The results are presented based on the three major themes in the conceptual framework which include supervision inputs/resources, supervision processes and practice, and supportive supervision outcomes.
Supportive supervision resources/inputs
Human resources
Supportive supervision teams (Supervisors)
A multi-disciplinary team of professionals from the SMoH, the CHD, UN agencies and the implementing NGOs conduct joint supportive supervision sessions. Each team member is allocated thematic areas to supervise based on her/his expertise (e.g., family planning, child health, nutrition, health data reporting, facility administration, and infection prevention and control). The monitoring visits, on the other hand, are mostly conducted by the CHD, the implementing NGOs, the fund managers, the donors and the third-party monitors. Generally, the health workers were satisfied with the supervisors and the support they receive. Nearly all the health workers described the supervisors as being polite, friendly, and acting as teachers and not like the police. In some counties, a few supervisors were reported to be harsh. For example, in one of the counties some health workers said “… for a small mistake they shout at you or send you packing” (FGD #8 & FGD #9). However, some managers mentioned that some counties lack adequate and competent CHD staff to conduct supportive supervision activities. The managers also reported a high turnover of staff at CHD and SMoH which compromise the consistency in knowledge related to supportive supervision.
Training on supportive supervision
The health managers acknowledged receiving either formal or on-the-job training sessions on supervision of health services. The training sessions on supportive supervision were mostly done as a component of other training sessions such as Health Management Information System (HMIS), leadership and management, and the expanded programme of Immunisation (EPI). A few managers received standalone training sessions on supervision of health services ranging from five to ten days through MoH collaborative arrangements with the Centre for Disease Control (CDC), World Health Organization (WHO), African Field Epidemiology Network (AFENET), African Medical and Research Foundation (AMREF), HPF, and United Nations Development Programme (UNDP). Nearly all the CHD and other health managers interviewed had training on the use of the QoC mobile application and on-the-job training on how to use the quantified supervisory checklists (QSC). The fact that few managers were formally trained in the supervision of health services raises questions about the quality and effectiveness of supportive supervision sessions conducted in the counties.
Supervisor and supervisee motivation
Many health workers from the FGDs were satisfied with the way supervision is conducted but requested the duration of the visits to be increased so that there is adequate time to discuss, share and jointly develop action plans. There were some health workers from Juba, Torit, Pariang, and Rubkona counties who were not satisfied with supportive supervision because they do not get feedback. For others, the action plans they developed are not implemented. The managers indicated that some health partners like UNICEF and WHO provide monetary allowances to the supervisors, for example, MoH officials who go for supportive supervision and spend a night out of their duty stations. Where no overnight stay is anticipated many organisations do not provide any allowances except for refreshments like water, biscuits and sometimes lunch. Some managers, however, referred to instances where some supervisors refuse to participate in supportive supervision activities where no allowances are provided. This has implications for ownership, especially from the CHD and/or SMoH which negatively affects health service delivery.
Financial and logistical resources
Funding and implementation of action plans
Generally, supervision is challenged by a lack of funds to execute some action plans, especially those that required money. Most of the supportive supervision initiatives are donor-funded and channelled through the implementing NGOs. There is limited funding from the government to support the supervision of the health service. The managers mentioned that despite having supervision plans, there are inadequate funds to implement the action plans and the recommendations arising from the supportive supervision activities. Such challenges are beyond the control of the CHD and the implementing NGOs, particularly when the recommended activities are outside the donor approved plans and priorities.
Transport
There is a lack of reliable means of transport in most counties to facilitate supportive supervision activities. Motor vehicles are the most used means of transport. Most vehicles are very old, and they keep breaking down. These vehicles and fuels are provided by health partners; the implementing NGOs, fund managers’ state teams, UN agencies, the CHD and SMoH. Where there are rivers like in Unity and Central Equatoria states supervisors use boats (canoes) to cross the rivers. In Torit County, some managers use motorbikes to access the health facilities during the rainy season. Due to insecurity in Yei County, the motorcycles are only used to supervise facilities within the town. Air transport is used to travel from Juba to the states and/or interstate movement due to insecurity and bad roads. For example, a manager from Torit County said that “…these days the supervision teams from Torit to Kapoeta travel by air because of the insecurity on the roads and once they reach there, they use a two vehicle convoy movement for security reasons” (SSI #7).
Tools and equipment
Most managers complained of a lack of stationeries for printing the checklists, smartphones, and/or tablets for ODK and QoC applications. Many health facilities also mentioned the lack of essential diagnostic equipment to facilitate service delivery and quality of health care.
Supervision processes and practices
Two main supervision approaches were used, namely supportive supervision and monitoring visits. These included one-to-one and group supervision sessions.
Purpose and function
The health managers stated that the current supportive supervision activities focus on the functionality of the whole health system rather than individual health workers and provide some training opportunities. The emphasis is more on the management tasks, and less specific on clinical aspects. The supportive supervision visits cover most aspects related to primary care delivery, pharmaceutical management, availability and use of medical equipment, the quality of care, and the community health initiatives. The monitoring visits are spot checks to verify staff attendance, the functioning of the health facilities, data quality, availability of drugs, and follow up on action plans from the previous supervision visits as well as to prioritise the locations in need of supportive supervision. From the interviews, it emerged that some health managers could not differentiate whether they were conducting monitoring or supportive supervision visits.
