In Madagascar, a hilly island nation of 20 million, many people live in small, widely scattered hamlets often made up of just a few houses. Hamlets may be many kilometers apart, and many people may have to walk hours or even days to the health center to seek care.

The Santénet2 project, which is known locally as KM Salama, engages nearly 11,000 community health workers in Madagascar to offer basic health care and education in communities that are more than 5 kilometers from a health center and when necessary, make referrals to the health center. These community health workers are appointed by the village council and are typically literate, well-respected people in the community. These workers are trained to focus either on women and offer basic reproductive health care including prenatal care and family planning information and contraceptives; or focus on children and offer integrated management of childhood illness and nutrition services.

All of the community health workers participate in a five-day, intensive training program, which teaches them specific skills such as how to offer contraceptives including Depo Provera injections and how to diagnose malaria in children using a rapid diagnostic test. The training also covers non-clinical skills that are critical to the work such as the importance of respectfully welcoming clients, maintaining confidentiality and recordkeeping

Evaluating What’s Working in Training and Supervision

A recent qualitative evaluation of the program suggests that these trainings do offer community health workers important technical skills and improve their mastery of the use of simple medical equipment such as the timers to monitor infant breathing. The evaluation also showed that these workers could successfully document consultations and referrals and identify when to treat patients and when to refer them to the local health center.

In interviews, two health workers shared their thoughts on the most valuable parts of the training:

For me the strong point [of the training] was that we were shown how to give Depo Provera injections because normally women have to wait in line at the hospital, and they are all employed and in a hurry to get to work. It is very good that we know how to give this injection. It is a strong point.
—Female community health worker, 51 years old, Anjeva Gare

For me, after having received the training, the community then trusted me, and I would say that, for them, my house has become a little hospital. Parents don’t go to the real hospital unless I refer them, and that only happens if I can’t help them here. The community has confidence in me, and they come if the child is sick, even at night.
—Male community health worker, 49 years old, Talata Ampano

The project evaluation found that most community health workers have good working relationships with the health center managers, a finding that supports proposed changes in the supervisory system. Previously, health workers met every three to six months with Santénet2 project supervisors, the project is now moving towards more frequent and local supervision by the health center and local non-governmental partners, in keeping with the project’s commitment to local ownership and sustainability.

Challenges for Community Health Workers

The qualitative evaluation also identified four of the program’s specific challenges. First, some of the community health workers do not have scales to weigh children. Having a baby weighed is popular among mothers and allows the health worker to regularly interact with them. Secondly, the evaluation showed that health workers occasionally run out of stock of essential medicines, which can mean that clients go without treatment or have to be referred to a health center, often affecting the community’s opinion of the preparedness of the health worker. A third problem identified in many villages was that community health workers were seeing clients in their homes because they have nowhere else to receive them. 

Some village social development committees have responded to this need by encouraging villagers to build a separate health hut where consultations can take place discreetly. Finally, community health workers themselves expressed the need for additional, and more holistic, training to offer their clients the best care. For example, they suggested that community health workers focused on maternal care should also be trained in basic pediatric care and vice versa so the health workers can care for their female clients and the clients’ children at the same time. One community health worker who focuses on pediatric care said: 

Learning how to manage childbirth is our wish, and we would like to be trained in this. Once, in my village, my sister-in-law was about to give birth, and they called me, but when I arrived she had already delivered. I was afraid and asked myself, ‘What am I supposed to do?’ I was ashamed because I am a health worker, and I didn’t even know how to deal with the umbilical cord.
—Female community health worker, 42 years old, Anjeva Gare

Echoes of Early Change

The evaluation identified specific ways to strengthen the reach and effectiveness of the community health worker training program. Anecdotal evidence also suggests the program is already prompting important changes such as clients reporting they are seeking health care earlier.

With regard to illnesses, we no longer wait until the illness gets serious, but as soon as the illness starts, for example a fever or headache, we immediately go and consult the community health worker.
—Female client, 32 years old, Fianarantsoa

As the project progresses, epidemiological evidence is needed to evaluate the community health workers' effects on the population's health, but initial data suggests that more people are seeking malaria treatment and family planning services and that the number of cases of diarrhea are down.

At the time of the harvest in April-May, fevers are very widespread among children. Before, the child would die after two days. Now the fever may last up to four days, but then the child gets better. You see, even if we don’t have the statistics, we can see ‘echoes’ of the project…Now if someone is ill, when mothers and fathers go and see the community health worker, they get help. They either get advice as to how to treat the child or the recommendation to go to the health center.
—Male client, 48 years old, Talata Ampano

Santénet2 is a USAID-funded project, which is led by RTI International and supported by IntraHealth International.

Photo © 2000 Lisa Folda, courtesy of Photoshare