An Anthropological History of Nepal's Female Community Health Volunteer Program: Gender, Policy, and Social Change

"For Nepal's FCHVs [female community health volunteers], it has been argued that their volunteer status is exactly what has earned them their community respect and trust...as payment would otherwise threaten their social status in their communities.... But this ignores the deeply gendered aspects of CHW labor and remuneration..."



Community health workers (CHWs) are central to programmes addressing health inequalities, as they are often tasked with serving underserved populations and are embedded in their communities. However, systematic literature reviews have found that the equity-promoting effects of CHW programmes are often uneven. This has been attributed to CHWs lacking adequate health systems supports, which may make it difficult for CHWs to meet programmatic goals. In an effort to shed light on these and other issues - and with a gender-tuned lens - this study examines the 35-year trajectory of Nepal's female community health volunteers (FCHVs).



Based on a content analysis of primary and secondary research materials, grey literature, and government reports across several regions in Nepal, the analysis runs from 1977 to 2019, covering a time period during which Nepal experienced many transitions - epidemiologically, demographically, economically, and culturally. During the 1970s, Nepal was one of the economically poorest countries in the world. Over the next decades, Nepal saw vast reductions in poverty and illiteracy, fertility, and maternal and infant mortality. This period also saw vast changes in the governance landscape, including the introduction of democracy following a People's Movement (jana andolan, 1990), a violent decade-long civil war (1996-2006), three constitutions, the fall of monarchy (2008), and a shift to federalisation with the 2015 constitution. The analysis in this paper contextualises findings within these larger sociopolitical shifts.



Looking into this history illuminates that issues of gender, workload, and pay - the subject of discussion and debate in today's CHW literature now - have been a focus since the inception of the programme. Following experiments with predominantly male community volunteers during the 1970s, Nepal scaled up the all-female FCHV program in the late 1980s and early 1990s, in part because of programmatic goals focused on maternal and child health. FCHVs gained legitimacy as health workers in part through participation in donor-funded vertical campaigns. For example, in 1997, oral polio vaccine (OPV) campaigns were integrated into the National Vitamin A Program (NVAP), to be administered by FCHVs during National Immunization Days (NIDs). The duties associated with these national campaigns came with a renewal in FCHVs' perceived legitimacy as health workers in the eyes both of the community and programme managers.



Over the years, the Vitamin A and polio programmes, as well as literacy programmes, built FCHVs' confidence. Over time, too, FCHVs contributed to local planning meetings and interacted repeatedly with health workers and elites. Over time, FCHVs' increasing role in local leadership was reflected in their being elected into local government.



FCHVs received a stable yet modest regular stipend during the early years, but since it was stopped in the 1990s, incentives have been a mix of activity-based payments and in-kind support. With increasing outmigration of men from villages and growing work responsibilities for women, the opportunity cost of health volunteering increased.



By the early 2010s, approximately 50,000 FCHVs were active across Nepal. Around this time, FCHVs began expressing their dissatisfaction around insufficient pay publicly, through formalised protests in Kathmandu and by forming labour unions to represent their rights. These movements culminated into a charter of demands calling for increased allowances and additional benefits. However, "collective voice or action may be especially difficult for CHWs operating in hierarchical government health systems, given that CHWs are at the lowest tier of the hierarchy...".



Unionising had the unfortunate effect of deepening some government officials' skepticism about the FCHV programme. A Kathmandu Post article quoted a ministry official: "Since this is voluntary work, the Ministry cannot allocate a salary for such a large number of volunteers." The push to eliminate the FCHV programme also came in part from a feeling that FCHVs did not have a place in the vision of a modern, medicalised health system for Nepal.



However, given the breadth and success of the FCHV programme, along with the political power held by the 50,000+ workforce, eliminating the cadre is not a simple proposition. Respondents at national and local levels said in 2014 and 2017 interviews that it was difficult to get FCHVs to retire, which speaks to the dedication of FCHVs towards their role, as well as the strong identity they have built over their decades-long service. Yet, the future and legitimacy of these workers in the face of shifting community demands remains uncertain.