Assessment of primary laboratory facilities for rural health care preparedness in District,

Rahi Jain1 and Bakul Rao2

1Centre for Technology Alternatives for Rural Areas (CTARA), Indian Institute of Technology Bombay (IITB), , India-400076, Telephone:+91 9869762701, [email protected]

2Centre for Technology Alternatives for Rural Areas (CTARA), Indian Institute of Technology Bombay (IITB), Powai, Mumbai, India-400076, Telephone:+91 9619182552, [email protected] Corresponding Author: Rahi Jain, Centre for Technology Alternatives for Rural Areas (CTARA), Indian Institute of Technology Bombay (IITB), Powai, Mumbai, India-400076, Telephone: +91 9869762701, [email protected]

Acknowledgement

We would like to acknowledge the support provided by the Dr. Prashant Narnaware, District Collector,

Osmanabad, for granting us permission and providing support during the stay in

Osmanabad. We would also like to acknowledge the support of District Health Office, Osmanabad,

Maharashtra and all the respondents for their support.

Funding: None

Conflict of Interest: The authors declare that they have no conflict of interest.

1 Assessment of primary public laboratory facilities for rural health care preparedness in Osmanabad District, India

Abstract

Government of India has provided Indian Public Health Standards to improve rural health care services and health status, but still rural laboratory is a cause of concern. This study is performed to understand the laboratory facility-level gaps that need to be addressed to improve the public primary health centers (PHCs) present in rural areas. The laboratory assessment is performed for governance, financing, resources and services and results are validated with the PHC laboratory performance. The current assessment shows critical gaps in the facilities regarding governance, services, resources and financing required for the laboratory services at the rural primary health care level. Governance and services need to be strengthened the most followed with sustained availability of resources and financing.

Poor health status in rural areas necessitates public health response based on health systems. Therefore, health system preparedness in form of laboratory services are essential in primary health care facilities.

Keywords: health care facility; facility preparedness; public laboratories; rural health; India; Bayesian

Network

1 Introduction

The rural areas in India hold records for 80% of all deaths and nearly 90% of deaths due to communicable diseases, as well as records for maternal, perinatal, and nutritional conditions (Office of Registrar

General, 2009). Prevalence of poor health care risk factors (unhealthy diet, reduced physical activity, smoking, hypertension, poor food quality) is increasing and recent studies showed that hypertension and diabetes in 40% (Devi et al., 2013) and 10% (Nazir et al., 2012) of adult Indians respectively. Risk factor control requires multi-disciplinary approach that includes strengthening health system, approaching social determinants of health and health care financing (Gupta et al., 2011). Majority users belongs to economically weaker sections (Pandey et al., 2017; Ranson et al., 2012), which hinders their access to private facilities that are not always affordable. This makes public health care system more responsible

2 for the rural health care.

In accordance with the Alma Ata Declaration (World Health Organization, 1978), India focused on providing primary health care facilities to rural areas. India launched National Rural Health Mission

(NRHM) in 2005 to provide preventive and basic curative and laboratory health care services in rural areas for the major health issues (MoHFW, 2005). It aims to provide rural health care services and integrate horizontally all vertical disease-based programmes at district level. Primary health care system in rural India has Primary Health Center (PHC) with catchment area of 30000 rural population, which is first point of contact for i) laboratory services, and ii) medical doctor/officer (MO) in rural areas

(MoHFW, 2012).

NRHM provides Indian Public Health Standards (IPHS) to maintain the PHC quality (MoHFW, 2012).

However, over the years PHC have focused on providing the preventive, childbirth and treatment services in rural areas, as a consequence it is possible that certain key aspects of laboratory services are neglected.

Medical laboratories strengthen the health care system by providing up to two-third of medical decision making (Forsman, 1996; Khatri and Frieden, 2002). The current study was performed to understand the functioning and preparedness of laboratory facilities in PHCs using Osmanabad District, Maharashtra,

India as case study.

