Quality of Healthcare Services Rural India

VIKALPA • VOLUME 36 • NO 1 • JANUARY - MARCH 2011 51

Developing nations have been focusing on relevant infrastructure, technology, disease con-trol, and health outcomes in terms of deaths and disability-adjusted life years, largely ignor-ing the service quality aspect from the patient’s viewpoint. However, researchers opine thatreal improvement in quality of care cannot occur if the user perception is not involved.Patients’ perception is significant as it impacts their ‘health-seeking behaviour’ includingutilization of services, seeks involvement in issues directly related to them, enables theservice provider to meet their expectations better, and provides relevant information to thepolicy makers to improve the quality.

Some studies conducted in the recent years have made attempts to develop multi-dimen-sional scales and measure quality of healthcare services in the developing nations. Thecurrent study seeks to assess the perception of patients towards quality of healthcare ser-vices in rural areas of seven districts of Uttar Pradesh based on the scale developed byHaddad et al (1988) after making adjustment for Indian culture and language. 500 patientswere contacted at the healthcare centres. A response rate of 79.2 per cent was obtainedresulting in 396 complete questionnaires. The 23-item scale employed in the study com-prised five homogeneous sub-scales and tested well for reliability.

The findings illustrated some interesting differences in user perception regarding servicequality and how they varied between different healthcare centres and according to thedemographic status of patients. It was observed that:

• ‘Healthcare delivery’ and ‘financial and physical access to care’ significantly impactedthe perception among men while among women it was ‘healthcare delivery’ and ‘healthpersonnel conduct and drug availability’.

• With improved income and education, the expectations of the respondents also increased.It was not merely the financial and physical access that was important but the manner ofdelivery, the availability of various facilities and the interpersonal and diagnostic aspectof care as well that mattered to the people with enhanced economic earnings.

• What was most astonishing was the finding that the overall quality of healthcare serv-ices is perceived to be higher in Primary Healthcare Centres than in CommunityHealthcare Centres (CHCs). Inadequate availability of doctors and medical equipments,poor clinical examination and poor quality of drugs were the important drawbacksreported at CHCs.

The current study demonstrates that the instrument employed was reliable and possessedthe power to discern differences in the opinion of people on the basis of demographic factorsand point out the quality differences in different healthcare centres. It could be employed toevaluate healthcare quality perception in other rural and urban regions of the country andto assess the perception of users towards private healthcare centres. Further, research couldbe conducted on price-quality relationship. The government and policy makers are urged toconsider the perceptions of patients as well in order to affect improvement in the quality ofservices and subsequently increase their utilization.

R E S E A R C H

includes research articles thatfocus on the analysis and

resolution of managerial andacademic issues based on

analytical and empirical or caseresearch

ExecutiveSummary

Quality of Healthcare Services inRural India: The User Perspective

J K Sharma and Ritu Narang

KEY WORDS

Quality of HealthcareServices

Primary Health Centres

Community Health Centres

Service Delivery

User Perspective

Rural India

Policy-makers

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The role of government in ensuring that its country’shealthcare system provides optimal services forits population has been greatly emphasized upon

(The World Health Report, 2000). Improvement in thequality of primary healthcare services apart from increas-ing accessibility and affordability has become a matter ofgrave concern for the developing nations in the recentyears. However, the meaning of quality in healthcare sys-tem has been interpreted differently by different research-ers. Ovretveit (1992) identified three “stakeholder”components of quality: client, professional, and manage-rial. From the client’s viewpoint, it is the meeting of thepatient’s unique need and want (Atkins, Marshall andJavalgi, 1996) at the lowest cost (Ovretveit, 1992), pro-vided with courtesy and on time (Brown et al., 1998) whileprofessional quality involves carrying out of techniquesand procedures essential to meet the client’s requirementand managerial quality entails optimum and efficientutilization of resources to achieve the objectives definedby higher authorities. According to the Institute of Medi-cine (2001), quality in healthcare is, “the degree to whichhealth services for individuals and populations increasethe likelihood of desired health outcomes and are consis-tent with current professional knowledge.” Meeting theobjectives of both physicians and patients has beenequated with the concept of quality in healthcare by someresearchers (Morgan and Murgatroyd, 1994) while oth-ers have focused on user perception, technical standards,and provision of care (Boller et al., 2003; Hulton, Mathewsand Stones, 2000). Quality of care comprises structure,process, and health outcomes (Peabody et al., 1999); andthere are eight dimensions of healthcare service delivery:effectiveness, efficiency, technical competence, interper-sonal relations, access to service, safety, continuity, andphysical aspects of healthcare (Brown et al, 1998). Theconcept of quality is multifaceted connoting differentmeanings to different stakeholders such as government,service provider, hospital administration, and patients.

