Indian Journal of Public Health

ORIGINAL ARTICLE
Year
: 2021  |  Volume : 65  |  Issue : 2  |  Page : 124--129

Assessment of grassroot level health care service delivery system in a community development block of Haryana: A cross sectional study


Kritika Upadhyay1, Siva Santosh Kumar Pentapati2, Rai Singh3, Sonu Goel4,  
1 Assistant Project Coordinator, Department of Community Medicine and School of Public Health, PGIMER, Chandigarh, India
2 Medical Officer, Medical & Health Services Department, NTPC Limited, Chandigarh, India
3 Public Health Nursing Officer. Department of Community Medicine and School of Public Health, PGIMER, Chandigarh, India
4 Professor of Health Management. Department of Community Medicine and School of Public Health, PGIMER, Chandigarh, India

Correspondence Address:
Sonu Goel
Department of Community Medicine and School of Public Health, Postgraduate Institute of Medical Education and Research, Chandigarh
India

Abstract

Background: Health-care service delivery is one of the components of six building blocks of World Health Organization Health System Framework. In order to monitor the progress of health-care service delivery, it is necessary to monitor its dimensions. Objective: The current study aimed to assess the health-care service delivery at the lowest health-care delivery post in Haryana. Methods: In this cross-sectional observational study conducted in 17 randomly selected subcenters of Block Shahzadpur, Haryana, from July 2019 to March 2020, an Evaluation Framework was developed to monitor health-care service delivery through its three parameters, namely, service delivery, service provision, and facility assessment. The pretested, semi-structured tools were designed on Epi collect online (version 5) application using the available validated tools. Results: The mean service delivery score for antenatal care assessment, postnatal care assessment, and immunization is 74.9 (78.9%), 24.7 (98.6%), and 40.2 (87.3%), respectively, with an overall score of 139.8 (84.2%). The mean service provision score as assessed by patients and their caregivers through exit interview on five elements was 97%. The mean total score for facility assessment parameter was 81.7 (86.9%). The overall health service delivery score calculated by adding scores of all three parameters was 318.4 (maximum attainable score = 360, 88.4%). Conclusion: A good correlation was observed between individual parameters with total score, indicating higher performance of health-care delivery system. The future studies should focus on understanding the gaps at grassroot level and lay down the dashboard indicators for objectively evaluating health-care delivery system.



How to cite this article:
Upadhyay K, Kumar Pentapati SS, Singh R, Goel S. Assessment of grassroot level health care service delivery system in a community development block of Haryana: A cross sectional study.Indian J Public Health 2021;65:124-129


How to cite this URL:
Upadhyay K, Kumar Pentapati SS, Singh R, Goel S. Assessment of grassroot level health care service delivery system in a community development block of Haryana: A cross sectional study. Indian J Public Health [serial online] 2021 [cited 2021 Sep 23 ];65:124-129
Available from: https://www.ijph.in/text.asp?2021/65/2/124/318357


Full Text



 Introduction



World Health Organization (WHO) has formulated a Health System Framework that describes health service delivery as one of the components of six building blocks.[1] Strengthening health-care service delivery is important to the achievement of the sustainable development goals.[2] Service delivery is the first output of the various inputs of health system including health workforce, procurement and supplies, and financing. To monitor progress of health service delivery, it is necessary to monitor these dimensions.[1]

Government of India has launched an overarching National Rural Health Mission (NRHM) in 2005 (now National Health Mission) to provide accessible, affordable, and quality health-care service to the community.[3] India's National Health Policy (2017) aims at strengthening service delivery at grassroot level through its Human Resource Development Strategy.[4] The comprehensive, accessible, good quality service delivery for a wide coverage of population has contributed toward reductions in child morbidity and mortality,[5] encouraging immunization uptake,[6] promoting breastfeeding,[5] and improve outcomes of various national health programs. However, the efforts at strengthening the health-care delivery system are ineffective because of the inability to deploy and retain of sufficient numbers of trained grassroot health functionaries, inadequate drug supply, poor health financing, and lack of reliable information systems.[7],[8],[9],[10]

Among the various methods to monitor health-care service delivery, routine health facility reporting system is being used as it focuses on wide range of key health services pertaining to facility infrastructure, equipment and supplies, support systems, management systems, and providers' adherence to standards, using standard reporting formats. The United States Agency for International Development (USAID) and Macro International Inc., have developed a comprehensive facility survey instrument called Service Provision Assessment for collecting data of health facilities.[11] Similarly, a balanced score-card approach was developed in Afghanistan to monitor health services using facility survey, health worker interviews, client–provider observations, and exit interviews.[12] However, these methods are limited by increased time and cost, decreased access, and longer intervals between the survey and requirement of stringent criteria of complete listing of health facility.

