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Role Of Civil Society Organisations In Formulation Politics Essay

To explore the role of civil society organisation in creating the right to health discourse since the end-1990s and its culmination in the right to health legislation in India.

Design and Method: This is an exploratory research study making use of qualitative research techniques. The People's Health Movement-India (Jan Swasthya Abhiyan JSA) has been chosen as the case study and it’s Right to Health Care Campaigns. The major JSA right to health care campaign can be analysed under three heads of Jan Swasthya Abhiyan's engagements: with the National Human Rights Commission, political Parties, Commission on Social Determinants of Health and National Rural health Mission.

Main data source for the study has been documents of the JSA and the drafts of the three bills. Reports, minutes of the meetings, conference documents, studies etc. along with E-Mails of Jan Swasthya Abhiyan E-group from 2000 to 2010 has been used as data. The data materials have been analysed by using the descriptive qualitative content analysis method.

Result and Conclusion: This paper contributes to the ongoing debates on the draft National and states health Bills in India. The study shows that there has been an influential role of civil society in formulation of right to health care in India. JSA’s various advocacy network campaigns constantly demanded for right to health and health care and therefore the final outcome of this is the draft of National Health bill in 2009. Throughout this it also shows that civil society is a space for influencing health policy and their formulation and monitoring. The interconnections between the two concepts right to health and Civil Society, which both are challenging and upholding the existing order in public health system with their limitation.

Introduction

The two concepts civil society and rights remain ambiguous, complex and contested. These two conceptions are widely used in development paradigm according to the contexts. There are different schools of thought have influenced theoretical debates and empirical research interpretations over time. The nature of civil society and meaning of rights has diverse characterization with their pros and cons. In some context both concept has been used by dominant authoritarian regimes for disaffirmation. State and market control several civil society organizations through financial support. Some civil society groups are working in favour of government programmes and some dissent against approaches of the state. As against civil society, 'political society' is a term used for. (Kothari )

Recently the Civil society has become an important actor and resource for health care its ability to influence processes of transformation in health systems and public policy-making. They are demanding from accountability and responsiveness in public health system. Role of civil society has seen as service providers, policy advocates.

Rights are social claims which help individuals attain their best selves and help them; rights are claims against injustice and a demand for justice (Moser et al. 2001). Rights are guarantors of welfare gains, every winning of ‘rights’ likewise strengthens them (Patnaik 2010). Bosanquet defines “A right is a claim recognized by society and enforced by state”. A right is an entitlement or justified claim to a certain kind of positive and negative treatment from others (Garrett, 2004). “Rights dominate modern understandings of what actions are permissible and which institutions are just. Rights structure the form of governments, the content of laws, and the shape of morality as it is currently perceived. To accept a set of rights is to approve a distribution of freedom and authority and so to endorse a certain view of what may, must, and must not be done”. [1] A right is based on principles of social justice. Rights and laws are uniquely intertwined both conceptually and politically. Social movements use the language of rights and all legal discourses are animated by weighing and competing rights (Menon, 2004). Various scholars have attempted to conceptualize the term civil society. Generally, Civil society is considered as a space between state and the market and is contributing in different ways in demanding rights of the people and civil society is an alliance or confederation of democracy (Khilnani 2002). This research applied the various elements in concept of civil society as the arena of collective action around shared interests, purposes and values engagement of different actors. It is distinct from the state, the family and the market. Civil society provides space for diverse interests to interact, where people come together to debate, discuss, associate, and seek to influence society. Civil society cannot be analyzed in isolation from the state they are interdependent. Although independence from the state is a defining feature, civil society interacts closely with the state and is shaped by the enabling environment defined by the state. Civil society in turn acts as a link between the state and citizens, promoting perspectives, accountability, voice and channeling of information to people. (Abiew and Keating 2004)

Civil society and the Right to health discourse are both important phenomena in efforts to improve the health conditions and access to health care. The fulfilment of social security is principally mandatory on welfare state. It includes ensured provision of conditions for improvement of health, including health care. However there have been tremendous changes in nature and the role of state and market after 1990, when neo-liberal policies were officially adopted in India. After the neo-liberal economic development policies becoming effective in social sector the civil society organizations role has been increased. Civil society has being as the prime mover of development in favour of the marginalised. The continuing gross disparities in health status and access to health care are violations of the rights of the deprived sections of society due to deep structural injustice within and beyond the health sector. The civil society groups were highlighting the limitations of the state for social change and transformation.

