Determining quality of public

health care services in rural India

Ritu Narang
Department of Business Administration, University of Lucknow,
Lucknow, India
Abstract
Purpose This paper aims to measure the perception of patients towards quality of services in
public health care centres in rural India.
Design/methodology/approach A 23-item scale that tested well for reliability and construct
validity was employed for the study. Mixed sampling technique was employed to select the sample. A
total of 500 respondents from Eastern, Western and Central regions of Uttar Pradesh were surveyed.
Findings The survey instrument had an overall Cronbachs alpha value of 0.96 and was able to
discern differences across various socio-demographic characteristics of the respondents. The opinions
of the respondents towards health care quality were not very favourable. Negative scores were
obtained on items, availability of adequate medical equipments and availability of doctors for
women. Education, gender and income were found to be signicantly associated with user perception.
Research limitations/implications The current study was limited to measuring the perceived
quality of health care services in public centres only. Moreover, as the study was conned to the state
of Uttar Pradesh so caution has to be exercised in making generalisations for the entire nation.
Practical implications Valuable insights into the quality of services at public health care centres
in rural India have been provided by the study.
Originality/value Knowledge about the patients perception towards health care quality is one of
the most important steps towards introducing reforms in the health care sector. Identication of areas
that require immediate improvement in public health care centres provides valuable guidance to the
policy makers who can devise suitable strategies to make these centres more sensitive and responsible
to the needs of the rural population. This can lead to restoration of faith in public health care centres
and subsequently their increased consumption.
Keywords Medical care, Quality, Primary care
Paper type Research paper
Introduction
Research in service quality has gained much prominence in recent years but its nature
of intangibility makes it extremely difcult to dene and measure it (Boltan and Drew,
1991a; Boulding et al., 1993) and leads to different interpretations by various
stakeholders. The quality of health care services has been dened as the degree to
which health services for individuals and populations increase the likelihood of desired
health outcomes and are consistent with current professional knowledge (Institute of
Medicine, 2001, p. 21). It comprises three elements: structure, process and outcome
(Donabedian, 1966). Structure relates to infrastructure, technology and resources while
The current issue and full text archive of this journal is available at
www.emeraldinsight.com/1477-7274.htm
The author duly acknowledges the partial support provided by the funds made available under
UGC Major Research Project, Identifying business opportunities in rural health care system
during tenth plan for preparation of this paper.
Quality of public
health care
services
35
Received 20 June 2010
Revised 6 September 2010,
26 September 2010
Accepted 1 October 2010
Clinical Governance: An International
Journal
Vol. 16 No. 1, 2011
pp. 35-49
qEmerald Group Publishing Limited
1477-7274
DOI 10.1108/14777271111104574
process is the interaction between service providers and patients that results in health
outcomes. Outcomes can be measured in terms of deaths, disability-adjusted life years,
patient satisfaction or responsiveness (WHO, 2000).
Maxwell (1984) has asserted that quality in health care comprises a comprehensive
six dimensional framework that includes accessibility, relevance, effectiveness, equity,
social acceptability and efciency. However, this framework does not represent a
holistic approach to health care as some of the essential elements like structure, process
and outcome (Donabedian, 1966) have not been considered. Consequently, Wrights
matrix that combines the two models has been proposed by Maxwell (1992).
Health care quality can be assessed from two viewpoints: patients and technical or
professional (Institute of Medicine, 2001). The former includes assessment of service
providers ability to meet customer demand, customers perception and satisfaction
(Chatterjee and Yilmaz, 1993). Customer perception with respect to evaluation of health
care quality has been supported by a number of researchers (Donabedian, 1980, 1982;
Palmer, 1991; Reerink and Sauerborn, 1996). Emphasising this Peterson (1988) opines
that how the patient felt is more important than the caregivers perception of reality.
Researchers observe that quality perceptions impact satisfaction; that is the service
quality is the antecedent of satisfaction (Cronin and Taylor, 1992; Parasuraman et al.,
1994; Storbacka et al., 1994; Heskett et al., 1997; Kasper et al., 1999) and the latter exerts
strong inuence on purchase intentions (Cronin and Taylor, 1992). Studies conducted
in Nepal (Lafond, 1995), Vietnam (Guldner and Rifkin, 1993), Sri Lanka (Akin and
Hutchison, 1999), Bangladesh (Andaleeb, 2000) and Nigeria (Uzochukwu et al., 2004)
support strong relationship between patient perception and health care service
utilisation. Improving quality of healthcare services apart from increasing accessibility
and affordability to its population in the face of limited resources has become a major
challenge for developing countries that have taken little interest in the issue of
