Public policy implementation research

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 understood
The 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 understood
The 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 to
implement the same policy”.
132
CHAPTER V
HEALTH SERVICE DECENTRALIZATION IN NEPAL:
STATUS AND RECONSIDERATION
In this chapter, the concept of decentralization is reviewed, and legislation process and its
impacts on health service delivery are analyzed, particularly in Nepal. Besides, it examines
how health service decentralized planning is being executed in Nepal, and the mobilization
of 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. Background
Decentralization has been an incessant theme in Nepal over the last five decades. It has
evolved according to the rationale of successive regimes (Gurung, 2003). It ranges from the
Rana Rule (pre-1951), for cosmetic purposes, to the Panchayat period (1960-90), to sustain
elite power and further, for good governance after the restoration of democracy (post-
1990). Some legal initiations which include Local Administration Act (1965), District
Development Plan (1974), Decentralization Act (1982), Local Self–Governance Act
(1999), etc. have been carried out. Besides, 13 high-level task forces/commissions were
constituted for decentralization in four decades (Gurung 1998, p.47). However, there is
centralized government structure as problem which loathes delegating authority (Mickesell,
1999, p.145). In Nepal, the existing centralized decision-making, planning and budgeting
system as well as central control of resources have been considered major constraints for
good governance and decentralization reform process. In this context, the overall
133
administrative system, staffing arrangements and accountability needs to be shifted from a
central to local orientation. The resistance from line ministries to devolve resources both
financial and staff to local governments has been a major constraint(Bista, 2003). Weak
capacity, structure, excess number and size of local governments are another serious
constraint, which needs to be reviewed. The number of local governments in Nepal is
unreasonable and too large for effective and efficient planning, administration,
coordination, cost efficiency, resource allocation and service delivery (Bista, 2003).
5.2. Concept of Decentralization
Decentralization is widely believed that it increases possibilities for participation of all
stakeholders; people would be empowered to manage their affairs; people shoulder
responsibilities and feel ownership; and there would be a more efficient provision of public
goods and services for the people in general and the poor in particular. Therefore, GoN
emphasizes decentralization to devolve power in order to provide health service at the door
steps of the people.
Conceptually, decentralization within the state involves a transfer of authority to perform
some services to the public from an individual or an agency in central government to some
other individual or agency which is closer to the public to be served (Rondinelli and
Cheema, 1983). The transfer of authority can be done in two ways: territorial and
functional. The basis of transfer of territorial authority is placed at the lower level of
territorial hierarchy where service providers and clients are geographically closer.
Similarly, the authority transfer can also be made functionally. There are three types of
such transfer of authority: i) within formal political structure, ii) within public
administrative or parastatal structure and iii) from an institution of the state to a non-state
agency (Turner & Humle, 1997, p.152). Expected benefits of the decentralization are
assumed as it would promote local democracy, debureaucratization and mobilization of
people’s participation politically (Shrestha, 2000, p.55-56). From the administrative view
points, it improves administrative efficiency, make government quickly respond to the
needs and aspirations of the peoples’ and enhance the quantity and quality of services,
government provides to the people (Shrestha, 2000, p.56). Similarly, from development
134
view point, it leads to better decision-making and greater efficiency and effectiveness on
locally 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. It
can be argued of the possibilities of cost and risk of decentralization viz: loss of high scale
of economies and generation of duplication and underemployment of staff and equipment.
It can create coordination problem among inter- or intra-organization within the state. Due
to the lack of resources, there might be institutional constraints that can hardly cope with
the need and aspirations of the people. The possibility of disintegration of state also can be
denied in the decentralization process. In practice too, the challenges of good governance
through decentralization are many. In most developing countries, there has been a tendency
for independent governments to prefer delegating power within the public service
deconcentration rather than to locally elected authorities devolution. There has been
much rhetoric about participation and local autonomy, but central governments have
jealously guarded their power (Turner & Hulme 1997, p.151-175). Under the banner of
decentralization, leaders have introduced policies that concentrate power and decisionmaking
that weaken local areas. Serious devolutions have been rare, and deconcentration or
the establishment of mixed authorities have been favored modes for Third World Leaders
(Turner & Humle, 1997, p.174). Therefore, there seems a great tension between
deconcentration and devolution of power for service delivery in developing country at the
local level.
5.2.1 Legislation and its effect
In the case of Nepal, GoN has introduced one of the world’s most progressive legislation
for decentralization, devolving primary responsibility for local development to elected local
authorities (MoHP, 2006, p.9). As far as the health service decentralization program is
concerned, there is a provision of a committee headed by the Ministry of Health and
Population consisting of Ministry of Finance, Ministry of Local Development, Ministry of
Women, Children and Social Welfare and the National Planning Commission at the central
level. Interim Plan (2007) has outlined the guideline for the implementation of
135
decentralization scheme in districts. In view of the satisfactory results of the
decentralization program implemented districts, on the whole, where the health agencies
were handed over to the local bodies, such a policy would be continued to make the local
bodies or communities responsible for the operation and management of health agencies. In
the decentralization scheme, it is said that local health agencies’ management committees
will be given orientation training also. There will be a separate unit of management in the
region and department to conduct programs related to the decentralization scheme in the
districts and local levels. Progress measurement, supervision and monitoring will be
conducted by the central and regional levels without any external interference. There will
be coordination committees established from central to district levels to make the health
decentralization scheme more effective, in consultation with the Ministries of Health and
Population, Finance and Local Development. In addition, a decentralization policy will be
prepared and its implementation process launched as an integral part of community
empowerment (Interim Plan, 2007).
In order to map the extent of decentralization at the local level in our two sample local
government units, it is hypothesized that the more the power and authority is transferred
from the central level to the local level, the more the reproductive health policy would be
implemented effectively. From the field study, the result of the BVDC revealed that 67 per
cent respondents agreed that the transfer of power and authority from central level to local
level affected the high degree of reproductive health policy implementation. But, thirtyfour
per cent respondents disagreed that the transfer of power and authority from central
level to local level did not cause the reproductive health policy implementation. The result
showed that the degree of reproductive health policy implementation depend on the transfer
of 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 was
transfer of power and authority from central level to local level and there was also high
degree of reproductive health policy implementation while 51 per cent respondents
disagreed there was not transfer of power and authority in LSMC, but reproductive health
policy was also implemented. The agreement is that power and authority must be
136
transferred from central level to local level for the high degree of reproductive health
policy implementation. It showed that transfer of power and authority has direct
relationship for the purpose of reproductive health policy implementation. It is concluded
that more transfer of power and authority at the local level leads to more reproductive
health policy implementation.
Table 5.1: Responses on transfer of power and authority from central to local level
and degree of policy implementation
Transfer of power and authority
BVDC LSMC
Degree of
policy
implementation
Disagree Agree N Disagree Agree N
Disagree 66 33 32 49 35 30
Agree 34 67 24 51 65 45
Total N 41 15 56 35 40 75
Notes: Figures in italic are percentage
Source: Field study, 2009
The comparison between BVDC and LSMC showed that slightly more power was
devolved to the former than the latter. So far as it concerns the reproductive health policy
implementation, more reproductive health policy was implemented in LSMC than BVDC.
The conclusion can be drawn that more power and authority are not enough to implement
the public policy, it demands institutional capacity for the purpose of policy
implementation whatsoever power and authority is transferred. As ex-chairman of BVDC
said that the health post did not have the capacity to deliver reproductive health services to
the local people. Power and authority was transferred to the village level, but it lacked the
capacity. In other words, the village level health posts were not in a position to implement
the reproductive health policy to the degree that was prescribed. Therefore, decentralization
scheme is implemented more effectively at the municipal level (LSMC) than the village
level (BVDC).
