Health Service Provision in Tamil Nadu: Assessing Facility Capacity, Costs of Care, and Patient Pers by Institute for Health Metrics and Evaluation

H E A LT H SE RVI CE P ROVI SI O N IN TA MIL NA DU

Assessing Facility Capacity, Costs of Care, and Patient Perspectives

INSTITUTE FOR HEALTH METRICS AND EVALUATION UNIVERSITY OF WASHINGTON

A B C E

CCESS, OTTLENECKS, OSTS, AND QUITY

PUBLIC HEALTH FOUNDATION OF INDIA

HE ALTH SERVICE PROVISION IN TAM I L N AD U

Assessing Facility Capacity, Costs of Care, and Patient Perspectives

A B C E

CCESS, OTTLENECKS, OSTS, AND QUITY

Table of Contents 5 Acronyms

Terms and definitions

Introduction

Main findings Health facility profiles

Executive summary

ABCE project design

Facility capacity and characteristics Patient perspectives Efficiency and costs

48 Conclusions and policy implications 52 Annex

INSTITUTE FOR HEALTH METRICS AND EVALUATION UNIVERSITY OF WASHINGTON

PUBLIC HEALTH FOUNDATION OF INDIA

About Public Health Foundation of India

The Public Health Foundation of India (PHFI) is a public-private initiative to build institutional capacity in India for

strengthening training, research, and policy development for public health in India. PHFI adopts a broad, integrative

approach to public health, tailoring its endeavors to Indian conditions and bearing relevance to countries facing similar

challenges and concerns. PHFI engages with various dimensions of public health that encompass promotive, preventive,

and therapeutic services, many of which are often lost sight of in policy planning as well as in popular understanding.

About IHME

Collaborations

This project has immensely benefitted from the key inputs and support from Dr. K. Kolanda Swamy,

Director of Public Health and Preventive Medicine, Government of Tamil Nadu, and from Dr. Thamma Rao.

Approvals and valuable support for this project were received from the Tamil Nadu state government and district officials, which are gratefully acknowledged.

About this report

The Institute for Health Metrics and Evaluation (IHME) is an independent global health research center at the University

of Washington that provides rigorous and comparable measurement of the worldâ&#x20AC;&#x2122;s most important health problems and

evaluates the strategies used to address them. IHME makes this information freely available so that policymakers have

the evidence they need to make informed decisions about how to allocate resources to best improve population health.

Assessing Facility Capacity, Costs of Care, and Patient Perspectives: Tamil Nadu provides a comprehensive assessment

of health facility performance in Tamil Nadu, including facility capacity for service delivery, efficiency of service delivery,

and patient perspectives on the service they received. Findings presented in this report were produced through the

ABCE project in Tamil Nadu, which aims to collate and generate the evidence base for improving the cost-effectiveness

and equity of health systems. The ABCE project is funded through the Disease Control Priorities Network (DCPN), which is a multiyear grant from the Bill & Melinda Gates Foundation to comprehensively estimate the costs and cost-effectiveness of a range of health interventions and delivery platforms.

Acknowledgments

Acronyms

We especially thank all of the health facilities and their staff in Tamil Nadu, who generously gave of their time and facil-

ABCE

who participated in this work, as they too were giving of their time and were willing to share their experiences with the

ANM

itated the sharing of facility data that made this study possible. We are also most appreciative of patients of the facilities

field research team.

At PHFI, we wish to thank Rakhi Dandona and Lalit Dandona, who served as the principal investigators for the ABCE

project in India. We also wish to thank Anil Kumar for guidance with data collection, management, and analysis. The quantity and quality of the data collected for the ABCE project in India is a direct reflection of the dedication of the field

team. We thank the India field coordination team, which included Md. Akbar, G. Mushtaq Ahmed, and S.P. Ramgopal.

We also recognize and thank Venkata Srinivas, Sagri Negi, and Sheetal Bishnoi for data management and coordination

ANC

Access, Bottlenecks, Costs, and Equity Antenatal care

Auxiliary nurse midwife

CHC

Community health centre

DCPN

Disease Control Priorities Network

DEA DH

DOTS

Confidence interval

Data envelopment analysis District hospital

Directly observed treatment, short-course

with field teams.

IHME

Institute for Health Metrics and Evaluation

We also recognize and thank data analysts and Post-Bachelor Fellows at IHME: Roy Burstein, Alan Chen, Emily Dansereau,

NCD

Non-communicable diseases

At IHME, we wish to thank Christopher Murray and Emmanuela Gakidou, who served as the principal investigators.

Katya Shackelford, Alexander Woldeab, Alexandra Wollum, and Nick Zyznieuski for managing survey programming,

survey updates, data transfer, and ongoing verification at IHME during fieldwork. We are grateful to others who contrib-

uted to the project: Michael Hanlon, Santosh Kumar, Herbie Duber, Kelsey Bannon, Aubrey Levine, and Nancy Fullman.

IPHS OR

Odds ratio

PHFI

Public Health Foundation of India

SFA

Stochastic frontier analysis

PHC

Finally, we thank those at IHME who supported publication management, editorial support, writing, and design.

SDH

from PHFI.

SHC

This report was drafted by Marielle Gagnier, Lauren Hashiguchi, and Nikhila Kalra of IHME and Rakhi Dandona Funding for this research comes from the Bill & Melinda Gates Foundation under the Disease Control Priorities

Network (DCPN).

STI

WHO

Indian Public Health Standards

Primary healthcare centre Sub-district hospital Sub health centre

Sexually transmitted infection

Tamil Nadu

World Health Organization

A B C E I N TA M I L N A D U

TERMS AND DEFINITIONS

Terms and definitions

Definitions presented for key technical terms used in the report.

Table 1 defines the types of health facilities in Tamil Nadu; this report will refer to facilities according to these definitions.

Constraint

Table 1 Health facility types in Tamil Nadu1

a factor that facilitates or hinders the provision of or access to health services. Constraints exist as both “supply-side,” or

the capacity of a health facility to provide services, and “demand-side,” or patient-based factors that affect health-seeking behaviors (e.g., distance to the nearest health facility, perceived quality of care received from providers). Data Envelopment Analysis (DEA)

an econometric analytic approach used to estimate the efficiency levels of health facilities.

Health facility types in Tamil Nadu District hospital (DH)

These facilities are the secondary referral level for a given district. Their objective is to provide comprehensive

secondary health care services to the district’s population. DHs are sized according to the size of the district

Efficiency

a measure that reflects the degree to which health facilities are maximizing the use of the resources available

in producing services.

population, so the number of beds varies from 75 to 500. Sub-district hospital (SDH)

These facilities are sub-district/sub-divisional hospitals below the district and above the block level hospitals

Facility sampling frame

the list of health facilities from which the ABCE sample was drawn. This list was based on a 2012–2013 facility inventory published by the Tamil Nadu state government.

(CHC). As First Referral Units, they provide emergency obstetrics care and neonatal care. These facilities serve populations of 500,000 to 600,000 people, and have a bed count varying between 31 and 100. Community health centre (CHC)

Inpatient visit

a visit in which a patient has been admitted to a facility. An inpatient visit generally involves at least one night spent at the

facility, but the metric of a visit does not reflect the duration of stay. Inputs

tangible items that are needed to provide health services, including facility infrastructure and utilities, medical supplies and equipment, and personnel.

These facilities constitute the secondary level of health care and were designed to provide referral as well as

specialist health care to the rural population. They act as the block-level health administrative unit and as the gatekeeper for referrals to higher-level facilities. Bed strength ranges up to 30 beds. Primary health centre (PHC)

These facilities provide rural health services. PHCs serve as referral units for primary health care from subcentres and refer cases to CHC and higher-order public hospitals. Depending on the needs of the region, PHCs

may be upgraded to provide 24-hour emergency hospital care for a number of conditions. A typical PHC covers a

Outpatient visit

a visit at which a patient receives care at a facility without being admitted.

population of 20,000 to 30,000 people and hosts about six beds. Sub health centre (SHC)

Outputs

volumes of services provided, patients seen, and procedures conducted, including outpatient and inpatient care, laboratory and diagnostic tests, and medications. Platform

a channel or mechanism by which health services are delivered.

Along with PHCs, these facilities provide rural health care. SHCs typically provide outpatient care, which includes immunizations, and refer inpatient and deliveries to higher-level facilities.

1 Directorate General of Health Services, Ministry of Health & Family Welfare, and Government of India. Indian Public Health Standards (IPHS) Guidelines. New Delhi, India: Government of India, 2012.

Stochastic Frontier Analysis (SFA)

an econometric analytic approach used to estimate the efficiency levels of health facilities.

EXECUTIVE SUMMARY

Executive summary

• A service capacity gap emerged for the majority of

nel, but this was a quarter of that at district hospitals,

health facilities across several types of services. Many

while health centres averaged between one and 32

full capacity to properly deliver it, for instance lacking

provision and population size, this also demonstrates

facilities reported providing a given service but lacked

staff. While some of this variation is a result of service

functional equipment or medications. For example,

relative shortages in human resources for health.

ported providing routine delivery care, none were fully

Facility production of health services

programmatic and policy implications for the health

Health facilities saw increases in both outpatient and inpatient visits over time.

while all primary and community health centres re-

ith the aim of establishing universal health

and comparison of facility-level outputs, efficiency, capac-

coverage, India’s national and state gov-

ity, and patient experiences. It is with this information that

ernments have invested significantly in

we strive to provide the most relevant and actionable in-

expanding and strengthening the public

formation for health system programming and resource

health care sector. This has included a particular com-

allocation in Tamil Nadu.

mitment to extending its reach to rural populations and reducing disparities in access to care for marginalized

Facility capacity for service provision

sary for the country to critically consider the full range of

While most facilities report providing key health services, significant gaps in capacity were identified between reported and functional capacity for care.

groups. However, in order to realize this goal it is neces-

factors that contribute to or hinder progress toward it.

Since its inception in 2011, the Access, Bottlenecks,

Costs, and Equity (ABCE) project has sought to comprehensively identify what and how components of health

• Health facilities generally reported a high availability

livery, costs of care, and equity in care received – affect

care, routine deliveries, general medicine, and phar-

service provision – access to services, bottlenecks in de-

of a subset of key services. Services such as antenatal

health system performance in several countries. Through

macies were widely available across facilities.

the ABCE project, multiple sources of data, including

• Services for non-communicable diseases (NCDs)

facility surveys and patient exit interviews, are linked

were limited. While significant numbers of district

together to provide a nuanced picture of how facili-

hospitals reported providing psychiatry (77%) and car-

ty-based factors (supply-side) and patient perspectives

diology (77%), very few provided chemotherapy (8%).

(demand-side) influence optimal service delivery.

Availability decreased markedly at lower levels of the

Led by the Public Health Foundation of India (PHFI)

health system.

and the Institute for Health Metrics and Evaluation (IHME),

the ABCE project in Tamil Nadu is uniquely positioned to

• Basic medical equipment such as scales, stethoscopes,

drivers of health care access and costs of care. Derived

at all health facility levels, but laboratory equipment

findings presented in this report provide governments,

incubators were less readily available. For example,

equipped to do so. This discordance has substantial

system in Tamil Nadu, highlighting continued chal-

lenges in ensuring facilities have all the supplies they

community health centres, and primary health centres.

over the five years, with slight declines in sub-district

Ninety-two percent of sub health centres had electric-

hospitals and community health centres.

past government surveys.

Facilities showed capacity for larger patient volumes given observed resources.

• Access to piped water was relatively high at district

tem, with particular implications for diagnosing and

service provision.

treating NCDs.

The main topical areas covered in this report move

from an assessment of facility-reported capacity for care

• While ECGs and ultrasounds were widely available,

and the efficiency with which they operate; tracking facil-

particularly at lower-level health facilities. While 92%

types of service provision; and comparing patient per-

38% for community health centres. CT scans were

to quantifying the services actually provided by facilities

gaps also emerged with regard to imaging equipment,

ity expenditures and the costs associated with different

of district hospitals had X-rays, this figure was just

spectives of the care they received across different types

available in just 38% of district hospitals and 4% of

of facility. Further, we provide an in-depth examination

sub-district hospitals.

or the alignment of facility resources with the num-

nity health centres (88%), and primary health centres

ber of patients seen or services produced, we found

(87%), though it is notable that the figure is lowest for

district hospitals. Piped water was limited at sub health

a wide range of efficiency levels within facility types,

markedly lower at sub health centres (59%) than other

exist between the average facility and facilities with the

suggesting that a substantial performance gap may

centres (59%). Similarly, access to flushed toilets was

highest efficiency scores. Efficiency scores were rela-

facility types (85%–91%). These figures do reflect in-

tively low across all health facilities, with 74% being the

vestments into improving physical infrastructure at

• There was nearly universal access to phones and

areas of success and targets for improving health

• In generating estimates of facility-based efficiency,

hospitals (85%), sub-district hospitals (88%), commu-

from a state-representative sample of 168 facilities, the

ping to 45% at the sub health centre level. This shows

of immunization doses administered remained stable

ity, showing substantial improvement on figures from

such as glucometers, blood chemistry analyzers, and

limited capacity for testing throughout the health sys-

all facility types. Inpatient visits increased for all facility

• Functional electricity was available at all hospitals,

health facilities, though discrepancies remain between

alike with actionable information that can help identify

hospitals. Outpatient visits accounted for the large ma-

jority of patients seen per staff member per day across

types between 2007 and 2011. The average number

and blood pressure apparatus were widely available

international agencies, and development partners

creased, with the highest patient volumes at district

Physical infrastructure of health facilities has improved, but gaps in transport and communication remain.

inform the evidence base for understanding the country’s

only 69% of district hospitals had glucometers, drop-

• Between 2007 and 2011, outpatient numbers in-

need to provide a full range of services.

highest mean across platforms.

high- and low-level facilities.

• If they operated at optimal efficiency, district hospitals

could provide 249,706 additional outpatient visits with

computers across facility types. However, only 22%

the same inputs (including physical capital and per-

These findings have serious implications for the timely

21,906 additional outpatient visits.

sonnel), while primary health centres could produce

of primary health centres had any access to vehicles.

transportation of patients to receive higher levels

• These efficiency scores indicate that there is consid-

of care.

erable room for health facilities to expand service

production given their existing resources. Future work

on pinpointing specific factors that heighten or hinder

Nurses composed the majority of staff at district hospitals, while at other facility levels paramedical staff outnumbered both doctors and nurses.

facility efficiency, and how efficiency is related to the quality of service provision, should be considered.

• Staff numbers were concentrated at district hospitals

with an average of nearly 211 personnel. Sub-district

hospitals had the second highest number of person-

Costs of care

• Most patients received all drugs that they were prescribed during their visits. Proportions of patients

receiving all prescribed drugs ranged from 99% of

Trends in average facility spending between 2007 and 2011 varied between facility types, though all platforms recorded higher spending in 2011 than 2007.

Introduction

patients at sub-district hospitals and primary health centres to 80% at sub health centres.

• Spending on personnel accounted for the vast major-

With its multidimensional assessment of health ser-

ity of annual spending across facility types. Compared

vice provision, findings from the ABCE project in Tamil

to other facility types, sub-district hospitals and

Nadu provide an in-depth examination of health facility

primary health centres put a slightly greater propor-

capacity, costs of care, and how patients view their in-

tion of their total expenditure toward personnel, while

teractions with the health system. Tamil Nadu’s health

district hospitals put the greatest proportion toward

provision landscape was markedly heterogeneous and

medical supplies.

questions facing policymakers and health stakeholders in

experienced by its population, influencing

delivery:

service delivery, which is critical for identifying areas of

programs,2,3 identifying health system efficiencies and

• What are the bottlenecks in provision of

promoting the delivery of cost-effective interventions has

• How much does it cost to produce health services?

Travel and wait times were shorter for patients visiting lower-level facilities than higher-level ones.

service disparities or faltering performance. Expanded

the trends and drivers of facility capacity, efficiencies,

mal policymaking and resource allocation; however, due

and just under 80% of patients at primary health cen-

data, capturing information from health facilities, recipi-

• Nearly all patients receiving care at sub health centres, tres, reported traveling less than 30 minutes to receive

care. In contrast, nearly half of patients at district hos-

pitals had travel times of over 30 minutes, reflecting

the greater distances people travel to receive specialist treatment from facilities of this type.

• The large majority of patients waited less than 30

are they available?

ernment of India has prioritized expanding many health

become increasingly important.

analyses would also allow for an even clearer picture of

• What health services are provided, and where

can seek care and facilities can address their needs. At a

time when international aid is plateauing1 and the gov-

successful implementation and quickly responding to

each country or state for public sector health care service

the ease or difficulty with which individuals

will likely continue to evolve over time. This highlights

the need for continuous and timely assessment of health

Patient perspectives

he performance of a country’s health sys-

tem ultimately shapes the health outcomes

these services?

• How efficient is provision of these health services?

Assessing health system performance is crucial to opti-

Findings from each country’s ABCE work will pro-

and costs of care. With regularly collected and analyzed

to the multidimensionality of health system functions,4

vide actionable data to inform their own policymaking

ents of care, policymakers, and program managers can

Rigorously measuring what factors are contributing to or

analyses will likely yield more global insights into health

achieving optimal health system performance and the eq-

bottlenecks in service delivery, costs of care, and equity in

Tamil Nadu.

information for improving service delivery and popula-

comprehensive and detailed assessment seldom occurs.

yield the evidence base to make informed decisions for

hindering health system performance – access to services,

uitable provision of cost-effective interventions throughout

service provision – throughout a country provides crucial

processes and needs. Further, ongoing cross-country

service delivery and costs of health care. These eight

countries have been purposively selected for the overarching ABCE project as they capture the diversity of health

system structures, composition of providers (public and

tion health outcomes.

private), and disease burden profiles. The ABCE project

The Access, Bottlenecks, Costs, and Equity (ABCE)

minutes to receive care across all facilities. Nearly all

contributes to the global evidence base on the costs of

project was launched globally in 2011 to address these

patients seeking care at sub health centres received

and capacity for health service provision, aiming to de-

gaps in information. In addition to India, the multi-

velop data-driven and flexible policy tools that can be

seven other countries (Bangladesh, Colombia, Ghana,

velopment partners, and international agencies.

Patients gave higher ratings of health care providers than facility characteristics.

project was undertaken in six states: Andhra Pradesh

Institute for Health Metrics and Evaluation (IHME) com-

Tamil Nadu.

received vital support and inputs from the state Ministry

health centres, patients receiving care from doctors re-

the drivers of health service delivery across a range of set-

and interpretation. The core team harnessed information

care in less than 30 minutes. Wait times were longer at

pronged, multi-partner ABCE project has taken place in

hospitals, but overall less than 6% of patients waited

more than one hour to receive care.

adapted to the particular demands of governments, de-

Kenya, Lebanon, Uganda, and Zambia). In India, the ABCE

The Public Health Foundation of India (PHFI) and the

and Telangana, Gujarat, Madhya Pradesh, Odisha, and

• Across all facility types except community and sub

pose the core team for the ABCE project in India, and they

The ABCE project, with the goal of rigorously assessing

ported slightly higher levels of satisfaction than those

of Health and Family Welfare for data collection, analysis,

tings and health systems, strives to answer these critical

treated by nurses. Satisfaction with staff interactions,

from distinct but linkable sources of data, drawing from a state-representative sample of health facilities to create a

for both doctors and nurses, were lowest at district

large and fine-grained database of facility attributes, ex-

1 Institute for Health Metrics and Evaluation (IHME). Financing Global Health 2015: Development assistance steady on the path to new Global Goals. Seattle, WA: IHME, 2016. 2 Planning Commission Government of India. Eleventh Five Year Plan (2007-12). New Delhi, India: Government of India, 2007. 3 Planning Commission Government of India. Twelfth Five Year Plan (2012-17). New Delhi, India: Government of India, 2012. 4 Murray CJL, Frenk J. A Framework for Assessing the Performance of Health Systems. Bulletin of the World Health Organization. 2000; 78 (6): 717-731.

hospitals and generally higher at health centres.

• Facility characteristics, such as cleanliness and privacy,

received generally low ratings from patients. Cleanliness at hospitals received particularly low marks. As

with staff interactions, patient satisfaction with facility characteristics was higher at health centres.

penditure, and capacity, and patient characteristics and

outcomes. By capturing the interactions between facility characteristics and patient perceptions of care, we have

been able to piece together what factors drive or hinder optimal and equitable service provision in rigorous, data-driven ways.

A B C E I N TA M I L N A D U

We focus on the facility because health facilities are the

consider the factors that affect patient perceptions of and

main points through which most individuals interact with

experiences with the state’s health system. By considering

the health system or receive care. Understanding the ca-

a range of factors that influence health service delivery,

pacities and efficiencies within and across different types

we have constructed a nuanced understanding of what

health system performance at the level most critical to

facilities in the state of Tamil Nadu.

immensely valuable to governments and development

haustive; rather, they align with identified priorities for

of public sector health facilities unveils the differences in

ABCE project design

helps and hinders the receipt of health services through

patients – the facility level. We believe this information is

The results discussed in this report are far from ex-

partners, particularly for decisions on budget alloca-

health service provision and aim to answer questions

tions. By having data on what factors are related to high

about the costs of health care delivery in the respective

icymakers and development partners can then support

tion of health facility capacity across different platforms,

facility performance and improved health outcomes, pol-

state in India. This report provides an in-depth examina-

evidence-driven proposals and fund the replication of

specifically covering topics on human resource capacity,

these strategies at facilities throughout India.

facility-based infrastructure and equipment, health ser-

The ABCE project in India has sought to generate the

vice availability, patient volume, facility-based efficiencies,

equity of health service provision. In this report, we ex-

factors of health service delivery as captured by patient

efficiencies and costs associated with service provision for

Table 2 defines the cornerstone concepts of the ABCE

evidence base for improving the cost-effectiveness and

costs associated with service provision, and demand-side

amine facility capacity across platforms, as well as the

exit interviews.

each type of facility. Based on patient exit interviews, we

project: Access, Bottlenecks, Costs, and Equity.

ABCE Facility Survey

or the ABCE project in India, we conducted primary data collection through a

Through the ABCE Facility Survey, direct data collec-

two-pronged approach:

tion was conducted from a state-representative sample of

health service platforms and captured information on the

1. A comprehensive facility survey administered to a

following indicators for the five fiscal years (running from

representative sample of health facilities in select

April to March of the following year) prior to the survey:

states in India (the ABCE Facility Survey)

• Inputs: the availability of tangible items that are

2. Interviews with patients as they exited the

needed to provide health services, including in-

sampled facilities

frastructure and utilities, medical supplies and equipment, pharmaceuticals, personnel, and

Here, we provide an overview of the ABCE sur-

non-medical services.

vey design and primary data collection mechanisms.

• Finances: expenses incurred, including spending on

All ABCE survey instruments are available online at

infrastructure and administration, medical supplies

http://www.healthdata.org/dcpn/india.

and equipment, pharmaceuticals including vaccines,

Table 2 Access, Bottlenecks, Costs, and Equity

and personnel. Facility funding from different sources (e.g., central and state governments) and revenue

Access, Bottlenecks, Costs, and Equity

from service provision were also captured.

• Outputs: volume of services and procedures pro-

Access

duced, including outpatient and inpatient care,

Health services cannot benefit populations if they cannot be accessed; thus, measuring which elements are

emergency care, and laboratory and diagnostic tests.

driving improved access to – or hindering contact with – health facilities is critical. Travel time to facilities, user fees, and cultural preferences are examples of factors that can affect access to health systems.

• Supply-side constraints and bottlenecks: factors

that affected the ease or difficulty with which patients

Bottlenecks

received services they sought, including bed avail-

Mere access to health facilities and the services they provide is not sufficient for the delivery of care to popula-

ability, pharmaceutical availability and stockouts,

tions. People who seek health services may experience supply-side limitations, such as medicine stockouts, that

cold-chain capacity, personnel availability, and

prevent the receipt of proper care upon arriving at a facility.

service availability.

