|DR. B. C. DAS GUPTA MEMORIAL ORATION
|Year : 2011 | Volume
| Issue : 2 | Page : 70-80
An assessment of rural health care delivery system in some areas of West Bengal-An overview
Sandip Kumar Ray1, Subhra S Basu2, Amal Kumar Basu3
1 Professor and Head, Department of Community Medicine, K.P.C. Medical College and Hospital, Kolkata, India
2 Assistant Professor, Department of Community Medicine, Medical College and Hospital, Kolkata, India
3 Faculty, Department of Community Medicine, K.P.C. Medical College and Hospital, Kolkata, India
|Date of Web Publication||22-Sep-2011|
Sandip Kumar Ray
Professor & Head, Department of Community Medicine, K.P.C Medical College, Kolkata
Source of Support: Government of West-Bengal & IPHA, Conflict of Interest: None
| Abstract|| |
A cross sectional observational study was carried out in three districts of West Bengal by following observational, quantitative and qualitative methods during July to December 2006 to find out the extent of utilization, strengths, weaknesses and gap as well as suggest recommendations in connection with health care delivery system for the state of West Bengal, India. A total of 672 episodes of illnesses were reported (2 weeks recall) by the study population of the three selected districts in three geographically separated divisions of West Bengal. None did seek care from any health facilities for treatment in case of 221 (32.89%) episodes; especially from tribal areas where in case of 76.19% none sought any health care from any facilities depended on their home remedies. In rest of episodes the (451), majority preferred government health facilities (38.58%), followed by Unqualified quacks (29.27%) due to low cost as well as living in close proximity, 27.27% preferred qualified Private practitioners and only 4.88% preferred AYUSH, as a first choice. Referral was mostly by self or by close relatives/families (61%) and not by a doctor. Awareness is required to avoid unnecessary referral. Cleanliness of the premises, face-lift, and clean toilet with privacy and availability of safe drinking water facilities could have an improved client satisfaction in rural health care delivery systems. This could be achieved through community participation with the involvement of PRI. However, as observed in the study RCH services including Family Planning as well as immunization services (preventive services) were utilized much better while there was a strong need of improvement of Post Natal Care, otherwise, Neonatal and Maternal mortality and morbidity will continue to be high.
Keywords: Rural health care delivery system, Utilisation, Assessment
|How to cite this article:|
Ray SK, Basu SS, Basu AK. An assessment of rural health care delivery system in some areas of West Bengal-An overview. Indian J Public Health 2011;55:70-80
|How to cite this URL:|
Ray SK, Basu SS, Basu AK. An assessment of rural health care delivery system in some areas of West Bengal-An overview. Indian J Public Health [serial online] 2011 [cited 2020 Feb 27];55:70-80. Available from: http://www.ijph.in/text.asp?2011/55/2/70/85235
| Introduction|| |
The utilization of any social services, including health services, has never been equitably distributed throughout society. People with access to the facilities are generally found to make greater use of them than people who have neither knowledge nor access to the facilities.  Some sociologists have come to a conclusion that it is the structure through which medical services are dispensed that alienates lower-class patients.  The majority of respondents utilizing public health-care facilities were lower class (62%) compared to middle class (38%) in a Mexican study where it was also observed that for every lower-class respondent indicating the use of private facilities, there were three middle-class respondents. 
The concept of health centre was first brought by Lord Dawson in England during 1920. As early as 1928 Govt. of Mysore established the first health unit in the country at Mandya. Establishment of health centers at Nazafgarh, Singur, Poonamallie, Trivandrum, Lucknow and at other places in collaboration with Rockefeller foundation and Govt of India between 1931 to 1939 was an important landmark in the history of health care delivery system. In 1946 Bhore Committee recommended establishment of primary and secondary health units under short and long term program. In 1948 the West Bengal Government started their scheme of having a 10-bedded health centre at the Union and a 50 bedded health center at each Thana (an area covered by Police station), to serve a population of 10,000 and 100,000 respectively.  Later on, it was observed that the state of West Bengal was one of the earliest state to implement the recommendation by introducing Primary Health Centre units in a block with 3-5 subsidiary health centres for 60 to 80 thousand population to cover entire state  based on the Bhore Committee recommendation. Late Chief Minister of West Bengal, Dr B C Roy, initiated these ideas. This was considered later on by Govt of India as CHC for 100000 and PHC for 30000 population.
In 1952 the Planning Commission gave the standard health plan of 6 bedded health centre at each block and a 40 bedded health centre, at the head quarter of each Community Development Project Area, which was later on modified.  A study, conducted during 1967-69 by Seal and Bose,  revealed certain defects and deficits in the rural health services as well as apathy of the people to utilize the services rendered in West Bengal, which was subsequently corrected.