Further, the existing traditional evaluation methods (TEM) for assessment of skills of grassroot level health-care workers have been used with limited success. These methods are not based on objectively measuring the clinical skills, cognitive knowledge, and competency of health-care worker. Besides, they are limited by their subjectivity and assessment of theoretical rather than simulating practical performance. To overcome these limitations, the objective structured clinical examination (OSCE) has become a standard method of assessment in recent times. WHO-SEARO, in its efforts toward effective teaching and evaluation, has also recommended OSCE as a competency-based approach and integrated learning of health-care professionals.[13]

Various studies globally have assessed health service delivery with respect to different domains such as human resource for health,[14] procurement and supply,[15] health financing[16] utilizing methods such as health facility census, health facility survey, and routine health facility reporting system.[1] In India, very few studies have comprehensively assessed health service delivery using these parameters. Further, other studies have focused on reductions in child morbidity and mortality,[5] promoting breastfeeding,[5] encouraging immunization uptake,[6] and promoting maternal health.[17],[18] In addition, existing literature has used TEM of assessment which does not reflect the real scenario and was found to be time consuming and cumbersome.[19],[20]

Against this background, the current study was conducted to assess the health-care service delivery at the lowest health-care delivery post in a Community Development Block of Haryana, India.

 Materials and Methods



Study settings

Haryana is one of the northern states of India with about 25 million inhabitants in 22 districts. Each district has 3–4 Community Development Blocks with each block catering to approximately 80,000–100,000 population. The health system delivers its services with the help of 2630 subcenters (SCs), 486 Primary Health Centres (PHCs), 94 community health centers (CHCs), and 57 general hospitals.[21] Block Shahzadpur in District Ambala is a field practice area of the Department of Community Medicine and School of Public Health, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh. PGIMER has been providing comprehensive preventive and promotive services as a part of Memorandum of Understanding (MOU) was signed between PGIMER, Chandigarh, and Department of Health, Government of Haryana. Shahzadpur block has a population of around 0.2 million. The public health infrastructure includes a CHC, 4 Primary Health Centers (PHCs), and 30 SCs. SC is the most peripheral and first point of contact between the primary health care system and the community. The current study implies “grassroot level” as the most basic level of health-care facility (subcentre) which is manned by auxillary nurse midwifery (ANM).[22] ANM is the first contact person between the community and health services. The study covered the nonsubcentre village as well when they randomly selected homes from ANM register (from any of the 5 to 6 villages looked after by her) for Home based post natal care (HBPNC) assessment.

Study design and sampling

The current study used a cross-sectional observational study design to assess all subcenters (n = 17) of two randomly selected Primary Health Centers (out of thirty subcenters of 4 PHCs in the block) and their ANMs of block Shahzadpur, Haryana. The health indicators of Shahzadpur are not different as compared to other health facilities in Haryana.[23]

Development of evaluation framework

A literature search to identify the various health service delivery parameters was done. Among the various documents, balanced score card developed by Ministry of Public Health in Afghanistan[24] and Service Provision Assessment development by USAID and Macro International Inc.[25] were selected as the reference documents for evaluation framework in the current study. Based on the review of these two documents, we found that three parameters, namely, service delivery; service provision, and facility assessment were common in assessing health service delivery, which we included in our study. Under service delivery, maternal and child health (MCH) services such as antenatal care (ANC), postnatal care (PNC), and immunization were included, whereas service provision contained patient satisfaction through exit interview and facility assessment included infrastructure, drugs, records, and Information, Education, and Communication (IEC).

