{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,23]],"date-time":"2026-09-23T16:08:54Z","timestamp":1790179734758,"version":"4.1.0"},"reference-count":70,"publisher":"Oxford University Press (OUP)","license":[{"start":{"date-parts":[[2026,9,9]],"date-time":"2026-09-09T00:00:00Z","timestamp":1788912000000},"content-version":"am","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"DOI":"10.13039\/501100003042","name":"Else Kr\u00f6ner-Fresenius-Stiftung","doi-asserted-by":"publisher","id":[{"id":"10.13039\/501100003042","id-type":"DOI","asserted-by":"publisher"}]},{"name":"BIH Charit\u00e9 Clinician Scientist Programme"},{"DOI":"10.13039\/501100015676","name":"Charit\u00e9\u2014Universit\u00e4tsmedizin Berlin","doi-asserted-by":"publisher","id":[{"id":"10.13039\/501100015676","id-type":"DOI","asserted-by":"publisher"}]},{"name":"the Berlin Institute of Health at Charit\u00e9"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":[],"abstract":"<jats:title>Abstract<\/jats:title>\n                  <jats:p>Community health workers (CHWs) are essential to tuberculosis (TB) and human immunodeficiency virus (HIV) responses, yet many programmes rely on volunteer-based models that assume sustained motivation despite weak system support. CHW motivation is widely understood to be shaped by organizational and health system conditions. We examine how structural and organizational conditions shape CHW motivation in TB and HIV care in Madagascar, drawing on self-determination theory (SDT), which conceptualizes motivation as shaped by the fulfilment of needs for autonomy, relatedness, and competence. We conducted a convergent mixed-method study (March\u2013October 2024), combining a survey of 408 CHWs across four regions with qualitative data from five focus group discussions with CHWs (n = 26) and 24 interviews with institutional actors. SDT was applied within a socio-ecological framework to analyse how individual, community, and health system factors influence autonomy, relatedness, and competence. CHWs reported strong commitment to community health, yet operated under significant structural constraints: Most CHWs lived in economic poverty, with 74.3% reporting household incomes below 100 000 MGA\/month (\u2248 $22.1), while 95.8% CHWs held additional full-time occupations. Motivation was characterized by value-driven commitment alongside dependence on external incentives. However, economic precarity, fragmented remuneration systems, insufficient training and supervision, lack of occupational protection, and weak institutional integration constrained CHWs\u2019 autonomy, relatedness, and competence. Incentive-based approaches enabled short-term participation but generated distortions in task prioritization and undermined trust when payments were inconsistent. CHW motivation emerged as a dynamic outcome of the interaction between strong value-based commitment and programme and health system conditions. SDT helps explain how fragmented and unreliable support constrains core psychological needs, producing fragile engagement despite high commitment. Strengthening CHW programmes requires the coherent and reliable delivery of predictable remuneration, training and supervision, occupational protection, and formal integration into the health workforce.<\/jats:p>","DOI":"10.1093\/heapol\/czag110","type":"journal-article","created":{"date-parts":[[2026,9,8]],"date-time":"2026-09-08T11:40:19Z","timestamp":1788867619000},"source":"Crossref","is-referenced-by-count":0,"title":["From motivation to governance: structural determinants of community health worker engagement in TB and HIV care in Madagascar"],"prefix":"10.1093","author":[{"given":"Larissa","family":"Hecht","sequence":"first","affiliation":[{"name":"Charit\u00e9 - University Medical Center Berlin, corporate member of Freie Universit\u00e4t Berlin and Humboldt-Universit\u00e4t zu Berlin, Charit\u00e9 Center for Global Health, Global Digital Last Mile Health Research Lab , Charit\u00e9platz 1, 10117 Berlin ,","place":["Germany"]},{"name":"Speciality Network Infectious Diseases and Respiratory Medicine Charit\u00e9 - University Medical Center Berlin, corporate member of Freie Universit\u00e4t Berlin and Humboldt-Universit\u00e4t zu Berlin, , Charit\u00e9platz 1, 10117 Berlin ,","place":["Germany"]},{"name":"\u00c4rzte fu\u0308r Madagaskar e.V. , Naunhofer Stra\u00dfe 22, 04299 Leipzig ,","place":["Germany"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Onja Gabrielle","family":"Ravololohanitra","sequence":"additional","affiliation":[{"name":"Doctors for Madagascar , Department for Monitoring, Evaluation and Research, Lot IIM 98 G Antsakaviro, 101 Antananarivo ,","place":["Madagascar"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Anne","family":"Neumann","sequence":"additional","affiliation":[{"name":"Charit\u00e9 - University Medical Center Berlin, corporate member of Freie Universit\u00e4t Berlin and Humboldt-Universit\u00e4t zu Berlin, Charit\u00e9 Center for Global Health, Global Digital Last Mile Health Research Lab , Charit\u00e9platz 1, 10117 Berlin ,","place":["Germany"]},{"name":"Speciality Network Infectious Diseases and Respiratory Medicine Charit\u00e9 - University Medical