Accelerating Best Practices in Peer Support Around the World

Scale Up and Sustainability of CHW Programs

Melissa Mayer, MPH Candidate

Pallas and colleagues (2013) systematically reviewed the evidence for sustainability and scale-up of community health worker (CHW) programs in low- and middle-income countries, revealing several major challenges to systematically evaluating scale-up and sustainability efforts. Definitions of sustainability vary widely, and comparing scale-up efforts across programs, sites, and countries is difficult. Comparability across CHW programs and countries is particularly challenging; a program considered large-scale and sustained in one country might be viewed as small-scale or short-term in another setting. With these challenges in mind, the researchers developed four questions to guide selection of relevant studies:

  1. Does the article specifically address factors related to the diffusion, dissemination, or scale-up of the CHW program from one geographical setting to another?
  2. 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)?
  3. Does the article specifically address factors related to the large-scale implementation of the CHW program (e.g., nationwide implementation)?
  4. Does the article specifically address factors related to the sustainability of the CHW program over time (i.e., over multiple years)?

Literature Search

A database search found 603 articles, of which 108 had abstracts that met inclusion criteria. Of these 108 abstracts identified, 19 were determined to be appropriate for the study after analyzing the full text.

In determining success or failure of scale-up or sustainability efforts, the researchers asked, “Did the CHW program spread to new user groups, operate at large scale, and/or operate over multiple years?” Articles in which a CHW program reported few or no barriers to the scale-up or sustainability of the CHW program or some barriers that were surmounted were deemed a “success.” Articles that reported some barriers that were not overcome were deemed “mixed success and failure”, and articles that reported that the CHW program did not scale up or was not sustained were classified as “failure.”

Enabling Factors and Barriers to Scale-Up and Sustainability

In all, 23 enabling factors and 15 barriers to CHW program scale-up and sustainability were extracted from the 19 articles. The authors grouped these into three main categories and identified the most common enabling factors and barriers in each category:

(1) CHW program design and management

  • Most common enabling factor: Consistent management and supervision
  • Most common barrier: insufficient pay or incentives for CHWs relative to other employment opportunities

(2) Community fit

  • Most common enabling factor:  recruitment of CHWs from and by the community
  • Most common barrier:  lack of community support or value for the CHW

(3) Integration with the broader environment

  • Most common enabling factor: CHW program integration or cooperation with healthcare providers and/or health system
  • Most common barrier:  Lack of respect for CHWs or lack of integration into the health system


Pallas et al. have identify some common findings across scale-up and sustainability studies of CHW programs in low- and middle-income countries, as well as clear gaps in the research that future studies may address.

CHW programs must be acceptable to the local community. Acceptability should be based on the expressed importance of various health concerns by the local community, rather than just “objective health needs.”

Motivating CHWs is important, but no single motivating mechanism works universally across CHW programs. Rather, CHW program planners may consider a variety of monetary and social benefits (including community recognition, preferential access to microcredit, etc.) to encourage continued CHW participation.

While it is clear that outside funding sources are nearly universally required for sustainability of CHW programs, it is less clear from this study why some CHW programs receive funding while others do not. The authors invite researchers to inquire further on this topic.

Pallas et al. advise CHW program planners to consider the three main areas in which they classified their results:  (1) management and design of the CHW program, (2) fit of the CHW program with the community served, and (3) integration with the broader political, economic, and health system environment. However, they acknowledge that some degree of program failure is common and that there are many paths to CHW program success, as evident by the wide range of barriers and facilitating factors identified in this study.

Some degree of program failure is common and there are many paths to program success…

The authors also leave us with some concrete questions, developed from the authors’ review of barriers and facilitators to scale-up and sustainability. This review provides a strong foundation for those program planners, policy makers, and researchers grappling with questions about how to plan for and evaluate CHW program sustainability and scale-up.


Pallas SW, Minhas D, Pérez-Escamilla R, Taylor L, Curry L, Bradley EH. Community health workers in low- and middle-income countries: what do we know about scaling up and sustainability? Am J Public Health. 2013 Jul;103(7):e74-82. Available at:

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