Data collection tools

The pretested, semi-structured tools were designed on Epi collect online (version 5) application using the available validated tools. For the first parameter, i.e., service delivery, skill lab for RMNCH + A services training manual[26] was used for the assessment of antenatal and postnatal services and ANM handbook by MOHFW, GOI was used for immunization services. In addition, an OSCE tool was used for assessing the skills of ANM related to MCH. For second parameter, i.e., service provision, the patient satisfaction was assessed by an tool adapted from a research article by Adhikary et al.[27] For third parameter, i.e., facility assessment, Indian Public Health Standard guidelines,[22] and RMNCH + A supportive supervision checklist of Ministry of Health and Family welfare for facility assessment[28] were used. The draft tools were later discussed in the meetings with Chief Medical Officer of the district Ambala; Senior Medical officer of Block Shahzadpur, lady health visitor (LHV) and auxiliary nurse midwives of the area; faculty and residents of Community Medicine and School of Public Health, PGIMER, Chandigarh. The final tool was shared with the district authorities in advance before undertaking the study.

Under antenatal assessment, ANM was asked to demonstrate pregnancy detection test, history taking skills, skills for undertaking general physical examination including the height, weight, pulse, blood pressure, abdominal examination including the fundal height, fundal grip, fetal heart rate, hemoglobin estimation, testing urine for glucose and protein, and administration of tetanus toxoid (TT). For assessing skills pertaining to immunization, ANM was observed for three broad domains, i.e., before, during, and after the immunization session, whereas PNC skills were evaluated under four sections comprising checking of mother and child protection card, newborn assessment, mother assessment, and counseling of mother. The tool developed for the facility assessment covered infrastructure, drugs, records, and IEC. The exit interview from patients had questions related to demographics, satisfaction to the services delivered, and questions on whether the participant intended to visit again and recommend to others.

Data collection

The data collected for the assessment were over 9-month period, from July 2019 to March 2020. The necessary permissions from the state administration were taken before the visit. The data collectors, namely, senior resident, a person with degree in Community Medicine; Junior Demonstrator, a person with Masters of Public Health degree; and a Medical Social Worker were trained by the Faculty of Public Health who holds MD degree in OSCE assessment. OSCE was done by Junior Demonstrator under supervision of Senior Resident/Faculty of the post. An official schedule of visits by data collectors was shared with the ANM and concerned Medical Officers before the collection of data. Three days a week were planned for each subcenter. Exit interview of patients/attendants (n = 71, i.e., 4–5 per health facility) attending the facility along with ANC assessment were done on Tuesday, Immunization and PNC assessment on Wednesday and facility assessment was done on Friday.

Data management and analysis

The data were collected through Epi-collect 5, exported to MS Excel, and data cleaning was done. The responses were assessed by the number of steps performed under various skills pertaining to ANC, Immunization, and PNC. A score of 1 was given for performing correct step, while 0 for incorrectly or not performing it. For example, if ANM performs 3 steps out of 5 in OSCE checklist for urine sugar estimation, she shall score 3/5. The facility assessment is marked on an ordinal scale, i.e., Yes/No/Not available or “available and functional,” “available but not functional,” and “not available.” For the purpose of analysis, “Yes” or “available and functional” was given a score of 1 and “No/Not available/available but not functional” was given a score of 0.

Analysis was done in STATA 13.0 (Stata Corp., College Station, Texas 77845 USA). As the ordinal scale data were converted to discrete data, the relevant nonparametric tests were used. Data validation exercise was done for all the data collected. For exit interview, descriptive characteristics were comprehensively assessed and reported in terms of counts, frequencies, mean, standard deviation (SD), median, and interquartile range (IQR). Kolmogorov–Smirnov test was done to assess the normality of data. Based on the normality of distribution, ANC, PNC, Immunization, and facility level assessment scores were reported in the form of mean and SD or median and IQR. Correlation between different assessment scores and with total score was done and Spearman's rank order correlation coefficients were calculated.

Ethics

The study was a part of the routine data collection under supportive supervision component of National Rural Health project under a MOU of Institute with Government of Haryana with an overall goal of improvement of health-care delivery. The Institutional Ethics Committee has approved the study protocol vide approval no: PGI/IEC-11/2017-757. Informed consent was obtained from all participants before the interview.

