Suchergebnisse

Raportissa tarkastellaan sotilaallisen t&k-panostuksen ja kilpailukyvyn välisiä yhteyksiä. Aineistona käytetään brittiläisen International Institute for Strategic Studies -laitoksen (IISS) "The Military Balance" -raportin tietoja länsimaiden sotilaallisen t&kpanostuksen kehityksestä. Julkisen vallan sotilaallisia t&k-panostuksia verrataan maiden julkisiin siviilipuolen t&k-menoihin, sotilaallisiin hankintamenoihin, sekä suhteessa maiden BKT:hen ja puolustusbudjetteihin. Raportissa on mukana myös tiivis katsaus sotilaallisen t&k-panostuksen ja tuottavuuden välistä yhteyttä kuvaavista kansainvälisistä tutkimuksista. Raportin tulosten mukaan sotilaallisella t&k-panostuksella ja kilpailukyvyllä ei ole suoraa yhteyttä. ; This study discusses the relationship between military R&D and competitiveness. The study is based mainly on a British International Institute for Strategic Studies -institutes publication "The Military Balance", and furthermore its information about the development of Western countrye´s military R&D-stakes for the years 1994 -2001. Government military R&D is compared for government R&D, defence expenditure and also to the countries gross domestic product and defence budgets. The study also includes tight review about the previous international studies, which are focused to study the relationship between military R&D and productiveness. The study concludes, that there are no direct connection between military R&D and competitiveness.

This paper is an analysis of the foreign Aid Policies of two OECD Development Assistance Committee member countries – Finland and Ireland. The analysis reveals that both Finland and Ireland share high principles on their relations with the developing world, although their current policy outlooks appear to differ significantly. Despite Finland's good economic performance and prosperity largely generated by the global demand and market access, the government has so far failed to include the increasing of ODA on its priority agenda. In addition to the declining commitment, the selection criteria for Finnish aid recipients appears to be partially commercially motivated. Ireland on the other hand has a solid record of targeting the poorest of the poor with its development assistance and has recently increased development country focus in national policies. The challenge for Ireland is the effective utilisation of these funds and even more importantly keeping the government's public, international commitment to the 0,7 percent recommendation level despite the possible future slowdown of the economy.

Since the early 1950's the foreign policy of the German Democratic Republic (GDR) towards Sweden and the other Western European states was dominated by a striving for diplomatic recognition. This thesis examines that striving through an analysis of the East German-Swedish relations from 1949 until 1972. The main focus is on the years 1954-1972. The thesis draws mainly on East German archival material from the ruling communist party SED (Sozialistische Einheitspartei Deutschlands) and the GDR foreign ministry. A starting point of the thesis is that GDR generally used all its contacts abroad to further its foreign political goals. GDR's efforts to develop the relations with Sweden on seven different areas are investigated. An important aim is to analyse GDR's political utilisation of areas, such as culture and traffic, that normally are not considered political or studied by traditional political history. The application of the concept of public diplomacy is central in this context. The analysis of the Ostseewoche (Baltic Week) is a significant part of the investigation of areas that traditionally not are considered as being part of foreign policy. The Osteewoche was a week filled with cultural activities and sport. The analysis of the inaugural ceremony and other activities of the Ostseewoche shows that even official East German ceremonies were used for purposes of foreign policy. However, GDR's relations with Sweden on the normal foreign policy arenas such as diplomacy and economy are also analysed. Great weight is given to analysing the perceptions of the political elite and the foreign policy actors to understand why certain actions were taken and why certain elements were significant of the GDR foreign policy. The question of which political instruments were the most important to the East German efforts to improve the relations with Sweden is also investigated. An important result of the thesis is that GDR had a comprehensive strategy for the development of the relations with Sweden. The main elements of this strategy were in place 1958 and did largely not change since. The spreading of a positive GDR-image was a very significant element of the East German foreign policy. Sweden was one of the most important Western European countries to the GDR foreign policy during this period of time.

