Effective health service planning and delivery: A qualitative case study exploring health service users perspectives

Abstract


Introduction
Provision of effective healthcare service is an important component of good health outcomes.Harrington et al. 1 claim that patients who access regular health services have better healthcare outcomes.In recent decades, access to quality healthcare services has prevented infectious diseases (tuberculosis (TB), HIV, malaria), reduction in mother and child deaths, and eradication of smallpox 2 .For instance, according to World Health Organization (WHO), since 2000, 63 million lives have been saved from tuberculosis through interventions linked with the WHO End TB Strategy 3 .In addition, in 2019, 54 countries had low TB incidence of less than 10 TB cases per 100 000 people 4 .These countries are mostly from the WHO regions of Americas and European Region, with few other countries in the Eastern Mediterranean and Western Paci c regions 4 .Further, maternal mortality has declined by 38 percent between 2000 and 2017, from 342 deaths to 211 deaths per 100, 000 live births 5 .The provision of effective healthcare services that is easily accessible and affordable by the local community is important for better healthcare outcomes [6][7][8] .
In contrast, the provision of effective health services is a di cult task and has never been easy for health services providers 9 .Many authors dispute the meaning of effective health services and its application at the point of delivery [10][11][12] .Many literatures associate effectiveness with numerical values, such as accomplishment of established targets and measuring the amount of money spent on health service against planned activities [13][14][15] .As a result, it does not represent the true picture of overall health services.
Furthermore, the views of the general population are ignored, particularly the views of the health services consumers 16,17 .It is therefore proper to investigate the de nition of effectiveness in the context of people accessing health services.In Berman et al. 15 opinion, effectiveness should be de ned by health services users' interpretation and understanding, and determine if there are any real health bene ts and improvement to the health of the individuals and community through the health services provided by the healthcare system.Similarly, Regmi 11 argues that health services consumers' opinions and experiences can be useful for planning and scaling up health interventions.
There is no global de nition of effective healthcare services.However, the World Health Organization (WHO) outlined the features of effective health services with availability, accessibility, acceptability, and quality 18 .According to WHO 19 , availability means that public health facilities are operating and provide the required health services with high standard health programs.In addition, adequate supply and relevant number of health professionals' who are competent with right skills to meet the demand of the population 20 .Accessibility is when every citizen has access to health facilities, goods and services within their geographical location 19 .Furthermore, WHO explains that acceptability of healthcare services means all health institutions must respect the code of medical practice and should be culturally relevant to serve the needs of everyone regardless of its gender.Quality healthcare is de ned as a well-functioning health system working in harmony, is built on having trained and motivated health workers, a well-maintained infrastructure, and, a reliable supply of medicines and technologies, supported with adequate funding, and evidence-based policies 18 .
An important aspect of healthcare planning and delivery is utilizing patients' experiences and views 17 .
Smith et al. 17 proposed that recommendations from the patients could provide valuable information for strategic planning and development of healthcare services model.This study argues that subjective experience from the patients' may provide useful insights for interactive planning and delivery of health services that meet the needs of speci c groups of patients 17 .Similarly, Regmi 15 concluded that service users convey strong information about the health sector and their involvement in the policymaking and decision-making process may result in positive change to the district health services.Another study done by Francis, Gurch, and Bertha 21 call for an assessment of the current health care delivery system to ensure that patients utilize the appropriate level of healthcare.Despite the increasing advocacy of the importance of patients voices in healthcare delivery globally 17,22 , their voices are not always heard and included in the planning and management of health services.
An integrated approach to planning and managing health services using users' experiences provided a strong foundation for planning healthcare.In the PNG healthcare system, users' experiences of healthcare are under-discussed.There is a need to discuss such a context from the users' perspective.This research aims to explore users' views of effective health services and investigate barriers or challenges affecting the effective management of health services.The ndings from this study may provide useful insights for health services planning and management to improve the effectiveness of health services.

