Community Health Worker Supervision: Maximizing Effectiveness and Retention CRIGLER

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?
10/13/2015CORE Group: CHW Supervision
2

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
3

Supervision: in Context
4

Actors and Influencers
5

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?
6

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
7

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
8

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
9

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?
10

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
11

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
12

Approaches to Supervision
 1 Traditional or External Supervision
 2 Group Supervision
 3 Peer Supervision
 4 Community (or Health Committee) Supervision
13

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.
14

Group Supervision
 Objectives: Links CHW to health system: protocols,
supplies, collection of data, group support
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
15

Peer Supervision
 Objectives: Using peers, such as other CHWs, to aid in
supervision of CHWs
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)
16

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
17

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.
18

Future Generations/Peru
Brief overview:
External Supervision from Health Center or District Health
Office with Community Facilitators
19

Helen Keller
International/Burkina Faso
Brief overview:
Group supervision with VHCs
20

CORE Group Polio Project/
India
Brief overview:
Peer supervision and use of coordination meetings
21

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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Community Health Worker Supervision: Maximizing Effectiveness and Retention CRIGLER

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Community Health Worker Supervision: Maximizing Effectiveness and Retention CRIGLER