Facilitative Supervision: A Vital Link in Quality Reproductive Health Service Delivery
Beverly Ben Salem and Karen J. Beattie
AVSC has long been committed to finding innovative ways to help improve the quality of the clinical services clients receive. Through the development of approaches like COPE, inreach, and whole-site training, we are working to help all levels of service providers at clinics and hospitals become more responsive to the needs of clients as well as staff. These tools focus on giving clients and providers an important role in discovering and implementing ways to improve service quality.
Since traditional supervisory systems may not be conducive to "empowering" staff and clients to participate in problem solving, AVSC is now proposing a new approach,facilitative supervision, which complements our quality-improvement tools by giving clients and site staff the support they need to become part of the quality-improvement process.
Our work on supervision has focused on external supervisors--that is, persons who are responsible for geographic areas and who serve as intermediaries between a service-delivery point and an institution such as a Ministry of Health or NGO country headquarters. However, the principles of facilitative supervision can also apply to supervision within a given facility.
The first part of this paper defines facilitative supervision and explains how it differs from conventional supervision. The second part presents examples of the steps an institution can take to move from a traditional supervisory system to a facilitative system. Thereafter, examples of facilitative supervision in action are given, followed by a discussion of ways to evaluate the success of this approach.
This paper is intended to be a companion piece toAVSC Working Paper No. 7, "Quality Management for Family Planning Services: Practical Experience from Africa." [Footnote 1]
DEFINITION AND BACKGROUND
AVSC defines facilitative supervision as an approach to supervision that emphasizes mentoring, joint problem solving, and two-way communication between the supervisor and those being supervised. This definition recognizes that supervisors play an essential role as intermediaries who can facilitate the implementation of institutional goals and who can facilitate local-level problem solving and quality improvement. The use of the term facilitative supervision does not imply criticism of conventional supervision systems. Rather, the aim is to focus attention on a key concept of supervision--joint problem solving--and to remind us that traditional "inspection" alone is not conducive to helping sites achieve continuous quality improvement. Ideally, management facilitates quality improvement by involving service providers in identifying and resolving problems. This may involve reorientation of systems as well as individuals.
When supervisory systems change to become more facilitative, it does not mean that management no longer has a directive role. Management remains responsible for determining the goals of the organization, planning the implementation of work, and making available the facilities, equipment, training, and other resources needed to achieve those goals.
Supervision and Continuous Quality Improvement
To help promote continuous quality improvement at all levels of clinic services, AVSC is developing tools and approaches that include COPE,[Footnote 2] inreach,[Footnote 3] whole-site training,[Footnote 4] cost-analysis methodology for clinic-based family planning methods,[Footnote 5] and AVSC's approach to medical monitoring and supervision. [See Figure 1] The use of these tools and approaches has repeatedly pointed to the need to focus special efforts on strengthening weak supervisory systems--the vital, "missing" link in quality management.
In the field of reproductive health, it is appropriate to focus on clients and how their needs are being met by clinic staff. However, while striving to achieve the aim of satisfying clients, it should be acknowledged that service providers also have needs. One basic need is for an appropriate and functional supervisory system.
Many obstacles to providing consistently high-quality services can be overcome by local staff after they become aware of their own ability to effect positive change. (This "empowerment" is one reason for staffs' enthusiasm for COPE, which helps staff resolve many problems on their own.) However, some items surpass capacities for action by local staff and instead are related to linkages (or the lack thereof) between service sites and higher levels of authority. In many instances, problems identified by staff reflect the need for supervisors to devote more time and provide more guidance to sites.
Conventional Supervision: Constraints and Missed Opportunities
Supervisors are essential to achieving an organization's mission. Not only do they perform the important task of interpreting the goals of the organization for staff, but they also coordinate the resources--people, time, materials, and money--necessary to achieve those goals.
A conventional model of supervision is often found in the health care systems in which family planning programs are situated. This conventional model emphasizes assessing actions in the past rather than seeking opportunities that look to the future. In other words, the emphasis is on scrutinizing individual performances and assessing end results instead of collaborating with staff to improve work processes and to ensure that quality services are provided to clients.
This model, focusing on individuals rather than processes, does not take into account other factors that affect an individual's ability to carry out her or his job. In addition, by focusing on the "subordinate and not the goal... the supervisor [is] not taking initiative to contribute to the aims of the organization." [Footnote 6]
Supervisory systems miss opportunities for improvement when they focus only on the things that go wrong. In addition, supervisors are often frustrated in their work because they cannot meet the need for support evidenced by those they supervise. Budgetary constraints, geographic constraints, and lack of supervisory training can result in missed opportunities for quality improvement.