2 Method

2.1 Settings

The Osmanabad district has eight blocks (Talukas) with 84% of the entire district’s population (1.7 million) inhabiting in rural areas (Office of Registrar General and Census Commissioner, 2011). It is one of the India’s drought prone districts (Gore et al., 2010), so rural areas do not have access of 24*7 water supply. All villages are electrified (Rural Electrification Corporation Limited (RECL), 2017), but power cuts are common in villages.

The district has secondary and primary health care facilities, but do not have any tertiary health care facility like medical colleges, speciality hospitals. The urban areas have secondary health care facilities 3 i.e., one District Hospital, one Maternity and Child Hospital, three Sub-district hospital and seven

Community Health Centers (CHCs). The rural areas only have primary health care facilities that consist of 206 SCs and 42 PHCs. The interaction with District Health Office (DHO) bureaucrats and health care facility staff suggests that PHC pharmacists and DHO bureaucrats do the district level budget making for the rural laboratory facilities. The budget making is done based on past field experience and does not involve use of any mathematical model or representation from laboratory experts or staff.

2.1.1 Services

DHO focuses only on haemoglobin, HIV, malaria, tuberculosis, pregnancy, urine albumin, urine sugar, blood sugar, and blood group tests services of laboratories in PHCs. All tests, except malaria, and tuberculosis, are kit-based tests that provide results in 1–2 minutes. The remaining two tests are microscopy-based tests and provide results in 10 minutes.

Quality assurance is performed only for malaria and tuberculosis tests with 2–3% of the monthly tested samples are sent to district malaria and tuberculosis offices respectively, to crosscheck the results. The district biomedical waste management involves four steps: waste segregation, disinfection, closed dumping, and deep-pit incineration. Alternatively, instead of incineration, waste can be given to a biomedical waste collection agency. The PHCs have cleaning staff to maintain PHC cleanliness including laboratories.

The other basic services provided are seating and toilet facilities. The PHCs provide services of collecting patient malaria and tuberculosis sample from home, SC as well as from PHC OPD and inpatient department (IPD) and send the sample to the nearest public health facility for testing. The OPD hours are based on local need to increase laboratory access. The morning timing to start OPD vary from 8:00 am to

9:30 am, while evening OPD is started at 4:00 pm across all PHCs. Additionally, laboratory sample testing starts almost simultaneously upon laboratory sample collection. The test results and report delays depend on test type and the laboratory location. Kit-based tests have lower time delays when compared to the other tests. Further, time delays are less when PHC has laboratory in its premises as compared to PHC

4 not having laboratory in its premises.

2.1.2 Resources

The resources are provided by DHO, but PHC can procure resources using RKS funds to meet its emergency or unique local needs. In case of consumables, the procurement process for laboratory consumables is manual and is initiated by the PHC Pharmacist. Pharmacist prepares an indent form, obtains MO approval and takes approved form to DHO inventory store. The store clerk approves the form and provides stock to the pharmacist, who brings it back to the PHC.

The laboratory instruments maintenance takes 1–15 days after repairperson/engineer examines the instrument. The repairperson/engineer is accessed through either routine maintenance or non-routine maintenance mechanisms. Routine maintenance involves periodic checks (once per 1–12 months) of the instruments to minimise breakdown. It can be done either by supplier or higher authorities. Non-routine maintenance requires that the PHC or LT take initiative to repair instruments, which is done by either contacting supplier/private repairperson or higher authorities. If the instrument is under an annual maintenance contract, the supplier repairs the instrument, otherwise, the instrument can be taken to any local private repairperson. Higher authorities can respond to the PHC’s needs within 1–180 days, as the repairperson either visits PHC or PHC takes an instrument to a repairperson/higher authority office.

The PHC data management is done both manually and electronically using registers and online software

(like District Health Information System [DHIS] and Maternity and Child Tracking System [MCTS]) respectively. Manual records are more comprehensive and less accessible for higher authorities than electronic data. Only summary of manual records is sent to higher authorities. Some of the manual records maintained are type of test, test results, patient profile and consumable inventory. Electronic records do not maintain records of tests performed using RKS funds, nor do they account for tests that are not in higher authority focus.

