Diagnosing Quality of Reproductive Health Services Provided through Public Health System in India: Application of System's Framework
Sodani, P. R., Journal of Services Research
Quality of care has emerged as a central issue in reproductive health. The need for improving quality is intensely realized, as the health services remain grossly under-utilized despite an extensive network of infrastructure and manpower. The study has been carried out to assess the quality of care of reproductive health services and to determine factors responsible for the current level of quality of reproductive health services in the context of public health system in Udaipur district of a major Indian State Rajasthan. The study is based on both primary and secondary data. It has used both quantitative and qualitative information. Bruce Quality of Care framework has been used to assess the quality of care, which incorporate six elements: choice of methods, information given to users, technical competence, interpersonal relations, follow-up/continuity mechanisms, and appropriate constellation of services. These elements reflect six aspects of the services, identifying client experience as critical. The quantitative score for each indicator has been calculated. The overall score for the quality of care for the district worked out to be 37 on a scale of 0 to 100. This shows that the current situation of quality of care in the district is poor. To determine the factors affecting the current performance of quality of care, a systems approach, using Jain's Diagnostic Model (consisting of five components, viz., Desired Output, Environment, Input, Information, and Process) has been used. After detailed diagnosis of these components, a few vital factors have been identified as highly important, with low favourablity and highly manipulable for improving systems performance.
Quality improvement in providing of reproductive health (RM) services is expected to have an important impact on efficiency, client satisfaction and utilisation (Geyndt, Willy De 1995; Satia, Jay, 1993; and Pathfinder International, 1993). Quality of care is often considered unaffordable for programs with limited financial resources. However, ensuring quality of care is more likely to result in a more efficient use of resources, because the interventions will have greater health benefits. It will result in a larger, more committed clientele of satisfied clients.
Recent attention to the quality of RH services has highlighted the fact that historically, these services have usually been evaluated more in terms of the degree to which they have achieved demographic objectives, such as fertility decline or the reduction of infant and maternal mortality, than in terms of the quality of the services deployed to achieve those outcomes. The quality of routine operations of RH services that daily serve millions of people worldwide and may have significant impacts on both safe and informed contraceptive choices and safe motherhood practices has become the focus of donor and government attention only in the last few years.
India has made considerable progress in the last few decades in expanding the public health system and reducing the burden of disease. The National Health Policy (NHP) of 1983 has set targets for improving the health status of the population and reducing fertility. An extensive infrastructure has been developed during the last decade for public provision of primary health care services. Partly as a result of these efforts, the infant mortality rate (IMR) at the all India level had been reduced to 74 per 1,000 live births by 1994. The situation is more alarming in the case of Rajasthan. The present health care system in Rajasthan is faced with serious problems with respect to efficiency, effectiveness and quality. These problems prevent the health system from achieving the desired outcomes.
Quality of care has emerged as a central issue in reproductive health. The need for improving quality is intensely realized, as the health services remain grossly under-utilized despite an extensive network of infrastructure and manpower. The focus of the large projects at state or national level has mainly been on infrastructure and manpower development, with less concerted attempts to improve the service utilization and service quality (UNFPA, 1992).
The objectives of the paper are to assess the quality of care of reproductive health services and to determine factors responsible for the current level of quality of services in the context of primary health care in Udaipur district of a major Indian state, Rajasthan.
The study was conducted in Udaipur district of Rajasthan. District as a unit was identified for the study. The Udaipur district was selected because; a) it is one of the 90 poor performing districts in India, identified by the Department of Family Welfare, Ministry of Health and Family Welfare, Government of India. The poor performing districts are characterized by high birth rates, high infant mortality rates and very low levels of institutional deliveries.; b) it is one of the tribal districts of Rajasthan with about 40 per cent tribal and disadvantaged population; and c) The researcher is well acquainted with the district and has had experience of working with the Health Department in various projects in the district. Hence, it was assumed that the district management would render better cooperation in collecting data and information.
