LE Why Did They Join ? Exploring the Motivations of Rebel Health Workers in Nepal

There has been little systematic research on the factors that motivate people to become rebel health workers. This study explores the motivating factors of individuals who joined the Maoists as health workers in Nepal and presents the findings based on semi-structured interviews conducted with the Maoist health workers trained and mobilised by the Unified Communist Party of Nepal-Maoist during the armed struggle with the government (1996-2006). Maoist ideology, service attitude, state injustice, involvement of a family member in the armed conflict, grievance over poor health services and gaining status were the motives for joining the rebel health services. Their motives are categorised as: (a) individual; (b) political and (c) socio-cultural factors. Post-conflict social policy in Nepal should take into consideration the reasons individuals joined the rebellion and listen to their voices to help promote sustainable peace and improve health care services in communities affected by the conflict.

Health workers have always tended to move in search of better living and working conditions, improved salaries and opportunities for professional development, be it within their own country -from rural to urban areas or from public to private sector -or from one country to another (Awases et al. 2003).Moreover, health workers tend to leave underserved and neglected areas, including those susceptible to armed violence, because of lack of modern facilities and insecurity (Dolea, Stormont and Braichet 2010;Zurn et al. 2010).
How to motivate and retain health workers remains a critical problem for public sector health systems, particularly in low and middle-income (so-called 'developing') countries (Willis-Shattuck et al. 2008).The problem is even more alarming in countries disrupted by armed conflicts which experience a high shortage of health workers (Pavignani 2011).Whilst war and violent conflict commonly destroy human life and property (Buhmann et al. 2010;de Jong 2010), many volunteer to risk their lives for a cause in which they believe (Panter-Brick 2010;Guichaoua 2007).This paper deals with the question: Why do people join wars as rebel health workers?Joining a political party for ideological reasons is common practice in peace time in many societies, but what specific factors motivate individuals to work as rebel health workers in a violent conflict is not well researched.It is important to have an understanding of the motives behind joining rebel health service as it can help (a) address the root causes of the armed conflict; and (b) post-conflict redevelopment of health services.
However, systematic information on Nepal's rebel health workers mobilised by the Communist Party of Nepal (Maoist), during the insurgency, is limited.Therefore, our study examined the factors which motivated health workers to join health services established by the Unified Communist Party of Nepal-Maoist during the decadelong (1996)(1997)(1998)(1999)(2000)(2001)(2002)(2003)(2004)(2005)(2006) armed conflict in Nepal.The uprising against the government began in February 1996, launched by the Communist Party of Nepal-Maoist (CPN-M).The Maoists mainly gained control in the more remote and rural parts of the country.In 2005 King Gyanendra declared a state of emergency and took over power.This side-stepping of parliament brought seven political parties together to form an alliance with the CPN-M in 2006 against the king.This united opposition movement in turn resulted in a shift in power and ultimately a peace agreement in 2006.
Maoist health workers interviewed for the study had been working in remote areas and provisional camps, and some of them were working in, or managing, the operation of primary health centres in areas controlled by the Maoists.During the insurgency, they worked largely underground, but their work became more public after the peace negotiations of 2006.At the time of the study, these Maoist health-care workers were waiting for the outcome of the peace process, as the peace negotiations could affect their future career.This study was conducted immediately following the peace negotiations in an attempt to explore their career aspirations.
Bhimsen Devkota (BD) interviewed 15 Maoist health workers, six females and nine males, who were recruited using snowballing sampling (MacDougall and Fudge 2001;Shaver 2005).The interviews took place between November 2007 andMarch 2008, and, to  Semi-structured interviews (van Teijlingen and Forrest, 2004) were conducted with the Maoist health workers; each lasted between 1 and 1½ hours.The interviews were first transcribed in Nepali, and subsequently translated into English.The transcripts were initially analysed using NVivo version 7 (QSR International Pty.LTD, 2007) to generate key themes and sub-themes.The themes were further analysed by using steps of the framework analysis (Krueger 1994;Pope, Ziebland and Mays 2000;Ritchie and Spencer 1994).The process followed: a) familiarisation of the recurrent themes; b) identifying a thematic framework; c) indexing; d) charting and e) mapping and interpretation.The findings below are reported with relevant quotes from the 15 interviewees.
The following section presents the conceptual framework, discussing the multiple factors determining motivation to join rebel health services.Next, the study findings are presented, starting with the characteristics of the rebel health workers followed by their motivation for joining.The discussion section analyses the motivating factors suggested by the study, compared with studies conducted in Nepal and other countries, where available and relevant.Finally, in the conclusion, the findings with suggestions for ways forward are summarised.

