Assessment of Primary Laboratory Facilities for Rural Health Care Preparedness in Osmanabad District,India

Abstract

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

Keywords

Health care facility public laboratories rural health India Bayesian network

Introduction

The rural areas in India hold records for 80% of all deaths and nearly 90% of deaths due to communicable diseases, as well as records for maternal, perinatal and nutritional conditions (Office of Registrar General, 2009). Prevalence of poor health care risk factors (unhealthy diet, reduced physical activity, smoking, hypertension, poor food quality) is increasing and recent studies showed hypertension and diabetes in 40% (Devi et al., 2013) and 10% (Nazir et al., 2012) of adult Indians, respectively. Risk factor control requires a multidisciplinary approach that includes strengthening the health system, resolving social determinants of health and health care financing (Gupta et al., 2011). Majority of users belong to economically weaker sections (Pandey et al., 2017; Ranson et al., 2012), which hinders their access to private facilities that are not always affordable. This makes public health care system more responsible for rural health care.

In accordance with the Alma-Ata Declaration (World Health Organization, 1978), India focused on providing primary health care facilities to rural areas. India launched the National Rural Health Mission (NRHM) in 2005 to provide preventive and basic curative and laboratory health care services in rural areas for major health issues (MoHFW, 2005). It aims to provide rural health care services and integrate horizontally all vertical disease-based programmes at district level. Primary health care system in rural India has primary health centre (PHC) with catchment area of 30,000 rural population, which is the first point of contact for (a) laboratory services and (b) medical doctor/officer (MO) in rural areas (MoHFW, 2012).

NRHM provides Indian Public Health Standards (IPHS) to maintain PHC quality (MoHFW, 2012). However, over the years, PHCs have focused on providing preventive, childbirth and treatment services in rural areas, as a consequence it is possible that certain key aspects of laboratory services are neglected. Medical laboratories strengthen the health care system by providing up to two-thirds of medical decision-making (Forsman, 1996; Khatri & Frieden, 2002). The current study was performed to understand the functioning and preparedness of laboratory facilities in PHCs using Osmanabad district, Maharashtra, India as a case study.

Method

Settings

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

The district has secondary and primary health care facilities, but does not have any tertiary health care facility like medical colleges or specialty hospitals. The urban areas have secondary health care facilities, that is, one district hospital, one maternity and child hospital, three sub-district hospital and seven community health centres (CHCs). The rural areas only have primary health care facilities that consist of 206 sub-centres (SCs) and 42 PHCs. The interaction with district health office (DHO) bureaucrats and health care facility staff suggests that PHC pharmacists and DHO bureaucrats do the district-level budget-making for the rural laboratory facilities. The budget-making is done based on past field experience and does not involve the use of any mathematical model or representation from laboratory experts or staff.

Services

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

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

The other basic services provided are seating and toilet facilities. The PHCs provide services of collecting patient malaria and tuberculosis samples from home, SC, as well as from PHC OPD and inpatient department (IPD) and send the sample to the nearest public health facility for testing. The OPD hours are based on local need to increase laboratory access. The morning timing to start OPD varies from 8:00 am to 9:30 am, while evening OPD is started at 4:00 pm across all PHCs. Additionally, laboratory sample testing starts almost simultaneously after laboratory sample collection. The test results and report delays depend on the test type and the laboratory location. Kit-based tests have lower time delays when compared to the other tests. Further, time delays are less when a PHC has a laboratory on its premises as compared to a PHC not having a laboratory on its premises.

Resources

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

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

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

Financing and Governance

PHC mainly gets resources and services from higher authorities. Only limited monetary funds ($2,681.4 per year ($1 = ₹65.27)) called RKS funds are provided by NRHM to meet emergency needs (MoHFW, 2012). In terms of governance, MO is the head of the PHC and is responsible for day-to-day PHC governance, operations and decision-making (MoHFW, 2012). In India’s centralised governance structure (explained in Appendix I), MO represents the PHC to higher authorities.

