Article

Health Infrastructure Disparities in Journal of Infrastructure Development

12(1) 25–38, 2020
Punjab: An Inter-district Analysis © 2020 India Development Foundation
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DOI: 10.1177/0974930620902311
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Gulshan Kumar1
Jagmohan Singh2

Abstract
Economic and social development can be achieved by improving the health conditions of people which,
in turn, depend upon the development and provision of health infrastructure facilities in any region
or society. Better and sound health infrastructure is of paramount importance to support the health
conditions of people in any region. Keeping this in mind, the present study has attempted to examine
the inter-district disparities in health infrastructure in Punjab. Using principal component analysis, a
district-level health infrastructure index (HII) for Punjab has been constructed at three points of time,
that is, 1994, 2008 and 2018. The study detected the presence of inter-district disparities in health infra-
structural facilities in Punjab. Barnala, Faridkot, Fatehgarh Sahib, Mansa and Shri Muktsar Sahib have been
identified as improving districts, whereas Amritsar, Firozpur, Hoshiarpur, Jalandhar, Kapurthala, Ludhiana,
Moga, Patiala and Tarn Taran appeared under deteriorating category. Bathinda, Gurdaspur, Rupnagar and
Sangrur have been traced under fluctuating district category while Sahibzada Ajit Singh (SAS) Nagar and
Shaheed Bhagat Singh (SBS) Nagar have emerged as stable districts for the study period.

JEL Classification: C38, H54, I19

Keywords: Health infrastructure index, inter-district disparities, principal component analysis, Punjab

1. Introduction

Economic development is a multifaceted process by which a country ameliorates the economic and
social well-being of its citizens involving qualitative as well as quantitative changes in human capital,
living standard of people, educational facilities and health status, etc. The development of social infra-
structure in general and health infrastructure in particular reflects the quality of life of people in any
country. The linkages between health and development have been well acknowledged, and health may
not be regarded as an end product of development but a crucial contributor to the development process
of a nation (Lyngdoh 2015). Good and vibrant health is an essential determinant of higher labour produc-
tivity, improved levels of well-being and economic growth. Moreover, for achieving the indispensable

1
University Institute of Legal Studies, Panjab University, Chandigarh, India.
2
Department of Evening Studies—Multi Disciplinary Research Centre, Panjab University, Chandigarh, India.

Corresponding author:
Gulshan Kumar, University Institute of Legal Studies, Panjab University, Chandigarh 160014, India.
E-mail: jsgsass40@rediffmail.com
26 Journal of Infrastructure Development 12(1)

societal objectives of economic growth and poverty alleviation, creation and provision of health infra-
structure is of paramount importance (Pradhan, Kumar, and Sanyal 2011).
World Health Organization (1948) in the preamble to its constitution defined health as ‘a state of
complete physical, mental and social well-being and not merely an absence of disease or infirmity’.
Health is an asset people possess and is the ability of people to develop to their potential during their
lives. Infrastructure is a physical framework of facilities to provide goods and services to the public
(Lakshmi and Sahoo 2013). Health infrastructure consists of physical health care infrastructure, that is,
hospitals, community health centres (CHCs), primary health centres (PHCs), dispensaries, ayurvedic
institutions, unani institutions, homoeopathic institutions, and beds in medical institutions, and man-
power resources, that is, doctors, midwives, nurses, etc. An efficient and sound health infrastructure is
an important determinant of improved health status of people. Role and importance of health infrastruc-
ture in eradicating diseases and improving crude birth rate, crude death rate, life expectancy, infant
mortality rate, and maternal mortality rate, etc., is well recognised all over the globe. Provisioning and
working of any health care system can be well understood by its health infrastructure facilities. The goal
of health care system is to enhance health status of people which is feasible in complementarity with
sound health infrastructural set up.

