Towards Health for All 

Towards Health for All

I think that there is only one way to science – or to philosophy, for that matter: to meet a problem, to see its beauty and fall in love with it; to get married to it and to live with it happily, till death do ye part – unless you should meet another and even more fascinating problem or unless, indeed, you should obtain a solution.

But even if you do obtain a solution, you may then discover, to your delight, the existence of a whole family of enchanting, though perhaps difficult, problem children, for whose welfare you may work, with a purpose, to the end of your days.

Karl R. Popper

I wish to develop the Renaissance concept of Opera, where people work together closely to resolve the issues they face, from a participatory, equal, just, co-operative, sustainable, mutual and whole system perspective.


Declaration of Alma-Ata

International Conference on Primary Health Care, Alma-Ata, USSR, 6-12 September 1978

“The Conference strongly reaffirms that health, which is a state of complete physical, mental and social wellbeing, and not merely the absence of disease or infirmity, is a fundamental human right

and that the attainment of the highest possible level of health is a most important world-wide social goal whose realization requires the action of many other social and economic sectors in addition to the health sector.”[1]

I understand most of the pathways and solutions have been worked out and implemented successfully somewhere on this planet.  The issues then are around transference and implementation of solutions.

Keri Smith “How to be an explorer of the world”[2] is probably a valuable starting point “You have immense powers”


I understand the starting point for implementation should be audit.  This is a very wide use of this term, and is actually about individuals, families, communities, neighbourhoods, villages, towns, cities defining and agreeing what to do together, using ecological, economic and equality tools.

This immediately causes a structural issue – what to audit, how to audit, how to learn to audit, how to report, how to learn to report. I understand this is an educational function – it is not only academic and theoretical, but hands on, involved, learning, thinking, iterating, experimenting, adapting.  It needs to become a core function and way of working of universities.

Future search is an example.

Future search is a PLANNING MEETING that helps people transform their capability for action very quickly. The meeting is task-focused. It brings together 60 to 80 people in one room or hundreds in parallel rooms.

Future search brings people from all walks of life into the same conversation – those with resources, expertise, formal authority and need. They meet for 16 hours spread across three days. People tell stories about their past, present and desired future. Through dialogue they discover their common ground. Only then do they make concrete action plans. The meeting design comes from theories and principles tested in many cultures for the past 50 years.

It relies on mutual learning among stakeholders as a catalyst for voluntary action and follow-up. People devise new forms of cooperation that continue for months or years.

Future searches have been run in every part of the world and sector of society.[3]

Participatory Rural Appraisal is similar

“Participatory Rural Appraisal (PRA) describes a growing family of approaches and methods to enable local people to share, enhance and analyze their knowledge of life and conditions, to plan and to act. PRA has sources in activist participatory research, agroecosystem analysis, applied anthropology, field research on farming systems, and rapid rural appraisal (RRA).

In RRA information is more elicited and extracted by outsiders; in PRA it is more shared and owned by local people. Participatory methods include mapping and modeling, transect walks, matrix scoring, seasonal calendars, trend and change analysis, well-being and wealth ranking and grouping, and analytical diagramming. PRA applications include natural resources management, agriculture, poverty and social programs, and health and food security. Dominant behavior by outsiders may explain why it has taken until the 1990s for the analytical capabilities of local people to be better recognized and for PRA to emerge, grow and spread.[4]

I have met John Rowan and his work is also about this

Human inquiry: a sourcebook of new paradigm research Peter Reason, John Rowan

J. Wiley, 1981 – Psychology

Sets forth a new paradigm for the philosophy and practice of research in fields of human activity: a collaborative, experimental approach in which inquiry is firmly rooted in subjects’ experience of their lives. Covers the philosophy, methodology, practice and prospects of the new paradigm, showing how to do research with people rather than on people. Synthesizes material from researchers pursuing similar paths in Europe, North America, Africa and India as well as relevant reprints and appreciations of classical material.[5]

Charles Leadbetter is arguing for similar approaches

“Learning from the Extremes


Published early in 2010 by Cisco, Learning from the Extremes examines how social entrepreneurs around the world are devising new approaches to learning in extreme social circumstances – favelas, slums, informal settlements – when there are few teachers, schools, text books. The radically innovative approaches they develop challenge conventional wisdom about schooling and provide new insights into how the developed world should reform its education systems.[6]

For, With, By and To

In the spring of 2010 I began work on a project called For, With, By and To, which argues there are only four main ways in which we organise most social activities or address social changes. For solutions are delivered to us. With solutions we devise cooperatively with other. By solutions depend on self motivation and DIY. To solutions depend on instruction, command and coercion, to get things done. Crudely speaking the 20th century was shaped by the rise of more complex, powerful and sophisticated For and To solutions in virtually every walk of life, at the expense of With and By solutions, cooperation and self help. This dependence on For and To solutions has come at great costs, not least the ability of those delivering to abuse their power. We need to redress this imbalance and develop more effective With and By solutions in virtually every area of life, from learning and health, to ageing and dying, to politics and the environment.


