Voices from the front line: Community health workers’ perspectives on effectiveness and needs in Madagascar’s tuberculosis response
7 affiliations
- 1Monitoring, Evaluation, and Research, Doctors for Madagascar, Antananarivo, Madagascar.
- 2Global Digital Last Mile Health Lab at Charité Center for Global Health, Charité - University Medical Center Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany.
- 3Community Health Worker, Antananarivo, Madagascar.
- 4Programme National de Lutte contre la Tuberculose, Antananarivo, Madagascar.
- 5Community Health Worker, Ampanihy, Madagascar.
- 6Speciality Network: Infectious Diseases and Respiratory Medicine, Charité - University Medical Center Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany.
- 7Berlin Institute of Health at Charité - University Medical Center Berlin, Berlin, Germany.
Abstract
Community health workers (CHWs) are central to primary health care delivery in Madagascar, yet their perspectives on what enables effective work are rarely centered in program design and implementation. This study aims to examine the lived experiences of Malagasy CHWs engaged in tuberculosis (TB) program activities and to develop context-specific recommendations to strengthen their effectiveness in Madagascar’s TB response. We conducted a qualitative study nested within the formative phase of a participatory action research initiative aimed at strengthening Madagascar’s community health workforce. TB program support was used as a tracer condition for universal health coverage-relevant service delivery. Five focus group discussions were held with 26 CHWs in August-September 2024 in two contrasting regions (Analamanga and Atsimo-Andrefana). Discussions were conducted in Malagasy and its dialects, audio-recorded, transcribed, translated into French, and analyzed using inductive reflexive thematic analysis. CHWs articulated five interlinked priorities for effectiveness in the TB response: (1) stable and equitable socio-economic protection; (2) standardized, continuous, and practical training; (3) formative and collaborative supervision; (4) reliable provision of tools, equipment, transport, and personal protective equipment; and (5) recognition and integration within communities and the health system. CHWs emphasized reliability and fulfillment of promised entitlements and described fragmentation across implementing partners as a key source of inequity, uncertainty, and demotivation. CHWs’ accounts point to a persistent implementation gap between policy commitments and the reliability of day-to-day support. Addressing fragmentation and strengthening coordinated national stewardship and partner accountability will be essential to ensure predictable, equitable support for CHWs - a prerequisite for advancing equitable progress toward universal health coverage in Madagascar.
Related
- Projected population level impact and cost-effectiveness of clinic and community-based tuberculosis screening approaches
- Drug-Resistant Tuberculosis in Rural Eastern Cape: Integrating Whole-Genome Sequencing, Conceptual Transmission Modelling and Community-Based Participatory Research
- S100A8/A9 as a biomarker for differentiating pulmonary tuberculosis from community-acquired pneumonia in children: a multicenter cohort study in China
- Effectiveness of community-based care pathways and relapse prevention strategies in schizophrenia: a systematic review and bibliometric analysis
- Effectiveness of integrated tuberculosis and depression treatment led by non-specialist health workers versus standard care among persons with tuberculosis in a low-resource setting: A quasi-experimental non-randomized controlled trial
BibTeX
@article{ravololohanitra2026voices,
title = {{Voices from the front line: Community health workers’ perspectives on effectiveness and needs in Madagascar’s tuberculosis response}},
author = {Onja Gabrielle Ravololohanitra and Alphonsine Razanamiarana and Michel Tiaray Harison and Justine Nafeno and Lydia Raveloarisoa and Harizaka Emmanuel Andriamasy and Haingotiana Razafimanantsoa and Anne Neumann and Nadine Muller},
journal = {PLOS Global Public Health},
year = {2026},
month = oct,
doi = {10.1371/journal.pgph.0005797},
url = {https://journals.plos.org/globalpublichealth/article?id=10.1371/journal.pgph.0005797},
note = {CC BY},
}
RIS
TY - JOUR
TI - Voices from the front line: Community health workers’ perspectives on effectiveness and needs in Madagascar’s tuberculosis response
AU - Onja Gabrielle Ravololohanitra
AU - Alphonsine Razanamiarana
AU - Michel Tiaray Harison
AU - Justine Nafeno
AU - Lydia Raveloarisoa
AU - Harizaka Emmanuel Andriamasy
AU - Haingotiana Razafimanantsoa
AU - Anne Neumann
AU - Nadine Muller
PY - 2026
DA - 2026/10/22
JO - PLOS Global Public Health
DO - 10.1371/journal.pgph.0005797
UR - https://journals.plos.org/globalpublichealth/article?id=10.1371/journal.pgph.0005797
AB - Community health workers (CHWs) are central to primary health care delivery in Madagascar, yet their perspectives on what enables effective work are rarely centered in program design and implementation. This study aims to examine the lived experiences of Malagasy CHWs engaged in tuberculosis (TB) program activities and to develop context-specific recommendations to strengthen their effectiveness in Madagascar’s TB response. We conducted a qualitative study nested within the formative phase of a participatory action research initiative aimed at strengthening Madagascar’s community health workforce. TB program support was used as a tracer condition for universal health coverage-relevant service delivery. Five focus group discussions were held with 26 CHWs in August-September 2024 in two contrasting regions (Analamanga and Atsimo-Andrefana). Discussions were conducted in Malagasy and its dialects, audio-recorded, transcribed, translated into French, and analyzed using inductive reflexive thematic analysis. CHWs articulated five interlinked priorities for effectiveness in the TB response: (1) stable and equitable socio-economic protection; (2) standardized, continuous, and practical training; (3) formative and collaborative supervision; (4) reliable provision of tools, equipment, transport, and personal protective equipment; and (5) recognition and integration within communities and the health system. CHWs emphasized reliability and fulfillment of promised entitlements and described fragmentation across implementing partners as a key source of inequity, uncertainty, and demotivation. CHWs’ accounts point to a persistent implementation gap between policy commitments and the reliability of day-to-day support. Addressing fragmentation and strengthening coordinated national stewardship and partner accountability will be essential to ensure predictable, equitable support for CHWs - a prerequisite for advancing equitable progress toward universal health coverage in Madagascar.
SN - 2767-3375
ER -