Supervision to improve the quality of primary health care in low- and middle-income countries

Researchers in the Cochrane Collaboration conducted a review of the impact of supervising healthcare workers on the quality of primary health care in low- and middle-income countries. After searching for all relevant studies, they found nine studies. Their findings are summarised below.

Health worker supervision

Supervision from higher levels of the health system, such as district headquarters, to the local level is widely recommended. Supervision is seen as a way of supporting often isolated primary health care workers and ensuring the quality of the health services they provide. However, supervisory visits need certain logistics including time and transport, and can be relatively costly.

The studies in this review took place in nine countries in Africa, Asia and Latin America, in both rural and urban areas. Most of the studies looked at the supervision of health care professionals (including nurses, midwives, health officers and physicians), while two studies examined the effect of supervision on community or lay health workers. The number of supervisory visits generally varied from one to six over a period of up to nine months.

What happens when health workers are supervised?

The evidence was of low to very low quality and the studies showed mixed results. Compared to no supervision, some studies showed that supervision had a small benefit on health worker practices and knowledge, while other studies showed no benefit or were inconclusive. We are therefore uncertain about the effects of supervision on the quality of primary healthcare services.

 A summary of this review for policy-makers is available here

Authors' conclusions: 

It is uncertain whether supervision has a substantive, positive effect on the quality of primary health care in low- and middle-income countries. The long term effectiveness of supervision is unknown.

Read the full abstract...

Primary healthcare (PHC) workers often work alone or in isolation. Healthcare managerial supervision is recommended to help assure quality; but this requires skilled supervisors and takes time and resources. It is therefore important to assess to what extent supervision is beneficial and the ways in which it can be implemented.


To review the effects of managerial supervision of health workers to improve the quality of PHC (such as adherence to guidance or coverage of services) in low- and middle-income countries.

Search strategy: 

We searched The Cochrane Central Register of Controlled Trials (CENTRAL) 2011, Issue 1, part of The Cochrane Library., including the Cochrane Effective Practice and Organisation of Care (EPOC) Group Specialised Register (searched 10 March 2011); MEDLINE, Ovid 1950 to March Week 1 2011 (searched 08 March 2011); EMBASE, Ovid 1980 to 2011 Week 12 (searched 08 March 2011); CINAHL, Ebsco 1981 – present (searched 10 March 2011); LILACS, VHL (searched 10 March 2011).

Selection criteria: 

Randomised controlled trials, controlled before-and-after studies, and interrupted time series studies, conducted in PHC in low- and middle-income countries. Supervision includes site visits from a central level of the health system, plus at least one supervisory activity. We excluded studies aimed solely at improving the clinical skills of PHC workers.

Data collection and analysis: 

We extracted data using a predefined form and assessed for risk of bias using the EPOC risk of bias criteria. Data are presented in a narrative way without pooling the effects on the outcomes as studies and outcomes were diverse.

Main results: 

Nine studies met the inclusion criteria: three compared supervision with no supervision, five compared enhanced supervision with routine supervision, and one study compared less intensive supervision with routine supervision. Most outcomes were scores relating to providers’ practice, knowledge and provider or user satisfaction. The majority of the outcomes were measured within nine months after the interventions were introduced. In two studies comparing supervision with no supervision, small benefits on provider practice and knowledge were found. For methods of enhancing supervision, we identified five studies, and two studies of frequent supportive supervision demonstrated small benefits on workers performance. The one study examining the impact of less intensive supervision found no evidence that reducing the frequency of visits had any effect on the utilisation of services. The GRADE evidence quality for all comparisons and outcomes was "low" or "very low".