The relationship between primary healthcare providers and their external supervisors in Rwanda

Abstract

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.

Development and validation of the ExPRESS instrument for primary health care providers’ evaluation of external supervision

“…We used focus group discussions with separate groups of providers and supervisors to explore the relationships between evaluative and formative supervision activities and between supervisors and providers. Methods and results are reported elsewhere [14,19]. …”

“…In Rwanda, external supervisors regularly visit primary health care facilities (health centres) for evaluative and formative supervisory purposes [14,19]. The external supervisors work in teams under the district hospital to which health centres refer.…”

“…The external supervisors work in teams under the district hospital to which health centres refer. Supervisors are typically clinically experienced nurses with a higher nursing degree [19]. One of the major supervision drivers is the monthly or quarterly performance evaluations, which constitute the core of a nationwide performance-based financing system [14].…”

“…Supervision encounters may happen between one or more supervisors and one or more providers. The lack of a personal supervisor together with a high turnover, absenteeism and frequent provider shifts between services, make it likely that providers interact with a new supervisor at each supervision encounter [14,19]. …”

“…Moreover, to empower providers with an opportunity to give feedback to supervisors within an otherwise asymmetric power relation [19]. The tool should thus focus on aspects of supervision potentially modifiable by supervisors, and cover key concepts in supportive supervision within health care.…”