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Harmonizing community-based health worker programs for HIV: a narrative review and analytic framework De Neve, Jan-Walter; Boudreaux, Chantelle; Gill, Roopan; Geldsetzer, Pascal; Vaikath, Maria; Bärnighausen, Till; Bossert, Thomas J Jul 3, 2017

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REVIEW Open AccessHarmonizing community-based healthworker programs for HIV: a narrative reviewand analytic frameworkJan-Walter De Neve1,2* , Chantelle Boudreaux2, Roopan Gill3, Pascal Geldsetzer2, Maria Vaikath2, Till Bärnighausen1,2,4and Thomas J. Bossert2*AbstractBackground: Many countries have created community-based health worker (CHW) programs for HIV. In most ofthese countries, several national and non-governmental initiatives have been implemented raising questions ofhow well these different approaches address the health problems and use health resources in a compatible way.While these questions have led to a general policy initiative to promote harmonization across programs, there is aneed for countries to develop a more coherent and organized approach to CHW programs and to generateevidence about the most efficient and effective strategies to ensure their optimal, sustained performance.Methods: We conducted a narrative review of the existing published and gray literature on the harmonization ofCHW programs. We searched for and noted evidence on definitions, models, and/or frameworks of harmonization;theoretical arguments or hypotheses about the effects of CHW program fragmentation; and empirical evidence.Based on this evidence, we defined harmonization, introduced three priority areas for harmonization, and identifieda conceptual framework for analyzing harmonization of CHW programs that can be used to support theirexpanding role in HIV service delivery. We identified and described the major issues and relationships surroundingthe harmonization of CHW programs, including key characteristics, facilitators, and barriers for each of the priorityareas of harmonization, and used our analytic framework to map overarching findings. We apply this approach ofCHW programs supporting HIV services across four countries in Southern Africa in a separate article.Results: There is a large number and immense diversity of CHW programs for HIV. This includes integration of HIVcomponents into countries’ existing national programs along with the development of multiple, stand-alone CHWprograms. We defined (i) coordination among stakeholders, (ii) integration into the broader health system, and (iii)assurance of a CHW program’s sustainability to be priority areas of harmonization. While harmonization is likely acomplex political process, with in many cases incremental steps toward improvement, a wide range of facilitatorsare available to decision-makers. These can be categorized using an analytic framework assessing the (i) healthissue, (ii) intervention itself, (iii) stakeholders, (iv) health system, and (v) broad context.Conclusions: There is a need to address fragmentation of CHW programs to advance and sustain CHW roles andresponsibilities for HIV. This study provides a narrative review and analytic framework to understand the process bywhich harmonization of CHW programs might be achieved and to test the assumption that harmonization isneeded to improve CHW performance.Keywords: Community health workers, Harmonization, Low- and middle-income countries, HIV* Correspondence: jwdeneve@mail.harvard.edu; tbossert@hsph.harvard.edu1Institute of Public Health, Heidelberg University, Heidelberg 69120, Germany2Department of Global Health and Population, Harvard T.H. Chan School ofPublic Health, 665 Huntington Avenue, Boston, MA 02115, United States ofAmericaFull list of author information is available at the end of the article© The Author(s). 2017 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, andreproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link tothe Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.De Neve et al. Human Resources for Health  (2017) 15:45 DOI 10.1186/s12960-017-0219-yBackgroundAs the HIV epidemic matures, the emphasis ofcommunity-based health worker (CHW) programs istransitioning to long-term HIV services, and the associ-ated health system demands have grown [1]. With healthworkforce constraints, the World Health Organization(WHO) has promoted “task shifting” toward less costlyand more available health personnel [2]. One implicationof this has been the rapid expansion of both nationaland donor-driven/supported CHW programs, which hasoccurred in parallel with a shift in CHW responsibilitiesto include activities beyond health promotion. There isan increasing expectation that CHWs will participate indisease surveillance and data collection activities, as wellas play an active role in the diagnosis and referral forcare, and in efforts to roll out anti-retroviral treatment(ART) coverage [3]. CHW programs have been suggestedto play a “transformative” role in scaling up HIV servicesfor achieving the 90-90-90 treatment goals—includingthrough community-level “test-and-treat” initiatives [4–9],differentiated care models [10], and there have been callsto dramatically increase the number of CHWs in HIV en-demic settings [11–13].However, as this transition to greater responsibility forCHWs has occurred, these cadres and the broader“community health system” have generally received in-creased scrutiny [14, 15]. Researchers and policy-makershave noted a number of challenges to the implementa-tion of task shifting for HIV treatment and care, includ-ing the integration of CHWs into national healthsystems [3] and political and financial sustainability ofCHW programs for HIV [16]. An important issue is thedynamic and utilization across national cadres and thedonor-driven/supported cadres that were created forvertical programs such as HIV. As the resources aimedat (and reliance upon) these cadres increase, there is anincreasing need to consider how to streamline CHW-ledHIV activities to lend greater effectiveness and efficien-cies [17]. In addition, heavy reliance on donor fundingfor many CHW cadres supporting HIV service deliveryraises urgency for greater consideration of long-termsustainability [18–20].A range of policy initiatives have increasingly pro-moted alignment of CHW initiatives [21–24]. In 2013,the Global Health Workforce Alliance (GHWA), analliance of government leaders, donors, health workers,and civil society—facilitated by the United States Agencyfor International Development (USAID), the NorwegianGovernment’s agency for development (NORAD), andmembers of the Frontline Health Workers Coalition(FHWC)—announced their commitment for the needto “harmonize” support of community health workers[22, 25]. The announcement built on three guidingprinciples for the harmonization of CHW programs(the “three ones”): one national strategy, one author-ity, and one monitoring and accountability framework[22]. This public commitment signaled a broad argu-ment for the need to develop a coherent and harmo-nized approach to community-based health workersupport within countries. The CHW commitmenthelped bring critical attention to the harmonization ofCHW programs for HIV because of the history ofCHW cadre creation specific for HIV and expansionof cadre responsibilities with the push for achieving90-90-90 goals [9]. Harmonization of CHW programsfor HIV may have been further impeded by an ab-sence of an understanding of key harmonization is-sues and history of development of programs underan emergency response for HIV. Few systematic ef-forts have been undertaken to understand the processby which harmonization of CHW programs might beachieved, and there is a lack of a common languageand conceptual framework to inform future researchefforts and policy (see Additional file 1 for additionalbackground information on CHWs and CHW pro-gram fragmentation).To address this gap in the literature, the narrative re-view and analytic framework in this study have beencompiled to build upon these existing efforts and guidethe development of country case studies to investigatefactors for harmonization of community-based healthworkers for HIV in Lesotho, Mozambique, South Africa,and Swaziland (De Neve JW, Garrison-Desany H,Andrews KA, Sharara N, Boudreaux C, Gill R, GeldsetzerP, Vaikath M, Bärnighausen T, Bossert TJ. Harmonizationof community health worker programs for HIV: a four-country qualitative study in Southern Africa, submitted).First, we further define the concept of harmonization,introduce three priority areas for harmonization (coordi-nation, integration, and sustainability), and include anoverview of factors thought to facilitate or hinder each.We then provide an analytic framework, first introducedby Atun et al. in 2010 [26], and incorporate the three pri-ority areas in the framework.MethodsDocumentsWe conducted a narrative review of the existingpublished and gray literature. We conducted multiplerounds of literature searches in PubMed and GoogleScholar. The search strategy was conducted iterativelyusing English search terms, beginning with broad searchterms (e.g., “fragmentation,” “community health workerprograms”) and progressively expanded based on find-ings (e.g., “coordination,” “integration,” “sustainability”).We supplemented search results with several relevantpublications previously known to the study team, includ-ing previous literature reviews [27–29] and seminalDe Neve et al. Human Resources for Health  (2017) 15:45 Page 2 of 10works [20, 30, 31] on the harmonization of healthprojects and programs. The search strategy also includedmanual searches of bibliographies of previous literatureon health program-related harmonization. We searchedarticles regardless of date of publication. We first arbi-trarily selected and reviewed the full-text versions of sev-eral articles from diverse fields with our search terms inthe title to get a sense of the range of definitions andconceptions of the term in the social sciences. We thenreviewed the first 100 titles of articles which includedour search terms anywhere in the text. We reviewed thefull-text versions of all articles whose primary focus wasrelated to the harmonization of CHW programs. In total,we reviewed the