A Comparative Study to Analyze the Cost of Curative Care at Primary Health Center in Ahmedabad

Objectives:

To determine the unit cost of curative care provided at Primary Health Centers (PHCs) and to examine the variation in unit cost in different PHCs.

Materials and Methods:

The present study was carried out in three PHCs of Ahmedabad district namely Sanathal, Nandej, and Uperdal, between 1 April, 2006 and 31 March, 2007. For estimating the cost of a health program, information on all the physical and human resources that were basic inputs to the PHC services were collected and grouped into two categories, non-recurrent (capital resources vehicles, buildings, etc.) and recurrent resources (salaries, drugs, vaccines, contraceptives, maintenance, etc.). To generate the required data, two types of schedules were developed, daily time schedule and PHC/SC (Subcenter) information schedule.

Results:

The unit cost of curative care was lowest (Rs. 29.43) for the Sanathal PHC and highest (Rs. 88.26) for the Uperdal PHC, followed by the Nandej PHC with Rs. 40.88, implying severe underutilization of curative care at the Uperdal PHC.

Conclusions:

Location of health facilities is a problem at many places. As relocation is not possible or even feasible, strengthening of infrastructure and facilities at these centers can be taken up immediately.     

Health Resources in a 200,000 Urban Indian Population Argues the Need for a Policy on Private Sector Health Services

Background:

There are limited primary data on the number of urban health care providers in private practice in developing countries like India. These data are needed to construct and test models that measure the efficacy of public stewardship of private sector health services.

Objective:

This study reports the number and characteristics of health resources in a 200 000 urban population in Pune.

Materials and Methods:

Data on health providers were collected by walking through the 15.46 sq km study area. Enumerated data were compared with existing data sources. Mapping was carried out using a Global Positioning System device. Metrics and characteristics of health resources were analyzed using ArcGIS 10.0 and Statistical Package for the Social Sciences, Version 16.0 software.

Results:

Private sector health facilities constituted the majority (424/426, 99.5%) of health care services. Official data sources were only 39% complete. Doctor to population ratios were 2.8 and 0.03 per 1000 persons respectively in the private and public sector, and the nurse to doctor ratio was 0.24 and 0.71, respectively. There was an uneven distribution of private sector health services across the area (2-118 clinics per square kilometre). Bed strength was forty-fold higher in the private sector.

Conclusions:

Mandatory registration of private sector health services needs to be implemented which will provide an opportunity for public health planners to utilize these health resources to achieve urban health goals.     

Health Status and Health Care Experiences among Homeless Patients in Federally Supported Health Centers: Findings from the 2009 Patient Survey

Objective

To examine health status and health care experiences of homeless patients in health centers and to compare them with their nonhomeless counterparts.

Data Sources/Study Setting

Nationally representative data from the 2009 Health Center Patient Survey.

Study Design

Cross-sectional analyses were limited to adults (n = 2,683). We compared sociodemographic characteristics, health conditions, access to health care, and utilization of services among homeless and nonhomeless patients. We also examined the independent effect of homelessness on health care access and utilization, as well as factors that influenced homeless patients'' health care experiences.

Data Collection

Computer-assisted personal interviews were conducted with health center patients.

Principal Findings

Homeless patients had worse health status—lifetime burden of chronic conditions, mental health problems, and substance use problems—compared with housed respondents. In adjusted analyses, homeless patients had twice the odds as housed patients of having unmet medical care needs in the past year (OR = 1.98, 95 percent CI: 1.24–3.16) and twice the odds of having an ED visit in the past year (OR = 2.00, 95 percent CI: 1.37–2.92).

Conclusions

There is an ongoing need to focus on the health issues that disproportionately affect homeless populations. Among health center patients, homelessness is an independent risk factor for unmet medical needs and ED use.     

Reproductive,Maternal, Newborn,and Child Health in the Community: Task-sharing Between Male and Female Health Workers in an Indian Rural Context

Background:

Male community health workers (CHWs) have rarely been studied as an addition to the female community health workforce to improve access and care for reproductive, maternal, newborn, and child health (RMNCH).

Objective:

To examine how male health activists (MHAs) coordinated RMNCH responsibilities with existing female health workers in an Indian context.

Materials and Methods:

Interviews from male and female CHWs were coded around community-based engagement, outreach services, and links to facility-based care.

