B.V. Babu, G.R. Varma, A.N. Nayak and K.

Rath Utilisation of Primary Healthcare Services

Utilisation of Primary Healthcare Services

Experiences and Perceptions of a Rural Community
in East Godavari District
B.V. BABU, G.R. VARMA, A.N. NAYAK AND K. RATH

The present study intends to assess the utilisation of and satisfaction on government
healthcare system by the community in East Godavari district of Andhra Pradesh,
India. The study is a community-based, cross-sectional study utilising both
quantitative and qualitative methods. Majority of the people said that the visits of
peripheral health workers were regular and their services were relevant to the needs
of the people. More women are satisfied with these services than men. Almost 60 per
cent of people are satisfied with the services available at different healthcare
institutions. The qualitative data revealed that some members of the vulnerable
communities expressed their dissatisfaction with the healthcare providers by citing
incidences of discrimination due to caste and economic condition. Some respondents
of the present study were also dissatisfied with the functioning of the health services,
and with the attitude of healthcare providers at different health institutions.
Functioning of the primary health centre (PHC) system and the attitude of the staff
were reasons for dissatisfaction of the people of this area. Though the health outreach
of rural Andhra Pradesh is better than the national scenario, to improve further, the
attitude of the staff of PHCs should be reoriented. Discrimination between different
economic/ethnic groups has a great impact on health outreach in toto. A substantial
number of people have no trust on the local health system by virtue of which they
prefer the services of private practitioners. Therefore, confidence-building measures
should be taken by providing ‘quality healthcare services’ at the PHC level.
Dr. B.V. Babu is Assistant Director (Social Science), Mr. G.R. Varma is Research
Assistant in WHO/TDR Project, and Mr. A.N. Nayak and Ms. K. Rath are Senior
Research Fellows in Division of Epidemiology, Regional Medical Research Centre,
Indian Council of Medical Research, Bhubaneswar, Orissa, India.

INTRODUCTION
India being the largest democracy in the world, with a sheer size of its
population characterised by diversity, initiated the process of planned
development to raise the living standard of its people, soon after its
Independence. Establishment of primary health centres (PHC) in
community development blocks was an integral part of the community
development programme, launched in the year 1952 on the basis of the
recommendations of the Bhore Committee with the aim to spread the
modern medicine in rural areas. One of the important
recommendations of the Bhore Committee was to establish first level
referral centres, the PHC, which was to cover only a population of
236 B.V. Babu, G.R. Varma, A.N. Nayak and K. Rath

10,000 and to have six doctors (including various medical specialists),

75 beds and public health staff for preventive care (India, 1946).
Altogether, during the First Five-Year Plan of Independent India, 725
PHCs were established. Each PHC complex, located at the
headquarters of the community development block, consisted of the
main centre with six beds and four sub-centres, one medical officer, one
sanitary inspector, four midwives and two ancillary persons (India:
Office of the Director-General of Health, 1998). Subsequently,
extensive changes and extension in stages have occurred in the
organisation and infrastructure of health services following the review
of a number of expert committees worked on the utilisation pattern of
health system. As a signatory of the Alma Ata Declaration of 1978,
India was committed to attain the goal of ‘Health for All’ by the year
2000, through its primary healthcare approach (World Health
Organisation, 1978). Thus, national health policies, which the
government adopts periodically, have provided the necessary direction
for reorienting and restructuring the health services with long term
perspectives. Recent national health policy had laid stress on the
provision of preventive, promotive and rehabilitative health services
and works with an objective to place the health of the people in the hand
of the people through primary healthcare approach (India: Office of the
Director-General of Health, 1998). An alternative model has also been
recommended by the joint committee of the Indian Council of Medical
Research (ICMR) and Indian Council of Social Science Research
(ICSSR) to provide adequate, efficient and equitable referral services to
the people and to integrate promotive, preventive and curative aspects
of health after analysing the situation where 85 per cent of the
population have no access to any form of healthcare (ICSSR and ICMR,
1980).
For the majority in India, primary healthcare is provided by PHCs
and their sub-centres with community participation. However, various
components of primary healthcare system like curative services,
availability of facilities and drugs, preventive activities, attitude of the
health personnel towards the people, visits of the peripheral health
workers, and so on, need appropriate evaluation through both
quantitative and qualitative approaches. Therefore, the present paper
aimed to study the utilisation of government health services as viewed
by the community in the rural areas of East Godavari district of south
India.

