Table 2

Microcontext of primary healthcentresinIndia (source: data from interviews and focus group discussions)

Actors perceptionsActor practices
Health system
  • Primary health centres viewed as a vehicle for programme and schemes, rather than as a provider of integrated care.

  • There is little financial support and encouragement of activities—like the OPD—from the authorities.

  • Primary health centres viewed with derision within the health system as a hospital that does not have many facilities.

  • Primary health centres viewed (by doctors) as place where professional support from peers is absent. Doctors work gets reduced to administrative work.

  • Few drugs available for curative care at these centres. The higher tiers better suited for curative care.

Health system
  • Non-incentivised OPDs get less attention

  • In coping with too many schemes and programme, health workers concentrate only on activities with targets

  • There is focus on reporting activities rather than doing them

  • There is no incentive for not referring/ treating at primary health centres

  • Doctors hesitate to take risks due to fear of punitive action and lack of peer support (nurses are protected by doctors to some extent)

  • Primary health centres viewed as a small hospital that has nothing much in terms of facilities or drugs.

  • Community finds very few services of primary health centres relevant to their basic curative care needs.

  • Primary health centres sometimes treated as a pharmacy to obtain a stock of drugs or tonics.

  • Mismatch on perceptions of what primary care entails—between community and the health system actors.

  • Community often does not understand the logic behind having many tiers of care. Community views referral with suspicion (as staff shirking their duty).

Expectations from primary healthcentres: Guaranteed presence of the doctor, attention from the doctor and other staff, strong drugs and more ‘variety’; all laboratory reports must come on time. Instant relief must be obtained; and the patient must not be asked to come again and again. Even if primary health centres are geographically a little distance away, these can be visited if the trip is worth the effort.
  • Healing norms in the community are oriented towards instant relief—this is mismatch with the practices at primary health centres. However, the local private practitioners cater to these needs.

  • There is wariness about public institutions and their employees in the community

  • Doctors at primary health centres process people in the OPD mechanically. Community not satisfied with such processing

  • Community dissatisfied with the experience at these centres nurse interaction; waiting time; staff’s way of speaking to them and delay in laboratory reports. (especially in contrast to private practitioners)

  • Community members demand clinically irrational treatments at primary health centres.

  • OPD, Out Patient Department.