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Am J Public Health. 2013 Jul;103(7):e74-82. doi: 10.2105/AJPH.2012.301102. Epub 2013 May 16.

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

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  • 1Yale School of Public Health, New Haven, CT 06520-8034, USA.



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).


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.


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.


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.

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