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Consultation on Supportive 

Supervision to Strengthen Capacities 

of Frontline Workers and 

Service Providers 

22-23 November, 2012, New Delhi 

Organised by 

UNICEF in Collaboration with the Ministry of Health & Family 

Welfare and Ministry of Women & Child Development 

Consultation on Supportive Supervision to Strengthen 

Capacity of Frontline Workers and Service Providers 

i

Consultation on Supportive 

Supervision to Strengthen Capacities 

of Frontline Workers and 

Service Providers 

22-23 November, 2012, New Delhi 

Organised by 

UNICEF in Collaboration with the Ministry of Health & Family 

Welfare and Ministry of Women & Child Development

Acknowledgments 

UNICEF is grateful to the Ministries of Health and Family Welfare (MoHFW) and Women 

and Child Development (MoWCD) for their guidance and support in organising a 

Consultation on Supportive Supervision to Strengthen Capacities of Frontline Workers. 

The two-day consultation was held in New Delhi on November 22-23, 2012. A special 

word of thanks to Dr. Rakesh Kumar, Joint Secretary, MoHFW, Dr. Shreeranjan, 

Joint Secretary, MoWCD, Dr. Ajay Khera, Deputy Commissioner (Child Health 

and Immunization), MoHFW and Dr. Henri Van Den Hombergh, (UNICEF) for their 

keen guidance and inputs in the conceptualisation and processes leading up to the 

consultation and discussions. 

This report captures the proceedings of the two-day event with suggested 

recommendations and roadmap. The consultation concept, design and report were 

put together by Dr. Pavitra Mohan, Health Specialist, UNICEF and Ms. Geeta Sharma, 

C4D Specialist, UNICEF, with support from Ms. Taru Bahl, consultant. 



3

List of Abbreviations 

ALMSC : Anganwadi Learning Monitoring and Support Committee 

ANM : Auxiliary Nurse Midwife 

ASHA : Accredited Social Health Activist 

AWW : Anganwadi Worker 

AWC : Anganwadi Centre 

CBO : Community Based Organisation 

CDPO : Child Developmentq Project Officer 

CMO : Chief Medical Officer 

DTC : District Training Centre 

GAVI : The Global Alliance for Vaccines and Immunization 

GoI : Government of India 

HBNC : Home Based New Born Care 

HR : Human Resource 

ICDS : Integrated Child Development Scheme 

ICT : Information, Communication, Technology 

IMNCI : Integrated Management of Neonatal and Childhood Illness 

INHP : Integrated Nutrition and Health Project 

MCH : Maternal and Child Health 

MDG : Millennium Development Goals 

MO : Medical Officer 

MoHFW : Ministry of Health & Family Welfare 

MoIC : Medical Officer in-Charge 

NGO : Non Governmental Organisation 

NIPCCD : National Institute of Public Cooperation and Child Development 

NRHM : National Rural Health Mission 

PHC : Primary Health Centre 

PIP : Programme Implementation Plan 

RAPID : Regular Appraisal of Programme Implementation in District 

RCH : Reproductive and Child Health 

RED : Reach Every District 

4 


Capacity of Frontline Workers and Service Providers

RI : Routine Immunization 

SHRC : Systems State Health Resource Centre 

SBA : Skill Birth Attendants 

SCNU : Special Care Newborn Unit 

SRC : State Resource Centre 

SSA : Sarva Shiksha Abhiyaan 

SS : Supportive Supervision 

TNNP : Tamil Nadu Nutrition Project 

ToT : Training of Trainer 

UIP : Universal Immunization Programme 

VHND : Village Health and Nutrition Day 

VHSNC : Village Health, Sanitation and Nutrition Committee 

WCD : Women and Child Development 



5

CONTENTS 

Acknowledgments 3 

List of Abbreviations 4 

Introduction & Background 9 

Proceedings of the Consultation 13 

Recommendations 52 

Annexure 1: Programme Agenda 56 

Annexure 2: List of Participants 58 

Annexure 3: Concept Note 

Workshop on Supportive Supervision 60

Introduction & Background 

Defining Supportive Supervision: Voices from the Consultation 

“Supportive Supervision is a process of guiding, helping and encouraging 

providers to improve their work continuously and to provide better quality 

of services by practicing minimum standards of performance.” 

“Supportive supervision is an attitude first and a process second. 

It is the creation of an environment that allows providers to develop 

professionally.” 

“It is not a one-time event, but a connected series of events, over a period 

of time.” 

Vistaar Project 

“Supportive Supervision is the regular and dependable interaction between 

a worker and more experienced professional, designed to identify and solve 

problems, improve services and advance skills and knowledge through mutual 

collaboration.” 

“Supportive Supervision enhances performance and assures integration 

of the primary healthcare (PHC) system to more efficiently and equitably 

promote improved health using positive reinforcement, objective 

measurable actions and goals to achieve PHC objectives.” 

Dr. Jon Rohde 



9

In a country as geographically and culturally diverse as India, frontline workers act as 

important and sometimes last mile delivery points of services to people. The auxiliary 

nurse midwife (ANM), accredited social health activist (ASHA) and anganwadi worker 

(AWW) along with a range of community volunteers, reach out directly to families as 

part of government implementation mechanisms providing advice, referrals, linkages, 

diagnosis and information. 

Various monitoring and evaluation tools have been formulated under the National 

Rural Health Mission and other government programmes to strengthen hands of these 

community volunteers. The need for Supportive Supervision has been felt in recent 

times, given the increasing workload and expectations which this cadre is faced with. 

As a process, it promotes quality at all levels of the health system by strengthening 

relationships within the system, focusing on identification and resolution of problems, 

optimising allocation of resources, promoting high standards, team work and better twoway 

communication (Marquez and Kean 2002). While many approaches have been 

proposed to improve quality of health services (quality assurance, continuous quality 

improvement, client-centered services, district team problem-solving, fully functional 

service delivery points), the Supportive Supervision approach improves services by 

focusing on meeting staff needs for management support, logistics, and training and 

continuing education. 

Goals of Supportive Supervision 

• y To promote efficient, effective, and equitable health care. 

• y To work with health staff to establish goals, monitor performance, identify and 

correct problems, and proactively improve quality of service. 

• y To build confidence, motivation, negotiation and leadership skills and 

competencies of workers. 

• y To recognise good practices and help health workers maintain high performance 

levels. 

Examples of Supportive Supervision 

An analysis of Supportive Supervision and mentoring in Tanzania’s National AIDS 

Control Programme in 2009, showed positive results such as timely reporting, improved 

supplies management, improved patient management and adherence to national 

guidelines. Healthcare professionals interviewed for the study, specifically perceived it 

to be helpful in building capacity, motivating and improving confidence. 

The Global Alliance for Vaccines and Immunization (GAVI) partners identified it as a 

high priority and critical gap in immunization. It has also been used in the education 

sector, where it was embedded in implementation plans of both government and NGO 

programmes. Government structures such as Block Resource Centres and Cluster 

Resource Centres provide ongoing supervision and support to teachers. A combination 

of pre and in-service training, classroom observations, monthly workshops and 

teachers’ forums provide ample space for a supportive structure of supervision. 

3 

MSH Occasional Paper No. 2, 2006 

4 

A Manual for Comprehensive Supportive Supervision and Mentoring on HIV and AIDS Health Services, 2009 

10 



In the corporate world, this approach has been woven into the entrepreneur and 

leadership programmes. A cadre of Shakti women entrepreneurs was created in over 

12 states to reach over 70 million consumers for Unilever. A Building Leadership 

Trainees programme for the same corporate used a 15-month training programme for 

young recruits to provide organisational support in the form of buddies, coaches and 

mentors to ensure that leadership development was not left to chance, but was part of 

everyday life. 

Government Initiatives 

Government of India rolled out the Supportive Supervision System, under NRHM in 

2010, after extensive consultations to address accountability (thematic and geographic), 

quality of service delivery, facility operationalisation and training. The 8 th Joint Review 

Mission Report of the Reproductive and Child Health Programme, Phase II, flags 

lack of supportive supervision and quality of services provided for Home Based New 

Born Care (HBNC) as areas of concern and recommends strengthening supportive 

supervision for Integrated Management of Neonatal and Childhood Illness (IMNCI), 

amongst other things. 

In a similar vein, the National Institute of Public Cooperation and Child Development 

(NIPCCD) training for ICDS block functionaries is increasingly stressing on 

convergence of services at various levels of implementation; developing requisite skills 

of functionaries required for guiding grassroots level workers in preschool education, 

health & nutrition and community participation. The emphasis is on equipping them 

with knowledge for effective leadership, supportive supervision and management of 

ICDS Projects 5 . 

Time for Innovative Thinking 

Moving from traditional and hierarchical supervision systems to more supportive ones 

requires innovative thinking and time to change attitudes, perceptions and practices. 

Though there are many examples and case studies where Supportive Supervision has 

been used to improve health worker performance and immunization coverage, longterm 

and sustainable results have not been thoroughly documented. 

In the current scenario in India, there has been considerable talk of Universalization 

of ICDS, expansion and increased outlays. Huge supervisory structures, provision 

for joint supervision, guidelines and directives are in place. The alignment of health 

and ICDS sectors is expanding though supervision continues to be affected by a nonregular 

cadre that must contend with high work pressure in the absence of desired 

level of human resource and severe transport constraints. The subject of Supportive 

Supervision therefore requires renewed emphasis and clear guidelines. 

5 

NIPCCD Training Activities, 2012. 



11

Rationale 

Frontline functionaries are the interface of service system with community on crucial 

behaviours related to health, nutrition, water and sanitation. Hence, both their capacity 

building and quality of exchange with communities and families are critical determinants 

in ensuring families’ receptivity for adoption of essential health practices and willingness 

to access and demand services. There is broad agreement in the development sector, 

about rapid developments in the profile and responsibilities of frontline functionaries. 

This has clearly necessitated an assessment of their skills, capacities and enabling 

tools to help them perform their tasks well. Coupled with this, the current discourse on 

HR development in the health sector provides an opportunity for a complete revamp of 

the supervisory cadres and systems in Health Departments and ICDS. 

Given this context, even though Supportive Supervision is the weakest process 

in the management of health and related services, there still are opportunities that 

can be leveraged to strengthen this mechanism as a tool to improve motivation and 

performance of frontline workers. 

Objectives of the Consultation 

• y To build a common understanding of Supportive Supervision as an effective 

capacity building/performance improvement tool for frontline workers. 

• y To share and document good practices on Supportive Supervision. 

• y To identify opportunities to incorporate it into existing systems. 

• y To list concrete options/steps to address challenges discussed. 

• y To provide a broad roadmap and action points towards implementation. 

• y To collate inventories of tools, aids and technologies to facilitate Supportive 

Supervision. 

12 



Proceedings of the 

Consultation 

The consultation began with an overview of the agenda and the objectives of the 

two-day consultation provided by Ms Geeta Sharma, Communication for Development 

Specialist, UNICEF, New Delhi. She informed that there would be a skype call with 

Dr. Jon Rohde from South Africa, Ex-Country Representative, UNICEF, India, outlining 

a Theoretical Framework for Supportive Supervision within the context of India. It would 

briefly capture discussions and interactions amongst participants on different aspects 

of Supportive Supervision. This would be followed by presentation of seven case 

studies from states where Supportive Supervision was carried out successfully. Groupwork 

activity would entail discussants taking up aspects related to facility-based and 

community-based supervision to develop a set of suggestions/recommendations and 

roadmap with clearly articulated action points within the short, medium and long-term. 

SESSION 1: Welcome and Introduction 

Setting the Context 

Dr. Henri Van Den Hombergh, Chief, Health Section, UNICEF welcomed participants 

and apprised them of the current scenario relating to Supportive Supervision and the 

motivation behind holding a two-day consultation on the subject. He informed that at 

several preparatory meetings, UNICEF along with Women and Child Development 

Department (WCD) had agreed to address Supportive Supervision. They were of the 

view that this would impact ICDS which in turn would affect outcomes of NRHM. By 

enhancing efficacy of frontline health workers such as ASHAs, ANMs, AWWs and 

LHVs, rates of neonatal and child mortality would see a dramatic dip, amongst other 

things. 

According to him, in the past too, there had been talk of Supportive Supervision at 

multiple forums, such as project meetings, studies, planning workshops and PIP 

meetings, but not enough had been done on the field in a structured and organised 

manner. There wasn’t much clarity over the role and job description of frontline workers. 

However, in places where they were supervised and given importance, they were more 

visible, motivated and effective, creating an overall atmosphere of goodwill and trust. 



13

Henri hoped that the Consultation would help identify issues and provide insights to 

develop a standard blueprint that would allow a transition from ‘knowledge to practice’. 

He explained that all workers needed supportive supervision and counselling to create 

a sustainable reality for India’s frontline workers who were the front runners in ensuring 

child rights and child health. 

Emerging Needs and Responses for Strengthening 

Supportive Supervision 

Dr. Shreeranjan, Joint Secretary, Ministry of Women and Child Development 

acknowledged ICDS as a well-structured programme with an inbuilt supervisory 

mechanism that included elaborate guidelines for all levels. According to him, ICDS was 

in a continuous state of evolution, and an embodiment of care and empowerment. A 

reason for its being well run and managed was that it followed a system of decentralised 

decision making. Also, its design provided scope to follow a convergent approach to 

supervision. 

In his view, supervision comprised of two words, namely, super and vision. The 

‘super’ part referred to knowledge while ‘vision’ related to its dissemination. WCD 

was one of the biggest stakeholders of NRHM apart from programmes like water 

and sanitation, drinking water and NREGA which were Universalised post 2007-08 in 

the country and were now finding their feet. He admitted that in the 12th plan, these 

programmes would need more mindful action, dedication and commitment than just 

money. Window of opportunity in ICDS was its evolving to a stage of mission mode 

and being Universalised. Its strengthening and restructuring had been approved by 

the government. More than 37,000 technical persons were being added, mostly at 

the block and district level. He apprised that ICDS itself has 14 lakh AWCs and 7776 

projects. The advocacy and locking and interlocking in the system seamlessly with 

NRHM, ICDS and other programmes like water and sanitation would be an important 

aspect of Supportive Supervision. 