improving quality of health care until recently (Reerink and Sauerborn, 1996; Smits
et al., 2002; Uzochukwu et al., 2004).
This paper aims to measure patients perception towards quality of health care
services in rural India by using a 20-item scale developed by Haddad et al. (1998). It
emphasises the importance of clients opinions as one of the steps towards introducing
reforms in health sector in order to make the system more sensitive and responsible to
the requirements of the population.
Relevance and objectives
The Indian government has made stupendous efforts through the vast institutional
network and diverse human resource (Satpathy and Venkatesh, 2006), comprising
Accredited Social Health Activist (ASHA) workers, ayurveda, yoga and naturopathy,
unani, siddha, and homoeopathy (AYUSH) practitioners, midwives, nurses, doctors,
pharmacists, community health workers, Anganwadi[1] worker, lab technicians, and
pharmacists, to reduce the regional imbalances and inequities and improve the
accessibility of health care services to rural areas where the majority of the Indian
population resides. The National Rural Health Mission (NHRM) was set up in 2005
with the objective of providing effective, efcient and accountable health care
programs to the rural population in the country with special attention being focused on
those states of the country that have either weak public health indicators or weak
infrastructure or both. This mission also seeks to revitalise local health traditions by
CGIJ
16,1
36
bringing AYUSH (Indian systems of medicine) into the mainstream public health
system.
Though a number of initiatives in the form of health programmes and setting up a
vast infrastructure have been undertaken by the government, the selective,
fragmented strategies and lack of resources have made the health system
unaccountable: that is, unable to address peoples growing expectations and
deliver quality services (Ministry of Health and Family Welfare, 2005; Bhandari and
Dutta, 2007). Consequently, the importance of public health care centres in India has
been declining due to poor quality of services (Bhandari, 2006) and their inability to
meet the health outcomes (Satpathy and Venkatesh, 2006). The lopsided focus on
access and affordability causing negligence to quality has been reported in other
developing nations as well (Reerink and Sauerborn, 1996).
Considering that almost 300 million people live below the poverty line and are
greatly dependent upon the almost free health services from the public sector, its role
cannot be undermined or ignored. Improving service quality is one of the measures
that requires to be undertaken for achieving improvements in the health care system as
the patients perception impacts the health-seeking behavior (Uzochukwu et al., 2004;
Ministry of Health and Family Welfare, 2005). User perspectives therefore constitute
valuable inputs towards effective improvement in various areas of health care quality.
Considering that very little research has been done on assessing the quality of health
care services from a user perceptive in rural India, the current paper seeks to address
that gap.
Method
Research instrument
Numerous studies on service quality in various service sectors have been guided by the
SERVQUAL framework (Parasuraman et al., 1985, 1991, 1994). Despite its extensive
use it has been debated upon by the academicians with respect to statistical properties
(Carman, 1990; Cronin and Taylor, 1992; Brown et al., 1993; Boltan and Drew, 1991b;
Babukas and Boller, 1992; Cronin and Taylor, 1994; Van Dyke et al., 1997),
measurement problem (Reidenbach and Sandifer-Smallwood, 1990; Brown et al., 1993;
Andaleeb and Basu, 1994) and the number of dimensions (Carman, 1990). Realising
that appropriate measurement tool (Reerink and Sauerborn, 1996) should be employed
for measuring health care quality in developing nations researchers have made some
attempts in this direction. However, a number of such studies have been conned to
family planning while others have not established the validity of their research
instruments. On the other hand, Haddad et al. (1998) have developed and proved the
reliability and validity of their 20-item scale that recorded the users opinion about the
quality of primary health care services in Guinea. Their scale comprised three
subscales: health care delivery, personnel and facilities. It reported a reliability of 0.88
and has been successfully used in other developing nations namely, Burkina Faso and
rural Vietnam (Baltussen et al., 2002; Duong et al., 2004).
The same scale has been employed for the current study. However, in order to adapt
the instrument to reect the cultural context an exploratory study was carried out. In
total, six focus group discussions and 12 in-depth interviews were conducted in two
districts of the state of Uttar Pradesh to identify the factors employed in evaluating the
quality of health care services. A large number of items were generated that
Quality of public
health care
services
37
overlapped with Haddads study indicating conceptual similarity. The generated items
with eigenvalue of more than 1 were included resulting in 23 items. Each scale item
comprised ve opinions that ranged from a score of 22 for very unfavourable, 21
for unfavourable, 0 for neutral, 1 for favourable and 2 for very favourable.
The questionnaire was translated from English into Hindi, the principal language of
the state of Uttar Pradesh, where the study was conducted. It was pre-tested to ensure
that the wording, sequencing of questions, length and range of scale was appropriate.
