People's Voice Survey

A high-quality primary care system consistently provides care that improves or maintains health, is trusted by the people, and responds to changing population needs. To understand whether the primary care system is meeting these goals, it is critical to understand the experiences and perspectives of the people whom the system is intended to serve. However, in many low- and middle-income countries, governments and facility managers currently do not have any information at all on the population’s experiences and perspectives. When people’s voices are not heard in primary care performance measurement, governments and policymakers lack critical insights for health systems improvements, including information about the dynamics of how the population uses (or does not use) the primary care system, the coverage of key primary care services, and the population’s trust and confidence in the system. 

The PVS is a phone-based survey designed to integrate people’s voices into primary care performance measurement. It enables rapid assessment of primary care performance from the population perspective to inform health system improvement. It includes information on utilization patterns, coverage of primary care services, perceptions of health system quality (i.e. user experience and care competence), and trust in the overall health system. By using mobile phone-based data collection, the PVS can be deployed rapidly to provide timely and locally representative data on health system performance. With the PVS, locally representative and immediately relevant data on health system performance can be generated in less than a month once the appropriate systems have been established. This information can be used by the population and advocacy groups to advocate for health system improvements, and by governments and facility managers to inform system reforms and track performance over time.

By amplifying the voices of the populations whom primary care systems are intended to serve, we aim to shed light on gaps in health care service quality, improve system accountability, and, ultimately, improve the performance of primary care systems.

Our solution therefore serves populations in low- and middle-income countries by incorporating their perspectives into primary care performance measurement and improvement efforts, enabling a people-centered approach to primary care improvement.  It can bring attention to inequities in the population’s experience of the primary health care system, and raise public awareness of health system challenges so that the population can demand change. Our solution also serves governments and facility managers by providing them with (almost) real-time information on system and facility performance, and allowing to them compare performance over time or across regions and countries. 

Our project team is comprised of researchers at the Swiss Tropical and Public Health Institute (STPH), the University of KwaZulu-Natal (UKZN), the Lao Tropical and Public Health Institute (Lao TPH), and the University of Zambia. We are part of QuEST, a global Research and Development (R&D) network for health system innovation, with a primary objective to develop measurement tools that capture health system quality to inform health system improvements. Our team members have deep expertise in health systems research in the settings where we work. We also work closely with national governments as well as regional and international organizations to ensure that the findings of the PVS are suitable for use informing policy decisions and in evaluation of programs to improve health care access and quality.

Along with the other members of QuEST, we began developing and rigorously testing the PVS in 2020, and we are now working to scale it up, aiming to demonstrate its feasibility and relevance to key decision makers in LMICs. We have conducted workshops and discussions on the PVS with a wide range of national, regional, and global-level stakeholders. Survey development included rigorous testing through cognitive interviews in 11 countries (Kenya, Ethiopia, South Africa, the United States, Peru, Uruguay, Columbia, Laos, China, Cambodia, and Mexico) and pilot studies in eight countries (Kenya, Ethiopia, South Africa, India, Peru, Uruguay, Columbia, and Laos). Early findings from the PVS shed light on important patterns in bypassing of public primary health care systems, and gaps in trust and confidence in public primary health care systems. Building on our experience to date, we are prepared to scale up the use of this tool across many settings. 

We aim to develop the PVS into a highly accessible and widely used tool to maximize impact on health system performance worldwide. We are applying to MIT Solve for support as we further scale the PVS, demonstrating its value to policymakers in Zambia and Laos, two countries which are highly representative of LMICs in Sub-Saharan Africa and Asia.

If we receive support from MIT Solve, we plan to expand our work on the PVS into a new domain: the measurement of primary care performance specifically in urban settings. While our current work focuses on creating national-level snapshots of primary care performance, we believe that large-scale implementation of the PVS specifically in urban settings would demonstrate another high-value use of this tool and provide important insights to policymakers.

We plan to implement the PVS in Lusaka, Zambia and Vientiane, Laos, two highly-urban capitals with very high mobile phone density and active patient populations. In these settings, the PVS can enable mapping of where people seek care (e.g., identifying patterns of bypassing of public primary care systems), measurement of inequalities in health care access and utilization in urban populations, and identification of high- and low-performing health facilities from the perspective of the population. Due to high mobile phone density in these two cities, it will be possible to achieve a high level of granularity in our measure of system performance with large samples (target sample size of over 2,000 respondents) within a short period of time. We aim to demonstrate to policymakers the potential value of rapid and, potentially, repeated mobile phone survey measurement of primary care in urban settings.