2. Review of Literature

Analysis of infrastructure, in general and health infrastructure, health care services and health outcomes
in particular, through formation of composite indices is very prominent among researchers and policy-
makers. Available literature on the subject has been scanned, reviewed and then discussed as below.
Rout (2007) constructed a composite index of health infrastructure to examine the inter-district vari-
ations in health infrastructural facilities in Orissa. The study found 53 per cent of districts fall under
developed health infrastructure category while 23 per cent districts fall within relatively low health
infrastructure category. Kumar and Singh (2010) made an attempt to examine the status and utilisation
pattern of health infrastructure in rural Punjab. In the study, 180 rural households from 18 villages of
Jalandhar, Bathinda and Fatehgarh Sahib districts of Punjab were surveyed during the second half of
2007–08 to study the utilisation pattern of health services. The study revealed wide disparities in health
infrastructure and health indicators between rural and urban areas of the state. The study suggested the
government should take necessary action to improve quality of public health services in rural areas.
Kumari and Raman (2011) formulated composite indices of health and educational attainment at two
points of time, that is, 1990–91 and 2007–08, for Uttar Pradesh using principal component analysis.
The study detected the existence of inter-district variations with respect to health and education attain-
ment. It was also observed that the districts with good health attainment are worse performers as far as
educational attainment is concerned and vice versa. Saikia and Bhattacharjee (2011) constructed
Mazziotta–Pareto Index (MPI) to quantify the health facilities available in 26 districts of Assam. The
study suggested the state government should take initiatives to promote equal distribution of health
services in different districts. Lakshmi and Sahoo (2013) developed health infrastructure index for the
state of Andhra Pradesh for the time period 1980–2010 by using principal component analysis tech-
nique. The study observed significant and positive bearing of health infrastructure on health dimensions
like crude birth rate, life expectancy at birth, etc. The study concluded that public health facilities are
vital for satisfying the basic health requirements of the people in the state. Anand (2014) attempted to
measure inequality in health status and health care services through composite indices of health status
and health services in Uttar Pradesh and Bihar. Lower overall health status, presence of wide
Kumar and Singh 27

inter-district and inter-regional health disparities have been discovered in the two states. The study
further detected the existence of lower health status disparities and relatively high disparities in health
infrastructure in Uttar Pradesh as compared to Bihar. Roy and Mondal (2015) examined the block-level
health care infrastructure of Malda district in West Bengal by developing a health index. The study
identified that 3 blocks out of total 15 blocks fall under comparatively more developed blocks category,
4 blocks under comparatively developed blocks category and remaining 8 blocks fall under compara-
tively less developed category. The study suggested that health infrastructure should be strengthened to
improve the health conditions of the people. Lyngdoh (2015) computed a health care infrastructure
index for the eight north-eastern states for the years 2001 and 2011. The study applied principal com-
ponent analysis on 16 indicators, covering physical infrastructure as well as manpower resources to
construct health care infrastructure index and detected that Tripura and Mizoram were the better per-
forming states during both of the periods under study; Arunachal Pradesh reported a huge improvement
in 2011 over 2001, while Assam and Meghalaya emerged as the poor performers in the region. Further,
the study concluded that it is need of the hour to address various problems associated with public health
care system in the north-eastern states. Chaudary (2016) constructed a state-level annual time series
health index for the time period from 1983–84 to 2005–06. As per the study, health index showed
improvement in material access over the years for all the states of India, while health infrastructure and
health care utilisation has improved between the time period ranging from 1983–84 to 1994–95 and
stagnated since mid-1990s. The study suggested that better rural health status can be achieved by bring-
ing down health risks, strengthening rural health infrastructure and increasing health awareness. Goel
and Garg (2018) examined the status of health infrastructure in Haryana state by formulating a health
infrastructure index for the time period 1991–92 to 2011–12. The study detected variations in the avail-
ability of health infrastructural facilities in the state and suggested government should take necessary
action to improve the status of health infrastructure in the state.
No study related to the construction of health infrastructure index (HII), particularly for the state of
Punjab that too spearheading the examination of the inter-district disparities, could be traced. The pre-
sent study is an attempt to fill the gap in literature by analysing inter-district health infrastructure dispari-
ties in Punjab through construction of a district-level composite HII.

3. Objectives of the Study

The main objectives of the study are as follows:

1. To examine inter-district disparities in health infrastructure of Punjab.

2. To analyse the growth of health infrastructural facilities at district level in Punjab.

4. Description of the Study Area

Punjab is a state in northern region of India having a geographical area of 50,362 km2 with population of
27,743,338 inhabitants, which is scattered over 20 districts, 77 tehsils, 217 towns and 12,581 villages
(Government of India 2011). (It is notable that at present, total number of districts is 22.) It is flanked by
Jammu and Kashmir to the north, Himachal Pradesh to the east and Haryana and Rajasthan to the south.
In Punjab, public health care system operates at three levels, namely (a) at primary level which con-
sists of CHCs, PHCs and dispensaries provide the curative (outpatient care), preventive and promotion
28 Journal of Infrastructure Development 12(1)

Table 1. Demographic, Socio-economic and Health Profile of Punjab in Comparison to Aggregate at National Level

