Computers & Industrial Engineering 167 (2022) 107991

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Computers & Industrial Engineering

journal homepage: www.elsevier.com/locate/caie

A hierarchical capacitated facility location-allocation model for planning

maternal healthcare facilities in India
Ankit Chouksey *, Anil Kumar Agrawal , Ajinkya N. Tanksale
Department of Mechanical Engineering, Indian Institute of Technology (BHU) Varanasi, Uttar Pradesh 221005, India

A R T I C L E I N F O A B S T R A C T

Keywords: The present work on maternal healthcare in India is motivated by its current status emerging out of limited
Operations research in healthcare availability and accessibility of related facilities. Planning for the required maternal healthcare facilities, from
Maternal healthcare basic ones to neonatal ones, is a tedious task from the financial perspectives of both users and the government.
Facility location and allocation
This problem has been addressed by proposing a mixed-integer linear programming formulation for determining
Mixed-integer linear programming
Problem decomposition
the optimal number and location of these capacitated and varied facilities and also for the allocation of mothers-
Valid inequalities to-be to these facilities while minimizing the overall cost. Suitable additional valid inequalities are proposed to
be incorporated into the NP-hard model for reducing the computational burden. For further computational
advantage, a sequential approach is also proposed. Comparative performance of the proposed approaches has
been analyzed using several problems with wide variation in the problem parameters’ values. The sequential
approach is found to be very effective and computationally efficient. The results of the sensitivity analyses with
respect to coverage distance, capacity, referral proportion and fixed cost provide important and practical insights
related to the mix of the facilities to be established. The application of the model for a district in India proves the
suitability of the model in the Indian context.

1. Introduction
The World Health Organization (WHO) envisions a world where
every mother-to-be (MTB) receives quality care during pregnancy,
childbirth, and the postpartum period with no mortality due to avertable
causes (Maternal health WHO, 2021). The United Nations (UN) also
recognizes maternal healthcare as a prime goal in its millennium
development goals program (United Nations, 2015). On account of
medicinal headways and the rigorous efforts of the government and non-
government organizations, such as WHO and UN, a significant
improvement has been witnessed in the status of maternal healthcare
across the globe. As a result, the global Maternal Mortality Ratio (MMR)
fell by 44 percent in 2015 as compared to that in 1990 (WHO, UNICEF,
UNFPA and Group, 2015). In India, the maternal mortality per 100,000
births has diminished from 437 in 1990 to 167 in 2015 (Millennium
Development Goals - Final Country Report of India, 2017), which is a
sizeable reduction in MMR. In spite of these accomplishments, 810
women still die every day in the world from preventable causes during
pregnancy and childbirth (Maternal Mortality WHO, 2021). Out of
these, 94% of the deaths occur in developing countries (World Health
Organization, 2019). In India alone, 120 women die per day on average
due to the causes associated with pregnancy (UNICEF India, 2019). For
some of her states, this figure goes beyond 200 (National Health Profile,
2018). The survey by National Health Profile (2018) also finds maternal
mortality to be higher in rural areas and more among impoverished
communities. In India, around 66% of the population lives in rural areas,
and most of them are below the poverty line (World Bank, 2021).
Different surveys reveal the fact that a large number of MTBs from rural
areas do not have access to the courses recommended by WHO, such as
four check-ups and fetus assessments during the antenatal period and
necessary vaccinations during the antenatal and neonatal periods
(Antenatal Care WHO, 2021). It may be due to either poor facilities at
the healthcare unit or the long distance that pregnant women may have
to travel to reach a healthcare unit. Because of this, the institutional
deliveries aided by skilled personal are as low as 50% in many parts of
India (Ministry of Health and Family Welfare, 2017). The lack of
accessibility and availability of the maternal healthcare facilities were
observed to be the most critical factors leading to the poor status of
maternal healthcare in the country. Naturally, an improvement in the
’availability’ and ’accessibility’ of the maternal healthcare facilities will

* Corresponding author.
E-mail addresses: ankitchouks.rs.mec17@itbhu.ac.in (A. Chouksey), akagrawal.mec@itbhu.ac.in (A.K. Agrawal), ajinkya.mec@iitbhu.ac.in (A.N. Tanksale).

https://doi.org/10.1016/j.cie.2022.107991
Received 10 August 2021; Received in revised form 27 January 2022; Accepted 30 January 2022
Available online 4 February 2022
0360-8352/© 2022 Elsevier Ltd. All rights reserved.
A. Chouksey et al.
advance the status of maternal health in India. For this purpose, it is
essential to develop a network of maternal healthcare facilities along
with a plan for allocating MTBs to these facilities.
The present paper discusses the problem of locating different types of
healthcare facilities for maternal healthcare in India for the reasons
mentioned above. A mixed-integer linear programming (MILP) model of
this problem has been developed. The model aims to minimize the total
cost of establishing various kinds of maternal healthcare facilities and
the travel cost of MTBs to these facilities, including that for referrals. The
developed facility location model is hierarchical (i.e., a system of
different types of interacting facilities) and successively inclusive (i.e., a
higher level will also provide all lower-level services (Sahin and Süral,
2007)). The proposed model performs better than the p-median facility
location-allocation model. The model has been further improved in
terms of its computational requirements by including a proposed set of
additional valid inequalities.
An administrative unit (such as Tehsil) in India may have thousands
of villages. Thus, getting a good quality solution in a reasonable time
will be an arduous task as the proposed model will involve too many
variables and constraints in solving the location and allocation problem
simultaneously. The sequential approach proposed in this paper helps to
cut down the computational requirements sizeably without practically
compromising on the solution quality. The effectiveness and efficiency
aspects of the proposed solution approaches are demonstrated through
the computational experiments carried out using several problem in­
stances with wide variations.
The remainder of the paper is organized as follows. Section 2 makes a
brief review of the literature to identify the gap and to demonstrate the
novelty of the present work. In Section 3, the essential features of the
considered maternal healthcare problem are presented. The mathe­
matical programming formulation of the problem is provided in Section
4. Various approaches to solve the mathematical model are discussed in
Section 5. The results of computational experiments are presented in
Section 6. Section 7 demonstrates the effectiveness of the proposed
model by solving the maternal healthcare planning problem for the
Chadauli Tehsil of the district of Chandauli in the state of Uttar Pradesh
in India. Finally, Section 8 concludes the paper and presents the scope
for future research work.
2. Literature review
Facility location and allocation problems have attracted the atten­
tion of many researchers from the past several decades. Probably, the
first reported work is from Weber (1929) that addresses warehouse
location and allocation problem from the viewpoint of minimizing the
total distance to be covered from the warehouse to the customers.
Subsequent work has been witnessed in modelling pro­
duction–distribution systems (Scott, 1971; Ro and Tcha, 1984; Tcha and
Lee, 1984; Van Roy, 1989; Gao & Robinson, 1992; Aardal et al. 1996;
Pirkul and Jayaraman, 1996; Tragantalerngsak et al., 1997; Aardal,
1998; Pirkul and Jayaraman, 1998, Hinojosa et al., 2000; Eben-Chaime
et al., 2002, Widener and Horner, 2011), solid waste management sys­
tems (Barros et al., 1998), education systems (Teixeira and Antunes,
2008), postal delivery services (Sheu and Lin, 2012) and healthcare
system (Tien et al., 1984; Rahman and Smith, 2000; Ndiaye and Alfares,
2008; Ghaderi and Jabalameli, 2013; Khodaparasti et al., 2017; Galvao
et al., 2002; Galvao et al., 2006; Jang and Lee,2019). Gould and Lein­
bach (1966) mathematically modelled facility location problem along
with the allocation problem to determine the location of hospitals and
their capacities in the western part of Guatemala. Their work has been
enriched and extended by several researchers in different application
contexts. A good amount of such work is available in the research papers
due to Ahmadi-javid et al. (2017), Sahin and Süral (2007), Farahani
et al. (2014), and Torkestani et al. (2016). Subsequent two sub-sections
provide more details about the past work regarding healthcare facility
location-allocation in general and maternal healthcare in particular.
2
Computers & Industrial Engineering 167 (2022) 107991
2.1. General healthcare facility location-allocation
Narula and Ogbu (1979) developed a hierarchical location-allocation
model by including referrals under the assumption of sufficient available
capacity for fulfilling the demand. Without considering the capacity of
the facilities, this problem was further studied in the context of maxi­
mizing the coverage or minimizing the total weighted travel distance
(Tien et al., 1984; Rahman and Smith, 2000; Ndiaye and Alfares, 2008;
Khodaparasti et al., 2017). Even though the researchers tried to maxi­
mize the coverage, but some were definitely not covered. India, being a
welfare state, cannot afford to do so. It needs to cover all the aspirants.
Further, weighted travel distance minimization, in a sense, can be
treated as the minimization of the overall travel cost. Pursuit of the
minimization of the weighted travel distance may cause some of the
MTBs to cover a large weighted distance. In case all the weights are the
same, it may amount to cover a large distance. In the Indian context, the
government and the public at large do not desire MTBs to cover a large
distance. Thus, it becomes necessary to cover the whole population
while ensuring that the MTBs do not have to cover a large distance in
visiting the maternal healthcare facilities and that the cost incurred on
travel and establishment of the facilities is the minimum. These concerns
not addressed so far have been taken care of in the present paper.
Another variation seen in the research work related to the healthcare
problem is in terms of the consideration of the capacity of these facil­
ities. The uncapacitated problem was addressed by Tien et al. (1984),
Rahman and Smith (2000), Ndiaye and Alfares (2008), and Khodapar­
asti et al. (2017). The models proposed in these researches have limited
acceptance in practice due to the assumption of the infinite capacity of
healthcare facilities. A very high allocation of patients to a health center
is going to affect the quality of the service provided by the centre. To
arrest such a problem, many authors have come up with hierarchical
location-allocation models taking the capacity of the facilities being
finite (Griffin, Scherrer, & Swann, 2008; Guerriero, Miglionico, & Oli­
vito, 2016; Güneş & Yaman, 2010; Mitropoulos, Mitropoulos, Giannikos,
& Sissouras, 2006; Shariff, Moin, & Omar, 2012, and Zarrinpoor et al.
2017). For the complete coverage of the population with the finite ca­
pacity of the service facilities, the number of facilities was rightly taken
as flexible in these works. Its optimal value was determined by deciding
proper location of the health facilities in conjunction with proper allo­
cations of the patients to them. In such a case, with the number of the
facilities taken as fixed due to budget constraints, etc., some of the pa­
tients may be left allocated. For such a situation, optimal location and
allocation were determined by Rastaghi et al. (2018) by considering the
cost of unfulfilled demand of the patients. Their formulation of the
problem is a two-level hierarchical healthcare facility location model
that minimizes the cost for the establishment of the healthcare facilities,
cost of unfulfilled demand, and the total travel cost of the patients while
taking care of micro-level issues, such as the ones related to the number
of doctors, nurses, and equipment, etc. With growing awareness among
the masses in India regarding healthcare coupled with the Indian gov­
ernment’s will to provide quality service to its people, the quality cannot
be compromised, at least at the planning stage. For this reason, the
present paper considers the finite capacity of the facilities for each type
of service and keeps their number flexible and left to be optimally
decided.
2.2. Maternal healthcare facility location-allocation
Limited work is available on the planning of the healthcare facilities
for MTBs. Galvão et al., 2002 developed a hierarchical facility location
model for perinatal care. They developed an uncapacitated three-level
successively inclusive hierarchical location model for determining the
optimal location of the facilities providing perinatal care at the time of
childbirth and during the postpartum period for Rio de Janeiro, Brazil.
Their focus was on the users of these facilities. So they chose to locate a
prespecified number of the facilities while keeping the cost of travel
A. Chouksey et al. Computers & Industrial Engineering 167 (2022) 107991

