Evaluation of primary health care in riyadh, saudi arabia.

Primary health care (PHC) is a new concept in the health field. Its objective is to deliver integrated health service (curative and preventive). The Alama-Ata conference in 1978 urged countries to adopt the PHC approach to promote the health of all people. The expansion of PHC created the need for various types of evaluations (structure process and outcome).The aim, of this study is to assess PHC in Riyadh in terms of structure and outcome. The study was conducted at three PHC centers (A, B & C). The samples of the study included 300 consumers. Two instruments were used to collect data. Instrument I is an assessment sheet measuring resources in terms of availability and quality. Instrument II is a 4 pointlikert scale measuring consumer satisfaction. Validity and reliability were established before data collection. Descriptive and inferential statistics were used.The results show that the centers' human resources do not measure up to the ideal standards, particularly those in center C. The clinical support areas are under-equipped in centers A and C. The facilities in the three centers are inadequate. The Majority of the consumers studied were female Saudis, illiterates and housewives. The majority of the consumers were satisfied with the services, acid no differences were found between Saudis and non-Saudis.

INTRODUCTION

Primary Health Care (PHC) is a new concept in the health field. The objective of which is to deliver integrated health services (curative and preventive) and to upgrade the health status of the community. The concept of PHC was first formulated by Lord Dawson of England in 1920.1 A few years later it was propounded in New York and California. It was first put into practice in Russia after the 1918 revolution. The concept attracted wide-spread interest after the second World War. In India, the health survey and planning commission issued a report in 1947 advocating PHC centers for the entire population.

The Alma-Ata conference in 1978 urged countries to adopt the PHC approach. It abolished in 1980 all its former health offices, maternal and child health centers and dispensaries; and amalgamated their services to make a total of 889 centers which provide both curative and preventive aspect of care. In 1987, the number of centers increased to 1477 centers.2 The expansion in the PHC created a need for various types of evaluation to measure the quality of the service provided, and determine the extent to which its objective have been achieved.

A review of literature reveals that there are several levels of health evaluation. The experts however, agree on three main levels (structure, process and outcome) which were first proposed by Donabedian3 According to the WHO, the components of the structure level in the evaluation consist of the resources in terms of health manpower, facilities and equipment.4 Research studies conducted in India in 1966, in Bahrain, in Egypt and Yemen in 1981 found considerable differences in the patterns of staffing and equipments across the centers5 The inadequacy in resources may act as a constraint in achieving the objective of PHC.

On the other hand, “process” evaluation entails assessments of the way in which resources are used. It involves an assessment of the nature of the interaction between the consumers and other health workers, the extent to which care objectives have been reached, the specific technique or procedures used, and coordination among the health members of the team.6 Research studies investigating “process” evaluation, however, tended one or more of the process aspects, as well as the interaction between the consumer and the health personnel.

Donabedian mentioned that a major drawback in process evaluation is a weakness of the scientific basis for many of the accepted practices.7 Grundy and Craventein indicated that outcome evaluation reflects quality of care with greater validity than do process measurements.8 The outcome approach deals with the health outcomes (recovery rates, morbidity, mortality, and patients’ satisfaction). Many researchers recommended the study of patient satisfaction as an important aspect of outcome. Historically, patients’ satisfaction studies began to appear in the literature in the late 1950's. There was a growing awareness, at that time, of the patients as an elevator of health care. Thereafter, many studies were conducted assessing patient satisfaction using a variety of methods.91011

Most of those studies found that patients were generally satisfied. Areas of dissatisfaction were related to insufficient information patients were given about their treatment and progress, and overcrowding in waiting rooms.12 Chetwynd found that patients complained that hospitals were short staffed, and that there were long waiting lists.13 In a study conducted by Schulbery and Baker, it was found that 50% of mothers in the pediatric clinic expressed dissatisfaction with the waiting time.14 No studies could be found in literature that investigated the quality of primary health care in Saudi Arabia using different levels of evaluation. It is hoped that such a study will identify strengths and weaknesses in services, and delineate strategies for improvement.

RESEARCH PROBLEM

What is the quality of primary health services in the Riyadh city, in terms of resources available and consumer satisfaction?

Aims of the study

Assess the extent to which the available resources at three PHC centers in Riyadh (Kingdom of Saudi Arabia) correspond with specified standards.