NEED FOR STUDY

Developing nations have been focusing on relevant in-frastructure, technology, disease control, and health out-comes in terms of deaths and disability-adjusted life years,largely ignoring the service quality aspect from thepatient’s viewpoint. However, researchers opine that realimprovement in quality of care cannot occur if the userperception is not involved (Thompson and Sunol, 1995).Patients’ perception is significant (Donabedian, 1980) as

it impacts their ‘health-seeking behaviour’ (NationalCommission on Macroeconomics and Health Report,2005) including utilization of services (Haddad andFournier, 1995; Reerink and Sauerborn, 1996), seeks in-volvement in issues directly related to them (Calnan,1988), enables the service provider to meet their expecta-tions better (Calnan, 1998), and provides relevant infor-mation to the policy makers to improve the quality. Studiesin developing nations in Asia such as Sri Lanka (Akinand Hutchinson, 1999), Nepal (Lafond, 1995) andBangladesh (Andaleeb, 2000) have confirmed the impactof perceived quality of healthcare services on the utiliza-tion. Evidently, quality of healthcare is important anddemands continuous attention. Keeping this in mind, thecurrent study aims to measure the perception of usersavailing rural healthcare services in India with a view toprovide valuable information to the policy makers aboutthe areas that need attention for improvement in qualityof healthcare. Furthermore, it seeks to further develop ananalytical framework for the measurement of perceivedquality of healthcare.

METHOD

Instrument for Survey

The most popular tool for measuring quality has beenSERVQUAL which was developed by Parasuraman,Zeithaml and Berry, (1985) and has been applied in vari-ous businesses including industrial, commercial, non-commercial, and services settings (Babakus and Mangold,1992; Dabholkar, Thorpe and Rentz, 1996; Kang andKostas, 2002, Seock-Jin and ll-Soo, 2006). However, de-spite its extensive application, SERVQUAL has been criti-cized on both theoretical and operational aspects(Babakus and Mangold, 1989; Carman, 1990; Cronin andTaylor, 1992; Redman and Mathews, 1998). The prob-lems related to measurement have also been cited in thecontext of hospitals (Reidenbach and Sandifer-Smallwood, 1990).

Some studies conducted in the recent years have madeattempts to develop multi-dimensional scales and mea-sure the quality of healthcare services in the developingnations. Andaleeb (2000) explored five dimensions ofperceived quality of care: responsiveness, assurance,communication, discipline, and ‘bribe money’ paid tohealth staff in a study conducted in Bangladesh. Haddad,Fournier and Potvin (1998), developed and validated a

QUALITY OF HEALTHCARE SERVICES IN RURAL INDIA: THE USER PERSPECTIVE


20-item instrument for use in Guinea. The dimensionsincluded in the study were healthcare delivery, person-nel, and health facility. Later, Baltussen et al (2002)adapted this scale in the context of Burkina Faso andidentified four dimensions of healthcare quality: healthpersonnel and conduct, adequacy of resources and ser-vices, healthcare delivery, and financial and physicalaccessibility. Duong et al. (2004) have also demonstratedthe feasibility, reliability, and validity of the instrumentdeveloped by Haddad, Fournier and Potvin (1998) in thecontext of rural Vietnam. They identified four factors tomeasure the client perceived quality: healthcare delivery,health facility, interpersonal aspects of care, and accessto services. The research tool employed in the presentstudy is based on the scale provided by Haddad, Fournierand Potvin (1988) to assess the perception of patients to-wards quality of healthcare services after making adjust-ment for Indian culture and language.

