NEPAL’S FRONTLINE HEALTH WORKERS

By: Rose Zulliger

Case Studies of Large-Scale Community Health Worker Programs was derived from the Developing and Strengthening Community Health Worker Programs at Scale: A Reference Guide and Case Studies for Program Managers and Policymakers, edited by Henry Perry, Lauren Crigler, and Steve Hodgins.

Originally published in May 2014 by USAID’s flagship Maternal and Child Health Integrated Program (MCHIP), it was created in response to the rapid increase in and expansion of CHW programs in low- and middle-income countries over the past decade. In January 2017, a companion document was prepared to provide guidance on 13 case studies, including Afghanistan, Bangladesh, Brazil, Ethiopia, Niger, India, Indonesia, Iran, Nepal, Pakistan, Rwanda, Zambia, and Zimbabwe. CHW Central is serializing the case studies over time. 

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Summary
Background

The first Nepal Health Sector Program (NHSP) was implemented in 2004 to 2009. It worked to provide equitable access to free basic health services.

Case Studies of Large-Scale Community Health Worker Programs was derived from the Developing and Strengthening Community Health Worker Programs at Scale: A Reference Guide and Case Studies for Program Managers and Policymakers, edited by Henry Perry, Lauren Crigler, and Steve Hodgins.

Originally published in May 2014 by USAID’s flagship Maternal and Child Health Integrated Program (MCHIP), it was created in response to the rapid increase in and expansion of CHW programs in low- and middle-income countries over the past decade. In January 2017, a companion document was prepared to provide guidance on 13 case studies, including Afghanistan, Bangladesh, Brazil, Ethiopia, Niger, India, Indonesia, Iran, Nepal, Pakistan, Rwanda, Zambia, and Zimbabwe. CHW Central is serializing the case studies over time. 

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Summary
Background

The first Nepal Health Sector Program (NHSP) was implemented in 2004 to 2009. It worked to provide equitable access to free basic health services.

Implementation

Each health facility has, in additional to one professional health worker, one VHW, one MCH Worker (MCHW), and usually nine (but sometimes more) Female CHVs (FCHVs) to serve a catchment population of 5,000–10,000 people.

Roles/responsibilities

Each of the three types of CHWs has a defined scope of work. The MCHWs are full-time employees who offer reproductive services for women. The VHWs are also full-time workers, and they offer family-oriented services such as immunizations and management of newborn infections. The FCHVs are part-time volunteers who provide basic services and health education.

Incentives

MCHWs and VHWs are formally employed and paid by the government for their services. Motivating factors for FCHVs include nonfinancial incentives like a clothing allowance and community recognition.

Supervision

VHWs and MCHWs supervise the FCHVs who work in their catchment areas. VHWs and MCHWs are responsible for resupplying the FCHVs and for providing support, advice, and feedback during monthly supervision visits.

Impact

Among low-income countries, Nepal has been a global leader in reducing its under-5 mortality rate, its MMR, and its fertility rate. In fact, it achieved the MDGs for child health and for maternal health in 2010. There is widespread agreement that CHWs in Nepal, particularly the FCHVs, have played an important role in achieving these important goals.

What is the historical context of Nepal’s Community Health Worker Program?

The FCHV Program began in 1988, but faced early difficulties such as a lack of well-trained volunteers, a lack of supplies, and an inability to provide locally desired services, not to mention the challenges of working in mountainous areas with a highly dispersed rural population often reachable only by foot.¹ In the 1990s, the National Vitamin A Program began to work with FCHVs to distribute vitamin A to all children 6–59 months of age.² The FCHVs’ role was further solidified in 1991 with the development of the first National Health Policy under democratic rule. The policy restructured the health system to bring health services closer to the people through health posts and sub-posts, vertically integrated programs, and the development of a new cadre of frontline workers, the MCHWs.³

The first NHSP from 2004 to 2009 was developed to increase equality of access and to improve health outcomes. It also sought to coordinate external donors to improve aid effectiveness. In 2006, an Interim Constitution was developed that defined the rights of Nepalis to “free basic health services,” among other rights.⁴

Following the success of the first NHSP, Nepal developed a second NHSP for 2010–2015, which set forth the following goals:⁴

• To increase access to and utilization of quality essential health care services
• To reduce cultural and economic barriers to accessing health care services and harmful cultural practices, in partnership with non-state actors
• To improve the health system to achieve universal coverage of essential health services

The second NHSP describes the need to scale up FCHV services and to increase the demand for formal health services such as institutional delivery. A broad range of goals are also described to improve overall health service functionality, such as improved financial management, increased timeliness of procurement, and increased governmental financing of health services.

