Maswa District Hospital, located in a remote region of northwestern Tanzania, offers a variety of basic services, including family planning. In the past, visits made by regional supervisors were infrequent and short, consisting mainly of the traditional sharing of tea and routine statistics collection.

Meanwhile, many staff members believed that only these supervisors or other people at headquarters had the authority to solve problems. With neither management nor staff taking responsibility for problem solving, sometimes even small issues went unresolved, and staff became discouraged by their inability to meet clients' needs.

But changes are afoot in the way that service providers like Maswa are being supported by regional supervisors and health authorities. Supervisors are joining with staff members to remove impediments to providing quality services--often within a matter of months and with little additional expense.

Focus on Clients' Needs

The new supervisory approach, which AVSC calls "facilitative supervision," aims to refocus the role of the supervisor to the task of meeting service providers' needs so that they can better meet clients' needs. Eleven doctor-and-nurse teams supervise the 91 sites across the country offering services in permanent and long-term contraceptive methods.

Fostering an atmosphere of teamwork, these supervisors bring the message to staff that management encourages and supports their involvement in problem-solving. They help staff implement continuous quality improvement themselves by providing whatever they need--be it additional training and equipment or the tools necessary to focus on and solve problems. During visits, the supervisors also monitor the medical quality of services and bring expendable supplies.

AVSC, working in partnership with the Tanzanian Family Planning Association (UMATI), is training the supervisory teams and holding annual workshops for family planning managers. This is part of a larger collaborative effort by AVSC, UMATI, the Ministry of Health, and Marie Stopes International to develop an enduring management and supervisory system that will sustain and promote the country's rapidly expanding reproductive health program.

Quarterly Visits

Dr. Wilfred Mongo and Lawrencia Ngossi, the supervisory team who gained responsibility for Maswa and the 10 other hospitals in the region less than a year ago, visit each site at least quarterly. Each of their three visits to Maswa this year has lasted longer than traditional supervisory visits, often more than a day.

The team has initiated many training programs throughout the hospital and is working to certify trainers and trainees. Two doctors are currently receiving training in providing additional contraceptive methods, and a staff member is being trained to provide much-needed maintenance and repair of all kinds of equipment, from blood pressure machines to beds.

Reducing Infection Risk

One of the most significant outcomes of the supervisors' participation at Maswa has been the hospital-wide introduction of infection prevention procedures. This important success stems from the team's introduction of on-the-job training and COPE, AVSC's widely used self-assessment and problem-solving technique.

Through COPE, the staff identified the need for buckets and bleach for decontamination, a vital component of the infection prevention process. However, they were pessimistic about securing the money to purchase these supplies, since they believed that all spending had to be approved in a lengthy process by the central office in Dar es Salaam, the capital.

After raising the issue with the supervisors, the staff learned that approval was not needed to allocate funds for such purchases. So they used income from recently introduced patient fees to pay for the supplies, and now each ward has a decontamination station. Supervision initially aimed at family planning services helped bring safer services to the entire hospital.

Heightened Morale

Enthusiasm is running high throughout Maswa hospital. One surgeon commented, "People are solving problems that administrators used to handle. People are happy, even the administrators are happy."

Dr. Mongo added, "We did not expect the level of changes that had happened... [The new approach] is a relief--previously staff and supervisors were blindfolded."

Similar reactions and commitment--on the part of supervisors and staff alike--have brought changes to the other sites as well. Many roadblocks have been cleared in the path to improving the quality of services across Tanzania, and heightened morale promises to make improvement an ongoing process.

Anne Lang Frahn is a program associate in public affairs for AVSC International.