District health managers’ perceptions of supervision in Malawi and Tanzania

Abstract

BackgroundMid-level cadres are being used to address human resource shortages in many African contexts, but insufficient and ineffective human resource management is compromising their performance. Supervision plays a key role in performance and motivation, but is frequently characterised by periodic inspection and control, rather than support and feedback to improve performance. This paper explores the perceptions of district health management teams in Tanzania and Malawi on their role as supervisors and on the challenges to effective supervision at the district level.MethodsThis qualitative study took place as part of a broader project, “Health Systems Strengthening for Equity: The Power and Potential of Mid-Level Providers”. Semi-structured interviews were conducted with 20 district health management team personnel in Malawi and 37 council health team members in Tanzania. The interviews covered a range of human resource management issues, including supervision and performance assessment, staff job descriptions and roles, motivation and working conditions.ResultsParticipants displayed varying attitudes to the nature and purpose of the supervision process. Much of the discourse in Malawi centred on inspection and control, while interviewees in Tanzania were more likely to articulate a paradigm characterised by support and improvement. In both countries, facility level performance metrics dominated. The lack of competency-based indicators or clear standards to assess individual health worker performance were considered problematic. Shortages of staff, at both district and facility level, were described as a major impediment to carrying out regular supervisory visits. Other challenges included conflicting and multiple responsibilities of district health team staff and financial constraints.ConclusionSupervision is a central component of effective human resource management. Policy level attention is crucial to ensure a systematic, structured process that is based on common understandings of the role and purpose of supervision. This is particularly important in a context where the majority of staff are mid-level cadres for whom regulation and guidelines may not be as formalised or well-developed as for traditional cadres, such as registered nurses and medical doctors. Supervision needs to be adequately resourced and supported in order to improve performance and retention at the district level.

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“…[2] A lack of individualized performance feedback could be an important factor constraining performance improvement, especially in district hospital settings in Malawi and other African countries where feedback is often not provided. [3][4][5] The provision of individualized performance feedback is made more feasible by growing opportunities to automate the measurement of clinical performance, brought about by the rapid growth of electronic health information technology (eHealth) in LMICs. [6][7][8] We use the term eHealth to refer to any electronic health information technology, such as electronic medical record (EMR) systems, laboratory information systems, and pharmaceutical information systems used to support the delivery of healthcare.…”

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“…However, studies undertaken in the health system have often reported such risks as obstacles. [35] This study harnessed the benefits of risk, such as enabling stakeholders to appreciate each other’s interests, strengths and weakness.…”

The Impact of Supportive Supervision on the Implementation of HRM processes; A Mixed-Methods study in Tanzania

“…A study from Malawi reported that many staff and facilities in their study lacked written job descriptions and, even when present these tended to be generic [23]. But even when job descriptions are available other studies [24] have found that the actual tasks staff did were not necessarily reflected in these documents [23].…”

“…In addition job descriptions are not widely available and performance indicators not generally agreed in Tanzania. In addition, although job descriptions were provided, the actual tasks staff did were not necessarily reflected in these documents [23]. A key lesson from successful quality and performance improvement interventions is that for change to be sustained and institutionalized there must be an internal enabling environment conducive to initiating, expanding, and sustaining the change [2].…”

“…Factors including low output of new health workers by medical schools, out migration of health workers to other sectors or more lucrative countries, or remuneration and adverse working conditions [32,33] are attributable to health worker shortage and performance. In Tanzania, supervision at the regional level is supported by Council Health Management Teams (CHMTs) and supportive supervision is viewed as a necessary part of HRM process [23]. But effective integration and implementation of supportive supervision still remains a challenge [34].…”