QUALITY OF HEALTH CARE SERVICES
SELECTED ANNOTATIONS


1. An assessment of delivery pattern of MCH services in urban Varanasi

Author                 : Agrawal K., Tandan J., Srivastava P., et al.
Source                 : Indian Journal of Preventive and Social Medicine, 1994
Place of study     : Varanasi, Uttar Pradesh
Location              : Urban
Period of study    : Not Stated
Type of Research : Empirical, Evaluative, Community-based

Aim: To assess the delivery pattern of MCH services.

Methodology: The delivery pattern of MCH services were assessed by taking into account both the providers view point as well as that of beneficiaries. Five hundred beneficiaries were selected through systemic random sampling technique from the Family Register of FHWs of a randomly selected ward Bhelupura of Varanasi Corporation. Data were collected from these beneficiaries by administering a pretested and fully structured questionnaire at their residences for the type and extent of domicilary services provided by LHV/ANM. Health care personnel were assessed through record analysis of the center for two consecutive years.

Findings: Only 26.2 per cent of the beneficiaries had knowledge of MCH centres. Around 25 per cent of the beneficiaries had utilised them.

The ratios of various health care providers, such as, medical officers, public health nurses, health visitors, ANMs and trained dais to population were not fulfilling the government recommended ratios. It is concluded that the health care providers therefore were unable to cater optimum services to the beneficiaries.

Reviewer's note: The universe has introduced a bias in the sample and is evident from demographic profile of the sample. Moreover, the socio-economic and demographic data are not at all used in the analysis to throw light on linkages, if any exist. Indicators used for assessment are grossly inadequate.

Key words: Health Care provider, Delivery Pattern, Beneficiary, Quality of Services.

2. An innovative simplified MCH score for assessing ideal babies in the Well Baby Shows of Postpartum Outreach Programme

Author                  : Anandalakshmy P.N. and Mittal S.
Source                  : Indian Journal of Maternal and Child Health, 1995
Place of study      : New Delhi
Location               : Urban
Period of study     : 1987-1992
Type of research  : Empirical, Descriptive, Community-based

Aim: To develop a simplified MCH scoring system for the community-based assessment of babies.

Methodology: The study population consisted of the 83,000 people catered to by the AIIMS's Postpartum Programme. Welfare services to improve maternal and child health status included periodic baby shows, immunisation camps, ideal family shows and family welfare camps.

The parameters included for the MCH scoring systems were age at marriage and educational status of the eligible couple, wife's age at first childbirth, number of living children in relation to duration of marriage, immunisation status of living children, and inter-birth interval and contraceptives used for limiting/spacing. Also included were the usual criteria of general health and hygiene of children enrolled for the community-based assessment of babies in these family welfare and immunisation camps-cum-well baby shows. The score was also used to gauge the coverage of the services rendered in the area. It details the scoring system for the various parameters.

Findings: The data from the five clusters were presented separately for five, three or two years, depending upon the period of service provision in the respective areas. The other variable that impacted the scores was the 'mode of service provision', that is weekly clinics or periodic health services or services provided by the weekly mobile health van. The areas with weekly clinics showed better scores. However, the other services also had a positive impact.

It helped to strengthen promotional and educational activities in areas where poor scores were observed. The scoring system is viewed as a rapid assessment tool, which can be used by field workers and nursing students without any formal training in statistics or research methodology.

Reviewer's note:
The top-down approach dominates the methodology. It is driven by programmatic goals. The criteria included are beyond the control of the couple. The study does not talk about participation rates in such a show vis-à-vis the proportion of total eligible couples/children. Nowhere do the parameters or the scoring system seem to assume the importance of 'processes' that constitute the programme.

Key words:
Methodology of Scoring, Well Baby Show, Postpartum Programme, MCH & Family Welfare, Immunisation Coverage, Target Group.



3. An assessment of family welfare communication activities at the primary health centre level


Author                 : Bahl S.K. and Trakroo P.L.
Source                 : The Journal of Family Welfare, 1996
Place of study     : Haryana
Location              : Rural and Semi-urban area
Period of study    : Not Stated
Type of research : Empirical, Evaluative, Health Centre-based

Aim: To assess the IEC aids and materials supplied to a PHC and their utilisation under the family planning and MCH programmes. To assess the communication abilities of the health personnel at different levels of primary health care. To assess the reach of communication persons and their activities in the community.

Methodology: The primary health centre under study covered over 148,000 people, scattered across 123 villages and semi-urban areas. The villages were selected with regard to their access to health care facilities, i.e., one village where the PHC was located, one village where the sub-centre was located and two villages that did not have any health centre. The reach of communication activities was assessed from about 250 villagers residing in four villages of the PHC block. The data were collected through observation, interview schedules and available records.

Findings: There was a variation in the use of IEC material across the staff categories. All the health workers and field supervisors reported that they used posters quite regularly during their fieldwork while the medical officers did not. Only 15 of the workers reported using pamphlets/leaflets during the last one year. The models had been used only by 5 per cent of the workers. Flip charts, slides, flash cards and graphs had not been used because they were not available. On the communication skills indicator, none of the health workers scored high; most (84%) had low communication skills. An assessment of the knowledge, attitudes and practices of the health personnel with regard to various dimensions of MCH and family planning indicated that health workers, supervisors and medical officers were at different levels. An assessment of the reach of health personnel indicated that the reach and effectiveness of the communication activities leaves much to be desired.

There is a need to keep proper records of IEC material in order to reduce its misuse, and to develop a community-based feedback system to evaluate the total IEC efforts for enhancing accountability. Health personnel also need to be trained for effective interpersonal communication. The potential of folk media needs to be exploited in villages. The preparation of IEC material must be decentralised to meet local needs, cut expenditure and to provide opportunities for local talent.

Reviewer's note: The study does not highlight the reasons why health workers do not use IEC aids and materials. Knowing the reasons would have helped overcome the constraints and strengthen the IEC component in Family Welfare and MCH programmes.

Key words:
IEC activities, Communication, Skills, Health Personnel.