 Results



The results of study are presented under three parameters of health service delivery, namely, service delivery, service provision, and facility assessment.

Service delivery

The mean service delivery score for ANC assessment, PNC assessment, and immunization is 74.9 (78.9%), 24.7 (98.6%), and 40.2 (87.3%), respectively, with an overall score of 139.8 (84.2%). The elements which had maximum scores under ANC component of service delivery were pregnancy detection 9.6 (96%), followed by history and physical examination 9.9 (90%). The least score was accounted for TT administration 2.2 (22%). Under PNC component, maximum scores were recorded for new born examination 10 (100%) and advice and counseling 5 (100%), whereas postimmunization practices recorded maximum score 5 (90%) under immunization component of service delivery. Based on distribution of data, only TT administration was presented in terms of median and IQR [Table 1].{Table 1}

Service provision

Service provision was assessed through exit interviews of patients and their caregivers. A total of 71 patients from 17 health subcenters were interviewed while exiting the health facility. None of the participants denied participation in the study. The mean age of participants was 60 years among males and 39 years among females. Most of the participants were either illiterate (31%) or studied up to secondary education (35%) and were unemployed (79%). The average distance from their house to subcentre is around 200 m and meantime taken by them for seeking medical advice was 15 min.

The mean service provision score as assessed by patients and their caregivers through exit interview on five elements (cleanliness and hygiene, basic facilities such as water/electricity/toilet, etc., investigations/drugs availability, advise on treatment/follow-up, behavior of the ANM) was97%. All (100%) participants answered that they intend to visit subcenter again and recommend to others.

Facility assessment

The mean total score for facility assessment parameter is 81.7 (86.9%). Under it, infrastructure 21 (92.8%) scored maximum followed by display of IEC materials 20 (92%). The score of various components under the facility assessment parameter are provided in [Table 2].{Table 2}

The overall health service delivery score was calculated by adding scores of all three parameters, namely, service delivery, service provision, and facility assessment. Thus, the mean total score was 318.4 (maximum attainable score = 360, 88.4%).

Further analysis revealed strong correlation between ANC and total score (Spearman's ρ= 0.74) followed by facility assessment and total score (Spearman's ρ= 060).

 Discussion



The grassroot level health-care delivery system is usually neglected in many parts of the country. After NRHM (lately termed as “National Health Mission"), it received a major boost in terms of human resources, supplies, and management information system.[29] The current study is one among the very limited studies done in India which comprehensively assessed health-care delivery system at grassroot level. In most of the studies conducted all over India, assessment was done only for some of its components. Patil et al.[23] and Sodani and Sharma[30] have covered ANC, PNC, and immunization services but have not undertaken the facility assessment and exit interview. Another study done by Goel et al.[20] is similar to the current study and covered MCH services comprehensively; however, patient satisfaction was not undertaken.

The study also used the novel idea of giving skill scores of ANMs based on the novel OSCE technique. A composite score was obtained based on these individual domain and subdomain scores, which is useful to comprehensively assess health-care delivery system. This shall also be helpful in comparing different health-care facilities. In most of the studies conducted in India,[17],[18],[23],[30],[31],[32] assessment was expressed in the form of frequency (percentage of subcenters covering) which does not give a fair idea about the overall assessment score of various health services parameters. In the current study, the gaps identified after skill assessment of ANMs was helpful in building their skills along with identifying their training needs. The health workers were simultaneously taught regarding the processes that were observed to be wrong or missing during the OSCE examination. The results of the skill assessment of ANMs were motivating as they knew the need and purpose of services delivered at the primary health-care level. The mean score of the present study was comparable with other studies, wherein the skills were above average.[19],[20] In addition, facility assessment guided in streamlining their record keeping practices and logistics management at health facility.

In the current study, besides focusing on assessing the necessary infrastructure and skills, the patient's perspective is being also taken for getting holistic view of health-care delivery system. This serves as a triangulation measure to assess the quality of the services provided. None of the studies done in India have covered the assessment of the subhealth centers this way.

