{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,22]],"date-time":"2026-10-22T17:42:48Z","timestamp":1792690968578,"version":"4.5.0"},"reference-count":38,"publisher":"Public Library of Science (PLoS)","issue":"10","license":[{"start":{"date-parts":[[2026,10,22]],"date-time":"2026-10-22T00:00:00Z","timestamp":1792627200000},"content-version":"vor","delay-in-days":0,"URL":"http:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"DOI":"10.13039\/501100003042","name":"Else Kr\u00f6ner-Fresenius-Stiftung","doi-asserted-by":"publisher","award":["2024_EKHA.61"],"award-info":[{"award-number":["2024_EKHA.61"]}],"id":[{"id":"10.13039\/501100003042","id-type":"DOI","asserted-by":"publisher"}]},{"DOI":"10.13039\/501100002839","name":"Charit\u00e9 \u2013 Universit\u00e4tsmedizin Berlin","doi-asserted-by":"publisher","award":["NA"],"award-info":[{"award-number":["NA"]}],"id":[{"id":"10.13039\/501100002839","id-type":"DOI","asserted-by":"publisher"}]}],"content-domain":{"domain":["www.plosglobalpublichealth.org"],"crossmark-restriction":false},"short-container-title":["PLOS Glob Public Health"],"abstract":"<jats:p>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\u2019s TB response. We conducted a qualitative study nested within the formative phase of a participatory action research initiative aimed at strengthening Madagascar\u2019s 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\u2019 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.<\/jats:p>","DOI":"10.1371\/journal.pgph.0005797","type":"journal-article","created":{"date-parts":[[2026,10,22]],"date-time":"2026-10-22T17:23:27Z","timestamp":1792689807000},"page":"e0005797","update-policy":"https:\/\/doi.org\/10.1371\/journal.pgph.corrections_policy","source":"Crossref","is-referenced-by-count":0,"title":["Voices from the front line: Community health workers\u2019 perspectives on effectiveness and needs in Madagascar\u2019s tuberculosis response"],"prefix":"10.1371","volume":"6","author":[{"ORCID":"https:\/\/orcid.org\/0009-0002-1944-7526","authenticated-orcid":true,"given":"Onja Gabrielle","family":"Ravololohanitra","sequence":"first","affiliation":[{"name":"Monitoring, Evaluation, and Research, Doctors for Madagascar","place":["Antananarivo, Madagascar"]},{"name":"Charit\u00e9 - University Medical Center Berlin, corporate member of Freie Universit\u00e4t Berlin and Humboldt-Universit\u00e4t zu Berlin","place":["Berlin, Germany"],"department":["Global Digital Last Mile Health Lab at Charit\u00e9 Center for Global Health"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Alphonsine","family":"Razanamiarana","sequence":"additional","affiliation":[{"name":"Community Health Worker","place":["Antananarivo, Madagascar"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-4310-5633","authenticated-orcid":true,"given":"Michel","family":"Tiaray Harison","sequence":"additional","affiliation":[{"name":"Programme National de Lutte contre la Tuberculose","place":["Antananarivo, Madagascar"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Justine","family":"Nafeno","sequence":"additional","affiliation":[{"name":"Community Health Worker","place":["Ampanihy, Madagascar"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Lydia","family":"Raveloarisoa","sequence":"additional","affiliation":[{"name":"Programme National de Lutte contre la Tuberculose","place":["Antananarivo, Madagascar"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Harizaka Emmanuel","family":"Andriamasy","sequence":"additional","affiliation":[{"name":"Monitoring, Evaluation, and Research, Doctors for Madagascar","place":["Antananarivo, Madagascar"]},{"name":"Charit\u00e9 - University Medical Center Berlin, corporate member of Freie Universit\u00e4t Berlin and Humboldt-Universit\u00e4t zu Berlin","place":["Berlin, Germany"],"department":["Global Digital Last Mile Health Lab at Charit\u00e9 Center for Global Health"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0000-7037-8066","authenticated-orcid":true,"given":"Haingotiana","family":"Razafimanantsoa","sequence":"additional","affiliation":[{"name":"Monitoring, Evaluation, and Research, Doctors for Madagascar","place":["Antananarivo, Madagascar"]},{"name":"Charit\u00e9 - University Medical Center Berlin, corporate member of Freie Universit\u00e4t Berlin and Humboldt-Universit\u00e4t zu Berlin","place":["Berlin, Germany"],"department":["Global Digital Last Mile Health