Background
Use of Community Health Workers (CHWs) in healthcare provision is increasing worldwide [
1‐
3]. In particular, CHWs have become a central feature of many Primary Health Care (PHC) programmes in resource-poor areas of low-income countries. They are viewed as important contributors to achieving the Millennium Development Goals (MDGs) for maternal and child health [
1,
2,
4]. National and international decision-makers are turning to CHWs to strengthen PHC and to support post MDGs – Sustainable Development Goals – which aim to provide universal access to reproductive healthcare [
1,
3‐
5]. While some CHW programmes are small independent projects, others are large nationwide programmes managed by government agencies, such as Female Community Health Volunteers (FCHVs) in Nepal. FCHVs are the lowest level or ‘first contact’ PHC providers within the public healthcare system.
Over the last two and half decades, Nepal has experienced a significant reduction in maternal mortality despite continued poverty, political conflict and a limited provision of universal healthcare services [
6‐
8]. Despite high home delivery rates (72%) and a low rate of skilled attendants at birth (36%) [
9], Nepal reduced its Maternal Mortality Ratio (MMR) by 80% from 850 to an estimated 170 deaths per 100,000 live births between 1991 and 2011 and achieved the MDG Five [
10], compared with a 47% decline worldwide [
11]. The remarkable reduction in MMR has also been accompanied by improvements in women’s education coupled with the increased use of contraception and the associated decline in fertility rates [
12]. Some 52, 000 FCHVs working across the country distribute temporary contraception or offer referrals for other methods of family planning [
13]. These volunteers are often credited for the improvement in maternal health in rural Nepal [
6,
10,
14] but there is no empirical evidence to support this.
FCHVs are typically local women above 25 years of age who receive a basic 18 days of training in various PHC topics, including maternal and child healthcare services [
15]. Although FCHVs are expected to work part-time with an average of five to six hours work per week [
13], it may vary depending on the programmes in which FCHVs are involved. FCHVs appear to be committed to volunteering as their retention rate is very high (96%) [
13]. Social respect, religion and moral duty were reported as key reasons for such high motivation, but this was mainly the policy-makers point of view [
16]. The voices of these volunteers in policy-making are missing. The fact that all the volunteers are female demands further research because female CHWs are more likely to work unpaid than their male counterparts indicating a huge level of gender disparity [
17,
18].
Before the beginning of the FCHV programme in 1988, basic maternal and child health care including family planning services was provided by a group known as community health leaders. They included both male and female volunteers but the males were not easily accepted by female service users. Because of this the male volunteers were replaced by female volunteers or FCHVs, who are married and are mothers. Female service users often find it easier to discuss their pregnancies and childbirth with female volunteers as shown by Feldhaus et al. [
19]. In addition to the unpaid FCHVs, there are paid CHWs who work full-time and can be male (village health workers) and female (maternal and child health workers), but FCHVs are the key PHC providers in villages.
FCHVs’ service provision is not without challenges. Mothers may not use their services if they feel that the service quality is poor, as shown by a study in remote Nepal which found that almost 67% of women never sought services from FCHVs [
20]. Services of CHWs are also affected by health systems factors, such as the availability of training, supervision, access to medical supplies and provision of monetary and non-monetary incentives, which are often challenging in poor-income countries [
1,
3,
21]. Despite the challenges, the role of FCHVs have been extended to include a wide range of promotional, preventive or curative healthcare services [
22‐
25].
The main role of FCHVs is to facilitate mothers’ groups meetings, where women from local villages gather and discuss health topics. FCHVs refer pregnant women or mothers for health checks, provide iron tablets and distribute misoprostol to prevent post-partum haemorrhage. They also maintain a record of health activities and report this to local health facilities [
26]. The growing use of FCHVs in the provision of maternity care for the rural population means that understanding the FCHVs’ view is important. This is because the development of CHW programmes and policies requires the communication of knowledge that includes the views of people working on the ground [
27]. However, little is known about the views and experiences of FCHVs [
28,
29] and how the work of FCHVs is viewed and experienced by service users and local health workers. This study aims to provide subjective insights into the role and experience of FCHVs. While some issues found in our study might be specific to particular Nepalese villages, others are common to a wider range of settings. We assess how the inclusion of FCHVs in a government healthcare system facilitated the provision of maternity care in two different contexts and the challenges they faced undertaking their role as volunteers.
