Below is the citation, abstract and selected extracts of a new study from Tanzania in the open-access journal Human Resources for Health. For me, it is a reality check that many CHWs are not provided supportive supervision, and are instead managed top-down. Clearly, a shift is needed across the CHW workforce, from ‘control and correction’ to ‘support and mentorship’. The paper also highlights the importance of dual pillars of personal support for CHWs: the CHW supervisor and the community leader.

CITATION: Initial experiences and innovations in supervising community health workers for maternal, newborn, and child health in Morogoro region, Tanzania

Timothy Roberton, Jennifer Applegate, Amnesty E Lefevre, Idda Mosha, Chelsea M Cooper, Marissa Silverman, Isabelle Feldhaus, Joy J Chebet, Rose Mpembeni, Helen Semu, Japhet Killewo, Peter Winch, Abdullah H Baqui and Asha S George. Human Resources for Health 2015, 13:19  doi:10.1186/s12960-015-0010-x

http://www.human-resources-health.com/content/13/1/19

ABSTRACT

Background: Supervision is meant to improve the performance and motivation of community health workers (CHWs). However, most evidence on supervision relates to facility health workers. The Integrated Maternal, Newborn, and Child Health (MNCH) Program in Morogoro region, Tanzania, implemented a CHW pilot with a cascade supervision model where facility health workers were trained in supportive supervision for volunteer CHWs, supported by regional and district staff, and with village leaders to further support CHWs. We examine the initial experiences of CHWs, their supervisors, and village leaders to understand the strengths and challenges of such a supervision model for CHWs.

Methods: Quantitative and qualitative data were collected concurrently from CHWs, supervisors, and village leaders. A survey was administered to 228 (96%) of the CHWs in the Integrated MNCH Program and semi-structured interviews were conducted with 15 CHWs, 8 supervisors, and 15 village leaders purposefully sampled to represent different actor perspectives from health centre catchment villages in Morogoro region. Descriptive statistics analysed the frequency and content of CHW supervision, while thematic content analysis explored CHW, supervisor, and village leader experiences with CHW supervision.

Results: CHWs meet with their facility-based supervisors an average of 1.2 times per month. CHWs value supervision and appreciate the sense of legitimacy that arises when supervisors visit them in their village. Village leaders and district staff are engaged and committed to supporting CHWs. Despite these successes, facility-based supervisors visit CHWs in their village an average of only once every 2.8 months, CHWs and supervisors still see supervision primarily as an opportunity to check reports, and meetings with district staff are infrequent and not well scheduled.

Conclusions: Supervision of CHWs could be strengthened by streamlining supervision protocols to focus less on report checking and more on problem solving and skills development. Facility health workers, while important for technical oversight, may not be the best mentors for certain tasks such as community relationship-building. We suggest further exploring CHW supervision innovations, such as an enhanced role for community actors, who may be more suitable to support CHWs engaged primarily in health promotion than scarce and over-worked facility health workers.

EXTRACTS FROM FULL TEXT (selected by Neil PW)

‘Supportive supervision emphasizes the human aspect of supervision and involves reciprocal relationships between health workers, their supervisor, and other stakeholders. It focuses on goal-setting, identifying and resolving problems through discussions between the health worker and supervisor, promoting high standards, teamwork, and two-way communication [21]. Supportive supervision focuses more on mentoring, problem solving, and proactive planning, than on checking registers and the verification of data [24]. Quality improvement programmes in sub-Saharan Africa, including Tanzania, have suggested that supportive supervision and mentoring could help to achieve high-quality health services [26].’

‘Another development in the supervision of CHWs is the inclusion of community members as part of a CHW’s support structure. Recent frameworks have put CHWs in the interface between the health system and the community [6],[28], and increasingly policy-makers are seeing supervision as involving both health facility and community supports [6]. The involvement of community leaders has the potential to enhance community embeddedness, buy-in from community members, and community accountability. A recent study in Tanzania concluded that the involvement of village leaders in CHW supervision has the potential to increase the number of supervision contacts and improve the accountability of CHWs within the communities they serve [16].’

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HIFA profile: Neil Pakenham-Walsh is the coordinator of the HIFA campaign (Healthcare Information For All) and co-director of the Global Healthcare Information Network. He is also currently chair of the Dgroups Foundation (www.dgroups.info), a partnership of 18 international development organisations promoting dialogue for international health and development. He started his career as a hospital doctor in the UK, and has clinical experience as an isolated health worker in rural Ecuador and Peru.  For the last 20 years he has been committed to the global challenge of improving the availability and use of relevant, reliable healthcare information for health workers and citizens in low- and middle-income countries. He is also interested in the wider potential of inclusive, interdisciplinary communication platforms to help address global health and international development challenges. He has worked with the World Health Organization, the Wellcome Trust, Medicine Digest and INASP (International Network for the Availability of Scientific Publications). He is based near Oxford, UK.       www.hifa2015.org  Twitter: @hifa_org FB: facebook.com/HIFAdotORG     neil.pakenham-walsh AT ghi-net.org

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