Design and implementation of community engagement interventions towards healthcare quality improvement in Ghana: A methodological approach

Alhassan, Robert Kaba; Nketiah-Amponsah, Edward; Arhinful, Daniel Kojo Article Design and implementation of community engagement interventions towards healthcare quality improvement in Ghana: A methodological approach Health Economics Review Provided in Cooperation with: Springer Nature Suggested Citation: Alhassan, Robert Kaba; Nketiah-Amponsah, Edward; Arhinful, Daniel Kojo (2016) : Design and implementation of community engagement interventions towards healthcare quality improvement in Ghana: A methodological approach, Health Economics Review, ISSN 2191-1991, Springer, Heidelberg, Vol. 6, Iss. 49, pp. 1-13, https://doi.org/10.1186/s13561-016-0128-0 This Version is available at: https://hdl.handle.net/10419/175614 Standard-Nutzungsbedingungen: Die Dokumente auf EconStor dürfen zu eigenen wissenschaftlichen Zwecken und zum Privatgebrauch gespeichert und kopiert werden. Sie dürfen die Dokumente nicht für öffentliche oder kommerzielle Zwecke vervielfältigen, öffentlich ausstellen, öffentlich zugänglich machen, vertreiben oder anderweitig nutzen. Sofern die Verfasser die Dokumente unter Open-Content-Lizenzen (insbesondere CC-Lizenzen) zur Verfügung gestellt haben sollten, gelten abweichend von diesen Nutzungsbedingungen die in der dort genannten Lizenz gewährten Nutzungsrechte. Terms of use: Documents in EconStor may be saved and copied for your personal and scholarly purposes. You are not to copy documents for public or commercial purposes, to exhibit the documents publicly, to make them publicly available on the internet, or to distribute or otherwise use the documents in public. If the documents have been made available under an Open Content Licence (especially Creative Commons Licences), you may exercise further usage rights as specified in the indicated licence. http://creativecommons.org/licenses/by/4.0/ RESEARCH Open Access Design and implementation of community engagement interventions towards healthcare quality improvement in Ghana: a methodological approach Robert Kaba Alhassan 1,2* , Edward Nketiah-Amponsah 3 and Daniel Kojo Arhinful 2 Abstract Background: Nearly four decades after the Alma-Ata declaration of 1978 on the need for active client/community participation in healthcare, not much has been achieved in this regard particularly in resource constrained countries like Ghana, where over 70 % of communities in rural areas access basic healthcare from primary health facilities. Systematic Community Engagement (SCE) in healthcare quality assessment remains a grey area in many health systems in Africa, albeit the increasing importance in promoting universal access to quality basic healthcare services. Purpose/objective: Design and implement SCE interventions that involve existing community groups engaged in healthcare quality assessment in 32 intervention primary health facilities. Methods: The SCE interventions form part of a four year randomized controlled trial (RCT) in the Greater Accra and Western regions of Ghana. Community groups (n= 52) were purposively recruited and engaged to assess non-technical components of healthcare quality, recommend quality improvement plans and reward best performing facilities. The interventions comprised of five cyclical implementation steps executed for nearly a year. Wilcoxon sign rank test was used to ascertain differences in group perceptions of service quality during the first and second assessments, and ordered logistic regression analysis performed to determine factors associated with groups’perception of healthcare quality. Results: Healthcare quality was perceived to be lowest in non-technical areas such as: information provision to clients, directional signs in clinics, drug availability, fairness in queuing, waiting times, and information provision on use of suggestion boxes and feedback on clients’complaints. Overall, services in private health facilities were perceived to be better than public facilities (p< 0.05). Community groups dominated by artisans and elderly members (60 + years) had better perspectives on healthcare quality than youthful groups (Coef. =1.78; 95 % CI = [−0.16 3.72]) and other categories of community groups (Coef. = 0.98; 95 % CI = [−0.10 2.06]). Conclusions: Non-technical components of healthcare quality remain critical to clients and communities served by primary healthcare providers. The SCE concept is a potential innovative and complementary quality improvement strategy that could help enhance client experiences, trust and confidence in healthcare providers. SCE interventions are more cost effective, community-focused and could easily be scaled-up and sustained by local health authorities. Keywords: Community engagement, Healthcare quality, Primary health facilities, Ghana * Correspondence: [email protected] 1 Amsterdam Institute for Global Health and Development, University of Amsterdam, Amsterdam, The Netherlands 2 Department of Epidemiology, Noguchi Memorial Institute for Medical Research, University of Ghana, Legon, Accra, Ghana Full list of author information is available at the end of the article © The Author(s). 