Construction of the final appropriate peer supervision model involved iterative processes which included analysis and synthesis of raw data. This overarching appropriate peer supervision model is accentuated by four sub-dimensions namely a) Incentives b) clearly defined roles c) mediation d) role model . The different sizes of the developed dimensions arising as a result of the different components therein highlight the varying time and resources that will be required for each dimension to accentuate appropriate peer supervision. The biggest dimension will require the most time and resources (Figure 1). Nevertheless, all dimensions will synergise one another in an iterative manner with no single dimension being sufficient on its own but rather all four working in tandem to define an appropriate peer supervisor. Figure 1 is the constructed model for an appropriate peer supervisor for private drug sellers at district level in rural Uganda.
Role model
Role modelling seemed to be the most talked about dimension of peer supervision. Drug sellers said that a good peer supervisor was one who was more educated than the rest and as such, will be able to conceptualise complicated cases through his or her professional experience and give advice. The drug sellers preferred that advice be passed on in form of counselling rather than the traditional harshness associated with government inspectors. Relatedly, the drug sellers felt that since peer supervisors would be chosen from among them, they would understand challenges faced and therefore be a little more lenient during supervision which would yield better outcomes than locking up drug shops as has been during inspection visits.
“You can even tell them the challenges you encounter during your operations and they can advise you on what to do or help you make corrections where possible” (P20: FGD5, comprehensive nurses, district without drug shop association)
As far as the inspectors were concerned, there was a general perception that if there was a way of identifying a role model from amongst drug sellers who would mobilise fellow drug sellers, this would ease the licensing process. Drug inspectors become harsh when they find unlicensed drug sellers prescribing and dispensing drugs. In the event that it was not possible to choose from the existing drug sellers, the inspectors suggested choosing people from the district local government structure. The inspectors suggested having sub-county and parish mobilisers in the event that it was not feasible to have appropriate peer supervisors selected from drug sellers.
“Possibly, if we can come up with strategies of identifying people from amongst them[drug sellers] to act as mobilisers, that can encourage them to license and bring them to us so that we have a free atmosphere. We have sub county structures. Parish mobilisers can play a big role if we work together to improve the services of drug sellers.” (KII, district without drug shop association)
Confidentiality was another attribute drug sellers felt was very important for one to be considered a good peer supervisor. This is because besides providing clinical services, the goal of selling drugs is to make profit. This introduces an element of competition among fellow drug sellers. The drug sellers mentioned that they preferred a peer supervisor who maintained the highest level of confidentiality and was not the kind to divulge too many personal details. The drug sellers felt that if the peer supervisor was to disclose too many business secrets, this would jeopardise the trade resulting in clients preferring some drug sellers over the others. Some issues raised by drug sellers included misdiagnosing patients and offering faulty treatment.
“Also I might not supervise the colleague whom we don't get along with because he takes my clients away” (P24: FGD3, nursing assistants, district without drug shop association)
In a bid to identify a peer supervisor who maintains confidentiality, drug sellers said they were very comfortable identifying such a person themselves through a transparent and democratic process. They felt that they knew each other and that they knew who was and who was not capable of maintaining confidentiality and supervising appropriately. This democratic process would also ensure that the system does not impose a tyrant on them who would make the running of business very hard. When asked how they preferred to choose the peer supervisor, some drug sellers preferred the ballot method while others preferred either raising their hands in support or lining at the back of the preferred candidate. Drug sellers also said that they preferred peer supervisors going for further training facilitated by the government and receiving a monthly allowance if time and opportunity allowed.
“I think on the issue of the peer we should be choosing that person ourselves. Secondly; if there is any opportunity such as an organization or the government providing them with some money, let them go and study and be at higher level than us concerning establishment of a drug shop. Let them also be given an opportunity of receiving salary every month after all, they will be working amongst us” (P16: FGD1, nursing assistants, district without drug shop association)
Drug sellers also felt that besides adhering to high standards of confidentiality, a good peer supervisor was one who will have a balanced cultural world view. In the course of our verbal interaction with the drug sellers, they mentioned that conflict amongst them was natural and it would be good if they got a peer supervisor who would not take any sides if conflict arose. They mentioned that conflict arises from relationships as well as through business competition. They felt that it would be good if the peer supervisor remained neutral and stuck to his supervisory role and did not interfere with other social problems.
“Another view madam is that I may not be getting along well with another drug seller especially my neighbour because we might be sharing the same woman. Or, the patients prefer my medication to his. So, the peer supervisor should deal away with segregation.” (P22: FGD3, nursing assistants, district without drug shop association)
Drug sellers also felt that an appropriate peer supervisor is one who would advocate for more workshops and seminars which would help everyone get more knowledge about common childhood illnesses thus improving treatment through advanced learning. They also said that a good peer supervisor would be one who promotes hard work in business since that supervisor would do their job more routinely.
“We talked of workshops and seminars for those peer supervisors but even we the drug sellers also need to be trained in such seminars such that we are updated of any new developments.”
