Hajamamy Rakotoarisoa | October 2015
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Presentation at the Global Maternal Newborn Health Conference, October 19, 2015

Madagascar’s community health policy promotes community-based maternal, neonatal, reproductive and child health service delivery by CHVs in areas at >5km from a health center. Despite many years of technical support to CHVs, the quality of services delivered by CHVs remains poor and uneven. A USAID evaluation of CHVs in 2011 found that between 49% and 60% of CHVs do not perform services according to norms and standards. The USAID MIKOLO project’s quality assurance (QA) strategy combines on-the-job supervision of CHVs by local NGOs with group-based supervision in partnership with the head of the nearest health center and systematic performance monitoring linked to step-wise certification. Performance is measured quarterly through observation using a checklist that generates a performance score.  When a CHV specialized in child health achieves at least 80% in two consecutive quarters, s/he will be trained and licensed to also provide maternal, neonatal and reproductive health services, and vice versa. Subsequent achievement of 80% then leads to certification as peer-supervisors. This QA approach was introduced among 4,138 CHVs in 375 communes in Madagascar in 2014. We analyzed performance improvement and measured the effectiveness of this approach over a 6 month period, using chi square tests.  Among CHVs offering maternal, neonatal and reproductive health services, 30% achieved >80%. Among CHVs offering child health services, 27% did. Among those who subsequently offered all services, 23% (958) became peer supervisors. Performance increased among CHVs who offer only child health services from 60% à 68% (p<0.02) and among CHVs who offer maternal, neonatal and reproductive health services from 49% à 68% (p<0.001).

Conclusion: Standardized performance monitoring linked to certification and opportunities for CHVs to expand their service range and become peer supervisors leads to improved CHV performance and thus increased uptake of maternal, newborn, reproductive and child health services.