concEptuAL frAmEwork: muLtI-fActor ApproAch to rEbEL motIvAtIon
Literature on motivation of civilian health workers exists but specific studies on what motivates rebel health workers are scant.Therefore, we undertook a literature review on the motivation of rebels in general and that of rebel healthcare workers in particular, in order to establish a conceptual framework.We included literature covering armed conflicts elsewhere as well as the conflict in Nepal.Figure 1 is a schematic overview of the literature highlighting that people's motivation to join a rebellion is determined by a number of individual, political and sociocultural factors.

Individual factors:
Studies suggest that economic or material incentives and non-material incentives such as power, status, autonomy and opportunity for career development drive individual rebels.Studies also found materialistic gain (greed), position and power (Collier and Hoeffler 2004;Collier and Sambanis 2002;Gates 2002;Weinstein 2002), and lack of fulfilment of needs (Mitchell 1981;Venhaus 2010) as possible reasons for joining the rebellion.Collier and Sambanis (2002) and Weinstein (2002) suggested economic endowment or materialistic gain theory as rebel motivation.The few studies carried out in Nepal reiterate that economic underdevelopment and poverty were key causes behind the conflict (Devarajan 2005;Leve 2007;Macours 2010;Parwez 2006).

Socio-cultural factors:
A number of socio-cultural factors are associated with rebel motivation.They include gender inequality and caste/ethnic exclusion (Gurung 2005;Gautam, Baskota and Manchand 2001;Leve 2007;Parvati 2004), family connectedness (Olsson 1988;Venhaus 2010), and the desire to gain social prestige and serve the people.
These three sets of motivating factors apply to the motivation of armed insurgents and there is paucity of systematic information on why individuals choose to work as a rebel health worker.Moreover, most published findings are based either on secondary data, or studies at agency level.Our paper, however, is based on primary research with a sample of rebel health workers.

rESuLtS
The age-range of the interviewed rebel health workers varied from 21 to 49 years and their education from eighth grade to degree level (15 years old to undergraduate).The majority had completed less than ten years of education.Maoist health workers generally had some clinical experience in the paramedical field, had basic education, knew a little English and had an interest in health services.
Two-thirds of the Maoist health workers had received paramedical or health training prior to joining the Maoists, while four of them had undergone 'ordinary' training (1½ months) provided by the Maoists, and one remaining health worker had taken 'medium' level training (2½ months), again provided by the Maoists.
Four of the 15 health workers interviewed were executive members of ANPHWA, an open health front of the UCPN-M.Two of them were responsible for treatment and rehabilitation of wounded members of the People's Liberation Army (PLA).Two of the Maoist health workers had worked in a Maoist health centre in a remote district whilst the rest had worked in various PLA cantonments.
Our qualitative findings suggest five sub-themes of individual, political and socio-cultural factors motivating individuals to become a Maoist health worker.They are: a) wanting to serve; b) Maoist ideology; c) state atrocity and injustice; d) involvement of family in the armed conflict and e) grievance over poor service delivery.Interestingly enough, despite asking specifically about it we found that the two sub-themes 'financial incentives' and 'gaining social recognition and status' had not acted as motivating factors for joining as a rebel health worker.

desire to serve people
Interviewees often wanted to serve people or the wider society, as one of them put it: "I thought I could serve the people best being a Maoist health worker.It offered me an opportunity to serve people on their doorstep.I could help on the war front (yudda morcha) and in treating people from our base areas." (ID 11) Another health worker claimed: "I thought if I did not serve these poor people, no one would help them out.To realise this, I had to work with a force that wanted to change the status quo ideologically.I found Maoists very appropriate for this." (ID 05)