full-text versions of approximately 50articles, book chapters, and case studies. We prioritizedarticles for analysis that focused on issues related toharmonization of CHW programs and CHW-led HIV ser-vices in low- and middle-income settings. In our full-textreview, we searched for and noted evidence on three cat-egories: (i) definitions, models, and/or frameworks relatedto harmonization; (ii) theoretical arguments or hypothesesabout the effects of CHW program fragmentation and/orharmonization; and (iii) empirical evidence.AnalysisOur analysis of documents proceeded in three steps.First, we further defined the concept of harmonizationand identified three priority areas for the harmonizationof CHW programs based on two previous articles relatedto harmonization. Specifically, we built on a previousmulti-country study on the sustainability of donor-supported health projects by Bossert [31] and on aGHWA report on the coordination, integration, and sus-tainability of CHW programs [22]. These articles pio-neered work on harmonization of donor-supported healthprograms and informed our identification and definitionof priority areas for CHW program harmonization. In oursynthesis of reviewed documents, we then described majorissues and relationships surrounding these priority areasfor harmonization of CHW programs, including key ad-vantages, disadvantages, facilitators, and barriers for eachof the three areas. We focused our synthesis on CHW-leddelivery of HIV services such as HIV education, HIV test-ing campaigns, ART adherence counseling and monitor-ing, home-based care delivery, and community supply ofART. When evidence on HIV services specifically wasscarce, we additionally aimed to describe evidence onCHW programs that offered related health services(such as sexual and reproductive health services [32]).Second, in the absence of a comprehensive frameworkfor harmonization, we extended an existing frame-work for the integration of health services, previouslysuggested by Atun et al. [26], to our three priorityareas of harmonization. Third, we used this analyticframework to map findings from our narrative review. Asnoted above, this analysis serves as a basis for a separate,empirical study in Southern Africa aimed at understand-ing how the harmonization of existing CHW programssupporting HIV might be achieved (De Neve JW,Garrison-Desany H, Andrews KA, Sharara N, BoudreauxC, Gill R, Geldsetzer P, Vaikath M, Bärnighausen T,Bossert TJ: Harmonization of community health workerprograms for HIV: a four-country qualitative study inSouthern Africa, submitted). Our emphasis has been toclearly define harmonization of CHW programs for HIV;to identify priority areas, a set of factors likely to facilitateor inhibit each; and to suggest an analytic framework thatpermits a systematic assessment of existing CHW pro-grams for HIV.ResultsDefinition and three priority areas for harmonizationBased on our review, we define “harmonization” broadlyas public and non-state programs and initiatives that arecompatible with larger health systems and the collabor-ation between all involved actors to contribute togetherto a comprehensive and sustainable systems approach inadvocacy, programming, funding, implementing, moni-toring, and building the knowledge base for CHW pro-grams for HIV [22]. Harmonization of CHW programsfor HIV can occur along a number of dimensions. Weidentified coordination among development partners andother stakeholders, integration into the broader healthsystem, and assurance of a CHW program’s sustainabil-ity to be the priority areas (see Table 1 for an overview).Aid coordination is defined as “any activity or set of ac-tivities, formal or non-formal, at any level, undertakenby the recipient in conjunction with donors, individuallyor collectively, which ensures that foreign inputs to thehealth sector enable the health system to function moreeffectively…” [22]. Among CHW programs, coordinationefforts seek to reduce duplication, fragmentation,Table 1 Three priority areas for harmonization of CHW programs1. Coordination: Activities undertaken to ensure that inputs into thehealth sector enable the health system to function more effectivelyand in accordance with local priorities over time [61]. Among CHWprograms, coordination efforts seek to reduce duplication,fragmentation, confusion created by competing models, andoverlap of responsibilities of differently trained CHWs in the samegeographic areas [22, 26].2. Integration: Absorption of CHW programs into existing networks oflarger health systems such as the Ministries of Health or largeprivate providers. Integration is defined as the extent, pattern, andrate of adoption and eventual assimilation of health interventionsinto each of the critical functions of the health system [26].3. Sustainability: Continued use of program activities for thelong-term achievement of desirable program outcomes [18].Sustainability is a key element of CHW-led HIV services which aretransitioning out of vertically funded sources [33–35].De Neve et al. Human Resources for Health  (2017) 15:45 Page 3 of 10confusion created by competing models, and overlap