This article aims to discover the disparities in the geospatial distribution of healthcare facilities in Haryana, one of the states of India. The sufficient availability and accessibility of healthcare facilities is a crucial factor in the cure, care, and prevention of unhealthiness. It is the foundation for disease eradication, ameliorating the crude death rate, crude birth rate, infant mortality rate, life expectancy, and maternal mortality rate, and many other health indicators. The purpose of the healthcare system is to improve people's health, which is possible in conjunction with excellent healthcare infrastructure (Sheaff 1998; Van der Maesen and Cadman 2015; Waldmüller 2015).
The impacts of a good public health system transcend “health” alone. The significance of an adequate and effective public healthcare system goes far beyond its impacts on individuals. The effectiveness and added value of both of these social systems for societal prosperity have been explained and discussed by many scholars (Joseph and Phillips 1984; Rosenberg 2014; Shannon and Dever 1974). The standard of living in any nation, among other metrics, can be gauged by looking at how well its societal infrastructure and public health infrastructure have developed (Diener and Suh 1997; Guagliardo 2004; Nijhuis 2017; Wallace and Abbott 2007). It is widely accepted that improved (public) health is an outcome of every prosperous nation's integrated development strategy (Lyngdoh 2015). The multidimensional development process encompasses both qualitative and quantitative improvements in health, education, and overall living standards. Improved health outcomes, as a crucial factor in national development strategies (Lyngdoh 2015), contribute to increased labor productivity, higher levels of well-being, and greater economic prosperity (Diesendorf and Hamilton 2020; Mathar 2011). According to Lu Ann Aday and Ronald Andersen's (1974) seminal work on healthcare utilization, geographic factors are integral to comprehensively understanding healthcare access and designing effective interventions. Furthermore, development and availability are mandatory for achieving the crucial societal goals of reducing poverty and stimulating economic growth (Ahmed et al. 2023; Jensen 2008; Pradhan et al. 2011). Realizing these infrastructure conditions for effective healthcare constitutes a significant challenge and a paramount responsibility of governments. Good health is even considered a primary aspect of human rights (Nijhuis and Van der Maesen 2021). The studies we have cited thus far endorse the multifactorial and multidimensional nature of societal influences and processes that can lead to either good or poor health outcomes.
The comprehensive approach, encompassing curative, preventive, and promotional approaches, is referred to in this study as “health promotion.” The promotion of health means that this domain is not only a matter for health-oriented professionals, policies, and politics. It is also a concern for the economy, the environment, and the general welfare of society. From such a comprehensive perspective, it becomes clear why public health has been established as a crucial indicator of the Human Development Index (HDI) and has therefore come to be considered as one of the basic challenges facing governments the world over. Human development is indeed a multidimensional processes through which a nation improves its inhabitants’ welfare and socioeconomic and sociocultural standards. It should also be recognized that improvements in public health also imply contributions to people's living standards, socioeconomic security, and educational capabilities with a view to helping them enjoy an acceptable level of social quality in their daily lives. At the collective level, population health contributes significantly to the economic and cultural prosperity of communities, regions, and nations. Against the backdrop of the above considerations, this study was carried out to assess the geospatial dispersal of healthcare facilities in Haryana districts as a factor in enhancing both personal and population health in the state.
The reasons behind geospatial disparities in the availability and accessibility of healthcare facilities in relation to individual and population health are clarified through the lens of social quality theory (SQT), which provides the theoretical framework and the social quality approach (SQA), which translates this theory into practical policy and interventions. In this context, it is important to note that while SQT and SQA are distinct, they are closely related: SQT offers the conceptual understanding of how societal factors influence quality of life and health outcomes, while SQA applies these theoretical insights to develop actionable strategies. In the following sections, the workings of personal and population health, as well as the complexities involving other personal (constitutional) factors and societal (conditional) factors, are investigated and interpreted through the lens of the comprehensive social quality (SQ) perspective (Van der Maesen 2020). The SQ perspective, which builds upon both SQT and SQA, provides a comprehensive framework for understanding the complexities that are at stake in the emergence of unhealthiness, the sustenance of health, and health promotion policies and actions. It makes health comprehensible as an outcome of interactive (either productive or destructive) processes with personal factors and societal influences. Thus, while SQT provides the theoretical foundation, and SQA offers a practical approach to addressing social inequalities in health, the SQ perspective integrates these elements into a broader, interpretative framework that guides policy and research. The SQ perspective has already been discussed by various scholars (Joseph and Phillips 1984; Rosenberg 2014; Shannon and Dever 1974). Our study acknowledges the role of healthcare services in correspondence with Rod Sheaff's (1998) findings on healthcare utilization patterns. Additionally, it supports Mark Guagliardo's (2004) and Claire Wallace and Pamela Abbott's (2007) assertion that improvements in healthcare go hand in hand with advancements in education and general living standards, which highlights the multidimensionality of social development as used in the HDI. The SQ perspective, mostly implicitly, is deployed in our interpretations of the findings of our study and underpins the need for our policy recommendations to be comprehensive. It also leads us to conclude that the measures needed to eliminate the disparities found in our study are morally justified.
The study is structured as follows: in the second section, the methodology of our study is explained. In the third section, the findings regarding the availability and accessibility of healthcare facilities across Haryana districts are presented and briefly discussed. In the final section, which contains our conclusions and recommendations, we revisit the roots, meanings, and implications of our findings. From there, we present our considerations and recommendations for policymakers at various governmental levels to remedy the unequal distribution of healthcare services in Haryana.
