Sikivu

Delivering high-quality health services is a critical component of achieving Sustainable Development Goal 3, which aims to promote good health and well-being worldwide. Poor health services led to high mortality, high morbidity, diminished economic productivity, and eventually poverty.

In order to combat these ill effects, Tanzania, with a population of over 50 million people, has implemented a number of plans to expand health services (Vision 2025, Health Sector Reform, Health Sector Strategic Plan III, Primary Health Services Development Program, etc.), but in addition to the quantity of healthcare available, the quality of healthcare needs to be addressed to improve health outcomes performances.

According to the National Bureau of Statistics in Tanzania 2020, there are approximately 7,163 dispensaries and 926 health facilities throughout the country that are providing health care services to over 50 million people. Primary health care facilities in Tanzania on average were staffed with 13.1 health workers. Urban primary health care facilities had more staff (24.5 providers) compared to rural facilities (6.0 providers).

Public facilities had fewer staff members than their private counterparts. Over half (55%) of health workers were nurses. Although only 10% of Tanzania’s population lived in Dar es Salaam, the city was home to 45% of all doctors. In contrast, 70% of the population and 85% of the poor lived in rural areas but they were served by only 28% of the country’s health workforce, and a mere 9% of its doctors. These stark service delivery inequalities are likely to translate and even reinforce welfare inequality.

Millions of local communities in Tanzania rely on primary health care services that are inefficient, ineffective, and oftentimes corrupt. This is a huge problem since primary health services are essential in the lives of local communities: think about the pregnant mother who walks long distances for facility delivery or A patient who missing essential medicines from primary health care and buys them at a higher price in private pharmacy.  The problems are as follows:

A.Lack of trustworthy feedback mechanism: Patient experience is a core component of primary health care performance improvement. The ability of patients to communicate their experiences and to read reviews about healthcare services is an important process that is vital to the overall improvement of the healthcare system. However, relies on the existence of a trustworthy feedback mechanism.

B.unaware of the proper channels to offer feedback about the performance and quality of primary health services: Community members visiting health facilities are unaware of the proper channels to offer feedback about the performance and quality of primary health services that they receive and health facility authorities are unaware of the issues faced by the community when accessing health services.

When patients know where quality health care can be found and providers have direct insight into what needs improvement the system as a whole can advance. For this to take place, however, health care users and providers must have proactive not only in generating and collecting feedback but also in interpreting and using that data to inform actions. Currently, in Tanzania, there is no transparent mechanism where patients and the general public can express their healthcare experiences and access the experiences of others.

Lack of a platform to facilitate communication between patients and medical staff prevent quality improvement in health service delivery. Moreover, without a platform to share community feedback, primary health facilities lack data about their performance, and quality of health service delivered by facilities and cannot leverage feedback to inform resource mobilization and timely intervention.

To improve this, the government introduced “Sanduku la Maoni”, (a Swahili language phrase meaning “Physical suggestion box”)- which refers to the box attached to the wall as the physical system for collecting and aggregating the patients and local community client feedback at public-sector primary health care facilities.

However, 90% of this physical existing system is ineffective, lacks transparency, and fails to provide information to the community at large. There are several barriers limiting patients and  local community clients from providing feedback on primary health care performance and quality through suggestion boxes:

• Lack of confidentiality and Fears: Since suggestion boxes were positioned in open areas, health facility users hesitate to use them for fear of negative consequences in terms of health services they could receive after being noticed by healthcare providers who might punish them. These systems are not anonymous nor easy to access.
• Mistrust of primary health care facility Management: Since the suggestion box is managed, handled, and supervised by the health facility in charge of the health facility in question, it is possible that the complaints may not reach the intended organs responsible for handling the complaints.
• Corruption/ Demand for bribes and Illiteracy: Rather than make the effort to seek better services, some local community clients would consider paying a bribe to hasten the process. Inaccessible options for feedback: There is little consideration for language barriers and for people living with disabilities, who are mostly. Many of the rural area dwellers cannot read and write. This state of illiteracy makes it difficult for them to participate effectively in channeling their complaints through the most commonly used means—the suggestion box, which requires that they write down their complaints and possible suggestion.
• Time-consuming:  Health facility users are not comfortable with the use of the suggestion boxes as it takes a long time from the date when they deposit their complaints to the time their complaints reached members of the health facility committees. In addition, some health service users complained that they did not even see the envisaged or desired changes in the health service delivery despite the previously made suggestions/complaints they
• Unstructured and difficult to analyze the feedback data from the suggestion box: Healthcare workers and officials often seek out more patients and local community client feedback but this is unstructured and difficult to analyze. Therefore, client feedback may only be reviewed a few times a year and receives insufficient attention in decision-making and planning processes. The Tanzanian government has a goal to collect feedback from 50% of clients by 2030.

