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Indian Journal of Community Medicine

Comparison of Public and Private Malaria Services: Implication for Improving the Quality Perception Among the Users from a Low Socio-Economic Locality of Surat, India

Author(s): Vibhavendra S Raghuyamshi, Vikas K. Desai and Pradeep Kumar

Vol. 28, No. 2 (2003-04 - 2003-06)


Research question: Services for malaria care provided by which sector (public or private) are preferred by the community?

Objectives: To determine the hierarchy of the service related factors influencing the utilization of malaria services (irrespective of the sectors) and to compare the urban health centers (UHCs) run by the Surat Municipal Corporation (SMC) and the private practitioners (PP's) on these factors.

Study design: Cross-sectional descriptive study by interview method.

Setting: Inhabitants of a poor locality of Surat city.

Participants: Informants (one each) from the 100 households from the locality selected by random sampling.

Study variables: Service related factors influencing use of malaria services and rating UHCs and the PP's on these factors.

Statistical analysis: Calculation of mean scores with 95% confidence intervals and t statistics.

Results: Seven factors were identified and rated by the community as important for malaria care. 'Good medicines' was perceived as most important and the 'less waiting period' as least important factor. Participants rated the services by PP's as better than of UHCs for malaria care for all the seven factors. Except for two factors namely doctor is good and the medicine is good, the difference was statistically significant.

Keywords: Malaria care, Private practitioners, Public care providers


Public health sector is often blamed for inefficiency and non-responsiveness1. On the other hand, private sector is perceived as more flexible and client oriented. In terms of satisfaction, users appear more satisfied with the PP's2, though it could be relative in the absence of real alternative. However, this cannot be ignored since satisfaction is seen as the measure of the quality of services3. Studies have highlighted the weaknesses in the public sector and the preference for the private services4. At the same time, it's also acknowledged that services at public facilities are more rational, guideline-based and conservative on drug prescribing5,6.

The private health sector of most of the developing countries, though popular, is poorly regulated and, therefore, has its down side as well7,8. Tight government fiscal situation has renewed the interest in public-private partnership9. There is much to be gained by learning from the strengths and weaknesses of each of these two sectors. There are some studies on the factors influencing the utilization of the health services4,10. However, we know little on the hierarchy of these factors that may help for priority setting. In this cross-sectional, descriptive study, conducted in a poor socio-economic locality of Surat City of India in 1999, we have attempted to determine it.

Material and Methods:

Hundred households were interviewed using structured interview technique from a lower socio-economic locality of Surat City. The choice of the locality was based on the logistics and expectation that the utilization of the UHC would be more in a lower socio-economic area. The sample size was calculated using the formula, n = (t2pq/d2) (where t = 1.96 at 95% confidence; p = population proportion; q = 1-p; d = allowable error. For this study, we presumed maximum variability, hence p = 0.5; q = 0.5; d = as 20% of p, i.e. 0.1 giving a power (1-d) of 80%. Sample size thus yielded was of 100 informants. The sample was drawn through random sampling. The interview covered questions on the service related factors affecting the utilization of malaria services and how public and private services compared on those factors. The eldest available household member above 15 years present at the time of survey was interviewed. In case the house was locked or no one above 15 years was available, next sampled house was visited.

Prior to the data collection, a limited interaction with select families of the area revealed seven common service related factors influencing the utilization of malaria services in this locality. These seven factors were used to determine the order of their preference. Finally, the public and private malaria services were compared. The seven service related factors were each written on separate card of different colours. The participants were asked to arrange the cards according to their preference - in a descending order with the most favoured factor on the top. The factors were then given scores based on the arrangement of the cards. The top card getting the highest score of 7 and the bottom card the lowest of 1. The weighted average of these scores gave the hierarchy of the service-related factors. At the same time each respondent was also asked to rate and score public and private malaria services as good (3), average (2) and bad (1) for each of the seven factors. This quantification gave the comparative standing of public and private malaria services as perceived by the study participants.

Results: Service-related factors affecting the utilization of malaria services:

Hierarchical arrangement of the service related factors affecting the utilization of malaria services both in public and private sectors. 'Good medicines' with the highest score was the most important factor, whereas, 'less waiting period' with lowest score was the least important factor. The first four factors i.e. good medicines, gets relief, good doctor and good behaviour of the doctor would be referred as 'quality-related' factors in the following discussion.

