Christine's Story
Nakuru County lies within the Great Rift Valley to the northwest of Nairobi. Over the last three years, it has seen a decline in maternal mortality rates, linked to improvements in health facilities and greater availability of trained maternity staff and equipment. But there is still a lot to do. Jacaranda assessed Nakuru over a period of nine months, and found its sub county - Nakuru East - was consistently receiving patient reports of abuse, staff disrespect, or malpractice in some of its facilities.
Jacaranda recognized that health system design was providing little to no opportunity for these types of concerns to reach health providers and health system managers, meaning care quality remained low, and health interventions were being planned and implemented without the input of those they serve. Low health seeking behavior can be addressed by making interventions responsive to the direct needs of the end-user.
We saw an opportunity through PROMPTS to improve care quality by closing health system gaps between patient, provider, and managers. Each month, mothers enrolled to PROMPTS receive an SMS. It asks them to fill out a simple client experience survey, aimed at better understanding how they have been treated in facilities, and the quality of care they received. The data is collected in ‘scorecards’, reports that rate facilities on factors such as respectful care, or number of clinical steps performed. Facilities receive their scorecards monthly which helps them take targeted action - whether increasing bed capacity, or giving nurses and midwives skills in emergency care.
Jacaranda recognized that the situation in Nakuru East could be reversed by simply increasing the frequency of the feedback these facilities received and, in doing so, increasing their responsiveness to negative patient experiences. Scorecards were shared weekly with facilities in Nakuru Each, helping providers identify gaps early and take rapid action.
For four years, Christine Nowerukoi has worked as a nurse and midwife in the Lanet Health Center in Nakuru East. Mums from across the county come for antenatal (ANC) and postnatal (PNC) care, family planning services, and are referred to the maternity ward to deliver. When her facility started receiving weekly feedback from PROMPTS, she noted an immediate change in the way things were run in the facility. ‘Each Monday, we all receive an email from Jacaranda with specific feedback from our clients’. She explains. ‘When we receive negative reports of staff rudeness, for example, we sit down to discuss it as a team, and make sure it’s rectified’.
In facilities with high volumes of patients (the Lanet Health Center delivers over 110 babies a month), nurses can often feel overrun in the face of longer shifts and limited resources, compromising both the time they can spend with their patients, and the quality of care that patient receives. PROMPTS offers a solution. ‘We’re now better at planning our daily activities and managing our workload.’ explains Christine. ‘Because of the messages clients receive through PROMPTS, mothers are now turning up to the facility at the right time and keeping their appointments. It’s helping us be more effective’.
PROMPTS is also bringing providers closer to their patients. Patients are more receptive to information they hear from nurses if it correlates with the messages they receive through PROMPTS. Providers are also able to understand what constitutes a bad patient experience, and shape their behaviors to improve it. ‘Because of PROMPTS, we are now able to understand our clients and their needs better.’ explains Christine. ‘Sometimes we receive feedback from patients saying they are grateful for the care they received. This really motivates us’.
Jacaranda saw that while significant improvements were taking place in facilities, to make them sustainable, they needed support and action from the sub-county and county. Scorecards were also shared with sub-county and county health managers. Since PROMPTS - and the feedback it provided - was introduced in Nakuru East, its Reproductive Health Coordinator (RHC) Doreen Ouko, ‘Not only are mothers now better at attending antenatal care,’ she says, referencing the appointment reminders that PROMPTS shares with mothers via SMS. ‘But also, the quality of care has gone up. Providers are more accountable these days as they worry about receiving negative feedback. And the clients are clearly more happy’.
By understanding the situation on the ground better, managers were able to visit target facilities in-person, to dig deep into why and where these negative responses were stemming from. ‘In one report there were complaints about respectful maternal care.’ explains Doreen. ‘The reports help me share better feedback and best practices with the providers in facilities.’
Within just one month of weekly feedback, Nakuru East was the highest performing sub-county of those where Jacaranda operates. By giving mums a voice in the health system, Jacaranda is able to close the feedback loop between patients, providers, and health system managers and drive targeted improvements to care quality.