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

Abstract

BackgroundCommunity 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.ObjectiveTo determine the impact of supervision strategies used in low- and middle-income countries and discuss implementation and feasibility issues with a focus on CHWs.DesignA 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.ResultsA 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.ConclusionFew 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.

Improving community health worker performance through supportive supervision: a randomised controlled implementation trial in Pakistan

“…This finding accords with research, which suggests that supervision and feedback significantly improve CHW performance . Higher quality of supervision contributes to better CHW performance just as much as increased frequency of supervision . Therefore, improving the clinical skills of LHSs along with more frequent field visits where they could repeatedly demonstrate correct clinical practices was likely to have improved LHW skills .…”

Knowledge and practice of health extension workers on drug provision for childhood illness in west Gojjam, Amhara, Northwest Ethiopia

“…HEWs who were supervised biannually were less like to have a good practice on drug provision than those who were supervised monthly. This finding is consistent with studies conducted in Uganda and other low-income countries [50,51]. Besides, HEWs who had no national guidelines were less likely to have a good practice of drug provision than those who had national guidelines.…”

The performance of community health workers in the management of multiple childhood infectious diseases in Lira, northern Uganda – a mixed methods cross-sectional study

“…Studies have shown that support supervision is critical for improving the performance of CHWs (11). However, despite its importance, the implementation of support supervision has been identified as a weak link in many CHW programs (31, 32). Yet, it is not clear how this can be effectively implemented (33).…”