Assessment of community health workforce governance in federal Nepal.

How Community Health Worker (CHWs) programs are governed shapes their performance. CHW governance can be challenged by CHWs' accountability to both governments and their communities, and the need to coordinate between multiple actors. Furthermore, little is known about how decentralization impacts CHW governance. We examined Nepal's Female community health volunteers (FCHV), where a 2015 constitutional change to federalism-a major governance reform representing one form of decentralization-shifted the responsibility for community health governance to local municipalities. We assessed FCHV governance in the federal landscape and provide preliminary insights into how federalization has impacted FCHV governance in its early years. We identified opportunities and challenges brought by federalization for six actors: federal, provincial and municipal governments, international donors, FCHVs and their representative organizations (unions), and non-governmental organizations. Our qualitative case study comprised 26 semi-structured interviews and five focus groups conducted with FCHVs, health workers, federal and municipal government representatives, researchers, and FCHV union, donor and NGO representatives, across four districts in Bagmati Province, combined with analysis of 259 documents. We analysed these data using a theoretical framework of CHW governance adapted from seven existing frameworks on health workforce and community health governance. We show that FCHV governance was characterized by improved accountability, transparency, participation, and responsiveness to local needs, to some extent. Decentralization remained incomplete, with governance challenged by limited budgetary and administrative decision-space at local levels, in part because of continued central-level control and limited revenue-raising capacity, coordination, and enforcement challenges, as well as lack of role clarity. While donors and NGOs participate in decision-making, FCHVs and their representative organizations are not consistently consulted. The results indicate that strengthening FCHV governance in federal Nepal will require capacity-building of municipalities while loosening the federal grip.