Chinese Studies
2013. Vol.2, No.3, 121-127
Published Online August 2013 in SciRes (http://www.scirp.org/journal/chnstd) http://dx.doi.org/10.4236/chnstd.2013.23019
Copyright © 2013 SciRe s . 121
Engaging Civil Society Organizations in Adolescent Reproductive
Health Policy Process in Mainland of China
Xu Jieshuang1, Verhart Noor tje2, Stephen Pearson3, Qian Xu1*
1School of Public Healt h, Fudan University, K e y Laboratory of Public H e al t h Safety, Ministry of Education,
Shanghai, China
2Royal Tropical Institute, Amsterdam, The Netherlands
3The Nuffield Centre for International Health & Development, Leeds Institute of Health Sciences,
University of Leeds, Leeds, UK
Received April 7th, 2013; revised May 16th, 2013; accepted May 29th, 2013
Copyright © 2013 Xu Jieshuang et al. This is an open access article distributed under the Creative Commons
Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the
original work is properly cited.
This paper explored how Chinese civil society organizations (CSOs) had been involved in an adolescent
reproductive health policy process and its implications for other developing countries with similar politi-
cal and social contexts. The case study was the 6th cycle of the Country Program on adolescent reproduc-
tive health (Jan. 2006-Dec. 2010). It was a multi-phased, retrospective qualitative study in Guangxi
autonomous region. Six categories of policy actors including politician, CSO, policy-maker, health man-
ager, development partner and researcher were interviewed, 34 documents were reviewed and 1 partici-
patory stakeholder workshop was held between Jun. 2007 and Apr. 2008. We focused on different CSOs
that had been involved in different stages of the policy process, what strategies they had used to interact
with the policy process and how they influenced the content and implementation of the policy. Our results
showed that new forms of CSOs in China were emerging, with different mechanisms being used to ex-
press their voice and influence the policy process. The involvements of CSOs in the adolescent reproduc-
tive health policy process also showed how new opportunities were arising in a rapidly changing Chinese
political context, but various factors might affect their involvement in policy process. Critical amongst
these were the characteristics of the CSOs, the wider political context of the country and the nature of the
policy itself.
Keywords: Health Policy; Adolescent Reproductive Health; Civil Society
Introduction
China has the largest population of adolescents in the world:
nearly 194 million adolescents aged 10 - 19 account for 14.6%
of the national population (Zhongguo guojia tongjiju 中国国家
统计局, 2009). Because of long-lasting cultural traditions in
China, sex has been viewed as a taboo subject with concerns
that promoting sexuality education for adolescents encourages
sexual behaviors (Wang et al., 2005). It is very hard for stu-
dents to get systematic and comprehensive sexual and repro-
ductive information from their schools (Zhang et al., 2007).
China’s social and economic development and improvements in
its people’s lives and health standards have been accompanied
by a continuing decrease in the age of sexual maturity (Zhong-
guo xuesheng tizhi yu jiankang yanjiuzu 中国学生体质与健
康研究组, 2002). Changing social values and norms related to
sex and marriage have affected adolescents’ attitudes and be-
haviors (Gao et al., 2003). These changes can be measured by
increases in premarital sexual behaviors and problems (such as
unintended conceptions, sexually transmitted infections, and
even HIV/AIDS) associated with adolescents’ lack of sexual
and reproductive health knowledge and skills (Gao et al., 2003).
The 1994 International Conference on Population and De-
velopment (ICPD) resulted in a Program of Action agreed by
179 countries (including China). Adolescent and reproductive
health issues and the need for appropriate services and coun-
seling specifically suited for that age group were important
aspects of the Program. In response to the new prominence
given to reproductive health in international fora, the Chinese
government gave more emphasis in policies to high-quality
reproductive health/family planning information and services
(Guojia renkou yu jihua shengyu weiyuanhui 国家人口与计划
生育委员会, 2000). This represented a shift from the govern-
ment’s previous focus on prioritizing population control.
The ICPD also called for greater participation of civil society
in reproductive health matters to improve policy formulation
and implementation. Civil society organizations (CSOs) have
been identified as one of the most important determinants af-
fecting policy processes (HEPVIC Consortium, 2007).
China had a highly centralized political system, which was
based on a planned economy and administrative management
(Wang, 2010). The development of CSOs in China had been
strict and therefore limited under those circumstances espe-
cially before the 1980s. Since the early 1990s, however, re-
forms had brought changes to the political system and public
*Corresponding author.

