Group supervision was introduced as a quality improvement intervention to improve the performance of Health Extension Workers (HEWs) providing maternal health services in Sidama Zone, Ethiopia. The intervention included training supervisors and implementing monthly group meetings where HEWs discussed collected data, problems, and solutions. Results showed the intervention improved HEW motivation and regularity of supervision meetings. Utilization of maternal health services increased, including antenatal care attendance and skilled delivery rates. However, challenges included lack of transportation support for supervisors and high supervisor turnover. Overall, the findings demonstrated that group supervision can positively impact HEW performance and maternal health outcomes.

1. Perception and experience of group supervision as
quality improvement intervention to improve
performance of health extension workers on maternal
health in Sidama Zone, South Ethiopia
The REACHOUT project is funded
by the European Union
1
Aschenaki Zerihun REACH
Ethiopia
February 2017

2. Background
• Through the post-2015 universal health coverage agenda;
CHWs will be a vital link to communities to expand access
to health service beyond the current reach of formal health
systems
• In 2004 Ethiopia launched its flagship community based
health program known health extension program (HEP)
• CHWs in Ethiopia are known as Health Extension workers
(HEWs) and are key actors in providing community based
health services

3. Background …
• HEWs are female, trained for one year, and salaried
• 2 HEWs deployed per a village to serve about 5000 population
and provide 16 health extension packages in four major areas
• Supervised by catchment health center professionals and
services connected by a referral system within primary health
care unit
• Supported by volunteer community members known as health
development army (HDA)

4. Ethiopian Health System
FMOH
Regional
Health
Bureau
Zonal
health
dept.
District
Health
Office
Health Center
Health
post
(2HEWs
)
Health
post
(2HEWs)
Health
post
(2HEWs
Health
post
2HEWs
Health
post
(2HEWs)
HDA ( one to five network):
voluntary community members

5. • It is widely acknowledged and emphasized in the literature
that the success of CHW programs hinges on regular and
reliable support and supervision
• However; supervision for community health workers
(CHWs) is one of the most challenging program elements to
implement
• Health managers and other supervisors commonly neglect
supervision, and many supervisors lack the knowledge,
skills and tools for effective and supportive supervision

6. Overview of quality improvement (QI) intervention on
supervision
• REACHOUT: is a multi-country research project
implemented in six African and Asian countries aiming at
improving effectiveness and efficiency of CHWs
• In the first year of the project; a context analysis was
carried out to identify facilitators and barriers to HEWs
performance on maternal health
• The findings of the context analysis informed the
introduction of group supervision as QI intervention in
Shebedino district , Sidama zone; South Ethiopia

7. Overview of (QI) intervention…
• Group supervision is a form of supervision whereby HEWs
come together to meet with their supervisor at a catchment
health center in a monthly basis to discuss on
– Collected data
– Problems encountered
– Sharing suggestions for local solutions and continuing education
• Its is a forum to share experiences, challenges, and filling
capacity gaps among the HEWs

8. Overview of (QI) intervention…
• The QI intervention was introduced in Shebedino district ,
Sidama zone; South Ethiopia
Shebedino district
• One of the 19 districts in the zone having 32 rural villages with a
population of 290,319
• 1 primary hospital, 9 health centres, 32 health posts
• 32 HEWs’ supervisors based at catchment health centres

9. Sidama Zone
SNNPR
Ethiopia Shebedino District
Aroresa
Bensa
Boricha
Hulla
Dara
Loka Abaya
Chire
Dale
Chuko
Bursa
Malga
Gorche
Arbe Gonna
Bona Zuria
Shebe Dino
Hawassa Zuria
Wonosho
Hawasa Town
Wondo-Genet
South Omo
Keffa
Gamo GofaBench Maji
Sidama
Gurage
Dawro
Selti
Wolayita
KT
Hadiya
Segen Peoples'
Konta
Sheka
Gedio
Yem
Alaba
Hadiya
Basketo
Somali
Oromia
Afar
Amhara
SNNPR
Tigray
Gambela
Benshangul Gumuz
Dire Dawa
Addis Ababa
Fura
Telamo
Abela Lida
Remeda
Howoliso
Dila Aferara
Dirimo Aferara
Tara Mesa
Sedeqa
Gala Galo
Alawo Ano
Nure Dulecha
Dobe Toga
Galuko Haro
Konisire Ano
Asera domero
Midire Genet
Dobe Negasha
Dila Chanige
Gobohebisha
Haribe Shesho
Harbe Hagawo
Harbe Gonamero
Galiko Hirye
Dila Gumibe
Murancho Kutala
Gonoba Godo
Bonoya Merede
Delecha Teberako
Morochi Shonidola
Morochi Negasha
Gonowa Gabelo
Leku Town
Dobe Toga
Sedeqa
Gobohebisha

