Supervision is a process of guiding, helping, training, and encouraging staff to improve their performance in order to provide high-quality healthcare services. A guideline has been published by Managemnt Division in 2066 BS to systematize the supervision process at different levels which specialy focuses on supportive and integrated supervision. n conclusion, effective health worker supervision is informed by health system data, uses continuous quality improvement (QI), and employs digital technologies integrated into other health system activities and existing data systems to enable a whole system approach. Effective supervision enhancements and innovations should be better integrated, scaled, and sustained within existing systems to improve access to quality health care.

1. Supervision in Health

2. Outline of presentation
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1. Introduction
2. Types of Supervision
3. Role of supervisor
4. Supervision in health system of Nepal
5. Sample supervisory checklist
6. Problems/ challenges regarding supervision
7. Conclusion and recommendations
8. References

3. Supervision
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• Supervision is a process of guiding, helping,
training, and encouraging staff to improve their
performance in order to provide high-quality
healthcare services.
• Way of ensuring staff competence, effectiveness
and efficiency through observation, discussion,
support and guidance to make the best use of their
knowledge, skills and to improve their abilities.
• Contribute postively toward accomplishing the
organizations goal and objectives.

4. Types of supervision
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1. Direct Supervision
• Field Visit/Observation
• Check-list
• Interview
• Feedback
• Client's exit interview
2. Indirect Supervision
• Reports/Records
• Appraisal of work-plan
• Questionnaire
• Daily diary
• Consumer's feedback

5. Role of supervisor
Administrative Role: Planning, organizing, controlling, performance
appraisal, development of check-list, reporting and follow-up
Technical Role: Support and guidance in implementing the tasks and
correcting the problems
Human relation Role: Behaviour, team spirit, motivation, conflict
resolution, personal contacts, communication
Development Role: Training and development for better performance,
career development
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6. 4*4*4 model of Supervision
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Figure: 4 x 4 x 4 model of supervision (Wonnacott, 2012, p54)

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Stakeholders
• Service users
• Staff
• The organisation
• Partner
organisations
Functions
• Management
• Development
• Support
• Mediation
Elements
• Experience
• Reflection
• Analysis
• Action
4*4*4 model of Supervision

8. Supervision as Performance Improvement
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9. A guideline has been published by Managemnt Division in 2066 BS to
systematize the supervision process at different levels which specialy
focuses on supportive and integrated supervision.
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10. I. Supportive Supervision
• Supportive supervision is a process of helping staff to improve their
own work performance continuously and is carried out in a respectful
and non-authoritarian way with a focus on using supervisory visits
as an opportunity to improve knowledge and skills of health staff.
• Supportive supervision encourages open, two-way communication,
and building team approaches that facilitate problem-solving.
• It focuses on monitoring performance towards goals, and using data
for decision-making, and depends upon regular follow-up with staff to
ensure that new tasks are being implemented correctly.
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11. Supportive supervision-Module
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Setting up a supportive supervision system
Planning regular supervisory visits
Conducting supportive supervision visits
Follow up

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1. Setting up a supportive supervision system
• Training a core set of superviors.
• Creating checklist and recording forms.
• Ensuring appropriate resources available: vehicles, per diem,
areas for collaboration with other programs.
2. Planning regular supervisory visits
• Where: using data to decide priority supervision sites
• When: schedule supervision visits using a workplan
• What subjects to train: identify training needs and skills
that need updating.