A qualitative study comprising six focus group discus-sions and twelve in-depth interviews was conducted toidentify whether the 20-item scale developed by Haddad,Fournier and Potvin (1998) was relevant to rural India.The participants comprised those who had visited thepublic hospital in the last six months and thus were rep-resentatives of the patients experiencing healthcare ser-vices in government hospitals. The findings of thequalitative research revealed conceptual similarity in theperception of the patients in Guinea, Burkina Faso, andVietnam. Though there was considerable overlappingbetween the original items and those identified by theIndians, some modifications were made to the originalscale to reflect the Indian context. The generated itemswith Eigen value of more than 1 were included resultingin 23 items. Each scale item comprised five opinions thatranged from a score of -2 for ‘very unfavourable,’ -1 for‘unfavourable,’ 0 for ‘neutral,’ +1 for ‘favourable,’ and +2for ‘very favourable.’

Studies have reported positive impact of quality care ondemand (Akin and Hutchison, 1999; Andaleeb, 2000) orrepeat/future visits. So, questions regarding overall qual-ity of services provided by the healthcare centres and theintention to repeat visit were asked to establish the rela-tionship between quality of services and repeat visits. Thesecond part of the questionnaire solicited informationpertaining to demographic characteristics. The question-naire was then translated from English to Hindi, the prin-cipal language of Uttar Pradesh. It was pre-tested to ensure

that the wording, sequencing of questions, length, andrange of scale were appropriate. Low level of literacy andnegligible exposure to this kind of study made it difficultfor respondents to comprehend the scale. It was there-fore, adapted to a ‘money scale’: zero paisa (very unfavou-rable), 25 paisa (unfavourable), 50 paisa (neutral), 75 paisa(favourable), and 100 paisa (very favourable) for the pur-pose of administering the questionnaire.

Subjects

The study was conducted in the rural areas of the dis-tricts of Gonda, Pratapgarh, Sitapur, Hardoi, Varanasi,Gorakhpur, and Bareilly in the state of Uttar Pradesh.One Community Health Centre (CHC) and two PrimaryHealth Centres (PHCs) were selected at random from eachof these districts. A sample size of 500 was distributedamong these districts in proportion to the rural popula-tion of the respective district. This meant that 14 per centof the respondents were drawn from Gonda, another 14per cent from Pratapgarh, 17 per cent from Sitapur, 16 percent from Hardoi, 10 per cent from Varanasi, 16 per centfrom Gorakhpur, and the remaining from Bareilly. Therespondents comprising both OPD (Outpatient Depart-ment) and IPD (Inpatient Department) patients were se-lected in a purposive manner ensuring that they hadutilized the healthcare services at the public healthcarecentres within the last six months. Before administeringthe questionnaire, the meaning of the scale was explainedto them. The representation of scale in the form of moneywas easier for the respondents to comprehend. Despitetremendous efforts made by the researcher, a responserate of 79.2 per cent was obtained resulting in 396 com-plete questionnaires.

RESULTS

Scale Properties

Factor analysis technique was employed to examine thestructure of the relationship among variables represent-ing the perceived quality dimensions of healthcare ser-vices in India. Prior to running the factor analysis, theKaiser-Meyer-Olkin (KMO) measure of sampling ad-equacy and the Bartlett’s test of sphericity were performed.The generated score of KMO was 0.92 and highly signifi-cant Bartlett’s test of sphericity supported the appropri-ateness of using factor analysis to explore the underlyingstructure of perceived quality of healthcare services. An“Eigen value greater than 1” criterion was employed for