Determine the consumer satisfaction with different PHC services.

METHODOLOGY

Setting: the study was conducted in three PHC centers (serving the largest population in Riyadh City). These were Al-Arija Al-Garbi center (A), AI-Margab center (B) and Al-Nasim AI-Shargy center (C).

Sample: the study included two samples consisting of three centers (chosen purposely): The city was divided into three main geographical zones from each geographical area, the center serving the largest population was selected to determine the quality of resources, the second sample consisted of 300 consumers chosen systematically (every fifth client) from the selected centers to measure their satisfaction. Criteria for selection included Saudi or non-Saudi, adult male or female, having a file served by the center for a period of at least 6 months.

Tools: Two tools were used in this study: instrument I (assessment sheet measuring the resources in terms of availability and quality) and instrument II (a 4 point liken scale measuring consumer satisfaction). Instrument I consisted of a cover sheet (including general information about the center, 19 items related to the total number of medical, paramedical and assistant workers available at the center, 13 items related to facilities. The face validity of the instrument I was checked by asking eight judges from different disciplines and MOH officials to evaluate the instrument. Evaluators generally agreed on the instrument content and scoring system.

Instrument II consisted of demographic data, and a 4 point rating scale of 40 statements grouped into six categories (accessibility, continuity, humaneness, thoroughness informativeness and effectiveness). The rating ranged from strongly agree (4 points) to strongly disagree (1 Point). When the item was not applicable it was coded as 9. Instrument II validity was checked by asking ten judges to evaluate the instrument in terms of clarity of wording, relevance to purpose of the study, appropriate length of the questions, and the scoring system. Results revealed that the instrument is valid; 97.8% of the experts agreed on instrument 11, while 2.2% disagreed. Pilot tests were carried out on both instruments and the necessary instruments were made.

Data collection: Phase 1 of the study lasted for two weeks; data was collected through the structure observation and record review method using instrument I. Phase II lasted for 1 1/2 months, data was collected through the interview method using instrument II. Each patient was interviewed for an average of 15 minutes in a separate room, arranged for the study before seeing the physician.

Data analysis: Descriptive and inferential statistics were used on instrument I data. Chi square tests were used for comparisons of the differences in demographic data between the three centers at 0.5 level. One way of variance (ANOVA) was done to determine any statistical differences in equipment and facilities between the three centers, In the situation where the F-value was found to be significant, a further analysis of least square difference (LSD) was conducted to determine which paired comparison created the difference. Cross tabulation's were done between nationality and the other independent variables for the second sample. ANOVA was again used to time differences in consumer satisfaction between the three centers. T-test was used to compare satisfaction between Saudis and Non-Saudis.

RESULTS AND DISCUSSION

Table 1 shows the man power available at the three centers in comparison with MOH required standards. It is clear from the table that the three centers varied considerably in meeting the staffing requirements, with center C having the lowest number of staff. The three centers exceeded the MOH staffing requirements with respect to the physicians, nurses and servants categories, and did not meet the requirements for 5 categories, (public health physician, dental nurse assistant, community health worker and physiotherapist).

Table 1

Manpower Available at the three PHC Centers in Comparision with the M.O.H. Required Standards

This result has several implications. First, it denotes that there is discrepancy in staffing between the centers although they are all supposed to be large centers (serving more than 7000 inhabitants). This discrepancy may lead to inefficient utilization of resources across the centers, and consequently to inadequacy in the services provided. Roomer reported similar variation in staffing patterns in PHC centers in India.15 Secondly, this result is a variation in staffing within each center, may imply that some important aspects of PHC (community teaching and home services) are not teeing covered, or that these aspects arc taken over by other categories who are less qualified for the job. In either situation there is a need for the Saudi MOH to reexamine the centers staffing patterns to ensure the success of its PHC mission. Finally, the over excess of servants (34) in center A is an indication that some categories are hired when there is no actual need for them. That is not only a waste of man power and financial resources, but it also leads to poor organization and assignments and disturbances in work flow.