2.1.3 Financing and Governance

PHC mainly gets resources and services from higher authorities. Only limited monetary funds ($2681.4 5 per year (1USD=65.27INR)) called as Rogi Kalyan Samiti (RKS) funds are provided by NRHM to meet emergency needs (MoHFW, 2012). In terms of governance, MO is head of the PHC and is responsible for day-to-day PHC governance, operations and decision-making (MoHFW, 2012). In India’s centralized governance structure (explained in Appendix I), MO represents the PHC to higher authorities.

2.2 PHC Laboratory Preparedness Analysis

The 42 PHC laboratories of Osmanabad District was analysed for its governance, financing, resources and services status. The visit was made to PHCs and interactions with PHC MO and LT and other staff members were done based on their availability during July–August 2015.

The questionnaire survey is prepared to assess the PHC laboratory. The questionnaire is prepared using the various criteria given in the IPHS. Certain other criteria were added to the list based on past field experience and interactions with public health professionals. The complete list of criteria is classified into services, resources, financing and governance, which is given in Appendix II. The PHC gets the score of

‘one’ or ‘zero’ for each indicator based on whether it meets or does not meet the indicator criteria.

2.3 Statistical Analysis

The percentage of criteria met by the PHC out of the total number of criteria provides the total preparedness score of PHC laboratory. The preparedness score of each category is also calculated for each PHC.

2.4 PHC Laboratory Preparedness Validation The PHC laboratories were analysed to determine their performance for validating the laboratory preparedness results. Accordingly, the Bayesian network analysis is performed to understand the performance of PHCs based on their laboratory status. Bayesian Networks (BN) graphically represents probabilistic relationship between the parameters in the system as well as marginal probability of parameters. BN has two components namely nodes and arcs that represent parameters and connection between parameters respectively. The arc formed between the parameters is such that the parameter representing condition/constraint is the parent node and the parameter representing the occurrence of an 6 event in the given condition/constraint is the child node. The values of the arc are conditional probability of occurrence of an event given the probability of parent node. It does not have any feedback loop and provided directed relationship between parameters(Cooper and Herskovits, 1992).

The BN model was developed for PHCs using six parameters namely governance, financing, resources, services, staff workload (SW) and number of samples collected (NSC). The data for SW per week and

NSC per week was provided by the DHO, Osmanabad. The study used hill-climbing (HC) algorithm in

‘bnlearn’ package in R to prepare model (Scutari, 2009). HC is a score-based algorithm in which a random sub-optimal solution of model is built and solution is improved till desirable condition is maximised. It suffers from the issue of local maxima (Yuret and Maza, 1993) and wrong linkage

(Friedman et al., 1999). Accordingly; the model is built in two steps. In first step, the base model is prepared using the unconstrained HC algorithm. In second step, certain parent–child node relationship constraints were added to HC algorithm based on the base model iteratively to obtain the final model. The statistical condition optimised for the model is Bayesian Information Classification (BIC), which is commonly used for discrete data sets (Neath and Cavanaugh, 2012).

3 Results and Discussion

The good laboratory must meet all the IPHS and other criteria used in this study. The study is performed for the 42 PHC laboratories in the Osmanabad District, India. During the field study, the responses of all laboratories for all criteria could not be obtained, as the target respondent (such as the LT or MO of the

PHC) was not always available.

3.1 PHC Laboratory Preparedness

The response for all the criteria is obtained for 15 out of 42 PHC. It is found that overall preparedness level of PHCs varies from 26.92 to 50% with average preparedness level of 38.72% (Figure 1). The preparedness status is lowest for service category with only six out of 31 responding PHCs have criteria preparedness score of more than 50%. The average preparedness level is lowest for governance category

(33.33%). This indicates a need to strengthen the laboratories in PHCs.

