Innovation in supervision and support of community health workers for better newborn survival in southern Tanzania Elibariki Mkumboa,*, Claudia Hansona,b,c, Suzanne Penfoldc, Fatuma Manzia and Joanna Schellenbergc a
*Corresponding author: Tel: +255755633711; Fax: +0222771714; E-mail: [email protected]
Received 13 December 2013; revised 12 February 2014; accepted 17 February 2014 Background: Home visits by community health workers may help to improve newborn survival, but sustained high-quality supervision of community volunteers is challenging. Objectives: To compare facility-led and community-linked supervision approaches of 824 community health volunteers working to improve newborn care in Southern Tanzania. Methods: Using a before–after design, we compared 6 months of supervision reports from each approach. Results: During the community-linked approach over 50 times more supervision contacts were recorded than during the facility-only supervision approach (1.04 contacts per volunteer per month vs 0.02), and the volunteer–supervisor ratio reduced from 7.8 to 1.6. Conclusion: Involving community leaders has the potential to improve supervision of community health volunteers. ClinicalTrials.gov Identifier: NCT01022788; http://clinicaltrials.gov/ct2/show/NCT01022788?term=INSIST&rank=1 Keywords: Community health workers, Newborn health, Supervision, Tanzania
Introduction Globally, almost 3 million babies die each year in the neonatal period.1 Home visits by trained community health workers (CHWs) in the first week of life to promote warmth, hygiene and breastfeeding, can improve newborn survival.2 However, supervision and support of CHWs, who are often volunteers, are challenging and neglected issues.3,4 Here we compare a community-linked approach of supervision and support of community health volunteers with a conventional approach led from health facilities. We report supervision contacts per volunteer, using a before-and-after design.
Materials and methods Setting In early 2010, in six districts of Lindi and Mtwara regions in southern Tanzania, 824 community volunteers (two per village) were trained to make home-based counseling visits to promote essential newborn care.5 They were expected to conduct a minimum of three visits to women during pregnancy, and two postnatal. Community volunteers from 1–2 wards (a ward comprises 4–5 villages) were invited to attend regular quarterly review meetings
(QRMs), to share experience, refresh knowledge, discuss challenges and agree action points. These meetings included village leaders and health facility Reproductive and Child Health (RCH) staff and were chaired by district health managers, with project staff attending roughly half of the meetings.
Facility-led supervision approach Between April and October 2010, community volunteers were supervised by the person in charge of the RCH section of the nearest health facility, usually a nurse from a dispensary. These 105 facility-based supervisors were trained for 6 days, and each supervised 6–10 volunteers.5 They were supposed to make one supervision visit in the community every 3 months, to include an accompanied home visit for technical support. A supervision checklist reinforced key messages for volunteers to discuss at home visits. QRMs included plenary discussion and review of each individual volunteer’s work.
Community-linked supervision approach From January 2011, Village Executive Officers (VEOs), governmentsalaried village leaders, were introduced as additional supervisors.
# The Author 2014. Published by Oxford University Press on behalf of Royal Society of Tropical Medicine and Hygiene. All rights reserved. For permissions, please e-mail: [email protected].
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Ifakara Health Institute, Plot 463 Kiko Avenue, Mikocheni Dar es Salaam, Tanzania; bDepartment of Public Health Sciences, Karolinska Institutet, Widerstro¨mska Huset, 17177 Stockholm, Sweden; cDepartment of Disease Control, London School of Hygiene & Tropical Medicine, Keppel Street, London WC1E 7HT, UK
SHORT COMMUNICATION
Int Health 2014; 6: 339–341 doi:10.1093/inthealth/ihu016 Advance Access publication 7 April 2014
E. Mkumbo et al.
Each of the 412 VEOs met monthly with community volunteers in their own villages to discuss community-related issues affecting their work. In addition, facility supervisors were supposed to have monthly facility-based technical supervision meetings. Under this approach, QRMs included structured discussions for small groups of volunteers, with separate groups of VEOs and facility supervisors, with feedback to a concluding plenary discussion.