There is no transparent mechanism where patients and the general public can express their health experiences and access the experience of others. Patients and local community clients have an instilled fear of consequences from raising any concerns on primary health care services. This is more so when the local community clients are not assured of their anonymity when they give feedback at a primary health facility. “If you visit a primary health center in Tanzania, there is no anonymous way in which you could easily share your experience at the center, except for dropping a handwritten note in a wooden suggestion box. Since community doesn’t have an independent platform to raise their voice, local governments ignore their needs and can’t detect where the problems are”.

For instance, if a patient makes a complaint through the suggestion box on absenteeism among medical professionals, poor quality of medical service, and a lack of accountability between the people who provide medical services and the people they are serving, it is the same workers who also manage the suggestion box hence the chances of the complaint ever reaching the disciplinary organ are slim or simply nil.

Such complaints, they said, ended up being dumped at the same health facility without ever reaching the intended target, and hence no immediate actions are taken to redress the situation. This situation causes apathy among service users as they don’t get feedback and they don’t experience any changes. Patients believe that their welfare is not a priority for primary health facilities. This not only demotivates patients from giving feedback on the services provided but also from accessing these services in the first place.

Moreover, Primary health facilities in rural areas are the most limited access to health infrastructure resources: (including trained healthcare workers, inpatient hospital care, and information on available services). The understocking of essential medicines & supplies in most public primary health facilities leads to unnecessary suffering and even deaths of innocent community members. Local community members who are in need of medicine and medical supplies currently have no way to know whether what they need is available locally. To find out they must go to their nearest health facility and wait often for hours and sometimes only to discover that the medicine they require is not available. When this occurs, a private pharmacy may be their only option but only if they are able to afford the higher prices. 

These data remain largely inaccessible to primary health care facilities supervisors. The current system is inefficient it cost time, money for community members, and even life. These problems result from the lack of a platform to provide real-time data relevant to necessary supervisors for proper and timely decision-making. Accurate information on these services is scarce, and large-scale surveys are expensive to implement. As a result, both community and local governments - who often cannot afford to send monitors out to remote areas - struggle to piece together an accurate picture of health services, and of where and how services should be improved.

Sikivu is a Swahili language phrase meaning “responsiveness”. This is a digital patient-centered and community platform for primary healthcare facilities which uses simple, replicable, low-cost user-friendly data collection technology tools (Unstructured Supplementary Service Data- (USSD) or open-access Open Data Kit) uploaded to mobile phones that allow patients and local community clients to give anonymous, real-time, and reliable views and feedback about their experiences of using the primary healthcare facilities. This will inform two-pathway responsive communication decisions between primary healthcare patients, health facility service providers, and local and national government institution's decision makers/supervisors’ levels which ultimately leads to improving the performance of primary healthcare outcomes for all communities. 

This includes decisions about how to better reach marginalized patients, monitor, and improve the quality of primary healthcare services performance, prioritize resources and activities, and engage in performance improvement.

Our platform can be broken down into three components, data collection from clients, data analytics of the feedback, and the creation of tools for decision-makers

• Data collection from patients and local community users of primary healthcare facilities.  They use their own mobile phones to provide feedback anonymously about their experiences. We enable this data collection and transfer a crucial step to increase primary health care performance and improve the quality.
• Data analytics of the anonymous views and feedback about the experiences of using primary healthcare facilities: We aggregate, visualize, analyze and share the patient's and  local community users’ data on a real-time and local basis
• Creation of tools for decision-makers: We provide insights to healthcare workers and public health decision-makers on the importance of the use of high-quality data for performance improvement and monitoring helping them to take timely actions to optimize the performance and improve service. We believe that greater use of performance data will result in positive gains in primary health care services effectiveness, efficiency, quality of service, coverage, and equity.

