title: Initial experiences and innovations in supervising community health workers for maternal, newborn, and child health in Morogoro region, Tanzania.
abstract: BACKGROUND
  Supervision is meant to improve the performance and motivation of community health workers (CHWs). However, most evidence on supervision relates to facility health workers. The Integrated Maternal, Newborn, and Child Health (MNCH) Program in Morogoro region, Tanzania, implemented a CHW pilot with a cascade supervision model where facility health workers were trained in supportive supervision for volunteer CHWs, supported by regional and district staff, and with village leaders to further support CHWs. We examine the initial experiences of CHWs, their supervisors, and village leaders to understand the strengths and challenges of such a supervision model for CHWs.
  
  
  METHODS
  Quantitative and qualitative data were collected concurrently from CHWs, supervisors, and village leaders. A survey was administered to 228 (96%) of the CHWs in the Integrated MNCH Program and semi-structured interviews were conducted with 15 CHWs, 8 supervisors, and 15 village leaders purposefully sampled to represent different actor perspectives from health centre catchment villages in Morogoro region. Descriptive statistics analysed the frequency and content of CHW supervision, while thematic content analysis explored CHW, supervisor, and village leader experiences with CHW supervision.
  
  
  RESULTS
  CHWs meet with their facility-based supervisors an average of 1.2 times per month. CHWs value supervision and appreciate the sense of legitimacy that arises when supervisors visit them in their village. Village leaders and district staff are engaged and committed to supporting CHWs. Despite these successes, facility-based supervisors visit CHWs in their village an average of only once every 2.8 months, CHWs and supervisors still see supervision primarily as an opportunity to check reports, and meetings with district staff are infrequent and not well scheduled.
  
  
  CONCLUSIONS
  Supervision of CHWs could be strengthened by streamlining supervision protocols to focus less on report checking and more on problem solving and skills development. Facility health workers, while important for technical oversight, may not be the best mentors for certain tasks such as community relationship-building. We suggest further exploring CHW supervision innovations, such as an enhanced role for community actors, who may be more suitable to support CHWs engaged primarily in health promotion than scarce and over-worked facility health workers.
authors.affiliation: Johns Hopkins Bloomberg School of Public Health, 615 North Wolfe Street, Baltimore, MD, 21205, USA. timroberton@jhu.edu.
authors.forename: Timothy
authors.initials: T
authors.lastname: Roberton
authors.affiliation: Johns Hopkins Bloomberg School of Public Health, 615 North Wolfe Street, Baltimore, MD, 21205, USA. japplegate@jhu.edu.
authors.forename: Jennifer
authors.initials: J
authors.lastname: Applegate
authors.affiliation: Johns Hopkins Bloomberg School of Public Health, 615 North Wolfe Street, Baltimore, MD, 21205, USA. aelefevre@gmail.com.
authors.forename: Amnesty E
authors.initials: AE
authors.lastname: Lefevre
authors.affiliation: Muhimbili University of Health and Allied Sciences, United Nations Road, 65001, Dar es Salaam, Tanzania. ihmosha@yahoo.co.uk.
authors.forename: Idda
authors.initials: I
authors.lastname: Mosha
authors.affiliation: Jhpiego, 1615 Thames Street, Baltimore, MD, 21231, USA. chelsea.cooper@jhpiego.org.
authors.forename: Chelsea M
authors.initials: CM
authors.lastname: Cooper
authors.affiliation: Johns Hopkins Bloomberg School of Public Health, 615 North Wolfe Street, Baltimore, MD, 21205, USA. msilverman2011@gmail.com.
authors.forename: Marissa
authors.initials: M
authors.lastname: Silverman
authors.affiliation: Johns Hopkins Bloomberg School of Public Health, 615 North Wolfe Street, Baltimore, MD, 21205, USA. ifeldha1@jhu.edu.
authors.forename: Isabelle
authors.initials: I
authors.lastname: Feldhaus
authors.affiliation: Johns Hopkins Bloomberg School of Public Health, 615 North Wolfe Street, Baltimore, MD, 21205, USA. jchebet@jhu.edu.
authors.forename: Joy J
authors.initials: JJ
authors.lastname: Chebet
authors.affiliation: Muhimbili University of Health and Allied Sciences, United Nations Road, 65001, Dar es Salaam, Tanzania. rcmpembeni@yahoo.com.
authors.forename: Rose
authors.initials: R
authors.lastname: Mpembeni
authors.affiliation: Ministry of Health and Social Welfare, 6 Samora Machel Avenue, 11478, Dar es Salaam, Tanzania. hi.semu@gmail.com.
authors.forename: Helen
authors.initials: H
authors.lastname: Semu
authors.affiliation: Muhimbili University of Health and Allied Sciences, United Nations Road, 65001, Dar es Salaam, Tanzania. jkillewo@yahoo.co.uk.
authors.forename: Japhet
authors.initials: J
authors.lastname: Killewo
authors.affiliation: Johns Hopkins Bloomberg School of Public Health, 615 North Wolfe Street, Baltimore, MD, 21205, USA. pwinch@jhu.edu.
authors.forename: Peter
authors.initials: P
authors.lastname: Winch
authors.affiliation: Johns Hopkins Bloomberg School of Public Health, 615 North Wolfe Street, Baltimore, MD, 21205, USA. abaqui@jhu.edu.
authors.forename: Abdullah H
authors.initials: AH
authors.lastname: Baqui
authors.affiliation: Johns Hopkins Bloomberg School of Public Health, 615 North Wolfe Street, Baltimore, MD, 21205, USA. ageorg22@jhu.edu.
authors.forename: Asha S
authors.initials: AS
authors.lastname: George
mesh_terms: D001291:Attitude of Health Personnel; D002648:Child; D000067576:Child Health; D003150:Community Health Workers; D005260:Female; D006268:Health Facilities; D006801:Humans; D000068104:Infant Health; D007231:Infant, Newborn; D000068097:Maternal Health; D000068101:Maternal-Child Health Services; D010559:Personnel Management; D011247:Pregnancy; D012111:Residence Characteristics; D013636:Tanzania; D014838:Volunteers