Strengthening community health worker’s supervision through a person-centric approach

Our study was designed, implemented, and evaluated to explore the impact of a novel package of interventions to support Community Health Workers’ (CHWs) supervision, focussing on improving the relationships of the CHWs with their supervisors. The study was carried out in the aftermath of the second wave of COVID-19 in India and was designed to account for the revised roles and relationships amongst the CHWs and their supervisors. Our findings underline the need for a person-centric approach in programme design to positively influence CHW supervisors’ performance and to empower CHWs. It also underpins the need to strengthen supervisory relationships especially in crisis response and management.

Challenges

Scholarship from across low and middle-income countries contends supervision received by community health workers (CHWs) is typically punitive, and is delivered in an audit style, largely based on checking registers and other documents. Such an approach can have a demotivating impact on health workers’ performance. In the absence of clear feedback and problem-solving efforts, CHW performance and supervision is predominantly oriented towards documentation and procedural compliance. However, this stands in contrast with the work that CHWs carry out, which is broadly relational in nature and built on their ability to forge a trusting relationship with the community and other health system actors. This leads to a dissonance in the performance of CHWs and their supervisors, where both cadres continue to perform an instrumental role in a relational context.

Studies also examine the importance of supportive supervision in the performance, motivation, and legitimacy of CHWs. However, there remains little evidence on how supervisory structures should be designed or how they can be made effective in a particular context.

Our approach

Our study focussed on supervision received by the CHW cadre of Accredited Social Health Activists (ASHAs) in the east Indian state of Bihar. ASHAs are supervised by ASHA Facilitators (AF), identified from among the ASHA cadre, and are typically mapped to 20–25 ASHAs each. The study was carried out in three blocks of Vaishali district in Bihar: two blocks served as treatment units and the third served as a comparison group. The package of interventions constituted additive approaches to support in-field supervision offered by AFs and their supervisors of the block community mobilisers. This was delivered through a one-time training session focussed on soft skills and techno-managerial training, followed by on-the-job, post-training support between August 2021 and January 2022. The post-training coaching and mentoring support was delivered through routine visits to a sub-sample of the training recipients. The post-training support was tailored to the changing in-field situations due to the pandemic.

• Our training was built on extensive supportive supervision and community health system literature and delivered to the supervisory cadres of two treatment blocks over a course of five days.
• Upon conclusion, the post-training support, or coaching and mentoring components were administered to the AFs of one block in Vaishali over five months.
• These efforts were further supported with an all-supervisory workshop. The pilot was concluded by offering the AFs a more condensed catalogue on supervisory practices with a supportive supervision pocket guide.

Outcomes

We assessed impact using a mixed-methods, quasi-experimental research design comparing the ASHAs whose AFs received the training, coaching and mentoring support with the ASHAs whose supervisors did not.

We found:

• Improved ASHA-AF relationship: ASHAs of trained and coached AFs displayed enhanced skills and improved role clarity, and also reported greater comfort in supervisory interactions. AFs punctuated their supervision experiences with words like ‘support’, ‘help’, and ‘respect’. Trained and coached AFs also offered greater support to ASHAs managing COVID-19 related role stress. This insight also underpins the critical role of supportive supervision in pandemic management efforts.
• Improved supervisory communication: AF-ASHA meetings were more structured, focussing on engagement of all attendees, greater peer-communication, discussions, and problem-solving.
• Enhanced problems solving support: Interviews indicate greater collaboration, and support to ASHAs towards resolution of problems related to community engagement, working with beneficiaries, and health system related resource gaps.

Study results speak to community health system literature, responding to gap in evidence regarding empowering impact of contextualised supportive supervision interventions on CHWs means, motives, and opportunities to perform. The approach also offers insights for practitioners seeking to curate and draw from our approach.