Suitability, scalability, and sustainability of community health worker-led task sharing for hypertension in Nepal: a rapid review

INTRODUCTION

Hypertension (HTN) poses a substantial public health burden in Nepal, 27.3%of the population and contributing significantly to non-communicable diseases (NCDs), including deaths and disabilities from cardiovascular diseases (CVDs).¹ Effective HTN management necessitates a robust primary healthcare system with competent human resources for health (HRH) to alleviate pressure on secondary and tertiary facilities. Improving efficiency in HRH spending can lead to more efficient health systems, optimizing resources and expanding coverage.² Nepal faces huge burden of gap in HTN care cascade, with 20% prevalence among 15 years and older population, only 50.2% are aware of their condition, 31.7% under treatment and 18% controlled blood pressure, highlight the unmet need for HTN patient care.³ Globally, "task sharing" has emerged as a key strategy to mitigate HRH shortages and improve healthcare access. The world health organization (WHO) defines task sharing as "a way to create a more rational distribution of tasks and responsibilities among different cadres of health workers.” This approach is often used in areas such as reproductive, maternal, newborn, and child health, and is increasingly applied in NCD management, particularly in low- and middle-income countries.⁴ The core objectives of task sharing extend beyond merely addressing healthcare professional shortages; it also promotes sustainable healthcare practices through the efficient utilization of local resources and active community involvement.⁵ In Nepal, FCHVs are examples of a less specialized cadre of health workers who can be mobilized for community-based awareness, screening, monitoring, referral and follow-up for HTN prevention and management.⁶

LITERATURE RESEARCH

This study employed a qualitative synthesis of published secondary literature and national reports to explore the feasibility of task sharing through FCHVs in Nepal’s healthcare system, specifically for HTN prevention and management. A targeted search was conducted to identify documented examples of task sharing and to systematically examine contextual factors influencing its success. The analysis focused on identifying enablers and barriers to implementation, scalability, and sustainability of FCHV-led interventions, drawing insights from both peer-reviewed sources and grey literature relevant to Nepal’s public health infrastructure.

SUITABILITY: A NATURAL FIT, BUT WITH CAVEATS

FCHVs were conceived as voluntary health educators, community mobilizers, referral agents, and service providers, with a particular focus on maternal, child, and reproductive health in 1980s, contributing primarily to maternal and child health improvements in Nepal.⁷ Their evolving roles are now being explored for the prevention and management of NCDs, including HTN type 2 diabetes mellitus and chronic obstructive pulmonary disease, in terms of both feasibility and effectiveness.^8,9 Their ability to reach households, provide counselling on lifestyle modifications, and conduct initial simple CVD risk screening and blood pressure monitoring at the community level is valuable, particularly in hilly geographic areas of Nepal where access to health facilities is limited, and has been tested with success.¹⁰ A prominent, successful demonstration of the effectiveness of task sharing for HTN using FCHVs in Nepal is the community-based intervention for blood pressure reduction in Nepal (COBIN) trial.¹¹ This trial demonstrated that FCHV-led HTN intervention-home visits to provide lifestyle counselling on and blood pressure monitoring-resulted in significant reduction in blood pressure in community settings. Although their suitability appears promising due to their deep community ties and trust, the effectiveness of FCHVs depends on sustained training, clear protocols, and support systems to ensure they can effectively manage the complexities of HTN care.

SCALABILITY: PROMISING POTENTIAL, SYSTEMIC HURDLES

The scalability of the FCHV-led HTN programs in Nepal is supported by the existence of a well-established network of over 52,000 FCHVs, working in each ward (the smallest administrative unit) of Nepal.¹² The existing FCHV training and supervision infrastructure can facilitate the rapid deployment of standardized training programs; and their community acceptance and trust can facilitate the active uptake of health HTN interventions.¹³ However, scaling up requires an enabling policy and regulatory framework that explicitly supports task sharing for HTN prevention and management.¹⁴ Health facility readiness at the primary care level in terms of supply chains to ensure adequate stock levels of anti-hypertensive medications needs to be ascertained.¹⁵ Frequent and involvement of all the relevant stakeholders especially community leaders, local people, patients, care givers etc., to provide culturally sensitive care is paramount for community acceptance.⁶

SUSTAINABILITY: A DELICATE BALANCING ACT

Task sharing through FCHVs for HTN prevention and control is poised for sustainability in Nepal due to their deep community integration, proven cost-effectiveness, and alignment with national health priorities. Moreover, leveraging the existing FCHV network can minimize or strengthen long-term viability. However, while short-term interventions have successfully demonstrated their effectiveness and cost-effectiveness, long-term follow-up revealed that the benefits of the intervention were not maintained after cessation of active intervention and without incentives provided to FCHVs.^15,16 Financial sustainability remains a critical concern, as FCHVs receive limited compensation and significant costs are associated with training of new workforce, establishing referral mechanisms, blood pressure screening and monitoring, inventory and supply chain maintenance for anti-hypertensive medications.⁸ Embedding FCHV roles within the formal system and securing reliable funding streams are critical to preserve the gains achieved through community-based task sharing interventions for HTN prevention and management.

