Introduction

1.1 Background
Bangladesh has made significant progress in recent times in many of its social
development indicators particularly in health. This country has made important gains
in providing primary health care since the Alma Ata Declaration in 1978. All health
indicators show steady gains and the health status of the population has improved as
reflected in the significant decrease in infant (42 per 1000 live birth), maternal (2.9
per 100 live birth) and under-five mortality (53.8 per 1000 live birth) rates over the
last decades, with a marked increase in life expectancy at birth (60.25years) and
achieving

a credible record of sustained 90% plus vaccine coverage in routine

Expanded Programme of Immunization, (EPI) along with National Immunization

Days (NID) since 19951. But some of this progress is uneven and there still exists
inequalities between different groups and geographical regions.
The frequency of field workers visit per household could not adequately meet the
need of a family for healthcare, especially reproductive healthcare. Community clinics
would replace labor intensive and costly health care services with cost-effective
extensive health and family planning services at one location2.
The Alma Ata declaration emphatically embraces community participation in health
care and stresses the links between health and other sectors of society. As far as health
care delivery are concerned, the key issues are access and affordability.3 Although the
declaration underlines the importance of improving the efficiency of service delivery
and performance to recover costs, it does not mention quality, let alone provide any
guidance of how the quality of primary health care could be achieved. Although some
increase in the utilization of modem health care is noted, researches from Ghana,
Burkina, and Mali4,5 shows that the availability of primary health care in and of itself
does not ensure its utilization.
The establishment of community clinics (CC) is based on the experience of a pilot
project at Abhaynagar in Jessore and Mirersarai in Chittagong. The group exercise at
Mirersarai in Chittagong demonstrated that 71% and 67%, respectively, of the
existing outreach sites may be phased out. The participants from Mirersarai

emphasize that even the female clients are able to reach community clinic located
within 10-15 minutes walking distance. In the workshop at Abhoynagar it is seen that
46% of the existing outreach sites might be phased out.6
The delivery of primary health care in Bangladesh has been taking a remarkably new
shape through establishment of 18000 community clinics, the one stop service
delivery for every six thousand populations.
The Health and Population Sector Programme (HPSP) 1998-2003, envisioned a
client- centered and financially sustainable system to deliver high-quality essential
services to the population, specially to the vulnerable group, i.e. women, children, and
the poor. The package is designed to improve the health status of families through
comprehensive measures, meeting required standards of quality, and making it
available at one single service-delivery site to ensure reduced production costs and the
optimal use of resources. At the grassroots or community level, this

new service-

delivery model, warrants a shift in approach from the home-visitation and

makeshift

the centres (satellite clinics/EPI outreach sites) to the community clinic-based servicedelivery plus limited home visits. This indicates that the existing outreach/satellite
clinics and the domiciliary services need to be phased out gradually in the reorganized
service-delivery plan. The community clinics will be the only major service-delivery
outlet at the grass-root level to provide basic health and family-planning services.
Nevertheless, limited home visits by the community clinic providers will still be
continued as a back up to prevent dropout of critical services and to provide services
for population with limited access.
The study of consumer preferences shows that people in Bangladesh wants one stop
services.7 Therefore the government has decided to re-organize services by unifying
health and family planning services at upazilla level and below and decides to provide
services in a three-tiered fixed facility based one stop delivery system, with the
upazilla health complex at the upazilla level, the union health and family welfare
center at the union level, and the community clinics at the ward or village level. The
union health and family welfare centers and upazilla health complex have
complementary functions serving as the facilities for referral and support for the
community clinics of the respective unions and upazila.

The decision of community clinic establishment for every six thousand population at
village or ward levels is to provide Essential Service Package (ESP) to the rural
people, particularly the poor at free of cost, in a consistent location designed for easy
access at the time of need. One
Health Assistant (HA) and one Family Welfare Assistant (FWA) have been posted in
each community clinic to provide health and family planning services from 9 am
to 4 pm on all working days. A doctor has been assigned to supervise the activities of
each community clinic. The community clinics are supplied with 23 essential drugs to
treat common illness such as fever, abdominal pain, diarrhea, cold and cough along
with family planning activities and immunization services.
Government constructs community clinics on donated land by the community people
and its management is supposed to be given to a committee named as community
group, consisting 9 to 11 members taken from the local community and having
representatives from villagers,

including three women, poor landless people. 8 The

members of the committee will elect or nominate one among them as chairman and
the Union Parishad chairman will work as ex-officio, chief patron and supervisor.
The utilization of a health care system, public or private, formal or informal may
depend on socio-demographic factors, social structures, level of education, cultural
beliefs and practices, gender discrimination, status of woman, economic and political
systems, physical and financial accessibility environmental conditions and disease
pattern and health care system itself. 9-12 Studies uncover that severe deficiencies in
existing primary health care facilities are related to diagnosis, treatment, and
counseling of patients as well as in the supervision of health workers for the following
primary care activities: Growth monitoring and promotion, immunization, case
management for malaria, diarrhea and acute respiratory infections.13
There are not so many studies on community clinic particularly on its utilization.
Although the study under Health Systems Development Programme funded by
World Health Organization on Assessment of the community clinics: Effects on
service delivery, quality and utilization of services in 2002 was extensive but it was
too early to see the utilization of services as because many community clinic were yet
to be commissioned then and health personnel were not posted everywhere.

Therefore, studies on utilization of primary health care services in developing

countries are considered here. The concept of community clinic, as a part of
reorganizing the health care delivery system in developing countries like Bangladesh
is to ensure the delivery of initial services of the Essential Service Package (ESP) to
the vulnerable populations including women, children and poor.
A variety of factors have been identified as the leading causes of poor utilization of
primary health care services including poor socio-economic status, lack of physical
accessibility, cultural beliefs and perceptions, low literacy level of mothers and house
heads, large family size etc. Review of global literature suggests that all these factors
can be classified into following classes cultural and socio-demographic factors,
womens autonomy, economic conditions, physical and financial accessibility, and
disease pattern and health service issues.
Household surveys revealed that the perceived low quality of health care was one of
the main reasons why people did not attend primary health care services in cases of
illness.14,

15

Client perceived quality of services and confidence in the health care

provider affect the health service utilization inputs, which could be assessed with ease
and at low cost, were frequently used as proxies for quality. Such input indicators
included the presence of drugs in health centers, staffing, and the availability of
electricity or running water. The high use of govt. health care facilities is attributed
mostly to issues of acceptability such as easy access, shorter waiting time, longer or
flexible opening hours, better availability of staffs and necessary drugs, better attitude
of health service provider giving patient hearing to the problem of client, sufficient
time for examining them and explaining them about their problem, more
confidentiality in socially stigmatized diseases.
The health seeking behavior and choice of care provider is largely determined by type
of symptoms experienced for the illness and duration of illness in number of days.
Traditional beliefs tend to be intertwined with peculiarities of the illness itself and a
variety of circumstantial and social factors. This complexity is reflected in the health
seeking behavior, including the use of home prescriptions, delay in seeking biomedical treatment and non-compliance with treatment with and with referral advice.
The attitude of the health provider and patient satisfaction with treatment play a role
in health seeking behavior. The role of patient satisfaction is a crucial determinant for
4

utilization and success of health care delivery system and its long term viability. The
World Health Organization has created a performance system based on five composite
measures in which health system responsiveness (patient satisfaction and its
distribution in the population of varying economic status. Studies in the developing
world have shown a clear link between patient satisfaction and a variety of
explanatory factors, among which service quality is prominent.16
The aim of this study was to see the utilization of services provided by community
clinic, assessing its performance achieving delivery of essential service package to the
community people and also to see the perception of the community people regarding
the quality of services.

1.2. Justification of the study

Increasing attention has been paid to the quality of care as a means to enhance the
effectiveness of health care systems in developing countries. Patients perception of
quality of care is critical to understand the relationship between quality of care and
utilization of health services and increasingly it is treated as an outcome of healthcare
delivery.17-20 Experiences in Bangladesh21, Vietnam22, BurkinaFaso23 provide growing
evidence that the perceived quality of health care services and other socio-cultural and
economic factors has a strong impact on utilization patterns. 24 The study on several
dimensions of perceived quality of health care service in Bangladesh including
responsiveness, assurance, communication, discipline and bakhsis (unofficial
payments) shows arbitrarily, that these factors have a relatively greater influence on
individuals decision regarding utilization compared with access and costs.
The public sector health services are unsuccessful providing health and family
planning services according to the expectation of people. The government adopted a
strategy to build up a partnership of public sector facilities and the providers with the
community to address the health needs of the local population efficiently and
effectively and to ensure a long term sustainability of the essential health care
provision and thus to support service development. Community clinics have been
considered as the entry point of partnership between government and the community
with a view that community will be involved in management and operation of
community clinics participating from site selection, land donation, supervision of its
construction, operational management, day to day repair and maintenance as well
motivating the community to bring change in their health seeking behavior. As the
outreach centers, satellite clinics which were serving as means of delivery of ESP are
gradually being replaced by community clinics and the domiciliary services will be
only in a limited form for groups or individuals who are at risk, the most neglected
including the extreme poor, follow up on drop-outs for family planning for back
referred cases. So its very important to see and monitor whether the community
clinics are meeting their objectives set for them in HNPSP for providing ESP services
efficiently and effectively.
It has passed more than 2 years that the community clinics have made functional. The
Ministry of Health & Family welfare is claiming that on an average everyday twelve

patient are getting health care services from the community clinics. The study on
improving access to health care for the poor and vulnerable in Bangladesh shows that
the overall activities of community clinics covered by the survey are not impressive
and as a result, the objectives of the community clinics are not being fulfilled as had
been hoped. Most of the clinics were found to be closed and none had any drugs when
the survey was conducted. The quality of construction was also found to be poor at
some of the surveyed community clinics. Lack of essential drugs at the community
clinics has already given a bad reputation for being an unreliable source of health
care.
Community clinics have the potential to be a major source of health services for the
poor and vulnerable and there are also risks in that some previously successful
outreach services are to be replaced, and there is a need to ensure that the benefits of
these are retained.
This study aimed to find out the perception of the community people regarding the
quality of services which is considered as a very important factor for utilization of
health care delivery services.
This study finding might help giving important information which would help the
policymakers in formulating strategies for further improvement in the initiative and
thus utilization of community clinic. For strengthening this initiative identification of
problem as well as factor related to utilization is very important. Until and unless the
barriers are identified the service cannot be improved.