4. Inter-regional variations in health services in Andhra Pradesh

Author                : Baru R.V.
Source                : Economic and Political Weekly, 1993
Place of study    : Krishna, Guntur, Mahbubnagar and Medak, Andhra Pradesh
Location             : Rural and Urban
Period of study   : 1961-86
Type of research : Empirical, Analysis of Secondary Data

Aim: To study inter-regional differences in allopathic health services provided by the government, private and voluntary sector in Andhra Pradesh.

Methodology: The study reviewed policy and contrasted health infrastructure and manpower in two economically advanced and two backward districts of Andhra Pradesh.

Findings: The author compared the health infrastructure (using various indicators like doctor or hospital bed/population ratios) available in these districts. The public sector bed/population ratio for advanced districts was more favourable than for backward ones but from 1961 onwards the gap has narrowed down. PHC/population ratios presented little variation across the two sets of districts. The sub-centre/population: ratio was poorer in backward districts. The review of various categories of personnel in the public sector shows that there was no significant difference between two sets of districts as far as doctors were concerned. There was a difference in the personnel/population ratios across selected districts for nurses and paramedical staff. This paucity of paramedical staff in backward districts affected the functioning of PHCs and SCs in these areas.

The public health care amenities were concentrated in villages with a population of 5,000 or more in all four districts, reducing accessibility of services in backward districts where villages were comparatively smaller, more dispersed and unlikely to be connected by pucca roads.

Information on the private sector was limited. The author observes that the voluntary sector, mainly comprising missionaries, was also skewed towards advanced talukas in advanced districts. Pucca roads, communication and electricity seemed to influence the presence of these agencies. A number of voluntary agencies seemed to have stationed themselves in and around Hyderabad so that the staff could live within the city.

The overall trend was for health services in all three sectors to be concentrated in the more advanced districts (with the least variation seen for public health services). The author concludes that political factors, and the general level of economic and infrastructural development influences the spread of health services in all the three sectors.

Key words:Health Services, Public, Private, Voluntary.


5. Maternal care receptivity and its relation to perinatal and neonatal mortality

Author                : Bhardwaj N., Hasan S.B. and Zaheer M.
Source                : Indian Paediatrics, 1995
Place of study    : Uttar Pradesh
Location             : Rural
Period of study   : 1987-88
Type of research : Empirical, Analytical, Community-based

Aim: To assess maternal care services provided to pregnant mothers at their doorsteps and to find out why women are not availing of antenatal services.

Methodology: Two hundred and twelve pregnant women in different trimesters were identified from the study area and were registered and followed up every month till delivery and the neonatal period. Antenatal services were provided to these mothers at their doorsteps through home visits to overcome different reasons for non-utilisation such as physical inaccessibility, long waiting hours and socio-economic factors. A scoring system was adopted to assess the maternal care services provided to the sample population. The scoring system took into account the following factors: (i) time of commencement of antenatal care; (ii) frequency of antenatal home visits; (iii) number of doses of tetanus toxide immunisation accepted; and (iv) place and person attending the delivery. During follow-up, scores were assigned to each of these factors. The scores were added to give the 'Maternal Care Receptivity'(MCR). Depending on the score, MCR was ranked as high (11 to 8), moderate (7 to 4) or poor (3 to 0). Routine antenatal check-ups were also carried out.

Findings: The study showed that of 212 women, the majority (75.9%) were moderate in their receptivity of maternal care services. About 17 per cent of the women were poor in their reception and only 7 per cent of the women were highly receptive of the maternal care services even when they were provided at their doorsteps.

The study found that the major cause of under-utilisation of services was the illiteracy of the women, ignorance of the necessity of antenatal services and a deep-rooted faith in the TBAs. Statistical analysis showed that mothers who were poor or moderate in their reception of maternal care services have higher rates of perinatal and neonatal mortality whereas mothers with high MCR did not have any perinatal and neonatal mortality. The study showed the need to generate awareness among mothers through health education for better reception of maternal health services.

Reviewer's note: The study does not give the socio-demographic characteristics of the respondents, which are important variables affecting receptivity to services.

Key words:Maternal Care Receptivity, Perinatal Mortality, Neonatal Mortality.

6. The extent of information provided by health personnel to parturient mothers during their stay in the labour room

Author                : Celcy M.
Source                : Indian Journal of Nursing & Midwifery, 1998
Place of study    : Vellore, Tamil Nadu
Location             : Not Applicable
Period of study   : Not Stated
Type of research : Empirical, Descriptive, Health Centre-based

Aim:
To assess the type and quality of information provided to normal parturient mothers by labour room personnel (nurses, doctors, ANMs and students).

Methodology: A sample of 60 mothers was drawn using the simple random sampling method. Data were collected from the time of admission until two hours after delivery. The various areas of care covered were admission, rest and sleep, fluid therapy, breathing exercises, elimination, pelvic examination, catheterisation, instrumentation, second stage/ third stage of labour, immediate postnatal care and breast-feeding. Information provided with rationale was considered complete and given a score of 2. Information without rationale was given a score of 1. Percentages, mean, SD, 't' test and 'F' test were the statistics used.

Findings: Only 38.4 per cent of the required information was provided during the stated period, which is highly inadequate. The most information was provided in the areas of rest and sleep and second stage labour (>60%). The focus on second stage labour was presumably to safeguard the health of the baby and to complete the second stage labour as quickly as possible. It was also influenced by the midwife or obstetrician's distress and excessive anxiety about the outcome of labour. The least amount of information (<10%) was given during per vagina examination, catheterisation and instrumentation. Demographic variables were not significantly associated with the amount of information given.

Giving adequate information in this situation positively influences the mother's psychological needs and smoothens the process of childbirth. It is her right to get a clear explanation of the proposed treatment she will undergo in a hospital. Specific information and assurance areas are listed. It is suggested that structured informational guides be given to all antenatal mothers during their last visit to antenatal clinics. Nurses need to recognise this need, which also helps to project a positive image of nursing and midwifery in India.

Reviewer's note: Recognition of women's right to information during maternal care is a good beginning.

Key words:Information, Parturient Mothers, Communication, Childbirth, Labour.

