Conclusión del capitulo

This chapter presents the results of the research from health extension workers,

supervisors, and health system managers. The meaning units and categories that were identified regarding participants’ perceptions and experiences of supportive

supervision were organised as categories within each of the four domains of inquiry that this study explored: the context in which supportive supervision took place; the implementation of supportive supervision; the outcomes of supportive supervision; and challenges to supportive supervision. The chapter begins with a presentation of the results from each group individually followed by an analysis of the results across participant groups. It is important to note that, as described in Chapter 2 regarding the context of the case study, the majority of supervisors who were assigned under the new supportive supervision system had no prior experience as supervisors. They were clinical nurses working at health centres, who were then assigned to supervise HEWs at health posts in addition to their clinical duties at health centres. Upon the

implementation of supportive supervision, most prior supervisors, who had been working as full time supervisors based in district health offices, were shifted to other roles within district health offices.

Health Extension Workers

As illustrated in Table 7 below, HEWs’ perceptions and experiences of supportive supervision were categorised under the four domains of inquiry that were explored in this study – context, implementation, outcomes, and challenges. While the inclusion of the frequency of participants within each category does not fully reflect the nuance and complexity of my results, it is included to provide an overview of the results.

Table 7: Domains and Categories – Health Extension Workers

Domains and Categories Frequency

Context

Satisfaction from serving the community 10/10

Frustration with infrastructural challenges 7/10

Frustration with inability to pursue education and low salary 10/10

Infrequent supervision in previous system was demotivating 8/10

Previous system of supervision was controlling and punitive 9/10

Fear of previous supervisors 7/10

Implementation

Frequency and duration of supervisory visits increased under supportive supervision 10/10

Weekly work plans were jointly created and reviewed 10/10

Supervisors worked alongside HEWs to implement work plans 10/10

Supervisors worked in place of HEWs to ensure service continuity at the health posts 8/10

Skills development took place during supervisory visits 10/10

Outcomes

Weekly work plans motivated HEWs 9/10

Supervisors’ participation in service delivery motivated HEWs 8/10

Close supervisory relationships facilitated supportive supervision 9/10

Shift in perception of supervision from control to support 8/10

Increased satisfaction and motivation from improved performance under supportive supervision 10/10 Gender preferences regarding supervisor were based on pragmatism in facilitating community health services 10/10 Preference for supportive supervision when compared to previous system of supervision 10/10 Challenges

Supervisors need to be more knowledgeable regarding health post activities 9/10 Supervisors’ high workloads at health centres meant that they were not always available when needed 7/10 HEWs’ high workloads at health posts meant that they wanted even more frequent supervision 8/10 Difficulty paying for phone credit due to low salary limited contact with supervisors 3/10

Context

HEWs reported a number of contextual factors that were relevant to understanding their experiences and perceptions of supportive supervision. These included the strong sense of satisfaction that they derived from working to help their own communities, their frustration with infrastructural and institutional barriers, and the challenges that they faced under the supervision system that preceded supportive supervision. As described in Chapter 3, participants were all female, according to the government’s requirement for the role, had an average age of 24.5 years, and they had worked as HEWs for an average of seven years. Supportive supervision was implemented in 2012, as discussed in Chapter 2, and as such participants had experienced the new supportive supervision system for approximately two years when interviews took place.

Satisfaction from serving the community. HEWs reported that serving their own communities was deeply satisfying. Notably, they described feeling this way consistently throughout their time in the role, and, therefore, this can be interpreted as a contextual factor that predated the implementation of supportive supervision. For instance, one participant described her satisfaction by saying, “I became so happy after doing this job because we are saving the lives of mothers, brothers, and children in the community” (HEW 4). Similarly, another HEW said, “I have always been so satisfied by what we are doing for the community” (HEW 8). Many HEWs described feeling particularly satisfied by supporting mothers and babies. One participant expressed this by saying, “Because I like to serve mothers, seeing mothers hold healthy babies is great and wonderful” (HEW 7). Another HEW illustrated the satisfaction she derived from supporting women through childbirth, which she

described as follows when referring to her experiences under the previous system of supervision, “I felt so much pleasure when I supported a mother who gave birth to a healthy child after being assisted by me” (HEW 5). Importantly, these examples illustrate that HEWs’ satisfaction was derived not only from engaging with mothers but

from witnessing the impact of their work. For instance, one HEW expressed this by saying, “I have always worked on my job with great pleasure. For example, I am happy when I teach them about maternal and child health issues, like long term family

planning methods. And I am always happy when mothers later ask me about using these methods” (HEW 1). This HEW’s experience indicates that seeing her teaching translate into requests for services that mothers had previously been unaware of was an integral part of the satisfaction she derived from her work.

