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

Non-communicable disease (NCD) risk factors such as hypertension, diabetes, and smoking represent an increasing burden in Nepal, where access to equitable and affordable care remains limited. Task-sharing with Female Community Health Volunteers (FCHVs) offers a potential strategy to improve community-based NCD management, but its feasibility and scale up requires careful assessment. As part of 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 organizational representatives. Thematic analysis revealed five core findings. Community members demonstrated awareness of NCD risk factors but reported deep mistrust in government health services, driven by negative experiences with public sector care, financial and structural barriers, and perceived discrimination. Perceptions of FCHVs were shaped by limited community exposure to their roles beyond maternal and child health. While some community members expressed skepticism about FCHVs capacity to manage NCDs, others valued their familiarity and accessibility, particularly when services were reliably supported. FCHVs and FB-CHWs emphasized that infrequent training, limited supervision, and chronic stockouts of supplies undermined service delivery. Financial strain and lack of consistent incentives also challenged FCHV retention and motivation. Stakeholders stressed that sustainable integration of community-based NCD care would require reliable government resourcing, local ownership, and alignment with existing systems. Participants also expressed cautious interest in mHealth strategies, such as SMS and audio messages, to support patient awareness and follow-up. These findings informed the final design of SCALE-NCD, a multi-component task-sharing intervention, and underscore the need to address structural constraints, institutional trust, and workforce support in scaling community-based NCD care programs in resource-limited settings.