This study has provided insights of the supervision practices in South Sudan and ascertains the contribution of supportive supervision to quality improvement in the health sector. In this section the study findings are discussed based on the notion that there are interactions between the inputs, processes, and expected outcomes of supportive supervision. Like any other system that goes through the stages of production to achieve results, supervision requires inputs/resources to facilitate the processes of production, which ultimately lead to the results. Knowledge, skills and tools are some of the key drivers that promote and improve the quality of services delivered [
32]. Robust supportive supervision requires resources such as a competent health workforce with the capacity to plan, communicate, motivate, train, and build capacity within the health sector. This health workforce in turn requires financial and logistical support to execute its duties (such as money, transport, and medical equipment).
This study corroborates the observations that South Sudan is a challenging working environment and that the health sector is complicated by protracted crises, poor infrastructure, weak health workforce capacity, and inadequate health systems [
4,
6,
33]. The health sector is inadequately funded and over-dependent on donors [
6,
21,
34,
35]. Several contextual factors that affect the implementation of supportive supervision were identified, such as conflicts, insecurity, bad roads, and natural disasters such as floods and/or frequent breakdown of vehicles. These conditions are known to contribute to the reduction in the frequency and/or the lack of supportive supervision visits [
6,
36,
37]. Due to these conditions, health workers miss out on learning opportunities and interactions with supervisors to discuss their challenges. This negatively affects the quality of health service delivery [
38].
Although joint supportive supervision was conducted by a multidisciplinary team of supervisors, we found a lack of adequate and competent SMoH and CHD officials to conduct supervision. This was attributed to the high attrition of trained staff from the government departments in search of green pastures with the humanitarian organizations. This is comparable to the findings from a Pakistan study, which identified a severe lack of skills and training among the supervisors for EPI services [
39]. The supervisors are expected to provide on-the-job training to health workers. Therefore, it is essential that they are well informed and trained in the general principles of supervision, including communication techniques, problem identification and solving skills as well as coaching and on-site training [
15,
18,
30,
40]. This study found that most supervisors did not receive formal training in supportive supervision and health services but were instead trained on the job. Scholars argue that promoting effective supportive supervision necessitates supervisors to be knowledgeable and skilled in teaching, appraising, counselling, providing professional advice, and fostering interpersonal relationships [
13,
41]. Training in supportive supervision improves supervisors’ knowledge, communication and problem-solving skills, which positively influence acceptance, motivation and job satisfaction [
42‐
44].
Generally, health workers had positive views about the supervisors despite the delays in following up on the action plans from the relevant county authorities. However, the health workers were dissatisfied with the timing of supportive supervision sessions, especially when the supervisors go in the morning hours when the patients are many and health staff hardly have time to attend to the supervisors. The health workers acknowledged receiving coaching and mentorship on various aspects of health service delivery and quality of care, which motivates them to improve their knowledge and skills. This appears to confirm the findings from a study by De Carlo et al. [
45] that suggested that supervisor honesty and responsible behaviours have a positive influence on workers’ performance and motivation.
The study findings show that supervision activities are mostly funded by donors. The funding was reported to be inadequate to support the supervision activities and to implement the action plans developed. The World Health Organization [
7] proposes that to set up an effective supportive supervisory system, there is a need to ensure the availability of adequate budgets and resources. These budgets should cater for transport, fuels, allowances for supervisors and drivers, stationery, and other tools, such as checklists and smartphones/tablets, to facilitate the activities of supervisors [
7,
30,
46]. The inadequate budget allocations in South Sudan limit the activities that can be implemented, including the payment of allowances for supervision. This could explain why some supervisors absent themselves from supervision visits where allowances are not provided for. A study in the Pacific region showed that the low budget allocations, coupled with the low motivation of health managers due to low salaries and limited incentives, are barriers to supportive supervision within the health systems [
47]. Other studies from Gambia, Tanzania, and Zimbabwe have demonstrated that adequate budget allocations to the districts led to effective and sustainable supportive supervision practices [
46,
48,
49]. Similar to the Pacific study [
47], this study found that the counties lacked reliable means of transport and logistics. This means that the supervisors have limited access to vehicles (which in many cases are very old) and other logistics to enable them to undertake frequent supervision visits in their counties [
46,
47]. In addition, where air travel is required, the flights are costly; therefore, frequent travel is required to supervise the locations, especially where access is challenged by insecurity and either the lack of or poor road network.
