# Introduction fter realizing the need and importance of NGO, Government of Nepal (GON) has opened avenues for NGOs to be a partner in development sectors such as education, health service, community development, women and others since 1990. Likewise, Interim Constitution, 2006 has also given space to create conducive environment for NGOs in Nepal. Interim constitution of Nepal (2006) has already declared free primary health services as a fundamental right for every Nepali citizen and has illuminated ways for reflecting the declaration in respective acts and regulations. Till this date, more than thirty thousands NGOs were affiliated with Social Welfare Council (SWC), an institution to look after NGOs in Nepal. Among them, there are near about one thousands NGOs which aim to deliver health services in Nepal. Specifically, a national health policy (NHP), 1991 aimed at enhancing the health status of the country, addressing service delivery as well as administrative structure of the health system was adopted. In this NHP, GON has recognized NGOs as a convenient partner including private sectors. Onwards' periodic plan particularly the Eight Plan (1992-97), the Ninth Plan (1997)(1998)(1999)(2000)(2001)(2002), the Tenth Plan (2002)(2003)(2004)(2005)(2006)(2007) and the Interim Plans and second long term health plan were developed in consistent with the NHP. The 2006 data showed that the maternal mortality ration (MMR) was 281 deaths per 100,000 live births. This represented a decrease of 32 per cent over the 2000 figure that stood at 415. Similarly Family Health Division (2009) showed that MMR was 229 deaths per 100,000 live births. Similarly, contraceptive prevalence rate (CPR) is also improved 39 per cent in 2000 to 45 per cent in 2010. Adolescent birth rate is also increased by one per cent in comparison with the data of 2006. Likewise antenatal care (ANC) was also increased from 29 per cent in 2005 to 50.2 per cent in 2010. The one fundamental question can be raised that such slow improvements of reproductive health indicators are natural or caused by the NGOs or others. Hence, this study assesses the role played by NGOs to implement the reproductive health policy in terms of people's satisfaction. # II. # NGO's Role Conceptually, the meaning of NGOs refers to intermediary service organizations that are non-profit but do not have a membership base in the community. Other scholars define NGOs more broadly, to include any non-profit organization including membership and service-based organizations. Thus, NGOs preserve a unique and significant space between the for-profit sector and government. NGOs are organizations which are neither governmental (public sector) organizations (such as central or local government services or public hospitals, schools or universities), nor private (for-profit) commercial organizations, such as transnational corporations. Therefore, pundit of development have been emphasized that Non-governmental Organization(NGO) can be a one of the important actor for the sake of development including government and private sector in developing country in particular. The reasons behind the emergence of NGOs are government failure and market failure. NGO as social entrepreneur can satisfy the demands for public goods such as education and health services left by such failure (James, 1987). Brown and Korton (1991, p.48) argues NGOs might come into existence to be remedies in case of 'market failure' situations because markets tend to be 'especially vulnerable to failure in developing countries. NGOs have been creating their space in societies where government and market have not been serving. In such cases NGOs could emerge because people trust them more than the profit organization. Esman and Uphoff argued that NGOs play the role of local intermediaries to fulfil the 'organizational gap'. According to this model, a local intermediary mobilises the people to participate in governmentinitiated programs. NGOs could be a potentially effective medium, which could be utilised in delivering services to the rural areas of developing countries. In this way, NGOs are taken as an alternative institutional framework through which the rural poor and socially disadvantaged groups are served better than the traditional bureaucratic mechanisms. This trust in development thinking has created an unprecedented scope for NGOs to operate in the development field. The global search for viable options to support grassroots development has provided a context for the growth of NGOs everywhere. NGOs are now treated as instruments not only for strengthening the notions of self-help and self-reliance among the people but also for helping generate a systematic process of awareness-building through education, training in areas of social and economic significance, organization through collectivises and mobilization of action through these activities (Berg, 1987). # Experience from South Asia: Experiences from other parts of the world, including India, Pakistan 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). NGOs in Nepal have provided basically three types of services viz. socio-cultural services (education, advocacy and awareness raising); Community development services (the integrated provision, usually of health, drinking water, sanitation, and environmental protection); and economic services (savings and credit management, labor exchange, micro-irrigation, and marketing) (ESP, 2001, p.126). In case of Nepal, Dhaka (2006) argued that NGOs have evolved in the natural course of time and space to meet the needs of the livelihood of society and country. People found these NGOs as new institutions to voice and address their need. Therefore, government has to come to accept NGOs as their helping support, to many of their developmental project. However, he questioned that being non-profiteering voluntary NGOs their undoubted credibility depends on their stable selfsupporting ability to maintain themselves to the required span of time till they achieve their targets. NGOs' presence is volatile as they indefinitely depend on uncertain donors. Similarly, K.C. (2012) argues that NGOs in Nepal have created space as intermediaries since 1990 but not so accountable towards the public as envisioned because NGOs are project -oriented. When the project completes, NGOs leave the place without any headache of continuity of services. Thus, she opines that sustainability of their activities has become a major issue for NGOs. On this background, this study analyses the degree of reproductive health policy implementation at local level of Nepal from the perspective of people's satisfaction. # III. # Policy Implementation 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'. Conceptually, implementation means carrying out, accomplishing, fulfilling, producing or completing a given task. Pressman and Wildavsky (1973) define it in terms of a relationship to policy as laid down in official documents. 