ServiTrack

We are solving the generic challenge of poor performance of PHC considering the issue of poor quality data that do not inform actions to improve performance in service delivery. We are also focusing on collecting reliable and quality data as evidence to measure performance and inform actions for PHC performance improvement in service delivery. Irrespective of the service components of PHC, the quality of data generated about such services will inform actions for improvement. Innovatively, our solution will provide a simple strategy to document the quality of service delivery both in the public and private sectors. Currently, inadequate data generated and poorly reported statistics, especially in Nigeria are derived from public health institutions despite the large patronage of privately owned and managed health care institutions who also drive the health insurance schemes either for the national or state agencies. Importantly, Nigeria ranks low in PHC performance indicators as such also relates to a lack of data in many aspects of service delivery compared to many African countries, There are 16 service components in PHC, and the core performance indicators are based on inputs, systems, service delivery, and outputs with ultimate outcome of good health and wellbeing. Service delivery is measured from nine (9) perspectives. These are (i) Perceived access barrier due to treatment cost that measures percent (%) of client who self report problems in accessing health care due to cost of treatment; (ii) Perceived access barrier due to distance that measures percent (%) of client who self report that the distance they have to travel to receive medical advice or treatment is a hindrance to their care seeking behaviour, (iii) Provider absence rate that measures number of clinical staff actually present at the facility compared to the expected number of staff at a given time, (iv) Diagnostic accuracy that measures the number of cases correctly diagnosed out of number of patients seen out of number of patient examined as observed through clinical vignettes of multiple common options - this is used as proxy for provider competence impacting the clinical quality of care delivered to the patient, (v) Adherence to clinical guidelines - number of relevant history and examination questions asked by providers during clinical encounter compared to the total number of relevant history and examination questions that should have been asked, (vi) Case load per provider that measures the average number of out-patients visits seen by provider per day which has critical impact on service quality, (vii) DPT3 drop out rate measuring the gap between DPT 1 and 3 that measures the drop out rate (this will be substituted by other long-span immunization drop out rate in relevant immunization schedules that have population relevance e.g Hepatitis, Tetanus Toxoid for women or reproductive age, Vaccination against Cervical cancer); (viii) TB Treatment success rate among new TB cases- measures % of TB cases successfully treated and notified to the national immunization database (to be substituted with other communicable and non-communicable diseases that have relevance with drug compliance and adherence); (ix) Care-seeking for suspected child pneumonia - measures % of Under-5years old with suspected Pneumonia in the 2 weeks preceeding the survey taken to an appropriate health care facility. 

This project will be focusing on eight (8) indicators; four existing indicators (Provider absence rate, Diagnostic accuracy, Adherence to clinical guidelines, and Caseload per provider) and four (4) new indicators derived from adopting the human rights framework. Significantly, the new indicators relate to psychosocial measures of performance in the context of service providers' and users' satisfaction as such relate to their rights, obligations and responsibilities in healthcare management. Importantly, quality is seldom explored from the perspective of service users, this project will further explore and incorporate user-defined rights-based quality indicators. From another perspective, performances of service providers are also seldom assessed in the context of the respect for their rights in service delivery context. This framework offers universal attributes to conceptualize rights, obligations, responsibilities, and expectations for healthcare in the context of service provision and service reception by both service providers and service users. This ensures non-discrimination and equality, participation, and accountability in health policies, programs, and practices. 

Health workers currently generate data in paper-based format with inherent errors resulting in poor quality data. Service users are seldom involved in data generation to track and evaluate services received with the plan for quality assurance and improvement. We propose a technologically moderated audit and feedback mechanism Apps, (Servitrack) to holistically collect data from the dual systems of service providers, and service users on the three components of PHC performance indices - access index, quality index, and service coverage index from a pilot PHC centre in a State in Nigeria.  

The initiation and development of the main service delivery platform - the Total Care Management Platform (TCMP) (to which ServiTrack is to be incorporated) was a collaborative process between health professionals, community leaders, population groups drawn from the community and computer scientists. Total Care Management Platform (TCMP) is a multipronged app that contains software for health professional groups with expertise to manage the health care needs of individuals within population-group context. The app also has the client input component aimed at enhancing access to comprehensive care with the platform powering activities that cover health literacy and promotion, health screening guidelines and link to screening centers, monitoring of health status, health responsibilities and actions, referral for specialized care and support and general health care access for population groups considering three communicable and non-communicable diseases. ServiTrack is a plug in and second level app to leverage on existing partnerships that had evolved between service providers and users that initially focused on enhancing access to care. ServiTrack is an innovation that will remove the paper-based method of old in many PHC facilities, with a built-in reward system for both service providers and users to enhance a habit-forming behaviour towards the use of the app and spontaneous capturing of services provided and used using some indicators. The easy-to-use nature of the app on a mobile device will make it attractive to both service providers and users. The feedback mechanism provides added value, encouraging performance behaviour. It is also proposed to be leveraged to improve the capacity of all users, and ultimately improve the quality of care and outcome. 