Planning and coordination of supervision
Many health workers mentioned that the CHD officials inform them about the planned supportive supervision visits through letters, e-mails or telephone calls. A few health workers from Torit and Yei Counties, however, indicated that some supervisors just show up at the health facilities without notice. The managers mentioned that the supportive supervision visits are planned based on the data received from the facilities. Often, supervisory visits also happen because some health facilities have not been visited for a long period. At times, the facilities are visited at the request of national MoH, and UN agencies due to problems reported to them from the community. One manager from Juba County said, “We visit a facility, or a county based on the health data we receive and sometimes due to emergency situations” (SSI #14). In some counties, the locations or health facilities to visit for supportive supervision are selected randomly.
Assembling a team of supervisors for the planned supervision visits was mentioned as a challenge by the health managers. The absence of supervisors when they are required leads to distortion and cancellation of the supportive supervision visits. At times, the supervisors either find health facilities closed, or staff absent from duty. There was insufficient coordination of supervision activities between the national and the sub-national levels. The health workers from the FGDs mentioned that supportive supervision teams visit the facilities in the morning hours when the client load is high, which inconveniences the patients since all the health workers are taken up by the supervisors. At the same time, this limits the duration the supervisors engage with the health workers. Like a health worker from Yei County said, “… at times the supervisors ask us (staff) to release patients to give them (supervisors) time to answer their questions” (FGD #9). Other health workers from Torit County indicated that “… sometimes the supervisors come at very late hours for example around 3 or 4 pm and hardly spend enough time to listen to our (health workers) challenges” (FGD #13). The health workers from most FGDs, suggested that supervisors should come after midday or a time when the client load is low to have meaningful engagements.
Frequency of supportive supervision
Usually, supportive supervision visits take place quarterly while the monitoring visits are done monthly but sometimes ad hoc. It was, however, noted that some facilities are supervised regularly (some take even up to six months or more to be supervised). Unlike the monthly or ad hoc spot checks, the quarterly supportive supervision visits include on-the-job training sessions on several topics such as completing registers, the use of clinical guidelines, and infection prevention and control practices.
Duration of the supportive supervisory visits
The time spent during supportive supervisory visits vary by the type and size of the health facility. The health managers and some health workers indicated that the supervisors spend approximately 30 minutes in a PHCU, two to four hours in PHCC and in the hospitals, they may take up to five hours. A health manager from Juba County said “… I (supervisor) have an experience where a PHCU is a small ‘tukul’ (hut) with just one room and maybe with two staff, so that would not take more than an hour to supervise” (SSI #10). It was not uncommon to find that the supervision teams visited more than two or more facilities per day especially for the smaller health units.
Tools used for supportive supervision
There are multiple tools used by supervisors in the health facilities, some of which have almost similar information. Paper-based checklists are the most used tools during supervisory visits. These checklists include the quantified supervisory checklist (QSC) - used quarterly by the MoH, CHD and the implementing NGOs and other programme specific checklists like for nutrition - used during the monitoring visits. There are also web-based tools such as the HPF Quality of Care (QoC) application and Open Data Kit (ODK) - used to supervise immunisation services. Nearly all the health managers indicated that the QSC is user friendly and less time-consuming. An NGO manager from Yei County said that “... although there is some information missing in the QSC, we (NGO) have added accessory tools (such as for laboratory, nutrition, de-worming services) to collect relevant data for quality improvement” (SSI #36). Some health workers also mentioned that some supervisors visit facilities without clear supervision objectives and checklists.
Content of supportive supervision
According to the health workers, the supervisors move in teams and visit all departments in the health facilities to look at the registers, outpatient services, maternal and child health services, infection prevention and control, the pharmacy, the community health activities, laboratory activities and the general management of the facility. The supervisors also discuss with the health workers the action points arising from the visits through a feedback mechanism. A health worker from Jur River County said that “… if there is anything to be corrected, the supervisors give immediate on-site guidance to the staff to improve” (FGD #3).
Nearly all FGD participants acknowledged receiving mentorship and coaching during supportive supervision. For example, mentoring on how to conduct health education sessions, record keeping, including completing the patient registers, and updating drugs stock cards as well as de-junking expired drugs. Additionally, during supportive supervision, the health workers get opportunities to interact with, SMoH, CHD staff and other health partners like UN and NGO staff. An FGD participant from a PHCC in Torit County said “… they (health workers) see the supervision as the climbing a ladder for them (health workers) to correct mistakes and learn” (FGD #5).
Communication and feedback
The health managers mentioned that they mostly give immediate verbal feedback about their supportive supervision findings. This was corroborated by many health workers during the FGDs. The feedback sessions involve all health facility staff to brief them on the findings and agree on the immediate actions as well as the recommendations for improvement. There were, however, some health workers from Juba, Torit and Rubkona counties who said that they have never received any feedback after supportive supervision. In addition to the verbal feedback, many facilities had supervision registers where supervisors write their findings, recommendations, and action points. The written feedback acts to reinforce the information shared during supportive supervision.