METHODS

Study Area
The present study was undertaken in the East Godavari district of
Andhra Pradesh, a southern state of India. The population of East
Godavari district is 75.7 million (India: Office of the Registrar-General,
 Utilisation of Primary Healthcare Services 237

2001). The Government of India categorised some castes into Scheduled

Castes (SCs) and Backward Castes (BCs). The SCs include the castes
that were once considered as untouchables, and the BCs are a mixed
group of artisan and servicing castes. These categories are entitled to
receive positive discrimination in educational, employment and other
developmental opportunities to raise their status. The literacy rate of
the district is 65.5 per cent, which is nearer to the figures of Andhra
Pradesh (61 per cent) and India (65 per cent) (India: Office of the
Registrar-General, 2001). The National Family Health Survey-2
(NFHS-2) survey indicated an infant mortality rate of 66 per 1,000 live
births in Andhra Pradesh, and for 1996–2001, life expectancy is
projected to 61.6 years for males and 63.7 years for females (NFHS-2:
Andhra Pradesh, 2000). The district is divided into 62 community
developmental blocks (mandals) and each block bases a PHC. Each
PHC covers a population of 40,000–60,000 and each PHC consists of
12–15 sub-centres and each sub-centre covers upto three villages and a
population of 5,000. At the sub-centre level, one or two peripheral
health workers exist, while at the PHC level, medical doctors and other
paramedical staff undertake both curative and preventive services.

Data Collection and Analysis

The data for the present paper were drawn from 12 villages sampled
from four blocks of the district during September–October, 1999. From
each block, one PHC village, one sub-centre village, and one village
having neither a PHC nor a sub-centre were selected randomly. The
data were of both quantitative and qualitative type. Quantitative data
were collected from 582 respondents (289 men and 293 women) of all
communities using a pre-tested interview schedule. The respondents
were selected randomly from all parts of the village to cover all
communities. The schedule consisted of close-ended questions with
three to four alternative responses. The questions related to the
problems faced at the health centres were open-ended. Responses
elicited were categorised during analysis. Equivalent narrations of
problems were pooled and percentages were calculated. The
quantitative data were processed and analysed by using Epi-Info 6
(Epidemiology Programme Office, Centre for Disease Control, Atlanta
and The Global Programme on AIDS, World Health Organisation,
Geneva, Switzerland). The qualitative data were obtained through
in-depth interviews and focus group discussions. From each block, six
in-depth interviews were conducted with key informants in the village,
such as community leaders, members of the local administrative
bodies, and teachers (Lengeler, Mashinda, Savigny, Kilima, Morona
and Tanner, 1991; Pelto and Pelto, 1978). In addition, nine focus group
discussions per block were conducted with members of vulnerable
communities, namely the SCs and BCs, to elicit their perceptions
(Khan, Anker, Patel, Barge, Sadhwani and Kohle, 1991; Kline, Kline
238 B.V. Babu, G.R. Varma, A.N. Nayak and K. Rath

and Oken, 1992). The in-depth interviews and focus group discussions
were recorded by note-taking and audio cassette recording. At the end
of each interview/discussion, the audio cassettes were played back and
the text was transcribed along with field notes. These notes were
entered into a personal computer in a word processor and were
analysed by using Textbase Beta (Centre for Qualitative Research,
Institute of Psychology, Aarhus University, Risskov, Denmark).

RESULTS
The quantitative data obtained through the study is analysed and
presented in Table 1. The respondents were enquired about various
aspects of services they are receiving from the PHC and sub-centre as
well as from health workers. From the analysis of quantitative data, it
is evident that, majority of people are satisfied with the visits of health
workers to their locality.