The purpose of this thesis is to map and assess the organisational and ideological development of the European Liberal Democrat and Reform party, the ELDR. More specifically, it seeks to analyse the degree of integration between the members of the ELDR over time, to identify factors that may or may not generate integration, to relate the development of the ELDR to earlier research about European parties, and finally to contribute to the ongoing debate about whether or not the traditional national party families are about to establish parties at the European level. The thesis is based on the assumption that parties adapt to their environment, in this case, the system of multi-level governance that characterises the European Union. As the European parties are composed of national parties, they are also dependent on the member parties' opportunities and motives for cooperation. If there is integration, we can, however, not only expect the European parties to adapt to their environment. As they become independent actors, they may also influence their environment. In other words, we can anticipate interaction between the European and national levels that leads to mutual adaptation, or Europeanisation. To be able to capture the interaction between the two levels, theories from international relations and comparative politics are combined. Based on interviews, participant observation, documentary research and content analysis of European election manifestos, the analyses shows that the members of the ELDR have over time reached a rather advanced level of integration, both organisationally and ideologically. Although it is possible to identify constraining factors to this development, the ELDR has, at least from what is known from literature, reached about the same level of development as the two other European parties, the Christian democratic EPP and the Social democratic PES. The internal integration of the ELDR is the outcome of a successive transfer of power from the member parties to the ELDR. By now, the ELDR can therefore be defined as a rather independent actor and as a type of party at the European level. This type of party is, however, not comparable to national parties. It is instead adapted to the institutional structure of the European Union, with, at least partly, a different organisation and different functions from those of national parties. ; digitalisering@umu

This document summarises the outcome of a regional training workshop, "Interactive and dynamic approaches on forest and land use planning in Southern Africa". It was organised in December 2001 by the government of Botswana in cooperation with organisations in Zimbabwe and South Africa and with Swedish financial and technical support. The workshop aimed at exposing the participants to new cross sector approaches on strategic forest and land use planning, including the Area Production Model (APM) and concept, and to provide a platform for possible future development work in this field. It concerned such issues as the role of planning in relation to policies and local development, information and data needs in planning, the use of scenario modelling in land use planning, how to narrow the gap between "planning from above" and "planning from below", and the roles and interaction of different stakeholders in the planning process. The workshop had been proposed by the participating countries following an international training programme on policy and strategy development in Sweden. The 18 participants from three countries included central and local government staff concerned with forest and land use planning at the national and sub-national level, researchers and NGOs. The workshop consisted of two weeks of lectures, seminars and field based case studies and a concluding seminar, in which the participants presented their experiences and conclusions about the APM concept to a broader group of decision makers. Some of the main conclusions drawn by the participants were that the APM was a useful tool for promoting dynamic and multi-sector planning. At the same time the Model has a number of technical shortcomings that needs to be addressed. Those shortcomings were identified and discussed throughout the workshop. The need to keep the model simple and transparent was acknowledged. It was proposed that "homes" should be identified for the model in each country. Those homes should build up and maintain capacity to develop and adapt the model to the local conditions and priorities. INTRODUCTION. The workshop "Interactive and dynamic approaches on forest and land-use planning in Southern Africa" was arranged in Botswana in December 2001. It aimed at exposing the participants to new cross sector approaches on strategic forest and land use planning, including the Area Production Model (APM), and to provide a platform for possible future development work in this field. The workshop was the concluding step of a process that had been running for several years. It provides important lessons on approaches to cross-sectoral land use planning in Southern Africa. The process started in 1998, when there were several participants from Botswana, South Africa and Zimbabwe in an annual international course "Development of National Forest Policies and Strategies", organised by the Swedish National Board of Forestry and funded by Sida. Those participants strongly suggested that the Area Production Model, (APM), which had been demonstrated during the course, might be highly relevant in Southern Africa. As a response, the Country Capacity Building (CCB) project (a Sida funded project aiming at forest policy issues), set up a training programme in discussions with the three countries. As a first step, key personnel from the forest authorities