Low level of literacy and negligible exposure to this kind of study made it difcult for
respondents to comprehend the scale. It was therefore, adapted to a money scale: zero
paisa[2] (very unfavourable), 25 paisa (unfavourable), 50 paisa (neutral), 75 paisa
(favourable) and 100 paisa (very favourable) for the purpose of administering the
questionnaire.
Sampling and data collection
A mixed sampling technique was employed to select the appropriate sample. For the
purpose of study the state of Uttar Pradesh[3] was divided into three geographic
regions: Eastern, Central and Western regions. The sample size of 500 was distributed
to these three regions in proportion to the rural population of the respective regions.
Thereafter, two districts representing each region were selected randomly. The
number of respondents selected from each district was in proportion to the rural
population of the respective districts. A sampling frame from which the random
sampling units could be drawn was unavailable hence, purposive sampling technique
was employed. The criterion of inclusion in the study was that the respondent should
have utilised the health care services at the public health care centres within the last six
months. The head of the village, panchayat members and paramedical staff at the
PHCs and CHCs were contacted for initial identication of sampling units.
Subsequently, some of the respondents and other people (non-respondents) who had
gathered to witness the data collection process also provided referrals. This method
was considered acceptable (Trochim, 2002; Grinnell and Unrau, 2010) due to lack of
sampling frame.
A sample size of 500 was chosen keeping in mind the average size of samples
(Malhotra and Dash, 2009) in similar studies (Haddad et al., 1998; Baltussen et al., 2002;
Duong et al., 2004; Uzochukwu et al., 2004). Data was personally collected during the
period between March-August 2008. Verbal consent was obtained from the respondent
prior to administration of questionnaire. Before administering the questionnaire the
meaning of the scale was explained to them. The representation of scale in the form of
money was easier for the respondents to comprehend.
Data analysis
Factor analysis based on principal component extraction followed by Varimax rotation
was employed to examine the structure within the 23-item scale. The KMO value and
Bartletts test of sphericity were used to examine the strength of relationship among
the factors. Reliability of the scale was investigated through Cronbachs alpha
coefcient. ANOVA analysis and t-test were performed to understand the differences
in perceived quality across socio-demographic characteristics of the patients.
CGIJ
16,1
38
Results
The respondents were curious about the purpose of study and were enthusiastic in
expressing their views on the overall performance of health care centres. Though they
were forthcoming in airing their views, their comments were general in nature. When it
came to recording their responses to the questionnaire, a number of them were hesitant.
They were coaxed into completing the questionnaire but only 396 complete
questionnaires could be obtained. Despite being heavy consumers of health care
services, women were sceptical or reluctant to respond. Consequently, the majority of
respondents were males (75 percent). A total of 59.6 percent of the respondents were
literate, 55.30 percent were above 30 years and 54 percent of them earned income above
Rs. 3,000 per month. Table I shows the demographic prole of the respondents.
Scale properties
On the basis of item analysis, 23 items were selected (Table II). The factor analysis of
the items based on the basis of principal component extraction by using Varimax
rotation resulted in ve homogeneous sub-scales with the eigenvalues of 4.1, 3.8, 3.8,
2.8 and 2.4. All the items had factor loading above 0.45 and the total variance explained
after rotation was 74.22 percent with communalities after extraction ranging from 0.59
to 0.83. Appropriateness of factor analysis was assessed by examining sampling
adequacy. The KMO measure of sampling adequacy of 0.92 and the signicant
Bartletts test of sphericity clearly demonstrated that the factors were related.
The rst subscale comprised seven items related to health care delivery (HCD):
adequate availability of doctors, good diagnosis, satisfaction over prescriptions,
quality of drugs, recovery/cure, sufcient time to patients and payment arrangements.
The second subscale included ve items related to interpersonal and diagnostic aspect
of care (IDC): overall reception facility, honesty, good clinical examination,
follow-up/monitoring of patients, adequate medical equipment. The third subscale,
facility, included ve items: adequacy of rooms, adequate availability of doctors for
Independent variable n %
Gender
Female 99 25.0
Male 297 75.0
Literacy status
Literate 236 59.6
Illiterate 160 30.4
Age (years)
,30 177 44.7
.30 219 55.3
Income level (Rs
a
)
, 1,000 71 17.9
1,001-3,000 111 28.0
. 3,000 214 54.0
Note:
a
US$1 Rs.40 approximately
Table I.
Demographic prole of
the respondents
Quality of public
health care
services
39
women, neat and clean hospital premises, clean appearance of staff, and proper
disposal of waste. The fourth subscale contained three items related to health
personnel conduct and drug availability (HPCDA): compassion and support, adequate
respect to patients and availability of all drugs. The last subscale, nancial and
physical access to care (FPC), comprised three items: nancial feasibility of treatment,
ease of obtaining drugs and easily approachable.
The scale was tested for reliability. It had an overall Cronbachs alpha value of 0.96
