4.

1 Health in Mumbai, Maharashtra

In Mumbai, a city of approximately 18[55] million people, over 50% of the population lives in the
slums. With a city’s population expanding at a rate faster than infrastructure to address it, health
is likely to be impacted severely, with the underprivileged communities being the hardest hit. In
Mumbai, urban poverty manifests into informal settlements and slums which have little or no
access to sanitation, water supply, education, and health infrastructure. This dramatic increase in
the population of cities in developing countries has put enormous pressure on services like water,
sewerage, housing and transport.
The infant mortality rate (IMR) in the city is 40% and the maternal mortality rate (MMR) is
14%. The survey conducted by Reproductive and Child Health (RCH) and Centre for Operations
Research and Training (CORT) in 1999 states the sex ratio in the city as 872 females per 1000
males, net migration has contributed 19% to the population growth of the city. The crude birth
rate (CBR) in the city is 16.6 per 1000 and the general marital fertility rate (GMFR) is 108.7 per
1000. Nearly 76% of the children and 42.1% of women in the city are anemic; this percentage in
the slum and non-slum areas is 45.5 and 37.4, respectively. Nearly 50% of the children under
three years are underweight (measured in terms of weight-for-age), 40% are stunted (height-for-
age) and 21% are wasted (weight-for-age).[56]

According to the Maharashtra Economic Survey 2004-05, the incidence of poverty in the rural
areas of the State dropped from 58% per cent in 1973-74 to 24% per cent in 1999-2000. In the
same period, in urban areas it dropped from 43.9 per cent to 26.8 per cent. At present, the
incidence of poverty is higher in urban areas than in the rural areas.

Of the 2,38,247 children weighed in June 2005 at various anganwadis in Mumbai, 1,066 were
severely malnourished, according to government figures. In 2002, a study conducted by Neeraj
Hatekar and Sanjay Rode of the University of Mumbai's Department of Economics, projected a
floor estimate of least about 750 children dying of malnutrition in Mumbai alone each
year. [57] Further, the rates of malnutrition are higher in the urban poor than the rural average.
When looking at access to health services, the presence of infrastructure seems to make little
difference in how the poor seek health care. Table 3.1 indicates that despite the presence of
infrastructure (hospitals, health posts), only about 43% of the urban poor actually access health
services.

Mumbai is a good example of challenges of health care access for the urban poor. With some of
the finest health care institutions in the country, the urban poor often face health problems that
are similar to those effecting the rural population. The next section provides insight into the
existing health infrastructure in the city of Mumbai.

4.2 Existing Infrastructure in Mumbai

The MCGM’s existing public health system is a stark contrast in infrastructure and utilization.
Under its programs for public health care, the MCGM runs four major hospitals, 16 peripheral
hospitals, five specialized hospitals, 168 dispensaries, 176 health posts, and 28 maternity homes
with a staff of over 17,000 employees. The Corporation also runs three medical colleges. Of the
total 40,000+ hospital beds in the city, the MCGM run hospitals have about 11,900 beds. As
many as 10 million patients are treated annually in the Out-Patient Departments (OPDs) in the
MCGM hospitals.
The largest hospital, the King Edward Memorial Hospital and Medical College, alone annually
treats 1.2 million patients in its OPD. The state government has one medical college, three
general hospitals and two health units with a total of 2,871 beds. Each of the peripheral hospitals
is linked to one of the four super specialty hospitals. The health posts and the dispensaries are
linked to the peripheral hospitals in their respective Wards. These health posts were established
under the World Bank Funded project called IPP-V, and resulted in the set up of the Health Posts
which were meant to serve as the primary link between the citizen and the government.[58]

Mumbai’s health is reported through the yearly report “The Mumbai Health Profile”.
Information from profiles dating 1997-2004 has been used in the following analysis. The first
and most important aspect of Mumbai is the population and its growth. The chart below
represents the growth of the population from 1997-2004.
Figure 4.1 Growth in the Population of Mumbai[59]

According to this analysis, the population has been growing at a rate of (to be added).
The birth rates and death rates are often indicative of the population growth. The reason for over
population remains the high birth rate. Despite the fact that the birth rate has decreased, the death
rate has also decreased. The decrease in death rate can be contributed to better health (for some),
increased nutrition, the growing economy and general evolution of the population. However, the
rate at which the death rate decreased is still not equal to the birth rate. Mumbai’s birth versus
death rate is illustrated in the figure below:

The high birth rate is often correlated with a high infant mortality rate (IMR). Although the IMR
has significantly decreased in the last 50 years, it still remains a major problem for those who
cannot access health care during pregnancy and after birth of a child. Some parents feel the need
to have a safety net in case on or two children die along the way. The figure below represents the
IMR rate in Mumbai:
This table shows that the IMR rates in Mumbai have decreased over the last 7 years.

The current IMR reported by the MCGM is at 35% per 1000 births. However, this is merely the
tip of the iceberg as neo-natal deaths are often under-reported and death rates of children under 5
years old are not evaluated by the MCGM. The infant deaths below 1 year of age for the years
1997-2004 are indicated in the table below:

Table 4.1: Infant deaths of children below 1 year (1997-1999 data unavailable)
2001 2002 2003 2004
7255 7142 7403 6505

Although the numbers are decreasing, it is unclear according to the data, which intervention has
played the largest part in slowly bringing down the IMR.

The Maternal Mortality Rate (MMR) is an indicator of how many mothers are dying after
childbirth. Add information about maternal mortality. The figure below indicates the MMR in
Mumbai.

As Mumbai comes into a new age of economic prosperity, one can postulate that the health of
the city as a whole has suffered in this process. As the urban middle and upper classes have more
choices on where they seek care (mostly high specialty, private institutions) the checks and
balances that kept the MCGM public health department running efficiently are no longer
applicable.
5. Services in Detail
Healthcare in Mumbai is run under the jurisdiction of the MCGM. It functions to provide health
care to the citizens in affordable and accessible manner. Mumbai’s health care system is
probably one of the most elaborate urban health systems in the country. It is unique because it
provides care at three different levels, and functions to (hopefully) provide health care at a
minimum cost to the consumer.

5.1 Functions of the Public Health Department

The Public Health Department of the MCGM not only provides basic health care facilities but
also manages other aspects related to preventive and social or community medicine. The
Department is divided into zonal set-ups for administrative purposes. There are five such zones,
which cover 23 Wards (nine city Wards, eight western suburban Wards and six eastern suburban
Wards). The Deputy Municipal Commissioner handles each zone. Each Ward has a separate
Ward Office and the Ward Medical Health Officer (MHO) heads the Public Health Department
in that Ward. The Department carries out the following activities:
• Registration of births and deaths and maintenance of statistics
• Regulation of places for disposal of dead
• Maternity and child welfare and family welfare services, school health services
• Control of communicable diseases
• Food sanitation and prevention of adulteration of food
• Control of trades likely to pose a health hazard
• Insect and pest control
• Impounding stray cattle, immunization and licensing of dogs
• Regulation of private nursing homes
• Medical relief through hospitals
• Issuance of international health certificates for traveling abroad
• Ambulance and hearse services
• Treatment of contagious diseases
This section is an overview and analysis of the existing MCGM structure in relation to services
and access to health care.

5.2 Dispensaries and Health Posts

There are 168 dispensaries and 176 health posts set up in Mumbai. The health posts were set up
from a World Bank Initiative called IPP-5 (India Population Project 5) which sought to set up
primary health care centers in Mumbai from 1988-1996. When the World Bank pulled out, the
MCGM took the responsibility of the health posts and dispensaries. However, due to various
issues in budgeting, prioritization at the MCGM, and other reasons that are not well-documented,
the quality of services offered at these health posts and dispensaries is not quite meeting the
needs and demands of the public that accesses this system. The health posts provide medications
for DOTS as well as medications for basic ailments (cough, cold, fever, gastrointestinal issues)
while the dispensary has a doctor that is there to provide medical check ups. Unfortunately, these
dispensaries and health posts don’t function at maximum utilization rates due to large scale
vacancies, disconnect of the staff and the community, and general ignorance toward quality.
While there are always exceptions, due to the overall lack of facilities and resources given at the
primary level, health posts are not universally utilized to access primary health care.
5.3 Maternity Homes
There are 28 maternity homes run by the MCGM. Maternity homes were meant to be a referral
point from the primary health care systems. In an ideal situation, if a pregnant woman went to a
dispensary for prenatal care, a doctor there would refer her to a maternity home or peripheral
hospital for institutional delivery. However, the maternity homes are suffering under severe
neglect due to lack of equipment, on the site decision making, and quality of care. Additionally,
the controversial practice of charging fees for reproductive and child health has led to an
apathetic view of maternity homes.

