Using citizen voices to improve Health care in East Africa

Public health care systems in East Africa are put under an enormous pressure to continue to provide good health care to an ever growing population. Approximately 88.13% of Ugandans living below 2 USD a day access health care through government facilities each year, which are at least 12 million people. Kenya faces similar challenges. There are about 4,700 health care facilities in Kenya that cater to the population of 44 million residents. The public sector serves more than half of these residents and accounts for about 51% of all health care needs. The reason public health care takes precedence over the private sector is the affordability at government owned health care facilities as prices are greatly subsidized, some services are even offered for free to residents. At the same time, public hospitals in Uganda and Kenya are severely under-resourced and provide services that are inefficient and corrupt.  These challenges include long waiting times, lack of medicines, lack of attention or respect from staff and absent doctors. The COVID pandemic has put an additional burden on the health care system: while serving more patients, protective measures and operating procedures have to be followed, which further affects the work environment of healthcare professionals. But if these professionals were incentivised to create a client-oriented environment, many challenges could be solved. 

There is also a lack of effective communication between communities and the health facilities that serve citizens. According to research conducted by the Uganda National Health Users’/Consumers’ Organization (UNHCO), there is low awareness of existing feedback mechanisms for patients (primarily suggestion boxes), many facilities don’t have a suggestion box at all and in places where they do exist many are never opened,. which deprives communities of the right to participate in the improvement of the services they receive and assume their position as stakeholders.

Equipped with the feedback data to find out which services and departments need improvements, health administrators can make a lot of changes to improve the quality of the services provided. The problem we’re trying to solve is that health facilities currently don’t use citizen feedback to improve their service quality, and are not motivated to make those improvements.

SEMA uses IoT feedback devices, installed directly at Health facilities. These devices bring in the majority of the data that we present back to public offices through a custom dashboard and monthly reports. On the face of it, this is only repurposing an existing solution (feedback devices, as one might find in airport bathrooms). The way we pitch SEMA in the public sector, though, is as follows: imagine you’re the Minister of Health in Uganda, with one of the lowest-quality and most corrupt police forces in the world.
Where would you start to improve it? You don’t have any idea which actual station is most corrupt, which is actually providing good services that can be used as a model, and most importantly, what’s happening right now, this morning.

The SEMA IoT system is revolutionary in the context in which it is implemented for the first time: public services in Ugandan. Our devices – and the dashboard that displays their data – provide a real-time, daily overview of which offices are succeeding or failing in real time. This means our theoretical Minister could log in every morning and immediately spot where the power is out, computer systems have failed, or a Health facility in-charge has not showed up to work.
When partnered with the in-depth, qualitative information gathered from face-to-face interviews, this makes an incredibly powerful tool for real, service-level day-to-day improvements to service quality.
Technically, there are several innovations we are extremely proud of with our devices.
First of all, the majority of device components are proudly made in Uganda. Our device shell is made locally, from recycled Ugandan plastics. A local entrepreneur gathers plastic waste from dump, and using a hand-powered plastics injection machine and a custom mould, presses each SEMA device shell at a cost of less than 2 USD per shell. The device stand (tabletop or floor stand) and visibility/marketing attachments are also made in Uganda at MoTIV, a local hardware innovation workshop.
Secondly, all firmware is developed in Uganda by one of the many talented software engineers in the Kampala ecosystem.
Finally, all devices are hand assembled in Uganda by SEMA’s own engineers.
These innovative aspects led to SEMA’s selection to present at Uganda’s first Government ICT Expo, where President Museveni met our team, examined the technology, and tweeted a photo of SEMA to showcase technology that was actually built for Ugandans and by Ugandans: “There will always be money to fund local innovations. Once you show that we can use it, we can then show the money.”

Our feedback tools allow any citizen to give feedback on their experience at a health facility. Evidence has shown our solution has a positive impact on the behaviors of frontline workers at health facilities. The solution SEMA provides equips public health facilities with the data they need to change staff behavior that improves service delivery to citizens.

Health services touch every single citizen. Millions of Africans are pushed into extreme poverty every year because of out-of-pocket and outpatient health expenses. Poor health services have been cited as one of the major challenges that Kenyans, Ugandans and Africans as a whole face. These challenges include long waiting times, lack of medicines, lack of attention or respect from staff and absent doctors. There is also a lack of effective communication between communities and the health facilities that serve citizens. Structures for data collection, reporting, and feedback exist at every level of the health care system, however their level of functionality is marginal.

