Supportive Supervision: Some Activities are Possible Remotely, While Others Require Precautions to Avoid COVID-19 Transmission

In Eswatini, GHSC-PSM has provided supportive supervision since 2019. The approach combines regular performance assessment, hands-on supportive supervision visits (SSV) and training with performance recognition. A core team of four regional pharmacists, four project logistics staff, two regional laboratory focal persons and a supply chain focal person from each clinical implementing partner operates the program. Before the emergence of COVID-19, the team conducted quarterly in-person supportive visits to 133 high-volume facilities in this relatively small country bordered by Mozambique and South Africa.

To help reduce the spread of COVID-19, the SSV program adopted a virtual approach, contacting health facilities by phone, mentoring them on identified areas of sub-optimal performance, and collecting supply chain performance data. Using data from the Commodity Tracking System (CTS), the team has monitored and mentored facilities with ongoing reporting problems. In addition, the team has used facility stock status reports in CTS that show stock levels of tracer commodities to mobilize stock re-distribution to avert supply risks. Using previous support supervision performance data, the team prioritized facilities whose performance was lower than targets on agreed indicators, such as accurately filling in stock cards and adhering to ordering schedules.

From January to March, 2021, the program targeted 34 facilities for mentoring through virtual supportive supervision. From April to June, 2021, the program selected 13 facilities for in-person visits. The table below summarizes the performance on selected supply chain indicators of the 13 facilities that received in-person SSV.

The performance for two key measures improved, and most performance levels remained above the target of 80 percent. The recording of stock card monthly issues was the only area the team identified for immediate ongoing mentorship.

Despite the changes to supportive supervision necessitated by COVID-19, consumption data reporting rates for anti-retroviral medicines improved from 77.8 percent in October 2019 to 100 percent in June 2021 in 48 sites that report to the tracking system. Stock out rates of HIV/AIDS tracer commodities at facilities fell markedly from 4.7 percent in 2019 to 0.4 percent in 2021. Sustained stock availability at facilities gave a firm foundation for multi-month dispensing (MMD) and decentralized drug distribution, thereby reducing the frequency of visits to health facilities. Fewer visits resulted in decongested facilities, increased convenience to clients, and reduced risk of COVID-19 transmission for clients and healthcare workers.

Given the success of the initiative, the team will now combine in-person and virtual supportive supervision and mentorship. To maximize coverage, virtual mentorship will mostly target facilities with sustained acceptable performance.

In Ethiopia, GHSC-PSM operates a comprehensive and integrated supportive supervision program called Results Oriented Supportive Supervision (ROSS) that oversees human resources, finance, infrastructure, information, service delivery and governance issues to improve supply chain functions at health facilities. GHSC-PSM adapted the program to the context of COVID 19 and, to reduce supply risks, remotely supported health facilities to be resupplied from the Ethiopia Pharmaceutical Supply Agency (EPSA) or exchange health commodities with nearby facilities.

The project participated in COVID-19 task force meetings of regional health bureaus to ensure the project's activities, including ROSS, aligned with the Ethiopian government's strategies. Through ROSS, GHSC-PSM engaged with stakeholders to create local solutions to health facilities' challenges, ensure the system's sustainability and create ownership of the supervision system. In a significant change to the program to account for COVID-19, the project shifted from a paper-based system to SurveyCTO, a digital platform that helps to conduct supervision using mobile phones, tablets or computers (online or offline), review and validate collected data, and then provide data analysis and reports. The project used virtual platforms like Microsoft Teams to provide orientation and updates on the revised supportive supervision tool to its 17 field support specialists and evaluate the supervision program and health facilities' performance.

GHSC-PSM further reduced the need for on-site visits through increased use of alternative communications, including emails, telephone calls and group chat forums to share information, resources and feedback and collect reports. For necessary site visits, the project adapted supportive supervision to reduce the risk of exposure to COVID 19 through:

• Limited the number of people in a vehicle and at on-site meetings.
• Arranged air travel, when applicable, to reduce the duration of potential exposure during travel.
• Provided face masks, gloves and hand sanitizer to all participants, including drivers, and required wearing masks during working hours.
• Advised participants to keep physical distancing among each other and with health facility staff during visits and discussions.
• Met with individual staff and teams at health facilities instead of with one large group.
• Conducted discussions in large, well-ventilated rooms or in outdoor areas when possible.
• Advised participants to avoid or minimize contact with unnecessary people and materials – including paper and pens–during visits.

To further reduce COVID transmission risks, GHSC-PSM initially prioritized supportive supervision to 480 high-volume facilities and later expanded that number to 600. To minimize time spent and the number of contacts during visits, the project abridged its site-level checklist to focus on high-priority issues, such as implementing multi-month dispensing (MMD) of ARVs, promotion of activities that ensure stock monitoring, and availability of ARVs, contraceptives and maternal health commodities.

Through ROSS, the project remotely supported health facilities to be resupplied from EPSA and get products from nearby facilities. The project encouraged health facilities to coordinate among themselves with stock exchanges to prevent supply risks, encouraging phone and other available communications platforms to coordinate action. To facilitate remote access to updated requesting and reporting forms for the logistics management information system, the project distributed electronic versions via email and an instant messaging app and paper versions to woredas (the third level of administrative divisions in Ethiopia).

A key challenge for the program was motivating health facility staff to maintain health supply chain activities during such a difficult time. To boost their confidence and morale, GHSC-PSM routinely communicated with health facility staff through telephone and email and showed them ways to reduce the risk of COVID transmission through supportive supervision and other methods. Ethiopia's supervision program helped identify the health supply chain's strengths and weaknesses and improve the availability of essential commodities. The table below shows the availability of key health commodities during the COVID-19 pandemic.

Because of the success of revised supportive supervision, GHSC-PSM plans to keep in place changes made to the program post-COVID, both because of the approach's proven success and the cost-effectiveness related to reduced travel, streamlined communication and more.

While wealthier countries aim to vaccinate most of their populations in 2021, the timeline for emerging economies may fall well into 2022. Because of this, travel within USAID-supported countries may remain restricted for many months to come.

Adapting technical support programs—like supportive supervision—to the context of the COVID-19 pandemic requires flexibility, creativity and new and old technologies. Even if supportive supervision returns to its pre-COVID forms, lessons learned from the last year and more can be quickly applied during future crises, including natural disasters and public health emergencies.