Users Online: 1981 Home Print this page Email this page Small font sizeDefault font sizeIncrease font size


Home About us Editorial board Search Ahead of print Current issue Archives Submit article Instructions Subscribe Contacts Login 

 Table of Contents  
Year : 2022  |  Volume : 66  |  Issue : 3  |  Page : 287-291  

Does health financial resource correlate with physical health infrastructure?

1 Research Scholar, Department of Economics, North Eastern Hill University, Shillong, Meghalaya, India
2 Assistant Professor, Department of Economics, North Eastern Hill University, Shillong, Meghalaya, India

Date of Submission14-Apr-2022
Date of Decision28-Jul-2022
Date of Acceptance29-Jul-2022
Date of Web Publication22-Sep-2022

Correspondence Address:
Darishisha W Thangkhiew
Department of Economics, North Eastern Hill University, Mawlai, East Khasi Hills - 793 150, Meghalaya
Login to access the Email id

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijph.ijph_535_22

Rights and Permissions

Background: Is building physical health infrastructure (PHI) a priority for state governments within the northeastern states (NES) of India? The decentralization mechanism initiated by the government of India to synergize health care across states seems highly unequal. Certain Indian states such as Kerala, Uttarakhand, and Himachal Pradesh have achieved phenomenal progress in the health-care system through a decentralized mechanism. Objectives: The study attempts to examine the PHI of NES and public health resources. Methods: The study has employed the Euclidian Distant Method (EDM) which fulfills various compulsive and instinctive properties; specifically, normalization, symmetry, monotonicity, proximity, uniformity, and signaling inclusively. This method ranks the states in terms of infrastructure availability and public health resources. Second, the correlation was done to see the relationship between the PHI of NES and public health resources. Results: The results of the EDM show that Arunachal Pradesh ranked the highest in the Index of Public Health Infrastructure, whereas Assam ranked the lowest. The Index of Public Health Resource shows interesting results. Assam has remained at the lowest rank and inconsistency of ranks among the other NES. The correlation between the indices is positive, yet not encouraging. Conclusion: This implies that building up health infrastructure and responding to the demand for health-care infrastructure still stands ignored and rather remained stagnant.

Keywords: Euclidean Mistance Method, north-eastern states, physical health infrastructure, public health resource

How to cite this article:
Rymbai MS, Thangkhiew DW. Does health financial resource correlate with physical health infrastructure?. Indian J Public Health 2022;66:287-91

How to cite this URL:
Rymbai MS, Thangkhiew DW. Does health financial resource correlate with physical health infrastructure?. Indian J Public Health [serial online] 2022 [cited 2023 Apr 2];66:287-91. Available from:

   Introduction Top

Modern health infrastructure plays a significant role in health-care provision. Since the formulation of the National Health Policy, the major focus was to ensure primary health care through decentralization and augmenting public health finance. The three-tier health system was established (Primary Health Centers [PHC], Community Health Centers [CHC], and Subcenters). It is through physical health infrastructure availability that the other supplementary elements such as accessibility and affordability may be achieved. In addition (PHI), immediate health-care treatment would forestall preventable deaths and minimize mortality and morbidity. However, is the building up of PHI an important component in the developmental activities of the state governments in the northeastern states (NES)?

Considering the importance of PHI, India as a whole has failed to meet the health-care requirement.[1],[2] There exist huge disparities among the rural and urban areas, southern and northeast states in terms of health-care financing, the state's capacity building of health infrastructure, and the efficiency of the states in its health inputs. The disparities exist within subnational levels as well, such that urban areas are surrounded by the government, nongovernment, or other corporate health care; however, the rural populace has limited health-care facilities and therefore lacks even basic immunizations.[3],[4] In addition, other issues involve a weak primary health-care sector, unequally distribution of skilled human resources (limited health-care providers such as paramedical staff, doctors, nurses, and specialists), large unregulated private health care, low and constant public health spending, fragmented health information systems, irrational use and spiraling costs of drugs and technology, and finally, weak governance and accountability.[4],[5],[6],[7]

In contrast to the public health infrastructure, there is an exceptionally developed private health care. India ranks among the world's top 20 countries with the highest private health care which is backed by highly qualified practitioners with a high-quality treatment and technology, which is least found in public health-care institutions. The exemplary quality of private health care is contrasting when compared to public health care with minimum health-care spending and health-care services.[6] With a low public health-care availability and the concomitant diseases, it has resulted in a declining health and economic status, wherein the population spends a higher proportion of their total expenditure on health care. The high expenditure could have been lesser, if public health care was sufficient; however, the large private health sector dominates and absorbed the major share of health expenditure.[7]

