metadata: authors: 0: author: Heaver,Richard A.
docna: 0: docna: Using field visits to improve the quality of
            family planning, health, and nutrition programs : a
            supervisor's manual
docty: Policy Research Working Paper
subtopic: Health Care Services Industry,Health Service Management and Delivery,Nutrition
teratopic: Health, Nutrition and Population
abstracts: cdata!: Most health professionals who have
            worked in rural areas have had the experience of being
            supervised badly: the flying visit by a superior who
            inspects the records, delivers a critical speech, and
            disappears without ever finding out what is really going on
            in the health center area. Such visits seem designed more to
            demonstrate the supervisor's authority than to help the
            field worker to serve local people better. This manual is
            designed to help field supervisors supervise in a way that
            deepens insights into local situations, supports health
            workers, and focuses on improving the quality of service to
            the poor. The checklist of questions is not intended to be
            definitive or rigidly applied. Depending on the needs of a
            given program, some areas may need to be probed more deeply,
            and others shortened or omitted altogether. The author
            provides guidelines for: planning visits to a program area;
            visiting villages and talking with mothers; visiting health
            care workers; visiting nutrition workers; and using findings
            to make changes in program design or implementation, to
            reorient the way supervision is done, and to change worker
            behavior. He also provides a sample field visit report.
repnme: repnme: Using field visits to improve the quality
            of family planning, health, and nutrition programs : a
            supervisor's manual
display_title: Using field visits to improve the
            quality of family planning, health, and nutrition programs :
            a supervisor's manual
listing_relative_url: /research/1991/10/699852/using-field-visits-improve-quality-family-planning-health-nutrition-programs-supervisors-manual
topicv3: Health Workforce m1326573 631,Nutrition m1326779 644,Health Services Delivery m1327294 1305,Health m1504661 3480,Malnutrition m1627088 4737
publishtoextweb_dt: 2010-07-01T00:00:00Z
historic_topic: Health, Nutrition and Population
origu: Pop & Human Resources Department
no_of_pages: 25
author_keys: 0: author_key: 91481
model_extractions: # **Policy Research**

# **Fopulation, Health, and Nutrition**

WPS 797 This paper is a joint product Of the Population, Health, and Nutrition Division. Population ar,d Human Resources Departmcnt and the Population and Human Resources Division, Technical Department, Asia Rcgional Olfice. Copies are available frce fromii the World Bank, 1818 H Street NW, Washingtoni DC 20433. Please contact Otilia Nadora, room S _6-065,_ extension 31091 (20 pages). October 1991.

Most health professionals who have worked in rural areas have had **thC** experience of being supervised badly: the flying visit **by** a **superior** who inspects Lhe records, delivers a critical speech, and disappears without ever finding out what is really goinig on in Lhe health center area. Such visits seem designed more to demonstraite the supervisor's authority than to help the field worker to serve local people better.

This manual is designed to help lield supervisors supervise in a way that deepens insights into local situations, supports health workers, and focuses on improving the quality of service to **the** poor.

The checklist of questions is nol intended to be definitive or rigidly applied. Depending on the needs of a given ptogram, some areas may need to be probed more deeplv, and others shortened or omiitted altogether.

Heaver provides guidelines for planning (a first visit and subsequent) visits to a program area; for visiting villaiges and talking with motiers; for visiting health care workers; lbr visiting nutrition workers; and for using findings to make changes in pri -ram design or implemental ion, to reorient the way supervisioni is done, and to change worker behavior. He also provides a sample fieid visit report.

The Policy Rescamh Working Papers disseiminate the f!ndings of work under wax in thc Bank. An objective of the scries is to get thesc findings out quickly. even if presentatiot-s are less than fully polished. The findings, interpretations, and conclusion% in these papers do not nececsarily repreT',.t off'icial Rank polic\.

Prodtuced hy the Policy Rescarch Dissemination Ccntcr
# CONTENTS

|I.|INTRODUCTION ...............................|. l1|
|---|---|---|
|II.|PLANNING THE VISIT .........................|........ L|
|III.|VISITING VILLAGES ..........................|.......<br>3|
|IV.|VISITING HEALTH WORKERS ....................|.............<br>8|
|V.|VISITING NUTRITION WORKERS .................|...............<br>11|
|VI.|MAKING USE OF THE PROCESS ..................|..............<br>15|

# ANNTEX

SAMPLE FIELD VISIT REPORT ........................ .......... 18
## USING FIELD VISITS TO IMPROVE FAMILY PLANNING. HEALTH

## AND NUTRITION PROGRAM QUALITY

## A SUPERVISOR'S MANUAL

## I. INTRODUCTION

Most health professionals who have worked in rural areas have had the experience of being supervised badly: the flying visit by a superior who inspects the records, delivers a critical speech, and disappears, without ever finding out what is really going otl in the health center area. Such visits seem more designed to demonstrate the supervisor'z authority than to help the field worker co better serve local people.

