How do local participatory governance reforms influence equitable access to health services? The role of Panchayati Raj Institutions in Kerala, India

印度公共卫生基金会、伦敦卫生与热带医学学院以及印度政府卫生与家庭福利部的国家卫生系统资源中心（NHSRC）将共同探讨地方参与式治理（LPG）改革如何影响公平获得卫生服务。社会部门（如卫生或教育）的液化石油气需要通过涉及地方社区和利益攸关方的参与性和审议进程，对服务进行分散规划和监督。液化石油气对健康获取的有益影响已得到广泛承认，但这种变化的实际途径尚未得到充分研究，环境在影响这些途径中的作用也知之甚少。本研究旨在利用印度喀拉拉邦Panchayati Raj Institution （PRI）改革的案例研究来解决这些知识上的差距。在印度，液化石油气是PRIs的同义词，PRIs是在村、街道和区级运营的地方选举机构，拥有包括医疗保健在内的社会服务的财政和行政权力。喀拉拉邦是广泛实施PRI改革的一个例子，因此为明确确定影响的背景和途径提供了最佳实践方案。我们的概念模型基于全球证据，这些证据表明，液化石油气改革对多个治理领域产生了影响，包括政治、公民社会和公共行政。由此产生的政治问责制、社区赋权和卫生系统反应能力方面的改善可以协同作用，促进公平获得卫生保健。这些广泛假定的影响途径为更详细的实证研究提供了一个基本框架。具体目标:1。通过对印度喀拉拉邦Panchayati Raj Institution （PRI）地方治理体系的案例研究，阐明地方参与式治理机构（LPG）影响穷人和弱势群体获得医疗保健的途径2。了解喀拉拉邦在卫生保健领域实施液化石油气改革的政策背景3。探索和加强创新卫生政策和系统研究（HPSR）方法在探索液化石油气及其对不同低收入和中等收入国家（LMIC）环境中公平获得医疗保健的影响方面的应用。该研究将采用创新的HPSR方法，利用社会科学，包括现实主义调查和以行为者为中心的政策实施方法。定性方法，包括在四个地区进行的深入访谈和焦点小组，将有助于获取相关政策行为者（代表PRI委员会、服务使用者、民间社会和卫生系统）的生活经验。数据将使用英国国家社会研究中心（UK National Centre for Social research）开发的政策研究“框架”方法进行分析，结合预先确定的和新出现的主题。随着研究的进展，数据收集策略将被反复修订，这将是HPSR方法创新的基础。在研究即将结束时，我们将召开一次研讨会，分享初步发现并制定更大的建议。更大的提案将审查液化石油气机制在促进印度几个邦和撒哈拉以南非洲国家获得更多服务方面的作用。这项研究源于印度决策者表达的需求，即更深入地了解如何支持液化石油气促进健康，并将满足这一需求。NHSRC在研究中的整体作用将促进政策采纳研究结果。研究结果将支持问责制，支持公民更多地参与影响他们的决策，并最终使中低收入国家的边缘化人群更容易获得医疗保健。该研究还将有助于HPSR领域的概念创新和方法，并有助于加强英国和印度的研究合作。

The Public Health Foundation of India, the London School of Hygiene & Tropical Medicine and the National Health Systems Resource Centre (NHSRC) of the Ministry of Health & Family Welfare, Government of India will come together to explore how local participatory governance (LPG) reforms influence equitable access to health services. LPG of social sectors (such as health or education) entails decentralised planning and oversight of services, undertaken through participatory and deliberative processes involving local communities and stakeholders. The salutary impact of LPG on health access is widely acknowledged, however the actual pathways of such change are not well researched, and the role of context in influencing these pathways also remains poorly understood.This research aims to address these gaps in the knowledge, using the case study of Panchayati Raj Institution (PRI) reforms in Kerala state, India. In India, LPG is synonymous with PRIs - locally elected bodies operating at village, sub-district and district levels with financial and administrative powers over social services including health care. Kerala is an example of extensively implemented PRI reform, and hence offers a best-practices scenario for clear identification of contexts and pathways of influence.Our conceptual model is informed by global evidence suggesting that LPG reforms have influences on multiple governance arenas, including politics, civil society and public administration. Resultant improvements in political accountability, community empowerment and health system responsiveness can act synergistically to enhance equitable access to health care. These broad putative pathways of influence provide a basic framework for more detailed empirical investigation.Specific objectives:1. Explicate the pathways through which institutions of local participatory governance (LPG) influence access to health care for the poor and vulnerable, through a case study of the Panchayati Raj Institution (PRI) local governance system in Kerala state, India2. Understand the policy context of implementation of Kerala's PRI reforms for LPG in health care3. Explore and strengthen the application of innovative Health Policy & Systems Research (HPSR) approaches in exploring LPG and its influence on equitable access to health care across different low & middle-income country (LMIC) settingsThe study will engage innovative HPSR approaches drawing on the social sciences, including realist enquiry and actor-focused approaches to policy implementation. Qualitative methodology, including in-depth interviews and focus groups conducted in four districts, will help access the lived experiences of involved policy actors (representing PRI committees, service users, civil society and health systems). Data will be analyzed using the "framework" approach for policy research developed by the UK National Centre for Social Research, combining pre-determined and emerging themes.Data collection strategies will be revised iteratively as the study progresses, an approach that will be fundamental to innovating with HPSR methods. Towards the end of the study, we will convene a workshop to share preliminary findings and develop a larger proposal. The larger proposal will examine the role of LPG mechanisms in facilitating greater access to services in several Indian states and countries in sub-Saharan Africa.The study emerges from needs expressed by policymakers in India, for deeper understanding of how to support LPG for health, and will fulfill that need. The integral role of NHSRC in the study will facilitate policy uptake of findings. The findings will support accountability and greater citizen participation in decisions that affect them - and ultimately greater access to healthcare for marginalized people, across LMIC settings. The study will also contribute to conceptual innovation and methods in the field of HPSR, and help strengthen UK-India research collaborations.