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3. Conducting supportive supervision visits
• Observation
• Use of data
• Problem-solving
• On-the-job training
• Recording observations and feedback
4. Follow-up
• Follow up on agreed actions by supervisors and supervised
staffs
• Regular data analysis
• Feedback to all stakeholders

14. II. Integrated Supervision
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Action
Plan
Supervisor
visit
Implementa
tion and
feedback
Reporting
Intrgrated
Supervision
Cycle
Figure: Integrated supervision Cycle

15. 1. Action Plan
• It is the pre-determined periodic plan for the conduction of supervision
in well managed manner.
• It includes the determination of supervisor and their time schedule of
supervision.
• Every conducting supervision should prepare periodic (annual,
quarterly and monthly) supervision plan which has to be approved by
the higher authority, District health office in case of PHC and HP.
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16. Things to be included in Action plan
• Period of action plan (monthly, quarterly, annual)
• Name of the supervisor
• Supervision period and date
• Name of the health facilities to be supervised
• Name of personnel by whom the plan is prepared and approved
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17. Aspects to be considered during preparation of
Action plan
• Number of the health facilities to be supervised, total number of staffs
• Allocated Target and budget of the supervision
• Distance of the health facility to be supervised, availability of transportation
facility and estimated time period
• Geography and climatic condition of the health facility to be supervised
• Strategic direction of the integrated supervision guideline about the minimum
frequency of the supervision at different level
• Priority should be given to the health facilities that are not able to achieve the
expected targets.
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18. 2. Supervisory Visit
The following aspects of the health facility to be supervised is to be
studied prior to supervision:
• Demographic status and the targets of different program
• Physical and financial achievement status of the targeted program
of health institution
• Report of the previous supervision and the implementation status as
suggested by the report.
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19. Methods of Supervision
• Group or individual discussion with the staffs of health facility
• Study of the records of the different program. i.e. HMIS records
• Study of reports and monthly monitoring sheet.
• Direct observation
• Study of meeting minute
• Discussion with community people, members of HFOMC, client and
FCHV.
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20. Categorization of problems
Every supervisor being the part of integrated supervision, should have
to analyze the status of the supervised health facility and categorize the
problems into two parts:
• Problems that can be solved locally by health facility
• Problems that need the higher authority
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21. Tools of supervision
Supervision Checklist: Every supervision should be conducted with
the proper use of integrated supervision checklist provisioned by
Management division.
Supervision Diary: Different aspects of the health facility that can't
be stated on the check-list are to be recorded in diary such as problems
and their causes, local initiations to solve the problems etc.
Supervision booklet: Every heath institution should have supervision
booklet so that the supervisor can record different aspects of the
supervisory visit of respective health facility.
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22. Tools of supervision
• Supervision report: Supervision report is to be prepared with the use
of check list and supervision diary.
• Supervision record (log-book): Every institution conducting
supervision of health facility under it, has to record the integrated
supervision visit in supervision log- book. This log book helps to
know the details of supervision in one shot which could be very
beneficial in future supervision of same health facility.
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23. 3. Reporting
• Every supervisor has to submit the supervision report to the
authorized person or institution using standard format.
• The timely submission of the report can help to address the problem in
time.
• Usually the report has to be submitted within 7 days of supervision to
the authority.
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24. The report consists of:
• Name of the health facility, date of supervision and to whom report is
submitted with date.
• Strengths of the health facility in brief
• Problems or things to be improved
• Underlying causes of the problems
• Immediate efforts done by the supervisor to solve the problem at spot
• Actions that has to be taken by higher authority
• Suggestions in brief (remarkable activities done by HF, reward,
motivation or any punishment etc)
• Name of the supervisor and their designation
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3. Reporting

25. 4. Implementation and Feedback
• The submitted report should be studied and reviewed by the authority of
the respective institution discussing with the supervision team.
• The immediate actions that could be conducted by the authority should
be taken to address the necessary and appropriate problems.
• The problems that could be addressed by higher authority should be
forwarded as suggestions in written form.
• Follow up of the implementation of the suggestions should be done in
periodic basis.
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26. • The feedback should be done in two steps after the completion of the
supervision followed by submission of report.
 Spot feedback during supervision, if possible, should be given,
otherwise it should be forwarded as soon as possible.
 The actions that has to be taken by the respective or higher level
authority to address the issues diagnosed by the supervision
should be forwarded.
• The supervision work has to be monitored and reviewed in continuous
manner so as to make it more effective in future.
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4. Implementation and Feedback