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determining the number of factors. In order to obtain moreinterpretable results solution, Varimax rotation was usedto rotate the solution. This caused the loadings to be dis-tributed among the selected factors making it easier tointerpret results. Factor loadings of 0.5 or greater on afactor were regarded as significant. As shown in Table 1,the factor analysis of the 23-item scale on the basis ofprincipal component extraction by using Varimax rota-tion converged in sixteen iterations and resulted in fivehomogeneous sub-scales with the Eigen values of 4.127,3.817, 3.798, and 2.440. The total variance explained afterrotation was 74.216 per cent with the communalities af-ter extraction ranging from 0.592 to 0.829. SPSS version13 software was used for performing all statistical analy-

sis. The factors so obtained were named in accordancewith the nature of their underlying construct keeping inmind the statements that had higher loading on a spe-cific factor. Subsequently, they were named ‘healthcaredelivery,’ ‘interpersonal and diagnostic aspect of care,’‘facility,’ ‘health personnel conduct and drug availabil-ity,’ and ‘financial and physical access to care.’

The first subscale with Cronbach alpha 0.92 includedseven items related to ‘healthcare delivery’ (HCD): ad-equate availability of doctors, good diagnosis, satisfac-tion over prescriptions, quality of drugs, recovery/ cure,sufficient time to patients, and payment arrangements.The second subscale, ‘interpersonal and diagnostic as-

Table 1: Factor Analysis of the Instrument

Items Components/Factors Communalities

1 2 3 4 5 after Extraction

Healthcare Delivery

Adequate availability of doctors 0.490 0.421 0.466 0.141 0.031 0.655

Good diagnosis 0.541 0.472 0.458 0.321 0.018 0.828

Satisfaction over prescriptions 0.636 0.313 0.138 0.408 0.162 0.715

Quality of drugs 0.598 0.273 0.486 0.339 -0.041 0.785

Recovery/ cure 0.783 0.307 0.260 0.182 0.112 0.820

Sufficient time to patients 0.780 0.194 0.027 0.133 0.339 0.778

Payment arrangements 0.598 -0.009 0.297 0.326 0.496 0.798

Interpersonal and Diagnostic Aspect of Care

Overall reception facility 0.218 0.639 0.234 0.450 0.177 0.745

Honesty 0.244 0.527 0.187 0.486 0.365 0.741

Good clinical examination 0.390 0.674 0.231 0.232 0.250 0.776

Follow-up, monitoring of patients 0.180 0.646 0.342 0.321 0.291 0.755

Adequate medical equipment 0.200 0.791 0.387 0.104 -0.051 0.829

Facility

Adequacy of rooms 0.367 0.219 0.619 0.180 0.173 0.628

Adequate availability of doctors for women 0.284 0.519 0.625 0.147 -0.188 0.797

Neat and clean hospital premises 0.102 0.193 0.729 0.275 0.110 0.667

Clean appearance of staff 0.338 0.158 0.562 0.226 0.293 0.592

Proper disposal of waste 0.007 0.313 0.755 0.005 0.332 0.779

Health Personnel Conduct and Drug Availability

Compassion and support 0.279 0.382 0.112 0.756 0.102 0.819

Adequate respect to patients 0.221 0.267 0.267 0.696 0.164 0.703

Availability of all drugs 0.453 0.374 0.407 0.463 0.004 0.725

Financial and Physical Access to Care

Financial feasibility of treatment 0.463 -0.014 0.163 0.036 0.660 0.678

Ease of obtaining drugs 0.188 -0.120 0.279 0.503 0.543 0.675

Easy approachability 0.028 0.283 0.059 0.120 0.826 0.781

Percentage variance explained by factor after rotation 17.945 16.595 16.512 12.554 10.610

Extraction Method: Principal Component Analysis with four factor extraction. Rotation Method: Varimax with Kaiser Normalization.Rotation converged in 16 iterations.



pect of care’ (IDC) with Cronbach alpha 0.91 comprisedfive items: overall reception facility, honesty, good clini-cal examination, follow-up/monitoring of patients, ad-equate medical equipment. The third subscale, ‘facility’with Cronbach alpha 0.85, included five items: adequacyof rooms, adequate availability of doctors for women, neatand clean hospital premises, clean appearance of staff,and proper disposal of waste. The fourth subscale withCronbach alpha 0.84 contained three items related to‘health personnel conduct and drug availability’(HPCDA): compassion and support, adequate respect topatients, and availability of all drugs. The last subscale,‘financial and physical access to care’ (FPAC) withCronbach alpha 0.71, comprised three items: financialfeasibility of treatment, ease of obtaining drugs, and easyapproachability.

