Health systems responsiveness refers to the legitimate expectations, usually the non-health (behavioural) dimensions that the users of any health system may have during their interaction or contact with the system itself. The AP Health Systems Responsiveness Survey collected information on several aspects of individuals perceptions regarding their usage of and interaction with the health systems. A time window of the previous 12 months was determined while asking questions relating to their personal experiences of the health system.

Of all the respondents that were interviewed, 66.4% had actually received any form of health care during the past 12 months from the time they were interviewed. 69.9% of the females and 62.4% of the males that were interviewed had received some type of health care during the past one year. This number seems to be very high. But there is great possibility that people may have included any sort of preventive health care, like immunisation, health campaign programmes, etc., as receiving health care.

When we look at the people that have been using home care they seem to constitute a very small percentage of all of the respondents. They constitute 2.8% of all the people that have been interviewed. When we look at who are using these services we find that 3.6% of all females and 1.8% of all males are using home care services. We also see that the major usage is in the rural areas. This is consistent with the fact that home care is provided by regular visits from the ANMs (auxiliary nurse midwife) from the primary health centres and subcentres. This facility is not available in the urban areas. The small proportion of urban people that are receiving home care may primarily be from family physicians, neighbourhood physicians or other health providers.

60.2% (3093) of all the respondents, interviewed, have received health care on an out-patient basis. This confirms our earlier hypothesis that most people have been using health care on an ambulatory basis. Of course, these people may also be availing some home care service as well. Most of the primary health centres in the rural areas do not have proper facilities for hospitalisation. People in the urban areas have access to health facilities and do not prefer to be hospitalised unless they are forced to.

Of all the respondents only 427 had been hospitalised (stayed overnight) in any health care institution. This is around 2.8% of the whole sample. This shows that most of the health care received by people is not primarily at home. People may be preferring to receive health care on an out-patient basis unless otherwise required. We also see that the rural people to have used the overnight facility more than the urban people. Rural persons may be resorting to a safe practice of recovering well before returning back home. We also see that the more females belonging to the rural areas are staying overnight in health care institutions. This pattern of females staying overnight in health facilities more than males has also been studied in other studies (PSS, APVVP, 2000). The reason has been attributed to the fact that females generally prefer to stay in health facilities as they do not have other people to care for them and generally are able to receive some rest from house-chores while sick. When the male members are sick they can expect the women members in the house to take care of them and as a result do not prefer to stay overnight in hospitals/health facilities.

We also looked at when was the last time people had visited a health facility for their health needs We found that 24.2% of the respondents had made a visit within the last 30 days of the interview, 19.4% had made a visit within the last 3 months, 8.6% within the last 6 months, 6.5% within the last 6-12 months and 1% could not recollect when they visited during the previous year. Here we see that 60.8% of our urban sample and 61.7% of the rural sample had made a visit to any health facility during the previous year.

In order to be able to assess the dimension of prompt attention, we looked at the average time that people took to reach a destination of health care facility from the time a health need arose to the time they were actually able to get health care. This also we catergorised in terms of setting as well as gender. We saw that of all the respondents that actually used any health care service, the average time taken for any urban female was 56.4 minutes and for an urban male was 55.2 minutes. There is not much of any difference between urban male and urban females. The average time taken for any average urban person to reach a health care facility and get first contact is 55.8 minutes. Looking at the substantial growth of the private health sector in the urban areas, the average time looks to be quite reasonable. This indicates that the access to any health care facility is quite good in the urban areas

When we look at the rural group we see that the average time taken for any rural female is 157.2 minutes or approximately 2 hours and 37 minutes. For the rural male it is 126 minutes or 2 hours and 6 minutes. The average time taken by any average rural person is 141.6 minutes or approximately 2 hours and 21 minutes. The difference between the rural male female is 31.2 minutes. The difference between the urban average and rural average is about 85.8 minutes or approximately 1 hour and 25 minutes. Looking at the low distribution of health facilities in the rural areas the average time looks to be quite encouraging.