(P15: FGD4, nursing assistants, district with drug shop association)
Clearly defined roles
This category was talked about with clarity by drug sellers because of the experience they had with government inspection which has many actors and is largely unstructured. To the drug sellers, an appropriate peer supervisor is one who will have predictable timing and routine of supervision. Drug sellers also felt that a good peer supervisor is one who will have appropriate supervision tools. Such tools will include a supervision check list. The drug sellers said that peer supervisors will need to have clearly defined tasks such as checking on education levels of drug sellers, operating room space, storage area for drugs, presence of toilet and hand washing facilities. Not being so intrusive to the extent of reaching drug sellers’ bedrooms in search for illicit drugs was another concern that was raised. In all, they mentioned that a peer supervisor would be a good first line supervisor before other layers of supervision take precedence if they exhibited professional ethics and standards.
“Some have a policy of coming up to where we sleep in search of drugs and for me I think that has to change. They should know their boundaries and only work within those limits. Just in case they find anything wrong within those limits, then I can seek for an apology.” (P15: FGD4, nursing assistants, district with drug shop association)
In having clearly defined roles, drug inspectors also felt that peer supervisors ought to work within a clearly defined organisational structure. This was stressed by one key informant as he said that when drug sellers are under one organisation, they are easy to regulate and following them up is easy. He intimated that the original thinking behind initiation of drug shops in the country was to act as a temporary stop gap measure for government inadequacies. However, the key informant was dismayed at how drug sellers through their organisations had become so powerful to the extent that they had dragged the NDA to courts of law. He said that every attempt at trying to streamline drug sellers is treated with a lot of suspicion. He lamented that the drug sellers had gone to great lengths to undermine policy by forming associations even where they were non-existent previously.
“I think it is a good initiative. Because in our systems, these [drug sellers] were supposed to be temporary stop gaps but I can see they are entrenched. They are down there serving the poor and hard to reach. You have heard of how they [government] tried to faze them out but you have heard the noise they have made. I think even those who had no association have organized them.” (KII, inspector, NDA)
Incentives
This dimension comprised three properties namely transport, remuneration and a combination of transport and remuneration. Drug sellers and inspectors recognised the need to offer appropriate incentives if the supervision process was to be smooth. While some drug sellers felt that either giving money in form of a monthly stipend or a bicycle was enough for smooth peer supervision, others felt that an amalgamation of the monthly stipend and a bicycle were the most appropriate incentives for time spent during supervision. The drug sellers suggested that government should buy the bicycles and the money should be given as a transport refund.
“They should be given at least a bicycle and allowance to facilitate their supervision.” (P24: FGD3, nursing assistants, district without drug shop association)
On the other hand, inspectors also felt that putting in place an incentive was a good initiative for peer supervision. The inspectors said that the incentives would best be executed at the level of drug shop associations if well managed. This would benefit both the drug sellers and the peer supervisors. They emphasized the fact that the incentives should be passed on through the drug shop association because the association was formed at district level. As such, the drug shop association would be controlled by district authorities and not be a parallel structure.
“May be at district level, these associations would work when they are better organized. Some of them were saying these people are just getting money. But I think if they are well organized and people know the benefits [of incentives], they can work out.” (KII, inspector, NDA)
Mediation
The dimension of mediation was divided into three namely: de-sensitisation, interpersonal style and counselling skills.
Drug sellers in the focus group discussions felt that an effective peer-supervisor was one who would be able to diminish negative tendencies associated with fear of government inspectors in what was termed as de-sensitisation. This is because during inspection, government inspectors ensure that errant drug sellers are arrested and their drugs are confiscated. In addition, they are insulted and ashamed in front of patients. Whereas this is more common amongst the unregistered drug sellers, the registered drug sellers tend to take no chances when government inspection is on-going. For this reason, participants in the focus group discussions felt that they would prefer someone who will be recognised as a first line supervisor before the more superior supervisors intervene. These assertions are highlighted in the quote below.
“I know those people [peer supervisor] will be approachable and not mistreat us. What they will do is to make a report and tell us where we have done well. They will not be as harsh as those people [inspectors]. That is why those people [peer supervisors] should be chosen from amongst us.” (P17: FGD 2, Nursing assistants, district without drug shop association)
As far as interpersonal style of the peer supervisor was concerned, participants in the focus group discussions said that since their businesses were running on very little capital, they would prefer someone who understands the challenges of raising such capital and the losses incurred when drugs are confiscated. As such, for one to be considered an appropriate peer supervisor, that person will need to be sociable, of good character and able to help when there is an overwhelming number of patients. The following quote captures what was said.
“That’s why we mentioned that they should train the peer supervisor to have social manners and be able to assist when they get to your drug shop and find many clients.” (P28: FGD2, nursing assistants, district with drug shop association)
Having good counselling skills was another attribute mentioned for one to be considered an appropriate peer supervisor by drug sellers in the focus group discussions. The drug sellers told the lead investigator of the study (AB) that in the event they were caught doing the wrong thing, they preferred being advised and warned before being punished as is the norm with government inspectors.
“For me I think that if they [peer supervisors]get me with something am not supposed to do, say a drug, they have to first warn me and if I repeat the same thing again, they can report me” (P15: FGD4, nursing assistants, district with drug shop association)