7 3.1.1 Governance

MO plays the critical role in the PHC governance as (s)he is the head of the PHC. Accordingly, for good

PHC governance, a good MO governance capability is the prerequisite. However, this study shows that the governance capability of MO is inadequate (Figure 2). It is found that less than 50% MO think that they have decision-making authority for day-to-day operations (IG1). Further, this issue is reflected in the other indicators. Many MO struggle with decision-making as they struggle to estimate the timeline for decision implementation (IG2) and find the decision-making process difficult (IG3). The good PHC laboratory functioning requires a better planning and understanding of the time it would take to upgrade/repair instruments (IG4) and access to different resources (IG5), but many MO struggle with it.

Finally, a good governance key characteristic is trust placed by the leader in its staff and its services (IG6)

(Wong and Cummings, 2009), but the study finds that many MOs are unable to meet this criteria. Such a scenario of no representation of the laboratory and weak governance capability of MO can affect the functioning of the PHC laboratories.

3.1.2 Financing

RKS funds are very limited and used to meet the emergency and low-cost needs of the PHC. The study finds that at least 48% of the PHCs are unable to meet local laboratory needs based on the resources provided and they have to rely on RKS funds (IF1) (Figure 2). It is important to note that the number of unsatisfied PHCs could change, as the DHO may not provide resources for all tests in all years. Further, the most of the RKS funds are used for performing tests mentioned in IPHS (Table 1).

3.1.3 Resources

According to IPHS, the resources required for PHC laboratory’s testing services are workforce, diagnostic infrastructure, consumables, and information. However, considering the reference scenario in which each resource indicator standards are met by all PHCs, it is found that PHCs are not meeting all the resource indicator standards (Figure 3). It is found that there is deficit of workforce (IR1) and its quality (IR2).

Only 23 out of 42 PHCs have the LT and only 9 out of 23 LTs are skilled enough to perform tuberculosis

8 testing. (Rao et al., 2013) had mentioned that there is a lack of workforce in rural health institutions in

India. Further, during the field interactions respondents mentioned that MOs are not given in-service training to manage PHCs and many LTs are not given complete in-service training for better performance of existing tests like malaria or to conduct tests like tuberculosis. The implication of unmet IR1 and IR2 criteria is that the other PHC staffs have extra work i.e., i) to collect malaria and tuberculosis samples, ii) send collected malaria and tuberculosis samples to other public health facility, and iii) perform kit-based tests.

In terms of the infrastructure, while, all 42 PHCs have other basic infrastructure units like storage facilities and a communication facility, they struggle in meeting IPHS requirement of a separate laboratory room, and 24-hour water and electricity (IR3). In terms of the availability of resources to conduct the tests focused by the DHO, it is found that the most PHCs can obtain test standards (IR4) and

SOPs (IR5) from higher authorities, and many find that the tests are easy to perform (IR6).

In terms of consumables stock, IPHS recommends that PHC should avoid zero-stock scenario (MoHFW,

2012), but 14 PHCs have run out of stock in the last year (IR7). A good functioning laboratory needs easy stock procurement process (IR8), but the current strategy seems to be described as difficult by 31 PHCs.

The stock maintenance strategy has been variable across the PHCs in terms of regular inventory checks

(ranging from stock check per 1–30 days), and buffer stock maintenance (ranging from 1%–66% of the total stock). Such variation in stock maintenance strategy indicates a process of stock management optimization undergoing in the PHCs for better functioning in the current stock procurement policy. In terms of instrument maintenance, while, four instrument maintenance mechanisms (IR9) are known across the district, none of the PHCs has any knowledge of these four mechanisms. In this study, 27 respondents know of only one mechanism, furthermore, most found the instrument maintenance process

(IR10) difficult.

3.1.4 Services

The IPHS 2012 had recommended various tests for the PHC (MoHFW, 2012), but the district has focused

9 on haemoglobin, HIV, malaria, tuberculosis, pregnancy, urine albumin, urine sugar, blood sugar, and blood group tests. Among the district-focused tests (IS1), most PHCs are unable to perform all of these tests (Figure 4) and some perform other tests as well (Figure 5). It shows in Figure 4 that other basic services like seating facilities (IS2) is present for all PHCs, but toilet facilities for both male and female

(IS3) is not present in all PHCs. The indicators cleanliness (IS4) and biomedical waste management (IS5) are important services for quality assurance, and staff and patient safety, but performance in both indicators is below standard for most PHCs.

