April, 2017 - SUPPORT Summary of a systematic review | print this article |

Does managerial supervision improve the quality of primary healthcare?

The expansion of primary healthcare has been accompanied by the shifting of responsibilities for healthcare delivery across to more geographically peripheral health workers. Such health workers, including those with limited formal training, often work in remote areas. Managerial supervision has been identified as a mechanism through which these health workers could be supported, thereby helping to maintain or improve the quality of primary healthcare.

Key messages

 

  • Managerial supervision may improve provider practices and knowledge compared with no supervision.
  • It is uncertain whether managerial supervision improves drug stock management.
  • It is uncertain whether ‘enhanced’ managerial supervision (e.g. increased supervision, the use of tools such as checklists) improves the performance of lay or community health workers or midwives; the proportion of children receiving adequate care; or patient and health worker satisfaction.
  • ‘Less intensive’ managerial supervision (e.g. fewer visits) may lead to little or no difference in the number of new family planning client visits or the number of clients that revisit.
  • The need for additional resources for managerial supervision needs to be addressed when developing policies for and implementing supervision strategies.
  • When implementing managerial supervision, other factors such as whether the healthcare system and organisational culture of healthcare teams are centralised or decentralised should also be considered.

 

 

Background

Managerial supervision provides a link between district and geographically peripheral health staff, and is important to both staff performance and motivation. Managerial supervision often includes problem solving, reviewing records, and observing clinical practice, and is undertaken during staff visits to supervisers as well as during meetings held at peripheral health centres. 

It is important to differentiate managerial supervision from educational and clinical supervision. For the latter, supervisors are not necessarily staff from a more central level; supervision is not the main link between health system tiers; the supervision has a clinical and educational rather than a managerial focus; and the supervision is not focused mainly on administrative or managerial activities and does not form part of regular management procedures.  


 



About the systematic review underlying this summary

Review objectives:To summarise opinions on the definition of supervision of primary healthcare; to compare these definitions to supervision in practice; and to appraise the evidence of effects of supervision on sector performance.
Type of What the review authors searched for What the review authors found
Study designs & interventions Routine supervision visits by health staff from a centre (such as a district office) to Primary Health Care (PHC) staff in both urban and rural areas. Randomised trials, non-randomised trials, controlled before-after studies, and interrupted time series studies.
5 cluster randomised trials and 4 controlled before-after studies. The interventions were: routine supervision, enhanced supervision, less intensive supervision, and no supervision.
Participants Healthcare units (health centres) or providers (including lay health workers) at the PHC level.
Studies were conducted in Africa (Benin, Ethiopia, Kenya, South Africa, Zimbabwe), Asia (Nepal, the Philippines, Thailand) and Latin America (Brazil).
Settings Health services, rural or urban, in low- and middle-income countries.
Rural areas (5 studies) and settings that were both rural and urban (3 studies). One study did not specify the study area.
Outcomes Service quality measures, including changes in provider practice, adherence to guidelines or service coverage. Also, population or patient satisfaction, change in provider knowledge and provider satisfaction with supervision.
Service quality, user satisfaction, provider knowledge and satisfaction. Other outcomes included the cost of supervision and service utilisation.
Date of most recent search: March 2011
Limitations: This is a well-conducted systematic review with only minor limitations.
Bosch-Capblanch X, Liaqat S, Garner P. Managerial supervision to improve primary health care in low- and middle-income countries. Cochrane Database of Systematic Reviews 2011, Issue 9. Art. No.: CD006413.

Bosch-Capblanch X, Liaqat S, Garner P. Managerial supervision to improve primary health care in low- and middle-income countries. Cochrane Database of Systematic Reviews 2011, Issue 9. Art. No.: CD006413. DOI: 10.1002/14651858.CD006413.pub2.

Summary of findings

The review included nine studies. These were conducted in Africa (Benin, Ethiopia, Kenya, South Africa, Zimbabwe), Asia (Nepal, the Philippines, Thailand) and Latin America (Brazil). Five were based in rural areas, three in both rural and urban areas, and one did not specify the setting.

 

1) Managerial supervision versus no supervision

Three studies were included in this comparison.

 

  • Managerial supervision may improve provider practices and knowledge compared with no supervision. The certainty of this evidence is low.
  • It is uncertain whether managerial supervision improves drug stock management as the certainty of this evidence is very low.

