The People’s Health Movement
- Ravi Narayan, Ravi NarayanCentre for Public Health and Equity, Society for Community Health Awareness, Research and Action (SOCHARA)
- Claudio Schuftan, Claudio SchuftanIndependent Public Health Consultant
- Brendan Donegan, Brendan DoneganDepartment of Anthropology, London School of Economics
- Thelma NarayanThelma NarayanDirector - Academics & Policy Action Epidemiologist, Public Policy Society for Community Health Awareness Research and Action (SOCHARA
- and Rajeev B. R.Rajeev B. R.Dental Public Health, Society for Community Health Awareness Research and Action (SOCHARA)
The People’s Health Movement (PHM) is a vibrant global network bringing together grass-roots health activists, public interest civil society organizations, issue-based networks, academic institutions, and individuals from around the world, particularly the Global South. Since its inception in 2000, the PHM has played a significant role in revitalizing Health for All (HFA) initiatives, as well as addressing the underlying social and political determinants of health with a social justice perspective, at global, national, and local levels.
The PHM is part of a global social movement—the movement for health. For more than a century, people across the world have been expressing doubts about a narrowly medical vision of health care, and calling for focus on the links between poor health and social injustice, oppression, exploitation, and domination. The PHM grew out of engagement with the World Health Organization by a number of existing civil society networks and associations. Having recognized the need for a larger coalition, representatives of eight networks and institutions formed an international organizing committee to facilitate the first global People’s Health Assembly in Savar, Bangladesh, in the year 2000. The eight groups were the International People’s Health Council, Consumer International, Health Action International, the Third World Network, the Asian Community Health Action Network, the Women’s Global Network for Reproductive Rights, the Dag Hammarskjold Foundation and Gonoshasthaya Kendra. All these groups consistently raised and opposed the selectivization and verticalization of Primary Health Care (PHC) that followed Alma Ata leading to what was called Selective PHC (i.e., not the original comprehensive PHC). These groups came together to organize the committee for the first People’s Health Assembly and then to form the Charter Committee that led to the People’s Health Charter, which finally led to the actual PHM.
Within PHM, members engage critically and constructively in health initiatives, health policy critique, and formulation, thus advancing people’s demands. The PHM builds capacities of community activists to participate in monitoring health-related policies, the governance of health systems, and keeping comprehensive PHC as a central strategy in world debate. The PHM ensures that people’s voices become part of decision-making processes. The PHM has an evolving presence in over 80 countries worldwide, consisting of groups of individuals and/or well-established PHM circles with their own governance and information-sharing mechanisms. It additionally operates through issue-based circles across countries.
The People’s Health Movement (PHM) is a vibrant global network bringing together grass-roots health activists, public interest civil society organizations, issue-based networks, academic institutions, and individuals from around the world, particularly the Global South. Since its inception in 2000, the PHM has played a significant role in revitalizing Health for All (HFA) initiatives, as well as addressing the underlying social and political determinants of health with a social justice perspective, at global, national, and local levels. This article summarizes the most significant features and milestones of the movement over nearly two decades.
This article makes use of an analytical distinction between social movements and social movement organizations.1 For more than a century, people across the world have been expressing doubts about a narrowly medical vision of health care, and calling for focus on the links between poor health and social injustice, oppression, exploitation, and domination.2 The individuals, organizations, and networks producing these critiques calls for change, and related actions are a social movement—the movement for health. In contrast, the People’s Health Movement comprises those individuals, organizations, and networks producing a particular set of statements, actions, and organizing efforts that try to “join the dots” between specific instances and situations and a larger social totality, “taking aim” at particular targets in order to move the world toward a more just, fair, and healthy social order. This article refers to the PHM as a social movement organization which draws on the ideas of the movement for health, which represents a vision for what is currently making the world sick and what a “social vaccine” might look like.3
Social movements can be “from above” or “from below,” but there is something inherently conflictual about a social movement in the sense that a social movement is, by definition, an entity seeking to change—that is, move—aspects (or the entirety) of a social order that exists because it benefits dominant social groups (Touraine, 1985). The PHM is a social movement project “from below,” in the sense that it takes the side of “the people” against globalization, privatization, and commercialization of health “from above” (Harris & Seid, 2004).4
The article covers five main areas:
The context in which the PHM was created;
The first global People’s Health Assembly, which in some sense “gave birth” to the PHM in the year 2000;
What the PHM is and how this has developed since the year 2000;
The PHM’s impact; and
The continuing need for the PHM in the world today.
This section outlines the context for the creation of the PHM in the year 2000.
The Movement for Health and PHM
Medicine is a social science and politics is nothing else but medicine on a large scale. Medicine as a social science, as the science of human beings, has the obligation to point out problems and to attempt their theoretical solution; the politician, the practical anthropologist, must find the means for their actual solution.—Rudolf Virchow (1821–1902)5
Social movements and social movement organizations emerge at particular times and places, in response to a particular social, political, and economic context. This section outlines some of the factors leading to the emergence of the movement for health and the PHM.
As with other social movements, it is possible to say that at the heart of the emergence of the movement for health and the PHM is a three-stage process: first, the experience of deprivation, oppression, and exploitation; second, the emergence of an awareness of the causes that lie behind that experience; and third, the emergence of action intended to address those causes.
Within the movement for health and the PHM, an important element is the presence of physicians who, like the 19th-century German doctor, anthropologist, and public health activist Rudolf Virchow quoted above, realize that the causes of their patients’ maladies lie “upstream,” and then start to join the dots in order to build up a picture of how social, political, and economic processes at local, national, or global levels are contributing to people getting sick (Taylor & Rieger, 1985). The next logical step is to come to the idea that the work of a healer can lie in working toward a social vaccine. The step after that is to come to the idea that collective action is needed—joining forces with others, combining and extending the knowledge of each individual in the process (see, e.g., Zurbrigg, 1984).
With this in mind, this section discusses three key factors that can be identified in the emergence of the PHM in the year 2000:
A set of “problems” (discussed as “the global crisis”) that lie beyond the door to the clinic;
A set of “solutions” that others are already advocating (discussed as “existing responses”); and
A specific, immediate context that led to the idea to hold the first global People’s Health Assembly in the year 2000.
The Global Crisis and Its Effect on Health
By the year 2000, the world was experiencing a global crisis that was well entrenched and deeply affected the prospects of health the world over. Key elements included:
Adverse effects of economic changes on people’s health and access to health/social services;
Increasing poverty and hunger;
Widened gaps between rich nations and countries rendered poor and increased inequalities within countries;
Lack of access to basic entitlements (food, water, sanitation, land, shelter, education, livelihood) by large proportions of the population;
Rapid depletion of planetary resources;
Upsurge of conflicts/violence;
Increasing concentration of global resources in fewer hands, which basically maximizes their profits;
New economic/political policies affecting the lives, livelihoods, health, and well-being of people in both the south and the north;
Deteriorating, unevenly distributed, and inappropriate public services; and
Privatization undermining principles of universal access to health and equity.
These issues were some of the primary concerns of the founding organizations of the People’s Health Movement when they called for the first People’s Health Assembly in December 2000.
From PHM’s Perspective
From its launching in 2000, the PHM put its efforts most importantly into CPHC and into the “Health for All” movement; however, many other elements in the global situation for health have worsened since: inequalities have increased, the Universal Health Coverage initiative has not proceeded in a way that PHM values would support, and the World Health Organization (WHO) has been weakened. This, despite the PHM having constantly adapted to the broader social, environmental, and economic context (Global Health Watch, 2017, § A, pp. 13–17).