Closely linked to the previous issue of access to health care is the next question of interest. We found that 34.3% of the respondents that used any health care always received the care as soon as they wanted, 22.1% usually got it as soon as they wanted, 4.1% sometimes got it and 0.9% never got it as soon as they wanted. This approach has always been a tricky one because, one is never able to know the difference in expectations of people in different setting and different socioeconomic groups. The fact that more rural people feel that they always received health care "always" as soon as they wanted does not mean that the access to health service in the rural areas is much more and better organised than the urban area. It may be possible that the expectations of the rural population is so less that they may not even be having any so called "legitimate" expectations. Empirical evidence has been confirming that the higher the socioeconomic status and higher the awareness, the higher is the expectation from any health systems (Murray & Chen, 1992).

Respondents that availed ambulatory care, inpatient care, home care etc., were asked to report their personal experiences regarding all the eight dimensions in one of the five categories ranging from very good to very bad.

There was some attempt to find out which of the eight dimensions were rated as most important and least important by the respondents. This will give an insight as to what is valued more over the other by the community, which subsequently can be determining factor while planning and organising the health services. Of all the respondent that gave a rating of most important, we found that 53% of the respondents gave a rating of most important to prompt attention, 23% to communication, 14% to dignity, 3% to choice of provider, 2% each to social support, basic amenities and confidentiality and 1% to autonomy over treatment. It is clear and evident that the top three most important dimensions as rated by respondents are prompt attention, communication and dignity. Access to health care services is still an issue that has to be dealt with in order that people are able to get health care as soon as they need them. Here, the issue is not just physical distance, even though it is a significant one. Access to health services also refers to the psychological and behavioural barriers that people may have in not being able to access health care services.

While looking at the percent distribution of all the least importantly rated dimension we find that social support has been rated by 38% of respondents as least important, 4% for communication and choice of provider, 9% for dignity and autonomy over treatment, 8% for confidentiality, 7% for basic amenities and 2% for prompt attention and then to communication. Here, it has again been confirmed that respondents give maximum importance to prompt attention. Choice of provider is not an issue that respondents are worried about. Autonomy over treatment is still not an issue too in a culture where people think that the doctor knows what is best for them.

As has been emphasised before one of the goals of any health system is financial. This means that any health systems should work towards moving in a direction so as to protect interests of the general population, especially the economically impoverished. If the health system has been structured in such a manner that it has a tendency to exclude a chunk of the population, then it is not serving its purpose. If someone has to pay a catastrophic price to receive any health care then also the health system is not serving its purpose. In order to know whether the health system is actually fulfilling its financial goal a question was asked to all respondents, that had a health need, if they were ever refused health care because they could not afford it we found that 15.6% said they were actually refused health care because they could not afford it. Most of them from the rural setting. 17.9% of the rural people were refused when they sought health care, while 8% of the urban people were refused while seeking health care. Table 22 has the details.

We also wanted to know how many persons actually did not seek any health care in spite of having a health need because they could not afford it, we found 36.3% of the respondents had, in the last 12 months, not sought any health care because they could not afford it. 41.1% of our rural sample and 21.2% of our urban sample did not seek any health care because they could not afford it. This is a highly alarming number. But one should be cautious here that these persons have actually not sought any health care because they thought that they could not afford it. In any case if persons have such perceptions about health systems, it is also some food for thought for health planners. No matter how good a health system is, if it cannot gain the trust and faith of its users it is not worth it.

In both these findings one finds a big difference between the rural and urban population in terms of their health seeking behaviour. The urban areas have a lot of public hospitals that are well equipped to deal with any emergency situation, while the public health care institutions in the rural or semi-rural areas are not well equipped. Hence, rural people tend to rely on the private health care institutions for any health need. Our surveyors collected a lot of qualitative information regarding the health seeking behaviour which was later compiled through a focus group discussion. The respondents while answering this question mentioned that they could not rely the primary health centres for any serious health need and preferred to go to a private clinic or provider who would dispose them quickly with pills or injections. This would enable the people to get back to their work soon.

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