1.3 Bosch-Capblanch&Garner 2008 TropicalMedicine&InternationalHealth

Tropical Medicine and International Health
doi:10.1111/j.1365-3156.2008.02012.x
volume 13 no 3 pp 369383 march 2008
Systematic Review
Primary health care supervision in developing countries

Xavier Bosch-Capblanch and Paul Garner
Liverpool School of Tropical Medicine, Liverpool, UK
Summary
objectives To (a) summarise opinion about what supervision of primary health care is by those
advocating it; (b) compare these features with reports describing supervision in practice; and (c) to
appraise the evidence of the effects of sector performance.
methods Systematic review. Reports were classified into three groups and summarised using appropriate methods: policy and opinion papers (narrative summary), descriptive studies (systematically
summarised) and experimental or quasi-experimental studies (design and outcomes systematically
summarised). Data presented as narrative summaries and tables.
results 74 reports were included. In eight policy and opinion papers, supervision was conceptualised as
the link between the district and the peripheral health staff; it is important in performance and staff
motivation; it often includes problem solving, reviewing records, and observing clinical practice; and is
usually undertaken by visiting the supervisees place of work. In 54 descriptive studies, the setting was the
primary health care (PHC) or specific services and programmes. Supervisor-supervisee dyads were
generally district personnel supervising health facilities or lay health workers. Supervision mostly meant
visiting supervisees, but also included meetings in the centre; it appeared to focus on administration and
checking, sometimes with checklists. Problem solving, feedback and clinical supervision, training and
consultation with the community were less commonly described in the descriptive studies. Supervision
appears expensive from studies that have reported costs. In 12 quasi-experimental trials, supervision
interventions generally showed small positive effects in some of the outcomes assessed. However, trial
quality was mixed, and outcomes varied greatly between studies.
conclusions Supervision is widely recommended, but is a complex intervention and implemented in
different ways. There is some evidence of benefit on health care performance, but the studies are
generally limited in the rigor and follow up is limited. Further research delineating what supervision
consists of and evaluating it in the context of unbiased comparisons would guide the implementation of
effective supervision as part of the management of PHC.
keywords supervision, developing countries, health services administration, health workers, training,
management, performance, quality of care
Introduction
Why should district health team members be motivated to commit themselves to the tedious task of
administrative supervision and consider this as a
normal part of their duties? (Meuwissen 2002).
Primary health care (PHC) emphasises universal access to
health services (WHO-UNICEF 1978a). The movement
was accompanied by an expansion of basic health services
in developing countries provided by paramedical and
community health workers (Cueto 2004). Inevitably some
health workers worked in isolation, in remote rural areas
2008 Blackwell Publishing Ltd
(Greenwood et al. 1990), with problems communicating

with the centre (Loevinsohn et al. 1995).
Policy makers viewed supervision as a way to help link
basic health units and the district centre through visits
(Walt 1990; WHO 1991). It aimed to help implement PHC
(WHO-UNICEF 1978a,b) and to improve quality of care
(Tarimo 1991). Peripheral workers had limited training
and the responsibility for providing PHC was delegated to
them, and supervision was to provide support, training and
enhance community participation (WHO1991). Supervision reflected a specific approach of formal face-to-face
monitoring and support for health staff with limited
training. With inadequate base training, health workers are
369
X. Bosch-Capblanch and P. Garner Supervision of health services in developing countries
less likely to be self-supporting, particularly if they are

working alone. They thus require higher levels of assistance
than more senior colleagues (Litsios 1974).
Subsequent policies, including health sector reforms
(Mills et al. 2001) and decentralisation, meant that supervision became even more relevant (Valadez et al. 1990;
MAQ 2002), with management support being part of the
system reform at all levels (Mills et al. 2001). Others
emphasised that improving the working and living conditions of health workers is key to PHC delivery (Segall
2003), and the role of supervision in staff development
(Martnez 2001).
In light of the emphasis on supervision in managing
health services in developing countries over the years and
the renewed interest in PHC (Haines et al. 2007) we
reviewed the topic. We adopted the Oxford English
Dictionary definition of supervision: general management,
direction, or control; oversight, superintendence (OED).
We developed a simple management framework to guide
our thinking (Figure 1). This links health worker performance on the right with supervision on the left. Supervision
comprises problem solving in dialogue with health workers, checking that they are providing good quality services
according to national or local norms, and monitoring
outputs. Supervision happens in the workplace with
immediate feedback to the health worker to assist in
maximising his her performance.
Our three objectives were (a) to find out how supervision
is defined by those advocating it in PHC in developing
countries; (b) to compare these features with reports
Supervision
Performance
Feedback
Problem
identification &
solving
PHC worker
Compare service
delivered against
norms
Activities e.g.
immunisation
Examine information
against expected
outputs
Outputs e.g.
vaccine
coverage
Health outcomes
e.g. mortality
Figure 1 Management framework for supervision.
370
describing supervision in practice; and (c) to appraise the