1. 3 Conceptual Frameworkof utilization of community clinic:

1.3 Conceptual Framework of utilization of community clinic:

Utilization of Community Clinic

Access

Health service related factors:

*Availability of drugs & services.
*Quality of services
*Attitude of Health personnel
towards patient -Compassion Respectfulness,
Openness ,
Honesty,
Time spent to explain the illness
to the patient.
*Waiting time at community
clinic.
*Cost of services.

Socio-economic &
demographic factors:
Socio-economic status
Level of education
Age, sex, religion, Marital
status ,
Occupation of head, Size
of the family
Health seeking
behaviour: in various
Physical, socio-economic,
cultural & political
context. The choice of
care depends on 1)
Cost involved 2) quality
of care provided

Other Factors:
Socio-cultural
factors less
empowered position
of women in family,
Cultural belief &
practices .Gender

discrimination,
Status of woman,
Political system,
environmental
condition and Social
structure.

Acceptability of Services:
Patient perception
experience with
o &Income
service provided by Community Clinic

1.4 Research Questions

To what extent the ESP services of community clinic are utilized by the
target population?

What is the perception of the study sample about the quality of services
provided by community clinic?

What are the predictors influencing utilization of community clinic?

1.5 Objectives
9

General objectives
To determine the utilization of ESP services provided by the community clinic and
its predictors.

Specific objectives
1) To estimate the utilization of ESP services provided by community clinic.
2) To determine the perception of the study sample about service quality of
community clinic.
3) To assess the influence of their perception on utilization of those services.
4) To determine the influence of socio-economic status of study sample of
community clinic.
5) To identify the predictors of utilization of ESP services provided by the
community clinic.

10

1.6 Variables in the study

Socio- demographic variables
1.
2.
3.
4.
5.
6.
7.
8.

Age
Sex
Educational status of the sample
Occupation of the sample
Number of family members
Monthly Expenditure on average
Ownership of residence
Housing Condition:
i. Construction material of the floor
ii. Construction material of the roof
iii. Construction material of the wall
9. Possession of land for their residence
10. Possession of land for cultivation
11. Source of drinking water
12. Source of lighting
13. Type of latrine uses

Key variables related to utilization of services

1. Immunization
A. For children under two years of ageWhether the child was vaccinated from community clinic.
B. For female of reproductive age group (15-49 years)
Whether immunized with tetanus toxoid or not?
2. Contraceptive methods If the eligible couple

Using contraceptive methods regularly or not

Whether procure contraceptives from community clinic

3. Ante-natal care (in her last pregnancy)

Ante-natal care from community clinic Yes/ No

4. Post-natal care
5. Treatment of children for minor illness
6. Treatment of other family members for minor illness
7. Registration of the pregnant women
8. Health education on personal hygiene, care of new born, care of pregnant mother,
danger signs of pregnancy etc.

11

Variables related to perception of quality of Health care service:

Health care related:
1. Capability of the health care personnel in community clinic to find out what is
wrong with the patient.
2. Capability of the health care personnel to prescribe the drugs that are needed by the
patient.
3. Availability of drugs in the Community Clinic.
4. Quality of the drugs that are supplied from the Community Clinic.
5. Outcome of the patient treated in community clinic.

Health personnel related:

1. Skill of the health personnel examining the patient in Community Clinic.
2. Follow up of the recovery of patients by the health personnel in Community Clinic.
3. Empathy in the attitude of the health personnel towards patient in Community
Clinic.
4. Respect for the patient in the attitude of the health personnel in Community Clinic.
5. Openness of the health personnel with the patient while providing services.
6. Time they spend examining the patient.
7. Time they spend for explaining patient about their illness.
8. Honesty of the health personnel, working in the Community Clinic.
Health care Facilities related:
1. Distance & accessibility of the community clinic.
2. Equipments in the community clinic.
3. Fee charged in the community clinic.
4. Opportunity of fee waving.
5. Number of health personnel in the Community Clinic adequate or not.
6. Health personnel for treating womens disease.
7. Waiting and examination room for the patients in the Clinic.

12

13

2 Literature Review

This study was designed to estimate the utilization of Essential service package (ESP)
services provided by the community clinic, determine the perception of the study
sample about service quality of community clinic and assess the influence of their
perception on utilization of those services. For the in-depth conceptualization of the
study problem, acquiring the background information and for selecting appropriate
methods a considerable number of research articles published in different national and
international journals, reports, abstracts and textbooks were reviewed thoroughly and
critically. For the search of literature various organizations and institutions libraries
specially library of National Institute of Preventive and Social Medicine,
Dissemination and Information Service Center (DISC) of International Center for
Diarrhoeal Disease Research, Bangladesh (ICDDR , B) and different websites were
explored.

2.1 Community Clinic

The community clinics are the public health care delivery centers at the grass root
level to deliver the initial services of ESP. These community clinics are to bring
family planning, preventive health services and limited curative services closer to the
population, and to improve the efficiency of service provision, partly by replacing
outreach services provided from a fixed point. Community clinics (CC) are to provide
services for around 6000 people, and it is envisaged that their location would make
them accessible for 80% of the population within less than 30 minutes walking
distance. The design is to be simple - two rooms with drinking water and lavatory
facilities, and a covered waiting area. Funds for building the clinics were provided
centrally, but communities are to donate land. This is planned to create the sense of
ownership in the community.
Each clinic should have two staff, one health assistant and one family welfare
assistant. There is a specified allocation of equipment and a range of drugs necessary
to deliver the ESP services. Staff from the community clinics would continue to
provide a limited range of outreach services, especially in the early period after
14

opening, and staff from higher levels in the system would visit on a regular basis to
provide additional services and to supervise the community clinic staff. The
development included a training programme for community clinic staff.

2.1.1 Background
Before introduction of Health and Population sector programme (HPSP) on 1st July
1998 the Ministry of Health and Family Welfare (MOH&FW) used to have two
separate cadres at all levels to provide and manage health and family planning
services. Often the clients could not obtain health, reproductive health and family
planning services from the same service point. The separate service structure was an
impeding factor for delivering the planned ESP because it had integrated health and
family planning services. Therefore, the government decided to reorganise services by
unifying health and family planning services at upazila level and below. It decided to
provide services in a three-tiered fixed facility-based one-stop delivery system, with
the Upazila Health complex (UHC) at the upazila level, the Union Health and Family
Welfare Center (UHFWC) at the union level, and the community clinics (CC) at the
ward/village level.
There is shift from the home-based to a static centre-based service-delivery system.
The five year plan (1998-2003) of the MOH&FW is aimed at providing a range of
essential health and family planning services i.e.the ESP, specially to the vulnerable
groups, i.e., women, children, and the poor. The HPSP has delineated three basic
features for delivery of the ESP:

Client-oriented services
Unified management and
One-stop service-delivery.

There was interruption of services of the community clinics as the policymakers

decided to shift from the concept of community clinic during 2002 to 2009. But for
about last two and half years they have been re-opened and till date 10,322
community clinics are functioning and measures are already taken to strenghthen
them through increasing manpower and logistics.

15

2.1.2 The concept of design of community clinic

To meet the reorganized service-delivery strategy at the community level, fixed-site
clinics featuring a one-stop service centre, referred to as community clinic (CC),
under the supervision of a unified management, will gradually replace the existing
home-visit approach. Given the substantial changes suggested in the HPSP, the
implementation of ESP delivery, including operationalization of CCs, need close
monitoring to derive sufficient information to fine-tune and modify the approach as
required.
1. One stop service: As many behavioural change communication and other services
as possible would be provided at one place on each working day.
2. Accessibility: Maximum half an hour travel-time to the service provision point.
3. Coverage: 80% coverage of population living within the half an hour walking
distance to the service points.
4. Quality: Services to be provided according to the defined standards.
5. Efficiency: Providing more services for the same costs, or same services at less
cost, in a more accessible way.
6. Community participation: Involvement and participation of community in
designing, planning, monitoring and helping to implement the program. The
community is to donate the land in a suitable location and assist in constructing the
clinic.
7. Population based planning: Services are based on the needs of the defined
population.
8. Technical competence: Availability of skilled human resources with multiple
skills.
9. Logistic and supply: Availability of medicines, vaccines, cold chain and
instruments according to the level of services.
2.1.3 The functions of community clinics are:
1. Registration of pregnant women
2. Behavioural change communication on hygiene, diet, immunization, breast-feeding
etc.

16

3. Informing pregnant women in advance to attend the clinic for family welfare
volunteer services and ensuring that pregnant women come for antenatal services.
4. Maintaining the expected date of delivery information to provide assistance if
danger

signals appear.