Supervision approaches
Two main approaches were used to supervise health services in South Sudan: monitoring and supportive supervision visits. While monitoring visits were primarily focused on verifying health service delivery activities in health facilities, supportive supervision interventions were more focused on improving performance and quality of care [
50,
51]. The supportive supervision interventions mostly dealt with administrative functions, and less effort was put into the supervision of clinical aspects. Embedding clinical supervision into the health system is known to be beneficial to the organisation, professional development, and patient care [
52]. Supportive supervision ensures that health workers have the appropriate knowledge, skills, and motivation to deliver quality health services. Therefore, the quality of care cannot be achieved unless the healthcare providers’ clinical knowledge and skills are improved. Studies have demonstrated the benefits of supportive supervision in quality improvement. In Ethiopia and Uganda, studies have shown that supportive supervision contributes to increased adherence to standards and clinical treatment guidelines [
13,
53,
54] and better management of pharmaceuticals [
55]. Another study in Bangladesh found improvement in the quality of care of infants and children with sepsis due to sustained clinical supervision efforts [
56]. These research findings contrast with our findings demonstrating that during supervision, little emphasis was given to improving the clinical skills of the health workers. This implies that the quality of care cannot be improved without focusing on the knowledge and skills of the health providers.
The research findings show that supportive supervision was mostly driven by the data received from health facilities, although other factors, such as emergencies, played a role in deciding the locations to supervise. Having reliable and timely data provides supervisors with the opportunity to identify areas of focus, the kind of support needed, problem-solving, and the possibility of targeted supervision [
57]. The success of supportive supervision hinges on meticulous planning and coordination among the supervisors and the health workers they supervise [
42]. Our findings show some gaps in the coordination among the supervisors but also with the health workers. For example, where the supervisors do not show up for supervision, where the health workers are absent, or where facilities are closed during the visits. Similar to the findings from Benin [
58] and Kenya [
42], the lack of coordination leads to disagreement, confusion, and wastage of scarce resources used to plan for supportive supervision visits.
The study found that supportive supervision visits were performed quarterly, while monitoring visits were monthly and/or ad hoc. There were also variations in the time spent supervising a health facility ranging from 30 minutes to 5 hours. The frequency of supervisory visits and the duration between the visits are crucial in quality improvement [
50,
59]. However, there is limited evidence in the literature to show the ideal frequency and length of supportive supervision. This may be because supervision practices are not standard and cannot be compared as such, and the duration also depends on the focus and breadth of the supervision. Nonetheless, scholars report that supportive supervision should be regular [
50,
52,
60]. Studies have demonstrated that supportive supervision interventions can be effective where there are regular supervisory visits to health facilities to develop relationships, monitor performance, and improve problem-solving skills [
59‐
61]. Therefore, sufficient time investment is needed to achieve maximum benefits from supportive supervision. Studies conducted in Nigeria and Tanzania demonstrated that increasing the frequency of supervision had a positive impact on some dimensions of health service delivery, such as infrastructure, human resources for health, essential drugs and clinical practice [
59,
62]. In Ethiopia, some scholars found that with regular supportive supervision, there was an improvement in pneumonia case management among under-five children [
13]. However, another study from Kenya found limited evidence that increasing the frequency of supervision visits improved health service delivery [
42]. Additionally, a study conducted in Northern Ghana found that regular supervision was insufficient in improving the productivity of health workers [
63].
It is essential to have the right supervision tools to assist supervisors in conducting effective supervision. The study found that supervisors use various tools, but the most used was the paper-based MoH quantified supervision checklist. Other supervision tools were the Open Data Kit and the Quality of Care mobile application. Using different toolkits and/or checklists is a missed opportunity for aligning priorities in the quality of care [
7,
50,
64]. Most health workers received immediate on-site verbal feedback from their supervisors, but written feedback was rare. Some health workers received neither verbal nor written feedback. Those who received feedback found it constructive and had a chance to correct their mistakes and learn new developments. These findings corroborate other studies that have highlighted the importance of feedback in promoting learning and staff development [
60,
64,
65].
