In rural Nigeria, primary health centers have no formal way of collecting patient feedback. This gap strips patients of the rights they deserve, deprives clinic management of valuable inputs for improving quality of care, and limits the ability of state and federal policymakers to oversee the clinics. To address these issues, Reboot, in partnership with the World Bank and the Nigerian government, created My Voice, an SMS-based citizen feedback platform to enable citizen-driven improvement of public services.

To use My Voice after a visit to a primary health clinic, patients simply respond to a free SMS survey asking questions about the quality of care they received. The resulting data informs the healthcare community of real-time challenges like clinic closures, lack of supplies, or abusive treatment. The platform enables citizens to speak honestly about government services, and empowers government with evidence to respond to citizen needs. As an innovative monitoring tool for the healthcare ecosystem, My Voice channels citizen reporting to health clinic managers, local government officials, and high-level decision makers who can use citizen voice to make informed management decisions.

Knowing that the design of My Voice would only be as good as our understanding of its users and their environment, Reboot employed a six-month immersive research and design process, including in-depth, ethnographic interviewing, service trials, site observation, and embedded user-testing in facilities and with government stakeholders.

To ensure that users would understand, trust, and adopt My Voice, we adopted a holistic approach to program design and implementation. We conducted hands-on training for staff in interpreting and using patient feedback; we transitioned program management to local staff; we built strategies for integrating My Voice into national healthcare programs; and we created a tailored brand identity, promotional materials, user guides, and messaging campaign to ensure comprehension in a low-literacy region.

My Voice integrates easily with health clinics' everyday practices and procedures, legitimizing the platform for patients and minimizing work for clinic staff. The SMS survey, informed by extensive user-testing and iterations, makes texting responses easy and intuitive for inexperienced mobile users. Responses are analyzed, then distributed to people working at each stage of the healthcare system in formats tailored to fit their needs, ranging from web dashboard custom analyses to one-page printed summaries.

My Voice has already enabled unprecedented constructive dialogue among citizens, service providers, and policymakers on healthcare service quality-- 85% of patients were registered on My Voice in their local facilities during the launch period. Citizen feedback has led to changes in operational practices in Nigerian health facilities and informed investment decisions.

Our systems-oriented approach to designing and implementing My Voice demonstrates how citizen feedback can be collected and utilized in meaningful ways, even where cell phone networks are limited, and where the practice of government asking for and utilizing feedback is unfamiliar. Reboot is now working to scale My Voice to other sectors and other places, bringing a powerful option for amplifying individual voices and enabling responsive governance to more citizens worldwide.

THE PROBLEM

In rural Nigeria, primary health centers have no formal way of collecting patient feedback. This gap strips patients of the rights they deserve, deprives clinic management of valuable inputs for improving quality of care, and limits the ability of state and federal policymakers to oversee the clinics. To address these issues, Reboot, in partnership with the World Bank and the Nigerian government, created My Voice, an SMS-based citizen feedback platform to enable citizen-driven improvement of public services.

CONTEXT + CHALLENGES

We launched the My Voice pilot in 2014 in Wamba, a mountainous, rural region in central Nigeria. In Wamba, patients don't choose their doctor. Typically, the doctor they see is the one that works in the only clinic they can access. Wamba patients can't weigh options for different providers through reviews, or register their displeasure with the service they've received by going to a different doctor. At the same time, health clinics deal routinely with electricity outages, and acute shortages of supplies, equipment and staff capacity. And policymakers at state and federal levels lack the real-time data on clinic quality they might use to provide relevant advice, create new policies, and keep management accountable to the citizens they serve.

Reboot designed and implemented My Voice to help change this status quo: to give patients an opportunity to provide feedback on the quality of care that they receive, and to give clinics more information about their patients' needs.

At the outset, the project faced several barriers including low literacy and numeracy rates among patients (literacy in Nigeria as a whole is about 50 percent), and low citizen trust in government. Patients had low expectations for the government as a service provider, and Wamba patients were unaware of existing channels to provide feedback to service providers, and believed that even if such channels existed, their comments would not be wanted or used. Interviews with Wamba citizens highlighted just how uncommon the practice of formal healthcare feedback was: even the word "feedback" was unfamiliar.

