Introduction

The People’s Health Movement (PHM) is a global network formed in 2000 which comprises grassroots health activists, other civil society organizations, issue-based networks, academics, researchers and activists from low, middle and high-income countries. Its activity is conducted locally through country circles and globally through a range of campaigns. Underpinning all its activities is a commitment to ‘Health For All’, as it was interpreted in the 1978 World Health Organization (WHO) and United Nations Children’s Fund (Unicef) Alma-Ata Declaration on Primary Health Care (PHC)¹1 World Health Organization. Declaration of Alma-Ata. International Conference on Primary Health Care [internet].Alma-Ata: WHO; 1978.[accessed on 2018 Jan 2].Available on:http://www.who.int/publications/almaata_declaration_en.pdf?ua=1.
http://www.who.int/publications/almaata_... . This Declaration presented a comprehensive vision for PHC in that it related health services to the broader organization of society, calling for a new international economic order that would benefit developing nations, empowering democratic participation in health, and calling for action on social and environmental contexts that increased disease risks. Health services were to be multi-disciplinary, attuned to local need, and emphasize disease prevention and health promotion. Reducing the inequities between groups within nations and between nations was seen as vital and recognized in the call of ‘Health for All’ by the year 2000. Resistance to this visionary view of health was rapid and the call for selective PHC followed very soon after²2 Walsh JA, Warren KS. Selective primary health care: an interim strategy for disease control in developing countries. N Engl J Med. 1979;301(18):967-74.. In the subsequent decades to 2000 neo-liberalism become the dominant driving force behind public policy³3 Harvey D. A brief history of neoliberalism. Oxford: Oxford University Press; 2005. and structural adjustment of Low-to-Middle-Income Country (LMIC) economies was strongly promoted by the World Bank and International Monetary Fund (IMF)⁴4 Rudin J, Sanders D. Debt, structural adjustment and health. In: Benatar S, Brock G, editors. Global Health and Global Health Ethics. Cambridge: Cambridge University Press; 2011. p. 155-65.. These developments led to increasing disquiet among health activists and it became evident that ‘Health for All’ would not be achieved by 2000 and that economic inequities were actually increasing⁵5 Wade RH. Global growth, inequality, and poverty: the globalization argument and the political" science of economics. In: Ravenhill J, editor. Global Political Economy. 5.ed. Oxford: Oxford University Press; 2017. p. 319-55.. Moreover, it had become apparent that the World Health Organization had retreated from the strong support for PHC it had under the leadership of Dr. Halfdan Mahler and, driven by a continuing decline in assessed financial contributions by Member States, had recently indicated its intention to pursue Public-Private Partnerships⁶6 Velásquez G. Public-private partnerships in global health: putting business before health? Geneva: South Centre; 2014. in funding its operations. Against this background and as a counterweight to disturbing trends in WHO and successive World Health Assemblies the first People’s Health Assembly (PHA 1) was planned.

Origins of the movement

Eight networks and organizations (described in chart 1) came together to plan the PHA 1. All of them had advocated for different aspects of ‘Health for All’ and some had engaged with WHO to promote rational drug policy, comprehensive PHC, consumer rights in health care, sexual and reproductive health rights, regulate breast milk substitutes, and address social and economic determinants of health.

The announcement of a People’s Health Assembly clearly struck a chord with many, resulting in PHA 1 being attended by 1500 people from over 90 countries. In the lead up to the Assembly activists from various networks and countries drafted a People’s Health Charter which was revised and then endorsed by the delegates at the Assembly. Since PHA 1, three further Assemblies have been held in Cuenca, Ecuador (2005), Cape Town, South Africa (2012) and Savar, Bangladesh (2018) where the 4th Assembly (PHA 4) was held (see https://www.youtube.com/watch?v=Kmm5Hj0HNWA for video describing the event and providing some background to PHM in the voices of PHM activists). These Assemblies are in effect the ultimate governing forum where the Movement’s priorities and directions are refined and endorsed. They are inspiring events which motivate PHM’s adherents.