14 



Key Features of ICDS 

ICDS was a well structured programme. Prior to NRHM in 2005-06, only 45% habitation/ 

villages were covered by ICDS and the only health worker prior to ASHA, was ANM. 

There were villages where there was no outreach or health worker and therefore 

nutrition and health outcomes suffered. The anganwadi was a platform that served 

as a first outpost of health, nutrition, early learning and care. The issue needed more 

thrust. There were supervisors and a convergent approach to supervision between 

ANMs. With 1.4 lakh ANMs across the country, an average of 5-15 AWCs fall under one 

sub-centre. Spread of health institutions and structures at both sub-centres and PHCs 

had been more political than actual on the ground. The issue right now was of location 

which would need to be addressed through GIS and micro planning. 

In 2009, a guideline was issued in October, 2010 making it mandatory for supervisors 

to visit at least 50% women/anganwadis in their area. Joint visits were prescribed but 

only 30-40% were visited. With ICDS covering 15 states a year, the biggest challenge 

was to bring down burden of IMR, MMR, nutrition and governance, especially in Bihar, 

Madhya Pradesh, Uttar Pradesh or Jharkhand. It was time for Planning Commission to 

release funds for infrastructure, linking these to health outcomes. Vacancies needed to 

be filled and mobility support strengthened. 

Issues of Supervision 

• y Knowledge on programme components. 

• y Skill for supervision, facilitative actions and supervisory relationships. 

• y Availability of simple and appropriate tools for supervision. 

• y Training ( knowledge and skill based). 

• y Clarity of roles and accountability framework. 

Explaining these constraints, he said that there were challenges to conducting 

supervision at different levels. Vacancies of Supervisors and CDPOs was a commonly 

reported problem. In many places, there was a skewed AWC: Supervisor ratio. In 

remote areas, problem of mobility was seen as a hindrance to regular supervision. 

Many supervisors, for sake of convenience chose to stay close to sector/ block 

headquarters, visiting villages under their care occasionally. Apart from physical and 

logistical constraints, in many places, quality of supervision was patchy, restricted 

Fact File: ICDS supervision at grassroots level 

Villages: 6 lakh; Panchayats: 236,350 lakh 

Village Health and Sanitation Committee (VHSNC): 5 lakh 

AWC: 13.19 lakh 

ANM: 1.4 lakh 

ASHA: 8.49 lakh 

Sub-health Centres: 1.5 lakh 

ICDS supervisors: 35702 as against 54103 sanctioned 

AWC per sector: 25 



15

and confined to mere report collection and format filling, rather than actually checking 

for programme quality and assessment of frontline staff on a comprehensive list of 

indicators. 

Need for Supervision 

Resultantly, need for supervision existed in almost all areas of governance, programme 

implementation and service delivery. All supervisory staff had to keep upgrading their 

technical skills to make space for an integrated approach that helped them cover a 

range of topics including programmes on maternal care, child care, early learning 

and counselling, nutrition, health, sanitation and hygiene. In ICDS, a key challenge 

related to peoples’ involvement. Much of the ownership was neither by government 

nor community. Viewed more as a feeding centre, this had to be made more elaborate, 

by making things more things mandatory, involving panchayats, MPs and MLAs, since 

they carry constant feedback from their constituency and voters. 

Recent initiatives taken by ICDS to improve supervision and monitoring included 

introduction of a five-tier Monitoring & Supervision Committee at all levels, right up to 

Suggested reforms for improving quality of 

supervision in ICDS 

• y Provide knowledge and training on relevant programme components. 

• y Enhance skills that allow better facilitation and development of supervisory 

relationships. 

• y Make available simple and appropriate tools for supervision. 

• y Ensure greater clarity of roles and accountability framework. 

• y Develop a mission structure backed by technical support till block level with 

dedicated persons for monitoring. 

• y Create a special cadre for ICDS where ever missing. 

• y Fill up vacant positions through job contracts. 

• y Open cluster office for supervisors at strategically located AWCs to manage and 

provide guidance to 25 AWCs. 

• y Envisage greater role of VHSNC in supervision and monitoring of AWCs and 

linking the ALMSC to VHSNC. 

• y Revamp training with focus on enhancing skills and knowledge and help set up 

State Resource Centres. 

• y Promote Information, Communication Technology (ICT) to strengthen information 

base and disseminate knowledge. 

• y Provide mobiles to AWCs for real-time monitoring; and flexibility to states for 

innovations including supervision. 

• y Set up a grievance redressal cell at national level. 

16 



AWC. This included representation from other sectors, elected members, NIPCCD, 

F&B and experts. Revision of ICDS’s MIS and using it thereafter for supervising VHND, 

services, behaviours and referrals met with considerable success. Positive feedback 

was received from states for guidelines developed for conducting supervisory visits. He 

mentioned supervisory visits, as mandated in ICDS were clearly outlined. 

Quarterly visits: DPOs/RDD/ CEO were visited on quarterly basis. 

Half-yearly visits: DM/ ADMs/ CEO ZP visited minimum 25% blocks under their care. 

Yearly visits: State directorate officials made supervisory trips to 20% blocks; State 

Director, ICDS visited minimum 10% blocks /year; and State Secretary covered 25 blocks. 

Best Practices in Supervision 

• y In the Integrated Nutrition and Health Project (INHP), supervisory checklists were 

designed in a participatory manner focusing on critical behaviours and services. 

Based on trends based on checklists and interactions with AWWs, supervisors 

developed and conducted capacity building sessions for AWWs during monthly 

review meetings at sector level. 

• y Additional block-level nutrition instructions within Tamil Nadu Nutrition Project 

(TINP), ASAT, Dular and INHP utilised external resource persons; including local 

NGO staff and master trainers to help ICDS staff conduct Supportive Supervision 

and provide on-the-job capacity building inputs. 

Future Plans 

Dr. Shreeranjan informed that ICDS was finalising a framework with the health ministry 

to define the role of a frontline worker and undertake the important task of communitybased 

management of undernourished children. The issue of filling vacant posts would 

be taken up - posts for 54000 supervisors was vacant while there was an approval for 

56000, though in position there were only 35000 - this gap would be addressed. 

A proposal of collateral supervision was being considered. States like Tamil Nadu 

and Himachal Pradesh had AWW and not ASHAs, making it even more important to 

define roles of ASHA and AWW with ANM supervising both. In restructured ICDS, plans 

were afoot to add 3.4 lakh AWC in 200 high burden districts. In addition, a provision 

of Rs 2000-3000 crore in 12 th plan had been made for voluntary action. He urged 

knowledgeable practitioners, medical colleges, institutions, home science colleges and 

pediatric associations with expertise in child care, nutrition and health outcomes, to 

come, not-for-profit but voluntarily as a group to provide Supportive Supervision and 

advocacy. The bigger challenge was to motivate 14 lakh AWC, 8 lakh ASHAs, 22 lakh 

people and keep them motivated to deliver on all health expectations. 

The practice of sector meetings and MO level monthly meetings provisioned in the 

health system would be re-introduced. Also, AYUSH would be mainstreamed in NRHM 

in a more proactive manner. Dr. Shreeranjan emphasised that mainstreaming did not 

mean placing an AYUSH doctor in a sub-centre/backyard. This traditional wisdom 

had to be used better. It had helped people in remote areas survive. There were 8 

lakh registered AYUSH practitioners, equivalent to number of ASHAs. They should be 

seen performing voluntary action and collaborating more actively with AYUSH. He said 



17

that the ministry should come up with comprehensive schemes offering honoraria for 

basic health care in villages by any AYUSH doctor. These interventions will strengthen 

supportive supervision and bring about better health outcomes. 

Outlining Expectations of the Consultation 

Dr. Ajay Khera, Deputy Commissioner, Child Health and Immunization, Ministry 

of Health & Family Welfare, reiterated need for Supportive Supervision. In the context 

of NRHM, he said substantial investment had been made to improve Maternal and 

Child Health (MCH) outcomes. Much ground had been covered (India was polio free for 

over 22 months) but the country was still lagging on its Millennium Development Goals 

(MDG). Making investments alone would not be enough, unless backed by out-of-thebox 

thinking. Reports, state reviews and field notes had to be looked into and priority 

areas identified (equipment and supply, capacity building, programme management. 

He said supervision was not an altogether new concept, but a crucial missing link, 

which if addressed correctly, could enhance programme outputs greatly. 

Concerted effort had to be made to examine the current scenario and see how existing 

protocols and practices could be revived and strengthened and a blueprint drawn for 

new interventions. He recalled presence of Lady Health Supervisor and Male Health 

Worker who existed in the form of Leprosy Officers etc but who had vanished over 

the last decade. These positions had to be revived. Outlining expectations from the 

Consultation, he suggested: 

• y Specifying the kind of human resource element needed to do Supportive 

Supervision. 

• y Different models in thematic areas of continuum of care, immunization, family 

planning (FP), neo natal health, and Reproductive Maternal Newborn and Child 

Health (RMNCH) A-Plus strategy document. 

• y Unified team with unified structure needed with manuals, guidelines, HR and 

capacity building to come up with complete range of RCH activities. 

• y Institutionalising the system and having an integrated RCH Supportive 

Supervision model. 

18 



“I have been to the field and found the supervisor in many places saying he has 

to supervise the ANM but does not know what exactly to supervise. There has to 

be more clarity around all aspects of Supportive Supervision.” 

Dr. Khera was hopeful of a roadmap developing at the end of the Consultation, 

defining essential parameters for the way forward along with costing to enable make 

projections, that would be sustainable in the long term. The initiative will involve the 

Health department, along with AYUSH, members of civil society, academia and other 

partners. 

SESSION 2: Theoretical Framework for Supportive 

Supervision 

Jon E. Rohde, Former Representative of UNICEF in India in his presentation through a 

skype call from South Africa, outlined a theoretical framework for Supportive Supervision 

which could be effectively implemented in India. He enumerated that South Africa had 

undergone similar challenges which were addressed through the initiatives taken when 

a Supportive Supervision Policy was formulated. 

He updated the audience on the primary healthcare scenario in South Africa, where 

district hospitals were smaller than India’s, catering to a population of 0.5 to 1 million. 

Also, health centres or small 20- bedded hospitals/doctors received many referrals, but 

had little access to supervision per se. The country had 3500 nurse-run clinics catering 

to 1 to 10-15,000 population with 2-5 professional nurses/clinic plus aides. Add to 

this, the district was a major administrative unit, implementing all priority programmes 

and supply of drugs while overseeing these health centres. Supervisors were drawn 

from vertical programmes and they visited the centres sporadically, usually for only 

one programme, be it TB, Family Planning, HIV or EPI. They neither had a structure 

nor regularity of supervision visits. Also there was no recording or regular follow-up. 

However, this scenario went through transformative change – for the better - once the 

country adopted a special policy on Supportive Supervision with detailed guidelines 

and tools. Seeing the success of the South Africa experience and Jon’s own stint in 

India, he felt that the model could be adapted to suit India’s own healthcare system. 

The paras below outline some of his relevant thoughts around this: 

Formulating a Supervision Policy 

Advocating for the need to be guided by a Supervision Policy, Jon outlined a practical 

framework within the Indian context. The Policy could cover appointment of a single 

generalist supervisor who made regular scheduled visits. To facilitate the process, 

reliable transport for physical commuting could be provided. The supervisor would 

have to be up-to-date with information sharing and dissemination to enable him/her be 

informed about ground realities, government programmes and updates in facilities. Jon 

was of the view that the supervisor had to be vested with enough authority to mobilise 

support from higher levels. Having to revert to superiors for every decision on the field 

would lead to delays. By empowering supervisors to take spot decisions, community 

would have stronger faith and confidence in the supervisor. He suggested the need to 

have objective measures of success as key indicators which could further be guided by 

a comprehensive but flexible Supervisors Manual. 



19

Developing a Clinic Supervisor’s Manual 

The manual should guide and help supervisors organise their work better. By 

focusing on critical inputs and processes required to deliver essential PHC services, 

it should provide basic information about each clinical service, to enable an objective 

review of all required elements including supplies, actions and recording/monitoring 

mechanisms. Having a summary would serve as a review of all important aspects of 

clinic administration, financial management, staff motivation and performance. One of 

the direct benefits of the manual would be the supervisor’s ability to assess the extent 

of and actively encourage community involvement in clinic activities as also assess and 

improve staff knowledge and skills. 

The manual should have Standard Treatment Guidelines with patient reviews; Roadto-Health 

Cards; referrals to higher levels for clinical assessment and treatment; 

collection and use of data for decisions; community participation and training needs 

and tools for continuing education. It should be a living document, readily available on 

Internet and otherwise for use and local adaptation. Inputs received by users based 

on their experience and recommendations will make it more user-friendly, eventually 

leading to a structure that has more competent and satisfied personnel (supervisors 

and supervisees) providing improved health care for all. 

Supervisor’s Work Charter 

• y Recruit and train supervisors. 

• y Keep track of administrative tasks, schedule visits, plan content of clinic visits, 

prepare educational sessions, monitor clinic progress. 

• y Identify a small handful of measurable objectives to accomplish over a month. 

• y Develop mechanisms to build trust and increase competence in supervisors and 

supervisees. 

• y Strengthen networking by allowing supervisors to form part of a district team that 

interacts with each other in a way that supports lower levels. 

• y Find new ways and fine-tune existing methods of problem-solving. 

• y Continue self-learning and education to build confidence and skill-sets. 

Measure success in achieving locally set targets based on select performance 

indicators. 

Importance of Developing and Reviewing Checklists 

Jon suggested development and use of four different checklists, catering to specific 

outputs: 

• y ‘Red flag’ checklist: Lists basic line items and takes 5-10 minutes per visit. 

• y Monthly review checklist: Reviews facility functions and takes an hour a month. 

• y Quarterly checklist: Used for a more thorough review of all clinic functions and 

takes up to 2 hours, every 3 months. 

• y In-depth programme review: Designed to check each element of a given 

programme, this is a one-hour programme, done once a year, unless there is a 

problem beforehand. 

