5-Star PHC

Different methods to measure the quality of primary health care (PHC) have already been developed and used. Many of these rely on a set of indicators that assess various dimensions of PHC, such as financing, capacity, quality, and equity. However, the use of several indicators, while comprehensive, may also pose challenges in both data collection and interpretation. In many low- and middle-income countries (LMICs), some of the data required are not readily available. Furthermore, interpretation of several indicators, even when presented in a dashboard, is not always easy but rather complex. How does one really conclude that PHC is performing well or otherwise? In the midst of the popularity of these technical approaches, what is so far missing is the primacy of user experience. Quality should be determined by the people who are, after all, the end users of PHC services. Therefore, health system data on PHC performance and quality should be complemented by the voice of the people using accessible and already existing platforms.

Our solution to measure the quality of PHC is called "5-Star PHC." The goal is to produce "5-star" PHC facilities in LMICs based on the practical approach of collecting and addressing people's experience and feedback regarding PHC services. The solution is based on the already existing practice of reviewing places on Google Maps. Imagine yourself in any hypothetical place looking for a hotel where you would like to stay for the weekend. Typically, you will search for options using Google Maps and make an appraisal based on each hotel's ratings and reviews. If this practice is common to assess the quality of hotels and other establishments, why can't we build on this practice for a similar approach to assess the quality of PHC facilities? While it is common for hotels, restaurants, and other interesting places on Google Maps to have a good number of ratings and reviews, most PHC facilities in LMICs (if they are marked on Google Maps at all) are without ratings or reviews, representing a missed opportunity for a mechanism for feedback and improvement. We will therefore pilot and demonstrate the feasibility of 5-Star PHC as a mechanism to assess and improve PHC performance guided by three principles: (a) the people determine what is quality PHC; (b) the method is practical by leveraging on existing platforms for data collection; and (c) the practice is institutionalised as part of a cycle of learning PHC systems.

The use of Google Maps to review places is not new practice. What is new here is the application of the practice for a systemic evaluation of the quality of PHC facilities based on the ability of people to provide feedback using their mobile phones. Our idea is simple, but the potential for impact is high. Imagine a scenario in an LMIC where, through the institutionalisation of 5-Star PHC, all PHC facilities in the country are marked on Google Maps, each with its set of ratings and reviews. The people who access these PHC facilities are motivated to provide ratings and reviews. PHC facilities use the ratings and reviews as part of their internal audit mechanism, address the concerns raised in the reviews, and subsequently improve performance to attain higher ratings and more positive reviews. From the perspective of the national government, all PHC facilities can then be taken together where those achieving 5 star ratings are recognised and those with lower stars are provided with assistance to perform better. PHC facilities will have an opportunity to share reviews, learn for one another, and collectively address common concerns raised. When sustained through institutionalization, there is a cycle of client feedback and correction by the facility, resulting in the improvement of PHC overall.

People should be at the front and center of PHC. Our solution seeks to empower people to rate and review their PHC facilities. Therefore, people have an opportunity to determine what for them is quality PHC and participate in a mechanism for PHC performance measurement and improvement. Through the institutionalisation of 5-Star PHC, we anticipate that PHC facilities in LMICs become more responsive to the needs of the people. Furthermore, frontline health workers and managers who operate PHC facilities also have an opportunity to improve their performance by listening to people's feedback. 5-Star PHC is anticipated to impact the lives of people accessing PHC services by achieving higher satisfaction with the quality of services provided to them.

We are called as the Community Health and Health Care Systems research group. As the name of our group suggests, the focus of our work is community health. The Team Lead for 5-Star PHC is a health systems specialist from the Philippines who has a track record of working with communities and collaborators in the Philippines, Malaysia, Thailand, and Nepal. 5-Star PHC will be piloted leveraging on our existing partnerships with communities in the Philippines and India. Complementing these community links are the team's focus on a participatory approach in the performance of our work, as well as the wide range of technical expertise and resources available in the University of Bern that will contribute to successful implementation.

Our solution requires additional resources in order to be realized. The team has the expertise, as well as the existing networks and partnerships with communities to ensure sustainability of outcomes. However, we do not have the funds for pilot and demonstration. The desire to pilot the solution is the main reason for this application, including the opportunities that the Challenge provides for learning with other innovators and mentors on how to improve and sustain our solution.