At the moment, there are few rapid and comparable instruments for tracking primary care performance, and the tools that exist do not focus on the population perspective. Existing efforts to measure performance include assessment of users of health at specific facilities (e.g., patient exit surveys), which fail to capture perspectives of those who are not receiving care; and periodic cross-sectional household and facility-based surveys (e.g., Demographic & Health Surveys and Service Provision Assessments), which tend to be expensive, slow, and infrequent, and very limited in their scope. Existing tools omit important dimensions of primary care performance measurement such as user preferences, confidence, and trust in the system.

The PVS provides a rapid and affordable way to collect data from a representative sample of a population (e.g., at the national, regional, or municipal level). It provides insights from the perspective of the population, rather than the perspective of the health care delivery system. By surveying the general population, we are able to learn both about health system users and about non-users. The PVS can provide insights that are comparable across settings and over time, allowing countries to benchmark performance to others in a clear way and track the impact of health system reforms and policies over time. Furthermore, the PVS rigorously measures user confidence and trust in the health care system, which are critical aspects of health system performance measurement. Developed by an international team of health system experts with input from policymakers and practitioners, the PVS has been designed so that it will be suitable for use in national and local policy decisions and in evaluation of programs to improve health care access and quality.

The PVS has the potential to change primary care performance measurement in a sustained way. We plan to make all PVS materials publicly available, so that this tool can be used by any group worldwide. We have already seen significant demand for PVS results from national and regional-level stakeholders; as we further scale this solution, our goal is for the PVS to be implemented on a regular basis in many LMIC settings for more responsive primary care systems.

In the next year, we will begin to implement the PVS in an additional eight countries. We will share results from the PVS with policymakers at the national level in all participating countries, and at regional and international levels through presentations to regional bodies such as the Pan-American Health Organization (PAHO) and international bodies such as the World Health Organization and the World Bank.

In the next five years, we aim for the PVS to be implemented in a growing list of countries, for PVS implementation to be repeated in the early adopter countries in order to measure changes over time, and for results to be discussed in national health system planning meetings and global health policy discussions. We will achieve this by bringing new collaborators into our network, strengthening our relationships with key stakeholders, and sharing our materials publicly such that the PVS can be implemented by any group that is interested.

Our ultimate impact goal is for the population perspective (including needs, satisfaction, facilitators and barriers to access and utilisation of services, and confidence and trust in the primary care system) to be a routine input in health system planning, leading to more responsive primary care systems. With insights from the PVS, policymakers will be better equipped to design people-centric health system reforms, and populations will have greater trust in their health systems, recognizing that their perspectives are heard.

We will measure impact using a set of indicators that measure outputs, short-term outcomes, and long-term outcomes. These include:

Output indicators:

• Number of countries that implement PVS
• Number of countries that conduct repeated rounds of PVS to track changes over time
• Policy briefs, scientific manuscripts, and presentations sharing results from the PVS

Short-term outcome indicators:

• Number of cases in which the PVS results are discussed in national health system planning fora
• Number of cases in which PVS results are used by an advocacy group at the local, national, regional, or global level to advocate for improvements in primary care systems

Medium-term outcome indicators:

• Primary care policy changes in countries implementing PVS focused on addressing needs and issues raised by the PVS

Long-term outcome indicators:

• Levels of user satisfaction and trust in the health care system in countries implementing the PVS
• Coverage of essential primary health care services in countries implementing the PVS (aligned with SDG indicator 3.8.1)
• Improvements in health outcomes in countries implementing the PVS (aligned with SDG indicators 3.1-3.7)

We believe that providing accurate and timely information on population perspectives can help governments and health facility managers improve their services and help them to better meet their populations’ needs. To achieve this ultimate goal of better care, several steps are necessary:

• Demonstrate the value of collecting data on the population perspective
• Show the feasibility of fast and low-cost data collection using PVS in low income settings
• Help governments integrate these surveys into their routine operations

In order to achieve these critical steps within our theory of change, we propose the following activities and outputs

Activities:

