History of CHWs in LMICs
By definition, CHWs are individuals without formal tertiary education who are selected by community members to receive basic training in order to provide one or more health care functions in their communities . To understand the role of CHWs in low- and middle-income health systems, along with ethical challenges that may accompany their work, one must first examine how their usage came about. Widespread involvement of CHWs is not a new phenomenon [2, 4, 11, 12, 16]. The first CHWs can be traced back to rural China in the 1920s where community members received basic education to carry out health activities  such as recording births and deaths and providing vaccinations . This concept gained further attention around the world in the 1960s when international stakeholders began viewing this model as a strategy to improving access to healthcare services in rural areas where trained physicians often failed to reach. This concept began slowly being introduced in communities in other LMICs .
In the 1970s, multilateral agencies such as the WHO began exploring ways to use task shifting as a formal strategy to strengthen health outcomes in resource-limited contexts . This was most notably reflected in the 1978 Alma Ata declaration which envisioned CHWs as representing a pragmatic way of enhancing community involvement in health care delivery . This perception continued into the early 1980s where CHWs were viewed as being a cornerstone of the primary health care movement [7, 9, 13]. However, by the late 1980s and early 1990s, enthusiasm for CHWs began to quickly diminish [7, 12, 13]. This perceived lack of usefulness led to decreased interest in CHW programs, which mainly arose due to lack of adequate planning, training, management, and funding being incorporated into programs [4, 11]. Challenges with scale-up were therefore becoming apparent [7, 13], as concerns arose over their long-term role within health systems . These constraints were ultimately impacting the quality of care being delivered , as poor motivation and high attrition rates were becoming commonplace in CHW programs . During this time, key challenges began to arise, which were often a result of poor health financing and inadequate supervision from other health worker cadres . A debate thus began to surface over whether CHWs could indeed become mediators of health behaviour change or rather represented “narrow functionaries of the health system.” 
However, by the mid-1990s, a resurgence of CHW programs was observed. This was sparked by several factors, most notably, the rapid spread of the HIV epidemic [10,11,12] and growing interest in health care decentralization [10, 11]. More specifically, the HIV crisis caused many highly trained health workers to experience increased workloads, as they were expected to test people for HIV, place individuals living with HIV on a continuum of treatment services, and, by the mid-2000’s, roll-out ARTs while simultaneously tending to other duties . These cumulative responsibilities began exacerbating rates of worker absenteeism in health systems [1, 37], which was compounded by other issues including health worker migration and concerns that providers may become infected with HIV themselves . CHWs represented a cost-effective way of remedying some of these complex issues and were therefore increasingly deployed in HIV programs [2, 39].
More recently, CHWs were viewed as a way of addressing critical human resource shortages, which are often a result of health workers migrating from low- to high-income countries in search of better work opportunities [1, 2]. The growing demands for CHW programs have also reflected efforts to achieve the Millennium Development Goals (MDGs)  and now the Sustainable Development Goals (SDGs). Lately, governments have made efforts to better integrate CHWs within health systems. For example, this has recently taken place in Tanzania, Brazil, Venezuela, Pakistan and Ethiopia [35, 40, 41]. Integrating CHWs into national structures can strengthen program compatibility with local practices, improve referral systems and health worker relationships, and strengthen overall health service delivery . Yet despite this renewed interest in promoting CHW programs, older challenges persist. Some of these include poor training, supervision [35, 42] and lack of clear goals and priority setting . These challenges are mainly a result of CHW programs being introduced in rushed, unstructured, and top-down manners .
As this overview showcases, shifting health care tasks to CHWs in LMICs is not new, as it emerged decades ago [2, 4, 11, 12, 16]. However, renewed interest in CHW programs has been “more pragmatic than ideological.”  This is because CHWs have been largely perceived as a means to curbing health system challenges [7, 12] like the HIV crisis, rather than a strategy to providing employment to lower educated citizens, or increasing community engagement in the health care decision-making affecting their lives. Furthermore, as shown in the provision of HIV services, task-shifting is often used to address specific health issues through focused interventions. In other words, CHWs reflect an attempt to fill health system gaps that arise from programs becoming increasingly verticalized and privatized in their approach [10, 11, 43]. These factors have ultimately undermined the ability and responsibility for governments to respond to persistent health system challenges [14, 43], and within this, CHWs have been used as a means to filling this void. Distinct political and philosophical underpinnings therefore lie behind the promotion of CHWs, which may explain why their central roles within health systems have gone largely unnoticed [7, 12]. As more stakeholders become involved in the response to the HIV epidemic, it is imperative that individuals and institutions recognize the complex, heterogeneous practices of CHW programs [14, 22] to better ensure their essential roles within health systems are not exploited or overlooked.