ofresponsibilities of differently trained CHWs in the samegeographic areas [22, 26]. Integration is defined as “theextent, pattern, and rate of adoption and eventual as-similation of health interventions into each of the criticalfunctions of a health system” [26]. Integration refers tothe absorption of CHW programs into existing networksof larger health and/or community health systems, pri-marily the Ministries of Health or large private providers(non-governmental or commercial). Sustainability is de-fined as “the continued use of program components andactivities for the continued achievement of desirableprogram and population outcomes” [18]. Sustainability isa key element for CHW programs supported by transi-tioning donor funding, such as PEPFAR [33, 34] or theGlobal Fund [35]. We explore in detail possible advan-tages and mediators of each of these priority areas ofharmonization below.Area of harmonization: coordinationCoordination seeks to reduce duplication, fragmentation,confusion created by competing models, and overlap ofresponsibilities of differently trained CHWs, while build-ing important synergies across CHW programs. Thismay be particularly productive in contexts with multiplefaith-based, private, or other non-government CHWprograms. A recent review of CHW-led ART programsin sub-Saharan Africa, for instance, identified at least sixdifferent CHW programs in Ethiopia, six in Malawi, andeight in Uganda [36]. In such settings, it is likely thateach program has its own contracts and arrangementsfor health workers in their programs and parallel pro-jects are funded, delivered, and reported separately [22].Coordination among partners may reduce duplicationand help identify synergies among programs possiblyleading to overall efficiency gains. Working with andthrough existing local health services and mechanismscan help to strengthen them and avoids the creation ofparallel HIV services and/or competitive working prac-tices. Indeed, coordinated donor efforts can strengthengovernment efforts. In Rwanda, a non-governmentalorganization (NGO) provided coordinated salary supportto government community health initiatives, strengthen-ing the Ministry of Health’s community HIV program[37]. Coordinating the training and curriculum of CHWswith other health workforce also has educational bene-fits, since CHWs may benefit from interactions duringtheir training with other aspiring health workers. Coord-ination may avoid differences in training/career pros-pects between programs, which may lead to frictionacross programs operated by different organizations[22]. Coordination, however, should also allow innova-tive experimentation with different approaches (as op-posed to just imposing a uniform program).Factors affecting coordination Additional file 1:Table S2 displays key factors facilitating and inhibit-ing coordination of CHW programs. Facilitators ofcoordination include a clearly identified authority tooversee CHW programs [22]; solid government pol-icy and a regulatory and organizational frameworkanchoring CHWs into the public or private healthsystem; districts with strong planning and informa-tion systems; a common funding pool and plan; andappropriate supervision and support [38]. Sector-wide support platforms, for instance, can coordinatethe actions of multiple entities in support of healthsystem development and service delivery [38]. A fewexamples are the International Health Partnership (agroup of national governments, development agen-cies, and civil society organizations, which promotesdevelopment cooperation in the health sector), theHuman Resources for Health “Country CoordinatingMechanisms” (national committees that submit fundingapplications on behalf of the entire country to the GlobalFund to obtain funding for HIV-related projects), and theNational Human Resources for Health working groups in-volving a range of CHW stakeholders. Strategic collabora-tive partnership between communities and health systemsalso offers the potential for accelerating progress in im-proving CHW performance at scale [39]. On the otherhand, barriers to coordination include, for instance, the“NGO challenge”: NGOs who compete with each otherfor resources, rather than working together to streamlinethe various CHW programs [38]. The incentive structureof this financing system compels NGOs to offer a different“product” than their competitors, which may not onlyprovide positive innovations but also simply drivedifferent approaches that are not effective [38].Area of harmonization: integrationIn this study, integration refers to the alignment ofeither donor-supported or national CHW programs withexisting networks of larger health and/or communityhealth systems. Integration can play an important role infurther clarifying responsibilities, standardizing CHWprograms, establishing accountability, and establishingcareer paths and professional associations [38]. In Kenya,for instance, integration of HIV services into primarycare services was associated with significant increases inpatient satisfaction [40]. In Brazil, the integration ofCHWs into the existing civil service structure led