Building a Movement for Health


How we organise for action is often considered as something less important than the action itself. However, linked to our practices there are key issues such as the democracy of our movement as well as its potential to survive in an increasingly challenging (financial) environment.

Power relations are at the heart of our world. As a movement we unite to influence them. To the power of money, we oppose the power of people. Power does not always come in the tangible form of a policeman’s gun. Sometimes power is hidden in procedures: imposing a specific language, dress-code or written forms of expression before allowing someone to speak can exclude certain people and their concerns. Other times power is almost totally invisible. An ideology convincing people that poverty is due to individual failure makes economic power structures of exploitation invisible.

Outside power relations do not suddenly disappear within movements. Women often speak up less during meetings. The use of academic language can intimidate and exclude grassroots activists. For our movement to be both broad and effective, we need to act on these dynamics. Ensuring structures are in place to allow effective work together is important to movement work.

Read more at, a resource for understanding power relations in efforts to bring about social change.

Key message #5: Decide how to decide

Decision-making and power

There are several ways to make decisions in a group or an organisation.

The authoritative way is when a single person (e.g. the chairperson of the organisation), or a small group of persons (e.g. the steering committee), takes a decision for the rest of the group; this can come after a process of consultation, but those who are consulted do not have a say in the final decision.

Advantages: Rather quick decision

Disadvantages: Lack of information from “below”, lack of ownership by members which may lead to lack of unity

A different case, widespread in social groups of different kinds, is the decision by majority (voting): the position supported by at least half of the group plus one person is endorsed. Sometimes “qualified majority” is used, where for example at least 75% of the entire group needs to agree. Even though this is generally seen as a democratic process, experience shows that it can be quite oppressive for the minority who is in disagreement. Or, lead to a generalised consensus based on the more or less explicit pressure that the majority puts on the minority.

Advantages: Broader debate, potential of giving higher weight to certain groups

Disadvantages: Decision against part of the group, might forget about implicit, hidden or invisible power structures (did all really participate?)

Finally, decisions can be made through a process called “consensus”, based on the principle of inclusivity and with an explicit focus on the freedom and capacity of participants to express themselves. The process is facilitated so that participants may understand the reasons behind the different positions expressed by people, and may decide to change their opinion or to endorse the position expressed by the majority of the group while highlighting their reservations. Overall, the process aims at increasing the listening and mutual learning within the group, as well as the responsibility and ownership for the direction the group is taking.

Advantages: highly participatory, well-informed process, increased ownership, leads to better understanding of each other and the functioning of the group

Disadvantages: might be a rather long process, potential veto-power for one individual or a small group

In Italy many groups and movements reached through an action-research led by PHM noticed that, when the term “consensus” is used simply to indicate that people do not vote and seek to reach unanimity, it often means that the power dynamics are not managed and remain implicit. This can hide the existing imbalances, thus worsening their impact. Some groups highlighted how the consensus method is an ongoing process based on a “culture of consensus”, that develops self-awareness and self-consciousness but also requires taking good care of the relationships within the group.

Decision-making is often linked to the structure that a group or an organisation decides to have, that in turn is related to the distribution of power within the group. More hierarchical or structured groups tend to have a vertical process of decision-making, where the higher a person is in the structure, the more decisional power he or she holds. Less structured groups, who often call themselves “horizontal”, tend to adopt majority or consensus decision-making.

While this distinction may be done on paper, in real life social movements are much more complex. Managing power in a group is a big challenge, and choosing not to have a structure is by no means a solution as power is attached to many characteristics such as charisma, experience, resources, gender, age, profession… and not only to the role or position that one holds in an organisation.

For a good and concrete description of the consensus process, see (in French).

How to sabotage your organisation?

In 1944 the predecessor of the CIA published a manual teaching sabotage of meetings. Some of their advice we need to avoid:

1. Make speeches. Talk as frequently as possible and at great length. Illustrate your points by long anecdotes and accounts of personal experiences.

2. When possible, refer all matters to committees, for “further study and consideration”. Attempt to make the committee as large as possible (never less than five).

3. Bring up irrelevant issues as frequently as possible.

4. Haggle over precise wordings of communications, minutes, resolutions.

5. Refer back to matters decided upon at the last meeting and attempt to re-open the question of the advisability of that decision.

6. Slow down a decision. Advocate “caution”. Be “reasonable” and urge your fellow-conferees to do the same and avoid haste which might result in embarrassments or difficulties later on.

Read more here.

Key message #6: A group’s structure is a means to an end and not an end in itself

Structure, organisation and governance

The way in which PHM circles, groups and networks are organised is extremely diverse. In some cases, PHM is a registered organisation (as in the case of PHM South Africa), while in others it exists as an informal entity.

Registered organisations normally need to have a structure according to the laws and regulations of the country, including key roles and responsibilities (including legal responsibilities) that need to be defined. Non registered or informal organisations are, on the opposite, totally free to set up their own organisation.