The temporal access of laboratory in terms of number of hours per day laboratory is opened for OPD

(IS6) is less than IPHS recommendations of 6 hours per day in most PHCs. Similarly, temporal access of laboratory in terms of number of days per week laboratory is opened for OPD (IS7) is less than IPHS recommendations of 6 days per week in most PHCs. The median value (5.3 hours/day and 5.5 days/week) of both indicators is less than the mean value (5.5 hours/day and 5.6 days/week), indicating that at least

50% of PHCs fail to meet even the mean district value.

While, no laboratory tests delivery time is provided in IPHS, it is desirable to have test results in same day, since tests do not take more than 10 minutes to perform. However, test results of malaria (IS8) and tuberculosis (IS9) are not provided within a day in most PHCs, which also causes delay in reporting of test results.

3.2 PHC Laboratory Preparedness Validation The validation is performed in this study of four functioning parameters (governance, financing, resources, services) and two performance parameters (SW and NSC) indicator for 24 out of 42 responding PHCs due to data paucity for other PHCs. The descriptive statistics (Table 2) for each of the parameter shows that many PHCs failed to achieve even 50% of the functioning parameter values, as median is less than mean. In case of performance parameters, it is observed that average sample collection per week across the PHCs is 142 and the average staff workload for sample testing is 755.21 minutes/week.

10 The final BN model is prepared (Figure 6) based on base BN model (Appendix III) with better results

(BIC value is -94.66491 for final model vs. -88.7714 for base model) and no reverse linkages. The governance, finances and resources are parent nodes for NSC indicating a probabilistic relationship between functioning parameters and performance parameter. Further, NSC and SW are also found to have probabilistic dependency on each other with NSC as parent node and SW as child node. The parent-child relationship between laboratory status and performance parameters is expected as status parameters are laboratory input and performance is laboratory output. Further, SW is dependent on the quantum of work available i.e. total number of samples for testing in the laboratory, NSC.

The study finds a relationship between good laboratory status in terms of governance, financing and resources and laboratory performance (Figure 6). This finding supports the WHO standpoint on the relevance of governance, financing, resources and services for any health system functioning and outcomes (WHO, 2010). (Balfour et al., 2016) showed that good governance, resources and financing support and services improved the laboratory performance in New York, USA and enable them to deal emergency situations in a non-disruptive manner.

Further, it is observed that governance must be ‘high’ for NSC to be ‘high’. This indicates that performance is strongly dependent on governance. The governance criteria in this study focused on the indicators that ascertain the governance capability of the MO, accordingly, the result indicate the weak

MO governance capability reduces performance and strong MO governance capability increases performance. (Ferrelli et al., 2016) showed that provisioning of health governance training to health staff as part of the continuous profession development programme in Italy improved the hospital performance.

Additionally, various projects in Africa and Asia regarding laboratory strengthening and performance for

Tuberculosis (Wertheim et al., 2010), AIDS (Abimiku, 2009) and Polio (Gumede et al., 2016) programme were successful owing to good planning and governance capability of decision-makers or enhancing it.

This enabled better support and utilization of resources and finances as well as monitoring that resulted in better services.

Further, it is found that good resource and governance status plays an important role in good laboratory services and financing status (Table 3) and leading to improved laboratory performance. Further, all the 11 laboratory strengthening studies in resource-limited settings had shown success and also recommended focus on resources and financing of the laboratories (Abimiku, 2009; Elbireer et al., 2011; Gumede et al.,

2016; Nkengasong et al., 2009).