5.4 Municipal Hospitals

Municipal hospitals are meant to be the secondary and tertiary points of care for the patient
seeking healthcare in Mumbai. These hospitals also should be used as referral points, but when
patients have a free range of choices, as is in the MCGM health system, most of the primary
infrastructure is bypassed. There are four major hospitals, 16 peripheral hospitals and five
specialized hospitals. The four major hospitals are also medical colleges which infuse them with
a greater amount of financial resources and recognition than in the peripheral hospitals. The
peripheral hospitals should be a secondary referral point from the primary health care centers;
however, it is also plagued with low resources, centralized decision making, and little attention
on quality of care. If an urgent case is brought to a secondary hospital, it tends to be transferred
to a major hospital, and due to problems in ambulatory care, patients have little chance of
survival. The aforementioned case is especially true in the cases on deliveries and post-partum
emergencies.
5.5 Programs
The MCGM runs a complex set of programs to address the major health issues of the Mumbai. A
government run health department is important for two major reasons:
Controlling Infectious Disease: If public health sector does not work, diseases like malaria etc
will increase
Access to Public facilities: such as ambulatory care and emergency services
The following section describes these programs in detail and provides some insight into how
they are addressed by the MCGM Public Health Department.
5.5.1 Leprosy Control Program[62]
The Leprosy Control Program was started in 1890 and is based out of the Acworth Municipal
Hospital in Mumbai. The services provided by the hospital include inpatient services, out patient
services, peripheral clinics, field work, re-constructive surgery, training, and research. The
Leprosy Control Program has achieved a significant amount of success in Mumbai over the years
and is demonstrated in the table below:
Table 5.5.1.a: Cases and Deaths: Leprosy in Mumbai[63]
1997 1998 1999 2001 2002 2003 2004
Cases 4966 423 629 310 4297 3384 1651
Deaths 4 11 10 11 7 5 5
This table shows that the cases and deaths by Leprosy have decreased significantly in Mumbai
due to the availability of medication.

Though there is no explanation for the fluctuation in numbers over the years, it can be postulated
that treatment and detection methods for leprosy have been improved and implemented by the
MCGM. The decrease in number of deaths demonstrates that treatment programs are working
and there are adequate detection methods in place to address leprosy in Mumbai. This has just
been derived from observation, as there is little conclusive information in the Mumbai Health
Profiles 1997-2004.

5.5.2 Revised National Tuberculosis (TB) Control Program

The Revised National Tuberculosis Program (RNTCP) is a national initiative that is run under
the provision of the Mumbai District Tuberculosis Control Society (MDTCS) since 1999 for the
effective control and smooth implementation of the TB control program. [64] For the
implementation of this program, the MCGM has established:
Six District Tuberculosis Officers
119 Microscopic Centers have been established at municipal dispensaries, hospitals, and TB
clinics
903 DOTS Centers (Directly Observed Treatment, Short-Course- a WHO program) have been
established to help TB patients seek care for TB.
The RNTCP conducts many health awareness activities including health awareness month,
World TB Day, community meetings, street plays and more. MCGM also collaborates with
private providers in their PPM (Public Private Mix) Project. This project was started in 2002
with 2 zones and now covers 5 zones. This program consists of a public- private partnership
between the MCGM and private providers to implement the DOTS and RNTCP. According to
the Mumbai Health Profiles, the following tables represent the cases of TB that were reported:

Table 5.5.2.a: Cases and Deaths: TB in Mumbai

1997 1998 1999 2001 2002 2003 2004
Cases 44536 37707 14424 38238 40009 24620 25888
Deaths 9339 10583 8750 9345 8998 8929 8774
This table shows that the cases and deaths by TB. The number of cases has decreased while the
number of deaths has stayed relatively constant.

It is unclear from these numbers what intervention contributed to the change in cases reported.
The drastic change in numbers is not analyzed as per the Mumbai Health Profiles. It could be
attributed to the implementation of the RNTCP initiative, but does not explain the dramatic drop
in the rates of cases reported in 1999. This calls for further investigation of the results to take a
closer look at the reasons for the changing numbers. The number of deaths attributed to TB has
been on the decline since 2001. The decline rate is (To be added later).

5.5.3 Universal Immunization Program

The Expanded Program of Immunization was launched in the year 1978 for covering all children
up to five years. In 1985, the Universal Immunization Program was launched in 1985 to cover all
the children under one year with all vaccines to achieve the following targets:
Elimination of Neonatal Tetanus by the year 1995
Eradication of polio by 2000
Reduction of 90% cases of measles by 1995
Specific activities include:
Vaccine distribution and maintenance
Collecting data and information
Performance reports
Extended coverage evaluation survey
Extra activities as needed
The chart below takes a closer look at the immunization evaluation report for the BMC for the
most recent year (2004). [65]
Vaccine Target Achievement Percentage
Hepatitis B 200591 61,002 30.41%
DPT III (Diptheria, Polio, 200591 196526 97.97%
Tetanus)
Polio III 200591 196114 97.96%
BCG (TB Vaccine) 200591 203397 101.39%
Measles 200591 174009 86.74%
T.T. (M) (Tetanus) 220650 173249 78.51%
D.P.T. (B) 192570 163325 84.81%
Polio (B) 192570 167531 86.99%
D.T. (5) (Diptheria) 226754 156443 68.99%
T.T. (10) 226754 184694 81.44%
T.T. (16) 226754 146324 64.52%
The table above shows the target and achievement rates, clearly, while some met and exceeded
the target, others felt quite short.

The interpretation of these numbers demonstrates that while there are some significant successes
in the MCGM Universal Immunization Program (UIP), there are still some gaps in targets that
are yet to be reached.
For example, in 2004, there were 4584 cases of Infectious Hepatitis (reported) and 92
deaths[66] in Mumbai. The table below represents the cases and deaths in Mumbai of hepatitis:

Table 5.5.3.a: Cases and Deaths: Hepatitis in Mumbai

1997 1998 1999 2001 2002 2003 2004
Cases 3455 2929 2526 3627 3810 3488 4584
Deaths 207 192 184 135 78 51 92
This table shows that the cases and deaths by Hepatitis in Mumbai. It is unknown if it is
Hepatitis A or B.

These deaths could have been prevented if the achievement rates of Hepatitis B vaccines were
better. (Will clarify if we are talking about Hep A or Hep B) Although the deaths are not so high,
the number of cases is enough to create concern and demand some type of intervention. It should
be noted that this initiative was started in March 2003 and needs some time to actualize its goals.
Clearly, the UIP has achieved some significant success in the areas of DPT (Diptheria, Polio,
Tetanus), Polio, and BCG (Tuberculosis vaccine), but still needs to meet international standards
for Hepatitis, Tetanus and others.

5.5.4 Polio Eradication Program

The Polio Program is a part of the Universal Immunization Program. The Pulse Polio Program
(PPP) has achieved a 97.6% [67]rate for vaccinations. The Pulse Polio Program is an
administration of extra Oral Polio Vaccine does to all children irrespective of their immunization
status if they are below 5 years of age. This program has achieved significant success due to an
aggressive media campaign and drive.

5.5.5 National Malaria Control Program (NMCP)

The NMCP pursues malaria control through parasite control (surveillance branch) and vector
control. The purpose of the surveillance branch is to detect malaria cases from the community
and treat them immediately. In addition to health awareness to people, the NMCP also utilizes 3
methods of surveillance[68]:
Active: House to house survey of fever patients
Passive: Blood samples of all fever cases are taken by medical personal of the MCGM
Mass Surveillance: Looking at high risk communities more broadly

Although in 2004, malaria deaths were cited at 23[69], the number of reported cases was 13,522.
This cites a need for greater action in prevention, not just in monsoon season, but in all seasons.

