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



      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.


      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.


      Although areas of deficiency were identified, CHWs proved capable of providing high-quality contraception services.


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Contraception
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • United Nations
        The Millennium Development Goals Report 2011.
        United Nations, New York2011
        • MoH, Plan de Développement Secteur Santé 2007–2011
        Ministry of Health, Family Planning and Social Protection.
        Antananarivo, Madagascar2007
        • Cleland J.
        • Bernstein S.
        • Ezeh A.
        • Faundes A.
        • Glasier A.
        • Innis J.
        Family planning: the unfinished agenda.
        Lancet. 2006; 368: 1810-1827
        • Bhutta Z.A.
        • Lassi Z.S.
        • Pariyo G.
        • Huicho L.
        Global experience of community health workers for delivery of health related millennium development goals: a systematic review, country case studies, and recommendations for integration into national health systems.
        World Health Organization, Geneva2010
        • Berman P.A.
        • Gwatkin D.R.
        • Burger S.E.
        Community-based health workers: head start or false start towards health for all?.
        Soc Sci Med. 1987; 25: 443-459
        • Anonymous
        Madagascar 2008–09: results from the Demographic and Health Survey.
        Stud Fam Plann. 2011; 42: 221-226
        • Creanga A.A.
        • Gillespie D.
        • Karklins S.
        • Tsui A.O.
        Low use of contraception among poor women in Africa: an equity issue.
        Bull World Health Organ. 2011; 89: 258-266
        • Bradley S.E.K.
        • Croft T.N.
        • Fishel J.D.
        • Westoff C.F.
        Revising unmet need for family planning. DHS Analytical Studies No. 25.
        ICF International, Calverton, Maryland2012
        • Malarcher S.
        • Meirik O.
        • Lebetkin E.
        • Shah I.
        • Spieler J.
        • Stanback J.
        Provision of DMPA by community health workers: what the evidence shows.
        Contraception. 2011; 83: 495-503
        • Hoke T.H.
        • Wheeler S.B.
        • Lynd K.
        • et al.
        Community-based provision of injectable contraceptives in Madagascar: 'task shifting' to expand access to injectable contraceptives.
        Health Policy Plan. 2012; 27: 52-59
        • Crigler L.
        • Hill K.
        • Furth R.
        • Bjerregaard D.
        Community Health Worker Assessment and Improvement Matrix (CHW AIM): A Toolkit for Improving Community Health Worker Programs and Services.
        Published by the USAID Health Care Improvement Project. University Research Co., LLC (URC), Bethesda, MD2011
        • Wilson E.B.
        Probable inference, the law of succession, and statistical inference.
        J Am Stat Assoc. 1927; 22: 209-212
        • Mullany L.C.
        • Lee T.J.
        • Yone L.
        • et al.
        Impact of community-based maternal health workers on coverage of essential maternal health interventions among internally displaced communities in eastern Burma: the MOM project.
        PLoS Med. 2010; 7: e1000317
        • Utomo I.D.
        • Arsyad S.S.
        • Hasmi E.N.
        Village family planning volunteers in Indonesia: their role in the family planning programme.
        Reprod Health Matters. 2006; 14: 73-82
        • Sultan M.
        • Cleland J.G.
        • Ali M.M.
        Assessment of a new approach to family planning services in rural Pakistan.
        Am J Public Health. 2002; 92: 1168-1172
      1. Ward WB, Neumann AK, Pappoe ME. Community health education in rural Ghana: the Danfa project-an assessment of accomplishments. 1981–82. Int Q Community Health Educ 2005–2006;25:37–48.

        • Madden T.
        • Mullersman J.L.
        • Omvig K.J.
        • Secura G.M.
        • Peipert J.F.
        Structured contraceptive counseling provided by the Contraceptive CHOICE Project.
        Contraception. 2012; (Sep 5. [Epub ahead of print])
        • Rowe S.Y.
        • Kelly J.M.
        • Olewe M.A.
        • et al.
        Effect of multiple interventions on community health workers' adherence to clinical guidelines in Siaya district, Kenya.
        Trans R Soc Trop Med Hyg. 2007; 101: 188-202
        • World Health Organization
        Task shifting: rational redistribution of tasks among health workforce teams: global recommendations and guidelines.
        WHO, Geneva2008
        • Bulterys M.
        • Fowler M.G.
        • Shaffer N.
        • et al.
        Role of traditional birth attendants in preventing perinatal transmission of HIV.
        BMJ. 2002; 324: 222-224
        • Viswanathan K.
        • Hansen P.M.
        • Rahman M.H.
        • et al.
        Can community health workers increase coverage of reproductive health services?.
        J Epidemiol Community Health. 2012; 66: 894-900
        • Phillips J.F.
        • Bawah A.A.
        • Binka F.N.
        Accelerating reproductive and child health programme impact with community-based services: the Navrongo experiment in Ghana.
        Bull World Health Organ. 2006; 84: 949-955
        • Hossain M.B.
        Analysing the relationship between family planning workers' contact and contraceptive switching in rural Bangladesh using multilevel modelling.
        J Biosoc Sci. 2005; 37: 529-554
        • Douthwaite M.
        • Ward P.
        Increasing contraceptive use in rural Pakistan: an evaluation of the Lady Health Worker Programme.
        Health Policy Plan. 2005; 20: 117-123
        • Khan M.A.
        Factors associated with oral contraceptive discontinuation in rural Bangladesh.
        Health Policy Plan. 2003; 18: 101-108
        • Luck M.
        • Jarju E.
        • Nell M.D.
        • George M.O.
        Mobilizing demand for contraception in rural Gambia.
        Stud Fam Plann. 2000; 31: 325-335
        • UN Population Division
        World Contraceptive Use 2011.
        (Available at)
        • Genna S.
        • Fantahun M.
        • Berhane Y.
        Sustainability of community based family planning services: experience from rural Ethiopia.
        Ethiop Med J. 2006; 44: 1-8
        • United States Agency for International Development (USAID)
        Three successful sub-Saharan Africa family planning programs: Lessons for meeting the MDGs.
        USAID, Washington, DC2012
        • Baumgartner J.N.
        • Morroni C.
        • Mlobeli R.D.
        • et al.
        Timeliness of contraceptive reinjections in South Africa and its relation to unintentional discontinuation.
        Int Fam Plan Perspect. 2007; 33: 66-74
        • Grimes D.A.
        Forgettable contraception.
        Contraception. 2009; 80: 497-499
        • Rowe S.Y.
        • Olewe M.A.
        • Kleinbaum D.G.
        • et al.
        The influence of observation and setting on community health workers' practices.
        Int J Qual Health Care. 2006; 18: 299-305
        • Campbell J.P.
        • Maxey V.A.
        • Watson W.A.
        Hawthorne effect: implications for prehospital research.
        Ann Emerg Med. 1995; 26: 590-594
        • Rowe A.K.
        • Lama M.
        • Onikpo F.
        • Deming M.S.
        Health worker perceptions of how being observed influences their practices during consultations with ill children.
        Trop Doct. 2002; 22: 166-167
        • Hermida J.
        • Nicholas D.D.
        • Blumenfeld S.N.
        Comparative validity of three methods for assessment of the quality of primary health care.
        Int J Qual Health Care. 1999; 11: 429-433
        • Franco L.M.
        • Franco C.
        • Kumwenda N.
        • Nkhoma W.
        Methods for assessing quality of provider performance in developing countries.
        Int J Qual Health Care. 2002; 14: 17-24