There is plenty of literature on both civil society and the right to health but it is found to be extremely limited when it comes to issues surrounding the inter-relation of the two. Each one is a much used concept on its own, but connections underlying both have not been adequately researched and documented, especially for the Indian context. An interrogation of the claims of civil society as advocate for development in favour of the deprived has to be made to reach a critical understanding. It is in this context that the interconnections between the two concepts need to be analyzed and understood in relation to their historical trajectory and its impact on the public health discourse in India. This study assumes importance since there has been an active civil society on these issues in India and internationally in the past decade, and it is being increasingly involved in official policy and law making.

Civil society has been looked at from divergent view points and perspectives but for the purpose of this research civil society refers to the arena of collective action around shared interests, purposes and values in the context of the right to health. Civil society is a complex structure consisting of rights based individual and associational life, where the construction of a critical rational discourse based on the modes of social and political organization happens. Civil society has emerged as an important sphere in upholding democracy by virtue of its ability to interrogate the state, but the sphere itself is not devoid of the larger power structures which are concentrated in society. The sphere has to continuously reinvent itself so that it can negotiate with the state and the various hegemonising tendencies within its own sphere (Emirbayer & Sheller 1999).

The term engagement of civil society refers to the participation of Jan Swasthya Abhiyan (JSA) representatives conducted through direct and indirect interactions with government, political society, community and external agencies to influence decision making or pursue common goals in context of right to health and health care campaign. In this regard the study has analyzed Jan Swasthya Abhiyan’s engagement with the National Human Rights Commission (NHRC), programmatic engagement in National Rural Health Mission (NRHM), advocacy with political parties and engagement with the international Commission on Social Determinants of Health (CSDH) process of preparing a civil society report.

The entire outcome of engagements has produced the National Health Bill 2009 (Draft), The Gujarat Public Health Act, 2008 (Draft) and The Assam Public Health Act, 2010. This study has documented the engagement process and outcome in the form of the right to health acts, as well as the debate related to both.

Role of Civil Society in Health

Civil Society has always been a prominent actor in shaping health policies, health outcomes and actions around health. This has been happening in a number of ways through articulation of needs and demands. Demands take an organised form of action through articulation of alternatives and building of models by civil society. The engagements by Civil Society’s actions are linked to the existing economic and political realities. Thus, the actions of civil society organizations and movements are also informed by different historical circumstances. Such actions may vary, depending not only on circumstances but also on the nature of the Civil Society organisation involvement. However, there are in particular period’s tendencies of Civil Society action and reaction towards the prevailing dominant paradigm. For example if we take the dominant paradigm in the current global context as the ideology of neoliberalism, then we also see that much of Civil Society action is located in this paradigm, whether supportive or antagonistic to it. Analysis of this context has centred on the role of the state in the creation and maintenance of civil society. A libertarian position sees the development of civil society as a means of “rolling back the state.” The state is seen to interfere in the development of civil society by restricting the freedom of individuals. By contrast Román and Tovar see a central role of the state as advancing the development of civil society through the provision of state-funded structures to support and nurture it. Related issue is the question whether economic developments promote healthy civil society or does civil society promote a healthy economy. (Román and Tovar 2007) With the rise of neo-liberal health sector reforms, both government and civil society activities have been grounded in market relationships. Civil society organizations have been used as instruments of economic adjustment programs, privatization of health services, and as promoters of market values and consumerist behaviours (Ford et.al 2004)

The role of civil society in health sector is seen as service delivery actors. Recently The World Health Organisation has taking involvement and promotion of civil society organisation through Civil Society Initiative programme. This is a strategic alliance between the state and civil society to improve health. These trends motivated many CSOs to new actions including health service delivery and renewed advocacy for basic health rights and access to health resources (WHO 2001). Secondly the role of civil society in addressing the social determinants of health and its contribution to equitable health policies and health care systems has been described by analyzing evidence in the way CSOs, communities and social movements have dealt with particular issues at different levels and under different circumstances. (CSDH, 2007)

Context and Background: Civil Society and Development Discourses

The discourses of civil society in India emerge with the conceptualization of modern society, and the present new manifestation of civil society came forth after fall of socialist countries (Chatterjee, 1997). It has taken over as the new propagator of development discourse. This has emerged out of a profound notion of dissatisfaction with the state in carrying out its developmentalist functions. The process of economic development has left behind many people and increased inequalities in the system. Even after fifty years of a democratic welfare system, inequalities still persist in India (Dreze, 2002). The inefficiency and unresponsiveness of the state vis-à-vis the citizens has generated a crisis of legitimacy for the state institution. Excessive bureaucratization and dominance of institutions of local governance by the rural elite resulted in exclusion of the common people from decision making. The entrenched socio-economic inequalities and divisiveness, so very characteristic of India, have on the one hand obstructed the realization of democratic aspirations of equality and equal opportunity to the unprivileged and on the other have resulted in a situation where the benefits of development have been appropriated by the dominant sections (ibid 2002).

