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Abstract
Citizen report cards on health care providers have been identified as a potential means to increase citizen engagement, provider accountability and health systems performance. Research in high-income settings indicates that the wording, presentation and display of performance information are critical to achieve these goals. However, there are limited insights on developing effective report card designs for middle- and low-income settings. We conducted cognitive interviews to assess consumers’ understanding, interpretation of and preferences for displaying information for a health care report card in rural Tajikistan. We recruited a convenience sample of 40 citizens (20 women and 20 men aged 18–45) from rural areas of two provinces of Tajikistan (Soghd and Khatlon oblasts). The interview protocol was adapted from the model of cognitive interviews used in social science research to improve survey questionnaires. We used multivariate regression to assess understanding and interpretation of the report card; chi2 tests to assess differences in preferences for displaying information; and tests of proportions to assess the preferred comparison group. Respondents understood the main idea of the report card and are not confused by the indicators or display. However, many respondents had difficulties making comparisons, and when asked to identify worst-performing services. Respondents preferred detailed rankings using school grades, comparisons of their local clinic with the regional or national average performance, and the use of color in the report card. We found some heterogeneity across the two provinces. Overall, our findings are promising regarding the citizens’ comprehension of health care report cards in rural Tajikistan, while underscoring the challenges of effectively providing health care performance information to communities. Cognitive interviews and iterative testing can support an effective implementation of reporting initiatives.
Highlights
Public report cards are one tool in a wider suite of approaches to increase the accountability and performance of service providers, in the healthcare field [1,2,3,4,5,6]
We focused on the regional comparison since, in practice, the report cards could be adapted to each locality
The sample-average score of 56% for the “understanding” index indicates that a large number of respondents had difficulty explaining the meaning of the report card content or provide examples for the categories and services listed on the report card, such as “maternal and child health” and “children under age 5 monitored”
Summary
Public report cards are one tool in a wider suite of approaches to increase the accountability and performance of service providers, in the healthcare field [1,2,3,4,5,6]. Most of the existing research on the use of healthcare quality report cards originates in high-income countries, primarily the United States. In such settings, report cards are often intended to inform the choice of provider (e.g., [1]) and may serve to complement regulatory approaches to maintain performance and quality standards [6]. Report card initiatives in low- and middle-income countries tend to focus on facilitating citizen engagement and priority setting by introducing monitoring and accountability to the public sector [4,8]. The effectiveness of these initiatives in improving quality of care in low-income settings, has not yet been firmly established
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