Primary healthcare has been considered as a major agenda in many national and international policies and gained enormous attention by Global leader [1]. Following the 1994 International Conference on Population and Development (ICPD) in Cairo, emphasis was given on providing a broader range of primary healthcare (PHC) services in a package to minimize the costs [2]. The Essential Service Package (ESP) was targeted especially to women, children and poor, intended to offer quality services from one stop facilities that would be client oriented. Enhancing the quality of health care delivery in developing countries through provision of ESP is a key element to increased utilization of these services in the target population.

In the last two decades there was a huge growth in urban population in Bangladesh [3]. It is a great challenge for the public sector to meet up the growing needs of health care services in urban areas of Bangladesh, particularly for the urban poor. Under the Health and Population Sector Program (HPSP), the Government of Bangladesh aimed to provide ESP package accessible through fixed site clinics that was aimed at maximizing health benefits, meeting needs of clients, strengthening service delivery, and improving health systems management. In recent years, partnerships with NGO networks are sought to improve the access of primary health care services through introducing urban clinics with quality service provision. In Bangladesh, two NGO networks “The Urban Primary Health Care Project (UPHCP)”, and “Smiling Sun Franchise Program (SSFP)” were introduced with the intension of improving the quality of healthcare services in urban areas especially the poor and marginalized by provision of affordable health services in a sustainable manner [4,5]. Both the projects was targeted to provide increased accessibility, proximity of health care facilities, improved quality of services, and consequently increased user satisfaction.

Client satisfaction, a core element of quality of care has been associated with several patient aspects, namely therapy adherence and continuity of care [6] also with loyalty [7] of provider. Assessments of satisfaction allow the integration of the patients’ view into the operational activities, identification of gaps, and adjustment of imperfections in health services [8-10]. Andaleeb et al. reported that perceived quality of services was very crucial for achieving client satisfaction; quality of services as perceived by the clients were closely linked with satisfaction which included factors like responsiveness, assurance, communication and discipline at the facility [11]. A study done at the government facilities of rural Bangladesh reported that most powerful predictor for client satisfaction was providers’behavior which was given more importance by the clients over the technical competence of the provider [12]. Thus, it is not only important to know the result of the service experience, but also what are the causes and dimensions that lead to satisfaction or dissatisfaction.

GIZ introduced a multidisciplinary Project at City Corporation Level with the goal of strengthening urban health systems, establishing a framework of quality management principles and the facilitation of the delivery of quality services at primary health care settings. This study considered patient satisfaction as an indicator of quality of care that is aligned to client oriented approaches to service provision. It was also intended to identify the factors that are related to perceived quality of services so that more effective approaches can be taken to fine tuning and quality improvement at facilities. The present study explored both users and non-users’ perspective on perceptions regarding accessibility, availability of services in the locality, preference to alternative services and potential challenges and barriers for not availing services offered from the two selected primary healthcare facilities in the project area.

Methods

The study was a descriptive cross sectional study which used both qualitative and quantitative methods. A quantitative survey was carried out among customers/consumers at exit points of two types of healthcare facilities run by Urban Primary Health Care Project (UPHCP) and Smiling Sun Franchise Program (SSFP). In-depth interviews and Focus Group Discussion (FGD) was carried out among non-users of the services in the same catchment area. The study was conducted in the city corporation areas of Sylhet during 2009 to 2010.

Clinics under Urban Primary Health Care Project (UPHCP) and Smiling Sun Franchise Program (SSFP) provided ESP services in the Sylhet City Corporation areas to the underserved population. UPHCP covered about 339,281 populations in 18 wards under city corporation areas while SSFP covers 12 wards having a population of 223,059. The clinics targeted the low income population, migrants/refugees, and women and youth in providing primary care clinics like family planning, maternal care, female care, child care, and common diseases.

From each type of healthcare facility (SSFP and UPHCP) the required sample was 400 considering unknown proportion of client satisfaction 80% power and 10 degree of freedom. Thus, the total sample was 800. We included 7 clinics from each type of healthcare facility and respondents were proportionately distributed in 14 clinics.

Quantitative data

A semi-structured questionnaire was designed to examine several aspect of service delivery. Topics covered in the questionnaire were based on local context and service availability in the primary health care centers in the city corporation area. It considered many items under quality service provision like accessibility, waiting time, availability of basic amenities, satisfaction with cost of services, relationship between patient and providers, availability of laboratory, radiological and pharmacy facilities, information and communication. Socio demographic information of the respondents was collected along with care seeking preferences and current awareness of various health care providers. Clients were also asked about various aspects related to providers’ technical proficiency during consultations like proper history taking, physical examination, maintaining confidentiality etc. Users were asked whether or not they were satisfied with the care received, and then they were asked about their possible reasons for dissatisfaction.

