Findings

Working Definition of "Supervision" for Purposes of the Learning Package

There are as many definitions of the term "supervision" as there are people who supervise; each person tends to define supervision for his or herself by highlighting the elements of the job that are most important to him or her. The terms "supervision" and "management" are often used interchangeably. Some people understand supervision to be a subset of management—specifically addressing the human resource element—while others believe management is a skill area intrinsic to supervision.

The Kenya Inservice Reproductive Health Training Curriculum defines supervision as "... all the activities that ensure that personnel perform their duties effectively. In some situations, the service provider is expected to supervise the work of other providers and subordinate staff" (Kenya MOH/DPHC 1995). The Family Planning Manager’s Handbook states more simply that the purpose of supervision is to "guide, support, and assist staff to perform well in carrying out their assigned tasks" (Wolff, Suttenfield and Binzen 1991).

Whatever its relationship to management, the term "supervision" is often met with suspicion. Its general meaning is frequently interpreted as "keeping an eye on someone" or checking that work is done in the way it is supposed to be done. When seen as "policing," such negative views toward supervision often reflect the real experiences of many health providers.

According to Bond and Holland (1998) "clinical supervision should be about empowerment and not control, hence emphasizing that the route to professional accountability is through building confidence and self-esteem, which in turn requires careful, supportive feedback." In their textbook on clinical supervision, Bond and Holland (1998) define clinical supervision as an enabling and reflective process that helps achieve quality services: "Clinical supervision is regular, protected time for facilitated, in-depth reflection on clinical practice. It aims to enable the supervisee to achieve, sustain and creatively develop a high quality of practice through the means of focused support and development. The supervisee reflects on the part she plays as an individual in the complexities of the events and the quality of her practice. This reflection is facilitated by one or more experienced colleagues who have expertise in facilitation and the frequent, on-going sessions are led by the supervisee’s agenda...."

During this assessment, informants were asked to give their definition of the term "supervision" (shown in Figure 1). The most commonly mentioned themes or concepts included: "providing guidance," "checking," "monitoring and evaluation" and "ensuring that what needs to be done is done."

Figure 1. Definition of "Supervision" (As Expressed by Key Informants)

"Supervision involves checking and providing guidance on performance of tasks" "Process of getting activities done according to plan of activities" "Giving task guidance, correcting, monitoring and evaluation" "Leading, guiding, counseling in order to achieve desired results" "Ensure what is to be done is done the right way" "Coordinates services in health institutions, deploying and ensuring materials are available for the staff to use" "Assessment of staff motivation, evaluation of duties" "Ensure what needs to be done is being done correctly and efficiently" "Close look at what you are doing and monitoring the workers for the betterment of institution" "Overseeing activities being performed including: training, service delivery, planning, implementing and feedback" "My involvement in seeing that things are done the right way and right time" "Supervision is: identify problems with service provider and see how you can solve them together" "Supervision is someone planning, organizing, coordinating services and carrying out continuous monitoring and evaluation" "Supervision is someone charged with the responsibility" "To ensure what needs to be carried out is carried out"

Description of Existing Supervision System

Informants from various levels of the healthcare delivery system were asked to describe the supervision system as they know it—some from the perspective of a supervisor and others from the perspective of a supervisee. They were asked to identify several of the system’s key strengths and weaknesses and to make recommendations for its improvement. Summaries of their responses are grouped below.

Central Level Supervision

Supervisors interviewed included: the NCK and the MOH/DPHC Training Division

One reason the NCK does not participate in supervision activities is because there is a shortage of personnel within the council. The interviewees acknowledged that the supervision of nursing services is weak. When the staffing situation improves, the NCK will revive the inspectorate department that was responsible for supervision activities in the 1980s.

The MOH/DPHC Training Division is responsible for supervising 13 training sites (DTCs), each of which has five practicum sites. Although the DPHC trainers are charged with providing external supervision to the training sites, they have not received any training in supervision.