TABLE 1: Responses on Functioning of Peripheral Health Workers and

Health Institutions by Gender

Responses regarding health service Men Women Total

(n=289) (n=293) (n=582)
How often does a government health worker visit your part of village?
Regularly 210 (72.66) 204 (69.62) 414 (71.13)
Once in a while 65 (22.49) 75 (25.60) 140 (24.05)
Rarely 14 (4.84) 14 (4.84) 28 (4.81)
Are the services of government health workers relevant to your need?
Yes 228 (78.89) 242 (82.59) 470 (80.76)
No 50 (17.30) 45 (15.36) 95 (16.32)
Don’t know 11 (3.81) 6 (2.05) 17 (2.92)
Are the services of government health worker satisfactory?
Yes 226 (78.20) 239 (81.57) 465 (79.90)
No 55 (19.03) 46 (15.36) 95 (16.32)
Don’t know 8 (2.77) 8 (2.73) 16 (2.75)
When did you or any of your family last visit a government health facility?
In the last month 88 (30.45) 102 (34.81) 190 (32.65)
More than a month ago 116 (40.14) 116 (39.96) 232 (39.86)
Never visited 85 (29.41) 75 (25.60)) 160 (27.49)
Are the services of the government health facility relevant to your need?
Yes 176 (60.90) 176 (60.07) 352 (60.48)
No 79 (27.34) 79 (29.96) 158 (27.15)
Don’t know 34 (11.76) 38 (12.97) 72 (12.37)
Are the services at the government health facility satisfactory?
Yes 184 (63.67) 176 (60.07) 360 (61.86)
No 75 (25.95) 75 (25.60) 150 (25.77)
 Utilisation of Primary Healthcare Services 239

Responses regarding health service Men Women Total

(n=289) (n=293) (n=582)
Don’t know 30 (10.38) 42 (14.33) 72 (12.37)
Are you facing these problems at the government health facility?
Waiting period too long 21 (7.27) 13 (4.44) 34 (5.84)
Too far away 19 (6.57) 42 (7.85) 42 (7.22)
Medicines not available 26 (9.00) 18 (6.14) 44 (7.56)
Timing out convenient 3 (1.04) 3 (1.02) 6 (1.03)
Staff is rude 2 (0.69) – 2 (0.34)
Staff is absent 4 (1.38) 2 (0.68) 6 (1.03)
Services are expensive – – –
No trust/confidence on government health 17 (5.88) 17 (5.80) 34 (5.84)
service
Others 88 (30.45) 109 (37.20) 197 (33.85)
Don’t know 11 (3.81) 10 (3.41) 21 (3.61)

Source: Figures in parentheses indicate percentage.

Around 71 per cent people said that the health worker visits their area
regularly and more than 80 per cent of people thought that the services
provided by the health workers were relevant to their needs. However,
only 16 per cent people did not agree and opined that the services of
health workers were not relevant to their needs. Around 80 per cent
people were satisfied with the services of health workers. With regard to
the functioning of PHCs and sub-centres, it was observed that more than
one-fourth of respondents had never visited either a PHC or sub-centre.
Around 60 per cent of those visited have opined that services provided by
government health institutions are relevant to their needs and the same
number of people (61 per cent) is satisfied with the services. But around
60 per cent of people have stated different problems experienced
particularly at PHCs. They include non-availability of staff,
non-availability of medicines, lack of confidence on government health
services, and so on. There are no gender differences in these findings. We
attempted to know whether any discrepancies existed among SCs and
BCs (Table 2). No significant differences have been noticed with regard
to the services of peripheral health workers or health institutions.
TABLE 2: Responses on Functioning of Peripheral Health Workers and
Health Institutions by Groups of the Community

Responses regarding health service Men Women Total

(n=289) (n=293) (n=582)
How often does a government health worker visit your part of village?
Regularly 67 (68.37) 165 (70.82) 175 (72.31)
Once in a while 24 (24.49) 61 (26.18) 53 (21.90)
Rarely 7 (7.14) 7 (3.00) 14 (5.79)
240 B.V. Babu, G.R. Varma, A.N. Nayak and K. Rath

