Quality of Public Health Care

jurisdiction. They have to study the major health problems in their areas and send monthly reports to the CMOH or Block Medical Officer Health (BMOH). Medical tasks and administrative tasks are equal parts of their responsibilities. However, the administrative functions they have to perform are very time-consuming. They have to maintain the registers, write reports every month, attend meetings and trainings, coordinate their employees and do the daily correspondence. Ranga Rao found that in Tamil Nadu the number of registers was 40, monthly reports 52 and correspondence 6 letters a day (Ranga Rao 1993: 85-88). The monthly reports are mostly handed in personally at the monthly district level meetings (own observation). Relations between MOs, who are mostly outsiders, and employees, often local residents, can be problematic. The local influence of paramedical staff and the existence of powerful unions lead to difficulties in maintenance of discipline.

The CHC has specialised services, it is staffed with 4 MOs (Surgeon, Obstetrician, Physician and/or Pediatrician), 7 nurses and other paramedical staff leading to a total number of 25 (MoHFW 2002a). Family planning operations and other small curative services are offered here. However, the figures provided here are only policy requirements and do not correspond with the actual situation of rural primary health care.

3.2.2. Quality of Public Health Care

3.2.2.2. Public Health Personnel

However severe the shortfall of health care facilities is, the lack of doctors and paramedical staff in the existing rural facilities hampers quality of public health care even more. Despite the high output of doctors from medical colleges, nearly 6 % of PHCs have no doctor, 9% lack a pharmacist, and 23 % have no lab technician (MoHFW 2002a: 38).

In all of India the ratio of public sector physicians to population is as low as 0.2 per 1000 persons (Peters et al. 2002: 41). Most of the urban educated doctors are not willing to serve in rural areas, where infrastructure and payment are poor. The private sector in turn offers high technology and good payments, most often in an urban location, where living standards are much higher than in rural areas. Incentives to bring more doctors to rural areas include housing allowances and obligatory two years of rural services for students who want to continue their education with Post Graduate courses (Misra et al. 2003: 125).

All the attempts have not been fruitful so far. The state’s dilemma is high spending on education of doctors which will not be working in public services later on. The kind of education medical students receive is also blamed for their lack of enthusiasm for rural areas. While social and preventive medicine is only a side subject, Western medical care models and technologies are the major part of teaching. Therefore, it is not surprising that a large number of doctors also emigrate to the United States of America, Great Britain and Arabian countries (4,000-5,000 each year; Duggal 2000: 11).

The National Health Policy summarises the inadequacy of public health facilities as a combination of insufficient funding, lack of staff and consumables, obsolescent and unusable equipment, deteriorated buildings, lack of essential drugs, and inadequate capacities (MoHFW 2002b: 9). The quality of public health services can be further evaluated looking into utilization, access and equity of health care.

3.2.2.3. Utilization of Public Health Services

Overall utilization of public health services is very low. The utilization rate for outpatient care is less than 20 % (MoHFW 2002b: 22; Peters et al. 2002: 7). Figure 3.17 shows the shares of the public sector in the delivery of immunization, prenatal care, institutional deliveries, hospitalization and outpatient care for patients above and below the poverty line (Peters et al. 2002: 7). While the share of the public sector in immunization is more than 80 %, it declines for the other services. The figures indicate that the public sector plays an important role in immunization, prenatal care and institutional deliveries, where its share is around or above 50 %. The public sector distribution to hospitalization and outpatient care is less significant. The figures also indicate that patients below the poverty line use public sector facilities more in all categories than patients above the poverty line.

Figure 3.17: Utilization of Public and Private Services by Income Status

The estimates for all of India are partly corresponding with but also contradicting village level studies. Banerjee et al. found in their study on health care delivery in Rajasthan that public services are more used by the richer third of the population (Banerjee et al. 2004:

945). Higher income in this study was also associated with a higher frequency of visits and higher monthly absolut expenditure on health. However, according to household budget all income groups spend the same amount for health care (7 %). The study also reflects that private health services were the most important source for health care delivery for all income groups, followed by public health services and traditional healer¹⁴. The poor and the middle income group were more likely to use the traditional healer than

14 - Traditional healer (ojha) is a person with no medical degree, who practises faith healing (ojha-tona). “The idea of ojha-tona is to get rid of any possible evil spirit causing illness.” (Ray/ Bhaduri 2001: 15).

Source: Peters et al. 2002: 7

the public system. Ranga Rao in turn discovered that villagers in Andhra Pradesh, Tamil Nadu and Karnataka preferred the PHC doctors (72.2 %) to the private practitioners (27.8 %; Ranga Rao 1993: 148). Traditional healers were again popular in the poorer sections of population, but most people who decided to use the services of the private doctors preferred doctors with a qualified degree (77.1 %). In Gujarat contacts of women to traditional healers outnumbered all other services (67 %), followed by services from a non-governmental organization (56 %, Aga Khan Health Services), government services (35 %) and private services ranking last (20 %)¹⁵ (Vissandjée et al. 1997: 143).

Income is not the only variable influencing utilization of health services. Education, occupation, age, households assets like tap water, family structure, severity of illness and others also influence the decision to use health services (see Vissandjée et al. 1997;

Pallikadavath et al. 2004; Pillai et al. 2003; Chacko 2001). Vissandjée et al. highlights that older age, higher education, access to tap water and membership of higher caste for women is positively associated with private doctor use (Vissandjée et al. 1997: 143-145).

