Evaluation of a volunteer community-based health worker program for providing contraceptive services in Madagascar

BACKGROUND: Madagascar recently scaled up their volunteer community health worker (CHW) program in maternal health and family planning to reach remote and underserved communities. STUDY DESIGN: We conducted a cross-sectional evaluation using a systematic sample of 100 CHWs trained to provide contraceptive counseling and short-acting contraceptive services at the community level. CHWs were interviewed on demographics, recruitment, training, supervision, commodity supply, and other measures of program functionality; tested on knowledge of injectable contraception; and observed by an expert while completing five simulated client encounters with uninstructed volunteers. We developed a CHW performance score (0-100%) based on the number of counseling activities adequately met during the client encounters and used multivariable linear regression to identify correlates of the score. RESULTS: CHWs had a mean performance score of 73.9% (95% confidence interval [CI]: 70.3-77.6%). More education, more weekly volunteer hours, and receiving a refresher training correlated with a higher performance score. We found no other associations between measures of the components previously identified as essential for effective CHW programs and performance score. CONCLUSIONS: Although areas of deficiency were identified, CHWs proved capable of providing high-quality contraception services.