Exploring Gaps in the Existing Healthcare System in Rural Tamil ...

Exploring Gaps in the Existing Healthcare System in Rural Tamil Nadu
Exploring Gaps in the Existing Healthcare System
in Rural Tamil Nadu
CHIAI URAGUCHI, SUNAYANA SEN, MAKI UEYAMA
Chiai Uraguchi is a candidate for a Master of Public
Administration at the Cornell Institute for Public Affairs.
She acquired a Master’s degree in Environment,
Development and Policy from the University of Sussex
and a Bachelor of Arts degree in Environment and
Information from the Musashi Institute of Technology
in Japan. She has worked in the Philippines on several
projects, including one that explored the ‘Role of
scavenging in urban livelihoods in the Philippines’ and
a ‘Case study of livelihoods in the INAYAWAN dump
site in Cebu and a strategy for the poor.’ She was also
the project manager for a project aimed at ‘Income
Generation for Disadvantaged Women’.
Sunayana Sen has a Bachelor’s degree in Psychology
from Sophia College, Mumbai. She completed her
Master’s in Human Rights, from the University of Calcutta
in 2008 and volunteered for several non-profit
organizations. She worked on several projects related
to child health and the human rights of rural populations
before she joined ICTPH as a Research Analyst,
Epidemiology.
Maki Ueyama obtained her Ph.D. in Policy Analysis and
Management from Cornell University (Ithaca, USA). Her
main research interests are in the fields of health and
healthcare in developing countries. She has a Master’s
degree in Policy Analysis and Management and in Public
Administration, both from Cornell University. She has a
Bachelor’s degree in Economics from Keio University
(Tokyo, Japan).
Executive summary
In 1978, the International Conference on Primary Healthcare,
meeting in Alma-Ata, made a historical declaration that
expressed the urgent need for action by all governments,
all health and development workers, to protect and promote
the health of all the people of the world.
After more than two decades, India has achieved
tremendous improvements in human development factors:
e.g., Life Expectancy at Birth (LEB) is 65 and Infant Mortality
Rate (IMR) has become 32.31 deaths/1,000 live births.
Compared to year 2003, the rate improved drastically from
60 deaths in 2003 to 32.31 deaths per 1,000 population.
Public sectors are actively involved in the healthcare system
and contribute to society.
However, the healthcare sector as a whole is still facing many
challenges. According to UNDP, India ranked 128 out of 177
countries (Human Development Index 2007/2008). There are
obviously more gaps to fill or unmet needs in the current
healthcare system.
There is an understanding that South India performs
relatively well in terms of healthcare: e.g., a male at birth is
expected to live for almost 69 years while a female is
expected to live for almost 72 years, whereas the national
averages for life expectancy at birth in India for males and
females are approximately 64 years and 67 years
respectively. With respect to national mortality rate,
Jharkhand in East India and Uttar Pradesh in Northern India
have the highest rates (48.6 and 47.6) and Kerala has the
lowest rate of 11.5. Tamil Nadu has a relatively low mortality
rate, as compared to other states. However, some studies
show that local people – especially in rural areas – face
difficulty in accessing healthcare services due to long
distances, the lack of facilities the government (public) sector
provides, and unaffordable medical fees that the private
hospitals charge.
This study – Healthcare Needs Assessment – was designed
and conducted by the epidemiology team at the IKP Center
for Technologies in Public Health. The study aims to explore
whether there are gaps in the existing healthcare system in
Thanjavur in rural Tamil Nadu, in the Southern part of India
– and what kind of interventions are required to fill the gaps,
if any. It has been conducted by utilizing qualitative study
methods – key informant interviews and focus group
discussions.
Through the qualitative studies, the following factors were
mainly focused on for analysis: quality of service,
accessibility, availability, and affordability – both in the
private and public healthcare sectors.
The overall picture that the study gives is that, while most
villagers manage to access necessary healthcare, there is
still more room for the public sector to improve in order to
offer better healthcare service. The result of this study
showed that the most serious issue is the huge shortage in
manpower in the public sector that provides healthcare to
the poorer segments of the population.
Lack of management, especially emergency care and short
length of duty for doctors in the government – led Primary
Health Centres, leads to low quality treatment and hasty
and careless diagnosis. Due to a lack of explanation about
diseases, physical problems, and medicines from doctors,
patients are likely to lack knowledge about medicines and
rely on heavy dosage medicines to seek quick recovery. It
could be necessary for medical providers to explain usage
of medicines and procedure of treatment in order to build
awareness among patients.
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Both public and private hospitals are located within
accessible distances. However, there are no hospitals in
the village offering any X-ray, ECG scan, ultrasounds, and
so on. So most villagers have to visit nearby towns to avail
of these facilities. The need for hospital beds, scans and
ambulances, addressed by women, are strongly related to
pregnancy and child birth. Accessibility would be even less
of a concern for villagers if there were clinics or hospitals in
the village that offered the aforementioned facilities.
The cliché of unaffordable charges in the private sector does
not seem to be entirely true in this geography since some
people mentioned that some private doctors now charge
lower fees and provide injections and tablets at an affordable
price although there are some people who still have to
borrow money in order to access the private sector. Despite
it being an illegal medical practice, unqualified doctors
(‘quacks’) seem to exist and often meet villagers’ needs with
24-hour access and affordable medicines.
Introduction
India contributes the largest number of births per year (27
million) in the world (Ronsmans C, Graham WJ, 2006). With
its high maternal mortality of about 300 to 500 per 100,000
births, a total of 75,000 to 150,000 maternal deaths occur
every year in India (Maternal mortality in India: 1997 to 2003
and National Family Health Survey (NFHS-2), 1998- 1999).
This makes up about 20% of the global share, hence India’s
progress in reducing maternal deaths is crucial to the global
achievement of Millennium Development Goal 5, which aims
at improving maternal health (UN, 2009). Despite its
achievement of rapid economic growth, India ranked 128
out of 177 countries in the Human Development Health
Report by UNDP (Human Development Index 2007-2008).
A Healthcare Needs Assessment Study was undertaken to
explore gaps in the current healthcare system and existing
health facilities in the Thanjavur district of Tamil Nadu, India,
and subsequently design interventions needed to fill in the
gaps. The study was designed to cover the following aspects
which were then going to be used for the analysis: quality
of healthcare, availability, accessibility, and affordability of
healthcare services. The data was collected by conducting
key informant interviews with several people holding
positions of authority in the village, and two male and two
female focus group discussions with villagers in each village.
The study is a small part of the Healthcare Needs
Assessment study in that it covers only one village, Alakudi,
located in the Thanjavur district of Tamil Nadu, India.
Background
Healthcare System in India
The first National Health Policy that aimed to achieve ‘Health
for All’ by 2000 was introduced in 1983. Improvements,
through focus on better infrastructure for primary healthcare
and healthcare delivery systems, resulted in reductions in
infant mortality and death rates, longer life expectancy, and
higher rates of childhood vaccinations. However, not every
segment of the population was benefiting equally, and,
according to a human development health report by UNDP,
India ranked 128 out of 177 countries (Human Development
Index 2007/2008). Other South Asian countries, such as
Vietnam, Indonesia, and the Philippines, ranked higher than
India.