Yet field visits provide an important opportunity to improve program quality--if they are properly planned, if supervisors spend encIs.1 time talking to the right people, and if the right questions are asked in the right manner. They provide an opportunity not only to find out what is happening at the periphery and take corrective ac-ion, but also to improve the process of supervision through demonstracing how to go about it in a noninspectional, supportive way.

This paper is an attempt to pull together field experience in supervision in the form of a manual. It is primarily aimed at helping aid agency staff supervise in a way which deepens insight into local situations, is supportive of health workers, and is focussed on improving the quality of service to the poor. It may also be useful to health sector managers in developing countries who are interested in reorienting their own process of supervision.

It should be emphasized that the checklists of questions given below are not intended to be definitive or to be rigidly applied. Depending on the needs of a given program, some areas may need to be probed more deeply, while others can be shortened or omitted altogether.

# II. PLANNING THE VISIT

Most unproductive field visits go wrong before the supervisor steps into his jeep, because they have been inadequately planned. Time spent before the trip on setting it up right is a good investment. This section suggests some do's and **don'ts** for planning field visits.
2 The First Visit To A Program Area If you want to see the poorest people, they likely will not live near the state or district capital. Specify who you want to see, or you may be taken to nearer, better off areas, and to the health facilities which are shown to all visiting dignitaries.

Make sure you set aside enough time. If you have less than 1-2 full days in the field net of driving time, the trip probably isn't worth doing.

Agree with those planning the trip how many facilities you will visit. As a general guide, you should not plan to visit more than two facilities in a half day (even if the driving' distances between them are short), if you want the time to find out what is happening in them. You need to allow at least two hours net of driving time for a visit to _a._ village and its health post. If you don't spezify what you want, you may get a whistlestop tour of six or eight facilities or villages in a day, with half the time spent in the car.

Question the trip planners about the performance ratings of the facilities to be visited. Are they in the top third, middle third, or bottom third of the league? If they are planning to show you the best, try to get a more even distribution.

Agree on the balance you want between time spent in higher level facilities, health posts, and villages. Try and arrange it so that you visit health posts and villages early in the day, higher level facilities later; then, if the schedule is delayed. you won't miss out on the crucial inter-face between service providers and clients.

Try to ensure that the key program decision-makers travel with you. This has three benefits. It gets senior staff away from their files and gives the-l a taste of field reality. It will give you time to get to know them on a personal level, and build up the trust needed to work together. And most important, the snared view of program problems and constraints--based on what you see, not statistics or reports--is the best foundation for reaching consensus on changes in program strategy.

But try and ensure that the cavalcade of cars and accompanying staff is limited. It is impossible to interview field workers and mothers successfully if they are intimidated by large numbers of government officials standing in the background.

Ascertain if your hosts plan any ceremony attached to the visit. If they would like you to open a new health center, politely refuse if you can; this sets the tone that this is a working visit, not a political tour.
3

# Subseauent Visits

Hopefully, the time spent with senior program managers during a first visit will help develop a shared understanding about the approach to supervision. It should then be possible to ask, for subsequent visits, if the following can be arranged.

1. Surprise visits to health facilities. The ideal is to drive to the district capital, look at a district map, and choose on the spot the facilities you will visit that day. This minimizes the chances that the facilities will have been specially staffed, stocked with drugs, or even repainted for your visit. Whether this is possible will depend on whether your counterpart has confidence after your first visit that it is safe to show you the program's problems, because you genuinely want to work with him to improve things rather than show him up.

2. No official receptions, garlands or speeches. These may be essential during the first visit, for the host to demonstrate that he is honoring his guest. A quiet word from the program manager can usually ensure that subsequent visits are low key, without giving offence.

3. Meeting with local politicians last, not first. On your first visit, you will probably have to call on local politicians on your arrival, for reasons of protocol. They often keep you waiting, so that your whole schedule is disrupted. It should be possible to arrange that on subsequent visits you will see them last, on the grounds that the meeting will be more productive if you can calk about what you have seen. This also helps to send the message that local politicians have a substantive not just ceremonial role vis-a-vis local health services.

4. Reduce the cavalcade to two cars. Ideally, you should be able to reduce your escort to one car from head-quarters, carrying you and the key program decision-makers; and one car from the district, with staff who know the place you are going to.

# III. VISITING VILLAGES

The typical supervisor spends most or all of his field visit time in health centers talking to health staff, rather than in villages talking to local people. Yet the only way to find out whether outreach is taking place, whether health education is working, and what the clients' views are of the local health services, is to talk not to service providers but consumers. If the focus of your project or program is on outreach and preventive care, probably two thirds of field visit time should be spent talking to mothers, and only one third talking to health workers.

A common argument used by field trip organizers against the idea of surprise visits to health centers is that the worker may be absent, on tour in an outlying village. This does not matter. By asking the kinds of questions
4 outlined below, a fairly good picture can be built up of health service performance whether or not the worker is present.