Responses and Growing Interest in a Larger Coalition
While the Alma Ata Declaration positioned Health for All (HFA) as a movement for health championed by national governments with international health and development agencies (WHO, 1978), in the years that followed the declaration, many began to feel that a movement of public interest civil society organizations and health activists would be required as a countervailing power to global and national health policymaking, to ensure that HFA became a reality through policy and practice to transform the health system. Academics and health activists described the need for such a movement (Voluntary Health Association of India, 1997). A publication on the politics of primary health care (PHC) and child survival, with an in-depth critique of oral rehydration therapy, noted:
Achieving an equitable social order conducive to health will require nothing less than a worldwide uprising—a global non-violent revolution. We can work towards such global solidarity through a two-step process. The first step is to act at local level, where we can help increase people’s awareness of the causes of their day–to–day hardships and help them formulate strategies to improve their immediate situation and defend their rights. The second step is to link these local initiatives to broad national and international coalitions. To stand a chance of success, this “people’s health movement” must be as global as the system it seeks to transform.(Werner, Sanders, Weston, Babb, & Rodriguez, 1997)
More voices were raised within academia and in the policy and activist community as the year 2000 neared, with HFA still a distant goal.
While previously existing community health projects and programs did add to the development of WHO’s HFA strategy, they continued to grow after Alma Ata. They then defied alternative technical PHC programs not based on the holistic Alma Ata principles. It was the engagement of these groups with WHO through various civil society networks and associations (1980–1999) that brought about the idea of the need for a larger coalition. On the issues of essential drugs—and on a more rational HFA-oriented drug policy—Gonoshasthaya Kendra, Health Action International (HAI), the International Organization of Consumer Unions, the Third World Network, and the Dag Hammarskjold Foundation (DHF) were the first to engage; on gender and women’s reproductive rights issues, the Women’s Global Network for Reproductive Rights engaged; and on issues related to the code on the promotion of breastmilk substitutes and countering the industry International Breast Feeding Action Network, the DHF and HAI engaged.6
Additionally, all of them consistently raised and opposed the social and political context of HFA, as well as the selectivization and verticalization of PHC that followed Alma Ata leading to what was called Selective PHC (i.e., not the original comprehensive PHC). On this, the contribution of IPHC and the Asian Community Health Action Network (ACHAN) need mention here as well. All of these eight organizations coalesced, first to organize the committee for the first PHA and then to form the Charter Committee that led to the People’s Health Charter, which finally led to the actual PHM. Halfdan Mahler once famously noted that it was this informal relationship of the WHO with civil society (prominently, the PHM) that led to all of the HFA-oriented innovations on issues of essential drugs, infant feeding, the Code, and the WHO’s FCTC (Framework Convention on Tobacco Control), and so on!
Specific Context in Which Idea for a PHA Emerged
The previous subsection mentioned a large number of networks. It was the experience of all of these networks, particularly through their participation and interactions in the annual World Health Assemblies of the World Health Organization, that contributed to the felt need for a people’s health assembly where people’s voices and the involvement of public interest civil society had to become active, and not peripheral or marginalized by the prevailing rules and red tape. The culture of dialogue and celebration which was planned and experienced in the first People’s Health Assembly in Savar, Bangladesh was, therefore, designed to show that a counter to the World Health Assembly (WHA) culture was possible! Since then, the PHM has always put together a pre-WHA workshop where allied organizations join to look at the WHA agenda and to prepare a coordinated civil society response to the resolutions coming up for discussion.
It has been suggested that the idea of a People’s Health Assembly “which would act as a forum where people’s voices would be given pride of place” was first proposed in 1987 by K. Balasubramanian, in the context of the first planning meeting of Action for Rational Drugs in Asia in Bangkok (John, 2006). The 25th anniversary report of Health Action International stated that “Successive World Health Assemblies where the health decision makers of the world congregate each year had failed to address the needs and aspirations of the poor and the world …,” and therefore a suggestion was made for “the idea of a PHA which would act as a forum where people’s voice would be given pride of place. It took thirteen years for the idea to germinate, take root and flower” (John, 2006). In short, there was an urgent need to challenge the neglect of the HFA goal by WHO and governments, that is bringing people, the public social good, and democracy with diverse voices into health policymaking.
Thus the People’s Health Assembly was explicitly conceptualized as a counterpoint to the annual World Health Assemblies. It is worth noting that the first People’s Health Assembly, in 2000, took place one year before the first World Social Forum, which has tended to meet each year in January, at the same time as the annual meeting of the organization to which it is a counterpoint, the World Economic Forum, which meets in Davos, Switzerland. The consistent links with the World Health Forum (WHF) process (i.e., seeking wider links with civil society beyond health) must be emphasized here. In the 2004 WHF in Mumbai, the PHM came out with declarations that were particularly significant in this respect.
The First Global People’s Health Assembly (2000)
This section describes the first Global People’s Health Assembly (PHA), the birthing moment of the People’s Health Movement.
The First Global Assembly
The first Global PHA was held from December 4 through December 8, 2000, in Savar, Bangladesh, on the rural campus of Gonoshasthaya Kendra (literally, the People’s Health Center in Bangla), the first hospital established in independent Bangladesh in 1972. The Assembly is widely regarded as a watershed moment energizing a global movement. This diverse international multisectoral gathering brought together individuals, groups, organizations, networks, and movements long involved in the struggle for health. The Assembly concluded with a decision to continue to work together as the global People’s Health Movement. The Assembly also produced the People’s Charter for Health, which PHM describes as the “most widely endorsed consensus document on health since the Alma Ata Declaration” (PHM website).
Over 1,500 people from 77 countries, including 17 state delegations from India, spent five days in Savar sharing their concerns and experience about the challenges faced in realizing HFA (People’s Health Assembly, 2001). They celebrated small and large initiatives that enhanced community initiatives and struggles surrounding HFA. Decades of community health action at the local level had led to an analysis showing that there was a need for a larger countervailing effort toward the social goal of HFA, as articulated in 1978. This effort needed to address the structural constraints and barriers that were being encountered.
One of the central preoccupations of scholars of social movements is the question of why movements form. In the 19th and early 20th centuries, the traditional argument was that movements emerge in contexts of rapid social change and/or rapid increases in discontent or grievances of would-be movement participants. In contrast, resource mobilization theorists have argued that grievances are secondary, and that “movements form because of long-term changes in group resources, organisation, and opportunities for collective action” (Jenkins, 1983). A strong case can be made that the People’s Health Assembly in 2000, which led to the creation of the People’s Health Movement, is best understood from the perspective of resource mobilization theory.
Social movement theorists have argued that “mobilization does not occur through recruitment of large numbers of isolated and solitary individuals. It occurs as a result of recruiting blocs of people who are already highly organized and participants” (Oberschall, 1973, p. 125). The organizers of the People’s Health Assembly in 2000 successfully brought together existing social networks around an event focused on a set of key ideas: the broken promise of the Alma Ata Declaration (health for all by the year 2000) and the limitations of the WHO and its World Health Assembly. The creation of the People’s Health Movement, and its continuing existence two decades later, indicates the strength of the initial networks and key ideas, and their ability to galvanize people and organizations across the world into collective action in defense of people’s health.
Many social movement scholars argue that social movements succeed where organizers manage to combine a compelling account of a situation (an account which “frames” or defines three elements: social reality; grievances or discontent; and claims, demands, and calls for action) with effective use of social networks which make it possible for information and ideas to be shared among activists and allies (Tarrow, 1998). Resource mobilization theory, in particular, argues that “broad, diffuse, disorganised collectivities such as the general public” are unlikely to mobilize without the “entrepreneurial” efforts of organizers capable of “seizing on major interest cleavages and redefining long-standing grievances in new terms” (Jenkins, 1983). The success of the People’s Health Assembly can therefore be attributed to the effective mobilization of existing networks and the key ideas of Alma Ata, health for all by the year 2000, WHO and WHA, which were (and still are) important cultural symbols within the movement for health.
The remainder of this section describes and analyzes the first global assembly.