In such a situation, where the citizens lack the resources and voice to raise their concerns, civil society initiatives claim to play a crucial role in bringing them into the public sphere so that their voice can be heard. Civil society is thus projected as replacing the state in its operations, but this notion is based on a limited understanding of the sphere itself. Since the boundaries for the functioning of civil society is provided by the state itself. So an understanding which looks at civil society independently from the state and market is flawed since classically too civil society has been looked along with the two spheres. Civil society has been conceptualised as a space between state, market and people for claiming the rights of the people (Spurk, 2001).

India had a matured civil society during the British colonial period. This civil society fought for mainly two causes, one was political freedom and the other social change (Nilsen, 2007). In the Post independence period, in the early 1970s, the Nehruvian model of planned development resulted in widespread discontent among large sections of the population. To counter these growing discontents after the 1970s, a large number of Civil Society Organizations emerged as part of New Social Movements. Various networks emerged during this process. In the 1970-80s, the concept of civil society in India came into greater prominence in academic discourse. It has been seen as challenging the state and market authoritarianism, emerging as strong political opposition to governments. Shift occurred in the late 1980s in Indian political scenario. The reason for that can be seen as a lack of accountability and failure of the state agencies to follow the rules and orders in providing welfare to its citizens. The realization politics of welfare services gave rise to civil society organizations against the Indian welfare state. The reason of failure of welfare state in democratic India is the dominant social hieratical power structure, shifted into Indian political society and redistribution of wealth and power did not translate into hands of marginalized classes through the welfare mechanism (Aspalter 2003).

Response of state to discontent was incorporate civil voice through Participation politics. Broad changes in the concept and nature of state and civil society can be seen from the policy and plan documents. For example the Seventh Five-Year plans 1985 to 1990, Ninth Plan 1997 to 2002 and the Tenth Plan 2002 to 2007 that emphasised on increasing the participation of Civil Society Organizations in planning and development. The government has stressed the need for the partnership with NGOs in crucial areas such as medical care and education.

The new social movements are “the main route to shifting political action in civil society from the current condition of mainly isolated, local initiatives, easily ignored by the power structure and vulnerable to manipulation and co-option. The ultimate objective of these many diverse movements must be embedding civil society in governance systems worldwide.” [2] 

The emergence of grassroots politics was a significant aspect regarding the JP movement and it paved the way for various social movements. Movements ranging from civil liberties, idea of ecology, rights of women, and Dalit identity were emerging during the 1980’s. They were actually developing a space to negotiate with the government for their various demands. These movements were looking at the issues like poverty and oppression from a new perspective which was missing from the earlier class based movements. It was actually questioning the developmental paradigm and democratic culture of India. Thus, women’s rights, ecological degradation etc. became the new concerns of the movements. In the field of health, several new community health initiatives emerged. Inequality in welfare provision and disgruntlement about state gave nationwide space to JP movement and idea of ‘Total Revolution’. Second it gave rise to New Social Movement (NSM). In health two kind of mode have been seen. Many medical doctors were part of JP movement and JP movement these doctors stated the group call Medico Friend Circle (MFC) for restructuring the health system. They had question the clinical and techno centric model of health care. These, together with a large number of medicos and non-medicos formed the network Medico Friends Circle (MFC). It was a group of medical professionals and social activists who were concerned about making structural changes in the Indian health system. This was probably the first civil society network in health in India. The perspective of MFC had pro-public health principles [3] .

