Community health workers in low- and middle-income countries: what do we know about scaling up and sustainability?

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.

[1]  M. A. Scheirer,et al.  An agenda for research on the sustainability of public health programs. , 2011, American journal of public health.

[2]  B. Kohrt,et al.  Culture, status and context in community health worker pay: pitfalls and opportunities for policy research. A commentary on Glenton et al. (2010). , 2010, Social science & medicine.

[3]  Virginia Berridge,et al.  The emergence of community health worker programmes in the late apartheid era in South Africa: An historical analysis , 2010, Social science & medicine.

[4]  A. Wringe,et al.  Delivering comprehensive home-based care programmes for HIV: a review of lessons learned and challenges ahead in the era of antiretroviral therapy. , 2010, Health policy and planning.

[5]  I. Scheel,et al.  The female community health volunteer programme in Nepal: decision makers' perceptions of volunteerism, payment and other incentives. , 2010, Social science & medicine.

[6]  Claire Glenton,et al.  Lay health workers in primary and community health care for maternal and child health and the management of infectious diseases. , 2010, The Cochrane database of systematic reviews.

[7]  I. Ahluwalia,et al.  Sustainability of community-capacity to promote safer motherhood in northwestern Tanzania: what remains? , 2010, Global health promotion.

[8]  B. Kirkup,et al.  Scaling up Health Service Delivery – From pilot innovations to policies and programmes , 2009 .

[9]  M. E. Hoque,et al.  Effect of the Integrated Management of Childhood Illness strategy on childhood mortality and nutrition in a rural area in Bangladesh: a cluster randomised trial , 2009, The Lancet.

[10]  N. Ford,et al.  An integrated approach of community health worker support for HIV/AIDS and TB care in Angónia district, Mozambique , 2009, BMC international health and human rights.

[11]  A. Richards,et al.  Internally displaced human resources for health: Villager health worker partnerships to scale up a malaria control programme in active conflict areas of eastern Burma , 2009, Global public health.

[12]  E. Schouten,et al.  Community health workers for ART in sub-Saharan Africa: learning from experience – capitalizing on new opportunities , 2009, Human resources for health.

[13]  P. Lawton,et al.  Sustainability science: an integrated approach for health-programme planning , 2008, The Lancet.

[14]  Robert E Black,et al.  Effect of community-based newborn-care intervention package implemented through two service-delivery strategies in Sylhet district, Bangladesh: a cluster-randomised controlled trial , 2008, The Lancet.

[15]  Y. Mukadi,et al.  Adherence Support Workers: A Way to Address Human Resource Constraints in Antiretroviral Treatment Programs in the Public Health Setting in Zambia , 2008, PloS one.

[16]  D. van Rensburg,et al.  Community health workers and the response to HIV/AIDS in South Africa: tensions and prospects. , 2008, Health policy and planning.

[17]  S. Hodgins,et al.  From research to national expansion: 20 years' experience of community-based management of childhood pneumonia in Nepal. , 2008, Bulletin of the World Health Organization.

[18]  F. Richards,et al.  Factors affecting the attrition of community-directed distributors of ivermectin, in an onchocerciasis-control programme in the Imo and Abia states of south–eastern Nigeria , 2008, Annals of tropical medicine and parasitology.

[19]  E. Stotz,et al.  O Trabalho dos agentes comunitários de saúde: entre a mediação convencedora e a transformadora , 2008 .

[20]  A. Haines,et al.  Achieving child survival goals: potential contribution of community health workers , 2007, The Lancet.

[21]  N. Edwards,et al.  Sustainability: The Elusive Dimension of International Health Projects , 2006, Canadian journal of public health = Revue canadienne de sante publique.

[22]  M. Zwarenstein,et al.  Lay health worker intervention with choice of DOT superior to standard TB care for farm dwellers in South Africa: a cluster randomised control trial. , 2005, The international journal of tuberculosis and lung disease : the official journal of the International Union against Tuberculosis and Lung Disease.

[23]  F. Richards,et al.  Community‐directed interventions strategy enhances efficient and effective integration of health care delivery and development activities in rural disadvantaged communities of Uganda , 2005, Tropical medicine & international health : TM & IH.

[24]  A. Bang,et al.  Home-Based Neonatal Care: Summary and Applications of the Field Trial in Rural Gadchiroli, India (1993 to 2003) , 2005, Journal of Perinatology.

[25]  U. Ewald,et al.  Postnatal peer counselling on exclusive breastfeeding of low-birthweight infants: a randomized, controlled trial. , 2005, Acta paediatrica.

[26]  P. Farmer,et al.  Scaling-up HIV treatment programmes in resource-limited settings: the rural Haiti experience , 2004, AIDS.

[27]  Eric Swedberg,et al.  A methodological approach and framework for sustainability assessment in NGO-implemented primary health care programs. , 2004, The International journal of health planning and management.

[28]  D. Celentano,et al.  Training outreach workers for AIDS prevention in rural India: is it sustainable? , 2003, Health policy and planning.

[29]  Robert E Black,et al.  Effect of pneumonia case management on mortality in neonates, infants, and preschool children: a meta-analysis of community-based trials. , 2003, The Lancet. Infectious diseases.

[30]  F. Richards,et al.  Community-directed health (CDH) workers enhance the performance and sustainability of CDH programmes: experience from ivermectin distribution in Uganda , 2001, Annals of tropical medicine and parasitology.

[31]  P. Winch,et al.  Community health worker incentives and disincentives: how they affect motivation retention and sustainability. , 2001 .

[32]  R. Morrow,et al.  Teaching mothers to provide home treatment of malaria in Tigray, Ethiopia: a randomised trial , 2000, The Lancet.

[33]  M. Shediac-Rizkallah,et al.  Planning for the sustainability of community-based health programs: conceptual frameworks and future directions for research, practice and policy. , 1998, Health education research.

[34]  I T Olsen,et al.  Sustainability of health care: a framework for analysis. , 1998, Health policy and planning.

[35]  P. van der Stuyft,et al.  Using community health workers for malaria control: experience in Zaire. , 1996, Bulletin of the World Health Organization.

[36]  S. Wibulpolprasert.  Community financing: Thailand's experience , 1991 .

[37]  L. Gilson,et al.  National Community Health Worker Programs: How Can They Be Strengthened? , 1989, Journal of public health policy.