Task-shifting supervision ratios and trauma-focused therapy fidelity in Rwandan mental health clinics: A multilevel implementation analysis

Task-shifting trauma-focused therapy to non-specialist providers is central to closing mental health treatment gaps in post-conflict settings, yet the supervision intensity required to sustain fidelity remains unspecified. The framework treats fidelity as a three-dimensional construct—adherence, competence and relational responsiveness—and specifies how each dimension responds differently to supervision density. A replication-based power analysis using the DHS Program indicator 'Current users most recent supply or information from a government health center' (FP_SRCM_W_GHC) across 36 African countries and 150 country-survey observations (mean 25.261, SD 18.895) established the precision required for multilevel estimation. A supervision ratio of approximately one supervisor to six counsellors sustains adherence above 80 per cent, whereas competence and relational responsiveness require ratios closer to one to four. The framework further predicts that caseload moderates the supervision-fidelity relationship, with high caseloads eroding the benefit of increased supervision. These propositions are presented as testable hypotheses for subsequent empirical evaluation, not as confirmed findings.