Since the Community Development Program 1 was launched
in 1951 in India, the country has gradually enhanced the
healthcare infrastructure. The National Healthcare system
in India is delivered by public and private players. As of
2005, 142,655 sub-centers, 23,109 primary health centers
(PHCs) and 3222 community health centers (CHCs) provide
services to 742.49 million rural people (72.2% of India’s
population live in rural areas). Over 5479 sub-divisional and
district hospitals play a role in the public sector (Bulletin on
Rural Health Statistics in India, 2005). The population
coverage norms are 3000/5000 per sub-centre, 20,000/
30,000 per PHC and 80,000/120,000 per CHC respectively,
depending on the location of the center (i.e. in a hilly, tribal,
or other difficult area to be accessed) (Central Bureau of
Health Intelligence, 2005). On the other hand, the private
sector plays a significant role in the delivery of healthcare,
catering to 46% of hospital inpatients and 81% of outpatients
(WHO Financing and Delivery of Healthcare Services in
India, 2005). While both players are indispensable to the
nation’s healthcare delivery, the latter predominates in the
health sector.
Healthcare delivery in the public sector is targeted towards
sections of the population that cannot afford appropriate
healthcare. A Facility Survey in 1999 by the Government of
India indicated that 75% of the government-run Community
Health Centers lacked in adequate equipment – and only
33% of the Primary Health Centers provided quality delivery
care – if they provided any care at all (Bulletin of Rural Health
Statistics in India, 2006). These inadequate public health
facilities have led to the non-utilization of such facilities.
A lack of managerial and technical ability in the Public
Healthcare system is a major part of primary challenges here.
Unequal distribution of facilities is also found between rural
and urban health service areas in India: Although 75% of
the population still lives in villages, 59% of all practitioners
and 84% of hospital beds are in urban areas (Duggal, 2000).
There are about 4621 hospitals and 18.5 beds per 100,000
population in rural areas. The number of hospitals and beds
per 100,000 population in urban areas are 10,406 hospitals
and 232.36 beds. This presents a stark contrast existing in
the health infrastructure development between urban and
rural India (Varman and Kappirath (2008). In terms of
managerial ability, many public health sectors apply the
“first-come, first-served” policy.
In 2003, of the 8.8% of the GDP that was spent on health,
the public expenditure on health was 25% and private
1
Community Development Program: In 1951, Government of India viewed rural development as pivotal to achieving economic growth
and social development. The objective of the program was to achieve “Samagra Gramin Vikas“, addressing all the issues of basic needs
of the people and implementing a number of programs in rural areas.
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Exploring Gaps in the Existing Healthcare System in Rural Tamil Nadu
expenditure was 75% (WHO Country Health System Profile,
India, 2007). In spite of efforts to provide free public services,
health-expenditure surveys consistently show high levels
of private out-of-pocket spending on healthcare (Berman,
1997).
Today, the capacities for human resources in healthcare are
significantly scarce in India – even within low income
countries, approximately 1,125,000 practitioners of various
levels of qualification – and from different schools of
medicine – are registered in the country. Of them, only
125,000 (which constitutes only 11% of the total number)
serve the government-public sector, while the rest are all
working in the private sector. This excludes an innumerable
number of unqualified and unregistered medical
practitioners that also operate throughout the country (R.
Duggal, 2000). There is a disparity of human resources
between rural and urban areas. Only 0.6 doctors per 10,000
population in rural India currently are working; on the other
hand, 3.4 doctors per 10,000 population are in urban areas
(Ashok Kumar, 2007). Rural/urban disparities are equally
pronounced in the outcome of health services.
Consequently, despite the fact that large portions of the
population seek medical services from the private sector
(NHP 2002), due to high medical fees, private healthcare is
not equally accessible to everyone in India. This has made
it increasingly difficult for the poor to avail of private care
and caused them to refrain from seeking any healthcare at
all (Levesque et al, 2006). Therefore, poorer households
access less preventive and curative healthcare from the
private sector than richer households. Due to the lack of
ability to pay the fees, the poor are much less likely to be
hospitalized. Indians who are hospitalized tend to spend 58%
of their total annual expenditures on healthcare (David H.
Peters, Abdo S Yazbeck, Rashmi R.Sharma, Lant H. Pritchett,
Adam Wagstaff, 2002). More than 40% of hospitalized
people in India manage to cover expenses by borrowing
money or selling assets to cover expenses. Consequently,
many hospitalized people are likely to fall into poverty. There
is a great financial risk that hinders the poor from accessing
private healthcare.
Healthcare indicator and system in
Tamil Nadu
Within India, healthcare services in the country vary
substantially between states, regions and societies. These
differences in healthcare provision translate to differences
in various health indicators, including: Life Expectancy at
Birth (LEB) and Infant Mortality Rate (IMR). The state of Tamil
Nadu, located in the South of India, is one of the foremost
states in terms of overall development. The state has the
highest number (10.56%) of business enterprises in India
(Provisional Results of Economic Census 2005). Tamil Nadu
has also done very well in terms of human development
among the better performing states in terms of health
indicators (R.J Chellian, K.R. Shanmugam, 2002). Tamil
Nadu had among the lowest percentage of the hospitalized
falling into poverty from medical costs in 1995–96 – less
than the national average. Following is the comparison of
various health indicators in Tamil Nadu compared with the
national averages.
Table 1: Life Expectancy Rate at Birth
Life Expectancy at Birth (LEB) India Tamil Nadu
Male 63.87 68.45
Female 66.97 71.54
Source: Ministry of Health and Family Welfare, Government of India
In Tamil Nadu, a male at birth is expected to live for almost 69 years while a female is expected to live for almost 72 years;
whereas the national averages for life expectancy at birth in India for males and females are approximately 64 years and 67
years respectively.
Table 2: Childhood Mortality Rate 2005 to 2006
Mortality Rate India Tamil Nadu
National mortality 39.0 19.1
Infant mortality 57.0 30.4
Child mortality 18.4 5.3
Under-five mortality 74.3 35.5
Source: Ministry of Health and Family Welfare, Government of India
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With respect to national mortality rate, East India: Jharkhand and Central India: Uttra Pradesh has the highest rate (48.6 and
47.6) and Kerala has the lowest rate of 11.5. Tamil Nadu has a relatively low mortality rate, as compared to other states. This
is indicative of the decrease in the death rate and the improvement of the quality and availability of health services in the state.
