The Accountability Politics of Reducing Health Inequities: Learning from Brazil and Mozambique.

健康不平等--即由社会、经济或政治因素造成的健康不平等，不公平地使穷人和被边缘化的人处于不利地位--正使数百万人陷入贫困。除非这些问题得到解决，否则将全民医疗覆盖作为2015年后可持续发展目标中设想的更公平世界的一部分的承诺的努力可能会导致更多的浪费和不公平，因为新的医疗服务和资源将无法到达最需要它们的人手中。例如，在莫桑比克，尽管该国整体健康指标有所改善，但表现最好的地区和表现最差的地区之间的婴儿死亡率差距在1997至2008年间实际上有所增加。然而，尽管许多低收入和中等收入国家未能将经济增长转化为为最贫穷者提供更好的医疗服务，但一些国家--包括巴西--已经采取了坚定和有效的行动。将巴西这样的强国与莫桑比克这样表现相对较弱的国家区分开来的一个关键因素是问责政治：正式和非正式的监督和控制关系，确保卫生系统管理人员和服务提供者为最贫穷的人提供服务，而不是将他们排除在外。自20世纪90年代中期以来，巴西改变了卫生政策，试图确保最贫穷的人和地方都得到基本服务。这一转变是由许多因素推动的：呼吁享有健康权的强大社会运动；政治竞争，因为政客们意识到改善穷人的医疗保健为他们赢得了选票；改变了医疗服务合同的改革，改变了地方政府和其他提供者确保服务惠及穷人的激励措施；以及大众参与，确保公民在制定健康优先事项和公民监督服务的决策中拥有发言权。然而，这些因素并不适用于所有公民群体，有些人--特别是该国的土著人民--在改善健康结果方面继续落后于整体人口。该项目旨在解决ESRC-DFID呼吁的结构不平等这一关键的交叉问题，及其核心研究问题“哪些政治和体制条件与有效的减贫和发展有关，国内外行为者可以做些什么来促进这些条件？”，方法是比较巴西和莫桑比克以及两国不同地区问责制政治的层面。随着莫桑比克和巴西寻求实施类似的政策以改善服务的提供，研究小组将在每个国家考察一个政治竞争激烈、经济不平等程度很高的城市地区和一个人口作为一个整体在政治上被边缘化和服务不足的农村地区，考察管理者、提供者和公民之间权力关系的变化以及卫生系统绩效的变化，以便更好地了解在不同情况下如何为不同的贫困和边缘化群体服务。作为两个经济、政治和政策联系日益密切的葡语国家，巴西和莫桑比克也处于有利地位，可以从巴西寻求通过其南南合作方案促进的那种经验交流和相互学习中受益。该项目将通过与巴西和莫桑比克的组织密切合作来支持这一相互学习进程，这些组织通过使用社区记分卡和加强卫生监督委员会来努力促进社会问责，并将这些努力与南部非洲及其他地区更广泛的参与和卫生公平工作网络联系起来。

Health inequities - that is, inequalities in health which result from social, economic or political factors and unfairly disadvantage the poor and marginalised - are trapping millions of people in poverty. Unless they are tackled, the effort to fulfill the promise of universal health coverage as part of the fairer world envisaged in the post-2015 Sustainable Development Goals may lead to more waste and unfairness, because new health services and resources will fail to reach the people who need them most. In Mozambique, for example, the gap in infant mortality between the best-performing and worst-performing areas actually increased between 1997 and 2008, despite improvements in health indicators for the country as a whole. However, while many low- and middle-income countries are failing to translate economic growth into better health services for the poorest, some - including Brazil - stand out as having taken determined and effective action. One key factor that differentiates a strong performer like Brazil from a relatively weak performer like Mozambique is accountability politics: the formal and informal relationships of oversight and control that ensure that health system managers and service providers deliver for the poorest rather than excluding them. Since the mid-1990s, Brazil has transformed health policy to try to ensure that the poorest people and places are covered by basic services. This shift was driven by many factors: by a strong social movement calling for the right to health; by political competition as politicians realised that improving health care for the poor won them votes; by changes to health service contracting that changed the incentives for local governments and other providers to ensure that services reached the poor; and by mass participation that ensured citizen voice in decisions on health priority-setting and citizen oversight of services. However, these factors did not work equally well for all groups of citizens, and some - notably the country's indigenous peoples - continue to lag behind the population as a whole in terms of improved health outcomes.This project is designed to address the ESRC-DFID call's key cross-cutting issue of structural inequalities, and its core research question "what political and institutional conditions are associated with effective poverty reduction and development, and what can domestic and external actors do to promote these conditions?", by comparing the dimensions of accountability politics across Brazil and Mozambique and between different areas within each country. As Mozambique and Brazil seek to implement similar policies to improve service delivery, in each country the research team will examine one urban location with competitive politics and a high level of economic inequality and one rural location where the population as a whole has been politically marginalised and under-provided with services, looking at changes in power relationships among managers, providers and citizens and at changes in health system performance, in order to arrive at a better understanding of what works for different poor and marginalised groups in different contexts.As two Portuguese-speaking countries that have increasingly close economic, political and policy links, Brazil and Mozambique are also well-placed to benefit from exchanges of experience and mutual learning of the kind that Brazil is seeking to promote through its South-South Cooperation programmes. The project will support this mutual learning process by working closely with Brazilian and Mozambican organisations that are engaged in efforts to promote social accountability through the use of community scorecards and through strengthening health oversight committees, and link these efforts with wider networks working on participation and health equity across Southern Africa and beyond.