Understanding and Measuring Responsiveness of Human Resources for Health in Rural Bangladesh
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Introduction Responsiveness of human resources for health (HRH) is defined as the social actions that health providers do to meet the legitimate expectations of service seekers. Lack of responsiveness may dissuade patients from early care seeking, diminish their interest in adopting preventive health information, decrease trust with health service providers, and marginalize at-risk population groups, leading to compromised wellbeing. Most importantly, responsiveness is related to the human rights of the patients. The overall goal of this dissertation was to examine HRH responsiveness in rural Bangladesh, to develop a scale to measure the responsiveness, and finally to demonstrate the application of the measurement method. This goal has been addressed in three separate manuscripts, which aimed to answer the following questions, respectively: 1. What are the perceptions of outpatient healthcare users and providers regarding what constitutes responsiveness of physicians in rural Bangladesh? 2. How can we measure the responsiveness of physicians in rural Bangladesh? 3. What are the differences in responsiveness of physicians between those working in the public sector as opposed to those working in the private sector in rural Bangladesh? Methods This study adopted a multiphase mixed methods design, in which the qualitative part was followed by a quantitative part in data collection (sequential).In the latter stage of the project, both qualitative and quantitative aspects simultaneously complemented each other in data analysis and interpretation (concurrent). Data collection took place in rural parts of Khulna, a southwestern division of Bangladesh. The qualitative portion consisted of in-depth interviews (IDI) of physicians (seven public, five private, five informal), in-depth interviews of clients (n=7), focus group discussions (FGD) with clients (two sessions each with males and females), and participant observations in consultation rooms of public, private, and informal sector healthcare providers (one week in each setting). The quantitative research consisted of structured observation (SO) of 393 physicians (195 from public and 198 from private sector). This data was collected for developing a scale of responsiveness through exploratory factor analysis (EFA), involving 64 items (generated through the qualitative part of this project). This data was also intended for applying the scale, once developed, to compare the responsiveness of public and private sector physicians. Inter-rater reliability was assessed by same three raters observing 30 consultations, using the scale (later named as Responsiveness of Physicians Scale or in short ROP-Scale). Study data were collected between August 2014 and January 2015.Qualitative data were analyzed by the framework analysis method. World Health Organization’s (WHO) health systems responsiveness framework was modified, based on literature review and expert opinions, to include the following domains for qualitative analysis: Friendliness, Respecting, Informing and guiding, Gaining trust, and Optimizing benefit. Quantitative data were analyzed by EFA, followed by assessment of internal consistency by ordinal alpha coefficient and inter-rater reliability by intra-class correlation coefficient (ICC). For comparing responsiveness of public and private sector physicians two sample t-test, multiple linear regression (MLR), multivariate analysis of variance (MANOVA), and descriptive discriminant analysis (DDA) were used. This dissertation presents three manuscripts. Manuscript-1 presents the qualitative component to facilitate understanding of the local perceptions around responsiveness of physicians. Manuscript-2 presents the quantitative data to develop a psychometric scale to measure responsiveness of physicians and then to evaluate the reliability and validity of the scale. Manuscript-3 used a mixed methods approach to compare responsiveness of public and private sector physicians. Results Manuscript-1 showed that user and provider perceptions of responsiveness of physicians in rural Bangladesh often overlapped but at times diverged. Due to high patient load, physicians in the public sector usually failed to spend enough time with patients for proper history taking, asking questions, examining, and reassuring. Although not satisfactory, according to patients in qualitative part of the research, physicians in the private sector were more responsive towards the patients, especially in terms of conducting examinations with care, asking questions, and giving little reassurance. Most of the patients complained that physicians in general (i.e., both in public and private sectors)were not responsive, especially in terms of talking to them enough, compassionately touching them (for examining, for giving reassurance), and explaining their condition. They also complained of losing trust in physicians, as they seemed not to be caring, but businesslike. Patients demanded that, in order to be responsive, physicians should not only be prescribing drugs, but also be sensitive to patient’s financial status. Physicians should tell them the cost of treatment, try to understand whether patients can afford it, and if necessary, tailor the treatment accordingly. On the other hand, physicians also acknowledged their inadequacies, but attributed these to the overall health systems constraints, patient loads, lack of proper training on responsiveness issues, and often abuse by the patients. Psychometric analyses, described in manuscript-2, identified 34 items grouped under five domains (or subscales) to constitute the Responsiveness of Physicians Scale or, in short, ROP-Scale. The five domains, derived through EFA and later named through discussing with the relevant experts, are as follows: Friendliness, Respecting, Informing and guiding, Gaining trust, and Financial sensitivity. There were high inter-factor correlations between Respecting and Informing and guiding, and between Respecting and Friendliness. The scale has a very high internal consistency with ordinal alpha coefficient of 0.91. Inter-rater reliability was also very high with intra-class correlation coefficient (ICC) (2, k) of 0.84. The scale also demonstrated face validity (through expert consultation), content validity (through qualitative research and literature review) and criterion validity(concurrent validity by correlation coefficient of 0.51 with consultation time; and known-group validity by comparing public and private sector physicians’ responsiveness with private sector scoring 0.18 higher mean score). The quantitative part of manuscript-3 was based on the application of ROP-Scale, in which an average of the score of 34 items was considered as the overall responsiveness score. Each item had four response categories, with the lowest score of one (signifying lack of responsiveness) and the highest of four (signifying best practice). The study found the mean responsiveness score of public sector physicians to be1.98 and that of private sector physicians(in this manuscript only formal private sector was considered in both qualitative and quantitative analysis)2.16; and the difference statistically significant in t-test with t statistic of -6.04 (p-value <0.01). The difference remained statistically significant in the multivariable models after adjusting for the confounding covariates such as age, gender and local origin of the physician and age, gender and level of education of the patient. Qualitative data added value to this finding by suggesting that, despite slightly better responsiveness of private sector physicians, none of the sectors were sufficiently responsive, according to service seekers. In domain-specific evaluation of responsiveness, the public sector outperformed the private sector in domains of Gaining trust and Financial sensitivity. The domain Respecting was identified in DDA as the most important domain in dividing the public and private sector based on responsiveness. The qualitative part of the study found the private sector physicians to be more tolerant, polite, and courteous than the public sector physicians, as opined by patients. Nevertheless, private sector physicians were criticized by patients for attending more patients than their capacity, prescribing more diagnostic tests, and showing reluctance to refer patients who they failed to treat. Qualitative findings supported the quantitative findings that public sector physicians were more prudent in gaining trust and being financially sensitive to the patients. Conclusions This study demonstrated the detailed process of development and application of a psychometrically validated ROP-Scale. In this process, I reviewed the earlier work on health systems as well as HRH responsiveness, defined the HRH responsiveness, discussed caveats in different aspects of understanding and measuring responsiveness, proposed a conceptual framework to examine HRH responsiveness, identified five domains of HRH responsiveness, presented the findings across the domains of responsiveness, and compared the responsiveness of public and private sector physicians’ responsiveness. This study can pave the way for further research work, for example, on determinants of responsiveness, on contribution of responsiveness on health outcomes, validation studies in other settings and among other cadre, and comparative studies. This study can also contribute in the national and international policy decision-making. For example, at national level, this study can aid in in-depth understanding of expectation of people around performance of HRH, developing a context specific curriculum on doctor-patient communication, developing a guideline for regulatory interventions, and improving community ownership over health services. At international level, similar type of locally relevant testing of constructs and items can be tested, benefitting from the methodological and conceptual inputs from this study. This research can open up further avenues in the health policy and system research (HPSR) concerning the HRH both at local and global level.