|Year : 2015 | Volume
| Issue : 1 | Page : 53-63
Patient perceptions and expectations from primary health-care providers in India
Rashmi Ardey, Rajeev Ardey
Family Medicine, Karuna Medical Center, Delhi, India
|Date of Web Publication||27-Feb-2015|
19, Shivalik Apartments, Alaknanda, New Delhi
Source of Support: None, Conflict of Interest: None
Introduction: The study of patient satisfaction at the primary care level has been mostly neglected in India. Aim: This objective of this study was to assess indices of Patient Satisfaction at the level of the family physician which is usually the first point of contact between the patient and the health-care system. Materials and Methods: This study was carried out at a Private Primary Health-Care Center in a semirural area in New Delhi, by exit interviews in the form of a questionnaire from patients randomly selected from people visiting the center during the study period. Statistical Analysis: Descriptive statistical analysis was carried out on the data collected. Results: The findings revealed that 83.58% of the patients were satisfied with the general experience and the behavior of the health-care provider and 85.9% were satisfied with the treatment and care provided, only 65.5% were satisfied with the physical environment of the clinic. However, the percentage of patients who would recommend the facility to their friends was overwhelming (94.6%). Conclusion: These results show that private health-care providers are still the first choice for any form of medical care. However, there was definitely a gap between the increasing expectations of the patients for more information, better Patient-Provider interaction, more control over the treatment process and better amenities even at the Primary Care level. It is this gap, which needs to be fulfilled to facilitate better utilization of Primary Health-Care Services in the community and reduce pressure on tertiary care services in order to ensure Universal Health Coverage. This study would also help us understand the challenges for Primary Care service providers, private and public, in a low socioeconomic urban setting.
Keywords: Family physicians, patient perceptions, primary care, primary health care
|How to cite this article:|
Ardey R, Ardey R. Patient perceptions and expectations from primary health-care providers in India. J Family Med Prim Care 2015;4:53-63
|How to cite this URL:|
Ardey R, Ardey R. Patient perceptions and expectations from primary health-care providers in India. J Family Med Prim Care [serial online] 2015 [cited 2019 May 19];4:53-63. Available from: http://www.jfmpc.com/text.asp?2015/4/1/53/152254
| Introduction|| |
Primary Health Care forms the bedrock of the health-care services of a country. It is the quality of health care available to the majority of the population that determines the health status of the country and is the best indicator for the level of social development of the country. The important conditions of Primary Health-Care Services are that they should be: Efficient with regard to cost, techniques and organization; Readily accessible to those concerned; Acceptable to the community served; At a reasonable cost.  Health-care services should be available in a manner and language that is suitable to the community and population it serves and accommodating of local traditions and customs, and at a price which the population can afford. Patient satisfaction has been linked to increased patient compliance, continuity of care, better clinical outcomes, and greater service utilization and risk management. Patient satisfaction is thus a key marker for the quality of health-care delivery and an important indicator for evaluation and improvement of health-care services.  Studies of Patient Satisfaction in health care originated in the USA during the 1950s. The earliest studies attempted to identify patient characteristics such as age, gender, and race to predict patient satisfaction levels (Apostle and Oder 1967;  Bertakis et al. 1991  ). Another group of studies analyzed health-care attributes such as nursing care, physician care, etc. to identify attributes that influence overall patient satisfaction (Ware et al. 1975; Ross et al. 1993; Dansky and Brannon 1996; Oswald et al. 1998). Dr. Veera Prasad in his comparative study of patient satisfaction said that there are five determinants of patient satisfaction.
Reliability: The ability to perform the promised service dependably and accurately.
Responsiveness: The willingness to help the patients and provide prompt service.
Assurance: The knowledge and courtesy of employees and their ability to convey trust and confidence.
Empathy: The provision of caring and individualized attention to patients.
Tangibles: The appearance of physical facilities, equipment, personal, and communication materials. 
A study was carried out to identify which attributes of a primary health-care experience access, staff care and physician care, and which aspects of each attribute are most significant in patients' response to the services they receive. Analysis showed that among the three attributes, physician care was most influential, closely followed by the staff care, with access having least influence.
However, it is the combination of all these factors that influence patient satisfaction, and need to be assessed to ensure a positive experience at the health-care facility. 
