India : Equity Effects of Quality Improvements on Health Service Utilization and Patient Satisfaction in Uttar Pradesh State

Abstract

This study investigates the impact of a
 health systems development project in Uttar Pradesh, India,
 on utilization of health services and patient satisfaction
 for the poor and lower caste members. The project began in
 July 2000, and introduced a range of reforms including
 management training, new staffing and service patterns,
 provision of essential drugs, and repair of equipment and
 facilities. The study uses a quasi-experimental design to
 compare changes in new outpatient visits and patient
 satisfaction at project and non-project health facilities.
 All public health facilities were scored according to health
 and economic conditions of the population and physical
 conditions of the facility, with the poorest scoring
 facilities selected for the project. A survey of service
 utilization, user perceptions, and economic status was
 conducted in 1999 at project facilities and an equal number
 of randomly selected control sites, stratified by level of
 facility: district and women's hospitals, community
 health centers (CHCs) and primary health centers (PHCs). A
 subsequent survey conducted in 2003 assessed changes in a
 systematically selected subset of the baseline sites. There
 was a consistent increase in mean monthly outpatient visits
 at all levels of project sites compared to controls,
 indicating that the project has improved overall utilization
 levels. Although patients from the poorest 40 percent of the
 population increased utilization at all types of facilities
 except the women's hospitals, the wealthiest 40 percent
 had larger increases at each level of facility. Lower caste
 members gained at all facilities relative to higher caste
 members. The project had a significantly positive impact on
 patient satisfaction at lower levels of facilities (CHCs and
 PHCs), but not for patients from the poorest 40 percent.