The pressing dilemma of the Indian Health System seems to be a continuing format, and the achievement of Universal Health Coverage is far-fetched.[8],[9] Since the Structural Adjustment Program 1990, new development strategies in the country have had a negative impact on the government's functions, whereby certain strategies have limited the scope for development of the health sector.[10],[11],[12],[13] For instance, the major aspects of the International Monetary Fund–World Bank reforms comprised curtailment of health sector investments, higher advantages to the private investors, disinvestments of the health sector, the establishment of user fees, and overall technological advancements in public health care. The ongoing strategies include higher attention to technocentric approaches to health care, emphasizing health industries, and a high focus on biomedical approaches.[14],[15],[16],[17],[18],[19]

In the case of the NES, several studies have examined the health-care infrastructure availability, accessibility, and status. It is no surprise that the inadequacy and bounded diversification of health-care infrastructure would be more pronounced.[20],[21],[22],[23],[24] Although PHI such as SC, PHC, and CHC along with various facilities and workforce resources portray a better picture in a majority of the NES compared to other states of India. However, the health-care performance of the NES does not meet the required objectives and norms of the Indian Public Health standards.[25] Throughout all pieces of literature, studies have examined the status and availability of PHI; however, no study has examined the relationship between public health expenditure and health infrastructure for the NES. Therefore, we intend to fill this gap through this study.

   Materials and Methods Top

The analysis is exclusively based on secondary data. Several government reports (national and state) were taken into consideration to ensure the accuracy of data. On the initial data enquiry, several reports have been scrutinized: National Health Accounts, NITI Aayog Annual Reports, NRHM Reports, Ministry of Health and Family Welfare Reports, Central Statistics Office, and Ministry of Statistics and Program Implementation. However, to have consistency in the data, public health expenditure data have been availed from the Reserve Bank of India State Finance Reports.[26] The data obtained from the source are at the current prices; therefore, we have converted the data at constant 2004–2005 prices using a suitable gross domestic product (GDP) deflator. PHI consists of SC, PHC, and CHC, and the data for these were taken from the Rural Health Statistics Reports 1992–1997, 1997–2002, 2002–2007, 2007–2012, and 2012–2017.[27] For analysis, PHCs, CHCs, and SCs are considered as these forms of the basic three-tier of the health system.

The analysis is intended to find the correlation between health financial resources and physical health infrastructure. On this note, we constructed the Index of Public Health Infrastructure (IPHI). For construction of the IPHI, the following variables have been taken: PHCs, CHCs, and SCs. For the construction of the Index of Public Health Resources (IPHR), the following variables have been taken: per capita health expenditure, share of health expenditure to GDP, share of health expenditure to state's own revenue, and the share of health expenditure to grants

Clearly, the method of construction corresponds to the United Nations Development Program (UNDP) indices of the Human Development Index (HDI), Human Poverty Index, and Gender Development Index. We have considered observing one dimension of public health infrastructure by constructing the dimension index employing the formula:

In the above formula, Ai implies the actual value of dimension I; mi implies the minimum value of dimension i; Mi implies the maximum value of dimension i. The values derived from the construction clearly indicate the achievements of the states. Note that the higher the value of the dimension implies the better rank states, whereas the lower value implies the worse rank state.

The construction of the IPHI then follows the Euclidean Distance Method (EDM). An alternative method to the construction of HDI has been proposed by employing the EDM, which fulfills various compulsive and instinctive properties; specifically, normalization, symmetry, monotonicity, proximity, uniformity, and signaling inclusively.[28] These properties constitute the principal components of a dimension index. It is noted that the UNDP Goal Post Method employs a different approach toward the construction of an index by assigning prefixed minimum and maximum values; however, in the EDM, the empirically obtained minimum and maximum values are considered. On considering the variables taken for constructing the health infrastructure index, (PHCs, CHCs, and Subcenters), di is first constructed after which the EDM is constructed using the maximum and minimum values obtained. The range of IPHI lies within 0–1 such that 0 ≤ di ≤1. The higher the value of IPHI (closer to 1) implies the best-performing state, whereas on the other hand, the value closer to zero implies the worse-performing state. The IPHI index is then measured using the normalized inverse EDM for the distance points di. Note that, di is subtracted by 1 and normalized by √ 2, which would lay out the normalized inverse EDM.[29] Algebraically, the IPHI index is represented by the following formula:

Through the IPHI and IPHR, we are able to rank the PHI and the public health resources of the NES. Following it, there is a need to analyze the association between public health resources and the available health infrastructure. Since we focus on public PHI, the establishments are entirely dependent on the government's expenditure. This will depict the efforts of the government to build PHI in the NES. In order to find the association, we examined the correlation between the indices (IPHI and IPHR).