However, this study had certain limitations as well. In addition to a small sample size for exit interviews, a mixed-method approach could have been used in the study to reveal different aspects regarding the deficiencies from various stakeholders and probable scope for the improvement of service delivery. Besides, other health-care workers such as male purpose Health Worker, Health Attendants, LHV, Accredited Social Health Activist, and Anganwadi workers were not included in the study. The current study focused mainly on the assessment of MCH services and the facility (subhealth center). Other national health programs were not covered in the present study. As the study was conducted in subhealth centers under only one CHC, study findings cannot be generalized. Time-motion part of the frontline workers is not covered comprehensively in the current study.

 Conclusion



The overall health service delivery score was calculated by adding scores of all three parameters, namely, service delivery, service provision, and facility assessment was high at 88.4%. Besides, a good correlation was observed between ANC, facility assessment scores with total score, indicating higher performance of health-care delivery system. The patients are fully satisfied with the quality of services provided at the grassroot level health-care system. The future studies should focus on understanding the gaps in the health-care service delivery at grassroot level and lay down the dashboard indicators that can objectively evaluate the health-care delivery.

Acknowledgment

We would like to thank ANMs of Shazadpur block, Haryana.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1World Health Organization. Monitoring the building blocks of health systems: A handbook of indicators and their measurement strategies [Internet]. 2010 [cited 2021 May 11]. Available from: https://www.who.int/healthinfo/systems/WHO_MBHSS_2010_full_web.pdf. [Last accessed on 2021 May 11].
2Gera R, Narwal R, Jain M, Taneja G, Gupta S. Sustainable development goals: Leveraging the global agenda for driving health policy reforms and achieving universal health coverage in India. Indian J Community Med 2018;43:255-9.
3NHM: National Health Mission. Available from: https://nhm.gov.in/index4.php?lang=1&level=0&linkid=445&lid=38. [Last accessed on 2020 Aug 02].
4Principles KP, Goals SQ, Thrust P, Investment EA, Health P, Services PC, et al. National Health Policy; 2017. Available from : https://www.nhp.gov.in/nhpfiles/national_health_policy_2017.pdf [Last accessed on 2021 May 11].
5Lassi ZS, Salam RA, Das JK, Bhutta ZA. Essential interventions for maternal, newborn and child health: Background and methodology. Reprod Health 2014;11 Suppl 1:S1.
6Nandi A, Kumar S, Shet A, Bloom DE, Laxminarayan R. Childhood vaccinations and adult schooling attainment: Long-term evidence from India's Universal Immunization Programme. Soc Sci Med 2020;250:112885. Available from: https://www.sciencedirect.com/science/article/pii/S027795362030104. [Last accessed on 2021 May 11].
7Hazarika I. Health workforce in India: assessment of availability, production and distribution. WHO South East Asia J Public Health 2013;2:106-12.
8Rao KD. Human Resources Technical Paper I 1 Situation Analysis of the Health Workforce in India; 2012. Available from: http://uhc-india.org/uploads/SituationAnalysisoftheHealthWorkforceinIndia.pdf. [Last accessed on 2020 May 05].
9Rao M, Rao KD, Kumar AK, Chatterjee M, Sundararaman T. Human resources for health in India. Lancet 2011;377:587-98.
10Rao KD, Shahrawat R, Bhatnagar A. Composition and distribution of the health workforce in India: Estimates based on data from the National Sample Survey. WHO South East Asia J Public Health 2016;5:133-40.
11Belay H, Lippeveld T. Inventory of PRISM Framework and Tools: Application of PRISM Tools and Interventions for Strengthening Routine Health Information System Performance- MEASURE Evaluation. Working Paper Series [Internet]. University of North Carolina at Chapel Hill Chapel Hill, NC 27516; 2013. Available from: https://www.measureevaluation.org/resources/publications/wp-13-138. [cited 2021 May 11].
