Assessing Facility Capacity, Costs of Care, and Patient Perspectives

Transcription

1 HEALTH SERVICE PROVISION IN TAMIL NADU Assessing Facility Capacity, Costs of Care, and Patient Perspectives A B C E CCESS, OTTLENECKS, OSTS, AND QUITY INSTITUTE FOR HEALTH METRICS AND EVALUATION UNIVERSITY OF WASHINGTON PUBLIC HEALTH FOUNDATION OF INDIA

2 HEALTH SERVICE PROVISION IN TAMIL NADU Assessing Facility Capacity, Costs of Care, and Patient Perspectives A B C E CCESS, OTTLENECKS, OSTS, AND QUITY Table of Contents 5 Acronyms 6 Terms and definitions 8 Executive summary 11 Introduction 13 ABCE project design 18 Main findings Health facility profiles 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

3 About Public Health Foundation of India Collaborations 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. 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 IHME 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 world 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. 2 3

4 Acknowledgments Acronyms We especially thank all of the health facilities and their staff in Tamil Nadu, who generously gave of their time and facilitated the sharing of facility data that made this study possible. We are also most appreciative of patients of the facilities who participated in this work, as they too were giving of their time and were willing to share their experiences with the 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 with field teams. At IHME, we wish to thank Christopher Murray and Emmanuela Gakidou, who served as the principal investigators. We also recognize and thank data analysts and Post-Bachelor Fellows at IHME: Roy Burstein, Alan Chen, Emily Dansereau, 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 contributed to the project: Michael Hanlon, Santosh Kumar, Herbie Duber, Kelsey Bannon, Aubrey Levine, and Nancy Fullman. Finally, we thank those at IHME who supported publication management, editorial support, writing, and design. This report was drafted by Marielle Gagnier, Lauren Hashiguchi, and Nikhila Kalra of IHME and Rakhi Dandona from PHFI. Funding for this research comes from the Bill & Melinda Gates Foundation under the Disease Control Priorities Network (DCPN). ABCE ANC ANM CHC CI DCPN DEA DH DOTS IHME IPHS NCD OR PHC PHFI SDH SFA SHC STI TN WHO Access, Bottlenecks, Costs, and Equity Antenatal care Auxiliary nurse midwife Community health centre Confidence interval Disease Control Priorities Network Data envelopment analysis District hospital Directly observed treatment, short-course Institute for Health Metrics and Evaluation Indian Public Health Standards Non-communicable diseases Odds ratio Primary healthcare centre Public Health Foundation of India Sub-district hospital Stochastic frontier analysis Sub health centre Sexually transmitted infection Tamil Nadu World Health Organization 4 5

5 ABCE IN TAMIL NADU 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 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). Table 1 Health facility types in Tamil Nadu 1 Health facility types in Tamil Nadu Data Envelopment Analysis (DEA) an econometric analytic approach used to estimate the efficiency levels of health facilities. Efficiency a measure that reflects the degree to which health facilities are maximizing the use of the resources available in producing services. Facility sampling frame the list of health facilities from which the ABCE sample was drawn. This list was based on a facility inventory published by the Tamil Nadu state government. 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. Outpatient visit a visit at which a patient receives care at a facility without being admitted. Outputs volumes of services provided, patients seen, and procedures conducted, including outpatient and inpatient care, laboratory and diagnostic tests, and medications. 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 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 (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) 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 population of 20,000 to 30,000 people and hosts about six beds. Sub health centre (SHC) 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. Platform a channel or mechanism by which health services are delivered. 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, Stochastic Frontier Analysis (SFA) an econometric analytic approach used to estimate the efficiency levels of health facilities. 6 7

6 EXECUTIVE SUMMARY Executive summary A service capacity gap emerged for the majority of health facilities across several types of services. Many nel, but this was a quarter of that at district hospitals, while health centres averaged between one and 32 facilities reported providing a given service but lacked staff. While some of this variation is a result of service full capacity to properly deliver it, for instance lacking provision and population size, this also demonstrates functional equipment or medications. For example, relative shortages in human resources for health. while all primary and community health centres re- W ith the aim of establishing universal health coverage, India s national and state governments have invested significantly in expanding and strengthening the public health care sector. This has included a particular commitment to extending its reach to rural populations and reducing disparities in access to care for marginalized groups. However, in order to realize this goal it is necessary for the country to critically consider the full range of 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 service provision access to services, bottlenecks in delivery, costs of care, and equity in care received affect health system performance in several countries. Through the ABCE project, multiple sources of data, including facility surveys and patient exit interviews, are linked together to provide a nuanced picture of how facility-based factors (supply-side) and patient perspectives (demand-side) influence optimal service delivery. Led by the Public Health Foundation of India (PHFI) and the Institute for Health Metrics and Evaluation (IHME), the ABCE project in Tamil Nadu is uniquely positioned to inform the evidence base for understanding the country s drivers of health care access and costs of care. Derived from a state-representative sample of 168 facilities, the findings presented in this report provide governments, international agencies, and development partners alike with actionable information that can help identify areas of success and targets for improving health service provision. The main topical areas covered in this report move from an assessment of facility-reported capacity for care to quantifying the services actually provided by facilities and the efficiency with which they operate; tracking facility expenditures and the costs associated with different types of service provision; and comparing patient perspectives of the care they received across different types of facility. Further, we provide an in-depth examination and comparison of facility-level outputs, efficiency, capacity, and patient experiences. It is with this information that we strive to provide the most relevant and actionable information for health system programming and resource allocation in Tamil Nadu. Facility capacity for service provision While most facilities report providing key health services, significant gaps in capacity were identified between reported and functional capacity for care. Health facilities generally reported a high availability of a subset of key services. Services such as antenatal care, routine deliveries, general medicine, and pharmacies were widely available across facilities. Services for non-communicable diseases (NCDs) were limited. While significant numbers of district hospitals reported providing psychiatry (77%) and cardiology (77%), very few provided chemotherapy (8%). Availability decreased markedly at lower levels of the health system. Basic medical equipment such as scales, stethoscopes, and blood pressure apparatus were widely available at all health facility levels, but laboratory equipment such as glucometers, blood chemistry analyzers, and incubators were less readily available. For example, only 69% of district hospitals had glucometers, dropping to 45% at the sub health centre level. This shows limited capacity for testing throughout the health system, with particular implications for diagnosing and treating NCDs. While ECGs and ultrasounds were widely available, gaps also emerged with regard to imaging equipment, particularly at lower-level health facilities. While 92% of district hospitals had X-rays, this figure was just 38% for community health centres. CT scans were available in just 38% of district hospitals and 4% of sub-district hospitals. ported providing routine delivery care, none were fully equipped to do so. This discordance has substantial programmatic and policy implications for the health system in Tamil Nadu, highlighting continued challenges in ensuring facilities have all the supplies they need to provide a full range of services. Physical infrastructure of health facilities has improved, but gaps in transport and communication remain. Functional electricity was available at all hospitals, community health centres, and primary health centres. Ninety-two percent of sub health centres had electricity, showing substantial improvement on figures from past government surveys. Access to piped water was relatively high at district hospitals (85%), sub-district hospitals (88%), community health centres (88%), and primary health centres (87%), though it is notable that the figure is lowest for district hospitals. Piped water was limited at sub health centres (59%). Similarly, access to flushed toilets was markedly lower at sub health centres (59%) than other facility types (85% 91%). These figures do reflect investments into improving physical infrastructure at health facilities, though discrepancies remain between high- and low-level facilities. There was nearly universal access to phones and computers across facility types. However, only 22% of primary health centres had any access to vehicles. These findings have serious implications for the timely transportation of patients to receive higher levels of care. Nurses composed the majority of staff at district hospitals, while at other facility levels paramedical staff outnumbered both doctors and nurses. Staff numbers were concentrated at district hospitals with an average of nearly 211 personnel. Sub-district hospitals had the second highest number of person- Facility production of health services Health facilities saw increases in both outpatient and inpatient visits over time. Between 2007 and 2011, outpatient numbers increased, with the highest patient volumes at district hospitals. Outpatient visits accounted for the large majority of patients seen per staff member per day across all facility types. Inpatient visits increased for all facility types between 2007 and The average number of immunization doses administered remained stable over the five years, with slight declines in sub-district hospitals and community health centres. Facilities showed capacity for larger patient volumes given observed resources. In generating estimates of facility-based efficiency, or the alignment of facility resources with the number of patients seen or services produced, we found a wide range of efficiency levels within facility types, suggesting that a substantial performance gap may exist between the average facility and facilities with the highest efficiency scores. Efficiency scores were relatively low across all health facilities, with 74% being the highest mean across platforms. If they operated at optimal efficiency, district hospitals could provide 249,706 additional outpatient visits with the same inputs (including physical capital and personnel), while primary health centres could produce 21,906 additional outpatient visits. These efficiency scores indicate that there is considerable room for health facilities to expand service production given their existing resources. Future work on pinpointing specific factors that heighten or hinder facility efficiency, and how efficiency is related to the quality of service provision, should be considered. 8 9

7 Costs of care Most patients received all drugs that they were prescribed during their visits. Proportions of patients Introduction Trends in average facility spending between 2007 and 2011 varied between facility types, though all platforms recorded higher spending in 2011 than receiving all prescribed drugs ranged from 99% of patients at sub-district hospitals and primary health centres to 80% at sub health centres. Spending on personnel accounted for the vast majority of annual spending across facility types. Compared to other facility types, sub-district hospitals and primary health centres put a slightly greater proportion of their total expenditure toward personnel, while district hospitals put the greatest proportion toward medical supplies. Patient perspectives Travel and wait times were shorter for patients visiting lower-level facilities than higher-level ones. Nearly all patients receiving care at sub health centres, and just under 80% of patients at primary health centres, reported traveling less than 30 minutes to receive care. In contrast, nearly half of patients at district hospitals 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 minutes to receive care across all facilities. Nearly all patients seeking care at sub health centres received care in less than 30 minutes. Wait times were longer at hospitals, but overall less than 6% of patients waited more than one hour to receive care. Patients gave higher ratings of health care providers than facility characteristics. Across all facility types except community and sub health centres, patients receiving care from doctors reported slightly higher levels of satisfaction than those treated by nurses. Satisfaction with staff interactions, for both doctors and nurses, were lowest at district 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. With its multidimensional assessment of health service provision, findings from the ABCE project in Tamil Nadu provide an in-depth examination of health facility capacity, costs of care, and how patients view their interactions with the health system. Tamil Nadu s health provision landscape was markedly heterogeneous and will likely continue to evolve over time. This highlights the need for continuous and timely assessment of health service delivery, which is critical for identifying areas of successful implementation and quickly responding to service disparities or faltering performance. Expanded analyses would also allow for an even clearer picture of the trends and drivers of facility capacity, efficiencies, and costs of care. With regularly collected and analyzed data, capturing information from health facilities, recipients of care, policymakers, and program managers can yield the evidence base to make informed decisions for achieving optimal health system performance and the equitable provision of cost-effective interventions throughout Tamil Nadu. T he performance of a country s health system ultimately shapes the health outcomes experienced by its population, influencing the ease or difficulty with which individuals can seek care and facilities can address their needs. At a time when international aid is plateauing 1 and the government of India has prioritized expanding many health programs, 2,3 identifying health system efficiencies and promoting the delivery of cost-effective interventions has become increasingly important. Assessing health system performance is crucial to optimal policymaking and resource allocation; however, due to the multidimensionality of health system functions, 4 comprehensive and detailed assessment seldom occurs. Rigorously measuring what factors are contributing to or hindering health system performance access to services, bottlenecks in service delivery, costs of care, and equity in service provision throughout a country provides crucial information for improving service delivery and population health outcomes. The Access, Bottlenecks, Costs, and Equity (ABCE) project was launched globally in 2011 to address these gaps in information. In addition to India, the multipronged, multi-partner ABCE project has taken place in seven other countries (Bangladesh, Colombia, Ghana, Kenya, Lebanon, Uganda, and Zambia). In India, the ABCE project was undertaken in six states: Andhra Pradesh and Telangana, Gujarat, Madhya Pradesh, Odisha, and Tamil Nadu. The ABCE project, with the goal of rigorously assessing the drivers of health service delivery across a range of settings and health systems, strives to answer these critical 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, Planning Commission Government of India. Eleventh Five Year Plan ( ). New Delhi, India: Government of India, Planning Commission Government of India. Twelfth Five Year Plan ( ). New Delhi, India: Government of India, Murray CJL, Frenk J. A Framework for Assessing the Performance of Health Systems. Bulletin of the World Health Organization. 2000; 78 (6): questions facing policymakers and health stakeholders in each country or state for public sector health care service delivery: What health services are provided, and where are they available? What are the bottlenecks in provision of these services? How much does it cost to produce health services? How efficient is provision of these health services? Findings from each country s ABCE work will provide actionable data to inform their own policymaking processes and needs. Further, ongoing cross-country analyses will likely yield more global insights into health 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 private), and disease burden profiles. The ABCE project contributes to the global evidence base on the costs of and capacity for health service provision, aiming to develop data-driven and flexible policy tools that can be adapted to the particular demands of governments, development partners, and international agencies. The Public Health Foundation of India (PHFI) and the Institute for Health Metrics and Evaluation (IHME) compose the core team for the ABCE project in India, and they received vital support and inputs from the state Ministry of Health and Family Welfare for data collection, analysis, and interpretation. The core team harnessed information from distinct but linkable sources of data, drawing from a state-representative sample of health facilities to create a large and fine-grained database of facility attributes, expenditure, 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

8 ABCE IN TAMIL NADU We focus on the facility because health facilities are the main points through which most individuals interact with consider the factors that affect patient perceptions of and experiences with the state s health system. By considering ABCE project design 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 of public sector health facilities unveils the differences in helps and hinders the receipt of health services through health system performance at the level most critical to facilities in the state of Tamil Nadu. patients the facility level. We believe this information is The results discussed in this report are far from ex- immensely valuable to governments and development partners, particularly for decisions on budget allocations. By having data on what factors are related to high facility performance and improved health outcomes, policymakers and development partners can then support evidence-driven proposals and fund the replication of these strategies at facilities throughout India. haustive; rather, they align with identified priorities for health service provision and aim to answer questions about the costs of health care delivery in the respective state in India. This report provides an in-depth examination of health facility capacity across different platforms, specifically covering topics on human resource capacity, facility-based infrastructure and equipment, health ser- F or the ABCE project in India, we conducted primary data collection through a two-pronged approach: 1. A comprehensive facility survey administered to a representative sample of health facilities in select states in India (the ABCE Facility Survey) ABCE Facility Survey Through the ABCE Facility Survey, direct data collection was conducted from a state-representative sample of health service platforms and captured information on the following indicators for the five fiscal years (running from April to March of the following year) prior to the survey: The ABCE project in India has sought to generate the evidence base for improving the cost-effectiveness and equity of health service provision. In this report, we examine facility capacity across platforms, as well as the efficiencies and costs associated with service provision for each type of facility. Based on patient exit interviews, we vice availability, patient volume, facility-based efficiencies, costs associated with service provision, and demand-side factors of health service delivery as captured by patient exit interviews. Table 2 defines the cornerstone concepts of the ABCE project: Access, Bottlenecks, Costs, and Equity. 2. Interviews with patients as they exited the sampled facilities Here, we provide an overview of the ABCE survey design and primary data collection mechanisms. All ABCE survey instruments are available online at Inputs: the availability of tangible items that are needed to provide health services, including infrastructure and utilities, medical supplies and equipment, pharmaceuticals, personnel, and non-medical services. Finances: expenses incurred, including spending on infrastructure and administration, medical supplies Table 2 Access, Bottlenecks, Costs, and Equity and equipment, pharmaceuticals including vaccines, and personnel. Facility funding from different sources Access, Bottlenecks, Costs, and Equity (e.g., central and state governments) and revenue from service provision were also captured. Access Health services cannot benefit populations if they cannot be accessed; thus, measuring which elements are 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. Bottlenecks Mere access to health facilities and the services they provide is not sufficient for the delivery of care to populations. People who seek health services may experience supply-side limitations, such as medicine stockouts, that prevent the receipt of proper care upon arriving at a facility. Costs Health services cost can translate into very different financial burdens for consumers and providers of such care. Thus, the ABCE project measures these costs at several levels, quantifying what facilities spend to provide services. Outputs: volume of services and procedures produced, including outpatient and inpatient care, emergency care, and laboratory and diagnostic tests. Supply-side constraints and bottlenecks: factors that affected the ease or difficulty with which patients received services they sought, including bed availability, pharmaceutical availability and stockouts, cold-chain capacity, personnel availability, and service availability. Table 3 provides more information on the specific indicators included in the ABCE Facility Survey. 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

9 ABCE IN TAMIL NADU ABCE PROJECT DESIGN Table 3 Modules included in the ABCE Facility Survey in India SURVEY MODULE SURVEY CATEGORY KEY INDICATORS AND VARIABLES Module 1: Facility finances and inputs Module 2: Facility management and direct observation Inputs Finances Revenue Personnel characteristics Facility management and infrastructure characteristics Input funding sources, managing authority, and maintenance information Availability and functionality of medical and non-medical equipment 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 User fees; total revenue and source Total personnel by cadre Funding sources of personnel Health services provided and their staffing; administrative and support services and their staffing Characteristics of patient rooms; electricity, water, and sanitation Facility meeting characteristics Guideline observation Sample design 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 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 public sector health facilities at all levels of services based on the structure of the state health system (Figure 2). Figure 1 Sampled districts in Tamil Nadu Direct observation Latitude, longitude, and elevation of facility. Facility hours, characteristics, and location; waiting and examination room characteristics Module 3: Lab-based consumables, equipment, and capacity Facility capacity Lab-based tests available Figure 2 Sampling strategy for health facilities in a district in the ABCE survey in India 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 Inventory of procedures for sterilization, sharp items, and infectious waste Inventory of personnel 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 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 14 15