At the primary health care level, where all data are captured and generated, health workers lack capacity in terms of skills to record accurate data, conduct the analysis, and effectively use the information for decision-making. According to research conducted by the Uganda National Health Users’/Consumers’ Organization (UNHCO), there is low awareness of existing feedback mechanisms for patients (primarily suggestion boxes), many facilities don’t have a suggestion box at all and in places where they do exist many are never opened, which deprives communities of the right to participate in the improvement of the services they receive and assume their role as stakeholders.   
It is exactly these facilities that do not have access to data on their own performance, don’t have enough staff and lack morale to improve their service delivery. 

The Ministry of Health in Uganda is however very keen on keeping staff motivated and monitoring their performance, they just don't have the resources to do so. Their interest in SEMA is high because we are the only provider who can offer them a competitive solution. At the same time, citizens visiting these facilities do not have a voice in evaluating them and feel disempowered. Bribes continue to be inherent in service delivery and disproportionately impact the poorest. SEMA has evidence that our presence reduces service-level corruption rates by 20% and has a direct effect on absenteeism, waiting times, friendliness of staff and discrimination. All of these elements affect the lives of people visiting public health clinics.

Our main impact metric is improved health service delivery, measured through an increase in satisfaction levels as reported by citizens. Impact measurement for SEMA further consists of monthly follow-ups to track whether health public officers:
Have used the SEMA citizen feedback reports in their team meetings, shared the reports with colleagues, and/or hung them on public notice boards for citizens to see;
Have made concrete improvements to their office or services based on the SEMA citizen feedback reports (i.e. improved the waiting area, changed staff, provided a training)
Have changed their attitude or behaviour towards citizens (i.e. come more often on time, smile more often, etc.)
These factors are recorded in the SEMA Impact Dashboard. This dashboard also tracks automatically whether citizen satisfaction and waiting times improved at an office over time. Together, these factors help us to determine whether services are improving and offices are receptive to the SEMA system.

SEMA is a team of community activists, feminists and civic leaders. The core team currently consists of 10 full-time employees, mostly based in Uganda. We have one Operations Manager in Nairobi who is building our Kenyan office and has extensive experience working with data and government partnerships. We also currently have over 60 data collectors(youth) who are engaged with SEMA on a Traineeship contract and receive reimbursements for each shift they do to collect data (both in Uganda and Kenya). SEMA’s Board of directors consists of 4 non-executive international directors, and 2 executive international directors. SEMA also has an Advisory Board of 5 Ugandan experts. 

The SEMA team has combined experience of over 40 years and is dynamic and talented in building and sustaining an innovative solution for community development. Every team member is involved directly from the start of a journey with a public institution until the point of measuring impact. Each team member comes from a different cultural and educational background and hence is able to bring diversity to the team. 
The team has developed skills over time with the engagements of different public institutions which include, technology development, citizen & public officer engagements, research and impact tracking.

The SEMA team will deliver and scale this product and take it to the next level because the team takes joy in learning what works and what doesn’t when trying to improve public service delivery and since 2018 the team has continuously tested various data-to-action strategies that provide different incentives to public offices in order to improve service delivery, foster transparency in public offices and enhance mobility from different stakeholders.

The SEMA system of IoT devices, face-to-face conversations, and at-distance survey techniques has been used by over 255,000. 

It’s not only about how many people used the system, it’s about what happened as a result. Our data to action strategies (available at www.taktosema.org/data-to-action) have transformed this citizen participation into real impact. We have measured that 70% of offices that use SEMA make concrete, measurable improvements to service quality, and 80% of offices that use SEMA reduce their waiting times for citizens.

Beyond the numbers, many offices make meaningful improvements. One station used SEMA’s data to make the choice to re-assign desk staff so that female clients would only be helped by women officers. Another station chief noted: “The presence of the SEMA device is the way I remind my staff to always treat people well!”

We have secured financial support from four public sector clients in Uganda (the Ministry of Justice, the Kampala City Authority, the Ministry of ICT, and the Financial Intelligence Authority), as well as two private sector clients and seven donor supporters. In 2019, SEMA received the International Anti-Corruption Excellence Award from the President of Rwanda and the Emir of Qatar.

