Cost of delivering primary healthcare services through public sector in India

Background & objectives: Public health spending on primary healthcare has increased by four times (in real terms) over the last decade and continues to constitute more than half of the total public health expenditure. The present study estimated the cost of providing healthcare services at sub centre (SC) and primary health centre (PHC) level in four selected States of India. Methods: A total of 51 SCs and 33 PHCs were selected across the four States (Himachal Pradesh, Odisha, Kerala and Tamil Nadu) of India. The economic cost of delivering health services at these facilities was assessed using bottom-up costing methodology during the reference year of 2014-2015. The cost of capital items was annualized and allocation of shared resources was based on appropriate apportioning statistics. Results: The mean annual cost of providing health services at SC and PHC was ? 0.69 million (US$ 11,392) and ? 5.1 million (US$ 83,837), respectively. Nearly 3/4th and 2/3rd of this cost at the level of SC (74%) and PHC (63%) were spent on salaries. In terms of unit cost, the costs per antenatal care and postnatal care visit were ? 221 (173-276) and ? 333 (244-461), respectively, at SCs. Similarly, the costs of per patient outpatient consultation and per bed day hospitalization at PHC level were ? 121 (91-155) and ? 1168 (955-1468), respectively. Interpretation & conclusions: The cost estimates from the present study can be used in economic evaluations, assessing technical efficiency and also for providing valuable information during scale-up of health facilities.

Clients' Perspective for Quality of Services at One of the Urban Primary Health Centres (U-PHC) at Municipal Corporation Area in One of the cities of Western India

Introduction: Client satisfaction surveys are central to quality improvement at health facility. It helps in identifying areas of low satisfaction and steps to maximize patient satisfaction. Objectives: To assess client satisfaction towards services at Out Patient Department (OPD) of at an U-PHC under Ahmedabad Municipal Corporation (AMC), identify areas of low satisfaction and suggest feasible remedial measures for improvement. Method: Out of 74 U PHCs under AMC, 1 was selected through simple random sampling. Quality of care was evaluated through client's feedback which was gathered through 10 check points (on structure, process and outcome) developed by state level quality team. Responses of 300 adult (> 18 years) subjects and their mean ± standard deviation scores were calculated. These subjects were selected nd thconsecutively as 25 cases (new cases who came first and were willing) on every 2 and 4 Mondays for 6 months (Sep 2019 – Feb 2020). Results: While availability of drugs was perceived as very satisfying that of investigations was relatively an area of concern. Overall, only 1 client rated the services as average while all rest (99.6%) rated services as very good to excellent. Conclusion: Quality of services at this U PHC was good to excellent and had wider acceptability among its client.

Social acceptance and job satisfaction of ASHA workers in the Garo Hills Division of Meghalaya: a cross-sectional study

Background: ASHAs were appointed by NRHM to provide preventive, promotive and curative healthcare services in the rural including tribal villages in Meghalaya. However, their social acceptance and job satisfaction remain less studied. Hence our study aimed at it.Methods: A cross-sectional study was conducted among 140 ASHAs from randomly sampled 142 villages across 15 PHCs in five districts. To collect data, we used a semi-structured back-translated and validated questionnaire consisting socio-demographic profile of ASHAs, level of perceived social acceptance and job satisfaction. Data were analysed using SPSS version 22.0.Results: Mean and median age of ASHAs were 33.29 and 32.00 years respectively. Over 63% belonged to Garo tribes, 67% studied high school, and 91% married. Village elders selected 76% of ASHAs, and 81% were as ASHAs for at least eight years. About 86% were trained in a minimum of three modules and all found their training effective. While 92% had the medical kit always filled, 100% had registers updated, and 94.3% facilitated VHND and FHD meetings. About 97% accompanied the pregnant women, 96.4% attended PHC meetings regularly and 83.6% organized VHSNC meeting. Though 93.5% reported a high acceptance of ASHAs' services, social acceptance of ASHAs was rather to some extent for 36.4%. Almost 52% of ASHAs were dissatisfied with job and 61% were unhappy with their performance-based remuneration.Conclusions: Community must be aware of ASHAs’ role, and their job satisfaction has to be increased with a corresponding increase in incentives while developing strategies to ease the process of payments.