# On Arrival

Courtesy call. On arrival, you will probably be asked to meet the village headman. This courtesy call can be made useful with the following kLnds of questions.

1. What are the main occupations of the people in your village? What do the best off people do? What do the worst off people do? Have things been getting better or worse over the last few years? Who has done better? Who did less well? Where do the poorer people live in the village? (It cen be useful, and can help break the ice, for you and the headman to sketch a map of the village together.)

2. What do you see as the main health and nutrition problems in your village? Do you see any difference between now and a few years ago?

3. Who are the providers of health care in the village, modern and traditional? Who do the people like best? Do you have any personal contact with the health service? What kind? What are the problems with the health services? If more money could be made available for services in your village, how would you like to see it spent?

Where to go and who to talk to. You now know who the poor people are and where they live. If your time is short, head for that part of tne village, because it is especially important to know if the health worker visits there regularly. Try to avoid the headman accompanying you, since he may intimidate your interviewees. One way of doing this politely is to ask if you may go round alone, but then come back at the end of the visit to tell him about what you saw.

When you get there, let the health worker choose the first house you visit. This will be a house the worker visits regularly, arid may be untypical. But this will let you see the best part of her work, and will make her feel more comfortable. After this first visit, you should choose the houses you visit, and the people you talk to.

In some cultures and with some interviewees, it is possible to walk up to a house, be invited in, and be in an open and frank discussion in ten minutes. In others, home visits will be seen as intrusive, or the arrival of a higher status outsider in the home may lead to an attack of nerves. In such cases, you may do better to stop in a public place used by women, such as the well, and start chatting to people there. Mothers may be less shy in a group where they can support each other, and in the open air rather than enclosed surroundings.

Try and talk to mothers who have children with them. Then you can talk about the health of the children in front of you. This helps to personalize the talk, and is more comfortable for the mother--she can pay
5 attention to the children as she talks, rather than feeling fixed by your steely gaze.

Translation. Spending a little time organizing this is very important. If the local dialect is different from what is spoken in the capital, have one of the local health workers act as translator; even if local people understand the national language, they may be uncomfortable and less open speaking in it. But if the local language is the same as the national language, have the program director from the central ministry do the translating, providing you feel he will not lose face. Getting him to ask the questions will involve him in the process like nothing else. (By day two, an initially status-conscious program manager is often so interested in what's happening that he wants to take over the questions anyway.) Try to ensure that exactly what you say is translated. Usually, translators will at some point rephrase your questions, add questions of their own, or try to influence the interviewee's response. Even if you don't understand the language, you can usually pick this up because the translated questions will become longer than your originals, and the answers yo.u get will not be to exactly the question you asked.

Try to ensure that exactly what the interviewee says is translated. Usually, some embroidery or opinions of the translator will get added, or he may simply tell you not the interviewee's answer, but what he thinks you need to hear. You can usually sense, in the same way, that this is happening.

# Talking To Mothers

Throughout this section, the word mother should be taken to include mothers-in-law and grandmothers as well, since these are equally important influencers of maternal and child health. Try to talk to some men as well, but in many cultures they will be out at work.

Every time you move to a new mother or group of women, remember to have the translator explain what you are doing in the village. Have him say that you are there to find out about the health problems in the village, and whether any help can be provided to improve things. Don't let people feel you are there to check health service performance--although you are--or they will clam up. They have to live with the health worker whose performance you are asking them to criticize.

The questions given below, and throughout this manual, are illustrative rather than complete. Note the order of questions. Questions about the family and its health status are asked first. This establishes your concern about the interviewee. Questions about possibly sensitive topics, such as family planning or worker effectiveness, are toward the end, when hopefully rapport will have been built up.

Don't carry an outline with you of questions you want to ask, and don't take notes. This applies to interviews with both clients and service providers. They will not speak freely if you have a clipboard in front of
6 you. After each visit, take a little time in the car to write up some notes while things are fresh in your mind.

Social and Health Status. Do you come from this village? Have you lived here a long time?

2. Do you have some other work apart from working in the house? What does your husband do? (Knowing this, and looking at their house and dress, you know the income level without asking.) 3. How many children do you have? What are their ages? (You have already discovered something about probable family planning use.) 4. Have you had any particular health problems in your family recently? When was that? How bad was it? What did you do about it? (n.b. you can often see health problems, such as scabies or PEM, in the children in front of you; note whether these are identified by the mother.) 5. When you or your children are ill and you can't curb it at home, who do you go to? (If both traditional and modern practitioners are used. find out hy, and who is used for what kind of illness.) Child care. Have your children had any problems with diarrhea? (A good one to start with--almost everyone has had.) How long did it last? Was it severe? What did you do about it? Do you feed your children differently wnen they have diarrhea? (If she knows about rehydration, find out if she knows how to make home mixture, and the quantity and frequency of giving this.) 2. Have any of your children had fever recently? How bad was it? What did you do about it? Do you feed your children differently when they have fever? (Find out whether she can recognize a severe ARI and knows to call the health worker.) 3. Have your children been immunized? What for? When, and who by? Have they had their Vitamin A supplement?

