Objectives. We sought to provide a systematic review of the determinants of success in scaling up and sustaining community health worker (CHW) programs in low- and middle-income countries (LMICs).

Methods. We searched 11 electronic databases for academic literature published through December 2010 (n = 603 articles). Two independent reviewers applied exclusion criteria to identify articles that provided empirical evidence about the scale-up or sustainability of CHW programs in LMICs, then extracted data from each article by using a standardized form. We analyzed the resulting data for determinants and themes through iterated categorization.

Results. The final sample of articles (n = 19) present data on CHW programs in 16 countries. We identified 23 enabling factors and 15 barriers to scale-up and sustainability, which were grouped into 3 thematic categories: program design and management, community fit, and integration with the broader environment.

Conclusions. Scaling up and sustaining CHW programs in LMICs requires effective program design and management, including adequate training, supervision, motivation, and funding; acceptability of the program to the communities served; and securing support for the program from political leaders and other health care providers.

Community health workers (CHWs) play a critical role in primary health care delivery, particularly in low- and middle-income countries (LMICs). Also known in some contexts as village health workers, community health promoters, lay health workers, or promotores, CHWs provide basic public health services and medical care and are typically members of the communities in which they work.1,2 Activities of CHWs may include educating community members about health risks, promoting healthy behaviors, or linking community members with providers at formal health care facilities. Community health workers can range from volunteers working without material compensation to paid employees of a country’s public health system; in some cases, even when CHWs do not receive a salary, they may receive other material benefits such as periodic training stipends, financial incentives, or preferential access to health care or microcredit.1,2 Community health workers lack a professional health care certification, which distinguishes them from other health care providers such as doctors or nurses.3 Because of their ability to reach community members at relatively low cost, CHWs have been proposed and deployed as a means for achieving a wide range of disease prevention and health system strengthening objectives.4,5

The positive impact of CHWs on disease prevention, healthy behavior adoption, and access to care has been documented in diverse contexts.2,3,6 In LMICs, CHWs have been found to be effective in reducing neonatal mortality,7 child mortality attributable to pneumonia,8 and mortality caused by malaria.9,10 In addition, CHWs have been successful in promoting improved health behaviors including exclusive breastfeeding,11 adherence to HIV antiretroviral therapy and counseling,5,12 childhood immunization,3 early prenatal care usage,13 and tuberculosis treatment completion.14 They have also been a central component in the implementation of Integrated Management of Childhood Illness strategies, which have succeeded in reducing child mortality in multiple LMICs.1,15

Despite the substantial evidence about the positive impact of CHWs as a model of care, less is known about effective approaches to scaling up and sustaining CHW programs. One challenge in synthesizing this evidence is the absence of explicit definitions for scale-up and sustainability in the empirical literature about CHW programs. Previous definitions of health program scale-up have focused on either the process of a program expanding from a smaller to a larger implementation arena or the state of a program being implemented in a widespread manner.16,17 Sustainability of health programs has been defined in previous literature as “the continued use of program components and activities for the continued achievement of desirable program and population outcomes,”18(p2060) and it has been measured in diverse ways such as a program’s duration, the resources required to enable the program to survive, or the duration of the program’s benefits.19–22 A related challenge is one of comparability across CHW programs and countries; a program considered large-scale and sustained in one country might be viewed as small-scale or short-term in another setting. Therefore, we sought to develop criteria for identifying cases of scale-up, sustainability, and success of CHW programs and to apply these criteria in a systematic review of the existing empirical literature on scaling up and sustaining the CHW model in LMICs to extract key enabling factors for success. This information can provide useful guidance to policymakers, practitioners, and researchers seeking to promote CHW models of primary care more broadly.

We conducted a systematic review of the academic literature on the scale-up and sustainability of CHW programs in LMICs. We conducted literature searches in MEDLINE, CINAHL, EMBASE, Web of Knowledge, PsycINFO, Global Health, EconLit, Social Sciences Citation Index, International Bibliography of Social Sciences, Social Services Abstracts, and Sociological Abstracts. We included any literature published since the earliest date indexed in each database up to the December 2010 search date. The keywords used to search for CHWs were “community health worker,” “community health aide,” “community worker,” “village health worker,” “barefoot doctor,” “health mediator,” “lay health worker,” “promotore de salud,” “peer counselor,” “community health agent,” and “agente comunitário de saúde.” The keywords used to search for scale-up and sustainability were “replication,” “scale up,” “sustainability,” “diffusion,” “dissemination,” “take up,” “innovation,” “diffusion of innovation,” “technology transfer,” “information dissemination,” “acculturation,” “assimilation,” and “fidelity.”

