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A Day’s March to the Midwife – Administrative experts monitor new approach in Nepal’s healthcare system

Scientists from the University of Potsdam recently visited Nepal to monitor the impact of a government program to foster the decentralization of health governance. They started their tour in the capital Kathmandu and traveled to the districts Doti and Kailali in the western part of the country. Nepal’s medical sector is a nursing case. Particularly in the country’s peripheral regions, centralized structures hinder adequate medical care. The two-year project, headed by Professor Harald Fuhr and Professor Werner Jann, was completed in 2013.

Being able to see a physician when you get sick, sufficient access to medicine when you suffer from pain and adequate conditions during childbirth – all this goes without saying in Germany. In Nepal, however, people do not have adequate medical care and can only dream of such conditions. In response, the Nepalese government implemented a pilot program in 20092010 to at least partially improve medical care. Instead of having to rely exclusively on a strongly centralized health care system, the local administrations in four out of 75 districts received between 2.5 and 4 million Nepalese Rupees – between 19,000 to 30,000 Euros – of additional funding to address the direst needs, i.e. in district hospitals or in the small village huts where nurses and sometimes even midwifes work. These facilities lack everything: trained physicians, medicine, and equipment. Leaving nothing to chance, the minimum and maximum amounts of allocated money for each level of the healthcare system were strictly defined.

The Deutsche Gesellschaft für Internationale Zusammenarbeit (GIZ) took part in the project from an early stage, operating in two of the affected districts in western Nepal: Doti and Kailali. This is where Harald Fuhr, Professor of International Politics, and his five-member research team took part in the project. The scientists and the GIZ closely coordinated their work and were supported by Werner Jann, Professor of Administration in Potsdam. “We did not evaluate any concrete healthcare services but monitored whether the management and the local administrational structure changed after being given more freedom,” Fuhr explains his research assignment. These aspects were also discussed in advance with Nepal’s Ministry of Health and Ministry of Local Development.

The scientists’ research design allowed them to not only draw clear conclusions but also served as an important tool for the partner institute in Kathmandu. Establishing local scientific capacity was an integral component from the very beginning. The Nepalese experts were able to support and partially conduct the evaluation. What are the work routines in each facility? What is its structure, and how is the management organized? What will happen to the additional money? These and other questions allowed the team to take stock of the situation. They monitored whether the allocation of funds led to any changes. Their research design differentiated between three groups: (1) those with no changes in the overall institutional conditions and financial resources, (2) those included in the decentralized healthcare reform program without complementary GIZ support, and (3) those included in the reforms with complementary GIZ support. “We were actually able to work in a laboratory condition of sorts, which is rare in the field of social sciences,” Fuhr’s assistant Bastian Jantz explains. “The control groups were well-suited to determining the effect of the implemented measures.”

Their work also turned out to be real field research. After taking a propeller plane from Kathmandu to Dhangadhi, the researchers had to cover 500 km through Nepal’s lowlands and midlands – in a jeep. “The streets in Nepal are actually not that bad,” Jantz describes the situation. “Sometimes you see a scooter but hardly any cars,” the scientist reports, illustrating another problem. Traveling long distances is difficult for many Nepalese because they simply lack suitable vehicles. The hilly landscape around the monitored districts Doti and Kailali makes it difficult to reach the villages, which are also far away from each other. “It may happen that a pregnant woman from a very remote area has to walk a whole day to be able to give birth with the help of a midwife,” Jantz says.

The research team actually found the impassable terrain ideal in that it demanded local responsibility. Out of 95 villages and settlements, 38 benefited from the program and 10 received additional GIZ support. An additional 12 uninvolved areas were used for evaluation. The university team visited about 10 different healthcare facilities and talked to locally responsible representatives. “The tour was not that difficult,” Jantz remembers. “You got used to the spicy food, and you were able put up with the lack of heating and cold water in the hostels with the help of a thick sweater and a bit of robustness.” The hospital conditions turned out to be much more appalling. “We were shocked, especially by the lack of hygiene.”

When Jantz thinks back to the two-and-a-half-week trip, he mainly remembers very friendly and open people, who seemed happy despite the obvious shortages. “When we got to the villages, the people welcomed us very cordially and immediately wanted to talk to us,” he reports.

The results of the researchers’ evaluation offer some mild encouragement. Health governance has improved in the monitored villages. The local population has been – and this is an important aspect – integrated more comprehensively into the discussion about priorities of local healthcare services. There were additional local resources and new quality guidelines. Other indicators, however, showed no change or only a slight upward trend. Important medicine was still lacking.

“The timeframe and the individual groups might have been too small,” Fuhr surmises. “To improve health care with such measures requires perseverance.” He and his colleagues submitted all collected data to the local political and business experts. The research institute in Kathmandu that supported the evaluation has been able to build on them. It nevertheless remains to be seen how the government will use the results. In such an unstable country, the balance of power and political interests change.


Monitoring the Impacts of Decentralizing Health Governance in Nepal
Lead: Prof. Dr. Harald Fuhr; Prof. Dr. Werner Jann
Duration: 2011–2013
Funded by: Deutsche Gesellschaft für Internationale Zusammenarbeit (GIZ)

Principal Investigators

Prof. Harald Fuhr studied political sciences, sociology, economics, economic, and social history at Goethe University Frankfurt am Main and the Philipps-Universität Marburg/Lahn from 1972 to 1979; PhD (1985) and habilitation (1993) in Constance. Since 1997 he has been Professor of International Politics at the University of Potsdam.


Universität Potsdam
Wirtschafts- und Sozialwissenschaftliche Fakultät
August-Bebel-Str. 89, 14482 Potsdam
E-Mail: hfuhruni-potsdamde

Prof. Werner Jann studied political sciences, mathematics, and economics in Berlin and Edinburgh (Scotland) from 1970 to 1976; PhD (1982) and habilitation (1989) at the German University of Administrative Sciences – Speyer. Since 1993 he has been Professor of Political Science, Administration, and Organization at the University of Potsdam.


Universität Potsdam
Wirtschafts- und Sozialwissenschaftliche Fakultät
August-Bebel-Straße 89, 14482 Potsdam
E-Mail: jannuni-potsdamde

Assistant Researchers:
Bastian Jantz, Julka Jantz, Dr. Markus Seyfried

Text: Petra Görlich, Online-Editing: Agnes Bressa, Translation: Susanne Voigt