As with other aspects of medical services, supervision is often deficient due to budgetary constraints. Transportation and subsistence budgets for those required to cover a geographic area are often insufficient or unavailable, making it impossible for them to actually carry out supervisory duties. In order to conduct necessary visits, supervisors in some AVSC-supported programs in Africa reportedly have traveled in taxis hired by the day--a practical solution that's not tenable for the long term. Visits conducted in circumstances such as these may be perfunctory and of short duration, thus jeopardizing the quality of the supervision provided.
Supervisors asked to cover many sites within a large geographic area may only be able to provide superficial supervision. In reality, much of the supervisor's time is spent on the road, getting from place to place. When, as often occurs, it takes a day to travel to a site and a morning to complete protocol visits with district or site officials, a supervisor may only have a couple of hours to spend actually observing services and talking to staff at the site before she or he must depart. On such a visit, the supervisor may not have an opportunity to talk with different levels of staff or to spend time looking into particular problems.
What a supervisor actually observes during a tour may not be relevant, simply because of the time of day when the "inspection" takes place. For example, if one of the supervisor's tasks is to monitor the quality of clinical services, clients may be inconvenienced and services may be disrupted or rescheduled in order for the supervisor to observe interaction with clients, clinical technique, infection prevention procedures, and postsurgery monitoring. The resulting "snapshot" of services is distorted by the limited amount of time, the wide range of issues to cover, the perceptions of the few people with whom the supervisor interacts, and the very nature of an "inspection" visit. [See Figure 2]
After such a visit, the supervisor may leave behind instructions for things to be changed, followed up, or improved, but since neither the supervisor nor the site staff knows when the next visit might occur, little accountability or responsibility exists for ensuring that these instructions are followed. With brief supervisory visits spaced far apart, there is little capacity in most systems for resolving problems, and opportunities for continuous quality improvement are few.
In contrast, with the facilitative approach, supervisors ideally spend more time actually working at each site--perhaps two days instead of two hours. Devoting this much time to a site allows the supervisor to better understand and work with site staff to identify and begin to resolve problems. This may initially be more costly than short visits; however, over time less of the supervisor's time will be required as the capacity of site staff to monitor and rely upon themselves to solve problems grows.
Lack of supervisory training
In many instances, staff are promoted to the supervisory level because of their reliability and good work, technical expertise, or their tenure with an organization. These staff are then expected to supervise others, often without adequate training or preparation, under the assumption that the same qualities that enabled them to perform well in their previous jobs will apply to the new situation. In fact, they may be supervising staff whose jobs bear no relation to their own past experience.
For example, some supervisors are expected to conduct medical monitoring, although they may not have the technical skills to do so and may receive no special training in techniques and approaches for medical monitoring.
In addition, few resources are devoted to training supervisors in the art of supervision. They receive little or no training to develop the communication and decision-making skills that would enable them to support quality improvement at the site level. When there is any training, it is often geared to the inspection model, informing supervisors about what checklists and reports are required in order to quantify results. Unfortunately, data that is collected to satisfy institutional requirements is rarely used by supervisors to help staff at the site level to monitor and evaluate their own activities.
Because of budgetary, geographic, and supervisory training constraints, many opportunities for improving the quality of services are lost. On the other hand, with appropriate training and with more rational use of time and resources, supervisors can become catalysts for establishing or improving existing quality-assurance procedures in sites for which they are responsible.
In COPE exercises, staff frequently identify training needs as a problem to be resolved at the site. Supervisors can play a role in planning for training, in gaining access to the necessary resources for training, and, if they have the requisite skills, in providing some of the training themselves.
Improving Quality through Facilitative Supervision
Ideally, facilitative supervisors play the important role of intermediary: their continuous feedback to higher levels of management on successes, constraints, and failures in the provision of services helps management plan future improvements. At the same time, their support to the sites and staff they supervise helps achieve the institution's goals. It is important to remember, however, that facilitative supervision is only part of a process leading to the achievement of improved quality of services--it is not a stand-alone intervention.
Site staff and service providers are experts on how services are provided: placing problem-solving tools in the hands of staff enables them to improve and maintain the quality of the services they provide; encouraging managers and supervisors to support this and to develop facilitative styles of management are essential steps in overall quality improvement.
