Health services supervision in a protracted crisis: a qualitative study into supportive supervision practices in South Sudan.

BACKGROUND: The health system in South Sudan faces extreme domestic resource constraints, low capacity, and protracted humanitarian crises. Supportive supervision is believed to improve the quality of health care and service delivery by compensating for flaws in health workforce management. This study aimed to explore the current supervision practices in South Sudan and identify areas for quality improvement. METHODS: The study employed qualitative approaches to collect and analyse data from six purposefully selected counties. Data were collected from 194 participants using semi-structured interviews (43 health managers) and focus group discussions (151 health workers). Thematic content analysis was used to yield an in-depth understanding of the supervision practices in the health sector. RESULTS: The study found that integrated supportive supervision and monitoring visits were the main approaches used for health services supervision in South Sudan. Supportive supervision focused more on health system administration and less on clinical matters. Although fragmented, supportive supervision was carried out quarterly, while monitoring visits were either conducted monthly or ad hoc. Prioritization for supportive supervision was mainly data driven. Paper-based checklists were the most commonly used supervision tools. Many supervisors had no formal training on supportive supervision and only learned on the job. The health workers received on-site verbal feedback and, most times, on-the-job training sessions through coaching and mentorship. Action plans developed during supervision were inadequately followed up due to insufficient funding. Insecurity, poor road networks, lack of competent health managers, poor coordination, and lack of adequate means of transport were some of the challenges experienced during supervision. The presumed outcomes of supportive supervision were improvements in human resource management, drug management, health data reporting, teamwork, and staff respect for one another. CONCLUSION: Supportive supervision remains a daunting task in the South Sudan health sector due to a combination of external and health system factors. Our study findings suggest that strengthening the processes and providing inputs for supervision should be prioritized if quality improvement is to be attained. This necessitates stronger stewardship from the Ministry of Health, integration of different supervision practices, investment in the capacity of the health workforce, and health infrastructure development.

Text messaging app improves disease surveillance in rural South Sudan.

BACKGROUND: In South Sudan, remote health facilities face challenges in submitting weekly surveillance reports for epidemic-prone diseases due to long distances and difficult terrain health workers must cover to hand-deliver paper reports. Not only are patients unable to access care while health workers are away, identification of and timely response to an infectious disease outbreak is hampered. METHODS: Data journey mapping with stakeholders was conducted in three counties in Eastern Equatoria State to inform an appropriate mHealth solution. A short message service (SMS) application was selected because it did not require internet connection and only needed minimal equipment investments. The SMS app was designed using open source Android software due to low set-up and maintenance costs. Health facility staffs use personal phones to send an SMS in a predetermined format to the County Health Department (CHD) Android phone base. CHD staff review data; once verified, CHD exports the data to existing health information system software for onward submission to the State Ministry of Health (SMOH). To engender perceived value and incentive use, health workers must use personal airtime to send the SMS; they receive a bonus if they submit reports on time. For long-term sustainability of the system, CHDs have incorporated system maintenance costs into their monthly budgets. RESULTS: Eighty-nine health workers and 21 CHD staff were trained to use the SMS app. They found the innovation interesting and easy to use. All three counties increased on-time submissions upon introduction of the app. The predefined SMS template is important for data accuracy. Availability of a dedicated CHD staff and mobile network coverage in the most remote areas present ongoing challenges to timely report submissions in some counties. CHDs declare the SMS app has revolutionized weekly disease surveillance reporting in their counties. Eastern Equatoria SMOH has requested scale up of this app to all counties of the state. National Ministry of Health (MOH) has expressed strong interest in scaling up the initiative for monthly data reporting. CONCLUSIONS: The SMS app has improved timeliness and efficiency of weekly disease surveillance reporting. It overcomes transportation challenges of health reporting in remote areas and improves access to patient care since health workers do not need to leave post to deliver the report. Minimal start-up and operation costs make this an appropriate solution in resource-poor contexts with a high likelihood of long-term sustainability.