Guidelines for Implementing

Supportive Supervision
A step-by-step guide with tools
to support immunization
This document was made possible through the support of the Bill & Melinda Gates Foundation.

Program for Appropriate Technology in Health (PATH) is an international, nonprofit,

nongovernmental organization whose mission is to find and implement solutions to critical health
problems, especially those affecting women and children. PATH is widely recognized for its
collaborative work with local and international partners and its success in building and sustaining
public- and private-sector partnerships. PATH shares knowledge, skills, and technologies with
governments and nongovernmental partners in low-resource settings around the world. For PATH,
“appropriate” technologies and interventions are those that meet critical health needs in an affordable
and culturally acceptable manner.

Copyright © 2003, PATH. All rights reserved. Material in this document may be used for
educational or noncommercial purposes, provided that an acknowledgement line accompanies the
material.

Any part of this manual may be photocopied or adapted to meet local needs without permission from
PATH, provided that the parts copied are distributed free or at cost (not for profit) and that credit is
given to PATH. PATH would appreciate receiving a copy of any material in which parts of this
manual are used. Material(s) should be sent to PATH.

Recommended Citation
Children’s Vaccine Program at PATH. Guidelines for Implementing Supportive Supervision: A
step-by-step guide with tools to support immunization. Seattle: PATH (2003).
Guidelines for Implementing Supportive Supervision: A step-by-step guide with
tools to support immunization

December 2003

Please contact the Children’s Vaccine Program at PATH for questions or requests for additional
copies.

Children’s Vaccine Program

PATH
1455 NW Leary Way
Seattle, WA 98107
USA

Tel: 206-285-3500
Fax: 206-285-6619
Email: [email protected]
Website: www.ChildrensVaccine.org
 iii

Table of Contents
Acronym list ................................................................................................................................. iv

Acknowledgements ....................................................................................................................... v

Foreword....................................................................................................................................... vi

I. Introduction ............................................................................................................................ 1

II. Moving toward supportive supervision ................................................................................ 1

A. Understand the country context and mobilize appropriate national support ..........................2
B. Make supervisors part of the training process.........................................................................4
C. Work with supervisors to plan and conduct supportive supervision........................................4
D. Stay motivated ..........................................................................................................................7
E. Build sustainability ..................................................................................................................8

III. Case studies and available tools ........................................................................................... 8

IV. Conclusion.............................................................................................................................. 9

Case studies
Case study 1: District supportive supervision following health sector reform in Tanzania
Case study 2: COPE® and facilitative supervision in Kenya and Guinea
Case study 3: Planning and implementing supportive supervision in Honduras
Case study 4: Innovative strategies for supportive supervision in Andhra Pradesh, India

Annexes
Annex A. Sample checklists
Annex B. Sample supervision budget
Annex C. Supervisory roles assigned to each level of the national health system
Annex D. Suggested service delivery workplans
Annex E. Sample observation worksheet
Annex F. Skills matrix for monitoring and management support for provinces and districts
Annex G. Sample dropout rate monitoring chart
Annex H. GAVI Core Immunization program indicators
Annex I. Summary health management field report
Annex J. Web sites

References
Guidelines for Implementing Supportive Supervision iv
December 2003

Acronym list
AD Auto-disable
AED Academy for Educational Development
AEFI Adverse Events Following Immunization
ANM Auxiliary Nurse Midwife
AP Andhra Pradesh
ASHONPLAFA Associatión Hondureña de Planification de la Familia
BCG Bacillus of Calmette and Guerin
COPE® Client-Oriented, Provider-Efficient
CVP Children’s Vaccine Program
DHMT District Health Management Team
DFID Department for International Development
DTP Diphtheria, Tetanus, and Pertussis
EPI Expanded Programme on Immunization
GAVI Global Alliance for Vaccines and Immunization
ICC Interagency Coordinating Committee
IEC Information, Education, Communication
IMCI Integrated Management of Childhood Illness
JICA Japanese International Cooperation Agency
MAQ Maximizing Quality in Health
MCH Maternal and Child Health
MIS Management Information System
MOF Ministry of Finance
MOH Ministry of Health
MNT Maternal and Neonatal Tetanus
MSH Management Sciences for Health
MV Measles Vaccine
NGO Nongovernmental organization
NIP National Immunization Program
OPV Oral Polio Vaccine
PAHO Pan American Health Organization
PATH Program for Appropriate Technology in Health
PNA Performance Needs Assessment
QAP Quality Assurance Project
QI Quality Improvement
RED Reaching Every District
TBA Traditional Birth Attendant
TNA Training Needs Assessment
TOT Training of Trainers
TT Tetanus Toxoid
UNICEF United Nations Children’s Fund
UNFPA United Nations Population Fund
USAID United States Agency for International Development
VVM Vaccine Vial Monitor
WHO World Health Organization
Guidelines for Implementing Supportive Supervision v
December 2003

Acknowledgements
These guidelines were developed by Anne McArthur, Children’s Vaccine Program (CVP) at
Program for Appropriate Technology in Health (PATH); Linda Bruce, PATH; and Molly Mort,
CVP/PATH. They are based in part on documents produced by PATH, the World Health
Organization (WHO), United Nations Children’s Fund (UNICEF), the Pan American Health
Organization (PAHO), BASICS II, PRIME II, the United States Agency for International
Development’s (USAID) Maximizing Quality in Health Initiative, the Quality Assurance Project,
and EngenderHealth. Please see the References section for information on these sources.

Primary Reviewers: Jhilmil Bahl, WHO/Vaccines and Biologicals; Stanley Foster, Emory’s
Rollins School of Public Health; Evariste Mutarabuka, WHO-African
Regional Office (WHO/AFRO); Modibo Dicko, WHO/AFRO; Erin
Mielke, EngenderHealth; Alasdair Wylie, Immunization Management
Consultant; James Cheyne, Willow Gerber, Scott Wittet, and Heidi
Lasher, PATH.

PATH and WHO would like to thank the many other contributors who kindly agreed to
interviews and provided insightful feedback when reviewing these guidelines. Many thanks to:
Julian Bilous, WHO; Thada Bornstein, University Research Corporation, LLC; Vance Dietz,
PAHO; Rebecca Fields, Academy for Educational Development (AED); John Grundy,
Australian International Health Institute; John Lloyd, CVP/PATH; Jules Millogo, BASICS;
Robert Steinglass, BASICS; Barbara Stillwell, WHO; Syed Mizan Siddiqi, BASICS; and Kim
Winnard, AED.
Guidelines for Implementing Supportive Supervision vi
December 2003

Foreword
In order to provide safe and cost-effective immunizations to people at risk, health workers need to be
well trained on immunization practices and management. Training and capacity building are key
elements to improve access to sustainable, high-quality immunization services. Four main steps are
involved to develop this capacity:

• Conducting training needs assessments.

• Providing pre- and in-service education.
• Conducting supportive supervision, including continuing education.
• Monitoring and evaluating training programs.

The Global Alliance for Vaccines and Immunization (GAVI) partners have identified supportive
supervision as a high priority and a critical gap in immunization training. Supportive supervision is
also one of the five key elements of the “Reaching Every District”1 strategy to accelerate progress
toward GAVI’s goal of reaching 80 percent DTP3 coverage in 80 percent of developing country
districts (WHO 2002). The following guidelines have been compiled in response to this need. They
are designed to be adapted for local context to help national managers and country staff understand
and include supportive supervision methodologies as part of routine immunization management. The
purpose of these guidelines is to:

1. Define supportive supervision and show how it can improve immunization programs.

2. Outline major steps that should be considered when introducing and implementing
supportive supervision.

3. Provide country examples of supportive supervision, highlighting different approaches and

lessons learned.

4. Identify and disseminate available tools that can be used for supportive supervision.

These guidelines are designed to be adapted for local context. Checklists and tools are included
as possible models for immunization programs. Because supportive supervision is a lesson “in
progress,” we encourage readers to send feedback, questions, and other examples of tools and
case studies to the Immunization Training Partnership website (www.who.int/vaccines-
diseases/epitraining) to share with others.

We hope that these guidelines serve as a useful resource for you.

1
The five key elements of the “Reaching Every District” strategy are: reestablishing outreach vaccination; supportive
supervision; links between community and service; monitoring for action; and planning and management of resources.
 Guidelines for Implementing Supportive Supervision
I. Introduction
Many institutions’ response to poor performance is to provide in-service training. Long-term
capacity building takes time and planning, and should include a needs assessment, in-service
training based on results of the assessment, supervision, and continuing education. Supervision is
an excellent opportunity to provide follow-up training, improve performance, and solve other
systemic problems that contribute to poor immunization coverage. Though there are many
examples and case studies where supportive supervision has been used to improve health worker
performance and immunization coverage, long-term and sustainable results have not been
thoroughly documented. The following guidelines focus on supportive supervision—a process
that promotes sustainable and efficient program management by encouraging effective two-way
communication, as well as performance planning and monitoring.

Ongoing supervision is an important, often overlooked, step to ensuring quality immunization

services. While supervision can be a very participatory process, traditional supervisory visits
focus more on inspection and fault finding rather than on problem solving to improve
performance. Health workers often receive little guidance or mentoring on how to improve their
performance. They are frequently left undirected, with few or no milestones to help assess their
performance, until the next supervisory visit. Motivation is hard to maintain in such an
atmosphere.

Supervisors often lack the technical, managerial, or supervisory skills needed to effectively
evaluate health facilities across the many sectors for which they are responsible. In addition to
assessing performance, supervisors are also expected to monitor services, evaluate management,
and ensure that the health facility supply chains are working properly—all in a short period of
time. Consequently, they are unable to provide adequate technical guidance and feedback to
improve service delivery.

Supportive supervision requires staff time, costs for per diem, and travel to remote sites. Health
budgets frequently do not allocate sufficient funds or personnel to conduct supportive
supervision, making regular visits difficult to finance and coordinate. Furthermore, supervisors
need support and authority from the central or district level to implement supervision or make
changes to improve services at a health facility.

II. Moving toward supportive supervision

Supportive supervision is “a process that promotes quality at all levels of the health system by
strengthening relationships within the system, focusing on the identification and resolution of
problems, and helping to optimize the allocation of resources—promoting high standards,
teamwork, and better two-way communication.” (Marquez and Kean 2002)

A cornerstone of supportive supervision is working with health staff to establish goals, monitor
performance, identify and correct problems, and proactively improve the quality of service.
Together, the supervisor and health workers identify and address weaknesses on the spot, thus
Guidelines for Implementing Supportive Supervision 2
October 2003

preventing poor practices from becoming routine. Supervisory visits are also an opportunity to
recognize good practices and help health workers to maintain their high-level of performance.
(See Table 1 for a comparison of traditional supervision and supportive supervision.)

