Community Health Volunteers (CHVs) are frontline public health workers who are trusted members of and/or have an unusually close understanding of the community they serve. This trusting relationship enables CHVs to serve as a liaison/link/intermediary between health/social services and the community to facilitate access to services and improve the quality and cultural competence of service delivery.

The U.S. Agency for International Development (USAID) released a report with UNICEF and the President’s Malaria Initiative today that assesses the strengths and weaknesses of Madagascar’s Community Health Volunteer (CHV) activities. Serving more than 5,700 villages, CHV activities have operated for more than a decade, with recent expansion to more than 35,000 volunteers nationally. The report provides a snapshot of the CHVs’ performance as well as the successes achieved and challenges that remain in providing them with sufficient training, supervision, and support for improvement.

Ministries of health and donor organizations in developing countries around the world are increasingly relying on CHVs as a strategy to improve access to lifesaving primary health care services for rural and remote populations in a context of critical health workforce shortages. CHVs are volunteer community members who offer basic health care services at the community level. In Madagascar, USAID and UNICEF are among the donors currently supporting CHV training and supervision.

The USAID Health Care Improvement Project (HCI), managed by University Research Co., LLC, led the research. Using qualitative and quantitative methods, data analyzed included a self-assessment by CHVs, their supervisors, and stakeholders; interviews and focus groups with CHVs and their supervisors; a survey of nearly 250 CHVs from 16 districts; and 1,245 observations of CHVs’ performance.

The CHVs assessed provided basic reproductive health and family planning (RH/FP) services and child health services following the community-based Integrated Management of Childhood Illness (c-IMCI) strategy for improving child survival. PMI found that, on average, CHVs performed 75% of tasks in ill child assessments and 74% of tasks in RH/FP services correctly. CHVs performed best in the treatment of severe malnutrition (with 78% of children correctly treated); they performed less well in the correct treatment of cough (42%). The report found that CHVs helped a client make an informed family planning choice 89% of the time. However, they only correctly assessed conditions that make oral contraceptives inadvisable in two-fifths of encounters. 
Key results and recommendations for improvement in CHV performance and the support provided to CHVs include:

• Clarifying roles and expectations: While CHVs understood their responsibilities, health center and district level staff as well as community members had expectations that exceeded the role of CHVs. Almost one-third of c-IMCI CHVs and 17% of RH/FP CHVs felt that gaining the respect of the community was their biggest challenge. However, nine out of every ten CHVs felt happy to be able to help their communities.
• Reporting and preventing stock-outs: Nearly 70% of participating CHVs reported stock-outs, including both basic commodities and life-saving medicines, and just over half reported using order forms, which maintain sufficient inventory of supplies.
• Strengthening referral and counter-referral systems: A key responsibility of CHVs is to identify seriously ill community members, refer them to nearby health centers for more advanced care, and follow up with clients when they return home. The report revealed that only six out of ten CHVs have ever referred a client to a health facility and infrequently receive information on counter-referrals from facilities.
• Supporting training: While all CHVs received initial training, ongoing or refresher training was sporadic. Only half of c-IMCI CHVs and one-third of RH/FP CHVs reported receiving ongoing training. Refresher training was associated with better performance. Some reported having to wait more than six months for refresher training.
• Planning supportive supervision: In general, less frequent visits by CHV supervisors was associated with poorer performance by CHVs. Some CHVs reported that they received between one and five visits in the previous year.

“This report demonstrates how data can inform action,” said Dr. M. Rashad Massoud, Senior Vice President for the Quality & Performance Institute at URC and Director for HCI. “Understanding where the gaps are—and what is behind them—form a strong foundation for improving health care delivery.”

The Need for Evidence
Many low- and middle-income countries are increasing their investments in and support for large-scale CHV programs to extend the reach of inadequate health systems to hard-to-reach and underserved populations. However, as noted in a 2012 USAID Evidence Summit, there is a lack of evidence on how best to support CHVs to ensure scale-up and sustained, optimal performance. This report contributes to the much-needed evidence base to inform governments and donors where to target their efforts to effectively support CHVs.