An analysis of health services coverage of a primary health centre in West Bengal indicated that lower income groups utilized the services more (17.7%), than higher income groups (4.1%). PHC services declined significantly with distance from the primary health center. 19.2% of the families surveyed used Medicare.  Women in 58% of the families used the prenatal services of the facility, 6% received prenatal care from private practitioners, and 36% received no prenatal care. Reasons given for not using the facility were 1) using the clinic was too time consuming, 2) the staff was unfriendly, 3) a lack of interest in the services provided. There was no significant difference between prenatal service utilizers and nonusers in regard to caste.  Utilizers were somewhat more likely to live in households with a literate household head than nonusers. 
The main objectives were as follows:
- To find out the extent of utilization of health care delivery services in the studied areas
- To understand the health care seeking behavior of the community
- To assess the strengths and weaknesses of the health care delivery system at the community development block.
- To suggest measures to improve health care delivery system at the community level.
| Materials and Methods|| |
Study type : It was a cross sectional observational study, carried out in three districts of West Bengal from July to December 2006.
Sample size: Sample size for house to house survey was determined by the standard technique for a prevalence study. Taking into consideration, 71.05% utilization of PHC services (31.57% acceptance as first choice and 39.47% as second choice),  with 10% allowable error and a design effect of 2, sample size calculated to be 322 and rounded off to 330 for each one of the districts.
Sampling frame and place of study: Two stage sampling at District level and then at Block level was done.
Stage 1: Considering the fund and time constraints, three districts from the state of West Bengal were chosen after discussion with the state government and funding agency. One district each was chosen from Presidency, North Bengal and Burdwan divisions of West Bengal as follows:
- Presidency division: Murshidabad
- North Bengal division: Uttar Dinajpur
- Burdwan division: Purulia
Stage 2: To have a wider coverage at the district level, in each district three blocks were chosen randomly. Thus, a total of nine blocks were covered in three districts. The selected blocks were covered for household and facility survey in the following way:
- BPHC 1: 110 households were covered at Block Primary health Center (BPHC) village. If 110 house-holds are not there in that village the adjacent village was covered.
- BPHC 2: 110 households were covered in a village which was situated 5 km. away from BPHC but not close to any nearby PHC. If 110 house-holds are not there in that village the adjacent village was covered.
- BPHC 3: 110 households were covered in a village which was 10 km. away from BPHC and not close to any PHC. If 110 households are not there in that village the adjacent village was covered.
- In addition, 9 BPHCs in the 9 blocks and one SC from each block were used for facility survey.
Methods of Data Collection
- House to house survey in sample households of the district to find out the extent of utilization of services provided by public and private sectors, reasons for utilization and non utilization etc.
- Exit interview of the persons to understand about common morbidities, time taken for registration and medical care, distance traveled etc.
Qualitative methods and Observation:
- In depth interview of key informants
- Focus Group Discussion (FGD)
- Observation of facilities, namely BPHCs and Sub-centres
Study tools: Pre-designed and pretested proforma was used for quantitative survey and a guide for qualitative methods of data collection.
| Result|| |
Three districts (One each from each division of West Bengal state) were chosen randomly for the purpose of study. These districts were Uttar Dinajpur, Mursidabad and Purulia. Total households covered during the survey were 997 in these districts with a minimum target of 330 per district as a sample size. Among the respondents 404 (40.52%) and 593 (59.48%) were male and females respectively. Religion-wise distribution showed 793 (79.54%), 178 (17.85%) and 26 (2.61%) respondents were Hindu, Muslim and Christian respectively. General Caste was 555 (55.67%) while rest (44. 33%) was either Schedule caste 314 (31.49%) or Scheduled tribe 128 (12.83%). Majority 734 (73.62%) belonged to Nuclear families and the rest 263 (26.38%) were from joint families.
