Quality of Healthcare Services in Rural India: The User Perspective

R E S E A R C H includes research articles that focus on the analysis and resolution of managerial and academic issues based on analytical and empirical or case research Quality of Healthcare Services in Rural India: The User Perspective J K Sharma and Ritu Narang Executive Summary Developing nations have been focusing on relevant infrastructure, technology, disease control, and health outcomes in terms of deaths and disability-adjusted life years, largely ignoring the service quality aspect from the patient s viewpoint. However, researchers opine that real 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 including utilization of services, seeks involvement in issues directly related to them, enables the service provider to meet their expectations better, and provides relevant information to the policy makers to improve the quality. Some studies conducted in the recent years have made attempts to develop multi-dimensional scales and measure quality of healthcare services in the developing nations. The current study seeks to assess the perception of patients towards quality of healthcare services in rural areas of seven districts of Uttar Pradesh based on the scale developed by Haddad et al (1988) after making adjustment for Indian culture and language. 500 patients were contacted at the healthcare centres. A response rate of 79.2 per cent was obtained resulting in 396 complete questionnaires. The 23-item scale employed in the study comprised five homogeneous sub-scales and tested well for reliability. The findings illustrated some interesting differences in user perception regarding service quality and how they varied between different healthcare centres and according to the demographic status of patients. It was observed that: KEY WORDS Quality of Healthcare Services Primary Health Centres Community Health Centres Service Delivery User Perspective Rural India Policy-makers Healthcare delivery and financial and physical access to care significantly impacted the perception among men while among women it was healthcare delivery and health personnel 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 of delivery, the availability of various facilities and the interpersonal and diagnostic aspect of 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 services is perceived to be higher in Primary Healthcare Centres than in Community Healthcare Centres (CHCs). Inadequate availability of doctors and medical equipments, poor clinical examination and poor quality of drugs were the important drawbacks reported at CHCs. The current study demonstrates that the instrument employed was reliable and possessed the power to discern differences in the opinion of people on the basis of demographic factors and point out the quality differences in different healthcare centres. It could be employed to evaluate healthcare quality perception in other rural and urban regions of the country and to assess the perception of users towards private healthcare centres. Further, research could be conducted on price-quality relationship. The government and policy makers are urged to consider the perceptions of patients as well in order to affect improvement in the quality of services and subsequently increase their utilization. VIKALPA VOLUME 36 NO 1 JANUARY - MARCH 2011 51

The role of government in ensuring that its country s healthcare system provides optimal services for its population has been greatly emphasized upon (The World Health Report, 2000). Improvement in the quality of primary healthcare services apart from increasing accessibility and affordability has become a matter of grave concern for the developing nations in the recent years. However, the meaning of quality in healthcare system has been interpreted differently by different researchers. Ovretveit (1992) identified three stakeholder components of quality: client, professional, and managerial. From the client s viewpoint, it is the meeting of the patient s unique need and want (Atkins, Marshall and Javalgi, 1996) at the lowest cost (Ovretveit, 1992), provided with courtesy and on time (Brown et al., 1998) while professional quality involves carrying out of techniques and procedures essential to meet the client s requirement and managerial quality entails optimum and efficient utilization of resources to achieve the objectives defined by higher authorities. According to the Institute of Medicine (2001), quality in healthcare is, the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge. Meeting the objectives of both physicians and patients has been equated with the concept of quality in healthcare by some researchers (Morgan and Murgatroyd, 1994) while others have focused on user perception, technical standards, and provision of care (Boller et al., 2003; Hulton, Mathews and Stones, 2000). Quality of care comprises structure, process, and health outcomes (Peabody