It started with the first cries of “degage” that resonated across southern and central Tunisia to the streets of the capital in the winter of 2010. Through the ups and downs of Tunisia’s transition, one constant has been the citizens’ demand that the government listen to their voices, in other words, the demand for greater accountability.
While the marches and sit-ins are a clear public demonstration of discontent, policy makers in Tunisia have struggled to prioritize multiple and competing demands. Public opinion polls, banned under the former dictatorship but common today, rarely touch on bread and butter issues, such as how citizens feel about the most basic public services. One such issue is access to and the quality of health care, where systematic feedback from citizens has long been lacking. As part of a pilot project funded by the Korean Trust Fund, a World Bank Group team of health and information and communication technology (ICT) specialists worked with the Ministry of Health in Tunisia to develop and test an ICT-based citizen feedback system in three hospitals.
Starting from scratch
The implementation of the project was a challenge. Providing formal feedback on public services is new to Tunisians, and public service providers were even less accustomed to this novel concept.
Using a new approach, driven by the latest technology, the project’s aim is to make giving and administering feedback as easy as possible. It started with the development of a new software application that could be administered by health care professionals and be used and understood by patients.
This innovative application was developed by a local Tunisian consulting firm using two types of ICT software: LimeSurvey, an open source tool to create online surveys, and JasperSoft, a business intelligence platform used widely to analyze data collected from a variety of sources.
A mobile version of the application was developed for a tablet, allowing hospital staff to collect feedback in Arabic and French from any location. Interactive kiosks were also installed in hospital lobbies to allow citizens to provide feedback independently at any time. Results were then uploaded to a secure website that could be accessed by hospital and Ministry of Health project managers.
The application allows for automated analysis of survey responses which show aggregated totals and graphic results. Furthermore, the app renders the collecting of feedback from 2,000 citizens across three hospitals, quick, technically easy, and relatively inexpensive. This valuable experience can be replicated in hospitals across Tunisian.
What did citizens say?
For one thing, citizens tend to think of doctors and nurses as competent, rating their technical abilities highly. However, on all other areas of their hospital experience, things look bleaker. Ratings were very low for waiting times for treatment and receiving test results, the availability of medicines, the cost of services, and above all, the physical state of hospital facilities and equipment.
Below charts illustrate results obtained in Charles Nicolle Hospital in Tunisia during the November 2012 survey.
Interestingly, and contrary to expectations, citizens’ views were similar across the three hospitals, despite the fact that they were different types of facilities: a large, urban hospital in Tunis, a small hospital in the northern, semi-rural region of Bizerte, and a small hospital in the southern, less economically advantaged region of Medenine.
Given the ease and use of the tool in helping to improve public service delivery, the Tunisian government is looking at ways to roll out the tool throughout all public hospitals. The aim is to build trust through democratic participation and data driven feedback. This can help ensure that feedback can effectively trigger change and make public services more accountable to citizens’ needs.