Methodology
Study Area and Materials
The study area is the state of Haryana, situated in northern India (Fig. 1). With a geographic area of 44,212 km² and a total population of 25,351,462 as of 2011, Haryana is divided into 22 districts, 72 subdivisions, 93 tehsils, 140 blocks, 154 towns, 6,848 villages, and 6,222 panchayats.1
Location of the Study Area: (a) Haryana in India, (b) Haryana Districts
Citation: The International Journal of Social Quality 13, 2; 10.3167/IJSQ.2023.130202
The analysis is based on secondary data sources from the District Statistical Handbook published by the Department of Economics and Statistical Affairs (2022),2 the Census of India 2011,3 the Office of the Registrar General and Census Commissioner of India, the Ministry of the Interior, and the Government of India. All maps and figures in this article were created by the authors using administrative boundary data from the Survey of India.
Definitions of Healthcare Infrastructure
In the following core concepts, the dependent and independent variables used in our analysis are identified and elaborated. The independent variables are various types of healthcare facilities that enable us to differentiate between the disparities found. The dependent variables, used for assessing the disparities in the quality of the current infrastructure, are the availability and accessibility of the identified types of facilities.
The concept of healthcare infrastructure refers to a system of physical facilities that provide promotional, preventive, curative, and other care services to the population in a particular area (Fiksel 2006; Kagermann 2015; Lakshmi 2013). Hospitals, Community Health Centers (CHCs), Primary Health Centers (PHCs), Dispensaries, and Health Subcenters (HSCs) make up the current healthcare infrastructure. In these facilities, human resources such as doctors, nurses, and midwives constitute the workforce, which is equally important for the quality of services. The same holds for input resources such as financial means and professional qualities. Thus, it should be noted that availability and accessibility are only two measures of the quality of healthcare services in various districts of Haryana. Numerous other functional capacities and qualities constitute the overall quality of the healthcare delivered. Our study addresses public healthcare facilities. The adjective “public” refers in our study to government-run and funded services; thus, it does not include privately run and owned facilities.
The primary level includes CHCs, PHCs, dispensaries, and HSCs. At this level, services such as immunization, maternal and child healthcare, and family welfare services are provided in addition to preventive and curative outpatient services. At the secondary level, community hospitals and other district-level health facilities provide general medical and preventive care to inpatients and outpatients. The tertiary level encompasses hospitals providing specialized outpatient and inpatient care, catering to a wide range of medical needs.
CHCs serve as the first referral centers for four PHCs and function as rural hospitals. They are established and maintained by the state government under the Minimum Needs Program. Since their inception with the declaration of the five-year plan, CHCs have been established based on population norms. According to the Indian Public Health Standards (IPHS) of 2010, one CHC is recommended for every 120,000 persons in plain areas and one per 80,000 persons in hilly, tribal, or desert areas. The establishment and maintenance of CHCs were and are aimed at enhancing healthcare availability and accessibility.
PHCs in India have a crucial position in the public health system, being the second tier after HSCs. According to the IPHS of 2012, PHCs are considered the cornerstone of rural health services and serve as the initial points of contact with qualified public-sector doctors (Ministry of Health and Family Welfare 2012). They provide curative, preventive, and promotional healthcare and are often visited by patients from dispensaries and HSCs. Population norms guide the establishment of PHCs, recommending one PHC for every 30,000 people in plain areas and one for every 20,000 in hilly, tribal, or desert areas (Ministry of Health and Family Welfare 2010). Public hospitals at the subdistrict and district levels also receive referrals from PHCs. This system has been in place since the sixth five-year plan in India.
Dispensaries and HSCs are used interchangeably, as indicated in the National Health Policy (Ministry of Health and Family Welfare 1983). These centers serve as the first interface between the primary care system and remote rural communities. HSCs are supposed to serve 3,000 people in hilly or tribal areas and 5,000 people in plain areas according to the revised IPHS of 2012 (Ministry of Health and Family Welfare 2012). Health education and services related to maternal and child health, family welfare, nutrition, immunization, and communicable disease control are basic tasks for these subcenters.
Availability and Accessibility Ratios and Composite Ranking
The availability of healthcare facilities in a specific district is defined as the number of (various types of) facilities per population in that district. The accessibility of infrastructure in a specific district is defined as the number of facilities per geographic area (km²) in that district. In our study, the levels of availability and accessibility of the above-classified healthcare facilities were assessed per district and expressed in ratios (see Fig. 2).
Availability and Accessibility Ratios of the Healthcare Infrastructure
Citation: The International Journal of Social Quality 13, 2; 10.3167/IJSQ.2023.130202
To provide an overall assessment of the combined levels of availability and accessibility, the so-called composite ranking was calculated. To calculate this composite ranking, the outcomes of the availability and accessibility ratios of all facilities were included (see Fig. 3).
Composite Ranking of the Distribution of Healthcare Infrastructure
Citation: The International Journal of Social Quality 13, 2; 10.3167/IJSQ.2023.130202
The composite ranking expresses the overall availability and accessibility of the whole healthcare infrastructure in a specific district. The ranking of the quality of healthcare infrastructure according to the composite measure highlights disparities in accessibility and availability. The lower the score, the better the district is regarding healthcare infrastructure; the higher the score, the worse the situation (see columns 12 and 13 of Table 3). Through spatial maps, we will visually depict the uneven distribution of facilities, emphasizing the need for targeted interventions to address the identified gaps.