Our findings show that although action plans were developed at multiple levels during supportive supervision, there was a lack of clear follow-up mechanisms due to limited funds. This demotivates the health workers and deters problem-solving. For supportive supervision to be effective, a mechanism for problem-solving should be prioritised with interventions geared towards the quality of supervision, training of supervisors and development of problem-solving skills [
66]. When the quality is poor, supportive supervision cannot improve the quality of services unless problems within the system are addressed [
67]. Studies have shown that problem-solving supervision approaches generally lead to teamwork, motivation, skill sharing, and promote cross-learning [
10,
11,
39,
40,
42].
Scholars mention performance observations, constructive feedback mechanisms, opportunities for learning and improvement, and joint problem-solving approaches as important aspects of supportive supervision [
13,
18,
64]. The study findings show that the supervisors check the registers, hold discussions with the health workers, provide on-the-job training, jointly develop action plans to solve the identified problems and strengthen relationships between the supervisors and supervisees. This is comparable to what other studies found in Pakistan, where the supervisors checked registers and provided on-the-job training sessions to improve the knowledge and skills of health workers to enhance immunization services [
39]. Similar to our findings, a study by Kok et al. [
10] in four African countries (Ethiopia, Kenya, Malawi, Mozambique) found that supervisors check registers, and the progress of implementation of activities, discuss possible solutions to the problems identified and provide mentoring when it is needed.
Supportive supervision outcomes
Based on the study findings, some health managers said that sustained supportive supervision efforts have resulted in the recruitment of qualified health workers, improved staff attendance and improved staff attitudes towards each other and the patients. Additionally, there is presumed improvement in health data reporting, drug management, and marginal improvement in the use of standard treatment guidelines as well as infection prevention and control measures, all attributed to the on-the-job training sessions given during supervision. Our findings corroborate those from the Mozambique study [
44], where health workers perceived improvements in their performance, motivation, increased participation, and voice amongst themselves due to supportive supervision. Avortri and others [
13] have also alluded to the potential of supportive supervision in improving the quality of health care and enhancing the skills of health workers. Other studies have shown that supportive supervision can increase job satisfaction and lead to the formation of relationships where trust, teamwork, and two-way communication are fostered. This consequently raises health workers’ morale, motivation and knowledge and skills towards performance and quality improvement [
8,
44,
46,
51].
The insights from this study give rise to various recommendations to guide supportive supervision initiatives in South Sudan and similar settings. There is a need to enhance stewardship of the MoH and its subsidiaries at the state and county levels to take full responsibility for all supportive supervision activities. The health managers should be trained on supportive supervision approaches such as appraisal, communication, problem identification and solving skills to facilitate effective supervision of health services. Additionally, there should be timely and constructive feedback with actionable plans. Supportive supervision visits to the health facilities should be regular to enable follow-up on the issues spotted during the previous supervisory visits and implementation of the agreed action plans. The objectives of supportive supervision visits should be communicated to health workers before the visits for adequate preparations. The time dedicated to supportive supervision should be sufficient to facilitate learning and problem-solving activities. This is crucial for motivation and performance. Furthermore, to avoid duplication of efforts and align priorities, there is a need to harmonise and integrate supportive supervision tools and guides across the country. Focused supportive supervision should be encouraged based on the problems identified to ensure quality improvement. Adequate funds should be provided to facilitate the supervision processes and implementation of the action plans. Last, there should be an investment in transport (such as four wheel drive vehicles), training of the health workforce, and medical equipment to facilitate the provision of quality health services.
Study limitations
This study was subject to several limitations. The study was susceptible to recall bias when responding to some of the FGD questions; however, the researchers tried to refer to the most recent supportive supervision visit that the participants attended. The study also did not include observations of the actual supportive supervision sessions; hence, the findings are based on the information given by the participants. Insecurity and the poor state of the road network due to floods in Kapoeta led to the cancellation of three FGDs where the researcher could not access the participants in the health facilities.
The four authors’ roles in providing technical assistance to the HPF programme and their interplay with research participants, some of whom were known to them, might have introduced certain participant biases. The participants were recruited through the SMoH and CHD networks who are also receiving some funding for health services delivery from the HPF programme, which might have led to some degree of participant bias. Some participants from the CHD, implementing NGOs, and health workers were getting either salaries or incentives from the HPF programme, and they might have assumed that giving undesirable responses could lead to a reduction in their funding. This could have resulted in being less critical about the supervision activities they are responsible for. The researchers mitigated this by reiterating that the responses they gave are treated confidentially and anonymously and will not have any impact on their employment or benefits but that instead the research was meant to gain insight into supportive supervision practices and ultimately identify areas for improvement.