Primary health care supervision in developing countries.

OBJECTIVES: To (a) summarise opinion about what supervision of primary health care is by those advocating it; (b) compare these features with reports describing supervision in practice; and (c) to appraise the evidence of the effects of sector performance.
METHODS: Systematic review. Reports were classified into three groups and summarised using appropriate methods: policy and opinion papers (narrative summary), descriptive studies (systematically summarised) and experimental or quasi-experimental studies (design and outcomes systematically summarised). Data presented as narrative summaries and tables.
RESULTS: 74 reports were included. In eight policy and opinion papers, supervision was conceptualised as the link between the district and the peripheral health staff; it is important in performance and staff motivation; it often includes problem solving, reviewing records, and observing clinical practice; and is usually undertaken by visiting the supervisees place of work. In 54 descriptive studies, the setting was the primary health care (PHC) or specific services and programmes. Supervisor-supervisee dyads were generally district personnel supervising health facilities or lay health workers. Supervision mostly meant visiting supervisees, but also included meetings in the centre; it appeared to focus on administration and checking, sometimes with checklists. Problem solving, feedback and clinical supervision, training and consultation with the community were less commonly described in the descriptive studies. Supervision appears expensive from studies that have reported costs. In 12 quasi-experimental trials, supervision interventions generally showed small positive effects in some of the outcomes assessed. However, trial quality was mixed, and outcomes varied greatly between studies.
CONCLUSIONS: Supervision is widely recommended, but is a complex intervention and implemented in different ways. There is some evidence of benefit on health care performance, but the studies are generally limited in the rigor and follow up is limited. Further research delineating what supervision consists of and evaluating it in the context of unbiased comparisons would guide the implementation of effective supervision as part of the management of PHC.