The Patient's Perspective on the Functioning of the Primary Healthcare Centres in Bangalore,India: An Illustrated Guide

Abstract

India's healthcare system is, for a large part, organized around a vast network of Primary Healthcare Centres (PHCs) that form the pillar on which the public healthcare sector functions. The World Health Organization (WHO) has emphasized the important role that PHCs play in strengthening community health and the provision of healthcare. Although a few studies have assessed specific elements of services offered by PHCs, only a few have studied the patients’ perspectives on the functioning and performance of PHCs in the Indian context. A qualitative research methodology was employed to explore the opinions of 188 patients attending one of three PHCs in Bengaluru (India), using in-depth interviews and thematic analysis. Results showed that patients assessed PHC based on the nine themes that broadly can be classified into components of the center, and that of the personnel. The patients valued the behavioural aspects of the personnel during service delivery and should be configured into the PHC performance.

Introduction

India's public healthcare system is for a large part organized around Primary Healthcare Centres (PHC) providing preventive and promotive healthcare along with few curative services at the community level contributing immensely to the attainment of Sustainable Development Goals. These PHCs refer patients to higher primary healthcare facilities for secondary and tertiary care when needed. Given the important role that PHCs play, an assessment of their performance is critical. In the literature, the assessment of general healthcare facilities has been explored extensively with little consideration for PHCs assessment..^1,2 The existing framework focuses on the input-output or the indicators as per the building blocks of the health system. ³ While there are some studies that have assessed specific elements of the programs or services delivered at PHCs, few evaluated the overall functioning of PHCs from the patient's perspective, especially in the Indian context.

Generally, the individual's assessment of the PHC functioning is influenced by various factors: a person's background, which includes their cultural, educational, and socio-economic status; one's healthcare experiences; and underlying expectations. Furthermore, the assessment depends on the context of evaluation and thus a good performance reflects the environment in which PHCs are functioning. Therefore, a “good” performance is specific to the context, and the stakeholder's perspective of the evaluation. ⁴ India recognizes the importance of patient and community participation and monitoring as a key factor in enhancing the health care of the population. ⁵ Hence, their views on the PHC functioning are essential. In line with this, the study explores the PHC functioning and performance from the patient's perspective in the urban district of Bangalore, Karnataka, India.

Methodology

A qualitative research methodology was used to explore the patient perspectives on functioning and performance of PHCs in India. This study received approval from the Ethics Review Committee of Manipal University, Manipal, India.

This research was conducted in three PHCs located in Bangalore, Karnataka State, India selected based on the number of babies delivered in the facilities. The adult patients or the parents/guardians of children/patients visiting PHC for care who consented to participate in the study were included to elicit their claims and concerns and to discover the criteria adopted by them to assess the PHC. The 188 persons (45 male and 143 female) were interviewed in the local language until saturation in individual centres. The respondents were aged between 19 to 84 years and were from various walks of life. The interview lasted from 8 to 40 min. These in-depth interviews were conducted using interview guides focused on the patients’ healthcare expectations, beliefs, and experiences to elicit their perception of the functioning and performance of their PHC. The audio recordings of the interviews were translated, transcribed, and analyzed using Atlas-TI software with a thematic analysis approach. ⁶

Results

The analysis of the patient's interviews showed that nine themes were of significance to the patients utilizing services at these PHCs. They are (1) the availability of diverse and rich care by doctors round the clock and by specialists; (2) access to diagnostic services; (3) the availability of medicines; (4) a well-maintained PHC infrastructure; (5) considerations of the cost of care and medicines; (6) the behaviour and attitude of staff; (7) the punctuality of personnel; (8) the effectiveness of the prescribed treatments; and (9) the presence of well-organized services that enabled the PHC to function efficiently. These performance criteria were important to the patients, irrespective of the positive or negative assessment during the interview. The themes are related in a partly hierarchical order to each other. Figure 1 gives the pictorial representation of the PHC performance from the patient's perspective.

Figure 1.

Performance of the PHC from the patient's perspective.

