摘要：Public sector health systems that provide services to poor and marginalized populations in developing countries face great challenges. Change associated with health sector reform and structural adjustment often leaves these already-strained institutions with fewer resources and insufficient capacity to relieve health burdens. The Strategic Approach to Strengthening Reproductive Health Policies and Programs is a methodological innovation developed by the World Health Organization and its partners to help countries identify and prioritize their reproductive health service needs, test appropriate interventions, and scale up successful innovations to a subnational or national level. The participatory, interdisciplinary, and country-owned process can set in motion much-needed change. We describe key features of this approach, provide illustrations from country experiences, and use insights from the diffusion of innovation literature to explain the approach’s dissemination and sustainability. THE MILLENNIUM DEVELOPMENT Goals and United Nations conferences of the 1990s set an ambitious global agenda for health and development, including reproductive health. National governments were called upon to increase availability and access to services and education, improve quality of care and gender equity, and respond more effectively and equitably to the persistent problems of obstetric emergencies, unwanted pregnancies and unsafe abortions, childhood deaths, and the HIV/AIDS crisis. These expectations are now being raised at a time when weak public sector health institutions are in a process of transformation. Structural adjustment policies and economic downturns have reduced the resource base available to the public sector; moreover, health sector reform is confronting public health services with uncertainty and ongoing change. 1 – 4 Added to an already weak institutional capacity, these conditions make it difficult for health systems to innovate. Because of this dilemma, it is essential to identify strategies that allow governments to respond to the needs and challenges of their constituents. The Strategic Approach to Strengthening Reproductive Health Policies and Programs, or simply the Strategic Approach, is a method for building such capacity. It enables countries to identify and prioritize service needs, test appropriate interventions, and then scale up successful innovations to a subnational or national level. Innovation here is defined as “an idea, practice, or object that is perceived as new by an individual or other unit of adoption.” 5 (p11) As Rogers noted, 5 it matters little whether the practice is new or whether it is only perceived to be new—if it is perceived to be new, it is considered to be an innovation. The Strategic Approach assists governments with innovating and is itself an innovation because it differs from other approaches. It is not a panacea or a magic bullet but an incremental, interdisciplinary, and country-owned process that can set in motion much-needed change. The Strategic Approach was originally developed by the World Health Organization (WHO) and its partners to reorient the introduction of contraceptive methods from a technology-driven approach to one that is focused on quality of care and people’s needs and rights. 6 – 9 As countries began to apply the Strategic Approach during the 1990s, it was met with considerable enthusiasm. More and more governments requested assistance with applying the methodology. The Strategic Approach has now been implemented in 25 countries and has been adapted to be applicable for a range of reproductive health concerns (Table 1 ▶ ). Seven countries have conducted its first stage—the strategic assessment of needs—2 or more times to address different reproductive health concerns or programming challenges. Although the Strategic Approach to date has been applied only to reproductive health, it is applicable to other areas of public health. TABLE 1— Countries Implementing the Strategic Approach, Year Initiated, Type of Reproductive Health Focus, and Stage Initiated or Completed Focus Strategic Assessment of Needs, Year Service Delivery Research Scale Up of Successful Innovations Contraceptive introduction and quality of care for family planning Brazil, 1993 X X Vietnam, 1994 X X South Africa, 1994 X X Zambia, 1995 X X Myanmar, 1996 X X Chile, 1996 X X Chongqing, China, 2000 Oman, 2004 X X Maternal mortality and family planning Bolivia, 1994 Dominican Republic, 2001 Guatemala, 2001 X X Nepal, 2003-2004 Paraguay, 2004 X X Adolescent health Kyrgyzstan, 1999 Prevention of unsafe abortions Viet Nam, 1997 X X Romania, 2001 X Mongolia, 2003 Ghana, 2005 Moldova, 2005 X X Reproductive tract infections Latvia, 2000 X Ghana, 2001 X Brazil, 2002 X X China, 2002 X X Kosovo, 2004 X HIV/AIDS Brazil, 2001 X Cervical cancer Bolivia, 2002 Uttar Pradesh, India, 2004 X Reproductive health Burkina Faso, 1996 Ethiopia, 1997 X X Myanmar, 1998 X X Lao PDR, 1999 X Yunnan, China, 2002 Rajasthan, India, 2004 X Open in a separate window
