Department of International Health

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
Control (117) DH 25, FDH 25 CHC 27, PHC 30
Project (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
Distribution of New OPD Visits at CHC by Wealth
Quintile 2002
Project Concentration Index -0.08 Control
Concentration Index -0.10
13
Distribution of New OPD Visits at District
Hospital by Wealth Quintiles 2002
Project Concentration Index 0.33 Control
Concentration Index 0.23
14
Patient Satisfaction at Project and Control
Facilities, 1999-2003
15
Changes in Patient Satisfaction By Level of
Facility
0.70

p-value lt 0.01 p-value lt 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
16
Changes in Level of Satisfaction By Caste Type
of Facility
0.80

p-value lt 0.01 p-value lt 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
17
Changes in Level of Satisfaction By Type of
Housing Type of Facility
1.60

p-value lt 0.01 p-value lt 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
18
Distribution of Patient Satisfaction at CHCs by
Quintile 2003
19
Project Impact on Patient Satisfaction Using
Propensity Score Matching
20
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