Assessing Quality of Care: To assess the quality of care in Udaipur district, the Bruce Quality of Care framework has been used (Bruce 1990). Bruce has proposed that several program features can be thought of as the operational components of quality of care in family planning programs. These program features are the six elements that together constitute quality of care: (1) choice of methods; (2) information given to clients; (3) technical competence; (4) interpersonal relations; (5) Follow-up or continuity mechanisms; and (6) appropriate constellation of services. These elements reflect six aspects of services that clients experience as critical. This framework is meant to provide an ordered point of departure from which to develop a description of the service unit and define its quality. The framework is centered on the experience of those who have gained access to services. The client usually does not see the apparatus behind her experience, all the vital work required to provide the services. Thus, policies, resource allocation decisions, and management tasks that precede the delivery of services are not directly experienced, but their outcome and the service giving is. The analytical framework proposed by Bruce (1990) links the hypothesized relationships between program effort, quality of service experience, and its outcome. The Bruce Framework was proposed for family planning programs, however, in the present analysis we used the framework developed by Sodani, which is fundamentally an extension of Bruce framework for the Safe Motherhood programs includes family planning and mother and child health (MCH) programs (Sodani 1997, 1999). The extended framework suggested by Sodani has been quite useful and beneficial for the program managers working in developing countries.
To measure the quality of care it is necessary to make each element operational. The indicators are identified to measure each element. The identified indicators provide a detailed picture of the quality of services provided at the grassroots level. Each indicator is derived by using the frequency distribution for a single item, collected from concurrent evaluation (1). The raw frequencies are normalized by ensuring that all are measured on a scale from 0 to 100, where 100 is the highest score. The quantitative scores for each indicator are calculated in this manner. The summary scores for each element are the average of all the constituent indicators of that element, because each is felt to be of equal importance. Exactly the same considerations have been followed for development of overall summary score of quality for the program, each element weighted equally.
Since data on other component of reproductive health (RH) i.e. reproductive tract infection (RTI)/sexually transmitted disease (STD), acquired immuno deficiency syndrome (AIDS) were not available, therefore, only two components i.e. family planning (FP) & safe motherhood (SM) were included in the study.
Factors Influencing Current Performance: To determine the factors affecting the current level of quality of care of reproductive health services, system approach, specifically, Jain's Diagnostic Model is used (1998).
The concrete way of describing a system is to say that its anatomy consists of five basic components, namely 1) Desired Output (DO), 2) Environment, 3) Inputs, 4) Information, and 5) Process. Its physiology is characterized by the interdependence of these components, and change in one component vibrates through all the other components. The greater the degree of interdependence among components, the more cohesive is the system. According to framework a system's performance is a function of the DO, Environment, Inputs, Information and Process:
System Performance = f (DO, Environment, Inputs, Information, Process)
Desired Output (Component I) According to the model, we have to find whether the system under study (i.e. Quality of care of RH services) has any stated DO; if yes, then, whether the DO is measurable, acceptable by all the stakeholders, precise, and easy to understand.
Environment (Component II) includes those factors, which influence the system, but are not under the direct control of the system processor. In other words, those are the 'givens'. The identified environmental factors are analyzed and rated on a five-point scale in terms of their importance (how important the factor is in influencing the quality of care), favourability (the extent to which the factor makes a positive contribution), and manipulability (how easy it is to influence the factor).
Inputs (Component III) include all that enter the system on the consent of the processor. The consent may be automatic or imposed on the processor. The inputs mainly include resources (financial and manpower), technology (buildings and transport), customers, supplies, donations, etc. They are analyzed in terms of quantity and quality. The identified input factors are analyzed and rated on a five-point scale in terms of their importance, adequacy, and manipulability.
Information (Component IV) The quality (i.e. reliable, timely, accurate, complete, and relevant) information on all the other components (Desired Output, Environment, Inputs and Process) of the system are needed by the manager for effective management of the system. The identified factors are analyzed in terms of their adequacy, quality, importance and manipulability. The rating for each factor has been done on a five-point scale.