Data collection and analysis
Ethical approval Ethical approval was recived from review boards of Ifakara Health Institute and the National Tanzania Medical Research Co-coordinating Committee through the Tanzania Commission for Science and Technology. Ethical and research clearance was also obtained from the London School of Hygiene & Tropical Medicine. ClinicalTrials.gov Identifier: NCT01022788; http://clinicaltrials.gov/ ct2/show/NCT01022788?term=INSIST&rank=1
Results During the 6-month period of the facility-led supervision, only 89 volunteer–supervisor contacts were recorded, an average of 0.02 contacts per volunteer per month (Figure 1). During the 6-month period of the community-linked supervision approach, 1440 volunteer–supervisor contacts were recorded with facility supervisors, and a further 3708 with VEO supervisors,
Discussion Following the creation of a role for village leaders in the supervision of community health volunteers the frequency of supervision contacts increased over 50-fold, in part due to an increase in contacts with facility staff for technical support. However, we acknowledge that we are only able to report on the quantity of the supervision, and not on the quality. The change in supervision contact frequency could be due to three main types of factors: sharing the supervisory work between more people; increasing accountability; and temporal confounding–a limitation of this study. Firstly, the inclusion of VEOs increased the total number of supervisors and shared the work between more people. Health facility staff often feel overwhelmed, and additional roles such as supervision of volunteers can be difficult to incorporate into routines. Secondly, as health workers, volunteers and VEOs are often part of the same community, directly involving community leaders in supervision might have increased pressure to provide appropriate technical support. The position of the VEOs in their community might also have increased accountability toward the community, an important aspect6 to ensure sustainability. Further, the QRM changed after the introduction of the community-linked supervision to include joint review which may have created a community-based control mechanism. The group focus for evaluation and assessment may have improved team work and morale and might have created a more positive environment for the supervision. Thirdly, we acknowledge that other issues that changed over time–temporal confounders– may partly account for the increase in supervision contacts. Despite work to document contextual changes we are unaware of any community or health systems factors that could have had such a dramatic and timely effect on volunteer–supervision contacts. Involving community leaders in supervision can have a positive effect on supervision-contacts and may improve accountability of health workers to their communities.
Authors’ contributions: The study was conceived by EM, SP and JS. EM wrote the first draft of the manuscript. CH, SP, FM and JS critically revised the manuscript and all authors read and approved the final version. EM is the guarantor of this paper.
Figure 1. Facility-led and community linked supervision models. This figure is available in black and white in print and in color at International Health online. CHW: community health worker; VEO: Village Executive Officer.
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Acknowledgements: The authors thank facility staff and health management teams of Mtwara Rural, Lindi Rural, Nachingwea, Ruangwa, Tandahimba and Newala Districts as well as Mtwara and Lindi regional health officers. We thank Nelson Mkwao, Silas Temu, Iddy Kisung’a and Evaristus Nyanda, as well as Donat Shamba, Tara Tancred and David Schellenberg. Funding: This study is part of INSIST (ClinicalTrials.gov NCT01022788), funded by the Bill & Melinda Gates Foundation through Saving Newborn
Downloaded from http://inthealth.oxfordjournals.org/ at Univ. of Massachusetts/Amherst Library on September 7, 2015
Copies of all supervision forms were brought to each QRM. We collected supervision forms during QRMs from June to November 2010 and again from January to June 2011. Using a tally sheet, we counted the supervision contacts reported on these forms. This was done twice by two different people, and differences resolved with reference to the original forms. The number of supervision contacts per volunteer–month and the ratio of volunteers to supervisors were calculated.
giving a total of 5148 supervision contacts, or 1.04 contacts per volunteer per month, 0.29 contacts with facility staff and 0.75 contacts with VEOs. Under this approach, two contacts per volunteer per month were expected. The inclusion of VEOs increased the number of supervisors from 105 to 517 and reduced the ratio of volunteers per supervisor from 7.8 to 1.6.