In 2019 PHM has the following networks as affiliates:

The ideology and vision of the People’s Health Movement

The ideology and vision of PHM drew on those of the original networks and organizations. The People’s Charter for Health (PCH), elaborated in the year leading up to the first People’s Health Assembly (PHA 1) in December 2000, enshrines PHM’s vision. It was adopted at PHA 1. Subsequently, the PCH has been refined and adapted to evolving circumstances and augmented by declarations that have resulted from subsequent People’s Health Assemblies and statements in response to critical global health issues (see chart 2).

Global Health context - analysis of root causes of ill-health and inequality

The PHM analysis of the global context stresses that the current paradigm of development, which is characterized by individualism, anthropocentrism and neoliberal capitalism underpins growing health inequities. This analysis notes that governments in high-income countries, working closely with transnational corporations, are promoting neo-liberal policies to manage the contemporary crisis of globalized capitalism in the interests of the transnational capitalist class. With help from a set of one-sided ‘trade and investment’ agreements, these policies are either being accepted by or being forced on the governments of low and middle-income countries and their populations as well as on the majority in high-income countries. The resulting national policies that include fiscal austerity and deregulation of economic activity are having far reaching consequences for the social conditions that shape people’s health, and also for the approach to and funding of health care. PHM notes that such policies are worsening the fundamental determinants of health, and progressively crippling healthcare infrastructure and delivery of services. They are also encouraging national governments to abdicate their responsibility for public health, while ushering in privatization of public goods, including health services, often through introducing insurance regimes. PHM also points to the patriarchal, racist and homophobic nature of the currently dominant ideology which also serves to increase discrimination and so affect people’s health. PHM notes the threats to human and planetary health posed by conflicts, mass forced migrations and a rapidly changing climate.

One of the unique features of PHM is that its ideological positions are developed through a dialectic between scholarly analysis and reflection on lived experience. This is seen most clearly at the Assemblies where research and analysis of the contemporary political economy of health are presented alongside testimonies from people whose lives reflect its impact. For example, analysis may describe the impact of trade deals which privilege the needs of big agricultural trans-nationals and the testimonies might include those of small farmers undermined by the trade deals. A further example is that analysis might point to the growing influence of private medicine in a particular country and a testimony might describe the ways in which private medicine discriminates against the poor. Combining the knowledge from research and lived experience encourages political debate from which PHM positions are developed and then enshrined in declarations and statements.

An important aspect of PHM’s work is acting as a bridge between the local and the global. PHM works on many global issues as described below but remains rooted in a concern with the health issues of local communities. Analysis and action undertaken locally are informed by an understanding of globalized neoliberal capitalism. PHM also takes local concerns to the global level such as to the World Health Assemblies. Much of the awareness and learning which is conducted through PHM is focused on encouraging understanding of how seemingly distant and removed global economic and political dynamics affect local health issues. As an example, this process could include analyzing how vertical health programs focused on particular diseases and funded by public-private initiatives that often include large philanthropic organizations such as the Gates Foundation have had the effect of de-skilling and weakening public health services because they offer better pay and reduce the pool of people available for employment by national health systems¹⁶16 Cailhol J, Craveiro I, Madede T, et al. Analysis of human resources for health strategies and policies in 5 countries in Sub-Saharan Africa, in response to GFATM and PEPFAR-funded HIV-activities. Global Health. 2013;9(1):52-66.. A further example is raising awareness in mining communities of how trans-national corporations are able to evade their responsibilities concerning the negative health impacts from environment they despoil through mining activity.

How PHM is governed

A sustained effort at evolving a representative, democratic governance and decision making structure for this movement, which is primarily a network of networks, has been experimented with over the years.

