Enhancing quality of care: the role of supportive supervision and mentorship in the female health worker program in Somalia’s hard to reach and fragile context

INTRODUCTION

The female health worker (FHW) program is a critical component of Somalia's strategy to mitigate its high maternal and child mortality rates.^1,2 However, the program's impact has historically been constrained by systemic failures in the support structure for frontline health workers. Traditional supervision was often infrequent and disciplinary, failing to perform the essential functions required for a high-functioning community health system.³

Globally, supportive supervision and mentorship is recognized as one of the foundations of effective community health programs.⁴ Yet, evidence from fragile states like Somalia often treats supportive supervision and mentorship as a massive intervention. To truly understand its importance, it must be broken down into its core functions. Prior studies suggest that these functions include clinical mentoring, performance management, and psychosocial support, but a cohesive framework linking these roles directly to health outcomes is needed.^5,6

The FHW program in Somalia employs a multi-layered supportive supervision and mentorship framework.⁷ This includes: Quarterly FHS-led supervision, where FHS conduct field visits to monitor FHW performance and provide on-site coaching; quarterly joint supervision, involving joint assessments by multiple stakeholders including federal, state and regional health ministry officials and health technical partner (HTP); monthly linked health facility meetings, facilitating regular interaction between FHWs, community members (represented by the community health committees) and health facility staff for service integration and referral strengthening; and quarterly data review meetings, focused on analyzing service delivery data, identifying performance gaps, and planning targeted interventions.

This study posits that the success of a supportive supervision and mentorship program relies on its ability to the effectively perform multiple, simultaneous functions.

The study analyzes data from a digital supervision dashboard to show how a structured supportive supervision and mentorship system for FHWs in Somalia, directly contributed to improved FHW retention and expanded coverage of life-saving health services from January 2022 to December 2025.

METHODS

Study type and design

The study conducted a longitudinal program evaluation using retrospective analysis of routine health program data from the FHW program. The analysis focused on correlating the implementation intensity of a supportive supervision and mentorship approach with key performance and outcome indicators.

Study setting and period

The study was conducted across multiple hard-to-reach and fragile districts in Somalia where the FHW program operates, including areas in Southwest State, Jubaland, Galmudug, Hirshabelle, Puntland and Banadir Regional Administration. The analysis covered the period from January 2022 to December 2025 (48 months).

Data source and selection criteria

All data were extracted from the program's digital supervision dashboard, which aggregates service delivery reports submitted monthly by FHWs and validated by FHS. The dashboard includes data from all active FHWs during the study period. Inclusion criteria for data in this analysis were: reports from FHWs who had been active for at least three months during the study period; complete monthly data submissions; and data verified by supervisors during field visits. Supervision reports were also analyzed to generate qualitative insights. No patient-level data were accessed; only aggregated, anonymized service statistics were used.

The intervention: establishment of a supportive supervision and mentorship model

The FHW program’s supportive supervision and mentorship approach was designed to provide different functions. FHS, ministry of health (MOH) staff and PSI’s M and E staff were trained to conduct direct observational coaching during monthly and quarterly visits, focusing on different clinical skills for ANC, safe vaccination practices, maternal and child nutrition and effective client counselling. This targeted the improvement of service quality.⁸ The program employed a multi-layered supportive supervision and mentorship framework consisting of four core components implemented throughout the study period:

Quarterly FHS-led supervision

FHS conducted field visits every quarter to monitor FHW performance, observe clinical interactions, and provide on-site coaching and mentorship on ANC, immunization referrals, nutrition counseling, and data documentation.

Quarterly joint supervision

Multi-stakeholder teams comprising federal MOH, federal member state MOH officials, regional health authorities, and HTP staff conducted joint supervisory visits to assess program implementation, validate data, and address systemic challenges.

Monthly linked health facility meetings

Regular meetings were held between FHWs, community health committees, and health facility staff to strengthen service integration, facilitate client referrals, and address community-level barriers to care.

Quarterly data review meetings

Supervisors and FHWs convened quarterly to analyze service delivery data visualized in program dashboards, identify performance gaps, recognize high-performing FHWs, and develop action plans for improving coverage.

During all supervision contacts, supervisors provided positive reinforcement, jointly solved work-related challenges (e.g., supply stockouts, community resistance), and documented field-level challenges to escalate to Project implementation units at federal member state ministries of health, thereby facilitating flow of information and resources back to the FHWs, and overall system responsiveness.

Logic model

The study's logic model illustrates the causal pathway from program inputs to the health impacts. This framework demonstrates how the multi-layered supervision approach functions synergistically to improve FHW performance and health service coverage.

