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NGO COALITIONS FOR GLOBAL HEALTH PROMOTION
Thelma Narayan*, Marilyn Wise**, Tesfamicael Ghebrehiwet****
Introduction - NGOs, the origins of primary health care and health
1.
promotion.
The primary health care movement sprang up in an autonomous manner in
different parts of the world, in the 1960s and 1970s. Rooted in the community
and voluntary sector, initiatives developed in different social and cultural
situations, exhibiting a rich diversity. The movement gained global visibility and
legitimacy from national governments through the World Health Assembly in
1977, and the International Conference on Primary Health Care jointly organized
by WHO and UNICEF in 1978 in Alma Ata. Ever since then there have been
ripple effects and cross currents in the health and health care related sectors. One
of the strong positive currents that emerged was that of health promotion. It is
important to recall the different collective experiences, forces and perspectives
that developed the Health for All goals and strategies.
Dr. Mahler Director
General of WHO at the time publicly states that it was the non- governmental
organizations (NGOs) who pressed WHO strongly to move beyond a disease
focused, expert dependant, techno-managerial approach, based on the dominant
system of medicine, to one wherein community participation, inter-sectoral
coordination and appropriate technology were important. The key underlying
principles of primary health care (PHC) were social justice and equity with a shift
beyond doctors, diagnostics and drugs to addressing the conditions for health. An
important component was health education, which grew in strength to emerge as
health promotion. NGOs, professionals and people across the globe sustained the
spirit of primary health care through decades when it met with resistance and
neglect. The Ottawa Charter of 1986 introduced a clear focus on fundamental
conditions or basic determinants for health such as peace, shelter, education, food,
income, ecosystems and resources.
Ownership and initiatives by states,
international bodies and experts provide a professional strategic approach and
increase coverage. However communities and community based organizations
(CBOs) may get excluded in decision making, while powerful interests get
accommodated. Public health ethics and principles of universal human rights
suggest that the challenge before the health promotion community is to build
partnerships upholding the public good in health, by addressing health
* Dr.Thelma Narayan, Co-ordinator, Community Health Cell, Secretary, Society for Community Health Awareness,
Research and Action, Bangalore, India, email: chc@sochara.org, Joint Convenor Peoples Health Movement Of
India.
The PHM is active in over 100 countries globally.
** Dr. Marilyn Wise, International Union for Health Promotion and Education, Email: marilynw@health.usyd.edu.au.
The
IUHPE is a global network working to promote health worldwide and contributes to the achievement of equity in
health
between and within countries.
*** Dr. Tesfamicael Ghebrehiwet Consultant, Nursing & Health Policy ,International Council of Nurses, Geneva,
Switzerland, E-mail: tesfa@icn.ch The International Council of Nurses is a federation of 126 national nurses
associations representing the millions of nurses worldwide. Operated by nurses for nurses, ICN is the international
voice of nursing and works to ensure quality care for all and sound health policies globally.
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determinants and respecting cultural diversity in a transparent manner. The role
of communities, CBOs and NGOs along with the state should be central.
I. Contextual challenges to global health promotion
In the year 2005, despite increasing knowledge and wealth, health goals remain a
distant dream for the social majority globally. Inequalities in wealth and health
have grown. Efforts to medicalise health, with professional control over
information, are now compounded by commercial and corporate interests in
medical and health care and professional education. The stakes of multinationals,
producers of pharmaceuticals, medical equipments, and medical insurance
companies are at a much higher scale. Globalisation provides for free flow of
information and ideas. The use of information and communication technology has
benefited many. However, macro-economics, speculative financial flows and
global trade policies adversely affect livelihoods, food and human security, the
environment, and purchasing capacity of a significant proportion of people.
While health status has improved for some, disparities are growing, health gains
are being lost and new problems are emerging. Community impacts of corporate
led globalization point to increasing denial of health and access to health care.
Conflicts of interest that underpin many of these developments need to be clearly
addressed by the health promotion community. Strategies need to address health
determinants including war and conflict, unhealthy trade practices, environmental
injustice, recognizing the complexities involved. Partnerships with affected
communities and NGOs are critical. This paper reviews the role of NGOs, The
strengths and opportunities of potential and existing partnerships and peoples
movements in health promotion and in addressing health determinants.