This is a pivotal moment for SEMA to test and transition its model to serve at a bigger scale with public health facilities in Uganda and Kenya. The budget we’re looking for in order to scale up across 50+ health facilities in both countries, benefiting 1 million citizens after 3 years, amounts to € 100,000 USD. We expect to use this budget in a period of 18 months to also continue to improve our data collection/delivery system, to lower the cost of our product, expand our ‘sales’ in both the public and private sector, and with our results build on behavioral science research in partnership with the Busara Centre for Behavioral Economics.

SEMA’s system is designed for the Ugandan user. Our locally made push-button devices and face-to-face interviews are accessible to every layer of society, including citizens without mobile phones or internet access. We design our systems in a way that meet people where they are, not where Western digital platforms hope they’ll be. This creates our unique selling proposition: quantitative and qualitative data that has proven to help public offices with making real improvements to their service delivery.

Existing alternatives to giving feedback at most public offices for citizens in East Africa include suggestion boxes, which the World Bank notes are “reportedly not systematically analysed or acted upon.” Secondly, government bodies regularly deploy performance/household surveys, conducted on average 3 years and costing millions of dollars. Neither alternative provides real-time or office-specific data. Tech platforms that have tried to launch in Uganda or Kenya and failed include IPaidaBribe, AskYourGov, and WeSpeak. These platforms have failed either because of 1) low usage by citizens, often by taking an overly-digital approach; or 2) inability to turn feedback into actual service improvements.

Health facilities hardly ever receive feedback on their own office performance and therefore don’t feel accountable to the needs expressed by citizens. No change is expected to happen at the service delivery level if civil servants are not addressed directly and incentivised to improve. When perceived criticism on public service is handled fairly, transparently and in a timely manner, reputation and image are enhanced, staff morale improves, public confidence in government grows and most importantly, public servants know what changes and interventions are necessary to improve public services.

SEMA introduces feedback tools at local public offices, such as health facilities, municipality offices and police stations. We gather feedback through two ways. Firstly, we deploy locally-produced IoT feedback devices, which by one press of a button (a happy or sad smiley face) allows any citizen, regardless of their literacy level or mobile phone usage, to give feedback. Secondly, we conduct on-site in-person interviews through a student-run network of data collectors. Through these interviews we gather deep and rich feedback data in local languages on why citizens are happy or unhappy with the service. Every month, we present the feedback to local civil servants in one-pager score reports with rankings. Our behavioral science approach and impact are what makes our solution unique and powerful.

Through SEMA, citizens have an active voice in evaluating their local public institutions, such as critical justice and health services, and hold them accountable to provide fair and nondiscriminatory services. The result based on this feedback loop are behavioral changes at the staff level that improve service delivery at health and other critical service facilities citizens rely on every day. We expect in the long-run our solution will highlight the importance of behavioral science mechanisms to improve service delivery and create more incentivized, accountable and transparent critical public and private services.

1. Ensure transparent and accountable institutions at all levels of government (SDG 16.6). 

To improve the confidence citizens have in sharing their opinion about health service delivery, by showing them that feedback matters. The next time they visit a local hospital, they will notice the service has improved. Our expected outcomes therefore are an increased number of citizens sharing their feedback at hospitals, and improved health service delivery at more public health facilities in East Africa. 

In guiding our key indicators, we are guided by our theory of change. Our key indicators include:

• Number of concrete actions/improvements offices report to make as a result of citizen feedback.
• Number of citizens reached to gather feedback. (This demonstrates SEMA’s reach to the citizens that receive different public services). 
• Improved performance by public servants to meet the needs of citizens. (This is obtained from data and evidence from feedback mechanisms that inform decision-making (they use reports in meetings, share results with others, compare results overtime and have targets to be met).
• Updated existing client care systems towards better service delivery.
• Management implements changes that can improve services systematically (new policy guidelines, budget allocations).

The SEMA feedback mechanism supports achieving the long term objective of improving the quality of services at public institutions, in particular health facilities. Causal chain:

Ultimately we find that the key to creating impact in the public sector is the relationship building and hyperlocal reporting that happens at the local office level. It is extremely rare in East Africa that feedback is given directly to the local office. Most public sector assessments are done at a national level, and delivered to HQs. What sets the SEMA feedback system apart is that it is entirely built on a hyper-local approach.

By gathering qualitative and quantitative feedback data from citizens, and delivering it in easy-to-understand reports and by creating behavioral incentives to local civil servants at health facilities, we are able to create service-level improvements executed by the local offices, leading to improved service delivery experienced by more citizens through reduced wait times, bribes, less discrimination and more resolved problems.