Unfortunately, while several studies have been carried out which have explored the parameters of patient satisfaction in tertiary care centers and large hospitals in India, very little attention has been paid to studies of patient satisfaction at the primary care level, especially GPs running solo clinics, which form the bulk of private primary care services.
The aim of this study was to identify and assess patients' perceptions, expectations, and experiences of services provided by Family Physicians with the objectives of:
- Identifying patient perceptions of the doctor patient relationship
- Identifying which attributes of a primary health-care experience have the most impact on patient satisfaction
- Estimate the indices of patient satisfaction based on people who have utilized the services
- Suggest ways and means of improving these services to ensure improved patient compliance and ultimately better outcomes.
| Materials and Methods|| |
This survey was carried out by exit interviews in the form of a questionnaire of patients selected randomly over a 6-week period from those attending the Primary Care Center during the study period.
Study design: Exit interviews of patients selected randomly from those who attended the clinic during the study period, using a questionnaire survey.
Sampling technique: Precise randomization of the sample was not possible as clinic visits were neither planned nor predictable.
Sampling criteria: Patients visiting the clinic were selected randomly, accepting their choice to come to the clinic and take the survey as a part of the selection procedure. Patient selection bias was avoided by asking nearly every patient who came to the clinic to take the survey. Questionnaire forms were given out to all those who consented to take the survey. One hundred and thirty forms were distributed among patients, out of which 100 questionnaire forms were returned completely filled.
Setting: A private, single physician, primary care clinic in a semirural area of New Delhi.
Population: The general population of the area consists mainly of first-generation migrants from the village, most of whom barely had primary education. However, the demographic profile is now changing with a lot of the younger generation being better educated and more aware than their parents.
Participants: For exit interviews, patients who have utilized the clinic services during the period of study.
Methodology: The questionnaires were filled in by patients coming to the practice over a 6-week period starting from 19th August to 30 th September, 2010.
For people who were illiterate or unable fill up the feedback form, the questions were translated into Hindi by one of the clinic staff and any assistance, if required, in filling up the questionnaire was offered. They were also offered the option of filling up the form at home and dropping it off later. Patients were not required to mention their names, ensuring anonymity.
Data collection tool: The questionnaire was designed to reflect the patients' opinions, ease and availability of services, acceptability of the center and general satisfaction with the services provided in order to cover three main areas - quality of treatment, accessibility, and interpersonal issues.
The questionnaire was divided into following categories:
- Demographic characteristics of the patients
- Nature of visit
- Information about treatment and experience at the clinic
- Satisfaction with paramedical staff
- Other ancillary facilities
- Overall clinical experience
In the questionnaire space was provided for patients to write about what delighted them about the clinic as well as what they thought clinic could do to improve patient care services. This helped us get information on some uncovered areas in the questionnaire. People were also asked questions regarding their views on accessibility, physical facilities, and infrastructure of the clinic.
Indices: The key indices in the questionnaire, used in this study, were grouped into the following sub scales:
- Accessibility, availability, convenience
- Interpersonal aspects
- Time spent with doctor
- Technical quality
- Paramedical staff
- Physical environment
- Financial aspects
- General satisfaction.
Statistical analysis: Descriptive statistical analysis was carried out on the data collected.
Ethical consideration: During the study, verbal informed consent was sought from all the respondents before the start of each interview.
Implications: The survey reflects the patients' opinions and not the actual performance of the physician. It gives us vital information regarding the acceptability and appropriateness of the health-care services being provided at the health-care center. Further patient behavior, such as compliance with the prescribed treatment, follow-up visits, etc. depend on the patients' perceptions and experiences at the clinic and therefore, from the perspective of future results, their opinions and satisfaction levels with the health-care providers are an important indicator of the final outcome.
Socio-demographic characteristics of the respondents
Response rate: Out of the 130 questionnaires handed out, 100 gave in the filled questionnaire, resulting in a response rate of approximately 72.92%.
Age distribution: Out of the hundred responses from patients over 15 years of age, most of the respondents were between the ages of 25 and 34, approximately 41%, and the age groups between 18 and 24 and again between 35 and 49 were almost equally represented at 23% and 27%, respectively [Graph 1].
Gender analysis: The male respondents outnumbered the female respondents 56% male respondents versus 44% female respondents [Graph 2].