7. A synthesis of research findings on quality of services in the Indian Family Welfare Programme

Author                : Foo G.H.C.
Source                : Proceedings from the National Workshop, 1996
Place of study     : 10 States of India
Location              : Rural
Period of study    : Not Stated
Type of research : Empirical, Meta-analysis of Research Studies

Aim: To synthesise available evidence on the standards of care provided by the Indian programme and the relationship between quality of care and effective family planning use.

Methodology: A review of available evidence from qualitative and survey research on the quality of care provided by the family welfare program. This is a synthesis of 28 research papers presented at the workshop.

Findings: The findings from various qualitative and survey research projects have been collated and analysed under three aspects: user's perception of quality of care; provider's perception of quality of services and the problems faced; and linkages between quality of care and contraceptive use.

The synthesis of findings on the users' perspective revealed that clients perceive the private sector as offering health and family planning services that are superior in quality to those offered by the government. In addition, clients' assessments of the individual dimensions, which compositely define quality of care, displayed considerable interstate variation, paralleling the standards of service extent in the states. All these studies found that clients were generally not offered a method choice, and that the information they were given by providers on individual contraceptive methods was extremely limited, with the issues of contraindications and side-effects seldom raised. In spite of such marked deficiencies in the quality of care, clients' expectations were so low that the majority expressed satisfaction with the services they receive.

The synthesis of findings on the providers' perspective revealed the negative effect of method specific family planning targets on the quality of services offered by family planning providers as well as the need to arrive at commonly agreed upon standards of care, which guide providers' performance. Medical officers felt that the inadequacy of infrastructural facilities and logistical supplies together with the late payment of salary and the lack of travel allowances mitigate against the provision of quality services. ANMs were unable to define quality, to identify gaps in their services, or to propose improvements. They were generally satisfied with their work.

The synthesis of findings from various studies can attribute the poor quality of care in sterilisation camps to the intersection of a number of factors. These include inadequate physical infrastructure and logistical support, absence of clear guidelines and protocols setting standards to be met in services and procedures; an absence of understanding what constitutes quality services; and indifference among many providers to adhering to standards of performance and to the human dimension entailed in providing health services; and finally, the provision of services largely within the context of meeting targets and thereby achieving volume rather than quality.

The report concludes with some findings of the effects of quality of care indicators like frequency of visits by health workers, client-provider interaction time, women's perception of health services on contraceptive use and continued use.

Key words: Quality of Care, Family Welfare Programme, Users' Perspective, Providers' Perspective.

8. Quality of family planning services in India: The user's perspective

Author                : Gangopadhay B. and Das D.N.
Source                : The Journal of Family Welfare, 1997
Place of study    : Delhi
Location             : Urban
Period of study   : 1993
Type of research : Empirical, Evaluative, Health Centre-based

Aim: To find out the causes of the failure of the National Family Welfare Programme.

Methodology: A questionnaire was administered to 125 females in the age group of 15-45 who had ever used contraception. It contained questions regarding socio-economic and household information and had open-ended questions to elicit their perception on family planning methods, source of information, and selection of family planning methods. The information received was checked with records maintained at family planning centres and from the AWW.

Findings: The respondents were mainly from the low-income, underprivileged group. About 85 per cent of the respondents were receiving services from the family planning centre of nearby hospitals, 10 per cent from private doctors and the rest (5%) from other government hospitals and dispensaries in the city. The respondents mostly belonged to the lower socio-economic group. The respondents had an average of at least two living children irrespective of the method used. The main sources of FP information were neighbours and relatives (87%), doctors (81%) and the electronic media (70%). The cafetaria approach was not practised in government facilities. A third of the respondents reported that they received poor quality of counselling and their fears and doubts were not addressed. Private practitioners were preferred because they offer better information and counselling, save time with smaller queues and convenient timings, and also because the contraceptives are of better quality. Many recorded cases of contraceptive failure may reduce the faith of couples on the family planning programme.

The findings depict the need to develop an IEC programme to increase the awareness of the benefits of child spacing. They also reveal that the service providers should be sensitive to the clients' needs and help them make an informed choice. The political and religious leaders should actively participate in the population programme.

Reviewer's note: The methodology adopted for the study was not adequately articulated. The method of sample selection is not given. Only females were interviewed.

Key words:
Users' Perspective, Evaluation, Family Planning Programme, Informed Choice.

9. Women's perspectives on the quality of general and reproductive health care: Evidence from
rural Maharashtra


Author                : Gupte M., Bandewar S. and Pisal H.
Source                : Improving Quality of Care in India's Family Welfare Programme The Challenge Ahead, 1999
Place of study
    : Pune, Maharashtra
Location              : Rural
Period of study   : 1994-96
Type of research : Empirical, Analytical, Community-based

Aim:
To understand women's needs in a variety of situations, in which they seek health services, including abortion services.

Methodology: Six villages were selected on the basis of their access to health services, their size (ranging from 1,500 to 3,500 inhabitants), and accessibility by transport to nearby towns. In monthly focus group discussions that took place over eight months, data were gathered on women's needs for health care delivery. On the basis of the discussions, a list of 21QHC indicators was drawn up.

To understand women's needs related to abortion in real-life situations, they were asked not only about abortion services but also about general health care and obstetrical care needs. Of a total of 67 women, 61 ever-married women who had regularly been part of the focus-group meeting were interviewed about QHC, 49 were interviewed about their choice of providers, and 67 were interviewed about their preference for public or private abortion services. The first two involved rank–ordering exercises. Women were required to be literate for this. As the three interviews were lengthy, it proved impossible to interview all 67 women for all three sets of data.

Findings:
The study documents women's choice of providers, their feelings about both public and private health services, and their perceptions of QHC. The concept of QHC, according to them, was not a fixed entity, but instead depended on their social circumstances and specific health needs. The contrast between some of the QHC indicators for abortion and non-abortion services helps one to understand the complex social milieu in which women's decision-making (or lack of it) about abortion in particular and sexuality in general takes place.

