INTRODUCTION

A primary health center (PHC) is a first port of call to a qualified doctor of the public sector in rural areas and caters to the sick and those who directly report or are referred from subcenters for curative, preventive, and promotive health care.1 A typical PHC is required to serve a population of 20,000 in hilly and tribal areas and 30,000 in plains with 6 indoor/observation beds. A PHC acts as a referral unit for 6 subcenters.2 The PHCs should become a 24-hour facility with nursing facilities.1

Standards are the main driver for continuous improvement in quality. The performance of PHCs can be assessed against set standards1 called the Indian Public Health Standards (IPHS) recommended for PHCs in early 2007. The IPHS documents of 2007 have been revised in 2012, keeping in view resources available with respect to functional requirements of PHCs with minimum standards, such as building, manpower, instruments and equipment, drugs, other facilities, etc. The revised IPHS has incorporated the changed protocols of the existing health programs and initiatives, especially with respect to noncommunicable diseases.1 A wide range of services are prescribed by the IPHS to fulfill the minimum requirements at PHCs, such as medical care through outpatient department (OPD) and 24-hour emergency services, maternal and child health (MCH) services, basic laboratory services, minor surgical procedures, implementation of various National Health Programs, etc.1

The overall objective of IPHS for PHCs is to provide health care, i.e., quality oriented and sensitive to the needs of the community. These standards would also help monitor and improve the functioning of the PHCs. This study was carried out under the supervision of the Department of Community Medicine of Government Medical College (GMC), which is a newly established college in the rural areas of Kannauj district of western Uttar Pradesh, a backward district with poor health indicators.

AIMS AND OBJECTIVES

  • To assess the infrastructure, equipments, instruments, staffing, and other facilities

  • To assess the services being provided at PHCs

  • To find out the reasons for nonutilization of health services and suggest remedial measures for the same

MATERIALS AND METHODS

This was a cross-sectional study. Two PHCs, namely Thatiya and Umerda of Tirwa block of Kannauj District, were randomly selected for assessment. These PHCs are about 12 km away from the medical college. Health care providers, mainly medical officers, were interviewed using pretested, precoded pro forma for 2 months (June and July 2015). The IPHS guidelines for PHCs revised in 2012 were used to compare and assess the quality of PHCs. Ethical approval for the study was taken from the Ethics Committee of the college (Table 1).

For data collection, transmission, and management, data were entered in standardized formats by the investigator. Each patient was given a unique identifier, and the personal name of the patient was not used in data analysis. The data captured through the questionnaire were entered into a computer-generated excel sheet. For statistical analysis, Statistical Package for the Social Sciences was used. The information was randomly checked for completeness by the faculty of community medicine in GMC Kannauj before entry onto a computer. Descriptive analysis was used as per study requirements.

Table 1: Subcenters and population covered under PHCs

Thatiya PHC, N = 77,939      Umerda PHC, N = 72,792
PHC subcenterPopulation      PHC subcenterPopulation
Khama9,567      Umerda13,937
Basta9,873      Kudrina8,706
Paithana10,324      Khanpur9,822
Thatiya8,182      Bahosi11,361
Behata10,078      Majhila8,923
Badohosi13,431      Diyora9,617
Jainpur16,484      Balanpur10,426

Implications of the Study

Despite the small sample size due to time and logistics constraints, the study will provide sufficient insights into the planning and management of health services. Improved quality care at the primary level will reduce avoidable burdens at the tertiary level. It will enhance the treatment sought and will reduce the burden of disease in the community.

RESULTS

It was found that both of the PHCs were catering to more than 70,000 people and had seven subcenters serving the health needs of about 8,000 to 16,000 people. The location of both PHCs was accessible to almost all people as reported by them. Thatiya PHC has 12 rooms, while Umerda PHC is being run only with 3 rooms.