Qualitative data

Two FGD (one with non-user males another with non-user females) and 17 in-depth interviews (IDIs) were done among non-users of clinic services to understand their perception, expressed needs and reported reasons for not using the clinic services. Respondents for qualitative data collection were selected purposively from the catchment areas of the clinics. Inclusion criteria of the respondents were; male and females who reside within the catchment areas of the selected clinics but did not obtain any services offered from the clinics. FGD and IDIs were done using flexible guidelines. Content analysis was done manually with qualitative information obtained through FGD and in-depth interviews. Data collection was anonymous. Informed consent was obtained prior to data collection.

Data analysis

Quantitative data was coded and then entered by data management assistants. Statistical software SPSS (version 17) were used for data analysis. Descriptive analysis was done and 95% confidence interval was presented where appropriate.

Ethical approval

The study was approved by the Institutional Review Board of icddr,b ( International Centre for Diarrhoeal Disease Research, Bangladesh).

Socio-demographic characteristics of the respondents

A total of 800 patients attending the various departments were included in the study. Table 1 shows socio-demographic characteristics of the respondents. The higher proportions of the respondents were adolescents, in the age group 20-24 and 25-29 years, received services from SSFP clinics (36.2% and 27%) compared to UPHCC clinics (30.6% and 22.8%). Majority of the respondents were women; 92% in UPHCC and 96% in SSFP. Higher proportions of respondents in UPHCC clinics (20%) compared to SSFP clinics had a family income of taka 3000 or less per month. The majority of the respondents was housewives and constitutes 74% and 81.9% for the UPHCC and SSFP respectively while the rest were students, day labor, maid servant etc. Most common occupation of the household heads for both UPHCC and SSFP was business (47.7% and 26%) followed by service (18.3% and 23%). About 20% of the respondents in both clinics reported that they had 4 members in their families.

Table 1: Socio-demographic characteristics of the respondents.

User’s views and perceptions on clinic and services

About half of the respondents in UPHCC clinic and 36.8% in SSFP reported that distance of clinics to their residence was less than one kilometer (Table 2). However, around 60.9% of the respondents in both clinics mentioned that they would require 1 to 10 minutes to reach the facilities. The most common transportation to reach the facility during last time visit was rickshaw or by foot in both facilities followed by baby taxi and bus. Among the total respondent, 70% of the respondents visited the clinics once or twice in last three months. Among the total respondents, most of the participants at UPHCC (25.4%) came for taking general treatment where common purpose of visit at SSFP was ANC (20.4%) respectively. In addition, purpose of coming to receive FP service, TT, child immunization, and ARI of child were 18.1%, 12.3%, 11.5% and 10.3% in UPHCC and 15.5%, 15.5%, 12.2% and 16.4% in SSFP respectively. More than 60% of the respondents in each clinic were aware about the following services provided by the clinics; FP services, ANC, and child immunization. Only few respondents (3- 9%) were aware that RTI/STI related services provided in the clinics.

Table 2: User’s views and perceptions on clinic and services.

Perceptions on quality of services (Satisfaction to the clinic services)

Table 3 showed the reasons for satisfaction. The main reason of satisfaction in UPHCC was ‘low cost services’ (51.6%) while ‘well behave from provider’ (80.6%) in SSFP (Table 3). Majority of the respondents came for taking treatment in UPHCC (42.9%) compared to SSFP (25%) due to free of service. Other reasons for satisfaction in UPHCC and SSFP were, waiting time was not long (30.6% and 14.8%), provider examine carefully (24% and 18.8%), experienced provider (14.9% and 3.6%), sufficient medicine supply (10.9% and 4.3%) and maintained confidentiality (8.5% and 8.9%) (Table 3).

Table 3: Reasons for satisfaction to the clinic services.

Experience of antenatal care:

During the data collection period, a total of 139 respondents had come to the clinics (77 in UPHCC and 62 in SSFP) for taking ANC services (Table 4). The most common suggestion during ANC visits (87.7% and 96.8% for UPHCC and SSFP) was to take nutritious food. About 25% (UPHCC) and 34% (SSFP) respondents stated that provider suggested for delivery in NGO clinics. Majority of the respondents in both facilities (92.2% and 98.4% for UPHCC and SSFP) mentioned that weight was taken during ANC visit. Other common assessments were done during ANC for both UPHCC and SSFP were, measurement of blood pressure (97.4% and 100%), height taken (46.8% and 48.4%), eye examination (67.5% and 90.3%), urine test (46.8% and 71%), ultrasonography (22.1% and 21%), and iron supplementation (57.1% and 67.7%). 27.3% of the respondents received TT from UPHCC while 40.3% of the respondents received TT from SSFP.

Table 4: Antenatal care.

