The Women Who Keep Nepal Healthy

The female community-health-volunteer program in Nepal has been highly effective at helping those who live far from clinics and hospitals—but could use some improvements.

A meeting with female community-health workers (Stephen Peterson / Flickr)

With their distinctive blue saris, 52,000 female community-health volunteers are at the front lines of medical care in Nepal. Since 1988, they’ve provided maternal and child health information and health services throughout the Himalayan kingdom, treating diarrhea and pneumonia, the primary causes of childhood mortality, as well as other diseases that crop up among Nepal’s rural-dwelling citizens.

The volunteer program is aimed at remote communities a half-day’s walk or more from clinics or hospitals. Some areas still lack roads, places where doctors and other medical professionals are unable or unwilling to go.

The female volunteers initially undergo two nine-day training sessions, with a five-day refresher course every five years. They may be particularly helpful in the realm of maternal health, because their female patients may feel more comfortable sharing their problems, such as those related to reproductive health, with another woman, said Sabina Pradhan, who worked in the government’s family-health division on this volunteer program.

In the decades since the program began, maternal mortality rates in Nepal have declined. They nearly halved between 1996 and 2006. Childhood mortality rates are also on the downswing. For children under five years of age, mortality was 54 deaths per 1,000 live births in 2001, down from 61 five years earlier.

“It’s hard to pinpoint one reason [why]. Part of it could be the contributions of the female community-health volunteers, part of it is more trust in health facilities,” said Isha Nirola, the community-health director at Possible, a nonprofit which works with Nepal’s Ministry of Health to bolster its services. “It’s been very successful in the mass distribution of medicines.”

That proximity to their patients is a great strength of these women who live in the communities they serve. In a recent study, after Nepali mothers gave birth, more than half of such volunteers arrived within 30 minutes—and three-quarters within 60 minutes.

The study looked at residents of Dhanusha, a district in the plains of central Nepal where 89 percent of the population lives in rural areas, and approximately 67 percent of women deliver their babies at home. The volunteers identified low-birth-weight infants with spring scales 80 percent of the time. Mothers had 40 percent accuracy. Low birth weight is a major risk factor in neonatal death, and armed with this early assessment, the volunteers and families could take action.

When the devastating 7.8 earthquake hit Nepal in April, many volunteers were victims themselves, said Stuti Basnyet, a senior development and communications specialist at USAID/Nepal. Ten were killed in the 12 most-affected districts. “In the immediate aftermath of the quake, they were in no position to help others on any great scale,” she wrote in an email.

“Three months on, while the struggle to rebuild lives and livelihoods continues…most have resumed their work.” She added that female community-health volunteers “continue to remain the backbone of many of Nepal’s public-health programs.”

Other countries have launched similar programs, but Nepal has “one of the biggest, longest running successful programs in the world,” said Claire Glenton, senior scientist at the Norwegian Knowledge Centre for the Health Services.

In Glenton’s study of female community-health volunteers, a new mother shared her story with researchers: After giving birth, she hemorrhaged and her baby died. A female community-health volunteer stopped her bleeding. “Inside me I thought, ‘It’s because of unawareness mothers are dying. It’s because of unawareness our kids are dying … I need to work for this community.’ So with this thought, I became an FCHV.”

Less than five percent of female community-health volunteers drop out of the program each year, the study found. The volunteers report being motivated by their enhanced social standing, religious, and moral duty.

“Whenever someone is ill in our community, they come looking for us first,” a volunteer reported in the study. “It’s a matter of pride for us to be taking care of our neighbors and community members.”

A recent study found that volunteers seem to raise the self-confidence of mothers, which could help prevent child injuries. Three focus groups were conducted between September 2013 and May 2014, in rural Makwanpur district in central Nepal, where many residents are subsistence farmers and survive on remittances from family working abroad. Participants reported that they felt able to speak in public on behalf of their children for the first time during discussions they had with the community-health volunteers, which in turn empowered them to identify risks and hazards and implement community-wide actions such as filling up ditches and putting fences around the roof and balconies on houses.

However, these volunteers and their services aren’t a cure-all for maternal and child health issues. In another study, public-health researchers questioned 446 caregivers of children under five years of age in the mid-western hill region of Nepal, asking about their usual health practices for childhood illness, whether they used local health services when their children were ill, their children’s health condition, and their satisfaction with health services.

Two-thirds of the people surveyed had never sought care for their children’s illness from health-care volunteers. More than half were unaware of help these volunteers could provide for acute respiratory infection and diarrhea, and many were underusing services in pregnancy, delivery, and postpartum newborn care.

Compare that to the wide public recognition and support for vitamin A supplements, which are administered by these volunteers to prevent malnutrition and blindness in children. About 90 percent in the survey had made use of that resource, due largely to the government’s promotional efforts after the deficiency was identified as a major problem in Nepal.

Even with that success, many families in the hill region still had their doubts about the volunteers. Among the caregivers whose children suffered from an illness within the last seven months, more than 90 percent did not visit a female community-health volunteer.

More than half complained about the volunteers’ lack of medicine, due to delays in supply that led to shortages. More than a quarter claimed female community-health volunteers provided incompetent care, with inefficient service and lack of interpersonal manners.

A study published last year found that 70 percent of female community-health volunteers in a poor western district were illiterate. Their minimal formal education hampered their ability to log visits and they relied on their memory or the assistance of literate family members or colleagues. More highly-educated health-care workers at hospitals and health posts have questioned the legitimacy of the volunteers, and have been at times unwilling to work with them, according to the study. The long distance between some villages and a local hospital— sometimes up to a four hour walk each way—also limited the ability of volunteers to attend group trainings and their ability to refer or transport patients.

The next iteration of this program may be to create a professional network of community health-care workers, with greater oversight, the introduction of compensation and frequent training that capitalizes upon Nepal’s growing female-literacy rate, said Nirola, Possible’s community-health director. “It’s about taking female community-health volunteers to the next level.”