XU J. S. ET AL.
management, which had created a more favorable environment
for CSOs and citizen participation (Lu, 2005). Since then, the
Chinese government had actively called on these so-called “so-
cial forces” to subsidize and filled gaps in state services (Wang,
2009). The number and variety of CSOs have grown, alongside
their roles, capacities and scope of activities. In relation to the
need for better adolescent reproductive health (ARH) services
and the ICPD meeting calling for increasing inclusion of CSOs,
including in the area of reproductive health for adolescents,
CSOs are able to gain space to influence the policy process in
China.
In this article, a United Nations Population Fund (UNFPA)
sponsored national ARH program was used as a policy case
study. The article explored how Chinese CSOs had been in-
volved in this particular policy process, focusing on the formu-
lation of this program action plan at the national level and the
implementation at county level. We also analyzed the strategies
that CSOs used to influence the program, what impact that had
on the content and the implementation of the program and the
factors that influenced their strategies and impact.
Methods
The study was approved by the institutional review board of
the School of Public Health, Fudan University, Shanghai, China
(Identification code 07-01-0067).
Study Desi gn
Data for this article were collected in the HEPVIC (Health
Policy Making in Vietnam, India and China) project aiming to
understand and compare how health policies were made in
three Asian countries. A full description of the methods used
was reported by Green et al. (2011). The study in China was
conducted in Guangxi autonomous region, with a focus on an
ARH policy process developed at the national level and imple-
mented in one project county. As a summary, this was a multi-
phased, retrospective qualitative study structured around three
phases:
 Phase one—preliminary data collection and data analysis
 Phase two—main data collection
 Phase three—main data analysis and follow-up
This incremental approach to the research design allowed
phases two and three to be informed by the results of the pre-
vious phases. Non-random, purposive sampling was used to
select respondents.
Participants
To ensure that the voices of different types of actors were
heard in the research, six categories of policy actors were de-
veloped (see Table 1), with respondents recruited for each cate-
gory. At Phase One, 2 key informants with knowledge, experi-
ence and perceptions of the case study policy processes were
selected. One was an ARH expert who has been involved in
policy development processes; another was a researcher whose
research field had been focusing on ARH in China for many
years. At Phase Two, 13 respondents were key actors identified
by the Phase One respondents and research team who had been
involved in policy making or implementation process, and
through snowballing by phase two respondents until informa-
tion saturation.
Documents review provided data on the evidence and written
documents informing the policy process. They also provided
another data source to be compared with other sources to iden-
tify and explain consistencies and inconsistencies in reporting.
34 documents were selected which provided a written record of
some aspect of the case study’s policy processes. They included
7 policy documents at the national and local level, 9 webpage
from the websites of UNFPA, China Family Planning Associa-
tion (CFPA) 中国计划生育协会, China Youth Network (CYN)
中国青年网络 and National Population and Family Planning
Commission (NPFPC) 国家人口与计划生育委员会, 7 re-
search report of CP6 ARH program, 6 meeting minutes and 5
other documents. Finally, follow-up interviews were done through
phone calls, emails and participatory stakeholder workshop,
which was held involving policy process actors and other stake-
holders to raise, justify and re-examine different views (see
Table 2).
Procedure
Semi-structured in-depth interviews were conducted in Chi-
nese face-to-face between Jun. 2007 and Apr. 2008. After ob-
taining an informed consent form, a digital voice recorder was
used to record all interviews. All interviews were conducted in
a private room. The author acted as interviewer, and another
researcher acted as observer. The observer kept track of the
questions asked, recorded any important emergent issues the
interviewer needed to ask as follow-up, and noted any impor-
tant non-verbal interactions. All interviews were transcribed
into Chinese by the research observer soon after completion.
Transcripts were checked to “clean” the data, and to allow the
Table 1.
Summary of interviewees recruited.
Type of re s p ondent Definition Number of
respond ent
Politician Political fig ures at all levels (country, province, state), but probably not d i rectly involved in health policy processes 1
Civil society Organised entities, includin g private sector NGOs, patients’ organisa tions, Women’s Committees, profe ssional
associations, etc. 4
Policy-maker Health public sector officials whose responsibilities include the formulation, development, monitoring and
implementation of health policies 3
Health manager Programme managers and health staff (public and private sectors) at the fr on tline of servi ce delivery who focus on
policy implementation 4
Development partner All international funding bodie s that may or m ay not be physically represente d in the country, but may affect health
policy processes 1
Academic/researcher Academic scholars (indivi duals or organisations) who possess knowledge pertinent to the policy processes 2
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XU J. S. ET AL.
