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Department of International Health

Department of International Health. Effect of quality improvements on equity of health service utilization and patient satisfaction in Uttar Pradesh, India. David H Peters Krishna Rao GNV Ramana February 19, 2004. Background: Uttar Pradesh (UP). Population: 166 million

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Department of International Health

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  1. Department of International Health Effect of quality improvements on equity of health service utilization and patient satisfaction in Uttar Pradesh, India David H Peters Krishna Rao GNV Ramana February 19, 2004

  2. Background: Uttar Pradesh (UP) • Population: 166 million • U5M: 123 /1,000 births • TFR: 4.0 children • Female Literacy: 43% • Poverty Headcount: 42% • Public Health Services: • Low quality • Low satisfaction • Low utilization • Large SES inequities

  3. Intervention: Uttar Pradesh Health Systems Development Project (UPHSDP) • Physical Inputs: • Essential drugs delivered • Repairs of buildings and equipment • Management Improvements: • Motivational exercises for managers • Management training • Human Resources Changes: • Relocation of staff to fill mismatches • Visiting clinician service initiated

  4. Research Questions • Can improving the quality of public clinical services in a resource poor environment in India improve: • utilization of health services • patient satisfaction? • For disadvantaged groups?

  5. Methods and Sample Uttar Pradesh Health Facilities District Hospital (DH), Female DH (FDH), Community Health Center (CHC), Primary Health Center (PHC) Facilities scored on infrastructure, utilization and area economic characteristics; poorer scoring facilities assigned to UPHSDP Project (117) DH 25, FDH 25 CHC 27, PHC 30 Control (117) DH 25, FDH 25 CHC 27, PHC 30 • Baseline survey 1999; • Control facilities selected randomly from non-project facilities; • Convenience sample of patients for exit interviews. July 2000 UPHSDP effective Project (25) DH 6, FDH 6 CHC 7, PHC 6 Control (22) DH 6, FDH 6 CHC 5, PHC 5 Follow-up survey Apr-May03

  6. Study Sample Size

  7. Variables Studied • Outcomes • New Outpatient Visits • Overall Patient Satisfaction Scale: 1 (Strongly Disagree) to 5 (Strongly Agree) • Measures of Inequality • Caste Status • Housing • Asset Quintiles (Follow-up survey)

  8. New Outpatient Visits at Community Health Centers

  9. Changes in Mean New Outpatient Visits by Level of Facility 700 600 500 400 Difference of difference in mean monthly new OPD visits 300 ((Project 02-Project 00) - (Control 02-Control 00) 200 100 0 District Hospital Female Hospital Community Primary Health Health Center Center

  10. Changes in Mean New Outpatient Visits by Caste & Level of Facility 1200 1000 800 600 400 ((Project 02-Project 00) - (Control 02-Control 00) Difference of difference in mean monthly new OPD visits 200 0 District Hospital Female Hospital Community Health Primary Health -200 Center Center -400 -600 Low Caste High Caste

  11. Changes in Mean New Outpatient Visits by Housing Type & Level of Facility 1000 800 600 400 200 ((Project 02-Project 00) - (Control 02-Control 00) Difference of difference in mean monthly new OPD visits 0 District Hospital Female Hospital Community Health Primary Health -200 Center Center -400 -600 -800 Kacha Semi-pucca Pucca

  12. Patient Satisfaction at Project and Control Facilities, 1999-2003

  13. Changes in Patient Satisfaction By Level of Facility 0.70 ** ** p-value < 0.01 * p-value < 0.05 0.60 0.50 * 0.40 0.30 Difference of Difference in Mean Outpatient Satisfaction (Project 03-Project 99) - (Control 03-Control 99) 0.20 0.10 0.00 District Hospital Female Hospital Community Health Primary Health -0.10 Center Center -0.20

  14. Changes in Level of Satisfaction By Caste & Type of Facility 0.80 ** p-value < 0.01 * p-value < 0.05 ** * 0.60 * 0.40 Difference of Difference in Mean Satisfaction 0.20 (Project 03- Project 99)- (Control 03-Control 99) 0.00 District Hospital Female Hospital Community Health Primary Health Center Center -0.20 -0.40 Low Caste High Caste

  15. Changes in Level of Satisfaction By Type of Housing & Type of Facility 1.60 ** p-value < 0.01 * p-value < 0.05 * 1.40 1.20 1.00 0.80 ** ** Difference of Difference in Mean Satisfaction 0.60 (Project 03-Project 99)-(Control 03-Control 99) 0.40 0.20 0.00 District Hospital Female Hospital Community Health Primary Health -0.20 Center Center -0.40 -0.60 Kacha Semi-pucca Pucca

  16. Conclusions • Reform efforts can improve utilization and patient satisfaction, but relationships are complex • Effects stronger for poor at lower levels of facilities, where intervention more complete: • Utilization increases preferentially by low caste and poorly housed at PHCs and CHCs, but mixed effects at hospitals • Patient satisfaction increases at PHCs and CHCs, but not consistently for different vulnerable groups • Better consistency in management of evaluation would yield better results

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