We have chosen an AR approach. The researchers involved have perfect mastery of this concept, which is adapted to both the country’s context and the problem [36]. The AR approach will make it possible to continuously adapt the project and ensure maximum effectiveness for better citizen participation and consideration of users’ needs in health decision making. AR is “a participatory democratic process that involves the development of practical knowledge of interest to the population, rooted in a participatory worldview that emerges at this particular historical period” [37].

Using an AR approach, which enables rapid learning, this project (named TechnOlogie PartIcipation Citoyenne en santé [TOPICs]) will study the acceptability, process, effectiveness, and financial cost of the digital device for citizen participation in health in urban and rural areas. It will also analyze the potential for using the evidence produced—in other words, the potential of the data collected by the device (TF-IVS) to improve practices. Finally, this research will draw lessons from the AR implementation to facilitate a possible national scale-up in the event of a successful outcome.

The objective of this project is to evaluate, in Burkina Faso, the large-scale implementation and acceptability of a technological system for collecting people’s opinions on the health system, with a view to improving health governance and informing citizens about their health-related rights and duties.

The research questions (RQs) are as follows:

RQ1. What are the challenges involved in setting up, operating on a large scale, and using the digital device to gather the opinions of users and health workers about the Burkinabè health system?

RQ2. What factors internal or external to the AR project influence acceptance of the digital device to gather the opinions of users and health workers about the Burkinabè health system?

RQ3. What factors internal or external to the AR project influence the decision making of the actors or decision-making bodies based on the results of the digital device?

RQ4. How effective is the digital device in gathering the opinions of users and health workers about the Burkinabè health system?

RQ5. What are the economic costs of setting up and operating a system to collect the opinions of users and health workers on the Burkinabè health system?

RQ6. What are the effects of the knowledge transfer (KT) strategy and process on decision making?

We first focused on defining needs and challenges, as well as on discussions with structures already carrying out similar experiences (to avoid duplication and ensure our process would be complementary to theirs).

We met with authorities and stakeholders from the central government, the region, and localities in the targeted areas. Then we collected information and made an inventory of the existing situation. This was followed by a process of validating our information and strategies. This work with stakeholders established the beginning of project ownership, a shared understanding of the implementation strategies, and mutual agreement on expected responsibilities and results.

Finally, we defined the geographic area to be covered by the AR project based on the possibility of applying our AR project both in urban areas (more suited to ICT implementation) and in rural areas in order to verify its feasibility. The issues related to project implementation in both rural and urban areas were among the main challenges considered in this preparation phase. Figure 1 presents the theory of change for the AR project.

Different types of evaluations will be carried out:

This AR project is based on evidence gathered through both a rigorous literature search and a previous pilot experiment that identified various subjects on which health center users and health professionals wanted to give their opinions on the health system [35].

Furthermore, because health interventions are strongly influenced by their context, this intervention was carefully conceptualized in relation to the Burkinabè situation [38]. As indicated by Craig et al [38], the following dimensions were taken into account: (1) the contexts in which the AR is intended to be applied, (2) the ways in which causal mechanisms and modes of delivery are context dependent, and (3) the dimensions of the context and how they are defined. As such, the Template for Intervention Description and Replication (TIDieR) for population health and policy (PHP) interventions will be helpful to report our AR project [39].

A group of four partners will implement this AR project: the International Health Unit (USI) of the University of Montreal, Canada; the Institut de recherche pour le développement (IRD), France; Heidelberg University, Germany; and the nongovernmental organization (NGO) Action-Gouvernance-Interaction-Renforcement, groupe de Santé en Développement (AGIR-SD), Burkina Faso. The AGIR-SD will conduct activities with the assistance of the IRD and University of Montreal researchers and the USI. The AGIR-SD is also involved in a teamwork process with a civil society organization (CSO) to raise public awareness and to organize information activities on the existence of the TF-IVS. Collaboration will be established between the German NGO Hilfe zur Selbsthilfe (HELP) and the AGIR-SD for coverage of the AR zones.

