Health services supervision in a protracted crisis: A qualitative study into supportive supervision practices in South Sudan.

Abstract

Background: The health system in South Sudan faces extreme domestic resource constraints, low capacity, and protracted humanitarian crisis. Supportive supervision is believed to improve the quality of health care and service delivery by compensating for flaws in the health workforce management. This study aimed to understand the current practices of supervision in South Sudan and identify areas for quality improvement.Methods: The study employed qualitative approaches to collect and analyse data from six purposefully selected counties. Data were collected from 194 participants using semi-structured interviews (43 health managers) and focus group discussions (151 health workers). We used thematic content analysis to yield an in-depth understanding of the supervision practices in the health sector.Results: The study found that integrated supportive supervision and monitoring visits were the main approaches used. Supportive supervision focused more on health system administration and less on clinical matters. Although fragmented, supportive supervision was carried out quarterly while monitoring visits were either conducted monthly or ad hoc. Prioritization for supportive supervision was mainly data driven. Paper-based checklists were the most used supervision tools. Many supervisors had no formal training on supportive supervision and only learned on-the-job. The health workers got on-site verbal feedback and most times on-the-job training sessions through coaching and mentorship. Action plans developed during supervision were inadequately followed up due to insufficient funding. Insecurity, poor road networks, lack of competent health managers, poor coordination, and lack of adequate means of transport were some of the challenges experienced during supervision. The presumed outcomes of supportive supervision were improvements in human resource management, drugs management, health data reporting, teamwork, and staff respect for one another.Conclusion: Supportive supervision remains a daunting task in the South Sudan health sector due to a combination of external and health system factors. Our study findings suggest that strengthening the processes and providing inputs for supervision should be prioritised if quality improvement is to be attained. This necessitates stronger stewardship from Ministry of Health, integration of different supervision practices, investment in the capacity of the health workforce, and health infrastructure development.