An in-depth exploration of health worker supervision in Malawi and Tanzania Susan Bradley, Centre for Global Health, TCD & HSSE team Supported by: Irish Aid & Ministry of Foreign Affairs, Denmark UNIVERSITY EDUARDO MONDLANE Faculty of Medicine

Part of the larger HSSE study Objectives Describe DHMT perceptions of the role and purpose of supervision Explore the problems faced in instituting regular supportive supervision in their health facilities

Methods Semi-structured interviews, covering a range of HRM issues Malawi - 26/28 districts; n=20, District Health Officers, District Nursing Officers, and a small number of Human Resources Officers Tanzania - Random selection of one region in each of Tanzania’s 8 zones; all districts in these regions; n=39, District Health Secretaries, Reproductive and Child Health Coordinators, District Medical Officers and one District Nursing Officer

Results - Malawi Wide range of attitudes to the nature and purpose of the supervision process More discourse centred on inspection and control Lack of clarity about systems and processes Lack of appraisal system or other mechanisms to measure individual staff performance Some DHMT calls for a change to supervision that is a supportive, continuous process

Results - Tanzania Broad agreement on a supervision paradigm of support and improvement More discussion of supervision’s links to performance and motivation of staff Clear systems reported – MOHSW supervision guidelines, MTUHA logbooks, OPRAS (open performance appraisal system) being introduced

Barriers to effective supervision HRM policy – implementation gap Plans for what to do, but not how to do it Lack of skills or HRM capacity Conflicting responsibilities and demands on DHMT/senior facility staff time Finances, transport and accessibility National changes in SOP not communicated to district level

Key findings Recognition that health workers need to be supported and appreciated; lack of mechanisms to measure or reward effort, or support performance Task shifting - link to underperformance of signal functions despite being trained; implications for QOC “...large numbers is nothing on its own. It is better to have numbers of good quality…they need to be followed up, supervised…when they start working. Not that after the training just dump them...” DHO, Malawi

Recommendations Prioritisation and adequate resourcing of supervision as a key HRM activity Increase MOH commitment to supportive supervision as a mechanism to monitor and improve QOC Strengthen HRM practice at district level and facility level Shift the focus of supervision to teams Develop a supportive supervision model

Conclusion Supervision plays a key role in performance and motivation, and is particularly important in a challenging work environment or in the context of task shifting. Policy level attention is crucial to ensure a systematic, structured process that is adequately resourced and supported in order to improve health worker performance and retention at the district level.

With Thanks HSSE Team: AMDD, Mailman School of Public Health, Columbia University, USA Centre for Global Health, Trinity College, University of Dublin Centre for Reproductive Health, College of Medicine, Malawi Dept. of Community Health, Eduardo Mondlane University, Mozambique Ifakara Health Institute, Tanzania Realizing Rights: Ethical Globalization Initiative, USA Regional Prevention of Maternal Mortality Network, Ghana Funders: IrishAid & Ministry of Foreign Affairs, Denmark