Illness and death every day anger us. Not because there are people who get sick or because there are people who die. We are angry because many illnesses and deaths have their roots in the economic and social policies that are imposed on us.
– voice from the People’s Health Assembly, Cuenca, Ecuador –We live in capitalism. Its power seems inescapable. So did the divine right of kings. Any human power can be resisted and changed by human beings.
– Ursula Le Guin –
The global (health) crisis and its roots
The current dominant model of development, based on market liberalisation and capitalist globalisation, has notoriously failed to deliver Health for All. In fact, our health and the health of the planet has been crushed by neoliberal policies that are typical of present day capitalism.
The global economy has had a rough time over the past few years, creating greater inequities in health and in its social determinants. This recent period is foreshadowed by a forty-year-old uncontrolled experiment in neoliberal globalization, during which a particular ideology – neoliberalism – dominated the rules by which capitalism has expanded. There are differing definitions of neoliberalism, but they distill to the same belief: that free markets, sovereign individuals, free trade, strong property rights and minimal government interference are the best recipe for improving human well-being.
Neoliberal globalisation has resulted in an immense concentration of power amongst a wealthy and corporate elite. The exploitation of many by a few is illustrated by the fact that – during a period of unprecedented wealth generation – the numbers living in poverty have increased especially in Africa and South Asia, and today the wealthiest 1% in the world has as much wealth as the rest of the planet’s population combined1. This situation undermines democracy and social justice; even in countries with progressive governments, there is a lack of accountable, transparent and democratic decision-making, spaces for democratic participation are disappearing and protest is being criminalized.
Reports on the state of the world’s health appear daily in the world’s media. UN agencies, NGOs and academic institutions produce vast amounts of data, statistics and analysis. However, too often the state of preventable ill-health is framed as a problem of disease, geography, bad luck or poor government. Rarely is it properly framed as a symptom and outcome of political and economic choices, or the current form of globalisation which has created a deep division between a minority of ‘winners’ and a majority of ‘losers’, whilst simultaneously placing the world in an unprecedented environmental crisis. Widespread conflict and the resulting displacement of peoples from their livelihoods are also part of this picture.
In the view of the PHM, the current global health crisis is a consequence of the failure to address the social, political and environmental determination of health, resulting in an erosion of food sovereignty, in higher levels of inequality, as well as in a lack of fair and equitable access to water, housing, sanitation, education, employment and universal and comprehensive health services. Moreover, preventable ill-health and disability are being perpetuated by the aggressive marketing of unhealthy products such as tobacco, alcohol, junk food and beverages; by the pollution of our air, our land and our water sources; by the grabbing of lands and other natural resources; and by the forced eviction of vast numbers of people, including indigenous peoples, from their lands and homes.
Civil society as a driving force for change
Strong people’s organisations and movements, struggling for more democratic, transparent and accountable decision‐making processes, are fundamental to address and reverse this situation. While governments have the primary responsibility for ensuring an equitable approach to health and human rights, a wide range of civil society groups and movements, and the media have a critical role to play in demanding progressive policy development and in the monitoring of its implementation.
Over the last 20 years, the role of public interest civil society in influencing policies at the global level has been increasingly relevant, strengthened by the development of global networks and campaigns. Notable successes have included improved mechanisms for debt reduction in low-income countries, blocking the proposed Multilateral Agreement on Investment (MAI), the Doha Ministerial Declaration on Access to Essential Medicines, and blocking agreements of the World Trade Organisation (WTO) at WTO Ministerial meetings in Seattle and Cancún. The ongoing international campaign to stop new free trade agreements such as the Transatlantic Trade and Investment Partnership (TTIP) has won significant battles, especially to increase transparency in negotiations. However, at best, all these successes have been only able to limit the damage – trying to prevent decisions which would make the situation worse (e.g. MAI, WTO Ministerials and the TTIP), to limit the impact of previous adverse decisions (e.g. TRIPS), or, in the case of debt, to limit the side effects of the prevailing model of economic structural adjustment which had already imposed devastating costs for more than a decade. Where decisions have successfully been blocked, this has often been temporary.