Table 1: Comparison of traditional and supportive supervision (Marquez and Kean, 2002)
Action Traditional supervision Supportive supervision
Who performs supervision External supervisors designated External supervisors designated
by the service delivery by the service delivery
organization organization; staff from other
facilities; colleagues from the
same facility (internal
supervision); community health
committees; staff themselves
through self-assessment
When supervision happens During periodic visits by Continuously: during routine
external supervisors work; team meetings; and visits
by external supervisors
What happens during Inspection of facility; review of Observation of performance and
supervision encounters records and supplies; supervisor comparison to standards;
makes most of the decisions; provision of corrective and
reactive problem-solving by supportive feedback on
supervisor; little feedback or performance; discussion with
discussion of supervisor clients; provision of technical
observations updates or guidelines; onsite
training; use of data and client
input to identify opportunities
for improvement; joint problem-
solving; follow-up on
previously identified problems
What happens after supervision No or irregular follow-up Actions and decisions recorded;
encounters ongoing monitoring of weak
areas and improvements;
follow-up on prior visits and
problems

Moving from traditional, hierarchical supervision systems to more supportive ones requires
innovative thinking, national buy-in, and time to change attitudes, perceptions, and practices.
This document is the result of recommendations from various partners who recognize the
importance of supportive supervision and who are implementing it in their programs. Program
managers should adapt these guidelines to their local situation and share their results with others.

A. Understand the country context and mobilize appropriate national support

Before implementing supportive supervision, it is important to understand the supervisory

systems that have already been established, including knowing who makes the decisions on
supervision and how it is funded.

1. Find out what supervision policies currently exist and assess whether they allow for
supportive supervision. If there is a policy in place, determine how effectively it is being
Guidelines for Implementing Supportive Supervision 3
October 2003

implemented; assess the number of supervision visits scheduled; and determine the number
of visits actually carried out.

2. If supervision is part of integrated health services, find out whether supervisors will be
responsible for integrated health care systems or for immunization services alone. Take this
into account when budgeting for supervision. (See Case Study 1 on integrated supervision.)

3. Find out who does the supervision and the other responsibilities of these supervisors. Also
find out how much time they have to commit to supportive supervision.

4. Build on successful supervision currently in place in other health sectors. Use the same
standards, approaches, and vocabulary to ensure consistency. (See Case Studies 1-4 for
different approaches to supervision.)

5. If there is no policy or it needs to be updated, participate in its development and/or revision

and advocate for appropriate ministries and other stakeholders to be involved in the process.

6. Advocate for financial support to implement supportive supervision by:

• Using district-level microplanning to estimate what resources are needed for effective
supportive supervision.

• Preparing a budget with actual costs of conducting supportive supervision for Interagency
Coordinating Committee (ICC) and Ministry of Health (MOH) review. Costs should
include funding for supervisor training, per diem for supervisory visits, transportation
costs, purchase of vehicles, etc. (See Annex B for a sample budget.)

• Investigating local resources within the community such as community health

committees and local governments.

• Preparing a persuasive argument using available data to advocate to decision makers on

the benefits of supportive supervision.

• Mobilizing senior-level managers to lobby for adequate funding for supervision costs
within the ICC, the MOH, and Ministry of Finance (MOF).

7. Advocate for supportive supervision with the ICC, MOH, and MOF to ensure that adequate
funds are made available and that these funds are not reduced during the budgeting process.

8. Incorporate supportive supervision into annual health budgets, national work plans, and
financial sustainability plans.

9. Galvanize institutional support for supportive supervision. Supervisors need standard

procedures, authority to make decisions, training, and sufficient funds to carry out their jobs
effectively.
Guidelines for Implementing Supportive Supervision 4
October 2003

10. Involve senior-level managers to help make all levels of supervision a priority and ensure
that all supervisors are held accountable. (See Annex C on different supervision
responsibilities at the national and subnational levels, developed by WHO/AFRO.)

B. Make supervisors part of the training process

Supervisors can play a very important role in the training process and their involvement in a
training program is critical for buy-in. They can also help ensure that the training needs of the
health workers are addressed. Below are suggestions on how to involve supervisors in training:

1. Update supervisors on current policies, new immunization practices, techniques, and

management skills.2

2. Train supervisors on how to coach, mentor, effectively communicate, and conduct

performance planning. This will build their supervisory skills to better guide service
providers to improve performance and solve problems at the health facility level.

3. Involve supervisors in the training process—conducting training needs assessments, building

training-of-trainers (TOT) skills, and carrying out workshops. Because they know the issues
at the health facility level, supervisors can help identify training needs and performance gaps,
and develop training priorities for vaccinators.

4. Train supervisors on adult learning and training techniques. This will strengthen their
capacity to deliver effective on-site instruction and follow-up.

5. Involve supervisors in the development of training curricula and job aids. This ensures buy-in
and builds the capacity of the supervisor to effectively transfer skills and knowledge to health
workers.

6. Help supervisors build a receptive environment for new techniques by updating all staff on
new practices. For example, if a nurse at the health center is going to be trained in new waste
disposal practices, the supervisor can brief the health center staff on the new technique and
how to support this practice.

C. Work with supervisors to plan and conduct supportive supervision

Many program managers use the following steps to implement supportive supervision in their health
programs.

2
Immunization Essentials is a useful guide for EPI managers developed by USAID. Information will be available soon on
the Immunization Training Partnership website (www.who.int/vaccines-diseases/epitrainig).
Guidelines for Implementing Supportive Supervision 5
October 2003

1. Prepare in advance for supervisory visits

• Plan to conduct regular supervisory visits. When supervisory visits are made routinely,
supervisors are better able to monitor performance and can identify and address problems
before they negatively impact service delivery.

• Arrange visits when supervisors can observe an immunization session, interview clients,
and arrange for staff meetings without adding extra burden to the staff. Some institutions
recommend monthly supervisory visits, others quarterly. Lesser performing health
facilities should receive more frequent visits.

• Organize the supervisory visit by:

– Reviewing objectives of annual and multi-year plans.
– Developing clear objectives for the visits.
– Following up on recommendations made during previous visits.
– Collecting helpful publications, materials, and supplies for the health facility.
– Preparing updates and/or refresher training to present during the visit.

• Plan to spend sufficient time (from several hours, to a full day or more) to conduct the
supervisory visit. The amount of time of a supervisory visit varies depending on the
needs of the health facility. For example, in some cases a two-day visit would be more
effective than just one day. It allows the supervisor enough time for meeting with the
health worker to discuss performance goals, meeting with the community, assessing the
facility’s cold chain, and traveling.

• Stick to the schedule and respect the health workers’ time. Always schedule a return visit
before leaving the site.

2. Set expectations for performance

• Develop job descriptions, expectations, and standards of performance. Supervisors should

prepare these together with the staff being supervised.

• Determine measurable performance goals together with staff. Make sure that the goals
are realistic and attainable.

• Develop measurable indicators, milestones, and tools so that staff can monitor their
progress toward goals. (See Annex D for a sample workplan.)

• Develop a supervisory team within the health facility that can provide day-to-day support
and supervision.

• Introduce a self-assessment/feedback system.

Guidelines for Implementing Supportive Supervision 6
October 2003

3. Monitor and assess performance of the health facility

• Observe immunization sessions and note strengths and weaknesses. (See Annex E for
observation worksheet.)

• Talk to clients about the quality of services, preferably away from the health facility—
you will be more likely to receive honest answers.

• Involve the community in the evaluation process. Ask community members how they are
treated when they visit the facility. Do they know about reactions to immunization? Do
they know what to do about them? Do they know when to return? Meet with designated
community leaders during the visit to get their feedback.

• Check the availability of stock and the condition of equipment.

• Check cold chain and vaccine quality.

• Review health facility records, including coverage and dropout rate monitoring charts.
(See Annex G for a sample dropout rate-monitoring chart.)

• Meet with the supervision team within the facility and ask for additional feedback on
service delivery.

• Use information gathered during the visit to discuss progress with the health facility
team.

• Always start out by presenting the health staff and facility’s positive attributes.

• Review indicators, milestones, and performance with staff. (See Annex H for a list of
GAVI core immunization program indicators that can be adapted to the local context.)

• Assess performance goals and make adjustments as needed.

• Both the supervisor and supervisee should keep a written log/record of items discussed,
including strengths and weaknesses, and actions to be taken (by whom and by when).

4. Identify gaps and solve problems in positive ways

• Praise health workers in public for good performance and for practices that meet quality
standards. Correct performance only in private.

• Provide staff with informational updates on policies or new recommended practices.

Guidelines for Implementing Supportive Supervision 7
October 2003

• Discuss findings and recommendations with the health facility team:

– Ask the staff to identify areas of strength and weakness. A supervisor can serve as a
facilitator and help the staff develop strategies for solving problems.
– Give constructive feedback.
– Find causes and reasons for poor performance—is it a capacity issue? An equipment
or supply issue? Motivation?
– Discuss, listen, give feedback, and solve problems together.
– Review coverage data and drop-out rates. Work with the team to identify reasons for
drop-out rates and strategies for improvement.
– Set target coverage rates for improvement.

5. Provide support and strengthen capacity of health care providers to meet performance goals

• Identify information/training needs together with staff.

• Work with health facility and district- or central-level authorities to set priorities.

• Provide on-site updates and training.

• Develop job aids according to priorities. Be prepared to leave job aids at the health
facility, but consider leaving behind only the job aids related to priorities.

• Follow up on equipment and supply problems in a timely manner with the district or
central level authorities.

• Work on ways to improve the delivery system with the district- or central-level
authorities.

D. Stay motivated

Staying motivated to use supportive supervision can be a challenge. Motivation can decline when
supervisors and health workers are poorly paid or transferred, and when results are hard to see.
Staff can become discouraged when performance planning is burdensome. The following
suggestions may help:

• Give praise and recognition to health workers for what they are doing right. Even if
monetary recognition is not possible, recognition can come in other forms. Health
workers can be recognized in official letters, newspapers, newsletters, by awarding
certificates acknowledging good work, and by receiving new uniforms, pins, bags, or
prizes for a job well done.

• Identify career growth or leadership opportunities and provide guidance and training
needed for advancement.

• Involve health workers in the planning process and encourage supervisors to work
together with health facility staff and the community to develop checklists, job aids,
monitoring tools, etc.
 Guidelines for Implementing Supportive Supervision 8
October 2003

• Act on feedback from the health workers. For example, if a health center needs a new
refrigerator and a supervisor is able to lobby the central-level authorities to procure one,
health workers will feel valued and that they have an impact.

• Establish regular monthly meetings with all health facilities within a district. The
meetings could coincide with when health workers collect their pay. This provides an
opportunity for health workers to learn new approaches and strategies used in different
health facilities and to receive continuing education. It can also be a forum to
acknowledge their achievements and their sites. Work with organizers to ensure that time
is allocated for this.

E. Build sustainability

The first step to ensuring sustainability of supportive supervision is to institutionalize it within

the government system. This can be done in several ways:

• Incorporate supervision into the national budget and work plan or into the district-level
microplans. This helps make supervision a recurring, funded cost.

• Increase decision maker and manager awareness of the benefits of supportive supervision
by:
– Collecting data on positive results gained from supportive supervision, such as
improved performance of health workers, improved immunization coverage, or
increased utilization of resources.
– Lobbying government officials and decision makers on the benefits and effectiveness
of supportive supervision. Show data on improved quality, cost-effectiveness (e.g.
reduced vaccine wastage), and increased coverage.
– Continually advocating for supportive supervision at the central-, district-, and health
center-levels to maintain visibility of supportive supervision as a key element to
quality service delivery.