Costs

Table 3 provides more information on the specific

Health services cost can translate into very different financial burdens for consumers and providers of such

indicators included in the ABCE Facility Survey.

care. Thus, the ABCE project measures these costs at several levels, quantifying what facilities spend to provide services. Equity

Various factors influence how populations interact with a health system. The nature of these interactions either facilitates or obstructs access to health services. In addition to knowing the cost of scaling up a given set of

services, it is necessary to understand costs of scale-up for specific populations and across population-related factors (e.g., distance to health facilities). The ABCE project aims to pinpoint which factors affect the access to and use of health services and to quantify how these factors manifest.

A B C E I N TA M I L N A D U

Table 3 Modules included in the ABCE Facility Survey in India SURVEY MODULE Module 1: Facility finances and inputs

SURVEY CATEGORY

KEY INDICATORS AND VARIABLES

Inputs

Input funding sources, managing authority, and maintenance information Availability and functionality of medical and non-medical equipment

Finances

Salary/wages, benefits, and allowances Total expenses for infrastructure and utilities; medical supplies and equipment; pharmaceuticals; administration and training; non-medical services, personnel (salaries and wages, benefits, allowances) Performance and performance-based financing questions

Revenue

User fees; total revenue and source

Personnel characteristics

Total personnel by cadre Funding sources of personnel Health services provided and their staffing; administrative and support services and their staffing

Module 2: Facility management and direct observation

Facility management and infrastructure characteristics

Characteristics of patient rooms; electricity, water, and sanitation Facility meeting characteristics Guideline observation

Direct observation

Latitude, longitude, and elevation of facility. Facility hours, characteristics, and location; waiting and examination room characteristics

Facility capacity

Lab-based tests available

Medical consumables and equipment

Lab-based medical consumables and supplies available

Module 4: Pharmaceuticals

Facility capacity

Drug availability and stockout information

Module 5: General medical consumables, equipment, and capacity

Medical consumables and equipment

Availability and functionality of medical furniture, equipment, and supplies

Module 6: Facility outputs

Facility capacity

Fund and vehicle availability for referral and emergency referral

General service provision

Inpatient care and visits; outpatient care and visits; emergency visits; home or outreach visits

Module 3: Lab-based consumables, equipment, and capacity

A B C E P R OJ E CT D E S I G N

Sample design

Figure 1 Sampled districts in Tamil Nadu

A total of 13 districts in Tamil Nadu were selected for

the ABCE survey (Figure 1). The districts were selected using three strata to maximize heterogeneity: proportion of

full immunization in children aged 12â&#x20AC;&#x201C;23 months as an indicator of preventive health services; proportion of safe delivery (institutional delivery or home delivery assisted

by skilled person) as an indicator of acute health services;

and proportion of urban population as an indicator of

overall development. The districts were grouped as high

and low for urbanization based on median value, and into

three equal groups as high, medium, and low for the safe delivery and full immunization indicators. Twelve districts

were selected randomly from each of the various combinations of indicators, and in addition the capital district

was selected purposively.

Within each sampled district, we then sampled pub-

lic sector health facilities at all levels of services based

on the structure of the state health system (Figure 2).

Figure 2 Sampling strategy for health facilities in a district in the ABCE survey in India

Inventory of procedures for sterilization, sharp items, and infectious waste Inventory of personnel

Laboratory and diagnostic tests Module 7: Vaccines

Facility procedures for vaccine supply, delivery and disposal

Source from vaccine obtained Personnel administering vaccine Procedures to review adverse events Disposal of vaccines

Vaccine availability, storage, and output

Stock availability and stockouts of vaccines and syringes Types and functionality of storage equipment for vaccines Temperature chart history; vaccine inventory and vaccine outputs; vaccine outreach and home visits Vaccine sessions planned and held

Selected facilities are in blue; unselected facilities from the sampling frame are in grey. DH: District hospital; SDH: Sub-district hospital; CHC: Community health centre; PHC: Primary health centre; SHC: Sub health centre

A B C E I N TA M I L N A D U

A B C E P R OJ E CT D E S I G N

Data collection for the ABCE survey in TN

Table 4 Types of questions included in the Patient Exit Interview Survey in India SURVEY CATEGORY

Data collection took place from October 2012 to Jan-

TYPES OF KEY QUESTIONS AND RESPONSE OPTIONS

Direct observation of patient

Sex of patient (and of patient’s attendant if surveyed)

Direct interview with patient

Demographic questions (e.g., age, level of education attained, caste)

uary 2013. Prior to survey implementation, PHFI and the

data collection agency hosted a two-week training work-

shop for 30 interviewers, where they received extensive

Scaled-response satisfaction scores (e.g., satisfaction with medical doctor)

training on the electronic data collection software (Dat-

Open-ended questions for circumstances and reasons for facility visit, as well as visit characteristics (e.g., travel time to facility) Reporting costs associated with facility visit (user fees, medications, transportation, tests, other), with an answer of “yes” prompting follow-up questions pertaining to amount

Stat), the survey instruments, the Tamil Nadu health

system’s organization, and interviewing techniques.

Following this workshop, a one-week pilot of all survey instruments took place at health facilities. Ongoing training

occurred on an as-needed basis throughout the course of data collection.

All collected data went through a thorough verification

process between PHFI and IHME and the ABCE field team.

Table 5 Facility sample, by platform, for the ABCE project in Tamil Nadu

In each sampled district, one district hospital (DH); all

sub-district hospitals (SDH, from a total of zero to three)

for each sampled DH; two community health centres

(CHC, from a total of two to five) for each sampled SDH;

FACILITY TYPE

two primary health centres (PHC, from a total of two to

FINAL SAMPLE

four) for each sampled CHC; and one sub centre (SHC,

District hospital

randomly selected for the study.

Sub-district hospital

Community health centre

interviewed at each facility, based on the expected out-

Primary health centre

were interviewed at district hospitals, 16 at SDH, 12 at CHC,

Sub health centre

on a convenience sample. The main purpose of the Pa-

Total health facilities

168

from a total of one to four) for each sampled PHC were

Patient exit interview survey

A fixed number patients or attendants of patients were

patient density for the platform. A target of 16 patients

10 at PHC, and five at SHC. Patient selection was based

Following data collection, the data were methodically cleaned and re-verified, and securely stored in databases

hosted at PHFI and IHME.

A total of 168 health facilities participated in the ABCE

project in Tamil Nadu. Eleven facilities were replaced (one

DH, one SDH, two CHCs, one PHC, and six SHCs) due to

data being unavailable for the years considered; the re-

porting chain of the sampled facility being incorrect; or

the facility having been functional for less duration.

tient Exit Interview Survey was to collect information on patient perceptions of the health services they received

and other aspects of their facility visit (e.g., travel time

to facility, costs incurred during the facility visit, and satisfaction with the health care provider). Table 4 provides more information on the specific indicators included in

the exit survey. This information fed into quantifying the

“demand-side” constraints to receiving care (as opposed

to the facility-based, “supply-side” constraints and bottlenecks measured by the ABCE Facility Survey).

M A I N F I N D I N G S : H E A LT H FA C I L I T Y P R O F I L E S

Main findings Health facility profiles T

Table 6 Availability of services in health facilities, by platform DISTRICT HOSPITAL (DH)

he delivery of facility-based health ser-

100%

Routine births

100%

Emergency obstetrics

100%

88%

75%

Antenatal care

100%

Surgical services

100%

92%

75%

Cardiology

77%

38%

generally offered fewer services than district hospitals

Psychiatric

77%

19%

and gynecology and accident and emergency services.

Accident, trauma, and emergency

100%

88%

Ophthalmology

100%

35%

75%

Pediatric

100%

92%

88%

General anesthesiology

100%

69%

54%

Blood bank

100%

27%

Dentistry

100%

77%

46%

92%

81%

82%

STI/HIV

100%

69%

83%

Immunization

100%

77%

92%

Internal/general med

100%

96%

Mortuary

100%

85%

municable diseases, such as cardiology, psychiatry, and

resources, ranging from personnel to phys-

chemotherapy, particularly at the sub-district and com-

ical infrastructure, that vary in their relative

munity levels. District hospitals reported a wide range

tors support the provision of services at lower costs and

tistry, and emergency obstetrics. Sub-district hospitals

importance and cost to facilities. Determining what fac-

of services such as blood banks, surgical services, den-

higher levels of efficiency at health facilities is critical in-

formation for policymakers to expand health system

but still reported high coverage of services like obstetrics

coverage and functions within constrained budgets.

Using the ABCE TN facility sample (Table 5), we

One-quarter of community health centres reported that

analyzed five key drivers of health service provision

they did not provide surgical services or emergency

at facilities:

obstetrics, while only around half provided dentistry

and anesthesiology.

• Facility-based resources (e.g., human resources,

infrastructure and equipment, and pharmaceuticals),

Human resources for health

which are often referred to as facility inputs.

A facility’s staff size and composition directly affect

• Patient volumes and services provided at facilities

the types of services it provides. In general, a greater

(e.g., outpatient visits, inpatient bed-days), which are

availability of health workers is related to higher service

also known as facility outputs.

utilization and better health outcomes.1 India has a severe shortage of qualified health workers and the workforce is

• Patient-reported experiences, capturing “de-

concentrated in urban areas.2 The public health system

mand-side” factors of health service delivery.

has a shortage of both medical and paramedical per-

• Facility alignment of resources and service

sonnel. The number of primary and community health

production, which reflects efficiency.

centres without adequate staff is substantially higher if

high health-worker absenteeism is taken into consider-

• Facility expenditures and production costs for

ation.3 The Indian Government is aware of the additional

service delivery.

requirements and shortages in the availability of health

These components build upon each other to create

workers for the future. The National Rural Health Mission,

a comprehensive understanding of health facilities in

for instance, recommends a vastly strengthened infra-

TN, highlighting areas of high performance and areas

structure, with substantial increases in personnel at every

for improvement.

tier of the public health system.4

Based on the ABCE sample, we found substantial het-

Facility capacity and characteristics

DOTS treatment

Burns

100%

58%

21%

Orthopedic

100%

31%

Pharmacy

100%

69%

23%

Alternative medicine

100%

92%

Diagnostic medical

100%

83%

Laboratory services

100%

96%

100%

15%

88%

Chemotherapy Dermatology

Outreach services LOWEST AVAILABILITY

Service availability

1 Rao KD, Bhatnagar A, Berman P. So many, yet few: Human resources for health in India. Human Resources for Health. 2012; 10(19). 2 Rao M, Rao KD, Kumar AK, Chatterjee M, Sundararaman T. Human resources for health in India. The Lancet. 2011; 377(9765): 587-98. 3 Hammer J, Aiyar Y, Samji S. Understanding government failure in public health services. Economic and Political Weekly. 2007; 42: 4049–58. 4 National Rural Health Mission. Ministry of Health and Family Welfare, Government of India. Mission Document (2005-2012). New Delhi, India: Government of India, 2005.

Across and within district hospitals, sub-district hospi-

tals and community health centres in TN (Table 6), several

notable findings emerged for facility-based health service provision. While fundamental services such as antenatal

care, routine deliveries, general medicine, and pharmacy

and laboratory services were nearly universally available,

COMMUNITY HEALTH CENTRE (CHC)

Total obstetrics and gynecology services

fewer facilities reported available services for non-com-

vices requires a complex combination of

SUB-DISTRICT HOSPITAL (SDH)

Figure 3 Composition of facility personnel, by platform TN District Hospital

Sub District Hospital

Community Health Centre

Primary Health Centre

Sub Health Centre

100 Number of Staff

Doctors

Nurses

Para-medical staff

Non-medical staff

150

200

erogeneity across facility types in TN by considering the

total number of staff in the context of bed strength (i.e., number of beds in the facility) and patient load (Figure 3).

Overall, the most common medical staff at district hospitals were nurses (63) followed by paramedical staff (58),

non-medical staff (51), and doctors (40), while at lower levels, paramedical staff outnumbered doctors and nurses.

This is reflection of the differential service offerings between higher- and lower-level facilities. Additionally, higher-level facilities tended to have a greater number of

health personnel overall. While a degree of this variation

is due to differences in service provision and population

size, some of this indicates relative shortages in human resources for health.

The greatest number of doctors, nurses, paramedi-

cal staff, and non-medical staff are concentrated at the

district hospitals (average of 211 total staff). Sub-district

hospitals reported the second highest number of personnel; however, the total personnel at these facilities

was one-quarter of what was reported by district hospitals (average of 52 total staff). Community health centres

HIGHEST AVAILABILITY

maintained a smaller body of health workers, an average

total of 32, with most of the medical staff being paramed-

Note: All values represent the percentage of facilities, by platform, that reported offering a given service at least one day during a typical week.

ical (17). Primary health centres reported, on average, 18

staff in total, most of which were paramedical staff (11). Fi-

nally, sub-health centres reported one paramedical staff

who performs immunizations, simple outpatient care, and community outreach.

A B C E I N TA M I L N A D U

Figure 4 Ratio of nurses and ANMs to doctors, by platform

Figure 5 Ratio of nurses and doctors to paramedical and non-medical staff, by platform

Vertical bars represent the platform average ratio.

M A I N F I N D I N G S : H E A LT H FA C I L I T Y P R O F I L E S

Figure 6 Ratio of beds to doctors by platform

Figure 7 Ratio of beds to nurses, by platform

Vertical bars represent the platform average ratio.

District Hospital

Sub District Hospital

District Hospital

Sub District Hospital

District Hospital

Sub District Hospital

Community Health Centre

Primary Health Centre

Community Health Centre

Primary Health Centre

Community Health Centre

Primary Health Centre

Nurses to doctors ratio

non-medical personnel; for instance, a ratio of 2 indicates

that there are two nurses and/or doctors staffed for every

The ratio of number of nurses to number of doctors

one paramedical/non-medical staff. Alternatively, a ratio

is presented in Figure 4. A ratio greater than 1 indicates

lower than 1 indicates that para-medical and/or non-med-

that nurses outnumber doctors; for instance, a ratio of 2

ical personnel outnumber nurses and/or doctors.

indicates that there are two nurses staffed for every one

The average ratio for district hospitals and sub-district

doctor. Alternatively, a ratio lower than 1 indicates that

hospitals was 1.0, though the range of ratios for dis-

doctors outnumber nurses; for instance, a ratio of 0.5 indicates there is one nurse staffed for every two doctors.

trict hospitals (0.7 to 2.0) was slightly narrower than for

cating that they staff more nurses than doctors. However,

tres were more homogenous, reporting an average ratio

sub-district hospitals (0.7 to 2.7). Community health cen-

District hospitals reported an average ratio of 1.8, indi-

of 0.4, with facilities reporting ratios that ranged from 0.2

the ratio reported by various district hospitals ranged

to 0.6. The ratio for primary health centres ranged from

from a low of 0.5 to a high outlier of 6.4. All but two

0.1 to 1.3, with an average of 0.4 doctors and nurses to

sub-district hospitals reported more nurses than doc-

paramedical and non-medical staff.

tors, with a ratio as high as 4.0 nurses to doctors. There

was less heterogeneity among community health centres,

Beds to doctors ratio

with ratios ranging from 0.4 to 2.5. Finally, primary health

The ratio of number of beds to number of doctors in

centres reported a wide range of ratios, from 0.3 to 4.0.

The average ratio of nurses to doctors was similar for dis-

2011 is presented in Figure 6. A ratio greater than 1 indi-

health centres (1.7).

of 2 indicates that there are two beds for every one doc-

cates that beds outnumber doctors; for instance, a ratio

trict hospitals (1.8), sub-district hospitals (1.7), and primary

tor staffed. Alternatively, a ratio lower than 1 indicates that

Nurses and doctors to paramedical and non-medical staff

doctors outnumber beds.

The average ratio of beds to doctors is highest in dis-

trict hospitals (9.7), followed by sub-district hospitals (8.0).

The ratio of number of nurses and/or doctors to num-

ber of paramedical and/or non-medical staff in 2012

Community health centres have an average of 5.2 beds

that nurses and doctors outnumber para-medical and

The average ratio among primary health centres is 2.4,

per doctor, though four facilities have ratios above 10.0.

is presented in Figure 5. A ratio greater than 1 indicates

gets could leave them with an excess of personnel given

with a range of 0.3 to 9.0. Two primary health centres re-

patient loads. While an overstaffed facility has a different

ported fewer beds than doctors.

set of challenges than an understaffed one, each reflects

a poor alignment of facility resources and patient needs.

Beds to nurses ratio

The ratio of number of beds to number of nurses in

To better understand bottlenecks in service delivery and

cates that beds outnumber nurses; for instance, a ratio

ty’s capacity (inputs) in the context of its patient volume

staffed. Alternatively, a ratio lower than 1 indicates that

ings in the “Efficiency and costs” section. As part of the

areas to improve costs, it is important to assess a facili-

2011 is presented in Figure 7. A ratio greater than 1 indi-

and services (outputs). We further explore these find-

of 2 indicates that there are two beds for every one nurse

nurses outnumber beds.

ABCE project in India, we compare levels of facility-based

to nurses was highest among district hospitals (5.9) and

services. In this report, we primarily focus on the delivery

trict hospitals and community health centres had a similar

include doctors, nurses, and other paramedical staff. It

Similar to the ratio of beds to doctors, the ratio of beds

staffing with the production of different types of health

lowest among primary health centres (1.8). While sub-dis-

of health services by skilled medical personnel, which

is possible that non-medical staff also contribute to ser-

average ratio of beds to nurses (5.0 and 5.2, respectively),

vice provision, especially at lower levels of care, but the

the range of ratios was much wider for community

ABCE project in India is not currently positioned to ana-

health centres (1.0 to 12.3) than for sub-district hospitals

lyze these scenarios.

(2.3 to 8.2).

In isolation, facility staffing numbers are less meaning-

Infrastructure and equipment

ful without considering a facility’s overall patient volume

Health service provision depends on the availability of

and production of specific services. For instance, if a facility mostly offers services that do not require a doctor’s

adequate facility infrastructure, equipment, and supplies

get may be less important than having too few nurses.

tial components of physical capital: power supply, water

volumes than others, and thus “achieving” staffing tar-

with the latter composed of laboratory, imaging, and

(physical capital). In this report, we focus on four essen-

administration, failing to achieve the doctor staffing tar-

and sanitation, transportation, and medical equipment,

Further, some facilities may have much smaller patient

other medical equipment. Table 7 illustrates the range of

A B C E I N TA M I L N A D U

M A I N F I N D I N G S : H E A LT H FA C I L I T Y P R O F I L E S

Table 7 Availability of physical capital, by platform DISTRICT HOSPITAL (DH)

Table 8 Availability of functional equipment, by platform

SUB-DISTRICT HOSPITAL (SDH)

COMMUNITY HEALTH CENTRE (CHC)

100%

92%

Piped water

85%

88%

87%

59%

Flush toilet

85%

96%

91%

65%

Hand disinfectant

92%

96%

91%

43%

100%

35%

96%

22%

69%

23%

58%

Landline phone

100%

96%

100%

90%

Computer

100%

98%

Functional electricity

Any 4-wheeled vehicle Emergency 4-wheeled vehicle

PRIMARY HEALTH CENTRE (PHC)

SUB HEALTH CENTRE (SHC)

100%

88%

92%

91%

96%

Child scale

92%

96%

93%

82%

Blood pressure apparatus

92%

100%

92%

Stethoscope

92%

100%

98%

Light source

85%

100%

92%

96%

59%

Glucometer

69%

42%

92%

89%

45%

Test strips for glucometer

69%

42%

83%

72%

35%

Hematologic counter

85%

42%

21%

13%

Blood chemistry analyzer

92%

69%

75%

59%

Incubator

92%

58%

13%

Centrifuge

92%

88%

96%

74%

Microscope

92%

96%

92%

56%

Slides

92%

100%

98%

47%

Slide covers

92%

88%

96%

89%

33%

form level, the sub health centre, access to improved

X-ray

92%

77%

38%

ECG

92%

85%

92%

disinfectant was broadly available as a supplementary

Ultrasound

92%

96%

88%

sanitation method at most platform levels, though it was

CT scan

38%

cilities, 13% reported a severe shortage of water at some

NA: Not applicable to this platform according to standards.

and even in primary health centres. At the lowest plat-

water sources and sanitation was significantly lower. Hand

health centres reported access to a functional electrical

supply, and just 8% of sub health centres lacked func-

tional electricity (Table 7). One facility reported relying

Medical equipment 100%

in sub-district hospitals and community health centres,

All hospitals, community health centres, and primary

SUB-HEALTH CENTRE

92%

flush toilets (Table 7). Notably, these figures were higher

Power supply

PRIMARY HEALTH CENTRE

92%

Note: Values represent the percentage of facilities, by platform, that had a given type of physical capital.

across platforms.

COMMUNITY HEALTH CENTRE

Wheelchair

HIGHEST AVAILABILITY

physical capital, excluding medical equipment, available

SUB-DISTRICT HOSPITAL

Adult scale

NA: Not applicable to this platform according to standards. LOWEST AVAILABILITY

DISTRICT HOSPITAL

Lab equipment

Imaging equipment

not available at many sub health centres. Among all fa-

solely on a generator for power. Inadequate access to consistent electric power has substantial implications

point during the year. These findings show a mixture of

for health service provision, particularly for the effective

both notable gains and ongoing needs for facility-based

storage of medications, vaccines, and blood samples,

water sources and sanitation practices among both hospi-

and these results demonstrate an improvement in the

tals and primary care facilities.

availability of electricity at the lowest platform levels

LOWEST AVAILABILITY

HIGHEST AVAILABILITY

Note: Availability of a particular piece of equipment was determined based on facility ownership on the day of visit. Data on the number of items present in a facility were not collected. All values represent the percentage of facilities, by platform, that had a given piece of equipment.

Transportation and computers

compared to 2007â&#x20AC;&#x201C;2008, when 87% of primary health

centres and 70% of sub health centres had a regular

Facility-based transportation and modes of commu-

electric supply.

nication varied across platforms (Table 7). In general, the

availability of a vehicle decreased down the levels of the

Water and sanitation

health platform, though more community health centres

85% of district hospitals had availability of improved

reported having a vehicle than did sub-district hospitals.

sanitation with a functional sewer infrastructure with

four-wheeled vehicles at all, which means transferring

water sources (functional piped water) and improved

Only around one-fifth of primary health centres had any patients under emergency circumstances from these

facilities could be fraught with delays and possible com-

5 International Institute for Population Sciences (IIPS). District Level Household and Facility Survey (DLHS-3), 2007-08: India, Tamil Nadu. Mumbai, India: IIPS, 2010.

plications. Community health centres had a relatively

high level of transport availability, with 96% having a four-

A B C E I N TA M I L N A D U

wheeled vehicle and 58% having dedicated emergency

M A I N F I N D I N G S : H E A LT H FA C I L I T Y P R O F I L E S

types of equipment should be available in hospitals and

transportation. Alongside transportation, communication

primary care facilities.6 Table 8 illustrates the distribution

is also a necessary facet of the efficient delivery of health

of SARA scores across platforms. In general, hospitals

Table 10 Availability of blood tests and functional equipment to perform routine delivery care, by platform

services. The availability of modes of communication was

had greater availability of medical equipment, and defi-

ported having a landline phone, and computer facilities

lower levels of care. Lacking scales and blood pressure

Testing availability

clinical data; these were generally available, but facilities

generally high at all facility levels: nearly all facilities re-

cits in essential equipment availability were found in the

were widely available across platforms.

cuffs can severely limit the collection of important patient

Equipment

at all levels reported missing some of these vital pieces

For three main types of facility equipment – medical,

of equipment.

lab, and imaging – clear differences emerge across levels

Microscopes and corresponding components were

of health service provision, with Table 8 summarizing the

largely prevalent among all facilities, except at primary

availability of functional equipment by platform.

health centres where many reported having slides but al-

We used the WHO’s Service Availability and Readi-

most half had no microscope to use them with. Additional

ness Assessment (SARA) survey as our guideline for what

testing capacity was relatively high in district hospitals but 6 World Health Organization (WHO). Service Availability and Readiness Assessment (SARA) Survey: Core Questionnaire. Geneva, Switzerland: WHO, 2013.