The findings indicate that women's major concerns about the quality of general health care services reflect the needs of any rural population. The services must be nearby and easily accessible, and a doctor should be available for handling emergencies at any time. Women expect a doctor to pay attention when he examines and treats them. Most women consider empathy, concern and counselling from the doctor very important, especially in abortion care. Cleanliness is an important criterion for general health care and deliveries. In the case of abortion care, among married women, the doctors' insistence on the husband's signature was a major obstacle. In case of abortion outside marriage, secrecy was given precedence over all other considerations. Confidentiality on the part of the doctor received the highest cumulative score and was the first ranked score among the indicators of quality.

In various health care-seeking situations - ranging from minor illnesses to chronic illnesses, emergency, ANC/PNC, delivery gynaecological illnesses, sex determination, abortion within and outside marriage - women choose providers pragmatically. The first choice of married women seeking abortions is the private sector, as the government programme asks for the husband's signature and pressurises them about contraception. Women resent having to pay for health services in the private sector because a PHC staff is insensitive towards women or its facilities are inadequate.

Key words: Quality of Health Care, Women's Perspectives, Providers.

10. Evaluation of quality of family welfare services at the primary health centre level

Author                : Task Force, ICMR
Source                : Indian Council of Medical Research, 1991
Place of study     : Nationwide
Location              : Rural
Period of study    : 1987-89
Type of research   : Empirical, Evaluative, Health Centre-based

Aim: To carry out an independent evaluation of family welfare services being offered at the level of Primary Health Care centres.

Methodology: ICMR in collaboration with the state health directorates carried out a study through its network of 35 Human Reproduction Research Centres located in medical colleges in different parts of the country. A total of 398 PHCs from 199 districts, located in 18 states and a Union Territory (Pondicherry) were evaluated. A major component of the assessment of quality involved observation of the ANMs in the field and while they were providing services. This was complemented by an examination of the records and reports maintained at the PHCs and sub-centres for their completeness and accuracy. Further, the records of a sub-sample of beneficiaries were examined to find out the details of care provided. These were matched with the responses of the beneficiaries. The limitations of the methodology are mentioned.

Findings: According to the new pattern recommended, there should be one PHC for 30,000 population. The data from this study indicates that the recommended pattern was achieved in only 12 per cent of PHCs. It was observed that resources in terms of physical facilities were comparatively satisfactory at PHCs, but greatly deficient at the level of sub-centres which are really the first contact point for the community. This was especially so with respect to routine antenatal care. With regard to manpower, there was a substantial shortage of ANMs. In fact, the sanctioned pattern of ANMs indicated a need for increasing the number of posts for this category of health functionary. Nearly half of the sub-centre's facilities for normal delivery were absent. The majority of the PHCs were lacking in functional equipment and/or trained manpower to carry out pregnancy termination even after two decades of the MTP Act.

Antenatal, intra-natal, neonatal and child care services were included for the evaluation of MCH care provided at PHCs. The study underlined the urgent need to equip ANMs with better skills and facilities so as to improve their performance in various aspects of MCH care. Records were found to be deficient in details of care provided. Facilities were virtually non-existent at sub-centres, which are the very first level of contact for the community. In the case of postnatal care, surprisingly, advice on family planning was the only component addressed "properly" during the postnatal period, confirming the programme's emphasis on family planning. The situation with regard to support facilities like water supply, toilet facilities and availability of transport was generally satisfactory.
Reviewer's note: This study does not reveal the impact of multiple factors on the performance of ANMs in MCH care delivery.

Key words: Primary Health Centre, Sub-centre, Quality of Care.

11. Patient satisfaction in the context of socio-economic background and basic hospital facilities: A
pilot study of indoor patients of LTMG Hospital, Mumbai


Author                : Iyer A., Jesani A. and Karmarkar S.
Source                : CEHAT
Place of study     : Mumbai
Location              : Urban
Period of study    : 1996
Type of research : Empirical, Descriptive, Health Centre-based

Aim: To assess the quality of services provided by the Lokmanya Tilak Municipal General (LTMG) Hospital through the patients' perspective.

Methodology:
The authors interviewed 123 indoor patients - that is about 10 per cent of the bed strength - during their stay in hospital to assess their satisfaction with hospital services. Patients were selected by the simple random method A close-ended interview schedule was used for data collection. Information was collected on the reasons for seeking care at LTMG Hospital, their experience of indoor care, quality and adequacy of physical and medical facilities, interpersonal provider-patient relationships, expenditure incurred and the patient's satisfaction with hospital care.

Findings: The study found gender bias in the allocation of beds per ward (33% for females compared to 46 % for males). This bias is further marked (20% for females compared to 55% for males) when the all-female beds in obstetrics are excluded. About 6.9 per cent of all female patients belonged to the 18-45 age group. Four-fifths of these women were admitted for gynaecological and obstetric care. About 54 per cent were non-earners. A high proportion of females among non-earners, their low representation in the service sector and much lower average income levels, indicated gender-specific economic activities. The majority of patients were literate. However, the percentage of post-matriculate education was low (10.5%) and lower still among female patients. A majority of the patients were Hindus, and most of them belonged to the upper castes. The proportion of scheduled castes in the sample was exactly twice the 1991 census figures for Greater Bombay. The data about living conditions, when seen in the light of other socio-economic data, showed that patients seeking indoor care at LTMG hospital were in many ways disenfranchised members of society. The largest number of patients were those who lived most of the year in Mumbai, indicating that the hospital has largely remained a metropolitan institution. Its role as a regional centre is indicated, but not to any significant degree. The study found that though the hospital is a tertiary-level care provider, about a third of the patients did not seek medical treatment from any other provider before coming to the hospital. About a third of patients were referred.

The study found that dissatisfaction with private providers creeps in earlier than it does in the case of public providers. The majority of the patients came to the hospital because they perceived it to be good, with adequate support facilities. The study reported on the quality of care provided by the hospital in terms of the quality and adequacy of physical facilities, inter-personal relationships, adequacy of medical facilities, and the patient's satisfaction with these.
Based on their findings, the authors recommend steps to improve and strengthen peripheral public health care as well as hospital management.

