Supply-side Readiness for Universal Health Coverage: Assessing Service Availability and Barriers in Remote and Fragile Setting

The study was conducted to a) Evaluate the service readiness and b) Ascertain supply side barriers inhibiting service provisioning in rural, remote and fragile district in India. We employed a mixed method study design encompassing Service Provisioning Assessment of entire network of public health facilities using Service Availability and Readiness Assessment (SARA) module of WHO in conjunction with Indian Public Health Standards Guidelines (IPHS). Qualitative information was collected via Field Observations, Key informant interviews and Focus group discussion with stakeholders ranging from leaders to laggards. A concise index of General Service Availability, Service Specific Availability and Facility Readiness was computed along with exploratory data analysis using Principal Component Analysis. Further, determinants of facility readiness were elucidated using Generalized Ordinal Logistic Model. Qualitative findings were analyzed via content analysis. Results indicated poorest readiness in lower-tier facilities with particularly abysmal readiness for basic amenities, diagnostic capacity and preparedness for emergencies and non-communicable diseases. The estimates for logistic model revealed that degree of vulnerability of facilities, type of facility and frequency of monitoring and supervision significantly impacted the readiness. Qualitative analysis divulged lack of incentives for health workers, political interference, topographical constraints and security disruptions as major barriers stymieing service provisioning in study area.


Introduction
It has been unanimously acknowledged that strong health systems are paramount to achieve health system goals. Indicator 3.8.1 of Sustainable Development Goal targets coverage of essential health services (defined as average coverage of essential services based on tracer interventions including reproductive, maternal, newborn and child health, infectious diseases, non-communicable diseases (NCDs), service capacity and access among general and most disadvantaged population). Underpinning the need to strengthen fragile, resource-constrained health systems is the recognition that weak health systems impede attainment of global and national targets, and are insufficiently resilient to prepare for-and respond to-crises. Despite strong consensus on need to strengthen health systems there are inadequate methods to assess hordes of indices which can inform policy makers on priority areas for improvement (Wanzala, 2019). Albeit, current research does not adequately capture the complex, inter-connected relationship between health system building blocks and the setting in which they are situated (Glied, 2008). Assessing quality of care requires that certain criteria and standards are identified in order to translate general dimensions of quality into something parsimonious that can be measured and interpreted.
Structural measures in the Donabedian's paradigm of structure, process and outcomes gauges the care attributes of healthcare delivery settings in the setting where care occurs (Donabedian, 1988). The assessment of structural quality of care divulges if the care provided under conditions are conducive or inimical to provision of care. These measures are symptomatic with system's readiness, comprehensive assessment of which is pertinent to evidence based policymaking and optimal resource allocation by transcribing identification of bottlenecks in service delivery. Data for measuring structural dimension of quality care including facility infrastructure, staffing and clinical training are extracted from health facility records and surveys. Previous literature delving into health systems performance over-represent tertiary and secondary health facilities, circumventing lower level peripheral facilities providing 1st contact of care (Macarayan et al., 2018). Assessing facility readiness is paramount as it connotes the capacity of facilities to provide essential care for resilience to health challenges. As countries around the world agreed to Declaration of Astana, reaffirming their commitment to strengthen primary healthcare systems as an essential step towards achieving Universal Health Coverage (UHC), it is opportune to explore strategies for targeted action by tracking the progress towards UHC in different contexts.
In the context of health being state subject in India, it is incumbent upon state governments to implement policies to achieve provisioning of accessible and affordable healthcare. Thus, it is imperative for local governance to formulate framework to provide essential basic package to its citizens and have critical discourses and conjectures on benefit package in regional context that can be transmuted into increased access at community level. Also, in the context of decentralisation, estimation of standardised, replicable and comparable supply-side readiness metric at subnational and disaggregated level is imperative for context specific evidence for prioritisation of interventions but remains a colossal challenge due to lack of dependable and representative data sources. The systematic data and studies underscoring the levels, determinants and barriers to service availability at subnational level are rather limited for comprehensive and detailed assessment. Moreover, existing studies on service readiness are not exhaustive and does not circumscribe entire spectrum of services rather focuses on narrow unidimensional metric measured either by type of condition or type of intervention (Biswas et al., 2018;Boerma et al., 2014;Islam et al., 2016;Ssempiira et al., 2018). Our study strives to address this gap by conducting comprehensive study and providing synoptic view by leveraging on small area methodologies enunciating the nuances of supply-side readiness.
Healthcare access in difficult settings such as rural, remote and fragile zones poses unprecedented challenges prompting providers to confront myriad complexities stemming from paradoxical nature of setting in which they operate. Providers in contested borderlands have to reckon with peculiar threats generating a situation of unpredictability and uncertainty. They have to face number of hazards including stray bullets and shells coming from across border/mine related threats when operating at zero line. However, the border context of conflict is often neglected by researchers whereas it is germane to explore the multifaceted nature of conflict. This issue of insecurity impinging on functioning of health systems gets exacerbated by unfavourable conditions such as weak governance, geographical remoteness, reluctance of health workers to function in remote and fragile areas, harsh terrain and weather conditions. However, no attempt in existing studies has been made to incorporate these vulnerabilities from supplyside dimension. However, our work attempted to succinctly summarise these vulnerabilities in a conflicted borderland and explore the impact of level of these vulnerabilities on the capacity of system to deliver care.

Objectives
Objective of the study is to (a) evaluate the service readiness of health facilities and create a concise index subsuming plethora of discrete indicators and (b) ascertain supply-side barriers in service provisioning via stakeholder's analysis. Study also strives to expand analytical domain unravelling context and area specific intricacies associated with service delivery.