Study approach
This research employed a qualitative research approach based on social constructivism theory.
According to Boyland 23 , the purpose of a social constructionism approach is to construct social context and social reality.Guba and Lincoln 24 believe that the human world is different from natural, physical science.Therefore, it must be studied differently as an individual construct and assign meaning to the world through their interpretations and interactions with the world 25 .Boyland 23 explains that social constructionism is about constructing knowledge about reality, and not constructing reality itself.The motive of this approach is to employ numerous data sources to explore the same phenomenon from different perspectives because social reality is contextually embedded within its local settings 23 .

Study setting
PNG is located on the northeastern end of Australia and is the largest island country in the Paci c region in terms of its landmass and economy 26 .It shares bothers with Indonesia on the West, Solomon Islands on the east and Australia on the south 27 .PNG is one of the most linguistically, culturally and geographically diverse country in the world with over 850 different languages and 9.2 million inhabitants 26 .Papua New Guineans are predominantly Christians with very few cultural religionists.More than 87% of the populace are subsistence farmers and live in rural and remote locations, while others work in white-collar jobs, arts and crafts and businesses.The state comprises 22 provinces and 89 districts with each province divided into districts and each district consist of more than ten local level governments 6,26 Organization of healthcare services in PNG Healthcare services in PNG are provided through a network of uni ed structure 26 .One national referral hospital, four regional specialist hospitals, 20 provincial hospitals supported a network of 2400 aid posts, 500 health centers, and 45 urban clinics 28 .Health employees that provide health care include community health workers, nursing o cers, health extension o cers (HEOs), doctors and other support services staff 29 .The Aidpost serves a catchment population of between 500 and 1500 at the community level 26,28 .
The customary villages in PNG has than 500 people, each aid post is responsible for one to six villages.
Community health workers (CHWs) usually work at the aid post and provide general primary healthcare and provide information on healthy lifestyle and health promotion to prevent diseases 30 .A health center serves a population of between 2000 -20,000 people.Respective health centers provide curative and public health services and act as a referral facility for about 5 and aid posts (Figure 1).District hospitals or district health centers provide comprehensive curative and preventive healthcare and act as a referral health facility for all acute health problems for the health centers in the district 26,30 .
The National Department of Health (NDoH) provides advisory roles and policy formulation, while the provincial and district health services provide coordination and supervision to the implementation of national health policies in the province, districts and local level.The employees of the national department have the overall responsibility for monitoring policy and standards, offer technical support, coordinate the national health information system and health policy and data management 30 .
The research was conducted at a level one-primary healthcare facility in Madang Province, located at the Northern coast of the mainland of PNG 31 .Based on my observation, the facility was staffed by professional nurses with weekly medical consultations performed by doctors who are also full-time academics, with an average of 15 patients per staff contact hours.Furthermore, based on my health facility investigation, skin diseases, malaria, and simple cough were the common causes of outpatient attendance.The choice of the study site was in uenced by the feasibility of doing the research, travel cost, and time.Additionally, this health facility was selected because no such study was conducted to assess the effectiveness of its health services and the barriers affecting the health services from the perspective of users.The health facility served a total population of more than 3000 people including students, academics, and the nearby community.The results may be useful for policy makers and university administrators for planning to make health service delivery more effective and accessible to its users.

Participants
Between June and November 2020, 21 in-depth interviews were conducted with health services users and health professionals.The participants were selected using the non-probability purposive sampling technique to accomplish theoretical sampling 32 .The nal sample includes the study population and represented the full range of demographic variables such as age, sex, education, religion, and experiences.The health facility attendance record was used as the sampling frame.The size of the sample was not xed at the start of the research so sample and data collection grew simultaneously, the sample size was based on the results of the data analysis, and the recruitment (data collection) continued until saturation of emerging key themes or categories was reached 32 .The participants included 05 academics,09 undergraduate students, and 07 adult patients from the nearby community.
The age of the interviewees ranged from 18 -73 years.Table 1 shows the general characteristics of the health services users.