Sr. No. Indicator Punjab All India Source

1. Total population( (in millions) 27.74 1210.85 Census of India (2011)
2. Decadal percentage population growth 13.89 17.64 Census of India (2011)
3. Crude birth rate 14.9 20.4 Sample registration system
(SRS) statistical report (2016)
4. Crude death rate 6.0 6.4 SRS statistical report (2016)
5. Total fertility rate 1.7 2.3 SRS statistical report (2016)
6. Infant mortality rate 21 34 SRS statistical report (2016)
7. Maternal mortality ratio (SRS, 2014–16) 122 130 SRS special bulletin on maternal
mortality in India (2014–16)
8. Sex ratio 895 940 Census of India (2011)
9. Percentage population below poverty 11.3 29.5 Department of Planning,
line Government of Punjab (2015)
10. Literacy rate (%) 75.84 74.04 Census of India (2011)
11. Female literacy (%) 70.73 65.46 Census of India (2011)
12. Male literacy (%) 80.44 82.14 Census of India (2011)
13. Schedule caste population (in millions) 8.86 201.37 Census of India (2011)

care services such as immunisation, maternal and child health, and family welfare; (b) at secondary level
which includes tehsil and district-level hospitals providing curative (outpatient and inpatient care) and
preventive care services; and (c) at tertiary level which includes hospitals attached to the public and
private medical colleges and hospitals established by the Union Government providing specialised out-
patient and inpatient care. Table 1 shows the demographic, socio-economic and health profile of Punjab
in comparison to aggregate at national level.

5. Database and Analytical Tools

The present study aimed at examining inter-district disparities in health infrastructure in Punjab through
the construction of a district-level composite HII capturing various dimensions of health infrastructure
at three points of time, that is, 1994, 2008 and 2018.Various indicators to construct HII have been selected
by developing insight from the review of literature. The present study has used secondary data which
were culled from various issues of Statistical Abstract of Punjab, Government of Punjab (1994, 2008
& 2018). The indicators (modified) used to construct HII are as follows:

A1—Number of hospitals per 100,000 population.

A2—Number of Community Health Centres (CHCs) per 100,000 population.
A3—Number of Primary Health Centres (PHCs) per 100,000 population.
A4—Number of dispensaries per 100,000 population.
A5—Number of ayurvedic institutions per 100,000 population.
Kumar and Singh 29

A6—Number of homoeopathic institutions per 100,000 population.

A7—Number of doctors per 1,000 population.
A8—Number of midwives per 1,000 population.
A9—Number of nurses per 1,000 population.
A10—Number of beds per 1,000 population.

Here, the indicators A1, A2, A3, A4, A5, A6 and A10 represent physical infrastructure, while indicators A7,
A8 and A9 represent manpower resources in the health sector of Punjab state. PHCs and dispensaries
serve rural areas of the state. PHCs are the first link between village community and the medical officer.
In medium/smaller towns and some larger villages, CHCs provide health care facilities and CHC is the
first referral unit for PHCs offering specialist care, while in large urban towns, hospitals provide tertiary
health care facilities (both the curative and preventive). Hospitals, CHCs, PHCs and dispensaries provide
allopathic health care facilities, while ayurvedic and homoeopathic institutions are part of Ayurveda,
Yoga & Naturopathy, Unani, Siddha and Homoeopathy (AYUSH) system of indigenous medicine.
Doctors, midwives and nurses represent manpower resources in the state which are an important part of
health infrastructure.
Modification of indicators has been exercised to assess the availability of resources in real sense, that
is, to get a true relative picture as there are huge inter-district differences in population between different
districts of Punjab. All indicators except the number of beds per 1,000 of population (as it was already
available in comparable form, i.e., per 1,000) have been modified using data for mid-year projected
population for the concerned districts over the study period.
To modify the indicator, number of hospitals per 100,000 population (A1) in district i at time period t
following procedure has been applied:

Ait
A1  *100, 000 (1).
Pit

where Ait = number of hospitals in district i at time period t.

Pit = mid-year projected population of district i at time period t.

The same procedure has been followed to modify indicators, namely (A2), (A3), (A4), (A5) and (A6).
In case of indicator, number of doctors per 1,000 population (A7) in district i at time period t following
modification procedure has been adopted:

Ait
A7  *10, 000 (2).
Pit

where Ait = number of doctors in district i at time period t.

Pit = mid-year projected population of district i at time period t.

