Topic: BusinessCase Study

Last updated: February 9, 2019

Public policy implementation research, although practised globally mainly in the west for quite some time, is a new attempt in developing countries. The fact is that implementation inevitably takes different shapes and forms in different cultures and institutional settings (Hill & Hupe, 2002, p.1). A review of literature reveals a number of models which relate to the implementation of public policy. The majority of these models have been developed from Western context, ideas and points of views (Schofield, 2004, p. 284).

In a developed country, market mechanisms are overrated and the critical role of the state and societal culture is underrated (Dror, 1992, p. 276 – 279). Conceptually, implementation can be defined as a process, output and outcome. It is a process of a series of decisions and actions directed towards putting a prior authoritative decision into effect. The essential characteristic of implementation process is the timely and satisfactory performance of certain necessary tasks related to carrying out of the intent of the law. It can also be defined in terms of output or extent to which programmatic goals 24 have been satisfied. Finally, at the highest level of abstraction, implementation outcome implies that there has been some measurable change in the larger problem that was addressed by the program, public law or judicial decisions (Lezter et al., 1995, p.

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87). The translation of policy into practice in developing countries is a challenging and legitimate concern (Saetren, 2005, p.573). But, the policy implementation process in developing country shares a great deal with the process of in more developed country (Lazin, 1999, p.151). However, the factors such as the effects of poverty, political uncertainty, people’s participation as well as the unique character of each developing country cannot be ignored in the policy implementation process.

As first, ‘poverty is a state of economic, social and psychological deprivation occurring among people or countries lacking sufficient ownership, control or access to resources to maintain minimal acceptable standards of living’ (UNDP, 2002, p.10). Poverty has a direct influence on the policy implementation process. The intended results cannot be achieved due to poverty in a developing country. Lane (1999), in an article entitled ‘Policy Implementation in Poor Countries’, argues that the problems connected with policy implementation in developing or Third World countries are intertwined with basic economic and political conditions. He contends that political stability and economic development are closely interrelated.

On the one hand, low level of economic development leads to political instability and, on the other hand, political instability worsens poverty. Effective policy implementation improves poverty situation in the Third World countries, which need both economic development and political stability. He is optimistic about the possibility of closing the gap between the rich and poor countries, provided strong and stable regimes utilize available economic resources to foster economic growth and development. Second, political uncertainty is an endemic condition to policy-making and implementation (Hanekom ; Sharkansky, 1999). Political uncertainty refers to military threats, domestic violence, political regime change and so on. Uncertainty is likely to be more pronounced in developing than in developed countries due to severely limited resources, extensive demands for public services and investment, weak political institutions and limited 25 capacities for policy-making and program implementation amidst all other difficult conditions (Caiden ; Wildavsky, 1974 as quoted in Nagel ; Lazin 1999, p.37-38).

In a paper entitled ‘Policymaking and Implementation in the Context of Extreme Uncertainty: South Africa and Israel’, Hanekom and Sharkansky (1999) confirm the relationship between political uncertainty and policy implementation. Their paper illustrates uncertainties in each country by reference to past and recent events, and links these uncertainties to the country’s political, policy-making and policy implementation traits. Extreme uncertainty is likely to affect the quality of policy-making and program implementation in both types of countries, but in different ways that show the influence of each country’s own traits. Finally, they recommend ways for other governments of developing countries to cope with uncertainties. Third, participation in public policy implementation processes is not so pronounced, and the channels for participation are less well-established in developing countries. At the same time, the state structures, whatever their weaknesses, are relatively powerful vis-à-vis their societies.

But, the interface between state and society is constantly changing. Of all the causes of poor policy evaluation in developing countries, the most serious institutional flaws are in political systems (Jain, 1992 ; Moharir, 1992). Furthermore, a common assumption is that implementers are involved at every stage of the policy-making process, and that they are often the most powerful groups in setting the policy agenda. In many developing countries, participation of lower level in the selection of sets of options is rare, and the choices are made by central-level policymakers. Very often, the problems the Third World bureaucracies have to deal with are more difficult to solve than those in developed countries, compounded by limited resources for implementation (Jain, 1992, p.24 ; Moharir, 1992, p.257). In this line, fourth, socio-administrative culture is another factor that affects policy implementation.

Administrative culture differs from country to country. Culture incorporates social values, beliefs, norms and practices. It is defined as the collective programming of the mind, which is developed in the family in early childhood and reinforced in school and organizations; these mental programs contain a component of 26 national programmes (Hofstede ; Hofstede, 2005, p.4). They are expressed in different values that predominate among peoples from different countries. Hofstede classifies four dimensions: power distance, uncertainty avoidance, individualism versus collectivism, and masculinity versus femininity.

It can be argued that, along these dimensions, dominant value systems in different societies can be ordered, which affect policy implementation processes in predictable ways. A study of administrative culture in Bangladesh reveals that the bureaucracy in Bangladesh is characterized somewhat more by traditional than by modern norms (Jamil, 2002, p.121-122). It is characterized by relatively high degree of power distance between authority and common citizens, low tolerance for ambiguities, dependence on traditional sources of information, low tolerance of bureaucrats than egalitarian, more positive towards Non-government Organization (NGOs), and preference for employees with traditional qualities (ibid). Fifth, people’s trust of public institutions, public awareness, accessibility and availability of services, and so on, should be taken into consideration for the sake of successful policy implementation in a developing country. Besides, interdependence between developed and developing countries arising from globalization is growing. It has direct impact on the design and implementation of the policy of the country.

Usually, aid conditionality as per the interest of the donor country determines whether a policy is translated into practice or not in a developing country. Despite an increased interest in public policy implementation in developing countries, it is surprising that so little empirical studies have actually been carried out in Nepal, especially from the socio-administrative perspective. Therefore, this study attempts to explore and understand the implementation process in reproductive health service delivery at the local level in Nepal. This study argues that public policy implementation studies are not valuefree due to socio-cultural, political and economic variations in the country’s context. It may lead to new forms of policy implementation not yet well understoodThe Government of Nepal (GoN) has been emphasizing upon the health sector on the basis of sectoral approach.

GoN has been designing health policies regularly with the changing context. Since 1975, Nepal’s health policy was directed towards providing minimum services to the maximum number of people. Following the declaration of the ‘Health for All’ Strategy’ in 1978, GoN undertook policy measures and programs for the promotion of health at the national and district levels. In 1991, a National Health Policy-1991 (NHP) aimed at enhancing the health status of the country’s rural population, addressing service delivery as well as the administrative structure of the health system was adopted. The Eighth Plan (1992-97), the Ninth Plan (1997-2002), and the Second Long-Term Health Plan (1997-2017) were developed in keeping with the National Health Policy, 1991. The basic features are: a) Developing integrated and essential health care services at the district level and below; b) Encouraging active community participation and the mobilization of the private sector to develop general as well as specialized health services; c) Ensuring quality assurance in health care; d) Promoting inter- and intra-sectoral coordination; e) Decentralization of heath administration; f) Developing the traditional system of medicines; and g) Promoting the participation of national and International Non-government Organization (INGOs), private enterprises and foreign investors. Further, the Nepal Health Sector Program Implementation Plan (NHSP-IP) (2002-2009), and the Tenth Plan (2002-2007) aim to provide an equitable, high quality health care system for the people. The Tenth Plan also incorporates the Millenium Development Goals (MDGs) with emphasizing on reducing child mortality, improving maternal health and combating HIV/AIDS, malaria and other diseases in health sector.

Similarly, Health Sector Reform Strategy (HSRS) was developed on the basis of the Tenth Plan (2002-2007) and MDGs. It aims at moving the health sector towards strategic planning and a Sector-Wide Approach (SWAP). It provides operational guidelines for implementing the outputs of the HSRS (such as those related to improvement in supply of health care services and sector-wide management issues, including the management of financing and resource mobilization, physical assets and human resource development, as well as an integrated information system). To implement those policies, GoN has constituted health institutions throughout the country. These health institutions include Hospitals (87), Health Centers (6), Health Posts (697), Ayurvedic Hospitals (287), Primary Health Centers (205) and Sub-Health Posts (3,129). Besides, GoN mobilizes the NGOs and Community-based Organizations (CBOs) and the private sectors to implement the reproductive health policies in Nepal. For providing health service to the people, GoN manages the medical, para-medical and nonmedical employees as front line health workers in each health institution, except for the NGOs and privately-run hospitals.

Implementation inevitably takes different shapes and forms in different cultures and institutional settings. This point is particularly important in an era in which processes of ‘government’ have been seen as transformed into those of ‘governance’ (Hill & Hupe, 2002, p.1).

Implementation literally means carrying out, accomplishing, fulfilling, producing or completing a given task. The founding fathers of implementation, Pressman and Wildavsky (1973) define it in terms of a relationship to policy as laid down in official documents. 36 According to them, policy implementation may be viewed as a process of interaction between the setting of goals and actions geared to achieve them (Pressman & Wildavsky, 1984, p. xxi-xxiii).

Policy implementation encompasses those actions by public and private individuals or groups that are directed at the achievement of objectives set forth in policy decisions. This includes both one-time efforts to transform decisions into operational terms and continuing efforts to achieve the large and small changes mandated by policy decisions (Van Meter & Van Horn, 1975, p.447). According to Mazmanian and Sabatier (1983, p.

20-21), policy implementation is the carrying out of a basic policy decision, usually incorporated in a statute, but which can also take the form of important executive orders or court decisions. The starting point is the authoritative decision. It implies centrally located actors, such as politicians, top-level bureaucrats and others, who are seen as most relevant to producing the desired effects. In their definition, the authors categorize three types of variables affecting the achievement of legal objectives throughout this entire process. These variables can be broadly categorized as: tractability of the problem(s) being addressed; the ability of the statute to favourably structure the implementation process; and the net effect of a variety of political variables on the balance of support for statutory objectives.

Successful implementation, according to Matland, requires compliance with statutes’ directives and goals; achievement of specific success indicators; and improvement in the political climate around a programme (as quoted in Hill ; Hupe, 2002, p.75). In this line, Giacchino and Kakabadse (2003) assess the successful implementation of public policies on decisive factors.

According to them, these are the decisions taken to locate political responsibility for initiative; presence of strong project management or team dynamics and level of commitment shown to policy initiatives. Apart from this, the success of a policy depends critically on two broad factors: local capacity and will. Questions of motivation and commitment (or will) reflect the implementer’s assessment of the value of a policy or the appropriateness of a strategy.

Motivation or will is influenced by factors largely beyond the reach of policy environmental stability; competing centres of authority, contending priorities or pressures and other aspects of socio-political milieu can also profoundly influence an implementer’s willingness. This emphasis on individual motivation and internal institutional conditions implies that external policy features have limited influence on outcomes, particularly at lower level in the institution (Matland, 1995). From the above discussion, implementation can be conceptualized as a process, output and outcome. It is a process of a series of decisions and actions directed towards putting a prior authoritative decision into effect. The essential characteristic of implementation process is the timely and satisfactory performance of certain necessary tasks related to carrying out of the intent of the law.

Implementation can also be defined in terms of output or extent to which programmatic goals have been satisfied. Finally, at highest level of abstraction, implementation outcome implies that there has been some measurable change in the larger problem that was addressed by the programme, public law or judicial decisions (Lester et al., 1995, p.

87). This study is basically focused on input, process and outputs of the reproductive health policy implementation in Nepal. The input factors are reproductive health policy, front line health workers and financial resource. Similarly, the process 38 factors are health institutions, level of decentralization and socio-administrative culture. The outputs are measured in the form of the results of the reproductive health policy implementation. Public policy implementation research, although practised globally mainly in the west for quite some time, is a new attempt in developing countries. The fact is that implementation inevitably takes different shapes and forms in different cultures and institutional settings (Hill ; Hupe, 2002, p.1).

A review of literature reveals a number of models which relate to the implementation of public policy. The majority of these models have been developed from Western context, ideas and points of views (Schofield, 2004, p. 284).

In a developed country, market mechanisms are overrated and the critical role of the state and societal culture is underrated (Dror, 1992, p. 276 – 279). Conceptually, implementation can be defined as a process, output and outcome. It is a process of a series of decisions and actions directed towards putting a prior authoritative decision into effect. The essential characteristic of implementation process is the timely and satisfactory performance of certain necessary tasks related to carrying out of the intent of the law. It can also be defined in terms of output or extent to which programmatic goals 24 have been satisfied.