The scale was tested for reliability. It had an overallCronbach’s alpha value of 0.96 that ranged from 0.706 to0.919 for the subscales. The reliability was highest for‘interpersonal and diagnostic aspect of care’ (0.92) andlowest for ‘financial and physical access to care’ (0.71).The overall mean score was 1.782.

Subgroup Analysis

The demographic profile of the respondents is shown inTable 2.

Table 2: Demographic Profile of Respondents

Variables Numbers %(N=396)

Gender Female 99 25.0

Male 297 75.0

Literacy Literate 236 59.6

Illiterate 160 30.4

Income per month < Rs 1,000 71 17.9

*Rs 1,001-3,000 111 28.0

>Rs 3,000 214 54.0

Age < 30 years 177 44.70

>30 years 219 55.30

*1 US dollar = Rs. 50 approximately

The intention of the patients to repeat visit was regressedagainst overall quality score as well as scores for differ-ent components of quality in order to determine differ-ences in perceptions among respondents relative todemographic characteristics and healthcare centres. Forthis purpose, a linear regression model was employed to

study the relationship between the intention to repeat visit(dependent variable) at the public healthcare centre andthe components of health service quality (independentvariables). The findings indicate that the socio-economicprofile of the respondents and the healthcare setup wassignificantly associated with the perception regardingquality of service and the intention to pay repeat visit(Table 3). For most of the variables, ‘healthcare delivery’and ‘financial and physical access to care’ were seen tobe significantly associated with the intention to repeatvisit. It was observed that ‘healthcare delivery’ and ‘fi-nancial and physical access to care’ significantly im-pacted the outcome among men while among women itwas ‘healthcare delivery’ and ‘health personnel conductand drug availability’. The finding that among <30 yearage group, it is the financial and physical accessibility ofthe service that is associated with the outcome, impliesthat the low-cost structure and relative nearness of thesefacilities are most important factors with no associationbeing shown with any of the other mooted components.Interestingly, among the IPD (Inpatient Department) pa-tients, the variables ‘interpersonal and diagnostic aspectof care,’ ‘facility,’ and ‘health personnel conduct and drugavailability’ along with ‘healthcare delivery’ were sig-nificantly associated whereas ‘financial and physicalaccess to care’ was not, thus implying that when the pa-tient had to be admitted into the hospital, the financialand physical accessibility took a back seat while for OPD(Outpatient Department) patients, ‘healthcare delivery’and ‘financial and physical access to care’ were mostsignificant. The outcome variable showed varying asso-ciation with the components of quality for different in-come groups. All the dimensions except ‘health personnelconduct and drug availability’ showed significant asso-ciation for respondents with income above Rs 3,000 permonth. It is inevitable that with growing income levels,more options are available to patients thereby affectingtheir intention to repeat visit. For illiterates, only‘healthcare delivery’ is significant but as the level of edu-cation increases, other variables such as ‘interpersonaland diagnostic aspect of care’ and ‘financial and physi-cal access to care’ also gain priority. In Primary HealthCentres, ‘healthcare delivery,’ ‘health personnel conductand drug availability,’ and ‘financial and physical ac-cess to care’ were found to be significantly associatedwith the outcome while in community health centres, only‘financial and physical access to care’ was statisticallysignificant.

