Scorecard metrics for assessing the extent of integration of community health worker programmes into national health systems

Background The effectiveness of community health workers (CHWs) in delivering community-based preventive services is often curtailed by inadequate or complete lack of integration of the CHW programmes into national health systems. Although literature has defined the context and guidelines for integrating CHW programmes into health systems, indicators to quantitatively assess the extent of integration are inadequately addressed. Aim This article presents an integration scale – CHW Programme Integration Scorecard Metrics (CHWP-ISM) – for measuring the extent of CHW programme integration into national health systems. Setting Literature review and policy documents were focused on sub-Saharan Africa, while interview participants were drawn from six African countries. Methods A deductive–inductive approach to item and measurement scale development was employed. Information obtained from a combination of diverse literature sources, subject matter expert (SME) interviews and documentary abstraction from publicly available policy documents advised item generation for the proposed CHWP-ISM. The study qualitatively captured the sectoral CHW integration, thematically analysed the data and culminated in the quantitative integration metrics. Results Analysis of the responses from six SMEs and abstraction from policy documents resulted in the compilation of metrics with a total of 100 indicators for the CHWP-ISM scale that could be used to assess the level of CHW programmes integration into national health systems. The indicators were categorised along the six World Health Organization’s (WHO) health systems building blocks. Subject matter expert responses corresponded well with abstracted results from the 18 country CHW programmes, indicating content validity. Conclusion The proposed scorecard metrics can be used to quantitatively rate the extent of CHW programmes integration into health systems, in an attempt to strengthen health systems to improve health outcomes.


Introduction
Community health workers (CHWs) possess a unique public health advantage that enables them to be more effective as compared with other healthcare cadres in the delivery of community-based health services. Some of the factors that enable CHWs to effectively deliver community-based health services are as follows: (1) they mostly belong to and operate within their local communities 1,2 , (2) they are trusted by local community members, 2,3 especially where communities take part in CHWs selection themselves and (3) their cultural competency, 1,4 proximity and availability in communities even beyond official working hours for local health facilities. 1,2 Evidence highlighting CHWs' potential and effectiveness in strengthening health systems to improve health outcomes by making services more accessible and acceptable has been steadily mounting. 5,6,7,8,9 However, research also points out that the proved potency of CHWs in improving health outcomes is being curtailed by the lack of integration of CHW programmes into national health systems. 5,6,10,11,12,13,14 Nevertheless, it has been reported that high-performing CHW subsystems are dependent on deep integration into health systems 5,15 because they enjoy support from other health system actors. Integration of a CHW programme into formal healthcare systems has thus been pointed out as a critical component that is requisite to the design and implementation of effectual and maintainable CHW programmes. 16,17,18,19,20 As a result, CHW programme integration has become a critical topic of international deliberations and concern to the global public health community, as evidenced by current World Health Organization's (WHO) recommendations to member states to integrate CHW programmes into national health systems. 2,21,22,23 Recent literature has defined the context, mechanisms and guidelines for integrating CHWs programmes into mainstream health systems, 5,6,21,22,23,24,25,26,27,28,29,30 but not many studies have quantitatively assessed the extent of CHW programmes integration into respective health systems in sub-Saharan Africa (SSA). This study aimed at identifying the integration metrics for assessing the extent of CHW programmes integration into national health systems in SSA. The study also undertook content validity for the identified scale items. This study adopted the definition of integration by Atun et al., 31 which states 'the extent and nature of adoption and eventual assimilation of CHW programme into each of the critical functions/ building blocks of a health system'.

Methodology
The study employed a deductive-inductive approach to item and measurement scale development. Information was obtained from a combination of literature reviews, interviews with field experts and documentary abstractions from publicly available policy documents of 18 sub-Saharan African countries. The study formulated a conceptual framework that guided the integration metrics item identification and development.