In the same manner, indicators (A8) and (A9) have been dealt with to modify their form, that is, ‘per
1,000’ in parity with indicator A7. Data pertaining to number of beds per 1,000 population (A10) was
already available in the required form (i.e., per 1,000) and was used in the analysis in its given form.
Nine indicators except number of midwives per 1,000 population (A8) (due to unavailability of data
for the indicator) have been used for the years 1994 and 2008, while for year 2018, all 10 indicators have
been used for index construction.
30 Journal of Infrastructure Development 12(1)

To examine inter-district disparities in the health infrastructure of Punjab, HII has been constructed
using weighted mean approach (Dhillon and Singh 2012; Kumar, Batra and Attri 2017) by applying
following formula on selected indicators:
n
∑ NW i=1 ij i
HII j = n
(3).

∑ W i=1 i

where HIIj = health infrastructure index for jth district.

Nij = Normalised value of ith variable for jth district.
Wi = weight of ith variable.
Wi = sum of the weights.

Min–max normalisation technique (OECD 2008; Goel and Garg 2018) has been used to normalise the
variables, and the normalised values for all variables come up within a limit of 0–1. The following formula
has been applied to normalise values of ith variable for jth district:

Actual Value of VariableAi − Minimum Value of VariableAi

N ij = (4).
Maximum Value of VariableAi − Minimum Value of VariableAi

Principal component analysis technique of factor analysis has been used to obtain weights for the selected
variables. This multivariate statistical technique analyses the interrelationship among a large numbers of
variables by describing these variables in terms of their common underlying dimensions known as fac-
tors (Hair et al. 2006). To identify underlying dimensions or factors, factor analysis has been used. Factor
analysis explains the correlations between a set of correlated variables and identify a new, smaller set of
uncorrelated variables which replace the original set of correlated variables (Malhotra and Dash 2018).
Factors have been extracted using principal component analysis approach of factor analysis. Principal
component analysis technique linearly converts an original set of correlated variables into a smaller set
of uncorrelated factors called principal components with a minimal loss of information. Principal com-
ponents or factors (Pi, i = 1 to n), which are orthogonal to each other, are linear combinations of variables
(Aj, j = 1 to m) which can be represented as:

P1 = a11 A1+ a12 A2 + a13 A3 + ………+ a1m Am

P2 = a21 A1+ a22 A2 + a23 A3 + ………+ a2m Am
. . .
. . .
. . .
Pn = an1 A1+ an2 A2 + an3 A3 + ………+ anm Am
or
m
Pi = ∑ aij Aj (5).
j=1

Kumar and Singh 31

where aij is factor loading depicting correlation between the original variable and the factor, which is
calculated in such a way that resulting principal components are uncorrelated. First principal component
accounts for highest variance in the data, the second component the next highest and so on (Malhotra and
Dash 2018). The relationship of variables to the underlying factors is expressed by factor loadings, and
factor loadings with large values imply that factors and variables are strongly related. The factor loadings
with values greater than or equal to 0.45 (ignoring signs) are considered as significant and retained (Hair
et al. 2006). Latent root, that is, eigenvalue, criterion has been used to extract factors. An eigen value
depicts the amount of variance explained by a factor. Factors with eigen value greater than 1 are consid-
ered as significant (Hair et al. 2006) and used in analysis.
Relative weights for the variables have been assigned (Kaur and Dhillon 2015; Kaur and Kaur 2018) as:

Wi = FikVk (6).

where Wi indicates weight of ith variable.

Fik indicates factor loading of ith variable on kth factor.
Vk indicates variation explained by kth factor.

Further, the relative position of districts regarding health infrastructure status on the basis of HII index
has been ascertained by assigning ranks to the districts for each point of time. The district which keeps
highest index value for a given point of time has been assigned 1st rank, whereas the district with
second highest index value has been assigned 2nd rank and so on. The district getting 1st rank in the
index indicates better health infrastructural facilities as compared to the district with 2nd rank, while
the district in 3rd position keeps relatively lower health infrastructural facilities in relation to the dis-
tricts with 2nd and 1st rank for a given point of time (see columns iii, v and vii of Table 5 vertically
for application and results).
The study further focused at analysing the growth of health infrastructural facilities at district level in
Punjab. Districts have been given ranks according to their performance in terms of HII for the years
1994, 2008 and 2018. Descending rank (say from 5th to 4th to 3rd…) of a district in time period t (1994)
in contrast to the time period t′ (2008) and t″ (2018) exhibits improvement in the performance of a dis-
trict, while ascending rank (say from 4th to 5th to 6th…) in time period t (1994) in comparison to the
time period t′ (2008) and then in time period t″ (2018) evinces deterioration in the performance of a
district in health infrastructural facilities (see rows 1 to 22 of Table 5 horizontally for application and
results). On the basis of performance in HII, the districts have been categorised into four categories, that
is, improving, deteriorating, fluctuating and stable. The districts whose HII ranks are continuously
descending over the study period fall under improving district category; the districts whose HII ranks are
continuously ascending fall under deteriorating district category; the districts with mixed performance
fall under fluctuating district category; and the districts with stable rank over the entire study period have
been put into stable district category.