What Are Nepal’s health needs?

Nepal is a country with immense health needs and substantial barriers to service delivery. It is a very poor country and most rural inhabitants live in mountainous areas. Service delivery within Nepal is complex given the country’s geography. For example, 40% of individuals in the Mountain Region have to travel 1–4 hours to reach their closest health facility.

Nonetheless, substantial progress has been made in health outcomes over the past 20 years, such as an under-5 mortality rate of 48 per 1,000 live births in 2011 compared to 135 in 1990, but challenges remain. For example, nearly half (41%) of all children younger than 5 years of age are stunted from chronic malnutrition. Although health outcomes and service usage have become more equitable across castes, ethnic groups, and wealth quintiles, major disparities still remain. For example, women in the highest income quintile are 12 times more likely to have a trained health worker attend their delivery than women in the poorest quintile.⁴

TB is an additional challenge in Nepal: approximately 45% of the population has latent TB and 40,000 people each year develop active disease.⁴ There is also a chronic shortage of health workers in Nepal.⁵

As mentioned previously, the National Health Policy of 1991 restructured the health system to bring health services closer to the people by constructing health posts and sub-posts and introducing a new cadre of workers, the MCHWs.⁶ An effort was also made to integrate vertical programs (e.g., immunization and FP) at the district level. The health system in Nepal continues to be centralized and confronts many challenges regarding human resources, including low worker retention, low productivity and morale, and high turnover.⁵

What type of program has been implemented?

VHWs, MCHWs, and FCHVs are all based out of local health facilities that serve catchment populations of 5,000–10,000 people. Each health facility has one professional health worker, one VHW, one MCHW, and usually nine (but sometimes more than nine) FCHVs.⁷ These cadres work closely together, supporting one another’s scope of work. For example, FCHVs mobilize the communities for immunization by VHWs while FCHVs distribute vitamin A with the logistical support of the other cadres.⁷

FCHVs are frontline, part-time service providers who work an average of 8 hours each week.⁸ They receive some financial compensation for certain functions, but they are predominantly volunteers. There is, however, currently discussion regarding provision of cash incentives and some FCHVs are asking for salaries (Sabina Pradham, personal communication, 2012). MCHWs are full-time salaried government employees (R Shesthra, personal communication).

FCHVs primarily promote healthy behavior through motivation and health education,⁴ but they also mobilize communities to participate in immunization campaigns, detect and treat common childhood illnesses, provide medications for DOT for TB, distribute ORS packets and zinc for treatment of childhood diarrhea, and treat children with symptoms of pneumonia with cotrimoxazole tablets.^1,2,4,9

Furthermore, FCHVs are now involved in reproductive and maternal health care through distribution of FP supplies and the dispensation of misoprostol, a tablet taken immediately after childbirth to reduce the risk of postpartum hemorrhage. FCHVs also provide community education and counseling to facilitate healthy practices and generate demand for maternal, neonatal, and child health services.⁶ FCHVs are currently being trained to place an antiseptic on the umbilical cord immediately after birth as well as to resuscitate newborns who have birth asphyxia.⁴

MCHWs are full-time workers whose services include FP, treatment of patients at outreach clinics, clinical case management of childhood illnesses, health education/promotion, and participation in immunization and vitamin A campaigns. They also facilitate referrals and are responsible for the supervision of FCHVs.⁶

VHWs are also full-time workers whose services are similar to those offered by MCHWs.⁷ These include provision of immunizations, management of newborn infections, and supervision of FCHVs.⁶

What about the community’s role?

Women’s groups and local Village Development Committees (VDCs) are highly involved in the selection and oversight of FCHVs. Women’s groups are also expected to discuss FP and to provide information to other women who are not in the groups. There have been challenges with some women’s groups that did not function well, though, so guidelines were developed on how to strengthen women’s groups. Following the development of these guidelines, a pilot program was implemented that improved the functioning of women’s groups and provided increased support to FCHVs. These groups also became more aware of their authority to remove FCHVs. New guidelines have now been finalized and are being implemented in the western part of the country; they will later be scaled up nationally (S Pradhan, personal communication, 2012).