PHM’s ultimate decision making forum is the People’s Health Assembly where consensus is strived for through debate. Between these gatherings PHM is governed by a Global Steering Council (GSC) with two co-Chairs. The GSC comprises regional representatives and representatives from some of the linked networks as well as a representative of the Advisory Council. The GSC is supported by a small secretariat, whose members receive modest salaries. In 2019, the secretariat was located in Cape Town, South Africa, Delhi, India and Brussels, Belgium. The GSC has a coordinating commission (7 members) which meets monthly normally through Skype and makes most day-to-day decisions for PHM. PHM has also established an Advisory Council which comprises people who have given long service to the movement and are invited by the GSC to join.

The Global PHM has also established campaign groups to develop and mobilize around key cross-cutting global themes. The six campaign themes current in 2019 were developed and adopted at the 4th People’s Health Assembly and are:

These themes frame the campaigns of PHM within country circles and globally. Within each theme issues are relevant globally and have local impacts. PHM brings together the knowledge from both perspectives. Additional campaigns and groups may evolve as new challenges and insights emerge. These themes do not exclude the development of campaigns within countries on pressing national health challenges.

Governance of each country circle is varied. At one extreme is South Africa where PHM is a registered organization, while in most other settings the circle is an informal network of individuals and like-minded organizations. Country circles vary in size from a handful of people in some countries to the massive PHM in India. The PHM in India (known in the local vernacular as Jan SwasthyaAbhiyan - JSA) is a coalition of 22 national networks, alliances, movements, resource groups and federation of NGOs, which focus on health, development, science, women’s issues, health rights of children and people who are marginalized and environmental health issues. A JSA National Coordinating Committee with networks and state level representatives plan and organize different campaigns and initiatives on different aspects of health policy. Different states have evolved their own state level networks that focus on state level policy and health challenges while also promoting and participating in the national campaigns.

Country circles are clustered into regional groupings to encourage intra and inter regional coordination, and information sharing. In 2019 these regions are: South East Asia and Australia, South Asia; India (JSA); West and Central Africa; East and Southern Africa; Middle East, Latin America which comprises four sub-regions; North America; and Europe. These regions each nominate representatives to the GSC.

Major global campaigns of the movement

Globally, in addition to the six campaign themes listed above, PHM has a series of longstanding initiatives designed to influence global health debates and actions.

Global Health Watch

The PHM in coordination with several other networks, produces a regular independent, ‘alternative World Health Report’ - the Global Health Watch (GHW). Five of these reports have been published and the sixth is planned for mid-2021. Each edition of the GHW is different and is a collaborative exercise of a large number of individuals, academic institutions and organizations

GHW 5¹⁷17 People's Health Movement, Medact, Health Action International, et al. Global Health Watch 5: An Alternative World Health Report. London: UK: Zed Books; 2017. had contributions from over 120 individuals and 70 organizations globally. Each GHW contains sections that analyze the politico-economic context of global health, key social determinants, trends in health systems and also includes a section titled ‘Watching’ in which government, international aid agencies, health and development agencies and foundations are critically reviewed. In more recent Watches a section titled ‘Resistance’ features inspiring and innovative campaigns and initiatives to strengthen the ‘Health for All’ movement in different countries and globally. The contents of GHW 5 are shown in chart 3.

WHO Watch

The formation of PHM was in significant part driven by a disappointment with the role of WHO in the years leading up to 2000. These disappointments were recorded in the People’s Health Charter which demanded,

PHM’s frustrations continued and resulted in regular engagement with WHO. Initially a WHO Advocacy Circle included annual participation in the NGO Forum for Health session at the WHA and a technical briefing on PHM and the Charter in 2003. Later PHM established ‘WHO Watch’ through which selected members of PHM attend the WHO Executive Board meeting held in January each year and the World Health Assembly in May. The on-the-ground Watchers tend to be younger members and so the process is a great training ground and recruitment vehicle for PHM. The deep policy analysis is supported by experienced PHM members. Through their combined efforts, and supported by PHM members around the world, detailed, insightful and policy relevant critiques of resolutions and statements presented to the governance structures of WHO are available on-line. Feedback from a number of low and middle-income country policy actors suggests that the PHM commentaries are immensely helpful in assisting them drafting their policy responses and one commented “We make use of the product of WHO watch very well”^19(105) .