Screening for autonomic neuropathy using validated non-invasive scale among diabetes patients treated in the selected primary health centres of Puducherry, India: an operational research

Background: Diabetes autonomic neuropathy (DAN) is a complication of diabetes which has direct implications on the mortality of diabetes patients. American Diabetes Association (ADA-2017) guidelines recommend early recognition and treatment of DAN. In this regard, we conducted a study among diabetic patients treated in the selected PHCs of Puducherry to determine the proportion with DAN and to assess the factors associated with DAN.Methods: A cross-sectional analytical study was conducted among diabetics and information on socio-demographic details, morbidity and behavioural risk factors were elicited using semi-structured interview schedule. The COMPASS-31 questionnaire was administered to assess the autonomic neuropathy symptoms. The data was captured using EpiCollect mobile app and analysed using Stata 12.0 software. The proportion of DAN was expressed as percentage with 95% confidence interval. The association between independent factors and DAN was assessed using multivariate generalized linear models. The prevalence ratio with 95% CI was used to express the strength of association.Results: Of the total 303 individuals with diabetes, 32 {10.6% (95% CI: 7.3%-14.6%)} were screened positive for autonomic neuropathy using COMPASS-31 scale. The number of individuals with diabetes who needed to be screened (NNS) for finding one with autonomic neuropathy was 10 (303/32).Conclusions: One in ten individuals with diabetes was screened positive for autonomic neuropathy. With good yield, there is need for including autonomic neuropathy screening as a component in the comprehensive care provided to diabetes patients in the primary health centres.

Challenges faced by the patients in the management of risk factors of non-communicable diseases in a government primary health care setting of Puducherry

Background: India’s current approach for intervention in non-communicable diseases (NCDs) is more in terms of early diagnosis and treatment. The focus should also be on the management of risk factors in the diseased individuals. The objectives of the study are to measure the risk factors of NCDs, lifestyle modification followed by them and to assess the challenges in reducing the risk factors of NCDs faced by the study population.Methods: The study was conducted between March and June 2017 in 2 government primary health centres (PHCs) in Puducherry. Based on systematic random sampling, 200 patients enrolled in NCD clinic with diabetes mellitus, hypertension, Stroke and myocardial infarction were selected for the study. After obtaining written informed consent, data was collected.Results: Out of 200 participants, majority of them were in the age group of 51-70 years (60%), females (71%) and living in nuclear family (83%). Among 200 participants, 23.5% of them had diabetes mellitus, 42% had hypertension and 24% had diabetes with hypertension. The risk factors that many of the participants had were excessive salt and sugar intake, overweight and obesity, less vegetable and fruits intake and alcohol consumption. Out of 200 participants, the major challenges in reducing the salt and sugar intake were lack of awareness and no family support.Conclusions: Most of the participants were oldest females who had diabetes or hypertension. The most common NCD they were suffering from were diabetes and hypertension. The major challenge in the management of NCDs is lack of awareness.

Satisfaction levels of patients visiting primary health care centers in border areas of Jammu division

Background: Patient satisfaction surveys are one of the most important feedback systems for any hospital to understand patient concern and take necessary corrective measures. The study was done in primary health centers in border areas of Jammu division to know the satisfaction among the patient and describe their socio-demographic profile.Methods: Study was cross-sectional questionnaire based study conducted among the inpatient of the primary health center, Paragwal from 01 July 2018 to 30 November 2018. Data was collected using a pre-tested questionnaire and entered in an excel sheet and analysed using SPSS 20.Results: A total of 110 respondents participated in the group. The mean age of the study subjects was 43.4±9.7 years and majority (86%) of the respondents was married, higher proportions of males (71%) and majority subjects (77%) were illiterate. According to Kuppuswamy scale, 66% of the study subjects belong to low socio-economic status (SES). There was no statistical significant association of socio-economic status, age, literacy. Female gender was associated with satisfaction regarding explanation of illness.Conclusions: In the present study, we found that majority of the participant were satisfied. However, the areas like congestion and time management needs improvement.