Health system challenges affecting HIV programs in LMICs
Poor health financing is compounded in many LMICs by a large shortage of health workers. For instance, in Zambia and Myanmar, health spending accounts for only 5.35% and 4.95% of their total GDP . These figures are near the average health expenditure rate across all LMICs, which is 5.37%; however, high income countries invest on average 12.38% of their GDP into health spending . Moreover, only 9.1 physicians and 56.8 physicians are available in Zambia and Myanmar for every 100,000 people . These figures are minuscule compared to countries like Canada or the United States, which have ratios of 253.9 and 256.8 physicians per 100,000 people respectively . In many LMICs, of the few health workers that are available, they are unevenly distributed. For example, in Tanzania, nearly twice as many health personnel work in urban than rural areas , yet approximately 67% of Tanzanian citizens reside in rural parts of the country .
HIV prevalence rates vary across LMICs and are highest in sub-Saharan Africa, and in particular, Southern Africa. For example, in 2016, HIV prevalence among people aged 15 to 49 in Swaziland, Botswana and South Africa was 27.2, 21.9 and 18.9%, respectively . Meanwhile, Southeast Asian countries such as Thailand and Indonesia have an HIV prevalence of 1.1 and 0.4% among adults aged 15 to 49. HIV prevalence is 0.5% in Guatemala and 2.1% in Haiti . The last decade has witnessed extensive efforts to increase access to HIV care and treatment services, with varying regional success. For example, in Tanzania and Haiti in 2015, only 53% of of people aged 15 and over living with HIV had access to ART . This figure is below the global targets set for HIV treatment, such as the United Nation’s (UN’s) 90–90-90 goals. More specifically, these goals aim to ensure that by 2020, 90% of people living with HIV will know their status, 90% of people living with HIV will be accessing treatment, and 90% of people on treatment will be virally suppressed . Since only 53% of individuals over age 15 who are living with HIV are currently accessing treatment in these countries, much progress still needs to be made to achieve the UN’s second ‘90’ target. CHWs are viewed as having an important role in remedying this gap.
Although CHWs play a vital role in HIV service delivery, task shifting has occurred rather informally in LMICs, as little evidence showcases which tasks have been delegated from one cadre to another. For instance, poor recordkeeping and undefined roles in South Africa have caused many CHWs to perform duties outside their portfolio and skillsets [11, 50]. This has made it difficult to track how many CHWs are deployed in under-resourced health systems and can lead to further challenges. For instance, in settings such as the Mkuranga District of Tanzania, many village residents have reported not knowing that CHWs are working in their respective communities . These issues may be a result of task shifting occurring as an ad hoc coping strategy to addressing health worker shortages [2, 21] rather than a systematic policy strategy. Important challenges are therefore impeding CHW’s abilities to provide timely, high-quality HIV services to targeted populations in LMICs. Within contexts where proliferation of new cadres has occurred rather rapidly, close consideration needs to be given to identifying and resolving practical and ethical challenges that undergird their work. One tangible way of achieving this is by using a set of ethical principles, which will be expanded on in the following section.
As showcased, CHWs represent feasible strategy for promoting community outreach , which has been fundamental in ART scale up [5, 16]; however, implementation concerns still persist. Some of these concerns include maintaining high standards of safety and quality care [2, 5, 11, 16, 21], reducing CHW attrition [1, 18, 51], standardizing training and supervision [5, 7, 8, 10, 21, 26, 52, 53], improving access to basic supplies , aligning CHWs with broad health system strengthening [5, 8], and prioritizing fair compensation [1, 5,6,7, 16, 19, 52]. These challenges cut across several CHW programs and are fraught with ethical concerns. To better understand these recurring issues, while further ascertaining ways to mitigate them, a set of ethical principles can be examined.
Principlism is a normative ethical framework which is used to navigate practical decision-making in the delivery of health care services . As Coughlin highlights , principles play a prominent role in moral reasoning and can help reveal ethical underpinnings that may form the backdrop to many health problems. By specifically referring to a set of principles, an individual can more clearly elucidate a health dilemma while identifying a strategy to potentially resolve it . In this sense, making principlist observations in health care can aid key stakeholders with pragmatically navigating ethical challenges that emerge in research- and practice-based settings .