The lack of services role in the laboratory performance for this study (Figure 6) does not necessarily mean the lack of importance because the indicators of services used for measuring services quality (availability of functional toilets, OPD hours and delay in malaria result) and safety (cleanliness of laboratory facilities and managing biomedical waste) is potentially not affecting users decision-making. Informal interactions with rural people and medical staff suggested that most of the users coming to PHCs are those lacking financial capacity to afford private services in urban areas or even travel long distance to access urban public facilities. This leaves the users to rely on the PHC services. The complete dependence of economically weak users creates little incentive for the public health planners to focus on services quality and safety. Further, the per capita district domestic product of Osmanabad is around $280 is only half of the state average (YASHADA, 2014) which indicates a weak economic status of district.

4 Conclusion

Preparedness for comprehensive rural health care from laboratory services at primary health care level is sub-optimal due to critical gaps in PHC laboratory functioning of Osmanabad district. This study highlights the need for strengthening laboratory in PHCs for better rural health care so as to achieve universal health care coverage goals and reduce disease burden.

Conflict of Interest: On behalf of all authors, the corresponding author states that there is no conflict of interest.

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15 Table 1: The RKS funding sources for different tests in different PHCs Number of PHCs requesting funds for a particular test* Non- IPHS Funding source IPHS B G V b S S S b P T A I S T C T E H B G B U U H H H The PHC received testing resources from the district; however, the resources were insufficient to meet the testing needs and 1 3 7 4 0 2 2 6 4 6 1 0 thus used RKS funds (both sources) The PHC received no testing resources from the district, so in order to meet their testing needs, RKS funds were used (RKS 0 0 0 1 1 1 0 1 0 1 0 4 sources) *Gram staining (GS), tuberculosis (Tb), blood sugar (BS), blood group (BT), hemoglobin (Hb), human immunodeficiency virus (HIV), syphilis (S), typhoid (T), urine albumin (UA), pregnancy test (HCG), urine sugar (US), and hepatitis B (HEPB)

Table 2: Descriptive Statisitics of the Funcitoning and Performance Parameters (n=24)* Governance Resources Services NSC** SW** Mean 2.76 3.38 2.95 142 755.21 Median 2.75 3.50 2.75 129 455.00 Standard deviation 1.05 1.26 0.86 75.58 871.32 Min 1.00 1.00 1.71 22 16.00 Max 5.00 6.00 4.50 311 3062.00 *Financing Parameter is not shown as it could take only two values of 0 or 1. **NSC (Number of Samples collected per week), SW (Staff Workload, Number of minutes spent on sample testing per week)

Table 3: Conditional Proability of occurence of different parameters status Condition (n) Event (n) Resources Status Governance Status Low (14) High (10) Low (9) 0.64 0.36 High (15) 0.54 0.46 Financing Status Services Status Governance Status, Resources Low High Low High Status (15) (9) (9) (15) Low, Low (6) 0.84 0.16 0.67 0.33 Low, High (3) 0.36 0.64 0.00 1 High, Low (8) 0.64 0.36 0.36 0.64 High, High (7) 0.56 0.44 0.28 0.72

16 Figure 1: Radar Diagram depicting overall PHC preparedness level (% of criteria met) and four individual parameter namely services, resources, financing and governance Figure 2: Percentage of PHCs that have achieved a good status across governance (IG) and financing (IF) parameters Figure 3: Percentage of PHCs that have achieved a good status across resource parameters Figure 4: Percentage of PHCs that have achieved a good status across service parameters Figure 5: The number of PHCs out of 42 in which a particular test is performed Figure 6: Final BN Model

17 Figure 7: Radar Diagram depicting overall PHC preparedness level (% of criteria met) and four individual parameter namely services, resources, financing and governance

18 Figure 8: Percentage of PHCs that have achieved a good status across governance (IG) and financing (IF) parameters

19 Figure 9: Percentage of PHCs that have achieved a good status across resource parameters

20 Figure 10: Percentage of PHCs that have achieved a good status across service parameters

21 Figure 11: The number of PHCs out of 42 in which a particular test is performed

22 Figure 12: Final BN Model

23 Appendix I Indian Health System Rural Governance Structure and Functioning

The public laboratories in rural areas are part of rural health care facilities. Hence, they are part of the public health care governance structure and do not have any separate governance structure.

