BACKGROUND: It may be assumed that supportive supervision effectively builds capacity, improves the quality of care provided by frontline health workers, and positively impacts clinical outcomes. Evidence on the role of supervision in Sub-Saharan Africa has been inconclusive, despite the critical need to maximize the workforce in low-resource settings.
OBJECTIVES: To review the published literature from Sub-Saharan Africa on the effects of supportive supervision on quality of care, and health worker motivation and performance.
SEARCH STRATEGY: A systematic review of seven databases of both qualitative and quantitative studies published in peer-reviewed journals.
SELECTION CRITERIA: Selected studies were based in primary healthcare settings in Sub-Saharan Africa and present primary data concerning supportive supervision.
DATA COLLECTION AND ANALYSIS: Thematic synthesis where data from the identified studies were grouped and interpreted according to prominent themes.
MAIN RESULTS: Supportive supervision can increase job satisfaction and health worker motivation. Evidence is mixed on whether this translates to increased clinical competence and there is little evidence of the effect on clinical outcomes.
CONCLUSIONS: Results highlight the lack of sound evidence on the effects of supportive supervision owing to limitations in research design and the complexity of evaluating such interventions. The approaches required a high level of external inputs, which challenge the sustainability of such models.
BACKGROUND: Community health workers (CHWs) are an increasingly important component of health systems and programs. Despite the recognized role of supervision in ensuring CHWs are effective, supervision is often weak and under-supported. Little is known about what constitutes adequate supervision and how different supervision strategies influence performance, motivation, and retention.
OBJECTIVE: To determine the impact of supervision strategies used in low- and middle-income countries and discuss implementation and feasibility issues with a focus on CHWs.
DESIGN: A search of peer-reviewed, English language articles evaluating health provider supervision strategies was conducted through November 2013. Included articles evaluated the impact of supervision in low- or middle-income countries using a controlled, pre-/post- or observational design. Implementation and feasibility literature included both peer-reviewed and gray literature.
RESULTS: A total of 22 impact papers were identified. Papers were from a range of low- and middle-income countries addressing the supervision of a variety of health care providers. We classified interventions as testing supervision frequency, the supportive/facilitative supervision package, supervision mode (peer, group, and community), tools (self-assessment and checklists), focus (quality assurance/problem solving), and training. Outcomes included coverage, performance, and perception of quality but were not uniform across studies. Evidence suggests that improving supervision quality has a greater impact than increasing frequency of supervision alone. Supportive supervision packages, community monitoring, and quality improvement/problem-solving approaches show the most promise; however, evaluation of all strategies was weak.
CONCLUSION: Few supervision strategies have been rigorously tested and data on CHW supervision is particularly sparse. This review highlights the diversity of supervision approaches that policy makers have to choose from and, while choices should be context specific, our findings suggest that high-quality supervision that focuses on supportive approaches, community monitoring, and/or quality assurance/problem solving may be most effective.
The use of clinical guidelines has been shown to confer benefits for care delivery in high-income settings, but little is known about their implementation in low-income settings. We conducted a systematic literature review on the implementation of World Health Organisation (WHO) clinical guidelines for hospital care in low-income settings. We searched Medline, Global Health and Scopus for articles describing the implementation of clinical guidelines issued by the WHO for hospitals in low-income countries. Each article in the final sample was reviewed independently by two reviewers who harmonised their findings to identify key factors affecting the implementation process, which were grouped into thematic categories through negotiated consensus among project team members. Seventeen studies met the inclusion criteria. Factors affecting the guideline implementation process in low-income countries were (1) degree of support from facility management and Ministry of Health, (2) credibility and acceptability of clinical guidelines from the perspective of health care providers, (3) efforts to adapt clinical guidelines to local circumstances and (4) use of guides and checklists for implementation. These four factors consistently emerged in our review and should be considered when designing future strategies to implement clinical guidelines in low-income countries.