Lab at Charit\u00e9 Center for Global Health"]}],"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","place":["Berlin, Germany"],"department":["Global Digital Last Mile Health Lab at Charit\u00e9 Center for Global Health"]},{"name":"Charit\u00e9 - University Medical Center Berlin, corporate member of Freie Universit\u00e4t Berlin and Humboldt-Universit\u00e4t zu Berlin","place":["Berlin, Germany"],"department":["Speciality Network: Infectious Diseases and Respiratory Medicine"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-1199-9716","authenticated-orcid":true,"given":"Nadine","family":"Muller","sequence":"additional","affiliation":[{"name":"Monitoring, Evaluation, and Research, Doctors for Madagascar","place":["Antananarivo, Madagascar"]},{"name":"Charit\u00e9 - University Medical Center Berlin, corporate member of Freie Universit\u00e4t Berlin and Humboldt-Universit\u00e4t zu Berlin","place":["Berlin, Germany"],"department":["Global Digital Last Mile Health Lab at Charit\u00e9 Center for Global Health"]},{"name":"Charit\u00e9 - University Medical Center Berlin, corporate member of Freie Universit\u00e4t Berlin and Humboldt-Universit\u00e4t zu Berlin","place":["Berlin, Germany"],"department":["Speciality Network: Infectious Diseases and Respiratory Medicine"]},{"name":"Berlin Institute of Health at Charit\u00e9 - University Medical Center Berlin","place":["Berlin, Germany"]}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"340","published-online":{"date-parts":[[2026,10,22]]},"reference":[{"issue":"3","key":"pgph.0005797.ref001","doi-asserted-by":"crossref","first-page":"240","DOI":"10.1370\/afm.2208","article-title":"Roles and functions of community health workers in primary care","volume":"16","author":"AL Hartzler","year":"2018","journal-title":"Ann Fam Med"},{"key":"pgph.0005797.ref002","volume-title":"Declaration of Astana: global conference on primary health care","author":"World Health Organization, United Nations Children\u2019s Fund","year":"2018"},{"key":"pgph.0005797.ref003","volume-title":"WHO guideline on health policy and system support to optimize community health worker programmes","author":"World Health Organization","year":"2018"},{"key":"pgph.0005797.ref004","volume-title":"A comprehensive description of three national community health worker programs and their contributions to maternal and child health and primary health care: case studies from Brazil, Ethiopia, and Nepal","author":"HB Perry","year":"2016"},{"key":"pgph.0005797.ref005","doi-asserted-by":"crossref","DOI":"10.1136\/bmjgh-2018-001046","article-title":"Towards universal health coverage: what are the system requirements for effective large-scale community health worker programmes?","volume":"4","author":"U Lehmann","year":"2019","journal-title":"BMJ Global Health"},{"key":"pgph.0005797.ref006","year":"2023"},{"key":"pgph.0005797.ref007","author":"Community Health Impact Coalition","year":"2023"},{"issue":"1","key":"pgph.0005797.ref008","doi-asserted-by":"crossref","first-page":"1","DOI":"10.1111\/napa.12060","article-title":"Community health workers and social change: an introduction","volume":"39","author":"K Maes","year":"2015","journal-title":"Ann Anthropol Pract"},{"issue":"1","key":"pgph.0005797.ref009","doi-asserted-by":"crossref","first-page":"272","DOI":"10.1186\/s12875-024-02523-0","article-title":"From the periphery to inclusion within the health system: promoting community health worker empowerment as a way forward","volume":"25","author":"L Stansert Katzen","year":"2024","journal-title":"BMC Prim Care"},{"issue":"12","key":"pgph.0005797.ref010","article-title":"The role and recognition of community health workers in research-a global survey","volume":"12","author":"Community Health Impact Coalition research study group. 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Alamgir","family":"Hossain","sequence":"first","affiliation":[{"name":"ICDDR: International Centre for Diarrhoeal Disease Research Bangladesh","place":["BANGLADESH"]}],"role":[{"vocabulary":"crossref","role":"editor"}]}],"short-title":[],"issued":{"date-parts":[[2026,10,22]]},"references-count":38,"journal-issue":{"issue":"10","published-online":{"date-parts":[[2026,10,22]]}},"URL":"https:\/\/doi.org\/10.1371\/journal.pgph.0005797","relation":{},"ISSN":["2767-3375"],"issn-type":[{"value":"2767-3375","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,10,22]]}}}