“We thought we were performing very well, but actually we were making mistakes. Supervision brought out our weaknesses and enabled us to improve.”

In the Louga region of northwestern Senegal, the PRIME II Project has helped to strengthen the supervisory skills of head nurses and the health management team in Kebemer District. The district team supervises the nurses, who in turn supervise community-based health workers (CBHWs) charged with delivering basic services to the district’s most remote areas.

The supervision activity complemented a pilot project in Kebemer (population 150,000) testing two approaches for community-based services: one model featured mobile CBHWs traveling via horse and cart, and the second relied on stationary CBHWs providing services at health huts. Launched by Senegal’s Ministry of Health in 2001 with support from USAID and technical assistance from the Population Council, the pilot project explored alternative ways to improve access to family planning and reproductive health care in a country where only 8% of married women aged 15 to 49 use modern methods of contraception.

Worldwide, studies often find weaknesses in supervision systems, which are frequently overburdened and understaffed. When supervisors adopt supportive approaches and contributing systems are strengthened, the potential to affect a variety of factors influencing provider performance rises.

PRIME’s efforts to help supervisors become more effective are guided by the Performance Improvement (PI) approach, a systematic process to identify desired and actual performance, analyze the root causes of gaps, and select interventions to close the gaps. In Kebemer, interventions included workshops in facilitative supervision and the development of a guide and supervisory tools to help establish clear performance expectations and ensure regular and constructive performance feedback.

The final evaluation of the two-year activity found that 89% of the 69 CBHWs sampled felt at ease with their supervisors, 81% had a performance workplan (compared to none prior to the intervention), and 94% stated that supervisory feedback had contributed to improved performance.

“Between the supervisor and us, there are no more barriers,” affirmed one CBHW. “We deal with all issues; otherwise, we could not do our work. I ask questions about everything I do not know.”

While 88% of CBHWs reported receiving assistance from their supervisors in procuring resources, issues related to workload, transportation and logistics present challenges to achieving performance goals. As another CBHW stated, “The villages are too distant and often inaccessible for our health talks and integrated home visits. Some drugs are frequently out of stock. The maintenance of the horse presents problems, and if it is not well fed it will not be able to cover the distance.”

Still, supportive supervision from the head nurses enabled CBHWs to increase community-level access to family planning and reproductive health information and services through activities such as home visits, community health education and referral, and distribution of oral contraceptives and condoms.

“The supervisor helped me organize talks on family planning by providing me with supplies and information, education and communication materials, and by sensitizing community members to the importance of my work,” emphasized a CBHW. “He did not forget me. It makes me more motivated that he is interested and likes the work that I was trusted to do.”

The PRIME II Project, funded by USAID and implemented by IntraHealth International and the PRIME partners, works around the world to strengthen the performance of primary providers as they strive to improve family planning and reproductive health services in their communities.

PRIME Voices #28, Senegal: Supportive Supervision for Community-Based Health Workers, 3/31/04.