|Year : 2015 | Volume
| Issue : 3 | Page : 136-140
Quality of health care in primary health care system: A reflection from Indian state
Virendra Kumar, Anindya Jayanta Mishra
Department of Humanities and Social Sciences, Indian Institute of Technology Roorkee, Roorkee, Uttarakhand, India
|Date of Web Publication||20-May-2015|
Department of Humanities and Social Sciences, Indian Institute of Technology Roorkee, Roorkee - 247 667, Uttarakhand
Source of Support: None, Conflict of Interest: None
Quality in primary health care services is a key component in reducing all-cause mortality and disability cases. Quality in primary health care services is associated with adequacy of the features of primary health care and provision of preventive and promotive services. The purpose of the current study is to summarise the quality of primary health care in Uttar Pradesh (UP) and to identify important barriers that hamper quality service achievement. This review study was carried out in the year 2014 by searching Science Direct, PubMed and JSTOR, official reports and books. The search was conducted using the keywords primary health care, quality of primary health care, health indicators and barriers in health care delivery along with the term Uttar Pradesh and India. Studies were included if they address these pre-defined aspects of primary health care and published after the introduction of National Rural Health Mission in India. Therefore, studies, conducted before 2005 and not covered the aspects of primary health care are excluded from this review study. A total of 27 articles met the inclusion criteria out of 176 searched studies. The study results indicate that the quality of primary health care services is abysmally poor in primary health care setting of UP. The state has some of the deplorable health outcomes among the Indian states as consequences of poor quality in health care services. There are numerous barriers that impede quality services achievement and service utilisation.
Keywords: Primary health care, quality of care, Uttar Pradesh
|How to cite this article:|
Kumar V, Mishra AJ. Quality of health care in primary health care system: A reflection from Indian state. Int J Health Syst Disaster Manage 2015;3:136-40
|How to cite this URL:|
Kumar V, Mishra AJ. Quality of health care in primary health care system: A reflection from Indian state. Int J Health Syst Disaster Manage [serial online] 2015 [cited 2019 Nov 17];3:136-40. Available from: http://www.ijhsdm.org/text.asp?2015/3/3/136/157367
| Introduction|| |
As guided by the declaration of Alma-Ata on primary health care in 1978, Primary health care forms the backbone of health care service delivery.  India, being a signatory to Alma-Ata declaration, is dedicated to promote the health and well-being of its people through primary health care services. It is the first level of contact between care seekers and health care providers. ,, In India, the primary health care services are provided to the rural population through a network of primary health centres (PHCs) and sub-centres (SCs). , These public health institutions are intended to render health care to the rural population with emphasis on preventive and promotive aspects of health care.
It is verified by the studies that quality in primary health care services is associated with adequacy of the features of primary health care and provision of preventive and promotive services.  The quality of primary health care services are closely intertwined with health outcomes.  It has been also recognized by the studies that focused primary health care helps to improve health outcomes and people can access it even at very low cost.  In current scenario, the state of health outcomes is worst in Uttar Pradesh (UP). ,, The worst status of health outcomes demonstrates that the health system is delivering poor quality of health care services.
UP is a highly populous state of India having 199.6 million population which contribute 16.5% population to the total population of India. A major portion which is, 155.41 million people of this population lives in rural area.  To promote health care in rural areas, the constitution of India has approved health as a fundamental human right meaning to that state ensures health services to its people. 
The UP government is facing the variety of challenges in delivering health care especially to rural areas. The roots of rural primary health care service delivery problems can be attributed directly to the conditions which commonly prevail within the rural areas. These conditions work as a risk factor in various health related problems. In this situation of susceptibility, people need good quality of primary health care services with better preventive and promotive measures.  Whereas, the rising cost of health care, insufficient health care staff, undersupply of medicines, inadequate basic laboratory and emergency services and improper referral services leads to poor quality of health care services in UP. 