Area Setting
The study was conducted in Poonch district which is a high focus district of Jammu and Kashmir state in India. It is one of the remotest districts of Jammu and Kashmir with heavy military deployment as it is bounded by Line of Control (porous boundary between Indian and Pakistani administered Kashmir and is one of the most complex frontier systems in the world) and is bearing the brunt of cease fire violations. The topography of district is hilly and mountainous barring few low-lying valleys and Pir Panjal range separating it from Kashmir region. The district is also low performing in terms of health indicators and has been categorised as 'high priority district' by Ministry of Health and Family Welfare based on poor performance in health composite index. For decades, the intricate linkage between the external dimension (Indo-Pak conflict) and internal dimension (militancy in the area) leading to proxy wars and military skirmishes exacerbated the ordeal of border population having an abode in this area. Multitude of security disruptions through shelling and firing and fear perpetuated by armed conflict is causing obstruction of access to health workers and patients, rendering the health system pregnable.
The district is divided into three medical blocks and all of them have been chosen for study. There are insurmountable healthcare access barriers in region which is reflective in suboptimal health facility coverage. Health facilities represented in survey were categorised as (a) Second tier District hospital and Community health centres (DH and CHCs) providing secondary healthcare; (b) First tier Primary health centres (PHCs) serving as first point of contact between population and healthcare providers; and (c) Sub-centres which are the peripheral health institution available to rural population. These components were assessed separately due to varying standards thus, disparate number of variables for various hierarchies of facilities were used as tracer indicators. As a fallout of armed militancy and infiltration of militants via porous borders, whole border is fenced and at numerous places fencing is done much inside zero line enclosing vast swathes of population and these lands are fenced and gated ensuing obstructions to access. Some of the health facilities and catchment population are inside this zero line and all of them have been included in the survey.

Study Framework
The study employed concurrent embedded mixed method approach to collect quantitative information with qualitative nuances where each method was implemented simultaneously and interactively. The qualitative strand was embedded within quantitative design, representation of which is given in Figure  1. Public facilities census encompassing 137 sub-centres, 44 PHCs, 3 CHCs and 1 DH was conducted to gauge general service availability and service specific availability (depth of coverage). The district representative data was collected from all three medical zones in district. The survey elicited information on measures pertaining to performance and quality of health service delivery system.
Qualitative methods entailing multifarious techniques such as observations, casual conversations, key informant interviews (KIIs) and focus group discussions (FGDs) were conducted for critical stakeholder's analysis. Fifteen KII's were conducted with leaders with varying degree of power including people from Ministry of Health, Directorate of Health and Family Welfare, Civil Administrators, District Health Officials and Officials from National Health Mission. KII's also encompassed 25 in-depth interviews with paramedical staff and facility incharges. Further, eight FGD's with community health workers, six FGD's with Panchayat members and six FGD's with community local leaders and local population were also conducted.

Data Collection Tool
A standard core questionnaire was administered containing compendium of checklist which was designed based on guidelines of Indian Public Health Standards. Information was collected across various dimensions and service package as proposed in WHO's Service Availability and Readiness Assessment framework for quantitative enquiry (World Health Organization, 2013). Detailed data on following modules was collected: 1. Service availability: Service availability captured the domains of infrastructure, human resources for health and utilisation. Information on these indicators was collated from administrative records and Health Management Information System database. The indicators were expressed as percentage score, compared with benchmark set by WHO. 2. General service readiness: In order to elicit the information on general service readiness, a survey questionnaire collected information via checklist of tracer items across dimensions of a) amenities b) equipment c) medicines d) diagnostics and e) infection control protocols. The list of tracer items within each construct is provided in Data collection tools for qualitative analysis included semi-structured discussion guides, pre-tested interview guides, field notes, image data recording, etc. in order to discern maximum information. Participants and sample selection ensured saturation of data and potential transferability of findings to other contexts and settings. Stakeholder's analysis explored the themes such as geographical barriers, travel time, condition of infrastructure, governance issues and quality and mix of health-workers which were not in precinct of quantitative analysis.

Data Analysis Tool
The analysis was conducted separately for different tier of facilities and indices were generated for Service availability, General Service readiness and Service specific readiness. Service availability index subsumed three components: (1) Health services Infrastructure Index-Average score of three indicators: facility density, inpatient beds and maternity beds.
(2) Health workforce index-Average score of core health workers as against mandated in guideline.
(3) Service utilisation index-Average score of two indicators: outpatient visits and hospital discharges. Further, General service readiness was derived by computing mean availability of tracer items for each subdomain by dividing total number of facilities having tracer item available (value = 1) by total number of facilities, multiplied by 100 to get a percentage value. An overall general readiness score was calculated based on unweighted mean of domains. Finally, Service specific readiness was gauged by calculating summary scores for each service based on proportion of availability of each tracer item. Further, quantitative methods employed polychoric principal component analysis (PCA) 1 for exploratory data analysis in order to identify the features/domains causing maximum variation in the readiness scores. The results were analysed by variance distribution according to PCA factor loadings by approximating principal components with input variables that demonstrate importance of variables based on proportion of variances contributed/explained by input variables. The components were rotated using oblique rotation in order to obtain sharper conceptual solutions to interpret prominent variables. Since, PCA is only suitable for continuous data as it is developed for the samples from multivariate normal distribution, a more suitable variant of PCA using Polychoric correlation matrix was employed. Polychoric correlation is the correlation between two ordinal variables obtained as the maximum likelihood estimate under the assumption that the ordinal variables are obtained by coarsening a bivariate normal distribution (Kolenikov, 2016). Further, method of Parallel Analysis based on Monte Carlo extensions was implemented to make decisions about component retention (Glorfeld, 1995;Horn, 1965). Those components whose adjusted eigenvalues were greater than 1 were retained.
Finally, determinants impacting health facility readiness were unravelled by employing Partial Proportional Odds Variant of Generalised Ordinal Logit Model. A three-category dependent variable was constructed based on health facility readiness scores, methodology for which is described in the third section of this article. The readiness scores across the facilities were then divided into three quartilespoor readiness, fair readiness and good readiness. Generally, for ordinal multi-level categories of outcome variable such as in readiness score, ordinal logistic regression (parallel lines model/proportional odds variant) is used for modelling. However, the assumptions embedded in this variant are overly restrictive and are often violated that can be checked using Brant test. Brant test in our study revealed that two covariates, that is, vulnerability and staff position did not meet proportional odds assumption indicating that ordered logit model is mis-specified and alternate variant of ordered logit should be adopted. Hence, partial proportional odds model which is a special case of generalised ordered model was fitted to overcome the lacunae inherent in parallel-lines model. The chosen model is less restrictive allowing the effect of independent variables to vary with the point at which categories of dependent variables are dichotomised. Partial proportional odds model used in the study is commonly denoted as where, Xi is a vector of explanatory variables, βj is a vector of estimable parameters and αj and α (j − 1) are the upper and lower thresholds for readiness scores. Y represents ordinal dependent variable and M is the number of categories of ordinal dependent variable. In order to facilitate the interpretation and compute the direction and magnitude of determinants on facility readiness score, elasticities (marginal effects) were computed. Qualitative data was analysed to explore themes or divergent cases by manifest content analysis following a deductive approach. All transcripts from in-depth interviews and discussions were recorded, transcribed verbatim and translated from local dialect to English. Data was coded line by line and higher level themes were generated using NVivo 10 software. To organise the comparison of findings from disparate data sources, both quantitative and qualitative findings were mapped around various dimensions of health system.