In the case of smaller groups, this may consist of an assembly of members and, in some cases, a coordinating/steering group. When the organisation is more complex, different solutions can be adopted. For example JSA (Jan Swasthya Abhiyan, which is the PHM network in India), being a nation-wide network as well as a social movement, decided to adopt a flexible framework and both formal and informal governance structures. The formal structure comprises a National Coordinating Committee and a secretariat, that meet regularly. There are at least two meetings in a year with one at the larger level convening all members.

In the Italian experience, associations that act in collaboration with institutions tend to prefer more conventional forms of organisation, often based on hierarchy and representation, while self-organised experiences tend to opt for models that are more open to participation and shared responsibility. While being registered increases the opportunities to participate in projects and receive funds, being non registered allows for a more plural identity, participation and diversity (e.g. in the experience of JSA, which is the PHM network in India). They are also able to act and to position themselves using a wide variety of strategies and tactics.

The structure of a group is linked to the capacity to take decisions and act. In Italy many groups and movements reached through the action-research led by PHM talked about the challenge to be inclusive and participatory while deciding on action within tight and often unpredictable timelines (e.g. to react to undemocratic decisions by a local government, or protect an occupied building from eviction). In order to address this challenge, movements choose different organisational models, also in relation to their political culture and to the historical and social context in which they operate. Some groups, including Grup-pa (PHM-linked network), choose to explicitly say that the organisation, though guided by participatory practices, includes different levels of operational responsibility depending on the interests, available time and personal involvement of each individual.


In terms of membership, PHM adopts different settings. In parallel with the structure and, to a certain extent, the longevity of the circle, this ranges from more formal procedures to much looser ways of affiliation. The settings differ also in that they are more targeted at organisations or at individuals.

In India, mostly collectives and platforms have been targeted as opposed to individuals or small NGOs. However individual NGOs are encouraged to join at the State level. The People’s’ Health Charter did form a basis for membership, but not necessarily in any direct way and often people join JSA because of more recent campaigns or activities. The attraction of JSA lies in the platform it provides for health rights, and more generally in the sense of belonging to a larger group. Joining the JSA enhances the ability of single organisations to contribute to change, it provides peer recognition of the work and fulfills the desire to show solidarity. For the approval of new members the process is formal and is taken up by the national secretariat and the application is passed on to the National Coordinating Committee, where membership is approved if two members recommend it and if there are no strong or serious objections.

In most other countries, PHM membership is composed by both individuals and organisations and no formal process is in place. Members become so by informal affiliation that usually happens after taking part in some of the activities organised and then remaining connected via electronic media (mailing lists, newsletters, etc.).

In many PHM groups there is ambivalence about the issue of membership, with no clear system for signing up members, and certainly none to resign! Follow up of members is a common challenge, and while there are very few instances of people or groups leaving the PHM, in most cases they tend to become dormant, some because of a lack of follow up and others because they have their own priorities and feel a specific issue has not been taken up that should be. Openness to other people’s priorities is necessary for keeping members engaged, which may not happen if a single group is dominating leadership.

Advantages of membership organisations: facilitates structure, people take up formal commitment, feel they belong to something, offer contact data and facilitate communication, potentially allows for a broad and more transparent decision-making process

Disadvantages of membership organisations: too open member structure can increase vulnerability to repression, engagement of members can be time-consuming and require significant resources (human and material)

Key message #7: The community is a space for building bonds of trust and solidarity

Social movements and the community

As a social movement, PHM addresses issues that are relevant to the whole of the population, and not only to those directly engaged in health such as health professionals or patients.

For example, the People’s School of Health in Medellin (Colombia) – a popular education strategy that has made important contributions to the social movement in the city and has enriched the dialogue between academia, social movements and popular organizations – is a space of convergence for 23 social organizations and some municipalities, including health care user associations, patient groups, victim committees, trade unions, organizations of students, professors and pensioners, as well as health activists.

In terms of engaging the broader (non-activist) population, many PHM groups organise outreach activities directed to the community. For example, the organisations involved in PHM in the Democratic Republic of Congo periodically organise activities with the population to clean the roads and the common spaces in the neighbourhood. PHM Brazil has also been involved in such a programme in a marginalised area of the city of Porto Alegre. And many of the activities of JSA in India target the general population.

Many groups in Italy do not speak of “target groups” but see the community as a space for building bonds of trust and solidarity. This is a key aspect of their political project and reflects the central role attributed to relationships, and to experiencing them in a new way. They see territories as networks of relationships and affections, in which it is possible to imagine new wor(l)ds and ways, because they are made of stories, memories, strengths, conflicts, daily life frustrations, mutuality, confidence, and creativity. Breaking with a merely geographical vision of territories, some movements speak about the existence of an “emotional geography” that links them with other movements further away. These experiences tend to be far from the institutions, and often define themselves “clandestine”; they narrate and create every day an alternative to the capitalist system, based on new forms of social organisation that put into practice values such as cooperation, mutuality and openness.

Key message #8: For greater sustainability, rely on multiple resources

Sustainability of the movement

Besides reaching out to new organisations, a real challenge is how to sustain the commitment and the work, both in terms of core functions and in follow up of members and network organisations.

In the experience of PHM South Africa, to develop and sustain programmatic activism is not a quick process. And, in the quest to build a people’s health movement more broadly, you may end up producing members for another organisation: while this may contribute broadly to building a health movement, it does not build PHM’s capacity, without which it will not have the strength to broaden its engagement.

