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

Abstract

Abstract Background: Supportive supervision is a key determinant of service quality and provider performance, and is particularly pertinent to low-resources settings where supervisors are pivotal to the performance of health workers. To strengthen the human resource management (HRM) function at district and health facility level we implemented the Support, Train and Empower Managers (STEM) project to increase the capacity of managers to support and supervise their staff in Tanzania. Methods: This study used a mixed-methods design, utilising data from health facilities to assess changes in practice and employing focus group discussions to explore perceptions of supervisors 12 months following implementation of STEM in three regions of Tanzania. The present study focused on the perceptions of supervisors on the implementation of supportive HRM processes and how these influenced the supervision practice. Results: The most notable behavioural change attributed to STEM was the introduction of systemic record keeping systems, including staff files and job descriptions. The systems led to an improved work environment and improved communication between health providers and supervisors. In-turn this eased the supervision process and saved on time spent supervising staff. Introduction of registers to monitor staff movement into and out of the facility reduced unexplained absences while availability of clear job descriptions led to more efficient use of HR. Conclusion: Supportive supervision can promote implementation of HRM policies leading to an enabling environment for management to support staff, thereby improving staff morale and retention. Lessons learned from STEM can be incorporated in rolling out such an intervention in other settings and can also enhance our knowledge about developing supportive supervision interventions. Keywords supportive supervision, supervisors, health workers, Record Keeping Introduction Supervision is one of the most relevant tasks in health systems management [1] and is particularly essential to enhance delivery of quality services [2]. In low-income settings supervisors are pivotal to the performance of health workers as sometimes they are their only link with the health system [3]. However, too often they lack skills, useful tools, transportation, and are burdened with administrative duties [2,4]. In these contexts, HRM practice (such as supervision, training and promotion) is often reduced to mere ritual [5] and supervision takes the limited form of inspecting performance against checklists, a process characterised by fault finding and reprimanding [2]. Improving the attitudes of supervisors towards health workers and the quality of their interactions, using the existing workforce, is a relatively inexpensive approach [6]. Previous interventions aimed at improving supervision tend to focus on training supervisors alone, an approach that has proven less than effective in improving performance [7]. If properly done, supervision can provide professional development to health workers, improve motivation as well as job satisfaction [8]. Health programmers and providers are increasingly favouring other forms of supervision that focus on addressing problems in service delivery [9]. Supportive supervision is one such approach and is defined as “an approach to supervision that emphasizes joint problem-solving, mentoring and two-way communication between the supervisor and those being supervised [2]. Evidence from programme evaluations and research studies in various countries suggests that supportive supervision promotes service quality. In six countries– Bangladesh, Brazil, Honduras, Kenya, Nepal, and Tanzania–the introduction of supportive supervision as part of service improvement initiatives yielded promising results in both service quality and provider performance [2]. In particular multifaceted interventions, for example training plus supervision, which address multiple determinants of performance, can increase the capacity of supervisors to support their staff [10]. A rigorous evaluation carried out in Kenya to reinforce adherence to supportive guidelines after health workers took part in training and workshops resulted in significant gains in the knowledge and practice scores gained, compared to those gained through training alone [11]. Similarly, an intervention in Honduras that incorporated participatory workshops with supervisors to develop vision and strategies of supervision resulted in increased open dialogue between supervisors and supervisees leading to high achievement of performance goals [8]. Increasing the frequency and duration of supervision, changing activities assumed during supervision, involving multidisciplinary teams in supervision, as well as incorporating tools such as guidelines and checklists are more likely to improve performance than single interventions [2]. Tools and techniques of supportive supervision, such as structured guidelines for external supervision and selfassessment instruments, are readily usable by health workers and supervisors in a wide range of settings [12]. National guidelines for supervision are in place in most low income settings [13,14] but studies show that the use of such tools during supervisory visits is more the exception than the rule [4]. Guidelines and checklists can support supervisors to understand what they are to do and how to do it and can facilitate supportive supervision to assess working conditions and the technical competence of staff [2]. Studies from low-income settings indicate that structured observation using checklists and immediate feedback can result in improved performance [11]. But while such tools can be effective in systemizing supervision, they may actually hinder supervision, particularly if they are lengthy leading to fatigue and mechanical use [4,15]. For example, study conducted with supervisors in Zimbabwe to measure the quality of supervisorprovider interactions concluded that supervisors viewed checklists as inventory tools and hence tedious and unnecessary for routine supervision [4]. The use of guidelines and checklists may support the supervision process, but may not be enough to effect change in the long- term, unless complimented with agreed set of priorities, budget, follow-up, audit and feedback to lead to changes and influence performance [16]. Good record-keeping is fundamental to professional practice but often regarded as tedious and left to be done at the end of a shift. Lack of records, for example absentee registers for staff is common. Absenteeism is a major problem; key staff members may spend most of their time attending trainings or report ill frequently [17] resulting in low health worker performance and outputs. Inadequate staffing levels may be compounded by a high level of absenteeism which reduces access to services [18]. It has been noted that a fair and accurate performance review may begin with tracking employee behaviours and patterns [19] for example introducing registers of arrival and departure time. Adequate supervision could reduce absenteeism and mitigate some factors that reduce health workers productivity [20]. The application of health worker management strategies through supportive supervision, improved supply of essential goods and integrated on the job training could reduce absenteeism and non- productivity [20]. Staff training, monitoring and regular supervision are important to successful improvement in records keeping. Productivity of health staff in developing countries is often described as sub-optimal and that personnel are under-utilized [21,22]. A shortage of employees particularly in developing contexts means that available professionals are often deployed to work in areas not related to their skills. This represents a form of wastage, especially if shortages of those skills exist in the country [17]. Health workers’ job descriptions are often unavailable [18] and workloads do not match staffing levels [17]. A substantial portion of staff time may be spent on administrative duties [17] as opposed to treatment and caring activities [22]. 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]. The objective of this study was to assess the effect of supportive supervision strategy on implementation of HRM processes following a cluster controlled trial intervention, STEM (Support, train and empower managers). This approach differed from other supportive supervision approaches in two ways. First, it addressed the role of managers in motivating and retaining staff, an aspect that h