DISTRICT HOSPITAL

SUB-DISTRICT HOSPITAL

COMMUNITY HEALTH CENTRE

PRIMARY HEALTH CENTRE

Hemoglobin

92%

100%

96%

65%

Glucometer and test strips

69%

38%

79%

72%

Cross-match blood

92%

31%

Blood pressure apparatus

92%

100%

IV catheters

92%

100%

98%

Gowns

92%

96%

100%

91%

Measuring tape

92%

100%

98%

Masks

85%

92%

96%

83%

Sterilization equipment

92%

83%

57%

Adult bag valve mask

92%

88%

96%

59%

Ultrasound

92%

96%

88%

Infant scale

85%

92%

96%

94%

Scissors or blade

92%

96%

100%

Needle holder

92%

100%

98%

Speculum

92%

96%

100%

Forceps

92%

85%

Dilation and curettage kit

92%

88%

67%

59%

Neonatal bag valve mask

92%

100%

96%

Vacuum extractor

92%

50%

42%

30%

Incubator

85%

42%

21%

22%

100%

54%

Medical equipment

Delivery equipment

Table 9 Availability of tests and functional equipment to perform routine antenatal care, by platform DISTRICT HOSPITAL

SUB-DISTRICT HOSPITAL

COMMUNITY HEALTH CENTRE

PRIMARY HEALTH CENTRE

SUB HEALTH CENTRE

Testing availability Urinalysis

92%

96%

92%

48%

16%

Hemoglobin

92%

100%

96%

65%

14%

Glucometer and test strips

69%

38%

79%

72%

33%

Blood typing

92%

54%

Blood pressure apparatus

92%

100%

92%

Adult scale

92%

88%

92%

91%

86%

Ultrasound

92%

96%

88%

100%

95%

69%

27%

63%

31%

Functional equipment

Service summary Facilities reporting ANC services Facilities fully equipped for ANC provision based on above tests and equipment availability

Service summary Facilities reporting delivery services Facilities fully equipped for delivery services based on above tests and equipment availability

NA: Not applicable to this platform according to standards. LOWEST AVAILABILITY

HIGHEST AVAILABILITY

Note: Availability of a given delivery item was determined by its availability at a facility on the day of visit. All values represent the percentage of facilities, by platform, that had the given delivery item. The service summary section compares the total percentage of facilities reporting that they provided routine delivery services with the total percentage of facilities that carried all of the recommended pharmaceuticals and functional equipment to provide routine delivery services.

NA: Not applicable to this platform according to standards. LOWEST AVAILABILITY

HIGHEST AVAILABILITY

Note: Availability of a given ANC item was determined by its availability at a facility on the day of visit. All values represent the percentage of facilities, by platform that had the given ANC item. The service summary section compares the total percentage of facilities reporting that they provided ANC services with the total percentage of facilities that carried all of the functional equipment to provide ANC services.

A B C E I N TA M I L N A D U

M A I N F I N D I N G S : H E A LT H FA C I L I T Y P R O F I L E S

Table 11 Availability of blood tests and functional equipment to perform general surgery, by platform DISTRICT HOSPITAL (DH)

SUB-DISTRICT HOSPITAL (SDH)

COMMUNITY HEALTH CENTRE (CHC)

PRIMARY HEALTH CENTRE (PHC)

Testing availability

poorer in sub-district hospitals, community health centres,

38% of facilities.

89% of primary health centres had a glucometer, only

ments in equipping health facilities with basic medical

had one. Additionally, blood chemistry analyzers were

ensuring that these facilities carry the supplies they need

to this trend: while 92% of community health centres and

92%

100%

96%

65%

Cross-match blood

92%

31%

cates limited capacity for addressing non-communicable

ment is necessary. Other essential equipment, including

Blood pressure apparatus

92%

100%

IV catheters

92%

100%

98%

Sterilization equipment

92%

83%

57%

Gowns

92%

96%

100%

91%

Masks

85%

92%

96%

83%

Adult bag valve mask

92%

88%

96%

59%

Surgical equipment Scissors

92%

96%

100%

Thermometer

92%

96%

78%

General anesthesia equipment

92%

81%

71%

Scalpel

92%

96%

67%

Suction apparatus

92%

96%

88%

74%

Retractor

92%

88%

75%

28%

Nasogastric tube

92%

88%

57%

Blood storage unit/refrigerator

92%

46%

25%

Intubation equipment

92%

81%

67%

31%

Service summary Facilities reporting general surgery services Facilities fully equipped for general surgery services based on above tests and equipment availability

100%

92%

75%

46%

85%

21%

NA: Not applicable to this platform according to standards. LOWEST AVAILABILITY

HIGHEST AVAILABILITY

Note: Availability of a given surgery item was determined by its availability at a facility on the day of visit. All values represent the percentage of facilities, by platform, that had the given surgery item. The service summary section compares the total percentage of facilities reporting that they provided general surgery services with the total percentage of facilities that carried all of the recommended functional equipment to provide general surgery services.

Overall, these findings demonstrate gradual improve-

69% of district hospitals and 42% of sub-district hospitals

Hemoglobin

Medical equipment

ment, with the exception of X-ray, which was available in

and primary health centres. There were some exceptions

equipment in TN, as well as the continued challenge of

available in only 69% of sub-district hospitals. This indi-

to provide a full range of services. Measuring the avail-

diseases (NCDs) such as diabetes, for which this equip-

specific deficits, but assessing a health facilityâ&#x20AC;&#x2122;s full stock

ability of individual pieces of equipment sheds light on

of necessary or recommended equipment provides a

hematologic counters and incubators, were notably

more precise understanding of a facilityâ&#x20AC;&#x2122;s service capacity.

missing from community health centres and primary

Focus on service provision

health centres.

For the production of any given health service, a

District hospitals had good availability of imaging

equipment, with the notable exception of CT scans, which

health facility requires a complex combination of the ba-

showed somewhat patchier availability of imaging equip-

personnel who are adequately trained to administer nec-

4% having CT scanners. Community health centres had

it is important to consider this intersection of facility re-

sic infrastructure, equipment, and pharmaceuticals, with

were available in 38% of facilities. Sub-district hospitals

essary clinical assessments, tests, and medications. Thus,

ment, with 77% reporting the availability of X-ray and only

sources to best understand facility capacity for care. In

relatively high availability of essential imaging equip-

Table 12 Availability of laboratory tests, by platform DISTRICT HOSPITAL (DH)

SUB-DISTRICT HOSPITAL (SDH)

COMMUNITY HEALTH CENTRE (CHC)

PRIMARY HEALTH CENTRE (PHC)

Blood typing

92%

54%

Cross-match blood

92%

31%

Complete blood count

92%

81%

17%

Hemoglobin

92%

100%

96%

65%

HIV

92%

85%

88%

20%

Liver function

92%

35%

Malaria

85%

73%

96%

56%

Renal function

92%

42%

Serum electrolytes

62%

Spinal fluid test

46%

Syphilis

92%

85%

42%

Tuberculosis skin

92%

88%

92%

20%

Urinalysis

92%

96%

92%

48%

NA: Not applicable to this platform according to standards. LOWEST AVAILABILITY

HIGHEST AVAILABILITY

Note: Availability of a given test was determined by its availability at a facility on the day of visit. All values represent the percentage of facilities, by platform, that had the given test.

A B C E I N TA M I L N A D U

M A I N F I N D I N G S : H E A LT H FA C I L I T Y P R O F I L E S

Figure 8 Number of outpatient visits, by platform

this report, we further examined facility capacity for a

Note: Each line represents outpatient visits for an individual facility, with the bold line depicting the average for the platform. Scales are different for each platform.

eral surgery, and laboratory testing. For these analyses

Antenatal care services

subset of specific services â&#x20AC;&#x201C; antenatal care, delivery, gen-

In TN, according to the National Family Health Sur-

vey-4, 81% of women had at least four antenatal care

of service provision, we only included facilities that re-

ported providing the specific service, excluding facilities

800000

SDH

vided nor the quality of care received. Through the ABCE

but did not report providing it in the ABCE Facility Sur-

Facility Survey, we estimated what proportion of facilities

vey. Thus, our findings reflect more of a service capacity

stocked the range of tests and medical equipment to con-

â&#x20AC;&#x153;ceilingâ&#x20AC;? across platforms, as we are not reporting on the

duct a routine ANC visit. It is important to note that this list

facilities that likely should provide a given service but

Visits 400000

1000000 Visits

was not exhaustive but represented a number of relevant

have indicated otherwise on the ABCE Facility Survey.

supplies necessary for the provision of ANC.

200000

500000

though, neither reflects what services were actually pro-

that were potentially supposed to provide a given service

600000

1500000

(ANC) visits during their last pregnancy. 7 This figure,

7 International Institute for Population Sciences (IIPS). National Family Health Survey (NFHS-4), 2015-2016: Tamil Nadu Factsheet. Mumbai, India: IIPS, 2016.

OP visits by facility

OP visits average

PHC

100000

Figure 9 Number of inpatient visits (excluding deliveries), by platform Note: Each line represents inpatient visits for an individual facility, with the bold line depicting the average for the platform. Scales are different for each platform.

2009

2008

2007

2011

2010

OP visits by facility

OP visits average

2011

150000 100000

10000

SHC

2010 OP visits average

50000

2009

OP visits by facility

2007

2008

2009

2010

2007

2011

2000 1500 500

2010 OP visits average

2007

2008

2009

IP visits by facility

2011

2009

OP visits by facility

2010 IP visits average

Visits 1000

2000 2008

2009

PHC

Visits

2000 0

2007

2008

IP visits by facility

IP visits average

CHC

3000

Visits 4000 6000

8000

IP visits by facility

2008

SDH

Visits

100000

20000

50000 0

2007

150000

80000 Visits 60000

2011

40000

150000 Visits 100000

200000

CHC

2010

OP visits by facility

2009

2008

2007

2011

2010

Visits

2009

1000

2008

50000

2007

2010

2007

2011

2008

2009

IP visits by facility

IP visits average

2010 IP visits average

2011

A B C E I N TA M I L N A D U

M A I N F I N D I N G S : H E A LT H FA C I L I T Y P R O F I L E S

Figure 10 Number of deliveries, by platform

Figure 11 Number of immunization doses administered, by platform

Note: Each line represents deliveries for an individual facility, with the bold line depicting the average for the platform. Scales are different for each platform.

Note: Each line represents immunization doses for an individual facility, with the bold line depicting the average for the platform. Scales are different for each platform.

2010

2011

500

PHC

2009

2010

400000 Doses administered 100000 200000 300000

CHC

0 2007

2011

2008

2009

Deliveries by facility

Deliveries average

2010

2011

Deliveries average

2007

2008

Across the levels of care, we found a substantial gap

munity health centres, and primary health centres in this

between facility-reported capacity for ANC provision and

survey reported providing ANC services, few were ad-

the fraction of the facilities fully equipped to deliver ANC

striking with sub-district hospitals, where only 27% of fa-

from district hospitals to the lower levels of care, reported

equately supplied for care. This discrepancy was most

care. This service-capacity gap meant that many facilities,

cilities were fully equipped to provide ANC, largely due to

providing ANC but then lacked at least one piece of the

the fact that just 38% carried glucometers and test strips.

functional equipment needed to optimally address the

One-third of district hospitals were not fully equipped,

Immunization doses by facility

Immunization doses average

SHC

Doses administered 1000 1500 2000

ANC is presented in Table 9. While all hospitals, com-

2007

2008

2009

Immunization doses by facility

range of patient needs during an ANC visit. Lack of sim-

again due to the lack of a functional glucometer and

ple tests or material for tests (such as glucometer and test

strips. There was a paucity of testing availability at primary

strips) prevented most facilities from being listed as fully

and sub health centres. In general, however, availability of

equipped to provide ANC services. These findings do not

2009

2008

2007

2011

2010

2009

Immunization doses by facility

500

functional equipment was fairly high.

2010

2011

Immunization doses average

PHC

The availability of tests and functional equipment for

Immunization doses by facility

Immunization doses average

2500

Deliveries by facility

2009

2008

2007

2011

2010

2009

Doses administered 5000 10000 15000

100 0

2008

Immunization doses by facility

Deliveries 200 300

800 Deliveries 400 600 200 0

2007

Deliveries average

50000

2009

400

1000

2008

Deliveries by facility

CHC

Doses administered 50000 100000 2007

2011

Doses administered 10000 20000 30000 40000

2010 Deliveries average

SDH

2009

Deliveries by facility

20000

2008

1000

Deliveries 2000

Deliveries 5000 10000 0

2007

150000

4000

SDH

3000

15000

2010

2011

Immunization doses average

2010

2011

Immunization doses average

A B C E I N TA M I L N A D U

M A I N F I N D I N G S : H E A LT H FA C I L I T Y P R O F I L E S

Table 13 Characteristics of patients interviewed after receiving care at facilities

though this is still a notable gap. The availability of in-

SDH

CHC

PHC

SHC

TOTAL

Total patient sample

422

569

413

603

270

2277

Percent female

54%

55%

63%

61%

82%

61%

<16

12%

11%

10%

16–29

32%

26%

36%

33%

41%

32%

30–39

21%

22%

18%

21%

26%

21%

40–49

17%

18%

15%

16%

13%

16%

>50

19%

23%

21%

23%

17%

21%

Scheduled caste/scheduled tribe

27%

29%

27%

34%

25%

29%

Other backwards caste

60%

56%

60%

58%

65%

59%

Patient’s age group (years)

Education attainment None

18%

22%

18%

24%

18%

20%

Classes 1 to 5

21%

25%

26%

24%

19%

23%

Classes 6 to 9

29%

27%

21%

27%

26%

Class 10 or higher

33%

26%

29%

31%

36%

30%

DH: District hospital; SDH: Sub-district hospital; CHC: Community health centre; PHC: Primary health centre Note: Educational attainment refers to the patient’s level of education or the attendant’s educational attainment if the interviewed patient was younger than 18 years old.

suggest that these platforms are entirely unable to pro-

Figure 12 Patient travel times to facilities, by platform

vide adequate ANC services; it simply means that the vast

majority of facilities did not have the recommended diagnostics and medical equipment for ANC.

Delivery care services

99% of deliveries in TN occur in a health facility, and

SDH

67% in a public facility.8 Availability of essential equipment is necessary for providing high-quality delivery care;

CHC

mostly available across platforms, though availability de-

cubators and vacuum extractors was notably lacking at

clined at lower-level facilities, particularly with regard to

sub-district hospitals, community health centres, and pri-

sterilization equipment and adult bag valve masks, which

mary health centres, despite these being essential items

were available in less than two-thirds of sub health cen-

for service provision. Cross-match blood tests were also

tres. Availability of surgical equipment was also relatively

not widely available outside of district hospitals.

high at hospitals, with the exception of blood storage

This finding is cause for concern, as not having access

units at sub-district hospitals. There were large gaps in

to adequate delivery equipment can affect both maternal and neonatal outcomes at all levels of care.

9,10

surgical equipment in community health centres and

Again, we

primary health centres, indicating a lack of capacity to

found a substantial gap between the proportion of facil-

provide surgical services. It is also crucial to consider the

ities, across platforms, that reported providing routine

human resources available to perform surgical proce-

delivery services and those that were fully equipped for

dures, as assembling an adequate surgical team is likely

their provision.

to affect patient outcomes. Given the nature of documentation of human resources in the records, such data could

General surgery services

not be captured, but future work on assessing surgical ca-

Availability of essential tests and equipment for gen-

pacity at health facilities should collect this information.

eral surgery services are presented in Table 11. There was

Laboratory testing

a lack of cross-match blood tests and blood storage units

across all platforms. Essential medical equipment was

The availability of laboratory tests is presented in Ta-

ble 12. While all district hospitals and sub-district hospitals offer the range of laboratory services, there were gaps

9 Nyamtema AS, Urassa DP, van Roosmalen J. Maternal health interventions in resource limited countries: a systematic review of packages, impacts and factors for change. BMC Pregnancy and Childbirth. 2011; 11(30). 10 Wall SN, Lee ACC, Carlo W, Goldenberg R, Niermeyer S, Darmstadt GL, et al. Reducing intrapartum-related neonatal deaths in low- and middle-income countries — what works? Seminars in Perinatology. 2010; 34: 395–407.

trict hospitals and decreased at lower facility levels, with

Figure 13 Patient wait times at facilities, by platform

Figure 14 Patient scores of facilities, by platform

in test availability. Availability was generally high in disparticularly large gaps among primary health centres.

However, some tests had low availability at all levels. Se-

SDH

CHC

these results are presented in Table 10. Availability was

PHC

generally highest in district hospitals, declining at lower

levels with notable gaps among community and primary

SHC

health centres. While all facility levels offered routine

60 Percent (%)

< 30 min.

delivery services, no community or primary health cen-

100

tres had all essential tests and equipment available, and

> 30 min.

only 4% of sub-district hospitals were fully equipped.

PHC

SHC SHC

0 0

60 Percent (%)

< 30 min.

100

60 Percent (%) <6 8-9

> 30 min.

100

6-7 10

This number increased to 54% among district hospitals,

DH: District hospital; SDH: Sub-district hospital; CHC: Community health centre; PHC: Primary health centre; SHC: Sub health centre

8 International Institute for Population Sciences (IIPS). National Family Health Survey (NFHS-4), 2015-2016: Tamil Nadu Factsheet. Mumbai, India: IIPS, 2016.

DH: District hospital; SDH: Sub-district hospital; CHC: Community health centre; PHC: Primary health centre; SHC: Sub health centre

DH: District hospital; SDH: Sub-district hospital; CHC: Community health centre; PHC: Primary health centre; SHC: Sub health centre Note: Facility ratings were reported along a scale of 0 to 10, with 0 as the worst facility possible and 10 as the best facility possible.

A B C E I N TA M I L N A D U

M A I N F I N D I N G S : H E A LT H FA C I L I T Y P R O F I L E S

Table 14 Proportion of patients satisfied with facility visit indicators, by platform DISTRICT HOSPITAL

SUBDISTRICT HOSPITAL

COMMUNITY HEALTH CENTRE

inpatient visits (other than deliveries) by year are pre-

number of outpatient visits increased slightly over five fis-

inpatient visits have increased for all platforms. District

sented in Figure 9. Over time, the average number of

platform, is presented in Figure 8. In general, the average

PRIMARY HEALTH CENTRE

SUB HEALTH CENTRE

Staff interactions

Nurse/ANM

time. The number of outpatient visits by fiscal year, by

Medical provider respectfulness

57%

63%

73%

72%

77%

Clarity of provider explanations

57%

55%

71%

70%

79%

Time to ask questions

48%

56%

69%

66%

73%

Medical provider respectfulness

61%

64%

72%

74%

92%

hospitals provided care for an average of 50,332–56,729

cal years. Patient volume was highest in district (average

inpatient visits per fiscal year. Sub-district hospitals pro-

of 619,435–658,125 visits per year). Sub-district hospitals

reported an average of 200,278–221,487 visits per year,

vided care for an average of 7,938–13,711 visits per year,

nity health centres (average of 58,034–64,999 visits per

its (an average between 717 and 1,018 inpatient visits

more outpatient visits (average of 37,091–45,806 visits per

fewer inpatient visits (on average 333–606 visits per

while community health centres provided far fewer vis-

which was nearly triple the number reported by commu-

per year). Primary health centres reported substantially

year). Primary health centres reported more than 40 times

year). It is important to note that the ABCE Facility Survey

year) than sub-health centres (average of 752–969 visits

did not capture information on the length of inpatient

per year).

stays, which is a key indicator to monitor and include in

Doctor

Inpatient visits generally entail more service demands

58%

64%

70%

72%

58%

Time to ask questions

51%

60%

68%

70%

67%

Cleanliness

36%

37%

50%

56%

Privacy

50%

42%

58%

54%

58%

Facility characteristics

LOWEST AVAILABILITY

HIGHEST AVAILABILITY

rum electrolyte tests, useful as part of a metabolic panel

Figure 15 Availability of prescribed drugs at facility, by platform

and to measure symptoms of heart disease and high

blood pressure, had low availability in district hospitals

(62%), sub-district hospitals (8%), and community health

centres (8%). Spinal fluid tests were also rare among fa-

cilities, present at only 46% of district hospitals and 4% of

sub-district hospitals. Liver and renal function tests were

SDH

widely available at district hospitals, but lacking from

CHC

other facility levels. There were striking gaps in the capac-

ity to test for infectious diseases at primary health centres,

PHC

as only 20% reported the availability of HIV or tuberculosis tests, and just 56% had tests for malaria.

SHC

The reported number of deliveries, by platform and

facility resources such as beds .The reported number of Clarity of provider explanations

future work.

than outpatient visits, including ongoing occupancy of

60 Percent (%)

Got none/some of the drugs

Figure 16 Determinants of satisfaction with doctors

Female Male >=40 years 16-39 years Other castes Backwards caste Any schooling No schooling Not given all prescribed drugs Given all prescribed drugs Wait time <30 min Wait time >=30 min DH PHC CHC SDH

2 Odds Ratio

Facility outputs

100

Measuring a facility’s patient volume and the number

Got all perscribed drugs

of services delivered, which are known as outputs, is crit-

DH: District hospital; SDH: Sub-district hospital; CHC: Community health centre; PHC: Primary health centre; SHC: Sub health centre

ical to understanding how facility resources align with

Dotted vertical line represents an odds ratio of one. Black points represent the reference groups, which all carry an odds ratio of one. Compared to the referent category, significant odds ratios and 95% confidence intervals are represented with blue points and horizontal lines, respectively. Odds ratios that are not significant are represented by green points, and their 95% confidence intervals with a green horizontal line. Any confidence intervals with an upper bound above 4 were truncated for ease of interpretation.

in average outpatient volume across platforms and over

DH: District hospital; SDH: Sub-district hospital; CHC: Community health centre; PHC: Primary health centre

patient demand for care. Figure 8 illustrates the trends

A B C E I N TA M I L N A D U

M A I N F I N D I N G S : H E A LT H FA C I L I T Y P R O F I L E S

over time, is presented in Figure 10. District hospitals re-

tals and community health centres. The highest volume of

each year of observation, while sub-district hospitals re-

hospitals, with an average between 25,783 and 30,947

ported an average between 3,291 and 3,940 deliveries in

immunization doses administered was seen in sub-district

ported an average of 505–586 deliveries per year. While

Table 15 Input-output model specifications CATEGORY

doses per year. District hospitals reported an average be-

many hospitals experienced an increase in the number

Inputs

tween 17,285 and 17,771 doses administered in each year

of deliveries over time, several hospitals reported de-

of observation. Community health centres reported pro-

creasing numbers over the five years of observation.

viding an average number of doses between 4,808 and

Community health centres reported an annual average

5,815 per year, similar to primary health centres, which

ies were reported in primary health centres (an average of

per year. Sub health centres reported an average of 752–

number of deliveries between 174 and 269. Few deliver-

Model 1

Outputs

Inputs

vices is only half of the health care provision equation; the

time, by platform, is presented in Figure 11. The average

other half depends upon patients seeking those health

number of doses administered remained stable over the

services. Many factors can affect patients’ decisions to

five fiscal years, with slight declines in sub-district hospi-

seek care, ranging from associated visit costs to how pa-

Expenditure on personnel

Fifty-four percent of patients who went to district

Expenditure on pharmaceuticals

hospitals traveled fewer than 30 minutes, 32% traveled

between 30 minutes and one hour. At primary health cen-

Outpatient visits

tres these proportions were 78% and 17%, respectively,

Inpatients visits (excluding deliveries)

while at sub health centres nearly all patients traveled for less than 30 minutes. This finding is not unexpected, as

these are the closest health facilities for many patients,

Number of beds

particularly those in rural areas. It also reflects the fact that

Number of doctors

many patients travel longer distances to receive the kind

Number of nurses

A facility’s availability of and capacity to deliver ser-

The number of immunization doses administered over

the time needed for round-trip visits.

Immunization visits

Patient perspectives

Immunization

only reported on the time spent traveling to facilities, not

VARIABLES

Deliveries

880 doses per year.

tient visits is higher among the lower platforms.

ties than higher-level. It is important to note that patients

All other expenditure

reported an average of 4,979–6,460 doses administered

82–167 deliveries per year). The ratio of deliveries to inpa-

travel time for patients seeking care at lower-level facili-

Number of ANMs

of specialized care offered at hospitals.

