Exploring the motivations of female community health volunteers in primary healthcare provision in rural Nepal: A qualitative study
Sarita Panday, Edwin van Teijlingen, Amy Barnes
PLOS Global Public Health · 2024 · DOI: 10.1371/journal.pgph.0003428
Countries: Nepal
What Was Studied
This qualitative study explored what motivates and demotivates Nepal's Female Community Health Volunteers (FCHVs) to deliver primary healthcare, examining individual, organisational, and community-level influences using the Franco et al. (2002) motivation framework. Data were collected in 2014 across two contrasting rural districts — Dhading (hill) and Sarlahi (Terai, bordering India) — through 31 semi-structured interviews (20 FCHVs and 11 paid local health workers) plus 3 focus group discussions with 15 additional volunteers, totalling 45 participants purposively sampled for ethnic and caste diversity (including marginalised Chepang and Tamang groups in the hills, and Madhesi and Muslim groups in the Terai) and varying years of service. Interviews were conducted in Nepali, transcribed, translated into English, and analysed thematically in NVivo, with a subset independently double-coded to check reliability.
What They Found
Across 45 participants, FCHVs described strong individual-level commitment to serving mothers and children, but this motivation was undermined by inadequate compensation: the standard travel incentive of NRs 200 (about £1.33) fell far short of the NRs 400 (about £2.58) per person per day volunteers had to pay someone else to cover their farm work while volunteering. A national survey cited in the paper found FCHVs' average working hours rose from 1.7 to 3.1 hours per day between 2006 and 2014, even as compensation stayed largely unchanged since incentives were first set between 1988 and 1992. A village-level FCHV support fund (NRs 50,000 per village) existed, yet only 66% of FCHVs had even heard of it and just 51% were members. At the organisational level, volunteers described 'bureaucratisation' — expanding, uncompensated reporting duties on maternal and child health indicators, which paid health workers emphasised over the actual caregiving work. At the community level, as FCHVs took on more clinical tasks, community members increasingly (and mistakenly) assumed they were salaried, undermining the social recognition that had previously sustained their motivation — despite this, volunteer attrition remained low (under 5%).
What This Means for Nepal
Nepal's ~50,396 FCHVs (DoHS Annual Health Report 2080/81) remain unpaid volunteers 38 years after the 1988 programme launch, receiving only allowances — a Rs 10,000 dress allowance, Rs 12,000 annual transport allowance, a 50% NHIP premium subsidy, and a Rs 20,000 farewell payment at 60 — and FY2026/27 raised the transport stipend by 50% while stopping short of salarisation, exactly the partial, disincentive-laden response this paper warns against. Three actions follow: (1) since FCHVs fall under local governments' constitutional Schedule 8 'basic health and sanitation' mandate, local governments should use their now-larger internally-funded health budgets to pilot performance-linked top-up payments and actively publicise the village-level FCHV fund, given this study found only half of volunteers were fund members; (2) DoHS/MoHP should audit and digitise FCHV reporting requirements, aligned with the ongoing DHIS2 digital-health push, to reduce the uncompensated 'bureaucratisation' burden identified here; (3) MoHP's Family Welfare Division should run community-awareness campaigns clarifying FCHVs' unpaid status to counter the misperception — documented in both Dhading and Sarlahi — that volunteers are salaried staff, which this study found erodes the community recognition volunteers rely on.
Contextualisation
Nepal's ~50,396 Female Community Health Volunteers (FCHVs) — unpaid since the programme began in 1988 and now paying half the NHIP premium as one of their few financial benefits — remain the backbone of rural primary healthcare, particularly in remote districts like Karnali where formal physician posts go unfilled. This qualitative study is among the few to ask FCHVs themselves, rather than policymakers, what sustains their motivation, directly speaking to DoHS's own documented concern about an ageing FCHV cadre and inconsistent compensation risking dropout. Its findings on opportunity costs and bureaucratic burden are directly relevant to the FY2026/27 budget decision to raise the FCHV transport stipend by 50% while stopping short of salarisation.