Emergence of People's Health Movement

Two decades ago, civil society organizations were involved in the demand for equitable health care through the Declaration of Alma Ata. More than it was adopted at the International Conference at Alma-Ata on Primary Health Care its promised "Health for All by 2000". Primary Health Care approach was accepted by member countries to provide health care as frame work. But as the year 2000 approached it was clear that this promise had been, largely, forgotten by governments and international institutions around the world. The discontent rose all over world by civil society group for forgotten commitment by governments. Raised of new social movement gave shape to discontent and create platform for civil society groups in anti globalization campaign. The health civil society organizations, groups, networks, and non-government organizations part of these global and national agitations. In this context the major apprehension of civil society groups working in the area of health is how to protect the basic health rights of people. These primary concerns were lead towards formation of People Health Movement.

Later, in the year 2000, the discontent due to failure of the goal of Alma Ata declaration gave emergence to the people's health movement. Jan Swasthya Abhiyan (JSA) emerged as the India chapter of the global Peoples Health Movement (PHM). JSA is a network of Civil Society organisations and social movements in the field of public health. JSA has been at the forefront in demanding Right to Health in India and putting forward Health as a basic fundamental human right. JSA had built various campaigns to fulfil this dream of equitable health care. (JSA 2007)

Engagement with State through National Human Rights Commission (NHRC)

Right to health campaign started in 2001 at the conceptual level. Idea of right to health and frameworks for right to health in Indian context widely discuss through various workshop of seminar and other programme. Through this process activist were identify systemic issue with large number of health care right denial throughout country.

The legitimate rationale of JSA engagement with NHRC was the negligence of government towards health care it convert into denial of base right to life. The documentation of cases of Denial of Health Care was launched nationally. JSA collected testimonies of denial of basic health care as a human rights violation. This was undertaken all over India, public hearings were held and reports presented to the National Human Rights Commission. This was central strategy of the campaign in the years 2002 to 2005.

These cases were meant not only for the National Public Hearing, but should be fully used at the state level. A concern was expressed by JSA members that focusing on the weaknesses of the Public Health System alone might indirectly benefit the private medical sector. To the contrary it was argued that the framework and demands that were raised as part of the Right to Health Care campaign are for strengthening the Public Health System, under people’s monitoring. It is only from the Public Health System that we can demand a set of comprehensive health services, since it runs on taxpayer’s money and is accountable to all citizens. As we establish the legal and social right to certain basic health services, the Government would be pressurized to strengthen and reorient the public health system, in order to deliver these services

Jan Swasthya Abhiyan used this platform for health advocacy. The role of NHRC was identified as the bridge between people and the executive government institutions.

The National Public Hearing held in New Delhi in December 2004 was two-day long programme, where Jan Swasthya Abhiyan and civil society representatives presented key cases of denial and structural deficiencies were noted in the various regional hearings, followed by delineation of state-wise systemic and policy issues related to denial of health care. This was followed by a joint presentation by NHRC and Jan Swasthya Abhiyan on the spectrum of health care rights, which need to be protected, fulfilled and promoted. This included the special health rights of vulnerable social groups such as women, children, persons affected by HIV/AIDS, persons with mental health problems, migrant and unorganized workers, the urban poor and persons affected by conflict or displacement.

Outcome NHRC engagement

JSA finalized National Action Plan on Right to Health Care with NHRC. That sent to the Central and all State Governments for action on widespread and serious denial of health care and violation of health rights during various public hearings, this action plan has asked State governments to undertake a series of actions to ensure quality health services for all. JSA demanded the immediate implementation of the NHRC action plan to prevent ongoing serious health rights violations and to guarantee quality health services for all citizens, relating to care from both public and private health sectors.

Engagement with Political Parties

It is generally considered that civil society promotes democracy and its resistances against the state help in making political society accountable to citizens and societies. Some civil society groups have been engaging with the ‘political society’, some working with state and most of the civil society groups who are not working with the state are not anti-state but are working with communities for action outside the state apparatus and programmes. These groups question the accountability and responsiveness of state towards society and made more influence power of the individual and local community. The unresponsiveness of India's political parties and government has encouraged the Indian public to mobilize through nongovernmental organizations and social movements. [4] 

Civil society organizations in India have had a relatively weak record of organized engagement with the political society members, with very few organizations in the country that have a good conception of the nature of engagement that is required with the political classes to bring about desired change. Even when civil society groups have been successful at getting certain policies changed, in the overwhelming majority of cases the engagement and 'advocacy' has been with the government and not with the political society members. There are a growing number of civil society groups that have begun to focus on 'watching' government, analyzing its performance, and advocating for social justice measures. But these efforts need sustained work with political parties across the country. (Basu 2009)

In the run up to the general election were held in India in four phases between April 20 and May 10, 2004, the ‘Right to Health Care’ campaign launched by JSA organised various programmes to persuade the political parties to include ‘right to health’ in their manifesto. For that a public event on ‘Parties face the people’ was organized on 12th of March in New Delhi. [5] JSA had planned various strategies as part of the advocacy process to influence Indian political society.

