A multifaceted intervention to improve health worker adherence to integrated management of childhood illness guidelines in Benin. The effect of two models of supervision on selected outcomes. The impact of supervision on stock management and adherence to treatment guidelines: a randomized controlled trial. Improving primary health care through systematic supervision: a controlled field trial. Improving adherence to family planning guidelines in Kenya: an experiment. Participatory supervision model: building health promotion capacity among health officers and the community. Quarterly versus monthly supervision of CBD family planning programs: an experimental study in northeast Brazil.
We evaluated an intervention to support health workers after training in Integrated Management of Childhood Illness (IMCI), a strategy that can improve outcomes for children in developing countries by encouraging workers' use of evidence-based guidelines for managing the leading causes of child mortality.
                We conducted a randomized trial in Benin. We administered a survey in 1999 to assess health care quality before IMCI training. Health workers then received training plus either study supports (job aids, nonfinancial incentives, and supervision of workers and supervisors) or usual supports. Follow-up surveys conducted in 2001 to 2004 assessed recommended treatment, recommended or adequate treatment, and an index of overall guideline adherence.
                We analyzed 1244 consultations. Performance improved in both intervention and control groups, with no significant differences between groups. However, training proceeded slowly, and low-quality care from health workers without IMCI training diluted intervention effects. Per-protocol analyses revealed that workers with IMCI training plus study supports provided better care than did those with training plus usual supports (27.3 percentage-point difference for recommended treatment; P < .05), and both groups outperformed untrained workers.
                IMCI training was useful but insufficient. Relatively inexpensive supports can lead to additional improvements. To evaluate the effect of training in two different supervisory models on the supervision itself, the quality of care, and job satisfaction of nurses in different service settings in a district health service (DHS) in South Africa.
                As part of a larger health systems study, the results of supervision training were evaluated. The quantitative study was done in three health districts in South Africa.
                The modified matrix (MM) model of supervision was taught and implemented in District A, the Centre for Health and Social Studies (CHESS) model in District B, and the control was District C. Checklists based on direct observation and record reviews were used to measure quality of care (quality of hand-over between shifts, nursing records, management of chronic diseases, and implementation of universal precautions). Questionnaires were used to measure perception of supervision and patient satisfaction. Chi-square analysis was done.
                Supervision ratings before and after the interventions differed significantly in the total sample, but not by district. In the district with the MM model, care for people with chronic diseases improved significantly, but other measures did not. The supervision training had some influence, but more measures of effectiveness of supervision training are needed. Ensuring the availability of essential drugs and using them appropriately are crucial if limited resources for health care are to be used optimally. While training of health workers throughout Zimbabwe in drug management (including stock management and rational drug use) resulted in significant improvements in a variety of drug use indicators, these achievements could not be sustained, and a new strategy was introduced based on the supervision of primary health care providers. This was launched in 1995 with a training course in supervisory skills for district pharmacy staff. In order to evaluate the impact of the supervision and the effectiveness of the training programme, adherence to standard treatment guidelines (STG) and stock management protocols was evaluated in a randomized controlled trial. The study compared three different groups of health facilities: those that received supervision for either use of STG (n = 23) or stock management (n = 21) - each facility acting as control for the other area of supervision - and a comparison group of facilities which received no supervision (n = 18). On-the-spot supervision by a specially trained pharmacy staff, based around identified deficiencies, took place at the start of the study and 3 months later. The evaluation compared performance on a variety of drug management indicators at baseline and 6-8 months after the second supervisory visit. The results of the study showed that, following supervision, overall stock management improved significantly when compared with the control and comparison groups. Similar improvements were demonstrated for adherence to STG, although the effect was confounded by other interventions. The study also showed that supervision has a positive effect on improving performance in areas other than those supervised, and demonstrated that pharmacy technicians with limited clinical skills can be trained to influence primary health care workers to positively improve prescribing practices. Allocating resources to supervision is likely to result in improved performance of health workers with regard to the rational use of essential drugs, resulting in improved efficiency and effectiveness. Most primary health care services in developing countries are delivered by staff working in peripheral facilities where supervision is problematic. This study examined whether systematic supervision using an objective set of indicators could improve health worker performance. A checklist was developed by the Philippine Department of Health which assigned a score from 0 to 3 on each of 20 indicators which were clearly defined. The checklist was implemented in 4 remote provinces with 6 provinces from the same regions serving as a control area. In all 10 provinces, health facilities were randomly selected and surveyed before implementation of the checklist and again 6 months later. Performance, as measured by the combined scores on the 20 indicators, improved 42% (95% Cl = 29% to 55%) in the experimental group compared to 18% (95% Cl = 9% to 27%) in the control group. In the experimental, but not in the control facilities, there was a correlation between frequency of supervision and improvements in scores. The initial cost of implementing the checklist was US $ 19.92 per health facility and the annual recurrent costs were estimated at $ 1.85. Systematic supervision using clearly defined and quantifiable indicators can improve service delivery considerably, at modest cost. QUALITY PROBLEM: Research in Kenya in the mid-1990s suggested poor quality family planning services and limited access to services. Clinical guidelines for family planning and reproductive health were published in 1991 and updated in 1997, but never widely distributed.
