Reimagining Integrated Community-Based Health Services in Low- and Middle-Income Countries: A Case Study of the Female Community Health Volunteers in Nepal

Female community health volunteers (FCHVs) have a pivotal role in improving population health, particularly maternal and child health in Nepal. Since the introduction of the FCHV program in 1988, they have functioned as a critical interface between the community and the formal health system. FCHVs have been increasingly mobilised for other functions, such as screening and follow-up of non-communicable diseases, and/or health emergencies. These additional roles have not been structured and integrated into the routine health care model. Moreover, the current FCHV-led model, while instrumental in past successes, may not be sustainable in its existing form. In this paper, we critically review and examine the current literature to argue that the community health system needs to be restructured and reframed. This is necessary for multiple reasons a) changing epidemiological and demographic profile; b) societal change; c) the growing challenge of ensuring fair and reliable compensation; d) complex health needs; and e) increase in the expected services delivered by community health workers. An integrated community health system that emphasises integrated service models and linkage between facility and community-based care is urgently needed. Expanding the role of salaried, facility-based auxiliary health workers, mobilising people with lived experiences alongside strategic mobilisation of FCHVs, present a viable pathway to strengthen and sustain community health systems. Future efforts should prioritise developing a context-specific framework for FCHVs mobilisation and evaluating the cost-effectiveness of diverse care models. • Community health workers are central to improving population health outcomes. • Their roles have expanded over time, without formal integration to health systems • A comprehensive model of care integrating facility- and community-based systems, is essential • The sustainability of large-scale FCHV programmes requires health system support and monitoring.