However, the Local Self-Governance Act, 1999 mandates local government bodies to
manage and supervise sub or Health Post and their functioning, local committees and VDC
and bodies like Health Management Committee (HMC) should control resources and
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management of sub or health post (MoHP, 2006). Another discrepancy is the allocation of
responsibilities without any provision for the required resources. These differences in rules
and regulations between Local Self-Governance Act, 1999, current periodic plans and
Ministry of Health and Population guidelines and the role of local bodies (VDCs, and
DDCs) 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 for
social services, including health. In addition, VDCs can generate additional resources to
cover the services. No extra central government funds accompany the new arrangements
under Sub or Health Post handover. While the committees have the responsibility to
oversee and monitor the functioning of health staff, they have no responsibility for hiring or
firing 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. In
the current climate, the chairman is the VDC secretary. The guidelines state that the
committee must have four women as members and two candidates have to represent the
dalit/Janajati community (with one being a woman). The Sub-Health Post Management
Guidelines outline the functions of the Sub-Health Post Management Committee but no
role or responsibility to address gender and social inclusion concerns are stated. The
functions are stated in a neutral manner, based on the assumption that services will reach
all the members of the community. In an interview with the ex-chairmans of the Sub-
Health Post Management Committee, Bangsing and Chilaunebash, “the responsibility of
the management is not transferred in the true sense. People have no access to resources.”
5.2.2 Tension between devolution and deconcentration
The Local Self –Governance Act 1999 develops a unique mixture of devolution and
deconcentration. On the one hand, Nepal has started decentralizing health-care delivery by
transferring funds and responsibilities for managing health facilities to locally constituted
Local Health Management Committees (LMHCs), in 2001. The logic behind this
devolution is that by making health-care providers accountable to a local committee, the
local residents will have more say in how public resources for health are used and that
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consequently 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 other
sectors. 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 study
showed that total mean score of level of delegated authority was improving. At present in
totality, it is 2.55, which is above average.
Table 5.2: Level of delegated authority
Categories LSMC BVDC Total (mean)
Mean (Now) 2.56 2.54 2.55
Mean (5 years ago) 1.87 1.94 1.91
Total N 91 84
Three points scale i.e. 1- deteriorated, 2- Neither deteriorated nor improved, 3-Improved,
Source: Field study, 2009
Five 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, while
the 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 at
the local level was improving, but not satisfactory because quality and quantity of
reproductive health service delivery was not found as prescribed.
In comparison between LSMC and BVDC, the delegated authority was more in LSMC
than in BVDC. It meant that more reproductive health policy was implemented in LSMC
than in BVDC.
However, while examining Local Self-Governance Act, 1999 in Nepal, there are two
problematic points of contact between deconcentration and devolution. First, from a
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functional backdrop of deconcentration, it is represented by the ministries with their lines
of managerial authority stretching out to the districts. Shrestha (2000, p.42-3) points to the
problematic relationship between the deconcentrated line agencies represented at the
district level and devolved system of DDCs and VDCs: “Since the jurisdictions of the local
body and line agencies overlap, the DDC itself yields little competence to influence the
decision-making of the line agencies in the district. The line agencies function under the
direct and exclusive administrative control of their respective ministries which provide
them 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, are
required by the Local Self-governance Act to develop new forms of planning and
accountability. LAFC (2000, p.41) also points out that “although local bodies have powers
to monitor locally based government agencies and NGOs, they are not complete because
their powers are not mandatory.”
The second form of deconcentration in Nepal is integrated deconcentration. This is
represented 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 is
evaluated 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 the
local level. It clearly showed that there was a mismatch between the spirit of devolution
and deconcentration. As a result, it hampered with the reproductive health policy
implementation at the local level.
5.2.3 Spatial hierarchy
It is hypothesized that less spatial hierarchy is more reproductive health policy
implementation. In Nepal, the territorial units within a country were divided into fourteen
zones, 75 districts and more than 4,000 VDCs and a number of municipalities for the
political and administrative purpose in 1963 (Thapa, 1963). The zonal level was created
basically for political purposes to filter political representation to the Rastriya Panchayat
(National Assembly) and for security surveillance (Subba, 2004, p.775-788). The districts
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were assigned administrative and development functions, which later (1965-70) were
considered the basis of decentralization (Gurung, 2006, p.22). In 1972, the country was
divided 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 their
regional offices/directorates at the designated regional centers with the dismantling of
department 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 offices
collect the monthly reports from districts and zonal offices, and report periodically to the
Ministry. Later on, these regional directorates were kept under the Department of Health
Service which was revived after the restoration of democracy. These regional health offices
are not under the control of regional administrative offices but accountable to the respective
central 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 the
autocratic regime. But, there are ten zonal hospitals in the country. These zonal hospitals
were established under the Developmental Act (2059 BS). These hospitals are directly
accountable toward the Ministry, not regional health directorate or regional administration.
Zonal and regional administrators have been appointed recently due to security reasons not
development concern. These regional and zonal offices have no right to monitor, supervise
and give feedbacks to regional service delivery offices e.g. health offices. The underlined
reason is the lack of adequate delegation of authority, whereby these regional offices
became redundant hierarchy between the central and district levels. Besides, the
applications of regional perspective in Nepalese development are the highly centralized
system of governance and the primacy of sectoral approach (Gurung, 2005). Therefore, it
discontinued the chain of command, which led to weaker implementation of the health
policy, particularly reproductive health policy. In an interview, the Director of Department
of Health Service said that the organizational arrangement of health services was not
satisfactory. It brought the spatial hierarchy only, which made it difficult to implement the
health policy.
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5.2.4 Decentralized planning
More decentralized planning means more people’s participation that leads to more
reproductive health policy implementation. The decentralized planning process emphasizes
to ensure active people’s participation in local development process aimed at enhancing the
production of goods and services for the promotion of the welfare of the local people in
general and rural poor in particular (Shrestha, 2000, p.85).
According to Lohani (1980), mass participation in the implementation of decision
can be effective only when there has been mass participation in decision making as
well… those participation in implementation should be viewed as a system of
interlocking relationship between the villagers, the village level institution that
mobilizes this participation, and than the higher level institution further up to the
national level.
It makes the people the focal point for entire development activities and goods and
services. Similarly, it mobilized the public, private, corporate bodies and social and NGOs
sectors for accelerating the development process at the local level.
It is hypothesized that greater people’s participation in the planning process leads to more
reproductive health policy implementation. Based on the field study, in BVDC, the result
showed that 70 percent respondents who argued that there was people’s participation in
planning process, there was also high degree of reproductive health policy implementation
while 60 percent who disagreed of people’s participation also said that there was high
degree of reproductive health policy implementation. Therefore, agreement of the degree of
reproductive health policy implementation does not depend on people’s participation in
planning process.
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Table 5.3: People’s participation in planning making process at local level and degree
of policy implementation
People’s participation
BVDC LSMC
Degree of
policy
implementation
Disagree Agree N Disagree Agree N
Disagree 40 30 26 55 35 41
Agree 60 70 54 45 65 49
Total N 20 60 80 35 55 90
Note: Figures in italic are percentage
Source: Field study, 2009
Similarly, in LSMC, the result showed that sixty-five per cent of the respondents accepted
that people’s participation in the planning process led to high degree of reproductive health
policy implementation. On the other side, forty-five percent disagreed about the
participation of the people in planning process even than there was also reproductive health
policy implementation. It meant that the degree of reproductive health policy
implementation does not depend on the people’s participation in the planning process at
LSMC.
In comparison between BVDC and LSMC, the people’s participation in planning process
was slightly better in BVDC than LSMC. However, the degree of reproductive health
policy implementation was concerned; it was found that it did not depend on the people’s
participation in planning making process. Categorically, more BVDC respondents were
involved in the planning process than LSMC respondents. It meant that there was local
people’s involvement in program offered by the health institutions. However, ex-chairman
of Bangsing VDC said that the planning process in the health post was only a show. This
was 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. The
study has depicted that 53 percent of the local leaders, 9 percent of NGO activists, 3
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percent of the common people and 35 percent of the people at large were involved in the
planning process.
Table 5.4: Involved actors for the planning process in the health institutions
Categories LSMC BVDC Total
Local Leader % 44 62 53
NGO activists % 18 – 9
Lower People % 4 2 3
People at large % 34 36 35
Total N 91 84 175
Source: Field study, 2009
The Table No. 5.4 showed that 62 per cent of the respondents agreed that local leaders in
BVDC were involved in the planning process whereas and 44 per cent in LSMC. There
were no NGO activists related to the health sector in BVDC. The NGOs were active only in
LSMC area. The data showed that slightly more common people were involved in BVDC
than LSMC. In an interview, the ex-chairman of Bangsing VDC said that educated males
people did not stay back in the village. This made it difficult to mobilize the local people
for reproductive health policy implementation.
