Supportive supervision for community health workers : a case study of Ethiopia's Health Extension Programme

Abstract

Supervision of community health workers (CHWs) is an essential component of primary health care programmes. Yet supervision systems tend to focus on inspection and fault finding, which have been found to be demotivating for CHWs. As a result, there has been a shift towards supportive supervision, an approach that emphasises joint problem solving, mentoring, and constructive feedback. While there is some evidence that this approach is associated with increased motivation and improved productivity among CHWs, there is limited empirical evidence available to those implementing CHW programmes to assist them in designing more effective supportive supervision systems. In particular, there is an identified need for more qualitative research in this area. Moreover, although there is extensive literature regarding supervision in fields such as psychology and nursing, research to date on supportive supervision for CHWs has not been contextualised within this literature. Therefore, the purpose of this study was to explore perceptions and experiences of supportive supervision for CHWs in a primary health care programme, in order to advance supervision theory by relating findings from a real-life context to an existing framework of supervision. This instrumental case study explored supportive supervision in the context of Ethiopia’s Health Extension Programme. In response to challenges in the supervision of Ethiopia’s national cohort of over 35,000 CHWs (who are referred to as health extension workers (HEWs) in Ethiopia), the Ministry of Health began implementing a system of supportive supervision in 2012. While several studies have explored experiences of supervision in CHW programmes, no qualitative case studies have specifically examined supportive supervision for Ethiopian HEWs. Therefore, Ethiopia’s Health Extension Programme was identified as a particularly interesting context in which to explore supportive supervision for CHWs in primary health care programmes. In order to examine this research problem, this case study employed descriptive and interpretive approaches to qualitative research. Four domains of inquiry were identified regarding perceptions and experiences of supportive supervision: the context in which supportive supervision took place; the implementation of supportive supervision; the outcomes of supportive supervision; and challenges to supportive supervision. Interview guides were developed based on these four domains, and semi-structured interviews were conducted with a total of 33 participants, including health extension workers, supervisors, and health system managers. Health system managers included representatives from four levels of the health system, ranging from health centres to the Ministry of Health. Interviews at the Ministry of Health took place in Addis Ababa; all other interviews took place in the region surrounding Awassa in southern Ethiopia. All interviews were audio-recorded and transcribed. Data were analysed using constant comparative analysis to identify meaning units and categories within each of the four domains of inquiry. The context in which supportive supervision was implemented was characterised by a strong sense of satisfaction among HEWs, derived from serving the community, alongside deep frustration with institutional and infrastructural barriers to providing community health services. The implementation of supportive supervision involved a one-day orientation for supervisors; an increase in the frequency of supervision from once every one to three months under the previous supervision system to one to five visits per week under supportive supervision; the use of weekly work plans which were jointly created and reviewed; an emphasis on on-the-job training for skills development of HEWs; and supervisors being held accountable for HEWs’ performance. The main outcomes of supportive supervision included supervisors feeling responsible for HEWs’ performance and consequently providing health services alongside HEWs during supervisory visits; skills sharing between HEWs and supervisors; the development of a close supervisory relationship marked by trust and openness; and perceived increases in HEWs’ satisfaction, motivation, and performance under supportive supervision when compared to the previous system of supervision. The key challenges to supportive supervision were the need for further training for supervisors; work overload among both HEWs and supervisors; and lack of transportation for supervisors. The findings were examined in relation to existing frameworks of supervision, and Proctor’s Supervision Alliance Model was found to most closely reflect supportive supervision in Ethiopia’s Health Extension Programme. Proctor’s emphasis on the restorative function of supervision as the foundation of the normative and formative functions corresponds with this study’s main finding: across all participant groups there was a consistent perception that the effectiveness of supportive supervision was dependent on the strength of the supervisory relationship. This theoretical finding has important practical implications for supportive supervision systems in primary health care programmes. The restorative function of supportive supervision could be operationalised through supervisory training emphasising communication skills and respectful engagement, within supervision systems that aim to achieve a high frequency of supervision along with consistent use of work plans. This study’s emphasis on the practical application of theoretical findings informed by contextual realities represents an important and original contribution to knowledge regarding supportive supervision, particularly as CHW programmes are rapidly expanding throughout the world.