Results:

Community-based engagement: MHAs completed tasks both dependent and independent of their gender, such as informing couples on safe RMNCH care in the antenatal and postnatal periods. MHAs motivated males on appropriate family planning methods, demonstrating clear gendered responsibility. Outreach services: MHAs were most valuable traveling to remote areas to inform about and bring mothers and children to community health events, with this division of labor appreciated by female health workers. Link to facility-based services: MHAs were recognized as a welcome addition accompanying women to health facilities for delivery, particularly in nighttime.

Conclusion:

This study demonstrates the importance of gendered CHW roles and male-female task-sharing to improve access to community health events, outreach services, and facility-based RMNCH care.     

Client Satisfaction on Maternal and Child Health Services in Rural Bengal

Background:

Services are being provided by health functionaries to the community with the objective of fulfilling their satisfaction but sometimes this is not working for the target population.

Objectives:

The study was conducted to assess the satisfaction of clients′ receiving maternal and child health services and to elicit clients′ suggestion for improving the services.

Materials and Methods:

Anexit interview was employed to collect data using a predesigned and pretested schedule.

Results:

Most of the populations were adult clients. In respect of satisfaction, responses of the clients were either satisfactory (54.31%) or good (23.56%) on maternal and child health services; ‘poor or very poor around 20% and it was significantly worse in respect of satisfaction’. Most of the clients (63.06 to 73.94%) expressed their responses as satisfactory and good regarding the assessment of doctors and it was significant. Most of them (73.31%) expressed satisfactory “response” on the quality of services given by nursing staffs. Suggestions of clients for improving the level of satisfactionwere sought and in this respect, response was little.

Conclusions:

Mostly satisfactory observations on maternal and child health services were found in respect of clients'' satisfaction and there was scope to improve the quality and quantity of services, and accordingly actions may be taken in the working field.     

A Comparative Evaluation of Public Health Centers with Private Health Training Centers on Primary Healthcare Parameters in India: a Study by Data Envelopment Analysis Technique

Background:

The evaluation of primary healthcare services provided by health training centers of a private medical college has not been studied in comparison with government health facilities in Indian context. Data envelopment analysis (DEA) is one such technique of operations research, which can be used on health facilities for identifying efficient operating practices and strategies for relatively efficient or inefficient health centers by calculating their efficiency scores.

Materials and Methods:

This study was carried out by DEA technique by using basic radial models (constant ratio to scale (CRS)) in linear programming via DEAOS free online Software among four decision making units (DMUs; by comparing efficiency of two private health centers of a private medical college of India with two public health centers) in district Muzaffarnagar of state Uttar Pradesh. The input and output records of all these health facilities (two from private and two from Government); for 6 months duration from 1^st Jan 2014 to 1^st July 2014 was taken for deciding their efficiency scores.

Results:

The efficiency scores of primary healthcare services in presence of doctors (100 vs 30%) and presence of health staff (100 vs 92%) were significantly better from government health facilities as compared to private health facilities (P < 0.0001).

Conclusions:

The evaluation of primary healthcare services delivery by DEA technique reveals that the government health facilities group were more efficient in delivery of primary healthcare services as compared to private training health facilities group, which can be further clarified in by more in-depth studies in future.     

Barriers to Use of Workers' Compensation for Patient Care at Massachusetts Community Health Centers

Objectives

To examine barriers community health centers (CHCs) face in using workers'' compensation insurance (WC).

Data Sources/Study Setting

Leadership of CHCs in Massachusetts.

Study Design

We used purposeful snowball sampling of CHC leaders for in-depth exploration of reimbursement policies and practices, experiences with WC, and decisions about using WC. We quantified the prevalence of perceived barriers to using WC through a mail survey of all CHCs in Massachusetts.

Data Collection/Extraction Methods

Emergent coding was used to elaborate themes and processes related to use of WC. Numbers and percentages of survey responses were calculated.

Principal Findings

Few CHCs formally discourage use of WC, but underutilization emerged as a major issue: “We see an awful lot of work-related injury, and I would say that most of it doesn''t go through workers'' comp.” Barriers include lack of familiarity with WC, uncertainty about work-relatedness, and reliance on patients to identify work-relatedness of their conditions. Reimbursement delays and denials lead patients and CHCs to absorb costs of services.

Conclusion

Follow-up studies should fully characterize barriers to CHC use of WC and experiences in other states to guide system changes in CHCs and WC agencies. Education should target CHC staff and workers about WC.     

Infant Deaths – Data Disparity and Use of Ante,Intra and Post-natal Services Utilization: An Experience from Tribal Areas of Gujarat

Background:

Infant death depends upon the care during the infancy and also upon the service utilization during antenatal and intra-natal periods and with its decline, it is necessary to find the under-reporting if any and identify the most appropriate agency for its reporting.