The Indian government in recent years has taken robust steps to promote universal health care through National Rural Health Mission (NRHM) Phase-1 (2005-2012) and Phase-2 (2012-2017) to carry out statutory architectural correction in the primary health care delivery system. The goal of this mission is to improve the availability of and access to quality health care for the people of rural areas. The mission introduced a health cadre called Accredit Social Health Activist (ASHA) to bridge the gap between people and health centres to enhance the utilisation of health care services. , The present study seeks to use a comprehensive review of literature to investigate the quality of primary health care in UP and identify important barriers that hamper quality service achievement.
| Materials and Methods|| |
Two methods were used to gather evidences for this paper: A literature review and scan of government reports. This review study was carried out in the year 2014. To obtain the data, an online database search was conducted using PubMed, Science Direct, JSTOR and the official websites of Census, Ministry of Health and Family Welfare government of India and other related government reports and books. The search was conducted using keywords; primary health care, quality and performance of primary health care delivery system, patient satisfaction, health indicators and barriers in health care delivery along with the term UP.
Studies were included if they addressed, pre-defined aspects of primary health care and primary health care system. The published international peer reviewed health related journals; official reports and books were taken into account. The studies conducted after the introduction of the NRHM that is, 2005 onwards were included in this review paper. The reason being, NRHM has supposedly added a new dimension in rural health care service delivery with menu of primary health care services. A total of 27 articles met the inclusion criteria out of 176 collected articles.
To make the study more precise, studies conducted before the introduction of NRHM are not considered in the present study. Reports of non-government organisations, unpublished materials, conference papers are not included in this study. Studies also were not included in this review if they do not cover aspects of primary health care.
| Results|| |
The results of this systematic review are divided into two sections: The first section assesses the quality of health care in UP whereas the second section talks about the barriers in quality health care service achievement.
Quality of health care in Uttar Pradesh
This section of the study seeks to show the quality of primary health care in terms of availability of health care infrastructure, manpower, utilisation of health care services and health outcomes of UP.
Health care infrastructure and manpower
In spite of large gains in health status since independence, the poor rural dwellers continue to suffer widely from preventable or curable diseases.  The present study found that studies have consistently illustrated inadequate health care infrastructure and severe shortage of health care professionals in UP which remains a major constraint in primary health care service delivery [Table 1]. , Inadequate health infrastructure is marked by low doctor-population ratio, doctor-nurse ratio, population-bed ratio, population per health/sub-centre ratio [Table 2]a and b. ,,
|Table 1: Shortfall in health infrastructure as on March 2012 in EAG states as per census population|
Click here to view
According to Starfield et al.,  adequate availability of primary care physicians at health centres reduces disparities in health and deliver better health outcomes. However, government of UP fails to maintain sufficient health care infrastructure and adequate supply of health manpower in the rural areas. It was found in the primary health care system; the health professionals have been complimented by a range of public health programme activities along with their defined job responsibilities. , In such a scenario, they are not able to pay proper attention to care seekers and the quality of health care is put on stake.
Service utilisation is one of the important determinant of health care delivery along with the availability of services. To ensure a good level of utilisation of health care services, quality in primary health care services is essential and equally important determinant in meeting the needs of the people.  The review results indicate that the utilisation of health care services is abysmal in primary health care setting of Uttar Pradesh. , The rate of utilisation of primary health care resources declines with derisory infrastructure and increasing distances from the source of care.  The utilisation of maternal health care services was also very poor in the primary health care setting of UP. , Utilisation of public health care services is very low among the vulnerable sections of the society. ,
The truncated utilisation of public health care services indicate that access to basic and quality health care is still far away from the reach of the rural population in UP. However, it has been already evidenced that more accessible facilities are likely to be more effective because the rate of resource utilisation influences patient outcome for many categories of illness.  [Table 3] shows the facilities that are unavailable at PHCs.
The health system aims to improve the health status of people by lowering mortality and disability ratios.  Uttar Pradesh carries a large burden of India's morbidity along with the problem of high maternal mortality. Reducing maternal mortality is the central objective of NRHM and one of the goals of the Millennium Development Goals (MDGs). The primary health care plays a life-saving role in maternal health, therefore needs to be more effective and appropriate. ,,
According to Gupta et al.,  among the maternal deaths 68% mothers die due to pregnancy related causes, however, most of the deaths occur during the postnatal period who did not receive any health care during the antenatal period. The neonatal mortality is also very high in UP.  The current situation of these health outcomes exposes the poor quality of health services in UP.
Barriers in quality health care service achievement
Besides inadequate health care infrastructure, manpower and huge workload on health professionals this section tries to bring out some other barriers that hamper quality health care service achievement.