to thecompatibility of programs with government, financial,and service delivery health systems, whereas in India,integration reduced conflict between different actors ofthe health sector [41]. The integration of CHW servicesinto national health systems or a large private providercan take different forms, such as partial integration (e.g.,though not part of civil service, CHWs receive standardizedDe Neve et al. Human Resources for Health  (2017) 15:45 Page 4 of 10incentives from the government, in the case of integrationinto national health systems) or full integration (e.g., CHWsthat are part of the civil service and paid standardizedmonthly salaries by the government).Factors affecting integration Factors facilitating inte-gration include the perceived relative advantage ofnationally recognized CHW programs (Additional file 1:Table S2). In Ethiopia, CHW clients preferred to receivehealth-related information or advice from Health Exten-sion Workers over other community volunteers [42].Similarly, a positive perspective of CHWs by politiciansand community members can facilitate integration.Community members reported positive perceptions ofCHWs in Ethiopia and Pakistan [42, 43]. For CHW pro-grams where women may play a more predominant role(such as those that have integrated HIV services withsexual and reproductive health services [32]), improvedwomen’s rights and empowerment may also increase in-tegration [44]. On the other hand, factors inhibiting inte-gration of CHW programs may include a lack of properdefinition of tasks of CHWs. In Brazil, a limited defin-ition of CHW tasks affected acceptability of CHWs byother health workers, resulting in sub-optimal integra-tion into the health system [45]. In Pakistan and India,discrimination based on social-cultural practices, age,and/or marital status has hindered the full integrationof CHW programs [46, 47]. The existence of paralleland hierarchical communication structures may alsoaffect integration. In India, a hierarchical communica-tion structure resulted into rigidity and top-downpower which constrained the flow of health informa-tion [48]. Other barriers include ineffective incentivestructures of CHWs and inadequate infrastructureand supplies [41], in addition to lack of ownershipand political support for CHW programs [22].Area of harmonization: sustainabilitySustainability of the HIV response suggests that a coun-try has the enabling environment, services, systems, andresources required to effectively and efficiently controlthe HIV epidemic in the long term [34]. Sustainability isa key challenge for CHW programs predominantly sup-ported by uncertain and/or transitioning donor funding[30]. Researchers and policy-makers have increasinglysought to understand how the longer term sustainabilityof these programs can be better assured, thus enablingthe continued and improved achievement of desirableprogram outcomes [18]. In addition to allowing systemsto keep operating, the sustainability of a program couldenable CHW initiatives to take a longer time horizon andbetter anticipate future needs (such as those resultingfrom changes in HIV treatment guidelines). Sustainedprograms may also be able to focus on investments whosereturns are likely to be evident only after some time.Factors affecting sustainability Previous reviews onsustainability have suggested three important influences,including (i) program-specific factors (e.g., CHW pro-gram design and implementation), (ii) organizationalfactors and setting (e.g., program leadership), and (iii)underlying contextual factors [20, 31] (Additional file 1:Table S2). One factor facilitating the sustainability ofCHW programs may be the program’s consistent andadequate supervision of CHWs. In South Africa, for in-stance, clinical leaders directly supervised CHW pro-grams [49], whereas in India, supervision includedbiweekly on-site supervision of CHWs [50]. Anotherlikely facilitating factor is the degree of “community fit”[18]. In Uganda, CHWs were selected by members oftheir community which likely reduced CHW attrition[51]. Other facilitating factors include the integrationwith the broader environment. In Botswana, CHWsworked alongside professional nurses in health facilitiesand received government pensions [52]. Conversely, fac-tors inhibiting sustainability may include insufficient payor incentives for CHWs relative to other employmentopportunities [46]. The absence of sufficient financial in-centives and availability of more lucrative employmentelsewhere were causes of attrition among CHWs in theDemocratic Republic of the Congo (DRC), Mozambique,and Nigeria [53–55]. Other factors inhibiting sustainabilityinclude a lack of community support for CHWs and dis-trust [56], in addition to limited human, technical, andfinancial resources. In the DRC, for instance, communitieswere dissatisfied that CHWs provided preventative ser-vices (as opposed to treatment services) [53].Analytic framework for harmonization of CHW programsAtun et al. propose a framework to consider the diffu-sion of health sector initiatives into the broader healthsystem [26]. First proposed as an approach to