There were 672 episodes of illnesses, based on 15 days recall, reported by 997 clients (0.67 episodes per person) covered in three districts, during the study period. Observation revealed that majority of the clients (25. 89%) utilized government health facilities ie Sub centre, PHC and BPHC/CHC, followed by private practitioners (18.3%) and quacks or unqualified practitioners (19.64%). AYUSH or traditional healers were used by 2.98% and 0.29% respectively while 32.89% did not avail any health facilities for the episodes of illnesses [Table 1]. In regard to utilization of government health facilities, the findings revealed that 13.85%, 21.62% and 42.92% utilized government health facilities for treatment of episodes at Purulia, Murshidabad and N. Dinajpur respectively with an overall percentage of 25.89% [Table 1].
|Table 1: Utilization of health facilities as fi rst choice by respondents for episodes of illnesses|
Click here to view
Further analysis revealed, out of a total of 672 episodes, 221 (32.89%) episodes did not avail any health care facilities for treatment of their mild illnesses like fever, diarrhea, skin infection etc. Leaving aside the 32.89% episodes, who did not avail any health facilities, 174 (38.58%) episodes utilized only government health facilities followed by 132 (29.27%), 123 (27.27%) and 22 (4.88%) episodes who availed Unqualified quack, Qualified Private practitioners and AYUSH respectively for undergoing treatment of their illnesses [Figure 1].
|Figure 1: Utilization of different health facilities as the fi rst choice by the respondents|
Click here to view
Free drug supply (29.6%), good treatment (27%), close proximity (18.4%), round the clock availability (14.5%) and low cost incurred for the services (10.5%) were the main reasons for opting to government health facilities. On the other hand good treatment was considered to be the main reason for utilizing the private health facilities (>60%). Only 11.4% reported good behavior of private practitioners. Round the clock availability (43%), low cost (23.6%) and close to home (19.5%) were the principle reasons for availing services of unqualified quacks, who were also practicing modern allopathic medicines.
Majority travelled by foot to reach all these health facilities (47.45%) followed by rickshaw (28.6%), bus (10.86%) and cycle (4. 66%) for obtaining treatment [Figure 2]. Most of the sub-centers, PHC and quacks were within the range of 1-4 km distance excepting in tribal areas. More than 25% BPHC and private practitioners were situated beyond 5-10 km distance or more.
|Figure 2: Mode of transport to reach the (a) health facilities (b) referral health facilities|
Click here to view
"Number of Nursing homes is an indicator of pattern of preference. I have seen in those areas, where socio-economic status is better, nursing homes are flourishing. Here, there are less nursing homes - only 35 nursing homes in this district which meant that people are utilizing govt. services," Chief Medical Officer of Health (CMOH) of one district commented.
Expenses were pointed out as the major weakness of private health care - "One DC (dilation and curettage) costs Rs 300-400" as told by a PHN. "Govt. Services lack glamour/outward show - so people feel that services are mechanically delivered. It is opposite at private sector -i.e "with sweet wards they take out money from the purse of the patient or its party". Distance and poor communication is a constraint to utilization of existing govt. health facilities". -CMOH.
Out of 451 episodes, who sought medical care from different categories of medical personnel, 271 (60.09%) did not show any dissatisfaction with the treatment and 63 (13.97%) were dissatisfied while the rest 117 (25.04%) did not like to comment. Amongst the satisfied individuals, clients attending government health facilities was not dissatisfied to the extent of 35.42% followed by quack (31.36%) and private doctors (28.02%).
Although around one fourth clients were not able to decide where to go when treatment failed in a specific health facility (for referral), yet around 45% of the respondents wanted to choose government health facilities of nearby areas for treatment. Twenty five percent also preferred private doctors in this regard. Two major causes of referral were "referred for better treatment" (46.3%) and "not cured" (31.3%). In majority of the cases the referral was either by self (34.3%) or by a family member (26.7%). Only in 15% cases referral was done by a doctor. It was observed that referral transport was mainly bus (34.3%) followed by rickshaw (19.4%) and foot (17.9%), even car was used to the extent of (7.4%).
Average time to reach the referral facilities was 75.2 minutes with a range of 02 to 300 minutes. Major problems faced at the time of referral were high cost (38.46%), long waiting time (30.77%), inadequate services (23.08%) and non availability of medicines (23.08%). Average expenditure incurred was ` 127.02 with a range of expenditure from ` 08 to 1000. Around 25.72% of the clients took loan to meet the expenses while 68.07% did not like to disclose whether they took any loan or not. Among the patients, 65.7% were either cured or showing an improvement. Regarding others, they were unable to make comments at that moment due to unstable condition of the patients. One BPHN stated that some referrals ended up in private doctors' chambers. A District Magistrate expressed that "basically people go to the providers who are most accessible and available".
It was observed that 99% chose government health facilities for immunization. They preferred government health facilities as they provide free (80%) as well as good quality of (32%) services. Similarly excepting 31% of the pregnant women, majority received ANC services from government health facilities at least 3 times (as per old norms) while only a few, availed the services from private practitioners. Besides, majority of the mothers accepted post natal services also from government health facilities. They were mainly given advice on immunization (80%) and breast feeding (49%).