Both service providers and service users would be involved in data collection with the added value of active participation of both service providers and users.

ServiTrack will serve two complementary targets, healthcare workers and healthcare service users. The healthcare workers are physicians, nurses, nurse-midwives, pharmacists, community health officers, community health extension workers, pharmacy technicians, laboratory scientists /technologists /technicians, and informaticians. The healthcare service users at the PHC level are males and females across the life span utilizing the PHC involved in the project. 

Currently, healthcare workers provide first-level care at the PHC levels in public and private facilities. Most of the time, they use paper-based data gathering tools that are time-consuming and only capture scanty data on a few diseases with little or no feedback to make meaningful decisions either to improve the quality of care or the process of service delivery. There is hardly an opportunity for service providers to have feedback on the quality of care provided as seen by the service users with the motive of using such feedback for performance improvement.

From the perspective of service users, they are seldom involved in service delivery appraisal and documentation with the aim of capturing the volume of services needed, services used, and the quality of services received. Service users also rarely have prompt feedback on performance indicators as such relate to health promotion, enhanced self-care, self-responsibility, and health care seeking and managing behaviour as such could result in improved health outcomes. 

The team comprises health professionals (in academics, policy, programmes, service delivery, and management) administrators involved in human resource for health capacity building and PHC services delivery, community representatives, computer scientists, informaticians, and, representatives of population groups using PHC services.

This project is building on an existing project, Total Care Management Platform (TCMP) which was a collaborative intervention involving healthcare professionals, computer scientists, and community members. This new project is an off-shoot of the TCMP that started by establishing relationships with the primary community with the constitution of the 20 member-Health Committee. The Health Committee has representatives of the stakeholders, including the community members who are service users and working together as volunteers to support healthcare delivery with health professionals in the health facility.  Health professionals and community members are working together to generate and track data on health and disease patterns, generate the community database, healthcare access database, and service delivery database. In developing and using the TCMP, community members are also involved in determining appropriate technology and engaging in capacity building to enhance their self-care and self-responsibility in achieving healthcare access at the PHC level.

The team has a challenge with finance to build on previous efforts that sought to advance universal health coverage by initiating a technology-moderated service package for expanded access to service delivery along the continuum of health literacy, health promotion, and healthcare. The current TCMP project supports access to limited services in PHC with little focus on PHC performance measurement. Financial support will facilitate bringing on board the dimension of improved access to more PHC services, enhanced service delivery quality improvement and performance measurement. Financial support will also facilitate scaling up and strengthening of e-health systems in PHC in Nigeria

Combined service provider and service user collaboration to further performance tracking for the purpose of service improvement in PHC is unusual and a trial model of furthering client engagement, especially in Nigeria. Motivating commitment to improvement by both healthcare service providers and service users will further drive quality and comprehensive data gathering to also bridge data gaps.  Data gathering in public and private primary healthcare service delivery facilities, a new model of private-public partnership in advancing quality improvement will provide better quality data in the context of volume, coverage, and comprehensive evidence that will speak to all aspects of service delivery in the 16 service components of PHC ultimately.  Data generation with in-built feedback model will also be helpful in the continuous capacity assessment and building loop targeting both service providers and users at the PHC level.

Successful implementation of the model for a few services would result in scaling up to cover all services in PHC.

The goals for the next year are: To successfully deploy ServiTrack in all health facilities involved in this study; To improve data quality; Increase data demand; Increase data use for decision making

The goals in the next five years are: To improve the quality of care; To increase client satisfaction; To reduce morbidity and mortality; Scale up the use of ServiTrack in all health facilities in Southwest Nigeria.

These are to be achieved in the context of specific activities outlined in the six (6) objectives of the project. These objectives are to:

1. Assess the existing data on PHC Service delivery performance indicators covering the 16 service components of PHC.

Activities: Review for PHC services performance indicators for the 16 service components in study sites.

(1. Health education, 2. Food and nutrition, 3. Maternal, child health and family planning, 4. Water and Sanitation, 5. Expanded programme on Immunization, 6. Prevention and control of locally endemic diseases, 7. Provision of essential drugs, 8. Control and treatment of non-communicable diseases, 9. Mental health, 10. Dental health, 11. Appropriate treatment of minor ailments and injuries, 12. Promotion of Occupational health, 13. Care of the elderly, 14. Care of the physically challenged, 15. Sexual and reproductive health. 16. School health services

2. Assess the extent to which services provided comply with the standard required of the service delivery performance indicators.

Activities:

(1) Review of Records of services provided over a year in 16 service areas of the project.

