Suchergebnisse

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

Kunnat ovat suuren muutoksen keskellä. Kuntarakenneuudistus sekä sosiaali- ja terveydenhuollon palvelurakenneuudistus tulevat muuttamaan kuntien hallintoa merkittävästi. Kari Hakarin tutkimus tarkastelee yhden suuren kaupungin hallinnonuudistusta uuden julkisen hallinnan teorian näkökulmasta. Uusi julkinen hallinta on kunnallishallinnon uudistamisen kolmas vaihe, joka on kehittynyt perinteisestä julkishallinnosta ja tätä seuranneesta uudesta julkisjohtamisesta. Tutkimuksen tavoitteena on arvioida, onko uudesta julkisesta hallinnasta kuntien hallinnonuudistusten uudeksi suunnaksi. Tutkimuksella tuetaan myös kuntien käytännön kehittämistoimintaa. Tutkimuskohteena on Tampereen kaupungin toteuttama kokonaisvaltainen toimintamallin uudistus. Uudistus muodostuu kolmesta osasta: pormestarijärjestelmästä, tilaaja–tuottaja-mallista sekä asiakaslähtöisestä prosessiajattelusta. Tutkimustulokset osoittavat, että Tampereen muutosprosessi toteuttaa varsin hyvin uuden julkisen hallinnan mukaista ajattelua. Se ei kuitenkaan edusta tätä moderneimmillaan, vaan perustuu vahvasti sekä byrokraattisen organisaation rakenteisiin että uuden julkisjohtamisen mukaiseen markkinoistumisen tavoitteeseen. Näyttää siltä, että Tampereenkin toimintamalli kaipaa päivittämistä, jotta se pystyy vastaamaan paremmin tulevaisuuden haasteisiin. Moderni uuden julkisen hallinnan kokonaisuus kuntien hallinnon kehittämisen näkökulmasta muodostuu 1) avoimesta kumppanuudesta asukkaiden, palvelutuottajien ja muiden sidosryhmien kanssa, 2) paikallisuuden ja yhteisöllisyyden korostamisesta, 3) monimuotoisesta suorasta ja edustuksellisesta demokratiasta, 4) asiakaslähtöisestä palvelujen kehittämisestä, 5) tulosperusteisesta palveluiden hankinnasta sekä 6) monimuotoisesta palvelutuotannosta. Muutos vallankäytössä on yksi uuden julkisen hallinnan ominaispiirre. Kunnan johtaminen edellyttää monimutkaistuvassa yhteiskunnassa uusia välineitä ja toimintatapoja. Tutkimuksen mukaan moderni kunnan johtaminen perustuu onnistuneelle yhdistelmälle pehmeää ja kovaa valtaa. Tutkimuksen mukaan uusi julkinen hallinta voi kehittyä kuntien hallinnonuudistusten perustaksi. Tätä tukee se, että uudessa julkisessa hallinnassa kehittämisperiaatteet muodostavat loogisen kokonaisuuden, jota voidaan käytännössä toteuttaa monin välinein erilaisissa tilanteissa. Lisäksi on olemassa ilmeinen tarve yhteiselle visiolle, jotta välttämättä edessä oleva kuntien hallinnonuudistus pystytään toteuttamaan. Uudet, isot reformit tarvitsevat aina mallin, johon muutos voidaan perustaa. Uuden julkisen hallinnan kehittymistä tukee myös se, että hallinnon kehittämisen käytännön toteutukset sekä kansainvälisesti että Suomessa toteuttavat jo monella tavoin uuden julkisen hallinnan mukaisia hallinnonuudistuksen kehityssuuntia. Tutkimus tuo uutta tietoa uuden julkisen hallinnan käytännön toteutuksesta suuressa suomalaisessa kaupungissa. Se näyttää myös suuntaa kuntien kehittämistyölle yhdistäen käytäntöä ja teoriaa ja tuo näin tietoa sekä käytännön kuntien kehittämistehtävissä toimiville että tutkijoille. Tampereen toimintamallin päivittämiselle se tarjoaa päämäärän, jota kohti edetä. ; The subject of this dissertation is the new public governance from the perspective of the local government management reforms. The research question is: how is the new public governance reflected in local government reforms? The research ques-tion will be examined from the perspectives of theory, practice and power relations. The empirical object of the study is the management reform of the City of Tampere, Finland. The reform includes three parts: the mayoral system, the purchaser-provider model and the customer-oriented process organization. The study also aims at the development of municipal operations, and presents new public governance as a comprehensive "theory of practice", which combines theory and practice and allows municipalities to find perspectives, tools and a theoretical framework for their management reforms. The study consists of four separate published sub-studies and this summary. The first sub-study deals with the theory of new public governance within the framework of the management reform of the City of Tampere. The second and third sub-studies are concerned with a variety of practical implementations of new public governance in the City of Tampere management reform. The fourth sub-project addresses power relations. In this summary the results are presented from the perspective of a management model, networked service development and the change in the exercise of power. Questionnaires were the empirical basis of the first two sub-studies, the third examined written documents and used interviews with experts and fourth sub-study relied on theme interviews with directors. New public governance (NPG) represents the third wave of the management re-forms evolving from a traditional public administration, and that following the new public management. An essential feature of the new public governance is that it does not completely reject earlier administrative reforms, but rather complements them with new solutions. NPG is based on the view that the public administration is no longer able alone to control society, but the success of governance is based on the partnership with the private and third sectors as well as with the citizens. Within the framework of new public governance one can, at least to some extent, identify three distinct trends. The differences between the trends are mainly in emphasis placed on various matters. Discussion of the new public governance started in network governance. Next, the new public governance was discussed from the perspective of democratic decision-making and public participation. The third emphasis seems to be on the new public governance as a development of customer-focused services and co-production. The results show that the process of change of the City of Tampere can be imple-mented quite well within the new public governance paradigm. At the beginning of the process the new public management was a decided basis of the reform. In the phases of preparation and implementation constraints and international experiences of weaknesses were perceived in the new public management model. On the basis of this, the management model has been developed further so that issues of new public governance such as local democracy, participation, networks and transparency of government have become stronger. The management model of Tampere does not, however, represent the new public governance in its modern form. The Tampere model is built on a basis of democracy and regulation of traditional public administration as well as the quasi-markets of the new public management. The modern new public governance reform seems to be moving especially towards a customer-oriented service development. According to this study the change in the use of power seems to be one of the characteristics of society's growing complexity and new public governance. There is a need for new instruments for leadership and in the exercise of power in an in-creasingly complex society. The modern municipal leadership is based on a suc-cessful combination of soft and hard power. The growth of new public governance as the next paradigm of management re-forms can be justified from three different perspectives. First, the new public gov-ernance is a logical entity. It brings together coherent principles of management reform, which can be implemented in practice by a variety of techniques in different situations. Second, there is an obvious need for a common vision for local gov-ernment reforms. New, large-scale reforms always need a new paradigm in which a change can be set up. There is a need for a common vision for the municipalities and their functions in order to implement local government reform. The new public governance could be the entirety that can show the way for the necessary man-agement reform of municipalities in Finland. Third, the practical implementations of management reforms both internationally and in Finland are already realizing the trends of management reform of new public governance in a number of ways.