Female community health volunteers to reduce blood pressure: feasible and sustainable?
Authors: K C Bhuvan, Saval Khanal
Journal: The Lancet Global Health (2018)

Dinesh Neupane and colleagues (January, 2018)1Neupane D McLachlan CS Mishra SR et al.Effectiveness of a lifestyle intervention led by female community health volunteers versus usual care in blood pressure reduction (COBIN): an open-label, cluster-randomised trial.Lancet Glob Health. 2017; 6: e66-e73Summary Full Text Full Text PDF Scopus (86) Google Scholar report the effectiveness of a lifestyle intervention to reduce blood pressure led by Nepalese female community health volunteers (FCHVs). Although we agree with the authors that the FCHV-led lifestyle intervention, alongside blood pressure monitoring, can be a good initiative for blood pressure reduction, we have concerns about its feasibility and sustainability. The FCHV programme, which was started by the Ministry of Health in 1988, involves trained female volunteers in the promotion of public health topics, such as immunisation, vitamin A supplementation, and maternal and child health, to the local community.2Panday S Bissell P Teijlingen E Simkhada P The contribution of female community health volunteers (FCHVs) to maternity care in Nepal: a qualitative study.BMC Health Serv Res. 2017; 17: 623Crossref PubMed Scopus (47) Google Scholar, 3Khatri RB Mishra SR Khanal V Female community health volunteers in community-based health programs of Nepal: future perspective.Front Public Health. 2017; 5: 181Crossref PubMed Scopus (58) Google Scholar Each FCHV has to cover one ward (the smallest administrative unit of Nepal, consisting of about 50 households) in their particular village, and at present Nepal has over 52 000 FCHVs. The FCHVs make a huge contribution to the improvement of basic health-care services in Nepal in terms of the delivery, coverage, and quality of such services and have, therefore, contributed towards the improvement of health care-indicators in Nepal.2Panday S Bissell P Teijlingen E Simkhada P The contribution of female community health volunteers (FCHVs) to maternity care in Nepal: a qualitative study.BMC Health Serv Res. 2017; 17: 623Crossref PubMed Scopus (47) Google Scholar The FCHV programme was built on a willingness to volunteer being woven into Nepalese society and its success was linked to the FCHVs' sense of moral duty and the social recognition they receive.4Schwarz D Sharma R Bashyal C et al.Strengthening Nepal's Female Community Health Volunteer network: a qualitative study of experiences at two years.BMC Health Serv Res. 2014; 14: 473Crossref PubMed Scopus (31) Google Scholar However, there have been concerns about the compensation and benefits received by the FCHVs with respect to their expanding roles and the difficulties they face in balancing the volunteering with social and family responsibilities.4Schwarz D Sharma R Bashyal C et al.Strengthening Nepal's Female Community Health Volunteer network: a qualitative study of experiences at two years.BMC Health Serv Res. 2014; 14: 473Crossref PubMed Scopus (31) Google Scholar, 5Justice J JHPIEGO: a study of the concept of volunteerism: focus on community-based health volunteers in selected areas of Nepal. JHPIEGO, Baltimore2003Google Scholar With all these services provided for free, the addition of responsibilities without any remuneration to compensate might demotivate them in the public health activities they are already performing. If there is a plan for remuneration, a feasibility study should be done to clarify whether remunerating FCHVs would be more effective clinically and economically than increasing spending on the more skilled and trained workforce, such as assistant pharmacists, community medical assistants, and auxiliary nurse midwives. Furthermore, other problems exist, such as the socioeconomic disparities within FCHVs and the effect of this on their knowledge and practice, the absence of best practice guidelines for community health volunteers, and the skewed availability of resources and quality of community health services across villages and districts with different human development index values.4Schwarz D Sharma R Bashyal C et al.Strengthening Nepal's Female Community Health Volunteer network: a qualitative study of experiences at two years.BMC Health Serv Res. 2014; 14: 473Crossref PubMed Scopus (31) Google Scholar Hence, there is a need for comprehensive investigation of the organisation, responsibilities, and structures of FCHVs before any blood pressure reduction programme should be rolled out to them. However, we do acknowledge Neupane and colleagues' contribution in showing the clinical effectiveness of incorporating FCHVs into this type of programme. We declare no competing interests. Effectiveness of a lifestyle intervention led by female community health volunteers versus usual care in blood pressure reduction (COBIN): an open-label, cluster-randomised trialA simple, FCHV-led lifestyle intervention coupled with monitoring of blood pressure is effective for reduction of blood pressure in individuals with hypertension and ameliorates age-related increases in blood pressure in adults without hypertension in the general population of Nepal. Full-Text PDF Open AccessFemale community health volunteers to reduce blood pressure: feasible and sustainable? – Authors' replyWe thank K C Bhuvan and Saval Khanal for their Correspondence regarding our Article.1 Their letter addresses important issues regarding the feasibility and sustainability of Nepal's female community health volunteer (FCHV) programme. Full-Text PDF Open Access