2016 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. Alhassan et al. Health Economics Review (2016) 6:49 DOI 10.1186/s13561-016-0128-0 Background Community participation in health service planning and implementation is a key principle in the Alma-Ata Declaration of 1978 with the fourth article stating that “people have the right and duty to participate individually and collectively in the planning and implementation of their health care”[1]. The Declaration also states that primary healthcare should promote maximum community and individual self-reliance and participation in the planning, organisation, operation and control of primary healthcare services. This premise underscores the vital role communities play in the implementation of effective and sustainable health plans and policies. Community engagement in health is essential to developing countries where resources are scarce albeit demand for healthcare remains high. Leveraging existing community structures and resources towards healthcare quality improvement is therefore an option worth considering. Morgan and Lifshay [2] defined community engagement in the context of public health as dynamic relationships and dialogue between community members and local health professionals with varying degrees of community and higher level health authorities’involvement in decision-making and control. Coulter [3] indicated that there are at least four roles for community engagement in health namely: determine local needs and aspirations; promote health and reduce health inequalities; improve service design and the quality of healthcare, and strengthen local accountability. Morgan and Lifshay [2] proposed a framework for structured community engagement summarized into seven (7) steps in descending order: (1)local health authorities taking the lead and directing the community to act; (2)information sharing plan with the community; (3)soliciting periodic community input and consultation; (4)community members serving as conduits of information/feedback to and from the local health authorities; (5)power-sharing that involves defining and solving problems together; (6)community initiating decisions; (7)community sharing information with local health authorities. Though this framework was initially developed in the context of Western healthcare systems with emphasis on chronic diseases, the ideas remain relevant to primary healthcare in developing health systems. The framework by Morgan and Lifshay [2], the theory of social capital [4] and theory of change [5] informed theoretical basis for the systematic client/community engagement (SCE) interventions described in this paper. Besides these theories, findings of baseline qualitative and quantitative interviews and series of stakeholder engagement workshops informed the design and implementation of the SCE interventions. Ghana seems to have some level of structured community participation in health service planning and implementation, especially at the primary healthcare level [6–9]. The Community-based Health Planning and Services (CHPS) programme adopted in Ghana in 1999 aimedtoreducebarrierstogeographicalaccesstohealthcare with an initial focus on deprived and remote areas of rural districts [9]. Although the CHPS programme contributed significantly to improved health outcomes and accelerated community participation in health, the focus did not emphasize community engagement in healthcare quality assessment. In Ghana, client/community involvement in healthcare quality assessment is conventionally limited to exit interviews during patient satisfaction surveys, albeit this strategy is increasingly proving ineffective in healthcare quality improvement. Patient satisfaction surveys (though relevant) have a limitation of potential biased assessment especially when interviews are conducted in health facility premises [10–13]. The limitations of these conventional approaches underscore the need to complement them with structured community engagement in healthcare quality assessment. This paper describes the methodology, implementation process and outcome of SCE interventions implemented in 32 primary healthcare facilities in two regions in Ghana for nearly 12 months. It is expected that the findings and experiences will guide policy makers and researchers contemplating replication of the SCE interventions in other settings in Africa and beyond. Overview of the SCE Interventions The WOTRO-COHEiSION Ghana project is a four-year randomized controlled trail (RCT) initiated in 2011 to contribute (via evidence-based research findings) towards removing barriers to (re)enrolment in Ghana’snational health insurance scheme through client-centered healthcare and health insurance system [14]. As part of the study design, SCE interventions were implemented