In industry, managers are acutely aware of the costs of poor quality (for example, spending time to appraise what went wrong initially, then devoting the resources necessary to repeat work that is faulty). In every field of endeavor, poor quality results not only in time wasted to redo work, but ultimately in the loss of valuable customers. Those who provide family planning services are becoming more aware of the cost of poor quality in similar terms: when they are not treated with respect, when they receive poor-quality services, or when they do not receive the service they want, clients "vote with their feet" and do not return to a facility.
Providing high-quality services means meeting the needs of clients with a minimum of effort, waste, and rework.[Footnote 7] Problems can be anticipated and prevented by ensuring that staff members understand what quality is and feel responsible for providing quality services. In industrial settings, this is known as "moving quality assessment upstream."[Footnote 8]
In the past two decades, theories have been advanced to challenge the traditional concept that assuring and improving quality is the result of external review, inspection of the end result, and a heavy investment in supervisors whose major function is to monitor staff.[Footnote 9] In these theories, the focus has shifted to anticipating and preventing problems rather than correcting them. Instead of finding fault and leveling blame at individuals, the emphasis now is on determining whether or not existing work processes are planned, designed, and implemented in such a way as to achieve the desired end result--a high-quality service that meets clients' needs. In this spirit, the facilitative approach suggests that improving quality should be a facet of every action or process that ultimately leads to delivery of a service. [See Figure 3]
A facilitative supervisor constantly asks himself or herself the following questions: Are the services provided meeting the needs of clients? Are staff continuously assessing the quality of their work and the processes by which they do their work?
Facilitative supervision seeks to foster this kind of quality-improvement philosophy within an organization. As institutions begin to assess, define, and evaluate the kind of quality service they wish to provide, supervisors can facilitate the process by interpreting institutional goals towards improving quality for site staff. At the same time, they can facilitate the process of quality improvement at the site level by helping site staff prioritize activities and gain access to resources and by providing appropriate technical assistance and support.
A critical role in problem solving
With COPE, AVSC embarked on a program of technical assistance to introduce specific quality-improvement ideas at the institutional and clinic level. In the numerous countries where COPE has been introduced, we have found that clinic staff usually identify problems that fall into two broad categories:
In both cases, supervisors play critical roles in supporting the implementation of action plans developed locally to improve the quality of services.
For problems that can be addressed by local staff, the supervisor facilitates local problem solving by being supportive of staff action and by being available for discussion with staff if obstacles arise. Supervisors may also play important roles in helping to prioritize the actions that staff have identified so that items that may be critical in terms of health care safety (such as infection prevention or technical competency) are addressed immediately, before staff begin to tackle less urgent problems (such as the availability of informational materials or the lack of signs to direct clients to services).
There are a number of ways supervisors facilitate problem solving at the site level. For instance, if staff identify a variety of training needs, the supervisor may be able to conduct training or to identify someone else capable of conducting that training. Additionally, the supervisor may be able to identify the resources needed for training to take place at the site, thus increasing the impact of training at that facility.
When dealing with solutions for which staff need additional assistance, the supervisor's role is critical for staff to be able to accomplish their goals. In these instances, the supervisor facilitates either staff's access to resources or the articulation of a problem to higher-level management. For problems that cannot be addressed at the site level, the supervisor is the conduit to higher levels of management. By bringing such opportunities for improvement to the attention of higher authorities, the supervisor can be a catalyst for institution-wide improvements.
Key Concepts of Facilitative Supervision
The four key concepts that contribute to AVSC's definition of facilitative supervision are described below.
1. The supervisor is a catalyst for quality improvement.
More power should be placed in the hands of supervisors to make changes and improve services. Supervisors become the catalysts for change by creating an environment of teamwork in which change and improvements in the quality of services can flourish.
2. Joint problem solving, with full staff participation and using simple, practical tools, will foster the quality-improvement process.
Supervisors must know standard problem-solving steps: defining a problem, analyzing possible causes, identifying possible solutions, developing an action plan to implement solutions, and evaluating the results. Related to this philosophy is the notion that the site should be the focus of quality-improvement efforts. For example, if training is required, rather than sending some individuals to a central training location, training should, whenever possible, take place at the site and include as many individuals as possible. Similarly, the supervisor and site staff should join forces to identify the resources needed to improve the quality of services provided.
3. Facilitative styles of communication and support are essential.
A facilitative style of supervision emphasizes mentoring and coaching of individuals and groups. Good communication skills that facilitate dialogue with site staff are essential.