Objectives:

(1) To document disparities between different reporting systems about infant deaths and find out the under-reporting if any and identify the most appropriate agency and (2) To identify utilization of health services during ante, intra and post-natal period for all infant deaths.

Materials and Methods:

Study was conducted in 51 villages of 3 Primary Health Centers (PHCs) from a tribal dominated Taluka (block) of South Gujarat during September - November 2005. Information was gathered for 1 year (1 September 2004 to 31 August 2005) from 4 sources namely health care system, Integrated Child development services (ICDS) scheme, Civil Registration System (CRS) and Investigator himself (Gold standard). Data was collected in a designed verbal autopsy questionnaire by house to house survey and analyzed in Epi Info.

Results:

A total of 48 infant deaths were recorded by investigator against reported 2, 10 and 8 infant deaths by CRS, Health System and ICDS respectively. While profiling these 48 infant deaths it was found that only 29.2% mothers received full antenatal care (ANC) and 60.4% delivered at home (by untrained personnel). Not a single delivery was done at PHCs or its sub centers (SC). In 25% cases there was poor cord care. 39.6% mothers did not breastfeed and 35.4% gave pre-lacteal feeding.

Conclusions:

There was gross underreporting of infant mortality in all 3 agencies. The utilization of ANC and post natal care (PNC) services was poor in these death cases. Health system and ICDS need to be sensitized to work in coordination to provide quality ANC, INC and PNC to prevent such avoidable infant deaths.     

Racial/Ethnic Disparities in Health and Health Care among U.S. Adolescents

Objective

To examine racial/ethnic disparities in medical and oral health status, access to care, and use of services in U.S. adolescents.

Data Source

Secondary data analysis of the 2003 National Survey of Children''s Health. The survey focus was children 0–17 years old.

Study Design

Bivariate and multivariable analyses were conducted for white, African American, Latino, Asian/Pacific Islander, American Indian/Alaskan Native, and multiracial adolescents 10–17 years old (n = 48,742) to identify disparities in 40 measures of health and health care.

Principal Findings

Certain disparities were especially marked for specific racial/ethnic groups and multiracial youth. These disparities included suboptimal health status and lack of a personal doctor or nurse for Latinos; suboptimal oral health and not receiving all needed medications in the past year for African Americans; no physician visit or mental health care in the past year for Asian/Pacific Islanders; overweight/obesity, uninsurance, problems getting specialty care, and no routine preventive visit in the past year for American Indian/Alaska Natives; and not receiving all needed dental care in multiracial youth.

Conclusions

U.S. adolescents experience many racial/ethnic disparities in health and health care. These findings indicate a need for ongoing identification and monitoring of and interventions for disparities for all five major racial/ethnic groups and multiracial adolescents.     

Patient��s Utilization and Perception of the Quality of Curative Care in Community Health Centers of the Fifth Commune of Bsamako

Background:

Community health centers are an important component of the health system in Mali. Despite the adhesion of the populations and the commitment of the authorities, many things must be done to improve the quality of care provided in those structures.

Objectives:

The study aimed to know the patients’ utilization and perception of the curative care in the community health centers of Bamako and the physicians’ satisfaction of their work condition and perspective in the community health sector.

Materials and Methods:

A cross-sectional study was conducted in nine community health centers of Bamako in 2008. A total of 270 patients were interviewed through a face-to-face interview. Thirteen physicians took a self-administrated questionnaire relating to their material and financial conditions and their plan for the future.

Results:

The sample was characterized by the low literacy (32.6%) and socio-economic level (15.9% of steady income).139 patients claimed the nearness as the reason of the choice of the health center whereas only 51 claimed the health staff skill. The women felt more satisfied than men (P=0.005) and illiterates felt more satisfied than bachelors and beyond (P=0.034). The patients claimed the reduction of waiting time, the improvement of information and the creation of news services. 30.80% of physicians were satisfied from their material and financial conditions, 38.46% were motivated and 76.92% planned to leave their health center.

Conclusion:

Although a high level of satisfaction regarding the provided service was observed, user reported some shortage in the quality of care and claimed a widening of CSCom capability.     

Putting People First: A Primary Health Care Success in Rural India

Background:

The World Health Report, 2008, contains a global review of primary health care on the 30th anniversary of the Declaration of Alma-Ata. The period covered by the study reported on here corresponds with that of the Report, allowing for a comparison of achievements and challenges in one primary health care centre vis-a-vis the WHO standards.