So far as decentralized health planning is concerned; health service delivery is arranged
along sectoral line agencies and local health organizations. The Ministry of Health and
Population 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 a
weak mechanism for feeding the concerns of the local communities into the planning
process, because the planning levels are physically and institutionally far from the local
people (Shrestha, 2000). However, this necessarily does not mean that there is no
integration of planning efforts across different sectors, but integration often takes place at
higher levels where the decisions are made on the allocation of resources. At the
implementation level, there is little integration among the line agencies. Some integration
appears where the extension services are multipurpose and cover wide range of areas, but
planning and intervention of program are generally carried out by each separate technical
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team recruited by central government in accordance with what they consider to be priorities
for their sector (Paudel, 2002, p.194.) However, as revealed by the study, the degree of
decentralized planning had somewhat improved compared to five years ago. The total mean
score 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 planning
Categories LSMC BVDC Total
Now (mean) 2.66 2.50 2.58
Five yrs ago (Mean) 1.97 2.00 1.98
Total N 91 84 175
Three points scale i.e. 1- deteriorated, 2- Neither deteriorated nor improved, 3-Improved
Source: Field study, 2009
The mean score for LSMC was 2.66 compared to 1.97 five years ago. Similarly, the mean
score for BVDC was 2.5, on comparison to 2.00 five years ago. It showed that the level of
decentralized planning was more or less of similar degree at both places.
However, integrated health service planning approach retains most of the core ideas of
holistic planning, but is more focused on major key issues. It does not seek to analyze all
components and linkages to prevent the planning document from being a historical
document rather than a strategic one. The interpretation is done with a limited focus for a
number of reasons. First, it accepts that we are unlikely to be able to understand all
variation in a system, and relatively small numbers of variables cause a large proportion of
variations in health service delivery. Besides, this keeps more realistic expectations and
allows plans to be completed in a more reasonable time frame (Michel 1996). Integrated
planning approach tries to integrate planning activities across the various sectors at all
levels. Generally, the process of integration commenced with a top-down mode
establishing national level planning mechanism and institution. However, the
institutionalization of integrated planning frequently involves some degree of devolution of
planning responsibilities and resources allocation on lower levels of administration.
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Coordination across sectors is relatively better at these levels and planning mechanisms are
closer to the communities.
In Nepal, the health service sector is based on a target-oriented approach, where the target
is passed down from the top, i.e. from the National Planning Commission to Ministry level
to the district level. However, often the target given to the local levels is unrealistically
high and impossible to fulfill (UNFPA, 1989, p.171). Because of the wide chasm between
the targeted policy goals and their implementation, most people feel dejected. The fact
seems to be that irrespective of the commitment and resources of the agencies in charge of
the 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 for
implementers at each level. It appears that figures and statistics receive a disproportionate
amount of importance. In others words, the targets themselves are more important than how
to achieve them. According to UNFPA, the management at the Ministry of Health and
Population suffers from over-centralized planning and budgeting, poor financial and
information management, a personnel system too dependent on informal criteria, poor staff
motivation and poor supervising practices. Furthermore, there is a lack of “objective”
evaluation. In the case of health service, problems are under-reported and achievements
over-reported (UNFPA, 1989). A lack of trained staff to do policy analysis is a further
problem (Moharir, 1992, p.261). It appears that one problem reinforces the other problems.
For example, the absence of specification and appropriate planning is aggravated by
incorrect information.
5.2.5 Increasing disparity
Increasing disparity of health institution from the perspective of availability of health
service means a lower degree of reproductive health policy implementation. In Nepal, there
are more than four thousand health institutions constituted throughout the country. These
health institutions are Hospitals (87), Health Centers (6), Health Posts (697), Ayurvedic
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Hospitals (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 respondents
opined the appropriateness of the health institution sites. Categorically, 100 per cent BVDC
respondents agreed on the appropriateness of the health institutions sites, likewise 75 per
cent LSMC respondents accepted appropriateness of their health institution sites.
Table 5.6: Proper place for health institution sites
Categories LSMC BVDC Total
Yes % 75 100 87
No % 25 – 13
Total N 91 84 175
Source: Field study, 2009
However, the number of health units does not realistically reflect the status of health
service facility across rural and urban areas. There are two important aspects to be
considered: 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 health
facility is constrained due to greater ‘friction of space’, measured in term of rugged
topography 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, this
shows the disparity between urban and rural areas. This friction of space caused the low
level of reproductive health policy implementation.
5.3.Mobilization of NGOs
It is hypothesised that the mobilization of NGOs/CBOs for reproductive health services
complements the reproductive health policy implementation. The data revealed that the
NGOs have become one of the fastest growing sectors in Nepal, particularly after the
political change of 1990. There are over 60,000 registered NGOs all over the country. Out
of these NGOs, 30,000 (approx) are affiliated with Social Welfare Council (SWC), a
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government bureau for looking after the NGOs (SWC, 2011). There could be numerous
unregistered groups for civic action, which might have long historical backgrounds. Due to
the absence of proper recording systems, it is difficult to get the precise number of NGOs
in Nepal (Dhakal, 2006, p.118).
Table 5.7: NGOs affiliated with Social Welfare Council Sector-wise
Sector Number Percent
Community and Rural Development 18,625 61.5
Youth Service 4,321 14.26
Women Service 2,305 7.61
Environmental Protection 1,318 4.35
Child Welfare 951 3.14
Moral Development 876 2.89
Health Service 703 2.32
Handicapped and Disabled Service 597 1.97
Educational Development 492 1.62
AIDS and Abuse 88 0.29
Total 30,284 100
Source: Social Welfare Council, 2011, www.swc.org.np
Social Welfare Council categorized these NGOs into ten types. Among them, the number
of Community and Rural Development NGOs account for 61.5 percent; the highest number
of 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 see
Table No.5.7)
The distribution of the health service related NGOs within Nepal is not seen as
homogenous. The NGOs are concentrated only in a few districts. For example, near about
fifty percent of the NGOs are in Kathmandu, the capital city of Nepal. The rest of the
NGOs 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.
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Table 5.8: Distribution of health service related NGOs District-wise
Districts Number Percentage
Kathmandu 344 49
Lalitpur 55 8
Kavre 30 4
Kaski 21 3
Bhaktapur 16 2
Chitawan 16 2
Morang 13 2
Banke 12 2
Dhanusa 11 1
Dhading 11 1
Source: SWC, 2011
Sixteen districts have one NGO each, six districts have two each, nine districts have 3
NGOs 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, and
two districts have eight NGOs each. Most of the NGOs are based in the district
headquarters. In 12 districts, there is not even a single NGO working in the health service
sector.
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 the
development cooperation funding strategy of international donor agencies such as World
Bank, Organization for Economic Cooperation and Development (OECD), Asian
Development Bank (ADB), etc. helped for opportunity to play an increased role in the
socio-economic activities. Secondly, the democratization of political system and economic
liberalization also contributed to the proliferation of NGOs in Nepal. Thirdly, the
government has changed the national development strategy and considered NGOs as
development partners which also encouraged people’s participation in national
development activities through NGOs. All this provided a congenial environment for
increasing the number of national NGOs in Nepal, particularly since 1990s.
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However, it has also been recognized that NGOs seem to be indispensable allies in the
delivery of primary health-care, not only because they supplement government resources
but also because there is much to be learnt from their experiences, expertise and innovative
ventures. Moreover, NGOs have considerable advantage over the public sector because of
their personalized approach, motivation, and necessary zeal, sympathy for the deprived
sections, responsiveness to the people’s need, creativity, and above all, the flexibility to
experiment 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 more
implementation of the reproductive health policy. However, the field study showed that
there 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 health
services at their place and also accounted to high degree of reproductive health policy
implementation, whereas 56 per cent disagreed that NGOs and CBOs were not delivering
reproductive health services, but reproductive health policy was also implemented in their
absence. The difference between these two categories was not big difference. It means that
CBOs and NGOs are delivering reproductive health services at LSMC along with the other
actors. It did not show the significant role of NGOs and CBOs in the reproductive health
policy implementation at local level.
Table 5.9: Do you know that NGOs/CBOs are delivering reproductive health services
at your place and degree of policy implementation?