evidence of the effects of sector performance.
Material and methods
We considered any type of published study in any language
describing supervision in health services of developing
countries. We searched in Medline (1966 up to March
2006) with the terms Health Services Administration[MeSH] AND (supervis* OR outreach*) and Developing Countries[MeSH]; the Cochrane Library (Issue 1,
2006) and the WHO online library (March 2006) with the
terms supervision and outreach. Other studies known to
us and references in the included studies were also
examined. Studies were included if they were explicitly
addressing supervision either as the main topic or as a
collateral issue with some description or valuation about
the implementation or its effects. News reports and
newsletters were excluded.
XBC retrieved the titles and abstracts of studies,
screened them to identify the relevant ones and further
scrutinised them applying the inclusion criteria, consulting
PG when in doubt. Studies were classified according to the
study design into policy and opinion, field reports and
surveys, and comparative studies. Data were extracted on
country and region, study design, health area, supervisors,
supervisees, components and tools of supervision, outcomes or comments on the effectiveness of supervision and
costs. Comparative studies were those that compared
supervision with controls or any other intervention,
whether experimental, quasi-experimental or repeated
measures in time of a single group.
Our methods for analysis depended on the objective. For
policy and opinion papers (Objective 1) we prepared a
narrative review of the features of supervision across the
papers. For field reports and surveys (Objective 2) we
developed a set of descriptors to assess what the authors
meant by supervision, the context of its implementation,
and the effects claimed by the authors. For comparative
studies (Objective 3) one author assessed the methodological quality of the studies using standard criteria: baseline
measurements of groups, concealment of allocation
sequence, blindness and loss to follow-up (EPOC 2002).
Outcomes of comparative studies were classified as impact
(for example, mortality), output (for example, coverage) or
knowledge (included reported behaviour), and tabulated.
RESULTS
The search identified 789 studies, of which 155 were
relevant. Of those, 74 met the inclusion criteria; the other
81 were excluded.
Objective 1. Policy and expert opinion: what is

supervision?
Eight studies were policy and opinion (Table 1). One of the
eight (Flahault et al. 1988) was a manual about supervision
providing detailed information about the activities
involved in supervision, the profile and training of supervisors, the way to conduct supervisory visits and examples
of forms. The other seven studies described supervision in
the areas of PHC, obstetric care and public health
surveillance. They outlined in variable detail the meaning
of supervision in the context of the health system and its
main components and tools.
Some papers described supervision as a link between the
tiers of the health system (Flahault et al. 1988, Nimo 1984)
and auxiliary services such as laboratories (McNabb et al.
2002). Flahault et al. state that the purpose of supervision
is to promote continuing improvement in the performance
of health workers by ensuring that objectives of health
programmes are adequate and consensual, by managing
the difficulties encountered by staff, by motivating staff
and by improving staff performance, including continuing
education and planning for training. Authors viewed it as
top priority to maintain care standards (Fendall 1980) and
to boost staff morale (Waterson 1982). Other studies
emphasised the link to performance (Gibson & McClelland 1990), responsibility, dialogue and sharing of work
(Agboton & Villod 1981) or assessing the quality of health
care provided (Larsen 1987).
Supervision is carried out in a regular basis (Agboton &
Villod 1981; Flahault et al. 1988, Gibson & McClelland
1990; Nimo 1984) and in the most complete description it
involves 14 steps, from the study of documents, identification of priorities and planning, up to training and
reporting (Flahault et al. 1988).
Supervision has also been related to training to the point
that the shorter the training the more supervision is
required (Agboton & Villod 1981). More widely, supervision embraces all measures to ensure that personnel
carry out their activities effectively and become more
competent at their work (Gibson & McClelland 1990).
Across all documents, three components emerged with
some degree of consistency: problem solving, reviewing
information with the supervisee and observation of
clinical practice. Most studies mention training, but in
different ways: formal training, follow-up to formal
training and on the job training. Some but not all
mention consultation with users or the community, and
some mention checklists. Although the context varies, for
the majority of studies supervision involves on-site visits
to the supervisees workplace. Box 1 summarises our
findings.
Box 1 Summary of the features of supervision from policy and

opinion papers
Supervision in primary health care in middle and low income
countries:
Is the link between the central (district) tier of the health system
and the peripheral rural health care delivery staff in the district
Is important for performance and helping motivate staff.
Often includes (a) problem solving; (b) reviewing records; (c)
observation of clinical practice.
Frequently involves visits to the supervisees place of work.
Objective 2. Field reports: what does supervision consist