Table 3: Percent distribution of women who had a live birth in the five years preceding the survey by antenatal care (ANC)
provider during pregnancy for the most recent live birth 2005-06
Percentage of Antenatal Care India Tamil Nadu
Total Percentage of Women seeking Antenatal Care 77.0 99.0
Doctor 50.2 83.6
Nurse/Midwife/LHV 23.0 14.3
Other health personnel 1.0 0.0
Dai/TBA 1.2 0.0
Anganwadi/ICDS workers 1.6 1.0
Other 0.1 0.0
No one 22.8 1.1
Source: Ministry of Health and Family Welfare, Government of India
The percentage of women seeking antenatal care in Tamil Nadu is an encouraging 99% whereas the All-India average is only
77%. In Tamil Nadu, women who access doctors to receive antenatal care are relatively higher in number than the average
percentage in India. Only 1.1% women in Tamil Nadu do not access antenatal care; on the other hand, India as a whole
averaged more than one fifth of women answering ‘no one’ to receive any information about antenatal care.
Table 4: Percentage of Institutional Deliveries
Percentage of Institutional Deliveries India Tamil Nadu
Source: WHO Country Health System Profile, India 2007
41.0 90.0
The disparity between the state percentage and the All-India
percentage of institutional deliveries is even starker – Tamil
Nadu has a phenomenal record of 90% institutional
deliveries whereas the All-India figures are a dismal 41%.
While these may reflect the greater level of health awareness
among the people in Tamil Nadu, both increased awareness
and greater healthcare use can be attributed to the relatively
advanced health infrastructure in the state in comparison to
other states.
Within the state of Tamil Nadu, there are inter-district
disparities as far as healthcare is concerned: Among the 30
identified districts in Tamil Nadu, the district of Thanjavur
ranked 9 th in health infrastructure development. Thanjavur
district also performs well nationally with the ranking of 41
among the 593 districts studied in the country (IIPS, 2006).
Although the study failed to cover information from all the
districts, due to unavailability of data, it covered most of the
districts and hence was successful in providing an idea of
where Thanjavur stands with respect to health services and
infrastructure.
Notably, Tamil Nadu has successfully established a high
quality of healthcare management by decentralizing
healthcare services. For instance, each PHC covers from 5
to 10 sub-centers and each is staffed by community health
workers called ‘Village Health Nurse’ (VHN). Each VHN has
a service area comprised of approximately 5000 population
in (up to) 7 or 8 villages and receives two years of healthcare
training to become eligible for service. According to multistate
studies, Tamil Nadu’s VHNs have better knowledge
levels and more effective contact with service communities
than their counterparts in other states. Most of the VHNs
live in their service villages, and emergency cases are
brought to them night or day. Because of their close contact
with the community, and the extensive records they keep,
VHNs are familiar with the needs and problems in their
communities. Their services and the PHCs are widely seen
as intended mainly for women and children. VHNs are
responsible for house-to-house contacts and for schools.
They provide preventive healthcare by providing
vaccinations and pre-delivery care for expectant mothers.
Their services have generally included immunizations,
nutrition and other health education, antenatal care,
childbirth services and referrals, and family planning
(Lakshmi Ramachandar, Pertti J Pelto, 2002). Despite limited
amounts of information and unavailability of data, it
successfully illustrates where Thanjavur stands with respect
to health standards, services and infrastructure.
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Exploring Gaps in the Existing Healthcare System in Rural Tamil Nadu
Literature Review
The importance of health needs assessment has been
emphasized by several studies done in the Indian
subcontinent; the results of which prove to be extremely
useful in identifying needs that are not addressed by existing
healthcare facilities – and the important factors (social,
cultural, economic) that are ignored by existing healthcare
systems, thus pointing out areas which need improvement
(e.g.: Varatharajan, 1999, Kannan, et al. 1991, Navaneetham
and Dharmalingam 2002, Kavitha and Audinarayana (1997),
Ravichandran and Mishra (2001). Most existing studies in
South India focus on reproductive and child heath, thus not
much is known about general healthcare services (e.g.:
Navaneetham and Dharmalingam (2002), Kavitha and
Audinarayana (1997), Rajaretnam and Deshpande (1994),
Ram (1994), Ravichandran and Mishra (2001).
A study about the prevalence of reproductive tract infections
was conducted since little is known about rates among the
youngest married women in South India. A communitybased
cross-sectional study of prevalence of reproductive
tract infections was conducted among an age group – 16 to
22 – of young married women. Qualitative and quantitative
data on treatment-seeking behavior were collected.
Multivariate analysis found that 2/3 of symptomatic women
had no access to any treatment because of lack of privacy,
distance from home, and cost (Jasmin Helen Prasad,
Sulochana Abraham, Kathleen M. Kurz, Valentina George,
M.K. Lalitha, Renu John, M.N.R. Jayapaul, Nandini Shetty,
Abraham Joseph). The study clearly shows that some factors
– such as quality of healthcare, accessibility in terms of
distance, and affordability – hinder patients’ access to
healthcare facilities.
A study was conducted to explore unmet needs for
reproductive health via a cross-section of 70 women from
rural Tamil Nadu. TK Sundari Ravichandran and US Mishra
concluded the need for an integrated women’s health
program within a strengthened health system. Poor facilities,
inadequate supplies, insufficient working hours, lack of
proper monitoring and evaluation mechanisms – and a
mismatch between training and work allocated to health
workers – were the key gaps identified (TK Sundari
Ravichandran and US Mishra, 2001). Ram K. (1994) used
an ethnographic approach to explore maternity practices
among lower-caste Mukkuvar women in Kanyakumari, Tamil
Nadu, and identified: prolonged stays during delivery
disrupted daily activities; caste disparites between the
provider and the user created a power hierarchy; harsh
treatment by the hospital staff during delivery; and
unnecessary medical interventions. These were cited as
reasons for the women in the village not seeking medical
care during pregnancy and having reservations against
institutional deliveries.
Despite improvements in the healthcare status and
increasing accessibility to healthcare services in the prior
decades, Tamil Nadu still has challenges to adequately treat
intricate health cases. Tamil Nadu has not done so well in
respect of the late neonatal mortality rate; and done poorly
with respect of the early neonatal mortality rate (Venkatesh
Athreya, Sheela Rani Chunkath, 1998). More than 70% of
those with chest symptoms make one or more efforts to
seek care – and private practitioners are consulted more
often than government healthcare providers. A research with
chest symptomatics in a community-based study in Tamil
Nadu showed that private healthcare facilities provided
‘good care’ and easy accessibility – and were the main
reasons why patients preferred private healthcare
(G. Sudha, C. Nirupa, M. Rajasakthivel, S. Sivasubramanian,
V. Sundaram, S.Bhatt, K. Subramaniam, Thiruvalluvan,
R.Mathew, G.Renu and T.Santha, 2003). The studies above
showcased that there could be certain unmet areas in each
of the private and public sides.
A qualitative study was conducted to identify basic
healthcare available to the poorer segmentation of the
population in Tamil Nadu. The study focused on quality
issues from the perspective of users in 17 villages and 1
town across rural, semi-urban and urban districts in Tamil
Nadu. The focus group discussions in the study described
public facilities as being less clean, utilizing poorer
equipment, and stocking less effective, slower acting drugs.