Supervisors must know how to facilitate discussions during group meetings, must acquire skills of giving and receiving feedback in an appropriate manner, and must learn how to listen effectively in order to improve communication. An understanding of adult learning processes is also key to communicating with site staff.[Footnote 10] Supervisors must learn when and how to use different styles of decision-making (that is, command, consultation, consensus, or delegation).
4. Supervisors must have solid technical knowledge for the duties they are to perform and must know how and where to gain access to additional support.
Supervisors must know the broad array of services that are available at a site, as well as what the national standards and guidelines call for in terms of the quality of those services. While they may not be technically proficient enough to evaluate all aspects of service delivery, supervisors must know how and where to gain access to additional support when needed.
In addition to these four key concepts, a number of factors contribute to good supervisory skills, including:[Footnote 11]
Identifying techniques for assessing the extent to which a specific supervisor meets the above criteria for excellence is a topic requiring attention in the future, as AVSC strives to provide technical assistance in the area of supervision.
The Supervisor's Role
As part of the ongoing process of developing supervisory systems, AVSC routinely holds brainstorming sessions with both external and internal supervisors. When asked to identify their main responsibilities, participants cite a plethora of activities that fall into a few general categories: planning, training, monitoring, coordinating, visiting sites, motivating staff, problem solving, providing services, managing complications, collaborating with other organizations, evaluating services, and managing data needed for reporting.
Based on experience in clinical settings and on feedback from service providers, AVSC has performed a task analysis to illustrate the "facilitative" approach to supervision and to clarify how various aspects of supervisors' duties fit into the framework. [Note: The figure illustrating this model is only available in the print version of this Working Paper; contact AVSC to obtain a copy.] In this model, the basic role of the supervisor is to address the needs of family planning providers to enable them to manage the quality-improvement process. Providers are at the center of the three principal functions of supervisors in the AVSC model. To be successful, supervisors must work effectively with those they supervise. The COPE process often points out the link between meeting providers' needs and ensuring clients' rights to quality services. These rights and needs serve as assessment tools and indicators. [See Figure 5]
Function: Address providers' needs for good management and supervision
Activity: Help site staff understand and implement the quality-management process
Staff may need orientation to better understand the quality of their own services and may need guidance as they embark upon the quality-improvement process. The supervisor provides leadership and support for this process and for developing the team approach to quality management on site that will lead to increased quality and client satisfaction. If COPE has not already been done at the site, the supervisor introduces the COPE assessment tool (or arranges for a facilitator to do so) and supports site staff in resolving problems identified and evaluating quality at the site. Sites in which COPE has been previously introduced may benefit from conducting a COPE update. By arranging for the training of COPE facilitators on-site, the quality-improvement process can continue, with COPE updates carried out from time to time.Specific tasks include:
Activity: Help site staff plan objectives and evaluation
The supervisor may need to orient staff and management at sites to overall program goals of the country and agency and help to develop site-specific objectives and work plans. Sites may need help with record-keeping and guidance to understand how to evaluate their progress by analyzing statistical report data. The supervisor acts as liaison between headquarters and sites to promote common awareness of needs and resource utilization.Specific tasks include:
Function: Address providers' needs for good supplies and site infrastructure
Activity: Help site staff ensure availability of equipment and supplies
Staff may need training to correctly assess their needs for equipment or expendable supplies, as well as to establish systems for maintaining inventory records to ensure adequate stock levels. When stock-outs occur, the consequences can be devastating for clients and family planning programs alike: for the client, the result may be unintended pregnancy; for the program, confidence lost in the continuity of service provision may be impossible to restore.Specific tasks include:
Activity: Help site staff improve the physical aspects of their sites
A supervisor may bring good ideas about how to improve the physical layout of services based on observation or experience elsewhere. For example, some of the bottlenecks identified during the client-flow analysis section of a COPE exercise may be alleviated by making minor changes in how staff use their time or how clients move through the clinic. Sometimes it is necessary to identify and prepare areas that allow for privacy during family planning counseling and to designate areas in the wards where information about contraception can be given.Specific tasks include:
Function: Address providers' needs for information, training, and development
Activity: Help site staff know and apply service standards, norms, and policy
Staff need to be made aware of national and agency clinical standards and policies. Service providers feel vulnerable when they lack clear directives and guidelines from in-country officials or when directives are outdated or contradictory. Service provision is adversely affected, and may even be withheld, if official authorization or clarification is not received.