4. How do you feel about your children's diet? Are you able to give them everything that you want them to eat? What do they normally eat on a typical day? Do you feed them differently from other family members? (Find out if she knows the importance of green vegetables.) 5. When you had your last child, did you have enough breast-milk for him? Did you give him anything other than breast-milk in the first six months? How long did you continue breast-feeding? How old was he when you started to give solid food? What did you give him, and how much?

6. When your last child was just born, how soon after did you first feed him, and what did you give him?
7 Maternal care. When you were going to have your last baby, did you get any particular advice from the health worker? Do you remember how far along with your pregnancy you were when you talked with her?

2. Did you eat more. or less, or the same, wh.ile you were pregnant? Did you eat new kinds of food, or stop eating some foods?

3. Did you take any iron pills while you were pregnant? When did you start? How often did you take them?

4. Where did you go to have the baby? Who helped you give birth? Did you or the birth attendant have any special kit? What were the things you needed to be careful about when you had the baby?

Family plannning. Would you like to have another baby? If no, what can be done? What do you think is the ideal number of chilAren? What does your husband think?

2. If another baby is planned, how soon are you planni'ng? If a delay Is preferred, what can be done to ensure this? What do you think is the best gap between babies? What does your husband think?

3. Are many people in the village using family planning these days? What are the methods which are the most popular, and why? Do younger and older women seem to prefer different methods?

4. (If the mother is prepared to say whether she is contracepting and what she is using.) How did you know about this method? What made you choose it? (If advised by a health worker.) What other methods did she tell you about? What did she say about their advantages and disadvantages?

Effectiveness of outreach. Is there a health worker who looks after this village? What is her name? Has she ever visited you at home? Have you ever visited her in her clinic?

2. When was the last time she visited your house? And when was the time before that? (n.b. questions about specific events will get more reliable answers than 'how often does she come'?).

3. The last time she came to your house, how long did she stay talking with you? What did you talk about? Did she give you any particular advice? Did you ask her any particular questions?

4. Have you ever met with the supervisor of your health worker? When was that, and what happened at that meeting?
8

# IV. VISITING HEALTH WORKEII

# On Arrival

If there are several of you in your review team, split up, and have the others go visit another health center in the local area, or go talk co the villagers while you are talking to the health worker. Health workers will not talk to you openly if they have a large audience, especially if there are senior staff in it.

Launching straight into a face to face interview can be nervewracking for the health worker, who may feel interrogated. It is often best to start the visit by asking her to show you around her clinic and quarters. This takes the spotlight off her and helps to break the ice. It also gives you the opportunity to ask her whether the design of the facility suits her needs, and whether it is being kept properly maintained for her. This kind of interest signals you care about her, and have probably not come to find fault.

This initial tour will probably also tell you two things. By the look of the place, you can usually see whether it has been done up for your arrival. And by the amount and kinds of personal effects in the health worker's quarters, you should be able to tell whether she is actually living there. This is important information. Workers who are actually living in the local town and not their quarters cannot be doing effective outreach, because much of their day is spent commuting from local town to the health center.

As you go round the clinic, glance at the visitors book. If it's full of names from the capital or abroad, you have been had. This is the show-piece center they bring all distinguished visitors to. Don't spend too long.

Note that the following questions cover most topics of importance other than the inspection of registers. This is because most supervisors concentrate on this already, thus sending the signal that it is recordkeeping, and not outreach and preventive care, which is really important.

# Talking To Health Workers

Once again, the order of questions is important. It is useful to scart with questions about the local area, because these are legitimate; the worker knows she knows about this and you don't. Do not start with questions about her technical knowledge, or she will feel that you have come to test he , and will be ill at ease. , ly ask general questions about what problems s has toward the end of the interview, when rapport has been established; earlier on, she may feel obliged to tell you that everything is fine, or give you a stock complaint, such as the inadequF-y of the drug supply.

Local knowledge. How long have you been the health worker in this area? (If she is a newcomer, you can keep the interview short.)
9 2. How many people are there in your health<sup>center area? What do</sup> you see as the main health problems? (Compare<sup>this with your knowledge of the</sup> actual epidemiology.) Are there groups of particularly<sup>poor people in your</sup> area? What do they do for a living? Do they<sup>seem to have different health</sup> prcblems from other people?

