HEALTH MOVEMENT IN INDIA

HEALTH MOVEMENT IN INDIA

Drs Abhay Shukla and Anant Phadke

Activities initiated to counterpoise the current health system, attempting to collectively influence health determinants, health care and health related ideology in a democratic, may be regarded as the health movement in our country. While activities, which improve determinants of health, may be taken up for their own sake (struggle for higher wages, land and against displacement) and while these may have a significant effect on health, they cannot be regarded as part of the health movement per se. However, a struggle for improving a determinant of health ( e.g. for adequate quality and quantity of drinking water) if taken up by people with the explicit primary objective of improving their health, may be considered as a component of the health movement. Most activities of the health movement, to become effective, require some application of health science. The main thrust of this movement is self-reliance based on the resources and initiative of the participants themselves.

RATIONALE

The conventional thinking on health dismesses it as a largely personal issue, something that is primarily influenced by personal behavior, habits, life style etc. In such a framework, there would be little justification for a 'movement' on health. However, a range of historical experience and scientific evidence shows that the health of communities and populations is decisively influenced by factors which operate at a level broader thatn personal – not only obviously 'social'determinants like nutrition, environment, sanitation etc., but also availability of medical care, prices and policies related to essentail drugs, socially prevalent concepts about health etc. It logically follows that to decisively improve the health of a large group of people, the appropriate approach would be to address these issues in the form of a movement, collective action by people, towards the specific goal of making conditions more conducive of health.

To social activists, health is a relevant issue to be integrated with other points on the social agenda. Activists who oppose the dominant structure find similar hegemonic forces operate in the health sphere, too –medical profession, drug industry, health bureaucracy etc. The conventional system perpetuates an ideology of victim-blaming, with a focus on technocratic, top-down solutions which ordinary people often find difficult to question. Those who seek to change society in a basic way realize that social change is impossible while leaving the critical sector of health untouched. A broad-based movement for health would have to operate at least at three levels.

Health determinants: Only an overall equitable, sustainable and just society can ensure basic health for all its citizens. So. One level of he health movement is to struggle against ill influence on health (pollution, lack of sanitation, poor nutrition, psychosocial factors etc), and work for a society which has an alternative, healthier pattern of development.
Health care system: The most visible and 'perceived' determinant of health is the health care system. This needs to be critiqued and persistent demands made to ensure that it becomes more responsive to people's needs. On the other hand, there is space to build up small model health care systems which are prototypes for the future and which form the basis for new demands.
Health care ideology: The existing system of thinking which blames the poor, women and other marginalized groups for their own ill health has to be overturned. The dominance of usually upper caste men in the decision-making in health care needs to be reversed. Assisting women village-health workers to carry out functions which people usually ascribe only to doctors, is one of the many ways to challenge this ideology.

BROAD OBJECTIVES

One major thrust of the health movement has been to generate public awareness regarding the commercialised, and to an extent, the exploitative nature of health care in our country today, and to generate pressure for changes in health policies, making them responsive to people's needs. Generating collective initiatives on important local health issues and even building up local alternatives to challenge the existing health care system are important activities of the health management. Certain groups and individuals have assisted this movement by carrying out research, perpetration of alternative training/awareness material, and conducting advocacy/lobbying on important health issues.

IMPORTANT EXPERIENCES

Experiences of the health movement on Indian may be broadly divided into three categories.

Campaigns for awareness and policy change
These initiatives have often been spearheaded by comparatively small groups of activists with some professional training in health or related fields. They have formed networks of concerned activists, have often used media and judiciary to press for policy changes and have often succeeded in creating awareness or sometimes even bringing about policy change on key health issues. Some examples:

Various people's science groups and consumer groups like KSSP, Delhi Science Forum, Lok Vigyan Sanghatna, ACASH etc., are the prominent examples. Their role has been mainly in publishing and disseminating materials which have exposed exploitative/irrational activities of the drug industry, unscientific government drug policy, against health-related superstitions etc.
The organisations mentioned above, with several others, came together to lobby for a rational drug policy in India. These organisations formed the All India Drug Action Network, and have consistently campaigned for changes in government drug policy with some success.
Campaigns on women's health issues such as ban on pre-natal sex determination have been taken up by women's groups in Maharashtra. One other issue of such nature was the campaign against forcible hysterectomy (removal of uterus) of mentally retarded young women in Pune. A similar nationwide campaign against hazardous contraceptives has been taken up by various women's groups.
Professional organizations and trade unions of health functionaries (resident doctors/medical students) have also, besides their sectoral demands from time to time voiced demands for improvement in health services and supplies in public hospitals and have even expressed concerns regarding unscientific drug policy etc.
Some periodicals are published to give a rational, pro-people outlook to a professional audience, notable among which are journals on rational drug therapy like BODHI, BSRT, and drug disease, and doctors. Issues in Medical ethics has a similar audience and approach.
One platform of health activists of various inclinations and backgrounds notable in having functioned continuously over the last 25 years, providing a forum for debate and sharing o ideas relevant to the health movement, namely the Medico Friend Circle (MFC).
Recently, the primary health care collective, an offshoot from the MFC, has been campaigning in Maharashtra for legal status to health workers.