In screening the search results, we excluded articles that did not address CHWs, defined as “persons trained to assist professional health personnel in communicating with residents in the community concerning needs and availability of health services,” which is the definition for community health aides from the US National Library of Medicine’s Medical Subject Headings.23 In a post hoc analysis, we checked the robustness of our exclusion decisions against an alternative CHW definition from the World Health Organization2 and found that we had not excluded any article that would have been included under the alternative definition. For screening purposes, we defined sustainability as whether the CHW program itself operated over multiple years. We then used 4 questions to determine if an article fit our study objective of identifying factors associated with CHW program scale-up and sustainability:

    Does the article specifically address factors related to the diffusion, dissemination, or scale-up of the CHW program from one geography to another?

    Does the article specifically address factors related to the diffusion, dissemination, or scale-up of the CHW program from one target population to another (e.g., from newborns to children younger than 5 years) or from one health subsector to another (e.g., from HIV/AIDS to maternal and child health)?

    Does the article specifically address factors related to the large-scale implementation of the CHW program (e.g., nationwide implementation)?

    Does the article specifically address factors related to the sustainability of the CHW program over time (i.e., over multiple years)?

The database searches yielded 603 unique articles after we eliminated duplicates (see Figure 1 for sampling process). We screened the abstracts of all articles in this initial sample (n = 603). We excluded an article at the abstract screening stage if it did not address CHWs as defined in this study (n = 287) or if it did not discuss the scale-up or sustainability of CHWs (n = 208). We then screened the full text of those articles retained following abstract screening (n = 108). At the full-text screening stage, we excluded an article if it did not meet this study’s definition of CHWs (n = 19), if it did not address scale-up or sustainability of CHWs (n = 54), if it did not address LMICs (n = 7), if it was superficial in its discussion of CHWs or did not provide empirical evidence about the scale-up or sustainability of CHW programs (n = 3), if the article was subsequently retracted by its publishing journal (n = 1), if the source was redundant with another source already included in the final sample (n = 1), or if we were unable to obtain the full text of the article (n = 4). Following the full-text screening, we retained 19 articles for data extraction and analysis (appendix available as a supplement to this article at http://www.ajph.org).

Two research team members (EHB and SWP) independently conducted data extraction from the final sample of articles (n = 19) by using a preestablished data extraction form. For each article, the data extraction process identified the study design, the geographic location and type of health activities of the CHW intervention, the key findings related to scale-up and sustainability of the CHW intervention, and the degree of success in scaling up and sustaining the intervention. For purposes of data extraction, we defined CHW program success by using the question, “Did the CHW program spread to new user groups, operate at large scale, and/or operate over multiple years?” We classified an article as presenting a CHW program “success” if it reported few or no barriers to the scale-up or sustainability of the CHW program or some barriers that were surmounted, as “mixed success and failure” if it reported some barriers that were not overcome, and as “failure” if it reported that the CHW program did not scale up or was not sustained. The 2 team members harmonized differences in preliminary data extraction results through discussion to arrive at a final set of factors influencing the success of CHW program scale-up and sustainability. Enabling factors and barriers to scale-up and sustainability were then grouped into thematic categories, with disagreements resolved through negotiated consensus between the 2 team members.

The 19 articles in the final sample included studies representing a range of geographies, methods, and CHW program areas (Table 1). The final sample included studies from 16 countries, with sub-Saharan African countries having the greatest number of studies in the sample (n = 8). A majority of articles (n = 11) examined CHW programs focused on specific diseases such as HIV/AIDS, tuberculosis, malaria, river blindness, and pneumonia. Seven of the studies used quantitative methods with either cross-sectional (n = 4) or longitudinal (n = 3) designs. Six of the studies used qualitative methods, such as in-depth interviews, focus groups, or qualitative observation, and 4 articles presented retrospective case studies. The sample also included a commentary on one of the qualitative studies in our sample and a literature review of home-based care for people living with HIV.