PHC Laboratory Preparedness Analysis

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

The questionnaire survey is prepared to assess the PHC laboratory. The questionnaire is prepared using the various criteria given in the IPHS. Certain other criteria were added to the list based on past field experience and interactions with public health professionals. The complete list of criteria is classified into services, resources, financing and governance, which is given in Appendix II. The PHC gets a score of ‘one’ or ‘zero’ for each indicator based on whether it meets or does not meet the indicator criteria.

Statistical Analysis

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

PHC Laboratory Preparedness Validation

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

The BN model was developed for PHCs using six parameters namely governance, financing, resources, services, staff workload (SW) and number of samples collected (NSC). The data for SW per week and NSC per week was provided by the DHO, Osmanabad. The study used hill-climbing (HC) algorithm in ‘bnlearn’ package in R to prepare the model (Scutari, 2009). HC is a score-based algorithm in which a random sub-optimal solution of the model is built, and the solution is improved till a desirable condition is maximised. It suffers from the issue of local maxima (Yuret & Maza, 1993) and wrong linkage (Friedman et al., 1999). Accordingly, the model is built in two steps. In the first step, the base model is prepared using the unconstrained HC algorithm. In the second step, certain parent–child node relationship constraints were added to HC algorithm based on the base model iteratively to obtain the final model. The statistical condition optimised for the model is Bayesian information classification (BIC), which is commonly used for discrete data sets (Neath & Cavanaugh, 2012).

Results and Discussion

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

PHC Laboratory Preparedness

The response for all the criteria is obtained for 15 out of 42 PHCs. It is found that the overall preparedness level of PHCs varies from 26.92% to 50%, with average preparedness level of 38.72% (Figure 1). The preparedness status is lowest for service category, with only 6 out of 31 responding PHCs having a criteria preparedness score of more than 50%. The average preparedness level is lowest for governance category (33.33%). This indicates a need to strengthen the laboratories in PHCs.

Figure 1.

Radar Diagram Depicting Overall Primary Health Centre (PHC) Preparedness Level (% of Criteria Met) and Four Individual Parameters, Namely, Services, Resources, Financing and Governance.

Governance

MO plays a critical role in the PHC governance as they are the head of the PHC. Accordingly, for good PHC governance, a good MO governance capability is the prerequisite. However, this study shows that the governance capability of MO is inadequate (Figure 2). It is found that less than 50% of MOs think that they have decision-making authority for day-to-day operations (IG1). Further, this issue is reflected in the other indicators. Many MOs struggle with decision-making as they struggle to estimate the timeline for decision implementation (IG2) and find the decision-making process difficult (IG3). A good PHC laboratory functioning requires better planning and understanding of the time it would take to upgrade/repair instruments (IG4) and access to different resources (IG5), but many MOs struggle with it. Finally, a good governance key characteristic is the trust placed by the leader in its staff and its services (IG6) (Wong & Cummings, 2009), but the study finds that many MOs are unable to meet this criterion. Such a scenario of no representation of the laboratory and weak governance capability of MO can affect the functioning of the PHC laboratories.

Figure 2.

Percentage of Primary Health Centres (PHCs) That Have Achieved a Good Status across Governance (IG) and Financing (IF) Parameters.

Financing

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

Table 1.

The Rogi Kalyan Samiti (RKS) Funding Sources for Different Tests in Different Primary Health Centres (PHCs).

Funding Source	Number of PHCs Requesting Funds for a Particular Test^*
	IPHS										Non-IPHS
	GS	BS	BT	Hb	HIV	S	T	UA	HCG	US	Tb	HEPB
The PHC received testing resources from the district; however, the resources were insufficient to meet the testing needs and thus used RKS funds (both sources)	1	3	7	4	0	2	2	6	4	6	1	0
The PHC received no testing resources from the district, so in order to meet their testing needs, RKS funds were used (RKS sources)	0	0	0	1	1	1	0	1	0	1	0	4

Note: ^*Gram staining (GS), blood sugar (BS), blood group (BT), haemoglobin (Hb), human immunodeficiency virus (HIV), syphilis (S), typhoid (T), urine albumin (UA), pregnancy test (HCG), urine sugar (US), tuberculosis (Tb) and hepatitis B (HEPB); IPHS, Indian Public Health Standards.