5. Referral to higher levels

6. Providing FP methods including pills and condoms
7. Informing families in advance about outreach clinics and ensuring that children are
immunized at the correct times.
8. Oral Rehydration Salt, Vitamin-A, Anti- helminthics, Acute Respiratory Infections,
Direct

observed

treatment

strategy

for

Tuberculosis,

Multi-Drug

resistant

Tuberculosis for Leprosy, Anti-malaria etc.

2.2 The community clinic and ESP services:
It is already mentioned earlier that under the HPSP, the ESP be delivered in a threetiered service-delivery model. At the grassroots and community level, the new
service-delivery model warrants a shift in approach from the current home-visitation
and makeshift centers (satellite clinics/EPI outreach sites) to the community clinic
-based service-delivery plus limited home visits. This indicates that the existing
makeshift outreach/satellite clinics and the domiciliary services will be phased out
gradually. In the reorganized service-delivery plan, the community clinics will be the
only major service-delivery outlet at the grassroots level to provide basic health and
family-planning services. Nevertheless, limited home visits by the community clinic
providers will still be continued as a back up to prevent dropout of critical services
and to provide services for population with limited access.
The Health and Population Sector Programme (1998-2003) aimed to bring important
changes to health and family planning services in Bangladesh. The introduction of a
sector wide approach

brought a series of changes in the planning, financing and

delivery of services. The government realized the difficulties in providing all the
services needed by all segments of the population due to resource constraints. Hence,
the policy makers decided to design a health service that would achieve the greatest
health impact per taka spent, could be provided in a sustained way, and would satisfy
the need of the most vulnerable in the society women, children and poor.
Accordingly, the MOHFW devised an ESP for phased implementation in Bangladesh.
17

A key component was the development of the new ESP to meet the needs of the poor,
especially in rural areas and particularly women and children.
The elements of ESP are grouped into the following five areas:
Reproductive healthcare,
Child health care,
Communicable disease control,
Limited curative care, and
1. Behaviour change communication.
2.3 Utilization of services provided by community clinic

A very few study have been conducted on community clinic and the study that was
done to see its utilization in 2002 seems to be too earlier and at a stage when the
logistic support were withdrawn as per decision of policy level to switch over from
the concept of community clinic. Now, we can see that the community clinics have
been re-opened for about two and half years and different measures are being taken to
strengthen their facilities like employing more manpower and extending coverage of
services. As the community clinics have been established with the view to provide the
initial services of the ESP that is the service programme formed by the policymakers
to ensure the primary health care in our country so studies on the utilization of
primary health care in different parts of the world were reviewed for the purpose of
the study.
A study of the community clinics: Effects on service delivery, quality and utilization
of services to assess the extent to which the community clinics were operating
efficiently and effectively, and whether they were meeting the objectives set for them
in HPSP in provision of ESP services. Using a combination of quantitative and
qualitative techniques the study gathered evidence from service users, local influential
people, service providers, managers, planners and policy makers. The study also drew
on policy and management documents, routine statistics,

and

previous

studies

and reports that included information on community clinics. The sample of

clinics covered all parts of the country and included a wide mixture of types of
setting.
The Findings of the study are:

18

1) Location of clinics: The majority of community clinics are well located, in all the
senses considered. A minority are very poorly located, with flooding and very difficult
access. The travel time criterion is not easy to meet in areas of relatively sparse
population, but in most cases it was met or nearly met.
2) Construction of clinic buildings: Most of the community clinics in the study have
the specified two rooms and are built using appropriate materials. In many cases the
quality of construction is below the necessary standard, and buildings are already
showing signs of dilapidation. All community clinics are expected to have two
operational toilets and safe drinking water. Very few met these standards, with many
having only one toilet, and even these were

in

poor

condition. Few had safe

drinking water.
3) Furniture and equipment: Most community clinics were found to have some items,
but few were found to have all the specified furniture, and almost none have all the
specified equipment. Deficiencies are sufficiently serious to have effects on service
quality.
4) Community participation in development and operation of community clinics: In
most cases community groups (CGs) are set up, but few working effectively. Previous
experience in Bangladesh suggests that there is a need for effective mechanisms to
allow more ownership by local communities, but this is not yet happening in
community clinics.
5) Staff posting to community clinics: Some community clinics have the two staff,
many have one and in some cases there are no staffs posted. However, even where
staff are posted to community clinics it is often difficult to find them and productivity
seems low.
6) Skills of staff: Staff in community clinics are provided with training, and some
of this training is good.
7) Supply of drugs: In most cases most of 23 drugs are being available at the time of
opening, but supplies are limited and intermittent. The arrangements for supply of
drugs to community clinics are falling behind to achieve even a reasonable level of
availability.
19

8) Opening hours: Half of the community clinics are effectively closed, and are
providing little or no service. In a quarter of the clinics the services are often
available, and in other cases opening was erratic, and often only limited services such
as immunization are available.
9) Service quality: Evidence from this study suggests that the perceived quality of
services, including behaviour of providers, is considered poor by the users.
Another study on improving access to health care for the poor and vulnerable in
Bangladesh covered 93 respondents from 12 community clinics spread over five
districts. The study shows that the overall activities of community clinics covered by
the survey are not impressive and, as a result, the objectives of the community clinics
are not being fulfilled as had been hoped. Most of the clinics are closed and none have
any drugs during the survey. The quality of construction is also poor at some of the
community clinics. Lack of essential drugs at the community clinics are giving a bad
reputation as an unreliable source of health care.
An average of about 40 patients attends the surveyed community clinics each day as
long as the supplied drugs lasts. Most of the patients are reported to be women and
children and from poor backgrounds. This suggests that community clinics have the
potential to be a major source of health services for the poor and vulnerable.
There are gaps of 2-14 days when services are not being provided even when drugs
are in stock. The reasons cited for these were weekly and national holidays and the
service providers attending meetings, conducting field visits, preparing Geographical
Reconnaissance and managing satellite clinics.
Study conducted in forty community clinics to analyze the maternal health

care

delivery system in Bangladesh by the MOH & FW and the London School of Hygiene
and Tropical Medicine finds that 31(78%) community clinics are non-functioning.
The study reported that out of the 9 functioning community clinics around half are
functioning in a clean environment. The others do not have either water supply, or
usable sanitary latrines. The study finds poor physical location as a major barrier to
access to these community clinics. Only six of the forty community clinics surveyed

20

(15%) are to be easily accessible. Almost 85% are poorly located either in terms of
approachability or difficulty in access due to inappropriate site selection. Some are
accessible only by boat.

As regards to community groups the study report shows that 71% of the community
groups are not functioning or not formed at all. Supervision and monitoring of the
clinics by the higher authority is not in line with government policy. Most are visited
only occasionally, and not as per the schedule prescribed by the government.

Most of the community clinics surveyed are poor performing. The use of these clinics
by the local people is low. Only 19 percent of the clinics surveyed remains open on all
working days. Twenty-eight percent are open once a week while 38 percent clinics are
reported to be open only once in a month. Fifteen percent of clinics are closed after
formal opening. The mean time open per day is 2 hours (0.5 hour). The study finds
that the poor performance is also due to the acute shortage of drugs and equipment.
On an average, these clinics reported not more than 7-10 patients a day. Despite a
very low use and attendance of patients in the clinics, the mean consultation time for
the patients in these clinics are only 0.73 minutes (0.5 minutes). This suggests a lack
of motivation among the service providers of community clinics to perform their jobs.
Twenty six percent of the service recipients said that the community clinics lack
privacy, 21% mentioned unavailability of drug and medical supplies, 20% reports
rude attitudes of service providers. Inadequate clinical skills among providers are also
reported.
2.4 Utilization of primary health care A study by Lartson et al. done in 1984 in rural clinics in Ghana assessed the process
of providing maternal and child care13. They compared actual (observed) performance
levels with expected levels for a number of diagnostic, therapeutic and counseling
tasks. They found significant performance gaps, especially in the area of physical
examination and in the counseling of patients or clients.

[[[[[[

one of the first large-scale comprehensive efforts to provide detailed information on

how primary health care services were delivered in developing countries was carried
21

out

by the United States AID -financed Primary Health Care Operations Research

(PRICOR) project (1985-1992) whose studies spanned 12 countries.

Using a direct observation of over 6000 patient-provider encounters, this project
uncovered severe deficiencies in the diagnosis, treatment, and counseling of patients
as well as in the supervision of health workers for the following primary care
activities: Growth monitoring and promotion, immunization, case management for
malaria,

diarrhea and acute respiratory infections.11

Similarly, Sauerborn et al.25 analyzed maternal and child health services in a rural
districtof Burkina Faso. They reported that especially the task of screening for risk
factors in both under fives' clinics and antenatal clinics was came out well below
standard. They also found that communication in both curative and preventive
clinics was poor, e.g. only 5% of mothers who brought their children to under fives'
clinics received any kind of counseling during their visit.
Bjorck et a!. observed 539 primary care visits and found that, according to local
standards of care, only 65 (12%) of the patients

were

adequately

diagnosed

and treated.26 The same weakness in the process of primary health care provision was
reported by Gamer et al. for managerial tasks, such as cold chain support and
maintenance in 76 rural health centers in Papua New Guinea.27 It is therefore no
surprise that

community satisfaction with the primary health care service is low,

specially in the domain of interpersonal skills of health personnel. Gilson et al found it

from a study in Tanzania.28
All those study findings can be summarized to identify the reasons for poor or bad
quality of services in health care delivery in developing countries. Though there are
scaracity of human resources, buildings, equipments and finance to run the services
but besides other conceptual reasons are there which delayed the tackling the issue of
quality of care in these countries.
1. Overemphasis on quantity and access. In the Alma Ata Declaration, 1978 the issue
of primary health care got the priority to be on the fore front of the health policy
agenda which decisively altered the health policies. The declaration emphatically

