An anthropological history of Nepal's Female Community Health Volunteer program: gender, policy, and social change.

BACKGROUND: 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). METHODS: 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. RESULTS: 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. CONCLUSIONS: 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.

Hospital Payer and Racial/Ethnic Mix at Private Academic Medical Centers in Boston and New York City.

Academic medical centers (AMCs) are widely perceived as providing the highest-quality medical care. To investigate disparities in access to such care, we studied the racial/ethnic and payer mixes at private AMCs of New York City (NYC) and Boston, two cities where these prestigious institutions play a dominant role in the health care system. We used individual-level inpatient discharge data for acute care hospitals to examine the degree of hospital racial/ethnic and insurance segregation in both cities using the Index of Dissimilarity, together with recent changes in patterns of care in NYC. In multivariable logistic regression analyses, black patients in NYC were two to three times less likely than whites, and uninsured patients approximately five times less likely than privately insured patients, to be discharged from AMCs. In Boston, minorities were overrepresented at AMCs relative to other hospitals. NYC hospitals were more segregated overall according to race/ethnicity and insurance than Boston hospitals, and insurance segregation became more pronounced in NYC after the Affordable Care Act. Although health reform improved access to insurance, access to AMCs remains limited for disadvantaged populations, which may undermine the quality of care available to these groups.