Supervision of Community Health Workers in Low- and Middle-Income Countries
Huyen Vu, MPH
Community health workers (CHWs) serve an increasingly important role as intermediary between patients and health services. In low-income and middle-income countries, where healthcare systems often face resource shortages, CHWs find themselves taking on a wide range of tasks and responsibilities. In these settings, providing strong supervision for CHWs is vital to ensuring consistent quality of care.
Studies suggest that effective supervision of CHWs can motivate them, create a sense of legitimacy for both CHWs and the community they serve, identify and correct poor CHW practices, and help resolve challenges unique to CHWs (Jenkins R et al., 2013; Ledikwe J et al., 2013). In practice, however, the quality of CHW supervision is highly variable due to lack of skills and tools, limited transportation resources, financial obstacles, and cultural factors in the local health systems.
In an effort to help improve the quality of CHW supervision, Zelee Hill and her colleagues recently conducted a systematic review to identify different CHW supervision strategies that have been applied in low- and middle-income countries, along with implementation issues of those strategies. Below are some key findings from the review.
Gold-standards for CHW supervision
Supportive/facilitative supervision is considered the gold-standard practice in CHW supervision.
- Description: This approach is a process of guiding, monitoring and coaching CHWs to promote compliance with practice standards, and ensure the delivery of quality of care services. The strategy allows supervisors and supervised CHWs to work together as a team to achieve shared goals and objectives. Typically, a formal health worker from a local health center or district health facility provides supervision on a monthly or quarterly basis.
- Implementation issues: Time consuming process, challenges in maintaining supervision coverage and motivation, providing intensive external support during initial supervision, organizing lengthy supervisory visits, and providing timely post-supervision visit feedback.
- Example models: Lady Health Worker Program (Pakistan), Integrated Management of Childhood Illness (Benin), and Health Extension Workers Program (Ethiopia).
Innovative approaches to CHW supervision
Group supervision is identified as the most time and resource efficient practice as it allows supervisors to cover a large geographic area at lower cost. It is at least as effective as standard supervision, and can even be more feasible in some settings.
- Description: This approach involves a formal health worker supervising a group of CHWs (at a facility or in a community). On a monthly or quarterly basis, multiple CHWs come together for a facilitated meeting with their supervisor. Meetings may include regular supervisory activities such as data collection, problem discussion, and continuing education.
- Implementation issues: As this requires strong leadership and management skills, it would become challenging if supervisors are really not “supervisors.”
- Example models: Vurhonga Child Survival Project (Mozambique), and Female Community Health Volunteer Program (Nepal).
Peer supervision shows the most potential as it takes advantage of peer-to-peer empathy to facilitate supervision of CHWs through on-the-job training and mentorship.
- Description: In this approach, peers take on supervisory roles through peer-to-peer learning, support and problem-solving. Specifically, it focuses on having CHWs help other CHWs learn new skills and assess the quality of work performed by peer CHWs. Peer supervision can be conducted quarterly and be a substitute for traditional supervision for cost-saving purposes. Some common forms of peer mentorship include observation and feedback, stronger peers supporting weaker peers, and group meetings for problem discussion and solving.
- Implementation issues: May not be a best practice in all settings as it could create tensions between CHWs; CHWs may not challenge each other or be able to recognize their peers’ weakness; possible high workloads due to staff turnover.
- Example models: Integrated Management of Childhood Illness (Rwanda).
Community supervision is based on the idea that a community can hold CHWs accountable if they have relevant information about the delivery of services and patient rights.
- Description: In this approach, community groups, members, or associations play a role in defining expectations, providing feedback, and tracking CHW activity through monthly meetings.
- Implementation issues: Challenges in measuring success or impact; requires community-based training, resources, materials as well as strong community-based organizations.
- Example models: Community-based monitoring public primary health care provider (Uganda), and Community-Directed Interventions Program (multiple African countries).
- Description: This approach allows CHWs to self-identify their own strengths and weaknesses in specific practice areas by completing a knowledge test or quality improvement checklist, in the absence of a supervisor. The assessment, which can be conducted weekly, monthly, quarterly or at will, is usually followed by guidance on how to improve performance. The test result may be recorded and shared with a supervisor later.
- Implementation issues: Feasibility issues for this strategy include arranging time and recalling session to complete forms, fatigue with filling the same forms repeatedly, and accuracy of the self-assessment result from low-performing CHWs.
Many strategies exist to ensure effective supervision of CHWs, yet care should be taken to match the best strategy to the setting. Lauren Crigler and colleagues stress the importance of achieving an agreement among key policymakers, stakeholders, and program managers on a supervision strategy before the supervision approach is designed. Some principles to consider are:
- Study and identify what has already existed in the system, and build upon it
- Use a bottom-up approach by involving CHWs and local communities in the design and implementation of supervision process
- Concentrate on planning of supervision, and make sure to monitor progress
- Hold all parties accountable, including senior managers, supervisors, CHWs, communities, and clients
- Develop skills at all levels, such as teamwork, data management, problem identification, prioritization, and resolution.