The TF-IVS will be implemented on a larger scale than the pilot project developed in Burkina Faso in 2014 [35], particularly in rural, semiurban, and urban areas, in order to be able to compare results according to place of residence and contextual realities, while taking into account the project’s resources.

Of the three regions targeted by the AR project, two include the country’s two largest cities (Ouagadougou and Bobo Dioulasso); these have a predominantly urban population. Diébougou is a rural area, which represents a challenge to test technological AR. The TF-IVS project will cover 14 health districts located in 3 regions (see Figure 2). It should be noted that in rural areas, just over half of the population (55.8%) owns a mobile phone, whereas in urban areas, almost 9 of 10 people (87.0%) own a mobile phone [40].

The direct beneficiaries are the users of health services in the health regions of the Center, the Hauts bassins, and the province of Bougouriba and, more particularly, women, girls, and the poor, as well as health workers and community relays. Secondary beneficiaries are the entire population; health system managers; decision makers; and political, administrative, customary, religious, and CSOs.

In Burkina Faso, three operators share the mobile telephony market: Onatel, Telecel, and Orange. The mobile phone penetration rate was 95.95% in 2019 (Regulatory Authority for Electronic Communications and Posts [RAECP]) [41]. Mobile phone ownership rates are 79.4% for men and 51.7% for women. Almost two-thirds (64.3%) of Burkinabè aged 15 years or over owned a mobile phone in 2014. It is also known that half of the poorest 20% of individuals have a functional mobile phone, as do 82.3% of the richest 20% of individuals [40]. At the national level, 87.4% of individuals who did not own a phone but had used one in the past 30 days used the phone of a household member, and 12.4% used the phone of a non-household member. This access to phones is an opportunity for the initiative to succeed.

This health AR project will develop a TF number, free of charge, reachable from any landline or mobile phone, anonymous and available 24 hours a day, 7 days a week, in any of the 9 main languages spoken in the areas targeted by the project. Phone users will use their phone keypad to respond to questions. Service users and health workers will answer two different questionnaires designed for their group. Figure 3 outlines the various phases of the call and the separate themes covered for service users and health workers.

While maintaining anonymity for ethical reasons, the system will request elements characterizing the caller, such as the city in which the health center is located, the health district in which the health worker is practicing, the sex of the caller, and their age group. The data collected will be stored on a local server secure and replicated in Burkina Faso. The data will be instantly transferred to the database accessible via the internet for collection.

Thus, persons calling the TF number will be able to answer the IVS questionnaire (Figure 3) and then will get an opportunity, at the end of the satisfaction measurement questionnaire, to receive information about their health-related rights and duties. The information about health rights that will be disseminated will have been validated by the project’s technical committee.

A technological platform will be developed and managed by AfricaSys, which supported the pilot TF number project tested in 2015 [35] by the NGO AGIR-SD. The technological platform (Figure 4) will consist of a combination of the TF number, the IVS, the database, a computer, and a website (where the database is located). Figure 5 summarizes the design, process, and targets of the AR project.

The required infrastructure is based on continuous electrical, telephone, and internet access. A power generator is installed in Ouagadougou, in a facility belonging to the Institut de recherche au développement, to cope with frequent power and internet interruptions.

Support activities will be carried out. Communication activities will focus mainly on media and nonmedia communication campaigns in French and local languages. These will be implemented throughout the project to make known the device being made available to the population and health workers to express their opinions. Different communication channels will be used to enable the project to effectively achieve its communication objectives. This media campaign will be reinforced by social integration activities in the form of information and awareness-raising sessions in the community (talk-debate, discussion groups, sketches, etc). These will be aimed at encouraging people to use the digital devices available. Through a participatory approach, the project will involve several stakeholders and implement four packages of community activities:

The AR project will consider the population of the three areas targeted as well as the associated health workers. The total population covered in the 14 health districts covered by the TF-IVS is presented in Table 1 [42].

Table 2 presents the situation (in 2018) of the public and private health infrastructures and the health worker population in the TF-IVS coverage areas [43]. The following are considered health workers: specialist physicians, general physicians, pharmacists, dental surgeons, specialized nurses, biology laboratory technicians, state-registered nurses, registered nurses, state midwives, and state medical officers [44].

