How, why, and under what circumstances can supportive supervision programs improve malaria case management? A realist program theory.

Supportive supervision (SS) programs aim to enhance the quality of care by strengthening the performance of health providers. Commonly part of broader quality improvement efforts, SS programs are increasingly used in low-and middle-income countries to improve malaria case management. Despite substantial investments and some positive outcomes, little is known about what drives their effectiveness. A realist evaluation was conducted in Tanzania and Benin to explain how, why, and under what circumstances SS programs can improve the facility-based management of uncomplicated malaria in children under five. A program theory was developed through a team-based analysis of empirical data collected in both countries at two time points. Data included 218 in-depth and 12 structured interviews with stakeholders, 154 audits of febrile case management decisions, and four health facility audits. Stakeholder perspectives identified three acceptability mechanisms driving SS program outcomes in the studied contexts: the affective attitude, self-efficacy, and burden of the program as perceived by key actors. The pathway through which these mechanisms were perceived to shape malaria case management (diagnosis and treatment) practices was defined by the 1) extent to which the program was integrated into the public health system; 2) frequency with which SS visits were conducted by appropriate supervisors; 3) degree to which supervisors coached, rather than policed, supervisees; and 4) level of collaboration achieved between supervisees and supervisors. The program actors' perception of the program's effectiveness was also found to be crucial to its sustainability. This study explains the dynamics driving SS program outcomes and underscores the role played by the cognitive and emotional responses of program actors. These insights are likely to be transferable to other settings with similar contexts and can help inform the design, implementation, monitoring, and evaluation of new and ongoing SS programs.