5.5.6 Mumbai District AIDS Control Society (MDACS)

MDACS is a program that was started in 1998 as an initiative of the MCGM. MDACS functions
as an over-seeing body to all the programs related to HIV/AIDS in the city of Mumbai. MDACS
has several activities including:
Establishing and tracking of STI/RTI services
Condom Promotion
Targeted Intervention
IEC
Youth and AIDS
Voluntary Counseling and Testing Centers (Confidential)
Prevention of Parent to Child Transmission (PPTCT)
Blood Safety
Care and Support
Training and Surveillance
Monitoring and Evaluation
Inter-sectoral Collaboration: Work Place Intervention

Through MDACS there are clearly a large amount of interventions focused to address and
control HIV/AIDS in Mumbai. The tables below give some indication of cases and reported
deaths according to the health profiles of the MCGM:
Table 5.5.6.a: Cases and Deaths of AIDS reported in Mumbai[70]
1997 1998 1999 2001 2002 2003 2004
Cases 180 384 3682 1909 2018 4445 3190
Deaths 25 66 100 178 179 889 278
This table shows that the cases and deaths by AIDS in Mumbai. The cases and deaths remain
inconsisten with little explanation.

These numbers also seem to bring about some questions as to why there is such a fluctuation of
reported deaths between 2002-2004. The WHO reports that HIV has a 0.9% prevalence in India.
The numbers from Mumbai do not corroborate with the national statistics for many reasons.
(Explain reasons here)

5.5.7 School Health Program (SHP)[71]

The SHP is a critical component of community health care. As school-going children comprise
approximately 20% of the population, it is important to promote health awareness amongst them
and their families. The objectives of the school health program include:
Promotion of positive health
Prevention of diseases
Early diagnosis, treatment, and follow-up of defects
Awakening of health consciousness in children
Provision of a healthy school environment
To achieve these objectives, the SHP provides a mix of health assessments, curative services,
rehabilitation, follow-up, healthy child and school competitions, child to child/family/community
programming, immunization, first aid and emergency care, statistics, training and other activities.
These programs reach approximately 5 lakh children per year through Std. 1, 3, 5, 7, 9.[72] The
school health program is run jointly under the health department (which is responsible for
administration) and the education department (which is responsible for logistics).[73] Each year,
the SHP plays a critical role in helping children access health care. Through
parent/teacher/community meetings, the idea of community health is re-enforced in these
children to underscore the important role everyone plays in a healthy community. Additionally,
due to the nature of follow-up in the SHP, children are able to get treatment without creating a
stressful situation in their family.

The SHP works with 7 special school clinics at Nair, Nair Dental, K.E.M., Sion, Cooper,
Rajawadi, and Bhagwati hospitals. During 2003-2004, the SHP program has admitted between
41,980 and 35,991 children into these specialty clinics, respectively. The SHP has also been
beneficial for the screening of TB and Polio and picked up such rare conditions such as
Rheumatic and Congenital Heart Disease and such illnesses. Additionally, the extensive health
education program reached out to parents, teachers, nurses, and awarded health trophies to
deserving children and schools. The School Health Program is an innovative method of
providing healthcare to children who are from impoverished populations.

5.5.8 Respiratory System Diseases

One omission from the MCGM health programming is Respiratory Systems Disease, which, as
demonstrated in the table below, are presenting an increasing health threat for residents of
Mumbai
Deaths
Reported
1997 1998 1999 2001 2002 2003 2004
Respiratory 7270 7377 7332 7223 2412 8293 8174
Disease
This table shows the deaths reported by respiratory disease from 1997-2004.

The table above illustrates a disturbing trend in the city, the rapid rise of deaths of respiratory
problems. Due to the fact that there are many infectious and communicable/non-communicable
diseases that need to be addressed, respiratory disease has been reported, but there are no
interventions reported in the Mumbai Health Profiles. It is important to note that, these are the
deaths reported, and most likely represents a fraction of the actual cases of respiratory disease.
By respiratory diseases, we are specifically referring to asthma, bronchitis, upper respiratory
infections, etc. According to a study conducted in the D-West ward by the American Journal of
Respiratory and Critical care medicine, the asthma prevalence in the Mumbai sample (3.5%
based on physician diagnosis, but 9 to 12% when including symptomatic subjects without
diagnosis).[74] With an under-reported 9 to 12 prevalence (number of cases of the disease at a
specific time) of respiratory ailments, there is a greater need for some intervention by the
MCGM. An NGO called the Oasis Foundation claims the air is so bad in Mumbai, it is
equivalent to smoking 40 cigarettes per day.[75]
In another report by the Environmental Health Department of the MCGM, it was estimated that
43.3% of the population has reported some type of a respiratory illness (this can be asthma,
bronchitis, allergic rhinitis, and chronic obstructive pulmonary disease).[76] This only
underscores the imperative need for more of a focus on respiratory care for a population that is
literally choking on its environment.
6. Successes
6.1 School Health Program
The School Health Program (SHP) is a good indicator of a successful initiative of the MCGM.
One of the main indicators of their success is the fact that they have a very long vacancy rate.
Out of 37 positions, only 5 are vacant.[77] This statistic seems acceptable compared to the high
rates of vacancies at the MCGM at this time. There are several other reasons that contribute to
the success of this program.
Decision-Making Process: Since this program falls under the jurisdiction of the Public Health
Department as well as the Education Department, it enjoys a more independent decision-making
process. This helps management take the lead in certain situations and can lead to greater
innovations within the program
Staff Continuing Education: The SHP encourages doctors to continuously be learning throughout
their employment process. Staff are encouraged to go to workshops, trainings, and courses. This
keeps staff stimulated and helps them apply new strategies to the way they treat their patients.
Immediate Follow-Up: If a child is not well and needs urgent care, the doctors are able to refer
them to clinics immediately. There is no worry about the family taking the time and care to go to
a hospital, wait, and seek care there itself.
Administration Team: The administration team seems to be up to date with everything. Weekly
reports are required in addition to meetings, updates, and follow-up. When staff feel accountable
to someone, they are more likely to perform their job well.
These are just a few of the examples of what works in the School Health Program. Overall, it
seems that de-centralized decision making, continuing education, timely follow-up and strong
leadership can make a program that sees up to 5 lakh children per year a success.
6.2 Polio Eradication
The eradication of polio was also a successful initiative of the MCGM. Through the National
Pulse Polio Campaign, Mumbai has achieved success due to the publicity and easy dosage. The
Pulse Polio Campaign asserts that any child, regardless of immunization status, should receive a
drop of polio. Community Health Volunteers (CHV’s) have been a critical aspect of this
campaign, by going door-to-door in various communities to ensure that everyone is receiving the
required dosage. The national emphasis has made a difference to bring together the entire nation
around the focus of polio eradication. The same amount of dedication, for other illnesses, could
also be utilized to eradicate other preventable diseases in Mumbai.
7. Services
It has been quite challenging to find clear outlines of the range of services and programs
provided by the MCGM. According to the Executive Health Officer (EHO), the MCGM is
constructing guidelines for provisions of health services in the following areas:
1 dispensary/health post per 50,000 people within 1.5 km.
1 facility with a maternity ward for every 150,000 people within 3 km.
1 general hospital for every 350,000 people within 5 km.
Each of these facilities corresponds to the three-tiered (primary, secondary, tertiary) healthcare
system initiated by the Government of India. The dispensary, the primary health care center, is
expected to provide treatment for fever, cold, etc. and provide outreach services, MCH
vaccinations.