(Table III). The Cronbachs alpha value ranged from 0.71 to 0.92 for the subscales. The
reliability was highest for interpersonal and diagnostic aspect of care (0.92) and
Components/factors
Items 1 2 3 4 5
Communalities after
extraction
Health care delivery
Adequate availability of doctors 0.49 0.66
Good diagnosis 0.54 0.83
Satisfaction over prescriptions 0.64 0.72
Quality of drugs 0.60 0.79
Recovery/cure 0.78 0.82
Sufcient time to patients 0.78 0.78
Payment arrangements 0.60 0.80
Interpersonal and diagnostic aspect of care
Overall reception facility 0.64 0.75
Honesty 0.53 0.74
Good clinical examination 0.67 0.78
Follow-up, monitoring of patients 0.65 0.76
Adequate medical equipment 0.79 0.83
Facility
Adequacy of rooms 0.62 0.63
Adequate availability of doctors for
women 0.63 0.80
Neat and clean hospital premises 0.73 0.67
Clean appearance of staff 0.56 0.59
Proper disposal of waste 0.76 0.78
Health personnel conduct and drug availability
Compassion and support 0.76 0.82
Adequate respect to patients 0.70 0.70
Availability of all drugs 0.46 0.73
Financial and physical access to care
Financial feasibility of treatment 0.66 0.68
Ease of obtaining drugs 0.54 0.68
Easily approachable 0.83 0.78
Percentage variance explained by factor
after rotation 17.95 16.60 16.51 12.55 10.61
Notes: Extraction method: principal component analysis with four factor extraction; rotation method:
Varimax with Kaiser normalisation; rotation converged in 16 iterations
Table II.
Factor analysis of the
instrument
CGIJ
16,1
40
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of perceived quality
Quality of public
health care
services
41
lowest for nancial and physical access to care (0.71). The overall mean score was
1.78. The scoring was done by using the method of average of items for a particular
factor. Thus for a particular factor, the possible mean range lay between 22 to 2.
Overall scores were calculated by summing the mean scores of all the four factors
under study. The positive mean scores of factors reected a relatively higher
perception regarding quality of service being provided but further analysis points at
some unfavourable opinions held by the clients.
Analysis
ANOVA and t-test were employed to determine the differences in respondents
perceptions towards quality of services with respect to socio-demographic factors
(Table IV). Signicantly higher mean scores were observed amongst females on the
items good diagnosis ( p 0.005), satisfaction over prescription (p 0:019),
quality of drugs (p 0:009), recovery/cure (p 0:023), sufcient time to patients
(p 0:007) and payment arrangements ( p , 0.001) as compared to males.
Males had signicantly higher scores for the item adequate availability of doctors
(p 0:009). As far as adequacy of medical equipment was concerned, no signicant
differences were seen between males and females, though here again females scored
higher as compared to males. The most signicant point to be noted here is that the
mean scores of both males and females were negative, indicating the poor availability
of medical equipment.
Contrary to differences in perception among the two genders, age played a relatively
lower role in determining the perception of the patients towards quality of health care
services though signicant differences were observed among different income groups.
Educational status seemed to affect the perception of the respondents as signicant
differences were seen for each item. The overall quality was judged very low by those
who were more educated as was observed in Burkina Faso (Baltussen et al., 2002).
Discussion
The paper seeks to understand the quality of services in public health care centres in
rural India by using a reliable tool. The psychometric properties of the Indian version
of the scale show good internal consistency and construct validity. Five factors were
identied from the factor analysis: health care delivery system, interpersonal and
diagnostic aspect of care, facility, health personnel conduct and drug availability
and nancial and physical access to care. The mean score was high for nancial and
physical access to care and health care delivery system. The tool is able discern
differences across various socio-demographic characteristics. Education, gender,
income and to some extent age tend to impact the quality perception among the Indian
respondents. However, the disproportionate representation of females in the study may
have impacted the overall rating of the service quality and acted as a limitation.
Earlier studies have reported a tendency among the respondents to judge
favourably the various aspects of service quality (Haddad et al., 1998; Newman et al.,
1998). However, contrary to these researches the current study does not report a
favourable opinion of the respondents towards health care quality. This nding is
similar to that in Burkina Faso (Baltussen et al., 2002). However, there has been a
consistent higher rating given by females on several aspects of quality as opposed to
CGIJ
16,1
42
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7
0
.
1
4
1
4
Q
u
a
l
i
t
y
o
f
d
r
u
g
s
0
.
5
2
0
.
9
0
0
.
1
7
1
.
2
2
.
6
1
0
.
0
0
9
0
.
2
4
1
.
1
0
0
.
2
7
1
.
1
8
2
0
.
3
2
0
.
7
5
1
0
.
6
3
1
.
0
0
0
.
1
4
1
.
0
9
2
0
.
5
9
1
.
0
3
4
9
.
7
5
0
0
.
3
3
1
.
1
9
0
.
3
8
1
.
1
0
.
1
7
1
.
1
4
1
.
4
3
0
.
2
4
1
5
R
e
c
o
v
e
r
y
/
c
u
r
e
0
.
6
4
0
.
9
5
0
.
3
6
1
.
0
5
2
.
2
9
0
.
0
2
3
0
.
3
2
0
.
9
3
0
.
5
2
1
.
1
0
2
1
.
9
1
0
.
0
5
7
0
.
7
2
0
.
9
2
0
.
2
4
0
.
9
8
2
0
.
1
6
1
.
0
7
2
9
.
8
0
0
0
.
2
9
1
.
2
2
0
.
6
5
1
.
0
2
0
.
3
7
0
.
9
6
3
.
5
9
0
.
0
2
9
6
S
u
f

