Co-designing PROFESS: a community health worker support framework to strengthen engagement in TB and HIV care in Madagascar

Community health workers (CHWs) are central to primary health care in low- and middle-income countries, yet their engagement is often uneven across health domains. In Madagascar, approximately 50,720 CHWs serving on a voluntary, unsalaried basis link communities to the formal health system, but only a minority is actively engaged in tuberculosis (TB) or HIV service delivery despite substantial disease burden. This community case study describes a two-stage initiative by a consortium of government disease programmes, an NGO, and an academic partner to strengthen CHW engagement in TB and HIV care in Madagascar. Stage 1 combined a cross-sectional survey of CHWs across four regions with a nested qualitative component identifying system-level constraints. Stage 2 convened national, sub-national, and community-based stakeholders across sectors in a three-day design-thinking workshop, producing PROFESS, a seven-lever framework operationalised as a guide for strengthening CHW support including concrete measures related to Protection (financial), Recognition, Coordination, Formation (training), Equipment, Supervision, and Security of CHWs. PROFESS has been validated by the Malagasy Ministry of Public Health and published as an operational guide. This case highlights two key lessons for fragmented, evidence-scarce settings: workforce-support frameworks anchored in foundational system functions are transferable across disease domains, and co-design produces institutionally adoptable outputs only when paired with operational elaboration. Remaining challenges include the definition of minimum support packages and the sequencing of implementation across levers. A pilot implementation of PROFESS is currently underway, with first results expected in 2027.