Using of Mystery Clients' Experiences and Feedback to Improve the Quality of Family Planning Services in Northern Ghana: Evidence From an Uncontrolled Quasi-experimental Study.

Introduction Although there is a global increase in modern contraceptive uptake, some countries, including Ghana, have stalled, particularly in the northern part of the country. One contributory factor is the quality of family planning services provided at health facilities. Conventional methods used to assess the quality of care in health facilities may not be effective in identifying quality issues in areas like reproductive health. Nevertheless, mystery client (MC) surveys and feedback have been used globally to identify sensitive issues that conventional methods may have missed. However, there is limited evidence of their use in family planning services in Ghana. This study, therefore, aimed to use the MC approach with feedback to improve the quality of family planning service delivery based on specific actionable points in Northern Ghana. Methods Three rounds of mystery client surveys were completed in a quasi-experimental design with no control group in eight health facilities in 2019. Different sets of mystery clients were used, and feedback was given to health workers after each survey. Quality of care was graded using 13 actionable points. These actionable points include "Warm reception", "Confidentiality and Privacy", "Service available 24/7", "Identifying wandering clients", "Availability of preferred commodity", among others. The total score for each health facility was calculated, and the mean score for the eight facilities was determined. T-test and repeated-measures ANOVA were used to determine whether service improvement was significant. Minutes of feedback sessions were documented, and content analysis was done to identify relevant themes and codes. Results Grading for the three rounds of the mystery client surveys showed consistent service improvement for successive rounds. The mean scores of the quality of family planning services increased from 20.0 (±6.9) to 30.4 (±6.2), and the p-value is 0.0032. Some identified themes from the content analysis of the feedback sessions included "risk of identification of MCs by health workers", "reactions of health workers to their performance", and "district health authorities' decision to adopt the MC approach into their monitoring strategies". Conclusion Using successive mystery client surveys with the associated feedback based on specific actionable points improved the quality of family planning services. Decision makers should incorporate mystery client surveys with feedback in their monitoring strategies to identify sensitive issues that would be missed using conventional methods.