Study Findings
Characteristics of the State of Haryana
To be able to value the results of our study from a national perspective, it is necessary to depict relevant characteristics of the state of Haryana. It will enable us to appreciate the significance of our study from a wider perspective. In Figure 4, the sociodemographic and socioeconomic characteristics of the state of Haryana are compared with the same characteristics of India as a whole.
Socioeconomic, Sociodemographic, and Health Profile of Haryana compared to Aggregate at the National Level
Citation: The International Journal of Social Quality 13, 2; 10.3167/IJSQ.2023.130202
Haryana shows a higher literacy rate compared to India (75.55 percent vs. 74.04 percent). This higher score could lead to improved health awareness and possibly, in a positive way, affect healthcare utilization. Haryana's higher decadal growth rate of 19.90 percent compared to 17.70 percent indicates higher healthcare needs and possibly a relatively more refined healthcare infrastructure. The slightly higher sex ratio in Haryana (890 women per 1,000 males compared to the national average of 879) impacts healthcare requirements, especially for women. Haryana's relatively low maternal mortality rate (6.0 per 100,000 live births vs. 8.0) expresses a favorable picture, where as its fertility (2.0 per 1,000) and infant mortality rates (28 per 1,000 live births) are average for India. The overall sociodemographic picture reveals that Haryana ranks as an average state in India.
Availability Ratios
Table 1 presents the absolute numbers related to the availability of all different facilities in Haryana. In Figures 5 and 6, the availability ratios per type of healthcare facility are visualized on the geographical map of Haryana. Based on these outcomes, the findings per facility category are briefly summarized and discussed.
Haryana District Populations and Number of Present Facilities
| Districts | Total Population | No. of Hospitals | *x1 | No. of CHCs | *x2 | No. of PHCs | *x3 | No. of Dispensaries | *x4 | No. of HSCs | *x5 |
|---|---|---|---|---|---|---|---|---|---|---|---|
| Ambala | 1,128,350 | 3 | 376,117 | 5 | 225,670 | 22 | 51,289 | 3 | 376,117 | 104 | 10,850 |
| Bhiwani | 1,132,169 | 7 | 161,738 | 7 | 161,738 | 29 | 39,040 | 3 | 377,390 | 144 | 7,862 |
| Charkhi Dadri | 502,276 | 1 | 502,276 | 3 | 167,425 | 15 | 33,485 | 0 | 0 | 76 | 6,609 |
| Faridabad | 1,809,733 | 2 | 904,867 | 4 | 452,433 | 16 | 113,108 | 7 | 258,533 | 58 | 31,202 |
| Fatehabad | 942,011 | 3 | 314,004 | 6 | 157,002 | 24 | 39,250 | 1 | 942,011 | 137 | 6,876 |
| Gurugram | 1,514,432 | 5 | 302,886 | 4 | 378,608 | 15 | 100,962 | 3 | 504,811 | 76 | 19,927 |
| Hisar | 1,743,931 | 6 | 290,655 | 9 | 193,770 | 39 | 44,716 | 4 | 435,983 | 200 | 8,720 |
| Jhajjar | 958,405 | 4 | 239,601 | 6 | 159,734 | 27 | 35,496 | 3 | 319,468 | 126 | 7,606 |
| Jind | 1,334,152 | 4 | 333,538 | 8 | 166,769 | 34 | 39,240 | 1 | 1,334,152 | 171 | 7,802 |
| Kaithal | 1,074,304 | 3 | 358,101 | 6 | 179,051 | 27 | 39,789 | 0 | 0 | 144 | 7,460 |
| Karnal | 1,505,324 | 4 | 376,331 | 7 | 215,046 | 33 | 45,616 | 7 | 215,046 | 151 | 9,969 |
| Kurukshetra | 964,655 | 2 | 482,328 | 6 | 160,776 | 22 | 43,848 | 1 | 964,655 | 119 | 8,106 |
| Mahendragarh | 922,088 | 2 | 461,044 | 7 | 131,727 | 25 | 36,884 | 0 | 0 | 120 | 7,684 |
| Nuh | 1,089,263 | 1 | 1,089,263 | 4 | 272,316 | 22 | 49,512 | 0 | 0 | 138 | 7,893 |
| Palwal | 1,042,708 | 2 | 521,354 | 5 | 208,542 | 20 | 52,135 | 0 | 0 | 89 | 11,716 |
| Panchkula | 561,293 | 3 | 187,098 | 2 | 280,647 | 9 | 62,366 | 13 | 43,176 | 51 | 11,006 |
| Panipat | 1,205,437 | 2 | 602,719 | 7 | 172,205 | 20 | 60,272 | 2 | 602,719 | 89 | 13,544 |
| Rewari | 900,332 | 2 | 450,166 | 5 | 180,066 | 21 | 42,873 | 0 | 0 | 112 | 8,039 |
| Rohtak | 1,061,204 | 3 | 353,735 | 7 | 151,601 | 23 | 46,139 | 5 | 212,241 | 115 | 9,228 |
| Sirsa | 1,295,189 | 4 | 323,797 | 8 | 161,899 | 32 | 40,475 | 1 | 1,295,189 | 158 | 8,197 |
| Sonipat | 1,450,001 | 2 | 725,001 | 9 | 161,111 | 38 | 38,158 | 3 | 483,334 | 164 | 8,841 |
| Yamunanagar | 1,214,205 | 3 | 404,735 | 8 | 151,776 | 23 | 52,792 | 1 | 1,214,205 | 113 | 10,745 |
| Total | 2,535,1462 | 68 | 372,815 | 133 | 190,612 | 536 | 47,297 | 58 | 437,094 | 2,655 | 229,883.31 |
| Mean | 1,152,339.18 | 3.09 | 443,697.84 | 6.05 | 204,086.88 | 24.36 | 50,338.42 | 2.64 | 435,410.41 | 120.68 | 10,449.24 |
| SD | 325,390.46 | 1.51 | 223,049.46 | 1.89 | 788,38.79 | 7.60 | 19,931.38 | 3.16 | 445,434.09 | 37.75 | 5,469.97 |
| CV | 28.24 | 48.82 | 50.27 | 3.25 | 38.63 | 31.20 | 39.59 | 119.69 | 102.30 | 31.28 | 52.35 |
For X1, X2, X3, X4, and X5, see Figure 3.