The Preparatory Process
As discussed in the previous section, over some years, networks and institutions connected with like-minded groups to discuss the HFA gaps and to plan strategies for action. Representatives of eight networks and institutions formed an international organizing committee to facilitate the first assembly. These included the International People’s Health Council, Consumer International, Health Action International, the Third World Network, the Asian Community Health Action Network, and the Women’s Global Network for Reproductive Rights, as well as the Dag Hammarskjold Foundation, and Gonoshasthaya Kendra (GK). Several other institutions, Non-governmental organizations (NGOs), networks, public interest civil society organizations, social movements, and HFA activists across the world supported and participated in the idea of the assembly. The organizing committee was supported by a PHA secretariat initially based in Penang, Malaysia, which later moved to GK, in Savar, Bangladesh. It initiated a news briefing service keeping everyone involved in the planning process. Regional coordinators for Africa, South Africa, Asia, South East Asia, Europe, the Pacific region, and Latin America were identified to initiate work at the country level, organizing regional meetings and consultations. Pre-assembly activities in locations from Africa, the Arab countries, Asia, Europe, Latin America, North America, and the Pacific became a symbol of the truly global mobilization (PHA Secretariat, 2000). One of the largest pre-PHA mobilizations at the country level was the Indian Health Assembly held in Kolkata, West Bengal, India, shortly before the People’s Health Assembly in Savar. Both events, the Indian and the global assembly, are captured in a film showcasing the spirit and creativity of this significant gathering addressing continuing challenges in the HFA journey (The Health Protestors-India, 2001).
Five draft background papers developed through discussions and e-dialogue covered five major barriers to achieving the HFA goal. Their titles are self-explanatory: (i) The Political Economy of the Assault on Health; (ii) Equity and Inequity Today: some contributing social factors; (iii) The Medicalization of Health Care and the Challenge of HFA; (iv) The Environmental Crisis: threats to health and the ways forward; and (v) Communication as if People Mattered: adapting health promotion and social action to the global imbalances of the 21st century.
These papers were widely circulated, requesting comments, case studies, and suggestions for actions (People’s Health Assembly, 2000a).
A PHA drafting group consolidated the papers, with comments from the global dialogue, into a discussion paper for the assembly, stating: “The quest for sustainable societies calls for drastic changes in the current world order. It requires the formation of strong broad-based people’s movements. All movements (health, environment, social, women, among others) must join forces and be seen as part of the same overall movement for social change, social and gender justice” (People’s Health Assembly, 2000b).
The program included plenary sessions with testimonies from people across the world, followed by reflections and panel discussions (People’s Health Assembly Secretariat, 2000; People’s Health Movement Secretariat, 2000). Daily thematic discussions were held on health, life, and well-being; inequality, poverty, and health; health care and health services; environment and survival; and the ways forward.
Afternoons were busy with over 100 concurrent sessions, allowing participants to discuss a variety of health challenges related to their immediate interest or situation as encountered in their countries and regions. Ideas for action from these sessions fed into an evolving draft charter for people’s health that built on an interactive process before and during the assembly.
The assembly had a range of complementary sessions with theater, poetry, songs, exhibitions, displays, and evenings with cultural expressions from different regions. Local women’s committees from neighboring villages organized and provided a range of meal options in typically constructed, small village thatched eateries within the assembly campus, adding a strong local community dimension with local people’s participation in the assembly. A daily printed news bulletin published over the five days reported from various sessions, with interviews and messages from participants from across the world.
The People’s Charter for Health
During the Assembly, the PHM’s People’s Charter for Health was finalized through daily consultations. The last day was devoted to ways forward. The People’s Charter for Health was discussed and adopted unanimously. The Charter supported a resolve to continue building solidarity and collective work, through evolution of a global People Health Movement network, to advocate and act on all the elements of the “call to action” in the Charter (People’s Health Assembly, 2000c).
The Charter is an expression of common concern of the movement, a vision of a better and healthier world, a call for more radical action, a tool for advocacy for people’s health, and a rallying point around which a global health movement can gather and other networks and coalitions can be formed.
The Charter is one of the most translated health documents globally, and is now available on the PHM website in 34 languages, with many more language translations available and evolving as the movement spreads to different regions of the world (People’s Health Assembly, 2000c).
The Charter’s preamble emphasizes the following:
Health is a social, economic, and political issue;
Health is above all a fundamental human right;
Inequality, poverty, exploitation, violence, and injustice are at the roots of ill health;
HFA means that powerful interests have to be challenged; and
Political and economic priorities have to be drastically changed.
The Charter builds on the following perspectives:
Encourage people to develop their own solutions; and
Encourage people to hold local authorities, national governments, international organizations, and corporations accountable.
The Charter builds on the following vision:
A world with equity, ecologically sustained development and peace;
A world in which a healthy life for all is a reality;
A world that respects, appreciates, and celebrates all life and diversity;
A world that enables the flowering of people’s talents and abilities to enrich each other; and
A world in which people’s voices guide the decisions that shape our lives.
The Charter has a call for action at all levels (individual, community, national, regional, and global) that provides the basis for action in four areas:
Health as a human right;
Tackling the broader determinants and challenges of health, especially economic, social, political, environmental, as well as war, violence, and conflict;
Promoting a people-centered universal and comprehensive PHC; and
Promoting peoples’ participation for a healthy world.
The People’s Health Charter lists a range of action initiatives suggested by PHA participants as being needed to combat the ill effects of the triple assault by the forces of globalization, liberalization, and privatization of health, health systems, and health care.
The Impact of the Assembly and the Charter
To this day, the first global health assembly is widely regarded as a key moment for civil society activism in the health arena. Not only was the emotive charge overwhelming, but people left with the clear idea that concerted action was imperative. PHA1 sowed the seed of a global network of systems that has, at the time of this writing, been active for two decades.
A concluding essay in a special publication on global development noted that “The People’s Health Movement is clear evidence that the existing linkages between globalization and health are contestable. … Its People’s Charter for Health provides a significant expression of alternatives ‘from below’ to the present globalization, privatization and commercialization of health coming ‘from above’” (Harris & Seid, 2004).7
Understood in the way Harris and Seid suggest, the People’s Charter for Health became the basis for the movement. Concrete action initiatives emerged at various levels, globally, regionally, and at a country level. This comprehensive document containing analytical as well as action points for health is probably the most significant contribution of the PHM from 2000 onward.
A recent PHM report describing initiatives undertaken in 2016 is a good indicator of how the Charter has been translated into action at various levels all across the vibrant diversity of the movement (People’s Health Movement, 2016).
Evidence of the current validity of the Charter is that the PHM has not undertaken to revise or update it. It remains a beacon for the movement and for health activists elsewhere. After PHA1, each subsequent PHA brought in newer agenda items and groups. This is reflected in the respective declarations: PHA2 focused on militarization, environmental health, traditional medicine, culture, and healers and health researchers (see the Cuenca declaration). PHA3 focused on widening regional involvement, especially from Africa, and also on extractive industries. PHA4, which took place in Savar in 2018, marked the 40th anniversary of the Alma Ata Declaration.
The People’s Health Movement (2000–)
Shortly after Savar, the Assembly grew into what is today the People’s Health Movement.
This article makes use of a distinction between social movements, defined by their goals and interests, and social movement organizations, defined by their particular organizational structure. These two concepts are ideal types, and in reality the PHM sits somewhere in the middle, and it could be described as belonging to an in between category of “intermediary” social movement organizations with “centralised structures with semi-autonomous locals and autonomous locals loosely coordinated through federative structures” (Jenkins, 1983).
PHM Global and most country circles are not incorporated (registered) and do not have a formal membership, so “joining the PHM” is more or less a personal statement plus collective recognition, which sounds more like a movement than an organization. At the same time, what makes the local and thematic groups within the PHM look more like an organization than a movement is that while the PHM draws upon the ideas of what this article calls the movement for health, the PHM has a more specialized mission and an orientation. The mission is about helping to build a global social movement for health as a response to globalization and its role in the determination of health care and health/disease. The orientation is centered on a strong political economic analysis of the relationships between globalization and health (David Legge, personal communication).
Objectives of PHM
The 2016 PHM report (People’s Health Movement, 2016) have reiterated the objectives of the movement:
To promote Health For All through equitable, participatory, and intersectoral movements and seeing it as a human rights issue;
To advocate for government and other health agencies to ensure universal access to quality health care, education, and social services, responding to people’s needs and not to their ability to pay;
To promote participation by people and people’s organizations in the formulation, implementation, and evaluation of all health and social policies and programs;
To promote health, equity, and sustainable development as top priorities in local, national, and international policymaking;
To encourage people to develop their own solutions to local health problems; and
To hold local authorities, national governments, international organizations, and corporations accountable.
