The effect of supervision on community health workers’ effectiveness with households in rural South Africa: A cluster randomized controlled trial

Abstract

Background Community health workers (CHWs) can supplement professional medical providers, especially in rural settings where resources are particularly scarce. Yet, outcomes of studies evaluating CHWs effectiveness have been highly variable and lack impact when scaled nationally. This study examines if child and maternal outcomes are better when existing government CHWs, who are perinatal home visitors, receive ongoing enhanced supervision and monitoring, compared to standard care. Methods and findings A cluster randomized controlled effectiveness trial was conducted comparing outcomes over 2 years when different supervision and support are provided. Primary health clinics were randomized by clinic to receive monitoring and supervision from either (1) existing supervisors (Standard Care (SC); n = 4 clinics, 23 CHWs, 392 mothers); or (2) supervisors from a nongovernmental organization that provided enhanced monitoring and supervision (Accountable Care [AC]; n = 4 clinic areas, 20 CHWs, 423 mothers). Assessments were conducted during pregnancy and at 3, 6, 15, and 24 months post-birth with high retention rates (76% to 86%). The primary outcome was the number of statistically significant intervention effects among 13 outcomes of interest; this approach allowed us to evaluate the intervention holistically while accounting for correlation among the 13 outcomes and considering multiple comparisons. The observed benefits were not statistically significant and did not show the AC’s efficacy over the SC. Only the antiretroviral (ARV) adherence effect met the significance threshold established a priori (SC mean 2.3, AC mean 2.9, p Conclusions Supervision and monitoring were insufficient to improve CHWs’ impact on maternal and child outcomes. Alternative strategies for staff recruitment and narrowing the intervention outcomes to the specific local community problems are needed for consistently high impact. Trial registration Clinicaltrials.gov, NCT02957799. In a randomised controlled trial, Dr. Mary Jane Rotheram-Borus and colleagues investigate the effect of supervision on community health workers’ effectiveness in households of rural South Africa. Author summary Why was this study done? There are too few health professionals in low- and middle-income countries, and there will be too few until about 2050. Healthcare tasks are being shifted to 2 million community health workers (CHWs). Yet, the efficacy of these CHWs often disappears when randomized controlled trials (RCTs) are ended and national programs are implemented. What did the researchers do and find? Existing government-employed CHWs serving 8 deeply rural health clinics were randomized by clinic in a cluster effectiveness RCT to either standard supervision or enhanced accountable monitoring and supervision by a nongovernment organization. The CHWs and perinatal mothers/children were monitored at 5 points over the first 2 years of life. Supervision did not lead to significantly better outcomes for mothers and children. Yet, it is noteworthy that 11 of 13 outcomes were better when CHWs received enhanced, accountable supervision, compared to standard care. What do these findings mean? A key component of implementation at scale in the real world is the ability to hold CHWs accountable and to release CHWs not meeting expectations. To successfully deploy CHWs in a manner that has significant and sustained improvements, the procedures for selecting and recruiting CHWs may be critical.