This study aimed at constructing a model of an appropriate peer supervisor for private drug sellers at district level in rural Uganda based on views of drug sellers and their inspectors. Effort was put into understanding how the model fitted within the already existing models of supervision. This aim was against a plethora of published evidence on the continued inappropriate treatment of paediatric febrile illnesses associated with the existing method of self- supervision in Uganda. Findings reveal a complex nexus of individual, institutional and policy challenges augmented by the fact that there is no clear framework under which public resources can be allocated for supervision of the private sector. The dimensions that emerged from theory building interlaced for appropriate supervision. There is need for government to pilot peer supervision among rural drug sellers to purge the existing supervision gap. Themes from the data are discussed in the section below.
Comparison with Bernard’s discrimination and the SAS models
As depicted in Fig. 1, role modelling seemed to be the most talked about dimension of peer supervision. Drug sellers preferred someone they could easily relate with given the context in which they operate. This relationship has been found to be pivotal and in agreement with both the SAS and Bernard’s discrimination models as precursors for appropriate supervision [11]. However, Bernard’s discrimination model does not elaborate in detail the supervision relationship which makes it hard to compare with results of this study. There is growing support for the need to improve supervisor-supervisee relationships because this improves internal support supervision quality rather than supervision frequency which is emphasized by many government agencies involved in supervision at unit level like drug shops in low income countries [14, 34]. As far as rural drug sellers are concerned, this can best be achieved when the supervision relationship between the supervisor and drug seller is cordial.
In addition, drug sellers wanted clearly defined roles of supervisors and a defined list of expectations for drug sellers. This is based on the current situation where for instance, inspectors have certain expectations from drug sellers which are largely prescribed by the law and do not expect drug sellers to have any expectations. This notion of expectations being uni-lateral is not in agreement with Bernard’s discrimination model which is more prescriptive when it comes to defining roles. In Bernard’s model, supervisors adjust according to the needs of the supervisees. Hence, the supervision style for novices is different from expert supervisees.
In our study however, we could not apply Bernard’s discrimination model because drug sellers from the two districts had already been trained on how to manage febrile children less than 5 years by the Clinton Health Access Initiative (CHAI) and were assumed to be at the same level in terms of appropriate treatment. More applicable was the SAS model where drug sellers wanted the roles of the peer supervisor to be less explicit and not to exceed formative and summative evaluation functions. However, while using the SAS model, caution should be exercised because the common assumption is that once a drug shop has been licensed, the seller operating the drug shop should engage in the right practise. This notion of self-supervision with no superior and authoritative level of supervision obliterates feedback which is the whole mark of supervision. Research shows that when supervision is structured, the process offers an opportunity for feedback, self-assessment, and peer assessment [35, 36]. This can only happen when there are clear terms of engagement handed to supervisors by the organisation responsible for supervision as well as a clear definition of who does supervision, how and when it occurs [37, 38]. From our study, there was no structure responsible for supervision of drug shops other than relegating the supervision function to the duly licensed drug sellers. This deviates from what the SAS model prescribes and makes the whole self-supervision process untrustworthy, unprofessional and prone to abuse.
Furthermore, that which drug sellers referred to as the government approach to supervision was actually inspection and was referred to as a financial burden transferred to drug sellers. This is because drug sellers felt that the fuel refund demanded by DDIs every time they made an inspection visit to drug shops was unfair since the drug sellers pay annual license fees and other statutory taxes. Moreover, the government facilitates DDIs on a monthly basis to carry out their inspection mandate. This dimension of incentives is not talked about either by the SAS or Bernard’s discrimination model hence an extension to the existing models.
In sum, an appropriate peer supervisor was described as one who had the ability to rescind harsh government policies aimed at affecting the day-to-day running of drug shops. Such decisions may include but are not limited to harassment, embarrassment and intimidation of drug sellers. This revelation was made based on the fact that inspection of drug shops in Uganda is carried out in a harsh manner. Since the current method of self-supervision has not resulted in desired treatment outcomes especially for febrile children aged 5 years or less, it is envisaged that democratically selecting peer supervisors with good mediation skills will purge this glaring gap of supervision. This will be possible when the peer supervisors have good counselling skills described and supported by both the SAS and Bernard’s discrimination model [11].
The basic assumption is that such a person would be an influential person trusted by government agencies and drug sellers. This person would be an ideal and efficient first line supervisor before other supervisors at a much senior level get involved. Decisions made by the peer supervisor should make sense to government agencies and drug sellers creating a good environment for offering services to the community while making profit from their business at the same time.