et al., 1999); and there are eight dimensions of healthcare service delivery: effectiveness, efficiency, technical competence, interpersonal relations, access to service, safety, continuity, and physical aspects of healthcare (Brown et al, 1998). The concept of quality is multifaceted connoting different meanings to different stakeholders such as government, service provider, hospital administration, and patients. NEED FOR STUDY Developing nations have been focusing on relevant infrastructure, technology, disease control, and health outcomes in terms of deaths and disability-adjusted life years, largely ignoring the service quality aspect from the patient s viewpoint. However, researchers opine that real improvement in quality of care cannot occur if the user perception is not involved (Thompson and Sunol, 1995). Patients perception is significant (Donabedian, 1980) as it impacts their health-seeking behaviour (National Commission on Macroeconomics and Health Report, 2005) including utilization of services (Haddad and Fournier, 1995; Reerink and Sauerborn, 1996), seeks involvement in issues directly related to them (Calnan, 1988), enables the service provider to meet their expectations better (Calnan, 1998), and provides relevant information to the policy makers to improve the quality. Studies in developing nations in Asia such as Sri Lanka (Akin and Hutchinson, 1999), Nepal (Lafond, 1995) and Bangladesh (Andaleeb, 2000) have confirmed the impact of perceived quality of healthcare services on the utilization. Evidently, quality of healthcare is important and demands continuous attention. Keeping this in mind, the current study aims to measure the perception of users availing rural healthcare services in India with a view to provide valuable information to the policy makers about the areas that need attention for improvement in quality of healthcare. Furthermore, it seeks to further develop an analytical framework for the measurement of perceived quality of healthcare. METHOD Instrument for Survey The most popular tool for measuring quality has been SERVQUAL which was developed by Parasuraman, Zeithaml and Berry, (1985) and has been applied in various businesses including industrial, commercial, noncommercial, and services settings (Babakus and Mangold, 1992; Dabholkar, Thorpe and Rentz, 1996; Kang and Kostas, 2002, Seock-Jin and ll-soo, 2006). However, despite its extensive application, SERVQUAL has been criticized on both theoretical and operational aspects (Babakus and Mangold, 1989; Carman, 1990; Cronin and Taylor, 1992; Redman and Mathews, 1998). The problems related to measurement have also been cited in the context of hospitals (Reidenbach and Sandifer- Smallwood, 1990). Some studies conducted in the recent years have made attempts to develop multi-dimensional scales and measure the quality of healthcare services in the developing nations. Andaleeb (2000) explored five dimensions of perceived quality of care: responsiveness, assurance, communication, discipline, and bribe money paid to health staff in a study conducted in Bangladesh. Haddad, Fournier and Potvin (1998), developed and validated a 52 QUALITY OF HEALTHCARE SERVICES IN RURAL INDIA: THE USER PERSPECTIVE

20-item instrument for use in Guinea. The dimensions included in the study were healthcare delivery, personnel, and health facility. Later, Baltussen et al (2002) adapted this scale in the context of Burkina Faso and identified four dimensions of healthcare quality: health personnel and conduct, adequacy of resources and services, healthcare delivery, and financial and physical accessibility. Duong et al. (2004) have also demonstrated the feasibility, reliability, and validity of the instrument developed by Haddad, Fournier and Potvin (1998) in the context of rural Vietnam. They identified four factors to measure the client perceived quality: healthcare delivery, health facility, interpersonal aspects of care, and access to services. The research tool employed in the present study is based on the scale provided by Haddad, Fournier and Potvin (1988) to assess the perception of patients towards quality of healthcare services after making adjustment for Indian culture and language. A qualitative study comprising six focus group discussions and twelve in-depth interviews was conducted to identify whether the 20-item scale developed by Haddad, Fournier and Potvin (1998) was relevant to rural India. The participants comprised those who had visited the public hospital in the last six months and thus were representatives of the patients experiencing healthcare services in government hospitals. The findings of the qualitative research revealed conceptual similarity in the perception of the patients in Guinea, Burkina Faso, and Vietnam. Though there was considerable overlapping between the original items and those identified by the Indians, some modifications were made to the original scale to reflect the Indian