Although waiting places were available at both the PHCs, their conditions were pathetic. The building was in need of maintenance and repair. At Umerda, injections were being given in waiting areas. Electrical supply was around 10 to 12 hours. Regarding water supply, it was found that although hand pumps were installed at both the PHCs, at Thatiya, they were not functional. As there was no water supply at Thaitya PHC, water outlet, wash basin, and toilets were nonfunctional. The most distressing fact was that there were no sweepers at both the PHCs. The medical officers-in-charge (MO-IC) were paying from their own pocket for cleanliness. Boundary and fencing was present at Thatiya PHC again in dilapidated conditions, while there was no fencing or boundary at the Umerda PHC. There was no computer, telephone, transport, and ambulance facility at both the PHCs. Waste disposal of the PHCs was not proper. It was being collected at the corner and burned by sweeper weekly. There was no residential facility at Umerda PHC, so there was no question of a staying MO-IC at the PHC. At Thatiya PHC, three types of residences were present, but they were not in good condition and due to lack of basic amenities, the MO-IC was not staying there.

Table 2: Physical infrastructure of PHC

Thatiya PHC      Umerda PHC
Type of roomFunctionNo.TypeFunctionNo.
OPDAllopath – F2      OPDAllopath – F01
      AYUSH – NF                  AYUSH – NF      
IndoorNF2      Indoor
LaboratoryOnly sputum1      Laboratory0
StoreF1      Store0
Injection roomF1      Injection room0
EmergencyNF1      Emergency
Drug storeF1      Drug storeF1
OTNF1      OT0
NHPRNTCP, Leprosy1      NHP0
Cloak roomFunctional1      Clark roomF

*F: Functional; NF: Nonfunctional; NHP: National Health Program; OT: Operation theater; RNTCP: Revised National Tuberculosis Control Program; AYUSH: Ayurveda, Yoga and Naturopathy, Unani, Siddha and Homoeopathy

Table 3: Some other characteristics of physical infrastructure

      Thatiya PHCUmerda PHC
Waiting place availableYes      Yes      
Is waiting place protected from sun/rain water?YesBut plastering and painting are not well doneYesPlastering and painting are not well done
Room flooring/plastering doneYesNot in good conditionYesNot in good condition
Electrical supplyYesFor 10 hrsYesFor 12 hrs
Type of water supplyNoStalled – NFYesHand pump – functional
Room for clinicYesAttached examination roomYesSingle
Water outlet in clinic roomYesBut not usedYesWorking
Wash basin provided and functioningYesNF due to no water supplyYesFunctioning using hand pump water
Toilet availableYesNF – no water supplyYesFunctional
Is location of PHC accessible to all?YesAlmostYesAlmost
Maintenance of cleanliness      By an external sweeper paid by MO from his salary (Rs 300/month)      External sweeper paid by MO from his salary (Rs 250)
Boundary wall/fencingYesBut no proper plastering.No
Telephone, computerNoNo
Waste disposaldoneNot properly disposed; collected at the corner and burned by sweeper weeklyDoneCollected outside of the PHC and burned by sweeper
Transport/ambulanceNoNo
Residential facilityYesBut not used by anyoneNo
No. and type of residential quartersYesType I – III, Type-II room and Type III – I room suiteNo
Is MO-IC staying at PHC?NoReason – no basic facilitiesNoNo residential facility

NF: Nonfunctional

Doctors were running the centers mainly with stethoscope, blood pressure (BP) instruments, and thermometers. Even the weighing machine, only for adults, was available at only one PHC, Thatiya. Similarly, among the list of desirable equipments, mainly tuning fork and otoscopes were available at both the PHCs. As far as essential reagents and instruments required in laboratory were concerned, at Umerda PHC, no laboratory was present; so no reagents were available. At Thatiya PHC, only sputum testing was being done; hence, related reagents like Gram's iodine, KOH solution, etc., were available. Similarly, light microscope was available only at Thatiya PHC. In the name of furniture, both the PHCs have only one examination table, two writing tables, few rickety chairs, bench, three almirahs, dustbins, bucket and mugs, etc. Puncture proof bags were available only at one PHC (Thatiya).

Table 4 reveals lists and number of furniture as per the IPHS guidelines, and furniture and their number available at PHCs. One can see that only basic furniture was available and was not in the required numbers. In the name of furniture, they have only one examination table, two writing tables, few rickety chairs, bench, three almirahs, dustbins, bucket and mugs, etc. They have no wheelchairs, stretchers, curtains, gas stoves, utensils, and generators. Puncture-proof bags were available only at one PHC (Thatiya).