For example, policies on spousal consent are the subject of confusion in many countries. Some individual providers insist upon having the signed consent of a husband before providing a permanent family planning method for a woman, even though the policies of the country do not require it. Access to services may be denied as a result.
Supervisors can provide links with other implementing agencies in their assigned geographical areas. By so doing, service providers can share information and mutual reassurance regarding program implementation, especially in the absence of official endorsement.Specific tasks include:
Activity: Help site staff address clinical and nonclinical training needs
Staff may need guidance to determine needs for training and may need support from supervisors to understand the benefits to be gained from localized training. Supervisors help site staff plan and implement whole-site training (an integrated approach to training that views a service-delivery site as a system and treats staff as members of the team that makes the system work). This training usually consists of orientations and updates and makes the most of local resources. If external expertise is needed, the supervisor's role is to help staff gain access to that expertise.
For skill training, supervisors may also help to organize on-the-job training. Training may sometimes be conducted at a centralized training facility, but this should be restricted to cases in which, for example, the skill to be acquired is completely new to the institution or to the site. The task of supervisors in assessing the competency of trainees and monitoring their use of newly-acquired skills is extremely important. Supervisors must either be able to certify clinical trainees as competent, or have access to medical staff who can do so. Supervisors also serve as catalysts for ensuring that the medical quality of services is monitored on a routine basis and provide support or access to resources for medical monitoring, as needed.Specific tasks include:
MAKING THE TRANSITION TO FACILITATIVE SUPERVISION IN FAMILY PLANNING PROGRAMS
The process used to introduce facilitative supervision into a service-delivery system depends on the level of development of the family planning program, as well as the extent to which quality-improvement processes have already been instituted. In general, however, before introducing the concept of facilitative supervision, decision-makers within an institution must recognize supervision as a vital area that deserves investment of time and material resources. Creating an environment in which supervision can flourish is a prerequisite to making the transition to more facilitative styles of management.
So that they will understand that supervision is a key element in the process, policy makers and managers must be aware of the benefits that accrue to an organization that continuously seeks to improve quality. In addition to considering the costs of poor quality (notably that clients flee from poor-quality services), policy makers and managers should understand the high cost of poor supervision. Resources are often used to support a nonfunctional system, just because "it has always been done that way."
Policy makers and managers should also consider the increased cost-effectiveness likely to occur when:
An effective supervisory system can help bring about the benefits listed above, as well as help interpret institutional goals, standards, and guidelines for site staff.
Policy makers and managers need to be convinced of the value of facilitative supervision. Once the need for effective supervision is acknowledged and its benefits anticipated, adequate support must be provided to enable this former "missing link" to become the foundation for achieving programmatic and strategic objectives.
Introducing Facilitative Supervision in Three Stages
The following is a description of the three-stage process AVSC has used to introduce facilitative supervision in Africa. This approach should be adapted or modified as appropriate for different settings.
The three-stage introduction of facilitative supervision as used in Africa takes approximately two years, although the time may vary within each institution.[Footnote 12] Each stage in the process begins with a workshop that is followed by on-the-job training in order to model and practice supervision techniques and to provide "coaching" to the team of supervisors. [See Figure 6]
Initially, the supervision workshops are facilitated by the institution's supervisors with support from AVSC staff. As soon as possible, the process is taken over by the institution itself.
Stage IIn Stage I, a workshop is organized to focus on:
In the initial orientation workshop, emphasis is placed on changing the supervisor's attitude from "policing" sites to facilitating the quality-improvement process. Although not listed as a topic on the program, the workshop process allows participants to identify the strengths and constraints of their current supervisory system.
Simple tools and approaches to assist in local problem solving (such as COPE and inreach) are introduced. Workshop participants consider the use of site-level family planning committees for discussion of activities and results and also discuss the ways adult learning theory might be applied in supervision. Discussion focuses on the supervisor's role in the context of local problem solving and quality improvement and on the materials and support the supervisor will need in order to carry out this role. Participants discuss the linkage between supervision and training and the technical skills required by supervisors.