DPHC trainers do not carry out integrated supervision; they only provide support supervision in the area of RH. Detailed RH clinical skills and training skills checklists are available for them to use, but a supervision checklist that includes other general performance issues does not exist. DPHC trainers always give notice to the sites before visiting them. Upon completion of the supervision visit, reports are written by the trainers and feedback is given to the training sites and to those supervised.

The DPHC supervision system lacks essential resources for effective supervision such as computers, photocopiers and transportation.

District Level Supervision

Supervisors interviewed included: Medical Officer of Health/Machakos District and DPHNs from Kakamega and Siaya Districts

In general, all members of DHMTs have supervision responsibilities that reflect their respective areas of technical expertise. One member of each DHMT, the DPHN, has had specialized training in RH and therefore is responsible for supervision of RH services for the district. At times, DHMT members go out for supervision visits as teams, while at other times they conduct supervision individually.

In both Kakamega and Siaya districts, all 14 DHMT members have had training in supervision and, in theory, carry out routine supervision for about five days each month. In practice, however, the Siaya DHMT took part in supervision for only ten days in the last quarter.

No checklists are available for routine supervision. In Machakos, topics for supervision visits are planned around specific issues or problems at the site. Supervision is mostly crisis-oriented, and the team member who makes the visit relies on the identified problem to plan his or her visit.

In Kakamega, all routine supervision in the district is supported financially by the MOH. Specific project supervision (e.g., supervision for the community-based distributor [CBD] program and RH training activities) is supported by donors. In the past, the Kakamega DHMT members or the preceptor rarely joined RH project staff (e.g., for CBD or adolescent fertility management projects) on supervision visits. Since a preceptorship meeting in October 1998, DHMT members and the preceptor have accompanied RH project staff on supervision visits more often.

The Kakamega DHMT carries out supervision visits to the CBD project sites four times a year. Two of these visits are supported by the sponsoring agency, German Technical/Development Assistance Organization (GTZ), and two by the DHMT. CBD activities in all districts are supervised by project staff on a monthly basis. The CBD program has a supervision checklist but it is not used by the DPHN or the CBD supervisors. No explanation was given for the failure to use the checklist.

In Siaya District, about 50% of project-specific supervision is carried out by project staff who plan the supervision visit together with the DHMT. The Siaya DHMT members, however, do not join RH project staff for supervision visits. Donors support 50% of supervision activities while the DHMT provides financial support for the other 50%. It is anticipated that the RH supervision system will be sustained by fees for services and income-generating activities (e.g., sale of cards, client files and syringes).

The MOH/Machakos claims that reports are good when they are received; however, an examination of the reports revealed that they predominantly consist of service statistics. The Kakamega DPHN claimed that the quarterly supervision reports are clear and a good representation of the quality of reproductive services provided. The DPHN from Siaya did not agree. The reports have been helpful to the work of the DPHNs from both districts who believe that regular supervision visits improve quality.

Training Supervision

Supervisors interviewed included: DTC Coordinators, Kakamega and Machakos Districts

The DTC coordinators are accompanied by the preceptor when carrying out monthly support supervision to the hospital-based training site. Only once did a DTC coordinator from Machakos go on a supervision visit to a training site with the DPHN. Plans have been made to conduct supervision at training sites outside the hospital, but these plans have not yet been implemented.

During their visits, the DTC coordinators conduct support supervision for activities other than RH. In Kakamega, supervision tools or checklists are used for assessing RH clinical and training skills, but not for general supervision. In Machakos, the DTC coordinator makes her own tools or checklists. She admitted that she does not use her reports to plan subsequent supervision activities.

The DTC coordinators felt that they were providing adequate support supervision to the trainees at the hospital and that their efforts have improved linkages between preservice, inservice and service providers. The RH supervision process, however, is hampered by inadequate training in supervision, lack of transportation, poor coordination of supervision activities and lack of clarity regarding the respective supervision roles of the DHMT members, trainers and other supervisors.