Finally, at the highest level of abstraction, implementation outcome implies that there has been some measurable change in the larger problem that was addressed by the program, public law or judicial decisions (Lezter et al., 1995, p. 87). The translation of policy into practice in developing countries is a challenging and legitimate concern (Saetren, 2005, p.573). But, the policy implementation process in developing country shares a great deal with the process of in more developed country (Lazin, 1999, p.

151). However, the factors such as the effects of poverty, political uncertainty, people’s participation as well as the unique character of each developing country cannot be ignored in the policy implementation process. As first, ‘poverty is a state of economic, social and psychological deprivation occurring among people or countries lacking sufficient ownership, control or access to resources to maintain minimal acceptable standards of living’ (UNDP, 2002, p.

10). Poverty has a direct influence on the policy implementation process. The intended results cannot be achieved due to poverty in a developing country. Lane (1999), in an article entitled ‘Policy Implementation in Poor Countries’, argues that the problems connected with policy implementation in developing or Third World countries are intertwined with basic economic and political conditions. He contends that political stability and economic development are closely interrelated. On the one hand, low level of economic development leads to political instability and, on the other hand, political instability worsens poverty. Effective policy implementation improves poverty situation in the Third World countries, which need both economic development and political stability.

He is optimistic about the possibility of closing the gap between the rich and poor countries, provided strong and stable regimes utilize available economic resources to foster economic growth and development. Second, political uncertainty is an endemic condition to policy-making and implementation (Hanekom & Sharkansky, 1999). Political uncertainty refers to military threats, domestic violence, political regime change and so on. Uncertainty is likely to be more pronounced in developing than in developed countries due to severely limited resources, extensive demands for public services and investment, weak political institutions and limited 25 capacities for policy-making and program implementation amidst all other difficult conditions (Caiden & Wildavsky, 1974 as quoted in Nagel & Lazin 1999, p.

37-38). In a paper entitled ‘Policymaking and Implementation in the Context of Extreme Uncertainty: South Africa and Israel’, Hanekom and Sharkansky (1999) confirm the relationship between political uncertainty and policy implementation. Their paper illustrates uncertainties in each country by reference to past and recent events, and links these uncertainties to the country’s political, policy-making and policy implementation traits.

Extreme uncertainty is likely to affect the quality of policy-making and program implementation in both types of countries, but in different ways that show the influence of each country’s own traits. Finally, they recommend ways for other governments of developing countries to cope with uncertainties. Third, participation in public policy implementation processes is not so pronounced, and the channels for participation are less well-established in developing countries.

At the same time, the state structures, whatever their weaknesses, are relatively powerful vis-à-vis their societies. But, the interface between state and society is constantly changing. Of all the causes of poor policy evaluation in developing countries, the most serious institutional flaws are in political systems (Jain, 1992 & Moharir, 1992). Furthermore, a common assumption is that implementers are involved at every stage of the policy-making process, and that they are often the most powerful groups in setting the policy agenda.

In many developing countries, participation of lower level in the selection of sets of options is rare, and the choices are made by central-level policymakers. Very often, the problems the Third World bureaucracies have to deal with are more difficult to solve than those in developed countries, compounded by limited resources for implementation (Jain, 1992, p.24 & Moharir, 1992, p.

257). In this line, fourth, socio-administrative culture is another factor that affects policy implementation. Administrative culture differs from country to country. Culture incorporates social values, beliefs, norms and practices. It is defined as the collective programming of the mind, which is developed in the family in early childhood and reinforced in school and organizations; these mental programs contain a component of 26 national programmes (Hofstede & Hofstede, 2005, p.4).

They are expressed in different values that predominate among peoples from different countries. Hofstede classifies four dimensions: power distance, uncertainty avoidance, individualism versus collectivism, and masculinity versus femininity. It can be argued that, along these dimensions, dominant value systems in different societies can be ordered, which affect policy implementation processes in predictable ways. A study of administrative culture in Bangladesh reveals that the bureaucracy in Bangladesh is characterized somewhat more by traditional than by modern norms (Jamil, 2002, p.121-122). It is characterized by relatively high degree of power distance between authority and common citizens, low tolerance for ambiguities, dependence on traditional sources of information, low tolerance of bureaucrats than egalitarian, more positive towards Non-government Organization (NGOs), and preference for employees with traditional qualities (ibid). Fifth, people’s trust of public institutions, public awareness, accessibility and availability of services, and so on, should be taken into consideration for the sake of successful policy implementation in a developing country. Besides, interdependence between developed and developing countries arising from globalization is growing.

It has direct impact on the design and implementation of the policy of the country. Usually, aid conditionality as per the interest of the donor country determines whether a policy is translated into practice or not in a developing country. Despite an increased interest in public policy implementation in developing countries, it is surprising that so little empirical studies have actually been carried out in Nepal, especially from the socio-administrative perspective.

Therefore, this study attempts to explore and understand the implementation process in reproductive health service delivery at the local level in Nepal. This study argues that public policy implementation studies are not valuefree due to socio-cultural, political and economic variations in the country’s context. It may lead to new forms of policy implementation not yet well understoodThe Government of Nepal (GoN) has been emphasizing upon the health sector on the basis of sectoral approach.

GoN has been designing health policies regularly with the changing context. Since 1975, Nepal’s health policy was directed towards providing minimum services to the maximum number of people. Following the declaration of the ‘Health for All’ Strategy’ in 1978, GoN undertook policy measures and programs for the promotion of health at the national and district levels. In 1991, a National Health Policy-1991 (NHP) aimed at enhancing the health status of the country’s rural population, addressing service delivery as well as the administrative structure of the health system was adopted. The Eighth Plan (1992-97), the Ninth Plan (1997-2002), and the Second Long-Term Health Plan (1997-2017) were developed in keeping with the National Health Policy, 1991. The basic features are: a) Developing integrated and essential health care services at the district level and below; b) Encouraging active community participation and the mobilization of the private sector to develop general as well as specialized health services; c) Ensuring quality assurance in health care; d) Promoting inter- and intra-sectoral coordination; e) Decentralization of heath administration; f) Developing the traditional system of medicines; and g) Promoting the participation of national and International Non-government Organization (INGOs), private enterprises and foreign investors. Further, the Nepal Health Sector Program Implementation Plan (NHSP-IP) (2002-2009), and the Tenth Plan (2002-2007) aim to provide an equitable, high quality health care system for the people.

The Tenth Plan also incorporates the Millenium Development Goals (MDGs) with emphasizing on reducing child mortality, improving maternal health and combating HIV/AIDS, malaria and other diseases in health sector. Similarly, Health Sector Reform Strategy (HSRS) was developed on the basis of the Tenth Plan (2002-2007) and MDGs. It aims at moving the health sector towards strategic planning and a Sector-Wide Approach (SWAP). It provides operational guidelines for implementing the outputs of the HSRS (such as those related to improvement in supply of health care services and sector-wide management issues, including the management of financing and resource mobilization, physical assets and human resource development, as well as an integrated information system). To implement those policies, GoN has constituted health institutions throughout the country. These health institutions include Hospitals (87), Health Centers (6), Health Posts (697), Ayurvedic Hospitals (287), Primary Health Centers (205) and Sub-Health Posts (3,129). Besides, GoN mobilizes the NGOs and Community-based Organizations (CBOs) and the private sectors to implement the reproductive health policies in Nepal. For providing health service to the people, GoN manages the medical, para-medical and nonmedical employees as front line health workers in each health institution, except for the NGOs and privately-run hospitals.

Implementation inevitably takes different shapes and forms in different cultures and institutional settings. This point is particularly important in an era in which processes of ‘government’ have been seen as transformed into those of ‘governance’ (Hill ; Hupe, 2002, p.1). Implementation literally means carrying out, accomplishing, fulfilling, producing or completing a given task. The founding fathers of implementation, Pressman and Wildavsky (1973) define it in terms of a relationship to policy as laid down in official documents.

36 According to them, policy implementation may be viewed as a process of interaction between the setting of goals and actions geared to achieve them (Pressman ; Wildavsky, 1984, p. xxi-xxiii). Policy implementation encompasses those actions by public and private individuals or groups that are directed at the achievement of objectives set forth in policy decisions.

This includes both one-time efforts to transform decisions into operational terms and continuing efforts to achieve the large and small changes mandated by policy decisions (Van Meter ; Van Horn, 1975, p.447). According to Mazmanian and Sabatier (1983, p.20-21), policy implementation is the carrying out of a basic policy decision, usually incorporated in a statute, but which can also take the form of important executive orders or court decisions. The starting point is the authoritative decision. It implies centrally located actors, such as politicians, top-level bureaucrats and others, who are seen as most relevant to producing the desired effects.

In their definition, the authors categorize three types of variables affecting the achievement of legal objectives throughout this entire process. These variables can be broadly categorized as: tractability of the problem(s) being addressed; the ability of the statute to favourably structure the implementation process; and the net effect of a variety of political variables on the balance of support for statutory objectives. Successful implementation, according to Matland, requires compliance with statutes’ directives and goals; achievement of specific success indicators; and improvement in the political climate around a programme (as quoted in Hill & Hupe, 2002, p.75). In this line, Giacchino and Kakabadse (2003) assess the successful implementation of public policies on decisive factors. According to them, these are the decisions taken to locate political responsibility for initiative; presence of strong project management or team dynamics and level of commitment shown to policy initiatives. Apart from this, the success of a policy depends critically on two broad factors: local capacity and will.

Questions of motivation and commitment (or will) reflect the implementer’s assessment of the value of a policy or the appropriateness of a strategy. Motivation or will is influenced by factors largely beyond the reach of policy environmental stability; competing centres of authority, contending priorities or pressures and other aspects of socio-political milieu can also profoundly influence an implementer’s willingness. This emphasis on individual motivation and internal institutional conditions implies that external policy features have limited influence on outcomes, particularly at lower level in the institution (Matland, 1995). From the above discussion, implementation can be conceptualized as a process, output and outcome.

It is a process of a series of decisions and actions directed towards putting a prior authoritative decision into effect. The essential characteristic of implementation process is the timely and satisfactory performance of certain necessary tasks related to carrying out of the intent of the law. Implementation can also be defined in terms of output or extent to which programmatic goals have been satisfied. Finally, at highest level of abstraction, implementation outcome implies that there has been some measurable change in the larger problem that was addressed by the programme, public law or judicial decisions (Lester et al., 1995, p.87).

This study is basically focused on input, process and outputs of the reproductive health policy implementation in Nepal. The input factors are reproductive health policy, front line health workers and financial resource. Similarly, the process 38 factors are health institutions, level of decentralization and socio-administrative culture. The outputs are measured in the form of the results of the reproductive health policy implementation. ave not done any homework in the policy issue.

One NGOs activist remarked”the policy designing process in Nepal is very easy and quick but very difficult toimplement the same policy”.132CHAPTER VHEALTH SERVICE DECENTRALIZATION IN NEPAL:STATUS AND RECONSIDERATIONIn this chapter, the concept of decentralization is reviewed, and legislation process and itsimpacts on health service delivery are analyzed, particularly in Nepal. Besides, it examineshow health service decentralized planning is being executed in Nepal, and the mobilizationof the NGOs and private sector for the reproductive health policy implementation. For this,decentralization is taken as independent variables of health service decentralization.5.

1. BackgroundDecentralization has been an incessant theme in Nepal over the last five decades. It hasevolved according to the rationale of successive regimes (Gurung, 2003). It ranges from theRana Rule (pre-1951), for cosmetic purposes, to the Panchayat period (1960-90), to sustainelite power and further, for good governance after the restoration of democracy (post-1990). Some legal initiations which include Local Administration Act (1965), DistrictDevelopment Plan (1974), Decentralization Act (1982), Local Self–Governance Act(1999), etc. have been carried out. Besides, 13 high-level task forces/commissions wereconstituted for decentralization in four decades (Gurung 1998, p.

47). However, there iscentralized government structure as problem which loathes delegating authority (Mickesell,1999, p.145). In Nepal, the existing centralized decision-making, planning and budgetingsystem as well as central control of resources have been considered major constraints forgood governance and decentralization reform process. In this context, the overall133administrative system, staffing arrangements and accountability needs to be shifted from acentral to local orientation. The resistance from line ministries to devolve resources bothfinancial and staff to local governments has been a major constraint(Bista, 2003). Weakcapacity, structure, excess number and size of local governments are another seriousconstraint, which needs to be reviewed.