Data collection
Before the data collection, study participants were given guided topics focused on three major questions: (1) users' perspectives of effective health services planning and delivery, (ii) barriers and problems encountered, if any, while accessing the healthcare services, (iii) actions required to improve the effectiveness of the healthcare services.A topic guide was developed based on the literature review and the researchers' re ection on health services users' perceptions (Box 1).The same topic guide was used for all participants to allow exibility for any additional issues to be discussed.The topic guide employed in this research was piloted with three health services users in another non-study health facility to improve the validity of the questions 33 .Based on the results, the guide was slightly modi ed for use in the selected study site.The interviews were conducted at the location selected by the participants.The academics were interviewed in their o ce while the students were interviewed at the students meeting venue and patients from the community were interviewed at their homes.
Box 1 Topic guide • Tell me about your understanding of effective health services planning and delivery?
• What have been the barriers and problems while accessing health services at the primary health care facility (in terms of drugs, operations, staff, health services, information, infrastructure)?
• Do you think that the health services provided by the health facility met your health needs?
• What are some activities that can be implemented to improve the planning and delivery of health services at the health facility?

•
Is there anything further you would like to discuss?

Data analysis
The qualitative study used semi-structured in-depth interviews (IDIs) to generate experiential data from health services users who are frequent users of the health facility.In order to provide some contextual data to the results, participants were asked to describe their views of an effective health service, problems they may encounter, if any, while accessing health services at the facility and how to improve the planning and delivery of health services of the health center to determine the model of healthcare.The interviews were audio-recorded with permission from the participants using a digital voice recorder and later transcribed verbatim including emotional expressions into the computer using Microsoft @Word 2016.The interviews were imported to QDA Miner Lite software for qualitative data management and analyzed to expose coding structures: categories, sub-categories, themes, and codes 34 .QDA Miner Lite facilitated each interview to locate terms and sentences (phrases) that formed the foundation for the development of themes and sub-themes and also facilitate association between each interviews 35 .The transcribed document was emailed to the participants, who were asked to check the written document and agree or disagree with what was written.Any disagreements were resolved accordingly.

Ethical consideration
Informed consent was sought from each participants prior to the start of the study, after they have read the participant information sheet.

Study limitations
This study has several limitations.First, the study site is limited to a level 1 health facility.Therefore, the ndings may not be automatically generalized to other health settings elsewhere.However, provision of effective health services is a global concern among all healthcare providers.Hence, healthcare providers may nd the results helpful for planning health services.Second, the study site is a private clinic, and the cost of healthcare services is high.Majority of the participants are university staff and students with a high level of socioeconomic status and therefore may not re ect the views of people with lower socioeconomic status in the community.The researcher was unable to recruit many patients from the nearby community that uses the health facility due to time limitations.Therefore, there may have been a selection bias in the sample.However, the purpose of the study was to identify areas that need improvement to health services so the key informants from the university may provide useful information that may bene t the nearby community.

Results
Characteristics of the respondents Table 2 summarized the respondents' demographic characteristics.A total of 21 in-depth interviews were conducted with the health services users (5 males and 16 females).Participants were grouped based on their basic demographic variables, e.g., age, sex, education, religion, experience, and marital status.The majority (n=16/21) of the participants were female compared with 5 male participants with an average age ranging from 20 -79 years old.Respondents were asked if they were frequent users of the health facility.This data was important, as personal experience of the phenomenon under study was signi cant to provide an in-depth rich subjective experience of the effectiveness of the health services and problems that may impede the planning and delivery of healthcare services.Five key themes emerged from this study: availability, accessibility, acceptability, quality, and health systems challenges.