of?
Fifty-four studies from 1979 up to 2006 provided data for
this section: 20 field reports and 34 surveys. Field reports
were any narrative description of supervision; surveys
reported quantitative findings: 16 were health facility or
health workers surveys; seven included surveys to patients
or examination of patients records; and 10 contained both
health facility and consumer patient data. Another study
was a review of surveys of patient-provider encounters in
several countries (Nicholas et al. 1991). Only three studies
had an explicit definition of supervision, and only a few
were explicitly focused on supervision: six studies had the
term supervision in the title.
Studies were from four continents, half of them in Africa
(Table 2). Twenty-one (39%) studies comprised PHC as a
whole, and the rest addressed several disease-specific areas,
or drug management.
The supervisor-supervisee dyads were split roughly
equally between three types of relationships: district staff
supervising health facilities, district or health facilities staff
supervising lay health workers and a miscellaneous group,
which included other types of supervisors, such as doctors
or specially trained project staff.
Supervision was undertaken either through visits of
supervisors to the supervisees place of work (38 studies), or
through meetings, e.g. of various staff at the district centre
(nine studies). Two other studies reported visits together
with meetings.
Administrative activities were common, including
information (data collection) and resources and supplies
management (Table 2), with the implication around
checking data and supplies. Direct clinical support was
less common, as was consultation with the community.
Problem solving was reported in one-fifth of studies; only a
few studies reported feedback to the supervisees. Some
studies had incentives attached to supervision, either as
motivators for supervisors or linked to supervisees performance (Table 2).
371
372
Health
area
PHC
NA
Obstetric The roles of senior obstetricians

care
supervising peripheral health units. 6
goals: act as a consultant, help with
clinical problems; assess the quality of
care; provide in-service education for the
midwives; ensure that they have the best
equipment possible; interpreting the
needs of midwives to health care
authorities; and support the midwives in
their contacts with the community.
Flahault et al.
(1980)
Gibson &
McClelland
(1990)
Larsen (1987)
Supervision of health care centres

is needed to ensure quality
health care. Describes six components.
Overall range of measure to ensure that
personnel carry out their activities
effectively and become more competent
at their work
PHC
Presents the phases to establish a

national PHC programme, informing
management of the best ways to
conduct supervision and training.
Supervision is an educational process.
The short the training the more
supervision is required.
Supervision is on-site consultancy
sessions devoted to actual
problem-solving. Educational and
administrative. Objective: provision of
effective Primary Health Care
Manual about supervision: concept of
supervision, activities involved in
supervision, examples of supervision
instruments, how to supervise,
supervisors profile and training
supervisors.
Main focus
Fendall (1980)
Agboton & Villod NA

1981
Author year
Table 1 Characteristics of the eight policy and opinion papers

Components
and tools
NA
Peripheral units
District Medical Officer

in district hospital
Experienced doctor
(1) Establishment of
contacts; (2) review of
targets; (3) observation of
the health workers; (4)
identification of gaps; (5)
consultation with the
community; (6) reporting
to the health team. Follow-up and solutions of
problems
Regular
Six components:
and
communication, teaching,
frequent seeing patients, tour of the
health centre, assessing
performance, and follow
up. Assess performance,
follow-up training; communication and observation of health facilities.
Feedback provided.
Checklists
Visits
Control of staff, problem
solving, follow-up of
training, review of
information, management
of resources and supplies,
and community
involvement. Human
relationships. Incentives.
Community
Visits
Health Workers
Regular
Focus on evaluation,
schedule correction of errors,
reinforce understanding,
review on information
and collect options from
the community.
Recording grid
Visits and Problem solving, review of
meetings information. Also reports,
statistics, protocols,
circulars, courses.
Visits
Health centres.
District level
Anyone is
entitled
Village health
agent;
health teams
Team that provided

training; personnel
of HC
NA
Supervisee
Supervisor

Clinical supervision
and observation of
practices
Visits
(1) Level A
(community
level)
(2) Level B
NA
Twice a Supervisors are provided

month with motorised bicycles
Nineteen studies mentioned the tools used for supervision, and this included recording grids, checklists, written
instructions, standardised forms, revision of achievements
and rapid assessment tools.
In 24 studies, the authors provided an opinion about the
effects of supervision on quality of health care or utilisation
of services: fifteen were positive about the effects and nine
reported poor implementation.
Eight studies reported on the costs of supervision, which
were estimated in a variety of ways. In half of the studies,
authors considered costs involved in supervision as
expensive (Grosskurth et al. 2000 notes that supervision
was the single most expensive component of recurrent
costs, for example).
A number of studies described barriers in implementing
effective supervision (Box 2).
Objective 3. Effectiveness of supervision
NA-not available.
Waterson (1982)
PHC
The role of the physician in a PHC

system in developing countries. Three
functions: consultation, supervision
and training. Supervision is essential
both to maintain standards and to
boost morale. Top priority.
(1) Level B
(local council
sub areas)
(2) Level C (district)
Doctor in PHC
Incentives being the

supervisor role a
motivator
NA
Facilities and labs
at health
facility, district and
regional levels
NA
McNabb et al. 2002 Public

