CHWs (5) Supportive supervision (2)

21 October, 2019

Dear HIFA colleagues,

As we discuss Recommendation 6 on Supportive Supervision, it will be helpful to review the evidence. The Guideline Development Group carried out a systematic review of the evidemnce

'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).'

I was unable to find Annex 6, but the Guideline notes that '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.'

The citation and abstract of one of these studies is shown below.

CITATION: Glob Health Action. 2014 May 8;7:24085. doi: 10.3402/gha.v7.24085. eCollection 2014.

Supervising community health workers in low-income countries--a review of impact and implementation issues.

Hill Z1, Dumbaugh M2, Benton L2, Källander K3, Strachan D2, ten Asbroek A4, Tibenderana J3, Kirkwood B4, Meek S3.


BACKGROUND: Community health workers (CHWs) are an increasingly important component of health systems and programs. Despite the recognized role of supervision in ensuring CHWs are effective, supervision is often weak and under-supported. Little is known about what constitutes adequate supervision and how different supervision strategies influence performance, motivation, and retention.

OBJECTIVE: To determine the impact of supervision strategies used in low- and middle-income countries and discuss implementation and feasibility issues with a focus on CHWs.

DESIGN: A search of peer-reviewed, English language articles evaluating health provider supervision strategies was conducted through November 2013. Included articles evaluated the impact of supervision in low- or middle-income countries using a controlled, pre-/post- or observational design. Implementation and feasibility literature included both peer-reviewed and gray literature.

RESULTS: A total of 22 impact papers were identified. Papers were from a range of low- and middle-income countries addressing the supervision of a variety of health care providers. We classified interventions as testing supervision frequency, the supportive/facilitative supervision package, supervision mode (peer, group, and community), tools (self-assessment and checklists), focus (quality assurance/problem solving), and training. Outcomes included coverage, performance, and perception of quality but were not uniform across studies. Evidence suggests that improving supervision quality has a greater impact than increasing frequency of supervision alone. Supportive supervision packages, community monitoring, and quality improvement/problem-solving approaches show the most promise; however, evaluation of all strategies was weak.

CONCLUSION: Few supervision strategies have been rigorously tested and data on CHW supervision is particularly sparse. This review highlights the diversity of supervision approaches that policy makers have to choose from and, while choices should be context specific, our findings suggest that high-quality supervision that focuses on supportive approaches, community monitoring, and/or quality assurance/problem solving may be most effective.

Best wishes, Neil

Coordinator, HIFA Project on Community Health Workers - Supported by the World Health Organization

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HIFA profile: Neil Pakenham-Walsh is coordinator of the HIFA global health campaign (Healthcare Information For All - ), a global community with more than 19,000 members in 177 countries, interacting on six global forums in four languages. Twitter: @hifa_org FB: