Each year 27 million children are born to India. Around ten percent of them do not survive to 5 years of age. India contributes to 25 percent of the over 6.9 million under-five deaths occurring worldwide every year. The quality of human resources of any country is largely determined by the quality of the child development services [1]. India is still lagging behind ideal health conditions as seen from infant mortality rate and under five mortality rate of 47/1000(2010) and 59/1000 live birth (SRS-2010) [2].

India has tried to cope up with these problems by formulating various national health programmes and strategies for prevention and control of under five mortality rates. The quality of care was emphasized at the International meeting organized by WHO in Almaty in 1998 to celebrate 20 years of the Alma-Ata Declaration [3]. Responsiveness, which is one of the three intrinsic goals of a Health system, could also be regarded as a measure of the quality of care.

Health care quality assessment and improvement has become a growing issue in health care system of all countries. Quality influences both health status and satisfaction. The quality of care generally means the degree of excellence of the medical care delivered. Quality is achieved when accessible services are provided in an efficient, cost-effective and acceptable manner. Quality is achieved when the needs and expectations of the customer are met [4].

Patient’s satisfaction is an important part of health care. It is also a measure of quality of care. Avedis Donabedian (1966; 1980) [5] described quality as including: structure (viewed as the capacity to provide high quality care), process (often termed as performance) and outcome.

As studies on child health care quality was not done previously in this region, the present study had been proposed to be carried out in Kamrup district of Assam to assess the quality of child health care services at primary and secondary level and to identify the weakness so that the appropriate measures might be taken to provide responsive and effective care to every child.

Study Design: Cross-sectional study

Service Input- The service input comprised of infrastructures, drugs & supplies, provider’s availability( skilled/ trained), and availability of protocols/ guideline.

Service Process- It includes the technical quality of service counselling (providing the clients with important information in an acceptable way) and procedure of delivery of services. It was assessed by an observational proforma (Checklists for CHC/ PHC & S/C).

Service Output- It includes the clients satisfaction level availing the child health care services at the Community health centres and Primary health centres. The interview schedule was prepared from Operational Manual of Quality Assurance for District Reproductive and Child health services in Public health system.

In the present study, for client satisfaction had been assessed by exit interview on the basis of 12 point scale & scoring system for positive responses. Based on the number of positive responses, services were categorized as ‘very good’ 10-12points graded as A; ‘good’ 7-9points as B; ‘average’4-6points graded as C; and ‘poor’ 1-2points graded as D.

The data had been collected by exit interview in the OPDs using pretested & predesigned structured schedule. The child health services include ARI, diarrhoea, immunization and others. Three clients were interviewed for each service area in each of the facility. Thus, a total 96 clients were interviewed for client satisfaction.

Statistical Analysis: The statistical analysis was carried out by using percentages.

The role of health manpower in determining the quality of health care is now increasingly appreciated. There were only 66.66% availability of Obstetrics & gynaecology specialist and paediatrician. Physician were available in 33.33% of CHCs. None of the CHCs had the available surgeon in position. Anaesthetist were available in 2 of 3 CHCs. The MOs were available in all the CHCs. Other supporting manpower including staff nurses, pharmacists/ compounder, lab.

The advice on immunization and follow-up visits as well as updated/ completed immunization card was also found to be 100% at all the S/Cs. The drop out rates were also traces by the ANM. Anganwadi workers and ASHA also were found to be participated during the immunization sessions at all the Sub-centres.

Table No 7 shows the distribution of CHC and PHC according to the availability of equipment and supplies. From the table, it had been observed that the availability of BP apparatus with stethoscope and weighing machine (adult/ infant) were available to all the CHCs and PHCs. The autoclave/ boiler were available in 66.66% of CHCs and 60% of PHCs.

The complete delivery kits were available in all the CHCs and PHCs. The sterile MVA syringes were available in 66.66% of CHCs and none of the health care facilities had the available EVA. The paediatric resuscitation kits were available in all the CHCs and PHCs.

Table No 8 shows the distribution of clients satisfaction on child health care services at Primary health care centres. The shows that the satisfaction level of clients on child health i.e on ARI 03as ‘very good’ and 08 as ’good’; on diarrhoea ‘very good’ 01,’good’12; and ‘average’ 07;on immunization ‘very good’06, as good’12, as ‘poor’02; on others ‘very good’05, as ‘good’04.

So, out of 60 clients 11 had’ very good ‘level of satisfaction, 36 had ‘good’, 07 had ‘average’ and 02 had ‘poor’ level of satisfaction on child health care services at Primary health care centres.