Educational level: A large proportion of the respondents Were going in for education, with 51% graduates and 11% postgraduates. What was even more gratifying was that in several families, even though the older generation had barely studied up to the primary level or were even illiterate, the younger generation had laid greater emphasis on education perhaps seeing in education the easiest way out of the lower socioeconomic class of their parents [Graph 3].
Income levels: In spite of higher educational levels - a majority (56%) still persisted in giving their income levels as below ` 2, 00,000 per annum [Graph 4].
General experience at the health-care facility
Satisfaction with interpersonal skills of the doctor: A majority of the patients rated the Interpersonal skills of the Doctor, including respect, courtesy, and empathy shown to the patients as excellent (52%); and 35% gave it a grading of very good [Graph 5].
Waiting time: The maximum number of patients (58%) had a waiting time of approximately 10 min before they were seen by the doctor. A further 21% had to wait for 15 min and a small number, 18%, received medical care within 5 min [Graph 6].
Satisfaction with time given by the doctor: More male patients (60.71%) were inclined to give a rating of excellent to this aspect of the service, while a lesser number of the female patients (59.09%) rated the time given by the doctor as excellent. A number of patients gave a rating of very good to this part of health care, giving a score of 91.36% for female patients [Graph 7], 90.36% for male patients [Graph 8], and a combined score of 90.86% to this aspect of health-care services.
Accessibility (time taken to come to the clinic): A large percentage of the patients (47%) took less than 15 min to reach the clinic, while another 41% said it takes them between 15 to 30 min to reach the clinic [Graph 9].
Accessibility (mode of travel to reach the clinic): Majority of the patients (46%) came to the clinic on foot, with 18% and 17% coming by two-wheeler and auto-rickshaw, respectively [Graph 10].
Availability: Only 21% and 28% of the respondents pronounced the clinic timings as excellent and very good, respectively, with a large percentage (46%) being dissatisfied with the clinic timings [Graph 11].
Treatment and related information
Effectiveness of the treatment: This was the most single most important reason for selection and recommendation of the clinic. A large percentage of the respondents (54%) rated the effectiveness of the treatment offered at the health-care facility as excellent, while another 33% rated it as very good. The rest of the respondents (13%) said that the effectiveness of the treatment was good [Graph 12].
Explanation about the treatment plan: This was given a rating of excellent by 59% of the patients surveyed, while another 33% assessed it as very good. A small minority of patients (7%) rated the doctor's explanation about the treatment plans as merely good and a further 1% said it was fair [Graph 13].
Explanation about the medicines and side effects: 56% of the respondents said that the doctor's explanation about the medication and any possible side effects was excellent, with another 33% rating it as very good. Ten percent of the patients surveyed, said that it was good and 1% called it fair [Graph 14].
Explanation of the purpose and necessity of any tests required: An overwhelming 96% were satisfied with the doctor's explanation of the purpose and necessity of any tests to be done, whereas 4% thought that the doctor's explanation inadequate [Graph 15].
Opportunity to ask Questions: Of the patients surveyed, 39% thought that the physician gave excellent opportunity to ask questions, and another 48% thought it was very good. Eleven percent thought the doctor gave good opportunity to ask questions and 1% gave it a rating of fair [Graph 16].
Response of the paramedical staff
Helpfulness and responsiveness of the staff: 41% rated the helpfulness and responsiveness of the staff at the clinic as excellent, 43% as very good and another 6% and 10% as good and fair, respectively [Graph 17].
Cleanliness of waiting area, toilets, etc.: Only 69% of the patients surveyed were satisfied with the cleanliness level at the clinic, with 31% saying it was unsatisfactory [Graph 18].
Availability of drinking water, adequate seating, etc.: Only 62% of the patients surveyed expressed satisfaction with the seating arrangements and other facilities, with the remaining 38% thinking that the center needed to improve the seating and waiting area [Graph 19].
Overall satisfaction level: A majority of the patients (72%) expressed overall satisfaction with the health-care facility, with the remaining 28% rating it as very good [Graph 20].
Cost of treatment: Only 31% rated the cost of treatment at the clinic as excellent, while a majority, 51% said it was very good. Another 18% rated the cost of treatment at the center as good [Graph 21].
Chances of recommendation: 73% of the patients surveyed said that the chances of recommending the clinic to their friends and relatives was very high, and the remainder, 27%, rated their chances of recommending the clinic as high [Graph 22].
