The sharp decline in child mortality in Nepal after the 1980s has been attributed to different inexpensive community-based interventions [7, 15-17] led by local health workers and FCHVs. Studies around the world have shown that community-based interventions with minimal training to community health volunteers and ensuring the availability of life-saving key commodities contributes to the decline in child mortality [18-21]. Our study findings demonstrate that nearly two out of three FCHVs were involved in providing at least one child health service in the last three months before the survey. There is no doubt about the importance of FCHVs in rendering child health services. For instance, 67% of all the diarrhoea cases in the country were reported by FCHVs in fiscal year 2017/18 . However, it is also relevant to understand the reasons for not providing child health services by the remaining FCHVs. This might be related to motivational factors as well as supply-side factors, partly explained by our study findings, but need further exploration.
In our study, availability of key commodities (Cotrimoxazole tablet, Zinc tablet and ORS) with FCHVs was significantly associated with providing child health services. The limited availability of commodities severely restricts FCHVs’ ability to provide services and affects the community trust on them. The major reason for this is due to the inadequate stock of drugs in health facilities which is again the consequence of procurement and transportation hurdles. Reducing commodity stock-out rates across health facilities in Nepal and equipping FCHVs with these commodities could thus reasonably be assumed to contribute to improved service delivery and child health outcomes. Though the importance of local health workers cannot be ignored, mobilization of FCHVs has supported in bringing services closer to the community in a country which has been suffering from a chronic shortage of human resources for health. A study from Nepal has indicated that women did not prefer to contact FCHVs during the illness of their child because of their incompetency and lack of medicines. Thus, for an effective FCHV program, their mobilization needs to be continuously monitored and supervised by local health workers with regular competency-based training and sufficient supply of logistics.
The government of Nepal has created an FCHV fund- a micro-credit fund which is managed by FCHVs. They use this fund in income-generating activities. Our study revealed that the utilization of money from the fund was associated with child health service delivery by FCHVs. The fund might have strengthened their economic status, increased the sense of belongingness and improve their performance which is also supported by a qualitative study done in Nepal.
Our study showed a difference in child health service delivery as per caste and province which might be due to variation in literacy by district and by caste/ethnic group [13, 23].
Similarly, FCHVs who supported PHC-ORC and ANC related activities were more likely to provide child health services as compared to those who did not support these activities. Evidence-based interventions to improve child survival has been documented[21, 24] which has shown that continuum of care needs to be in focus to reduce child mortality and morbidity. These key interventions include family planning, ANC, skilled attendant at birth, postnatal care for mother and newborn, vaccine and antibiotics for treatment of pneumonia. Involving FCHVs in these wide ranges of interventions would aid in the integration of maternal, child and newborn services thus leading better outcomes in human capital and development. It is however equally important to consider the work burden of FCHVs while task shifting and also capacitate FCHVs to deal with cultural and religious issues that surround during pregnancy and childbirth in Nepal[25, 26].
Our study showed that the participation of FCHVs in health mother’s group meeting was associated with the delivery of child health services. These meetings are unique platforms to discuss different health issues and are attended by local women. Studies from Nepal have shown that frequent interactions between mothers and FCHVs were related to the use of child health services from FCHVs  and reduction in underweight and stunting status among children. Similarly, a study from Makwanpur, Nepal  and Jharkhand and Orissa of India had shown that participatory intervention involving women’s group can decrease both maternal and neonatal mortality and improve service utilization. The functionality of health mother’s group meeting could thus be argued as an important intervention to improve child health in the community settings.
The use of mobile phone and wireless technology has a huge potential to improve the health and wellbeing of the resource constraint communities through communication and exchange of skills among health workers and with communities [30, 31]. The use of the mobile application to improve maternal and neonatal health outcomes has been studied among FCHVs in Nepal which has shown promising results [32, 33]. Our study findings also showed that the use of the mobile phone by FCHVs was associated with child health service delivery indicating that a mobile phone could play a potential role to improve child health outcomes. We assume that FCHVs are likely to be contacted through mobile phone in case of emergency or other health needs by the communities leading to increased service utilization of child health services.
Our study findings demonstrated that FCHVs who were involved in the local level committees were more likely to provide child health services than those who were not involved in similar committees. RB Khatri, SR Mishra and V Khanal  however are of the view that the involvement of FCHVs in other non-health programs such as forest user groups, community development groups, education, and microcredit and saving groups could compromise their working hours in the health sector leading to poor performance. We put forward that such involvement may open opportunities for social networking leading to higher self-esteem and increased performance. However, monitoring of the activities of FCHVs needs to be done by health facilities and local governments for effective performance management of these cadres.
Our study findings indicate that incentives do not affect the delivery of child health services by FCHVs. This might be because of their volunteering role and that FCHVs are motivated by social recognition which is also supported by a qualitative study done in Nepal . Studies have however shown that the issue of fair compensation for FCHVs needs to be addressed [10, 35, 36] as economic insecurity is a strong barrier to volunteering. Motivational activities like the provision of training and dress allowance for FCHVs were not significantly associated with the delivery of child health services in this study. The reason might be that FCHVs had joined volunteerism with the least expectation. In our study, education of FCHVs was not significantly associated with the child health service delivery. This finding contrasts with a study from Dhanusha, Nepal where the educational status of FCHVs was associated with their knowledge and performance on maternal and child health services.
Nepal is in the early stage of implementation of federalism and the constitution has identified health as a fundamental right. While the federal government is responsible for overseeing broader policy, the province and local governments are responsible for the management of the health services [38, 39]. In the changed federal governance, the task of managing FCHVs comes under the direct responsibility of the local level governments (municipality, rural municipality) who were previously managed by local health posts and primary health centres. The role of local-level governments would thus be crucial to motivate these cadres for contributing to the health of the communities. The FCHVs are complimentary cadres to improve the health of the communities and their effort alone might not be sufficient. It is also necessary that there is increased community demand for health care and the availability of quality health services at health institutions.
This study is based on large sample size and the findings can be generalizable to the entire country. However, there are inherent limitations to the study. Firstly, its cross-sectional study design does not allow establishing causation. Secondly, this study only focuses on the FCHV’s) perspective and thus there is an indication of further research to understand the community and service provider’s side perspectives. Furthermore, this study doesn't identify the main reasons for not providing or providing child health services. Future research may be needed to explore these factors in detail. Despite limitations, this study provides useful evidence for the policymakers and programmatic managers for understanding the factors influencing the performance of FCHVs in providing child health services. The evidence can thus be utilized for efficient and effective utilization of these cadres for improved child survival.