Abstract

Despite increasing calls to integrate and prioritise sexual and reproductive health (SRH) services in universal health coverage (UHC) processes, several SRH services have remained a low priority in countries’ UHC plans. This study aims to understand the priority-setting process of SRH interventions in the context of UHC, drawing on the Malaysian experience. A realist evaluation framework was adopted to examine the priority-setting process for three SRH tracer interventions: pregnancy, safe delivery and post-natal care; gender-based violence (GBV) services; and abortion-related services. The study used a qualitative multi-method design, including a literature and document review, and 20 in-depth key informant interviews, to explore the context–mechanism–outcome configurations that influenced and explained the priority-setting process. Four key advocacy strategies were identified for the effective prioritisation of SRH services, namely: (1) generating public demand and social support, (2) linking SRH issues with public agendas or international commitments, (3) engaging champions that are internal and external to the public health sector, and (4) reframing SRH issues as public health issues. While these strategies successfully triggered mechanisms, such as mutual understanding and increased buy-in of policymakers to prioritise SRH services, the level and extent of prioritisation was affected by both inner and outer contextual factors, in particular the socio-cultural and political context. Priority-setting is a political decision-making process that reflects societal values and norms. Efforts to integrate SRH services in UHC processes need both to make technical arguments and to find strategies to overcome barriers related to societal values (including certain socio-cultural and religious norms). This is particularly important for sensitive SRH services, like GBV and safe abortion, and for certain populations.

摘要

尽管越来越多的人呼吁将性与生殖健康 (SRH) 服务纳入全民健康覆盖 (UHC) 进程并对其进行优先排序，但一些 SRH 服务在各国的 UHC 计划中仍然处于低优先级。本研究旨在借鉴马来西亚的经验，了解 UHC 背景下 SRH 干预措施的优先级设定过程。采用了一个现实的评估框架来检查三个 SRH 示踪干预措施的优先级设定过程：怀孕、安全分娩和产后护理；性别暴力（GBV）服务；和堕胎相关服务。该研究使用了定性的多方法设计，包括文献和文件审查以及 20 次深入的关键知情人访谈，以探索影响和解释优先级设定过程的背景-机制-结果配置。为有效地确定 SRH 服务的优先次序，确定了四个关键的倡导策略，即：(1) 产生公众需求和社会支持，(2) 将 SRH 问题与公共议程或国际承诺联系起来，(3) 使内部和外部的拥护者参与进来公共卫生部门，以及 (4) 将 SRH 问题重新定义为公共卫生问题。虽然这些策略成功地触发了机制，例如政策制定者对 SRH 服务的优先排序的相互理解和更多认同，但优先级的水平和程度受到内部和外部背景因素的影响，特别是社会文化和政治背景。优先级设定是反映社会价值观和规范的政治决策过程。将 SRH 服务整合到 UHC 过程中的努力既需要进行技术论证，也需要找到克服与社会价值观（包括某些社会文化和宗教规范）相关的障碍的策略。这对于敏感的 SRH 服务（例如 GBV 和安全堕胎）以及某些人群尤其重要。