Integrated Supportive Supervision Checklist for Health Post

1. Background Information of the HP:

Date of ISS conducted: ……………………………………………………
Region: ………………………………………zone ………………………… Woreda: ………………………………………
Name of the HP: ……………………………………………………
Responsible body:
o Name: ……………………………………………………………………………… Mobile Phone: …………………………………
Name of kebele:....................
Total expected Catchment Population for the HP: …………………………………………………………………
 Under one…………..
 Under five ………..
 Pregnant women…………….
 Women in reproductive age group( 15-49years)………….
No. of households in the kebele: ………………………………………
No. of model households graduated: ………………………………………

What actions were taken to improve identified problems in the last supervision?
sr. Last implemented Not implemented Reason for not Action plan
recommendation implemented
1.
2.
3.
4
5

Circle the appropriate score for each question in the checklists. Scoring is done based on scores of 0, 1
or 2.
- 0 score represents a “NO” response or addresses the criteria listed below the question
- 1 score represents a “PARTLY” response or addresses the criteria listed below the question
- 2 score represents a “YES” response or addresses the criteria listed below the question
 Section1: Maternal Health
Maternal Health Yes partl N Comment
y O
Family planning
1.1 What FP service do you provide?( Inject 2 1 0
able contraceptives, Condom, OCP ,
Implanon)
1.2 Average No. of clients per Month
(If the service is available) will get the data
from report
1.3 Is there trained FP Service Providers? 2 0 Specify trained
Do you have Jobs Aids, and National Specify
Family planning guide
Antenatal care
1.4 Do you provide ANC service? 2 0
1.5 What service do you provide during ANC
visit?
1.6 Do you provide iron? For how long? (Check 2 0
registration)
1.7 Do provide TT+2? (Check registration) 2 0

1.8 From ANC followers in your health post

how many of them did you refer to health
center for at least one ANC visit for the last
quarter?
1.19 Do you test HIV during ANC visit and 2 0
delivery
Delivery services
1.10 Do you provide delivery services? 2 0
1.11 Did you receive safe and clean delivery 2 0
training?
1.12 Do you provide misoprostol after delivery? 2 0
(check registration)
1.13 Do you give BCG and OPV 0 at birth? 2 0
(check registration)
1.14 Do you support for the mother on early 2 0
initiation of BF & feeding of Colostrums
1.15 How many pregnant mothers did you refer
to health center for delivery service for the
last 3 months?
Post Natal care
1.16 Do you provide PNC? If yes, when (1st day,
3rd and 7th days), check registration. Check 2 0
if the mother is advised on OBF.
1.17 Do you provide post Abortion care services
S1 Add all the 2 and 1 responses together
and enter the total in the space provided
S2 Divide the total from S1 by 14. Multiply
the result by 100.
 Section2: Under five

Activities yes partl No comment

y
2.1 Do you provide ICCM service? 2 0
2.2 Is there ICCM chart booklet in place and 2 0
used?
2.3 Is the registration book filled & complete? 2 1 0
Yes= complete and properly classified Partly
= complete but not properly classified
No=incomplete
2.4 Does the HP have ORT corner? 2 0
2.5 Does the HP have OTP services? 2 0
2.6 Do you conduct GMP regularly? 2 0
2.7 Did the HP provide Vit A supplementation & 2 0
de worming for <5? (Check registrations)
S1 Add all the 2 and 1 responses together and
enter the total in the space provided
S2 Divide the total from S1 by 14. Multiply
the result by 100.

Section 3: EPI
Activities Ye Partl No Comment
s y
3.1 Is Vaccination given in the kebele regularly? 2 0
HP who have refrigerator expected to give
daily basis
Yes=if daily or outreach program is not
interrupted in last quarter?
3.2 Does the HP have a copy of the current year 2 0
RI MP available at the HP?
3.3 Is there a current Session List of static, 2 0
outreach and mobile vaccination sessions
available for the health post catchment area

3.4 Is there EPI monitoring chart for the Health 2 0

post correct and up-to-date to the previous
month?
3.5 Does the health worker properly 2 1 0
documenting EPI registration book
3.6 Does number of children in the tally sheet
correspond with the register, the monthly
 report, and the EPI chart for the previous
month?
3.7 Does the Health worker use multiple dose 2 1 0
vial policy while (Discard opened Vials of
BCG ,Measles after Six Hours & T.T &
OPV/IPV labelled when opened & use up to
28 days ) ?
3.8 Have all antigens been available for all 2 1 0
planned sessions in the last 3month?
3.9 Does the HF Have Adequate stock balance
Vaccine?
3.10 Does the health post has defaulter tracing
mechanism in place?
3.11 Do all vaccine vials good condition have
readable labels, are not expired, and all are
in VVM stage 1&2?