Policy Document for Dialogue with Political Parties: The policy document to be used by JSA for dialogue with political parties before the coming general elections, deliberately focused only on the health care system, and the recommendations were also focused on issues regarding the health care system that could be implemented in the near future. It was accompanied by the People's Health Charter, to outline the larger consensus vision of JSA regarding health. This document was printed and disseminated before the event [6] .

Suggestions on the draft was related to issues of bureaucratization of the health services; neglect of the training of health administrators, state of the key institutions for education, training, research and evaluation of public health; the morbid cadre structure; the abject surrender to vertical programmes; rapid growth of capitation fee medical colleges. [7] 

Involvement Reservation about BJP and Shivsena: There was debate around engagement of JSA with Bhartiya Janta Party (BJP) and Shivsena in the pre election campaign. Majority of JSA members see the "Virus of Communalism" as a major threat to health, and therefore did not think it appropriate to provide a platform to the party identified with it. Some members felt that not having representatives from all the parties would defeat the purpose of the dialogue. JSA should also use this opportunity to expose the BJP's projection of the "India Shining" image, with hard facts of declining statistics and health care indicators presented in front of those who claim the reverse. It would be strategically better if they are there than if they read about it. [8] But the decision in Mumbai meeting was to avoid BJP/Shivsena.

Difference between two election dialogues: in 2004 election dialogue JSA policy brief. The policy brief in2004 was titled 'Make Health care a fundamental right!’ JAS decided to advocate concentrating mainly for Right to Health with reference to the draft National Health bill in the general election of 2009. The tentative 31 point lists of issues were shortlisted through JSA group discussion and the second issue considered important to be taken up was Community based Monitoring under the NRHM.

Outcome of Political Parties Engagement

If this draft considered appropriate, it may start with / contain a shorter two-three page 'People's Health Manifesto' which encapsulates the key policy changes being proposed, and can be taken by political parties for incorporation into their respective manifestos. Some political leaders may focus on this even if they do not internalize the entire brief.

This policy brief (with People's health manifesto) circulated to all political parties, and shared with Lok Sabha candidates with whom JSA units might have a dialogue. The idea is to widely disseminate certain key ideas regarding major changes required in the Health sector.

The policy brief and manifesto also be shared with other platforms and coalitions, which are interacting with political parties in the pre-election period with a pro-people perspective. [9] , [10] 

Engagement with State through National Rural Health Mission

The Government of India launched the National Rural Health Mission (NRHM) in 2005 to improve the quality of life of rural people. For that government considered it necessary to do architectural correction in the basic health care delivery system. The Goal of the Mission is to improve the availability of and access to quality health care by people, especially for those residing in rural areas, the poor, women and children. [11] 

One of JSA activist was pointed in interview that the improvement of rural health care system has been demanded by civil society organizations for a long time. In context of NRHM civil society groups have claimed that NRHM is an outcome of civil society efforts. Several discussions and debates have taken place on the conceptualization and implementation of NRHM in India. It has also been much debated in the forum of JSA

Engagement of JSA in NRHM

During the emergence of NRHM, the main issues pertaining in JSA were being discussed on email group (e-group), JSA had analysis of the various components of the NRHM based on a study of the relevant documents and other information, and planning of the “People’s Rural Health Watch”, by JSA to monitor the implementation of the NRHM, at State and National levels, with a view to influence it in a pro-people direction.  [12] Another agenda added by health activists were that planning for interaction with and providing resource support to NGOs/ civil society groups working in NRHM implementation at all levels with a view to influencing it in a pro people direction." [13] 

The key decision of JSA was to prepare NRHM health Alert. This NRHM Alert was JSA document highlighting critical issues related to the mission. It clearly stated JSA positions on NRHM. It’s prepared to state Jan Swasthya Abhiyan’s position on the NRHM so as this document helped the JSA groups and partners to decide how they could possibly engage with Rural Health Mission. It was prepared based on the review of various health documents by a number of JSA people. Several JSA resource persons and activists were involved in the drafting of this document.

