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ORIGINAL ARTICLE

Asian J Gerontol Geriatr 2006; 1: 13340

133Asian Journal of Gerontology & Geriatrics Vol 1 No 3 December 2006

Understanding elderly clientsatisfaction with primary health carein rural Bangladesh

P Biswas1MAP Lloyd-Sherlock2PhDS Zaman3PhD

ABSTRACT

Objective. To examine the elements o patient satisaction that aect andinuence health care utilisation by elderly people in rural Bangladesh.

Methods. Based on the Primary Health Care in Later Lie: ImprovingServices in Bangladesh and Vietnam (PHILL) projects qualitativebaseline study o older individuals and their caregivers in our villages

in the southeast region o Bangladesh, this study conducted six ocusgroup discussions and 30 in-depth interviews at village and householdlevels between February and November 2003, in a sample o elderlyindividuals and caregivers aged 60 years or older. A non-randomstrategy o sampling was used to achieve maximum variation or genderand economic status. Both physical and mental abilities o elderlyparticipants were considered while selecting respondents.

Results. Mobility, cost and payment exibility, and cultural perception omedical outcome are primary determinants o satisaction and utilisation.The private sector is more successul in meeting the particular demands oelderly satisaction, i.e. better availability and exible payment systems.

Conclusion. The private sector health care system has much to oer thegovernment system as it attempts to address the needs o the elderly.The elderly are highly heterogeneous and vary greatly with regard tosocioeconomic status. The user ee structure o the public health caresystem should reect this reality. A possible eective strategy would beto provide ree health care services or the poorest and most vulnerableelderly, and at ull cost or richer patients. Flexibility in the paymentsystem is vital. In rural amilies ability to pay or the health care is otenseasonal, especially or those engaged in agriculture. Credit purchaseor medicines and health care thereore appears attractive. There is

a critical need to coordinate between these private and public sectorprimary health care, especially with regard to specifc training needso local village providers, establishing an eective and timely reerralsystem to channel elderly patients to the public sector, and introduce amuch-needed preventive health care.

Key words: Aged; Bangladesh; Patient satisaction; Primary health care

1 Overseas Development Group,University o East Anglia, Norwich,United Kingdom

2 School o Development Studies,University o East Anglia, Norwich,United Kingdom

3 Researcher, BRAC, Bangladesh

Correspondence to: Priti Biswas, OverseasDevelopment Group, School of DevelopmentStudies, University of East Anglia, Norwich,NR 4 7TJ, UK. E-mail: [email protected]

INTRODUCTION

In most developing countries, changing demography

has been associated with increased average lie

expectancy and a higher proportion o elderly (>60 years) in the population. This increased number o

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Biswas et al

old people creates a unique and growing pressureon public health care delivery systems. More than inthe past, primary health care providers ace a rangeo illnesses and physical and mental conditionsprevalent in old age. The challenges posed bythe latter disorders dier rom those o the wider

population, with respect to both the type o illnessand certain associated constraints.

Primary health care has been defned as essentialhealth care based on practical, scientifcally soundand socially acceptable methods and technologymade universally accessible to individuals andamilies in the community. Moreover, it must be ata cost the community and country can aord andsustainable in the spirit o sel-reliance and sel-determination.1

The reality o primary health care or older people varies dramatically rom one society to another. Inmore-developed regions, primary health care isprovided by institutional networks that are moreor less sustained by public support, and servicesare sought rom them by elderly individuals. In thedeveloping world, the picture is rather dierent, asthe modern health care system might not be the frstpoint o contact or an elderly person. Insufcientknowledge about their health needs and their lacko autonomy are constraints that aect health caredecisions o the elderly.2 Furthermore, such decisionsare oten embedded in the wider amily circle o theelderly patient.3