 

Managerial supervision versus no supervision to improve the quality of primary health care

People:  Primary care providers
Settings
:  Health services in low and middle income countries
Intervention
: Managerial supervision
Comparison
: No supervision
Outcomes Impact Number of participants (studies) Certainty of the evidence
(GRADE)
Provider prescribing practices 
Managerial supervision may improve provider prescribing practices, including the percentage of prescriptions issued according to guidelines.
114 clinics
(2 studies)

Low

Provider knowledge 
Supervision may be associated with higher post-intervention prescribing and family planning knowledge scores.
114 clinics
(2 studies)

Low

Drug supply  It is uncertain whether supervision improves drug stock management because the certainty of this evidence is very low. 

21 Health facilities

(1 study)

Very Low 
GRADE: GRADE Working Group grades of evidence (see above and last page)

2) ‘Enhanced’ versus routine managerial supervision

Five studies compared ‘enhanced’ versus routine managerial supervision. Examples of ‘enhanced managerial supervision’ included: regular, monthly, supportive supervision; the use of checklists; providing a package of support; community involvement in supervision; and the use of different models of supervisory training. Routine managerial supervision, in contrast, included visits every two months without the training of supervisors or the use of checklists.

 

  •  It is uncertain whether ‘enhanced’ managerial supervision improves the performance of lay or community health workers or midwives; the proportion of children receiving adequate care; or patient and health worker satisfaction. The certainty of this evidence is very low.

 

 

‘Enhanced’ versus routine managerial supervision to improve the quality of primary healthcare

People:  Providers and users of health care
Settings
:  Health services in low- and middle-income countries
Intervention
: Enhanced’ managerial supervision
Comparison
: Routine managerial supervision
Outcomes Impact Number of participants (studies) Certainty of the evidence
(GRADE)

Performance of lay or community health workers

 


It is uncertain whether the performance of lay health workers improved. Performance was assessed using a scoring system including number of outreach visits, home visits, maternal-child health activities, etc. 

102 providers

(1 study)

 


Very Low

Overall performance of midwives

 

It is uncertain whether midwives’ overall performance score increased, based on indicators of service quality.

112 health facilities
(1 study)

 


Very Low

Children receiving recommended or adequate care

 

It is uncertain whether there were any differences in the proportions of children receiving recommended or adequate care.

(1 study)

Very Low 

Health worker job satisfaction

 

It is uncertain whether health workers’ job satisfaction scores improved.  6 health workers  (1 study) Very Low
Patient satisfaction It is uncertain whether patient satisfaction improved. 390 patients
(1 study)
Very Low
GRADE: GRADE Working Group grades of evidence (see above and last page)

3) ‘Less intensive’ versus routine managerial supervision

One study evaluated a reduction in the frequency of supervisory visits (from monthly to quarterly) on the performance of community-based family planning distributors (CBD). The intervention group received quarterly supervisory visits plus supplementary visits to deal with emergencies or to improve staff performance. The control group received the standard, monthly supervisory visits.

 

  • ‘Less intensive’ managerial supervision may lead to little or no difference in the number of new family planning client visits in either health facilities or the community, or in the number of clients that re-visit. The certainty of this evidence is low.

 

 

 

‘Less intensive’ supervision compared with routine supervision to improve the quality of primary healthcare

People:  Providers and users
Settings
: Health services in low and middle income countries
Intervention
: ‘Less intensive’ managerial supervision
Comparison
:Routine managerial supervision
Outcomes Impact Number of participants (studies) Certainty of the evidence
(GRADE)

New family planning clients enrolled via health facility-based posts (hospitals, clinics)

 


There may be little or no difference in the numbers of new patients enrolled in family planning in health facility-based posts.

247 centres
(1 study)


 

Low

New family planning clients enrolled via community-based posts (private homes, schools, community centres, town halls and rural villages)

There may be little or no difference in the numbers of new patients enrolled in family planning in community-based posts.

247 centres
(1 study)

Low 

Average number of client revisits per quarter (health facility-based posts)

 

There may be little or no difference in the number of family planning client revisits.  247 centres
(1 study)

Low

Average number of client revisits per

quarter (community-based posts)
There may be little or no difference in the number of family planning client revisits.

247 centres

(1 study)

Low

GRADE: GRADE Working Group grades of evidence (see above and last page)

 

Number of
participants 

(Studies)

Relevance of the review for low-income countries

Findings Interpretation*
APPLICABILITY

All the studies were conducted in low- and middle-income countries. However, the nature of the interventions and the outcomes assessed differed widely.