Participants
The study used two types of sources of information: the subject matter experts (SMEs) and documents (the country's CHW programme policies). Purposive and snowballing sampling techniques were used to identify six SMEs for the purpose of item generation through in-depth interviews between the months of July and November 2018. Expertise of SMEs was judged based on their involvement in CHWs' work as evidenced by the publication history in peerreviewed journals and participation in key CHW forums. Six SMEs agreed to participate in the interview survey.
Documents used for this study were conveniently sampled from Community Health Systems (CHS) Catalogue database (https://www.advancingpartners.org/resources/chsc). They comprised of country-specific CHS Catalogue produced by the United States Agency for International Development's (USAID's) Advancing Partners and Communities (APC) project (APC 2017). The CHS Catalogue is an online CHW resource pool that contains information on community health programmes, CHWs and CHW interventions. We focused on CHS Catalogues because they contained summaries of countryspecific CHW programme policies, strategies, guidelines, plans and reports. The CHS Catalogue is based on the WHO's health systems framework, which is the premise upon which this study's integration variables are built. Further inclusion criteria comprised of catalogues that focused specifically on sub-Saharan African countries, community health programmes, CHWs and CHW interventions at policy level.

Procedure
The study was conducted in a three-step procedure. The first step was literature and documentation review of CHW programmes that led to the identification and definition of the construct under study, which is integration of CHW programmes into national health systems. It was also used to deductively arrive at scale item generation. Item and scale development procedure employed the conceptual framework, which is described in the next section.
The second step involved SME interviews. Subject matter experts who were locally based were interviewed in person, whereas those who were out of the country were mainly interviewed telephonically (Skype), using unstructured but themed interviews. An interview guide based on the six integration variables was used to elicit respondents' views rather than open-ended questioning. Before each interview, SMEs were briefed and an operational definition of integration was provided to guide their understanding of the study concepts. Subject matter experts were asked to respond to how each of the a priori identified CHW integration variables would assess the extent of CHW programme integration into national health systems. Their responses were qualitatively recorded and thematically presented in Table 2, which is part of generated items.
The third step involved scale item content validation. This was conducted through documentary abstraction from publicly available CHS policy documents. We started by establishing if the country has policy documents that articulate the inclusion of CHW work. Thereafter, attention was directed at abstraction of evidence of integration for each WHO building block from the available policy documents. A web-based form was used to integrate the data abstracted from the policy documents scored as 'YES' or 'NO' to indicate the presence or absence of the evidence of integration at policy level. This was to facilitate the collection of data with minimum cost, ensure upsurge in response rate and allow for instant feedback, as advised in Refs. 32,33 The determination of 'YES' or 'NO' was done by the researchers based on pre-agreed criteria for assessing the evidence of integration. Two researchers abstracted the data from the policy documents. The first four policy documents were abstracted in parallel to find the level of agreement between the two based on the data abstraction form. Disagreement was resolved by a moderator. The policy data abstraction were carried out not only to assess the extent to which questions imitate the construct under study and that responses produce valid measurement, but also to ensure availability of enough data for scale development and validation as advised by Boateng et al. 34 The results are shown in Appendix 1. Data amassed through the given methods were analysed thematically to identify key integration themes and corresponding integration variables, parameters and indicators.
In summary, through existing literature on CHW programmes related to possible indicators 5,21,22,23,24,26,27,35,36,37,38 of the integration construct, 39,40 interviews of the SMEs 41 were used to deductively 42 and inductively 39,42 identify items for the integration measurement scale. Two methods were employed to define and identify the items that assess the integration of CHW programmes into national health systems at this stage to facilitate a balance of both the theoretical basis and manifest forms 34 that give a broader and more comprehensive 43,44 scale of measurement. Content validity was performed through documentary abstractions.