Haryana District Availability Ratios for Hospitals (a) and CHCs (b).
Citation: The International Journal of Social Quality 13, 2; 10.3167/IJSQ.2023.130202
District Availability Ratios for (c) PHCs and (d) Dispensaries/HSCs.
Citation: The International Journal of Social Quality 13, 2; 10.3167/IJSQ.2023.130202
Hospitals
The map (Fig. 5a) illustrates variations in hospitals across districts, divided by different rank and represented by different colors indicating relative adequacy. The majority fall within the 200,000–400,000 range, indicating an average socioeconomic status. Notably, Bhiwani, and Panchkula, rank among the best (gray) with populations below 200,000, due to focused development efforts or economic activities. Conversely, Nuh stands out as the worst-performing (red) district, due to insufficient infrastructure and economic opportunities.
CHCs
The analysis reveals notable variations in the ratios of CHCs per population across districts (Fig. 5b). Notably, districts highlighted in gray (131,726 to 151,775) exhibit optimal CHC availability, with Mahendergarh closely aligning with the 2012 IPHS (Ministry of Health and Family Welfare 2012) at a ratio of 1 CHC per 131,727 individuals. Mahendergarh, with a total population of 922,088 and 7 CHCs, ensures readily available healthcare.
Conversely, districts marked in red (280,646 to 452,433) indicate significant challenges, with Faridabad and Gurugram facing notable shortcomings in healthcare availability. According to the 2012 IPHS standards (Ministry of Health and Family Welfare 2012), the recommended CHC ratio is 1 per 120,000. Faridabad and Gurugram, with populations of 1,809,733 and 1,514,432 respectively, each have 4 CHCs. The high population density in these areas overwhelms existing healthcare facilities, resulting in a per capita shortage of CHCs.
PHCs
The map (Fig. 6c) illustrates variations in PHC per population ratios across districts, with differing shades indicating relative adequacy. Charkhi Dadri, Jhajjar, and Mahendergarh stand out in the green range, suggesting a highly available healthcare infrastructure. Notably, Charkhi Dadri, with a population of 502,276 and 15 PHCs, also ensures available healthcare. In contrast, Gurugram and Faridabad exhibit a concerning shortage, depicted in the red range. With populations of 1,809,733 and 1,514,432, respectively, they have 16 and 15 PHCs. The dense population in these districts strains the current healthcare infrastructure, leading to an inadequacy of PHCs per capita.
Dispensaries/HSCs
The availability of dispensaries surpasses the norm. Panchkula has the highest dispensary ratio (less than 43,176), and Faridabad has the lowest (964,655 to 1,334,152). Similarly, HSC ratios vary significantly across districts, highlighting an unequal distribution of resources. In the context of rural healthcare, the availability of dispensaries is difficult to interpret (Fig. 6d). The lack of dispensaries in some districts raises concerns regarding healthcare availability, especially in remote areas.
Accessibility Ratios
In Table 2, the absolute numbers related to the accessibility of healthcare facilities in the various Haryana districts are listed.
Haryana Districts (km²) and Number of Present Facilities
| District | Area | No. of Hospitals | *x6 | No. of CHCs | *x7 | No. of PHCs | *x8 | No. of Dispensaries | *x9 | No. of HSCs |
*x10 |
|---|---|---|---|---|---|---|---|---|---|---|---|
| Ambala | 1,574 | 3 | 524.67 | 5 | 314.80 | 22 | 71.55 | 3 | 524.67 | 104 | 15.13 |
| Bhiwani | 3,352 | 7 | 478.86 | 7 | 478.86 | 29 | 115.59 | 3 | 1117.33 | 144 | 23.28 |
| Charkhi Dadri | 1,426 | 1 | 1,426.00 | 3 | 475.33 | 15 | 95.07 | 0 | 0.00 | 76 | 18.76 |
| Faridabad | 741 | 2 | 370.50 | 4 | 185.25 | 16 | 46.31 | 7 | 105.86 | 58 | 12.78 |
| Fatehabad | 2,538 | 3 | 846.00 | 6 | 423.0 | 24 | 105.75 | 1 | 2538.0 | 137 | 18.53 |
| Gurugram | 1,258 | 5 | 251.60 | 4 | 314.50 | 15 | 83.87 | 3 | 419.33 | 76 | 16.55 |
| Hisar | 3,983 | 6 | 663.83 | 9 | 442.56 | 39 | 102.13 | 4 | 995.75 | 200 | 19.92 |
| Jhajjar | 1,834 | 4 | 458.50 | 6 | 305.67 | 27 | 67.93 | 3 | 611.33 | 126 | 14.56 |
| Jind | 2,702 | 4 | 675.50 | 8 | 337.75 | 34 | 79.47 | 1 | 2702.0 | 171 | 15.80 |
| Kaithal | 2,317 | 3 | 772.33 | 6 | 386.17 | 27 | 85.81 | 0 | 0.00 | 144 | 16.09 |