incurred by the users to be the minimum. They considered the health­
care facilities to be of three different types based on the services these
provide. They also considered the referrals for a higher level of service.
In the Indian context, it is also natural to have most referrals from the
lowest level. This is a practical requirement and thus cannot be ignored.
The model of Galvao et al. (2002) is a generalized and extended version
of the p-median problem and is hard to be solved in polynomial time. For
this reason, they proposed a Lagrangian-based heuristic for solving the
problem. They modified their uncapacitated model by considering the
finite capacity for the highest level of the health facility (Galvao et al.,
2006). The limited capacity had to cause some MTBs to seek the service
outside of the government facilities. The capacity of the facility may be
finite, but the number of these facilities cannot be taken as fixed in the
planning stage to provide full coverage in the Indian context. Baray and
Cliquet (2012) solve the problem by first selecting locations for the fa­
cilities to be established. Next, they try to select the locations from these
chosen sites for establishing sequentially from lowest to highest levels.
The facilities at different levels provide different services, uncommon
with the services at the other levels. The healthcare facilities for MTBs in
India do not have this sense of exclusivity, and a higher-level centre has
to provide services rendered even by the lower-level centres. The suc­
cessively inclusive concept used by Galvao et al. (2002) provides a right
framework for planning the maternal healthcare facilities in India. Jang
and Lee (2019) and Jang (2019) also have taken the exclusive view of
Baray and Cliquet (2012) regarding the type of healthcare facilities for
neonatal healthcare planning in South Korea. Their p-median formula­
tion (PM), coupled with the finite capacity of the facilities, does not help
to provide complete coverage. Increased coverage would require p to be
increased.
2.3. Gaps in the literature and contribution of the work
After reviewing the literature, many gaps have been identified. These
gaps (Table 1) are presented below, along with the work carried out in
the present paper to bridge the same.
• It is observed that a good number of researchers have formulated
healthcare problems, including those for MTBs, as a p-median

Table 1
Summary of the work available in the literature.
Reference Modeling Capacitated Referral Fixed Coverage Coverage Objective Heuristic Case study
approach cost distance distance proposed place
Minimize Maximize Minimize
for non- for referral
total coverage establishment
referral
weighted cost and
travel traveling cost
distance cost

General healthcare facility location allocations

Narula and PM ✓ ✓ – – – ✓ – – ✓ –
Ogbu
(1979)
Tien et al. PM – ✓ – – – ✓ – – – Jordan
(1984)
Rahman and MC – – – ✓ – – ✓ – – Bangladesh
Smith
(1999)
Mitropoulos PM ✓ε – – ✓ – ✓ – – – Western
et al. (2006) Greece
Griffin et al. MC ✓ – ✓ ✓ – – ✓ – – Georgia
(2008)
Ndiaye and PM/FC – – ✓ – – – – ✓ – Middle East
Alfares
(2008)
Gunes and – ✓ – ✓ ✓ – – – ✓ – Turkey
Yaman
(2010)
Shariff et al. MC ✓ – – ✓ – – ✓ – ✓ Malaysia
(2012)
Guerriero PM/MC ✓ – – – – ✓ ✓ – – Italy
et al. (2016)
Zarrinpoor FC ✓ ✓ ✓ – – – – ✓ ✓ Baluchestan
et al. (2017)
Khodaparasti PM ✓ ✓ – ✓ ✓ – ✓ ✓ ✓ Iran
et al. (2017)
Rastaghi et al. FC ✓ ✓ ✓ – – – – ✓ ✓ Iran
(2018)
Jang and Lee MC ✓ ✓ – ✓ ✓ – ✓ – – South Korea
(2019)

Maternal healthcare facility location allocations

Galvao et al. PM – ✓Φ – – – ✓ – – ✓ Rio-de-
(2002) Janeiro
Galvao et al. PM ✓Ψ ✓Φ – – – ✓ – – ✓ Rio-de-
(2006) Janeiro
Baray and PM/MC – – – – – ✓ ✓ – ✓ France
Cliquet
(2012)
Present work FC ✓ ✓ ✓ ✓ ✓ ✓ – ✓ ✓ India

Limitations: ε Only health centers are capacitated, hospitals are uncapacitated.

Ψ Only level 3 is capacitated.
Φ Referral is considered only for levels 2 to 3.
Legends: PM - p-median; MC - Maximum covering; FC - Fixed cost

3
A. Chouksey et al.
problem or maximum covering location problem. Such formulations
will not be applicable to the maternal healthcare problem being
addressed in this paper due to the requirement of complete coverage
of the population. The facility-location allocation model proposed in
this paper does not have this issue.
• No work is available related to the designing of any healthcare fa­
cilities where accessibility issues are addressed for non-referral cases.
Accessibility issues addressed by Khodaparasti et al. (2017) and Jang
and Lee (2019) are limited to only referral cases and that too for
general healthcare. Coverage distance is an important issue, partic­
ularly for MTBs in India. From this perspective itself, the government
of India has provided guidelines for keeping maternal healthcare
facilities within seven kilometres for referral and five kilometres for
non-referral cases. Taking care of accessibility issues helps MTBs in
availing of related healthcare services. Kumar et al. (2014) also
observe that providing facilities within five kilometres has increased
institutional delivery by 10%. The proposed mathematical model
addresses the accessibility issue by incorporating restrictions on the
maximum distance to be covered by an MTB for both referral and
non-referral cases.
• The issue of the referral for MTBs has been addressed by Galvao et al.
(2002). They consider referral only from mid-level facility to highest
level facility. Keeping in mind the requirements and practice in India,
the present work also considers referrals from the lowest level to mid
and highest levels.
• Most of the published research articles consider maternal healthcare
facilities to be uncapacitated. Galvao et al. (2006) took only the
higher-level facility type to be capacitated. In reality, every health
facility has a reasonable capacity going beyond which the service
quality is bound to get deteriorated.
• Very few authors attempted to propose a heuristic approach to solve
the maternal healthcare location-allocation problem in a computa­
tionally efficient manner. This paper not only provides an efficient
heuristic but also introduces valid inequalities (additional con­
straints) to be used with the proposed mathematical programming
model to solve the problem in lesser time using available optimiza­
tion software, GUROBI. The focus of the present work is on the
development of a framework for planning maternal healthcare fa­
cilities in India from the viewpoint of availability and accessibility.
The results on sensitivity analyses may also help the planners to
understand the impact on the plan due to variation in some of the
problem parameters.
• An application of the proposed hierarchical facility location-
allocation model for maternal care is presented for the planning of
the maternal healthcare facilities for the district Chandauli in India.
The focus of the present work is on the development of a framework
for planning maternal healthcare facilities in India from the viewpoint of
availability and accessibility. The results on sensitivity analyses may
also help the planners to understand the impact on the plan due to
variation in some of the problem parameters.
3. The maternal healthcare problem
In India, the healthcare facilities are planned in a decentralized
manner, and the related development is carried out at the division level
by the additional director (UPNRHM, 2021). The planning and control
of operations at the divisional level has a major issue in providing uni­
form accessibility to MTBs (Ministry of Health and Family Welfare,
2017). Further decentralization is desired to bring in more efficiency,
and thus the planning needs to be carried out at the Tehsil level as the
population of a Tehsil is now generally about the population of a divi­
sion some five decades ago (https://www.worldometers.info/world-po
pulation/india-population/). Each Tehsil has certain locations with
MTBs. MTBs are at different phases of their pregnancy and thus would
require different types of services. During the first and second trimesters
4
Computers & Industrial Engineering 167 (2022) 107991
of the pregnancy, the essential requirement is primary care consisting of
routine check-ups, vaccination, and diagnostic examinations. On
maturity of pregnancy, an MTB would require a facility for delivery. In
the case where complications in the pregnancy are detected beforehand,
cesarean delivery may be specified with or without the requirement of
neonatal assistance. Besides, some MTBs may require an unplanned
cesarean delivery on an emergency basis and subsequent neonatal
assistance. If such assistance cannot be provided at the allocated facility,
they will be referred to a higher level of facilities capable of providing
such assistance. It is so because all the healthcare facilities are not
identical in terms of the services provided by them, particularly in the
Indian context. In India, most of the requirements of MTBs are easily met
by the primary centres with basic facilities (service type 1). A few would
require facilities also to handle cesarean cases (service type 2) and a
comparatively less number of them to also provide neonatal assistance
(service type 3). A healthcare facility providing only type 1 service is
referred to as a Sub-Center (SC), while that providing type 1 and type 2
services as Primary Healthcare Center (PHC), and all the three (type 1,
type 2 and type 3) as Community Health Center (CHC) in further elab­
orations. These are also represented by respective indices as I, II and III
in the mathematical formulation. While establishing these centres, it is
desired that these are accessible and within a reasonable reach of each
MTB, not asking them to travel beyond a prespecified coverage distance.
The centres to be established are to be kept identical according to their
type for administrative convenience. Their service capacity is taken to
be limited and fixed. In case the coverage distance and/or the capacity
become bottlenecks, it will necessitate establishing additional centres. It
is assumed that the capacity for each service type for each facility type is
more than the local demand of MTBs at that location.
In case of an emergency at a lower-level centre, the MTBs will be
referred to a higher-level facility. For example, MTBs getting service of
type 1 in an SC can be referred to a PHC or a CHC to avail type 2 or type 3
service as the need may be. Referrals can be handled at the same centre
for higher-level services subject to the availability and capacity of the
service type at that centre. The notion of the coverage distance is also
applicable for referral cases.
In India, the facilities are planned at the government land, and thus
the cost is to be incurred only for the superstructure and the other
amenities. The facility of a type is going to be the same irrespective of
the location. Since payment for construction is paid by the government
according to its schedule, the establishment cost for a facility would not
change with the location. Thus, the fixed cost incurred for establishing a
facility at a location will depend upon its type and not the location.
Because each type of facility has a distinct type of infrastructure and
amenities, the cost of the establishment will vary. Further, a travel cost
will be incurred by an MTB in visiting a health facility from her location.
The Travel cost will also be incurred in referral cases if it requires the
moving of an MTB to a facility at a different location. The objective is to
minimize the sum of the total cost of establishing and operating the
facilities and the total cost incurred on visiting these facilities, including
referrals. The problem is referred to as a Hierarchical Capacitated Fa­
cility Location-Allocation (HCFL) problem in subsequent elaborations
and discussions.
The framework of the maternal healthcare planning undertaken in
the present work assumes the establishment of separate and dedicated
facilities for MTBs as the governments are focusing more on women
health (Janani Suraksha Yojana, 2005; National Rural Health Mission,
2005; Pradhan Mantri Surakshit Matritva Abhiyan, 2016) in an un­
precedented manner. If the planning worked out suggests the estab­
lishment of a maternal healthcare facility at a location where it already
exists, then the existing infrastructure will be provided for other hard-
pressed and infrastructure-deprived medical services. The following
descriptions will help in providing a better understanding of the prob­
lem framework considered in this paper.
A. Chouksey et al. Computers & Industrial Engineering 167 (2022) 107991