Notably, HEWs’ satisfaction from supporting their own communities was also inextricably linked to their commitment to the role. One participant described this in detail:

It has been 9 years for me doing the same job. There may be individuals who got opportunities for jobs in NGOs and other places. But I don’t want to change my work. I love my job and I am proud to support and serve the mothers in my community, who taught me when I was young and they were not educated. I will never leave this job or this place. Once upon a time, I was offered a higher position regarding women’s affairs politically and I was assigned at another district. I refused that position because I love to serve mothers. (HEW 6)

This HEW expressed a common feeling among participants – their role within the community and resulting familiarity with community members strongly influenced their commitment to the job. For instance, another HEW said, “I was born and raised here…I want to stay working in this area as an HEW, serving my own community” (HEW 2).

HEWs’ familiarity with the community also facilitated trust and openness in their relationships with community members, which was particularly important in their work with mothers. One HEW described this when she said, “I was born here in this same

locality, speaking the same language and having the same gender, so the mothers are free to tell me what they feel, their secrets and so on. Because of this I am happy and I like what I am doing” (HEW 9). This demonstrates the pivotal role that familiarity with community members played in fostering trusting relationships and, in turn, in HEWs’ satisfaction. Indeed, one HEW discussed her commitment to her community and her job satisfaction in terms of her own mother by saying, “I love to serve mothers; I do this job with great pleasure. I always remember my mother, she gave birth to 11 children. If there were such privileges previously like there are now, our mothers would not have suffered” (HEW 3). These examples illustrate the profoundly personal nature of HEW identity. By serving their own communities, HEWs developed commitment to and pride in their work, which in turn seems to have given them a strong sense of satisfaction. For instance, one participant described her satisfaction as follows, “I am proud to do this job, and feel pleasure to hear the name given to us, which is ‘health extension worker’” (HEW 8). This sense of pride was expressed by many HEWs. Yet, along with high levels of satisfaction, HEWs also reported deep frustration with infrastructural and institutional challenges to their work.

Frustration with infrastructural challenges. HEWs expressed their frustration with several infrastructural challenges to their work that they described as pre-dating supportive supervision. All participants in this study worked in rural settings, based in health posts, which are small two- to three- room single-story concrete

buildings, as described in Chapter 2. None of the health posts visited for this study had electricity or running water. A majority of HEWs reported that this lack of electricity and running water had consistently restricted their ability to provide services throughout their time in the role. One participant described the impact of these challenges on providing vaccines and conducting clean and safe deliveries for women in labour when she said, “We don’t have electric power for keeping vaccines at the health centre, we have the refrigerator, but we have never had the power. There is no clean water too.

When we conduct deliveries here, we have always had to buy water from other sources” (HEW 1). Another HEW demonstrated the direct impact that the lack of electricity had on her ability to provide vaccines by saying, “We don’t have a refrigerator in the health post due to poor access to electric power. So we can only provide vaccinations three times in a month, when the vaccines are brought to us. If I had a refrigerator in the health post, I could vaccinate every single child that comes to the health post” (HEW 10). Additionally, one HEW discussed the challenges she faced in procuring clean water from outside of the health post and the impact that this had on providing obstetric services when she said, “The other important thing that we don’t have is clean water. We have to wait in a long line to fetch water, since there is only one water pump in the locality, and we need water for many services in the health post, especially delivery services” (HEW 8). These examples illustrate the substantial impact that infrastructural challenges had on working conditions in this context.

Frustration with inability to pursue education and low salary. HEWs also expressed their frustration with institutional challenges, including their inability to pursue education independently and their perception that the salary they received for their work was too low relative to their effort. Regarding their pursuit of education, the Ministry of Health does not allow HEWs to study outside of the training provided by the government, and this has been a rule since the beginning of the HEW programme in 2004. All HEWs expressed their deep frustration with this rule and strongly felt that it was unreasonably restrictive of their professional development. One HEW explained this as follows, “There is an opportunity for education these days, but they don’t let you go do it by yourself. This is a limitation of our knowledge” (HEW 2). Another participant described this by saying, “In the government policy, one cannot study in private

colleges to be a nurse. It will not be considered, we must wait for the opportunity given by the government and this is unfair to us” (HEW 8).