Nonetheless, public interest civil society has a key role to play as a driver of change. Among the most important priorities for civil society activism is the democratic reform of global economic governance. Current governance arrangements are both a central cause of why the global economic system fails, and the greatest obstacle to overcome. An agenda of the needed change should include: significant reform and better regulation of the global financial system; rejecting austerity measures; implementing a much more progressive taxation system; closing tax havens; supporting a global taxation system; challenging the idea that the current model of growth is indispensable; reclaiming public space for people’s effective participation. Unless and until global governance structures change quite radically, civil society efforts on other issues will inevitably remain limited to damage control, and at best partially successful.
The need for a global social movement
The idea of changing our economic system and the underlying power structures that support it can seem like an impossible task. But the current situation was not given by the laws of nature. Instead, it was created and continues to be shaped by human beings. As such, we can change it!
There have been people (as individuals, organisations and networks) working to address the social determinants of ill-health and to achieve better health care in many different settings and countries and for many decades (and centuries). Social movements, operating at local, regional and national levels, have played and continue to play a critical role in creating the conditions for better health and access to affordable decent health care.
Until recently these were mostly local struggles addressing local factors, and the ‘need’ to become part of a global people’s health movement was not so pressing. However, in this era of globalisation, the social and political pathways towards better health, decent health care and health equity are increasingly determined at the global as well as national and local levels. And even the most ‘local’ issue or struggle has at least some roots in the economic and political dynamics and the policy-making processes at the global level.
Accordingly, the building of a global movement for Health for All has to be an important challenge for civil society activists. For the PHM, this project of building a global social movement, through which global as well as local barriers to Health for All can be addressed, is a critical priority.
The vision of a ‘global people’s health movement’ is not to be seen as aiming to co-opt the huge diversity of individuals, organisations and networks into a monolithic, centrally organised and directed PHM. These individuals and organisations have their own history, commitments and identities. To call for a strengthening of the people’s health movement implies calling for stronger communication links and collaboration when appropriate. However, the diverse purposes, ways of working and identities should not be compromised; indeed this rich diversity is the (strength of the) movement.
A “people’s” health movement
What I liked the most was meeting the ‘P’ in the HM.
– participant in the IPHU in Brussels, 2016 –
While we may agree that a global health movement is needed, we should also consider what kind of movement we actually need or want to strengthen/build. We have already spoken about the value of diversity; we may now address another aspect that can be summarised as follows: it is not only ‘what’ a movement does that brings about change; it is the way we get there, how we get, stay and act together and the kinds of organisations we build. This determines the nature and quality of what we can achieve. In other words, the process of building the movement through its day-to-day functioning, as well as its actions and ends, should be aiming at promoting health and wellbeing, starting with the very people who participate in the movement. This manual calls for consolidating such a process.
A movement is made by people and can be described as a living system. It is important to pay attention to the more tangible things like structure, governance and decision-making procedures, formal policies and logical frameworks through which it plans and gets organised. But the question is: ‘what makes it work?’. To learn this, we also have to pay attention to the values, principles and practices which guide the behaviours and actions of the people in the movement, the quality of human relationships and the way in which the movement responds, learns, grows and changes over time.
Being a member of a people’s movement means taking part in its coordinated global, regional, national and local actions and sharing the responsibility and ownership of these actions, including their impact on the movement. This implies a need to plan strategically so that what we do helps to build stronger links with existing organisations and networks (whose commitment to an equitable society is broadly aligned to ours), to reach into constituencies of people who may be inspired by the PHM project, to disseminate the PHM analysis and commitment more widely. Building the movement also involves working to create a shared culture which supports and spreads the values and aspirations of the movement.
History of PHM
The People’s Health Movement (PHM) was created in December 2000 following the first People’s Health Assembly (PHA) in Bangladesh. PHA 2000 had been convened by eight global civil society networks concerned that the slogan “Health for all by the year 2000” – which the World Health Organization (WHO) had promoted during the 1980s and 1990s – had not been achieved and that WHO in particular had progressively moved away from its strategy of comprehensive PHC aimed at achieving Health for All. The People’s Health Assembly, was a reference to the annual World Health Assembly, where ministers of health gather in Geneva as the governing body of WHO. However, this was to be a people’s health assembly.
PHA 2000 was attended by approximately 1500 participants from 92 countries (largely developing countries) and lasted five days. It included formal speeches, workshops, cultural programs, exhibitions, films and testimonies. The program encompassed the vast experiences of primary health care since Alma-Ata; reviewed the impact of structural adjustment and World Bank policies on health; explored a wide range of social determinants of health; and shared the experiences of the wider social movement for health around the world.