Sikivu aggregates these digital data over time across last-mile primary health facilities in remote rural geographic areas to analyze how patient experience differs. After data analysis from these primary health facilities, the report will be presented to their medical supervisors in digestible and customized patient performance feedback to understand how these primary healthcare facilities perform. This will enable government supervisors to better monitor performance, identify key challenges make decisions on how to adjust service provision, and help them better manage health resources & supplies.

Patients and local community users of primary healthcare facilities: Those living in low-income areas will benefit from quality care and good performance from primary healthcare facilities. They will have a medium to share their concerns on the quality of health service delivery and to receive feedback on actions taken by the health facility authorities to address these concerns. This feedback loop will increase their trust in the health system and foster collaboration to improve health service quality.

Primary healthcare facilities providers and their committees: Health service providers will be aware of the community’s perception of their services and areas for improvement. This information will facilitate better allocation of funds and planning prioritization. Our solution helps primary health committees within their facility with performance supervision processes by helping them to identify priorities, monitor gaps, and solution

Local government primary healthcare officials: The Feedback data can be used by Local government healthcare officials and healthcare workers to improve the quality and performance of the facility by identifying high-priority issues for improvement and necessary action plans

Elected political leaders (Village leaders, Ward leaders): Our solution builds Patients and large community trust in the primary healthcare system, making them more likely to use the quality services which are available to them and Increasing utilization of services by Community members. Feedback data can be used to improve Primary health facility Budgeting and resource allocation for more effective performance and monitoring of existing resources.

The Ministry of Health (MoH) and donors: Will be able to use data on limitations to high-quality healthcare access in specific communities to rate health facilities and mobilize resources for quality improvement. The community feedback data can be made available to donors or other stakeholders interested in improving healthcare services in Tanzania, and this data can inform their priority areas of focus and related funding decisions. We believe performance can be driven through a number of networks, at a low cost and by integrating into existing decision-making processes.

We are located in the community where they receive their healthcare services in primary healthcare facilities. The team has combined experience working in primary healthcare performance measurements. Our deep roots in primary healthcare give us a clear understanding of the ordinary patient’s experience, culture, and the community users that shaped primary healthcare services. All our team members personally get their health services in primary healthcare facilities and personally know how the families struggling with finding quality service in primary healthcare facilities. This is crucial to our primary healthcare performance service design, Quality improvement, and training for primary healthcare workers

Most importantly, our work is grounded in the experience and perspectives of our primary healthcare facility users. Over the past five months, we have interviewed and hosted focus groups with primary healthcare users, primary healthcare facility users, and community leaders to gather their perspectives and develop solutions aligned to their direct experience of using the primary healthcare facilities

Most of the people with whom we connected were from low-resource areas. After these interviews, now we want to host feedback sessions for primary healthcare facilities users and providers to weigh in on the strategies and solutions for improving the quality and performance we've designed based on their initial perspectives. 

We hope we can help to provide better performance measurements to primary healthcare facilities, and health outcomes and to provide opportunities for quality improvement thereby creating a sense of hope in the community and others like it.

The access to mentorship, coaching, and strategic advisory would be invaluable for our team to learn how to scale while maintaining quality and impact and strengthening our internal processes. This will help us in developing and refining the Business model, Financial (e.g., improving accounting practices, pitching to investors) Public Relations (e.g., branding/marketing strategy, social and global media) Product / Service Distribution (e.g., expanding client base) Technology (e.g., software or hardware, web development/design, data analysis, etc.) The Monitoring and evaluation support will strengthen our impact measurement framework.  We wish to develop skills in Data for Action and decision-making that allows us to lead the improvement of performance in primary healthcare and could benefit from training sessions, software packages, or consultations to support us in leveraging this technology to advance our mission. 