The number of local governments in Nepal isunreasonable and too large for effective and efficient planning, administration,coordination, cost efficiency, resource allocation and service delivery (Bista, 2003).5.2. Concept of DecentralizationDecentralization is widely believed that it increases possibilities for participation of allstakeholders; people would be empowered to manage their affairs; people shoulderresponsibilities and feel ownership; and there would be a more efficient provision of publicgoods and services for the people in general and the poor in particular.

Therefore, GoNemphasizes decentralization to devolve power in order to provide health service at the doorsteps of the people.Conceptually, decentralization within the state involves a transfer of authority to performsome services to the public from an individual or an agency in central government to someother individual or agency which is closer to the public to be served (Rondinelli andCheema, 1983). The transfer of authority can be done in two ways: territorial andfunctional. The basis of transfer of territorial authority is placed at the lower level ofterritorial hierarchy where service providers and clients are geographically closer.Similarly, the authority transfer can also be made functionally. There are three types ofsuch transfer of authority: i) within formal political structure, ii) within publicadministrative or parastatal structure and iii) from an institution of the state to a non-stateagency (Turner & Humle, 1997, p.152).

Expected benefits of the decentralization areassumed as it would promote local democracy, debureaucratization and mobilization ofpeople’s participation politically (Shrestha, 2000, p.55-56). From the administrative viewpoints, it improves administrative efficiency, make government quickly respond to theneeds and aspirations of the peoples’ and enhance the quantity and quality of services,government provides to the people (Shrestha, 2000, p.56). Similarly, from development134view point, it leads to better decision-making and greater efficiency and effectiveness onlocally specific plans, inter-organizational coordination, motivation of field level workers,and etc (Humle & Turner, 1997, p.156-157).However, these propositions of decentralization benefits seem from normative stance.

Itcan be argued of the possibilities of cost and risk of decentralization viz: loss of high scaleof economies and generation of duplication and underemployment of staff and equipment.It can create coordination problem among inter- or intra-organization within the state. Dueto the lack of resources, there might be institutional constraints that can hardly cope withthe need and aspirations of the people. The possibility of disintegration of state also can bedenied in the decentralization process. In practice too, the challenges of good governancethrough decentralization are many. In most developing countries, there has been a tendencyfor independent governments to prefer delegating power within the public servicedeconcentration rather than to locally elected authorities devolution.

There has beenmuch rhetoric about participation and local autonomy, but central governments havejealously guarded their power (Turner & Hulme 1997, p.151-175). Under the banner ofdecentralization, leaders have introduced policies that concentrate power and decisionmakingthat weaken local areas. Serious devolutions have been rare, and deconcentration orthe establishment of mixed authorities have been favored modes for Third World Leaders(Turner & Humle, 1997, p.174). Therefore, there seems a great tension betweendeconcentration and devolution of power for service delivery in developing country at thelocal level.5.2.

1 Legislation and its effectIn the case of Nepal, GoN has introduced one of the world’s most progressive legislationfor decentralization, devolving primary responsibility for local development to elected localauthorities (MoHP, 2006, p.9). As far as the health service decentralization program isconcerned, there is a provision of a committee headed by the Ministry of Health andPopulation consisting of Ministry of Finance, Ministry of Local Development, Ministry ofWomen, Children and Social Welfare and the National Planning Commission at the centrallevel. Interim Plan (2007) has outlined the guideline for the implementation of135decentralization scheme in districts. In view of the satisfactory results of thedecentralization program implemented districts, on the whole, where the health agencieswere handed over to the local bodies, such a policy would be continued to make the localbodies or communities responsible for the operation and management of health agencies.

Inthe decentralization scheme, it is said that local health agencies’ management committeeswill be given orientation training also. There will be a separate unit of management in theregion and department to conduct programs related to the decentralization scheme in thedistricts and local levels. Progress measurement, supervision and monitoring will beconducted by the central and regional levels without any external interference. There willbe coordination committees established from central to district levels to make the healthdecentralization scheme more effective, in consultation with the Ministries of Health andPopulation, Finance and Local Development. In addition, a decentralization policy will beprepared and its implementation process launched as an integral part of communityempowerment (Interim Plan, 2007).

In order to map the extent of decentralization at the local level in our two sample localgovernment units, it is hypothesized that the more the power and authority is transferredfrom the central level to the local level, the more the reproductive health policy would beimplemented effectively. From the field study, the result of the BVDC revealed that 67 percent respondents agreed that the transfer of power and authority from central level to locallevel affected the high degree of reproductive health policy implementation. But, thirtyfourper cent respondents disagreed that the transfer of power and authority from centrallevel to local level did not cause the reproductive health policy implementation. The resultshowed that the degree of reproductive health policy implementation depend on the transferof power and authority from central level to local level.In the case of LSMC, the result showed that 65 per cent respondents argued that there wastransfer of power and authority from central level to local level and there was also highdegree of reproductive health policy implementation while 51 per cent respondentsdisagreed there was not transfer of power and authority in LSMC, but reproductive healthpolicy was also implemented.

The agreement is that power and authority must be136transferred from central level to local level for the high degree of reproductive healthpolicy implementation. It showed that transfer of power and authority has directrelationship for the purpose of reproductive health policy implementation. It is concludedthat more transfer of power and authority at the local level leads to more reproductivehealth policy implementation.Table 5.

1: Responses on transfer of power and authority from central to local leveland degree of policy implementationTransfer of power and authorityBVDC LSMCDegree ofpolicyimplementationDisagree Agree N Disagree Agree NDisagree 66 33 32 49 35 30Agree 34 67 24 51 65 45Total N 41 15 56 35 40 75Notes: Figures in italic are percentageSource: Field study, 2009The comparison between BVDC and LSMC showed that slightly more power wasdevolved to the former than the latter. So far as it concerns the reproductive health policyimplementation, more reproductive health policy was implemented in LSMC than BVDC.The conclusion can be drawn that more power and authority are not enough to implementthe public policy, it demands institutional capacity for the purpose of policyimplementation whatsoever power and authority is transferred. As ex-chairman of BVDCsaid that the health post did not have the capacity to deliver reproductive health services tothe local people. Power and authority was transferred to the village level, but it lacked thecapacity. In other words, the village level health posts were not in a position to implementthe reproductive health policy to the degree that was prescribed.

Therefore, decentralizationscheme is implemented more effectively at the municipal level (LSMC) than the villagelevel (BVDC).However, the Local Self-Governance Act, 1999 mandates local government bodies tomanage and supervise sub or Health Post and their functioning, local committees and VDCand bodies like Health Management Committee (HMC) should control resources and137management of sub or health post (MoHP, 2006). Another discrepancy is the allocation ofresponsibilities without any provision for the required resources. These differences in rulesand regulations between Local Self-Governance Act, 1999, current periodic plans andMinistry of Health and Population guidelines and the role of local bodies (VDCs, andDDCs) are a major concern for enhanced community ownerships of Sub or Health Posts.Currently, VDCs receive central government grant of which 25 per cent are earmarked forsocial services, including health. In addition, VDCs can generate additional resources tocover the services. No extra central government funds accompany the new arrangementsunder Sub or Health Post handover.

While the committees have the responsibility tooversee and monitor the functioning of health staff, they have no responsibility for hiring orfiring them, which remains under the Ministry of Health and Population.The chair of the Sub-Health Post health committee is the VDC chairman when in post. Inthe current climate, the chairman is the VDC secretary. The guidelines state that thecommittee must have four women as members and two candidates have to represent thedalit/Janajati community (with one being a woman). The Sub-Health Post ManagementGuidelines outline the functions of the Sub-Health Post Management Committee but norole or responsibility to address gender and social inclusion concerns are stated.

Thefunctions are stated in a neutral manner, based on the assumption that services will reachall the members of the community. In an interview with the ex-chairmans of the Sub-Health Post Management Committee, Bangsing and Chilaunebash, “the responsibility ofthe management is not transferred in the true sense. People have no access to resources.”5.2.2 Tension between devolution and deconcentrationThe Local Self –Governance Act 1999 develops a unique mixture of devolution anddeconcentration. On the one hand, Nepal has started decentralizing health-care delivery bytransferring funds and responsibilities for managing health facilities to locally constitutedLocal Health Management Committees (LMHCs), in 2001. The logic behind thisdevolution is that by making health-care providers accountable to a local committee, thelocal residents will have more say in how public resources for health are used and that138consequently the quality of care will improve for the whole community.

On the other hand,Nepal has been practicing deconcentration since mid-20th century in health and othersectors. A key issue is that the point of contact between devolution and deconcentration,and the relations of authority be established.It is said that more delegated authority is more reproductive health policy implementation.Here, opinion have been sought to know the status of delegated authority. The field studyshowed that total mean score of level of delegated authority was improving. At present intotality, it is 2.

55, which is above average.Table 5.2: Level of delegated authorityCategories LSMC BVDC Total (mean)Mean (Now) 2.56 2.

54 2.55Mean (5 years ago) 1.87 1.94 1.91Total N 91 84Three points scale i.e. 1- deteriorated, 2- Neither deteriorated nor improved, 3-Improved,Source: Field study, 2009Five years ago, it was 1.

91, which neither meant deteriorated nor improved. Categorically,the mean score of LSMC (91 respondents) was 2.56, which was more than average, whilethe mean score of LSMC 5 years back was 1.87, that is below average.Similarly, at BVDC (84 respondents), the mean score of delegated authority was 2.54 now,compared to 1.94 five years ago.

The study showed that the level of delegated authority atthe local level was improving, but not satisfactory because quality and quantity ofreproductive health service delivery was not found as prescribed.In comparison between LSMC and BVDC, the delegated authority was more in LSMCthan in BVDC. It meant that more reproductive health policy was implemented in LSMCthan in BVDC.However, while examining Local Self-Governance Act, 1999 in Nepal, there are twoproblematic points of contact between deconcentration and devolution. First, from a139functional backdrop of deconcentration, it is represented by the ministries with their linesof managerial authority stretching out to the districts.

Shrestha (2000, p.42-3) points to theproblematic relationship between the deconcentrated line agencies represented at thedistrict level and devolved system of DDCs and VDCs: “Since the jurisdictions of the localbody and line agencies overlap, the DDC itself yields little competence to influence thedecision-making of the line agencies in the district. The line agencies function under thedirect and exclusive administrative control of their respective ministries which providethem with their annual programs including their targets and budgets.” Similarly, Adhikari(2001, p.9) sees the problem in terms of dual accountability of the line agencies which are,on one hand, accountable to parliament and the Auditor General and, on the other, arerequired by the Local Self-governance Act to develop new forms of planning andaccountability. LAFC (2000, p.41) also points out that “although local bodies have powersto monitor locally based government agencies and NGOs, they are not complete becausetheir powers are not mandatory.

“The second form of deconcentration in Nepal is integrated deconcentration. This isrepresented by the Local Development Officer (LDO) in the DDC or Secretary in the VDC.This post came under some criticism, they are working at VDC or DDC but their work isevaluated by the Secretary of the Ministry of Local Development (Collins and et al, 2003,p.

58-9). It raised the question of how they are accountable toward the elected leader at thelocal level. It clearly showed that there was a mismatch between the spirit of devolutionand deconcentration. As a result, it hampered with the reproductive health policyimplementation at the local level.5.2.

3 Spatial hierarchyIt is hypothesized that less spatial hierarchy is more reproductive health policyimplementation. In Nepal, the territorial units within a country were divided into fourteenzones, 75 districts and more than 4,000 VDCs and a number of municipalities for thepolitical and administrative purpose in 1963 (Thapa, 1963). The zonal level was createdbasically for political purposes to filter political representation to the Rastriya Panchayat(National Assembly) and for security surveillance (Subba, 2004, p.775-788). The districts140were assigned administrative and development functions, which later (1965-70) wereconsidered the basis of decentralization (Gurung, 2006, p.

22). In 1972, the country wasdivided into four development regions and later (1978) into five (Sharma, 2004, p.61-96).Since the formation of the development regions in 1972, various ministries established theirregional offices/directorates at the designated regional centers with the dismantling ofdepartment of the various sectoral ministries. There are five health regional directorates.These offices act as a pool between the central and district health offices. These officescollect the monthly reports from districts and zonal offices, and report periodically to theMinistry. Later on, these regional directorates were kept under the Department of HealthService which was revived after the restoration of democracy.

