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院和印度卫生与家庭福利部国家卫生系统资源中心(NHSRC)、印度政府将携手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让当地社区和利益攸关方参与和审议的进程，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已得到广泛认可，然而这种变化的实际路径还没有得到很好的研究，环境在影响这些路径中的作用也仍然没有被很好地了解。本研究旨在通过印度喀拉拉邦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，液化石油气等同于村、区和区各级由地方选举产生的机构，在包括医疗保健在内的社会服务方面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，以明确确定影响的背景和路径。我们的概念模型基于全球证据，表明液化石油气改革对包括政治、公民社会和公共行政在内的多个治理领域产生影响。由此带来的政治问责、社区赋权和卫生系统反应能力的改善可以协同行动，加强公平获得保健的机会。具体目标：1.通过对印度喀拉拉邦Panchayati Raj Institution(PRI)地方治理系统的案例研究，阐明地方参与式治理(LPG)机构影响穷人和弱势群体获得医疗保健的途径。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与系统研究(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)公平获得医疗保健的影响方面的应用本研究将利用社会科学的创新HPSR方法，包括现实主义询问和以行动者为重点的政策执行方法。定性方法，包括在四个区进行的深入访谈和焦点小组，将有助于了解有关政策行为者(代表革命制度委员会、服务用户、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开发的政策研究框架方法进行分析，将预先确定的和新兴的主题结合起来。数据收集策略将随着研究的进展而反复修订，这一方法将是创新HPSR方法的基础。在研究接近尾声时，我们将召开研讨会，分享初步研究结果，并制定一项更大的建议。这项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获得服务方面的作用。这项研究源于印度政策制定者表达的需求，即更深入地了解如何支持液化石油气的健康，并将满足这一需求。NHSRC在这项研究中的不可或缺的作用将促进政策对研究结果的理解。这些发现将支持问责和公民更多地参与影响他们的决策-最终使处于边缘地位的人在LMIC环境中更多地获得医疗保健。这项研究还将有助于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.