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Community Health
Worker Supervision Maximizing Effectiveness and Retention
Lauren Crigler
Crigler Global Consulting
October 8, 2015
CORE Group Meeting
Reflection for a Moment Literature is replete with statements that supervision is
critical to program success….
Reality says that supervision is virtually non-existent or
of questionable value
What do we hope to achieve?
Improve motivation and retention
Increase effectiveness and improve quality
Be scalable
Why is it so difficult to implement?
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Challenges to Supervision Travel expenses and logistics
Supervisors are not really “supervisors”
Supervisors do not have appropriate tools and support
to conduct supervision
Supervisors don’t understand the CHW role or the
context in which they operate
Gender issues – supervisors are often men and CHWs
are often female
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Supervision: in Context
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Actors and Influencers
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7 Key Questions What are the objectives of CHW supervision?
What strategies should shape the supervision approach?
What standards and guidelines should guide CHW performance?
Who will supervise? Who will supervise the supervisors?
How often should supervision be done?
How can you ensure that supervision visits are planned, implemented, and tracked?
How will information be used to improve performance?
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Q1: What are the objectives of
supervision?
Quality
Adherence to norms and guidelines
Drugs and supplies
Communication and information
Households, visits, EPI
Promotional messages, education
Supportive
Emotional, motivational
Coaching and problem-solving
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Q2: What strategies should
guide the approach? Build upon what exists
Use a bottom-up approach
Plan, and monitor implementation
Engage all levels for accountability
Develop capacity at all levels:
Data management
Teamwork
Problem-solving
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Q3:What standards should
guide performance? Foundation of quality is a thoughtful and thorough set
of standards/guidelines that are communicated to
everyone and that engage everyone—
CHWs
Supervisors
Program managers
Health committee
Community
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Q4&5: Who will Supervise
Whom? How Often? Who will supervise?
Who will supervise the supervisor?
How often will it happen?
Where will it happen?
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Q:6 Plan, Implement and
Track Yearly plans are made but not followed
Plans focus on coverage and health indicators while management processes are overlooked
Supervisors are rarely prepared for visits and visits are often not carried out
A plan is only as good as its implementation, monitoring and evaluation
Monitor and evaluate the process not only the outcomes
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Performance Improvement CHWs are the closest link to communities and asked to
collect lots of data
Data go up and rarely come back down
Supervisors usually do not use data for improving
performance
But they could, if information flow is planned and
organized, and supervisors, CHWs and communities
have access to the right kinds of data
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Approaches to Supervision 1 Traditional or External Supervision
2 Group Supervision
3 Peer Supervision
4 Community (or Health Committee) Supervision
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External Supervision Objectives: Links CHW to health system: protocols,
supplies, collection of data, one to one support
Prerequisites: Functioning and accessible HC, travel resources, available and prepared supervisors, tools
Benefits: Linkages to health system, clinical oversight, integration of new protocols, health system issues addressed (drugs). Also potentially scalable.
Challenges: Expensive, difficult to implement and monitor, requires functioning PHC system (to support and evaluate supervisors) and trained and available supervisors. Little to no community input.
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Group Supervision Objectives: Links CHW to health system: protocols,
supplies, collection of data, group support
Prerequisites: Functioning and accessible HC, travel resources, tools
Benefits: Linkages to health system, some clinical oversight, health system issues addressed (drugs). Also potentially scalable.
Challenges: Requires functioning PHC system (to support and evaluate supervisors), little if any input from community, CHWs receive less (or no) one-to-one coaching
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Peer Supervision Objectives: Using peers, such as other CHWs, to aid in
supervision of CHWs
Prerequisites: Functioning and accessible HC, travel
resources, appropriate tools
Benefits: Strong feedback component, peer to peer
learning, problem solving. Also potentially scalable but
requires district/local support
Challenges: Types and numbers of CHWs in proximity.
Peer-based training and materials. Facilitation skills.
Monitoring and evaluation (Quality control)
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Community-based
Supervision Objectives: Engaging the community in expectation-setting,
role development and recruitment. Also, in providing
feedback and guidance to CHWs
Prerequisites: moderate to high community engagement in
health or in another sector; access to data; authority to
incentivize or sanction for performance
Benefits: cost-saving; improved impact; direct response to
community needs
Challenges: managing linkages to health sector; clinical
quality management; PHC management at a local level
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Most Effective and Innovative
Interventions Use of peer assessments,
group assessments, self-assessments, community-assessments, and combinations of these
Use of checklists; and
Focus on problem-solving at the supervisor, provider, or community levels
Group supervision focused on goal setting and problem-solving
Engaging stronger peers to support weaker peers through on-the-job training and mentoring
Community monitoring of health worker performance; and
Onsite visits from supervisors, with periodic self-assessments (recorded and shared with a supervisor) and regular phone calls from a supervisor.
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Future Generations/Peru
Brief overview:
External Supervision from Health Center or District Health
Office with Community Facilitators
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Helen Keller
International/Burkina Faso
Brief overview:
Group supervision with VHCs
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CORE Group Polio Project/
India
Brief overview:
Peer supervision and use of coordination meetings
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Wrap up and Take-away Supervision is challenging, but ripe for innovation
Supportive supervision has several objectives:
design/implement to meet objectives
Adapt to local environment, use of data for
improvement, and engagement of resources (human:
groups, peers, communities) to share the responsibility
Effective supervision requires time, resources, and
careful planning and monitoring of implementation
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