22

embraces community participation in health care and stresses the links between the
health and other sectors of the society. As far as health care delivery is concern, the
key issues are access and affordability. Although the declaration underlines the the
importance of efficiency of service delivery and performance to recover costs, it does
not mention quality let alone provide any guidance of how the quality of primary
health care could be achieved. The poor perceived quality of health care delivery
services keeps people away from utilizing public health care service.
2. Inappropriate focus on inputs. Of the three elements of the Donabedian triad of
structure, process and outcome, the focus is put on the structure assessing quality.12
The reality in many developing countries made it tempting to equate lack of quality
with the absence or shortage of inputs.
3. The new concern for quality: The recognition that the quality of many health
services was, indeed, low. While the efforts are in right direction but the public health
sector is plagued by uneven demand and perceptions of poor quality. The
underutilization of available facilities is of significant concern countrywide. For
example one study done by Ricardo et al on 2004 showed that the overall utilization
of public health care services is as low as 30%.29
2.4 Factors related to utilization of health care
Not only in the developing countries also

the developed world recognize the

importance of patient satisfaction and his good perception on health care delivery
services for their long term viability and success. Donabedian in his study (1988)
suggests that patient satisfaction may be considered to be one of the desired outcome
of care.30
The patient who endures physical, psychological, economic, social experiences during
the overall health service delivery process would be able to make an appropriate
evaluative judgement of how they are treated, as reflected in their overall satisfaction
or dissatisfaction measures.
Studies in the developing world have shown a clear link between patient satisfaction
and a variety of factor, among which service quality has been prominent 14.This link is

23

also important in the health care system of Bangladesh. Earlier studies showed that
service quality can be measured by using SERVQUAL framework33.
The service factors responsible for the patient satisfaction as per the framework are as
follows:
1) Reliability it is the providers ability to perform the promised service.
2) Responsiveness health personnel to promptly respond to the patients need.
3) Assurance it is the knowledge, skill and courtesy of health personnel tht
assures the patient to sense the best.
4) Tangibles Physical evidence that the health care facility will provide
satisfactory services.
5) Communication that the patient ae consulted about the type of care and they
never feel to be left alone.
6) Empathy Health personnels empathy and understanding of patients problem.
7) Process feature it is the orderly management of the overall health care
service process.
Besides service factor two additional factors are related those are cost of the service
and its availability.
It is the conclusive outcome from those studies in the developing countries all over
the world that quality assurance, the main tool for quality improvement in the
developing countries. In quality assurance the first focus is on process but also not
ignoring the need to improve outputs.

2.5 Perceived quality care and utilization of community clinic

Patients perception of quality of care is critical to understand the relationship between
quality of care and and utilization of health services 16-18. Experiences in Bangladesh19
and also in China31, Nepal32 and other countries provides growing evidence that the
perceived quality of health care service has a strong impact on utilization patterns.

24

The low utilization of both community health workers and first line health services
was, to a large extent, due to consumers' perceptions of low quality of care.
It has become clear that the consumers are only willing to pay for health services, and
thus generate the revenues to fund them only, if they perceived that the services to be
of reasonable quality.

2.5.1 Assessment of perceived quality

The 20-item scale includes three subscales related to health care delivery, personnel
and facilities. There were 241 people in one city and two villages in Upper Guinea
who responded to the questionnaire.33 An item analysis preceded the test of
psychometric properties of the three subscales and of the total score. Reliability was
estimated by analyses of internal consistency and the Cronbach's alpha coefficient. A
variety of statistical procedures were used to test factorial validity, trait validity
(convergent and discriminant) and nomological validity. Results confirm the value of
the use of the scale developed and highlight the need to take into account the diversity
of how quality is perceived by lay people in developing countries. It is suggested that
the process of formalization of this type of measurement scale be pursued.
The questions were worded so that they could be administered during individual
interviews, with the interviewer recording the answers. For each question,
respondents could express one of three opinions:
a) unfavorable (1), b) neutral (0), or c) favorable (+1).
Of the 47 original items, 20 were retained and categorized into three groups (see
Appendix). The first group included five items related to health care delivery: one
item dealt with diagnosis, one with the care outcomes, and three with drugs
(prescription, quality and availability). The latter are known
to be of prime importance to users of services in developing countries and are among
the main reasons for resorting to care [11,4045]. The second group of items
included eight items referring to the attitudes and practices of the health care workers:
patient follow-up, clinical examination (which is not systematic, and is considered as
a mark of attention from the health care staff), the reception of the patient,

25

compassion, espect, time spent, explanation given on the health problem, and lasdy,
the honesty of the staff. The seven
items in the third group focused more specifically on the health care facilities. Three
items referred to accessibility and dealt with the adequacy of the fees, the possibility
of making special payment arrangements (credit), and distance. Four other items dealt
with resources: the adequacy of the number of doctors (as in other countries, this term
is used in Guinea to designate the majority of health care providers), doctors for
women's treatment, equipment and rooms.
The utilization of health care delivery services at grass root level to obtain health,
reproductive health and family planning services from the same service point by
skilled health personnel through their sympathetized care towards the patient with
assurance of quality of treatment and availability of necessary drug gives a good
perception on the quality of care. A single structure for health care delivery also
makes the proper utilization of minimum resources.

3. Materials and Methods

26

A study was conducted to estimate the utilization of services provided by the

community clinic, determine the perception of the study sample about service quality
of community clinic as per following methodology:

3.1 Study design

A cross sectional study was conducted to estimate the utilization rate of community
clinic and determine the influence of perceived service quality and assess the socioeconomic predictors on utilization of community clinic.

3.2 Study period:

A total period of the study was from January to June 2011. It was started with
literature review, then protocol preparation, data collection and finished with final
report submission. After development of questionnaire by the 2 nd week of April data
were collected in last week of April and 1st week of May. Data processing and analysis
were performed in the 2nd and 3rd week of May and report writing and interpretation
were done from the 4th week of May to the 1st week of June (work schedule is
annexed).

3.3 Place of the Study:

The study was undertaken in the catchment area of Meghdubee community clinic, located

at the Pubail union of Gazipur sadar upazila in Gazipur district. The catchment area
covered the whole Meghdubee village which includes three wards no 5,6 and 7 of pubail
union. The community clinic was located by the side of highway besides a school with very
easy and good accessibility from its whole catchment area. Its a two room structure with a
covered waiting area with toilet & water facilities and an open space in front of it (Annexure4).

3.4 Study population:

All the households having children less than 2 year of age in the catchment area of
Meghdubee community clinic were included as study population. As the community
27

clinics were re-opened for the last two and half years so the households having
children less than 2 year were selected as study sample to see the utilization of
services among them. As the community clinic were re-opened for the last two and
half years so the households having less than 2 years children were selected as study
sample to see the utilization of services among them.

3.5 Sample Size:

One hundred and two household having children less than 2 years of age in the
catchment area of Meghdube community clinic were recruited in the study.

3.6 Sampling Technique:

Purposive sampling was adopted. All the households in the catchment area of
Meghdubee community clinic who fulfilled the study selection criteria (having
children less than 2 years of age) were included in the study. As the community clinics
were re-opened for two and half years so the selection criteria of study sample was
determined as household having mother with less than 2 year children.

3.7 Data Collection Instrument:

A semi structured questionnaire was developed in English (Annex-2). The
questionnaire was developed using the selected variables according to the specific
objectives. The questionnaire contained questions related to:
1) Socio-demographic characteristics,
2) Aspects of treatment and health care,
3) Perceived quality of health care services and
4) Service received from the community clinic.
To measure the perceived quality of health care a 20-itemed scale comprising
questions related to health personnel, adequacy of resources and services, health care
delivery, and financial and physical accessibility,
The scale was developed and validated by Haddad et al 21,
The English questionnaire was translated into Bangla (Annex-3). Pre-testing was done
in the catchment area of adjacent Kudabo community clinic among seven respondents
for checking the appropriateness of wording and sequence of questions. According to
the findings of the pre-testing necessary changes were made.

3.8 Data collection technique:

28

Data were collected through face to face interview of the household at their residence by

using the questionnaire. Before the interview, the detail of the study was explained to
the eligible household and their verbal consent was obtained. The characteristics of
head of the head of the household were obtained by interviewing head and the other
necessary informations were mostly collected from the mother of the children. Both
the parents who were present took participation in the interview.
To cross check the information provided by those regarding immunization of the
children and mother the immunization card of the children and mother were reviewed.

3.9 Data processing and analysis:

After data collection, each questionnaire was checked to see whether it was filled
completely. Then they were stored after giving identification numbers. The data were
entered into computer with the help of Software Statistical Package for Social
Sciences (SPSS) for windows version 19.0. After frequency run, data were cleaned,
edited, coded and computed, edited, recoded computed. By using the 20-itemed scale
the total scores got from the study samples were categorized into four quartiles.
Data were presented by tables and graphs.
The quantitative data were analyzed to find out the mean, standard deviation and test
of normality.
The qualitative data were categorized into different categories based on their
characteristics. Statistical analysis was done mainly to see the association, significant
differences between the outcome and different independent variables. The variables of
different services were analyzed with different socio-economic variable to see their
influences whether statistically significant or not.
The association between utilization of different services and different categories of
perception were tested by doing 2 tests. [Logistic regression will be done to remove
the effects of confounders.]