context. The generated items with Eigen value of more than 1 were included resulting in 23 items. Each scale item comprised five opinions that ranged from a score of -2 for very unfavourable, -1 for unfavourable, 0 for neutral, +1 for favourable, and +2 for very favourable. Studies have reported positive impact of quality care on demand (Akin and Hutchison, 1999; Andaleeb, 2000) or repeat/future visits. So, questions regarding overall quality of services provided by the healthcare centres and the intention to repeat visit were asked to establish the relationship between quality of services and repeat visits. The second part of the questionnaire solicited information pertaining to demographic characteristics. The questionnaire was then translated from English to Hindi, the principal language of Uttar Pradesh. It was pre-tested to ensure that the wording, sequencing of questions, length, and range of scale were appropriate. Low level of literacy and negligible exposure to this kind of study made it difficult for respondents to comprehend the scale. It was therefore, adapted to a money scale : zero paisa (very unfavourable), 25 paisa (unfavourable), 50 paisa (neutral), 75 paisa (favourable), and 100 paisa (very favourable) for the purpose of administering the questionnaire. Subjects The study was conducted in the rural areas of the districts of Gonda, Pratapgarh, Sitapur, Hardoi, Varanasi, Gorakhpur, and Bareilly in the state of Uttar Pradesh. One Community Health Centre (CHC) and two Primary Health Centres (PHCs) were selected at random from each of these districts. A sample size of 500 was distributed among these districts in proportion to the rural population of the respective district. This meant that 14 per cent of the respondents were drawn from Gonda, another 14 per cent from Pratapgarh, 17 per cent from Sitapur, 16 per cent from Hardoi, 10 per cent from Varanasi, 16 per cent from Gorakhpur, and the remaining from Bareilly. The respondents comprising both OPD (Outpatient Department) and IPD (Inpatient Department) patients were selected in a purposive manner ensuring that they had utilized the healthcare services at the public healthcare centres within the last six months. Before administering the questionnaire, the meaning of the scale was explained to them. The representation of scale in the form of money was easier for the respondents to comprehend. Despite tremendous efforts made by the researcher, a response rate of 79.2 per cent was obtained resulting in 396 complete questionnaires. RESULTS Scale Properties Factor analysis technique was employed to examine the structure of the relationship among variables representing the perceived quality dimensions of healthcare services in India. Prior to running the factor analysis, the Kaiser-Meyer-Olkin (KMO) measure of sampling adequacy and the Bartlett s test of sphericity were performed. The generated score of KMO was 0.92 and highly significant Bartlett s test of sphericity supported the appropriateness of using factor analysis to explore the underlying structure of perceived quality of healthcare services. An Eigen value greater than 1 criterion was employed for VIKALPA VOLUME 36 NO 1 JANUARY - MARCH 2011 53

determining the number of factors. In order to obtain more interpretable results solution, Varimax rotation was used to rotate the solution. This caused the loadings to be distributed among the selected factors making it easier to interpret results. Factor loadings of 0.5 or greater on a factor were regarded as significant. As shown in Table 1, the factor analysis of the 23-item scale on the basis of principal component extraction by using Varimax rotation converged in sixteen iterations and resulted in five homogeneous sub-scales with the Eigen values of 4.127, 3.817, 3.798, and 2.440. The total variance explained after rotation was 74.216 per cent with the communalities after extraction ranging from 0.592 to 0.829. SPSS version 13 software was used for performing all statistical analysis. The factors so obtained were named in accordance with the nature of their underlying construct keeping in mind the statements that had higher loading on a specific factor. Subsequently, they were named healthcare delivery, interpersonal and diagnostic aspect of care, facility, health personnel conduct and drug availability, and financial and physical access to care. The first subscale with Cronbach alpha 0.92 included seven items related to healthcare delivery (HCD): adequate availability of doctors, good diagnosis, satisfaction 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. 54 QUALITY OF HEALTHCARE SERVICES IN RURAL INDIA: THE USER PERSPECTIVE