Process (Component V) It is the most important component. The DO is achieved through process. The process has two components: i) processor and ii) processing system. The processor can be defined as the key player of the system, who has the power/authority to achieve the DO. The following characteristics, which influence the processor in processing, are measured in this study: concern for quality of care, competence to provide quality services, and continuity with the system. These are assessed for current status and manipulability on a five-point scale. Processing is a function, which achieves the DO by manipulating all the boxes. These are assessed on importance, current status and manipulability on a five-point scale. The processing system is analyzed on various management practices used in the system. These are soundness of strategy, implementing, planning, monitoring, coordination, motivating, etc. These are assessed on current status and manipulability. For assessing the factors influencing the current performance of the quality of care, data are collected from published and unpublished sources as well as through discussions with various key personnel.
RESULTS AND DISCUSSIONS
Current Status of Quality of Care
The scores are presented on each element of quality of care. The scores are given for two reasons. First, to illustrate that describing quality of care in quantitative, aggregate terms is possible. A second reason for presenting them is the fact that these scores can be used by the program manager to assess the services provided by their programs. These are also helpful in developing a strategy for improving the quality of care. These scores cannot be said to represent good or bad quality, because absolute standards are inappropriate (Jain et. al., 1992). They could be used, however, within a standard-setting process for the particular district. These scores could be used as a benchmark to measure progress in improving the quality of services in the study district over the next few years. For a detailed discussion on each of the element readers are encouraged to refer the earlier work done by the author (Sodani, 1998). The summary indicator score for each element is given in Table 1. The overall score, based on the average of all element scores is 37, shows a poor quality of care.
Factors Influencing Current Performance of Quality of Care
Jain's Diagnostic Model, starts with the desired output of the system. In the present study, 'system' is the quality of care of reproductive health services in Udaipur district. The system's performance, here, means performance of reproductive health services with respect to quality of care. It is observed that the system measures the performance of reproductive health services in terms of the number of clients receiving contraceptive methods (i.e. intra uterine device (IUD), oral pills and condom), and the number of pregnant women registered for antenatal services. These performance indicators are not able to say anything about the quality-ofcare being provided by the health department in the district. These performance indicators tell us about the coverage of the services only.
High performing systems tend to have a firm statement on the Desired Output (DO). Further, this statement tends to be clear, precise, measurable, and acceptable to all major stakeholders. The Target-Free Approach emphasizes on providing quality services, but there are no guidelines and indicators for quality of care. An important finding of the study is that neither the Government of Rajasthan nor Udaipur district has a clear statement on the desired output pertaining to quality of services. What is stated is as follows: "The programme's performance should not be seen with respect to targets, but there is need to give more attention to the quality aspect" (Directorate of Medical & Health Services (DM&HS) 1996).
The above statement is very vague. The statement is not clear, precise, and measurable. The government had not set any specific indicators for measuring the quality of care. In the absence of a clear statement of goals and sound indicators for measuring quality of care, it is no surprise that so little progress has been made to achieve high quality.
In providing quality of RH services in Udaipur district, the environmental factors play an important role. The system has to depend on the physical characteristics of the area and the socio-economic and demographic characteristics of the population. The stakeholders, namely, the Government of Rajasthan, Non Governmental Organisations (NGOs), voluntary agencies, research and training institutions, private practitioners and traditional practitioners, also have influenced the system. Other factors, i.e. infrastructure development, policy guidelines, political interference have also influenced the system's performance.
Physical Characteristics: Udaipur district is situated in the southern part of Rajasthan, and is oval in shape with a very narrow strip stretching towards the north. It lies between 23 0 46' and 260 2' north latitudes and 730 and 740 35', east latitudes. The district covers an area of 12412 sq. km. The northern part of the district consists generally of an elevated plateau, while the eastern part has vast stretches of fertile plains. The southern part is covered with rocky, hills and dense forests, whereas the western portion, known as the Hilly Tracts of Mewar, is composed of the Aravali range. Stretching from Bhim tehsil of Rajasmand district, the Aravali range runs south-westerly and spreads towards the valley of the Som river. There are two important passes in Aravali range, viz., Desuri Nal and Sadri. Udaipur district's major portion is covered with rocky hills, which are well covered with forests. The river Banas and its tributaries flow through the eastern parts of the district. Other rivers in the district include Som, Jakham, Wakal, Sei, Sabarmati, and Berach. All these are non-perennial rivers, which flow during the rainy season only. These geographical conditions have resulted in vast rural areas with isolated communities and sparse distribution of households. It is responsible for lesser contact between service provider and client, which results in less continuity services to the rural and remote areas of the district. In the rainy season, some parts of the district get disconnected with the district headquarters, because of rivers, affecting the supply of contraceptives and monitoring of district level officers.