Organization and Structure
The PHM is a global network of “Health For All” activists drawn from various sectors, including civil society and academic institutions. The PHM gradually evolved from small groups of individuals and organizations into more well-established “circles” in many countries. These circles have evolved their own structures, governance framework, decision-making, programs, and initiatives. The circles are clustered into regional groupings enhancing intra- and inter-regional coordination and information sharing. Presently, the PHM’s regions include Southeast Asia and Australia; South Asia; India; West and Central Africa; East and Southern Africa; the Middle East, Latin America; North America; and Europe.
The PHM has a global Steering Committee with representatives of its founding networks, regional coordinators, and network partners. The PHM Global Committee has one or two senior PHM member co-chairs and a young co-chair, who was nominated in 2019. A small global Coordination Committee drawn from the steering committee takes care of the day-to-day decisions and meets virtually on a monthly basis. The PHM has a global secretariat since 2000. It is hosted by a region and is led by a convener, usually a senior member from the hosting region with a small core team to support coordination and communications. The global secretariat was first based in GK in Savar till 2003. It then moved to Bangalore, India, hosted by the Society for Community Health Awareness, Research and Action (SOCHARA) till 2006. Then it moved to Cairo, Egypt, hosted by the Association for Health and Environmental Development for the Middle East and North Africa region till 2010. Since then, it has been based primarily in Cape Town, South Africa, with a satellite in New Delhi.
The PHM has operated on limited budgets. Its work is facilitated by participating individuals and organizations in a spirit of volunteerism. An International Advisory Committee with senior PHM members advises the secretariat.
Lessons learned have proven that these groups need to and have constantly evolved to experiment with new frameworks and strategies to enhance representativeness; inner democracy in decision-making; coordination between circles, countries, regions, and programs; and effectiveness of policy and programmatic action (People’s Health Movement, 2000a).
The PHM, with its affiliated circles and networks, has four core programs, apart from the ongoing HFA campaigns in each country and region.
Critical Engagement with WHO Through PHM’s WHO-Watch
WHO and UNICEF, key facilitators of the Alma Ata Declaration, did not attend the first People’s Health Assembly despite having been invited. PHA participants endorsed the concept of comprehensive PHC and the need for WHO to actively continue its promotion. The charter suggests, “a radical transformation of the World Health Organization (WHO) is needed so that it responds to health challenges in a manner which benefits the poor, avoids vertical approaches, ensures inter-sectoral work; involves people’s organizations in the World Health Assembly and ensures independence from corporate interests” (People’s Health Assembly, 2000c).
Subsequently, a series of in-house workshops organized by WHO—with some PHM public health activist participation—led WHO in 2001 to announce a Civil Society Initiative to enhance its dialogue with these groups. In its early years, the PHM set up a WHO advocacy circle that regularly attended World Health Assemblies in Geneva as public interest civil society representatives. The PHM was there to raise the concerns vented in its charter. Along with other NGOs officially recognized by WHO, the PHM progressively evolved a formal engagement strategy primarily around the WHAs in Geneva to advocate with member delegations on many aspects of a change toward Health For All-oriented policies (R. Narayan, 2006).
Soon, a focused initiative evolved—the WHO Watch. Through this, young PHM members from different countries were trained (and are being trained) to attend WHO Executive Board meetings and the World Health Assemblies. They engage in discussions with country delegates to pursue advocacy efforts working toward pro-people, Health For All strategies (Fabbri, 2015). Watching at WHO headquarters, and now regional WHO committee meetings, has included documentation, analysis, monitoring, liaison, and advocacy with WHO country representatives and national government representatives. This has met with varying degrees of success. Prior to attending, an analysis is carried out of the resolutions coming to the floor and a two- to three-page summary is prepared depicting the PHM’s position toward the respective issues delegations. The same is distributed to all member state delegations, thus making clear to them what civil society’s positions are. The WHO Watch website is a section of the global health watch website where analyses and notes are available to all concerned for further action (Global Health Watch).
It is undeniable that the WHO Watch has had an impact. Member state delegates know of it and read Watch summaries. The WHO secretariat is also well aware of its presence and influence and continues to welcome the PHM/MMI partnership in the deliberations of the Executive Board, as well as the World Health Assembly.
Global Health Watch
Since 2005, every three to four years, the PHM together with other partners, publishes an independent, alternative World Health Report (WHR) entitled the Global Health Watch (GHW). These comprehensive analytical reports focus on critiquing the widening disparities in health and access to health care; on cross border threats to health; on the social determination of health and also, most importantly, propose alternative visions of health and health action based on human rights, on action on the social determinants of health and nutrition, and on the empowerment of communities, especially the marginalized. To date, five GHWs have been published by Zed Books. All publications are edited by a secretariat, supported by other groups.
Each GHW edition is a collaborative exercise between a host of individuals, academic institutions, and organizations “who share a desire to improve the state of global health and to express their solidarity with the need to tackle the social and political injustice that lies behind poor health” (People’s Health Movement, Global Equity Gauge Alliance, & Medact, 2005). The first report had contributions from over 120 individuals and 70 organizations globally. Each GHW includes a section titled “Holding to Account” which reviews government, international aid agencies, health and development foundations, and funds. A section called “Resistance” in more recent GHWs outlines salient features of campaigns and initiatives to strengthen HFA action in different geographies.
The first GHW was released in 2005, the second in 2008 (People’s Health Movement, Medact, & Global Equity Gauge Alliance, 2008), the third in 2011 (People’s Health Movement, Medact, Health Action International, Medico International, & Third World Network, 2011), the fourth in 2014 (People’s Health Movement, Medact, Medico International, Third World Network, Health Action International, ALAMES, & Health Poverty Action, 2014) and the fifth was published in November 2017.
The GHWs have been influential in that several public health curricula in universities all over the world refer to it as essential reading material. Public health professionals and national and international civil servants are reading successive issues and often cite/quote from them in their writings.
International People’s Health University
The International People’s Health University (IPHU) is the PHM’s main political economy of health education and research program. IPHU’s aim is to contribute to HFA by organizing and resourcing relevant learning, as well as sharing and planning opportunities for activists and professionals, particularly from the Global South. A separate website tracks its activities (International People’s Health University, 2005). Since July 2005, IPHUs have been holding short courses lasting 5 to 15 days each entitled “The Struggle for Health” specifically designed for young health professionals and human rights activists. These short courses in different languages are hosted by country circles and academic institutions. Some are accredited by various universities for students working on a master’s degree in public health. The faculty are drawn from senior PHM members and well-known local activists. They share perspectives, life journeys, and struggles to inspire participants as an intergenerational exchange. IPHU groups interact with each other through social networking. Alumni work together on small projects or in collaborative research projects. In 2016, for instance, IPHUs were held in Kathmandu, Nepal; Brussels, Belgium; San Salvador, El Salvador; Seattle, USA; Cape Town, South Africa; and London, UK. Networking is encouraged among the IPHU participants around themes and policy action initiatives. The IPHU initiative orients young health professionals and activists to continue addressing the challenges of HFA. This has been a major contribution of the movement (Sanders, Guigliani, Antunes do Nascimento, & Legge, 2010).
Over 1,000 young cadres from all continents have been through different IPHUs. A small number of these alumni have become active in the running of the global movement and a big percentage continue to be active in the struggle for health in their respective national environments.
Global Health Governance
This newer initiative of the PHM “aims to improve the global environment for health by changing the information flows and power relations that frame global health decision-making and implementation. The project was launched as an initiative of PHM, the South Centre, the Third World Network and other international organizations and networks” (People’s Health Movement, 2016). The focus is both on watching at the WHO Executive Board (EB) and World Health Assembly (WHA), as described earlier, on providing critical support to ad hoc WHO-watching workshops held around EB and WHA meetings to help “watchers” understand the dynamics of global governance issues in health and related challenges. These workshops are held before the WHO EB and the WHA, plus some WHO regional meetings. Activists from beyond the PHM watching group can and do attend and learn from these workshops and their organizations and networks can thus enhance the watching process and strengthen global health governance. A Global Geneva Health Hub (G2H2) was set up in 2016 to unite forces of public interest civil society organizations watching WHO with the aim of further democratizing global health policy making (G2H2).