systemat-ically consider the integration of health sector activities,expanding the lens to include other priority areas ofharmonization may allow us to better understand whyinterventions may fail to achieve full harmonization,even in the face of many facilitating factors. A key ad-vantage of extending this framework to other priorityareas of harmonization (beyond integration alone) is thatit suggests a common language that can also be appliedto assess harmonization more broadly. We thus do not sug-gest a new framework, but rather a “framework +” that en-ables the systematic and holistic exploration of the extentto which different CHW interventions are harmonized invaried settings and the reasons for the variation. Specific-ally, in seeking to understand integration, Atun et al. arguefor a broad approach, noting that “the extent to whichDe Neve et al. Human Resources for Health  (2017) 15:45 Page 5 of 10[health sector interventions] are integrated…will be influ-enced by the nature of the problem being addressed, theintervention, the adoption system [stakeholders], the healthsystem characteristics, and the broad context”.Each of these five elements of the analytic frameworkhave applicability to harmonization activities for CHWprograms for HIV and can be described as they contrib-ute toward a harmonized approach for specific CHW in-terventions (Fig. 1). First, a health priority must beconsidered in light of other health priorities, and theurgency and scale of the issue, including the socialnarrative which surrounds it. More urgent issues, forinstance, may initially necessitate a more targeted ap-proach, with efforts for integration occurring furtherdown the line. Second, less complex and better knownCHW interventions may be easier to duplicate and likelyto be more amenable to integration than newer or morecomplicated interventions which must be customized tospecific target groups. CHW programs delivering HIVservices, for instance, might not be considered asstraightforward as childhood immunizations (i.e., an eas-ily identifiable target group and schedule that makes ithighly adaptable), but less complex than maternal andchild health programs with multiple interrelated inter-ventions rolled into one. Third, the perceptions and rela-tive power of the various stakeholders involved withCHW programs is a critical question in the path toharmonization. The adoption and implementation ofCHW programs often depends on a wide range ofactors, including various government officials, commu-nity leaders, donors, and expert observers; and the pres-ence of advocates can be a key determinant. Fourth,integration and sustainability further depend on thebroader health system’s structural and financial capacityto absorb CHW programs. Finally, the broader context,including the “demographic, economic, political, legal,ecological, sociocultural…and technological factors inthe environment” [26] can play a critical role in enablingor hindering CHW program harmonization. Populationsin wealthier settings, for instance, may be more hesitantto see CHWs as “appropriate” health providers vis-à-visprofessional health workers.Mapping three harmonization priority areas to analyticframeworkFinally, we incorporate the three priority areas ofharmonization into our extended analytic “framework+”. Table 2 considers different topics included in our re-view, categorized by the elements of our framework (thenature of the health issue, the intervention, the variousstakeholders, health system characteristics, and broadercontext of CHW programs) and three priority areas ofharmonization (coordination, integration, and sustain-ability). This five-by-three table allows us to visualizeand better understand why CHW programs may fail toachieve either partial or full harmonization. It also allowsus to test the assumptions that the topics listed in thetable contribute to harmonization in future empiricalstudies. We note that there is significant overlap oftopics across areas of harmonization and elements ofthe analytic framework. The perception of a CHW’s pro-gram effectiveness among community members andpolicy-makers, for instance, appears both in the integra-tion and sustainability columns in Table 2. Both coordin-ation and integration into the wider health system arealso oft-cited facilitators of sustainability (e.g., for theircontribution to be sustained, CHW programs may needto be integrated into the wider health system [57]).Harmonization spans many levels of the health system,and the three priority areas are deeply intertwined.Nevertheless, the various topics listed in Table 2 couldbe considered by policy-makers and researchers and ad-dressed for a more harmonized approach to community-based health worker programs for HIV.DiscussionThis narrative review of the published and gray literaturefurther defines the concept of harmonization, introducesthree priority areas, provides an overview of factorsthought to facilitate or hinder each, and integrates theminto an analytic framework. While the three priorityareas and elements of the analytic framework are inter-connected and the overlapping drivers of these conceptsFig. 