(2) Review of available guidelines and protocols for service delivery in the 16 service areas of the project

3. Develop performance indicators for measuring Health-related rights, responsibilities and expectations as new indicators of motivating health providers and users of PHC services for efficiency in service delivery 

Activities:

• Conduct survey among health providers and service users using rapid assessment techniques on knowledge, attitude and practices related to health-related human rights, obligations and expectations in PHC
• Conduct brainstorming sessions on ideal sets of health-related human right obligations, responsibilities and expectation
• Map out ideal indicators to data collection tools
• Create short list of indicators and share with experts
• Select core indicators for use in PHC service delivery performance

4. Develop ServiTrack to capture service delivery performance indicators from service providers and users

Activities:

• Collect data from service providers and users to development the Apps

5. Build capacity of service providers and users on the three (3) new service delivery performance indicators (human rights, responsibilities and expectations in healthcare for service providers and users

Activities

• Train Service providers on use of ServiTrack in the service delivery performance indicators
• Train Service Users on use of ServiTrack in the service delivery performance indicators
• Conduct Beta Testing of the Apps with Service providers and Users

6. Test the use of ServiTrack in capturing data on the 8 service delivery performance indicators from service providers and users

Activities:

• Conduct pre=post intervention study on the use and efficacy of ServiTrack to capture data on the service delivery performance indicators
• Disseminate findings 

Some of the measurable indicators that we would use to measure progress in the project include:

(1)availability of data to track the performance indicators on the 16 service components of PHC

(2) improved compliance of service providers with standard of service delivery”

(3) improved utilization of performance indicators for measuring rights and responsibilities of service providers 

(4) improved utilization of performance indicators for measuring rights and responsibilities of service users

(5) Increased utilization of ServiTrack for data capture

(6) Improved awareness of health service providers of their rights and responsibilities by  60% at the end of 5 years 

(7) Improved awareness of health service users of their rights and responsibilities by  60% at the end of 5 years

(8) Improved documentation of PHC service delivery indicators by 80% at the end of 5 years

Theory of Change for the Project

INPUT

Data on Service Performance Indicators

What are the services provided in the PHC

facilities in the study sites?

What are the PHC service performance

indicators used in the study settings?

What are the methods and processes

of data processing?

PROCESS

Develop ServiTrack

Use ServiTrack by Service Providers and Service Users

OUTPUT

Quality Data on Service Performance Indicators,

Increase data Demand

Increase data use, monitoring and feedback for nquality improvement

OUTCOME

Improved Service Uptake at PHC Facilities

Improved quality of care;

Increase client satisfaction

Scale up of the use of ServiTrack in all health facilities in Southwest Nigeria

IMPACT

Improved Health Status

of Population Groups and Individuals;

Reduced morbidity and mortality

Digital technologies have become central to enhanced access to healthcare at the primary healthcare level. Our project is maximizing the gains of digital technologies in healthcare by integrating Community-Family-Individual  Data Base into a dynamic health information sharing, education and communication in health and disease,  consultation, clinical management and support in the context of electronic health records. The ServiTrack is bringing the dimension of service provider-service user partnership in digital technology use for service improvement through a digital feedback mechanism. The digital feedback mechanism enables quick response with positive digital markers (motivators) for positive quality service indicators and alert (encouragers) to negative low-quality service indicators to both service providers and service users using performance indicators paying due attention to rights, responsibilities, actions to achieve optimal health outcomes.

Healthcare workers and service users. Every health care worker clocks service-related activity at the time of engaging in such behaviours. Every service user also clocks an activity that relates to service use.  

The primary motivation for this project is to facilitate access to health care to vulnerable populations in the context of economic, social, health and environmental, gender, and human rights-related limitations to access to healthcare. Many of these limitations are observed to expand vulnerabilities among population sub-groups, people with ethnoreligious, disability challenges, and families and individuals with social challenges in the State of focus. Representation of the stakeholders in the implementation of the innovation 

The project is adopting the integrated Model from diverse perspectives. As a digital app, it is combining the bricks (offline) and clicks (online) model of presence at all times using the ServiTrack as digitally moderating quality assurance apps to communicate among clients-service providers as partners. From another perspectives the Integrated model of a blend of social service cum business model is being adopted in managing the business of healthcare provision, monitoring, tracking, feedback for capacity building and quality service performance as values in this project. 

Diverse sources of funding for the deployment of the main platform, the Total Care Management Platform to which ServiTrack is to be harnessed are planned. beyond the payment of a token for use of the platform either by individual service user directly or through partnership with health insurance agencies either with service delivery at public or private institutions, the team also have a business component of supporting capacity building for deployment of digital tools for service enhancement.   

The team currently have a grant worth 30,000 Euro that is been used on the principal platform, the Total Care Management Platform, to which ServiTrack is to be harnessed. The team also will continue to expand the research-for-service orientation beyond resources generated from the services provided by members of the team.