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Perceived Quality of the Health Centres

Student’s t-test was conducted to identify differences be-tween primary and community health centres. A verysurprising finding which came to the fore was that theoverall quality of healthcare services was perceived to behigher in primary health centres than in community healthcentres (Table 4). Statistically significant differences wereobserved on ‘healthcare delivery’ with low scores beingrecorded for all the variables for community health cen-tres. Inadequate availability of doctors (p= 0.023) and poorquality of drugs (p= 0.009) were the most important draw-backs reported at these centres. Furthermore, in compari-son to primary health centres, poor clinical examination(p= 0.043) and inadequate availability of medical equip-ments (p=0.001) were found at the community health cen-tres. However, inadequate availability of doctors forwomen was perceived at primary health centres (meanscore of -0.09) than at community health centres. Nostatistically significant differences were detected for thefactor ‘health personnel conduct and drug availability.’There were statistically significant differences for the sub-scale ‘financial and physical access to care.’ It was inter-esting to observe that patients perceived it easier to obtaindrugs and approach the primary health centres and foundthe financial feasibility to be low in the community healthcentres.

DISCUSSION AND CONCLUSION

The study examines the quality of primary healthcareservices in rural areas in the state of Uttar Pradesh inIndia by using a 23-item scale. This scale was based on a20-item instrument developed and validated for use inGuinea by Haddad, Fournier and Potvin (1998) andadapted to reflect the Indian context. The adapted scaleincluded three more variables, namely, neat and cleanhospital premises, clean appearance of staff, and properdisposal of waste. These factors had emerged after focusgroup discussions and in-depth interviews. The scaletested well for reliability with an overall Cronbach’s al-pha value of 0.96. Another study (Dhar, 1979) conductedin India had also considered general cleanliness as animportant factor for utilization of services. Explaining themeaning of scale was found to be difficult at the time oftesting the scale and hence it was modified in the form ofmoney scale which the respondents found easier to com-prehend. The mean scores were reported to be positive forall the factors; being high for ‘interpersonal and diagnos-tic aspect of care’ (0.096) and ‘financial and physical ac-cess to care,’ (0.821), low for ‘healthcare delivery system,’(0.414) and very low for ‘health personnel conduct anddrug availability’ (0.296) and ‘facility’ (0.156).

The survey illustrated some interesting differences in userperception regarding service quality components that

Table 3: Components of Perceived Quality that Impact Repeat Visit Relative to Demographic Characteristics andHealth Centres