20 



These supervisory checklists should evolve as the programme improves and move 

from measuring inputs and processes to outputs and impact. In an attempt to further 

refine the supervisor’s scope of review and monitoring, findings can be reviewed, 

leaving behind in the clinic a copy of each checklist used and annotated with expected 

activities planned for the next month. Back in the office, the supervisor will file forms 

under each clinic, making a list to follow-up activities and prepare summary of findings. 

These would then be recorded and summarised for the entire district, drawing attention 

of district management team and district manager, highlighting important signs of 

progress and problems. 

Jon concluded his presentation drawing attention to the Alma-Ata Declaration which 

undertook Supportive Supervision by using a manual that could be easily modified to 

realise PHC principles. It dealt with health education, nutrition, water and sanitation, 

MCH, immunization, locally endemic diseases, appropriate treatment of common 

diseases, mental health, and provision of essential drugs, all in the context of the local 

community and existing resources. The supervisor was finally geared to guide the 

management of resources and community relations as well as ensure service provision 

and quality of care. 

Discussion 

• y Supervisory cadre comprises male and female. Clear horizontal 

structures must be laid out in the SS Policy defining authority and 

responsibility of supervisors to help achieve desired actions. 

• y Have clearly delineated set of tasks for ASHAs, supervised by 

someone seen as a helper. The system has to be adapted so as 

not to be too overwhelming. Workers should see it as a qualifying 

and enhancing process. 

• y ASHAs need to be supervised by the next level in the frontline 

hierarchy, like say ANM, who in turn is supervised by Block 

supervisor. Ideally, ASHA should be supervised by the nearest subcentre. 

• y Doctors in PHCs must be challenged with more important things 

like human development, of which SS is an integral part. Refresher 

course at PHC level is needed. 

y • Generalist supervisor is not the answer to everything, Rather s/he 

must be viewed as a liaison, to let people know what is going on at 

the sub-centre. 



21

SESSION 3: Innovations and Best Practices 

The session, chaired by Mr. Kali Prasad Pappu, UNOPS had presentations highlighting 

best practices from seven states, followed by discussions. 

• y Integrating Supportive Supervision in Systems SHSRC, Chhattisgarh. 

• y Outsourcing Supervision and Building Blocks with Block Supervisors, Aligarh 

Muslim University/UNICEF. 

• y Strengthening Systems of Supervision: Experiences from the Vistaar project. 

• y Integrated Family Health Initiative: Early Experiences, CARE. 

• y Key Incentives to Support Supervision: Society for Applied Studies. 

• y Leveraging Support through Community Mobilisers: Micronutrient Initiative, Bihar. 

• y On-the-job Handholding: Supporting Classroom Teaching: Sarva Shiksha 

Abhiyaan, Ministry of Human Resource Development. 

Integrating Supportive Supervision in Systems SHRC, 

Chhattisgarh 

Mr. Prabhodh Nanda, Programme Coordinator, SHSRC, Raipur, shared the 

experience of the Mitanin programme, implemented by Government of Chhattisgarh in 

2002, emerging as a successful health intervention. 

Background and Fact File 

‘Mitanin’ which means ‘friend’, was positioned as a representative of the community. 

One Mitanin was selected per rural habitation. Currently, 66,000 women volunteers or 

Mitanins provide health education to the community, linking them with formal healthcare 

services. 

22 



Title of Project: Mitanin Programme as Health System Reform 

Duration: 2002 onwards 

Implementing Agencies: Department of Health & Family Welfare, Government of 

Chhattisgarh. 

Coverage: In all 16 districts and 146 blocks 

Objectives 

• y To provide preliminary cure at hamlet level for common ailments. 

• y To organise and empower women and weaker sections of society. 

• y To strengthen role of Panchayats in health sector. 

• y To promote grassroots health planning. 

• y To integrate training, deployment, support and monitoring of Community Health 

Activists (Mitanins) to yield measurable outcomes. 

Programme Structure 

State level: State Health Resource Centre is a state civil society partnership institution 

guided by a State Advisory Committee with about 30 people comprising training cum 

monitoring team. 

District level: District RCH society and District Coordination Committee/Task Force. 

Highlights of the programme 

Measuring performance: Mitanins’ performance is measured by indicators which 

include number of newborn who received 6 designated visits; pregnant women 

motivated to go for ANC check-up; visits to children under 3 years for nutrition advice; 

medicines given; advise given on home/herbal remedies; referrals made for institutional 

delivery, family planning, cataract, TB, leprosy; check if VHSNC had a meeting during 

the month; cases addressed relating to nutrition security and social exclusion; support 

to women affected by domestic violence. 

Monitoring: Mitanin performance is monitored though MIS reports filled by Mitanin 

trainers who ask them oral information in their monthly cluster meetings; MIS reports are 

consolidated by Block Coordinator at block level and District Coordinators at district level. 

Role of Supportive Supervision 

Supportive Supervision under Mitanin programme was used to enhance performance 

of the cadre through regular interactions with trained facilitator’s within field setting. 

However, it was neither aimed at generating data for monitoring nor to take punitive 

action against poor performing Mitanins. 



23

Mitanin Support Structure: Key to the Success of the 

Programme 

Mitanin Trainer (MT) : One for every 20 Mitanins (total 3100) 

Block Coordinators : Two for every block (total 294) 

Block Nodal Person : One per block (total 146 from Govt. side) 

District Coordinator : One for every district and 2 for bigger districts (total 35) 

Members : Seven in every SHRC 

To strengthen support structure, regular ongoing trainings are provided, similar to those 

received by Mitanins (50 days over 16 modules). Currently, 17 th module is in progress. 

The support structure received additional two days training on Supportive Supervision 

with a view to creating self-image of Mitanin Trainer as “Trainer”/“Facilitator” as opposed 

to “boss”/ “data-collector”. 

Mitanin Trainers: They provide training to Mitanins in residential camps and onthe-job 

training and Supportive Supervision to Mitanins through home visits, hamletlevel 

meetings and cluster meetings; support VHSNCs by facilitating preparation and 

execution of Village Health Plans and, record keeping; support Mitanins in availing 

benefits of Mitanin Welfare Fund. They are selected from amongst Mitanins of the 

cluster through a written test by a Block-level Committee headed by BMO. MT gets 

paid by BMO on the basis of number of days of work done. About 90% MTs are women. 

Planning and reviewing work of MTs is done through fortnightly Block-level meetings in 

which District Coordinator facilitates planning and review, interacts with BMO and other 

health staff; Block Coordinators make field visits (1-2 field visit per MT in a month) to 

monitor MTs and train them on-the-job; MTs report to Block Coordinators; have a fixed 

day schedule for around 15 days a month; submit day-wise plan for each month and 

later day-wise work report. 

Block Coordinators: They provide ToT to MTs in residential camps; plan Mitanin 

trainings with BMO to supervise Mitanin Training; on-the-job training, support in solving 

problems and monitoring MTs by participating in home visits, hamlet level meetings, 

VHSNC meetings; support District Coordinator for fortnightly meetings, compile 

monthly MIS reports; verify monthly work done by MTs; interact with BMO to seek 

support for field-level problems; attend one District-level meeting a month. Initial Block 

Coordinators were selected from amongst pool of trainers created from civil society. 

Now they are selected from amongst MTs through a written test, by a Committee 

headed by BMO. About 65% of them are women. 

Value addition to the programme 

24 

MTs maintained motivation levels of Mitanin (According to an Evaluation 80% 

Mitanins acknowledged support provided by their MTs); majority of VHSNCs meet 

regularly and plan for village health. MTs helped create a link with Panchayats. 

Through home visits, 70-80% of newborn, malnourished children, pregnant women, 

sick children are covered; campaigns involving mobilisation (prevention of malaria, 

screening for suspected TB, Child Nutrition Counselling) work to a large extent; major 

motivation for MT comes from social recognition that the role brings as leader of a 

team of Mitanins. 



District Coordinators: They are appointed by SHRC and have no structured, 

formal office. Their role is field-based and they provide classroom training to Block 

Coordinators and supervise training of MTs; conduct fortnightly meetings of MTs at 

block level; support BMO for selection of any new MTs or Block Coordinators; provide 

on-the-job training and Supportive Supervision to Block Coordinators; compile monthly 

MIS reports of Mitanin programme and submit to SHRC and District Nodal Officer; 

monitor quality of Mitanin Training. 

Challenges in Implementing SS 

Gaps in capacity: Gaps in capacity of MTs, BCs and DCs impact outcomes related to 

identification of newborn illness, nutrition counseling and record keeping for VHSNCs. 

This can be addressed through training on Supportive Supervision. 

Coverage issues: Scattered habitation pattern in many tribal areas requires MT to 

cover large distances. MT : Mitanin ratio in such areas needs to be relaxed. 

Limited understanding of health system: Greater awareness needed around all 

components of VHSNC and its Untied Grant. 

Not always effective: MTs are used as a medium to put pressure on Mitanins which 

does not always produce results. 

Diversion to other duties: MTs sometimes are diverted to other duties like staying in 

family planning/RSBY card distribution camps, VHSNC expenditure audits etc. 

Delay in compensation: MTs face delays in receiving compensation and TA which can 

be demotivating. 

High attrition: If MT leaves, selection of new MT does not happen immediately; annual 

attrition is around 5-10%. 

Outsourcing Supervision and Building Blocks with Block 

Supervisors, Aligarh Muslim University/UNICEF 

Prof. Abdul Martin, Chairman, DPO, SOC and SCO, Aligarh Muslim University 

and Dr. Mohammad Arif Khan, Assistant Professor, Aligarh Muslim University 

presented the Aligarh Model of Supportive Supervision for Child Survival. 


Given the high IMR, lack of structured support after CCSP training of ASHAs and 

absence of an existing model of CCSP Supportive Supervision, the Health Department, 

AMU & UNICEF visualised the need for developing a Model of Supportive Supervision 

in Aligarh District to guide various child health related outcomes. 

Title of Project: Supportive Supervision of Comprehensive Child Survival Programme 

(CCSP-SS) 

Implementing Agencies: Department of Sociology & Social Work, AMU, Aligarh and 

UNICEF, Lucknow. 

Project Coverage: Six blocks of Atrauli, Dhanipur, Gangiri, Jawan, Khair and 

Lodha in Phase-I (July 2009 to June 2010) and remaining six blocks of Akrabad, 



25

Bijoli, Chandaus, Gonda, Iglas and Tappal in Phase-IIa (July 2010-March 2011) and 

Phase-IIb (April-September 2011). The ongoing Phase III was launched on18 th October 

2011 and will be completed by 31 st Dec 2012. 

Project Staff: One Project Director supported by 2 Assistant PDs, 1 district Project 

Coordinator and 12 Block Supervisors. 

Implementation Strategies & Activities of Different Phases 

Phase-I (July 2009 - June 

2010) 

Providing Supportive 

Supervision to ASHAs in 

six blocks 

Completing data collection 

for familial practices 

Mobilising MSW students 

to adopt healthy practices 

Strengthening liasioning 

with Health Department 

at District, Block & Sub 

Centre levels 

Innovations 

Phase-II (July 2010 - Sept. 

2011) 

Providing Supportive 

Supervision to ANMs/LHVs 

with continuing support to 

ASHAs 

Replicating Phase-I 

activities in remaining six 

blocks 

Completing maintenance 

of Village Health Index 

Register (VHIR) by ASHAs 

and RI Register by ANMs 

Supporting ASHAs to 

develop effective counselling 

skills to tackle harmful 

traditional practices affecting 

new born by group meetings 

Providing support for RI 

sessions 

Phase III (18th Oct 2011 – 31st 

Dec 2012) 

Building supervisory capacity of 

ANMs/LHVs to ensure quality 

supervision of ASHAs and 

further supervisory sustenance 

Continuing Supportive 

Supervision of ANMs and ASHAs 

Facilitating joint work plan of 

ANMs and ASHAs to bridge 

gaps 

Ensuring supervision by Block 

level officers-MOICs/HEOs/ 

Health supervisors 

Documenting 

and disseminating activities 

Categorisation of ASHAs: Some of the ASHAs showed remarkable improvement in 

performance. To further enhance their performance and motivate the remaining, they 

were categorisation under A, B and C. Peer group learning was encouraged. 

Strengthening sub-centre: Facilitation support for sub-centre wise ANM/ASHAs 

meetings; facilitation support for ASHA Village Health Awareness Meeting; motivating 

ANMs to participate in village meetings; VHIR/RI completion initiative. 

Capacity building/thematic skill building in monthly meetings of ASHAs/ANMs: 

This was done through a number of activities/initiatives. Daily planning and feedback 

sharing through morning and evening meetings of project and field staff helped 

evaluate progress 24X7 as also encouraged opportunities for cross learning among 

Block Supervisors to resolve problems. 

Maintaining a Daily Diary: The diary was used to record daily activities. It was made 

mandatory for Block Supervisors to update it daily. The diaries were checked by District 

Project Coordinator on alternate days and by Project Director on weekly basis. 

Regular meeting with Government health officials: These entailed coordination 

with Chief Medical Officer, Nodal Officer-CCSP, DPM/DCM (NRHM) and all Block 

26 



Medical Officers. They aimed to increase involvement, support and interest of health 

functionaries in CCSP to get expected results. A bi-monthly Review meeting was held 

with health officials and stakeholders. 

Reporting Mechanism: Facilitate visit of District/Block-level officials for monitoring 

Supportive Supervision activities of Block Supervisors/ASHAs/ANMs. Regular 

monitoring of Project activities by DPC, APDs and Project Director. 

The project was supported with a set of key enabling factors which included strong 

support from Health department at all levels; structured, regular handholding support 

to ASHAs/ ANMs at their respective place of work; thematic capacity building of 

ASHAs/ ANMs in monthly/ Sub-centre level meetings; joint planning, implementation & 

monitoring mechanism of health department and AMU; trained well-knit project team 

of S-CCSP-SS, AMU. 

Key Results: Findings which Demonstrate Challenges and Hindrances 

The project led to a vastly improved situation where ASHA/ANM were provided Supportive 

Supervision in assessing the newborn as per 0-2 months newborn assessment format on 

IMNCI/ CCSP guidelines. The findings were based on data collected from 12 blocks of 

Aligarh district and analysed by project team of CCSP-SS, AMU, Aligarh. 

• y Unavailability of formats which usually took months to procure/fill. 

• y Unavailability of VHIRs. 

• y Demotivated ASHAs due to non-payment of incentives on time. 

• y ANMs feeling the burden and complaining about the same. 

• y Non replenishment of ASHA drug kit. 

• y ‘C’ category ASHAs not reporting properly. 

• y As many as 12% ASHAs not being able to read and write. 

Strengthening Systems of Supervision: Experiences 

from Vistaar project 

I am happy that now at least someone from the medical department visits our facility, 

encourages us for the good work we are doing and solves our problems. Earlier, we 

used to feel alone and neglected”. 

Sunita Rawat, Skilled Birth Attendant, Uttar Pradesh 

Ms. Madhuri Narayan, Project Director, Vistaar Project, Intrahealth, through 

her presentation validated that supervision was critical for improving performance, 

especially in scenarios plagued by high vacancies for supervisory positions (ICDS) 

and where there was difficulty in ensuring regular and adequate supervisory field visits. 

Title of Project: Vistaar 

Duration: 2006-12 

Implementing Agencies: USAID supported Government of India and State 

Governments of Uttar Pradesh and Jharkhand. 



27

Objectives 

• y To improve maternal, newborn and child health and nutrition by providing 

strategic technical assistance. 

• y To generate evidence on effective, efficient and expandable MNCHN approaches. 

• y To advocate for scale-up of successful MNCHN approaches. 

Triggers for Mainstreaming Supportive Supervision 

• y Improve health and nutrition outcomes dependent on performance of frontline 

workers. 

• y Supervisors play a key role in helping frontline workers perform to expected 

standards and ensuring better quality. 

• y Prevailing scenario where supervisors were provided one-time training ignoring other 

areas; role of supervisors not defined clearly; absence of regular and structured 

supervision; lack of sufficient resources (transport, essential supplies, guidelines); 

supervisors acting as inspectors rather than facilitators, educators and problemsolvers; 

limited or inconsistent use of checklists and feedback by supervisors. 

Intervention Design 

Strengthening Supportive Supervision included a multipronged approach comprising of: 

Capacity building: Creating knowledge, skills and attitudes for effective supervision. 

Training: Supervisors provided training for technical competence in critical areas of 

work to support frontline workers. 

Supervisor interactions: Utilisation of monthly meetings and VHNDs to increase 

supervisory interactions. 

Data management: Routine collection and use of data to improve performance. 

Strengthening Supervision 

SBA performance 

Designing 3-day training for MOs to clarify 

performance expectations from SBAs and 

supervisory responsibilities 

Developing competency in technical areas 

such as plotting partographs, AMTSL, etc 

Strengthening concepts of Supportive 

Supervision, including communication and 

problem solving skills 

AWW performance 

Reviewing existing guidelines and directives 

Conducting performance needs assessments 

Developing a 3-day supervision training for 

Mukhiya Sevikas and CDPOs 

Introducing a supervisory checklist 

Strengthening monthly meetings to 

complement field visits including VHNDs 

Promoting use of data to make programme 

and performance improvements 

Undertaking capacity building, feedback and 

problem-solving 

Strengthening supervisory skills of ANMs and 

LHVs for onsite support/guidance to ASHAs 

Forming and building capacity of Technical 

Resource Groups 

28 



Results 

“If ASHAs could not fill the registers, we too could not help them since we ourselves did 

not know how to do it. Now, with training and experience, we can help them solve this 

and other related problems.” 

Ramvati, ANM, Jharkhand 

As a result of the intervention 99% ANMs reported having a copy of the job description 

in writing at endline compared to 32% at baseline; 200 MOs were trained on Supportive 

Supervision; over 2600 supervision checklists were filled by trained MOs to ensure 

standardised and systematic supervision; 75 SBAs were awarded appreciation 

certificates at monthly meetings in Deoghar over a 9- month period. 95% AWWs 

reported interacting with their Supervisor 3-4 times in the last quarter. Nearly 95% 

interaction took place during sector meetings; 62% AWC routine visits or 39% on 

VHNDs. About 89% reported that Mukhya Sevikas howed them how to fill the register 

and use job-aids correctly. 

Learnings 

• y Performance can improve with clarity on performance expectations, linking tasks 

directly to outcomes. 

• y Training cannot be a one-time activity; systematic post training follow-up is 

critical. 

• y Performance improves when supervision is an extension of training and supports 

training content. 

• y Providing supervisory skills and tools to supervisors can help address essential 

support needs of frontline workers. 

• y Supervisory interactions can be increased by using field visits, VHNDs and 

monthly meeting platforms. 

• y Adequate in-house capacity can be built within the system to facilitate and sustain 

ongoing capacity building, feedback and problem-solving in routine monthly 

meetings. 

• y Costs of these efforts is minimal and requires substantial time of government 

staff. 

• y District-level ownership needs to be backed by support at state and national 

level for sustainability. 

Integrated Family Health Initiative: Early Experiences, 

CARE 

Dr. Shreedhar from CARE, in his presentation focused on organizing supervision of 

MCH interventions and insights gained from CARE’s work with the health and ICDS 

departments. 


Initial research of the existing scenario revealed that existing programmes were 

capable of achieving substantial results. Frontline workers were willing to learn and be 

led and main reasons for failure included being poorly focused on results at operational 



29

levels; activities not sufficiently influenced by causal thinking and strategic planning; 

competing, sometimes chaotic priorities; bureaucratic and political impatience; and 

most failures relating to professional leadership at middle levels where supervision 

was poorly informed, focused, organised and supported. Based on these findings, a 

programme strategy was developed through INHP. 

Title of project: Integrated Nutrition and Health Project (INHP) 

Duration:1996-2010 

Implementing Agencies: USAID, BMGF 

Coverage: 8 states, 100-250 million population, mainly ICDS (outreach preventive 

services); Bihar, 30-100 million population, both Health and ICDS (outreach and facility) 

Objectives 

To provide catalytic technical support at operational levelscovering MMR, NMR, 

malnutrition, TFR, FIC 

Programme Implementation 

The two arms of the programme were: 

i. Outreach services strengthening (RMNCHN) through behaviour change and 

service coverage. 

ii. Strengthening access and QoC in facilities for maternal, newborn and FP. 

The programme demonstrated simple, doable solutions which included incremental 

hands-on learning, improved supervisory interactions, tools, generation and use of 

relevant data, quality improvement; better interpersonal communication by ASHA, AWW 

using existing supervisory interactions between ANM-ASHA at VHSND; LS-AWW at 

sector meetings and field visits; MoIC/BHM-ANM in weekly (Tuesday) meetings; Block 

officials-FLWs at monthly meetings. All activities were marked by ad hoc priorities with 

short-term activity focus; were limited to FP-immunization-SNP; marked by lack of 

strategic vision or plan, poor coordination, low self-esteem and low respect for each 

other. There was no focus on behaviour change, making it difficult for the programme 

to show results. 

Results 

• y Seven monthly rounds completed since April involving 2500 sub-centres across 

137 blocks in 8 districts. 

• y 60-70% participation of ASHA and AWW in sub-centre meetings. 

• y 20% ANM ‘taking over’; 50% actively participating; ANM present in over 90% SC 

meetings. 

• y High level of acceptance at all levels in both programmes; state interested in 

using same approach for content beyond RMNCHN. 

• y Expecting early results on home visits, behaviour change by Jan 2013. 

30 



Learnings 

• y Functional overlap between ASHA, AWW can be creatively used. 

• y ANM is the natural RMNCHN guide for ASHA and AWW in a leadership capacity. 

• y ANM needs tools to help organise her interactions with ASHA, AWW. 

• y Any data collected is primarily for use at the same level, not reporting. 

• y Main input of the catalyst project is a period of handholding facilitator support for 

ANM; focused on demonstrating how she can sustain focus of FLWs on what is 

critical for results. 

• y Similar catalytic approach could work for other levels of supervision, and for 

areas beyond project focus. 

Going forward, a more professional approach will be needed to make space for healthy 

dialogue backed by supporting software, to restore confidence, trust and transparency. 

Discussion 

• y Need to bring in convergence especially where there are too many vertical 

programmes and supervisors. This would help conserve resources. 

• y MCHIP provided technical expertise to a group of people hired through state 

government in NRHM. There can be a transfer of technique to NRHM. For 

instance in Haryana, a group of BDS doctors did their MPH and were deputed for 

SS in RAPID activity. After two trainings they did it themselves and the amount for 

this was factored in PIP. 

• y Through training, cadre building and empowerment, nurses and midwives can be 

positioned in places where there is scarcity of doctors. Nurses in QA teams would 

have better outcomes but with some caveats. Also, it has been seen that when 

nurses are sent to labour rooms, they have to face resistance from senior nurses 

who refuse to comply to younger nurses, who they feel are not at par with them, 

especially since their salaries are lower. To overcome this pecking order issue, 

it may be worthwhile to send an outsider who is not of the same cadre to ensure 

compliance and joint working. 

• y Governments are risk averse to contracting private parties. Development 

partners and UN agencies tend to do it far more easily. What is needed are better 

contracting mechanisms. 

y • For benefit of states, accreditation of technical institutions can be done by a 

central body in a methodical and transparent body. 



31

Dr. Rakesh Kumar, Joint Secretary, Ministry of Health and Family Welfare, 

Government of India, appreciated UNICEF taking the initiative to hold a 2-day 

Consultation on an important topic. He was particularly happy to see people who were 

hands-on in the field, conducting Supportive Supervision, attending the Consultation. 

According to him there were a number of constraints which were impeding progress 

on this front. Human resource was a major constraint, with unfilled vacancies. In 

states like Uttarakhand and Uttar Pradesh they were as high as 40% and in others 

close to 25-30%. Resource constraint was a major issue and so was the inability 

to ensure quality standards and clear communication. If earlier the role of ANM 

was specific (ANC, RI etc), today, everything that was decided at the ministry level, 

landed at her doorstep. 

With greater responsibility there was a paradigm shift in roles and responsibilities of 

frontline workers. Lack of guidelines and clear terms of reference served as strong 

grey areas. Compounding the problem was shortage of supervisors. According 

to Dr. Kumar, while formulating guidelines was important, more critical was the 

need to develop a full-fledged policy that could look at Supportive Supervision 

in totality. The goal was to ultimately have an effective and efficient system in 

place. The policy should outline resource availability, roles, number of visits which 

a supervisor should make, kind of transport facility s/he should avail of and manner 

in which information should be shared. The policy document should serve as a 

solution that goes beyond standalone effective successful pilots, leading to an 

overall systems improvement. 

32 



Key Incentives to Support Supervision: Society for 

Applied Studies 

Dr. Sarmila Mazumdar, Deputy Director, SAS, Centre for Health Research and 

Development Society for Applied Studies (SHRD) shared outcomes of a research 

trial to determine effectiveness of implementing IMNCI strategy on a district-wide scale 

with a view to reduce neonatal and infant mortality. A cluster randomized effectiveness 

trial was carried out in 18 PHCs covering a population of 1.1 million. In her presentation, 

she provided a brief background of how Supportive Supervision was mainstreamed in 

overall programming. 

Title of Project: Impact of the Indian Integrated Management of Neonatal and 

Childhood Illness Strategy on Neonatal and Infant Mortality in Haryana, India. 

Duration: 2012 

Implementing Agency: UNICEF, WHO, Research Council of Norway in collaboration 

with Government of Haryana. 

Coverage: 18 PHCs covering a population of 1.1 million in Haryana. 

Objectives of the Study 

• y To improve skills of CHWs and health workers to strengthen Supportive 

Supervision. 

• y To ensure optimal implementation of IMNCI strategy through Supportive 

Supervision. 

• y Solve queries/challenges encountered by workers; collect and cross-check 

monthly reports to improve accountability. 

• y To acknowledge and appreciation worker motivation and performance. 

• y To undertake quality assurance through monitoring and feedback. 



33

Focus of Supportive Supervision 

• y Helping workers follow-up all referred cases. 

• y Checking availability of all supplies with workers. 

• y Supervising Women’s Group Meeting conducted by workers. 

• y Providing feedback to study Field Managers, health and ICDS and to workers. 

• y Ensuring all incentives are paid in time. 

• y Improving motivation and performance of workers; undertaking quality 

assurance. 

• y Setting up SNCUs and stabilisation units at district hospitals and peripheral 

government institutions to facilitate referrals. 

• y Mobilising existing system of ambulance services for referral transportation and 

awareness creation. 

• y Involving men in the community and Panchayat. 

Triggers for the Initiative 

At the outset, a range of problems were identified in supervision which included vacant 

positions, high workload of frontline workers, irregular supervisory visits, poor quality 

of supervision, absence of hands-on training, poor motivation of workers, high attrition 

and a scenario where most supervisors came from other cities and towns. 

Implementation 

Extensive planning: Alternative approaches were worked out in consultation with 

Government, covering aspects related to hiring of supervisors, providing transport, 

incentives, skill training and feedback. 

Recruitment: Supervisors were recruited but they reported directly to health and 

ICDS system. 

Training: 8 days IMNCI training was provided as a Health Worker Module followed by 

2 days of the supervisor module by National Level trainers at Government Hospitals 

in Delhi. 

Duty schedules developed: Monthly rosters were prepared and specified number of 

ASHA/ANM assigned for supervision; each supervisor supervised 30-40 AWW/ASHA, 

3-4 ANM and 15-20 TBAs. 

Women-friendly initiatives: Women group meetings were held by ASHAs and special 

medicine depots were opened in their homes. 

Reporting and Monitoring: Apart from checklists and supervisory tasks, there was an 

independent cross check-in with families with new births; and feedback was taken on 

supervisors. 

34 



Leveraging Support through Community Mobilisers: 

Micronutrient Initiative, Bihar 

Dr. Devaji Patil, State Programme Managar, Micronutrient Initiative, India, in his 

presentation shared inputs on quality assurance through Supportive Supervision in the 

context of the Childhood Diarrhoea Management Programme in Bihar. 