3. NGO Partnerships for Global Health Promotion
The role of civil society organizations (CSOs) has received increasing importance
in public policy and health policy over the past decade. As more financial and
other resources were invested in this sector, the profile of its constituent groups
changed. Different agencies define CSOs and NGOs differently. There is need for
clarity in understanding the heterogeneity of this sector, and to recognize the
unique roles of different constituents for global health promotion. NGOs in the
1960s and 1970s were largely not -for - profit voluntary organizations working
towards integral development. In health they included medical service through
hospitals, health centres, and mobile clinics run by charities, missions and
philanthropic organizations. With experience and reflection this group developed a
deeper community based understanding of the dynamics of health, health care and
development in different socio-cultural situations. They were often able to achieve
what governments in resource poor situations could not. With professional and
social skills developed through working in difficult circumstances they became
alternative experts, and the sector soon became an additional policy option. With
growing recognition, money and influence, the profile of NGOs and new entrants
to the sector changed . NGOs now include corporate NGOs, with companies
setting up Trusts and Societies, building brand images, obtaining tax benefits and
blurring the profit and not for profit sector. Government NGOs (GONGOs) and
other new entities developed to overcome the bureaucracy of government.
Professional associations’ and research bodies with a high degree of knowledge
2
and expertise, such as the International Union for Health Promotion and Education
comprise another important section. NGO networks developed at national and
global levels with a specific focus on health. During the past decade a global
people’s health movement emerged with a strong focus on health determinants and
a right’s based approach to health care. The potential for partnerships are thus
many. Including those that can impact on health determinants provide a strategic
option to global health promotion.
4. Creating enabling environments for NGO coalitions for health promotion
The Millennium Development Goals (MDGs) provide a renewed framework for
partnerships between governmental and nongovernmental organizations to create
an environment conducive to development and elimination of poverty .
Investment in health is critical for development and achievement of the MDGs.
Through advocacy for healthy public policy, NGOs increase community health
literacy and knowledge. NGOs with diverse structures and functions are the sine
quo non in health promotion due to their grass roots presence and closeness with
communities, which enables them to respond to people’s health needs, concerns
and aspirations.
One of the corner stones of solidarity is sharing and defining common objective,
in this case the promotion of health. The objective to be attained should be time
bound and measurable. It requires carefully designed strategies with each
partner assuming specific roles (Berhane Ras Work, Inter Afrocan Committee)
NGOs understand that health is produced not just by hospitals and health
professionals, but by individuals and families in the context of their daily lives and
by influencing health determinants. NGOs are a positive force through direct
health empowerment and action with people, as well as by working on the deeper
issues. They apply the principles of health promotion including capacity
development, knowledge transfer, community participation, empowerment,
intersectoral collaboration, equity and advocacy for sustainable development."
The agenda for health promotion involves tackling multiple determinants of
health. No single governmental or nongovernmental organization can deal with
the multiplicity of issues. This is a sound rationale for NGOs to establish
networks and alliances between themselves and with academia, governmental and
other organizations to maximize their resources and achieve better outcomes.
Partnerships provide an opportunity to make best use of the strengths and
comparative advantage of each organization. However NGO coalitions do not
occur by chance.
To be effective partnerships must be planned, fostered and managed. Partnerships
can be focused and time bound to achieve defined outcomes or work through
long-term commitments. An example is the Geneva based NGO Ad Hoc Advisory
Group on Health Promotion.
1 General Assembly resolution 55/2, para. 12
2 Ottawa Charter for Health Promotion, (1986).
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NGO Ad Hoc Advisory Group on Health Promotion
Born as an outcome of the WHO 4th International Conference on Health
promotion in Jakarta in 1997, the Group supported implementation of its
recommendations, and worked in partnership with others towards the Global
Conference on Health Promotion in Mexico City, 2000. The Group comprises
several NGOs whose activities include health promotion and education, health co
operatives, nursing, rural women; social welfare, women’s health and those whose
main mandate may not be “health”.
Member’s commitment to health promotion helps pool resources and expertise in
tackling health determinants. For example, Associated County Women of the
World (ACWW) partners with local NGOs, and Governments to provide literacy
centers in Mali. ACWW provides partial funding and expertise to help local
NGOs achieve their goals with community ownership and ongoing monitoring3.
The wide diversity of activities, international structures and grass root
involvement give the NGO Ad Hoc Group its richness of approach, experience
and expertise. Working collectively and individually, and in close partnership with
WHO headquarters, the Group has kept the Jakarta and Mexico agendas in the
forefront of the NGO community. The Group hosts briefings at the World Health
Assembly on NGO and government partnerships in health promotion. This would
not have been possible for any single NGO. By their work and commitment, the
Ad Hoc Group contributes to the attainment of the Millennium Development
Goals.
