Association between supportive supervision and performance of community health workers in India: a longitudinal multi-level analysis

Lakshmi Gopalakrishnan,Purnima Menon,Rasmi Avula,Nadia Diamond-Smith,Dilys Walker,Lia Fernald,Sumeet Patil

doi:10.1186/s12960-021-00689-7

Abstract

IntroductionCommunity health workers (CHWs) deliver services at-scale to reduce maternal and child undernutrition, but often face inadequate support from the health system to perform their job well. Supportive supervision is a promising intervention that strengthens the health system and can enable CHWs to offer quality services.ObjectivesWe examined if greater intensity of supportive supervision as defined by monitoring visits to Anganwadi Centre, CHW-supervisor meetings, and training provided by supervisors to CHWs in the context of Integrated Child Services Development (ICDS), a national nutrition program in India, is associated with higher performance of CHWs. Per program guidelines, we develop the performance of CHWs measure by using an additive score of nutrition services delivered by CHWs. We also tested to see if supportive supervision is indirectly associated with CHW performance through CHW knowledge.MethodsWe used longitudinal survey data of CHWs from an impact evaluation of an at-scale technology intervention in Madhya Pradesh and Bihar. Since the inception of ICDS, CHWs have received supportive supervision from their supervisors to provide services in the communities they serve. Mixed-effects logistic regression models were used to test if higher intensity supportive supervision was associated with improved CHW performance. The model included district fixed effects and random intercepts for the sectors to which supervisors belong.ResultsAmong 809 CHWs, the baseline proportion of better performers was 45%. Compared to CHWs who received lower intensity of supportive supervision, CHWs who received greater intensity of supportive supervision had 70% higher odds (AOR 1.70, 95% CI 1.16, 2.49) of better performance after controlling for their baseline performance, CHW characteristics such as age, education, experience, caste, timely payment of salaries, Anganwadi Centre facility index, motivation, and population served in their catchment area. A test of mediation indicated that supportive supervision is associated indirectly with CHW performance through improvement in CHW knowledge.ConclusionHigher intensity of supportive supervision is associated with improved CHW performance directly and through knowledge of CHWs. Leveraging institutional mechanisms such as supportive supervision could be important in improving service delivery to reach beneficiaries and potentially better infant and young child feeding practices and nutritional outcomes.Trial registration : Trial registration number: https://doi.org/10.1186/ISRCTN83902145

Highlights

Community health workers (CHWs) deliver services at-scale to reduce maternal and child undernutri‐ tion, but often face inadequate support from the health system to perform their job well
Compared to CHWs who received lower intensity of supportive supervision, CHWs who received greater intensity of supportive supervision had 70% higher odds (AOR 1.70, 95% CI 1.16, 2.49) of better performance after controlling for their baseline performance, CHW characteristics such as age, education, experience, caste, timely payment of salaries, Anganwadi Centre facility index, motivation, and population served in their catchment area
Higher intensity of supportive supervision is associated with improved CHW performance directly and through knowledge of CHWs

Summary

Introduction

Community health workers (CHWs) deliver services at-scale to reduce maternal and child undernutri‐ tion, but often face inadequate support from the health system to perform their job well. The term “Community health workers” covers a broad category of lay and educated, formal and informal, paid and unpaid, health workers Their role typically involves educating community members about health risks, promoting health behaviors, and referring community members to formal health system services [2]. A considerable amount of research synthesized in various systematic reviews highlights that CHWs programs have successfully improved breastfeeding practices and immunization uptake, reduced pneumonia, diarrhea, and delayed bottle feeding, and promoted essential newborn care [4, 9, 10]. A slightly dated review of CHWs from India found robust evidence of the positive role CHWs play in expanding vaccination coverage by targeting hard-to-reach households, timely tracking of children, and sensitizing rural communities about vaccination services [11]

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