Constant HCD IDC Facility HPCDA FPAC

a 95% CI B B B B B

Lower Upper

Overall 0.659 0.615 0.703 0.223* 0.062* -0.018 -0.013 0.113*

Female gender 0.857 0.741 0.973 0.146* -0.034 0.065 -0.141* 0.032

Male gender 0.642 0.589 0.696 0.281* 0.065 -0.020 -0.031 0.097*

Age<30 years 0.656 0.586 0.726 0.105 0.085 0.056 -0.015 0.151*

Age >30 years 0.625 0.563 0.686 0.351* 0.010 -0.021 -0.055 0.074*

OPD Patients 0.608 0.549 0.666 0.250* 0.019 -0.023 0.001 0.128*

IPD Patients 0.748 0.678 0.819 0.249* 0.154* 0.186* -0.206* -0.027

Income <1000 0.700 0.594 0.807 0.172 -0.061 0.104 -0.160* 0.170*

1001-3000 0.611 0.526 0.696 0.433* -0.020 -0.015 0.013 -0.024

>3000 0.641 0.580 0.701 0.191* 0.173* -0.118* 0.045 0.159*

Uneducated 0.737 0.684 0.790 0.265* 0.051 0.027 -0.073 0.011

Up to Class 8 0.666 0.515 0.816 0.004 0.179 0.364* -0.200 0.075

Above Class 8 0.622 0.530 0.714 0.190* 0.207* -0.068 -0.029 0.322*

Type=PHC 0.680 0.622 0.738 0.275* 0.057 -0.019 -0.081* 0.077*

Type =CHC 0.509 0.388 0.629 0.098 -0.030 0.094 0.191 0.158*

*Statistically significant at 0.05 level



impacted their intention to repeat visit and how they var-ied between different healthcare centres and according tothe demographic status of patients. Impact of demo-graphic factors such as age, gender, and education onutilization of healthcare services has been reported byother studies as well (Feldstein, 1979; Pathak, Ketkar andMajumdar, 1981; Garg, 1985; Faizi, 1996). It was observedthat ‘healthcare delivery’ and ‘financial and physicalaccess to care’ significantly impacted the perceptionamong men while among women it was ‘healthcare de-livery’ and ‘health personnel conduct and drug avail-ability.’ It may be noted that in rural India, it is the manwho is expected to provide for various expenses of thefamily and make transportation arrangements to the hos-

pitals for the patient. This has got reflected in the find-ings of the study. Women, on the other hand, are emo-tional and expect compassion and empathy at the placeof treatment.

With improved income and education, the expectationsof the respondents also increased. It was not merely thefinancial and physical access that was important but themanner of delivery, the availability of various facilities,and the interpersonal and diagnostic aspect of care aswell that mattered to the people with enhanced economicearnings. However, it was surprising to observe that illit-erates and those with less education did not considerfinancial and physical access to the centres important

Table 4: Differences in Perceived Service Quality between CHCs and PHCs

Healthcare Centres

PHCs CHCs(No. of respondents=297) (No. of respondents=99)

Scale (Dependent Variable) Mean SD Mean SD “t” “p”

Healthcare Delivery

Adequate availability of doctors 0.23 0.95 -0.03 1.09 2.287 0.023

Good diagnosis 0.37 0.95 0.09 1.12 2.451 0.015

Satisfaction over prescriptions 0.55 1.00 0.21 0.98 2.886 0.004

Quality of drugs 0.34 1.13 0.00 1.13 2.614 0.009

Recovery/ cure 0.51 1.04 0.21 0.98 2.460 0.014

Sufficient time to patients 0.83 0.97 0.06 1.05 6.702 0.000

Payment arrangements 1.13 0.95 0.39 1.05 6.508 0.000

Interpersonal and Diagnostic Aspect of Care

Overall reception facility 0.11 0.93 0.21 1.10 -0.891 0.373

Honesty 0.42 0.93 0.21 1.10 1.868 0.062

Good clinical examination 0.21 0.97 -0.03 1.20 2.027 0.043

Follow-up, monitoring of patients 0.18 0.94 0.15 1.31 0.250 0.803

Adequate medical equipment -0.46 1.03 -0.03 1.20 -3.484 0.001

Facility

Adequacy of rooms 0.12 1.01 0.12 1.13 0.000 1.000

Adequate availability of doctors for women -0.09 1.11 0.18 1.17 -2.083 0.038

Neat and clean hospital premises 0.34 0.89 0.27 1.09 0.583 0.560

Clean appearance of staff 0.35 0.85 0.39 1.08 -0.383 0.702

Proper disposal of waste 0.15 0.92 0.15 1.08 0.000 1.000

Health Personnel Conduct and Drug Availability

Compassion and support 0.54 0.92 0.36 1.07 1.546 0.123

Adequate respect to patients 0.37 0.85 0.24 1.13 1.219 0.224

Availability of all drugs 0.16 1.09 0.09 1.09 0.559 0.577

Financial and Physical Access to Care

Financial feasibility of treatment 1.22 0.76 0.58 0.99 6.760 0.000

Ease of obtaining drugs 0.82 0.87 0.39 1.10 3.913 0.000

Easy approachability 0.81 0.96 0.33 1.07 4.133 0.000

Student‘s t-test conducted to compare mean difference between CHCs and PHCs.

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and were willing to travel great distances for treatment.Overall this suggests that with improvement in socio-eco-nomic status, various aspects of service quality assumeimportance for the optimal utilization of services and thepolicy makers need to be sensitive about it. It has beenobserved that though the Indian government has madeefforts to set up a vast network of healthcare centres in deepinterior regions of rural areas, their importance is declin-ing due to neglect of service quality (Bhandari, 2006).