PHM also attends other WHO-convened events and provides commentary on the outputs. For example, a group of PHM members attended the WHO Conference on Health Promotion in Helsinki and published an alternative declaration to the official one (https://phmovement.org/phm-declaration-at-8th-global-conference-on-health-promotion-2013/) and also published an alternative declaration to the WHO World Conference on Social Determinants of Health held in Rio in 2011 (https://phmovement.org/alternative-civil-society-declaration-at-the-world-conference-on-the-social-determinants-of-health-2011/).

The International People’s Health University

The International People’s Health University (IPHU) is PHM’s main education and cadre-building program. From 2005 IPHU has organized short courses in different regions of the world for young health activists and new contacts of PHM. These short courses (a few days to 2 weeks in duration) are held in different languages and are hosted by different country circles and sympathetic academic institutions. They are accredited by some universities for Master in Public Health programs. The faculty are drawn from more senior PHM members and activists who share their perspectives and life journeys and struggles to inspire the participants. The typical objectives of an IPHU course are shown in chart 4.

Although evaluation of the IPHUs have established that most participants have found these courses inspiring they have been met with mixed success in inspiring the participants to become active in PHM in their home country. Although some do, it is clear that more follow up after the courses could increase the extent to which this happens¹⁹19 Bodini C, Sanders D, Sengupta A. The Contribution of Civil Society Engagement to the Achievement of Health for All. Cape Town: People's Health Movement; 2018..

‘Health for All’ Campaign

This campaign is concerned with realizing the right to health nationally and globally. The PHM website says of the campaign that it is a global organizing framework for different mobilization actions by civil society networks and social movements around the world and aims to inform and influence governments to address structural and systemic weaknesses in the health system.

Practically, this usually translates into national circles developing or participating in actions to address key current health challenges, which are unique to each country. Such actions are as diverse as a recent campaign in Ghana for improved sanitation in the aftermath of a cholera epidemic, to an ongoing campaign for a ‘Peoples National Health Insurance’, spearheaded by PHM South Africa, an ongoing campaign in Australia to maintain and defined the national public health insurance system and a campaign in the UK to defend the National Health Service. In addition, the six campaign themes described above offer country circles additional possible foci for organizing.

PHM has been reflective about its activism to achieve ‘Health for All’. This has best been reflected in its recent research work funded by the Canadian International Development Research Council (IDRC). This involved PHM undertaking a large multi-center study examining civil society engagement in the struggle for ‘Health for All’. Over four years, 130 activist-researchers in 10 countries produced 50 research reports and an overarching report at the conclusion of this work¹⁹19 Bodini C, Sanders D, Sengupta A. The Contribution of Civil Society Engagement to the Achievement of Health for All. Cape Town: People's Health Movement; 2018..

Getting social determinants of health on the WHO agenda

PHM was one of the groups arguing for the establishment of a WHO group that would consider what was needed to achieve greater health equity. The WHO response under the then Director General Dr. Lee was to establish the Commission on the Social Determinants of Health (CSDH). One of PHM’s nominees to this Commission was appointed as a Commissioner and PHM was centrally involved in the civil society engagement of the CSDH. Moreover, PHM activists and sympathizers were members of several of the nine knowledge networks established to undertake the in-depth work of the Commission. PHM’s involvement was reflected in the relatively progressive nature of the CSDH’s report which included a call for attention to unfair global trade agreements, accountability of transnational corporations and action on the unequal distribution of power, money and resources which underpin global health inequities. In the 11 years since the CSDH report there has been limited progress in implementing its recommendations but at the recent World Health Assembly (May, 2019) WHO announced it was establishing a Division for Healthier Populations with a branch devoted to social determinants of health.

