1. Engaging Citizens in Quality Improvement and Results-Based Financing
September 21, 2018
Photo Credit: Creative Commons
Engaging Citizens in Quality Improvement and Results-Based Financing

2. Citizen Feedback in Tanzania
Agenda 01
Citizen Feedback in Tanzania 02
Mobile Technology and Citizen Feedback 03
Implementation Lessons
Photo Credit: Creative Commons

3. What is happening in Tanzania with citizen feedback?

4. Results-Based Financing in Tanzania
Results-Based Financing (RBF) is a program that transfers funds to healthcare facilities when they achieve performance targets
In Tanzania, the Ministry of Health (MOH) is targeting “needy” health facilities, providing RBF funds as additional support to boost service delivery
Funders include USAID and the World Bank
Targets include quantity and quality indicators, including one for citizen engagement
RBF was piloted in 2015, first in Kishapu District, then Shinyanga Region; now scaled to three regions

5. RBF Verification for Citizen Feedback: Labor-intensive data collection and an unused suggestion box
Regional
and District
Facility
Community

6. How can mobile technology support RBF’s citizen feedback indicator?

7. What We All Know About mHealth and Mobile Initiatives
Mobile phones are increasingly common in Africa
Mobile is “faster and cheaper” for data collection
Data can improve decisions
But how do we get ordinary people to use mobile services
to provide high-quality data to improve our programs?

8. Our Design: ‘Sauti Yangu’
Objective: operationalize the RBF citizen feedback indicator on the quality and availability of health services
To achieve this objective:
Translate the RBF citizen feedback questionnaire into a series of SMS messages
Adapt proven IQSMS reporting system
Pilot the IQSMS application for citizen feedback in 45 health facilities in Kishapu District

9. ‘Sauti Yangu’ Flow 15085 Voluntary registration
SMS “Sauti”
Voluntary registration
Send an SMS to a dedicated short code to begin the dialogue
Answer 13 multiple choice questions (in Swahili)
Provide basic demographic information (but no identifying information)

10. ‘Sauti Yangu’ Flow IQSMS and Guided User Interface (GUI)
IQSMS collects all of the data
GUI provides a dashboard, along with both canned reports and customizable queries
GUI is available on any internet-enabled device

11. RBF Verification for Citizen Feedback: Labor-intensive data collection and an unused suggestion box
Regional
and District
Facility
Community

12. RBF Verification for Citizen Feedback: Continuous, real time feedback directly to decision-makers
Regional
and District
Facility
Community

13. Applying the Principles for Digital Development
Design with the User
We adapted the existing RBF questionnaire to develop the SMS questions
We verified the wording, order, and breadth of questions with RHMT, CHMT, and health care workers
We designed the GUI data visualizations in collaboration with the RHMT and CHMT

14. Applying the Principles for Digital Development
Build for Sustainability
We obtained a dedicated short code to ensure continuity
We purchased a server for the RHMT to host the service
We prepaid for the SMS messages to allow time to identify an alternative financing model

15. Applying the Principles for Digital Development
Reuse and Improve
We adapted the existing RBF questionnaire rather than create new questions to support the citizen feedback indicator
We adapted existing, open-source IQSMS software
IQSMS is already interoperable with DHIS2, allowing reporting to the national system

16. Applying the Principles for Digital Development
Address Privacy and Security
We do not collect any personal or potentially identifying information
Although system “administrators” can send messages to participants, they cannot view any mobile phone numbers

17. What can we learn from implementation?

18. Supportive Factors
Buy-in at all levels, with regular support on the ground from the RHMT and CHMT
Using ICT to improve a process rather than solve a problem
Fitting in with an existing initiative—the data are already being collected, and we are making it easier
Adaptation of an existing platform (IQSMS) that has already been proven to work in remote areas of Tanzania
Real-time data
Over 2,400 registered community health workers and nurses are using the system and over 817 sites send reports via IQSMS.

19. When being attended to, did the medical staff take time to listen to you carefully?
Did the medical staff explain matters (services that you received) to you appropriately?
Initial results supported the collaborative design of the dashboard.

20. Was the staff at the facility caring, friendly, and welcoming?
Initial results supported the collaborative design of the dashboard.

21. Expected Unexpected Government Telecoms
Barriers to Implementation: Delays in Setting Up a Dedicated Short Code
Expected
Unexpected
Government
Telecoms

22. Potential Future Challenges—and Mitigation Strategies
Involve village executive officers
Involve ward executive officers
Community Health Worker turnover
GUI available on mobile, as well as desktop/laptop
CHMTs plan to follow up with immediate issues via phone
CHMT has offered to print and distribute reports to facilities
Closing the feedback loop to the facility level
Designated system users can send messages to anyone who provided feedback for a given facility (without seeing numbers to protect patient confidentiality)
Closing the feedback loop to the community level

23. How will we know it is worth continuing? How do we improve adoption?
What is next?
How will we know it is worth continuing?
Regular and useful feedback
Government adoption (scale as RBF scales)
Cost effectiveness
How do we improve adoption?

24. How will we know it is worth continuing? How do we improve adoption?
What is next?
How will we know it is worth continuing?
Small incentives to increase user uptake
Small stipends to CHWs to continue as promoters
Include VEOs and WEOs
Connect with other initiatives
Most importantly, people need to see value in providing feedback, so they need to hear from the health system that something is being done as a result of their actions
How do we improve adoption?
This is a panel on Mobile Money. I acknowledge that this application is not a mobile money system. As designed, our IQSMS feedback platform does not include digital financial applications. HOWEVER, it serves as a promising use case for future adaptation – as noted here in ideas for improvement including potential incentives (through digital payments) for CHWs promoters and users. 

25. Correspondence Sindri Kinnier Technical Advisor—Informatics
Rebecca Mbuya-Brown
Senior Associate—Health
Clement Marcel
Strategic Information Advisor
Photo Credit: Creative Commons
Correspondence