Creating Vulnerability Index
Vulnerability index is a parsimonious yet practical tool to adjust healthcare delivery based on access and gauge the relative exigencies faced by various facilities in the context of difficult/fragile setting. The index was constructed incorporating myriad of indicators adapted and modified from High Level Expert Group Report on Universal Health Coverage for India (Planning Commission of India) and the scores for each indicator were assigned across facilities based on exposure, sensitivity and resilience after having deliberations with district administrative authorities (Planning Commission, 2011). The method coalesced 13 indicators representing vulnerability on a scale of 0-50. The index takes into account variables capturing (1) isolation factor such as travel time to healthcare facility by walk/other modes of transport, difficulty of terrain, availability of transport, distance to major district roads and public transport; (2) density of health workers given, population density and geography; (3) infrastructural impediments such as condition of the roads and availability of government accommodation; (4) security threat such as cross border firing zones and militancy affected areas; and (5) marginalised population such as proportion of tribal population in the catchment area. The detailed description of indicators and weighting strategy for vulnerability index calculator is propounded in Table A.1.

Patient and Public Involvement Statement
Patient and public were not involved in analysis of this study. Figure 2a summarises the components of service availability in the district. There were 3.7 facilities (at all levels of hierarchy) per 10,000 population as against the required norm of 2 per 10,000 population culminating into an overall score of 1.6 for facility density. Inpatient bed density was nondescript with only 7.13 beds per 10,000 population yielding a score of 28%. However, the score of maternal bed density was better at 85%, indicating priority setting for Maternal and Child Health Programmes. The density of core health workers was 15.01 per 10,000 health workers vis à vis the health workforce density threshold of 23. Delving further into the workforce mix, it was found that the shortage of specialists and doctors was particularly striking with district having 54% vacancy of specialists and 76.6% vacancy of medical officers. There was only one doctor per 6,241 population as against the guideline of one doctor per 1,000 population. Doctor-patient ratio in DH was 1/9,880 which is 10 times less than recommended ratio, PHC had a ratio of 1/5,878. Majority of doctors available in PHCs were absorbed via Indian System of Medicine, whereas, all the New-Type Primary Health Centre (NTPHC) were bereft of any doctor. Outpatient utilization that measures the number of outpatient visits to health facilities during one year relative to total population of same geographical area was 1.64 as compared to the target of 5, thereby, generating a score of 32.5%. Inpatient utilisation (hospital discharges per 100 population excluding deliveries) was 88.3% of target with 8.83 people getting hospitalised per 100 population.

General Service Readiness
General service readiness is illustrated in Figure 3. Hospitals exhibited high readiness scores on an average (76%) as compared to new type PHCs (24%). The average item availability for basic equipment ranged from 29% to 89% with lowest score for new type PHCs and highest for DH. The average score for standard precaution against infection was 60.2% across all level of facilities. The highest average readiness score was noted in CHCs with a value of 79%. Laboratory diagnostic capacity was subjacent for new type PHCs at meagre 4%. Essential medicines and amenities were most likely to be unavailable even in high performing facilities.
For sub-centres, results from PCA revealed that two extracted components from 71 tracer indicators explained 22% variance. However, for PHCs, two extracted components from 221 tracer indicators explained 31.6% variance. For each component, relative size of coefficients depicting the commonality in coefficients is illustrated in Figure 4. The principal component for sub-centres was weighted most heavily on equipment, whereas second component was representative of medicines. Estimated coefficients on principal component for PHCs on the other hand, had maximal relative strength on diagnostics, whereas the second component represented medicines.

Amenities
Around 6.66% sub-centres reported complete absence of the tracer items for amenities and one-fourth facilities had less than 25% of seven tracer items. However, only half of sub-centres had readiness score greater than 50%. A tenuous 10% PHCs were equipped with 50% of the 58 tracer items. None of the PHC had communication network such as email or National Informatics Centre (NIC) terminal although all of them were endowed with electricity having power backup and government ownership of building with adequate premises. However, only three PHCs had residential quarter for staff members and 40% did not have residential arrangements for medical doctors. Also, this was more pronounced for new type PHCs where none of the facility had quarter for staff members and 88.88% were bereft of quarters for medical officers. Moreover, the electricity/power supply in new type PHCs was intermittent as well with just two facilities having continuous power supply. Hospitals on the other hand were found to be relatively accoutred with amenities vis à vis lower level of facilities.  scree plots generated from PCA. For sub-centre, results from Horn's parallel analysis revealed that first component with eigenvalue greater than 1 explained 44.54% of common variance and was weighted heaviest for emergency transport and communication network. Concomitantly, the first four components explained 65.5% common variance for PHC's and the principal component was characterised most strongly for infrastructural impediments like provision of quarters for medical officers and government ownership of building.

Equipment
There was a perceptible variation in the availability of equipment in sub-centres and hospitals. In subcentres, the availability of equipment ranged from 4% to 70% with the average availability of 40%. A total of 12 facilities had less than one-fourth items. Striking difference in readiness scores was found between PHC's and NTPHC's. None of the PHC had inventory of eye care equipment and only three PHC's were equipped with phototherapy unit and manual vacuum aspiration/medical termination of pregnancy (MVA/MTP) suction aspirators, whereas, none of the equipment in newborn baby corner and neonatal paediatrics unit (radiant warmer, laryngoscope/enotracheal euipment, mucus extractor and baby bassinet etc.) were available in NTPHCs. NTPHC's score (29%) was specifically low for delivery preparedness and cold storage. CHCs and DH were devoid of equipment required for NCD care and none of the facility had e-ventilator for operation theatre, non-invasive ventilator, spirometer, dialysis machine, memography, stadiometer and colposcope, etc. CHCs with a readiness score of 68% and DH with a score of 88% were efficacious vis à vis primary care facilities. As illustrated in Figure A2 in Appendix, for sub-centres, only one component had adjusted eigenvalue >1 explaining 33.8% variation. Principal component was represented predominantly by equipments required for delivery such as delivery forceps, cord cutting scissors and sterilisers. On the other hand, for PHCs as illustrated in Figure  A1, two components explaining 53.29% variance explained the common variance. Principal component was characterised by neonatal care such as availability of neonatal resuscitation mask, resuscitation kit, feeding tubes and radiant warmer for babies. Further, second component revealed the dominance of indicators associated with delivery preparedness.

