BackgroundExternal supervision of primary healthcare facilities in low- and middle-income countries often has a managerial main purpose in which the role of support for professional development is unclear.AimTo explore how Rwandan primary healthcare supervisors and providers (supervisees) perceive evaluative and formative functions of external supervision.DesignQualitative, exploratory study.DataFocus group discussions: three with supervisors, three with providers, and one mixed (n = 31). Findings were discussed with individual and groups of supervisors and providers.ResultsEvaluative activities occupied providers’ understanding of supervision, including checking, correcting, marking and performance-based financing. These were presented as sources of motivation, that in self-determination theory indicate introjected regulation. Supervisors preferred to highlight their role in formative supervision, which may mask their own and providers’ uncontested accounts that systematic performance evaluations predominated supervisors’ work. Providers strongly requested larger focus on formative and supportive functions, voiced as well by most supervisors. Impact of performance evaluation on motivation and professional development is discussed.ConclusionWhile external supervisors intended to support providers’ professional development, our findings indicate serious problems with this in a context of frequent evaluations and performance marking. Separating the role of supporter and evaluator does not appear as the simple solution. If external supervision is to improve health care services, it is essential that supervisors and health centre managers are competent to support providers in a way that transparently accounts for various performance pressures. This includes delivery of proper formative supervision with useful feedback, maintaining an effective supervisory relationship, as well as ensuring providers are aware of the purpose and content of evaluative and formative supervision functions.

BackgroundExternal supervision of Rwandan primary healthcare facilities unfolds as an interaction between supervisors and healthcare providers. Their relationship has not been thoroughly studied in Rwanda, and rarely in Africa.AimTo explore perceived characteristics and effects of the relationship between providers in public primary healthcare facilities and their external supervisors in Rwanda.SettingWe conducted three focus group discussions with primary healthcare providers (n = 16), three with external supervisors (n = 15) and one mixed (n = 5).MethodsFocus groups were facilitated under low-moderator involvement. Findings were extracted thematically and discussed with participating and non-participating providers and supervisors.ResultsWhile external supervision is intended as a source of motivation and professional development in addition to its managerial purpose, it appeared linked to excessive evaluation anxiety among Rwandan primary healthcare providers. Supervisors related this mainly to inescapable evaluations within performance-based financing, whereas providers additionally related it to communication problems.ConclusionExternal supervision appeared driven by systematic performance evaluations, which may prompt a strongly asymmetric supervisory power relation and challenge intentions to explore providers’ experienced work problems. There is a risk that this may harm provider motivation, calling for careful attention to factors that influence the supervisory relationship. It is a dilemma that providers most in need of supervision to improve performance may be most unlikely to benefit from it. This study reveals a need for provider-oriented supportive supervision including constructive attention on providers who have performance difficulties, effective relationship building and communication, objective and diligent evaluation and two-way feedback channels.