Assembly meets to tackle health needs of the poor

More than a thousand members of the People's Health Movement from about 90 mostly poor countries will meet at the People's Health Assembly in Cuenca, Ecuador, next week. The movement (http://www.phmovement.org/) is a global advocacy network of people's organisations, civil society groups, non-governmental organisations, women's groups, social activists, academics, health professionals, and policy makers. This will be the second time that they have come together in a meeting, aimed at giving a voice to the poor.

The first People's Health Assembly, was held in Savar in Bangladesh in 2000, and attracted almost 1500 health activists. It was convened by Zafrullah Chowdhury and his colleagues to discuss the failure to achieve the goal of health for all by the year 2000 (BMJ 2004;329:1127). This was the ambitious target that health ministers from 134 countries signed up to at the Alma-Ata conference in Kazakhstan in 1978.

Poverty, widening economic inequality, globalisation, unfair trade, and poor health governance were held to blame. Governments and the United Nations' agencies concerned with health were charged with failing to enact the principles set out in the Alma-Ata declaration, which called for the development of comprehensive equitable primary health care services (BMJ 2000;321:1361-2).

During that meeting, the People's Health Movement came together, and a call to arms was drawn up and endorsed in the form of the People's Charter for Health (http://www.healthwrights.org/). The charter, to which signatories continue to be added, demands that health and human rights should prevail over economic and political concerns and that people, especially poor people in less developed countries, should have a much greater influence on the development of national and international health policy.

The assembly in Cuenca will continue the debate within the People's Health Movement on how to narrow the vast and growing health and wealth divide between rich and poor countries. It will reinforce the call to take radical action to counteract the underlying economic, social, political, and environmental drivers of the divide. It is also set to discuss the tone and outcome of last week's G8 summit and the impact of the Make Poverty History campaign.

The meeting will be held at the medical school in Cuenca, which has pioneered a community based curriculum, with strong emphasis on looking at the determinants of ill health and health inequity. Halfway through the assembly, on 20 July, a new report (billed as the alternative world health report) will be launched.

The Global Health Watch 2005-6 Report will be released simultaneously in London (at an open public meeting at the Royal Society of Arts) and subsequently in Geneva, South Africa, Berlin, and Amsterdam. The 359 page report, to which over 120 individuals and 70 organisations have contributed, has been compiled by members of the People's Health Movement and the Global Health Equity Alliance (http://www.gega.org.za/) with support from Medact (http://www.medact.org/).

“It is explicit about the social and political causes of ill health and poverty,” said David McCoy, a public health specialist and managing editor of the report. “As a civil society report it has been able to say things that the UN agencies, [the World Health Organization], and Unicef in particular, can't say. And more to the point [it can] comment on the capability and effectiveness of these agencies who are charged with protecting and promoting health.”

The report is set to be critical of WHO's past leadership on health. David Sanders, professor of public health at the University of the Western Cape, South Africa, and a major contributor to the report, underlines why: “During the 1990s, WHO relinquished its leading role in determining global heath policy, and the World Bank has taken over. Over the past two decades macroeconomic policies pursued by the bank have had a negative impact on health equity, and the global crisis in health, especially in Africa has barely been addressed.

“During this time WHO has produced sheaves of information on the global burden of disease and cost effective interventions but said very little about the causes of ill health, foremost among which are poverty, socioeconomic inequity, the adverse effects of globalisation on the poor, unfair trade, and poor health governance.”

Professor Sanders is particularly critical of the market reforms that have been introduced by the World Bank in poor countries, which have fuelled the development of private health services and further denuded the public sector of staff and resources. User fees prevent the poorest and most vulnerable getting access to essential medical care and in some countries even more basic commodities, such as water.

“In South Africa, water supplies are now managed by a public-private partnership. User charges kick in once per capita consumption exceeds 25 l a day (the average per capita consumption of water in the US is 250-300 l a day). This has had a hugely negative impact on health and wealth. Poor families are now spending up to 20% of their income on water. When this happened in Bolivia, mass public protest forced the government to retract.

“We can't reverse globalisation but we can do more to mitigate its adverse effects on the poor, foremost by pushing for fair trade. More aid is needed too. Intermittent grand charitable gestures by rich countries are not enough. Promises to deliver aid are frequently broken. The poorest countries are bankrupt and wholly unable to deliver cost effective interventions such as immunisation because their health systems have collapsed.” Professor Sanders supports the view that new sources of revenue are needed to help the poorest countries, such as introducing taxes on global currency exchange, air travel, and arms.

Despite their criticism of WHO, Professor Sanders and Dr McCoy recognise that the organisation has changed under new leadership and is more sensitive to the issues raised in the report. The establishment earlier this year of WHO's independent Commission on the Social Determinants of Health (www.who.int/social_determinants) is, they say, clear evidence of this. The commission, chaired by Michael Marmot, has a three year remit to compile evidence of community interventions that improve health through action on social determinants from countries with low and medium incomes.

“Intersectoral interventions have much potential to improve health and reduce health inequalities,” Professor Marmot told the BMJ last week. “We know that people's health is hugely influenced by the conditions in which they live and work. We are keen to work closely with civil society groups to inform and extend our knowledge of how community interventions improve health.”

“I am impressed, for example by the positive impact on child health of a Latin American initiative that provides mothers with a small income to spend on sending their children to school and to nutritional centres. I am looking forward to going to Cuenca to explain our work and to get the input of the People's Health Movement into the commission's thinking. We need to establish how we can make common cause.”