How to do work that people notice and make our voice heard
Our actions include advocacy and policy dialogue, campaigns and demonstrations. In addition to their impact on policy and decision-making, these can be key strategies to build and/or strengthen our movement.
A long journey starts with a single step (in the right direction!)
Any mobilisation, any action, any campaign, any movement has a purpose. In most cases, the experience within PHM suggests that a combination of both short-term, immediately tangible change and long-term structural change is highly desirable.
It is really important to have concrete goals that can be achieved, even if they are small. Victories fuel mobilisation, by keeping people motivated. But a broader framework is useful to overcome the tendency to make things happen – “do stuff” – without thinking through how it better serves the objective.
It is important to realise that different people/groups will have different priorities in terms of goals. In order to find out what were the priorities in health, PHM Scotland created an online survey and organised meetings with the (disadvantaged) communities through an action-research initiative. While the online survey, completed largely by academics and policy advocates, focused primarily on the bigger picture (social determinants of health), the communities declared that their most urgent problems were very practical, such as the accessibility of public services.
Struggles around short-term objectives benefit from being embedded in a vision of broader social transformation. In El Salvador, workers of two hospitals that had been closed to await privatisation, took up the struggle, not as a struggle for their jobs, but as a broader struggle against privatisation. They created a coalition of peasants, students and public sector unions by linking the outsourcing of services, the privatisation of the public health system at large, and privatisation of other essential services. A very practical short-term objective – stopping privatisation – contributed to creating a wider movement against privatisation, and eventually to the emerging of the National Health Forum (FNS), an influential nation-wide civil society network.
In Vermont (USA), activists wanted to promote a change in health systems towards universal public healthcare. Instead of talking only about the economic benefits of such change, they spoke about health as a human right putting people (back) at the center of policy and practice. The shift in discourse from costs to needs and from figures to values united communities long divided on other issues. It set the stage for a broader movement for all economic and social rights. Similarly, the high participation of the general population (not only activists) in the Italian water referendum showed that the theme resonated strongly with a wider audience.
Broadening people’s participation
Most experiences within PHM still appear to be initiated by a relatively small core group of passionate actors: one single organisation, a number of health professionals or academics, community leaders or organisations. Having such a committed steering group is important. But it is imperative that oppressed groups set their own objectives and that the way work is done itself changes power relations. This process requires being conscious of one’s own social, economic or other status might be in a group setting.
Listening is more critical than talking, and communication should keep in mind one’s social position accordingly. PHM India shares the importance of taking the struggle beyond selected intellectual and NGO circles and making it part of the public consciousness. Without it one cannot succeed in placing Health for All on the political agenda of the nation.
Underlying this approach is an analysis of power relations. All actors have power, sometimes overwhelming power. Awareness raising very often starts with raising the idea that change can happen. Bringing people together in determining their own destiny is a central feature of empowerment, understood as influencing power relations.
In several Latin American experiences this ended up contributing to government change. In Nicaragua, the struggle around the Rancho Grande municipality was a case in point. With a state apparatus initially supporting the interests of a Canadian mining company, activists set out to raise awareness but also organise local communities. They did so by identifying potential allies, including parents of school children, worried about education, and local priests, even though the Church elsewhere appeared less supportive. Initial awareness-raising was followed almost instantly by organising strategies, including door-to-door visits, organised trips, meetings, and creating a space for the organisation. Organising in turn reinforced awareness-raising practices and facilitated mobilisation, with a semester-long “school-strike” as a particular highlight.
Joining other diverse mobilisations can be helpful. In El Salvador the National Health Forum (FNS) connected with other health platforms joining, broadening and supporting trade union demonstrations on salaries. In India a major dimension of the process was the linkage between advocacy/agitation for policy changes and voluntary/NGO work amongst communities including work in health care delivery. By providing space for synergy, the number of networks involved and therefore the outreach and the credibility of the entire process could be enhanced.
Mobilising material resources for action
A movement needs resources. Material resources might come from donors. However, several experiences within PHM point to the risk of overly depending on a limited number of donors regarding material resources.
