摘要：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.