maoist ideology
Several Maoist health workers were driven by their political conviction, as expressed by the following Maoist health worker: "While I was working as a government health worker, I had studied the ideology of the Maoists.The policy ideology that it embodied shook me (uddelit).It gave me thoughts (chetana).I realised that for a change to materialise, politics was necessary.Therefore, I concluded that the politics of change could be the Maoists' politics of class struggle.Gradually, my contacts with the Maoists party workers increased.I decided to resign from my post.One fine morning, I left my job and walked away." (ID 03) A former Maoist health worker, turned lawmaker, had a rather theoretical source of inspiration: "I was personally motivated with the work of Norman Bethune in the Chinese revolution and Dr. DD in India.In the twentieth century, the revolutionaries could not train medical doctors, we had to depend on paramedical staff.We accepted this reality and trained our own health workers." (ID 14)

State atrocity/injustice
The respondents mentioned police arrests, torture and false allegations as reasons for joining the Maoist rebellion.Almost all those who had been students prior to their recruitment reported repression by the police as a main push factor.One paramedical student who had joined the Maoists said: "The police arrested me while I was studying to become a Community Medical Assistant (CMA) … They [the police] jailed me for several days … in the Far-West Region.One day they released me from jail but I was always under police surveillance.I felt my life at risk from the enemy.I joined the Maoists after my release from jail." (ID 01) A key member of a Maoist support organisation and coordinator of one of the nine autonomous states declared by the UCPN-M made a similar response: "I joined the Party seven years ago.After completing plus two education, I was admitted to study CMA.Right from my admission, the class enemies1 started to chase me.As a result, I joined the Party." (ID 04) Another Maoist health worker, who was a government village health worker (VHW), used the term Prashasan (administration) as a push factor."I think many of our colleagues were compelled to join because of atrocities of the police and the army.Two of my colleagues who are working in this hospital now were nearly killed by the 'enemies' ." (ID 06) following in the footsteps of family members Family legacy was also a pull factor for the Maoist health workers.A less frequent view was that their family members were associated with the Maoist Party prior to their recruitment.Having relatives within the party meant individuals were put under police surveillance and ultimately forced to go underground.This is reflected in the following statement: poor health services delivery A few Maoist health workers highlighted the inequity within the health services and poor health services delivery in their localities as factors for his joining the Maoist movement: "Well.... at that time, I was in charge of a health centre in the SS district.I did not know that I was a sympathiser of the Maoists in the beginning.I used to keep some personal medicines at my residence.My health post had very limited drugs, hardly sufficient for two months, to distribute to the needy people.I was the only help for the people.They could never buy a full dose of drugs out of their pocket.….When my stock ran out, I could not give them any drugs, not even a tablet of Cetamol.I could do nothing for them, except disappointing and frustrating them.This was commonplace for the majority of people in rural villages." (ID 03) He further added: "What happens if you have water in a cup and people ask you to fill their vessels?I realised it was impossible within that system." (ID 03) Another health worker said: "There were no drugs in the health post; and people had no access to hospitals, even if they went to hospital, the doctor would not be present.…The status of people was vulnerable (jarjar).I could not bear this situation and I felt that I should help these people through bringing a system that could help them.I did not see any alternative other than the Maoists to improve the situation of the poor people." (ID 08)

financial incentives
Maoist cadres were generally not motivated by economic benefits.One fifth of the health workers interviewed reported that they were salaried government workers before joining the Maoists.They reported that the Maoist Party gave them a very small amount of money for expenses.One health worker claimed she worked almost voluntarily, compared with her previous government salary: (Her face lightens up.) "Do you know our party gives us 500 rupees (US $ 7) each month as pocket money.This is equal for all of us, no matter how high or low the position.We live here and eat at the mess.I am happy with this money.You know my salary was nearly 5,000 rupees in the government at that time, but I was not satisfied.I am very satisfied now.I cannot compare.The main thing is that the Party has given chetana (ideology) to me, before this, I could not analyse things on a political basis." (ID 12) One female health worker stated that, instead of gaining financially from the Maoists, she had 'proletarised' herself by giving her property to the Party: "We had our house, land and little properties in the past.After my husband and I joined the Party, we gave whatever was left to us to the Party." (ID 06) One health worker who was from a cantonment also got only 500 rupees per month from the Maoist Party during the conflict.This payment increased to 3,000 rupees after entering the provisional camp agreed between the United Nations Mission to Nepal (UNMIN), UCPN-M and the Government of Nepal.The conversation follows: Interviewer: Did you get a regular salary or money from the Maoists?"Before the peace negotiation, the Party used to provide us with 500 rupees per month for snacks, toothbrushes and paste, soap and clothes." (ID 07) Interviewer: How did you feel getting such a tiny amount?
"We used to feel proud at that time as we thought that we were working for liberation of the poor people.We were guided by an ideology.Now the government pays us 3,000 rupees a month.We were more satisfied when we used to get 500 from the Party." (ID 07) Another Maoist health worker, who had previously worked with an international organisation and also in a government hospital, mentioned that pocket money given by the Party was sufficient because of her 'simple living': "I wouldn't have to pay for food normally.While I used to work in the rural districts, I used to wear on lungi (loin cloth) and T-shirts I had carried with me from home.I even used to save some money out of this salary (Rs.500)." (ID 02)

