External supervisors provide evaluative supervision

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External supervisors provide evaluative supervision (consisting of so-called quantite ´ and qualite ´) aiming to ensure a certain service standard and applying performance evaluations for PBF. In addition, the same group of supervisors are responsible for providing formative (tech- nical) supervision aiming to help healthcare providers improve skills and performance. The lat- ter ideally takes place at a date prior to evaluation visits, but may in practice be combined with it. Providers were likely to use the term supervision in its global sense for both evaluative and formative categories. In fact, most providers did not differ between the two categories of super- vision, and the distinction was unknown to some, such as an experienced A1 nurse in FGD5: I do not understand it. Are there “formative” and “evaluative” supervisions?Are they different? On the contrary, supervisors in all discussions would differ between the ‘formative’ and ‘evaluative’ categories, usually referred to respectively as simply supervision and evaluation . While one provider and few supervisors seemed satisfied with supervision as it is, many supervisors and providers suggested the formal supervision structure should give higher prior- ity to formative functions, here an A2 nurse in FGD6: Formative supervisionsare not [happening] enough. Most of the time they come to give marks or count what isrelated to the money of PBF. And an A2 nurse in the mixed FGD: They[supervisors]give you marks ( . . . ).Theymainly look at what you have done wrongly. Theymay eveninsult you; but teaching isnot often seen. No supervisor directly expressed appreciation for the task of evaluation. Some stated a pref- erence for supportive functions, such as a supervisor in FGD3: Table 2. Evaluative and formative (technical) supervision of health centres in Rwanda. Category Evaluative supervision Formative/technical supervision Main objective Evaluate patient utilisation ( Quantite ´ ) and quality aspects ( Qualite ´ ) of selected services Help providers improve performance Tools Complete checklists Summary checklists and clinical guides Marks for PBF Yes No Schedule Quantite ´ : Monthly. Date pre-announced. Qualite ´ : Quarterly. Date unannounced. Quarterly, or as needed. Date pre-announced. PBF: Performance Based Financing; Qualite ´ and Quantite ´: Local French terms for two aspects of evaluative supervision. https://doi.org/10.1371/journal.pone.0189844.t002 Evaluative and formative functions of external primary healthcare supervision in Rwanda PLOS ONE | https://doi.org/10.1371/journal.pone.0189844 February 20, 2018 8 / 23
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I like doing a supervisionwhich isrelated to training [formative] rather than evaluating ( . . . ). This isbecause it makes me feel at peace that I have done my work asit issupposed to be. Many supervisors described their line of work as pre-dominantly formative, either by using evaluation visits to provide feedback, or because visits in practice often combined functions of evaluative and formative supervision. Not all supervisors agreed whether this is the case on the ground, as this dialogue in FGD3 between two supervisors:
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