Supportive supervision of mid level health workers in rural Nepal for improved job satisfaction, motivation and quality of care.

Many low-income countries are suffering from shortages of health workers in rural areas. To expand access to health care, mid level health workers with up to three years training are being expected to complete tasks that higher cadres of health worker would usually undertake. Yet these cadres are largely ignored at a policy level. To enable these health workers to fulfill their potential and provide good quality care, they need to be adequately supported and supervised. Research suggests that health workers may respond better to supervision if their supervisor is aware of their emotional needs, and they build trust through listening, empathy and responding to their individual concerns (Cummings et al. 2010).

This development grant will enable us to develop supportive supervision interventions for mid level health workers in rural Nepal, which will then be implemented through existing systems and evaluated in subsequent research. We will conduct a review of the literature using a realist methodology to understand for whom and in what circumstances interventions work. This will inform the development of supportive supervision interventions in Nepal. We will collect data from policy makers, programme implementers, managers, and health workers to describe existing systems, their weaknesses and collate the learning from national pilot interventions. This information will be discussed in a working group of government and non government participants who will meet regularly. This will help us to develop feasible interventions that have a broad level of support. A health economist will then model intervention costs. Interventions will be presented, debated and prioritised in a workshop with participants from the district and central level. On finalising interventions, a methodology will be designed to evaluate and understand the effect of these interventions, with input from experts and the working group. Funding sources will be identified to implement the interventions and research the effect of a supportive supervision intervention for mid level health workers in rural Nepal. We will disseminate our learning from this process through international peer reviewed publications, briefing papers, conferences and social media.

Many low-income countries are suffering from a shortage of health workers in rural areas. In response to this, tasks are being shifted to mid level cadres who are often working without adequate management and support mechanisms. These cadres require emotional and clinical support in order to develop and retain their skills, and an enabling environment to provide good quality care. The evidence base about the impact of supportive supervision on primary health care is weak, and there is a need to develop the theory about how supportive supervisions may work.

We will conduct action research with central and district level stakeholders, and health workers to describe and explore the difficulties facing mid level health workers, and discuss current weaknesses in existing supervisory mechanisms. We will also explore supervision preferences of mid level health workers, and the effect of gender and difference in cadre on supervisory needs through qualitative interviews in three districts. We will critically examine pilot interventions and conduct a realist review of the national and international literature to identify potential interventions which could be implemented for mid level health workers in rural Nepal. Findings will be fed back and discussed in a working group, and interventions presented to a wider group of stakeholders at a workshop. Cost information will also be prepared and presented at this workshop. After participatory prioritisation of interventions, we will develop an evaluation methodology and theories of change, which we will present at a dissemination meeting. We will seek funding for the implementation and evaluation of the prioritised supportive supervision interventions, and identify pilot districts in which to test interventions. We will disseminate our methodology and interventions among academic and practitioner audiences.

What are the likely impacts of the specific studies undertaken during development grant?
Our research with mid level health workers and managers about supervision preferences and the inadequacies of existing systems will be of international interest, as will model interventions and evaluation frameworks. There is little evidence about what works to support mid level health workers, and the relationships and mechanisms of action for specific leadership styles and outcomes are under-theorised. Our research will advance the theory about how interventions may work to motivate health workers.
At a national and district level, there is a need for more human resources for health research, particularly on how to retain health workers in rural areas. Our primary research will add to the knowledge base and help inform development of human resource management policies. Our research may also increase awareness about the need for management training, and help inform the development of pre and in service training for mid level and management level health workers.
The capacity of participants to develop theory based interventions, and design appropriate and feasible evaluation frameworks will be developed. Those participating in working groups, and workshops will actively engage in the design of interventions and evaluation methods and they will 'learn by doing'.

How might the evidence generated by future related larger research studies have an impact?
Evidence from larger research studies will have an international impact, developing knowledge about the implementation and outcomes of supportive supervision for mid level health workers in rural areas. There will be a focus on evaluating impacts but also in advancing theory about how interventions were effective or not effective and we will also monitor process outcomes. We will consider the effect of context and implementation on the effectiveness of the intervention which will help policy makers and programme implementers decide on the feasibility of the intervention for scale-up, nationally and internationally.

At present there is a lack of evidence about whether supportive supervision has an impact on health care provision in low income countries. This research will help to build this evidence base.

In Nepal, the impact of a larger study will stimulate change at a policy level, particularly as interventions will be designed and prioritised by national level stakeholders. If the intervention is found to be effective, scale-up is likely to occur. The ownership of interventions, and involvement of donors, central level stakeholders and policy makers in creating interventions and evidence about their effectiveness will enable appropriate supportive supervision interventions to be developed and implemented at scale. If the intervention is not effective, the capacity developed to analyse and review this issue as a collective will facilitate analysis and reformulation of interventions. Patients, health workers, and district level stakeholders (trainers and managers) will be affected by a larger study.