For over ten years, Christine Nowerukoi’s work has centered around bringing new life into the world. As a nurse midwife in the Lanet Health Center, a large public facility in Nakuru East sub-county, she and her colleagues have managed the safe delivery of countless newborns, and guided expectant and new mothers through pre and postnatal care.
Recent years have seen many more women across Kenya choose facility-based delivery, attributable in part to the introduction of a free maternity insurance scheme, Linda Mama. The Lanet Health Center is no exception; during peak months, some 150 babies are delivered within the maternity ward. But high volume doesn’t always correlate with high quality. Significant quality of care gaps contribute to over half (55%) of all maternal deaths in Kenya, and the country’s maternal mortality rate (362 deaths/100,000 births) remains well above the global average.
In Nowerukoi’s facility, long working hours, high staff turnover and lack of supportive supervision have had an impact on general motivation and, in turn, the quality of services their clients receive. Recent government-backed efforts have gone some way to improve workplace ‘stressors’ in facilities, but a data gap remains; providers lack a means to elicit feedback on how mothers experience services to inform their capacity to deliver them. In Kenya, few formal channels exist for women to share their experiences beyond ‘exit interviews’ which are unanonymized, costly and tricky to scale.
Jacaranda Health’s digital health tool, PROMPTS, offers a solution. Launched in 2017 with support from Johnson & Johnson Foundation, the SMS-based platform doubles as a two-way messaging ‘companion’ to guide mothers through pregnancy and postpartum, and a scalable approach to connect providers with the needs of their clients. Mothers on the platform are routinely prompted, via SMS, to anonymously report on their experiences in facilities—from the way they were treated to the clinical competency of the nurse that served them—and the resulting feedback is shared with facilities via readable memos called ‘Scorecards’.
Nowerukoi noted a palpable shift in how things were run when the Scorecards were introduced in her facility. “Each Monday, we all receive an email from PROMPTS with specific feedback from our clients,” she explains. “When we receive negative reports of staff rudeness or poor service provision, we sit down to discuss it as a team and make sure it’s rectified.”
The Scorecards not only build greater accountability towards high quality care, but also promote efficiencies and job satisfaction in facilities. Nurses can rapidly pinpoint specific issues—like long waiting times or poor patient-provider communication—to improve patient and workload management. “We’re now better at planning our daily activities and managing our workload,” she adds. “Our clients receive information through PROMPTS, meaning they’re now turning up to the facility at the right time and keeping their appointments. It’s helping us be more effective.”
Direct client feedback is also helping nurses like Nowerukoi understand what constitutes a bad client experience, and adjust behaviors to avert it. “The scorecards are bringing us closer to our clients,” says Nowerukoi. “Sometimes we receive feedback from patients saying they are grateful for the care they received. This really motivates us.”
Sustainably improving care quality in facilities requires both inputs and actions across multiple health system levels. Each month, Jacaranda shares the monthly Scorecards with health system managers across Kenya, like Nakuru East’s Reproductive Health Coordinator Doreen Ouko. “It's clear the scorecards are impacting quality,” says Ouko. “Providers are more accountable as they worry about receiving negative feedback, and the clients are clearly more happy.”
But beyond an accountability tool, the scorecards are offering Coordinators like Ouko greater visibility on what’s happening on the ground, helping them target supervision and support towards underperforming facilities. “In one report there were complaints about long waiting times,” explains Ouko. “We realized this was a sign of providers performing over and above capacity—something they needed our support to alleviate.”
More than 400,000 women across Kenya have shared their experiences of care through PROMPTS. Jacaranda is now laying foundations for PROMPTS as a longer-term national resource that its government partners can sustainably own and finance within the health system as a low-cost, high-impact channel to improve quality. While the platform is always free for mothers and maintains a low running cost ($0.74 per user), several efforts are underway to ensure, at scale, it remains inclusive for mothers and cost-effective for governments. This includes research into whether Interactive Voice Response might be a viable alternative to SMS for low-literacy mothers, and partnership with local telecoms like Safaricom to subsidize the cost of bulk SMS.
Historically (and perhaps inevitably), the effectiveness of ‘client-side’ tools has been measured by their impact on the end user. But as the scope and functionality of these tools increases, the term ‘client-side’ seems to disregard their potential to influence services, and the motivation of providers delivering them. Health promotion or delivery of healthcare services are too often treated in silo—but digital tools like PROMPTS can do both.
At a time when health workers, especially in low-resource countries like Kenya, are facing increasing levels of stress and burnout, PROMPTS is one of the ways the Johnson & Johnson Center of Health Worker Innovation’s Resilience Collaborative and Jacaranda Health are collaborating to use technology as an enabler. PROMPTS focuses on improving outcomes for both clients and health workers—a critical consideration if we are to build a thriving workforce, given the unintended consequences of technology, both positive and negative.
“Our days are often long, but it’s gratifying that they’re spent on supporting our clients through what can be a difficult or even lonely period,” says Nowerukoi. “We see the feedback as a positive challenge. If we continue improving our services, our clients will continue to use and benefit from them. It’s the reason why we do what we do.”