Developing Consensus Indicators to Assess Pharmacy Service Quality at Primary Health Centres in Yogyakarta, Indonesia

@#Background: There have been no existing performance indicators to measure the overall quality of pharmacy services, including the aspects of drug management and clinical pharmacy services, at primary health centres in Indonesia. This study aimed to obtain these indicators based on a consensus of experts. Methods: The modified Delphi method was used to obtain the consensus. The initial indicators, based on a literature review, were evaluated and assessed by members of the expert panel through three rounds of repetition until the consensus was reached. The expert panel members were selected based on their knowledge of or expertise in pharmacy service performance and geographical considerations. Analysis of the expert panel consensus level was determined by calculating the mean and interquartile range. Results: Fifteen expert panel members started the first round (93.7% of the 16 targets) with 12 of them (75%) completing the third round of the modified Delphi method. Three expert panel members were representatives of the Regency Health Office, and the others were pharmacist practitioners at primary health centres from three different regencies. The consensus results were 26 indicators of drug management, 19 indicators of clinical pharmacy services, and two indicators of overall pharmacy performance. Conclusion: The consensus indicators for measuring drug management, clinical pharmacy services, and overall pharmacy performance can be used as a reference and standard to measure the quality of pharmacy services at primary health centres. Therefore, the measurement results are more relevant if compared between one and other studies.

Urban health: Needs urgent attention

Urban population in our country has increased at an annual rate of 2.7% during the last decade and it is estimated that by 2031, there would be about 600 million people living in urban India. The fast pace of urbanization has come to stay with increasing proportion of urban poor and vulnerable with health indicators much worse than their rural counterparts. The need to provide health care to urban poor has been emphasized in the past in various health committees' reports and National 5-year Development Plans, but no significant dent was made to improve the urban health scenario of the country. The National Urban Health Mission launched in May 2013 provides us a concrete mechanism to address special health needs of urban population with focus on urban poor. There is a strong need to set up primary healthcare system in urban areas and systematically deal with urban health challenges in terms of vector-borne diseases, rising incidence of noncommunicable diseases, air pollution and acute respiratory infections, road traffic accidents, trauma, and injuries. The initiatives to address these challenges do not remain confined to health sector alone but also need to be supported by sectors other than health such as social welfare, women and child development, road transport and highways, school education, drinking water, and sanitation. We really need to address wider and social determinants of health to effectively improve the urban health scenario.

Adoption of hand hygiene practices among health care providers.

Background: Hand hygiene is the most important measure to avoid the transmission of harmful germs and prevent health care-associated infections. Hand washing with plain soap removes loose transient flora even though it does not remove pathogens from the hands of healthcare workers. Proper hand hygiene is cheap, most effective, easiest and foremost method of reducing health care associated infections. This study was carried out to know the present status of hand hygiene practices and the barriers to adherence. The objective of the study was to assess the adoption of appropriate hand hygiene practices among health care providers and to find out the reasons for non-adoption. Methods: A cross sectional study was done to assess the adoption of appropriate hand hygiene among health care providers (Doctors, nurses, lab technicians) in upgraded/ block PHCs of Thiruvallur district... The data was analysed by SPSS-16. Proportion & chi square test was used to assess the statistical significance at 5% α. Results: In PHC’s there were 32 doctors, 61 nurses and 17 lab technicians which constitute to 110 heath care providers. Hand hygiene practices were satisfactory among 40 (36%) Z = 9 and the difference is statistically significant p<0.05. Conclusions: Hand hygiene protocols will reduce the nosocomial infections. Hand hygiene is the most important measure to avoid the transmission of harmful germs.

Utilization of health facilities at primary health centre by rural community of Pondicherry.

Background: The utilization of services at Primary Health Centre (PHC) by the community differs from place to place and changes over the time based on the availability of quality of services. It is also necessary to evaluate the utilization trend of primary health centre services by the community. Objective: to know the pattern of utilization by rural community on availability, utilization and perception of facilities at primary health center. Material and methods: A cross sectional, descriptive, community based study was done during September to November 2014 in selected sample from PHC area by interviewing 300 families on various aspects at their doorstep. The date collected from each family on the aspects such as awareness, availability, utilization and perception of facilities at primary health center. Results: More than 80% were aware about the PHC, its location and more than 75% on availability of free medicines and laboratory investigations. Many preferred to visit PHC for their ailments and waiting time for treatment was less than 30 minutes and 70% of families visited the PHC at least once since last 3 months for some kind of health problems. The common ailments were respiratory problems, fever episodes and accidental injuries. Nearly 50% were aware about the contents in the display of posters on various health education topics. Conclusion: Periodic assessment of pattern of utilization of PHC is important to improve the service utilization by the community through their involvement.