10 ABCE IN TAMIL NADU ABCE PROJECT DESIGN Table 4 Types of questions included in the Patient Exit Interview Survey in India SURVEY CATEGORY Direct observation of patient Direct interview with patient TYPES OF KEY QUESTIONS AND RESPONSE OPTIONS Sex of patient (and of patient s attendant if surveyed) 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; two primary health centres (PHC, from a total of two to four) for each sampled CHC; and one sub centre (SHC, from a total of one to four) for each sampled PHC were randomly selected for the study. Demographic questions (e.g., age, level of education attained, caste) Scaled-response satisfaction scores (e.g., satisfaction with medical doctor) 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 Table 5 Facility sample, by platform, for the ABCE project in Tamil Nadu FACILITY TYPE District hospital 13 Sub-district hospital 26 FINAL SAMPLE Data collection for the ABCE survey in TN Data collection took place from October 2012 to January Prior to survey implementation, PHFI and the data collection agency hosted a two-week training workshop for 30 interviewers, where they received extensive training on the electronic data collection software (Dat- 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. 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 reporting chain of the sampled facility being incorrect; or the facility having been functional for less duration. Patient exit interview survey A fixed number patients or attendants of patients were interviewed at each facility, based on the expected outpatient density for the platform. A target of 16 patients were interviewed at district hospitals, 16 at SDH, 12 at CHC, 10 at PHC, and five at SHC. Patient selection was based on a convenience sample. The main purpose of the Patient 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). Community health centre 24 Primary health centre 54 Sub health centre 51 Total health facilities

11 MAIN FINDINGS: HEALTH FACILITY PROFILES Main findings Health facility profiles T he delivery of facility-based health services requires a complex combination of resources, ranging from personnel to physical infrastructure, that vary in their relative importance and cost to facilities. Determining what factors support the provision of services at lower costs and fewer facilities reported available services for non-communicable diseases, such as cardiology, psychiatry, and chemotherapy, particularly at the sub-district and community levels. District hospitals reported a wide range of services such as blood banks, surgical services, dentistry, and emergency obstetrics. Sub-district hospitals Table 6 Availability of services in health facilities, by platform Total obstetrics and gynecology services DISTRICT HOSPITAL (DH) SUB-DISTRICT HOSPITAL (SDH) COMMUNITY HEALTH CENTRE (CHC) 100% 100% 100% Routine births 100% 100% 100% Emergency obstetrics 100% 88% 75% Antenatal care 100% 100% 100% Surgical services 100% 92% 75% Cardiology 77% 38% 8% Figure 3 Composition of facility personnel, by platform District Hospital Sub District Hospital Community Health Centre Primary Health Centre Sub Health Centre TN higher levels of efficiency at health facilities is critical information for policymakers to expand health system coverage and functions within constrained budgets. Using the ABCE TN facility sample (Table 5), we analyzed five key drivers of health service provision at facilities: Facility-based resources (e.g., human resources, infrastructure and equipment, and pharmaceuticals), which are often referred to as facility inputs. Patient volumes and services provided at facilities (e.g., outpatient visits, inpatient bed-days), which are also known as facility outputs. Patient-reported experiences, capturing demand-side factors of health service delivery. Facility alignment of resources and service production, which reflects efficiency. Facility expenditures and production costs for service delivery. These components build upon each other to create a comprehensive understanding of health facilities in TN, highlighting areas of high performance and areas for improvement. Facility capacity and characteristics Service availability Across and within district hospitals, sub-district hospitals 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, generally offered fewer services than district hospitals but still reported high coverage of services like obstetrics and gynecology and accident and emergency services. One-quarter of community health centres reported that they did not provide surgical services or emergency obstetrics, while only around half provided dentistry and anesthesiology. Human resources for health A facility s staff size and composition directly affect the types of services it provides. In general, a greater availability of health workers is related to higher service utilization and better health outcomes. 1 India has a severe shortage of qualified health workers and the workforce is concentrated in urban areas. 2 The public health system has a shortage of both medical and paramedical personnel. The number of primary and community health centres without adequate staff is substantially higher if high health-worker absenteeism is taken into consideration. 3 The Indian Government is aware of the additional requirements and shortages in the availability of health workers for the future. The National Rural Health Mission, for instance, recommends a vastly strengthened infrastructure, with substantial increases in personnel at every tier of the public health system. 4 Based on the ABCE sample, we found substantial het- 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): Hammer J, Aiyar Y, Samji S. Understanding government failure in public health services. Economic and Political Weekly. 2007; 42: National Rural Health Mission. Ministry of Health and Family Welfare, Government of India. Mission Document ( ). New Delhi, India: Government of India, Psychiatric Accident, trauma, and emergency 77% 19% 0% 100% 100% 88% Ophthalmology 100% 35% 75% Pediatric 100% 92% 88% General anesthesiology 100% 69% 54% Blood bank 100% 27% 8% Dentistry 100% 77% 46% DOTS treatment 92% 81% 82% STI/HIV 100% 69% 83% Immunization 100% 77% 92% Internal/general med 100% 100% 96% Mortuary 100% 85% 0% Burns 100% 58% 21% Orthopedic 100% 31% 0% Pharmacy 100% 100% 100% Chemotherapy 8% 4% 4% Dermatology 69% 23% 4% Alternative medicine 100% 100% 92% Diagnostic medical 100% 100% 83% Laboratory services 100% 96% 100% Outreach services 0% 15% 88% LOWEST AVAILABILITY HIGHEST AVAILABILITY Note: All values represent the percentage of facilities, by platform, that reported offering a given service at least one day during a typical week. 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, paramedical 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 maintained a smaller body of health workers, an average total of 32, with most of the medical staff being paramedical (17). Primary health centres reported, on average, 18 staff in total, most of which were paramedical staff (11). Finally, sub-health centres reported one paramedical staff who performs immunizations, simple outpatient care, and community outreach Number of Staff Doctors Para-medical staff Nurses Non-medical staff 18 19

12 ABCE IN TAMIL NADU MAIN FINDINGS: HEALTH FACILITY PROFILES 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 Figure 6 Ratio of beds to doctors by platform Vertical bars represent the platform average ratio. Figure 7 Ratio of beds to nurses, by platform Vertical bars represent the platform average ratio. Vertical bars represent the platform average ratio. 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 The ratio of number of nurses to number of doctors is presented in Figure 4. A ratio greater than 1 indicates that nurses outnumber doctors; for instance, a ratio of 2 indicates that there are two nurses staffed for every one doctor. Alternatively, a ratio lower than 1 indicates that doctors outnumber nurses; for instance, a ratio of 0.5 indicates there is one nurse staffed for every two doctors. District hospitals reported an average ratio of 1.8, indicating that they staff more nurses than doctors. However, the ratio reported by various district hospitals ranged from a low of 0.5 to a high outlier of 6.4. All but two sub-district hospitals reported more nurses than doctors, with a ratio as high as 4.0 nurses to doctors. There was less heterogeneity among community health centres, with ratios ranging from 0.4 to 2.5. Finally, primary health centres reported a wide range of ratios, from 0.3 to 4.0. The average ratio of nurses to doctors was similar for district hospitals (1.8), sub-district hospitals (1.7), and primary health centres (1.7). Nurses and doctors to paramedical and non-medical staff The ratio of number of nurses and/or doctors to number of paramedical and/or non-medical staff in 2012 is presented in Figure 5. A ratio greater than 1 indicates that nurses and doctors outnumber para-medical and non-medical personnel; for instance, a ratio of 2 indicates that there are two nurses and/or doctors staffed for every one paramedical/non-medical staff. Alternatively, a ratio lower than 1 indicates that para-medical and/or non-medical personnel outnumber nurses and/or doctors. The average ratio for district hospitals and sub-district hospitals was 1.0, though the range of ratios for district hospitals (0.7 to 2.0) was slightly narrower than for sub-district hospitals (0.7 to 2.7). Community health centres were more homogenous, reporting an average ratio of 0.4, with facilities reporting ratios that ranged from 0.2 to 0.6. The ratio for primary health centres ranged from 0.1 to 1.3, with an average of 0.4 doctors and nurses to paramedical and non-medical staff. Beds to doctors ratio The ratio of number of beds to number of doctors in 2011 is presented in Figure 6. A ratio greater than 1 indicates that beds outnumber doctors; for instance, a ratio of 2 indicates that there are two beds for every one doctor staffed. Alternatively, a ratio lower than 1 indicates that doctors outnumber beds. The average ratio of beds to doctors is highest in district hospitals (9.7), followed by sub-district hospitals (8.0). Community health centres have an average of 5.2 beds per doctor, though four facilities have ratios above The average ratio among primary health centres is 2.4, with a range of 0.3 to 9.0. Two primary health centres reported fewer beds than doctors. Beds to nurses ratio The ratio of number of beds to number of nurses in 2011 is presented in Figure 7. A ratio greater than 1 indicates that beds outnumber nurses; for instance, a ratio of 2 indicates that there are two beds for every one nurse staffed. Alternatively, a ratio lower than 1 indicates that nurses outnumber beds. Similar to the ratio of beds to doctors, the ratio of beds to nurses was highest among district hospitals (5.9) and lowest among primary health centres (1.8). While sub-district hospitals and community health centres had a similar average ratio of beds to nurses (5.0 and 5.2, respectively), the range of ratios was much wider for community health centres (1.0 to 12.3) than for sub-district hospitals (2.3 to 8.2). In isolation, facility staffing numbers are less meaningful without considering a facility s overall patient volume and production of specific services. For instance, if a facility mostly offers services that do not require a doctor s administration, failing to achieve the doctor staffing target may be less important than having too few nurses. Further, some facilities may have much smaller patient volumes than others, and thus achieving staffing tar- gets could leave them with an excess of personnel given patient loads. While an overstaffed facility has a different set of challenges than an understaffed one, each reflects a poor alignment of facility resources and patient needs. To better understand bottlenecks in service delivery and areas to improve costs, it is important to assess a facility s capacity (inputs) in the context of its patient volume and services (outputs). We further explore these findings in the Efficiency and costs section. As part of the ABCE project in India, we compare levels of facility-based staffing with the production of different types of health services. In this report, we primarily focus on the delivery of health services by skilled medical personnel, which include doctors, nurses, and other paramedical staff. It is possible that non-medical staff also contribute to service provision, especially at lower levels of care, but the ABCE project in India is not currently positioned to analyze these scenarios. Infrastructure and equipment Health service provision depends on the availability of adequate facility infrastructure, equipment, and supplies (physical capital). In this report, we focus on four essential components of physical capital: power supply, water and sanitation, transportation, and medical equipment, with the latter composed of laboratory, imaging, and other medical equipment. Table 7 illustrates the range of 20 21

13 ABCE IN TAMIL NADU MAIN FINDINGS: HEALTH FACILITY PROFILES Table 7 Availability of physical capital, by platform Table 8 Availability of functional equipment, by platform DISTRICT HOSPITAL (DH) SUB-DISTRICT HOSPITAL (SDH) COMMUNITY HEALTH CENTRE (CHC) PRIMARY HEALTH CENTRE (PHC) SUB HEALTH CENTRE (SHC) Functional electricity 100% 100% 100% 100% 92% Piped water 85% 88% 88% 87% 59% Flush toilet 85% 96% 96% 91% 65% Hand disinfectant 92% 96% 96% 91% 43% Any 4-wheeled vehicle 100% 35% 96% 22% NA Emergency 4-wheeled vehicle 69% 23% 58% NA NA Landline phone 100% 96% 100% 100% 90% Computer 100% 100% 100% 98% NA NA: Not applicable to this platform according to standards. LOWEST AVAILABILITY Note: Values represent the percentage of facilities, by platform, that had a given type of physical capital. HIGHEST AVAILABILITY Medical equipment DISTRICT HOSPITAL SUB-DISTRICT HOSPITAL COMMUNITY HEALTH CENTRE PRIMARY HEALTH CENTRE SUB-HEALTH CENTRE Wheelchair 92% 100% 100% 100% NA Adult scale 92% 88% 92% 91% 96% Child scale 92% 96% 96% 93% 82% Blood pressure apparatus 92% 100% 100% 100% 92% Stethoscope 92% 100% 100% 100% 98% Light source 85% 100% 92% 96% 59% Lab equipment Glucometer 69% 42% 92% 89% 45% Test strips for glucometer 69% 42% 83% 72% 35% Hematologic counter 85% 42% 21% 13% NA Blood chemistry analyzer 92% 69% 75% 59% NA Incubator 92% 58% 13% 7% NA Centrifuge 92% 88% 96% 74% NA physical capital, excluding medical equipment, available across platforms. Power supply All hospitals, community health centres, and primary health centres reported access to a functional electrical supply, and just 8% of sub health centres lacked functional electricity (Table 7). One facility reported relying solely on a generator for power. Inadequate access to consistent electric power has substantial implications for health service provision, particularly for the effective storage of medications, vaccines, and blood samples, and these results demonstrate an improvement in the availability of electricity at the lowest platform levels compared to , when 87% of primary health centres and 70% of sub health centres had a regular electric supply. 5 Water and sanitation 85% of district hospitals had availability of improved water sources (functional piped water) and improved sanitation with a functional sewer infrastructure with 5 International Institute for Population Sciences (IIPS). District Level Household and Facility Survey (DLHS-3), : India, Tamil Nadu. Mumbai, India: IIPS, flush toilets (Table 7). Notably, these figures were higher in sub-district hospitals and community health centres, and even in primary health centres. At the lowest platform level, the sub health centre, access to improved water sources and sanitation was significantly lower. Hand disinfectant was broadly available as a supplementary sanitation method at most platform levels, though it was not available at many sub health centres. Among all facilities, 13% reported a severe shortage of water at some point during the year. These findings show a mixture of both notable gains and ongoing needs for facility-based water sources and sanitation practices among both hospitals and primary care facilities. Transportation and computers Facility-based transportation and modes of communication varied across platforms (Table 7). In general, the availability of a vehicle decreased down the levels of the health platform, though more community health centres reported having a vehicle than did sub-district hospitals. Only around one-fifth of primary health centres had any four-wheeled vehicles at all, which means transferring patients under emergency circumstances from these facilities could be fraught with delays and possible complications. Community health centres had a relatively high level of transport availability, with 96% having a four- Microscope 92% 96% 92% 56% NA Slides 92% 92% 100% 98% 47% Slide covers 92% 88% 96% 89% 33% Imaging equipment X-ray 92% 77% 38% NA NA ECG 92% 85% 92% NA NA Ultrasound 92% 96% 88% NA NA CT scan 38% 4% NA NA NA NA: Not applicable to this platform according to standards. 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

14 ABCE IN TAMIL NADU MAIN FINDINGS: HEALTH FACILITY PROFILES wheeled vehicle and 58% having dedicated emergency transportation. Alongside transportation, communication is also a necessary facet of the efficient delivery of health services. The availability of modes of communication was generally high at all facility levels: nearly all facilities reported having a landline phone, and computer facilities were widely available across platforms. Equipment For three main types of facility equipment medical, lab, and imaging clear differences emerge across levels of health service provision, with Table 8 summarizing the availability of functional equipment by platform. We used the WHO s Service Availability and Readiness Assessment (SARA) survey as our guideline for what types of equipment should be available in hospitals and primary care facilities. 6 Table 8 illustrates the distribution of SARA scores across platforms. In general, hospitals had greater availability of medical equipment, and deficits in essential equipment availability were found in the lower levels of care. Lacking scales and blood pressure cuffs can severely limit the collection of important patient clinical data; these were generally available, but facilities at all levels reported missing some of these vital pieces of equipment. Microscopes and corresponding components were largely prevalent among all facilities, except at primary health centres where many reported having slides but almost half had no microscope to use them with. Additional 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, Table 10 Availability of blood tests and functional equipment to perform routine delivery care, by platform Testing availability 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% NA NA Medical equipment Blood pressure apparatus 92% 100% 100% 100% IV catheters 92% 100% 100% 98% Gowns 92% 96% 100% 91% Measuring tape 92% 100% 100% 98% Masks 85% 92% 96% 83% Sterilization equipment 92% 92% 83% 57% Adult bag valve mask 92% 88% 96% 59% Ultrasound 92% 96% 88% NA Delivery equipment Infant scale 85% 92% 96% 94% Table 9 Availability of tests and functional equipment to perform routine antenatal care, by platform Testing availability DISTRICT HOSPITAL SUB-DISTRICT HOSPITAL COMMUNITY HEALTH CENTRE PRIMARY HEALTH CENTRE SUB HEALTH CENTRE Urinalysis 92% 96% 92% 48% 16% Hemoglobin 92% 100% 96% 65% 14% Glucometer and test strips 69% 38% 79% 72% 33% Blood typing 92% 92% 92% 54% NA Functional equipment Blood pressure apparatus 92% 100% 100% 100% 92% Adult scale 92% 88% 92% 91% 86% Ultrasound 92% 96% 88% NA NA Service summary Facilities reporting ANC services 100% 100% 100% 100% 95% Facilities fully equipped for ANC provision based on above tests and equipment availability 69% 27% 63% 31% 5% Scissors or blade 92% 96% 100% 100% Needle holder 92% 100% 100% 98% Speculum 92% 96% 100% 100% Forceps 92% 92% 92% 85% Dilation and curettage kit 92% 88% 67% 59% Neonatal bag valve mask 92% 92% 100% 96% Vacuum extractor 92% 50% 42% 30% Incubator 85% 42% 21% 22% Service summary Facilities reporting delivery services 100% 100% 100% 100% Facilities fully equipped for delivery services based on above tests and equipment availability NA: Not applicable to this platform according to standards. LOWEST AVAILABILITY 54% 4% 0% 0% 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

