中国青少年生殖健康相关政策的过程及实施可行性的案例研究
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摘要
一、研究背景
1994年的国际人口与发展大会开始明确青少年(10-19岁)的性与生殖健康需求不同于成年人,把青少年的生殖健康确定为应当优先关注的领域之一。在国际社会的积极倡导下,各国都通过创造安全和支持性的环境、向青少年/未婚青年提供信息生殖健康信息和服务、培养个人技能和鼓励青年(15-24岁)参与决策等干预措施来促进青少年的生殖健康。
公共政策即“社会公共权威在特定的情境中,为达到一定目标而制定的行动方案或行动准则”,卫生政策也属于公共政策。国家的政策法规对促进青少年生殖健康有着深刻的影响和导向作用,中国迄今尚未出台青少年生殖健康的专项政策,更缺乏对政策制定和实施的相关研究。
我国政府在联合国人口基金的资助下,自1998年开始在第4周期(1998-2002)的生殖健康/计划生育国际合作项目中开辟了青少年生殖健康项目,并逐渐扩大试点范围到第5周期(2003-2005)和第6周期(2006-2010)。由于缺乏全国性的专项政策,我们选择了覆盖全国30个省市的第6周期生殖健康/计划生育项目中的青少年生殖健康项目方案作为相关政策的研究案例。研究在特定的政策背景下有哪些参与者与政策过程发生互动,他们的参与程度如何?在政策的制定过程中是否考虑了实施过程中人力资源、卫生系统和卫生服务提供的关键因素?政策制定是否利用证据使决策更高质量、更科学性?是否有公民社会组织参与使决策更加民主化?政策中的内容之一--青少年/青年友好服务的全面实施选择现有的妇幼保健机构是否可行?本研究致力于填补这些空白,为今后我国出台青少年生殖健康专项政策提供偱证的政策建议,提高我国青少年/未婚青年的生殖健康水平。
二、研究目的
对中国青少年生殖健康相关政策的制定和实施过程进行分析,探讨政策过程中的决定因素,并研究此相关政策在我国现有的妇幼保健机构全面实施的可行性,为今后我国出台青少年生殖健康的专项政策提供循证的决策依据和政策建议。
三、研究内容与研究方法
1.中国青少年生殖健康相关政策过程的案例研究：采用非随机目的抽样的方法在国家和项目县层面选择包括政府官员、公民社会组织、决策者、卫生管理者、国际发展伙伴、学者共15人进行关键知情人半结构式深入访谈直至信息饱和,结合使用文献分析法,建立中国青少年生殖健康相关政策过程研究理论框架模型,从政策背景、政策过程、政策内容和政策参与者等影响政策的主要方面对第6周期青少年生殖健康项目方案的制定和实施过程进行分析,重点关注卫生系统、人力资源、卫生服务提供、公民社会组织和循证决策等关键因素对政策过程的作用及影响。
2.卫生系统实施青少年/青年友好服务可行性的案例研究：CP6青少年生殖健康项目的内容之一--“青少年/青年友好服务”的实施选择了项目县的妇幼保健机构,但前一部分的案例研究仅仅反应了在一个项目县的试点研究情况,为了了解全面实施的可行性,本部分兼顾分层、区域差异还有调查的可行性采用目的抽样的方法,对我国全部55家三级妇幼保健机构和50%二级妇幼保健机构(225家),利用卫生政策实施的资源投入模型从财政资源、硬件条件、物资与健康教育材料、人力资源、信息管理系统、相关制度与政策支持以及青年参与7个方面评价了我国妇幼保健机构全面实施青少年/青年友好服务的可行性。
3.中国青少年生殖健康政策体系的问题和发展趋势分析：采用社会学的内容分析法,回顾自新中国成立后颁布的所有青少年生殖健康相关政策,主要从青少年性与生殖健康权力、性与生殖健康教育、性与生殖健康服务和未婚青年流动人口政策四个维度定量与定性相结合、并结合国家层面决策者的个人深入访谈分析现有政策体系存在的问题和发展趋势。
4.未来制定中国青少年生殖健康政策的建议：综合本研究的主要发现,提出未来出台青少年生殖健康专项政策的循证政策建议。
四、主要研究结果
(一)中国青少年生殖健康相关政策过程的案例研究
1.国际宏观环境对青少年生殖健康问题的重视,中国政府对国际社会的政治承诺和工作重点的转变,国际合作项目为开展青少年生殖健康项目提供了技术可行性,再加之我国国内青少年/未婚青年生殖健康问题的凸显,以及公民社会组织在青少年生殖健康教育和服务方面的积极探索积累了有益的经验,这些都推动了青少年生殖健康项目被列入政策议程。
2.CP6青少年生殖健康项目由UNFPA发起,国家层面的政策制定过程除了有政府机构如商务部、卫生部和国家人口计生委的参与,也包括了国内的公民社会组织如专家组、中国计划生育协会和中国青年网络。项目县层面的政策实施由当地项目领导小组负责,计生、卫生、教育部门和青年代表各承担了不同的职责。国家协调委员会和项目县领导小组的成立在政策实施过程中发挥了积极的协调作用,保证了多部门的协作配合,为项止的顺利实施提供了可行性。
3.在政策过程中,通过前期经验总结、领导与协调机制、过程监督和评估机制统筹考虑了人力资源、服务提供、卫生系统和公民社会组织的参与4个关键因素,为CP6青少年生殖健康项目的顺利实施增加了可行性。同时政策过程科学地参考了对以往项目的评估结果和重大国际事件等证据,因而项目完全符合国际倡导的青少年生殖健康项目框架,并发扬前期工作的优势,改进不足。在项目方案的执行过程中遇到了种种阻力如教育部门的有效参与不足、项目资金的划分不清和投入不足、以及人力资源缺乏和执行体系不完善等问题都影响了执行的效果,制约了政策目标的实现。
(二)卫生系统实施青少年/青年友好服务可行性的案例研究
1.CP6青少年生殖健康项目政策内容之一是在卫生系统的妇幼保健机构向青少年/未婚青年提供生殖健康友好服务。现有妇幼保健机构中向青少年/未婚青年提供服务的部门主要是青春期门诊。按照卫生部1995年《妇幼保健机构评审标准》的要求--三级和二级妇幼保健机构都要在其二级专业分科中设置“青春期保健”门诊,对一级妇幼保健机构未做要求。但目前三级妇幼保健机构开展青春期临床保健门诊比例仅40.0%,二级机构的比例更低为11.1%；不同区域妇幼保健机构中开展青春期临床和保健门诊的情况也不同,以华中和华北最高超过25%,华东、华南和西南接近20%,东北和西北地区最低分别为12.2%和3.6%。三级和二级妇幼保健机构绝大多数都位于城市,现有青春期门诊的设置格局根本无法满足青少年/未婚青年日益增长的生殖健康需求。
2.中国为青少年/未婚青年提供性与生殖健康服务现还处在起步阶段,在妇幼保建机构的各项工作中尚未受到必要的重视和支持。青春期门诊都无独立的科室建制,而是作为二级专业归属于其他临床或保健科室。无论是三级机构还是二级机构,大多数存在一些共性问题：例如服务人员仍然沿用过去单一的成人服务模式；服务时间不适合青少年就诊；对外宣传青春期保健及其门诊的力度不够,被动地等患者上门；男性青少年明显地被排除在服务之外；环境布置对青少年缺乏吸引力；不能有效地保护隐私；免费避孕措施配备不足,健康教育材料青少年取用不方便；缺乏青年参与；缺乏规范的技术常规；服务费用青少年的经济能力无法承受；服务提供者的理念和技能有待提高等等,目前大多尚不具备青少年/青年友好服务实施的可行性。
3.经多因素分析调整了可能的影响因素后,环境布置对青少年友好、多种信息宣传方式、面向青少年的多种服务模式以及青年参与青春期门诊的设计和运营是青春期门诊总评价得分的有利因素。参与青少年生殖健康项目的实施有少量门诊运营经费的支持并不足以提高友好服务实施的可行性。也在更大规模的研究基础上进一步验证了第二章政策过程的研究结果：虽然国际合作项目的实践经验提供了技术的可行性,但项目实施过程中缺乏有效的激励机制,导致友好服务的开展不利。因此青少年/青年友好服务实施的可持续性发展必须依赖完善的政策保障与财政支持。
(三)中国青少年生殖健康政策体系的问题和发展趋势分析