A comprehensive audit must include sustainability, or as the Germans put it “ecological orientation”. Friends of the Earth and the PSI define sustainability in the context of four principles.  (Elkin 1991).[7]


The effects of any human activity must consider the needs and aspirations of future generations, of your great grandchildren’s great grandchildren. The planetary support systems and a minimum environmental ‘capital’ stock should be maintained.


The full and true environmental cost of any human activity should be taken into account.  The precautionary principle should be used.

It is very difficult to define sustainability constraints, although work is being undertaken on critical loads and habitats.  It is better to define development paths which will not breach possible constraints.


Futurity can be understood as inter-generational equity.  Intra-generational equity, between the first and third worlds, between women and men, between adults and children, the young and the old, the able and disabled people, the poor and the rich, is the third principle of sustainability. The entire planet cannot achieve Western resource consumption levels and these pathways are not sustainable for the long term future.


Participation is a logical result of seriously addressing equity.  Everyone’s views matter. Government becomes responsible for ensuring participatory,co-operative action occurs.  Everyone needs to be enabled to share equally in the processes of decision making and implementation.

Audit Questions

Hesperian has produced a sample list of audit questions.[8]

To Help Determine Community Health Needs and at the Same Time Get People Thinking


What things in your people’s daily lives (living conditions, ways of doing things, beliefs, etc.) do they feel help them to be healthy?

What do people feel to be their major problems, concerns, and needs—not only those related to health, but in general?


What are different houses made of? Walls? Floors? Are the houses kept clean? Is cooking done on the floor or where? How does smoke get out? On what do people sleep?

Are flies, fleas, bedbugs, rats, or other pests a problem? In what way? What do people do to control them? What else could be done?

Is food protected? How could it be better protected?

What animals (dogs, chickens, pigs, etc.), if any, are allowed in the house? What problems do they cause?

What are the common diseases of animals? How do they affect people’s health? What is being done about these diseases?

Where do families get their water? Is it safe to drink? What precautions are taken?

How many families have latrines? How many use them properly? Is the village clean? Where do people put garbage? Why?


How many people live in the community? How many are under 15 years old?

How many can read and write? What good is schooling? Does it teach children what they need to know? How else do children learn?

How many babies were born this year? How many people died? Of what? At what ages? Could their deaths have been prevented? How?

Is the population (number of people) getting larger or smaller? Does this cause any problems?

How often were different persons sick in the past year? How many days was each sick? What sickness or injuries did each have? Why?

How many people have chronic (long-term) illnesses? What are they?
How many children do most parents have? How many children died? Of what? At what

ages? What were some of the underlying causes?
How many parents are interested in not having any more children or in not having them

so often? For what reasons? (See Family Planning, p. 283.)


How many mothers breast feed their babies? For how long? Are these babies healthier than those who are not breastfed? Why?

What are the main foods people eat? Where do they come from? Do people make good use of all foods available?

How many children are underweight (p. 109) or show signs of poor nutrition? How much do parents and school children know about nutritional needs?

How many people smoke a lot? How many drink alcoholic or soft drinks very often? What effect does this have on their own and their families’ health? (See p. 148 to 150.)


Does the land provide enough food for each family?
How long will it continue to produce enough food if families keep growing?

How is farm land distributed? How many people own their land?
What efforts are being made to help the land produce more?
How are crops and food stored? Is there much damage or loss? Why?


What role do local midwives and healers play in health care?

What traditional ways of healing and medicines are used? Which are of greatest value? Are any harmful or dangerous?

What health services are nearby? How good are they? What do they cost? How much are they used?

How many children have been vaccinated? Against what sicknesses?
What other preventive measures are being taken? What others might be taken? How important are they?


What are the most important things that affect your people’s health and well-being—now and in the future?

How many of their common health problems can people care
for themselves? How much must they rely on outside help and medication?

Are people interested in finding ways of making self-care safer, more effective and more complete? Why? How can they learn more? What stands in the way?

What are the rights of rich people? Of poor people? Of men? Of women?
Of children? How is each of these groups treated? Why? Is this fair? What needs to be changed? By whom? How?

Do people work together to meet common needs? Do they share or help each other when needs are great?

What can be done to make your village a better, healthier place to live? Where might you and your people begin? “

The Millenium Development Goals



This paper is about achieving the final Millennium Development Goal – developing a global partnership for development. The John Hopkins University Bloomberg School Of Health Coursera course is a brilliant course, and is already positioned be a starting point for participants to implement these ideas worldwide. A comment in the Guardian might be an important clue.

“Transition is like a huge open-source research and development project, he says”.[9]

Much of the work has been done, is it now a matter of formalizing the pathways, training and implementing?

Business Plan

I propose the development of a business plan to enable this.   This course would be part of a much larger academic and practical resource base to spread these ideas, help with implementation and related matters so that the vision of Alma Ata becomes reality everywhere.  The aim is that the methods outlined would be core to the professional training of a very wide group of people – to be honest, I am unclear if it is irrelevant to anyone!