Table 2.
Summary of data collection.
Phase
Method One Two Three
In-depth interview 1 ARH expert
1 academic
(n = 2)
1 politician
4 CSO membe rs
3 policy-m akers
4 health managers
1 development partner
(n = 13)
Document review
7 policy documents
9 from we bs it es
7 research reports
6 meeting minutes
5 other documents
(n = 34)
Participatory stakeholder workshop 12 participants were presented at Nanning, Guangxi in Feb 14 th, 2008.
(n = 1)
interviewer and observer to confirm the accuracy of transcrip-
tion. Personal names and other identifier information were re-
moved from the transcripts. Access to data (transcripts, records)
was restricted to approved members of the research team. Data
were stored in secure electronic locations (access-protected
directories on computers).
Once a relevant document was identified, a full-text paper or
electronic copy was obtained. As documents were of different
lengths, layouts and formats, a pro forma sheet was therefore
designed to extract pertinent information and register inter-
pretations in a standardized format. One pro forma sheet was
completed for each document. It was divided into four sections:
basic information, content, context, and any other comments.
Data Analysis
A framework approach was taken to analyze and triangulate
the three data sources (Ritchie, 1993), assisted by NVivo 7.
NVivo is a qualitative data analysis computer software package.
It has been designed for qualitative researchers working with
very rich text -based a nd/or mul timedi a i nformation, where de ep
levels of analysis on small or large volumes of data are re-
quired.
The thematic framework was determined by considering and
synthesizing two key factors: the key concepts and themes
identified in the project conceptual framework and the themes
emerging from familiarization with the data. Each transcript
and document was coded both by the author and research ob-
server. Different opinions were then discussed until consistency
was reached.
Findings
CSOs that Have Been Involved in Policy Process
The policy case study was embodied by a national program
called the Country Program 6 (CP6) ARH (Country Program 6th
cycle Adolescent Reproductive Health—see Figure 1) and
sponsored by UNFPA. UNFPA had assisted the Chinese gov-
ernment to implement 5 cycles of reproductive health/family
planning country programs (CP1-CP5) by the end of 2005. CP4
and CP5 started to have ARH program components and these
programs were implemented by the CFPA in 30 program coun-
ties in 1998 (see Figure 1). The country programs were led by
UNFPA in collaboration with the Chinese government. Four
main types of CSOs were involved in the policy process around
the CP6 ARH program:
UNFPA is the world’s largest international funder of popula-
tion cooperation activities. Its two main roles in the CP6 ARH
program were as the donor and partner for implementation with
the Chinese government. This respondent recalled the pivotal
role UNFPA had in initiating, facilitating and coordinating all
stakeholder collaboration in the formulation and implementa-
tion of the program:
“UNFPA and the Chinese government both provided 50% of
the program fund … Apart from funding the program, UNFPA
played the role of promotion and acceleration. First it pushed
our government, and then coordinated between the other actors
(CSO member 2)”.
CFPA, formed in 1980, is a national non-profit organization,
technically directed by the NPFPC. It has a close relationship
with the government, which funds its running costs. Its network
covers most parts of China and reaches the grass-roots, with an
effective operation system and regular activities.
CYN was formed in 2004 by a group of university students in
Beijing, supported by UNFPA and CFPA. It was a volunteer
based national youth organization. Its sub-national network had
youth representatives at the program county level. This respon-
dent described the rather small nature of this CSO which is
relatively independent from government:
“6 - 7 university students called a core group at national
level and 30 youth representatives at county level (one per
county). Together they raised funds from UNFPA, Ford Foun-
dation and other international resources (CSO member 1).”
Expert panels from the Ministry of Health (MOH) and
NPFPC mainly included researchers from domestic research
institutions, universities, and civil society organizations. Ex-
perts in the panels were selected by the MOH or NPFPC based
on their expertise and profile in ARH and other relevant policy
areas. They worked as a government “think tank” to provide
policy suggestions to policy makers.