1 Framework for analyzing the harmonization of CHWprograms for HIVDe Neve et al. Human Resources for Health  (2017) 15:45 Page 6 of 10complicate the establishment of concise definitions, eachacts in a distinct way, and each faces its unique challenges.Factors facilitating and inhibiting harmonization are alsohighly context-specific, and increased harmonization islikely to be a complex political process, with in many casesincremental steps toward improvement. In settings withdecentralized government, for instance, minor steps maybe required to achieve harmonization of CHW programsfor HIV. Conversely, countries with a stronger centralgovernment or a large existing national CHW programmay be able to achieve harmonization rather quickly. Thegovernment of Rwanda, for instance, coordinated salarysupport to CHWs with a non-governmental organization[37], and Brazil and Ethiopia placed their CHWs entirelyinto an existing civil service structure [41], whichsubstantially facilitated the harmonization of theirCHW programs. One advantage of the conceptual ap-proach suggested in this study is that it proposes a com-mon language and framework that can be applied acrossdifferent settings. This framework is likely informative tocountry-level decision-makers in settings with a large HIVepidemic, complex health systems, and multiple donors,in addition to other stakeholders involved with commu-nity health initiatives in low- and middle-income settings.The analytic framework can be applied, for instance, incountries to explore which factors may be particularlyimportant for increased harmonization in order to in-form policy and practice in ways that can lead to im-proved health system performance. While the expansionof CHWs and their roles remains an explicit strategy inglobal efforts to end the HIV epidemic [9, 13], there arefew documented cases of integrating donor-led HIVCHW programs into larger providers and sustainingHIV service delivery in the long term. Future researchshould also carefully map harmonization efforts at thesub-national and community level, where many CHWprograms are implemented (and should likely be coordi-nated). We also note that, while the literature generallyhighlights the benefits of harmonization, there is lessdiscussion surrounding the trade-offs associated with it.It is not clear that the solution to the many difficultiesassociated with fragmented CHW programs lies in inte-grating them entirely into a national health system. Theloose processes in the employment of CHWs, for in-stance, may have advantages [19]. The open-ended anddynamic nature of community structures may allow forinnovations which improve inclusiveness, local flexibility,and a range of motivations to be part of a health system“continuum” [19].Finally, we recently applied the analytical frameworkproposed in this article in a four-country study in SouthernAfrica to assess the harmonization of CHW-led HIVTable 2 Mapping priority areas of CHW program harmonization to analytic frameworkCoordination Integration SustainabilityFrameworkHealth issue Coordination between HIV and otherhealth priorities; availability of astandardized communityhealthcare packageVariability in health priorities betweennational and sub-national levelsEasily identifiable health issues; broadnessof focus and training of CHWs; reach ofcoverage of servicesIntervention Existence of cadres with specialized skills(which may be more complex to manageand evaluate); existence of parallel trainingand support structures for CHWsEquivalence between differently trainedCHWs; CHW hiring procedures; level ofworkload and supervision of CHWs;existence of standardized incentives;level of professionalizationLevel of workload and supervision ofCHWs; local modifiability; existence ofstandardized incentives; communityparticipation and involvement of localdecision-makers; CHW demographics;gender biasStakeholders Number of stakeholders; awarenessof need for coordination; existence ofsimilar funding timelines, forums (suchas working groups) and reports;result-oriented programming andreporting; “NGO challenge”Perceived effectiveness of program;involvement of multiple public orprivate actors; position and powerof health professionals; pace of CHWscale-up; dependence onexternal actorsStrength of leadership; level ofcommitment to coordination andintegration; dependence on externalactors; perceived effectiveness of theintervention; level of community buy-inHealth system Existence of a single organizationalstructure dedicated to communityhealth initiatives; level of decentralization;training of health workers; coordinationwith health facilitiesFormal recognition of CHW programsby government; parallel supply chains;standardized training, supervision andmonitoring of CHWs; public or privatecapacity; existence of a commonfunding poolPublic or private resources; existence ofCHW training refreshers; attrition amongyoung CHWs; coordination and integrationof CHW programs; “NGO challenge”;predictability of fundingBroad context Level of political support amongall stakeholders and across governmentlevels (or large private providers) forCHW-led