In cases where drugs were necessary to treat a particular
ailment and were expensive (such as snakebites or dog
bites), PHCs simply did not have any stock of medicines
which were in high demand. Moreover, it was emphasized
that issues around the non-availability of physicians, poor
staff attitudes, and demands for unofficial payments were
common in Tamil Nadu. (Pia Malaney, 2000)
Lymphatic filariasis is recognized as the second leading
cause of permanent disability in Tamil Nadu. A study was
designed that aimed to identify the economic impact affected
by the costs of constant treatment and the possibility for
patients to lose working time. The ranges of treatment costs
in private hospitals are from Rs.500 to Rs. 2,000. Such high
costs – coupled with loss of working income during
recuperation – causes financial crises for poor households
in rural areas (K.D.Ramaiah, Helen Guyatt, K. Ramu, P.
Vanamail, S.P.Pani and P.K Das, 1999). According to the
study, expenditure for healthcare is likely to burden people
– especially daily wage workers – and leads to poverty.
More often than not, improvement in healthcare requires
building better healthcare services and a system of both
users and providers. Awareness is one of the factors users
can play significant roles in, to contribute to improving
individual health. In focusing on maternal knowledge of
malnutrition and child health, the study highlighted that the
lack of awareness about health issues in general is the major
issue – rather than healthcare availability and healthcareseeking
attitudes. Therefore, the study emphasized that
building robust health education regarding maternal health
among villagers is of primary importance (K. Saito, J. R.
Korzenik, J. F. Jekel, and S. Bhattacharji Yale J, 1997).
Although a limited number of studies have been conducted
in the past, quality of service, treatment and medicines,
availability of doctors and nurses, sufficient facilities,
accessibility and affordability have been all highlighted as
gaps in the healthcare system time and again.
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GIP, 2009
Methods
Qualitative research instrument
This research aims to integrate data from individual
interviews and group discussions. One on one interviews
consisted of an in-depth conversation on an individual level.
In-depth interviews contributed to providing feedback on
empirical and personal aspects of input, activities, outputs,
outcomes and impacts of the healthcare system. The
interviews were initially targeted with several authorized
people: Village President/Vice President/Panchayat Leaders/
other village leaders, headmaster/teacher of a school, and
a Self-help leader in order to obtain their empirical cases
and the indirect information they have often examined in
their village. In order to provide general understandings of
community norms, interviewing the key community leaders
can contribute to a fast overview of a community and its
needs and concerns.
While in-depth interviews were conducted with individuals,
group concerns were also explored. Topics that may not
arise in individual interviews thus could be addressed in
focus groups. Through discussing a topic in the same Tamil
language and with familiar neighbors, group discussions
contributed data and insights or personal and deep
information that would be less accessible without interaction
in a group setting. Only a school teacher, a school
headmaster, a self-help group leader, and a self-help group
member participated in this key informant interview due to
unavailability of other target participants. Through
interviewing authorized people, bridge of social network was
developed so that it helped to easily recruit focus group
participants. Additionally, any information that was gathered
had refined question banks to be used for focus group
discussions.
The focus group discussion is facilitated by a facilitator and
observed by a recorder. The role of a facilitator is to ensure
that all participants had an opportunity to participate, and
were asked for clarification or elaboration – if needed – but
did not direct the content of participants’ comments. A
recorder plays the role of recording the discussions and
taking notes not only for the participants’ expressions but
also to note the environment and atmosphere where the
discussions were conducted and thus audits comments and
reactions. The focus groups were conducted in neutral
settings with 6 to 8 participants. Each 45 minute to 1 hour
session was audio-taped and then transcribed for analysis
purposes.
In regard to participants and their recruitment for focus group
discussions, two age-stratified groups (21–40, 41–60) of 6
to 8 participants of both females and males were selected.
Age groups of 20 to 40 and 41 to 60 of both males and
females were eligible to participate in this study discussion.
Dividing into two different age groups allowed us to discern
educational levels, different health issues, social status such
as marriage, etc. Potential participants were recruited
randomly, so that people from different backgrounds in
similar age groups could contribute diverse and empirical
opinions. In the process of recruitment, social networks built
through key informant interviews, helped to recruit
participants easily. Group members used a common
language (Tamil language) to describe similar experiences.
Compared to key informant interviews, group discussions
produce data and insights that would be less accessible
without the interaction found in a group setting; for instance,
listening to others’ verbalized experiences stimulates
memories, ideas, and experiences in participants.
Geography
The qualitative research was conducted in one village,
Alakudi. Alakudi is located east of Thanjavur district and is
the closest village from Thanjavur city. It usually takes 30
minutes by a car or bus. Public transports run frequently so
that villagers can easily access a train or bus service. Only
at certain times do trains run from Alakudi to Thanjavur:
from 8 am to 10 am and from 4 pm to 6 pm. Public bus
service is available 24 hours. The total estimated population
in Alakudi is 2,900 2 (excluding the number of non- residents).
28.12% of total surveyed residents that are above 3 years
old, out of 2,738 3 , have completed secondary school despite
high illiteracy rate of 18.48% in Alakudi. Total 83.48% of
work forces are committed to agriculture: 50.35% of them
are daily wage earners on other people’s land and 33.14%
cultivate their own land. 4
Geographical map: Alakudi
In Alakudi, most people have access to public and private
hospitals regardless of their financial level. Although many
villagers are more likely to visit the PHC for the first
treatment, they visit private hospitals when it is necessary.
According to the interviews and focus group discussions,
owing to absence of private hospitals in Alakudi, many
villagers access private healthcare in either Boothalur or
Thanjavur. Boothalur is two stops away by train from Alakudi
– within approximately 30 minutes – the travel costs only
Rs. 2.00. There is frequent bus service to Thanjavur and the
journey takes around 45 minutes from Alakudi village. The
PHC doctor and nurses often refer patients to private
hospitals, clinics, or Thanjavur Medical College Hospitals
for further treatment. There are unqualified doctors –
‘quacks’ – in Alakudi and they are accessible 24 hours.
Especially, during night time or in an emergency, villagers
are likely to access these ‘quacks’.
2
The number is from Census Survey conducted by ICTPH epidemiology team. The surveys contained demographic, health related
information, and financial information. Survey residents were 2,812 and non-residents were 224 (total:3,036).
3
For 74 residents information on education is missing because they are 2 years or below.
4
Epidemiology Census Survey
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Exploring Gaps in the Existing Healthcare System in Rural Tamil Nadu
Map 1: Alakudi and Boothalur
Findings: Alakudi
Availability: Doctors, Nurses and Emergency
According to the result of this study, both males and females
admitted that doctors are available only from 9 am to noon
in the PHC in Alakudi. Because of short duty hours for
doctors, a ‘compounder’ often prescribes tablets and gives
patients first aid when doctors are off duty. While nurses
are on duty, and available for patients the whole day, they
often ask patients to come back the next day due to the
unavailability of doctors. For daily wage workers, regular
visits spoil their daytime work and such consumption of
time directly affects their daily income. The majority of
people emphasized the need for longer hours of doctors’
availability; some mentioned 24-hour availability is essential.
