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This action by the Health Volunteers Organisation of Nepal (HEVON) and Nepal Health Volunteers Association (NEVA) is notable in a context of deep divisions on political lines between the federations to which these two unions belong.
There are currently more than 52,000 Female Community Health Volunteers working across Nepal in rural and semi urban areas to provide safe motherhood, child health, family planning and immunization services. FCHVs also treat cases of lower respiratory tract infections and refer more complicated cases to healthcare institutions. Each volunteer provides services to approximately 125 households, representing around 600 people. FCHVs provide the essential link between vulnerable populations in rural and poor communities and the formal health system.
Despite irregular working hours due to dealing with emergencies as well as routine work for around six hours a day and up to six days a week, FCHVs do not receive a salary and are only provided with limited incentives, such as yearly clothing allowance, refreshment allowance during training and a stipend during vaccination campaigns. In total, these allowances represent less than 10% of the legal minimum wage in Nepal of NPR 9,700 (€75).
Both Pakistan and India also provide large-scale community-based health services through a programme that does not account for a permanent workforce and its remuneration. However, the conditions in Nepal are worse. The Nepalese government invokes the spirit of voluntarism that characterises Nepalese society, the supposedly 'natural' role of women in caring for their families and communities, and the fact that there is no deception involved as the workers are informed from the beginning that they are volunteers. However, FCHVs are increasingly convinced of the legitimacy of their demands to be recognised as workers of the health system, as they showed in a Public Meeting held by PSI in Kathmandu on 12 January.
Under the title 'Challenges facing FCHVs: Learnings from South Asia' participants from Pakistan, India, and Finland joined the meeting in Nepal. Representatives of the government tried to justify the current situation but they were squarely challenged by the FCHVs present in the room.
Bal Krishna Suvedi, Former Director of Family Health Division, Primary Health Care Revitalization Division and Policy, Planning and International Cooperation Division reminded the participants of the origin of the programmes rooted in the history of free-willing voluntarism in times of disasters, such as during earthquakes. Taking the analogy forward, he argued that the rates of maternal and child mortality in remote areas are akin to a health disaster and FCHVs are the modern volunteers responding to it. However, Gita Thing, Vice President of NEVA replied that while disaster response is a punctual event, today FCHVs have a regular monthly and annual workload as well as monthly reporting at the local health facility. “We are proud of the role we play in our community and the contribution we make to saving lives. However, we do not want to be heroes, we just want the basic facilities to be able to do our job and the rights that are associated to our condition as workers of the public health system,” she stated.
Dilli Raman Adhikari, Deputy Director, Family Health Department, Ministry of Health and Population of Nepal spoke of the crucial role played by FCHVs in the context of a severe shortage of skilled health workforce, especially in remote areas of the Himalayan region. “In the mountains, FCHVs are the doctors of their communities. They are the most accessible health workers in their communities,” he said. He then spoke of the motivational factors and the in-kind and in cash support that the government provides to FCHVs. In-kind support includes bicycles, umbrellas, and a bag. Yet, only 8% of FCHVs receive this in-kind support. With regard to cash allowances, Adhikari argued that the clothing allowance, refreshment allowance during trainings and stipend during vaccination days have been increased on a regular basis and are now NPR 7000 a year, NPR 150 a day and NPR 400 a day respectively. Bagawati Ghimire, President of HEVON, took the floor to respond that this support is inadequate. “A yearly clothing allowance was enough in the 1990s, it is not enough anymore in today's economic context. Today a salary is required to keep our families going,” she affirmed.
Representatives of Nepalese National Centres General Federation of Nepalese Trade Unions (GEFONT) and Nepal Trade Union Congress (NTUC) expressed their support for the demand to be recognised as workers. Researcher Bijoya Roy, showed that while there are similar programmes in other countries in South Asia, in those countries and under pressure from the unions, governments have agreed to some of the demands of the workers. This is for instance the case in Pakistan where the equivalent workforce called Lady Health Workers (LHWs) have not only been recognised as workers, but absorbed as permanent employees. Today LHWs receive the current minimum wage of PKR 15,000 per month (around €110).
There are currently three unions of FCHVs active in Nepal. NEVA, registered in 2009, and Female Health Worker Association, FeHWA or Mahila Swasthya Sebika Shramik Sangh, registered in 2012, were instrumental in ensuring regular increases in the allowances paid to FCHVs, such as the introduction of an annual clothing allowance, as well as ensuring that the government provides them with an identity card accredited by the Ministry of Health and Population. NEVA currently has 5,000 members. HEVON is a newer union, registered in 2016, that counts 12,000 non-paying members. HEVON emerged from the union of health workers Health Professionals Organisation of Nepal (HEPON), as a group wishing to work in a more focused way on the issues specific to this category of workers. Over the past year, NEVA and HEVON have had the opportunity to come together to organise events in different parts of the country, based on which they decided to take this to the next step and develop a common set of demands.
Nepal is in a period of transition as it restructures its governance system into a federal democracy constituted of a union of seven provinces. Elections held at the end of 2017 saw a left-wing coalition sweeping parliament, bringing expectations that the new government will prioritise social sectors, including healthcare. However, it is not clear how the division of responsibilities between the Union and the Provinces will affect the employment structure of FCHVs and their demand for regularisation. Trade unions need to increase their organisational strength at the Provincial level.
Further, public health experts have raised concerns that providing decent wages to FCHVs will affect the sustainability of the programme in the current situation of limited resources. The FCHV programme is fully funded by international aid. Trade unions will need to present arguments showing how those resources can be obtained and collected. Currently, subsidiaries of foreign companies operating in Nepal enjoy very low tax rates. Demands for tax justice can bring together a broader coalition, including other workers in the public health system and the progressive civil society movement along with FCHVs in a demand for universal and quality public healthcare services.
Finally, a key challenge lies in the need to increase the confidence of community-based health workers so that they can argue the legitimacy of their demands and win over the support of the broader public, especially in their communities. Low levels of literacy mean many FCHVs feel inadequate to make claims on formal employment jobs in a context of high informality of the economy and rampant under-employment. The highly informal nature of FCHVs’ employment makes it difficult for them to identify with the common understanding of what a worker is. It is through discussion that these doubts can be clarified, and this is a challenge that the leadership of the unions involved in this struggle need to tackle.