• Develop a team approach to increase supportive supervision at a health facility and make
it a routine procedure, with or without frequent visits from the central or district level.
Health facility staff can develop supervision plans that fit their structures and conduct
regular self-assessments to monitor their performance.

III. Case studies and available tools

The following case studies illustrate the different approaches to supportive supervision:

1. District supportive supervision following health sector reform in Tanzania

The District Health Management Team in Tanzania involves an integrated supervision team
and uses a matrix to conduct and monitor supervision. Supervision is now more frequent and
health workers use it as an opportunity to solve problems.
 Guidelines for Implementing Supportive Supervision 9
October 2003

2. COPE® and facilitative supervision in Kenya and Guinea

Using EngenderHealth’s Client-Oriented, Provider-Efficient (COPE®) model, (a
participatory supervision approach that includes self-assessment and performance plans),
immunization services in Kenya and Guinea improved, as did health worker performance and
attitudes toward supervision.

3. Planning and implementing supportive supervision in Honduras

A reproductive health, nongovernmental organization (NGO) in Honduras adopted a strategy
to improve supervision and service delivery while reducing costs. The group looked at
performance issues and developed a supervision system to address them. Performance goals
were achieved, service quality improved, and client satisfaction increased.

4. Innovative strategies for supportive supervision in Andhra Pradesh, India

New strategies are being developed and adapted for supportive supervision, including
outsourcing supervision to medical schools.

There are many reference tools available for supportive supervision that are easily adapted to suit
various program needs. Examples of these useful tools and websites can be found in the annexes
to this document.

IV. Conclusion
Supportive supervision fosters a collaborative approach to strengthen health worker performance
and immunization services. It has been an effective tool for improving performance for many
organizations. These guidelines and tools can be adapted. They can provide a starting point to
develop a supportive supervision system or help to streamline already existing supervision
systems.
Case studies
Guidelines for Implementing Supportive Supervision
October 2003

Case study 1: District supportive supervision following health sector reform in Tanzania

Following health sector reform in 1999, the MOH in Tanzania developed an integrated health
package to guide essential health service delivery. Recognizing the importance of supportive
supervision, the MOH included a plan to bring a team of supervisors to district health facilities to
evaluate how services are being delivered, provide feedback, and conduct on-site training.
Funding for supervision comes from the MOH through basket grants, with funds contributed by
various donors to support delivery of essential health services.

All members of the District Health Management Team (DHMT), and some co-opted members,
were trained in the objectives of health sector reform: promoting partnerships in the district,
managing health resources, and planning and providing district health services. Supervision
training was included as a part of the management module.

Prerequisites of integrated supervision

Effective integrated supervision requires:

• A functioning health care system.
• A reliable health management information system (MIS).
• Committed health personnel with training in crucial aspects of priority programs.
• Availability of sufficient financial resources.
• Well-organized and adequate transportation for accessing health facilities.
• Well-prepared supervision plans.
• Integrated supervision tools (e.g. checklists and questionnaires) prepared by
representatives of priority programs. These tools should include all essential health
services such as HIV/AIDS, IMCI, Malaria, and EPI (WHO regional office, 2003).

Supervision matrix
The DHMT matrix highlighted that
there was insufficient
One of the supervision and management tools to come out of transportation to carry out the
this training is a supervision matrix. needed supportive supervision
visits. As a result, the MOH
purchased a vehicle for supervision
Prior to supervision visits, the DHMT: in each district and trained
• Prepares a matrix listing the months and dates of all the transport officers with funds
supervisory visits; the routes and vehicles for each trip; received from DANIDA.
the facilities to be visited; and the members of the
supervision team.
• Ensures logistics and supplies needed for the visit.

During the supervision visit

For each supervision visit:

• The team develops a supervision checklist using national guidelines and the previous
supervision report.
• Four members of the DHMT conduct supervision visits on a monthly basis. The teams
alternate until all of the district’s health facilities (both public and private) have been
visited.
Guidelines for Implementing Supportive Supervision
October 2003

• When the team reaches the facility, they divide into specific areas of specialization
following the checklist (e.g. disease management, nursing care, vaccine/immunization
issues, managerial issues, HIV/AIDS). The team supervises health workers through direct
observation and interviews.
• Immediate feedback is encouraged, and the team debriefs with the head of the facility.
The team then meets with all staff and provides general feedback, praise, and suggestions
for improvement.
• On-the-job training is also provided during the supervision visit.
• If a technical problem is found and the team feels it cannot be corrected, then the problem
is presented to the rest of the DHMT members or to the area specialist for further
management or action.

After the supervision visit

• The team goes back to the district headquarters, writes a full report, and discusses results
with the whole DHMT core and co-opted members. Action items are listed for remaining
challenges that were not resolved during the facility visit.
• A copy of the full supervision report is sent back to each visited facility and another copy
is sent to Regional Health Management Team (RHMT).
• Difficult issues that could not be resolved by the DHMT are referred to the RHMT. The
process then continues until all health facilities in the district have been reached.

Supervision at the regional level by the RHMT follows the same process and format. Difficult
problems are sent to the MOH for further discussion and possible solutions.

Lessons learned and results

Since this system has been adopted, health workers have noticed a significant improvement in
supervision. Supervisory contact is more frequent, problems are being solved, and on-the-job
training is being conducted. Supervisory visits have become an opportunity for health workers to
solve problems and learn additional skills. Health workers are no longer afraid to address
challenges and are able to work with the DHMT to resolve them.
Guidelines for Implementing Supportive Supervision
October 2003

Case study 2: COPE® and facilitative supervision in Kenya and Guinea

COPE® is part of a quality improvement (QI) package developed by EngenderHealth and

implemented with institutions in developing countries. The QI package is a continuous process
that involves all levels of staff at a health facility to assess the situation at the site and work as a
team to improve services. EngenderHealth uses facilitative supervision, medical monitoring, and
whole-site training as part of its overall approach. It uses simple tools to implement these
approaches, including COPE®.

Approach

The COPE® philosophy is one of participation, teamwork, ownership, and shared responsibility.
There is a large focus on clients, staff development, capacity building, and supervisor
engagement. COPE® is a process with a set of tools for health care staff to continuously assess
and improve quality of care. It is built on a framework of client rights, staff needs, and consists
of the following four tools:

• A self-assessment guide (one for each of the client rights and staff needs)
• A client interview guide
• A client flow analysis
• An action plan

The self-assessment guide encourages staff to review how they perform daily tasks and serves as
a catalyst for analyzing the problems they identify. The guides contain key questions based on
international clinical and service standards. The tools also highlight client-provider interactions
and other client concerns.

Supervision is a key to quality improvement. District and facility supervisors receive training in
facilitative supervision that emphasizes two-way communication, coaching, mentoring, and joint
problem solving. Supervisors then work with health facility staff to improve quality of service.
The COPE® process helps supervisors apply this facilitative approach to supervision by
encouraging teamwork among all levels of staff, providing a forum for staff and supervisors to
exchange ideas, and relying on staff to identify and solve problems through self-assessment and
by learning the group’s needs (Dohlie et al., 2002).

Lessons learned and results

In 1999, EngenderHealth adapted COPE® tools for use in child health services in Kenya and Guinea.
For 15 months, eight selected study sites implemented a COPE® approach and eight control sites
were chosen. The hypothesis of this intervention is that by introducing COPE® the providers and
sites would undergo personal and organizational changes that would enable them to take action and
improve the quality of service provided (Bradley et al., 2002).

At the end of the 15-month study, researchers visited the sites in Kenya and Guinea to observe
provider-client interactions. Programmers felt that after the COPE® intervention, providers would
examine client interactions and solve problems that may exist, and practices would improve.
Guidelines for Implementing Supportive Supervision
October 2003

Observers watched 160 immunizations of children up to five years old and obtained the following
results:

Table 2. Provider-caregiver interactions

Intervention site Control sites
Provider discussed immunization schedule 87.5% 72.5%
Provider gave information on side effects after
63.3% 25.3%
immunization (mentioned at least two)
Provider discussed what caregivers should do
69.9% 36.5%
about side effects
Source: Bradley et al., 2002.

Researchers also conducted exit interviews with caregivers who had not been observed to check
their knowledge on immunization after a visit to the clinic. Results showed that the caregivers
were getting more complete information in the intervention districts than in the control districts,
indicating improved service by the provider.

Table 3. Exit interview results

Intervention site Control sites
Caregiver recall of information about measles 55% 40.6%
Caregiver recall of information about polio 69.4% 54.5%
Child received birth polio vaccine 80.0% 56.2%
Child received BCG vaccination 84.3% 78.1%
Source: Bradley et al., 2002.

Focus groups were set up and participants asked how their perceptions of supervision had
changed during the intervention.

Table 4. Staff perspectives on outside supervision: percentage of staff who agree strongly
with statements
Intervention site Control sites
We truly benefit from supervision 61.0% 21.5%
They help us with supplies 66.2% 17.5%
They help us with training 64.9% 22.5%
®
They help us do COPE 64.9% 1.3%
They help solve problems 62.3% 20.0%
They include us in their discussions 62.3% 32.5%
Source: Bradley et al., 2002.

Results show that participants felt supervision was better than before and that supervisors were
practicing their new skills and were following up on problems identified through COPE®. There
was a new focus on the issues being faced at the facility level and on problem solving. In Guinea,
supervisors felt that they were part of the facility team and the participants felt that there was
improved service delivery because of the supervisors’ enhanced skills. Clients of the intervention
Guidelines for Implementing Supportive Supervision
October 2003

sites were “very satisfied” with the overall service received — 69.8% in the intervention sites;
48.4% in the control sites (Bradley et al., 2002).
Guidelines for Implementing Supportive Supervision
October 2003

Case study 3: Planning and implementing supportive supervision in Honduras [(Marquez

and Kean, 2002), (Management Sciences for Health, 2001)]

The NGO, Associatión Hondureña de Planificación de la Familia (ASHONPLAFA), is the

largest reproductive health provider in Honduras. Cost-cutting measures at ASHONPLAFA had
reduced the budget for supervision visits and training and the organization wanted to establish a
more cost-effective, integrated supervision system. With technical assistance from Management
Sciences for Health (MSH) in 1999, ASHONPLAFA took the following steps to introduce a new
supervisory system and strengthen supervisory skills throughout their operations.

Step 1: Stakeholder agreement & institutional context

Stakeholders agreed that interventions should focus on supervisors and supervisees.

Step 2: Conducting the performance needs assessment (PNA)

1. Defining desired status

Desired performance was defined in a workshop involving 25 supervisors from all levels of the
organization. The group defined criteria for performance excellence, including supervisory
values.