The Victorian Patient Satisfaction Monitor are a set of indices that have been developed by the Department of Health, State Government of Victoria, Australia, to measure the adult patients' satisfaction with the care and services provided by the State's public acute and subacute hospitals. They have been slightly modified in this study to assess the key dimensions of the patients' experience at the primary care health-care facility. Each index is calculated from the (two or more) survey questions that best represent the relevant aspects of the health-care experience. These indices had been originally developed for hospital admissions and have been slightly modified for usage in an out-patient satisfaction survey. The indices cover the following aspects:
- General patient information
- Treatment and related Information
- Response of the paramedical staff
- Physical environment, amenities etc
- Overall experience, including cost.
The overall care index (OCI) was calculated by:
- Totaling the scores for each parameter and ranking it according to the maximum possible score for each parameter [Table 1]
- The cumulative score for each group of parameters, representing different aspects of patient satisfaction, were ranked [Table 2]
- These cumulative scores were then scored according to their degree of relevance to the OCI [Table 2]
- OCI was calculated according to the individual score of each parameter and its relevance and weightage in the OCI [Table 2] 
- Overall care index calculated was 84.175% [Table 3].
| Results|| |
Most of the respondents were between the age group of 25 and 34, with a preponderance of males (56%) and a large percentage of graduates (51%) in the group. However, this might also be explained by the relative inclination of the resident female population to leave the "writing work" to their husbands or any other male relative accompanying them.
General experience at the health-care facility
A large number (52%) gave a rating of excellent to the physician's interpersonal skills, with another 35% of the respondents gave him a rating of very good for their interpersonal skills. Waiting time was given a score of 78% and time given to the patients by the doctor getting a score of 90.86%. Accessibility - considering both the time taken and mode of travel to reach the clinic - was 82.25% but convenience of the clinic timings or availability of the treating physician was only 72.8%, giving the health-care facility a total score of 83.58% for this aspect of patient care.
Most physicians in private care give patients adequate time, are respectful and courteous, express empathy, and develop a personal rapport with the patient-inspiring trust and confidence in the doctor which is an essential part of healing and is often missing in larger set-ups. Since most of these health-care providers are running solo clinics, they provide a continuity of care combined with in-depth knowledge of the patients' previous medical history, leading to better care.
Availability and accessibility
The survey revealed that while most patients were satisfied with the accessibility, availability remained a sore point for most patients, with a large percentage (46%) being dissatisfied with the timings at the clinic. This, unfortunately, is a problem for most solo physician clinics, which also form the largest group of private primary care providers in India.
It is physically almost impossible for a single physician to be available to suit the convenience of all patients. The usual target group for this practice belongs to the lower socioeconomic strata. Any loss of working days is not acceptable to this group, and they need extremely prolonged working hours at the clinic so that the physician is available at both ends of their working hours. This makes it difficult for solo physician clinics to provide long service hours demanded by the patients.
Effectiveness of the treatment was the most important factor for selection and recommendation of the clinic, along with adequate information about the disease and explanations about the treatment plans, investigations, and effect of medicines and side effects.
A combination of all these factors, with good clinical outcomes being the most important, resulted in over 50% of the respondents giving the clinic a rating of excellent and 33% rating it as very good. The total score for this category was 89.4%.
This remains the most important criterion for selection and recommendation of the clinic. Everything else is secondary to the main purpose of the health-care facility - to heal. Clinical outcome is still the most important factor for the patients' decision to either continue with the same physician or switch to another physician or health-care facility. The best interpersonal skills will not compensate for less effective treatment. Patient satisfaction and trust in the health-care provider improves patient compliance and ultimately the clinical outcome.
Information about treatment plans
Changing expectations of patients, with increasing education and awareness, has also led to an increasing expectation of information about his illness, the treatment plan and the effects and side-effects of the medicines prescribed.
Private providers in this situation have an edge over their counterparts in government set-ups. Since the patient is paying directly for the treatment and tests etc., if any, the treating physician has to convince them of the importance and significance of any treatment plans before he can go ahead. This gives the feeling to the patients of active participation in the healing process.
Opportunity to ask questions
The treating physician must welcome any opportunity of involving the patient in the treatment process. The chances of litigation are greatly decreased if the patients are kept informed and involved at every step of the treatment.
Responsiveness and helpfulness of the paramedical staff
Forty percent rated the helpfulness and responsiveness of the staff at the clinic as excellent, 43% as very good and another 6% and 10% as good and fair, respectively. The contribution of the nursing and other paramedical staff to the proper functioning of a health-care facility is well established.