Discussion on Engagement in NRHM

A debate had taken place around the issue of role of JSA's engagement and role as a civil society organization in the national rural health mission. Jan Swasthya Abhiyan's goals included improving health care of the rural masses. Therefore, some members proposed that JSA members be involved in the implementation of the NRHM. This raised the larger crucial questions within JSA, as to what is the role of civil engagement as an Civil Society Organizations in the domain of public health and what would be JSA's stand or position or contribution in improving the health status or health care services for the large section of rural population. Implementation and monitoring were viewed as the possible roles. However, some others held the opinion that JSA should not get involved in implementation at all. One of the arguments for this was that designing of NRHM is unimaginative because it has not taken into account the epidemiological condition of India and therefore is bound to fail.

One group of public health activists even expressed certain reservations on the issue of NRHM watching; especially with government financing it out of NRHM funds. One senior academician argued that JSA was not well prepared to implement the services of NRHM. “My concern is that an ill-prepared JSA will be co-opted by the establishment.” Action of JSA to watch NRHM is going to fail due to the outreach of NRHM and outreach of JSA is not going to mach. [14] and strength of JSA to implement NRHM or to watching implementation is limited, because NRHM is design for 18 state programmes. Work of JSA within country is in limited area. “What is the outreach of JSA and what is the public health competence of the few who dare to do the `Action watching’?”

In defence of this argument one of the public health activists mentioned that , First objection pointed that watching NRHM - both on grounds of competence and on grounds of outreach is a question mark. [15] Another group of activists defended that it’s not only about watching, it is about the engagement of civil society groups in the government programme (NRHM). [16] 

After much discussion a resolution was taken on the line of argument about co-option by government in NRHM. [17] The need to critically engage with the emerging NRHM, and to keep a regular ‘Watch’ on various aspects, including its policy, implementation and funding, based on suggestions and responses from various JSA activists, after analyzing the available documents and information on NRHM, that helped to firm up the JSA position on all aspects of the Mission; this also has a bearing on JSA related organizations deciding about ‘watchful involvement’ in certain activities related to the Mission. Additional discussion would focus on the idea of an NRHM ‘Watch’ (to be appropriately named based on consensus) what this would seek to do, how information would be analyzed and used, what responsibilities various organizations are willing to take regarding watching state and national level aspects of the Mission, and as relevant, how this would be financially supported. [18] 

Watching Government through People’s Rural Health Watch

People’s Rural Health Watch (PRHW) was an initiative to collect information on, access and analyze the activities under the NRHM, both at the state and national levels; communicate and disseminate all such documentation and information through reports and other means, and provide feedback for improvement. The idea of a People’s Rural Health Watch (PRHW) was conceived of and outlined by JSA at a National Consultation in May 2005, following the implementation of the NRHM in April 2005 by the United Progressive Alliance (UPA) government. The PRHW was viewed as a way of taking forward the `Right to Health’ campaign of JSA, launched in September 2003. Given the objectives of the NRHM to improve rural health services, PRHW would be an activity to assess whether or not the healthcare infrastructure was being strengthened in a pro-people direction, and to assess whether or not people were getting health services with the introduction and implementation of NRHM. Information on implementation at the state level was to be collected through field surveys, it was also decided to study relevant policies and planning documents, and look at financial allocations and funding sources of NRHM (JSA 2007).

Community Based Monitoring and JSA

JSA had organized a nationwide Right to Health care campaign in 2003-04, enabling activists to document and publicizes cases of ‘denial of health care’ in a ‘Right to Health’ framework. In order to prevent the recurrence of denial of health-care needs of the people, and to move towards fulfilling the goal of people’s right to health care, a series of recommendations were presented to the government in a public hearing in 2004. It is important to note here that need for a community based monitoring system of health services was originally articulated in this set of recommendations. Further, in the National Public hearing on ‘Right to health care’ organized in 2004 by JSA, a National action plan was released by the National Human Rights Commission (NHRC) in which operationalisation of mechanisms for joint monitoring at District, State and National levels involving Health departments and civil society representatives was clearly recommended. (JSA 2006, Kakade 2008)

In parallel to these activities, JSA also organized a dialogue with national political parties in March 2004, thus ensuring that strengthening the public health system became a part of the political discourse in the 2004 national general elections. In response to these and other factors, the NRHM was launched in 2005 by the Union Ministry of Health and Family Welfare, under the United Progressive Alliance government (UPA). NRHM had a range of components related to strengthening of public health services in rural areas. However, two key factors facilitated the inclusion of Community based monitoring of health services (CBM) within the NRHM framework. First, the planners of NRHM felt that introducing an officially sanctioned community monitoring programme would fill a critical gap in the Mission’s system for validation of information. Second, the framework of CBM was significantly shaped and promoted through sustained people-oriented advocacy by members of JSA.

