Institute of Sociology and Political Science, Faculty of Social and Educational Sciences, Norwegian University of Science and Technology, Edvard Bulls veg 1, 7491, Trondheim, Norway.
Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, Maryland, 21205, USA.
Int J Equity Health. 2024 Apr 13;23(1):70. doi: 10.1186/s12939-024-02177-5.
Community health workers (CHWs) are central to Primary Health Care globally. Amidst the current flourishing of work on CHWs, there often is a lack of reference to history-even in studies of programs that have been around for decades. This study examines the 35-year trajectory of Nepal's Female Community Health Volunteers (FCHVs).
We conducted a content analysis of an archive of primary and secondary research materials, grey literature and government reports collected during 1977-2019 across several regions in Nepal. Documents were coded in MAXQDA using principles of inductive coding. As questions arose from the materials, data were triangulated with published sources.
Looking across four decades of the program's history illuminates that issues of gender, workload, and pay-hotly debated in the CHW literature now-have been topics of discussion for observers and FCHVs alike since the inception of the program. Following experiments with predominantly male community volunteers during the 1970s, Nepal scaled up the all-female FCHV program in the late 1980s and early 1990s, in part because of programmatic goals focused on maternal and child health. FCHVs gained legitimacy as health workers in part through participation in donor-funded vertical campaigns. FCHVs received a stable yet modest regular stipend during the early years, but since it was stopped in the 1990s, incentives have been a mix of activity-based payments and in-kind support. With increasing outmigration of men from villages and growing work responsibilities for women, the opportunity cost of health volunteering increased. FCHVs started voicing their dissatisfaction with remuneration, which gave rise to labor movements starting in the 2010s. Government officials have not comprehensively responded to demands by FCHVs for decent work, instead questioning the relevance of FCHVs in a modern, medicalized Nepali health system.
Across public health, an awareness of history is useful in understanding the present and avoiding past mistakes. These histories are often not well-archived, and risk getting lost. Lessons from the history of Nepal's FCHV program have much to offer present-day debates around CHW policies, particularly around gender, workload and payment.
社区卫生工作者（CHW）是全球初级卫生保健的核心。在当前社区卫生工作者工作蓬勃发展的情况下，即使在已经存在几十年的项目研究中，也常常缺乏对历史的参考。本研究考察了尼泊尔女性社区卫生志愿者（FCHV）35 年的轨迹。
我们对 1977 年至 2019 年期间在尼泊尔几个地区收集的初级和二级研究材料、灰色文献和政府报告的档案进行了内容分析。使用 MAXQDA 对文件进行编码，采用归纳式编码原则。随着材料中出现问题，与已发表的来源进行数据三角测量。
纵观该计划 40 年的历史，有问题的性别、工作量和薪酬——现在在 CHW 文献中激烈争论——自该计划开始以来一直是观察员和 FCHV 讨论的话题。在 20 世纪 70 年代实验性地使用主要由男性组成的社区志愿者之后，尼泊尔在 20 世纪 80 年代末和 90 年代初扩大了全女性 FCHV 计划，部分原因是专注于母婴健康的方案目标。FCHV 通过参与由捐助者资助的垂直运动成为了有合法地位的卫生工作者。FCHV 在早期获得了稳定但适度的定期津贴，但自 20 世纪 90 年代停止发放以来，激励措施一直是基于活动的支付和实物支持的混合体。随着男性越来越多地从村庄外流和女性工作责任的增加，健康志愿服务的机会成本增加了。FCHV 开始对薪酬表示不满，这导致了从 21 世纪 10 年代开始的劳工运动。政府官员没有全面回应 FCHV 对体面工作的要求，而是质疑 FCHV 在现代、医学化的尼泊尔卫生系统中的相关性。
在公共卫生领域，了解历史有助于理解现在并避免过去的错误。这些历史往往没有得到很好的存档，有丢失的风险。尼泊尔 FCHV 计划历史的经验教训为当前围绕 CHW 政策的辩论提供了很多启示，特别是在性别、工作量和薪酬方面。
