Voices from the front line: community health workers perspectives on effectiveness and needs in Madagascars tuberculosis response

BackgroundCommunity health workers (CHWs) are central to primary health care delivery in Madagascar, yet their perspectives on what enables effective work are rarely centered in programme design and implementation. Evidence is needed on the support CHWs receive in practice and the priorities they identify to strengthen effectiveness and equity. MethodsWe conducted a qualitative study nested within the formative phase of a participatory action research initiative aimed at strengthening Madagascars community health workforce. Tuberculosis (TB) programme 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. ResultsCHWs 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 emphasised reliability and fulfilment of promised entitlements and described fragmentation across implementing partners as a key source of inequity, uncertainty, and demotivation. ConclusionsCHWs accounts point to a persistent implementation gap between policy commitments and day-to-day support. Strengthening CHW effectiveness in Madagascar will require coordinated national stewardship and partner accountability to deliver a predictable minimum support package and to include CHWs meaningfully in programme design and evaluation.