Availability
Most of the respondents are concerned over the availability of healthcare providers at the health facility to provide the required services.They were concerned that the few health workers at the facility have affected the utilization of basic health services.The responses and the meaning the participants talked about in terms of their perceptions of effective planning and delivery of health services when they were asked the question are presented here with the supporting quotes.Respondents said that the availability of health workers and speci c healthcare services were the key interpretation of the respondents' perceptions of effective planning and health services delivery.The majority of the respondents identi ed the presence of health workers as an effective element of health services delivery system: "I suggest that at least two more nurses and a doctor should be employed to provide adequate health services.At the moment, there is no fulltime doctor and that complicated health conditions are referred to the provincial hospital.There are more patients at the hospital and we have to wait for many hours to consult a doctor" (Participant 004).
"An additional nurse should also be recruited to increase the current staff strength.Currently, only one nurse lives inside the campus and takes all emergency cases and when she is absent, there is no-one else to report to particularly during the weekends" (Participant 007) Some respondents noted that ensuring the availability of adequately trained and competent PHC providers at the health institution is a signi cant element of health service planning.The respondents' perceptions of effective healthcare are that the presence of an appropriate number of healthcare providers is of limited bene ts if providers are absent from their planned duties or if health services delivery is structured in such a way that patients are unable to access skilled healthcare provider at convenient times."I think that the current health workers are very experienced in their work.They do right diagnosis and prescribe correct treatment and you get better.It is good to recruit additional staff but they should also consider their skills and experience like a midwife to provide mothers clinic or Paediatric nurse to attend to our children when they are sick (Participant 007).
Respondents feel that patients can only receive high quality healthcare from competent health workers if those health workers are present in facilities and trained in relevant healthcare.Others shared similar views that even with the availability of large numbers of health workers, inadequately trained and skilled providers will unlikely contribute to individual or community health outcomes.

Accessibility
Findings from the semi-structured interviews revealed that HCWs' skills and attitudes were in uential on their health-seeking behavior.The majority of the respondents' view accessibility as an indicator of effective health services planning and delivery.Nineteen health services users highly commended the health workers for their positive attitudes, and actions while seeking treatment at the clinic.This approach has established a positive environment for open communication and dialogue between health providers and users.As a result, respondents stressed that they were not ashamed to provide speci c details of their medical conditions.On the other hand, the participants are concerned about the cost of healthcare.Respondents highlighted that the high cost of healthcare is a barrier to accessing healthcare for residents of lower socioeconomic status.Participants are concerned that patients coming from disadvantaged settings may not afford the cost of healthcare.Besides, the majority of the participants expressed concerned over the lack of information regarding the operating hours.They emphasized that effective communication to end-users about health services is an element of good management.Participants are concerned that there is no information from the HCWs about how to access clinical services during medical emergencies.
"Services provided is superb!Staff are very helpful" (Participant 001)."I trust the nurses so I want to tell them about all my health problems, because I know they will help me" (Participant 0020)."The clinic is convenient for me to access and also it has excellent team of clinical staff.The clinic has a friendly receptionist who is also very helpful.Most of the times, I book in to see medical doctors who are polite, professional and provide the best care and advice.On few times, I had appointment with the nursing staff.In addition, nursing staff are knowledgeable and provide best care.I have no negative comments but praises" (Participant 006).
The cost of some services are expensive, I feel for those that are unemployed and come from squatter settlements" (Participant 016)."There is not even any form of notice who to contact during emergencies" (Participant 004, 011).
The respondents' claims indicated that access to comprehensive, quality healthcare services are important for promoting and maintaining disease, reducing unwanted disabilities, and premature death.The healthcare industry is one of the key domains that in uence the local population.This study reveals the important role of health professionals and socioeconomic status as narrated by the study respondents.As healthcare expenditure increases and the sector continues to grow, accessibility remains a major concern in many countries, particularly populations with lower socioeconomic status (LSES).

Acceptability of health services
Respondents emphasized the signi cance of providing health services according to end-users needs and expectations.The design and organization of health care services should be done according to current health and demographic information.In that way, healthcare providers are con dent that health services are relevant to the needs of patients.Health services are provided to different segments of the population including men, women, and children.The respondents stressed that health services should be tailored to meet such groups.However, respondents stressed that due to lack of consideration of end-users needs, some vital services such as mother and child health, emergency services, and microscopy are not provided.As a result, some female respondents stressed that their work is affected because they had to care for their sick child at the nearby general hospital.
"We have specialist doctors working part-time on campus except a Pediatrician -we have so many children especially babies on campus and if we had a Pediatrician, it would be very good for us.Babies need special care and special attention and it is vital we have a specialist for children on campus.When my baby gets sick, I do not work and this affects my students, especially those of us who are teaching.With advice from a pediatrician we will feel that our babies are okay and that we can go to work otherwise, we take sick leave and nurse them at home or go somewhere else to look for help.The services provide by the public health system is very ine cient" (participant 002).This situation was largely ine cient, especially from the users' perspectives.Indeed, the users spend a lot of time travelling to other health settings, had to suffer a great deal of stress queuing at the health facility to get the treatment or see the physicians.Very often the public health facility is overcrowded with patients and they have to wait long hours.