Sikivu has disrupted the conventional primary health care performance measurement model by allowing patients and  local communities to express concerns about the quality of health services that they receive. Sikivu is a groundbreaking technology that enables primary healthcare users to transform their mobile phones into “virtual official suggestion boxes” which allows the communities to share the performance feedback of primary healthcare in a convenient, efficient and affordable manner. Their phone numbers act as the ‘virtual official suggestion boxes’ that can share their views about the service they receive and notifies the authority of recommended actions. With this certainty, we save time and resources. We have brought to the fold communities who were initially excluded from physical suggestion boxes due to lack of anonymity, distances, and infrastructure

We created the created value by delivering the transparency that exposed the false data reports being published in primary healthcare facilities. Our reports documented an important number of data that were not reported by the mainstream data collection methods. Additionally, we covered a wider geographical area than both mainstream data collection methods.

Finally, through our insight-to-action strategies, Sikivu applies a human-centered design (HCD) approach to improve the performance of primary healthcare, solve the identified challenges (Example: wait times, patient satisfaction, and efficient use of resources), and implement a workflow redesign to meet both primary health care expectations and the needs of healthcare workers. We will consult with government supervisors, patients, healthcare workers, and local community members to work through the core HCD phases of inspiration, ideation, and implementation, and develop relevant solutions.

Goals for the Next Year  

• Integrate the expertise of primary healthcare facilities, patients, community users, and community leaders for creating a patient-centered platform for primary healthcare facilities which uses simple, replicable, and low-cost user-friendly data collection technology tools that allow patients and  local community clients to give anonymous, real-time and reliable views and feedback about their experiences of using the primary healthcare facilities.
• Working with primary healthcare facilities in charge, patients, health government officials, and community leaders to better understand the needs for performance improvement. 
• Developed a variety of continuous feedback loops: We will conduct pilots to make improvements and validate our approach before adding on more. We conducted user testing through one-on-one interviews, and other design exercises to better understand the perspectives of performance and quality improvement for primary healthcare users and providers.    
• Conduct ongoing data collection and insight to action with primary healthcare users and the providers.  These will be developed based on user testing and in-depth interviews in a local language
• Report regularly to local and national government institutions' decision makers/supervisors about the performance of their primary healthcare facilities: We share data about the primary healthcare facilities with local and national government institutions' decision makers/supervisors to inform the findings and trends to help inform their policy and advocacy for performance improvement.   
• Incorporated empathy-building data collection and insight to action into our design process: We understand the difficulty individuals may encounter when using new technology.

Goals in the Next Three to Five Years  

Measuring long-term impact: We will measure the long-term potential impact of performance improvement such as wait times, patients’ satisfaction, efficient use of resources, and workflow redesign to meet both primary healthcare expectations and the needs of healthcare workers. We need assistance to build and learn from such measurements. 

Scaling Up: Our technology can work anywhere in the world; our implementation programs rely heavily on primary healthcare facilities' local partnerships. We need to create systems that would be easier to replicate and implement for the potential of primary healthcare facilities' performance improvement. We will need to update our business model to scale more rapidly than our current operating model allows.

Increasing behaviorally segmented marketing. We need to have the access to the data that should allow us to support the performance improvement of primary healthcare facilities based on what actions and behaviors they are taking. 

Building more connections with technology Platforms. We want to expand our network with nonprofit technology organizations. We also need to determine how to best maintain our unique culture by drawing from start-up technology so the organization can source great talent as we grow.

• The number of citizen feedback and providing this data to the local government improve the oversight of health service providers. We hope to bridge the gap between limited, expensive monitoring by the government, and widespread, cheap monitoring by service users through USSD, providing a model for more citizen monitoring projects.
• A total number of actionable data that help the government to improve decision-making on health services, using USSD to monitor and improve the health services provided in primary health facilities. Working with citizen-led health management committees, the project team is supporting the introduction of community scorecards to identify gaps in health services and prioritize healthcare needs.
• Total number of community/citizens using a USSD platform to feed their concerns and comments
• Increasing primary healthcare facilities' trust and engagement: The platforms will increase the trust with local communities, and also improved the primary healthcare facilities' reputation in relation to local governments. Many primary healthcare facilities will see patients and community users as valuable partners who can assist them with their work, especially in terms of getting key information out to large swathes of the population in fast, effective, and nuanced ways.
• Improve service/program delivery: The platform will strengthen relationships between citizens, governments, and citizens had better opportunities to effectively ‘whistle blow’ on primary healthcare facilities that were failing to deliver and hold officials to account. 
• Increased citizen engagement: Citizens will have the platform to stay informed and organize themselves to participate in meetings, and send concerns and questions on government.