Gaining position and status
Interviewees had mixed discourses regarding being motivated by status and/or power.None of the Maoist health workers reported that they were attracted by power and positions in the Maoist organisation.Rather, they expressed pride in joining the People's War.One government health worker, who had joined the Maoists at a time when the success of war was uncertain and the government repression of the Maoists was severe, said: "I was on the government staff and I was also running a private clinic successfully in a mid-western district.In the beginning, the UCPN-M had no health workers with it.The development of war demanded many of us to join.I decided to support the war and joined in." (ID 10) When he was asked further about his position in the Maoist Party, he replied: "In the past, I looked after the mid-western region of the Maoist health sector as a full-time member.During the conflict, I coordinated the health sector of the 'new regime' (naya satta).At present, I am a lawmaker on behalf of UCPN-M." (ID 10) Another Maoist health worker recollected: "I provided treatment to many wounded comrades during the Kilo Siera and Romeo operations launched by the enemies.The reactionary government had announced that Maoists were finished.But when we captured hundreds of policemen, including a Deputy Superintendent of Police (DSP) … people recognised our strength.We were involved in providing treatment to the injured policemen captured in the war.This was the first time I treated people whom I used to hate." (ID 14) dIScuSSIon Our findings suggest that, while some Maoist rebel health workers had one dominant reason for joining the armed struggle, many others joined for a combination of factors.Becoming a member of a rebel group depends on a combination of factors, as suggested in research conducted with ex-combatants in Guatemala (Hauge 2007) and Burundi (Fuhlrott 2008).
One recurrent view of the interviewees was that Maoist ideology was a key driver for joining the insurrection.There existed a strong link between self-reported class-based revolutionary consciousness of the Maoist health workers and their motivation to become a rebel health worker (Devkota and van Teijlingen 2010, p. 112).This finding is similar to Adams' (1998) that Nepalese state-funded general paramedics working in rural areas were dedicated to political movements and their conscientiousness.Moreover, our study supports previous findings that political indoctrination and education through one-on-one contacts, door-todoor campaigns and cultural programmes were key elements of the Maoist recruitment strategy (Eck 2007;Karki and Bhattarai 2004).
The Maoist health workers tended to claim that there were no economic incentives for joining the rebellion, in contrast to the general economic endowment or materialistic gain theory (Collier and Sambanis 2002;Devarajan 2005;Leve 2007;Macours 2010;Parwez 2006;Weinstein 2002).Previous studies conducted in Nepal considered poverty, geographic suitability for insurgency (Bohara, Mitchell and Nepal 2006;Lecomte-Tilouine and Gellner 2004) and political exclusion and grievances (Gurung 2005;Hutt 2004;Thapa 2003) to explain growth and sustainability of the rebel motivation.Parwez (2006) concluded that the probability of conflict is higher in areas with lower life expectancy, income and road density.The Maoists' base areas in the mid and far-western regions are considered to have similar characteristics.In contrast to this, one study indicates the probability of occurrences of engagement in conflict is higher among individuals with higher levels of educational attainment (Gautam, Banskota and Manchanda 2001;Leve 2001).The low literacy rates in the Maoist regions contradict this, but the higher educational level among the mid and upper level leaders of the UCPN-M is in line with the above finding (Shah and Pettigrew 2009).
Whatever the political affiliation, it is likely that the Maoist health workers tended to be a group of individuals motivated by concern about public well-being and more willing to serve in the parts of the country most in need of health workers.
Having a family member sympathetic to the Maoist ideology, and/or a family member or close relative killed, tortured, disappeared or prosecuted by the state apparently attracted interviewees towards the Maoist rebellion.According to Olsson (1988), these elements trigger violence.The work by Gersony (2003), Hossain and colleagues (2006), Leve (2007), Pettigrew and Shneiderman (2004) and Parvati (2003) support our findings that grievance, frustration and police atrocities trigger the motivation towards rebellion.Venhaus (2010) suggested that people get socialised into seeking revenge in these environments, and joining the rebellion is the next logical step.
None of our research participants mentioned gender and caste discrimination as the reason for joining the insurgency, as found in studies by Danida (2005) and Gurung, (2005).However, it supports Gersony's (2003) finding that caste and gender were not important reasons behind the Maoist rebellion in the western hill districts.
We also explored whether any of the Maoist health workers joined involuntarily.All participants claimed that they joined voluntarily and they painted positive experiences on their involvement with the Maoists.Our find-ings concur with studies carried out among female fighters in Guatemala (Hauge 2007) and in Nepal (Ogura 2004;Whelpton 2005).Our findings might have been different if the interviews had been conducted during the time of open conflict and with general combatants instead of the Maoist health workers.In a negotiated post-conflict situation where the Maoists have the opportunity to share government power and enjoy many privileges, their response might have been coloured.However, this is an on-going debate among scholars of conflict (Brett and Specht 2004).
People can have a multitude of motives for joining an ideologically-guided rebellion.It could be individual, social, ideological, economical or psychological, or a combination of these motives.Many of the study findings seem similar to studies carried out elsewhere.We consider that there is no single mindset and the dynamics are not clear, as they tend to be complex and context specific.
Our study suggests that the Maoist health workers followed a pathway while becoming involved in the violent conflict.They followed a socialisation process in a violent environment (Olsson, 1988).Their journey to Maoist revolution often started right from the family.They gained revolutionary consciousness through interaction with the family members who had some form of grievance and had encountered violence from the state, and who may have had connections with the Maoist workers and activists.The process further extended to their peers in the community and gained momentum.As our research participants reported, in many remote villages of the western districts of Nepal, the entire village supported the Maoist cause and that was how they became a Maoist, as highlighted by the statement, "Everybody in this village is a Maoist." It suggests that people from a community with a history of general conflict are more likely to be involved in violent conflict.
Many villages, particularly in western Nepal, have a history of brutal state repression during the time of the absolute monarchy and the post-democracy governments (e.g.Romeo and Kilo Sierra operations) under the constitutional monarchy, which generated strong public opposition against the state and its security forces (Gersony 2003;Leve 2007).
Further, on the socialisation in a violent environment, the Maoist health workers joined the support organisations of the Maoists such as its revolutionary wings for students, youth, teachers, women, farmers and labourers.At some time, they came into contact with Maoist party members and activists and took part in their mass mobilisation activities and meetings.When the state became aware of this involvement or sympathies through its 'informers' , it stepped up repressive measures to maintain 'law and order' , and the security forces started harassing these supporters of the Maoists, even though some were only passive sympathisers.
The Maoist health workers were frequently arrested by the police.Because of the animosity with the police and government military forces, some saw no option other than joining the Maoists.The Maoists were quick to issue them membership, part-time membership in the beginning, which after six months to one year, normally became full-time.However, those who were recruited directly to the militia during the height of the Maoist war might not have followed this trajectory.
Unlike the civilian health workers, the Maoist health workers appeared to be motivated more by political ideology, political exclusion, grievances against the government health care system and state repression and less by financial benefits, personal career development, and personal status or working conditions.
Finally, this study has several strengths and weaknesses.The key strength is that this was the first academic study on the motivation of Nepalese Maoist health workers.Similar to other studies conducted in dangerous environments (Kovarts-Bernat 2002; Shah and Pettigrew 2009), we consider the possibility of limitations such as self-selection bias of interviewees, issues of relationship, complicity, representation (Pettegrew, Shneiderman and Harper 2004) and access, ethics and security (Sriram et al. 2009).Some interviewees may have tried to satisfy their superiors or the Party while responding to the researcher, despite efforts to create an environment to elicit anonymous or confidential answers from them.However, we did not find any evidence of coercion during interviews.The government health workers from the Maoist stronghold areas could have been included to assess and compare their motivation in their job as a health worker.Future research should examine whether the motives of the Maoist leaders and followers converge or not.We suggest using additional methods to triangulate the study methods and findings.