1.青少年是中华人民共和国公民,享有法律赋予公民的权利,虽然现有的政策法规都包含了青少年健康和发展权益的内容,但国家层而迄今仍没有关于青少年的性与生殖健康权利的专项立法。保障权利,法律先行。青少年的性与生殖健康权利只有以法律的形式所确认,才有可能使之得到保障,也才能推动青少年生殖健康专项政策的产生,进而促使问题通过公共政策的途径得到有效解决。
2.我国政府在性教育法律体系的建设上已经取得了比较显著的进展,但性教育在政策之间定义的不一致,政策的可操作性不强,缺乏系统的教学体系建设,教师缺乏、其知识与能力有待提高以及缺乏面向校外青少年/未婚青年的性教育政策和实施体系,这些都制约了性教育政策的实施效果。滞后于时代发展的性教育政策有待于进一步完善。
3.向育龄群众提供生殖健康/计划生育服务是我国的基本国策,但在实际执行过程中,青少年/未婚青年一直被排除在外,他们的生殖健康服务需求没有得到足够重视,政府向青少年/未婚青年提供生殖健康服务的计划仍然不明晰。怎样保证他们对生殖保健服务的可及性与可接受性应成为今后政策关注的焦点。
4.未婚青年流动人口作为社会弱势群体,面临着比同龄常住人口更多、更复杂的生殖健康风险。现有的政策法规虽然有加强未婚青年流动人口生殖健康教育和服务的原则性条款,但他们能够享受哪些生殖健康公共服务、具体由什么机构负责、怎样来实施、以及经费由谁来保证都未明确规定。推进流动人口计划生育基本公共服务均等化应该充分考虑怎样保障未婚青年流动人口享受与已婚育龄人群同样的生殖健康权力。
5.青少年生殖健康需要在政策支持、教育和服务等多个维度共同促进,其实施需要建立长效的跨部门的合作机制,打破部门之间协作上的壁垒,才能使促进青少年/生殖健康政策实现积极的效果和可持续效应。
五、政策建议
建议将青少年生殖健康置于国家公共政策议程的优先地位,出台青少年生殖健康专项政策,并将重点放在政策过程的关键因素、考虑政策实施的可行性以及改进目前政策体系存在的问题等方面：
1.加强高层倡导,推动青少年生殖健康纳入政策议程,确保其在政策内容里得到有效落实。
2.高度重视青少年／未婚青年的性与生殖健康权利,在政策法规中明确他们的性与生殖健康权利,并构建保障权利实现的实施体系,确保他们获得适宜和可接受的信息、教育和服务。
3.进一步完善青少年性教育政策及实施体系,包括：明确性教育的策略和目标,并据此制定全国统一的教学大纲和教学内容；完善性教育教学体系建设；加强师资培训；促进校外青少年和流动人口的性教育政策和实施体系的建立；并建立科学、有效的性教育评价制度和体系。
4.制定青少年生殖健康服务的专项政策,包括：把青少年生殖保健作为国家基本公共卫生服务纳入医疗服务体系之中；建立适宜青少年/未婚青年生殖健康需求的卫生服务体系；加强服务提供者的能力建设；加强青少年参与友好服务提供；提高青少年/青年友好服务机构的知名度和影响力；加强信息系统建设；完善和开发青少年生殖保健服务技术规范；发挥公民社会组织的积极作用。
5.关注未婚青年流动人口的性与生殖健康需求,在政府的统一组织领导下,明确各相关部门的管理责任和服务职能,由医疗卫生、计划生育、劳动与社会保障保障以及社会其它各部门联手联动来构建面向未婚青年流动人口完善的教育和服务体系。
6.政府要高度重视,从战略高度和长远角度制定和落实青年参与决策的制度和法律,不断丰富青年的参与方式,扩大青年的参与范围,提高青年的参与水平。
7.加强公民社会组织与政府的良性互动合作关系,政府要赋予公民社会组织更多的职能,引导其从“被动参与”到“主动参与”再到“制度性参与”；对于独立的公民社会组织,政府要加强技术和资金支持,促进他们的发育、成长和成熟。作为公民社会组织本身,应加强组织完善和能力建设,发挥自身优势,主动介入政策过程提出自己的利益诉求和政策主张。
8.国务院妇儿工委应作为牵头部门,发挥其跨部门的强大协调优势,推动和促进各级政府部门、政府部门与公民社会组织之间的协调和互动,共同营造促进青少年生殖健康的良好支持性环境。
I. Background
ICPD identified that adolescent sexual and reproductive health (RH) needs were different from adults, and highlighted the importance and priority of adolescent sexual and RH in1994. With the advocacy by international community, many countries had made their efforts to promote adolescent RH through creating safe and supportive environment, provision of RH information and services, developing personal skills and encouraging youth participation in policy decision.
Public policy is defined as'public authorities develop action plans or rules to reach certain goads under specific circumstances'. Health policy belongs to public policy. National health policy plays key guiding roles and has profound impact in promoting adolescent RH.
Up to now, there hasn't been specific national adolescent RH policy in China, and further lacked of adolescent RH policy development and implementation research. With the support from UNFPA, Chinese government implemented country project4th cycle(1998-2002) RH/family planning program adolescent RH program(called CP4ARH program), and expanded the coverage in5th cycle(2003-2005) and6th cycle (2006-2010). CP6ARH program is chosen as our policy case study. We intend to fill the gaps in terms of how actors interact with policy process under specific policy background and the extent of their participation? Whether the policy development process considers key determinants in policy implementation such as human resource, health system and service delivery? Whether policy development makes use of evidence to make policy decision more scientific? Whether there is civil society participation in policy process to make it more democratic? Whether MCH hospital is appropriate for adolescent friendly service implementation from program piloting to scaling up? Our study will provide evidence-based policy suggestion for future national specific adolescent RH policy development.
