title: Supervising community health workers in low-income countries--a review of impact and implementation issues.
abstract: 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.
  
  
  METHODS
  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.
  
  
  CONCLUSIONS
  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.
authors.affiliation: Institute of Global Health, University College London, London, UK; zhill.ich@gmail.com.
authors.forename: Zelee
authors.initials: Z
authors.lastname: Hill
authors.affiliation: Institute of Global Health, University College London, London, UK.
authors.forename: Mari
authors.initials: M
authors.lastname: Dumbaugh
authors.affiliation: Institute of Global Health, University College London, London, UK.
authors.forename: Lorna
authors.initials: L
authors.lastname: Benton
authors.affiliation: Malaria Consortium, London, UK.
authors.forename: Karin
authors.initials: K
authors.lastname: Källander
authors.affiliation: Institute of Global Health, University College London, London, UK.
authors.forename: Daniel
authors.initials: D
authors.lastname: Strachan
authors.affiliation: Department of Population Health, London School of Hygiene and Tropical Medicine, London, UK.
authors.forename: Augustinus
authors.initials: A
authors.lastname: ten Asbroek
authors.affiliation: Malaria Consortium, London, UK.
authors.forename: James
authors.initials: J
authors.lastname: Tibenderana
authors.affiliation: Department of Population Health, London School of Hygiene and Tropical Medicine, London, UK.
authors.forename: Betty
authors.initials: B
authors.lastname: Kirkwood
authors.affiliation: Malaria Consortium, London, UK.
authors.forename: Sylvia
authors.initials: S
authors.lastname: Meek
mesh_terms: D003150:Community Health Workers / Q000458:organization & administration* / Q000592:standards; D003906:Developing Countries; D006801:Humans; D009934:Organization and Administration / Q000592:standards; D010559:Personnel Management / Q000379:methods / Q000592:standards; D011785:Quality Assurance, Health Care / Q000379:methods / Q000458:organization & administration
keywords: ICCM; community health worker; developing country; health worker; lay health worker; low-income country; supervision