PHA 2000 was preceded by a series of events held across the world. The most dramatic of these was the mobilization in India. For nearly nine months prior to the assembly, local and regional initiatives took place, including people’s health enquiries and audits; health songs and popular theatre; sub-district and district level seminars; policy dialogues and translations into regional languages of national consensus documents on health; and campaigns challenging medical professionals and the health system to become more oriented to Health for All. Finally, over 2000 delegates travelled to Kolkata, most riding on five converging people’s health trains, where they brought forth ideas from 17 state and 250 district conventions. After two days of simultaneous workshops, exhibitions, two public rallies for health and a myriad of cultural programs, the assembly endorsed the Indian People’s Health Charter. About 300 delegates then travelled to Bangladesh, mostly by bus, to attend PHA 2000. Similar preparatory initiatives, though less intense, took place in Bangladesh, Nepal, Sri Lanka, Cambodia, Philippines, Japan and other parts of the world, including Latin America, Europe, Africa and Australia.
PHA 2000 adopted the People’s Charter for Health, which outlined the global health situation, identified the main barriers to Health for All and adopted a set of principles, priorities and strategies to guide the people’s health social movement globally. The Charter (since translated into more than forty languages) has proved to be a powerful leadership document in the years since December 2000. It expresses the commitment of PHM.
Vision of PHM: equity, ecologically-sustainable development and peace are at the heart of our vision of a better world – a world in which a healthy life for all can become 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; a world in which people’s voices guide the decisions that shape our lives. [People’s Charter for Health, 1st People’s Health Assembly, 2000
The second People’s Health Assembly (PHA 2) followed in July 2005, in Cuenca, Ecuador, with 1492 participants from 80 countries. PHA 2 was organized around nine streams, including issues of equity and people’s health care; intercultural encounters on health; trade and health; health and the environment; gender, women and health sector reform; training and communicating for health; the right to Health for All in an inclusive society; health in people’s hands; and PHM affairs.
The third People’s Health Assembly (PHA3) took place in Cape Town, South Africa, in 2012. It was attended by 800 people from around 90 countries, and celebrated the successes of a growing People’s Health Movement, especially the development of new country circles in Africa. PHA3 recognised the need to build a more effective and broad-based social movement, and to this end committed – in a final document called the Cape Town Call to Action – to building alliances with others who seek progressive and transformative change, including movements of informal and formal health sector workers, the landless, indigenous peoples, women and youth, those struggling against big dams, nuclear power plants, dangerous mining, hazardous working conditions and others. Among other things, the Call to Action also engages the PHM to communicate more broadly its alternative visions, analyses and discourses, and to continue providing information and facilitating the sharing of information on the international context and country experiences.
No change will happen without the mobilisation of the people through the building of social and political power amongst people and communities. We commit ourselves to building alliances with others who seek progressive and transformative change. [Cape Town Call to Action, 3rd People’s Health Assembly, 2012]
How PHM is organised
PHM as an organisation and a network includes:
- country circles (core activists plus affiliated organisations),
- affiliated organisations and networks (globally, regionally and nationally);
- regional coordinating structures, and
- the global structures (the Global Secretariat, Steering Council and Coordinating Commission or Coco).
The Global Steering Council includes regional representatives of country circles and representatives of the various networks who are affiliated with PHM at the global level; the CoCo is the executive committee of the Steering Council. The Secretariat is the only paid staff of the PHM, its small number varies according to the needs and the available resources.
PHM Global is not a ‘legal person’ and does not receive monies or itself enter contracts directly. Since its formation in 2000 PHM has been supported by NGOs which are part of PHM, in most cases in the country where the Global Secretariat is based. These hosting organisations have managed incoming monies, banking, contracting, auditing and reporting. In some cases they have also provided additional administrative support for the Secretariat.
PHM is part of a much wider people’s health movement including activists and organisations working in many different settings, not always linked with PHM. The wider people’s health movement can be defined as including all of those activists and organisations who are working in various ways to achieve the kinds of outcomes – all of which are essentially integral to health and social equity – which are described in the People’s Charter for Health.