Ⅱ. Research goal To analyze the development and implementation process of adolescent RH policy and to explore the determinants of the policy process by a policy case study; to investigate whether the current MCH care facilities are feasible for adolescent friendly service implementation from a larger scope and finally provide evidence-based policy suggestions.
III. Research contents and methodologies
1. Case study of adolescent RH policy process in China:non-random, purposive sampling was used to select15key policy informants including politician, civil society organization(CSO), policy-maker, health manager, researcher and development partner at national and program county level. Semi-structured interview was conducted until information saturation, combined with document analysis method. Policy process research framework was designed to analyze the policy development and implementation from the aspects of policy context, policy content, policy actors and policy process, with the focus on the impacts of key determinants of health system, human resource, service delivery, CSO and evidence-based policy making and their inter-relationship on policy process.
2. The feasibility of adolescent RH service implementation from a larger scope in MCH hospitals:One component of CP6ARH program was adolescent friendly service. It was implemented within current maternal and child health (MCH) facilities. The previous qualitative study only reflected the result of piloting in1program county. In order to investigate the feasibility of policy implementation in a larger scope, non-random, purposive sampling was used to survey55tertiary and225secondary MCH hospitals, taking into account both stratum, region difference and research condition restriction. Health resource input model was used to evaluate the feasibility of implementing adolescent friendly service within current MCH facilities from the perspective of health financing, physical facilities, materials and equipments, human resources, Information system, youth participation, policies and guidelines.
3. Gap and trend analysis of adolescent RH policy system in China:Content analysis was used to review issued policies, laws and regulations related to adolescent RH in China before Dec1st,2011( of Beijing University). In-depth interview was combined to analyze the gap and trend of current policy system in terms of adolescent RH right, sexuality education, sexual and RH services and unmarried young floating population.
4. Policy recommendations:Based on our research results, evidence-based policy recommendation was provided for future specific national adolescent RH policy development.
IV. Main results
1. Global context values adolescent RH problems; political commitment and the change in the Chinese government's FP work emphasis; international sponsored program provides policy solutions; adolescent RH problems are prominent in China; and CSOs accumulate successful experiences in adolescent RH education and services; all these lead to finding a good entry point and the opening of policy windows that put the CP6ARH program onto the policy agenda.