3.12 Have all health workers offering EPI

services received EPI training?
Yes = all trained, No = only some or none
trained
S1 Add all the 2 and 1 responses together and
enter the total in the space provided
S2 Divide the total from S1 by 24. Multiply
the result by 100.

Section 4: HIV

Activities Ye Partl No Comment

s y
4.1 Do you give counseling service for clients? 2 0

4.2 Do you give couple counseling service for 2 0

clients?
4.3 Do you refer patients with common OI 2 0
symptoms?
If yes, specify some of the symptoms
4.4 Do you advise families of PLHIV to get 2 0
tested for HIV?
4.5 Do you support PLHIVs on adherence to 2 0
care and treatment?
(for those who have disclosed their status)
4.6 Do you trace patients who are lost to follow 2 0
up from care and treatment? (for those who
have disclosed their status)
S1 Add all the 2 and 1 responses together and
enter the total in the space provided
S2 Divide the total from S1 by 12. Multiply
the result by 100.

Section5: TB

Activities Ye Partl No Comment

s y
5.1 Do you do symptomatic screen and refer TB 2 0
suspects for diagnosis?
5.2 Do you receive feedbacks for the referred 2 1 0
suspects?
Yes = when all feedback received regularly ,
Partially= when feedback received
Irregularly, No= when no feedback is
received
5.3 Do you provide contact tracing for TB 2 1 0
patients?
Yes= If contacts of TB patients are traced,
Partially= If contact tracing is done for only
some of the patients, No= If no smear
positive contacts are traced

5.4 How do you ensure treatment adherence?

Check Treatment card for completeness

5.5 Do you use treatment supporters? 2 0

S1 Add all the 2 and 1 responses together and

enter the total in the space provided
S2 Divide the total from S1 by 8. Multiply the
result by 100.

Section 6: Malaria control

 Activities Ye Partl No Comment
s y
6.1 Do you manage all malaria with multi 2 0
species RDT test?

6.2 Is there malaria outbreak during the last 2 0

quarter?(check the chart)
if yes ,what was the reason & what
measure taken?

6.3 Is there a malaria epidemic monitoring 2 1 0

chart available and updated?
5.4 Do you provide Appropriate anti malaria 2 0
drugs? (check the registration)

6.5 Is there ITN replacement/ distribution 2 0

plan?

6.6 Have you had ITNs stock out for 2 0

replacement distribution? If yes what is the
reason for stock out?

6.7 Did the HP identify and map mosquito 2 0

breeding sites?
(What actions are taken)
6.8 Is there Kebele map with 1 km2 grids 2 0
used for epidemic monitoring
6.9 Is there IRS plan? 2 0

S1 Add all the 2 and 1 responses together

and enter the total in the space provided
S2 Divide the total from S1 by 18. Multiply
the result by 100.

Section 7: Hygiene and sanitation

 Activities Ye Partl No Comment
s y
7.1 Is the health post compound clean? 2 0

Clean- free from solid wastes, flowing liquid

waste

7.2 Is there VIP latrine facility in the health 2 1 0

post?

Yes=available, ventilated and clean,

partly=available & either not clean &
ventilated, No=not available

7.3 Is there safe and adequate water supply in the 2 1 0

health post?
Yes=if it is safe and adequate, partly=I
either of them fulfilled.
no=if the water is not safe and adequate
7.4 Is there proper solid waste disposal 2 1 0
mechanism in the health post?
Yes=incinerator and closed pit available,
partly=open pit available
7.5 Is there hand washing facility in the health 2 0
post
7.6 Is there demonstration site in the health post? 2 0
demonstration site—a place where latrine
with hand washing, solid and liquid waste
disposal model, health full housing mode l
etc are constructed
S1 Add all the 2 and 1 responses together and
enter the total in the space provided
S2 Divide the total from S1 by 12. Multiply
the result by 100.

