Insights from our evaluation of Piramal Swasthya's training approach outlining ways to strengthen the supervision of CHWs.
Community Health Workers (CHWs) perform crucial frontline roles in delivering critical health goods and services. This delivery relies on a strong mix of knowledge, skills, motivation, and resources to engage with beneficiaries and encourage positive health behaviours.
Whilst training can be a strong source of this mix of knowledge and skills, ongoing supervision can also offer on-the-job support for improved CHW performance, and research increasingly suggests that the quality of supervision is positively associated with improved CHW performance. However, numerous studies from a range of countries and programmes have found that CHW supervision is often inadequate, is marked by low coverage, is disorganised, and lacks sufficient training for supervisors to offer problem solving support to CHWs. In fact, in the context of India, evidence indicates that supervisor’s knowledge levels have been no better than that of the CHWs themselves.
Researchers and practitioners have long advocated offering stronger support and guidance to CHWs, and to improve the relationship between CHWs and their supervisors. This approach is likely to increase knowledge and skill-sharing amongst supervisors and supervisees, which is expected to cascade into improved motivation, self-efficacy and strengthened CHW performance. In turn, this should lead towards improving maternal and child health outcomes and more broadly towards the achievement of Universal Health Coverage objectives. Several investigations across low- and middle-income countries have therefore attempted to unpack the impact of offering supportive supervision (SS) training for CHW supervisors.
Piramal Swasthya Management and Research Institute (Piramal Swasthya) in India is currently undertaking one such initiative to improve the supervision of CHW’s, and make the process more supportive. Piramal Swasthya is collaborating with NITI Aayog (Government of India’s public policy think tank) to work in 25 Aspirational Districts across seven states. They have developed a SS training module for the immediate and block-level supervisors of the CHW cadres of Auxiliary Nurse Midwives (ANMs), Anganwadi Workers (AWWs), and Accredited Social Health Activists (ASHAs). The training is designed to cover the key skills needed to strengthen supervisors’ performance, such as essential communication skills, leadership skills, teamwork, and practicing and planning SS.
As part of our qualitative evaluation of Priamal Swasthya’s SS training approach we carried out in-depth telephone interviews with 56 respondents across four states, representing implementers, designers, trainers, and trainees. Here, we present our insights on high-value and potentially scalable components, offering avenues to strengthen the roll-out of similar SS based approaches across India by outlining the content and delivery-related pathways to strengthen the supervision of CHWs.
Designing effective content
‘Think about it. It has never been told to government supervisors before—that your behaviour is very strict.’- PSMRI SS training implementation staff, Bihar.
Piramal Swasthya’s SS training brought together sector and block supervisory cadres of nutrition and health departments using content which was generic and could be used across departments/ health workers. They relied heavily on visual cues and pop-culture references to Bollywood movies, which are memorable sources of content as opposed to more theoretical component.
However, this type of training content lacked a specific health or nutrition focus, and supervisors were unable to apply this to their day-to-day activities. Future interventions must also include practical sessions and field visits, in addition to interactive content, which would help to achieve greater impact.
Delivering for impact
As a route to forge greater departmental buy-in, several block and sector supervisors were also serving as trainers themselves. However, this dual mandate – as both a recipient of training and as a trainer – confounded the training’s impact. Having dedicated teams of state or district trainers would help to overcome this challenge.
It emerged strongly that everyone recognised how critical SS is. However, participants continued to view it as a secondary mandate, not as a routine activity within supervision. Many agreed to its importance, but also reiterated that there was not enough time, especially given the existing deliverables. This insight reinforces a need to embed SS in the everyday work of supervisors during training delivery, and in the aftermath through greater in-task support for supervisors.
‘Earlier, I used to scold them very badly, but after attending the training other people have noticed saying that now you spend more time in sharing some new things and motivate us and make us laugh.’- Block supervisor, Madhya Pradesh
There is some evidence of increasing self-reported behaviour change by supervisors– some even recognised their previous shortcomings, and the need to be more supportive. However, there were mixed results in how effective such interventions had been, with impact yet to be seen in the sector supervisor’s relationship with the CHWs. This could potentially be addressed through more frequent training and with extended hand-holding support for supervisors. Further, findings also indicated that supervisors face increased stress, often aggravated by a need to meet targets while also being supportive. This suggests a need to make systemic shifts in supervisor’s workload, including active efforts to offer routine mental wellness support to health workers and their supervisors. This would help them deal with everyday work-related stress and sensitise them not to view SS as an additional or burdensome task, one often compounded by the high number of supervisory vacancies. However, Piramal Swasthya attempted to account for this gap by training ‘functional’ supervisors to ensure quality supervision despite systemic challenges. This is a design parameter which future interventions can adopt.
Ways forward: Making SS training effective.
Broadly, Piramal Swasthya’s SS based training addresses the dual objective of behaviour change, which entails recognition of prior behaviours and the necessity for change, and capacity building via skill training. Both these objectives demand routine training, and sustained support, which is offered with an iterative and reflexive view. However, replicating similar interventions mandates a training content-level upgrades and changes in the roll out of the training to be more effective to influence CHW’s supervision and performance. The impact of these efforts will be further supported by shifts within the health/nutrition systems to strengthen the supervision offered to CHWs and make such efforts sustainable.
Content: changes to the CHW supervisor’s training require greater cadre-centric and task-centric focus, with stronger field exposure, time management components to prioritise performance, and problem-solving content to overcome system level bottlenecks. The training content also needs greater contextual nuance to reflect on district-specific elements such as the local culture and stronger health systems knowledge.
Delivery: through identifying and empowering a dedicated cadre offering on-the-ground support to CHW supervisors. This cadre can offer handholding and troubleshooting support to maximise supervisor’s SS knowledge and skills gain and retention. This is crucial for institutionalising effective SS.
Ensuring sustainability: greater state buy-in and ownership is key for SS to be institutionalised sustainably within health systems. This can be achieved by using state capacities to train supervisors in the short term, and by identifying and building the capacity of supervisors to offer coaching and mentoring support to new supervisors in the long run.
Bibha Mishra is a Research Coordinator at Oxford Policy Management
Bhagwati Pandey is an External Consultant
The authors would like to extend their gratitude to Piramal Swasthya for their invaluable support in carrying forward this study and facilitating the interviews with the respondents.