These regional health officesare not under the control of regional administrative offices but accountable to the respectivecentral offices. It made regional level as superfluous hierarchy (Gurung, 2006, p.22).After the restoration of democracy, zonal administration was abolished as a vestige of theautocratic regime. But, there are ten zonal hospitals in the country.

These zonal hospitalswere established under the Developmental Act (2059 BS). These hospitals are directlyaccountable toward the Ministry, not regional health directorate or regional administration.Zonal and regional administrators have been appointed recently due to security reasons notdevelopment concern. These regional and zonal offices have no right to monitor, superviseand give feedbacks to regional service delivery offices e.g. health offices.

The underlinedreason is the lack of adequate delegation of authority, whereby these regional officesbecame redundant hierarchy between the central and district levels. Besides, theapplications of regional perspective in Nepalese development are the highly centralizedsystem of governance and the primacy of sectoral approach (Gurung, 2005). Therefore, itdiscontinued the chain of command, which led to weaker implementation of the healthpolicy, particularly reproductive health policy. In an interview, the Director of Departmentof Health Service said that the organizational arrangement of health services was notsatisfactory. It brought the spatial hierarchy only, which made it difficult to implement thehealth policy.

1415.2.4 Decentralized planningMore decentralized planning means more people’s participation that leads to morereproductive health policy implementation.

The decentralized planning process emphasizesto ensure active people’s participation in local development process aimed at enhancing theproduction of goods and services for the promotion of the welfare of the local people ingeneral and rural poor in particular (Shrestha, 2000, p.85).According to Lohani (1980), mass participation in the implementation of decisioncan be effective only when there has been mass participation in decision making aswell… those participation in implementation should be viewed as a system ofinterlocking relationship between the villagers, the village level institution thatmobilizes this participation, and than the higher level institution further up to thenational level.It makes the people the focal point for entire development activities and goods andservices. Similarly, it mobilized the public, private, corporate bodies and social and NGOssectors for accelerating the development process at the local level.It is hypothesized that greater people’s participation in the planning process leads to morereproductive health policy implementation. Based on the field study, in BVDC, the resultshowed that 70 percent respondents who argued that there was people’s participation inplanning process, there was also high degree of reproductive health policy implementationwhile 60 percent who disagreed of people’s participation also said that there was highdegree of reproductive health policy implementation. Therefore, agreement of the degree ofreproductive health policy implementation does not depend on people’s participation inplanning process.

142Table 5.3: People’s participation in planning making process at local level and degreeof policy implementationPeople’s participationBVDC LSMCDegree ofpolicyimplementationDisagree Agree N Disagree Agree NDisagree 40 30 26 55 35 41Agree 60 70 54 45 65 49Total N 20 60 80 35 55 90Note: Figures in italic are percentageSource: Field study, 2009Similarly, in LSMC, the result showed that sixty-five per cent of the respondents acceptedthat people’s participation in the planning process led to high degree of reproductive healthpolicy implementation. On the other side, forty-five percent disagreed about theparticipation of the people in planning process even than there was also reproductive healthpolicy implementation. It meant that the degree of reproductive health policyimplementation does not depend on the people’s participation in the planning process atLSMC.In comparison between BVDC and LSMC, the people’s participation in planning processwas slightly better in BVDC than LSMC. However, the degree of reproductive healthpolicy implementation was concerned; it was found that it did not depend on the people’sparticipation in planning making process.

Categorically, more BVDC respondents wereinvolved in the planning process than LSMC respondents. It meant that there was localpeople’s involvement in program offered by the health institutions. However, ex-chairmanof Bangsing VDC said that the planning process in the health post was only a show. Thiswas in the form of voluntary labor contribution at the local level.

It is assumed that some actors should be involved in the planning process. Local Self-Governance Act, 1999 outlines that local leaders, women, local NGOs and CBOs,minorities and others should be involved in the planning process at the local level. Thestudy has depicted that 53 percent of the local leaders, 9 percent of NGO activists, 3143percent of the common people and 35 percent of the people at large were involved in theplanning process.Table 5.4: Involved actors for the planning process in the health institutionsCategories LSMC BVDC TotalLocal Leader % 44 62 53NGO activists % 18 – 9Lower People % 4 2 3People at large % 34 36 35Total N 91 84 175Source: Field study, 2009The Table No.

5.4 showed that 62 per cent of the respondents agreed that local leaders inBVDC were involved in the planning process whereas and 44 per cent in LSMC. Therewere no NGO activists related to the health sector in BVDC.

The NGOs were active only inLSMC area. The data showed that slightly more common people were involved in BVDCthan LSMC. In an interview, the ex-chairman of Bangsing VDC said that educated malespeople did not stay back in the village. This made it difficult to mobilize the local peoplefor reproductive health policy implementation.So far as decentralized health planning is concerned; health service delivery is arrangedalong sectoral line agencies and local health organizations. The Ministry of Health andPopulation and its departments along with other private and NGOs cover the health sector.Generally, they follow directives and targets set by national development policy and plans.But, the ministry and department have their own policies and programs.

There is virtually aweak mechanism for feeding the concerns of the local communities into the planningprocess, because the planning levels are physically and institutionally far from the localpeople (Shrestha, 2000). However, this necessarily does not mean that there is nointegration of planning efforts across different sectors, but integration often takes place athigher levels where the decisions are made on the allocation of resources. At theimplementation level, there is little integration among the line agencies. Some integrationappears where the extension services are multipurpose and cover wide range of areas, butplanning and intervention of program are generally carried out by each separate technical144team recruited by central government in accordance with what they consider to be prioritiesfor their sector (Paudel, 2002, p.194.) However, as revealed by the study, the degree ofdecentralized planning had somewhat improved compared to five years ago.

The total meanscore at present is 2.58 which is more than the average. This figure was 1.98 five years ago,which means it had neither deteriorated nor improved.Table 5.5: Level of decentralized planningCategories LSMC BVDC TotalNow (mean) 2.

66 2.50 2.58Five yrs ago (Mean) 1.97 2.

00 1.98Total N 91 84 175Three points scale i.e. 1- deteriorated, 2- Neither deteriorated nor improved, 3-ImprovedSource: Field study, 2009The mean score for LSMC was 2.

66 compared to 1.97 five years ago. Similarly, the meanscore for BVDC was 2.5, on comparison to 2.00 five years ago.

It showed that the level ofdecentralized planning was more or less of similar degree at both places.However, integrated health service planning approach retains most of the core ideas ofholistic planning, but is more focused on major key issues. It does not seek to analyze allcomponents and linkages to prevent the planning document from being a historicaldocument rather than a strategic one. The interpretation is done with a limited focus for anumber of reasons. First, it accepts that we are unlikely to be able to understand allvariation in a system, and relatively small numbers of variables cause a large proportion ofvariations in health service delivery. Besides, this keeps more realistic expectations andallows plans to be completed in a more reasonable time frame (Michel 1996). Integratedplanning approach tries to integrate planning activities across the various sectors at alllevels.

Generally, the process of integration commenced with a top-down modeestablishing national level planning mechanism and institution. However, theinstitutionalization of integrated planning frequently involves some degree of devolution ofplanning responsibilities and resources allocation on lower levels of administration.145Coordination across sectors is relatively better at these levels and planning mechanisms arecloser to the communities.In Nepal, the health service sector is based on a target-oriented approach, where the targetis passed down from the top, i.e. from the National Planning Commission to Ministry levelto the district level.

However, often the target given to the local levels is unrealisticallyhigh and impossible to fulfill (UNFPA, 1989, p.171). Because of the wide chasm betweenthe targeted policy goals and their implementation, most people feel dejected. The factseems to be that irrespective of the commitment and resources of the agencies in charge ofthe implementation, some policies are impossible to implement from the outset (Hoppe,1992, p.327)It is found that health policies are very general without specified tasks and objectives forimplementers at each level.

It appears that figures and statistics receive a disproportionateamount of importance. In others words, the targets themselves are more important than howto achieve them. According to UNFPA, the management at the Ministry of Health andPopulation suffers from over-centralized planning and budgeting, poor financial andinformation management, a personnel system too dependent on informal criteria, poor staffmotivation and poor supervising practices. Furthermore, there is a lack of “objective”evaluation. In the case of health service, problems are under-reported and achievementsover-reported (UNFPA, 1989).

A lack of trained staff to do policy analysis is a furtherproblem (Moharir, 1992, p.261). It appears that one problem reinforces the other problems.For example, the absence of specification and appropriate planning is aggravated byincorrect information.5.2.5 Increasing disparityIncreasing disparity of health institution from the perspective of availability of healthservice means a lower degree of reproductive health policy implementation. In Nepal, thereare more than four thousand health institutions constituted throughout the country.

Thesehealth institutions are Hospitals (87), Health Centers (6), Health Posts (697), Ayurvedic146Hospitals (287), Primary Health Centers (205) and Sub-Health Posts (3,129). Among them,75 per cent of the health institutions are located in the rural areas of the country.As regards the appropriate sites for health institutions, 87 per cent of the respondentsopined the appropriateness of the health institution sites. Categorically, 100 per cent BVDCrespondents agreed on the appropriateness of the health institutions sites, likewise 75 percent LSMC respondents accepted appropriateness of their health institution sites.Table 5.6: Proper place for health institution sitesCategories LSMC BVDC TotalYes % 75 100 87No % 25 – 13Total N 91 84 175Source: Field study, 2009However, the number of health units does not realistically reflect the status of healthservice facility across rural and urban areas.

There are two important aspects to beconsidered: distribution pattern of health institutions and quality of service (Shrestha, 2006,p.125). In remote areas, particularly in Mountain and Hilly areas, access to available healthfacility is constrained due to greater ‘friction of space’, measured in term of ruggedtopography and distance. Moreover, available health service in such areas is of low quality.On the other hand, access to available service is easy in Terai and urban areas due to low’friction of space’ resulting from transport facilities and favorable terrain. Therefore, thisshows the disparity between urban and rural areas. This friction of space caused the lowlevel of reproductive health policy implementation.5.

3.Mobilization of NGOsIt is hypothesised that the mobilization of NGOs/CBOs for reproductive health servicescomplements the reproductive health policy implementation. The data revealed that theNGOs have become one of the fastest growing sectors in Nepal, particularly after thepolitical change of 1990. There are over 60,000 registered NGOs all over the country. Outof these NGOs, 30,000 (approx) are affiliated with Social Welfare Council (SWC), a147government bureau for looking after the NGOs (SWC, 2011). There could be numerousunregistered groups for civic action, which might have long historical backgrounds. Due tothe absence of proper recording systems, it is difficult to get the precise number of NGOsin Nepal (Dhakal, 2006, p.118).

Table 5.7: NGOs affiliated with Social Welfare Council Sector-wiseSector Number PercentCommunity and Rural Development 18,625 61.5Youth Service 4,321 14.26Women Service 2,305 7.61Environmental Protection 1,318 4.35Child Welfare 951 3.14Moral Development 876 2.89Health Service 703 2.

32Handicapped and Disabled Service 597 1.97Educational Development 492 1.62AIDS and Abuse 88 0.29Total 30,284 100Source: Social Welfare Council, 2011, www.

swc.org.npSocial Welfare Council categorized these NGOs into ten types. Among them, the numberof Community and Rural Development NGOs account for 61.

5 percent; the highest numberof NGOs in Nepal, whereas AIDS and Abuse Control NGOs are only 0.29 percent.Similarly, the Health Service related NGOs number only 703 (2.32 percent). (For detail seeTable No.5.7)The distribution of the health service related NGOs within Nepal is not seen ashomogenous. The NGOs are concentrated only in a few districts.

For example, near aboutfifty percent of the NGOs are in Kathmandu, the capital city of Nepal. The rest of theNGOs are also located in more developed districts, like Lalitpur (8%), Kavre(4%),Kaski(3%), Bhaktapur(2%), Chitawan(2%), Morang(2%), Banke(2%), Dhanusa (1%),Dhading (1%) etc.148Table 5.8: Distribution of health service related NGOs District-wiseDistricts Number PercentageKathmandu 344 49Lalitpur 55 8Kavre 30 4Kaski 21 3Bhaktapur 16 2Chitawan 16 2Morang 13 2Banke 12 2Dhanusa 11 1Dhading 11 1Source: SWC, 2011Sixteen districts have one NGO each, six districts have two each, nine districts have 3NGOs each, six districts have four NGOs each, and three districts have five NGOs each.Similarly, seven districts have six NGOs each, two districts have seven NGOs each, andtwo districts have eight NGOs each. Most of the NGOs are based in the districtheadquarters. In 12 districts, there is not even a single NGO working in the health servicesector.Dhakal (2006, p.