Again, only stethoscope, BP instruments, thermometer, not in required numbers, were present. They have no hub cutter or needle destroyer.

Both the PHCs were grossly understaffed. Thatiya was being run by 8 and Umerda by only 3 health personnel.

Services Provided at PHCs

Only allopathy OPDs at both PHCs were running for 4 to 5 hours. No 24-hour emergency services, inpatient services, operational labor room, and OT were there. Laboratory services (only sputum testing) were available at Thatiya PHC only.

Emergency Services

No 24-hour emergency services were being provided at both the PHCs

Table 4: Availability of equipments and furniture at the PHCs

Name of furniture and no. as per IPHS guidelines (No.)Thatiya PHC      Umerda PHC
Yes/No numberF/NF      Yes/No numberF/NF
Examination table (4)1F      1F
Writing table with two sheets (6)2F      2F
Plastic chairs for patient's attendant (6)4F      4F
Armless chairs (16)3F      2F
Full size steel almirah (7)3F      3F
Table for immunization (1)No      1F
Bench for waiting area (2)2F      2F
Wheelchair (2)No      No
Stretcher on trolley (2)No      No
Wooden screen (1)No      No
Foot step (5)No      No
Coat rack (2)No      No
Bedside table (6)6NF      3NF
Bed stead iron for inpatient (6)No      3NF
Baby cot (2)No      No
Stool (10)3F      1F
Medicine chest (1)1F      No
Lamp (3)No      No
Side wooden racks (4)2F      No
Fans (6)3F      2F
Basin (2)2NF      2F
Basin stand(2)2NF      2F
Buckets and mugs (4 each)2F      2F
LPG stove (1)No      No
LPG cylinder (2)No      No
Saucepan with lid (2)No      No
Tube lights (8)5F      2F
Water receptacle (3)No      No
Rubber plastic shutting (2 m)2 mtF      2 mtF
Drum with tap for storing water (2)No      No
Mattress for beds (12)6NF      3NF
Foam mattress for operation theater (3)No      No
Bed sheets (30)6NF      6NF
Pillow with cover (30)6NF      6NF
Blankets (18)6F      6F
Baby blankets (4)No      No
Towels (18)No      No
Foam mattress for labor operation theater (2)No      No
Curtains with rods (20 m)No      No
Dustbins (2)2F      2F
Puncture proof bags – as per need5F      No
Generator (1)No      No

F: Functional; NF: Nonfunctional; LPG: Liquefied petroleum gas

Table 5: List of medicine/surgical equipments

Name of equipment and no. as per IPHS guidelines (No.)Thatiya PHC      Umerda PHC
Yes/No numberF/NFYes/No numberF/NF
BP apparatus (3)1F      1F
Stethoscope (3)1F      1F
Tongue depressor (10)No      No
Torch (2)1F      1F
Thermometer (4)1F      1F
Hub cutter (2)No      No
Needle destroyer (2)No      No
Labor OT1NF      No
OT table (1)No      No
Arm board for adult and child (4)No      No
Instrumental trolley (2)1NF      No
Intravenous stand (10)6NF      3NF
Shadowless lamp (2)No      No
Mackintosh for labor OT – as per needNo      No
Red bags – as per need5F      No
Black bags – as per needNo      No
Blackboard (1)No      No
Public address system (1)No      No

F: Functional; NF: Nonfunctional; OT: Operation theater

Table 6: Manpower at PHCs

StaffEssentialThatiya PHC      Umerda PHC
      AvailableRemarks      AvailableRemarks
Medical Officer – Bachelor of Medicine & Bachelor of Surgery11      1
MO – AYUSH/Lady medical officer10Vacant      0Vacant
Accountant/clerk10Vacant      0Vacant
Pharmacist11      0Vacant from March 18, 2015
Nurse-midwife/staff-nurse312 needed      0Vacant
Health workers (F)10Vacant      0Vacant
Health Assistant (Male)11      1      
Health Assistant/Lady Health Visitor (F)10Vacant      0Vacant
Health educator10Vacant      1Vacant
Computer operator10Vacant      0Vacant
Laboratory technician11      1
Cold chain and vaccine logistic assistant11      0Vacant
Multiskilled Gp D worker22      1Optometrist, 1 – vacant
Sanitary worker cum watchman10Vacant      0Vacant
Pharmacist AYUSH10Vacant      0Vacant