The importance of this relatively new partnership and its aims is highlighted by the need of public interest civil society to coalesce and present a unified front when dealing with Geneva-based United Nations’ organizations.
Health For All Campaigns
While the PHM as a global network facilitates global initiatives, its core potential and strength lie in country circles that organize and promote local initiatives and campaigns as countervailing power to health policy decision-making at country and state/provincial and community levels. The focus of the action is on the right to health (Schuftan, Turiano, & Shukla, 2009). Many country circles have their own websites linked to the global website. Their community-based work and initiatives of policy advocacy and engagement supporting local health struggles can be tracked on the PHM website. The latest report of the movement outlines activities in Latin America, Europe, North America, Southeast Asia (Philippines, Cambodia, Malaysia), Australia, India (several states, including Rajasthan, Chhattisgarh, Madhya Pradesh, Karnataka, and Tamil Nadu), and Africa (South Africa, Uganda, Tanzania). These included activities around World Health Day, engagement with campaigns around trade agreements, the privatization of services, the role of extractive industries, issues of food and nutrition, as well as providing support to global and local campaigns, developing and/or signing statements, writing articles, and carrying out research. Country and regional circles focus on local and regional challenges in addition to providing solidarity with global initiatives (People’s Health Movement, 2016).
Different country circles have very different degrees and styles of engagement, and much of what is done by PHM members remains unreported.
PHM India: A Case Study
PHM India, known as Jan Swasthya Abhiyan (JSA), is the Indian chapter of the PHM with activities that promote and engage (or if necessary, counter) Health For All policies at the country level. The work of the JSA was noted in the World Health Report 2008 (WHO, 2008), and is the focus of an unpublished doctoral dissertation (Donegan, 2012).
The PHM in India is a coalition of 22 national networks, alliances, social movements, resource groups, and federations of NGOs working in India and focusing on health, development, science, women’s issues, health rights of children and the marginalized, the environment, and other health-related challenges. In 2000, after a year of extensive and intensive community mobilization efforts, a National Health Assembly with over 2,500 participants was held in Kolkata on November 30 and December 1, just prior to the global assembly in Savar. An Indian’s People’s Health Charter was adopted and JSA was created as a broad national platform to continue collective work on health and health care with a focus on human rights and social justice. Booklets were prepared for mobilization purposes on themes such as globalization and health, comprehensive PHC, basic health needs, health of marginalized groups, and commercialization of health care. Dr. Halfdan Mahler, former WHO DG, described these booklets as the “best expression of primary health care and its politics. … They are the bible of primary health care, a glorious milestone on the tortuous road to primary health care” (Jan Swasthya Abhiyan-PHM-India, 2004, back cover quote). These books were translated into several Indian languages and, in 2004, the English versions were published as a resource book for the movement.
Following is a list of some of the significant activities of JSA:
A campaign on health as a human right was launched in April 2001;
A critique of the National Health Policy, 2002 was published and widely discussed;
Public hearings on the denials of the right to health were organized in collaboration with the National Human Rights Commission in 2004;
Public dialogues on health issues with political parties were held before the national election in 2004;
A Peoples Rural Health Watch was initiated in eight states;
A National Coordinating Committee with networks and state-level representatives plans and organizes different campaigns and initiatives on different aspects of health policy;
Since 2009, the PHM India has been evolving the People’s Health Manifesto before each major national election and advocating for it;8 and
Network members of JSA initiated campaigns on gender issues, pharmaceutical policy, intellectual property rights, and campaigns for access to essential medicines.
A second National Health Assembly was held in Bhopal in February 2006 with the theme “Defending People’s Health in an Era of Globalisation” (T. Narayan, 2006). The third National health Assembly was held in Raipur, Chhattisgarh in September 2018.9 Ongoing activities and reflections continue in 20 states.
The Indian PHM has clearly been the most active circle, especially in the first 10 years of the movement. Much activity is now also coming from PHM circles in South Africa, Latin America, and Europe.
Later Assemblies, Declarations, and Anniversary Publications
The PHM keeps abreast of new challenges and developments globally, regionally, and nationally that have a significant impact on health. It has organized regular global meetings and eventually has come up with new declarations responsive to evolving realities to keep the global movement current.
The emotive aspects of PHAs certainly were a high point in the assemblies. The sense of solidarity, brotherhood, and sisterhood prevails throughout. Videos from these events testify to this high spiritedness—including one by the BBC in its Life Series video entitled “The Health Protesters” in 2000. There are several examples of these.
The Alma Ata Anniversary Pack, 2003
The PHM Secretariat prepared background material with analysis of the post-Alma Ata experience by the PHM in its mobilization to promote the goals of CPHC. This was published as separate book in India (Narayan & Unnikrishnan, 2003).
The Mumbai Declaration, 2004
This declaration (People’s Health Movement, 2004a) was prepared during the World Social Forum in Mumbai in January 2004, where 700 delegates from 44 countries endorsed it and called for action in six areas:
End corporate led globalization;
End war and occupation;
Implement comprehensive and sustainable PHC;
Confront the HIV/AIDS epidemic with a PHC and health systems approach;
Reverse environmental damage caused by unsustainable development strategies; and
End discrimination by applying right-to-health principles.
People’s Charter for HIV/AIDS, Bangkok, 2004
This Charter brought together the voices and concerns of PHM members and people living with or affected by the HIV/AIDS epidemic. It was released at the end of the 15th International AIDS conference in July 2004. The charter was finalized at a special discussion in a satellite symposium attended by delegates and AIDS activists including PHM activists from several countries (People’s Health Movement, 2004b).
Second People’s Health Assembly, Cuenca, Ecuador, 2005
The second PHA from the July 17 to 22, 2005 further analyzed global health problems and discussed strategies to promote HFA, building on progress by the movement since the Savar assembly. The second assembly included the first course of the International People’s Health University, a research encounter with health policy researchers and health activists on research for people’s health, a children’s encounter, and the release of the first edition of the Global Health Watch as an alternative world health report by the PHM with a parallel Latin American adaptation. A health and human rights thematic group was launched at the time. The global assembly was richly supplemented by a celebration of traditional healing cultures and healers, and it began with a gathering of native people and healers of the Andes and all over the world. They facilitated the opening ceremony and released a statement on behalf of the native peoples of the world, reminding us of their pride in “our healthy and harmonious coexistence with the nature, to tell the world that the present crisis, defined by exploitation, inequality and discrimination must end … and a better world be made in which people’s health represents that world, with joy, solidarity and harmony.” The statement made significant suggestions based on native culture and traditions (People’s Health Movement, 2005c).
This dialogue with traditional medicine and people’s health traditions, which is still an emerging area in the PHM agenda, was further strengthened by a South Asian regional conference a year later (AIFO, 2006).
The Cuenca Declaration, 2005
This declaration came out at the end of the second PHA and re-endorsed commitment to
“a socially and economically just world in which peace prevails: a world in which all people whatever their social and economic condition, gender, cultural identity and ability, are respected, are able to claim their right to health and celebrates life, nature and diversity”(People’s Health Movement, 2005a, p. 1).
The declaration encouraged the following:
Implementing the principles of the right to health in an era of hegemonic globalization;
Promoting health in an intercultural context;
Advancing the right to HFA in the context of gender and personal diversity;
Protecting the right to health in the context of environmental degradation;
Ensuring worker’s health and safety by defending and extending existing rights;
Defending the right to health in the face of war, militarization, and violence; and
Promoting CPHC and sustainable, quality local and national health systems.
It was in Cuenca where, after thorough analysis, the PHM decided that its original charter needed no amendment or additions. It still stood. The Cuenca Declaration picked up on new developments since 2000 and presented the additional actions on which the movement should embark in order to keep up with the times. Noteworthy in this respect was the launch of the PHM’s Global Right to Health Campaign that ended up covering 15 counties.