2. Defining actual status

ASHONPLAFA's supervisory system was assessed to look at authority, functions, performance

planning, and supervisors’ needs and procedures. Findings and recommendations of the
assessment were presented to ASHONPLAFA’s senior management and selected supervisors.
The main findings included:
• Cost-cutting measures had expanded supervisor responsibilities but reduced resources for
supervisory visits and skills training.
• Some procedures manuals were in place, but not a supervision system with integrated
criteria and policies.
• Standards and procedures were already defined, however their organization-wide
communication/dissemination was in process.
• Goals and expectations focused only on productivity and not on quality.
• Bimonthly performance evaluations were frequently subjective. Performance goals were
not negotiated and/or previously negotiated goals were not referred to.
• Personnel excellence criteria did not exist.
• The recognition system was measured mostly in short-term results.
• Each area of the organization had different criteria for supervisor performance and
different procedures.
• Supervisors complained that completing forms took too much time.
Guidelines for Implementing Supportive Supervision
October 2003

3. Analyzing data and doing root-cause analysis

At a supervisory skills training workshop, ASHONPLAFA’s senior management and selected

supervisors used the findings and recommendations to define the current supervision situation
and address the desired organizational performance within the new context. Results indicated:
• Managers were sometimes cutting important supervision, planning, and training activities
in order to reduce short-term costs.
• Operational staff were not included in the development and implementation of
organizational policies, due to fewer planning meetings and supervision visits with less
opportunity to share information.
• Although ASHONPLAFA had a series of procedure manuals as well as guidelines and
standards generated by specific departments, it lacked standard, institution-wide
supervision guidelines and procedures. It also needed a systematic process for training
managers in supervisory skills.

Multiple problems were related to the same cause; an excessive focus on short-term financial
sustainability was producing a conflict between the volume and quality of services provided and
long-term organizational sustainability. This conflict was also affecting the work environment.

Step 3: Select interventions

During the workshop, supervision came to be understood as a comprehensive system where

everyone is responsible. Components of the supervisory system were defined as:
• Philosophy: objectives, criteria for excellence, supervision style, profiles, and levels.
• Strategies:
– Quality assurance program: Guidelines and standards are developed in a participatory
manner and are available and visible in every service delivery site.
– Management information system: Data is collected and analyzed each month by
every region and clinic.
– Performance planning and evaluation: Every two months, supervisors and supervisees
evaluate and negotiate goals together to improve supervisee performance.
– Performance recognition system: Based on individual and clinic performance,
incentives are distributed every two months to all personnel in the organization.
– Meeting system: Monthly meetings are held in every clinic and region to analyze data
as well as discuss the causes of and solutions to identified problems.
– Field visits: Visits to clinics are based on identified needs, and staff use standardized
procedures and protocols during the visits.
– Continuous supervision training: Long-distance learning and annual workshops are
held to reinforce the new supervision philosophy and skills.

Reducing costs and increasing productivity helped ensure progress towards financial
sustainability. Maintaining communications and helping personnel to improve the volume and
quality of services is equally important. In order to achieve both goals, the working group
realized that the only way to proceed was to focus efforts on individual staff behavior and their
capacity to “self monitor”. Maintaining productivity and quality of services at a low cost depends
upon a comprehensive supervision system with components such as: developing standards and
Guidelines for Implementing Supportive Supervision
October 2003

guidelines, planning meetings, negotiating, providing feedback and evaluation, using indicators
and an information system, completing selected field visits, and giving recognition.

Step 4: Implement interventions and change management

ASHONPLAFA formed working groups of supervisors and assigned projects to each working
group to develop and implement one of the components of the new supervisory system described
above. After a series of workshops, ASHONPLAFA developed new supervision procedures, a
manual, and tools to guide supervisory visits. Supervision now includes:

1. Joint performance planning by supervisors and supervisees.

2. Evaluation and determination of performance goals every two months.
3. On-going long-distance learning and annual supervisor workshops to develop and reinforce
supervisor skills.

Step 5: Monitor and evaluate performance

During the second workshop, criteria for excellence and evaluation procedures for supervisors
and supervisees were discussed. Every two months personnel and organizational performance (at
local and regional levels) are measured and rewarded by supervisors. After the launch of the new
systems and the supervision manual, the supervisors working group decided to meet every six
months to evaluate the implementation and results of the new system. The supervisors discussed
the following results at their first meeting:

• Senior executive management agreed to increase delegation of authority to regional and

departmental supervisors. This resulted in more participatory and inclusive supervisory
processes, and opened dialogue between supervisors and supervisees.
• Integrated standards for supervisory excellence into the new organizational quality
assurance system.
• Modified the performance evaluation system to eliminate subjectivity, and included
performance-planning dialogue between supervisor and supervisee as part of the
evaluation process.
• Reviewed and modified the more subjective and divisive aspects of the performance
incentives plan.
• Developed streamlined cost- and time-efficient tools and procedures for supervisory field
visits.
• Designed and disseminated a new integrated supervisory system and procedures manual.
• Improved transparency and timeliness of dissemination of supervision policies.
• Adapted the functions and responsibilities of certain supervisory positions to better suit
departmental, organizational, and programmatic needs.
• Put a plan in place for ongoing training and reinforcement of supervisory skills.

Lessons learned and results

1. Increased open dialogue between supervisors and supervisees regarding performance

planning and evaluation and has helped staff achieve performance goals.
Guidelines for Implementing Supportive Supervision
October 2003

2. Standards for supervisory excellence have been integrated into their overall quality assurance
system. The proportion of ASHONPLAFA’s operating budget obtained from local sources
has continued to rise; from 51 percent before the supervision interventions to 63 percent, 20
months after the launch of the new system.
3. Client satisfaction has remained high (97%) and client access, as measured in couple years of
protection, has also increased.
Guidelines for Implementing Supportive Supervision
October 2003

Case study 4: Innovative strategies for supportive supervision in Andhra Pradesh, India

In early 2001, the Government of India’s Department of Health and Family Welfare, along with
the Children’s Vaccine Program (CVP) at Program for Appropriate Technology in Health
(PATH), initiated a project to improve routine immunization in the state of Andhra Pradesh
(AP). Introduction of hepatitis B vaccine is part of this project. During the project’s first two
phases, 12 districts with 850 health centers serving a population of approximately 40 million
people were included. In November 2003 the project will expand to 11 more districts so that the
total population covered will be nearly 80 million people—all served by approximately 1,500
health centers. In Andhra Pradesh supervisors do not make regular visits to their sites, and the
size of the project poses a significant challenge to carrying out routine supportive supervision
visits to help improve immunization coverage.

The project identified the following main challenges to hepatitis B introduction:

• Immunization sessions are not being conducted.
• Hepatitis-B vaccine and DTP vaccine uptake is not equal.
• Auto-disable (AD) syringes are not being used as expected.
• Cold chain management is poor.
• Injection waste disposal recommendations are not being followed.
• Reports are not properly prepared.
• A high proportion of infants are immunized too early or too late.

The Government of Andhra Pradesh and CVP are currently adopting strategies for supportive
supervision to help resolve these and other problems, including job satisfaction. The following is
a list of strategies currently underway in Andhra Pradesh.

Supervision visits

A national supervisory system exists in AP but does not function well. Supervisors rarely visit
health centers, and when they do, they are not usually well informed and rarely look into the
details of how the program is supposed to operate. As part of their commitment to improving
supervision, the government has recently opened six new posts for supervising supervisors who
are responsible for three to four districts with a combined population of about 10 to 12 million
people.

Maps and Indicators

Following 23 coverage surveys (each composed of 14 children in 40 clusters), the Government

of India developed a series of maps and indicators to benchmark the districts using 13 indicators
of program success. The maps are posted in every health center and in offices involved in
immunization, right up to the Chief Minister’s office in Hyderabad. The data provide a
comparison of how health centers are performing, and as a natural result, staffs are having a
friendly competition to improve coverage rates. A data tracking system using the same indicators
as the surveys is currently being devised to help health workers collect the data they need to
track their own performance. When the program expands to cover the whole state in November
2003, all the development effort will be placed on “continuous quality improvements” so that the
statewide coverage for full immunization increases from 72 percent to 85 percent by 2006.
Guidelines for Implementing Supportive Supervision
October 2003

Monthly meetings

Monthly meetings are held in each district for health workers to meet, review their coverage
data, and share lessons learned. It is a chance for them to compare practices and get further on-
site training.

Out-sourcing supervision

The government and CVP are out-sourcing supervision to local medical colleges. Postgraduate
medical students and medical school faculty support the government supervision system and
strengthen it by providing a fresh perspective to the system. Outsourcing supervision also
provides university members with real experiences from the rural and urban slum health service
sites. Recent university graduates have status that gives them some perceived authority in the
delicate art of supportive supervision. Unfortunately most health workers involved in
immunization are female and most recent graduates of medical schools are male. This presents a
challenge to equitable program management, but proper supportive supervision protocols can
provide the most positive backdrop for the gender imbalance.

The purpose of this outsourcing is to provide a fast upgrade in supervision, while building
capacity for the government and encouraging new recruits to public health to develop skills they
will need throughout their careers. After just two months of implementation the cost of
supervision is approximately US$20 per health center visit. At this rate the statewide total cost
per year for all health centers is about US$270,000 (US$20 for each visit to 1,500 health centers
every one to two months). This cost is currently being covered by CVP but one of the functions
of the pilot project in two districts—with a combined population of over 5 million people—is to
demonstrate the feasibility and effectiveness of out-sourcing supervision.

The following strategies are under consideration:

1. Community involvement

The team is also looking into the possibility of involving village health committees in
supervision. Local health committees may pay for supervision and could follow up with
supervisors to make sure that they are visiting sites and improving service quality in the
local community.

2. Setting up a three-level supervision system

The team is developing a system to identify high performing, lesser performing, and poor
performing health centers. Each center would receive more or less frequent supervision visits
according to their status. The status of the centers would be regularly evaluated based on
service improvements or declines and performance levels and status would change
accordingly. The criteria for each of the three levels would continually increase, encouraging
the centers to improve their performance when compared to their colleagues in other health
centers.
Guidelines for Implementing Supportive Supervision
October 2003

3. Using local NGOs to support the government health supervision system

With over 1,500 health centers to be visited, supervision is a huge task. Steps are being taken
to recruit local NGOs to take on a similar role to that of the medical schools. First indications
are that these organizations are willing and enthusiastic about this responsibility and
negotiations are proceeding on how the supervisors’ findings can be translated into action by
the government services.
Annexes
Guidelines for Implementing Supportive Supervision A-1
October 2003

Annex A. Sample checklists

Sample Supervision Checklist for Program Managers and Medical Officers ................................ 2
EPI Checklist for the Supervision of Health Centers...................................................................... 4
Supervision Checklist Questions for Reducing Dropout Rates ...................................................... 5
Checklist for Improving Supervision: A Team Approach.............................................................. 7
Check List for the Supervision of Immunization Program Province/Municipality/District........... 8
Supervisor Check list for Immunization Program at Health Center level .................................... 11
Guidelines for Implementing Supportive Supervision A-2
October 2003

Sample Supervision Checklist for Program Managers and Medical Officers3

Indicators to check Questions to ask

Monthly immunization report • Is the report up-to-date?
• Is the report clear?
• How many children were immunized compared to
targets?
• Are the vaccines indented regularly to each ANM
on Wednesday and Saturday?
• Does the ANM take enough of each vaccine to a
session?
• Are all ANMs submitting regular reports on
vaccine doses administered?
Fixed and outreach immunization schedules • Are all the planned immunization sessions being
held?
Immunization register • Look at the summary reports. How many doses of
vaccine were administered in each ANMs area?
• How does this compare with the eligible
beneficiaries estimates for the area?
Monthly surveillance reports • Have the last three months reports been sent in on
time?
• Have there been any unusual outbreaks of the
disease?
Schedules and micro-planning • Are the maps of the area covered by the health
center available at the health center?
• Are sub-center and outreach schedules available
on the wall?
• Are the dates/times of immunization at each site
displayed at a central location?
Vaccine and supply stocks • Has the ANM properly recorded use of vaccines?
• Are all vaccines and supplies in sufficient stock at
the health center?
• Is the cold chain being maintained?
• Have any vaccines expired?
• Are all VVMs okay?
• Is there enough vaccine to last six weeks?
Injection Safety and Safe Disposal • Are the ANMs well supplied with AD syringes
and safety boxes?
• Is there an agreed upon method for safe disposal
of the safety boxes at the health center and sub-
centers?
• Are the safety boxes also being used for all
disposable and AD syringes? (They should be
used for all syringes.)
• Is other waste being put in the safety box—caps,
packaging, cotton wool, etc.? (Other waste should
not be put in safety boxes.)