Delivering of reproductive health services
BVDC LSMC
Degree of
policy
implementation
Yes No N Yes No N
Disagree – 51 43 36 44 37
Agree – 49 41 64 56 54
Total N – 84 84 39 52 91
Note: Figures in italic are percentage
Source: Field study, 2009
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Experiences from other parts of the world, including India and Bangladesh, have also
demonstrated that NGOs can assist in providing people with information, technical support
and decision-making possibilities, which could enable them to share in opportunities and
responsibilities 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 in
providing services such as health. Prominent INGOs working in health are the United
Mission to Nepal, Save the Children (US and UK), Netherlands Leprosy Relief, the Asia
Foundation, Plan International, and Marie Stopes International. The key national NGOs are
the Family Planning Association of Nepal, Aama Milan Kendra (Mothers’s Club), Nepal
Contraceptive Retail Sales Company, Nepal Red Cross Society, and Nepal Vitamin A
Program (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 was
not satisfactory.
Table 5.10: Are you satisfied with the role played by NGOs/CBOs?
Categories LSMC BVDC Total
Yes % 24 – 24
No% 76 – 76
Total N 91 – 91
Note: Figures in italic are percentage
Source: Field study, 2009
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Categorically, 76 percent of the LSMC respondents opined that people were unsatisfied
with the role played by the NGOs and CBOs with respect to reproductive health service
delivery. Only 24 percent of the respondents opined that they were satisfied with the role
played 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 and
community women’s groups which are involved in a range of activities, from managing
forests to organizing small-scale savings and credit programs including health service
delivery (ESP, 2001).
NGOs can play an active role in the creation and mobilization of assets, launch appropriate
activities and create an environment to promote access to livelihood items. Due to their
grassroots attachment, direct approach, flexible and easy delivery to the needy
groups/areas, they provide better services to their target group. However, there is a debate
on their role in Nepal. This study showed that 67 per cent respondents opined that the
NGOs 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/CBOs
Categories LSMC BVDC Total
Urban Centric % 33 – 33
Donor Centric % 67 – 67
Total N 69 – 69
Source: Field study, 2009
However, NGOs as development partners of government have been vaguely specified in
the policy document, and lacuna of the policies regarding NGOs’ function can be seen
explicitly. It is natural that in the absence of a clear policy direction for selecting certain
type of functions, target group or the area are often subject to whims, caprices and/or
simply interest of the intervening organization such as NGOs and often direct/ indirect
direction of the donor organization. Some of the important policy shortcomings for
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bringing NGOs to address health issues in Nepal are as follows (Interview with NGO
activists).
· There is a lack of clear direction for the functions in term of nature of works, types
of target groups, geographic location, etc for the NGOs in Nepal.
· Most of the NGOs are guided by a project approach rather than a long-term
approach with enhanced institutional capacity.
· Coordination is one of the missing parts of the NGO landscape. It is difficult to find
out the type of NGOs based on nature of work, capacity, know-how and
geographical coverage. Though social-welfare council- a governmental
coordinating body- is responsible for coordinating both NGOs and INGOs, due to
the 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 the
urban areas, though the severity of the problems is more in the rural areas. This
points to the fact that the increased number of NGOs do not contribute much in
improving the livelihood of the people living in poverty and other forms of
vulnerability. Such a situation also affects NGO dynamism in Nepal.
However, the role of NGOs in Pharmacy, Laboratory and other sectors of health policy
implementations 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 Care
Private health care is run by individuals or by groups of individuals similar to commercial
organizations (ESP, 2001). The individuals are mostly health workers of different levels
who run their private clinic either full time or on a part-time basis. Most of the government
health employees work in their private clinics in the urban areas. The privately run drug
stores (pharmacy) also dispense medicines including many antibiotics. The commercial
organizations are usually named nursing homes that are similar to the hospital in terms of
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service facilities. The private sector, both commercial organizations and individual
practitioners, are limited in the town (ESP, 2001). The present government policy is to
involve the private sector in health services so that government health policy would be
implemented properly. It can be said that more involvement of private health clinics/
nursing homes/ private hospitals can implement the health policy especially reproductive
health policy.
The private sector provision of health services is increasing. Many Nepalese still resort to
local herbal cures and faith healers to cure their illnesses, whilst many other attend private
ayurvedic and homeopathic practitioners. There are approximately 100 private hospitals
and nursing homes and thousands of private health clinics and laboratories offering access
to conventional medicine. These facilities are mainly available in the urban centers, mostly
in the Kathmandu Valley (DOHS, 2008).
From the study, it was also revealed that there was no private health clinics/ Nursing
Homes/Private Hospitals in the study area i.e. BVDC. In the case of LSMC, 59 percent of
the respondents opined that private health clinics/nursing homes/private hospitals are
involved in the reproductive health delivery and private sectors also contributing to
implement the reproductive health policy.
Table 5.12: Are private health clinics/Nursing homes/private hospitals working at
your place and degree of reproductive health policy implementation?
Delivery of reproductive health service by private sectors
BVDC LSMC
Degree of
policy
implementation
Yes No Yes No
Disagree – 51 41 –
Agree – 49 59 –
Total N – 84 91 –
Note: Figures in italic are percentage
Source: Field study, 2009
At LSMC, there were private health clinics, nursing homes and private hospitals delivering
health services. It means that reproductive health policy was implemented fairly i.e.
154
reproductive health services was delivered by the nursing homes, private clinics, private
hospitals, etc. Hence, they are contributing to implement reproductive health policy in
LSMC.
Regarding to the satisfaction of the reproductive health service delivered by the private
sector, only 56 per cent of the LSMC respondents were satisfied with the role played by the
private clinics/Nursing Home/ Private Hospitals. A service recipient remarked that the
service 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/ private
hospitals?
Categories LSMC BVDC Total
Yes % 56 – 56
No % 44 – 44
Total N 91 – 91
Source: Field study, 2009
However, there is a growing concern over the lack of regulations in the provision of basic
services provided by the private sector. The government has been attempting to address this
by developing quality standards. In 2001, GoN developed the “Standard Guideline and
Treatment Protocols’ which is executed in publicly and privately run health clinics,
hospitals and nursing homes (ESP, 2001, p.128). However, the laboratory services provide
by public and private sectors are often of poor quality. There is no clear policy for quality
assurance in public, private and NGO health systems. The legal framework for
implementing quality assurance is weak or absent, especially in the private sector. In
addition to this, private, NGOs and development partner funding is not effectively
coordinated, not linked to the government’s overall health sector plans.
5.5. Conclusions
In the study, it is hypothesized that more the decentralization scheme, there is likely to
enhance more reproductive health policy implementation. Decentralization was taken as a
155
convenient tool to reinforce respective regime’s political power in spite of it being an
incessant theme in Nepal for the last five decades. Some legal initiations for the
decentralization were also made. At present, Local Self-governance Act, 1999 is in
operation. It mandates local government bodies to manage and supervise Health Posts and
Sub-Health Posts in order to deliver health service effectively including other
developmental activities. However, there is mismatch between the allocation of
responsibilities and the provision of required resources. There are contradictory rules and
regulations between Local Self-governance Act, Interim Plan and Ministry of Health and
Population guidelines and the role of local bodies. As a result, the jurisdictions of the local
bodies and the line agencies overlap. Local bodies cannot influence the decision-making of
line agencies.
The field study showed that more power was devolved in BVDC than LSMC. So far as the
reproductive health policy implementation was concerned, more reproductive policy was
implemented in LSMC. It identified that power and authority devolved is not sufficient
condition for policy implementation, it demands capacity as well. In LSMC in compare
with BVDC, there was more option for receiving the reproductive health services. For
example, private sectors’ hospitals/nursing home/clinic and NGOs including government
hospitals were delivering reproductive health services. But, in BVDC, there were no
alternative except government run health post.
There is tension between devolution and deconcentration process in Nepal. From the thrust
of Local Self-governance Act, 1999, local bodies are the main service providers to the
common 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. The
jurisdiction of the local body and line agencies overlaps. From the field study, it is seen
that the level of delegated authority was improving, but not to the desired level. Therefore,
there seems weak reproductive health policy implementation.
GoN has constituted regional development office to facilitate and support the local level so
that people need not come to the central level. In this line, five health regional directorates
were established. Similarly, zonal offices were also established with the aim to monitor,

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They have 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 to
implement the same policy”.