The following guidelines are recommended for areas with a population of 25,000 - 50,000:
1 female doctor
1 public health nurse
3-4 nurse midwives
3-4 male M.P.W
1 Class IV (woman)
1 computer/clerk
1 voluntary women health workers – 1 for every 20,000 people
Laboratory
Sterilization, M.T.P, vaccines
Areas with populations greater than 50,000 need to be divided into two areas with populations of
under 50,000 in each. According to the same report, primary health care consisted of the
following services:
Outreach services
Population Education
Information, motivation about family planning
Health Education
Environmental sanitation
Personal Hygiene
Communicable diseases
Nutrition
M.C.H. & E.P.I
Preventive Services
Immunization
Ante-natal, Post-natal and infant care
Prophylaxis against anemia
Prophylaxis against Vitamin A deficiency
Presumptive treatment of malaria
Identification of suspected cases of leprosy and tuberculosis
Filariasis
Infant Feeding
Family Planning Services
Nirodh, conventional contraceptives and oral pills
I.U.D. insertion
 Sterlization and other M.T.P. Services via referral to hospital or through mobile vans
Curative
Fist aid during accidents and emergencies
Treatment of simple ailments
Supportive Services (Referral)
High risk maternity cases
Sterilization and M.T.P.
Diagnosis and treatment of tuberculosis and leprosy
Laboratory services for diagnosis o malaria matter requiring doctors services/hospitalization
Reports and Records
Preventive services
Family planning acceptors
Vital events
Morbidity and Mortality in respect of:
Malaria
Tuberculosis
Leprosy
Diahrroeal diseases
Maintenance of family cards for population covered
Through various policies and guidelines, the MCGM realizes the urgent need for having
accessible and community based services for those that access public health care. However,
when it comes to implementation of these services, there are several challenges that impede the
utilization of municipal-run health care facilities. The following challenges are some of the major
barriers to the provision of equal distribution of health care services to the underprivileged
population of Mumbai.

7.1 MCGM Health Budget

As per the Municipal Corporation Act, the MCGM is primarily concerned with providing
preventive health care services in the city. However, the current focus seems to be leaning
toward curative care in a major way. In the following budget, it is evident that the majority of
funding goes to tertiary and secondary care.[78]
Rs. In Crore
Capital Works Plant and
Revenue (Civil) Machinery Total
1. Public Health
Department 98.4 3.7 75 102.1

2. Medical Relief and 599.4 (537 Medical

Education (Including Relief)
Medical Relief and (62.4 Medical
Medical Education) Education) 62.7 45.6 707.4
3. Measures to Control
Environmental Air
Pollution 3.7 11.2 69.3 4.4
Total 701.5 66.3 46.2 813.3

Clearly, the budget illustrates the above point as the budget for curative services and medical
education are nearly 7/8ths of the entire budget of the MCGM health program. The cost of
medical relief is greater in comparison with the cost of preventive services. However, for the
sake of the budget, it all falls under the category of “Medical Relief”. Additionally, because
medical education is mainly subsidized, many colleges can not collect revenue from the medical
colleges, as may be the case in other countries. This point can be validated when looking at the
top four 3rd-tiered hospitals[79]:

Rs. In Crore
Hospital Name Revenue Total
KEM Hospital & GSM College 114.1 137.5
LTMG Hospital & College 93.2 124.1
BYL Nair & TNM College 70.9 111.7
Nair Hospital & Dental College 7.4 9.7
Total of Major Hospitals 383

When we look further at the budgets of the special and periphery hospitals, we get a better idea
of where the priorities lie in the funding of medical institutions:
Name of Special & Peripheral Hospitals Rs. In Crore
1 Bhajekar Hospital 1.4
2 ENT Hospital 3.0
3 Eye Hospital 1.7
4 K.B. Bhabha Hospital Bandra 15.9
5 K.B. Bhabha Hospital Kurla 8.4
6 Mun. General Hospital Ghatkopar 19.9
7 Bhagwati Hospital 14.4
8 MTA Mun General Hospital 8.9
9 Cooper Hospital 21.8
10 DN Mehta Hospital Chembur 4.1
11 VN Desai Hospital, Santa Cruz 8.9
12 MW Desai Hospital, Malad East 4.6
13 VD Savarkar Hospital, Mulund 3.4
14 MGH Barvenagar Hospital 3.6
15 SK Patil Hospital Malad East 1.7
16 Centenary Hospital, Kandivali 3.7
17 Centenary Hospital, Govandi 6.7
18 Mahatma Jyotiba Phule Hospital, Vikhroli 4.7
19 Siddhartha Nagar, Goregaon 3.4
20 BSES Mun Gen Hospital, Andheri West 2.7
Total 138.9
Many of the peripheral and secondary hospitals listed above are located in the suburbs, while the
4 major hospitals are located on the south side of Mumbai. This presents many challenges for
those that end up having to seek care at secondary and primary institutions. Infectious Disease
and Tuberculosis hospitals also do not get priority in terms of funding[80]:
Name of Hospital Rs. In Thousands
1 Katsurba Hospital 14,37,07
2 GTB Hospital 17,65,48
3 RDTB Clinic Dadar 41,70
4 Shamaldas Gandhi Marg TB Clinic 30,74
5 Balaram Street TB Clinic 23,33
6 TB Clinic, Khar 93,04
7 Nawab Tank, TB Clinic 27,16
8 Acworth Leprosy Hospital 1,40,03
Total 35,58,55

And finally, the category of “others” which loosely covers health posts, maternity homes, and
dispensaries is at the bottom of priority list.[81]
Name Rs. In Thousands
1 Maternity Homes, Children Welfare Services etc 59,03,21
2 Dispensaries 20,58,71
3 CHMS (PH) 3,54
4 Central Analytical Lab 29,02
Total 79,94,40
6 Public Health Department 98,39,60
7 Measures to Control Environmental Air Pollution 3,69,70

The figures above demonstrate that there are several gaps in terms of priority in funding to the
various health initiatives of the MCGM. A close look at the budget shows a major gap in the
primary, secondary and tertiary levels of care.
A budget analysis can demonstrate the trends in fund allocation and expenditure as part of the
MCGM.

Budget analysis:

Source- Budget Estimates A, 2005-2006, as prepared by Municipal Commissioner, BMC

Appendices to Budget Estimates A, Revenue Income and Expenditure (combined) 2005-2006, as
prepared by Municipal Commissioner, BMC
For- Public Health Dept., comparisons being made between budgeted estimates of 2004-2005
and 2005-2006
The increase in income for the budget estimate from 2004-2005 to 2005-2006 is given as Rs.
252.47*, whereas the increase in expenditure for the budget estimate from 2004-2005 to 2005-
2006 is Rs. 443.53. Deficits for sure with exp. almost double the amount of income.
Budget estimates for the yr. 2005-2006 have increased w.r.t. 2004-2005, but mostly under salary
and administrative component. For example- General Superintendence- almost doubled; under
Rabies Control, Licensing of dogs; under Medical Relief and Education for King Edward
Memorial Hosp. Figures on page H-158 gives a better picture for it. The wages since 1999-00
until now have increased by almost 100% and form the major chunk of total exp. when
compared to others (other budget analysis tools can be employed to highlight the above point).
Page- H-159 shows ‘wages’ under the head of “Controllable Expenses” that have actually grown
in an uncontrollable fashion, whereas the increase in “Obligatory Expenses” mentioned above it
has not been much.
Budgeted estimates for repairs (as part of General Superintendence, under Rabies- increase by
ten times); for Medicines, Instruments and Inoculations (under Epidemics) and for Equipment
(under Medical Relief and Education for King Edward Memorial Hosp.- increase by 100%)have
also increased significantly. The thing to be noted is that while all these increments are being
made on paper, are they also being materialized or do they continue to be on paper only.
The budgeted amount to be invested for equipment (under Vector, Pest and Rodent Control) has
been reduced by almost Rs. 200, 000.
Budgeted amount under Rabies Control for ‘payment for sterilization of dogs’ has gone down by
Rs. 300,000.
The exp. under has decreased from Rs. 200,000 to a mere figure of Rs. 30,000.
The summary and concise form of detailed estimates given at page no. H-160 clearly shows that
the estimates for 2005-2006 when compared to that of 2004-2005 have been on a decline for
most of the elements of Public Health Expenditure, though it has also increased for others. To
mention a few heads where it has declined- Epidemics; Vector, Pest and Rodent Control;
Laboratory; Dispensaries (under Medical Relief and Education) etc. Examples where the
increase has taken place- Rabies Control; Life Guard Services at Juhu, Versova, Hospitals,
Maternity Homes etc.