Reviewer's note: The limitations of the methodology were explicitly articulated. The authors note that the responses of the patients may have been influenced by the hospital environment since the interviews were conducted while the patients were still admitted. The study findings could have been strengthened by complementing patient interviews with provider interviews.

Key words:
Quality of Care, Patients' Satisfaction, Public Health Care Facility.

12. A longitudinal study on some aspects of maternal and child health in an urban community of
Ahmedabad


Author                 : Kartha G.P., Kumar P. and Purohit C.K.
Source                 : Indian Journal of Preventive and Social Medicine, 1993
Place of study     : Ahmedabad City, Gujarat
Location              : Urban
Period of study    : 1989
Type of research : Empirical, Descriptive, Prospective, Community-based

Aim:
To study the pattern of ANC, and the morbidity and pregnancy outcome; and to identify MCH problems in the locality.

Methodology:
A baseline house-to-house survey enumerated all couples in a geographically-defined urban area. All new pregnancies that occurred in that area were registered and followed-up for antenatal care and delivery. The study population consisted of 500 families with a total population of 2,564. In all, 36 pregnant women were followed till term.

Findings: The socio-demographic features of the studied families showed that the majority of families were nuclear, small-sized, and belonging to the middle- to lower-middle class. The sex ratio was 815. The literacy rate was 74.1 per cent. The overall quality of antenatal care was good. The majority of the pregnant women had regular antenatal check-ups with an average of 3.7 visits. Twenty-six of the 36 pregnant women were fully vaccinated against tetanus. Three-fourths of the mothers said they had regularly taken iron and folic acid supplements. Most were home deliveries, though trained birth attendants or health personnel supervised the majority of deliveries. The total pregnancy wastage was 4. Low birth weight (according to the Indian criteria, ie < 2,000 gm) stood at 10.3 per cent.

The study areas showed a positive health profile – low birth rate (13.2), low infant mortality (27), high contraceptive prevalence rate (72.0 %), and a low incidence of LBW. The study area is served by government., non-government and private health agencies. The effect of positive health cannot, therefore, be attributed solely to this urban health centre. However, the joint effect of these services presents a positive picture of maternal and child health.

It is concluded that the available health services have helped combat morbidity and mortality. Apart from these health interventions, however, the high literacy rate, especially of females, and the predominantly middle class social milieu in the studied area could also have contributed to better maternal and child health levels. The study also emphasised the need for a similar study with a large sample and control population.
Reviewer's note: Despite the longitudinal design of the study, the findings are purely descriptive in nature. Consequently, the impact of socio-demographic variables is not assessed.

Key words:
Maternal and Child Health Care, Urban slums, Urban Health Centre.


13. Situation analysis of Medical Termination of Pregnancy (MTP) services in Gujarat, Maharashtra, Tamil Nadu and Uttar Pradesh

Author                : Khan M.E., Rajagopal S., Barge S., et al.
Source                : Working Paper, CORT, Baroda, 1998
Place of study    : Gujarat, Maharashtra, Tamil Nadu and Uttar Pradesh
Location             : Rural
Period of study   : 1992-97
Type of research : Empirical, Descriptive, Health Centre-based

Aim: This is part of a larger study conducted by this organisation to develop a database on the availability of abortion facilities and to identify the reasons for the under-utilisation of MTP services.

The extent of MTP facilities in rural and semi-urban areas was central to this study, which also attempted to pinpoint how many of the MTP facilities were approved, and what the quality of the MTP services was as regards trained personnel and required infrastructure.

Methodology: In this multicentric study, the method of situational analysis of MTP services was used. It was conducted in two phases. Gujarat and Maharashtra were covered in the first phase and Tamil Nadu and UP in the second phase. The methodology in the second phase was revised, based on the experiences of the first phase. Clients' perceptions on the quality of MTP services were also studied. It is a large study in terms of coverage. It covered 61 districts from four states. In Gujarat and Maharshtra it covered about 58 per cent of the total number of districts, while in UP and Tamil Nadu it covered between 38-40 per cent. The sample size was 510 health care units (public sector: 380, private sector: 130). It also included about 241 private abortion providers who were trained in Indian systems of medicine or homoeopathy.

Findings: That MTP services are differentially distributed over the states has been shown using the secondary data. The survey data indicates that not all the public sector units which have been allowed to provide MTP services are functional. This was due to various reasons: lack of trained doctors, lack of equipment, lack of both trained doctor and equipment, non-functional equipment, no anaesthetist, etc. At the public health care units, the MTP providers were not always trained.

Post-abortion contraception was insisted upon, though it is not a pre-condition for obtaining MTP care, except in UP. As regards this, Maharashtra and UP showed declining trends.

It was observed that the quality of training was not up to the mark. Inadequate training was attributed to a low case- load of MTP in the designated training institutions and low priority given to the MTP trainees over the resident doctors/MD students. Also mentioned were the other administrative and financial hurdles which serve as demotivating factors for trainees, and also dissuade their superiors from sending them for MTP training.

As regards essential equipment, Gujarat and Maharashtra were relatively better off, while UP was the poorest. Essential drugs were generally available in all states except Gujarat, where availability was comparatively on the lower side.

Clients' perception of the quality of MTP services were sought on 'information exchange' and the waiting period, efforts made to protect modesty and make the client comfortable, and costs incurred for the procedure. In general the study indicates that MTP services have not been given the attention they deserve.

Reviewer's note: The study covers only the registered MTP service centres. A large number of non-registered institutions provide abortion care.

Key words: MTP Services, Quality of MTP Services, Clients' Perception on Quality of MTP Services Received.

14. Streamlined records benefit maternal and child health care

Author                : Kumar R.
Source                : World Health Forum, 1993
Place of study    : Ambala, Haryana
Location             : Rural
Period of study   : Not Stated
Type of research: Empirical, Evaluative, Health Centre-based

Aim: To evaluate a simplified home-based MCH recording and reporting system.