3. If there isn't already one, ask her to<sup>do a sketch of her</sup> health center area, showing the main villages<sup>and hamlets. How do you travel</sup> to the villages? How long does it take you<sup>to get to each village? Which are</sup> tbe hard to reach areas? Do the poorer people live<sup>in particular areas?</sup> 4. Do you know how many 0-3 year children<sup>there are in your area?</sup> (There should be about 70-90 per thousand population<sup>in Asia, 100-120 in</sup> Africa.) Do you know how many pregnant women<sup>there currently are in your</sup> area? (There should be about 20-30 per thousand<sup>population in Asia, about 40</sup> in Africa. These are important questions; they<sup>show whether she is aware of</sup> the her key target population. For example,<sup>if she thinks, as is common, that</sup> there are about ten pregnant women, then you<sup>know already that ante-natal care</sup> is not effective in this area.) I I S. Do you know of any deaths in your area in<sup>the last year? What</sup> were they due to?

Work routines. In general, it is better to<sup>ask specific questions</sup> about what the worker did on a specific day;<sup>if you ask general questions</sup> about what she normally does, you are more<sup>likely to hear what she is supposed</sup> to do than what she actually does.

1. Do you have a regular work routine for each<sup>week or each</sup> month? How do you divide up your time between<sup>working in the clinic, going</sup> out in the villages, going for meetings, and<sup>keeping up your records?</sup>

2. When was the last day you spent in the villages?<sup>Let's think</sup> back to that day, and talk about it, so I can<sup>understand better how health</sup> workers here plan their work. How did you<sup>decide which village to visit? And</sup> when you got there, how did you decide which<sup>families to visit?</sup> 3. On that particular day, how long did you stay in<sup>the village?</sup> How many houses did you visit? How long<sup>did you stay in each house? What did</sup> you talk about? Was there any group meeting<sup>with mothers?</sup> 4. Did you assist with any deliveries in the past<sup>six months?</sup> How many? Where did they take place?<sup>Were there any complications?</sup> Technical knowledge. In general, it is better to<sup>ask questions</sup> about particular cases she has recently had,<sup>than to ask general questions</sup> about whether she knows a particular thing.<sup>The former comes across as you</sup> familiarizing yourself with her area and<sup>her views, the latter as a test.</sup>

1. Have you had any child diarrhea cases recently?<sup>What did you</sup> advise the mother? Supposing the diarrhea<sup>is persistent--what</sup> then?
10 2. Have you had any child fever cases recently? What did you tell the mother? (Find out if she knows when ARI can be home treated, when it needs the anti-biotic she has at her level, and when it needs referral to a higher level.) 3. Out of the pregnant women in your area in the last year, have you had any with obstetric complications? What are the signs you use to identify if a woman is likely to have this kind of problem?

4. Have you seen any low birth-weight baby in your area recently? What advice did you give the mother about this baby?

5. What contraceptive do you advise women to take? If a woman is interested in a temporary method, which methods do you feel are suitable for which types of people? Think back to the last time you recommended orals to someone--what advice did you give her? Health education Rractices. What are the main wrong health and nutrition practices you see in this area? Has the health service,'or you personally, targeted any particular p-actices as ones to try and change as a priority? How are you goi.ag about that?

2. What are the different types of ILEC methods in use in this area? Which do you find the most effective? Why is that?

3. Are there any particular groups in the area who are specially resistant to practices you want to promote? Who are they and what are the practices? Is anything special being done about this? (Key question, to know if she understands about segmenting her market, and developing different strategies to meet different needs.) 4. Are there some mothers in the area who are particularly highly motivated about health and nutrition? Who are they? Are they doing anything differently to care for their chilren? Do you use them to help you in any way?

5. Are there any women's groups in your area? Do you use them in any way to help your work?

6. Are chere any other workers from other government or nongovernment organizations in your area? Do you work with them, and if so how?

Training. How long ago was it you had your pre-service training? Thinking back on it, which were the things you found most useful for your work? What would you have liked to spend more time on?

2. Have you had any in-service training? When and where was that, and who was doing the teaching? How long was the course? How much was in the classroom, how much in a clinic or hospital, and how much in a village? Do you feel the need for in-service training again this year? What would you like to be taught about?
11 3. Thinking back to the last training session, what<sup>were the most</sup> useful topics to your work? Whlat would you have liked to spend more time on? How many hours or days were spent on technical<sup>things? How many on health</sup> education? How did they teach you health<sup>education? (Role-playing for inter-</sup> personal IEC?) Did they teach you about planning<sup>your work routines?</sup> SuRervisory support. Who do you report<sup>to in the local health</sup> service? When did you last have a visit from<sup>that person? And when was the</sup> time before that? Last time he or she came,<sup>how long did he/she stay? What</sup> did you talk about? Did he give you any special<sup>training or advice? Did you</sup> raise any particular problems?