   Results Top

[Table 1]a depicts the Euclidean Distance results through which an index was constructed to categorize the states in terms of best-performing state and either way. The value closer to 1 implies the best-performing states, whereas the value closer to 0 implies the least. On this note, the comparison of health infrastructure had been made for the years 1995, 2000, 2005, 2010, and 2015, respectively. On the broad preview of the index, Arunachal Pradesh has the ascendancy while maintaining the best-ranking state in terms of health-care infrastructure during the years 2005, 2010, and 2015. This clearly depicts the efforts of the state government toward assuring infrastructure availability. On the other hand, health infrastructure availability in Assam continued to deteriorate over the years and remained the lowest-ranked state during the years 2005, 2010, and 2015. Given the categorization of groups that fall under high and low level, IPHI value that lies below 0.4 are categorized as medium and low states and IPHI values ranging beyond 0.4 are the high-level states.[30] Based on this grouping, considering the year 2015, Arunachal Pradesh, Mizoram, and Nagaland are considered high-level states, whereas Assam, Manipur, Meghalaya, Sikkim, and Tripura are considered low-level states.
Table 1a: Index of public health infrastructure (1995-2015)

Click here to view

[Table 1]b depicts the IPHR of the NES. The index obtained is interesting. We find that among the NES, Assam has remained the lowest-ranked state over the period, despite being the largest state among the NES. This thus depicts that Assam has the lowest public health resources. On the other hand, the first-ranked state differed in different years. For instance, Sikkim ranked first in 1995; Nagaland in 2000, Arunachal Pradesh in 2005, Mizoram in 2010, and finally, Manipur in 2015. This thus shows that majority of the NES are striving toward the generation and allocation of public health financial resources. On the other hand, it also depicts the inability of the states to keep pace with the health financial requirements to maintain stability and sustainability.

On obtaining the indices (IPHI and IPHR), we proceed toward establishing the correlation between the indices to justify whether the financial health resources have any relationship with PHI in the NES of India. The results displayed in [Table 2]d and [Table 2]e can be explained simultaneously. The correlation results are not encouraging, although a positive correlation was observed [Table 1]c. It was only in the year 2005, wherein the correlation between the indices is encouraging and significant. However, in the years 2000 and 2010, there was a moderate correlation, and finally, in the years 1995 and 2015, we found a low correlation. The positive correlations were also insignificant in the years 1995, 2000, 2010, and 2015.

The low correlations could be justified in [Figure 1]. We observe that infrastructure development lacks in the NES of India. There was an increase in the PHI in some years, and it is disappointing to see the 0% growth in some states over the years. Considering the growth during the period 1995–2000, we observe that in states such as Assam, Manipur, and Sikkim, there was a 0% growth in the PHI. On the contrary, we observed a higher growth in Arunachal Pradesh and Nagaland. A similar pattern for Assam continued during the period 2000–2005. In another reference period from 2010 to 2015, it is observed that the growth of PHI is not to be celebrated, excluding Tripura with relatively a better growth; the majority of states depicted a negligible growth in PHI.
Figure 1: Growth of health infrastructure in NES (2015). NES: North-eastern states, CHCs: Community Health Centers, SCs: Subcenters, PHCs: Primary Health Centers

Click here to view

   Discussion Top

Assam is the largest state among the NES, and the population of the state is 50 times more than the smallest state, Sikkim. On this note, Sikkim clearly has a higher health infrastructure compared to Assam. It must be pointed out that given the much lesser population existing in most of the NES excluding Assam, the numbers of health infrastructure availability ought to be favorable. However, the results depict insufficiency, indicating the disinclination of the state governments to respond to health-care demand. Given that the NES have a major rural area consisting of multiple districts, the question of even distribution of health-care infrastructure stands unanswered. However, on observing the Rural Health Statistics Reports (RHS Reports 1992–1997, 1997–2002, 2002–2007, 2007–2012, and 2012–2017), it is clearly observed that there is an uneven distribution of health-care infrastructures among the districts of the states. Although Arunachal Pradesh, Mizoram, and Nagaland fall under the high-level states in terms of health-care infrastructure availability, it should be noted that several issues regarding distribution, functioning, and shortfall of the required facility are prominent. Taking the instance of the year 2015, there is a shortfall of 10, 21, 17, 44, and 13 Subcenters in Arunachal Pradesh, Assam, Manipur, Meghalaya, and Nagaland, respectively. In the case of PHC, there are 4 and 17 shortfalls in Meghalaya and Tripura. In the case of CHCs, there is a shortfall of 37 in Assam, 15 in Manipur, 4 in Meghalaya, 50 in Sikkim, and 26 in Tripura. In case of functioning health-care infrastructure, there are still ongoing rented buildings, buildings under construction, and the number of required buildings that has not been initiated (RHS Report 2014–2015).

