CHWs (3) Supportive supervision

20 October, 2019

Dear HIFA colleagues,

Welcome to Part 2 of our discussion on CHWs! In part 1 we looked at Recommendations 1-5 of the CHW Guideline, on selection, pre-service training and certification. In Part 2 we'll explore Recommendations 6-10, which cover supervision, remuneration, career prospects, and workload.

Recommendation 6 suggests certain strategies to use for supportive supervision of CHWs:

1. appropriate supervisor–supervisee ratio allowing meaningful and regular support;

2. ensuring supervisors receive adequate training;

3. coaching and mentoring of CHWs;

4. use of observation of service delivery, performance data and community feedback;

5. prioritization of improving the quality of supervision.

How do these relate to current practice in your country/experience? Are they implementable in your country/experience?

Here are some extracts from the Guideline on this topic:

'The importance of adequate supervision of CHWs is well recognized. International evidence suggests that regular and systematic supervision, with clearly defined objectives, can improve the performance of CHWs involved in primary health care (100–102). Supportive supervision that targets and measures knowledge and skills, motivation, and adherence to correct practices provides incentives that positively impact performance (103). There is also emerging evidence suggesting that employing mobile phones, including for better supervision, can improve health care delivery in resourcelimited settings (104).

'A typical challenge however is a lack of resources to provide a supportive supervision and environment to optimize the capacity of CHWs (21, 105, 106). It is essential to streamline the supervision process by identifying effective strategies and including them in the implementation of interventions.

'The evidence retrieved and analysed for the purpose of this guideline reiterated the importance of supportive supervision and identified a number of supervision strategies in the context of different programmes and initiatives. However, the studies typically did not compare specific supervision strategies against others in terms of effectiveness, costs, acceptability, feasibility or other outcomes.'

'In light of the very low certainty of the evidence and the need to adapt supervisory strategies to the requirements of different contexts, this recommendation was a conditional one.'

SUMMARY OF EVIDENCE

'The systematic review (Annex 6.6) on the question – “In the context of community health worker programmes, what strategies of supportive supervision should be adopted over what other strategies?” (107) – identified 13 eligible studies: nine quantitative, of which five were RCTs, and four qualitative.

'The studies came from India (three studies), Ethiopia, Kenya, and Uganda (two studies each), and Lao People’s Democratic Republic, Malawi, Pakistan, and the United Republic of Tanzania (one study each). Various approaches and modalities of supervision were found to be effective in improving various aspects of CHW programme performance (108–114), in some cases also showing a dose–gradient response (115), while on limited occasions there was no measurable difference on some outcomes between the study arm receiving the supervision intervention and the study arm that did not (116, 117). The qualitative studies found evidence that different supportive supervision strategies were deemed helpful and reinforced motivation by the CHWs themselves (116, 118–120).'

'The systematic review of reviews found several studies confirming the critical importance of supportive supervision to enhance CHW quality, motivation and performance (13, 51, 121–125). However, it similarly found very limited evidence on which supervisory approaches work best. Supervision that focuses on supportive approaches, quality assurance and problem solving may be most effective at improving CHW performance (as opposed to more bureaucratic and punitive

approaches) (17, 105, 126).'

The term 'supportive supervision' is not further defined per se, but 'The stakeholder perception survey identified most supportive supervision strategies (including coaching, observation at community and facility, community feedback, and supervision by trained health workers) to be acceptable and feasible,

but lower levels of acceptability and especially of feasibility were identified for direct supervision of service delivery and supervision conducted by other CHWs'.

The Full Guideline is available here: https://apps.who.int/iris/bitstream/handle/10665/275474/9789241550369-en...

Best wishes, Neil

Let's build a future where people are no longer dying for lack of healthcare information - Join HIFA: www.hifa.org

HIFA profile: Neil Pakenham-Walsh is coordinator of the HIFA global health campaign (Healthcare Information For All - www.hifa.org ), a global community with almost 20,000 members in 180 countries, interacting on six global forums in four languages (English, French, Spanish, Portuguese). Twitter: @hifa_org FB: facebook.com/HIFAdotORG neil@hifa.org