2. CP6adolescent RH program was initiated by UNFPA. In addition to government sections such as the ministry of commerce, the ministry of health, and China population and family planning committee, development at national level also involved expert panel, China family planning association and China youth network. Implementation at county level was responsible by county leadership group. Family planning, health system and education department all bear various responsibilities. National Coordination Committee and county leadership group were set up to ensure smooth implementation and multi-departmental coordination.
3. Human resources, health system, service delivery and CSO are4key determinants existing in the policy process. These factors were considered in an integrated way through reviewing of the CP5ARH program, program leadership and regulation strategy, and M&E strategy. This ensures feasibility of smooth implementation for CP6adolescent RH program. International events and research data/pilot program report were used as evidence in policy process, therefore, the program matched international practices and reinforce the strengths and improve on the weaknesses revealed by previous ARH program. However, barriers in the implementation process had restricted the achievement of policy goals. These obstacles include:the limited participation of the education department, the unclear identification of a program budget (especially for the ARH program), problems regarding human resources, and the implementation system itself.
4. Based on from the ministry of health in1995, it required that tertiary and secondary MCH facilities should set up adolescent health care outpatient clinics. However, current situation is not optimistic. The percentage of establishing adolescent health care outpatient clinic is40.0%and11.1%among tertiary and secondary MCH facilities (P<0.01). The percentage in various regions in China is different (P<0.05). The highest is not more than25%in middle and north China region, then east China; south China and west-south China regions are close to20%; east-north and west-north regions are the lowest, being12.2%and3.6%respectively.
5. Adolescent health care outpatient clinics all belong to women's department, gynecology department, or RH department. No matter tertiary or secondary MCH facilities, they all have some common problems:service providers still use adult health care model; time is not appropriate for clients; poor advocacy and waiting for clients passively; male adolescent are excluded from services; environment is not attractive for adolescent; confidentiality is not properly protected; no enough free contraception; health education materials is not easy to reached; lack of youth participation; lack of clinical guideline; cost of service is not acceptable by adolescent; service providers'attitudes and skills need to be upgraded, etc. Most MCH facilities are not feasible for implementation of adolescent friendly services.
6. Multiple linear regression shows that environment being friendly to adolescent, multiple advocacy strategies, integrated service modes and youth participation in clinic design&service provision are associated with higher average score of a MCH facility. Being involved in CP6adolescent RH program and receiving some fund support for the clinic is not sufficient enough to improve the feasibility of implementing adolescent friendly service. It confirms the result from chapter II:although international ARH program provide technical feasibility, without inspiring mechanism, adolescent friendly service is very difficult to implement. As a result, sustainability of adolescent friendly service must reply on good policy and financial support.
7. Adolescent are citizens of our country. They should possess civic rights authorized by law. Though current policy and regulations contains some contents of adolescent health and development, there hasn't been national adolescent RH rights policy.
8. The Chinese government has made progress in setting up a legal framework for sex education for adolescent. However, problems such as definition of sexuality education being inconsistent between policies; policies being not operational; teachers' knowledge and skill needs to be improved; poor teaching system; and Lack of policies on sex education for young migrants and out-of-school populations all influence the effect of policy implementation. Sexuality education policy has lagged behind society advances, and needs to be improved.
9. Provision of RH/family planning services for people at childbearing age is our basic state policy. However, adolescent/unmarried youth have been excluded from this system. Their RH needs have been largely ignored in the legal framework. A governmental plan in provision of clinical services for adolescent/unmarried youth is still unclear. How to ensure their access to RH/family planning services should be the focus for future policy development.
10. Being as vulnerable population, unmarried floating young people are facing more complicated RH risk compared with city residents. Although current legal framework has some articles in principle to improve RH education and services for them, what public RH services are available for them, who are responsible for implementation, how to implement and financial support are all not clear. Improving family planning basic public service equalization for floating population should ensure that unmarried youth enjoy the same RH rights as married couples.
11. Adolescent RH promotion needs to be worked both from the perspectives of supportive policy environment, education and service. It's implementation requires long term cross-sectoral cooperation. Only the barriers of government departments are broker through, can adolescent reproductive health policy achieve positive result and sustainable effect.
Ⅴ. Policy suggestions
We suggest that adolescent RH should be set up as higher priority within state public policy agenda, and our government should issue specific national adolescent reproductive health policy focusing on following aspects:
1. Advocacy towards policy makers should be improved. Adolescent reproductive health should be put onto the state strategic development agenda to ensure it is embodied in policy content.
2. Adolescent reproductive health rights should be highly emphasized and clearly identified in legal framework. At the same time, implementation system should be designed to ensure their access to appropriate and acceptable RH information, education and services.
3. Sexuality education policy system should be improved in terms of clear identification of its strategy and goal, developing national unified teaching guideline and contents, improving teaching system, strengthening teachers' training, establishing legal framework addressing sex education provision for young migrants and out-of-school youth, and developing&implementing an effective monitoring and evaluation system.
4. Developing specific adolescent reproductive health service policy including involving adolescent reproductive health care into state basic public health services, setting up appropriate reproductive health care system for adolescent/unmarried youth, strengthening service providers'capacity and information system building, encouraging youth participation in service provision, building reputation for health facilities, developing adolescent reproductive health care guideline, and give full scope of CSO's active roles.
5. Unmarried young migrants RH needs should be paid attention to. Government should clearly identify related departments' responsibilities and functions. Department of health care, family planning system, labor and social security and other departments should cooperate to establish better education and service system for them.
6. The government should develop law and regulations to ensure youth participation in policy decision from strategic and long term perspective.
