within the PHM are a number of people, networks and
organisations with long experience of international collaboration. If that
wisdom is used to continue to clarify issues of leadership and governance
over the coming months, and developing principles and guidelines for how
important decisions are made, there is a strong likelihood that the PHM will
continue to grow and increase its impact.
Strategic thinking and planning
The dynamics of movements and many networks are that they
often respond to situations as they arise: a policy has been issued that
needs to be challenged; a threat to the environment has become evident; a
human right has been violated. Something needs to be done now, with urgency.
People need to be mobilised to take action. However, all of this needs to be
put into the context of a strategic framework. What does the movement or
network hope to achieve in three years? In five years? In 25 years? What is
the direction in which the movement is moving? What are ways it might get
there, and how will it know it is making some progress? These are questions
that need to be embedded in the thinking and planning of any effective
movement or network.