 

  • ‘Enhanced’ managerial supervision (for example, more frequent visits) is not necessarily more beneficial. ‘Less intensive’ mangerial supervision may have the same effects as routine supervision.

 

How centralised or decentralised a healthcare system is may be important when implementing managerial supervision. For instance, in a more decentralized system, managerial supervision from higher levels of the health system may be less acceptable to local professionals who are used to managing their own work.

 

  • Understanding the organisational culture of healthcare teams may be important when implementing managerial supervision (for instance, when deciding on the intensity required).
  • Policymakers and managers may need to consider a wider range of options to support connections between peripheral and central health services. Costs and feasibility will need to be balanced when deciding whether, for example, meetings could be held at a district centre; whether managerial supervision could be integrated into the managerial activities of other sectors at a district level; and whether peer-to-peer support is an option.
  • In practice, separating managerial, clinical and educational supervision might be difficult and it may be helpful to consider these different types of supervision together.

 


EQUITY
No equity related findings were explicitly reported in the included studies. Managerial supervision may improve health worker satisfaction and, by so doing, help to retain health workers in rural or peripheral health units and so improve access to healthcare to underserved areas.
ECONOMIC CONSIDERATIONS
 Only some descriptive economic data were reported in the review. No economic evaluations were found. Supervision requires additional resources such as rewards for lay or community health workers, training, supervisory staff time, and other associated costs. Resource use and costs need to be addressed in the planning and implementation of supervision strategies.
MONITORING & EVALUATION
The benefits of supervision were not consistent across the studies included in the review, partly because of the differences in the interventions, and the methodological limitations of the studies. No harms were explicitly reported.

More rigorous studies of supervision need to be undertaken. If managerial supervision is implemented, consideration should be given to ways to monitor and evaluate its effects and costs.


*Judgements made by the authors of this summary, not necessarily those of the review authors, based on the findings of the review and consultation with researchers and policymakers in low-income countries. For additional details about how these judgements were made see: http://www.support-collaboration.org/summaries/methods.htm

 

Additional information

Related literature

Bailey C, Blake C, Schriver M, Cubaka VK, Thomas T, Martin Hilber A. A systematic review of supportive supervision as a strategy to improve primary healthcare services in Sub‐Saharan Africa. International Journal of Gynecology & Obstetrics. 2016; 132(1): 117-25.

 

Clements CJ, Streefland P. Malau C. Supervision in primary health care – can it be carried out effectively in developing countries? Current Drug Safety. 2007; 2: 19-23.

 

Kleiser H, Cox DL. The Integration of Clinical and Managerial Supervision: a Critical Literature Review. The British Journal of Occupational Therapy. 2008; 71 (1): 2-12(11).

 

Moran AM, Coyle J, Pope R, Boxall D, Nancarrow SA, Young J. Supervision, support and mentoring interventions for health practitioners in rural and remote contexts: an integrative review and thematic synthesis of the literature to identify mechanisms for successful outcomes. Human resources for health. 2014;12(1):10.

 

Yegdich T. Clinical supervision and managerial supervision: some historical and conceptual considerations. Journal of Advanced Nursing. 1999; 30: 1195–1204.

 

This summary was prepared by

Cristian Herrera, Unit for Health Policy and Systems Research, School of Medicine, Pontificia

Universidad Católica de Chile, Chile; and Simon Lewin, Norwegian Institute of Public Health,

Norway.

 

Conflicts of interest

None declared. For details, see: www.supportsummaries.org/coi

 

Acknowledgements

This summary has been peer reviewed by: David Yondo, Xavier Bosch-Capblanch, and Simon Goudie.

 

The review should be cited as

Bosch-Capblanch X, Liaqat S, Garner P. Managerial supervision to improve primary health care in

low- and middle-income countries. Cochrane Database of Systematic Reviews 2011, Issue 9. Art.

No.: CD006413.

 

The summary should be cited as

Herrera C, Lewin S. Does managerial supervision improve the quality of primary healthcare?

A SUPPORT Summary of a systematic review. April 2017. www.support-collaboration.org/summaries.htm

 

Keywords

All summaries: Evidence-informed health policy, evidence-based, systematic review, health systems

research, health care, low- and middle-income countries, developing countries, primary health care

This summary: supervision, supportive supervision, quality assurance, management, managerial

 



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