Voices from the front line: Community health workers' perspectives on effectiveness and needs in Madagascar's tuberculosis response.

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.