15 ABCE IN TAMIL NADU MAIN FINDINGS: HEALTH FACILITY PROFILES Table 11 Availability of blood tests and functional equipment to perform general surgery, by platform Testing availability DISTRICT HOSPITAL (DH) SUB-DISTRICT HOSPITAL (SDH) COMMUNITY HEALTH CENTRE (CHC) PRIMARY HEALTH CENTRE (PHC) Hemoglobin 92% 100% 96% 65% Cross-match blood 92% 31% NA NA Medical equipment Blood pressure apparatus 92% 100% 100% 100% IV catheters 92% 100% 100% 98% Sterilization equipment 92% 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% 100% Thermometer 92% 96% 96% 78% General anesthesia equipment 92% 81% 71% 6% Scalpel 92% 96% 96% 67% Suction apparatus 92% 96% 88% 74% Retractor 92% 88% 75% 28% Nasogastric tube 92% 92% 88% 57% poorer in sub-district hospitals, community health centres, and primary health centres. There were some exceptions to this trend: while 92% of community health centres and 89% of primary health centres had a glucometer, only 69% of district hospitals and 42% of sub-district hospitals had one. Additionally, blood chemistry analyzers were available in only 69% of sub-district hospitals. This indicates limited capacity for addressing non-communicable diseases (NCDs) such as diabetes, for which this equipment is necessary. Other essential equipment, including hematologic counters and incubators, were notably missing from community health centres and primary health centres. District hospitals had good availability of imaging equipment, with the notable exception of CT scans, which were available in 38% of facilities. Sub-district hospitals showed somewhat patchier availability of imaging equipment, with 77% reporting the availability of X-ray and only 4% having CT scanners. Community health centres had relatively high availability of essential imaging equip- Table 12 Availability of laboratory tests, by platform ment, with the exception of X-ray, which was available in 38% of facilities. Overall, these findings demonstrate gradual improvements in equipping health facilities with basic medical equipment in TN, as well as the continued challenge of ensuring that these facilities carry the supplies they need to provide a full range of services. Measuring the availability of individual pieces of equipment sheds light on specific deficits, but assessing a health facility s full stock of necessary or recommended equipment provides a more precise understanding of a facility s service capacity. Focus on service provision For the production of any given health service, a health facility requires a complex combination of the basic infrastructure, equipment, and pharmaceuticals, with personnel who are adequately trained to administer necessary clinical assessments, tests, and medications. Thus, it is important to consider this intersection of facility resources to best understand facility capacity for care. In Blood storage unit/refrigerator 92% 46% 25% NA Intubation equipment 92% 81% 67% 31% DISTRICT HOSPITAL (DH) SUB-DISTRICT HOSPITAL (SDH) COMMUNITY HEALTH CENTRE (CHC) PRIMARY HEALTH CENTRE (PHC) Service summary Facilities reporting general surgery services 100% 92% 75% 46% Facilities fully equipped for general surgery services based on above tests and equipment availability 85% 21% 0% 0% Blood typing 92% 92% 92% 54% Cross-match blood 92% 31% NA NA Complete blood count 92% 81% 17% 2% Hemoglobin 92% 100% 96% 65% NA: Not applicable to this platform according to standards. LOWEST AVAILABILITY HIGHEST AVAILABILITY HIV 92% 85% 88% 20% Liver function 92% 35% 8% NA Malaria 85% 73% 96% 56% 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. Renal function 92% 42% 4% 2% Serum electrolytes 62% 8% 8% NA Spinal fluid test 46% 4% 0% NA Syphilis 92% 85% 42% NA 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

16 ABCE IN TAMIL NADU MAIN FINDINGS: HEALTH FACILITY PROFILES Figure 8 Number of outpatient visits, by platform 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. Visits OP visits by facility DH OP visits average Visits OP visits by facility SDH OP visits average this report, we further examined facility capacity for a subset of specific services antenatal care, delivery, general surgery, and laboratory testing. For these analyses of service provision, we only included facilities that reported providing the specific service, excluding facilities that were potentially supposed to provide a given service but did not report providing it in the ABCE Facility Survey. Thus, our findings reflect more of a service capacity ceiling across platforms, as we are not reporting on the facilities that likely should provide a given service but have indicated otherwise on the ABCE Facility Survey. Antenatal care services In TN, according to the National Family Health Survey-4, 81% of women had at least four antenatal care (ANC) visits during their last pregnancy. 7 This figure, though, neither reflects what services were actually provided nor the quality of care received. Through the ABCE Facility Survey, we estimated what proportion of facilities stocked the range of tests and medical equipment to conduct a routine ANC visit. It is important to note that this list was not exhaustive but represented a number of relevant supplies necessary for the provision of ANC. 7 International Institute for Population Sciences (IIPS). National Family Health Survey (NFHS-4), : Tamil Nadu Factsheet. Mumbai, India: IIPS, Visits OP visits by facility CHC Visits OP visits average Visits OP visits by facility OP visits by facility SHC OP visits average PHC OP visits average 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. Visits Visits IP visits by facility DH CHC IP visits average Visits Visits IP visits by facility SDH PHC IP visits average IP visits by facility IP visits average IP visits by facility IP visits average 28 29

17 ABCE IN TAMIL NADU MAIN FINDINGS: HEALTH FACILITY PROFILES 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. Deliveries DH Deliveries SDH Doses administered DH Doses administered SDH Deliveries by facility Deliveries average Deliveries by facility Deliveries average Immunization doses by facility Immunization doses average Immunization doses by facility Immunization doses average Deliveries CHC Deliveries PHC Doses administered CHC Doses administered PHC Deliveries by facility Deliveries average Deliveries by facility Deliveries average Immunization doses by facility Immunization doses average Immunization doses by facility Immunization doses average The availability of tests and functional equipment for ANC is presented in Table 9. While all hospitals, community health centres, and primary health centres in this survey reported providing ANC services, few were adequately supplied for care. This discrepancy was most striking with sub-district hospitals, where only 27% of facilities were fully equipped to provide ANC, largely due to the fact that just 38% carried glucometers and test strips. One-third of district hospitals were not fully equipped, again due to the lack of a functional glucometer and strips. There was a paucity of testing availability at primary and sub health centres. In general, however, availability of functional equipment was fairly high. Across the levels of care, we found a substantial gap between facility-reported capacity for ANC provision and the fraction of the facilities fully equipped to deliver ANC care. This service-capacity gap meant that many facilities, from district hospitals to the lower levels of care, reported providing ANC but then lacked at least one piece of the functional equipment needed to optimally address the range of patient needs during an ANC visit. Lack of simple tests or material for tests (such as glucometer and test strips) prevented most facilities from being listed as fully equipped to provide ANC services. These findings do not Doses administered SHC Immunization doses by facility Immunization doses average 30 31

18 ABCE IN TAMIL NADU MAIN FINDINGS: HEALTH FACILITY PROFILES Table 13 Characteristics of patients interviewed after receiving care at facilities DH SDH CHC PHC SHC TOTAL Total patient sample Percent female 54% 55% 63% 61% 82% 61% Patient s age group (years) <16 12% 11% 10% 8% 4% 9% % 26% 36% 33% 41% 32% % 22% 18% 21% 26% 21% % 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% 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% 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. though this is still a notable gap. The availability of incubators and vacuum extractors was notably lacking at sub-district hospitals, community health centres, and primary health centres, despite these being essential items for service provision. Cross-match blood tests were also not widely available outside of district hospitals. This finding is cause for concern, as not having access to adequate delivery equipment can affect both maternal and neonatal outcomes at all levels of care. 9,10 Again, we found a substantial gap between the proportion of facilities, across platforms, that reported providing routine delivery services and those that were fully equipped for their provision. General surgery services Availability of essential tests and equipment for general surgery services are presented in Table 11. There was a lack of cross-match blood tests and blood storage units across all platforms. Essential medical equipment was 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: mostly available across platforms, though availability declined at lower-level facilities, particularly with regard to sterilization equipment and adult bag valve masks, which were available in less than two-thirds of sub health centres. Availability of surgical equipment was also relatively high at hospitals, with the exception of blood storage units at sub-district hospitals. There were large gaps in surgical equipment in community health centres and primary health centres, indicating a lack of capacity to provide surgical services. It is also crucial to consider the human resources available to perform surgical procedures, as assembling an adequate surgical team is likely to affect patient outcomes. Given the nature of documentation of human resources in the records, such data could not be captured, but future work on assessing surgical capacity at health facilities should collect this information. Laboratory testing The availability of laboratory tests is presented in Table 12. While all district hospitals and sub-district hospitals offer the range of laboratory services, there were gaps in test availability. Availability was generally high in district hospitals and decreased at lower facility levels, with particularly large gaps among primary health centres. However, some tests had low availability at all levels. Se- Figure 12 Patient travel times to facilities, by platform suggest that these platforms are entirely unable to provide adequate ANC services; it simply means that the vast majority of facilities did not have the recommended diag- Figure 13 Patient wait times at facilities, by platform Figure 14 Patient scores of facilities, by platform nostics and medical equipment for ANC. DH SDH CHC PHC Delivery care services 99% of deliveries in TN occur in a health facility, and 67% in a public facility. 8 Availability of essential equipment is necessary for providing high-quality delivery care; these results are presented in Table 10. Availability was generally highest in district hospitals, declining at lower DH SDH CHC PHC DH SDH CHC PHC SHC Percent (%) < 30 min. > 30 min. levels with notable gaps among community and primary health centres. While all facility levels offered routine delivery services, no community or primary health centres had all essential tests and equipment available, and only 4% of sub-district hospitals were fully equipped. SHC Percent (%) < 30 min. > 30 min. SHC Percent (%) < DH: District hospital; SDH: Sub-district hospital; CHC: Community health centre; PHC: Primary health centre; SHC: Sub health centre This number increased to 54% among district hospitals, 8 International Institute for Population Sciences (IIPS). National Family Health Survey (NFHS-4), : Tamil Nadu Factsheet. Mumbai, India: IIPS, 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

19 ABCE IN TAMIL NADU MAIN FINDINGS: HEALTH FACILITY PROFILES Table 14 Proportion of patients satisfied with facility visit indicators, by platform Staff interactions Nurse/ANM Doctor DISTRICT HOSPITAL SUB- DISTRICT HOSPITAL COMMUNITY HEALTH CENTRE PRIMARY HEALTH CENTRE SUB HEALTH CENTRE 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% Clarity of provider explanations 58% 64% 70% 72% 58% time. The number of outpatient visits by fiscal year, by platform, is presented in Figure 8. In general, the average number of outpatient visits increased slightly over five fiscal years. Patient volume was highest in district (average of 619, ,125 visits per year). Sub-district hospitals reported an average of 200, ,487 visits per year, which was nearly triple the number reported by community health centres (average of 58,034 64,999 visits per year). Primary health centres reported more than 40 times more outpatient visits (average of 37,091 45,806 visits per year) than sub-health centres (average of visits per year). Inpatient visits generally entail more service demands than outpatient visits, including ongoing occupancy of facility resources such as beds.the reported number of inpatient visits (other than deliveries) by year are presented in Figure 9. Over time, the average number of inpatient visits have increased for all platforms. District hospitals provided care for an average of 50,332 56,729 inpatient visits per fiscal year. Sub-district hospitals provided care for an average of 7,938 13,711 visits per year, while community health centres provided far fewer visits (an average between 717 and 1,018 inpatient visits per year). Primary health centres reported substantially fewer inpatient visits (on average visits per year). It is important to note that the ABCE Facility Survey did not capture information on the length of inpatient stays, which is a key indicator to monitor and include in future work. The reported number of deliveries, by platform and Time to ask questions 51% 60% 68% 70% 67% Facility characteristics Cleanliness 36% 37% 50% 56% 56% Privacy 50% 42% 58% 54% 58% Figure 16 Determinants of satisfaction with doctors LOWEST AVAILABILITY Figure 15 Availability of prescribed drugs at facility, by platform DH SDH CHC PHC SHC Percent (%) Got none/some of the drugs Got all perscribed drugs DH: District hospital; SDH: Sub-district hospital; CHC: Community health centre; PHC: Primary health centre; SHC: Sub health centre HIGHEST AVAILABILITY rum electrolyte tests, useful as part of a metabolic panel 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 facilities, present at only 46% of district hospitals and 4% of sub-district hospitals. Liver and renal function tests were widely available at district hospitals, but lacking from other facility levels. There were striking gaps in the capacity to test for infectious diseases at primary health centres, as only 20% reported the availability of HIV or tuberculosis tests, and just 56% had tests for malaria. Facility outputs Measuring a facility s patient volume and the number of services delivered, which are known as outputs, is critical to understanding how facility resources align with patient demand for care. Figure 8 illustrates the trends in average outpatient volume across platforms and over Female Male >=40 years 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 Odds Ratio 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. DH: District hospital; SDH: Sub-district hospital; CHC: Community health centre; PHC: Primary health centre 34 35

20 ABCE IN TAMIL NADU MAIN FINDINGS: HEALTH FACILITY PROFILES over time, is presented in Figure 10. District hospitals reported an average between 3,291 and 3,940 deliveries in each year of observation, while sub-district hospitals reported an average of deliveries per year. While many hospitals experienced an increase in the number of deliveries over time, several hospitals reported decreasing numbers over the five years of observation. Community health centres reported an annual average number of deliveries between 174 and 269. Few deliveries were reported in primary health centres (an average of deliveries per year). The ratio of deliveries to inpatient visits is higher among the lower platforms. Immunization The number of immunization doses administered over time, by platform, is presented in Figure 11. The average number of doses administered remained stable over the Figure 17 Determinants of satisfaction with nurses Female Male >=40 years 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 SHC PHC CHC SDH five fiscal years, with slight declines in sub-district hospitals and community health centres. The highest volume of immunization doses administered was seen in sub-district hospitals, with an average between 25,783 and 30,947 doses per year. District hospitals reported an average between 17,285 and 17,771 doses administered in each year of observation. Community health centres reported providing an average number of doses between 4,808 and 5,815 per year, similar to primary health centres, which reported an average of 4,979 6,460 doses administered per year. Sub health centres reported an average of doses per year. Patient perspectives A facility s availability of and capacity to deliver services is only half of the health care provision equation; the other half depends upon patients seeking those health services. Many factors can affect patients decisions to seek care, ranging from associated visit costs to how pa Odds Ratio 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. DH: District hospital; SDH: Sub-district hospital; CHC: Community health centre; PHC: Primary health centre; SHC: Sub health centre Table 15 Input-output model specifications Model 1 Model 2 CATEGORY Inputs Outputs Inputs Outputs VARIABLES Expenditure on personnel Expenditure on pharmaceuticals All other expenditure Outpatient visits Inpatients visits (excluding deliveries) Deliveries Immunization visits Number of beds Number of doctors Number of nurses Number of ANMs Number of paramedical staff Number of non-medical staff Outpatient visits Inpatients visits (excluding deliveries) Deliveries Immunization visits tients view the care they receive. These demand-side constraints can be more quantifiable (e.g., distance from facility) or intangible (e.g., perceived respectfulness of the health care provider), but each can have the same impact on whether patients seek care at particular facilities or have contact with the health system at all. Using data collected from the Patient Exit Interview Surveys, we examined the characteristics of patients who presented at health facilities and their perspectives on the care they received. Table 13 provides an overview of the interviewed patients (n=2,277) or their attendants at public facilities. Most patients were female (61%), and the majority of patients identified as part of a scheduled caste/scheduled tribe (29%) or other backwards caste (59%). 80% of patients had some education, and all facilities saw patients with a range of educational attainment. 41% of patients were under the age of 30. Travel and wait times The amount of time patients spend traveling to facilities and then waiting for services can substantially affect their care-seeking behaviors. Among the patients who were interviewed, we found that travel time to a facility for care (Figure 12) differed by the platform, with shorter travel time for patients seeking care at lower-level facilities than higher-level. It is important to note that patients only reported on the time spent traveling to facilities, not the time needed for round-trip visits. Fifty-four percent of patients who went to district hospitals traveled fewer than 30 minutes, 32% traveled between 30 minutes and one hour. At primary health centres these proportions were 78% and 17%, respectively, 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, particularly those in rural areas. It also reflects the fact that many patients travel longer distances to receive the kind of specialized care offered at hospitals. Wait time is also an important determinant of patient satisfaction. The large majority of patients waited less than 30 minutes to receive care at all platforms (Figure 13), and nearly all patients seeking care at sub health centres (94%) received care within 30 minutes. Wait times were 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 hour to receive care. Patient satisfaction with care We report primarily on factors associated with patient satisfaction with provider care and perceived quality of services by patients on medicine availability and hospital infrastructure, as these have been previously identified to be of significance in the patient s perception of quality of health services in India. 11 Ratings of patient satisfaction, based on a scale from zero to 10, with 10 being the highest score, are presented in Figure 14. Overall, patients were satisfied with the care they received and, in general, ratings were higher for higher-level platforms. Few patients (6%) gave a rating of 10, and the majority rated the facility they attended an 8 or 9 (42% of all patients). Among patients seeking care at community health centres, only 9% rated the facility below a 6; among patients seeking care at sub-district hospitals, this proportion is 14%. Patients were also asked more detailed questions about satisfaction with providers and facility characteris- 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):