On the one hand, funds can disappear. With austerity, community groups involved in PHM Scotland are working in contexts of entrenched deprivation; while faced with cuts in programmes and salaries and retrenchment of staff. On the other hand, even with the best intentions, donors can influence priorities, strategies, actions or even absorb local initiatives. As donors support one specific type of action rather than another, a movement might lose its holistic, system-critical or long-term perspective.
Material resources can be found through pooling or independent fundraising. The Italian campaign against the privatisation of water was entirely self-funded through individual donations. For the referendum, with more funds required, the campaign asked citizens to “bet on the yes” by giving money to the organising committee. Involving a broad network of organisations with each contributing according to their abilities, is another obvious way of sharing costs. The network strategy of PHM India illustrated how this may be done. People’s mobilization met over 85 percent of the costs incurred, but a critical 15 percent for centralized expenses at state and national level was made possible only by extensive sharing of financial resources. Some organizations had a training infrastructure and supported boarding and lodging expenses. Others contributed to promotion activities. Others funded booklets. PHM in Maranhao (northern Brazil) used an approach in which members contributed a small sum each, periodically, to fund the movement.
The experience of PHM Kenya shows the importance of transparently and democratically managing resources even when a vision is shared. Obtaining funds and assets was for them both a benefit and a source of problems. Managing and sharing internal assets among different groups can provoke conflict and undermine solidarity of the movement. Consider carefully before collaborating with separate funding managed by members themselves, versus creating a joint programme with shared assets.
Targets of actions
In many cases PHM groups seek to target key actors and influence them over policies and decisions or behaviors that have an impact on health. These actors often include a mix of national or state policy makers, local authorities, or even communities. Within a rights-based approach, public authorities are logically the central targets of mobilisations and in PHM experiences their role as duty-bearers becomes obvious in practice. They are the focal point of advocacy, policy dialogue, campaigns and demonstrations.
Depending on the concrete context, the interaction with, and ways of influencing, these actors take several forms, from cooperative to outright confrontational. As actors react and/or change, so does interaction. A key actor can be cooperative or repressive, attempt to co-opt or divide. Cooperation can have many advantages. In the experience of PHM Brazil, the involvement of local authorities supporting long-term public health concerns of a community allowed for real change. In El Salvador a new government, resulting from the support of trade unions and national public health movements, took a very cooperative stance towards the movement. This influenced not only straightforward health issues, but also tax reform. However, the movement did not limit itself to supporting one or the other actor during elections. It did not pin all its hopes on government cooperation. So when the cooperative, progressive government lost its parliamentary majority, street mobilisation could still be counted on to influence power relations, in favour of more progressive policies. Both in Brazil and El Salvador, cooperation did not mean merger. Social mobilisation remained independent. This way, movement-building enables continued influence on power relations.
Division in the social movement can occur for many reasons. Repression is one. But concessions by authorities might also convince some people to stop the struggle. However, seeing the bigger picture, in which the concessions are framed as but an intermediate victory, might limit this tendency. Outright repression clearly asks for a special set of answers. Finding innovative ways of protesting, within the limits set, but also more covert organising helped to deal with repressive environments.
The co-optation by public authorities of Indigenous peoples’ initiatives in Australia was a mixed blessing. These primary health care initiatives existed for many years, when authorities decided to co-opt them. On the one hand, because they were now part of a national policy, means at their disposal for service delivery increased tremendously. On the other hand, bottom-up control and participatory management lessened. Ownership of the initiative has shifted away from the communities towards less accountable entities.
Actions that are visible, attract people and make an impact
Visible actions are an essential part of communication and movement building. When the Canadian Ontario Coalition Against Poverty (OCAP) symbolically set up a hunger clinic in front of Ontario Legislature, this attracted a huge amount of interest. On one day, the highly visible action gathered millions in valuable income for poor people. The Nicaraguan school strike, albeit on a longer timescale, appears as a similar example: when parents learned that a mining company would be allowed to give “environmental education” directly every week to the children, (sanctioned by the Ministry of Education) parents simply kept their kids at home. The school strike garnered attention in ways that previous protests marches hadn’t. Finding media that would publicize their resistance – locally, nationally and internationally – was also important.