BACKGROUND: An estimated 6.9 million children die annually in low and middle-income countries because of treatable illneses including pneumonia, diarrhea, and malaria. To reduce morbidity and mortality, the Integrated Management of Childhood Illness strategy was developed, which included a component to strengthen the skills of health workers in identifying and managing these conditions. A systematic review and meta-analysis were conducted to determine whether IMCI training actually improves performance.
METHODS: Database searches of CIHAHL, CENTRAL, EMBASE, Global Health, Medline, Ovid Healthstar, and PubMed were performed from 1990 to February 2013, and supplemented with grey literature searches and reviews of bibliographies. Studies were included if they compared the performance of IMCI and non-IMCI health workers in illness classification, prescription of medications, vaccinations, and counseling on nutrition and admistration of oral therapies. Dersminion-Laird random effect models were used to summarize the effect estimates.
RESULTS: The systematic review and meta-analysis included 46 and 26 studies, respectively. Four cluster-randomized controlled trials, seven pre-post studies, and 15 cross-sectional studies were included. Findings were heterogeneous across performance domains with evidence of effect modification by health worker performance at baseline. Overall, IMCI-trained workers were more likely to correctly classify illnesses (RR = 1.93, 95% CI: 1.66-2.24). Studies of workers with lower baseline performance showed greater improvements in prescribing medications (RR = 3.08, 95% CI: 2.04-4.66), vaccinating children (RR = 3.45, 95% CI: 1.49-8.01), and counseling families on adequate nutrition (RR = 10.12, 95% CI: 6.03-16.99) and administering oral therapies (RR = 3.76, 95% CI: 2.30-6.13). Trends toward greater training benefits were observed in studies that were conducted in lower resource settings and reported greater supervision.
CONCLUSION: Findings suggest that IMCI training improves health worker performance. However, these estimates need to be interpreted cautiously given the observational nature of the studies and presence of heterogeneity.
OBJECTIVE: Implementation of the Integrated Management of Childhood Illness (IMCI) strategy with an 11-day training course for health workers improves care for ill children in outpatient settings in developing countries. The 11-day course duration is recommended by the World Health Organization, which developed IMCI. Our aim was to determine if shortening the training (to reduce cost) reduces its effectiveness. METHODS: We conducted a systematic review to compare IMCI's effectiveness with standard training (duration ≥11 days) versus shortened training (5-10 days). Studies were identified from a search of MEDLINE, two existing systematic reviews, and by contacting investigators. We included published or unpublished studies that evaluated IMCI's effectiveness in developing countries and reported quantitative measures of health worker practices related to managing ill children under 5 years old in public or private health facilities. Summary measures were the median of effect sizes for all outcomes from a given study, and the percentage of patients needing oral antimicrobials or rehydration who were treated according to IMCI guidelines. FINDINGS: Twenty-nine studies were included. Direct comparisons from three studies showed little difference between standard and shortened training. Indirect comparisons from 26 studies revealed that effect sizes for standard training versus no IMCI were greater than shortened training versus no IMCI. Across all comparisons, differences ranged from -3 to +23 percentage-points, and our best estimate was a 2 to 16 percentage-point advantage for standard training. No result was statistically significant. After IMCI training (of any duration), 34% of ill children needing oral antimicrobials or rehydration were not receiving these treatments according to IMCI guidelines. CONCLUSIONS: Based on limited evidence, standard IMCI training seemed more effective than shortened training, although the difference might be small. As sizable performance gaps often existed after IMCI training, countries should consider implementing other interventions to support health workers after training, regardless of training duration.
OBJECTIVE: To assess the effectiveness of pharmaceutical systems interventions in improving the availability of essential medicines at the primary care level.
METHODS: Literature search for examples of pharmaceutical systems interventions in low and middle income countries that evaluated the impact of specific interventions on medicines' availability. Qualitative and quantitative studies were included.