Although originally developed in bioethics as a way of navigating individual cases where patient rights and autonomies are being breached, principlism can also be applied in public health contexts [27, 29, 54]. Unlike medicine, which is more individualistic in nature, public health is foremost concerned with promoting the health of populations by balancing the needs and desires of individuals, communities, and governments . Common principles used to negotiate public health interactions include justice, trustworthiness, and respect [20, 27]. In this sense, principlism can provide a coherent analysis of the ethical issues that undergird public health interventions, as it can help stakeholders to examine and eventually resolve public health dilemmas . This method of analysis is particularly useful in this paper as, currently, there appears to be no consensus on a structured way of addressing the aforementioned ethical challenges that emerge in CHW programs in LMICs.
What ethical principles should then be applied to guide HIV service delivery in CHW interventions in low- and middle-income settings? Many principles used in medical ethics can still be applied to public health contexts. For instance, as noted above, inadequate training and compensation can place unfair burdens on CHWs; this closely ties to the justice principle, which is often raised in biomedical ethics contexts, such as the work by Beauchamp and Childress  and in the Belmont Report . Similarly, ensuring individuals like CHWs are provided with clear information so they can make informed decisions and properly conduct their tasks relates to the Respect for Persons principle raised in the Belmont Report . Ensuring that welfare gains are maximized and that CHWs do not encounter unnecessary health risks as a result of their work can be covered in the beneficence principle [28, 55]. We have therefore included each of these high-level principles into our framework.
Mid-level principles are also relevant when working with CHWs in under-resourced contexts. For example, while some of the above principles may imply that fair remuneration be prioritized, these efforts will inevitably require additional resources, which can be hard to come across in healthcare delivery programs in many LMICs. The principle of proportionality  is therefore important to consider, as it can help program implementers and policymakers recognize that non-financial incentives, such as educational rewards and recognition by peers, may need to be considered. Lastly, HIV programs in LMICs are often conducted in collaboration between international and national stakeholders. This presents great opportunities for resources to be pooled; however, there is potential for miscommunications to arise in these cross-cultural contexts. Therefore, the final principle included is the principle of cultural humility, which we have adapted from Stones’ analysis of CHW programs in the United States .
Respect for persons
Respect for Persons recognizes that all people have worth and therefore deserve to be respected. It acknowledges that every person has basic rights, such as their right to exercise their own autonomy and to make decisions without undue interference from others [28, 55]. Moreover, it has close ties to the Formula of Humanity, as it recognizes that all people have value and therefore should not be exploited or used merely as a means to achieving an institutional ends .
According to this principle, it is crucial that CHWs be given adequate information so they can exercise their full autonomy and make informed decisions. This is particularly important, as CHWs can often be in vulnerable positions due to their low levels of education and status compared to other health personnel. Despite this, some CHWs have reported being recruited into interventions without being given adequate training or information on how to properly conduct their tasks . To circumvent this dilemma, when recruiting CHWs, they should be provided with clear instructions on the full scope of their tasks. They should also be told upfront whether they will be remunerated for their work; moreover, they can be notified whether there are opportunities for career advancement. Each of these endeavours can enable CHWs to make more informed decisions when undertaking their work.
Furthermore, it is critical for CHWs to not be viewed merely as a means to addressing gaps existing in HIV care delivery. One way of doing this is to recognize the limitations of CHW work; otherwise, CHWs risk being undervalued and exploited in HIV programs. For instance, it is important to provide CHWs with workloads that are feasible and match their levels of expertise. Despite this, cases have been reported where CHWs feel overburdened due to their workloads being simply too much to manage [16, 51]. To circumvent this challenge, program implementers can interview CHWs throughout HIV programs to understand if their workloads are manageable and to identify if CHWs require further support. By taking these limitations into account, CHWs can become viewed not merely as a means to addressing gaps that doctors or nurses cannot fill, but rather as critical assistants who are providing important services in HIV programs.
Justice is a principle that is shaped by the concept of respect but further adds to it . Specifically, the justice principle argues that all people be treated fairly and given an opportunity to be heard [20, 30]. Justice therefore has important procedural implications, as it seeks to ensure that all stakeholders have equal opportunity to take part in procedural activities . Likewise, it can have distributive impacts, as it strives to ensure the benefits and burdens of programs are distributed more fairly across all groups involved [28, 29].