Sub centre and BPHC were mostly chosen by the beneficiaries for antenatal care. However, it was noted that one third of the clients were not utilizing the antenatal care services for at least 3 times or more.
Family planning services are provided by government sectors without any cost involvements of clients. Around 69% utilized family planning methods comprised mostly of sterilization (27.98%) while only 6.8% were using condoms. Further, during the study period, some court order had made the doctors apprehensive of taking up sterilization operation for family planning as mentioned by some.
Post natal care was provided through sub centre and BPHC mainly. The quality of care was appeared to be poor. No postnatal care was provided to 22.31% of the beneficiaries. The care provided was mainly "advice on breast feeding". Advice on positioning and attachment was not included at all during message disseminations. Advice on care of stitch and perineal toileting was hardly given (5.78%). However, the advice on immunization was given to the extent of more than 90%.
The data from exit interview revealed that more than 56% had to wait for more than 30 minutes to 4 hrs to meet the doctor in addition to their travel time. 17% spent 1 to 4 hours to meet the doctors. "Distance and poor communication is a constraint to utilization of existing govt. health facilities" - An indepth interview report.
It was reported by 6%, 27% and 23% clients that toilets were 'usable', 'not at all usable' and 'dirty needed cleaning' in the surveyed government institutions. Similarly only in 55% of the facilities safe drinking water was available for use. Restrooms were either of poor quality or the clients did not use it while it was not available only in 3% health facilities.
Exit interview data showed ANC, fever, cough and cold and diarrhea as common conditions for which patients attended the clinic. Further exit interview revealed that only 29.75% of the clients were fully satisfied.
Facility Survey Report
- Waiting space was present in 5 sub center and 7 BPHC/CHC out of 9
- Mopping up of floors was done in 7 out of 9 BPHC/CHC and in 5 out of 9 SC
- Drinking water through tube-well/tap was present in all the studied health facilities except one SC
- Quarters for staff was present in all BPHCs, but needed repair
- Antenatal care was provided by all BPHCs and Sub centers and deliveries were conducted by all BPHCs on an average 75 per month with a range of 50-125
- Family planning services were provided in all the studied facilities. Condom, Oral pill and Copper T was available in the facilities except one Sub centre where Copper T was not available
- Treatment of minor illnesses was done in all the facilities except in one sub centre.
- All BPHCs are performing minor operations. Some of these are performing operations like Hydrocele, abscess, foreign body extraction, small tumors. All national health programs were implemented
- Referral services was provided for few common conditions like MI, CVA, Eclampsia, complicated labor, Intestinal obstruction, Accident, head injury, poisoning from BPHCs. From sub centre Pneumonia and risk pregnancy were referred to BPHC
- All health facilities except one sub centre had electric connection
- Waste papers were seen in 5 BPHC/CHC and spitting stain in 4. Dust bins were seen in 5 sub centre 3 BPHCs. It should be available in all such facilities
- Screen was not available in almost all facilities for maintenance privacy of female patients.
- Among the latrines at BPHC one was fully blocked and was not usable. One was partially blocked and one partially usable while in two latrines doors and windows were either not existing or broken
- In case of delivery of Antenatal care at BPHCs, 4 offered weekly services, 2 daily, 1 tri weekly, 2 biweekly and rest 4 weekly. None of the sub centers studied conducted deliveries
- In regard to delivery of postnatal care appropriate records were not available.
- Scope for Emergency Obstetric services: OBG specialist was not available 2 facilities, Anesthetist and blood transfusion facilities was not available in all these facilities while equipments were not found in 5 facilities
- Capacity building for sub centre staff was poor in past 12 months, while these group of staff need more frequent training for sustenance of both knowledge and skill.
- More time in registration and less time in examination and advice at BPHC in comparison to Sub centers.
| Discussion|| |
The study was conducted in the three divisions of West Bengal by using qualitative and quantitative research methods. People belonged to different religious and caste groups, participated in the survey. Socio-economic class could not be elicited due to inconsistent data on income. Like other studies female participation was more in this study too. An international study also reported that women have higher medical care service utilization and higher associated charges than men although the appropriateness of these differences was not determined. However, these findings have implications for health care. 
A substantial number of the respondents (44.33%) belonged to both Scheduled Caste and Scheduled Tribe families, who represented, mostly, from the poorer section of the community. The earlier study in a primary health centre (presently known as CHC/BPHC) in West Bengal indicated that lower income groups utilized the services more (17.7%), than higher income groups (4.1%). 