Table No-1: Distribution of Manpower at the CHCs and PHCs.

Table No-2: Distribution of Manpower at the Sub-centre

Table No-7: Availability of Equipment and Supplies at CHC and PHC.

Table No-8: Distribution of client satisfaction on Child health care services at Primary Health Centre

The role of health manpower in determining the quality of health care is now increasingly appreciated. There were only 66.66% availability of Obstetrics & gynaecology specialist and paediatrician. Physician were available in 33.33% of CHCs. According to Facility Survey (2003), reported that the specialist Obs/gynaecologist (51%) and paediatrician (54%) were available at CHCs in India.

The staff nurse (83%), pharmacists (81%) and laboratory technicians (87%) were available at CHCs in India. The National Commission on Macroeconomics and Health Survey (2005) showed that in CHCs alone, there is a shortfall of 62% sanctioned posts of specialists and of the remaining 38% are lying vacant.

Kapilashrami MC observed [6] that doctors, if posted doctor prefer to sit in their private clinics even during working hours.

Health systems have to be responsiveness to the needs of the customer satisfaction and the community [11]. Ray SK (2004-05) reported in his study that inadequate waiting space and unusable toilets at BPHC and S/C level in three districts in West Bengal.

Agarwal M et al (2001) in their study reported that the facility of separate room for consultation was totally absent in rural areas and at health posts. According to Facility Survey (2003), reported that 31% had separate LR, 55% had separate toilet with running water, 56.1% had drinking water facility at CHC level.

At FRUs, 53.3% separate aseptic L.R, 62.6% separate toilet with running water and 50.9% of water facility. In the present study at PHCs level only 60% facilities had bed with mattresses, rubber cover and sheets for the clients. At all India level (2003, facility survey), reported 48.4% having LR, 66.5% water supply, 52.3% toilet facility and 71.3% had at least one bed at PHCs.

In Assam, 85.02% having water supply, 56.21% LR facility, 37.59%and 41.70% having at least one bed at PHCs (Facility Survey, 2003). The toilet facility and curtain on windows to ensure privacy for the clients comfort had been observed in 70% of the Sub-centres in this study. None of the S/Cs had the electricity facility with backup.

The sitting arrangements and drinking water facilities were available in all the S/Cs. By facility survey 2003, reported 78.8% having drinking water facility, 73.6% toilet facility, 43.1% had electricity facility at S/Cs level. In the present study, the infection prevention supplies at CHCs and PHCs were available. Sharma P et al [18] also in their study reported non-availability of disposable gloves and antiseptic solutions at the health facilities.

In the present study, it had been observed that all the CHCs and PHCs had well maintained the immunization service delivery. The post immunization advice regarding side effects and follow up were observed in only 66.66% of CHCs and 60% of PHCs. The vaccines logistics and supplies were available in all the health care facilities.

Agarwal M et al, 2004 reported only 30% of clients were advised about importance of completing vaccination schedule in comparison to 73,3% among urban clients, only 2/3^rd clients were reminded about the next visit.

None of the S/C s had the available supply of paediatric resuscitation kit, labour table, step stool. In a study conducted by Agarwal M et al in 2001, stated that only 66.66% had stethoscope and BP instruments, weighing machine available at S/cs.

By facility survey 2003, reported 86.7% & 84.9% had infant & adult weighing machine, 65.9% BP apparatus, 79.5% stethoscope available at S/Cs in India. Steefland et al (1999) 14 in a multicounty study for assessment of EPI services found shortages of needles in two out of seven centres and syringes in four out of seven centres in Phillipines. The assessment of client satisfaction is inevitably subjective, because of educational, social, economic and linguistic differences between health professional and their clients.

The perception of quality varies from person to person according to individual’s knowledge, values and resources (Humberto de Novaes, 1993). In this study, most of the patients were satisfied with child health care services at the health care facilities. By B S Akoijam et al (2007) [21] reported that most of the patients were satisfied with overall care received by the health care provider at the tertiary care hospital.

By Banerjee B (2003) [20] in their study found that the main deficiency regarding days and timing of the availability of specific services and the location of different service outlets within the centre by the clients.

The present study concluded that the quality of child health services were average at CHCs, PHCs and S/C level. The child health care activities that observed at the CHCs and PHCs in areas of immunization services and cold chain maintenance was found to be satisfactory.

Recommendation: Based on the studies the following findings are recommended-

 - The infrastructure gap of S/C,PHC,CHC should be met.

- Available untrained manpower should be trained and vacancy should be filled-up.

- There must be periodical orientation of medical as well as paramedical staffs at the health care facilities.