Discussion
This study has provided insights into the experiences of the FCHVs in volunteering in the provision of maternity care. While there have been previous studies of experiences and perceptions of CHWs, our study is the first of its kind from Nepal; bringing together perspectives from the FCHVs, their service users and paid local health workers; and focusing on two geographically distinct regions – the hill and Terai. While Dhading is a hill district with better resources and better connections to referral networks and Kathmandu (the capital city) than most of the hill districts in the Central and Far Western regions, some study villages remain isolated with relatively difficult access to healthcare services. The main finding of the study is that the FCHVs supported by the government healthcare system can deliver basic maternity care in resource poor areas as seen by their work in these two settings. The FCHVs are by necessity providing services beyond expectations – assisting childbirth, distributing medicines and emergency contraception – that are elsewhere undertaken by professional health workers. As provision of facility-based childbirth services in resource-poor areas is still beyond the reach of many resource-poor countries [
38], the findings presented here illustrate how the FCHVs facilitate maternal healthcare provision in such settings, including the challenges they face and potential solutions that might be externally applicable.
The FCHVs reported that they assisted with deliveries although technically they were not supposed to do so. In doing so, they bridged the gap between the poor health care provision and the community, as Nepal lacks sufficient numbers of professional midwives to deliver such services [
39]. This situation is unlikely to change in the near future due to difficulties recruiting and retaining midwives or doctors in the villages, since they often choose to live in urban regions and work in the private sector ([
40], [
41]). Therefore, the FCHVs involvement in childbirth was essentially a necessity rather than an option in the geographically inaccessible areas [
42]. Similar findings have been noted in Afghanistan and Pakistan where the poor accessed healthcare services from the CHWs, while wealthier groups were able to use skilled attendants [
43,
44]. This indicates that the services of CHWs can be beneficial in resource-poor areas because they allow people to receive at least basic healthcare services.
We found that the main difference between the two study regions was the support available to the FCHVs from government health centres. Compared to the FCHVs in Terai, the FCHVs in the hill villages were relatively well supported in terms of training, supervision and access to medical supplies such as paracetamol, antacids, metronidazole and vitamin tablets so that they could treat some minor ailments such as headaches, diarrhoea and fevers. Earlier studies suggest that if CHWs were able to provide medicines to the villagers, even if it was only vitamin tablets, then the village population were likely to place their trust in them [
45,
46]. However, if the volunteers are not trained then their actions can be harmful as in the example of a volunteer giving injections in our study. While our study shows the possibility of expanding the role of volunteers in medicine distribution, contextual and health system factors need to be considered for the programme to function as seen in Ghana [
47].
Unlike FCHVs in the hill region, the FCHVs in Terai could not provide any medicines as the health centres lacked a sufficient supply. This not only reduced volunteers’ regular health activities, but also reduced their morale as seen by some volunteers’ unwillingness to visit pregnant women. In addition, the illiteracy of some volunteers meant that they reported information verbally. Health workers often did not verify the information and saw the volunteers as information providers. A lack of connection between healthcare centres and the FCHVs was seen which if it continues, threatens the sustainability of the programme. For the CHWs within government system to work, the government not only needs to own the programme and makes strategies for its implementation [
47], but it also needs to ensure that the implementation of the programme is effective. The support of the health system is thus extremely important to the morale and therefore the activity and interest of the volunteers.
Our study also showed that the FCHVs used innovative approaches to the delivery of health information, such as sharing health messages through local songs and visiting new mothers with food hampers. Such local practices could be useful ways to raise awareness about danger signs during pregnancy, childbirth or post-partum; and to inform women of free healthcare services at public health centres. In doing so, the expectation is that pregnant women could attend health centres with the capacity to manage complicated deliveries, which is another challenge in resource-poor areas [
38]. Nonetheless, the importance of informal sharing of maternal health messages by the FCHVs is highly relevant in rural regions and has been reported in other maternal health programmes [
48].
We found that money was one of the key concerns of FCHVs, who clearly expressed the need for monetary compensation for volunteering. The volunteers’ domestic responsibilities often mean that they do not have the same amount of time for volunteering. While volunteers are increasingly expected to deliver a range of PHC, financial support for these groups remains limited. Yet, FCHVs sometimes had to pay out of their pocket and often did not receive reimbursement for their expenses. In addition, as the volunteers are mostly poor and overburdened, asking them to provide their services for free prevents them from working and is not sustainable [
25,
49]. If CHWs are expected to provide regular and effective maternal healthcare services they should therefore be remunerated as shown by a growing volume of research in South Asia and Africa [
1,
50‐
54].
