Towards improved health service quality in Tanzania: An approach to increase efficiency and effectiveness of routine supportive supervision

Abstract

Effective supportive supervision of healthcare services is crucial for improving and maintaining quality of care. However, this process can be challenging in an environment with chronic shortage of qualified human resources, overburdened healthcare providers, multiple roles of district managers, weak supply chains, high donor fragmentation and inefficient allocation of limited financial resources. Operating in this environment, we systematically evaluated an approach developed in Tanzania to strengthen the implementation of routine supportive supervision of primary healthcare providers. The approach included a systematic quality assessment at health facilities using an electronic tool and subsequent result dissemination at council level. Mixed methods were used to compare the new supportive supervision approach with routine supportive supervision. Qualitative data was collected through in-depth interviews in three councils. Observational data and informal communication as well as secondary data complemented the data set. Additionally, an economic costing analysis was carried out in the same councils. Compared to routine supportive supervision, the new approach increased healthcare providers' knowledge and skills, as well as quality of data collected and acceptance of supportive supervision amongst stakeholders involved. It also ensured better availability of evidence for follow-up actions, including budgeting and planning, and higher stakeholder motivation and ownership of subsequent quality improvement measures. The new approach reduced time and cost spent during supportive supervision. This increased feasibility of supportive supervision and hence the likelihood of its implementation. Thus, the results presented together with previous findings suggested that if used as the standard approach for routine supportive supervision the new approach offers a suitable option to make supportive supervision more efficient and effective and therewith more sustainable. Moreover, the new approach also provides informed guidance to overcome several problems of supportive supervision and healthcare quality assessments in low- and middle income countries.

Fig 1. Chart of the three-stage process of the e-TIQH supportive supervision approach [37].

Fig 2. Key features of the e-TIQH supportive supervision approach [–39].

Fig 3. Map of Tanzania with councils where the e-TIQH supportive supervision approach was implemented (status 2008).

Morogoro Region: (1) Kilosa DC (later split into Kilosa DC and Gairo DC), (2) Mvomero DC, (3) Morogoro DC, (4) Kilombero DC, (5) Ulanga DC; Pwani Region: (6) Bagamoyo DC, (7) Rufiji DC; Iringa Region: (8) Iringa MC. Asterisks mark the three study councils.

Fig 4. Activities conducted during routine CHMT and e-TIQH supportive supervision.

¹The preparatory meeting included setting up the teams and their routes; logistics included informing health facilities and request transport and per diems; ²Data entry after routine CHMT supportive supervision was hardly ever done; ³Charging devices was reported to take seven minutes for six tablets per team and day; ⁴Quality dimension 1 was evaluated as a team and subsequently quality dimensions 2 to 6 were assessed concurrently by one assessor each; ⁵Provision of feedback included the completion of five page feedback summary form; ⁶Estimated time for data processing (quality check and uploading survey forms) was one and a half hours per team and day.

Fig 5. Comparison of routine CHMT and e-TIQH supportive supervision.

Upwards arrows show a perceived improvement and downwards arrows a perceived decline when switching from routine CHMT to e-TIQH supportive supervision. Perceived change based on the qualitative data (statements given frequently and/or across administrative levels and sectors) is given by single (likely change) and double (clear change) arrows. Asterisks indicate that the particular change could primarily* or partially⁽*⁾ be attributed to the usage of an electronic tool per se. For items without an asterisk or an asterisk in brackets ⁽*⁾, the overall e-TIQH supportive supervision approach was relevant as well. For physical resources it was assumed that tablets need be bought.

Fig 6

Possible supportive supervision schedule showing assessment days required by the supportive supervision approach in an average rural (A) and urban (B) council. Vertical lines indicate a working day, consisting of eight hours (08:00–16:00). For simplicity schedule presented was developed for one team assessing the whole council.