Patient perception of attributes of primary care: a study of Aam Aadmi Mohalla Clinics in Delhi, India

Abstract

Background

Aam Aadmi Mohalla Clinics (AAMC) are the community level public primary care facilities recently introduced to strengthen primary care in Delhi, India by bringing affordable healthcare close to home.

Objectives

This study looks at the primary care attributes of AAMC from a patient perspective, to assess their features, strengths and weaknesses.

Methods

Using a primary care survey tool, a cross-sectional survey of 360 users was conducted at 18 facilities across 9 districts of Delhi to gather information on six dimensions of primary care delivery. Thematic analysis of responses to quantitative, multiple-choice and Likert scale questions using percentage of respondents in each category; and a strengths, weaknesses, opportunities and suggestions (SWOS) framework, was used to examine the primary care attributes.

Results

AAMCs have done well in improving proximity, availability, physical and financial access to primary care with respondents reporting their residence within 1 kilometre of AAMCs (95%), physician being available (100%), free drugs in stock (99%). Service delivery is however not comprehensive with missing preventive care. Respondents reported missing gatekeeping, weak referral mechanism (6–19%), and low physician’s familiarity with their overall health (2%).

Conclusion

AAMCs have brought affordable healthcare with free medicines and diagnostics to neighbourhood. There is an opportunity for attaining universal healthcare that is responsive to user needs through provision of comprehensive care. Compulsory enrolment of neighbourhood population with an electronic database of patients has an immense potential to improve longitudinality and coordination of care.

Introduction

Primary care (PC), defined as the first point of contact with the health system,¹ is pivotal in providing universal health coverage and serving the overarching goals of a health system.^2–4 Recent reforms by the Government of India (GoI) are focussed on provision of comprehensive PC to augment the existing provision of selective PC in public facilities.⁵ The State government of National Capital Territory of Delhi (GNCT) upgraded the mobile health clinics and built Aam Aadmi Mohalla Clinics (AAMCs)/neighbourhood clinics to bring PC closer to the common people.⁶ These are desirable moves, given inequitable and fragmented healthcare delivery due to division of financing and delivery of services between the Union, State and local governments and the co-existence of private and public providers.

The Indian Public Health Standards (IPHS) laid down by the GOI in 2006 for public facilities specify the criteria for providing a minimum quantity and quality of services.⁷ However, establishment of the defined infrastructure is not sufficient to ensure universal access, acceptance, and utilisation of healthcare. Healthcare utilisation in public sector continues to remain low in India, with only 30% visits to public facilities, among those seeking outpatient care in 2017x2013;18.⁸

Attributes of PC are important in determining the timely usage of health services not only for curative care but also for preventive care. The attainment of PC attributes is important in strengthening health service delivery and fulfilling the objectives of a health system.⁹ While studies on some aspects like quality of PC can be found,^10,11 most other studies in India pertain to facility surveys to assess the availability of infrastructure, medical supplies, and human resources to determine facility performance according to IPHS.^12–14 There are no known studies on attributes of PC in India.

This study examines the attributes of PC at AAMCs in Delhi, India, using a patient perspective and assesses the strengths and weaknesses of PC delivery. Such studies can help to improve the delivery of healthcare that is acceptable and responsive to user needs, promote healthcare utilisation behaviour and serve to attain the larger objectives of a health system. The survey tool developed for this study can be adapted for the assessment of PC facilities elsewhere.

Methodology

AAMCs were introduced in 2015 for providing PC at neighbourhood level by GNCT with a modest infrastructure and manpower. They were established to provide basic outpatient care for common illnesses; first-aid for injuries; dressing of minor wounds; referral services; and free dispensing of 125 essential medicines and 229 free diagnostics, and preventive care.¹⁵ A comparison of services provided by AAMCs and Health and Wellness Centres (HWC) introduced under Ayushman Bharat—Health and Wellness Program in 2018 is shown in Box-1, Supplementary material.

Attributes of PC at AAMCs have been studied along seven dimensions

First contact.

First contact is the initial contact made by a patient with a facility/provider when a need arises and may be used to gauge the strength of PC in promoting health seeking behaviour among users. It was analysed by type of facility normally visited when sick, reasons for visiting a facility, and timeliness of seeking care.

• Reasons for visiting the facility were analysed using a barriers-to-care framework which refers to the factors that may act as deterrents in establishing contact with the health system. The respondents were asked to choose among reasons such as distance, affordability, quality of care, and faith on the provider for visiting the facility.

• Timeliness of first contact was determined by the number of days after the onset of ailment when the patients visit the health facility. Respondents were asked about the number of days they had been sick before visiting the AAMC.

