Manzi Fatuma, Hamon Jessie K, Agbodjavou Mena K, Hoyt Jenna, Kuwawenaruwa August, Kionga Yusufu, Agossou Christian, Kabanywanyi Abdunoor M, Boyi-Hounsou Christelle, Lusasi Abdallah, Lazaro Samwel, Saliou Ramani, Kpemasse Augustin, Reaves Erik, Kitojo Chonge, Hassani Ahmed Saadani, Gnanguenon Virgile, Dossou Jean-Paul, Webster Jayne
U.S. President's Malaria Initiative (PMI), PMI Insights Consortium, 437 N 34th Street, Seattle, WA 98103, United States.
Ifakara Health Institute, Kiko Ave, Plot 463, Mikocheni, Dar es Salaam, Tanzania.
Health Policy Plan. 2025 Jun 12;40(6):600-612. doi: 10.1093/heapol/czaf020.
Supportive supervision (SS) programs aim to enhance the quality of care by strengthening the performance of health providers. Commonly part of broader quality improvement efforts, SS programs are increasingly used in low-and middle-income countries to improve malaria case management. Despite substantial investments and some positive outcomes, little is known about what drives their effectiveness. A realist evaluation was conducted in Tanzania and Benin to explain how, why, and under what circumstances SS programs can improve the facility-based management of uncomplicated malaria in children <5 years. A program theory was developed through a team-based analysis of empirical data collected in both countries at two time points. Data included 218 in-depth and 12 structured interviews with stakeholders, 154 audits of febrile case management decisions, and 4 health facility audits. Stakeholder perspectives identified three acceptability mechanisms driving SS program outcomes in the studied contexts: the affective attitude, self-efficacy, and burden of the program as perceived by key actors. The pathway through which these mechanisms were perceived to shape malaria case management (diagnosis and treatment) practices was defined by the (i) extent to which the program was integrated into the public health system; (ii) frequency with which SS visits were conducted by appropriate supervisors; (iii) degree to which supervisors coached, rather than policed, supervisees; and (iv) level of collaboration achieved between supervisees and supervisors. The program actors' perception of the program's effectiveness was also found to be crucial to its sustainability. This study explains the dynamics driving SS program outcomes and underscores the role played by the cognitive and emotional responses of program actors. These insights are likely to be transferable to other settings with similar contexts and can help inform the design, implementation, monitoring, and evaluation of new and ongoing SS programs.
支持性监督（SS）项目旨在通过强化卫生服务提供者的表现来提高医疗服务质量。作为更广泛质量改进工作的常见组成部分，SS项目在低收入和中等收入国家越来越多地被用于改善疟疾病例管理。尽管投入了大量资金并取得了一些积极成果，但对于推动其有效性的因素却知之甚少。在坦桑尼亚和贝宁进行了一项现实主义评价，以解释SS项目如何、为何以及在何种情况下能够改善5岁以下儿童单纯性疟疾的医疗机构管理。通过对在两个时间点在两国收集的实证数据进行基于团队的分析，形成了一个项目理论。数据包括对利益相关者的218次深度访谈和12次结构化访谈、154次发热病例管理决策审计以及4次医疗机构审计。利益相关者的观点确定了在研究背景下推动SS项目成果的三种可接受性机制：关键行为者所感知到的项目的情感态度、自我效能感和负担。这些机制被认为塑造疟疾病例管理（诊断和治疗）实践的途径由以下因素决定：（i）项目融入公共卫生系统的程度；（ii）合适的监督者进行SS访视的频率；（iii）监督者指导而非监管被监督者的程度；以及（iv）被监督者与监督者之间实现的协作水平。还发现项目行为者对项目有效性的认知对其可持续性至关重要。本研究解释了推动SS项目成果的动态过程，并强调了项目行为者的认知和情感反应所起的作用。这些见解可能适用于其他具有类似背景的环境，并有助于为新的和正在进行的SS项目的设计、实施、监测和评价提供信息。