Poor condition of grassroots health workers
In primary health care delivery system the grassroot level health workers (Auxiliary Nurse Midwife (ANM), Multipurpose Health Workers (MPW), ASHA, Anganwadi Workers (AWW) play a vital role in provisioning of primary health care services . In fact, they are the key drivers of the primary health care system, but the government has no similar focus for them. The health system does not provide them adequate and appropriate facilities. At their health centres they are facing the problems like; inadequate and poor condition of residential flats, irregular electricity and drinking water supply and there are hardly any provision of security. At the same time they suffer from high workload, poor working conditions, low incentives and role conflict.  In such a scenario these problems become a constraint for grassroots health workers to provide quality health care services.
To deliver quality health care services and achieve the improved health outcomes, fair access and good management are essential. However, in the review it was found that management of primary health centres is disappointing.  The reason is that the primary health care system does not conduct regular monitoring of their services which further leads to less responsiveness of health care providers. , Therefore, there are remarkable differences found in the quality of health care between government managed and non-government managed health care services. Non-government managed hospitals deliver patient focused, better quality of care, whereas the government managed hospitals deliver poor quality of services.  Perceptions of poor quality of health care may in fact drive away patients from using the available services because health issues are among the most important human concerns.
Policy related barriers
The government programmes and policies in India primarily focus on curative services and prophylactic interventions while there are no similar focus on preventive and promotive health care services. The major concern of the government policies has been towards family planning services and population control. , Tertiary level of care is given more weightage than primary level health care by the policy makers.
The UP government has been constantly focusing on the diseases that have been almost controlled like polio and still it has been allocated with huge funds for its prevention and control. However, there are many other diseases like malaria, cholera and diarrhoea which severely affect the people, but policy makers have no similar focused approach for the same. 
| Discussion|| |
Primary health care is habitually expounded as the foundation of health care systems.  It is expected that primary health centres should render guidance to its people about making their health better by providing quality preventive and promotive health care services and at the time of more specialised care refer them to the suitable specialist.  In UP, the quality of primary health care services is found disappointing which precedes numerous preventable health problems to its advance stage and contributes to disability.  Due to the poor quality of health care services UP is suffering from the problem of worst health outcomes even among the Empowered Action Group (EAG) states.
To improve the current scenario of the worst health outcomes in UP quality in primary health care services is recommended. For the quality improvement in primary health care, a full-fledged infrastructure (adequate doctor-population ratio, doctor-nurse ratio, population-bed ratio, population per health/sub-centre ratio) is obligatory and that are missing from the primary health care setting of UP.  Timely supply of drugs, regular monitoring of various health programmes and manpower shortfall remains a major challenge to the primary health care system. In addition, the preventive and promotive services are the major concern of the primary health care system, but the policy makers have no similar focus on it. The falsely conceived government policies could not locate genuine needs of the population.
It was also pointed out by the various studies that due to high workload on health care providers their attitude towards work was found unsatisfactory. They have poor interpersonal communication skills which lead to communication gap a result of which they are not able to respond adequately to the needs of the care seekers. ,,
The billing system and health insurance schemes are complicated and the care seekers are not able to take benefit out if it's cause of the long and unclear process. The availability of sufficient and timely medicines, the referral services of the government health centres are not up to the required level. , The patients having prior experiences of these irregularities in the public hospitals, would hardly prefer public hospitals at the time of health care need.
Similarly, poor management of health care services is also a contributing factor in delivering low quality health care services in Uttar Pradesh.  There is a need of regular monitoring and supervision to enhance the quality in primary health care services. Along with quality health care services, health services should be more pro-poor, client friendly and respond to the preventable diseases timely. There is a lack of clarity in job responsibilities among grassroots health workers which leads to confusion in their work. They are also suffering from poor working conditions, low incentives and high workload. The policy documents should clearly speak of the role and function of the grassroot health workers. The government has to enhance their attention on grassroot level health workers otherwise they will remain as sufferer being least in the health system hierarchy.
| Conclusion|| |
Health indicators are poor in the areas where poor primary health care services are delivered. In UP, due to poor quality in health care services the public hospital users are less satisfied than those in the private hospital users as they get quality treatment. Therefore, improvement in the quality of primary health care services are needed to improve the current health status. Improvement in quality fills the gap between actual and achievable practice and leads to better health outcomes. To improve the quality and health outcomes a full fledged infrastructure is mandatory. To reduce the disease burden and health inequalities the government policies has to enhance their focus on preventive and promotive health care services. The motive is that if the health system is equipped enough in preventing the diseases or health problems in its pre-pathogenesis phase, the health problems can be substantially minimized.
| References|| |
Sodhani PR, Sharma K. Strengthening primary level health service delivery: Lesions from a state in India. J Family Med Prim Care 2012;1:127-31.
