By: Dr. Kate Tulenko
This is the tenth chapter of the CHW Reference Guide produced under the Maternal and Child Health Integrated Program, the United States Agency for International Development Bureau for Global Health’s flagship maternal, neonatal and child health project.
Chapter 10 of the CHW Reference Guide explores the critical and complex issue of the supervision of community health workers (CHWs). Supervision of CHWs is a core health systems function that is often poorly understood and undervalued. Supervision is often incorrectly viewed as policing or as an unnecessary expense, but as this chapter shows, when supervision is properly designed and implemented, it can yield significant rewards in terms of quality of care, productivity, and retention of health workers.
As a synthesis of the current literature on supervision of CHWs, the chapter presents a series of strong takeaways that can be applied to CHW programs in almost any setting. Solutions are offered to the most stubborn challenges of CHW supervision, including budgeting, travel, and overburdened and poorly prepared supervisors. The chapter presents an incredibly helpful list of key questions to ask when designing supervision systems for health workers. If all CHW programs would consider these questions, we’d see a significant improvement in the quality of supervision.
The chapter explores the three main objectives of supervising CHWs: improve the quality of services, exchange information, and create a supportive work environment for the CHW. It also explains how both the community and the health system have a role in the supervision of CHWs. The need for supervision standards, guidelines, and job aids is discussed, as well as how to use information to improve CHW performance.
Different models of CHW supervision are explored, including facility-based supervision, direct supervision in the community, group supervision, peer supervision, and community supervision. The chapter includes a discussion of the promise of mHealth supervision (the supervision of CHWs via mobile devices). Where transportation remains a chronic problem either due to issues of budget, lack of functioning vehicles, or road conditions, mobile phone supervision or the use of professional transport companies should be considered.
In addition to enabling CHWs to interact with their supervisors more often, mobile phones open up the possibility of remote viewing of data, ePayment, and more. New mobile phone applications such as mHero can be used for systemic two-way SMS communication with health workers both during emergencies and routine work in addition to exchanging data, these systems can be used to assess the mental health and motivation levels of health workers remotely. Such mobile phone applications, which can be made interoperable with the rest of the health system, can integrate supervision into larger data exchange and communications systems, allowing greater coordination and deeper analysis. Interactive Voice Response for distance learning on standard mobile phones can also push out new information when guidelines are updated as well as during epidemics. Hotlines can be set up for “just in time” supervision or technical assistance for CHWs.
Finally, the chapter ends with a discussion of finding the time for supervision. To avoid overwhelming supervisors with too many duties, space must be made in a supervisor’s schedule for effective supervision. This can be accomplished through a variety of means, including through dedicated supervisors who do not have clinical responsibilities or through eliminating the burden of travel on the supervisor by bringing groups of supervisees to the supervisor’s work site. The chapter ends with sample supervision checklists and documentation.
There is still much to be done in the field of supervision, many innovations to be tested and challenges to be explored. Supervision competencies (how to get the most of supervisory visits and how to work as a supervisor or peer supervisor) need to be integrated into the pre-service education of CHWs. Supervisors must be trained in how to supervise and in many cases supervisees need to be trained in how to use constructive feedback. In many settings, workers may never have received feedback before and may react to constructive criticism by shutting down or becoming demotivated. CHW supervision will benefit from the push to professionalize CHWs. As CHWs become standardized at the national level and professional associations, standards of care, and methods to remove negligent and unqualified CHWs are established, their supervision will also be standardized and elevated, as it has with higher level workers. These higher level workers can also benefit from the lessons learned from CHW supervision. The reality is that many mid- and high-level health workers are not adequately supervised and what is learned from cost-effective supervision of CHWs can be applied to mid-and high-level health workers to improve their work experience as well.
As the global health community looks toward Sustainable Development Goals and Universal Health Coverage, supervision needs to be seen as an essential input which leverages the existing resources in communities, including individual CHWs, their peers, higher level cadres, and the community. Supervision can play an important role in health systems resiliency. Most models of health systems resiliency emphasize the importance of communications and local capacity. When formal communications are interrupted by emergencies, the informal communications between supervisors and supervisees (especially via mobile phone) can serve as a key element of communication. In addition, peer supervision builds strong teams and robust capacity at the local level. This way, if communities are cut off from central governments in times of crisis, the peer supervision group can support one another to continue to provide their valuable services as well as respond directly to the emergency. The role of supervision of CHWs as a form of governance also needs greater recognition and exploration. CHWs are often the only formal representative of the central government in many communities.
Supervision is strongly linked to citizen voice and to women’s empowerment. When community members have a role in supervising their CHWs, they can—sometimes for the first time—have a say in the delivery of government service. Community involvement that starts in the health sector can then expand to other sectors so that communities are empowered to speak up about the quality of other crucial government and private services including education and transportation. In many societies it may not be the custom for a woman to be “superior” to a man or to tell him what to do. Female supervisors supervising male CHWs may be the first time that some communities see a woman superior to a man at the local level. The existence of supervisory jobs also creates a career ladder for women to earn larger salaries and become more economically independent.
Ultimately, CHWs have special supervision needs. Their general level of education, literacy, and numeracy is usually much lower than other health workers and their period of formal CHW training is often less than a year. CHWs usually practice alone and are required to reach out to families, many of whom may not want their help and may disparage them as not being real health workers. This isolation, stress, and low level of skills can result in high levels of burnout, absenteeism, and attrition. We hope that by investing in high-quality supervision for CHWs that we can help them reach their full potential and help communities achieve optimum health.
Kate Tulenko, MD, MPH, MPhil, is a physician and global health specialist committed to primary care and developing solutions to the global shortage in the health workforce. After joining the World Bank in 2002, she helped create the Bank’s Africa Health Workforce Program in order to address the shortage, low productivity, and maldistribution of health workers throughout Africa. Tulenko is globally recognized for her expertise in health workforce and health systems, and has served as an advisor to national governments on health policy and reform as well as on expert panels for the World Health Organization, the American Public Health Association, the Global Health Workforce Alliance, the American Hospital Association, and others. Currently she serves as IntraHealth International’s Vice President of Health Systems Innovation, leading work on providing health workforce staffing and human resource management to health facilities and digital health in the global south.