I am very aware this is a very very long term project – possibly generational, maybe not if the right things are done at the right times and places.[10]

The people who have already done this course need to be kept in touch and share thinking and solutions.  This might be via a membership organization of some type.

An accessible structured library and resource centre may need developing – it may already exist, and just requires publicizing and curating.

Is there a clear syllabus of best practice, of what to learn when, how and why?  This might include being pro-active, ecological orientation, participation, equality, justice, enabling, clean water, appropriate technology, Blue zones, Rural and urban issues, Hospitals, Institutions, Permaculture, Celebration, Microfinance, Sewage, Water, Chaos, Complexity, Emergence, Ecocities, Solar thermal technology, Lockheed water filtering, Education – a village curriculum,

Audit – social, environmental, financial, power, energy, Systems – knowledge, decision-making, statistics, professionals, Quality, Whole systems, Planning architecture accessible design self build passivhaus

Appendix: The existing picture

The following is informative.


BRAC is a development organisation dedicated to alleviate poverty by empowering the poor, and helping them to bring about positive changes in their lives by creating opportunities for the poor.

Our journey began in 1972 in the newly sovereign Bangladesh, and over the course of our evolution, we have been playing a role of recognising and tackling the many different realities of poverty. We believe that there is no single cause of poverty; hence we attempt tackling poverty on multiple fronts.

Our priorities

Focus on women – BRAC places special emphasis on the social and financial empowerment of women. The vast majority of its microloans go to women, while a gender justice programme addresses discrimination and exploitation.

Grassroots Empowerment – BRAC’s legal rights, community empowerment and advocacy programmes organise the poor at the grassroots level, with ‘barefoot lawyers’ delivering legal services to the doorsteps of the poor.

Health and Education – BRAC provides healthcare and education to millions. Our 97,000 community health workers offer doorstep deliveries of vital medicines and health services to their neighbours. BRAC also runs the world’s largest private, secular education system, with 38,000 schools worldwide.

Empowering farmers – Operating in eight countries, BRAC’s agriculture programmes work with governments to ensure food security by producing, distributing and marketing quality seeds at fair prices, conducting research to develop better varieties, offering credit support to poor farmers and using environmentally sustainable practices.

Inclusive Financial Services – BRAC attempts alleviating poverty by providing CEP and TUP services, disbursing over a billion dollars in microloans annually, augmenting microfinance with additional services like livelihood and financial literacy training. Farmers get access to seasonal loans, high quality seeds and technical assistance. Millions now have the freedom to take control of their lives.

Self-Sustaining Solutions – BRAC’s enterprises and investments generate a financial surplus that is reinvested in various development programmes subjected to poverty alleviation.

Our strengths

Thinking local, acting global – Besides Bangladesh, BRAC spreads antipoverty solutions to 10 other developing countries, which are Uganda, Tanzania, Sierra Leone, South Sudan, Liberia, Haiti, Afghanistan, Pakistan, Sri Lanka and the Philippines.

Unprecedented scale and reach – Today, BRAC reaches an estimated 126 million people with over 100,000 employees worldwide.


What Others Say About BRAC

“BRAC has done what few others have. They have achieved success on a massive scale, bringing life-saving health programmes to millions of the world’s poorest people.” —Bill Gates, co-chair, The Bill and Melinda Gates Foundation

“[Sir Fazle Hasan] Abed’s story proves just how much people with vision and commitment can change the world.” —Bill Clinton,former President of the United States

“BRAC is the most astounding social enterprise in the world.” —Paul Collier, author of The Bottom Billion

“The billion dollars in micro-loans that BRAC extends each year to poor people is just the beginning of the story of this remarkable organisation.” —George Soros, chairman, Open Society Institute

“Through its visionary moves, BRAC has made a huge contribution to social change in Bangladesh and abroad.” —Amartya Sen, Nobel laureate in economics

“By most measures the largest, fastest growing non-governmental organisation in the world – and one of the most businesslike.” —The Economist.

The BRAC Family Today

  1. 97,000 community health promoters providing essential healthcare worldwide, with maternal, neonatal and child health services covering 24.5 million in Bangladesh alone
  2. 1.14 million children currently enrolled in BRAC’s 38,000 primary and pre-primary schools, with 9.51 million graduates and over 260,000 teens from disadvantaged backgrounds get life skills training in BRAC’s youth empowerment clubs
  3. 5.54 million micro-borrowers with a cumulative loan disbursement of USD 9.73 billion
  4. 25 million people have access to clean toilets thanks to BRAC’s sanitation entrepreneurs
  5. Over 600,000 rural poor women being organised through 11,234 Polli Shomaj and 1,217 Union Shomaj; Nearly 4.3 million people reached per year by our 376 popular theatre teams in Bangladesh only
  6. 101,222 human rights and legal education graduates and 19,252 local community leaders’ workshop participants[11]

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