218) outlined the reasons for the growth of NGOs in Nepal as follows.Firstly, the changed international political arena and global environment and thedevelopment cooperation funding strategy of international donor agencies such as WorldBank, Organization for Economic Cooperation and Development (OECD), AsianDevelopment Bank (ADB), etc. helped for opportunity to play an increased role in thesocio-economic activities. Secondly, the democratization of political system and economicliberalization also contributed to the proliferation of NGOs in Nepal. Thirdly, thegovernment has changed the national development strategy and considered NGOs asdevelopment partners which also encouraged people’s participation in nationaldevelopment activities through NGOs. All this provided a congenial environment forincreasing the number of national NGOs in Nepal, particularly since 1990s.149However, it has also been recognized that NGOs seem to be indispensable allies in thedelivery of primary health-care, not only because they supplement government resourcesbut also because there is much to be learnt from their experiences, expertise and innovativeventures. Moreover, NGOs have considerable advantage over the public sector because oftheir personalized approach, motivation, and necessary zeal, sympathy for the deprivedsections, responsiveness to the people’s need, creativity, and above all, the flexibility toexperiment with innovative and alternative approaches in order to solve health problems(Ali, 1991, p.

9).It can be said that greater involvement of NGOs/CBOs in the area means moreimplementation of the reproductive health policy. However, the field study showed thatthere was no NGO and CBO delivering reproductive health services in the study area i.e.BVDC.