Infection Control Protocol
Results indicated that facilities lacked robust infection control infrastructure as none of the Healthcare Associated Infections surveillance system existed in place. The list of tracer items incorporated practices such as incineration of infectious materials, use of disinfectants and gloves, availability of deep burial pit and colour coded dustbins, etc. For sub-centres, more than one third facilities had only 25% protocols in place. The readiness of NTPHCs was abject as compared to PHCs. The overall domain score ranged from 40%-90% for PHCs and 0-80% for NTPHCs. CHCs and DH, however, were complying with 79% and 75% protocols, respectively. PCA results for sub-centres conceded that principal component explained 41.22% variance and weighed positively on sewerage system and appropriate disposal of waste material. Whereas for PHCs, proportion of variance explained by first two components with eigenvalues >1 was 77.29%. The first component was characterised by availability of guidelines and infection control protocol. Further, the second component was positively associated with the presence of sewage system and negatively associated with adequate hypodermic syringe for single use.

Diagnostics Services
Diagnostic capacity of facilities surveyed is represented in Figure 3. Sub-centres which are stipulated to provide very basic diagnostic tests could effectuate only 43% readiness. Less than one tenth facilities had all four tracer items and more than one fourth facilities were traipsing around score of 25% indicating suboptimal performance. PHCs, on an average, were obscured by low readiness reaching just 50% score. Very few facilities conducted sputum test or possessed reagents and testing kits such as KOH solution, Gram's iodine and safranin stain. Further, all NTPHCs except one had a score of less than 10% and 63% facilities were unequipped with even basic kits such as Hb meter, colorimeter and urine dipstick. There was serious vacuity pertaining to capacity for diagnosis of NCDs in CHCs and DH as none of them was providing services such as memography, colposcopy, endoscopy, stress test, Coomb's test, Pap smear and CT scan. On the sanguine side, all the hospitals that are designated as Diagnostic Microscopy Centres were conducting an array of serological, pathological and microbiological tests such as urine analysis, stool analysis, rheumatoid arthritis (RA) factor test, venereal disease research laboratory (VDRL) test, liver function test (LTF) test, rapid plasma reagin (RPR) for syphilis and ultrasound, etc. Around 82.52% variance was explained by two components in sub-centres. Principal component was highly loaded on availability of urine albumin and sugar testing kit and second component was characterised by the collection of sputum samples in facility. Further, Horn's parallel analysis indicated first two components explained 61% common variance in PHCs. Rotated factor loadings on principal component was denotative of presence of reagents such as colorimeter, safranin stain followed by availability of functional microscope in laboratory. Whereas, second component evinced presence of reagents and consumables required for testing of Tuberculosis with loadings ranging from 0.19 to 0.61. Figure 3 illustrates the distribution of health facilities based on availability of non-expired drugs. Tracer list of medicines comprised of 38 drugs for sub-centres and on an average, sub-centres were stocked with 52% drugs. Only half of facilities had anti-allergic and antibiotics, moreover, average availability of injectables and fluids was negligible with a score of 2%. In a more expansive drug list and consumables, PHCs were stocked with 37% medicines whereas, NTPHCs egregiously had less than one fourth of medicines. No PHC had insulin, inhalators and injectibles such as amikacin and streptomycin, drugs for mental health disorders, antidotes for poisoning, expectorants, drugs for cardiovascular diseases and consumables like spinal disposable needle. However, all PHCs were stocked with vaccines for immunisation and basic first aid kit. The domain score for CHCs and DH was 63% and 60%, respectively, although, hospitals were also bereft of adequate consumables such as mucus sucker, catheters and drugs required to treat NCD condition. PCA for sub-centres elucidated first four components explaining 53.38% common variance. Rotated component loadings for principal component underscored positive and heavy loadings on consumables for first aid such as cotton bandages, povidone iodine solution followed by anti-allergens and antibiotics. Subsequent components were characterised by availability of antibiotics. Further, for PHCs, injectibles and consumables were loaded heaviest on principal component. In a dissimilitude to first component, injectibles, however, weighed down the second component but were positively associated with drugs related to blood pressure and cardio-vascular diseases such as nifedipine, isosorbide and glyceryl trinitrate. First two components explained 32.18% common variance for primary care institutions. Inadequate supply of drugs was identified as paramount domain leading to patientprovider wedge. At PHC level, the average time taken for medicine to reach facility post-indenting was six weeks and the same was eight weeks for sub-centres. Among the medicines which were unavailable in sub-centres at time of survey, nearly 20% were out of stock for three to six months, whereas 40% were out of stock for more than six months. However, half of tracer drugs, surgical and suture items mandated under essential drug list were not procured and supplied ever by state medical supply corporation. Figure 5 presents a succinct snapshot of the capacity of facilities delivering broad spectrum of services. Substantial heterogeneity in the readiness scores was found across the package and facility type underscoring variation in the quality of care. On an average, the readiness of district and sub district hospitals across platforms was colossally different from facilities at the lower hierarchy of pyramid. Reproductive, maternal and child health were identified as better performing, as facilities had an average of 91%, 70% and 66% of requisite components and supplies for provision of immunisation, family planning and maternal and child care respectively. The dissimilitude between DH and lower level health centres for birth preparedness and complication was immense with DH effectuating 75% desired inputs and processes for delivery care, whereas NTPHCs and sub-centres were impaired with decrepit standards having 23% and 27% composite scores, respectively. Adding a caveat, only one tenth sub-centres and NTPHC's reported providing obstetric and newborn services thereby, highlighting a major lacunae in the delivery care. The readiness of services under Disease Control Programme exhibited similar pattern with sub-centres having disconcertingly low scores. The average readiness for management of tuberculosis and leprosy incorporating screening, referral and follow-up on cases with confirmed diagnosis and prescribed treatment was 60% for higher level facilities which was suboptimal for priority targeted interventions. The capacity of facilities to optimally diagnose and treat NCDs across the continuum of care is abysmally low across all levels of facilities. For respiratory conditions, though 81% facilities provided services but no facility had all tracer commodities and staff for administering services and were equipped with only 38% of recommended requirements. Concomitantly, while facilities catering to secondary care provided 38% of services for diabetes, these figures nosedived for primary care facilities and further deflated down to 0% for sub-centres. The degree of readiness for cardiovascular diseases oscillated between 29% for hospitals and merely 6% for sub-centres. Although lower level facilities are relegated with basic functions such as screening, referral and monitoring of symptoms of cancer, they failed to comply with the norms and were completely defunct in provision of services. The provisioning of mental health services was also amiss in all facilities and only counselling-related services were provided in some facilities. Only 6% public health workers in rural peripheries reported that they were providing counselling services albeit, they were not trained in counselling. In spite of the high exposure to risk in the district, emergency preparedness scores were low at merely 30% for DH and 9% for subcentres. Poor readiness was found for indicators such as presence of bunkers in vulnerable facilities, availability of bullet proof ambulances, strong communication network and availability of surgeons and blood transfusion, etc. Table 1 presents description of variables and results of generalised ordered model where a unit increase in independent variable, alters probability of falling in the jth alternative (outcome) marginally in percentage terms. For each facility, general readiness score as described under heading Data Analysis Tool was calculated by coalescing scores across five dimensions encompassing a legion of tracer indicators. Distribution of average facility scores was fitted into quartiles to create a three-level ordinal scale for health facility readiness which is the dependent and polychotomous variable with outcome falling into three quartile categories, that is, high, medium and low. Vulnerability score, facility type and administrative area had the highest marginal impact on outcome probabilities. Medium vulnerability score was found to be associated with poor readiness as it was 14.7% more probable than lower vulnerability score to result in poor readiness. However, facilities with high vulnerability scores were 19.1% more likely to have poor outcome and conversely, 19.8% less likely to yield good readiness compared to the reference category. It can be surmised from table that frequent supervision and monitoring were associated with 9.2% lesser probability in yielding poor readiness than infrequent supervisory visits. Although, better supervision was more likely to have good readiness, this finding was statistically insignificant. Facility type was found to be another impregnable factor impacting the dependent variable as physician led clinics and hospitals were 24.7% less likely to have poor readiness and 14.3% more likely to have good readiness than peripheral sub-centres. In terms of magnitude, effect of facility type was more pronounced at lower levels of readiness score. Similarly, the impact of administrative block was quite cogent in explaining the readiness scores as facilities in health block Mendhar had 14.4% lesser probability to result into poor readiness and 14.7% more probability to result in good readiness vis à vis block Mandi. Understaffing of facilities however, was 10.3% more likely as compared to no vacancy of core health workers to result in poor readiness. Notes: CHC = community health centre; DH = district hospital; PHC = primary health centre; VHSNC = village health sanitation and nutrition committee. *Significant at 10% level of significance,**Significant at 5% level of significance, ***Significant at 1% level of significance.

