Our study design does not simply allow transfer of results to other districts or HCs. It is theoretically possible that critique presented is unique to our sample. To explore transferability, we presented our findings on several occasions (latest in October 2016) to providers and supervisors from participating and non-participating facilities to request their critique and modifications. This confirmed and refined our findings and interpretation and brings confidence that results are still relevant and not representing isolated cases. Still, our data do not allow quantification of problems revealed, such as inappropriate use of power among supervisors and excessive evaluation anxiety among providers. They may be the exception rather than the rule, yet we are confident they are harmful and significant enough to require attention and action. Other studies would be needed to estimate their magnitude.