1. The maximum coverage distance for referral visits need not be the The mathematical model of the Hierarchical Capacitated Facility
same as that for a non-referral visit. Location-Allocation (HCFL) problem is presented hereunder using the
2. Fixed and operating costs related to the establishment of healthcare above notations.
facilities have been worked out on a daily basis, and so the demand ∑∑ ∑∑∑ ∑∑∑∑
(1)
′

for the services rendered by these facilities. Minimize Fjt ytj + cij xlij + cjk xlljk
3. A location of an MTB is also a potential location for establishing
j∈J t∈T i∈I j∈J l∈L j∈J k∈J l∈L l′ ∈L

healthcare facilities. Subject to

∑
4. The formulation xlij = Wil , ∀i ∈ I, ∀l ∈ L (2)
j∈J

The following notations have been used in the problem formulation. { }

∑ ∑
Sets and Indices x12
jk = θ 12
x 1
ij , ∀j ∈ J (3)
I: set of locations of MTBs, I = {1, 2, ..., m}, indexed by i
k∈J i∈I

J : set of locations of potential facilities, J = I, indexed by j,k and n { }

L: set of service types offered, L = {1, 2, 3}, indexed by l and l
′ ∑ ∑
13
xjk = θ 13 1
xij , ∀j ∈ J (4)
T: set of types of facility, T = {I, II, III}, indexed by t and u
k∈J i∈I
Parameters
{ }
d1 : a limit on the maximum distance to be covered by an MTB during a non- ∑ ∑ ∑
referral visit 23
xjk = θ 23 2
xij + 12
xnj , ∀j ∈ J (5)
d2 : a limit on the maximum distance to be covered by an MTB during the referral k∈J i∈I n∈J
visit
dij : distance between locations i ∈ I and j ∈ J
∑ ∑
x1ij ⩽ Q1t ytj , ∀j ∈ J (6)
djk : distance between facility locations j ∈ J and k ∈ J i∈I t∈T
Cij : travel cost incurred by an MTB for visiting the facility at a location j ∈ J from
its current location i ∈ I ∑ ∑ ∑
x2ij + x12
kj ⩽ Q2t ytj , ∀j ∈ J (7)
Cjk : travel cost incurred by an MTB for referral visit from current facility location
i∈I k∈J t∈T
j ∈ J to a referral facility at location k ∈ J
Ftj : fixed cost on establishing a facility of type t ∈ T at location j ∈ J ∑ ∑ ∑ ∑
capacity of service type l ∈ L available with facility type t ∈ T x3ij + x13
kj + xkj23 ⩽ Q3t ytj , ∀j ∈ J (8)
Qlt :
i∈I k∈J k∈J t∈T
Wli : number of MTBs at a location i ∈ I requiring service type l ∈ L
θll : proportion of referrals for service type l ∈ L from service type l ∈ L, where
′ ′

Q2I = Q3I = Q3II = 0 (9)

l >l
′

∑
ytj ⩽ 1 , ∀j ∈ J (10)
t∈T

⎧ if a facility for non - referral visit at a location j ∈ J is within the coverage distance of an MTB
⎨ 1,
αij = at a location i ∈ I (i.e., dij ⩽d1 ),
⎩
0, otherwise

⎧ if a referral facility at a location k ∈ J is within the coverage distance of a lower level facility
⎨ 1,
βjk = at location j ∈ J (i.e., djk ⩽d2 ),
⎩
0, otherwise

∑
xlij ⩽ αij ytj Qlt , ∀ i ∈ I, ∀ j ∈ J, ∀l ∈ L (11)
t∈T

∑
(12)
′ ′ ′
xlljk ⩽ βjk ytk Ql t , ∀ j, k ∈ J, ∀l, l (> l) ∈ L
t∈T
Decision variables

xlij : number of MTBs from location i ∈ I allocated to a facility at location j ∈ J to xlij ⩾ 0, ∀i ∈ I, ∀j ∈ J, ∀l ∈ L (13)
receive service type l ∈ L
xlljk : number of MTBs allocated under referral for availing a higher service type l ∈
′ ′

(14)
′ ′

L located at k ∈ J who were availing service type l ∈ L at a facility in location

xlljk ⩾ 0, ∀j, k ∈ J, ∀l, l (> l) ∈ L
j ∈ J (l > l)
′

ytj ∈ {0, 1}, ∀j ∈ J, ∀t ∈ T (15)

{
ytj =
1, if a facility of type t ∈ T is located at j ∈ J, The mathematical model can be understood from Fig. 1 that shows a
0, otherwise
part of the regional flows of MTBs to various facility types. Three

5
A. Chouksey et al.
Fig. 1. Allocation of Mothers-to-be in a different type of facilities.
mathematical expressions in the objective function (1) respectively
represent the fixed cost of establishing the healthcare facilities, the cost
of travel for visiting a facility, and the cost of travel upon referral. The
formulation takes care of the stated assumptions related to the cost for
the establishment of facilities and the service demand worked out
appropriately on a daily basis. Constraint (2) ensures complete fulfil­
ment of the demand of various service types of all the MTBs. The number
of MTBs referred from service type 1 to 2 and 3 is determined by the
constraints (3) and (4), respectively. Similarly, the number of MTBs
referred from service type 2 to 3 is determined by the constraint (5). It is
taken as the fraction of those MTBs who directly visit from their location
for service type 2 and also those which were earlier referred for service
type 2. Constraints (6), (7) and (8) ensure that the total allocation of
MTBs, including referrals, should not be more than the available ca­
pacity of the required service type at the facility type. Constraint (9)
inherits the true characteristics of lower-level facility types. SC (repre­
sented by index ‘I’) does not have the capacity for providing service
types 2 and 3; PHC (represented by index ‘II’) does not have the facility
to render service type 3. Constraint (10) ensures that only one type of
healthcare facility can be established at a location. Constraint (11) states
that the MTB at location i ∈ I can be assigned to a facility at location j ∈ J
if the required service type is available at the facility within the coverage
distance. Constraint (12) states that the MTBs at facility j ∈ J can be
referred for a higher level of service type to a facility at location k ∈ J if
the facility is located within the coverage distance from location i.
Constraints (13), (14) and (15) define the nature of decision variables.
5. Solution approaches
All the approaches presented in this section use the classical Branch
and Bound (B & B) method (Hillier et al., 2014) to solve the MILP
problem. The difference is in terms of consideration of some additional
constraints and/or the way the mathematical model of Section 4 is
handled in a phase-wise manner to arrive at the optimal or reasonably
good solution. The additional constraints do not modify the character­
istics of the problem. These are based on the understanding of the fea­
tures of the problem and to help in reducing the computational effort.
These approaches have been named as (1) HCFL simultaneous approach
(2) VI-HCFL simultaneous approach, and (3) Sequential approach. In the
first two approaches, the problem of location and allocation is solved
6
Computers & Industrial Engineering 167 (2022) 107991
considering the issue of locating all type of facilities (SC, PHC, CHC)
simultaneously. In the sequential approach, it is carried out differently.
First, the determination of location and allocation for CHC is carried out.
Taking this as input, the location and allocation problems related to PHC
are addressed next and in the last for SC. To solve the proposed MILP
model, the GUROBI optimization solver was used with an interface in
Python (Van Rossum & Drake, 2011) on a personal computer with an
Intel Core i7 processor with a speed of 3.40 GHz and 8 GB RAM.
5.1. HCFL simultaneous approach
In this approach, the classical B & B method is used to solve the
mathematical model of Section 4 as such, with no addition of constraints
or improvisations. GUROBI is used as a solver that uses some of its in-
built solution techniques such as primal simplex, dual simplex, and
barrier method for the faster convergence.
5.2. VI-HCFL simultaneous approach
While experimenting with the mathematical model using GUROBI, it
was observed that the solver hardly took a few minutes to solve the
model in providing the optimal solution for a small size problem with
fewer variables and constraints. As the problem size increases, the
number of variables and constraints increases drastically (exponen­
tially). For a large size problem (e.g., for the Tehsil level planning in
India where a Tehsil can have more than 1000 villages as potential lo­
cations), the solver could not find the optimal solution even in a couple
of days on the system mentioned earlier. The problem is computation­
ally difficult to solve in a reasonable amount of time because of its
inherent combinatorial nature and the used B & B method. B & B method
causes the associated tree to expand drastically with the increase in the
number of integer variables. In order to reduce the computational time,
it is important to reduce the size of the B & B tree by reducing the
number of B & B nodes required to solve the model (Pochet and Wolsey,
2006). For this purpose, some additional valid inequalities have been
added to the proposed model. Some of the proposed valid inequalities
are redundant constraints. Anjos & Vieira (2017) have reported the valid
inequalities, in the form of redundant constraints, to be very useful in
the use of B & B method to improve the lower bound for a minimization
problem even if they do not help in reducing the set of feasible solution.
A. Chouksey et al. Computers & Industrial Engineering 167 (2022) 107991

