Supervisor autonomy also appeared threatened as some

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among many supervisors that providers are annoyed with or feel disturbed by supervision. Supervisor autonomy also appeared threatened as some expressed that accountability for per- formance evaluation leaves little or no time to work as they prefer, i.e. to deliver more forma- tive supervision and support. The PBF system in Rwanda deliberately avoids employing penalty risks as part of the incen- tive structure [ 48 ]. Yet, providers in our data speak more about risks of low marks, blame and lower income than about chances of rewards. Also, they sometimes engage in blame discus- sions over who should be punished when certain requirements are not fulfilled. This indicates, as suggested elsewhere [ 23 ], that rewards may assume a punitive quality over time. Study limitations External supervision includes both control and support practices, and at study onset it was important to verbalise and discuss our preference towards the latter. Throughout data genera- tion and analysis we also discussed a potential bias among ourselves to sympathise with pro- viders as an underdog in an asymmetric power relation, much like one may sympathise with the patient in a patient-doctor relationship. While these inclinations may have influenced the study, it was our agreed aim to be aware of and discuss them in order to generate data grounded in the reality of supervision, and make interpretations grounded in the data. The abundance of critical and sensitive information in our data (within a traditionally authoritarian culture where one does not easily criticize another) suggests participants in gen- eral felt secure. However, social desirability among colleagues might have triggered exaggera- tions. We suspect this is not a significant problem, in particular due to several examples where participants disagreed or modified each other. Our study is an insight into perceptions of 15 providers in 3 of approximately 495 HCs, and 16 supervisors in 3 of 39 districts hospitals at a certain point in time [ 49 ]. For transferability to other HCs and districts our triangulation efforts help somewhat as findings were presented to Evaluative and formative functions of external primary healthcare supervision in Rwanda PLOS ONE | February 20, 2018 18 / 23
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and discussed with providers and supervisors in other regions and district. While our main results were represented across all FGDs we cannot rule out they are exceptions compared to other facilities, although we have no suggestions why they should be. Being a qualitative study of supervision within a context of PBF there are obviously limitations concerning transferabil- ity of findings to other countries. Also, we do not study the development of supervision over time. While PBF incentives are problematized as introjected regulation, the study does not inform whether the locus of causal- ity of motivation was more or less internalized prior to the introduction of PBF.
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