Key elements for continuity seem to be:

  • the importance of sustained leadership;
  • the delicacy of organisational affiliation and alliances (where you may lose relationship with organisations when their members leave the PHM steering committee);
  • the variability of conditions on the ground;
  • the vagaries of funding;
  • and that organising invariably takes a long time.

When it comes to resource mobilisation, it definitely is a concern of most PHM groups that heavily rely on voluntarism.

In JSA most resources are generated in kind and through informal contributions, volunteer time and use of existing offices. From time to time, JSA has also received funds for specific activities or for support to the secretariat, such as WHO support for work on social determinants. Largely the organization is self financed and this is considered to be a historical approach given that in the mobilisation for the National Health Assembly there was no central proposal and no central receipt of funds. People were asked to use their own resources to come to the meeting and contribute their bit to the total meeting expense. This remains the guiding principle. If there is a specific project that JSA undertakes, one of the members will receive the funds and there is strict documentation. Some JSA members have provided infrastructural support, hosting the secretariat for instance. Mass organisations who are part of JSA contribute very small amounts as they have no fundraising or project activity, while others who have some form of resources contribute more. Financing by members is based on their capacity. While there are occasional attempts at creating a buffer or raising funds, this seldom takes shape and in many respects the JSA respondents felt the approach to resources was fine.

In Italy almost all the groups need to look for funds in order to support their activities and projects. In many cases, there are activists who sustain the group’s activities without any compensation, while investing in them much of their energies and time. In a social context of general and widespread precariousness, several experiences reflect on the possibility of self-sustenance through militancy. Many questions arise from this issue, for instance whether the fact of being paid alters the nature of the political action, transforming activism into a job. To this question movements give different practical answers. In some cases, the idea of remunerating activism has been rejected. In others, mixed solutions have been found, with some people acting on a voluntary basis and others being paid. This solution requires however a higher degree of organisational complexity, and is often a cause of conflicts, also as a result of the social taboo that surrounds money. From an organisational point of view, many experiences are still experimenting, often with a tendency not to create rigid rules but rather to tolerate high, or very high, degrees of autonomy, while prioritising working on the process and taking care of the interpersonal relationships.

Starting from the need of economic sustainability, some experiences in Italy have elaborated reflections and experimented different practices of economic management. These are often inspired by the principles of self-management and self-income, and rely on mutuality and solidarity developed in support networks that do not only exchange money or material work. Many groups highlight the importance of these networks as forms of self-sustenance, rejecting the idea or possibility of a stand-alone self-sufficiency. Support networks and mutuality are key also in generating forms of indirect income, based on the possibility to access, for free or contributing according to the resources that a person has, to training opportunities, cultural activities, services, as well as accommodation and food, and not least to spaces for social relations.

Besides the above mentioned forms of self-sustenance, the main way to access economic support is through public calls for projects (issued by public institutions, private foundations, etc.). This requires the groups to adopt a recognised, and often pre-registered, legal form. As a consequence, the number of associations has grown a lot in recent years, leading to increasing levels of competition among groups. It also causes groups to focus on problems for which there is funding available, limiting the political power of addressing unpopular or marginalised causes. In this way, the system induces a fragmentation of the existing groups, rather than promoting aggregation and synergies. It could be argued that this is a strategy to allow the existence only of what is consistent with the current economic and social system, and perhaps to increase the control and limit the potential harm of alternative social groups.

Enablers of movement building

According to JSA, enablers of movement building are the following:

1. Continuously updating strategies in keeping with newly emerging situations.

2. Ensuring maximum inclusiveness and continuous outreach.

3. Good quality, updated analysis, which addresses concerns that people are facing.

4. Need to be constantly in touch with the network members.

5. Place for network members to display their individual/organization identity without undermining the group solidarity.

6. Activities where many can contribute, some in a major way, some in a minor way.

7. Strategies of financing, both the node and other key constituents.

8. A good proportion of the membership should come from individuals organizations who do not depend on this work for their incomes, but have the time to contribute to this work.

Can activism be a profession?

A key issue raised by many groups and movements in Italy concerns the delicate balance between work and activism.

On the one hand, some highlight how professionalising activism may lead to having a paid workforce, but one that needs to respond to external priorities and timelines (e.g. in terms of project deadlines, funding allocation, etc.).

On the other hand, the need to combine work and activism arises when activism is a full-time occupation, that requires to be economically sustained.

An interconnected aspect is the consideration that, in order to be fully sustainable, political activism needs to take into account also personal needs. Several groups try to address the issues of life and activism as a whole, and do not seek sustainability in each of the two separately.

Remunerating work seems to devalue the noble motive for voluntarism (including political action) and this can lead to a paradox: a full-time form of “existential activism” that is however not worth any income. In these conditions, activism can result in self-exploitation, even if in its premises it declares to oppose any form of exploitation in society.

Advantages of voluntarism: political autonomy, freedom from donor influence and conflictual issues of income redistribution

Disadvantages of voluntarism: does not challenge the functioning of the current system, or lead to creating viable social, political and economic alternatives