using existing community groups/associations to assess healthcare quality in selected primary health facilities. The SCE interventions aimed at empowering communities in healthcare quality improvement as a strategy to promote client trust and confidence in healthcare providers and the National Health Insurance Scheme (NHIS). The assumption is that active community engagement in healthcare quality assessment has the potential to decrease perceived barriers to utilizing healthcare and health insurance services and ultimately enhance active participation in the NHIS. Objectives of the SCE interventions include: diminishing identified barriers to enrollment in the NHIS and utilization of healthcare services; increase client/community participation in healthcare quality assessment; reduce communication gaps between clients and healthcare providers through effective information dissemination; Alhassan et al. Health Economics Review (2016) 6:49 Page 2 of 13 increase and sustain provider accountability to clients/ communities; empower clients and promote clientcentered healthcare and health insurance system in Ghana. Two categories of SCE interventions were implemented namely: MyCare (also called Intensive Engagement) and Light Engagement (LE). The LE intervention used existing community groups/associations to identify gaps in service delivery in healthcare facilities. The identified gaps were communicated to all intervention health facilities and encouraged to initiate necessary corrective measures with a promised token incentive, should service providers succeed in narrowing the quality care gaps. The MyCare component involved clients and relevant stakeholders in a participatory process. The focus was on individual clients contrary to the group approach in the LE. The LE interventions employed mainly qualitative methods while MyCare interventions used both qualitative and quantitative methods. Both categories of interventions were implemented and evaluated concurrently. For the purposes of this paper, the emphasis was on the LE interventions. The MyCare component of the SCE interventions is detailed in Fenenga et al. [15]. Methods LE interventions setting The LE interventions were implemented in Greater Accra (predominantly urban) and Western (predominantly rural) regions of Ghana. Only primary healthcare facilities (i.e. clinics and health centres) accredited by the National Health Insurance Authority (NHIA) were purposively sampled to participate in the study. The NHIA is the regulatory body of the NHIS in Ghana. Accredited clinics/health centres were purposively sampled because they are relatively less complex and could easily be monitored for impact of implemented interventions. A total of 16 administrative districts were sampled at random (eight from each region) and four health facilities allocated to each district. In every district, two out of the four facilities were randomly picked to receive interventions and the remaining two assigned as controls; nine out of the 16 districts were rural and seven were urban. Figure 1 shows geographic distribution of health facilities by districts. LE interventions design and randomization Random allocation of health facilities into the different intervention and control arms of the project was conducted such that in each district, the names of all 4 health facilities were written on pieces of paper. Subsequently, for each district at a time, two ballots (representing health facilities) were randomly picked without replacement to receive intervention. Per this criteria 32 health facilities and their catchment area were randomly assigned as intervention facilities and the remaining 32 as controls. Out of the 32 intervention facilities 26 were randomly picked to receive the LE interventions (13 from each region) and the remaining six assigned the MyCare interventions (three from each region). Detailed description of the MyCare and LE interventions has been given in Fenenga et al. [15]. In this paper, the focus was on the design and implementation steps of the community engagement interventions and not on impact evaluation of the interventions. In terms of location, 18 of the 32 intervention facilities were sampled from rural areas and 14 from urban areas. In terms of ownership 21 intervention facilities were private and 11 were public. Figure 2 illustrates the interventions design. LE implementation steps The LE interventions comprised of five steps implemented for nearly one year (between June, 2013-March, 2014). The first step involved recruitment and training of facilitators, and identification of existing community groups/associations within the catchment area of the selected health facilities in the sampled districts. A total of 52 facilitators were recruited and trained. 