Quality of healthcare
The quality of healthcare is an important indicator of effective health services.The participants in this study associated quality of healthcare with expressions such as best, timely, fast, and good staff behavior.About 17 participants reported that the general level of care given at the clinic is outstanding compared to other public health facilities.Furthermore, another 15 participants reported that they have no major problems accessing health services and consulting health workers to seek medical treatment.Additionally, they feel comfortable talking to staff, as they are responsive to their needs.The participants stressed that the quality of health services they receive is of a high standard.They are given medical treatment on time with low waiting time at the clinic.The healthcare workers are caring as this is re ected in the level of care given to patients and the high rate of recovery after taking the prescribed treatment.One participant said that: "Services provided at clinic are the best by any standard as far as PNG's public health care system is concerned.Best in the sense that service is provided on time, patients do not wait on long queues, staff are friendly and polite and they talk to you nicely.Treatment given also is effective, meaning you get healed once the staff start you on treatment for whatever condition you present to them" (Participant, 008).
The above respondents' narratives generally re ected the core attributes of quality healthcare that is measured by six domains: safety, effectiveness, patient-centeredness, timeliness, e ciency, and equitability.Healthcare quality remains an important discussion topic for both clinicians and patients 36 .

Lack of continuity of health services
Most respondents reported that disruptions to health services due to the closure of the clinic were seen as a major barrier to accessing clinical services.Furthermore, the closure has affected the continuity of treatment for the health problems.The majority of the participants consider access to health services from 5pm to 7am, weekends, and public holidays as problematic.Most of the respondents agree that access to health services is di cult during these times.Others, about twelve respondents even reported that there is no contact information on who to consult during emergencies.Interviews with health care providers a rmed that there is no formal arrangement with the university administration for overtime work during these hours as highlighted by the users.As such, they a rm that they don't work shifts and overtime and no contact information is posted for patients to access health workers.They explain that they are allowed to work from 8 am to 5 pm daily during weekdays and not on weekends and public holidays.Additionally, another HCW noted that employment of a permanent medical o cer at the clinic would address the accessibility issues raised by the users.
"Only if you happen to know one of the staff it is easy to call upon them during the weekend" (HCW 001), "I sign the contract to work from 8 o'clock am to 5 o'clock pm from Monday to Friday.I am not allowed to work after hours, weekend and on public holidays.But I do help patients when they come to my house as part of my community services since I started work here" (HCW 001).
"It need a fulltime medical o cer and leader who will plan strategic development of services" (HCWs 002).)"Sadly, we do not have an emergency number that we can call in emergency.And we also do not know if a clinic staff/ or doctor available for assistance in emergency after hours and on weekends" (Participant 008).
Continuity of healthcare services has always been a core pillar of PHC services.Health users who receive continuity of care have improved health outcomes, higher satisfaction rates, and the healthcare they receive is more cost-effective 36 Inadequate health services infrastructures' health services users responded that inadequate health services infrastructure such as a laboratory facility was an impediment to access and using of health services.The participants suffered additional challenges traveling to the pathology for simple blood examinations.The participants expressed disappointment over the absence of other health services.Both healthcare providers and service users expressed a need to start minor blood examinations at the health center.My interview with healthcare providers agree with the patients of setting laboratory facilities to resolve the problem.
"In terms of laboratory services, start with malaria microscopy.As this is the most common lab investigation ordered by o cers at the clinic and clients have to go all the way to Paramed to do the test and bring the results back down to the clinic.It is a very time consuming exercise" (HCW 005)."I suggest that the pathology section to check for Malaria parasites be available here at the clinic instead having patients walk all the way to Paramed for check-up then back to the clinic to get medication" (Participant 001).
Although a strong infrastructure depends on many institutions, PHC providers are considered key players of essential health services.PHC facilities provide opportunities for health service users to prevent disease, promote health, and respond to both acute and chronic health threats.Infrastructures is the basis for planning, delivering, evaluating, and improving community health 5 .