User’s requirement for other services

The respondents were asked whether they required other services that were unavailable in the clinics; 28 users in UPHCC clinics and 15 users in SSFP clinics mentioned such event. Types of services demanded by users in UPHCC and SSFP clinics were; delivery supply (14.3% and 26.7%), (Table 5). 6.7 % of the respondents of SSFP clinics mentioned that Gynecologist should be there in the clinics while 3.6% of the respondents of UPHCC clinics required “X-ray” facilities.

Table 5: Types of other services required by the users (which are not available at clinics).

Utilization of child care services

A total of 68 users in UPHCC clinics and 56 in SSFP clinics visited for child health care for some common problems of age group 0-5 years. The commonly reported child health problems for which services were sought by the respondents in UPHCC and SSFP (Table 6) were; diarrhea (30.9% and 23.2%), cough (36.8% and 30.4%), asthma (13.2% and 1.8%), fever (14.7% and 26.8%), skin disease (2.9% and 1.8%) and others (1.5% and 16.0%).

Table 6: Types of health problems experienced by children.

Non users’ and new comers’ perspectives

The respondents were asked about the reasons for not attending the clinics for services even they were living in the vicinity of the clinics.

Most of the female non users mentioned that they did not know about the specific services provided by the clinics. Few of them reported that clinic is far away from their residence. While private hospitals are located nearby so they obtained services from there. Some of the women thought that these clinics were only for provision of contraceptive methods so they did not consult them for other health reasons. Few women perceived that these clinics do not provide good quality treatment as they refer to other hospital. Participants expressed their needs as clinics should have child specialists, should have the arrangement for delivery, should have all arrangements for management of delivery complications, and should provide free treatment and medicine supply for poor patients.

Most of the male non-users opined that clinics were only accommodative for females as they could see only female patients visited the clinics. They thought that males are not being treated in these facilities. Some of the male participants mentioned that men’s secret diseases like syphilis are not being treated in these clinics whereas, they knew about few ‘MBBS’ (qualified) doctors around the area whom they could consult for health problems. Males expressed their needs as: treatment should be provided by male doctors to males, clinics should perform wide range of pathological tests, separate sitting arrangement required for male & female. They demanded that qualified doctors ‘MBBS’ should be available in the clinics. They expected that male health workers should visit door to door to promote/campaign for clinic services among males. They also expected that clinics should cover wide range of services comparable to services available in other large facility like ‘Osmani Medical College hospital’.

Self treatment was common among the non-users (as defined in the method section). It was found that respondents preferred to buy medicines directly from pharmacy rather visiting any health care facilities for common health conditions. One such expression was,

“I didn’t suffer from any dangerous disease so I did not need to go to any doctor. If I suffer from cold or fever then I buy medicine from pharmacy.”

Most of the non-users reported that they did not know about the services offered by the clinics. One respondent said,

“I don’t know about these services. Nobody visited my house to tell about the services, I have no idea about these clinics.” Another male respondent expressed his views as,

“People say, those are clinics for females where males are not being treated so why should I go there”. Unawareness about the clinics and range of services provided was a major cause for not visiting the clinics. Male also thought that clinics provide services only for females.

Few respondents wanted that clinics in their locality would take care of wide range of diseases particularly chronic diseases like diabetes. Such a respondent stated, “I am a diabetic patent. As they do not provide treatment for diabetic problems, I don’t go there.” In few instance nonusers relied on their relatives for consultation for health problems. “I always visit to maternal uncle for my health problems. I feel comfort to consult a family person with whom I can freely share my problems and he/she would listen to me minutely”. Some of the respondents were influenced by perceptions/notions deciding not to visit the clinics. One expression was, “I have heard from others that the ‘standard’ (meant quality) of services of these clinics is not good. They don’t examine the patient with care and don’t want to listen to the history of disease”.

Almost all the respondents expressed that they preferred to get free services and treatments. Some expressions were;

“Government hospitals don’t ask for money but these clinics ask for money. If I would be given free services I would prefer to go there.”

“I have heard these clinics l asks for money whereas in govt. hospital one can get service without fee”. In few instances external look of the facility was important to the respondents. One opinion was, “This clinic is not to the level of my expectation; facilities are like small houses which don’t look like hospital.” “There are many ‘big’ hospitals in my locality where I can get all kinds of treatment from expert doctors (MBBS), spending small amount of money.” Few respondents were discouraged to visiting the clinics as they heard from their relatives that the clinics do not provide good services, such a respondent stated,

“I am not comfortable receiving treatment from such clinics because one of my relatives condition was worse after receiving their treatment, so they had no way but to refer the patient to other hospital.”

In summary, the reported reasons for non-use of the facilities were-clinics were not accommodative/equipped for service provision of chronic diseases, external look of the clinics were not like formal hospitals, clinics were perceived to being catering females not males, lack of equipment, lack of specialist physicians, lack of capacity to cover wide range of pathological tests, services were not free of cost, and quality of services were not up to the level of respondents’ expectation.