Determinants of Health Facility Readiness Scores
(

Supply-side Barriers to Service Availability
The findings from qualitative analysis were convergent with quantitative findings. However, stakeholder analysis underscored some emergent themes and sub-themes which were not in precinct of quantitative methodology as illustrated in Table 2. Geographical inaccessibility and workforce shortage were identified as paramount barriers by all stakeholders across the spectrum. Core health workers at the facility level also reported readiness and structural components along with security threats as a stumbling block towards road to UHC. Similar concerns were echoed by community members and local leaders as well. However, for leaders with some degree of power such as district health managers, head of departments and civil administrators, financing for healthcare infrastructure and regulatory challenges pertaining to accountability and transparency were considered to be Achilles heel. Leader with highest power during in-depth interview articulated governance issues in conjunction with paucity of healthworkers and geographical remoteness in posing unprecedented challenges. Some of the major barriers and exemplar narratives ascertained by content analysis are illustrated in Table 3 and are discussed in the following section.

Workforce Component Absorption and Retention
In conjunction with shortage of specialists and physicians; absorption and retention of paramedics was identified as a colossal challenge. Health workers were unwilling to serve in the study area due to confluence of dampening factors such as isolation, difficult terrain, dense forests, absence of road and transportation network, shelling hazards, absence of residential accommodation, inaccessibility to market and contractual mode of employment. Due to non-existent incentive structure, health workers were found to be taking political patronage from local leaders for internal adjustment to get themselves attached to district/block headquarters from their original location of posting, leaving remote area underserved. Simultaneously, workers serving in remote areas were more susceptible to absenteeism and dereliction of duty. This posed challenges with distribution and skill mix of health workforce with more than sanctioned workers in easy to access areas and worker scarcity/unmotivated workers in villages. Stakeholders at multiple hierarchical levels were congruent in asserting workforce to be the most important barrier.