Table

TABLE 1— Characteristics of Final Literature Review Sample Regarding Scale-Up or Sustainability of Community Health Worker Programs in Low- and Middle-Income Countries

TABLE 1— Characteristics of Final Literature Review Sample Regarding Scale-Up or Sustainability of Community Health Worker Programs in Low- and Middle-Income Countries

CharacteristicArticles With Characteristic, No.
Geographic area of CHW programa
 Sub-Saharan Africa: Zaire, Nigeria, Uganda, Ghana, Mozambique, Botswana, South Africa8
 South Asia: India, Pakistan, Nepal, Sri Lanka7
 Latin America and Caribbean: Brazil, Colombia, Haiti3
 Southeast Asia: Burma1
 East Asia: China1
 Low- and middle-income countries (general)1
Responsibility area of CHWs
 AIDS/HIV and/or tuberculosis5
 Maternal, child, and newborn health or family planning6
 River blindness3
 General2
 Malaria2
 Pneumonia1
Methods used in study
 Qualitative in-depth interview, focus group, or participant observation6
 Cross-sectional interviews or questionnaire4
 Case study4
 Pre–post intervention with comparison group2
 Pre–post intervention without comparison group1
 Thought piece using empirical evidence from other studies1
 Literature review regarding CHWs for home-based HIV care1
Success of scale-up or sustainability of CHW program
 Success6
 Mixed success and failure9
 Failure3
 Unclear1

Note. CHW = community health worker. The sample size was n = 19 articles.

aTotal is greater than 100% because 1 article covered 3 countries.

The data extraction process identified 23 enabling factors and 15 barriers to scale-up or sustainability of CHW programs, which we grouped into 3 thematic categories: (1) CHW program design and management, (2) community fit, and (3) integration with the broader environment (Table 2). The first category of CHW program design and management referred to not only the program’s objectives, structure, and components, but also the implementation of the program including ongoing management and supervision. The second category, community fit, referred to the degree to which the CHW program was compatible with community norms and was viewed as valuable by community members. The third category, integration of the CHW program with the broader environment, referred to the degree to which the CHW program was integrated with the health system and supported by parties outside the community, such as government and international aid donors.

Table

TABLE 2— Enabling Factors and Barriers for Scale-Up and Sustainability of Community Health Workers

TABLE 2— Enabling Factors and Barriers for Scale-Up and Sustainability of Community Health Workers

FactorsArticles Citing Factor, No.
Enabling factors
Program design and management
 Consistent management and supervision of CHWs and CHW program8
 Respected and motivated people were selected as CHWs6
 Intensive training (some articles specify ongoing or interval training)4
 Pay, stipend, or transportation support provided4
 Effective supply chain3
 Female involvement3
 CHW position was viewed as path to a job later2
 Data about program efficacy were based on credible trial1
 Charismatic initial leader of CHW program1
 CHWs were given preferential treatment or access to other health and development services (e.g., microcredit, clinician appointments at health clinic)1
 Flexible schedule for fulfilling CHW role1
 Narrowly focused set of tasks or role (disease-specific)1
 Regular monitoring and feedback; evaluation data used1
 Adaptation encouraged during early program phases1
 Program conducted in community with educated residents but limited employment options1
Community fit
 CHWs were recruited from or by the community8
 CHW approach was aligned with religious and moral norms of social service5
 Tasks of CHW viewed as valuable and focused by community5
 Strong community partnership, support, or champions, including cooperation of CHW program with existing community organizations2
 Adaptation to community needs2
Integration with the broader environment
 Integration or cooperation with broader health system or existing health care providers8
 Ministry of Health or other government support, as reflected in financial support and rewards for CHWs, advocacy for CHWs, or initiation of CHW program7
 CHWs coordinated their activities with nonhealth development programs1
Barriers
Program design and management
 Not enough pay or incentive for CHWs; CHWs wanted other employment, found other employment that paid more, or had other employment or work that competed with CHW role8
 Weak management and supervision of CHWs and CHW program6
 Poor training of CHWs4
 Lack of fidelity to recommended disease diagnosis and treatment practices2
 Work overload for CHWs because of bureaucratic procedures1
 Distance between houses and work sites1
 Lack of supplies needed by CHWs1
 Stress or low morale among CHWs1
Community fit
 Lack of community support or lack of perceived value of CHW5
 Lack of support from family members or spouses for CHWs’ role1
Integration with the broader environment
 CHW was not respected or not integrated in hierarchy of health system5
 Provider resistance to CHW role3
 Lack of or reduction in support from Ministry of Health, competition from other health programs2
 Political upheaval1
 Unpredictability or reduction of donor funding for CHW program1