pect of care (IDC) with Cronbach alpha 0.91 comprised five items: overall reception facility, honesty, good clinical examination, follow-up/monitoring of patients, adequate medical equipment. The third subscale, facility with Cronbach alpha 0.85, included five items: adequacy of rooms, adequate availability of doctors for women, neat and clean hospital premises, clean appearance of staff, and proper disposal of waste. The fourth subscale with Cronbach alpha 0.84 contained three items related to health personnel conduct and drug availability (HPCDA): compassion and support, adequate respect to patients, and availability of all drugs. The last subscale, financial and physical access to care (FPAC) with Cronbach alpha 0.71, comprised three items: financial feasibility of treatment, ease of obtaining drugs, and easy approachability. The scale was tested for reliability. It had an overall Cronbach s alpha value of 0.96 that ranged from 0.706 to 0.919 for the subscales. The reliability was highest for interpersonal and diagnostic aspect of care (0.92) and lowest 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 in Table 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 *1 US dollar = Rs. 50 approximately >30 years 219 55.30 The intention of the patients to repeat visit was regressed against overall quality score as well as scores for different components of quality in order to determine differences in perceptions among respondents relative to demographic characteristics and healthcare centres. For this purpose, a linear regression model was employed to study the relationship between the intention to repeat visit (dependent variable) at the public healthcare centre and the components of health service quality (independent variables). The findings indicate that the socio-economic profile of the respondents and the healthcare setup was significantly associated with the perception regarding quality 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 to be significantly associated with the intention to repeat visit. It was observed that healthcare delivery and financial and physical access to care significantly impacted the outcome among men while among women it was healthcare delivery and health personnel conduct and drug availability. The finding that among <30 year age group, it is the financial and physical accessibility of the service that is associated with the outcome, implies that the low-cost structure and relative nearness of these facilities are most important factors with no association being shown with any of the other mooted components. Interestingly, among the IPD (Inpatient Department) patients, the variables interpersonal and diagnostic aspect of care, facility, and health personnel conduct and drug availability along with healthcare delivery were significantly associated whereas financial and physical access to care was not, thus implying that when the patient had to be admitted into the hospital, the financial and physical accessibility took a back seat while for OPD (Outpatient Department) patients, healthcare delivery and financial and physical access to care were most significant. The outcome variable showed varying association with the components of quality for different income groups. All the dimensions except health personnel conduct and drug availability showed significant association for respondents with income above Rs 3,000 per month. It is inevitable that with growing income levels, more options are available to patients thereby affecting their intention to repeat visit. For illiterates, only healthcare delivery is significant but as the level of education increases, other variables such as interpersonal and diagnostic aspect of care and financial and physical access to care also gain priority. In Primary Health Centres, healthcare delivery, health personnel conduct and drug availability, and financial and physical access to care were found to be significantly associated with the outcome while in community health centres, only financial and physical access to care was statistically significant. VIKALPA VOLUME 36 NO 1 JANUARY - MARCH 2011 55

Table 3: Components of Perceived Quality that Impact Repeat Visit Relative to Demographic Characteristics and Health 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 Perceived Quality of the Health Centres Student s t-test was conducted to identify differences between primary and community health centres. A very surprising finding which came to the fore was that the overall quality of healthcare services was perceived to be higher in primary health centres than in community health centres (Table 4). Statistically significant differences were observed on healthcare delivery with low scores being recorded for all the variables for community health centres. Inadequate availability of doctors (p= 0.023) and poor quality of drugs (p= 0.009) were the most important drawbacks reported at these centres. Furthermore, in comparison to primary health centres, poor clinical examination (p= 0.043) and inadequate availability of medical equipments (p=0.001) were found at the community health centres. However, inadequate availability of doctors for women was perceived at primary health centres (mean