7. Improve virtuous interaction between CSOs and government. Our government should authorize more functions to CSOs and direct them from 'passive participation' to 'active participation', and further'institutional participation'. For those independent CSOs, government should provide financial and technical support. CSOs should enhance organization consummation and capacity building, make full use of their advantages, and actively interact with policy process in order to propose their own interest and policy suggestion.
8. National Working Committee on Children and Women should take the leading role to promote collaboration between government departments, CSOs and government so as to create supportive environment for promoting adolescent RH.
1994年的国际人口与发展大会开始明确青少年(10-19岁)的性与生殖健康需求不同于成年人,把青少年的生殖健康确定为应当优先关注的领域之一。在国际社会的积极倡导下,各国都通过创造安全和支持性的环境、向青少年/未婚青年提供信息生殖健康信息和服务、培养个人技能和鼓励青年(15-24岁)参与决策等干预措施来促进青少年的生殖健康。
公共政策即“社会公共权威在特定的情境中,为达到一定目标而制定的行动方案或行动准则”,卫生政策也属于公共政策。国家的政策法规对促进青少年生殖健康有着深刻的影响和导向作用,中国迄今尚未出台青少年生殖健康的专项政策,更缺乏对政策制定和实施的相关研究。
我国政府在联合国人口基金的资助下,自1998年开始在第4周期(1998-2002)的生殖健康/计划生育国际合作项目中开辟了青少年生殖健康项目,并逐渐扩大试点范围到第5周期(2003-2005)和第6周期(2006-2010)。由于缺乏全国性的专项政策,我们选择了覆盖全国30个省市的第6周期生殖健康/计划生育项目中的青少年生殖健康项目方案作为相关政策的研究案例。研究在特定的政策背景下有哪些参与者与政策过程发生互动,他们的参与程度如何?在政策的制定过程中是否考虑了实施过程中人力资源、卫生系统和卫生服务提供的关键因素?政策制定是否利用证据使决策更高质量、更科学性?是否有公民社会组织参与使决策更加民主化?政策中的内容之一--青少年/青年友好服务的全面实施选择现有的妇幼保健机构是否可行?本研究致力于填补这些空白,为今后我国出台青少年生殖健康专项政策提供偱证的政策建议,提高我国青少年/未婚青年的生殖健康水平。
二、研究目的
对中国青少年生殖健康相关政策的制定和实施过程进行分析,探讨政策过程中的决定因素,并研究此相关政策在我国现有的妇幼保健机构全面实施的可行性,为今后我国出台青少年生殖健康的专项政策提供循证的决策依据和政策建议。
三、研究内容与研究方法
1.中国青少年生殖健康相关政策过程的案例研究：采用非随机目的抽样的方法在国家和项目县层面选择包括政府官员、公民社会组织、决策者、卫生管理者、国际发展伙伴、学者共15人进行关键知情人半结构式深入访谈直至信息饱和,结合使用文献分析法,建立中国青少年生殖健康相关政策过程研究理论框架模型,从政策背景、政策过程、政策内容和政策参与者等影响政策的主要方面对第6周期青少年生殖健康项目方案的制定和实施过程进行分析,重点关注卫生系统、人力资源、卫生服务提供、公民社会组织和循证决策等关键因素对政策过程的作用及影响。
2.卫生系统实施青少年/青年友好服务可行性的案例研究：CP6青少年生殖健康项目的内容之一--“青少年/青年友好服务”的实施选择了项目县的妇幼保健机构,但前一部分的案例研究仅仅反应了在一个项目县的试点研究情况,为了了解全面实施的可行性,本部分兼顾分层、区域差异还有调查的可行性采用目的抽样的方法,对我国全部55家三级妇幼保健机构和50%二级妇幼保健机构(225家),利用卫生政策实施的资源投入模型从财政资源、硬件条件、物资与健康教育材料、人力资源、信息管理系统、相关制度与政策支持以及青年参与7个方面评价了我国妇幼保健机构全面实施青少年/青年友好服务的可行性。
3.中国青少年生殖健康政策体系的问题和发展趋势分析：采用社会学的内容分析法,回顾自新中国成立后颁布的所有青少年生殖健康相关政策,主要从青少年性与生殖健康权力、性与生殖健康教育、性与生殖健康服务和未婚青年流动人口政策四个维度定量与定性相结合、并结合国家层面决策者的个人深入访谈分析现有政策体系存在的问题和发展趋势。
4.未来制定中国青少年生殖健康政策的建议：综合本研究的主要发现,提出未来出台青少年生殖健康专项政策的循证政策建议。
四、主要研究结果
(一)中国青少年生殖健康相关政策过程的案例研究
1.国际宏观环境对青少年生殖健康问题的重视,中国政府对国际社会的政治承诺和工作重点的转变,国际合作项目为开展青少年生殖健康项目提供了技术可行性,再加之我国国内青少年/未婚青年生殖健康问题的凸显,以及公民社会组织在青少年生殖健康教育和服务方面的积极探索积累了有益的经验,这些都推动了青少年生殖健康项目被列入政策议程。
2.CP6青少年生殖健康项目由UNFPA发起,国家层面的政策制定过程除了有政府机构如商务部、卫生部和国家人口计生委的参与,也包括了国内的公民社会组织如专家组、中国计划生育协会和中国青年网络。项目县层面的政策实施由当地项目领导小组负责,计生、卫生、教育部门和青年代表各承担了不同的职责。国家协调委员会和项目县领导小组的成立在政策实施过程中发挥了积极的协调作用,保证了多部门的协作配合,为项止的顺利实施提供了可行性。
3.在政策过程中,通过前期经验总结、领导与协调机制、过程监督和评估机制统筹考虑了人力资源、服务提供、卫生系统和公民社会组织的参与4个关键因素,为CP6青少年生殖健康项目的顺利实施增加了可行性。同时政策过程科学地参考了对以往项目的评估结果和重大国际事件等证据,因而项目完全符合国际倡导的青少年生殖健康项目框架,并发扬前期工作的优势,改进不足。在项目方案的执行过程中遇到了种种阻力如教育部门的有效参与不足、项目资金的划分不清和投入不足、以及人力资源缺乏和执行体系不完善等问题都影响了执行的效果,制约了政策目标的实现。
(二)卫生系统实施青少年/青年友好服务可行性的案例研究
1.CP6青少年生殖健康项目政策内容之一是在卫生系统的妇幼保健机构向青少年/未婚青年提供生殖健康友好服务。现有妇幼保健机构中向青少年/未婚青年提供服务的部门主要是青春期门诊。按照卫生部1995年《妇幼保健机构评审标准》的要求--三级和二级妇幼保健机构都要在其二级专业分科中设置“青春期保健”门诊,对一级妇幼保健机构未做要求。但目前三级妇幼保健机构开展青春期临床保健门诊比例仅40.0%,二级机构的比例更低为11.1%；不同区域妇幼保健机构中开展青春期临床和保健门诊的情况也不同,以华中和华北最高超过25%,华东、华南和西南接近20%,东北和西北地区最低分别为12.2%和3.6%。三级和二级妇幼保健机构绝大多数都位于城市,现有青春期门诊的设置格局根本无法满足青少年/未婚青年日益增长的生殖健康需求。