To carry out the different types of evaluations proposed before, we will adopt both a mixed-methods [45] and a multimethod approach.

This study protocol emerged during a series of meetings with authorities and stakeholders from the central government, the region, and areas in the targeted areas regarding their health and health care needs. This project is aimed at the population and health workers; they were indirectly involved in this study’s design. This project is based on evidence gathered through both a rigorous literature search and a previous pilot experiment in Burkina Faso that identified various subjects on which health center users and health professionals wanted to give their opinions on the health system. For the evaluation of the implementation, operation, use, acceptance, and efficiency of the digital device, the persons involved will mainly be the project team members, the sociohealth authorities, and community members. Finally, to maximize collaboration and to ensure that knowledge users are invested in using the study findings, a KT approach will be embedded throughout this project. Those who will benefit will be participants both in KT training sessions, including project team members, and in deliberative workshops and key informants from relevant ministries.

The data collected through the TF-IVS will be analyzed regularly, and the results will be disseminated on an ongoing basis to provide users of the health system and health authorities at all levels of the system with evidence to improve decision making. This sharing of results will be done through regular feedback to administrative personnel, health authorities, and CSOs. In addition to the activities planned in the KT strategy (as described in the Data Collection and Analysis section), the data-sharing strategy is defined as follows:

Ethical approval was obtained from the Institutional Health Research Ethics Committee (IRSS) on September 24, 2019. The protocol research project registration number is 23–2019/CEIRES.

The use of the TF number will be free and voluntary. No personal information will be compiled from it. In this way, the data collected will be anonymous and kept confidential. The telephone operators who route the calls to the platform have contractually agreed to respect the confidentiality of the data and metadata of the calls. The software publisher has also contractually committed not to monitor or use identification data. Number capture, even if partial, was activated to identify the source telephone operators and quantify the share of each in terms of call flow (an important metric for the project). Finally, the software publisher has implemented additional security mechanisms for accessing and using the data with (1) secure individual access via a virtual private network (VPN), (2) a connection via a login and password to access the data, and (3) the implementation of a mechanism that allows, via pseudo-anonymization based on the SHA-256 hash algorithm, to transform each actual telephone number into a unique and irreversible digital fingerprint. A correspondence table has been set up in a different database, always with secure access.

All individual interviews will be conducted after the free and informed consent of the people interviewed. There is no risk associated with participating in this research project. The people who will be met will not receive any financial reward for their participation.

However, AR has policy and ethical implications that go well beyond the pure concerns of the free and informed consent of human subjects encountered in traditional research. Access to data; information use during and after investigation; the intellectual property of publishable materials resulting from the process; decision making throughout the study; and the impact of change on the individuals, organizations, and interest groups involved are essential issues that will inevitably confront the researchers.

mHealth technologies should contribute to improving the conditions of access to and provision of health care, while supplying a means to support public health policies [27]. Given human resource shortages and a lack of material and infrastructural support, the mobile device consequently would appear to reduce financial costs [66], be time effective, and overcome distances. Thus, mHealth constitutes a useful tool for reducing the technical and human burden of setting up surveys, making it possible to develop multiple data sources that are easily accessible and transferable between actors. Many such interventions [67] in sub-Saharan Africa offer information or prevention services [29] or give patients an opportunity to call a TF number and talk with a contact person. However, the use of SMS has shown its limitations [68], especially when addressing a rural population. In the literature, there are few interventions using ICTs associated with the IVS to improve health services access and health system governance at the same time.

Our protocol is innovative for several reasons: On the one hand, it proposes a technology associated with an evidence-based approach, adapted to the context, performed on a large scale, equitably and presumably at low cost; on the other hand, this approach is original in its AR dimension with communities and local NGOs, which includes a real KT component and spatial analysis of data, while using mixed methods of AR evaluation.