| Karnal | 2,520 | 4 | 630.00 | 7 | 360.0 | 33 | 76.36 | 7 | 360.00 | 151 | 16.69 |
| Kurukshetra | 1,530 | 2 | 765.00 | 6 | 255.00 | 22 | 69.55 | 1 | 1530.0 | 119 | 12.86 |
| Mahendragarh | 1,899 | 2 | 949.50 | 7 | 271.29 | 25 | 75.96 | 0 | 0.00 | 120 | 15.83 |
| Nuh | 1,507 | 1 | 1,507.00 | 4 | 376.75 | 22 | 68.50 | 0 | 0.00 | 138 | 10.92 |
| Palwal | 1,359 | 2 | 679.50 | 5 | 271.80 | 20 | 67.95 | 0 | 0.00 | 89 | 15.27 |
| Panchkula | 898 | 3 | 299.33 | 2 | 449.0 | 9 | 99.78 | 13 | 69.08 | 51 | 17.61 |
| Panipat | 1,268 | 2 | 634.00 | 7 | 181.14 | 20 | 63.40 | 2 | 634.00 | 89 | 14.25 |
| Rewari | 1,594 | 2 | 797.00 | 5 | 318.80 | 21 | 75.90 | 0 | 0.00 | 112 | 14.23 |
| Rohtak | 1,745 | 3 | 581.67 | 7 | 249.29 | 23 | 75.87 | 5 | 349.00 | 115 | 15.17 |
| Sirsa | 4,277 | 4 | 1,069.25 | 8 | 534.63 | 32 | 133.66 | 1 | 4277.0 | 158 | 27.07 |
| Sonipat | 2,122 | 2 | 1,061.00 | 9 | 235.78 | 38 | 55.84 | 3 | 707.33 | 164 | 12.94 |
| Yamunanagar | 1,768 | 3 | 589.33 | 8 | 221.00 | 23 | 76.87 | 1 | 1768.0 | 113 | 15.65 |
| Total | 44,212 | 68 | 16,030 | 133 | 7,388 | 536 | 1,793 | 58 | 18,709 | 2,655 | 360 |
| Mean | 2,010 | 3 | 729 | 6 | 336 | 24 | 82 | 3 | 850 | 121 | 16 |
| SD | 918.17 | 1.50 | 321,84 | 1.89 | 100.05 | 7.60 | 20.22 | 3.15 | 11.8.97 | 37.75 | 3.59 |
| CV | 45.69 | 48.82 | 44.17 | 31.25 | 29.79 | 31.20 | 24.81 | 119.69 | 130.41 | 31.28 | 21.97 |
For x6, x7, x8, x9, and x10, see Figure 3.
Hospitals
In terms of healthcare accessibility, Figure 7 shows districts in blue having very high accessibility, with Gurugram standing out as the best. The excellent accessibility is attributed to the proper allocation of hospitals and the proximity to other medical facilities. Conversely, in districts such as Nuh and Charkhi Dadri, accessibility to healthcare is notably hindered by the considerable distance to medical facilities. Each of these districts is served by only one hospital, leading to restricted healthcare resources and significant challenges in accessibility. A notable number of districts fall within the moderate and high categories, reflecting a varied healthcare landscape.
District Accessibility Ratios of Hospitals
Citation: The International Journal of Social Quality 13, 2; 10.3167/IJSQ.2023.130202
CHCs
The map below (Fig. 8e) shows varying levels of accessibility to CHCs across districts, which are categorized by rank (very high to very low). The majority of districts adhere to standard norms, yet certain areas distinguish themselves. Notably, districts such as Yamunanagar, Panipat, and Sonipat exhibit the highest levels of accessibility, and so are included in the best rank (blue) owing to their well-developed healthcare infrastructure. Among these districts, Panipat notably boasts the highest number of CHCs with a total of 7, catering to an area of 1,268 km². Conversely, districts like Sirsa and Bhiwani rank lowest (red), indicating significant challenges in healthcare access, which are likely exacerbated by factors such as population density and geographic remoteness. Additionally, socioeconomic factors, such as poverty and lack of awareness, contribute to the reduced accessibility of CHCs in these areas.
District Accessibility Ratios for (e) CHCs and (f) PHCs.
Citation: The International Journal of Social Quality 13, 2; 10.3167/IJSQ.2023.130202
PHCs
The map (Fig. 8f) categorizes districts based on the accessibility ratios of PHCs. Sonipat (blue), showcasing very high accessibility at 55.84. The high accessibility of healthcare is due to the strategic placement of health facilities, robust transportation networks, and proactive community health initiatives. Conversely, districts like Sirsa and Bhiwani (red) display very low PHC accessibility. The low accessibility of PHCs in districts like these is attributed to inadequate healthcare infrastructure, insufficient healthcare personnel, geographical remoteness, and challenges in transportation.
Dispensaries
The map (Fig. 9) categorizes districts based on dispensary accessibility ratios. Notably, Faridabad ranks in the blue range, signifying very high accessibility. Conversely, Sirsa is highlighted in red, indicating very low accessibility. The reasons behind these variations are attributed to factors such as healthcare infrastructure, population density, and geographical considerations.
