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ORIGINAL ARTICLE
Year : 2021  |  Volume : 65  |  Issue : 2  |  Page : 136-141  

Facilitators and barriers of service utilization: Perspectives of stakeholders in a family health center of central Kerala - A qualitative study


1 Associate Professor, Department of Community Medicine, Government Medical College, Thrissur, Kerala, India
2 Senior Resident, Department of Community Medicine, Government Medical College, Thrissur, Kerala, India
3 Junior Resident, Department of Community Medicine, Government Medical College, Thrissur, Kerala, India

Date of Submission05-Aug-2020
Date of Decision18-Feb-2021
Date of Acceptance07-Apr-2021
Date of Web Publication14-Jun-2021

Correspondence Address:
Sajna Mathumkunnath Vijayan
Nandanam, Gandhinagar 2nd Street, Cheroor P. O, Thrissur - 680 008, Kerala
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijph.IJPH_995_20

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   Abstract 


Background: Transformation of Primary Health Centers to Family Health Centers (FHC) in Kerala is a new movement. It is important to study the perspectives of stakeholders about it so that strengthening of the facilitators and tackling the barriers can be done. Objectives: The objectives of this study were to understand the perspectives of patients and health-care workers on the facilitators and barriers of service utilization in a FHC in Central Kerala. Methods: Descriptive qualitative study was done for a period of 3 months at FHC, Mundur, Thrissur district, Kerala. In-depth interview of medical officer, health supervisor, and accountant was conducted. Two focus group discussions at the FHC among Accredited Social Healthcare Activists (ASHAs) and patients and one among community members were done. The Attride-Stirling's thematic network analysis framework was followed for data analysis. The findings are reported in accordance with Consolidated Criteria for Reporting Qualitative Research guidelines. Results: The facilitators identified for service utilization are good behavior of staff, evening outpatient department and special clinics, improved infrastructure and clean premise, trust in ASHA workers, subsidized laboratory service, local self-government involvement, funds, and rewards. The barriers of service utilization are staff shortage and workload, lack of awareness among general population about some services, and shortage of medicines. Conclusion: The concept of FHC is agreeable to both the health-care workers and the community. The barriers can be tackled at this stage, and there is a scope to improve health-care quality if this model is introduced across the country.

Keywords: Family Health Center, health service utilization, Kerala health model


How to cite this article:
Vijayan SM, Puliyakkadi S, Chalil S. Facilitators and barriers of service utilization: Perspectives of stakeholders in a family health center of central Kerala - A qualitative study. Indian J Public Health 2021;65:136-41

How to cite this URL:
Vijayan SM, Puliyakkadi S, Chalil S. Facilitators and barriers of service utilization: Perspectives of stakeholders in a family health center of central Kerala - A qualitative study. Indian J Public Health [serial online] 2021 [cited 2021 Jul 30];65:136-41. Available from: https://www.ijph.in/text.asp?2021/65/2/136/318370




   Introduction Top


The WHO definition of quality of care is “the extent to which health-care services provided to individuals and patient populations improve desired health outcomes. To achieve this, health care must be safe, effective, timely, efficient, equitable, and people-centered.[1]” The United Nation's Sustainable Development Goal strives to improve this access to quality essential health-care services and access to safe, effective, quality, and affordable essential medicines and vaccines for all.[2] This people-centered improved quality of care should begin with the advancement of primary health care.

Primary health care is a whole-of-society approach to health and well-being centered on needs and preferences of individuals, families, and communities. It addresses the broader determinants of health and focuses on the comprehensive and interrelated aspects of physical, mental, and social health and well-being.[3] India's 2017 National Health Policy commits the government to investing >2/3rd of resources to primary health centers.[4] The southernmost state of India with its “Kerala model” in health is well known for its health indicators comparable to developed countries. The state is now in view of developing a Kerala model of primary health care. In the year 2017, 170 primary health centers were selected to be transformed as Family Health Centers (FHCs).[5]

Transforming Primary Health Centers into FHCs is done by redefining the package of services and improving their quality. Mission Aardram of Kerala state aims at creating “People Friendly” Health Delivery System by addressing the second-generation health-care issues. The approach will be need based and aims at treating every patient with “dignity."[6] The transformed services also aim to achieve universality and comprehensiveness. The service provision through FHC will be institution based, field, or outreach based. Curative services, counseling, health education, immunization, medicolegal, pharmacy, and laboratory services are some of the institution-based services. Field-based services include outreach activities carried out for various public health programs and routine services by Junior Public Health Nurse, Junior Health Inspector, Accredited Social Healthcare Activists (ASHAs), and Anganwadi worker.[7]

Since the FHC is a new concept, it is imperative to understand the perspectives of stakeholders so that strengthening of the facilitators and tackling the barriers in service utilization can be done. The aim of this study was to understand the perspectives of patients and health-care workers on the facilitators and barriers of service utilization in a FHC in Central Kerala.