concLuSIon
The Maoist ideological consciousness tended to be the main driving force for joining the Maoist rebellion.The course of socialisation of violence appears to be built into the individual, their family and communities.Apart from ideological considerations Maoist health workers tended to be motivated by concern about public well-being.They also expressed a willingness to serve in the rural parts of the country most in need of health workers.
At present, Nepal is in the post-conflict transition.There is an attempt to integrate Maoist ex-fighters into the regular Nepalese army.It might be useful to consider the Maoist health care workers as a slightly separate sub-group.With the appropriate re-training, they may offer a solution to another key problem in Nepal, namely the lack of effective and sustained health care provision in rural areas (Devkota and van Teijlingen 2009).These Maoist health workers have worked in many remote areas, exactly the kind of areas where there is a critical need for trained staff to deliver minimum health services.Understanding their original motivation to become rebel health workers is a first step towards dialogue.
We suggest that those involved in the process of postconflict peacebuilding in Nepal should examine and address the factors that motivated the disenchanted and frustrated health workers to turn to armed violence.It is important to know their aspirations and ideas about their future careers as both have implications for the redevelopment of health services and peacebuilding in the current transition period in Nepal.
maintain anonymity, quotes in this paper only identify interviewees by a number.The Nepal Health Research Council granted ethical permission for the study while the Health Division of the UCPN-M (United Communist Party Nepal-Maoist) and ANPHWA (All Nepal Public Health Worker's Association) facilitated access to their health workers (Devkota and van Teijlingen 2010).