Structure

The Indian basic governance structure has three main levels namely central level, state level and district level. The centralised rural health governance structure as shown in bold line of Figure IA starts with central government at central level. Below central government, the governance structure gets bifurcated into state government and centrally sponsored National Rural Health Mission (NRHM). State government is at state level and general scenario and NRHM is at central level and specific scenario.

Figure IA: Rural public health care governance structure

Below state government, the governance of health care is bifurcated into state health department (SHD) and district collectorate (DC). SHD is at state level and DC is at district level. Below SHD, at district level, governance structure is bifurcated into urban and rural public health care governance structure governed by district hospital (DH) and district health office (DHO) respectively. Under DHO lies the

24 Primary Health Center (PHC) followed by Sub center (SC). Below NRHM and DC, DHO comes directly followed by PHC and SC.

Functioning

The goals and funds are provided by central government to state government and NRHM as shown in

Figure IB. State government provides the goals and funds to SHD and DC. SHD provides governance, resources and financing to DHO. The DHO provides governance, resources and financing to PHC and

PHC provides governance, resources and financing to SC. DC cooperates with SHD and provides its governance, resources and financing to DHO both directly and indirectly through District Panchayat.

Similarly, NRHM also cooperates with SHD and directly provides its governance, resources and financing to DHO.

The proposal for next year budget funds is a bottom-up approach as shown in dotted line. SC sends its proposal to PHC followed by PHC sending its proposal to DHO. DHO sends creates four separate proposal and send one proposal each to SHD, DC, District Panchayat and NRHM.

25 Figure IB: Rural public health care governance functioning

26 Appendix II Criteria used for PHC laboratory assessment

The data was collected using field surveys administered from July–August 2015. Osmanabad City is the operations base, as daily visits were made to the 42 PHCs via a hospital transport facility, public transport

(ST buses), and local transport (e.g., bike lifts, sand-carrying tractors, and shared autos). Prior to every survey, the respondents were provided with a verbal explanation of the survey’s relevance.

The criteria assessed during the survey were either obtained from IPHS or based on field experience and interaction with interactions with public health professionals. These criteria are divided into four categories namely services, resources, financing and governance. The measurable indicators were created for certain criteria that could not be measured directly.

In terms of services, IPHS has recommended 27 basic laboratory tests for PHCs. The service quality is recommended by crosschecking the test results with other laboratories, and by maintaining cleanliness and biomedical waste management. The non-emergency laboratory services are functional during the

Outpatient Department (OPD) working hours. IPHS has recommended that the OPD working hours should be 6 hours per day (4 hours in the morning and 2 hours in the evening) for 6 days a week

(MoHFW, 2012). These recommendations are used as criteria as shown in Table IIA. The additional criteria used in the study are delays in obtaining malaria and tuberculosis sample test results after collecting the sample.

27 Table IIA: Service criteria and indicators evalauted in the survey Cod Sourc Services Criteria Indicator e e IS1 Perform IPHS tests Perform the district focused nine tests IPHS* Provide seating facility IS2 IPHS to patients Provide functional IS3 Functional toilet is available for both male and female patients IPHS toilet to patients Laboratory related area in the PHC (namely, the OPD room, laboratory room, IS4 Clean laboratory area and wardroom) is clean in terms of no spit marks, a clean floor, and no wall IPHS peeling Biomedical waste IS5 management is DHO recommended all four steps of bimedical waste management is done IPHS performed Opened for OPD IS6 patients for at least 6 IPHS hours per day Opened for OPD IS7 patients for at least 6 IPHS days per week Delay in malaria test Not more than one day delay occur in the PHC laboratory when obtaining IS8 None results malaria results once a patient’s sample is collected Delay in tuberculosis Not more than one day delay occur in the PHC laboratory when obtaining IS9 None test results tuberculosis results once a patient’s sample is collected * The preliminary survey showed that no PHC has all the tests recommended in IPHS, so study assessed the PHC in its ability to perform the tests focused by the district as these tests are part of IPHS standards.