The IVS will be used to administer a survey to patients and health workers in the areas targeted by the project. This questionnaire was constructed through a rigorous scoping review that referenced the content offered to patients to measure satisfaction with the quality of and access to health care in West Africa [69-72]. It incorporates topics chosen by callers during the first phase of the TF-IVS pilot project [35] in connection with health system reforms, particularly in terms of the introduction of certain free services [73].

This AR project is to be carried out on a large territorial scale, integrating urban, rural, and periurban territories. The three zones combined cover 25% of the national population and are therefore intended to be reasonably representative of national opinion.

This questionnaire has been designed to be anonymous, adaptable, accessible, equitable, user friendly, and understandable (with clear instructions) to a heterogeneous population. For this purpose, a faithful translation into eight languages will make it possible to offer this service to the entire community of the targeted localities. This service will be available for all, everywhere and anytime, allowing people to give their opinion openly and anonymously.

The choice was made to conduct an audio survey rather than using SMS, because the former does not require any writing or reading skills and can thus be accessible to everyone. The necessary device is easy to use (the service is intuitive and easy to handle) and does not require a smartphone, just a touch phone.

Sustainability is an essential consideration when implementing an AR project [74]. Here, sustainability is supported on two fronts: (1) the call is free for the target populations and the user’s device is widely available (can be purchased or borrowed) and (2) costs are low, in terms of human and financial resources, for the organization that finances the project.

Moreover, touch-key technology enables additionally detailed, rigorous, and objective analysis, while being more efficient in terms of resources and time. It facilitates data management, in that data can be processed automatically online. Analyses will be executed over time and geographically. These spatiotemporal data represent a relevant added value for the evaluation of the project because they will measure spatial disparities in health care quality satisfaction. In addition, these types of mapping results are data that can be easily explained to decision makers and the public [75].

The uniqueness of this AR project lies, in particular, in the importance of making results available in several ways to different actors and in as many geographical areas as possible (at the regional and health district levels). This can be done by implementing an elaborate KT strategy based on the evidence regarding KT effectiveness [76]. The strategy will consist of (1) training [77] all implementing partners in techniques for making research results accessible to and usable by decision makers and the public from the start of the project and (2) presenting these results (problems identified by the AR and recommendations and proposals for action plans) at deliberative workshops, at the middle and end of the project, in the form of policy briefs [78] to complement the evidence produced by the project with other data from local expertise so that the resulting AR can be piloted in a feasible, applicable, and research-informed manner. The results of this work will be disseminated and shared through various information and awareness-raising strategies to encourage their adoption by health actors [79], and in particular by making data available on the platform to decision makers and other stakeholders in the health system.

However, for this KT strategy to be successful, it will be necessary to carry out in parallel the essential activity of making people aware of their health-related rights and duties, while informing them about the existence and the importance of using the TF number. Indeed, significant efforts will be made to create an enabling environment for people to understand and accept the system and be able to use it [80]. For that purpose, the AR project envisions involving local radio stations, communities, spiritual groups, trade unions, and local, religious, customary authorities.

The last main strength of this project is the evaluation approach, which is suited to complex problems. It will be subtle, in that it will be designed according to mixed methods, where each method will be applied rigorously in relation to the criteria set out before in the methodology. A convergent sort mode will be used to connect the data from a quantitative phase with the collection and analysis of data from another qualitative phase in order to be able to produce an assessment as relevant as possible throughout the AR project.

To have a healthy society, everyone must be able to benefit from UHC, which implies an approach centered on the right to health. Achieving this goal requires not only strong political will but also the participation of all stakeholders. It is in this perspective that our AR project will take place. To improve health governance, we propose to exploit the technological potential of mobile telephony by offering a free service aimed at legitimately highlighting poor practices to serve as a basis to improve their management with the support of public opinion and health workers. In this way, the AR project would empower people to participate in democratic processes and to enjoy and exercise their human rights. Special attention will be paid to evaluating the project. By measuring its effectiveness, or lack thereof, we will be able to understand why, how, and under what conditions it can be most successful, based on the evidence produced. This approach could be relevant for supporting governments in their quest to improve population health.