in Botswana, South Africa and Zimbabwe, underwent a post­ graduate course at the Swedish University of Agricultural Sciences (SLU) in Umea, Sweden. The course took place in March 2000 and was focused on the ideas and applications of the APM. In a second step, a workshop designated for a wider audience, including governmental as well as non­ governmental organisations, was planned for mid 2000. The workshop was originally intended to be a two-phase arrangement. The first phase to be arranged in Zimbabwe, focusing on model theory with only limited field work, and a second phase, were the participants would split up and work a realistic case in a designated study area in each of the three countries involved. Unfortunately, the political situation in Zimbabwe during spring 2000 made it necessary to postpone the workshop. About a year later, in spring 2001, it was agreed among the interested countries to move it to another country in the Region, after the Ministry of Agriculture, Botswana, had generously accepted to host the workshop. The two-phase design of the workshop was by now reduced to a single event, with the joint study-area around Serowe in the eastern part of Botswana. The APM is a simulation model developed by Professor Nils-Erik Nilsson in co-operation with FAO. The Model, including an application concept, has been further developed by the Swedish University of Agricultural Sciences (SLU), Department of Forest Resource Management and Geomatics. The Swedish team of resource persons in the Botswana workshop have all been instrumental in the previous development work of the Model. The APM has been field tested on numerous occasions in South and Southeast Asia. This workshop, however, is the first occasion the model is used in Southern Africa. In spite of the simplicity and flexibility that characterises the model, the new setting was considered a major challenge when planning the workshop. The workshop results have given new and partly unexpected results in terms of both usefulness and applicability of the model. The Country Capacity Building project focuses on forest policy development. In modem terminology, nfp (national forest programmes) is a highly relevant term. Key strategies include support to demand driven processes, investment in human knowledge and, not least, a belief that personal commitment is as important for success as political commitments. On behalf of the organisers, I would like to thank the Ministry of Agriculture, Botswana, and the key­ persons from Botswana, South Africa and Zimbabwe. Without their commitment and enthusiasm, the positive outcome of the workshop would not have been possible.

Is there a common notion amongst the political and military leadership in Sweden on how to defend the country? Several events in the arena of international politics during the 20th century argue for the importance of coherence between political and military thinking. Different focus during peacetime has subsequently caused fatal consequences in times of war. This thesis studies a less obvious case: Sweden, a small-state, during the 1990's in the aftermath of the Cold War. In the effort of identifying inconsistency between the political and military level the study deals with a more comprehensive issue for any democratic society: How shall the elected political leadership exercise control over an authority (subordinated the government and) with deeply rooted professional values and with authority vested in it of crucial importance for national survival? Although several of government authorities play key roles in this respect the Armed Forces stands out to be the single most important entity. The thesis approaches the problem by studying one measure of control: the defence doctrine. The doctrine is analysed by studying various documents provided by the political decisionsprocess and with interviews involving a significant number of actors in the politico-military leaderships. The purpose has been to identify whether there is any inconsistency prevailing in the perception of values to be protected by the Armed Forces in case or war, what poses threat to these values and finally how to counter the threats. Hence, the political and military views on defence doctrine are examined. The last element of the doctrine, how to deal with the perceived threats, is embodied in the strategy for countering threats. Comparative studies involving Norway and Finland have been made to provide relevant references for the findings and provide a framework for elaboration on the differences between political and military priorities encapsulated in the research hypothesis. In addition, the research hypothesis involved the assumption that technical, tactical and operational decisions would serve as explanations for any inconsistency between military and political priorities. Piecemealed low-level decisions were assumed to unintentionally diverge bottom- up perceptions and create tensions if the politico-military interaction is not fully functional or if the politicians do not fully comprehend the implications of their decisions. The empirical findings suggest differences in the consistency of the politico-military leadership when comparing Sweden with Norway and Finland. For Sweden, the findings suggest a relative good politico-military adherence regarding values and threat perceptions. However there is a disparity in the views on what strategy to adopt and the military leadership has a more offensive mindset than the political leadership. The empirical data has primarily been collected from processes. To provide a better explanation for the findings the structure of security policymaking has been adopted in a new conceptual model based on Edward Luttwak's 'vertical dimension'.