Socio-economic Characteristics: The status of women is very low. The uneven sex ratio might be explained by the unfavourable accessibility to modern health services for women. The literacy rate in the district especially among women is significantly lower than the average literacy rate of the state. The broad stratum of literate in the district forms 35.5 per cent of the total population as ascertained during the 1991 census. However, there is still a marked difference in the literacy rates of the two sexes. Female literacy rate is falling behind male literacy rate in all parts of the district (in both rural and urban area). A majority of the population in the district belongs to Scheduled Tribes (around 37 per cent). This is a tribal belt, where most of the people reside on hills and mountains. Hence, the nature of the population is not compact, but scattered. The tribal people are very poor and backward, and their means of sustenance is either the forest or the agriculture. The agricultural practices in the tribal areas are very primitive and they have to depend on the monsoon as the main source of water to irrigate their crops. As far the economic status of the district is concerned, a majority of the population is engaged in agriculture and agriculture related work. But, about 60 per cent of the work force is unemployed.
Early adolescent marriage is common in the state, as well as in Udaipur district. Adolescent and child marriages have an adverse affect on the reproductive health of the mother, and the health of the new born. This, in turn, results in high maternal and child morbidity and mortality in the district. The community in the district is traditionally oriented, and has little contact with modern society. Even today, a majority of the people has a traditional perception about diseases and their treatment. In case of illness, they often approach the local healers and other traditional health providers. It affects interpersonal relations of providers with clients.
Population Characteristics: The population of the district is predominantly rural in character. According to the 1991 census, about 82.9 per cent of the people live in rural areas. The district has recorded a growth rate of 22.5 per cent as compared to the state growth rate of 28.4 per cent. The growth rate in the rural areas of the district during the decade works out to 19.6 per cent, while it comes to 39.1 per cent in urban areas meaning thereby that the population of the district has grown at a faster rate in urban areas than in its rural areas. According to the 1991 census, density of population in the district is 167 persons per sq. km. There is a sharp variation in the density of population in rural and urban areas. In the rural areas, the density of population is only 161 persons per sq. km. The sparse population makes provision of reproductive health services by the health workers in rural areas very difficult. According to the 1991 census, 8.3 per cent and 36.8 per cent people among the total population in the district belong to Scheduled Castes and Scheduled Tribes. A majority among the Scheduled Castes and Scheduled Tribes reside in the rural areas of the district. Out of the total Scheduled Caste population, 78.2 per cent are rural based, and among the Scheduled Tribes, 97 per cent live in the rural areas of the district. This situation influences the continuity of services.
Resistant Communities: The district health officials have identified various communities, i.e., Banjara, Patel, Garadiya, Kalbeliya, Gadia Luhar, and Kanzar, as 'resistant' to accepting the family welfare and health services provided by the department. The district health department estimated the population of such communities around 2.75 lakhs in the district. The Banjaras and Kalbelliyas are basically nomads who keep moving from place to place. Therefore, it is difficult for the district level health system to provide quality services to them in reproductive health. The other communities, due to their traditional beliefs and values, do not attach much importance to reproductive health services. It affects the interpersonal relations and continuity of services.