Note. CHW = community health worker. The sample size was n = 19 articles.

Program Design and Management

The most frequently cited enabling factor in the program design and management category was consistent management and supervision of CHWs and the CHW program (n = 8). Examples of consistent management of CHWs included biweekly on-site supervision of female CHWs providing home-based neonatal care in Gadchiroli, India24; the use of standardized checklists for supervision of female CHWs providing childhood pneumonia treatment in Nepal25; and direct supervision by clinician leaders of CHW programs in South Africa.26 Enabling factors related to CHW selection included the selection of respected and motivated people such as teachers, retired health personnel, and educated youths (n = 6), and the selection of women (n = 3). Four articles identified intensive training, often interspersed with periods of practice in the community, as an enabling factor. We also identified several different strategies for motivating CHWs to perform their assigned tasks as enabling factors, including providing a salary, stipend, or transportation payment to CHWs (n = 4), as well as the potential for the CHW role to provide an opportunity for other paid employment later (n = 2). Other enabling factors identified in only a single source are listed in Table 2.

The most frequently identified barrier to scale-up and sustainability in the literature was insufficient pay or incentives for CHWs relative to other employment opportunities (n = 8). In many of the cases reviewed, CHWs were de facto volunteers working without any formal salary; the absence of sufficient financial remuneration and the availability of more lucrative employment alternatives was a cause of attrition among CHWs in such settings as India, Zaire, Mozambique, and Nigeria.27–30 For example, in Nigeria, community distributors of ivermectin who were farmers were more likely to remain in the program than those who were civil servants or students whose alternative employment options might take them away from the community.30 Some program design elements might also raise the implicit costs of CHW service, such as increasing the distance between houses or communities for which a CHW is responsible (n = 1). For example, CHWs in Nigeria who had to travel long distances between communities were more likely to attrit.30

Weak management and supervision of CHWs was also mentioned repeatedly in the literature as a barrier to the scale-up and sustainability of CHW programs (n = 6). In several cases, those in supervisory roles were not trained, accountable, or rewarded for their CHW supervision activities. For example, clinic-based health workers in Burma required additional training in time management and adult learning methods to take on new roles as CHW supervisors.31 In Botswana, the health facility staff who supervised CHWs assigned them additional facility-based responsibilities that detracted from CHWs’ community-based work.32 Similarly, in South Africa, respondents indicated that nurse supervisors were unfamiliar with community-based work and were unable to support CHWs in meaningful ways.26 In other cases, the CHW program presented a novel way of delivering health services for which the existing management practices of the health system were ill-suited. For example, a CHW program in China’s Yunnan province utilized participatory training methods that were not immediately understood or supported by local health officials.33 Other barriers in this category included poor training of CHWs (n = 4), CHWs’ lack of fidelity to recommended disease diagnosis and treatment practices (n = 2), lack of necessary supplies (n = 1), work overload for CHWs because of bureaucratic procedures (n = 1), and stress or low morale among CHWs (n = 1).

Community Fit

The most frequently cited enabling factor in the community fit category was the recruitment of CHWs from and by the community (n = 8), which enhanced CHWs’ credibility and accountability to the communities they served, whether the community was a target population, a geographically delimited territory, or a kinship group.30,31,34–38 For example, in Burma, clinic-based health care workers recruited local residents, such as teachers and retired health workers, to serve as CHWs in politically sensitive conflict zones to which clinic workers could not travel.31 In Uganda, community-directed distributors of ivermectin were selected by members of their kin group and assigned to provide services to their kin group; this use of existing community social structures reduced the practice of distributors charging fees for their services and allowed the program to achieve its coverage target.34,35 Another enabling factor in this category included the alignment of the CHW approach with religious or moral norms of social service (n = 5), such as in Nepal, where CHWs believed their service to be contributing toward their dharma, or religious merit.39,40 Defining the scope of CHW tasks was also an opportunity to enhance community fit, whether by giving CHWs tasks that were seen as valuable by the community (n = 5) or adapting the CHW model to community needs (n = 2). Introducing the CHW program through existing community organizations or with the support of a traditional community leader was a final enabling factor in this category (n = 2).

