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、伦敦卫生和热带医学院以及印度政府卫生和家庭福利部国家卫生系统资源中心将共同探讨地方参与性治理改革如何影响公平获得卫生服务。社会部门（如卫生或教育）的公共部门会计准则要求通过地方社区和利益攸关方的参与和审议进程，对服务进行分散的规划和监督。液化石油气对健康获取的有益影响是公认的，但这种变化的实际途径没有得到很好的研究，并在影响这些途径的背景下的作用也仍然知之甚少。本研究旨在解决这些知识的差距，使用的案例研究的Panchayati拉吉机构（PRI）的改革在喀拉拉邦，印度。在印度，LPG是PRI的同义词-地方选举产生的机构，在村、分区和地区一级运作，对包括保健在内的社会服务拥有财政和行政权力。喀拉拉邦是广泛实施的PRI改革的一个例子，因此提供了一个最佳实践方案，明确识别的背景和路径的影响力。我们的概念模型是由全球证据表明，液化石油气改革对多个治理领域，包括政治，民间社会和公共行政的影响。由此产生的政治问责制、社区赋权和卫生系统反应能力的改善可以协同作用，促进公平获得卫生保健。这些广泛的影响路径为更详细的实证研究提供了一个基本框架。通过对印度喀拉拉邦Panchayati Raj机构（PRI）地方治理系统的案例研究，阐明地方参与性治理机构（LPG）影响穷人和弱势群体获得医疗保健的途径。了解喀拉拉邦的公共关系改革的政策范围内实施液化石油气在医疗保健3。探索和加强创新的卫生政策和系统研究（HPSR）方法的应用，探索LPG及其对不同低收入和中等收入国家（LMIC）环境公平获得医疗保健的影响这项研究将采用创新的HPSR方法，借鉴社会科学，包括现实主义调查和以行动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，将有助于获得有关政策行为者（代表刑法改革委员会、服务用户、民间社会和卫生系统）的实际经验。数据分析将使用英国国家社会研究中心开发的政策研究“框架”方法，结合预先确定的和新出现的主题。随着研究的进展，数据收集策略将反复修订，这种方法对于HPSR方法的创新至关重要。在研究接近尾声时，我们将召开一个研讨会，分享初步研究结果，并制定一个更大的建议。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更多地获得服务方面的作用。该研究源于印度决策者表达的需求，以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有助于政策对研究结果的理解。调查结果将支持问责制和更大的公民参与影响他们的决策-并最终为边缘化人群提供更多的医疗保健服务。该研究还将有助于HPSR领域的概念创新和方法，并有助于加强英国与印度的研究合作。

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.