3.10 Ethical considerations

Prior to the initiation of the study ethical clearance was taken from the NIPSOM
Ethical Review Committee. The study included neither included any invasive

29

procedure nor any private issue and no drug was tested. Before initiation of the
interview a brief introduction on the aims and objectives of the study was presented to
the respondents. They were informed about their full right to participate or refuse to
participate in the study. A complete assurance was given that all information provided
by them will be kept confidential and their names or anything which can identify them
would not be published or exposed anywhere. After completion of these procedures
the interview will be started with their due permission. The research was conducted in
full accord with ethical principles.

3.11 Limitations of the study

Although maximum care had been taken by the researcher at every step of the study,
still some limitation exists:

Since its a cross sectional study, the association it suggests might not be a true
association.

The study was conducted on a small sample the household having children
less than 2 year of age in the catchment area of one community clinic due to
time constraint. Therefore it might not represent all the community clinics of
the country.

The questionnaire though its reliability was done through pre-testing but as it
was not validated may not be sufficient to serve the purpose for measuring
perception accurately

The scale that used for measurement of perceptions was though validated at
their place of study and appeared to be an appropriate instrument to assess
patient perceptions on quality of care. But the categories of perception bad,
average, good and very good were made by doing quartiles of the total score
we got from the study samples is subjected to be the reflection of the

perceptions of that specific population studied.

For measuring perception only quantitative studies were not sufficient,
arrangement of focus group discussion could have given better result.

30

4. Results

A cross sectional study was conducted to assess the utilization of community clinic A
total of 102 households having children less than 2 years of age were selected as study
samples. The analyzed data are presented in this chapter through tables and graphs.
The results of the study are described in the following sections.

31

The influences of different socio-demographic factors like education, occupation,

monthly expenses, family size, possession of land for housing on utilization of
different services of community clinic were determined.

4.1 Socio-demographic characteristics of the households

In this study the socio-economic characteristics of the selected households including
monthly expenses, housing condition, possession of land, source of drinking water
and light and type of latrine used and as well as characteristics of household head
were collected. This section shows frequency of the related variables.
4.1.1 Data related to head of household
4.1.1.1 Age and sex
All the household head were male except one female. In this study the age of the head
of the household varied from 20 to 59 years with the mean age of 31.41 years and
standard deviation 7.02 years. The age was categorized into three categories. The
frequency distribution showed that the 20 to 29 years and 30 to 39 years age group
included equal proportion of respondents (45.1% and 44.1%, respectively) [Table:
4.1].

4.1.1.2 Educational status

The educational status was categorized into three categories and almost half of them
were in primary to below secondary (47%) level educated.[Table 4.1]
4.1.1.3 Occupational status

32

The occupational status of the households were broadly categorized into four
categories and lowest were skilled labourer (13.7%), and highest, businessmen
(41.2%) [Table 4.1].
4.1.2 Household characteristics
4.1.2.1 Religion
All the one hundred and two respondents were Muslims
4.1.2.2 Family size
According to number of family members households were categorized into two
family types. The frequency distribution showed that 59 were of family with having
four or less members (57.8%) and rest were with bigger families [Table 4.2].

4.1.2.3 Average monthly expenditure

According to the average monthly expenditure the households were divided into three
categories. Frequency distribution showed that 38.2% of the households were having
average monthly expenditure of taka 5,000 or less, 49% between taka 5,001-10,000
and rest were having monthly expenses more than taka 10,000 [Table 4.2].

4.1.2.4 Land for residence

Frequency distribution showed that 48% of the household had land less than five
decimal for their housing and rest were having more than five decimal of land.[Table
4.2]
4.1.2.5 Cultivable land
Majority of the household (69.6%) had no land for cultivation and 18.6% had land
more than 50 decimal [Table 4.2].
4.1.2.6 Source of drinking water
33

It has been found that 72 (69.6%) of the respondents were using water from shallow
tube well [Table 4.2].
4.1.2.7 Source of light
Majority (84.3%) of the respondent used to have electricity as their source of light.
[Table 4.2]
4.1.2.8 Type of latrine
Majority of the respondents (55.9%) used water sealed latrine and additional 37.3%
used latrine with septic tank.[Table 4.2]
Table 4.1. Characteristics of household head

Characteristics
20-29years
30-39yrs
40yrs
Pre-primary
Primary to below secondary
Secondary and above
Unskilled labour
Skilled labour
Service holder
Business

Age
Educational
status
Occupation

Frequency
46
45
11
27
48
27
20
14
26
42

Percentage
45.1
44.1
10.8
26.5
47.0
26.5
19.6
13.7
25.5
41.2

Table 4.2 Socio-demographic characteristics of the household:

Characteristics
Family size
Monthly expenses
(in taka)
Living land

4
>4
5000
5001-10000
>10000
<5decimal
5 decimal

No. of the
households
59
43
39
50
13
49
53

Percentage
57.8
42.2
38.2
49.0
12.7
48.0
52.0
34

possession
Land possession for
cultivation
Source of light
Source of drinking
water
Type of latrine

No land
<50 decimal
50 decimal
Electricity
Hurricane
Shallow tube well
Deep tube well
Pit latrine
Water sealed or ring slab
Septic tank

71
12
19
86
16
72
30
7
57
38

69.6
11.6
18.6
84.3
15.7
70.6
29.4
6.9
55.9
37.3

4.2 Utilization of community clinic and socio-economic status

4.2.1 Utilization of community clinic for contraceptives
It has been found that out of total one hundred and two study samples eighty nine
were using contraceptives. Regarding procurement of their contraceptives the figure
4.1 shows thirty eight of them (42.7%) collected their contraceptives from the
community clinic and rest of them from sources other than community clinic. [Fig
4.1]

35

Fig: 4.1 showing use of contraceptive delivery services of Community clinic

4.2.1.1 Educational status of the household head and utilization of community

clinic for contraceptives:
It was found that the utilization of contraceptive services from the community clinic
decreased with the increase in the educational level of the head of the household. The
utilization of services were maximum (53.8%) in the households having head with
pre-primary level education. But the findings were not statistically significant (p
>0.05).

4.2.1.2 Occupation of the household head and utilization of community clinic

services for contraceptives:
The skilled and unskilled labourers were utilizing community clinic for contraceptives
more commonly (59.3%) than the service holders (36.4%) and the businessmen
(35.9%).But the difference was not significant.
[Table 4.3]
4.2.1.3 Average monthly expenditure of the household and utilization of
Community Clinic Services for contraceptives:

36

It was found that the utilization of community clinic for contraceptives in the group
with average monthly expenses of 5000 was 54.3%, in group with monthly
expenses 5001-10000 was 40.9% and in the group with monthly expenses >10000
was 11.1% so with the increase in the monthly expenditure the use of contraceptives
from the community clinic decreased but 2 test did not find any association [Table
4.3].
4.2.1.4 Ownership of land for residence and utilization of community clinic for
contraceptives:
Those having land for housing 5 decimal used to take contraceptives from the
Community Clinic 46.5% more commonly than those having land for their housing
>5 decimal (40.0%). [Table 4.3]
4.2.1.5 Family size and utilization of community clinic for contraceptives:
Regarding size of the family those having 5 or more members were utilizing
contraceptive services (39.5%) relatively less than those having 4 or less member
(46.0%). The 2 test did not find any association. [Table 4.3]

Table 4.3.Utilization of contraceptive delivery services from the community clinic

and socio-demographic characteristics

37

Characteristics
Education
Pre- primary education
Primary to below
secondary
Secondary and above level
Occupation
Skilled and unskilled
labour
Service Holder
Business

Contraceptives delivery
services
No
Yes
N
%
N
%
12
46.2 14
53.8
22
53.7 19
46.3
16

76.2

05

23.8

11
14

40.7
63.6

16
08

59.3
36.4

25
11

64.1
40.7

14
16

35.9
59.3

Average monthly
expensess
5000 Tk.
500110000Tk.
> 10000Tk.

16
26
08

45.7
59.1
88.9

19
18
01

54.3
40.9
11.1

Land possession for

residence
5 decimal land
>5 decimal land

23
27

53.5
60.0

20
18

46.5
40.0

Size of the family

Having 4 or less member
Having 5 or more member

27
23

54.0
60.5

23
15

46.0
39.5

p -value

4.58

NS

4.10

NS

5.62

.
NS

0.38

NS

0.37

NS

4.2.2 Utilization of community clinic for ante-natal care

38

The figure 4.2.2 shows fifty eight pregnant mothers (56.9%) had the ante-natal care
from the community clinic and the rest forty four mothers did not receive that from
community clinic. [Fig 4.2]
Fig: 4.2 Utilization of ante-natal care from community clinic

Whether she visited community clinic for ante-natal care

4.2.2.1 Educational status of the household head and utilization of ante-natal
care service:
It has been found that the utilization of ante-natal care services from the community
clinic among the pre-primary level was 55.6% and in primary to below secondary
level was 63.8%.The utilization of ante-natal care from community clinic in
educational status of secondary and above level was 40.7%.So the people having
higher level of education was less utilizing the ante-natal care services from
community clinic. The 2 test did not find any association. [Table 4.4]
4.2.2.2 Occupation of the household head and utilization of ante-natal care
services
It has been found among the occupational categories the skilled and unskilled labourer
group were utilizing ante-natal care services from the community clinic 61.8% more
than the service holder (53.8%) and the business (50%) group. The 2 test did not
find any association. [Table 4.4]
4.2.2.3 Average monthly expenditure of the household and utilization of antenatal care service:
39