These valid inequalities provide a better lower bound and faster A careful examination will reveal that constraint (20) is a combina­
convergence. These additional valid inequalities are presented and dis­ tion of constraints (2) and (6), constraint (21) to be the combination of
cussed below. constraints (2), (3) and (7), and constraint (22) to be the combination of
constraints (2), (4), (5) and (8). Constraints (20), (21) and (22) show
5.2.1. Valid inequality for ensuring the availability of the established that the total capacity of each type of service in the entire system should
facilities within the coverage distance for each service type for each location be at least equal to the total number of MTBs seeking the respective
Constraints (11) relates flow variables (xlij ) with the facility estab­ services directly and referrals for higher-level services.
lishment variables (ytj ) with coverage distance issue in perspective. This The result on the effectiveness of these valid inequalities in reducing
the computation time is presented in Section 6. Because of the possibility
constraint will cause the flow variables to assume any value from zero to
of bringing down the time, the above valid inequalities are incorporated
the capacity level value of the service types available at the corre­
in the mathematical model proposed in Section 4 to be used in the
sponding facility type in the absence of constraints (6), (7) and (8).
various stages of the approach discussed in the next sub-section.
These constraints relate flow variables with the facility establishment
variables along with the available capacity but do not address the
maximum coverage distance issue. Because of these, there is room for 5.3. Sequential approach
working on a large number of not so useful combinations of values for
flow and facility establishment variables. To curtail these meaningless This approach is basically composed of three stages. It draws basic
combinations, it is desired to ensure that the facilities are located within motivation from Relax-and-Fix (RF) and Fix-and-Optimize (FO) heuris­
the maximum coverage distance and have sufficient capacity to meet the tics. RF method was developed by Dillenberger (1994) to find an initial
requirements of the allocated MTBs for all the service types. This is feasible solution for lot sequencing problems. Subsequently, many au­
achieved by adding the following valid inequality to the HCFL model. thors have used the RF approach to find the initial solution to large scale
∑∑ problems, such as lot sizing and scheduling problem (Absi & Heuvel,
αij ytj Qlt ⩾ Wil , ∀ i ∈ I, ∀l ∈ L (16) 2019; Araujo et al., 2007; Beraldi et al., 2008), production and distri­
j∈J t∈T
bution planning problem (Bilgen, 2014), travelling umpire problem
The above inequality can be seen to be related to constraints (2) and (Oliveira et al., 2014) and routing problem (Oliveira and Scarpin, 2020).
(11). RF decomposes a large MILP problem into smaller sub-problems that can
be solved easily. All the binary variables are relaxed initially. The
5.2.2. Valid inequality for ensuring the availability of higher-level facilities partially relaxed MILPs are solved iteratively by fixing the variables in
within the maximum coverage distance of lower-level facility for referrals each stage. The feasible solution obtained by RF is then fed to FO tos
Similar to the discussion and deliberation made in Section 5.2.1, it improve the solution quality further. FO was used by Gintner et al.
can be observed that the constraint set of the mathematical model (2005) for bus scheduling problems. It was formally introduced by
proposed in Section 4 does not directly address the issue of availability Helber & Sahling (2010) to solve a multi-level capacitated lot-sizing
of referral facilities within the maximum coverage distance of the lower- problem. FO also decomposes the MILP problem into smaller sub-
level facilities. From this perspective, the following valid inequalities are problems, with each having a lesser number of binary variables, some
added to the proposed mathematical model. free and the rest fixed. After solving the sub-problem iteratively, the
∑ solution quality was found to improve. FO has been found to be efficient
yIj ⩽ βjk yIIk , ∀ j ∈ J (17) for large scale MIP problems, such as production planning problem
k∈J
(Bilgen, 2014; Wolter & Helber, 2015), inventory problems (Tanksale &
∑ Jha, 2019) and facility location-network design problems (Ghaderi &
yIj ⩽ βjk yIII
k ,∀j ∈ J (18)
k∈J
Jabalameli, 2013; Moreno et al., 2015), and high school time-tabling
problem (Dorneles et al., 2014). The three-stage sequential approach
∑
yIIj ⩽ βjk yIII (19) proposed to solve the HCFL model is based on these concepts. The three
k ,∀j ∈ J
k∈J stages are: (i) construction stage, (ii) improvement stage, and (iii)
refinement stage. The actions to be taken at these stages are presented in
Constraint (17) and (18) will respectively and directly ensure the
respective Figs. 2a, 2b, and 2c, and the same are further discussed as
availability of PHC (indexed by II) and CHC (indexed by III) within the
follows.
coverage distance of SC (indexed by I). Similarly, constraint (19) will
ensure the establishment of referral facility as CHC (indexed by III)
5.3.1. Construction stage
within the coverage distance of PHC (indexed by II).
At this stage, binary establishment variables are taken sequentially
for each service type. Because of a few binary establishment variables
5.2.3. Valid inequality for ensuring the availability of the capacity of each
taken, the computational requirements is expected to reduce. In this
service type on an overall basis
process, the allocation problem of CHCs is focused first. The corre­
The constraint set of the mathematical model proposed in Section 4
sponding yIII
j variables are taken as binary, while this requirement is
does not directly address the issue of the required total capacity of the
healthcare system as a whole with the demand. The following valid relaxed for yIIj and yIj variables. With a relaxed condition, the proposed
inequalities added to the proposed model will ensure that the capacity of mathematical model with valid inequalities is used to obtain the optimal
the facilities to be established should be at least equal to the overall location of CHCs. With this optimal location of CHCs and taking now yIIj
requirement of each service type. variables as binary, the mathematical model is again used to find out
∑ ∑∑ optimal locations for PHCs. The optimal solution thus obtained is ready
Wi1 ⩽ ytj Q1t (20)
i∈I j∈J t∈T
with optimal locations for PHCs and CHCs. Now, with yIj variables as
binary and the current optimal locations for the two higher-level facil­
∑ ∑ { } ∑∑
Wi2 + θ12 Wi1 ⩽ ytj Q2t (21) ities, the mathematical model will be used to solve the problem to find
i∈I i∈I j∈J t∈T the optimal location of SCs. While solving the location problems, allo­
∑ ∑ { } ∑ { } ∑∑ t 3t cation problems are also solved.
Wi3 + θ13 Wi1 + θ23 Wi2 + θ12 W 1 ⩽ yj Q (22) In the construction stage, the locations of CHCs are worked out first
i∈I i∈I i∈I j∈J t∈T as it generates opportunities for service types 1 and 2 as well. This
amount of availability for service types 1 and 2 will be taken into

7
A. Chouksey et al.
Fig. 2a. Pseudo-code for the construction stage of sequential approach.
consideration while deciding the establishment of its lower-level facil­
ities. Going otherwise from SCs to CHCs, a lot of spare capacity will
unnecessarily be left as lower-level requirements will be taken care of
while deciding lower-level facilities. The higher-level facilities decided
later will leave extra capacity for the lower facilities as these are to
provide a lower level of services as well. Thus, the establishment cost
will be unnecessarily high.
In the sequential facility allocation approach discussed above, the
decision taken earlier will govern the decisions taken later. Thus, the
locations determined may not be the best ones. It is with this concern the
improvement stage will be followed, and the same is discussed below.
5.3.2. Improvement stage
New optimal locations of CHCs were determined using the current
optimal locations of SCs and PHCs to do away with the bias resulting
from the construction stage. With this new optimal location of CHCs and
the existing locations of SCs, the optimal locations for PHCs will be
discovered next. In the last, with the current optimal locations of PHCs
and CHCs, the optimal locations of SCs will be determined. Two-third of
the total number of establishment variables (corresponding to two fa­
cility types) will be given a fixed value. It is only one-third of the total
binary variables (corresponding to the facility type whose locations are
to be determined) that are taken as free variables. This naturally helps in
sizably reducing the computational requirement.
5.3.3. Refinement stage
In the earlier two stages, the optimal locations for each facility were
obtained sequentially, one after the other, and never simultaneously.
This sequential determination of optimal locations will have an inherent
8
Computers & Industrial Engineering 167 (2022) 107991
bias, which on removal may result in a better solution. This stage helps
in doing so and is detailed below.
At this stage, a fresh assignment of CHCs, PHCs and SCs is worked out
at the locations identified in the improvement stage and using HCFL
model for finding optimal allocation decisions as well. The mathemat­
ical model used at this stage, with the valid inequalities, will be of much-
reduced size due to known locations for the facilities. The problem size
reduces due to zero value assigned to location and flow variables cor­
responding to those locations that did not find any facilities located in
them at the improvement stage.
Due to the reduction in the number of integer variables and con­
straints on account of prefixing of values for a good number of the de­
cision variables, the computational requirement decreases drastically,
and the solution obtained is generally better as compared to the solution
obtained after the improvement stage. The reduction in the number of
establishment variables causes an exponential reduction in the total
number of decision variables.
6. Computational experiment
Computational experiments have been carried out to:
1. analyze the usefulness of the proposed valid inequalities,
2. check the effectiveness and computational efficiency of the proposed
sequential approach, and
3. perform sensitivity analyses to understand the impact of variation in
the problem parameters on the solution.
The extensive computational experiments used randomly generated
A. Chouksey et al. Computers & Industrial Engineering 167 (2022) 107991

Fig. 2b. Pseudo-code for the improvement stage of the sequential approach.

Fig. 2c. Pseudo-code for the refinement stage of the sequential approach.

Euclidean distance alone. However, the distance between the demand

Table 2
nodes is taken as Euclidean distance simply for the purpose of experi­
Capacity (units) of the facilities.
mentation. For example, for a 50 node problem, 50 coordinates were
Service types Problem class generated randomly on a grid of 100 by 100. All the 50 coordinates were
D10, D20 D50, D100, D200, D300, D400 uniformly distributed over the grid. The distance matrix was prepared
SC PHC CHC SC PHC CHC
considering the Euclidean distance between each of them. The cost of
visiting a facility was taken to be proportional to the distance. Demands
1 300 500 800 1000 1200 1500
originating from various locations for service types 1, 2, and 3 were
2 0 300 500 0 1000 1200
3 0 0 100 0 0 300 taken as random numbers uniformly distributed over (50, 1000), (20,
400), (1, 20), respectively. The numbers taken were representative of
the true condition where the requirement of service type 1 is the highest
datasets, and the same are detailed in the following sub-section. and that of service type 3 being the lowest. The capacity taken for
various service type at the three facility types is as shown in Table 2. The
6.1. Generation of test instances proportion of referrals from service type 1 to 2, 1 to 3, and 2 to 3 were
taken as 0.1, 0.03, 0.05, respectively. It is estimated using the data
Seven problem classes were taken with the number of locations available in the Indian context. The maximum distance that an MTB can
varying between 10 and 400. These problem classes are designated as travel to reach a facility from her origin (i.e., coverage distance) was
D10, D20, D50, D100, D200, D300, and D400. For each problem class, taken as 50 units, while in the case of referral as 70 units. The fixed costs
five instances were generated. The demand nodes (or the locations of incurred on establishing a single unit of SC, PHC, and CHC were taken as
MTBs) are generated randomly by taking them to be uniformly distrib­ 100,000, 500,000, and 1,000,000 units, respectively.
uted over a grid of 100 by 100 for problem classes D10, D20, and D50, The reduction in the number of establishment variables causes an
and 200 by 200 for the remaining problem classes. The proposed model exponential reduction in the total number of decision variables, and this
and solution methodologies are not limited to the consideration of can be verified from Fig. 3 that has been drawn for the problem instances

9
A. Chouksey et al. Computers & Industrial Engineering 167 (2022) 107991

Fig. 3. Increase in (a) total number of variables (b) number of establishment variables.

