The relationship between primary healthcare providers and their external supervisors in Rwanda

BACKGROUND External supervision of Rwandan primary healthcare facilities unfolds as an interaction between supervisors and healthcare providers. Their relationship has not been thoroughly studied in Rwanda, and rarely in Africa. AIM To explore perceived characteristics and effects of the relationship between providers in public primary healthcare facilities and their external supervisors in Rwanda. SETTING We conducted three focus group discussions with primary healthcare providers (n = 16), three with external supervisors (n = 15) and one mixed (n = 5). METHODS Focus groups were facilitated under low-moderator involvement. Findings were extracted thematically and discussed with participating and non-participating providers and supervisors. RESULTS While external supervision is intended as a source of motivation and professional development in addition to its managerial purpose, it appeared linked to excessive evaluation anxiety among Rwandan primary healthcare providers. Supervisors related this mainly to inescapable evaluations within performance-based financing, whereas providers additionally related it to communication problems. CONCLUSION External supervision appeared driven by systematic performance evaluations, which may prompt a strongly asymmetric supervisory power relation and challenge intentions to explore providers' experienced work problems. There is a risk that this may harm provider motivation, calling for careful attention to factors that influence the supervisory relationship. It is a dilemma that providers most in need of supervision to improve performance may be most unlikely to benefit from it. This study reveals a need for provider-oriented supportive supervision including constructive attention on providers who have performance difficulties, effective relationship building and communication, objective and diligent evaluation and two-way feedback channels.