It has been found that the utilization of ante-natal care from Community Clinic in the
group with average monthly expenses of 5000 was 56.4%, in group with monthly
expenses 5001-10000 was 57.1% and in the group with monthly expenses >10000
was 46.2%.So we can say that those having average monthly expenses more than
10000 were utilizing the ante-natal care services less from the community clinic. The
2 test did not find any association. [Table 4.4]
4.2.2.4 Ownership of land for housing and utilization of ante-natal care service:
Those having land for their housing 5 decimal were utilizing the ante-natal care
services from the community clinic 59.2% more than those having land for their
housing >5 decimal and

were utilizing 51.9% ante-natal care services from

community clinic. The 2 test did not find any association. [Table 4.4]
4.2.2.5 Size of the family and utilization of ante-natal care service:
Regarding size of the family those having 5 or more member were utilizing ante-natal
care services (65.1%) relatively more than those having 4 or less member (50.8%).
The 2 test did not find any association. [Table 4.4]

Table 4.4 Utilization of ante-natal care from community clinic and sociodemographic characteristics

40

Socio-demographic
characteristics
Education
Pre- primary education
Primary to below secondary
Secondary and above level

Ante-natal care
No
Yes
%
N
%
37.0 17
63.0
39.6 29
60.4
55.6 12
44.4

N
10
19
15

Occupation
Skilled and Unskilled labour
Service Holder
Business

11
12
21
11

32.4
46.2
50.0
32.4

23
14
21
23

67.6
53.8
50.0
67.6

Average monthly expensess

Expensess 5000
Expensess 5001--10000
Expensess > 10000

15
22
07

38.5
44.0
53.8

24
28
06

61.5
56.0
46.2

5 decimal land
>5 decimal land

18
26

36.7
49.1

31
27

Size of the family

Having 4 or less member
Having 5 or more member

29
15

49.2
34.9

30
28

p -value

2.35

NS

4.77

.NS

0.91

NS

63.7
50.1

1.58

NS

50.8
65.1

2.06

NS

Land possession for residence

41

4.2.3 Utilization of community clinic for tetanus immunization to pregnant

mothers
The figure 4.3 shows that eighty seven (85.3%) pregnant mothers had their vaccine
for tetanus during pregnancy from the community clinic.[Fig 4.3]

Fig: 4.3 utilization of tetanus immunization among pregnant mothers

4.2.3.1 Educational status and Utilization of immunization of pregnant mothers

for tetanus:
The frequency distribution shows that the service of Community Clinic for
immunization of pregnant mothers for tetanus was more utilized group of pre-primary
education 100% than utilized in primary to below secondary and secondary and above
level where utilization were 70.2% and 81.5% , respectively.
The Fischers exact test found association and the p value <.025. [Table 4.4]
4.2.3.2 Occupation of head of household and utilization of immunization of

42

pregnant mothers for tetanus:

Regarding occupational status of the head of the household it was seen that the
utilization of vaccination of pregnant mothers for tetanus was less among the service
holder group, 76.9% than skilled and unskilled labour group and business group
which were 88.2% and 88%, respectively. The 2 test did not find any association.
[Table 4.5]
4.2.3.3 Average monthly expenses of household and utilization of immunization
of pregnant mothers for tetanus:
It has been found that the utilization of immunization of pregnant mothers for tetanus
from Community Clinic in the group with average monthly expenses of 5000 was
89.7%, in group with monthly expenses 5001-10000 was 82.0% and in the group with
monthly expenses >10000 was 84.6%.So it can be said that those having average
monthly expenses of 5000 were utilizing immunization of pregnant mothers for
tetanus more than others from community clinic. The 2 test did not find any
association. [Table 4.5]
4.2.3.4 Ownership of land for housing and utilization of immunization of
pregnant mothers for tetanus:
Those having land for their housing 5 decimal were utilizing the immunization of
pregnant mothers for tetanus from the community clinic 85.7% more than those
having land for their housing >5 decimal and were utilizing 84.9% immunization of
pregnant mothers for tetanus from community clinic but the difference in uses was
very insignificant. The 2 test did not find any association. [Table 4.5]
4.2.3.5 Size of the family and utilization of immunization of pregnant mothers for
tetanus:
Regarding size of the family those having 5 or more member were utilizing
immunization of pregnant mothers for tetanus (88.4%) relatively more than those
having 4 or less member (83.1%). The 2 test did not find any association. [Table
4.5]

43

Table 4.5 Utilization of immunization of pregnant mothers for tetanus and

Socio-demographic characteristics

Education
Pre- primary education
Primary to belowsecondary
Secondary and above level

Immunization of
tetanus for pregnant
mothers
No
Yes
N
%
N
%
00
00.0 27
100.0
10
20.8 38
70.2
05
18.5 22
81.5

Occupation
Skilled and Unskilled labour
Service Holder
Business

04
06
05

11.8
22.1
11.9

30
20
37

88.2
76.9
88.0

Average monthly expensess

5000 Tk.
500110000Tk.
> 10000Tk.

04
09
02

10.3
18.0
15.4

33
41
11

89.7
82.0
84.6

Socio-demographic
characteristics

Land possession for residence

5 decimal land
>5 decimal land

07
08

14.3
15.1

42
45

85.7
84.9

Size of the family

Having 4 or less member
Having 5 or more member

10
05

16.9
11.6

49
38

83.1
88.4

p -value

**7.62

.02

1.95

NS

1.05

NS

0.01

NS

0.56

NS

** Fishers exact test value given.

4.2.4 Utilization of community clinic for immunization to the children

44

Eighty-two (80.4%) children were vaccinated from community clinic, and the rest
twenty two children were not vaccinated from the community clinic. So it can be said
that the utilization of vaccination of children from community clinic was 80.4%. [Fig
4.4]

Figure 4.4: Utilization of immunization by children from community clinic

4.2.4.1Educational status and utilization of community clinic for immunization to

the children:
The frequency distribution shows that the service of community clinic for
immunization to the children was more utilized in the group of pre-primary education
96.3% than was utilized in primary to below secondary and secondary and above level
where utilization were 75.0% and 74.1% , respectively.
The 2 test found association. [Table 4.4]

4.2.4.2 Occupation of head of household and utilization of community clinic for

immunization to the children:

45

Regarding occupational status of the head of the household it was seen that the
utilization of immunization to the children was less among the service holder group,
76.9% than skilled and unskilled labour group and business group which were 79.4%
and 83.3%, respectively. The 2 test did not find any association [Table 4.6].
4.2.4.3 Average monthly expenses of household and utilization of community
clinic for immunization to the children:
It has been found that the utilization of immunization to the children from community
clinic in the group with average monthly expenses of 5000 was 89.7%, in group
with monthly expenses 5001-10000 was 72.0% and in the group with monthly
expenses >10000 was 84.6%.So it can be said that those having average monthly
expenses of 5000 were utilizing immunization to the children more than others from
community clinic. The 2 test did not find any association [Table 4.6].

4.2.4.4 Ownership of land for housing and utilization of community clinic for
immunization to the children:
Those having land for their housing 5 decimal were utilizing the immunization to
the children from the community clinic 81.6% more than those having land for their
housing >5 decimal and are utilizing 79.2% Immunization to the children from
community clinic but the difference in uses was not very significant. The 2 test did
not find any association [Table 4.6].
4.2.4.5 Size of the family and utilization of community clinic for immunization to
the children:
Regarding size of the family those having 5 or more member were utilizing
immunization to the children (83.7%) relatively more than those having 4 or less
member (78.0%). The 2 test did not find any association [Table 4.6].

Table 4.6 Utilization of community clinic for providing immunization services to

the children and socio-demographic characteristics

46

Vaccination of children in
community clinic
Yes
No

Socio-demographic
characteristics
Education
Pre- primary education
Primary to below secondary
Secondary and above level

26
36
20

96.3
75.0
74.1

01
12
07

03.7
25.0
25.9

Occupation
Skilled and Unskilled

27

79.4

07

20.6

labour
Service Holder
Business

20
35

76.9
83.3

06
07

23.1
16.7

Average monthly expensess

5000 Tk.
500110000Tk.
> 10000Tk.

35
36
11

89.7
72.0
84.6

04
14
02

10.3
28.0
15.4

2
5.90

p -value

.05

0.45

NS

4.54

NS

0.09

NS

0.52

NS

Land possession for

residence
5 decimal land
>5 decimal land

40
42

81.6
79.2

09
11

18.4
20.8

Size of the family

Having 4 or less member
Having 5 or more member

46
36

78.0
83.7

13
07

22.0
16.3

4.2.5 Utilization of community clinic for treatment of children for minor illness:
It has been found that thirty six (35.3%) children out of one hundred and two were
treated in community clinic for minor illness and the rest were treated in other health
facilities, private chamber. [Fig 4.5]

Fig: 4.5 Utilization of treatment of children for minor illness

47

4.2.5.1 Educational status and utilization of community clinic for treatment of

children for minor illness:
The frequency distribution showed that the service of community clinic for treatment
of children for minor illness was more commonly utilized in the group of primary to
below secondary (45.8%) than others. The 2 test did not find any association [Table
4.7].
4.2.5.2 Occupation of head of household and utilization of community clinic for
treatment of children for minor illness:
Regarding occupational status of the head of the household it was found that the
utilization of treatment of children for minor illness was less among the business
group, 31.0% than skilled and unskilled labourers (38.2%) and service holders
(38.5%). But the difference was not that significant. The 2 test did not find any
association [Table 4.7].
4.2.5.3 Average monthly expenses of household and utilization of Community
Clinic for treatment of children for minor illness:
It was found that the utilization of treatment of children for minor illness in the group
with average monthly expenses of 5000 was 38.5%, in group with monthly
expenses 5001-10000 was 32.0% and in the group with monthly expenses >10000
was 38.5%.So it can be said that those having average monthly expenses of 500110000 were utilizing treatment of children for minor illness less than others from
community clinic but the difference was not significant. The 2 test did not find any
association [Table 4.7].

