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Review Article

Abstract

Achieving quality in primary health care

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.

Key words: Accessible, community, health services, primary health care, quality

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.[1]
PHCs were established to provide accessible and affordable primary health care to people.[1]

Anil P Pandit,
Meenal Kulkarni,
Swati Sonik
Symbiosis Institute of Health
Sciences, Pune,
Maharashtra, India
Address for correspondence:
Dr. Anil P Pandit,
Symbiosis Institute of Health
Sciences, Pune - 411 004,
Maharashtra, India.
E-mail: apandit70@hotmail.com
Access this article online

Primary health-care services include the following components:

1. Education for the identification and prevention/control of prevailing health challenges.
2. Proper food supplies and nutrition, adequate supply of safe water, and basic sanitation.
3. Maternal and childcare, including family planning.
4. Immunization against the major infectious diseases.
5. Prevention and control of locally endemic diseases.
6. Appropriate treatment of common diseases using appropriate technology.
7. Promotion of mental, emotional, and spiritual health.
8. Provision of essential drugs (WHO and UNICEF, 1978).[1]
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.[1]

Website: www.nabh.ind.in
DOI: 10.4103/2319-1880.174346
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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.
37

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Pandit, et al.: Quality in primary health

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 healthcare system can be defined as one that is accessible, appropriate,
available, affordable, effective, efficient, integrated, safe, and
patient related.[1]
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 populations 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.[2]
Quality of health-care services provided can be assessed along
the following dimensions:
1. Adequately equipped and easily accessible public health
facility.
2. Appropriate and timely clinical care.
3. 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[3] are as follows:
a. 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.
b. 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.[3]
c. Quality control: One of the major lacunae in Indias 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.
d. 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 peoples 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.[4]
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

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Pandit, et al.: Quality in primary health

of disease can be expected to rise dramatically if public

investment in the health sector is not raised significantly to
contain their spread.

2. Audits of health-care service delivery for better accountability;

and
3. Bi-annual evaluation of this process for greater transparency.

Information technology

Leadership

Indias 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.

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.[5]
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.

An example of such an innovation is the idea of an

Integ rated Health Management Infor mation 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.

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 Crche 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.[6] This will help to reduce the absenteeism of the
people from the work and improve the quality of the primary
health care.

[5]

Another example is of ASHA tracking system introduced in

PHCs 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.

Community participation
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
1. Strengthening Panchayat Raj Institutes for better designing
and management;
39

Financial incentives

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

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Pandit, et al.: Quality in primary health

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.

REFERENCES

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.

2.

1.

3.
4.

Financial support and sponsorship

Nil.

5.

Conflicts of interest

6.

There are no conflicts of interest.

Park K. Health Care of the Community. In: Park K, editor. Parks Text
Book of Preventive and Social Medicine. 20th ed. Jabalpur: Banarsidas
Bhanot; p. 780-800.
Yeravdekar R, Yeravdekar VR, Tutakne MA, Bhatia NP, TambeM.
Strengthening of primary health care: Key to deliver inclusive
healthcare. Indian J Public Health 2013;57:59-64.
Economic Survey 2013. Times of India; 2013.
Datta A. Indias Primary Health Care Needs Quick Reforms. Available
from:http://india.forbes.com/article/universal-health-care/indiasprimary-health-care-needs-quick-reform/34899/1. [Last accessed
on 2015 June 30].
Excellent Care for All. Available from: http://www.Health.gov.
on.ca, Feb 12, 2015 Ontario.caFranais.[Last accessed on
2015 July 16].
Bajpai N, Goyal S. Primary Health Care in India: Coverage and
Quality Issues. CGSD Working Paper No. 15. Colombia University.
New York. 2004.

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