Supervision of services involved in
health
public health surveillance. Support
sur-veillance activities: supervision,
communication, training and
resource provision.
Nimo (1984)
PHC
Describes the tiers of the
health system (A, B, C).
Author year
Table 1 (Continued)
Health
area
Main focus
Supervisor
Supervisee
Visits
Components
and tools
Twelve studies used experimental or quasi-experimental

designs to assess the effects of supervision or complex
interventions containing supervision: one cluster randomised control trial, seven controlled before-and-after
studies, one comparing data from a Demographic Surveillance System over several years; and three were comparisons of repeated measures in time (Table 3). Four studies
concerned prescribing, three maternal and child health
(MCH) services, three malaria and two were about
reproductive health.
Participants were staff of health units (five studies), users
(including clinical encounters and prescriptions, four
studies) or both (three studies). Interventions varied in their
complexity. Loevinsohn et al. (1995) assessed the effects
of a checklist supporting supervision against simple
supervision; other interventions included supervision
enhanced by training (Costello et al. 2001; Delacollette
et al. 1996; Kafuko 1997; Trap et al. 2001; Uys et al.
2005; Zeitz et al. 1993), audit and feed back (Kafle et al.
1997), inputs of resources (Chalker 2001) and two were
complex interventions (Curtale et al. 1995; Hill et al.
2000). Miller et al. 1996 compared supervision frequency
6 years apart. Hill et al. who reported impact on mortality,
stated that supervision was only one of the many components on the improvement of child survival (Hill et al.
2000).
Two studies reported impact outcomes: mortality (Hill
et al. 2000) and malariometric indicators (Delacollette et al.
1996); 11 studies reported outputs of health services (e.g.
coverage) and two studies reported knowledge or awareness
(a few studies reported more than one type of outcome).
The detail of the reports made it difficult to assess
quality. For example, blinding in the assessment of
373
Table 2 Elements of supervision in the 54 papers (20 field reports

and 34 surveys) included in the review (policy and opinion papers
and comparative studies excluded)
Number
All field reports and descriptive studies
By region of the study
Africa
Asia
America
Oceania
Not reported
By health area
Primary Health care
Reproductive health
Child health
Fever malaria
Drug management
Other
Supervisor-supervisee dyads
District supervising HU
District or HU supervising LHW
Other arrangements
Supervision implementation
Only visits to the periphery
Only meetings at the supervisory base
Visits and meetings
Not reported
Year frequency of visits:
median (IQ Range)
6
Components
Information (e.g. collection of data)
Resources and supplies management
Problem solving
Clinical observation
Community involvement
Follow up training
Control of staff
Feed-back
Incentives attached to supervision
Observation of practices
Effects of supervision as reported by authors
Positive
Supervision poorly implemented
Not reported
Costs reported
Percentage
54
100
27
15
8
3
1
50
28
15
6
2
21
14
5
5
3
6
39
26
9
9
6
11
19
18
17
35
33
31
38
9
2
7
70
17
4
13
(9)
19
16
12
11
10
8
7
7
6
5
35
30
22
20
19
15
13
13
11
9
15
9
30
8
28
17
56
15
HU: Health Unit. LHW: Lay Health Workers. Percentages: over

the total number of studies.
outcomes was unclear in all but two of them (except in

Chalker 2001; Hill et al. 2000 and Zeitz et al. 1993; where
it was not applicable). In two studies (Curtale et al. 1995;
Trap et al. 2001) loss to follow-up exceeded 20%.
Ten studies showed at least one outcome favouring
intervention (although one did not report the value of the
statistical significance). One study (Delacollette et al.
374
1996) showed this at the level of impact; another showed it