Present study showed, an overall utilization of government health facilities (including CHC, PHC and SC) at the block level was better (38%) than the earlier studies. , Ghosh's study showed only 19.2% of the families surveyed used medical care from the studied PHC area  while Ray et al observed 31.57% accepted P.H.C services as the first choice followed by private allopath (64.04%), home remedies (3.51%) and folk practitioners (0.88%).  At this juncture, it should be pertinent to mention that, in the present study, when the data of utilization of government health facilities was segregated to BPHC/ CHC, PHC and SC it was observed that utilization rate was only 17% [Table 1] for BPHC/CHC (earlier functioned as PHC) and thus utilization rate appeared to be slightly lesser than the earlier studies at Bhatar village  as well as in a village at Hugli.  But these should not be considered as an important issue, as at the time of earlier studies, sub-centers were not functional at an expected level. It was also observed in the study that utilization of government health facilities was appeared to be more in North Dinajpur followed by Mushirdabad and least in Purulia. Reasons given for not using the Government facility, as reported earlier, were i) using the clinic was too time consuming, ii) unfriendly staff, iii) a lack of interest in the services provided.  The findings of the qualitative survey also corroborated that government services were lacking in glamour and outward show and people felt that services were delivered mechanically and not emotionally.
The findings of the study on health care delivery system conducted by NCAER, 1999-2000 indicated that in case of the districts in U.P., the utilization rate was lower than the present study (around 13% of the episodes get treated in public facilities) in spite of the fact that the average cost of treatment per episode in public facilities was only one-half of that in private facilities. This happens, perhaps, because of the inadequacy of the public facilities compared to the prevalence of morbidity in these districts.  But the study conducted by Seal and Bose during 1967-69 on some Primary Health Centre areas of West Bengal noticed that only 43.5 percent persons did not avail any O.P.D. services. He also pointed out that 11.3 percent never took any help at any time from P.H.C. However, a study on the utilization of P.H.C. services carried out in Miraj Taluk, Maharastra showed that 8.8 percent households visited P.H.C., 11.9 percent visited sub-centre and 3.9 percent visited both P.H.C. and sub-centre i.e. 24.6 percent visited P.H.C., and sub-centre or both for medical help and three-fourth of the visitors to the P.H.C. and sub-centre are from the villages where P.H.C. and sub-centres where situated. The utilization of government health facilities in UP and Miraj Taluk was poorer in comparison to the present study at West Bengal while utilization rate of present study was slightly lesser than the earlier study of Seal et al. ,
Curative services had maximum demand from the clients. One in-depth interview reported that 'services most in demand' were the curative services at the government health facilities. According to a CMOH "a 30 bed BPHC always remained almost occupied". Types of cases came to government health facilities were "non progression of labor, complications of labor, complications of newborn, meningitis, cerebro-vascular and cardio-vascular emergencies including CVA, road traffic accidents, snake bite and cases requiring major surgical and orthopedic interventions as well as blood transfusion.
"The long waiting hours at the facility was a major deterrent". Some also opined distance and poor communication facilities might also be responsible for poor utilization particularly in hilly and tribal areas from where very poor utilization rate was observed.
Non-utilization and Cost issues
Non-utilization of any health facilities and opting for home remedies was highest in tribal district of Purulia (76.19%). This could be mainly due to their poor knowledge, attitude, accessibility and economic conditions to avail the services. In summary, it might be commented that in comparison to those studies carried out at different time period, the present study showed a better utilization rate of government health facilities in comparison to most the studies excepting in a tribal area. It was further corroborated by the findings of qualitative survey that "There were 4 patients admitted in 2 beds in the free ward whereas the paying beds were empty in government health facilities. People prefer government health facilities due to certain weaknesses of private sectors. Private Nursing homes mostly conduct deliveries. They were not admitting critical cases or carrying out the critical operations in rural areas in particular. There was lack of skilled manpower also, specially trained nurses. Expenses were pointed out as the major weakness of private health care and therefore so much rush was noticed in government facilities" - a report from in depth interview. It was expensive as revealed from qualitative survey findings. On the contrary, a FGD with the few clients commented a negative attitude about the government health facilities and cost incurred by stating that "we only go to hospitals to register ourselves. Most of the medicines had to be purchased from outside". It was also revealed that only few drugs, if available in sufficient amount, would have solved their problem of non-availability of medicine. Other indepth interview commented that cost of curative treatment was excessive even in government facilities -"No money with us and with all hardship we have to come after lending gold ornaments. One injection costs Rs 70 when our daily earning was less than this". The long waiting hours were a major deterrent as mentioned by some in qualitative assessment.
According to the clients in qualitative interview, "the doctors did not have any time for giving instructions and the other workers tell us only about immunization and ORS. Nobody explains what was there in the report". This was very simple matter, which could have been taken care of. Therefore, government sector service providers should be oriented to provide client centered and demand driven care which satisfy the client and which would bring the clients more close to government health facility and their sufferings will be less.