Requirements will vary from region to region and from supervisor to supervisor, depending on the supervisor's background and on the current needs of the institution. These might include technical skills in infection prevention, technical competence in the provision of specific family planning methods or procedures, or the skills needed to provide a general family planning orientation, to give a contraceptive technology update, to read and use site and other data to improve the quality of services, or to give an update on counseling skills. During the workshop, participants review the materials and guidelines available to assist the supervisor in performing these roles. [See Figure 1]
After the workshop, supervisors can begin to put these principles into practice in performing their routine work with support from their institutions (and from AVSC, if required). They can immediately begin to put into practice the communication skills they have acquired. If possible, they should observe COPE exercises conducted by a trained facilitator--or better still, facilitate COPE themselves with support from someone who has experience in conducting COPE. Participating in COPE gives supervisors an opportunity to learn more about the process and to begin thinking about how they might support their site in implementing an action plan for solving problems identified through COPE. Planning for training activities can also be practiced because the identification of training needs is always an important outcome of COPE exercises.
Stage IIWorkshop topics in Stage II include:
During the second workshop, lessons learned in Stage I are reinforced. Supervisors begin to address the ways to help site staff set their own objectives by facilitating a COPE exercise and by assisting staff in prioritizing the actions they have identified for themselves. Participants begin to focus in more depth on the training needs identified by COPE participants--how to prioritize them, how to develop training plans, and how to garner the necessary resources to achieve the desired result. Supervisors have role-play sessions in which they can test their knowledge of adult learning theory in the process of mentoring. Through a mixture of support, coaching, mentoring, and training, site supervisors are oriented to consider the needs of individual staff and to determine how to prioritize those needs.
When they return to their posts, supervisors again incorporate what they have learned into their routine work, with support from their institutions. They may conduct follow-up COPE exercises, sharpen their training and mentoring skills, or develop coordinated training plans.
Stage IIIThe workshop in Stage III introduces more complex supervisory skills, building on the lessons learned in the two previous stages, including:
Topics covered in the workshop include the design of long-term training plans, ways to use records and statistics to improve quality, and methods of designing and evaluating programs using measurable indicators. To help participants increase their skill in training design, the workshop trainers introduce key concepts of training that might be used to conduct a training-of-trainers workshop and discuss the use of on-the-job training guides for obtaining standardized outcomes. This enables supervisors to provide training during supervisory visits and to design site training programs.
Workshop trainers explain that client reports and statistics can be more than items that must be prepared in order to meet the needs of the bureaucracy. Participants are encouraged to discuss the content of reports with site staff, so that staff will view them as indicators of client satisfaction and of strengths and weaknesses in service delivery. For example, if the number of new clients coming to a service has dropped recently, supervisors are encouraged to discuss this with staff to determine the possible causes of the drop and the corrective actions they can take. If the number of new clients has suddenly increased, this again is cause for discussion, because the reasons for the increase may be something that should be shared more widely in the institution.
AVSC is currently testing an evaluation tool to help supervisors measure progress in improving quality more objectively than can be done using COPE action plans.[Footnote 13] This tool, jointly designed by AVSC, the Tanzanian Ministry of Health, and UMATI (Uzazi Na Malezi Bora Tanzania, the family Planning Association of Tanzania), is organized around the same principles as COPE: clients' rights and providers' needs. It is intended to complement the COPE process and aid in local problem solving, while still allowing the supervisor to measure progress over time, to aggregate information for more than one site, and to be able to provide information to the institution on the outcomes of their efforts to continuously improve the quality of services.
EXAMPLES OF FACILITATIVE SUPERVISION IN ACTION
In Tanzania, the family planning program has expanded rapidly during the past five years. Although services are now available in more than 3,000 service-delivery points throughout the country, many of these are small dispensaries and health centers that can only provide a limited number of family planning methods.
Until recently, permanent and long-acting methods were available in only the two largest urban areas. At present, in-country institutions, with support from AVSC International and other donors, are expanding the number of sites that offer all available modern contraceptive methods (to a total of more than 100 by the year 2000). Key to this program expansion are six zonal doctor-nurse teams whose role is to facilitate the integration of permanent and long-acting methods into existing family planning service-delivery points.
Working with supervisors from the Tanzanian Ministry of Health (MOH), the zonal teams ensure that service quality is strengthened. The MOH supervisors are trained to assist sites in identifying what they need to provide quality family planning services (be it management support, training, or equipment) and in meeting those needs internally or with external assistance. Supervisors form teams with site staff to try to eliminate problems before they occur.
Serving as middle managers and trainers, these teams help transform the MOH goals of expanding the number of service sites that provide permanent and long-acting methods into reality. They facilitate communication between the sites and their zonal or central headquarters and between public sector and private sector service providers. They improve linkages between the various sites in their area as well as between each site and its respective headquarters. They work to introduce and implement protocols for clinical methods and assist in resource management, helping to leverage additional resources for family planning services. They improve the supervision of sites, and promote the concept of whole-site training.[Footnote 14]
In Bangladesh, the family planning program has been in place and an array of permanent and long-acting methods have been available for a much longer period of time than in Tanzania.