in one of the repeated periods of time defined to measure
mortality (Hill et al. 2000). Most other studies measured
outcomes at output level and all studies reported at least
one outcome with no statistically significant differences
between groups. Seven studies reported more than three
outcomes and none of them identified a primary outcome.
The time of follow-up was usually <1 year, in one case only
2 months (Zeitz et al. 1993).
Three studies reported or commented on costs, which
included equipment, drugs (Chalker 2001), transport and
per diems (Curtale et al. 1995); Costello et al. signalled
that local governments could not afford supervisory visits.
Discussion
Features of supervision
We expected wide variation in the meaning and content of
supervision. However, the comparison between the manuals and policy documents with the field-based reports in
relation to the features of supervision were fairly consistent: peripheral visits, regular visiting, and activities
around checking information and checking supplies.
In the policy documents, the central role of supervision in
performance and motivation was clear. In the field reports,
the central role of administrative checking, and examination of records of activities at each facility is to be expected,
and suggests a level of control around hecking up on
people. What was interesting was that problem solving was
less commonly mentioned, yet in a supportive relationship
between supervisor and supervisee, joint problem-solving
might be motivating and helpful. Similarly, less than 15%
mentioned feedback. These approaches are well-recognised
in improving staff performance but they seem to be less
centrally placed in supervision programmes. We may have
thus detected a gap between policies around motivation
(requiring problem solving and performance) and the
implementation of supervision where problem solving and
feedback appear less important.
Checklists are sometimes a feature of supervision and
provide supervisors with a structure for their visits, but this
may encourage a more authoritarian, controlling approach
to supervision, rather than listening, problem-solving and
feedback. On the other hand, monitoring of performance is
required to take remedial action and give appropriate
feedback. These approaches to supervision could be
compared to identify the best one in terms of quality of
care and health impact.
The policy documents did not refer to resource implications of supervision, but some of the field reports and
trials did. The load that supervision poses on supervisors
Box 2 Barriers to effective implementation of supervision

Environment
Health service
and resources
Supervisors
Supervisee and
Community
Armed conflict (e.g. Nicaragua, El Salvador)

Geographical isolation of communities
Supervision programmes are difficult to sustain
No transport available or means to ensure transport to undertake
supervisory visits
District teams are too young to have experience
Supervisors not qualified (e.g. assistant secretaries)
Supervisors are inadequately trained
Supervision diverts time from clinical tasks
Absenteeism of supervisors at follow-ups
Poor community involvement
Low attendance of supervisors and supervisees at supervisory
meetings
Misunderstanding of the role of supervisor by supervisees
and community (e.g. drug distributors rather than problem solvers)
Capps & Crane (1989);

Heldal et al. (1997)
Capps & Crane (1989)
Meuwissen (2002)
Aitken (1994); Altigani (1992);
Snell & Dualeh (1988)
Campos-Outcalt et al. (1995)
Nicholas et al. (1991)
Lamboray (1979)
Graham-Jones & Nabarro (1988)
Kaseje et al. (1987)
Mangay-Angara (1981)
The box below summarises the features of supervision from field reports and surveys.
Box 3 Summary of the features of supervision from field reports and surveys
Mostly consists of central supervisors visiting peripheral health
care staff, but can include visits to the centre;
Focuses on administration and checking, sometimes with
checklists; less common is problem solving, feedback and
clinical supervision.
Sometimes includes training and consultation with the
community.
Is expensive, and has a number of barriers to effective
implementation.
and supervisees time and other resources that a number of

studies highlighted would certainly suggest an integrated
approach rather than different supervisors for different
disease control programmes, and the need to be clear that it
is effective.
Throughout the literature, supervision was often linked
with training (supervision training, follow-up of training,
or identifying training needs). However, intensive supervision may also be costly when it is meant to reinforce
training of multi-function staff in the phase of integration
of vertical programmes (Criel et al. 1997). Clinical supervisionchecking diagnostic or therapeutic skills did not
feature widely and this may indeed relate to the different
functions of health facilities, or the skills mix of staff.
Over half of the studies examined the impact of a
particular short-term intervention in one area of health
care, such as reproductive health. This may assist governments or donors in achieving particular targets: indeed, the
evaluation study may well be part of the programme of
implementation. However, more sustainable models of
supervision embedded in the health system and
encompassing more than one disease control programme