Table 3
Optimal solutions obtained by HCFL and VI-HCFL approaches for some problems.
Problem Problem Instance HCFL formulation VI-HCFL formulation Sequential approach
class number number
UB LB Gap Time UB LB Gap Time UB Time D1 D2
(%) (sec) (%) (sec) (sec) (%) (%)

D10 1 1 3,655,273 3,655,273 0.00 0.24 3,655,273 3,655,273 0.00 0.26 3,655,273 0.39 0.00 0.00
2 2 3,245,764 3,245,764 0.00 0.27 3,245,764 3,245,764 0.00 0.20 3,245,764 0.37 0.00 0.00
3 3 3,647,216 3,647,216 0.00 0.36 3,647,216 3,647,216 0.00 0.18 3,648,201 0.35 0.03 0.03
4 4 3,229,844 3,229,844 0.00 0.38 3,229,844 3,229,844 0.00 0.13 3,229,844 0.30 0.00 0.00
5 5 3,233,145 3,233,145 0.00 0.56 3,233,145 3,233,145 0.00 0.25 3,233,145 0.27 0.00 0.00

D20 6 1 3,957,152 3,957,152 0.00 132 3,957,152 3,957,152 0.00 0.85 3,957,152 0.81 0.00 0.00
7 2 3,366,991 3,366,991 0.00 258 3,366,991 3,366,991 0.00 2.18 3,366,991 1.37 0.00 0.00
8 3 4,363,713 4,363,713 0.00 100 4,363,713 4,363,713 0.00 1.43 4,363,713 1.02 0.00 0.00
9 4 3,985,069 3,985,069 0.00 165 3,985,069 3,985,069 0.00 1.55 3,985,069 1.40 0.00 0.00
10 5 4,474,788 4,474,788 0.00 34 4,474,788 4,474,788 0.00 2.24 4,475,439 1.59 0.02 0.02

Table 4
Problems in which the same UB is obtained by HCFL and VI-HCFL formulations.
Problemclass Problem Instance Sequential approach
number number
HCFL formulation VI-HCFL formulation

UB LB Gap Time UB LB Gap Time UB Time D1 D2

(%) (sec) (%) (sec) (sec) (%) (%)

D50 11 1 6,198,274 6,198,274 0.000 790 6,198,274 6,198,274 0.000 204 6,205,247 14 0.113 0.113
12 2 6,191,730 6,191,730 0.000 3095 6,191,730 6,191,730 0.000 55 6,193,841 13 0.034 0.034
13 3 6,280,104 6,201,740 0.012 7200 6,280,104 6,280,104 0.000 161 6,283,516 18 0.054 0.054
14 4 5,797,499 5,717,716 0.014 7200 5,797,499 5,797,499 0.000 104 5,797,499 14 0.000 0.000
15 5 6,802,824 6,791,343 0.002 7200 6,802,824 6,802,824 0.000 158 6,803,499 17 0.010 0.010

undertaken for experimentation. values as a percentage of UB.

6.2. Experimental results on the suitability of proposed approaches
The experimental results related to the efficiency and efficacy of the
solution approaches presented in Sections 5.1, 5.2, and 5.3 are provided
in Tables 3, 4, and 5. In these tables, columns labelled as ‘D2’ and ‘D1’
present the percentage by which the upper bound (UB) values obtained
by the sequential approach (Section 5.3) are more than that from HCFL
or VI-HCFL formulations, respectively. The comparison was made based
on the upper bound value as the problem seeks to minimize the overall
cost. Further, the upper bound value will correspond to a feasible so­
lution, while the lower bound may not be. Columns labelled as ‘Gap’
measure the gap between upper bound (UB) and lower bound (LB)
Table 3 contains the results for those problems for which all the three
approaches (HCFL, VI-HCFL and Sequential approach) yielded optimal
solutions. Naturally, the LB and UB values for these cases are equal. For
all these problems (except problem number 1), the inclusion of all the
valid inequalities into the mathematical model shows clear improve­
ment by way of lesser CPU times taken for resulting in the optimal so­
lutions. The improvement, even though it is smaller for the VI-HCFL
approach for problem class D10, becomes remarkably very high for D20
problem class. Naturally, the use of valid inequalities has played its
dividend in reducing the CPU time requirement or the computational
effort drastically. The sequential approach is better than the VI-HCFL
approach for D20 problem class but not for the D10 problem class in
terms of the CPU time requirement. Since the VI-HCFL approach was

10
 A. Chouksey et al. Computers & Industrial Engineering 167 (2022) 107991

better than the HCFL for D20 problem class, the sequential approach is

0.015
0.019
0.037
0.072
0.039

0.157
0.077
0.102
0.080
0.054

0.056
0.179
0.152
0.096
0.016

− 0.269
− 0.467
0.343
− 0.881
− 0.255
much better in terms of CPU time requirements than the two approaches

D2 (%)
for the D20 problem class. The quality of the solution obtained from the
sequential approach is very good, and the same can be witnessed from
columns D1 and D2.

–23.454
− 11.331

− 18.774
− 18.135
− 19.360
0.007
0.012
0.037
0.072
0.034

0.179
0.025
0.046
0.095
0.030

0.022
0.147
0.083
0.038
0.000
D1 (%)

Table 4 contains the results for those problem instances for which VI-
Sequential approach

HCFL formulation has yielded the optimal solution. GUROBI solver did
not converge for HCFL formulation even in a high CPU time of 7200 s for
problems 13, 14, and 15. This table also finds the sequential approach to
Time (sec)

2679 be taking the least amount of CPU time and VI-HCFL formulation to be
1824
2551
2190
1940

3011
3380
3680
3312
2955

3815
4345
4606
4606
4605
629
623
627
452
171

better than HCFL formulation from this perspective. Thus, the sequential
approach turns out to be the best from the CPU time requirement
perspective. The sequential approach could result in the optimal solu­
11,784,249
11,786,967
11,895,361
11,781,110
13,484,309

22,360,590
23,326,391
23,011,816
21,931,671
22,409,148

34,210,107
33,137,687
33,632,356
34,135,816
34,726,252

44,977,721
45,477,897
45,586,773
44,822,761
45,522,335
tion for one of the problems (problem number 14) taking just 14 s,
whereas VI-HCFL took more than seven times of CPU time to yield the
UB

optimal solution, and HCFL could not yield the solution even in 7200 sec
(514 times of the CPU time for sequential approach). Even though the
Time (sec)

sequential approach is quite fast, but is marginally poor. It is evident

from entries in columns ‘D1’ and ‘D2’. However, even the highest gap of
7200
7200
7200
7200
7200

7200
7200
7200
7200
7200

7200
7200
7200
7200
7200

7200
7200
7200
7200
7200
0.113% (for problem number 11) is a very small number. This table
evidences VI-HCFL to be superior to HCFL both in terms of efficiency and
Gap (%)

efficacy. On an overall basis, the sequential approach can be observed to

0.09
0.10
0.10
0.11
0.10

1.33
1.78
0.49
0.59
0.45

0.50
0.83
0.47
0.41
1.37

0.72
1.48
0.68
2.09
1.35
be the best, with the resulting solution quality being practically the same
as from VI-HCFL.
Table 5 contains the results for the remaining problem instances.
11,771,613
11,772,991
11,879,440
11,759,353
13,466,221

22,028,220
22,894,610
22,876,101
21,784,573
22,296,504

34,018,507
32,804,918
33,425,026
33,963,793
34,244,296

44,772,705
45,016,508
45,120,680
44,275,504
45,020,484

Since the HCFL or VI-HCFL approaches were taking too much CPU time
to arrive at the optimal solution, the rest of the analysis on efficacy and
VI-HCFL formulation

LB

efficiency for large size problems was carried out while limiting the CPU
time to 7200 s. Looking into the UBs for HCFL and VI-HCFL approaches,
11,782,473
11,784,725
11,891,016
11,772,656
13,479,087

22,325,435
23,308,370
22,988,457
21,914,078
22,397,013

34,190,936
33,078,453
33,581,420
34,102,981
34,720,646

45,099,260
45,691,319
45,430,940
45,220,943
45,638,762

it is found that the two are equivalent for problems 18 and 19. In the rest
cases, VI-HCFL approach is superior not only in terms of UB value but
also in terms of the gap between UBs and LBs (a tighter band). From this
UB

perspective, the sequential approach is found to be very marginally

inferior to the HCFL and VI-HCFL approaches but for D400 problem
Time (sec)

class for which it is better. For problem classes as D100, D200, or D300
7200
7200
7200
7200
7200

7200
7200
7200
7200
7200

7200
7200
7200
7200
7200

7200
7200
7200
7200
7200

(which are close to the Indian context), the sequential approach has
concluded itself quite early and yielded reasonably good solutions as
well. It is obvious from the entries in the columns related to ‘D1’ and
Gap (%)

‘D2’. Wilcoxon signed-rank test was applied to the CPU time for each of
12.24
24.58
19.89
19.94
20.62
2.09
2.64
1.16
2.28
2.85

1.64
2.16
1.86
0.64
1.35

1.13
1.25
1.80
2.36
2.00

the proposed approaches. The test found the sequential approach to be

better than both the HCFL (p = 0.00001) and VI-HCFL formulations (p =
0.00001). VI-HCFL formulation was found to be better than HCFL
11,536,985
11,474,852
11,753,485
11,504,419
13,095,001

21,953,476
22,817,655
22,573,663
21,769,827
22,100,827

33,816,967
32,674,682
33,000,545
33,317,291
34,033,008

44,518,013
44,810,000
44,960,221
43,836,145
44,812,241

formulation with p = 0.0008.

Based on the above observations, it can be concluded that the
LB
HCFL formulation

addition of valid inequalities helps in reducing the computational effort,

and the proposed sequential approach is practically a better approach
11,783,409
11,785,575
11,891,016
11,772,656
13,479,673

22,320,525
23,320,474
23,001,255
21,910,910
22,402,508

34,202,506
33,088,955
33,604,363
34,122,862
34,726,111

50,725,329
59,412,153
56,123,253
54,752,318
56,451,591

compared to the other approaches for resulting in a good solution (quite

close to the optimal one).
UB

6.3. Experimental results on the efficacy of proposed valid inequalities

Instance number

Section 6.2 demonstrated the usefulness of valid inequalities. In view

of this, it is desired to further investigate the effectiveness of these in­
equalities individually. This section is devoted to this end. Table 6 shows
the results from the use of valid inequalities for the various problem
1
2
3
4
5

1
2
3
4
5

1
2
3
4
5

1
2
3
4
5
Results for other problem instances.

classes when added individually to the HCFL model. ‘Gap’ in this table
Problem number

refers to the gap between UB and LB values as a percentage of UB value.

For a fair comparison, a maximum CPU time of 7200 s was allocated to
the GUROBI solver.
It can be observed from this table that all the versions of the
16
17
18
19
20

21
22
23
24
25

26
27
28
29
30

31
32
33
34
35

formulation yielded optimal solutions for problem classes D10 and D20.
Only the inclusion of valid inequality 3 yielded optimal solutions for all
Problem class

instances of problem class 50. Not only this, it has taken the least CPU
time for all D10, D20, and D50 class of problems. For the other
Table 5

D100

D200

D300

D400

remaining problem classes (D100, D200, D300, and D400), CPU time
was limited to 7200 s. For these problem classes, the gap between UB

11
 A. Chouksey et al.
Table 6
Comparison of HCFL formulation with valid inequalities.
Problem Problem HCFL formulation Valid Inequality 1 (Section 5.2.1) Valid Inequality 2 (Section 5.2.2) Valid Inequality 3 (Section 5.2.3)
class number
UB LB Gap Time UB LB Gap Time UB LB Gap Time UB LB Gap Time
(%) (sec) (%) (sec) (%) (sec) (%) (sec)

D10 1 3,655,273 3,655,273 0.00 0.24 3,655,273 3,655,273 0.00 3.40 3,655,273 3,655,273 0.00 0.27 3,655,273 3,655,273 0.00 0.16
2 3,245,764 3,245,764 0.00 0.27 3,245,764 3,245,764 0.00 3.71 3,245,764 3,245,764 0.00 0.26 3,245,764 3,245,764 0.00 0.17
3 3,647,216 3,647,216 0.00 0.36 3,647,216 3,647,216 0.00 1.78 3,647,216 3,647,216 0.00 0.48 3,647,216 3,647,216 0.00 0.20
4 3,229,844 3,229,844 0.00 0.38 3,229,844 3,229,844 0.00 0.94 3,229,844 3,229,844 0.00 0.59 3,229,844 3,229,844 0.00 0.17
5 3,233,145 3,233,145 0.00 0.56 3,233,145 3,233,145 0.00 1.89 3,233,145 3,233,145 0.00 0.67 3,233,145 3,233,145 0.00 0.17