The community health worker programme integration variable identification framework
The dimensions of the domain under study were determined a priori, as contained in Boateng et al. 34 The integration of CHW programmes into health system was premised on the WHO's Health Systems building blocks framework for health systems strengthening (HSS). 45 Specific efforts of CHW programmes in strengthening health systems were set at improving the already existing blocks which are as follows: service delivery, human resources for health, information, medical products, financing and leadership and governance as stated in the WHO's building blocks. 45 The WHO's building blocks framework has been criticised for failure to acknowledge the interconnectedness and interaction of the various health systems components, as well as customers and communities who are the critical core of health systems. However, the adoption of the framework for this study was premised on the fact that some of the concerns have since been addressed in a revised version of the framework. 46 The study also employed some of Perry et al.'s interlinkages between the WHO's health systems building blocks 45 and CHW programmes, 27 as explicated in the 2013 CHW Assessment and Improvement Matrix (AIM) best practice for CHW programme functionality. 26 For the purpose of this study, the corresponding CHW programme components that seek to strengthen respective six critical functions of the health system to improve health outcomes were identified as CHW recruitment, education and certification (REC) 21,22,23 , CHWs' roles and responsibilities, CHWs' remuneration, CHWs' supervision, CHWs' information management and CHWs' equipment and supplies 22,23,26,27,35 for the development of the measurement metrics scorecard as illustrated in Figure 1.
Based on extant literature, the CHW programme components illustrated in Figure 1 were incorporated and used to build a more parsimonious yet robust CHW integration framework. In addition to the WHO's health systems building blocks and their corresponding CHW programme components, this study used three more parameters by which the construct of integration was examined at a more refined resolution: the process of integration, the evidence of integration and status of integration. To satisfy the process of integration parameter, selected countries had to have policy documents that clearly articulated procedures for the inclusion of CHW work. Availability of government/Ministry of Health (MOH) policy-generated standardised guidelines on each of the CHW programme components that seek to improve corresponding WHO's health systems building blocks provided evidence of integration.
Lastly, the status of integration zoomed into the actual extent or degree of integration. This component is adopted from the study by Atun et al., 47 who proposed that integration status of health interventions (CHW programmes) into health systems can assume different forms. They could either be fully, partially or not integrated at all, in line with the respective building blocks of the health systems. 31,48,49 Based on CHW integration components as illustrated in Figures 1  and 2, this study proposes a quantitative interpretation of CHW programmes integration. The presence or absence of integration indicators is used to score all the aspects that make up specific integration parameters. Thereafter, the aggregation of the integration indicators is judged against the scale to determine the extent of integration (expressed as a percentage). Therefore, drawing from existing literature, 26,27,35,37,45,47,50 this study used an integration conceptual framework ( Figure 2) within which an integration scorecard metrics was developed, whose core elements are: • WHO's health systems building block • corresponding CHW programme component • process of integration • evidence of integration • status of integration

Demographic characteristics of human participants
All six SMEs who participated in this study had more than 15    •The process of integration: Government through the health system/MOH institute policies that define and describes CHW roles and responsibilities. •Evidence of integration: Health systems provides policy-generated guidelines on the roles, responsibilities, tasks, functions, duties and activities of CHWs and their relationship to the health system. The presence or absence of the chosen indicators will be indicated on a scorecard.

•Status of integration:
The presence or absence of integration indicators will be used to score all the aspects that make up this integration parameter. There after the aggregation of the integration indicators will be judged against the scale to determine the extent of integration in percentage.
•The process of integration: Follows that the health system/MOH provides policies that articulate how recruitment, training and certification will be provided to the CHWs to prepare them for their role and ensure acquistion of required skillset for safe and quality care ).
•The evidence of integration: Health system/MOH provides policy derived training plans and/or guidelines, training curricula, training databases or records (Crigler et al. 2013).

•Status of integration:
The presence or absence of integration indicators will be used to score all the aspects that make up this integration parameter. Thereafter the aggregation of the integration indicators will be judged against the scale to determine the extent of integration in percentage.

CHW Documentation and Information Management (Use of Data) Health Information (WHO 2007)
•The process of integration: Requires that the government through MOH/health system provides policy guidelines on CHW documentation and information management (Crigler et al. 2013).
•Evidence of Integration: Include standardised CHW notebooks, recording formats, record keeping guidelines how CHWs document visits, how community-level data flow to the health system and back to the community and how they are used for quality improvement ).