Title of project: Childhood Diarrhea Management Programme 

Coverage: 

Phase I: Banka, Bhagalpur, Samasthipur, Sitamarhi, Seohar 

Phase II: Munger, Khagaria, Saharsha, Madhepura, Supaul 

Phase III: Nalanda, Sheikpura, Gaya, Jahanabad, East Champaran 

Implementing Agencies 

MI: Learning from the pilot project. 

State Health Society: Supporting the model in demonstration districts; involving Block 

Community Mobiliser. 



35

Demand 

Generation 

Quality 

care 

Quality 

assurance 

Supply 

adequacy 

Children Investment Fund Foundation: Providing overall support. 

Objectives 

• y To strengthen training component for supervisors and go beyond the one-time 

training effort. 

• y To identify gaps in the programme and address motivation levels of frontline 

functionaries. 

Implementation Strategy 

State level training: This covered field experience, clarity of ASHA/AWW roles, 

introduction to checklists, making the most of field visits and finalising action plans, 

demonstration of ORS/Zinc preparation and compliance level of caregivers to diarrhoea 

treatment. 

Enabling factors: These included support from State Health Society; mobility support; 

state-level training; data analysis and feedback. 

Challenges: Human resource issues and complexity that an MoICs faced when 

dealing with an OPD rate of 250-300 a day made it difficult for them to supervise 

ASHAs in places where there were more than 200 in a block. Absence of continuous 

engagement; reviews at Block level; Supervisors KAP; collection, authentification 

and payment of mobility support; data analysis and feedback issues; and ensuring 

adherence were part of their charter. 

A near absence of a supportive environment; low priority accorded to diarrhoea 

management; facility-level issues; difficulty in coordination and frequent staff turnover 

36 



contributed to slowing down of the programme. In many places the community felt 

comfortable working with ASHAs but not with senior ANMs. Working with the system 

was a challenge but these issues could be resolved as in case of NRHM, when it took 

up issues related to MCH. 

Key Results 

“I have noted how often supervisors listened to me and went away and the work 

remained undone. Now I see a change in their behaviour.They seek my help and 

share their field-level problems with a lot more trust and confidence. This is helping me 

perform better,since problem solving is prompt and the cadre too is motivated.” 

BCM Phase I district 

Blocks Month Visits per 

month 

Proposed 

Expected 

(70%) 

Achieved 

68 10 4 2720 1671 61% 

59 (actual 

trained ) 

10 4 2360 1671 72% 

Select Achievements 

• y Meetings conducted in friendlier setting, making it easier for ASHA facilitators to 

focus on Supportive Supervision. 

• y Above 85% ANM and 2/3 rd ASHA/AWW had knowledge of definition/classification 

of dehydration. 

• y An average 90% ANMs, and 80% ASHA/AWW were aware of age-wise Zinc 

doses. 

• y Zinc Syrup and ORS was supplied to all functionaries. 

• y Use of IPC tools went up significantly. 

• y Number of caregivers who received 10+ Zinc and 2 ORS packets went up 

sizeably. 

• y Over 2/3 caregivers were aware of ORS and Zinc preparation. 

• y Approximately 2/3 FLWs were visited and among them more or less same 

proportion of FLWs visited caregivers on 5 th day or before. 

Discussion 

• y Regarding mobility support, the programme was implemented in three phases. Its 

sustainability will be the key to its success. 

• y Effort must be made to involve the ANM, LHV and/or ASHA facilitator. 

• y Working with the system is always a challenge but issues can be worked out like 

NRHM taking up issues related to MCH. 



37

Next Steps 

New ways of strengthening capacity building of supervisors would have to be identified. 

Field interaction revealed a perceived need for adequate communication tools, 

especially pictorial aids. These should be made available more readily. This along with 

training would help develop their self confidence in interacting with community, under 

varied circumstances, helping bring better results in convincing community members 

on key behaviours. Caregiver-level interaction had potential to increase. Good role 

clarity about themselves and role of ASHA, ASHA Facilitators, AWW and ANMs would 

help them leverage each of these relationships to advantage. 

On-the-job Handholding: Supporting Classroom 

Teaching: Sarva Shiksha Abhiyaan, Ministry of Human 

Resource Development 

Mr Venkatesh Malur, UNICEF, in his presentation shared the process of supporting 

classroom teachers in a programme supported by the government. He cited 

commonality of issues which the education and healthcare sectors faced, namely 

in terms of mobility and keeping their respective cadres motivated. The classroom 

teaching project supported teachers in schools, building capacity of teacher educators 

at cluster, block and district levels. It looked at the individual teacher and surrounding 

systems which needed to be capactitated, while providing on-site support. 


On-site school support existed only on paper but at school level, the system was 

negligible in terms of mobility, infrastructure, basic issues of textbooks not coming on 

time etc, making it imperative to enhance teacher performance. This was realised post 

Plan of Action in early 2000 and the project was piloted in Karnataka before feeding 

into a national plan. 

Title of project: Advancement of Educational Performance through Teacher Support 

(ADEPT) 

Time: 2006 onwards 

Objectives 

• y To identify performance standards for teachers, head teachers; teacher trainers; 

teacher support institutions. 

• y To develop strategies to reach standards. 

• y To identify gaps in desired and present performance. 

• y To evolve appropriate strategies to bridge gaps. 

Implementing Agencies: An MHRD-UNICEF initiative, ADEPTS worked closely with 

NCERT, national and state-level experts and institutions. 

Triggers for Mainstreaming Supportive Supervision 

• y Training inputs into teachers tends to focus on coverage, rather than translate 

into classroom performance. 

38 



• y Absence of performance benchmarks/standards for teachers, trainers, or CRC- 

BRC-DIETs. 

• y Insufficient means of assessing performance, or directing inputs towards desired 

improvement in classroom performance. 


Planning meetings and field visits: In 2006 a regional consultation was held in three 

regions to develop standards; in 2007, across the state, field visits were carried out 

to test and contextualise standards; final round of consultations were held to develop 

state-specific standards; strategy matrix – action plan was developed to improve 

performance; a national support plan emerged and MHRD issued a Government Order 

to integrate ADEPTS into Annual work plans for SSA. 

Understanding ground realities: 5 million school teachers across 1.3 million schools; 

teacher absenteeism of 24%; ASER - National figures showed that only 58% children 

in Class 5 could read Class 2 level text; quality was a serious issue; review of teacher 

development practices was under consideration – however, there was no standard 

benchmark to see how teachers performed in classrooms; tools and capacity to assess 

supervisors was missing; and classroom teaching process was not captured; teacher 

support system – CRC, BRC, DIET too needed improvement. 

Developing performance standards/benchmarks: Performance standards/ 

benchmarks for teachers, trainers and support institutions were identified; gap between 

desired standard and present performance of teachers and development/ support system 

was assessed through peer state review, involving cross-state visits; in-depth review of 

in-service teacher training and support practices in SSA states, involving state teams and 

resource persons was conducted; states were helped to customise and contextualise 

emerging benchmarks/standards, appropriate strategies to help states bridge gaps in 

performance evolved and were incorporated in AWPBs. These were implemented, in 

many states, strategies/ programmes in an indicator-based, phased manner. 

Developing a consultative evaluative process: This was developed at the district 

level, helping teachers provide solutions to their own quality improvement problems 

rather than having the state academic body or directors giving a directive.This was 

not imposed and teachers worked to put it into a system. Implemented as part of SSA 

ADEPTS Benchmarks 

• y Performance was seen as what a person actually does as part of his 

professional requirements, in keeping with his context and abilities. 

• y Benchmarks identified comprised of performance statements and 

indicators. 

• y Indicators for each performance statement categorised according 

to four levels of difficulty, providing a ready reckoner, or means 

of assessing level of teacher performance and desired next 

improvement. 

• y Benchmarks for teachers covered the four broad dimensions (or 

‘environments’) that covered her ambit of work: cognitive, social, 

organisational and physical. 



39

framework, it became a part of the system and was integrated thus, and thereafter 

factored into their work plan and budget. This was done in a phased manner, taking 

3-3.5 years to move across the state. 

Peer assessments and school visits: State field teams undertook peer assessment for 

each other. This worked well allowing them to share and learn from one another. School 

visits happened for three months and monthly meetings were done at the cluster level 

where teachers shared/analysed findings of the process and went back to baseline to 

see what they achieved. Decision making happened at monthly meetings. They did not 

go back to Director or state MoIS. Everything happened at block and cluster level. 

Ownership and enthusiasm: Teachers and cluster resource coordinators felt involved 

since they were part of something they were creating. This was embedded in the 

national and state planning frameworks with proper allocation of budgets and issuance 

of directives/government orders. 

Outputs: A range of standards and tools were developed and tested. These included 

Standards for Teacher Performance/Trainer Performance/HMs, CRCs, BRCs, DIETs 

and SCERTs. Also state-specific versions of standards, tools (for assessing current 

performance against standards), Peer State Reviews, Desk Reviews of Teacher 

Training and inputs towards improved planning for quality improvement would need to 

be developed. 

Including in annual SSA work plan: The programme was implemented in the planning 

process of the annual SSA work plan. Performance standards were reviewed, baseline 

was done, enabling conditions provided and then rolled out in schools. Preparations 

were done in regular schools at block and cluster levels. Resource groups were created 

at state, block and district level and implementation of the process was done through 

in-service teacher training that provided 20 days budget for training in a year. 

Teachers’ standards divided into various levels of difficulties: These included 

cognitive dimension to understand background of children and their academics levels; 

social dimension to create warm and attractive emotional environment; physical 

dimension to encourage children to maintain the school and keep their class tidy; 

organisational dimension to ensure teacher arrives on time and stays till closing time. 

Establishing partnerships: State Core Teams (SSA + SCERT); State Field Teams to 

undertake Peer Assessment; National Core Team (involving NCERT & MHRD); MHRD 

supervision and TSG support; National Coordinator and UNICEF support at different levels. 

Next Steps 

The initiative would need to be further embedded into the education system at the 

state level. It would need involvement of Teacher Associations; refining of standards to 

make it more contextual; capacity building of teachers, head teachers, CRCs & BRCs 

linked to Adepts; strong Code of Conduct for teachers and administrators to create 

greater ownership and definitive statements like, “I will not let any child be abused in 

my school”. Some of the inherent systemic limitations would need to be overcome, like 

there being too much focus on documentation; short-term duration of teachers; and 

lack of consistent leadership. 

40 



Discussion 

• y When the process was completed and reviewed in 2010, it was acknowledged as an 

innovation because it was a consultative process involving the ministry and states. States 

which voluntarily came forward had the consultative workshops first. The project was 

implemented in districts which had good staffing structures (not many transfers and vacancies). 

The process evolved from there and workshops were held at that level. 

• y There are no short cuts when dealing with frontline functionaries. If they have to be motivated, 

their experiences must be listened to. 

• y If you ask them to come to a district or state-level workshop, only a district official will speak. 

But, by going away from district headquarters and state capital to where they organise the 

workshop, a lot more facilitation and positive actions would be seen. 

• y The process was led by the state and national teams, including technical support group which 

acted more like a facilitator. 

The consultative process led to ownership and pride, allowing schools to learn from 

each other. They visited blocks; developed standards and implemented them; localised 

and contextualised standards; experienced openness that allowed a certain level of 

observation in a classroom during cross visits; was open to analysis and allowed 

decision making at block and cluster level with the district vouching for it, making the 

initiative sustainable. 

The Session chairman concluded by saying that legitimacy of supervision had to start 

and a policy initiative would be a good way of legitimising it. To enable supervisors 

to perform better, an established review system had to be established (monthly or 

quarterly), data understood, and greater role clarity and accountability with better grip 

on cost implications needed. 

Recap of discussions 

provided by 

Dr. Pavitra Mohan 

Summarising key takeaways from the 

first day’s presentations, Dr. Mohan 

acknowledged the consensual sentiment 

across the board, pointing towards the huge 

supervisory structure within the government 

health system needing joint supervision, 

guidelines and directives. Supervision was affected by a non-regular cadre, large number of 

vacancies and transport issues. There was need for significant expansion of support structures 

at the sector, block and district levels; collateral/ peer supervision; drawing lessons from NRHM; 

increased outlays and human resources; improved coverage and declining mortality; renewed 

emphasis and clear guidelines. An explicit Supportive Supervision Policy was needed along with 

sanctioning of resources within PIPs. 



41

SESSION 5: Strengthening Supportive Supervision for 

Immunization 

The discussions in this session covered different aspects of Supportive Supervision 

within facilities (primary /community health centres/district hospitals) and communities 

at state, district and block levels. Their suggestions, based on experience, served as 

valuable inputs in outlining a skeletal roadmap that could guide Supportive Supervision. 

Dr. Rajeev and Dr. Bhupendra Tripathi from ITSU, in their presentation talked 

of intensifying Routine Immunization (RI) Programme in high-focus states and 

strengthening Supportive Supervision. Dr. Rajeev said that whenever there was talk of 

intensifying RI, there was talk of Supportive Supervision. He agreed that the supervisory 

cadre was deficient, needing continuous attention from programme managers. While 

supervisors did not need to know everything to guide frontline workers, they had to have 

the wherewithal to identify issues and advise higher offices for appropriate programme 

interventions. According to him, all current best practices had a “Resource Support 

Approach” which was at a significant cost. 


India’s national immunization status stood at 61% 6 with Uttar Pradesh, Bihar, Rajasthan 

and Madhya Pradesh contributing 2/3 rd of the country’s unimmunized cohort. Annual 

Health Coverage (AHS 2011) showed significant improvement in Bihar, MP and 

Rajasthan though special efforts were needed in low performing states to improve the 

national average. 

Title of Project: Regular Appraisal of Programme Implementation in District (RAPID): 

A model of Supportive supervision. 

Implementing Agencies: USAID and WHO. 

Coverage: Select districts of Jharkhand and Uttar Pradesh and Haryana. 

Objective 

To improve programme performance at district and sub-district levels for Immunization. 