At LSMC, 64 per cent opined that NGOs and CBOs were delivering healthservices at their place and also accounted to high degree of reproductive health policyimplementation, whereas 56 per cent disagreed that NGOs and CBOs were not deliveringreproductive health services, but reproductive health policy was also implemented in theirabsence. The difference between these two categories was not big difference. It means thatCBOs and NGOs are delivering reproductive health services at LSMC along with the otheractors. It did not show the significant role of NGOs and CBOs in the reproductive healthpolicy implementation at local level.Table 5.9: Do you know that NGOs/CBOs are delivering reproductive health servicesat your place and degree of policy implementation?Delivering of reproductive health servicesBVDC LSMCDegree ofpolicyimplementationYes No N Yes No NDisagree – 51 43 36 44 37Agree – 49 41 64 56 54Total N – 84 84 39 52 91Note: Figures in italic are percentageSource: Field study, 2009150Experiences from other parts of the world, including India and Bangladesh, have alsodemonstrated that NGOs can assist in providing people with information, technical supportand decision-making possibilities, which could enable them to share in opportunities andresponsibilities for action in the interest of their own health (Rashid ; et al, 2011).Today, in Nepal, the government encourages NGOs to work with the support of INGOs inproviding services such as health. Prominent INGOs working in health are the UnitedMission to Nepal, Save the Children (US and UK), Netherlands Leprosy Relief, the AsiaFoundation, Plan International, and Marie Stopes International. The key national NGOs arethe Family Planning Association of Nepal, Aama Milan Kendra (Mothers’s Club), NepalContraceptive Retail Sales Company, Nepal Red Cross Society, and Nepal Vitamin AProgram (DOHS, 2005/06).The following range of services are provided by NGOs/CBOs (ESP, 2001, p.126):· Socio-cultural services: education, advocacy and awareness raising;· Community development service: the integrated provision, usually of health,drinking water, sanitation, and environmental protection; and· Economic services: savings and credit management, labor exchange, microirrigation,and marketing.From the study, it is seen that the role played by the NGOs and CBOs was not satisfactory.Seventy-six percent of the respondents opined that the role played by NGOs and CBOs wasnot satisfactory.Table 5.10: Are you satisfied with the role played by NGOs/CBOs?Categories LSMC BVDC TotalYes % 24 – 24No% 76 – 76Total N 91 – 91Note: Figures in italic are percentageSource: Field study, 2009151Categorically, 76 percent of the LSMC respondents opined that people were unsatisfiedwith the role played by the NGOs and CBOs with respect to reproductive health servicedelivery. Only 24 percent of the respondents opined that they were satisfied with the roleplayed by NGO and CBO (for details see Table No 5.10).However, the NGOs have been particularly successful in facilitating social mobilization.They have been involved in establishing a large number of self-help organizations andcommunity women’s groups which are involved in a range of activities, from managingforests to organizing small-scale savings and credit programs including health servicedelivery (ESP, 2001).NGOs can play an active role in the creation and mobilization of assets, launch appropriateactivities and create an environment to promote access to livelihood items. Due to theirgrassroots attachment, direct approach, flexible and easy delivery to the needygroups/areas, they provide better services to their target group. However, there is a debateon their role in Nepal. This study showed that 67 per cent respondents opined that theNGOs were donor- centric and the remaining 33 per cent respondents as urban-centric.Hence, it showed that the NGOs are either urban or donor-centric.Table 5.11: Dissatisfaction with role of NGOs/CBOsCategories LSMC BVDC TotalUrban Centric % 33 – 33Donor Centric % 67 – 67Total N 69 – 69Source: Field study, 2009However, NGOs as development partners of government have been vaguely specified inthe policy document, and lacuna of the policies regarding NGOs’ function can be seenexplicitly. It is natural that in the absence of a clear policy direction for selecting certaintype of functions, target group or the area are often subject to whims, caprices and/orsimply interest of the intervening organization such as NGOs and often direct/ indirectdirection of the donor organization. Some of the important policy shortcomings for152bringing NGOs to address health issues in Nepal are as follows (Interview with NGOactivists).· There is a lack of clear direction for the functions in term of nature of works, typesof target groups, geographic location, etc for the NGOs in Nepal.· Most of the NGOs are guided by a project approach rather than a long-termapproach with enhanced institutional capacity.· Coordination is one of the missing parts of the NGO landscape. It is difficult to findout the type of NGOs based on nature of work, capacity, know-how andgeographical coverage. Though social-welfare council- a governmentalcoordinating body- is responsible for coordinating both NGOs and INGOs, due tothe lack of institutional capacity the coordination function has become inefficient.· There is a severe lack of monitoring and evaluation of NGOs’ activities in Nepal.· On top of these problems, 70 per cent of the total NGOs are still concentrated in theurban areas, though the severity of the problems is more in the rural areas. Thispoints to the fact that the increased number of NGOs do not contribute much inimproving the livelihood of the people living in poverty and other forms ofvulnerability. Such a situation also affects NGO dynamism in Nepal.However, the role of NGOs in Pharmacy, Laboratory and other sectors of health policyimplementations is ill-defined. Besides, there is lack of adequate policy guidelines,strategies and mechanisms for functional coordination of policy issues among public,private and NGO sectors and GoN development partners.5.4. Private Health CarePrivate health care is run by individuals or by groups of individuals similar to commercialorganizations (ESP, 2001). The individuals are mostly health workers of different levelswho run their private clinic either full time or on a part-time basis. Most of the governmenthealth employees work in their private clinics in the urban areas. The privately run drugstores (pharmacy) also dispense medicines including many antibiotics. The commercialorganizations are usually named nursing homes that are similar to the hospital in terms of153service facilities. The private sector, both commercial organizations and individualpractitioners, are limited in the town (ESP, 2001). The present government policy is toinvolve the private sector in health services so that government health policy would beimplemented properly. It can be said that more involvement of private health clinics/nursing homes/ private hospitals can implement the health policy especially reproductivehealth policy.The private sector provision of health services is increasing. Many Nepalese still resort tolocal herbal cures and faith healers to cure their illnesses, whilst many other attend privateayurvedic and homeopathic practitioners. There are approximately 100 private hospitalsand nursing homes and thousands of private health clinics and laboratories offering accessto conventional medicine. These facilities are mainly available in the urban centers, mostlyin the Kathmandu Valley (DOHS, 2008).From the study, it was also revealed that there was no private health clinics/ NursingHomes/Private Hospitals in the study area i.e. BVDC. In the case of LSMC, 59 percent ofthe respondents opined that private health clinics/nursing homes/private hospitals areinvolved in the reproductive health delivery and private sectors also contributing toimplement the reproductive health policy.Table 5.12: Are private health clinics/Nursing homes/private hospitals working atyour place and degree of reproductive health policy implementation?Delivery of reproductive health service by private sectorsBVDC LSMCDegree ofpolicyimplementationYes No Yes NoDisagree – 51 41 -Agree – 49 59 -Total N – 84 91 -Note: Figures in italic are percentageSource: Field study, 2009At LSMC, there were private health clinics, nursing homes and private hospitals deliveringhealth services. It means that reproductive health policy was implemented fairly i.e.154reproductive health services was delivered by the nursing homes, private clinics, privatehospitals, etc. Hence, they are contributing to implement reproductive health policy inLSMC.Regarding to the satisfaction of the reproductive health service delivered by the privatesector, only 56 per cent of the LSMC respondents were satisfied with the role played by theprivate clinics/Nursing Home/ Private Hospitals. A service recipient remarked that theservice offered by the private sector is expansive. Common people can hardly afford it.Private sector provides the reproductive service timely than public sectors.Table 5.13: Are you satisfied with the role of private clinics/Nursing homes/ privatehospitals?Categories LSMC BVDC TotalYes % 56 – 56No % 44 – 44Total N 91 – 91Source: Field study, 2009However, there is a growing concern over the lack of regulations in the provision of basicservices provided by the private sector. The government has been attempting to address thisby developing quality standards. In 2001, GoN developed the “Standard Guideline andTreatment Protocols’ which is executed in publicly and privately run health clinics,hospitals and nursing homes (ESP, 2001, p.128). However, the laboratory services provideby public and private sectors are often of poor quality. There is no clear policy for qualityassurance in public, private and NGO health systems. The legal framework forimplementing quality assurance is weak or absent, especially in the private sector. Inaddition to this, private, NGOs and development partner funding is not effectivelycoordinated, not linked to the government’s overall health sector plans.5.5. ConclusionsIn the study, it is hypothesized that more the decentralization scheme, there is likely toenhance more reproductive health policy implementation. Decentralization was taken as a155convenient tool to reinforce respective regime’s political power in spite of it being anincessant theme in Nepal for the last five decades. Some legal initiations for thedecentralization were also made. At present, Local Self-governance Act, 1999 is inoperation. It mandates local government bodies to manage and supervise Health Posts andSub-Health Posts in order to deliver health service effectively including otherdevelopmental activities. However, there is mismatch between the allocation ofresponsibilities and the provision of required resources. There are contradictory rules andregulations between Local Self-governance Act, Interim Plan and Ministry of Health andPopulation guidelines and the role of local bodies. As a result, the jurisdictions of the localbodies and the line agencies overlap. Local bodies cannot influence the decision-making ofline agencies.The field study showed that more power was devolved in BVDC than LSMC. So far as thereproductive health policy implementation was concerned, more reproductive policy wasimplemented in LSMC. It identified that power and authority devolved is not sufficientcondition for policy implementation, it demands capacity as well. In LSMC in comparewith BVDC, there was more option for receiving the reproductive health services. Forexample, private sectors’ hospitals/nursing home/clinic and NGOs including governmenthospitals were delivering reproductive health services. But, in BVDC, there were noalternative except government run health post.There is tension between devolution and deconcentration process in Nepal. From the thrustof Local Self-governance Act, 1999, local bodies are the main service providers to thecommon people. But, line agencies of each ministry are stretched out to the district level.These agencies do not want to delegate their power and authority to the local bodies. Thejurisdiction of the local body and line agencies overlaps. 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One NGOs activist remarked”the policy designing process in Nepal is very easy and quick but very difficult toimplement the same policy”.132CHAPTER VHEALTH SERVICE DECENTRALIZATION IN NEPAL:STATUS AND RECONSIDERATIONIn this chapter, the concept of decentralization is reviewed, and legislation process and itsimpacts on health service delivery are analyzed, particularly in Nepal. Besides, it examineshow health service decentralized planning is being executed in Nepal, and the mobilizationof the NGOs and private sector for the reproductive health policy implementation. For this,decentralization is taken as independent variables of health service decentralization.5.1. BackgroundDecentralization has been an incessant theme in Nepal over the last five decades. It hasevolved according to the rationale of successive regimes (Gurung, 2003). It ranges from theRana Rule (pre-1951), for cosmetic purposes, to the Panchayat period (1960-90), to sustainelite power and further, for good governance after the restoration of democracy (post-1990). Some legal initiations which include Local Administration Act (1965), DistrictDevelopment Plan (1974), Decentralization Act (1982), Local Self–Governance Act(1999), etc. have been carried out. Besides, 13 high-level task forces/commissions wereconstituted for decentralization in four decades (Gurung 1998, p.47). However, there iscentralized government structure as problem which loathes delegating authority (Mickesell,1999, p.145). In Nepal, the existing centralized decision-making, planning and budgetingsystem as well as central control of resources have been considered major constraints forgood governance and decentralization reform process. In this context, the overall133administrative system, staffing arrangements and accountability needs to be shifted from acentral to local orientation. The resistance from line ministries to devolve resources bothfinancial and staff to local governments has been a major constraint(Bista, 2003). Weakcapacity, structure, excess number and size of local governments are another seriousconstraint, which needs to be reviewed. The number of local governments in Nepal isunreasonable and too large for effective and efficient planning, administration,coordination, cost efficiency, resource allocation and service delivery (Bista, 2003).5.2. Concept of DecentralizationDecentralization is widely believed that it increases possibilities for participation of allstakeholders; people would be empowered to manage their affairs; people shoulderresponsibilities and feel ownership; and there would be a more efficient provision of publicgoods and services for the people in general and the poor in particular. Therefore, GoNemphasizes decentralization to devolve power in order to provide health service at the doorsteps of the people.Conceptually, decentralization within the state involves a transfer of authority to performsome services to the public from an individual or an agency in central government to someother individual or agency which is closer to the public to be served (Rondinelli andCheema, 1983). The transfer of authority can be done in two ways: territorial andfunctional. The basis of transfer of territorial authority is placed at the lower level ofterritorial hierarchy where service providers and clients are geographically closer.Similarly, the authority transfer can also be made functionally. There are three types ofsuch transfer of authority: i) within formal political structure, ii) within publicadministrative or parastatal structure and iii) from an institution of the state to a non-stateagency (Turner & Humle, 1997, p.152). Expected benefits of the decentralization areassumed as it would promote local democracy, debureaucratization and mobilization ofpeople’s participation politically (Shrestha, 2000, p.55-56). From the administrative viewpoints, it improves administrative efficiency, make government quickly respond to theneeds and aspirations of the peoples’ and enhance the quantity and quality of services,government provides to the people (Shrestha, 2000, p.56). Similarly, from development134view point, it leads to better decision-making and greater efficiency and effectiveness onlocally specific plans, inter-organizational coordination, motivation of field level workers,and etc (Humle & Turner, 1997, p.156-157).However, these propositions of decentralization benefits seem from normative stance. Itcan be argued of the possibilities of cost and risk of decentralization viz: loss of high scaleof economies and generation of duplication and underemployment of staff and equipment.It can create coordination problem among inter- or intra-organization within the state. Dueto the lack of resources, there might be institutional constraints that can hardly cope withthe need and aspirations of the people. The possibility of disintegration of state also can bedenied in the decentralization process. In practice too, the challenges of good governancethrough decentralization are many. In most developing countries, there has been a tendencyfor independent governments to prefer delegating power within the public servicedeconcentration rather than to locally elected authorities devolution. There has beenmuch rhetoric about participation and local autonomy, but central governments havejealously guarded their power (Turner & Hulme 1997, p.151-175). Under the banner ofdecentralization, leaders have introduced policies that concentrate power and decisionmakingthat weaken local areas. Serious devolutions have been rare, and deconcentration orthe establishment of mixed authorities have been favored modes for Third World Leaders(Turner & Humle, 1997, p.174). Therefore, there seems a great tension betweendeconcentration and devolution of power for service delivery in developing country at thelocal level.5.2.1 Legislation and its effectIn the case of Nepal, GoN has introduced one of the world’s most progressive legislationfor decentralization, devolving primary responsibility for local development to elected localauthorities (MoHP, 2006, p.9). As far as the health service decentralization program isconcerned, there is a provision of a committee headed by the Ministry of Health andPopulation consisting of Ministry of Finance, Ministry of Local Development, Ministry ofWomen, Children and Social Welfare and the National Planning Commission at the centrallevel. Interim Plan (2007) has outlined the guideline for the implementation of135decentralization scheme in districts. In view of the satisfactory results of thedecentralization program implemented districts, on the whole, where the health agencieswere handed over to the local bodies, such a policy would be continued to make the localbodies or communities responsible for the operation and management of health agencies. Inthe decentralization scheme, it is said that local health agencies’ management committeeswill be given orientation training also. There will be a separate unit of management in theregion and department to conduct programs related to the decentralization scheme in thedistricts and local levels. Progress measurement, supervision and monitoring will beconducted by the central and regional levels without any external interference. There willbe coordination committees established from central to district levels to make the healthdecentralization scheme more effective, in consultation with the Ministries of Health andPopulation, Finance and Local Development. In addition, a decentralization policy will beprepared and its implementation process launched as an integral part of communityempowerment (Interim Plan, 2007).In order to map the extent of decentralization at the local level in our two sample