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Efforts to scale community health worker programs within primary health care systems in 7 countries illustrated that these efforts are best understood as a complex process of institutional reform. Successful scale up depends on a problem-driven political process; requires that models develop solutions that align with resources, capabilities, and commitments of key stakeholders; and emerges from iterative cycles of learning and improvement., Key Findings Despite strong interest and policy commitments from many countries, models for community-based primary health service delivery have been slow to achieve full scale or deliver quality that matches their potential. Reform requires a carefully choreographed effort to enroll key stakeholders to support change by spotlighting a locally relevant gap in the existing health system's performance. Designing and launching community health programs depends heavily on local context and must draw from models that are available within a given health system and that align with the resources, capabilities, and commitments of key stakeholders. Reform should be viewed as an ongoing adaptive and evolutionary process; learning, governance, and management systems must be designed with this trajectory in mind. Key Implications Ministries of health, development partners, and other reform stakeholders can: Use the principles in the reform cycle process to identify gaps and priorities for technical work or investmentExamine community health efforts to identify where technical approaches can be complemented by political, institutional, and reform approachesCritically examine projects that implement term-limited, externally driven interventions and adapt designs to promote sustained, well-integrated community health programs at scale, To develop guidance for governments and partners seeking to scale community health worker programs, we developed a conceptual framework, collected observations from the scale-up efforts of 7 countries, workshopped the framework with technical groups and with country stakeholders, and reviewed literature in the areas of health and policy reform, change management, institutional development, health systems, and advocacy. We observed that successful scale-up is a complex process of institutional reform. Successful scale-up: (1) depends on a carefully choreographed, problem-driven political process; (2) requires that scaled program models are drawn from solutions that are available in a given health system context and aligned with the resources, capabilities, and commitments of key health sector stakeholders; and (3) emerges from iterative cycles of learning and improvement, rather than a single, linear scale-up effort. We identify stages of the reform process associated with each of these 3 findings: problem prioritization, coalition building, solution gathering, design, program readiness, launch, governance, and management and learning. The resulting Community Health Systems Reform Cycle can be used by government, donors, and nongovernmental partners to prioritize and design community health worker scale-up efforts, diagnose challenges or gaps in successful scale-up and integration, and coordinate the contributions of diverse stakeholders.