c
i
e
n
t
t
i
m
e
t
o
p
a
t
i
e
n
t
s
0
.
8
8
0
.
9
2
0
.
5
6
1
.
0
7
2
.
7
0
.
0
0
7
0
.
4
7
1
.
0
0
0
.
7
7
1
.
0
6
2
2
.
8
1
0
.
0
0
5
0
.
8
5
0
.
9
8
0
.
3
8
1
.
0
5
0
.
2
8
1
.
0
4
1
3
.
1
6
0
0
.
5
4
1
.
0
5
0
.
8
1
1
.
0
7
0
.
5
8
1
.
0
2
2
.
2
1
0
.
1
1
1
7
P
a
y
m
e
n
t
a
r
r
a
n
g
e
m
e
n
t
s
1
.
4
8
0
.
7
1
0
.
7
7
1
.
0
5
6
.
3
1
0
.
0
0
0
0
.
8
3
1
.
0
1
1
.
0
4
1
.
0
3
2
2
.
0
4
0
.
0
4
2
1
.
1
9
1
.
0
1
0
.
7
6
1
.
0
3
0
.
4
7
0
.
8
7
1
9
.
8
2
0
0
.
6
7
1
.
0
3
1
.
0
3
1
.
0
6
1
.
0
0
1
.
0
0
3
.
3
5
0
.
0
3
6
I
n
t
e
r
p
e
r
s
o
n
a
l
a
n
d
d
i
a
g
n
o
s
t
i
c
a
s
p
e
c
t
o
f
c
a
r
e
8
O
v
e
r
a
l
l
r
e
c
e
p
t
i
o
n
f
a
c
i
l
i
t
y
0
.
4
8
0
.
7
1
0
.
0
2
1
.
0
3
4
.
1
9
0
.
0
0
0
0
.
1
9
0
.
9
1
0
.
1
0
1
.
0
2
0
.
9
2
0
.
3
6
0
.
3
7
0
.
9
6
0
.
2
4
0
.
8
7
2
0
.
5
0
.
7
9
3
1
.
5
8
0
0
.
4
2
1
.
1
2
0
.
2
7
0
.
9
5
2
0
.
0
3
0
.
9
1
7
.
2
6
0
.
0
0
1
9
H
o
n
e
s
t
y
0
.
7
9
0
.
6
9
0
.
2
3
1
.
0
2
5
.
0
3
0
.
0
0
0
0
.
3
9
0
.
9
4
0
.
3
6
1
.
0
1
0
.
3
4
0
.
7
3
5
0
.
5
7
0
.
9
1
0
.
3
3
0
.
9
5
2
0
.
0
9
1
.
0
2
1
6
.
9
3
0
0
.
3
8
1
.
1
6
0
.
4
9
0
.
9
2
0
.
3
1
0
.
9
5
1
.
1
8
0
.
3
0
7
1
0
G
o
o
d
c
l
i
n
i
c
a
l
e
x
a
m
i
n
a
t
i
o
n
0
.
3
9
0
.
9
2
0
.
0
7
1
.
0
6
2
.
7
1
0
.
0
0
7
0
.
1
7
1
.
0
0
0
.
1
4
1
.
0
7
0
.
3
1
0
.
7
5
6
0
.
4
2
0
.
9
0
0
.
1
9
1
.
0
1
2
0
.
5
3
1
.
0
7
3
3
.
5
3
0
0
.
2
1
1
.
2
3
0
.
2
2
0
.
9
7
0
.
1
0
1
.
0
0
0
.
6
0
0
.
5
4
8
1
1
F
o
l
l
o
w
-
u
p
,
m
o
n
i
t
o
r
i
n
g
o
f
p
a
t
i
e
n
t
s
0
.
5
8
0
.
9
3
0
.
0
4
1
.
0
5
4
.
5
4
0
.
0
0
0
0
.
3
4
1
.
0
2
0
.
0
4
1
.
0
4
2
.
8
5
0
.
0
0
5
0
.
4
4
0
.
9
5
0
.
3
8
0
.
9
6
2
0
.
6
3
0
.
9
0
4
5
.
8
4
0
0
.
5
4
1
.
1
6
0
.
2
2
0
.
9
9
0
.
0
3
0
.
9
9
6
.
8
6
0
.
0
0
1
1
2
A
d
e
q
u
a
t
e
m
e
d
i
c
a
l
e
q
u
i
p
m
e
n
t
2
0
.
2
7
0
.
9
7
2
0
.
3
8
1
.
1
3
0
.
8
7
9
0
.
3
8
0
2
0
.
2
4
