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 Table of Contents 
Year : 2019  |  Volume : 8  |  Issue : 10  |  Page : 3242-3246  

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

1 TB and Communicable Disease, International Union Against Tuberculosis and Lung Disease (The Union), South-East Asia Regional Office, New Delhi, India
2 Immunization Technical Support Unit, Public Health Foundation of India (PHFI), New Delhi, India
3 Department of Public Health Planning, National Health Systems Resource Center (NHSRC), Ministry of Health and Family Welfare, Government of India, New Delhi, India

Date of Submission23-Jul-2019
Date of Decision21-Aug-2019
Date of Acceptance29-Aug-2019
Date of Web Publication31-Oct-2019

Correspondence Address:
Dr. Banuru M Prasad
The Union, C-6 Qutub Institutional Area, New Delhi
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jfmpc.jfmpc_577_19

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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.

Keywords: Accessibility, incentive to doctors, public health facilities, universal health coverage

How to cite this article:
Prasad BM, Baruah J, Khanna P. Research to policy on defining accessibility of public health facilities to ensure universal health coverage. J Family Med Prim Care 2019;8:3242-6

How to cite this URL:
Prasad BM, Baruah J, Khanna P. Research to policy on defining accessibility of public health facilities to ensure universal health coverage. J Family Med Prim Care [serial online] 2019 [cited 2021 May 7];8:3242-6. Available from: https://www.jfmpc.com/text.asp?2019/8/10/3242/269992

  Introduction Top

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.[2],[3] 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 theFirst 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 Top

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.[10],[11]

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 Top

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

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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

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  Discussion Top

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]

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 Top

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.


The study was conducted under the guidance of Dr. T. Sundararaman, former Executive Director of NHSRC. The credit of redefining hard-to-reach health facility lies with NHSRC. We take this opportunity to thank Dr. Rajni Ved, current Executive Director of NHSRC, for her guidance. We also take this opportunity to thank the entire Public Health Planning team of NHSRC and agencies involved in the data collection process.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Gangolli LV, Duggal R, Shukla A. Review of Healthcare in India. Mumbai: Centre for Enquiry into Health and Allied Themes; 2005. Available from: http://www.cehat.org/cehat/uploads/files/rhci.pdf. [Last accessed on 2017 Mar 20].  Back to cited text no. 1
Government of India. Fifth Five Year Plan (1976-1979). New Delhi: Planning Commission of India; 1976.  Back to cited text no. 2
Government of India. Ninth Five Year Plan (1997-2002). New Delhi: Planning Commission of India; 1996.  Back to cited text no. 3
Central Bureau of Health Intelligence. National Health Profile; 2017. Available from: http://www.cbhidghs.nic.in/E-Book%20HTML-2016/index.html#285/z. [Last accessed on 2017 Mar 20].  Back to cited text no. 4
Government of India. Eleventh Five Year Plan (2007-2012). New Delhi: Planning Commission of India; 2013.  Back to cited text no. 5
Government of India. National Rural Health Mission Framework for Implementation. New Delhi: Ministry of Health and Family Welfare; 2005.  Back to cited text no. 6
Government of India. First Common Review Mission. New Delhi: National Rural Health Mission; 2007. Ministry of Health and Family Welfare. Avaliable from: http://nhsrcindia.org/sites/default/files/1st%20CRM%20Main%20Report%202007.pdf. [Last accessed on 2017 Mar 20].  Back to cited text no. 7
World Bank. India-Reducing Poverty in India: Options for More Effective Public Services. Washington D.C.: World Bank; 1998. Poverty Reduction and Economic Management Division, South Asia Region. Report No.: 17881. Available from: http://documents.worldbank.org/curated/en/793451468752712746/India-Reducing-poverty-in-India-options-for-more-effective-public-services. [Last accessed on 2018 Mar 01].  Back to cited text no. 8
Indrayan A. Trends in access to medical and health services in rural areas of India. Montreux: International Association for Official Statistics (IAOS), Statistics, Development and Human Rights; 2000. Available from: www.portal-stat.admin.ch/iaos2000/indrayan_final_paper.doc. [Last accessed on 2017 Mar 25].  Back to cited text no. 9
Duggal R. Centre for Enquiry into Health and Allied Themes. [Online]; 2003 [cited 2016 Apr 20]. Available from: http://indiaresource.org/issues/globalization/2003/publichealthsystems.html.  Back to cited text no. 10
Government of India. Tenth Five Year Plan (2002-2007). New Delhi: Planning Commission of India; 2002.  Back to cited text no. 11
National Health Systems Resource Centre. Incentivization of Skilled Professionals to Work in Public Health Facilities Located in Inaccessible, Most Difficult and Difficult Rural Areas. 2013. New Delhi. Available from: http://nhsrcindia.org/sites/default/files/Inaccessibility%20Concept%20Note.pdf. [Last accessed on 2017 Feb 20].  Back to cited text no. 12
National Health Systems Resource Centre. Proposed Central Scheme for Incentivization of Skilled Professionals to Work in Public Health Facilities Located in Inaccessible, Most Difficult and Difficult Rural Areas. New Delhi: National Health Systems Resource Centre; 2013.  Back to cited text no. 13
Government of India. Twelfth Five Year Plan (2017-2022). New Delhi: Planning Commission of India; 2017.  Back to cited text no. 14
Government of Chhattisgarh. Chhattisgarh Rural Medical Corps (CRMC). 2017 February 14. 2017. Department of Health and Family Welfare. Available from: http://cghealth.nic.in/ehealth/CRMC/crmc000122022017.pdf. [Last accessed on 2017 Mar 10].  Back to cited text no. 15
The Hindu. Incentives for Doctors Serving in Remote Areas of Odisha. 2015. Available from: http://www.thehindu.com/news/national/other-states/incentives-for-doctors-serving-in-remote-areas-of-odisha/article7152127.ece. [Last accessed on 2017 Mar 15].  Back to cited text no. 16
Government of Tamil Nadu. Medical Education -Awardingofincentive marks to the in-service candidatesfor heir service rendered in the remote/difficult/rural areas for admission to Post Graduate Medical Coursesby considering their working places –Orders –Issued. Government Order. Chennai: Health and Family Welfare, HEALTH AND FAMILY WELFARE (MCA-1) DEPARTMENT; 2019. Report No.: G.O. (Ms.) No. 86.  Back to cited text no. 17
Lisam S, Nandi S, Kanungo K, Verma P, Mishra JP, Mairembam DS. Strategies for attraction and retention of health workers in remote and difficult-to-access areas of Chhattisgarh, India: Do they work? Indian J Public Health 2015;59:189-95.  Back to cited text no. 18
[PUBMED]  [Full text]  
Government of India. Distribution of Medical Colleges and Seats. 2016 November 18. Press Information Bureau. Available from: http://pib.nic.in/newsite/PrintRelease.aspx?relid=153790. [Last accessed on 2017 Mar 12].  Back to cited text no. 19
Government of India. National Health Policy 2017. New Delhi: Ministry of Health and Family Welfare; 2017.  Back to cited text no. 20
Ramani S, Sivakami M, Gilson L. How context affects implementation of the primary health care approach: An analysis of what happened to primary health centres in India. BMJ Global Health 2019;3:e001381.  Back to cited text no. 21
National Health Systems Resource Centre. Why Some Doctors Serve in Rural Areas: A Qualitative Assessment from Chhattisgarh State. New Delhi: Ministry of Health and Family Welfare; 2010.  Back to cited text no. 22


  [Table 1], [Table 2]


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