Governance Component Accountability and Transparency
Less accountability oversights, irregularity and duplicity in monitoring and supervision visits, deliberate fudging of data, absence of internal checks and balances were reported by community representatives and stakeholders with medium-to-high power but without direct leadership role. Stakeholders with both leadership and medium power revealed about political interference in recruitment and transfers of workers as main detriment in effective and geographically equitable provisioning of services. However, frontline workers mentioned lack of accountability and transparency in the supply chain of medicines and consumables. Albeit, social and financial accountability measures were considered as satisfactory for all stakeholders.  'Doctors and specialists aren't ready to serve in this area, they seek security and opportunities of urban area. Either they don't join or via political patronage get adjustment done to other place. Half of the workers are contractual and have not been regularised for many years. With meagre salaries and lack of incentives, it is difficult to retain workers in high risk and remote conditions'.
-Leader with high power Absenteeism 'My centre is amidst thick forest, a 3-hr walk through army camps, and it is impossible for me to go to that area alone. I have to depend on my brother/ husband/relative to chaperon me so, it's impossible to reach there on a daily basis. I am shouldering the responsibility of 5,300 population as another worker is never present'.
-MPW, Female, Sub-centre Governance Transparency 'Procurement and supply chain management is quite fuzzy. We don't entirely know how medical corporation is taking the decision. There's no clear policy on quantum of supplies. Public procurement law and tendering procedure isn't credible enough. Not to forget the lack of transparency and fairness in financial auditing and budgetary decisions. If you ask me, informal payments to auditors are a norm'.
-Official with medium power and no leadership Accountability 'It is difficult to adhere to accountability measures. It is impossible to conduct the regular supervisory visits to the facilities located in inaccessible areas. Firstly, we don't have supervisory vehicles; Secondly, the monitoring team is hesitant to visit such isolated locations. There is also excessive interference of local politicians in recruitment and transfers of health workers, thereby, workers with strong political contacts often remain absent from facility and resort to dereliction of duty with impunity. If we have to avoid confrontation with political leaders, we often have to acquiesce to whims of such workers'.
-Leader with medium power Readiness Infrastructure 'We operate from this single, kutcha rented room with no storage facility. We are grappling with problem of thefts every year. There's no compound wall and there are gaps in windowpanes due to which locals break and steal furniture, medicines and even record registers. Entire untied funds get dissipated in replacing lost items'.
-MPW, Female, Sub-centre Medicine 'I received only 1,000 antifebrile tablets to last 13 months. Two elderly females down with fever, visited facility last week after trudging a distance of 2 hours. But the medicine was out of stock, and they left exasperated. Next day only we were supplied with boxes of expired ORS. I expressed dissent, but they forced it upon me saying it's your buck to deal with. Now I am buying essential medicines from my own money and dumping expired ones'.

Transportation
'From these far-flung areas, we have to take our women to district headquarter for delivery after paying hefty amount to hire private vehicle as there's no public transport post 3pm. Even for other ailments, we don't want to walk for hours only to find the facility closed or without drugs'.

Communication
'This facility is just a stone's throw away from Pakistani post. It is directly in target range of shelling and is casualty prone area. Mobile network is barred here due to security reason, so it becomes impossible to contact ambulance or emergency services during golden hour. Also, due to that, it is an ordeal to reach and mobilise people for vaccination, VHND meetings and VHNSC meetings'.

Contextual
Geographical 'I am a sole worker here and every day I walk at knife edge trail. I start by 7am from home but can only reach facility by 12 noon after hiking for 3 hrs. I am forced to lock the facility by 2:00 pm for the fear of missing last vehicle back home. Administration is pestering me to stay near the facility; but where's the accommodation'? -MPW, Female, Sub-centre Cultural 'We educate and sensitise people about institutional deliveries, but they say, they will be forced to undergo C-section in hospital. People say our women have to do lot of physical work in difficult terrain which they can't do after C-section and also argue that Maulavi Sahib has denied permission for vaccination as its haram'.
-ASHA worker (Table 3 Continued) ( Sociopolitical 'People don't allow their kids to take Albendazole during school health programmes as they are afraid that it's a conspiracy by ruling government to stop the progeny of Muslim minority community. They fear their kids won't be able to procreate after this. It is becoming difficult to tackle this mass hysteria'.
-Leader with low power External Security threats 'As you can see, we have to cross the border's fencing to reach facility and firing/shelling ensues erratically at the drop of the hat. Every day we have to cross Army enclosure post cordoning formalities encumbered with fear and uncertainty. After crossing the fence, we have to walk for 2 kms amidst thick forests and bushels. During winters when fog gathers, it exacerbates the risks as leopards prowl here. Our medical officer sleeps in labour room with shell sprinters puncturing holes in the wall incessantly. When shell hits near labour room, he shifts to general ward to sleep and vice versa'.
-Class IV worker, PHC Climate condition 'Post rainy season jungle metamorphosis into dangerous den and there's burgeoning of grass and tall maize crops, making it a lurking ground for wild bears and providing recesses for militants. Last season another ASHA worker was mauled by bear while going for vaccination outreach. I had a bad fall in the snow during winters during outreach. I haven't been regularised for last 10 years and earning peanuts. Is it worth it'? -ASHA worker Source: The authors.

Infrastructure and Amenities
On infrastructure front, even though quantitative results indicated favourable facility density scores, the condition of buildings was dilapidated and deficient posing challenges for effective service delivery. Subcentres, particularly, were in decrepit condition as 74% were operating from rented premises. Stakeholder's narratives highlighted infrastructural constraints for both facility building and residential quarters for doctors and health workers in remote pockets. Health workers reported dearth of personnel accommodation at health post and in surrounding community as a barrier in provisioning of effective care.

Diagnostic Capacity
In-depth interviews with laboratory technicians divulged that even if facility had the diagnostic capacity, other conditions were not conducive for operations. It was further revealed that due to geographical inaccessibility, there was a choice trade off between public and private providers. However, patients generally chose latter due to time-flexibility for services. Community members and local leaders also asserted that lack of laboratory facilities forces patients to get tested from private laboratories, thereby, subjecting them to catastrophic payments and inconvenience.

Medicines and Consumables
Frontline health workers divulged that they are always faced with predicament on account of drug shortage and irrational supply of drugs with short shelf life. Shortage and stock outs of antibiotics, anti-allergens, anti-inflammatory drugs and non-availability of drugs for NCDs such as diabetes, blood pressure and heart related diseases were particularly disconcerting for providers. Expiry of medicines was also identified as debilitating issue plaguing facilities, thereby, perversely impacting already constrained supply of medicines. Paradoxically, distribution of excess and near-expiry medicines and supplements such as vitamin A, IFA tablets, albendazole catering to vertical health programmes and non-adherence to requisition list was discomfited for workers. Health workers conceded that they often procure essential drugs and consumables such as cotton and syringes with meager untied funds. Further, professing, workers revealed that uptake of outpatient care is particularly low due to non-availability of drugs.

Equipment
In-depth conversations with health workers divulged that workers often resorted to obsolete methods of treatment or denied care to patients due to unavailable/non-functional equipments. Some of the supply of equipments did not commensurate with the requirements and were supplied in surplus making it redundant, for example, few sub-centres received around 20 thermometers each in the month preceding to survey whereas, lacked or had dysfunctional blood pressure (BP) apparatus. Hospital administrators emphasised the need for medical gas pipeline, portable ventilator and blood transfusion facility for emergency response in conflict situation.