21 ABCE IN TAMIL NADU MAIN FINDINGS: HEALTH FACILITY PROFILES Table 16 Average and range of inputs and outputs, by platform. INR denotes Indian Rupees. Table 17 Average annual cost in INR, by platform, last fiscal year. INR denotes Indian Rupees. DISTRICT HOSPITAL SUB-DISTRICT HOSPITAL COMMUNITY HEALTH CENTRE PRIMARY HEALTH CENTRE DISTRICT DISTRICT HOSPITAL SUB-DISTRICT HOSPITAL COMMUNITY HEALTH CENTRE PRIMARY HEALTH CENTRE Personnel expenditure (INR) Pharmaceutical expenditure (INR) 56,556,802 (6,492, ,503,416) 7,343,161 (1,771,439-12,103,611) 16,471,282 (1,972,154-64,633,828) 1,405,913 (320,046-4,244,187) 9,403,170 (2,990,895-52,689,648) 236,908 (85, ,232) 3,735,343 (237,240-8,011,006) 159,776 (79, ,856) District 1 15,383,021 8,511,807 2,668,189 District 2 119,704,784 14,915,623 6,157,839 2,932,572 District 3 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 Other expenditure (INR) 7,742,626 (134,917-27,240,558) 1,149,703 (112,272-9,471,909) 2,847,552 (39,093-30,170,106) 2433,04 (38,489-1,649,957) 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 Inputs Number of beds Number of doctors 343 (84-608) 79 (16-258) 21 (3-37) 4 (1-14) 39 (20-78) 11 (2-41) 5 (1-13) 2 (1-6) 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 Number of nurses 65 (27-163) 15 (2-44) 4 (1-7) 3 (0-5) 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 Number of paramedical staff 64 (16-127) 16 (2-39) 17 (6-30) 11 (3-20) District 13 41,088,188 41,899,892 15,192,691 2,964,931 Number of non-medical staff 58 (9-144) 8 (0-27) 5 (1-9) 2 (0-9) Empty cells were either dropped from analysis due to data availability, or there were no facilities to sample of that platform. Outpatient visits 663,351 (225,699-1,144,003) 215,165 (4, ,210) 63,947 (17, ,765) 40,508 (13,500-77,361) Figure 18 Average total and type of expenditure, by platform, Outputs Inpatient visits (excluding deliveries) Deliveries Immunization doses 52,311 (7, ,668) tics (Table 14). Most patients were unsatisfied with facility cleanliness at district hospitals (64%) and sub-district hospitals (63%), and dissatisfaction with privacy in these facility types was also high (50% and 58%, respectively). Health centres performed slightly better than hospitals on both these metrics. Three parameters were assessed to document satisfaction with health providers being treated respectfully by the provider, clarity of explanation provided by the provider, and that provider gave enough time to ask questions about health problem or treatment using a 5 point Likert scale, with the highest ratings of good and very good responses combined as satisfied, and rest as not satisfied. Using the three parameters of satisfaction, 10,971 ( ,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) a composite satisfaction variable was created separately for doctors and nurses if a patient reported good/very good for all three parameters, it was categorized as satisfied. At district hospitals, sub-district hospitals, and primary health centres, patients receiving care from doctors reported slightly higher levels of satisfaction than those receiving care from nurses and ANMs. This trend was reversed in sub health centres, where patients were more satisfied with nurses and auxiliary nurse midwives (ANMs), with the exception of very high satisfaction scores for doctor respectfulness in sub health centres. Generally, satisfaction was higher at health centres than at hospitals. Expenditure in 100,000 Rupees Expenditure in 100,000 Rupees DISTRICT HOSPITALS Personnel Pharmaceuticals and consumables Other COMMUNITY HEALTH CENTRES Expenditure in 100,000 Rupees Expenditure in 100,000 Rupees SUB-DISTRICT HOSPITALS Personnel Pharmaceuticals and consumables Other PRIMARY HEALTH CENTRES Personnel Personnel Pharmaceuticals and consumables Other Pharmaceuticals and consumables Other 38 39

22 ABCE IN TAMIL NADU MAIN FINDINGS: HEALTH FACILITY PROFILES Figure 19 Average percentage of expenditure type, by platform, 2011 District Hospital Sub District Hospital Community Health Centre Primary Health Centre Percent of Total Expenditure Personnel Access to affordable drugs has been interpreted to be part of the right to health. Among 1,620 patients who were prescribed drugs and attempted to obtain those drugs during the visit, 1,552 received all prescribed drugs (Figure 15). This ranged from 99% of patients at sub-district hospitals and primary health centres to 80% of patients at sub health centres. Many complex factors affect patient satisfaction with the medical care they receive. Given this, a multivariate logistic regression was conducted in order to determine which patient and facility characteristics were associated with patient satisfaction with both medical doctors (Figure 16) and nurses/anms (Figure 17). For each characteristic for example, the age or sex of the patient the odds ratio (OR) is presented. The OR represents the odds that a patient is satisfied given a particular characteristic, compared to the odds of the patient being satisfied in the absence of that characteristic. An OR and 95% confidence interval (CI) greater than 1.0 indicates that there are greater odds of being satisfied with care as compared to the reference group. An OR and 95% CI below 1.0 indicates that there are lower odds of being satisfied with care than the reference group. Pharmaceuticals and consumables Other For example, while the OR for patients under age 40 years being satisfied with care from a doctor is 0.88 (95% CI: ) as compared to patients age 40 years and older, it is not statistically different from an OR of 1.0 (Figure 16). This means that, considering all other characteristics, patients under age 40 are not more or less satisfied with care from doctors than patients 40 years and older. In Figures 16 and 17, ORs that are statistically significant are signified by blue points, with blue horizontal bars representing their confidence interval. ORs that are not statistically significant are represented with green points and green confidence bars. Compared to patients of another group, there was slightly lower satisfaction with doctors for male patients (OR: 0.75, 95% confidence interval [CI]: ). Controlling for all other factors, compared to patients who sought care at district hospitals, patients who sought care at primary health centres were more satisfied with care from doctors (OR: 2.39, 95% CI: ). Receipt of all prescribed drugs was associated with higher satisfaction with nurses, as compared to patients who received some or none of the prescribed drugs (Figure 17, OR: 2.43, 95% CI: ). Compared to patients who sought care at district hospitals, those who sought care at sub health centres (OR: 3.74, 95% CI: ) and community health centres (OR: 3.35, 95% CI: ) had higher satisfaction with nurses. Efficiency and Costs The costs of health service provision and the efficiency with which care is delivered by health facilities go handin-hand. An efficient health facility uses resources well, producing a high volume of patient visits and services without straining its resources. Conversely, an inefficient health facility is one where the use of resources is not maximized, leaving usable beds empty or medical staff seeing very few patients per day. We present technical efficiency analysis for district hospitals, sub- district hospitals, community health centres and primary health centres. Analytical approach An ensemble model approach was used to quantify technical efficiency in health facilities, combining results from two approaches the restricted versions of Data Envelopment Analysis (rdea) and Stochastic Distance Function (rsdf). 12 Based on this analysis, an efficiency 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 Figure 20 Outpatient load per staff, by platform Visits Visits DH OP visits per staff by facility OP visits per staff average CHC OP visits per staff by facility OP visits per staff average DH: District hospital; SDH: Sub-district hospital; CHC: Community health centre; PHC: Primary health centre Visits Visits OP visits per staff by facility OP visits per staff average PHC OP visits per staff by facility OP visits per staff average Note: each line represents an individual facility, with the bolded line depicting the average for the platform. Scales are different for each platform type. SDH 40 41

23 ABCE IN TAMIL NADU MAIN FINDINGS: HEALTH FACILITY PROFILES Figure 21 Inpatient load per staff by platform Figure 22 Deliveries per staff by platform Visits DH Visits SDH Deliveries DH Deliveries SDH IP visits per staff by facility IP visits per staff average IP visits per staff by facility IP visits per staff average Deliveries per staff by facility Deliveries per staff average Deliveries per staff by facility Deliveries per staff average CHC PHC CHC PHC Visits Visits Deliveries Deliveries IP visits per staff by facility IP visits per staff average IP visits per staff by facility IP visits per staff average Deliveries per staff by facility Deliveries per staff average Deliveries per staff by facility Deliveries per staff average 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. 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. score was estimated for each facility, capturing a facility 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 rdea and rsdf approaches compute efficiency scores ranging from 0% to 100%, with a score of 100% indicating that a facility achieved the highest level of production relative to all facilities in that platform. This approach assesses the relationship between inputs and outputs to estimate an efficiency score for each facility. Recognizing that each type of input requires a Distance Functions, and an Ensemble Model. PLOS ONE. 2016; 11(2): e an inpatient visit uses more resources and more complex types of equipment and services than an outpatient visit), we applied weight restrictions to rescale each facility s mixture of inputs and outputs. The incorporation of additional weight restrictions is widely used in order to improve the discrimination of the models. Weight restrictions are most commonly based upon the judgment about the importance of individual inputs and outputs, or reflect cost or price considerations. The resulting ensemble efficiency scores were averaged over five years and between the two input models. into outpatient visits, inpatient visits, delivery, and immunization. Two input-output specifications were used, with the inputs being different in the two models. The inputs and outputs are listed in Table 15. The detailed data utilized for this analysis are documented in the annex. The average and range of inputs and outputs for the variables are presented in Table 16. Costs of care Total expenditure, by district and platform, is presented in Table 17. In terms of annual total expenditures, trends in average facility spending varied by platform between 2007 and 2011 (Figure 18). All platforms recorded slightly higher levels of average expenditures in 2011 than in 2007, which appeared to be largely driven by increased spending on medical supplies and personnel. Figure 19 shows the average composition of expenditure types across platforms for Notably, sub-district hospitals and PHCs spent a slightly greater proportion of their total expenditures on personnel than other platforms. On the other hand, expenditures on medical supplies were 42 43

24 ABCE IN TAMIL NADU MAIN FINDINGS: HEALTH FACILITY PROFILES Figure 23 Immunizations per staff per day by platform Figure 24 Range of efficiency scores across platforms DH SDH Doses administered Doses administered Immunization doses per staff by facility Immunization doses per staff average CHC Doses administered Doses administered Immunization doses per staff by facility Immunization doses per staff average PHC District Hospital Community Health Centre Sub District Hospital Primary Health Centre Immunization doses per staff by facility Immunization doses per staff average Immunization doses per staff by facility Immunization doses per staff average District Hospital Mean: 74.4 Sub-district Hospital Mean: 55.7 Community Health Centre Mean: 63.1 Primary Health Centre Mean: 64.2 Median: 75.5 Median: 54.9 Median: 61.7 Median: 65.2 IQR: IQR: IQR: IQR: 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 circle represents the five-year facility average efficiency score; IQR refers to intra-quartile range. highest the at district hospitals, with other expenditure (Figure 20), inpatient visits (Figure 21), deliveries (Figure per staff was low for primary health centres, where inpa- munity health centres, and 36 per staff in primary health highest at community health centres. 22), and immunization doses (Figure 23) per staff are pre- tient visits are rare. Overall, as expected, outpatient visits centres. There was quite a bit of variation of these ratios It is important to note that data availability on the input sented. District hospitals produced an average of 3,183 accounted for the overwhelmingly large majority of the within a platform and over time, however. and output indicators varied across the facilities and platforms, with more non-availability for PHCs. Facilities with five years of missing data for any input or output variable were dropped from analysis. In addition, the data were smoothed where necessary based on the trends seen in inputs or outputs for that facility. To further illustrate the production of outputs per inputs in this case, staff a simple ratio of outpatient visits outpatient visits per staff, though the ratio ranged greatly. The average ratio for sub-district hospitals was 4,476 visits per staff, for community health centres 2,198, and for primary health centres 2,488. This gradient differed for inpatient visits, with district hospitals providing 264 inpatient visits per staff, sub-district hospitals providing 246, community health centres providing 30, and primary health centres providing 30. The range of inpatient visits patients seen per staff per day across the platforms. Fewer deliveries were performed per staff than other services, with an average of 17 deliveries per staff in district hospitals, eight per staff in sub-district hospitals, eight per staff in community health centres, and eight per staff in primary health centres. For immunization, 50 doses were administered per staff in district hospitals, 572 per staff in sub-district hospitals, 191 per staff in com- Efficiency results Using the five fiscal years of data to estimate the efficiency scores for all facilities, two main findings emerged. First, efficiency scores were relatively low across all health facilities, with 74.4% being the highest mean across platforms. Second, the range between the facilities with highest and lowest efficiency scores was quite large 44 45

25 ABCE IN TAMIL NADU MAIN FINDINGS: HEALTH FACILITY PROFILES Table 18 District-wise efficiency scores (%), by platform DISTRICT/ PLATFORM DISTRICT HOSPITAL SUB DISTRICT HOSPITAL COMMUNITY HEALTH CENTRE PRIMARY HEALTH CENTRE Figure 25 Observed and estimated additional visits that could be produced given observed facility resources District OUTPATIENT VISITS INPATIENT VISITS District District District District District District District District District District District District White cells were either dropped from analysis due to data availability, or there were no more facilities to sample of that platform. District Hospital Sub District Hospital Community Health Centre Primary Health Centre District Hospital e+06 Outpatient visits Observed DELIVERIES Deliveries Estimate additional visits District Hospital Sub District Hospital Community Health Centre Primary Health Centre District Hospital 0 20,000 40,000 60,000 80,000 Inpatient visits Observed Estimate additional visits IMMUNIZATION DOSES within platforms, suggesting that a substantial performance gap may exist between the average facility and facilities with the highest efficiency scores. Figure 24 depicts this range of facility efficiency scores across platforms for TN. Efficiency by district is presented in Table 18. There is variation in facility efficiency both between and within districts. Some of the least efficient primary health centres were in the same district as the least efficient sub-district hospitals (for example, District 7). District 14, for example, had the most efficient primary health centre but the least efficient sub-district hospital. While one primary health centre in District 10 was 69% efficient, another was only 37% efficient. Given observed levels of facility-based resources (beds and personnel), it would appear that many facilities had the capacity to handle much larger patient volumes than they reported. Figure 25 displays this gap in potential efficiency performance across platforms, depicting the possible gains in total service provision that could be achieved if every facility in the ABCE sample operated at optimal efficiency. We found that all types of facilities could expand their outputs substantially given their observed resources. Based on our analyses, the highest level of care, district hospitals, had the greatest potential for increasing service provision without expanding current resources. Overall, based on our estimation of efficiency, a large portion of TN health facilities could increase the volume of patients seen and services provided with the resources available to them. On average, district hospitals could provide 249,706 additional outpatient visits with the same inputs, while primary health centres could see an average of 21,906 additional outpatient visits. Sub-district hospitals could administer an average of 26,727 additional immunization doses with the same inputs if all facilities were efficient. At the same time, many reports and policy documents emphasize that pronounced deficiencies in human resources for health exist across India in the public sector health system, such that significant [human resources for health] will be required to meet the demand for health services. 13 Our results suggest otherwise, as most facilities 13 Rao M, Rao KD, Kumar AK, Chatterjee M, Sundararaman T. Human resources for health in India. The Lancet. 2011; 377(9765): Sub District Hospital Community Health Centre Primary Health Centre 0 1,000 2,000 3,000 4,000 5,000 Deliveries Observed Estimate additional deliveries in the ABCE sample had the potential to bolster service production given their reported staffing of skilled personnel and physical capital. These findings provide a data-driven understanding of facility capacity and how health facilities have used their resources in TN; at the same time, they are not without limitations. Efficiency scores quantify the relationship between what a facility has and what it produces, but these measures do not fully explain where inefficiencies originate, why a given facility scores higher than another, or Sub District Hospital Community Health Centre Primary Health Centre 0 10,000 20,000 30,000 40,000 50,000 Immunization doses Observed Estimate additional doses what levels of efficiency are truly ideal. It is conceivable that always operating at full capacity could actually have negative effects on service provision, such as longer wait times, high rates of staff burnout and turnover, and compromised quality of care. These factors, as well as less tangible characteristics such as facility management, are all important drivers of health service provision, and future work should also assess these factors alongside measures of efficiency