The study reported that new comers were less aware compared to the older residences in the area about the location of the health care facilities and range of services offered by the facilities. The new comers came to know about the facilities from their neighbors who resided in the area for long. Perceived quality of care of the specific facility and experiences of by the neighbors were important influential factor to the new comers deciding whether to visit that facility.

Respondents around UPHCC catchment area who not used service from the clinic were expressed the following expectations from the clinic: free treatment and medicine supply, free caesarean operation, provision of less expansive services, free services for poor people (though it is available but non user were unaware about this) (it is already done but non-users were unaware about this), information about clinic should be done through advertisement in newspaper, TV and others media.

Respondents around SSFP catchment area expressed the following expectation from the clinic. Respondents expressed that facility should cover wide range of pathological tests, more physicians having MBBS degree, motivation of the people is needed for service utilization, should employ gynecologist, eye specialist, and child specialist, physicians who can treat and manage diabetes, s, should conduct hysterectomy operation, should employ male physicians for treating males, cabin facility for staying over nights in clinics if required, services comparable to other hospital.

The present study attempted to assess the availability, accessibility, and perceived satisfaction of the patients at selected primary health care centers in a city corporation area in Bangladesh. Although the results of the study indicate that most of the respondents interviewed were generally satisfied with the services they received, it identified some needs and gaps to be addressed for better service provision. The findings of this study would be useful to the program managers if these are transformed into actions for improving the quality of services by adjusting the gaps.

The overall satisfaction of the respondents with the services they received from the primary health care centers was high (over 90%), which is similar to the study done in Kuwait [13], in Muskat (81%) [14], and in Tehran [15]. However, there are few other studies where overall satisfaction of primary health service recipients was little low: 60 to 75% [16,17]. These variations in terms of level of satisfaction possibly resulted due to variation in the study settings, the programmatic approaches, and differences in study population. However, client satisfaction could also be influenced by socio cultural differences and variations in levels of literacy [10], and methodological variations of the study [18]. Studies done in Bangladesh and India reported that longer waiting time was a major element for liking or disliking a particular facility [12,19]. The present study reported that waiting time was acceptable to most of the clients, which might have attributed positively to their overall satisfaction.

Both users and non-users in the present study expressed for some needs and expectations: they wanted to receive a wide range of services from the facility, needed more options for laboratory tests, demanded for specialist physician for child health care, and expected to have arrangements for C-section deliveries. Another study done among clients in an urban primary health care center reported that coverage or package of services in primary health care services facilities were very crucial and might affect consumers’ satisfaction [11]. Study done in Tanzania and Burkina Faso also emphasized that drug availability in the facility was a key element in terms of client satisfaction with primary health care services [20,21].

The present study attempted to generate information on both users’ and non-users’ perspectives capturing the situation in a broader aspect. Some of the non-users preferred alternative facilities like government hospitals which offered free services. Akin and Hutchinson also reported that prices tend to deter use of a particular facility [22]. Similarly, Baltussen et al. and Lobo et al. emphasized that low price of services contributes positively to satisfaction of the clients [9,21]. The clinics in the study area already had the provision of offering services with low costs by introducing special cards to the poor but many of the non-users seemed to be unaware about it. However, Fein points out that consumer unawareness about medicine and health, combined with fear and customs may inhibit the consumers from utilizing services [23]. Clients in the present study valued the formal structural look of the facility. Gilson et al. also found that structural capacity/arrangement of a facility might be an important factor for being chosen by the clients [24]. However, Akin and Hutchinson reported that perceived severity of illness may also influence the choices of healthcare facility and would be one of the reasons for bypassing facility nearby [22]. Female non-users mainly expressed their demand on delivery facility, ultrasonography, hysterectomy operation while male demanded for male physician for their clinical care.

The study has some limitations. The responses were selected from two types of primary health care clinics having different operational structures in service delivery, so we did not attempt to make comparison but conducted descriptive analysis. We did not perform analysis at facility or individual levels. We assessed overall satisfaction but did not apply scoring method using scales. The results from the study are specific for selected health facilities; results should not be generalized for other facilities in other city corporation areas.

An attempt to assess different parameters of quality health care at the primary health care facilities has provided us certain areas that need corrective efforts to improve quality. More diagnostic and inpatient facilities need to be made to enhance the comfort and satisfaction of the patients and that can also reduce the necessity of referral. Increased use of BCC materials are needed for effective communication with the patients during service provision. Services providers can tap additional needs for the entire family, thus unexpressed needs of the other family members can be addressed. There are ample opportunities to campaign for these clinic facilities in the locality particularly targeting the nonusers. Future study can focus strategies how to address needs of nonusers, for instance, community health promoters can be introduced building awareness at the community about availability of services in the facility and enhancing utilization of care. Further study should be carried out exploring the providers’ perspectives assuring improved and quality services.