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Table 4 Supervision approach(es) employed in large-scale CHW programmes

From: Community health workers at the dawn of a new era: 7. Recent advances in supervision

Country Facility/district Group Community Peer Dedicated Dominant supervision approach
Afghanistan X X     Each health facility supporting health posts has a community health supervisor (CHS) that visits health posts to support and supervise the CHWs. In addition, the CHWs come monthly to the supporting health facility for a joint meeting with the other CHWs. During these encounters, the CHWs receive continuing education and have an opportunity to discuss problems encountered in day-to-day work [13]
Bangladesh (Government CHW programme)      X Family welfare assistants (FWAs) are supervised by male supervisors, called family planning inspectors, with whom they meet at least twice per month during field visits. Health assistants (HAs) are supervised by assistant health inspectors, each of whom is responsible for three HAs (one in each ward) [14]
Bangladesh (BRAC NGO CHW programme) X    X (dual-tier)   Direct supervision of shasthya shebikas (SSs) is conducted by shasthya kormis (SKs). SKs are supervised by BRAC area managers [15]
Brazil X      Community health assistants (CHAs) are supervised by nurses and physicians from the family health teams based at the local clinics with which they are attached. The supervision process varies among family health teams depending on capabilities and needs [16]
Ethiopia X   X X (dual-tier)   Health extension workers (HEWs) are primarily supervised by the health centre staff, who conduct regular supportive supervision visits to improve the capacity of HEWs to provide health services to the community. The village health committee and community members are also very involved in supporting the HEWs and evaluating their performance. HEWs provide supervision and support to Women’s Development Army volunteers [17]
Ghana X   X X (dual-tier)   Community health officers (CHOs) are supervised monthly by public health nurses, physician assistants, and subdistrict community health planning and services coordinators. CHOs supervise community health volunteers (CHVs) monthly. Community health management committees also supervise the work of the CHVs [18]
Guatemala (Government CHW Program, closed in 2013) X      CHWs were supervised by the mobile health team. CHWs also reported directly to a técnico en salud rural (rural health technician) who was under the supervision of a physician or professional nurse [19]
India (current CHW programme) X      Accredited social health activists (ASHAs) report to ASHA facilitators, and anganwadi workers (AWWs) report to anganwadi supervisors (mukhya sevikas) [20]
India (defunct Village Health Guides programme) X   X    There was no formal supervision. Village health guides went to the PHC centre to collect their salaries and connect with the staff there [21]
Indonesia X   X    While the nearest community health centre (Puskesma) provides technical guidance and support, the real accountability of the CHWs (kaders) is to the village committee that appointed and supports them in their work [22]
Iran X      Higher-level staff, including those from rural and urban centres of comprehensive health services and district health centres, as well as the deputy for health at universities of medical sciences, make regular supervisory visits to health houses and health hosts. University professors and faculty from the University of Medical Sciences evaluate programme effectiveness and quality, and then they make decisions about needed programme revisions [23]
Kenya X      Each CHV should receive supportive supervision monthly from a community health extension worker (CHEW), either at the health facility or in the community. The supervision consists of training, review of reports, and household visits with a CHEW. CHEWs follow a checklist to ensure quality supervision [24]
Liberia      X Each community health service supervisor (CHSS) supervises approximately 10 CHAs. The CHSS is a new cadre. Each CHSS has already been trained as a health worker (nurse, midwife, or physician’s assistant) and receives an additional four weeks of training. Supervision occurs both in the field and during monthly meetings at the nearest health facility [25]
Madagascar X      Agents communautaires (ACs) are supervised by the head of the peripheral basic health centres (chef centre de santé de base), while agents communautaires nutritional (ACNs) report to an animator, who is a supervisor employed by a local NGO that has been contracted by the National Nutrition Office to provide nutrition services. There was no formal linkage between ACNs and Ministry of Health (MOH)-operated basic health centres until 2019 [26]
Malawi X    X (dual-tier)   Health surveillance assistants (HSAs) are supervised on a monthly basis by a senior HSA and then on a quarterly basis by an assistant environmental health officer, an environmental health officer, or a community health nurse. HSAs themselves supervise other community-level cadres such as traditional birth attendants and village health and water committees [27]
