Citizen Feedback to promote health worker accountability

In many settings, clients of health services do not have a voice to provide feedback on the quality of care received at health facilities. Yet disrespectful care and inadequate services are not uncommon in many low resource settings.

Some governments are looking to introduce performance based financing (PBF) as a way to improve incentivize high quality service provision. One component of this is collecting feedback from clients to understand their satisfaction with the quality of care provided. Traditional methods of collecting this data are challenging and costly as it often requires an independent data collector to track down clients and locate them in their homes to conduct interviews. When approached, clients may be reluctant to give honest feedback if they do not know and trust the data collector.

D-tree International supports many programs which include cadres of Community Health Workers (CHWs), equipped with mobile decision support tools, who visit clients in the community, provide counseling and health education, and support linkages to health facilities. These CHWs are uniquely suited to collect client feedback about the quality of services at health facilities since they develop trust with families over time.

Every time a client indicates she attended a health facility (for example, for antenatal care, labor and delivery, or to receive a family planning method) the mobile app prompts the CHW to ask about the quality of services at that visit. With the permission of the client, this data can then be fed into government PBF systems and used to review quality of care and increase accountability of health workers.

An example of this is D-tree's work in Zanzibar through the Safer Deliveries program. D-tree partners with the Zanzibar Ministry of Health (MoH) to train Community Health Workers to use mobile tools to support pregnant and postpartum women in their communities. Women and their families are visited multiple times during pregnancy and the postpartum period and receive support to develop a tailored birth plan, pre-arrange transport, and save money for delivery. The program is implemented at scale in Zanzibar and supports approximately 80% of pregnant women.

In 2015, the Zanzibar MoH began a PBF initiative which aimed at improving the quality of care at health facilities.

To collect citizen feedback, the MoH hired an external group to visit women who attended a health facility for antenatal care, postnatal care and delivery services. This was a costly and inefficient process which involved staff time and transportation to reach individual women in the community.

To eliminate these costs and improve efficiency of data reporting, the Safer Deliveries program worked to integrate CHW data about client experiences into the PBF program.

To do this, the Safer Deliveries program worked with the MoH to add specific, PBF-oriented, questions to the CHW mobile application.

D-tree's previous work with citizen feedback for family planning services had established that asking subjective questions such as "Were you satisfied with the quality of services" tended to invite uniformly positive responses which deeper enquiries found were essentially misleading. Questions of a more direct and specific nature help clients to feel comfortable responding with sometimes uncomfortable truths.

Questions for the PBF initiative were therefore crafted to be objective and specific in order to elicit responses which reflect more accurately the reality in the clinics. Here we show a couple of examples of such questions:

These questions were configured in the mobile application, and responses were directly shared with the PBF technology partners so that data could be integrated into the overall PBF finance scheme.

Client feedback data are being used by the Zanzibar MoH to review the quality of services and make programmatic decisions to improve the quality of service delivery. For example, the MoH can track how much money clients are paying for ANC, PNC and delivery services despite the expectation of free maternal health services.

The MoH is also able to drill down to the health facility level to identify which facilities are charging the most money and work with health facility staff to reduce fees charged for services. Similarly, the MoH can track where and why women are turned away when they try to access health services.

Sample dashboard screenshots

The Zanzibar MOH uses this data regularly to engage in dialogue with health facilities about the quality of respectful, comprehensive care. During quarterly review meetings with the Safer Deliveries program, each district health team presents on findings from the program dashboard and discusses ways the data can inform discussions and actions to continue to improve the quality of service delivery.

D-tree International


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