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 both one-time efforts to transform decisions into operational terms and continuing efforts to achieve the large and small changes mandated by policy decisions. In a word of 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 and legal objectives as well. It implies centrally located actors, such as politicians, toplevel bureaucrats and others, who are seen as most relevant to producing the desired effects. O'Toole (2003, p.266) defines policy implementation as government intention on the part of government to do something or stop doing something and the ultimate impact of world of actions. More concisely, he remarks that policy implementation refers to the connection between the expression of governmental intention and actual result (O'Toole, 1995, p.43). Likewise, policy implementation concerns how governments put policies into effect. From the above discussion, implementation can be conceptualized as on going process which incorporates series of decisions and actions directed towards putting a prior authoritative decision into desired effect. It also includes the timely and satisfactory performance of certain necessary tasks related to carrying out of the intent of the law. For sake of implementation of the public policy, it demands favourable structure of implementation process, specified objectives of public policy, capacity and will of implementer, management plan along with performance indicators. IV. # Reproductive Health Policy Implementation In general, policy implementation refers to putting the policy into practice so that its objective is achieved. This study is basically focused on implementation of reproductive health policy in Nepal. Here, to what extent the intent of this policy is implemented by NGOs, is analysed in this study in Nepal. Whether the desired effects of law are produced or not, is examined in two local units of Nepal i.e Bangsing Development Committee (BVDC) and Lalitpur Sub-metropolitan City (LSMC). In case of Nepal, the reproductive health policy is not defined concretely in a policy document. However, these documents 1 lays emphasis on providing reproductive health information, providing health services during the pregnancy, increasing the use of family planning services, replacing traditional healing methods by modern methods, and implementing two child per couple program. Following table shows status of implementation of reproductive health policy in Nepal. No For the study purpose, implementation of reproductive health policy means putting into effects of as mentioned above indictors which are prescribed in the policy documents. While operationalizing the dependent variable i.e. reproductive health policy implementation, it was revealed from the study that 40 and 98 percent of BVDC and LSMC respondents respectively got the reproductive health information from the health institutions, ward clinics, schools, TV, radio, newspapers, etc. They got information on nutrition, immunization, rest, family planning, safe motherhood and danger signs in pregnancy, bleeding, etc. # "Table The study showed that more LSMC (90 percent) respondents accepted family planning devices than BVDC (68 percent) respondents. Regarding pregnancy, it was found that more LSMC women were provided care during pregnancy than the BVDC women. People often used to be provided services like antenatal care, birth preparedness and care at childbirth. Likewise, the study showed that the traditional healing practices were replaced by the modern methods. More LSMC respondents (90 percent) accepted modern methods of healing practices than BVDC (59 percent) respondents. In addition to this, two-children-per-couple program was implemented more in LSMC than BVDC. 73 per cent of LSMC respondents accepted this norm, whereas only 50 per cent of the BVDC respondents accepted it. The field study showed that more LSMC (94 per cent) respondents opined that the average marriageable age was increased, than BVDC (68 per cent) respondents. Besides, child bearing space was also increased at both places. The above mentioned facts and figures showed that the indicators of reproductive health policy were improved more in LSMC than BVDC. V. # Methodology In this explanatory research, growth of NGOs in Nepal, delivery of reproductive health services, Satisfaction of people due to their role have been identified as an independent variables whereas the reproductive health policy implementations act as dependent variable for the study. This study adopted both quantitative and qualitative methods. For this, both primary and secondary data/ information were generated and utilized as per necessity. The primary data/information was collected through interviews with key-informants and 175 questionnaires. Out of 175 respondents, 84 respondents were from BVDC and 91 from LSMC. These data were tabulated by using SPSS. Bi-variate analysis was carried out for the analysis. Secondary information was collected from sources such as Nepal's government's appropriate documents, office records of relevant offices, published and unpublished information by various individuals and the institutions. # VI. # Findings a) Mobilization of NGOs in Nepal 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 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). 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. " "Table 3 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 Volume XXI Issue I Version I 24 ( ) 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. 