26 CONCLUSIONS AND POLICY IMPLICATIONS Conclusions and policy implications T o achieve its mission to expand the reach of health care and establishing universal health coverage, 1 India has strived over the past 10 years to expand and strengthen the public sector of health care, with a focus on reaching rural areas. The country recognizes disparities and has sought to enact policies and implement programs to expand access to essential and special services for marginalized groups. 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 building blocks of the health system, 2 is linked to facility capacity to provide individuals with the services they need and want. With the appropriate balance of skilled staff and supplies needed to offer both essential and special health services, a health system has the necessary foundation to deliver quality, equitable health services. The availability of a subset of services, including routine delivery, antenatal care, general medicine, pharmacy, and laboratory services, was generally high across facility types in Tamil Nadu, reflecting the expansion of these services throughout the state. However, clear differences remain between facility types. Sub-district hospitals notably lack certain essential services: for example, only 69% provide STI/HIV services and 77% provide immunizations, meaning that availability is lower in these facilities than in community health centres. Moreover, substantial gaps were identified between facilities reporting availability of these services and having the full capacity to actually 1 Planning Commission Government of India. Twelfth Five Year Plan ( ). New Delhi, India: Government of India, World Health Organization (WHO). Everybody s Business: Strengthening health systems to improve health outcomes: WHO s Framework for Action. Geneva, Switzerland: WHO, deliver them. While almost all facilities, across platforms, indicated that they provided routine delivery care, only 54% of district hospitals, 4% of sub-district hospitals, and no lower-level facilities had the full stock of medical supplies and equipment to optimally provide these services. These gaps were also evident for ANC in all facility types. While 85% of district hospitals were fully equipped to provide general surgery, only 21% of sub-district hospitals and no lower-level facilities were fully equipped. In general, district hospitals were well equipped with medical, laboratory, and imaging equipment, with the notable exception of CT scans. The availability of equipment declined through the levels of the system, particularly with regard to laboratory equipment and imaging equipment. Closing these gaps and making sure that all facilities are fully equipped to optimally provide essential services warrants further policy consideration. Chronic diseases (e.g., cardiovascular diseases, mental health disorders, diabetes, and cancer) and injuries are the leading causes of death and disability in India, and are projected to increase in their contribution to the burden of disease during the next 25 years. 3,4,5 Much of the care for chronic diseases and injuries is provided in the private sector and can be very expensive. 45 Many NCD-related services, including cardiology, psychiatry, and chemotherapy, are notably lacking at various levels of care. While 77% of district hospitals provide cardiology and psychiatry services, only 8% provide chemotherapy. The availability of all these services declines markedly at lower facility levels, including sub-district hospitals as well as community health centres. Such gaps in the 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, : a systematic analysis for the Global Burden of Disease Study The Lancet. 2016; 388: Patel V, Chatterji S, Chisholm D, Ebrahim S, Gopalakrishna, G, Mathers C et al. Chronic diseases and injuries in India. The Lancet. 2011; 377: 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), : a systematic analysis for the Global Burden of Disease Study The Lancet Oct 7; 388: health system will exacerbate disparities by not dealing appropriately with NCDs while continuing to endeavor to eliminate major infectious diseases like tuberculosis, HIV, and malaria, or to reduce neonatal and infant mortality. Furthermore, there also is a paucity of essential equipment for NCD services at lower facility levels, including glucometer/test strips, though district hospitals are generally well-equipped. These findings support the need for immediate action to scale up interventions for chronic diseases through improved public health and primary health care systems that are essential for the implementation of cost-effective interventions. Recent studies show that India has a severe shortage of human resources for health. 6 It has a shortage of qualified health workers and the workforce is concentrated in urban areas. In the context of a shortage of qualified health personnel at all levels of the health system, but especially rural areas, 7,8,9 results reveal disparate staffing patterns between facilities. Hospitals employ a large number of staff. At the lower, community levels, paramedical staff including nurses and ANMs provide the majority of care to patients (based on reported staffing). These staffing patterns are not unexpected based on the hierarchy of care. However, nurses do not have much authority or say within the health system, and the resources to train them are still inadequate. A call has been made to the government to urgently address the issues of human resources through a comprehensive national policy for human resources to achieve universal health care in India. However, it should be noted that despite the shortfall in human resources, the study findings suggest suboptimal efficiency in production of services with the given level of human resources. Adequate operational infrastructure is essential for the functioning of a facility, which in turn affects the efficiency of service provision. In Tamil Nadu, all hospitals and community and primary health centres and almost all sub health centres had access to functioning electricity, and only one facility reported being solely dependent on a generator. This means a higher quality of service 6 Rao M, Rao KD, Kumar AK, Chatterjee M, Sundararaman T. Human resources for health in India. The Lancet. 2011; 377(9765): Government of India, Twelfth Five Year Plan ( ). 8 Hazarika I. Health Workforce in India: Assessment of Availability, Production and Distribution. WHO South East Asia Journal of Public Health. 2013; 2(2): Rao M, Rao KD, Kumar AK, Chatterjee M, Sundararaman T. Human resources for health in India. The Lancet. 2011; 377(9765): provision, as it allows for reliable storage of medications, vaccines, and laboratory samples. Access to piped water was more variable in these types of facilities; it was particularly lacking in sub health centres, with all other facilities showing availability of 85% 88%. Access to flushed toilets was actually lower in district hospitals than in community and primary health centres, though again, sub health centres recorded the lowest levels overall. That so many facilities did report access to essential resources like water, sanitation, and electricity likely reflects India s commitment 10,11 to upgrade all facilities so they meet Indian Public Health Standards. However, the marked discrepancies evident between sub centres and other types of facility suggest that there should be a sustained focus on making sure that these resources reach the lowest levels of the health system. Communication is also an important facet of health service delivery. In general, facilities in Tamil Nadu had good access to phones and computers, which makes for more efficient referrals and coordination. However, access 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 and curative care. Facility production of health services Overall, the number of outpatient visits by year and platform was relatively stable over the five years of observation. Volume of outpatient visits was considerably lower at the lower health facilities. The volume of inpatient visits and deliveries increased over the five years of observation for most platforms. The highest volumes of visits were held by district hospitals, followed by sub-district hospitals. Facility expenditure is dominated by personnel costs accounting for, on average, at least 70% of total costs. Efficiency scores reflect the relationship between facility-based resources and the facility s total patient volume each year. Average efficiency scores by platform ranged from 55.7% to 74.4%, indicating patient volume could substantially increase with the observed levels of resources and expenditure. Within each platform, there is great variation in the efficiency of health facilities between and within districts. With this information, we 10 Planning Commission Government of India. Eleventh Five Year Plan ( ). New Delhi, India: Government of India, Planning Commission Government of India. Twelfth Five Year Plan ( ). New Delhi, India: Government of India,

27 ABCE IN TAMIL NADU CONCLUSIONS AND POLICY IMPLICATIONS estimated that facilities could substantially increase the key component of health system performance in terms provisions at the facility they visited. In general, satis- vice provision was observed. number of patients seen and services provided, based on of cost to facilities and service production. While these faction was higher with doctors than nurses or ANMs It is not possible to assess the outputs by disease/ their observed levels of medical personnel and resources costs do not reflect the quality of care received or the at hospitals, but not at all health centres. Holding other condition other than that for deliveries, as data are not in As India seeks to strengthen public sector care specific services provided for each visit, they can enable factors constant, male patients were less satisfied with captured or collated by disease groups at the facilities. At to reduce the heavy burden of out-of-pocket expendi- a compelling comparison of overall health care expenses their care from doctors, and patients who received all the higher-level facilities, collation of patients seen at the tures, 12,13 stakeholders may seek to increase efficiency by 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 providing more services while maintaining personnel, ca- capture information on the quality of services provided, from nurses. to assess the level of duplication of patients across the pacity (beds), and expenditure. as it is a critical indicator of the likely impact of care on Most patients experienced short travel and wait times. departments. Furthermore, documentation of patients as Further use of these results requires considering ef- patient outcomes. Most patients traveled less than 30 minutes to receive a new patient or a follow-up patient was neither standard- ficiency in the context of several other factors, including quality of care provided, demand for care, and expediency with which patients are seen. The policy implications of these efficiency results are both numerous and diverse, and they should be viewed with a few caveats. A given facility s efficiency score captures the relationship between observed patient volume and facility-based resources, but it does not reflect the expediency with which patients are seen, the optimal provision of services, demand for the care received, and equity in provision of services to serve those who are disadvantaged. 14 These are all critical components of health service delivery, and they should be thoroughly considered alongside measures of efficiency. On the other hand, quantifying facility-based levels of efficiency provides a data-driven, rather than strictly anecdotal, understanding of how much TN health facilities could potentially expand service provision without necessarily increasing personnel or bed capacity in parallel. Costs of care Average facility expenditure per year differed substantially across platforms. We were unable to estimate Patient perspectives Patient satisfaction is an important indicator of patient perception of the quality of services provided by the healthcare sector. 15,16 Evaluation of services by patients is important for purposes of monitoring, increasing accountability, recognizing good performance, and adapting patient-centric services, and for utilization of services and compliance with treatment. A major strength of this study is that patient satisfaction was assessed across the various levels of public sector health care in the state. The public health system in India designed as a referral hierarchical system to provide a continuum of health care, and as a consequence of this, failure at one level can impact the chain of care at another level. 17 Although various government initiatives have led to improved basic service delivery at primary care health facilities over the last few years, still a large number of patients directly visit higher-level facilities, leading to over-crowding of those facilities, 18 which impacts quality of care as it stretches facility resources in terms of both infrastructure and staff. In addition, the persistent shortage of medical staff in pub- care, with patients at lower-level facilities reporting the shortest travel times. Hospitals had the highest proportion of patients who had to wait more than 30 minutes to receive care; the lowest proportion of patients waiting more than 30 minutes was at sub health centres. However only 6% of patients waited more than one hour to receive care. Finally, nearly 20% of patients at sub health centres reported being unable to acquire prescribed drugs. Ensuring that all patients may obtain prescribed medications at the time of their visit should be a priority, as it facilitates adherence and continuity of care. With the developmental priorities for the government of India clearly highlighting the need to increase user participation in health care service delivery for better accountability, 20 understanding how patients perceive the quality of the existing public health services, encompassing various dimensions of care such as time to receive medical attention, staff behavior, etc., could contribute to developing strategies to improve performance and utilization of the public health system. 21 Health information system ized nor practiced across most health facilities. Therefore, data interpretation is possible only in terms of number of visits and not in terms of number of patients. Data were either incomplete or inaccurate at some facilities for expenditure, patient-related outputs, and staff numbers. In general, the expenditure documentation had the most bottlenecks with these data available across various sources for a given facility. For example, it is not possible to document the expenditures at a given facility without procuring relevant data from the facility, a higher level of facility (block level), district health society, and at times from the state. The most limited capacity was to capture the expenditure on drugs, medical consumables, and supplies. Summary The ABCE project was designed to provide policymakers and funders with new insights into health systems and to drive improvements. We hope these findings will not only prove useful to policymaking in the state, but will also inform broader efforts to mitigate factors that impede the equitable access to or delivery of health services in India. It is with this type of information that the individual the costs of care by type of services (such as outpatients, lic facilities only aggravates the crowded condition at This study was dependent on the data availability at building blocks of health system performance, and their inpatients, deliveries, immunization, etc.) or by type of these facilities. 19 the facilities for the various inputs and outputs. Because critical interaction with each other, can be strengthened. disease/condition (such as TB, diabetes, etc.) as such data Findings indicate that patients were generally satisfied of the vast extent of data that were collected for five fi- More efforts like the ABCE project in India are needed to are not readily available at the facilities. Estimating such with the care they received, and ratings and satisfaction nancial years across the facilities, there are several lessons continue many of the position trends highlighted in this costs of care and identifying differences in patient costs were generally higher at lower levels of care. However, regarding the common bottlenecks within the health in- report and overcome the identified gaps. Analyses that across the type of platforms is critical for isolating areas many were not satisfied with the cleanliness or privacy formation system, both at the facility level and at the state take into account a broader set of the state s facilities, to improve cost-effectiveness and expand less costly ser- level. In general, there is weak staff capacity for data cap- including private facilities, may offer an even clearer pic- vices, especially for hard-to-reach populations. Nevertheless, these results on expenditures offer insights 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: UNICEF. Narrowing the gaps: The power of investing in the poorest children. New York, NY: UNICEF, Mpinga EK, Chastonay P. Satisfaction of patients: a right to health indicator? Health Policy. 2011; 100(2-3): 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: National Health Mission, Ministry of Health and Family Welfare, Government of India. Framework for Implementation National Health Mission ( ). New Delhi, India: Government of India, Bajpai V. The Challenges Confronting Public Hospitals in India, Their Origins, and Possible Solutions. Advances in Public Health 2014; 2014: Rao M, Rao KD, Kumar AK, Chatterjee M, Sundararaman T. Human resources for health in India. The Lancet. 2011; 377(9765): ture, management, and use (interpretation or planning) at all levels. No system of regular review of data at the facility level that could guide planning or improvement of ser- 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, World Health Organization (WHO). Global Health Observatory Data Repository. Geneva, Switzerland: WHO, ture of levels and trends in capacity, efficiency, and cost. Continued monitoring of the strength and efficiency of service provision is critical for optimal health system performance and the equitable provision of cost-effective interventions throughout the states and in India

28 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 District Platform Year Beds Doctors Nurses Paramedical Nonmedical Outpatient Inpatient Vaccinations Births Personnel Infrastructure + utilities Medical supplies + pharmaceuticals Administration and training Non-medical 2 District Hospital (DH) ,066,885 94,463 6,041 4,042 29,562,816 7,720,422 7,214, ,645 4,030,000 2 District Hospital (DH) ,119, ,896 4,848 4,031 30,625,188 7,857,414 7,810, ,587 4,660,000 2 District Hospital (DH) ,141, ,975 3,967 3,993 33,149,616 8,093,496 8,511, ,800 5,025,000 2 District Hospital (DH) ,219,695 90,942 4,015 4,191 34,492,848 8,255,150 8,412, ,100 5,428,000 2 District Hospital (DH) ,041, ,059 4,411 4,505 37,963,276 8,466,725 8,713, ,000 5,684,000 2 Sub-district Hospital (SDH) ,543 2, ,888, , ,374 17, ,560 2 Sub-district Hospital (SDH) ,367 1, ,972, , ,834 42, ,800 2 Sub-district Hospital (SDH) ,861 3, ,756, , ,107 41, ,300 2 Sub-district Hospital (SDH) ,833 2, ,573, , ,423 50, ,402 2 Sub-district Hospital (SDH) ,898 3, ,439, , ,813 75, ,695 2 Community Health Centre (CHC) ,348 1,109 4, ,226, , ,339 51,651 26,080 2 Community Health Centre (CHC) ,604 1,026 4, ,742, , ,707 47,791 33,473 2 Community Health Centre (CHC) ,013 1,052 4, ,157, , ,242 50,141 41,184 2 Community Health Centre (CHC) ,011 1,355 4, ,598, , ,581 42,386 23,390 2 Community Health Centre (CHC) ,285 1,149 4, ,185, , ,961 10,924 17,725 2 Primary Health Centre (PHC) , , ,637, , ,629 23,075 7,434 2 Primary Health Centre (PHC) , , ,834, , ,647 15,175 26,290 2 Primary Health Centre (PHC) , , ,988, , ,293 8,999 27,245 2 Primary Health Centre (PHC) , , ,158, , ,307 41,691 20,375 2 Primary Health Centre (PHC) , , ,304, , ,268 16,653 48,141 2 Primary Health Centre (PHC) , , ,487,805 97, ,998 21,273 3,490 2 Primary Health Centre (PHC) , , ,684, , ,999 31,696 16,200 2 Primary Health Centre (PHC) , , ,814,813 98, ,547 54,611 22,370 2 Primary Health Centre (PHC) , , ,948,811 99, ,000 46,723 28,635 2 Primary Health Centre (PHC) , , ,094, , ,390 27,326 50,975 2 Sub-district Hospital (SDH) , , ,359,315 3,383, ,919 16,195 24,854 2 Sub-district Hospital (SDH) , , ,673,693 3,389, ,163 17,925 46,206 2 Sub-district Hospital (SDH) ,361 1,968 50, ,170,000 3,415, ,834 33,101 30,

29 FACILITY INFORMATION STAFF AND BEDS OUTPUTS EXPENDITURE District Platform Year Beds Doctors Nurses Paramedical Nonmedical Outpatient Inpatient Vaccinations Births Personnel Infrastructure + utilities Medical supplies + pharmaceuticals Administration and training Non-medical 2 Sub-district Hospital (SDH) ,067 2,234 55, ,264,342 3,487, ,678 36,604 87,663 2 Sub-district Hospital (SDH) ,354 2,995 51, ,702,567 3,488, ,542 37, ,988 2 Community Health Centre (CHC) ,696 1,153 2, ,413, ,574 89,628 29,731 9,095 2 Community Health Centre (CHC) ,832 1,976 5, ,718, , , ,326 10,830 2 Community Health Centre (CHC) ,340 1,753 5, ,085, , ,127 58,375 49,085 2 Community Health Centre (CHC) ,765 2,504 4, ,483, , , ,291 45,941 2 Community Health Centre (CHC) ,645 1,138 3, ,862, , , ,021 37,665 2 Primary Health Centre (PHC) , , ,711, , ,234 22,749 5,470 2 Primary Health Centre (PHC) , , ,827, , ,739 17,290 11,601 2 Primary Health Centre (PHC) , , ,945, , ,905 22,221 20,800 2 Primary Health Centre (PHC) , , ,031, , ,264 43,723 21,025 2 Primary Health Centre (PHC) , , ,204, , ,036 33,921 38,565 2 Primary Health Centre (PHC) , ,650 89, ,499 3,150 4,500 2 Primary Health Centre (PHC) , , , ,998 6,032 10,940 2 Primary Health Centre (PHC) , , , ,855 11,364 20,066 2 Primary Health Centre (PHC) , ,190 96, ,616 18,514 14,195 2 Primary Health Centre (PHC) , , , ,240 9,038 21,825 3 District Hospital (DH) ,144,003 35,686 11,230 3,960 98,100,184 1,733,605 11,926, ,458 1,162,617 3 District Hospital (DH) ,942 37,637 9,608 3, ,142,456 1,929,940 10,920, ,343 1,138,279 3 District Hospital (DH) ,500 37,931 9,986 3, ,270,576 1,634,328 11,827, ,955 1,405,289 3 District Hospital (DH) ,830 36,935 9,561 2, ,495,432 2,125,572 11,225, ,803 1,343,120 3 District Hospital (DH) ,279 33,903 10,314 2, ,908,712 1,681,760 11,426, ,652 1,754,676 3 Sub-district Hospital (SDH) ,905 7,033 2, ,768,250 1,238,766 1,401,195 50, ,755 3 Sub-district Hospital (SDH) ,498 3,731 1, ,163,144 1,233,379 1,625,288 55, ,000 3 Sub-district Hospital (SDH) ,973 4,985 1, ,157,024 1,497,361 2,035, , ,879 3 Sub-district Hospital (SDH) ,897 6,302 1, ,480,108 1,258,886 1,445,771 85, ,050 3 Sub-district Hospital (SDH) ,175 5,216 1, ,288,772 1,263,926 1,590,507 84, ,500 3 Community Health Centre (CHC) , , ,584, , ,864 19,320 83,950 3 Community Health Centre (CHC) , , ,828, , ,105 16, ,000 3 Community Health Centre (CHC) , , ,959, , ,482 21, ,300 3 Community Health Centre (CHC) , , ,144, , ,562 22, ,050 3 Community Health Centre (CHC) , , ,278, , ,772 60, ,756 3 Primary Health Centre (PHC) , , ,545, , ,278 15,650 8,948 3 Primary Health Centre (PHC) , , ,725, , ,117 53,090 15,418 3 Primary Health Centre (PHC) , , ,967, , ,524 4,688 31,800 3 Primary Health Centre (PHC) , , ,087, , ,649 8,400 46,845 3 Primary Health Centre (PHC) , , ,136, , ,994 19,605 6,780 3 Primary Health Centre (PHC) , , ,106, , ,277 2,245 10,000 3 Primary Health Centre (PHC) , , ,171, , ,066 2,355 27,