On the performance and quality of primary healthcare services, resource allocations make sure as many people as possible have a say in the quality of health services and their needs are reflected in decision making.

Our theory of change suggests that if we provide a digital patient feedback service built on low-cost, widely accessible USSD technology to collect patient feedback, views and experiences of care recipients share actionable insights, and include citizen voice at the public-sector primary health care facilities with public health decision-makers in local and national government in Tanzania. Then, this service supports patient-centered, higher-quality, and responsive essential healthcare services, which ultimately leads to improved healthcare outcomes for all communities. We are partnering with the government to deeply integrate this service into existing government processes and technologies, and to scale this service nationally to all 8,000 public-sector facilities in Tanzania, which serve over 55 million people.

Sikivu will use an Unstructured Supplementary Service Data- (USSD) & calls for feature phone users, a mobile application, WhatsApp for smartphone users, and a web application for computers to allow healthcare users to freely evaluate healthcare services performance and give feedback on the quality of services they have received from a particular primary health facility. The key services/elements of the Sikivu platform are:

A.Health service rating services: Sikivu will enable patients and  local community users to freely evaluate healthcare services performance. We will provide community-generated services health rating services data to improve health care outcomes and include marginalized voices at the heart of public health decision-making. Designed to increase the transparency, accountability, and performance in primary health care services.

B.Real-time tracking of essential medicine and supplies:  Sikivu will allow the patients and  local community users to monitor the performance of accessibility of affordable medicines and medical supplies at their public primary healthcare facilities, saving both lives, time, and money

C. Peer-to-peer learning tool: Sikivu will connect health workers to each other at the right time with the right information so that the right action is taken for the patient.

We will be working with rural communities, digitally mapping the availability, accessibility, and quality of health services. The tool will combine patient satisfaction surveys, community scoring cards, and service quality assessments to gather the information that is critical for making life-saving services work. This data will be linked to GPS references of health facilities and displayed on a map to give a clear picture of where the data was collected. The team aims to create clear and compelling evidence that local government uses to plan services, and that citizens and CSOs can use to make sure quality services are actually being delivered.

We will apply a mixed methods approach by taking qualitative and quantitative approaches to collect the primary health care data for performance and Quality improvement. We will use the following member of the team to collect the data:

A.Through using the local change agents: We will identify local change agents who will act as catalysts to facilitate community members to define and address primary healthcare facilities' performance problems through increasing community participation in deliberations and decision-making. The local change agents will collect the data from local citizen groups, diagnosing core issues in their community and problem-solving around them, particularly through involving and collaborating with local authorities. The identified local change agents will take on directly engaging with local authorities making information requests and functioning as conduits between citizens and primary healthcare facilities. The ultimate plan of this strand of work is to see citizens who are acting and organizing for change, use multiple strategies to drive their own destiny and their primary healthcare facilities are largely supportive and responsive to their demands.

B.Through community themselves: The patients and community clients use Sikivu every day, collecting valuable data every time they use health facilities. There are many data that primary health facilities collect through patient record systems. However, Sikivu collects data that is different. The Sikivu data is the communication between health workers, and communities and getting advice from each other often across multiple health facilities. This data and the way are visualized and sent to health managers helps catalyze better decision-making. For example, a patient seeking antenatal care may be asked to rate the quality of the service provided by responding to specific questions about their interaction with the care provider.

We are currently working to enhance diversity, equity, and inclusion among our staff and data collection and insight to action. We ensure and prioritize diversity, equity, and inclusion in all aspects of our organization. We have identified addressing disparities as a core component of our work and have brought in experts to discuss how diversity, equity, and inclusion can be reflected in the data collection processes. Our data collection reflects the inclusion of patients and the diversity of communities.  While we have taken small steps, we are committed to taking larger steps to further enhance diversity, equity, and inclusion as a core principle of our company culture. 

We believe that representative participation in data collection and insight to action from all demographic groups is essential to embed equity into this next chapter of primary health care performance. Specifically, this project will focus on the inclusion of demographic groups who typically do not participate in research because of barriers created by cultural considerations. 