D20 6 3,957,152 3,957,152 0.00 132 3,957,152 3,957,152 0.00 712 3,957,152 3,957,152 0.00 375 3,957,152 3,957,152 0.00 1.05
7 3,366,991 3,366,991 0.00 258 3,366,991 3,366,991 0.00 125 3,366,991 3,366,991 0.00 289 3,366,991 3,366,991 0.00 2.22
8 4,363,713 4,363,713 0.00 100 4,363,713 4,363,713 0.00 184 4,363,713 4,363,713 0.00 183 4,363,713 4,363,713 0.00 9.02
9 3,985,069 3,985,069 0.00 165 3,985,069 3,985,069 0.00 168 3,985,069 3,985,069 0.00 146 3,985,069 3,985,069 0.00 2.06
10 4,474,788 4,474,788 0.00 34 4,474,788 4,474,788 0.00 46 4,474,788 4,474,788 0.00 41 4,474,788 4,474,788 0.00 1.53

D50 11 6,198,274 6,198,274 0.00 790 6,198,274 6,198,274 0.00 1038 6,198,274 6,198,274 0.00 511 6,198,274 6,198,274 0.00 129
12 6,191,730 6,191,730 0.00 3095 6,191,730 6,191,730 0.00 3449 6,191,730 6,191,730 0.00 1261 6,191,730 6,191,730 0.00 53
13 6,280,104 6,201,740 1.25 7200 6,280,104 6,202,994 1.23 7200 6,280,104 6,217,998 0.99 7200 6,280,104 6,280,104 0.00 85
14 5,797,499 5,717,716 1.38 7200 5,797,499 5,719,738 1.34 7200 5,797,499 5,721,474 1.31 7200 5,797,499 5,797,499 0.00 68
15 6,802,824 6,791,343 0.17 7200 6,802,824 6,802,824 0.00 7200 6,802,824 6,747,027 0.82 7200 6,802,824 6,802,824 0.00 97
12

D100 16 11,783,409 11,536,985 2.09 7200 11,782,473 11,536,975 2.08 7200 11,782,510 11,538,051 2.07 7200 11,782,473 11,771,358 0.09 7200
17 11,785,575 11,474,852 2.64 7200 11,785,575 11,519,277 2.26 7200 11,785,575 11,518,946 2.26 7200 11,785,121 11,773,742 0.10 7200
18 11,891,016 11,753,485 1.16 7200 11,891,016 11,756,496 1.13 7200 11,891,856 11,753,853 1.16 7200 11,891,005 11,879,309 0.10 7200
19 11,772,656 11,504,419 2.28 7200 11,774,342 11,502,188 2.31 7200 11,773,878 11,501,924 2.31 7200 11,772,656 11,762,574 0.09 7200
20 13,479,673 13,095,001 2.85 7200 13,479,115 13,095,068 2.85 7200 13,479,087 13,098,492 2.82 7200 13,479,087 13,467,479 0.09 7200

D200 21 22,320,525 21,953,476 1.64 7200 22,335,763 21,954,026 1.71 7200 22,333,464 21,955,130 1.69 7200 22,321,977 22,028,432 1.32 7200
22 23,320,474 22,817,655 2.16 7200 23,340,027 22,555,403 3.36 7200 23,312,522 22,554,997 3.25 7200 23,308,838 22,900,445 1.75 7200
23 23,001,255 22,573,663 1.86 7200 23,000,573 22,852,383 0.64 7200 23,007,616 22,856,128 0.66 7200 22,986,891 22,926,397 0.26 7200
24 21,910,910 21,769,827 0.64 7200 21,925,477 21,631,193 1.34 7200 21,923,493 21,634,603 1.32 7200 21,924,579 21,850,921 0.34 7200
25 22,402,508 22,100,827 1.35 7200 22,398,202 22,091,246 1.37 7200 22,407,109 22,092,295 1.40 7200 22,392,277 22,299,714 0.41 7200

D300 26 34,202,506 33,816,967 1.13 7200 34,210,945 33,818,531 1.15 7200 34,223,244 33,818,860 1.18 7200 34,193,563 34,017,860 0.51 7200
27 33,088,955 32,674,682 1.25 7200 33,078,632 32,678,101 1.21 7200 33,111,218 32,676,864 1.31 7200 33,082,617 32,803,184 0.84 7200

Computers & Industrial Engineering 167 (2022) 107991

28 33,604,363 33,000,545 1.80 7200 33,612,411 33,001,050 1.82 7200 33,631,041 33,001,437 1.87 7200 33,597,512 33,423,550 0.52 7200
29 34,122,862 33,317,291 2.36 7200 34,116,394 33,315,314 2.35 7200 34,153,279 33,315,737 2.45 7200 34,100,633 33,674,276 1.25 7200
30 34,726,111 34,033,008 2.00 7200 34,727,290 34,034,461 2.00 7200 34,772,342 34,034,204 2.12 7200 34,703,570 34,242,378 1.33 7200

D400 31 50,725,329 44,518,013 12.24 7200 59,423,462 44,514,788 25.09 7200 60,681,311 44,515,650 26.64 7200 44,939,674 44,774,595 0.37 7200
32 59,412,153 44,810,000 24.58 7200 52,397,030 44,811,786 14.48 7200 56,482,929 44,809,854 20.67 7200 45,375,618 45,019,215 0.79 7200
33 56,123,253 44,960,221 19.89 7200 52,876,735 44,960,927 14.97 7200 75,324,206 44,955,178 40.32 7200 45,434,007 45,113,672 0.71 7200
34 54,752,318 43,836,145 19.94 7200 55,913,366 43,836,270 21.60 7200 58,531,805 43,836,739 25.11 7200 44,740,039 44,275,170 1.04 7200
35 56,451,591 44,812,241 20.62 7200 57,911,578 44,812,882 22.62 7200 81,289,578 44,803,821 44.88 7200 45,377,451 45,018,494 0.79 7200
A. Chouksey et al. Computers & Industrial Engineering 167 (2022) 107991

Table 7 sections.
Results of Wilcoxon signed-rank test.
Effectiveness of inclusion of p-value Observation 6.4.1. Impact of coverage distance
(statistically Location problems with a prespecified coverage distance are basi­
significant) cally covering problems (Daskin, 2011). In these problems, the choice of
Valid inequality 1 over HCFL 0.79486 No coverage distance generally has a significant impact on the solution. The
Valid inequality 2 over HCFL 0.06876 No problem chosen in the current work considered two types of distance:
Valid inequality 3 over HCFL 0.00001 Yes one for allocation of MTBs to a facility from their origin and the other for
Valid inequality 2 over valid inequality 1 0.04884 Yes
Valid inequality 3 over valid inequality 1 0.00001 Yes
referrals to another facility. As mentioned in Section 6.1, the values of
Valid inequality 3 over valid inequality 2 0.00001 Yes these distances are 50 and 70, respectively. For the sensitivity analyses,
All the valid inequalities together over HCFL 0.00001 Yes the coverage distances are varied one at a time in the range of 10 to 130
with a step size of 10. The impact of the coverage distance on the overall
cost is summarised in Fig. 4. In general, a reduction in the maximum
coverage distance should cause more facilities to be created to meet the
and LB values for HCLF formulation was high in most of the cases
demand. In extreme cases (when the maximum coverage distance is
compared to when the proposed inequalities were included in it indi­
specified to be very low), every location will then have at least one CHC
vidually. Wilcoxon signed-rank test was applied to the gap values for
to meet the requirement of all three types of services. With the decrease
each variation of HCFL formulation. The result of the test is shown in
in the maximum coverage distance, the travel cost is likely to come
Table 7. This table shows that the inclusion of valid inequality 3 (Section
down while the facility establishment cost to go up. Since the facility
5.2.3) is quite useful and effective. Valid inequality 3 (Section 5.2.3) can
establishment cost is expected to be high compared to the travel cost, a
be observed to perform better compared to the other two valid in­
equalities from the solution quality perspective. No statistically signifi­
cant difference was found in the use of valid inequalities 1 or 2. When all
the valid inequalities are included in the HCFL formulation, it remains to
be seen whether the effectiveness is mostly governed by valid inequality
3 or by the other two inequalities as well. For this, the results with the
inclusion of valid inequality 3 (shown in Table 6) were compared to the
results from the VI-HCFL formulation shown in Tables 3, 4 and 5. Wil­
coxon signed-rank test on CPU time resulted in a p-value of 0.13888,
meaning thereby that the difference in CPU time requirement is insig­
nificant. However, this test performed on the ‘Gap’ value resulted in a p-
value of 0.00001. It clearly shows that the use of all the three valid in­
equalities proposed in this paper is more effective than the use of valid
inequalities 3 (Section 5.2.3) alone.
The above experimentation demonstrates the usefulness of the pro­
posed inequalities for the problem considered in this paper.

6.4. Sensitivity analysis

Sensitivity analyses have been carried out to analyze the effect of the
various parameters, such as coverage distance, fixed cost, referral pro­
Fig. 5. Effect of maximum coverage distance for non-referral visits on the
portion, and capacity. For this purpose, problem number 14 has been
number of various facility types established.
taken. The results of the analyses are provided in the following sub-

Fig. 4. Effect on the overall cost due to variation in maximum coverage distace (a) a non-referral visit and (b) for a referral visit.

