The female community health volunteer programme in Nepal: Decision makers’ perceptions of volunteerism, payment and other incentives
Section snippets
Background
A recent systematic review concludes that the use of lay or community health workers (CHWs) can lead to significant benefits, for instance in increasing immunization uptake (Lewin et al., in press). While the review offers important information about the effectiveness of CHW interventions, it was not designed to examine factors that influence their sustainability.
One much-debated issue concerns whether or not CHWs should be paid. While some programmes offer salaries, CHWs in many initiatives
Objectives
The study’s objective is to explore the attitudes of stakeholders who have participated in the design and running of the FCHV Programme. The study addresses the following questions: what do these stakeholders believe motivates the FCHVs, what incentives do they judge to be appropriate, and how do these attitudes reflect the views and expectations of FCHVs themselves, and what can be learnt from these data about volunteerism within CHW programmes?
Data collection
Data collection took place in 2009. We used a qualitative approach and purposively selected stakeholders who were directly involved in the design, implementation and running of the FCHV Programme. We included informants who had been involved at different periods of time. We also attempted to identify informants believed to be critical of current practice regarding FCHVs’ lack of salaries.
Our informants included a significant proportion of the MoHP managers who have been responsible for the FCHV
Ethics
The Nepal Health Research Council’s ethics committee approved the project proposal. We asked informants to sign a consent form after being informed about the study purpose, and told them that they could withdraw from the interview at any time.
Community and FCHV empowerment
Informants who were MoHP officials in the 1970s and 1980s described an atmosphere in which the Alma Ata declaration call for “Health for all” and the use of lay people to empower their own communities, were on the agenda among donors and in their own government.
Informants reported that their first attempt, in 1979, to establish a programme had attracted mainly men. In 1988, the current programme was established in collaboration with the Nepalese Women’s Association and based solely on female
Discussion
The FCHV Programme illustrates that it is possible to deliver important health interventions through a nationwide volunteer programme on a sustained basis. Our respondents suggest that non-financial incentives may not only be sufficient within certain contexts, but that regular salaries could threaten programme sustainability. In addition to the financial burden salaries would impose, salaries could weaken the social respect given to FCHVs, thereby threatening their motivation.
Conclusion
Rather than emphasising the necessity of adequate and sustained wages as essential to the effectiveness and sustainability of CHW programmes (WHO et al., 2007), our study highlights the necessity of adequate and sustained, financial or non-financial, context-specific incentives. A high level of attention should be paid to ensuring that the expectations of CHWs, programme managers and policy makers are in alignment if low attrition and high performance are to be achieved.
Acknowledgements
We would like to thank all of the participants in this study who shared their experiences with us. Our thanks also to Judith Justice, John Quinley, Jeevan R Sharma and Peter Winch and to the anonymous peer reviewers for their helpful feedback to the manuscript. This research was made possible through funding provided by the Research Council of Norway. Any mistakes or opinions that the article may have are, of course, the responsibility of the authors.
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2022, Social Science and MedicineCitation Excerpt :But many officials and actors also argue that CHWs should not be financially incentivised because this might undermine their “volunteer spirit” (Maes and Kalafonos, 2013; Maes, 2014 see also Prince and Brown, 2016). Variations of this argument have also been made by social scientists (e.g. Glenton et al., 2010) and many officials I encountered in Zambia made these arguments. Governments are also often reluctant to offer CHWs future careers with the health system because they need CHWs to remain within their communities where there is an urgent need for their labour.