Discussion

As the provider of healthcare, the Government, focuses on key performance indicators of a PHC as per Indian Public Health Standards. However, the aim is performance and enhancing service utilization, and thus assessments from the perspective of patients gain significance and relevance. The main themes expressed by patients were the centre and personnel performance. The patients identified the performance of the PHC center itself as the availability of services; the quality of the infrastructure; and the cost of care. Regarding the personnel, the efficiency of care that they provided, which depended on the knowledge they would have acquired during their education/training, as well as the resources available were regarded as important. This is in line with the literature. ⁷ Regarding personnel, also their communication skills and the personal qualities they brought to their human interactions, their punctuality and on how well they were organized while delivering services were regarded important. The major criterion that patients considered important was the attitude or the behaviors of the staff, including those of nurses and doctors.

Healthcare is part of the service industry, and like all service industries, success depends on the behaviors and attitudes of the staff toward their “customers”, who in this case are the patients. ⁸ An initial observation indicated that the performance of the PHC involves an interaction between various parameters, which include individual expectations about the government facility, as well as patients’ experiences at private and government facilities.

The presence of adequate and positive physical settings ensured that facilities met patient criteria and could lead to a facility having a sustainable competitive advantage. ⁹ Overall cleanliness and the decor and cheerfulness of the facilities are tangible aspects and important components of healthcare service and seem to relate positively to patient satisfaction in another study. ¹⁰ When healthcare services are provided in a welcoming environment, the mood of both patients and care providers will be enhanced, contributing to an environment that is conducive to healing; these factors are linked to patient satisfaction and indicate that the care providers are well-intentioned toward their customers, thus ensuring that patients recommended the facility to others. ¹¹ A model for PHC performance should thus reflect these themes when the functioning of PHCs is being evaluated.

The organization of services and the smooth functioning of the PHC synergize with the positive aspects of their infrastructure all of which contribute to patient recovery and better healthcare outcomes. Although the organization of services may be considered as components relevant only to the centre and to personnel, patients clearly indicated that they held personnel responsible for these factors and considered these elements to be a requirement. All too often, the patient's opinion is either ignored or simply taken for granted.

In India, a significant proportion of the population tends to fall under the poverty line because of catastrophic health expenditures, hence enhancing the performance of the public health system should be researched further so as to improve the health of the community at large. The patient's focus on the availability of services and the effectiveness of the process of care delivery is valid but, many patients laid emphasis on the availability of services that were often in the scope of secondary and tertiary care. One of the criteria that the WHO emphasizes is the distribution of financial contributions from providers or from other implementing agencies. ¹² The cost of care and medicines contributed to out-of-pocket expenditure, a factor that might significantly affect the patients’ decisions on whether to visit a government PHC or to go to a private care provider.

While utilizing the services of PHCs, the participants compared government PHCs to private facilities, and the trade-off was achieved between the cost of care and their expectations, as well as the experiences from the healthcare facility (government and private).

When one expects more than the standard of services, this might lead to one discounting the actual performance. Another important criterion for this would be patients not being familiar with the level of care and the service spectrum that is provided. This could lead to frustration, and friction between the patients and the provider ultimately leading to violence. A good cordial relationship is what creates a conducive environment for caregiving. ¹¹

The study helped identify nine themes for PHC evaluation by the patients in a partly hierarchical order but did not establish the order of preferences. This will have to be addressed in the follow-up study using a quantitative methodology to provide practical applications.

Conclusion

The patient's perspective, that is, the responses of people who are experiencing the healthcare services at PHCs in India were captured using qualitative research methods. Based on the analysis of 188 interviews, nine themes were found to represent the PHC performance. Such themes could be used to ensure continuous improvement in service delivery leading to better utilization of services provided. Orienting the patients on the scope of service available at PHC and other higher public health facilities would lead to a better assessment of the services, optimization of the service utilization, and thus better overall health of the population. Factors of PHC assessment from the patient's perspective are essential and should be considered.

Strengths and Weaknesses

The study focused on obtaining patients’ views and their assessments. The participants were from diverse educational backgrounds resulting in a complete array of performance parameters. As the study was conducted among the patients of urban PHC and not among the community the results are applicable to the population using the PHC and not the general public.

Recommendations for Further Research and Practice

Knowing the consumer's perspectives on the assessment of the PHC leads to the identification of areas for improvement or supplement service provision by Public Private Partnerships or other collaborations. A tool to assess PHCs by the patients including the themes identified in the study should be developed and validated.