Section 8: Logistics, supplies, job aids, manuals and health education materials
Sr Type Yes partl No Comment
No y
Check the availability of the following
supplies. Use Yes if available for at least
one month.
8.1 OCP 2 0

8.2 Depo 2 0

8.3 Implanon 2 0

8.4 Iron folate 2 0

8.5 Mebendazole/ Albendazole 2 0

8.6 Arthemisin (Quartem) 2 0

8.7 Amoxicillin 2 0

8.8 Paracetamole 2 0

8.9 ORS with Zinc 2 0

8.10 Vaccines 2 0

8.11 AD syringe & mixing syringe 2 0

8.12 Furniture 2 1 0

8.13 Delivery equipment (bed,kit, fetoscope, 2 1 0

sterilizer )
8.14 Malaria case management guide 2 0

TB pocket guidelines 2 0

8.15 Pocket guide for new vaccines 2 0

8.16 Family health card 2 0

8.17 ID 2 0

S1 Add all the 2 responses together and

enter the total in the space provided
S2 Divide the total from S1 by 34. Multiply
the result by 100.
 Section 9: Social mobilization

9.1 Is there social mobilization committee in 2 0

your kebele?
9.2 Do social mobilization committee meet 2 0
regularly in your kebele?
9.3 Do social mobilization committee have their 2 0
own plan? (see the plan)

9.4 How frequent do you conduct performance

review meeting with the health center/ ?

9.5 How frequent Do the HC Staff support the

health post?

S1 Add all the 2 responses together and

enter the total in the space provided
S2 Divide the total from S1 by 6. Multiply
the result by 100.

Section: 10 Public health emergency & Preparedness

Activities Yes Partly No Comment
10.1. Are there national PHEM guidelines?
(Measles, Cholera ,
Meningitis ,Malnutrition ,AFP guideline
& MPDSR Implementation guideline

10.2 Does the health facility have different Specify

surveillance reporting formats, list them-
10.3 Is active case search done in the health
facility itself in the last 3 months

10.4 Can the respondent properly state the case

definition for AFP, Measles, NNT,
Cholera & Maternal death
10.5 Does the health facility surveillance tools
are available (AFP stool cup, test tube
Vaccine carriers,)
10.6 Are there updated case files for all
reported cases for the last 3 years ( AFP,
NNT, Measles & maternal death)

10.7 Is weekly trend monitoring done for

priority PHEM disease in the catchment?
10.8 Did the HF emergency stocks of drugs and
supplies at all times in the past six
 months?

10.9 Does the emergency drug and supplies in

the stock sufficient for the coming three
months?

10.10 Is there any outbreaks occurred in the last

6 months in your zone/district/health
centre?
10.11 Did all 6 month-5 years children and
PLWs screened last 3 months?

6-59month: Target________
screened%___

PLW: Target_______________
Screened %______

10.12 Does the heath facility have protocols

guide lines for the management of SAM
cases?

10.13 Did you monitor weekly SAM data by

HP? If yes see the trends?

10.14 Does health facility have Supply

requirement identified for 3months with
expected number of children?
10.15 .Is there up to date stock control
mechanism? (Use of bin cards)

10.16 Was there any stock out of the critical

supplies for SAM management in the past
3 months? (If Yes, for how long?)

10.17 Does the HF doing active surveillance/

case search /
10.18 Are active surveillance activities reported
to higher level?
S1 Add all the 2 responses together and
enter the total in the space provided
S2 Divide the total from S1 by 36. Multiply
the result by 100.
 Section: 11 Curative and Rehabilitative, Health Service Section & planning
Activities Yes Partly No Comment
11.2 Does the facility establish Drug and therapeutic committee
(DTC) & Auditable Pharmaceuticals Transactions and
Services (APTS)? Check the assignment of members by
official letters & their minutes?

11.3 Does the facility use and report RRF every two months
regularly for EPSA supplying products? (Check at least the
two preceding reports before your day of visit)?

11.4 Does the health facility conduct inventory at least once in a

year and quarterly for APTS sites? (The inventory should
be supported with an official letter and disseminated to all
concerned)

11.5 Does the HF have functional sterilization equipment &

tools like autoclave

11.6 Does the Health post have HMIS hardy copy reporting
format?

11.8 Did the health post completely filed last 3 month HMIS
report?

S1 Add all the 2 responses together and enter the total in

the space provided
S2 Divide the total from S1 by 34. Multiply the result by
100.
 Summary of findings

…………………………………………………………………………………………………

………………………………………………………………………………………………………

………………………………………………………………………………………………………….

………………………………………………………………………………………………………………….

1. Summary of action points agreed

Action Points Responsible Date Due

2. Signature of the supervisee and supervisors

Name of the supervisee Signature Name of the supervisor Signature

1. 1.
2. 2.
3. 3.