International Health
Lives (Save the Children), as well as by UNICEF Tanzania, Batchworth Trust, and Laerdal Foundation.
2 WHO; UNICEF. Home visits for newborn child:a strategy to improve survival. Geneva: World Health Organization and United Nations Children’s Fund; 2009.
Competing interests: None declared.
3 Lehmann U, Sanders D. Community health workers: what do we know about them? The state of evidence on programmes, activities, costs and impact on health outcomes of using community health workers. Geneva: World Health Organization; Evidence and Information for Policy, Department of Human Resources for Health; 2007.
Ethical approval: We received ethical approval from review boards of Ifakara Health Institute and the National Tanzania Medical Research Co-coordinating Committee through the Tanzania Commission for Science and Technology. Ethical and research clearance was also obtained from the London School of Hygiene & Tropical Medicine.
1 UN Inter-agency Group for Child Mortality Estimations. Levels and Trends in Child Mortality. Estimates developed by the UN Inter-agency Group for Child Mortality Estimation. New York: UNICEF, WHO, The World Bank, and United Nations; 2013.
5 Borghi J, Cousens S, Hamisi Y et al. STUDY PROTOCOL: Improving newborn survival in rural southern Tanzania: a cluster-randomised trial to evaluate the impact of a scaleable package of interventions at community level with health system strengthening. 2013;http:// researchonline.lshtm.ac.uk/1343294/ [accessed 5 December 2013]. 6 Pallas SW, Minhas D, Pe´rez-Escamilla R et al. Community health workers in low- and middle-income countries: what do we know about scaling up and sustainability? Am J Public Health 2013;103:e74–82.
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Downloaded from http://inthealth.oxfordjournals.org/ at Univ. of Massachusetts/Amherst Library on September 7, 2015
References
4 Jaskiewicz W, Tulenko K. Increasing community health worker productivity and effectiveness: a review of the influence of the work environment. Hum Res Health 2012;10:38.
*Corresponding author: Tel: +255755633711; Fax: +0222771714; E-mail: [email protected]
Received 13 December 2013; revised 12 February 2014; accepted 17 February 2014 Background: Home visits by community health workers may help to improve newborn survival, but sustained high-quality supervision of community volunteers is challenging. Objectives: To compare facility-led and community-linked supervision approaches of 824 community health volunteers working to improve newborn care in Southern Tanzania. Methods: Using a before–after design, we compared 6 months of supervision reports from each approach. Results: During the community-linked approach over 50 times more supervision contacts were recorded than during the facility-only supervision approach (1.04 contacts per volunteer per month vs 0.02), and the volunteer–supervisor ratio reduced from 7.8 to 1.6. Conclusion: Involving community leaders has the potential to improve supervision of community health volunteers. ClinicalTrials.gov Identifier: NCT01022788; http://clinicaltrials.gov/ct2/show/NCT01022788?term=INSIST&rank=1 Keywords: Community health workers, Newborn health, Supervision, Tanzania
Introduction Globally, almost 3 million babies die each year in the neonatal period.1 Home visits by trained community health workers (CHWs) in the first week of life to promote warmth, hygiene and breastfeeding, can improve newborn survival.2 However, supervision and support of CHWs, who are often volunteers, are challenging and neglected issues.3,4 Here we compare a community-linked approach of supervision and support of community health volunteers with a conventional approach led from health facilities. We report supervision contacts per volunteer, using a before-and-after design.
Materials and methods Setting In early 2010, in six districts of Lindi and Mtwara regions in southern Tanzania, 824 community volunteers (two per village) were trained to make home-based counseling visits to promote essential newborn care.5 They were expected to conduct a minimum of three visits to women during pregnancy, and two postnatal. Community volunteers from 1–2 wards (a ward comprises 4–5 villages) were invited to attend regular quarterly review meetings
(QRMs), to share experience, refresh knowledge, discuss challenges and agree action points. These meetings included village leaders and health facility Reproductive and Child Health (RCH) staff and were chaired by district health managers, with project staff attending roughly half of the meetings.
