|Year : 2015 | Volume
| Issue : 2 | Page : 37-40
Achieving quality in primary health care
Anil P Pandit, Meenal Kulkarni, Swati Sonik
Symbiosis Institute of Health Sciences, Pune, Maharashtra, India
|Date of Web Publication||19-Jan-2016|
Dr. Anil P Pandit
Symbiosis Institute of Health Sciences, Pune - 411 004, Maharashtra
Source of Support: None, Conflict of Interest: None
This review article tries to provide an insight into how we can improve the quality of primary health-care services provided in a primary health center (PHC) setup. Primary health care is essential health care made universally accessible to individuals and acceptable to them through their full participation and at a cost that the community and the country can afford. Unlike the previous approaches (e.g. basic health services, integrated health care, and vertical health services) that depended upon taking health-care services to the doors of the people, primary health-care approach starts with the people themselves.
Keywords: Accessible, community, health services, primary health care, quality
|How to cite this article:|
Pandit AP, Kulkarni M, Sonik S. Achieving quality in primary health care. J Nat Accred Board Hosp Healthcare Providers 2015;2:37-40
|How to cite this URL:|
Pandit AP, Kulkarni M, Sonik S. Achieving quality in primary health care. J Nat Accred Board Hosp Healthcare Providers [serial online] 2015 [cited 2020 Jan 28];2:37-40. Available from: http://www.nabh.ind.in/text.asp?2015/2/2/37/174346
| Introduction|| |
The term "primary health care" refers to the "essential health care." Primary health center (PHC) is where the individuals, families, and the community have the first level of contact with the health-care system. 
PHCs were established to provide accessible and affordable primary health care to people. 
Primary health-care services include the following components:
- Education for the identification and prevention/control of prevailing health challenges.
- Proper food supplies and nutrition, adequate supply of safe water, and basic sanitation.
- Maternal and childcare, including family planning.
- Immunization against the major infectious diseases.
- Prevention and control of locally endemic diseases.
- Appropriate treatment of common diseases using appropriate technology.
- Promotion of mental, emotional, and spiritual health.
- Provision of essential drugs (WHO and UNICEF, 1978). 
A typical PHC covers a population of 20,000 in hilly, tribal, or difficult areas and 30,000 populations in plain areas with 6 indoor/observation beds. It acts as a referral unit for six subcenters and refer out cases to child health center (CHC) (30 bedded hospital) and higher order public hospitals located at subdistrict and district levels.
However, as the population density in the country is not uniform, the number of PHCs would depend upon the caseload. For the proper functioning of the PHC, it is essential that it maintains a certain level of standard or quality. 
| Quality in Primary Health Centre|| |
The word "quality" has several different meanings. To define "quality" in primary health care is difficult because it is an intricate environment where the need varies with demographics of the community and the geographic region. A quality health-care system can be defined as "one that is accessible, appropriate, available, affordable, effective, efficient, integrated, safe, and patient related". 
Within the public health system, primary health-care services are provided through subcenters and PHCs in rural areas and urban health posts and family welfare centers in urban areas, which are generally the population's first point of contact with any health care personnel when seeking medical help. As the majority of the Indian population live in rural areas, provision of essential and quality health services through sub-centers and PHCs is crucial in determining any access to health care services for most people, especially women and children.
In India, the quality of health-care services provided by the public health system is extremely low along almost all the following criteria depending on which the quality of the service can be judged: Infrastructure, availability of drugs and equipment, regular presence of qualified medical personnel, and treatment of patients. 
Quality of health-care services provided can be assessed along the following dimensions:
- Adequately equipped and easily accessible public health facility.
- Appropriate and timely clinical care.
- Patient satisfaction with health care received and the outcome of treatment.
Some of the important points that should be considered in assessing the quality of the service in a PHC  are as follows:
- Infrastructure: A PHC should have the following in terms of infrastructure: The building in which it is housed should be in good condition; availability of electricity and running water; and the presence of a telephone or some means of communication for situations where ambulatory and emergency care may be required. Moreover, the facility needs to have basic drugs and equipment such as a refrigerator, sterilizers, etc.
- Medical personnel: There is a shortage of doctors, nurses, and other trained medical personnel in these center, especially in rural areas, as medical personnel in general, do not want to settle in rural and remote areas. As a result, many posts in the subcenters and PHCs in rural areas remain vacant. Also medical practitioners need to keep up with the latest developments in medicine that is lacking in them. 
- Quality control: One of the major lacunae in India's PHC is lack of quality control. There is little public enforcement to ensure appropriate standards of care in clinical practices. PHCs rarely follow all the norms and conditions that should be followed for the proper disposal of biomedical wastes. Biomedical wastes are being disposed in the centers that are located near any water body. This is a big hazard to the life of the people who are residing in those areas. Also there is a lack of proper water sanitation in the PHCs that are located in the rural areas. The Medical Council of India, the main body overseeing standards of health care in the country, has no process in place whereby the competence of the doctors are assessed against the standards of care when they renew their registration.
- Less incentives: It has been found that doctors, nurses, and other medical practitioners rarely get any incentives for their efforts and hard work that they are putting to improve the health-care system of India. This has led to adverse effects like their prolong absenteeism from their jobs and this situation is common to almost all the PHCs. According to one study, absenteeism among doctors was as high as 43% and among the other health workers it was 39%, across all the government health care facilities in India.