CSOs’ Involvement in Different Stages of the Policy
Process
The policy process could roughly be divided in four stages
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XU J. S. ET AL.
Figure 1.
ARH program in China.
(Sutcliffe, 2006): agenda setting, formulation, implementation
and monitoring & evaluation. It was through these stages that
the role and influence of CSOs was being looked at in this
study.
Agenda Setting
Since the 1980s, the Chinese government has started to en-
courage school health education. This gradually became focu sed
on sexual & reproductive health and prevention of HIV/AIDS.
This development followed the Chinese commitments and the
action plan that was developed after ICPD. As one respondent
recalled:
“Reproductive health/family planning work in China [came
to] meet international trends […] Adolescent sexual and re-
productive health had thus increasingly become a work-em-
phasis of the Chinese government now (policy maker 1)”.
Concurrently, UNFPA commissioned an evaluation of its
ARH component at the end of the UNFPA Country Program 5.
The evaluation identified some successful experiences that had
improved adolescent reproductive health (Hu et al., 2005). On
the basis of these results, UNFPA decided to extend their sup-
port for ARH in CP6. The newly funded CP6 ARH program
was timely, as it coincided with the government’s ICPD com-
mitments and also their new political focus on a human devel-
opment and service-orientated approach to the family planning
system. A policy maker recalled:
“The intervention fields of this [CP6 ARH] program were
both [ones] that UNFPA and the Chinese government paid
attention to, being identical with the government’s work em-
phasis (policy maker 2)”.
As a result UNFPA, in collaboration with the Chinese gov-
ernment, organized a first consultative meeting in Beijing in
November, 2005 to discuss the upcoming CP6 program. Pre-
sent at this meeting were the MOH, NPFPC, and their expert
panels. The increasing commitment of the Chinese government
to meet international standards and the success of CP5 ensured
that ARH had enhanced and sufficient visibility on the political
(and therefore, policy-making) agenda.
Policy Formulation
With ARH better-established on the political agenda, activi-
ties shifted towards formulating the ARH policy. In December,
2005, UNFPA organized a second national consultative con-
ference in Beijing, where many stakeholders were present.
“UNFPA invited all actors who had been involved in the
CP5 ARH program—including Marie Stopes International, the
MOH and its expert panel, the NPFPC and its expert panel,
CFPA and CYN to have a discussion about the China/UNFPA
CP6 Action Plan 2006-2010 (development partner)”.
Actors who had been involved in implementation of the CP5
ARH program presented their own proposals for the policy. For
example, this respondent recalled the inputs provided by the
relatively newer-established and less powerful actor, the CYN:
“CYN core group members presented proposal on youth par-
ticipation and the CFPA presented its proposal on life skills-
based education at the meeting, and led the discussion respec-
tively (CSO member 2)”.
Recognizing that the CYN had relatively less capacity and
experience as an actor in policy formulation, UNFPA and
CFPA actively supported CYN’s participation in the confer-
ence:
“UNFPA management staff supported youth participation in
the ARH program. They and CFPA helpe d CYN to design its
proposal, and UNFPA persuaded the MOH and the NPFPC to
accept it at that conference… (CSO member 1)”.
A policy maker confirmed the role of the CFPA in the fol-
lowing statement:
“During the whole development process of the CP6 Country
Program Action Plan, the CFPA, as a CSO, played a key role.
It was very active in China, and especially experie nced in the
ARH field. Why the NPFPC paid attention to the ARH issue
was due to this fact. The CFPA, as an NGO, could actively
involve itself in cooperative programs. Where their work [in 4th
and 5th cycle ARH program] is effective, they can push forward
the country’s policy development (Policy maker 1).”
After two days discussion, the “China/UNFPA CP6 Action
Plan 2006-2010” was drafted. UNFPA then presented the draft
plan to the Ministry of Commerce (the leading agency of the
Chinese government dealing with foreign affairs), which circu-
lated the Plan within Chinese government departments. The
final decision-making for the “China/UNFPA CP6 Action Plan
2006-2010” was undertaken by the Ministry of Commerce, the
MOH/expert panel, the NPFPC/expert panel, and UNFPA in
March, 2006.
Program Implementation
Once approved, a National Coordination Committee was set
up for program administration. Membership included UNFPA,
Ministry of Commerce, MOH, NPFPC and Marie Stopes Inter-
national. Through regular National Coordination Committee
meetings organized by UNFPA, an active partnership approach
was promoted at the national level.
