Supervision is the process of directing and supporting staff so that they may effectively perform their duties. Supervision may include periodic events, such as site visits or performance reviews, but it also refers to the ongoing relationship between a staff member and a supervisor.
In health care settings, supervision often includes oversight and implementation of clinical and non-clinical tasks and activities that affect the organization, management, and technical delivery of health services, such as control of work processes and systems, maintenance of facilities and infrastructure, and monitoring and improvement of system-wide performance. Beyond this technical role, there is also an important human dimension to the supervisor-health worker relationship. In low-resource settings, where many health providers work alone or in small groups in remote sites, the supervisor may be the only link to the larger health system.
Supervisory audit of health worker performance is one of the few audit and feedback interventions widely used in LMIC. Anecdotal evidence and the few published studies suggest that supervisory audit can be effective in increasing performance according to standards. A Quality Assurance Project study in Niger measured the impact of structured supervisory feedback on health worker adherence to Integrated Management of Childhood Illness (IMCI) standards for assessment, treatment, and counseling of sick children. The study found that supervisory feedback had a significant short-term impact on IMCI performance, although the effect was not universal across all IMCI skill areas; it had the greatest effect in areas where health workers had been performing poorly (Kelley et al. 2000).
Supervision has traditionally been viewed as a key approach to improving the quality of health care and the performance of health care providers, especially given the labor-intensive nature of health service delivery. This is particularly true in developing countries, where supervision remains one of the most direct ways for an organization to affect what its staff does. At the same time, adequate supervision is frequently not realized or sustained, and many supervisors lack the knowledge, skills, and tools for effective supervision.
Governments and donors have invested significant resources to strengthen supervision systems in LMIC through supervisor training and supervisory tools and checklists. The Government of South Africa, for example, has made primary health care supervision as cornerstone of the national health care system. The Department of Health’s Primary Health Care Supervision Manual contains guidelines for quality supervision, use of supervision support checklists, conduct of in-depth technical program reviews, and tools for working with Primary Health Care Facility Committees (Department of Health 2009).
International health agencies have reached consensus in recent years about the key functions of supervision: setting objectives, providing training and guidance, monitoring and evaluating performance, providing feedback, motivating staff, and providing support to solve problems (Marquez & Kean 2002). At the same time, a growing body of experience from different settings suggests that broadening and enhancing how supervision functions can be performed––by involving health workers themselves, peers, and even communities. Evidence suggests that these alternative approaches achieve better health worker performance and outcomes than traditional supervisory approaches, and some evidence indicates that these approaches may be more sustainable.
Text box: Improving Community Case Management of Childhood Illness through
Supervision and Performance Feedback in Rwanda
The Kabeho Mwana Project, implemented by Concern Worldwide, in partnership with the International Rescue Committee and World Relief in six districts of Rwanda, used several quality improvement strategies in a project designed to scale-up integrated community case management (iCCM) of malaria, diarrhea, and pneumonia:
- Equipped and trained community health workers (CHWs) to carry out community case management (CCM) for malaria, diarrhea, and pneumonia.
- Organized CHW peer-support and collaboration groups (heavily modified Care Groups, since referred to as CHW peer support groups)
- Supervised CHWs by Cell Coordinators (CHW peers) and Community Health In-Charges, with funding provided to health centers to support supervision visits by the In-Charges every three months.
- Assessed and provided feedback from supervisors based on the standards supervision checklist developed by the Ministry of Health (MOH).
- Provided job aids to support behavior change communications.
- Developed an IMCI Bulletin or scorecard that provided feedback every six months to districts and health centers on the quality of their services based on their performance on a set of indicators for compliance with agreed-upon standards.
- Held feedback meetings where Cell Coordinators, Data Managers, and Community Health In-Charges reviewed the scorecard, discussed its meaning, problem-solved around implementation challenges, and planned next steps.
MOH staff interviewed during the project’s final evaluation “generally and often spontaneously referred quite positively to the experience with the Bulletin and the feedback meetings, described as a set package.” The project achieved a high-level of appropriate care seeking for fever in the six districts, at 75%, with appropriate treatment increasing from 20% to 43% of cases from 2006–2011. Other indicators also improved, such as vitamin A coverage (from 66% to 86%), point-of-use water treatment (31% to 65%), and handwashing (2% to 19%).
Source: Sarriot & Kabeho Mwana Final Evaluation Team, 2011.