Supportive Supervision is a key component of Reach Every District (RED) strategy 

formulated in 2002 by immunization partners to improve immunization coverage. It 

includes five components and has Supportive Supervision as a focus area. The subject 

had no systematic approach in the country’s Universal Immunization Programme 

(UIP). Development partners, especially MCHIP, UNICEF and PATH, in collaboration 

with state governments, medical college and NGOs applied modified models of RED 

strategy and Supportive Supervision in poor performing districts of many states. 

6 

Latest UNICEF Coverage Evaluation Survey (CES 2009) 

42 



UNICEF operates in Karnataka, West Bengal, Orissa, Gujarat and Rajasthan and 

works through medical colleges with allocation of districts. Here, weekly monitoring and 

mentoring is carried out and monthly feedback provided at district level. For MCHIP, the 

model was revised for periodic assessment – RAPID, where after six months there was 

dissemination of findings, preparation of improvement plan, and training, and repeat 

follow-up assessment after 6 months. In select districts of Jharkhand and UP, district 

consultants were deployed for regular follow-up and mentoring. A collaboration with 

UNICEF and WHO for RAPID in UP and Jharkhand was carried out to support NRHM 

in Haryana. 

Issues that make Supportive Supervision difficult 

Little involvement with states: Current models of Supportive Supervision in UIP met 

with limited success because they were led and coordinated by development partners 

with little or no initiative from states. They had a “Resource Support Approach” and 

needed significant cost. Also, wherever it was carried out, it was episodic, sans regular 

hand-holding or mentoring and whatever mentoring was done, it did not ensure the 

capacity within the system. 

Scalability and sustainability: These models would be scaled up by building current 

technical, managerial and human resource capacity within the government system 

which are currently a major challenge. 

Constraints in UIP systems: Inadequate human resources across cadres with many 

vacant positions; no plans for regular training and capacity building of available staff; 

deficient technical and managerial capacity at state, district and block/PHC (lack of 

structured programme management approach to diagnose/solve problems). 

Suggestions and Next Steps 

An intensification plan was prepared keeping in mind that poor performance was due to 

lack of structured management approach. To support frontline workers, first priority had 

to be given to create a proper management support system at all levels; and Supportive 

Supervision was needed across levels. Sustainability will require mobilisation of 

resources from within the health system. Support from partners too would be essential 

in the initial phases for capacity building. An overall strong data management and 

monitoring system would be needed to guide programme interventions. 

A proposed intensification plan included augmentation of human resources from 

NRHM/state to strengthen/ establish Programme Management Cells at all levels; to 

develop strategic technical and management capacity within the system; create teams 

to support districts, PHCs and health workers through Supportive Supervision and 

mentoring approach; strengthen institutional mechanisms for programme oversight 

and monitoring; establish task forces at state and district level; leverage expertise and 

experience of development partners for capacity building of people in the system, and 

to ensure quality in the initial phase; besides implementing modified RED strategy with 

special emphasis on Supportive Supervision for improving performance of frontline 

health workers; and developing a central repository of data at state under state RI cell. 



43

In the State immunisation team, state EPI officer will be in charge and will be supported 

by State Immunisation Manager, Coordinator and State Immunisation Coordinator and 

Distirct Support team, depending on number of districts the state has. Also, for vaccine 

and logistics, there will be dedicated people supported by supportive staff. Similar 

model will be followed at district level on smaller scale where District Immunization 

Officer will be supported by a team to run the programme and at block level the Block 

Medical Officer will be duly supported. In the next phase, there will be more clarity on 

how to implement the SS model. 

Programmes need to be designed keeping local context in mind. MCHIP had brought 

out a small model which was a short-term duration process for fault-finding. If provided 

quantitative status, it would involve state, district, block and field staff. The model did 

not involve anyone from outside the district. Involvement was only at the inter-block 

level. Issues were identified and discussed within 3-4 days and all discussions were in 

quantitative manner. It was like a regular appraisal programme in the district and could 

apply to any programme. 


The programme followed the RED strategy which had two components. RAPID helped 

undertake regular views of the RI programme in the areas of programme management; 

cold chain, vaccine and logistics management; injection safety and immunization 

waste disposal; records, reports and use of data for action. By improving quality of 

immunization programme, it hoped to improve vaccination coverage. 

The project helped undertake periodic assessment of all facilities and select session 

sites, ensuring on-site correction and providing on-site capacity building through 

demonstrations. It also used data for action and follow-up. The programme was 

conducted on a 6-monthly basis and could be further customised. It was completed 

in 3-4 days, providing feedback to all cadres of health functionaries; informing gaps; 

and facilitating corrective actions at each level. It helped scale-up the RAPID process 

and was led by results. The Government of Jharkhand scaled up RAPID in all 24 

districts through NRHM funds (2011-12 & 2012-13). In UP, it was rolled-out in 32 poor 

performing districts (out of 75) along with UNICEF. Government of Haryana is scaling 

up RAPID in all districts. It was also piloted by State Governments of MP and Odisha. 

Key elements of RAPID included the 3 ‘R’s, namely right supervisor, right tools and right 

resources. The 3 ‘W’s were addressing issues related to where, when and what. Team 

approach aimed for capacity building of health system staff; which was further facilitated 

by external supervisors with full participation of the District and Block Medical Officers. 

Results of 5 rounds of RAPID conducted in focus districts of Jharkhand in all the cold 

chain points saw facilities graduating from 36% poor, 55% average and only 9% good 

(during round 1) to 0% poor, 25% average and 75% good (at fifth round).For effective 

RAPID round it was important to inform facilities about supervisory visits in advance; 

follow-up on recommendations made during previous visits; collect latest materials, 

and supplies for the health centre; spend sufficient time; schedule return visit before 

leaving the health centre; and ensure each visit was useful to health centre staff. 

44 



SESSION 6: Supportive Supervision for Facility-based 

Perinatal Care 

Strengthening Capacity for Service Delivery: Family 

Friendly Hospital Initiative 

Dr. Prasanth, FFHI informed at the outset that the initiative was an in-house quality 

certification programme. It had evolved over a period of time and much of the experience 

was related to Bihar. Introduced in Bihar in 2008 with district planning process under 

NRHM, in early 2009,it facilitated the creation of a State Quality Assurance Cell 

within civil society. At that time FFHI worked with a meager staff and the Supportive 

Supervision format was prepared by civil society. The checklist was very objective and 

the Comprehensive Format with Qualitative & Quantitative information had an MOV & 

Scoring. The state quality assurance cell prepared a Schedule of Visits, communicating 

the same to all districts. This information had to be sent within 3 days to the cell. Where 

visit was not made, the reason was communicated and a substitute sent in some cases. 

Alliances and feedback were in-built into the process. 

Key Highlights 

• y No new standards defined (IPHS). 

• y Quality Assurance and Supportive Supervision carried out with initial 

handholding followed by on-site mentoring. 

• y The Vision – Family reflected strong attitudinal change, helping ownership of 

process. No third party was involved and effort was made to involve and take 

care of all groups– mother, child, man. 

• y Focus was on implementation of existing quality standards and improving 

performance by utilising existing HR and financial resources by facility team. 

• y Community feedback and skill labs for competency-based training followed by 

mobile mentoring, leading to an enabling environment and recognising good 

performance. 

Results 

Gujarat implemented the programme and UP was one of the first to implement among 

high focus states though it showed slow progress. In Bihar, all DPs (BMGF & CARE 

(8), DIFD (7) and UNICEF (5) agreed to take up the FFHI process for the assigned 

districts; currently 184 facilities are at various stages of progress. In Jharkhand, 17 

district hospitals took it up and so far 4 certifications are ready. 

Supportive Supervision for FBNC: Experience from 

Tamil Nadu 

Prof. J. Kumutha, ICH & HC, RCC Chennai in her presentation talked of developing a 

structured schedule for visits in consultation with Special New Born Care Units (SNCU). 

The project was developed in 2009 as a facility-based new born care unit where one part 

was dedicated to mentoring and monitoring. It assessed implementation; strengthened 

skills; developed standard clinical practice of perinatal and neonatal care; built optimal 



45

infrastructure, ensuring adequate supply of equipment; continued support for quality 

service delivery; undertook data collection and analysis; and provided technical support 

to state NRHM. 

The process entailed developing a structured schedule for visits in consultation with 

SNCUs; capacity building; on-site visit/support and off site support; standardised 

monthly reporting; feedback services; and interactive discussion with all SNCUs by 

video conferencing. It provided support through personal visits; monthly statistics 

analysis & feedback; visits by administrative heads; review meetings every 2 month / 

video conferencing; annual refresher training; and team visits. The team comprised of 

Monitoring: Professor / Asst. professor/ DM (neo) post graduates – ICH &HC; RCC 

coordinator / RCC Clinical Nurse; Staff Nurse from ICH. 

Components of mentoring included checking for availability (space, manpower, 

equipment, drugs); capacity building (Nodal officer – SNCU; SNCU MOs; obstetricians; 

staff nurses of SNCUs, LR, PN ward and OT; Cleaning staff/Security); delivery of 

obstetric and neonatal care (Protocols in place, Skill & Technical guidance, Perusal of 

46 



ecords and data collection); assessment report (To SNCU; administrators; district & 

state). 

Implementing Partners: UNICEF; EKAM (NGO); SRHM, TNHSP; GVK-EMRI; SECT 

(NGO), NCC. 

Assessment was carried out of clinical practice (admission and discharge policy, 

resuscitation, early initiation of breast feeding, KMC, early introduction of feeding, use 

of antibiotics, infection control and post natal rounds); critical review of performance 

(infrastructure, power back-up, oxygen source, lab facility); capacity building. 

Results 

• y Admission policy and Antibiotic policy: Admission & Referral Policy were 

standardised; antibiotic usage streamlined; microbial culture facility not available 

in all SNCUs. 

• y Where infrastructure was concerned, it was found that space for neonatal care 

was adequate but space for mothers, storage and soil area was inadequate. 

• y Oxygen source was central but not 24 hours though other sources were 

adequate. 

• y Electricity situation saw frequent power cuts and generator back-up was not 

uniform. 

• y There were maintenance issues with regard to equipment and drugs with 

problems related to pulse oximeter probe, temperature probe of warmer and 

infusion pump; a tie-up with NGO- EKAM for equipment maintenance addressed 

some of these issues. 

• y IV fluids and drugs were found in adequate supply. 

Enabling factors: These included timely flow and proper utiisation of sanctioned funds, 

cooperative hospital heads, creating academic environment, supportive feedback, 

listening and finding solutions. 

Challenges: Included poor follow-up of SNCU graduates, neonatal transport, attrition 

of trained staff nurses/doctors, inadequate salary, round-the-clock oxygen and 

uninterrupted power supply, inadequate lab services, database standardisation and 

getting time/permission for visits. 

Lessons learnt: Better understanding of problems at ground level; documentation 

not given importance; reciprocal relationships working better; administrative support 

being of critical value; sustained effort needed for quality improvement; systematic 

reinforcement needed. There was also need for commitment, time and contribution to 

community, with funding options. 

Next steps: Include follow-up clinic services, tracking of SNCU graduates, capacity 

building of mentors and expanding the teams and integration with NRHM activities 

including funding. 



47

Parijaat: Improving Quality of Maternal & Newborn 

Healthcare in Public Health Facilities of Rajasthan 

Dr. Sharad Iyenger, from ARTH, Udaipur shared the gist of the programme, Parijaat 

and how it helped bring about a marked improvement in the lives of new born infants 

in the project areas. The project aimed to improve quality of delivery and newborn 

care, in selected high case-load public health facilities of 12 districts of Rajasthan. It 

demonstrated its effectiveness by using quality improvement for better supervision. 

Coverage: Began with 12 districts and retreated to 10. 

Implementing Agencies: Department of Medical, Health & Family Welfare; UNFPA; 

Action Research & Training for Health (ARTH). 


Preparatory activities: Developed consensus in the state on recommended practices 

at each stage of labour; Expert group consultation organised involving faculty of all 

medical colleges; recommendations developed on key delivery and newborn care 

practices in health facilities. 

Strengthening safe practices: All institutional deliveries are not safe and safety itself 

is linked to number of safe practices. The project suggested the following: 

In 2011, conducted orientation training of service providers and managers; strengthened 

SBA training; conducted quarterly quality improvement visits to each facility. 

In 2012, undertook maternal perinatal outcome monitoring; ensured greater involvement 

of block and district managers. 

Strengthened Skill Birth Attendants (SBA) training; assessed gaps in training 

infrastructure and quality; Training of trainers of SBAs (24 batches-410 trainers & 

senior NMs); facilitated improvement in training processes. 

Undertook Quarterly Quality Improvement visits and worked with project personnel and 

people from the state. 

Assessment of facilities: A number of tools were developed to assess quality of 

childbirth and neonatal care services. These included facility assessment checklist; 

delivery observation formats; interviews with women in postpartum wards; and records 

review. Some of the findings of the assessment carried out in 88 facilities revealed: 

• y Many irrational practices continue with the most critical pertaining to 

augmentation of labour. 

• y The project made use of Social Science Post Graduates trained by Parijat. They 

were supported with PPTs, capsular videos and information and trained on finding 

gaps and using appropriate resources, many of which were taken from already 

developed archives of UNICEF and other development partners. 

• y Adherence to current practices as also new born care and breast feeding 

initiation improved. 

48 



There were things that did not improve. For instance, hand washing before conducting 

delivery was 7% before intervention and remained at 7%. Post partum check-up 

declined and there was little effort to go and see the mother and new born immediately 

after delivery. 

Next Steps 

Greater participation of health department officials in quality assurance exercise 

(quarterly AFTA cycles) will strengthen all aspects of maternal and newborn health 

care. Cost of quality assurance visit currently comes to Rs 8000-9000 which can come 

down with better economies of scale. Monitoring of maternal and perinatal outcomes 

by facilities would be the best motivator, since most clinicians thrive on practice. Further 

development of in-facility short training capsules on priority topics using multi-media 

technologies need to be explored and expanded. Preparation of “tool-kit” to implement 

such an intervention in other districts or states would help promote adherence to 

protocols and promote productive work culture. There is also need for action in medical 

colleges to act as role models demonstrating ethical behaviour and norms. 

