By: Alain Koffi and Banaventure Rakatomalala
Faced with the fourth highest rates of chronic malnutrition globally, Madagascans increasingly rely on the support of CHWs trained in general health or specialized in nutrition-related services. Nutrition-related services include providing education about healthy food choices and cooking strategies as well as treatment for moderate acute malnutrition. Overall, the combined use of CHWs in Madagascar contributes to modest gains in health and nutrition.
In Madagascar, 63% of the population lives in rural areas. The country has the fourth highest prevalence rate of chronic malnutrition in the world. The insufficient number of health professionals, their misdistribution, and the shortage of facilities result in limited and unequal access to health and nutrition services. CHWs come in two cadres in Madagascar: Agents Communautaires de Nutrition (ACNs), with a focus on nutrition-related activities, and Agents Communautaires (ACs), with a focus on general health activities.
For years, the delivery of health and nutrition services was operated by the Ministère de la Santé Publique (Ministry of Public Health, herein MSANP) and the Office National de Nutrition (ONN) in parallel. In 2019, the Government of Madagascar began a joint implementation initiative by MSANP and ONN in order to improve its national health and nutrition outcomes in eight regions of the country.
ACs receive 5 to 12 days of initial training on topics such as Integrated Community Case Management, family planning, immunizations, tuberculosis, malaria and other common primary health care (PHC) issues. The initial training of ACNs is usually 10 to 15 days.
Both cadres take part in the promotion of health of the community and in the prevention and treatment of diseases and conditions. ACs are trained to treat certain conditions such as diarrhea, with oral rehydration solution, and offer medications for malaria. ACNs provide treatment of moderate acute malnutrition and monitor nutritional status, in addition to health promotion activities such as nutrition education and cooking demonstrations for mothers. Both ACs and ACNs provide home visits and conduct outreach activities.
Incentives and remuneration
The incentives for the CHWs vary across cadres, regions and projects. ACs receive no formal regular payment except per diems for trainings and campaigns. ACNs receive a monthly payment of 50,000 AR (about US$ 17), but only when there is an active project (which is usually financed by an external donor). Both ACs and ACNs may occasionally receive non-financial incentives such as donated food items, community recognition, and support such as labor to help build their houses.
ACs are supervised by the head of the peripheral basic health centers (Chef Centre de Santé de Base) while ACNs report to an Animator, who is a supervisor employed by a local NGO that has been contracted by ONN to provide nutrition services. There was no formal linkage between ACNs and MSANP-operated basic health centers until 2019.
Madagascar has made modest gains in maternal, neonatal, child health and nutrition, and progress has been slow and stagnant at times. Still, many see that CHWs have contributed to these improvements since they are a cornerstone of PHC in Madagascar, especially in remote and underserved areas.