DISCUSSION

This review underscores the expanding role of FCHVs in Nepal as a strategic response to the rising burden of HTN. The findings are consistent with global literature that supports task sharing as an effective solution to address shortages in HRH.^4-5 FCHVs in Nepal are well-positioned to support HTN care due to their trusted community presence and prior success in maternal and child health programs.⁷ Evidence from the COBIN trial ¹¹ confirms that FCHV-led interventions can effectively reduce blood pressure. However, their success depends on consistent training and support systems.^8,10 Nepal’s large FCHV network and existing training infrastructure provide a strong foundation for scaling HTN interventions. Yet, challenges such as the lack of a formal policy framework, limited primary care readiness, and the need for culturally sensitive stakeholder engagement must be addressed. While short-term interventions have shown cost-effectiveness and community acceptance, long-term sustainability is uncertain due to limited financial incentives, weak integration into the formal health system, and the cessation of support post-intervention.^6,14-16 These findings align with broader evidence emphasizing the need for institutional support and dedicated funding for community health worker programs.^8,14

This rapid review is limited by its targeted search strategy, which may have excluded relevant studies, especially unpublished or non-English sources. The absence of formal quality appraisal and reliance on descriptive synthesis may affect the depth and reliability of findings. Additionally, the context-specific focus on Nepal limits generalizability to other settings.

CONCLUSION

Task sharing through FCHVs can be a feasible, scalable, and sustainable strategy for HTN management in Nepal. However, realizing this potential requires a concerted effort to address systemic barriers, secure long-term funding, and embed FCHVs within the formal health system. To ensure suitability, scalability, and sustainability, a comprehensive strategy is essential-one that includes a stable financial model, continuous capacity building, robust community engagement, and strong policy support. Without these foundational elements, task sharing will be short lived and struggle to deliver its intended impact.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: Not required

REFERENCES

1. 1. Dhungana RR, Pandey AR, Shrestha N. Trends in the Prevalence, Awareness, Treatment, and Control of HTN in Nepal between 2000 and 2025: A Systematic Review and Meta‐Analysis. Int J HTN. 2021;2021(1):6610649.
2. 2. Wierzejska E, Giernaś B, Lipiak A, Karasiewicz M, Cofta M, Staszewski R. A global perspective on the costs of HTN: a systematic review. Arch Med Sci. 2020;16(1):1.
3. 3. Khanal A, GC S, Dahal I, Mishra S, GC VS, Wasti SP, Ghimire R. Hypertension care cascade in Nepal: findings from Nepal Demographic and Health Survey 2022. medRxiv. 2025.
4. 4. WHO. Task sharing to improve access to essential health services: report of a WHO consultation, 2017, Geneva, Switzerland. Geneva: World Health Organization, 2017. Report No.: WHO/RHR/17.20. Available at: https://www.who.int/publications/i/item/WHO-RHR-17. Accessed on 12 August 2025.
5. 5. World Health Organization. Task sharing: rational redistribution of tasks among health workforce teams: global recommendations and guidelines. Geneva: World Health Organization; 2008. Available at: https://iris.who.int/bitstream/handle/10665/43821/9789241596312_eng.pdf?sequence=1. Accessed on 12 August 2025.
6. 6. Tan J, Xu H, Fan Q, Neely O, Doma R, Gundi R, et al. HTN care coordination and feasibility of involving female community health volunteers in HTN management in Kavre District, Nepal: a qualitative study. Global Heart. 2020;15(1):73.
7. 7. Panday S, Bissell P, Van Teijlingen E, Simkhada P. The contribution of female community health volunteers (FCHVs) to maternity care in Nepal: a qualitative study. BMC Health Services Res. 2017;17:1.
8. 8. Adhikari TB, Gyawali B, Rijal A, Sapkota A, Högman M, Karki A, et al. Community-based management of chronic obstructive pulmonary disease in Nepal-Designing and implementing a training program for Female Community Health Volunteers. PLOS Glob Public Health. 2022;2(3):e0000253.
9. 9. Gyawali B, Sharma R, Mishra SR, Neupane D, Vaidya A, Sandbæk A, et al. Effectiveness of a Female Community Health Volunteer-Delivered Intervention in Reducing Blood Glucose Among Adults with Type 2 Diabetes: An Open-Label, Cluster Randomized Clinical Trial. JAMA Netw Open. 2022;5(12):e2247534.
10. 10. Rawal LB, Sun Y, Dahal PK, Baral SC, Khanal S, Arjyal A, et al. Engaging Female Community Health Volunteers (FCHVs) for cardiovascular diseases risk screening in Nepal. PLoS One. 2022;17(1):e0261518.
11. 11. Neupane D, McLachlan CS, Mishra SR, Olsen MH, Perry HB, Karki A, et al. Effectiveness of a lifestyle intervention led by female community health volunteers versus usual care in blood pressure reduction (COBIN): an open-label, cluster-randomised trial. The Lancet Global Health. 2018;6(1):e66-73.
12. 12. Khatri RB, Mishra SR, Khanal V. Female Community Health Volunteers in community-based health programs of Nepal: Future perspective. Front Public Health. 2017;5:181.
13. 13. Rawal LB, Kharel C, Yadav UN, Kie K, Tuhin B, Corneel V, et al. Community health workers for non-communicable disease prevention and control in Nepal: a qualitative study. BMJ Open. 2020;10:e040350.
14. 14. Sharma P. Female Community Health Volunteers (FCHVs) in Nepal: Current challenges and opportunities in their role in non-communicable diseases (NCDs) screening and diagnosis. One Health. 2024;4(1):22-5.
15. 15. Thapa R, Zengin A, Neupane D, Mishra SR, Koirala S, Kallestrup P, et al. Sustainability of a 12-month lifestyle intervention delivered by community health workers in reducing blood pressure in Nepal: 5-year follow-up of the COBIN open-label, cluster randomised trial. The Lancet Global Health. 2023;11(7):e1086-95.
16. 16. Krishnan A, Finkelstein EA, Kallestrup P, Karki A, Olsen MH, Neupane D. Cost-effectiveness and budget impact of the community-based management of HTN in Nepal study (COBIN): a retrospective analysis. The Lancet Global Health. 2019;7(10):e1367-74.