6. Results and Discussion

This section presents the results of the empirical investigation of inter-district disparities in health infra-
structure of Punjab. Since health infrastructure includes various indicators, an attempt has been made to
formulate a composite HII in order to analyse the growth level of health infrastructure in the state.
32 Journal of Infrastructure Development 12(1)

HII has been constructed using the weights computed by principal component analysis approach of fac-
tor analysis for the years 1994, 2008 and 2018.
The results of factor analysis of selected indicators for the year 1994 are presented in Table 2. Table
2 shows that two factors are extracted from nine selected health infrastructure indicators for 12 districts
of Punjab, which explains 71.62 per cent inter-district variations. The first factor explains 35.91 per cent
of total inter-district variations in health infrastructure in Punjab. The most important indicator loaded on
the first factor is number of dispensaries per 100,000 population with factor loading 0.939 followed by
number of ayurvedic institutions per 100,000 population (0.817), number of CHCs per 100,000 popula-
tion (0.748), number of homoeopathic institutions per 100,000 population (0.702) and number of hospi-
tals per 100,000 population (0.614). The second factor accounts for 35.704 per cent of total inter-district
variations and contains indicators such as number of beds per 1,000 population, number of doctors per
1,000 population, number of PHCs per 100,000 population and number of nurses per 1,000 population
with factor loading values 0.910, 0.873, 0.842 and 0.406, respectively.
The results of factor analysis for the year 2008 are presented in Table 3 and show that three factors are
extracted from nine indicators for 20 districts of Punjab explaining 73.84 per cent inter-district variations.
The first factor explains 28.96 per cent of variance and includes number of hospitals per 100,000 popula-
tion (0.818), number of doctors per 1,000 population (0.720), number of PHCs per 100,000 population
(0.705) and number of CHCs per 100,000 population (0.703). The second factor accounts for 22.88 per cent
of the total variance and includes number of homoeopathic institutions per 100,000 population (0.925),
number of ayurvedic institutions per 100,000 population (0.698) and number of beds per 1,000 population
(0.690). The third factor explains 21.99 per cent of the total variations which is based on number of dispen-
saries per 100,000 population (0.735) and number of nurses per 1,000 population (0.708).
The results of factor analysis for the year 2018 are presented in Table 4. Four factors are extracted on the
basis of 10 selected health infrastructure indicators for 22 districts of Punjab which explain 76.17 per cent

Table 2. Results of Factor Analysis for the Year 1994

Factor Loadings Weights in

Variables Component 1 Component 2 Weights Percentage
A1 0.614 0.596 22.053 8.985
A2 0.748 −0.364 26.866 10.947
A3 0.176 −0.842 30.062 12.249
A4 0.939 −0.015 33.726 13.742
A5 0.817 −0.389 29.344 11.956
A6 0.702 −0.331 25.213 10.273
A7 −0.270 0.873 31.169 12.700
A9 −0.323 0.406 14.495 5.906
A10 −0.210 0.910 32.490 13.238
Eigenvalue 3.233 3.213
Per cent variance explained 35.917 35.704
Cumulative variance explained in per cent 35.917 71.622
Source: Authors’ calculations using SPSS version 20.
Note: Bold value indicates highest factor loading of a variable on components.
Kumar and Singh 33

Table 3. Results of Factor Analysis for the Year 2008

Factor Loadings Weights in

Variables Component 1 Component 2 Component 3 Weights Percentage
A1 0.818 −0.016 0.116 23.691 13.937
A2 −0.703 −0.131 0.462 20.360 11.977
A3 −0.705 0.127 0.388 20.418 12.011
A4 −0.241 0.435 0.735 16.167 9.510
A5 −0.104 0.698 0.641 15.971 9.395
A6 0.112 0.925 0.098 21.165 12.451
A7 0.720 −0.121 −0.335 20.852 12.267
A9 0.109 0.054 −0.708 15.573 9.161
A10 0.578 −0.690 0.168 15.788 9.287
Eigen value 2.607 2.059 1.980
Per cent variance explained 28.962 22.882 21.996
Cumulative variance 28.962 51.844 73.840
explained in per cent
Source: Authors’ calculations using SPSS version 20.
Note: Bold value indicates highest factor loading of a variable on components.