Infection Control Protocols
Even though health workers were conversant with standard operating procedures and guidelines, lack of supplies and infrastructural constraints made it difficult to practice standard precaution. The consumables required for infection control such as gloves and needles had very limited supply, thus, compelling health workers to divert budget from untied grant allocated to facilities under National Health Mission. All health workers griped about grappling with problem of waste disposal as they had to dig kutcha pit every time for disposing syringe/needles in the absence of pucca pit in the premises. Health workers also narrated the absence of government ownership of buildings as a stumbling block for adherence to infection control. Workers explained that adhering to hygiene/sanitation protocols is also incumbent upon the house owners of rented buildings from where the subcentre is operated as the owners were also residing cheek by jowl in the same building.

Financial Component Availability of Funds
Leaders underscored the role of inadequate public health financing in stalling the infrastructure projects. They further maintained that inadequate budgetary allocation and absence of alternate fund source were impeding the interventions such as retention of workers and setting up diagnostics laboratory etc. However, annual untied funds earmarked for urgent and discrete activities were perceived to be inadequate by staff members. All the participants of FGDs with village health committees also admitted that amount of untied funds is grossly inadequate. Staff members further suggested that amount of Rs 10,000 for sub-centres operating from government buildings and Rs 5,000 for rented buildings was meagre to purchase essentials such as labour table for delivery or other equipment and consumables for facility. Workers also conceded that mandatory informal payments to auditors further deflate the budget and delays in fund release introduces inefficiencies in fund utilization.

Structural Component Transport and Communication
Rudimentary road network and arduous terrain compelled health workers to use diverse form of transportation to reach health facilities which was further impeded by low frequency of public transportation in the area. Due to dearth of staff accommodation, majority of workers would commute long distance on daily basis to facilities and experience restrictions related to opening hours of facilities due to exiguous public transportation. In areas with no road network, many staff members explained that attending work everyday is implausible as they have to walk for hours at high elevation daily to reach facility. Additionally, absence of mobile network in hard to reach and border areas was reported to obstruct service delivery.

Contextual Component
Geographical Accessibility In context of hilly and remote areas, high facility density score which is elucidated in quantitative results should be interpreted with caution as it does not necessarily translate to physical accessibility for dispersed population living in higher reaches. Some geographic pockets were completely inaccessible necessitating setting up of new facility/upgradation of lower tier facility manned with well trained staff members. Community health workers and paramedic staff chronicled arduous long walk to facility in harsh and rugged terrain as an impediment for them to provide care. Also, conducting outreach activities and immunisation camps was reportedly daunting in hard to reach high altitude forest area. These barriers get exacerbated during winter and rainy season when most of the area is inundated by rains and snow thereby, compelling the closure of facilities seasonally.

External Component Security Threat
The degree to which a facility delivers effective care is sensitive to the stressors emanating from internal or external environment. In our area context, facilities were navigating multitude of structural, nonstructural and functional security challenges emanating from conflict, topographical, seismological and extreme weather conditions. Officials expounded the need and absence of bullet proof ambulances and bunkers for facilities across shelling zone to protect health workers posted in the line of fire. Additionally, health workers narrated that the exposure and threats from animal attacks and militant activities especially during rainy season compel them for absenteeism. Community health workers in a group discussion recounted some co-workers getting attacked by animals in higher reaches of thick forests while on duty, thereby, dampening their efforts to reach these areas.

Discussion and Conclusion
The study intended to unravel various barriers of supply-side readiness and its associated factors. Our analysis of structural readiness revealed copious and pervasive gaps in basic capacity to deliver healthcare services. None of the facilities surveyed possessed all the resources required for providing services. The dissimilitude in readiness scores between various levels of facilities was confounding. Sub-centres and new type PHCs were particularly low performing and invariantly had less readiness vis à vis hospitals. Similar findings were found in other studies across different regions in low and middle income countries (LMICs) where hospitals had significantly greater inputs and concentration of resources as compared to health centres and dispensaries (Bintabara et al., 2019;Boyer et al., 2015;Iyer et al., 2015;Ssempiira et al., 2018;Winter et al., 2017). The challenges confronting peripheral rural institutions were vexed ranging from workforce shortage, poor monitoring and evaluation, suboptimal budgetary allocation and lack of community participation. Non-availability of basic amenities such as water, electricity and basic medicines profoundly undermined the functioning of facilities. The facilities lacked availability of all resources simultaneously for effective delivery, for example, if skilled birth attendant (SBA) were available at the facility, labour room was absent, therefore, rendering the skilled workforce redundant to provide obstetric care. As a corollary, poor and vulnerable individuals relying on free services in peripheral facilities remained underserved thus, validating the inverse care law. Spatial concentration of resources intertwined in rural-urban dichotomy entailed that the referral system in public healthcare network in district was weak. Our study revealed low readiness score particularly for diagnostic capacity with the lowest readiness for NTPHCs. The NTPHCs were upgraded from allopathic dispensaries and sub-centres to streamline and strengthen existing health system, yet, half of the NTPHCs were operating from unsafe rented buildings and none of them had medical officer or functional laboratory. People residing in catchment area of these facilities were compelled to travel to district/block headquarters for diagnostic services and purchase medicines from open markets at exorbitant rates. These results concur with another study that reported in Bangladesh, facilities at all levels had lowest scores for diagnostic capacity (Shawon et al., 2018). Another study conducted in India reported absence of diagnostics for routine blood, urine and stool examination especially in Empowered Action Group states such as Assam where only 20% PHCs had basic laboratory facilities (Ninama et al., 2014).
The unavailability of basic drugs contravenes the ethos of UHC as expenditure on medicines is dominant cause of catastrophe and impoverishment at household level. The out of pocket expenditure (OOP) on drugs for ambulatory care was 59.73% of total OOP in rural areas of Jammu and Kashmir in 2014 (calculated from National Sample Survey Office (NSSO), 71st round). Our estimates of 31% average availability of medicines in PHCs bears similitude with the study conducted on paediatric drugs in PHC in a district of Kashmir where 34.8% drug availability and 115 days of stock-out was found. (Iqbal et al., 2015). Recently, Jammu and Kashmir government adopted Free Drug Policy in 2016 entitling citizens to free essential generic drugs in order to mitigate burden of healthcare costs via Jammu and Kashmir Medical Supply Corporation (JKMSCL) (Government of Jammu and Kashmir, 2016). However, multiplicity of supply chain issues such as incongruity between procurement and requisition, shortage of corpus funds and payment delays to suppliers, delay in lifting medicines from regional drug warehouse, convoluting tender process involving multiple corrigendum and procurement of consumables with high commission impeded drug provisioning via JKMSCL.
Our findings accentuated lowest readiness for NCDs as compared to the targeted packages such as Immunisation, Maternal and Child Services, Family Planning, etc. This was consonant with results reported from similar studies. Studies conducted in constraint settings divulged that facilities demonstrated lower capacity for treating NCDs as compared to infectious diseases (IHME, 2014;Jigjidsuren et al., 2019;Mutale et al., 2018). Despite being biggest contributor of disease burden, targeted interventions for NCDs are missing. Specifically, the acknowledgement of epidemiological transition by local health system and infirmities in the surveillance and integration of chronic diseases in health information system has led to lack of reliable data for evidence-based policymaking.
In order to unpack the contextual factors, our study examined the determinants of health facility readiness and found that greater degree of vulnerability, sporadic monitoring visits and lower level of facility to have higher probability of having poor readiness which is symptomatic with results from other studies in low resource and difficult settings (Bintabara et al., 2017;Oyekale, 2017). Absence of monitoring has been associated with workforce absenteeism and defunct rural facilities. Also, the role of supply-side vulnerabilities which is a complex dimension operates via different pathways to impede the service delivery. The triple whammy of geographical remoteness, disturbed security scenario and lack of basic amenities result in cannibalisation of health workforce via internal adjustment mechanism. Further, armed conflicts, internal disturbances and other types of unrest create a generalised state of insecurity that often makes maintaining a minimally functional health system really impossible (Nickerson, 2015). Although, local administration started the initiative of distribution of first aid kits and training of general population in the border villages but lack of resources to purchase bullet proof ambulances, absence of underground bunkers in facilities and exposure of health workers to the vagaries of shelling continued to deprive border population of even rudimentary health services. This is particularly alarming in a tense security scenario as population living along the borders are for most part powerless, with little control over their environment and are also extremely vulnerable to physical and psychological injury. It is also tenable to have robust emergency preparedness and response as people residing in study sites find themselves in direct line of fire as the area is strewn with landmines and is perturbed by cross border shelling and militarised encounters. Emergency referral is critical in improving outcomes in such time sensitive conditions

