|Title||Piloting innovations in Nepal’s community health worker program|
|Publisher||Global Delivery Initiative; KDI School|
|Publication Date||2019 - 09|
|Country||Nepal||Holding||Global Delivery Initiative|
|Series Title||Global Delivery Initiative|
In the 1990s, Nepal was a poor country in need of a stronger health system, especially in rural areas. Service delivery was difficult, particularly due to the country’s geography. For example, many people had to travel up to four hours to reach their nearest health facility (Zulliger, 2017). A civil war that ran from 1996 to 2006 made this already difficult situation even worse. The conflict disrupted the delivery of health services, as it destroyed community health posts, forced health workers to leave their posts, and led to the deaths of health workers (Singh, 2004). Despite these challenges, Nepal made substantial progress in health outcomes. The under-5 mortality rate dropped from 140 per 1,000 live births in 1990 to 45 per 1,000 in 2011, according to World Bank data.1 The maternal mortality rate fell from 851 deaths per 100,000 live births in 1991 to an estimated 328 in 2011.2 One factor contributing to those positive health trends was the creation of the Female Community Health Volunteer (FCHV) program. The Family Health Division of Nepal’s Department of Health Services introduced the FCHV program in 1988 (Ministry of Health and Population, 2014). At its inception, the program focused on voluntary family planning activities, but it expanded over time to include a variety of other activities, including health promotion, health services, and the collection of demographic data (Kandel & Lamichhane, 2019). By 2014, these volunteers offered services including: treatment of diarrhea and acute respiratory infections, immunization, family planning counseling, nutrition activities, counseling for pregnant women, knowledge of pregnancy complications, pregnancy and newborn services, and recognizing and referringfor newborn complications (Ministry of Health and Population, 2014). Government health care initiatives used the FCHV network for their own community-based programs, owing to the trust that FCHVs had built over time (Kandel & Lamichhane, 2019). More than 52,000 women were active in the program as of 2017 (Khatri, Mishra, & Khanal, 2017). The FCHV program had made an impact by connecting people in difficult-to-reach areas to the health system, but by the 2000s the Nepali government wanted to accomplish more. Neonatal and infant mortality remained high in the country and preventable infant- and child-specific diseases, such as diarrheal diseases and respiratory infections, were among the top 10 leading causes of death in Nepal. Mortality rates were higher in rural areas compared to urban areas, and particularly high in mountainous regions of the country, due to limited health infrastructure and challenging terrain (Merchant, Devlin, & Egan, 2016). Socioeconomic inequities were also apparent in the health system, as better-educated and wealthier women tended to have access to better maternal healthcare. In 2008, a Nepal-based non-governmental organization called Nyaya Health Nepal (nyaya could be translated as “justice” in Nepali) began working with the national health ministry to improve health services in one Nepali district.4 To improve health outcomes in the area it targeted, Nyaya soon began looking for ways to strengthen community-based health services and improve the FCHV program.