4.1. Investing in Human Resources and Capacity Building
Human resources are the lynchpin to achieve health and development goals.
Distortions in health care priorities hinder progress in health promotion.
Major distortions include concentration of health facilities and personnel on
urban populations rather than rural, on tertiary care rather than primary, on
curative care rather than on promotive and preventative services and on the
middle-class and better off rather than on the poor4.
Though the primary health care strategy promoted by WHO was designed to
achieve greater equity and universal coverage, health reform and economically
driven models of care reduced public spending on health and social services
leading to growing inequities5.
Besides misallocation and mal-distribution of resources, access to health care
is hampered by shortage of competent health professionals capable of
providing comprehensive health care. Poor investment in training, recruitment
and retention, force health care workers to look for ‘greener pastures’ leading
to brain drain. Nurses and physicians trained at public cost migrate from
•’ Joanna Koch, Associated County Women of the World
4 Swedish International Development Agency (undated), Health is Wealth.
5 Braveman, P. & Tarimo, E.. Social inequalities in health within countries: not only an issue for affluent nations.
Social
Science & Medicine 54 (2002): 1621-1635
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poorer countries to the developed world, leaving health care facilities in a state
of collapse.
Nursing staff shortages cause closure of essential health care facilities,
including emergency rooms. Serious shortages in all health professional
categories in Zimbabwe resulted in closure of health facilities and reduced
access to services6. The New York Times reported, "the nation is currently
engulfed in a huge nursing shortage which is going to get worse”7. In the
United Kingdom there is concern that: "the National Health Service (NHS)
does not have enough pairs of hands to deliver the care that the nation
needs... and hospitals are turning abroad to find staff .
Shortages of doctors are reported in several countries including Botswana,
Ghana and Guinea Bissau. In some developing countries, shortage of nurses
and doctors often results in staffing rural clinics by poorly trained personnel
ill-equipped to provide comprehensive services including health promotion. In
these circumstances, it is likely that investment in health promotion will
continue to be eroded and neglected. NGO coalitions and all stakeholders need
to address this issue on priority.
Health promotion strategies draw upon multiple actors and stakeholders
including multilateral organizations such as UN agencies; development
banks; national and local governments; faith-based groups, citizen’s
organizations; international, national and local NGOs; WHO collaborating
centres; academic institutions; trade unions; the arts and entertainment
industry; the private sector and others. Collaborative efforts by stakeholders
who promote the public good in health is crucial for success. For example, the
progress made in onchocerciacis control was only possible with committed
partnerships. While reducing under-nutrition and universalizing access to
water and sanitation attract less attention, regressive policies of some
organizations also reverse health gains.
Community Empowerment
Different stakeholders, working with empowered communities can become a
powerful voice, lobbying governments to invest in human resources
particularly for health promotion training and capacity building. NGO
networks have a convening power and a large outreach capacity enabling them
to bring about a “paradigm shift” from the curative to the preventive,
promotive and social health model.
Training and capacity building by NGOs are characterized by active
community participation, empowering individuals and families to increase
control over the determinants of their health, and to demand universal access
6 Mutizawa-Mangiza, D (1998), The impact of health sector reform on public sector health worker motivation in
Zimbabwe.
Major applied research, 5, working paper 4. Partnerships for Health Reform, Bethesda.
7 New York Times 12 April 2001
8 Jeremy Laurence, Health Editor, The Indipendent, 26 November 2002.
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to health care. NGOs and health profession associations should be enabled to
become “social health activists”.
4.2. Strengths, weakness, opportunities and threats to coalition building
Strengthening NGO coalitions for health is necessary in the current landscape
characterized by declining development resources, increasing privatization of
services, and reverse transfer of resources from developing countries9.
Coalitions need to be built with skill, care and mutual trust using strategies
that include identifying opportunities and partners with shared goals; reaching
agreements; maintaining and evaluating partnerships ,0. This takes time and
resources.
Challenges faced include selecting partners, working with communities,
defining partnerships goals, setting time frames, mobilising resources and
keeping long term commitments to meet complex evolving needs. Often
unequal distribution of power and decision-making within NGO groups or
between NGOs and governments can negatively impact outcomes and
sustainability of partnerships. Corporate interests working through
governments and international bodies can be counterproductive. Lack of trust
and suspicion between NGOs and governments is a potential threat.
Coalitions can multiply actions outlined in the Ottawa Charter: building
healthy public policy, creating supportive environments, strengthening
community action, developing personal skills, and reorienting health
services11.