30 FACILITY INFORMATION STAFF AND BEDS OUTPUTS EXPENDITURE District Platform Year Beds Doctors Nurses Paramedical Nonmedical Outpatient Inpatient Vaccinations Births Personnel Infrastructure + utilities Medical supplies + pharmaceuticals Administration and training Non-medical 3 Primary Health Centre (PHC) , , ,238, , ,019 2,250 54,737 3 Primary Health Centre (PHC) ,981 1,108 1, ,307, , ,551 16,246 54,478 3 Primary Health Centre (PHC) ,878 1,347 2, ,204, , ,720 58,784 57,000 3 Sub-district Hospital (SDH) ,379 1,908 1, ,165, , ,126 31, ,342 3 Sub-district Hospital (SDH) ,540 2,225 1, ,418, , ,548 26,688 55,821 3 Sub-district Hospital (SDH) ,740 3,897 1, ,678, , ,627 20, ,166 3 Sub-district Hospital (SDH) ,305 4,590 1, ,947, , ,163 17,445 69,827 3 Sub-district Hospital (SDH) ,223 6,827 2, ,223, , ,030 27, ,686 3 Community Health Centre (CHC) ,132 1,334 5, ,437, , ,276 25,070 63,254 3 Community Health Centre (CHC) ,175 1,112 5, ,584, , ,263 15,197 68,600 3 Community Health Centre (CHC) ,790 1,169 4, ,264, , ,862 14, ,520 3 Community Health Centre (CHC) ,190 1,223 17, ,115, , ,173 15, ,500 3 Community Health Centre (CHC) ,802 1,265 5, ,919, , ,426 14,735 70,679 3 Primary Health Centre (PHC) , , ,150, ,011 82,745 3,251 4,724 3 Primary Health Centre (PHC) , , ,503, , ,624 14,140 21,916 3 Primary Health Centre (PHC) , , ,723, , ,823 15,067 20,522 3 Primary Health Centre (PHC) , , ,937, , ,855 58,100 63,500 3 Primary Health Centre (PHC) , ,186, , ,904 42,594 40,648 3 Primary Health Centre (PHC) , ,294,212 22, ,098 10,823 51,500 3 Primary Health Centre (PHC) , , ,335,660 21, ,282 11,610 54,590 3 Primary Health Centre (PHC) , , ,406,824 20, ,053 12,080 54,000 3 Primary Health Centre (PHC) , , ,498,176 37, ,201 13,300 59,000 3 Primary Health Centre (PHC) , , ,538,352 30, ,200 13,600 63,750 4 District Hospital (DH) ,233 21,010 2,442 3,415 6,492, ,133 5,017,705 72, ,018 4 District Hospital (DH) ,816 25,356 1,659 4,404 6,716,595 7,273,183 6,102,681 75, ,866 4 District Hospital (DH) ,029 26,752 1,880 5,078 6,904,794 2,772,765 6,004,617 80, ,358 4 District Hospital (DH) ,774 27,775 1,704 4,818 7,104, ,593 6,304,433 82, ,850 4 District Hospital (DH) ,917 27,395 1,910 5,140 7,261, ,846 7,304,904 83, ,819 4 Sub-district Hospital (SDH) ,807 5, ,376, , ,229 5,994 21,143 4 Sub-district Hospital (SDH) ,735 8, ,514, , ,593 11,033 3,795 4 Sub-district Hospital (SDH) ,944 9, ,884, , ,440 16,167 55,706 4 Sub-district Hospital (SDH) ,801 8, ,606, , ,626 20,201 72,045 4 Sub-district Hospital (SDH) ,373 2,515 31, ,910, , ,465 30,505 34,700 4 Community Health Centre (CHC) , , ,236, , , ,879 63,300 4 Community Health Centre (CHC) , , ,424, , ,401 1,364, ,600 4 Community Health Centre (CHC) ,687 1,796 8, ,617, , ,738 1,781, ,175 4 Community Health Centre (CHC) ,536 1,566 8, ,852, , ,027 1,288, ,702 4 Community Health Centre (CHC) ,307 1, ,057, , ,527 1,639, ,350 4 Primary Health Centre (PHC) , ,277, , ,644 12,423 7,

31 FACILITY INFORMATION STAFF AND BEDS OUTPUTS EXPENDITURE District Platform Year Beds Doctors Nurses Paramedical Nonmedical Outpatient Inpatient Vaccinations Births Personnel Infrastructure + utilities Medical supplies + pharmaceuticals Administration and training Non-medical 4 Primary Health Centre (PHC) ,046 1,282 2, ,378, , ,408 16,768 18,935 4 Primary Health Centre (PHC) ,688 1,307 3, ,482, , ,625 18,921 47,550 4 Primary Health Centre (PHC) ,362 1,430 3, ,590, , ,142 21,128 59,233 4 Primary Health Centre (PHC) ,027 2,205 5, ,696, , ,929 37,696 65,188 4 Primary Health Centre (PHC) , , ,123, ,504 97, ,635 4 Primary Health Centre (PHC) , , ,219, , ,566 2,810 43,500 4 Primary Health Centre (PHC) , , ,319, ,279 98,115 5, ,861 4 Primary Health Centre (PHC) , , ,422, , ,601 8, ,441 4 Primary Health Centre (PHC) , ,528, , ,941 5, ,964 4 Sub-district Hospital (SDH) ,274 2, ,649, , ,254 67,790 39,365 4 Sub-district Hospital (SDH) ,766 2, ,868, , ,883 87,540 40,000 4 Sub-district Hospital (SDH) ,055 4, ,099, , , ,605 51,990 4 Sub-district Hospital (SDH) ,442 6, ,343, , , ,014 53,700 4 Sub-district Hospital (SDH) ,945 5, ,601, , , ,552 74,900 4 Community Health Centre (CHC) ,882 1,707 3, ,022, , , ,788 21,765 4 Community Health Centre (CHC) ,529 1,720 1, ,447, , , ,750 25,885 4 Community Health Centre (CHC) ,268 1,807 2, ,896, , , ,085 42,535 4 Community Health Centre (CHC) ,984 2,275 3, ,370, , , ,559 64,765 4 Community Health Centre (CHC) ,063 2,359 3, ,872, , , ,372 50,475 4 Primary Health Centre (PHC) , , ,370, ,426 89,086 7,118 4,299 4 Primary Health Centre (PHC) , , ,624, , ,085 52,335 8,660 4 Primary Health Centre (PHC) , , ,896, , , ,939 14,800 4 Primary Health Centre (PHC) , , ,190, , ,552 84,662 13,990 4 Primary Health Centre (PHC) ,948 1,314 4, ,505, , , ,679 16,780 4 Primary Health Centre (PHC) , , ,258, , ,940 24,925 9,582 4 Primary Health Centre (PHC) ,335 1,143 5, ,358, , ,185 52,474 17,950 4 Primary Health Centre (PHC) ,309 1,709 4, ,462, , , ,256 24,173 4 Primary Health Centre (PHC) ,005 1,237 3, ,569, , , ,380 17,860 4 Primary Health Centre (PHC) ,670 1,158 5, ,680, , , ,558 21,825 5 District Hospital (DH) , , ,820 49,698,636 14,896,651 6,618, ,793 1,966,184 5 District Hospital (DH) , ,596 5,779 2,475 62,641,228 15,518,619 6,717, ,785 1,479,248 5 District Hospital (DH) ,000,795 59, ,489 64,578,588 15,035,472 7,020, ,323 2,067,487 5 District Hospital (DH) ,992 42, ,763 69,529,840 15,872,825 6,622, ,281 9,644,161 5 District Hospital (DH) ,991 46,596 6,604 3,459 80,164,960 15,754,151 8,422, ,699 11,272,708 5 Sub-district Hospital (SDH) ,310 20,582 10,881 3,497 30,945,390 4,901,502 2,806,004 76,442 1,527,236 5 Sub-district Hospital (SDH) ,871 20,332 18,100 2,753 31,952,816 4,885,070 3,196,062 58,484 1,755,292 5 Sub-district Hospital (SDH) ,736 20,883 20,178 2,853 32,965,540 4,992,678 3,566,082 53,835 2,570,014 5 Sub-district Hospital (SDH) ,231 25,026 19,772 2,783 39,975,752 5,158,520 3,648, ,351 4,110,386 5 Sub-district Hospital (SDH) ,750 26,415 15,936 3,799 40,753,028 5,195,006 4,244,187 81,582 4,195,

32 FACILITY INFORMATION STAFF AND BEDS OUTPUTS EXPENDITURE District Platform Year Beds Doctors Nurses Paramedical Nonmedical Outpatient Inpatient Vaccinations Births Personnel Infrastructure + utilities Medical supplies + pharmaceuticals Administration and training Non-medical 5 Community Health Centre (CHC) , ,431,071 39, , Community Health Centre (CHC) , ,657,847 39, , Community Health Centre (CHC) ,978 1, ,925,512 39, , Community Health Centre (CHC) , ,168,281 39, , Community Health Centre (CHC) , ,460,372 39, , Primary Health Centre (PHC) , , ,996,702 61,356 86,330 8, ,320 5 Primary Health Centre (PHC) , , ,089,384 63, ,388 8, ,530 5 Primary Health Centre (PHC) , , ,184,932 81, ,799 8, ,040 5 Primary Health Centre (PHC) , , ,282,835 71, ,995 9, ,190 5 Primary Health Centre (PHC) , , ,384,986 74, ,423 10, ,780 5 Primary Health Centre (PHC) , , ,488, , ,998 23, ,220 5 Primary Health Centre (PHC) , , ,792, , ,994 23, ,460 5 Primary Health Centre (PHC) , , ,002, , ,997 25, ,360 5 Primary Health Centre (PHC) , , ,218, , ,997 26, ,570 5 Primary Health Centre (PHC) , , ,442, , ,685 28, ,970 5 Sub-district Hospital (SDH) ,495 2, ,584, , ,354 3,457 2,000 5 Sub-district Hospital (SDH) ,880 2, ,765, , ,770 4,144 1,883 5 Sub-district Hospital (SDH) ,714 3, ,192, , ,306 3,850 3,908 5 Sub-district Hospital (SDH) ,816 4, ,718, , ,553 3,885 9,392 5 Sub-district Hospital (SDH) ,555 4, ,854, , ,357 3,509 18,673 5 Community Health Centre (CHC) , , ,990, , ,965 18,495 9,500 5 Community Health Centre (CHC) , , ,534, , ,003 27,164 13,449 5 Community Health Centre (CHC) , , ,815, , ,572 18,929 20,660 5 Community Health Centre (CHC) , , ,686, , ,650 22,882 30,230 5 Community Health Centre (CHC) , , ,401, , ,856 25,076 48,600 5 Primary Health Centre (PHC) , , ,250,140 84, ,173 23,000 9,000 5 Primary Health Centre (PHC) , , ,381,587 87, ,366 55,500 9,500 5 Primary Health Centre (PHC) , , ,517,100 82, ,567 59,300 9,500 5 Primary Health Centre (PHC) , , ,656,804 82, ,128 52,215 15,341 5 Primary Health Centre (PHC) , , ,800, , ,905 61,269 12,049 5 Primary Health Centre (PHC) , , ,466,470 80,782 80,000 40,753 80,250 5 Primary Health Centre (PHC) , , ,542,753 59,378 99,997 38,205 82,250 5 Primary Health Centre (PHC) , , ,621,395 54,351 94,996 40,455 96,012 5 Primary Health Centre (PHC) , , ,702,470 55, ,996 30,499 82,100 5 Primary Health Centre (PHC) , , ,786,052 51, ,018 29,643 80,975 6 District Hospital (DH) ,699 90,483 7,261 3,388 51,823, ,155 6,508,595 21,507 3,015,500 6 District Hospital (DH) , ,313 5,730 3,147 53,530, ,633 6,950,630 59,583 3,000,000 6 District Hospital (DH) ,622 98,209 6,454 2,890 57,982, ,401 7,193, ,018 3,021,000 6 District Hospital (DH) ,706 91,362 6,055 2,810 60,245, ,432 7,216, ,327 3,038,

33 FACILITY INFORMATION STAFF AND BEDS OUTPUTS EXPENDITURE District Platform Year Beds Doctors Nurses Paramedical Nonmedical Outpatient Inpatient Vaccinations Births Personnel Infrastructure + utilities Medical supplies + pharmaceuticals Administration and training Non-medical 6 District Hospital (DH) ,562 85,330 5,192 3,580 62,108, ,178 7,515, ,887 3,000,000 6 Sub-district Hospital (SDH) ,595 8,245 16, ,895,646 2,348, ,482 11, ,236 6 Sub-district Hospital (SDH) ,365 8,467 34, ,846,696 1,147, ,443 1, ,584 6 Sub-district Hospital (SDH) ,891 14,669 48, ,547,145 1,168, ,772 6, ,667 6 Sub-district Hospital (SDH) ,559 13,091 67, ,915,536 1,325, , , ,705 6 Sub-district Hospital (SDH) ,903 19,370 63, ,587,300 1,390, , , ,453 6 Community Health Centre (CHC) , , ,010, , ,207 15, ,599 6 Community Health Centre (CHC) , , ,907, , ,915 18,117 1,342,240 6 Community Health Centre (CHC) , , ,362, , ,920 22, ,975 6 Community Health Centre (CHC) , , ,834, , ,524 23, ,781 6 Community Health Centre (CHC) , , ,497,524 1,118, ,851 26, ,277 6 Primary Health Centre (PHC) , , ,359, ,392 99,243 5,684 6,238 6 Primary Health Centre (PHC) , , ,792, , ,214 10,911 15,369 6 Primary Health Centre (PHC) , , ,326, , ,246 12,108 13,731 6 Primary Health Centre (PHC) , , ,358, , ,203 10,324 14,670 6 Primary Health Centre (PHC) , , ,639, , ,058 13,086 18,835 6 Primary Health Centre (PHC) , , ,133, ,263 97,310 2,395 1,000 6 Primary Health Centre (PHC) , , ,271, , ,240 6,320 6,810 6 Primary Health Centre (PHC) , , ,412, , ,890 7,058 7,017 6 Primary Health Centre (PHC) , , ,581, , ,171 9,831 9,545 6 Primary Health Centre (PHC) , , ,718, , ,225 17,050 9,830 6 Sub-district Hospital (SDH) ,368 1,944 1, ,413, , ,381 4,399 19,848 6 Sub-district Hospital (SDH) ,510 1,925 2, ,702, , ,894 4,373 17,717 6 Sub-district Hospital (SDH) ,117 2,093 2, ,147, , ,485 4,173 16,584 6 Sub-district Hospital (SDH) ,773 2,459 3, ,874, , ,354 5,678 19,978 6 Sub-district Hospital (SDH) ,566 2,384 3, ,323, ,649 1,050,608 5,432 22,765 6 Community Health Centre (CHC) , , ,743, , ,593 6, Community Health Centre (CHC) ,977 1,146 9, ,836, , ,041 12,068 1,098 6 Community Health Centre (CHC) ,436 1,228 7, ,594, , ,655 14,430 46,310 6 Community Health Centre (CHC) ,638 1,206 5, ,004, , ,611 32,769 30,631 6 Community Health Centre (CHC) ,533 1,469 6, ,849, , ,586 51,252 86,207 6 Primary Health Centre (PHC) , , ,123,905 56, ,441 3,478 32,540 6 Primary Health Centre (PHC) , , ,634,850 57, ,798 3,563 34,560 6 Primary Health Centre (PHC) , , ,856,700 56, ,396 3,603 49,270 6 Primary Health Centre (PHC) , , ,560,447 56, ,024 3,311 53,310 6 Primary Health Centre (PHC) , , ,011,006 56, ,107 3,302 53,760 6 Primary Health Centre (PHC) , , ,513, ,486 88,853 4,955 23,992 6 Primary Health Centre (PHC) , , ,163, , ,909 15,969 76,914 6 Primary Health Centre (PHC) , , ,510, , , ,915 50,