More than 30% of the patients were clearly dissatisfied with the cleanliness level at the center and 38% thought that the seating and waiting area at the clinic needs improvement. This is a major area of dissatisfaction. In corporate hospitals, this is a major opportunity to score over government and subsidized care providers. At the level of private primary care providers, however, the situation is quite different - this being one area which is often compromised due to scarcity of resources.
Cost of treatment
Only 31% of the patients rated the cost of treatment at the clinic as excellent, while a majority, 51% said it was very good.
Cost is a major deterrent to consumers of the health care. Most people feel that the cost of health care is prohibitive. The patient is often unaware of the hidden costs of the health-care facility and considers the full charge at the facility as the doctors' fee, leading to a feeling that treatment costs are disproportionately high.
This unfortunately leads to under-cutting of prices by health-care providers to maintain patient's loyalty, which in turn leads to compromising on certain facilities - a no-win situation all round. This may be the reason why many smaller nursing homes, which could provide the longer hours of service and emergency services that patients demand, are no longer economically viable.
Overall satisfaction level
A majority of the patients (72%) expressed overall satisfaction with the health-care facility, with the remaining 28% rating it as very good. The overall satisfaction level was quite high, borne out by the fact that a large majority of consumers also said that the chances of recommending the center was quite high.
Chances of recommendation
Seventy three percent of the patients surveyed said that the chances of recommending the clinic to their friends and relatives was very high and the remainder (27%) rated their chances of recommending the clinic as high.
| Discussion|| |
Private primary care physicians or family physicians have a long tradition of personal medical care comprehensive in its response to the needs of people and reasonably accessible in their neighborhood. In India, the vast majority of patients regard the general practitioner as first port of call for health concerns and as the health professional who they trust to give them advice and treatment. The family physician usually has a long-standing relationship with the patient, leading to a better understanding of the previous medical history and the sociocultural background of the patient vital for complete healing and a feeling of greater trust in private health-care providers. With intimate knowledge and understanding of patients' previous medical history as well as the family background and long standing relationship with the patient, the family physician is the ideal person to help the patient take a more active role in both the curative and preventive aspect of health care - leading to improved patient compliance, better clinical outcomes, and improved health status of the community.
The satisfaction of the patients with their primary care providers has been aptly borne out by this study. However, the changing expectations of the patients toward health-care providers and health-care facilities and increasing commercialization of health care has led to people demanding more from their health-care providers than just effective treatment. With rising levels of education and awareness, providers need to offer patients greater involvement in the treatment, show empathy and respect toward their patients along with.
In today's world, corporatization of health care and competition among private health-care providers for paying customers has ensured that providers have strong reasons for obtaining feedback regarding their services and service quality, and to act upon the results so obtained.
The patients' perspectives may reveal lacunae in the system of health-care delivery, which may be unrecognized by the providers. Patient feedback helps not only in evaluation and monitoring the quality of health care but is also a way to improve clinical and functional outcomes.
Satisfaction or dissatisfaction has the following components:
Need-A need for a service.
- Expectation - An expectation of what the standard or level of the service
- Experience - The actual experience-at the time of usage of the health-care services
- Comparison - Comparing with preconceived ideas of the levels of service
- Satisfaction - Satisfaction or dissatisfaction. 
Assessment of patient satisfaction is assuming greater importance because:
- Satisfied patients are loyal to a health-care facility, resulting in repeat visits and increased revenue
- Recommendations by a satisfied patient have a greater impact on building a positive image of the hospital in the mind of the population than any other means of marketing
- A disgruntled or dissatisfied patient will also dissuade his friends and relatives from visiting that particular health-care center
- An Outraged patient may give rise to a lot of ill will, but health-care providers will never really know how many patients simply do not find the level of care at a particular health-care facility not satisfactory and choose another health-care provider, without anyone being the wiser.
Patient Satisfaction studies can be utilized by health-care managers:
- To identify patient perceptions and expectations of the health-care delivery system
- To assess how far the expectations of the patients have been realized and identify lacunae, if any
- To evaluate the quality of care
- To develop initiatives to improve the quality of care
- To identify any unmet needs of the patients for upgrading present services or offering a new service
- As one of the outcomes of the health-care delivery system.
