Murthy Ranjani K, Klugman Barbara
Health Policy Plan. 2004 Oct;19 Suppl 1:i78-i86. doi: 10.1093/heapol/czh048.
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.
本文探讨了亚洲地区社区参与世界银行支持的卫生部门改革的概念与实践，以及这种参与在加强性与生殖健康（SRH）服务提供方面的问责制上取得了多大进展。文章认为，在亚洲大多数改革中，所设想的社区参与范围仅限于项目管理和服务提供，并且是在通过非参与性过程确定的优先事项范围内进行的。建立社区卫生结构、权力下放和社区融资是改革中用于促进参与和问责制的三项重要策略。关于这些策略影响的证据稀少，这表明边缘化群体以及基于性与生殖权利的群体在参与论坛中的代表性不足，而且卫生人员与公众之间的权力等级在这些论坛中有所体现。社区融资并未带来更强的服务问责制。由于上述限制，社区参与卫生部门改革很少能加强在提供全面性与生殖健康服务方面的问责制。在此背景下，基于权利（包括性与生殖权利）的群体和研究人员需要参与卫生部门改革的设计、监测和评估，既作为内部参与者，也作为外部压力团体。如果参与要实现卫生及性与生殖健康服务的问责制，那么增强民间社会代表权力的参与合同、参与配额（针对妇女、其他边缘化群体和基于权利的组织）以及对这些利益相关者在领导力以及性与生殖权利和健康方面的能力建设投资是先决条件。因此，社区参与和服务问责制要求国家投入更多而非更少的资源。