South Asian Regional Conference on Traditional Medicine and the Right to Health for All, Bangalore, India, 2006
This dialogue with traditional medicine and people’s health traditions, which is still an emerging area in the PHM agenda, was further strengthened by a South Asian regional conference a year later in which a consensus statement and a call for action at global, regional, and local levels evolved (AIFO, 2006).
Third People’s Health Assembly, Cape Town, 2012
This assembly centered around testimonies and stories of success and failure, violations of people’s right to health, and the impact of neoliberal globalization on people’s lives with suggestions on ways in which to rectify injustices and inequalities in the world today. Facilitators included 175 resource persons from 45 countries, leading plenaries and sub-plenaries with participants from over 90 countries, the majority being from low-income and lower middle-income countries. There were self-organized activities and the Cape Town call for action was agreed upon. It was an opportunity for the movement to reflect on its experiences and emerging challenges (People’s Health Movement Global Secretariat, Cape Town, 2012).
Although held in the midst of a cold winter in the southern hemisphere, PHA3 was yet another worthy success for the movement. Importantly, it brought together African activists who had not previously been active in the PHM. After Cape Town, the PHM has had several working circles in western, central, eastern, and southern Africa.
The Cape Town Call for Action, 2012
Twelve years after the launch of the movement, participants collectively endorsed its alternative vision and called for action toward the following:
A reformed economic system that values every individual, not every dollar;
Just, fair, and democratic political and economic processes and institutions;
Better and transformed global heath governance free from corporate influence and influence of unaccountable private actors; and
Equitable public health systems that are universal, integrated, and comprehensive, providing a platform for appropriate action on the social determination of health.
Participants compiled action initiatives both for the movement and for health policies and health systems globally and locally (People’s Health Movement, 2012).
The call, again, was an update of the challenges and tasks ahead for the movement.
4th People’s Health Assembly, Savar, Bangladesh, 2018
The most recent gathering of PHM circles from all over the world was the Fourth Assembly, which was recently concluded in the year of the 40th anniversary of the Alma Ata Declaration. It became an opportunity for the movement to take stock of its work and impact for nearly two decades (People’s Health Assembly, 2018).
Impact and Some Lessons Learned
This section discusses the impact of the PHM since its creation in the year 2000.
Assessing the Impact of Movements and Movement Organizations
We can begin to study social movements as isolated confrontations between single social actors and their opponents, but—particularly when we examine their outcomes—we quickly arrive at the more complex and less tractable networks of politics. It is through the political opportunities seized and created by challengers, movements, and their allies and enemies that major cycles of contention begin.(Tarrow, 1998)
This article has made use of a distinction between social movements and social movement organizations. As suggested by Tarrow (1998), it is often easier to see the global impact of movements than it is to see the global impact of movement organizations. For example, it is easier to say that the women’s movement across the world has made a global impact than it is to say that a particular feminist organization has made a global impact. On the other hand, it may be far easier to attribute local, “micro” impacts to specific campaigns and actions by a movement organization. So, then, in evaluating the impact of the PHM, it makes sense to focus on some of the concrete and specific impacts made by the PHM.
While it is easy to say that the health movement has had impact, and easy to say that specific campaigns have had impact, it is much more difficult to say that the PHM as a movement organization has had impact, unless one is very clear on what it is trying to do. For the purposes of this article, let us state that what the PHM is trying to do is not to single-handedly change the world completely but instead to make solid contributions to changing the world by: changing institutions, endorsing new concepts/arguments/frames of reference on the health agenda globally (and nationally and locally), and getting people talking about the PHM approach and ideas in different countries. And the PHM has very clearly done those things in concrete ways for almost 20 years, since the PHA in Savar in 2000.
In terms of the concrete and specific impacts that the PHM has had, the remainder of this section focuses on three in particular:
“Global” impacts on global-level institutions and discussions (e.g., WHO, Commission on Social Determinants of Health);
“Local” impacts, particularly in the form of the dissemination of the Charter and other PHM declarations, the formation of regional, thematic, and national PHM chapters and groups; and
The campaigns, training workshops, and other actions initiated by “local” chapters and groups.
This section presents many examples of the impact of the PHM, primarily as case studies of impact. There are many other examples that have not been included here due to limitations of space.
A brief discussion of some lessons learned by PHM organizers is included at the end of the section.
Global Impacts on Global Institutions
Since 2000, the PHM has been a strong proponent of a people-led globalization of solidarity, opposing corporate-led globalization and neoliberal economic policies that devalue and commodify health. Over the years, this role of the PHM in globalizing health solidarity from below to counter the top-down globalization of health policies has been increasingly recognized. Consequently, PHM and resource persons linked to it have been invited to participate in various global health policy meetings and processes.
Revisiting and Revitalizing Efforts Toward CPHC
Starting with a series of in-house seminars in 2001, the PHM charter was introduced and discussed informally. This led to an invitation to a dialogue of PHM leaders with the WHO DG. This was followed by an invitation to present the PHM and its charter at a technical briefing in the WHA in 2002. From then on, the PHM began a proactive engagement with WHO to revitalize its commitment to CPHC. In May 2003, 82 PHM delegates attended the WHA and made a defense of CPHC through various advocacy strategies.
By 2006, the PHM had established a strong presence as an advocate of CPHC and was later involved in the renewal of PHC efforts by the next WHO DG. This further led to PHM-related resource persons being involved in the planning of the WHR of 2008 devoted to PHC. The PHM contributed to it and participated in its external review before its release in Almaty, Kazakhstan (WHO, 2008).
Putting Social Determinants of Health on the Global Agenda
The People’s Charter for Health is the first global declaration that strongly advocates the important of social determinants of health (People’s Health Assembly, 2000c).
In a follow-up to World Civil Society Forum discussions in Geneva, PHM panelists made a case for a “poverty and health commission” to be established with WHO and PHM engagement to act on the social determinants of health. Meetings with the WHO DG followed, leading to an engagement with WHO in 2003 This resulted in the participation of a WHO team in the 3rd International Health Forum in Defense of People’s Health hosted by the PHM at the World Social Forum in Mumbai in 2004 (R. Narayan, 2006).
In a message to the PHA in 2005 in Cuenca, Ecuador, the WHO DG acknowledged the congruence between WHO and the PHM by noting that “combining our strength and uniting our efforts, we have achieved a great deal and we will achieve a great deal together … as the people’s charter for health puts it, our common vision is ‘a healthy life for all’. Thank you for adding your voices and strength to the pursuit of this great objective” (People’s Health Movement, 2005b). The dialogue continued with steps leading to the formation of the WHO Commission on Social Determinants of Health and its final reports (CSDH, 2008). The PHM was closely engaged with this process since the planning meeting in London before the commission was actually announced; the PHM Steering Committee co-chair was a commissioner and facilitated civil society dialogue in various regions. A draft document evolved from the dialogue. Finally, at the World Conference on Social Determinants of Health in Rio de Janeiro, Brazil in 2011, PHM resource persons were deeply engaged in the processes and panels. While contributing to the WHO Declaration (WHO, 2011), the PHM also organized a satellite meeting to prepare a more binding (dissenting) statement as perceived being needed by civil society organizations (People’s Health Movement, 2011b).
The engagement of the PHM with the CSDH included PHM members attending the preplanning meeting of the process; a PHM Steering Committee co-chair being nominated as commissioner; PHM-linked resource persons being consulted by the CSDH secretariat; the PHM being invited to organize a dialogue for commissioners with civil society in different regions; several PHM-linked resource persons invited to be part of these created knowledge hubs; PHM presenting an alternative CSDH report; and strong PHM representation and engagement being at the Rio de Janeiro conference during the launch of the CSDH report (R. Narayan, 2006).
In addition, PHM academics and health activists published a paper on the concept of a social vaccine as a metaphor for action on social determinants (Baum, Narayan, Sanders, Patel, & Quizhpe, 2009).