Table 4. Results of Factor Analysis for the Year 2018

Factor Loadings Weights in

Variables Component 1 Component 2 Component 3 Component 4 Weights Percentage
A1 0.182 0.152 0.678 0.257 12.937 8.566
A2 −0.702 0.178 0.016 −0.037 14.255 9.439
A3 −0.082 0.926 0.024 0.005 18.282 12.106
A4 −0.388 0.771 0.277 −0.017 15.221 10.079
A5 −0.286 0.387 0.668 −0.297 12.746 8.440
A6 −0.107 −0.047 0.937 −0.084 17.879 11.839
A7 0.767 −0.091 0.094 0.367 15.575 10.313
A8 0.010 −0.181 −0.070 0.876 14.932 9.888
A9 0.014 0.519 0.091 0.740 12.614 8.353
A10 0.816 −0.073 −0.157 −0.304 16.570 10.972
Eigen value 2.031 1.974 1.908 1.705
Per cent variance explained 20.307 19.743 19.082 17.046
Cumulative variance 20.307 40.050 59.132 76.178
explained in per cent
Source: Authors’ calculations using SPSS version 20.
Note: Bold value indicates highest factor loading of a variable on components.
34 Journal of Infrastructure Development 12(1)

of total inter-district variations. The first factor explains 20.30 per cent of total variations in inter-district
disparities in health infrastructure in Punjab. The most important indicators in the first factor are number
of beds per 1,000 population with factor loading 0.816 followed by number of doctors per 1,000 popula-
tion (0.767) and number of CHCs per 100,000 population (0.702). Number of primary health care cen-
tres per 100,000 population with factor loading 0.926 and number of dispensaries per 100,000 population
with factor loading 0.771 loads on the second factor which accounts for 19.74 per cent of the total vari-
ance. The third factor explains 19.08 per cent variance and contains indicators such as number of homoe-
opathic institutions per 100,000 population, number of hospitals per 100,000 population and number of
ayurvedic institutions per 100,000 population with factor loading values 0.937, 0.678 and 0.668, respec-
tively. The fourth factor accounts for 17.046 per cent variance and includes number of midwives per
1,000 population with factor loading value of 0.876 and number of nurses per 100,000 population with
factor loading value of 0.740.
District-level HII for the state of Punjab has been constructed on the basis of selected indicators of
health infrastructure using weighted mean approach. Principal component analysis technique has been
applied to calculate the weights. HII for the years 1994, 2008 and 2018 is presented in Table 5 along with
the resulting ranks of the different districts. In 1994, Kapurthala was at the top of HII with a value of
0.6775 followed by Hoshiarpur (0.5602), Rupnagar (0.5510), Amritsar (0.4841) and Jalandhar (0.4568).
Bathinda had the lowest HII value (0.1601) in 1994. Other districts with low HII value were Faridkot
(0.3412), Sangrur (0.3594), Firozpur (0.3626) and Ludhiana (0.3670). Table 5 shows that HII, in 2008,
lied between 0.2923 and 0.5973. SBS Nagar occupied the top position with highest value (0.5973), while
Hoshiarpur maintained its second position with index value of 0.5485. Other districts which followed
Hoshiarpur were Kapurthala (0.5477), Faridkot (0.5128) and Rupnagar (0.5094). Shri Muktsar Sahib
had the lowest position with index value 0.2923 followed by Fatehgarh Sahib (0.3085), Moga (0.3190),
Ludhiana (0.3258) and Mansa (0.3387). In 2018, SBS Nagar maintained its first rank with index value
of 0.5856 followed by Rupnagar (0.5232), Faridkot (0.5160), Kapurthala (0.5101) and Hoshiarpur (0.4537).
Table 5 further shows that Pathankot (0.1766) was the worst performer in 2018, while Fazilka (0.2208),
Ludhiana (0.2414), Moga (0.2732) and Amritsar (0.2864) performed slightly better than Pathankot.
Table 5 further reveals that position of Amritsar, Firozpur, Jalandhar, Ludhiana and Tarn Taran dis-
tricts has deteriorated drastically over the years. Amritsar which was at 4th rank in 1994, shifted to 10th
rank in 2008 and further plunged to 18th rank in 2018. Firozpur district experienced a downfall from 9th
rank in 1994 to 13th in 2008 and further experienced a marginal fall to 14th rank in the year 2018. Rank
of Jalandhar declined to 8th in 2008 from 5th in 1994 and further deteriorated to 17th position in 2018.
Rank of Ludhiana which was 8th in 1994 drooped to 17th in 2008 which further declined to 20th in 2018.
Tarn Taran experienced a steep downfall from 6th rank in 2008 to 16th in 2018. Barnala marginally
improved its rank to 9th position in 2018 from 11th position in 2008. In the year 1994, the rank of
Bathinda district was 12th, which got augmented to 9th in the year 2008 and then experienced a downfall
to 11th position in the year 2018. Faridkot improved upon its position by securing 4th rank in 2008 from
11th in 1994 which further escalated to 3rd rank in the year 2018. Fatehgarh Sahib showed improvement
in its rank from 19th in 2008 to 15th in 2018. Rank of Gurdaspur district plunged to 14th in 2008 from
7th in 1994, and it got improved to 6th rank in the year 2018. Hoshiarpur maintained 2nd position for the
year 1994 and 2008, but its rank declined to 5th in the year 2018. Kapurthala which secured 1st rank in
1994 got relegated to 3rd rank in 2008, and it further plunged to 4th rank in the year 2018. In 2018,
Mansa, Shri Muktsar Sahib and Sangrur augmented their ranks from 16th, 20th and 15th to 8th, 13th and
10th, respectively. Moga shifted to 19th position in the year 2018 from its 18th position in 2008. Rank
of Patiala declined to 7th in 2008 from 6th in 1994, and it remained at 7th spot in the year 2018. Rupnagar
experienced a downfall in its rank to 5th position in 2008 from 3rd position in 1994, but it secured 2nd
Kumar and Singh 35