Medical officer should understand these facts and should not prescribe any medicine unnecessarily (only essential medicine) and those which costs too high, especially for the poor. The prescription of medicines should be rational. The drug inventory at primary care facilities should be reviewed and strengthened with the goal to provide them to all patients free of cost. Whenever any costly medicine or life saving drug is urgently required, it can be purchased locally from flexifunds available with the facility or PRI.
Preventive service Utilization
Sub centre and BPHC were mostly chosen by the beneficiaries for antenatal care. However, it was sad to note that 31% of the clients were not utilizing the antenatal care services for at least 3 times or more (earlier recommendation). The utilization of antenatal services, as reported recently, has been shown that 81.6% and 63. 3% had minimum 3 and 4 Antenatal visits respectively in rural area while in urban area the corresponding figure was 87.2% and 75.9%.  The present study has shown slightly lesser rate of utilization but the studies were carried out at different time period. Health worker females should be trained time to time, especially on Skill based training.
An attempt should be made to improve both antenatal and family welfare services which also needed improvement. Utilization of preventive services appeared to be better than the study by Ghosh et al where it was observed that 71.8, 28.3 and 27.2 percent chosen Maternal and Child Health Care Services; 45.7, 18.2 and 17.3 percent chosen Family Welfare Planning Services and 64.4, 55.7 and 55.7 percent chosen immunization services at different level of geographic distances.  It appeared that utilization of preventative services from government sources were better than curative services in the studied areas. They availed government health facilities for preventive care as the services were provided free of cost with a good quality and cordial behavior as found out in the present study. But in case of curative services same cordial behavior could not be seen. Qualitative survey findings also corroborated it. "Greatest strength of government health facility was immunization services. Free supply of immunization and cordial approach of health workers in delivering immunization services were the main reasons for availing the immunization services by the community. Those who are not availing immunization services from government institution belonged mostly from the upper socio economic group. Inter personnel communication as well as frequent communication through electronic media will further improve the utilization of services by the upper class0".
Family planning services are provided by government sectors without any cost involvements of clients. Around 69% practiced family planning methods and mostly sterilization. The effort to improve condom use through IEC, appeared to authors, has yielded very little results (only 6.8% were using condoms). Further some court order had made the doctors apprehensive of taking up sterilization operation for family planning as mentioned by some. These must be seriously looked for, otherwise sterilization operation will be reduced with further reduction in the couple protection rate. Some other suggestions proposed were
Post natal care was provided through sub centre and BPHC mainly. The quality of care was appeared to be poor. No postnatal care was provided to 22.31% of the clients. The care provided was mainly immunization and advice on breast feeding. Advice on positioning and attachment was not included at all during message disseminations. Until and unless breast feeding advice contains such information along with exclusive breast feeding and timely complementary feeding, advice would not be complete. Advice on Care of stitch and perinatal toileting was hardly given. However, the advice on immunization was given to the extent of more than 90%. Post natal care appeared to be a neglected issue. The public health professionals did not take it seriously as it did not have immediate impact. It was further corroborated at the time of facility survey that there was no register for postnatal care at the facility level when other registers were available at the facilities. Experience suggested that this area was neglected even at the time of RCH training and it was felt that emphasis on post natal care should be given.
A joint training on RCH with the help of health, ICDS and panchayat functionaries will further improve the utilization of Antenatal care and RCH services. Health worker females should be trained time to time, especially on Skill based training. Experience suggested that this area of post natal care was neglected even at the time of RCH training and it was felt that emphasis on post natal care should be given.
Although satisfaction level of client, attending government health facilities was slightly higher (35.42%) than the quack (31.36%) while on the contrary to the belief that clients of private doctors had least satisfaction (28.02%) even when findings of qualitative survey revealed that "more personal attention was paid not only to the patients and but also to their accompanying persons as well as good treatment was considered to be the main reason for availing the private health facilities". Other study reported that a majority of the beneficiaries from Haryana have expressed their satisfaction over the health care services delivered by sample PHCs, while majority of beneficiaries from Orissa and Uttar Pradesh found to be dissatisfied with the availability and accessibility of the existing health care services in their sample PHCs.  Present study showed better client satisfaction in comparison to the study mentioned in this context. Sometimes in BPHC the problems faced were slightly higher due to non-cooperation / non-cordial behavior of certain categories of staff. FGD revealed some clients expressed their satisfaction regarding the services provided by the Government health facilities and wanted to use these facilities provided it would have a client centered facilities with informed choices.