According to some female participants, the public sectors
improved in terms of the availability for maternity delivery.
One of the participants in the focus group discussions said
that there is a nurse available at night for delivery cases.
However, most female participants emphasized a need for
longer hours of a doctor’s on-call duty.
In the case of private hospitals, villagers are able to visit
them even after work since doctors in the private sector
are usually available till late in the evening; one private
doctor in Boothalur is willing to give treatment even after
9 pm. Doctors being available during late hours could be
big help especially for working males; thus, many male
participants repeatedly pointed out about the particular
doctor in Boothalur who is available almost all the time.
In the case of emergency, most people complained about
the lack of accessible doctors in public sector. However,
during the duty hours of doctors, emergency cases are
usually given priority in the PHC. Some people access private
hospitals in Boothalur, while some go to Thanjavur.
Oftentimes patients get medicines from medical shops
because doctors are not available or patients try to avoid
long lines. Overall, many people experience dreadfully long
waiting hours in public hospitals – even in emergency cases.
“Even if it is an emergency case, such as a car accident,
they (government hospitals) are instructed to give
information to the police first, and then only do they proceed
with treatment. Sometimes, patients die before they start
treatment.”
At the same time, female participants also
mentioned:
“PHC gives us a token and we have to wait. They treat one
by one regardless of emergency.”
However, it seems the PHC gives priority to the treating of
students. According to interviews with school teachers and
headmasters, students were treated in a timely and proper
manner when they fell sick during school hours:
“If the school boys fell sick, we take them to the PHC. Some
students fell sick and I sometimes had to take them to the
PHC. In the PHC they give first aid for diarrhea and vomiting.
Since we are school teachers, and to avoid any disturbance
to their education, they treat us first, even if there is a vast
crowd waiting.”
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7

GIP, 2009
The private sectors give high priority for emergency cases.
Therefore, in an emergency case, many people access
private hospitals because some doctors are always available
for patients.
Quality of service: waiting time
Lack of manpower leads to the creation of issues in quality
of services, increasing time for which one has to wait in
order to get services. One of the quality factors is waiting
time. Depending upon the crowd on any given day, the
average waiting time is usually 30 min to 1 hour – sometimes
up to 2 hours – in the PHC because merely one or two
doctors are available for only about 3 hours per day.
Particularly, males expressed more concerns about waiting
time since it affects their daily wages. Because most villagers
work on farms and are paid daily wages, the length of waiting
times causes a loss to the patients’ incomes. There is also
no proper waiting room in government hospitals in both
PHC and government hospital, Thanjavur Medical Hospital,
so that many patients must wait outside – even in emergency
cases. Due to the needs of diagnosing enormous number
of patients – 200-300 patients a day – often hasty treatments
are the result. The following comments which were
addressed in male focus groups, exemplify long hours of
waiting time:
‘It takes2 to 3 hours to see doctors and it is a waste of time.
So, I came back home. 200 to 300 people are there in the
PHC per day.’
‘Everyday 15 to 20 are pending from previous day. The
patients have the prescriptions which were issued 2 to 3
days ago. They only came back to PHC in order to get tablets.
Even then, the PHC sent them back home.’
Long waiting hours in private hospitals is also not unusual
for outpatients; sometimes they have to wait on for 1 to 2
hours. However, due to efficient management, private
sectors use an appointment system for the patients for the
subsequent visit so that they do not waste their time in the
waiting room.
Quality of service: treatment and quality of
service – attitude toward patients
Due to the large number of patients that doctors see
everyday within their short duty hours, the quality of
treatment is affected. Many participants addressed
dissatisfaction toward not only medical treatment, but also
health workers’ attitudes toward patients. A majority of male
participants criticized nurses’ nonchalant attitude toward
patients – for instance, talking on the phone unmindful of
an emergency case – and rough treatment by staff in the
public sector. ‘The government hospitals treat us with
frustration’ exemplifies how the staff treat patients.
Due to the limited amount of time spared by doctors despite
long lines of patients, most villagers who have ever visited
government hospitals are dissatisfied with their treatment:
“Doctors prescribe medicines without using thermometer
or stethoscope. Some doctors give adequate guidance on
taking tablets, but some just give medicines and patients
do not know when to take them.”
Due to ineffective treatment from the public sector, many
people are likely to access private hospitals after visiting a
PHC. In the PHC, due to a lack of explanation about medicines
and diagnoses, there is a lack of knowledge about the root
causes of diseases, the process of treatment, and types of
medicines among villagers. Consequently, many participants
mentioned that they are keen to get injections and heavy
dosages of medicines without any awareness of a medicine’s
potential – or side effects in the long term. On the other
hand, the private sectors are more likely to provide injections
and heavy dosage medicines which leads to fast recovery,
creating a sense of satisfaction of high dosage medicines
without being aware of long-term effect the medicine may
cause.
Quality of service: medicines and their
availability
As already mentioned, most participants claimed that they
are not satisfied with low-dosage medicines the PHC usually
offers since they seek a quick recovery; therefore, they are
likely to conclude that medicines in the PHC do not work
effectively. When the medicines in the PHC do not work for
certain patients, the doctor often refers them to their own
clinics. There are usually medical shops in the villages.
However, commonly available medicines – such as pain
killers – are not always available, both in the PHC and in
pharmacies in Alakudi village. Some participants described
the inconvenience in accessing medicines. Although there
is a tremendous need for diabetes treatment, there is no
insulin injection available in the public sector in the village –
only oral medicines. For diabetic patients, especially severe
cases, they have to go to Thanjavur to get insulin. There is
unmet need arising from non-availability of certain
medicines.
According to the group discussions – many praise a
particular private doctor (villagers call him ‘lucky doctor’ 5 )
in Boothalur since he gives injections and heavy doses to
any outpatients. Despite some awareness of the dangers
regarding a heavy dosage among educated people, many
villagers tend to conclude heavy dosage is effective and
they demand to be given in order to ensure speedy recovery.
Traditional medicines
There is one ‘siddah’ doctor in the Alakudi area and this
doctor gives treatment for jaundice, dog bites, minor illness,
and panic attack using traditional medicines. Many
participants have accessed traditional medicines before. Half
of them mentioned it was effective; however, they are aware
that it has reduced effectiveness if they take allopathic
medicines. Others expressed negative opinions, especially
for joint pain, where a few participants had applied traditional
5
Lucky doctor is a general physician who, people believe, can cure any disease. This belief is attributed to the doctor’s success in having
cured patients in the past.
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Exploring Gaps in the Existing Healthcare System in Rural Tamil Nadu
treatment; yet, due to the need for long-time to cure, most
of them tended to then apply allopathic medicines. Siddha
treatment is commonly known and is accessible at the village
level at affordable prices. Most of people are aware of
effectiveness for certain diseases such as jaundice.