Pattanaik BK. Community participation, Panchayati raj and rural healthcare. In: Verma SB, Jiloka SK, Pathak AC, editors. Rural Healthcare and Housing. 1 st
ed. Delhi: Deep and Deep Publishers; 2006. p. 264-72.
Park K. Textbook of preventive and social medicine. 21 st
ed. India: Bhanot Publications; 2011. p. 827-51.
Pandey N. Perspective on accessibility of public health facilities in rural Uttar Pradesh, India. Int J Soc Sci Interdiscip Res 2013;2:69-74.
Mehrotra S. Public health systems in UP: What can be done? Econ Polit Wkly 2008;43:46-53.
Leatherman S, Ferris TG, Berwick D, Omaswa F, Crisp N. The role of quality improvement in strengthening health systems in developing countries. Int J Qual Health Care 2010;22:237-43.
Family welfare statistics in India. Ministry of health and family welfare, Government ofIndia; 2011. Available from: https://nrhmmis.nic.in/PubFWStatistics%202011/Complete-BOOK.pdf [Last accessed on 2014 Oct 10].
Jackson PT, Acharya A, Mills A. An assessment of the quality of primary healthcare in India. Econ Polit Wkly 2013;48:59-61.
Ramani KV, Mavlanker D. Health systems in India: Opportunities and challenges for improvements. J Health Organ Manag 2006;20:560-72.
Starfield B, Shi L, Macinko J. Contribution to primary care to health systems and health. Milbank Q 2005;83:457-502.
Kruk ME, Porignon D, Rockers PC, Van Lerberghe W. The contribution of primary care to health and health systems in low and middle- income countries: A critical review of major primary care initiatives. Soc Sci Med 2010;70:904-11.
Khan Z, Mehnaz S, Ansari MA, Khalique N, Siddiqui AR. Existing practices and barriers to avail of maternal healthcare services in two slums of Aligarh. Health Popul Perspect Issues 2009;32:113-23.
Narang R. Determining quality of public healthcare services in rural India. Clin Gov Int J 2011;16:35-49.
Socio-economic indicators National Health Profile. Ministry of health and family welfare. Government of India. 2011. Available from: [Last accessed on 2014 Jul 10].
Willis JR, Kumar V, Mohanty S, Kumar A, Singh JV, Ahuja RC, et al
., Saksham Study Group. Utilisation and perception of neonatal healthcare providers in rural Uttar Pradesh, India. Int J Qual Health Care 2011;23:487-94.
Gupta N, Kumar S, Saxena NC, Nandan D, Saxena BN. Maternal mortality in seven districts of Uttar Pradesh-An ICMR task force study. Indian J Public Health 2006;50:173-8.
Ergler CR, Sakdapolrak P, Bohle HG, Kearns RA. Entitlements to healthcare: Why is there a preference for private facilities among poorer residents of Chennai, India? Soc Sci Med 2011;72:327-37.
Bhargava A, Chowdhury S, Singh KK. Healthcare infrastructure, contraceptive use and infant mortality in Uttar Pradesh, India. Econ Hum Biol 2005;3:388-404.
Broemeling AM, Watson DE, Black C, Sabrina TW. Measuring the performance of primary healthcare: Existing capacity and potential information to support population-based analyses. Healthc Policy 2009;5:47-64.
Jacobs B, Ir P, Bigdeli M, Annear PL, Van Damme W. Addressing access barriers to health services: An analytical framework for selecting appropriate interventions in low-income Asian countries.
Health Policy Plan 2012;27:288-300.
Pandve HT, Pandve TK. Primary healthcare system in India: Evolution and challenges. Int J Health Syst Disaster Manage 2013;1:125-8.
Jeffrey H, Aiyar Y, Samji S. Understanding government failure in public health services. Econ Polit Wkly 2007;59-61.
[Table 1], [Table 2], [Table 3]