Suchergebnisse

Nothing exceptional happened in front of the youth association building in Kalajoki on 9 September 1953. There was a minor confrontation between regional police forces and local youth, but hundreds of similar events happened in small municipalities across Finland. The event took about ten minutes, nobody was seriously hurt, and collective feelings quickly calmed down. However, after extensive investigations, the regional prosecutor thought otherwise and prosecuted half a dozen local men for rebellion against the state in January 1954. The district court agreed. The municipality was shocked, and the Finnish society was taken by surprise. The case ended up in Supreme Court. This book analyses why and how the last rebellion in the history of Finland occurred in a tiny municipality on the west coast of Finland. The analysis is based on historical microsociology that integrates the insights of microhistory and microsociology into event structure analysis and collective memory studies.

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

Hallinnon uudistaminen liian yksiäänistä ja kaavamaista Jenni Airaksisen väitöskirja Hankala hallintouudistus kohdistuu suomalaisen kunnallishallinnon uudistamiseen. Tutkimus osoittaa, että kaavamaisuuteen ja liialliseen konsensukseen perustuva uudistaminen voi pahimmillaan johtaa toiminnan taantumiseen tai jopa estää muutoksia. Poliittis-hallinnollisella eliitillä on pyrkimys ylläpitää sisäistä kiinteyttään ja tämä estää erilaisten näkökulmien esiintulon uudistamiskeskustelussa. Tämä puolestaan johtaa yksiääniseen uudistamiseen ja liialliseen konsensukseen. Tutkimuksen perusteella uudistuksissa mukana olevilla ihmisillä oli hyvin erilaisia käsityksiä uudistuksen tavoitteesta ja tehtävästä. Nämä käsitykset olivat keskenään osin voimakkaassakin ristiriidassa. Hallintouudistus tulkittiin kuntien haasteiden kannalta oikeanlaisena ja tarpeellisena toimintana, mutta samaan aikaan sen pelättiin johtavan kuntien päätösvallan ja itsenäisyyden menettämiseen. Ristiriitaiset käsitykset eivät kuitenkaan nousseet keskusteluun vaan uudistuksen läpikäyväksi teemaksi nousi konfliktien välttäminen ja konsensuksen tavoittelu, mikä käytännössä johti siihen, että uudistuksen tavoitteet jäivät saavuttamatta. Vaikeiden asioiden välttely johti siihen, että käytännön uudistaminen osoittautui liian hankalaksi. Yksiäänisyyteen pyrkivän ja kaavamaisen uudistamisen mahdollisuudet saada aikaan muutoksia ovat hyvin rajalliset. Rajallisuus korostuu entisestään, mikäli päätöksenteossa pyritään erilaisten mielipiteiden peittämiseen ja uudistusta eteenpäin vievien eliittiryhmien kiinteyden ylläpitämiseen. Hallinnon uudistamisessa tarvitaan uusia ja luovia tapoja ratkaista ongelmia. Uudet ratkaisut voivat kuitenkin syntyä vain, jos uudistamisessa kyetään luopumaan yhden yhteisen päämäärän ja sen tavoittelun ihanteesta ja hyväksytään uudistamiseen liittyvä moniäänisyys. Hallinnon uudistamista tulisi tutkimuksen mukaan tarkastella prosessina, jossa erilaisten tulkintojen ja preferenssien kamppailu on normaalia toimintaa. Tällainen lähestymistapa voidaan suomalaisessa kompromissi- ja konsensushakuisessa kulttuurissa kokea vaikeaksi, mutta mikäli hallinnon uudistamisessa toimivat ryhmät jättävät vaikeat asiat pois agendaltaan konsensustavoitteen nimissä, päädytään hallinnon uudistamisessa helposti hankalaan hallinnon uudistamiseen. HANKALA HALLINNON UUDISTAMINEN näkyy pienten askeleiden kautta tapahtuvina, kompromissiratkaisuista kehittyneinä, pirstaleisina hallinnon uudistamisen osahankkeina, joiden kautta voidaan muutosten toteuttamisen sijaan ylläpitää olemassaolevia rakenteita ja vältellä muutosta. ; Troublesome Nature of Administrative Reform The topic of my research is an administrative reform which is studied as a dynamic and contextualised phenomenon. The aim was to understand the nature and the essence of an administrative reform in the context of local government in Finland. The Regional Support Project (Seutukuntien tuki -hanke) was chosen as an empirical example of a reform in this study. The project was launched by the national government in 2000 as a response to the transition process of local governance of Finland. In this context the municipalities were trying to solve the contradiction of their diminishing resources and increasing demands by increasing voluntary cooperation in service provision and regional development. The aim of the project was to promote inter-municipal cooperation by means of state support and permissive legislation. The empirical data is qualitative and the method of analysis is based on grounded theory. The purpose of the method is to produce a practical theory derived from the experiences of those people who have lived through the administrative reform. The process of analysis was to define emerging concepts and make continuous comparisons to the empirical data and to other conceptual innovations. By linking the discovered concepts to each other, the patterns of social behavior and meaning of action were generated. The empirical data of the study was collected during 2000 2005. The primary data consists of 154 interviews and approximately 60 pages of observation material. The data was collected in the national level steering group of the reform and in all of the eight districts (comprising 55 municipalities) taking part in the project. The secondary data includes official documents of the Regional Support Project produced by the central government, different districts and the municipalities. The grounded theory -procedure revealed four partly conflicting frames. The different frames are the rhetoric and the reality of governance practices, national government as the reformer of autonomous local government, the fear of hollowing out local government and the gap between the elite and the masses. The phenomenon of administrative reform is experienced and interpreted differently depending on the frame adopted. In a situation, where contradicting frames are visible, a conflict is possible and even probable. However, this was not the case in the administrative reform studied. Instead, the most evident patterns of behavior in the reform process were pronounced pursuit of consensus, compromise seeking and avoidance of conflict. My research shows that the core process of an administrative reform is maintaining the cohesion of the elite . With this concept it was possible to connect the discovered contradicting frames to each other. Through an analysis of the interplay between the different frames and the core process, the dynamics of the administrative reform are unfolded. Essential in understranding the dynamics of an administrative reform is the existence of the conflicting frames and coincident objective of maintaining the cohesion of the elite. This combination is likely to lead to a wobbly and slow process and shows the troublesome nature of an administrative reform. The theoretical model created in this research, shows the process of an administrative reform as an application of unisonous instrumental-rational patterns. The possibilities of the above-mentioned approach are highly limited in producing new ways of function. Such limitedness is even more problematic in a multi-actor, network-type situation, where different interpretations of situations are not confronted but concealed in the fear of conflicts. Instead, administrative reform practices could be seen as historically and culturally defined processes of production of meanings, where the struggle of different ideas and interpretations is considered normal. The acceptance of struggle as a part of administrative reform requires that the individuals of the decision-making elites are ready to function in groups, where anxiety is allowed to be present at times. The groups the decision-making elites in administrative reforms are trying to find new creative solutions to the problems they face. Creative solutions develop in situations where genuine negotiation between different meanings and interpretations is present. Negotiation is however not possible in a situation where the fundamental objective of an elite-group is to prevent the individuals of the group from exposing to anxiety. If this is accepted, it is likely to lead to small steps, bad compromises and fragmented application of reform practices. In the context of administrative reforms this is problematic for it can lead to the regression of action or actually supporting the practices already functioning. These insights indicate why the nature of administrative reform is troublesome.