The main innovation of our solution is the importance placed on people's voice as the key determinant of quality in PHC. While most other approaches to PHC performance measurement focus on statistics, our solution focuses on human experience and client feedback. The solution also leverages on the existing platform of Google Maps, which is already widely used, instead of creating something new. What is therefore new here is not the technology but the adoption of an existing technology for the new purpose of assessing PHC quality.

In the short-term (i.e. 1 year), we should have promoted the practice of rating and reviews of PHC facilities in our pilot sites in the Philippines and India. We will monitor this based on the increasing number of ratings and reviews received by PHC facilities in the pilot sites. We will achieve this through close collaboration with the PHC facilities and community engagement to mobilize more contributions to ratings and reviews.

Within the same year, the frontline health workers and managers of PHC facilities should have appreciated the usefulness of the ratings and reviews and integrated it in their performance assessment cycle. We will ensure this by involving frontline health workers and PHC facility managers early and throughout the process of piloting.

Within 5 years, our goal is to scale-up the solution in a national scale through the development and implementation of a national policy that institutionalizes 5-Star PHC as a mechanism for PHC quality assurance in the country. At this stage, the solution is also potentially introduced in other LMICs. We will achieve this by engaging the relevant government agencies (e.g. MOH) and showcasing our solution to the wider audience of policymakers and other stakeholders beyond the pilot sites.

Our answer to this question has been partly addressed in the previous section. To add to that answer, we will organize our indicators into the following:

Output indicators: no. of PHC facilities marked on Google Maps, no. of ratings and reviews received by each facility per quarter, no. of ratings and reviews received by each facility through time

Outcome indicators: average no. of stars for each facility per quarter, content of reviews (positive vs. negative) received by each facility through time, acceptability of the review process among patients/clients, acceptability and perceived utility of the review process among PHC facility managers and frontline health workers 

Impact indicators: a policy for the institutionalization of 5-Star PHC for performance measurement of PHC facilities, satisfaction of patients/clients in the quality of PHC services, comparative improvement in PHC performance measures using other tools (e.g. PHCPI vital signs) consistent with the improvement in PHC facility ratings/reviews.

5-Star PHC will use the platform of Google Maps that is accessible to anyone with a smartphone. Therefore, we are not creating a new technology but instead leveraging on an existing platform and applying it to the assessment of PHC performance. For example, it is estimated that about 70% of the population of a country like the Philippines use a smartphone, which indicates the potential for high participation in the solution.

Our solution will require no additional data collector. Data is readily accessible from the ratings and reviews provided by people on Google Maps. The staff of PHC facilities review the feedback and address the concerns raised by clients. When the process of reviewing the feedback from Google Maps is integrated into the formal audit mechanism of PHC facilities, the staff of PHC facility are incentivized to regularly review their rating and improve accordingly. 

Our team, as part of the University of Bern, is governed by the overall university strategy for promoting equal opportunities and gender equality among staff. More about our approach to diversity, equity, and inclusivity here.

Our team is part of the University of Bern, which is a state-funded university in Switzerland and one of the leading universities in Europe. At the Institute of Social and Preventive Medicine (ISPM), we provide undergraduate and postgraduate education and carry out interdisciplinary research in the fields of social and behavioural health, clinical epidemiology and biostatistics, and international and environmental health.

Our core income is ensured by annual contributions from the Swiss government at federal and cantonal levels. We have a good track record of securing external funding from various financing instruments to expand our work. The seed money to pilot the solution will come from the grant to be secured from the Challenge. As our solution is the application of an already existing platform, there is no need to fund the development of new technology or the purchase of equipment. Sustainability of the solution is ensured by the ownership of the process by the PHC facilities, people in the community, and the government itself. In the longterm, we anticipate that sustainability of 5-Star PHC will be attained not really through a new revenue stream but instead through the institutionalization of the cycle of feedback and improvement in the performance measurement of PHC facilities with the support of an enabling policy by government.

The University of Bern undergoes financial auditing every year and our financial statements are published as part of the annual report, the most recent of which is available here.