Responses regarding health service Men Women Total

(n=289) (n=293) (n=582)
Are the services of government health workers relevant to your need?
Yes 79 (80.61) 182 (78.11) 200 (82.64)
No 19 (19.39) 55 (19.31) 31 (12.81)
Don’t know – 6 (2.58) 11 (4.55)
Are the services of government health worker satisfactory?
Yes 75 (76.53) 184 (78.11) 197 (81.40)
No 23 (23.47) 41 (17.60) 37 (15.20)
Don’t know – 8 (3.43) 8 (3.31)
When did you or any of your family last visit a government health facility?
In the last month 28 (28.57) 80 (34.33) 76 (31.40)
More than a month ago 53 (54.08) 76 (32.62) 126 (52.07)
Never visited 17 (17.35) 77 (33.05) 64 (26.45)
Are the services of the government health facility relevant to your need?
Yes 58 (59.18) 130 (55.79) 155 (64.05)
No 37 (37.76) 70 (30.04) 51 (21.07)
Don’t know 3 (3.06) 33 (14.16) 36 (14.88)
Are the services at the government health facility satisfactory?
Yes 57 (58.16) 134 (57.51) 160 (66.17)
No 38 (38.78) 66 (28.33) 46 (19.01)
Don’t know 3 (3.06) 33 (14.16) 36 (14.88)
Are you facing these problems at the government health facility?
Waiting period too long 9 (9.18) 10 (4.29) 15 (6.20)
Too far away 10 (10.20) 12 (5.15) 20 (8.26)
Medicines not available 13 (13.27) 10 (4.29) 21 (8.68)
Timing out convenient – 5 (2.15) 1 (0.41)
Staff is rude 2 (2.04) – –
Staff is absent 4 (4.08) – 2 (0.83)
Service are expensive – – –
No trust/confidence on government health 1 (1.02) 23 (9.87) 10 (4.13)
service
Others 21 (21.43) 95 (40.77) 72 (29.75)
Don’t know – 6 (2.58) 15 (6.20)

Source: Figures in parentheses indicate percentage.

 Utilisation of Primary Healthcare Services 241

In addition to the quantitative data, an attempt was made to

understand people’s perceptions on the services of health workers and
health institutions through in-depth interviews of key informants and
focus group discussions with different groups of people. The
information obtained from the key informants substantiates the
findings of household sample survey. Most of the key informants
reported that the health workers visited the village regularly and asked
about the health condition of the people. But during her visit she gave
importance to pregnant women and the family planning programme.
She encouraged people to adopt contraception to control their family
size. However, some key informants were not satisfied with the role of
health workers. One of the informants remarked negatively: ‘The ANM
[auxiliary nurse-midwife] comes once in 15 days. She asks about health
problems, but she doesn’t give any medicine’. Of course, the
respondents were aware of some of the activities of health workers.
They expected that the health workers should provide vaccines to
children and pregnant women. They also think that the health worker
should motivate people for family planning. But it has been found that
the health workers failed to satisfy some sections of people. Though the
discrimination on caste lines is not visible in the quantitative data,
these feelings are unveiled during qualitative surveys. One SC youth
reported, ‘The ANM comes occasionally, once in a month. She doesn’t
come to our houses because our houses are at the end of the village and
we are untouchables. But if we call she comes reluctantly’. Though this
number is small, some people are not satisfied with the way of ANM
worked. One key informant said, ‘The ANM never comes to our village,
we only go to her for treatment, if we need it. But she comes to us for the
polio vaccination programme. But for other types of diseases, she tells
the villagers to come to her house’.
With respect to the functioning of health facilities (PHCs or health
sub-centres), the information obtained from key informants revealed
that a majority of the population availed government health facilities,
though some people reported that they had no faith on the treatment
available at government health institutions. Generally, the poor people
utilise the government health facilities and some are dissatisfied with
the services provided by these government health centres. Some key
informants and participants of focus group discussions reported the ill
behaviour of healthcare providers, non-availability of medicine and
practice of bribing at government health institutions. Majority of the
informants voiced the non-availability of medicines; one respondent
voiced his agony: ‘The hospital is meant for rich people. If the higher
caste or rich people go to the hospital they provide proper care. For the
labourer it is not a hospital. The pharmacist scolds us when we go there.
He tells, “You are coming daily for medicines”.’ Regarding health
services at government hospitals, another young respondent said: ‘No
service is available in the hospital without giving a bribe’. Regarding
242 B.V. Babu, G.R. Varma, A.N. Nayak and K. Rath

the district hospital, an elderly old person expressed, ‘Usually we go to

the Kakinada General Hospital. We have to give bribe even to the gate
keeper to enter into the hospital. They don’t treat us properly. They ask
us to come repeatedly’.
The focus group discussions with the SC and BC members revealed
that majority of these communities were utilising the services of
government health institutions. Though sporadic, a few participants
reported incidences of discrimination between the rich and poor and
discrimination on the basis of caste by healthcare service providers.