Availability of care.

Availability of health professionals and timely supply of services and materials is important to serve the health requirements of the population. This was assessed by availability of doctors/physician, drugs and diagnostic services at AAMCs.

Comprehensiveness of care.

Services are comprehensive when all types of curative, preventive, promotive and rehabilitative services are provided by the facility. The survey gathered information about the awareness among respondents about the availability of the listed services (free or paid) that were available at any given facility.

Accessibility of care.

Lack of access to care can be a hindrance to health care utilisation despite availability of care. Accessibility of care was assessed by physical and financial accessibility.

• Physical Accessibility refers to the ease with which the users can use the available facilities and services. Three indicators were used to gauge physical accessibility: ease of contacting the doctor during and outside of the facility working hours; distance of the facility from the patients’ homes; and waiting time for the patients at the facility to see the doctor. During the working hours ease of contacting the doctor was assessed by whether the respondents had to take a prior appointment or could walk-in to the facility without prior appointment. Ease of contacting outside the working hours was assessed by the availability of doctors on phone or for home visits.

• Financial Accessibility pertains to affordability of healthcare by the user. This was gauged by respondents reporting free services at the facility, respondents linked to prepayment schemes for healthcare and if the respondents incurred OOP on travel, drugs, and diagnostics even while seeking care at AAMC.

Longitudinality of care.

Longitudinality is the long-term relationship between the patient and the physician/provider. It was captured by the familiarity of the doctor with the medical history of the patient, the practice for sending reminders about upcoming appointments to patients, and linkage between diagnostic services, patients, and providers regarding sharing of diagnostic reports.

Coordination of care.

Coordination of care refers to the linkage between primary, secondary, and tertiary care. Indicators used for judging coordination were, whether the patient visited the facility for gatekeeping purposes; the doctor discussed the places the patient could go to for specialist care; the patient received any support for getting appointment with the specialist; the doctor provided medical records of the patient to be shared with the specialist (forward linkage); and the doctor received any records back from the specialist for follow-up care (backward linkage).

Quality of care.

Quality of care was studied in terms of structural aspects, physician behaviour, and patient satisfaction.¹⁰ Structural quality was gauged by availability of infrastructure, drugs in stock, functionality of equipment, and cleanliness. Physician behaviour was assessed by users’ perception about whether physician gave them sufficient time to discuss problems/worries; and whether the physician/staff were polite. Quality was also judged in terms of adoption of hygienic practices such as physician using gloves or cleaning hands before physical examination. Patient satisfaction was determined by examining if the facility had a system of taking patient feedback on grievances and service effectiveness.

Data

Sample design and sample size.

At the time of the survey, 180 AAMCs were operational in Delhi. A 10% purposive sample of 18 AAMCs was selected by picking 2 AAMCs from each of the 9 previously undivided districts in Delhi, to have a spatially representative sample of facilities. AAMCs are being operated out of two types of structures, porta cabins and permanent rooms. Accordingly, of the 2 AAMCs chosen from each district, 1 of each type was selected.

Survey design.

Exit interviews of patients visiting the AAMCs were conducted from February to March 2019 to gather information about their socio-economic background, health problems, and their perceptions about the attributes of the healthcare facility. Using a structured questionnaire, face to face interviews were conducted, with 20 patients selected randomly at each facility, leading to a sample of 360 patients. The sample size was determined by the feasibility of recruitment within the study budget and time frame. Facility survey was also undertaken to assess the physical infrastructure. Informed consent was taken from the patients and providers before conducting the interviews.

Survey tool.

Separate tools were created for survey of patients and facility. The survey tools were enriched by literature review, PC Evaluation Tool,¹⁶ IPHS,⁷ India Health Surveys,¹⁷ and PC Assessment Tool.¹⁸ A peer review was undertaken by experts and stakeholders; the officials of Ministry of Health and Family Welfare, GoI, Delhi State Health Mission, GNCT; and General Secretary, Delhi Medical Association. The survey tools were finalised after a pilot survey and surveyor feedback.

Data analysis.

The patient survey tool contains questions on quantitative values, multiple-choice and Likert scale ranging from 1 (always) to 4 (never) on specific aspects of PC. The responses from Likert scale were converted into binary by combining the first two categories as yes and the remaining two categories as no. PC attributes were analysed as percentages of respondents in particular categories of responses and average values of quantitative responses. The facility survey was used for assessing structural quality of care. All the responses were analysed thematically. Data analysis was done on Stata 14.2 and Excel.

