This study tested whether supportive supervision (SS) improves outcomes of malnourished children at the outpatient level, along with improving overall quality of and access to care, as well as quality of data.
Arua is one of the districts in Uganda’s West Nile region that hosts a large number of refugees. Most recent estimates indicate that the prevalence of moderate and acute malnutrition in children in this region is significantly higher than the national estimates (10.4% and 5.6% respectively). Official data from 2016 indicated that the average cure rate of malnourished children treated at health centres (HC) in the district was approximately 50 per cent, far below the international SPHERE standards of 75 per cent, thereby suggesting deficiencies in the quality of care. So far, no robust study has explored the effectiveness of SS in improving health outcomes of children with malnutrition.
The SS intervention comprised a peer-to-peer high frequency supervision, using the national nutrition guidelines as reference, encouraging networking and community engagement. This was in two phases: the first entailed delivering SS to HC staff only, while the second included extending SS to community health workers as well.
The primary outcome was the rate of cured children. Secondary outcomes measured at the individual level, included other health outcomes (i.e. non-responders, defaulters, transfer, death); quality of case management (measured by predefined process indicators); quality of data (measured by predefined indicators). Overall quality of services (assessed using the national NSDA tool that, based on predefined criteria, evaluates 10 key areas across four categories, namely: poor, fair, good or excellent) and access to care (measured by the number of children accessing care) were measured at the HC level.
This was a cluster randomised controlled trial with HC as the unit of randomisation. The intervention was delivered at the health system level (i.e. to HC staff), while the primary outcome (i.e. cure rate of malnourished children) was measured at the population level, among children treated in the HCs involved in the study.
The six HCs in Arua with the higher volume of work were randomised to receive either intervention (enhanced SS) or control (standard of care). Children with malnutrition presenting at the HC level were enrolled and each child was followed up individually at fixed intervals.
Overall, 765 children were screened and 737 children were enrolled. All enrolled children were included in the final analysis. Children in the intervention group had a higher frequency of risk factors for negative outcomes.
In the HCs receiving SS, the cure rate was significantly higher than in the control facilities (mean difference of 38.9 per cent). The defaulting rate was significantly lower in the intervention HCs as compared to control facilities. Overall, less than five per cent of children had any of the other health outcomes (non-responder, out-patient therapeutic care transfer, in-patient therapeutic care transfer, dead), and there were no statistically significant differences among allocation groups. After controlling for all baseline characteristics, being in the intervention group was significantly associated with an increased likelihood of being cured.
Quality of case management did not significantly differ between the two groups for most indicators. Diagnosis, ready-to-use therapeutic foods treatment, HIV evaluation, counselling and assignment of the exit outcomes were correctly performed in most cases in both groups. On the other side, complementary treatment was correctly assigned only in 58.8 per cent of control facilities, compared to 94 per cent of intervention facilities.
At baseline, all facilities except one scored, in any of the 10 assessment areas of the NSDA tool, either poor or fair, without significant difference between the intervention and control groups. At the end of the study period, both groups had increased the number of areas scoring either good or excellent, with a significant difference between the intervention and control arms.
After the extension of SS to the community health workers, there was a significant 28.6 per cent increment (118 children) in the total number of children enrolled in the intervention facilities compared to the control facilities.