Improving Primary Care Quality Through Supportive Supervision and Mentoring: Lessons from the African Health Initiative in Ethiopia, Ghana, and Mozambique

Introduction: Supportive supervision and mentoring (SSM) is crucial to primary care quality and effectiveness. Yet, there is little clarity on how to design and implement SSM and make it sustainable in primary health care (PHC) systems. The 3 African Health Initiative partnership projects introduced strategies to do this in Ethiopia, Ghana, and Mozambique. We describe: (1) how each partnership adapted SSM implementation strategies, (2) the dynamics of implementation and change that ensued after intervening within PHC systems, and (3) insights on the SSM sustainability as a mainstay of PHC. Methods: Researchers from each project collaboratively wrote a cross-country protocol based on those objectives. For this, they adapted implementation science frameworks-the Exploration, Preparation, Implementation, and Sustainment model and the Consolidated Framework for Implementation Research-through a qualitative theme reduction process. This resulted in harmonized lines of inquiry on the design, implementation, and potential sustainability of each project's SSM strategy. In-depth interviews and focus group discussions were conducted with stakeholders from PHC systems in each country and thematic analyses ensued. Results: Across the projects, SSM strategies acquired multiple components to address individual, systems, and process-related determinants. Benefits arose from efforts that addressed workerlevel attitudes and barriers, promoted a wider learning environment, and enhanced collaborative structures and tools for monitoring performance. Peer exchanges and embedded implementation research were critical to the perceived effectiveness of SSM strategies. Discussion: Despite differences in their approach to SSM implementation, there are common crucial ingredients across the SSM strategies of the 3 AHI partner projects from which important lessons arise: (1) positioning learning and adaptation opportunities within the routine workings of PHC systems, facilitation, and technical support to reflect and utilize new knowledge; (2) multisectoral collaboration, particularly with academic organizations; and (3) building PHC decision-makers' and implementation teams' capacity for evidence-informed change.