DISCUSSION

Rural health services in India are provided through a network of

integrated health and family welfare delivery system. These are mainly
dependent upon networking of PHCs, which involve in both curative
and preventive activities as well as promoting family welfare services.
The PHCs are the first contact point between the village community
and the medical officer, whereas sub-centres are the most peripheral
contact point between the PHC and the community. Lack of access to
these institutions is a reflection of an overall deprivation and it results
on many health indicators. Many studies indicated that the health
services are inaccessible or poorly accessible for the poor and
disadvantaged communities of the society (Babu, Chhotray, Hazra and
Satyanarayana, 2000 and 2001; Ghosh and Mukherjee, 1989; Goyal,
1990; Kumar, 1982). To make the health facilities more accessible, the
government has taken initiatives to establish sub-centres and PHCs
within the reach of the people. Though a total of 1,335 PHCs and 10,568
sub-centres were functioning in Andhra Pradesh (India: Office of the
Director-General of Health, 1998), people are far reaching from the
government health services. During the study, many people reported
troubles, which are attributable to the distance of health centre. Many
studies have shown that great majority of those who do make use of the
PHC services come from villages within a radius of only a few
kilometres (Chuttani, 1976). Banerji (1982) assessed the average
distance from any particular village to PHC is in between 10 and 15
kilometres. For simple symptomatic treatment or preventive care, the
journey to these health institutions is very affordable to people of low
socioeconomic status in terms of loss of wages and travel costs. Duggal
(1994) opined that PHCs are usually under-utilised because they fail to
provide their clients with the desired amount of attention and
medication, inconvenient locations, and long waiting time. Utilisation
of health services is a complex phenomenon, which is affected by
various factors: people’s perception about illness, severity of illness,
need for healthcare, knowledge about healthcare services, economic
and social accessibility of health system, and biases of the healthcare
providers (Madhiwalla, Nandraj and Sinha, 2000).
 Utilisation of Primary Healthcare Services 243

Functioning of PHCs and the attitude of the staff of the health

institutions are some other reasons for the dissatisfaction of the people
of this area. Some people complained that the PHCs did not have the
required medicines and the staff demanded bribes from the people.
Though the health outreach of rural Andhra Pradesh is better than the
national scenario, the attitude of the PHC staff, including peripheral
health workers, should be reoriented. Discrimination between different
economic classes and ethnic groups has a great impact on health
outreach in toto. Therefore, after understanding the realities of the
present health situation, attempts should be made to provide ‘equity in
health’. Otherwise people will lose faith in the existing healthcare
system. The PHCs should be well equipped to provide health services at
the peripheral level. Further, from our findings, it is also clear that a
substantial number of people have no trust in the local health centres
by virtue of which they prefer the health service of private
practitioners. Therefore, confidence-building measures should be taken
among the people by providing ‘quality healthcare services’ at the PHC
level.
Globalisation, a process whereby national and international policy-
makers promote domestic deregulation and external liberalisation, has
also a complex influence on the utilisation of healthcare services
(Cornia and Paniccia, 2000). The Indian Government initiated a major
economic reform programme in June 1991 to increase economic growth.
Social sector expenditure, including on heath, declined considerably
resulting in the development of public sector facilities. India’s public
expenditures on health are a relatively low 0.9 per cent of the GDP,
considerably below the average of 2.8 per cent for low and middle
income countries and the global average of 5.5 per cent (World Bank,
2000). Thus, government spending on health is poor in India. It is far
lower than the optimum for any economy; governments in India’s ‘social
economy’ contribute only 17 per cent to the country’s healthcare
resources whereas those of European ‘market economy’ allocates 75 per
cent (Dreze and Sen, 2002). Government spending in India is the fifth
poorest in the world; only Cambodia, Congo, Georgia and Sierra Leone
rank below India (World Health Organisation, 2000). Per capita
government spending too falls below the minimum financial
requirement (US$ 30-40 per year) to cover essential healthcare needs of
an individual in a developing country (WHO, 2001). The low level of
public spending is compounded by (a) a highly inefficient use of
available resources, and (b) sharp inequalities with regard to access to
healthcare based on region, class, caste and gender (Varatharajan,
Godwin and Arun, 2004). The government sector is able to meet only 18
per cent of outpatient and 40 per cent of the in patient care in the
country (India: Ministry of Health and Family Welfare, 2002).
Although it is performing relatively well in the areas of immunisation,
antenatal care, institutional deliveries and hospitalisation, about 10
244 B.V. Babu, G.R. Varma, A.N. Nayak and K. Rath