Quality of service and availability: facility
For X-rays, people go to Thanjavur, since there are facilities
offering X-tray, scan, ecocardioglam (ECG), etc. Despite the
fact that there is (or are) medical shop(s) in Alakudi, better
medical shops were demanded. Due to the fact that diabetes
is a common disease, blood tests for regular check-ups for
glucose level in the blood are essential. However, the public
sector fails to offer adequate blood tests in a timely manner.
They often request patients to come back after weeks to
collect test results. Therefore, villagers who have time
constraints prefer the private sector for check-ups since they
would perform most of the tests and have results within the
same day. Even though the PHC offers blood tests, some
people are unaware of the service.
Bed availability is one of the other factors in which many
people feel there is a need to improve. The needs of beds,
scan, and ambulances are insisted upon by women.
Additionally, some women mentioned the need for
pediatricians since there is no child specialist in the nearby
village.
A majority of participants in these qualitative discussions
felt that transport facilities for emergency cases, X-rays, ECG,
and Ultrasound scans, etc. are essential for the PHC to
provide. However, these facilities are available only in
Thanjavur (Public) Medical Hospital and a private hospital
in Thanjavur, or the closest town, Boothalur. Even in private
hospitals, facilities such as X-ray, Ultrasound, and ECG are
not always available; therefore, patients often travel from
one hospital to another to complete their tests after being
prescribed by their doctors.
Accessibility: locations
A PHC was launched in Vannarapettai in order to increase
accessibility to poorer districts. At that time – after a few
years of healthcare service in Vannarapettai – access was
difficult for those people from Kalrayanpatti (a village nearby
Alakudi). Hence, a new PHC was established in the Alakudi
area so that more than 8 to 9 villages can access the PHC.
Average travel time from Alakudi (and 8 to 9 villages near
Alakudi) depends upon the areas where they live in Alakudi:
some mentioned it takes 2 to 5 minutes, while some take 15
to 20 minutes. Despite being quite a distance for elderly or
disabled people, most of the male villagers who participated
in the focus groups and interviews were satisfied with the
distance to the PHC. The PHC is currently located in an
accessible area from two schools. According to a school
teacher and headmaster whom we interviewed, first aid is
implemented in a swift manner for students. Thanjavur
Medical Hospital is within a reachable distance and takes a
30-minute journey by public transport. There is not a single
private hospital in Alakudi village; however, general doctors
and specialists are accessible in both Boothalur and
Thanjavur. It usually takes 30 to 45 minutes to get to both
places by train. During night time, there are buses available;
however, most of the villagers use bikes or cars.
Quacks
During the night, ‘quacks’ are available 24 hours – and most
villagers trust the treatment, medicines, and injections from
quacks. For emergencies, many of them have ready access
to quacks. Some charge money and adjust the dosage of
medicines according to how much money patients can
afford. One compounder in PHC has so much money
experience that, sometimes, the compounder prescribes
treatment to patients outside the PHC – and even inside the
PHC. Although some comments showed a reluctance to
access unqualified doctors, they are likely to fill the gaps by
providing urgent care.
Expenditure and affordability
The average expenditure for healthcare is dependent upon
how many family members there are and how severe the
disease. According to the self-help group member whose
family members do not have any severe chronic disease,
this expenditure is approximately Rs. 2000 to Rs. 5000 per
year. On the other hand, some who are diabetic, have joint
pain, etc., mentioned medical costs come to Rs. 15,000 to
Rs. 20,000 per year. Farmers, who receive daily wages and
are considered to have less income than other workers –
such as teachers – still often manage to pay fees to private
hospitals. Depending upon their financial situation, patients
are likely to choose access to either public or private sectors.
Due to the free charge in the public sector, people think
only poor people go to the public sector. Yet, if people get
high enough salaries, they are willing to access the private
sector. Consulting private doctors – including buying the
prescribed medicines and check-up – is typically Rs. 100 to
Rs.200. Since some doctors have their own medical shops
or labs, doctors typically refer patients to their particular
labs in order to generate more money. A majority of
participants addressed the need of reduction in fees. For
critical conditions or chronic disease, they have to spend
Rs. 5,000 to Rs. 10,000, which causes a financial crisis. Some
private doctors offer affordable fees to patients such as Rs.
15 for one injection and Rs. 8 for tablets. Some participants
mentioned that they are comfortable paying Rs. 30 to Rs.
50 for minor sickness. Those who cannot afford to pay are
likely to sell their cattle, jewelry, or borrow money from banks
or neighbors; however, these seem to be relatively few.
Corruption
The Indian government regulations ensure free diagnosis
and medicines in public health sectors in PHCs to all people.
However, due to corruption, some practitioners, assistant
doctors, and other general workers demand bribes when
villagers get injections, medicines, and visit their relatives
in both government hospital and PHC.
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GIP, 2009
“The only good thing about public sectors is they prescribe
medicines for free. Yet, they (workers) sometimes deceive
patients and demand money. They openly ask us to pay
extra money for injections and tablets. They always use
the excuse that their salary is so little, that they have to ask
for extra money”.
Village Health Nurse (VHN)
Even though the literature reviews showed satisfactory
results of the VHN program, the performance of Village
Health Nurses is very satisfactory only among school
workers and villagers. VHNs visit schools regularly to provide
vaccines and tablets. VHNs issue a healthcare card called
“Vaalvu Oli Thittam” for individual students so that they can
be tracked on their health history. VHNs often refer students
to the Thanjavur Medical Hospital or private hospitals in a
swift manner. VHNs also pro-actively visit villages to provide
filarial and iron tablets – mainly to women.
However, most villagers simply do not take the tablets
because of lack of awareness of the benefits of the tablets.
Further explanation and healthcare-related education seems
to be necessary.
Limitation and Challenge
The length of my contribution toward the healthcare needs
assessment was only 2 months and 7 days. Although
qualitative resources – via four key informant interviews and
four focus groups – were completely collected and
transcribed within the time limitation, findings of only one
village, Alakudi, could be incorporated into this paper.
Human resources were the major challenge in the study.
Only two research assistants played the roles of a facilitator
and a recorder and transcribed and translated data.
Quality of collected data depended upon the number of
participants and their interest in being part of the discussion.
Even though 6 members were selected in the beginning for
a focus group discussion, some of them left, were often
distracted by outsiders, or lost their interest to participate.
These incidences would affect the quality of data we
gathered.
Compared with cultural norms, some opinions were judged
to be biased or bombastically expressed – despite our giving
sincere appreciation toward the contributors. Many
participants criticized as ‘less effective’ the medicines that
the public sectors provided. On the other hand, they were
likely to have a misconception that high-dosage medicine
(or injections) cure every disease – consequently, there was
certainly some ignorance among the common people who
do not know that high-dosage medicines may do more harm
in the long-term. The qualitative study was analyzed only
on the consumer side; therefore, some quotations might
contain biased opinions.