Facility Level Supervision

Supervisors interviewed included: Medical Superintendents (MS), Hospital Matrons and Facility In-Charges for Kakamega and Siaya Districts

MS are responsible for supervising all departments within the hospital. The MS at Siaya District Hospital makes a supervision schedule and supervises daily. He also conducts monthly meetings for staff. The MS from Kakamega would like to supervise more often then his usual twice weekly visits but is unable to because of conflicting responsibilities and a heavy workload.

Neither MS has had formal training in supervision. The hospital matrons claimed to have had formal training in supervision skills.

Supervision tools are not available in either the Kakamega or Siaya hospitals. Departmental reports and records form a basis for action and improvement of services. The hospital matrons prepare for supervision on a daily basis by making a list of areas to be supervised. The matron from Siaya District completes her self-designed checklist while observing client-provider interactions and notes mistakes in a notebook.

According to the matron at Kakamega General Hospital, the current supervision system does not provide adequate support to the RH service providers. It is not common practice for DHMT members to join the matrons in supervision visits. The hospital supervision system is maintained by Government of Kenya funds that are far from adequate. In Kakamega, donor support of RH supervision in the hospital is about 15%. When the donor withdraws, it is hoped that supervision of RH services will be sustained by cost-sharing funds.

The supervision system in Siaya is constrained by a shortage of staff, inadequate fuel and transportation, poor telephone service, inadequate supply of gloves and JIK (bleach), and lack of supervision checklists. Supervision in Kakamega is constrained by lack of resources and space in service areas.

Supervisees interviewed included: Clinical Officer (CO) In-Charge, Nursing Officer In-Charge of Nursing Services and Deputy In-Charge of the Health Centre, Kakamega and Siaya Districts

Neither the Makunga Rural Health Demonstration Centre nor the Bushiri Rural Health Demonstration Centre (Kakamega District) was given notice before the most recent supervision visit. The health center in Siaya was given notice by the District Health Office. In both districts, the RH supervision teams (consisting of the DPHN, the DTC coordinator and the preceptor) supervise activities other than RH. During the supervision team’s visit, the Siaya DPHN gave drugs, gas and expendable supplies to the facility.

The in-charges at both health centers in Kakamega received feedback at the end of the supervision visits; this feedback was negative at the Bushiri Health Demonstration Centre. The in-charge at the health center in Siaya was not given feedback. Feedback at the Kakamega health centers was given with the service provider present. The length of the last supervision visits varied: 1 hour (Bushiri), 45 minutes (Makunga) and 20 minutes (Siaya). In spite of these variations in supervision practices, the in-charges from all three health centers see some positive results from the supervision visit.

Service Providers

Supervisees interviewed included: Kenya Enrolled Nurse-Midwife/Enrolled Health Visitor (KENM/EHV) and Kenya Enrolled Community Nurse (KECN), Kakamega District

Two service providers were interviewed at the health center level in Kakamega District. Both described the same process. They recalled being supervised by the DPHN during the last RH supervision visit. During the supervision session, the supervisor observed the service provider when providing services to clients, evaluated the quality of records and examined the equipment to determine whether it was clean, adequate and in working order. The RH supervisor did not use a checklist.

When the RH supervision team came, they supervised activities other than the RH services. The total visit took 1 hour for one service provider and 25 minutes for another. Both service providers and the in-charges received constructive feedback from the supervisor during the last visit. The supervisees claim that the last supervision visit was helpful to them and their clients.

Donors

GTZ

Support supervision is one component of GTZ support to its extensive CBD program in Kenya. The supervision component provides fuel funds, lunch allowances and bicycles to be used by CBD supervisors. It is believed that the DPHN and CBD supervisors do not supervise effectively, and consequently supervision of the CBD program is poor. A CBD supervisor’s checklist is available but not used.

