PHA-Exchange> PHM evaluation summary report

[Andrew Chetley]

Hi,
Below is a copy of the summary report from the evaluation of the first
PHA and the development of the PHM. The full report will be finalised
and on the PHM website (www.phmovement.org) by the end of November.
Best wishes,
Andrew Chetley

Challenging injustice:
giving voice to people's right to health

Summary report of an evaluation of the People's Health Movement
November 2004

Introduction
This summary report is one output from a three-year participatory
evaluation exercise  that has helped to engage the PHM leadership in an
analytical learning process based on ongoing experience. The evaluation
has looked into the preparation of the PHA, the Assembly itself, and
follow-up activities. Led by Exchange - a networking and learning
programme on health communication - it has assessed the current status
of PHM activities, explored ways to reinforce and enhance current
accomplishments, and examined approaches to strengthen and sustain
monitoring mechanisms. The full evaluation report - Keeping the promise:
The people's response to health for all - is available on the PHM
website: www.phmovement.org . This summary was written by Andrew Chetley
and Cecilia Muxi, members of the international evaluation team.

>From PHA to PHM

A global People's Health Movement (PHM) began to emerge in December
2000, when nearly 1500 people from over 90 countries met for five days
in Savar, Bangladesh to re-establish health and equitable development as
top priorities in local, national and international policy-making. In
the intervening four years from this initial People's Health Assembly
(PHA), the movement has stumbled, struggled, and become stronger, and
today is having an increasing impact on health policy and practice. 

An indicator of the impact that PHM is now having comes from its
interaction with the World Health Organisation. 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 requested by the
Director-General's Office to explore closer engagement with the PHM.

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 Alma Ata declaration on Primary Health Care were used
during 2003 to help mobilise further action. Communication processes
within the movement are improving related network functioning and
governance.   More attention is now being paid to building and
developing strong and effective alliances and working relationships with
other networks, movements and organisations, as well as to engage in an
strategic thinking planning exercise, including the development of a
communication strategy.

The People's Charter for Health, elaborated through a worldwide
consultative process and finalised and endorsed at the PHA, has 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.

PHA : A unique approach to social mobilisation

A key feature of the People's Health Assembly (PHA) is that there was no
real model for this type of exercise. There are many examples of
international meetings, but few that feature a focus on people's voices
or that start from local experience. 

This People's Health Assembly - the first of its kind - was a unique
social mobilisation exercise. In country after country, it involved
people in village meetings, in district meetings, in national events, in
regional workshops to prepare for the global gathering in Bangladesh. 

Along the way, the voices of the people were heard: 
*	articulating their demands for better health, justice, peace and
equity
*	reaffirming their rights and responsibilities to be involved in
the decisions that affect their lives and their health
*	confirming that the right to health is one of the basic human
rights to which they are entitled.

The five-day meeting in Bangladesh provided an opportunity for people
involved in health, development, human rights, agriculture, trade and
economics, the environment and many other fields to converge, to share
ideas and continue a process of building a coalition to drive change.
Anyone who took part in the PHA describes it as a transformational
process. It changed their lives. The challenge now is to see if the
inspiration, solidarity and linkages that occurred can be sustained.

A significant outcome of the process is that it has begun to elaborate
new models for organising, new approaches to giving voice to the
vulnerable and new ways to advocate for social change.

[Box 1: Anger at injustice
A young village health worker from Nepal enacted for everyone the plight
of a young woman who was typical of many she worked with in villages.
She was in bonded labour, had no food, no money. Her husband had died.
Now, in order to feed her child, she would have to offer her into bonded
labour. How could she put her daughter through the misery that she had
faced all her life? Her final, impassioned cry was 'God help me or let
me die.'

Thelma Narayan from India responded to this by adding that the story
reflected the situation of millions of women in Asia and highlighted the
gender inequality of poverty and ill health. 'It is the suffering that
moves us,' she said. 'Our anger at the injustice has led us to develop
strategies to cope. What we are recognising is that this is a global
phenomenon and therefore the response needs to be global. We need to
address the issue of power and to look at how power affects the lives of
people. It is our role to influence those who hold power.' - end of Box
1]

Planned achievements

The PHA process aimed to develop and endorse a People's Charter for
Health and to achieve a further seven outputs:
*	hearing the unheard 
*	re-enforcing the principle of health as a broad cross-cutting
issue
*	sharing and enhancing knowledge, skills, motivation and advocacy
for change
*	improving communication between concerned groups and
institutions
*	developing enhanced cooperation between concerned actors in the
field
*	enhancing media interest in health/equity issues
*	increasing involvement of the poor in the dialogue process.