Policy and program implications
Given the critical service delivery gap filled by drug sellers in underserved areas in many low income countries, this research highlights a critical policy and program area that needs to be addressed. This research demonstrates that inspection in its current state can only ensure compliance with set guidelines albeit with some degree of coercion. However, evidence shows that there is a great deal of uncertainty as to whether inspection alone can improve quality of care among drug sellers in low and middle income countries [39, 40] and yet supervision has been found to be effective in improving the quality of health care [1, 41]. This research therefore points to the fact that there is need to have a supervision policy put in place and a framework under which resources for supervision of private sector drug sellers can be dispensed. It is envisaged that once inspection is augmented with supervision, the appropriateness of treating febrile children will improve.
The research findings show that currently, government inspection which is the closest in terms of supervision is detached from the experience of drug sellers and as such, there is a strained relationship between government inspectors and drug sellers. The inspection process is characterised by fault finding and is aimed at arresting and apprehending offenders rather than counselling with intent to improve practise. Moreover, evidence shows that supervisors are regarded as pivotal by supervisees [42, 43]. This happens most especially when information from supervisees needs to be synthesized and passed on to top level management in a manner that sustains a favourable operational climate. The manner in which the information is passed on must favour both the supervisees and the organisation under which they operate. It is therefore important that under the supervision framework, suitable personnel who are referred to as role models in this study be vetted before they are appointed as supervisors by the responsible government agencies.
Relatedly, it is important that the vetted and appointed personnel be adequately motivated by being provided the right means of transport and sufficient financial resources to carry out supervision. As other studies have shown, it is important to have a good incentive structure clearly communicated by responsible authorities or organisations mandated with supervision [44]. This enables supervisors not to be passive, absent or adopt unwanted behaviour such as soliciting illicit funds from drug sellers [45, 46]. It is well understood that financial resources are very scarce especially in low and middle income countries. However, with an appropriate supervision framework in place, the cost of supervision can be cost shared by the private sector, government and development partners where possible. This would go a long way in improving the quality of care by drug sellers for febrile children less than 5 years of age. Introduction of a supervision framework will also go a long way in reducing harshness through mediation while improving the quality of care as has been mentioned in studies done elsewhere [1, 47].
Areas of future research
Views gathered from this study were used to construct a model for an appropriate peer supervisor. It is important that this model be implemented to test how good it is in the context of rural drug sellers. During implementation, evidence gathered will reveal whether all four dimensions of the model are necessary for the model to be effective or some dimensions can be done without. Field implementation of the model in the rural area will be very important since almost 60% of the people in Sub-Saharan Africa live in rural areas [48].
It is also important that future studies consider how cost effective the peer supervision model is and what other adjustments can be done to this model to make it affordable for drug sellers. It is important that the peer supervision model is cost effective otherwise, the drug sellers pass on this high cost to the end users who are caregivers of febrile children. In addition, it is important to know whether once implemented, the peer supervision model will be embraced by drug sellers since the model involves people engaged in the same trade who may be competing with each other already.
Study limitations
This study did not use therapy quality scales (TQS) to measure general and specific skills of inspection and peer supervision during data collection [49]. Instead, views from participants were explored using a constructivist grounded theory approach by Kathy Charmaz [24].
Therefore the accounts on peer supervision are characterized by subtle meaning of participants’ perceptions and should not be interpreted as actual measurements of appropriate peer supervision. Although we present findings from drug inspectors, strictly speaking, inspectors are mandated to uphold the law by looking out for errant drug sellers. In essence, we interviewed them because there was no other authority charged with supervising private drug sellers. As such, our work has several areas of concordance and deviance typical of exploratory qualitative studies [50].
The drug sellers interviewed in this study were duly licensed and trained by CHAI. Results gathered from this study can therefore be generalised to other drug sellers in low income countries that have been registered and or licensed in accordance with statutory laws and received some form of medical training. The researchers were cognisant of the fact that unlicensed drug sellers also exist and provide a service to communities in which they live. However, because they work illegally and stand a high chance of being prosecuted when found, it is highly unlikely that the views expressed by drug sellers in this study would apply to the unlicensed drug sellers. This may have created a bias because not all drug sellers that serve the community were included in the study and yet their views may have been different and vital in enriching the study results.