We Cannot Supervise and Train Our Way Towards Better Health Systems

At a global health conference recently, the session facilitator asked the question, “What does a [insert individual, job title or Ministry department here] need to be successful at their job?” In forums like these, it’s a question everyone working international development typically asks at one point or another.

What I’ve also found is that when the conference ballroom doors close and development folk gather over 3-course meals within the privacy of gated and guarded lodges- what the question really looks like is, “Why can’t [insert individual, job title, Ministry department or country name here] just do their job?”

What follows always follows: a problematic, condescending, paternalistic, and often borderline (if not all the way) racist and classist tirade berating country nationals’ skills, capacity, personal motivation, and government corruption. When asked about health workers specifically, the go-to are: supervision and training. Supervision, training and the allowances that go with them have dominated the greater majority of conversations I’ve observed with local and international stakeholders working to improve healthcare, especially in last mile under resourced communities in the Global South. I’ve also wondered though, why do we think we can supervise and train our way towards better health systems?


Why do we think we can “Mommy” countries out of poverty- as if we could just stand by the door and watch populations and governments clean their rooms until it gets done when and how we say it should?

At a human centered design session, we were asked to think about what a community health worker needs to be successful, putting the community health worker at the center of our thinking, before even approaching the design of an intervention (tool, policy, etc.). We were then asked to draw links these resources may have to each other, outside of how they are linked to the community health worker. My partner immediately defaulted to supervision for accountability. I pushed her, as well as others at my table, to put themselves at the center of our perceptions of the community health worker. What do I, Jodi-Ann Burey, need to be successful at my job? That goes beyond my boss, my computer and my paycheck- though all, especially the latter, are critical. My supervisor doesn’t track my time and micromanagement certainly won’t keep me accountable to high job performance. There are so many other elements that motivates my work. Likewise, we need to think beyond supervision and training for what community health workers need– much deeper and wider than what I had time to illustrate during the group activity.

HCD CHW

Drawing connections on what a community health worker needs to be successful

There is most certainly a space for supervision and training to promote consistently high quality healthcare services and measured impact on that being so. However, wrapped around a community health worker- like their clients- exists a whole system wide, cross-cutting diversity of interlocking resources supporting their work. The mostly highly trained health worker can’t do much without reliable supply chain of health commodities; the most robustly supervised community health worker may still be subjected to isolation without support from peer-leveled colleagues.

There are a gazillion factors linked to employee performance, motivation, satisfaction and success. I’ve counted. Why do we not afford the fullness of this research that so much guide how we work in headquarters to our in-country colleagues?

Unfortunately, some people I’ve encountered in the international development industry are so blinded by these biases they neglect to recognized rational behavioral responses: I read a proposal recently that went on about how health workers were not motivated, needing better- you guessed it- supervision and training to do their jobs. A few paragraphs down, the writers go on to describe the logistical gaps that prevented health workers from receiving payment for several months at a time. I assure you, if I wasn’t paid for several months, I wouldn’t be very motivated either.

A few years ago, I visited a rural health center only to find that the only nurse was home sick. My colleagues and I visited her home to see how she was feeling, and found her sitting on the floor in her yard stripping beans. I flushed with frustration. How could the one nurse in this community (seemingly) play hooky? Then I paused. She is the ONLY nurse in the community. If I had that burden, I’d take a day off for myself too.

There exists an historical power held by Westerners- both toxic and intoxicating- that too often disallows many from regarding in-country partners with mutual respect, humanity and understanding. I often find myself wondering how this thinking flows with the inertia of elitism and condescension associated with the (neo)colonial dynamic of international development. I ponder whether that’s why some of my in-country colleagues pronounce USAID as “U-SAID” whereas Westerns typically pronounced it as “U-S-A-I-D” or “US-AID.”

What is supervision and training besides evidence of an underlying belief that people need to be told what to do and monitored to ensure they do it.  Why do we think we can “Mommy” countries out of poverty- as if we could just stand by the door and watch populations and governments clean their rooms until it gets done when and how we say it should? We supervise people we don’t trust and train people who we think lack skills. If this is our approach, we will continue to lose opportunities to build real equitable partnerships built on mutual respect and reciprocation that can achieve one of the most foundational goals connecting our work: to support healthy sustainable communities and save lives.

Moving forward, I urge my colleagues to put supervision and training on the side- not discarded, but not aggrandized either. Push beyond the things we think we can control. Release the guise of capacity building. Support our in-country colleagues with a same dynamic and holistic approach we use on ourselves.

 

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