Abstract
BackgroundSupervision 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.MethodsQuantitative 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.ResultsCHWs 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.ConclusionsSupervision 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.
Highlights
Supervision is meant to improve the performance and motivation of community health workers (CHWs)
This paper explores the experiences of CHWs, supervisors, and village leaders involved in the Integrated MNCH Program, to understand the initial strengths and challenges of its CHW supervision model and to offer further insight into innovations that support CHWs
We used this framework to assess whether, and to what extent, the supervision offered to CHWs reflects the supportive and community-embedded supervision model the Integrated MNCH Program set out to implement
Summary
Supervision is meant to improve the performance and motivation of community health workers (CHWs). Most evidence on supervision relates to facility health workers. A common challenge concerns human resource management: how to ensure the retention, motivation, and sustained competence of CHWs, who often have limited education, operate in isolation far from health facilities, and sometimes receive only nominal pay. One component of health programmes that is often advocated to address human resource challenges is supervision [5,6,7,8,9,10,11,12]. Supervision of facility-based health workers has received noticeable attention over the past 10 years [13]. Researchers have suggested that supervision can increase both the performance and motivation of health workers [14], the evidence for these assertions is limited. Compared to other front-line health workers, CHWs have less training, and CHWs operate at a distance from their supervisors, in the village, whereas facility-based health workers generally have a supervisor in place at their health facility
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