or the PHC system as a whole may be more effective and
efficient, and worth carefully evaluating with well
designed quasi-randomised methods.
Effectiveness and performance
The effects of supervision described in the comparative
studies provide evidence of benefit, with clear evidence in
particular outcomes. However, care is required in interpretation and extrapolation of those findings. The interventions often evaluated multiple arms, and some of the
differences reported may not be accounted for by just the
supervision component. Few studies stated their primary
outcome, and multiple significance testing and selective
reporting is likely to be a problem. Second, programmes
were often well financed, so the replicability outside of the
context of a special research study is unclear. To explore
these and other factors, we are conducting a rigorous
analysis with careful critical appraisal of each study using
the criteria of the Cochrane Collaboration (BoschCapblanch & Garner 2007).
Other reviews have explored the link between supervision and performance. Rowe et al. (2005) summarised
reviews of determinants of performance of health workers,
and examined a range of interventions. They concluded
that management approaches, such as supervision, audit
and feedback, generally had moderate to large effects,
based on other peoples reviews, mainly on drug management. Ross-Degnan et al. 1997 reviewed training strategies
in relation to prescribing. In this carefully carried out
systematic review, one component of supervision was audit
and feedback, which appeared to be effective. A third
375
376
MCH
The Gambia,
19821996
Vietnam,
19941996
Hill et al.
(2000)
Chalker
(2001)
Prescribing
Malaria
Country, year Health area
Delacollette
Zaire,
et al. (1996) 19851987
Author year
ITS
DSS
CBA
Study
design
Intervention and
control groups
I: complex PHC
intervention,
including
supervision of
village health
workers and
traditional birth
attendants by
Community
Health nurses
C: no
intervention
I: Money for
217 Commune
drugs, donation
health workers
in 12 districts of for equipment;
monthly visits
Hai Phong
province
by district
supervisors to
community
health stations.
C: rolling
controls
Data from
Demographic
Surveillance
system in 40
villages
Several rounds of I: introduction

and training of
malariometric
household
Community
surveys
Health Workers
(CHW) for
malaria,
supervised by
HU staff; small
monetary
reward
C: routine care
Sample size
Output
Output
Impact
Output
Impact
Impact
Outcome
category
Table 3 Comparative studies, ordered by strength of the outcome category and by author name
95% CI:
3.0 to 80.1; 1.4 to 2.7
2.4 to 15.3; 1.1 to 3.1
I: 4.9; C: 2.0
I: 6.0; C: 1.9
Ranges
only significant in
in several
1989-92
periods: 0.74 to for infants: 0.67 (95%
1.14 (infant)
CI:
and 0.74 to
0.50 to 0.90).
1.07
(childhood);
Not reported
95% CI:
1.6 to 2.1
1.7 to 2.2
not significant
Statistical
significance
1.9
1.9
-
Results
69% (baseline), P < 0.01 for second

% of patients
who received
46%, 48%,
measure
antibiotics (four 40%
measures,
19947)
30%, 91%, 93% P < 0.001 for second
% of patients
and 98%
measure (3 months
who received
after intervention)
adequate
compared with
antibiotic doses
baseline
(measured at
four time points
between years
1994 and 1997)
Rate ratios (two

year period) of
malaria
reduction:
prevalence
incidence
mortality
Reduction of
crude
parasitological
index (PI) high
parasitaemia
index (HPI)
Health seeking
behaviour items
Rate ratios
of infant and
under-five
mortality
(1982-96)
Main outcomes

Nepal
Uganda
Kafle et al.
(1997)
Kafuko
(1997)
Reproductive
Health
Miller et al.
(1996)
Kenya, 1989
and 1995
PHC
Loevinsohn
Philippines,
et al. (1995) 19911992
Prescribing
Prescribing
Author year
Table 3 (Continued)
CBA
CBA
Cluster
RCT
CBA
Study
design
Intervention and
control groups
99 (year 1989)
and 147 (year
1995) Service
Delivery Points
Intervention: 21
HUs; control:
42 HUs. 30
prescriptions in
each HU and 9
observations of
encounters
I: National
reproductive
health
programme. C:
same in 1989
I: supervision by
District Public
health officer +
audit feed-back
at the end of
each
supervision,
with guidelines
and tools
C: no
intervention
15-36 patients
I1: treatment
encounters in
guidelines +
127 HC
training + 12
monthly
supervision
visits of HUs by
members of the
District Health
team;
I2: guidelines +
training;
I3: only
guidelines
C: no
intervention
Intervention: 56 I: integrated
HUs; control 68 supervisory
HUs
checklist
C: supervision
without
checklist
Sample size
Output
Output
Output
Score (maximum
60)
summarising 20
indicators at 0
and 6 months
Proportion of
cases treated
according to
guidelines; same
for malaria
cases
SDP receiving
supervisory
visits
Before: 11 to 40; No statistically

after: 6 to 39
significant; changes in
other outcomes cannot
be attributed to
supervision.
Improvement in Significant in I1
all groups but C (P = 0.007) and I2
(P = 0.047)
I: from 26 to 37 P = 0.003
points;
C: from 27 to 32
points
a) Improvements Not reported

a) Number
in Il and I2;
of drugs
prescribed for b) in I2;
general cases; c) in Il and I2
b) in antibiotic
prescribed;
c) in injections
prescribed
Significant
improvements
(p not reported)
Statistical
significance
Output
Not reported
Results
Decrease
injections,
increase
consultation
time and
prescription
according to
guidelines
Main outcomes
Output
Outcome
category