PHM India shows the usefulness of linking advocacy to service-provision by voluntary/NGO work amongst communities including work in health care delivery. Service provision can be a highly visible means of work, and also feeds the experience of the direct impact on people into the advocacy work.
A PHM-linked experience from the Philippines of Advocates for Community Health illustrates how undertaking mental health workshops assists in the painstaking process of winning trust in oppressed and traumatized communities. Helping people to collaborate allowed for finding allies like local church communities and youth organizations, changing the balance of power and pressuring local authorities. Empowerment and increased assertiveness helped to achieve a temporary mining ban, and reduce military repression.
Etoile du Sud, a PHM member organisation of the DR Congo, decided to organise weekly neighbourhood activities around hygiene. These bring people together to work around cleaning their streets, front gardens or improving sewerage. They create groups, connections and ideas that can last. This contributes significantly to their ability to mobile larger crowds during crucial advocacy moments.
If more high-impact actions are not possible, simply holding regular activities contributes to keeping the momentum going. Ideally, activities are in line with key strategic goals for the movement, but in the case of PHM Uganda consistently organising activities helps maintain relationships in an otherwise unclear environment, when relationships may otherwise lapse. Actions show people the movement exists, help to identify that it is real, even when coordination is minimal.
Most of PHM Kenya’s activities are conducted by members through their own group, organization or as individuals. Even though others in the movement are not aware of many of these activities, they often use the name of PHM Kenya and the global call for “Health for All… Now!”. This also shows members’ dedication to the movement’s principles.
Don’t let them off the hook
Every struggle requires continuous follow-up for a variety of reasons.
Every concession can make ground for another. When the health movement in El Salvador blocked privatisation, they stepped it up and supported the reform of the national health system. Health continued to be a major issue for years. As progressive health reforms were enacted, the movement started demanding fiscal reform to broaden state revenue.
Tit-for-tat strategies are useful, requiring monitoring of decisions made by authorities. The Canadian Ontario Coalition Against Poverty (OCAP) started off by helping people to register for a benefit called the Special Diet, providing up to $250 a month per person. Then tit-for-tat started. When authorities rejected applications, OCAP followed each one closely to get them accepted. Mass delegations were taken to authorities to overturn adverse decisions. The fact that people had to fight to obtain the benefit actually added to the momentum of the campaign. When the administration tried to restrict access, OCAP occupied the Mayor’s office, while allied health care providers protested vigorously. When the benefit application form was adapted, OCAP crashed a fundraising dinner for the Liberal Party and held a large night march. When, five years later, authorities tried to abolish the benefit, a march on the headquarters of the Ontario Liberal Party and a small occupation blocked it. When conditions were tightened, people walked into supermarkets, filling up their carts with items totalling very near the $250 amount provided under the benefit. When items were rung through, they explained the money to pay had been taken away by the Government and asked the supermarket to provide them free of charge and send the bill to the Premier of Ontario.
Wins can be precarious! The Italian right to water campaign pushed authorities back in a two-step strategy. First, many local water committees, trade union representatives, political parties and associations elaborated a proposed law to protect water and its quality, and bring integrated water services and management under public control through participatory democracy. The goal was at least 50.000 signatures required to present the law proposal before Parliament. In the six-month campaign, 406.626 signatures were collected. In spite of this success, the proposal was never discussed, and finally expired. Several initiatives were nevertheless organised to make Parliament discuss it, including a large demonstration in December 2007. When the government, in 2009, approved the privatisation of all local public services, guaranteeing profit for the service provider, water movements proposed a referendum in order to cancel these decrees. In a three-month period (April-June 2010), local committees collected almost 1,5 million signatures; only 500.000 were necessary for a referendum. Over 27 million Italians (more than 50% of those who could vote, and over 90% of voters) agreed to cancel the decision. The government never obliged.