Ethical considerations

Ethical approval was not required for this study as it involved a retrospective analysis of anonymized, aggregate program data collected during routine implementation of the FHW program. No identifiable patient or health worker information was accessed or used in this analysis.

Statistical analysis

Data was extracted from the program dashboard into Microsoft excel for cleaning and analysis. Descriptive statistics were used to calculate frequencies and percentages for process indicators (number of active FHWs, percentage receiving timely supervision). Cumulative totals were calculated for outcome indicators (ANC contacts, Penta1 vaccinations) over the study period. Trend analysis was conducted to examine changes in indicators over time and to correlate the scale-up of supervision activities with changes in service outputs. Qualitative data from supervision reports were analyzed using thematic analysis to identify recurring themes related to supervision functions and their perceived impact.

RESULTS

FHW workforce and supervision coverage

The implementation of the supportive supervision and mentorship framework was associated with substantial improvements across all indicators (Table 1). The active FHW workforce increased by 63%, from approximately 500 in 2022 to 1,388 by December 2025.

Concurrently, the proportion of FHWs receiving timely supervision rose from 30% to 92% over the same period.

Maternal health service coverage

Cumulative ANC contacts provided or referred by FHWs demonstrated exponential growth throughout the study period, increasing from 695 in 2022 to 80,782 by December 2025 (Table 1).

The steepest increase coincided with the period of highest supervision coverage (January 2024-December 2025).

Child immunization coverage

The number of children receiving the first dose of pentavalent vaccine (Penta1) through FHW-facilitated services increased more than 130-fold, from 1,478 in 2022 to 198,820 by December 2025 (Table 1).

This substantial increase closely tracked the expansion of supervision coverage and intensity.

Qualitative findings from supervision reports

Thematic analysis of supervision reports revealed 4 consistent themes regarding functions of supportive supervision:

Skill building

FHWs reported increased confidence in clinical skills following targeted on-site coaching.

Motivation

Regular positive feedback and recognition improved job satisfaction and performance.

Problem-solving

Supervisors helped address supply chain gaps and community resistance.

Accountability

Data reviews created awareness of performance targets and coverage gaps.

DISCUSSION

This analysis shows that the impact of supportive supervision and mentorship in Somalia's FHW program is best understood by examining the discrete, yet interconnected functions it performed. The documented improvements in workforce size and service coverage are not the result of a generic "supervision" activity, but the direct output of a system designed to address specific system failures through targeted functions, as illustrated in the logic model (Figure 1).

The synergy of activities within supportive supervision and mentorship approach in achieving health outcomes

The program’s supportive supervision and mentorship model ensured quality by transitioning from fault-finding to skill-building. This enhanced the technical competence of FHWs. Good-quality services such as ANC and nutrition assessments and referrals for immunization-built community trust, which is a prerequisite for sustained service utilization.⁹

The introduction of data-driven accountability transformed FHWs’ performance. Reviewing performance data with a supervisor turned abstract numbers into data that guided decision making. This led to more proactive community outreach and a direct increase in the volume of services provided.¹⁰

The significant expansion of the FHW workforce is a critical finding. In a challenging operating environment, the supportive supervision and mentorship model provided the psychological support and practical problem-solving necessary to reduce burnout and attrition. This function ensured that the program's most valuable asset, the FHW, was retained and functional.¹¹

The supportive supervision and mentorship model also acted to integrate the program interventions. This ensured that it was not an isolated intervention but was embedded within the broader health system. Facilitating two-way communication enabled resources to be provided as needed.

Limitations

The observational nature of this study limits its ability to claim absolute causality. However, the strong temporal correlation between the roll-out of the robust supportive supervision and mentorship model and the observed improvement in outcomes provides a compelling argument for its effectiveness. Additionally, this study analyzed aggregated service data and did not have access to individual patient-level demographic data (e.g., age, parity, geographic sub-district). Future program monitoring should include disaggregated patient data to enable more granular analysis of equity and coverage across different population subgroups.

CONCLUSION

For policymakers and program managers, this study offers a new approach for designing, implementing, and evaluating supportive supervision models. Moving forward, the goal should not just be to conduct supervision visits, but to ensure that supervision systems are designed to perform different functions. Investing in this supportive supervision and mentorship approach is a strategic investment that contributes greatly to the competence of community health workers. This is essential for achieving sustainable healthcare impact in fragile and conflict prone settings like Somalia.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: The study was approved by the Institutional Ethics Committee

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