48

4.2.5.4 Ownership of land for housing and utilization of community clinic for
treatment of children for minor illness:
Those having land for their housing 5 decimal were utilizing the treatment of
children for minor illness from the community clinic 40.8% less than those having
land for their housing >5 decimal and were utilizing 44.4%, but the difference in uses
was not that significant. The 2 test did not find any association [Table 4.7].

4.2.5.5 Family size and utilization of community clinic for treatment of children
for minor illness:
Regarding size of the family those having 5 or more member were utilizing treatment
of children for minor illness (37.2%) relatively more than those having 4 or less
member (33.9%). The 2 test did not find any association [Table 4.7].

Table 4.7 Utilization of Community Clinic for treatment of children for minor
illness and Socio-demographic characteristics
Treatment of children for
Socio-demographic
characteristics

minor illness

No

Yes

Education
Pre- primary education
Primary to below

21
26

77.8
54.2

06
22

22.2
45.8

secondary
Secondary and above level

19

70.4

08

29.6

p -value

4.73

NS

49

Occupation
Skilled and Unskilled

21

61.8

13

38.2

labour
Service Holder
Business

16
29

61.5
69.0

10
13

38.5
31.0

Average monthly expensess

5000 Tk.
500110000Tk.
> 10000Tk.

24
34
08

61.5
68.0
61.5

15
16
05

38.5
32.0
38.5

residence
5 decimal land
>5 decimal land

29
37

59.2
56.1

20
16

40.8
44.4

Size of the family

Having 4 or less member
Having 5 or more member

39
27

66.1
62.8

20
16

33.9
37.2

0.59

NS

0.46

NS

1.25

NS

0.11

NS

Land possession for

4.2.6 Utilization of community clinic providing limited curative services

It was found from their frequency distribution that thirty seven (36.3%) of family
members had their treatment for minor illness from the community clinic and rest
other than community clinic. So it can be said that limited curative service provided
by Community Clinic was utilized 36.3%. [Fig 4.2.6]
Fig: 4.6 Utilization of limited curative care services from community clinic

50

4.2.6.1 Educational status and utilization of limited curative care services by

community clinic:
The frequency distribution showed that the limited curative care services by
community clinic was more commonly utilized in the group of primary to below
secondary education (54.2%) than utilized in pre-primary (22.2%) and secondary and
above level (18.5%).It was found that utilization decreased with the increase in the
educational level.
The 2 test found association and the p value was <.025. [Table 4.8]

4.2.6.2 Occupation of head of household and utilization of limited curative care

services by community clinic:
Regarding occupational status of the head of the household it was found that the
limited curative care services by Community Clinic was less utilized among the
business group, (21.4 %) than skilled and unskilled labourer (47.1%) and service
holders (46.2%).. The 2 test found association and p value was <.05. [Table 4.8]
51

4.2.6.3 Average monthly expenses of household and utilization of limited curative

care services by community clinic:
It was found that the utilization of limited curative care services from community
clinic decreased with increase in the average monthly expenses and it was 23.1% in
those having monthly expenses of > 10,000, 38.0% in 5001 to 10,000 and 38.5% in
5000 groups. The 2 test did not find any association. [Table 4.8]
4.2.6.4 Ownership of land for housing and utilization of limited curative care
services from community clinic:
Those having land for their housing 5 decimal were utilizing the limited curative
care services by Community Clinic 46.9% more than those having land for their
housing >5 decimal and were utilizing 26.4% and the difference in uses is that
significant. The 2 test found association and p value was <.025. [Table 4.8]
4.2.6.5 Family size and utilization of limited curative care services by community
clinic:
Regarding size of the family those having 5 or more member were utilizing limited
curative care services from community clinic (34.9%) relatively less than those
having 4 or less member (37.3%). The 2 test did not find any association. [Table
4.8]

Table 4.8 Utilization of limited curative care services by community clinic and
socio-demographic characteristics:

Socio-demographic
characteristics

Education

Limited curative care by

community clinic
Treatment Treatment in
other then Community
Community clinic
clinic
N
%
N
%

p -value

52

Pre- primary education

21
22
22

77.8
45.8
81.5

06
26
05

22.2
54.2
18.5

12.64

002

Service Holder
Business

18
14
33

52.9
53.8
78.6

16
12
09

47.1
46.2
21.4

6.81

.03

Average monthly expensess

5000 Tk.
500110000Tk.
> 10000Tk.

24
31
10

61.5
62.0
76.9

15
19
03

38.5
38.0
23.1

1.12

NS

4.64

.025

0.62

NS

Primary to below secondary

Secondary and above level

Occupation
Skilled and unskilled labour

Land possession for

residence
5 decimal land
>5 decimal land

26
39

53.1
73.6

23
14

46.9
26.4

Size of the family

Having 4 or less member
Having 5 or more member

37
28

62.7
65.1

22
15

37.3
34.9

4.3 Perceived quality care and utilization of services provided by

community clinic
It is the perception of the client over the quality of service delivery and mostly
depends on the factors related to the health care facility. Those were relatively little on
the structural but more on the availability of health personnel, their attitude towards
patient, and their time devotion towards patient in examining their problem,
explaining their illness, skill to diagnose problems and prescribing correct drug.
Besides the waiting time, waiting and examination room and availability of drugs
played role which in the context of country like ours is important.
By analyzing their responses they showed to different components of the 20-itemed
scale21 that was used to measure the perception that near about half of the study
population had average perception, a little less than one fourth had good perception
and more than one fourth had poor perception about the quality of service provided by
the community clinic. [Table 4.9].

53

But the study samples responded differently to few of the components, which were
not very similar like we have described above. Though we found from the analysis
that the percentage of responses in the good perception category was less than 25%
but regarding treatment cost it was 73.5% and to distance of community clinic and
quality of the drugs they used to provide were 43% and 41.2%, respectively. Similarly
the average perception category showed 82.4% responses regarding waiting and
examination room and the responses of poor perception category were maximum to
the equipments and availability of drugs, were 74.5% and 53%, respectively.
It was found in this study population that perceived quality of care greatly influenced
the utilization of services from the community clinic and that was statistically
significant.
The effects of perceived quality care on utilization of different services are described
below:

4.3.1 Perceived quality of care and utilization of community clinic services for
contraceptives.
No association was observed between perceived quality of care and use of
contraceptives from community clinic. But the distribution showed that contraceptives
were more commonly used from community clinic by those who had very good
perception (63.2%) followed by those with average perception [Table 4.10].
4.3.2 Perceived quality of care and utilization of community clinic for ante-natal
care
It was found that the utilization of ante-natal care increased with the improvement in
perception level and those with very good perception utilized ante-natal care most
commonly (86.4%) while 15.4% of the poor perceived respondents utilized the
service.(p<0.001) [Table 4.10].
4.3.3 Perceived quality of care and utilization of community clinic for tetanus
immunization of pregnant mothers

54

The utilization of tetanus immunization was low among pregnant mothers with poor
perception 61.5% in comparison to other perception categories (>90%). The Fishers
exact test found the difference significant (p <0.001).
4.3.4 Perceived quality of care and utilization of community clinic for
immunization of children:
The utilization was found low among those with poor perception (61.5%) in
comparison to other categories (>85%). The 2- test found their significant difference
(p<.05). [Table 4.10]
4.3.5 Perceived quality of care and utilization of community clinic for treatment
of children for minor illness:
It was found that none of the households with poor perception went to the community
clinic for the treatment of minor illness of their children, while utilization was high in
those who had good or very good perception The 2- test found association and the p
value <.025. [Table 4.10]
4.3.6 Perceived quality of care and utilization of community clinic for limited
curative services
Those with poor perception did not go to the community clinic for the treatment of
family members for minor illness and utilization of the service increased with the
improvement of perception (p <.025). [Table 4.10]

55

Table 4.9 Response of study population to different components of measuring

scale for perception
Different components of health
care facilities for measuring
perception

Not
More or
good/adeqaute less
adequate
N

Skill of health personnel

Drugs prescribed how much
essential for patient
Collection of drug from
community clinic
How well they examine the patient
How much compassionate towards
the patient
Quality of drugs supplied from
community clinic
Prognosis of the patient treated in
cc

Adequate/Good

27
28

26.5
27.5

%
N
%
48
47.0
27
26.5
50
49.0
24
23.5

54

53.0

44

43.1

04

03.9

28
27

27.5
26.5

54
51

52.9
50.0

20
24

19.6
23.5

24

23.5

36

35.3

42

41.2

27

26.5

65

63.7

10

09.8

56

Openness of health personnel

towards patient
How much the health personnel
follow up patient
How much respectful health
personnel towards pt
Time devoted towards patient
Time for explaining illness to the
patient
Honesty of the health personnel
Fee charged for treatment
reasonable
Waving of the treatment charge
easily or tough
Distance of community clinic
Health personnel working
adequate or not
Health personnel well suited for
treating women
Equipments sufficient or not
Waiting and examination room

27

26.5

50

49.0

25

24.5

33

32.4

54

52.9

15

14.7

28

27.5

57

55.9

17

16.7

28
29

27.5
28.4

54
54

52.9
52.9

20
19

19.6
18.6

30
22

29.4
21.6

53
05

52.0
04.9

19
75

18.6
73.5

21

20.6

06

05.9

75

73.5

04
23

03.9
22.5

54
75

52.9
73.6

44
04

43.1
03.9

28

27.5

61

59.8

13

12.7

76
18

74.5
17.6

26
84

25.5
82.4

00
00

00.0
00.0

57

Table 4.10 Perceived quality of health care and utilization of services from
community clinic
Perceived quality of health care and utilization of services provided by
Community Clinic
No
Yes
2
N
%
N
%
Utilization of contraceptive delivery services
Bad perception
14
70.0
06
30.0
5.26
Average perception
14
53.8
12
46.2
Good perception
15
65.2
08
34.8
Very good perception 07
36.8
12
63.2