RESULTS: Seventeen studies were included, on privatisation of drug distribution, user-fees, revolving drug funds (RDFs), supervisory visitation programmes, staff training initiatives, community-directed interventions (CDIs) and disease-specific drug programmes. We found no studies on non-monetary staff incentives or the use of national pharmacy standards. Generally, the quantity and quality of evidence was low; evidence was strongest for supervisory visitation programmes and CDIs.
CONCLUSION: Several interventions have the potential for improving medicines' availability without requiring large-scale international cooperation or global policy change. The absence of evidence in this field does not prove lack of effect. There is a need for more systematic studies of multi-faceted pharmaceutical interventions to improve drug availability in the context of difficult health systems, such as structured supervision of remote health facilities, CDIs, staff training, integration of disease-specific programmes, implementation of national pharmacy standards, non-monetary staff incentives and measures to ensure cost is not a barrier to access. A standardised approach to measuring the availability of essential medicines is needed.
OBJECTIVES: To (a) summarise opinion about what supervision of primary health care is by those advocating it; (b) compare these features with reports describing supervision in practice; and (c) to appraise the evidence of the effects of sector performance. METHODS: Systematic review. Reports were classified into three groups and summarised using appropriate methods: policy and opinion papers (narrative summary), descriptive studies (systematically summarised) and experimental or quasi-experimental studies (design and outcomes systematically summarised). Data presented as narrative summaries and tables. RESULTS: 74 reports were included. In eight policy and opinion papers, supervision was conceptualised as the link between the district and the peripheral health staff; it is important in performance and staff motivation; it often includes problem solving, reviewing records, and observing clinical practice; and is usually undertaken by visiting the supervisees place of work. In 54 descriptive studies, the setting was the primary health care (PHC) or specific services and programmes. Supervisor-supervisee dyads were generally district personnel supervising health facilities or lay health workers. Supervision mostly meant visiting supervisees, but also included meetings in the centre; it appeared to focus on administration and checking, sometimes with checklists. Problem solving, feedback and clinical supervision, training and consultation with the community were less commonly described in the descriptive studies. Supervision appears expensive from studies that have reported costs. In 12 quasi-experimental trials, supervision interventions generally showed small positive effects in some of the outcomes assessed. However, trial quality was mixed, and outcomes varied greatly between studies. CONCLUSIONS: Supervision is widely recommended, but is a complex intervention and implemented in different ways. There is some evidence of benefit on health care performance, but the studies are generally limited in the rigor and follow up is limited. Further research delineating what supervision consists of and evaluating it in the context of unbiased comparisons would guide the implementation of effective supervision as part of the management of PHC.
National governments and international agencies, including programmes like the Global Alliance for Vaccines and Immunizations and the Global Fund to Fight AIDS, Tuberculosis and Malaria, have committed to scaling up health interventions and to meeting the Millennium Development Goals (MDGs), and need information on costs of scaling up these interventions. However, there has been no systematic attempt across health interventions to determine the impact of scaling up on the costs of programmes. This paper presents a systematic review of the literature on the costs of scaling up health interventions. The objectives of this review are to identify factors affecting costs as coverage increases and to describe typical cost curves for different kinds of interventions. Thirty-seven studies were found, three containing cost data from programmes that had already been scaled up. The other studies provide either quantitative cost projections or qualitative descriptions of factors affecting costs when interventions are scaled up, and are used to determine important factors to consider when scaling up. Cost curves for the scaling up of different health interventions could not be derived with the available data. This review demonstrates that the costs of scaling up an intervention are specific to both the type of intervention and its particular setting. However, the literature indicates general principles that can guide the process: (1) calculate separate unit costs for urban and rural populations; (2) identify economies and diseconomies of scale, and separate the fixed and variable components of the costs; (3) assess availability and capacity of health human resources; and (4) include administrative costs, which can constitute a significant proportion of scale-up costs in the short run. This study is limited by the scarcity of real data reported in the public domain that address costs when scaling up health interventions. As coverage of health interventions increases in the process of meeting the MDGs and other health goals, it is recommended that costs of scaling up are reported alongside the impact on health of the scaled-up interventions.
