Cross-sectional, hospital based study was conducted in two tertiary care medical college hospitals which were situated at two district headquarters in southern India. The Public Health model (PH model) hospital was fully controlled by the government whereas the public private partnership (PPP) model hospital was under the administrative control of the government with routine services being provided by the private medical college. The summary of the public private partnership model in one of the hospitals is depicted in [Table/Fig-1].

[Table/Fig-1]:

PPP Model

The sample was a convenience sample. Patients admitted between 10am to 12 noon on weekdays were enrolled. Data was collected after Institutional ethics committee permission by pretested questionnaires, filled by parents of inpatients from February 2011 to February 2012. Informed consent was obtained from parents of enrolled patients.

A minimum sample size of 448 in each hospital was required based on an earlier study done in a government medical college hospital in Northern India [8] that showed 74% satisfaction, to detect a difference of 10% in the satisfaction levels among the responders in the two hospitals with a power of 90% with a pα 5%.

Parents who left against advice (LAMA) (n=44 in PH and 19 in PPP) and parents of children who expired (n=25 in PH and 59 in PPP) were excluded from the study. Incomplete forms from PH (14) and PPP model (10) hospital were also excluded. A total of 461 in patients from the PH model hospital and 580 from the PPP model hospital were finally eligible to be included in the study.

Structured pretested questionnaire in local language Kannada was used to collect details of the perceived quality of health care. The questionnaire had domains regarding the location and accessibility of health facility, time spent waiting, manner and quality of physician, manner and quality of nurse, manner and quality of other supporting staff, perception of equipment, explanation of treatment details and the general comfort. Details of parent’s perception were rated on a 5 point scale ranging from 1-5 in each of these domains. Besides this the parent was also asked to rate the overall satisfaction on a scale ranging from 1-10. Four or more in the 5 point scale in each domain was considered good rating. Parents of patients were considered to be satisfied overall when they rated eight and more in the scale of 10 points. Questionnaire was filled by parents of paediatric patients at discharge and anonymity was maintained. A pre-trained medical social worker helped the parents in case they could not fill it by themselves.

Data were entered in SPSS version 17. Descriptive statistics like mean, percentages were calculated. Chi-square test and t-test were used to compare the data of the two hospitals. Binary logistic regression analysis was done to see if difference in patient satisfaction between the two hospitals was due to socio-demographic factors. Overall satisfaction was considered dependent and hospital type with various demographic factors as covariates. Age group was divided into newborn and child; socio-economic class by Kuppuswamy classification [9] into higher (classes 1,2 and 3 combined) and lower (class 4 and 5 combined); hospital stay into more than 10 days or less. The predictive value of the individual perception domains on the overall satisfaction was calculated for each hospital using binary logistic regression by entering overall satisfaction as dependent and each of the domains as covariates. The p-value of less than 0.05 was considered significant.

[Table/Fig-2] shows the comparison between PPP model hospital and PH model hospital with regards to clinical work, infrastructure, human resources and outcome. The PH model had greater number of inpatients and deliveries. However the overall intensive care facilities and were better in PPP model hospital enabling it to manage very sick children in contrast to PH model hospital.

Socio-demographic features of inpatients enrolled are depicted in [Table/Fig-3]. There were no significant differences in the age-group, sex and outcomes of inpatients of two hospitals. Socio-economic class and parental education were higher in parents of children admitted at PPP model hospital. Hospital stay at PPP model hospital was longer.

The parents of inpatients of PPP model hospital were significantly more satisfied than those of PH model hospital {O.R. (CI)=23.58 (16.13-34.48); p<0.001} even when controlled for age-group, sex, maternal education level, type of family, hospital-stay and socioeconomic class by binary logistic regression model.

[Table/Fig-4] shows comparison of perception among parents of inpatients admitted in two hospitals with regards to different domains. Among the category of responders who had overall satisfaction (satisfaction rating ≥8 in the 1-10 scale) from PPP model, perceived the care as good (rating ≥4 in the 1-5 scale) in most domains compared to their counterparts from PH model.

The domains of patient perception that were significant predictors of overall satisfaction are shown in [Table/Fig-5]. In PPP model hospital duration of time spent waiting for treatment and manner of other support staff were significant predictors for overall satisfaction while other domains were less influencing on parental satisfaction. In the PH model hospital counseling regarding treatment was a significant positive influencing factor of overall satisfaction. However, lack of equipment had negative influence on satisfaction in PH model hospital.