Policy Recommendations
It was underscored from our study that it is pertinent to bolster existing primary care facilities in our study setting rather than starting new facilities. There is need to circumspect about the issue of staff shortage and absenteeism which was particularly nettlesome. As per previous evidence, change in organisational behaviour using surveillance as characterised by practice of record keeping, frequent monitoring of employee absence behaviour, detection of absences and setting of thresholds for individual action which upon breach set off a cascade of management action oriented measures are found to be some strategies effective in LMICs (Kiwanuka et al., 2014). Further, introduction of biometric monitoring system can be explored to reduce absenteeism, for example, a pilot project in Karnataka, India that involved providing real-time tracking of attendance in PHCs ameliorated absenteeism amongst paramedical staff. Intervention analogous to Chhattisgarh Rural Medical Corp (CRMC), which is an integrated incentive scheme to attract and retain doctors in underserved, remote and difficult areas including conflict areas that encompasses financial incentives, residential accommodation, life insurance and extra credits for postgraduate level to eligible doctors can be envisioned in the study area as CRMC reduced vacancies of doctors from 90% to 45%. Concomitantly, action-oriented methods such as community-based monitoring, social audits, Jan Sunwayis coupled with incentives based on vulnerability index (higher payments for hard-to-reach locations) should be considered. Also, a copious amount of budgetary allocation should be made to purchase armored ambulances and fortify facilities against bullet/shelling attacks in border areas.
Another formidable barrier of geographical inaccessibility can be transcended by setting up telemedicine nodes in inaccessible facilities. Hybrid model of telemedicine using both store and forward (asynchronous) as well as real time (synchronous) connectivity within Hub and Spoke framework can be introduced to provide accessible, affordable and quality healthcare. Sub-centres in remote catchment areas acting as spokes can be transformed to e-sub-centre where telemedicine nodes can be established connecting them via satellite link with hub acting as specialty nodes. There is cogent evidence of benefits of introducing such models in collaboration with Indian Space Research Organization (ISRO) in tribal, hilly and remote areas of India. ISRO in collaboration with State governments in India covered 384 hospitals with 60 specialty hospitals connected to 306 remote/rural/district/medical college hospitals and 18 mobile telemedicine units. An intervention congruous to this model can be explored in our contextual setting.
The conflation of quantitative and qualitative insights highlighted the need to augment peripheral health facilities specifically for services such as obstetric and newborn care, NCD care and emergency preparedness. The efficacy of these facilities was particularly constrained by lack of diagnostics and essential medicines. Targeted interventions entrenched in Central Government's flagship schemes such as setting up of government pharmacies dispensing generic drugs at affordable prices and pharmacies specially established to provide drugs, implants, surgical disposables and other consumables for cancer and heart disease at heavily discounted rates should be prioritised to complement the drug supply via medical corporation. Further, under the aegis of Ministry of Health and Family Welfare, Indian Council of Medical Research has drafted first National Essential Diagnostics List (NEDL) to be implemented soon to improve the availability of quality diagnostics. Implementation of NEDL is recommended to be prioritised in the study area and integrated with telemedicine to improve patient outcomes and reduce out of pocket expenditure. It is also suggested to implement WHO's package of essential NCD disease interventions for primary healthcare in low resource settings (WHO PEN) providing evidence based clinical guidelines to improve access and quality of NCD services delivered at primary health-care facilities.

Infection Control Protocols
Composite score of tracer indicators capturing mean availability of a) Infrastructure such as Deep burial pit for waste management, Sewage system, Handwashing facility etc. and b) Adherence of protocols such as Asepsis (sterilization, disinfection, cleaning twice a day, fumigation after each procedure) Waste disposal (color-coded bins/bags, puncture proof containers for disposing needles and sharps) Infection control practices (segregation and treatment of biomedical waste, use of disposable syringes and examination gloves, use of masks and protective clothes including cap, gown, gloves, hand washing with soaps, sanitizer etc.) Source: Adapted from High Level Expert Group on UHC, Government of India and own Conceptualisation.