We define technology broadly as the application of science and evidence-based knowledge to the practical aims of human life. For MIT Solve and our mission to drive innovation to solve world challenges, it’s important that your solution is using technology to solve a problem facing your community and/or the world and seeks to benefit people and the planet. We welcome solutions that are using apps, SMS technology, software, AI, robots, drones, blockchain, and virtual reality, and what you might commonly think of technology in this modern era! We also welcome solutions that are leveraging traditional, ancestral and natural technologies, and knowledge systems. That could be using centuries-old irrigation or building techniques, plant-based solutions that can reduce the effects of climate change, biodegradable sanitary pads, and so much more.

Our solution is a hybrid of an IOT and SaaS application. The SEMA feedback device is an IOT device with a five point scale where clients in public offices can rate the service provided at these institutions. The data is stored on the device and then uploaded to the cloud servers(databases). The other part of the feedback system is the dashboard which uses the Saas architecture. The dashboard is used internally by the team to maintain the devices and externally by the public institutions to track client satisfaction in real time. The SEMA dashboard uses the data that was uploaded to the cloud servers from the feedback device to break down data into different insights that can enable public officers to make better decisions on improved services.
The code for all our applications is internally maintained by the technology team and is not open source.

SEMA touches on matters of community participation through encouraging all groups of people including women, non citizens to provide feedback on the services that they have received from Health centers. We aim to achieve equal participation through ensuring that our data collectors engage a representative number of women and men at the public offices we work with. While we engage with the population, we carry out community outreaches aimed to teach the public about the benefits of providing feedback and the relevance of the feedback system.

In addition to this, we seek to address matters of knowledge sharing among women by encouraging female university students to take part in our traineeship program. Half of the students that we engage with are young ladies in the community without work experience. We provide them with training in basic tech and device maintenance, communications, research and project management as well as data analysis. Trainees who have gone through our program have reported having more confidence when they visit public offices and having gained the ability to provide feedback on the services that they receive.

There are two customer segments that are important to understand in order to get a full picture of SEMA’s go-to-market strategy: public and private sector clients. Revenue streams from public clients consist of ministries, municipal and city government. Revenue streams from private clients include corporations with many brick-and-mortar locations (private health facilities), and smaller, social enterprises seeking to track their impact (sales, medicine distribution points).

Public sector sales cycles are remarkably long: up to 2 years to make a single sale. SEMA’s understanding of this sales cycle is what sets us apart as a market leader in Uganda. We first conduct free pilots to prove the impact and value of the system, funded by donors and awards. We time this pilot to conclude just prior to budget negotiations for the following fiscal year, so that we can make our strongest case for a SEMA budget line or a public procurement process. The strongest channels for initiating contact in both public and private sector sales will continue to be personal and professional connections. This is why a great deal of business development time at SEMA is devoted to networking, developing local boards, and seeking exposure opportunities such as the International Anti Corruption Conference, where SEMA has been represented since 2018, and events such as the Ugandan ICT Expo, where SEMA presented in 2019.

To become financially stable, we are now having government institutions pay for the service for example to measure at Health centers in Kampala, the Kampala Capital City Authority has had to pay for the past two years for SEMA to collect this feedback. The ministry of Justice and constitutional affairs as well. 

Our finacial sustainability has been successful as we have received grants and awards and also signed contracts with government institutions to measure  feedback at government institutions.

Examples of grants received in the past include;In 2018, SEMA raised approximately $42,000 in our first year of operations. This first year was 100% donor-funded: primarily, two foundations in the United States and Europe.

In 2019, SEMA raised approximately $173,000 in our second year. For the first time, this included direct payments from a government ministry (the Ministry of ICT of the Government of Uganda) to introduce the SEMA system at public offices. We also expanded and diversified our donor base to include Africa-based foundations.

In 2020, SEMA raised approximately $320,000, coming from both public and private sources and including the Anti-Corruption Excellence Award funds. During 2020, we signed our first contracts with the Kampala City Authority, the Financial Intelligence Authority and the Ministry of Justice. This annual amount also includes our first private sector revenue for data-gathering at public healthcare offices during COVID.

In 2021 and 2022, SEMA had running contracts with Kampala City Capital Authority and the Ministry of Justice and constitutional affairs for about UGX 290,000,000. During the two years we also received funding from USA for approximately $240,000.

At current funding levels and with the signed contracts we have on hand, we have runway to continue operations in Uganda until September 2024.