In 2006, the Union Health Ministry constituted a panel of civil society experts called the Advisory Group on Community Action (AGCA) to support community based action related to NRHM. Several of its members were members of the JSA network. The AGCA discussed the possible modalities for operationalising community based monitoring and noted that CBM requires more complex and diverse partnerships compared to other elements of NRHM. They recommended that a pilot program be implemented in selected districts in nine states of the country (Assam, Chhattisgarh, Jharkhand, Karnataka, Madhya Pradesh, Maharashtra, Orissa, Rajasthan, and Tamil Nadu). (Kakade 2008)

This activity which is built into NRHM and is supported by the public health system, involves participatory monitoring of health rights by community members and civil society organizations, including regular preparation of community ‘report cards’, discussing the required improvements in multi-stakeholder monitoring committees, and periodic conduction of public hearings on health rights. Although strictly speaking it is not an activity of JSA groups alone, JSA groups and individuals have played and continue to play a central role in this activity in various states. [19] 

CBM is a framework and space for establishment of Health rights within the public health system. This framework is being used by JSA member organizations to ensure that people can claim their right to health care in the context of rural health services. CBM seeks to significantly change the traditional vertical power relationship between educated, articulated health care providers and less educated, less influential village community members. The CBM model that has evolved in Maharashtra is a significant step for moving towards such equalization of power. This model is towards making the health system accountable to people, and enabling people to demand their health rights. Enabling citizens to monitor and hold accountable public systems can become a vehicle for community empowerment and democratizing social systems beyond the health sector. [20] 

International Engagement of JSA with Commission on Social Determinants of Health

The World Health Organization has constituted Commission on the Social Determinants of Health (CSDH) in 2005. This is a clear indication of recognition of need for a greater focus on upstream determinants. The Commission has marked them “causes of the causes”. The main objective of Commission on Social Determinants of Health was to reinforce and unite actions and policies that promote equity and address the social determinants of health. In this regard, CSDH has identified what civil society organizations are doing and what they need in order to strengthen their work on social determinants of health (Marmot 2005, Baum 2006). Major focus areas of CSDH are compile evidence on successful interventions and formulate policies that address key social determinants, particularly in low-income countries; raise societal debate and advocate for implementation by member States, civil society, and global health actors of policies that address social determinants and define a medium and long-term action agenda for incorporating social determinants of health interventions, approaches into planning, policy, and technical work within WHO (Marmot 2005)

Rationale for Engagement with CSDH : Advocacy on social determinants of health has been the global agenda of People's Health Movement. PHM's agenda included advocacy strategies and their proactive and assertive promotion of these deeper determinants of health and health care in framework of people health Charter. The principles of the PHM charter state that “health is primarily determined by the political, economic, social and physical environment and should, along with equity and sustainable development, be a top priority in local, national and international policy-making. And the preamble of the charter has included “Health is a social, economic and political issue and fundamental human right. Inequality, poverty, exploitation, violence and injustice are at the root of ill-health and the deaths of poor and marginalized people” (Narayan 2006)

After the First People’s Health Assembly 2000 at Savar, Bangladesh, the evolving people health movement set up a small WHO advocacy circle that began to use every opportunity to engage with WHO and encourage it to rediscover its original mandate and commitment to the social determinants of health. Over the next three years, this continuous engagement led to a series of interesting events and dialogues that began to put people pressure on WHO in different ways. These included a set of provocative in-house workshops at WHO headquarters by a PHM-linked health policy resource person in April 2001. These workshops led to the announcement of the Civil Society Initiative by the WHO Director-General and an invitation for dialogue to a group of PHM leaders at the next World Health Assembly in May 2001. The active participation in World Health Assembly 2001 helped to put the Social Determinants of Health on the global agenda through continued engagement with the WHO. PHM helped gather evidence for the WHO final report on the Social Determinants of health released in August, 2008 (Narayan 2006).

