Impact of a district-wide health center strengthening intervention on healthcare utilization in rural Rwanda: An interrupted time series analysis

Background: An informed citizenry is necessary for citizens to demand accountability from service providers. A citizen’s charter is one approach intended to inform citizens about service entitlements and standards. The key assumption of a charter is to inform citizens about their rights so they can, in turn, exert pressure on service providers to improve performance. Nepal has recently implemented a charter program in its primary health care facilities. Despite some empirical findings on the effect of charters on awareness of rights and services, there is a scarcity of local literature about how charters have been implemented and their effect on health service delivery. The aim of this study is to gauge the level of awareness of the charter, explore the process of implementing it, and the perceived impact on transparency and accountability in a primary health care setting of Nepal. Methods: Using a mixed methods case study design, a total of 400 service users, health facility committee members and service providers were recruited from 22 of 39 public health facilities in the Dang District. Interviewer-administered structured questionnaires were used to collect quantitative data. In addition, qualitative interviews with 39 key informants were conducted to provide more detailed and contextual information. Quantitative data were analyzed using SPSS 16; qualitative interviews were transcribed and then analyzed using QSR Nvivo 10. Ethical approval was obtained from the Human Ethics Committee of Otago University and Nepal Health Research Council, and written consent was granted by all participants. Findings: There was low awareness (15%) among service users of existence of the charter. Literate respondents were more likely to be aware than illiterate (p Interpretation: Poor implementation and low public awareness of the charter has limited it to a mere information tool suggesting the need for consultation with citizens in charter development. This study was limited to a single district of Nepal, but a thick description of the study context helped to provide detail of the charter implementation and its perceived effects. Funding: Otago University. Abstract #: 02GMHE001