3
Reprinted from Introduction of Hepatitis B Vaccine in the Universal Immunization Programme: A Handbook for
Programme Managers and Medical Officers with permission from the Government of India, Child Health Division,
Department of Family Welfare, Ministry of Health and Family Welfare. Please contact them for further information.
Guidelines for Implementing Supportive Supervision A-3
October 2003

Sample Supervision Checklist for Program Managers and Medical Officers (cont.)

Checklist for immunization session Satisfactory? If not, was

behavior
corrected?
Immunization register is complete and all patients are listed by name
and address.
New immunization cards are given to newborns and exchanged for
old cards of babies coming in for their first dose of DPT and
Hepatitis B vaccines.
All children are screened before services are provided (at a
minimum, children should be screened for their age and
immunization status).
Mothers are told what vaccine is being given and when to return for
her next appointment.
ANM washes hands before beginning the immunization session.
Vaccine is reconstituted correctly just before the immunization
session.
Children are positioned correctly for immunizations.
The injection site is cleaned with water if necessary.
Intra-dermal injection technique is correct (a small, raised lump
should appear at the injection site).
Subcutaneous injection technique is correct (given in deltoid muscle
of arm).
Intra-muscular injection technique is correct (given in anterolateral
aspect of the thigh).
Oral polio vaccine administered correctly.
No patients were turned away for false contraindications (such as
illness, fever, respiratory infection, diarrhea).
Mothers are treated with respect.
Used needles/syringes deposited in safety box immediately after use
(no recapping).
Safety boxes are being filled to appropriate level.
Filled safety boxes are safely disposed. (Personally verify the site of
disposal and the method.)
Guidelines for Implementing Supportive Supervision A-4
October 2003

EPI Checklist for the Supervision of Health Centers4

Health Center: ___________________________________________________________
Date: _____________________ Date of last visit: ________________________

Any negative response means that there is a problem and causes of which must be found.

Supervise through INTERVIEWS WITH HEALTH WORKERS and EXAMINATION OF REGISTERS

1. Was the temperature of the refrigerator recorded twice a day and did it remain between +2C and +8C since
the last visit? Yes No
Reading of current temperature: _________________

2. Have the vaccine stocks always been adequate (that is, sufficient but not in excess) since the last visit?
Yes No

3. Have all the planned immunization sessions (fixed sessions and outreach sessions) taken place since the
last visit? Yes No

4. Have the vaccination control tables been correctly used and are they up-to-date?
Yes No

5. Are the following dropout rates less than 10% (between OPV1 and OPV3, between TT1 and TT2, and
between MV and BCG)? Yes No

6. Compare the current immunization coverage of the health center to its annual coverage objectives. Can the
health center attain its coverage targets?

Yes No
BCG coverage?
DPT3 coverage?
OPV3 coverage?
Measles coverage?
TT2+ coverage?
“Protection from birth” coverage?

7. Do the number of cases of measles, neonatal tetanus, and polio recorded at consultations correspond to the
number mentioned in the monthly surveillance report?
Yes No

8. Since the last visit, have zero cases of polio or neonatal tetanus been recorded at the health center?
Yes No

9. Has any case of measles been recorded since the last visit? Yes No

10. Are vaccination and surveillance reports sent each month to the district on time?
Yes No

11. Do you record and notify undesirable post-immunization manifestations?

Yes No
12. Do you use auto-disable syringes? Yes No

4
Reprinted from Mid-Level Management Course for EPI Managers with permission from WHO African Regional Office.
Please contact them for further information.
Guidelines for Implementing Supportive Supervision A-5
October 2003

13. Do you use safety boxes for the disposal of needles and syringes?
Yes No
14. Do you administer vitamin A under your routine program?
Yes No

Supervise through OBSERVATION OF HEALTH WORKERS:

Observe the health workers while they vaccinate at least five women and five children. Answer questions 15
and 16 in the space provided below:

15. Is the immunization status of women and children checked?

16. Is each injection carried out with a sterile syringe and a sterile needle?

WOMEN Question 15 Question 16

First observation Yes No Yes No
Second observation Yes No Yes No
Third observation Yes No Yes No
Fourth observation Yes No Yes No
Fifth observation Yes No Yes No

CHILDREN
First observation Yes No Yes No
Second observation Yes No Yes No
Third observation Yes No Yes No
Fourth observation Yes No Yes No
Fifth observation Yes No Yes No

Supervision through INTERVIEWS WITH WOMEN:

17. Ask to see the vaccination card(s). Have the vaccination schedules of the women and children and rules
regarding contra-indications been observed today?

18. Ask the women the following question: “When must you come back for your next vaccination and/or that
of your child? (Compare the answer to the information provided on the vaccination card. If her answer
does not correspond to the nearest date indicated, indicate the answer as “no”.)
Question 17 Question 18
First interview Yes No Yes No
Second interview Yes No Yes No
Third interview Yes No Yes No
Fourth interview Yes No Yes No
Fifth interview Yes No Yes No
Six interview Yes No Yes No
Seventh interview Yes No Yes No
Eighth interview Yes No Yes No
Ninth interview Yes No Yes No
Tenth interview Yes No Yes No

Ask each woman if she has suggestions for improving the vaccination services:
______________________________________________________________________________
Guidelines for Implementing Supportive Supervision A-6
October 2003

Supervision Checklist Questions for Reducing Dropout Rates5

Supervisors can use the following questions as a checklist for action:

! Who is being served by the program?

! Are vaccine levels displayed at the clinic? Are dropout rates calculated? Are wards with low
coverage identified?
! Who should be served by the program?
! Is a map of the catchment area displayed prominently at the clinic? Can the clinic provide basic
information about the population it serves: number of births annually, number of children less
than one year of age, population of rural and urban areas by village or ward.
! Are the target diseases occurring?
! Are charts of the EPI target diseases displayed at the clinic? When such cases occur, does staff
try to determine why the children were not protected?
! Are supplies and equipment adequate?
! Is the temperature in each refrigerator checked and recorded daily? Have all the readings been
within acceptable limits? Have immunization sessions been cancelled because of insufficient
supplies? Is any vaccine out of date? Do abscesses occur following vaccination?

5
Reprinted from Making existing immunization services more efficient; Increasing immunization coverage by reducing by
reducing drop-out rates with permission from WHO-UNICEF. Please contact them for further information.
Guidelines for Implementing Supportive Supervision A-7
October 2003

Checklist for Improving Supervision: A Team Approach6

For Clinic Managers

____ Discuss with your supervisor ways in which supervision can be made more effective.

____ Solicit input from your clinic staff about how the supervisory system can be changed to
improve overall clinic performance.

____ Develop guidelines with your supervisor for introducing a team supervision approach.

____ Create a team supervisory system that functions between supervisory visits.

____ Decide with your staff and supervisor what educational and training programs are necessary
to improve clinical and management skills.

____ Discuss problems with your staff and work with them to find solutions.

For Supervisors

____ Develop a supervisory system that focuses on supervising clinic activities and achievement of
clinic objectives, rather than on day-to-day individual performance.

____ Discuss and agree on an approach to supervision that involves the clinic manager and staff as
part of the supervisory team.

____ Be an advocate for the clinic manager and staff to ensure that they can take advantage of
educational and training opportunities.

____ Be well prepared for a supervisory visit by reviewing previous recommendations and actions
you have taken to support the clinic’s activities.

____ At the end of each supervisory visit, prepare a list of actions with the clinic manager and staff
that you all agree to implement before the next supervisory visit.

____ Be committed to providing timely and regular feedback to your clinics.

6
Reprinted from Improving Supervision: A Team Approach with permission from Management Sciences for Health.
Please contact them for further information.
Guidelines for Implementing Supportive Supervision A-8
October 2003

Kingdom of Cambodia
Ministry of Health Nation – Religion – King
National Center for Maternal and Child Health
I. National Immunization Program

Check List for the Supervision of Immunization Program Province/Municipality/District7

Name of Supervisor :…………………………………………………………………

Province/Municipality: …………………Operational District :………………….
Date of Supervision:……../….…./…..….Date of Previous supervision : …/……/…

A- Checking Activities of Regular Immunization:

1- Is the number of providing technical assistance to immunization section equally implemented as the number planned?
* Yes / No
2- Have the result reports on immunization activities been received on time from operational district?
* Yes / No
3- Has the result report on immunization activities been appropriately calculated?
* Yes / No
4- Have the report documents about immunization activities been appropriately kept and stored?
* Yes / No
5- Has the graphic of the following up the coverage rate of the vaccination been appropriately done every month?
* Yes / No
6- Has the rate of waste between vaccine under 10% been checked?
- BCG/ Measles Yes / No
- Polio 1-3 Yes / No
- DTC-HepB 1-3 Yes / No
- Tetanus 1-2 Yes / No (pregnancy)

7- Comparison of Immunization‘s results:

Type of Vaccines Implementation Annual Plan

BCG ……..% ……..%
DTC ……..% ……..%
Polio 3 ……..% ……..%
Measles ……..% ……..%
TT2+ ……..% ……..% (Pregnancy)
TT2+ ……..% ……..% (no pregnancy)

8- Did they do the PAB? Y/N

B- Control cold chain, vaccine and immunization tools:

Name of person responsible for cold chain: ………………………………..
9- Is the fridge working and kept appropriately? Y/N
10- Are the vaccines kept appropriately? Y/N
11- Are the vaccines being kept in the cold chain have debris or freeze? Y/N
12- Are the vaccines expiry date? Y/N
13- Is there any vials unlabelled? Y/N
14- Does the color of VVM change? Y/N
15- Is there anything besides vaccine been kept in the fridge? Y/N
16- Is there any vaccine supply record and has it been filled correctly? Y/N

7
Reprinted from Monitoring and Management Support Strategy with permission from the Cambodian National
Immunisation Program, National MCH Centre, Ministry of Health. Please contact them for further information.
Guidelines for Implementing Supportive Supervision A-9
October 2003

a- Vaccine? Y/N correct/incorrect

b- Tools? Y/N correct/incorrect
c- Compare the number of vaccine in monthly report
with the inventory record within the last 3 months? correct/incorrect

Vaccine vial Vaccine Vial

BCG………..dose DTC……….dose
Polio……….dose Tetanus…….dose
Measles…….dose Hepatitis B…dose

d- The actual number of vaccine has been used within the last 3 months?

