An overview of all the above roles played by civil society and social movements in the engagement towards catalyzing Health in All Policies led to the identification of some innovative instruments of engagement, some of which are now finding place even within government and international planning and strategy documents. Six such innovative instruments are mentioned below:
The idea of monitoring and analyzing closely the emerging trends in situation analysis, data, statistics, and performance outputs and impacts by civil society groups outside the formal public health system, at all levels has been gaining ground over the years, providing space and opportunity for trend analysis and comment which is different from the official reports. The Global Health Watch of the People’s Health Movement which is brought out every few years as an alternative World Health Report (1-3). At regional level with a focus particularly Africa, the EQUINET (4) and the Global Equity Gauge Alliance (5) has also been recognised. At a country level a good example of a Watch is the People’s Rural Health Watch which is a civil society monitor the National Rural Health Mission in India (6). The most innovative website that has been developed based on access to health and development data and indices from UN sources is ‘Gapminder’ which focuses primarily on Equity and related trends between regions and country (7)
Another instrument of engagement which has been developed in many regions by civil society, is the idea of people’s tribunals and right to health hearings. In this innovation an informal jury of legal officials is setup and representatives of the community or patients/citizens at large are invited to share their experiences of the health services and programs, in the presence of health and development officials of the Government. This platform provides people opportunity to air their concerns and invites government officials to respond to the concerns and issues raised in generic ways. In India the Right to Health hearings organized by the People’s Health Movement at regional and national level in collaboration with the National Human Rights Commission are good example of this approach. A people’s tribunal on the World Bank Policies in Health and Development has also been organized. In some countries these are also called citizen juries. In recent years the National Rural Health Mission strategy document has internalized this instrument providing space for Jan Sunwai’s (people’s hearings) (8) The Ministry of Environment in India has also recently included this instrument in the Health and Environmental impact assessment (HIA and EIA) which is mandated as part of emerging state and national environmental policy to mitigate the health and development hazards of unplanned development, migration and displacement. As part of this process the local community is also invited to assess the needs and the plans in a process of participatory planning.
In the last decade regular, often annual assemblies of health and development activists have been organized at state level, country level, and internationally to bring civil society and social movement representatives together to share experiences, analyse the impact of campaigns and plan strategies locally, nationally, and globally in a spirit of solidarity. The most significant of such assemblies had been the people’s health assemblies organized by the people’s health movement in Savar Bangladesh, 2000 AD; in Cuenca, Ecuador in 2005 and in Capetown South Africa in 2012 leading to the People’s Charter for Health, the Cuenca declaration and the Capetown statement. (9,10) Additionally the well known World Social Forum (WSF) process started in Porto Allegre Brazil which has also developed into country level, regional and global annual for a has included health as a key theme within the forum and often also as a satellite activity leading to various consensus declarations and documents. (11) The Mumbai declaration of 2004 which evolved from the international health forum associated with World Social Forum, Mumbai 2004 is well known (12).
Campaigns have always been the sheet anchor of civil society action on health issues. Starting from the orthodox trade union type of protest /solidarity marches – the so called red flag demonstrations, campaigns have begun to innovate other forms of expressions of solidarity including human chains, candle light vigils, and in many parts of Latin America into all sorts of carnival oriented aspects which helps to innovate a new culture of protest and solidarity through music, street theatre, and other art forms. Groups like Greenpeace have taken this further through various forms of symbolic and creative action to get the message to decision makers and policy makers.
As part of the political process it is not uncommon for civil society and social movement groups to dialogue with formal political parties before state and national elections. This has been going on for years with different civil society organizations raising issues and facilitating dialogue with different groups. However with increasing recognition that Health in All Policies requires also the All for Health approach and the evidence that Health for All requires action on Social, Economic, Political and Cultural determinants that go far beyond ideologically determined action, there is increasing effort to evolve health manifesto’s, policy briefs, and charters that are then distributed to all political parties with a message that Health is too important to be left to one group or the other. This approach which has now begun to be applied by the People’s Health Movement in India by the development of a Health Policy news brief in 2004 before the national elections and a people’s health manifesto in 2009 before the national election has begun to increase the importance of health on the political agenda of the country. (13) In 2004 the process contributed along with other factors to the reorientation of the emerging National Rural Health Mission towards the policy of communitization even more emphatically, which was sustained by civil society participation in task forces and advisory groups of NRHM. This trend has now begun to emerge at state and district level before elections at this level. It is too early to demonstrate the impact but perhaps the increasing public dialogue on universal health care in the country is at least one obvious impact of such engagement. (8) The JSA developed a Health Manifesto in February–March 2014 prior to the General Elections in April- May. This was disseminated to political parties and others and a meeting with political parties organized. Four parties have significant sections in their manifestos on health, with a major party placing the Right to Health as its top most priority!
Sustained policy engagement and dialogue–whether as critical constructive engagement; oppositional and confrontational; or in consensus development mode are process instruments which are recognized and used as increasingly effective tools. The processes by which various strong interests in health influence health policy process in any country operate, are only more recently being studied, scrutinized, interrogated and engaged with. (14, 15) The evolution of the National Rural Health Mission in India; community monitoring and community action for health in the NRHM; in Thailand the National Health Act and National Health Assembly (16) and the changes in distorted childhood immunization policies in the state of Tamilnadu in India are examples of sustained processes in three very different contexts and levels. The World Health Report 2008 on Primary Health Care records the role of civil society and social movements in its section on ‘Mobilizing the Communities’ by recognizing these experiences and instruments of engagement in India, Bangladesh, Chile, Western Europe and Mali, demonstrating that this is now an increasing global trend (17).