Rowe et al (Lancet 2005;366:1026-35) had suggested that “supervision and audit with feedback is generally effective” in achieving and maintaining high-quality performance of health workers in low-resource settings. IMaD conducts regular supervisory visits to a select sample of health facilities in Benin. In FY2010 IMaD visited a group of 60 health facilities 3 times each. Due to the staggared approach taken by IMaD for scaling up the number of facilities included in the intervention, only 36 of the 60 health faciities have been visited 4 times by the end of FY2010. During each round of supervisory visits, IMaD supervisors, who were previously trained in health facility evaluations and evaluated for malaria microscopy competency, collect information on the current state of health facility practices as they pertain to malaria diagnostics and treatment. During these visits the supervisors are also expected to provide on-the-job training for individual staff members should there be deficiencies in their performance conducting routine diagnostic procedures (e.g., malaria slide preparation, staining and reading), general laboratory practices (e.g., record keeping, stock issues, QA/QC schemes) or treatment of malaria (e.g., discussion of proper treatment). In FY2010 IMaD supervisors provided training to 100, 280, 234 and 137 laboratory staff and 83, 233, 137 and 84 clinical staff during the 1st, 2nd, 3rd, and 4th supervisory visits, respectively. Supervisors provide comments and feedback to health facility staff during each visit and suggest methods of improving specific practices when necessary. Maintaining continuity with respect to the cadre of supervisors routinely conducting the visits ensures accountability among the health facility staff to improve performance while fostering a reliable system of support at the same time. The following images show aggregate facility performance in malaria microscopy (staining and reading of malaria slides) as well as malaria treatment (prescriber adherence to negative malaria tests). For these particular data series, if IMaD interventions are positively received, one would expect to see an increase in the height of the bars for microscopy performance as the rounds of outreach progress and a decrease in the height of the bars for the proportion of health facilities prescribing antimalarials to patients with negative tests (which is, alternatively, a measure of prescriber adherence to malaria laboratory tests).