The number, type, and scope of service-delivery points are also much greater. In collaboration with the Directorate of Family Planning and with support from the U.S. Agency for International Development, AVSC is conducting a client-centered, clinic-based family planning services program in six sub-districts (thanas) in Bangladesh. This program includes a focus on improving local-level planning and supervision systems.
The supervisory system in Bangladesh is well-established, and there are different levels of supervision: from the central to the district level, from the district to the thana level, and from the thana level to local health centers. AVSC works to improve local planning in this system by establishing or strengthening coordinating committees and by introducing COPE. The facilitative supervision process described in this paper is being adapted to meet the needs of the Bangladesh program. In addition, the project emphasizes whole-site training and improving the referral systems between the different levels of services.
The Directorate of Family Planning also manages Family Planning Clinical Supervision Teams (FPCSTs). The role of these mobile teams is to work to assess the medical quality of family planning and maternal and child health services in specific geographic areas. These teams are responsible for the supervision of clinical family planning services in all governmental facilities, as well as those administered by NGOs.
In 1993, the Directorate requested AVSC's assistance to help increase the FPCSTs' effectiveness in medical supervision and on-site guidance to service providers. AVSC works with the FPCSTs to develop their supervisory training and skills for medical site visits, contraceptive technology updates, and workshops; to develop a responsive system for tracking medical complications; to orient teams on infection prevention procedures; and to help teams introduce COPE. AVSC also works with the Directorate to monitor and evaluate this introduction process.
AVSC believes that the evaluation of this approach to supervision should follow the same principle as the approach itself--it should be conducted by the supervisors and site staff themselves, with assistance from outsiders such as AVSC, as necessary.
Program Evaluation Tools
AVSC has developed a set of program evaluation tools that can be used annually by the supervisors and family planning teams at each site.[Footnote 15] The tools, which have been developed and tested in Tanzania, are meant to be adapted for use in other countries as well.
The tools differ from traditional supervisors' checklists in three ways.
First, the tools relate to COPE and therefore should be introduced to the sites as such and should be used in a similar way. Site staff are encouraged to evaluate their services with the supervisor in a nonthreatening, awareness-raising fashion. Although some objectivity may be lost, the data collected will be principally the property of the site staff, rather than of the headquarters. As such, the results stand a better chance of being used by the sites and their supervisors as impetus for discussion and as measurements of progress.
Second, the tools are designed for site staff and supervisors to be able to look at the progress of an individual site over time and to evaluate the program as a whole rather than to compare the progress of different sites.
Finally, the indicators of quality in the tools are closely linked to the COPE assessment guides and are organized in a similar way. As in COPE, the indicators correspond to the rights of the client and the needs of providers. [See Figure 5] The program evaluation tool consists of ten checklists, as follows:Clients' right to
Each checklist requires the supervisor to observe and talk with staff about specific topics. For example, under clients' right to access, supervisors are asked to raise questions with staff, such as: Is the clinic open at least five days per week? Are MCH/FP services housed in the same building? What methods are available? Are there signs that indicate the location of the family planning clinic? Can single women or adolescents receive services? Can men pick up condoms without going into the MCH, family planning, or outpatient departments? Can pill clients routinely obtain more than six packs of pills? Are pregnancy tests available? Once the evaluation is completed, the checklists are scored, using a simple scoring system.
AVSC is now considering ways to weight the responses to each item so that items of priority (such as indicators of good infection prevention procedures or technical competency) are distinguished from other important, but less critical items (such as signs for clients indicating where to go for services). Supervisors are encouraged to discuss the scores with staff and to reassure staff that the scores are meant to help the site measure its own progress, not to compare the site's score with the scores of other sites.
Because these tools are a standardized instrument, supervisors are able to aggregate results from several sites to determine which problems appear to be system-wide (thus needing institutional attention), and which problems appear to be location specific. The results can be useful to headquarters staff in determining where to focus institutional energies in improving quality of services. They can also be used to provide information to technical assistance agencies and donors on progress made in improving quality.