Discussion
The purpose of this study to explore healthcare users' experience of e cient healthcare services and problems affecting the delivery of health services at a primary healthcare (PHC) facility.The results from the semi-structured interviews of 21 health service users at the local PHC institution, Madang Province, PNG, supported this purpose.The respondents view effective health service as a vital determinant of population health.They relate to access to healthcare services with the availability of healthcare professionals at the health facility.The respondents also view accessibility as not just about having adequate health personnel's' but are adequately trained to provide both public and clinical healthcare services.The study also found that the respondents associated quality healthcare with continuity of health services.The respondents justify that the absence of clinical care and malfunctioning health facility as indicators of a weak health care system.The majority of the respondents asserted that discontinuity of health services and de ciencies in the health infrastructure pose a threat to positive health outcomes.
The results generated from this study are consistent with a previous study that assessed the healthcare delivery for in the USA 37 .A study by Karen 37 , measuring the challenges of social and structural issues as an impediment to healthcare, found that children without health insurance and those in rural locations cannot afford access to mental and dental health services.A recent study by August et al 2 , on the effects of medicines availability and stock-outs on household utilization of healthcare services in Tanzania, found a strong association between the individual's healthcare utilization and constant availability of drugs at the health institutions.The study highlighted the signi cance of medical supplies in promoting accessibility to healthcare services in resource-constraint countries.The study concludes that systematic planning and organization of medical supply from the macro to micro-level is a key aspect of quality healthcare services.In another study by Daniel et al. 1 , access to healthcare services was historically associated with demographic and socioeconomic determinants.This study found a strong relationship between residing in an urban community and accessibility and usage of healthcare.This study also found signi cant variations in healthcare use and access and certain socioeconomic and demographic populations.This study concluded that a persistent evidence of inequitable association exists between socioeconomic status (SES) and primary contact with the PHC system.
The study explored users' perceptions of e cient health services and obtained multiple theories associated with healthcare delivery.Berman et al. 22 explained that effective health service delivery and performance provide an opportunity for patients to access and use health services.Furthermore, Berman emphasized that quality health services require adequate inputs such as e cient allocation of limited resources, and adaptation to new changes and technologies.There are several interpretations of the same event, but the most popular is made by Berman et al. 22 and Suman & Bhutani 38 that utilizing a combination of nancial, physical, and human resources may promote organizational effectiveness.
Berman and colleagues concluded that improving organizational performance is a signi cant assurance to the effective delivery of healthcare.Despite the heterogeneity of the respondents, the recurrent themes from the participants relates to availability, accessibility, affordability, acceptability and quality healthcare as indicators of e cient healthcare delivery.

Study strengths and limitations
This study has some limitations.The majority of the participants were residents from the university and limited residents from the nearby community due to time limitations.Additionally, the users are academics and therefore, were committed within their end-of-semester assessments and therefore unable to conduct follow up face-to-face interviews.As is common with qualitative case studies, this study is limited to a small primary healthcare facility and the results cannot be automatically generalized to other settings elsewhere.However, delivering effective health services is a global concern and is well articulated in other studies 39 , and therefore, policymakers, health managers, and clinicians in other health settings may nd this study useful for planning and delivery of healthcare services.

Conclusion
From the respondents' views, this study suggests that improved population health is associated with availability, acceptability, and utilization of quality health care.It supports ndings from previous studies regarding access to healthcare services as key determinants of community health.The results from this study call for an evaluation of the current healthcare system, particularly at the primary healthcare level, as the primary point of contact to the formal healthcare system, and the need for developing a contextual model of healthcare that meets the needs of the service users.We concluded that health services planning and delivery should be equally supported with insights from health services users.However, caution needs to be exercised when interpreting the results and generalizing to the general population because of the limited study sample size and relatively small private primary healthcare facility. Figures

Table 1
Basic characteristics of interviewed healthcare users

Table 2
Summary of generated themes and codes/nodes