In the reality o village lie, the elderly peopleare serviced by both public and private healthcare providers. In many developing countries, thepublic sector has attempted to expand its share oprimary health care in rural areas, but still suersrom underutilisation.4,5 In this regard, patient/clientsatisaction has become an important indicator othe perceived quality o health care inuencingservice utilisation. In the developed world, the ocuson patient/client satisaction in the health sector wasrelated to marketing and health care accountability.6National health care systems in the developing worldare only now becoming more sensitive to the needor more client-based delivery approaches.7,8 Withthis aim client satisaction with primary health careservices has to be multidimensional and vary within

each cultural context and according to actors such asage and gender.9,10

With an estimated 141 million people, Bangladeshis the eighth most populous country in the world.11,12Except or some small island states, it has the highestpopulation density in the world and according torecent statistics it is also one o the poorest; currently,one third o the population lives beneath the poverty

line, earning less than USD1 a day, and 85% o thepoor reside in rural areas.11,13 Decreased ertility14 andimproved lie expectancy15 has rapidly increased thenumber o elderly people, now 6% o the population,or 7.3 million inhabitants. Bangladesh thereorehas one o the largest populations o elderly in the world, and the number is projected to more thandouble by 2025.16 In Bangladesh, the health caresystem is comprised o a range o public and privatesector health care providers. The public sector isorganised into our distinct tiers: medical college

hospitals, district hospitals, Thana Health Complexes(THC), and union health and amily welare centres(UNHFC). Private sector providers include non-governmental organisations (NGOs) and other non-proft entities, traditional and homeopathic providers,qualifed pharmacists and unlicensed drug sellers,qualifed and unqualifed modern care providers, andgovernment doctors engaging in private practices.13

Public sector primary health care services inBangladesh are provided through three main typeso health institutions: (i) the THC, designed tobring the primary health care to rural people; (ii)the UNHFC, also known as Family Welare Centresthat provides amily planning out-patient services atthe union level; and (iii) hospitals and clinics, whichserve as reerral points or primary health care. Aso 2000, Bangladesh had 460 rural thanas and 402thana-level health complexes. Government healthexpenditure has slightly risen recently and in 2002 was estimated as Tk.180 (US$1=Tk.59) per capita.The country has 3083 persons per hospital bed and4521 persons per physician.17 At the same time therehas been a dramatic expansion o primary health careinrastructure into rural areas, with important resultsin, or example, maternal care and amily planning.Nonetheless, Bangladesh is not meeting its statedgoal o comprehensive coverage reaching vulnerablegroups, like elderly people.18 One reason being thelack o any national policy or the elderly population,19in the absence o which, existing inrastructure hasbeen characteristically underutilised.4,20 Despite

the increased number o newly established thanahealth centres, their stafng with skilled medical

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Understanding elderly client satisfaction with primary health care in rural Bangladesh

proessionals remains a big challenge.21 Skilleddoctors oten are unwilling to work in rural areas,as a result, there is a decline in public confdence insuch primary acilities.22Very little attention has beendevoted to the actual quality o service delivered inthese health care outlets, or to how wide a range o

patients are covered by them.

This current system is supported by a combinationo government and donor investment. The closestpoint o access to this system is at the thana or unionlevel; however, the primary services oered at thesepoints are mainly concentrated on mother/childhealth and amily planning.23 World Bank and otherreports systematically document the absenteeism omedical proessionals, especially in poorer villagesand unions.22,24 With regard to maternal care, it points

to the structure o the Ministry o Health and Family Welare itsel as a cause o waste and inefciencyin health care delivery. The Health and PopulationSector Strategy states that the current structureunctionally impedes reerrals, generates conicts,and thus contributes to the low utilisation o publicacilities.25 Further evidence shows that althoughgovernment health acilities are supposed to providemost services almost ree o charge, inormal andunofcial charges can be as high as ten times theofcial rates.4,26,27 Andaleeb28 thereore argues thatcurrent shortcomings in the provision o publicprimary health careincluding poor responsivenessto patient needs, ineective communication, andcorrupt practicesaect its perceived quality, andthus the levels o satisaction and, ultimately, levelso utilisation.

The second option in rural areas is the networko private service providers, which includes ruralmedical practitioners (trained and non-trained),homeopaths, traditional healers (e.g. kabiraj, ojha,etc.), and medicine shopkeepers and drug retailers.Despite the signifcant eort and investment o thegovernment to create an eective and universalpublic sector health care system, the private sectorstill provides the majority o actual care in rural areas.For instance, in 1997, the private health care sectorsupplied over 71% o the total value o health services(value o health services or each provider as measuredby payments made by patients or by the governmenton their behal), with drug retailers accounting or a

ull 46%.13

As the private services are non-subsidisedand depend on income rom clients, they are more

responsive to customers expectation.29 Generally, inrural areas they are well known to village residentsand are easily accessible. Private service providers,or the most part, have not had ormal medicaltraining, and many have acquired their knowledgeand skills through intergenerational transmission.