Comparison of UHC and private clinics on the service-related factors:

Table I: Comparison of UHC and the private practitioners on the service-related factors (n=100). (All the scores are out of 3)

Factors Private Practitioners (PP's) UHC "t" "p"
Mean 95% CI Mean 95% CI
Gets Releif 2.42 2.28, 2.56 2.10 1.95, 2.25 3.13 0.002
Doctor is Good 2.45 2.31, 2.58 2.27 2.12, 2.42 1.80 0.072
Good Medicines 2.55 2,41, 2.69 2.51 2.37, 2.65 0.41 0.681
Good Ambience 2.56 2.44, 2.68 2.15 1.98, 2.32 4.01 0.0001
Doctor's Behaviour is good 2.56 2.43, 2.69 2.29 2.14, 2.44 2.64 0.0088
Outlet near Home 2.74 2.64, 2.84 1.83 1.67, 1.99 9.47 <0.0001
Waiting Period less 2.77 2.66, 2.88 1.78 1.64, 1.92 10.95 <0.0001

Study participants rated private practitioners (PP's) better on all the seven factors. Other than 'doctor is good' and 'good medicines', all other factors were significantly different between the UHC and the PP's. Another interesting observation was that the least favoured service-related factors, i.e., less waiting period and 'near your house' showed the most significant difference between the UHCs and the PP's (Table I).


Factors influencing the utilization of health services are classified into: characteristics of the subjects, disorders and the service11. The focus of this study was on. the service-related characteristics. The two important findings were: (a) 'quality related' factors were important utilization determining factors, in both PP's and UHCs and (b) major difference between the UHC and the PP's was the waiting period and the geographical accessibility of the health facility. The UHC and the PP's also differed on cleaner appearance, better behaviour of the doctors and getting relief. These differences, despite being significant were less so compared to the earlier two differences. It was further apparent that regarding dispensing good medicines and professional competency of the doctors (good doctor), there was not much difference between the UHCs and the PP's.

In our study area there was one UHC with a staff of over 30 including 2 qualified doctors; laboratory and indoor facilities; and a free referral system. It was within 3 kms. of walking distance from most of the study participants' residences and offered consultation for only Rs. 3 including free medicines and laboratory investigations. Despite this, the study participants rated PP's high on all the factors. Given that the UHC is in the neighbourhood with not much difference in the waiting time compared with PP's (35 and 25 minutes respectively)12, and that the study participants mentioned 'quality factors' to be most important utilization determining ones, it appears that there were other apparently 'invisible' reasons for this PP preference. The contradictory nature of the results (i.e., despite having cheap, geographically near and reasonably good malaria services at the UHC, the study participants favoured PP's on all the seven factors) hinting that these 'invisible' reasons could be moral hazard13 and or misplaced perception of the 'quality of malaria services' of the study participants. Cheap consultation, free medicines and free laboratory services were probably responsible for moral hazard, where people perceive free and cheap services to be bad or of poor quality. On the other hand it appears that the study participants perceived quality only as convenience. For them probably less waiting period and less travelling time were the only quality determining factors. Though these two factors are important determinants of quality, yet not too much importance should be laid on them, especially in settings where private health sector is poorly regulated, leading to lot of malpractice14. Additionally, on demand15 and liberal despensing6; flexible work hours and home calls16 make PP's more convenient to use, which may be inappropriately conceived as 'quality'. Thus, there is a need for improving the quality perception of malaria services, emphasizing on the professional criteria of quality among the users. Incorporating some incentive system for motivating the users to rely on the 'real' quality rather than only on the convenience factors can facilitate this process. Previous studies identified geographical accessibility10 and quality of care17 as two important service-related factors determining the utilization of the health services which are consistent with the findings of our study. However, we have also explored other factors in addition to these and obtained their hierarchy. We also compared UHC and the PP's on these factors. We have tried to show that in our context the PP preference for malaria services could be due to moral hazard and misplaced quality perception. Nevertheless, there is a need to conduct this study at a larger scale to have more power and precision.

It seems probable that the PP's can borrow guideline based treatment approach from the UHCs and the UHCs can borrow patient oriented, customized service approach (positive behaviour) from the PP's. This mutual improvement on the weaker features of both the UHC and the PP's could create a positive environment for broader, longer and more meaningful partnership between the two.


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Vibhavendra S Raghuyamshi: Deptt, of Oral Health Policy and Epidemiology, Harvard School of Dental Medicine, 188 Longwood Avenue, Boston, Massachusett 02115, USA
Vikas K. Desai and Pradeep Kumar: Deptt. of Preventive and Social Medicine, Government Medical College, Surat 395001, India

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