Swedish International Development Agency (SIDA)

The SIDA-supported program in Kenya is still in its formulation stage. The focus will be on district level capacity-building, with a concentration on RH. Three to six districts will be selected to receive assistance to become model districts with the goal of expansion at a later date. Supervision is a key area of discussion in the development of project documents and is considered essential to managing expansion. According to the informant, supervision must come from the provincial level because districts cannot supervise themselves, and effective supervision from the central level is unrealistic. SIDA hopes to participate in the field-testing of the supervision learning package planned for September 2000.

Implementing Organizations

AVSC International

AVSC offers facilitative supervision training and practice. Supervision training is attended by nurses and doctors from both public and private sectors (e.g., MCH/FP nurse in-charge or provincial gynecologists) who are already participating in supervision activities. The physicians selected for the training course must be trained in minilaparotomy and voluntary surgical contraception counseling, and the nurses must be trained in basic FP. Supervisors who complete the course are followed up frequently by AVSC and DPHC staff. The facilitative supervision course is one week in length and provides the following tools:

• Self-assessment checklist for quality improvement
• Orientation curriculum
• OJT curriculum
• COPE package

Although it is believed that the course results in improvements in service quality, AVSC staff recognize that the program faces a number of challenges. During an interview, an AVSC staff person mentioned that the selection criteria for supervisors is not always clear and the Provincial Health Management Team is not always involved, resulting in a lack of support from management at the provincial level. During training, trainee supervisors are rarely able to put theory into practice and facilitators have limited opportunity to provide them with feedback. Once on the job, physicians are often too busy to carry out their supervision responsibilities. Lastly, the supervision training has a vertical focus and is not integrated with other services.

Other Country Experiences

Uganda

The Uganda MOH is currently implementing the development of a national supervision system as a part of the general health sector program. The national supervision strategy includes: the development of national guidelines, the development of a supervision schedule, a plan to obtain a steady source of funds, the involvement of community leaders, training and advocacy programs, and the application of a cascade approach (i.e., center to district, district to facility, facility to community). The creation of a Joint Mission Agreement is planned that will specify areas to be supervised, the supervision methodology and the identification of indicators and expected outcomes. Areas to be supervised include: funds utilization, progress on national indicators and sector development in relation to macro economic development. This supervision system falls under the MOH’s Quality Assurance Programme and the jurisdiction of the director general.

The strategy specifies that Quality of Care supervision teams will conduct supervision visits on a quarterly basis to the districts, as well as to all hospitals and selected health facilities. The national supervision guidelines include indicators at district and health facility levels. These guidelines are intended to standardize general supervision into a modular format which all projects must follow. This structure, however, does allow for the application of technical supervision so that each individual project or health program can conduct its own targeted followup of technical areas.

Various programs have already developed their individual technical supervision guidelines and tools. For example, the Delivery for Improved Services in Health project has a 200-page supervision tool that includes 11 technical areas for following up their RH trainees. The National Health Information System Manual includes a district level module on support supervision.

An assessment of supervision activities of three USAID-assisted RH projects was conducted in 1997. It examined: the various supervision tools, the frequency and quality of supervision, a synthesis of supervision data, the utilization of system outputs, and the impact on service quality and sustainability (Burnham and Stinson 1998).

Tanzania

INTRAH has been involved in supervision training in Tanzania since 1995. INTRAH’s project trains trainers at the central level who then go on to serve as resources for continued supervision training at district and facility levels. The 3-week curriculum for central level training focuses on:

• Training skills, including curriculum development
• Supervision skills
• RH updates

Similar training was carried out for district level managers and facility level COs. The training for COs also included skills in providing OJT. Using a checklist, facilitators followed up the supervisor trainees several times during the next year. During these visits, they found that the supervisor trainees were using the skills they had learned in training (e.g., problem-solving, OJT and the provision of feedback).

After the initial two years of support by INTRAH, this project became fully supported by the MOH/Tanzania. The team of master trainers at the central level are now able to conduct trainings and develop training curricula. INTRAH believes the program could be improved if the curriculum included strategic planning and if more on-site training took place. INTRAH also recommends that Medical Training College (MTC) tutors be included in the training of supervisor trainers.

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