*Vacant, vacant from the beginning as told by MO-IC – never filled; AYUSH: Ayurveda, Yoga and Naturopathy, Unani, Siddha and Homoeopathy

Table 7: OPD services

Thatiya PHC      Umerda PHC
OPD TimingHours spent by MO-IC in fieldAverage daily patient loadOPD TimingHours spent by MO-IC in fieldAverage daily patient load
Per dayDays/weekPer dayDays/week
10 am–2 pm3 hrs230–35      9 am–2 pm3 hrs215–20

Others

ServicesThatiya PHCUmerda PHC
Referral services – YesMedical college and district hospitalsMedical college and district hospitals
Inpatient services – No
No. of beds63
Bed occupancy rate00
MCH including family planning – No            
Antenatal servicesNot at PHCNot at PHC
Deliveries at PHCNoNo
Postnatal care
Family planningNot at PHCNot at PHC
Care of child            
Routine and emergency care of sick children including integrated management of neonatal and childhood illnesses strategy, in patient care and prompt referralNoNo
Counseling on feeding, immunizationNoYes, 1st Wednesday of month
Vaccines and Vitamin A prophylaxis givenNoYes, 1st Wednesday of month
Condition of cold chainNoNo vaccine storage at PHC
Cases of severe malnutritionNoNo
Management of RTIs/STIs            
No. of cases/monthAbout 2
Kit availableNoNo

RTI: Reproductive tract infection; STI: Sexually transmitted infection

No MCH and family planning services were being provided at both the PHCs; only immunization services were being given at the Umerda PHC. The auxillary nurse midwifes (ANMs) provided these services at subcenters and directly reported to community health centers (CHCs). No records regarding these services were available at both the PHCs. We interviewed ANMs and accredited social health activist (ASHAs). They reported that they were motivating and counseling women on early initiation of breast feeding and immunization. The ANMs were providing immunization to pregnant women and children, but when asked about weighing of newborn children, they replied that they have a weighing machine (Salter's type), but did not know how to use it; hence, weighing of infants was not taking place.

Nutrition Services [Coordinated with Integrated Child Development Services (ICDS)]

Thatiya PHCUmerda PHC
YesYes
Health worker (HW) visiting aangan wadi centers (AWC): 4 times/monthHW visiting AWC: 4 times/month

School Health

ServiceThatiyaUmerda
ANMs/AWWs (a team of 2) visiting school once/week for screening, treatment of minor ailments, and referralYesYes
Doctor visiting based on screening reportYesYes

Promotion of Safe Drinking Water and Sanitation

ServiceThatiyaUmerda
Disinfection of water sources and coordination with public health department for safe drinking waterNoNo

Prevention and Control of Locally Endemic Diseases Like Malaria, Kala-azar, Japanese Encephalitis, Filaria, etc.

They were not being done at both the PHCs. No antimalarial drugs and other drugs for various endemic diseases were found at PHCs. One MO-IC reported confidentially that even if they diagnosed malaria, they provided negative reports. This was so as positive reports needed verification.

Other National Programs being Implemented through PHC

National programThatiya PHCUmerda PHC
RNTCPYesNo
National leprosy eradication programme (NLEP)YesNo
Pulse polio immunizationYesYes
Integrated child development servicesYesYes
Others (e.g., Janani Suraksha Yojana, Janani Shishu Suraksha Karyakaram, etc.)NoNo

RNTCP: Revised national tuberculosis control program

Among national health programs, only RNTCP and NLEP were being implemented through Thatiya PHC only, not at Umerda PHC. School health program and ICDS were being coordinated through both the PHCs

Collection and Reporting of Vital Events

No records were present at both the PHCs; grassroot level workers directly reported to the CHC.