•Status of integration:
The presence or absence of integration indicators will be used to score all the aspects that make up this integration parameter. Thereafter the aggregation of the integration indicators will be judged against the scale to determine the extent of integration in percentage.

CHW equipment and supplies Medical Products and Technologies (WHO 2007)
•The process for integration: Necessitates that the health system/MOH provides policy guide on how the requisite equipment and supplies are availed to CHWs when needed to deliver expected services ).
•Evidence of integration: For this variable would include MOH policy directed guidelines for CHW stocks and supplies, supply ordering procedures and forms, inventory forms and procedures (Crigler et al. 2013).

•Status of integration:
The presence or absence of integration indicators will be used to score all the aspects that make up this integration parameter. Thereafter the aggregation of the integration indicators will be judged against the scale to determine the extent of integration in percentage.

CHW incentives, remuneration and motivation Health Financing (WHO 2007)
•The process of integration: Entails that the health system/MOH provides policy that articulates how a balanced incentive package reflecting job expectations, financial compensation in the form of salary and non-financial incentives will be provided ). •Evidence of integration: Would include health system policy derived guidelines and records on financial incentives such as salary and bonuses based of performance and non-financial incentives such as training, recognition, certification, uniforms, medicines, etc. appropriate to job expectations CHW remunerations, incentives payments (Crigler 2013).

•Status of integration:
The presence or absence of integration indicators will be used to score all the aspects that make up this integration parameter. Thereafter the aggregation of the integration indicators will be judged against the scale to determine the extent of integration in percentage.

CHW Supervision Leadership and Governance (WHO 2007)
•The process of integration: Requires that the health system/MOH policy articulating how consistent support and clear supervision guidelines will be offered; assign supervisors to visit CHS for performance review, coaching, problem solving, skills development and data reviews (Crigler 2013).
•Evidence of integration: Would include MOH policy standardised guidelines on CHW supervision plans, supervisor job descriptions and qualifications, supervision checklists or other tools, supervision reports, supervision training documents (Crigler 2013).

•Status of integration:
The presence or absence of integration indicators will be used to score all the aspects that make up this integration parameter. Thereafter the aggregation of the integration indicators will be judged against the scale to determine the extent of integration in percentage.
suitable indicators that could be used to measure the extent of CHW programme integration into corresponding health systems building blocks. More generally, respondents suggested many integration indicators, which were well represented amongst the six critical functions of a health system, although the CHW supervision did not have as much indicators as did the other CHW programme components. work-related incentives such as provision of work aids, equipment and uniforms by the health systems could be used as indicators of CHW integration into national health systems. Community health workers' supervision had the most varied integration indicators from respondents ranging from the policy inclusion of supervision mechanisms and strategies, supervisor-supervisee ratios, provision of technical and administrative support, coaching and mentorship to CHWs' performance evaluation.
Meanwhile, the CHW information management component had two most featured integration indicators amongst the SMEs: the integration of CHW generated data into national health information system and consolidation of community and facility data. The other suggested integration indicators for this component were the use of standardised data collection tools and the definition of the roles of both CHWs and their supervisors in data collection. In addition, three SMEs suggested the inclusion of data confidentiality and data security mechanisms in policy documents. Lastly, SMEs suggested varied indicators for CHW equipment and supplies component. Some of the suggestions were inclusion of mechanisms and procedures (processes) of CHW equipment and supply provisions in policy documents. In addition, they also suggested policy articulation on safe disposal of medical waste generated through community service. The rest of the integration indicators for all the six CHW programme components are summarised in Table 1.