                Managers and trainers chose intensive, district-level training workshops to disseminate guidelines and update health workers on guideline content and best practices.
                Training workshops were held in 41 districts in 1999. Trainees were instructed to update their untrained co-workers afterwards. As a reinforcement, providers in randomly selected areas received a 'cascade training package' of instructional materials and training tips. Providers in 15 randomly selected clinics also received 'supportive supervision' visits as a second reinforcement.
                A cluster-randomized experiment in 72 clinics assessed the overall impact of the training and the marginal benefits of the two reinforcing activities. Researchers and trainers created several dozen indicators of provider knowledge, attitudes, beliefs and practices. Binomial and multivariate analyses were used to compare changes over time in indicators and in aggregated summary scores. Data from patient interviews were analysed to corroborate provider practice self-reports. Cost data were collected for an economic evaluation.
                Post-test data collected in 2000 showed that quality of care and access increased after the intervention. The cascade training package showed less impact than supportive supervision, but the former was more cost-effective.
                Service delivery guidelines, when properly disseminated, can improve family planning practices in sub-Saharan Africa. The Thai traditional health supervision model has been developed since 1991. However, many supervisors lack supervisory knowledge and skills. This study aimed to compare and identify the strengths and challenges of two different supervision models, in order to determine their effects on enhancing the health promotion capacity of health officers in two primary care units (PCU) in Chiang Mai Province, northern Thailand.
                The two models were implemented at two PCU in one semi-district, Chiang Mai Province, over a six-month period. The first model involved supervisors from the district level, with the full participation of health officers at the sub-district level. The second model was designed with the addition of community involvement in the supervision process. Before implementing the models, the district supervisors attended a retraining course to enhance their supervisory knowledge and ability. Questionnaires were used to assess health officers' job satisfaction, clients' perceived service quality and care satisfaction. Semi-structured interviews and qualitative observations were used to explore the involvement of health officers and the community, and to determine the strengths and challenges of each supervisory model.
                Both before and after the intervention, the PCU health officers appeared to have good and comparable job satisfaction levels. Bivariate analysis indicated that after the intervention, both supervisory models appeared effective in terms of clients' perceived service quality and satisfaction with care, among those who utilized the PCU. However, the second model, which allowed the community to participate in the supervision process, achieved better results. The qualitative findings suggested that the involvement of health officers caused a rapid change and improvement after the supervision. The involvement of the community helped the community itself to identify problems and formulate alternatives to meet the community's needs.
                This study shows positive outcomes for two forms of participatory supervision in a rural setting. There appear to be additional positive outcomes for the model that involved community participation. To ensure successful implementation, several issues, such as the supervisor's knowledge and ability, health officer workload and supervisory communication skills, need to be improved. The cost-effectiveness of reducing the frequency of routine supervision from monthly to quarterly was evaluated in a closely controlled field experiment conducted in a community-based distribution program in Piaui State in northeast Brazil. The results demonstrated substantial potential savings in supervisors' salaries and travel at no cost to program performance (new acceptors, revisits, distributor turnover). A possible reason for this finding was that most supervisory visits were primarily concerned with collecting inventory and service statistics, which probably contributed little to post performance. It was suggested that the number of supervisors and the frequency of supervision should be linked to productive rather than routine supervisory activities.
It is uncertain whether supervision has a substantive, positive effect on the quality of primary health care in low- and middle-income countries. The long term effectiveness of supervision is unknown.