Health Education and Behavior Change Communication

ServiceThatiyaUmerda
Information, education and communication materialNoOn human immunodeficiency virus, malaria, filarial, tuberculosis, and polio
Counseling roomNoCounselor does counseling on reproductive and sexual health to 10- 18-yr-olds and immunization

Basic Laboratories and Investigation Facilities Available

InvestigationsThatiyaUmerda
Routine urine, stool, and blood testNoNo
Blood groupingNoNo
Bleeding time, clotting timeNoNo
Diagnosis of RTI/STI with wet mounting Gram stainNoNo
Sputum testing for TBYesNo
Blood smear examination for malaria parasiteNoNo
Rapid test for pregnancyNoNo
Rapid plasma reagin test for syphilis/Yaws surveillanceNoNo
Rapid test for human immunodeficiency virusNoNo
Other (specify)NoNo

RTI: Reproductive tract infection; STI: Sexually transmitted infection; TB: Tuberculosis

Training given to Health Workers

Training of health workerThatiya PHCUmerda PHC
Cadre of health worker (ANMs, ASHAs)At block levelNo training at the PHC, provided at CHC and district hospital
Training of MO in last 5 yrsNoNo

Mainstreaming of AYUSH

No Ayurveda, Yoga and Naturopathy, Unani, Siddha and Homoeopathy (AYUSH) staff

Charter of Patients’ Right and Signposts in Local Languages

Not present at both the PHCs

Monitoring and Supervision

      Thatiya PHCUmerda PHC
Internal mechanism*Records maintained, checked, and supervised by MO*Records maintained, checked, and supervised by MO
Medical audit (State level)YesYes
Death auditNoNo
Survey of patients’ satisfaction and referral servicesNoNo
External mechanism (Panchayati Raj Institution, Village health Sanitation, Rogi Kalyan Samiti, etc.)NoNo

*Records, such as patient's register and logistics.

Various difficulties faced by MOs were scarcity of staff and medicines and the doctor not being consulted about need of medicines, and lack of basic amenities like water, electricity, and canteen. There were no fourth class employee and sanitation worker, no generator, and transport facility. At Umerda PHC, there were no residences for any category of employee. So, it was difficult for them to serve people in those areas.

DISCUSSION

The PHCs play a vital role in delivering health care to rural India. A PHC is established with a population norm of 20,000 people for hill and tribal areas and 30,000 for plain areas.2 In our areas, we found that both the PHCs were serving more than twice the prescribed norms of population (Thatiya; 77,939 and Umerda; 72,792). The PHC is also required to serve 6 subcenters within its jurisdiction.1 Here, both the PHCs had 7 subcenters. The national norms of population for subcenters are 3,000 for hills and tribal areas and 5,000 for plains. In our study areas, these subcenters were catering to the health needs of about 8,000 to 16,000 people, which are much more than the prescribed norms.

Regarding infrastructure, it was found that infrastructure at both the PHCs was not up to the standards set by IPHS. Thatiya PHC has 12 rooms, while conditions of Umerda PHC were more deplorable, as it was being run only in 3 rooms. Although waiting place was available at both the PHCs, they were in need of repair and were not very comfortable. As per IPHS guidelines,1 waiting areas should have adequate space and seating arrangements. Walls should carry posters imparting health education along with booklets/leaflets in local languages for the same purpose. Safe drinking water and toilets with adequate water supply, separately for males and females, should be available. Waiting areas should have fans and coolers.1 At Thatiya PHC, there was no water facility and the only toilet was nonfunctional. At Umerda PHC, a hand pump was there, and toilet could be used by using water from hand pump. The OPD room should have an attached room for examination.1 Thatiya PHC has an attached room, but at Umerda PHC, OPD was being run in a single room. There was boundary/fencing at Thatiya PHC, which was in need of repair, while no fencing at all was present at Umerda PHC. Cleanliness was not satisfactory, as there was no sweeper/IV class employee posted at both the PHCs. The MO told that they were paying from their own pocket (around Rs. 300) to a sweeper for cleanliness and disposing waste on weekly or bi-weekly basis. There were no transport and communication facilities at both the PHCs. Residences was constructed at Thatiya PHC only, but MO-IC did not stay there because of lack of basic amenities of life. Almost similar were the findings of a study report prepared by STEM 6II-7II on the health needs assessment in Uttar Pradesh.3

When the availability of equipments at both the PHCs was assessed against the list prescribed by IPHS guidelines, it was found that few essential equipments, mainly stethoscope, BP equipment and thermometer, were available at both the PHCs but not in required numbers. Adult weighing machine and binocular microscope were available at Thatiya PHC only. In desirable lists of equipments as per IPHS guidelines, only otoscope and tuning fork were available at both the PHCs. Few other studies in Uttar Pradesh3 and Rajasthan4 reported shortages of equipments at PHCs.