1
.
1
1
2
0
.
4
5
1
.
0
6
1
.
9
6
0
.
0
5
1
2
0
.
1
1
1
.
0
3
2
0
.
2
4
0
.
9
8
2
1
.
0
3
1
.
0
2
2
8
.
0
4
0
0
.
1
3
1
.
3
1
2
0
.
3
8
0
.
9
4
2
0
.
5
1
1
.
0
4
9
.
4
8
0
.
0
0
0
F
a
c
i
l
i
t
y
1
3
A
d
e
q
u
a
c
y
o
f
r
o
o
m
s
0
.
3
0
1
.
0
3
0
.
0
6
1
.
0
3
2
.
0
2
0
.
0
4
4
0
.
0
3
1
.
0
6
0
.
1
9
1
.
0
2
2
1
.
5
1
0
.
1
3
3
0
.
4
4
0
.
9
8
0
.
0
0
0
.
9
8
2
0
.
5
9
0
.
8
3
4
1
.
6
5
7
0
0
.
4
6
1
.
1
3
0
.
1
6
0
.
9
8
2
0
.
0
1
1
.
0
2
5
.
8
2
4
0
.
0
0
3
1
4
A
d
e
q
u
a
t
e
a
v
a
i
l
a
b
i
l
i
t
y
o
f
d
o
c
t
o
r
s
f
o
r
w
o
m
e
n
0
.
0
6
0
.
9
6
2
0
.
0
5
1
.
1
9
0
.
8
5
0
.
3
9
9
0
.
1
2
1
.
0
9
2
0
.
1
4
1
.
1
5
2
.
2
4
0
.
2
5
3
0
.
2
0
1
.
0
3
0
.
3
3
0
.
9
5
2
0
.
8
1
1
.
1
4
3
6
.
7
7
0
0
.
0
4
1
.
1
4
0
.
0
0
1
.
0
2
2
0
.
0
6
1
.
1
9
0
.
2
3
0
.
7
9
3
1
5
N
e
a
t
a
n
d
c
l
e
a
n
h
o
s
p
i
t
a
l
p
r
e
m
i
s
e
s
0
.
5
8
0
.
8
2
0
.
2
3
0
.
9
7
3
.
1
4
0
.
0
0
2
0
.
3
4
0
.
9
7
0
.
3
1
0
.
9
2
0
.
3
5
0
.
7
2
7
0
.
4
6
0
.
8
6
0
.
5
5
1
.
0
3
2
0
.
1
6
0
.
9
4
1
7
.
8
5
0
0
.
5
8
1
.
1
6
0
.
2
2
0
.
8
5
0
.
2
9
0
.
9
0
3
.
6
6
0
.
0
2
7
1
6
C
l
e
a
n
a
p
p
e
a
r
a
n
c
e
o
f
s
t
a
f
f
0
.
5
2
0
.
6
6
0
.
3
1
0
.
9
7
1
.
9
2
0
.
0
5
5
0
.
4
6
0
.
9
1
0
.
2
9
0
.
9
0
1
.
8
6
0
.
0
6
4
0
.
5
7
0
.
8
7
0
.
4
3
0
.
8
6
2
0
.
1
9
0
.
8
1
2
7
.
1
1
0
0
.
5
4
1
.
0
9
0
.
4
6
0
.
8
6
0
.
2
5
0
.
8
5
3
.
6
2
0
.
0
2
8
1
7
P
r
o
p
e
r
d
i
s
p
o
s
a
l
o
f
w
a
s
t
e
0
.
5
2
0
.
9
3
0
.
0
3
0
.
9
4
4
.
4
6
0
.
0
0
0
0
.
2
4
0
.
9
5
0
.
0
8
0
.
9
6
1
.
6
0
0
.
1
0
9
0
.
3
5
0
.
9
6
0
.
1
4
0
.
9
5
2
0
.
3
4
0
.
7
8
1
9
.
8
6
0
0
.
4
6
1
.
0
9
0
.
1
6
0
.
9
8
0
.
0
4
0
.
8
8
5
.
1
9
0
.
0
0
6
(
c
o
n
t
i
n
u
e
d
)
Table IV.
Perceived quality across
socio-demographic
characteristics
Quality of public
health care
services
43
G
e
n
d
e
r
A
g
e
E
d
u
c
a
t
i
o
n
I
n
c
o
m
e
F
e
m
a
l
e
s
(
n