7.2 Primary Health Care

Primary care is supposed to be the first point of access for the citizen. If primary health care
institutions are at the bottom of the priority list, then they will be treated similarly by the
consumer or patient. In Mumbai, the major issues around utilization of the public health care
system are quality of care, convenience, costs, distances, apathy among staff, and wide-spread
vacancies. As a result, people living Mumbai fail to access primary care services and proceed to
the tertiary level hospitals and private vendors for all their care, even that which is normally
addressed at the primary care level. This leads to overcrowding at the city’s third tier hospitals,
which have comprehensive services and better quality of care. According to a study conducted
by CEHAT (Centre for Enquiry into Health and Allied Themes) demonstrates that despite having
better health care services, people residing in Mumbai do not have proper access to health care as
32% of ailments remained untreated[82].

The MCGM’s described functions for dispensaries and health posts are described below:
Functions of Dispensaries:
Clinical management on OPD basis.
Immunization- polio, DPT, Measles, Tetanus, Toxid, Typhoid.
Preventive services.
In upgraded dispensaries- Laboratory services- Urine, stool, HB blood, and Malarial parasite.
(Out of 163 dispensaries- 60 are upgraded).
Health Education to the patients attending the dispensaries.
Medical examination of Municipal employees. On the whole, dispensaries, preventive, curative
services to the patients.

Functions of Health Posts:

Conducting baselines surveys of the community (of about 65,000 population) residing with in the
given geographical area.
Enlisting the eligible couples, motivating them for adoption of small family norms and providing
them with outreach services for contraception.
Immunizing children against the 6 vaccine preventable diseases viz. children tuberculosis,
diphtheria, tetanus, pertussis, poliomyelitis and measles through fixed center based and camp
approaches.
Preventing and treating case of nutritional anemia in mother and children by distributing iron-
folic acid tablets & syrup.
Vitamin A syrup to all children as prophylactic doses for Vitamin A deficiency.
Oral Rehydration salt packets to children of under-five age group suffering from diarrhea
Conducting Growth Monitoring Program for children of under-five age group.
Giving health education to all slum-dwellers.
Detection and treatment of cases of Leprosy, Tuberculosis, AIDS and Malaria.
Registration of unregistered births and deaths.
Detection of new home births and the motivation of such mothers to get their babies immunized.
Establishing effective Management Information System including proper record keeping and
timely reporting.
Developing and efficient referral system.

According to leading public health experts, improving primary care is the best method to
promoting health and preventing disease in countries with high populations and low
resources.[83] During a non- research based study of a primary health center in Chembur,
Mumbai, the author found that the majority of the patients coming there were either coming for
TB medication (42%) or basic health problems 53% (fever, cough, cold). Out of 19 people
surveyed, only one person complained about the process of sending a patient to a hospital, then
health post/dispensary, then hospital again. The majority of patients (73%) were satisfied with
the quality of health care because the doctor was good.[84] This comment was most always in
relation to the doctor and the effectiveness of the medicines. An analysis of MCGM dispensaries
in two wards at Mumbai showed that an average of 85 patients are treated every day, clearly
indicating high level of utilization of dispensaries as well. The other alternative source is private
health-care sector which is relatively inaccessible to the poor but also characterized by poor
quality infrastructure and manpower and was found to be indulging in profit motivated medical
malpractices.[85]

It is clear that the public health services in Mumbai are certainly utilized; however, it is the
quality of the care that should be addressed. While the research demonstrated that the people
going to the dispensaries and health posts were satisfied by the services, there are other wards
that are plagued with vacancies at curative level positions. For example, an interview of the K
east Ward Officer (also a doctor) revealed that out of 11 positions for medical officers, there are
currently 9 vacancies.[86] Staff dissatisfaction is high among the Community Health Volunteers
(CHV’s). The CHV’s were retained after IPP-V ended to serve as the “eyes and ears” of the
MCGM- performing such duties as immunization campaigns, home visiting, family planning
education, and more duties as required. Of the CHV’s I met, all of them complained of salaries
that were too low. These CHVs make up to Rs. 900 per month, which in contrast to the onus of
their work is too low, and if the burden of community health outreach must fall upon them.

Other examples of challenges at health posts and dispensaries include a visit of Dr. Janaki Desai
to a dispensary on Antop Hill with a group of foreign visitors. “I saw the doctor use a dirty, old,
un-sanitized needle to give the patient an injection. On top of that they were asking the visitors
for money to help support the health post”.[87] Dr. Desai heads the NGO the Niramaya Health
Foundation. The organization’s main focus is to provide health education and promote the
concept of prevention. “Due to the inadequate services provided by the MCGM, our clinics have
turned into the OPD’s instead of centers for promotion of good health and prevention of disease.
We hope to work more collaboratively on these issues.”[88] Dr. Desai also mentioned that their
NGO provides iron supplements (supplied by the MCGM) to young women, and these vitamins
have been “unavailable” for the last 6 months. The challenges of utilizing the public health
system is currently presenting a challenge for those who are trying to work within the system.

In contrast, in other wards and areas of Mumbai, some citizens prefer to access care by a private
provider. In the K East Ward, public preference for outpatient care services from a BMC facility
in the CEHAT study “Un-met Need for Public Health Care Services, in Mumbai, India” was
very low (14 per cent) when compared to that for inpatient care services. Here the majority of
households reported to seek treatment from the private sector (82 percent). As mentioned earlier,
there are only 11 public dispensaries in the area, which is grossly inadequate to meet the demand
for OPD care services of over 800,000 people residing in this area. Given the larger and
physically more accessible presence of private doctors, people are likely to prefer services from
private providers rather than seeking care from public health-care services outside the locality,
where “time” and “travel” costs are higher. Here the main worry is about the identity of private
providers in this low-income locality as many of the practicing doctors in the locality are likely
to be non-qualified practitioners and /or doing cross practice.[89] The reasons cited in this study
for choosing private care cited “offers good quality service” as the main reason. However, in
terms of affordability, the same respondents said they would prefer to go to a public facility-
however, due to lack of doctors and general unavailability; they had to seek care at a private
practitioner.[90]
Clearly, while the primary health care system does have many strengths, it is plagued with issues
of quality and access due to inconvenient timings, widespread vacancies, and lack of motivation
of staff.

7.3 Challenges at Secondary Hospitals and Maternity Homes

As is evident in the MCGM budget, the secondary (also referred to as peripheral hospitals) and
maternity homes do not receive adequate resources to support their respective institutions. The
budgeted allocation of 20 secondary hospitals is equal to the entire budget of KEM Hospital. In a
city that is expanding toward the suburbs, it is critical that the peripheral hospitals are also
prioritized in terms of development and offering of services. According to Dr. Sanjay Nagral, a
physician at Jaslok and Bhabha Hospital (Bandra), certain systems create inefficiency at
secondary hospitals. One is, despite the service, the perception is that government related health
services are always bad. Secondly, part of the problem is the bad attitude of the staff:
They think the patients are poor, so they deserve bad treatment
Senior staff reinforces this problem
Staff is genuinely inefficient
This is very true at the peripheral hospitals
Even proper seating arrangements at the OPD could ease the tension that is created by long
waiting time and staff inefficiencies[91]
Maternity homes are also not utilized properly, as surveys from the CEHAT study found that
seven to eight per cent of deliveries in Mumbai are still home deliveries. About 40% of the
population utilizes the public sector for antenatal services. According to Dr. Armida Fernandez,
founder of SNEHA, an organization working collaboratively with the MCGM to improve public
health care for Maternal and Child Health, According to Dr. Fernandez, the IMR in Mumbai is
40/1000 and the amount of neonatal deaths: 25/1000. Shockingly, the MMR in India is
equivalent to that in Mumbai (410/100,000). Clearly, there is a greater need for improvement of
care at the secondary level as well as the primary health care level.

7.4 Third Tier Hospitals

The third tier sector hospitals, KEM, Nair, Sion, and Nair Dental are known world wide for the
breadth and depth of their services. KEM is the flagship institution of medical education and
public facilities in Mumbai. These institutions provide comprehensive care, from general
medicine to cardiac surgery under their care. On the website for KEM, it states “The medical
college (school) provides training to about 2000 students in undergraduate, postgraduate and
super-specialty medical courses; in undergraduate and postgraduate physical and occupational
therapy; Masters and PhD courses in various allied specialties. A nursing school is also
maintained by these institutions. With about 390 staff physicians and 550 resident doctors, the
1800 bedded hospital treats about 1.8 million out-patients and 68,000 in-patients annually and
provides both basic care and advanced treatment facilities in all fields of medicine and
surgery.”[92] Clearly, colleges and hospitals of this caliber benefit greatly from the subsidization
of their services by the MCGM.