Strategic Engagement with CSDH

Represented in the Commissioners and Knowledge Networks

Members of PHM represented civil society and were engaged as commissioners in the various Knowledge networks of CSDH. The Commissioners comprise an independent body charged with WHO Secretariat coordinates; the various areas of work of the Commission Knowledge Networks provide the evidence base on which to identify priority actions and interventions. The Scientific Secretariat helps to coordinate the evidence base generated by the Knowledge Networks. This strategic engagement of PHM with CSDH had helped to put forward the civil society agenda at the global level.

Dominating the Civil Society Component

Civil Society had provided an important input in terms of experiences on the ground and across sectors. The major roles of civil society had been to frame critical analysis about the rapid changes happening in health and formulate public opinion on the issues of health as a basic fundamental right; to engage in dialogue with policy planners and Government functionaries for ensuring the health to all; to. Build campaigns on critical health policy issues; and to mobilize community for people monitored health systems.

Civil society organisations are seen as one of the arms of the Commission, based on a perception that they can play a balancing role in the work of the Commission and influence some of its recommendations by bringing in experiences that are people and movement centred. JSA members feel that this move is a genuine attempt to make this Commission more responsive to people’s concerns. [21] .

Civil society was viewed as important to provide ‘the people’s perspectives’, and to carry on the process so that it produces something larger when the Commission’s life ends in 2008. The CSDH process is a progressive move by WHO and JSA had used this opportunity given to it as a Civil Society organization. If JSA do not engage, there will be others to fill the gap, which may divert the CSDH process to undesirable conclusions. However, given the background of some of the Commissioners, JSA should be vigilant at every stage of the process, even while engaging with the process. [22] 

People's Health Movement India has perspectives on Social Determinants of health, articulated through the Indian People’s Charter for Health 2000, Asian People’s Charter on HIV/ AIDS, 2003, The Mumbai Declaration, 2004, National Right to Health Care Campaign Documents, 2004-05. They have used this perspective in order to engage with the CSDH process.

Major achievement of engagement with CSDH:

Civil society Mobilization: Several countries based and regional consultation meetings.

Role of PHM in Knowledge commission generation: Active participation in the Knowledge Networks’ processes of evidence collection and creation.

Three independent civil society reports submitted to the Commission on Social Determinants of Health.

Other Campaigns and Issues Related to Right to Health

JSA has organised several campaigns on various issues which was directly connected with right to health issue. Such as Campaign against Sex Selective Abortions, Involvement in the Right to Food Campaign, Hunger Watch, TRIPS and the Indian Patent Amendment Act, Initiatives related to Drug Policy, Initiatives related to Health Policy, The Role of Civil Society in Drafting Bills.

Summary and Discussions

This paper contributes to the ongoing debates on the draft National and states health Bills in India. The study shows that there has been an influential role of civil society in formulation of right to health care in India. JSA’s various advocacy network campaigns constantly demanded for right to health and health care and therefore the final outcome of this is the draft of National Health bill in 2009. Throughout this it also shows that civil society is a space for influencing health policy and their formulation and monitoring. The interconnections between the two concepts right to health and Civil Society, which both are challenging and upholding the existing order in public health system with their limitation.

It is evident from the preceding campaigns and various engagement of JSA. That civil society has played a major role in highlighting the issue of 'right to health' as a means of ensuring access of all sections of the Indian population, and especially the deprived and underserved, to quality health care as per need. The implications of the international discourse on right to health in the present context, JSA’s activities as a Civil Society Organization in India related to advocacy for the right to health care and the legislations drafted to encode the right, which can be seen as partly an outcome of these efforts. In the final analysis, we find that the civil society activities have encompassed advocacy as well participation in drafting of the bills at state and national levels. It has also attempted to work towards the same objective through participation in the national government initiatives to strengthen the health service system through the National Rural Health Mission. While some successes can be attributed to the systematic civil society campaign in terms of the official action towards which the campaign had built pressure, the debates around various components of the campaign activities and the present situation as regards the official operationalisation of this various dimensions highlight the dilemmas and potential limitations.

The first demand of people health movement is that the right to health should be a constitutionally guaranteed fundamental right as they are superior to standard laws. Fundamental Rights represent a very strong pillar of Indian democracy ensuring equal justice and freedom to all. In the present situation civil society organizations have been advocating right to health as fundamental human right under the international human right framework. There has been a shift from right to health as a constitutional fundamental right framework to international human rights framework. In addition the state has become signatory at the international level in guaranteeing protection for the human rights of all citizens but at the national level it fails to incorporate constitutionally provided fundamental right. Qadeer and Chakravarthi (2010)

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