What PHM stands for
In one of the presentations at the third People’s Health Assembly in Cape Town in 2012, four short, sharp, simple messages were suggested to indicate what the PHM struggles for:
- a life with security;
- opportunities that are fair;
- a planet that is habitable;
- governance that is just.
The first reclaims the security agenda by connecting it to employment, social protection, the environment and our safety and freedom. The demand for equal opportunities relates to how a fair taxation regime combined with higher social spending can level gross social disparities.
The need for a habitable planet needs little explanation; it is the ecology of the planet that will direct the radical politics of the future. Governance – the space where states, markets and civil society attempt to manage the crises of capitalist modernity – addresses the issue of social rights and political participation to decide where public investment should be made. People can mobilize in anger for a time, but it takes a larger and more inclusive vision of how we might live to sustain organized movements that can take us forward from there.
Another simple statement of purpose is the vision from the People’s Charter for Health, which commits activists to achieving equity, an ecologically sustainable development and peace … a world in which a healthy life for all is made 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; a world in which people’s voices guide the decisions that shape our lives. There are more than enough resources to achieve this vision (People’s Health Movement 2000).
There is a further challenge: activists in the progressive health movement need to revalorize the role of the state for its regulatory and redistributive functions; a state that provides the goods and services essential to public health. As we engage with this task, we need finally to reclaim the public space to fight for this. The world does not have a fiscal crisis. It is a crisis of inadequate taxation of the rich and unaccountable power of corporate capital . We are not living in conditions of scarcity. We are living in conditions of inequality. Our voices of opposition to neoliberal globalization need to be louder and stronger. Evidence and ethics are both on our side.
Where should health activists start?
Tackling the underlying global (political and economic) determinants of health and injustice can seem an impossible task. Capitalism (neoliberal or otherwise) has proved incredibly resilient to crises. But there are several ways in which health activists can participate in mounting a challenge.
- Recognize that the health sector is not alone in seeking a world that is just and sustainable. Peasants’ movements, labour organizations, environmental groups, women’s groups and many others are also critiquing the predatory inequities of neoliberal globalization and pressuring their governments for reforms.
- Globalization, and particularly its several binding trade and investment treaties, has placed constraints on the abilities of governments to manage economies for socially useful purposes. But national governments can push back such agreements to ensure that they have much stronger and legally binding language that protects their rights to regulate in any way they deem necessary to protect public health, the environment and other public goods and resources. It is national governments that ultimately are responsible for the shape globalization takes; they are the first targets for health advocacy aimed at securing a healthy, equitable and environmentally sustainable future.
- Most countries have social movement groups engaged in some form of advocacy work at the national level on one or another of the key globalization-related determinants of health within their borders. This work could be around improving or reasserting labour rights, expanding social protection coverage, increasing and improving the fairness of domestic taxation to finance public goods, ensuring access to quality healthcare without financial barriers, strengthening gender rights and those for marginalized or discriminated groups, protecting the environment and reducing fossil-fuel dependency, and so on. Such groups need to continue to ‘act locally’, but must progressively link up with their international counterparts to not only ‘think globally’, but also to ‘advocate globally’. They also need volunteer resources. Pick a group that is closest to supporting your local interest and commitment, and support its work nationally while ensuring the globalization dimension is never lost sight of.
- Keep abreast of globalization-related developments, and of useful critiques of neoliberal globalization and its reform and more revolutionary alternatives. Social media, blogs and online discussion groups have become important tools in maintaining a ‘watching brief’ on these developments.
- Avoid pessimism of the intellect, and practise optimism of the will. Consider optimism as a purposeful act of political resistance.
How to engage with PHM?
There are several ways to engage with PHM, at the local, regional or global level. If you are new to the movement, the first thing that you can do is to browse through our website at www.phmovement.org. After that, you can also subscribe to the PHM Exchange which is the movement’s newsletter.
Check the “About PHM” section to know who your regional representative is, and get in touch: he/she will be able to introduce you to the contact persons nearer to you, as well as give you information on the PHM global programs and regional activities.
Finally, you can follow PHM through our social media accounts on Facebook (PHM global) and Twitter (@PHMglobal).
Sources:
Global Health Watch 2
Global Health Watch 4
People’s Charter for Health
Cape Town Call to Action
The barefoot guide to working with organisations and social change
Reimagining activism. A practical guide for the great transformation