However, this system constitutes the frst point ocontact when illness occurs. I the problem can beadequately resolved at this village level, the patient will not consult the public sector. Although NGOsaccounted or only a small share o the health servicedelivery (3% in 1997), their role in health promotionhas been very important, especially with regard tocontraceptives use and oral re-hydration therapy.Non-governmental organisations in Bangladeshenjoy the reputation o having intimate knowledge ograssroots realities and eective community contact,

greater accountability, exibility, and innovativeness.This makes them better positioned to act as localservice providers.12,13

This paper explores the determinants o elderlysatisaction as it relates to experiences with theutilisation o public and private health care acilities.Using qualitative feld data rom rural Bangladesh, itassesses how and why the elderly choose betweenprivate and public health care providers.

METHODS

This paper is based upon a qualitative baselinestudy o primary health care or older people inrural Bangladesh.30 It was carried out in our villagesin Chandpur Sadar Thana, Chandpur district, insoutheast Bangladesh. Since the study largelyexplored attitudes and perceptions regarding healthcare decisions, a qualitative research methodology was adopted. The qualitative tools included ocusgroup discussions (FGD) and in-depth interviews atthe village and household level. The sample consistedo elderly individuals aged >60 years as well as theircaregivers. Sampling was non-random, purposive,and opportunistic. The researcher team sought outsources o maximum variation, such as gender andeconomic status, and ensured that older women as well as older men rom dierent wealth categories were included. The team also took advantage ointerviewing opportunities, which arose in the courseo feldwork. For example, i the selected individual

was absent, unable or denied participation, anotherindividual ulflling the research selection criteria,

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who was present and keen to be interviewed, wassubstituted. Both the physical and mental abilitieso elderly participants were taken into consideration while selecting respondents. During the feldworkphase, six FGD and 30 in-depth interviews wereconducted; typically they involved elderly individuals

and their caregivers, with an average o fve personsper session. The interviews were semi-structured andinormal, and respondents had ample opportunity totalk about issues in a exible, riendly environment.The qualitative data collection took place betweenFebruary and November 2003.

The feldwork explored the determinants osatisaction with health care in two interrelated ways.First, respondents were asked to discuss/evaluatetheir level o satisaction with the health care

they received. Second, it analysed the underlyingreasoning by which elderly people make healthcareseeking decisions. Although such decisionsare multidimensional, according to recent literaturepatient/client satisaction evidently has a majorimpact on patterns o utilisation.28,31,32

Previous studies suggest that satisaction isrelative33 and that its central dimension dependson patient expectations, in the sense that iexpectations are met satisaction is experienced.34-36In the context o marketing studies, there has beenwide use o disconfrmation theory to explain clientdissatisaction, but some have argued that thistheory is not easily applied to the health care sector.As Newsome and Wright34 state: health care is nothomogeneous; it is a distinctive, complex mixtureo emotion. Hence its tangible and the intangibleconsumption cannot be viewed in entirely the samelight as or a consumer product, such as a televisionor a washing machine.Schneider and Palmer10 argueuser opinion in health service quality assessmentis a social rather than a technical phenomenon.Moreover, use o quantitative questionnaires tocapture satisaction with health care services inindustrialised societies has been criticised or theirinevitably limited and simplistic approach to theexpression o satisaction. Williams6 emphasises thatpatients/clients maintain a complex set o importantand relevant belies which must be understood inattempting to assess client satisaction. In this regard,qualitative research methods oer a greater potential

or exploring belie systems and relating them tohealth care behaviour.10,37 In this study, or example,

the heterogeneous nature o the existing primaryhealth care services in rural Bangladesh as well asthe unique socio-cultural characteristics o this ruralpopulation are explicitly addressed in the qualitativemethodology.

Ater a review o available tools and techniques inthe feld o such qualitative research, a multimethoddata collection strategy was devised, or both thekey inormant in-depth interviews and FGD. Thesetechniques were employed with elderly respondentsand main caregivers in the study area to gather a widerange o perspectives on the relevant issues. Eachindividual was interviewed at his/her own premisesat his/her preerred times. Several respondents wereinterviewed several times on dierent topics relatedto their health care using personal experiences,

preerences, and satisaction. These iterativeinterviews created a unique opportunity to pursueimportant themes more systematically.