• Development and rigorous testing of the PVS
• Implementation of the PVS in low- and middle-income countries
• Analysis of data from population perspectives on primary care performance from the PVS; mapping of health system utilization patterns

Outputs:

• Clear and actionable insights from the PVS presented to policymakers in health system fora in low- and middle-income countries, as well as regional and international bodies
• Policy briefs summarising findings from the PVS and presenting key insights to inform primary care system improvements
• Scientific manuscripts summarizing findings from the PVS and presenting innovations in primary care performance measurement
• Publicly available survey tools and documentation supporting further implementation

Ultimately, we want to achieve the following outcomes:

Short-term outcomes:

• High quality data on primary care performance from the population perspective is discussed in health systems planning fora at local, national, and international levels
• Populations and advocacy groups are equipped with information to hold policymakers accountable for gaps in primary care system performance
• Policymakers have greater visibility on challenges in their health systems

Long-term outcomes:

• Health system reforms are designed to address problems raised by the PVS and make primary care systems more responsive to population needs
• Primary care systems in low- and middle-income countries deliver higher-quality care

Our solution uses mobile phone technology. As mobile phone coverage has increased in low- and middle-income countries, mobile phone surveys have become an increasingly feasible and effective way to reach the population and gain valuable perspectives on the performance of public services such as the primary health care system. The latest data suggests, that > 90% of households in LMICs have a cell phone now, and newly available central mobile phone registries make it possible to call mobile phone owners at random.

Relative to traditional household surveys, mobile phones provide a much cheaper and faster way to collect data. Relative to surveys based in health facilities, mobile phones allow us to collect data from a sample that is representative of the full population, rather than representative only of health system users. This is critically important because it enables us to understand the perspectives of those who have chosen not to seek care in the public health system, and work on understanding why. Many data collection efforts had to turn to mobile phone surveys during the COVID-19 pandemic; this experience has created a trove of knowledge and tools for performing these surveys to a very high standard. Our work on the PVS incorporates these lessons. 

Data are collected by trained data collectors using mobile phone survey technology. To date, the PVS has been implemented using different approaches: in some settings (e.g., Kenya), it is being implemented by contracting with private mobile phone survey companies; in others (e.g., Laos), we have directly employed a data collection team and established a local call center.

In each country where we implement the PVS, our work is led by local institutions with the support of the broader QuEST Network, in an approach that aims to center those who have true expertise in the health systems they are studying.

The PVS itself conducted in a manner to ensure that historically marginalized and disadvantaged groups are represented. For example, in Laos, the survey is being conducted in three languages to ensure that minority ethnolinguistic groups (historically excluded from public health research) are included. In addition, wherever possible, questions have been written in an inclusive manner, such as by including additional options for gender beyond “male” and “female to reflect the non-binary or transgender population that has historically been excluded from this type of work.

Findings from the PVS will also focus on shed light on inequities in health system performance, such as inequities in waiting time by socioeconomic status; inequities in user satisfaction by geographic region; or inequities in health system confidence by gender. We aim to ensure that advocacy groups and the broader public are equipped with information about the inequities in their health system so that they can demand change.

The PVS is currently supported by grant funding from different global health donors and institutions. This support has enabled us to develop and rigorously test our tool and begin to implement it in several countries. We plan to use further funding to implement the tool in different settings to further demonstrate its value. We will then ensure that all materials needed for PVS implementation are available as a public good so that it can be implemented by any group that is interested. Our goal is that, in the future, policymakers will demand the information available in the PVS, and donors and governments will be willing to fund it in different settings in an ongoing manner. 

Once the proposed concept has increased in visibility and there is sufficient demand from end users (policy makers, governments, international organizations), we expect that minimal funds required to curate the tool online and support other groups in implementing it.

To date, the PVS has been supported through grants from the Bill & Melinda Gates Foundation, the Swiss Development Corporation, and institutional funding from the Swiss Tropical & Public Health Institute. Interest from other groups in also conducting this (e.g., the European Union and the World Health Organization) suggests that further funding will be forthcoming and demand may continue. Ultimately, we hope to demonstrate that the data created by this system creates enough value for national governments to justify integrating these surveys into routine MoH operations. This will be feasible at a relatively low cost because we will make all PVS materials available as a public good, and PVS implementation benefits from the low-cost nature of mobile phone surveys.