On the other side of the feedback chain, healthcare service providers were wary of opening themselves up to patient scrutiny and the risks such feedback might present for their careers. This meant that simply developing a technology platform for patients to communicate with healthcare providers wouldn't be sufficient. We needed to design a program capable of empowering patients to offer feedback and motivating providers to make improvements based on patient comments.

The availability and reliability of technology in Wamba presented its own set of challenges. The strength and reliability of the available mobile networks are highly inconsistent, and the strength of these networks varies across the region. Of four national network operators, facilities often only receive a usable signal from a single operator, and even then it is limited to specific locations.

PROCESS + APPROACH

Reboot recognized that My Voice's success depended on its ability to stimulate meaningful government response. Our approach prioritized deep engagement with government service providers and policy makers alongside immersive ethnographic research, participatory design, and user-testing across multiple stakeholder cohorts. For the six-month duration of the design and development phase, our team established a temporary studio in Wamba and hired a local research team. We visited all of the participating health clinics multiple times each week by motorbike. We worked alongside the policymakers and program managers responsible for the primary health care system.

Immersing ourselves in the environment and context gave us a clearer view of health infrastructure and processes, and a deeper understanding of the needs, habits, and interests of the people who would use and operate the feedback system. It allowed us to participate in key decision-making meetings, surfacing opportunities for how My Voice real-time data could be included in program improvement discussions. We were able to user-test and iterate the SMS system, the training materials, and the feedback dashboard at each stage of the design process from paper prototypes to high-fidelity scenario trials, gathering inputs from stakeholders daily.

DESIGN

As we developed relationships with the clinic managers, healthcare workers, and local government staff, we listened to their inputs and used them to tweak the system, gradually iterating and improving. While initially skeptical, the community ultimately understood that My Voice was for them: built for their interests using their own ideas. They determined what information it would include, when feedback would be received, and what reports would look like through participatory design workshops. My Voice is comprised of two integrated and mutually-reinforcing components: a technology platform and a programmatic model. The My Voice technology platform collects citizen feedback and presents it to service providers and policymakers in formats tailored for their specific needs, technical capabilities, and operational resources: an online dashboard, printed reports, or in-person meetings. My Voice's programmatic model then works to integrate citizen feedback into service providers' management processes and community fora to encourage and facilitate timely, responsive service improvements. Key features of the My Voice design include:
A free, easy-to-use SMS platform for collecting citizen inputsSimple user interactions and intuitive content in familiar terminology accommodates literacy and language barriers among target user groups. A reverse-billed shortcode ensures the system is free for all users, addressing financial barriers to participation. Two models for feedback collection Interactive surveys initiated by health facilities; and Open-ended commenting self initiated outside of health facilities address individual preferences, capacities, and circumstances that may impact citizen participation. Both channels are integrated into familiar institutional processes or trusted community venues, helping encourage citizen use. Custom data reporting A web dashboard presents citizen feedback to service providers and policymakers in custom formats and frequencies. By presenting tailored and easily accessible real-time intelligence, My Voice helps government actors use visual analyses of citizen feedback in their day-to-day work. Training, guidance, and on-site support Training builds institutional capacity to provide timely, appropriate responses to citizen feedback. Helping government integrate citizen feedback into its program management channels and processes also supports My Voice's long-term sustainability.

RESULTS

Through intentional, contextually-informed programmatic and technological design, My Voice was able to integrate citizen feedback into existing healthcare management structures. Beyond channeling citizen voice to service providers and policymakers, My Voice also highlighted the potential benefits to each stakeholder in responding to citizen feedback and provided the technical assistance to help them do so.

During a nine-week pilot across 11 primary healthcare facilities, My Voice enabled unprecedented constructive dialogue around quality of care between patients, service providers, and public health officials. At the end of the pilot period, more than 80 percent of all patient visits were registered in the My Voice database. The project secured government support to use My Voice across multiple local government authorities. At the health clinic level, service providers began making incremental improvements based on patient feedback (for example: clarifying their payment processes, checking on staff more frequently, and keeping facilities open during nights and weekends). At the local government level, health department officials also saw the value of new data stream, and developed protocols to guide and monitor clinic responses to citizen feedback.
Reboot is now working to scale My Voice to other sectors and other places, bringing a powerful option for amplifying individual voices and enabling responsive governance to more citizens worldwide.