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 variousanganwadisin 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 / 20047255 / 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 arefour 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 / 2004Cases / 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: