The female community health volunteer programme in Nepal: Decision makers’ perceptions of volunteerism, payment and other incentives

https://doi.org/10.1016/j.socscimed.2010.02.034Get rights and content

Abstract

The Female Community Health Volunteer (FCHV) Programme in Nepal has existed since the late 1980s and includes almost 50,000 volunteers. Although volunteer programmes are widely thought to be characterised by high attrition levels, the FCHV Programme loses fewer than 5% of its volunteers annually. The degree to which decision makers understand community health worker motivations and match these with appropriate incentives is likely to influence programme sustainability. The purpose of this study was to explore the views of stakeholders who have participated in the design and implementation of the Female Community Health Volunteer regarding Volunteer motivation and appropriate incentives, and to compare these views with the views and expectations of Volunteers. Semi-structured interviews were carried out in 2009 with 19 purposively selected non-Volunteer stakeholders, including policy makers and programme managers. Results were compared with data from previous studies of Female Community Health Volunteers and from interviews with four Volunteers and two Volunteer activists. Stakeholders saw Volunteers as motivated primarily by social respect, religious and moral duty. The freedom to deliver services at their leisure was seen as central to the volunteer concept. While stakeholders also saw the need for extrinsic incentives such as micro-credit, regular wages were regarded not only as financially unfeasible, but as a potential threat to the Volunteers’ social respect, and thereby to their motivation. These views were reflected in interviews with and previous studies of Female Community Health Volunteers, and appear to be influenced by a tradition of volunteering as moral behaviour, a lack of respect for paid government workers, and the Programme’s community embeddedness. Our study suggests that it may not be useful to promote a generic range of incentives, such as wages, to improve community health worker programme sustainability. Instead, programmes should ensure that the context-specific expectations of community health workers, programme managers, and policy makers are in alignment if low attrition and high performance are to be achieved.

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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