Another interesting finding that emerged was with re-spect to IPD and OPD patients and their intention to visitthe health centre in future. For those visiting the hospitalfor minor health problems, physical and financial accessto health centres, availability of doctors providing suffi-cient time, and satisfactory prescription to help them re-cover fast were more important than other factors.However, for those requiring hospitalization, physicaland financial access became unimportant while all otheraspects of service assumed great significance. This is an-other lesson for service providers.

What was most astonishing was the finding that the over-all quality of healthcare services is perceived to be higherin primary health centres than in community health cen-tres. Inadequate availability of doctors and medical equip-ments, poor clinical examination, and poor quality ofdrugs were the important drawbacks reported at commu-nity health centres. This appears shocking as communityhealth centres form the uppermost tier of the primaryhealthcare system in the country and therefore medicalspecialists comprising surgeon, physician, gynaecolo-gist, and pediatrician supported by twenty-one para-medical and other staff are supposed to be in charge ofeach community health centre whereas just one medicalofficer supported by fourteen paramedical and other staffis in charge of the primary health centres. However, thecurrent study seems to corroborate the findings of other

researches (Choudhury et al., 2006; Bhandari and Dutta,2007) on the current scenario of rural healthcare centres.According to Bhandari and Dutta (2007), nearly 50 percent of the sanctioned posts of specialists at communityhealth centres were vacant in 2005 and the absenteeismrate among the primary health providers in India was thehighest (40%) among the surveyed countries (Chaudhuryet al., 2006). The fact that the patients opined that the fi-nancial feasibility was low in community health centresin comparison to primary health centres need further ex-ploration. As these centres are government-owned, onlya nominal amount is charged for the various medical fa-cilities. This finding contradicts the government’s objec-tive of making the health facility available at a very lowcost to the common man. The inadequate availability ofdoctors for women was also reported at primary healthcentres. It may be pertinent to note that there is no provi-sion for gynaecologists at these centres.

The current study demonstrates that the instrument em-ployed was reliable and possessed the power to discerndifferences in the opinion of people on the basis of demo-graphic factors and point out the quality differences indifferent healthcare centres. The selection of the respon-dents on the basis of convenience may have limited theprecision of the study but the findings urge the govern-ment and policy makers to consider the perceptions ofpatients as well in order to affect improvement in the qual-ity of services and subsequently increase their utiliza-tion. Immediate steps need to be undertaken to ensureavailability of doctors, medical equipments, and goodquality of drugs. The study was however, limited to cer-tain areas of Uttar Pradesh. Therefore, it is suggested thatsimilar studies be carried out in other rural and urbanregions of the country and include the private healthcareservice providers as well. Further, researches could beconducted on price-quality relationship.

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SERVQUAL Approach,” Journal of Health Care Marketing,10(4), 47-55.

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J K Sharma is a Professor in Business Administration at theUniversity of Lucknow, India. He has twenty-two years ofacademic and research experience and has international teach-ing experience as Assistant Professor in Hampton BusinessSchool, Virginia, USA. His areas of specialization include Stra-tegic Management, Managerial Accounting, and Finance. e-mail: [email protected]

Ritu Narang is an Assistant Professor at the Department ofBusiness Administration, University of Lucknow and her cur-rent areas of interest include services marketing, consumerbehaviour, and retail business. She has been a Senior Distin-guished Fellow at Hanken School of Economics, Finland andhas recently completed a major Research Project sponsoredby the University Grants Commission, Delhi. She has pre-sented papers at various national and international confer-ences and has a number of publications to her credit. She hasbeen involved in delivering invited talks to managers ofpublic and private sector organizations.

e-mail: [email protected]


The problems of health care can be solved if we stop

giving tax cuts to those who have the most, and start

making health care affordable for those working

harder and harder for too little.

— John F Kerry

Documents

Quality of Healthcare Services Rural India