377
378
Zimbabwe,
1996
South Africa
Nigeria, 1992 MCH

(Diarrhoea)
Trap et al.
(2001)
Uys et al.
(2005)
Zeitz et al.
(1993)
PHC
Prescribing
Author year
Table 3 (Continued)
Intervention and Outcome
control groups
category
169 nurses; 176

(clinics) and
270 (hospital)
patients, in 3
districts
I: training of
supervisors on
diarrhoea
management.
C: preintervention.
Output
Output
Output
I1: supervision
based on matrix
model; I2:
supervision
based on Centre
for Health and Output
Social Studies
C: usual training
on supervision Output
Output
24 HUs for each I: Quarterly
supervisory
arm:
visits on drug
intervention A
management
(stock
supervisors (I1)
management),
and standard
intervention B
Output
(guidelines) and treatment
guidelines (I2)
control.
C: no supervision
Sample size
ITS
29 Health
(March and workers in
May 1992) March and
31 in May
CBA
CBA
Study
design
Statistical
significance
I1: 7 to 26
I2: 0 to 27
C: )16 to 4
Statistical differences
found in 17 of the 27
items.
No difference in I1
No difference in I1 and
I2
No difference in I1 and
C (no data on B)
No difference beforeafter in I1 and C
4 indicators significant
1 indicator significant
I1: from -4 to 38 4 indicators significant

I2: -27 to 13
C: -7 to 0
None significant
Results
I1: from 33 to
32; I2: 30
(only after);
C: from
20 to 36
Score of job
I1: from 122 to
satisfaction
75; I2: 75.5
(only after)
Score of quality I1: from 11 to
12; I2: from 10
of care and
nursing records to 11
standards
Score of patient I1: from 11 to
satisfaction
15; I2: from 14
to 14.
Differences in % )1.7 to 62.1
of health
workers
performing
clinical
tasks, two
months apart
Median change
in score of nine
stock
management
indicators
(scores)
Median change
in scores of four
adherence to
standard
treatment
guidelines
indicators
Score of
perceived
supervision
Main outcomes

Country, year
Nepal, 1992
Author year
Curtale et al.
(1995)
Table 3 (Continued)
MCH
Health area
Controlled
Study
design
1080 mothers in
each group;
several
Community
Health
Volunteers
(CHV)
Sample size
% Of mothers
with
appropriate
health seeking
behaviour
% Full
immunisation,
anti-helminths
treatment
coverage,
correct
treatment for
ARI, growth
monitoring
uptake
% Of mothers
using ORT
Knowledge
Knowledge
Output
Output
% of CHV
answering
knowledge
items on night
blindness and
ARI
% Of mothers
utilising services
Knowledge
I: complex
nutrition
education
intervention
where health
post staff
supervises
CHV
C: usual care
Main outcomes
Outcome
category
Intervention and
control groups
I: 7894%;
C: 4376%
I: 22% to
84%;
C: <1% to
66%
I: 21% to
92%;
C: 4% to
24%,
I: 35%;
C: 4%
I: 33% to
99%;
C: 3% to
64%,
Results
P < 0.001
All items
P < 0.001
P < 0.001
All items
P < 0.001
All items
P < 0.001
Statistical
significance

379
380
Output
C: control; CBA: controlled before and after study; CI; confidence interval; DSS: demographic surveillance system (repeated measures); HU: health unit; I: intervention; MCH:
maternal and child health; ORT: oral rehydration therapy; RCT: randomised control trial.
Measures of the Statistically significant

improvement in 13 out
effect after
of 44 items.
adjusting for
baseline score:
from nonestimable to
9.7;
% Of users
Measures of the Statistically significant
properly
effect after
improvement in 24 out
treated at 0 and adjusting for
of 35 items.
6 months
baseline score:
from 0.6 to 3.9;
% Of
midwifes with
knowledge on
contraception
at 0 and
6 months
Knowledge
I: training about
40 HUs in each
client-provider
group and 869
and 859 users in information
exchange and
intervention
training of
and control
supervisors
groups
visiting
respectively
providers
C: usual care
CBA
Reproductive
Health
(family
planning)
Costello et al. Philippines,
(2001)
1997