Fig. 1 .
Fig. 1.Framework for analysing motives for joining rebel health services He added:"It was the Maoist ideology and our courage (bichar ra shahas) that encouraged us to work with the Maoists."(ID 14)    Maoist health workers mentioned Maoist mass meetings and cultural programmes motivating them to join: "I was associated with the revolutionary student front in 2001/2002.There was a public awareness campaign in the village.At that time, everybody was a Maoist in the village and I thought why not I?I also started to attend their programmes and became a Maoist.I got a part-time position in the Party in 2002 and, in the same year, I became a full-time member."(ID 12)

"
The People's War greatly intensified in my district in 2001.The District Administration (Prashasan) tortured me, accusing me of being a Maoist supporter.I was not allowed to continue my job.I left the job and joined the Maoists as a part-time member." (ID 08) Another female Maoist health worker who had worked previously as a government Maternal and Child Health Worker (MCHW) recollected: "After the declaration of the State of Emergency in 2001, the police started to come after me.I used to go to [the local administrative centre] to submit a monthly progress report on my health post.The police followed me many times.They suspected me of being a Maoist.They came to search my house twice.They even killed my buffalo and demolished my house.They beat my two children and me, and threatened to kill us.They wanted me to show them my husband, who I had not seen for a long time.How could I show my husband to them to kill?They came to my house many times.It was too much.They forced me to leave my house.I went underground in 2002." (ID 06) She further added:

"
My husband was a full-time member of the Party for 18 years.I worked in a government hospital in Kathmandu for many years.During the janayuddha (People's War), I used to treat war-wounded secretly in the hospital or used to treat them in personal residences in Kathmandu.When the war reached its peak, I became a full member, in 2003, and started my service." (ID 02) One interviewee had joined Maoists after her husband had gone underground: "I was a government health worker for five years.My husband had been involved in the Maoist party since 2001.He became Chief of the Maoists Village Government and went underground after 2002.But I was not a party supporter at that time, nor was I a member of it.When the circumstances turned unfavourable, I left my children and family and joined the Party." (ID 07)Parental involvement in the conflict was a key factor for another health worker: "I joined the war because my parents were forced to go underground.The 'reactionary government' declared my father a "terrorist" and put a million cash reward on his head.Both my father and mother went underground.Police used to search our house from time to time.Later on I also went into hiding."(ID 15)