34 FACILITY INFORMATION STAFF AND BEDS OUTPUTS EXPENDITURE District Platform Year Beds Doctors Nurses Paramedical Nonmedical Outpatient Inpatient Vaccinations Births Personnel Infrastructure + utilities Medical supplies + pharmaceuticals Administration and training Non-medical 6 Primary Health Centre (PHC) , , ,865, , ,848 96,880 29,110 6 Primary Health Centre (PHC) , , ,162, , ,630 51,240 99,830 7 District Hospital (DH) ,938 9,729 2, , ,500 4,652,155 20,687 91,229 7 District Hospital (DH) ,448 16,848 4,449 1, , ,714 5,010,731 13, ,034 7 District Hospital (DH) ,623 16,975 5,721 2,234 1,336, ,165 5,314,590 17, ,000 7 District Hospital (DH) ,278 19,008 4,841 1,815 2,079, ,132 4,813,948 28, ,100 7 District Hospital (DH) ,928 21,863 5,759 1,888 3,432, ,957 5,516,403 8, ,000 7 Sub-district Hospital (SDH) ,572 1,580 69, ,841, ,411 1,148,941 30,010 12,342 7 Sub-district Hospital (SDH) ,081 1,836 47, ,661,068 91,103 1,177,492 39,268 56,073 7 Sub-district Hospital (SDH) ,985 2,545 73, ,292,152 96,570 1,304,166 22,179 25,300 7 Sub-district Hospital (SDH) ,977 2,175 86, ,073,768 92,054 1,148,244 4,455 51,400 7 Sub-district Hospital (SDH) ,372 2,611 87, ,677, ,384 1,201,593 21,075 30,900 7 Community Health Centre (CHC) , , ,689, , ,110 19,198 3,225 7 Community Health Centre (CHC) , , ,963, , ,464 15,181 2,705 7 Community Health Centre (CHC) , , ,368, , ,052 11,695 14,638 7 Community Health Centre (CHC) , , ,849, , ,324 9,298 51,940 7 Community Health Centre (CHC) , ,605, , ,259 15,052 90,922 7 Primary Health Centre (PHC) , , ,503,836 60,468 89,114 14,875 12,000 7 Primary Health Centre (PHC) , , ,968,884 61, ,688 24,082 13,495 7 Primary Health Centre (PHC) , , ,161,976 74, ,250 23,075 46,100 7 Primary Health Centre (PHC) , , ,408,492 64, ,034 70,535 86,870 7 Primary Health Centre (PHC) , , ,648,588 73, ,155 6, ,695 7 Primary Health Centre (PHC) , , ,403,408 95,277 91,320 25, ,284 7 Primary Health Centre (PHC) , , ,557,632 96, ,027 1, ,555 7 Primary Health Centre (PHC) , ,720, , ,604 2, ,790 7 Primary Health Centre (PHC) , , ,891, , ,225 23, ,276 7 Primary Health Centre (PHC) , , ,073, , ,841 7, ,610 7 Sub-district Hospital (SDH) ,330 4,637 77, ,506, , ,931 9,500 15,000 7 Sub-district Hospital (SDH) ,797 3,954 88, ,047, , ,825 8,450 18,500 7 Sub-district Hospital (SDH) ,290 4,808 94, ,606,168 1,095, ,452 15, ,839 7 Sub-district Hospital (SDH) ,576 5, , ,181,616 1,011, ,703 26, ,452 7 Sub-district Hospital (SDH) ,523 4,064 2, ,774,860 1,101, ,278 38, ,655 7 Community Health Centre (CHC) , , ,397, ,324 85, ,935 6,094,000 7 Community Health Centre (CHC) , , ,584, , , ,403 11,015,215 7 Community Health Centre (CHC) , , ,951, , , ,760 12,404,148 7 Community Health Centre (CHC) , , ,150, , , ,610 12,608,300 7 Community Health Centre (CHC) , , ,436, , , ,512 29,618,150 7 Primary Health Centre (PHC) , , ,777,735 52,744 93, ,563 7 Primary Health Centre (PHC) , , ,800,851 52, ,022 3,986 2,

35 FACILITY INFORMATION STAFF AND BEDS OUTPUTS EXPENDITURE District Platform Year Beds Doctors Nurses Paramedical Nonmedical Outpatient Inpatient Vaccinations Births Personnel Infrastructure + utilities Medical supplies + pharmaceuticals Administration and training Non-medical 7 Primary Health Centre (PHC) , , ,934,983 54, ,812 6,104 21,812 7 Primary Health Centre (PHC) , , ,076,839 55, ,939 15,604 13,300 7 Primary Health Centre (PHC) , , ,226,928 59, ,645 9,244 28,390 7 Primary Health Centre (PHC) , , ,881, ,220 79,998 1,398 2,085 7 Primary Health Centre (PHC) , , ,032, , , ,430 7 Primary Health Centre (PHC) , , ,187, , ,117 8,008 49,750 7 Primary Health Centre (PHC) , , ,348, , ,170 49,932 83,689 7 Primary Health Centre (PHC) , , ,513, , ,065 8, ,715 8 District Hospital (DH) ,385 52,140 4,295 2,798 53,036, ,612 3,320,000 5,718 1,967,580 8 District Hospital (DH) ,803 87,151 3,632 4,206 54,666, ,375 3,350,000 13,007 2,006,475 8 District Hospital (DH) ,534 67,972 2,323 3,957 56,420, ,985 3,646, ,985 2,100,000 8 District Hospital (DH) ,234 85,203 3,358 3,567 57,951, ,647 5,343,169 27,204 2,200,000 8 District Hospital (DH) ,006, ,687 12,107 4,067 60,056, ,130 4,643,214 45,961 2,500,000 8 Sub-district Hospital (SDH) ,179 64,999 3,813 1,636 11,935, ,053 3,331,378 19,850 68,500 8 Sub-district Hospital (SDH) ,745 60,989 5,869 1,485 12,675, ,906 3,224,643 26, ,182 8 Sub-district Hospital (SDH) ,942 64,316 6,480 1,611 12,474, ,804 3,633,012 10, ,150 8 Sub-district Hospital (SDH) ,071 56,249 6,990 1,796 13,982, ,975 3,687,492 33,510 87,698 8 Sub-district Hospital (SDH) ,804 76,849 7,740 2,099 17,624, ,660 4,146,686 39, ,827 8 Community Health Centre (CHC) , , ,877, , ,640 40,602 18,778 8 Community Health Centre (CHC) , , ,058, , ,755 46,501 35,549 8 Community Health Centre (CHC) , , ,526, , ,601 54,561 25,000 8 Community Health Centre (CHC) , , ,562, , ,788 75,000 38,000 8 Community Health Centre (CHC) , , ,589, , ,900 90,941 36,175 8 Primary Health Centre (PHC) , , ,383 24, ,061 5,700 8,000 8 Primary Health Centre (PHC) , , ,193 28, ,066 10,400 22,520 8 Primary Health Centre (PHC) , , ,383 31, ,251 9,170 12,092 8 Primary Health Centre (PHC) , , ,222 37, ,354 10,450 41,532 8 Primary Health Centre (PHC) , , ,222 40, ,216 11,850 48,566 8 Primary Health Centre (PHC) , , ,536,495 47, ,672 56,641 25,064 8 Primary Health Centre (PHC) , , ,877,952 51, ,604 58,184 36,962 8 Primary Health Centre (PHC) , , ,184,336 59, ,545 63,048 27,200 8 Primary Health Centre (PHC) , , ,344,668 44, ,944 45, ,000 8 Primary Health Centre (PHC) , , ,509,956 41, ,125 61,408 45,168 8 Sub-district Hospital (SDH) ,615 1,130 34, ,892,026 1,256, ,046 48,512 20,068 8 Sub-district Hospital (SDH) ,097 20,070 47, ,564,976 1,238, ,464 74,934 34,694 8 Sub-district Hospital (SDH) ,722 36,975 76, ,302,964 1,226, ,970 37,976 65,597 8 Sub-district Hospital (SDH) , ,702 70, ,112,841 1,231, ,744 13,400 82,500 8 Sub-district Hospital (SDH) , ,888 31, ,002,412 1,225, ,565 57,698 32,000 8 Community Health Centre (CHC) , , ,311, , ,209 41,

36 FACILITY INFORMATION STAFF AND BEDS OUTPUTS EXPENDITURE District Platform Year Beds Doctors Nurses Paramedical Nonmedical Outpatient Inpatient Vaccinations Births Personnel Infrastructure + utilities Medical supplies + pharmaceuticals Administration and training Non-medical 8 Community Health Centre (CHC) , , ,518, , ,934 26, ,940 8 Community Health Centre (CHC) , , ,657, , ,310 13, ,015 8 Community Health Centre (CHC) , , ,770, , ,039 20, ,385 8 Community Health Centre (CHC) , , ,467, , ,892 26, ,100 8 Primary Health Centre (PHC) , , ,893,400 60, ,480 22, Primary Health Centre (PHC) , , ,983,505 53, ,102 7,759 10,890 8 Primary Health Centre (PHC) , , ,190,068 86, ,978 8,130 25,520 8 Primary Health Centre (PHC) , , ,241,114 56, ,628 17,751 49,734 8 Primary Health Centre (PHC) , , ,357,380 66, , ,811 55,287 8 Primary Health Centre (PHC) , , ,749, , ,225 20,505 2,160 8 Primary Health Centre (PHC) , , ,053, , ,870 34,342 4,000 8 Primary Health Centre (PHC) , , ,385, , ,003 2,615 45,945 8 Primary Health Centre (PHC) , , ,762, , ,319 12,610 79,635 8 Primary Health Centre (PHC) , , ,148, , ,631 13,650 88,195 9 District Hospital (DH) ,457 15,829 96,323 1,269 23,016,396 2,877,024 4,751, , ,660 9 District Hospital (DH) ,296 20,101 98,130 1,366 24,528,264 3,358,535 4,577, , ,096 9 District Hospital (DH) ,102 20, ,539 1,526 26,253,102 3,584,667 5,600, , ,158 9 District Hospital (DH) ,351 25, ,691 1,514 27,769,368 3,857,062 5,131, , ,189 9 District Hospital (DH) ,213 24, ,310 1,377 29,488,240 4,096,313 5,365, , ,177 9 Sub-district Hospital (SDH) , ,972, , ,926 9,346 9,285 9 Sub-district Hospital (SDH) , ,033, , ,409 21,664 9,411 9 Sub-district Hospital (SDH) ,219 1, ,096, , ,624 11,388 10,405 9 Sub-district Hospital (SDH) ,223 1, ,160, ,274 1,000,198 32,045 15,977 9 Sub-district Hospital (SDH) ,185 1, ,888, , ,199 38,655 17,900 9 Community Health Centre (CHC) , , ,403,877 1,859, ,881 38,328 3,121,667 9 Community Health Centre (CHC) , , ,676,576 1,818, ,477 69,246 3,842,567 9 Community Health Centre (CHC) , , ,150,418 2,034, ,276 71,071 5,965,134 9 Community Health Centre (CHC) , , ,484,374 1,981, ,161 50,645 6,480,620 9 Community Health Centre (CHC) , , ,407,936 1,879, ,182 60,795 9,427,994 9 Primary Health Centre (PHC) , , ,449, , ,533 1,072 7,217 9 Primary Health Centre (PHC) , , ,646, , ,998 20,932 16,836 9 Primary Health Centre (PHC) , , ,854, , ,005 25,347 14,423 9 Primary Health Centre (PHC) , , ,110, , ,973 25,262 11,210 9 Primary Health Centre (PHC) , , ,343, , ,409 97,394 10,050 9 Primary Health Centre (PHC) , , ,120, ,693 95,583 6,440 6,799 9 Primary Health Centre (PHC) , , ,186, , ,171 12,200 9,395 9 Primary Health Centre (PHC) , , ,254, , ,049 49,152 17,580 9 Primary Health Centre (PHC) , , ,323, , ,321 39,825 9,710 9 Primary Health Centre (PHC) , , ,395, , ,832 35,002 6,

37 FACILITY INFORMATION STAFF AND BEDS OUTPUTS EXPENDITURE District Platform Year Beds Doctors Nurses Paramedical Nonmedical Outpatient Inpatient Vaccinations Births Personnel Infrastructure + utilities Medical supplies + pharmaceuticals Administration and training Non-medical 9 Sub-district Hospital (SDH) , , ,522, , ,725 43, ,088 9 Sub-district Hospital (SDH) , , ,041, , ,565 14, ,971 9 Sub-district Hospital (SDH) , , ,538, , ,995 26, ,484 9 Sub-district Hospital (SDH) , , ,142, , ,478 21,450 53,100 9 Sub-district Hospital (SDH) , , ,744, , ,180 15, ,805 9 Community Health Centre (CHC) , , ,784, , ,485 79,150 2,984,600 9 Community Health Centre (CHC) , , ,231, , ,688 44,190 5,272,219 9 Community Health Centre (CHC) , , ,723, , , ,300 7,128,740 9 Community Health Centre (CHC) , , ,261, , , ,423 7,016,137 9 Community Health Centre (CHC) ,287 1,191 13, ,689, , , ,392 7,664,983 9 Primary Health Centre (PHC) , , ,616,485 60, ,930 8,132 1,029 9 Primary Health Centre (PHC) , , ,178,901 56, ,424 29,020 2,113 9 Primary Health Centre (PHC) , , ,490,754 54, ,495 46,500 3,206 9 Primary Health Centre (PHC) , , ,819,293 60, ,866 92,444 6,557 9 Primary Health Centre (PHC) , , ,165,572 59, , ,773 9,670 9 Primary Health Centre (PHC) , , ,678, , ,966 11,733 12,300 9 Primary Health Centre (PHC) , , ,774, , ,191 14,422 16,835 9 Primary Health Centre (PHC) , , ,857, , ,360 17,846 17,690 9 Primary Health Centre (PHC) , , ,961, , ,929 27,790 19,690 9 Primary Health Centre (PHC) , , ,070, , ,081 38,330 33,990 9 Sub Health Centre (SHC) , ,564 18,171 4,059 7,480 2, District Hospital (DH) ,760 47,626 35,751 12, ,795,504 6,406,656 5,445, ,700 1,796, District Hospital (DH) ,069 49,836 36,576 13, ,067,536 5,618,585 7,200, ,773 1,488, District Hospital (DH) ,337 50,225 38,248 12, ,440,760 6,761,593 6,900, ,708 1,714, District Hospital (DH) ,195 44,841 38,724 10, ,918,312 6,822,771 6,800, ,254 2,446, District Hospital (DH) ,760 45,870 40,197 14, ,503,416 6,318,203 7,045, ,411 1,290, Sub-district Hospital (SDH) ,716 11,282 5,545 2,403 38,793,280 1,307,828 2,558,484 41, , Sub-district Hospital (SDH) ,915 10,047 4,863 1,800 39,993,072 1,332,253 3,338,163 46, , Sub-district Hospital (SDH) ,008 10,998 5,432 1,680 41,229,972 1,376,831 2,922, , , Sub-district Hospital (SDH) ,376 12,591 3,566 1,691 42,505,124 1,436,038 2,898, , , Sub-district Hospital (SDH) ,830 12,313 6,299 1,722 43,819,716 1,355,756 3,149, , , Community Health Centre (CHC) , ,038, , ,538 24, , Community Health Centre (CHC) , , ,809, , ,976 24, , Community Health Centre (CHC) , , ,151, , ,538 25, , Community Health Centre (CHC) ,786 1, ,391, , ,464 25, , Community Health Centre (CHC) ,239 1,282 1, ,609, , ,750 26, , Primary Health Centre (PHC) , , ,220, , ,595 6,312 9, Primary Health Centre (PHC) , , ,392, , ,030 4,647 3, Primary Health Centre (PHC) , , ,640, , ,439 3,540 45,

38 FACILITY INFORMATION STAFF AND BEDS OUTPUTS EXPENDITURE District Platform Year Beds Doctors Nurses Paramedical Nonmedical Outpatient Inpatient Vaccinations Births Personnel Infrastructure + utilities Medical supplies + pharmaceuticals Administration and training Non-medical 10 Primary Health Centre (PHC) , , ,860, , ,518 5,509 47, Primary Health Centre (PHC) , , ,140, , ,738 4,350 30, Primary Health Centre (PHC) , , ,045,782 83, ,354 14,842 1, Primary Health Centre (PHC) , , ,139,983 83, ,397 11,484 12, Primary Health Centre (PHC) , , ,237,095 84, ,199 72,179 14, Primary Health Centre (PHC) , , ,337,211 82, ,715 97,950 12, Primary Health Centre (PHC) , , ,440,424 90, ,792 84, Sub-district Hospital (SDH) ,649 2, ,144, , ,398 10,271 63, Sub-district Hospital (SDH) ,666 2, ,303, , ,657 12,265 69, Sub-district Hospital (SDH) ,465 4, ,449, , ,694 12,900 69, Sub-district Hospital (SDH) ,229 4, ,627, , ,650 13,235 71, Sub-district Hospital (SDH) ,516 4, ,784, , ,468 14,320 74, Community Health Centre (CHC) , , ,088, , , ,582 38, Community Health Centre (CHC) , , ,373, , , ,720 38, Community Health Centre (CHC) , , ,702, , , ,440 91, Community Health Centre (CHC) ,660 1,238 4, ,017, , , , , Community Health Centre (CHC) ,375 1,047 4, ,947, , , , , Primary Health Centre (PHC) , ,393,931 46, ,000 12,800 1, Primary Health Centre (PHC) , ,614,139 48, ,999 15,000 8, Primary Health Centre (PHC) , ,845,388 49, ,998 17,800 10, Primary Health Centre (PHC) , ,872,390 52, ,004 22,500 9, Primary Health Centre (PHC) , ,325,912 53, ,496 41,500 44, Primary Health Centre (PHC) , , ,727, , ,511 2,841 55, Primary Health Centre (PHC) , , ,910, , ,823 1,504 49, Primary Health Centre (PHC) , , ,110, , ,929 1,429 44, Primary Health Centre (PHC) , , ,392, , ,830 1,925 80, Primary Health Centre (PHC) , , ,701, , ,955 4,075 57, District Hospital (DH) , ,315 12,195 4,796 70,336,368 8,104,355 8,233,413 26,230 1,734, District Hospital (DH) , ,893 7,010 4,289 72,484,712 8,300,838 10,117,705 26,383 1,795, District Hospital (DH) , ,668 6,551 4,068 74,754,344 8,540,757 10,220,730 27,078 2,115, District Hospital (DH) , ,382 6,893 3,769 77,066,336 8,958,439 11,121,673 27,561 1,623, District Hospital (DH) , ,729 7,252 5,192 79,449,840 9,072,930 12,103,611 28,560 1,721, Sub-district Hospital (SDH) ,806 1, ,627, , ,346 17,534 6, Sub-district Hospital (SDH) ,454 2, ,801, , ,444 7,082 14, Sub-district Hospital (SDH) ,523 2, ,980, , ,595 22,360 13, Sub-district Hospital (SDH) ,329 2, ,165, , ,730 39,474 26, Sub-district Hospital (SDH) ,387 3, ,356, , ,112 57,025 23, Community Health Centre (CHC) , , ,141, , ,531 10,116 9,872, Community Health Centre (CHC) , , ,333, , ,454 11,054 10,905,

