Maupin Jonathan Nathaniel
Vanderbilt University, Anthropology, Vanderbilt Place, Nashville, TN 37235-7703, USA.
Soc Sci Med. 2009 Apr;68(8):1456-63. doi: 10.1016/j.socscimed.2009.01.045. Epub 2009 Feb 25.
Governmental-contracting of non-governmental organizations (NGOs) is a central strategy of neoliberal health reforms in Central America. More than improving the equity, efficiency, and quality of health services, contracting presents a potential mechanism to redefine antagonistic relationships between the state and civil society, particularly in countries ravaged by political violence. In this paper I examine the process of heath reform in Guatemala through the implementation of the Sistema Integral de Atención en Salud (SIAS) in the municipality of San Martín Jilotepeque. Mandated in the 1996 Peace Accords, SIAS potentially facilitates decentralization and civil participation through governmental-contracting of NGOs to provide health services to underserved populations. Drawing on ethnographic interviews with NGO representatives, Ministry of Health (MOH) workers, and community health workers and midwives, I examine the contracting process and then address issues of equity, efficiency, and quality of services, as well as the process of decentralization. I argue that contracted NGOs are largely restricted to serve as administrators, removed from the delivery of services, and are heavily dependent upon the traditional MOH structure, which limits the ability of SIAS to improve health services or foster the processes of decentralization and democratization.
政府与非政府组织（NGO）签约是中美洲新自由主义卫生改革的核心策略。签约不仅旨在提高卫生服务的公平性、效率和质量，还提供了一种重新定义国家与公民社会之间对立关系的潜在机制，尤其是在遭受政治暴力蹂躏的国家。在本文中，我通过在圣马丁吉洛特佩克市实施综合卫生服务系统（SIAS）来考察危地马拉的卫生改革进程。SIAS在1996年《和平协定》中有规定，它有可能通过政府与非政府组织签约，为服务不足的人群提供卫生服务，从而促进权力下放和公民参与。通过对非政府组织代表、卫生部工作人员、社区卫生工作者和助产士进行人种志访谈，我考察了签约过程，然后探讨了服务的公平性、效率和质量问题，以及权力下放过程。我认为，签约的非政府组织在很大程度上仅限于充当管理者，远离服务提供，并且严重依赖传统的卫生部结构，这限制了SIAS改善卫生服务或促进权力下放和民主化进程的能力。