Summary of data abstractions for 18 countries
This section presents summarised characteristics of CHW programmes reviewed in terms of the region where the country is located in SSA, country name, CHW programme name and CHW cadre name. Out of a total of 18 CHW programmes under consideration, 8 were from West Africa, 5 from East Africa, 4 from Southern Africa, whilst there was 1 from Central Africa. The rest of CHW programme characteristics are in Table 2, whilst online Appendix 1 presents the data abstracted from policy documents and scored as YES or NO to indicate the presence or absence of evidence of integration at policy level. Appendix 1 presents the CHW Programme Integration Scorecard Metrics (CHWP-ISM) scorecard metrics in the form of thematically synthesised data on CHW programme components, integration parameters and integration indicators. Items for CHWP-ISM scale were generated from CHW programme components that map onto respective WHO's health systems building blocks. The SMEs' responses presented in Table 1 correspond with the abstraction results in online Appendix 1, showing content validity. Therefore, Appendix 1 presents a consensus arrived at through a synthesis of data obtained from three sources: literature review, SME interviews and document abstractions.
As indicated in online Appendix 1, most integration parameters scored variedly across the 18 countries. With regard to CHW REC, most countries that scored positively in all indicators save for government sponsorship for CHW training, which was not articulated in all the reviewed country policy documents. Another integration indicator that was missing in all reviewed countries is government policy requirement for CHW training providers' accreditation by a national accreditation board and policy guidance on CHWs' post-qualification academic and career progression pathways. For instance, Liberia's policy that provides guidance on CHWs' post-training accreditation should be carried out by the national accreditation board, whilst all other countries were silent on the matter.
The CHWs' roles and responsibilities and the CHWs' services linkage to health systems integration parameters were positively scored in the policy documents of all countries. However, Tanzania was the only country with evidence of all five indicators of the CHWs' contractual agreements integration parameter. With regard to CHW services linkage to health system integration parameter, most countries fared very well except for description of transport system

Discussion
This study set out to identify integration metrics for assessing the extent of CHW programmes integration into national health system in SSA. The study also undertook content validity for the identified scale items. This section thematically discusses the proposed components of CHWP-ISM measurement scale components, as analysed using data from literature and documentation review, interviews with field experts and documentary abstractions. The framework used to guide identification of scale items comprised of HSS building blocks, corresponding CHW programme component, process, evidence and status of integration. The proposed items and content validity results in Appendix 1 and online Appendix 1 comprise of HSS building blocks, analogous CHW programme component, integration parameters and indicators.

Community health worker recruitment, education and certification (human resources for health)
According to SMEs' interviews, literature and documentary abstraction outcomes, as shown in Tables 1 and 2  This study found evidence of process of integration at policy level by examining policy articulation of how CHW recruitment/selection criteria were conducted and how preservice training and certification were provided to the CHWs to prepare them for their roles and ensure acquisition of required skill set for safe and quality care. This resonates with other recommendations from research that CHW programmes must ensure that a core set of skills and information is provided to CHWs. 5 The evidence of integration sought for under this integration variable was therefore health system policy-derived CHW recruitment processes and selection criteria, training plans and/or guidelines, training curricula, training databases and certification. This resulted in the 20 items identified that may be used to quantitatively indicate CHW programme integration under REC, as shown in Appendix 1.

Community health workers' roles and responsibilities (service delivery)
According to our findings, specific integration parameters that could be used to measure the extent of CHW programme integration into the service delivery building block include articulation of CHWs' services linkages to the health systems, CHWs' scope of service, CHWs' roles and responsibilities and signing of contractual agreements between CHWs and their employers at policy level. These findings resonate with the earlier recommendations that national decisions on the services provided by the CHWs should apex into a minimum package of activities defined by the country policy grounded on the countries' epidemiological and community priorities. 9 This is because CHWs represent one of the channels for health service delivery through which preventive, curative or rehabilitative care 45 could be delivered to populations at the home, the community, the workplace or in health facilities. 45 Therefore, community health workers could be considered as an extension of the healthcare system that takes healthcare to the household and community levels. 9 As such, the amalgam of services delivered by the CHWs should mirror an integrated set of community health interventions that feed obviously into the service delivery building block of the health system. The study found evidence of the process of integration for this variable by evaluating the policy articulation for defining and describing the scope of their work in terms of roles and responsibilities. 26 Evidence of integration zoomed into policy-derived guidelines clarifying the CHWs' roles, responsibilities, tasks, functions, duties and activities of CHWs and their relationship to the health system. 35 This resulted in the 15 indicators identified that may be used to quantitatively indicate CHW programme integration under REC, as shown in Appendix 1.