2.中国为青少年/未婚青年提供性与生殖健康服务现还处在起步阶段,在妇幼保建机构的各项工作中尚未受到必要的重视和支持。青春期门诊都无独立的科室建制,而是作为二级专业归属于其他临床或保健科室。无论是三级机构还是二级机构,大多数存在一些共性问题：例如服务人员仍然沿用过去单一的成人服务模式；服务时间不适合青少年就诊；对外宣传青春期保健及其门诊的力度不够,被动地等患者上门；男性青少年明显地被排除在服务之外；环境布置对青少年缺乏吸引力；不能有效地保护隐私；免费避孕措施配备不足,健康教育材料青少年取用不方便；缺乏青年参与；缺乏规范的技术常规；服务费用青少年的经济能力无法承受；服务提供者的理念和技能有待提高等等,目前大多尚不具备青少年/青年友好服务实施的可行性。
3.经多因素分析调整了可能的影响因素后,环境布置对青少年友好、多种信息宣传方式、面向青少年的多种服务模式以及青年参与青春期门诊的设计和运营是青春期门诊总评价得分的有利因素。参与青少年生殖健康项目的实施有少量门诊运营经费的支持并不足以提高友好服务实施的可行性。也在更大规模的研究基础上进一步验证了第二章政策过程的研究结果：虽然国际合作项目的实践经验提供了技术的可行性,但项目实施过程中缺乏有效的激励机制,导致友好服务的开展不利。因此青少年/青年友好服务实施的可持续性发展必须依赖完善的政策保障与财政支持。
(三)中国青少年生殖健康政策体系的问题和发展趋势分析
1.青少年是中华人民共和国公民,享有法律赋予公民的权利,虽然现有的政策法规都包含了青少年健康和发展权益的内容,但国家层而迄今仍没有关于青少年的性与生殖健康权利的专项立法。保障权利,法律先行。青少年的性与生殖健康权利只有以法律的形式所确认,才有可能使之得到保障,也才能推动青少年生殖健康专项政策的产生,进而促使问题通过公共政策的途径得到有效解决。
2.我国政府在性教育法律体系的建设上已经取得了比较显著的进展,但性教育在政策之间定义的不一致,政策的可操作性不强,缺乏系统的教学体系建设,教师缺乏、其知识与能力有待提高以及缺乏面向校外青少年/未婚青年的性教育政策和实施体系,这些都制约了性教育政策的实施效果。滞后于时代发展的性教育政策有待于进一步完善。
3.向育龄群众提供生殖健康/计划生育服务是我国的基本国策,但在实际执行过程中,青少年/未婚青年一直被排除在外,他们的生殖健康服务需求没有得到足够重视,政府向青少年/未婚青年提供生殖健康服务的计划仍然不明晰。怎样保证他们对生殖保健服务的可及性与可接受性应成为今后政策关注的焦点。
4.未婚青年流动人口作为社会弱势群体,面临着比同龄常住人口更多、更复杂的生殖健康风险。现有的政策法规虽然有加强未婚青年流动人口生殖健康教育和服务的原则性条款,但他们能够享受哪些生殖健康公共服务、具体由什么机构负责、怎样来实施、以及经费由谁来保证都未明确规定。推进流动人口计划生育基本公共服务均等化应该充分考虑怎样保障未婚青年流动人口享受与已婚育龄人群同样的生殖健康权力。
5.青少年生殖健康需要在政策支持、教育和服务等多个维度共同促进,其实施需要建立长效的跨部门的合作机制,打破部门之间协作上的壁垒,才能使促进青少年/生殖健康政策实现积极的效果和可持续效应。
五、政策建议
建议将青少年生殖健康置于国家公共政策议程的优先地位,出台青少年生殖健康专项政策,并将重点放在政策过程的关键因素、考虑政策实施的可行性以及改进目前政策体系存在的问题等方面：
1.加强高层倡导,推动青少年生殖健康纳入政策议程,确保其在政策内容里得到有效落实。
2.高度重视青少年／未婚青年的性与生殖健康权利,在政策法规中明确他们的性与生殖健康权利,并构建保障权利实现的实施体系,确保他们获得适宜和可接受的信息、教育和服务。
3.进一步完善青少年性教育政策及实施体系,包括：明确性教育的策略和目标,并据此制定全国统一的教学大纲和教学内容；完善性教育教学体系建设；加强师资培训；促进校外青少年和流动人口的性教育政策和实施体系的建立；并建立科学、有效的性教育评价制度和体系。
4.制定青少年生殖健康服务的专项政策,包括：把青少年生殖保健作为国家基本公共卫生服务纳入医疗服务体系之中；建立适宜青少年/未婚青年生殖健康需求的卫生服务体系；加强服务提供者的能力建设；加强青少年参与友好服务提供；提高青少年/青年友好服务机构的知名度和影响力；加强信息系统建设；完善和开发青少年生殖保健服务技术规范；发挥公民社会组织的积极作用。
5.关注未婚青年流动人口的性与生殖健康需求,在政府的统一组织领导下,明确各相关部门的管理责任和服务职能,由医疗卫生、计划生育、劳动与社会保障保障以及社会其它各部门联手联动来构建面向未婚青年流动人口完善的教育和服务体系。
6.政府要高度重视,从战略高度和长远角度制定和落实青年参与决策的制度和法律,不断丰富青年的参与方式,扩大青年的参与范围,提高青年的参与水平。
7.加强公民社会组织与政府的良性互动合作关系,政府要赋予公民社会组织更多的职能,引导其从“被动参与”到“主动参与”再到“制度性参与”；对于独立的公民社会组织,政府要加强技术和资金支持,促进他们的发育、成长和成熟。作为公民社会组织本身,应加强组织完善和能力建设,发挥自身优势,主动介入政策过程提出自己的利益诉求和政策主张。
8.国务院妇儿工委应作为牵头部门,发挥其跨部门的强大协调优势,推动和促进各级政府部门、政府部门与公民社会组织之间的协调和互动,共同营造促进青少年生殖健康的良好支持性环境。
I. Background
ICPD identified that adolescent sexual and reproductive health (RH) needs were different from adults, and highlighted the importance and priority of adolescent sexual and RH in1994. With the advocacy by international community, many countries had made their efforts to promote adolescent RH through creating safe and supportive environment, provision of RH information and services, developing personal skills and encouraging youth participation in policy decision.
Public policy is defined as'public authorities develop action plans or rules to reach certain goads under specific circumstances'. Health policy belongs to public policy. National health policy plays key guiding roles and has profound impact in promoting adolescent RH.
Up to now, there hasn't been specific national adolescent RH policy in China, and further lacked of adolescent RH policy development and implementation research. With the support from UNFPA, Chinese government implemented country project4th cycle(1998-2002) RH/family planning program adolescent RH program(called CP4ARH program), and expanded the coverage in5th cycle(2003-2005) and6th cycle (2006-2010). CP6ARH program is chosen as our policy case study. We intend to fill the gaps in terms of how actors interact with policy process under specific policy background and the extent of their