Table 5. Health Infrastructure Index

Districts HIIPeriodt RankPeriodt HIIPeriodt′ RankPeriodt′ HIIPeriodt″ RankPeriodt″

Sr. No. (i) (ii) (iii) (iv) (v) (vi) (vii)
1. Amritsar 0.4841 4 0.3964 10 0.2864 18
2. Barnala# — — 0.3961 11 0.3706 9
3. Bathinda 0.1601 12 0.4124 9 0.3613 11
4. Faridkot 0.3412 11 0.5128 4 0.5160 3
*
5. Fatehgarh Sahib — — 0.3085 19 0.3363 15
6. Fazilka@ — — — — 0.2208 21
7. Firozpur 0.3626 9 0.3839 13 0.3364 14
8. Gurdaspur 0.4030 7 0.3719 14 0.4350 6
9. Hoshiarpur 0.5602 2 0.5485 2 0.4537 5
10. Jalandhar 0.4568 5 0.4336 8 0.3087 17
11. Kapurthala 0.6775 1 0.5477 3 0.5101 4
12. Ludhiana 0.3670 8 0.3258 17 0.2414 20
13. Mansa* — — 0.3387 16 0.3767 8
**
14. Moga — — 0.3190 18 0.2732 19
15. Shri Muktsar Sahib — — 0.2923 20 0.3382 13
@
16. Pathankot — — — — 0.1766 22
17. Patiala 0.4151 6 0.4471 7 0.4106 7
18. Rupnagar 0.5510 3 0.5094 5 0.5232 2
19. SAS. Nagar# — — 0.3893 12 0.3399 12
20. SBS. Nagar** — — 0.5973 1 0.5856 1
21. Sangrur 0.3594 10 0.3621 15 0.3652 10
22. Tarn Taran# — — 0.5070 6 0.3355 16
Source: Authors’ calculations using SPSS version 20.
Notes: (1) * Districts were established in 1992.
** Districts were established in 1995.
# Districts were established in 2006.
@ Districts were established in 2011.
(2) Periods t, t′, and t″ represent years 1994, 2008 and 2018, respectively.
(3) See vertically, columns (iii), (v) and (vii), 1st rank represents relatively better position of a district, while 22nd rank
represents worst position of a district in terms of health infrastructure in the state.
(4) See horizontally, row wise perusal of descending ranks [e.g., from 9th rank in period t to 8th rank in period t′ and
then to 7th rank in period t″] indicates improvement in health infrastructural facilities in a particular district and vice
versa.

