Description of the Systematic Community Engagement (SCE) interventions
Light Engagement (LE) Intervention
The LE intervention comprised of five steps that actively engaged clients in their communities to rate service quality in their nearest health facility and NHIS district office using predefined quality service proxies. The five implementation steps are:
Step 1: Recruitment and training of 52 facilitators, and identification of existing community groups/associations. One facilitator was assigned to each of the of 52 community groups in the two study regions (26 in each region). Eligibility criteria for selection of community groups included: documented evidence of routine meetings (at least four times a year); regular meeting venue; clear leadership structure; non-partisan, and active membership not less than an intuitive number of ten (10). The community groups comprised of 22 religious/faith-based groups; 8 traders groups; 1 widows group; 3 community volunteers groups; 3 musician groups; 5 artisans groups and 11 youth groups. Average group size was 29 members (SD = 20).
Step 2: First round of assessment of service quality based on group members’ most recent (at most 6 months) experiences with the intervention service providers. Service quality indicators at healthcare provider level were: attitude of staff; punctuality of staff; availability of drugs; information provision; opportunity for feedback. Indicators for the health insurer are: information provision; (re)enrolment; delivering what is promised, and opportunity for feedback. A proxy indicator called Net Promotor Score (NPS) was used to measure clients’ trust for service providers. During the assessment, community members were asked to rank their experiences of service quality on a Five point Likert scale ranging from 1 “Very disappointing” to 5 “Very satisfactory”, using a community score card. These same service quality indicators were used for the MyCare arm of the SCE interventions.
Step 3: Regional level validation and feedback sessions to disseminate the group assessment findings with facility heads, clients and NHIA representatives. This platform provided the service providers the opportunity to recognize and accept gaps in healthcare quality and agree on quality improvement plans with timelines and responsible persons.
Step 4: Follow-up on the service providers by facilitators (3 months after validation and feedback sessions) to ensure implementation of agreed action plans towards quality improvement.
Step 5: Rewarding best performing health facilities after a second round of community assessment (approximately six months after the first assessment). A citation plaque of honor and a token financial incentive of about US$ 280.0 was awarded best performing facilities to encourage competition among peers towards quality improvement.
Intensive Engagement ( MyCare ) Intervention
This component of the SCE interventions was implemented within the catchment area of intervention health facilities using a cyclical process involving clients, health care providers, and the NHIS district offices. Implementation of the MyCare arm of the SCE interventions involved six (6) cyclical steps namely:
Step 1: Recruitment and training of facilitators for the intervention activities.
Step 2: Semi-quantitative process where 30–50 clients (with evidence of NHIS active membership) were recruited at the exit of the intervention health facilities and later interviewed at home. Assessment of service quality focused on 10 predefined indicators related to service quality at the levels of the healthcare provider and health insurer (see LE interventions described earlier).
Step 3: Qualitative validation and feedback on semi-quantitative data with community representatives. Six (6) focused group discussions (1 in each catchment area) were conducted to discuss findings of the semi-quantitative interviews and action points taken to address identified service quality gaps.
Step 4: Briefing: intervention clinics and NHIS district offices were briefed on clients’ experiences of service quality.
Step 5: Joint stakeholder meeting where representatives of clients/community, healthcare providers, health insurers and regional/district level policy makers were invited to discuss and address identified gaps; a liaison person at the community follows up on the service providers to ensure action plans towards quality service improvement are implemented.
Step 6: Progress qualitative phase where clients are followed-up six (6) months after the joint stakeholder meeting to determine perceived changes in service quality. Service providers perceived to have improved were rewarded with financial incentives and a citation plague of appreciation.