localgovernment units, it is hypothesized that the more the power and authority is transferredfrom the central level to the local level, the more the reproductive health policy would beimplemented effectively. From the field study, the result of the BVDC revealed that 67 percent respondents agreed that the transfer of power and authority from central level to locallevel affected the high degree of reproductive health policy implementation. But, thirtyfourper cent respondents disagreed that the transfer of power and authority from centrallevel to local level did not cause the reproductive health policy implementation. The resultshowed that the degree of reproductive health policy implementation depend on the transferof power and authority from central level to local level.In the case of LSMC, the result showed that 65 per cent respondents argued that there wastransfer of power and authority from central level to local level and there was also highdegree of reproductive health policy implementation while 51 per cent respondentsdisagreed there was not transfer of power and authority in LSMC, but reproductive healthpolicy was also implemented. The agreement is that power and authority must be136transferred from central level to local level for the high degree of reproductive healthpolicy implementation. It showed that transfer of power and authority has directrelationship for the purpose of reproductive health policy implementation. It is concludedthat more transfer of power and authority at the local level leads to more reproductivehealth policy implementation.Table 5.1: Responses on transfer of power and authority from central to local leveland degree of policy implementationTransfer of power and authorityBVDC LSMCDegree ofpolicyimplementationDisagree Agree N Disagree Agree NDisagree 66 33 32 49 35 30Agree 34 67 24 51 65 45Total N 41 15 56 35 40 75Notes: Figures in italic are percentageSource: Field study, 2009The comparison between BVDC and LSMC showed that slightly more power wasdevolved to the former than the latter. So far as it concerns the reproductive health policyimplementation, more reproductive health policy was implemented in LSMC than BVDC.The conclusion can be drawn that more power and authority are not enough to implementthe public policy, it demands institutional capacity for the purpose of policyimplementation whatsoever power and authority is transferred. As ex-chairman of BVDCsaid that the health post did not have the capacity to deliver reproductive health services tothe local people. Power and authority was transferred to the village level, but it lacked thecapacity. In other words, the village level health posts were not in a position to implementthe reproductive health policy to the degree that was prescribed. Therefore, decentralizationscheme is implemented more effectively at the municipal level (LSMC) than the villagelevel (BVDC).However, the Local Self-Governance Act, 1999 mandates local government bodies tomanage and supervise sub or Health Post and their functioning, local committees and VDCand bodies like Health Management Committee (HMC) should control resources and137management of sub or health post (MoHP, 2006). Another discrepancy is the allocation ofresponsibilities without any provision for the required resources. These differences in rulesand regulations between Local Self-Governance Act, 1999, current periodic plans andMinistry of Health and Population guidelines and the role of local bodies (VDCs, andDDCs) are a major concern for enhanced community ownerships of Sub or Health Posts.Currently, VDCs receive central government grant of which 25 per cent are earmarked forsocial services, including health. In addition, VDCs can generate additional resources tocover the services. No extra central government funds accompany the new arrangementsunder Sub or Health Post handover. While the committees have the responsibility tooversee and monitor the functioning of health staff, they have no responsibility for hiring orfiring them, which remains under the Ministry of Health and Population.The chair of the Sub-Health Post health committee is the VDC chairman when in post. Inthe current climate, the chairman is the VDC secretary. The guidelines state that thecommittee must have four women as members and two candidates have to represent thedalit/Janajati community (with one being a woman). The Sub-Health Post ManagementGuidelines outline the functions of the Sub-Health Post Management Committee but norole or responsibility to address gender and social inclusion concerns are stated. Thefunctions are stated in a neutral manner, based on the assumption that services will reachall the members of the community. In an interview with the ex-chairmans of the Sub-Health Post Management Committee, Bangsing and Chilaunebash, “the responsibility ofthe management is not transferred in the true sense. People have no access to resources.”5.2.2 Tension between devolution and deconcentrationThe Local Self –Governance Act 1999 develops a unique mixture of devolution anddeconcentration. On the one hand, Nepal has started decentralizing health-care delivery bytransferring funds and responsibilities for managing health facilities to locally constitutedLocal Health Management Committees (LMHCs), in 2001. The logic behind thisdevolution is that by making health-care providers accountable to a local committee, thelocal residents will have more say in how public resources for health are used and that138consequently the quality of care will improve for the whole community. On the other hand,Nepal has been practicing deconcentration since mid-20th century in health and othersectors. A key issue is that the point of contact between devolution and deconcentration,and the relations of authority be established.It is said that more delegated authority is more reproductive health policy implementation.Here, opinion have been sought to know the status of delegated authority. The field studyshowed that total mean score of level of delegated authority was improving. At present intotality, it is 2.55, which is above average.Table 5.2: Level of delegated authorityCategories LSMC BVDC Total (mean)Mean (Now) 2.56 2.54 2.55Mean (5 years ago) 1.87 1.94 1.91Total N 91 84Three points scale i.e. 1- deteriorated, 2- Neither deteriorated nor improved, 3-Improved,Source: Field study, 2009Five years ago, it was 1.91, which neither meant deteriorated nor improved. Categorically,the mean score of LSMC (91 respondents) was 2.56, which was more than average, whilethe mean score of LSMC 5 years back was 1.87, that is below average.Similarly, at BVDC (84 respondents), the mean score of delegated authority was 2.54 now,compared to 1.94 five years ago. The study showed that the level of delegated authority atthe local level was improving, but not satisfactory because quality and quantity ofreproductive health service delivery was not found as prescribed.In comparison between LSMC and BVDC, the delegated authority was more in LSMCthan in BVDC. It meant that more reproductive health policy was implemented in LSMCthan in BVDC.However, while examining Local Self-Governance Act, 1999 in Nepal, there are twoproblematic points of contact between deconcentration and devolution. First, from a139functional backdrop of deconcentration, it is represented by the ministries with their linesof managerial authority stretching out to the districts. Shrestha (2000, p.42-3) points to theproblematic relationship between the deconcentrated line agencies represented at thedistrict level and devolved system of DDCs and VDCs: “Since the jurisdictions of the localbody and line agencies overlap, the DDC itself yields little competence to influence thedecision-making of the line agencies in the district. The line agencies function under thedirect and exclusive administrative control of their respective ministries which providethem with their annual programs including their targets and budgets.” Similarly, Adhikari(2001, p.9) sees the problem in terms of dual accountability of the line agencies which are,on one hand, accountable to parliament and the Auditor General and, on the other, arerequired by the Local Self-governance Act to develop new forms of planning andaccountability. LAFC (2000, p.41) also points out that “although local bodies have powersto monitor locally based government agencies and NGOs, they are not complete becausetheir powers are not mandatory.”The second form of deconcentration in Nepal is integrated deconcentration. This isrepresented by the Local Development Officer (LDO) in the DDC or Secretary in the VDC.This post came under some criticism, they are working at VDC or DDC but their work isevaluated by the Secretary of the Ministry of Local Development (Collins and et al, 2003,p.58-9). It raised the question of how they are accountable toward the elected leader at thelocal level. It clearly showed that there was a mismatch between the spirit of devolutionand deconcentration. As a result, it hampered with the reproductive health policyimplementation at the local level.5.2.3 Spatial hierarchyIt is hypothesized that less spatial hierarchy is more reproductive health policyimplementation. In Nepal, the territorial units within a country were divided into fourteenzones, 75 districts and more than 4,000 VDCs and a number of municipalities for thepolitical and administrative purpose in 1963 (Thapa, 1963). The zonal level was createdbasically for political purposes to filter political representation to the Rastriya Panchayat(National Assembly) and for security surveillance (Subba, 2004, p.775-788). The districts140were assigned administrative and development functions, which later (1965-70) wereconsidered the basis of decentralization (Gurung, 2006, p.22). In 1972, the country wasdivided into four development regions and later (1978) into five (Sharma, 2004, p.61-96).Since the formation of the development regions in 1972, various ministries established theirregional offices/directorates at the designated regional centers with the dismantling ofdepartment of the various sectoral ministries. There are five health regional directorates.These offices act as a pool between the central and district health offices. These officescollect the monthly reports from districts and zonal offices, and report periodically to theMinistry. Later on, these regional directorates were kept under the Department of HealthService which was revived after the restoration of democracy. These regional health officesare not under the control of regional administrative offices but accountable to the respectivecentral offices. It made regional level as superfluous hierarchy (Gurung, 2006, p.22).After the restoration of democracy, zonal administration was abolished as a vestige of theautocratic regime. But, there are ten zonal hospitals in the country. These zonal hospitalswere established under the Developmental Act (2059 BS). These hospitals are directlyaccountable toward the Ministry, not regional health directorate or regional administration.Zonal and regional administrators have been appointed recently due to security reasons notdevelopment concern. These regional and zonal offices have no right to monitor, superviseand give feedbacks to regional service delivery offices e.g. health offices. The underlinedreason is the lack of adequate delegation of authority, whereby these regional officesbecame redundant hierarchy between the central and district levels. Besides, theapplications of regional perspective in Nepalese development are the highly centralizedsystem of governance and the primacy of sectoral approach (Gurung, 2005). Therefore, itdiscontinued the chain of command, which led to weaker implementation of the healthpolicy, particularly reproductive health policy. In an interview, the Director of Departmentof Health Service said that the organizational arrangement of health services was notsatisfactory. It brought the spatial hierarchy only, which made it difficult to implement thehealth policy.1415.2.4 Decentralized planningMore decentralized planning means more people’s participation that leads to morereproductive health policy implementation. The decentralized planning process emphasizesto ensure active people’s participation in local development process aimed at enhancing theproduction of goods and services for the promotion of the welfare of the local people ingeneral and rural poor in particular (Shrestha, 2000, p.85).According to Lohani (1980), mass participation in the implementation of decisioncan be effective only when there has been mass participation in decision making aswell… those participation in implementation should be viewed as a system ofinterlocking relationship between the villagers, the village level institution thatmobilizes this participation, and than the higher level institution further up to thenational level.It makes the people the focal point for entire development activities and goods andservices. Similarly, it mobilized the public, private, corporate bodies and social and NGOssectors for accelerating the development process at the local level.It is hypothesized that greater people’s participation in the planning process leads to morereproductive health policy implementation. Based on the field study, in BVDC, the resultshowed that 70 percent respondents who argued that there was people’s participation inplanning process, there was also high degree of reproductive health policy implementationwhile 60 percent who disagreed of people’s participation also said that there was highdegree of reproductive health policy implementation. Therefore, agreement of the degree ofreproductive health policy implementation does not depend on people’s participation inplanning process.142Table 5.3: People’s participation in planning making process at local level and degreeof policy implementationPeople’s participationBVDC LSMCDegree ofpolicyimplementationDisagree Agree N Disagree Agree NDisagree 40 30 26 55 35 41Agree 60 70 54 45 65 49Total N 20 60 80 35 55 90Note: Figures in italic are percentageSource: Field study, 2009Similarly, in LSMC, the result showed that sixty-five per cent of the respondents acceptedthat people’s participation in the planning process led to high degree of reproductive healthpolicy implementation. On the other side, forty-five percent disagreed about theparticipation of the people in planning process even than there was also reproductive healthpolicy implementation. It meant that the degree of reproductive health policyimplementation does not depend on the people’s participation in the planning process atLSMC.In comparison between BVDC and LSMC, the people’s participation in planning processwas slightly better in BVDC than LSMC. However, the degree of reproductive healthpolicy implementation was concerned; it was found that it did not depend on the people’sparticipation in planning making process. Categorically, more BVDC respondents wereinvolved in the planning process than LSMC respondents. It meant that there was localpeople’s involvement in program offered by the health institutions. However, ex-chairmanof Bangsing VDC said that the planning process in the health post was only a show. Thiswas in the form of voluntary labor contribution at the local level.It is assumed that some actors should be involved in the planning process. Local Self-Governance Act, 1999 outlines that local leaders, women, local NGOs and CBOs,minorities and others should be involved in the planning process at the local level. Thestudy has depicted that 53 percent of the local leaders, 9 percent of NGO activists, 3143percent of the common people and 35 percent of the people at large were involved in theplanning process.Table 5.4: Involved actors for the planning process in the health institutionsCategories LSMC BVDC TotalLocal Leader % 44 62 53NGO activists % 18 – 9Lower People % 4 2 3People at large % 34 36 35Total N 91 84 175Source: Field study, 2009The Table No. 5.4 showed that 62 per cent of the respondents agreed that local leaders inBVDC were involved in the planning process whereas and 44 per cent in LSMC. Therewere no NGO activists related to the health sector in BVDC. The NGOs were active only inLSMC area. The data showed that slightly more common people were involved in BVDCthan LSMC. In an interview, the ex-chairman of Bangsing VDC said that educated malespeople did not stay back in the village. This made it difficult to mobilize the local peoplefor reproductive health policy implementation.So far as decentralized health planning is concerned; health service delivery is arrangedalong sectoral line agencies and local health organizations. The Ministry of Health andPopulation and its departments along with other private and NGOs cover the health sector.Generally, they follow directives and targets set by national development policy and plans.But, the ministry and department have their own policies and programs. There is virtually aweak mechanism for feeding the concerns of the local communities into the planningprocess, because the planning levels are physically and institutionally far from the localpeople (Shrestha, 2000). However, this necessarily does not mean that there is nointegration of planning efforts across different sectors, but integration often takes place athigher levels where the decisions are made on the allocation of resources. At theimplementation level, there is little integration among the line agencies. Some integrationappears where the extension services are multipurpose and cover wide range of areas, butplanning and intervention of program are generally carried out by each separate technical144team recruited by central government in accordance with what they consider to be prioritiesfor their sector (Paudel, 2002, p.194.) However, as revealed by the study, the degree ofdecentralized planning had somewhat improved compared to five years ago. The total meanscore at present is 2.58 which is more than the average. This figure was 1.98 five years ago,which means it had neither deteriorated nor improved.Table 5.5: Level of decentralized planningCategories LSMC BVDC TotalNow (mean) 2.66 2.50 2.58Five yrs ago (Mean) 1.97 2.00 1.98Total N 91 84 175Three points scale i.e. 1- deteriorated, 2- Neither deteriorated nor improved, 3-ImprovedSource: Field study, 2009The mean score for LSMC was 2.66 compared to 1.97 five years ago. Similarly, the meanscore for BVDC was 2.5, on comparison to 2.00 five years ago. It showed that the level ofdecentralized planning was more or less of similar degree at both places.However, integrated health service planning approach retains most of the core ideas ofholistic planning, but is more focused on major key issues. It does not seek to analyze allcomponents and linkages to prevent the planning document from being a historicaldocument rather than a strategic one. The interpretation is done with a limited focus for anumber of reasons. First, it accepts that we are unlikely to be able to understand allvariation in a system, and relatively small numbers of variables cause a large proportion ofvariations in health service delivery. Besides, this keeps more realistic expectations andallows plans to be completed in a more reasonable time frame (Michel 1996). Integratedplanning approach tries to integrate planning activities across the various sectors at alllevels. Generally, the process of integration commenced with a top-down modeestablishing national level planning mechanism and institution. However, theinstitutionalization of integrated planning frequently involves some degree of devolution ofplanning responsibilities and resources allocation on lower levels of administration.145Coordination across sectors is relatively better at these levels and planning mechanisms arecloser to the communities.In Nepal, the health service sector is based on a target-oriented approach, where the targetis passed down from the top, i.e. from the National Planning Commission to Ministry levelto the district level. However, often