servicesLevel of CHW program compatibilitywith local (community) structures;socioeconomic context andcultural values; political support forCHWs; community perceptionLevel of alignment with communitynorms and needs; level of politicalsupport and economic growth; levelof support from external actorsCHW community health worker, NGO non-governmental organization, MOH Ministry of HealthDe Neve et al. Human Resources for Health  (2017) 15:45 Page 7 of 10services (De Neve JW, Garrison-Desany H, Andrews KA,Sharara N, Boudreaux C, Gill R, Geldsetzer P, Vaikath M,Bärnighausen T, Bossert TJ: Harmonization of communityhealth worker programs for HIV: a four-country qualitativestudy in Southern Africa, submitted). The analytical frame-work outlined here has facilitated analysis in systematicallycomparing and contrasting CHW-led HIV services acrossthese four countries and to generate meaningful evidenceand inform policy around the harmonization of CHW-ledHIV services.LimitationsThis study has a number of limitations. First, we note thatthis review is not a systematic review of harmonization ofCHW programs and that we have sampled only a verysmall portion of the approximately 38 000 titles returnedby PubMed and Google Scholar with harmonization andcommunity health worker in their texts. Our intentionwas neither a comprehensive review of all the availableevidence nor an evaluation of the scientific quality of thearticles but a narrative review to establish a clear defin-ition of harmonization and a framework for analyzing theharmonization of CHW programs focused on CHW-ledHIV services. Second, the definition of CHWs varies[58, 59]. While the lack of agreement upon a definition ofCHWs is an important challenge in synthesizing evidence,we employed a broad definition [60]. Third, the distinctionbetween CHWs who deliver HIV services and those whodo not is not always clear in the literature. When evidenceon CHWs delivering HIV services specifically was scarce,we supplemented our review with evidence on CHWprograms that offered related health services.ConclusionsTo our knowledge, this study is among the first to pro-vide guidance for future research and policy to under-stand the process by which harmonization of CHWprograms for HIV might be achieved. This study furtherdefines harmonization, proposes three priority areas(coordination, integration, and sustainability), identifies aset of factors likely to facilitate or inhibit each, andsuggests a framework which permits a systematic assess-ment of existing CHW programs.Additional fileAdditional file 1: Additional context and research gaps. (DOCX 68 kb)AcknowledgementsWe are grateful for administrative support by Efren Mencia and EvelynKamgang and for helpful comments by Shayanne Martin, Adrienne Hurst,Edward Broughton, and Diana Frymus.FundingThis study was supported by the American people through the United StatesAgency for International Development (USAID) with funding from the USPresident’s Emergency Plan for AIDS Relief (PEPFAR) and implemented bythe Harvard T.H. Chan School of Public Health through the USAID ApplyingScience to Strengthen and Improve Systems (ASSIST) Project. The USAIDASSIST Project is managed by the University Research Co., LLC (URC), underthe terms of Cooperative Agreement AID-OAA-A-12-00101. The authors’views expressed in this paper do not necessarily reflect the views of USAIDor the United States Government.Availability of data and materialsData sharing is not applicable to this article as no datasets were generatedor analyzed during the current study.Authors’ contributionsTJB, PG, MV, TB, CB, RG, and JWDN conceptualized the study. JWDN, CB, andRG conducted the review and analysis under the guidance of TJB, PG, andTB. JWDN, CB, and RG wrote the first draft of the paper. TJB, PG, MV, TB, CB,RG, and JWDN suggested important improvements to the paper. All authorsread and approved the final manuscript.Competing interestsThe authors declare that they have no competing interests.Consent for publicationNot applicable.Ethics approval and consent to participateThis study has been reviewed by the Harvard T.H. Chan School of PublicHealth Institutional Review Board and was considered exempt from fullreview since it is based on previously published studies and anonymousdata with no identifiable information.Publisher’s NoteSpringer Nature remains neutral with regard to jurisdictional claims inpublished maps and institutional affiliations.Author details1Institute of Public Health, Heidelberg University, Heidelberg 69120, Germany.2Department of Global Health and Population, Harvard T.H. Chan School ofPublic Health, 665 Huntington Avenue, Boston, MA 02115, United States ofAmerica. 3BC Women’s Hospital, University of British Columbia, 4500 Oak St,Vancouver, Canada. 4Africa Health Research Institute, Mtubatuba,KwaZulu-Natal, South Africa.Received: 26 January 2017 Accepted: 18 June 2017References1. Perry HB, Zulliger R, Rogers MM. Community health workers in low-,middle-, and high-income countries: an overview of their history, recentevolution, and current effectiveness. 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