In Rubkona and Yei Counties, the managers also share the feedback on the findings from supportive supervision during the county quarterly review meetings. The review meetings are attended by the SMoH and CHD officials, health facility in-charges, fund managers (such as HPF) representatives, NGOs, UN representatives, as well as community and local government leaders. Another avenue for sharing the supervision findings with other health partners and donors is through the health cluster meetings held at the state and national levels.
The managers indicated that the feedback given during and after supportive supervision is well received by most of the health workers since it gives them opportunities to learn new skills and improve their knowledge. A manager from Jur River County said that “… I have not seen any instances where there is negative response or any push back from the health workers, because we (supervisors) are part of the same system and figuring out how to improve services delivery” (SSI #29). However, another manager from Rubkona County stated that “… there are few health workers who perceive feedback negatively, but it depends on how the supervisors communicate with them” (SSI #22). Some health workers appreciate their supervisors depending on the way you approach them, the way you coach them, the way you talk to them, and the way you give them feedback. A manager from Juba County said “… once you are harsh to the health workers during the feedback session they will fight back” (SSI #3). In Jur River and Wau counties where written feedback is given, the CHD officials take the lead in sharing the supervision report with the health facilities and the SMoH. At the facility level, the in-charge is responsible for communicating the supervision findings to her/his staff.
Problem solving
The health managers and the health workers mentioned that they normally develop action plans after supportive supervision visits. The follow up on the implementation of the action plans are divided into those of the health facility staff, the CHD, the implementing NGO, SMoH and sometimes the fund managers of the donor funds. Many health workers, however, noted a lack of a clear follow-up mechanism of action plans especially where funds are required. The health workers also said that sometimes the concerned health managers either do not or delay responding to their funding requests to implement the action plan activities.
Context of supportive supervision
The health managers mentioned conflicts and insecurity as the major impediment to the supervision of health services in the counties. Sometimes, the supervisors must deal with both the government and armed rebel groups' administrations to negotiate access to certain locations. Once cleared by both sides, then they can go ahead with the supportive supervision activities. During inter-community violence, the supervision teams withdraw and return once the security situation normalises. The health managers also indicated other access-related challenges such as poor road infrastructure, floods, vehicles getting stuck during the rainy season, and frequent breakdowns of the vehicles. The managers suggested that the government should improve the road infrastructures and the security and safety of the citizens and humanitarian workers.
Supportive supervision outcomes
Human resources management
According to the managers, the sustained discussions about staffing during supportive supervision activities have led to many counties recruiting more skilled health workers in the health facilities. A manager from Rubkona County said, “Because of supportive supervision, we (managers) are employing people based on the qualification, unlike before when the county was a war zone” (SSI #38). Many health managers cited some improvement in staff attendance. Some managers also observed that, although some facilities do not conform to signing attendance registers, there is considerable improvement in this aspect. To some extent, there are improved relations between the implementing NGOs, the CHD, and the SMoH because they participate in discussions and form part of the supportive supervision team. Other managers observed improved communication and cooperation among the health workers. The managers also noted the positive changes in the perceptions and attitudes of the health workers towards the patients.
Health information management
The managers alluded to some improvement in the completeness and timeliness of HMIS reports, data quality and availability of reporting tools in the health facilities. Through the routine data audits, the quality of reporting is improving since on-the-job training is provided during supportive supervision. A SMoH official from Unity State said that “…. although the data quality is not up-to-date, but at least it has improved so much due to supervision activities” (SSI #41).
Pharmaceutical management
There were mixed reactions from the participants about observed improvements in drug management. Some managers from Juba, Yei and Pariang counties mentioned that they have noticed changes in drug storage, supply, and availability as well as de-junking of expired drugs. On rational drug use, the managers mentioned that many facilities still have a challenge of prescribing drugs rationally.
Quality improvement
The managers cited some improvements in health service provision for some packages like EPI, Antenatal Care (ANC), and drug management in the health facilities. There is the increased use of standard treatment guidelines which to some extent has contributed to the presumed accuracy in diagnosis and drug prescription practices. There is also a noticeable improvement in some aspects of infections control and prevention like the segregation of medical and non-medical wastes in the health facilities. For example, a manager for Torit said, “I have seen a lot of improvement in terms of infection control and also quality of care given to the patients but now due to the issue of payment of incentive the services are deteriorating” (SSI #21). According to the managers, supportive supervision has helped them to look for opportunities to manage resources (including staff) better and improve the quality of care given to the patients. A CHD official from Rubkona County said that “…. our county was among the poorest performer in terms of HMIS reporting, but now, they are catching up on reporting and on the quality of care which is attributed to supportive supervision” (SSI #40). In Wau County, it was mentioned that until recently the health facilities that were not conducting staff meetings, are now conducting them, taking minutes and filing them for the records.