How ethnic discord impacts the relationship between health service delivery and state legitimacy: lessons from fragile Nepal

Purpose Despite extensive research on the relationship between service delivery and state legitimacy in fragile settings, we know little about how this relationship is impacted by ethnic discord, particularly when essential health services are delivered to an oppressed ethnic minority by an ethnic majority. This study addresses the research gap in the fragile setting of Nepal, characterized by unresolved ethnic tensions. It examines how Nepal’s Madheshi ethnic minority engages with state health services delivered by the Pahadi ethnic majority. The objective is to analyze how Madhesis’ perceptions of these services shape their views on state legitimacy. Design/methodology/approach Semi-structured interviews were conducted with 18 Madhesi patients and five Pahadi frontline healthcare practitioners at Narayani sub-zonal hospital, a state-run facility in Madhesh, the southern region of Nepal. Additionally, a focus group discussion was held with 11 Madhesi recipients of government health services in Madhesh’s Pipra rural municipality. Findings Madhesis viewed health service delivery and the Pahadi providers favorably and supported state legitimacy by commending the state’s commitment to provide free and equitable health services. In contrast, the Pahadi healthcare providers expressed skepticism and discontentment, perceiving Madhesi patients as ill-behaved and distrustful of their medical decisions. These providers often felt their authority was challenged by the Madhesi patients and their families. Originality/value The discrepancies in perspectives are striking. Healthcare workers predominantly viewed clients through an ethnic lens, whereas clients focused more on the professional provider–patient relationship. These findings provide new insights into the nuanced interplay of ethnicity in service delivery in fragile settings characterized by ethnic discord, where governments seek to enhance state legitimacy.