District Accessibility Ratios for Dispensaries and HSCs
Citation: The International Journal of Social Quality 13, 2; 10.3167/IJSQ.2023.130202
HSCs
The best-ranking districts, marked in blue on Figure 9, include Faridabad, Sonipat, and Kurukshetra. These districts boast very high accessibility to HSCs due to their strategic locations. On the other hand, the worst-ranking districts, highlighted in red, are (one again) Sirsa and Bhiwani. These areas demonstrate very low accessibility to HSCs, indicating potential challenges in healthcare access or infrastructure development, or the existence of geographical barriers.
Composite Ranking
Table 3 presents a composite analysis of the availability and accessibility ratios of public healthcare facilities. The ranking refers to the overall adequacy of the healthcare infrastructure. The table shows the ranking of 22 districts according to their composite rank (CR) of healthcare infrastructure. The score is calculated based on 10 indicators: R1 to R10 (see Fig. 3). These indicators include the availability and accessibility ranks of hospitals, CHCs, PHCs, dispensaries, and HSCs.
Composite Ranks of Healthcare Infrastructure in Haryana Districts
| 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | 10 | 11 | 12 | 13 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| District | *R1 | *R2 | *R3 | *R4 | *R5 | *R6 | *R7 | *R8 | *R9 | *R10 | Composite Rank Score | Rank |
| Jhajjar | 3 | 5 | 2 | 11 | 4 | 4 | 9 | 4 | 13 | 7 | 62 | 1 |
| Mahendragarh | 15 | 1 | 3 | 1 | 5 | 18 | 7 | 11 | 1 | 13 | 75 | 2 |
| Rohtak | 9 | 2 | 14 | 8 | 14 | 7 | 5 | 9 | 9 | 9 | 86 | 3 |
| Rewari | 14 | 14 | 10 | 1 | 9 | 16 | 12 | 10 | 1 | 5 | 92 | 4 |
| Kaithal | 10 | 13 | 8 | 1 | 3 | 15 | 16 | 16 | 1 | 14 | 97 | 5 |
| Sonipat | 20 | 7 | 4 | 15 | 13 | 19 | 4 | 2 | 15 | 4 | 103 | 6 |
| Palwal | 18 | 16 | 17 | 1 | 19 | 13 | 8 | 5 | 1 | 10 | 108 | 7 |
| Charki Dadri | 17 | 11 | 1 | 1 | 1 | 21 | 20 | 17 | 1 | 19 | 109 | 8 |
| Kurukshetra | 16 | 6 | 11 | 19 | 10 | 14 | 6 | 7 | 18 | 3 | 110 | 9 |
| Nuh | 22 | 19 | 15 | 1 | 8 | 22 | 15 | 6 | 1 | 1 | 110 | 9 |
| Faridabad | 21 | 22 | 22 | 10 | 22 | 3 | 2 | 1 | 8 | 2 | 113 | 11 |
| Bhiwani | 1 | 8 | 5 | 13 | 7 | 5 | 21 | 21 | 17 | 21 | 119 | 12 |
| Ambala | 11 | 18 | 16 | 12 | 17 | 6 | 11 | 8 | 12 | 8 | 119 | 12 |
| Panipat | 19 | 12 | 19 | 17 | 20 | 10 | 1 | 3 | 14 | 6 | 121 | 14 |
| Jind | 8 | 10 | 6 | 22 | 6 | 12 | 13 | 14 | 21 | 12 | 124 | 15 |
| Yamunanagar | 13 | 3 | 18 | 20 | 16 | 8 | 3 | 13 | 19 | 11 | 124 | 15 |
| Karnal | 12 | 17 | 13 | 9 | 15 | 9 | 14 | 12 | 10 | 16 | 127 | 17 |
| Fatehabad | 6 | 4 | 7 | 18 | 2 | 17 | 17 | 20 | 20 | 18 | 129 | 18 |
| Panchkula | 2 | 20 | 20 | 7 | 18 | 2 | 19 | 18 | 7 | 17 | 130 | 19 |
| Gurugram | 5 | 21 | 21 | 16 | 21 | 1 | 10 | 15 | 11 | 15 | 136 | 20 |
| Hisar | 4 | 15 | 12 | 14 | 12 | 11 | 18 | 19 | 16 | 20 | 141 | 21 |
| Sirsa | 7 | 9 | 9 | 21 | 11 | 20 | 22 | 22 | 22 | 22 | 165 | 22 |
For R1, R2, R3, R4, R5, R6, R7, R8, R9 and R10, see Figure 2.
In Table 3, Figure 10, and Table 4, through different numerical and visual expressions, detailed and categorized findings of the scores of composite rankings are shown. In Figure 10, CR scores are visualized in maps to highlight the geographical disparities. Table 4 categorizes districts in the state according to the composite ranking of public healthcare infrastructure.
District-Wise Composite Ranking for Specific Facilities and the Overall Score for Infrastructure
Citation: The International Journal of Social Quality 13, 2; 10.3167/IJSQ.2023.130202
Classification of Districts Based on Composite Ranking
| District Categorization of Public Health Care Infrastructure | Composite Ranking of Public Healthcare Infrastructure | Number of Districts | Name of the Districts |
|---|---|---|---|
| Very High | 62–97 | 5 | Jhajjar, Mahendragarh, Rohtak, Rewari, and Kaithal |
| High | 98–110 | 6 | Sonipat, Palwal, Charkhi Dadri, Kurukshetra, and Nuh |
| Medium | 111–121 | 4 | Faridabad, Bhiwani, Ambala, and Panipat |
| Low | 122–129 | 4 | Jind, Yamunanagar, Karnal, and Fatehabad |
| Very Low | 130–165 | 4 | Panchkula, Gurugram, Hisar, and Sirsa |
The composite ranks highlight significant differences in healthcare facilities across districts, emphasizing the presence of regional inequalities. The top five districts with the highest ratio are Jhajjar, Mahendragarh, Rohtak, Rewari, and Kaithal while the most deprived are Sirsa, Hisar, Gurugram, Panchkula, and Fatehabad. Jhajjar ranks the highest, while Sirsa is the lowest. The classification highlights possible geographical differences, as districts like Panchkula, Gurugram, Hisar, and Sirsa are classified as “very low,” indicating a need for targeted interventions. The districts of Jhajjar, Mahendragarh, Rohtak, Rewari, and Kaithal emerge as the top-performing districts with a “very high” composite ranking, indicating robust public health care infrastructure.