Vaccine vial Vaccine Vial

BCG………..dose DTC……….dose
Polio……….dose Tetanus…….dose
Measles…….dose Hepatitis B…dose

17- Is the transportation of central medical store appropriate on time and sufficient within the last trimester?
correct/incorrect
18- Number of receiving vaccines and tools that are dropped off within the last 6 months: ……………………….
19- How many districts that vaccines and tools reporting system from lower level are
appropriate and regular: ……………………….
20- Since the last supervision until now has the stock been ever interrupted or short:
a- vaccine? Y/N
b- Tools? Y/N

No Vaccine & Tool Amount of vaccine which Place where the Duration
which are short is short vaccine is short of short

C- Control the research of the diseases:

21- At provincial level is there any assignment to people to be in charge of follow up and
disease research? Y/N
Name of people in charge: ………………………………………
22- Since the previous supervision are monthly reports resulting from follow up and the
research of program diseases, and reactions occurring after vaccination have been sent
appropriately and on time? Y/N
23- At provincial level, does it have a table to follow up the research of
disease and it is filled appropriately? Y/N
24- Does it have a recording list for disease case at provincial level? Y/N
25- Since the previous supervision is there any case of program’s diseases
and any reactions occurred after vaccination at provincial level? Y/N
If yes, please fill it in :

Name of diseases # of village reported # case of disease # case of death

Polio
Measles
New born alive and die
before getting 28 days
Tetanus for baby
Pertussin
Reaction after vaccination

26- Does it have a map showing a research of disease

and have it filled appropriately? Y/N
27- Have provincial and district level received budget and T-shirts
Guidelines for Implementing Supportive Supervision A-10
October 2003

to support poliomyelitis measles and babies’ tetanus reporting cases Y/N

D- Good point that should be noticed:

…………………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………………
…………………………

E- Problems and causes had been observed during the time of supervision:
Problems/Constraints Actual causes Appropriate solving

Suggestion: …………………………………………………………………………………
………………………………………………………………………………………………
………………………………………………………………………………………………

Date: ……/………/……….

Name and Signature of Supervisor

Seen and approved by

Program Manager……………..
Chief………………
Guidelines for Implementing Supportive Supervision A-11
October 2003

Kingdom of Cambodia
Ministry of Health Nation – Religion – King
National Center for Maternal and Child Health
II. National Immunization Program

Supervisor Check list for Immunization Program at Health Center level8

Name of Supervisor :…………………………………………………………………

Province/Municipality: …………………Operational District :………………….
Health Center : ………........................... Date of Supervision:……../….…./…..….
Date of Previous supervision : …/……/……
General situation :
# of staff :………… Villages covered: ………… Total population:…………
Target children<1year………………..

III. I Questioning to Health Staff and Reports Checking

1- Is the number of immunization days implemented equal with the number planned? * Yes / No
2- Has the graphic of the following up the coverage rate of the vaccination been
appropriately done every month? * Yes / No
3- Has the rate of wastage between vaccine under 10% been checked?
- BCG/vaccine for Measles Yes / No
- Polio 1-3 Yes / No
- DTC-HepB 1-3 Yes / No
- Tetanus 1-2 Yes / No (pregnancy)
4- Comparison of the immunization ‘s results:

Type of vaccine Implementation Annual Plann

BCG ……..% ……..%
DTC 3 ……..% ……..%
Polio 3 ……..% ……..%
Measles ……..% ……..%
TT2+ ……..% ……..% (Pregnancy)
TT2+ ……..% ……..% (no pregnancy)

5- Check the immunization’s result in the reports and count the number in the immunization log sheet in the previous
month:

Type of vaccine In the reports In the immunization Correction

log sheet
BCG Yes / No
Measles Yes / No
DTC3 Yes / No
TT2+(pregnant women) Yes / No

6- Are there any appropriate refrigerator or glaciere to keep the vaccines? * Yes / No
7- Has the graphic of monitoring the cold chain “refrigerator or glaciere ” been correctly and regularly drawn every
month?
* Yes / No

8
Reprinted from Monitoring and Management Support Strategy with permission from the Cambodian National
Immunisation Program, National MCH Centre, Ministry of Health. Please contact them for further information.
Guidelines for Implementing Supportive Supervision A-12
October 2003

8- Are there vaccines expiry date?

* Yes / No
9- Are there any vials unlabelled?
* Yes / No
10- Does the color of VVM change?
* Yes / No
11- Is there anything besides vaccine being kept in the refrigerator?
* Yes / No
12- Are there any stock record and filled correctly? * Yes / No
a- Vaccine? *Yes / No Correct / Incorrect
b-Have the vaccines ever finished in the stock since the previous monitoring ?
( running out of the vaccine in the refrigerator over one day) * Yes / No
c- Tools? *Yes / No Correct / Incorrect
13- Have the cases of program’s diseases and allergies occurred after vaccination since the previous supervision at district
level?
* Yes / No
If yes, please fill in the table below :

Name of diseases Number of village reported # case of disease

Polio
Measles
Baby die before 28 days after
delivery
Tetanus of baby
Pertussin
Allergy after vaccination

14- Activities panning for providing vitamin A:

- Have the children at the age of 6 months to 5 years been provided as scheduled? Yes / No
(……..%)
- Have the women who breastfeed ( at the age of the first 2 months) been provided? * Yes / No
(……..%)
15- Are there any activities of providing Mebendazol? * Yes / No
16- Have you received budget for immunization activities since the previous monitoring? * Yes / No
17- Are there any “golden books“ ? Have the supervisors write on it during monitoring? * Yes / No

II Observation Immunization officers’ activities during immunizing

(Name of controlled place ………………)
18- Are the immunization days done regular every month? * Yes / No
19- Do the places, used for vaccination have the large shade? * Yes / No
20- Have the record forms been correctly filled during immunization day * Yes / No
21- Are the vaccine in its vial freezed before being destroyed? * Yes / No
22- Is there enough quantity of ice in the vaccine container? * Yes / No
23- Are the vaccines appropriately packed? * Yes / No
24- Are the vaccines, which are not expiry yet, used? * Yes / No
25- Are there any vaccines’ vials unlabelled * Yes / No
26- Is the vaccine appropriately mixed? * Yes / No
27-Have women and children been appropriately selected for immunization? * Yes / No
28- Do they appropriately sterilize a syringe and a needle for immunization a woman or a child? * Yes / No
29- Do they provide subcutaneous injection of BCG vaccine on the left shoulder ? *Yes / No
30- Do they provide intramuscularly injection of DTC vaccine on the right shoulder ? * Yes / No
31- Do they provide subcutaneous injection of measles vaccine on the thigh? * Yes / No
32- Do they provide vitamin A into children’s mouth by pining and pressing the capsule? * Yes / No
33- Do they provide mebandazol by inserting tablet into children’s mouth? * Yes / No
34- Do they provide vitamin A to women who breastfeed (the first two months) * Yes / No
Guidelines for Implementing Supportive Supervision A-13
October 2003

35- Did health staff tell mother and child about the date of the next vaccination? * Yes / No
36- Is the date of immunization day at the community appropriate? * Yes / No
37- Did you ask any information or research on program’s diseases during immunization day? * Yes / No
38- Do the commune leaders or volunteers help immunization activities? * Yes / No
39- Asking women about their awareness on immunization activities:

a- Asking for immunization card and check it to find out whether they have been appropriately vaccinated
today as mentioned in the calendar for woman and children? - Correct / Incorrect
b- aasas
Question for women: When do you and your child have to come for the next vaccination?( compare the
answer with the immunization card, if it is not correct as recorded, please tick the “incorrect”.
Question A Question B
First woman correct/incorrect correct/incorrect
Second woman correct/incorrect correct/incorrect
Third woman correct/incorrect correct/incorrect

Ask women’s opinion for improving immunization program:

…………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………
…………………………………

III- Key points that should be noticed:

…………………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………

IV- Problems and causes, which have observed during the monitoring

Problems/Constraints Actual causes Appropriate solving

Community suggestion: ……………………………………………………………………

………………………………………………………………………………………………
………………………………………………………………………………………………

Date: ……/………/……….

Health Center Chief Chief of Immunization section Name and Signature

at Health Center of Supervisor
Guidelines for Implementing Supportive Supervision B-1
October 2003

Annex B. Sample supervision budget

This is a sample tool for planning and calculating the cost of supervision visits. Distances, per diem
rates, and fuel and maintenance costs are normally found in district/regional microplans or in
national/district budgets.

Table A: Transportation costs per supervision visit

A B C D E F G
Total
Transportation Number of
Cost of transportation
Total Maintenance cost of supervision
District fuel per costs per year
kms per km supervision visit visits per
km =ExF
= (C+D) x A year
District 1 4,460 49 CFA 60 CFA 486,140 CFA 3 1,458,420 CFA
District 2 4,200 49 CFA 60 CFA 457,800 CFA 4 1,831,200 CFA
District 3 22,512 49 CFA 60 CFA 2,453,808 CFA 3 7,361,424 CFA
District 4 4,200 49 CFA 60 CFA 457,800 CFA 3 1,373,400 CFA
District 5 4,620 49 CFA 60 CFA 503,580 CFA 4 2,014,320 CFA

Table B: Per diem costs per supervision visit

A B C D E F
Number of Number of Number of Total per diem costs
Per diem
District per diem supervisors supervisors per year
rate
days per visit per visit visits per year =BxCxDxE
District 1 5000 CFA 2 1 3 30,000 CFA
District 2 5000 CFA 2 1 4 40,000 CFA
District 3 5000 CFA 4 2 3 120,000 CFA
District 4 5000 CFA 2 1 3 30,000 CFA
District 5 5000 CFA 2 2 4 80,000 CFA

Table C: Total supervision costs per year

A B C D
Total transportation cost Total per diem costs Total supervision cost
District per year per year per year
(Table A, column G) (Table B, column F) = B+C
District 1 1,458,420 CFA 30,000 CFA 1,488,420 CFA
District 2 1,831,200 CFA 40,000 CFA 1,871,200 CFA
District 3 7,361,424 CFA 120,000 CFA 7,481,424 CFA
District 4 1,373,400 CFA 30,000 CFA 1,403,400 CFA
District 5 2,014,320 CFA 80,000 CFA 2,094,320 CFA
Guidelines for Implementing Supportive Supervision C-1
October 2003

Annex C. Supervisory roles assigned to each level of the national

health system9
National level
The national EPI manager is responsible for the following supervisory roles:
o Definition of quality standards and norms as well as development of technical
guidelines for the implementation of EPI policies.
o Dissemination of these policies and guidelines to reach to sub-national level for
implementation (provinces, regions, districts, etc.)
o Training of staff on the policy and policy implementation guidelines to facilitate
proper application of standards and norms.
o Development of a supervisory checklist for central and sub-national level supervisors
to ensure uniformity of policy interpretation and its correct application throughout
the country.
o Development of a supervision plan and schedule to undertake supervision visits.
o Giving feedback on the results of supervision individually and through supervisory
reports, bulletins/newsletters or circular letters.
The role of the national EPI manager, therefore, consists of ensuring that national standards
relating to EPI are observed at all levels.