In relation to the characteristics of the medical and paramedical staff at the three centers, a big proportion were males, (53.8% in center A, 54.8% in center B and 50% in center C), and non-Saudis (69.2% in A, 87.1% in B, and 88.9% in C). The staff in center C were not as fluent in the Arabic language and not as experienced in PHC as those in center A and B. Furthermore the majority of the staff at center C did not attend PHC training courses offered by> MOH. Chi square values were significant for the proficiency in Arabic (X2 = 17.3, p < 0.05), years of experience (X2 = 21.06, p < 0.05) and attending training courses (X2 = 18.30, p, 0.05).

The result indicating a large proportion of the staff is not Saudis, or native Arabic speakers is disappointing. PHC workers need to be close to the community in order to be able to better understand their culture, beliefs and values.16 Sebai reported that 31 ‘% of the physicians working in primary care in the Kingdom and 43% of the nurses arc Non-Arab cxpatriates.17

Another implication for the lack of Saudi health personnel in PHC is a decreased community participation. In center C the staff is not experienced in PHC and are not attending courses. The MOH need to exercise more effort in providing incentive to PHC workers to encourage them to attend those courses. One needs little imagination to visualize the possible effect of PHC on peoples state of health if available human resources were efficiently well trained, adequately oriented towards their culture role in the community, and capable of activating people to participate in health programs.

Table 2 shows the condition of the equipment in the three centers in mean scores. The scores that could be obtained ranged from 1 to 4 points. The minimum acceptable score from MOH is 3 points. The table shows that the three centers varied considerably in meeting MOH requirements, with center C having the lowest mean scores. The clinical areas that are under-equipped in center A are the emergency, dressing, general clinic and pharmacy. In center B the areas are immunization, dressing and well-baby. In center C the areas arc emergency, maternity, well-baby and pharmacy. No significant differences were found between the three centers (f 2.33 = p > .05). This result indicates that either the center's staff are lacking equipment or that their equipment is in poor condition. In both instances, this acts as a barrier for providing a high quality services to the public. Freuned and Kalumba found that poor distribution and storage of equipment acts as a constraint to the provision of health services in Zambia.18 Table 2 also shows that center C had the lowest equipment mean scores in the support areas. No significant differences were found between the three centers (F 2.1 = 1.31, p > .05).

Table 2

Adequecy of equipment in the various clinical and support areas at the three PHC centers (out of 4 points).

As regards the centers facilities, the maximum score that can be obtained is 2 (the acceptable score for MOH). It is evident from table 3 that center B had the lowest mean score, followed by C and A. A statistical significant difference was obvious between the three centers (F 2.33 = 4.77, p < 0.05). This significance was created by comparing centers A and B (LSD = 0.92) and centers A and C (LSD = 0.66) since tabulated LSD is 0.05 = 0.54. This difference may be due to the fact that center1 A is owned by MOH (new design), while center B is an old MOH owned building and center C is a rented house, as most PHC centers in the Kingdom. The finding is contrary to the result obtained by EI-Rufaie who studied a psychiatric clinic in a primary care setting in Saudi Arabia.19 Further studies are needed to assess the other centers in the Kingdom.

Table 3

Adequacy of Facilities at the three PHC Centers (out of 2 points)

Regarding outcome evaluation, a total of 300 consumers were interviewed in the three centers to determine their satisfaction with the services. Seventy-nine percent of the sample were females, 69.8% were Saudis, 58.6% were 14 - 29 years of age, 57% were either illiterates or could just read and write, 71% were housewives. The majority of the sample visited the center either for treatment purposes (30.2%) or for “other” reasons (46.5%) such as accompanying a child or relative. The majority (69.4%) used private transportation to reach the centers. These percentages were more or less equally distributed across the three centers, except for the nationality and educational level where the majority (66%) were non-Saudis in center B, and also more educated.

The findings drawn from consumer satisfaction show that the centers arc most used by Saudis except in center B. This is probably due to the fact that non-Saudis tend to live in the center of the city, the location B. It is noticed that older people represent a minority in the study. This may be due to the fact that the number of elderly in the community is less than the other age groups. The majority in this study's consumers were females, mostly housewives. This finding is similar to the result reported by Hossouna who found that 93% of his sample in Bahrain were females.5 This may be due to the fact that females either come to the center for themselves, or for bringing their children. It is noticed that illiteracy was prevalent among the consumers, especially in Saudis in center A and C. Comparable findings were reported by Hassouna.