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: (i) documented evidence of regular meetings (at least once every two months), (ii) regular meeting venue, (iii) clear leadership structure, (iv) non-partisan in nature and activities and (v) active membership not less than an intuitive number of ten (10). These criteria ensured the groups were active in their activities and reasonably represent a cross-section of community opinion. There was no criteria for selecting individual members of the community groups. Since the focus was on engaging already existing community groups, existing composition of the groups was maintained to reflect the natural situation of the groups. The second implementation step entailed a first round of community group assessment of healthcare quality based on group members’most recent experiences with the particular intervention health facility in their community. Healthcare quality proxies used to guide community members during assessment were: (1)staff attitude, (2)punctuality to work, (3)client waiting time, (4)queuing system, (5)availability of drugs, (6)information provision to clients, (7)equal treatment for insured and uninsured clients, (8)complaint system for clients, (9)client-provider communication, and (10)net promoter score (NPS 1 ). During engagement sessions, group members used “Community Score Cards”to rate performance of their nearest health facility on these quality care proxies on a five-point Likert scale from 1 = “Very disappointing”to 5 = “Very Alhassan et al. Health Economics Review (2016) 6:49 Page 3 of 13 Satisfactory”. The group assessments were conducted in the communities to avoid possible bias and client intimidation at the health facility. Group ratings were based on the members’most recent experiences (at most six months) with the pertinent intervention health facility in the community. Anonymity of group members was assured by reporting group perceptions without individual personal details. The third implementation step validated community groups’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. During the fourth step, facilitators followed-up on the service providers (three months after validation and feedback sessions) to ascertain whether or not providers were implementing the agreed action plans towards quality improvement. The last step rewarded best performing health facilities after the second round of community assessment (approximately six months after the first Fig. 1 Geographic distribution of study facilities by districts. Source: WOTRO-COHEiSION Ghana Project Health Facility Survey Data (March-June, 2015) Alhassan et al. Health Economics Review (2016) 6:49 Page 4 of 13 assessment). A written citation of honor and a token financial incentive of about US$ 285.0 equivalence in Ghanaian Cedis was awarded to best performing facilities to encourage healthy competition among peers towards quality improvement. Besides the token financial reward given to each best performining health facility, it also cost approximately US$ 100.0 2 to conduct a round of community engagement session in a community. This amount was used to pay transportation and work allowance of the facilitator. Figure 3 shows the LE engagement implementation steps. Ethical considerations Ethical clearance was sought for the WOTRO-COHEiSION Ghana Project from the Ghana Health Service (GHS) Ethical Review Committee (ERC) (clearance number: GHSERC: 18/5/11). Written informed consent was also sought from individual participants who were literates. For those who were illiterates the study protocol was explained to them in the local language before consent was given by thumb-printing. Data analysis Two community groups were required to assess an intervention health facility during the first and second assessments. Per this criterion, total of 52 group reports were retrieved from the two study regions. Though the group assessments were done in the form of group discussions, overall perception per quality care indicator was attained by providing unanimous scores on a fivepoint Likert scale. This approach yielded quantitative data for analysis. Group ratings were recorded on the “Community Score Card”and later collated per health facility by trained facilitators. The group responses were all entered into STATA statistical analysis software (version 12.0) after cleaning and coding. Responses were analyzed based on group names and codes. For anonymity purposes, personal details of individual group members were not linked to the quality assessment ratings. Descriptive statistics were used to analysis the basic socio-demographic characteristics of the groups. Iterated principal factor (IPF) analysis was done to group 12 quality care proxies into five factors using the orthogonal varimax rotation option (Kaiser off). Cronbach’s alpha test was used to determine scale reliability for the 12 Likert scale items and the coefficient was found to be 0.92 which is above the 0.70 rule of thumb [16]. Wilcoxon sign rank test was used to test for group perception differences in the first and second group assessments. Overall differences in group perceptions based on facility ownership, location and region was determined using the