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INDIAN JOURNAL OF COMMUNITY HEALTH / VOL 32 / ISSUE NO 02 / APR - JUN 2020 [Should We Judge…] | Sarkar R et al
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SHORT ARTICLE
Should We Judge PHCs by Only IPHS Guidelines or Probe Further?
Rupa Sarkar 1, Mahesh E2
1Adjunct Faculty, PhD Scholar, CHRIST (Deemed to be University), Hosur Road, Bangalore; 2Assistant Professor, Department
of Economics, CHRIST (Deemed to be University), Hosur Road, Bangalore
Abstract
Introduction
Methodology
Results
Conclusion
References
Citation
Tables / Figures
Corresponding Author
Rupa Sarkar, Department of Economics, CHRIST (Deemed to be University), Hosur Road, Bangalore,
Karnataka – 560029
E Mail ID: rupasneha72@gmail.com
Citation
Sarkar R, Mahesh E. Should We Judge PHCs by Only IPHS Guidelines or Probe Further?. Indian J Comm Health.
2020;32(2):464-467.
Source of Funding: Nil Conflict of Interest: None declared
Article Cycle
Received: 04/04/2020; Revision: 11/05/2020; Accepted: 29/05/2020; Published: 30/06/2020
This work is licensed under a Creative Commons Attribution 4.0 International License.
Abstract
Background: Indian Public Health Standards (IPHS) evaluates supply side compliance of Primary Health Centers (PHCs).
Patient Satisfaction (PS) on the other hand, assesses the demand side. Objective: Examining the supply side compliance and
relating it to PS in the domain of Reproductive Health (RH). Methods: Using multistage stratified sampling, six rural and three
urban PHCs in sub-districts, Ramanagara and Channapatna, in District Ramanagara, state of Karnataka, India, were chosen.
Information collected using IPHS proforma for PHCs was compared with PS questionnaire (PSQ 18) data, collected from 398
patients visiting these facilities. Results: Using descriptive and inferential analysis, sub-optimal compliance levels in ease of
access, physical & human infrastructure, patient data and usage of untied funds was found. Existing behavioral compliance
was found to be optimal. These findings were in alignment with PS findings. Conclusion: Results call for PHC capacity building,
incentivization and a crucial need to look into PS side, before passing judgement about performance standard.
Keywords
PHC; IPHS; Health Standard Compliance; Reproductive Health; Facility Guidelines
Introduction
A 2015 Malaysian study using cross-sectional convenient
sample of outpatients revealed correlation among health
infrastructure and patient satisfaction.(1) A study using
World Health Organization (WHO) quality assessment
framework of patient satisfaction, adopted from the 1988
Donabedian model (framework of healthcare quality
evaluation by examining service provision), successfully
correlated healthcare infrastructure by measuring out-
patient experiences in 2018.(2) IPHS a similar quality
assessment supply side framework, is equally mindful of
the demand side of healthcare, as becomes clearly evident
from its proforma of compliance domains. Although many
IPHS guided district level PHC compliance studies were
undertaken earlier in states of Andhra Pradesh, Himachal
Pradesh, Gujarat, West Bengal and Karnataka, our study
findings reflect the equation between supply and demand
of healthcare facilities from solely RH perspective.
Aims & Objectives
To examine the alignment between the supply side of
PHCs with patient satisfaction they yield in order to cater
to their demand side.
Material & Methods
Study type: Cross-sectional study of PHCs and Patients
utilizing these facilities.
Study Population: 20000-30000 Patients of RH age group
(15-49) visiting these nine PHCs seeking treatment more
than once in last one year (May 2017-18) for RH related
issues of pregnancy, neo-natal, family planning, abortion,
miscarriage and RH disorders.
Study Duration: Seeking permission, data collection,
analysis and interpretation continued from March 2018 to
October 2019.
Sample Size and Selection Criteria: State of Karnataka in
the Southern Peninsular India, district Ramanagara and
sub-districts (taluka) Ramanagara and Channapatna were
chosen based on their mediocrity of RH indicators. The
specific PHC facilities were chosen by Medical Officers
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(MO) after instruction of District Health & Family Welfare
Office (DHFWO) keeping in mind their physical location
and staff experience. Rural PHCs (RPHCs) chosen were of
Laksmipura, Kanva, Kootagal, Kodamballi, Honganur and
Jagadapura. Urban PHCs (UPHCs) were Mehboobnagar,
Rayardoddi & S S Mohalla. First three RPHCs were from
Ramanagara taluka and the following three were in
Channapatna. First two UPHCs were in Ramanagara taluka
and the third one in Channapatna.
For arriving at a sample size of patients for demand side
survey, we used the information provided by the nine
PHCs, that a total 2341 RH related cases were treated in
OPD and in-patient cases in the month of May 2018. Based
on this, population for last one year was calculated at
maximum of 30000, sample size was estimated at 380
(Confidence interval 5 & Confidence Level of 95%). Total
398 patients were finally selected for the survey analysis.