The CP6 ARH program was implemented in 30 counties (in-
cluding one project county in Guangxi, in which data were
collected for this research). The CP6 ARH Program prioritized
high-quality ARH information and services, reflecting the
ICPD-led focus on these areas. The CFPA had accumulated
successful experiences in previous cycles of the ARH program
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XU J. S. ET AL.
in providing life-skilled peer education. They focused on peer
education and social mobilization using their grass-roots net-
work, while CYN mainly focused on youth participation.
Similar to the policy formulation stage, UNFPA supported
the participation of CYN in the implementation of the program
from the start. This had major consequences:
“At the NPFPC’s CP6 program launch meeting in April
2006 in Beijing, UNFPA helped CYN gain a two-hour slot to
address young people’s abilities. CYN had a session entitled
‘Why Should Adults Cooperate with Youths?’…I felt that the
session had the greatest influence on the NPFPC. As a result
[of it], the MOH invited CYN to deliver the same session at
their CP6 program launch meeting […] Later the NPFPC
would call upon CYN to do many things—the situation really
changed after that session (CSO member 1).”
At county level, a county leadership group was established
by local government to ensure good multi-departmental coor-
dination and collaboration of the program. All relevant depart-
ments in local government were involved in this group includ-
ing the CFPA county branch local youth representatives (the
CYN’s sub-national network). This respondent remembered the
supervisory support provided to the youth representative by
another member from the county leadership group .
“UNFPA hope that youth could be involved in the county
leadership group and dialogue would happen between youth
and adults. That’s was why a supervisor from this group was
set up to ensure youth’s voice could be heard at local level
(development partner).”
Similar to support provided in the policy formulation stage,
this arrangement aimed to help youth representatives become
actively involved in local decision making processes. However,
youth representatives had a limited mandate. In this project
county, he/she was only able to introduce ARH advocacy ac-
tivities for the “floating” (internal migrant) population.
“Progress was not that optimistic. The youth representatives
were weak; at the same time, they were not that bold. We no-
ticed this problem when we monitored our program. Young
people did take some initiative, sometimes not completely right,
but the current policy-making system did not foster this kind of
participation. Still, we would like to improve youth participa-
tion in the policy process (development partner).”
“The CYN was a kind of non-governmental organization without
a certain influence and scale, [and so] was not able to be in-
volved [in policy-making at local level] (health manager 3)”.
Monitoring & Evaluation
At the nat ional level, expe rt panels regularly visited program
counties. These visits were commissioned by the MOH and
NPFPC. The resulting reports informed and helped identity
important gaps in the further implementation of the policy. This
respondent recalled how the visits prioritized capacity strength-
ening for successful program implementation:
“In our schedule, expert panel members were required to
supervise program counties twice per year and write reports
after each field visit. The role of supervision was to help pro-
gram counties to improve capabilities of implementation and
provide technical support (policy maker 1)”.
Different Strategies CSOs Used to Influence the
Policy Process
The analysis identified four main strategies used by CSOs to
influence the policy process.
Building a Reputation as a Trustworthy and Successful
Policy Actor
UNFPA had been considered as a reliable partner, due to the
successful results of the country programs on ARH. At the
same time, UNFPA had been eager to continue their country
programs because of their global mandate to improve the sexual
health among adolescents worldwide. Together with the posi-
tive outcomes of the evaluation of CP5, UNFPA had been able
to continue their work. This had given them leverage to influ-
ence the policy process and to ensure that several actors were
involved at different stages.
The CFPA had been involved in the ARH program as an ac-
tive actor since 1998. Their successful experiences were cited
by these respondents as having helped CSOs to strengthen their
reputation and gain support from government leaders and de-
partments:
“About 10 years ago, some non-government organization
like CFPA started to collaborate with international organiza-
tions focusing on ARH issues. CFPA had accumulated success-
ful experiences and summarized good models [of ARH education
and services] (policy maker 2)”.
“I think CFPA was very active in China in terms of piloting
programs in the ARH field. Why NPFPC paid attention to the
ARH issue had something to do with CFPA’s successful work
[in previous ARH programs] (policy maker 1)”.