There were no fully equipped and operational labor room and equipment for Papanicolaou smear test as prescribed by the IPHS at both the PHCs. As far as essential reagents and instruments required in laboratory were concerned, there was no laboratory at Umerda PHC, so no reagents were available. At Thatiya PHC, only sputum testing was being done; so, related reagents like Gram's iodine, KOH solution etc., were available. Similarly, light microscope was available only at Thatiya PHC.

There were only few basic furniture and not in required numbers; only one examination table, two writing tables, few rickety chairs, bench, three almirahs, dustbins, bucket and mugs etc were present. They have no wheelchairs, stretchers, curtains, gas stoves, utensils, and generators. Puncture-proof bags were available only at one PHC (Thatiya). This is in consonance with findings of some other studies.3,4

Both the PHCs were understaffed. Thatiya PHC was being run by 8 and Umerda by only 3 health personnel; no AYUSH component was there. Understaffing is a common problem reported in many studies.3,4,6

When enquired about services being provided at both the PHCs, we found only OPDs were running for 4 to 5 hours. A total of 6 hours of OPD services out of which 4 hours in the morning and 2 hours in the afternoon for 6 days in a week is the prescribed norm of IPHS.1 Patient load was low at Umerda (15–20), while at Thatiya, it was 30 to 35, which is below the expected load of 40 patients as per IPHS.1 Raghunath et al5 reported overcrowding at center in Puducherry. The MO-IC spent 3 hours, twice a week, in the field as desirable by IPHS guidelines.

As per IPHS guidelines, 24-hour emergency services, which include appropriate management of injuries and accident, first aid, stitching of wounds, incision and drainage of abscess, stabilization of the condition of the patient before referral, dog bite/snake bite/scorpion bite cases, and other emergency conditions should be provided primarily by the nursing staff. However, in case of need, the MO may be available to attend to emergencies on call basis. The 24-hour emergency services were not being provided at both the PHCs.

Regarding MCH and family planning services, it was found that no components, except immunization services at Umerda PHC, were being provided at the PHCs. No deliveries and MTPs were taking place there. The records were present with ANMs; they were providing their services at subcenters and directly reporting to CHC. In some studies,4,6 MCH services were being provided at PHCs. Sadani and Sharma4 reported that in Rajasthan, MCH was being provided at PHCs, while no equipped newborn care center was present. Ninama et al6 also found that MCH services excepting MTP were being given to patients.

CONCLUSIONS AND RECOMMENDATIONS

It has been found that both the PHCs are not performing up to the expectations and standards due to various reasons like inadequate physical infrastructure and facilities at both the PHCs. Both of them are grossly under­equipped and understaffed. The supply of medicine is irregular and insufficient. They are providing inadequate and piecemeal services. Only OPD services are being provided that have many missing components like the MCH and family planning. Medical officers have their own problems; even the basic amenities of life like water, electricity, and canteen etc., are found lacking. Hence, medical officers cannot be blamed entirely. There are no fourth class employee and sanitation worker, generator, and transport facility. At Umerda PHC, there are no residences for any category of employee, so it is difficult for MOs to serve in those areas as they do not stay there. There is an urgent need to address these issues and ensure accountability at each level of health system. To ensure accountability, the Charter of Patient's Rights in the local language should be available in each PHC. Each PHC should have a Rogi Kalyan Samiti (RKS) for improvement of the management and service provisions of the PHC as per the guidelines of Government of India. Various agencies of villages like Panchayati Raj Institution, Village Health Sanitation and Nutrition Committee and RKS should also monitor the functioning of PHCs.

Conflicts of interest

Source of support: Nil

Conflict of interest: None