It is clear from this study's results that the consumer in centers A and C came to the centers for treatment reasons more often than preventive reasons. This implies that centers need to exercise more effort in educating the public about the preventive aspects of primary health care. Transportation was not a problem for the consu-mer since most of them used their own cars.

Table 4 shows that the consumers were generally satisfied (mean score were 3.02 for center A, 2.99 for B, 2.85 for C). No significant differences were found in the three centers. In the three centers, consumers were more satisfied with the humaneness and effectiveness categories than any other categories. Consumers in centers A and B were least satisfied with the continuous aspect of care; while those in center C were least satisfied with the informativeness category.

Table 4

Consumer's satisfaction mean scores in the 3 PHC centers

Comparable findings were reported by different researchers. Shulbery and Baker and Chetwynd found high level of satisfaction.1413 Lebow, after reviewing a 100 articles about satisfaction, found that 78% of the respondents expressed satisfaction in outpatients studies.10 Pascoe and Allison reported that 90% of their sample experienced some degree of satisfaction of health care.20

Despite preceding supporting results, care should be taken not to draw hasty conclusions. The results reported in this study drawn from “resources” evaluation arc in contradiction with consumers satisfaction ones. Most of the staff working in the care centers were found to be non-Saudis, and those in C were not proficient in the Arabic language, do not have enough experience, and did not attend training courses. Moreover the clinical and support areas in centers were below the acceptable standards.

These contraindications in different components of evaluation may be either real, and would therefore need to be further studied; or may be unreal; and in actuality, is a function of several other factors. First of all, it may be a function of high standards set by the MOH for the center resources; or it may be a function of the characteristics of the consumer's sample (majority illiterate female housewives). These conditions may also be due to cultural factors; the Saudi consumers may still be unaware of their rights, and therefore accept a low quality of service; or it may be that they are afraid to complain about the services for the fear that they would be treated unkindly by the center personnel. Finally, these contradictions in results may be due to methodological limitations. It has been the experience of the investigator that the patients are reluctant to complain until a certain degree of trust has been established between them and the interviewers. This would necessitate the use of other research methodologies (rather than questionnaires) to get to the real opinion of the Saudi in particular, and any other nationality, consumers in general. It would also necessitate studying other aspects of the outcome component and including process evaluation in future studies. Finally, studies are needed to investigate, in depth, the consumer satisfaction in relation to their characteristics.

As shown in table 5 the sample of Saudis and non-Saudis were most satisfied with the humaneness and effectiveness categories (3.59 and 3.50; and 3.16 and 3.28 respectively). The Saudis were least satisfied with the informativeness category; while the non-Saudis with the continuity of care category. No significant differences were found between the Saudis and non-Saudis in rating different categories.

Table 5

Distribution of Consumers Satisfaction Mean Scores According to Nationality

Several researchers found that humaneness and care effectiveness have high rates of satisfaction among consumers.521 Regarding the informative category, Fisher contrarily found that patients felt that their condition was adequately explained to them in outpatient clinics.22 As for the continuity category, Sebai found that the continuity of care was not proper in relation to the referral system and personnel health cards in Qasim.17

Accessibility of service was the most common problem encountered by the respondents in centers (A) and (C); while the effectiveness category was common in center (B). The highest recommendations for improvement of services given by the respondents pertained to the roughness category, especially in center (C). The lowest number of recommendations were given to continuity of care.

CONCLUSION AND RECOMMENDATIONS

This study attempted to evaluate primary care services in Saudi Arabia in terms of quality service consumer satisfaction. Three centers were studied as to their resources, and 300 consumers were interviewed to determine their satisfaction level with the services provided by the centers. It can be concluded from the study that:

The human resources in the centers do not measure up to the ideal standards, particularly those in center C.

The clinical and support areas are under equipped in centers A and C.

The facilities in the three centers arc inadequate.

The majority of consumers studied were female Saudis, illiterate and housewives.

The majority of consumers were satisfied with the services despite inadequate resources.

There were no difference in satisfaction level between Saudis and non-Saudis.

From the preceding conclusions, the following recommendations were proposed:

The Saudi MOH needs to pay more attention in improving and upgrading the centers resources.

Further research studies are needed to investigate the relationship between the different components of evaluation (structure, process and outcome).

Studies are needed to investigate the relationship between the consumers satisfaction and their demographic characteristics.

Studies are needed that investigate consumer's satisfaction using different methodologies.