The research team did not ask individuals directquestions about whether they were satisfed with aparticular source o health care service in the area.Rather, individual and household satisaction wasintroduced as part o the discussion regarding theutilisation o health care services. Thus, insights intosatisaction were ramed within an inormation owon how dierent sources were accessed. Admittedly,there are analytical challenges related to the inter-pretation o satisaction rom the perspective oboth interviewer and interviewee. However, it was elt that subjectivity was minimised simply bynot introducing direct questions using the termsatisaction. Without any pre-established criteria, therespondents were ree to express themselves anddiscuss their satisaction at multiple levels.

The resulting qualitative data set was processedusing text analysis techniques. Within the widerange o recorded responses, repeated patterns wereidentifed and underlying reasons explored. Thetext was reviewed several times to understand thecontexts o similar responses.

RESULTS

The data rom the qualitative interviews suggest thatpatient/client satisaction varies signifcantly between

public and private providers. In rural Bangladesh,satisaction with primary health care was based on (a)

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a rational evaluation and (b) an emotional reaction tothe structure, process, and outcome o services.38 Therational component o satisaction was usually statedin terms o the medical outcomes and whether thepatient considered the services to be adequate andappropriate. The emotional component was relatedto such things as responsiveness, respect, and

politeness.7

The comparison o elderly client satisactionbetween the public and private health care providersystems (Table ) identifed three actors that seemto determine satisaction with regard to this patientgroup. These actors were: mobility and access, costand payment exibility, and cultural perceptions othe medical outcome.

Mobility and access

Particularly in Bangladesh the mobility o the elderlyis a signifcant constraint. The necessity o travel toa THC or any other public health care acility was asubstantial burden or elderly individuals and theiramilies, not only because o the demands or travelbut also due to lost time (oten in waiting to beattended). By contrast, private sector health providersare available in villages and bazaars (i.e. located nearerthan public services), and most importantly, theycommonly make home visits to care or the elderlypatients. In the respondents words: The doctor (amedicine shop owner) is known to us, so we go tohim, we can get medicine on credit and he respectsolder persons. I needed, he makes home visits to seeolder patients...the doctor gave good medicine andI took expensive medicine too, with the blessing oGod I am ok now...(a 62-year-old male). For oldercouples living on their own without adult children,proximity is even more critical as sometimes an olderperson has to call upon the doctor at home. As one75-year-old male respondent living with his elderly

wie put it: When I eel ill, I ask my wie to call thatdoctor (a rural medical practitioner)...my wie calls

him and he comes whenever called...we are happywith his service.

Cost and payment fexibility

Related to the mobility actor is the cost o treatmentand exibility o payment. A major characteristico the elderly in rural Bangladesh is their fnancial

instability. Elderly pensions are inadequate relativeto rural livelihood needs. Since most amilies dependupon agriculture as their main source o income, cashavailability varies widely over the course o the year.Furthermore, many elderly rely upon remittancesprovided by migrated children, which is also anuncertain source o support. Thus, any additionaland unexpected cost associated with illness places asevere burden on the elderly individuals themselvesand on their amilies. The qualitative data suggestthat the relative cost o primary health care is lower inthe private sector. Although public health services areintended to be mostly ree-o-charge, there are realcosts associated with travel and the inormal payment(baksheesh) oten demanded by the middlemen whoserve as gatekeepers. Moreover, the patients requireto have money in hand and available in order to seeksuch services. As the respondents put this matter: ...better qualifed doctors (MBBS) are too expensive...unless the situation is very dangerous, we dont goto them(a 75-year-old male). ...I went to hospital(district hospital) once, stayed there or 2 days...I liked their treatment, but it costed me Tk.4000...too expensive (a 60-year-old male). ...when Iwas very ill, my son took me to a MBBS doctor inChandpur hospital, we cant go instantly o course,because one needs to have the money upront ortreatment there (a 68-year-old male). ...I preernot to go to a qualifed MBBS doctor, because wehave to have cash in hand to seek treatment, and ocourse it is more expensive...(an 83-year-old male).One respondent, a 75-year-old woman, provides an

example o how transportation costs increase or anelderly patient: It can be very expensive sometimes

Services Satisfaction indicators Dissatisfaction indicators

Governmentservices

Health service providers behaviour, politeness,showing respect to the patientsMedical outcome

Difcult to access the service, including payment obribe to the middle man to access ree service

Private services Flexible payment options and small discountEasy accessibility and providers availability orhome visitsMedical outcome

Late reerral to other specialised services whennecessary

Table

Indicators of satisfaction/dissatisfaction with government and private health care services

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to get ree treatment. For example, when one is well,a ticket or one seat on the mini-taxi is ok, but whenthe passenger is sick, you have to take the whole taxi,which, o course, is expensive.