The findings thus gathered were used to carry out a SWOS (strengths, weaknesses opportunities, and suggestions) analysis to provide suggestions for exploiting the untapped potential of AAMCs as the providers of PC.

Results

Two-thirds of the respondents were females, were in the age group 15–59 years, belonged to under-privileged social groups and 50% had either up to primary or no education. The mean per capita monthly income of the respondents was ₹3,000. One-third of the interviewees were suffering from fever, 37% reported body-aches, and 60% reported co-morbidities. Purpose of visit was reported as a new health problem, follow-up and routine check-up by 79%, 18% and 2% respondents respectively (Supplementary Table 1).

First contact

AAMC was the preferred facility choice for 54% respondents while 30% normally preferred to visit informal/traditional healers.

The foremost reason for visiting the AAMC was proximity to the facility (84%), followed by the availability of free drugs (62%) and free diagnostics (49%). Only 35% respondents visited the facility because of its reputation. Self-perceived quality of care in terms of being treated with dignity by the physician, facility cleanliness or low waiting time were less important (24%).

Regarding timeliness of first contact, 65% respondents visited the facility 10 days after the onset of a medical condition, indicating delayed care and poor health seeking behaviour among users (Fig. 1). Self-medication and ailment not perceived to be serious were the two predominant reasons for delayed visits (reported by 19% of the delayed users) (Fig. 2).

Availability of care

Most respondents reported that availability of physician for the mandated duration of 6 h per day 6 days in a week in the clinic. Given a total of 189 AAMCs each with 1 doctor working for 6 days per week for 6 h per day, and the total attendance of 5,307,310 during 2018–19,¹⁹ implied that the average time spent by a doctor per patient was 4 min. This was corroborated by the patients as only 7% respondents felt that physicians gave enough time to talk about worries/problems.

Availability of free drugs and diagnostics was reported by 99% and 81% respondents respectively.

Comprehensiveness of services

Availability of doctor’s consultation for curative care for minor ailment was reported by all respondents, only 5% respondents reported availability of preventive care. No one reported services such as emergency, community outreach, ophthalmic, dental etc (Supplementary Table 2).

Accessibility

Physical accessibility.

Most (95%) respondents reported living within 1 km of the AAMC that they visited.

The ease of contacting the doctor was reflected by the ability to walk-in without prior appointment during clinic hours by all respondents. For outside clinic hours, the patients had no way of contacting the doctor on telephone/home visit. The waiting time for 47% interviewees was 20 min or less, 51% spent between 20 and 60 min, and only 12% respondents spent more than 60 min.

Financial accessibility.

Availability of free consultation, drugs, and diagnostics was reported by 99% respondents, but 28% respondents reported OOP expenditure on travel, drugs, and diagnostics even while seeking care at AAMC. Respondents enrolled in any prepayment scheme were 1%, implying the need to incur an out-of-pocket payment for services not available at AAMCs.

Longitudinality of care

Though 94% respondents saw the same doctor most of the times, only 2% of them reported doctors’ familiarity with their overall health and only 1% received reminders for upcoming appointments. (Supplementary Fig. 1)

Coordination of care

AAMCs did not perform any gatekeeping. Forward linkage and backward linkage were reported by 19% and 6% respondents respectively. Diagnostic reports reaching patients via e-mail/message and reaching the physicians directly were reported by 1% and 11% respondents respectively. (Supplementary Fig. 2)

Quality of care

Structural quality in terms of infrastructure availability revealed over 90% of the surveyed AAMCs having a reception area, consultation room with examination table (Table 1). None of them had minor surgery room and wheelchair. While more than 80% AAMCs had toilets and drinking water, but toilets were not functional or clean at 33% facilities. Drugs were reported to be available in stock by 98% respondents.

Most respondents found the behaviour by doctors/staff to be polite (93%) but only 5% reported use of good hygiene practices.

Practice of receiving feedback for grievances and service effectiveness were reported by 99% and 2% respondents respectively.

SWOS analysis of AAMCs

The results of the analysis were used to identify the strengths, and weaknesses of AAMCs and a strengths, weaknesses opportunities, and suggestions (SWOS) analysis was undertaken to give a fillip to universal health coverage through these clinics (Table 2).

