Service accountability and community participation in the context of health sector reforms in Asia: implications for sexual and reproductive health services
Service accountability and community participation in the context of health sector reforms in Asia: implications for sexual and reproductive health services
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DOI：
10.1093/heapol/czh048
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发表时间：
2004-10-01
影响因子：
3.2
通讯作者：
Klugman, B
中科院分区：
文献类型：
--
作者：
Murthy, RK;Klugman, B
本文探讨了社区参与世界银行支持的亚洲卫生部门改革的概念和实践，以及这种参与在多大程度上加强了提供性健康和生殖健康服务方面的问责制。报告认为，亚洲大多数改革中设想的社区参与范围仅限于方案管理和服务提供，而且是在通过非参与性进程确定的优先事项范围内进行的。建立社区保健结构、权力下放和社区筹资是在改革中促进参与和问责制的三项重要战略。关于这些战略影响的证据很少，这表明边缘化群体和基于性权利和生殖权利的群体在参与论坛中的代表性很低，而且保健人员和公众之间的权力等级在这些论坛中发挥作用。社区融资并没有增强服务问责制。由于上述限制，社区参与卫生部门改革很少加强提供全面性健康和生殖健康服务方面的问责制。在这方面，基于权利（包括性权利和生殖权利）的团体和研究人员需要参与卫生部门改革的设计、监测和评价，既要从内部作为参与者，也要从外部作为压力团体。如果要通过参与实现健康和性健康和生殖健康服务问责制，就必须订立参与合同，加强民间社会代表的权力、（妇女、其他边缘化群体和基于权利的组织的）参与配额，并投资于这些利益攸关方在领导能力和性生殖权利及健康方面的能力建设。因此，社区参与和服务问责制要求国家增加而不是减少资源投资。
This paper examines the concept and practice of community participation in World Bank-supported health sector reforms in Asia, and how far such participation has strengthened accountability with regard to provision of sexual and reproductive health (SRH) services. It argues that the envisaged scope of community participation within a majority of reforms in Asia has been limited to programme management and service delivery, and it is occurring within the boundaries of priorities that are defined through non-participatory processes. Setting up of community health structures, decentralization and community financing are three important strategies used for promoting participation and accountability within reforms. The scant evidence on the impact of these strategies suggests that marginalized groups and sexual and reproductive rights based groups are poorly represented in the forums for participation, and that hierarchies of power between and amongst health personnel and the public play out in these forums. Community financing has not lead to enhanced service accountability. As a result of the above limitations, community participation in health sector reforms has rarely strengthened accountability with respect to provision of comprehensive SRH services. In this context, rights (including sexual and reproductive) based groups and researchers need to engage with design, monitoring and evaluation of health sector reforms, both from inside as participants and outside as pressure groups. Participation contracts enhancing powers of civil society representatives, quotas for participation (for women, other marginalized groups and rights-based organizations), and investment in capacity building of these stakeholders on leadership and sexual reproductive rights and health are pre-requisites if participation is to lead to health and SRH service accountability. Community participation and service accountability hence requires more and not less investment of resources by the state.