The map clearly shows that there is a substantial difference between the highest and lowest districts. Notably, the top five districts are all situated in the northern part of Haryana. The bottom five districts are all situated in the southern part. This seems to indicate that there is an overall disparity in the development of the northern and southern regions of Haryana.
An interesting outcome is that the nearby capital city of Gurugram was ranked in the lower districts of Haryana. Districts like Sirsa, Hisar, and Gurugram, which are the lowest-ranked, obviously need specific attention so that the availability and accessibility of their healthcare facilities can be improved.
Conclusion
In this section, we summarize our findings regarding availability and accessibility for specific facilities and districts. Then we highlight the findings concerning the composite ranking of healthcare infrastructure across districts. After that, we conclude our study with policy recommendations that are we consider to be morally justified by our study.
Specific Healthcare Facilities
The study reveals a differential distribution of government-funded hospitals in Haryana, with an average hospital population ratio of 372,815. Disparities do exist, with districts like Bhiwani exhibiting favorable ratios and others like Nuh facing challenges. Discrepancies are notable in districts such as Gurugram, Hisar, and Panchkula, indicating potential challenges in providing an adequate healthcare infrastructure. Political influences in resource allocation, as seen in Bhiwani, raise questions about equitable distribution. Disparities stem from factors like political and administrative neglect, economic productivity, and urban–rural disparities. Addressing these requires a nuanced approach that considers local contexts.
The analysis of CHCs in Haryana reveals a concerning inadequacy in the rural healthcare infrastructure. Notably, there is not a single district where one CHC serves less than 120,000 people. Faridabad and Gurugram stand out, with the population served per CHC exceeding three times the existing norm. In fact, in 21 out of 22 districts, the average number of people served by one CHC is more than 150,000, indicating a poor supply side of public healthcare infrastructure in the state. This situation highlights the overall inadequacy of rural healthcare, with CHC ratios consistently exceeding established norms across districts. Faridabad and Gurugram, in particular, exhibit significant challenges in the adequacy of CHC availability and accessibility. In contrast, Rohtak and Yamunanagar perform relatively better. The observed disparities stem from factors such as population density, rural–urban distribution, and challenges in resource allocation. Adhering to IPHS is deemed crucial for addressing these issues and improving the state of healthcare infrastructure in Haryana.
In the above analysis, not a single district meets the norm of one PHC serving less than 30,000 people. Faridabad and Gurugram have population-served ratios more than four and three times the norm, respectively, which can be attributed to their status as major cities near the national capital, New Delhi. Among the 22 districts, 14 have an average PHC population ratio exceeding 50,000:1, indicating challenges in availability and accessibility. Gurugram and Panchkula face the highest PHC availability ratios, while Charkhi Dadri exhibits comparatively better availability. The disparities stem from factors like population density, distribution, and urbanization. Addressing inadequacies requires redistributing resources to ensure equitable access across districts.
Availability and accessibility of dispensaries and HSCs are concerning, with an average population-served ratio exceeding the norm. Significant variations exist across districts. Panchkula, Karnal, and Faridabad demonstrate better accessibility, while districts like Ambala, Yamunanagar, and Sirsa face challenges. The absence of dispensaries in certain districts raises alarms about healthcare accessibility—variations attributed to population density, rural–urban distribution, and resource allocation. Targeted healthcare programs and resource redistribution are vital for improvement.
Composite Ranking
In line with the findings presented above, the composite ranking reveals significant disparities in healthcare infrastructure across districts in Haryana. Five districts, including Jhajjar and Mahendragarh, perform well, while others, like Sirsa and Hisar, face large challenges. A north–south divide is evident, suggesting potential regional disparities in development. Variability in composite ranks emphasizes the need for targeted investments in districts like Panchkula, Gurugram, and Sirsa. Disparities could result from multiple factors, including political and administrative neglect, economic productivity, and urban–rural disparities. Addressing these requires a comprehensive, context-specific policy intervention.
The assessed poor situation indicates challenges in healthcare access, particularly in districts with higher availability ratios. The disparities suggest potential regional imbalances in healthcare infrastructure, impacting residents’ well-being based on their geographical location. Resource allocation, influenced by political factors, contributes to disparities. Districts with historical significance or higher economic productivity receive preferential resource allocation. Varied healthcare infrastructure distribution stems from differences in urban and rural settings. Cultural factors influence healthcare planning and resource allocation.
Our study underscores the need for a nuanced understanding of healthcare disparities in Haryana. Disparities across distinct facilities highlight the complexity of factors influencing the adequacy of the healthcare infrastructure. The composite ranking provides a holistic view, emphasizing the need for targeted interventions. Addressing political influences, economic factors, and regional imbalances is crucial for developing context-specific policies that ensure equitable access to healthcare services across diverse districts in Haryana.
