Research to policy on defining accessibility of public health facilities to ensure universal health coverage.

BACKGROUND: The mandate to ensure the availability of doctors under Universal Health Coverage has been one of the most difficult issues to address in India. It is believed that the geographic location of health facilities has influenced the availability of doctors in rural areas, which may have resulted in long-standing vacancies. There was a need to classify facilities based on location and access, to propose policies and strategies. The classification was arrived through a consultative process, which led to ambiguity. AIM: The aim of this study is to develop a criteria to identify health facilities based on location considering accessibility indicators. SETTINGS AND
DESIGN: A cross-sectional operational research was conducted during 2010-2011 to collect data for public-health facilities above subcenters and below district hospitals across India.
MATERIALS AND METHODS: Data was collected for geographic, environmental, housing, and vacancy status of doctors; for which scores were assigned for each health facility.
RESULTS: A total of 20,528 (76%) were included for analysis out of 26,876 health facilities. Following application of criteria, 3,011 (11%) facilities were identified as eligible; of these, 1%, 3%, and 7% facilities were identified as inaccessible, most-difficult, and difficult facilities, respectively. The consultative meetings with state governments resulted in agreement on the criteria adopted.
CONCLUSION: The study demonstrated more robust criteria to define access to health care facilities by applying composite scoring methods, which was validated through a consultative process with key stakeholders. The study results were applied to incentivize doctors serving in difficult areas in a move to address human resource gaps in rural areas and ensure universal health coverage. Copyright:

Introduction

Universal Health Coverage; is the priority of the Government of India and efforts were made to ensure access to public health facilities, which can be traced in Five-Year Plans of India. The first Five-Year Plan focused on access to healthcare services and established health facilities based on recommendations from the Bhore committee report.[1] The subsequent plans revisited the recommended norms for establishing new facilities, and the norms were revised based on population covered by each facility considering the geographic terrains, especially in 5th and 9th Five-Year Plans.[23] The facilities’ nomenclatures were defined and facilities below the district hospitals are known as community health centers (CHCs) or block hospitals, which were established at ~80,000–120,000 populations. Each CHCs covered nearly 3 to 4 primary health centers (PHCs), which were established at ~20,000–30,000 populations and PHCs covered four to five subcenters (~5,000 population). Subcenters are the first community contact to healthcare system and PHCs are first contact with medical officers for providing primary care.

Over the years, with the increase in population, the numbe of public health facilities have increased exponentially and measures were defined to recruit doctors as per National Health Policies, 1982, and 2002 at these institutions.[4] Along with these measures, incentives, monitory/nonmonitory, were proposed to attract/retain doctors in rural remote areas and believed to have shown limited success [11th Five-Year Plan (2007–2012)].[5] In 2005, The National Rural Health Mission (NRHM) laid down six core areas and defined strategies to revitalize and revamp India's public health system with “human resource for health” as one of the priority areas to ensure universal health coverage.[6] During the First Common Review Mission of NRHM 2007, the failure to achieve targets was equated to the availability of human resources, especially doctors in rural areas.[7] The availability of doctors was believed to do with the location of health facilities and urbanization. Therefore, there was a need to assess the physical location of health facilities along with its distance from respective district head-quarters and to categorize them into accessible, difficult, most difficult, and inaccessible. The aim of this study was to develop criteria to classify facilities based on location considering factors related to accessibility.

Subjects and Methods

In India, the onus of establishing public health facilities was with respective states. Historically, PHCs were built on the lands donated by the landlords that were located far from the villages.[8] As a result, on an average a PHC covered an area of 144.17 km2 with a maximum radial distance of 6.78 km with a catchment population from 26.99 villages.[9] Over the years, due to limited funding for strengthening the network of healthcare services and high-vacancy status of doctors have resulted in poor availability of health services.[1011]

On 2nd July 2009, The Hon’ble Minister of Health and Family Welfare wrote to Chief Ministers of States about the challenges in reaching health services in hilly areas, desert areas, areas affected by social problem, areas having poor connectivity, and un-served and under-served tribal areas.[12] The Minister suggested the provision of incentives both monetary and nonmonetary for doctors and paramedical staff who served in these areas. The onus was given to respective state representatives to define accessibility to health facilities. Thus, prepared list of facilities identified as “difficult” was based on consultative process and was subjective, and this varied from states to states.[12] Therefore, nodal agency, National Health Systems Resource Centre (NHSRC), was entrusted to define methodology and conduct an independent analysis for the list submitted by states.