There should be a VDC everywhere FCHVs work. There are at least nine FCHVs associated with every VDC, but at times there may be as many as 50, depending on the population for which the VDC is responsible (S Pradhan, personal communication, 2012). There are also local FCHV associations, but none of these are fully representative of all FCHVs or national in scale.¹⁰ There are local health committees in Nepal that assist with FCHV selection and oversight, but they are not involved with MCHW selection.

How does Nepal select, train, and retain Its Community Health Workers?

The selection criteria for FCHVs are that they should be women aged 25–45 who are married with children, and preference is given to those who are literate and who are from or residing in the local community. In practice, FCHVs are often illiterate.¹¹ FCHVs undergo an initial 18 days of training with 5 days of refresher training every 5 years.⁴

MCHWs are women from or residing in the local community who have a 10th-grade education. VHWs can be male or female, but they must be literate, and they are recruited locally. MCHWs and VHWs both have an initial training of about 3 months.⁷

Compensation of FCHVs has been a very controversial component of the program because “there is a balance to be struck between compensating the women for the real financial and time costs that they incur in carrying out their duties, without losing the spirit of voluntary service to the community.”¹² Initially, FCHVs were paid a monthly stipend, but this was not sustainable and the stipend was discontinued.¹⁰

FCHVs receive an incentive for timely retirement at the age of 60 (although many do not want to retire). They also receive free services from Nepal’s Ex-Servicemen Contributory Health Scheme, which provides medical insurance for all ex-service personnel eligible for pension, as well as the serviceperson’s spouse and dependent children.¹² In addition, FCHVs are given an identification card and an annual day of honor in recognition of their service to the community.¹⁰ They are currently requesting access to income-generation schemes, free schooling for their children, and health insurance (S Pradhan, personal communication, 2012). A 2010 study by Glenton and colleagues explored policymakers’, program managers’, and FCHVs’ perceptions of motivation and incentives. The study highlighted the need for “context-specific incentives” for FCHVs.¹⁰ Despite being staffed by volunteers, the program has very low attrition rates, with less than 5% turnover each year.

A fund was developed by the Nepalese government in 2008–2009 that provided 50,000 Nepalese rupees (approximately US$600) for each of the 3,914 VDCs. The government is contributing an additional 10,000 rupees (approximately $120) to each of these funds every year. The interest from this endowment fund can be accessed by the FCHVs to support income-generation activities. Early evidence shows the program to be successful, although there are challenges with accounting at the village level (S Pradhan, personal communication, 2012).⁴ MCHWs and VHWs are formally employed and paid by the government for their services.¹³

How does Nepal supervise its Female Community Health Volunteers?

VHWs and MCHWs supervise the FCHVs that work in their catchment areas. They are responsible for providing the FCHVs with the supplies they need and for providing support, advice, and feedback during monthly supervision visits. Additionally, all FCHVs meet with their respective VDCs every 4 months to review progress.⁴ Although the FCHVs receive commodities from their supervisors, there are many challenges with the supply system and the demand for commodities often exceeds the supply.⁷

Data, particularly program evaluations and research in the field, are highly influential in programmatic policy development and implementation. There are, however, many challenges with the current HMIS. The current registers are complicated and have 30–40 indicators, representing a burden for FCHVs. This burden, coupled with the low levels of literacy among FCHVs, have led to concerns regarding the quality of the data collected (S Pradhan, personal communication, 2012).

How is the Community Health Worker Program financed?

VHWs and MCHWs are salaried staff of the MOH, so they receive their salary and benefits according to government rules and regulations. The costs of the FCHV program (basic training, refresher training, training materials, in-kind incentives, and so forth) are financed by donor agencies. Generally, the US Agency for International Development pays for the cost of training through its implementing partners (John Snow, Save the Children, Plan International, and others) and the United Nations Children’s Fund (UNICEF) provides materials for training and patient education (R Shrestha, personal communication, 2013).

What are the program’s demonstrated impact and continuing challenges?