Resources

According to IPHS, the resources required for PHC laboratory’s testing services are workforce, diagnostic infrastructure, consumables and information. However, considering the reference scenario in which each resource indicator standards are met by all PHCs, it is found that PHCs are not meeting all the resource indicator standards (Figure 3). It is found that there is a deficit of workforce (IR1) and its quality (IR2). Only 23 out of 42 PHCs have an LT, and only 9 out of 23 LTs are skilled enough to perform tuberculosis testing. Rao et al. (2013) mentioned that there is a lack of workforce in rural health institutions in India. Further, during the field interactions, respondents mentioned that MOs are not given in-service training to manage PHCs and many LTs are not given complete in-service training for better performance of existing tests like malaria or to conduct tests like tuberculosis. The implication of unmet IR1 and IR2 criteria is that the other PHC staffs have extra work, that is, (a) to collect malaria and tuberculosis samples, (b) send collected malaria and tuberculosis samples to other public health facilities, and (c) perform kit-based tests.

Figure 3.

Percentage of Primary Health Centres (PHCs) That Have Achieved a Good Status across Resource Parameters.

In terms of the infrastructure, while all 42 PHCs have other basic infrastructure units like storage facilities and a communication facility, they struggle to meet IPHS requirements of a separate laboratory room and 24-hour water and electricity (IR3). In terms of the availability of resources to conduct the tests focused by the DHO, it is found that most PHCs can obtain test standards (IR4) and standard operating protocols (SOPs) (IR5) from higher authorities, and many find that the tests are easy to perform (IR6).

In terms of consumables stock, IPHS recommends that PHCs should avoid zero-stock scenario (MoHFW, 2012), but 14 PHCs have run out of stock in the last year (IR7). A good functioning laboratory needs easy stock procurement process (IR8), but the current strategy seems to be described as difficult by 31 PHCs. The stock maintenance strategy has been variable across the PHCs in terms of regular inventory checks (ranging from stock check per 1 to 30 days) and buffer stock maintenance (ranging from 1% to 66% of the total stock). Such variation in stock maintenance strategy indicates a process of stock management optimisation undergoing in the PHCs for better functioning in the current stock procurement policy. In terms of instrument maintenance, while four instrument maintenance mechanisms (IR9) are known across the district, none of the PHCs has any knowledge of these four mechanisms. In this study, 27 respondents know of only one mechanism, furthermore, most found the instrument maintenance process (IR10) difficult.

Services

The IPHS 2012 had recommended various tests for the PHC (MoHFW, 2012), but the district has focused on haemoglobin, HIV, malaria, tuberculosis, pregnancy, urine albumin, urine sugar, blood sugar and blood group tests. Among the district-focused tests (IS1), most PHCs are unable to perform all of these tests (Figure 4) and some perform other tests as well (Figure 5). It shows in Figure 4 that other basic services like seating facilities (IS2) are present for all PHCs, but toilet facilities for both male and female (IS3) are not present in all PHCs. The indicators cleanliness (IS4) and biomedical waste management (IS5) are important services for quality assurance and staff and patient safety, but performance in both indicators is below standard for most PHCs.

Figure 4.

Percentage of Primary Health Centres (PHCs) That Have Achieved a Good Status across Service Parameters.

Figure 5.

The Number of Primary Health Centres (PHCs) out of 42 in Which a Particular Test is Performed.

The temporal access of the laboratory in terms of the number of hours per day the laboratory is opened for OPD (IS6) is less than IPHS recommendations of 6 hours per day in most PHCs. Similarly, temporal access of the laboratory in terms of the number of days per week the laboratory is opened for OPD (IS7) is less than IPHS recommendations of 6 days per week in most PHCs. The median value (5.3 hours/day and 5.5 days/week) of both indicators is less than the mean value (5.5 hours/day and 5.6 days/week), indicating that at least 50% of PHCs fail to meet even the mean district value.

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

PHC Laboratory Preparedness Validation

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

Table 2.