Community health workers' remuneration (health financing)
According to SMEs' interviews and document abstraction outcomes shown in Table 1, Appendix 1 and online Appendix 1 parameters for CHWs' remuneration include; the articulation of information on government funding for CHWs' incentives, CHWs' contractual agreements and guidelines on standardised packages for both financial and non-financial incentives in the policy documents. Our findings resonate with recommendations from other reviews that remuneration and provision of incentives for CHWs are essential and should be included in the health financing plan of the health systems. 5,9,23 In particular, the health system/MOH should provide policy that articulates how a balanced incentive package reflecting job expectations, financial compensation in the form of salary and nonfinancial incentives will be provided. 35 This is also in sync with WHO's recent strong recommendation to remunerate practicing CHWs for their work with a financial package commensurate with the job demands, complexity, number of hours, training and roles that they undertake. 21,23 This recommendation could have come as a response to earlier research findings that indicated lack of befitting remuneration as one of the renowned factors that diminish motivation and quality of work amongst CHWs. 9 This study found evidence of integration at policy level by examining policy articulation on guidelines and records on financial incentives such as salary and bonuses based on performance and non-financial incentives such as training, recognition, certification, uniforms and medicines appropriate to job expectations, CHWs' remunerations, incentives and payments. 26 This resulted in the 20 items identified that may be used to quantitatively indicate the extent to which CHWs' remuneration is integrated with the health financing building block of the health system as shown in Appendix 1.

Community health workers' supervision (leadership and governance)
According to our findings, specific integration parameters that could be used to measure the extent of CHW programme integration into the leadership and governance building block include articulation of supervision mechanisms and modalities, supportive supervision strategies and CHWs' performance evaluation by supervisors in policy documents. These findings harmonised with other recommendations that health system/MOH policy should describe how consistent support and clear supervision will be offered and assign supervisors to visit CHS for performance review, coaching, problem-solving, skills development and data reviews. 26 This buttresses several valuations of existing CHW programmes that cited lack of proper CHW supervision as one of obstacles to delivery of quality community health services by CHWs. 5,38,51,52 In response, direct and supportive supervision of CHWs by facility-based staff has been recommended as fundamental to strengthen integration of CHWs into health system. 9,21,23 This study found evidence of integration at policy level by examining policy articulation on CHW supervision plans, supervisors' job descriptions and qualifications, supervision checklists or other tools, supervision reports and supervision training documents. 35 This elicited 20 items identified that may be used to quantitatively indicate the extent to which CHW supervision is integrated into the leadership and governance building block of the health system as shown in Appendix 1.

Community health workers' documentation and information management (health information)
According to the SMEs' interviews and literature outcomes shown in Table 1 and Appendix 1, respectively, specific integration parameters that would indicate if CHWs' information management is integrated in the health information critical function of the health system include policy articulation of mechanisms for data collection and definition of both CHWs and their supervisors in data collection. These findings resonate with earlier recommendations that governments through MOH/health system ought to provide policy guidelines on CHW documentation and information management, 26 particularly pronouncing how CHW collected data streams to the health system and back to the community and the use of the data for improving quality of care 35 at community level. This is important because health knowledge and information gathered from different data sources via sundry channels is needed for decision-making at all levels of the health systems. 49 Community health workers are one of the channels through which important and hard-to-get health data can be mined from households.
The Earth Institute Technical Taskforce report submitted that the unique ability of CHWs to capture multifaceted and dynamic epidemiological and community swings at household level supplies critical information that advises health systems of their performance, especially with regard to local and national health priorities. 9 In this study, evidence of integration sought for under this CHW programme component included policy articulation on standardised use of data collection tools such as CHW notebooks and recording formats. We also examined policy pronunciation of record-keeping guidelines on how CHWs document visits, how community-level data flow to the health system and back to the community and how it is used for service improvement. 26 This culminated into 15 items that may be used to quantitatively indicate CHWs' information management and its integration into health information, which is a critical function of the health system as shown in Appendix 1.