Number of paramedical staff

Wait time is also an important determinant of patient

Number of non-medical staff

Model 2 Outputs

satisfaction. The large majority of patients waited less

Outpatient visits

than 30 minutes to receive care at all platforms (Figure 13),

Inpatients visits (excluding deliveries)

and nearly all patients seeking care at sub health centres

(94%) received care within 30 minutes. Wait times were

Deliveries

Immunization visits

longer at district hospitals (34% of patients waited more

than 30 minutes to receive care) and sub-district hospitals

(34%). Fewer than 6% of all patients waited more than one

Figure 17 Determinants of satisfaction with nurses

hour to receive care. tients view the care they receive. These “demand-side”

Patient satisfaction with care

constraints can be more quantifiable (e.g., distance from

Female Male

facility) or intangible (e.g., perceived respectfulness of

>=40 years 16-39 years

pact on whether patients seek care at particular facilities

Other castes Backwards caste

We report primarily on factors associated with patient

the health care provider), but each can have the same im-

satisfaction with provider care and perceived quality of

or have contact with the health system at all.

infrastructure, as these have been previously identified to

Surveys, we examined the characteristics of patients who

health services in India.11

the care they received. Table 13 provides an overview of

zero to 10, with 10 being the highest score, are presented

public facilities. Most patients were female (61%), and

they received and, in general, ratings were higher for

caste/scheduled tribe (29%) or other backwards caste

of 10, and the majority rated the facility they attended

services by patients on medicine availability and hospital

be of significance in the patient’s perception of quality of

Using data collected from the Patient Exit Interview

Any schooling No schooling

Ratings of patient satisfaction, based on a scale from

presented at health facilities and their perspectives on

Not given all prescribed drugs Given all prescribed drugs

in Figure 14. Overall, patients were satisfied with the care

the interviewed patients (n=2,277) or their attendants at

Wait time <30 min Wait time >=30 min DH SHC PHC CHC SDH

the majority of patients identified as part of a scheduled

higher-level platforms. Few patients (6%) gave a rating

(59%). 80% of patients had some education, and all facil-

an 8 or 9 (42% of all patients). Among patients seeking

41% of patients were under the age of 30.

ity below a 6; among patients seeking care at sub-district

care at community health centres, only 9% rated the facil-

ities saw patients with a range of educational attainment.

2 Odds Ratio

hospitals, this proportion is 14%.

Travel and wait times

Patients were also asked more detailed questions

about satisfaction with providers and facility characteris-

The amount of time patients spend traveling to facili-

ties and then waiting for services can substantially affect their care-seeking behaviors. Among the patients who

11 Rao KD, Peters DH, Bandeen-Roche K. Towards patient-centered health services in India—a scale to measure patient perceptions of quality. International Journal for Quality in Health Care. 2006; 18(6):414-421.

were interviewed, we found that travel time to a facility

for care (Figure 12) differed by the platform, with shorter

A B C E I N TA M I L N A D U

M A I N F I N D I N G S : H E A LT H FA C I L I T Y P R O F I L E S

Table 16 Average and range of inputs and outputs, by platform. INR denotes Indian Rupees. SUB-DISTRICT HOSPITAL

COMMUNITY HEALTH CENTRE

PRIMARY HEALTH CENTRE

56,556,802 (6,492,954119,503,416)

16,471,282 (1,972,15464,633,828)

9,403,170 (2,990,89552,689,648)

3,735,343 (237,2408,011,006)

1,405,913 (320,0464,244,187)

236,908 (85,069596,232)

159,776 (79,998429,856)

7,742,626 (134,91727,240,558)

1,149,703 (112,2729,471,909)

2,847,552 (39,09330,170,106)

2433,04 (38,4891,649,957)

343 (84-608)

79 (16-258)

21 (3-37)

4 (1-14)

39 (20-78)

11 (2-41)

5 (1-13)

2 (1-6)

15 (2-44)

4 (1-7)

3 (0-5)

64 (16-127)

16 (2-39)

17 (6-30)

11 (3-20)

58 (9-144)

8 (0-27)

5 (1-9)

2 (0-9)

Outpatient visits

663,351 (225,6991,144,003)

215,165 (4,103829,210)

63,947 (17,821170,765)

40,508 (13,50077,361)

Inpatient visits (excluding deliveries)

52,311 (7,662146,668)

10,971 (265-116,702)

908 (34-2,682)

480 (69-2,205)

3,999 (487-14,220)

561 (15-3,874)

237 (33-926)

132 (13-431)

10,846 (0-40,197)

25,856 (0-329,688)

5,356 (0-19,058)

5,874 (0-47,380)

14,915,623

6,157,839

2,932,572

16,263,143

5,854,098

9,817,366

4,003,384

District 4

93,398,448

27,209,300

7,036,143

4,214,529

District 5

67,691,752

7,796,161

11,579,260

5,243,899

District 6

33,335,870

14,403,316

4,904,956

District 7

15,156,273

7,368,294

3,144,209

District 8

7,046,398

35,766,028

4,886,277

District 9

127,700,392

26,264,536

7,724,846

4,519,042

District 10

95,598,248

12,327,551

12,638,121

4,589,543

District 11

66,003,392

27,048,824

13,004,020

5,014,610

District 12

17,334,950

7,197,371

13,139,467

4,358,396

District 13

41,088,188

41,899,892

15,192,691

2,964,931

Empty cells were either dropped from analysis due to data availability, or there were no facilities to sample of that platform.

Figure 18 Average total and type of expenditure, by platform, 2007-2011 DISTRICT HOSPITALS

SUB-DISTRICT HOSPITALS

a composite satisfaction variable was created separately

tics (Table 14). Most patients were unsatisfied with facility

cleanliness at district hospitals (64%) and sub-district hos-

for doctors and nurses – if a patient reported good/very

facility types was also high (50% and 58%, respectively).

isfied. At district hospitals, sub-district hospitals, and

both these metrics.

tors reported slightly higher levels of satisfaction than

faction with health providers – being treated respectfully

was reversed in sub health centres, where patients were

200 Expenditure in 100,000 Rupees 50 100 150 0

Immunization doses

119,704,784

District 3

2007

primary health centres, patients receiving care from doc-

Health centres performed slightly better than hospitals on

those receiving care from nurses and ANMs. This trend

Three parameters were assessed to document satis-

by the provider, clarity of explanation provided by the

more satisfied with nurses and auxiliary nurse midwives

questions about health problem or treatment – using a

scores for doctor respectfulness in sub health centres.

(ANMs), with the exception of very high satisfaction

provider, and that provider gave enough time to ask

Generally, satisfaction was higher at health centres than

5 point Likert scale, with the highest ratings of good and

2009

2011

2010

2007

Personnel

2008

2009

2011

2010

Personnel

Pharmaceuticals and consumables

good for all three parameters, it was categorized as sat-

pitals (63%), and dissatisfaction with privacy in these

2008

Pharmaceuticals and consumables

Other

COMMUNITY HEALTH CENTRES

Other

PRIMARY HEALTH CENTRES 50

Deliveries

District 2

Expenditure in 100,000 Rupees 20 30 40

Outputs

Number of non-medical staff

2,668,189

Number of paramedical staff

8,511,807

800

65 (27-163)

Number of nurses

PRIMARY HEALTH CENTRE

at hospitals.

very good responses combined as satisfied, and rest as

not satisfied. Using the three parameters of satisfaction,

Number of doctors

COMMUNITY HEALTH CENTRE

15,383,021

Expenditure in 100,000 Rupees 200 400 600

Number of beds

District 1

Inputs

Other expenditure (INR)

SUB-DISTRICT HOSPITAL

150

7,343,161 (1,771,439Pharmaceutical expenditure (INR) 12,103,611)

DISTRICT HOSPITAL

DISTRICT

Expenditure in 100,000 Rupees 50 100

Personnel expenditure (INR)

DISTRICT HOSPITAL

Table 17 Average annual cost in INR, by platform, last fiscal year. INR denotes Indian Rupees.

2007

2008

2009

2011

2010

2007

Pharmaceuticals and consumables

2008

2009

2011

2010

Personnel

Pharmaceuticals and consumables

Other

A B C E I N TA M I L N A D U

points and green confidence bars.

Compared to patients of another group, there was

Community Health Centre

slightly lower satisfaction with doctors for male patients

Primary Health Centre

trolling for all other factors, compared to patients who 80

8000 10000

6000

2008

sought care at district hospitals, patients who sought care

100

2009

2010

2007

2011

2008

at primary health centres were more satisfied with care

2009

2010

2011

OP visits per staff by facility OP visits per staff average

from doctors (OR: 2.39, 95% CI: 1.10–5.17).

Personnel Pharmaceuticals and consumables

Receipt of all prescribed drugs was associated with

Other

higher satisfaction with nurses, as compared to patients

CHC

4000

Visits 3000 4000

be part of the right to health. Among 1,620 patients who

2000

and community health centres (OR: 3.35, 95% CI: 1.22–

Visits

care at sub health centres (OR: 3.74, 95% CI: 1.29–10.83)

Access to affordable drugs has been interpreted to

2000

ure 17, OR: 2.43, 95% CI: 1.03–5.70). Compared to patients

5000

who received some or none of the prescribed drugs (Figwho sought care at district hospitals, those who sought

Efficiency and Costs

(Figure 15). This ranged from 99% of patients at sub-dis-

The costs of health service provision and the efficiency

trict hospitals and primary health centres to 80% of patients at sub health centres.

with which care is delivered by health facilities go hand-

the medical care they receive. Given this, a multivariate

producing a high volume of patient visits and services

Many complex factors affect patient satisfaction with

in-hand. An efficient health facility uses resources well,

logistic regression was conducted in order to determine

without straining its resources. Conversely, an ineffi-

ated with patient satisfaction with both medical doctors

not maximized, leaving usable beds empty or medi-

acteristic –for example, the age or sex of the patient – the

technical efficiency analysis for district hospitals, sub-

that a patient is satisfied given a particular characteristic,

health centres.

cient health facility is one where the use of resources is

which patient and facility characteristics were associ-

drugs during the visit, 1,552 received all prescribed drugs

1000

9.22) had higher satisfaction with nurses.

were prescribed drugs and attempted to obtain those

2007

2008

2009

2010

2007

2011

compared to the odds of the patient being satisfied in

An ensemble model approach was used to quantify

fidence interval (CI) greater than 1.0 indicates that there

technical efficiency in health facilities, combining results

are greater odds of being satisfied with care as compared

to the reference group. An OR and 95% CI below 1.0 in-

from two approaches – the restricted versions of Data

care than the reference group.

Function (rSDF).12 Based on this analysis, an efficiency

Envelopment Analysis (rDEA) and Stochastic Distance

dicates that there are lower odds of being satisfied with

For example, while the OR for patients under age

40 years being satisfied with care from a doctor is 0.88

12 Di Giorgio L, Flaxman AD, Moses MW, Fullman N, Hanlon M, Conner RO, et al. Efficiency of Health Care Production in Low-Resource Settings: A Monte-Carlo Simulation to Compare the Performance of Data Envelopment Analysis, Stochastic

(95% CI: 0.66–1.16) as compared to patients age 40 years

and older, it is not statistically different from an OR of 1.0

2010

Note: each line represents an individual facility, with the bolded line depicting the average for the platform. Scales are different for each platform type.

Analytical approach

the absence of that characteristic. An OR and 95% con-

2009

DH: District hospital; SDH: Sub-district hospital; CHC: Community health centre; PHC: Primary health centre

district hospitals, community health centres and primary

odds ratio (OR) is presented. The OR represents the odds

2008

OP visits per staff by facility OP visits per staff average

cal staff seeing very few patients per day. We present

(Figure 16) and nurses/ANMs (Figure 17). For each char-

PHC

6000

60 40 Percent of Total Expenditure

2007

6000

(OR: 0.75, 95% confidence interval [CI]: 0.58–0.98). Con-

Visits 4000 6000

are not statistically significant are represented with green

Sub District Hospital

2000

tal bars representing their confidence interval. ORs that

significant are signified by blue points, with blue horizon-

District Hospital

5000

and older. In Figures 16 and 17, ORs that are statistically

SDH

Visits 4000

satisfied with care from doctors than patients 40 years

Figure 20 Outpatient load per staff, by platform

3000

(Figure 16). This means that, considering all other char-

acteristics, patients under age 40 are not more or less

2000

Figure 19 Average percentage of expenditure type, by platform, 2011

M A I N F I N D I N G S : H E A LT H FA C I L I T Y P R O F I L E S

2011

A B C E I N TA M I L N A D U

M A I N F I N D I N G S : H E A LT H FA C I L I T Y P R O F I L E S

Figure 21 Inpatient load per staff by platform

Figure 22 Deliveries per staff by platform

2008

2009

2010

2007

2011

Deliveries 20

Deliveries 15 20

2007

2008

2009

2010

2011

2007

CHC

2009

2008

IP visits per staff by facility IP visits per staff average

2007

2011

2009

2010

2011

Deliveries per staff by facility Deliveries per staff average

PHC

Deliveries 20 30

Deliveries

100

2007

2008

2009

2010

2007

2011

Visits

Visits 40

2008

CHC

PHC

150

2010

Deliveries per staff by facility Deliveries per staff average

SDH

1000

200

Visits 400

Visits 2000 3000

600

4000

800

SDH

5000

2008

2009

2010

2011

2007

2008

IP visits per staff by facility IP visits per staff average

2009

2010

2007

2011

2008

2009

2010

DH: District hospital; SDH: Sub-district hospital; CHC: Community health centre; PHC: Primary health centre

Note: each line represents an individual facility, with the bolded line depicting the average for the platform. Scales are different for each platform type.

Note: Each line represents an individual facility, with the bolded line depicting the average for the platform. Scales are different for each platform type.

score was estimated for each facility, capturing a facilityâ&#x20AC;&#x2122;s

different amount of facility resources (e.g., on average,

For these models, service provision was categorized

use of its resources. Relating the outputs to inputs, the

an inpatient visit uses more resources and more com-

into outpatient visits, inpatient visits, delivery, and immu-

ranging from 0% to 100%, with a score of 100% indicat-

visit), we applied weight restrictions to rescale each fa-

the inputs being different in the two models. The inputs

relative to all facilities in that platform.

of additional weight restrictions is widely used in order

lized for this analysis are documented in the annex. The

rDEA and rSDF approaches compute efficiency scores

plex types of equipment and services than an outpatient

ing that a facility achieved the highest level of production

cilityâ&#x20AC;&#x2122;s mixture of inputs and outputs. The incorporation

This approach assesses the relationship between in-

to improve the discrimination of the models. Weight re-

facility. Recognizing that each type of input requires a

about the importance of individual inputs and outputs, or

puts and outputs to estimate an efficiency score for each

strictions are most commonly based upon the judgment

reflect cost or price considerations. The resulting ensemble efficiency scores were averaged over five years and between the two input models.

Distance Functions, and an Ensemble Model. PLOS ONE. 2016; 11(2): e0150570.

2011

Deliveries per staff by facility Deliveries per staff average

trends in average facility spending varied by platform be-

nization. Two input-output specifications were used, with

tween 2007 and 2011 (Figure 18). All platforms recorded

slightly higher levels of average expenditures in 2011

and outputs are listed in Table 15. The detailed data uti-

than in 2007, which appeared to be largely driven by in-

average and range of inputs and outputs for the variables

Figure 19 shows the average composition of expenditure

creased spending on medical supplies and personnel.

are presented in Table 16.

types across platforms for 2011. Notably, sub-district hospitals and PHCs spent a slightly greater proportion of their

Costs of care

total expenditures on personnel than other platforms. On

Total expenditure, by district and platform, is pre-

the other hand, expenditures on medical supplies were

sented in Table 17. In terms of annual total expenditures,

A B C E I N TA M I L N A D U

M A I N F I N D I N G S : H E A LT H FA C I L I T Y P R O F I L E S

Figure 23 Immunizations per staff per day by platform

Figure 24 Range of efficiency scores across platforms

2007

2008

2009

2010

100 80 2007

2011

2008

2009

2010

2011

Immunization doses per staff by facility Immunization doses per staff average

Doses administered 40 60 80

Doses administered 1000 2000 3000 4000

100

5000

SDH

3000 Doses administered 1000 2000

PHC

District Hospital

Sub District Hospital

Community Health Centre

Primary Health Centre

600 Doses administered 200 400

CHC

2007

2008

2009

2010

2007

2011

2008

2009

2010

2011

Immunization doses per staff by facility Immunization doses per staff average

District Hospital

Sub-district Hospital

Community Health Centre

Primary Health Centre

Mean: 74.4

Mean: 55.7

Mean: 63.1

Mean: 64.2

Median: 75.5

Median: 54.9

Median: 61.7

Median: 65.2

IQR: 70.0-82.0

IQR: 44.6-64.3

IQR: 56.4-70.8

IQR: 59.7-71.7

DH: District hospital; SDH: Sub-district hospital; CHC: Community health centre; PHC: Primary health centre Note: Each line represents an individual facility, with the bolded line depicting the average for the platform. Scales are different for each platform type.

highest the at district hospitals, with other expenditure

(Figure 20), inpatient visits (Figure 21), deliveries (Figure

Note: Each circle represents the five-year facility average efficiency score; IQR refers to intra-quartile range.

per staff was low for primary health centres, where inpa-

munity health centres, and 36 per staff in primary health

accounted for the overwhelmingly large majority of the

within a platform and over time, however.

highest at community health centres.

22), and immunization doses (Figure 23) per staff are pre-

tient visits are rare. Overall, as expected, outpatient visits

and output indicators varied across the facilities and plat-

outpatient visits per staff, though the ratio ranged greatly.

patients seen per staff per day across the platforms.

It is important to note that data availability on the input

sented. District hospitals produced an average of 3,183

forms, with more non-availability for PHCs. Facilities with

The average ratio for sub-district hospitals was 4,476 vis-

five years of missing data for any input or output variable

its per staff, for community health centres 2,198, and for

were dropped from analysis. In addition, the data were

primary health centres 2,488. This gradient differed for

smoothed where necessary based on the trends seen in

inpatient visits, with district hospitals providing 264 in-

To further illustrate the production of outputs per in-

246, community health centres providing 30, and primary

inputs or outputs for that facility.

puts â&#x20AC;&#x201C; in this case, staff â&#x20AC;&#x201C; a simple ratio of outpatient visits

centres. There was quite a bit of variation of these ratios

Efficiency results

Fewer deliveries were performed per staff than other

Using the five fiscal years of data to estimate the effi-

services, with an average of 17 deliveries per staff in dis-

ciency scores for all facilities, two main findings emerged.

trict hospitals, eight per staff in sub-district hospitals,

First, efficiency scores were relatively low across all health

eight per staff in community health centres, and eight

patient visits per staff, sub-district hospitals providing

per staff in primary health centres. For immunization, 50

facilities, with 74.4% being the highest mean across plat-

health centres providing 30. The range of inpatient visits

572 per staff in sub-district hospitals, 191 per staff in com-

highest and lowest efficiency scores was quite large

forms. Second, the range between the facilities with

doses were administered per staff in district hospitals,

A B C E I N TA M I L N A D U

M A I N F I N D I N G S : H E A LT H FA C I L I T Y P R O F I L E S

Table 18 District-wise efficiency scores (%), by platform DISTRICT/ PLATFORM

DISTRICT HOSPITAL 1

SUB DISTRICT HOSPITAL 1

Figure 25 Observed and estimated additional visits that could be produced given observed facility resources

COMMUNITY HEALTH CENTRE 1

PRIMARY HEALTH CENTRE 1

District 2

42.8

44.6

70.8

89.6

63.6

71.9

71.7

69.8

District 3

57.4

54.6

64.3

62.0

70.9

77.9

60.4

55.8

80.6

District 4

70.8

63.4

54.9

69.8

61.1

75.8

71.4

59.7

70.8

District 5

65.8

35.8

81.1

60.2

61.4

63.2

79.0

71.8

55.9

District 6

75.5

81.8

54.5

71.0

53.1

62.6

51.8

63.9

53.6

District 7

27.8

45.2

35.6

48.7

48.5

43.0

43.4

43.1

District 8

78.5

77.6

68.3

74.1

73.1

62.6

61.3

District 9

37.1

36.4

50.1

56.4

59.9

62.5

78.8

District 10

84.9

58.8

50.5

61.0

69.5

69.0

37.1

66.3

65.8

District 11

85.0

60.5

63.9

77.0

53.7

67.0

60.2

65.2

67.4

District 12

70.0

72.7

63.9

72.2

65.5

72.8

53.8

66.9

75.5

District 13

78.7

48.5

58.7

54.5

68.9

60.3

68.5

72.1

District 14

82.0

76.9

15.5

66.0

59.6

57.3

86.4

59.3

OUTPATIENT VISITS

Inpatient visits

District Hospital

Sub District Hospital

Community Health Centre

Primary Health Centre

200000

600000 400000 Outpatient visits

Observed

800000

1.0e+06

40,000 Inpatient visits

20,000

Estimate additional visits

Observed

DELIVERIES

60,000

80,000

Estimate additional visits

IMMUNIZATION DOSES

Deliveries

White cells were either dropped from analysis due to data availability, or there were no more facilities to sample of that platform.

within platforms, suggesting that a substantial perfor-

INPATIENT VISITS

Outpatient visits

Immunization Doses

District Hospital

Sub District Hospital

Community Health Centre

Primary Health Centre

outputs substantially given their observed resources.

mance gap may exist between the average facility and

Based on our analyses, the highest level of care, district

facilities with the highest efficiency scores. Figure 24

hospitals, had the greatest potential for increasing service

depicts this range of facility efficiency scores across plat-

provision without expanding current resources. Overall,

forms for TN.

based on our estimation of efficiency, a large portion of

Efficiency by district is presented in Table 18. There is

TN health facilities could increase the volume of patients

variation in facility efficiency both between and within dis-

seen and services provided with the resources available

1,000

2,000

Observed

3,000 Deliveries

4,000

5,000

10,000

Estimate additional deliveries

30,000 40,000 20,000 Immunization doses

Observed

50,000

Estimate additional doses

tricts. Some of the least efficient primary health centres

to them.

hospitals (for example, District 7). District 14, for example,

additional outpatient visits with the same inputs, while

efficient sub-district hospital. While one primary health

additional outpatient visits. Sub-district hospitals could

37% efficient.

doses with the same inputs if all facilities were efficient.

in the ABCE sample had the potential to bolster service

what levels of efficiency are truly ideal. It is conceivable

emphasize that pronounced deficiencies in human re-

nel and physical capital.

negative effects on service provision, such as longer wait

than they reported. Figure 25 displays this gap in poten-

health system, such that “significant [human resources for

facility capacity and how health facilities have used their

the possible gains in total service provision that could be

services.13 Our results suggest otherwise, as most facilities

were in the same district as the least efficient sub-district

On average, district hospitals could provide 249,706

had the most efficient primary health centre but the least

primary health centres could see an average of 21,906

centre in District 10 was 69% efficient, another was only

administer an average of 26,727 additional immunization

Given observed levels of facility-based resources

At the same time, many reports and policy documents

(beds and personnel), it would appear that many facilities

had the capacity to handle much larger patient volumes

sources for health exist across India in the public sector

tial efficiency performance across platforms, depicting

health] will be required to meet the demand” for health

achieved if every facility in the ABCE sample operated at optimal efficiency.

13 Rao M, Rao KD, Kumar AK, Chatterjee M, Sundararaman T. Human resources for health in India. The Lancet. 2011; 377(9765): 587-98.