   Materials and Methods Top


Descriptive qualitative study was done for a period of 3 months at FHC, Mundur, Thrissur district of Central Kerala. The study participants included patients, medical officer, health inspector, accountant, ASHA, and community members. The study was conducted after obtaining ethical clearance from institutional ethics committee-Government Medical College, Thrissur, order No: B6-155/2019/MCTCR (1) dated December 20, 2019. Informed consent was obtained from all the study participants.

The study adopted in-depth interviews and focus group discussions. To explore perceptions of the community, it was decided to collect data using focus group discussion among people representing community which included both patients coming to the health center and persons in the community. Medical officer, health inspector, and other staff represent the administration of the center. As there is variability in job responsibility among these, it was decided to do in-depth interview of these participants. Two focus group discussions were done at the FHC among ASHAs and patients. To ensure maximum variation in the collection of experiences, one focus group discussion was done at the field level for the community members. In-depth interview of medical officer, health supervisor, and accountant was done.

Convenience sampling was used to enroll participants in this study. The inclusion criteria for the health-care worker were those who were working in the FHC for the past 3 months. All services in the FHC were implemented in a phased manner. This was converted from PHC to FHC 2 months before the data collection. Hence, we have decided to include health-care workers who were working for at least 3 months. The inclusion criteria for the patients were those who visited the FHC more than twice in the past 6 months.

In the focus group discussions and key informant interviews, an open-ended thematic topic guide was used. It was designed to ensure that similar themes were covered in each discussion or interview. However, there was some flexibility for the interviewer so that questions can have a natural flow allowing the interviewer to probe on any specific topic. The topics were primarily focused on patients and community members perspective on the FHC services, the reasons of utilization and nonutilization, and the perceived difference in services between primary health center and a FHC. The staffs (including medical officer, health inspector, and accountant) and the field workers (ASHAs) perspectives on the facilitators and barriers on the use of services in the FHC were also explored. To ensure the reliability of the focus group discussions and interviews, the questions asked were continuously reviewed. This helped in reframing the questions, and using more appropriate and easily understandable concepts as the study progressed. All discussions and interviews were audio-recorded alongside hand-written field notes prepared by two Malayalam speaking note-takers. All interviews and FGDs were conducted in Malayalam language, manually transcribed in Malayalam from the audio-recordings and further translated and typed into English to allow for further review with coinvestigators.

To ensure that the qualitative data analysis process was methodical and transparent, the Attride-Stirling's thematic network analysis framework was followed. Each Malayalam transcript was read several times by the principal investigator and with two other coinvestigators. The transcripts were then manually coded, and the codes were discussed between the coinvestigators to clarify any differences of opinion or misunderstandings. At a point where no new concepts emerged from successive reviewing and coding of data, the code structure was considered complete and then applied to develop and report themes. The codes were then organized into categories and common themes between them identified. The final step, all the themes identified in the previous steps were assembled, and a thematic chart was drawn to reflect basic themes, organizing themes, and global themes. These global, organizing, and basic themes form the structure the following discussion section. Where appropriate, verbatim quotations from interview transcripts to illustrate responses related to relevant themes are used. The findings have been reported in accordance with Consolidated Criteria for Reporting Qualitative Research guidelines.


   Results Top


A total of 35 participants took part in the study – 1 medical officer, 1 accountant, 1 health inspector, 12 ASHAs, 8 patients, and 12 community members. Of these, 25 were females and 10 were males. Three focus group discussions were conducted among 8 patients, 12 ASHAs, and 12 community members, respectively. Individual in-depth interview of a medical officer, health inspector, and the accountant of the FHC was conducted. Duration of work experience (in their current role) of the staff participated in the study ranged from 3 months to 19 years.