Good and targeted communications that resonate with specific audiences are key. It matters not just what is communicated (a resonating narrative/message), but also how (socioculturally sensitive) and often by whom (local leaders, respected activists). In the experiences of PHM Kenya and Canada the importance of frequent communications between the movement’s members is highlighted (google groups, facebook, informal networks…). In India, Scotland and Bolivia PHM activists put great emphasis on empowerment of target groups through local presence and socio-culturally adapted communications: make it simple.
The “Health Care is a Human Right” campaign in Vermont USA highlights how politicians and most media outlets will go out of their way to overshadow the role of a people’s movement in fighting for and securing positive social change. The coverage of Vermont’s universal healthcare breakthrough focused on a handful of politicians, policy experts and doctors, while largely ignoring the collective voice and unified action of thousands of Vermonters. This serves to contain and potentially neutralize our policy victories and to lull community members into passivity.
Since we cannot depend on the mainstream media to cover our mobilizing efforts, values, needs and demands, we must tell our own stories, our own people’s history of how human rights were won for future generations. People must understand that without their own actions and their own media, change will not happen.
In order to make their voices heard, PHM groups use all sorts of media. In Bolivia, a national network for the right to health used short radio messages in a simple language, translated in local languages, to reach the most underprivileged population groups. Local leaders were involved, including through sharing material for community education and providing independent updated information to groups of patients and health workers.
Similar strategies are used in Nicaragua (municipality of Rancho Grande), where the population is fighting against the large gold mining company B2Gold. Their struggle has been successful in forcing the government to adopt protective legislation to preserve the environment (ban on open pit gold mining). Building awareness in the community is a key aspect of their struggle, that they do through door-to-door visits, community radio, organized trips to mining communities, videos about mining effects on the quality of water and forests in mining communities, finding media that publicize the resistance locally, nationally and internationally.
In India, during the mobilisation for the first People’s Health Assembly (PHA), a public awareness campaign was organised. In all states, the number of people involved in workshops, seminars, peoples’ dialogue, surveys and conventions was the main form of building up public awareness. A People’s Health Charter and five booklets had been prepared through a participatory process and translated in different local languages, and they became the central instruments through which the public understanding of the crisis in health care was built up. Poster campaigns also played a major role. The kalajathas – traveling street theatre – took the message to numerous districts. Rallies and processions also contributed – especially the rallies in Delhi (1,200 people) and Chennai (3,000 people) and of course in Kolkata (over 30,000 people mobilized).
Many PHM groups use public gatherings, participation in conferences and meetings as opportunities to spread a message to support the struggle for health. Some PHM material can be extremely useful in this sense. Besides the People’s Charter for Health, the Global Health Watch (GHW) can be used to organise dissemination and awareness raising meetings. To overcome the limitations represented by language (GHW is currently available only in English, although a Latin American edition of GHW4 has been published by ALAMES in 2015), in Porto Alegre (Brazil) the PHM group organised an open public course, addressing themes of the book to trigger discussions on global health and the social determinants of health. This course was promoted at the Federal University of Rio Grande do Sul and the state School of Public Health, it lasted two months with weekly 2-hour meetings; attendance was free and 35 people participated effectively.
New media use
In countries where media, and the political discourse in general, are controlled by the government and/or by political parties, the use of new social media becomes particularly useful. In Uganda, for example, the current government is intolerant to dissenting views from the public, especially those that look political. The movement responds by using social media (especially Facebook and Whatsapp), which have become instrumental in challenging the status quo.
In Palestine, a youth movement has (although briefly) managed to emerge in an otherwise stagnating political environment, dominated by the traditional political parties trapped in a hierarchical and conflicting power structure. This was linked also to the use of social media, that helped in overcoming the censorship of traditional forms of communication and the oppressive social control of older generations.
Social media are widespread also in other contexts where the political environment is less oppressive. The challenge here is how to navigate a huge flow of information. In Belgium, the PHM affiliated NGO Third World Health Aid (TWHA) has developed a tool to help movements in shaping their messages for social media (read more at http://m3m.be/sites/default/files/mailing/b_fiches3m3_reseaux.pdf – in French).