NHSRC arrived at a set of composite indicators through a series of consultative meetings with key stakeholders, and the indicators were categorized into (a) geographical access, (b) environmental conditions, (c) housing amenities, and (d) availability of doctors. Agencies were entrusted to collect data for individual facilities either by visiting the facility and/or through a telephonic call to health facility personnel. A team of experts at NHSRC reviewed the data (for completeness). Second, a three-stage data validation process was conducted: (i) NHSRC team randomly contacted 10% health institutions from respective states, (ii) the list of identified facilities was shared with states to confirm if the categorizations were appropriate, (iii) 10% of health facilities were located through “google maps,” other available maps. Third, composite scoring was applied, for example, the geographical scoring included A0 as accessible through A4 and A5 inaccessible. Similar scorings were applied for environment E0 as a good environment and E1 and E2 as difficult—hilly/tribal areas. The housing amenities were scored as H0–H3, looking at the availability of accommodation, school, electricity, water, etc. Vacancy was scored as V0–V3 based on the post of doctor remained vacant over the years. The detailed scoring criteria is elaborated in the draft guideline.[12] Each facility scores were computed across all the indicators and a facility was identified as Inaccessible, Most-Difficult, Difficult, and Accessible. Furthermore, the line-list of facilities provided by states was reviewed by applying the criteria and facilities were either upgraded or downgraded or a status-quo was maintained. The data was collected for 27,901 facilities as per Rural Health Statistics 2010. The data collected during 2010–2011 and the process of validation through consultative meetings continued for over 6 months. The study used secondary data sets and has no individual identifiers. The data is an open source available on National Health Systems Resource Center. We therefore did not seek ethical approval for the study.

Results

In the year 2010, there were 27,901 health facilities of which information was collected for 26,876 facilities (96%) from 620 districts across 26 states of India. State with the maximum area with hills had the highest number of facilities in “Inaccessible” category, which may have been influenced by high scores given to “environment” [Table 1]. Second, states with high density of forests had facilities under “Most Difficult” category. Third, facilities with average scores on access, environment, housing, and vacancy were grouped into “Difficult” to access facilities. A total of 3,011 (11%) facilities were identified by applying the criteria. Out of these, 1%, 3%, and 7% facilities were categorized as Inaccessible, Most-difficult, and Difficult facilities, respectively.

Table 1

National summary of “hard-to-reach” facilities along with population and infant mortality rate

States	Inaccessible	Most Difficult	Difficult	Total	% difficult facilities	Population in millions	Infant Mortality Rate
EAG states
Bihar	44	39	128	1846	11%	104	48
Chhattisgarh	33	131	215	859	44%	26	51
Jharkhand	0	24	64	515	17%	33	42
Madhya Pradesh	5	44	237	1488	19%	73	62
Orissa	2	60	166	1510	15%	42	53
Rajasthan	1	131	217	1870	19%	69	55
Uttar Pradesh	1	12	42	4205	1%	200	61
Uttarakhand	3	21	82	294	36%	10	38
NE states
Arunachal Pradesh	15	16	37	160	43%	1	31
Assam	51	41	51	952	15%	31	58
Manipur	9	10	10	88	33%	3	14
Meghalaya	4	21	38	133	47%	3	55
Mizoram	0	34	17	66	77%	1	37
Nagaland	3	11	15	144	20%	2	23
Sikkim	0	3	3	24	25%	1	30
Tripura	0	5	9	87	16%	4	27
Other states
Andhra Pradesh	5	43	54	1737	6%	85	46
Gujarat	0	3	43	1365	3%	60	44
Haryana (Mewat)	0	0	0	530	0%	25	48
Himachal Pradesh	18	56	124	522	38%	7	40
Jammu and Kashmir	27	27	35	460	19%	13	43
Karnataka	0	46	156	2517	8%	61	38
Maharashtra	3	21	88	2192	5%	112	28
Punjab (4 Distt.)	0	1	1	523	0%	280	34
Tamil Nadu	0	12	60	1533	5%	72	24
West Bengal	49	3	33	1256	7%	91	31
Total	273	815	1925	26876	11%	1211	42

