Community health worker involvement across domains and national infectious disease programmes in rural Madagascar: evidence of fragmentation and determinants of engagement

INTRODUCTION: Community health workers (CHWs) are central to primary healthcare (PHC) delivery and infectious disease control in low-income settings. In Madagascar, CHWs are mandated to contribute across multiple national disease programmes, yet evidence on their actual involvement and its determinants remains limited, particularly for HIV/AIDS and tuberculosis (TB). METHODS: We conducted a cross-sectional survey between March and June 2024 among CHWs in four regions (Analamanga, Atsimo Andrefana, Androy and Anosy). Using two-stage cluster sampling, districts and public primary health centres were randomly selected and all eligible affiliated CHWs were invited to participate. We assessed CHWs' self-reported involvement in health domains and disease response programmes, including HIV/AIDS, TB and malaria, over the preceding 2 years. Mixed-effects logistic regression models with random intercepts at the health facility level were used to identify factors associated with involvement. RESULTS: Among the 408 participating CHWs (response rate 81.8%), engagement was near-universal in maternal and child health (100%) and malaria-related activities (98.5%), but was limited for TB (23.8%) and HIV/AIDS (21.6%). Across regions, involvement in HIV/AIDS and TB was largely limited to sensitisation activities. Possession of written work guidance and previous disease-specific training were consistently associated with higher odds of involvement in HIV/AIDS (OR 3.73; 95% CI 2.09 to 6.66) and TB (OR 2.55; 95% CI 1.48 to 4.40). Reliance on non-governmental organisation-led support was not associated with increased engagement. CONCLUSIONS: In rural Madagascar, CHW involvement in HIV/AIDS and TB is low compared with malaria and maternal and child health. Engagement in HIV/AIDS and TB is driven by the availability of clear work guidance and disease-specific training. Strengthening integrated responses can draw on the malaria platform and anchor both diseases within routine activities of the national operational framework for CHWs. Public health donors and actors need to align disease-specific investments and actions with core PHC structures.