9
9
)
M
a
l
e
s
(
n

2
9
7
)
,
3
0
y
r
s
(
n

1
7
7
)
.
3
0
y
r
s
(
n

2
1
9
)
I
l
l
i
t
e
r
a
t
e
(
n

1
6
0
)
U
p
t
o
m
i
d
d
l
e
(
c
l
a
s
s
8
)
(
n

9
8
)
A
b
o
v
e
m
i
d
d
l
e
(
n

1
3
8
)
,
R
s
1
0
0
0
(
n

7
1
)
1
0
0
0
-
3
0
0
0
(
n

1
1
1
)
.
3
0
0
0
(
n

2
1
4
)
S
N
I
t
e
m
M
e
a
n
S
D
M
e
a
n
S
D

M
e
a
n
S
D
M
e
a
n
S
D

M
e
a
n
S
D
M
e
a
n
S
D
M
e
a
n
S
D

M
e
a
n
S
D
M
e
a
n
S
D
M
e
a
n
S
D

H
e
a
l
t
h
p
e
r
s
o
n
n
e
l
c
o
n
d
u
c
t
a
n
d
d
r
u
g
a
v
a
i
l
a
b
i
l
i
t
y
1
8
C
o
m
p
a
s
s
i
o
n
a
n
d
s
u
p
p
o
r
t
0
.
7
3
0
.
7
1
0
.
4
1
1
.
0
2
2
.
8
4
0
.
0
0
5
0
.
5
8
0
.
8
7
0
.
4
2
1
.
0
2
1
.
5
7
0
.
1
1
8
0
.
7
0
0
.
8
9
0
.
5
7
0
.
9
1
2
0
.
0
6
0
.
9
4
2
4
.
2
0
0
.
5
4
1
.
2
0
0
.
6
5
0
.
9
1
0
.
3
9
0
.
8
8
2
.
7
1
0
.
0
6
8
1
9
A
d
e
q
u
a
t
e
r
e
s
p
e
c
t
t
o
p
a
t
i
e
n
t
s
0
.
5
8
0
.
7
0
0
.
2
6
0
.
9
8
2
.
9
3
0
.
0
0
4
0
.
3
1
0
.
9
1
0
.
3
7
0
.
9
5
2
0
.
6
9
0
.
4
9
1
0
.
6
2
0
.
8
2
0
.
1
4
1
.
0
0
2
0
.
2
2
0
.
8
6
3
4
.
5
9
0
0
.
7
5
0
.
9
8
0
.
5
9
0
.
8
9
0
.
0
7
0
.
8
5
2
2
.
3
2
0
.
0
0
2
0
A
v
a
i
l
a
b
i
l
i
t
y
o
f
a
l
l
d
r
u
g
s
0
.
3
3
1
.
0
1
0
.
0
8
1
.
1
1
2
.
0
1
0
.
0
5
0
.
0
8
1
.
0
3
0
.
1
9
1
.
1
3
2
0
.
9
7
0
.
3
3
2
0
.
4
2
1
.
0
2
0
.
3
8
0
.
9
1
2
0
.
6
9
0
.
9
5
4
5
.
2
0
0
.
0
4
1
.
1
1
0
.
3
8
1
.
0
3
0
.
0
6
1
.
1
0
3
.
6
2
0
.
0
2
8
F
i
n
a
n
c
i
a
l
a
n
d
p
h
y
s
i
c
a
l
a
c
c
e
s
s
t
o
c
a
r
e
2
1
F
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Table IV.
CGIJ
16,1
44
that reported in Burkina Faso (Baltussen et al., 2002). There could be two possible
reasons for higher scores among females on major issues:
(1) The relative lower level of expectations among women owing to the social
complications.
(2) Most of the womens healthcare issues, especially those related to maternity, are
covered under national programmes which get an extra push from the state
government.
The overall mean score for the subscale interpersonal and diagnostic aspect of care
was very low (0.10), revealing the scope of tremendous improvement in this
component. Negative scores were obtained with regard to availability of adequate
medical equipment. An earlier study has also pointed out the lack of equipment,
improper functioning and poor repair facility (Bhandari and Dutta, 2007). Similar
ndings have been reported in other nations as well (Baltussen et al., 2002; Duong et al.,
2004). Patients may not be able to assess the technical procedures involved in the
diagnosis but human behaviour as well as the availability of machines does impact
their perception of quality.
Unavailability of doctors especially for women is another item that has obtained a
negative score as in case of Nigeria and Vietnam (Uzochukwu et al., 2004; Duong et al.,
2004). Poor involvement of health care employees and high rate of absenteeism has
been reported by earlier studies (Banerjee et al., 2004; Chaudhury et al., 2006).
Researchers (Majumder and Upadhyay, 2002) have reported that the elasticity
coefcient of paramedical staff is higher than that of medical staff thereby implying
that the former are easily available. Lack of facilities such as proper schools for
educating their children, regular supply of electricity, recreational facilities etc. are
responsible for failure of health care centres to attract or retain doctors in these
underdeveloped areas.
Contrary to the ndings of Baltussen et al. (2002) and Haddad et al. (1998)
respondents have rated nancial and physical access to health care as fairly good. This
could be due to the vast institutional network that has been created in the rural regions
of India (Satpathy and Venkatesh, 2006). The cost of treatment at these centres is
almost negligible. However, the identication of this dimension as a part of the quality
perception scale adds to the earlier empirical researches (Haddad et al., 1998; Baltussen
et al., 2002; Duong et al., 2004) pertaining to quality of care. What needs to be pondered
over is whether this approach of very low pricing is contributing towards lack of
motivation in enhancing service quality. Providing access to the health care services at
low or no price is of little value unless sufcient quality is maintained (Akin and