This study in contemporary history describes the transformation of the public sphere in Sweden during the period 1969-1999, and analyses the role of information technology and politics in the process. The overall aim of the study is to explain how, and why, the public sphere in Jürgen Habermas sense has deteriorated during a period of rapid technological and political change, when increasing attention has been given to information technology as a new tool for improving democracy and empowering citizens. Theoretical inspiration is drawn from two perspectives within the modern history of technology and sociology of technology; the LTS (Large Technical Systems) and STS (Science, Technology and Society) approaches, as well as from the regime theory concept within political science. This multidisciplinary framework provides the theoretical basis for the study, including terms as socio-technical systems, system builder, technification, interpretative flexibility, stabilization, closing and regime change. In addition, the analysis draws upon previous research in economic history, where focus often has been on the important role of institutions. The term path dependence is central in this tradition. The starting point for the study is the process of a mutual legitimization between citizens and political actors that traditionally has taken place within the public sphere. In return for citizens support and trust, political actors have granted format rights to the public space. Two aspects of this interdependence are addressed: Freedom of speech and citizen's access to public information, and their access to arenas where an exchange of political ideas and opinions is taking place. In the study, the former is a question of the legal system and the limits to freedom of speech in new medias such as the Internet, while the latter concerns citizen's technical means and possibilities to connect to electronic networks. Research interest is concentrated on the formal political system, focusing both actors and structural factors such as technological development, media convergence, ideological change and international integration in the transformation process. Four case studies of institutional changes during formative moments, within what is defined as the legal and the technical infrastructures, are conducted and represent the empirical base of the thesis. The case studies are centered on Swedish governmental commissions, on the government itself and on proceedings in the parliament, and concerns formation and transformation of computer law, as well as the deregulation and privatization of the technical infrastructure. In the latter process Televerket (Swedish Telecom) has been an influential promoter of competition and institutional separation between tele- and data communications, representing a major regime change in favour of market relations in the technical infrastructure. In the area of computer law, the Swedish regime dominated by SCB (Statistics Sweden) was incorporated into a joint European data protection regime, resulting in limitations of freedom of speech on the Internet. These regime changes have also transformed the role of the state, constituting a "net watchers state". Another important finding is that promotion of democracy and improvement of access to the public sphere, never was on the agenda in the political transformation processes studied, although a parallel discourse on democracy and information technology existed throughout the period studied.

This study starts out with the hypothesis that the integration process in Europe is connected to cross-border régionalisation, a process which supports the institutionalization of subnational cross-border cooperation - region-building. Cross-border régionalisation is characterized by the decentralisation of vertical links and enhanced opportunities for horizontal links across state borders. In addition, political integration is expected to have some impact on the cross-border institutional forms that emerge at the subnational level. Three different approaches are utilized in order to establish the empirical connection between political integration and region-building. These are: an analysis of the factors which determine the general pattern of cross-border cooperation in Europe, an analysis of the policy network related to the regional and structural policies of the European Union (EU), and case studies of cooperation in the heartland of Europe, the Regio Basiliensis along the external border of the EU, and the EUREGIO along one of the internal borders. Two