Given the guidelines of the Indian Public Health Standards (IPHS), there are several requirements for an improved health-care service. There are certain benchmarks regarding the availability of health-care infrastructure per district or state: essential requirements for a health-care building, health-care workforce, drug supplies, transport facilities, and quality assurance of health-care delivery and management. However, postanalysis, the achievements of the IPHS benchmarks among the NES are questioned. One major reason to question infrastructure development is the imbalance in the revenue and capital health expenditure. In observing the year 2015–2016, Nagaland had a share of capital to total health expenditure of 1.39%, and a grave concern shows in the state of Mizoram, wherein the share of capital health expenditure was 0% in 2011–2012.[26] In addition, the fluctuations in per capita health expenditure clearly imply the state's inability to keep pace with population growth and the health requirements.

   Conclusion Top

The associated analysis has provided an in-depth view concerning the infrastructure availability and the concentration of the governments toward health-care provision. On a hierarchical manner, Arunachal Pradesh, Mizoram, and Nagaland rank better; whereas, Assam, Manipur, Meghalaya, Sikkim, and Tripura rank low in the health-care infrastructure. The shortages of infrastructures observed are rather dispiriting. The health financial resources also depict fluctuating indexes, whereas health financial resources in the majority of NES fluctuate; Assam has retained the lowest position throughout the subperiods. The main motive was to seek out the infrastructure-building efforts of the governments through the allocation of health resources. The analysis thus points out the foremost response to the analysis that building up health infrastructure, and responding to the demand of health-care infrastructure still stands ignored and rather remained stagnant. Therefore, the policy implications from the analysis suggest the need for the states to consider the development of health infrastructures to ensure availability. This will indeed ease health-care seekers and ultimately curtail traditional health care.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