Sub-national levels (regional, provincial, and district)

The role of the sub-national EPI manager is to assist health workers at field level to provide
quality services. Health workers at this level encounter many problems, particularly when
they are posted to remote locations, where they often operate on their own. They need help in
planning their work, technical advice, in-service training, support in handling grievances,
disciplinary problems, good leadership and motivation.
The supervision at this level therefore entails:
o Making sure that the objectives at lower levels are consistent with the national
objectives.
o Determining what is being done well and encouraging staff to continue good work.
o Observing immunization procedures at immunization sites to see if the target
population is vaccinated according to EPI guidelines.
o Helping staff identify and solve problems using in-service training approach.
o Giving feedback in person or through letters and records in the special supervision
record books.

9
Reprinted from Module 21: Supervision for EPI Managers with permission from WHO African Regional Office, Mid-
Level Management Course for EPI Managers. Please contact them for further information
Guidelines for Implementing Supportive Supervision D-1
October 2003

Annex D. Suggested service delivery workplans10

The following workplans can be used to plan activities and monitor progress.

Once a supervisor has worked with health center staff to identify problems, they can use the
following work plan to organize and prioritize implementation.

Activity Person(s) Proposed Goal Next Evaluation

Responsible
1) •

2) •

3) •

Example:

Activity Person(s) Proposed Goal Next Evaluation

Responsible
1) Visit community • Doctor • Appropriate days for May 15, 2001
leaders to discuss best • Vaccinator immunization
immunization calendar sessions identified

2) Train health staff on • District Management • All health staff will July 30, 2001
national immunization Team be knowledgeable on
schedule and these topics
contraindications on
immunization

3) Check vaccination • Pediatric Nurse • All children with May 20, 2001
cards and/or clinical • Auxiliary nurse incomplete
histories of any child <5 • Vaccinator vaccination status
years of age visiting the will have a mark
health facility (for any “needs vaccination”
reason) on the record
• All eligible children
are immunized
4) Staff training on inter- • District management • All staff to have July 30, 2001
personal communications team friendly and helpful
attitude

10
Reprinted from Making existing immunization services more efficient: Increasing immunization coverage by reducing
by reducing drop-out rates with permission from WHO-UNICEF. Please contact them for further information.
Guidelines for Implementing Supportive Supervision D-2
October 2003

Suggested format for follow-up activity implementation

Activity Person(s) % Complete Obstacles to Solutions

Responsible Completion
Guidelines for Implementing Supportive Supervision E-1
October 2003

Annex E. Sample observation worksheet11

This is a problem analysis exercise/worksheet. It lists the observation, what are the possible or
likely causes of the problem/issue; who should initiate action; and possible/recommended
solutions.

Some observations from a visit to ………, District…………, (date)

1. Not clear what mechanism for tracking/fetching leftout/dropout.

2. No Male public health worker involved on health side - possibilities?

3. No BCG since 10 April (6 weeks)

Vit A not at session

4. Nurse-midwife register is session wise, cannot track individual women/children easily

5. Plenty of immunization cards with nurse-midwife and those attending for second time had cards.
Counterfoils had been taken off by nurse-midwife but not clear what use she had made of them;

6. Sterilization - insufficient needles/syringes (reusing); needle left in vial; no reconstitution (mixing)

syringes; no rack in sterilizer – nurse-midwife said had left to TBA to do sterilization as she had to go to get
vaccines at short notice

11
Courtesy of Alasdair Wylie, Immunization Consultant
Guidelines for Implementing Supportive Supervision F-1
October 2003

Annex F. Skills matrix for monitoring and management support for

provinces and districts12

KNOWLEDGE & SKILL

COMPETENCY LEVEL OF
TEAM KNOWLEDGE SKILLS
TASKS TEAM MEMBERS FOR
ROLES REQUIRED FOR TASK
EACH TASK
High / Medium / Low
Team Leader Lead the team Team leadership
Problem solve Problem solving
Advise PHD and OD on Knowledge of health sector
solutions and EPI planning
Monitor and Health Plan and Report writing
CIP Knowledge of MOH finance
Monitor status of outreach system
funding
Monitor NGO activity

Health Assess current coverage Data analysis

Information / Follow up target disease Data reporting
Surveillance reporting Problem solving
Recommend strategies for Disease outbreak response
improved coverage Report writing
Responding to reported
disease outbreak

Logistics/ Monitor cold chain and report Immunization safety

Cold Chain problems Vaccine management
Monitor vaccine stocks Cold chain principles
Monitor injection safety

HRD / IEC Conduct training needs How to conduct TNA

assessment How to conduct training
Conduct training follow up Follow up
Assess human resource How to plan human resources
requirements for for immunization
immunization Knowledge of AEFI
Report on AEFI How to respond to AEFI
Monitor impact of IEC
materials

12
Reprinted from Monitoring and Management Support Strategy with permission from the Cambodian National
Immunisation Program, National MCH Centre, Ministry of Health. Please contact them for further information.
Guidelines for Implementing Supportive Supervision G-1
October 2003

Annex G. Sample drop-out rate monitoring chart13

13
Courtesy of Uganda Expanded Programme on Immunization (UNEPI) and Dr. Robert Steinglass
 Guidelines for Implementing Supportive Supervision G-2
October 2003

Drop Out Rate Monitoring Chart, 200_.

Sub Health District: _______________
Health Facility: ___________________ District: ________

Month
J F M A M J J A S O N D
DPT 1 A. Month
B. Cumulative
DPT 3 C. Month
D. Cumulative
E. Cumulative Drop Out
DPT 1 - DPT 3 (B - D)
F. Cumulative Drop Out Rate %
60%
G. Bar Chart 55%
50%
45%
40%
35%
30%
25%
20%
15%
Good Performance 10%
Drop Out Rate 5%
10% or less 0%
- 5%
-10%
-15%
-20%
-30%
J F M A M J J A S O N D

INSTRUCTIONS: A. Enter the monthly total of DPT1 immunisations given to children below the age of one year.
B. Enter the cumulative total of DPT1 immunisations given. Cumulative includes the current monthly total plus
the monthly totals for all of the previous months during the year.
C. Enter the monthly total of DPT3 immunisations given to children below the age of one year.
D. Enter the cumulative total of DPT3 immunisations given.
E. Subtract the cumulative total for DPT1 from the cumulative total for DPT3. This is the cumulative total
number of drop outs for DPT1 to DPT3 for the year.
F. Calculate the Cumulative Drop Out Rate as follows:

DPT1 Cumulative Total - DPT3 Cumulative Total x 100

DPT1 Cumulative Total

G. Chart the Cumulative Drop Out Rate by shading in the area up to the drop out rate on the chart.

PLACE THIS CHART WHERE IT CAN BE SEEN BY YOUR STAFF, EVERY DAY ! 04/02
Guidelines for Implementing Supportive Supervision H-1
October 2003

Annex H. GAVI core immunization program indicators14

The following are some of the indicators identified by the GAVI Implementation Task Force in
their publication “Monitoring national immunization systems using core indicators”
(www.vaccinealliance.org). For the GAVI alliance partners monitoring purposes, the time period
for all indicators is one calendar year. Supervision should monitor and interpret district or
subdistrict indicators on a more frequent basis. We encourage you to adapt these indicators
according to your national, district, or sub-district context needs.

OPERATIONS

Service delivery

Proportion of districts in the country with >/= 80% DPT3 coverage among infants

Sub-function (area): coverage For example:

Comment: Key measurements of system • The country indicator (s) could be
performance and output. Major indicator “proportion of districts in each quintile”
corresponding to GAVI milestone: ‘by 2005, 80 • The country would then only report on
percent of developing countries will have routine one of the indicators “the proportion of
immunization coverage of at least 80 percent in all districts in the 80-100% quintile
districts. In the equity perspective, it allows
identification of a high priority geographic area.

Proportion of districts in the country with >/= 90% measles coverage among infants

Sub-function (area): coverage

Comment: Major indicator towards achieving reduction of measles mortality goal; also
emphasized under GAVI’s objective to support the national and international accelerated
disease control targets

Proportion of districts in the country with dropout rate (DTP1 to DTP3) of less than
10%.

Sub-function (area): utilization

Comment: A major indicator for the utilisation of existing services. Compares the number of
infants that started to receive immunizations with those who did not receive the last of
vaccines. May reflect problems of supply, staffing, quality of service delivery and demand.

Proportion of districts in the country that have been supplied with adequate (equal or
more) number of AD syringes for all routine immunizations during the year

Sub-function (area): injection safety

14
Reprinted from Monitoring national immunization systems using core indicators with permission from the GAVI
Implementation Task Force. Please contact them for further information.
Guidelines for Implementing Supportive Supervision H-2
October 2003

Comment: reflects the adoption of auto-disable (AD) syringes policy (and the progress
toward the adoption of the WHO – UNICEF – UNFPA joint statement) and the adequacy of
supply management (procurement and distribution of appropriate related equipment).
Particularly important to monitor as the Vaccine Fund decided to provide the injection safety
supplies for all infant immunizations.

Logistics and cold chain

National level wastage rates of DTP and new vaccines (Hepatitis B and Hib).

Sub-function (area): vaccine management

Comment: critical indicator regarding GAVI requirements for new vaccines. Interpretation
will need to be done according to the various factors influencing vaccine wastage: vial size in
use, open vial policy adoption, etc. The calculation of national wastage needs to be well
documented.

The vaccine wastage rate (%) = 100 – vaccine usage rate

Where the vaccine usage rate (%) =

No. doses used for immunization / {(number of vials opened for use + number of closed vials
discarded) * number of doses per vial}

Vaccine supply & quality

Proportion of districts in the country that had no interruption in vaccine supply during
the year

Sub-function (area): vaccine supply

Comment: definition of interruption in vaccine supply = district vaccine store has no
remaining doses of any one EPI vaccine, for any period of time. The above is a reflection of
vaccine management, vaccine storage and handling.

Surveillance and monitoring

Proportion of districts disease surveillance reports received at national level compared

to number of reports expected

Sub-function (area): reporting system

Comment: Evaluates the completeness of reporting, however, it does not assess whether the
reports are representative or well presented. This is crucial to evaluate the reporting system
information. The district disease surveillance report definition is the monthly or quarterly
report that should mention all vaccine preventable diseases. This is not disease specific.
Guidelines for Implementing Supportive Supervision H-3
October 2003

Proportion of districts coverage reports received at national level compared to number

of reports expected

Sub-function (area): reporting system

Comment: Evaluates the completeness of reporting, however it does not assess neither the
quality of the reports themselves nor their representativeness (of delivery facilities). This is
crucial to evaluate reporting system information.