score of -0.09) than at community health centres. No statistically significant differences were detected for the factor health personnel conduct and drug availability. There were statistically significant differences for the subscale financial and physical access to care. It was interesting to observe that patients perceived it easier to obtain drugs and approach the primary health centres and found the financial feasibility to be low in the community health centres. DISCUSSION AND CONCLUSION The study examines the quality of primary healthcare services in rural areas in the state of Uttar Pradesh in India by using a 23-item scale. This scale was based on a 20-item instrument developed and validated for use in Guinea by Haddad, Fournier and Potvin (1998) and adapted to reflect the Indian context. The adapted scale included three more variables, namely, neat and clean hospital premises, clean appearance of staff, and proper disposal of waste. These factors had emerged after focus group discussions and in-depth interviews. The scale tested well for reliability with an overall Cronbach s alpha value of 0.96. Another study (Dhar, 1979) conducted in India had also considered general cleanliness as an important factor for utilization of services. Explaining the meaning of scale was found to be difficult at the time of testing the scale and hence it was modified in the form of money scale which the respondents found easier to comprehend. The mean scores were reported to be positive for all the factors; being high for interpersonal and diagnostic aspect of care (0.096) and financial and physical access to care, (0.821), low for healthcare delivery system, (0.414) and very low for health personnel conduct and drug availability (0.296) and facility (0.156). The survey illustrated some interesting differences in user perception regarding service quality components that 56 QUALITY OF HEALTHCARE SERVICES IN RURAL INDIA: THE USER PERSPECTIVE

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. impacted their intention to repeat visit and how they varied between different healthcare centres and according to the demographic status of patients. Impact of demographic factors such as age, gender, and education on utilization of healthcare services has been reported by other studies as well (Feldstein, 1979; Pathak, Ketkar and Majumdar, 1981; Garg, 1985; Faizi, 1996). It was observed that healthcare delivery and financial and physical access to care significantly impacted the perception among men while among women it was healthcare delivery and health personnel conduct and drug availability. It may be noted that in rural India, it is the man who is expected to provide for various expenses of the family and make transportation arrangements to the hospitals for the patient. This has got reflected in the findings of the study. Women, on the other hand, are emotional and expect compassion and empathy at the place of treatment. 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 of delivery, the availability of various facilities, and the interpersonal and diagnostic aspect of care as well that mattered to the people with enhanced economic earnings. However, it was surprising to observe that illiterates and those with less education did not consider financial and physical access to the centres important VIKALPA VOLUME 36 NO 1 JANUARY - MARCH 2011 57

and were willing to travel great distances for treatment. Overall this suggests that with improvement in socio-economic status, various aspects of service quality assume importance for the optimal utilization of services and the policy makers need to be sensitive about it. It has been observed that though the Indian government has made efforts to set up a vast network of healthcare centres in deep interior regions of rural areas, their importance is declining due to neglect of service quality (Bhandari, 2006). Another interesting finding that emerged was with respect to IPD and OPD patients and their intention to visit the health centre in future. For those visiting the hospital for minor health problems, physical and financial access to health centres, availability of doctors providing sufficient time, and satisfactory prescription to help them recover fast were more important than other factors. However, for those requiring hospitalization, physical and financial access became unimportant while all other aspects of service assumed great significance. This is another lesson for service providers. What was most astonishing was the finding that the overall quality of healthcare services is perceived to be higher in primary health centres than in community health centres. Inadequate availability of doctors and medical equipments, poor clinical examination, and poor quality of drugs were the important drawbacks reported at community health centres. This appears shocking as community health centres form the uppermost tier of the primary healthcare system