Patient delight versus patient satisfaction:
A Delighted patient is a much more vocal and loyal consumer than a Satisfied patient. When we, as health care providers, exceed the patients' perceptions and expectations by providing a level of care that surpasses the expected level of care- we get a Delighted Patient. However, an Outraged patient is also much more likely to create negative publicity for the health-care facility.
Within the limits of this survey, patients appear to be quite satisfied with the health-care services provided at the center. Survey results have shown that patients place maximum emphasis on the effectiveness of the treatment and the behavior of the doctor, which has led to an overall high index of satisfaction.
The highest satisfaction levels are with the doctor-patient relationship, with a majority of the patients demonstrating a high degree of confidence in their physician.
However, patients have also become more demanding in respect of the other facilities that they expect from their health-care provider and have no qualms about expressing their dissatisfaction.
Unfortunately today, the Family physician is regarded as a relic of the past. With specialization and super specialization being the norm - family medicine or general practice seems to have become the last option of medical school graduates.
With ever-increasing emphasis on specialization and tertiary care, primary care has become the poor relation in modern day medicine. But this has also led to rising cost of health care and over-loading of tertiary care hospitals with patients who can easily be handled at the Primary Care level. Especially in a country like India, improved, more acceptable and accessible primary health care will greatly reduce the over-crowding and over-loading of our tertiary and teaching hospitals.
What is now required is to redesign the role and importance of the Family Physician and bring the focus back on primary health-care providers - who form the pillars of the health-care services of the community.
This study has certain limitations:
- Standardized questionnaires: Use of standardized questionnaires for evaluation of patient satisfaction may limit the patient's opportunity to express concerns about different aspects of care. Patients may have a complex set of important beliefs that cannot be expressed in terms of simple satisfaction
- Small sample size: Owing to the small number of questionnaires collected, the patient sample could not be considered a representative sample of the population or even those of all the patients who visited this center. Adequate study of the multiple factors that influence patient satisfaction needs a larger sample size and sophisticated statistical analysis which was not possible in this study due to a lack of resources
- Lack of randomization: Studies performed in primary care settings are not able to ensure precise randomization of the patient sample, as visits to the physician did not follow principles that could be planned or predicted. For this reason all patients coming to the practice were requested to take a survey questionnaire, accepting their choice to come for a visit and take the survey as part of the selection procedure
- Bias: Another limitation was introduced by the fact that the survey was carried out by the health-care provider, leading to bias on the part of the patients. It is important, therefore, that any patient Satisfaction Surveys to be carried out must be by an obviously uninvolved, uninterested third party to yield a more accurate picture of patient expectations, experiences and levels of satisfaction with the health-care facility
- Blurred lines between explanation and understanding: Difficulty of separating various aspects of the consultation that are closely connected, e.g. information cannot be totally separated from explanation and understanding, or from emotional support in certain situations
- Lack of standardized treatment: There are no standardized treatment protocols for general use for most diseases and symptom complexes in India, leading to improper and inaccurate assessment of competence of the providers
- Complexity of questionnaire: The questionnaire developed to assess the responses of the patients may also have been a little difficult for the patients to understand and rate. In any patient satisfaction survey, striking a balance between questionnaires that cover as many possible parameter of satisfaction and making it easy enough for the respondents to rate the services accurately is a difficult task
- Lack of comparison: It would also be useful if there was some element of comparison, either with another health-care provider or a government primary care facility.
These limitations reveal not only the lacunae of the selected method, but also the complexity of the science and art of medicine.
With greater emphasis and the growing realization of the place of the family physician in health-care delivery systems, Patient satisfaction surveys are valuable tools that can be used by health-care providers to assess the quality of care from the perspective of the patient (Christopher Guadagnino, PhD).  However, the study of Patient Satisfaction, especially in Primary Health Care where there is a great emphasis on the human aspect, is complex involving a number of quantitative and qualitative variables. Tools need to be developed which would be able to analyze the patients' needs and requirements and yet be simple enough to permit easy use by the respondents.
There are Patient Satisfaction Studies carried out in India, but almost all of them are associated with either hospitals or hospital associated chains. However, since private health-care providers are usually the first point of contact for a vast majority of people, further studies need to be carried out to understand the lacunae and drawbacks in the quality and cost effectiveness of these providers and what needs to be done to ensure Universal and Equitable Health Care.
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[Table 1], [Table 2], [Table 3]