We identified 2 barriers to scale-up and sustainability in the community fit category. The most frequently cited barrier was the lack of community support or value for the CHW (n = 5), such as in Zaire where the community was dissatisfied that CHWs provided only preventative rather than treatment services for malaria.29 The second barrier was lack of support from the CHW’s family members (n = 1), identified in a program in India in which CHWs dropped out of the program because their CHW duties left them with inadequate time for other household or family obligations.27

Integration With the Broader Environment

The most frequently cited enabling factor in this category was CHW integration or cooperation with the broader health system and existing health care providers (n = 8). Examples of integration included CHWs reporting data on pneumonia case diagnosis to Nepal’s National Health Information System,25 CHWs sharing information from their home visits with primary health care unit staff in Brazil’s Family Health Program,38 and CHWs in Botswana working alongside professional nurses in health facilities and enjoying health system benefits such as government pensions.32 Integration with the health system was also vital to the scale-up of vitamin A distribution by CHWs in Mozambique and Nepal; in each case, the country’s Ministry of Health managed CHW training and involved district or local Ministry of Health staff in oversight and supervision.25,28 Other enabling factors in this category were Ministry of Health or other government support manifested in financing or advocacy (n = 7) and coordination with nonhealth development programs (n = 1).

The most frequently cited barrier in this category was that CHWs were not respected or integrated into the hierarchy of the health system (n = 5). For example, in South Africa, the government provided funding to nongovernmental organizations to employ CHWs rather than incorporating CHWs into the public sector workforce; in this context, CHWs working in HIV/AIDS prevention and care in the Free State reported feeling exploited by health care facility staff and the Department of Health.41 Other barriers in this category were health care provider resistance to CHWs (n = 3), reduced prioritization by the Ministry of Health because of competition from other health programs (n = 2), general political upheaval in the country (n = 1), and the unpredictability or loss of external donor funding (n = 1).

The literature review results suggest several implications for policy and program efforts to scale up and sustain CHW programs in LMICs. First, CHW programs must be designed to be acceptable to the specific communities served. Developing CHW programs to fit the community requires understanding not only a community’s objective health needs but also its perceptions of which health services are most valuable, such as curative care services rather than preventive education services.1,32 Thus, CHW programs may need to start with “quick wins” and visible life-saving interventions such as vitamin A, obstetric care, or pneumonia treatment of infants to gain credibility and secure an audience for preventive activities such as counseling on reproductive health and nutrition.

Second, mechanisms for maintaining morale and motivation of CHWs need to be built into the CHW program, which will likely involve both material and social incentives. The academic and gray literature suggests that there is no single benefit scheme that will enable CHW program scale-up and sustainability in all contexts; multiple types of benefit schemes are possible, ranging from unpaid volunteers to salaried government employees. Setting stipends at levels commensurate with what CHWs might earn through other local employment opportunities was one strategy adopted to address this challenge in India.24 The literature also repeatedly identified the importance of providing CHWs with some ongoing form of nonmonetary motivation, typically in the form of social recognition.24,25,32,34,39 The gray literature provided additional examples of nonmonetary incentives provided to CHWs, including exemption of CHWs from community labor requirements, regular festivals held by the community to celebrate CHWs’ work, preferential access to microcredit, health care services, in-kind gifts such as foodstuffs, and special forms of identification such as badges or t-shirts.1,2,42 Appropriately designing CHWs’ scope of work to fit with the level of financial and human resources available for training, supervision, and incentives is another approach recommended to maintain CHW morale and motivation.1,2 For example, to avoid CHW apathy and attrition, CHW tasks may need to be limited to a level that can be effectively supervised and rewarded, given the program’s budget.