Infrastructure Development: The district lacks adequate infrastructure for transport and communication facilities. There is only one national highway, five state highways, and seven major district roads which connect important marketing centres in the district. All the important places of the district are connected by bus routes. The district is connected by a metre gauge line of the Western Railway. A rail line, connecting Mavli Junction with Marwar Junction, passes through the district. Separate line joining Delhi, Jaipur and Chittorgarth with Udaipur pass through Mavli. The Udaipur- Himmatnagar line is also connected to Udaipur City. Transportation and communication infrastructure is available in towns and cities. In villages, the facilities of transportation and communication are not good, only 40 per cent of the villages have the facilities of bus transport, 0.7 per cent have the facility of railway transport, and 18.3 per cent the facility of telephone in the village. Most of the community health centers (CHCs) and primary health centers (PHCs) are adequately connected, if reliable and regular public/government transport is available. The road infrastructure to the more isolated villages and sub-centers (SCs) is not adequate. Many hilly and tribal villages are connected by dust roads, making transport of referral patients from SCs or homes to referral institutions difficult. This influences the continuity of services in the district.
Stakeholders: The organizations, groups, and individuals that have an interest or "stake" in the success of the system are called stakeholders (Duncan, et al., 1995). Some of these stakeholders are almost always powerful or influential, some others are influential regarding only certain issues, and still others have little influence and power. The following key stakeholders are identified to assess their influence on the performance of the system: the Government of Rajasthan, donors, research and training institutes, NGOs/voluntary agencies, and traditional practitioners.
Government of Rajasthan The Government of Rajasthan is keen to improve the quality of RH services in the state. The Department of Medical, Health, and Family Welfare, Government of Rajasthan has initiated various efforts, i.e. conducting concurrent evaluation in the state for RH services to improve the quality of services. The district officials would get full support for improving the quality of services from the state government.
Donors Various international funding agencies are interested in providing funds to Udaipur district due to the low socio-economic and health status of the district. Due to tribal district, a number of organizations are providing funds for the socio-economic development. The United Nations Fund for Population (UNFPA), a major funding organisation in Rajasthan, is working for improving the quality of care in RH services. There are good chances for mobilizing funds for quality improvement in the district.
Research and Training Institutions Various research and training institutions are working in the state, and they can be very supportive in improving the quality of care in reproductive health services. The Population Research Centre of Mohanlal Sukhadia University, Udaipur, can be a good resource for conducting surveys for client satisfaction and other aspects of the programme. Tribal Research Institute, a state government organisation in Udaipur, is working for the socio-economic development of the tribal, is a good resource to know more about tribal culture and traditions. Indian Institute of Health Management Research, Jaipur, an organisation in the private sector, dedicated to improving the health status of the people through training, research, and conducting consultations in quality improvement in RH services, offers a good opportunity for the system. The State Institute of Health and Family Welfare, an organisation set up by Government of Rajasthan, is also working in the field of training and human resources development of health officials. It could be utilised by the system. The expertise available with these institutions could be manipulated for improving the quality of RH services in the district.
NGOs and Voluntary Agencies It has been recognized by the Government of Rajasthan that NGOs and voluntary agencies have considerable advantage over the government system in terms of acceptance and co-operation with the local communities because of their personalised approach, high degree of motivation, sensitivity, and responsiveness to the peoples' needs. NGOs are flexible enough to experiment with innovative and alternative approaches in solving reproductive health problems. There is a good stock of NGOs and voluntary agencies in the district, mostly small ones and working at the community level. Most of the NGOs in Udaipur district are active in the area of agriculture and a forestation, water supply, irrigation, and incomegenerating activities aimed at comprehensive socio-economic development at the community level, particularly among the tribal communities. In the reproductive health area, NGOs are less active in providing clinical services, but more active in information education communication (IEC).
The major NGOs, namely Seva Mandir, Astha, and Arth are the leading NGOs playing a pioneering role in the field of health care. Seva Mandir implements schemes, such as training of traditional birth attendants TBAs, provision of Mamta Kits (safe delivery kits), provision of antenatal and post-natal services through TBAs at community level. In addition, the organization aims at training pre-school teachers in first aid, hygiene, and sanitation. The agency is active in making awareness about STD/AIDS in the tribal areas, and areas close to National Highway No. 8, which passes through the district. The agency is active in supervision of workers by communities, and cost recovery of medicines, and has established local offices in the tribal areas. Astha, is a field based support/resource organization working with communities in the fields