   References Top

Ghosh D, Dinda S. Health Infrastructure and Economic Development in India; 2017. Available from: publication/319978925. [Last Accessed on on 2020 Aug 24].  Back to cited text no. 1
Patel V, Parikh R, Nandraj S, Balasubramaniam P, Narayan K, Paul VK, et al. Assuring health coverage for all in India. Lancet 2015;386:2422-35.  Back to cited text no. 2
Kumar A, Gupta S. Health Infrastructure in India: Critical Analysis of Policy Gaps in the Indian Healthcare Delivery; 2012. Available from: [Last Accessed on 2020 Aug 25].  Back to cited text no. 3
Kumar K, Singh S. Health infrastructure and utilization pattern in rural Punjab: Emerging public policy issues. J Econ Soc Dev 2010;6:79-86.  Back to cited text no. 4
Kathuria V, Sankar D. Inter-State disparities in health outcomes in rural India: An analysis using a stochastic production frontier approach. Dev Policy Rev 2005;23:145-63.  Back to cited text no. 5
Barua N, Pandav CS. The allure of the private practitioner: Is this the only alternative for the urban poor in India? Indian J Public Health 2011;55:107-14.  Back to cited text no. 6
[PUBMED]  [Full text]  
Selvaraj S, Karan AK. Deepening health insecurity in India: Evidence from national sample surveys since 1980s. Econ and Polit Wkly 2009;44:55-60.  Back to cited text no. 7
Ghuman B, Mehta A. Health Care Services in India: Problems and Prospects; 2009. Available from: policy_exchanges/conf_papers/Papers1551.pdf. [Last Accessed on 2020 Sep 16].   Back to cited text no. 8
Prinja S, Bahuguna P, Pinto AD, Sharma A, Bharaj G, Kumar V, et al. The cost of universal health care in India: A model based estimate. PLoS One 2012;7:e30362.  Back to cited text no. 9
Aggarwal RK. Social Sector Expenditure in India and Punjab: Trends during PreReforms (19801991) and PostReforms (19912011) Periods; 2011. Available from: /publication/283301974. [Last Accessed on 2018 Jun 20].  Back to cited text no. 10
Chokshi M, Patil B, Khanna R, Neogi SB, Sharma J, Paul VK, et al. Health systems in India. J Perinatol 2016;36:S9-12.  Back to cited text no. 11
Joseph KJ. Structural Adjustment 1n India: A Survey of Recent Studies and Issues for Further Research; 1996. Available from: Https:// Opendocs.Ids.Ac.Uk/Opendocs/Handle/20.500.12413/2906. [Last Accessed on 2020 Aug 22].  Back to cited text no. 12
Panchamukhi PR. Social impact of economic reforms in India: A critical appraisal. Econ Polit Wkly 2000;35:836-47.  Back to cited text no. 13
Hati KK, Majumder R. Health Infrastructure, Health Outcome and Economic Wellbeing: A District Level Study in India MPRA; 2013. p. 53363. Available from: [Last Accessed on 2021 Jun 03].  Back to cited text no. 14
Dev SM, Mooij J. Social sector expenditures in the 1990s analysis of central and state budgets. Econ Polit 2002;37:853-66.  Back to cited text no. 15
Joshi S. Impact of economic reforms on social sector expenditure in India. Econ Polit Wkly 2006;41:358-65.  Back to cited text no. 16
Kumar R, Soumya A. Fiscal policy issues for India after the global financial Crisis (2008–2010). Asian Development Bank Institute, Working Paper No. 249; 2010.  Back to cited text no. 17
Mukherjee S. State of Public Finance and Fiscal Management in India during 2001-16. National Institute of Public Finance and Policy, Working Series, 265; 2019.  Back to cited text no. 18
Sheth H. Changing trends in the healthcare sector in India. Abhinav Int Mon Refereed J Res Manag Technol 2014;3:42-6.  Back to cited text no. 19
Ferguson JC. Fatty acid and carbohydrate storage in the annual reproductive cyclice of Echinaster. Comp Biochem Physiol A Comp Physiol 1975;52:585-90.  Back to cited text no. 20
Das PK, Kar S. Public Expenditure, Demography and Growth: Theory and Evidence from India. Discussion Paper No. 9721; 2016. Available from: [Last Accessed on 2020, Jul 16].  Back to cited text no. 21
Saikia D, Das KK. Access to public healthcare in the rural Northeast India. NEHU J 2014;12:77- 100.  Back to cited text no. 22
Bhuyan R, Kalita N Goswami G. Health performance index and healthcare expenditure in Assam: Are there any structural change? Issues on Health and Healthcare in India. 2018. p. 22939. Available from: [[Last Accessed on 2019 Nov 06].  Back to cited text no. 23
Parveen A, Barua NA. Capacity creation in health infrastructure and their outcomes: A study in spatial disparity in Assam. Indian J Public Health Res Dev 2019;10:2456-61.  Back to cited text no. 24
Hossain F. Levels of health care and health outcomes in Northeast India. Indian Journal of Human Development 2019;13:221-32.  Back to cited text no. 25
Reserve Bank of India: State Finance Reports (199293 to 201920). Available from: AnnualPublications.aspx?head=State%20Finances%20:%20A%20 Study%20of%20Budgets [Last Accessed on 2021 Oct 07].  Back to cited text no. 26
Rural Health Statistics Reports: 199297, 19972002, 20022007, 20072012 and 20122017. Available from: https://ruralindiaonline. org/en/library/resource/ruralhealthstatistics. [Last Accessed on 2021 Oct 07].  Back to cited text no. 27
Nathan HS, Mishra S, Reddy BS. An Alternative Approach to Measure HDI; 2008. Available from: WP2008001.pdf. 29. [Last Accessed on 2021 Jul 03].  Back to cited text no. 28
Sarma M. Index of Financial Inclusion – A Measure of Financial Sector Inclusiveness. Working Paper No. 07/2012; 2008. Available from: Money_Finance_Trade_Development/working_paper_series/ wp_07_2012_Sarma_IndexofFinancialInclusion.pdf. [Last Accessed on 2021 Jun 20].  Back to cited text no. 29
Chatterjee S, Laha A. Association between public health care access and financing of health infrastructure in India: An interstate analysis. J Health Manage 2016;18:258-73.  Back to cited text no. 30


  [Figure 1]

  [Table 1]


    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
    Access Statistics
    Email Alert *
    Add to My List *
* Registration required (free)  

  In this article
    Materials and Me...
    Article Figures
    Article Tables

 Article Access Statistics
    PDF Downloaded137    
    Comments [Add]    

Recommend this journal