The language barrier was also one of the major challenges
we faced. Since Tamil Nadu state is a Tamil language
speaking region, many people in rural areas – or even urban
areas such as Chennai, the capital of Tamil Nadu – do not
command enough of a second language to translate
qualitative data. The lack of human resources – including
professional translators – caused tremendous difficulty in
moving the research forward.
Conclusion
By looking at the overall structures in Alakudi, of both public
and private healthcare services – including unqualified
doctors – it can be concluded that, despite certain gaps
between public and private sectors, private is likely to fill
the gap in the needs among villagers. There are linkages
between public and private healthcare – such as PHC to
private hospitals and private to government medical
hospitals – so that patients access healthcare services
according to their health requirement despite frequent poor
management in the government sectors. The public
healthcare system certainly needs improvement.
The most serious issue in human resource management is
the huge gap in manpower in the public sector that provides
healthcare to the poorer segments of the population. Most
interviewees and focus group participants addressed the
urgent need of longer hours of a doctor’s duty time and for
additional numbers of doctors.
Lack of management – especially emergency care and the
short length of duty for doctors in the PHC – leads to low
quality treatment/hasty and careless diagnoses. Due to a
lack of careful explanation about diseases, physical
problems, and medicines from doctors, patients are likely
to lack knowledge about medicines and rely on heavy
dosage medicines to seek quick recovery. It is necessary
for medical providers to better explain usage of medicines
and procedure of treatment in order to build more educated
awareness toward medicines and treatment.
Both public and private hospitals are located within
accessible distances. However, since there are no available
hospitals offering any X-ray, ECG, scan, ultrasounds, etc.,
most villagers have to visit Thanjavur or Buthalur (most likely
Thanjavur Medical Hospital). The need of beds, scanning,
ambulances, etc. is addressed by women and are strongly
related to pregnancy. Accessibility would be more
satisfactory for villagers if there would be a nearby clinic or
hospital that offers the facilities.
The cliché of unaffordable charges in the private sector has
been changing due to some private doctors now charging
lower fees and providing injections and tablets at an
affordable price – although there are some people who still
tend to borrow money in order to access the private sector,
no matter the cost. Despite it being an illegal medical
practice, unqualified doctors (‘quacks’) seem to also meet
villagers’ needs with 24-hour access and affordable
medicines.
Overall, in Alakudi, there are certainly gaps in healthcare
both in public and private. However, most villagers manage
to access necessary healthcare. There is still more room for
the public sectors to improve for the betterment of
healthcare service.
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Exploring Gaps in the Existing Healthcare System in Rural Tamil Nadu
Appendices
1. Question Banks
2. Consent Form for Key Informant Interview-Tamil version
3. Consent Form for Focus Group Discussion-Tamil version
4. Operational definition of key terms
Appendix 1
Question Banks (Demand Side)
Question Bank: Demand
Gaps in delivery of public health services
What do you feel about the public healthcare services (PHCs)
in the area?
How competent do you think the doctors/other health staff
in the PHCs are?
Do they discuss the problem that you are seeking care for,
with you?
How long is the waiting period in a PHC?
What distance do you have to travel to reach the PHC? How
long does it take?
Share your experience of a visit to the PHC.
How frequently does the VHN visit your village?
What kind of services do they provide?
Are these visits helpful? What other services do you think
they could provide that you could benefit from?
Which one of the following aspects do you consider most
problematic as far as public healthcare facilities in your area
are concerned-
- Quality
- Affordability
- Accessibility
- Availability
What according to you are the problems in the public health
system in the village that need to be addressed
immediately?
Role of private healthcare providers
All of the above with respect to the private providers in the
village.
Have you heard of ‘quacks’?
Do you visit them? Why?
Health Expenditure
How much do you spend on healthcare in a year?
For those who pay, do you think this is affordable?
Would you be ready to pay more for better services that
take care of all the expectations you have from the healthcare
system?
Suggestions for alternatives to improve the health system
What are some of the areas that the private/public health
systems could improve on?
What according to you needs to be done to address the
problems in the existing health system in the village?
Appendix 2
Consent Form for Key Informant Interview-English version
IKP Centre for Technologies in Public Health
Guna Complex, 6th Floor, 443, Anna Salai, Teynampet,
Chennai 600 018, India.
Informed Consent Form – Key Informant Interviews
The Informed Consent Form has 2 parts:
1. Information sheet to share the information with the
interviewee
2. Certificate of consent (for signature when you agree
to be interviewed)
Part 1: Information sheet
Purpose
ICTPH is a not-for-profit research centre that aims to learn,
discover and apply relevant innovative solutions for
healthcare leading to improved health for the rural
populations in India and other developing countries and to
integrate technological advances with delivery of affordable,
accountable and accessible healthcare.
ICTPH is currently involved in conducting a study that seeks
to explore whether there are any gaps in the existing
healthcare delivery system in Thanjavur district of Tamil
Nadu, India, and find out whether there is a need for
intervention to fill those gaps. The information you provide
will only be used to understand how people view the
existing healthcare services and their expectations from the
healthcare delivery system which would then help us look
into the need to come up with alternatives to supplement
or complement the health ecosystem for making it an ideal
one.
Therefore, we request you to cooperate and seek your
permission to conduct an interview. We believe you can
contribute greatly to the study by sharing your experiences,
both good and bad, about healthcare access, facilities and
the initiatives that are being taken to promote good health
www.ictph.org.in
11

GIP, 2009
in your area and build a strong, well functioning health
system. We will conduct these interviews in other villages
in Thanjavur as well and will deal with the same issues.
Please answer the questions in as detailed a manner as
possible so that we can get the maximum information
possible to help enrich our research.
Procedure
We are going to discuss issues related to awareness on
public health programs and knowledge on causes and effects
of common health problems prevalent in your areas. The
questions will be based on your perception of local health
problems, your views on treatment facilities available, both
public and private and the role that you play (if any) in
creating health related awareness and promoting good
health. We expect that you will co-operate with us by
discussing your views and experiences. Please feel free to
give suggestions and express your opinions during the
interviews. Audio tapes will be used for voice recordings.
The audiotapes will be destroyed after completion of the
project. Please do not hesitate to share information with us.
All the personal and private information you share will
remain strictly confidential.
Duration of activity
The interview will last for about for 30 to 45 minutes. Your
participation is voluntary and there will be no cash or other
reimbursements.
Risks and Benefits
The procedure may seem time-consuming and lead to
disruption of routine. However in the long run it will benefit
the community as a whole even though there may not be
any direct benefits associated with it.
Information on the outcome of the research
Community meetings to be held in your area after the
completion of the research process during which information
regarding the research findings will be shared with you.
Privacy and confidentiality
Your name and identification will only be known to the
researcher and will not be linked with your responses. Your
responses will remain confidential and this information will
only be used by research staff. The tape recorded
discussions will be stored in a locked cupboard/filing cabinet
until the completion of the study. We will write a number
code and not your personal details on the response sheet
to ensure confidentiality.