Mozambique X      A staff member at the nearest health facility supervises all agentes polivalentes elementares (APEs) in the facility’s catchment area. Supervisors meet with APEs on a monthly basis to review register books and distribute new commodity kits. They also make periodic supervisory visits to APEs in their communities [28]
Myanmar X      Community-based health worker (CBHW) supervision varies by programme for: HIV, malaria, tuberculosis, newborn/child health, and reproductive health, but generally relies on facility-based staff [29]
Nepal X X   X (dual-tier)   Most FCHVs visit their respective health facility every month; there, they receive supplies, materials, commodities, and programmatic advice and feedback. Supervision is done by auxiliary health workers [30]
Niger X    X (dual-tier)   Each health post is linked to a health centre. A staff member of the health centre is supposed to supervise agents de santé communautaire (ASCs), but this is infrequent and irregular. ASCs supervise relais volunteers [31]
Nigeria X X     Supervision of volunteer village health workers (VHWs) is variable and often involves NGO staff. CHEWs are supervised by the person in charge of the closest health facility. VHWs are supervised by CHEWs in group monthly meetings [32]
Pakistan      X Supervision is highly organized and multitiered. Lady health workers (LHWs) are each attached to a public health clinic and are supervised by an LHW supervisor. One LHW supervisor is responsible for supervising 25 LHWs. LHWs should have community-based supervision at least once a month, at which time the LHW supervisor meets with clients and with the LHW, reviews the LHW’s work using a structured monitoring checklist, and makes a work plan for the next month [33]
Rwanda X    X   CHWs are supervised directly by the health centre with the support of volunteer cell coordinators [34]
Sierra Leone X    X X Peer supervisors were formally introduced in 2016. Peer supervisors are full-time supervisors. They do not provide CHW services in addition to their supervisory roles. Peer supervisor selection prioritizes those who have previously served as CHWs and have been identified as high-performing leaders among the group of CHWs linked to a peripheral health unit. In addition to data collection and reporting, their role focuses on coaching, mentorship, and on-the-job training of the CHWs within their catchment area [35]
South Africa X     X Ward-based primary healthcare community outreach teams (WBPHCOTs) are supervised by outreach team leaders, who are higher-level (professional) or mid-level nurses specifically appointed or seconded from local PHC facilities. Teams refer clients and report to designated PHC facilities, which are also supposed to provide supplies and space for the outreach teams [36]
Tanzania X   X    The village health committee is responsible for overall supervision of the community-based health programme within the village catchment, including implementation of village health plans, mobilizing resources, compiling reports, and supervising the nominee and application process. CHWs receive administrative supervision from village executive officers, to whom they report daily. CHWs receive periodic on-the-job supportive supervision and training on clinical tasks from the in-charge/focal persons at the health dispensary or health centre to which the CHW is attached [37]
Thailand X      The village health volunteer (VHV) programme is under the primary healthcare division of the Department of Health Service Support of the MOH. VHVs are supervised by on-site local health workers. A web-based VHV information platform has been developed and is widely used, and a cell phone application has been introduced [38]
Uganda X      Village health teams (VHTs) are supposed to report to a health facility within their community where a health worker supervises them. A parish coordinator often offers support to all VHTs within a parish, and the district health educator is mandated to oversee the work of all VHTs in the district. Due to limited funding and human resource capacity, supervision of VHTs is often irregular and inconsistent [39]
Zambia X      CHAs are supervised by a skilled health worker who is the officer-in-charge at the health facility to which they are linked. Supervision is supposed to be conducted at the health facility and the community level on a monthly basis using standardized supervisory checklists, but is often not carried out because of the pressing clinical demands of the supervisors [40]
Zimbabwe X   X    VHWs are directly supervised by the nurse-in-charge at the nearest health centre within their ward. They report monthly and quarterly to their local health centre. They are also broadly supervised and supported by community leaders and the ward health team [41]
Number of case studies employing this approach 26 out of 29 3/29 6/29 8/29 5/29  
  1. “Dual-tier” supervision refers to one cadre of CHWs supervising a lower-level CHW cadre
  2. BRAC Building Resources Across Communities, NGO nongovernmental organization