Quality of clinical care and bypassing of primary health centers in India
Introduction
In recent years the goal of universal health coverage (UHC) has become a core objective for countries to achieve under the Sustainable Development Goals (SDGs) (United Nations, 2015). Many low-and-middle-income countries (LMICs) have invested substantial resources to strengthen facility-based (and community-based) primary health care services as a way of providing affordable basic curative and preventive services. These efforts have traditionally taken the form of building, staffing and supplying a vast network of public funded and operated health facilities. In India, for example, the public-sector health system aims to provide basic health services close to rural and urban communities via a vast network of sub-Centers, and Primary Health Centers (PHCs). Strengthening the capacity of the public-sector to deliver health services close to communities continues to be important for government policy – for instance, recent health system reforms undertaken in India, such as the National Health Mission, have invested in building more health centers, improving availability of essential medicines and supplies, and staffing health facilities (Ministry of Health and Family Welfare Government of India, 2005; Reddy, 2015). However, public-sector health centers operate in a complex health care market where they compete for patients with private (formal and informal) health care providers. In fact, only a minority of illness episodes treated in rural (12%) and urban (4%) India are at public sector health centers like PHCs and sub-centers, suggesting that they are largely bypassed by patients seeking ambulatory care (Government of India, Ministry of Statistics and Programme Implementation, & National Sample Survey Office, 2015).
India's rural public-sector health system consists of a hierarchical network of sub-Centers, PHCs, sub-district hospitals, and district hospitals. PHCs are central to facility-based delivery of basic curative and preventive health services to rural communities. They cover between 20,000 and 30,000 people and are the first level in the public system where a physician is present along with supporting health workers. The clinician can be a Medical Officer trained in allopathic medicine and/or an AYUSH Medical Officer trained in Indian systems of medicine (Ministry of Health and Family Welfare Government of India, 2012). The acronym AYUSH includes various Indian systems of medicine - Ayurveda, Yoga, Unani, Siddha, Homeopathy, and Tibetan. PHCs provide outpatient and occasionally inpatient care, maternal health services, family planning, public health services, and basic diagnostic and laboratory services. Nominal user fees are charged for curative services and this varies across states.
Studies in several LMICs have reported that patients often engage in bypassing behavior in which a patient travels past the nearest health center to seek services further away (Akin and Hutchinson, 1999; Kahabuka et al., 2011; Kanté et al., 2016; Karkee et al., 2015; Kruk et al., 2009, Kruk et al., 2014; Salazar et al., 2016; Shah, 2016). Various factors are associated with why health facilities are bypassed. Well known determinants include distance to the health facility and the cost of treatment (Akin and Hutchinson, 1999). Further, individual-level factors associated with a higher likelihood of bypassing include being economically better-off, perceived poor quality of health services, duration of symptoms, and disease severity (Kahabuka et al., 2011; Kanté et al., 2016; Karkee et al., 2015; Kruk et al., 2009, Kruk et al., 2014; Shah, 2016). Facility characteristics associated with bypassing include poor structural quality such as a lack of essential equipment, medicines, or diagnostics, while recent facility renovations have been associated with a lower likelihood of bypassing (Kahabuka et al., 2011; Karkee et al., 2015; Kruk et al., 2014). Studies focused on obstetric care report that there is a lower likelihood of bypassing facilities for delivery services as the number of obstetric and newborn care signal functions performed increases (Kanté et al., 2016; Kruk et al., 2014; Salazar et al., 2016).
Studies on the association between quality of care and bypassing typically measure quality based on observable structural aspects, such as having necessary staffing, drugs, supplies, and equipment. However, process quality or the quality of the clinical consultation such as the way the provider interacts with patients, and the technical ability of the provider, may also be an important driver of where patients seek treatment. One study showed that when the quality of the services offered is low, health services that are free and nearby to where patients live are not sufficient to prevent facility bypassing (Akin and Hutchinson, 1999). Another study reported that patients were more likely to visit health facilities that had more knowledgeable clinicians and where good prescription practices were followed (Leonard, 2014; Leonard et al., 2002; Leonard and Masatu, 2007).