13
A. Chouksey et al. Computers & Industrial Engineering 167 (2022) 107991

Table 8 lished. For example, in the case of configurations numbered as 1 and 9

Effect of change in the referral proportion. (Table 8), the referral proportion for service type 1 to service type 2 (θ12 )
Configuration number θ12 θ13 θ23 Number of established is going up from a value of 0.05 to 0.15. With the increase in the referral
proportion for service type 2, it is natural to have a possible increase in
SC PHC CHC
the number of facilities of type 2 (PHCs) and possibly of type 3 (CHCs)
1 0.05 0.03 0.05 6 2 4 due to the cascading effect resulting from referrals from service type 2 to
2 0.10 0.03 0.05 6 2 4
3 0.10 0.01 0.05 5 4 3
service type 3. However, a reverse of the above is witnessed (Table 8).
4 0.10 0.03 0.05 6 2 4 Even though the number of facilities of type 2 increases from 2 (θ12 =
5 0.10 0.05 0.05 5 1 5 0.05) to 3 (θ13 = 0.15), the cascading effect going to facilities of type 3 is
6 0.10 0.03 0.01 5 4 3
observed to be missing but to the number of SCs (going down from 6 to
7 0.10 0.03 0.05 6 2 4
8 0.10 0.03 0.1 5 1 5 4). This reduction in the number of lower-level facilities with an increase
9 0.15 0.03 0.05 4 3 4 in the higher-level facility type 2 can be observed in the case of con­
10 0.20 0.03 0.05 3 4 4 figurations 3 and 6, but now coupled with the decrease in the number of
11 0.30 0.03 0.05 2 5 4
health facility type 3 (CHC). In case the referral proportion of service
12 0.40 0.03 0.05 0 5 5
type 1 to service type 3 (θ13 ) is increased from 0.01 (configuration 3) to
0.05 (configuration 5), it causes an increase in the number of the facil­
net increase in the overall cost is to be experienced. This characteristic is ities of type 3 (CHCs) from 3 to 5 while causing a reduction in the
clearly evident from Fig. 4(a) and 4(b). Going in the reverse direction number of lower-level of the facility of type 2 (PHCs) by 3. Configuration
(increasing the maximum coverage distance), a reduction in the overall 8 in comparison to configuration 1 finds θ12 and θ23 getting doubled. It
cost is to be expected. However, this kind of trend is not evident in Fig. 4 shows a 100% increase in referrals. Under this circumstance, the number
throughout. After a particular maximum coverage distance (40 for the of each of SCs and PHCs is brought down by 1 instead of remaining
non-referral case and 50 for referrals), no reduction in the overall cost is
observed. It is so because when the requirement on the maximum
coverage distance is relaxed (a higher value of the maximum coverage Table 10
Effect of variation in the capacity of various service types in PHC.
distance), the model will try to take cost advantage by establishing more
lower-level facilities at a lower cost compared to the increase in the Configuration Service Service Number of established Objective
number type 1 type 2 function
travel cost. This advantage can be continuously gained until the SCs PHCs CHCs
value
maximum distance travelled is not constrained by the permissible
maximum coverage distance. It is this limit beyond which if the 24 1200 600 3 3 4 6,479,090
25 1200 800 4 3 4 6,095,160
maximum coverage distance increases, no change in the solution is
26 1200 1000 6 2 4 5,797,500
observed as the best trade-off between the cost of establishing the fa­ 27 1200 1200 6 2 4 5,795,270
cilities and the travel cost has already been sought. There is neither any 28 1200 1400 6 2 4 5,793,140
change in the number of facilities of each type nor in the location and 29 1200 1600 6 2 4 5,792,000
30 800 1000 6 2 4 5,805,450
allocation of MTBs at this stage. It can be noticed from Fig. 5 that shows
31 1000 1000 6 2 4 5,801,220
no change beyond the maximum coverage distance of 40 for the non- 32 1200 1000 6 2 4 5,797,500
referrals. 33 1400 1000 5 2 4 5,707,390
34 1600 1000 5 2 4 5,706,040
6.4.2. Impact of change in referral proportion 35 2000 1000 4 2 4 5,620,520
36 2200 1000 4 2 4 5,620,520
It is expected that the increase in the referral proportion may require
37 2400 1000 4 2 4 5,620,520
an increase in the number of the higher level of facilities to be estab­

Table 9
Effect of variation in the capacity of various service types in CHC.
Configuration number Service type 1 Service type 2 Service type 3 Number of established Objective function value

SCs PHCs CHCs

1 1500 1200 100 0 0 11 11,135,400

2 1500 1200 200 5 0 6 6,696,890
3 1500 1200 300 6 2 4 5,797,500
4 1500 1200 400 5 4 3 5,697,330
5 1500 1200 500 5 4 3 5,696,880
6 1500 1200 600 5 4 3 5,696,810
7 1500 600 300 2 5 4 6,876,730
8 1500 800 300 3 4 4 6,491,460
9 1500 1000 300 4 3 4 6,103,210
10 1500 1200 300 6 2 4 5,797,500
11 1500 1400 300 6 2 4 5,788,350
12 1500 1600 300 7 1 4 5,399,330
13 1500 1800 300 8 0 4 5,025,370
14 1500 2000 300 8 0 4 5,025,350
15 1500 2200 300 8 0 4 5,025,350
16 1000 1200 300 8 2 4 5,990,390
17 1200 1200 300 7 2 4 5,891,570
18 1500 1200 300 6 2 4 5,797,500
19 1800 1200 300 4 2 4 5,621,010
20 2000 1200 300 4 2 4 5,617,260
21 2200 1200 300 3 2 4 5,530,430
22 2400 1200 300 3 2 4 5,530,430
23 2600 1200 300 3 2 4 5,530,430

14
A. Chouksey et al. Computers & Industrial Engineering 167 (2022) 107991

Table 11 with a capacity of 100 for service type 3. While going further from
Effect of variation in the capacity of various service types in SC. configuration 2 to configuration 4, it is observed that the number of
Configuration Service Number of established Objective function required CHCs decreases as the combined capacity available for service
number type 1 value type 3 is good enough to handle the total demand for service type 3. For
SCs PHCs CHCs
configuration 5, the past trend of reduced number discontinues, and the
38 600 9 2 4 6,088,570 value of the number remains stationary. Going with the trend of the
39 800 7 2 4 5,893,020
40 1000 6 2 4 5,797,500
reduced number and taking 2 CHCs to be established will not serve the
41 1200 5 2 4 5,707,520 purpose as the combined available capacity of 2 X 5 = 1000 units will be
42 1400 4 2 4 5,623,260 less than the required demand of 1035. Going with 2 CHCs in configu­
43 1600 4 2 4 5,621,200 ration number 6, the demand of 1035 visits for service type 3 could have
been handled as the total available capacity will be 1200. But the
optimal solution is asking for the establishment of 3 CHCs. It is because
stationary. It is due to an increase in the number of CHCs from 4 to 5, and
of the restriction on the maximum coverage distance to be covered by an
also because CHC provides facilities for both service types 1 and 2. In the
MTBs. While going from configuration 4 to 6, a small improvement in
cases discussed so far, establishing an additional facility of higher-level
the objective function value is observed. It is because of the local
has resulted in a reduction in the number of next lower-level facilities.
adjustment of referral cases causing savings in the travel cost. Other­
The cascading effect, in fact, can go in either direction, forward and/or
wise, a sizeable change in the objective function value is noticed
backward. This can be observed from configurations 1, 9, 10, 11, and 12.
whenever the number of facilities to be established changes. A similar
No change in the number of the various facility types is observed when
trend can be noticed from the other configurations. It can be noticed that
θ12 is moved up from 0.05 to 0.10. When θ12 is increased to 0.15
the objective function value for configuration number 14 is less by 20
(configuration number 9), the number of PHCs increases by one while
units compared to that for configuration number 13 but having a value
bringing down the number of SCs by 2. A similar trend is observed going
equal to that for configuration number 15. Increasing the capacity value
further to configurations 10 and 11. In the case of configuration 12, it is
for service type 2, from 1800 (configuration number 13) to 2000
observed that the increase in θ12 , now from 0.3 to 0.4, does not cause
(configuration number 14), helps in carrying out adjustment by locally
any change in the number of PHCs. But the number of CHCs goes up
accomodating referral cases to result in a lower objective function value.
from 4 to 5, and the number of SCs comes down from 2 to zero.
But increasing this capacity to 2200 (configuration number 15) does not
The above analysis shows that the effect of referral proportion is not
help as the fullest advantage of the capacity enhancement had been
responded to by the model in a typical way, sometimes following our
exploited earlier itself. This characteristic can also be observed from
intuition and sometimes otherwise, all because of the highly combina­
configurations 21–23.
torial nature of the problem.
A general observation from Table 9 is that the increase in the ca­
pacity helps in reducing the overall facility establishment cost and/or
6.4.3. Impact of change in the capacity of maternal healthcare facilities
travel cost to a certain extent. Going beyond a particular limit, the
The result of the sensitivity analysis with respect to the capacity
enhancement of the capacity will not pay any dividend. Similar trends
available for each service type at different facility types has been pre­
can be observed from Tables 10 and 11 related to the capacity of service
sented in Tables 9, 10, and 11. In all these tables, the base capacity value
types 1 and 2 as may be relevant for SCs and PHCs.
is kept at what was provided in Table 2. The impact of change in the
capacity of a service type for a particular facility type has been analyzed
6.4.4. Impact of change in fixed cost
without modifying the capacity of remaining facility types, be it the
The results of this analysis are summarized in Table 12. This table
same service type or not. The experimentation is carried out with vari­
shows the results for a few variations in the fixed cost values for the sake
ations both on the lower and the higher sides of the capacity values for
of brevity, even though this analysis was carried out for many other
problem number 14 (Section 6.1).
combinations as well. Configuration number 11 is basically the example
In Table 9, configurations numbered as 1 to 6 show variation in the
problem (Section 6.1) without any change in the cost data. Configura­
capacity for service type 3, configurations 7 to 15 for service type 2, and
tions 1 to 10 represent the cases with a lower fixed cost value, while
configurations 16 to 23 for service type 1. Configurations 1 to 6 show
12–14 for the higher values. Going from configuration number 11 to 5
that the number of CHCs to be established decreases with the increase in
(decreasing fixed cost value) or going from 11 to 14 (increasing fixed
its capacity. It is what was expected. The total demand for service type 3
cost value), no change in the travel cost is observed and also in the
is 1035, including the cases of referrals. Configuration number 1 shows
number of SCs, PHCs, and CHCs to be established. The difference is in
that this demand for service type 3 is completely met by 11 CHCs, each
the overall fixed cost because of the modified value of the fixed cost

Table 12
Effect of variation in fixed cost.
Configuration number Fixed cost of Number of established Objective function value

SCs PHCs CHCs SCs PHCs CHCs Total fixed cost Travel cost Total cost

1 100 500 1000 9 25 13 26,400 9753 36,153

2 500 2500 5000 29 13 5 72,000 40,693 112,693
3 1000 5000 10,000 20 9 4 105,000 68,313 173,313
4 10,000 20,000 30,000 4 4 4 240,000 166,841 406,841
5 10,000 30,000 50,000 6 2 4 320,000 197,500 517,500
6 10,000 30,000 70,000 6 2 4 400,000 197,500 597,500
7 10,000 50,000 70,000 6 2 4 440,000 197,500 637,500
8 10,000 50,000 100,000 6 2 4 560,000 197,500 757,500
9 20,000 100,000 200,000 6 2 4 1,120,000 197,500 1,317,500
10 50,000 250,000 500,000 6 2 4 2,800,000 197,500 2,997,500
11 100,000 500,000 1,000,000 6 2 4 5,600,000 197,500 5,797,500
12 200,000 1,000,000 2,000,000 6 2 4 11,200,000 197,500 11,397,500
13 500,000 2,500,000 5,000,000 6 2 4 28,000,000 197,500 28,197,500
14 1,000,000 5,000,000 10,000,000 6 2 4 56,000,000 197,500 56,197,500

