In the past couple of decades, theories have been advanced to challenge the traditional concept that assuring and improving quality is the result of external review, inspection of the end result, and a heavy investment in supervisors whose major function is to monitor staff . In the recently proposed theories, the focus has shifted to anticipating and preventing problems rather than correcting them. Motivated by such theories, facilitative supervision, instead of finding fault and leveling blame at individuals, emphasized determining whether or not existing work processes are planned, designed, and implemented in such a way as to achieve the desired end result – providing a high-quality service that meets clients' needs. During the mid 1990s, Chambers and Long  in their paper that explored the theoretical and practical issues pertinent to the implementation and development of supportive clinical supervision showed that a facilitative approach to clinical supervision is therapeutic and self-propelling for both supervisor and supervisee .
In Ghana’s health delivery services, FSV as a system of management whereby supervisors at all levels in an institution focus on the needs of the staff they oversee is new. This paper presents the standard evaluation results of FSV, which formed an integral and crucial part of a Government of Ghana-Japan bilateral project implemented in the UWR of Ghana. The aim of the project was to support the expansion of CHPS to strengthen community health services in the region. Even though the CHPS as a priority programme designed for rural areas, which are mostly deprived of permanent health infrastructures , has chalked some successes, there have been some bottlenecks in terms of its scalability in the urban areas. If the adoption of FSV could improve CHPS’ efficiency and effectiveness irrespective of setting, it will contribute significantly to addressing some of our health care service delivery conundrums.
We show that all the nine districts enthusiastically embraced the FSV approach even though they differed markedly with regard to the degree of adherence to some set benchmarks. The benchmarks being referred to were developed taking into consideration management of supplies, management of transport and equipment, information management, management of meeting, technical support, and scores for report to the RHMT, DHMT, and SDHT. Previous studies have shown that CHPS is consistently associated with an increase of health care service delivery and receipt [1, 4]. However, those studies did not address process-related indicators being referred to in this study. The results of the current study, offer a novel insight regarding the feasibility of incorporating FSV into the CHPS initiative. In Donabedian’s framework for quality of care assessment, three different components of quality of care are noted: structure, process, and outcome . 'Structure’ refers to the attributes of the settings where health care occurs; 'process’ represents what is actually done in giving and receiving care (this is further divided in to interpersonal, and technical components); and 'outcome’ shows the effects of care on the health status of patients and populations. A successful implementation of FSV could have a positive impact on the 'process’ component of Donnabedian’s three-legged framework.
The structure of the health system in Ghana is such that DHMTs and SDHTs bear the responsibility of ensuring that primary health care services function. Therefore, the success of the CHPS strategy will, to some extent, depend on the performance of DHMTs and SDHTs in terms of facilitative supervision. The results of the study show that three DHMTs (Wa Municipal, Lawra and Jirapa) were graded as good while the remaining six DHMTs were adjudged as fair (Figure 2). Each of the areas of evaluation is crucial to the success of the CHPS strategy in the region. Therefore, improvements in each area would consequently improve service delivery through the CHPS approach. Typically, each DHMT has to implement strategies to work on their weaknesses while also improving (or at least maintaining its strengths).
Facilitative supervision visits were also conducted quarterly by the DHMT Supervisory Team over the SDHTs. The aggregated performances of the various SDHT for the study year show that Wa Municipal SHMTs scored the highest marks in reports to DHMT, management of supplies, information management and technical support to CHOs. Sissala East scored the highest mark in management of meetings and Sissala West scored highest mark in referrals. Lambussie SDHTs scored the lowest mark in four areas: report to DHMT, management of supplies, information management and management of meetings. Using the overall scores as shown in Figure 3, none of the SDHTs were grade as good and SDHTs in four districts performed poorly. The worst performance of SDHTs in districts relate to provision of technical support to CHOs; apart from SDHTs in Wa Municipal which scored 61% under technical support, SDHTs in all other districts scored below 50%. This poor performance under technical support calls for concern, since technical support is a key area that directly affects the activities of the CHOs (apart from supplies), who require support regularly to enable them function well in the communities.