Private sector providers, in contrast, charge

moderate ees or their services, but oer paymentexibilityees can be negotiated and paid later which makes their services more attractive to theelderly users and their amilies. Similarly, they tend topurchase their medicines rom local drug stores, wherethe shopkeepers also act as health service providers.They typically are well known by the elderly users, towhom they oer credit or medication purchases anddo not pressure them or payment. In many cases,these providers may be relatives or amily riends,which urther acilitates exibility o payment. In the

words o several respondent: ...He (a rural medicalpractitioner) is a good doctor, he treated my mother-in-law and my husband too. He gives us medicine oncredit, also gives us a little discount. I got well withhis medicineI still owe him Tk. 200 out o total costo treatment Tk. 500(a 60-year-old emale)....we goto him (a rural medical practitioner), he is known tous, and is there or us during good and bad times...we can get medicine on credit toohe is good andalso gives us a discount(a 70-year-old emale). ...this doctor (a rural medical practitioner) is treatingme or 30 years or high blood pressure. Since I amhis long-term patient, I can get treatment on credit,sometimes he also gives a discount.(a 64-year-oldemale who is also a health care providerkabiraj).

While the data suggest that cost is related tosatisaction among the poor elderly, a surprisingtwist occurs among the wealthier amilies. For themiddle and upper-middle class, the cost o medicineis directly related to its perceived eectiveness. Thuswhen the medicine is more expensive, it is believed toprovide better treatment. The respondents oten usedexpressions such as, I took an expensive medicine;I had Tk. 36 worth o injections and Tk. 13 worth otablets. For these amilies, client satisaction is notdetermined by the burden o health care expenses.

Cultural perception of the medical outcome

The most common illnesses reported among theelderly during the feldwork included eye problemssuch as cataracts, toothache, gastric pain, ever, body

pain, weakness, uterine problems, loss o appetite,tuberculosis, and arthritis. Since preventive health

care or the elderly does not exist in either the publicor private sector, the initial care-seeking decisionis based primarily on severity and the level odiscomort. Dissatisaction with private providers interms o the objective medical outcome usually shitscare seeking to another private practitioner or into

the public sector. The results o the research conveya very complex reality or the elderly. Thus, in someinstances, success o the medical outcome appears tobe a primary determinant o satisaction. In the wordso various respondents: o course, I am satisfed,my ever was cured ater 4 days with the medicine(64-year-old male). My brother took me to thedoctor (MBBS at Chandpur) when I lost eeling onmy let side...he treated me or 2 months, but hismedicine did not work. Then I went to other doctor(MBBS at Chandpur) who also treated or another 2

months also with no eect. Since then, I have beentreated by kabirajs...I am not happy with any o mydoctors or kabirajs, because my disease does not getbetter, I have been to everyone suggested. How canI be satisfed? (60-year-old male paralysed strokevictim).

Although the success o medical outcome can bean important indicator o client satisaction, culturalperception introduces an element o atalism into thequality assessment o the elderly. It is very commonor the elderly to have a cultural perception aboutthe ineectiveness o the treatment and medicinein later lie. Sometimes they show satisaction withthe eorts o the providers yet remain unwell, andexpress the view that medicine just does not workin old age. For example, there is a belie that nomedicine is available or some elderly diseases likearthritis.

The research reveals that client satisaction can bepositive in cases where improvement lasts or onlya short while because treatment was not continued.Also, in Bangladesh, patients simply become resignedto a situation that they associate with old age. In theirwords:First I went to Dr M (a homeopathic doctor)...he is a good doctor, we can get treatment on credit...last time I was ill with rheumatism, I went to him...his medicine ailed me; however, he is a good doctor.His medicine works better or young people, but orolder people it simply does not work(a 64-year-oldemale). His (a rural medical practitioner) treatment

is very good...he takes good care o the patients andhis medicine is good, too...I like him a lot, but, as I

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have said, medicine is not eective at an older age(a 64-year-old emale).

