The Innovate stage

In Équateur Province, the LSCI Innovate stage was centred on a 3-day classroom-based workshop in August 2017 that included 19 champions from the central, provincial and district levels. The workshop was facilitated by the VillageReach DRC Country Director, Programme Manager, Supply Chain Advisor and Provincial Project Manager. During the workshop, the facilitators introduced the LSCI model and facilitated classroom-based activities that aimed to provide the champions with foundational change leadership competencies rooted in supply chain. These competencies included team-building, supply chain assessment, advocacy for supply chain as an essential function of the Ministry of Health, mentorship and supportive supervision, and developing and implementing action plans.

As the culmination of the workshop, the champions defined key challenges in the supply chain and created a vision for a short-term change: to improve supply chain management at the district level by December 2017. The champions then developed an action plan for the next 3 months to work towards their vision and practice change leadership. They prioritised two key activities in the action plan: (1) to train frontline healthcare workers in supply chain management, and (2) to improve their own skills in conducting supportive supervision.

The Do stage

During the Do stage, the champions worked to accomplish the activities they defined in their action plan. Drawing on action learning principles, mentorship and coaching are a key part of the LSCI model, particularly during the Do stage. To this end, VillageReach staff accompanied the champions as they carried out the Do stage. In addition, a WhatsApp group was created with the aim of providing a platform for peer mentoring and for champions to share their experiences, seek and share advice, and build team spirit. The WhatsApp group was moderated by VillageReach staff, who were also available to respond to concerns that the champions could not address themselves, and who occasionally sent messages to check in with the group and initiate discussions after periods of inactivity. The timing of these activities in the Do stage is shown in figure 1.

To train frontline healthcare workers in supply chain management, the provincial and district champions worked together to plan and co-facilitate in-person trainings in three districts for 125 nurses and nurse assistants. These trainings targeted basic supply chain management tasks that nursing staff were responsible for accomplishing in their health centres, including how to inventory products, maintain records, complete order forms and store products safely. Following the trainings, the champions conducted supportive supervision every other month to observe the nursing staff’s supply chain management practices, provide on-the-job training to address gaps or deficiencies and motivate nursing staff by recognising what they were doing well.

The second key activity in the action plan, to improve champions’ skills in conducting supportive supervision, was intertwined with training and support of frontline healthcare workers. VillageReach staff acted as mentors and accompanied supervision teams made up of district and provincial champions to provide on-the-job training in supportive supervision of healthcare workers. Towards the end of the Do stage, the champions decided that it was important to share supportive supervision skills with their peers who were not directly participating in the LSCI. To that end, the champions worked with VillageReach to train 37 provincial and district managers on supportive supervision and on-the-job training in December 2017.

The Review stage

Finally, in the Review stage, the champions came together for a capstone workshop, which focused on appraising progress on the action plan and continuing to strengthen leadership skills. During the capstone, the champions also developed the next series of actions for supply chain improvement. Based on the experience from the first phase of supply chain improvement, the next series of actions prioritised data collection and use. The capstone also continued to promote teamwork among the champions and across levels to institutionalise the importance of a shared vision and of leading from all levels to achieve the vision together.

Effectiveness of action learning in leadership capacity building

Based on the champions’ self-evaluations at the end of the initial workshop (n=19), the vast majority (94%) felt that classroom-based activities in the Innovate stage allowed them to build leadership competencies (table 1). However, at least a third of the champions felt that they could not apply or still needed assistance to apply any given competency. Thus, while the classroom-based activities helped the champions gain some new skills and competencies, they felt they needed additional support to fully master these skills. The LSCI addressed this need by combining classroom-based skills building with experiential opportunities to apply those skills through action learning. This adds to evidence that action learning represents a promising approach for building leadership capacity.6 8–11

Combining action learning with the resources and opportunities to lead change

In this case, the LSCI was integrated into a larger intervention to improve supply chain performance. This provided the champions with a concrete opportunity to apply and practice their leadership skills in a real-world situation. In doing so, the LSCI built on existing research that leadership is not simply a set of cognitive skills that can be mastered through didactic methods.6 Rather, leadership must be cultivated as part of a person’s identity through application and practice in addressing real-world challenges and making changes.6 8 9 12 Furthermore, the LSCI seemed to strengthen the overall intervention by helping managers develop leadership skills to drive the changes in supply chain.