the target given to the local levels is unrealisticallyhigh and impossible to fulfill (UNFPA, 1989, p.171). Because of the wide chasm betweenthe targeted policy goals and their implementation, most people feel dejected. The factseems to be that irrespective of the commitment and resources of the agencies in charge ofthe implementation, some policies are impossible to implement from the outset (Hoppe,1992, p.327)It is found that health policies are very general without specified tasks and objectives forimplementers at each level. It appears that figures and statistics receive a disproportionateamount of importance. In others words, the targets themselves are more important than howto achieve them. According to UNFPA, the management at the Ministry of Health andPopulation suffers from over-centralized planning and budgeting, poor financial andinformation management, a personnel system too dependent on informal criteria, poor staffmotivation and poor supervising practices. Furthermore, there is a lack of “objective”evaluation. In the case of health service, problems are under-reported and achievementsover-reported (UNFPA, 1989). A lack of trained staff to do policy analysis is a furtherproblem (Moharir, 1992, p.261). It appears that one problem reinforces the other problems.For example, the absence of specification and appropriate planning is aggravated byincorrect information.5.2.5 Increasing disparityIncreasing disparity of health institution from the perspective of availability of healthservice means a lower degree of reproductive health policy implementation. In Nepal, thereare more than four thousand health institutions constituted throughout the country. Thesehealth institutions are Hospitals (87), Health Centers (6), Health Posts (697), Ayurvedic146Hospitals (287), Primary Health Centers (205) and Sub-Health Posts (3,129). Among them,75 per cent of the health institutions are located in the rural areas of the country.As regards the appropriate sites for health institutions, 87 per cent of the respondentsopined the appropriateness of the health institution sites. Categorically, 100 per cent BVDCrespondents agreed on the appropriateness of the health institutions sites, likewise 75 percent LSMC respondents accepted appropriateness of their health institution sites.Table 5.6: Proper place for health institution sitesCategories LSMC BVDC TotalYes % 75 100 87No % 25 – 13Total N 91 84 175Source: Field study, 2009However, the number of health units does not realistically reflect the status of healthservice facility across rural and urban areas. There are two important aspects to beconsidered: distribution pattern of health institutions and quality of service (Shrestha, 2006,p.125). In remote areas, particularly in Mountain and Hilly areas, access to available healthfacility is constrained due to greater ‘friction of space’, measured in term of ruggedtopography and distance. Moreover, available health service in such areas is of low quality.On the other hand, access to available service is easy in Terai and urban areas due to low’friction of space’ resulting from transport facilities and favorable terrain. Therefore, thisshows the disparity between urban and rural areas. This friction of space caused the lowlevel of reproductive health policy implementation.5.3.Mobilization of NGOsIt is hypothesised that the mobilization of NGOs/CBOs for reproductive health servicescomplements the reproductive health policy implementation. The data revealed that theNGOs have become one of the fastest growing sectors in Nepal, particularly after thepolitical change of 1990. There are over 60,000 registered NGOs all over the country. Outof these NGOs, 30,000 (approx) are affiliated with Social Welfare Council (SWC), a147government bureau for looking after the NGOs (SWC, 2011). There could be numerousunregistered groups for civic action, which might have long historical backgrounds. Due tothe absence of proper recording systems, it is difficult to get the precise number of NGOsin Nepal (Dhakal, 2006, p.118).Table 5.7: NGOs affiliated with Social Welfare Council Sector-wiseSector Number PercentCommunity and Rural Development 18,625 61.5Youth Service 4,321 14.26Women Service 2,305 7.61Environmental Protection 1,318 4.35Child Welfare 951 3.14Moral Development 876 2.89Health Service 703 2.32Handicapped and Disabled Service 597 1.97Educational Development 492 1.62AIDS and Abuse 88 0.29Total 30,284 100Source: Social Welfare Council, 2011, www.swc.org.npSocial Welfare Council categorized these NGOs into ten types. Among them, the numberof Community and Rural Development NGOs account for 61.5 percent; the highest numberof NGOs in Nepal, whereas AIDS and Abuse Control NGOs are only 0.29 percent.Similarly, the Health Service related NGOs number only 703 (2.32 percent). (For detail seeTable No.5.7)The distribution of the health service related NGOs within Nepal is not seen ashomogenous. The NGOs are concentrated only in a few districts. For example, near aboutfifty percent of the NGOs are in Kathmandu, the capital city of Nepal. The rest of theNGOs are also located in more developed districts, like Lalitpur (8%), Kavre(4%),Kaski(3%), Bhaktapur(2%), Chitawan(2%), Morang(2%), Banke(2%), Dhanusa (1%),Dhading (1%) etc.148Table 5.8: Distribution of health service related NGOs District-wiseDistricts Number PercentageKathmandu 344 49Lalitpur 55 8Kavre 30 4Kaski 21 3Bhaktapur 16 2Chitawan 16 2Morang 13 2Banke 12 2Dhanusa 11 1Dhading 11 1Source: SWC, 2011Sixteen districts have one NGO each, six districts have two each, nine districts have 3NGOs each, six districts have four NGOs each, and three districts have five NGOs each.Similarly, seven districts have six NGOs each, two districts have seven NGOs each, andtwo districts have eight NGOs each. Most of the NGOs are based in the districtheadquarters. In 12 districts, there is not even a single NGO working in the health servicesector.Dhakal (2006, p.218) outlined the reasons for the growth of NGOs in Nepal as follows.Firstly, the changed international political arena and global environment and thedevelopment cooperation funding strategy of international donor agencies such as WorldBank, Organization for Economic Cooperation and Development (OECD), AsianDevelopment Bank (ADB), etc. helped for opportunity to play an increased role in thesocio-economic activities. Secondly, the democratization of political system and economicliberalization also contributed to the proliferation of NGOs in Nepal. Thirdly, thegovernment has changed the national development strategy and considered NGOs asdevelopment partners which also encouraged people’s participation in nationaldevelopment activities through NGOs. All this provided a congenial environment forincreasing the number of national NGOs in Nepal, particularly since 1990s.149However, it has also been recognized that NGOs seem to be indispensable allies in thedelivery of primary health-care, not only because they supplement government resourcesbut also because there is much to be learnt from their experiences, expertise and innovativeventures. Moreover, NGOs have considerable advantage over the public sector because oftheir personalized approach, motivation, and necessary zeal, sympathy for the deprivedsections, responsiveness to the people’s need, creativity, and above all, the flexibility toexperiment with innovative and alternative approaches in order to solve health problems(Ali, 1991, p.9).It can be said that greater involvement of NGOs/CBOs in the area means moreimplementation of the reproductive health policy. However, the field study showed thatthere was no NGO and CBO delivering reproductive health services in the study area i.e.BVDC. At LSMC, 64 per cent opined that NGOs and CBOs were delivering healthservices at their place and also accounted to high degree of reproductive health policyimplementation, whereas 56 per cent disagreed that NGOs and CBOs were not deliveringreproductive health services, but reproductive health policy was also implemented in theirabsence. The difference between these two categories was not big difference. It means thatCBOs and NGOs are delivering reproductive health services at LSMC along with the otheractors. It did not show the significant role of NGOs and CBOs in the reproductive healthpolicy implementation at local level.Table 5.9: Do you know that NGOs/CBOs are delivering reproductive health servicesat your place and degree of policy implementation?Delivering of reproductive health servicesBVDC LSMCDegree ofpolicyimplementationYes No N Yes No NDisagree – 51 43 36 44 37Agree – 49 41 64 56 54Total N – 84 84 39 52 91Note: Figures in italic are percentageSource: Field study, 2009150Experiences from other parts of the world, including India and Bangladesh, have alsodemonstrated that NGOs can assist in providing people with information, technical supportand decision-making possibilities, which could enable them to share in opportunities andresponsibilities for action in the interest of their own health (Rashid & et al, 2011).Today, in Nepal, the government encourages NGOs to work with the support of INGOs inproviding services such as health. Prominent INGOs working in health are the UnitedMission to Nepal, Save the Children (US and UK), Netherlands Leprosy Relief, the AsiaFoundation, Plan International, and Marie Stopes International. The key national NGOs arethe Family Planning Association of Nepal, Aama Milan Kendra (Mothers’s Club), NepalContraceptive Retail Sales Company, Nepal Red Cross Society, and Nepal Vitamin AProgram (DOHS, 2005/06).The following range of services are provided by NGOs/CBOs (ESP, 2001, p.126):· Socio-cultural services: education, advocacy and awareness raising;· Community development service: the integrated provision, usually of health,drinking water, sanitation, and environmental protection; and· Economic services: savings and credit management, labor exchange, microirrigation,and marketing.From the study, it is seen that the role played by the NGOs and CBOs was not satisfactory.Seventy-six percent of the respondents opined that the role played by NGOs and CBOs wasnot satisfactory.Table 5.10: Are you satisfied with the role played by NGOs/CBOs?Categories LSMC BVDC TotalYes % 24 – 24No% 76 – 76Total N 91 – 91Note: Figures in italic are percentageSource: Field study, 2009151Categorically, 76 percent of the LSMC respondents opined that people were unsatisfiedwith the role played by the NGOs and CBOs with respect to reproductive health servicedelivery. Only 24 percent of the respondents opined that they were satisfied with the roleplayed by NGO and CBO (for details see Table No 5.10).However, the NGOs have been particularly successful in facilitating social mobilization.They have been involved in establishing a large number of self-help organizations andcommunity women’s groups which are involved in a range of activities, from managingforests to organizing small-scale savings and credit programs including health servicedelivery (ESP, 2001).NGOs can play an active role in the creation and mobilization of assets, launch appropriateactivities and create an environment to promote access to livelihood items. Due to theirgrassroots attachment, direct approach, flexible and easy delivery to the needygroups/areas, they provide better services to their target group. However, there is a debateon their role in Nepal. This study showed that 67 per cent respondents opined that theNGOs were donor- centric and the remaining 33 per cent respondents as urban-centric.Hence, it showed that the NGOs are either urban or donor-centric.Table 5.11: Dissatisfaction with role of NGOs/CBOsCategories LSMC BVDC TotalUrban Centric % 33 – 33Donor Centric % 67 – 67Total N 69 – 69Source: Field study, 2009However, NGOs as development partners of government have been vaguely specified inthe policy document, and lacuna of the policies regarding NGOs’ function can be seenexplicitly. It is natural that in the absence of a clear policy direction for selecting certaintype of functions, target group or the area are often subject to whims, caprices and/orsimply interest of the intervening organization such as NGOs and often direct/ indirectdirection of the donor organization. Some of the important policy shortcomings for152bringing NGOs to address health issues in Nepal are as follows (Interview with NGOactivists).· There is a lack of clear direction for the functions in term of nature of works, typesof target groups, geographic location, etc for the NGOs in Nepal.· Most of the NGOs are guided by a project approach rather than a long-termapproach with enhanced institutional capacity.· Coordination is one of the missing parts of the NGO landscape. It is difficult to findout the type of NGOs based on nature of work, capacity, know-how andgeographical coverage. Though social-welfare council- a governmentalcoordinating body- is responsible for coordinating both NGOs and INGOs, due tothe lack of institutional capacity the coordination function has become inefficient.· There is a severe lack of monitoring and evaluation of NGOs’ activities in Nepal.· On top of these problems, 70 per cent of the total NGOs are still concentrated in theurban areas, though the severity of the problems is more in the rural areas. Thispoints to the fact that the increased number of NGOs do not contribute much inimproving the livelihood of the people living in poverty and other forms ofvulnerability. Such a situation also affects NGO dynamism in Nepal.However, the role of NGOs in Pharmacy, Laboratory and other sectors of health policyimplementations is ill-defined. Besides, there is lack of adequate policy guidelines,strategies and mechanisms for functional coordination of policy issues among public,private and NGO sectors and GoN development partners.5.4. Private Health CarePrivate health care is run by individuals or by groups of individuals similar to commercialorganizations (ESP, 2001). The individuals are mostly health workers of different levelswho run their private clinic either full time or on a part-time basis. Most of the governmenthealth employees work in their private clinics in the urban areas. The privately run drugstores (pharmacy) also dispense medicines including many antibiotics. The commercialorganizations are usually named nursing homes that are similar to the hospital in terms of153service facilities. The private sector, both commercial organizations and individualpractitioners, are limited in the town (ESP, 2001). The present government policy is toinvolve the private sector in health services so that government health policy would beimplemented properly. It can be said that more involvement of private health clinics/nursing homes/ private hospitals can implement the health policy especially reproductivehealth policy.The private sector provision of health services is increasing. Many Nepalese still resort tolocal herbal cures and faith healers to cure their illnesses, whilst many other attend privateayurvedic and homeopathic practitioners. There are approximately 100 private hospitalsand nursing homes and thousands of private health clinics and laboratories offering accessto conventional medicine. These facilities are mainly available in the urban centers, mostlyin the Kathmandu Valley (DOHS, 2008).From the study, it was also revealed that there was no private health clinics/ NursingHomes/Private Hospitals in the study area i.e. BVDC. In the case of LSMC, 59 percent ofthe respondents opined that private health clinics/nursing homes/private hospitals areinvolved in the reproductive health delivery and private sectors also contributing toimplement the reproductive health policy.Table 5.12: Are private health clinics/Nursing homes/private hospitals working atyour place and degree of reproductive health policy implementation?Delivery of reproductive health service by private sectorsBVDC LSMCDegree ofpolicyimplementationYes No Yes NoDisagree – 51 41 -Agree – 49 59 -Total N – 84 91 -Note: Figures in italic are percentageSource: Field study, 2009At LSMC, there were private health clinics, nursing homes and private hospitals deliveringhealth services. It means that reproductive health policy was implemented fairly i.e.154reproductive health services was delivered by the nursing homes, private clinics, privatehospitals, etc. Hence, they are contributing to implement reproductive health policy inLSMC.Regarding to the satisfaction of the reproductive health service delivered by the privatesector, only 56 per cent of the LSMC respondents were satisfied with the role played by theprivate clinics/Nursing Home/ Private Hospitals. A service recipient remarked that theservice offered by the private sector is expansive. Common people can hardly afford it.Private sector provides the reproductive service timely than public sectors.Table 5.13: Are you satisfied with the role of private clinics/Nursing homes/ privatehospitals?Categories LSMC BVDC TotalYes % 56 – 56No % 44 – 44Total N 91 – 91Source: Field study, 2009However, there is a growing concern over the lack of regulations in the provision of basicservices provided by the private sector. The government has been attempting to address thisby developing quality standards. In 2001, GoN developed the “Standard Guideline andTreatment Protocols’ which is executed in publicly and privately run health clinics,hospitals and nursing homes (ESP, 2001, p.128). However, the laboratory services provideby public and private sectors are often of poor quality. There is no clear policy for qualityassurance in public, private and NGO health systems. The legal framework forimplementing quality assurance is weak or absent, especially in the private sector. Inaddition to this, private, NGOs and development partner funding is not effectivelycoordinated, not linked to the government’s overall health sector plans.5.5. ConclusionsIn the study, it is hypothesized that more the decentralization scheme, there is likely toenhance more reproductive health policy implementation. Decentralization was taken as a155convenient tool to reinforce respective regime’s political power in spite of it being anincessant theme in Nepal for the last five decades. Some legal initiations for thedecentralization were also made. At present, Local Self-governance Act, 1999 is inoperation. It mandates local government bodies to manage and supervise Health Posts andSub-Health Posts in order to deliver health service effectively including otherdevelopmental activities. However, there is mismatch between the allocation ofresponsibilities and the provision of required resources. There are contradictory rules andregulations between Local Self-governance Act, Interim Plan and Ministry of Health andPopulation guidelines and the role of local bodies. As a result, the jurisdictions of the localbodies and the line agencies overlap. Local bodies cannot influence the decision-making ofline agencies.The field study showed that more power was devolved in BVDC than LSMC. So far as thereproductive health policy implementation was concerned, more reproductive policy wasimplemented in LSMC. It identified that power and authority devolved is not sufficientcondition for policy implementation, it demands capacity as well. In LSMC in comparewith BVDC, there was more option for receiving the reproductive health services. Forexample, private sectors’ hospitals/nursing home/clinic and NGOs including governmenthospitals were delivering reproductive health services. But, in BVDC, there were noalternative except government run health post.There is tension between devolution and deconcentration process in Nepal. From the thrustof Local Self-governance Act, 1999, local bodies are the main service providers to thecommon people. But, line agencies of each ministry are stretched out to the district level.These agencies do not want to delegate their power and authority to the local bodies. Thejurisdiction of the local body and line agencies overlaps. 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