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Perception and experience of group supervision as quality improvement intervention to improve performance of health extension workers on maternal health in Sidama Zone, South Ethiopia

The REACHOUT project is funded by the European Union

Aschenaki Zerihun REACH EthiopiaFebruary 2017

Background

• Through the post-2015 universal health coverage agenda; CHWs will be a vital link to communities to expand access to health service beyond the current reach of formal health systems

• In 2004 Ethiopia launched its flagship community based health program known health extension program (HEP)

• CHWs in Ethiopia are known as Health Extension workers (HEWs) and are key actors in providing community based health services

Background …

• HEWs are female, trained for one year, and salaried

• 2 HEWs deployed per a village to serve about 5000 population

and provide 16 health extension packages in four major areas

• Supervised by catchment health center professionals and

services connected by a referral system within primary health

care unit

• Supported by volunteer community members known as health

development army (HDA)

Ethiopian Health System

FMOH

Regional Health

Bureau

Zonal health dept.

District Health Office

Health Center

Health post

(2HEWs)

Health post

(2HEWs)

Health post

(2HEWs

Health post

2HEWs

Health post

(2HEWs)

HDA ( one to five network): voluntary community members

• It is widely acknowledged and emphasized in the literature that the success of CHW programs hinges on regular and reliable support and supervision

• However; supervision for community health workers (CHWs) is one of the most challenging program elements to implement

• Health managers and other supervisors commonly neglect supervision, and many supervisors lack the knowledge, skills and tools for effective and supportive supervision

Overview of quality improvement (QI) intervention on supervision • REACHOUT: is a multi-country research project

implemented in six African and Asian countries aiming at improving effectiveness and efficiency of CHWs

• In the first year of the project; a context analysis was carried out to identify facilitators and barriers to HEWs performance on maternal health

• The findings of the context analysis informed the introduction of group supervision as QI intervention in Shebedino district , Sidama zone; South Ethiopia

Overview of (QI) intervention…• Group supervision is a form of supervision whereby HEWs

come together to meet with their supervisor at a catchment health center in a monthly basis to discuss on – Collected data– Problems encountered– Sharing suggestions for local solutions and continuing education

• Its is a forum to share experiences, challenges, and filling capacity gaps among the HEWs

Overview of (QI) intervention…

• The QI intervention was introduced in Shebedino district ,

Sidama zone; South Ethiopia

Shebedino district • One of the 19 districts in the zone having 32 rural villages with a

population of 290,319

• 1 primary hospital, 9 health centres, 32 health posts

• 32 HEWs’ supervisors based at catchment health centres

Sidama Zone

SNNPR

Ethiopia Shebedino District

Aroresa

Bensa

Boricha

HullaDara

Loka Abaya

Chire

Dale

ChukoBursa

Malga

Gorche

Arbe Gonna

Bona Zuria

Shebe Dino

Hawassa Zuria

Wonosho

Hawasa TownWondo-Genet

South Omo

Keffa

Gamo GofaBench Maji

Sidama

Gurage

Dawro

Selti

Wolayita

KTHadiya

Segen Peoples'

Konta

Sheka

Gedio

Yem

AlabaHadiya

Basketo

SomaliOromia

AfarAmhara

SNNPR

Tigray

Gambela

Benshangul GumuzDire Dawa

Addis Ababa

Fura

Telamo

Abela Lida

Remeda

Howoliso

Dila Aferara

Dirimo Aferara

Tara Mesa

Sedeqa

Gala Galo

Alawo Ano

Nure Dulecha

Dobe Toga

Galuko Haro

Konisire Ano

Asera domero

Midire Genet

Dobe Negasha

Dila Chanige

Gobohebisha

Haribe Shesho

Harbe Hagawo

Harbe Gonamero

Galiko Hirye

Dila Gumibe

Murancho Kutala

Gonoba Godo

Bonoya Merede

Delecha Teberako

Morochi Shonidola

Morochi Negasha

Gonowa Gabelo

Leku Town

Dobe Toga

Sedeqa

Gobohebisha

Overview of (QI) intervention…

• The QI intervention included training of HEWs’ supervisors and

HEP coordinators on supervision curriculum (six day )

• 32 HEWs’ supervisors and 3 HEP coordinators trained

• Group supervision facilitation guideline provided

• Regularly monitored by the catchment health center, district

health office and REACHOUT project staffs

• Meeting documented in a minute and monthly report submitted

Aim

The aim of the study was to explore experience with group supervision introduced as a QI intervention to improve HEWs performance in providing maternal health services in Sidama zone, South Ethiopia.

Methods

• Mixed study design employing in-depth interviews,

quantitative data tracking tool, baseline and end line data,

• Baseline end line HMIS data collected from 9 health posts

selected based on their performance (High, medium and low)

• 12 IDI with the HEWs: experience of supervision on motivation

• 8 IDIs with health system staffs (2 district health office, 2 health

center managers and 4 HEWs’ supervisors)

Methods…

• Interviews digitally recorded, transcribed and translated into

English and transcripts read independently by three researchers

• Key themes identified, coding frame work developed and coded

using Nvivo 10

• Each theme analyzed and summarized in narratives

• Quantitative data analyzed by simple statistics and summarized in

narratives

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Results

Motivation: Majority of the HEWs indicated that the group supervision made them feel more motivated“...group supervision increases my knowledge on area where I am supervised. Since I got something on which I forgot it because of that it motivates me to work hard ” (HEW, IDI)

Changes in supervision approach “In fact there was a practice of supervision before REACHOUT comes. It is a kind of why this done or not done or simply listing down weak sides without discussion how to correct. The other point, it was neither regular nor participatory; but this has been changed since the introduction of REACHOUT interventions” (HEW, IDI)

Results

Regularity of the meeting and attendance level The regularity of group supervision meetings and attendance level of HEWs increased from 4% to 70.4 % and 2.3% to 61% respectively at the end of the year

Attendance in antenatal care visitsThe proportion of mothers attended the first and 4th antenatal care (ANC) improved from 73% to 76% and 56% to 70 respectively

Results

Results

Attendance at pregnant women forum and skilled delivery The proportion of mothers attended pregnant women forum and gave birth at health facilities improved from 48% to 100% and 40% to 83 % respectively at the end of the year

One HEW described the improvement on maternal health use ““……It is Group Supervision that brought such a remarkable achievement on maternal health activity in our catchment and contributed for the best performance of our district..”

Results

• In spite of the positive results of the intervention; some challenges have been noticed to supervision

– Supervisors sometimes felt unsupported because of resources like transportation

– High turnover of supervisors

Conclusions

• The findings of this showed that group supervision is a promising strategy to improve motivation, performance and utilization of maternal health services

• The health system should be responsive for challenges like absence of transport facilities for supervisors to ensure supervision and design a strategies that would minimize high turnover of supervisors

Acknowledgements

Authors:Aschenaki Zerihun: REACH Ethiopia Daniel Gemechu: REACH Ethiopia Nega Teyikie: REACH Ethiopia Maryse C. Kok: Royal Tropical Institute, the Netherlands

Thanks to:

EU for funding the study Liverpool School of Tropical Medicine

KIT: Netherlands

South regional health bureau and Sidama zone health department

HEWs and other study participants