2. Do you have staff meetings at the local health<sup>center? How</sup> often? How long was the last one? Could you<sup>describe what happened at it?</sup> (Was it just inspection of registers, or was there<sup>training? Was there</sup> interchange of experience among para-medicals?<sup>Was there group problem-</sup> solving?) 3. Apart from your immediate supervisor, does anyone<sup>else give</sup> you any support here? (Does the local doctor take<sup>an interest? Has the local</sup> health education specialist been to visit?) Miscellaneous. Are there ORS packets in the<sup>center?</sup> Cotrimoxazole? (or the local drug of choice for<sup>MRIs.) Vitamin A? Iron?</sup> (Note the expiry dates, and whether damp or<sup>heat has got to the</sup> drugs/supplements.) Is there a blood pressure<sup>gauge? Equipment for</sup> sterilizing syringes? A child weighing scale?<sup>Do they work?</sup> 2. When was the last time your drug supply was replenished?<sup>(If</sup> it was last week, this was probably in your<sup>honor.) And when was the time</sup> before that? Which medicines do you find you<sup>use up first and run out of?</sup> Which do you use up slowest, and have to spare?<sup>When was the last time you</sup> ran out of one--or all--drugs? How long were<sup>you without it/them?</sup> 3. Do you have any particular problems in doing<sup>your work well?</sup> (With a nervous worker, who will automatically<sup>say no, this should be</sup> rephrased to: If there was anything we could<sup>do to help you do your work</sup> better, what would you like?)

# V. VISITING NUTRITION WORKERS

In some programs, the health worker is responsible<sup>for nutrition</sup> work; in others a separate worker looks after growth<sup>monitoring, growth</sup> charting, case management, and supplementary<sup>feeding where this is given. If</sup> these tasks are part of your program, the<sup>following questions and routines may</sup> be useful. Questions on nutrition education<sup>given above are not repeated</sup> here.
12 Knowledge of the local situation. How many people are living in your nutrition center area? Do you know how many of these are childreuL under three? (the age most nutritionally at risk; there should be 70-90 per thousand population in Asia, 100-120 per thousand in Africa.) 2. What is the normal diet of the people in your area? Does it change at different times of year? Do the poorer people eat differently from the better off people? What work do the poorer people do here? Do they work harder at particular times of year? Do they have less money at particular times of year?

3. Is there a malnutrition problem in your area? How can you know how bad it is? Which kinds of people are malnourished? Is it all the year round or seasonal? How has the nutrition situation changed over the<sup>last</sup> five years?

4. Do you know how many under threes are severely malnourished in your area? Moderately malnourished? How do you measure this? Do you know how many pregnant women are malnourished? How do you measure this?

5. Apart from people not having enough to eat, are there any other malnutrition problems in your area? Do you know how many children have vitamin A deficiency? How do you measure it? Do you know how many pregnant women have anaemia? How do you measure it? (mild, moderate, severe?) Why are these deficiencies a problem?

6. Do you know how many babies were born in your area in the last year? Do you know how many of them weighed less than then they should at birth? How do you define low birth weight here? How do you measure it, and who does the weighing?

Coverage. How many under threes have had their six-monthly vitamin A supplement? (where a mega-dose is given). How many pregnant women are currently receiving iron? (From these figures you can work out approximate coverage figures for these interventions.) 2. How many under threes were weighed/arm-banded by you in each of the last three months? (Go through the records and check the overall numbers. Look also at the weighing regularity for a sample of children; is it the same limited group of children being weighed regularly or a larger group being weighed irregularly? If much less than 80% of the under threes are being weighed/arm-banded, you have a problem; there could be significant malnutrition in the area which is not being detected.) 3. When and where do you do your growth monitoring? If it is on particular days of the month, how do you let mothers know? Do mothers help you bring the mothers together, or with the actual weighing/banding? If some mothers don't come when you are weighing, how do you get their children weighed?

4. How many pregnant women are there in your area at the moment? In your program, do you check whether they are putting on weight as they
13 should? How do you do that? How many of them are not doing as well as they should?

Case management. Ask the worker to pick out the growth charts for all the children with severe malnutrition. Note whether these children are being monitored regularly. Spend some time asking about each child; you must be sure whether the worker knows each child and its family well. These are the children most likely to die.

1. Why do you think that this child has moved down into grade three? Has it had any illnesses? Do you know how many brothers and sisters the child has? Are they malnourished too? Is this the first or last child in the family, or what?

2. How far away does this child's family live? How many incomeearners are in the family? Are they regularly employed, and what do they do? Are there any particular problems in the family?

3. Does the mother bring the child regularly for weighing? Does she have a copy of the child's growth chart? What nutrition advice have you given her? Does she follow it?

4. Does the child come for supplementary feeding? If not, why not? (Does the mother take the child to work with her?) If yes, who brings the child? Does the child seem to like the food? Can the child finish the food? If not, what do you do about that?

5. Has the local health worker seen this child? What did she have to say about her? (In the case of a persistently severely malnourished child). Has the child been taken to see a doctor? Do you know what his diagnosis was? Do you know if it was the local health center doctor. or a specialist child doctor?

6. If you have time, ask to be taken to the house of one of the severely malnourished children. Talk to the mother about the causes of her child's problem, and what she is doing about it.