In terms of procedural justice, while it is important for CHWs to receive ample guidance, supervision, and management from higher-educated health worker cadres, CHWs often receive few opportunities to provide feedback in HIV programs . This highlights breaches in procedural justice, as institutional arrangements have perpetually excluded them from providing their input in HIV programs . This issue can impact motivation and retention rates, as levels of dissatisfaction can arise from CHWs feeling as if they have few opportunities to provide feedback within HIV care delivery.
An effort to promote procedural justice was recently made in 2014 when CHWs were officially recognized as a professional health cadre in Tanzania when the Community Based Health Programme (CBHP) policy was approved. This policy tries to standardize and improve issues related to recruitment, training, employment, remuneration, supervision and performance assessment of CHWs . Beforehand, CHWs had to carry out tasks with little support or resources from the public sector. By formally recognizing their role within the health system, there is greater potential for CHWs to receive new opportunities for negotiating health service terms  and experience more growth and promotion in their roles . Although the integration process is impacted by several variables [6, 41], if done well, integrating CHWs into the health system represents a structured way to lessen fragmentation in HIV care delivery and address the larger crisis that is presented by a shortage of health workers . This recent policy shift therefore can reflect an effort to promote procedural justice, as CHWs may experience greater opportunities to influence decision-making procedures as a result of this policy change.
According to distributive justice, efforts should be made to ensure that CHWs do not undergo unfair burdens while executing their tasks . This challenge is ever more critical in LMICs, as many HIV programs are conducted between international and local stakeholders who may overlook context-specific burdens that CHWs may encounter from their work. For example, many CHWs report hopes of receiving financial rewards for their tasks yet are not fairly remunerated. In turn, CHWs may encounter unnecessary burdens, such as the need to rely on financial or material supports from their own family and/or community members so they can continue their work . Similar challenges arise when CHWs are required to pay their own transport fees to perform a job or function for which they receive little or no compensation [19, 33, 50]. CHWs and local authorities should therefore be consulted so that burdens such as these can be identified, along with solutions to overcome them , such as the need for honoraria to be distributed.
Specific efforts can be made to promote distributive justice. Many, but not all, CHWs work as volunteers and therefore receive none or very little monetary compensation for their contributions [9, 20, 52]. Policymakers and program officers should thus pay close attention to the burden that lack of remuneration places on CHWs , and how setting a minimum standard of compensation can help to alleviate it. Other avenues can be explored, such as providing adequate equipment and resources  to avoid CHWs from encountering unfair burdens as a result of their work. Specifically, if CHWs have to travel long distances to carry out home-based counseling services, resources such as bicycles can be incorporated into program budget setting [19, 33]. Additional materials can be considered, such as umbrellas [33, 52], backpacks , and medications , for example. Adequate training and supervisory support can also be established to ensure that CHWs are delivering HIV services with enough preparation and guidance [8, 21, 52, 53]. Doing so can also promote greater collaboration and teamwork amongst health care providers, which is more reflective of task ‘sharing’  than mere ‘shifting.’ Each of these endeavours reflect a steady effort to prioritize the justice principle. These efforts may also improve motivation, reduce attrition, and ultimately improve the quality of services that CHWs provide in HIV programs.
According to the principle of beneficence, health and human welfare benefits should be promoted within the provision of health care services [28, 55]. Beneficence is often described in combination with non-maleficence, which aims to promote actions that mitigate harms or suffering of others . According to this principle, public health interventions can be arranged so that they promote the well-being of individuals and communities, and minimize potential harms [29, 54]. The welfare gains may not only include improvements in health but social advantages such as community empowerment.
This principle has particular relevance to HIV programs. For example, in HIV service provision, CHWs may be placed in contexts where their own health may be at risk, such as conducting home-based HIV tests with inadequate protective equipment. Measures should therefore be taken to circumvent these issues. For instance, governments and institutions can ensure that CHWs are provided with proper equipment, such as latex gloves, when conducting HIV testing. This can allow CHWs to maintain and promote their health throughout their work.
Other circumstances may arise. For instance, peer educators (who are CHWs that are living with HIV themselves) risk being stigmatized from revealing their status when delivering HIV services . CHWs should thus be provided with adequate training and support to ensure that peer educators do not endure unnecessary emotional harms or other forms of violence as a result of their work . In public health contexts, it is equally important for CHWs to uphold this principle for wider social welfare gain. For instance, efforts can be made to protect community members from encountering undue social discrimination. It is therefore important for CHWs to be properly trained on ways to uphold and safeguard patient confidentiality throughout their work. Doing this will not only ensure that welfare is maximized and the beneficence principle is therefore being upheld, but it can also enable the respect for persons principle to be maintained. However, despite confidentiality being prioritized in HIV and CHW programs today, there are still circumstances where privacy is breached in HIV service delivery . For example, instances have been recorded where CHWs have left personal data of HIV patients on their desks or in their cars . It is therefore important that CHWs be reminded and provided with additional training so they can uphold patient privacy and confidentiality throughout their work.
