Keeping the Promise: The People's Response to Health For All

A global People's Health Movement (PHM) began to emerge in December 2000, when nearly 1500 people from over 90 countries met for 5 days in Savar, Bangladesh for a People's Health Assembly (PHA). Their goal was to re-establish health and equitable development as top priorities in local, national and international policy-making. This motivation grew out of several decades of civil society involvement, commitment and action: a global effort to increase awareness and strengthen comprehensive primary health care (PHC) strategies built in local communities.

This 91-page evaluation report provides an external assessment of the activities leading up to the PHA and the Assembly itself, as well as an exploration of efforts underway to develop follow-up activities and begin to develop a PHM. The London, UK-based organisation Exchange was approached to develop this evaluation process prior to the PHA. The evaluation team sought to document the activities that were being undertaken, to reflect upon them in a participatory manner, to identify lessons, to feed those lessons into ongoing social mobilisation and advocacy activities, and to identify ways of sharing those lessons more widely among organisations doing similar work.

The evaluation process drew on a combination of techniques and tools and a variety of sources and informants in an effort to enable the diversity of the PHA participants and their goals to be expressed, such as regional focus group sessions and reflection workshops, as well as structured, semi-structured and open-ended interviews with participants, organising group members, media, and other interested stakeholders. In an effort to assess progress, the evaluation team articulated a series of outputs and measurable indicators, as well as less quantifiable measures. The 7 key outputs are:

1. hearing the unheard
2. reinforcing the principle of health as a broad cross-cutting issue
3. formulating and endorsing People’s Charter for Health
4. sharing and enhancing knowledge, skills, and advocacy for change
5. improving communication between concerned groups and institutions
6. developing enhanced cooperation between concerned actors in the field
7. enhancing media interest in health/equity issues.

The evaluation shows that the PHA "was a unique social mobilisation exercise". To prepare for the global gathering, people all over the world participated in village meetings, district meetings, national events, and regional workshops. These gatherings provided opportunities for voices at the grassroots level to articulate demands for better health, justice, peace and equity; reaffirm their rights and responsibilities to be involved in the decisions that affect their lives and their health; and confirm that the right to health is one of the basic human rights to which they are entitled. The 5-day meeting itself (the Assembly) enabled a process of sharing ideas, and continuing a process of building a coalition to drive social change. "On balance, the overall impression of the Assembly itself from participants was that it was a unique, transforming experience. It had a profound impact on the 1500 people who attended, and nearly all of them have communicated with others about the experience in some way."

Evaluators found that one of the strengths of PHM, which grew out of that participatory process, is that it emerged out of associations and links between people and groups working in a range of sectors - health, environment, education, agriculture, nutrition, trade, economics. Another strength was that the movement was built from the bottom up, building on community level concerns and the reality of poverty at the grassroots.

Despite a lack of coordination and coherence early on in the birth of PHM, evaluators find that the movement is beginning to have global impact. One indicator of this impact is PHM's growing interaction with the World Health Organization (WHO). In December 2000, despite being invited at the highest level to attend the PHA, no one was officially representing the WHO. In January 2004, several representatives from the WHO attended the PHM activities around the World Social Forum in Mumbai, India and were asked by the Director-General's Office to explore closer engagement with the PHM. As a second example, evaluators point to the fact that the People's Charter for Health, elaborated through a worldwide consultative process and finalised and endorsed at the PHA, had - at time of evaluation - been spontaneously translated into more than 40 local languages. "This indicates the degree to which the Charter and its demands for social, political and economic change to improve health reflect and resonate with the reality of the situation facing the millions of people living in poverty."

In terms of regional impact, they find that "Strong and ongoing activities have been taking place in Asia (particularly South Asia) and in Latin America. Within South-East Asia and the Pacific and the Middle East, events connected to the 25th anniversary of the AlmaAta declaration on primary health care were used during 2003 to help mobilise further action. Communication processes within the movement are improving and more attention is now being paid to building and developing strong and effective alliances and working relationships with other networks, movements and organisations."

In addition to stressing PHA/PHM strengths, accomplishments, and impacts, evaluators offer a number reflections on challenges/weaknesses of the process, including:

• overwhelming burn out and exhaustion of some of the organisers of the Assembly, who faced severe stress in trying to cope with growing and unexpected numbers of participants
• lack of a plan (and the resources - human and financial - to carry it out) about how to follow up the Assembly and maintain the enthusiasm and solidarity that was expressed. "As a result, some of the dynamism of a new popular movement was initially lost."
• challenges in trying to maintain an effective network that combines a broad range of organisations and individuals - e.g., few African participants attended the PHA, and the scope for follow-up has been limited.
• unresolved issues in terms of guidance and leadership for the PHM (although there has been some discussion of possible structures - a series of interacting 'circles' or associations of people and organisations working on particular topics).

Among the lessons learned shared here the need for and/or importance of:

• more coordinated communication and information sharing
• review and reflection processes that stimulate analysis of the work, rather than simply undertake activities
• more time for planning and coordination of strategy
• better documentation of activities, which relates to internal and external communication
• more clarity and transparency on how activities are funding, how funds are being shared and made to work more effectively in combination and with complementarity
• increased attention to prioritising and selecting key areas for action - e.g., by selecting a few of the many action points laid out in the Charter.
• more focused strategic thinking and planning (including communication and evaluation strategies).