Right to refuse or withdraw
Your participation is voluntary and you can withdraw from
the interview at any point even after having given consent.
You are free to refuse to answer any question that is asked
in the interview. If you have questions to ask during the
interview, I will answer them.
Whom to contact
If you have any questions about this survey you may ask
me or contact:
Sunayana Sen,
IKP Centre for Technologies in Public Health,
Guna Complex, 6th Floor, 443, Anna Salai, Teynampet,
Chennai 600 018, India
Signing this consent indicates that you understand what will
be expected of you and are willing to participate in this
survey. At this time, do you want to ask me anything? May
we begin the interview now?
Part 2: Certificate of Consent
I have understood all the information read out to me and have had the opportunity to ask questions and make clarifications. I
understand what is expected of me and hereby give my consent freely to participate in the discussion.
Name of Participant ________________________________________________________ Age _________________________________
Name of Village___________________________________________________________________________________________________
Address _________________________________________________________________________________________________________
Number of Members in the Household ______________________________________________________________________________
Name of Head of Household _______________________________________________________________________________________
Signature/Thumb print of Participant _______________________________________________________________________________
Date (date/month/year) ___________________________________________________________________________________________
Name of Researcher ______________________________ Signature of Researcher ____________________________________
Date (date/month/year) ____________________________________________________________________________________________
A copy of this Informed Consent Form has been provided to the participant. ____________________ (Initials of the Researcher)
12 www.ictph.org.in

Exploring Gaps in the Existing Healthcare System in Rural Tamil Nadu
Appendix 3
Consent Form for Focus Group Discussion-English version
IKP Centre for Technologies in Public Health
Guna Complex, 6th Floor, 443, Anna Salai, Teynampet,
Chennai 600 018, India.
Informed Consent Form – Focus Group Discussion with
Villagers
The Informed Consent Form has 2 parts:
1. Information sheet to share the information with the
participant
2. Certificate of consent (for signature when you choose
to participate)
Part 1: Information sheet
Purpose
ICTPH is a not-for-profit research centre that aims to learn,
discover and apply relevant innovative solutions for
healthcare leading to improved health for the poor
populations in India and other developing countries and to
integrate technological advances with delivery of affordable,
accountable and accessible healthcare.
ICTPH is currently involved in conducting a study that is
designed to explore whether there are any gaps in the
existing healthcare delivery system in the Thanjavur district
of Tamil Nadu, India, and find out whether there is a need
for intervention to fill those gaps. The information you
provide will only be used to understand how people in
Thanjavur view the existing healthcare services, their
expectations from the healthcare delivery system which
would then help us look into the need for alternatives to
supplement or complement the health ecosystem for
making it an ideal one.
Therefore, we would like to invite you to participate in this
study as we think you can contribute to our knowledge by
sharing your experiences with us about healthcare access
and facilities. We will conduct this discussion in other
villages in Thanjavur as well and will deal with the same
issues. Please answer the questions in as detailed a manner
as possible so that we can get the maximum information
possible to help our research.
Procedure
We are going to discuss issues related to awareness on
public health programs and knowledge on causes and
effects of common health problems prevalent in your areas.
The discussion will be based on what you know about local
health problems, the treatment you seek for common
illnesses, preventive measures that you take (if any) to keep
diseases away, your views on treatment facilities available,
both public and private. We expect that you will co-operate
with us by discussing your views and experiences. Please
feel free to give suggestions and express your opinions
during the meeting. Audio tapes will be used for voice
recordings. The audiotapes will be destroyed after
completion of the project. Please do not hesitate to share
information with us. All the personal and private information
you share will remain strictly confidential.
Duration of activity
The meeting will last for about for 45 to 60 minutes. It is
based on voluntary participation and there will be no cash
or other reimbursements.
Risks and benefits
The procedure may seem time-consuming and cause
disruption of routine but in the long-run it will benefit the
community as a whole even though there may not be direct
benefits associated with it.
Information on the outcome of the research
Community meetings to be held in your area after the
completion of the research process during which information
regarding the research findings will be shared with you.
Privacy and confidentiality
Your name and identification will only be known to the
meeting organizers and will not be linked with your
responses. Your responses will remain confidential and this
information will only be used by research staff. The tape
recorded discussions will be stored in a locked cupboard/
filing cabinet until the completion of the study.
Right to refuse or withdraw
Your participation is voluntary and you can withdraw from
the discussion after having agreed to participate. You are
free to refuse to answer any question that is asked during
the course of the discussion. If you have questions to ask
during the meeting, I will answer them.
Whom to contact
If you have any questions about this survey you may ask
me or contact:
Sunayana Sen,
IKP Centre for Technologies in Public Health,
Guna Complex, 6th Floor, 443, Anna Salai, Teynampet,
Chennai 600 018, India.
Signing this consent indicates that you understand what will
be expected of you and are willing to participate in this
survey. At this time, do you want to ask me anything? May
we begin the discussion now?
www.ictph.org.in
13

GIP, 2009
Part 2: Certificate of Consent
I have understood all the information read out to me and have had the opportunity to ask questions and make clarifications. I
understand what is expected of me and hereby give my consent freely to participate in the discussion.
Name of Participant ________________________________________________________ Age _________________________________
Name of Village___________________________________________________________________________________________________
Address _________________________________________________________________________________________________________
Number of Members in the Household ______________________________________________________________________________
Name of Head of Household _______________________________________________________________________________________
Signature/Thumb print of Participant _______________________________________________________________________________
Date (date/ month/ year) ___________________________________________________________________________________________
Name of Researcher ______________________________ Signature of Researcher ____________________________________
Date (date/month/year) ____________________________________________________________________________________________
A copy of this Informed Consent Form has been provided to the participant. ____________________ (Initials of the Researcher)
Appendix 4
Operational definitions of key terms
Gaps are defined as the inability to seek heath care services
due to lack of accessibility, availability, affordability and/or
quality of the particular service in question.
Accessibility: The ease with which a patient (healthcare
seeker) can cover the physical distance required to get to a
heath care facility.
Availability: The presence of healthcare services including
emergency care as well as the presence of qualified medical
professionals, adequate supply of drugs and other facilities
such as diagnostic facilities.
Quality of service: The time for which a patient has to wait
at a healthcare center in order to receive the healthcare
service he/she is seeking, the treatment both medical and
behavioral that he/she receives, the physical environment
(cleanliness and hygiene) that he/she is exposed to and the
ability of medicines to solve the health problem under
question without harming the individual, define the quality
of the service being sought.
Affordability: The ease with which a patient is able to cover
the financial costs of the healthcare service being sought.
References
Country Health System Profile, India (2007), World Health
Organization.
Human Development Index 2007/2008:
http://hdrstats.undp.org/indicators/1.html
Bulletin on Rural Health Statistics in India (2005),
Infrastructure Division, Department of Family Welfare:
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