As is evident from the MGCM budget, the majority of the financial resources of the public health
department are allocated to these four major hospitals. In fact, their endowment makes up
approximately 7/8th (86%) of the entire public health budget. It is important to note that because
these are also medical colleges, the government in part, is also subsidizing the medical education
of students attending these colleges. Subsidizing medical education is hardly a new phenomenon;
however, the chances of the future physicians from these colleges integrating into the community
to fill the much needed gaps are minimal. The table below illustrates how minimal the medical
education fees truly are:
ALL FEES ARE FOR A TERM OF 6 MONTHS at Seth GS Medical College:[93]
First MBBS Rs.10,100
Second and Third MBBS Rs. 8,100
Postgraduate Medical degree courses (MS,MD,MCH,DM etc) Rs.14,800
Postgraduate Medical diploma courses (DVD,DMRD etc) Rs. 14,800
BSc Rs. 1750
MSc Rs. 5475
PhD Rs. 6275
The table above demonstrates how minimal the fees are for medical students.
Although KEM and the other medical colleges are quite competitive at the entrance point, the
fees are not really a barrier for those seeking medical education; even the completely poor fall
into various scholarship categories. As a result, the medical education or the cost of it is not a
critical point of contention for the student. Additionally, students and residents have their own
opinions about the state of the public health system:
“The secondary hospitals have no facilities.”
“We cannot practice without proper equipment and that is the major problem with the health
posts and dispensaries”.
“I would not prefer to work at a government facility if I had the choice”.[94]

These were the words of the residents interviewed at a general OPD in a hospital/medical school
by the author. The residents spoke of the challenges they had heard from the field and implied
that they would rather go into private practice or a fellowship than stay to practice in health
clinics. When asked how much they spent on their medical education, many stated that between
scholarships, waivers, and government quotas, many of them did not have to pay anything for
their medical education. Clearly, there is a gap between curative medicine and preventive
medicine in the Indian medical system.

It is known among doctors and faculty that Preventive and Social Medicine (PSM) is like the
step-child of Indian medicine. PSM is not widely developed or even understood by the doctors
who have that qualification. Additionally, the financial value of a doctor practicing PSM is also
quite low. Therefore, the idea of PSM, which is essentially public health, is brushed aside for
more curative services. However, the value of such a practioner, especially in communities and
clinics, would be invaluable for improving the health indicators of the urban community at large.
The undervaluing of PSM has led to a great divide between preventive and curative medicine at
the practical level at 3rd tier hospitals and medical colleges.

Another aspect that has paralyzed the public hospital system, especially at the 3rd tier, is the
opportunity for professors to have a private practice in addition to their work at the hospital. This
not only takes away precious time that could be spent in the community or doing trainings, but it
sets a bad example for young residents and interns about the purpose of a publicly funded
healthcare system. Additionally, as beneficiaries of the public system, their profits should not be
utilized for personal purposes. While the original creators of the policy may have been thinking
otherwise, this policy ultimately can be detrimental to the public health system.
Also on the website, is the list of salaries for the various posts at the hospital:
Position Salary
Resident Rs. 6500-8000 per month
 Lecturer Rs. 15,000 per month

Associate Professor Rs. 18,000 per month, provisional quarters

may be provided.
Professor Rs. 25,000 per month, provisional quarters
may be provided.

With salaries lower than what most people make at the bustling call center industry, it is no
wonder that doctors are not opting for government positions in health.
Finally, the biggest challenge at the third tier is not just the low school fees, private practices,
lack of emphasis on PSM, or low salaries- it is the lack of a referral system that leads to the
overcrowding of these hospitals. These hospitals are overcrowded with people coming for simple
ailments (cough, cold, fever, backache) that can be addressed at the primary care level.
Another non-scientific survey[95] was conducted in the general OPD of KEM hospital by the
author of 20 people visiting the GOPD for health care. Sixty-five percent came from areas that
had government hospitals and facilities: Wadala, Ullhasnagar, Malad, Bhyendar, Andheri, New
Mumbai, Bhandup, Sewri, and Govandi. Patient’s less serious ailments were cold and cough,
high blood pressure, acidity, dizziness, fever due to no access to cleaning water, and respiratory
infections. These conditions could easily have been cured at the primary health care level, at a
municipal dispensary or health post. When asked why they chose to KEM over their local public
health post or dispensaries, the answers varied from not knowing about local services to
dissatisfaction with quality of care. Overall, the majority of those coming to KEM came because
the doctors were good and the treatment was effective.
“Good Doctors, and good facilities for patients”, Housewife, Wadala
“I went to a private hospital and the doctors were rude. I came here and the doctors spoke to
me nicely”, Housewife, Ullhasnagar
“Doctors and facilities are good. Those who leave here, leave well” Male, Parel
“Treatment is done well, and they take time and do good. In the village, they give an injection,
and it doesn't work well. It is good. Its not easy to handle that many people”, Driver, Rajapur
Village
“If you come 1-2 times you get better relief. The procedure has become a little complicated, it
used to be better when people were prioritized based on illness”, Saleswoman, Bhayendar. She
also added that she is unaware of the public services offered near her home.

Overall, there was a major lack of awareness of the existing public health services offered near
their home, and a major perception that the doctors treated them with more respect at KEM than
anywhere else. The average amount of money spent going there for just travel averaged at about
Rs. 56 per person. This can be half of one day’s wages for daily laborers, and the waiting time
can surely cost them another day’s pay. Of course, this does not include the amount of money
they may have spent seeking health care from alternative sources of treatment. One woman
claimed to have spent Rs. 1000-1200 on her care in a private facility to no avail, and then
someone recommended she come to KEM. This study was conducted to get a sense of why
people chose to come so far to seek care. At the end of everything, more than the actual
treatment, it was the fact that the doctors were attentive, focused, spent time listening to each
patient, and generally had an affable manner about them.
Although this is quite similar to what was observed in the municipal dispensary, some of the
interviewees’ biggest complaints were that the doctors in the dispensaries did not treat them with
respect and dignity. The affable manner can be related to several different issues:
The residents are fairly young and were able to work with peers of a similar age group
KEM has each and every facility that is required for a doctor to come up with a proper diagnosis
The residents expressed that the emphasis on quality came from the senior management,
underscoring the administration’s commitment to quality of care
There was a good team environment where the work was distributed evenly and senior doctors
were very supportive to the juniors
Through this observational analysis, it seems that most people want someone who can speak to
them nicely and help them out with whatever ailment they are having. They don’t mind waiting,
or traveling for days, they just want respect and affability.

The other side of this survey is that due to timing problems, many of the doctors were present
during the interviews. This could have skewed the results of the survey as perhaps the patients
did not want to seem ungrateful. In fact, some of these patients arrive at the hospital so desperate,
any form of care that results in better health is helpful. While the responses do show a positive
image of the hospitals, it is important to remember the conditions under which the survey was
conducted. It is also important to remember that this was just a small survey of the patients and is
not meant to be indicative of the entire population that utilizes it.

While this example is just of one of the best institutions in Mumbai, another municipal teaching
hospital- Sion (and LTMG Medical College) often bears the geographical brunt of the influx of
patients bypassing the primary health care system. Since Mumbai is an island city and has
developed toward the suburbs, the majority of the 3rd tier hospitals ended up in the southern part
of Mumbai. This creates major barriers to access in care due to the distance and time involved in
reaching these hospitals from the suburbs. Sion hospital provides a break in that geographical
barrier from the suburbs to “town-side”. As a result, Sion hospital bears the burden of most
emergency cases, transfers from peripheral hospitals, casualties, and most aspects of urgent care.
As a result, Sion’s services are compromised due to work-overload on physicians, scarcity of
resources, and difficulty in managing overcrowding.