15
A. Chouksey et al.
associated with the establishment of SCs, PHCs, and CHCs. In configu­
ration number 4, a decrease in the total fixed costs has been witnessed
due to readjustment of the establishment of number SCs and PHCs, with
the number of PHCs going up from 2 to 4 and that of SCs going down
from 6 to 4. While going from configuration 4 to configuration 3, it is
found that the model establishes more number of SCs to help in cutting
down the travel cost by taking advantage of quite reduced fixed cost
associated with SCs. This trend continues even going to configuration
number 2 where fixed costs were reduced by a factor of 5 compared to
that for configuration 3. However, this trend does not continue while
going to configuration number 1 from configuration number 2 where the
fixed costs were reduced by a factor of 2. The numbers of higher-level
facilities, CHCs and PHCs, increase sizeably, while the number of SCs
comes down. It is so because the model now aims to cut down the travel
costs sizeably on both non-referrals and referral visits.
The above analysis shows that the relative differences in the facil­
ities’ fixed cost and the amount of difference between them impact the
number of facilities of each type to be established.
6.4.5. p-median formulation versus HCFL formulation
The proposed HCFL formulation treats the numbers of various
maternal healthcare facilities as decision variables. On the other hand, p-
median formulation due to Daskin (2011) or Galvao et al. (2002) would
require a prior determination of the number of facilities to be established
of each type. In case only one facility type exists, one can easily compute
‘p’ value for this facility, knowing its establishment cost and the size of
the budget. Galvao et al. (2002) use three different values of ‘p’ for the
different types of facilities. They do not elaborate as how could they
work out these numbers. In fact, determining the right ‘p’ values cor­
responding to these facilities would require solving the problem using
proposed formulations itself. Instead, a rough estimate of these numbers
can be worked out based on the overall demand and the capacity
available for various service types at these facilities. The method
adopted is detailed below with the help of an illustrative example. It
must be remembered that this method cannot be used or will result
infeasible solution when the coverage distance restriction becomes too
tight. For problem number 14 (Section 6.1), the minimum value of these
numbers has been worked out based on the total demand for each ser­
vice type (including referrals) and is given hereunder.
Total demand for service type 3 = 1,035
Total demand for service type 2 = 6,771
Total demand for service type 1 = 13,497
Since the higher-level facilities also provide services available at the
lower level facilities, it would be prudent to first determine the number
of CHCs, then the number of PHCs, and the number of SCs in the last.
Since a CHC has a capacity for service type 3 as 300, therefore a total of 4
CHCs has to be established. This will also provide the facility to serve
4,800 MTBs requiring service type 2 and 6,000 MTBs requiring service
type 1. As a result, the resulting total leftover requirement for the other
services at PHCs and SCs would be as follows.
Balance requirement for service type 2 = 1,971
Balance requirement for service type 1 = 7,497
Table 13
Comparison of performance of HCFL and p-median formulations.
Comparison data set Fixed establishment cost Formulation
SC PHC CHC
1 10,000 20,000 30,000 p-median
HCFL
2 10,000 30,000 50,000 p-median
HCFL
Computers & Industrial Engineering 167 (2022) 107991
A PHC has the capacity of 1000 for service type 2 for the example
problem. Therefore, 2 PHCs will be required. Since each PHC has the
capacity to accommodate 2,400 MTBs requiring service type 1, the
balance requirement of service type 1 would be 5,097 units. Since each
SC provides only service type 1 and has a capacity to serve 1,000 units, 6
SCs will be required. The above analysis shows that 4 CHCs, 2 PHCs, and
6 SCs need to be established. With these numbers, the p-median
formulation is used to solve the hierarchical facility location-allocation
problem considered in this paper without any constraint on the
maximum coverage distance.
For a fair comparison of the p-median formulation with the HCFL
model, a high coverage distance of 100 is taken while using the HCFL
model for experimenting with problem number 14. It is so as the
maximum distance between any two nodes of the 50 nodes problem is
less than 100. After considering a high coverage distance of 100 for both
referral and non-referral allocations, it is ensured that the HCFL model is
practically free from the constraints related to coverage distance and
now a fair comparison of the HCFL model can be made with the p-me­
dian formulation.
Table 13 shows the results for two sets of fixed establishment cost for
various facilities. However, such experimentation was carried out with
the other combinations of the fixed cost value. In all these experimen­
tations, the number of facilities to be established are taken as 6 SCs, 2
PHCs and 4 CHCs for the p-median formulation.
HCFL formulation provides a better result for comparison data set
number 1. Similar observations were obtained with the other data sets
not shown here. HCFL and p-median formulations yield the same result
for comparison data set number 2. But in no case, the p-median
formulation was found to provide a better result. For comparison data
set number 1, the p-median formulation would have required this
formulation to be used for many combinations of the values of the
number of SCs, PHCs and CHCs. This will be a very hard task for a
reasonable size problem and impractical. Based on this difficulty and the
experience from the experimentations, HCFL formulation is found to
perform better in comparison to the p-median formulation.
7. A case example
In this section, the healthcare location and allocation problem of
district Chandauli in the state of Uttar Pradesh, INDIA, has been
addressed. The district of Chandauli has a population of 19,52,756 with
a population density of 769 per sq. km according to the 2011 census
(Chandauli, 2011). It consists of three Tehsils (next level administrative
unit) named Chakia, Chandauli and Sakaldiha. The numbers of villages
in Chakia, Chandauli and Sakaldiha are 624, 522 and 494, respectively
(Chandauli, 2021). For the case example, Chandauli Tehsil has been
considered. The village population is taken from the census data
(Chandauli, 2011). Further, it is found that some of the villages have a
population below 100. The population of these villages is aggregated
with the nearby village as the number of MTBs from such villages is
going to be fractional and very small while working on daily demand.
Due to this, the number of significant village locations boils down to
356. The coordinates (latitude and longitude) of the villages were
extracted using Google search engine and were used to calculate the
road distance among them using Bing Maps API (Nasiri et al., 2018). The
population of MTBs in a village is determined by multiplying population
Number of established Total Fixed Cost Total Travel cost Total cost
SCs PHCs CHCs
6 2 4 220,000 196,825 416,825
4 4 4 240,000 166,105 406,105
6 2 4 320,000 196,825 516,825
6 2 4 320,000 196,825 516,825
16
A. Chouksey et al.
Location of villages
Proposed location of SCs, PHCs and
Existing location of SCs, PHCs and
Fig. 6. Location of facilities in the Tehsil of Chandauli, Uttar Pradesh, INDIA.
size and birth rate in that village following the scheme adopted by
Pradhan Mantri Surakshit Matritva Abhiyan (PMSMA, 2016). MTBs
from a location were assumed to be uniformly distributed throughout
the year to determine the daily demand of MTBs from a location. The
referral proportions and capacity of the facility types are the same as
detailed in Section 6.1. The maximum coverage distance between the
location of an MTB to its assigned healthcare facility is taken as 5 km,
and the maximum coverage distance between a healthcare facility and
another referral healthcare facility is taken as 7 km (Rural Health Sta­
tistics, 2019). The fixed costs of establishing a single unit of SC, PHC,
and CHC are taken as 100,000, 500,000, and 1,000,000, respectively.
This problem was solved using HCFL, VI-HCFL formulation and
sequential heuristic. All the three approaches required establishing 12
SCs, 1 PHC, and 59 CHCs. The sequential approach required the least
CPU time. Because of this, the locations for the facilities are almost the
same. Fig. 6 shows the location of these 12 SCs, 1 PHC, and 59 CHCs (a
total of 72 maternal healthcare facilities) along with the locations of
17
Computers & Industrial Engineering 167 (2022) 107991
CHCs
CHCs
existing 93 SCs, 4 PHCs, and 3 CHCs (a total of 100 general healthcare
facilities). The total number of existing facilities is 100 and is more than
the required total number of facilities as 72. A comparison between the
number of e.xisting and planned facility types clearly identifies the issue
in terms of ‘right’ availability, for example, 3 CHCs against 59 CHCs
required in the Chandauli Tehsil. Because of the huge shortage of
advanced maternal healthcare facilities, critical care services are bound
to be affected. Besides, the problem is with the facilities being general
and not specifically committed to meet the requirements of MTBs. In
Chandauli Tehsil, the non-availability of female doctors aggravates the
problem further as MTBs rarely visit a health centre with male doctors.
The proposed model depicts the right strategy to cope up with the issue
of accessibility and availability of maternal healthcare services for the
Chandauli Tehsil.
A. Chouksey et al.
8. Conclusions
In India, the mortality rate of the mother and child is quite signifi­
cant. Looking into the urgent need to reduce this number, state and
central governments in India are giving a lot of importance to maternal
healthcare. The same is also one of the missions of the Government of
India for general healthcare meant for poor people, named as Ayushman
Bharat Yojana. Based on this fact, it is necessary to establish and prop­
erly locate the Community Health Centres, Primary Healthcare Centres
and Sub-centers in the right mix and specifically for the mothers-to-be
(MTBs). Determination of the right location of these facilities in a
wide geographical area in India is a big and difficult task. It is because
the healthcare facilities are to be provided at the least cost even from the
perspective of its users. This paper endeavours to handle such a problem
by developing a hierarchical facility location-allocation mathematical
programming model. Besides determining the number and location of
maternal healthcare facilities, the model allocates MTBs to these facil­
ities for their varied service requirements, including referrals. The
formulation provides optimal results while minimizing the total cost
incurred in visiting and establishing the facilities. The proposed math­
ematical model is NP-hard and thus is hard to solve. In order to reduce
the computational burden, some improvisations have been suggested.
The addition of valid inequalities to the proposed model is found to be
quite useful. This concept can be applied to other similar combinatorial
problems in solving them efficiently. Another strategy for reducing the
computational effort has been developed for solving the problem
sequentially and each time of much smaller size. This sequential
approach produces much better solutions in the same amount of
computational time. The effectiveness and computational efficiency of
the sequential approach were also established by the statistical analysis.
Sensitivity analysis was carried out by varying the coverage distance,
referral proportion, capacity of the facilities, and fixed cost on estab­
lishing the facilities. During the sensitivity analyses, it was found that
the coverage distance and the capacity of the facilities play an important
role in minimizing the overall cost but up to a certain extent. The change
in the referral proportion impacts not only the number of higher-level
facilities but also of lower-level facilities. The fixed cost was found to
impact the mix of numbers of SCs, PHCs, and CHCs to be established.
When the same becomes very high compared to the travel cost, it does
not cause any impact.
The proposed formulation was used for finding a solution to a
maternal healthcare problem for Chandauli Tehsil (district of Chan­
dauli) in the state of Uttar Pradesh in India. The solution obtained a
significant gap between what exists and what is required towards
maternal healthcare facilities. The proposed formulation believes that
exclusive maternal healthcare facilities are to be planned. In case the
existing healthcare facilities are to be included in the decision making,
including augmentation of the existing capacity for maternal healthcare,
the proposed model can easily be extended to handle this reality. The
proposed strategies will still be equally applicable in reducing the
computational requirement sizably. In India, the childbirth rate is
almost constant. In case the same is not stationary in a country, the right
planning framework would require the growth factor to be considered in
the proposed formulation for effective planning.
CRediT authorship contribution statement
Ankit Chouksey: Conceptualization, Data curation, Formal analysis,
Investigation, Visualization, Methodology, Writing – original draft. Anil
Kumar Agrawal: Conceptualization, Validation, Supervision, Writing –
review & editing. Ajinkya N. Tanksale: Conceptualization, Methodol­
ogy, Validation, Supervision, Writing – review & editing.
Declaration of Competing Interest
The authors declare that they have no known competing financial
18
Computers & Industrial Engineering 167 (2022) 107991
interests or personal relationships that could have appeared to influence
the work reported in this paper.
Acknowledgement
The authors express a deep, profound and heartfelt sense of gratitude
to the anonymous reviewers whose valuable comments have been very
useful in improving the quality and readability of this paper
significantly.
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