We found that all types of facilities could expand their

production given their reported staffing of skilled person-

that always operating at full capacity could actually have

These findings provide a data-driven understanding of

times, high rates of staff burnout and turnover, and com-

resources in TN; at the same time, they are not without

tangible characteristics such as facility management, are

tween what a facility has and what it produces, but these

ture work should also assess these factors alongside

promised quality of care. These factors, as well as less

limitations. Efficiency scores quantify the relationship be-

all important drivers of health service provision, and fu-

measures do not fully explain where inefficiencies orig-

measures of efficiency.

inate, why a given facility scores higher than another, or

C O N C L U S I O N S A N D P O L I C Y I M P L I C AT I O N S

Conclusions and policy implications

health system will exacerbate disparities by not dealing

provision, as it allows for reliable storage of medications,

appropriately with NCDs while continuing to endeavor to

vaccines, and laboratory samples. Access to piped water

eliminate major infectious diseases like tuberculosis, HIV,

was more variable in these types of facilities; it was partic-

and malaria, or to reduce neonatal and infant mortality.

ularly lacking in sub health centres, with all other facilities

Furthermore, there also is a paucity of essential equip-

showing availability of 85%–88%. Access to flushed toilets

ment for NCD services at lower facility levels, including

was actually lower in district hospitals than in commu-

glucometer/test strips, though district hospitals are gen-

o achieve its mission to “expand the reach of

deliver them. While almost all facilities, across platforms,

health care and establishing universal health

indicated that they provided routine delivery care, only

for immediate action to scale up interventions for chronic

no lower-level facilities had the full stock of medical sup-

health care systems that are essential for the implementa-

54% of district hospitals, 4% of sub-district hospitals, and

sector of health care, with a focus on reaching rural areas.

plies and equipment to optimally provide these services.

tion of cost-effective interventions.

While 85% of district hospitals were fully equipped to

of human resources for health.6 It has a shortage of qual-

years to expand and strengthen the public

These gaps were also evident for ANC in all facility types.

to essential and special services for marginalized groups.

provide general surgery, only 21% of sub-district hospi-

ified health workers and the workforce is concentrated

general, district hospitals were well equipped with medi-

health personnel at all levels of the health system, but

exception of CT scans. The availability of equipment de-

ing patterns between facilities. Hospitals employ a large

regard to laboratory equipment and imaging equipment.

medical staff including nurses and ANMs provide the

fully equipped to optimally provide essential services

These staffing patterns are not unexpected based on the

Chronic diseases (e.g., cardiovascular diseases, men-

thority or say within the health system, and the resources

Our findings show that these goals are ambitious but attainable, if the country focuses on rigorously measuring

health facility performance and costs of services across

and within levels of care, and if it can align the different dimensions of health service provision to support optimal

health system performance.

Facility capacity for service provision

Optimal health service delivery, one of the key build-

capacity to provide individuals with the services they

need and want. With the appropriate balance of skilled

cial health services, a health system has the necessary

The availability of a subset of services, including rou-

tine delivery, antenatal care, general medicine, pharmacy,

and laboratory services, was generally high across facil-

ity types in Tamil Nadu, reflecting the expansion of these

services throughout the state. However, clear differences

cal, laboratory, and imaging equipment, with the notable clined through the levels of the system, particularly with

number of staff. At the lower, community levels, para-

more efficient referrals and coordination. However, ac-

Closing these gaps and making sure that all facilities are

majority of care to patients (based on reported staffing).

meaning that availability is lower in these facilities than

Communication is also an important facet of health

good access to phones and computers, which makes for cess to four-wheeled vehicles was low at primary health

centres. There is scope, then, to address these gaps in order to ensure that all patients receive timely emergency

hierarchy of care. However, nurses do not have much au-

and curative care.

Facility production of health services

to train them are still inadequate. A call has been made to

and are projected to increase in their contribution to

resources through a comprehensive national policy for

of the care for chronic diseases and injuries is provided

However, it should be noted that despite the shortfall in

at the lower health facilities. The volume of inpatient visits

NCD-related services, including cardiology, psychiatry,

efficiency in production of services with the given level of

tion for most platforms. The highest volumes of visits were

Overall, the number of outpatient visits by year and

the government to urgently address the issues of human

platform was relatively stable over the five years of obser-

human resources to achieve universal health care in India.

vation. Volume of outpatient visits was considerably lower

in the private sector and can be very expensive.45 Many

human resources, the study findings suggest suboptimal

and deliveries increased over the five years of observa-

and chemotherapy, are notably lacking at various levels

human resources.

held by district hospitals, followed by sub-district hospi-

tals. Facility expenditure is dominated by personnel costs

Adequate operational infrastructure is essential for

the functioning of a facility, which in turn affects the ef-

– accounting for, on average, at least 70% of total costs.

and community and primary health centres and almost

facility-based resources and the facility’s total patient

The availability of all these services declines markedly

ficiency of service provision. In Tamil Nadu, all hospitals

as well as community health centres. Such gaps in the

all sub health centres had access to functioning electric-

at lower facility levels, including sub-district hospitals

provide STI/HIV services and 77% provide immunizations,

of the health system.

tal health disorders, diabetes, and cancer) and injuries

and psychiatry services, only 8% provide chemotherapy.

bly lack certain essential services: for example, only 69%

making sure that these resources reach the lowest levels

service delivery. In general, facilities in Tamil Nadu had

of care. While 77% of district hospitals provide cardiology

remain between facility types. Sub-district hospitals nota-

ancies evident between sub centres and other types of

facility suggest that there should be a sustained focus on

especially rural areas, 7,8,9 results reveal disparate staff-

the burden of disease during the next 25 years.3,4,5 Much

foundation to deliver quality, equitable health services.

Public Health Standards. However, the marked discrep-

tals and no lower-level facilities were fully equipped. In

are the leading causes of death and disability in India,

staff and supplies needed to offer both essential and spe-

mitment10,11 to upgrade all facilities so they meet Indian

in urban areas. In the context of a shortage of qualified

warrants further policy consideration.

ing blocks of the health system, 2 is linked to facility

facilities did report access to essential resources like

water, sanitation, and electricity likely reflects India’s com-

Recent studies show that India has a severe shortage

The country recognizes disparities and has sought to enact policies and implement programs to expand access

centres recorded the lowest levels overall. That so many

diseases through improved public health and primary

coverage,” India has strived over the past 10 1

nity and primary health centres, though again, sub health

erally well-equipped. These findings support the need

Efficiency scores reflect the relationship between

volume each year. Average efficiency scores by platform ranged from 55.7% to 74.4%, indicating patient volume

ity, and only one facility reported being solely dependent

could substantially increase with the observed levels of

on a generator. This means a higher quality of service

in community health centres. Moreover, substantial gaps

were identified between facilities reporting availability

3 GBD 2015 Mortality and Causes of Death Collaborators. Global, regional, and national life expectancy, all-cause mortality, and cause-specific mortality for 249 causes of death, 1980–2015: a systematic analysis for the Global Burden of Disease Study 2015. The Lancet. 2016; 388:1459–1544. 4 Patel V, Chatterji S, Chisholm D, Ebrahim S, Gopalakrishna, G, Mathers C et al. Chronic diseases and injuries in India. The Lancet. 2011; 377: 413-28. 5 GBD 2015 DALYs and HALE Collaborators. Global, regional, and national disability-adjusted life-years (DALYs) for 315 diseases and injuries and healthy life expectancy (HALE), 1990–2015: a systematic analysis for the Global Burden of Disease Study 2015. The Lancet. 2016 Oct 7; 388:1603–1658

of these services and having the full capacity to actually

1 Planning Commission Government of India. Twelfth Five Year Plan (2012-17). New Delhi, India: Government of India, 2012. 2 World Health Organization (WHO). Everybody’s Business: Strengthening health systems to improve health outcomes: WHO’s Framework for Action. Geneva, Switzerland: WHO, 2007.

resources and expenditure. Within each platform, there

is great variation in the efficiency of health facilities be-

tween and within districts. With this information, we

6 Rao M, Rao KD, Kumar AK, Chatterjee M, Sundararaman T. Human resources for health in India. The Lancet. 2011; 377(9765): 587-98. 7 Government of India, “Twelfth Five Year Plan (2011-17).” 8 Hazarika I. Health Workforce in India: Assessment of Availability, Production and Distribution. WHO South East Asia Journal of Public Health. 2013; 2(2): 106-112. 9 Rao M, Rao KD, Kumar AK, Chatterjee M, Sundararaman T. Human resources for health in India. The Lancet. 2011; 377(9765): 587-98.

10 Planning Commission Government of India. Eleventh Five Year Plan (2007-12). New Delhi, India: Government of India, 2007. 11 Planning Commission Government of India. Twelfth Five Year Plan (2012-17). New Delhi, India: Government of India, 2012.

A B C E I N TA M I L N A D U

estimated that facilities could substantially increase the

C O N C L U S I O N S A N D P O L I C Y I M P L I C AT I O N S

key component of health system performance in terms

number of patients seen and services provided, based on

their observed levels of medical personnel and resources

to reduce the heavy burden of out-of-pocket expendiproviding more services while maintaining personnel, capacity (beds), and expenditure.

Further use of these results requires considering ef-

across states within India. Future studies should aim to

prescribed medication were more satisfied with care

facilities was not readily available, and it was not possible

Most patients experienced short travel and wait times.

departments. Furthermore, documentation of patients as

from nurses.

patient outcomes.

Most patients traveled less than 30 minutes to receive

Patient satisfaction is an important indicator of pa-

ency with which patients are seen.

The policy implications of these efficiency results are

tient perception of the quality of services provided by

with a few caveats. A given facility’s efficiency score cap-

tients is important for purposes of monitoring, increasing

and facility-based resources, but it does not reflect the

adapting patient-centric services, and for utilization of

provision of services, demand for the care received, and

of this study is that patient satisfaction was assessed

visits and not in terms of number of patients.

more than 30 minutes was at sub health centres. How-

cilities for expenditure, patient-related outputs, and staff

expediency with which patients are seen, the optimal

services and compliance with treatment. A major strength

reported being unable to acquire prescribed drugs.

equity in provision of services to serve those who are dis-

across the various levels of public sector health care

ered alongside measures of efficiency. On the other hand,

ral hierarchical system to provide a continuum of health

data-driven, rather than strictly anecdotal, understanding

impact the chain of care at another level.17 Although var-

service provision without necessarily increasing person-

service delivery at primary care health facilities over the

care, and as a consequence of this, failure at one level can

quantifying facility-based levels of efficiency provides a

of how much TN health facilities could potentially expand

ious government initiatives have led to improved basic

nel or bed capacity in parallel.

last few years, still a large number of patients directly visit higher-level facilities, leading to over-crowding of those

Costs of care

facilities, which impacts quality of care as it stretches fa18

Average facility expenditure per year differed sub-

cility resources in terms of both infrastructure and staff. In

stantially across platforms. We were unable to estimate

addition, the persistent shortage of medical staff in pub-

the costs of care by type of services (such as outpatients,

lic facilities only aggravates the crowded condition at

inpatients, deliveries, immunization, etc.) or by type of

disease/condition (such as TB, diabetes, etc.) as such data

are not readily available at the facilities. Estimating such costs of care and identifying differences in patient costs

across the type of platforms is critical for isolating areas

vices, especially for hard-to-reach populations.

sights into each state’s health financing landscape, a

12 Ibid. 13 Kumar AKS, Chen LC, Choudhury M, Ganju S, Mahajan V, Sinha A et al. Financing health care for all: challenges and opportunities. The Lancet. 2011; 377: 668-79. 14 UNICEF. Narrowing the gaps: The power of investing in the poorest children. New York, NY: UNICEF, 2017.

Finally, nearly 20% of patients at sub health centres

various sources for a given facility. For example, it is not

Ensuring that all patients may obtain prescribed medi-

without procuring relevant data from the facility, a higher

facilitates adherence and continuity of care.

at times from the state. The most limited capacity was to

of India clearly highlighting the need to increase user

and supplies.

had the most bottlenecks with these data available across

possible to document the expenditures at a given facility

level of facility (block level), district health society, and

cations at the time of their visit should be a priority, as it

capture the expenditure on drugs, medical consumables,

With the developmental priorities for the government

participation in health care service delivery for better ac-

Summary

countability,20 understanding how patients perceive the

The ABCE project was designed to provide policymak-

quality of the existing public health services, encompass-

ers and funders with new insights into health systems and

ing various dimensions of care such as time to receive medical attention, staff behavior, etc., could contribute to

to drive improvements. We hope these findings will not

zation of the public health system.21

inform broader efforts to mitigate factors that impede the

only prove useful to policymaking in the state, but will also

developing strategies to improve performance and utili-

equitable access to or delivery of health services in In-

Health information system

dia. It is with this type of information that the individual

This study was dependent on the data availability at

building blocks of health system performance, and their

of the vast extent of data that were collected for five fi-

More efforts like the ABCE project in India are needed to

regarding the common bottlenecks within the health in-

report and overcome the identified gaps. Analyses that

with the care they received, and ratings and satisfaction

nancial years across the facilities, there are several lessons

many were not satisfied with the cleanliness or privacy

formation system, both at the facility level and at the state

15 Mpinga EK, Chastonay P. Satisfaction of patients: a right to health indicator? Health Policy. 2011; 100(2-3):144-150. 16 Baltussen RM, Yé Y, Haddad S, Sauerborn RS. Perceived quality of care of primary health care services in Burkina Faso. Health Policy Plan. 2002; 17: 42-48. 17 National Health Mission, Ministry of Health and Family Welfare, Government of India. Framework for Implementation National Health Mission (2012-2017). New Delhi, India: Government of India, 2012. 18 Bajpai V. The Challenges Confronting Public Hospitals in India, Their Origins, and Possible Solutions. Advances in Public Health 2014; 2014: 27. 19 Rao M, Rao KD, Kumar AK, Chatterjee M, Sundararaman T. Human resources for health in India. The Lancet. 2011; 377(9765): 587-98.

Nevertheless, these results on expenditures offer in-

numbers. In general, the expenditure documentation

the facilities for the various inputs and outputs. Because

were generally higher at lower levels of care. However,

to improve cost-effectiveness and expand less costly ser-

ever only 6% of patients waited more than one hour to

these facilities.19

Findings indicate that patients were generally satisfied

Data were either incomplete or inaccurate at some fa-

to receive care; the lowest proportion of patients waiting

receive care.

The public health system in India designed as a refer-

data interpretation is possible only in terms of number of

shortest travel times. Hospitals had the highest propor-

accountability, recognizing good performance, and

service delivery, and they should be thoroughly consid-

a new patient or a follow-up patient was neither standard-

tion of patients who had to wait more than 30 minutes

tures the relationship between observed patient volume

advantaged. These are all critical components of health

to assess the level of duplication of patients across the

ized nor practiced across most health facilities. Therefore,

the healthcare sector.15,16 Evaluation of services by pa-

in the state.

the higher-level facilities, collation of patients seen at the

care, with patients at lower-level facilities reporting the

both numerous and diverse, and they should be viewed

captured or collated by disease groups at the facilities. At

their care from doctors, and patients who received all

capture information on the quality of services provided,

Patient perspectives

quality of care provided, demand for care, and expedi-

condition other than that for deliveries, as data are not

factors constant, male patients were less satisfied with

as it is a critical indicator of the likely impact of care on

ficiency in the context of several other factors, including

at hospitals, but not at all health centres. Holding other

It is not possible to assess the outputs by disease/

specific services provided for each visit, they can enable

a compelling comparison of overall health care expenses

tures,12,13 stakeholders may seek to increase efficiency by

vice provision was observed.

faction was higher with doctors than nurses or ANMs

costs do not reflect the quality of care received or the

in 2011. As India seeks to strengthen public sector care

provisions at the facility they visited. In general, satis-

of cost to facilities and service production. While these

critical interaction with each other, can be strengthened. continue many of the position trends highlighted in this

take into account a broader set of the state’s facilities, including private facilities, may offer an even clearer pic-

level. In general, there is weak staff capacity for data cap-

ture of levels and trends in capacity, efficiency, and cost.

ture, management, and use (interpretation or planning) at

Continued monitoring of the strength and efficiency of

all levels. No system of regular review of data at the facility

service provision is critical for optimal health system per-

level that could guide planning or improvement of ser-

formance and the equitable provision of cost-effective interventions throughout the states and in India.

20 Planning Commission, Government of India. Faster, sustainable and more inclusive growth: An approach to the Twelfth Five Year Plan. New Delhi, India: Government of India, 2012. 21 World Health Organization (WHO). Global Health Observatory Data Repository. Geneva, Switzerland: WHO, 2016.

Annex: Facility-specific data for 2007 to 2011 utilized for the efficiency analysis Please note that data may be missing for some years across the facilities based on availability of data. DH: District hospital; SDH: Sub-district hospital; CHC: Community health centre; PHC: Primary health centre

FACILITY INFORMATION

STAFF AND BEDS

OUTPUTS

EXPENDITURE Medical supplies + pharmaceuticals

Administration and training

Non-medical

Beds

Doctors

Nurses

Paramedical

Nonmedical

Outpatient

Inpatient

Vaccinations

Births

Personnel

Infrastructure + utilities

2007

415

112

1,066,885

94,463

6,041

4,042

29,562,816

7,720,422

7,214,515

200,645

4,030,000

District Hospital (DH)

2008

415

110

1,119,401

110,896

4,848

4,031

30,625,188

7,857,414

7,810,962

259,587

4,660,000

District Hospital (DH)

2009

415

110

1,141,394

109,975

3,967

3,993

33,149,616

8,093,496

8,511,810

261,800

5,025,000

District Hospital (DH)

2010

415

107

1,219,695

90,942

4,015

4,191

34,492,848

8,255,150

8,412,114

273,100

5,428,000

District Hospital (DH)

2011

415

107

1,041,971

118,059

4,411

4,505

37,963,276

8,466,725

8,713,547

275,000

5,684,000

Sub-district Hospital (SDH)

2007

217,543

2,103

180

210

13,888,862

613,452

758,374

17,870

112,560

Sub-district Hospital (SDH)

2008

177,367

1,969

329

14,972,237

632,317

806,834

42,900

192,800

Sub-district Hospital (SDH)

2009

194,861

3,261

368

129

15,756,458

678,092

915,107

41,865

208,300

Sub-district Hospital (SDH)

2010

166,833

2,477

121

16,573,468

700,002

876,423

50,650

267,402

Sub-district Hospital (SDH)

2011

200,898

3,180

134

148

17,439,540

696,382

891,813

75,238

337,695

Community Health Centre (CHC)

2007

89,348

1,109

4,664

226

7,226,222

636,529

239,339

51,651

26,080

Community Health Centre (CHC)

2008

86,604

1,026

4,759

228

7,742,067

501,366

270,707

47,791

33,473

Community Health Centre (CHC)

2009

89,013

1,052

4,104

266

8,157,808

906,986

341,242

50,141

41,184

Community Health Centre (CHC)

2010

80,011

1,355

4,492

271

8,598,956

904,626

323,581

42,386

23,390

Community Health Centre (CHC)

2011

90,285

1,149

4,125

246

9,185,064

525,378

390,961

10,924

17,725

Primary Health Centre (PHC)

2007

33,074

261

3,187

2,637,805

152,761

137,629

23,075

7,434

Primary Health Centre (PHC)

2008

39,486

381

3,154

117

2,834,559

145,995

157,647

15,175

26,290

Primary Health Centre (PHC)

2009

50,272

617

3,118

210

2,988,813

143,754

198,293

8,999

27,245

Primary Health Centre (PHC)

2010

54,730

599

3,194

154

3,158,811

164,241

204,307

41,691

20,375

Primary Health Centre (PHC)

2011

48,886

567

3,119

194

3,304,656

160,930

287,268

16,653

48,141

Primary Health Centre (PHC)

2007

57,063

692

4,880

2,487,805

97,952

119,998

21,273

3,490

Primary Health Centre (PHC)

2008

59,785

321

3,068

127

2,684,559

101,477

174,999

31,696

16,200

Primary Health Centre (PHC)

2009

51,620

525

8,817

134

2,814,813

98,677

199,547

54,611

22,370

Primary Health Centre (PHC)

2010

60,688

575

8,509

157

2,948,811

99,467

183,000

46,723

28,635

Primary Health Centre (PHC)

2011

51,365

436

9,459

122

3,094,656

101,952

228,390

27,326

50,975

Sub-district Hospital (SDH)

2007

116,122

901

39,916

7,359,315

3,383,181

524,919

16,195

24,854

Sub-district Hospital (SDH)

2008

100,529

964

39,501

7,673,693

3,389,299

639,163

17,925

46,206

Sub-district Hospital (SDH)

2009

130,361

1,968

50,114

9,170,000

3,415,434

848,834

33,101

30,286

District

Platform

Year

District Hospital (DH)

FACILITY INFORMATION

STAFF AND BEDS

OUTPUTS

EXPENDITURE Medical supplies + pharmaceuticals

Administration and training

Non-medical

Beds

Doctors

Nurses

Paramedical

Nonmedical

Outpatient

Inpatient

Vaccinations

Births

Personnel

Infrastructure + utilities

2010

145,067

2,234

55,994

10,264,342

3,487,586

706,678

36,604

87,663

Sub-district Hospital (SDH)

2011

163,354

2,995

51,897

10,702,567

3,488,408

707,542

37,791

191,988

Community Health Centre (CHC)

2007

104,696

1,153

2,919

337

6,413,418

291,574

89,628

29,731

9,095

Community Health Centre (CHC)

2008

146,832

1,976

5,631

386

6,718,964

345,886

118,757

113,326

10,830

Community Health Centre (CHC)

2009

165,340

1,753

5,131

325

7,085,992

448,082

122,127

58,375

49,085

Community Health Centre (CHC)

2010

170,765

2,504

4,185

234

7,483,233

427,022

127,548

215,291

45,941

Community Health Centre (CHC)

2011

154,645

1,138

3,587

242

7,862,268

456,149

139,478

123,021

37,665

Primary Health Centre (PHC)

2007

32,713

126

13,077

115

2,711,535

136,684

133,234

22,749

5,470

Primary Health Centre (PHC)

2008

37,409

240

3,250

134

2,827,132

138,134

149,739

17,290

11,601

Primary Health Centre (PHC)

2009

50,814

271

5,974

2,945,190

135,334

153,905

22,221

20,800

Primary Health Centre (PHC)

2010

44,967

180

3,348

3,031,024

137,748

143,264

43,723

21,025

Primary Health Centre (PHC)

2011

50,310

619

4,095

3,204,252

140,054

230,036

33,921

38,565

Primary Health Centre (PHC)

2007

39,680

308

462,650

89,709

126,499

3,150

4,500

Primary Health Centre (PHC)

2008

45,690

298

525,286

102,793

146,998

6,032

10,940

Primary Health Centre (PHC)

2009

71,419

354

566,810

103,185

181,855

11,364

20,066

Primary Health Centre (PHC)

2010

77,361

320

575,190

96,511

244,616

18,514

14,195

Primary Health Centre (PHC)

2011

65,642

393

556,287

126,951

232,240

9,038

21,825

District Hospital (DH)

2007

608

122

100

1,144,003

35,686

11,230

3,960

98,100,184

1,733,605

11,926,786

913,458

1,162,617

District Hospital (DH)

2008

608

122

101

857,942

37,637

9,608

3,380

101,142,456

1,929,940

10,920,849

442,343

1,138,279

District Hospital (DH)

2009

608

121

787,500

37,931

9,986

3,072

104,270,576

1,634,328

11,827,975

569,955

1,405,289

District Hospital (DH)

2010

608

120

760,830

36,935

9,561

2,622

107,495,432

2,125,572

11,225,971

678,803

1,343,120

District Hospital (DH)

2011

608

117

752,279

33,903

10,314

2,854

110,908,712

1,681,760

11,426,582

764,652

1,754,676

Sub-district Hospital (SDH)

2007

414,905

7,033

2,454

402

12,768,250

1,238,766

1,401,195

50,910

109,755

Sub-district Hospital (SDH)

2008

272,498

3,731

1,316

289

13,163,144

1,233,379

1,625,288

55,685

139,000

Sub-district Hospital (SDH)

2009

258,973

4,985

1,592

333

19,157,024

1,497,361

2,035,418

110,053

600,879

Sub-district Hospital (SDH)

2010

287,897

6,302

1,921

558

19,480,108

1,258,886

1,445,771

85,076

155,050

Sub-district Hospital (SDH)

