1. The rise and fall of supervision in a project designed to strengthen supervision on the Integrated Management of Childhood Illness (IMCI) strategy in Benin* * Published in Health Policy and Planning 2010;25:125–134. ICIUM_P2_presentation_v3.pptx Alexander K. Rowe, Faustin Onikpo, Marcel Lama, Michael S. Deming

2. Background and objective In developing countries, supervision is important for improving health worker performance Anecdotally, maintaining regular, high-quality supervision is difficult, but little in-depth research to explore why supervision is so challenging Trial in Benin to improve health worker adherence to IMCI guidelines involved strengthening supervision, and we wanted to study supervision process in detail Objective: Describe supervision process and identify contextual factors associated with strengths and weaknesses

3. Methods Design: Case study with prospective data collection Setting: 130 outpatient health facilities in 8 districts; each district had 1 primary supervisor Study population: District supervisors and their superiors Intervention: Workshop to define supervision protocol (2 contacts per quarter) & supervisor of supervisors to help improve quality; later, added quarterly planning workshops Data collection: Field diary, record review, surveys, focus group discussions (FGDs) and key informant interviews Quantitative outcome: % of planned supervision visits of IMCI-trained workers that actually occurred

4. Results: Supervision frequency and quality From 2001–2004, of 1186 expected IMCI supervision visits (2 per quarter), only 348 (29%) actually done Supervision quality was generally good  Of 348 supervision checklists, 91% were analyzed  67% had all sections completed  Almost all (97%) had most important sections completed (observe consultation & give feedback to health worker) Why was so little supervision done?  Timeline and narrative description  FGDs and key informant interviews

5. Timeline and narrative description

6. At first, almost no supervision occurred, although very few visits needed In reaction, quarterly workshops for planning and problem-solving

7. Supervision improved Two particularly effective staff left study area More IMCI training, so supervision workload increasing

8. More training, more supervision needed Loss of supervisor of supervisors New PH Director, who did not support supervision

9. More training, higher workload Decentralization Effective supervisor left

10. Why was so little supervision done? FGDs and key informant interviews Based on supervisors’ opinions: 1)Poor coordination 2)Inadequate management skills, ineffective mgnt teams 3)Lack of motivation 4)Problems related to decentralization 5)Incentives for non-supervision activities 6)Lack of leadership Based on our observations, we add to above list: 1)Increasing supervision workload 2)Time required for non-supervision activities 3)Loss of particularly effective supervisors

11. Conclusions Lessons learned: Numerous interrelated obstacles at multiple levels led to breakdown in supervision Recommendations:  Managers should monitor supervision, understand evolving influences on supervision, and use their resources and authority to both promote and remove impediments to supervision  As leadership can be crucial, managers, politicians, and donors should help make supervision a true priority Research: As with front-line clinicians, supervisors are health workers who need support. It is essential to identify effective and affordable strategies for improving supervision frequency and quality in developing countries

12. Thank you! “Results! Why, man, I have gotten a lot of results. I know several thousand things that won’t work.” Thomas A. Edison (1847-1931)