Strengthening the Global Commitment to Community-Based and Community-Oriented Health Systems Research
Since 2001, PHM members played an important role in various fora promoting and enhancing the role of people and communities in health research so that policy, systems strengthening, and practices arising out of the research process could become responsive to the people’s health needs and aspirations. This included active participation in annual fora of the Global Forum for Health Research and its ministerial summits on health research, and organizing a dialogue with researchers at the PHA2 in Cuenca; it also included participating in the WHO Task Force on Health System Research; the Bamako Intergovernmental Conference on Health and Equity; the Dialogue Papers in the Lancet, the Bulletin of WHO and other journals; the support to initiatives such as the Emerging Voices; and participation in WHO’s Health Systems conferences. Researchers with PHM links continue to contribute to the dialogue at various levels (McCoy, Sanders, Baum, Narayan, & Legge, 2004;Narayan & Narayan, 2012).
Local Impacts of the “Global” PHM
Perhaps the most visible local impacts of the PHM include the formation of country circles and thematic circles. However, central to the way global PHM activists operate are more “invisible” forms of impact, sometimes conceptualized as the creation of activist professionals rather than professional activists: the PHM is not changing the world but creating change agents, producing change-motivating documents and opportunities, as well as challenging institutions including WHO, regional WHO offices, UNICEF, among others. This includes, for example, training a large number of young, IPHU health activists and a smaller number of WHO watchers, and the consistent production of GHWs 1–5 by a large group of researchers, academics, and activists willing to be part of a collective CS perspective document which is now acknowledged as an independent evidence-based alternative World Health Report.
Impact of Local Chapters and Campaigns
In India, the engagement of JSA (PHM India) with health policy resulted in the communitization aspects of national health programs, with many JSA resource persons becoming members of different NRHM task forces. These efforts have been the focus of several academic research projects, including those by Donegan (2011, 2012) and Unnithan and Heitmeyer (2012).
Some Lessons Learned Along the Way
Since its inception, the PHM has had reflections, reviews, and evaluations. As a learning movement, it builds on praxis to respond to new situations and challenges, both external and internal. The first evaluation in 2004 examined the process of PHA1 and the development of the PHM in its first three years. The report insisted on the need for increased dialogue and communication among key movement focal points; enhanced dialogue and discussion in more global and national fora; improved communication strategies and practices, both internal and external; and enhanced cooperation so that the PHM constituency is seen as “a proactive, inclusive and welcoming movement.” One of the key challenges was the issue of diversity and the report noted “Above all, the pictures that emerge of the PHM in the evaluation are a celebration of diversity and it is that diversity that is the main strength of the PHM. Sustaining and maintaining a diverse, flexible and effective movement that serves as a platform for social change is the challenge that now faces the PHM” (Chetley & Muxi, 2004).
In 2005, the period between the Savar and the Cuenca PHAs was evaluated. In this case, the secretariat prepared a review of this phase. It identified four strategic thrusts crucial to long-term sustainability of the movement. These included mobilizing newer, youthful leadership; engaging with mainstream institutions in the public health system using strategic opportunities to build spaces for alternative thinking; inspiring and informing evidence gathering from academia and research institutions; and recognizing the PHM as a generic movement toward HFA and identifying partners at local, national, regional, and international levels in an effort to make its approach more inclusive (Narayan & Team, 2006).
In 2008, the PHM carried out a research study on Revitalizing HFA: Learning from Comprehensive PHC Experiences. This was an international, participatory, collaborative study. It aimed at identifying case studies chronicling efforts to implement CPHC reforms from countries around the globe and using an innovative approach of triads consisting of senior and junior researchers working with knowledge users from each country’s public health system. These were then compiled into a resource book of case studies on revitalizing HFA. The case studies selected were from Australia, Brazil, Democratic Republic of Congo, Iran, South Africa, South Asia, and more (Labonte, Saunders, Packer, & Schaay, 2017).
The second formal evaluation was carried out in 2011. It was conducted by a six-member team from India, Mexico, South Africa, Switzerland, Sweden, and Thailand. The team did extensive document reviews, conducted interviews, and applied an electronic survey questionnaire directed at the Steering Council, country focal points, IPHU alumni, and faculty (People’s Health Movement, 2011a). The main suggestions to strengthen the role of the PHM as a global actor in health included the following:
To increase the breadth and depth of the PHM as a movement and to strengthen its internal diversity;
To strengthen participatory strategic development and planning;
To set up improved communication strategies for better transparency and networking;
To develop local strategies that can influence WHO and global health governance; and
To carry out in-depth, far-reaching research, awareness-building, campaigning, advocacy, and social mobilizing in the areas of environment and health.
Research was carried out on civil society’s engagement in HFA activities.
This PHM-led action research project was completed in six countries (Brazil, Columbia, Democratic Republic of Congo, India, Italy, and South Africa). Its aim was to document and strengthen social movements and civil society organizations in achieving HFA. The project focused on five themes: movement building, knowledge generation and dissemination, capacity building, campaigns, and engaging with global health governance (People’s Health Movement, 2016).
Beyond a Focus on Health Services Advocacy
Some within the movement have wondered whether PHM’s primary focus on health services advocacy postponed more aggressive networking with other social, economic, and environmental organizations working on the same, mostly structural determinants of health. In fact, the PHM has branched out to embrace and engage with important new currents of action. For instance, the PHM’s Latin American Region has stressed the importance of the ecological determination of health by joining the “Buen Vivir” movement (Global Health Watch, 2017, § C1, p. 183). Issues of trade and health have also been a focus of PHM globally (Global Health Watch, 2017, §§ C4, D5, pp. 207, 316). PHM’s advocacy on food and nutrition has insistently stressed the role of transnational corporations (Global Health Watch, 2017, §§ C4, E2, pp. 8, 385). In terms of health services, the issue of commercialization of the same has also been part of active campaigning in the movement (Global Health Watch, 2017, §§ B1, B3, C3, C4, D2). Climate change and a gendered approach to sexual and reproductive health have also seen the PHM branching out to work with strategic allies (Global Health Watch, 2017, §§ C1, C2).
Taking the PHM Seriously
Since the first PHA in 2000, academia and policymakers are beginning to recognize the role of the PHM and comment on its impact. A brief compilation of diverse assessments taken from a wide range of global publications provides an idea of the increasing significance and influence of PHM:
Reporting in a mainstream weekly in India, a demographer, academic commented on the assembly as follows, “The people’s health assembly held in Dhaka, last December was as much a reassertion of people’s solidarity as it was a massive show of protest against the increasingly anti-people policies of international agencies, multinational companies and national governments” (Bose, 2001, p. 905).
A position paper of the Pan American Health Organization (PAHO) on renewal of PHC, noted the PHM approach as the “Health and Human Rights” approach, one of the four approaches in PHC that “stresses understanding health as a human right and the necessity of tackling the broader social and political determinants of health” (PAHO-WHO, 2007, p. 4).
An Open University textbook series on public health in the UK describes the PHM as “an international network of organizations and individuals that came together in 2000 to re-ignite the call for Health for All, Now! to re-establish health and equitable development as top priorities in local, national and international policymaking” (Lee & Collin, 2005). Another chapter in the same book notes “the People’s Health Movement emphasizes increasing the participation of local people in global health debates—on hearing the ‘voices’ of the unheard” (Rowson, 2005, p. 205).
A Swedish textbook on global health notes the contribution of the PHM in defining development as “networks such as the People’s Health Movement, argue that the involvement of local communities in development is a prerequisite for sustainability, effectiveness and the achievement of self-esteem and freedom.” It further describes the PHM as “a strong voice in the global health debate for free primary health care” (Lindstrand, 2006, p. 46).
A comprehensive book on globalization and health argues that the assessment of health is an important criterion for evaluating and monitoring the progress of globalization. A concluding chapter on the politics and ethics in health and equity identifies the PHM as an example of “The simultaneous rise of a global civil society movement pressing for political actions to shift the rules of contemporary globalization” (Schreker & Labonte, 2007, p. 284).