Being Involved in Expert Panels
Expert panels have been a well-used mechanism in the policy
making process in China (in some cases, even policy-drafting
groups). When expert panels were asked to provide evidence
through research and to form advisory committees, their voice
were listened to by policy makers due to long-established and
trusting working relationships.
“We were not health professionals, we can only made use of
expert panel [in policy making] (policy maker 1)”.
“We didn’t have national data reflecting ARH issues [when
making the policy]. Relevant information was from research
report [provided by expert panel members] focusing on a cer-
tain area, but it did give us basic scenario of how serious the
problem was (policy maker 2)”.
Lobbying
Some core group members from CYN had worked as Youth
Counselors for the International Planned Parenthood Federation
(IPPF) from 2003-2008. This work enabled good working rela-
tionships to be established with policy makers and expert panel
members from NPFPC. Consequently, the CYN used these
good relationships to advocate for acceptance of their proposal
on youth participation during breaks and dining periods at the
second consultative meeting in Beijing:
“We had many opportunities to participate at IPPF’s meet-
ings with policy makers from NPFPC. We took advantage of
these opportunities to introduce that CYN was a young people’s
organization in China, that we had been involved in the ARH
program, and how important youth participation was. Over
time, you could feel their level of knowledge and understanding
of this issue increased (CSO member 2).”
Being Involved as an Implementer of Policy
This strategy was described in a previous section.
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XU J. S. ET AL.
Discussion
The Involvement and Influence of CSOs in the Policy
Process
The previous sections described the influential involvement
of CSOs in the policy process, but how can we explain their
involvement and what impact did they actually have on the
pol ic y? Gaventa’s (2005) “power cube” approach (see Figure 2)
presented a dynamic understanding of how power operates,
how different interests could be marginalized from decision
making and the strategies needed to increase inclusion. The
power cube approach looked at how power was used in three
continuums (Gaventa, 2006):
 Places: the levels and places of engagement (local, nationa l,
international).
 Spaces: how arenas of power were created (provided or
closed, invited and created).
 Power: the degree of visibility of power (visible, hidden
and invisible).
The involvement of CSOs in the ARH policy process in
China can be analyzed using the above concepts. In terms of
spaces, at the national level the consultative conference initiated
by UNFPA allowed, besides policy makers, access to CSOs. In
addition to UNFPA, policy makers and the expert panels,
CFPA and CYN also were invited to discuss the potential pol-
icy content. The important roles and successful experiences of
the CFPA in previous ARH programs meant they gained credi-
bility and were therefore invited. As described in the results
section, CYN “claimed” space through their lobbying strategy
and donor support, and were therefore able to pursue their
agenda items in the formulation stage of the policy. The expert
panels were part of the closed space, as they were trusted and
well-established partners of policy makers. However, in addi-
tion to the essential role that experts played in the policy proc-
ess, their inclusion contributed to evidence-based policy mak-
ing.
The involvement of CSOs could also be understood with ref-
erence to the second power cube continuum, power. Experts’
power was visible, and based on the policy process procedures
in the Chinese context which value the contributions of this
group of actors. UNFPA exercised “hidden” power due to their
role as the main initiator, developer, funder and implementer of
the policy. While the Chinese government was formally in
charge of the policy process, without UNFPA the ARH pro-
gram would not have happened. Also, UNFPA maintained their
influence by controlling who got to the decision-making table
and what got on the agenda. This enabled CYN to play an im-
portant role in the policy process. While they were not able to
negotiate their power based on formal rules, they did it based
Figure 2.
Power cube theory.
on personal contacts and networks. As a result of the CYN
lobby, a monitoring indicator was included on the involvement
of youth (namely that “80% of the program counties should
take youth groups’ recommendations into consideration when
monitoring the program”) (The government of China and
UNFPA, 2006).
At local level, youth representatives did participate in the
program county leadership groups. However, the youth repre-
sentatives were not able to claim any space. Formally it was an
“invited space”, but the “invisible” structure of the social and
political ideology about policy making renders them unable to
conceive of bringing about change in their own interests. The
local government kept actual control over the process and made
decisions in a “closed” space.
Factors Influencing CSO Engagement in Policy
Process
CSOs’ engagement in the policy process could be explained
with reference to both contextual factors and the capacity and
characteristics of CSOs.