2011

273,175

5,216

1,620

470

20,288,772

1,263,926

1,590,507

84,217

160,500

Community Health Centre (CHC)

2007

43,860

414

2,222

4,584,000

277,946

139,864

19,320

83,950

Community Health Centre (CHC)

2008

41,364

540

2,100

179

4,828,560

282,790

164,105

16,154

109,000

Community Health Centre (CHC)

2009

51,266

716

2,109

343

4,959,720

275,893

208,482

21,800

131,300

Community Health Centre (CHC)

2010

44,842

725

2,002

334

5,144,160

295,146

233,562

22,206

154,050

Community Health Centre (CHC)

2011

44,352

808

2,298

294

5,278,200

343,116

370,772

60,400

228,756

Primary Health Centre (PHC)

2007

27,569

285

5,758

1,545,594

121,879

102,278

15,650

8,948

Primary Health Centre (PHC)

2008

35,964

264

5,709

194

1,725,308

124,818

158,117

53,090

15,418

Primary Health Centre (PHC)

2009

40,210

458

5,847

222

1,967,784

134,902

166,524

4,688

31,800

Primary Health Centre (PHC)

2010

42,754

837

6,028

235

2,087,220

138,476

182,649

8,400

46,845

Primary Health Centre (PHC)

2011

43,157

692

5,290

158

2,136,388

137,492

200,994

19,605

6,780

Primary Health Centre (PHC)

2007

26,157

509

1,989

2,106,325

264,258

140,277

2,245

10,000

Primary Health Centre (PHC)

2008

23,109

592

1,990

151

2,171,469

267,734

160,066

2,355

27,108

District

Platform

Year

Sub-district Hospital (SDH)

FACILITY INFORMATION

STAFF AND BEDS

OUTPUTS

EXPENDITURE Medical supplies + pharmaceuticals

Administration and training

Non-medical

Beds

Doctors

Nurses

Paramedical

Nonmedical

Outpatient

Inpatient

Vaccinations

Births

Personnel

Infrastructure + utilities

2009

24,481

829

1,990

177

2,238,627

283,820

158,019

2,250

54,737

Primary Health Centre (PHC)

2010

25,981

1,108

1,986

164

2,307,862

277,892

184,551

16,246

54,478

Primary Health Centre (PHC)

2011

21,878

1,347

2,774

161

2,204,680

331,714

211,720

58,784

57,000

Sub-district Hospital (SDH)

2007

99,379

1,908

1,399

145

8,165,801

116,410

519,126

31,280

115,342

Sub-district Hospital (SDH)

2008

113,540

2,225

1,589

129

8,418,352

140,900

511,548

26,688

55,821

Sub-district Hospital (SDH)

2009

121,740

3,897

1,776

136

8,678,714

180,502

623,627

20,242

148,166

Sub-district Hospital (SDH)

2010

132,305

4,590

1,881

153

8,947,129

183,637

667,163

17,445

69,827

Sub-district Hospital (SDH)

2011

148,223

6,827

2,400

127

9,223,846

244,667

920,030

27,363

103,686

Community Health Centre (CHC)

2007

50,132

1,334

5,064

344

4,437,569

316,081

182,276

25,070

63,254

Community Health Centre (CHC)

2008

45,175

1,112

5,661

290

4,584,129

349,544

157,263

15,197

68,600

Community Health Centre (CHC)

2009

46,790

1,169

4,995

286

6,264,847

338,395

144,862

14,180

112,520

Community Health Centre (CHC)

2010

42,190

1,223

17,603

224

7,115,217

342,457

215,173

15,500

143,500

Community Health Centre (CHC)

2011

42,802

1,265

5,674

242

7,919,430

317,232

117,426

14,735

70,679

Primary Health Centre (PHC)

2007

29,389

147

13,595

4,150,280

202,011

82,745

3,251

4,724

Primary Health Centre (PHC)

2008

36,485

417

2,266

4,503,923

200,106

146,624

14,140

21,916

Primary Health Centre (PHC)

2009

39,724

431

2,253

120

4,723,394

221,466

142,823

15,067

20,522

Primary Health Centre (PHC)

2010

41,106

423

2,336

106

4,937,377

201,066

167,855

58,100

63,500

Primary Health Centre (PHC)

2011

43,563

731

760

114

5,186,208

201,080

189,904

42,594

40,648

Primary Health Centre (PHC)

2007

40,681

210

792

102

1,294,212

22,157

129,098

10,823

51,500

Primary Health Centre (PHC)

2008

45,374

339

2,781

1,335,660

21,249

144,282

11,610

54,590

Primary Health Centre (PHC)

2009

44,070

439

2,609

159

1,406,824

20,939

148,053

12,080

54,000

Primary Health Centre (PHC)

2010

50,352

584

2,479

256

1,498,176

37,014

183,201

13,300

59,000

Primary Health Centre (PHC)

2011

50,156

668

1,729

297

1,538,352

30,571

220,200

13,600

63,750

District Hospital (DH)

2007

241

428,233

21,010

2,442

3,415

6,492,954

782,133

5,017,705

72,860

530,018

District Hospital (DH)

2008

241

507,816

25,356

1,659

4,404

6,716,595

7,273,183

6,102,681

75,870

548,866

District Hospital (DH)

2009

241

510,029

26,752

1,880

5,078

6,904,794

2,772,765

6,004,617

80,400

587,358

District Hospital (DH)

2010

241

496,774

27,775

1,704

4,818

7,104,145

840,593

6,304,433

82,460

707,850

District Hospital (DH)

2011

241

480,917

27,395

1,910

5,140

7,261,240

957,846

7,304,904

83,630

705,819

Sub-district Hospital (SDH)

2007

78,807

5,956

222

3,376,537

192,190

582,229

5,994

21,143

Sub-district Hospital (SDH)

2008

109,735

8,811

178

3,514,283

184,940

578,593

11,033

3,795

Sub-district Hospital (SDH)

2009

115,944

9,780

195

4,884,435

277,923

732,440

16,167

55,706

Sub-district Hospital (SDH)

2010

114,801

8,166

194

4,606,258

238,289

804,626

20,201

72,045

Sub-district Hospital (SDH)

2011

62,373

2,515

31,235

4,910,542

186,762

801,465

30,505

34,700

Community Health Centre (CHC)

2007

29,472

411

16,059

6,236,839

199,145

106,400

514,879

63,300

Community Health Centre (CHC)

2008

73,588

545

8,632

266

6,424,167

185,925

168,401

1,364,437

229,600

Community Health Centre (CHC)

2009

47,687

1,796

8,619

264

6,617,289

343,567

228,738

1,781,316

158,175

Community Health Centre (CHC)

2010

46,536

1,566

8,958

250

6,852,384

540,630

290,027

1,288,950

155,702

Community Health Centre (CHC)

2011

63,307

1,690

356

7,057,635

448,082

266,527

1,639,960

141,350

Primary Health Centre (PHC)

2007

40,378

479

133

3,277,097

150,236

130,644

12,423

7,650

District

Platform

Year

Primary Health Centre (PHC)

FACILITY INFORMATION

STAFF AND BEDS

OUTPUTS

EXPENDITURE Medical supplies + pharmaceuticals

Administration and training

Non-medical

Beds

Doctors

Nurses

Paramedical

Nonmedical

Outpatient

Inpatient

Vaccinations

Births

Personnel

Infrastructure + utilities

2008

36,046

1,282

2,772

230

3,378,451

135,811

152,408

16,768

18,935

Primary Health Centre (PHC)

2009

42,688

1,307

3,337

210

3,482,940

159,770

131,625

18,921

47,550

Primary Health Centre (PHC)

2010

46,362

1,430

3,211

197

3,590,660

174,070

192,142

21,128

59,233

Primary Health Centre (PHC)

2011

46,027

2,205

5,318

259

3,696,144

183,780

161,929

37,696

65,188

Primary Health Centre (PHC)

2007

21,183

355

11,474

3,123,353

158,504

97,971

680

10,635

Primary Health Centre (PHC)

2008

25,174

469

13,824

206

3,219,952

157,779

121,566

2,810

43,500

Primary Health Centre (PHC)

2009

36,788

792

22,663

235

3,319,539

168,279

98,115

5,201

143,861

Primary Health Centre (PHC)

2010

37,876

993

22,278

218

3,422,206

156,979

106,601

8,588

142,441

Primary Health Centre (PHC)

2011

43,477

849

208

3,528,048

162,279

136,941

5,100

121,964

Sub-district Hospital (SDH)

2007

69,274

2,424

185

4,649,817

401,472

455,254

67,790

39,365

Sub-district Hospital (SDH)

2008

80,766

2,920

204

4,868,257

452,942

575,883

87,540

40,000

Sub-district Hospital (SDH)

2009

94,055

4,592

324

5,099,071

490,751

760,070

166,605

51,990

Sub-district Hospital (SDH)

2010

96,442

6,196

432

118

5,343,063

499,315

806,867

210,014

53,700

Sub-district Hospital (SDH)

2011

98,945

5,762

223

5,601,096

547,908

834,956

219,552

74,900

Community Health Centre (CHC)

2007

90,882

1,707

3,386

222

9,022,450

397,213

164,724

128,788

21,765

Community Health Centre (CHC)

2008

60,529

1,720

1,318

228

9,447,145

453,883

194,853

162,750

25,885

Community Health Centre (CHC)

2009

63,268

1,807

2,960

214

9,896,038

516,907

263,972

385,085

42,535

Community Health Centre (CHC)

2010

65,984

2,275

3,727

244

10,370,398

522,294

315,391

234,559

64,765

Community Health Centre (CHC)

2011

68,063

2,359

3,773

200

10,872,208

395,939

368,836

551,372

50,475

Primary Health Centre (PHC)

2007

24,983

516

3,055

3,370,407

140,426

89,086

7,118

4,299

Primary Health Centre (PHC)

2008

23,433

508

3,359

133

3,624,095

140,115

117,085

52,335

8,660

Primary Health Centre (PHC)

2009

27,300

978

3,538

137

3,896,876

143,486

127,432

154,939

14,800

Primary Health Centre (PHC)

2010

31,245

912

3,949

139

4,190,189

142,230

150,552

84,662

13,990

Primary Health Centre (PHC)

2011

39,948

1,314

4,284

199

4,505,580

143,301

177,286

103,679

16,780

Primary Health Centre (PHC)

2007

32,367

697

7,108

3,258,149

410,368

100,940

24,925

9,582

Primary Health Centre (PHC)

2008

34,335

1,143

5,311

170

3,358,916

417,267

120,185

52,474

17,950

Primary Health Centre (PHC)

2009

45,309

1,709

4,272

210

3,462,799

412,090

164,479

138,256

24,173

Primary Health Centre (PHC)

2010

43,005

1,237

3,823

152

3,569,895

414,812

194,145

162,380

17,860

Primary Health Centre (PHC)

2011

34,670

1,158

5,068

118

3,680,304

416,547

235,304

196,558

21,825

District Hospital (DH)

2007

445

637,483

106,345

2,820

49,698,636

14,896,651

6,618,859

180,793

1,966,184

District Hospital (DH)

2008

445

826,356

119,596

5,779

2,475

62,641,228

15,518,619

6,717,097

328,785

1,479,248

District Hospital (DH)

2009

445

1,000,795

59,717

2,489

64,578,588

15,035,472

7,020,596

348,323

2,067,487

District Hospital (DH)

2010

445

984,992

42,336

2,763

69,529,840

15,872,825

6,622,404

398,281

9,644,161

District Hospital (DH)

2011

445

749,991

46,596

6,604

3,459

80,164,960

15,754,151

8,422,655

213,699

11,272,708

Sub-district Hospital (SDH)

2007

258

452,310

20,582

10,881

3,497

30,945,390

4,901,502

2,806,004

76,442

1,527,236

Sub-district Hospital (SDH)

2008

258

501,871

20,332

18,100

2,753

31,952,816

4,885,070

3,196,062

58,484

1,755,292

Sub-district Hospital (SDH)

2009

258

614,736

20,883

20,178

2,853

32,965,540

4,992,678

3,566,082

53,835

2,570,014

Sub-district Hospital (SDH)

2010

258

614,231

25,026

19,772

2,783

39,975,752

5,158,520

3,648,514

103,351

4,110,386

Sub-district Hospital (SDH)

2011

258

617,750

26,415

15,936

3,799

40,753,028

5,195,006

4,244,187

81,582

4,195,321

District

Platform

Year

Primary Health Centre (PHC)

FACILITY INFORMATION

STAFF AND BEDS

OUTPUTS

EXPENDITURE Medical supplies + pharmaceuticals

Administration and training

Non-medical

Beds

Doctors

Nurses

Paramedical

Nonmedical

Outpatient

Inpatient

Vaccinations

Births

Personnel

Infrastructure + utilities

2007

75,752

590

7,431,071

39,093

150,449

Community Health Centre (CHC)

2008

68,444

844

7,657,847

39,093

176,172

Community Health Centre (CHC)

2009

64,978

1,038

118

7,925,512

39,093

214,996

Community Health Centre (CHC)

2010

64,668

576

8,168,281

39,093

189,997

Community Health Centre (CHC)

2011

41,379

561

8,460,372

39,093

202,101

Primary Health Centre (PHC)

2007

32,591

205

10,771

2,996,702

61,356

86,330

8,090

157,320

Primary Health Centre (PHC)

2008

32,735

241

14,793

3,089,384

63,353

107,388

8,174

158,530

Primary Health Centre (PHC)

2009

38,975

403

20,350

3,184,932

81,301

140,799

8,640

160,040

Primary Health Centre (PHC)

2010

52,682

715

35,784

3,282,835

71,223

164,995

9,860

160,190

Primary Health Centre (PHC)

2011

53,274

843

32,965

3,384,986

74,808

232,423

10,308

161,780

Primary Health Centre (PHC)

2007

57,912

967

2,088

130

4,488,522

150,465

149,998

23,006

184,220

Primary Health Centre (PHC)

2008

53,781

967

6,297

114

4,792,291

162,991

174,994

23,273

186,460

Primary Health Centre (PHC)

2009

57,451

851

15,856

117

5,002,362

156,808

149,997

25,421

187,360

Primary Health Centre (PHC)

2010

56,340

948

47,380

5,218,930

163,797

159,997

26,631

196,570

Primary Health Centre (PHC)

2011

55,201

982

45,658

5,442,198

170,490

170,685

28,601

199,970

Sub-district Hospital (SDH)

2007

133,495

2,873

116

4,584,804

179,120

828,354

3,457

2,000

Sub-district Hospital (SDH)

2008

87,880

2,568

140

4,765,452

183,731

780,770

4,144

1,883

Sub-district Hospital (SDH)

2009

108,714

3,572

122

7,192,056

182,753

916,306

3,850

3,908

Sub-district Hospital (SDH)

2010

108,816

4,860

130

7,718,327

183,380

840,553

3,885

9,392

Sub-district Hospital (SDH)

2011

110,555

4,049

146

8,854,020

194,225

916,357

3,509

18,673

Community Health Centre (CHC)

2007

36,955

454

7,784

2,990,895

303,483

141,965

18,495

9,500

Community Health Centre (CHC)

2008

45,575

548

5,984

108

3,534,492

304,277

167,003

27,164

13,449

Community Health Centre (CHC)

2009

53,851

626

5,762

124

5,815,892

326,157

224,572

18,929

20,660

Community Health Centre (CHC)

2010

58,088

612

6,004

112

6,686,618

337,073

309,650

22,882

30,230

Community Health Centre (CHC)

2011

61,408

629

5,098

7,401,558

381,686

428,856

25,076

48,600

Primary Health Centre (PHC)

2007

32,096

520

5,653

4,250,140

84,041

147,173

23,000

9,000

Primary Health Centre (PHC)

2008

41,655

516

5,670

103

4,381,587

87,793

171,366

55,500

9,500

Primary Health Centre (PHC)

2009

45,174

789

5,649

139

4,517,100

82,166

169,567

59,300

9,500

Primary Health Centre (PHC)

2010

46,665

689

7,279

127

4,656,804

82,710

180,128

52,215

15,341

Primary Health Centre (PHC)

2011

42,640

644

7,956

4,800,828

107,549

209,905

61,269

12,049

Primary Health Centre (PHC)

2007

19,432

273

10,641

2,466,470

80,782

80,000

40,753

80,250

Primary Health Centre (PHC)

2008

21,532

471

16,227

2,542,753

59,378

99,997

38,205

82,250

Primary Health Centre (PHC)

2009

22,043

533

16,596

2,621,395

54,351

94,996

40,455

96,012

Primary Health Centre (PHC)

2010

22,031

496

17,397

2,702,470

55,874

114,996

30,499

82,100

Primary Health Centre (PHC)

2011

19,211

403

15,248

2,786,052

51,591

141,018

29,643

80,975

District Hospital (DH)

2007

313

523,699

90,483

7,261

3,388

51,823,836

350,155

6,508,595

21,507

3,015,500

District Hospital (DH)

2008

313

511,544

101,313

5,730

3,147

53,530,740

357,633

6,950,630

59,583

3,000,000

District Hospital (DH)

2009

313

412,622

98,209

6,454

2,890

57,982,896

343,401

7,193,214

174,018

3,021,000

District Hospital (DH)

2010

313

435,706

91,362

6,055

2,810

60,245,588

402,432

7,216,491

115,327

3,038,449

District

Platform

Year

Community Health Centre (CHC)

FACILITY INFORMATION

STAFF AND BEDS

OUTPUTS

EXPENDITURE Medical supplies + pharmaceuticals

Administration and training

Non-medical

District

Platform

Year

Beds

Doctors

Nurses

Paramedical

Nonmedical

Outpatient

Inpatient

Vaccinations

Births

Personnel

Infrastructure + utilities

District Hospital (DH)

2011

313

378,562

85,330

5,192

3,580

62,108,748

348,178

7,515,958

134,887

3,000,000

Sub-district Hospital (SDH)

2007

106,595

8,245

16,639

150

5,895,646

2,348,181

679,482

11,290

126,236

Sub-district Hospital (SDH)

2008

113,365

8,467

34,965

152

3,846,696

1,147,863

719,443

1,702

171,584

Sub-district Hospital (SDH)

2009

133,891

14,669

48,754

102

8,547,145

1,168,023

832,772

6,684

213,667

Sub-district Hospital (SDH)

2010

126,559

13,091

67,308

104

9,915,536

1,325,994

831,531

230,780

169,705

Sub-district Hospital (SDH)

2011

125,903

19,370

63,986

143

12,587,300

1,390,742

959,993

561,943

185,453

Community Health Centre (CHC)

2007

70,577

649

1,545

110

10,010,762

890,834

155,207

15,637

314,599

Community Health Centre (CHC)

2008

68,569

693

1,673

140

10,907,497

947,220

192,915

18,117

1,342,240

Community Health Centre (CHC)

2009

74,375

950

1,705

139

11,362,252

906,115

296,920

22,679

851,975

Community Health Centre (CHC)

2010

64,340

838

1,639

109

11,834,509

980,249

293,524

23,470

723,781

Community Health Centre (CHC)

2011

60,643

742

1,514

11,497,524

1,118,100

313,851

26,900

880,277

Primary Health Centre (PHC)

2007

21,258

156

2,222

5,359,124

176,392

99,243

5,684

6,238

Primary Health Centre (PHC)

2008

23,106

354

2,405

5,792,916

179,258

116,214

10,911

15,369

Primary Health Centre (PHC)

2009

23,994

344

1,653

3,326,576

187,510

110,246

12,108

13,731

Primary Health Centre (PHC)

2010

25,260

394

2,496

3,358,448

189,945

123,203

10,324

14,670

Primary Health Centre (PHC)

2011

26,930

405

2,401

3,639,722

213,610

128,058

13,086

18,835

Primary Health Centre (PHC)

2007

26,945

180

1,558

4,133,812

242,263

97,310

2,395

1,000

Primary Health Centre (PHC)

2008

34,137

316

1,691

4,271,064

213,336

114,240

6,320

6,810

Primary Health Centre (PHC)

2009

35,841

376

2,238

123

4,412,189

216,534

100,890

7,058

7,017

Primary Health Centre (PHC)

2010

31,166

175

1,585

4,581,308

219,339

130,171

9,831

9,545

Primary Health Centre (PHC)

2011

32,938

426

1,670

4,718,544

259,447

146,225

17,050

9,830

Sub-district Hospital (SDH)

2007

216,368

1,944

1,766

116

2,413,000

187,889

756,381

4,399

19,848

Sub-district Hospital (SDH)

2008

230,510

1,925

2,276

146

2,702,000

191,979

738,894

4,373

17,717

Sub-district Hospital (SDH)

2009

227,117

2,093

2,615

105

3,147,000

229,799

936,485

4,173

16,584

Sub-district Hospital (SDH)

2010

213,773

2,459

3,196

3,874,000

222,229

990,354

5,678

19,978

Sub-district Hospital (SDH)

2011

186,566

2,384

3,393

6,323,000

201,649

1,050,608

5,432

22,765

Community Health Centre (CHC)

2007

37,734

826

10,253

205

5,743,907

119,834

152,593

6,863

418

Community Health Centre (CHC)

2008

42,977

1,146

9,302

273

5,836,716

120,436

188,041

12,068

1,098

Community Health Centre (CHC)

2009

46,436

1,228

7,736

416

9,594,059

120,762

195,655

14,430

46,310

Community Health Centre (CHC)

2010

48,638

1,206

5,600

486

12,004,006

122,162

198,611

32,769

30,631

Community Health Centre (CHC)

2011

51,533

1,469

6,054

635

14,849,758

125,274

211,586

51,252

86,207

Primary Health Centre (PHC)

2007

45,497

3,524

6,123,905

56,359

138,441

3,478

32,540

Primary Health Centre (PHC)

2008

43,706

266

3,365

7,634,850

57,036

161,798

3,563

34,560

Primary Health Centre (PHC)

2009

52,441

373

4,146

100

7,856,700

56,216

162,396

3,603

49,270

Primary Health Centre (PHC)

2010

53,612

430

4,049

7,560,447

56,033

210,024

3,311

53,310

Primary Health Centre (PHC)

2011

51,652

536

3,067

105

8,011,006

56,754

265,107

3,302

53,760

Primary Health Centre (PHC)

2007

28,713

223

13,155

2,513,735

133,486

88,853

4,955

23,992

Primary Health Centre (PHC)

2008

34,614

227

1,013

112

3,163,756

138,511

114,909

15,969

76,914

Primary Health Centre (PHC)

2009

38,366

336

1,201

112

3,510,567

138,054

139,232

103,915

50,185

FACILITY INFORMATION

STAFF AND BEDS

OUTPUTS

EXPENDITURE Medical supplies + pharmaceuticals

Administration and training

Non-medical

Beds

Doctors

Nurses

Paramedical

Nonmedical

Outpatient

Inpatient

Vaccinations

Births

Personnel

Infrastructure + utilities

2010

37,535

286

1,100

3,865,992

142,228

162,848

96,880

29,110

Primary Health Centre (PHC)

2011

36,809

395

1,156

4,162,086

154,375

193,630

51,240

99,830

District Hospital (DH)

2007

421

102,938

9,729

2,648

969

769,012

206,500

4,652,155

20,687

91,229

District Hospital (DH)

2008

421

111,448

16,848

4,449

1,789

894,529

211,714

5,010,731

13,717

126,034

District Hospital (DH)

2009

421

119,623

16,975

5,721

2,234

1,336,638

391,165

5,314,590

17,393

263,000

District Hospital (DH)

2010

421

122,278

19,008

4,841

1,815

2,079,589

454,132

4,813,948

28,000

785,100

District Hospital (DH)

2011

421

121,928

21,863

5,759

1,888

3,432,428

738,957

5,516,403

8,000

806,000

Sub-district Hospital (SDH)

2007

97,572

1,580

69,011

166

37,841,640

103,411

1,148,941

30,010

12,342

Sub-district Hospital (SDH)

2008

107,081

1,836

47,330

116

39,661,068

91,103

1,177,492

39,268

56,073

Sub-district Hospital (SDH)

2009

107,985

2,545

73,777

157

60,292,152

96,570

1,304,166

22,179

25,300

Sub-district Hospital (SDH)