Perspectives of stakeholders on the facilitators of service utilization

Good behavior of staff toward patients seems to be a prime factor in motivating patients and community members to avail the service from FHC. Staffs also identify that better communication from their part has improved the service utilization and patient satisfaction. At the field level, ASHA's has gained trust from people. ASHA's inform people about the services available at the FHC. One of the notable changes after the conversion of PHC to FHC is the improved male participation in antenatal care. Another area with an exemplary patient-health-care provider relationship is the palliative care. The palliative care patients seem to wait for the palliative nurse from the FHC, and their visits are well received by them. The elderly members of the community are also interested in interacting with health-care workers and are eager to participate in the programs for the elderly conducted by FHC.

"All the staff here has good behavior to patients and they are ready to listen what we want to say” (Patient, FGD)

"In the field when we visit house, in each house we feel like we are considered as a family members, even the children when they see us, identify us as the one who gives injections. When we invite them for health education classes, they are very interested and make sure they attend, especially in the case of antenatal women, and now it is not just the antenatal women who attend the classes, but their husbands and mother in laws too. We feel proud working here” (ASHA, FGD)

Earlier the routine outpatient services were from morning to afternoon. Now, the FHC has an additional doctor and the outpatient department (OPD) functions till evening. This benefits the working population, especially in case of daily wage workers who have to suffer loss of pay if they take days off from work to to consult doctors. Also in case of school children , they won't have to take leave from school because they can consult the doctors after school hours. Special clinics especially geriatric services appear to motivate people from other panchayaths to avail treatment from here. Immunization service is well approved by the community, and they are educated on the need of vaccination of their children.

"Evening OPD is very helpful. We don't have to take leave to consult doctor. Our children can come back from school and go to the doctor in the evening. If we develop a nausea or vomiting in evening, we can just go the nearby health center, we don't have to go all the way to medical college."(Community member, FGD)

"The immunization clinic is always full, now people trust government hospitals for immunization. Even people from wealthy families approach the FHC for immunization because they know that we maintain the quality of the vaccines.” (ASHA, FGD)

Improved infrastructure such as seating arrangement in the waiting room and pharmacy has improved patient satisfaction. The well-maintained building, clean premises, and well-ventilated consultation room are important factors in quality improvement as perceived by staff and patients. The easy access to the health center and ample parking space has added to the utilization of services. The ambulance service is also well utilized. The park surrounding the health center seems to be esthetically pleasing for the community members. A designated area for yoga is available. Information boards and health education boards are placed at the entrance. These are well received by the patients and community members.

"The hospital has changed. We don't have to stand in queue. There are chairs to sit while we wait for our turn in the doctor's consultation room and in the pharmacy” (Patient, FGD)

"Earlier people used to have a notion that all government buildings are old and painted yellow, but this center has changed it completely. It is well maintained, and we even have a park for children in the health center premises” (Health Inspector, IDI)

The subsidized laboratory service increases the utilization of the FHC service, especially in case of people with noncommunicable disease. Local self-government is actively involved in the functioning of the health center. The center receives added funds for its activities. The rewards the health center receives for its performance have motivated the staff to put in more effort to elevate the quality of care.

"We are receiving added funds since we became a FHC, now we are able to utilize these funds for a lot of improvements in the center” (Accountant, IDI)

"The lab service here is affordable, I check my blood glucose from this lab whenever the doctor asks me, we don't have to pay any money for taking OP ticket” (Patient, FGD). As shown in [Table 1] we identified the facilitators and arrived at the basic theme and organizing theme from this.
Table 1: Thematic network analysis framework (from codes to global themes) codes basic themes identified organizing themes global themes

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Perspectives of stakeholders on the barriers of service utilization

The increase in the array of services offered and the increased timings are not met with an equivalent increase in the staff strength of the FHC. This led to higher workload on existing staff. The field staffs are also overworked, new programs are being introduced, and it is difficult to complete the field activity in time. The ASHAs receive their monetary benefits once in 6 months, and their view is that if they could receive it monthly, their motivation to work would be enhanced.

"Sometimes if one staff takes leave, there won't be another person to replace her, so one person will have to manage both pharmacy and observation room. It is difficult” (Patient, FGD)

Even though specialty clinics such as adolescent clinic and mental health clinic are functioning in FHC, many of the community members and patients are unaware of it. Patients are utilizing immunization and antenatal services which are traditionally known to be a part of the health center. When it comes to newly added services such as “Shwaas” and “Ashwaas,” only few are approaching for this specific service.