Initiatives for alternatives and focus on local health issues
Another important strand in the health movement in our country has been in the form of people's organisations taking up initiatives to address health problems of people in their area. Some examples of such initiatives:

Trade unions have built alternative health care services for their members and also to give low-cost and rational care to people from nearby villages. The most well-known and pioneering initiative in this regard has been Shahid Hospital, built in 1983 and sustained by the workers of CMSS (Chatisgarh Mines Shramik Sangh) in Durg, MP. Similar such attempts are Maitri Swasthya Kendra run by the organised workers of Kanoria Jute Mils, and a hospital run by volunteer doctors in collaboration with the workers of Indo-Japanese Steel Labour Union-both in West Bengal. These health care facilities have demonstrated the ability of organised workers to run an enterprise as complex and skilled as a hospital, in a rational way with minimal costs of care, with the help of inputs from committed doctors and health workers.
A few attempts have also been made by rural organizations to build alternative health care initiatives. One example is in Thane, Maharashtra, where in the context of a tribal people's organization, Kashtakari Sanghatna, where women health workers have been trained at the village level to treat simple illnesses at minimal cost. Some attempts have also been made to make the local health system more accountable in its functioning. The authors are involved in a project to give inputs to peoples Health Committees associated with various people's organizations, helping them to build village health worker programmes and also to press for better functioning of the health system locally.
In certain situations, organizations have responded to events or influences, which have had major impact on people's health. The various initiatives and groups which have come up in the aftermath of he Bhopal gas disaster, attempting to study, treat and also demand justice regarding the terrible health effects of this catastrophe are one notable example. Attempts by trade unions and support groups to take up occupational health problems of workers and by groups of affected people to highlight environmental degradation as a cause of ill health fall in the same category.

Research, training, publication and advocacy
A number of NGOs and other groups and individuals have contributed to strengthening the health movement in India by means of specific forms of support. This includes research which is relevant to taking up demands to campaigns, demonstration projects including health worker projects or a rational drug production unit (LOCOST) advocacy on women's health issues, regarding changes in medical education, preparation of training materials or publications which disseminate information etc. While most such efforts are dependent on external resources yet many have played a supportive role in strengthening the health movement.

FUTURE DIRECTIONS

As indicated in the discussions on the rationale of the health movement above, the scope of this movement is very broad ranging. This would include issues like inappropriateness of medical education, lopsided health research priorities, declining public expenditure on health care, pushing of hazardous contraceptives, etc. Different groups have tried to study and lobby for reforms in some of these issues.

Unfortunately, till now, initiatives on these issues have often remained isolated or limited to small groups. Today, with the winds of globalizations sweeping our society and economy, and the state trying to abdicate its role of providing social services to all (retracting from an already dismal performance), the challenges facing the health movement have grown. Instead of reform dictated by international capital, there is a need to press for reform from below, reforming health services and drug policy radically in a pro-people's direction. Basic services such as health care would have to be given priority even from the point of view of furthering development. At he same time, the numerous experiences of people's organizations and the voluntary sector need to be taken into account, and generalized.

Lobbying for some of the reforms like those in medical education, and research, may not take up the form of a mass movement. However, this can be done around other issues. For example, the demand for a 'people's health worker for every village' is both realizable and just, despite the failure of the government health worker programme. This needs to be worked out concretely, based on people's initiative, and pushed for by a coalition of social forces. Similarly, 'a rational low-cost drug store for every are' is an idea, which can be championed based on the success of he LOCOST experiment. Peoples monitoring of health centres and hospitals is an idea which will gain force in the coming years. Specific demand for women-sensitive health services and policies, rejecting hazardous reproductive technology and calling for appropriate research in this key area is called for. Greater democratic regulation of the private medical sector, ensuring that doctors prescribe in accordance wit standard guidelines for common illnesses following standard indications for common investigations (x-rays, pathological investigations etc), rationalization of fee structure for private doctors, and expecting certain minimum standards of infrastructure and care in both public and private hospitals are some of the areas which could be addressed by the movement. Decentralized surveillance, checking resurgent communicable diseases through integrated community based measures, effective citizens 'monitoring of the quality of environment, especially water and air, are other demands that would gain in strength. There is a growing need for coalitions with activists in women's groups, trade unions, people's organizations, environmental groups, groups working on sustainable development or new economic policies etc., to build the broadest possible front for health. Unless we put in all for health we cannot dream of health for all.

Health Action, Vol. 12, No. 12, December 1999, pp. 6-9.

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