SupRlementary feeding. How many mothers are receiving supplementary feeding (SF) in your area? How many children? Can we go through your records and see the nutrition status of these children? (Check to see whether there are malnourished children who are not being fed; or whether significant numbers of children who are not malnourished are being fed.) 2. Have you had any breaks in the supply of your SF in the past year? Does it arrive in good condition? Where do you store it? Does it last without going bad?

3. What is your system for deciding which mothers or children will get SF? Are they eligible immediately they fall into malnutrition/fail to gain weight, or after some weeks of observation? What advice do you give to mothers whose children need SF?
14 4. Do you serve the same food every day, or different recipes? Do the children like it? Do you serve different food for the mothers?<sup>Do</sup> they like it? Do you serve different food for children who are very<sup>young,</sup> and for severely malnourished children? Do they have any problems in<sup>eating</sup> or finishing the food? (Try to be present at a feeding time, because many workers will automatically say they have no problems in these areas.) 5. Where do the children and the mothers eat the food? Do you allow them to take the food home with them if they want to? If not, why not? If they do take home, do you see any problems with that? If there is take home, do you find that the malnourished children share the food with others in the family? Do you think that the food you give is fed by the mothers in addition to the food they would normally prepare, or do you think that the food you give means that the mothers don't have to make so much of their own food for their children?

6. Supposing a child who was malnourished has regained weight. Do you stop giving him the supplement? Immediately, or after some time? Do you find that some of the children who graduate from feeding get malnourished again and come back into feeding? Do you have any records on how often this happens? Do you notice anything in common about these children or their families?

Quality of growth monitoring. Check that the worker has both child and adult scales. Ask the worker to weigh and chart a small child, preferably one that looks undernourished. See whether a) she checks that the scale<sup>is</sup> zeroed before weighing; b) she is noting the exact weight or is rounding off and hence inaccurate; c) she can correctly enter the weight on the chart; and d) she can correctly identify the nutrition status of the child.

Take some time to look through the growth charts at the center. See if they have been regularly kept up--or are too regular. Signs that they were filled in yesterday in honor of your visit include unusually clean charts; clustering of the weights around particular figures; unusually neat lines all filled in with the same pen or pencil; and monthly weight gains that are improbably large.

Pick out some typical types of charts to see whether the worker knows how to use them for nutrition education. These might include<sup>a) charts</sup> dipping slowly into malnutrition between six months and a year--does the worker recognize that this is probably a weaning problem?; b) charts dipping very sharply into malnutrition in a particular month--does she recognize that this was probably a diarrhea or measles episode?; c) a comparison of two charts where the children are the the same weight for age, but one<sup>child is</sup> tracking steadily just below the top of grade two, and the other has recently moved down into grade two and is still in decline--can she differentiate stunting from nutritional decline? In each case ask the worker what advice she would give the child's mother.

If the worker is knowledgeable on the above, ask her to pull out the growth charts for the some of the children of the mothers who by now will have gathered around the center. See if the mothers a) know the nutrition
15 status of their child, b) know how it has been changing over the last few months, c) can read the growth chart, and d) can remember any advice that the worker has given them.

# V. MAKING USE OF THE PROCESS

The approach to field supervision illustrated above can be useful in impro:ing program quality in two distinct ways: use of the findings to make design or implementation changes to the program; and use of the process to reorient the way supervision is done and to change.worker behavior.

# Using The Findings

Are the findings valid? The systematic routines and questions summarized above are aimed at gaining as clear an understanding of what is happening in the field as is possible from brief visits. Clearly they'cannot substitute, in terms of depth of insight, for the findings of longer term participant observation studies in villages and health centers. But equally, such studies cannot be carried out on a routine basis over large areas.

Despite the inevitable limitations of brief visits, experience in several sectors with using structured interviewing as a rapid rural appraisal technique suggests that the insights gained are often more valid than those from large scale questionnaire surveys, which may be the only practical alternative. Such surveys may be based on statistically valid samples, but are not open-ended enough to fully explore program quality. They are also expensive and quickly out-dated.

The validity issue for this kind of field supervision is therefore not so much whether it reflects reasonably well what is going on in a given local area, a.s whether the local area you are visiting really reflects the successes and constraints of the program you are reviewing in general. Do not therefore pay too much attention to the findings of an individual field visit. Make field visits to several areas which you think should show differences in client knowledge or attitudes, in worker motivation, in health resource availability or in local managerial capacity, and only then begin to draw general conclusions. Cross-check the validity of the opinions you are forming with people knowledgeable about the area--especially experienced local health managers, and field researchers in the social sectors who may have worked in the area.