First, this policy case study existed in a specific time period
and its social, political and policy-making context. For example,
the established mechanism of expert panels in the Chinese pol-
icy process (discussed previously) gave them enhanced credi-
bility and legitimacy in this case study. Similarly, the decision
to represent the policy issue through a program rather than leg-
islation facilitated the involvement of a more diverse range of
actors, as program policy processes were less formal and hier-
archical.
The political context helped explain the structure and effec-
tiveness of working relationships between the government and
CSOs. CFPA, the largest and the first CSO in China to focus on
reproductive health issues, had a close working relationship
with the government. Both parties had a similar organizational
hierarchy from community up to national level. The CFPA also
received their main funding from the government. These two
factors made the CFPA an important partner for the Chinese
government in the policy process. CSOs in China are generally
closely linked to the government, but in that role, they can play
an important role in influencing the policy process. Tony Saich
(2000) argued for the advantages of this closeness, in that “so-
cial organizations could have considerable impact on the pol-
icy-making process” by retaining strong linkages to the party
and state, far more than if they were to try to create an organi-
zation with complete operational autonomy. In another HEP-
VIC ARH case study in Vietnam, the Youth Uni on, being “ q ua s i ”
independent with stro ng links to govern ment, has also bee n q ui t e
active in national ARH policy process from setting agenda,
policy development, to policy implementation (Ha et al., 2010).
Second, CSOs’ engagement was associated with their visi-
bility and capacity (technical, financial, social). The prominent
visibility and strong capacity of UNFPA in the case study was
clear. UNFPA had a long-established and proven working rela-
tionship with the Chinese government to successfully imple-
ment previous reprod uctive health programs. Consequently , th ei r
influence in the China ARH policy process was extensive.
Though the CFPA and CYN were all classified as CSOs,
their characteristics differed. CYN was relatively independent,
small-scale, volunteer-based and had limited capacity. Their
financial support was mainly program-based and came from
international sources. CYN also faced some challenges in terms
Copyright © 2013 SciRe s . 126

XU J. S. ET AL.
Copyright © 2013 SciRe s . 127
of long-term stability and difficulties to network without a close
relationship to the government. The case study showed some
evidence of their ability to influence the policy process at the
national level due to their personal contacts and donor support.
However, at the program county level, there was no clear
structure for civil society in decision making. Distrust from
local government had marginalized youth representative’s input
in policy implementation.
Conclusion
The HEPVIC research project focuses on policy processes
within the maternal health field. The findings have shown how
policy actors and their relative power is emerging as one of the
key determinants in health policy processes, even more than the
strength of evidence or other factors that have been studied as
potential influencing factors in the policy process (Sutcliffe,
2006). This specific case study on the ARH policy process in
China, describes how the different actors involved in different
stages of the process, have influenced the content and imple-
mentation of the policy. It shows the emergence of new forms
of civil society, and different mechanisms through which civil
society is able to express their voice and influence the policy
process in a rapidly changing Chinese political context.
The role of CSOs and their influence depends on many fac-
tors. In this case study, the nature of the policy issue played an
important role. Due to international developments such as ICP D,
and increasingly visible health problems at the national level,
the Chinese government was willing to address ARH issues. At
that moment, only a few CSOs had experience in this field, and
this was one of the reasons they were invited to contribute to
the formulation of the policy. However, being invited to meet-
ings does not mean that organizations have influence on the
proceedings or outcomes. In this case, the nature of the policy
process, and the important role of UNFPA, enables civil society
to make a difference while promoting their own agenda.
The involvement of CSOs in the Chinese policy process
shows how new opportunities are arising in a changing political
context. While the Chinese tradition of citizen participation has
been top-down, this case study shows how civil society is now
also playing a proactive role in advising and lobbying. This
case study also shows how a process led at the national level
may have challenges in being implemented effectively at the
local level. This has meant that in the implementation stage, the
role of civil society has been less substantial.
Our research was on ARH policy processes in China but, we
suggest that some of the findings and implications may be rele-
vant for other developing countries with similar political and
social contexts.
Acknowledgements
HEPVIC was supported by the European Community Sixth
Framework Program (INCO-CT-2005-517746). However, the
views of the article only reflect those of the authors.
The authors would like to thank colleagues at the School of
Public Health, Fudan University and all HEPVIC partners for
their contribution during the HEPVIC project. The research that
this paper was based on was supported by the EC under FP6.