participation? Whether the policy development process considers key determinants in policy implementation such as human resource, health system and service delivery? Whether policy development makes use of evidence to make policy decision more scientific? Whether there is civil society participation in policy process to make it more democratic? Whether MCH hospital is appropriate for adolescent friendly service implementation from program piloting to scaling up? Our study will provide evidence-based policy suggestion for future national specific adolescent RH policy development.
Ⅱ. Research goal To analyze the development and implementation process of adolescent RH policy and to explore the determinants of the policy process by a policy case study; to investigate whether the current MCH care facilities are feasible for adolescent friendly service implementation from a larger scope and finally provide evidence-based policy suggestions.
III. Research contents and methodologies
1. Case study of adolescent RH policy process in China:non-random, purposive sampling was used to select15key policy informants including politician, civil society organization(CSO), policy-maker, health manager, researcher and development partner at national and program county level. Semi-structured interview was conducted until information saturation, combined with document analysis method. Policy process research framework was designed to analyze the policy development and implementation from the aspects of policy context, policy content, policy actors and policy process, with the focus on the impacts of key determinants of health system, human resource, service delivery, CSO and evidence-based policy making and their inter-relationship on policy process.
2. The feasibility of adolescent RH service implementation from a larger scope in MCH hospitals:One component of CP6ARH program was adolescent friendly service. It was implemented within current maternal and child health (MCH) facilities. The previous qualitative study only reflected the result of piloting in1program county. In order to investigate the feasibility of policy implementation in a larger scope, non-random, purposive sampling was used to survey55tertiary and225secondary MCH hospitals, taking into account both stratum, region difference and research condition restriction. Health resource input model was used to evaluate the feasibility of implementing adolescent friendly service within current MCH facilities from the perspective of health financing, physical facilities, materials and equipments, human resources, Information system, youth participation, policies and guidelines.
3. Gap and trend analysis of adolescent RH policy system in China:Content analysis was used to review issued policies, laws and regulations related to adolescent RH in China before Dec1st,2011(
4. Policy recommendations:Based on our research results, evidence-based policy recommendation was provided for future specific national adolescent RH policy development.
IV. Main results
1. Global context values adolescent RH problems; political commitment and the change in the Chinese government's FP work emphasis; international sponsored program provides policy solutions; adolescent RH problems are prominent in China; and CSOs accumulate successful experiences in adolescent RH education and services; all these lead to finding a good entry point and the opening of policy windows that put the CP6ARH program onto the policy agenda.