27. • The concept is very important to bring overall change in the system
rather than the individual knowledge, attitude or skill.
• Using a team approach to supervision requires that the supervisor
disregard conventional disciplinary attitudes and shift from the role of
"inspector" to the role of "facilitator." Team supervision is oriented
toward teamwork, where problem solving is the main focus of the
interaction, and supervisors become on-the-job teachers who support
their staff.
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III. Team Approach Supervision

28. Supervision flowchart-Federal level
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Ministry of Health and
Population
Health
Emergency and
Disaster
Management Unit
Department of Health
Services
Department of Drug
Administration
Divisions
 PPMD
 HCD
 QARD
 PMD
 AD
Department of
Ayurveda

29. Supervision flowchart-Provincial level
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30. Supervision flowchart- Local level
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31. Sample supervisory checklist:
Immunization program
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32. Sample supervisory checklist:
Immunization program
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33. Example:
Supervision of National TB Program
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Figure 1: NTP line supervision Figure 2: NTP review system

34. Problems /Challenges regarding supervision in
health system of Nepal
• Supportive supervision not in place
• Inadequate supervision both in frequency and quality
• Insufficient amount of training for integrated supervision and not
practical in every context. Eg. Gynecologist as a supervisor could not
supervise paediatric ward
• Level of supervisor as an issue in federal context. Eg: 7th level
supervisor, 8th level superivisee
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35. Problems /Challenges regarding supervision in
health system of Nepal
• Lack of clear guidelines, tools and checklist
• No definite award and punishment based on supervision
• Low budget and use of supervisory budget in other activities
• Poor reporting and documentation
• Supervision not as mandatory, supervision report without visit
• Traditional system of supervision
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36. Conclusion and recommendations
• Update and implement integrated supervision checklist, supervision
plan and feedback tools
• Deploy functional feedback mechanism with provision of coaching
and mentoring services
• Develop monthly integrated online supervision calendar and submit to
higher authority to monitor effective execution at all levels
• Introduce reward and punishment system based on supervision results
• Integrate digital supervision data into supervision processes
• Increase use of health system information and performance data when
planning supervision visits to prioritize lowest-performing areas
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37. Conclusion and recommendations
• Expand and institutionalize supervision to reach, prepare, protect, and
support frontline health workers, especially during health emergencies
• Scale and replicate successful models across service delivery areas and
geographies.
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 In conclusion, effective health worker supervision is informed by health
system data, uses continuous quality improvement (QI), and employs digital
technologies integrated into other health system activities and existing data
systems to enable a whole system approach. Effective supervision
enhancements and innovations should be better integrated, scaled, and
sustained within existing systems to improve access to quality health care.

38. References
1. Garrison K, Caiola N, Sullivan R, Lynam P. Supervising Healthcare Services: Improving the
Performance of People
2. Deepak Karki. The Basics of Monitoring, Evaluation and Supervision of Health Services [Internet].
22:57:19 UTC [cited 2023 Jan 24]. Available from: https://www.slideshare.net/dekarki/the-basics-of-
monitoring-evaluation-and-supervision-of-health-services-in-nepal-37391386
3. Safal’s Public Health Officer Loksewa Comprehensive Review [Internet]. Heritage Publishers &
Distributors Pvt. Ltd. [cited 2023 Jan 24]. Available from:
https://heritagebooks.com.np/product/safals-public-health-officer-loksewa-comprehensive-review/
4. Annual Report FY 2077/78 (2020/21) [Internet]. 2022 [cited 2023 Feb 1]. Available from:
https://dohs.gov.np/annual-report-fy-2077-78-2019-20/
5. Achieving effective supervision [Internet]. Iriss. 2015 [cited 2023 Jan 21]. Available from:
https://www.iriss.org.uk/resources/insights/achieving-effective-supervision
6. Deussom R, Mwarey D, Bayu M, Abdullah SS, Marcus R. Systematic review of performance-
enhancing health worker supervision approaches in low- and middle-income countries. Hum Resour
Health. 2022 Jan 6;20:2.
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