In terms of resources, IPHS provides recommendation for human resources, infrastructure and consumables. A PHC needs to have both MO and laboratory technician (LT) for fully functional laboratory because patient cannot access public laboratory services without MO referral. Further, the staff in PHC should be regularly updated in his/her skills. In terms of laboratory infrastructure, PHC should have 24hrs water and electricity supply, and separate room. In terms of consumables, it is required that

PHC should have all 27 tests resources and maintain all test standards and standard operating protocols

(SOPs). Further, the consumables stocks should be managed so that PHC does not run out stocks. These recommendations are used as criteria as shown in Table IIB. Four additional criteria are used in the study.

Two criteria focused on determining the ease of operations namely performing test for LT/staff and procuring laboratory consumable stock in PHC. The other two criteria focused on instrument maintenance in laboratory in terms of knowledge regarding getting instrument repaired and ease of maintenance process.

28 Table IIB: Resource criteria and indicators evalauted in the survey

Code Resources Criteria Indicator Source IR1 Laboratory has human resource Availability of both MO and LT IPHS Laboratory staff skill up gradation IR2 LT can perform tuberculosis test IPHS training 24hr supply of water and electricity IR3 IPHS and a separate room Higher authorities provide test result IR4 IPHS standards along with test consumables Higher authorities provide test SOPs IR5 IPHS along with test consumables All laboratory tests are easy to IR6 None perform IR7 No case of zero stock No case of zero stock scenario in last one year IPHS All laboratory consumable stock IR8 None procurement process easy Knowledge of instrument IR9 All the four instrument maintenance mechanisms is known None maintenance process IR10 Instrument mainteance process is easy None

In terms of financing, PHC gets limited funds as RKS funds. However, IPHS has provided no criteria are provided to evaluate the laboratory use of RKS funds (i.e., financing). So, a new criterion for this category is used. The RKS funds are emergency funds of PHC that are meant to meet the critical PHC needs (Table IIC). Accordingly, the survey tried to ascertain the utilization of the RKS funds for the laboratory purposes. This will indicate if PHC has critical laboratory needs that were not considered during the centralised budgeting process.

In terms of governance, MO related criteria are focused as (s)he is the head of the PHC with day-to-day functioning responsibility. IPHS provides certain responsibilities to MO based on which governance criteria are considered. A PHC MO needs to understand that they are the head of the PHC. They should be able to make strategies and plans to implement various programmes as well as meet local health care needs. These recommendations are used as criteria as shown in Table IIC.

29 Table IIC: Financing and governance criteria and indicators evalauted in the survey Cod Sourc Financing Criteria Indicator e e Laboratory needs are met by the higher The PHC own funds (i.e., RKS funds) are not utilized for IF1 None authorities budgetary support laboratory services Cod Sourc Governance Criteria Indicator e e MO knows that (s)he is the main decision maker for the IG1 MO Awareness of its responsibility IPHS PHC's day-to-day operations IG2 MO ability to implement its decision Number of days to implement the decision can be estimated IPHS IG3 Decision implementation process is easy IPHS Ability to upgrade and repair the Number of days to upgrade and repair the instrument can be IG4 IPHS instrument estimated Number of days required to access different resources – IG5 MO can access different resources namely staff, consumables, instruments, and other facilities IPHS (transport, storage) can be estimated PHC MO trust its own laboratory test result, patient safety IG6 PHC MO trust its own laboratory services IPHS and patient privacy services

30 Appendix III Bayesian Network Base Results

The base BN model using unconstrained HC algorithm is prepared for all the six parameters (Figure

III.A). It shows a relationship between Governance and NSC, NSC and SW, NSW and Finances and SW and Resources. Among these relationships, the linkage of SW as parent node with NSC and resources as child nodes and NSC as parent node with governance as child node indicate reverse relationship. The parent-child relationship between laboratory functioning and performance parameters is expected as functioning is laboratory input and performance is laboratory output. Further, the staff workload (SW) is dependent on the quantum of work available i.e. total number of samples for testing in the laboratory,

NSC.

Figure III.A: Base BN Model

31