2. CP6adolescent RH program was initiated by UNFPA. In addition to government sections such as the ministry of commerce, the ministry of health, and China population and family planning committee, development at national level also involved expert panel, China family planning association and China youth network. Implementation at county level was responsible by county leadership group. Family planning, health system and education department all bear various responsibilities. National Coordination Committee and county leadership group were set up to ensure smooth implementation and multi-departmental coordination.
3. Human resources, health system, service delivery and CSO are4key determinants existing in the policy process. These factors were considered in an integrated way through reviewing of the CP5ARH program, program leadership and regulation strategy, and M&E strategy. This ensures feasibility of smooth implementation for CP6adolescent RH program. International events and research data/pilot program report were used as evidence in policy process, therefore, the program matched international practices and reinforce the strengths and improve on the weaknesses revealed by previous ARH program. However, barriers in the implementation process had restricted the achievement of policy goals. These obstacles include:the limited participation of the education department, the unclear identification of a program budget (especially for the ARH program), problems regarding human resources, and the implementation system itself.
4. Based on
5. Adolescent health care outpatient clinics all belong to women's department, gynecology department, or RH department. No matter tertiary or secondary MCH facilities, they all have some common problems:service providers still use adult health care model; time is not appropriate for clients; poor advocacy and waiting for clients passively; male adolescent are excluded from services; environment is not attractive for adolescent; confidentiality is not properly protected; no enough free contraception; health education materials is not easy to reached; lack of youth participation; lack of clinical guideline; cost of service is not acceptable by adolescent; service providers'attitudes and skills need to be upgraded, etc. Most MCH facilities are not feasible for implementation of adolescent friendly services.
6. Multiple linear regression shows that environment being friendly to adolescent, multiple advocacy strategies, integrated service modes and youth participation in clinic design&service provision are associated with higher average score of a MCH facility. Being involved in CP6adolescent RH program and receiving some fund support for the clinic is not sufficient enough to improve the feasibility of implementing adolescent friendly service. It confirms the result from chapter II:although international ARH program provide technical feasibility, without inspiring mechanism, adolescent friendly service is very difficult to implement. As a result, sustainability of adolescent friendly service must reply on good policy and financial support.
7. Adolescent are citizens of our country. They should possess civic rights authorized by law. Though current policy and regulations contains some contents of adolescent health and development, there hasn't been national adolescent RH rights policy.
8. The Chinese government has made progress in setting up a legal framework for sex education for adolescent. However, problems such as definition of sexuality education being inconsistent between policies; policies being not operational; teachers' knowledge and skill needs to be improved; poor teaching system; and Lack of policies on sex education for young migrants and out-of-school populations all influence the effect of policy implementation. Sexuality education policy has lagged behind society advances, and needs to be improved.
9. Provision of RH/family planning services for people at childbearing age is our basic state policy. However, adolescent/unmarried youth have been excluded from this system. Their RH needs have been largely ignored in the legal framework. A governmental plan in provision of clinical services for adolescent/unmarried youth is still unclear. How to ensure their access to RH/family planning services should be the focus for future policy development.
10. Being as vulnerable population, unmarried floating young people are facing more complicated RH risk compared with city residents. Although current legal framework has some articles in principle to improve RH education and services for them, what public RH services are available for them, who are responsible for implementation, how to implement and financial support are all not clear. Improving family planning basic public service equalization for floating population should ensure that unmarried youth enjoy the same RH rights as married couples.
11. Adolescent RH promotion needs to be worked both from the perspectives of supportive policy environment, education and service. It's implementation requires long term cross-sectoral cooperation. Only the barriers of government departments are broker through, can adolescent reproductive health policy achieve positive result and sustainable effect.
Ⅴ. Policy suggestions
We suggest that adolescent RH should be set up as higher priority within state public policy agenda, and our government should issue specific national adolescent reproductive health policy focusing on following aspects:
1. Advocacy towards policy makers should be improved. Adolescent reproductive health should be put onto the state strategic development agenda to ensure it is embodied in policy content.
2. Adolescent reproductive health rights should be highly emphasized and clearly identified in legal framework. At the same time, implementation system should be designed to ensure their access to appropriate and acceptable RH information, education and services.
3. Sexuality education policy system should be improved in terms of clear identification of its strategy and goal, developing national unified teaching guideline and contents, improving teaching system, strengthening teachers' training, establishing legal framework addressing sex education provision for young migrants and out-of-school youth, and developing&implementing an effective monitoring and evaluation system.
4. Developing specific adolescent reproductive health service policy including involving adolescent reproductive health care into state basic public health services, setting up appropriate reproductive health care system for adolescent/unmarried youth, strengthening service providers'capacity and information system building, encouraging youth participation in service provision, building reputation for health facilities, developing adolescent reproductive health care guideline, and give full scope of CSO's active roles.
5. Unmarried young migrants RH needs should be paid attention to. Government should clearly identify related departments' responsibilities and functions. Department of health care, family planning system, labor and social security and other departments should cooperate to establish better education and service system for them.
6. The government should develop law and regulations to ensure youth participation in policy decision from strategic and long term perspective.
7. Improve virtuous interaction between CSOs and government. Our government should authorize more functions to CSOs and direct them from 'passive participation' to 'active participation', and further'institutional participation'. For those independent CSOs, government should provide financial and technical support. CSOs should enhance organization consummation and capacity building, make full use of their advantages, and actively interact with policy process in order to propose their own interest and policy suggestion.
8. National Working Committee on Children and Women should take the leading role to promote collaboration between government departments, CSOs and government so as to create supportive environment for promoting adolescent RH.
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