Ndima Sozinho Daniel, Sidat Mohsin, Give Celso, Ormel Hermen, Kok Maryse Catelijne, Taegtmeyer Miriam
Department of Community Health, University Eduardo Mondlane, Maputo, Mozambique.
Faculty of Medicine, University Eduardo Mondlane, Salvador Allende Avenue, 702, Maputo, Mozambique.
Hum Resour Health. 2015 Sep 1;13:63. doi: 10.1186/s12960-015-0063-x.
Community health workers (CHWs) in Mozambique (known as Agentes Polivalentes Elementares (APEs)) are key actors in providing health services in rural communities. Supervision of CHWs has been shown to improve their work, although details of how it is implemented are scarce. In Mozambique, APE supervision structures and scope of work are clearly outlined in policy and rely on supervisors at the health facility of reference. The aim of this study was to understand how and which aspects of supervision impact on APE motivation and programme implementation.
Qualitative research methodologies were used. Twenty-nine in-depth interviews were conducted to capture experiences and perceptions of purposefully selected participants. These included APEs, health facility supervisors, district APE supervisors and community leaders. Interviews were recorded, translated and transcribed, prior to the development of a thematic framework.
Supervision was structured as dictated by policy but in practice was irregular and infrequent, which participants identified as affecting APE's motivation. When it did occur, supervision was felt to focus more on fault-finding than being supportive in nature and did not address all areas of APE's work - factors that APEs identified as demotivating. Supervisors, in turn, felt unsupported and felt this negatively impacted performance. They had a high workload in health facilities, where they had multiple roles, including provision of health services, taking care of administrative issues and supervising APEs in communities. A lack of resources for supervision activities was identified, and supervisors felt caught up in administrative issues around APE allowances that they were unable to solve. Many supervisors were not trained in providing supportive supervision. Community governance and accountability mechanisms were only partially able to fill the gaps left by the supervision provided by the health system.
The findings indicate the need for an improved supervision system to enhance support and motivation and ultimately performance of APEs. Our study found disconnections between the APE programme policy and its implementation, with gaps in skills, training and support of supervisors leading to sub-optimal supervision. Improved methods of supervision could be implemented including those that maximize the opportunities during face-to-face meetings and through community-monitoring mechanisms.
莫桑比克的社区卫生工作者（称为基本多能工作者（APEs））是在农村社区提供卫生服务的关键角色。对社区卫生工作者的监督已被证明能改善他们的工作，尽管关于其实施细节的报道很少。在莫桑比克，基本多能工作者的监督结构和工作范围在政策中有明确规定，并依赖于参考卫生机构的监督员。本研究的目的是了解监督的方式以及哪些方面会影响基本多能工作者的积极性和项目实施。
采用定性研究方法。进行了29次深入访谈，以获取有目的地挑选出的参与者的经验和看法。这些参与者包括基本多能工作者、卫生机构监督员、地区基本多能工作者监督员和社区领袖。在制定主题框架之前，对访谈进行了录音、翻译和转录。
监督按政策规定进行组织，但在实践中不规律且不频繁，参与者认为这影响了基本多能工作者的积极性。当监督确实进行时，人们感觉其更多地侧重于找茬而非具有支持性，并且没有涵盖基本多能工作者工作的所有领域——基本多能工作者认为这些因素会导致工作积极性下降。反过来，监督员感到缺乏支持，并认为这对工作表现产生了负面影响。他们在卫生机构的工作量很大，承担着多种角色，包括提供卫生服务、处理行政事务以及监督社区中的基本多能工作者。人们发现缺乏监督活动的资源，并且监督员陷入了他们无法解决的与基本多能工作者津贴相关的行政问题中。许多监督员没有接受过提供支持性监督的培训。社区治理和问责机制只能部分填补卫生系统提供的监督所留下的空白。
研究结果表明需要改进监督系统，以加强支持和激励，最终提高基本多能工作者的绩效。我们的研究发现基本多能工作者项目政策与其实施之间存在脱节，监督员在技能、培训和支持方面存在差距，导致监督效果不理想。可以实施改进的监督方法，包括那些在面对面会议期间以及通过社区监测机制最大化机会的方法。