10. Overview of (QI) intervention…
• The QI intervention included training of HEWs’ supervisors and
HEP coordinators on supervision curriculum (six day )
• 32 HEWs’ supervisors and 3 HEP coordinators trained
• Group supervision facilitation guideline provided
• Regularly monitored by the catchment health center, district
health office and REACHOUT project staffs
• Meeting documented in a minute and monthly report submitted

12. Aim
The aim of the study was to explore experience
with group supervision introduced as a QI
intervention to improve HEWs performance in
providing maternal health services in Sidama zone,
South Ethiopia.

13. Methods
• Mixed study design employing in-depth interviews, quantitative
data tracking tool, baseline and end line data,
• Baseline end line HMIS data collected from 9 health posts
selected based on their performance (High, medium and low)
• 12 IDI with the HEWs: experience of supervision on motivation
• 8 IDIs with health system staffs (2 district health office, 2 health
center managers and 4 HEWs’ supervisors)

14. Methods…
• Interviews digitally recorded, transcribed and translated into
English and transcripts read independently by three researchers
• Key themes identified, coding frame work developed and coded
using Nvivo 10
• Each theme analyzed and summarized in narratives
• Quantitative data analyzed by simple statistics and summarized
in narratives
14

15. Results
Motivation: Majority of the HEWs indicated that the group
supervision made them feel more motivated
“...group supervision increases my knowledge on area where I am
supervised. Since I got something on which I forgot it because of that it
motivates me to work hard ” (HEW, IDI)
Changes in supervision approach
“In fact there was a practice of supervision before REACHOUT comes. It
is a kind of why this done or not done or simply listing down weak sides
without discussion how to correct. The other point, it was neither regular
nor participatory; but this has been changed since the introduction of
REACHOUT interventions” (HEW, IDI)

16. Results
Regularity of the meeting and attendance level
The regularity of group supervision meetings and attendance
level of HEWs increased from 4% to 70.4 % and 2.3% to 61%
respectively at the end of the year
Attendance in antenatal care visits
The proportion of mothers attended the first and 4th
antenatal care (ANC) improved from 73% to 76% and 56% to
70 respectively

17. Results

18. Results
Attendance at pregnant women forum and skilled delivery
The proportion of mothers attended pregnant women forum
and gave birth at health facilities improved from 48% to 100%
and 40% to 83 % respectively at the end of the year
One HEW described the improvement on maternal health use
““……It is Group Supervision that brought such a remarkable achievement
on maternal health activity in our catchment and contributed for the best
performance of our district..”

19. Results
• In spite of the positive results of the intervention; some
challenges have been noticed to supervision
– Supervisors sometimes felt unsupported because of
resources like transportation
– High turnover of supervisors

20. Conclusions
• The findings of this showed that group supervision is a
promising strategy to improve motivation, performance
and utilization of maternal health services
• The health system should be responsive for challenges like
absence of transport facilities for supervisors to ensure
supervision and design a strategies that would minimize
high turnover of supervisors

21. Acknowledgements
Authors:
Aschenaki Zerihun: REACH Ethiopia
Daniel Gemechu: REACH Ethiopia
Nega Teyikie: REACH Ethiopia
Maryse C. Kok: Royal Tropical Institute, the Netherlands
Thanks to:
EU for funding the study
Liverpool School of Tropical Medicine
KIT: Netherlands
South regional health bureau and Sidama zone health department
HEWs and other study participants