Descriptive Statistics of the Functioning and Performance Parameters (n = 24).^*

	Governance	Resources	Services	NSC	SW
Mean	2.76	3.38	2.95	142	755.21
Median	2.75	3.50	2.75	129	455.00
Standard deviation	1.05	1.26	0.86	75.58	871.32
Min	1.00	1.00	1.71	22	16.00
Max	5.00	6.00	4.50	311	3,062.00

Notes: ^*Financing parameter is not shown as it could take only two values of 0 or 1.

NSC, number of samples collected per week; SW, staff workload, number of minutes spent on sample testing per week.

The final BN model is prepared (Figure 6) based on the base BN model (Appendix III) with better results (BIC value is –94.66491 for the final model vs. –88.7714 for the base model) and no reverse linkages. The governance, finances and resources are parent nodes for NSC indicating a probabilistic relationship between functioning parameters and performance parameters. Further, NSC and SW are also found to have a probabilistic dependency on each other with NSC as the parent node and SW as the child node. The parent–child relationship between laboratory status and performance parameters is expected as status parameters are laboratory input and performance is laboratory output. Further, SW is dependent on the quantum of work available, that is, total number of samples for testing in the laboratory, NSC.

Figure 6.

Final Bayesian Network (BN) Model.

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

Further, it is observed that governance must be ‘high’ for NSC to be ‘high’. This indicates that performance is strongly dependent on governance. The governance criteria in this study focused on the indicators that ascertain the governance capability of the MO; accordingly, the result indicates that weak MO governance capability reduces performance and strong MO governance capability increases performance. Ferrelli et al. (2016) showed that provisioning of health governance training to health staff as part of the continuous profession development programme in Italy improved hospital performance. Additionally, various projects in Africa and Asia regarding laboratory strengthening and performance for tuberculosis (Wertheim et al., 2010), AIDS (Abimiku, 2009) and polio (Gumede et al., 2016) programmes were successful owing to good planning and governance capability of decision-makers or enhancing it. This enabled better support and utilisation of resources and finances as well as monitoring that resulted in better services.

Further, it is found that good resource and governance status plays an important role in good laboratory services and financing status (Table 3), leading to improved laboratory performance. Further, all the laboratory strengthening studies in resource-limited settings had shown success and also recommended focus on resources and financing of the laboratories (Abimiku, 2009; Elbireer et al., 2011; Gumede et al., 2016; Nkengasong et al., 2009).

Table 3.

Conditional Probability of Occurrence of Different Parameters Status.

Condition (n)	Event (n)
Governance Status			Resources Status
	Low (14)			High (10)
Low (9)	0.64			0.36
High (15)	0.54			0.46
Governance Status, Resources Status	Financing Status			Services Status
	Low (15)	High (9)		Low (9)	High (15)
Low, Low (6)	0.84	0.16		0.67	0.33
Low, High (3)	0.36	0.64		0.00	1
High, Low (8)	0.64	0.36		0.36	0.64
High, High (7)	0.56	0.44		0.28	0.72

Note: *Bold numbers indicate large difference between low and high status.

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

Conclusion

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

Appendix I

Indian Health System Rural Governance Structure and Functioning

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

Structure

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

Figure IA.

Rural Public Health Care Governance Structure.

Below state government, the governance of health care is bifurcated into state health department (SHD) and district collectorate (DC). SHD is at the state level and DC is at the district level. Below SHD, at the district level, governance structure is bifurcated into urban and rural public health care governance structure governed by district hospital (DH) and district health office (DHO), respectively. Under DHO lies the primary health centre (PHC) followed by sub-centre (SC). Below NRHM and DC, DHO comes directly, followed by PHC and SC.

Functioning

The goals and funds are provided by the central government to the state government and NRHM as shown in Figure IB. State government provides the goals and funds to SHD and DC. SHD provides governance, resources and financing to DHO. The DHO provides governance, resources and financing to PHC and PHC provides governance, resources and financing to SC. DC cooperates with SHD and provides its governance, resources and financing to DHO both directly and indirectly through District Panchayat. Similarly, NRHM also cooperates with SHD and directly provides its governance, resources and financing to DHO.

Figure IB.

Rural Public Health Care Governance Functioning.