institutional factors are found to have a significant impact on the number of subnational cross-border cooperations, EU-membership and centrality. Federal constitution was shown not to be significant. It is suggested that the interaction between actors at different politico- administrative levels creates network relations, which typically bring both private and public actors together. More precisely, region-building is described as the outcome of the interaction which takes place between actors. A closer examination of the emerging policy network shows that community initiatives, the Interreg-programme in particular, improve the prospects for multi­level interaction. The EU plays a crucial role in providing the incentives for cooperation by increasing resource dependency and by establishing direct ties between the European Commission and a large number of subnational actors through partnerships. It appears as if the Commission wishes to demonstrate its capacity to deal with problems relevant to individual citizens. By, in part, bypassing central governments, it seems to increase its own importance vis- à-vis member states. The modus vivendi of cross-border region-building and régionalisation is the degree to which institutional actors at different levels share the same objectives. As shown by the case studies, there is a common interest in cross-border cooperation up to the point were public statues are introduced. Interests seem to coincide as long as the structures and contents of cross-border cooperation do not ultimately challenge the authority of state institutions. Therefore, it is not surprising that it seems impossible to give cross-border regions any rights under international law. Functional cooperation, rather than regionalist manifestations of cultural or political unity across borders, constitutes the backbone of region-building. Activities transcending borders are less controversial than those that may contribute to the establishment of new borders. It is concluded that region-building is a process which is embedded in the institutionalization of a multi-level interaction pattern. More favourable multilevel relations have been achieved through the transfer of some authority to the supranational level. This is the main reason why traditional integration theory fails to explain why there is a connection between political integration and cross-border cooperation. ; digitalisering@umu

VTT Symposium 191 ; Energian ja ympäristön leikkauskohdassa on viime vuosina tapahtunut suuria mullistuksia. Energiamarkkinat ovat vapautuneet ja osana kestävään kehitykseen pyrkimystä ekologinen ajattelu on saanut jalansijaa myös perinteisessä markkinataloudessa, tyyppiesimerkkinä vihreän sähkön käsite ja kierrätys. Ympäristöproblematiikassa on siirrytty megasarjaan, esimerkiksi ilmastokysymyksessä eletään suurten päätösten aikaa. Energia- ja ympäristöteknologian myynnissä myyjältä vaaditaan yhä enemmän osaamista. Tuotteiden käytön pitkäaikaiset ympäristöominaisuudet vaikuttavat ratkaisevasti kaupan syntyyn. Perinteisen kovan teknologian rinnalle tarvitaan uutta innovatiivista pehmoteknologiaa. SIHTI-ohjelma on paneutunut näihin kysymyksiin niin sanotuilla strategisilla selvityksillään. Ympäristönsuojelun ohjaukseen tarvittavaa tietoutta on luotu lukuisissa ympäristövaikutusten arvottamiseen liittyvissä hankkeissa sekä talouden ja ympäristönsuojelun optimia hakevissa selvityksissä. Yritystasolla tehtävää ympäristölaskentaa varten on luotu uusia työkaluja ja menetelmiä ja päästöpörssien monulotteisia vaiktuksia on analysoitu. Poliittisen päätöksenteon tueksi on kehitetty kasvihuonekaasujen kehitystä kuvaavia indikaattoreita ja analysoitu vaihtoehtoisten päästörajoitustekniikoiden kustannuksia ja tehokkuutta. SIHTI-ohjelmassa savukaasujen puhdistustekniikka-alueelle on syntynyt oma vahva tutkimuskokonaisuutensa, jonka ympärille on kehittynyt kansainvälisestikin arvostettuja tutkimusryhmiä. Pienhiukkasten tärkeimpiä päästölähteitä on kartoitettu, koostumuksia ja kokojakaumia mitattu ja erilaisia keinoja vaikuttaa pesureitten ja sähkösuodattimien erotustehokkuuteen tutkittu. Tutkimusryppääseen on kuulunut sekä teoreettisia mallinnuslaskelmia, laboratoriomitan laiteteknistä kehitystyötä että täyden mitan koetoimintaa. Osoituksena onnistuneesta panostuksesta on, että tutkimustuloksia on jo voitu hyödyntää kaupallisesti ja täyden mittakaavan laitetoimituksia ulkomaille on jo toteutettu. Uusia innovatiivisia teknisiä ratkaisuja ympäristöpäästöjen mittaamisella on myös kehitetty. Metsäteollisuuden ympäristövaikutusten hallinnan