Ensuring maintenance of equipment and a supply chain in a decentralised environment 

would further add to the quality of the intervention. 

SESSION 7: Group Work 

Dr. Pavitra Mohan, Health Specialist, UNICEF guided participants on forming two 

groups and shared the terms of reference for the activity. He informed that each group 

would have a rapporteur and presenter to work on themes that helped suggest support 

structures for integrated primary health care. Group 1 was asked to suggest support 

structure for Supportive Supervision from community to sector, block, district and state 

level. Group 2 was asked to suggest support structure for Supportive Supervision from 

facility/sector level. 

Both were asked to examine existing structures and present their thoughts on need, 

if any, for additional partnerships and engagements; look at resource depleted 

conditions and spell-out resource constraints before suggesting remedial action. 

The HR component merited discussion with ratios, tools and guidelines, partners, 

skills and training perspectives.The processes needed discussion around frequency, 

scheduling of visits, interface between supervisor and supervisee, review of meetings, 

decentralised planning and telecommunication. The groups were asked to suggest 

policy inputs to make this functional. Both presentations had to outline way forward in 

preparing guidelines, manual and roadmap, suggesting short, medium and long-term 

Supportive Supervision plan. 

GROUP 1: Supportive Supervision for Facilities 

Based on their understanding of the current status of PHCs, the group presented their 

suggestions. They were of the view that regular monitoring structures needed to be 

viewed from a different lens than those seen from a supervisory point of view. All levels 

of facilities called for regular Supportive Supervision, be they at PHC, block or district 

levels. For district hospitals, supervision could be provided by experts from medical/ 

nursing colleges, civil society and professional bodies. The cadre had to be a dedicated 



49

one with clear accountable roles and responsibilities. For convenience, they could be 

based out of the District Training Centre (DTC) or ANM Training School. The trainer 

could adopt the role of mentor and DTC, with Principal as Nodal person. The Supportive 

Supervision cadre should comprise of a team with expertise in clinical and non-clinical 

areas, with staff deputed from district administration structure and staff responsible for 

Supportive Supervision. Specific to PHCs, following suggestions were made: 

• y Define quality package and what needs to be supervised (clinical and nonclinical). 

• y Supervision to be integrated across national programmes. 

• y PHCs to be visited on bi-monthly basis by nurse mentors for general supervision 

complemented with less frequent visits (semi annually) by expert clinicians. 

• y Clinicians from FRUs to undertake clinical mentoring, facilitating linkages and 

referrals. 

• y PHC teams to be involved through self assessment and action planning, 

facilitating formation of facility quality improvement committees. 

• y Liasing with programme officers to be key; supervisory staff to meet programme 

officers every month to bring up system level issues for action. 

• y Regular administrative structure led by CMO to monitor implementation of 

Supportive Supervision visits. 

• y Strive for greater integration with DQA and move from knowledge to practice. 

GROUP 2: Supportive Supervision for Community 

The group strongly advocated for the need to adopt team-based approach in the 

community where ASHA, AWW, ANM worked together and where there was teambased 

supervisory structure. Currently, they work in three separate silos. Many positions 

need to be filled. Sometimes as many as 60 AWW are supervised by one supervisor. 

The group recommended a team-based approach within the community. Some of their 

suggestions included: 

50 



• y Joint supervision of Block Health Educator, LHV, Medical Officer, AYUSH 

Doctors, BPM, CDPO, others. 

• y Focus on both sector and block level. At sector-level there is ASHA supervisor on 

a ratio of 1:10 to 1:30; here AWW supervisors could come together and at blocklevel 

there could be rationalisation of deployment of supervisee team. 

• y Work with block health educators, block programme manager, AYUSH doctors, 

medical officers and LHVs who perform supervisory tasks. 

• y Form combined “District Health and Nutrition Society” as opposed to DHS that 

exists currently, encourage joint planning and oversight at district level. 

• y Build resources and capacity by developing soft skills to enhance confidence, 

management and interpersonal skills. 

• y Establish Supervised Focused Resource Centre focused on capacity building for 

supervisors. 

• y Have an AYUSH medical officer and allow him/her to link and integrate health 

and ICDS. Serving as a programme manager, let him work at sector level, 

coordinating between health and ICDS supervisor. Also, at policy level make sure 

he is conversant with all programmes. 

• y Give priority attention to supervisors’ report. 

• y Way forward to include mapping of existing tools/checklists to assess what works 

and what does not. 

• y Based on new team-based supportive supervision approach, define consolidated 

protocols for supervisory visits that integrate those from health and nutrition. 

• y Begin aligning sector/block/district level teams to integrated approach. 

Dr. Ajay Khera, responded to the group work and remarked that it was imperative 

for the sub-centre to be manned by the right people and to find ways of attending to 

every person who walked in for advice or check-up. He stressed that the centre had to 

be part community and part facility-based. It could not afford to be dependent only on 

ANM but needed 5-6 health workers. By having an integrated model, it could address 

some of these gaps. Integration would have to go beyond all RCH and other national 

programmes. 



51

Recommendations 

Based on presentations of the two days followed by discussions and group work, 

Dr. Pavitra Mohan, Health Specialist, UNICEF, outlined a set of recommendations. 

Support structures were identified in the context of NRHM and ICDS innovations, 

guidelines and checklists on Supportive Supervision. These can be embedded within 

institutional mechanisms. Suggestions covered entire integrated PHC care cycle, 

including community, sector, block, district and state resources, eventually contributing 

to strengthening health outcomes at community level. The proposed recommendations 

for frontline workers and facility-based service providers are mentioned under five 

broad heads: 

There was consensus amongst government officials, health care experts and donors 

that Supportive Supervision (SS) within the health care context, enhanced performance 

and assured integration of an entire primary health care system, contributing to greater 

efficiency, effectiveness and equitable health outcomes. It promoted quality at all levels 

by strengthening relationships; identifying and resolving problems; optimising resource 

allocation; and promoting high standards of team work and two-way communication. 

In other words, through regular and dependable interaction between a worker and a 

more experienced professional, it identified and solved problems, improved services 

and advanced skills and knowledge. 

The groups also felt that though increased investments in healthcare were leading 

to improved coverage (institutional births, immunization etc), improvement in quality 

of care had not been commensurate. In many Joint Review Missions and Common 

Review Missions, the absence of supportive supervision was identified as a critical 

bottleneck in improving performance of health staff and in delivering quality services. 

The RMCHA strategy recognised the need to strengthen supportive supervision of 

frontline workers (ASHAs, ANMs and AWWs) and service providers (staff nurses and 

medical officers), while providing a roadmap (short- to-medium term and long-term) for 

the same. 

52 



Key challenges in providing supportive supervision: 

Inadequate numbers of supervisors within the system: as an example, in many states, 

there is as much as 30-40% shortage of LHVs, and even larger shortage of Sector 

Supervisors. 

• y Restricted mobility of supervisors constrain the field supervision. 

• y Lack of “supportive” skills due to lack of training. 

• y Absence of authority to ensure compliance. 

• y Vertical programs with vertical supervision lead to fragmentation. 

• y No clear guidelines for supportive supervision. 

• y Absence of a supportive supervision policy. 

SUGGESTED ROADMAP: Short-medium term 

Supportive supervision of health facilities (focusing on delivery points: select 

sub-centres, 24X7 PHCs and CHCs): 

Engage generalist RCH nurse supervisors at block and district level: Some states 

have Block and District Public Health Nurses, who supervise staff nurses of PHCs in 

the catchment area. Expansion of such nurses in all high focus districts will strengthen 

Supportive Supervision. Different modalities can be utilised to engage these nurses. 

This can be done through regular recruitments, contracting out by the district health 

society and partnering with nursing institutions. Clear terms of reference will have to 

be prepared for these nurse-supervisors, providing them with required authority; and 

giving them with training in technical and supervisory skills. The District Public Health 

Nurse can be a part-time faculty of the district nursing or ANM training school. 

Prepare a clear plan of supervision: In addition to nurse supervisors, engage 

specialists in pediatrics and obstetrics of the district for Supportive Supervision of 

doctors and nurses in identified facilities. It may be useful to engage district and block 

programme managers and officials in the supervisory team. While the generalist 

nurse supervisors will make more frequent field visits for supervision, the officials and 

specialists can join in periodically (say, quarterly). Provision must also be made for 

adequate mobility allowance to ensure that she carries out the required field visits. 

Engage Medical College faculty for supportive supervision of district hospitals: 

Supportive Supervision by ICH in TN has led to significant improvement in quality of 

maternal-newborn care in 8 districts. Similar engagement of other medical college 

faculty in other districts will be helpful. 

Prepare integrated guidelines and checklists for supportive supervision 

Supportive Supervision of frontline workers 

Build skills of ANMs in ensuring supportive supervision of ASHAs and AWWs: 

While ANMs do perform supervisory functions informally, their skills in Supportive 

Supervision are limited. 



53

Engage available human resources in Supportive Supervision of frontline 

workers 

Potential supervisors of frontline workers: LHVs, ASHA supervisors, ICDS 

supervisors and AYUSH doctors can be trained as supervisors. Many states have 

used these human resources creatively for Supportive Supervision of frontline workers 

(for example, Orissa engages AYUSH doctors and ICDS supervisors in Supportive 

Supervision of the frontline workers). 

Strengthen ASHA support structures: Ensure presence of skilled ASHA facilitators 

at sector, block and district level backed by institutions for training and support. 

Use innovative ways of supervision using Information-Communication 

technology. 

Institutionalise non-financial incentives and recognition systems. 

Build supervisory plans, checklists and guidelines incorporating the above. 

SUGGESTED ROADMAP: Long-term 

Prepare a supportive supervision policy with clear line accountabilities, authority and 

support structures. 

54 



Annexure 1: 

Programme Agenda 

Consultation on Supportive Supervision 

to 

Strengthen Capacity of Frontline Workers and Service Providers 

MoHFW, MoWCD and UNICEF 

Draft Agenda 

22 nd – 23 rd November, 2012 

Vice Regal Hall, Hotel Claridges, Aurangzeb Road, New Delhi 

Workshop Objectives: 

• y Build a common understanding of Supportive Supervision as an effective 

capacity building/performance improvement tool for front line workers. 

• y Share and document good practices on supportive supervision. 

• y Identify opportunities to incorporate supportive supervision into existing systems. 

• y List concrete options/steps to address the challenges discussed. 

• y Provide a broad roadmap and action points towards implementation. 

• y Collate inventories of tools/aids and technologies to facilitate supportive 

supervision. 

DAY 1 – 22 nd Nov 2012 

Time Topic Facilitator 

09:00-09.30 Registration 

09.30-09.50 Welcome, Introductions and 

Expectations 

09.50-10.15 Emerging Needs and Responses 

for Strengthening Supportive 

Supervision: MoHFW 

Dr. Henri van den 

Hombergh, UNICEF 

Dr. Rakesh Kumar, Joint 

Secretary, Ministry of 

Health and Family Welfare 



55

10.15-10.40 Emerging Needs and Responses 

for Strengthening Supportive 

Supervision: MoWCD 

Dr.Shreeranjann, Joint 

Secretary, Ministry 

of Women and Child 

Development 

10.40-11.00 TEA 

11.00-11.30 Theoretical Framework for 

Supportive Supervision 

Dr. Jon Rohde, 

Ex- Country 

Representative, UNICEF 

India Country Office 

(Session through Webex) 

11.30-11.50 Comments Ministry of Health and 

Family Welfare 

11.50-12.10 Moderated Q & A Dr. M.E. Khan 

12.10-13.00 Innovations and Good Practices 

(Thematic: 15 minutes each) 

13.00-14.00 LUNCH 

Integrating Supportive Supervision in 

Systems SHSRC, Chhattisgarh 

Outsourcing supervision and building 

blocks with block supervisors: Aligarh 

Muslim University/UNICEF 



Strengthening systems of 

supervision: Vistaar, Intrahealth 

Integrated Family Health Initiative: 

Early experiences: CARE 

Key incentives to support 

supervision: Society for Applied 

Studies 

Leveraging support through 

community mobilizers: MI, Bihar 

15.00-15.30 Discussants Panel and Q and A 

Mr. Prabodh Nanda, 

SIHFW 

Aligarh Muslim University 

and UNICEF 

Ms. Madhuri Narayan 

Dr. Shreedhar 

Dr.Sarmila Mazumder 

Dr.Devaji Patil 

Discussants: Dr. Ajay Khera, Deputy Commissioner and Dr. Kali 

Prasad Pappu, UNOPS 

15.30-16.00 Activity: Visualization in participatory process (VIPP) 15 minutes 

16.00-16.15 TEA 



On the job handholding: Supporting 

classroom teaching: Sarva Shiksha 

Abhiyaan, MoHRD 


Mr. Venkatesh Mallur, 

UNICEF 

Discussants: Dr. S.K. Sikdar, Deputy Commissioner 

Chair: Dr. M.K. Bhan 

56 



DAY 2 – 23 nd Nov 2012 

Time Topic Facilitator 

9.00-9.30 Recap of Previous Day: Identifying 

Issues and Options 

09.30-10.00 Strengthening of Supportive 

Supervision for Immunization 

10.00-10.45 Supportive Supervision for Facility 

based perinatal care: 

Family Friendly Hospital Initiative: NHSRC 

Institute of Child Health- Chennai 

ARTH, Udaipur 


11.15-11.30 TEA 


UNICEF 

Dr. Rajeev and 

Dr. Balwinder, ITSU 

Dr. Prasanth, FFHI 

Dr. N. Kumutha 

Dr.Sharad Iyenger 

Discussants: Dr. Himanshu Bhushan, Deputy Commissioner and 

Dr. Paul Francis, WHO, India 

Chair: Dr. T Sundaraman, NHSRC 

11.30-1.30 Parallel Sessions: Thematic Group Work 

13.30-14.30 LUNCH 

Guidelines on Supportive Supervision for: 

Front line workers 

Facility based service providers 

(Group work to identify, in the context of 

NRHM and ICDS: innovations, guidelines 

on supportive supervision and checklists, 

inventory of tools for embedding in 

institutional mechanisms, improvement/ 

learning: training, remunerations, on the 

job hand holding, support tools, job aids 

and technology tools) 