Community health workers' equipment and supplies (medical products and technologies)
Our findings from both literature review and SMEs' interview show that integration parameters that could be used to specify if the CHW programme is integrated into the health systems' medical products and technology's critical function include mentioning of CHWs' equipment and supply mechanisms, procedures and processes in the policy documents. The findings resound with other recommendations that the health system/MOH should provide policy on how CHWs avail the necessary equipment and supplies when needed to deliver expected services. 35 Research has demonstrated how CHWs' acceptability in the community is closely tied to commodity availability. 5 It has been documented that if CHWs do not have a necessary supply to perform their duties, they lose credibility from the families they serve and will be rendered ineffective over the long term in improving child health outcomes. 9 Community health workers should therefore be furnished with a sturdy supply of all commodities and material support essential for their daily service delivery. This study found evidence of integration at policy level by examining policy articulation on guidelines for CHWs' stocks and supplies, supply ordering procedures and forms, inventory forms and procedures. 26 This culminated into 15-scale measures identified that it may be used to quantitatively indicate CHWs' equipment and supplies' integration into health information critical function of the medical products and technologies as shown in Appendix 1.
In developing the scorecard, the study made the assumption that all the six health systems building blocks contribute equally to the improvement of health outcomes. Further research is needed to ascertain contributory weights of each critical function.

Conclusion
The study aimed to identify scale items for a CHW integration scorecard metrics (CHWP-ISM) for assessing the degree of integration of CHW programmes into national health system in SSA. The proposed CHWP-ISM draws CHW integration variables that correspond with WHO's framework for HSS. It views the seamless and deliberate blending of CHW programme integration variables with critical national health system building blocks as one way of strengthening health systems to improve child health outcomes. Its use of WHO's six building blocks for health systems makes it applicable for evaluating the extent of integration of CHW programmes into the critical functions of the health system. This was intended to better the existing integration literature by juxtaposing CHW functions with the WHO's health system building blocks and in articulating how the former can be positioned to strengthen the latter. In other words, the study sought to examine not only how the health system structurally maps onto all essential CHW facets (integration variables) but also how these CHW facets link back to the various building blocks of a health system. This was explored with particular emphasis on public policies and guidelines that guide CHW programmes through evidence of CHWs inclusion into health system planning, budgeting and provision of logistical support. 35 This CHWP-ISM can be mainly used to quantitatively assess CHW programmes' extent of integration at national health systems level. But it may also, to some extent, be used to assess extent of CHWs at other levels of the health system, for example, local, district or provincial, particularly to indicate the interaction between the respective components of the health intervention under study and its corresponding WHO building block of the health system. The institutions and organisations that could benefit from the use of these recommendations include policymakers and advisers, health systems, ministries of health, donors, non-governmental organisations, programme managers and implementers and public health practitioners to mention but a few.
It is hoped that the use of this CHWP-ISM to assess the integration of CHW programmes can identify gaps that once addressed could better strengthen health systems to improve health outcomes in sub-Saharan Africa. For example, the scorecard recommends the involvement of community members and structures in CHWs' selection and recruitment. The scorecard can be used to identify a gap in this regard. Addressing this gap ensures that communities accept the CHWs and the health services that they offer. This enhances universal health coverage and achievement of health-related SDGs. However, the CHWP-ISM measurement scale needs to be subjected to statistical analysis, especially factor analysis to determine its dimensionality, construct validity and internal consistency in assessing the degree of integration of CHW programmes into national health systems.

Study limitations
The present study focused on policy level evidence of integration. This has a limited bearing on the gap between policy and practice, and hence, further research is needed to measure the evidence of integration of CHW programmes at implementation level. In addition, the study used the data collected from SMEs who were available during the short data collection window only. This also has a limited bearing on the kind of integration insights that might have been gained were it to extend to time that other SMEs would be available.