parantamiseksi on ohjelman puitteissa perusteellisesti mitattu ja mallinnettu haitallisten aineiden kulkeutumista eri virroissa ja prosessiyksiköissä sekä tutkittu ja kehitetty uusia säästävän teknologian ratkaisuja mm. sellutehtaan vesikiertojen sulkemiselle, viherlipeäsakan ja tuhkan hyödyntämiselle sekä siistauslietteen ja jätepaperin poltosta syntyvän tuhkan kierrättämiselle. Turvetuotannon valumavesien sekä pöly- ja melupäästöjen paremmalle hallinnalle on kehitetty uusia menetelmiä ja ohjeita, joita on jo otettu käyttöön. Vaihtoehtoisia ratkaisuja käytettyjen turvetuotantoalueiden jälkikäytölle on niin ikään tutkittu. Poikkitieteellisen lähestymistavan takia SIHTI-ohjelma on pyrkinyt tiedottamaan tutkimustuloksistaan mahdollisimman laajasti. Ohjelman vuosiseminaari ja sen yhteydessä pidettävät istunnot energiantuotannon päästöjen ympäristövaikutuksista, pienhiukkasten erottamisesta ja kiinteiden jätteiden hyötykäytöstä suovat oivallisen tilaisuuden niin esitelmänpitäjille kuin kuulijoillekin antaa oman panoksensa meitä kaikkia hyvin läheisesti askarruttavaan kysymykseen, mikä on oikea tie ja etenemistapa kestävään energiantuotantoon. ; Great revolutions have taken place in the intersection of energy and environment in recent years. The energy market has been liberated, and in part of sustainable development, an ecological pattern of thought has gained a footing in traditional market economy, typical examples being green electricity and recycling. As regards environmental problems, we have moved towards a mega-league; for example, we are living an era of great resolutions on environmental issues. More diversified knowhow is required from the sellers of energy and environmental technology. Long-term environmental impacts of the use of products are of decisive significance in business transactions. New innovative soft-line technology is required in addition to conventional hard technology. The Finnish National SIHTI Programme has attended to these issues via so-called strategic surveys. Knowledge required for the control of environmental protection was created in a number of projects on evaluation of environmental impacts and in assessments searching an optimum for economy and environmental protection. New tools and methods were developed for environmental accounting in enterprises, and diversified impacts of emission exchange were analysed. Indicators describing the development of greenhouse gases were developed and costs and efficiency of alternative technologies for limiting emissions were analysed to support political decision-making. In the SIHTI Programme, a strong research integrity was formed in the field of flue gas cleaning technology, and research groups with a high international esteem were also formed. Most significant emission sources of particulates were surveyed, their composition and particle size distributions were measured, and different tools of improving the separation capacity of scrubbers and electrical precipitators were studied. This research integrity included both theoretical modelling calculations, laboratory-scale equipment-technical development and full-scale testing. An indicator of successful focusing is that research results have already been utilised commercially, and industrial-scale equipment commissions have been executed. New innovative technical solutions for measuring emissions to the environment have also been developed. To improve the control of environmental impacts of the pulp and paper industry, the transportation of detrimental substances in different flows and process units were measured and modelled, and new solutions of non-waste technology were developed for closed water cycles in pulp mills, for the use of green liquor sludge and ash and for the recovery of ash from the combustion of deinking sludge and waste paper. In peat production, new methods and instructions were developed and introduced for the control of drainage waters and for dust emissions and noise problems. After-use alternatives for exhausted peat production fields were also studied. Due to the interdisciplinary approach, the SIHTI Programme has disseminated information about research results as widely as possible. The Annual Seminars of the Programme, and sessions on environmental impacts of emissions from energy production, separation of particulates, and utilisation of solid wastes have offered excellent opportunities to the lecturers and to the audience to bring their own contribution to the issue occupying our mind: what would be the right way of approaching sustainable energy production.