in the country and therefore medical specialists comprising surgeon, physician, gynaecologist, and pediatrician supported by twenty-one paramedical and other staff are supposed to be in charge of each community health centre whereas just one medical officer supported by fourteen paramedical and other staff is in charge of the primary health centres. However, the current 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 per cent of the sanctioned posts of specialists at community health centres were vacant in 2005 and the absenteeism rate among the primary health providers in India was the highest (40%) among the surveyed countries (Chaudhury et al., 2006). The fact that the patients opined that the financial feasibility was low in community health centres in comparison to primary health centres need further exploration. As these centres are government-owned, only a nominal amount is charged for the various medical facilities. This finding contradicts the government s objective of making the health facility available at a very low cost to the common man. The inadequate availability of doctors for women was also reported at primary health centres. It may be pertinent to note that there is no provision for gynaecologists at these centres. The current study demonstrates that the instrument employed was reliable and possessed the power to discern differences in the opinion of people on the basis of demographic factors and point out the quality differences in different healthcare centres. The selection of the respondents on the basis of convenience may have limited the precision of the study but the findings urge the government and policy makers to consider the perceptions of patients as well in order to affect improvement in the quality of services and subsequently increase their utilization. Immediate steps need to be undertaken to ensure availability of doctors, medical equipments, and good quality of drugs. The study was however, limited to certain areas of Uttar Pradesh. Therefore, it is suggested that similar studies be carried out in other rural and urban regions of the country and include the private healthcare service providers as well. Further, researches could be conducted on price-quality relationship. REFERENCES Akin, J and Hutchison, P (1999). Health Care Facility Choice and the Phenomenon of Bypassing, Health Policy and Planning, 14, 135-151. Andaleeb, S S (2000). Public and Private Hospitals in Bangladesh: Service Quality and Predictors of Hospital Choice, Health Policy and Planning, 15(1), 95-102. Atkins, P M; Marshall, B S and Javalgi, R G (1996). Happy Employees Lead to Loyal Patients, Journal of Health Care Marketing, 16(4), 14-23. Babakus, E and Mangold, W G (1989). Adapting the SERVQUAL Scale to Health Care Environment: An Empirical Assessment, Health Services Research, 26(6), 767-786. Babakus, E and Mangold, W G (1992). Adapting the SERVQUAL Scale to Hospital Services: An Empirical Investigation, Health Services Research, 26(6), 767-786. Baltussen, R M; Ye, Y; Haddad, S and Sauerborn, R S (2002). Perceived Quality of Care of Primary Health Care Ser- 58 QUALITY OF HEALTHCARE SERVICES IN RURAL INDIA: THE USER PERSPECTIVE

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SERVQUAL Approach, Journal of Health Care Marketing, 10(4), 47-55. Seock-Jin, Hong and ll-soo, Jun (2006). An Evaluation of the Service Quality Priorities of Air Cargo Service Providers and Customers, World Review of Intermodal Transportation Research, 1(1), 55-68. The World Health Report (2000). Health Systems: Improving Performance, Geneva: World Health Organization. Thompson, A G H and Sunol, R (1995). Expectations as Determinants of Patient Satisfaction: Concepts, Theory and Evidence, International Journal of Quality Health Care, 7, 127-141. J K Sharma is a Professor in Business Administration at the University of Lucknow, India. He has twenty-two years of academic and research experience and has international teaching experience as Assistant Professor in Hampton Business School, Virginia, USA. His areas of specialization include Strategic Management, Managerial Accounting, and Finance. e-mail: jkbaba@yahoo.com Ritu Narang is an Assistant Professor at the Department of Business Administration, University of Lucknow and her current areas of interest include services marketing, consumer behaviour, and retail business. She has been a Senior Distinguished Fellow at Hanken School of Economics, Finland and has recently completed a major Research Project sponsored by the University Grants Commission, Delhi. She has presented papers at various national and international conferences and has a number of publications to her credit. She has been involved in delivering invited talks to managers of public and private sector organizations. e-mail: ritu_vnarang@yahoo.co.in 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 60 QUALITY OF HEALTHCARE SERVICES IN RURAL INDIA: THE USER PERSPECTIVE