39 FACILITY INFORMATION STAFF AND BEDS OUTPUTS EXPENDITURE District Platform Year Beds Doctors Nurses Paramedical Nonmedical Outpatient Inpatient Vaccinations Births Personnel Infrastructure + utilities Medical supplies + pharmaceuticals Administration and training Non-medical 11 Community Health Centre (CHC) , , ,549, , ,134 18,980 12,285, Community Health Centre (CHC) , , ,001, , ,558 21,061 13,586, Community Health Centre (CHC) , , ,170, , ,473 30,743 14,000, Primary Health Centre (PHC) , , ,015, , ,252 3,050 5, Primary Health Centre (PHC) , , ,115, , ,339 4,159 18, Primary Health Centre (PHC) , , ,205, , ,931 10,650 16, Primary Health Centre (PHC) , , ,305, , ,803 15,667 33, Primary Health Centre (PHC) , , ,416, , ,222 27,040 32, Primary Health Centre (PHC) , , ,706, ,663 98,484 8,143 5, Primary Health Centre (PHC) , , ,828, , ,998 5,268 14, Primary Health Centre (PHC) , , ,939, , , ,022 33, Primary Health Centre (PHC) , , ,062, , , ,913 39, Primary Health Centre (PHC) , , ,197, , , ,682 36, Sub-district Hospital (SDH) ,114 11,898 2, ,182, ,981 1,383,039 2,781 4, Sub-district Hospital (SDH) ,059 5, ,652,524 99,781 1,265,706 11,356 1, Sub-district Hospital (SDH) ,091 6, ,136,627 99,601 1,631,203 25,717 57, Sub-district Hospital (SDH) ,256 7, ,635, ,909 1,649,965 27,153 98, Sub-district Hospital (SDH) ,889 6, ,150, ,587 1,566,779 10,587 95, Community Health Centre (CHC) , , ,859, , ,651 4,446 3, Community Health Centre (CHC) , , ,220, , ,496 1,615 1, Community Health Centre (CHC) , , ,600, , ,161 14,107 68, Community Health Centre (CHC) , , ,000, , ,330 20,754 66, Community Health Centre (CHC) , , ,421, , ,224 22,297 23, Primary Health Centre (PHC) , , ,663, ,607 99,597 6,380 11, Primary Health Centre (PHC) , , ,822, , ,999 10,271 44, Primary Health Centre (PHC) , , ,984, , ,752 15,293 45, Primary Health Centre (PHC) , , ,092, , ,534 6, , Primary Health Centre (PHC) , , ,257, , ,705 18, , Primary Health Centre (PHC) , , ,478, , ,127 3,582 6, Primary Health Centre (PHC) , , ,640, , ,894 2,280 6, Primary Health Centre (PHC) , , ,783, , ,737 4,755 58, Primary Health Centre (PHC) , , ,931, , ,697 3, , Primary Health Centre (PHC) , , ,680, , ,765 4,152 74, District Hospital (DH) ,652 21,597 11,615 2,789 38,748,084 14,973,706 6,623,814 52, , District Hospital (DH) ,251 17,055 12,878 3,761 39,953,660 15,026,028 10,700,127 59, , District Hospital (DH) ,236 21,212 16,003 2,999 41,189,348 15,324,242 8,100,027 73, , District Hospital (DH) ,820 24,007 14,684 2,428 42,463,248 15,220,878 9,085, ,945 1,215, District Hospital (DH) ,508 26,942 14,046 2,702 43,776,548 15,630,219 7,240, ,168 1,508, Sub-district Hospital (SDH) ,244 9,992 2, ,799, ,309 2,301, , ,

40 FACILITY INFORMATION STAFF AND BEDS OUTPUTS EXPENDITURE District Platform Year Beds Doctors Nurses Paramedical Nonmedical Outpatient Inpatient Vaccinations Births Personnel Infrastructure + utilities Medical supplies + pharmaceuticals Administration and training Non-medical 12 Sub-district Hospital (SDH) ,117 10,685 3, ,442, ,195 2,547,439 46, , Sub-district Hospital (SDH) ,902 11,628 3, ,105, ,636 2,636, , , Sub-district Hospital (SDH) ,234 12,799 3, ,789, ,976 2,917, , , Sub-district Hospital (SDH) ,086 7,083 3, ,494, ,351 2,708, , , Community Health Centre (CHC) , ,125, , ,000 1,695,561 5,881, Community Health Centre (CHC) , ,401, , ,999 2,693,294 3,022, Community Health Centre (CHC) , , ,686, , ,390 4,519,609 4,793, Community Health Centre (CHC) ,261 1,081 6, ,979, , ,538 4,322,606 6,041, Community Health Centre (CHC) ,202 1,807 7, ,279, , ,232 3,374,426 8,680, Primary Health Centre (PHC) , ,872, , , , , Primary Health Centre (PHC) , ,992, , , , , Primary Health Centre (PHC) , ,116, , , , , Primary Health Centre (PHC) , ,243, , , , , Primary Health Centre (PHC) , , ,374, , , , , Primary Health Centre (PHC) , , ,366, , ,103 2,578 93, Primary Health Centre (PHC) , , ,470, , ,995 3, , Primary Health Centre (PHC) , , ,577, , ,054 4, , Primary Health Centre (PHC) , , ,613, , ,652 5, , Primary Health Centre (PHC) , , ,721, , ,306 7, , Sub-district Hospital (SDH) ,052 8, , ,213,156 72,290 2,036, , , Sub-district Hospital (SDH) ,765 11, , ,207,092 77,352 3,283, , , Sub-district Hospital (SDH) ,285 14, , ,254,314 83,855 2,197, , , Sub-district Hospital (SDH) ,770 14, , ,354,132 87,010 3,066, , , Sub-district Hospital (SDH) ,249 10, , ,505,600 90,514 1,118, , , Community Health Centre (CHC) ,792 1,252 13, ,623, , ,397 3,120 30, Community Health Centre (CHC) ,628 1,219 2, ,849, , ,460 6, , Community Health Centre (CHC) ,673 1,056 2, ,030, , ,428 74, , Community Health Centre (CHC) , , ,216, , ,957 68, , Community Health Centre (CHC) , , ,408, , ,575 51, , Primary Health Centre (PHC) , , ,812, , ,845 34, , Primary Health Centre (PHC) , , ,882, , ,042 35, , Primary Health Centre (PHC) ,243 1,111 3, ,972, , ,525 35, , Primary Health Centre (PHC) ,182 1,185 2, ,077, , ,494 36, , Primary Health Centre (PHC) , , ,234, , ,747 36, , Primary Health Centre (PHC) , ,757, , ,997 13,748 6, Primary Health Centre (PHC) , , ,904, , ,595 12,979 7, Primary Health Centre (PHC) , , ,056, , ,799 72,250 10, Primary Health Centre (PHC) , , ,212, , ,207 90,173 13, Primary Health Centre (PHC) , , ,374, , ,991 95,635 22,

41 FACILITY INFORMATION STAFF AND BEDS OUTPUTS EXPENDITURE District Platform Year Beds Doctors Nurses Paramedical Nonmedical Outpatient Inpatient Vaccinations Births Personnel Infrastructure + utilities Medical supplies + pharmaceuticals Administration and training Non-medical 13 District Hospital (DH) ,134 29,011 8,041 2,187 7,931, ,803 4,960, , , District Hospital (DH) ,563 29,612 11,651 1,673 8,161, ,549 6,434, , , District Hospital (DH) ,873 31,708 10,532 1,840 8,330,600 1,007,115 6,232, , , District Hospital (DH) ,965 27,740 9,120 1,383 8,675,850 1,083,213 6,326, ,000 1,920, District Hospital (DH) ,100 28,313 10,883 1,462 8,794,750 1,120,963 7,531, ,000 1,792, Sub-district Hospital (SDH) ,052 1,941 1, ,852, , ,071 19,399 12, Sub-district Hospital (SDH) ,742 1,848 2, ,560,596 94, ,803 14,785 24, Sub-district Hospital (SDH) ,327 2,349 1, ,443, , ,236 20,741 32, Sub-district Hospital (SDH) ,452 1,787 1, ,607, , ,138 14,890 39, Sub-district Hospital (SDH) ,262 2,535 1, ,785,316 98, ,240 32,198 51, Community Health Centre (CHC) ,156 1,130 3, ,155, , ,332 1,421,231 83, Community Health Centre (CHC) ,016 1,543 4, ,531, , ,217 2,213, , Community Health Centre (CHC) ,390 1,333 3, ,919, , ,117 1,832, , Community Health Centre (CHC) ,391 1,824 3, ,318, , ,906 1,525, , Community Health Centre (CHC) ,104 1,806 3, ,730, , ,032 2,173, , Primary Health Centre (PHC) , , ,210, , ,476 7,164 21, Primary Health Centre (PHC) , , ,371, , ,039 4,208 17, Primary Health Centre (PHC) , , ,537, , ,687 14,099 19, Primary Health Centre (PHC) , , ,709, , ,561 47,068 10, Primary Health Centre (PHC) , , ,885, , ,319 35,968 14, Primary Health Centre (PHC) , , ,240 45, ,328 4,900 5, Primary Health Centre (PHC) , , ,680 46, ,515 7,000 6, Primary Health Centre (PHC) , , ,810 48, ,654 7,370 6, Primary Health Centre (PHC) , , ,080 49, ,468 8,000 7, Primary Health Centre (PHC) , , ,680 49, ,664 8,670 8, Sub-district Hospital (SDH) ,566 3,126 2, ,517,653 3,016, ,240 14,864 12, Sub-district Hospital (SDH) ,169 8,017 2, ,728,109 3,015, ,083 12,435 26, Sub-district Hospital (SDH) ,490 12,098 3, ,950,429 3,018, ,038 19,643 14, Sub-district Hospital (SDH) ,482 12,396 2, ,419,923 3,023, ,052 13,606 18, Sub-district Hospital (SDH) ,981 4,245 2, ,372,932 3,019, , , Community Health Centre (CHC) , , ,829, , ,863 11,214 52, Community Health Centre (CHC) , , ,285, , ,659 21,942 68, Community Health Centre (CHC) , , ,830, , ,858 21, , Community Health Centre (CHC) , , ,639, , ,500 22, , Community Health Centre (CHC) , , ,176, , ,733 31, , Primary Health Centre (PHC) , , ,581, , ,248 7,064 43, Primary Health Centre (PHC) , , ,791, , ,041 6,754 30, Primary Health Centre (PHC) , , ,024, , ,889 6, , Primary Health Centre (PHC) , , ,255, , ,901 9, ,

42 FACILITY INFORMATION STAFF AND BEDS OUTPUTS EXPENDITURE District Platform Year Beds Doctors Nurses Paramedical Nonmedical Outpatient Inpatient Vaccinations Births Personnel Infrastructure + utilities Medical supplies + pharmaceuticals Administration and training Non-medical 13 Primary Health Centre (PHC) , , ,497, , ,095 10, , Primary Health Centre (PHC) , , ,696, , ,968 12,013 23, Primary Health Centre (PHC) , , ,869, , ,106 9,464 11, Primary Health Centre (PHC) , , ,115, , ,421 7,397 82, Primary Health Centre (PHC) , , ,379, , ,019 19,257 78, Primary Health Centre (PHC) , , ,773, , ,752 19,987 48, District Hospital (DH) ,699 7,662 6, ,006, ,421 1,771,439 15,325 19, District Hospital (DH) ,310 10,194 7, ,884, ,726 2,004, , District Hospital (DH) ,753 14,784 7, ,206, ,341 2,972, , District Hospital (DH) ,332 12,994 7, ,527, ,376 3,129, , District Hospital (DH) ,333 14,113 8, ,886, ,447 3,290, , Sub-district Hospital (SDH) ,103 4,671 69, ,249, ,988 1,793,417 38, , Sub-district Hospital (SDH) ,251 3,633 1, ,721, ,890 1,371,186 32, , Sub-district Hospital (SDH) ,437 4,723 1, ,207, ,129 1,537, , , Sub-district Hospital (SDH) ,244 5,895 1, ,708, ,816 1,448, , , Sub-district Hospital (SDH) ,302 5,187 2, ,225, ,065 1,692, , , Community Health Centre (CHC) ,954 1,313 8, ,395, , ,040 6, , Community Health Centre (CHC) ,373 1,015 7, ,844, , ,825 6, , Community Health Centre (CHC) , , ,798, , ,134 10, , Community Health Centre (CHC) , , ,067, , ,564 16, , Community Health Centre (CHC) ,374 1,037 7, ,610, , ,809 16, , Primary Health Centre (PHC) , , ,564,907 98, ,482 3,997 3, Primary Health Centre (PHC) , , ,685,492 99, , , Primary Health Centre (PHC) , , ,809,436 97, ,622 2, , Primary Health Centre (PHC) , , ,936,852 99, ,539 18, , Primary Health Centre (PHC) , , ,067,844 95, ,286 4, , Primary Health Centre (PHC) , , ,833, , , , Primary Health Centre (PHC) , , ,052, , ,245 1, , Primary Health Centre (PHC) , , ,302, , ,393 2, , Primary Health Centre (PHC) , ,558, , ,713 1, , Primary Health Centre (PHC) ,612 1,142 5, ,877, , ,204 5, , Sub-district Hospital (SDH) ,962 24, ,961 51,990,464 1,671,650 3,198,514 18, , Sub-district Hospital (SDH) ,668 22,400 1,085 2,830 58,814,908 1,654,264 3,178,183 19, , Sub-district Hospital (SDH) ,114 22,536 1,126 2,762 60,695,412 1,655,487 3,689,209 19, , Sub-district Hospital (SDH) ,893 23,922 1,145 3,874 62,634,832 1,656,512 3,399,643 20, , Sub-district Hospital (SDH) ,210 24, ,354 64,633,828 1,656,912 4,109,763 21, , Community Health Centre (CHC) ,121 1,245 7, ,140, , ,886 30,166 6,495, Community Health Centre (CHC) ,019 1,502 6, ,315, , ,950 52,437 7,415, Community Health Centre (CHC) ,190 2,137 8, ,159, , ,427 45,663 9,676,

43 FACILITY INFORMATION STAFF AND BEDS OUTPUTS EXPENDITURE District Platform Year Beds Doctors Nurses Paramedical Nonmedical Outpatient Inpatient Vaccinations Births Personnel Infrastructure + utilities Medical supplies + pharmaceuticals Administration and training Non-medical 14 Community Health Centre (CHC) ,482 2,021 4, ,592, , ,289 80,030 10,285, Community Health Centre (CHC) ,588 2,682 4, ,789, , ,918 75,604 12,071, Primary Health Centre (PHC) , , ,109, , ,863 7,700 14, Primary Health Centre (PHC) , , ,174, , ,679 6,460 26, Primary Health Centre (PHC) , , ,241, , ,992 11,375 29, Primary Health Centre (PHC) , , ,311, , ,127 20,031 21, Primary Health Centre (PHC) ,923 1,057 10, ,382, , ,835 60,009 42, Primary Health Centre (PHC) , , ,875,663 93, ,699 14,143 30, Primary Health Centre (PHC) , , ,940,173 93, ,725 5,285 30, Primary Health Centre (PHC) , , ,995,479 91, ,721 8,355 45, Primary Health Centre (PHC) , , ,749,492 91, ,520 30,055 59, Primary Health Centre (PHC) , , ,156, , ,379 40,458 73,

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45 A B C E CCESS, OTTLENECKS, OSTS, AND QUITY INSTITUTE FOR HEALTH METRICS AND EVALUATION 2301 Fifth Ave., Suite 600 Seattle, WA USA TELEPHONE: FAX: engage@healthdata.org PUBLIC HEALTH FOUNDATION OF INDIA Plot 47, Sector 44 Gurugram, National Capital Region India TELEPHONE: FAX: contact@phfi.org