Policy-makers in Nepal perceived that paying volunteers is not feasible [
16] which could be due to the assumptions that women can volunteer their time as seen in the lay health worker policy development in South Africa [
55]. The belief that women can volunteer freely can also be related to the lower decision-making power of women than those of men [
18,
56,
57]. The dependency on female volunteers to support weak healthcare systems not only affects the volunteers at an individual level but also reinforces gender inequalities in the whole society [
17]. Further research is needed to include details of gender aspects within the health research so that underlying power relations and its effects can be explored [
18].
We also found that despite the challenges, all the FCHVs were committed to volunteering. Indeed, one of the key reasons for their continued willingness to volunteer in these roles was their perceived self-empowerment. The empowerment they described was related to opportunities for training and education as a result of volunteering, which enabled them to take care of themselves as well as the villages. This is consistent with other studies ([
58], [
59]) that showed that volunteering provided volunteers with skills which other members of their community group did not have. Such skills are especially important for women in rural Nepal, as they are rarely involved in household decision-making [
56,
57]. Similar findings were reported in Bangladesh and Ethiopia where CHWs volunteered because of their desire for self-development [
54,
60].
This study was conducted in specific areas of Nepal and therefore there are potential dangers in extrapolating findings across the whole diverse country. While this research sheds light on the subjective experience of FCHVs, no research to date has been able to demonstrate that the FCHVs roles themselves have an impact on maternal mortality or other health outcomes; quantitative studies are needed to do this. Yet qualitative methods is the best method for exploring people’s experiences or perspectives [
61]. The multiple methods of data collection, interviews, FGDs and field notes; and the use of triangulation enabled the researcher to include more comprehensive views of study participants. While most interviews went as planned, a few were interrupted. A FCHV who had been interviewed also participated in a focus group (Table
1) despite SP’s attempt to stop her involvement. The FCHV was enthusiastic to contribute to the group discussion. Sometimes participants’ family members or neighbours often interrupted the interviews as they were generally held on verandas outside houses. Questions directed at mothers or pregnant women were answered by either their husbands or mothers-in-law, who often influenced the uptake of pregnancy care services by these women, as reported in the literature [
57,
62]. In order to avoid such interruptions during the interviews, SP explained the importance of interviewing women on their own and wherever possible, she went out with the interviewees to the kitchen gardens or the open fields.
The research findings provide detailed insights into the subjective accounts of the FCHVs’ experiences in maternity care in two different settings within Nepal. We recognise that this paper does not cover the issue of trust and how this is negotiated between the FCHVs and the women they serve and the health system they represent, but that this will be explored in more detail in a subsequent paper. The findings from the current paper can be utilised to provide insights into future policy and programme decisions that the Nepali Ministry of Health and Population and other officials can then use to determine how best to move forward with the FCHV programme, as central level policy-makers are grappling with these challenges [
25]. In addition to the local relevance of this research, it is likely that aspects of the discussion presented above have relevance and are transferable elsewhere in Nepal as well as in similar resource-poor settings elsewhere.
Conclusions
The evidence from this study demonstrates that FCHVs, supported by the government healthcare system, play an important role in the provision of basic maternal healthcare in resource-poor settings in Nepal. As seen by the different working capacities of the FCHVs in the two study regions, their role continues to be highly relevant in remote villages, which have poor maternal health outcomes ([
7,
9]). In the absence of immediate access to healthcare, volunteers shared basic maternal and child health information and referred women for health checks or delivery. While the FCHVs in Terai could not function well and reported reduced work interest, the FCHVs in the hill region served beyond what was expected of them. For example, they assisted with childbirth, provided emergency contraception and distributed medicines. Their involvement in medicine distribution provides a compelling case for further exploration of expanded roles for community-based workers. In both study regions, monetary compensation for the FCHVs was by far the biggest concern and needs to be considered seriously if we want the FCHVs to remain motivated and continue working to improve maternal health in resource-poor areas. The good aspect of the FCHV programme was the volunteers’ perceived self-empowerment through volunteering, which kept them motivated at work.
This paper offers an important opportunity to hear directly from the FCHVs, who are the foundation of the Nepalese public healthcare system and provide PHC services to its rural communities. The benefits to women of the volunteers’ work were significant, as a result was that more pregnant women and mothers from the poorest communities were aware of existing healthcare services and would visit health centres, thereby filling the gap in service provision. In addition, the health awareness of these women volunteers is a substantial public health benefit. Their insight can facilitate programme and policy efforts to reach women in remote regions and to achieve universal healthcare coverage for maternal health thus possibly leading to further improvement in maternal health. We believe that the study findings have implications for other similar CHWs in resource-poor settings.