Malaria Branch, Division of Parasitic Diseases, Centers for Disease Control and Prevention, Atlanta, GA 30341-3724, USA.
Health Policy Plan. 2010 Mar;25(2):125-34. doi: 10.1093/heapol/czp054. Epub 2009 Nov 18.
In developing countries, supervision is a widely recognized strategy for improving health worker performance; and anecdotally, maintaining regular, high-quality supervision is difficult. However, remarkably little research has explored in depth why supervision is so challenging.
In the context of a trial to improve health worker adherence to Integrated Management of Childhood Illness (IMCI) guidelines and strengthen supervision in southeastern Benin, we used record reviews, focus group discussions, key informant interviews, and cross-sectional surveys to examine the supervision process.
Initially, little IMCI supervision occurred. The frequency increased substantially after implementing a series of workshops, but then deteriorated. Quantitative and qualitative data revealed obstacles to supervision at multiple levels of the health system. Based on supervisors' opinions, the main problems were: poor coordination; inadequate management skills and ineffective management teams; a lack of motivation; problems related to decentralization; health workers sometimes resisting IMCI implementation; and less priority given to IMCI supervision because of incentives for non-supervision activities, a lack of leadership, and an expectation of integrated supervision. To this list, based on our observations, we add: the increasing supervision workload, time required for non-supervision activities, project interventions not always being implemented as planned, and the loss of particularly effective supervisors. In terms of correctly completing steps of the supervision process, the quality of supervision was generally good.
Managers should monitor supervision, understand the evolving influences on supervision, and use their resources and authority to both promote supervision and remove impediments to supervision. Support from leaders can be crucial, thus donors and politicians should help make supervision a true priority. As with front-line clinicians, supervisors are health workers who need support. We emphasize the importance of research to identify effective and affordable strategies for improving supervision frequency and quality. (ClinicalTrials.gov number NCT00510679).
在发展中国家，监督是一种广泛认可的提高卫生工作者绩效的策略；并且，据传闻，维持定期、高质量的监督是困难的。然而，令人惊讶的是，很少有研究深入探讨监督为何如此具有挑战性。
在贝宁东南部开展的一项试验中，我们旨在提高卫生工作者对儿童综合管理（IMCI）指南的依从性并加强监督，我们使用记录审查、焦点小组讨论、关键知情人访谈和横断面调查来检查监督过程。
最初，很少进行 IMCI 监督。在实施了一系列研讨会后，监督的频率大幅增加，但随后又恶化了。定量和定性数据揭示了卫生系统多个层面存在监督障碍。根据监督员的意见，主要问题是：协调不力；管理技能和管理团队效率低下；缺乏激励；与权力下放相关的问题；卫生工作者有时抵制 IMCI 的实施；由于非监督活动的激励措施、缺乏领导力以及对综合监督的期望，对 IMCI 监督的重视程度降低。在此基础上，根据我们的观察，我们还添加了：监督工作量增加、非监督活动所需时间增加、项目干预措施未按计划实施以及特别有效的监督人员流失。在正确完成监督过程的步骤方面，监督质量总体良好。
管理者应监测监督情况，了解对监督的不断发展的影响，并利用其资源和权威，促进监督并消除监督的障碍。领导者的支持可能至关重要，因此捐赠者和政治家应该帮助使监督成为真正的优先事项。与一线临床医生一样，监督人员也是需要支持的卫生工作者。我们强调需要研究确定提高监督频率和质量的有效和负担得起的策略。（临床试验编号：NCT00510679）。