Nepal has made important progress in the past 20 years in improving health outcomes, particularly those related to the MDGs. The MMR has decreased from 539 deaths per 100,000 live births in 1991 to 229 in 2009, and the total fertility rate has decreased from 5.3 in 1991 to 2.9 in 2009. The under-5 mortality rate has had a similarly dramatic reduction, from 158 per 1,000 live births in 1991 to 50 in 2009.⁴ A number of factors have contributed to the improved health outcomes, but there is widespread agreement that CHWs have made important contributions to these achievements.

Challenges faced by the FCHV program include growing expectations that FCHVs will provide more services without increased support or incentives; this may compromise retention and recruitment of new FCHVs.³ Further, there are concerns that FCHV services are hampered by political affiliations and an aging workforce, problems with the supply chain, and a lack of human resources.^3,14

Another challenge is the current process of gradually phasing out the VHW cadre, who are traditionally responsible for first-line supervision of FCHVs. The VHWs will be replaced with better-qualified Auxiliary Health Workers; however, the latter may be less likely to be local to the area they serve.⁴

References

1. Curtale F, Siwakoti B, Lagrosa C, LaRaja M, Guerra R. Improving skills and utilization of community health volunteers in Nepal. Soc Sci Med. 1995;40(8):1117-1125.
2. Gottlieb J. Reducing child mortality with vitamin A in Nepal. In: Levine R, ed. Case Studies in Global Health: Millions Saved. Washington, DC: Center for Global Development; 2007:25- 31.
3. Pratap N. Technical consultation on the role of community based providers in improving maternal and neonatal health. Community Health Workers Meeting; 2012; Amsterdam, Netherlands.
4. Ministry of Health and Population, Government of Nepal. Nepal Health Sector Programme – Implementation Plan II (NHSP -IP 2) 2010 – 2015. 2010.
5. Global Health Workforce Alliance. CCF Case Studies: Nepal: Strengthening Interrelationship Between Stakeholders. 2010. Available at: http://www.who.int/workforcealliance/knowledge/resources/CCF_CaseStudy_Nepal.pdf.
6. Pratap N. Technical consultation on the role of community based providers in improving maternal and neonatal health. Community Health Workers Meeting; 2012; Amsterdam, Netherlands.
7. CHW Technical Task Force. One Million Community Health Workers: Technical Task Force Report. New York, NY: The Earth Institute; 2011. Available at: http://www.millenniumvillages.org/uploads/ReportPaper/1mCHW_TechnicalTaskForceRepo rt.pdf.
8. Shresta A. The female community health volunteers of Nepal. Global Health Evidence Summit: Community and Formal Health System Support for Enhanced Community Health Worker Performance. 2012; Washington, DC.
9. Fiedler JL. The Nepal National Vitamin A Program: prototype to emulate or donor enclave? Health Policy Plan. 2000;15(2):145-156
10. Glenton C, Scheel IB, Pradhan S, Lewin S, Hodgins S, Shrestha V. The female community health volunteer programme in Nepal: decision makers’ perceptions of volunteerism, payment and other incentives. Soc Sci Med. 2010;70(12):1920-1927.
11. Hodgins S, McPherson R, Suvedi BK, et al. Testing a scalable community-based approach to improve maternal and neonatal health in rural Nepal. J Perinatol. 2010;30(6):388-395.
12. Government of Nepal, Ministry of Health and Population (MoHP). Nepal Health Sector Programme-2 Implementation Plan (2010-2015). Kathmandu, Nepal: Government of Nepal; 2010:267. Available at: http://www.nhssp.org.np/health_policy/Consolidated%20NHSP- 2%20IP%20092812%20QA.pdf.
13. CHW Technical Task Force. One Million Community Health Workers: Technical Task Force Report. New York, NY: The Earth Institute; 2011. Available at: http://www.millenniumvillages.org/uploads/ReportPaper/1mCHW_TechnicalTaskForceRepo rt.pdf.
14. Global Health Workforce Alliance. Country Coordination and Facilitation (CCF) case studies 2010. 2013. Available at: http://www.who.int/workforcealliance/knowledge/resources/ccfresources/en/.  Accessed August 16, 2013.

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This case study was written by Rose Zulliger, a student in the Johns Hopkins Bloomberg School of Public Health.