Proportionality is a mid-level principle that argues that public health benefits be weighed against moral considerations . In other words, when making decisions, the principle of proportionality argues that all positive features be balanced against the negative consequences . This principle is important in public health contexts, as it implies that individual benefits be considered within the context of wider social good . In this sense, proportionality can enable decision-makers to evaluate a wide range of solutions and to choose the option(s) that are least infringing .
In HIV programs in LMICS, resource constraints need to be closely considered in decision-making processes. For instance, while it may be crucial for CHWs to be provided adequate compensation or supervision, program directors need to acknowledge that these activities will require more resources, which can be difficult to come by in LMICs . While the justice principle argues that fair remuneration be prioritized, in contexts where fiscal constraints deter CHWs from receiving standardized salaries, alternative non-financial incentive strategies can be explored, such as providing CHWs with flexible hours, strong management, or educational rewards [7, 33]. Providing CHWs with training opportunities may also result in greater quality HIV services being provided to patients; this is a wider social good that may outweigh the extra time and costs required for this training. There are other non-financial rewards. For example, CHWs can experience an increased sense of leadership and community connectedness from their work; moreover, they can be provided with more clearly defined roles, and supervisors can deliberately recognize CHW contributions [41, 51].
The principle of proportionality also implies that CHWs be given a fair workload and level of responsibility in comparison to their skillsets. While it is important to acknowledge that different levels of staff will inevitably exist in HIV programs, ethical and practical challenges can emerge when CHW are assigned tasks that do not proportionately match their levels of expertise. According to this principle, it therefore becomes more apparent that CHWs be delegated tasks that match their skillsets so they can feasibly carry them out.
The principle of cultural humility emphasizes the need for stakeholders to be open to exchanging cultural knowledge and skills throughout healthcare delivery to ensure that greater collaboration and partnership-building is promoted . This principle is particularly important in HIV programs in LMICs, as they are often carried out between individuals from various cultural backgrounds. For instance, HIV programs may involve local and international stakeholders representing NGOs, universities, government officials, and community members. Although transnational programs present an enormous opportunity for more resources to be pooled, if context-specific burdens are not considered, CHWs may disengage from their work . Misunderstandings can also arise if international stakeholders lack appropriate cross-cultural skills. It is therefore important for program designers, implementers and other relevant stakeholders undergo cultural competency training . This can better ensure that individuals are open to hearing and critically reflecting on cultural nuances that may affect HIV service delivery.
Another tangible way of promoting the cultural humility principle is allowing regular interviews or meetings to take place with CHWs in HIV programs, along with avenues to implement suggestions and recommendations. These interviews can shed light on cultural nuances that may be overlooked in service delivery. For instance, interviews with CHWs can reveal the need for transportation assistance to be provided, which may otherwise be overlooked and cause CHWs to become demotivated in their roles . It is therefore important that an overall approach towards self-reflection and cultural humility be upheld in HIV service delivery. Within these arrangements, the main burden should arguably be placed on dominant institutions (rather than CHWs), since these stakeholders hold arguably more power in these relationships . Thus, it is largely up to program designers and implementers to deliberately plan and incorporate opportunities for receiving feedback from CHWs within HIV programs.
As discussed, principlism represents a promising strategy to begin tackling ethical issues arising in public health contexts . The five aforementioned principles offer a tangible way to navigate complex decision-making in HIV care delivery in LMICs. However, there are limitations to using principle-based approaches in public health settings. Principlism risks having a reductionist tendency [29, 54], as it reduces complex ethical issues into a concise list of principles. In doing so, some of the nuanced challenges that may undergird these issues risk being oversimplified . Moreover, although principles serve as a guideline, they cannot always be strictly applied as there may be some contexts where they can be appropriately used and other instances where they cannot . Additionally, principles are subjective, as they leave considerable space for judgment regarding what ethical issues ought to be prioritized . The principles listed in this paper can therefore serve as a starting point to discussing and tackling public health ethical challenges  that emerge when CHWs are deployed in HIV programs. However, they do not represent a single, conclusive strategy to addressing the multifaceted issues discussed.