12Peters DH, Noor AA, Singh LP, Kakar FK, Hansen PM, Burnham G. A balanced scorecard for health services in Afghanistan. Bull World Health Organ 2007;85:146-51.
13World Health Organization. Training Modules for Teaching of Public Health in Medical Schools in South-East Asia Region. Geneva. World Health Organization; 2014.
14Kabene SM, Orchard C, Howard JM, Soriano MA, Leduc R. The importance of human resources management in health care: A global context. Hum Resour Health 2006;4:20.
15Kanyoma Kizito E, Khomba James K. The Impact of Procurement Operations on Healthcare Delivery: A Case Study of Malawi's Public Healthcare Delivery System. Glob J Manag Bus Res Adm Manag [Internet] 2013;13:26–36.
16Schieber G, Maeda A. Health care financing and delivery in developing countries. Health Aff (Millwood) 1999;18:193-205.
17Dhiman A, Goel NK, Walia DK, Galhotra A, Navpreet N. Assessment of health centers as per indian public health standards in chandigarh Tricity, India. Indian J Appl Res 2011;4:420-1.
18Bashar MA, Goel S. Are our subcenters equipped enough to provide primary health care to the community: A study to explore the gaps in workforce and infrastructure in the subcenters from North India. J Family Med Prim Care 2017;6:208-10.
19Jelly P, Sharma R. OSCE vs. TEM: Different approaches to assess clinical skills of nursing students. Iran J Nurs Midwifery Res 2017;22:78-80.
20Goel S, Verma M, Kishore K, Upadhyay K, Sharma V. Baseline assessment of primary healthcare delivery through subcenters of Northern India. Cureus 2019;11:e6391.
21Department of Economic and Statistical Analysis. Government of Haryana Vision 2030; 2017. Available from: http://esaharyana.gov.in/Portals/0/undp-2030.pdf. [Last accessed on 2020 Oct 05].
22Directorate General of Health Services Ministry of Health & Family Welfare Government of India. Indian Public Health Standards (IPHS) for Sub-Centres; 2007. Available from: http://www.pbnrhm.org/downloads/SC-IPHS.pdf. [Last accessed on 2020 Aug 02].
23Patil SK, Shivaswamy MS. Assessment of sub-centres of Belagavi district according to Indian public health standards 2012 guidelines: A cross sectional study. Int J Community Med Public Health 2017;4:1938.
24Peters DH, Noor AA, Singh LP, Kakar FK, Hansen PM, Burnham G. Balanced scorecard for health services in Afghanistan. Bull World Health Organ 2007;85:146-51.
25Ministry of Health and Social Welfare. Tanzania Service Provision Assessment Survey (TSPA) 2014-2015; 2016. Available from: https://www.nbs.go.tz. [Last accessed on 2020 Oct 05].
26Daksh Skills Lab for RMNCH+A Services: Training Manual for Facilitators; 2015. Available from: http://nhm.gov.in/images/pdf/programmes/maternal-health/guidelines/SKILLS_LAB_TRAINING_MANUAL_FACILITATOR.pd. [Last accessed on 2021 May 11].
27Adhikary G, Shawon MS, Ali MW, Shamsuzzaman M, Ahmed S, Shackelford KA, et al. Factors influencing patients' satisfaction at different levels of health facilities in Bangladesh: Results from patient exit interviews. PLoS One 2018;13:e0196643.
28RMNCH + A Supportive Supervision Plan & Checklists; 2013. Available from: https://www.ukhfws.org/uploads/documents/doc_3674_rmnch+a-sop-checklist.pd. [Last accessed on 2021 May 11].
29Gopalakrishnan S, Immanuel A. Progress of health care in rural India: A critical review of National Rural Health Mission. Int J Community Med Public Heal 2017;5:4.
30Sodani PR, Sharma K. Strengthening primary level health service delivery: Lessons from a state in India. J Family Med Prim Care 2012;1:127-31.
31Reddy NB, Prabhu GR, Sai TS. Study on the availability of physical infrastructure and manpower facilities in sub-centers of Chittoor district of Andhra Pradesh. Indian J Public Health 2012;56:290-2.
32Sadana R, Fort A, Pasricha R, Henry R. Technical Report 9: Assessment of Sub-Centers in Jhansi District in Preparation for Clinic-Based Family Planning (CBFP) Produced By: Rajeev Sadana; 1998. Available from: http://www.prime2.org/prime2/pdf/TR09.pd. [Last accessed on 2021 May 11].