The base of the primary health care system is the community level, where CHOs operate the CHPS compounds. A recent study in the Upper East Region of Ghana shows that supervision (especially one in which supervisor provides some support to the one being supervised) improves the productivity of health care workers at the CHPS level . For the productivity of CHOs in the Upper East Region to improve, SDHTs need to step up their performance. This is a key factor in raising health system output. Another observation is that the performance of DHMTs in terms of facilitative supervision visits does not seem to reflect in the performance of the SDHTs under the districts. The challenge is for the various DHMTs to step up their monitoring to ensure that SDHTs improve upon their performances.
Facilitative Supervision of CHOs is done monthly by SDHTs staff members. Overall, CHOs in all districts scored above 50%, with the exception of CHOs in Lambusie district who scored below 20%. The observed low performance of CHOs and SDHT in Lambusie in relation to FSV requires further investigation.
This pilot program in the UWR suggests that there is much to gain both individually and institutionally, from a transition to more facilitative styles of supervision. It is, however, almost axiomatic that institutions and organizations particularly in the field of health care where medical hierarchies dictate a conventional supervisory approach, may find - a shift from the conventional approach to this new approach daunting. Some may believe that the conventional approach of policing employees has stood the test of time and does not need alteration. Others may believe that changing to the FSV approach will take more time, resources, thought, and attention than is possible, given the level of resources available. Yet, others fear that management will lose their directive role when supervisory systems change from inspection to facilitative. We provide evidence to the contrary. In the UWR, management at the various districts and at the regional levels remained responsible for planning and implementation of work, making available the facilities, training, and other resources needed to achieve their targets. To those who argue that the facilitative approach will be resource-intensive, some activities in East Africa have shown that the approach is possible even in very resource-poor settings .
Other institutions elsewhere have evidence of the feasibility of the approach. In a number of countries notably in Bangladesh, Kenya, Tanzania, Zimbabwe, and Uganda, the fruits of FSVs are evident. In the 1990s, Tanzania witnessed a rapid expansion of a family planning program as a result of the approach. Facilitative supervisors from the Tanzanian Ministry of Health serving as middle managers and trainers worked to introduce and implement protocols for clinical methods and assisted in resource management. They also helped to leverage additional resources for family planning services . They also showed that in a facilitative supervisory fashion, high level practicum instructors were usually able to offset the effects of low level individual supervisors. They demonstrated that only those counselling trainees who encountered individuals functioning at high levels of facilitative conditions were able to grow on these dimensions.
That said we find it essential to do some nuancing of our study outcomes. First, we acknowledge that it will be unreasonable to wholly attribute the successes herein presented to the facilitative supervisory visits. The leadership provided by other investments by JICA in the CHPS, inputs from other stakeholders such as traditional leadership, and the district assembly could have contributed to this success story. In fact, the introduction of CHPS into districts occurs through extensive planning and community dialogue on the part of the health service and the community. A key principle of CHPS’ introduction is that traditional leaders of the community must accept the CHPS concept and commit themselves to supporting it. CHPS relies on participation and mobilization of the traditional community structure for service delivery. In this regard, the review by the Evidence Review Team 1 of the US Government Evidence Summit  on the theme: "Which community support activities improve the performance of CHWs?" is a relevant resource.
At this point, it is important to state two limitations that our study may suffer from. First, it was beyond the remit of our evaluation to measure whether or not the process-level desirable attributes of the facilitative approach translate into measureable service outcomes. Earlier studies provide evidence in line with this possibility. For instance, Kim et al.  showed that supportive supervision reinforces prompt reflection and learning, helping novice health personnel to improve their interpersonal communication skills (Kim et al., 2002). Even though this current study could not measure this relationship directly, we are confident that the findings of Kim et al.  will apply in our setting.
Second, we do acknowledge the inherent deficiencies with stakeholder response data. For instance, our data could have been biased by reliance on response data provided by participants in programme management, who might lack objectivity and independence in assessing the topics under review. It is, however, reasonable that the results, which are based not on some, but on all the health districts of the region, and collected through a triangulation of two methods, have considerable relevance.