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CHAPTER V
HEALTH SERVICE DECENTRALIZATION IN NEPAL:
STATUS AND RECONSIDERATION
In this chapter, the concept of decentralization is reviewed, and legislation process and its
impacts on health service delivery are analyzed, particularly in Nepal. Besides, it examines
how health service decentralized planning is being executed in Nepal, and the mobilization
of 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. Background
Decentralization has been an incessant theme in Nepal over the last five decades. It has
evolved according to the rationale of successive regimes (Gurung, 2003). It ranges from the
Rana Rule (pre-1951), for cosmetic purposes, to the Panchayat period (1960-90), to sustain
elite power and further, for good governance after the restoration of democracy (post-
1990). Some legal initiations which include Local Administration Act (1965), District
Development Plan (1974), Decentralization Act (1982), Local Self–Governance Act
(1999), etc. have been carried out. Besides, 13 high-level task forces/commissions were
constituted for decentralization in four decades (Gurung 1998, p.47). However, there is
centralized government structure as problem which loathes delegating authority (Mickesell,
1999, p.145). In Nepal, the existing centralized decision-making, planning and budgeting
system as well as central control of resources have been considered major constraints for
good governance and decentralization reform process. In this context, the overall
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administrative system, staffing arrangements and accountability needs to be shifted from a
central to local orientation. The resistance from line ministries to devolve resources both
financial and staff to local governments has been a major constraint(Bista, 2003). Weak
capacity, structure, excess number and size of local governments are another serious
constraint, which needs to be reviewed. The number of local governments in Nepal is
unreasonable and too large for effective and efficient planning, administration,
coordination, cost efficiency, resource allocation and service delivery (Bista, 2003).
5.2. Concept of Decentralization
Decentralization is widely believed that it increases possibilities for participation of all
stakeholders; people would be empowered to manage their affairs; people shoulder
responsibilities and feel ownership; and there would be a more efficient provision of public
goods and services for the people in general and the poor in particular. Therefore, GoN
emphasizes decentralization to devolve power in order to provide health service at the door
steps of the people.
Conceptually, decentralization within the state involves a transfer of authority to perform
some services to the public from an individual or an agency in central government to some
other individual or agency which is closer to the public to be served (Rondinelli and
Cheema, 1983). The transfer of authority can be done in two ways: territorial and
functional. The basis of transfer of territorial authority is placed at the lower level of
territorial hierarchy where service providers and clients are geographically closer.
Similarly, the authority transfer can also be made functionally. There are three types of
such transfer of authority: i) within formal political structure, ii) within public
administrative or parastatal structure and iii) from an institution of the state to a non-state
agency (Turner & Humle, 1997, p.152). Expected benefits of the decentralization are
assumed as it would promote local democracy, debureaucratization and mobilization of
people’s participation politically (Shrestha, 2000, p.55-56). From the administrative view
points, it improves administrative efficiency, make government quickly respond to the
needs and aspirations of the peoples’ and enhance the quantity and quality of services,
government provides to the people (Shrestha, 2000, p.56). Similarly, from development
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view point, it leads to better decision-making and greater efficiency and effectiveness on
locally 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. It
can be argued of the possibilities of cost and risk of decentralization viz: loss of high scale
of economies and generation of duplication and underemployment of staff and equipment.
It can create coordination problem among inter- or intra-organization within the state. Due
to the lack of resources, there might be institutional constraints that can hardly cope with
the need and aspirations of the people. The possibility of disintegration of state also can be
denied in the decentralization process. In practice too, the challenges of good governance
through decentralization are many. In most developing countries, there has been a tendency
for independent governments to prefer delegating power within the public service
deconcentration rather than to locally elected authorities devolution. There has been
much rhetoric about participation and local autonomy, but central governments have
jealously guarded their power (Turner & Hulme 1997, p.151-175). Under the banner of
decentralization, leaders have introduced policies that concentrate power and decisionmaking
that weaken local areas. Serious devolutions have been rare, and deconcentration or
the establishment of mixed authorities have been favored modes for Third World Leaders
(Turner & Humle, 1997, p.174). Therefore, there seems a great tension between
deconcentration and devolution of power for service delivery in developing country at the
local level.
5.2.1 Legislation and its effect
In the case of Nepal, GoN has introduced one of the world’s most progressive legislation
for decentralization, devolving primary responsibility for local development to elected local
authorities (MoHP, 2006, p.9). As far as the health service decentralization program is
concerned, there is a provision of a committee headed by the Ministry of Health and
Population consisting of Ministry of Finance, Ministry of Local Development, Ministry of
Women, Children and Social Welfare and the National Planning Commission at the central
level. Interim Plan (2007) has outlined the guideline for the implementation of
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decentralization scheme in districts. In view of the satisfactory results of the
decentralization program implemented districts, on the whole, where the health agencies
were handed over to the local bodies, such a policy would be continued to make the local
bodies or communities responsible for the operation and management of health agencies. In
the decentralization scheme, it is said that local health agencies’ management committees
will be given orientation training also. There will be a separate unit of management in the
region and department to conduct programs related to the decentralization scheme in the
districts and local levels. Progress measurement, supervision and monitoring will be
conducted by the central and regional levels without any external interference. There will
be coordination committees established from central to district levels to make the health
decentralization scheme more effective, in consultation with the Ministries of Health and
Population, Finance and Local Development. In addition, a decentralization policy will be
prepared and its implementation process launched as an integral part of community
empowerment (Interim Plan, 2007).
In order to map the extent of decentralization at the local level in our two sample local
government units, it is hypothesized that the more the power and authority is transferred
from the central level to the local level, the more the reproductive health policy would be
implemented effectively. From the field study, the result of the BVDC revealed that 67 per
cent respondents agreed that the transfer of power and authority from central level to local
level affected the high degree of reproductive health policy implementation. But, thirtyfour
per cent respondents disagreed that the transfer of power and authority from central
level to local level did not cause the reproductive health policy implementation. The result
showed that the degree of reproductive health policy implementation depend on the transfer
of 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 was
transfer of power and authority from central level to local level and there was also high
degree of reproductive health policy implementation while 51 per cent respondents
disagreed there was not transfer of power and authority in LSMC, but reproductive health
policy was also implemented. The agreement is that power and authority must be
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transferred from central level to local level for the high degree of reproductive health
policy implementation. It showed that transfer of power and authority has direct
relationship for the purpose of reproductive health policy implementation. It is concluded
that more transfer of power and authority at the local level leads to more reproductive
health policy implementation.
Table 5.1: Responses on transfer of power and authority from central to local level
and degree of policy implementation
Transfer of power and authority
BVDC LSMC
Degree of
policy
implementation
Disagree Agree N Disagree Agree N
Disagree 66 33 32 49 35 30
Agree 34 67 24 51 65 45
Total N 41 15 56 35 40 75
Notes: Figures in italic are percentage
Source: Field study, 2009
The comparison between BVDC and LSMC showed that slightly more power was
devolved to the former than the latter. So far as it concerns the reproductive health policy
implementation, more reproductive health policy was implemented in LSMC than BVDC.
The conclusion can be drawn that more power and authority are not enough to implement
the public policy, it demands institutional capacity for the purpose of policy
implementation whatsoever power and authority is transferred. As ex-chairman of BVDC
said that the health post did not have the capacity to deliver reproductive health services to
the local people. Power and authority was transferred to the village level, but it lacked the
capacity. In other words, the village level health posts were not in a position to implement
the reproductive health policy to the degree that was prescribed. Therefore, decentralization
scheme is implemented more effectively at the municipal level (LSMC) than the village
level (BVDC).