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). # b) Delivery of reproductive health services 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. However, forty nine per cent people from BVDC opined that there was reproductive health policy implemented without involvement of NGOs. 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. " # c) Perceived satisfaction 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 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). 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 Volume XXI Issue I Version I 25 ( ) 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 6 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. In an interview with NGOs activist, he opined that basically following types of NGOs are in Nepal. For example, I-PANGO-politically motivated NGOs, II. FANGO-Family NGOs, III.DONGO-donor driven NGOs, IV. BINGObrief-case NGOs & V. Real NGOs. Some of the important policy shortcomings for 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. # Conclusions NGOs are mushrooming in Nepal since 1990. There are 30 thousands (approx.) NGOs affiliated with SWC excluding the NGOs registered in local government. GON recognizes NGOs as a convenient partner among the others to implement the policy for the sake of service delivery. In health service sector alone, one thousands (approx.) NGOs are registered to deliver the health services in Nepal. Here, this study analyses to what extent these NGOs delivered health services particularly reproductive health at local level in Nepal and examines how much people were satisfied by service delivered by NGOs. The study revealed that reproductive health policy was more implemented at LSMC than BVDC. The study showed that more health information was received at LSMC than BDVC. There was more availability of family planning devices at LSMC than BVDC. Pregnant women got more care at pregnancy period in LSMC in compare with BDVC. Traditional healing methods were replaced by modern methods in LSMC. Still, people are practicing traditional methods for healing in BDVC. Twochildren-per-couple program was implemented more in LSMC than BDVC. Average marriageable age and child bearing space were increased in LSMC than BDVC. The study states that 64 per cent respondents at LSMC opined that NGOs were delivering health services at their places and also accounted to high degree of reproductive health policy implementation. Similarly, there was only 49 per cent reproductive health policy implemented at BVDC in the absence of NGOs. Regarding to the people's satisfaction, 76 per cent people were not satisfied with the role played by NGOs. The reasons outlined by the respondents were many NGOs were donor centric. There was not continuity of services when donors did not support them. Finally, very few NGOs were working in the health service delivery sector. These NGOs were basically concentrated in the urban areas, barring some exceptions. These NGOs were involved in delivering reproductive health services in urban areas. However, the charges against the NGOs were that they were urban and donor-centric. People were not satisfied due to discontinuity of NGOs services even though these NGO were focusing in creating health awareness in the society. VariablesBVDCLSMCHealth information received40 %98%Availability of Family planning devices68%98%Care at pregnancy period64%71%Replacement of traditional healing methods by modern methods59%90%Implementation of two child per couple program50%73%Increase in average marriage age68%94%Increasing childbearing space64%88%Total N=175N1=84N2=91Source: Field study, 2012 SectorNumberPercentCommunity and Rural Development18,62561.5Youth Service4,32114.26Women Service2,3057.61Environmental Protection1,3184.35Child Welfare9513.14Moral Development8762.89Health Service7032.32Handicapped and Disabled Service5971.97Educational Development4921.62AIDS and Abuse880.29Total30,284100Source: Social Welfare Council, 2011, www.swc.org.npSocial Welfare Council categorized these NGOsinto ten types. Among them, the number of Communityand Rural Development NGOs account for 61.5 percent;the highest number of NGOs in Nepal, whereas AIDSand Abuse Control NGOs are only 0.29 percent.Similarly, the Health Service related NGOs number only703 (2.32 percent). (For detail see Table No.2) DistrictsNumberPercentageKathmandu34449Lalitpur558Kavre304Kaski213Bhaktapur162Chitawan162Morang132Banke122Dhanusa111Dhading111Source: SWC, 2011 4Delivering of reproductive health servicesBVDCLSMCDegree of policy implementationYesNoNYesNoNDisagree-5143364437Agree-4941645654Total N-8484395291Note: Figures in italic are percentageSource: Field study, 2012 CategoriesLSMCBVDCTotalYes %24-24No%76-76Total N91-91Note: Figures in italic are percentageSource: Field study, 2012 CategoriesLSMCBVDCTotalUrban Centric %33-33Donor Centric %67-67Total N69-69Source: Field study, 2012 * Kathmandu: Resource Centre for Primary Health Care AAli 1991 Nepal and South-South Solidarity Status of health in Nepal * East Lansing: Centre for Advanced Study of International Development RBerg 1987 Mechigan State University Non-governmental organization: New force in third world development * Working more effectively with Nongovermental Organization LDBrown DCKorten Samuel Paul and Arturo Israel 1991 * Nongovernmental Organization and the World Ban cooperation for development World Bank Washington D.C. * NGOs in livelihood improvement TNDhakal 2006 Adroit Publishers New Delhi * Local organizations: Intermediates in rural development MEsman NUphoff 1984 Cornell University Press Ithaca, NY * Pro-poor governance Kathmandu: Enabling State Program 2001 * Nepal maternal mortality and morbidity study Family Health Division 2009. 2008/09 Family Health Division * Nepal millennium development goals progress report Gon 2010. 2010 National Planning Commission Kathmandu * Interim Constitution Gon 2006. 2006 Nepal Law Book Management Kathmandu * Implementing public policy MHill PHuppe 2002 Sage Publications London, New Delhi * Studying public policy: Policy cycles and policy subsystems MHowlett MRamesh 2003 Oxford University Press New Delhi * The Nonprofit sector in comparative perspective EJames W.W. 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