per cent of those below poverty line still seek immunisation from the
private sector. Similarly, the private sector accounts for 25 per cent of
antenatal care, 30 per cent of institutional deliveries, and 40 per cent of
hospitalisation among the people living below the poverty line. This,
however, leaves out a large chunk of unmet needs and about 60 per cent
non-institutional deliveries. Thus, the recent trends in health finance
and policies resulted that private sector is the dominant provider and
financier of healthcare in India.
Though a majority of the respondents have given positive remarks
towards the healthcare system in the quantitative household survey,
the qualitative research findings reflect that there are some
respondents who are not satisfied with the functioning of the
healthcare system. Respondents of the present study are, somehow,
dissatisfied about the functioning of the health service, attitude of
providers at different government health institutions, and sometimes
with non-availability of medicines. Other studies also reported similar
findings. Many maternal and child health indicators such as coverage
of antenatal check-up, coverage of pregnant women, and place and
assistance during pregnancy are higher for Andhra Pradesh than the
country’s average (NFHS-2: India, 2000). But the number of
institutional deliveries and antenatal care among SC and Scheduled
Tribe (ST) population is not encouraging (NFHS-2: Andhra Pradesh,
2000). These sections of people are yet to receive better healthcare
during pregnancy and post-partum period. The activities like providing
tetanus toxoid injections and iron folic acid tablets are dependant upon
the functioning of health workers. So the visits of health workers have
not yet provided optimum health outreach among the vulnerable
communities like the SC, ST and BC communities. People from these
underprivileged groups grumbled that health workers were
discriminating against them and were not giving adequate attention. It
was also reported that the health service providers were also creating
discrimination between the people of high income and lower
socioeconomic group. Zurbrigg (1984) identified the apathy of the staff
and the existing barrier between the doctor and the people of low
socioeconomic group as the reason of low utilisation and lower
satisfaction by the people. Banerji (1975) also expressed a similar
opinion. He said ‘the urban orientation of health staff distances them
from the rural population’. Sometimes, during visits, health workers do
not give equal attention to the people of lower segment such as the SCs
and BCs, though these are the people who utilise the government
healthcare system the most. This type of discrimination on the basis of
caste has also been reported from Orissa, one of the neighbouring states
of Andhra Pradesh (Babu, Chhotray, Hazra and Satyanarayana, 2000).
They reported the apathy of health workers and hesitation of health
staff to enter the houses of SCs and STs, which speaks volumes about
the care available to needy people. It is also evident from the present
 Utilisation of Primary Healthcare Services 245

study that people of SC and BC communities are utilising the facilities

of various health institutions along with other communities. Varma
(2003) reported that in rural Andhra Pradesh, the elite and
socioeconomically developed people usually depend on private
practitioners and private hospitals, even for preventive services. The
users of PHCs and its health workers are usually the poor and those
from the lower strata of the community. The health system and its
personnel need to reorient their attitude by developing their
managerial skill to deal with underprivileged groups and the rural
masses.

ACKNOWLEDGEMENTS
This study is part of multi-centric study of community directed treatment of
lymphatic filariasis, funded by the UNDP/World Bank/WHO’s Special Programme
for Research and Training in Tropical Diseases (TDR), World Health Organisation,
Geneva, Switzerland.

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THE INDIAN JOURNAL OF SOCIAL WORK, Volume 68, Issue 2, April 2007