Our goal was to develop a business model that serves the most primary healthcare facilities possible. We achieved this goal by measuring the performance of primary healthcare facilities and adapting our solution to fit various primary healthcare facilities, and by optimizing long-term sustainability. We believe this business model is the foundation for measuring the performance of primary healthcare facilities that will improve the quality of their services. 

Fit for purpose is both a matter of making our solution as patient-centered as possible and as Low-cost solution as possible:

• Patient-centered: We are building a scalable platform, to ensure that the process of rating the primary healthcare facilities can be effectively used by community and governments alike, to co-improve the quality and performance of health services together. We do this by Aggregating all rating feedback, simplifying them in accessible language, reaching out to individuals and gathering inputs, and analyzing and sharing citizen’s feedback with the Government - thereby building Government capacity to run effective Consultations, and gather actionable insights. We invest in deeply understanding our community needs and innovate on both performance improvements and new product development to ensure our products are meeting these needs.
• Low-cost solution: We invest in business model innovations that make our service cheaper but also ensure financing options are available.  

We measure our fit for purpose by a total number of community/citizens using a USSD platform to feed their concerns and comments about the performance and quality of primary healthcare services, and resource allocations making sure as many people as possible have a voice in the quality of health services and their needs are reflected in decision making. This fit for a purpose directly leads to more communities impacted. 

We define sustainability broadly, as we believe that a business model that is sustainable for the local performance measurements for primary healthcare and financially sustainable will create the most long-term impact. 

• Locally sustainable: A mobile platform that enables the community to rate the services of primary healthcare facilities and share their feedback on decisions in local languages while providing an avenue for the government to understand citizens’ priorities and gather feedback on performance in real-time.
• Sustainability in Patient-Driven Data: We invest in finding new ways to use local and sustainable methods- to build sustainability in patient-Driven Data.  We provide the community a way to give meaningful feedback to improve the performance of primary healthcare services and present this feedback in an effective way to offices and headquarters. By picking up what community values and recommend month after month, they make incremental improvements to their service quality.  We specialized in developing user-friendly data collection tools that allow all communities to give anonymous, quick, and reliable feedback about their experience at primary healthcare facilities.  After the data is gathered, it is presented in digestible and customized community feedback reports that allow even the lowest ranked public servants to understand how they are performing. Finally, our data-to-action strategies provide different incentives to primary healthcare facilities to improve their services, while sharing results at different decision-making levels, including local offices, headquarters, and Ministries.

We are identifying and developing relationships with donors who are interested in measuring the performance of primary healthcare services. We believe there is growing international interest in these two areas that we will be able to leverage to secure funding. Our plan is to achieve sustainability through sustained donations and grants. We count grant funding from foundations as health systems impact. It is used to fast-track growth and scale systems. This then increases our commerciality in the long term.  We consider partnerships with governmental and non-governmental institutions. We are currently developing a new business model based on monetizing the data that we collect in our business. This model will allow us to expand our revenue capability and the operating margins from our operations while reducing costs. However, we do not want to depend on funding as a source of income but would like to be self-sustaining by providing a service where a market need has been investigated.    

For the past six months, we were prototyping the solution through various experiments with potential partners, listening to the potential community and primary healthcare facilities, improving the customer journey, establishing the business/financial model and operation, designing strategies for business development and marketing and expanding the network to find growth opportunities. Following our pilot, has cultivated a diverse funding stream to support the measuring the performance of primary health facilities in rural communities, including (1) philanthropic support, individual donors, (2) awards (3) Financial sustainability has been the result of in-kind support from government partners, Pledged support of operational expenditures.

Our direct key customers are primary healthcare facilities that want to work using their actionable insight from patients, expertise, and experience to improve the quality and performance of primary healthcare facilities. We as a non-profit donate the time and capital to develop data collection tools while our partner organizations leverage community relationships to encourage involvement in our needs assessments and gather the manpower to measure the performance of primary healthcare facilities. 

We invest in reducing ongoing costs and increasing revenue to become sustainable. In order to build a solution at scale, we must become financially sustainable to encourage replicators to emerge. We believe replicators must be able to be Financially sustainable and viable within a few years in order to see mass replication that would lead to an industry.