However, the Local Self-Governance Act, 1999 mandates local government bodies to
manage and supervise sub or Health Post and their functioning, local committees and VDC
and bodies like Health Management Committee (HMC) should control resources and
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management of sub or health post (MoHP, 2006). Another discrepancy is the allocation of
responsibilities without any provision for the required resources. These differences in rules
and regulations between Local Self-Governance Act, 1999, current periodic plans and
Ministry of Health and Population guidelines and the role of local bodies (VDCs, and
DDCs) 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 for
social services, including health. In addition, VDCs can generate additional resources to
cover the services. No extra central government funds accompany the new arrangements
under Sub or Health Post handover. While the committees have the responsibility to
oversee and monitor the functioning of health staff, they have no responsibility for hiring or
firing 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. In
the current climate, the chairman is the VDC secretary. The guidelines state that the
committee must have four women as members and two candidates have to represent the
dalit/Janajati community (with one being a woman). The Sub-Health Post Management
Guidelines outline the functions of the Sub-Health Post Management Committee but no
role or responsibility to address gender and social inclusion concerns are stated. The
functions are stated in a neutral manner, based on the assumption that services will reach
all the members of the community. In an interview with the ex-chairmans of the Sub-
Health Post Management Committee, Bangsing and Chilaunebash, “the responsibility of
the management is not transferred in the true sense. People have no access to resources.”
5.2.2 Tension between devolution and deconcentration
The Local Self –Governance Act 1999 develops a unique mixture of devolution and
deconcentration. On the one hand, Nepal has started decentralizing health-care delivery by
transferring funds and responsibilities for managing health facilities to locally constituted
Local Health Management Committees (LMHCs), in 2001. The logic behind this
devolution is that by making health-care providers accountable to a local committee, the
local residents will have more say in how public resources for health are used and that
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consequently 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 other
sectors. 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 study
showed that total mean score of level of delegated authority was improving. At present in
totality, it is 2.55, which is above average.
Table 5.2: Level of delegated authority
Categories LSMC BVDC Total (mean)
Mean (Now) 2.56 2.54 2.55
Mean (5 years ago) 1.87 1.94 1.91
Total N 91 84
Three points scale i.e. 1- deteriorated, 2- Neither deteriorated nor improved, 3-Improved,
Source: Field study, 2009
Five 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, while
the 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 at
the local level was improving, but not satisfactory because quality and quantity of
reproductive health service delivery was not found as prescribed.
In comparison between LSMC and BVDC, the delegated authority was more in LSMC
than in BVDC. It meant that more reproductive health policy was implemented in LSMC
than in BVDC.
However, while examining Local Self-Governance Act, 1999 in Nepal, there are two
problematic points of contact between deconcentration and devolution. First, from a
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functional backdrop of deconcentration, it is represented by the ministries with their lines
of managerial authority stretching out to the districts. Shrestha (2000, p.42-3) points to the
problematic relationship between the deconcentrated line agencies represented at the
district level and devolved system of DDCs and VDCs: “Since the jurisdictions of the local
body and line agencies overlap, the DDC itself yields little competence to influence the
decision-making of the line agencies in the district. The line agencies function under the
direct and exclusive administrative control of their respective ministries which provide
them 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, are
required by the Local Self-governance Act to develop new forms of planning and
accountability. LAFC (2000, p.41) also points out that “although local bodies have powers
to monitor locally based government agencies and NGOs, they are not complete because
their powers are not mandatory.”
The second form of deconcentration in Nepal is integrated deconcentration. This is
represented 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 is
evaluated 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 the
local level. It clearly showed that there was a mismatch between the spirit of devolution
and deconcentration. As a result, it hampered with the reproductive health policy
implementation at the local level.
5.2.3 Spatial hierarchy
It is hypothesized that less spatial hierarchy is more reproductive health policy
implementation. In Nepal, the territorial units within a country were divided into fourteen
zones, 75 districts and more than 4,000 VDCs and a number of municipalities for the
political and administrative purpose in 1963 (Thapa, 1963). The zonal level was created
basically for political purposes to filter political representation to the Rastriya Panchayat
(National Assembly) and for security surveillance (Subba, 2004, p.775-788). The districts
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were assigned administrative and development functions, which later (1965-70) were
considered the basis of decentralization (Gurung, 2006, p.22). In 1972, the country was
divided 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 their
regional offices/directorates at the designated regional centers with the dismantling of
department 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 offices
collect the monthly reports from districts and zonal offices, and report periodically to the
Ministry. Later on, these regional directorates were kept under the Department of Health
Service which was revived after the restoration of democracy. These regional health offices
are not under the control of regional administrative offices but accountable to the respective
central 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 the
autocratic regime. But, there are ten zonal hospitals in the country. These zonal hospitals
were established under the Developmental Act (2059 BS). These hospitals are directly
accountable toward the Ministry, not regional health directorate or regional administration.
Zonal and regional administrators have been appointed recently due to security reasons not
development concern. These regional and zonal offices have no right to monitor, supervise
and give feedbacks to regional service delivery offices e.g. health offices. The underlined
reason is the lack of adequate delegation of authority, whereby these regional offices
became redundant hierarchy between the central and district levels. Besides, the
applications of regional perspective in Nepalese development are the highly centralized
system of governance and the primacy of sectoral approach (Gurung, 2005). Therefore, it
discontinued the chain of command, which led to weaker implementation of the health
policy, particularly reproductive health policy. In an interview, the Director of Department
of Health Service said that the organizational arrangement of health services was not
satisfactory. It brought the spatial hierarchy only, which made it difficult to implement the
health policy.
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5.2.4 Decentralized planning
More decentralized planning means more people’s participation that leads to more
reproductive health policy implementation. The decentralized planning process emphasizes
to ensure active people’s participation in local development process aimed at enhancing the
production of goods and services for the promotion of the welfare of the local people in
general and rural poor in particular (Shrestha, 2000, p.85).
According to Lohani (1980), mass participation in the implementation of decision
can be effective only when there has been mass participation in decision making as
well… those participation in implementation should be viewed as a system of
interlocking relationship between the villagers, the village level institution that
mobilizes this participation, and than the higher level institution further up to the
national level.
It makes the people the focal point for entire development activities and goods and
services. Similarly, it mobilized the public, private, corporate bodies and social and NGOs
sectors for accelerating the development process at the local level.
It is hypothesized that greater people’s participation in the planning process leads to more
reproductive health policy implementation. Based on the field study, in BVDC, the result
showed that 70 percent respondents who argued that there was people’s participation in
planning process, there was also high degree of reproductive health policy implementation
while 60 percent who disagreed of people’s participation also said that there was high
degree of reproductive health policy implementation. Therefore, agreement of the degree of
reproductive health policy implementation does not depend on people’s participation in
planning process.
142
Table 5.3: People’s participation in planning making process at local level and degree
of policy implementation
People’s participation
BVDC LSMC
Degree of
policy
implementation
Disagree Agree N Disagree Agree N
Disagree 40 30 26 55 35 41
Agree 60 70 54 45 65 49
Total N 20 60 80 35 55 90
Note: Figures in italic are percentage
Source: Field study, 2009
Similarly, in LSMC, the result showed that sixty-five per cent of the respondents accepted
that people’s participation in the planning process led to high degree of reproductive health
policy implementation. On the other side, forty-five percent disagreed about the
participation of the people in planning process even than there was also reproductive health
policy implementation. It meant that the degree of reproductive health policy
implementation does not depend on the people’s participation in the planning process at
LSMC.
In comparison between BVDC and LSMC, the people’s participation in planning process
was slightly better in BVDC than LSMC. However, the degree of reproductive health
policy implementation was concerned; it was found that it did not depend on the people’s
participation in planning making process. Categorically, more BVDC respondents were
involved in the planning process than LSMC respondents. It meant that there was local
people’s involvement in program offered by the health institutions. However, ex-chairman
of Bangsing VDC said that the planning process in the health post was only a show. This
was 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. The
study has depicted that 53 percent of the local leaders, 9 percent of NGO activists, 3
143
percent of the common people and 35 percent of the people at large were involved in the
planning process.
Table 5.4: Involved actors for the planning process in the health institutions
Categories LSMC BVDC Total
Local Leader % 44 62 53
NGO activists % 18 – 9
Lower People % 4 2 3
People at large % 34 36 35
Total N 91 84 175
Source: Field study, 2009
The Table No. 5.4 showed that 62 per cent of the respondents agreed that local leaders in
BVDC were involved in the planning process whereas and 44 per cent in LSMC. There
were no NGO activists related to the health sector in BVDC. The NGOs were active only in
LSMC area. The data showed that slightly more common people were involved in BVDC
than LSMC. In an interview, the ex-chairman of Bangsing VDC said that educated males
people did not stay back in the village. This made it difficult to mobilize the local people
for reproductive health policy implementation.