"I know that immunization clinic for children and antenatal clinic for pregnant ladies are available here but I didn't know about mental health and adolescent health services” (Community member, FGD)

Break in ensuring continuous supply of medicines is a concern for the patients, especially patients with chronic morbidities. Patients from other panchayats also approach this center for consulting the noncommunicable disease clinic, and when some medicines are not available, they become disappointed. The provision of glucose strips is requested by both the patients and field workers. Provision of drugs for noncommunicable disease in the subcenter is also appealed by patients.

"I consult here for my hypertension and diabetes. But sometimes medicine will not be available. I cannot afford to pay for it” (Patient, FGD) As shown in [Table 1 we identified the barriers and arrived at the basic theme and organizing theme from this.


   Discussion Top


The Government of India has shifted its focus to “quality” in health-care delivery and aims to provide comprehensive health care through health and wellness centers. The Kerala government has initiated Aardram mission which promotes comprehensive health care at grass root level.[7]

The Kerala state during the past two decades was witnessing the emergence of the profit-oriented private health-care sector, and people had begun to lose faith in the public health-care system. This was reflected in NFHS 4 survey which showed high private health-care utilization.[8] The Aardram mission with its FHC model was implemented in this context with the added aim of reinforcing trust in public health-care system.

Good communication was identified as a prime facilitator in service utilization of FHC. Ineffective communication leads to ineffective health-care delivery. This is evident from a study conducted by Tongue et al. who reported that 75% of the orthopedic surgeons in the study believed that they communicated satisfactorily with the patients, but only 21% of patients reported satisfactory communication with their doctors.[9] Other studies have also shown that patients expect better communication from health-care providers.[10] As per the Indian Public Health Standards for Primary health Centers, total 6 h of OPD services out of which 4 h in morning and 2 h in afternoon for 6 days in a week is recommended.[11] As per this study, evening outpatient services are well received, especially by daily wage workers. When we look at the loss of wages while attending morning OPD as an indirect cost which contributes to catastrophic health expenditure, the evening outpatient service gains more importance. The FHC provides geriatric services and rolls out innovative programs which receives good response. In India, population over the age of 60 is projected to increase from 8% in 2015 to 19% in 2050.[12] Considering this, the FHC model can be a pioneer in tackling the issues in geriatric health care. The traditional health center services such as antenatal care and immunization are also well utilized, however, there is low awareness regarding mental health services and adolescent health services. In this study, the easy accessibility to the health center in terms of transportation and good parking facility was identified as facilitator of health-care utilization. The analysis of revealed that geographic accessibility is an important determinant of utilization of health service.[13],[14] Improved infrastructure and cleaner premises are appreciated by the stakeholders. Similar positive reviews from stakeholders on improved infrastructure were seen in a Universal Health Coverage Primary Healthcare Pilot Project done in Kerala.[15] Elsewhere, in a qualitative study conducted in Nigeria, lack of infrastructure was identified as a barrier to health-care utilization. The improved funding, incentives and awards (through initiatives such as Kayakalp and NQAS )have raised the morale of the health workers. Indeed, if ample funds are available and used efficiently, it will lead to increased patient satisfaction and health-care utilization, as seen in the Universal Health Coverage Primary Healthcare Pilot Project.[15]

Shortage of staff is a major deterrent in providing quality of care as per the patients and health staffs perspective. A qualitative study done by Bhattacharyya has drawn attention to similar perspectives of the stakeholders in a health-care facility in Uttar Pradesh.[16] Equitable distribution of staff and an incentive structure for work efficiency based on pay for performance will go a long way in tackling this problem.[17] The shortage of continuous drug supply was found to be a barrier in utilization of service in the present study. Other researchers have drawn attention this shortage of medicine supply which was identified a factor which draws a thick line between the people and their usage of services of these health centers.[18] Ensuring uninterrupted drug supply would be one way to reinforce public health-care utilization.


   Conclusion Top


The concept of FHC is agreeable to both the health-care workers and community. Provider effort is a major determinant in health-care quality and utilization. The first step should be educating the providers on the quality of care that is expected of them, with emphasis on communication skills. The facilitators such as better infrastructure, added services, evening OPD, funds, and motivating awards should be implemented in the primary care setting in India. The challenges such as staff shortage and interruption of drug supply should be addressed. Adopting the FHC model with appropriate regional variations if required can tremendously improve the health-care quality of Indian public health sector.

Acknowledgment

The study acknowledges the Institutional research Committee of Government Medical College, Thrissur, Kerala, India, for releasing fund for the project. We also acknowledge the ASHA workers who have helped in data collection and participants for their valuable time and support.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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