1. Department of International Health Effect of quality improvements on equity of health service utilization and patient satisfaction in Uttar Pradesh, India David H Peters Krishna Rao GNV Ramana February 19, 2004

2. Background: Uttar Pradesh (UP) Population: 166 million U5M: 123 /1,000 births TFR: 4.0 children Female Literacy: 43% Poverty Headcount: 42% Public Health Services: Low quality Low satisfaction Low utilization Large SES inequities

3. Intervention: Uttar Pradesh Health Systems Development Project (UPHSDP) Physical Inputs: – Essential drugs delivered – Repairs of buildings and equipment Management Improvements: – Motivational exercises for managers – Management training Human Resources Changes: – Relocation of staff to fill mismatches – Visiting clinician service initiated

4. Research Questions Can improving the quality of public clinical services in a resource poor environment in India improve: (a)utilization of health services (b)patient satisfaction? For disadvantaged groups?

5. Methods and Sample Uttar Pradesh Health Facilities District Hospital (DH), Female DH (FDH), Community Health Center (CHC), Primary Health Center (PHC) Control (117) DH 25, FDH 25 CHC 27, PHC 30 Project (117) DH 25, FDH 25 CHC 27, PHC 30 Project (25) DH 6, FDH 6 CHC 7, PHC 6 Control (22) DH 6, FDH 6 CHC 5, PHC 5 Facilities scored on infrastructure, utilization and area economic characteristics; poorer scoring facilities assigned to UPHSDP July 2000 UPHSDP effective Follow-up survey Apr-May03 Baseline survey 1999; Control facilities selected randomly from non-project facilities; Convenience sample of patients for exit interviews.

6. Study Sample Size Number of Facilities Number of Patients 1999 Number of Patients 2003 ProjectControlProjectControlProjectControl PHCs65123108124103 CHCs75184106218148 Female Hospital 66155164183182 District Hospital 66195209370347 Total2522657587895780

7. Variables Studied Outcomes New Outpatient Visits Overall Patient Satisfaction Scale: 1 (Strongly Disagree) to 5 (Strongly Agree) Measures of Inequality Caste Status Housing Asset Quintiles (Follow-up survey)

8. New Outpatient Visits at Community Health Centers

9. Changes in Mean New Outpatient Visits by Level of Facility 0 100 200 300 400 500 600 700 District HospitalFemale HospitalCommunity Health Center Primary Health Center Difference of difference in mean monthly new OPD visits ((Project 02-Project 00) - (Control 02-Control 00)

10. Changes in Mean New Outpatient Visits by Caste & Level of Facility -600 -400 -200 0 200 400 600 800 1000 1200 District HospitalFemale HospitalCommunity Health Center Primary Health Center Low CasteHigh Caste Difference of difference in mean monthly new OPD visits ((Project 02-Project 00) - (Control 02-Control 00)

11. Changes in Mean New Outpatient Visits by Housing Type & Level of Facility -800 -600 -400 -200 0 200 400 600 800 1000 District HospitalFemale HospitalCommunity Health Center Primary Health Center KachaSemi-puccaPucca Difference of difference in mean monthly new OPD visits ((Project 02-Project 00) - (Control 02-Control 00)

12. Distribution of New OPD Visits at CHC by Wealth Quintile 2002 Project Concentration Index: -0.08 Control Concentration Index: -0.10

13. Distribution of New OPD Visits at District Hospital by Wealth Quintiles 2002 Project Concentration Index: 0.33 Control Concentration Index: 0.23

14. Patient Satisfaction at Project and Control Facilities, 1999-2003

15. Changes in Patient Satisfaction By Level of Facility -0.20 -0.10 0.00 0.10 0.20 0.30 0.40 0.50 0.60 0.70 District HospitalFemale HospitalCommunity Health Center Primary Health Center Difference of Difference in Mean Outpatient Satisfaction (Project 03-Project 99) - (Control 03-Control 99) ** * ** p-value < 0.01 * p-value < 0.05

16. Changes in Level of Satisfaction By Caste & Type of Facility -0.40 -0.20 0.00 0.20 0.40 0.60 0.80 District HospitalFemale HospitalCommunity Health Center Primary Health Center Difference of Difference in Mean Satisfaction (Project 03- Project 99)- (Control 03-Control 99) Low CasteHigh Caste ** * * ** p-value < 0.01 * p-value < 0.05

17. Changes in Level of Satisfaction By Type of Housing & Type of Facility -0.60 -0.40 -0.20 0.00 0.20 0.40 0.60 0.80 1.00 1.20 1.40 1.60 District HospitalFemale HospitalCommunity Health Center Primary Health Center Difference of Difference in Mean Satisfaction (Project 03-Project 99)-(Control 03-Control 99) KachaSemi-puccaPucca ** * ** p-value < 0.01 * p-value < 0.05

18. Distribution of Patient Satisfaction at CHCs by Quintile 2003

19. Project Impact on Patient Satisfaction Using Propensity Score Matching Project (n) Control (n) Average Project Effect SET-Stat All Facilities880780 0.0540.0461.182 District Hospitals369347-0.0970.083-1.172 Female District Hospital183182-0.0620.113-0.547 Community Health Center 218148 0.2860.0743.853** Primary Health Center110103 0.4070.1432.851**

20. Conclusions Reform efforts can improve utilization and patient satisfaction, but relationships are complex Effects stronger for poor at lower levels of facilities, where intervention more complete: –Utilization increases preferentially by low caste and poorly housed at PHCs and CHCs, but mixed effects at hospitals –Patient satisfaction increases at PHCs and CHCs, but not consistently for different vulnerable groups Better consistency in management of evaluation would yield better results