Wilcoxon-Mann-Whitney test as appropriate [17, 18]. Factors associated with overall Fig. 2 Interventions design. Source: WOTRO-COHEiSION Ghana Project (2013) & Alhassan et al. Perspectives of frontline health workers on Ghana’s National Health Insurance Scheme before and after community engagement interventions. BMC Health Services Research; 2016 16(192): 1–11; Legend: GAR: Greater Accra Region; WR: Western Region; LE: Light Engagement; n=sample size. NOTE: MyCare intervention is detailed in Fenenga et al. (2014) hence it is not elaborated in this paper Alhassan et al. Health Economics Review (2016) 6:49 Page 5 of 13 community perception of healthcare quality was determined using the ordered logistic regression (OLR) test at univariate and multivariate levels. Results Composition of community groups Out of the 52 engaged community groups, 22 were religious/faith-based; the rest were: eight traders groups; one widows group; three community volunteers groups; three music/singers groups; five artisans groups and 11 youth groups. Average group size during an engagement session was 29 members (Min = 8, Max = 91); thus, about 1,500 community members were engaged during the first and second engagement sessions. More than half of the groups were female dominated; 13 were male dominated; two were all males; five were all females, and one was balanced number of males and females. Approximately 56 % of the groups were a combination of literates and illiterates; 23 % were mainly literates, and 21 % mainly illiterates. In terms of age, 65 % of the groups had predominantly elderly members (31 + years) and 35 % had predominantly youthful members (18–30 years). The average meeting duration per group was 41 min (SD = 13.8) with an average contribution time per participant being 1.4 min (SD = 1.3) (see Table 1). Community perceptions on healthcare quality Analysis of pooled data of the 52 community group reports showed that information provision to clients on use of suggestion boxes was rated lowest on the fivepoint Likert scale but private facilities (mean = 2.8, p< 0.05) appeared to have been rated higher than public facilities (mean = 2.4, p< 0.05). Quality indicators such as client waiting times; drugs availability and respectfulness of health staff were perceived to be relatively better in private than public facilities (p< 0.05) (see Fig. 4). Similarly, likelihood of community members recommending their nearest health facility to friends and relatives (net promotor scores) was averagely rated 3.0 for public facilities and 3.4 for private facilities (p< 0.05). Likewise, private health facilities were perceived by community members to be relatively better in terms of availability of suggestion boxes for clients; punctuality and courteousness of staff (p< 0.05) (see Fig. 4). Comparison of the first and second group assessment scores showed that perception of healthcare quality appeared to have improved significantly across all the healthcare quality indicators during the second group assessments in 2014, suggesting an improvement over the first assessments conducted in 2013. Community members particularly perceived significant improvement in information provision to clients by healthcare providers (mean diff. = 2.40; p< 0.0001). Likewise, perceived drugs availability Fig. 3 LE implementation steps. Source: WOTRO-COHEiSION Ghana Project (2013) & Alhassan et al. Effect of community engagement interventions on patient safety and risk reduction efforts in primary health facilities: evidence from Ghana. PLoS One; 2015 10(11): 1–19; Legend: C=Client; P=Provider; I=Insurer Alhassan et al. Health Economics Review (2016) 6:49 Page 6 of 13 (mean diff. = 2.27; p< 0.0001); provision of feedback on client complaints (mean diff. = 2.02, p< 0.0001), and net promotor score (mean diff. = 2.02; p< 0.0001) were found to have improved significantly during the second round of assessment. Though there were perceived improvements in staff respectfulness/courteousness towards clients and punctuality to work, the marginal increases were relatively lower (p< 0.0001) (see Table 2). Using the pooled first and second assessments data, it was found (after performing an ordered logistic regression test) that artisan community groups were more likely to rate quality care indicators higher than other types of community groups (Coef. = 1.78; p< 0.05) (see Table 3). In terms of age, community groups that were predominantly elderly (31 + years) were more likely to perceive healthcare quality more positively than groups with predominantly youthful members (18–30 years) (Coef. =0.98; p< 0.05). Table 3 shows other factors associated with overall perceived quality care in the intervention health facilities. Discussion Community engagement in health is not an entirely new concept in Ghana [6, 7, 19, 20] although its implementation and focus has not been on healthcare quality assessment. The CHPS programme in Ghana was one of the key community-based interventions aimed at enhancing community participation