Supervision

Supervision is the process of directing and supporting staff so that they may effectively perform their duties. Supervision may include periodic events, such as site visits or performance reviews, but it also refers to the ongoing relationship between a staff member and a supervisor.

In health care settings, supervision often includes oversight and implementation of clinical and non-clinical tasks and activities that affect the organization, management, and technical delivery of health services, such as control of work processes and systems, maintenance of facilities and infrastructure, and monitoring and improvement of system-wide performance. Beyond this technical role, there is also an important human dimension to the supervisor-health worker relationship. In low-resource settings, where many health providers work alone or in small groups in remote sites, the supervisor may be the only link to the larger health system.

Supervisory audit of health worker performance is one of the few audit and feedback interventions widely used in low- and middle-income countries. Anecdotal evidence and the few published studies suggest that supervisory audit can be effective in increasing performance according to standards. A Quality Assurance Project study in Niger measured the impact of structured supervisory feedback on health worker adherence to Integrated Management of Childhood Illness (IMCI) standards for assessment, treatment, and counseling of sick children. The study found that supervisory feedback had a significant short-term impact on IMCI performance, although the effect was not universal across all IMCI skill areas: it had the greatest effect in areas where health workers had been performing poorly.

Supervision has traditionally been viewed as a key approach to improving the quality of health care and the performance of health care providers, especially given the labor-intensive nature of health service delivery. This is particularly true in developing countries, where supervision remains one of the most direct ways for an organization to affect what its staff does. At the same time, adequate supervision is frequently not realized or sustained, and many supervisors lack the knowledge, skills, and tools for effective supervision.

Governments and donors have invested significant resources to strengthen supervision systems in low- and middle-income countries through supervisor training and supervisory tools and checklists.  The Government of South Africa, for example, has made primary health care supervision as cornerstone of the national health care system. The Department of Health’s Primary Health Care Supervision Manual contains guidelines for quality supervision, use of supervision support checklists, conducting in-depth technical program reviews, and tools for working with Primary Health Care Facility Committees.

International health agencies have reached consensus in recent years about the key functions of supervision: setting objectives, providing training and guidance, monitoring and evaluating performance, providing feedback, motivating staff, and providing support to solve problems. At the same time, a growing body of experience from different settings suggests that broadening and enhancing how supervision functions can be performed––by involving health workers themselves, peers, and even communities. Evidence suggests that these alternative approaches achieve better health worker performance and outcomes than traditional supervisory approaches, and some evidence indicates that these approaches may be more sustainable.

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