2010

107,977

2,175

86,747

42,073,768

92,054

1,148,244

4,455

51,400

Sub-district Hospital (SDH)

2011

120,372

2,611

87,014

44,677,324

101,384

1,201,593

21,075

30,900

Community Health Centre (CHC)

2007

17,821

275

1,380

5,689,096

110,938

107,110

19,198

3,225

Community Health Centre (CHC)

2008

21,835

234

1,398

5,963,952

117,424

124,464

15,181

2,705

Community Health Centre (CHC)

2009

19,309

167

1,231

6,368,340

115,652

145,052

11,695

14,638

Community Health Centre (CHC)

2010

24,533

359

1,096

6,849,732

122,308

165,324

9,298

51,940

Community Health Centre (CHC)

2011

23,307

273

994

7,605,704

139,703

178,259

15,052

90,922

Primary Health Centre (PHC)

2007

19,270

188

2,755

5,503,836

60,468

89,114

14,875

12,000

Primary Health Centre (PHC)

2008

22,460

238

2,539

5,968,884

61,941

108,688

24,082

13,495

Primary Health Centre (PHC)

2009

24,062

350

2,416

111

6,161,976

74,815

120,250

23,075

46,100

Primary Health Centre (PHC)

2010

24,262

377

2,312

126

6,408,492

64,263

124,034

70,535

86,870

Primary Health Centre (PHC)

2011

21,432

322

1,895

116

6,648,588

73,513

155,155

6,470

134,695

Primary Health Centre (PHC)

2007

25,736

220

1,157

3,403,408

95,277

91,320

25,823

182,284

Primary Health Centre (PHC)

2008

30,460

259

1,338

3,557,632

96,891

110,027

1,025

199,555

Primary Health Centre (PHC)

2009

31,339

420

842

3,720,311

104,121

107,604

2,460

213,790

Primary Health Centre (PHC)

2010

30,997

258

1,104

113

3,891,986

112,159

128,225

23,508

236,276

Primary Health Centre (PHC)

2011

24,201

164

1,275

4,073,232

105,629

143,841

7,936

260,610

Sub-district Hospital (SDH)

2007

128

93,330

4,637

77,775

371

17,506,544

892,670

440,931

9,500

15,000

Sub-district Hospital (SDH)

2008

128

88,797

3,954

88,797

142

18,047,982

902,574

482,825

8,450

18,500

Sub-district Hospital (SDH)

2009

128

103,290

4,808

94,683

234

18,606,168

1,095,953

502,452

15,910

446,839

Sub-district Hospital (SDH)

2010

128

114,576

5,235

105,028

221

19,181,616

1,011,828

525,703

26,634

330,452

Sub-district Hospital (SDH)

2011

128

99,523

4,064

2,930

169

19,774,860

1,101,370

570,278

38,085

501,655

Community Health Centre (CHC)

2007

30,171

19,058

123

6,397,405

229,324

85,069

226,935

6,094,000

Community Health Centre (CHC)

2008

31,043

16,075

143

6,584,504

270,754

104,997

220,403

11,015,215

Community Health Centre (CHC)

2009

34,030

6,911

185

6,951,390

183,337

177,997

253,760

12,404,148

Community Health Centre (CHC)

2010

32,808

147

7,367

178

7,150,243

547,703

236,860

353,610

12,608,300

Community Health Centre (CHC)

2011

23,289

271

7,878

215

7,436,634

248,444

293,551

303,512

29,618,150

Primary Health Centre (PHC)

2007

17,526

105

1,509

2,777,735

52,744

93,972

843

1,563

Primary Health Centre (PHC)

2008

17,531

192

1,220

2,800,851

52,744

113,022

3,986

2,625

District

Platform

Year

Primary Health Centre (PHC)

FACILITY INFORMATION

STAFF AND BEDS

OUTPUTS

EXPENDITURE Medical supplies + pharmaceuticals

Administration and training

Non-medical

Beds

Doctors

Nurses

Paramedical

Nonmedical

Outpatient

Inpatient

Vaccinations

Births

Personnel

Infrastructure + utilities

2009

16,353

136

1,205

2,934,983

54,471

113,812

6,104

21,812

Primary Health Centre (PHC)

2010

16,000

172

1,305

3,076,839

55,003

127,939

15,604

13,300

Primary Health Centre (PHC)

2011

21,486

208

1,209

3,226,928

59,834

151,645

9,244

28,390

Primary Health Centre (PHC)

2007

19,459

1,198

4,881,177

476,220

79,998

1,398

2,085

Primary Health Centre (PHC)

2008

20,641

1,204

173

5,032,141

476,220

104,999

843

5,430

Primary Health Centre (PHC)

2009

21,196

6,005

178

5,187,774

480,368

153,117

8,008

49,750

Primary Health Centre (PHC)

2010

23,160

167

4,972

212

5,348,220

482,296

142,170

49,932

83,689

Primary Health Centre (PHC)

2011

26,898

220

5,512

238

5,513,628

483,976

197,065

8,760

102,715

District Hospital (DH)

2007

257

776,385

52,140

4,295

2,798

53,036,208

309,612

3,320,000

5,718

1,967,580

District Hospital (DH)

2008

338

857,803

87,151

3,632

4,206

54,666,856

361,375

3,350,000

13,007

2,006,475

District Hospital (DH)

2009

345

896,534

67,972

2,323

3,957

56,420,860

278,985

3,646,459

176,985

2,100,000

District Hospital (DH)

2010

331

776,234

85,203

3,358

3,567

57,951,932

408,647

5,343,169

27,204

2,200,000

District Hospital (DH)

2011

310

1,006,651

113,687

12,107

4,067

60,056,976

332,130

4,643,214

45,961

2,500,000

Sub-district Hospital (SDH)

2007

178

445,179

64,999

3,813

1,636

11,935,030

117,053

3,331,378

19,850

68,500

Sub-district Hospital (SDH)

2008

178

476,745

60,989

5,869

1,485

12,675,528

414,906

3,224,643

26,563

646,182

Sub-district Hospital (SDH)

2009

178

513,942

64,316

6,480

1,611

12,474,901

527,804

3,633,012

10,000

904,150

Sub-district Hospital (SDH)

2010

178

564,071

56,249

6,990

1,796

13,982,051

206,975

3,687,492

33,510

87,698

Sub-district Hospital (SDH)

2011

178

518,804

76,849

7,740

2,099

17,624,408

249,660

4,146,686

39,900

234,827

Community Health Centre (CHC)

2007

54,041

394

9,239

172

5,877,085

188,527

149,640

40,602

18,778

Community Health Centre (CHC)

2008

54,702

558

6,471

166

6,058,850

248,957

165,755

46,501

35,549

Community Health Centre (CHC)

2009

64,587

918

8,769

228

8,526,792

303,540

261,601

54,561

25,000

Community Health Centre (CHC)

2010

55,650

828

6,783

234

8,562,435

319,049

280,788

75,000

38,000

Community Health Centre (CHC)

2011

57,156

742

7,028

119

12,589,881

438,695

312,900

90,941

36,175

Primary Health Centre (PHC)

2007

40,494

101

5,189

385,383

24,789

135,061

5,700

8,000

Primary Health Centre (PHC)

2008

41,633

186

5,631

107

373,193

28,369

162,066

10,400

22,520

Primary Health Centre (PHC)

2009

42,699

316

19,088

129

385,383

31,969

147,251

9,170

12,092

Primary Health Centre (PHC)

2010

41,467

450

4,542

142

336,222

37,489

175,354

10,450

41,532

Primary Health Centre (PHC)

2011

42,752

368

5,376

117

336,222

40,023

158,216

11,850

48,566

Primary Health Centre (PHC)

2007

30,725

193

7,790

4,536,495

47,601

136,672

56,641

25,064

Primary Health Centre (PHC)

2008

34,934

240

8,918

115

4,877,952

51,553

124,604

58,184

36,962

Primary Health Centre (PHC)

2009

33,412

331

8,061

166

5,184,336

59,031

117,545

63,048

27,200

Primary Health Centre (PHC)

2010

26,792

391

9,385

169

5,344,668

44,492

145,944

45,610

270,000

Primary Health Centre (PHC)

2011

23,762

339

10,685

152

5,509,956

41,993

143,125

61,408

45,168

Sub-district Hospital (SDH)

2007

97,615

1,130

34,803

8,892,026

1,256,498

320,046

48,512

20,068

Sub-district Hospital (SDH)

2008

95,097

20,070

47,331

9,564,976

1,238,207

374,464

74,934

34,694

Sub-district Hospital (SDH)

2009

144,722

36,975

76,278

10,302,964

1,226,055

680,970

37,976

65,597

Sub-district Hospital (SDH)

2010

148,747

116,702

70,985

11,112,841

1,231,757

641,744

13,400

82,500

Sub-district Hospital (SDH)

2011

111,888

109,888

31,881

113

12,002,412

1,225,121

722,565

57,698

32,000

Community Health Centre (CHC)

2007

69,718

332

2,148

182

4,311,264

256,300

204,209

41,821

365

District

Platform

Year

Primary Health Centre (PHC)

FACILITY INFORMATION

STAFF AND BEDS

OUTPUTS

EXPENDITURE Medical supplies + pharmaceuticals

Administration and training

Non-medical

Beds

Doctors

Nurses

Paramedical

Nonmedical

Outpatient

Inpatient

Vaccinations

Births

Personnel

Infrastructure + utilities

2008

71,496

514

5,299

262

4,518,078

256,552

236,934

26,529

132,940

Community Health Centre (CHC)

2009

101,454

406

11,498

283

4,657,812

269,730

213,310

13,456

117,015

Community Health Centre (CHC)

2010

88,307

431

8,608

248

5,770,227

281,093

256,039

20,505

163,385

Community Health Centre (CHC)

2011

70,409

901

5,442

285

6,467,076

260,082

258,892

26,619

177,100

Primary Health Centre (PHC)

2007

41,783

255

7,349

2,893,400

60,770

139,480

22,535

780

Primary Health Centre (PHC)

2008

47,063

162

9,084

189

2,983,505

53,541

172,102

7,759

10,890

Primary Health Centre (PHC)

2009

47,063

175

9,929

240

3,190,068

86,535

162,978

8,130

25,520

Primary Health Centre (PHC)

2010

41,783

179

11,961

229

3,241,114

56,112

165,628

17,751

49,734

Primary Health Centre (PHC)

2011

36,094

254

12,110

200

3,357,380

66,340

223,469

119,811

55,287

Primary Health Centre (PHC)

2007

61,225

385

4,514

106

4,749,319

251,790

169,225

20,505

2,160

Primary Health Centre (PHC)

2008

92,141

679

4,623

162

5,053,581

228,823

187,870

34,342

4,000

Primary Health Centre (PHC)

2009

92,532

683

4,391

208

5,385,623

235,207

195,003

2,615

45,945

Primary Health Centre (PHC)

2010

65,270

778

4,440

184

5,762,383

283,502

205,319

12,610

79,635

Primary Health Centre (PHC)

2011

62,587

551

4,047

226

6,148,591

245,788

211,631

13,650

88,195

District Hospital (DH)

2007

186

200,457

15,829

96,323

1,269

23,016,396

2,877,024

4,751,680

158,515

342,660

District Hospital (DH)

2008

186

202,296

20,101

98,130

1,366

24,528,264

3,358,535

4,577,241

139,996

425,096

District Hospital (DH)

2009

186

233,102

20,036

115,539

1,526

26,253,102

3,584,667

5,600,000

164,013

381,158

District Hospital (DH)

2010

186

237,351

25,799

118,691

1,514

27,769,368

3,857,062

5,131,799

165,763

372,189

District Hospital (DH)

2011

186

221,213

24,811

104,310

1,377

29,488,240

4,096,313

5,365,900

168,568

442,177

Sub-district Hospital (SDH)

2007

29,551

265

1,972,154

241,957

779,926

9,346

9,285

Sub-district Hospital (SDH)

2008

32,614

278

2,033,145

253,853

846,409

21,664

9,411

Sub-district Hospital (SDH)

2009

33,219

1,065

2,096,027

232,665

919,624

11,388

10,405

Sub-district Hospital (SDH)

2010

36,223

1,075

2,160,851

266,274

1,000,198

32,045

15,977

Sub-district Hospital (SDH)

2011

47,185

1,448

3,888,848

355,829

940,199

38,655

17,900

Community Health Centre (CHC)

2007

52,335

723

3,623

181

6,403,877

1,859,528

136,881

38,328

3,121,667

Community Health Centre (CHC)

2008

58,107

853

3,296

133

6,676,576

1,818,804

184,477

69,246

3,842,567

Community Health Centre (CHC)

2009

57,948

805

3,347

114

7,150,418

2,034,906

241,276

71,071

5,965,134

Community Health Centre (CHC)

2010

51,542

747

3,245

140

7,484,374

1,981,369

291,161

50,645

6,480,620

Community Health Centre (CHC)

2011

43,788

552

4,812

103

7,407,936

1,879,000

354,182

60,795

9,427,994

Primary Health Centre (PHC)

2007

54,401

843

16,126

110

4,449,156

148,233

150,533

1,072

7,217

Primary Health Centre (PHC)

2008

54,952

877

15,399

225

4,646,472

149,004

174,998

20,932

16,836

Primary Health Centre (PHC)

2009

64,305

957

18,051

194

4,854,876

148,042

180,005

25,347

14,423

Primary Health Centre (PHC)

2010

55,277

692

13,533

179

5,110,968

153,885

159,973

25,262

11,210

Primary Health Centre (PHC)

2011

66,292

751

10,778

167

5,343,552

153,040

234,409

97,394

10,050

Primary Health Centre (PHC)

2007

28,143

309

5,228

2,120,839

147,693

95,583

6,440

6,799

Primary Health Centre (PHC)

2008

33,275

317

5,208

2,186,431

149,997

115,171

12,200

9,395

Primary Health Centre (PHC)

2009

36,968

362

5,067

2,254,052

148,206

112,049

49,152

17,580

Primary Health Centre (PHC)

2010

39,317

417

5,667

2,323,764

149,221

176,321

39,825

9,710

Primary Health Centre (PHC)

2011

39,221

532

6,194

2,395,632

156,336

161,832

35,002

6,450

District

Platform

Year

Community Health Centre (CHC)

FACILITY INFORMATION

STAFF AND BEDS

OUTPUTS

EXPENDITURE Medical supplies + pharmaceuticals

Administration and training

Non-medical

Beds

Doctors

Nurses

Paramedical

Nonmedical

Outpatient

Inpatient

Vaccinations

Births

Personnel

Infrastructure + utilities

2007

100,355

350

48,396

8,522,976

110,915

534,725

43,802

120,088

Sub-district Hospital (SDH)

2008

80,049

489

35,898

9,041,221

134,298

520,565

14,433

123,971

Sub-district Hospital (SDH)

2009

102,710

464

47,479

9,538,181

123,941

654,995

26,249

101,484

Sub-district Hospital (SDH)

2010

113,238

645

49,620

10,142,376

115,507

634,478

21,450

53,100

Sub-district Hospital (SDH)

2011

93,437

811

42,299

10,744,596

147,731

657,180

15,878

155,805

Community Health Centre (CHC)

2007

52,375

277

10,925

46,784,892

186,921

156,485

79,150

2,984,600

Community Health Centre (CHC)

2008

61,144

305

7,127

115

48,231,848

186,148

205,688

44,190

5,272,219

Community Health Centre (CHC)

2009

63,411

669

15,330

103

49,723,552

306,151

300,511

165,300

7,128,740

Community Health Centre (CHC)

2010

61,962

426

16,795

110

51,261,396

495,193

364,467

270,423

7,016,137

Community Health Centre (CHC)

2011

70,287

1,191

13,590

109

52,689,648

437,342

426,064

245,392

7,664,983

Primary Health Centre (PHC)

2007

30,995

303

12,950

5,616,485

60,839

119,930

8,132

1,029

Primary Health Centre (PHC)

2008

37,781

439

11,723

112

6,178,901

56,492

181,424

29,020

2,113

Primary Health Centre (PHC)

2009

46,343

431

5,813

123

6,490,754

54,630

219,495

46,500

3,206

Primary Health Centre (PHC)

2010

60,198

446

12,175

110

6,819,293

60,763

303,866

92,444

6,557

Primary Health Centre (PHC)

2011

60,532

440

9,996

106

7,165,572

59,832

429,856

104,773

9,670

Primary Health Centre (PHC)

2007

16,318

104

4,484

1,678,434

160,352

131,966

11,733

12,300

Primary Health Centre (PHC)

2008

19,185

4,073

1,774,669

157,113

149,191

14,422

16,835

Primary Health Centre (PHC)

2009

21,091

287

4,071

106

1,857,022

160,878

146,360

17,846

17,690

Primary Health Centre (PHC)

2010

29,984

417

4,398

125

1,961,710

160,253

166,929

27,790

19,690

Primary Health Centre (PHC)

2011

30,640

521

4,646

123

2,070,960

160,786

268,081

38,330

33,990

Sub Health Centre (SHC)

2007

2,921

648

261,564

18,171

4,059

7,480

2,750

District Hospital (DH)

2007

470

161

120

144

888,760

47,626

35,751

12,965

105,795,504

6,406,656

5,445,951

199,700

1,796,810

District Hospital (DH)

2008

470

159

123

144

944,069

49,836

36,576

13,226

109,067,536

5,618,585

7,200,000

245,773

1,488,174

District Hospital (DH)

2009

470

159

120

144

988,337

50,225

38,248

12,095

112,440,760

6,761,593

6,900,000

368,708

1,714,415

District Hospital (DH)

2010

470

163

124

144

733,195

44,841

38,724

10,489

115,918,312

6,822,771

6,800,000

442,254

2,446,462

District Hospital (DH)

2011

470

161

127

144

724,760

45,870

40,197

14,220

119,503,416

6,318,203

7,045,274

464,411

1,290,682

Sub-district Hospital (SDH)

2007

178

331,716

11,282

5,545

2,403

38,793,280

1,307,828

2,558,484

41,701

196,301

Sub-district Hospital (SDH)

2008

178

311,915

10,047

4,863

1,800

39,993,072

1,332,253

3,338,163

46,721

225,190

Sub-district Hospital (SDH)

2009

178

338,008

10,998

5,432

1,680

41,229,972

1,376,831

2,922,994

329,274

210,790

Sub-district Hospital (SDH)

2010

178

359,376

12,591

3,566

1,691

42,505,124

1,436,038

2,898,590

794,159

221,070

Sub-district Hospital (SDH)

2011

178

347,830

12,313

6,299

1,722

43,819,716

1,355,756

3,149,136

752,219

340,000

Community Health Centre (CHC)

2007

78,649

729

427

4,038,615

177,758

205,538

24,300

137,160

Community Health Centre (CHC)

2008

98,912

724

1,371

139

5,809,180

179,232

242,976

24,670

137,690

Community Health Centre (CHC)

2009

99,611

997

1,009

6,151,118

197,467

303,538

25,360

142,800

Community Health Centre (CHC)

2010

89,786

1,044

770

6,391,486

175,465

343,464

25,790

143,980

Community Health Centre (CHC)

2011

71,239

1,282

1,117

205

6,609,720

180,185

388,750

26,050

144,170

Primary Health Centre (PHC)

2007

49,036

337

5,536

4,220,829

101,758

147,595

6,312

9,960

Primary Health Centre (PHC)

2008

55,354

623

2,110

4,392,344

101,518

176,030

4,647

3,000

Primary Health Centre (PHC)

2009

57,657

644

2,176

4,640,302

101,962

172,439

3,540

45,355

District

Platform

Year

Sub-district Hospital (SDH)

FACILITY INFORMATION

STAFF AND BEDS

OUTPUTS

EXPENDITURE Medical supplies + pharmaceuticals

Administration and training

Non-medical

Beds

Doctors

Nurses

Paramedical

Nonmedical

Outpatient

Inpatient

Vaccinations

Births

Personnel

Infrastructure + utilities

2010

46,300

648

2,768

4,860,297

104,550

164,518

5,509

47,000

Primary Health Centre (PHC)

2011

37,527

711

3,547

5,140,488

109,755

251,738

4,350

30,315

Primary Health Centre (PHC)

2007

39,850

238

4,015

3,045,782

83,267

133,354

14,842

1,350

Primary Health Centre (PHC)

2008

30,604

248

4,025

3,139,983

83,254

183,397

11,484

12,547

Primary Health Centre (PHC)

2009

61,915

792

4,027

103

3,237,095

84,646

181,199

72,179

14,980

Primary Health Centre (PHC)

2010

50,841

765

3,996

3,337,211

82,046

170,715

97,950

12,533

Primary Health Centre (PHC)

2011

43,867

705

4,422

3,440,424

90,182

203,792

84,650

Sub-district Hospital (SDH)

2007

69,649

2,769

269

116

5,144,172

161,480

539,398

10,271

63,900

Sub-district Hospital (SDH)

2008

61,666

2,422

245

5,303,270

152,310

579,657

12,265

69,700

Sub-district Hospital (SDH)

2009

127,465

4,344

394

5,449,288

171,229

535,694

12,900

69,980

Sub-district Hospital (SDH)

2010

137,229

4,598

323

5,627,741

161,609

641,650

13,235

71,990

Sub-district Hospital (SDH)

2011

125,516

4,565

220

5,784,192

164,489

641,468

14,320

74,498

Community Health Centre (CHC)

2007

53,248

708

1,781

152

7,088,142

267,947

126,105

214,582

38,006

Community Health Centre (CHC)

2008

70,771

722

1,871

225

7,373,038

287,645

192,879

916,720

38,821

Community Health Centre (CHC)

2009

80,203

872

3,380

231

7,702,386

410,700

292,747

909,440

91,193

Community Health Centre (CHC)

2010

73,660

1,238

4,218

210

8,017,060

334,833

343,662

138,850

134,666

Community Health Centre (CHC)

2011

84,375

1,047

4,367

201

8,947,988

443,390

404,708

158,783

147,710

Primary Health Centre (PHC)

2007

43,537

322

626

4,393,931

46,942

120,000

12,800

1,575

Primary Health Centre (PHC)

2008

53,580

432

661

111

4,614,139

48,562

144,999

15,000

8,605

Primary Health Centre (PHC)

2009

45,728

530

709

128

4,845,388

49,962

149,998

17,800

10,222

Primary Health Centre (PHC)

2010

43,380

649

776

110

4,872,390

52,116

155,004

22,500

9,950

Primary Health Centre (PHC)

2011

35,294

718

746

5,325,912

53,762

148,496

41,500

44,450

Primary Health Centre (PHC)

2007

16,524

331

1,120

3,727,308

118,662

122,511

2,841

55,000

Primary Health Centre (PHC)

2008

17,327

607

1,814

3,910,284

120,365

143,823

1,504

49,903

Primary Health Centre (PHC)

2009

19,625

840

1,382

4,110,180

116,962

168,929

1,429

44,828

Primary Health Centre (PHC)

2010

16,663

446

3,058

4,392,804

119,962

168,830

1,925

80,216

Primary Health Centre (PHC)

2011

13,500

510

1,870

4,701,564

116,310

171,955

4,075

57,692

District Hospital (DH)

2007

440

839,523

124,315

12,195

4,796

70,336,368

8,104,355

8,233,413

26,230

1,734,430

District Hospital (DH)

2008

440

755,747

111,893

7,010

4,289

72,484,712

8,300,838

10,117,705

26,383

1,795,044

District Hospital (DH)

2009

440

814,829

146,668

6,551

4,068

74,754,344

8,540,757

10,220,730

27,078

2,115,044

District Hospital (DH)

2010

440

954,508

125,382

6,893

3,769

77,066,336

8,958,439

11,121,673

27,561

1,623,847

District Hospital (DH)

2011

440

986,455

138,729

7,252

5,192

79,449,840

9,072,930

12,103,611

28,560

1,721,008

Sub-district Hospital (SDH)

2007

66,806

1,154

207

116

5,627,344

140,634

477,346

17,534

6,589

Sub-district Hospital (SDH)