The revised IPHS guidelines were to be applied in 2012. Approximately half of the Haryana districts were identified as having received less than the average of the composite rank score for health infrastructure. This overall picture of disparity constitutes a most worrying societal issue concerning the public health situation and other societal problems in Haryana's districts. The research goals that we, considering our findings, would like to bring to the fore are (1) further refining of our findings on the adequacy of infrastructure by connecting them with related factors of healthcare quality; (2) looking at the social consequences of the receipt of a poor ranking and the related implications; and (3) examining the possible societal patterns and drivers that lie at the root of the found disparities.
Below, we present select recommendations for policymakers. In discussing these aspects, we implicitly make use of the SQ perspective.
Policy Recommendations
We would like to conclude this study with some recommendations to the government and other relevant policymakers. Because of the comprehensive scope of our study, covering aspects of cure, prevention, care, and promotion, our recommendations regard approaches to “health promotion.”
First, we would recommend that governments, at the district, state, and national levels, adopt the methodology used in this study as a common design to assess, judge, and control the geospatial distribution of healthcare facilities. This methodology, of course, needs further evaluation and development. A crucial issue that has not been realized in our study is to refine the assessment by including other relevant determining factors regarding the functioning and quality of the public healthcare system. The same holds for a large diversity of factors working in the sociodemographic, socioeconomic, sociocultural, and socioenvironmental spheres. The latter, of course, based on evidence, needs to be related to the functioning and outcomes of public health. This methodology should include operational directives and practical instructions regarding how to conduct a geospatial analysis. The establishment of such an assessment and control instrument needs to be accomplished in an interdisciplinary working group in which academics, policymakers, and practitioners participate. This endeavor, in an experimental setup, could take off in Haryana.
Second, financial and substantive assistance is needed for districts to achieve and sustain an equal distribution of public health infrastructure and resources. Health planners need to be trained to assess and compare the needs of each district regarding adequate resources to achieve an appropriate distribution of facilities. Hospitals, CHCs, PHCs, dispensaries/HSCs, and other facilities need to be kept small to allow for their widest possible dispersion to meet the needs of local rural communities. The planning in particular should be done hand in glove with the need for special medical facilities, such as specialist hospitals, that are more centrally located. In urban settings, the number of facilities turns out to be smaller, and the size of facilities such as hospitals and PHCs turns out to be larger.
As we have argued above, health is enhanced by numerous, indirectly (though strongly) health-related personal and conditional factors such as socioeconomic security (e.g., livelihood, income, and labor), social empowerment (e.g., consciousness-raising, training, and education), social inclusion, and social cohesion (e.g., political and community development). This means that “health promotion” policies aiming at the improvement of personal and population health should consistently include policies addressing issues like the general welfare, socioeconomic issues, and sociocultural issues, as well as socioenvironmental issues (e.g., housing, sanitation, and environmental safety). All these aspects influence the social quality of the circumstances of daily life and thus health.
To create joint, interdisciplinary, and intersectoral endeavors to develop and realize policies of health promotion, it is significant to acknowledge the importance of the moral contextual sphere in which prevailing values and ethical principles drive human behavior. The assessed disparities in the distribution of healthcare facilities most likely do not occur by chance or by occasional or structural mistakes in planning. Often, they do have a structural nature, which emerges from specific societal patterns and relationships. It would be most meaningful to expose the reasons why some districts are better off than others. As is the case in other situations of disparity between and neglect of particular communities and regions, the origins are rooted in specific socioeconomic, sociocultural, and sociopolitical societal patterns. In the sociopolitical dimension, the neglect of particular districts that are politically not considered fully-fledged or that are considered economically and culturally inferior is often to blame. Politicians and policymakers often consider a specific district not interesting in an economic sense (e.g., productivity) or a cultural sense (e.g., cultural inferiority). Importantly, a lack of political consciousness, voice, and power among local communities in these districts plays a role in the observed disparities. Additionally, do urban–rural disparities significantly compound these issues, which are particularly relevant in our analysis.
Societal (in particular political) sources of the emergence of disparities in the adequacy of health infrastructure are deeply rooted in values, traditions, interests, and behaviors oriented toward “superiority,” “self-interest,” and “neglect of the other.” As conceived and explained from the SQ perspective, “health promotion” is not only an endeavor involving the “subjective” and “objective/neutral” spheres. It needs to emphasize and address politics and the general public regarding the crucial importance of the adoption and guidance of good ethical principles in the “normative” sphere, such as “social justice,” “equal value,” “dignity,” and “solidarity.” The roots of adequate political choices and policies lie in the balanced combination of people's experiences (“the subjective”), information about reality (“the objective”), and the high esteem of moral principles (“the normative”).
Acknowledgments
We would like to thank Laurent J. G. van der Maesen and Harry G. J. Nijhuis for their valuable comments and suggestions, which greatly contributed to the improvement of this manuscript.
Notes
The Census of India for 2011, along with other important documents, can be found at the follwing website ran by the Office of the Registrar General and the Census Comissioner: https://censusindia.gov.in/census.website/ (accessed January 6, 2023).
Department of Economic and Statistical Affairs, Government of Haryana. Haryana Handbook of Statistics 2021–22: https://esaharyana.gov.in/ (accessed January 16, 2023).
Office of the Registrar General and the Census Commissioner, Ministry of Home Affairs, Government of India. Census of India 2011: https://censusindia.gov.in/ (accessed January 5, 2023).
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