Advocacy and communication

Existence of an advocacy and communications strategic plan (annual) with identified

focal point and annual budget

Sub-function (area): political commitment

Comment: Reviews a country’s proposed advocacy and communications activities but does
not give an indication of the quality of activities carried out. The level of resources allocated
gives an indication of commitment by the government.

FINANCIAL SUSTAINABILITY

Government financed recurrent program-specific immunization spending in

the past year per million US dollars of total government spending

Sub-function (area): financial sustainability

Comment: Shows the financial effort made from national sources for immunization.
Spending means actual expenditures, not budgeted or planned amounts.
Government financed includes direct Government spending and the expenditure of loan
funds. It excludes any external public financing, i.e. any support from the Vaccine Fund
(GAVI) or any grants from bilateral (DFID, JICA….) or multilateral (UNICEF, WHO…)
agencies provided to national government for immunization services.
Recurrent program-specific spending includes all recurrent spending on items such as
vaccines and supplies; wages and benefits for those personnel working exclusively on the
immunization program; and fuel, maintenance and per diem associated with immunization-
specific activities. It excludes spending on capital items (e.g. vehicles, cold chain equipment,
buildings) and all ‘shared’ personnel and other inputs (e.g. health workers who perform
immunization along with other service delivery and wages, per diem, and fuel for supervisors
who oversee immunizations along with other service delivery and health promotion
activities).

The denominator will be obtained separately from recognized international sources.

Guidelines for Implementing Supportive Supervision H-4
October 2003

STRENGTHENING HUMAN AND INSTITUTIONAL RESOURCES

Proportion of districts that have had at least one supervisory visit of all health facilities
in last calendar year
For example:
Sub-function (area): supervision • The country indicator (s) could be
Comment: Extremely useful for capacity building. “proportion of districts that have had 4,
Although once a year appears as a minimum 3, 2, 1, or 0 supervisory visits in the last
requirement for supervision, logistical field calendar year”
difficulties make the target (all health facilities • The country would report only one part
once a year) challenging. The supervisory visit of the indicators: all districts minus those
may not necessarily be specific to immunization in the 0 group.
but should include the supervision of immunization
activities.

MANAGEMENT DEVELOPMENT

Proportion of districts with microplans that include immunization activities

Sub-function (area): strategic planning

Comment. Does not give any information on the quality of the plan or to what extent
activities have been implemented. Reference guidelines: "Increasing immunization coverage
at health facility level" module.

Other relevant key indicators to measure progress towards global immunization goals15

Immunization policy
Proportion of countries with measles 2nd dose opportunity.
Proportion of countries combining delivery of vitamin A with immunization.
Proportion of countries with substantial disease (Hib) burden having introduced Hib with
routine.
Proportion of countries having introduced Hepatitis B.

Process indicators
Proportion of countries providing written feedback on immunization to district level at least
every quarter.
Proportion of countries with 3-5 year strategic plan for the national immunization system.
Proportion of countries with national annual work plan for immunization services.
Proportion of countries with injection safety as a component to the national workplan.

15
Not exhaustive list. These key indicators are the ones presented in the advocacy set by the partners of the alliance
Guidelines for Implementing Supportive Supervision H-5
October 2003

Output indicators
Proportion of countries with HepB3 coverage > 80% .

Outcome indicators
Proportion of countries certified polio-free.
Proportion of countries with MNT elimination status
number of districts as being of high risk for MNT (% of districts with <1 NT case per 1000
live births).
Guidelines for Implementing Supportive Supervision I-1
October 2003

Annex I. Summary health management Field Report16

Province_____________________ District____________________
Date________________________

HEALTH INFORMATION

Coverage
What are the existing coverage rates for DPT3?

Are they increasing, or decreasing compared with the same quarter last year?

Cause of change in coverage:

Action taken in the Province/District:

Follow up action required

Reported Diseases (Disease Surveillance)

What target diseases were reported in the last quarter?

Has there been a recorded disease outbreak in the last quarter?

Action taken in the Province/District:

Follow up action required

16
Reprinted from Monitoring and Management Support Strategy with permission from the Cambodian National
Immunisation Program, National MCH Centre, Ministry of Health.
Guidelines for Implementing Supportive Supervision I-2
October 2003

PLANNING & EVALUATION

Health Sector Plan & Coverage Improvement Plan

Are activities being implemented according to plan in the last quarter?

What are major problems with implementation?

Causes:

Action taken in the Province/District:

Follow up action required

Supervision, Post Activity Assessment, Data Quality Audit

Is supervision conducted on a regular basis?

Has post activity assessment been undertaken in the last quarter?

Result?

Have any major problems been identified during supervision?

What was the action taken in the Province/District/Health Center?

Follow up action required

Guidelines for Implementing Supportive Supervision I-3
October 2003

HEALTH FINANCING

What is the funding source for the PHD / OD?

Are finances being disbursed according to budget in the last quarter?

What are the Problems with financial disbursement?

What are the Causes of poor financial disbursement?

Indicators –
% Funds dispersed to province in the current year
% Funds dispersed to District in the current year
% Budgeted funds dispersed to health centers in the current year

Action taken in the Province/District/HC

Follow up action required

SERVICE DELIVERY & QUALITY IMPROVEMENT

Priority problems –

Cold Chain…………………………………………………………………….
Vaccines……………………………………………………………………….
Equipment……………………………………………………………………..
Transport………………………………………………………………………
Immunization safety…………………………………………………………..

Causes

Action taken in the Province/District

Follow up action required

Guidelines for Implementing Supportive Supervision I-4
October 2003

BEHAVIOUR CHANGE & HUMAN RESOURCE DEVELOPMENT

Any adverse events following immunization reported in last quarter?

Are there current weaknesses or strengths in IEC activity?

What is the level of support from local authorities for immunization?

Are sufficient health education materials available at PHD / OD / HC

Action taken in the Province/District/HC

Follow up action required

Training conducted in last quarter:

Training needs identified by managers:

Training follow-up conducted:

% of health centers with adequately trained staff:

Follow up action required

Report Written: Report Reviewed by: Report Reviewed by

TEAM LEADER REGIONAL MANAGER NIP MANAGER

Date:

Cc :

Provincial Health Director

Provincial EPI Manager
Guidelines for Implementing Supportive Supervision J-1
October 2003

Annex J. Web sites

Management Sciences for Health – The Managers Electronic Resource Center

For information on supportive supervision and many other managerial issues
www.erc.msh.org

EngenderHealth
For information on Quality Improvement and COPE®
www.engenderhealth.org

Immunization Training Partnership

For information and materials related to global immunization training activities.
www.who.int/vaccines-diseases/epitraining

PRIME II
For training and supervision resources
www.prime2.org/prime2/section/60.html

Children’s Vaccine Program at PATH

For training and immunization resources
www.childrensvaccine.org
Guidelines for Implementing Supportive Supervision
October 2003

References
Bradley, J. et al., COPE® for Child Health in Kenya and Guinea: An Analysis of Service Quality,
EngenderHealth, New York, 2002.

Dohlie, MB. et al., “Empowering Frontline Staff to Improve the Quality of Family Planning
Services: A Case Study in Tanzania”, Responding to Cairo, Case Studies of Changing Practice in
Reproductive Health and Family Planning, Population Council, New York, 2002.

Dohlie, M., Supportive Supervision, PRIME Pages, February 2002.

EngenderHealth, Facilitative Supervision Handbook, New York, 2001.

EngenderHealth, Improving Provider Performance: Results from Guinea and Kenya, 2002.

GAVI Implementation Task Force, Monitoring National Immunization Systems Using Core
Indicators, November 2002.

Government of India, Child Health Division, Department of Family Welfare, Ministry of Health
& Family Welfare, Introduction of Hepatitis B Vaccine in the Universal Immunization
Programme: A Handbook for Programme Managers & Medical Officers, 2002.

Kim, Y.M. et al., The Quality of Supervisor-provider Interactions in Zimbabwe, Operations

Research Results 1(5), USAID Quality Assurance Project, Bethesda, Maryland, 2000.

Kiran, V., Supervision and Monitoring in AP Immunization Strengthening Program, draft,

November 2002.

Management Sciences for Health, Improving Supervision: A Team Approach, The Manager’s
Electronic Resource Center. Available online at www.erc.msh.org.

Management Sciences for Health, Lessons from the Field: Performance Improvement Case Study
– ASHONPLAFA. Available online at www.pihealthcare.org.

Management Sciences for Health, Supervising and Supporting Your Staff, The Manager’s
Electronic Resource Center. Available online at www.erc.msh.org.

Marquez, L. and L. Kean, Making Supervision Supportive and Sustainable: New Approaches to
Old Problems, Maximizing Access and Quality Initiative, MAQ Paper No. 4, USAID,
Washington, DC, 2002. Available online at www.maqweb.org/maqdoc/MAQno4final.pdf

McMahon, R. et al., On Being in Charge: A Guide to Management in Primary Health Care,

World Health Organization, Geneva, 1992.

Mutabaruka, E. et al., Integrated Training and Supportive Supervision: A Challenge to Improved

Quality of Health Services in Countries, 2002.
Guidelines for Implementing Supportive Supervision
October 2003

Mutombo M., Supervision du PEV (Presentation), November 2002.

National Immunisation Program, National MCH Centre, Ministry of Health, Cambodia,

Monitoring and Management Support Strategy, Immunisation Coverage Improvement,
Cambodia, June 2003.

PRIME II, Stages, Steps and Tools: A Practical Guide to Facilitate Improved Performance of
Healthcare Providers Worldwide, 2003.

PRIME II, Transfer of Learning: A Guide to Strengthening the Performance of Health Care
Workers, 2003.

Salem, B. et al., Facilitative Supervision: A Vital Link in Quality Reproductive Health Service
Delivery, AVSC Working Paper No. 10, August 1996.

World Health Organization (WHO), Immunization in Practice (unpublished draft 4), March
2003.

WHO, Module 21: Supervision for EPI Managers, Mid-Level Management Course for EPI
Managers, Preliminary version, WHO African Regional Office, March 2003.

WHO, Supervision: An Under-utilized Management Tool to Identify Risk Areas, EPI Newsletter
– Expanded Program on Immunization in the Americas, Volume XXIV, Number 5, October
2002.

WHO, Supportive Supervision (Presentation), Meeting of the GAVI Implementation Task Force
on Supportive Supervision, Geneva, October 15-17, 2002.

WHO-UNICEF, Making Existing Immunization Services More Efficient: Increasing

Immunization Coverage by Reducing Drop-out Rates, 2003.

World Bank, “Designing an ECD Program – Planning and Evaluation – Supervision”, Early
Childhood Development Program Guide (in progress), Available online at
http://www.worldbank.org/children/programdesign/supervision2.html