The second actor that relates medical outcome toclient satisaction has been defned by Donabedian,38as the process o giving or receiving care. In

Bangladesh, even when the medical outcome is notsuccessul, the elderly will show appreciation or theway they were treated, i.e. with respect, dignity, andattentiveness. In the words o the respondents: Thedoctors and nurses in the Chandpur general hospitalwere very nice to me while I was in the hospital, I amvery happy with them; I think the hospital treatmentis very good(a 60-year-old male). I took my wie tothe hospital (district hospital) when she was very ill...she was there or 4 days, and the nurses behaviour wasbad. So I took her out o the hospital...I did not even

tell the doctor we were leaving. We arranged to put heron drips at home with the help o our regular doctor(a rural medical practitioner) (a 62-year-old male).In eect, i doctors do not rush the examination andwrite a prescription immediately, but explore patientsproblems with greater detail, the level o satisaction ishigher, regardless o the outcome. Phrases like takestime, examines careully, and touches and eelsprovide insights into the criteria or appropriate care.Another cultural actor that may govern satisaction isa sense o modesty or appropriateness. Some elderlypatients will avoid a health care provider who wishesto examine the patient directly. According to a 90- year-old emale respondent: My amily membersexplained my problem but he wants to see me. Ihave made a promise to God not to be examined byany doctor, so we go to places where they would notdemand to see me.

In the case o private health service providers,the sense o satisaction is largely determined bythe relationship between providers and the usersamilies. Easy accessibility and predictable availabilitysignifcantly enhances the level o satisaction o thecare-seeking elderly, especially when providers arewilling to make house calls during day or night. Forexample, We always go to him...he is our regulardoctor (a rural medical practitioner), and he isavailable whenever we need him, day or night...healso comes to our home when needed...we are happywith him(a 68-year-old male).

This high level o provider availability appears tooer a great deal o psychological comort to elderly

users. They recognise that a sudden illness mayoccur at any time, including at night, and limitedphysical mobility oten constrains access to otherproviders. Thus, the option o home visits providespeace o mind and, as such, contributes to the levelo satisaction.

DISCUSSION

In rural Bangladesh, primary health care services arenot yet able to meet the specifc health needs o itsincreasingly aged population. This inquiry into clientsatisaction as an overall assessment o primaryhealth care quality has identifed three important, butcomplex and interrelated determinantsmobilityand accessibility, cost and payment exibility, andcultural perceptions o medical outcome. While the

literature points to the success o the medical outcomeas a primary determinant o satisaction, the elderlysampled here portray a much more complex reality.Fieldwork reveals that they frst seek health careattention at the closest, most convenient venue. Inot cured, the patient will consult a range o, usually,private sector health care providers until the problemis resolved. Otherwise or i reerred, the patient willabsorb the cost and time o consulting the pubichealth care system or some other specialised service.O interest here is the observation that this processo care seeking does not tend to permanently identiyone or another care provider as preerable. Thus,when the same elderly person is again aicted withillness, the same process is repeated, which providesunique insights into utilisation preerences.

This study suggests that actors such as theinterpersonal relationship with the provider (wherethe provider is known to the elderly), availabilityor the home visits (including during nights), andpayment exibility are the major determinantso satisactionespecially as it aects utilisation.Positive medical outcome appears more secondary asthere is a strong cultural belie that ill health is a parto old age and the medication is less eective in oldage. In this sense, the private sector is more successulin meeting the particular demands o the elderly, i.e.better availability and a exible payment system thatis aordable to the elderly and their amilies.

Moreover, the private sector health care system

has much to oer the government system as itattempts to address the needs o the elderly. The

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elderly population is very heterogeneous, and variesgreatly with regard to socioeconomic status; the useree structure in the public health care system shouldreect this reality. A possible eective strategy wouldbe to provide ree health care services or the poorestand most vulnerable elderly, but at ull cost or the

rich. Flexibility in the payment system is vital. In alarge number o rural amilies, the ability to pay or thehealth care varies seasonally, especially or agricultural workers. This makes purchase or medicine andhealth care services on credit very attractive.

Finally, there is an important opportunity in theoverall provisioning o health care services to theelderly. This entails taking advantage o both privateand public delivery systems. There is a critical need tocoordinate between these two universes o primary

health care, especially with regard to specifc trainingneeds o local village providers and establishingan eective and timely reerral system. The systemshould channel elderly patients rom the privateto the public sector, and introduce much-neededpreventative health care component.

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