Discussion

The study showed that AAMCs have done well in bringing healthcare in proximity as 95% of the respondents reported living within one kilometre of the facility. Physical proximity was the predominant consideration for visiting any AAMC. For 54% of the respondents, AAMC was the facility of usual choice. Another study showed that establishment of AAMCs led to a switch of seeking care from informal to formal care.²⁰ However, the health seeking behaviour remains poor as reflected in the delay in seeking care. Self-medication, which was the primary reason for delayed care is a health concern, leading to inappropriate usage of medicines and microbial resistance.^21,22

While the interviewees reported the availability of a doctor during the mandated hours but there was no way to contact the physician outside office hours. The average time of 4 min per patient spent by the physician is a point of concern as studies have found that lower time spent by the physician reduces patient satisfaction,²³ preventive care²⁴; and promotes inappropriate prescribing and referring behaviour.²⁵ This study found that only 7% respondents felt that the physician gave enough time to talk about their problems. This has adverse implications for longitudinality of care as very few respondents reported familiarity of the physician with the patients’ history and overall health condition. The practice of sending reminders for upcoming appointments and sharing of patient information across primary and higher levels of care is non-existent leading to poor adherence to treatment as reflected in only 18% respondents making follow-up visits. Weak gatekeeping and referral mechanism lead to an excessive patient load on specialist care. In 2014, of the total outpatient ailments treated in urban areas in India, only 3.9% were in the public PC facilities, 17.3% were in public hospitals and rest in private facilities.²⁶

The AAMCs were found to be doing well in providing free curative care, and free drugs and diagnostics but the services provided are inadequate in terms of ophthalmic, dental, preventive, community outreach, and counselling services and limited in comparison with HWCs.^27,28

The emerging threats of non-communicable diseases, mental illnesses and lack of comprehensive healthcare in the public facilities imply that people have to incur huge OOP.²⁹ Our study also shows that despite free care at AAMC, 28% respondents incurred OOP and only 1% of the respondents were linked with prepayment schemes, indicating financial vulnerability on account of healthcare.

The infrastructural aspects of AAMCs were satisfactory but could be improved and while the behaviour of the doctors was reported to be polite, their attitude towards hygienic practices was poor. While AAMCs have a mechanism to receive patient grievances, there is no system to receive patient feedback on service effectiveness.

Our study provides a framework and tool for PC evaluation. A sample size of 360 respondents across 18 facilities provides a good sample for an exploratory analysis carried out in this paper, although only those AAMCs were surveyed which were functional and had sufficient patient load. Demographic categories of respondents may not be representative of patients at AAMCs as exit interviews of consenting individuals were conducted. Responses are based on assessment by the respondents and could be susceptible to some subjectivity bias. The study was not designed to provide a model for scaling information provision at a national level, but to examine the mechanisms critical to the success of providing primary health care.

Our results are supported by other studies that show that the strength of community-clinics lies in physical accessibility, affordability (free drugs and diagnostics), increased utilisation by under-privileged communities, while the challenges are lack of awareness about the services available, incomplete record-keeping, low physician-patient interaction time, absence of preventive care, first-aid facilities, and functioning referral system.^30–33

In conclusion, AAMCs have been found to play an important role by bringing affordable healthcare in close proximity, with free medicines and diagnostics. Most users at AAMCs belong to lower income and education groups and were either foregoing healthcare or seeking care at informal providers. AAMCs have succeeded in filling this gap in healthcare demand. But there is an opportunity for increasing the coverage of healthcare through provision of comprehensive care with a proactive community outreach. Compulsory enrolment of neighbourhood population with an electronic database of patients has an immense potential to attain universal healthcare with improved longitudinality and coordination.

Acknowledgments

Authors would like to thank Indian Council of Social Science Research (ICSSR) for supporting the original study awarded to Institute for Human Development (IHD), Dr Alakh Sharma, Director IHD for supporting the conduct of the study and to IHD team comprising Dr Sunil Sharma, Mr Jaswant Rao, Ms Garima Gambhir, Mr Danyal Owaisy and Mr S.P. Sharma for carrying out the field survey and data compilation. The authors are grateful to the staff at John Hopkins University for sharing their Primary Care Assessment Tool, and the Government officials in India for their feedback on the survey instruments. The authors would like to thank the respondents for participating in the survey.

Funding

This paper is a part of the original study ‘Cost Benefit Analysis of Alternative Models of Financing and Delivery of Primary Healthcare in Urban Areas: A Framework for Public Private Partnership’ which was funded by the Indian Council of Social Science Research (ICSSR) through a grant given to the Institute for Human Development. The second author is a visiting professor at the Institute. However, no funding was received by the authors for either completing the study or writing this paper.

Conflict of Interest

None.

Ethical approval

Written consent was obtained from the respondents participating in the survey.

Author contributions

R.G.: conceptualisation, methodology, survey administration, data curation, writing—original draft preparation, reviewing and finalisation. C.C.G.: conceptualisation, methodology, validation, project management, writing—reviewing, editing and finalisation.

Data availability

Data will be provided upon request with due permissions.

References