ADplving the findings. It is important not to use your interview findings to correct the behavior of workers on the spot. This is a common and tempting practice; most supervisors cannot resist demonstrating they know better, or showing their authority. But guiding the individual worker is the job of the worker's immediate supervisor, not yours. Correcting workers on the spot has three undesirable consequences. It may undermine your image as open-minded inquirer rather than inspector. It may undermine the authority of the worker's immediate supervisor. Most important, if you correct the health
16 worker in front of others, it will undermine the local<sup>respect for her which</sup> is essential for her effectiveness. The only exception<sup>to this rule is if the</sup> worker is doing something dangerous, such<sup>as not sterilizing syringes properly</sup> in an AIDS-endemic area. Then you must ensure<sup>that she is taken aside by one</sup> of the local supervisors and quietly corrected<sup>immediately.</sup> 'ur findings about constraints and problems should<sup>be used at two</sup> distinct levels. Where the problem appears to<sup>be a local one and not generic</sup> to the program, it should be discussed<sup>at the end of the day with local health</sup> service managers, and they should be asked to suggest<sup>a solution for it.</sup> More important for you, as a supervisor<sup>from the foreign aid agency</sup> or national capital, is to focus on those problems<sup>which are systemic in the</sup> program. There is no point in correcting an individual<sup>worker when some bad</sup> practice is widespread, because the problem<sup>lies not with her but with the</sup> training system which has ill-equipped her, or the<sup>MIS and supervision system</sup> which is sending her the wrong kinds of signals.<sup>Nor do most regional health</sup> service managers, given the centralized nature<sup>of most public health programs,</sup> have the power to correct these problems themselves.

Therefore, systemic problems need to be addressed at<sup>the center or</sup> state level through redesign of aspects of the program's<sup>software, after</sup> discussion with regional and central health service<sup>managers. But use the</sup> opportunity of your field visit to ask health<sup>workers and supervisors about</sup> possible solutions to systemic problems; they<sup>often know what needs to be</sup> done, even if they can't do it.

An example of the way in which an aide-memoire might be<sup>drafted to</sup> focus on systemic problems found during field<sup>supervision visits is given in</sup> the annex to this paper.

# Using The Process

Most supervisors focus on finding out what is<sup>going wrong and</sup> correcting things on the spot, at the<sup>expense of using the supervison process</sup> to improve program quality. The process can be<sup>used in at least three</sup> positive ways.

Giving Rositive feedback. Most supervisors focus<sup>and comment in</sup> their field visits on what is going wrong.<sup>Instead, focus on what is wrong</sup> and store it away for future analysis; but<sup>comment on what is going right.</sup> Praise the worker and her supervisor where<sup>they are doing well. This not only</sup> improves health service morale and performance.<sup>It sends important signals to</sup> your counterparts that you are on their side<sup>and not just a fault-finder.</sup> What you spend time on. Workers and their supervisors<sup>will note</sup> very quickly what you are spending time on. If you<sup>and the health service</sup> managers with you spend most of your supervision<sup>visit looking at health</sup> center records, you can bet that is what<sup>will workers will focus on before the</sup> next visit. If on the other hand, your time<sup>is spent in the village asking</sup> about outreach and the feelings of local<sup>people about the health service, this</sup> sends important signals to workers about what<sup>is important to management.</sup>
17 Workers do not respond to health policies<sup>or written guidelines; they respond</sup> to what they think their bosses think<sup>is important.</sup> Demonstrating how to supervise. Therefore,<sup>as important as what</sup> you find out from your visit is the demonstration<sup>effect of how you go about</sup> your visit. This is why it is important<sup>to have one or more senior program</sup> managers with you while you visit, because<sup>good supervision cannot be taught</sup> as easily as it can be picked up from<sup>observation. At the beginning, it may</sup> not be obvious to program managers<sup>why you are doing the things that you do</sup> and asking the questions you ask in the<sup>order and way you are. But they will</sup> quickly and usually enthusiastically catch on, and during the second and<sup>third</sup> days of a field trip can be encouraged<sup>to take over some of the interviewing.</sup> Once this point has been reached, you<sup>can usefully focus an evening</sup> discussion with your colleagues on the<sup>purposes of supervision, and how</sup> supervision can be managed to improve<sup>service quality. If the general</sup> approach to supervision you are demonstrating<sup>finds favor, discuss how it can</sup> be institutionalized in the health system. It is doubtful<sup>whether this can be</sup> done solely through in-service training<sup>courses, in view of the importance to</sup> learning of accompanying a good supervisor<sup>in the field and watching.</sup> Institutionalizing the process is therefore best done<sup>by senior</sup> managers themselves visiting the field<sup>regularly and reorienting their</sup> immediate subordinates; who in turn will<sup>take their immediate subordinates on</sup> field visits and orient them. A senior<sup>manager might aim to make such a trip</sup> once in two months; a middle manager<sup>once a month.</sup> The perceived costs of moving to such<sup>a system will be great.</sup> Managers will be taken away from their<sup>files, and will be unavailable to their</sup> political masters for several days<sup>at a time; they will be away from their</sup> families; and the travel may be uncomfortable.<sup>But the benefits are</sup> potentially tremendous, in terms<sup>of direct exposure to and real learning from</sup> the field; and in terms of demonstration<sup>and motivational effect on staff down</sup> the line.