The right to health is enshrined in international conventions and declarations, is one of the established human rights in many constitutions of post-colonial states, and is regularly cited at conferences or in appeals to improve the health situation of people in emergencies and disasters. However, the right to health only takes on reality where people claim it for themselves and work to implement it in the context of everyday adversities. In many places, medico partners have initiated or participate in such efforts. For example, in India, Zimbabwe and El Salvador.
India
Urban life is a growing feature of the Indian subcontinent, even though the majority of the population still live in the countryside. However, most city dwellers are left behind by ‘Shining India’, the booming neoliberal economy of the rising regional power, home to one-sixth of the world’s population. Informal, insecure employment, wretched living conditions and the continuous growth of the urban poverty areas from the inflow of rural poor are leading to a health situation which is often even worse than in rural areas, despite the greater density of health centres and private doctors.
Some 40,000 people live in the poverty quarter of KG Halli in Bangalore, the IT metropolis in the south Indian state of Karnataka. Hindus, Muslims and Christians, established locals and immigrants from the neighbouring states of Tamil Nadu and Kerala. This is where the Institute for Public Health (IPH) Bangalore, a member of the Indian branch of the People’s Health Movement (PHM), launched an ambitious project two and a half years ago to strengthen the right to health and health services of the poor inhabitants. Besides the employees of the Institute, other central actors in this are four community health assistants who come from this quarter and are receiving ongoing training by the IPH. They have a double function, providing very practical health promotion in supporting pregnant women and also acting as respected counsellors on questions of family planning, thanks to their independent and unbiased advice. Their house visits and familiarity with local conditions also enables them to act as ‘health researchers’, identifying problems such as a lack of water and sanitary supplies, waste disposal, poor road conditions and the difficult situation of widows and the extremely poor. To help them go beyond merely identifying the problems on hand, they have established a network of inhabitants, health centres (private and public), local medical practices and clinics and representatives of the responsible authorities, through which the problems can be addressed and solutions sought. This is not always easy, given the conflicts of interest between the various participants. In the past two years, the IPH team has made some progress in improving the health services in KG Halli. The most important effect of its work, however, is undoubtedly the experience people have gained that they can improve their own situation by raising their voices together. Such solidarity is by no means a matter of course in an area like KG Halli, with its ethnic, religious and cultural diversity. This ‘intercultural harmony’, as the goal of peaceful coexistence is known in India, is essential for successful representation of the interests of the otherwise voiceless and poor majority of the population who are rightfully claiming their share in ‘Shining India’.
Zimbabwe
‘Fit as a fiddle’ is how the government spokesman described the patriarch Robert Mugabe in mid-April 2012 on his return from the latest of his numerous trips to Singapore, to dispel any doubt about the state of health of the 88-year-old long-standing president, who expects to win again in this year’s election. The reason given for his journey was not further medical treatment, but rather to check on the progress of his daughter’s studies in Hong Kong. The contrast between the lifestyle of the former liberation fighter and most of his liberated people could hardly be greater. Hard-won independence was followed by a successful decade of development in the 1980s, including the establishment of a highly-regarded nationwide basic health service, although this success was erased in the 1990s by a combination of internal conflict, a failing economy and cuts demanded by the World Bank and IMF. The steady emigration of health service specialists to neighbouring South Africa or the old Commonwealth countries of the UK, Canada and Australia turned the claim to provide good healthcare for all into a hollow pretence.
A dramatic increase in HIV infections since the start of the 1990s has pushed the average life expectancy below 40 – a shocking world record. The recurring and escalating cholera outbreaks in the first decade of the new millennium highlight in particular the preventive shortcomings of the health service and the wretched state of the public infrastructure (water, wastewater).
Since 1998, the Community Working Group on Health (CWGH) – an alliance of 35 local and national civil society organisations – has been trying to do something to counter this trend and to re-establish the health service from the ground up. Like the Indian IPH, the CWGH focuses on mobilising local actors. ‘Health literacy’ (as the organisation understands and promotes it) covers not only knowledge of hygiene, prevention and what to do in case of sickness, but also active involvement in the health service through local and regional health councils. These are intervening in the field of health policy and supporting the democratisation process in Zimbabwe through joint initiatives for participative budget monitoring of the health programme for HIV/AIDS financed by the Global Fund and a nationwide campaign to incorporate the right to health in the new constitution. The appointment of CWGH Director Itai Rusike to the Public Health Advisory Committee to the Minister of Health in 2010 indicates that their strategy in supporting health rights may be succeeding.
El Salvador
In the smallest state on the Central American land bridge between the large neighbours in the North and South, something astonishing has been happening largely unobserved. For the first time since 1992 when the civil war came to an end, in 2009 the left-wing FMLN replaced the extreme right-wing ARENA party which had governed the country for the last 20 years and launched an ambitious programme of social reconstruction for the country. One core element is health reform, not only aiming at good health services for all, regardless of their financial abilities, but also promoting participation by the people themselves in decisions. This is not surprising, as activists in the People’s Health Movement in El Salvador have risen to important positions in the health ministry and are now trying to implement ideas nationally which were developed in the country’s ‘liberated zones’ during the civil war.
The medico partner Alianza Ciudadana contra la Privatización de la Salud (Citizens’ Alliance against Privatisation of the Health Service – ACCPS), a network of committed NGOs in the health sector, has been actively fighting the right-wing government’s plans to privatise national social security since 2002, and since the change of regime it has been working on the National Health Forum in a constructively critical style on drafting the health reforms.
The plans are ambitious, integrated health services (ECOS) with doctors, nurses and health promoters will not only provide therapy but also health education and preventive medicine. The five-member teams will be responsible for basic health services to around 600 families in rural areas or 1,800 families in urban areas, supplemented by teams of specialists for specific and rarer health problems. 450 of these teams have been formed since end-2010, and have since provided basic health services to marginalised local communities in El Salvador. In addition, local health committees of elected community representatives have been set up and are being trained by the Alliance. With their good local knowledge, they provide the ECOS with valuable information on health problems, and notify the people responsible of shortcomings in practical implementation of the reforms.
With support from medico, our partners in India, Zimbabwe and El Salvador make possible participation in health policy which goes beyond a voice at the local health centre to aim at changing social relationships.
In 2011 medico supported health policy projects in India, Zimbabwe and El Salvador to a total of EUR 218,666.32.