In case treatment failure and referral majority preferred (45%) to chose government health facilities of nearby areas for treatment. This meant, clients had some faith on such facilities that better services might be rendered or these facilities were used as these facilities would consider on cost issue for the services. It is also a fact that some government institutions and care providers provide better services than others for which they prefer that specific health facility. But, it was an important concern that, only 15% referral was made by a doctor in the study while most of the referrals were self referral. An intensive IEC drive should be undertaken for appropriate and timely referral by a doctor or a Paramedical staff with the further involvement of community and PRI. Appropriate and timely as well as correct place of referral should be emphasized to all of them. Maternal death review by Ray et al, also highlighted the need for urgent and appropriate referral for prevention of maternal death.  One Block PHN during in-depth interview stated that some referrals also ended up in private doctors' private chambers. Expenditure incurred at the referral health facilities, for undergoing treatment, considered to be high for the poorer section of the community. Around one fourth of the clients took loan to meet the expenses while two third of them did not like to disclose whether they took any loan or not. Some referral ended up in private doctors private chambers (might be through corrupt person) causing more hardship to the patient.
Differences in availing transport for reaching the health facilities were observed. In normal situation clients mainly reach the facilities either by foot or by rickshaw while in case of referral Bus, rickshaw even car was used.
The display of 'services available' will help the clients to have 'informed choices'. This was corroborated by one CMOH. The CMOH stated that the main problem was the lack of awareness in the community regarding the services available at the government health facilities. This view was corroborated by the Swasthya Karmadhyaksha of a district. People went to a BPHC for abortion services but that BPHC was not performing this service, which was not known to community and even to ICDS and Health functionaries. As a result client went back home and did abortion by a quack and ultimately died due to sepsis. Display of list of services could have prevented such incident and she should have been instructed to go to appropriate health facilities. It was recently observed that in a Rural Health training centre at 24 Parganas south display of services available, was beautifully placed in local language and it was observed that people were observing and enquiring about the services.
The data from exit interview revealed that more than 56% had to wait for more than 30 minutes to 4 hrs to meet the doctor in addition to their travel time. Longer time for OPD, engaging two doctors, wherever possible was needed as well as commencing OPD in time, could easily solve this problem. Further, if the health workers could stay at the Sub centers and are involved in treating minor illnesses, the OPD load would have been much reduced while community could get treatment at an accessible distance in a health care facility run by the government. This is not an impossible issue.
In this regard module based training should be introduced at the time of Internship training as well as at the time of entry into the health services for doctors, all public health professionals, group C and D staff. It should be a must. They should be taught about the interpersonal relationship and communication skills and how one can behave sweetly. This could satisfy the clients.
Exit interview data showed common conditions and morbidities for which patient attended the OPD like ANC, Fever, Cough and Cold, Diarrhea etc which could be managed at the Sub- center level. Skill based capacity building should be introduced in continuous manner for providing quality of care through Paramedical workers in regard to treatment of minor illness. At the time of facility survey capacity building at the grass-root level was not done in past one year. Clinical orientation for treatment of minor illnesses might be carried out at BPHC/CHC level by medical officer during OPD/IPD visits. However two important issues should be considered as follows:
- The prescription of Medicines should be rational. Less costly medicine should be prescribed
- Whenever any costly medicine or life saving drug is urgently required, PRI and Government Health facilities should work together to support poor clients with such essential medicine.
Much strength of state run health services at the grass root level was noticed while weaknesses were not negligible. There were many weaknesses which are doable like cleaning of indoor and outdoor as well as to keep premises clean, face-lifting so that people are attracted, Waste papers were thrown indiscriminately and dustbins were not available, which could be solved with very little cost. Spitting stains were seen here and there which should be cleaned. PRI and opinion leaders should told community that unnecessary spitting in hospital premises will cost government and indirectly cost them, too. Providing Screen for privacy, cleaning the blocked latrine and providing privacy should not be considered as big issue, this should have been provided by now. Registration should be simplified and more time should be given in treatment and care as well as explaining the prescription and report as a popular saying goes "what medicine can do best is care but not the cure always".
A module based training to improve the communication skill should be introduced at the time of Internship training as well as at the time of entry into the health services for all public health professionals including nursing, paramedical, group C and D. during training emphasis should be given on interpersonal relationship and communication skills.
| Conclusion|| |
It is often argued that increase in price of health care (by means of introduction of or increase in user fees, cost recovery system for diagnostic tests) in government facilities would not have significant adverse impact on the utilization of health care by the poor, if the quality of health care could be improved. 
