Non-communicable disease care in peri-urban Nepal: Potential for community-based interventions

Non-communicable diseases (NCDs) are a growing public health challenge in Nepal, driven by hypertension, diabetes, and smoking, and contributing substantially to morbidity and mortality. Access to equitable and affordable care remains limited, particularly in community settings. Task-sharing with Female Community Health Volunteers (FCHVs), a national cadre of volunteer community health workers primarily engaged in maternal and child health, offers a potential strategy to improve community-based NCD management, but its feasibility requires careful assessment. During the formative phase of the SCALE-NCD project, this qualitative study explored community and health system perspectives on NCD care and community-based delivery models in Pokhara, Nepal. Data were collected through 17 in-depth interviews and six focus group discussions with community members, FCHVs, facility-based community health workers (FB-CHWs), and representatives from government, public health, academia, and telecommunications. Thematic analysis revealed five core findings. Community members recognized NCD risk factors but reported deep mistrust in government health services driven by negative care experiences, financial, and structural barriers. Perceptions of FCHVs were shaped by limited community exposure to their roles beyond maternal and child health. While some participants questioned FCHVs' capacity to manage NCDs, others valued their familiarity and accessibility when services were reliably supported. FCHVs and FB-CHWs emphasized that infrequent training, limited supervision, chronic stockouts, financial strain, and inconsistent incentives undermined service delivery and FCHV motivation. Stakeholders stressed that sustainable integration of community-based NCD care would require government resourcing, local ownership, and alignment with existing systems. Participants expressed cautious interest in mHealth strategies, including SMS and audio messages, to support awareness and follow-up. These findings informed the final design of SCALE-NCD, a multi-component task-sharing intervention, and underscore the importance of strengthening FCHV training and supervision, ensuring supplies and incentives, and building community trust through consistent, locally supported service delivery when scaling community-based NCD programs in similar resource-limited settings.