PHA participants surveyed feel strongly that the unheard did have an
opportunity to be heard; that health was reinforced as a cross cutting
issue and that skills and knowledge were shared during the Assembly
itself. There was a less strong sense that communication between
different groups and opportunities for enhanced cooperation happened.
There was some uncertainty as to whether media interest was enhanced or
to what degree the poor were really involved. Those are not surprising
findings: communication processes, sustained interest and participation
and involvement are all characteristics that require time and sustained
interaction. In many ways, these are the challenges the newly developing
movement is facing.

[Box 2: 'The Assembly provided an opportunity for all of us to listen to
those voices and to become one with their struggles. The declaration of
the Charter will be but one step in making these voices heard by policy
makers, governments and international organisations.'
Dr Qasem Chowdhury, Gonoshashaya Kendra, Bangladesh -end of Box 2]

A transforming experience

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.

As a judge from India who attended said, 'The biggest achievement was
making the world aware that the health of the common folk had to be a
matter of international concern'.

The process that was set in motion to develop the PHA and get the event
held was a positive one. It involved a number of organisations and
networks, consulted widely on content issues, and reached out to a large
audience to encourage involvement and participation. However, there were
also difficulties: not least the overwhelming burn out and exhaustion of
some of the organisers who faced severe stress in trying to cope with
growing and unexpected numbers of participants. The sheer volume of
people who attended meant that some of the carefully planned mechanisms
to deal with debate and arrive at clear positions on many issues were
not able to function. The issues were certainly raised and the problems
articulated; clear expressions of possible solutions were not always
reached. Many of the people involved in organising the event are highly
critical of the outcomes.

A major failing of the process was the 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. It was nearly a year after the PHA that the ideas for
evolving a People's Health Movement that built on the first Assembly and
began to work towards implementation of the demands in the People's
Charter really began to develop. In that sense, the words of a professor
of medicine based in the UK have some relevance: 'It was a remarkable
and memorable achievement, but now what?'. Those words are echoed by a
representative from a civil society organisation in India who said, 'The
idea was good. The implementation could have been better.'

Taking the PHM forward

Up until the beginning of 2003, any assessment of the efforts to move
the PHM forward would have had little to say that was positive. Although
much work was going on behind the scenes, little was visible on the
ground, and where it was, it appeared patchy, sporadic and largely
uncoordinated through 2001 and 2002. Through 2003 and into 2004, greater
coherence is beginning to emerge. 

A large factor in the slow follow up to the PHA lay in the lack of a
clear strategic plan and a corresponding communication strategy to reach
out to different audiences. More recently, planning processes have come
into effect that are addressing this and beginning to develop strategic
approaches and concentrate on improving internal and external
communication.

Other issues that the PHM needs to address include:
*	maintaining and growing the movement (including the dynamics of
networking)
*	leadership and governance
*	strategic thinking and planning (including communication and
evaluation strategies).

Networking, linkages and alliances

There are enormous challenges in trying to maintain an effective network
that combines a broad range of organisations and individuals. Networks,
organisations, and individuals involved in the PHM work on a wide range
of issues - from the very specific to the very broad - and at a number
of levels - local, national, regional and international. 

Related to this is the issue of linkages to other networks, movements
and organisations that are working on issues that impact on health.
Enhanced cooperation is important so that the PHM is visibly seen as a
pro-active, inclusive and welcoming movement and is a platform that
enables people to participate, without them having to convert to a
particular belief, ideology or approach.

The synergy and interaction between the PHM and the International
People's Health Council (IPHC) - one of the original eight groups
involved in developing the PHA - is an example of this.

An area where the PHM has underperformed - although there are signs of
improvement - is in generating media interest and helping to shape the
external environment so that dialogue on public health issues is more of
a reality. This is not an easy area of work and forging stronger and
more effective alliances with networks of media personnel and those that
work with media is likely to be a useful strategy to pursue.

Leadership and governance

Although there has been some discussion of possible structures (a series
of interacting 'circles' or associations of people and organisations
working on particular topics) to provide guidance and leadership for the
PHM, there are still many unresolved issues. This is to be expected in
what is a 'young movement'. However, an encouraging comment that emerged
in the evaluation process is that it is a young movement 'with wisdom'. 

Strategic thinking and planning 

The dynamics of movements and many networks are that they often respond
to situations as they arise: a policy has been issued that needs to be
challenged; a threat to the environment has become evident; a human
right has been violated. Something needs to be done now, with urgency.
People need to be mobilised to take action. However, all of this needs
to be put into the context of a strategic framework which is light and
flexible while providing a unifying planning guide. 