So far as decentralized health planning is concerned; health service delivery is arranged
along sectoral line agencies and local health organizations. The Ministry of Health and
Population 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 a
weak mechanism for feeding the concerns of the local communities into the planning
process, because the planning levels are physically and institutionally far from the local
people (Shrestha, 2000). However, this necessarily does not mean that there is no
integration of planning efforts across different sectors, but integration often takes place at
higher levels where the decisions are made on the allocation of resources. At the
implementation level, there is little integration among the line agencies. Some integration
appears where the extension services are multipurpose and cover wide range of areas, but
planning and intervention of program are generally carried out by each separate technical
144
team recruited by central government in accordance with what they consider to be priorities
for their sector (Paudel, 2002, p.194.) However, as revealed by the study, the degree of
decentralized planning had somewhat improved compared to five years ago. The total mean
score 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 planning
Categories LSMC BVDC Total
Now (mean) 2.66 2.50 2.58
Five yrs ago (Mean) 1.97 2.00 1.98
Total N 91 84 175
Three points scale i.e. 1- deteriorated, 2- Neither deteriorated nor improved, 3-Improved
Source: Field study, 2009
The mean score for LSMC was 2.66 compared to 1.97 five years ago. Similarly, the mean
score for BVDC was 2.5, on comparison to 2.00 five years ago. It showed that the level of
decentralized planning was more or less of similar degree at both places.
However, integrated health service planning approach retains most of the core ideas of
holistic planning, but is more focused on major key issues. It does not seek to analyze all
components and linkages to prevent the planning document from being a historical
document rather than a strategic one. The interpretation is done with a limited focus for a
number of reasons. First, it accepts that we are unlikely to be able to understand all
variation in a system, and relatively small numbers of variables cause a large proportion of
variations in health service delivery. Besides, this keeps more realistic expectations and
allows plans to be completed in a more reasonable time frame (Michel 1996). Integrated
planning approach tries to integrate planning activities across the various sectors at all
levels. Generally, the process of integration commenced with a top-down mode
establishing national level planning mechanism and institution. However, the
institutionalization of integrated planning frequently involves some degree of devolution of
planning responsibilities and resources allocation on lower levels of administration.
145
Coordination across sectors is relatively better at these levels and planning mechanisms are
closer to the communities.
In Nepal, the health service sector is based on a target-oriented approach, where the target
is passed down from the top, i.e. from the National Planning Commission to Ministry level
to the district level. However, often the target given to the local levels is unrealistically
high and impossible to fulfill (UNFPA, 1989, p.171). Because of the wide chasm between
the targeted policy goals and their implementation, most people feel dejected. The fact
seems to be that irrespective of the commitment and resources of the agencies in charge of
the 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 for
implementers at each level. It appears that figures and statistics receive a disproportionate
amount of importance. In others words, the targets themselves are more important than how
to achieve them. According to UNFPA, the management at the Ministry of Health and
Population suffers from over-centralized planning and budgeting, poor financial and
information management, a personnel system too dependent on informal criteria, poor staff
motivation and poor supervising practices. Furthermore, there is a lack of “objective”
evaluation. In the case of health service, problems are under-reported and achievements
over-reported (UNFPA, 1989). A lack of trained staff to do policy analysis is a further
problem (Moharir, 1992, p.261). It appears that one problem reinforces the other problems.
For example, the absence of specification and appropriate planning is aggravated by
incorrect information.
5.2.5 Increasing disparity
Increasing disparity of health institution from the perspective of availability of health
service means a lower degree of reproductive health policy implementation. In Nepal, there
are more than four thousand health institutions constituted throughout the country. These
health institutions are Hospitals (87), Health Centers (6), Health Posts (697), Ayurvedic
146
Hospitals (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 respondents
opined the appropriateness of the health institution sites. Categorically, 100 per cent BVDC
respondents agreed on the appropriateness of the health institutions sites, likewise 75 per
cent LSMC respondents accepted appropriateness of their health institution sites.
Table 5.6: Proper place for health institution sites
Categories LSMC BVDC Total
Yes % 75 100 87
No % 25 – 13
Total N 91 84 175
Source: Field study, 2009
However, the number of health units does not realistically reflect the status of health
service facility across rural and urban areas. There are two important aspects to be
considered: 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 health
facility is constrained due to greater ‘friction of space’, measured in term of rugged
topography 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, this
shows the disparity between urban and rural areas. This friction of space caused the low
level of reproductive health policy implementation.
5.3.Mobilization of NGOs
It is hypothesised that the mobilization of NGOs/CBOs for reproductive health services
complements the reproductive health policy implementation. The data revealed that the
NGOs have become one of the fastest growing sectors in Nepal, particularly after the
political change of 1990. There are over 60,000 registered NGOs all over the country. Out
of these NGOs, 30,000 (approx) are affiliated with Social Welfare Council (SWC), a
147
government bureau for looking after the NGOs (SWC, 2011). There could be numerous
unregistered groups for civic action, which might have long historical backgrounds. Due to
the absence of proper recording systems, it is difficult to get the precise number of NGOs
in Nepal (Dhakal, 2006, p.118).
Table 5.7: NGOs affiliated with Social Welfare Council Sector-wise
Sector Number Percent
Community and Rural Development 18,625 61.5
Youth Service 4,321 14.26
Women Service 2,305 7.61
Environmental Protection 1,318 4.35
Child Welfare 951 3.14
Moral Development 876 2.89
Health Service 703 2.32
Handicapped and Disabled Service 597 1.97
Educational Development 492 1.62
AIDS and Abuse 88 0.29
Total 30,284 100
Source: Social Welfare Council, 2011, www.swc.org.np
Social Welfare Council categorized these NGOs into ten types. Among them, the number
of Community and Rural Development NGOs account for 61.5 percent; the highest number
of 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 see
Table No.5.7)
The distribution of the health service related NGOs within Nepal is not seen as
homogenous. The NGOs are concentrated only in a few districts. For example, near about
fifty percent of the NGOs are in Kathmandu, the capital city of Nepal. The rest of the
NGOs 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.
148
Table 5.8: Distribution of health service related NGOs District-wise
Districts Number Percentage
Kathmandu 344 49
Lalitpur 55 8
Kavre 30 4
Kaski 21 3
Bhaktapur 16 2
Chitawan 16 2
Morang 13 2
Banke 12 2
Dhanusa 11 1
Dhading 11 1
Source: SWC, 2011
Sixteen districts have one NGO each, six districts have two each, nine districts have 3
NGOs 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, and
two districts have eight NGOs each. Most of the NGOs are based in the district
headquarters. In 12 districts, there is not even a single NGO working in the health service
sector.
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 the
development cooperation funding strategy of international donor agencies such as World
Bank, Organization for Economic Cooperation and Development (OECD), Asian
Development Bank (ADB), etc. helped for opportunity to play an increased role in the
socio-economic activities. Secondly, the democratization of political system and economic
liberalization also contributed to the proliferation of NGOs in Nepal. Thirdly, the
government has changed the national development strategy and considered NGOs as
development partners which also encouraged people’s participation in national
development activities through NGOs. All this provided a congenial environment for
increasing the number of national NGOs in Nepal, particularly since 1990s.
149
However, it has also been recognized that NGOs seem to be indispensable allies in the
delivery of primary health-care, not only because they supplement government resources
but also because there is much to be learnt from their experiences, expertise and innovative
ventures. Moreover, NGOs have considerable advantage over the public sector because of
their personalized approach, motivation, and necessary zeal, sympathy for the deprived
sections, responsiveness to the people’s need, creativity, and above all, the flexibility to
experiment 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 more
implementation of the reproductive health policy. However, the field study showed that
there 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 health
services at their place and also accounted to high degree of reproductive health policy
implementation, whereas 56 per cent disagreed that NGOs and CBOs were not delivering
reproductive health services, but reproductive health policy was also implemented in their
absence. The difference between these two categories was not big difference. It means that
CBOs and NGOs are delivering reproductive health services at LSMC along with the other
actors. It did not show the significant role of NGOs and CBOs in the reproductive health
policy implementation at local level.
Table 5.9: Do you know that NGOs/CBOs are delivering reproductive health services
at your place and degree of policy implementation?