Plenary and Reporting Back – 

Dr. Ajay Khera, Deputy Commissioner 

Dr. Himanshu Bhushan, Deputy 

Commissioner 

Dr. S.K. Sikdar, Deputy Commissioner 

14.30-15.30 Sharing of Key Recommendations: 

Discussion on way forward 

Moderated Session 

Chairs: 

Dr. Rakesh Kumar, Joint Secretary, Ministry 

of Health and Family Welfare 

Dr. Ajay Khera, Deputy Commissioner, 

MoHFW 


15.30 – 16.00 Vote of Thanks and Wrap Up Dr. Henri Van Den 

Hombergh, UNICEF 



57

Annexure 2: 

List of Participants 

1. Dr. Deepti Agrawal, Technical Consultant, NonFw 

2. Dr. R C Agarwal, SAS 

3. Dr. Ritu Agrawal, Maternal Health Consultant, UNICEF, Country Office 

4. Malalay Ahmadzai, Health Specialist, UNICEF 

5. Dr. V K Anand, Health Specialist, UNICEF 

6. Dr. Anita Anasuya, Health Lead, TAST-DFID 

7. Dr. Ashtaq, Senior Advisor, RNE Embassy Norway 

8. Taru Bahl, Independent Communication Consultant & Freelance Journalist 

9. Dr. Bhupendra Tripathi, MCHIP 

10. Dr. Balwinder, Senior Associate, Ministry of Health & Family Welfare/ITSU 

11. Laura Carpenter, Institute of International Education, Delhi 

12. Dr. S Deb, Deputy Commissioner, MoHFW 

13. Dr. S Dutta, Immunization Specialist, UNICEF 

14. Dr. Sheel Dutta, Technical Consultant, ICDS 

15. Dr. Rajeev Gera, Senior Advisor, ITSU 

16. Dr. Satish Gupta, Health Specialist, UNICEF 

17. Dr. Henri Van Den Hombergh, Chief Health Section, UNICEF 

18. Sharad Iyenger, Chief Executive, ARTH, Udaipur 

19. Shivani Jha, Doc Consultant, Micronutrient Initiative of India 

20. Prabhat Kumar Jha, DHNSTC, UNICEF, Aligarh 

21. Dr. M Jagedreram, Health Specialist, UNICEF 

22. Dr. Ghazala Javed, Assistant Director (U), Department of AYUSH 

23. Abrar A Khan, Senior Advisor, Vistaar 

24. Dr. Mohd Arif Khan, Assistant Professor, Department of Sociology and Sociocultural, 

Aligarh Muslim University 

25. M E Khan, Senior ASS, Population Council 

26. Dr. Ajay Khera, Deputy Commissioner, MoHFW 

27. Dr. Suresh Kumar, Research Officer(AY), Department of AYUSH 

28. Farheen Khurshid, Independent Consultant, MIVCD 

29. Dr. J Kumutha, Programme, Head of Department, Neoratology, Institute of 

Child Health, Chennai 

30. Dr. Harish Kher, Technical Officer(CN), UNICEF 

58 



31. Anagha Khot, Project Management Specialist (HRH), USAID, India 

32. Dr. Manpreet Khurmi, Consultant, World Health, MoHFW 

33. Dr. Vijay Kiran, Nahil Team, MCHIP, USAID 

34. Dr. Rakesh Kumar, Joint Secretary, Ministry of Health and Family Welfare 

35. Shimontini Maitra, Senior Programme Coordinator, Child in Need Institute 

36. Dr. Pavitra Mohan, Health Specialist, UNICEF 

37. Prof. Abdul Martin, Chairman, DPO SOC & SCO Aligarh Muslim University 

38. Dr. Sarmila Mazumdar, Society of Applied Studies, CHRD 

39. Dr. Meena, Health Officer, UNICEF, BBSR 

40. Meenakshi, UNICEF 

41. Amrita Mishra, Programme Office, UNOPS-NIPI 

42. Dr. Krishnamurthy, Deputy Project Director, KHDT/VOM 

43. Dr. Kaninika Mitra, Health Specialist, UNICEF 

44. Prabhodh Nanda, Programme Coordinator, SHSRC, Raipur 

45. Madhuri Narayan, Project Director Vistaar Project, Intrahealth 

46. Dr. Narottam, Immunization Officer, UNOPS/NIPI 

47. Dr. Neelam, Joint Director, NIPCCD 

48. Dr. Raj Panda, Public Health Specialist, PHFI 

49. Dr. DevajiPatil, State Programme Manager, Micro Nutrient Initiative, Bihar 

50. Dr. Sandeep K Panigrahi, SPC-IMNCI for UNICEF Odisha 

51. Dr. K Pappu, Director, UNOPS 

52. Dr. Pawan Pathak, National Technical Officer, MCHIP/USAID 

53. Dr. Anju Puri, Senior Advisor, NBC USAID/MCHIP 

54. Dr. Raveesha, UNICEF, National 

55. Dr. Ajit Basanta Roy, State Coordinator RI (AVDS), UNICEF, Bandstand 

56. Prasanth K S, Senior Consultant, NHSRC 

57. Dr. Karan Sagar, Country Representative, MCHIP/USAID, New Delhi 

58. Geeta Sharma, Communication for Development Specialist, UNICEF 

59. Dr. S K Sikdar, Deputy Commissioner, MoHFW 

60. Ajit Kumar Singh, Consultant, NHSRC 

61. Manisha Solanki, Advisor, European Union 

62. Dr. Renu Srivastav, Consultant, Child Health Division, MoHFW 

63. Anna Stratis, Medical Officer, WHP 

64. Dr. Shreeranjann, Joint Secretary, Ministry of Women and Child Development 

65. Dr. TT Sundaraman, ED, NHSRC 

66. Dr. Javvad Suri, Technical Officer, MCHIP/USAID 

67. Dr. R Tandon, Senior Advisor, Save the Children 

68. Dr. Ajay Thakroo, MS UNICEF, Raipur 

69. Bhavani Tripathy, Communication Specialist, UNICEF 

70. Dr. Bhupendra Tripathi, National Lead Technical Officer, MCHIP, USAID 

71. Dr. Sanjiv Upadhyaya, Health Specialist, UNICEF, Hyderabad 

72. Dr. K Vanaja, Joint Director, Government of Tamil Nadu 

73. Dr. Leila Varkey, COO-TNAI-CIN, Trained Nurses Association of India 

74. Mr. Venkatesh, Education Specialist, UNICEF 

75. Jyothi Vynatheya, Research Associate, CGC, Earth Institute 



59

Annexure 3: 

Concept Note 

Workshop on Supportive Supervision i 

Background 

Supportive supervision is a process that promotes quality at all levels of the health 

system by strengthening relationships within the system, focusing on identification 

and resolution of problems, optimising the allocation of resources, promoting high 

standards, team work and better two-way communications (Marquez and Kean 2002). 

While many approaches have been proposed to improve the quality of health services 

(for example, quality assurance, continuous quality improvement, client-centred 

services, district team problem-solving, fully functional service delivery points), the 

supportive supervision approach improves services by focusing on meeting staff needs 

for management support, logistics, and training and continuing education. The goal 

of supportive supervision is to promote efficient, effective, and equitable health care. 1 

In the Health Sector, 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. It also seeks to help build the confidence, 

motivation, negotiation and leadership skills and competencies of the workers. 

Together, the supervisor and health workers identify and address weaknesses on the 

spot, preventing poor practices from becoming routine. Supervisory visits are also an 

opportunity to recognize good practices and help health workers to maintain their highlevel 

of performance. 

An analysis of Supportive Supervision and mentoring in Tanzania’s National AIDS 

Control Programme in 2009, showed positive results such as timely reporting, 

improved supplies management, improved patient management and adherence to 

national guidelines 2 . Health care interviewed for the study specifically perceived that 

supportive supervision was helpful in building their capacity, motivating and improving 

their confidence. Similarly, the Global Alliance for Vaccines and Immunization (GAVI) 

partners has identified supportive supervision as a high priority and a critical gap in 

immunization. 

1 

MSH Ocasional Paper No. 2, 2006 

2 

A Manual for Comprehensive Supportive Supervision and Mentoring on HIV and AIDS 

Health Services, 2009 

60 



Importantly, supportive supervision has also been used in other sectors such as 

education where this element is embedded in the implementation plans of both 

government NGO programmes. Government structures such as Block Resource 

Centres and Cluster Resource Centres provide on-going supervision and support to 

teachers. A combination of pre and in service training, class room observations, monthly 

workshops and teachers’ forums provide ample space for a supportive structure of 

supervision. 

In the corporate world,this approach has been woven into the entrepreneur and 

leadership programmes. A cadre of Shakti women entrepreneurs was created in 

over 12 states to reach out to over 70 millionconsumers for an FMG giant (Unilever). 

Similarly a Building Leadership Trainees programme for the same corporate uses a 15 

month training programme for young recruits to provide organizational support in the 

form of buddies, coaches and mentors toensure that leadership development is not left 

to chance, but is part of everyday life in the organization. 

Clearly then, moving from traditional, hierarchical supervision systems to more 

supportive ones requires innovative thinking and time to change attitudes, perceptions, 

and practices. 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. 

Rationale 

Over the last decade, India has seen impressive economic growth as well as progress 

in terms of human development. The economy has grown while the population below 

the poverty line has been gradually falling. The Government has launched several 

mission-mode flagship programmes on access to basic services such as health and 

nutrition, housing employment and water and sanitation, guided by the principles of 

inclusive growth. 

At the bottom of the pyramid of these flagships, are cadres of front line workers that 

act as important and sometime last mile delivery points of services to the people. The 

front line workers include theauxiliary nurse midwife (ANM) accredited social health 

activist (ASHA), Anganwadi worker (AWW) as well community volunteerswho reach 

out directly to families as part of government implementation mechanisms. 

The frontline functionaries are the interface of service system with the community 

on crucial behaviours related to health, nutrition, water and sanitation. Hence, both 

their capacity building and their quality of exchange with communities and families are 

critical determinants in ensuring families’ receptivity for adoption of essential health 

practices and willingness to access and demand services. 

There is broad agreement then, in the development sector, about rapid developments 

in the profile and responsibilities of front line functionaries. This has clearly necessitated 

an assessment of their skills, capacities and enabling tools to help them perform their 

tasks well. Coupled with this, the current discourse on HR development in the health 

sector provides an opportunity for a complete revamp of the supervisory cadres and 

systems in Health Departments and Integrated Child Development Schemes (ICDS). 



61

Given this context, even though supportive supervision is the weakest process 

in the management of health and related services, there still are opportunities that 

can be leveraged to strengthen this mechanism as a tool to improve motivation and 

performance of front line workers. 

The Government of India rolled out the supportive supervision System (SSS) in 2010, 

under NRHM in 2010, after extensive consultations to address accountability (thematic 

and geographic), quality of service delivery, facility operationalization and training. The 

8 th Joint Review Mission Report of the Reproductive and Child Health Programme, 

Phase II, flags up lack of supportive supervision and quality of services provided 

for Home Based New Born Care (HBNC) as areas of concern and recommends 

strengthening supportive supervision for IMNCI, among other things. 

In a similar vein, the National Institute of Public Cooperation and Child 

Development(NIPCCD) training for ICDS block functionaries is increasingly stressing on 

convergence of services at various levels of implementation; developing requisite skills 

of functionaries required for guiding grass roots level workersin preschool education, 

health & nutrition and community participation. The emphasis is on equipping them 

with knowledge for effective leadership, supportive supervision and management of 

ICDS Projects. 3 

Given the increasing recognition of the need to strengthen supportive supervision 

mechanisms across the sectors, the consultation will seek to address the following 

issues: 

• y Is there need for a comprehensive review of the supportive supervision strategy 

under NRHM, PHD and ICDS?Is there need to revise the job definitions of 

supervisors and should this be based on some generic and proven concepts/ 

definitions – such as supervisory functions recommended by WHO? 

• y Is there need for a comprehensive manual for health supervision that includes 

supervisory roles and responsibilities for PHC in order to obtain optimal 

performance from the supervisory cadre and build in effective supervision 

mechanisms for front line workers? 

Purpose and expected outputs 

A two-day workshop in November,2012 willdiscuss the challenges and opportunities 

in strengthening supportive supervision (including combined supervision of FLWS) as 

a tool to enhance the motivation and performance of front line workers. Informed by 

examples of challenges and good practices from other sectors, where such supervision 

has been tried, the workshop will seek to propose a road map for designing effective 

supportive supervision of front line health workers. 

The workshop will stake stock of issues such as approaches to supportive supervision, 

guidelines on supervision (or lack of effective implementation of guidelines); use of 

technology for supportive supervision; availability and job descriptions of supervisory 

cadre; supervisors’ own skills on interpersonal communication and counselling. Case 

studies highlighting good practices and challenges will inform the discussions. 

3 

NIPCCD Training Activities, 2012. 

62 



Participants 

The workshop participants will include representatives from the government at the 

national and state level, NGOs and private sector, multi-lateral and bi-lateral agencies 

working on public health, integrated child development and related sectors. 

Objectives 

The objectives of the two day workshop on supportive supervision for front line workers/ 

community based workers will be to: 

• y Build a common understanding of Supportive Supervision as an effective capacity 

building/performance improvement tool for front line workers. 

• y Share and document good practices on supportive supervision 

• y Identify opportunities to incorporate supportive supervision into existing systems. 

• y List concrete options/steps to address the challenges discussed 

• y Provide a broad roadmap and action points towards implementation 

• y Collate inventories of tools and aids and technologies to facilitate supportive 

supervision. 

Outputs 

The workshop Outputs will include a set of immediate and long term action points: 

• y A roadmap defining the key next steps to institutionalize/strengthen supportive 

supervision mechanisms in the government systems/programmes 

• y A compendium of good practices and synthesis note on supportive supervision 

• y A set of recommendations for the MoHFW and WCD on revising relevant 

guidelines to institutionalise supportive supervision. 

1 

Concept note developed by Dr. Pavitra Mohan and Ms. Geeta Sharma, UNICEF, India 



63

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