Madagascar health workers call for reliable support to fight TB

Community health workers (CHWs) are a backbone of primary health care in Madagascar, yet their practical needs and views are often missing from program planning. Corresponding author Nadine Muller and colleagues set out to put CHWs’ voices at the center of thinking about how to improve the country’s tuberculosis (TB) response as part of broader universal health coverage goals. Rather than studying policies on paper, the team embedded a qualitative investigation within the formative phase of a participatory action research effort aimed at strengthening the community health workforce. They used support for the TB program as a tracer condition — a way to focus on services that matter for many health priorities — and asked CHWs directly what helps them do effective, equitable work. The study aimed to document what support CHWs actually receive in practice and to surface the priorities those workers identify for making their work more reliable and fair. By listening to CHWs in two very different regions, the researchers sought practical, ground-level evidence to guide partners and government in improving day-to-day support for community-based care.

To gather detailed, first-hand perspectives the team held five focus group discussions with 26 CHWs in August–September 2024 in two contrasting regions, Analamanga and Atsimo-Andrefana. Discussions took place in Malagasy and its dialects, were audio-recorded, transcribed, translated into French, and analyzed using inductive reflexive thematic analysis. From those conversations 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 repeatedly stressed the importance of reliability and fulfilment of promised entitlements. They described fragmentation across implementing partners as a key source of inequity, uncertainty, and demotivation that undermines consistent care for people with TB and other health needs.

The accounts from CHWs point to a persistent implementation gap between policy commitments and the support workers actually receive day to day. The study concludes that strengthening CHW effectiveness will require coordinated national stewardship and partner accountability so that a predictable minimum support package is delivered consistently across regions. That package, CHWs said, should guarantee socio-economic protections, standardized and ongoing practical training, supportive supervision that helps rather than polices, reliable supplies and transport including personal protective equipment, and clear recognition and integration into health services and community structures. Including CHWs meaningfully in program design and evaluation was highlighted as essential; when CHWs help shape how programs run, supports are more likely to be practical, equitable, and sustained. These findings give a clear, actionable set of priorities for governments and partners aiming to close the gap between TB policy and practice through stronger community health systems.