Source of table: National Health Systems Resource Centre. Incentivization of skilled professionals to work in public health facilities located in Inaccessible, Most Difficult, and Difficult Rural Areas http://nhsrcindia.org/ health-facilities-inaccessibility Abbreviations: EAG: Empowered action group states, NE: North Eastern States of India. (a) Total health facilities for 2009, National Health Profile 2010, chapter 6 health infrastructure, page 172 (b) Infant Mortality data for 2010 from National Health Profile 2011, demographic indicators page 18 https://www.cbhidghs.nic.in/WriteReadData/l892s/06%20Demographic%20Indicators%202011.pdf, (c) Population from Census of India 2011.

Using the current methodology, 20% of total facilities identified by state were upgraded and 27% of facilities were downgraded [Table 2]. In addition to states proposed list of facilities, 1447 facilities were included. These inclusions were mainly from Bihar, West Bengal, and Madhya Pradesh states. The validation process confirmed that the facilities identified were the ones which needed support. However, there was 10% variation in scoring mainly in geographic access criteria which lead to variations in overall scoring. The states which had the maximum number of health facilities in difficult, most-difficult, and inaccessible were the sates with poor health indicators and utilization of health services.

Table 2

Re-defining “hard-to-reach” facilities by applying NHSRC criteria

States	Confirmed			Confirmation Total	Not confirmed Total	Inclusion			Inclusion Total	SQ Total	Grand Total
	UG	DG	Same			D	MD	IA
EAG states
Bihar	8	1	8	17	38	104	35	38	177	1270	1502
Chhattisgarh	35	182	135	352	227	19	3	0	22	256	857
Jharkhand	0	1	0	1	8	70	18	0	88	424	521
Madhya Pradesh	19	41	132	192	449	61	22	14	97	767	1505
Orissa	14	54	74	142	269	68	13	1	82	1187	1680
Rajasthan	29	22	35	86	101	156	70	0	226	443	1885
Uttar Pradesh	2	4	3	9	36	38	10	0	48	3459	3552
Uttarakhand	11	28	45	84	47	20	2	1	23	140	294
NE states
Arunachal Pradesh	12	4	30	46	48	15	7	4	26	41	161
Assam	27	18	70	115	101	12	10	10	32	757	1005
Manipur	12	0	3	15	5	8	3	3	14	52	86
Meghalaya	6	1	8	15	1	33	15	3	51	63	130
Mizoram	11	2	39	52	7	4	0	3	7	1	67
Nagaland	2	0	12	14	22	5	9	2	16	88	140
Sikkim	0	0	0	0	7	3	3	0	6	125	138
Tripura	0	0	5	5	11	8	1	0	9	39	64
Other states
Andhra Pradesh	36	9	53	98	346	0	0	0	0	3	553
Gujarat	2	8	13	23	86	23	0	0	22	566	697
Haryana (Mewat)	0	0	0	0	0	0	0	0	0	0	0
Himachal Pradesh	6	0	23	29	9	115	37	14	166	255	459
Jammu and Kashmir	23	2	20	45	8	21	14	11	46	338	437
Karnataka	15	15	34	64	204	114	25	0	139	2121	2528
Maharashtra	10	0	14	24	18	84	19	0	103	711	843
Punjab (4 Distt.)	0	0	2	0	8	0	0	0	0	0	10
Tamil Nadu	12	0	60	72	155	0	0	0	0	0	227
West Bengal	15	17	0	32	116	21	0	26	47	992	1187
Total	307	409	818	1532	2327	1002	316	130	1447	14098	20528

UG: Up-graded, DG: Down-graded, D: difficult, MD: most difficult, IA: inaccessible, EAG: empowered action group, SQ: Status Quo; NE: North Eastern States of India.