Mutual commitments to engagement between governments, civil society and
NGOs would help achieve better health. Governments need to see beyond
their term in office and to see the long-term role of health promotion. NGOs
and civil society need to be rooted in their reality, and to see beyond that
reality and their own constituencies to engage with a wider spectrum of
stakeholders. Both need to recognize barriers that prevent the realization of
health promotion in the community and to undertake cooperative measures to
tackle this12.
As an intergovernmental agency, WHO has a long history of working with
NGOs In health promotion WHO - NGO partnership from decision making to
evaluation has been fruitful. While partnerships are strong at WHO
headquarters, there is scope for improvement at country and regional levels.
9 United Nations Research Institute for Social Development, States of disarrary; the social effects of globalisation.
London,
UNRISD, 1995.
10 Kickbusch, I, and Quick, J 81998), Partnershps for Health in the 21st Century. World Health Statistics quarterly, 51,
6174.
11 Ottawa Charter for Health Promotion, 1986
12 Mano j Kurian, World Council of Churches, E-mail correspondence
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5. Global coalition’s promoting health, addressing determinants
Concern about the social determinants of health, and the difficulties faced by
governments and international bodies to effectively work on their own towards
Health for All goals, resulted in the emergence in the late 1990s of a much broader
global coalition, the Peoples Health Movement (PHM). Unlike the 1970s, health
groups and NGOs are now joined by women’s movements, the science and
literacy movement, the environment movement, trade unions, development groups
and many community based organizations, all of whom recognize that better
health is a common concern. Collective analysis, planning, action and reflections
with affected communities build solidarity. Groups from varied backgrounds and
cultures have become connected locally and globally through horizontal and
vertical linkages. This awakening culminated in the first Peoples Health Assembly
(PHA I) in December 2000 in Savar, Bangladesh, wherein 1493 persons from 75
countries debated health related issues over five days and adopted the Peoples
Charter for Health 13. Through thousands of prior community, village and town
meetings, the Charter built on perspectives of people, whose voices are rarely
heard. It clearly addresses health determinants, namely:
a) economic challenges posed by the global trading system, third world debt,
intellectual property laws, speculative international capital flows;
b) social and political challenges, including the right to work and livelihood,
gender issues, rights of expression, political participation and religious choice,
the weakening of public institutions and services;
c) environmental challenges including water and air pollution, climate change,
ozone layer depletion, nuclear energy and waste, toxic chemicals and
pesticides, loss of bio- diversity, deforestation and soil erosion ;
d) war, violence, conflict and natural disasters.
Action points concerning these issues, and for developing a people-centered
health sector with people’s participation resulted in much follow up.
Spontaneously translated into 50 languages (see www.phmovement.org) the
Charter has become one of the largest consensus documents on health providing a
framework for action. Since 2000, country, regional and issue based circles
evolved leading to specific action such as the right to health care campaign in
India; advocacy regarding global public private initiatives; policy dialogue with
the WHO; a global campaign on patents; the Peoples Charter on HIV/AIDS and
Asian People’s Alliance for Combating HIV/AIDS; the first Global Health Watch
report; International Health Forums; state national and LTNESCAP health
policies; a Tsunami Watch; and most importantly advocacy, street action and
community work, including training thousands of community health workers.
Media strategies resulted in greater national and local reporting of health issues
and controversies, including corruption. In some countries health moved higher
on the public and political agenda with commitments to increase budgetary
allocations. There has been support for the peace movement in the USA, Europe
and Asia, and a PHM response to disasters in Iran, Sri Lanka, and India. The
second Peoples Health Assembly in Cuenca, Ecuador in July 2005 raised issues
and concerns of the Americas and reviewed progress since PHA I.
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These activities took place without centralized funding and through a loose
networking structure. Partners from the South played an important role in
developing the Charter and strategies for action.
The PHM identifies people,
particularly those excluded, as its greatest resource and reservoir of talent and
energy. Providing space for community voice and agency has brought in
dynamism, diversity and focus on priorities. The health movement, along with
allied movements, is a force that is part of a globalization of solidarity from
below.
6. Conclusion
NGO coalitions with communities, governments and other organisations can
mobilise human, political, financial and scientific resources to make health
promotion the backbone of health care systems and services. There is a need for
the health promotion community to develop and sustain working links with local
communities, groups and movements working beyond the traditionally defined
health sector in order to influence health determinants. Working for equity in
health would involve challenging powerful interests. Public health ethics requires
that this be done. The paper provided an overview of NGO coalitions and
movements, their strengths, weaknesses, opportunities and threats, suggesting how
they make a difference in the health and wellbeing of communities
*****
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