PHM members and sympathizers were also involved with the development of the World Health Report in 2008, the 30th Anniversary of the Alma-Ata Declaration, including facilitating a technical session for WHO, contributing to some chapters and reviewing the report before finalization. PHM was also invited to attend the launch at Almaty, Kazakhstan and speak in a panel discussion. Similarly, PHM was invited to participate as a member of the International Advisory Group for the Global Conference on Primary Health Care for Universal Health Coverage on the occasion of the 40th Anniversary of the Declaration of Alma-Ata, held in Astana, Kazakhstan in October 2018. PHM expressed concerns with the official Astana Declaration in a civil society statement signed by several hundred organizations and individuals (https://phmovement.org/alternative-civil-society-astana-declaration-on-primary-health-care/).

Examples of Action in countries

The PHM draws its lifeblood from grass roots health movements across the globe. The overarching issues that are presented in chart 2 above translate into a massive impact on the health of local communities. Hence a vital component of the PHM network is its country circles. In mid-2019 there were approximately 70 active country circles. Examples of recent actions organized by country circles include:

South Africa: South Africa experiences an extremely high burden of disease including the world’s largest HIV/Aids epidemic, an persisting maternal and child health problems and a growing epidemic of non-communicable disease. It has a two-tiered health system- consisting of the public and private sectors with the latter housing most of the country’s skilled health personnel but covering less than 20% of the population at unaffordable prices, maldistribution of providers and facilities, over-servicing and lack of accountability. Public sector health services that provide for the majority are weak at primary and community levels and are of variable coverage and quality with many facilities experiencing severe staff shortages and sub-optimal governance and management. In response to these challenges the government has elaborated a policy termed the National Health Insurance scheme to provide Universal Health Coverage (UHC) through a single payer system that will purchase services from accredited public and private providers. PHM South Africa (PHM SA) has played a leading role among civil society organizations in mobilizing for a ‘People’s NHI’ whose key features are social solidarity, equity, comprehensive care and community participation. Although the recently legislated NHI Bill espouses these principles, PHM SA is concerned that private sector lobbying is increasingly influencing a deviation from these towards a scheme characterized by a multi-payer arrangement and differential coverage of sub-groups with differing employment status. The People’s NHI campaign is steadily gaining traction and PHM SA is being called upon within and outside the country to advise on the potential pitfalls of UHC.

India: Starting with the preparation of five little booklets as resource for the movement in 2000, later published as a resource book²¹21 AbiyanJS. Health For All Now! The People's Health Source Book. Chennai: South Vision; 2000., the JSA (PHM India) engaged with the revise National Health Policy, 2002 where JSA cautioned against legitimizing privatization and commercialization of health care in the country²²22 Abiyan JS. National Health Policy 2001 - Legitimising Privatization. Delhi: Delhi Science Forum; 2001.. Next a series of public hearings with the National Human Rights Commission on the denial of right to health care were organized. JSA’s continued policy engagement in various ways resulted in the National Rural Health Mission. JSA has continued to engage with health policy action and dialogue as the country develops its response to the Universal Health Coverage scheme. Many JSA state networks are responding to challenges including essential drug availability, countering commercialization and commodification of health care and specific policies like prevention of privatization of vaccine units, and all the while promoting community action for health.

Australia: action has included a campaign against the introduction of user fees to the national health insurance scheme Medicare, lobbying for improved funding for Aboriginal communitycontrolled health services and a campaign against trade agreements that will threaten health.

Scotland: held an open health assembly in which participants called for concrete proposals for collective action to reduce health inequities. This led to PHM Scotland developing a Scottish People’s Health Manifesto through an approach combining participatory action-research and proactive public health advocacy.

Europe: country circles participated in the demonstration and conference ‘Our Health is Not for Sale!’ that took place in Brussels, organized by European Network Against the Commercialization and Privatization of Health and Social Protection. Activists from PHM groups in Belgium, Italy, Croatia and France joined both events, along with members of other networks including trade unions and patient groups.