Center Berlin, corporate member of Freie Universit\u00e4t Berlin and Humboldt-Universit\u00e4t zu Berlin, , Charit\u00e9platz 1, 10117 Berlin ,","place":["Germany"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Michel","family":"Tiaray Harison","sequence":"additional","affiliation":[{"name":"Programme National de Lutte Contre la Tuberculose , Ex-B\u00e2timent IHS Analakely, Antananarivo 101 ,","place":["Madagascar"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Norosoa Assunta Felananirina","family":"Rakotoherimora","sequence":"additional","affiliation":[{"name":"Programme National de Lutte Contre les IST et le SIDA , Ambohimiandra, Antananarivo 101 ,","place":["Madagascar"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Emmanuel Harizaka","family":"Andriamasy","sequence":"additional","affiliation":[{"name":"Doctors for Madagascar , Department for Monitoring, Evaluation and Research, Lot IIM 98 G Antsakaviro, 101 Antananarivo ,","place":["Madagascar"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Haingotiana","family":"Razafimanantsoa","sequence":"additional","affiliation":[{"name":"Doctors for Madagascar , Department for Monitoring, Evaluation and Research, Lot IIM 98 G Antsakaviro, 101 Antananarivo ,","place":["Madagascar"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Julius Valentin","family":"Emmrich","sequence":"additional","affiliation":[{"name":"Charit\u00e9 - University Medical Center Berlin, corporate member of Freie Universit\u00e4t Berlin and Humboldt-Universit\u00e4t zu Berlin, Charit\u00e9 Center for Global Health, Global Digital Last Mile Health Research Lab , Charit\u00e9platz 1, 10117 Berlin ,","place":["Germany"]},{"name":"\u00c4rzte fu\u0308r Madagaskar e.V. , Naunhofer Stra\u00dfe 22, 04299 Leipzig ,","place":["Germany"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Nadine","family":"Muller","sequence":"additional","affiliation":[{"name":"Charit\u00e9 - University Medical Center Berlin, corporate member of Freie Universit\u00e4t Berlin and Humboldt-Universit\u00e4t zu Berlin, Charit\u00e9 Center for Global Health, Global Digital Last Mile Health Research Lab , Charit\u00e9platz 1, 10117 Berlin ,","place":["Germany"]},{"name":"Speciality Network Infectious Diseases and Respiratory Medicine Charit\u00e9 - University Medical Center Berlin, corporate member of Freie Universit\u00e4t Berlin and Humboldt-Universit\u00e4t zu Berlin, , Charit\u00e9platz 1, 10117 Berlin ,","place":["Germany"]},{"name":"\u00c4rzte fu\u0308r Madagaskar e.V. , Naunhofer Stra\u00dfe 22, 04299 Leipzig ,","place":["Germany"]}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"286","published-online":{"date-parts":[[2026,9,9]]},"reference":[{"key":"2026092311570330000_czag110-B1","doi-asserted-by":"publisher","first-page":"49","DOI":"10.1186\/s12939-021-01615-y","article-title":"Community health workers and health equity in low- and middle-income countries: systematic review and recommendations for policy and practice","volume":"21","author":"Ahmed","year":"2022","journal-title":"Int J Equity Health"},{"key":"2026092311570330000_czag110-B2","doi-asserted-by":"publisher","first-page":"112","DOI":"10.1186\/s40249-023-01164-2","article-title":"A potential transition from a concentrated to a generalized HIV epidemic: the case of Madagascar","volume":"12","author":"Alonso","year":"2023","journal-title":"Infect Dis Poverty"},{"key":"2026092311570330000_czag110-B3","doi-asserted-by":"publisher","first-page":"e023393","DOI":"10.1136\/bmjgh-2025-023393","article-title":"Community health worker involvement across domains and national infectious disease programmes in rural Madagascar: evidence of fragmentation and determinants of engagement","volume":"11","author":"Andriamasy","year":"2026","journal-title":"BMJ Glob Health"},{"key":"2026092311570330000_czag110-B4","doi-asserted-by":"publisher","first-page":"e044065","DOI":"10.1136\/bmjopen-2020-044065","article-title":"Community health workers\u2019 efforts to build health system trust in marginalised communities: a qualitative study from South Africa","volume":"11","author":"Anstey Watkins","year":"2021","journal-title":"BMJ Open"},{"key":"2026092311570330000_czag110-B5","doi-asserted-by":"publisher","author":"Ballard","DOI":"10.13140\/RG.2.2.27361.76644"},{"key":"2026092311570330000_czag110-B6","doi-asserted-by":"publisher","first-page":"e1598-608","DOI":"10.1016\/S2214-109X(23)00357-1","article-title":"Labour conditions in dual-cadre community health worker programmes: a systematic review","volume":"11","author":"Ballard","year":"2023","journal-title":"Lancet Glob Health"},{"key":"2026092311570330000_czag110-B7","doi-asserted-by":"publisher","first-page":"0046958018798493","DOI":"10.1177\/0046958018798493","article-title":"Expanding understanding of community health worker programs: a cross-sectional survey on the work, satisfaction, and livelihoods of CHWs in Madagascar","volume":"55","author":"Brunie","year":"2018","journal-title":"INQUIRY"},{"key":"2026092311570330000_czag110-B8","doi-asserted-by":"publisher","first-page":"298","DOI":"10.1093\/heapol\/czz025","article-title":"Does volunteer community health work empower women? 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