HEWs also emphasised that they were frustrated by watching their friends in other fields progress by pursuing degrees, while they themselves were not allowed to do so. For example, one HEW said, “My friends who were trained as teachers from the government’s teachers’ training colleges are now doing their degrees. But when it comes to our case, the government says that it will teach us by itself, and so they are limiting our knowledge” (HEW 3). HEWs also discussed the impact that their inability to pursue education independently had on their salary. One participant described this as follows:

There was a friend of mine who was educated in teaching. Now she is earning 2900 birr a month, and we are only paid 1300 birr. She has completed the diploma level and now is studying at the degree level. What we are frustrated about is that we are different from other civil servants when it comes to educational opportunities. We are not satisfied by our salary, nor are we getting the opportunity to upgrade ourselves. (HEW 7)

This HEW’s frustration with her low salary was echoed by all of the HEWs interviewed for this study. One HEW described this concern as follows, “There are conditions where the duties we have are not comparable with the advantage we get from the job. The tasks we are performing do not match the salary we are being paid” (HEW 10). Another HEW explained this in terms of the burden of having to work at night:

There is such a big difference between our salary and our work. For example, sometimes we serve clients in the middle of the night. When we spend the night in the health post, we are not paid for night duties like the professionals are, and we don’t have nights off. When you spend the night assisting a labouring mother, you suffer. There is no one who considers your suffering. (HEW 4)

For this HEW, salary seems to have functioned as a proxy for the Ministry of Health’s level of concern for her well-being, particularly when compared to other health

Despite the deep frustration that all HEWs expressed in relation to their salary and their inability to pursue education, each time an HEW conveyed frustration with these factors, she also emphasised her commitment to the role. For instance, one HEW said, “There are conditions that make you hopeless when you think about the reward we get, it may make you angry. But though there are such problems, we are happy and do our jobs with great pleasure because we are helping the community” (HEW 3). Another HEW expressed a similar sentiment when discussing her frustration with her salary by saying, “We are not satisfied with our salary, but our salary cannot be compared with the satisfaction that we get from the changes in the community” (HEW 6). Additionally, when discussing the frustration of not being able to pursue education, one participant expressed her conflicting feelings regarding her commitment to the role when she said, “If it was not for this I would be happy to continue working as an HEW. However, the change, the activity and the awareness that you see with the community make you continue the job” (HEW 5). This HEW’s comments clearly point to the interplay between frustration with being inhibited by institutional restrictions on the pursuit of education and satisfaction derived from community work. In her case, the frustration that she experienced was so intense that it impacted her desire to continue working as an HEW, yet as she described, her satisfaction from supporting her community helped to keep her in the role.

Infrequent supervision in previous system was demotivating. Most HEWs also described their frustration with institutional problems in terms of their perceptions and experiences of the supervision system that preceded supportive supervision. They reported that prior to the implementation of supportive supervision, supervisors visited infrequently. Most said that their previous supervisors had visited “every 3 months” (HEW 10). Another participant described this as follows, “We were waiting for the supervisor every month but they used to come every 3 months” (HEW 6). This led to HEWs feeling lonely and abandoned in the face of the immense responsibility of

providing health services to their communities. One HEW expressed her feelings about this in detail:

Previously, everything was only your responsibility because the supervisors did not feel responsibility. You were alone. For example, if one activity fell behind, like vaccination, you were alone to struggle. You were alone too, when you struggled to achieve the government’s plan that “no mother must deliver her child at home”. You were alone to gather mothers to educate them. You were always alone. (HEW 3)

More generally, HEWs felt that this infrequency had a negative impact on their motivation, which one HEW illustrated when she said, “In the previous system, I

worked hard and there was no one who came and supervised me regularly. There was no one who gave me frequent feedback. Because of that, I sometimes thought that I was simply tired without a reason” (HEW 4). Another HEW expressed similar

sentiments by saying, “In the former system, the supervisors rarely came. Maybe every quarter. This made me unmotivated and neglectful in my duties and because of that activities weren’t being performed based on the plans” (HEW 1). This HEW

demonstrates a perception shared by many of the participants: infrequent supervision not only impacted their motivation, but consequently inhibited their performance.

Previous system of supervision was controlling and punitive. Nearly all HEWs reported that when their previous supervisors did visit, their approach to supervision was controlling and punitive. For instance, one HEW described her

previous perception of supervision as follows, “In previous times, I thought a supervisor is someone who controls others” (HEW 9). Another HEW discussed her experiences of controlling supervision under the previous system by saying, “They simply came to control us and see what was happening in the health post” (HEW 5). Importantly, HEWs described controlling supervision in negative terms. One HEW expressed this when she said, “At that time when they came for supervision, it was just so bad and

difficult. My understanding about supervision during that time was that they were superior and it was to control us” (HEW 2). Another HEW described her previous supervision as controlling in terms of the focus on inspection by saying, “He was

controlling, sometimes he would just come and check in a hurry asking ‘Did you fill this, did you fill that?’ and then left the health post immediately. He didn’t really see

anything” (HEW 10). This HEW’s emphasis on her previous supervisor not seeing her work indicates that she felt that her work was not being acknowledged by her

supervisor. Another HEW described similar feelings in discussing her perceptions of the negative impact of the previous supervision system:

It was controlling before, he just came and asked “Why did you do this? Why was it like this?” He became very furious and left being angry. When they made supervision like this, it didn’t build me. I don’t think their supervision looked at my good achievements and it didn’t fill my gaps to teach me. He just