BackgroundSupervision is meant to improve the performance and motivation of community health workers (CHWs). However, most evidence on supervision relates to facility health workers. The Integrated Maternal, Newborn, and Child Health (MNCH) Program in Morogoro region, Tanzania, implemented a CHW pilot with a cascade supervision model where facility health workers were trained in supportive supervision for volunteer CHWs, supported by regional and district staff, and with village leaders to further support CHWs. We examine the initial experiences of CHWs, their supervisors, and village leaders to understand the strengths and challenges of such a supervision model for CHWs.MethodsQuantitative and qualitative data were collected concurrently from CHWs, supervisors, and village leaders. A survey was administered to 228 (96%) of the CHWs in the Integrated MNCH Program and semi-structured interviews were conducted with 15 CHWs, 8 supervisors, and 15 village leaders purposefully sampled to represent different actor perspectives from health centre catchment villages in Morogoro region. Descriptive statistics analysed the frequency and content of CHW supervision, while thematic content analysis explored CHW, supervisor, and village leader experiences with CHW supervision.ResultsCHWs meet with their facility-based supervisors an average of 1.2 times per month. CHWs value supervision and appreciate the sense of legitimacy that arises when supervisors visit them in their village. Village leaders and district staff are engaged and committed to supporting CHWs. Despite these successes, facility-based supervisors visit CHWs in their village an average of only once every 2.8 months, CHWs and supervisors still see supervision primarily as an opportunity to check reports, and meetings with district staff are infrequent and not well scheduled.ConclusionsSupervision of CHWs could be strengthened by streamlining supervision protocols to focus less on report checking and more on problem solving and skills development. Facility health workers, while important for technical oversight, may not be the best mentors for certain tasks such as community relationship-building. We suggest further exploring CHW supervision innovations, such as an enhanced role for community actors, who may be more suitable to support CHWs engaged primarily in health promotion than scarce and over-worked facility health workers.

Objective.This paper seeks to review the available evidence to determine whether a systems approach is employed in the implementation and evaluation of task shifting for mental health using lay providers in low- and middle-income countries, and to highlight system-wide effects of task-shifting strategies in order to better inform efforts to strength community mental health systems.Methods.Pubmed, CINAHL, and Cochrane Library databases were searched. Articles were screened by two independent reviewers with a third reviewer resolving discrepancies. Two stages of screens were done to ensure sensitivity. Studies were analysed using the World Health Organization's building blocks framework with the addition of a community building block, and systems thinking characteristics to determine the extent to which system-wide effects had been considered.Results.Thirty studies were included. Almost all studies displayed positive findings on mental health using task shifting. One study showed no effect. No studies explicitly employed systems thinking tools, but some demonstrated systems thinking characteristics, such as exploring various stakeholder perspectives, capturing unintended consequences, and looking across sectors for system-wide impact. Twenty-five of the 30 studies captured elements other than the most directly relevant building blocks of service delivery and health workforce.Conclusions.There is a lack of systematic approaches to exploring complexity in the evaluation of task-shifting interventions. Systems thinking tools should support evidence-informed decision making for a more complete understanding of community-based systems strengthening interventions for mental health.

Despite severe workforce and physical infrastructural deficiencies at Soroti Regional Referral Hospital, providers are adjusting and innovating to deliver surgical care.

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BackgroundAbout 5.8 million people die each year as a result of injuries, and nearly 90% of these deaths occur in low and middle-income countries (LMIC). Trauma scoring is a cornerstone of trauma quality improvement (QI) efforts, and is key to organizing and evaluating trauma services. The objective of this review was to assess the appropriateness, feasibility, and QI applicability of traditional trauma scoring systems in LMIC settings.Materials and methodsThis systematic review searched PubMed, Scopus, CINAHL, and trauma-focused journals for articles describing the use of a standardized trauma scoring system to characterize holistic health status. Studies conducted in high-income countries (HIC) or describing scores for isolated anatomic locations were excluded. Data reporting a score’s capacity to discriminate mortality, feasibility of implementation, or use for QI were extracted and synthesized.ResultsOf the 896 articles screened, 336 were included. Over half of studies (56%) reported Glasgow Coma Scale, followed by Injury Severity Score (ISS; 51%), Abbreviated Injury Scale (AIS; 24%), Revised Trauma Score (RTS; 19%), Trauma and Injury Severity Score (TRISS; 14%), and Kampala Trauma Score (7%). While ISS was overwhelmingly predictive of mortality, 12 articles reported limited feasibility of ISS and/or AIS. RTS consistently underestimated injury severity. Over a third of articles (37%) reporting TRISS assessmentsobserved mortality that was greater than that predicted by TRISS. Several articles cited limited human resources as the key challenge to feasibility.ConclusionsThe findings of this review reveal that implementing systems designed for HICs may not be relevant to the burden and resources available in LMICs. Adaptations or alternative scoring systems may be more effective.PROSPERO registration numberCRD42017064600.