The present maiden study reports advantage of public private partnership (PPP) in improving functioning of a public tertiary care hospital with regards to perceived quality of care by the beneficiaries. There was significantly increased satisfaction level among parents of children treated as inpatients at PPP model government district hospital compared to the other directly managed and operated by the government (PH model). These differences were present even when the various demographic parameters were controlled thus indicating positive influence of the model in providing better health care. The overall satisfaction level among responders of PPP model hospital was 91.2% which was similar to 93% reported in a private-for -profit setup in India [10]. It was higher than 74.1% reported in another tertiary care public hospital [8] and 79.5% in a charity hospital [11]. A 97.4% of the responders in the PPP model hospital would recommend it to others compared to 91.2% reported in a private hospital of North India [10]. Thus associating a district hospital to a private medical college could be considered as one of the measures to improve health care delivery to poorer sections of the community.

A study done in Bangladesh comparing private and public hospitals reported better satisfaction of patients treated in private sector in all respects except physician attributes [12]. Thus the quality of patient care as evidenced by patient satisfaction in the PPP model government tertiary care hospital of the present study is similar to the private-for-profit sector with an added advantage of it being within the monetary reach of the middle and lower socio-economic classes.

The poor satisfaction and patient perception ratings noted in the PH model hospital of the present study can be attributed to increased workload, poor infrastructure, inadequate facilities and human resources [Table/Fig-2]. Similar observations were made in a study done in a public tertiary care hospital in central India [2].

In the present study, among the group of responders who were overall satisfied, there were significant inter-hospital differences in perception of parents in all the domains of care except towards physician attributes. This suggests inability to provide quality care by ‘doctor centric’ approach. In the group of responders from PH model hospital who was unsatisfied also perceived that hospital lagged in every domain except for physician attributes in addition to accessibility of health facility. Thus importance needs to be given to ensure paramedical and housekeeping personnel along with good uninterrupted logistic support. The above findings are in concurrence with studies which reported that patient dissatisfaction was due to factors other than nursing and physician care [2,11].

In the PPP model hospital, duration of time spent in waiting for treatment and personal manner of other support staff predicted overall satisfaction. This finding concurs with findings of studies done in different settings and in various countries [13–18]. A systematic review article also points that the public sector frequently lacks in timeliness and hospitality towards patients [19]. In the PH model hospital, the explanation of treatment details to bystanders had a significant positive effect and perception about lack of equipment had a significant negative impact on overall satisfaction. Physician communication and information given to patients has found to impact patient satisfaction in other studies [18,20]. [Table/Fig-6] compares the findings of the present study with studies done in private and public hospitals in similar settings [8,10–12, 21].

Various PPP models are being implemented in healthcare sector in India. Radiological, pharmacy, canteen services have been contracted out to the private. Services of private have been availed for emergency transport and mobile diagnostic/healthcare facilities. Chiranjeevi Yojna provides institutional deliveries to poor women through private obstetricians. Besides these health insurance schemes like Yashaswini involves private hospitals. The management of primary health centers, community health centers and super-specialty hospital has been outsourced to the private in several states [22]. [Table/Fig-7] compares the present model with the models where private organization runs the hospital services. The PPP model in the present study has several advantages. The government gains by reduced expenditure on salary head, high end treatment, available professional expertise and effective budget utilization. The trained doctors contribute to addressing the problem of shortage of doctors in the country. The private organization operates the medical college and gains in terms of available clinical material for teaching medical students and reduced capital expenditure. The private medical college runs the hospital services efficiently so as to ensure that there is an increased influx of patients to train its students and meet medical council requirements. The public gains by the advanced modalities of treatment at free cost or highly subsidized rates. This model could bring patients to the more affordable public hospitals thereby reducing families getting trapped in the poverty–illness-poverty cycle.

This is a cross-sectional study with a convenience sample of in patients. The differences observed in the two hospitals may be due to different expectations in the responders [23]. Since the study was questionnaire based socially appropriate responses cannot be ruled out. However this deficiency has been partially offset by usage of a 5 point scale.

In conclusion the perceived quality of health care as evidenced by the satisfaction and perception ratings of responders was significantly better with the PPP model hospital. This model could be emulated in other tertiary care public hospitals of developing countries.

Contributors: BSB conceived and designed the study, acquired data, involved in analysis and interpretation of data, revised it critically for important intellectual content; SRR analysed and interpreted the data, drafted the article; SSR and AJ co-conceived the study, acquired data; revised it critically for important intellectual content;, AC was involved in data acquisition and critical revision. The final manuscript was approved by all the authors.

The data used in this work is a part of the project titled: ‘Role of Public Private Partnership (PPP) Projects on health seeking behavior, health care expenditure and utilization of health services related to Childhood illness: A comparative study between two districts in a South Indian State. The above project was funded by the Indian Council for Medical Research (ICMR).