in health in line with the Alma-Ata declaration of 1978. Even though the CHPS programme has contributed to increased accessibility to basic healthcare services in Ghana, the programme by design does not appear to include active engagement of community groups in healthcare quality assessment especially in the context of the NHIS. Impact evaluation studies by Alhassan et al. [21–23] on effects of community engagement interventions on healthcare quality, patient safety, efficiency in health service delivery, and health staff experiences with clients corroborate the increasing benefits and perhaps untapped potentials of active community engagement in health service planning and implementation. Table 1 Composition of community groups involved in LE interventions Group characteristics Average age Group location 18–30 years 31 + years Rural Urban Group type % % p-value % % p-value Religious (n= 22) 4 % 38 % 0.000** 15 % 27 % 0.432 Traders (n= 8) 0 % 15 % 10 % 6 % Widows (n=1) 0% 2% 2% 0% CVG (n=3) 8% 0% 4% 2% Music/singers (n=2) 4% 0% 2% 2% Artisans (n=5) 7% 2% 8% 2% Youth groups (n= 11) 13 % 7 % 13 % 7 % Total (n= 52) 36 % 64 % 54 % 46 % Gender distribution Male dominated (n= 15) 17 % 12 % 0.005** 15 % 13 % 0.779 Female dominated (n= 36) 17 % 52 % 37 % 33 % Equal distribution (n=1) 0% 2% 2% 0% Total 34 % 66 % 54 % 46 % Literacy/education + Mainly literates (n= 11) 8 % 13% 0.000** 15 % 6 % 0.421 ++ Mainly illiterates (n= 12) 21 % 2% 11 % 12 % Literates/illiterates (n= 29) 6 % 50% 27 % 29 % Total 35 % 65% 53 % 47 % Group dynamics Mean(SD) Mean(SD) p-value Mean(SD) Mean(SD) p-value Active membership (n= 52) 60.4(15.0) 60.2(18.3) 0.9668 56.6(16.9) 64.5(16.6) 0.0967* Engagement duration (n= 52) 41.5(17.0) 40.8(12.1) 0.8634 44.5(15.1) 37.1(11.2) 0.0523* Average time per discussant (n= 52) 1.7(1.4) 1.3(1.3) 0.3139 1.1(1.2) 1.7(1.5) 0.1203 Source: WOTRO-COHEiSION Ghana Project, 2014; Wilcoxon-Mann-Whitney test statistically significant (*p< 0.1; **p< 0.05); + Literates are operationally defined to include those who have a least secondary education certificate; ++ Illiterates are operationally defined to include those who did not complete basic education or did not attain formal education altogether and cannot read or write Alhassan et al. Health Economics Review (2016) 6:49 Page 7 of 13 In Ghana, healthcare quality assessment and improvement strategies are mainly technical and dominated by medical experts with little or no community engagement in the process. Perhaps this is largely because of the widely held anecdote that healthcare clients lack requisite health information to assess quality healthcare standards. The increasing role of communities and clients in healthcare quality improvement is however becoming evident and compelling for active community engagement to guarantee successful implementation and sustainability of health programmes [6, 8, 21–25]. Although community engagement in healthcare quality assessment has been found to potentially induce high client confidence and trust in health systems [6, 8, 25], the Fig. 4 Community perception of healthcare quality graphed by facility ownership. Source: Light Engagement Intervention data of the WOTROCOHEiSION Ghana Project (2013–2014). Legend: *Mean scores based on the five point Likert from 1 = “Very disappointing”to 5= “Very satisfactory”. High mean score depict higher group satisfaction with pertinent quality care proxy while lower mean scores suggest otherwise. Note: Net promotor score is the chances of recommending the health facility to a friend or relative based on the overall perceived quality of healthcare Table 2 Mean scores of quality indicators in health facilities (n= 52) Mean scores 2 nd assessment (2014) 1 st assessment (2013) p-value Quality indicators Mean (SD) b Mean (SD) Mean diff. Respectfulness of staff 4.2(0.7) 2.9(1.1) 1.30 0.0000 a Courteousness of staff 4.2(0.7) 3.2(1.0) 1.00 0.0000 a Punctuality of staff 4.4(0.6) 3.0(1.0) 1.40 0.0000 a Clear information provision to clients 4.1(0.8) 1.7(0.8) 2.40 0.0000 a Directions to clients in health facility 4.1(0.9) 2.4(1.1) 1.70 0.0000 a Availability of drugs 4.0(0.9) 1.8(0.8) 2.20 0.0000 a Fair queuing system 3.9(0.8) 2.2(1.2) 1.70 0.0000 a Waiting time for clients 3.6(0.9) 1.9(0.9) 1.70 0.0000 a Availability of suggestion boxes 4.2(0.7) 3.4(1.1) 0.80 0.0000 a Information on use of suggestion boxes 3.4(0.8) 1.52(0.7) 1.88 0.0000 a Feedback system on clients’complaints 3.8(0.9) 1.8(0.8) 2.00 0.0000 a Net promotor score + 4.2(0.7) 2.2(0.8) 2.00 0.0000 a Overall quality score 4.0(0.6) 2.3(0.6) 1.70 0.0000 a Source: WOTRO-COHEiSION Ghana Project (2013–2014); a Wilcoxon signed rank test statistically significant (p< 0.0001); b Means and SD rounded up to the nearest decimal; + Net promotor score is the client's chances of recommending the health facility to a friend or relative based on the overall perception of healthcare quality in the pertinent health facility Alhassan et al. Health Economics Review (2016) 6:49 Page 8 of 13