The role of female community health volunteers in maternal health service provision in Nepal : a qualitative study

Nepal achieved the Millennium Development Goal 5 by reducing its maternal mortality by more than two thirds. This achievement has been credited to Female Community Health Volunteers (FCHVs) delivering basic Maternal Health Service (MHS) to pregnant women and mothers in their communities. This thesis explores the role of FCHVs in MHS provision in two regions (the hill and Terai ), from the perspectives of health workers, service users, and FCHVs themselves. Data were collected between May 2014 and September 2014 using qualitative methods. Semi-structured interviews were conducted with 20 FCHVs, 11 health workers and 26 women in villages. In addition, four focus group discussions were held with 19 FCHVs and field notes were taken throughout the data collection. Data were analysed using thematic analysis. The study found that most participants viewed FCHVs as a valuable resource in improving MHSs. In both regions, the FCHVs raised health awareness among pregnant women or mothers and referred them for check-ups. They shared health messages through mothers' group meetings and the meetings were also used for discussions around budgeting and finance, which sometimes left little time for discussion on health topics. Such activities, combined with the FCHVs’ lack of education, often proved to be counterproductive to their service provision. The roles of FCHVs were crucial in the hill region where there was limited access to professional healthcare. An important area of FCHVs’ work involved accompanying and assisting women during delivery. In addition, they distributed medicines, administered pregnancy tests and informed women about emergency contraception and availability of abortion services. The FCHVs used novel methods to share maternal health information: for example, they sang folk songs which contained health messages or visited new mothers with food hampers. Such services were invaluable for women in the remote hill villages, who otherwise would not have received any healthcare. In terms of their motivations to volunteer, this study found that FCHVs viewed their work as a form of basic human and social responsibility. In addition, they reported feeling empowered as a result of training and socio-economic opportunities. However, a lack of financial and non-financial incentives was the key hindrance for them in delivering their services, followed by their perception of community misunderstanding about their services. In addition, health system factors such as lack of medical supplies and irregular supervision hindered them in carrying out their role effectively. In general, volunteers in the Terai received less support than those in the hill region. Furthermore, FCHVs perceived a lack of respect by some health workers towards them. A lack of coordination between government health centres and non-governmental organisations was also noted. The thesis concludes with several recommendations for policy makers, practitioners and researchers in order to improve the services by FCHVs. These include providing the FCHVs with context specific support - financial and non-financial incentives, access to supplies, educational training, and supportive supervision - to enable them to deliver services more productively. Recommendations are also made for ensuring that FCHVs are recognised and respected for their contribution to MHSs by local health workers and their communities, as well as coordinating activities among local organisations that mobilise FCHVs to ensure that their services flourish in the future.