Pro gradu ­tutkielma koostuu seuraavista osista: Rouvinen, Kaisa. Lisääntymisterveydenhuollon haasteet ja naisten hyvinvointi vähiten kehittyneissä maissa. Tampereen yliopisto. Terveystieteen laitos. Kirjallisuuskatsaus. Osasuoritus Pro gradu ­tutkielmaan. 26 s. 2003 Rouvinen, Kaisa. Quality of care in reproductive health services at health posts in Nepal. International EuroQuan Conference on Quality and Nursing Practice. Proceedings. Norsk sykepleieforbund. 1997; 224-231. Rouvinen, Kaisa. Quality of care in reproductive health services at five government health posts in Siraha District, Eastern Nepal. A dissertation submitted to the University of Liverpool (School of Tropical Medicine) in partial fulfilment of the degree of Master in Community Health. 95 pages. 1996 ; 1. JOHDANTO 6 2. LISÄÄNTYMISTERVEYS KEHITYKSEN INDIKAATTORINA 7 3. NAISEN ELÄMÄN TÄRKEÄT JA KRIITTISET VAIHEET 10 3.1. RASKAUS JA SYNNYTYS - TURVALLISEN ÄITIYDEN TAVOITE 10 3.2. PERHESUUNNITTELU JA ABORTTI 15 3.3. HIV JA MUUT SUKUPUOLITAUDIT 17 3.4. LAPSETTOMUUS JA LAPSEN SUKUPUOLI 19 3.5. SUKUPUOLIELINTEN TRADITIONAALINEN SILPOMINEN 20 3.6. KÖYHYYDEN, TRADITIOIDEN JA OLOSUHTEIDEN MERKITYS 22 4. HAASTEET JA MAHDOLLISUUDET 23 LÄHTEET 26 QUALITY OF CARE IN REPRODUCTIVE HEALTH SERVICES AT FIVE GOVERNMENT HEALTH POSTS IN SIRAHA DISTRICT, EASTERN NEPAL ACKNOWLEDGEMENTS 1 TABLE OF CONTENTS III LIST OF TABLES VI LIST OF FIGURES VII LIST OF ABBREVATIONS AND ACRONYMS VIII GLOSSARY IX EXECUTIVE SUMMARY X CHAPTER 1. INTRODUCTION 1 1.1. THE CLIENT AND THE CONCERN 1 1.1.1. Save the Children US in Nepal 1 1.1.2. Save the Children Siraha project 1 1.1.3. Problem statement 2 1.2. THE STUDY 2 1.2.1. Study question 2 1.2.2. Aim and objectives of the study 2 1.2.1. Action plan and accomplishment of the study 3 1.3. STUDY LOCATION 4 1.3.1. Nepal 4 1.3.2. Siraha District 4 CHAPTER 2. LITERATURE REVIEW 6 2.1. GLOBAL VIEWS OF WOMEN'S HEALTH 6 2.2. PRIMARY HEALTH CARE IN NEPAL 8 2.2.1. Safe Motherhood and Family Planning 8 2.3. QUALITY IN HEALTH CARE 10 2.3.1. What is quality? 10 2.3.2. Approaches to assessment of quality in health care 10 2.4. SELECTED ISSUES IN QUALITY OF HEALTH CARE 14 2.4.1. The structure of the health care and its relevance in quality assessment 14 2.4.2. Health care providers' job motivation and its impact on quality of health care 15 2.4.3. User satisfaction 16 2.5. CONCLUSION 17 CHAPTER 3. METHODOLOGY 19 3.1. EVALUATION OF HEALTH POST FACILITIES AND SERVICE ARRANGEMENTS 20 3.1.1. Study location 20 3.1.2. Selection of health posts 20 3.1.3. Issues and variables used to explore the objective 20 3.1.4. Tools and strategies of data collection 20 3.2. EXPLORING HEALTH CARE PROVIDERS' PERCEPTIONS ABOUT THE QUALITY OF CARE 21 3.2.1. Study population 21 3.2.2. Selection of informants 21 3.2.3. Issues and variables used to explore the objective 21 3.2.4. Tools and