2008

73,454

2,269

216

182

5,801,385

140,189

559,444

7,082

14,726

Sub-district Hospital (SDH)

2009

123,523

2,542

338

121

5,980,809

143,451

715,595

22,360

13,521

Sub-district Hospital (SDH)

2010

127,329

2,595

281

107

6,165,782

147,962

769,730

39,474

26,863

Sub-district Hospital (SDH)

2011

130,387

3,909

453

181

6,356,476

138,430

762,112

57,025

23,957

Community Health Centre (CHC)

2007

28,004

126

8,435

102

4,141,049

181,993

120,531

10,116

9,872,000

Community Health Centre (CHC)

2008

29,346

6,386

225

4,333,528

186,125

149,454

11,054

10,905,617

District

Platform

Year

Primary Health Centre (PHC)

FACILITY INFORMATION

STAFF AND BEDS

OUTPUTS

EXPENDITURE Medical supplies + pharmaceuticals

Administration and training

Non-medical

Beds

Doctors

Nurses

Paramedical

Nonmedical

Outpatient

Inpatient

Vaccinations

Births

Personnel

Infrastructure + utilities

2009

47,632

145

5,715

462

4,549,114

201,772

191,134

18,980

12,285,075

Community Health Centre (CHC)

2010

56,933

281

5,335

367

5,001,542

194,098

226,558

21,061

13,586,310

Community Health Centre (CHC)

2011

53,577

287

6,283

321

5,170,680

215,644

243,473

30,743

14,000,778

Primary Health Centre (PHC)

2007

26,802

11,341

104

3,015,754

102,112

116,252

3,050

5,343

Primary Health Centre (PHC)

2008

29,120

103

11,535

162

3,115,890

102,837

141,339

4,159

18,602

Primary Health Centre (PHC)

2009

34,914

282

11,268

233

3,205,238

107,037

154,931

10,650

16,515

Primary Health Centre (PHC)

2010

44,025

474

10,970

246

3,305,000

111,987

230,803

15,667

33,351

Primary Health Centre (PHC)

2011

41,550

361

10,180

241

3,416,940

125,037

281,222

27,040

32,950

Primary Health Centre (PHC)

2007

19,470

365

6,516

123

3,706,896

134,663

98,484

8,143

5,967

Primary Health Centre (PHC)

2008

19,679

342

3,944

188

3,828,408

140,283

104,998

5,268

14,112

Primary Health Centre (PHC)

2009

38,533

963

5,826

364

3,939,792

138,986

173,511

114,022

33,100

Primary Health Centre (PHC)

2010

36,955

819

6,511

317

4,062,272

146,806

182,403

143,913

39,151

Primary Health Centre (PHC)

2011

40,261

685

7,050

284

4,197,632

150,254

205,966

135,682

36,885

Sub-district Hospital (SDH)

2007

414,114

11,898

2,853

462

15,182,945

111,981

1,383,039

2,781

4,520

Sub-district Hospital (SDH)

2008

324,059

5,316

521

15,652,524

99,781

1,265,706

11,356

1,135

Sub-district Hospital (SDH)

2009

318,091

6,531

428

16,136,627

99,601

1,631,203

25,717

57,467

Sub-district Hospital (SDH)

2010

297,256

7,607

383

16,635,701

103,909

1,649,965

27,153

98,823

Sub-district Hospital (SDH)

2011

328,889

6,661

606

393

17,150,208

114,587

1,566,779

10,587

95,594

Community Health Centre (CHC)

2007

68,990

829

6,916

244

6,859,574

138,576

170,651

4,446

3,200

Community Health Centre (CHC)

2008

66,387

867

7,567

316

7,220,604

137,899

192,496

1,615

1,800

Community Health Centre (CHC)

2009

70,590

561

8,189

405

7,600,636

158,726

253,161

14,107

68,760

Community Health Centre (CHC)

2010

71,525

944

8,816

354

8,000,668

195,026

314,330

20,754

66,929

Community Health Centre (CHC)

2011

63,296

728

8,090

312

8,421,756

244,402

397,224

22,297

23,137

Primary Health Centre (PHC)

2007

31,961

415

7,987

111

4,663,950

184,607

99,597

6,380

11,040

Primary Health Centre (PHC)

2008

36,611

354

4,737

121

4,822,299

205,861

155,999

10,271

44,170

Primary Health Centre (PHC)

2009

43,910

559

6,030

238

4,984,989

211,370

166,752

15,293

45,290

Primary Health Centre (PHC)

2010

43,367

408

6,561

225

5,092,154

221,196

178,534

6,500

103,495

Primary Health Centre (PHC)

2011

46,184

450

7,469

181

5,257,932

217,271

188,705

18,320

105,284

Primary Health Centre (PHC)

2007

37,150

177

7,106

4,478,206

127,538

135,127

3,582

6,725

Primary Health Centre (PHC)

2008

41,161

254

3,938

111

4,640,206

127,689

153,894

2,280

6,760

Primary Health Centre (PHC)

2009

57,023

473

3,904

284

4,783,718

128,115

190,737

4,755

58,200

Primary Health Centre (PHC)

2010

62,157

727

4,126

257

4,931,669

129,716

202,697

3,401

103,140

Primary Health Centre (PHC)

2011

55,786

605

5,020

178

4,680,228

128,634

220,765

4,152

74,350

District Hospital (DH)

2007

230

547,652

21,597

11,615

2,789

38,748,084

14,973,706

6,623,814

52,149

948,735

District Hospital (DH)

2008

230

482,251

17,055

12,878

3,761

39,953,660

15,026,028

10,700,127

59,180

976,024

District Hospital (DH)

2009

230

608,236

21,212

16,003

2,999

41,189,348

15,324,242

8,100,027

73,968

909,704

District Hospital (DH)

2010

230

631,820

24,007

14,684

2,428

42,463,248

15,220,878

9,085,477

115,945

1,215,793

District Hospital (DH)

2011

230

632,508

26,942

14,046

2,702

43,776,548

15,630,219

7,240,314

101,168

1,508,573

Sub-district Hospital (SDH)

2007

373,244

9,992

2,808

612

20,799,160

280,309

2,301,561

120,452

248,617

District

Platform

Year

Community Health Centre (CHC)

FACILITY INFORMATION

STAFF AND BEDS

OUTPUTS

EXPENDITURE Medical supplies + pharmaceuticals

Administration and training

Non-medical

Beds

Doctors

Nurses

Paramedical

Nonmedical

Outpatient

Inpatient

Vaccinations

Births

Personnel

Infrastructure + utilities

2008

410,117

10,685

3,539

854

21,442,436

263,195

2,547,439

46,053

240,675

Sub-district Hospital (SDH)

2009

405,902

11,628

3,264

920

22,105,608

460,636

2,636,739

171,316

297,736

Sub-district Hospital (SDH)

2010

400,234

12,799

3,234

684

22,789,288

436,976

2,917,654

103,864

379,824

Sub-district Hospital (SDH)

2011

344,086

7,083

3,502

835

23,494,128

531,351

2,708,470

165,381

473,829

Community Health Centre (CHC)

2007

74,171

672

442

9,125,621

205,930

200,000

1,695,561

5,881,340

Community Health Centre (CHC)

2008

65,153

900

609

9,401,736

204,951

224,999

2,693,294

3,022,470

Community Health Centre (CHC)

2009

85,478

668

6,582

602

9,686,391

291,598

305,390

4,519,609

4,793,269

Community Health Centre (CHC)

2010

82,261

1,081

6,510

504

9,979,849

329,937

355,538

4,322,606

6,041,624

Community Health Centre (CHC)

2011

104,202

1,807

7,154

926

10,279,374

349,417

596,232

3,374,426

8,680,173

Primary Health Centre (PHC)

2007

39,393

340

118

3,872,989

205,962

119,999

382,713

177,133

Primary Health Centre (PHC)

2008

40,848

380

158

3,992,773

198,400

146,337

797,560

391,800

Primary Health Centre (PHC)

2009

53,544

451

156

4,116,262

202,318

149,998

778,722

460,300

Primary Health Centre (PHC)

2010

50,401

480

194

4,243,570

209,690

159,999

928,995

477,400

Primary Health Centre (PHC)

2011

54,217

363

8,478

190

4,374,816

272,727

197,643

770,063

607,167

Primary Health Centre (PHC)

2007

42,293

159

5,822

3,366,342

410,663

138,103

2,578

93,543

Primary Health Centre (PHC)

2008

44,952

187

5,975

191

3,470,456

433,627

162,995

3,576

110,144

Primary Health Centre (PHC)

2009

50,644

248

6,562

193

3,577,790

422,029

174,054

4,800

117,201

Primary Health Centre (PHC)

2010

49,468

270

6,141

195

3,613,287

415,028

181,652

5,971

119,400

Primary Health Centre (PHC)

2011

47,336

384

7,166

287

3,721,884

426,599

184,306

7,050

182,000

Sub-district Hospital (SDH)

2007

281,052

8,426

173,741

632

23,213,156

72,290

2,036,053

240,958

460,725

Sub-district Hospital (SDH)

2008

329,765

11,698

329,688

613

24,207,092

77,352

3,283,920

282,779

527,214

Sub-district Hospital (SDH)

2009

292,285

14,982

292,285

638

25,254,314

83,855

2,197,399

344,155

570,069

Sub-district Hospital (SDH)

2010

320,770

14,838

320,679

883

26,354,132

87,010

3,066,895

361,348

574,811

Sub-district Hospital (SDH)

2011

381,249

10,457

107,979

337

27,505,600

90,514

1,118,119

112,913

402,876

Community Health Centre (CHC)

2007

55,792

1,252

13,948

260

5,623,699

129,348

128,397

3,120

30,690

Community Health Centre (CHC)

2008

62,628

1,219

2,646

384

5,849,173

128,045

194,460

6,548

293,297

Community Health Centre (CHC)

2009

62,673

1,056

2,748

423

6,030,075

155,361

252,428

74,820

239,241

Community Health Centre (CHC)

2010

68,501

927

3,010

412

6,216,773

150,534

343,957

68,058

197,368

Community Health Centre (CHC)

2011

65,220

484

3,148

484

6,408,840

170,639

446,575

51,370

286,051

Primary Health Centre (PHC)

2007

58,937

365

3,440

183

3,812,853

213,000

129,845

34,925

273,848

Primary Health Centre (PHC)

2008

60,148

806

3,337

258

3,882,670

214,120

154,042

35,309

274,080

Primary Health Centre (PHC)

2009

66,243

1,111

3,228

312

3,972,412

226,710

160,525

35,654

274,550

Primary Health Centre (PHC)

2010

75,182

1,185

2,971

242

4,077,048

215,840

169,494

36,001

275,600

Primary Health Centre (PHC)

2011

69,792

755

3,999

262

4,234,573

217,880

225,747

36,645

278,300

Primary Health Centre (PHC)

2007

37,541

616

4,757,604

133,740

149,997

13,748

6,431

Primary Health Centre (PHC)

2008

43,343

546

2,673

281

4,904,746

134,710

153,595

12,979

7,530

Primary Health Centre (PHC)

2009

53,256

424

2,424

220

5,056,439

138,132

189,799

72,250

10,404

Primary Health Centre (PHC)

2010

55,939

402

2,318

187

5,212,823

142,746

169,207

90,173

13,905

Primary Health Centre (PHC)

2011

59,349

559

1,994

167

5,374,044

148,155

238,991

95,635

22,332

District

Platform

Year

Sub-district Hospital (SDH)

FACILITY INFORMATION

STAFF AND BEDS

OUTPUTS

EXPENDITURE Medical supplies + pharmaceuticals

Administration and training

Non-medical

Beds

Doctors

Nurses

Paramedical

Nonmedical

Outpatient

Inpatient

Vaccinations

Births

Personnel

Infrastructure + utilities

2007

256

894,134

29,011

8,041

2,187

7,931,292

883,803

4,960,978

380,000

477,000

District Hospital (DH)

2008

256

787,563

29,612

11,651

1,673

8,161,442

964,549

6,434,800

522,800

725,000

District Hospital (DH)

2009

256

757,873

31,708

10,532

1,840

8,330,600

1,007,115

6,232,101

559,500

660,000

District Hospital (DH)

2010

256

718,965

27,740

9,120

1,383

8,675,850

1,083,213

6,326,472

585,000

1,920,000

District Hospital (DH)

2011

256

663,100

28,313

10,883

1,462

8,794,750

1,120,963

7,531,522

614,000

1,792,000

Sub-district Hospital (SDH)

2007

115,052

1,941

1,185

161

5,852,526

100,384

643,071

19,399

12,910

Sub-district Hospital (SDH)

2008

112,742

1,848

2,785

5,560,596

94,730

744,803

14,785

24,295

Sub-district Hospital (SDH)

2009

116,327

2,349

1,566

6,443,508

100,676

799,236

20,741

32,815

Sub-district Hospital (SDH)

2010

113,452

1,787

1,428

6,607,950

100,052

846,138

14,890

39,525

Sub-district Hospital (SDH)

2011

141,262

2,535

1,650

6,785,316

98,091

946,240

32,198

51,980

Community Health Centre (CHC)

2007

78,156

1,130

3,954

128

12,155,799

420,113

167,332

1,421,231

83,045

Community Health Centre (CHC)

2008

63,016

1,543

4,009

163

12,531,751

441,384

202,217

2,213,578

105,321

Community Health Centre (CHC)

2009

63,390

1,333

3,286

155

12,919,330

471,405

263,117

1,832,539

165,361

Community Health Centre (CHC)

2010

62,391

1,824

3,085

275

13,318,896

470,864

288,906

1,525,844

154,412

Community Health Centre (CHC)

2011

63,104

1,806

3,623

349

13,730,820

482,668

319,032

2,173,320

118,936

Primary Health Centre (PHC)

2007

54,095

286

2,335

132

5,210,517

151,564

156,476

7,164

21,425

Primary Health Centre (PHC)

2008

53,248

280

2,293

129

5,371,666

143,685

152,039

4,208

17,686

Primary Health Centre (PHC)

2009

56,694

285

2,154

103

5,537,799

135,326

188,687

14,099

19,574

Primary Health Centre (PHC)

2010

48,895

374

2,171

105

5,709,071

144,527

163,561

47,068

10,034

Primary Health Centre (PHC)

2011

45,406

373

2,313

107

5,885,640

139,143

236,319

35,968

14,775

Primary Health Centre (PHC)

2007

54,344

347

7,503

148

237,240

45,186

173,328

4,900

5,000

Primary Health Centre (PHC)

2008

54,994

262

5,141

195

265,680

46,936

189,515

7,000

6,500

Primary Health Centre (PHC)

2009

50,402

371

5,486

186

272,810

48,486

168,654

7,370

6,800

Primary Health Centre (PHC)

2010

40,069

363

4,726

151

278,080

49,686

175,468

8,000

7,500

Primary Health Centre (PHC)

2011

38,306

424

7,180

182

293,680

49,686

288,664

8,670

8,500

Sub-district Hospital (SDH)

2007

88,566

3,126

2,950

4,517,653

3,016,649

673,240

14,864

12,313

Sub-district Hospital (SDH)

2008

93,169

8,017

2,500

4,728,109

3,015,821

949,083

12,435

26,683

Sub-district Hospital (SDH)

2009

98,490

12,098

3,109

4,950,429

3,018,077

855,038

19,643

14,506

Sub-district Hospital (SDH)

2010

97,482

12,396

2,000

6,419,923

3,023,295

924,052

13,606

18,447

Sub-district Hospital (SDH)

2011

119,981

4,245

2,450

7,372,932

3,019,179

923,900

440

11,900

Community Health Centre (CHC)

2007

59,391

110

4,830

8,829,729

240,544

207,863

11,214

52,696

Community Health Centre (CHC)

2008

76,092

235

4,861

159

9,285,621

240,314

250,659

21,942

68,138

Community Health Centre (CHC)

2009

84,363

450

5,050

219

9,830,019

242,496

299,858

21,410

217,353

Community Health Centre (CHC)

2010

83,074

460

5,068

212

10,639,410

255,376

369,500

22,486

175,943

Community Health Centre (CHC)

2011

97,980

433

5,868

182

11,176,500

239,614

403,733

31,219

283,811

Primary Health Centre (PHC)

2007

73,839

420

3,041

4,581,906

163,386

210,248

7,064

43,492

Primary Health Centre (PHC)

2008

57,810

396

3,648

4,791,951

163,386

182,041

6,754

30,440

Primary Health Centre (PHC)

2009

53,814

547

3,364

5,024,175

169,069

147,889

6,262

104,515

Primary Health Centre (PHC)

2010

53,713

581

2,831

100

5,255,212

195,460

165,901

9,810

157,807

District

Platform

Year

District Hospital (DH)

FACILITY INFORMATION

STAFF AND BEDS

OUTPUTS

EXPENDITURE Medical supplies + pharmaceuticals

Administration and training

Non-medical

Beds

Doctors

Nurses

Paramedical

Nonmedical

Outpatient

Inpatient

Vaccinations

Births

Personnel

Infrastructure + utilities

2011

49,455

353

3,752

130

5,497,740

174,894

186,095

10,509

165,177

Primary Health Centre (PHC)

2007

50,100

2,374

4,696,238

100,540

157,968

12,013

23,000

Primary Health Centre (PHC)

2008

54,336

161

2,417

4,869,352

105,676

178,106

9,464

11,128

Primary Health Centre (PHC)

2009

67,658

285

2,333

104

5,115,688

102,254

174,421

7,397

82,196

Primary Health Centre (PHC)

2010

55,905

333

2,745

5,379,364

108,251

199,019

19,257

78,120

Primary Health Centre (PHC)

2011

42,403

316

2,911

5,773,136

108,742

165,752

19,987

48,300

District Hospital (DH)

2007

225,699

7,662

6,350

568

35,006,760

123,421

1,771,439

15,325

19,657

District Hospital (DH)

2008

230,310

10,194

7,187

487

35,884,084

122,726

2,004,184

12,191

District Hospital (DH)

2009

284,753

14,784

7,190

588

37,206,616

121,341

2,972,917

15,556

District Hospital (DH)

2010

275,332

12,994

7,071

619

41,527,728

115,376

3,129,923

27,889

District Hospital (DH)

2011

292,333

14,113

8,039

783

41,886,804

113,447

3,290,787

72,772

Sub-district Hospital (SDH)

2007

4,103

4,671

69,096

599

15,249,552

831,988

1,793,417

38,379

215,000

Sub-district Hospital (SDH)

2008

6,251

3,633

1,753

449

15,721,188

421,890

1,371,186

32,000

210,000

Sub-district Hospital (SDH)

2009

11,437

4,723

1,994

443

16,207,411

386,129

1,537,297

119,472

220,000

Sub-district Hospital (SDH)

2010

13,244

5,895

1,855

388

16,708,672

494,816

1,448,788

166,478

255,000

Sub-district Hospital (SDH)

2011

31,302

5,187

2,071

415

17,225,436

535,065

1,692,467

154,944

285,512

Community Health Centre (CHC)

2007

44,954

1,313

8,094

245

9,395,218

215,271

143,040

6,872

171,184

Community Health Centre (CHC)

2008

44,373

1,015

7,527

382

9,844,637

215,649

187,825

6,221

145,349

Community Health Centre (CHC)

2009

46,781

856

7,373

318

10,798,642

221,771

221,134

10,036

204,170

Community Health Centre (CHC)

2010

43,396

617

7,372

262

11,067,026

221,571

280,564

16,375

187,224

Community Health Centre (CHC)

2011

45,374

1,037

7,619

270

11,610,336

222,647

344,809

16,411

115,200

Primary Health Centre (PHC)

2007

30,268

241

6,166

202

3,564,907

98,884

137,482

3,997

3,430

Primary Health Centre (PHC)

2008

34,574

227

6,035

240

3,685,492

99,099

117,430

919

191,573

Primary Health Centre (PHC)

2009

39,567

273

8,163

282

3,809,436

97,805

171,622

2,500

309,820

Primary Health Centre (PHC)

2010

33,730

245

7,433

254

3,936,852

99,605

139,539

18,230

133,134

Primary Health Centre (PHC)

2011

34,821

146

5,475

245

4,067,844

95,405

240,286

4,010

139,900

Primary Health Centre (PHC)

2007

49,174

407

6,627

142

4,833,308

125,605

172,276

967

13,071

Primary Health Centre (PHC)

2008

65,010

667

6,993

269

5,052,791

124,805

197,245

1,213

208,816

Primary Health Centre (PHC)

2009

67,501

781

6,498

257

5,302,707

125,805

207,393

2,224

241,418

Primary Health Centre (PHC)

2010

67,835

976

500

5,558,866

129,805

213,713

1,824

264,018

Primary Health Centre (PHC)

2011

69,612

1,142

5,840

439

5,877,136

123,885

261,204

5,020

209,760

Sub-district Hospital (SDH)

2007

198

710,962

24,205

973

2,961

51,990,464

1,671,650

3,198,514

18,617

166,114

Sub-district Hospital (SDH)

2008

198

815,668

22,400

1,085

2,830

58,814,908

1,654,264

3,178,183

19,061

182,890

Sub-district Hospital (SDH)

2009

198

664,114

22,536

1,126

2,762

60,695,412

1,655,487

3,689,209

19,440

191,392

Sub-district Hospital (SDH)

2010

198

743,893

23,922

1,145

3,874

62,634,832

1,656,512

3,399,643

20,550

193,246

Sub-district Hospital (SDH)

2011

198

829,210

24,608

777

2,354

64,633,828

1,656,912

4,109,763

21,600

204,329

Community Health Centre (CHC)

2007

71,121

1,245

7,012

335

7,140,985

663,770

141,886

30,166

6,495,158

Community Health Centre (CHC)

2008

68,019

1,502

6,479

259

8,315,480

668,225

229,950

52,437

7,415,892

Community Health Centre (CHC)

2009

80,190

2,137

8,903

371

9,159,633

689,667

225,427

45,663

9,676,897

District

Platform

Year

Primary Health Centre (PHC)

FACILITY INFORMATION

STAFF AND BEDS

OUTPUTS

EXPENDITURE Medical supplies + pharmaceuticals

Administration and training

Non-medical

Beds

Doctors

Nurses

Paramedical

Nonmedical

Outpatient

Inpatient

Vaccinations

Births

Personnel

Infrastructure + utilities

2010

79,482

2,021

4,439

383

9,592,393

747,396

275,289

80,030

10,285,330

Community Health Centre (CHC)

2011

80,588

2,682

4,855

632

10,789,552

854,114

334,918

75,604

12,071,868

Primary Health Centre (PHC)

2007

41,241

429

9,025

163

2,109,226

129,504

141,863

7,700

14,122

Primary Health Centre (PHC)

2008

46,086

523

9,037

261

2,174,459

131,023

165,679

6,460

26,500

Primary Health Centre (PHC)

2009

47,268

636

6,726

361

2,241,710

129,219

168,992

11,375

29,800

Primary Health Centre (PHC)

2010

48,039

774

8,051

365

2,311,041

128,887

181,127

20,031

21,700

Primary Health Centre (PHC)

2011

50,923

1,057

10,812

431

2,382,516

131,892

222,835

60,009

42,884

Primary Health Centre (PHC)

2007

26,102

174

4,830

1,875,663

93,716

112,699

14,143

30,919

Primary Health Centre (PHC)

2008

24,616

105

4,861

1,940,173

93,165

126,725

5,285

30,362

Primary Health Centre (PHC)

2009

27,182

328

5,032

153

1,995,479

91,215

133,721

8,355

45,633

Primary Health Centre (PHC)

2010

27,363

402

5,092

254

1,749,492

91,389

161,520

30,055

59,041

Primary Health Centre (PHC)

2011

29,159

451

5,868

254

1,156,505

100,738

254,379

40,458

73,380

District

Platform

Year

Community Health Centre (CHC)

A B C E

CCESS, OTTLENECKS, OSTS, AND QUITY

I N ST I T UT E F OR HEA LT H M ET R ICS AND EVA LUATION

PUBLIC HEALTH FOUNDATION OF INDIA

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Gurugram, National Capital Region 122002

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TE L E PH O N E : +1-206-897-2800

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