How are social determinants of health addressed in India?
Interview with Commissioner Mirai Chatterjee
Dr Mirai Chatterjee is the Coordinator of Social Security for India's Self-Employed Women's Association, SEWA - a trade union of over 200,000 self-employed women. She is responsible for SEWA’s Health Care, Child Care and Insurance programmes. Before this, she was General Secretary of SEWA for three years and Coordinator of SEWA Health Team for twelve years. Dr Chatterjee is on the boards of several organizations in India, including the Friends of Women’s World Banking and HealthWatch. She has been a member of national task forces on social security, health and poverty reduction. Most recently, she was appointed to the National Advisory Council and the National Commission for the Unorganised Sector.
How do you see your role as the Commissioner in relation to social change?
Social change requires action from different persons and groups in society, and various strategies. One such strategy is to organize at grass root level to build a mass organization and slowly a mass movement. That is what we have been trying to do at SEWA. We learned from Mahatma Gandhi and others that when you want to change things, you organize and unite all citizens behind the cause, and especially the poorest of all. This is how he built up a powerful movement for change while he was in South Africa and later to oust the colonial empire in India. But we have also learned, over the years, that organizing at the grass roots level alone is not enough. We have to change policies and programmes, and laws, that impede equity and justice; and adversely affect the lives of the poorest of citizens. Indeed, we have to change many policies if we are ultimately to change society. Action at the policy level - district, state, national and international - has a strong impact on how we organize. With enabling policies and laws, local people and workers are encouraged to organize better together. Thus, the movement for change gets new life and energy.
That is why I agreed to be a Commissioner. We see many health policies, and indeed the very approach to health, that need immediate re-orientation or even complete change. At the global level, for example, the move away from the social determinants approach to a targeted one in the health sphere resulted in countries and donors also following this approach. There have been many fall-outs of this change in approach, including a move away from the earlier more holistic and integrated primary health care approach. On the ground, this resulted in several separate programmes for health care - one for TB, another for Reproductive and Child Health (RCH) and a third for HIV/AIDS. These were not interconnected, as their lines of control differed. So we had parallel programmes worth millions of dollars serving the same communities but with, I believe, somewhat limited impact. Or at least we could have gone further in providing "Health for All" if we had taken a different approach. In sum, in today’s world, the global is local and visa versa, and we have to change things at various levels for lasting social change for the ordinary person on the street.
In your country, how are social determinants of health addressed?
I think in India, both at the policy level and at the grass roots level, the social determinants approach is well-accepted. In the case of the latter, it is felt that this approach accurately reflects the multifaceted nature of their lives, and thus their health. At the policy level, even in the pre-independence era, we had the Bhore Committee which promoted this approach. Promoting this approach on a philosophical or theoretical level is not a problem. What is difficult is putting it into practice on the ground - where it affects people. And this is where we run into difficulties: the "how" part. How do we develop programmes and services incorporating or based on this approach.
The way we try to address this approach at SEWA is linking our health security or social security programmes with our livelihood or work security ones. Thus, along with organizing street vendors for their rights or embroidery workers into a cooperative for better markets for their products, we also work with these women on the health front - preventive health education, TB control, making low cost medicines available and other health action. We also work to improve their housing, ensure safe drinking water and toilets for all to reduce illness and other health-related action. At the policy level, we have moved away from the social determinants approach to a vertical, "silo" approach. There are signs that this may change. But there is still much more to do in this regard.
In your view, what role do civil society organizations have in the Commission's process?
As I mentioned earlier, for any change to occur we have to build a movement at the grass roots, and involving all sections of society. Civil society is a key section. Civil society can raise issues it sees at the grass roots level and can bring these to the policy table. It can also act as a "watchdog" to see that appropriate, pro-people, pro-poor and pro-women policies are developed. And finally, it can see that these policies are actually implemented on the ground and can monitor these for their impact. People’s hopes are often pinned on civil society action. This is true for this Commission also. The commission itself came about partly through civil society action - so we have been there from its very inception. Now we have a responsibility to work closely with the Commission to see our dreams translated into reality, especially for the poorest and sickest in our countries. Already civil society colleagues have been active and are creating a base in several countries so that more people understand this Commission and its importance and can ultimately benefit from it. We are fortunate that our civil society colleagues are serious about this Commission and are so active.
What will be your defining indicator of success for the Commission?
I think there cannot be one defining indicator of success. We are talking of a change in approach to one that recognizes the social determinants of health, and actively integrates this into policies and programmes. The change has to come at all levels, change in global health policies spearheaded by the WHO, changes within WHO and in countries as well. For me the ultimate yardstick for success would be if Bhasrabai, an agricultural labourer and embroidery worker, and our member, experiences the change concretely in her remote desert hamlet in India. And, of course, other “Bhasrabais” too, in other countries.