Facility-led supervision approach Between April and October 2010, community volunteers were supervised by the person in charge of the RCH section of the nearest health facility, usually a nurse from a dispensary. These 105 facility-based supervisors were trained for 6 days, and each supervised 6–10 volunteers.5 They were supposed to make one supervision visit in the community every 3 months, to include an accompanied home visit for technical support. A supervision checklist reinforced key messages for volunteers to discuss at home visits. QRMs included plenary discussion and review of each individual volunteer’s work.
Community-linked supervision approach From January 2011, Village Executive Officers (VEOs), governmentsalaried village leaders, were introduced as additional supervisors.
# The Author 2014. Published by Oxford University Press on behalf of Royal Society of Tropical Medicine and Hygiene. All rights reserved. For permissions, please e-mail: [email protected].
339
Downloaded from http://inthealth.oxfordjournals.org/ at Univ. of Massachusetts/Amherst Library on September 7, 2015
Ifakara Health Institute, Plot 463 Kiko Avenue, Mikocheni Dar es Salaam, Tanzania; bDepartment of Public Health Sciences, Karolinska Institutet, Widerstro¨mska Huset, 17177 Stockholm, Sweden; cDepartment of Disease Control, London School of Hygiene & Tropical Medicine, Keppel Street, London WC1E 7HT, UK
SHORT COMMUNICATION
Int Health 2014; 6: 339–341 doi:10.1093/inthealth/ihu016 Advance Access publication 7 April 2014
E. Mkumbo et al.
Each of the 412 VEOs met monthly with community volunteers in their own villages to discuss community-related issues affecting their work. In addition, facility supervisors were supposed to have monthly facility-based technical supervision meetings. Under this approach, QRMs included structured discussions for small groups of volunteers, with separate groups of VEOs and facility supervisors, with feedback to a concluding plenary discussion.
Data collection and analysis
Ethical approval Ethical approval was recived from review boards of Ifakara Health Institute and the National Tanzania Medical Research Co-coordinating Committee through the Tanzania Commission for Science and Technology. Ethical and research clearance was also obtained from the London School of Hygiene & Tropical Medicine. ClinicalTrials.gov Identifier: NCT01022788; http://clinicaltrials.gov/ ct2/show/NCT01022788?term=INSIST&rank=1
Results During the 6-month period of the facility-led supervision, only 89 volunteer–supervisor contacts were recorded, an average of 0.02 contacts per volunteer per month (Figure 1). During the 6-month period of the community-linked supervision approach, 1440 volunteer–supervisor contacts were recorded with facility supervisors, and a further 3708 with VEO supervisors,
Discussion Following the creation of a role for village leaders in the supervision of community health volunteers the frequency of supervision contacts increased over 50-fold, in part due to an increase in contacts with facility staff for technical support. However, we acknowledge that we are only able to report on the quantity of the supervision, and not on the quality. The change in supervision contact frequency could be due to three main types of factors: sharing the supervisory work between more people; increasing accountability; and temporal confounding–a limitation of this study. Firstly, the inclusion of VEOs increased the total number of supervisors and shared the work between more people. Health facility staff often feel overwhelmed, and additional roles such as supervision of volunteers can be difficult to incorporate into routines. Secondly, as health workers, volunteers and VEOs are often part of the same community, directly involving community leaders in supervision might have increased pressure to provide appropriate technical support. The position of the VEOs in their community might also have increased accountability toward the community, an important aspect6 to ensure sustainability. Further, the QRM changed after the introduction of the community-linked supervision to include joint review which may have created a community-based control mechanism. The group focus for evaluation and assessment may have improved team work and morale and might have created a more positive environment for the supervision. Thirdly, we acknowledge that other issues that changed over time–temporal confounders– may partly account for the increase in supervision contacts. Despite work to document contextual changes we are unaware of any community or health systems factors that could have had such a dramatic and timely effect on volunteer–supervision contacts. Involving community leaders in supervision can have a positive effect on supervision-contacts and may improve accountability of health workers to their communities.