Utilization of ante-natal care

Bad perception
22
84.6
04
Average perception
12
38.7
19
Good perception
07
30.4
16
Very good perception 03
13.6
19
Utilization of vaccination of pregnant mothers
Bad perception
10
38.5
16
Average perception
03
09.7
28
Good perception
01
04.3
22
Very good perception
01
04.5
21
Utilization of vaccination of children
Bad perception
10
38.5
Average perception
04
12.9
Good perception
03
13.0
Very good perception 03
13.6

16
27
20
19

15.4
61.3
69.6
86.4
61.5
90.3
95.7
95.5
61.5
87.1
87.0
86.4

27.80
<0.001

**12.962

.002

7.873

< .
05

Utilization of treatment of children for minor illness

Bad perception
26
100
00
00.0
Average perception
22
71.0
09
29.0
Good perception
09
39.1
14
60.9
Very good perception 09
46.9
13
59.1

26.757

Utilization of limited curative care services

Bad perception
26
100.0
0
Average perception
20
64.5 11
Good perception
13
56.5 10
Very good perception 06
27.3 16

27.971

0.0
35.5
43.5
72.7

NS

<0..001

<0.001

** Fishers exact value taken

58

5. Discussion
The study was conducted to estimate the utilization of initial services of Essential
Service Package by the community clinic and the factors. A cross sectional study was
carried out among 102 study samples. The study sample were households having
children less than 2 years of age in the catchment area of Meghdubee community
clinic, Pubail union, Gazipur sadar upazila, Gazipur district.
These community clinics were to bring family planning, preventive health services
and limited curative services closer to the population, and to improve the efficiency of
service provision, partly by replacing outreach services with services provided from a
fixed point. There are also risks in that some previously successful outreach services
are to be replaced, and there is a need to ensure that the benefits of these are retained.
It was found previous study30 in 2002 that community clinics were playing at most a
limited role in the development of ESP services for those most in need. So to see its
utilization at present in delivering the initial services of ESP is important to provide
information to ensure the essential health care services to the population of
Bangladesh.
5.1 Sample profile: Socio-demographic characteristics
The majority of household interviewed were males as the interview were taken at
their residences and all the families were Muslim and mostly of conservative type.
In this study the socio-economic characteristics of the selected households including
monthly expenses, housing condition, possession of land, source of drinking water
and light and type of latrine used and as well as characteristics of household head data
were collected [Table 4.1.].
The average age of the household heads interviewed was around 30 years mostly with
educational level below secondary level and commonly business as their occupation,
having average monthly expenses of taka 5,000-10,000. Majority of the household
had no land for cultivation and more than half of them had more than 5 decimal land
for their housing [Table 4.1 & 4.2].

59

5.2 Utilization of services

For effective utilization of services of health care accessibility is an important factor
and the community clinic was easily accessible from most of the part of its catchment
area distance was not a problem to reach there.
In this study efforts were given to see the utilization of different type of services
provided by community clinic through collecting information from the clients.
The overall impact of socio-demographic variables over utilization of services
provided by community clinic was statistically not significant. This study finding was
similar to the findings of study carried out in other developing countries. The
utilization was found more related to the perceived quality care. The sociodemographic characteristics have little influence on perception of quality of service.
In their study at administered to 1081 patient at 11 health care centers in the health
district of Nouna, in rural Burkina Faso.21 It has been found that socio-demographic
characteristics contributed less than 10% to the variance on perceptions and the health
center variable contributed more than 90%.
Less than half of the eligible couple who were using contraceptives were utilizing the
contraceptive services from community clinic It was found that the utilization of
contraceptives from the community clinic decreased with the increase in the
educational level of the head of the household and more commonly utilized among
those with low socio-economic status [Table 4.3].
Regarding utilization of ante-natal care provided by community clinic it was found
that more than fifty percent pregnant mother had their ante-natal care from the
community clinic People having higher level of education were found utilizing the
ante-natal care services less and more commonly used among people of low socioeconomic status [Table 4.4].
Majority of the pregnant mothers had their vaccine for tetanus during pregnancy from
the community clinic irrespective of their socio-economic status though found
maximum among those with low educational level [Table 4.5].

60

The utilization of services of community clinic for immunization of the children

(80.4%) wass more among those with group of pre-primary education and having less
average monthly expenses [Table 4.6].
The utilization of services regarding treatment of the children for minor illness was
found to be a little more than a third of the children. And there were no significant
differences in the percentage of utilization among different groups with different
socio-demographic characteristics excepting it were found more utilized among those
with level of education of head of household primary to below secondary. [Table 4.7]
The treatment of family members from community clinic was found to be a little more
than in one third of the members who were treated for minor illness and it was
significantly found to be more with poor educational level of household head
relatively low socio-economic status were utilizing the service more. [Table 4.8]
So in this study it was revealed that the people with low socio-economic status with
low level of education were utilizing most of the services of community clinic more
commonly than with high socio-economic status and higher level of education except
immunization where the utilization were found more or less similar among all groups.
The study done on community clinic and its utilization in Bangladesh was Improving
Access to Health Care for the Poor and Vulnerable in Bangladesh 29 covered 93
respondents from 12 community clinics spread over five (5) Districts. The study
found that the overall activities of community clinics covered by the survey were not
impressive and, as a result, the objectives of the community clinics were not being
fulfilled as had been hoped.
But they did not looked out thoroughly to the utilization of specific services like the
researcher did in this study and though study covered 12 community clinics but the
sample size was small only 93.

61

5.3 Perceived quality care and utilization of services

Understanding populations perceptions of quality of care is critical for developing
measures to increase the utilization of health care services in both public and private
sector21. In this section the association or influence of perceived quality of care and
utilization services provided by the community clinic are discussed.
The contraceptive delivery services are more commonly utilized among those with
very good perception almost in two- third in comparison to those with poor perception
who utilizes in less than one-third.
It was found that there is increase in the utilization of Ante-natal care with increase in
perception level and those with very good perception were utilizing Ante-natal care
most commonly more than five times than those with poor perception. The influence
was statistically very significant (2 = 27.80 and the p value <.001)
The pregnant mothers with average, good and very good perception utilized services
of tetanus immunization more than one and half times than those with poor
perception. The influence was statistically significant (Fishers exact value= 12.962
and p value <.005).
Perceived quality care also influenced utilization of Immunization services to the
children and it was found to be utilized among those average, good and very good
perception almost one and half times more than those with poor perception. It was
statistically significant (2 = 7.87 and the p value <.05).
It was found that those with poor perception didnt go to the community clinic for the
treatment of minor illness of their children in comparison to the very good perception
who utilized the services in two third cases of their childrens minor illness. The
influence was statistically very significant (2 = 27.757 and the p value <.001).
Perceived quality care greatly influenced the utilization of limited curative services.
Those with poor perception did not go to the community clinic for the treatment of
family members for minor illness and those with very good perception utilized the
service more than two-third of their family members minor illnesses. The influence
was statistically very significant (2 = 27.971 and the p value <.001).

62

The study result clearly reflects that perceived quality of care significantly influencing
the utilization of services provided by community clinic.
Similar results found in other national and international studies. Patients perception
of quality of care is critical to understand the relarionship between quality of care and
utilization of health services, and increasingly it is treated as an outcome of health
care delivery16-19, 22. The findings of all those studies provided growing evidences that
perceived quality of care of health care services has a strong impact on utilization
patterns. In studies of the countries of the developing world household surveys
revealed that the perceived low quality of health care was one of the main reasons
why people did not attend primary health care services in cases of illness 8,9. This has
been reflected very much in this study which has revealed the significant impact of
perceived quality care on utilization of services provided by the community clinic.

63

6.1 Conclusion
A cross sectional study was conducted study was conducted to assess the utilization of
services provided by the community clinic,
The information from the study can be concluded as follows:
It was found that most of the services are being utilized at a very low rate in
comparison to the expected. We know that community clinic were established with a
view to cover 80% population of the community but except immunization all other
services were found far distant from their target. The utilization of services was found
maximum in case of immunization of pregnant mothers for tetanus (85-3%), followed
by immunization of children (80.4%). They utilization of services was found poor in
case of limited creative care (36.27%) and treatment of children for minor illness
(35.29%).
The utilization of services was found more among those with low socio-economic
status and poor level of education.
It was found that the Perceived quality of health care greatly influenced the utilization
of health care services. The socio-economic factor has little effect on perception. The
perception was dependent mostly on the health center variable like the availability of
drugs and health personnel, the attitude and behaviour and time they devote
examining the patient and explaining their problems.

64

Recommendations

The study findings revealed some important information regarding utilization of

services provided by community clinic.
The opening hours for providing services to the peoples in community clinics should
have to be ensured through proper monitoring.
The supply of drugs and the availability of health personnel should have to be
ensured.
To increase the perceptions of quality of care the skill and knowledge of the health
personnel should have to be improved through continued training programme.
The services of community clinic was found more commonly utilized by the people
with low socio-economic status and poor level of education, so the programme and
approaches should be designed in a form which is more acceptable to the them.
There should be extensive operational research work through expert research team to
see the utilization and progress of services and to find out the loop holes.
The community groups should be activated or reformed for monitoring the
operational activities and ensure the community participation.

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