Author year
Table 3 (Continued)
Study
design
Sample size
Intervention and
control groups
Outcome
category
Main outcomes
Results
Statistical
significance
review examined various interventions on drug prescribing,

and explicitly examined supervision in relation to clinical
guidelines, where it appeared complementary to initial
training and helped sustain intervention effects with
treatment guidelines programmes (WHO 2001).
Policy and research implications
It is common sense that there should be a link between
peripheral health units and the district centre, and that
monitoring of some form is required for good governance
(Segall 2003). Indeed, our simple framework (Figure 1)
appeared robust and consistent with the policy literature. It
would thus be misguided to recommend abandoning a
management approach just because the research demonstrating benefit is mixed. On the other hand, if it is
highly effective, then good research that demonstrates
this clearly could help with investment in health systems
strengthening, as well as the supply of drugs and
commodities.
In addition, research can show how supervision is best
carried out, and what makes it effective. This will require a
mix of rigorous quasi-experimental studies implemented
with resources that are consistent with what the health
sector in the country can afford. If indeed systems then
move forward with developing supervision more carefully,
it is important that there is a political commitment within
the system itself which ensures that the supervisor is
responsible for the success or failure of the supervisee:
thus good performance by the peripheral health worker
reflects on the work and integrity of the supervisor
(Umiker 2005).
Acknowledgements
We thank Vicki Doyle and Maria Paz Loscertales for
comments on the draft. Paul Garner is supported by a grant
from a project funded by the UK Department for International Development (DFID) for the benefit of developing
countries. The views expressed are not necessarily those of
DFID.
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Corresponding Author Xavier Bosch-Capblanch, Swiss Centre for Tropical Health Swiss Tropical Institute, Socinstrasse 57,
CH-4002 Basel, Switzerland. Tel.: +41 (0) 612848319; Fax: +41 (0) 612848103; E-mail: x.bosch@unibas.ch.
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Tropical Medicine and International Health

volume 13 no 3 pp 369383 march 2008

Primary health care supervision in developing countries

2008 Blackwell Publishing Ltd

(Greenwood et al. 1990), with problems communicating

Tropical Medicine and International Health

volume 13 no 3 pp 369383 march 2008

X. Bosch-Capblanch and P. Garner Supervision of health services in developing countries

less likely to be self-supporting, particularly if they are

describing supervision in practice; and (c) to appraise the

2008 Blackwell Publishing Ltd

Tropical Medicine and International Health

volume 13 no 3 pp 369383 march 2008

X. Bosch-Capblanch and P. Garner Supervision of health services in developing countries

Objective 1. Policy and expert opinion: what is

2008 Blackwell Publishing Ltd

Box 1 Summary of the features of supervision from policy and

Objective 2. Field reports: what does supervision consist

Obstetric The roles of senior obstetricians

Supervision of health care centres

Presents the phases to establish a

Agboton & Villod NA

Table 1 Characteristics of the eight policy and opinion papers

District Medical Officer

Team that provided

Tropical Medicine and International Health

X. Bosch-Capblanch and P. Garner Supervision of health services in developing countries

2008 Blackwell Publishing Ltd

Tropical Medicine and International Health

volume 13 no 3 pp 369383 march 2008

2008 Blackwell Publishing Ltd

Twice a Supervisors are provided

The role of the physician in a PHC

Incentives being the

McNabb et al. 2002 Public

X. Bosch-Capblanch and P. Garner Supervision of health services in developing countries

Twelve studies used experimental or quasi-experimental

Tropical Medicine and International Health

volume 13 no 3 pp 369383 march 2008

X. Bosch-Capblanch and P. Garner Supervision of health services in developing countries

Table 2 Elements of supervision in the 54 papers (20 field reports

HU: Health Unit. LHW: Lay Health Workers. Percentages: over

outcomes was unclear in all but two of them (except in

1996) showed this at the level of impact; another showed it

2008 Blackwell Publishing Ltd

Tropical Medicine and International Health

volume 13 no 3 pp 369383 march 2008

X. Bosch-Capblanch and P. Garner Supervision of health services in developing countries

Box 2 Barriers to effective implementation of supervision

Armed conflict (e.g. Nicaragua, El Salvador)

Capps & Crane (1989);

and supervisees time and other resources that a number of

2008 Blackwell Publishing Ltd

encompassing more than one disease control programme

Country, year Health area

Several rounds of I: introduction

69% (baseline), P < 0.01 for second

Rate ratios (two

Tropical Medicine and International Health

X. Bosch-Capblanch and P. Garner Supervision of health services in developing countries

2008 Blackwell Publishing Ltd

2008 Blackwell Publishing Ltd

Country, year Health area

Before: 11 to 40; No statistically

1.3 Bosch-Capblanch&Garner 2008 TropicalMedicine&InternationalHealth

1.3 Bosch-Capblanch&Garner 2008 TropicalMedicine&InternationalHealth