Sample demographic classification was based on gender
(males 22% & females 78%), age groups (15-25 (29%), 26-
35 (34%) & 36-49 (37%)), religion (Hindus 47%, Muslims
52% & others 1%), medical background (RH 38%,
pregnancy 17%, neo-natal 16%, family planning 17% &
abortion/miscarriage 12%), number of visits in last one
year (2-4 (27%), 5-8 (40%) & >8 (33%)), type of visits (OPD
40%, OPD + Inpatient 54% & Inpatient 6%), residing
distance from facility (<2 (18%), 2-5 (20%), 5-10 (27%), 10-
25 (27%) & >25 kms 8%), education levels (illiterate 4%,
primary 47%, secondary 35% & tertiary 15%),
employment type (regular salaried 24%, daily waged 34%,
self-employed 37% & unemployed 5%), income levels
(<0.1 (20%), 0.1-0.3 (37%) , 0.3-0.5 (35%) & > 0.5 million
INR per annum (7%)) and insurance status (insured 25% &
uninsured 75%).
Institutional Ethical Committee & Ethical concerns: Prior
Institutional Ethical Committee permission was sought
before the study was undertaken (CU: CFR: 01/04/18).
Post briefing to MO and staff, duly attested and filled by
senior staff, the questionnaires were collected from PHCs.
For the Demand side survey, after orientation about study
details, privacy concerns and interview environment,
verbal consent was taken from all participants. Minors and
illiterates were interviewed in the presence of another
adult family member. Data was aggregated maintaining
complete privacy of personal details.
Strategy for Collection: Reproductive and Child Health
(RCH) survey questionnaire for PHCs, used in District Level
Health Survey (DLHS), was used to collect initial PHC
details in RH domain. Later the IPHS proforma prescribed
for same domains was used to compare compliance levels.
IPHS proforma used to collect the supply side compliance,
had items related to Infrastructure, Services, Training,
Quality control and Behavior. PSQ 18 standardized
questionnaire (by Marshall and Hays) used for collecting
PS, had seven sub-scales of General Satisfaction, Technical
Quality, Interpersonal Manner, Communication, Financial
Aspects, Time spent with Doctor and Accessibility &
Convenience.
Data Analysis: Data was processed for descriptive (Mean
& SD) and inferential (chi square) statistics using Excel and
SPSS 20.
Results
All the six Rural PHCs had a range of 13-25 kms distance
from secondary healthcare. None barring one, had
birthing facilities or operating 24/7. Only 66% of RPHCs
had 6 beds as per guidelines. 30% didn’t have staff nurse.
11% didn’t have a female Medical Officer. None had
Female Health Assistant. 22 % had no Male Health
Assistant. Three Urban PHCs which were catering to twice
or thrice the amount of population recommended by IPHS
were having only 2-3 beds and not operating 24/7. Untied
funds, a quality enhancing tool, was either partially used
or information wasn’t provided indicating either
documentation issues or non-transparency. Moreover,
the ratings of facilities, a deciding factor for release of
funds and a lot of procedural formalities, either delayed
or complicated its usage. 100% Behavioral compliance
was being met. Demand side findings are tabulated at the
end after references.
(Table 1) PS shows the technical quality, general
satisfaction gained from the medical care in general and
accessibility is lowest. These items were dominated by
questions about infrastructure, its advancement level
along with access. This finding is in alignment with IPHS
compliance findings. All behavioural aspects show higher
satisfaction which also is in conformity with IPHS findings.
(Table 2) Chi square results show strong association
existing between Income level, Insurance coverage, Type
of visit (at p<0.00l), Employment type (at p<0.05), religion
and patient satisfaction. We found no significant
association between age, gender, number of visits,
medical background and patient satisfaction levels. The
possible reason behind religion being dominant factor
may be either higher utilization levels or lower ease of
access arising out of lack of awareness or discrimination
faced. Economic background like income, salary type and
insurance affects indirectly amount of dependence on
public healthcare, so yields dominant influence. Type of
visit explores the length of stay and infrastructural
amenities directly so might be a significant influence
leading to stronger association.
Discussion
Supply side: First finding supported by previous studies,
indicate inaccessibility barriers caused by far away
locations, infrastructural shortage (Personnel, Drugs,
certain Pathology tests, specific facilities like OT,
Radiology, Birthing, and Inpatient).(3 4 5 6) This led to long
commutes, wastage of time, longer uncertain waiting
periods, monetary loss from private health expenditures,
wage loss for daily wage earners and limited treatment
choices. Second finding throws light on PHCs not being
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466
able to provide accurate quantitative data on patient
details as stressed earlier by another study.(7) Third
finding was regarding untied funds usage where there
seemed to be either partial usage or an information
blanket. We found Arogya Raksha Samiti (ARS) handling
this component appropriately, taking along the local
community members into confidence.
Demand side: Statistically significant demographic
variables clearly indicated economic factors having
dominance over personal factors. As found earlier Length
of stay, Employment type, Income level and type of
healthcare sought were crucial.(2) Lowest satisfaction was
found in Technical Quality, Accessibility and Convenience
showing coherence with supply side findings as
corroborated by another earlier study.(8) Providers need
to shift their focus towards these unmet demands.