Clearly, there are many complicating factors regarding efficiency and access at municipal
hospitals in Mumbai. Even though services are of high quality at 3rd tier hospitals, they are still
plagued by issues of overcrowding, lack of referral systems and non-utilization of primary health
care services. It is important to understand the detrimental effect an uneven distribution of
services ends up having on the entire public health system. Indeed, due to some of the
compromised conditions (financial and otherwise) at primary and secondary levels, the system
itself encourages uneven access to health care.

7.5 Inconvenient Timings

The MCGM’s timings for health posts and dispensaries are generally 9am-4pm. This is often an
inconvenient time for people who are employed. Leaving work and spending an unspecified
amount of wait time can contribute to the frustration with public health facilities.

7.6 Locations
As it was alluded to previously, the major 3rd tier hospitals are located in the southern part of
Mumbai, while the city has expanded toward the suburbs in the north and east. This is common
urban phenomenon known as urban sprawl, is leading to compromised access to public health
care and is increasing the market for private practitioners (both qualified and un-qualified). In
the surveys conducted of the KEM OPD ward, many of the patients that came from various
distances were unaware of the locations or services offered near their home. Apart from the ones
who had a negative perception of it, many claimed to not know the locations of the government
health facilities. This happens for many reasons:
Due to extremely large populations to be covered by community health volunteers (1 per a
population of 60,000), each home that is supposed to be visited is often not
Since word of mouth is the most common method of reaching out to communities, the lack of
awareness propitiates throughout the community
If people know of a 3rd tier hospital that is effective, they will bypass the primary health care
system regardless of proximity.
Additionally, there was no map of Mumbai that had explicitly drafted the locations, timings, and
doctors at each health facility. A pamphlet of that nature would be useful to promote the
availability of government health care services.

7.7 Vacancies
Wide spread vacancies continue to plague the MCGM health system. In K East Ward, as
mentioned previously, there are nine vacancies out of eleven positions for Medical Officer’s of
Health. This is in an area that already suffers because of the lack of the municipal hospital in the
ward. When the survey was conducted at KEM General Out Patient Department, the residents
working there also mentioned that they were not interested in working at municipal dispensaries
due to lack of resources and facilities. The general disposition of the MCGM public health
department seems rather apathetic in relation to the high rates of vacancies. It seems to be an
acceptable norm that should just be accepted. This further complicates the case for expecting
patients to seek primary health care. If a patient goes once or even twice and the doctor is not
there or has left early, it becomes a dysfunctional health care center for them. Further, due to a
hiring freeze due to budget problems a few years ago, there were no positions filled.

There are several reasons for wide-spread vacancies at MCGM. First, the salaries for doctors are
not at a standard of living that would be appealing to many young doctors and the older doctors
that have been MCGM position for years often wait to retire to get benefits. Secondly, there are
no incentives for working at a community service level. Thirdly, there are hardly enough
facilities at primary and secondary level that make a doctor feel like they can diagnose/treat a
condition without having to refer the patient to a tertiary institution for further investigation.
Finally, given the financial remuneration is so limited for doctors, many would prefer to start
their own practice or work in a private institution.

7.8 Quality Assurance

Quality Assurance or quality of care does not mean sophisticated or exclusive care, but is
concerned with fully meeting the needs of those who need the service the most, at the lowest cost
to the organization, within limits set by higher authorities. Quality of care is cited as the main
reason the interviewees at the KEM GOPD chose to travel to KEM for their care. One hundred
percent of the patients mentioned the doctors are facilities were good. The doctors spoke to them
nicely and the treatment was effective. One woman mentioned that it was “very clean” as
compared with other hospitals she had been to. These correlated with the residents’ comments
that the facilities and resources available to them helped them serve the patients better.
Additionally, the presence of systems and availability of “one stop servicing” is extremely
beneficial. Because KEM has everything from X-ray facilities to MRI’s, patients don’t need to
seek care elsewhere.
In summary, Quality Assurance, as a concept is a systematic way of ensuring and maintaining
“quality” of services and has proved useful globally. Quality of care has 3 dimensions:
Client’s perspective: What do clients expect from the health services?
Professional’s perspective: Do services follow health care provider’s professional standards?
Management or Administrative perspective: Are the resources being used productively? Are the
services efficient?
Through a collaborative initiative between the MCGM and XXX project, an action research
project was implemented in 2 wards: H East and G North. This included 17 health posts, 16
dispensaries, 2 maternity homes, and 1 secondary hospital.

The focus of the project was to look at providers as agents of change. The project was limited in
terms of its interaction with the community, primarily because the project was aiming to reach
the community through the providers. The overall goal was to ensure quality health services for
women within the context of reproductive rights and health. The objectives were:
Improve, strengthen, and increase quality and range of health care services for women at all
levels
Enable women to have access to gender sensitive and user friendly services
Develop and build capacity of staff at 2 wards, training, monitoring and evaluation, and health of
women
This project worked closely within the MCGM structure with senior decision makers and health
managers in planning and intervention. Also the project focused on the capacity building of staff
in counseling, communication skills, training skills etc. The project also promoted quality
assurance and monitoring and evaluation.
This quality assurance system was implemented over 4 years and the team took every initiative
to ensure proper planning and implementation:
Workshops, planning, experimentations and interventions
Advocacy
Research
And in order to make sure everyone felt involved in the process, they established committees to
serve as links to the system, conducted participatory research and gave feedback, took all efforts
to ensure administrative support, and involved key persons from the MCGM. The main issues
that needed to be addressed were:
Information needs of clients
Attitudes of staff toward clients
Communication process between staff and clients
Diagnosis and prescriptions given by CHVs and ANMs (Auxilliary Nurse Midwives)
Training and supervision of staff
Referral process
Use of routine data
This project was very well planned, but was not accepted by the staff and administration teams
as it was thought of as a foreign concept. The project was opposed from many sides, and most
people claimed to not receive enough support from senior staff. The project did accomplish some
formidable goals, including two manuals for clinical guidelines in reproductive health for both
makes and females and a referral process that is described in the next section.

7.9 Referral Systems

The nature of the way people in Mumbai access public health care facilities would be greatly
improved if there were a referral system in place. In most countries, if a patient needs to see a
provider for a specialty, they must go through their primary care provider first. However, in a
system where the public is free to access health care at any level, the primary health care system
in bypassed and the patient heads straight to the tertiary or specialty care. When patients choose
to seek care at their own discretion, resources for primary and tertiary care are wasted and
tertiary resources are exhausted. This was evident in the KEM General OPD survey, where many
of the patients came for such common health issues such as fever, cold, cough, backache and
dizziness. If these patients had gone to their primary health care facility, it would have saved
both the hospital and the patients time and money. A referral system was tried and tested at
MCGM by the Women Centered Health Project. The process is described below:

An effective referral system would ensure optimum utilization of the three tier health care
delivery system of the MCGM and therefore use the available resources:
I. Objectives of the Referral System:
To ensure appropriate utilization of available resources
To ensure accessible, affordable health care services
To ensure patient and provider satisfaction
II. Pre-Requisites of an idea referral system:
Well defined levels of health care services based on availability of specialty services
Standard referral protocols
Administrative guidelines agreed upon by appropriate authorities governing various levels of
health care facilities
A well defined and well implemented feedback system
Focus on client and client centered in nature
Involvement of public as well as private sector
Strategies to enforce compliance

II. The proposed system for MCGM

This was looking at a well defined three tiered system with health posts and dispensaries at the
primary level, secondary hospitals, maternity homes and post partum centers as secondary and
teaching hospitals. The way it was proposed to work was that the priority would be given to the
referred patient. Patients being referred were getting a specially designed slip and would be
afforded benefits at the primary level.
This entire process did not work in the end because some of the staff were not clear about the
referral slips, this led to further patient dissatisfaction, people were unclear about how the system
was supposed to actually make things better.