Women with an occupation outside the household were also more likely to use private practitioners or non-governmental health services. All these variables were linked to more awareness and more freedom of choice of these women. Their preference for private doctors was associated with more modern and higher quality services offered there. The use of public antenatal care services of women in rural north India was positively related to women’s education, use of family planning services, older age at marriage, low parity and access to television (Pallikadavath et al. 2004). Social dynamics, biological factors and community level perceptions were important for utilization here. Out of these studies education emerges as one major determinant for utilization of health services. Pillai et al.

shows contradicting results. They found that higher education of the mother was linked to less care-seeking for their children. However, higher education in their study was thought to indicate more available resources in the households of the respective mothers which enables them to obtain care later.

3.2.2.4. Access to Public Health Services

While utilization is influenced by social, economic and cultural variables, distance, cost, quality of care and trust are further important for access to public health services.

Distance to health facilities was more important for women in Gujarat than the actual costs of services (Vissandjée et al. 1997: 145). In rural areas walking distance to health facilities is an important factor, because of the lack of transport. Hence, a distance of 5 km, which means one hour walking, is considered to be the maximum radius for PHC (Ranga Rao 1993: 146). Others have defined the distance of 1 km from the village centre as easy access (Paul et al. 2004: 924). The time needed for reaching the facility and going back as well as the time spend within the facility further constrain access since it means a loss of income. Peters et al. confirms for all of India, that costs were a more important reason for not seeking care for all income quintiles than distance (Peters et al. 2002: 292).

15 - Sum of percentage exceeds 100, because categories were not mutually exclusive and women used 0-4 health providers in the reference period (Vissandjée et al. 1997: 143).

Distance and cost are interlinked as shown above. Costs for public health services are an ambiguous subject. Primary health care at SC and PHC is free of charge, except a small registration fee (Rs. 0.25 - 2). Patients below poverty line do not have to pay for public hospital services at CHC or higher facilities either. Even though SC and PHC offer free services, they are often not adequately stocked with free medicines (Kamat 1995: 95).

Patients thus have to buy medicines from private pharmacists or from the doctor (Banerjee et al. 2004: 948; Ray/ Bhaduri 2001: 17). Public health officers might also charge for their services when working outside their official office hours (Banerjee et al.

2004: 949). The dependence of treatment on extra payment has been mentioned in other studies also (Ranga Rao 1993: 148; Misra et al. 2003: 121). Corruption in public offices is widespread in India and largely affects public services (Peters et al. 2002: 194).

Therefore, it appears that public services are not as free as they should be. Low-caste, uneducated households feel that their access to public services is limited as these services are biased towards high caste, educated and powerful people (Ray/ Bhaduri 2001: 17). This perception also reflects a lack of trust. Trust is an essential element for household decision-making on health service use (see Kamat 1995; Das/ Das 2003;

Pallikadavath et al. 2004). Experiences with public health services affect participation in health programmes and immunization activities (Das/ Das 2003: 111). Hence, bad experiences with the public health provider lead to less utilization of public services.

3.2.2.5. Availability of Care

Quality of care variables like access and utilization have already been mentioned, availability of care is another indicator. Availability of doctors and paramedical staff at public health facilities is a crucial determinant for quality of care and influences utilization of these facilities (see Banerjee et al. 2004; Devarajan/ Shah 2004; Ranga Rao 1993;

Kamat 1995). Absence rates¹⁶ in government facilities are high (see Figure 3.18).

Absence rates for doctors are higher than absence rates for teachers or health workers, they range from 28 to 67 %. Banerjee et al. findings correspond with these figures. In Rajasthan 45 % of medical personnel at the SC and 36 % of medical personnel at PHC or CHC were found absent (Banerjee et al. 2004: 948). Distance of facility to road has an impact on absence rates, in far-off SCs only 38 % of staff was present compared with the average of 55 % (Ibid.). Hence, availability of doctors is less in remote areas. Asked about their problems with the Primary Health Centres most respondents of a study in Andhra Pradesh, Tamil Nadu and Karnataka named absence of doctors as first criteria (Ranga Rao 1993: 149). Furthermore, facilities which are open more often, show higher utilization rates than facilities where the personnel are present less often (Banerjee et al. 2004: 948).

If the public facility is often closed, the poor are more likely to visit traditional healers (Ibid.). The experience of a closed facility obviously affects the service decision for the

16 - „The absence rate is the percentage of staff who are supposed to be present but are not on the day of an unannounced visit. It includes staff whose absence is ‘excused’ and ‘not-excused’.” (Devarajan/ Shah 2004:

910).

next time. The reason for high absence rates is seen in the lack of accountability of the public personnel (Devarajan/ Shah 2004: 911).

Figure 3.18: Absence Rates in Government Facilities

Lack of medicines and doctors, inadequate quality of service, and individual access and utilization barriers are responsible for the underutilization of public services in rural areas.

Public health policies and management have failed to address these issues. Insufficiency at the Ministry of Health (see above) affects all sub-national levels. Sub-national levels also do not appear to work effectively. The next section will look into the management and performance of National Health Programmes and into the status of primary health care in India.