Hutchison, 1999).
Conclusions
To conclude, it can be said that the current public health care system is fraught with
many problems that are perhaps making the users lose faith in it. The results throw
light on areas requiring urgent and immediate attention so that suitable strategies are
employed to improve the quality of health care services in public centres in order to
make them more sensitive and responsible to the needs of the rural population. This
could lead to restoration of faith in public health care centres and subsequently their
increased consumption. The tool employed in the current study has highlighted some
Quality of public
health care
services
45
of the indicators of quality such as availability of drugs, doctors, medical, equipments;
interpersonal and diagnostic aspect of care; health care delivery; proper disposal
system, cleanliness; health personnel conduct. These parameters can provide valuable
assistance in developing a quality assurance/improvement programme and be
employed to assess the quality of current public health care centres with a view to
bringing about improvement through incorporation of user perspectives.
The use of purposive sampling for selection of sampling units at the last stage of
sampling may constitute a limitation for the study. As the study was conned to a
single state with specic socio-cultural features generalisations for the entire nation
have to be used with caution.
Recommendations
It is recommended that the presence of doctors who are employed in the public health
care centres be ensured by the government through strict monitoring and adherence to
discipline but that is likely to cause resentment. The most viable solution for attracting
and retaining doctors appears to be the integration of the health development
programme with the education, infrastructure and industry development programmes
of the rural regions in order to effect substantial improvement. This, of course is a
long-term strategy. Another alternative could be that some incentives are provided to
the doctors to lure them into rural areas. This could be in the form of non-nancial
incentives such as early promotions, transfers to home towns after a certain period of
service, leave for higher studies after completion of certain period of time at the rural
posting and so on.
The role of pricing in improving health care quality needs to be understood. It
would be benecial for the government authorities and the administrators of these
health care centres to understand the market mechanism. Involvement of the private
sector in running of some of these centres could also be explored.
The current study was limited to measuring the perceived quality of health care
services in public centres only. Therefore, it is suggested that further research should
be carried out in the private health care centres in order to understand the quality
related problems prevalent there. Other areas that require probing include the
understanding of the relationship between quality of health care and demand; quality
and price (willingness to pay); and costs and revenues.
Notes
1. Anganwadi is a government sponsored child-care and mother-care centre in India.
2. One Indian Rupee 100 paisa.
3. Uttar Pradesh is Indias most populous state which is located in the Northern part of the
country.
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About the author
Ritu Narang is Assistant Professor (Lecturer) at the Department of Business Administration,
University of Lucknow and her current areas of interest include services marketing and retail
business. She has been a Senior Distinguished Fellow at Hanken School of Economics, Finland
and has recently completed a major research project sponsored by University Grants
Commission, Delhi. She has presented papers at various national and international conferences
and has a number of national and international publications to her credit. She has also been
involved in delivering invited talks to managers of public and private sector organisations. Ritu
Narang can be contacted at: ritu_vnarang@yahoo.co.in
Quality of public
health care
services
49
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