THE IMPACT OF SUPERVISORY TRAINING ON THE PERFORMANCE OF PRIMARY HEALTH CARE WORKERS IN GUATEMAL

A study consisting of sample household interviews was conducted on the service activities of 390 primary health care workers in eastern Guatemala to determine the extent to which their performance can be influenced by adequate supervision methods. Voluntary Health Promoters are trained by and work under the supervision of broadly prepared and experienced Rural Health Technicians. Promoters deliver a range of primary care services at the village-level: household visitation, census-taking, promotion of family planning techniques, organization of community campaigns for immunizations and malnutrition screening, reporting new cases of communicable childhood diseases, and instructing mothers in the preparation and use of an oral rehydration solution for pediatric diarrhea management. Estimates of the proportion of the eligible service population attended by Health Promoters were calculated at three time periods by surveying a random sample of families in a designated experimental area.;At the study mid-point efforts were initiated to improve levels of services coverage to families by upgrading Promoter supervision mechanisms. A simplified record-keeping system was introduced to Technicians for tallying Promoter service encounters. Well-focused review lessons on completing key service tasks were held for all Promoters. Problem-solving workshops on Promoter activity-reporting, training and supervision were held for the Technicians. Local Ministry of Health officials were assisted in formulating an overall work strategy to upgrade primary care services delivery.;Significant differences were noted in estimates of service levels after 6 to 8 months of program start-up which seem attributable to Promoter activity in the context of a new primary care structure.;Further, significant differences occurred in four service categories (Promoter visits to homes with children under 5 years or pregnant women, the distribution of supplemental food, Oral Rehydration Solution packets and contraceptives) after Promoter supervisors were provided with training and information tools. With respect to estimates of the four types of immunizations given to children under five there appeared to be significant differences for DPT and Polio immunization but not for Measles or BCG vaccine between the study midpoint and endpoint. Inexplicably, there was a significant decrease in the level of arm circumference measurement-taking among children under 5 years during this same time period. After the introduction of supervisory training, there was no apparent difference in service levels for the remaining service categories (census taking, Promoter reporting of communicable diseases of childhood and mothers' knowledge of the preparation and use of Oral Rehydration Solution packets for diarrhea management in children under 5 years). It seems that attempts to strengthen supervisory mechanisms had a limited impact on increasing Health Promoter service levels across the board. Best results were achieved in those Promoter services singled out for in-depth lesson review and concentrated program visibility.;The study documents the service impact of well-trained and adequately supervised Health Promoters on levels of care provided to rural Guatemalan families. The study outcomes are of interest to primary care practitioners, planners and evaluators concerned with the use of paraprofessional workers in developing nation settings.