This process is also being implemented through an NGO called SNEHA (Society for Education,
Health and Action for Women and Children). CINH (City Initiative for Neonatal Health) is a
collaborative initiative between the SNEHA, the International Perinatal Care Unit (IPU), UK and
the Bombay Municipal Corporation (BMC), CINH uses participatory techniques to involve
community members in urban slums and municipal health service providers to achieve:
• Improvements in maternal and newborn care practices and care seeking
• Provision of high quality antenatal and postnatal care at public health posts
• Continuous quality improvements for maternal and neonatal services at maternity homes and
hospitals

CINH has three essential components:

Improving public health systems
Improving maternal and neonatal health outcomes at the community-level
Developing these supply and demand interventions into a replicable model for urban slum
settings

A four-pronged approach will address these essential components:

Improvement in the quality of maternal and neonatal health care in all levels through the
development of a formal referral system in the BMC. This includes implementation of clinical
and administrative protocols for referral and transfer. To ensure sustained change, the
Appreciative Inquiry model will be used in addition to supportive supervision techniques.

The participatory development of antenatal, postnatal and neonatal (APN) service package for
health posts was developed to build support at the community level.

The use of action-research cycles with community groups to improve maternal and neonatal
health outcomes. This low-cost intervention trains local facilitators to lead community groups
through a process of identifying local challenges in maternal and neonatal health and evolving
workable strategies.

The development of evidence-based models for urban slums by building action research projects
with a strong evaluation component. Each intervention is participatory and includes capacity
building for sustainability. [96]
As CINH is being implemented throughout various public health care facilities in Mumbai, it is
important to look at it as a replicable model that can be utilized universally throughout the
system. Such a model can lead to greater efficiency as well as increased quality assurance
throughout the process.

7.10 Lack of Awareness

Lack of awareness covers a range of categories, lack of awareness of the patients regarding the
availability, locations, and timings of government services; lack of awareness within the staff
about quality assurance and quality of care; and lack of awareness of the multi-dimensional
aspect of the MCGM’s programming. There is no availability of a map in of the health services
being offered in each area. This leads to the general lack of awareness of services offered by the
MCGM. Patients feel there is a free range for them to access services anywhere, regardless of the
inconvenience. Staff are also largely unaware of the overall goals for quality services and
perform on a “fire-fighting” strategy, in which only the exigent issues are addressed, and there is
little adherence to ongoing strategy planning and setting up goals and work plans. Finally, it just
seems that there is a great disconnect between the different aspects of MCGM programming.
While some programs get national level priority (Polio and TB), some of the other programs like
environmental health and primary health care delivery through the CHV’s is not set as a priority
for funding. Although these programs are multi-dimensional and could be inter-sectoral, the
programming tends to run in a vertical fashion, all working toward goals without thinking of the
benefits of a more horizontal approach toward programming.

7.11 Public Health Disaster Management

In light of the recent outbreak of avian influenza, the MCGM needs to have a separate cell that
deals with public health disasters and outbreaks of diseases. If there is a cell that monitors public
health outbreaks around the world and tracks them before they reach Mumbai. Having a team
whose expertise is public health disaster management would be beneficial to the public health
department. This team would consist of media persons, public health experts, hospital
administration team, doctors, nurses, pharmacists, and community health workers. In this
situation, the outbreak needs to be attacked through a multi-dimensional approach:
A media person can be in charged of the reports that go out to the press. In its current state, the
communication between the media and the MGCM is antagonistic with plenty of skirting the
blame.
Public health experts can help figure out medical and preventive strategies to address the
outbreak. Currently, various staff from many departments have been pulled from other work to
address this issue. There is no real assessment of how far Mumbai bas been affected, thus
creating a state of panic and fear.
A hospital administration team is critical to setting up an operation to deal with the possibility of
a public health outbreak. The hospital beds to be used for quarantine as needed should be
decided beforehand as well. This team can be responsible for carrying out administrative and
laboratory tests as needed.
Doctors and Nurses are needed to help any urgent needs related to people who have already
contracted the illness. These providers should be vaccinated (if possible) before hand to all
illnesses that pose a threat.
Pharmacists can ensure that medications needed for the outbreak are available and not expired.
They should ensure enough stock just in case an outbreak is likely.
Finally, community health workers are needed to help keep the community educated and not
panic; especially the communities that live in large slum populations. The MCGM has put out
pamphlets regarding the Avian Flu, however, they are only in Hindi and Marathi, thus excluding
a large part of the slum-dwelling populations and impoverished communities.
Addressing issues during a time of disaster are never smooth, no matter how well planned out the
process is. However, adequate planning and team preparation can help decrease the “learning”
that happens along the way. In other words, disaster management teams should be adequately
prepared beforehand so that while some things may require thinking on the spot, other processes
can go according to standard procedure.
7.12 Water supply and sanitation
To be added

7.13 Challenges from the Private Sector

According to a World Bank Study, nearly 82 per cent of all health spending in India is
private.[97] The increasing competition of the private sector of health care combined with a larger
disposable income of the middle class has resulted in loss of patients from the public to the
private sector.
These patients cannot necessarily afford the exorbitant cost of the private health care facilities,
but are willing to go into debt or risk their financial security to seek care in the private sector.
The reputation of public health services, unfortunately have become so negative that those who
can, and even those who can’t, will opt to seek care in a private facility. According to Dr. Sanjay
Nagral, “this was not the case 20-25 years ago, because back then people did access the BMC
services”. At that time, the private sector was also not as developed. This also helped keep the
system in check, as everyone from politicians to plumbers were accessing the system. Today the
average middle-class person or upper class person doesn’t think to use the BMC’s services. Even
the poor re-consider it at times. Even though there are segments of the private sector which are
too expensive for the average middle class to afford, they will still seek care there.

According to Lokshahi Hakk Sanghatana, a democratic rights organization, said in its report,
`Creeping Privatization in Public Hospitals in Mumbai — Private Profit, People's Loss'[98], that
public hospitals come forward and administer care during times of social strife such as natural
calamities, riots and outbreak of diseases, while private hospitals do not. The report claims that
the MCGM is moving toward privatization at most of the municipal health facilities. According
to the report, privatization of health facilities has been taking place in many ways — hospitals,
services such as blood banks, dialysis centers and intensive coronary care units (ICCUs) have
been handed over to NGOs or private entrepreneurs. If there are no private funds available, the
report says, and then the expansion projects are generally unavailable.

The MCGM collaborates with some private practitioners for tuberculosis treatment, but other
private practioners do not report having the same treatment regimen across the board for TB
treatment. These types of partnerships need more transparency and communication so the health
outcomes of the patient are not affected negatively. Further, out of approximately 40,000 hospital
beds in Mumbai, the MCGM holds about 10,000, which means that over 3/4ths of the beds are
under the jurisdiction of the private sector.

Newer complications are due to arise out of the latest trends in medical tourism. With foreigners
investing their dollars and pounds in private health care in India, the hospitals will make a lot of
money, no doubt, but again the poor will remain without quality or quantity in terms of available
services. According to a report in the Hindu magazine, “Only seven years from now, the most
optimistic industry forecast posits, medical tourists hosted by India can pump Rs. 10,000 crores
into our economy. An estimated 1,50,000 such visitors a year already spend about Rs. 1,500
crores in India for treatment.”[99] The major question everyone is asking is, what does this mean
for the impoverished citizens of Mumbai. Although private hospitals have obligations for their
not-for-profit status under the Public Trust Act to provide healthcare free to the extent of 20 per
cent of their resources, there is no accountability or follow-up for this provision. As a result, the
poor don’t even see private care as an option, thus the frustration ends up coming out on the
public healthcare system.

7.14 Reporting and Data Collection

The Mumbai Health Profile is put out every year (approximately) in order to give an update of
the health programming and accomplishments. What is missing from the report is an analysis of
the numbers reported. It seems very haphazard that the numbers are just reported without any
indication of what could have led to an increase or decrease. For example, there are no
explanations for why the TB numbers have fluctuated so much over the years. One can assume
that the different policies that have been implemented may have contributed to it, but the report
itself does not make a connection between the interventions and the numbers. The reporting
process is a critical part of showing the successes and challenges of the MCGM.

Another aspect of the MCGM that needs to be revised is data collection. For example, the School
Health Program is a successful intervention, but the data is not centralized so that there can be
effective epidemiological monitoring of growth, malnutrition, rates of TB and other illnesses,
and follow up. In order to decrease the paper burden, it is important to establish a global
information system that allows staff to input data and allows universal access to it from all
MCGM facilities. A centralized, computerized data system could result in increased efficiency of
the process. This would in turn improve the reporting process as well.