Discussion

The study demonstrated the need for a robust method to identify and categorize public health facilities as difficult, most-difficult, and inaccessible. Identified facilities were further deliberated through consultative meetings. The series of consultative meetings with key stakeholders helped in the acceptance of the methodology. A policy note was released from NHSRC and team advocated with state for policy formulation to incentivize doctors serving in difficult public health facilities.[13]

The Twelfth Five-Year Plan (2017–2022) adopted the policy draft of NHSRC in the working group committees.[14] Few states, namely, Chhattisgarh,[15] Odisha,[16] Gujarat, Tamil Nadu,[17] Himachal Pradesh, and Maharashtra considered the criteria and revised their list of selected facilities. In addition, states proposed both monetary and nonmonetary incentives in their subsequent Programmed Implementation Plans (NRHM–PIPs). For example, in the state of Chhattisgarh, Chhattisgarh Rural Medical Corporation has implemented financial incentives, insurances, and additional marks/points in competitive exams, which is applicable for all health workers under the corporation.[18] Furthermore, Government of India, through its press release, revised the Post Graduate Medical Education Regulations with incentives to doctors serving in rural areas to pursue post-graduate courses (see Box 1 for details).[19] The National Health Policy 2017 also proposes financial and nonfinancial incentives for attracting, retaining doctors in hard-to-reach areas.[20]

Box 1

National Policy for Incentivization for doctors serving in “hard-to-reach“ areas

Press Information BureauGovernment of IndiaMinistry of Health and Family Welfare18-November-2016 14:43 ISTDistribution Of Medical Colleges and Seats

To encourage doctors working in remote and difficult areas, the Post Graduate Medical Education Regulations, 2000 provide :-

(i) 50% reservation in Post Graduate Diploma Courses for Medical Officers in the Government service, who have served for at least three years in remote and difficult areas; and

(ii) Incentive at the rate of 10% the marks obtained for each year in service in remote or difficult areas as up to the maximum of 30% of the marks obtained in the entrance test for admissions in Post Graduate Medical Courses.

Under the National Health Mission (NHM), there is provision for incentives like hard area allowance to doctors for serving in rural and remote areas, construction of residential quarters so that doctors find it attractive to join public health facilities in such areas. The States/UTs have also been advised to have transparent policies of posting and transfer, and deploy doctors rationally to provide medical care in rural areas.

Source: PIB http://pib.nic.in/newsite/PrintRelease.aspx?relid=153790

The public health system in India was seen as “social model” to deliver primary care, more specifically, the PHCs and CHCs as the first contact of community with doctor. Many of these centers are the first reporting units for most of the vertical health programs that focus on providing comprehensive care.[21] The availability of doctors will have an impact on the delivery of primary care and this can be demonstrated through doctors continuing in the service, which is dependent upon geographical affinities and familial association.[22]

The methodology described in this paper to review access to health facilities is a robust approach and over the perception criteria. However, the limitation of this methodology lies in composite indicators that weigh on “geographical access” indicator, where the distance is calculated taking district head-quarter as the reference point. Factors like other health facility or an urban city much nearer or just across the border of the current identified facility at below district head-quarter level were not considered. The researchers/authors of this study did not use the vacancy data that was collected as it was a dynamic/subjective and prone to errors and respondents were not aware of the number of sanctioned posts.

Conclusion

The study demonstrated more robust criteria to define access to health care facilities by applying composite scorning methods, which were validated through a consultative process with key stakeholders.

These criteria enabled states to revise the list of proposed public health facilities. The same was used to address gaps in human resources to provide healthcare services. The results were subsequently included in the formulation of policies to incentivize doctors serving in difficult areas in a move to ensure universal health coverage.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.