In addition, it appears to be important that the overall intervention in Équateur Province was flexible enough to allow the champions to define the actions they wanted to take in the Do stage. Although this intervention did have high-level goals and objectives, it afforded the champions enough space to set their own priorities in their action plans. For example, the supply chain training for nursing staff and supportive supervision training for district and provincial staff were not originally part of VillageReach’s workplan, but there was enough flexibility to provide resources for these activities. Interventions with a leadership capacity building component are unlikely to be effective if they do not provide emerging leaders with genuine opportunities to influence and lead change.

Building district-level leadership capacity

The LSCI built on supply chain leadership programmes such as Lead Lab13 and STEP14 by extending this model to the district level. By including champions from the lower levels of the supply chain in defining a vision and plan for change, it helped ensure buy-in from the personnel responsible for day-to-day implementation and oversight. Moreover, it positioned district health managers as champions for making these changes. As one district manager described:

Before (the LSCI), we were a little reluctant (about the changes in the supply chain)…but (the LSCI) changed our way of seeing things. [Before,] everything (all the indicators) was always just poor, poor, poor, poor. But when you have these trainings and you are able to share a vision with the healthcare workers, you start to have hope and optimism about how things can change and become better.

In addition, the focus on leadership specifically for supply chain seemed to be important for the district managers’ ability to lead change. These personnel are typically medical professionals who are well qualified to treat patients, but have had little training in supply chain management or leadership skills and cannot fully leverage their knowledge and experience to improve supply chain performance.2 3 17 The focus on supply chain, rather than leadership in general, appeared to be important in increasing district managers’ ability as leaders because they felt more confident in their knowledge of supply chain best practices. As one district manager puts it, “the supervisor needs to know more than the supervisee (to provide effective supervision).” This indicates that interventions aimed at strengthening supply chains should target both technical and leadership skills to empower staff to lead and sustain changes.

Inclusion of participants across administrative tiers

Several participants noted that a strength of the LSCI was that it brought central/provincial/district-level managers together as a team with the capabilities to support each other in achieving a shared vision. Through work in cross-tier teams, provincial staff were able to observe as district staff built competencies, which seemed to result in increased trust between levels. As a provincial manager noted, “They (district managers) are really beginning to internalise (supply chain leadership competencies).” This supports the existing evidence that cross-tier participation in leadership capacity building is important to ensure that a vision for change is shared across the levels of the health system and helps higher-level officials to recognise leadership capacity at the operational level.8 11

In addition, inclusion of both provincial and district staff in field-based activities during the Do stage provided the opportunity for provincial champions to coach district champions in providing supportive supervision for healthcare workers. According to a provincial manager, “Training and capacity building through joint (provincial and district) visits to the (service delivery points)… (allowed for) true capacity building.” As a result, staff at all levels felt supported in developing the necessary skills to lead change in improving supply chain performance.

Importance of mentoring and supportive supervision

In key informant interviews following the Review stage, champions repeatedly identified on-the-job mentoring and supportive supervision as key factors in improving supply chain performance. For example, many of the nursing staff reported that they had never been formally trained in the logistics functions that they were expected to undertake as part of their jobs such as stock-keeping, ordering and reporting. Participants noted that providing training and coaching for the nursing staff in these skills helped improve stock management in health facilities. During supportive supervision, district-level managers reviewed data management and stock-keeping practices, provided specific feedback for improvement and recognised what workers were doing well. Previously, managers had only told healthcare workers what they were doing wrong, often with limited coaching on how to improve. As one district manager reported:

Many health workers had limited experience in correctly recording and using data. I spent time with them on different data management tools, explaining the importance of each and assisting them to complete each form. At each visit (to) the health centre, I provided them with feedback and recommendations for further improvement.

Furthermore, there was a perception among the champions that building healthcare worker capacity through supportive supervision helped reduce stockouts. A provincial manager explicitly recommended that future efforts continue building on these processes:

[To reduce stockouts,] supportive supervision should be continued and expanded so that more people can master these skills. The more we can support workers at the operational level, the better things will work.