Materials and Methods:

This study uses qualitative and quantitative data from a rural primary care facility in Western Maharashtra, collected over three decades. It analyzes the four groups of reforms defined by WHO in the context of the achievements and challenges of the study facility.

Results:

According to the WHO Report, health systems in developing countries have not responded adequately to people’s needs. However, our in-depth observations revealed substantial progress in several areas, including in family planning, safe deliveries, immunization and health promotion. Satisfaction with services in the study area was high.

Conclusion:

Adequate primary health care is possible, even when all recommended WHO reforms are not fully in place.     

All Slums are Not Equal: Maternal Health Conditions Among Two Urban Slum Dwellers

Background:

Pregnant women inhabiting urban slums are a “high risk” group with limited access to health facilities. Hazardous maternal health practices are rampant in slum areas. Barriers to utilization of health services are well documented. Slums in the same city may differ from one another in their health indicators and service utilization rates. The study examines whether hazardous maternal care practices exist in and whether there are differences in the utilization rates of health services in two different slums.

Materials and Methods:

A cross-sectional study was carried out in two urban slums of Aligarh city (Uttar Pradesh, India). House-to-house survey was conducted and 200 mothers having live births in the study period were interviewed. The outcome measures were utilization of antenatal care, natal care, postnatal care, and early infant feeding practices. Rates of hazardous health practices and reasons for these practices were elicited.

Results:

Hazardous maternal health practices were common. At least one antenatal visit was accepted by a little more than half the mothers, but delivery was predominantly home based carried out under unsafe conditions. Important barriers to utilization included family tradition, financial constraints, and rude behavior of health personnel in hospitals. Significant differences existed between the two slums.

Conclusion:

The fact that barriers to utilization at a local level may differ significantly between slums must be recognized, identified, and addressed in the district level planning for health. Empowerment of slum communities as one of the stakeholders can lend them a stronger voice and help improve access to services.     

Clinical Quality Performance in U.S. Health Centers

Objective

To describe current clinical quality among the nation''s community health centers and to examine health center characteristics associated with performance excellence.

Data Sources

National data from the 2009 Uniform Data System.

Data Collection/Extraction Methods

Health centers reviewed patient records and reported aggregate data to the Uniform Data System.

Study Design

Six measures were examined: first-trimester prenatal care, childhood immunization completion, Pap tests, low birth weight, controlled hypertension, and controlled diabetes. The top 25 percent performing centers were compared with lower performing (bottom 75 percent) centers on these measures. Logistic regressions were utilized to assess the impact of patient, provider, and institutional characteristics on health center performance.

Principal Findings

Clinical care and outcomes among health centers were generally comparable to national averages. For instance, 67 percent of pregnant patients received timely prenatal care (national = 68 percent), 69 percent of children achieved immunization completion (national = 67 percent), and 63 percent of hypertensive patients had blood pressure under control (national = 48 percent). Depending on the measure, centers with more uninsured patients were less likely to do well, while centers with more physicians and enabling service providers were more likely to do well.

Conclusions

Health centers provide quality care at rates comparable to national averages. Performance may be improved by increasing insurance coverage among patients and increasing the ratios of physicians and enabling service providers to patients.     

Study on Patient Satisfaction in the Government Allopathic Health Facilities of Lucknow District, India

Background:

The outcome of any disease is influenced by the decisions to seek care, timely arrival at appropriate diagnostic and treatment services and the receipt of adequate care from service providers. Satisfaction in service provision is increasingly being used as a measure of health system performance. Satisfaction manifests itself in the distribution, access and utilization of health services. Objectives: To determine the areas and causes of low satisfaction among the patients and suggest methods for improvement.

Materials and Methods:

Multistage stratified random sampling was used to select the government allopathic health facilities of Lucknow district and systematic random sampling for the selection of the patients for the interview.

Results:

The accessibility was difficult in 42% patients and waiting time more than 30 min for 62.5% of those attending the tertiary level health facility. The satisfaction with the duration of the outpatient department (OPD) (64.6%) and the presence of signboards (46.6%) was also found to be low. The overall satisfaction regarding the doctor-patient communication was more than 60% at all the levels of health care facilities but that with the examination and consultation was less than 60% at the primary level as compared to more than 80% elsewhere. The most important motivating factor for the visit to the tertiary (48.2%) and secondary level (71.9%, 67.1%) of health facilities was the faith on doctors or health facility.

Conclusions:

The level of patient satisfaction is severely deficient in several areas and needs improvement for the achievement of optimal health of the people.     