This meant that for people seeking health-care services from these facilities, there was considerable uncertainty attached to a visit that is costly in terms of time and money. Even if they found these centers open, finding someone there was unlikely. Such uncertainty further attenuates people's desire to make use of public health-care facilities.
| Measures that can be taken to Improve the Quality in Primary Health Centre|| |
Increase public expenditure
The total expenditure done by the government on healthcare in both the public and private sector is just around 5% of the gross domestic product (GDP) till 2013. This expenditure was done by the government mostly on the recurrent items, particularly the salaries, and little was spent on capital investment and for the maintenance and upgrading the quality of existing infrastructure. The expenditure is mainly done on the curative care and not on the preventive care. 
Given the current serious deficiencies both in terms of quality and quantity of the primary health-care system, the burden of avoidable ill-health, mortality, and morbidity on the poor, especially women and children, is tremendous. Maternal and child health and family welfare services are essential services that can be made cost-effective by the subcenters and the PHCs.
Moreover, not only is the current burden of disease in India very high, but with AIDS, tuberculosis (TB), and malaria are threatening to become epidemics, the future burden of disease can be expected to rise dramatically if public investment in the health sector is not raised significantly to contain their spread.
India's health system is terribly outdated.  The health-care delivery system in each state is made of a network of PHCs, CHCs, subcenters, district hospitals, teaching institutes, and first referral units (FRUs), with overlapping functions and responsibilities and little communication. In order to make them more efficient, effective, and less wasteful health care system, the need is to streamline health-care delivery and develop an integrated health-care system that will avoid duplication of duties and make optimum use of personnel, infrastructure, and resources. In this endeavor, information technology can play a very important role. Appropriate delivery of health care requires complete and timely information management to keep track of patients' medical history, to make quick referrals to hospitals and other health facilities, both for more complicated health care needs as well as in the case of emergencies.
An example of such an innovation is the idea of an Integrated Health Management Information System developed by the Tamil Nadu Department of Health and Family Welfare. Under this system, each service delivery point in the health system at the primary, secondary, and tertiary levels as well as the administrative offices in the state health sector will be connected via computers. This would enable speedy flow of information as well as allow the state to monitor both the operation of its health system and health outcomes. It will enable online receipt and exchange of information thereby ensuring timely patient and health system management, including crisis management in cases of emergencies.
Another example is of ASHA tracking system introduced in PHC's in which the ASHA workers were to maintain the track record of the patients visited and treated in a year and the ASHA workers were given incentives based on this patient record.
The effectiveness of a health-care system is also affected by the ability of the community itself to participate in designing and implementing delivery of services. The opportunity to design and manage such delivery provides empowerment to the community as well as better access, accountability, and transparency. In essence, the health-care delivery must be made more consultative and inclusive. This can be achieved through a three-dimensional approach of
- Strengthening Panchayat Raj Institutes for better designing and management;
- Audits of health-care service delivery for better accountability; and
- Bi-annual evaluation of this process for greater transparency.
For successful implementation of quality improvement initiatives, effective clinical, administrative, and political leadership is required. Leaders can support quality improvement activities in the following ways:
- Create a vision for quality by setting shared goals for performance. 
- Build staff capacity for quality improvement. Training opportunities about quality improvement should be available for all staff and it should be included as part of their routine job expectations.
- Establish a quality improvement team at the center that will promote primary health care in the rural areas.
- The patient should be able to convey his need to the leader.
- Use available existing resources to strengthen quality improvement activities.
The doctors, nurses, and other medical practitioners who are involved in giving primary health care to the people should be given incentives for their extra efforts. Workers that are employed under the various health schemes, such as National Rural Health Mission, Rashtriya Swasthya Bima Yojana, Rajiv Gandhi Crèche Scheme for Children of Working Mothers (0-6 years old), Janani Suraksha Yojana, Janani Suraksha Karyakram, and Integrated Child Protection Scheme, which are started by the government, should be given extra incentives to keep them motivated and encouraged to work in these government-run schemes.  This will help to reduce the absenteeism of the people from the work and improve the quality of the primary health care.
Also training programs for the workers should be conducted to keep them updated of the latest information and methods to deliver quality primary health service.
| Conclusion|| |
As mentioned earlier, the word "quality" includes in it many factors such as availability, affordability, and accessibility. People residing in the rural areas will avail the primary health-care services only if the PHC provides the quality service that is affordable and easily assessable to them. Also the resources available are not utilized to the full capacity that leads to an increase in demand for more doctors, nurses, and other staff that can serve the community.
Quality cannot be achieved only by the improvement in infrastructure or increase in the number of staff, but when there will be collaborative efforts from the community as well as the government and dedication on the part of the healthcare personnel toward serving the community.
Improvement in quality of healthcare will lead to the economic growth of the country and to poverty eradication. Thus, the quality in primary health care forms part of the larger concept of human resources and development.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Park K. Health Care of the Community. In: Park K, editor. Park′s Text Book of Preventive and Social Medicine. 20 th
ed. Jabalpur: Banarsidas Bhanot; p. 780-800.
Yeravdekar R, Yeravdekar VR, Tutakne MA, Bhatia NP, Tambe M. Strengthening of primary health care: Key to deliver inclusive health care. Indian J Public Health 2013;57:59-64.
Economic Survey 2013. Times of India; 2013.
Bajpai N, Goyal S. Primary Health Care in India: Coverage and Quality Issues. CGSD Working Paper No. 15. Colombia University. New York. 2004.