Discussion

During the course of this performance analysis, the views of many stakeholders in RH were sought regarding the existing supervision system for RH. Many suggestions for the improvement of the supervision system as a whole were made during key informant interviews. The focus of this assessment, however, was to identify areas within the existing supervision system that could be improved through training interventions. Other, more systemic problems (e.g., personnel shortages, inadequate transportation and insufficient amounts of drugs and supplies) should be addressed by other interested partners.

Although very little training in supervision has been conducted within the health sector in Kenya, it is clear from the performance analysis that training is viewed as vital for improved supervisor performance. The development of a supervision learning package was welcomed by supervisors and service providers at all levels of the health system. It was agreed during the stakeholders meeting, however, to focus training where supervision would have the most direct impact on the quality of services—namely, on-site supervision.

Most health professionals in Kenya have a somewhat similar understanding of what supervision entails and how it should be carried out in an ideal situation. In reality, supervision practices have not been standardized. It is important to cultivate a common understanding of what supervision is, and advocate the positive impact it can have on the quality of RH service delivery. To this end, participants at the stakeholders meeting identified major duty categories for a supervisor and outlined tasks which would be addressed through the learning package.

The following section is organized around these major duty categories. For each duty category, a summary of key issues is presented and recommendations are made for the development of the supervision learning package. The key issues are an outcome of the performance analysis process: the needs assessment and the stakeholders meeting.

Supervision Learning Package Categories

Introduction

It is very important that this section presents a framework for supervision within the context of health sector policies and guidelines and provides a foundation for the remainder of the learning package. The introduction must define "supervision." As requested by informants and respondents, the introduction should provide a general understanding of the roles and responsibilities of a supervisor and give instruction on general supervision methods and tools.

Planning

Planning for supervision is already being done by supervisors throughout the health system. Although many supervisors lack standardized tools or checklists to help guide them during their duties, many develop checklists of their own. Some supervisors say that they use departmental reports and records for planning supervision; others admit that they do not use information at their disposal. Some plan for supervision on a daily basis, while others respond to requests or needs from their supervision sites. Generally, planning is crisis-oriented and improvised by individuals. Clearly, supervisors would benefit from learning how to become better planners, which would in turn help to standardize the supervision procedures.

Planning is a basic skill for good management but often supervisors do not consider themselves "managers." Many of the planning topics suggested during the assessment were very specific and reflected a narrow focus (e.g., "prepare a supervision schedule"). Participants at the stakeholders meeting, however, looked at planning as a broader management process. They suggested activities that range from conducting site needs assessments to setting goals and objectives to developing work plans that ensure adherence to the national RH guidelines.

Staffing

Supervisors want help in managing the staff they supervise. During the assessment, they asked for instruction in skills such as conflict management, setting performance objectives, developing consensus and deployment. They were particularly interested in learning about motivational issues such as facilitating teamwork, job productivity, job satisfaction and performance appraisals.

According to interviewees, feedback is almost always given during supervision visits to both the service provider and the in-charge of the facility. Some claim this feedback is constructive and useful while others find it negative. The quality of feedback is another key topic to be included in the learning package.

Training (Performance Improvement and Staff Development)

The supervisors requested training for themselves in other specific areas of RH, as well as training to learn how to organize and manage training on behalf of their supervisees. This chapter may have to be divided into two distinct sections. Or, tasks such as "assessing the clinical facility" may have to be addressed somewhere else in the package. It is clear, however, that this chapter should address topics such as providing guidance, coaching, preparing/organizing different types of training and following up trainees.

It is of interest to note that the supervisors themselves desire training or updates in RH and issues of quality. Although these needs are beyond the scope of the supervision learning package, it is important to link training in supervision to training in RH.

Information

Supervisors appear less interested in learning about managing data than they are in other duty areas. Supervisors may not be aware of the importance of information for management although it was recognized as necessary by meeting participants. Respondents articulated the need to improve report writing skills and, to a lesser degree, the use and sharing of information.

Logistics (Includes Physical Facility, Equipment and Supplies)

Respondents and meeting participants indicated that general skills in managing supplies and equipment are essential. Specific skills (e.g., ordering supplies and maintaining infrastructure), however, were not identified by supervisor questionnaire respondents as essential. Although supervisors may understand the need to oversee the management of supplies and equipment, they are not directly involved in the day-to-day logistics and so they do not see the need to have it included in training. Interestingly, the most common problems identified that affect supervision include lack of resources, shortages of drugs and supplies, and other logistical issues.

Problem-Solving

Problem-solving was unanimously identified as an essential general skill to learn.

Communication

Effective communication was identified as an essential skill by nearly all supervisors. Specific aspects of communication were also recognized as important (e.g., providing constructive feedback, writing reports, making presentations, managing groups, making linkages and involving the community).

Financial Management

Financial management was identified as an essential skill for supervisors. Respondents and meeting participants also expressed interest in learning about sustainability. During interviews, several respondents mentioned that support for supervision will be dependent on cost-sharing activities or fees for service.

Summary

The goal of any RH program is the delivery of quality healthcare services. Essential to the delivery of these services is a competent healthcare provider. Several factors affect the performance of the healthcare provider including job expectations, performance feedback, supplies and equipment, motivation, possessing the knowledge and skills to provide services, and supervision. Supervision is an essential intervention to maintain the performance of the healthcare provider, and improved supervision is unanimously recognized as important for the delivery of quality RH services in Kenya.

Although most supervisors define supervision in different ways, commonly mentioned themes or concepts include: "providing guidance," "checking," "monitoring and evaluation" and "ensuring that what needs to be done is done." These concepts endorse the definition for supervision provided by the Family Planning Manager’s Handbook, to "guide, support, and assist staff to perform well in carrying out their assigned tasks" (Wolff, Suttenfield and Binzen 1991).

During the course of this performance analysis, it was determined that most health professionals charged with supervision responsibilities in Kenya lack the full range of knowledge and skills to perform their job. Most supervisors are limited in these areas because they have received neither training in this area nor any support or reference materials on supervision. The intervention selected to improve supervisor performance includes the development of a supervision learning package and group-based and structured OJT courses. The development of a supervision learning package and training courses is welcomed by supervisors and service providers at all levels of the health system. The intent of the JHPIEGO-supported learning package, however, is to focus on the area where supervision has the most direct impact on the quality of services—namely, on-site supervision.

In addition to a lack of knowledge and skills, other causes of poor performance include: insufficient funds for transportation, lack of supervision tools (to be addressed in part through the development of the supervision learning package), infrequent supervision visits and inadequate national supervision guidelines. To maximize the effect of the training interventions, it is essential that these other causes of poor performance be addressed concurrently with the training of supervisors.

The supervisor plays a critical role in ensuring that members of the community receive quality reproductive healthcare services. To perform effectively, the supervisor not only needs to acquire the knowledge and skills to do the job, but needs to work in an environment that will allow the supervisor to have a positive effect on the quality of services.

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