Third, our findings suggest that successful CHW programs have been able to cultivate support and to withstand competition in the broader political and economic environment. Strategies to withstand competition and enhance support may include documenting improvements in service delivery and population health attributed to the CHW program, advocating regulations that restrict competition from other service providers (e.g., unlicensed pharmacies), leveraging the CHW platform to secure funding from other health and development programs, and developing funding mechanisms to which multiple parties contribute (e.g., community, local government, central government) to reduce reliance on a single funding source. Local government, national government, and nongovernmental organizations were the most frequently mentioned sources of support in the CHW program’s broader environment. Although our review of the literature found that the unpredictability or reduction of foreign donor support was a barrier to CHW program scale-up and sustainability, we found no evidence that the provision of foreign donor support enabled sustainability.

Fourth, the evidence highlights that CHW programs must find the right balance between community fit and integration with the broader environment in a context-appropriate manner during both design and implementation, which may require adaptation throughout the life of the program. The literature suggests that CHW approaches are successful if they are at once strongly connected to the community and also have a clearly defined role and relationship with the formal health system that is supported by government and other health service providers. Integration of CHWs with the existing health system can provide increased investment, training, coordination, and motivation for CHWs because their role may open future employment opportunities. Close ties of CHWs with the health system may also enhance the community’s perception of CHWs’ competence. Nevertheless, such ties may also alienate the CHW from his or her community or cause the community to lose trust in the CHW. For example, studies in the gray literature have found that CHWs’ affiliation with government services may have negative connotations for historical reasons,6 or CHWs may be perceived as government employees when they receive a regular government salary, which could reduce CHWs’ acceptance in the community.1,42 Managing this tension may require adjustments in the design of CHW incentives, the criteria for CHW selection, or the content of CHW training, with the right balance varying by context.

Finally, policymakers, practitioners, and researchers seeking to scale up and sustain CHW programs should develop CHW programs with attention to the 3 focal areas identified from the literature: (1) effective design and management of the CHW program, (2) fit of the CHW program with the specific communities served, and (3) integration of the CHW program with the broader political, economic, and health system environment (see the box on the next page). Although promoting enabling factors and avoiding barriers within each of these 3 categories may seem straightforward, the literature suggests that this process is complex and that some degree of failure is common. Designing the right mix of CHW selection criteria, task assignments, and motivational strategies at the start of a program is challenging and initial designs may require revision over time. Policymakers and program managers should therefore remain attentive to these issues and flexible to adapt to changing environments and constraints throughout the initial implementation and ongoing management of such programs.

Questions to Guide Development of Community Health Worker Programs in 3 Focal Areas
Table
Table
Program design and management
1. Are the community health worker (CHW) selection criteria designed to attract respected and motivated individuals in the community with few competing responsibilities or job opportunities?
2. Is the combination of financial, in-kind, and social benefits for CHWs appropriate
a. To deter trained CHWs from leaving the program for other jobs?
b. To compensate CHWs for the amount of time required for their tasks, including travel?
c. Given the resource limitations and time horizon of the program?
3. Will CHW training incorporate opportunities for practice-based learning in the community?
4. Is regular supervision affordable and feasible given the number of supervisors and those supervisors’ existing responsibilities?
5. Is there a process in place to collect data on CHW program performance and to use those data in program monitoring, evaluation, and decision-making?
6. Is there a process in place for the CHW program to learn from failures and adapt over the life of the program?
Community fit
7. Are the tasks that CHWs will be performing viewed as valuable by the community? Do these tasks respond to the community’s priorities for health services?
8. How will the community be involved in CHW selection?
9. Will integration with formal health care services (e.g., CHWs working in a government health clinic or receiving a government salary) be viewed favorably by the community?
Integration with the broader environment
10. How are CHW activities different from those of existing health care providers? How will CHWs interact with (i.e., exchange information and resources with) the health care system?
11. How will political support from existing health care providers such as doctors and nurses be secured and sustained?
12. How will political support from relevant government agencies be secured and sustained?
13. How will the CHW program be funded initially and over the longer term?
14. Has a funding mechanism been established to which multiple parties will contribute?
15. Are there other programs or groups that would compete financially or politically with CHWs? What is the comparative advantage of CHWs relative to these competitors?
Limitations