The authors also would like to all the respondents and facilita-
ors in the research field. t
REFERENCES
Zhongguo jihua shengyu xiehui 中国计划生育协会 (2006). Zhong-
guo jihua shengyu xiehui zhangcheng 中国计划生育协会章程.
2006 nian quanguo huiyuan daibiao dahui tongguo, Beijing. 2006年
全国会员代表大会通过, 北京.
Zhongguo xuesheng tizhi yu jiankang yanjiuzu 中国学生体质与健康
研究组 (2002). 2000 nian zhongguo xuesheng tizhi yu jiankang
diaoyan baogao 2000年中国学生体质与健康调研报告. Beijing:
Gaodeng jiaoyu chubanshe. 北京: 高等教育出版社.
Zhongguo qingnian wangluo 中国青年网络 (2007). 2007 nian
zhongguo qingnia n wangl uo nianhui baogao. Beijing. 2007年中国青
年网络年会报告. 北京.
Gao, E., Tu, X., & Lou, C. (2003). Reproductive health of unmarried
youth in China. Reproduction & Contraception, 21-31.
Gaventa, J. (2005). Reflections of the uses of the “power cube” ap-
proach for analyzing the spaces, places and dynamics of civil society
participation and engagement, CFP evaluation s e ries No. 4.
Gaventa, J. (2006). Finding the spaces for change: A power analysis.
IDS Bulletin, 37, 1-33. doi:10.1111/j.1759-5436.2006.tb00320.x
Green, A., Gerein, N., Mirzoev, T., Bird, P., Pearson, S., Anh, L. V. et
al. (2011). Health policy processes in maternal health: A comparison
of Vietnam, India and Ch i n a. Health Policy, 100, 167-173.
doi:10.1016/j.healthpol.2010.11.016
Ha, B. T. T., Green, A., Gerein, N., & Katrine, D. (2010). Health policy
processes in Vietnam: A comparison of three maternal health case
studies. Health Policy, 9 8, 178-185.
doi:10.1016/j.healthpol.2010.06.015
HEPVIC Consortium (2007). Revised unified research methodology.
Leeds: University of Leeds.
Hu, X., Xu, J., & Cen, S. (2005). Evaluation report, adolescent repro-
ductive health component of the project CPR/03/P01 “Reproductive
Health/Family Planning”. Shanghai: Shanghai Institute of Family
Planning Technical Instruction.
Lu, Y. (2005). The growth of civil society in China key challenges for
NGOs. Asia Program, ASP BP 05/01. London: Chatham House.
Zhongguo guojia tongjiju 中国国家统计局 (2010) 2008 nian an
nianling he xingbie fenlei renkou 2008年按年龄和性别分类人口.
http://www.stats.gov.cn/tjsj/ndsj/2009/indexch.htm
Guojia renkou yu jihua shengyu weiyuanhui 国家人口与计划生育委
员会 (2003). Guoji renkou fazhan dahui yilai de jinzhan 国际人口
发展大会以来的进展.
Ritchie, J., & Spencer, L. (1993). Qualitative data analysis for applied
policy research. In: A. Bryman, & R. Burgess (Eds.), Analyzing
qualitative data (pp. 173-194). London: Routledge.
Saich, T. (2000). Negotiating the state: The development of social
organizations in China. The China Quarterly, 161, 124-141.
doi:10.1017/S0305741000003969
Sutcliffe, S., & Court, J. (2006). A toolkit for progressive policymakers
in developing countries. London: Overseas Development Institute.
The government of China & UNFPA (2006). UNFPA country program
action plan 2006-2010. Beijing: The Government of China and UN-
FPA.
Wang, M., & Liu, Q. (2009). Analyzing China’s NGO development
system. The China N onprofit Review, 1, 5-35.
doi:10.1163/187651409X412705
Wang, B., Hertog, S., Meier, A., Lou, C., & Gao, E. (2005). The poten-
tial of comprehensive sex education in China: Findings from subur-
ban Shanghai. International Family Planning Perspectives, 31, 63-
72. doi:10.1363/3106305
Wang, T. (2010). China’s administrative reforms in the economic tran-
sition. Asian review of public administration (pp. 256-262). United
Nations Public Admi n i s t ration Network.
Zhang, L., Li, X., & Shah, I. H. (2007). Where do Chinese adolescents
obtain knowledge of sex? Implications for sex education in China.
Health Education, 107, 351-363. doi:10.1108/09654280710759269