Supervision is the process of directing and supporting staff so that they may effectively perform their duties. Supervision may include periodic events, such as site visits or performance reviews, but it also refers to the ongoing relationship between a staff member and a supervisor. In the health care setting, supervision includes oversight and implementation of clinical and non-clinical tasks and activities that affect the organization, management, and technical delivery of health services, including control of work processes and systems, maintenance of facilities and infrastructure, and monitoring and improvement of system-wide performance. Beyond this technical role, there is also an important human dimension to the supervisor-health worker relationship. In developing countries, where many health staff work alone or in small groups in remote sites, the supervisor may be the only link to the larger health system.
Supervisory audit of health worker performance is one of the few audit and feedback interventions used widely in developing countries. Anecdotal evidence and the few existing published studies suggest that supervisory audit can be effective in increasing performance according to standards. A Quality Assurance Project study in Niger measured the impact of structured supervisory feedback on health worker adherence to Integrated Management of Childhood Illness (IMCI) standards for assessment, treatment, and counseling of sick children. The study concluded that supervisory feedback had a significant short-term impact on IMCI performance, although the effect was not universal across all IMCI skill areas: it had the greatest effect in areas where health workers had been performing poorly.
Supervision has traditionally been viewed as one of the key approaches to improving the quality of health care and the performance of health care providers, especially given the labor-intensive nature of health service delivery. This is particularly true in developing countries, where supervision remains one of the most direct ways for an organization to affect what its staff does. At the same time, disappointment that the “promise” of supervision is frequently not realized or sustained is pervasive. USAID and its cooperating agencies have invested significant resources to strengthen supervision systems in developing countries through supervisor training and supervisory tools and checklists, yet interventions to strengthen supervision systems have often faltered after the pilot phase or have failed to demonstrate results independent of other efforts to improve service delivery.
International health agencies have reached consensus in recent years about the key functions of supervision: setting objectives, providing training and guidance, monitoring and evaluating performance, providing feedback, motivating staff, and providing support to solve problems. At the same time, a growing body of experience from different settings suggests that expanding the realm of how supervision functions can be performed––with ways of doing supervision that involve health workers themselves, peers, and even communities––may broaden and enhance supervision. Evidence suggests that these alternative approaches achieve better health worker performance and outcomes than traditional supervisory approaches, and some evidence indicates that these approaches may be more sustainable.