Methodology:
The study reviews the existing MCH recording and reporting system and then evaluates the implementation of a simplified, home-based recording system. A review of the recording and reporting system was conducted at 10 sub-centres under five PHCs. The registers maintained by health workers, as well as those of their supervisors and medical officers, were studied to ascertain the information system, the difficulties of recording and reporting, and ways of improving the system. Six months after the introduction of the new systems, 14 health workers were interviewed to gauge the usefulness of the new system.

Findings: A review of the existing system showed that records were incomplete. The procedures of record-maintenance were perceived to be cumbersome and time consuming. There were several other problems: there were no printed forms available; shortage of stationery led to registers being maintained on loose sheets; supervisors experienced difficulty in acquiring information from the health workers; and duplication of work dominated the information management system.

The study finds that though the new system was simpler to use and information retrieval and reporting was easier than before, only about 50 per cent of the records were updated. Though the records were properly completed, under-reporting of vital events continued.

The bottom-up approach made it possible to develop a community-based information system. Family cards were helpful in coordinating the efforts of various agencies providing maternal and child health services and avoiding duplication. The community can use this for evaluating services.

The major drawback was that senior administrators paid little attention to data on vital events. The author recommends commitment at the highest level and improved supervision in order to strengthen the information system.

Reviewer's note: Though the authors say that the main advantage of the simplified system is transmission of information to the community, it would be interesting to see whether the evidence suggests that this actually occurs and whether the community actually puts the information to use.

Key words: MCH, Management Information System.


15. Assessment of community attitude regarding the services of PHC: A medical geographic study

Author                : Kumar V.K. and Singh J.
Source                : Indian Journal of Preventive and Social Medicine,
1994
Place of study        : Varanasi, Uttar Pradesh
Location : Rural
Period of study        : Not Stated
Type of research        : Empirical, Descriptive, Community-based

Aim:
To assess community attitudes regarding PHC services and their level of satisfaction with and expectations from PHCs.

Methodology: The cross-sectional survey was conducted on 195 respondents (one adult member from each of the family who has utilized facilities from PHC at one time or the other).

Findings: The authors found communication between health staff and the community to be most problematic. They opine that monitoring of home visits by health staff and re-training to be imperative. They conclude that more than half the respondents were dissatisfied with the PHC services but would not complain for fear of penalization. The authors then list some of the common expectations of the community viz. free and better medicines, proper treatment, attention from PHC staff and an ambulance service for an emergency.

Reviewer's note: Only those respondents whose family had utilized the PHC services were included. The respondents may not be representative and it would have been also insightful to study the attitudes and expectations of those people who did not use PHC services.

Key words: Provider-client Communication, Community's Expectations, Health Services.

16. Quality of health and family planning services in rural Uttar Pradesh: The client's view

Author                : Levine R.E., Cross H.E., Chabbra S., et al.
Source                : Demography India, 1992
Place of study    : Uttar Pradesh
Location              : Rural
Period of study    : 1992
Type of research : Empirical, Descriptive, Community-based

Aim: To gain in-depth understanding of how villagers in Uttar Pradesh view both government and private health services, and how they think about the available family planning services.

Methodology: A special unit of the Indian Market Bureau carried out a set of 20 small, in-depth, focus group interviews with married, 15-34 year old males and females. The selection was made at the level of districts and villages. Districts were selected from each of the five socio-cultural regions. Villages with access to government health care services were selected. In each of the socio-cultural regions, four group discussions were held – three with women and one with men. Each FGD lasted for about hour and a half and was moderated by a trained group leader who followed a structured discussion guide. Discussions were tape-recorded, then translated into English. The transcripts were content-analysed.

Discussions on general health issues helped in establishing a rapport with the people before proceeding to the sensitive topic of contraceptive use.

The reports states the advantages and disadvantages of FGD and its implications for generalisation of the findings.

Findings: Important determinants of treatment-seeking behaviour fall into the categories of physical or financial access. In the Indian context, indicators of quality of care include experiences with effectiveness of treatment, thoroughness of examination, care by a doctor (as opposed to paramedical personnel), waiting time, timings of the facilities, provision of medication, provider-patient communication, and doctors' qualifications. The respondents evaluated the private sector positively on almost all the indicators except one, that is, qualification of the providers. The public sector was evaluated negatively on all the indicators, except two – treatment experience and qualification of providers.

There was a fairly high level of awareness of family planning methods among both men and women. Respondents reported that government health personnel do not involve them in the choice of a particular contraceptive method. Some also doubted the reliability or efficacy of the method. Respondents elaborated on the kind of family planning services they wanted.

The author provides a list of recommendations based on this data to overcome the existing constraints and shortcomings of the programme.

Key words: Quality of Health care, Family Planning Services, Focus Groups.

17. Physical standards in the private health sector

Author                : Nandraj S. and Duggal R.
Source                : Radical Journal of Health, 1996
Place of study     : Satara, Maharashtra
Location              : Rural and Urban
Period of study    : 1994-95
Type of Research: Empirical, Descriptive, Health Centre-based

Aim:
To document and review various guidelines available in the government, NGO and private sectors for the minimum physical standards necessary for provision of health care of various kinds.

The framework of minimum standards for quality care was evolved on the basis of existing information discussed as per the findings and its critique at a workshop.
Methodology: A sample of 53 practitioners from different systems of medicine and specialities and 49 hospitals was covered from two talukas of Satara district in Maharashtra. Both economically backward (EBA) and developed areas (EDA) were chosen to get a comparative and a representative picture of the state.

A combination of methodologies was used as this was an exploratory study. A range of secondary data sources was used to acquire information on private health facilities. The names of persons practicing without any qualifications were collected through informal discussions with key informants in the villages.

Findings: Some of the problems faced were: inadequacy of data on the size, functioning and nature of the private health sector; difficulties in categorising different aspects of physical standards as the size of health facilities ranged from three-bed to 500-bed hospitals; difficulties in defining the various units under study and their various functions; difficulties in defining qualitative terms for the observation schedule to minimise the subjectivity in observational data.