Delivering of reproductive health services
BVDC LSMC
Degree of
policy
implementation
Yes No N Yes No N
Disagree – 51 43 36 44 37
Agree – 49 41 64 56 54
Total N – 84 84 39 52 91
Note: Figures in italic are percentage
Source: Field study, 2009
150
Experiences from other parts of the world, including India and Bangladesh, have also
demonstrated that NGOs can assist in providing people with information, technical support
and decision-making possibilities, which could enable them to share in opportunities and
responsibilities 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 in
providing services such as health. Prominent INGOs working in health are the United
Mission to Nepal, Save the Children (US and UK), Netherlands Leprosy Relief, the Asia
Foundation, Plan International, and Marie Stopes International. The key national NGOs are
the Family Planning Association of Nepal, Aama Milan Kendra (Mothers’s Club), Nepal
Contraceptive Retail Sales Company, Nepal Red Cross Society, and Nepal Vitamin A
Program (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 was
not satisfactory.
Table 5.10: Are you satisfied with the role played by NGOs/CBOs?
Categories LSMC BVDC Total
Yes % 24 – 24
No% 76 – 76
Total N 91 – 91
Note: Figures in italic are percentage
Source: Field study, 2009
151
Categorically, 76 percent of the LSMC respondents opined that people were unsatisfied
with the role played by the NGOs and CBOs with respect to reproductive health service
delivery. Only 24 percent of the respondents opined that they were satisfied with the role
played 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 and
community women’s groups which are involved in a range of activities, from managing
forests to organizing small-scale savings and credit programs including health service
delivery (ESP, 2001).
NGOs can play an active role in the creation and mobilization of assets, launch appropriate
activities and create an environment to promote access to livelihood items. Due to their
grassroots attachment, direct approach, flexible and easy delivery to the needy
groups/areas, they provide better services to their target group. However, there is a debate
on their role in Nepal. This study showed that 67 per cent respondents opined that the
NGOs 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/CBOs
Categories LSMC BVDC Total
Urban Centric % 33 – 33
Donor Centric % 67 – 67
Total N 69 – 69
Source: Field study, 2009
However, NGOs as development partners of government have been vaguely specified in
the policy document, and lacuna of the policies regarding NGOs’ function can be seen
explicitly. It is natural that in the absence of a clear policy direction for selecting certain
type of functions, target group or the area are often subject to whims, caprices and/or
simply interest of the intervening organization such as NGOs and often direct/ indirect
direction of the donor organization. Some of the important policy shortcomings for
152
bringing NGOs to address health issues in Nepal are as follows (Interview with NGO
activists).
· There is a lack of clear direction for the functions in term of nature of works, types
of target groups, geographic location, etc for the NGOs in Nepal.
· Most of the NGOs are guided by a project approach rather than a long-term
approach with enhanced institutional capacity.
· Coordination is one of the missing parts of the NGO landscape. It is difficult to find
out the type of NGOs based on nature of work, capacity, know-how and
geographical coverage. Though social-welfare council- a governmental
coordinating body- is responsible for coordinating both NGOs and INGOs, due to
the 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 the
urban areas, though the severity of the problems is more in the rural areas. This
points to the fact that the increased number of NGOs do not contribute much in
improving the livelihood of the people living in poverty and other forms of
vulnerability. Such a situation also affects NGO dynamism in Nepal.
However, the role of NGOs in Pharmacy, Laboratory and other sectors of health policy
implementations 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 Care
Private health care is run by individuals or by groups of individuals similar to commercial
organizations (ESP, 2001). The individuals are mostly health workers of different levels
who run their private clinic either full time or on a part-time basis. Most of the government
health employees work in their private clinics in the urban areas. The privately run drug
stores (pharmacy) also dispense medicines including many antibiotics. The commercial
organizations are usually named nursing homes that are similar to the hospital in terms of
153
service facilities. The private sector, both commercial organizations and individual
practitioners, are limited in the town (ESP, 2001). The present government policy is to
involve the private sector in health services so that government health policy would be
implemented properly. It can be said that more involvement of private health clinics/
nursing homes/ private hospitals can implement the health policy especially reproductive
health policy.
The private sector provision of health services is increasing. Many Nepalese still resort to
local herbal cures and faith healers to cure their illnesses, whilst many other attend private
ayurvedic and homeopathic practitioners. There are approximately 100 private hospitals
and nursing homes and thousands of private health clinics and laboratories offering access
to conventional medicine. These facilities are mainly available in the urban centers, mostly
in the Kathmandu Valley (DOHS, 2008).
From the study, it was also revealed that there was no private health clinics/ Nursing
Homes/Private Hospitals in the study area i.e. BVDC. In the case of LSMC, 59 percent of
the respondents opined that private health clinics/nursing homes/private hospitals are
involved in the reproductive health delivery and private sectors also contributing to
implement the reproductive health policy.
Table 5.12: Are private health clinics/Nursing homes/private hospitals working at
your place and degree of reproductive health policy implementation?
Delivery of reproductive health service by private sectors
BVDC LSMC
Degree of
policy
implementation
Yes No Yes No
Disagree – 51 41 –
Agree – 49 59 –
Total N – 84 91 –
Note: Figures in italic are percentage
Source: Field study, 2009
At LSMC, there were private health clinics, nursing homes and private hospitals delivering
health services. It means that reproductive health policy was implemented fairly i.e.
154
reproductive health services was delivered by the nursing homes, private clinics, private
hospitals, etc. Hence, they are contributing to implement reproductive health policy in
LSMC.
Regarding to the satisfaction of the reproductive health service delivered by the private
sector, only 56 per cent of the LSMC respondents were satisfied with the role played by the
private clinics/Nursing Home/ Private Hospitals. A service recipient remarked that the
service 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/ private
hospitals?
Categories LSMC BVDC Total
Yes % 56 – 56
No % 44 – 44
Total N 91 – 91
Source: Field study, 2009
However, there is a growing concern over the lack of regulations in the provision of basic
services provided by the private sector. The government has been attempting to address this
by developing quality standards. In 2001, GoN developed the “Standard Guideline and
Treatment Protocols’ which is executed in publicly and privately run health clinics,
hospitals and nursing homes (ESP, 2001, p.128). However, the laboratory services provide
by public and private sectors are often of poor quality. There is no clear policy for quality
assurance in public, private and NGO health systems. The legal framework for
implementing quality assurance is weak or absent, especially in the private sector. In
addition to this, private, NGOs and development partner funding is not effectively
coordinated, not linked to the government’s overall health sector plans.
5.5. Conclusions
In the study, it is hypothesized that more the decentralization scheme, there is likely to
enhance more reproductive health policy implementation. Decentralization was taken as a
155
convenient tool to reinforce respective regime’s political power in spite of it being an
incessant theme in Nepal for the last five decades. Some legal initiations for the
decentralization were also made. At present, Local Self-governance Act, 1999 is in
operation. It mandates local government bodies to manage and supervise Health Posts and
Sub-Health Posts in order to deliver health service effectively including other
developmental activities. However, there is mismatch between the allocation of
responsibilities and the provision of required resources. There are contradictory rules and
regulations between Local Self-governance Act, Interim Plan and Ministry of Health and
Population guidelines and the role of local bodies. As a result, the jurisdictions of the local
bodies and the line agencies overlap. Local bodies cannot influence the decision-making of
line agencies.
The field study showed that more power was devolved in BVDC than LSMC. So far as the
reproductive health policy implementation was concerned, more reproductive policy was
implemented in LSMC. It identified that power and authority devolved is not sufficient
condition for policy implementation, it demands capacity as well. In LSMC in compare
with BVDC, there was more option for receiving the reproductive health services. For
example, private sectors’ hospitals/nursing home/clinic and NGOs including government
hospitals were delivering reproductive health services. But, in BVDC, there were no
alternative except government run health post.
There is tension between devolution and deconcentration process in Nepal. From the thrust
of Local Self-governance Act, 1999, local bodies are the main service providers to the
common 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. The
jurisdiction of the local body and line agencies overlaps. From the field study, it is seen
that the level of delegated authority was improving, but not to the desired level. Therefore,
there seems weak reproductive health policy implementation.
GoN has constituted regional development office to facilitate and support the local level so
that people need not come to the central level. In this line, five health regional directorates
were established. Similarly, zonal offices were also established with the aim to monitor,

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