Utilization of Government health facilities was around 38% followed by unqualified Practitioners and Private Practitioner. An attempt should be made to improve utilization by cordial behavior, providing more time for patient care by the doctor and staff, explaining their prescription and report, reducing the time for registration as well as waiting and finally cost of medicine which they can afford.
More than 95% preferred allopathic Medicine, why than government is spending so high on AYUSH services as they engage at least one M.O. government run services?
Large no of patients did not avail any services when they fall sick especially in the tribal district where distance, poor knowledge about the availability of the services and non-availability of the medicine might be some reasons in addition to the cost of treatment and transport. This needs serious attention from Government.
Referral was mostly by self or by close relatives/families. Awareness is required to avoid unnecessary referral.
Cleanliness of the premises, face-lift of BPHC and SC, informed choice and clean toilet with privacy as well as broken doors of the toilets needs attention and including availability of safe drinking water needed attention.
Client satisfaction could be improved through cordial behavior of all health care staff who are in constant contact with patients and their relatives. This could be achieved through community participation with the involvement of PRI.
However, as observed in the study RCH services including FP was well immunization services were (preventive services) utilized better but there is a strong need of improvement of Post Natal Care otherwise Neonatal and Maternal mortality and morbidity will continue to be high.
| Acknowledgement|| |
Authors deeply acknowledge Govt of West Bengal & UNDP for their kind financial support, Indian Public Health Association and its members for permiting the authors to undertake the study as well as those who particpated in the study in the rural Bengal. Special thanks to Dr B P SHAMROY, the than Special Secretary, Planning and Development Goverment of West Wengal for his kind guidance and support.
| References|| |
|1.||Maria Del Carmen Rivera-Worley. B.A., Class, alienation, familism and utilization of health-care facilities: A Mexican sample, A thesis in sociology submitted to the graduate Faculty of Texas tech university in partial fulfillment of the requirements for the degree of master of arts improved, Accepted August, 1978 accessed on 7 th Nov 201031295002083789. |
|2.||Mukherjee PK. Public Health Administration in India. In: Dr. BN Ghosh's a treatise on Preventive and social medicine. Calcutta: Academic Publisher; 1987. p. 7-20. |
|3.||Seal SC, Bose J. A study of morbidity patterns and standard of medical care in rural health centres of West Bengal. ICMR TRS No 22, 1973. p. 1-4. |
|4.||Seal SC, Bose J. A study of morbidity patterns and standard of medical care in rural health centres of West Bengal. ICMR TRS No 22, 1973. p. 82-108. |
|5.||Ghosh BN, Mukherjee AB. An analysis of health services coverage of a primary health centre in West Bengal. Indian J Public Health 1989;33:26-3. |
|6.||Ray SK, Mukhopadhyay BB, Das R, Ganguly MM, Mandal A, Roy SC. Extent of utilization of maternal care services of P.H.C. by the families of a rural area. Indian J Public Health 1984;28:122-7. |
|7.||Ray SK, Mukhopadhyay BB, Ganguly MM, Das R. Some aspects in the utilization of Primary health Centre services in a rural area of West Bengal. Proceedings of the 3 rd International Congress of the World Federation of Public Health Association and the 25 th Annual Conference of the Indian Public Helth Association. Indian Public Health Association, 110 Chittaranjan Avenue, Calcutta 700073. 1981 (printed in 1983). p. 518-23. |
|8.||Bertakis KD, Azari R, Helms LJ, Callahan EJ, Robbins JA. Gender differences in the utilization of health care services. J Fam Pract 2000;49:147-52. |
|9.||Government of India, programme evaluation organization, planning commission. New Delhi, August, 2001. Evaluation study on functioning of primary health centers (phcs) assisted under social safety net programme (SSNP). Available from: http://planningcommission. nic.in/reports/peoreport/peoevalu/peo_ssnp.pdf. [Last accessed on 14th July 2011]. |
|10.||Ram RE, Datta BK. A study on the utilization of Primary Health Centers and Sub-centers health services by the rural people of Miraj Taluk, Maharastra. Indian J Public Health 1976;20:134-8. |
|11.||Unicef, coverage Evaluation Survey, 2009, All India Report UNICEF New Delhi - 110003, India County Office, 2010. p. 80-1. (www.unicef.in). |
|12.||Roy SK, Mallik S, Kumar S, Biswas B. An evaluation of first referral units in border districts of West Bengal. J Obstet Gynecol India 2005;55:52-6. |
|13.||Abel-Smith B, Rawal P. Can the Poor Afford Free Health Services? A Case Study of Tanzania. Health Policy Plan 1992;7:329-41. |
[Figure 1], [Figure 2]