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

Introduction: Healthcare service is an essential determinant to population health. This qualitative case study aims to explore health service users’ perspective of effective health services delivery and the current challenges affecting the management and delivery of health services at a primary healthcare facility in Madang Province, Papua New Guinea (PNG). Methods: Qualitative data were collected using semi-structured interviews with key informants (KI) representing academics, undergraduate students, administration staff, patients and healthcare workers. The interviews covered three main areas: users’ views of effective health services, current challenges affecting effective planning and management of primary healthcare services, and interventions to improve health services planning and delivery. Results : The services users associated effective health services delivery with increased availability, accessibility, acceptability, and quality healthcare. Many factors exist to influence the effective planning and delivery of health services. The results show that health systems and personal factors have a major influence on the planning and health services delivery. Conclusion : The findings 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 meet the needs of the service users. We concluded that if health services users’ perspectives are considered in health policy, the local community may experience significant improvement in health status.


Introduction
Healthcare service is an important determinant of community health 1 . Globally, many healthcare providers aim to provide effective health services to improve the health of their citizens. Since the introduction of the primary healthcare (PHC) approach of healthcare delivery in 1978, the global community has witnessed significant improvement in population health 2 .
These improvements include the prevention of infectious diseases (tuberculosis (TB), HIV, malaria), reduction in mother and child deaths, eradication of smallpox, advancement in medical technology, and increased consumer participation in health service planning and decision-making 3 . Despite, these notable changes in the global community, weak health care systems in low and middle-income countries have prevented the local community from accessing health services. Numerous literature found that the prevailing country's economic, cultural, geographical, and political situations have major constraints on access and use of healthcare services [4][5][6] .
Papua New Guinea (PNG) healthcare system is struggling to deliver adequate healthcare services despite having a growing economy in previous decades 5,7,8

. The Asian Development
Bank reported that most of the health institutions have deteriorated affecting access to health services particularly the rural population 9 . Further, WHO (2018) categorized PNG among the top ten countries with a high burden of TB 10 . According to WHO, a good healthcare system provide quality health services that are readily available and accessed by the local community when they need them 11 . WHO further elaborates that quality health services are a key driver to improved health outcomes and lead to greater organizational effectiveness in planning and organizing healthcare services.
In contrast, the provision of effective public and clinical health services is a difficult task and has never been easy for health services providers 12 . Many authors dispute the meaning of effectiveness and its practicality and application at the point of delivery [13][14][15] . Many types of literatures associate effectiveness with numerical values, such as accomplishment of established targets and measuring the percentage of money spent on health service against planned activities. As a result, it does not represent the true picture of overall health services, and most importantly, the ingredients of inclusive and integrative views of the general population are ignored and grossly abused, particularly the views of the health services consumers on the current state of health knowledge 16,17 . It is therefore proper to investigate the definition of effectiveness in line with the current practice and health knowledge of people accessing health services. In Berman et al. 18 opinion, effectiveness should be defined by health services users' interpretation and understanding, and determine if there are any real health benefits and improvement to the health of the individuals and community through the health services provided by the healthcare system. Regmi 14 further argues that health services consumers' opinions and experiences can be useful for planning and scaling up health interventions.
The World Health Organization (WHO) associate effective health services with affordability, acceptability, availability, accessibility, and quality 19 . Quality healthcare is defined as a wellfunctioning health system working in harmony and 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 19 . Further, quality healthcare is one that is affordable with minimum cost, culturally acceptable to patients; basic services are available, and can be easily accessible when needed. In contrast, ineffective health services delivery is a main concern for many countries, particularly in low and middle-income countries (LMICs). Thus, the healthcare in LMICs is characterized by high cost of clinical care, poor access to basic drugs, inappropriate provision of health services, and absence of basic healthcare at the PHC level 19 .
The healthcare workforce is the vital domain of the healthcare system globally. Studies have shown that the availability of health workers increases access to health services 12 21 . These studies found that the lack of health workers in rural areas reduces access to health services. WHO (2009) asserted that other factors like health systems strengthening, governance, and community participation in the planning of health care services are equally vital for an effective healthcare system. Healthcare providers face an increasing demand from the public for access to health care and use of new equipment, new treatments, and use of the new model of care, at the same time expected high demand on the quality and safe care 22 .
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 the 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 specific groups of patients 17 Additionally, this study discovered several main concepts related to patients experiences including improved communication, desire to be treated with respect and dignity, need for coordination across the different levels of healthcare, and the desire for more personal choice and decision.
Numerous studies 17,18,23 have specifically examined the effectiveness of healthcare service delivery and management. This study done by Regmi 18 in Nepal 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 24 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 planning and management 17,25 , their voices are not always heard and included in the planning and management of health services. In PNG, there is a lack of data on users' perspectives of effective health services delivery. This study aims to explore users' perceptions of effective health services delivery and challenges affecting the planning and delivery of health services at the PHC facility.
We believe that an integrated approach to planning and managing health services using users' experiences provided a strong foundation for planning healthcare. Nevertheless, users' experiences of healthcare are under-discussed in the PNG health sector. There is an urgent need to discuss such a context from the users' perspective. A research conducted by Regmi 18 on the effectiveness of health services provided insights on barriers and facilitators to effective health services 18 . However, few studies on health services users' perceptions of efficient health services were done in PNG sites despite studies in other developing countries such as Nepal 18 . The purpose of this research is to explore users' views of effective health services and investigate barriers or challenges affecting the effective management of health services. The findings 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 26 the purpose of a social constructionism approach is to construct social context and social reality. Guba and Lincoln 27 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 28 . Boyland 26 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 26

Study setting
PNG is located on the northeastern end of Australia and is the largest island country in the Pacific region in terms of its landmass and economy 8

Organization of healthcare services in PNG
Healthcare services in PNG are provided through a network of unified structure 8 . 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 9 . Health employees that provide health care include community health workers, nursing officers, health extension officers (HEOs), doctors and other support services staff 30 . The Aidpost serves a catchment population of between 500 and 1500 at the community level 8,9 . 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 31   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 April and August 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 34 . The final 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 fixed 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 34 . 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' reflection on health services users' perceptions (Box 1). The same topic guide was used for all participants to allow flexibility 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 35 . Based on the results, the guide was slightly modified for use in the selected study site. The interviews were conducted at the location selected by the participants. The academics were interviewed in their office 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

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

Study limitations
This study has several limitations. First, the study site is limited to a level 1 health facility.
Therefore, the findings 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 find 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 reflect 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 benefit the nearby community. 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 significant 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  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 influence 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 significance 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 confident 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. This situation was largely inefficient, 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 reflected 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 reflected the core attributes of quality healthcare that is measured by six domains: safety, effectiveness, patient-centeredness, timeliness, efficiency, and equitability. Healthcare quality remains an important discussion topic for both clinicians and patients 38 .

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 difficult 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 affirmed that there is no formal arrangement with the university administration for overtime work during these hours as highlighted by the users. As such, they affirm 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 officer at the clinic would address the accessibility issues raised by the users. 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 38

Inadequate health services infrastructures'
The 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 study highlighted the significance 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 significant 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 efficient health services and obtained multiple theories associated with healthcare delivery. Berman et al. 25 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 efficient 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. 25 and Suman & Bhutani 41 that utilizing a combination of financial, physical, and human resources may promote organizational effectiveness. Berman and colleagues concluded that improving organizational performance is a significant 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 efficient healthcare delivery.

Methodological 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-ofsemester 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 7 , and therefore, policymakers, health managers, and clinicians in other health settings may find 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 findings 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.