Bypassing behavior has implications for government policies of investing resources in facility-based delivery of primary health care. Moreover, patients expectedly spend more time and money when they bypass nearby health centers and seek treatment farther away. This study aims to understand why patients living in proximity to a local PHC might bypass it when seeking care. In particular, we are interested in knowing if bypassing is associated with variations in the clinical competence of health care providers and the structural quality of PHCs. We define bypassing as a situation when ill members of a household located in proximity of a PHC choose to seek care at a health facility farther away. Competence of the health care provider is evaluated in terms of their knowledge to treat illnesses commonly seen in primary care settings. Studies have found that more knowledgeable providers also do more in practice, though the correlation may not be strong (Das and Hammer, 2014; Leonard and Masatu, 2010). Structural quality of the PHC was assessed in terms of the condition of physical infrastructure, availability of drugs, and regular presence of clinical care providers.
This study is located in the state of Chhattisgarh in eastern India. Chhattisgarh is a predominantly rural state with a large tribal (31%) population and has some of India's worst health indicators (International Institute for Population Studies, 2017). Infant mortality in the state (54 per 1000 live births) is higher than the national average (41), but has fallen substantially from a high of 71 in 2005 (International Institute for Population Sciences (IIPS); Macro International, 2016). The ten leading causes of disease burden, in descending order, are ischemic heart disease, diarrheal disease, cerebrovascular disease, lower respiratory infection, neonatal preterm birth complications, tuberculosis, chronic obstructive pulmonary disease (COPD), iron-deficiency anemia, other neonatal disorders, and sense organ disorders (India State-Level Disease Burden Initiative Collaborators, 2017). Other studies report that communicable diseases such as diarrhea, malaria, leprosy, and tuberculosis continue to be major health problems in the state (Galhotra et al., 2014). Chhattisgarh has an expansive range of public sector health facilities. However, these are largely bypassed – around 64% of households did not use a government health facility when seeking treatment (International Institute for Population Sciences (IIPS) and Macro International, n.d.). Moreover, the top two reasons for not using a government health facility was distance (56%) and quality of care (41%) (International Institute for Population Studies, 2017).
Section snippets
Study design
This study is based on a cross-sectional survey of health facilities and households in 2009 in Chhattisgarh, India (Rao et al., 2010).
Clinicians in the study: Several types of providers provide clinical care at PHCs in the state of Chhattisgarh including Medical Officers, AYUSH Medical Officers, Rural Medical Assistants (RMAs) and Paramedical professionals. Medical Officers are doctors trained in allopathic medicine and have completed at least a MBBS (Bachelor in Medicine Bachelor in Surgery)
Results
Overall, 37% of the patients seeking care visited the local PHC as their first point of contact for treatment, 53% visited a private provider, and 10% visited a hospital (public or private); this suggests that the majority (63%) of patients living in the vicinity of the local PHC bypassed it when seeking treatment outside their home. If patients going to hospitals are excluded, then more than half (59%) bypassed the local PHC. Most PHCs received some visits from local patients – only 8% PHCs
Discussion
PHCs were envisioned to be the primary source of curative (and preventive) services in the communities they serve. Because they operate in a complex health system environment, in reality they often are one of several sources of curative care services in their communities and compete with other formal and informal providers for patients. Bypassing nearby health facilities represents patients making choices about where to seek care among the set of providers that they can access. In our study
Conclusion
Health system reform programs in India and in many other low and middle-income countries have attempted to strengthen the quality of primary health care services by improving aspects of structural quality such as ensuring that health facilities are in good condition, are adequately supplied with drugs and equipment, and have the necessary staff in place. Yet, despite these investments, rural health centers are often bypassed by patients seeking care. Findings from this study suggest that a
Funding sources
Global Health Workforce Alliance, WHO; National Health Systems Resource Center, Government of India; and the State Health Resource Center, Government of Chhattisgarh.
Conflicts of interest
None declared.
Acknowledgements
The funding sources for this research are: Global Health Workforce Alliance, WHO (PO#200162584); National Health Systems Resource Center, Government of India; and the State Health Resource Center, Government of Chhattisgarh. Grant from Global Health Workforce Alliance, WHO was made to the Public Health Foundation of India. The funders have no role in the writing or decision to submit this research paper. The authors would especially like to thank the reviewers for their insightful comments in
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