Assessment of the efficiency of dental services in Turkey

Aim

The present study aimed to measure the efficiency of dental services at the provincial level in Turkey and to identify the potential areas of improvement.

Health care facility vulnerability in developing nations: strengthening health care policy-making and implementation

Background

In developing countries such as India, inadequate importance and consideration given to assessment of health care facilities negatively affects progress towards achieving health targets. India has focused on developing Primary Health Centres (PHCs) for rural basic laboratory and curative services. The local decision-makers do not have any national-level framework to evaluate the vulnerability of PHCs which are not meeting national PHC standards, nor do they have resources to meet national PHC standards.

Aim

The study proposed a framework to assess the public health care facilities for vulnerability.

Methods

A cross-sectional questionnaire survey was performed. The study used PHC laboratory services of 42 PHCs of Osmanabad District, India as a case study for proposed framework. The data assessment was carried out at district level, block level, PHC cluster level, and PHC level to provide flexibility to local decision-makers in taking remedial measures.

Results

Staff workload (73.17%), physician’s need (51.22%), and organization structure (36.59%) are the most prevalent challenges across PHCs. Multiple challenges are prevalent in the PHCs across districts. The PHCs with poor medical doctor (MD) capability or many challenges have shown poor laboratory performance.

Conclusion

Governance need to be strengthened in PHCs, followed by sustained support in resources and financing. Poor health status in developing nations necessitates a public health response based on health systems. Therefore, an assessment of health facility vulnerability in the form of laboratory services is essential in primary health care facilities.

     

The Effects of Medicaid Eligibility on Mental Health Services and Out‐of‐Pocket Spending for Mental Health Services

Objective

Millions of low‐income Americans will gain health insurance through Medicaid under the Affordable Care Act. This study assesses the impact of previous Medicaid expansions on mental health services utilization and out‐of‐pocket spending.

Data Sources

Secondary data from the 1998–2011 Medical Expenditure Panel Survey Household Component merged with National Health Interview Survey and state Medicaid eligibility rules data.

Study Design

Instrumental variables regression models were used to estimate the impact of expanded Medicaid eligibility on health insurance coverage, mental health services utilization, and out‐of‐pocket spending for mental health services.

Data Extraction Methods

Person‐year files were constructed including adults ages 21–64 under 300 percent of the Federal Poverty Level.

Principal Findings

Medicaid expansions significantly increased health insurance coverage and reduced out‐of‐pocket spending on mental health services for low‐income adults. Effects of expanded Medicaid eligibility on out‐of‐pocket spending were strongest for adults with psychological distress. Expanding Medicaid eligibility did not significantly increase the use of mental health services.

Conclusions

Previous Medicaid eligibility expansions did not substantially increase mental health service utilization, but they did reduce out‐of‐pocket mental health care spending.     

Patients’ Experiences in Different Models of Community Health Centers in Southern China

PURPOSE

Current health care reforms in China have an overall goal of strengthening primary care through the establishment and expansion of primary care networks based on community health centers (CHCs). Implementation in urban areas has led to the emergence of different models of ownership and management. The objective of this study was to evaluate the primary care experiences of patients in the Pearl River Delta as measured by the Primary Care Assessment Tool (PCAT) and the relationships with ownership and management in the 3 different models we describe.

METHODS

This cross-sectional study was conducted on-site at CHCs in 3 cities within the Pearl River Delta, China, using a multistage cluster sampling method. A validated Mandarin Chinese version of the PCAT–Adult Edition (short version) was adopted to collect information from adult patients regarding their experiences with primary care sources. PCAT scores for individual primary care attributes and total primary care assessment scores were assessed with respect to sociodemographic characteristics, health characteristics, and health care service utilization across 3 primary care models.

RESULTS

One thousand four hundred forty (1,440) primary care patients responded to the survey, for an overall response rate of 86.1%. Respondents gave government-owned and -managed CHCs the highest overall PCAT scores when compared with CHCs either managed by hospitals (95.18 vs 90.81; P = .005) or owned by private and social entities (95.18 vs 90.69; P =.007) as a result of better first-contact care (better first-contact utilization) and coordination of care (better service coordination and information system). Factors that were positively and significantly associated with higher overall assessment scores included the presence of a chronic condition (P <.001), having medical insurance (P = .006), and a self-reported good health status (P <.001).

CONCLUSIONS

This study suggests that government-owned and -managed CHCs may be able to provide better first-contact care in terms of utilization and coordination of care, and may be better at solving the problem of underutilization of the CHCs as the first-contact point of care, one key problem facing the reforms in China.