Authors’ contributions: The study was conceived by EM, SP and JS. EM wrote the first draft of the manuscript. CH, SP, FM and JS critically revised the manuscript and all authors read and approved the final version. EM is the guarantor of this paper.
Figure 1. Facility-led and community linked supervision models. This figure is available in black and white in print and in color at International Health online. CHW: community health worker; VEO: Village Executive Officer.
340
Acknowledgements: The authors thank facility staff and health management teams of Mtwara Rural, Lindi Rural, Nachingwea, Ruangwa, Tandahimba and Newala Districts as well as Mtwara and Lindi regional health officers. We thank Nelson Mkwao, Silas Temu, Iddy Kisung’a and Evaristus Nyanda, as well as Donat Shamba, Tara Tancred and David Schellenberg. Funding: This study is part of INSIST (ClinicalTrials.gov NCT01022788), funded by the Bill & Melinda Gates Foundation through Saving Newborn
Downloaded from http://inthealth.oxfordjournals.org/ at Univ. of Massachusetts/Amherst Library on September 7, 2015
Copies of all supervision forms were brought to each QRM. We collected supervision forms during QRMs from June to November 2010 and again from January to June 2011. Using a tally sheet, we counted the supervision contacts reported on these forms. This was done twice by two different people, and differences resolved with reference to the original forms. The number of supervision contacts per volunteer–month and the ratio of volunteers to supervisors were calculated.
giving a total of 5148 supervision contacts, or 1.04 contacts per volunteer per month, 0.29 contacts with facility staff and 0.75 contacts with VEOs. Under this approach, two contacts per volunteer per month were expected. The inclusion of VEOs increased the number of supervisors from 105 to 517 and reduced the ratio of volunteers per supervisor from 7.8 to 1.6.
International Health
Lives (Save the Children), as well as by UNICEF Tanzania, Batchworth Trust, and Laerdal Foundation.
2 WHO; UNICEF. Home visits for newborn child:a strategy to improve survival. Geneva: World Health Organization and United Nations Children’s Fund; 2009.
Competing interests: None declared.
3 Lehmann U, Sanders D. Community health workers: what do we know about them? The state of evidence on programmes, activities, costs and impact on health outcomes of using community health workers. Geneva: World Health Organization; Evidence and Information for Policy, Department of Human Resources for Health; 2007.
Ethical approval: We received ethical approval from review boards of Ifakara Health Institute and the National Tanzania Medical Research Co-coordinating Committee through the Tanzania Commission for Science and Technology. Ethical and research clearance was also obtained from the London School of Hygiene & Tropical Medicine.
1 UN Inter-agency Group for Child Mortality Estimations. Levels and Trends in Child Mortality. Estimates developed by the UN Inter-agency Group for Child Mortality Estimation. New York: UNICEF, WHO, The World Bank, and United Nations; 2013.
5 Borghi J, Cousens S, Hamisi Y et al. STUDY PROTOCOL: Improving newborn survival in rural southern Tanzania: a cluster-randomised trial to evaluate the impact of a scaleable package of interventions at community level with health system strengthening. 2013;http:// researchonline.lshtm.ac.uk/1343294/ [accessed 5 December 2013]. 6 Pallas SW, Minhas D, Pe´rez-Escamilla R et al. Community health workers in low- and middle-income countries: what do we know about scaling up and sustainability? Am J Public Health 2013;103:e74–82.
341
Downloaded from http://inthealth.oxfordjournals.org/ at Univ. of Massachusetts/Amherst Library on September 7, 2015
References
4 Jaskiewicz W, Tulenko K. Increasing community health worker productivity and effectiveness: a review of the influence of the work environment. Hum Res Health 2012;10:38.
