A multi-country study conducted in Tanzania and Benin highlights how supportive supervision (SS) programs can effectively improve malaria case management in young children—and reveals the key factors needed to sustain these efforts over time. 

Conducted between 2021 and 2023 and involving interviews with over 200 stakeholders, audits of health practices, and facility assessments, the research explains the dynamics driving SS program outcomes and underscores the role played by the cognitive and emotional responses of program actors.

The study, published in the Health Policy and Planning journal, was conducted by a consortium including Ifakara Health Institute, the London School of Hygiene & Tropical Medicine, and other partners, under the U.S. President’s Malaria Initiative (PMI). It was funded through the PMI Insights Consortium and carried out in partnership with the National Malaria Control Program in Tanzania and Benin.

Why supportive supervision matters
Supportive supervision is a widely used approach in low- and middle-income countries to improve healthcare quality. It emphasizes regular, constructive engagement between supervisors and frontline health workers—offering mentorship, guidance, and support rather than just oversight. While previous studies have shown that SS programs can have a positive effect, this research aimed to go beyond surface-level results and uncover why and how these programs actually work in practice.

Uncovering key success factors
Using a realist evaluation approach, the researchers looked at the experiences and perceptions of health workers and other key stakeholders across both countries. They conducted 218 in-depth interviews, 12 structured interviews, 154 audits of how febrile cases were handled, and four health facility assessments.

The analysis identified four key factors that influenced the success of these programs. These factors included, the extent to which the program was integrated into the public health system; frequency with which SS visits were conducted by appropriate supervisors; degree to which supervisors coached, rather than policed, supervisees; and level of collaboration achieved between supervisees and supervisors.

Attitudes, confidence, and manageability matter
Beyond these structural elements, the study also uncovered three psychological mechanisms that drive SS programs outcomes in the studied context: affective attitude (how emotionally positive health workers feel about the program), self-efficacy (their confidence in applying the guidance), and perceived burden (whether the program feels overwhelming or manageable). When these factors are addressed, health workers are more engaged and responsive, leading to better outcomes for patients.

A feedback loop that sustains improvement
A key takeaway from the research is the role of feedback. As health workers saw real improvements in their practices and patient outcomes, their trust in the SS programs grew. This in turn boosted their motivation, creating a positive feedback loop that sustained improved performance over time. The study shows that such trust and motivation are essential for lasting impact.

Lessons beyond malaria
Although the focus of the research was on malaria case management, the findings offer lessons that go far beyond this specific health issue. The study provides a model for designing and evaluating supervision programs across various areas of healthcare in low- and middle-income countries. By placing a strong emphasis on both the structural and human factors that drive performance, the findings are relevant to broader healthcare quality improvement efforts.

Investing in people and systems
Ultimately, the study shows that supportive supervision—when carefully designed and implemented—can transform how health workers provide care, especially in the fight against childhood malaria. Success lies not only in strong systems and regular supervision but also in recognizing the emotional, cognitive, and practical needs of the health workers delivering care. 

The authors recommend tailoring SS programs to local contexts and monitoring not just outcomes, but how health workers feel and respond to supervision. They also call for more research in different settings to refine the approach.

Ifakara’s contribution to the study
The study was led by Ifakara Health Institute scientist Fatuma Manzi, who served as the lead co-author, with additional Ifakara contributions from fellow scientists August Kuwawenaruwa and Yusufu Kionga.

Read the publication here.