Enhancing health professional clinical performance through supervision strategies: from 5311 facilities across eight countries in sick child healthcare

Background: Supervision remains a widely implemented strategy to improve clinical quality, but its independent impact and the means to enhance its effectiveness remain uncertain. We investigated the effectiveness of supervision alone and, in combination with feedback or training, on clinical quality in child healthcare, and explored the relationship between supervision alone and performance across different organisational contexts. Methods: Data were sourced from the Service Provision Assessment survey, covering 5311 health facilities, 6722 health providers, and 20 880 sick children across eight low- and middle-income countries (LMICs). We assessed health worker performance using 20 clinical quality indicators. We examined various supervision modalities, including supervision alone, supervision with feedback, and supervision with training. We considered organisational factors, such as quality assurance activities and data collection systems and applied multilevel regression models, adjusting for relevant covariates. Results: Supervision alone was not significantly related to clinical performance (coefficient = 0.101; 95% confidence interval (CI) = -0.00, 0.20). However, supervision combined with feedback (Coefficient = 0.171; 95% CI = 0.07, 0.27) or training (coefficient = 0.514; 95% CI = 0.41, 0.62) were both significantly associated with better performance. Organisational support, particularly through quality assurance activities (coefficient = 0.290; 95% CI = 0.14, 0.44) or data collection systems (coefficient = 0.130; 95% CI = 0.02, 0.24), transformed otherwise ineffective supervision into effective ones. The positive impact was stronger when both quality assurance and data collection systems were present (coefficient = 0.319; 95% CI = 0.17, 0.47). Conclusions: Supervision alone is inadequate in relation to better clinical quality in sick child healthcare services. A combination of supervision strategies, including feedback and training, along with institutional support, is likely to be associated with better health worker performance, particularly in LMICs. These findings highlight the need for integrated approaches to supervision, emphasising the role of institutional support in driving quality improvements in child health services.