Patients held PHC staff behavior, support,
communication, consultation quality in very high esteem
from both demand and supply sides which calls for
appropriate incentivisation as reported earlier.(9)
Conclusion
PHCs facing multiple supply side challenges, yet serve as
backbone of Indian Health system. Dedicated human
resource indicates involvement. Lagging physical
resources need to be made available to fulfil the structural
challenges by initiating key public investments at
grassroot level.
Recommendation
There is a strong need for intervention in accessibility
barriers caused by infrastructural shortage. Being mindful
of patient’s gender necessities through suitable staffing at
facilities would greatly help. Coordinated training in data
entry, closer collaboration with academic institutions and
IT sector are necessitated for training updates.
Strengthening of village communities crucial to take
initiatives to project their needs and suggest expenditures
under untied funds. Policy framers need to reinforce
meritorious staff contributions by suitable incentivization
including career growth, personal development and
monetary rewards as reiterated earlier.(10)
Limitation of the study
Larger number of PHCs and more sub-districts could
strengthen in generalising results.
Relevance of the study
Till now healthcare facilities in RH have been evaluated
from either supply or demand side. This study has
examined the purpose of these related perspectives
together for service alignment in RH.
Authors Contribution
RS: conceptualization, designing, implementation and
analysis. ME: reviewing.
Acknowledgement
The extensive support of DHFWO and Medical staff of
Ramanagara District is deeply appreciated. The study
wouldn’t be possible without the contribution of the
participants of the survey.
References
1. Ganasegeran K, Perianayagam W, Manaf RA, Jadoo SA, Al-Dubai SA.
Patient satisfaction in Malaysia's busiest outpatient medical care.
ScientificWorldJournal. 2015;2015:714754. doi:
10.1155/2015/714754. Epub 2015 Jan 12. PubMed PMID:
25654133; PubMed Central PMCID: PMC4306375.[PubMed]
2. Jena S & Gupta M. A survey of patient satisfaction of patients
attending a psychiatry outpatient clinic at a tertiary care centre.
International Journal of Community Medicine And Public Health
2018; 5(5):2026-30.
3. Kumar S, Dansereau EA & Murray CJ. Does distance matter for
institutional delivery in rural India? Applied Economics
2014;46(33):4091-103.
4. Osiya DA, Ogaji DS, & Onotai L. Patients’ satisfaction with
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5. Sriram S. Availability of infrastructure and manpower for primary
health centers in a district in Andhra Pradesh, India. J Family Med
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10.4103/jfmpc.jfmpc_194_18. PubMed PMID: 30613507; PubMed
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standards in primary health centers and community health centers
in Shimla District of Himachal Pradesh: A descriptive evaluation.
CHRISMED Journal of Health and Research. 2016 Jan 1;3(1):22.
7. A vision for primary health care in the 21st century: towards
universal health coverage and the Sustainable Development Goals.
Geneva: World Health Organization and the United Nations
Children’s Fund (UNICEF), 2018 (WHO/HIS/SDS/2018.X). Licence:
CC BY-NC-SA 3.0 IGO. Available from:
https://www.who.int/docs/default-source/primary-
health/vision.pdf.
8. Asraf M, Asraf F, Rahman A, Khan R. Assessing women’s satisfaction
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Res Intern Med Public Health 2012;4:1821-51.
9. Karnataka Evaluation Authority. Bangalore: Performance
Evaluation Study of NRHM in Karnataka-Project Report;
Grassroots Research and Advocacy Movement, Mysore,
Karnataka, India. Available from:
http://kea.karnataka.gov.in/sites/default/files/Evaluation%20of%
20the%20performance%20evaluation%20study%20of%20NRHM
%20in%20Karnataka%20.pdf.
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Tables
TABLE 1 P ATIENT SATISFACTION SUB -COMPONENT LEVELS
7 sub-scale
scores
General
Satisfacti
on
Technical
Quality
Interpersonal
Manner
Communic
ation
Financial
Aspect
Time Spent
with Doctor
Accessibility &
Convenience
Average
score/5*
2.78
2.9
3.62
3.49
3.52
3.23
3.17
Percentage
Satisfaction
55.6
57.8
72.3
69.8
70.0
64.6
63.4
Computed from SPSS output of Survey Data *Maximum score of five in a five-point Likert scale as suggested by the PSQ 18
questionnaire scoring key
TABLE 2 CHI -SQUARE TEST OF SIGNIFICANCE OUTPUT
Independent Variables
Pearson Chi-Square Significance
Gender
0.18
Age
0.85
Education Level
0.21
Income Level
0.000**
Number of Visits
0.13
Medical Background
0.47
Insurance Coverage
0.000**
Residential Distance from PHC
0.3
Religion
0.03*
Type of Visits
0.003**
Employment Type
0.03*
Computed from SPSS output of Survey Data * p<0.05 ** p<0.01