The majority (59%) of the health practitioners was concentrated in the urban areas. The gender and age distribution show a very high male concentration in both economically developed areas (EDA) and economically backward areas. The mean age of the EDA practitioner is higher and this is perhaps indicative of the push factor in EDAs as a consequence of over concentration which is forcing new practitioners to move gradually into EBAs. This is a welcome trend which needs to be encouraged. The local government can play an important role in discouraging new entrants in over-served areas. Only 9 per cent of the allopaths were found practicing in EBAs. An overwhelming majority were practising allopathy without having the necessary degree. Record maintenance was found very poor, with no proper format.

Three-fourths of the hospitals were situated in urban areas. In the last two decades the private sector has grown phenomenally. The doctor was the administrator of the institution for all the hospitals in the sample. The data revealed that in 85.7 per cent of the hospitals, patient were admitted only by the doctor-owner and only in 14.3 per cent of the hospitals could other doctors admit their patients. This practice was more prevalent in the EDA. None of the hospitals were registered by any authority. The average beds per hospital was 11, which raises the issue of efficiency and efficacy in running smaller hospitals.

Reviewer's note: This study contains an elaborate review of literature on the private health care sector. Limitations of the study and the problems faced during research are articulated. This would help direct research in this area in the future.

Key words:
Physical Standards, Quality, Health Care.

18. Programme inputs and performance of the family planning programme: Evidence from a comparative study of PHCs

Author                 : Narayana M.R.
Source                 : The Journal of Family Welfare, 1995
Place of study      : Chitradurga, Karnataka
Location               : Rural
Period of study     : 1990-91 to 1992-93
Type of Research: Empirical, Descriptive, Health Centre-based

Aim:
The paper examines the role of programme inputs in explaining the relative family welfare programme performances of PHCs.

Methodology: Six PHCs, two each from 'good', 'average' and 'poor performance' categories were selected, based on their 1990-91 performance (numerical achievement as a percentage of the target). One each from these three performance categories was with equal initial conditions and one each with unequal conditions. It covered five of nine talukas in the district. A structured questionnaire was administered in 1993.

Findings: The initial condition of the PHC as also the population it covers does not determine its relative performance. The availability and utilization of vehicles did improve programme coverage and performance though this was not always true. For sporadic sterilization camps, availability of good public/ private transport and a high level of awareness of the venue and timings of the camp were critical to the success of the camp. It was also seen that vacant posts of health staff make a strong difference between good and average performance rather than between good and poor performance. Strong dissatisfaction was evident in relation to the inadequacy of financial incentives to the various categories of health staff. It was also seen that the erratic supply of medicines and medical items had no relation to the PHC's performance.

A surprising finding was that the performance of PHCs was inversely related to the programme inputs, thus suggesting that performance was determined by factors beyond the recordable programme inputs, such as popularity, dynamism, commitment and motivation of the health staff. Secondly, the responsiveness, attitude and behaviour of the people towards family planning may also affect it. The authors conclude that there is no strict correspondence between programme inputs and performance. This implies that a practical solution for better and more balanced family welfare performance should aim at simultaneously (or discriminately) providing all (or selected) complementary (or substitutable) programme inputs in time, in adequate quantity and in adequate quality.

The author feels that an assessment of the role and problems of the programme inputs considered in this paper will help in rethinking targets for the PHCs.

Key words:
Family Welfare Programme, Performance, Programme Inputs,Comparative Study.


19. The effects of quality of services upon IUD continuation among women in rural Gujarat

Author                  : Patel D., Patel A. and Mehta A.
Source                  : Working paper, Action Research in Community Health (ARCH), Mangrol, Gujarat.
Place of study      : Rajpipla, Gujarat
Location               : Rural
Period of study      : 1987-95
Type of Research: Empirical, Descriptive, Community-based

Aim: To document the processes in developing a socio-culturally sensitive and specific health education programme and to assess the impact of this programme on levels of IUD continuation.

Methodology: Women with IUD insertion were prospectively followed-up for a period of two years to study continuation of IUD use. The study was conducted pre- and post-intervention. A health education programme was an intervention. There were 56 women in the pre-intervention and 80 in the post-intervention phase.

Findings: The authors initially undertook to understand women's fears of IUD and reasons for non-acceptance and discontinuation. A culturally-sensitive health education programme was then developed, mainly through free and informal communication (talks, slides, posters, pictures etc) at the clinic or community meetings. Women's anatomy was explained and the process of IUD insertion was demonstrated on a thermocol model.

With health education, overall IUD acceptance increased. This increase was more amongst tribal as compared to upper caste women. Discontinuation of IUD was significantly lower amongst women with post-IUD complaints in the intervention (i.e. during the health education programme) phase as compared to the earlier (non-intervention) phase. Though the proportion of women with post-IUD complaints was similar in both phases, retention of IUD was higher in the intervention phase. Continuation rates were significantly higher in the intervention phase especially when removal of IUD due to problems only was considered.

The authors conclude that specific and sensitive health education programmes (counselling) which address women's perceptions and apprehensions of IUD can improve continuation rates. The authors infer that intimate and prolonged interaction with women, or an exceptionally high order of dedication by the health worker (counsellor) is not mandatory for implementing such a health education programme. Visual materials and an explanation of the female anatomy are essential.

The study does not argue that the IUD is either the best spacing method available for rural women or the most preferred method. It demonstrates that given the voluntary choice of methods made by women, IUD's continuation rates can be improved markedly by providing specific health education which effectively addresses women's perceived fears and apprehensions.

Key word: IUD Acceptance, Health Education.


20. Quality of care in laparoscopic sterilisation camps: Observations from Kerala, India

Author                  : Ramanathan M., Dilip T.R. and Padmadas S.S.
Source                  : Reproductive Health Matters, 1995
Place of study      : Palakkad, Kerala
Location               : Rural
Period of study     : 1994
Type of Research: Empirical, Descriptive, Health Centre-based

Aim: To evaluate the quality of care provided at a sterilization camp under the FPP.

Methodology:
The study observed the events in a single sterilization camp and also interviewed 19 women clients prior to their participation in the camp. Cross-sections of husband were also interviewed before the women had operations. A few women were interviewed post-operatively. Some of the organisers of the camp were interviewed to identify the problems they faced in running the camps.