Challenges in Evaluating Quality-Improvement Approaches
How one evaluates the contribution of "quality" to the success of a reproductive health program remains an area of debate and discussion. Adding to the complexity is the desire to evaluate the cost-effectiveness of quality improvement approaches at the same time that programs are being asked to do more--to reorient family planning programs to incorporate screening and treatment for reproductive tract infections, to increase integration of services, to focus on postabortion care, to serve men and adolescents--while funding for reproductive health services seems ever more tenuous. Within this context, the seemingly greater cost of this more intensive approach is worrisome to many, yet our belief (shared by many others) is that the additional costs can be offset by reducing the costs of poor quality.
Another challenge is that we are hypothesizing that if providers' rights and needs are satisfied, if providers are trained and oriented toward high-quality service provision, and if functional supervisory systems are in place that assist in local problem-solving, then clients' knowledge and satisfaction will be enhanced and their reproductive health rights and needs will be met. The challenge of evaluation is ultimately to demonstrate the validity of this hypothesis.
Evaluation strategies must be flexible. It is important to pay attention to lessons learned and adaptations needed when new approaches are under development. Identifying objectives and indicators up front may be difficult because outcomes may not have been anticipated.
Evaluation strategies will likely utilize qualitative as well as quantitative methods to document the process of the development and introduction of new strategies, as well as to document both predicted and unanticipated problems or outcomes. Intervening variables that may occur after a project has started (such as changes in fees charged or the introduction of a social marketing activity, as was experienced in one project) may make it difficult to separate out the impact of quality-improvement approaches.
Introducing facilitative supervision requires change, and change can be difficult to manage.
Many institutions and organizations around the world--particularly in the field of health care where medical hierarchies dictate a conventional supervisory approach--may find this change daunting. Some may believe that what has become the conventional approach to supervision--inspection or policing employees--has been around a long time and does not need alteration. Others who have worked long and hard to reach supervisory status may aspire to become "inspectors" in the same mold as their predecessors. Still others may believe that changing to the kind of supervisory approach suggested here will take more time, resources, thought, and attention than is possible, given the level of resources available.
We at AVSC hope that this paper suggests that there is much to be gained, both individually and institutionally, from a transition to more facilitative styles of supervision. We believe that efforts expended in this labor-intensive approach will reap significant rewards in terms of improved services, especially when contrasted with the cost and consequences of poor quality.
We hope that the following expected outcomes will help managers determine that changing to a more facilitative approach is worthwhile:
Some institutions may have already made progress toward incorporating some facilitative supervision ideas into the system in which they work. If changes throughout the system are required, these can be undertaken gradually. Effecting change in systems requires time, but the process is already well underway in a number of countries in which AVSC works (notably in Bangladesh, Kenya, Tanzania, Zimbabwe, and Uganda).
Over the past 50 years, great strides have been made toward increasing clients' access to reproductive health services. These last few years of the twentieth century present an opportunity to consolidate the gains made in access by improving the quality of those services.
Site staff and service providers are the experts on how services are currently provided: building on this expertise with problem-solving tools that staff can use is the keystone to improving the quality of those services. Facilitative supervision is one approach which may contribute to improved and sustainable quality services.
Working Paper #10 Authors:
Beverly Ben Salem is assistant regional director for AVSC International programs in east and southern Africa. Karen J. Beattie is associate director of AVSC's Evaluation and Research Department.
The purpose of AVSC Working Papers is to capture on paper AVSC's experience and to disseminate the results of AVSC-supported research. We welcome your comments and suggestions.
This paper grew out of AVSC's work with its counterparts worldwide, including governmental institutions, NGOs, and the private sector to improve the quality of family planning services and to some degree has its roots in our work on medical quality assurance and on introducing COPE. Over the past year, many AVSC International staff members and consultants have provided input and comments on the drafts of this working paper. In particular, the authors would like to thank Libby Antarsh, Janet Bradley, Abu Faisel, Terrence Jezowski, Pamela Lynam, Yatshita Mutombo, Amy Pollack, Sylvia Vriesendorp, and Grace Wambwa. Special thanks go to Joseph Dwyer for his leadership in this area of AVSC's work and to Lynn Bakamjian for her support and encouragement. Special thanks also to Joanne Tzanis, who edited this paper.
This publication may be reproduced without permission, provided the material is distributed free of charge and the publisher and authors are acknowledged. This publication was made possible, in part, through support provided by the Office of Population, U.S. Agency for International Development (AID) under the terms of cooperative agreement HRN-A-00-98-00042-00. The opinions expressed herein are those of the authors and do not necessarily reflect the views of AID.
440 Ninth Avenue
New York, NY 10001