These policy and practice recommendations should be interpreted in light of several limitations of the study. First, many of the articles in our sample did not describe all stages of the scale-up process in equivalent levels of detail; for example, an article might discuss the early planning stages or final operational results of a CHW program but not the intermediate process of introducing CHW programs to new communities. Second, there were only 2 CHW programs (Female Health Volunteers in Nepal and Community Directed Distributors of Ivermectin in Uganda) that were discussed in more than 1 article in our sample. For those CHW programs described in only a single article, we were unable to triangulate data from multiple sources to confirm our identification of enabling factors and barriers. Our conclusions should therefore be understood in the context of the evidence made available in our sample articles, which may not be a comprehensive description of all aspects of the CHW programs studied.

Third, it is possible that our literature sample may be sensitive to the choice of definition used for CHW. We have confirmed the robustness of our results to an alternative CHW definition from the World Health Organization2 in a post hoc analysis that reexamined all 304 articles that had been excluded on this basis; we found that no article excluded under our definition would have been included under the alternative definition. Following Scheirer and Dearing18 we also note that our definition of sustainability captures only 1 dimension of CHW program continuation; we used this definition because it offered a minimum criterion that could be consistently applied in screening the search results. Fourth, we were unable to obtain 4 sources identified in our literature search. We cannot know if these excluded articles present data that differ systematically from those included in the review, although they represent less than 1% of the more than 600 articles retrieved from our database searches.

Finally, as a systematic review of the academic literature, this study did not include data that were unpublished or evidence from the gray literature, both of which may have valuable lessons learned, including relating to barriers that ultimately lead to program failure. Our results may therefore overrepresent features of CHW programs that can be measured and written about more easily. An implication of our study is that rigorous evaluation of CHW approaches needs to continue and accelerate to support evidence-based programming in this area.

Conclusions

Our review of the literature suggests several gaps that future research might address. First, it may be important to differentiate between processes that allow CHW programs to be implemented at a large (e.g., national) scale from inception and those that expand a CHW program from a smaller to a larger number of user groups. Second, it would be helpful to gain further understanding of best practices in assessing community receptivity and the degree of support in the broader environment before program design. An open question is whether the instances of failed scale-up because of poor community fit or limited integration with the health system could be remedied with better situational assessment tools or by more explicit use of this assessment evidence to inform program design.

A third area for future research is the question of how to sustain financial support for the CHW program over time. Of the examples of successful large-scale CHW programs in the literature reviewed here, only 1 (Nepal) has been sustained without substantial ongoing financial investment by a government or a national-level nongovernmental organization, suggesting that sustained investment by an entity external to the community and the CHWs themselves is key. Understanding why some governments and nongovernmental organizations sustain investment in CHW programs over time whereas others do not merits further inquiry. Finally, future research should consider other aspects of CHW program sustainability in addition to program duration to assess whether different sets of factors influence different measures of sustainability. These and other areas of future research can support the scale-up and sustainability of CHW programs and help realize the potential of this service delivery approach to improve health in LMICs.

Acknowledgments

The research for this study was supported by a grant from the Bill & Melinda Gates Foundation (contract 18542 with Yale University).

Note. The funder had no role in study design, data collection and analysis, decision to publish, or preparation of the article.

Human Participant Protection

Institutional review board approval was not needed for this study because the study did not involve human participants.

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Sarah Wood Pallas, MPhil, Dilpreet Minhas, MPH, Rafael Pérez-Escamilla, PhD, Lauren Taylor, MPH, Leslie Curry, PhD, and Elizabeth H. Bradley, PhDSarah Wood Pallas is with Yale School of Public Health, New Haven, CT. Dilpreet Minhas and Lauren Taylor are with Yale Global Health Leadership Institute. Rafael Pérez-Escamilla is with Office of Community Health, Yale School of Public Health. Leslie Curry and Elizabeth H. Bradley are with Yale School of Public Health and Yale Global Health Leadership Institute. “Community Health Workers in Low- and Middle-Income Countries: What Do We Know About Scaling Up and Sustainability?”, American Journal of Public Health 103, no. 7 (July 1, 2013): pp. e74-e82.

https://doi.org/10.2105/AJPH.2012.301102

PMID: 23678926