Findings:
Most of the women were in their 20s; on average they had two children. Their husbands were day labourers, semi-skilled and skilled workers among them. All the women were accompanied either by their husbands or women relatives. Junior public health nurses responsible for motivating these clients to accept sterilisation accompanied some.

The paper reports on the observation findings of a sterilization camp. One surgical team did 48 laparoscopic sterilizations in just over two hours (averaging 2 minutes and 40 seconds per sterilization) in clear violation of the norms laid down by the programme. Counselling of women before surgery was inadequate. The surgeon never changed his gloves, the linen on the operating tables was never changed. Though the building had facilities like access to running water, electricity with a standby generator in case of power failure, and attached toilet, these were inadequate. The women had to wait for a long time after completing registration formalities for the surgical team to arrive. Pelvic examinations were not done prior to sterilization for all women. Post-operative care was lacking. For nursing staff of the taluka hospital deputed for this, it meant extra work. The surgeon who officiated at this camp belonged to another taluka who had to finish his scheduled surgery at his own place and thus delayed the camp. According to the supervising doctor, the need to fulfil the targets frequently resulted in wrangling between health workers.

The authors conclude that though the situation at the sterilization camp was much better than other states, with efforts made to disinfect the place and sterilize the instruments, with better planning and management, available resources could be put to more effective use in organizing such camps more frequently. The lack of quality of care in service provision has far-reaching implications both for women's health and health policy.
Key words:Sterilisation Camp, Quality of Care.


21. Quality of client-provider interaction and family welfare services (MCH and FP programmes)
in rural Karnataka


Author                : Reddy P.H.
Source                : Working paper, Centre for Technology Development, Bangalore
Place of study    : Kolar, Kerala
Location             : Rural.
Period of Study  : 1994
of research         :
Empirical, Descriptive, Community and Health Centre-based

Aim: To examine how welfare programme personnel interact with clients in a given setting, and the quality and frequency of such interaction. To understand the providers' view of, and satisfaction with, the information and quality of family welfare services provided. To gather the clients' view of, and satisfaction with, the information and quality of family welfare services received.

Methodology: The contexts included were antenatal clinics, immunisation clinics, deliveries, postnatal services and family planning camps. Multiple qualitative research methods - observation, informal interviews and discussions, semi-structured interviews, and group discussions - were employed in the collection of data. Two PHCs and three sub-centres under each of the two PHCs were selected.

Findings: It was found that interaction between clients and ANMs was quite frequent, unlike that between clients and MHWs. The quality of interaction differed at the level of SCs and at higher levels. Better interaction at the sub-centre level was attributed to the necessity on the part of ANMs to be on good terms with clients to meet targets. The quality of interaction between clients and MHWs was poor. In general the quality of family planning services was found to be poor.

It is suggested that there is a need to allocate more funds to fill vacant posts, buy and supply adequate pre- and post-operative drugs etc. Periodic re-service training programmes need to be organised for medical, paramedical and non-medical personnel. The gaps in knowledge, skills and practices identified should be recognised while designing the curricula of these re-service training sessions. Top management should be committed to the concept of quality. Regular monitoring and supervision mechanism is required. It said that the present supervisory styles are autocratic and fault-finding. They should be changed to democratic and supportive supervisory styles. The author also suggests rewards for those maintaining quality and a demotion for the others.

Key words: Client-provider Interaction, Quality, Family Welfare Services.

22. Intra-Uterine Device as a means of contraception in our population

Author                  : Sarbajna S.
Source                  : Journal of Obstetrics and Gynaecology of India
Place of study      : Indian Iron and Steel Company Hospital
Location              : Not Stated
Period of Study    : 1977-87
Type of research :
Empirical, Descriptive, Retrospective, Health Centre-based

Aim:
To study the acceptability and complications of IUCD, causes of removal of IUCD, acceptance in different socio-economic groups, the attitude of women from different socio-economic groups towards IUCD and spacing, availability of paramedical personnel for motivation, attitude of health visitors.

Methodology: The hospital records of 460 women who had an IUCD inserted were reviewed over a period of 11 years. In addition, women were interviewed regarding their attitude towards IUCD.

Findings: During the study period of 11 years, 460 women used the IUCD, of which 169 (36.7%) had complaints, with 38 (8.4%) women removing the IUCD. Menstrual irregularity was found in the form of menorrahagia, dysmenorrhoea and spotting. This was more commonly encountered in the cases of post-MTP insertion. The most important cause of removal was menstrual irregularity. The others constituted failure of IUCD, severe vaginitis, opting for another method, and desire for pregnancy.

The majority of IUCDs were inserted for women from the middle socio-economic group. Women in the low socio-economic group were ignorant and indifferent about IUCD. Women from high and middle socio-economic groups showed a definite negative attitude towards IUCD, mainly due to the false belief that it caused cancer and menstrual irregularity.

The hospital had fewer health visitors than required. Health visitors were found to be indifferent towards the IUCD. It was revealed that they had an interest in tubectomy and vasectomy due to incentives involved in those. It is concluded that an adequate number of health visitors must be available for motivation.

Reviewer's note: Methods and subjects have been inadequately described in the study.

Key words: IUCD, Acceptability, Complications.

23. Quality of care at community hospital

Author                : Subrahmanyam V.
Source                : Economic and Political Weekly, 1997
Place of study     : Nellore, Andhra Pradesh
Location             : Rural
Period of study    : Not Stated
Type of research:
Empirical, Descriptive, Health Centre-based

Aim:
To find out the effects of medical negligence.

Methodology: Case studies were undertaken to explore the situation.

Findings: This study was undertaken in a Government Community Hospital in Kavali town of Nellore district to find out the factors that affect the right to health of common people. The study found that besides the negligence of health personnel, other factors are also responsible for the gross violation of the people's right to health. These include: politicisation of the institution, rampant corruption, profit motive of doctors, inadequate infrastructural facilities, unhygienic environment and the subservience of authorities to the ruling political bosses.

Key words:Right to Health, Negligence.

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