strategies of data collection 21 3.3. DESCRIBING THE LEVEL OF USERS' SATISFACTION 22 3.3.1. Study population 22 3.3.2. Selection of informants 22 3.3.3. Issues and variables used to explore the objective 22 3.3.4. Tools and strategies of data collection 23 3.4 ADDITIONAL DATA COLLECTION METHODS 24 3.5. PRE-TESTING AND TRANSLATION 24 3.6. DATA HANDLING AND STORAGE 25 3.7. DATA ANALYSIS 25 3.8. QUALITY ASSURANCE AND ENCOUNTERED CONSTRAINTS IN DATA COLLECTION 25 CHAPTER 4. RESULTS 27 4.1. EVALUATION OF HEALTH POST FACILITIES AND SERVICE ARRANGEMENTS 27 4.1.1. Location and accessibility 27 4.1.2. Target population and service statistics 27 4.1.3. Sub-health posts, outreach clinics and staffing 28 4.2.4. Waiting facilities at health posts 28 4.1.5. Rooms for counselling and MCH and FP services 28 4.1.6. Infection prevention 29 4.1.7. Equipment and instruments for use in MCH and FP 29 4.1.8. Availability of contraceptives and essential medicines 29 4.1.9. IEC material and activities 29 4.1.10. Record keeping and reporting 30 4.1.11. Health post management and supervision 30 4.1.12. Conclusion 30 4.2. HEALTH CARE PROVIDERS' PERCEPTION ABOUT THE QUALITY OF CARE 31 4.2.1. Job satisfaction and experience as a health care provider 31 4.2.2. Health workers' perception of what is good quality in health care 32 4.2.3. Health workers' perception about users' expectations 33 4.2.4. Health workers' suggestions for improvement of health care 33 4.2.5. What are the specific reasons for low utilisation of FP and AN services 34 4.2.6. Conclusion 35 4.3. QUALITY OF CARE FROM THE USERS' POINT OF VIEW 35 4.3.1. The sample 35 4.3.2. Perceptions of the quality of care 37 4.3.3. Suggestions for improvement for the quality of care at a health post 40 4.3.4. Conclusion 40 4.4. SUMMARY OF RESULTS 41 CHAPTER 5. DISCUSSION 43 5.1. IMPACTS OF STRUCTURE OF HEALTH CARE ON QUALITY OF THE SERVICE 43 5.1.1. Accessibility 43 5.1.2. Clinical settings and procedures 44 5.1.3. Service arrangements 44 5.2. HEALTH WORKERS' ROLE 47 5.2.1. Users' expectations contradicting providers' perceptions 47 5.2.2. Implications of health workers' perceptions for improvement of quality 48 5.2.3. Job motivation 48 5.2.4. Quality assurance cycle 50 5.3. CONCLUSIONS 50 5.4. COMMENTS ON METHODS USED IN THE STUDY 51 CHAPTER 6. RECOMMENDATIONS 53 REFERENCES 54 APPENDICES APPENDIX 1 PHOTPGRAPHS: WALL PAINTINGS AND TBA TRAINING 58 APPENDIX 2 MAPS OF NEPAL AND SIRAHA DISTRICT 59 APPENDIX 3 INVENTORY FORM FOR HEALTH POST FACILITIES 60 APPENDIX 4. BACKGROUND VARIABLES 70 APPENDIX 5.A STRUCTURED QUESTIONNAIRE FOR USER EXIT INTERVIEW 71 APPENDIX 5.B MAITHALI TRANSLATION OF THE QUESTIONNAIRE 75 APPENDIX 6 EVALUATION OF HEALTH POST FACILITIES AND SERVICE ARRANGEMENTS 79 APPENDIX 7. FINDINGS FROM HEALTH PERSONNEL IN-DEPTH INTERVIEWS 84 APPENDIX 8. USERS' EXPRESSIONS OF THE QUALITY OF CARE. QUOTATIONS. 85