PHM’s country circles are supported by an interactive manual ‘Building a movement for health - a tool for (health) activists’ (https://twha.be/PHM-manual). This manual describes the philosophy of PHM and provides practical advice, supported by lots of examples of how to take action in support of health. It places emphasis on the value of developing networks and coalitions with other groups including those mobilizing around the environment, water rights, food sovereignty, and with trade unions, small farmers and the women’s movement to campaign on issues of mutual interest.

Challenges faced by PHM

Like any social movement the PHM faces a number of organizational and campaigning dilemmas. Some of the most prominent are discussed below.

Is PHM a popular or professional movement?

PHM is a movement of committed activists. Many PHM activists are health professionals working directly with communities or progressive academics. By their nature the global programs inevitably involve predominantly professionals and academics. However, in several countries, especially in South Asia and Latin America, there are significant numbers of community practitioners and activists. There are sometimes tensions experienced as a result of the different backgrounds of members, ranging from differing emphases in the planning of actions to differing needs in terms of resources required to participate actively in country circles. These challenges notwithstanding, PHM is continuously exploring ways to increase the diversity of its base. This has generally been easier in situations where the tempo of struggle quickens and there is broader involvement of citizens.

Language

PHM strives to work in multiple languages. Its two main languages are English and Spanish. The People’s Health Charter has been translated into over 40 languages which includes Farsi, Guarani, Hausa, Ndebele, Quechua, Serer and Wolof, most of which are available on the PHM website. At the People’s Health Assemblies efforts are made to translate in to as many languages as possible using the support of public interest translators working for such organizations as Babel.

Funding: Global co-ordination on a shoestring

The Global PHM relies on donations from its members and some small contributions from the supporting networks. In past years PHM has also attracted core funding from donors including Oxfam Novib and Open Society Foundation. More recently donor funding has been secured for specific projects such as for strengthening global health governance - which has part funded GHW and WHO Watch to support the People’s Health Assemblies. PHM has managed to maintain a small decentralized global secretariat but most of PHM’s activities are the result of volunteer effort. The Global Health Watch, WHO watch and the IPHU are all primarily resourced by PHM supporters donating their time. Those on the governance structures are also volunteers.

Country circles are also largely fueled by volunteer effort. A few circles such as in South Africa and India are able to employ some staff. Funding has been obtained for an African outreach worker who has been successful in helping to facilitate new country circles in that region. The recent review of the contribution of civil society to working for ‘Health for All’ concluded with recommendations for bodies which fund civil society¹⁹19 Bodini C, Sanders D, Sengupta A. The Contribution of Civil Society Engagement to the Achievement of Health for All. Cape Town: People's Health Movement; 2018.. These suggested core funding in support of social movement civil society should be provided in order to strengthen the kind of country and global processes described in this article; processes which ultimately contribute to improved health globally. The report further recommended that funders should be aware of the limits and risks associated with tightly specified project funding. Instead of such tight funding agreements the report recommended that accountability should be based on and assessment of the core directions of the organization and its integrity.

Membership or network?

An unresolved debate within the movement concerns whether or not the PHM should develop options for individual and organizational membership and become a legally registered organization. Some argue that the movement is better as a ‘network of networks’ while others hold that membership with a progressive sliding scale of fees could enable the movement to be more self-sustaining but also allow for more structured representation and accountability of representatives.

Conclusions

In the near twenty years of its existence PHM has become one of the most powerful international voices presenting a progressive alternative to the dominant neo-liberal regime which governs the health and development discourse and direction. It has consistently spoken from the perspective of oppressed peoples and communities and argued that people’s and the eco-system’s health and the quest for equity should take precedence over the quest for private profit. Its consistent role of speaking truth to power is more than ever needed in an era in which inequities are increasing and power is being rapidly concentrated among the richest people and corporations in the world. Its vision of a people and eco-system centered world offers much better prospects for health equity.

References

Publication Dates

History