A textbook in Australia on the New Public Health refers to the PHM in its concluding chapter and notes “The People’s Health Movement and the World Social Forums provide prime examples of how civil society is envisaging a healthier and fairer world” (Baum, 2008, p. 582).
WHO’s Helsinki Declaration (Health Promotion Conference, 2013) specifically, and probably for the first time in the UN’s organizations’ history, mentions engagement/consultation with the People’s Movement as separate from civil society (non-governmental actors), recognizing the difference PHM has been calling for long.
We live in the era of the sustainable development goals (SDGs). For the PHM, the SDGs are a case of: Plus ça change, plus ça reste la même chose (“the more things change, the more they stay the same”). The SDG targets actually give nations too much latitude in defining their own “level of ambition,” therefore allowing them to choose their own particular targets so that the targets rather become “aspirational,” with each country able to “cherry-pick” from them. With little attention given to the SDGs to income distribution needs, the PHM points out that it would take 200 years to eliminate poverty. Notable also are the embedded contradictions in the SDGs between equitable, sustainable development, and the insatiable economic growth model of global capitalism.
With all these caveats, the SDGs risk becoming everyone’s business, but no one’s major responsibility. It thus falls on public interest civil society organizations like the PHM to hold both state and market to account. The SDGs are simply plagued by too many “woulds” and “shoulds,” rather than forceful statements of “will” and “shall.” The situation being what it is, the U.N. system has regrettably been under a neoliberal assault for decades and is facing its own test of contemporary relevance. The SDGs omissions are not due to an oversight; they are intentional. Only societal counterpower through organizations and movements of the people can force the needed redistribution mechanisms (i.e., what is needed is building broad domestic counterpower). A renewed attention to the importance of the social determinants is the only way forward. It is clear that change will not occur by itself. It will be the result of the clash of opposing forces. The PHM thinks we have to position ourselves on the side of the well-being for all and of a healthy planet and against profit for a few. We need to mobilize. Bottom line, building a stronger activist base remains essential to move governments forward on the SDGs seen from the perspective of their weaknesses as stated in this section. The PHM is on that track (Global Health Watch, 2017, §§ A1, A2).
On the Universal Health Coverage front, the PHM has already begun actively intervening in this dialogue and is linking UHC closer to the perspective of the Alma Ata Declaration (Sengupta, 2013).
Taking action on the social determinants of health, as well as including communities, social movements, and civil society in the development, implementation, and monitoring of Health for All is another PHM working track. Building health literacy in the population is the priority in this area (WHO, 2014). Together with partners, the movement has recently developed an interactive participatory action manual based on actions and learning from all over the world. This is being used by HFA activists and professionals, according to the Ticket to Work Health Assurance program (TWHA) and M3M, an Indian real estate development company (2017).
In sum, the PHM is active in different fronts, all geared toward promoting a new paradigm in health. With a focus on the social determination of health, individual and collective efforts can and are being renewed toward promoting the health movement and the rights of all to health.
The People’s Health Movement is a vibrant global network bringing together grass-roots health activists, public interest civil society organizations, issue-based networks, academic institutions, and individuals from around the world, particularly the Global South. Since its inception in 2000, the PHM has played a significant role in revitalizing Health for All initiatives, and addressing the underlying social and political determinants of health with a social justice perspective, at global, national, and local levels. This article has summarized the most significant features and milestones of the movement over nearly two decades.
This article used an analytical distinction between social movements (defined by goals and ideas) and social movement organizations (defined by organizational structure), and argued that the People’s Health Movement is a movement organization which draws on the ideas of the broader movement for health, which represents a vision for what is currently making the world sick and what a “social vaccine” might look like. Social movements and social movement organizations emerge at particular times and places, in response to a particular social, political, and economic context, and so the first two sections of this article describe the context in which the PHM emerged and the process by which the organizers of the first People’s Health Assembly in 2000 successfully brought together existing social networks at an event focused on a set of key ideas: the broken promise of the Alma Ata Declaration (health for all by the year 2000) and the limitations of the World Health Organization and its World Health Assembly.
The article’s third and fourth sections discuss the activities and impact of the PHM since the People’s Health Assembly in 2000. The challenge involved in such a discussion is that while this article acknowledges a distinction between social movements and social movement organizations, these two concepts are in fact ideal types. In reality, the PHM sits somewhere in the middle, and could be described as belonging to an in between category of “intermediary” social movement organizations with “centralized structures with semi-autonomous locals and autonomous locals loosely coordinated through federative structures” (Jenkins, 1983, p. 540).
Different country circles have very different degrees and styles of engagement, much of what is done by PHM members remains unreported, and central to the way global PHM activists operate are more “invisible” forms of impact, sometimes conceptualized as the creation of activist professionals rather than professional activists: the PHM is not changing the world but creating change agents, producing change-motivating documents and opportunities, as well as challenging institutions including WHO, regional WHO offices, UNICEF, and others.
Having said this, this article presents four core programs of the PHM: critical engagement with the World Health Organization through the PHM’s WHO-Watch; Global Health Watch (a series of alternative World Health Reports produced by the PHM); the International People’s Health University; and Global Health Governance (an initiative of the PHM in collaboration with the South Centre, Third World Network, and other international organizations and networks). The article also discusses PHM India, known as Jan Swasthya Abhiyan, which has clearly been the most active PHM country circle, especially in the first 10 years of the movement.
As the PHM reaches two decades, many challenges lie ahead, including critiquing and proposing new policies leading to more democratic health system and institutional reforms. The holders of the right to health the world over can expect the PHM to work on taking them toward the progressive realization of the right to health. Recognizing the right to health and health care at a country level as central, the PHM will strive for the creation of health rights-monitoring initiatives in several countries. Expect also for regional and global solidarity work on shared right-to-health issues and concerns to be carried out in coordinated campaigns, demanding action (People’s Health Movement, Medact, Health Action International, Medico International, & Third World Network, 2011).
The support of Mr. H. R. Mahadevaswamy of the Society for Community Health Awareness is acknowledged in the preparation of this article and to PHM colleagues at all levels for their solidarity and inspiration. Brendan Donegan acknowledges all the activists who helped him with his Ph.D. research and training and learning as an activist, funding for his PhD from the UK’s Economic and Social Research Council (ESRC), affiliation to the London School of Economics as a Visiting Research Fellow (2017–), as well as the support of his wife Dr. Carrie Heitmeyer.
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1. Much of the academic literature on social movements makes use of this distinction. It could be argued that this distinction is particularly important within the resource mobilization approach to the study of social movements (see, e.g., McCarthy & Zald, 1977, which emerged in the 1970s in response to the social movements of the 1960s (Jenkins, 1983).
2. For example, in 1848 Rudolf Virchow, often described as the father of social medicine, published an analysis of the typhus epidemic in Upper Silesia emphasizing economic, social, and cultural causes and political (rather than medical) solutions (Taylor & Rieger, 1985).
3. In 2007, David Legge, an active participant in and advocate of PHM, introduced one of us to this conceptual distinction between PHM as an organization and the movement for health. PHM is not “the movement”; PHM is an organization which is networking to build a movement (David Legge, personal communication).
4. The People’s Charter for Health declares that “Health for all means that powerful interests have to be challenged, that globalisation has to be opposed, and that political and economic priorities have to be drastically changed” (People’s Health Assembly, 2000c). The Charter is PHM’s primary declaration of intent.
6. Dr. Halfdan Mahler served three terms as director-general of the World Health Organization and has been described as the architect and defender of the Alma Ata Declaration of “Health for All by the year 2000” (Brown, Fee, & Stepanova, 2016). In a speech he made at the first People’s Health Assembly, in 2000 in Savar, Bangladesh, he described the successful efforts of NGOs in pushing WHO to action on essential drugs, primary health care, and breast milk substitutes as the “finest hour of the WHO” (Balasubramanian, 2006, p. 66).
7. The same publication included an invited essay on the PHM, written by two of us (Narayan & Schuftan, 2004).
8. See the People’s Health Manifesto 2019 by PHM India.
9. The third National Health Assembly in India of PHM Circle in India was held in Raipur, Chhattisgarh in September 2018.