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

Appendix II

Criteria Used for PHC Laboratory Assessment

The data were collected using field surveys administered from July to August 2015. Osmanabad City is the operations base, as daily visits were made to the 42 PHCs via a hospital transport facility, public transport (ST buses) and local transport (e.g., bike lifts, sand-carrying tractors and shared autos). Prior to every survey, the respondents were provided with a verbal explanation of the survey’s relevance.

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

In terms of services, IPHS has recommended 27 basic laboratory tests for PHCs. The service quality is recommended by cross-checking the test results with other laboratories and by maintaining cleanliness and biomedical waste management. The non-emergency laboratory services are functional during the outpatient department (OPD) working hours. IPHS has recommended that the OPD working hours should be 6 hours per day (4 hours in the morning and 2 hours in the evening) for 6 days a week (MoHFW, 2012). These recommendations are used as criteria as shown in Table IIA. The additional criteria used in the study are delays in obtaining malaria and tuberculosis sample test results after collecting the sample.

Table IIA.

Service Criteria and Indicators Evaluated in the Survey.

Code	Services Criteria	Indicator	Source
IS1	Perform IPHS tests	Perform the district focused nine tests	IPHS^*
IS2	Provide seating facility to patients		IPHS
IS3	Provide functional toilet to patients	Functional toilet is available for both male and female patients	IPHS
IS4	Clean laboratory area	Laboratory related area in the PHC (namely, the OPD room, laboratory room and wardroom) is clean in terms of no spit marks, a clean floor and no wall peeling	IPHS
IS5	Biomedical waste management is performed	DHO recommended all four steps of biomedical waste management are done	IPHS
IS6	Opened for OPD patients for at least 6 hours per day		IPHS
IS7	Opened for OPD patients for at least 6 days per week		IPHS
IS8	Delay in malaria test results	Not more than one day delay occurs in the PHC laboratory when obtaining malaria results once a patient’s sample is collected	None
IS9	Delay in tuberculosis test results	Not more than one day delay occurs in the PHC laboratory when obtaining tuberculosis results once a patient’s sample is collected	None

Note: ^*The preliminary survey showed that no primary health centre (PHC) has all the tests recommended in Indian Public Health Standards (IPHS), so the study assessed the PHC in its ability to perform the tests focused by the district as these tests are part of IPHS standards; DHO, district health office.

In terms of resources, IPHS provides recommendations for human resources, infrastructure and consumables. A PHC needs to have both medical doctor/officer (MO) and laboratory technician (LT) for a fully functional laboratory because patients cannot access public laboratory services without MO’s referral. Further, the staff in PHC should be regularly updated on their skills. In terms of laboratory infrastructure, PHC should have 24-hour water and electricity supply and a separate room. In terms of consumables, it is required that PHC should have all 27 tests resources and maintain all test standards and standard operating protocols (SOPs). Further, the consumables stocks should be managed so that PHC does not run out of stocks. These recommendations are used as criteria as shown in Table IIB. Four additional criteria are used in the study. Two criteria focused on determining the ease of operations namely performing tests for LT/staff and procuring laboratory consumable stock in PHC. The other two criteria focused on instrument maintenance in laboratory in terms of knowledge regarding getting the instrument repaired and ease of the maintenance process.

Table IIB.

Resource Criteria and Indicators Evaluated in the Survey.

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

Note: MO, medical doctor/officer; LT, laboratory technician; SOPs, standard operating protocols.

In terms of financing, PHC gets limited funds as RKS funds. However, IPHS has not provided any criteria to evaluate the laboratory use of RKS funds (i.e., financing). So, a new criterion for this category is used. The RKS funds are emergency funds of PHC that are meant to meet the critical PHC needs (Table IIC). Accordingly, the survey tried to ascertain the utilisation of the RKS funds for laboratory purposes. This will indicate if PHC has critical laboratory needs that were not considered during the centralised budgeting process.

Table IIC.

Financing and Governance Criteria and Indicators Evaluated in the Survey.