position in the year 2018. In the year 2008 and 2018, SBS Nagar and SAS. Nagar remained in 1st and
12th positions, respectively.
On the basis of performance in HII from 1994 to 2018, districts were categorised into four categories,
that is, improving, deteriorating, fluctuating and stable districts. Categorisation of the districts according
to their performance in HII is presented in Table 6. Table 6 reveals Barnala, Faridkot, Fatehgarh Sahib,
36 Journal of Infrastructure Development 12(1)

Table 6. Categorisation of the Districts of Punjab According to Performance in Health Infrastructure Index

District Number of
Category Districts Name of Districts
Improving 5 Barnala, Faridkot, Fatehgarh Sahib, Mansa and Shri Muktsar Sahib
Deteriorating 9 Amritsar, Firozpur, Hoshiarpur, Jalandhar, Kapurthala, Ludhiana,
Moga, Patiala and Tarn Taran
Fluctuating 4 Bathinda, Gurdaspur, Rupnagar and Sangrur
Stable 2 SAS Nagar and SBS Nagar
Source: Author’s own calculations based on available data for the study period.

Mansa and Shri Muktsar Sahib are included in the improving districts category as these districts have
shown improvements in HII, while Faridkot is the most improving district in the state. There are nine
districts, namely Amritsar, Firozpur, Hoshiarpur, Jalandhar, Kapurthala, Ludhiana, Moga, Patiala and
Tarn Taran, which fall under deteriorating districts category. Amritsar, Jalandhar and Ludhiana are worse
performers in terms of growth of health infrastructural facilities. Bathinda, Gurdaspur, Rupnagar and
Sangrur fall under fluctuating districts category as these districts have shown fluctuating growth in health
infrastructural facilities. SAS Nagar and SBS Nagar fall into stable districts category as they have shown
no improvement or deterioration in health infrastructural facilities over time. Fazilka and Pathankot were
not assigned into any category as both districts were created in July 2011, and it was infeasible to com-
ment upon any kind of improvement/deterioration made by the districts over the study period.

7. Summary and Conclusion

The present study examines inter-district disparities in health infrastructure in the state of Punjab for the
years 1994, 2008 and 2018 on the basis of a district-level composite HII. It is revealed that district
Kapurthala occupied the top position in the year 1994 followed by Hoshiarpur, Rupnagar, Amritsar and
Jalandhar, while Bathinda district appeared as worst performer on the health infrastructure front. In
2008, SBS Nagar was ahead of all followed by Hoshiarpur, Kapurthala, Faridkot and Rupnagar, while
Ludhiana Gurdaspur, Amritsar and Firozpur districts deteriorated their respective positions in 2008.
Shri Muktsar Sahib was at the lowest ebb, while Moga and Fatehgarh Sahib were slightly better placed
as compared to Shri Muktsar Sahib. For the year 2018, SBS Nagar was again observed at the top most
position followed by Rupnagar, Faridkot, Kapurthala and Hoshiarpur. Pathankot had the lowest index
value in the year 2018 followed by Fazilka, Ludhiana, Moga and Amritsar. The study, further, identified
that the three so-called advanced districts of the state, that is, Amritsar, Jalandhar and Ludhiana, are
among the deteriorating district category in terms of health infrastructural facilities and lagging behind
the districts such as Barnala, Faridkot, Fatehgarh Sahib, Mansa and Shri Muktsar Sahib.
On the basis of above discussion, one may conclude that there are extensive inter-district disparities
in health infrastructure development in Punjab which can only be addressed through formulation and
implementation of appropriate policies. Almost half of the districts of the state have been detected under
deteriorating category which is a matter of grave concern. Only five districts have shown improvement
regarding health infrastructural facilities over the study period, whereas four districts are transpired as
fluctuating districts. It is high time for the government to initiate necessary action to strengthen the
health infrastructure in the state on even basis. The districts observed to show dismal performance on
Kumar and Singh 37

health infrastructure front should be assigned more funds to bring them at par with their counterparts.
Moreover, government must take care of fresh appointment of doctors, nurses and supporting staff to
enhance manpower resources in this sector of state.
Finally, provision of adequate health infrastructure alone is not enough to yield better health outcome
as it also depends upon the maintenance as well as operational efficiency. Thus, to improve the health
status of people of the state, provision as well as maintenance of physical infrastructure and ensuring
availability as well as promotional efficiency of human capital in this sector are to be taken care of.

Declaration of Conflicting Interests

The authors declare that there is no conflict of interest with respect to the research, authorship and/or
publication of this article.

Funding

The authors received no financial support for the research, authorship and/or publication of this article.

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