Lessons learned

During the period from the end of the PHA to the present time, many
lessons have been learned and increasingly are being put into practice
to improve the work of the PHM. These include:
*	the need for more coordinated communication and information
sharing - internally and externally. Externally, there is a greater
visibility of the PHM in some arenas and fora. More could be done, but
the signs are encouraging
*	the importance of review and reflection processes to stimulate
analysis of the work, rather than simply undertake activities - this is
increasingly being incorporated into PHM steering group sessions and is
enabling a more strategic vision to emerge
*	allowing more time for planning and coordination of strategy -
in 2003, there was a strong urge to have a second PHA sometime in 2004.
It soon became evident that there was insufficient planning time for
such an event and it has been put back to 2005. This has also allowed
for a recognition that although there was no model for the 2000 PHA -
now there is a model, imperfect and in need of improvement, but the
planning time is now available to make those improvements
*	better documentation of activities - which relates to internal
and external communication. Internally, there is now much better
documentation. This still needs to be better translated for external
audiences to make more use of the communication channels that PHM has
available, but it is an essential first step
*	more clarity and transparency on how activities are funded, how
funds are being shared and made to work more effectively in combination
and with complementarity
*	the importance of prioritizing and selecting key areas for
action - the Charter has a wealth of action points. Any meeting or
workshop is capable of generating long shopping lists of things that
need to be done. Selecting a few of these that can be done is a skill
that enables action to be effective. This is something that the PHM
needs to continue to develop and practice to enable it to maximise its
impact.

Conclusions

There were seven outputs identified in the original project proposal for
the PHA. These outputs have been assessed in terms of pre-Assembly, the
PHM itself, and the PHA follow up.  Certainly, if we had had this
exercise done  18 months earlier, it would have portrayed a more
negative picture in terms of the post-PHA follow up.

This underlines the point that the development of the PHM is a social
process, one that it is difficult to accelerate. It takes time to build
trust, relationships, working practices and principles.  

It is important that there is a continual reflection process within the
PHM to focus not simply on the results, but on the way those results
were achieved. 

People's voices

An area that is more difficult to assess is the degree to which the
voices of the unheard are more evident, including in the planning,
leadership and governance of the movement. For the realities of
vulnerable people to have impact on policy debates and to lead the
demands for social change, considerable work needs to go into strategic
positioning of the stories and the messages they contain. Support for
the people whose voices are being raised needs to be strong. Their
capacity to express themselves in ways that will impact policy audiences
needs to be developed. And they need to be engaged in the analytical
process that helps to draw out meaning from their experience, which
helps them, in the words of Saul Allinsky, to digest that experience.

Their satisfaction with the results of any policy dialogues needs to be
continually assessed. This is one of the biggest challenges facing the
PHM.

>From lessons learned to strategic thinking, planning and action 

Is the PHM an appropriate platform for facilitating the voices of the
unheard to be heard? In 2004, indicators show moves in the right
direction:
*	There has been some enhanced co-operation. Links that are
evolving with key stakeholders have visible positive trends.
*	Enabling dialogue and discussion in a number of forums is
increasing, but there is scope for more. 
*	Communication strategies and practices - both internal and
external - are improving. The Secretariat is demonstrating leadership,
and the response of many participants in the movement to share
information is becoming more evident.

Diversity

One of the exercises that the evaluation team did with nearly 80 people
in 2003 in Geneva was to encourage them to identify how they came into
contact with the PHM and how they pictured their involvement. The
routes, the pathways, the doors through which they entered were diverse
and spread over time.  

The images of the movement that they drew were also diverse, but had
some common elements. The ideas of joining hands, connecting and working
together and of waves of energy, surging and growing were two powerful
currents. Above all, the pictures they drew were a celebration of
diversity and it is that diversity that is the main strength of the PHM.
Sustaining and maintaining a diverse, flexible and effective movement
that serves as a platform for social change is the challenge that now
faces the PHM.

What does the movement or network hope to achieve in three years? In
five years? In 25 years? What is the direction in which the movement is
moving? What are ways it might get there, and how will it know it is
making some progress? These are questions that need to be embedded in
the strategic thinking and planning of any effective movement or
network.

[Box 3: 'A revolution of hope' - the view of the PHM from Latin America

During a reflection workshop held in Nicaragua in late 2001,
participants identified the specific characteristics that they felt made
the People's Health Movement different and complementary to other social
movements or networks.

It is a call to all peoples for the creation and development of a
transforming power for society. The movement is not exclusive; it calls
on all peoples to constitute a force to create substantial and
significant changes in their different societies.
It is a unifying movement.
It proposes a different revolution: a revolution of hope.
It is a solidarity movement.
It struggles for the dignity of people.
It is a movement rooted in the community.
It shakes awareness.
It generates a sense of belonging. It offers participants the
possibility of becoming part of a great movement of social
transformation. Participants do not feel isolated, but connected and
coordinated with common purposes. - end of Box 3]