Code	Financing Criteria	Indicator	Source
IF1	Laboratory needs are met by the higher authorities budgetary support	The PHC own funds (i.e., RKS funds) are not utilised for laboratory services	None
Code	Governance Criteria	Indicator	Source
IG1	MO’s awareness of their responsibility	MO knows that they are the main decision-maker for the PHC’s day-to-day operations	IPHS
IG2	MO’s ability to implement their decision	Number of days to implement the decision can be estimated	IPHS
IG3	Decision implementation process is easy		IPHS
IG4	Ability to upgrade and repair the instrument	Number of days to upgrade and repair the instrument can be estimated	IPHS
IG5	MO can access different resources	Number of days required to access different resources—namely staff, consumables, instruments and other facilities (transport, storage) can be estimated	IPHS
IG6	PHC MO trusts their own laboratory services	PHC MO trusts their own laboratory test results, patient safety and patient privacy services	IPHS

Note: PHC, primary health centre; RKS, Rogi Kalyan Samiti; MO, medical doctor/officer; IPHS, Indian Public Health Standards.

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

Appendix III

Bayesian Network (BN) Base Results

The base BN model using unconstrained hill-climbing (HC) algorithm is prepared for all the six parameters (Figure IIIA). It shows a relationship between governance and number of samples collected (NSC), NSC and staff workload (SW), NSC and finances and SW and resources. Among these relationships, the linkage of SW as parent node with NSC and resources as child node and NSC as parent node with governance as child node indicate reverse relationship. The parent–child relationship between laboratory functioning and performance parameters is expected as functioning is laboratory input and performance is laboratory output. Further, the SW is dependent on the quantum of work available, that is, total number of samples for testing in the laboratory, NSC.

Figure IIIA.

Base Bayesian Network (BN) Model.

Footnotes

Acknowledgements

We would like to acknowledge the support provided by Dr Prashant Narnaware, District Collector, Osmanabad, Maharashtra for granting us permission and providing support during the stay in Osmanabad. We would also like to acknowledge the support of the District Health Office, Osmanabad, Maharashtra and all the respondents for their support.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article.

Funding

The authors received no financial support for the research, authorship and/or publication of this article.

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Assessment of Primary Laboratory Facilities for Rural Health Care Preparedness in Osmanabad District,India

Abstract

Keywords

Introduction

Method

Settings

Services

Resources

Financing and Governance

PHC Laboratory Preparedness Analysis

Statistical Analysis

PHC Laboratory Preparedness Validation

Results and Discussion

PHC Laboratory Preparedness

Radar Diagram Depicting Overall Primary Health Centre (PHC) Preparedness Level (% of Criteria Met) and Four Individual Parameters, Namely, Services, Resources, Financing and Governance.

Governance

Percentage of Primary Health Centres (PHCs) That Have Achieved a Good Status across Governance (IG) and Financing (IF) Parameters.

Financing

The Rogi Kalyan Samiti (RKS) Funding Sources for Different Tests in Different Primary Health Centres (PHCs).

Resources

Percentage of Primary Health Centres (PHCs) That Have Achieved a Good Status across Resource Parameters.

Services

Percentage of Primary Health Centres (PHCs) That Have Achieved a Good Status across Service Parameters.

The Number of Primary Health Centres (PHCs) out of 42 in Which a Particular Test is Performed.

PHC Laboratory Preparedness Validation

Descriptive Statistics of the Functioning and Performance Parameters (n = 24).*

Final Bayesian Network (BN) Model.

Conditional Probability of Occurrence of Different Parameters Status.

Conclusion

Appendix I

Indian Health System Rural Governance Structure and Functioning

Structure

Rural Public Health Care Governance Structure.

Functioning

Rural Public Health Care Governance Functioning.

Appendix II

Criteria Used for PHC Laboratory Assessment

Service Criteria and Indicators Evaluated in the Survey.

Resource Criteria and Indicators Evaluated in the Survey.

Financing and Governance Criteria and Indicators Evaluated in the Survey.

Appendix III

Bayesian Network (BN) Base Results

Base Bayesian Network (BN) Model.

Footnotes

Acknowledgements

Declaration of Conflicting Interests

Funding

References

Descriptive Statistics of the Functioning and Performance Parameters (n = 24).^*