A Report to the MCGM and the NGO Council

Recommended Policy Guidelines for Public Health

(Draft dated 1st May, 2006 for discussion)

Send comments to: By Meenakshi Verma, MPH - [email protected] - www.karmayog.org Public Health Consultant addressing civic and social issues

1 Topic Title: Page no.

Background 4 Probable value of report 4 Conclusion and summary 5 Recommendations (in brief) 7 Patient Bill of Rights 9 Patient Code of Conduct 10

Recommendations (expanded) 12 Executive Summary 22

1. Introduction and Background 40

2. National Policies in Health Care in India 43 2.1 National Health Policy 43 2.2 National Population Policy 47 2.3 Report of National Commission on Macroeconomics and Health 50 2.4 World Health Organization Country Profile 53

3. The Urban Poor and Health 56 3.1 Urban Population growth 56 3.2 Health Conditions 56

4. Mumbai, Maharashtra 59 4.1 Health in Mumbai, Maharashtra 60 4.2 Existing Infrastructure in Mumbai 61

5. Services in Detail 66 5.1 Functions of the Public Health Department 66 5.2 Dispensaries and Health Posts 67 5.3 Maternity Homes 67 5.4 Municipal Hospitals 68 5.5 Programs 68 5.5.1 Leprosy Control Program 68 5.5.2 Revised National Tuberculosis (TB) Control Program 69 5.5.3 Universal Immunization Program 70 5.5.4 Polio Eradication Program 72 5.5.5 National Malaria Control Program (NMCP) 73 5.5.6 Mumbai District AIDS Control Society (MDACS) 73 5.5.7 School Health Program (SHP) 74 5.5.8 Respiratory System Diseases 76

6. Successes 78 6.1 School Health Program 78 6.2 Polio Eradication 79

2 7. Services 80 7.1 MCGM Health Budget 82 7.2 Primary Health Care 88 7.3 Challenges at Secondary Hospitals and Maternity Homes 92 7.4 Third Tier Hospitals 93 7.5 Inconvenient Timings 99 7.6 Locations 99 7.7 Vacancies 99 7.8 Quality Assurance 100 7.9 Referral Systems 102 7.10 Lack of Awareness 105 7.11 Public Health Disaster Management 106 7.12 Water supply and sanitation 107 7.13 Challenges from the Private Sector 108 7.14 Reporting and Data Collection 109

8. Appendices 111 a. Patient Bill of Rights 111 b. Patient Code of Conduct 112 c. Probable Value of the Report 113 d. Training Activity for the BMC 114 e. Integrating public health issues into the LACGs 115 f. Apex Health Committee 115 g. Author’s Note 116

Appendix 1: Questionnaire for Utilization of Tertiary Health Care Services 117 Appendix 2: Health Post Survey Results- Vashi Naka Health Post, Chembur 119 Appendix 3: KEM General Out Patient Department Survey Results 120

II Best Practices in Other Countries 122 a. Participatory Budgeting in Porto Alegre, Brazil 122 b. Cambodia’s Non Profit Path to Health Care 124 c. Subsidized Health Care in the Philippines 125

III Works Cited 126

3 Background This report started as a discussion between the members of the NGO Council and the MCGM after it was found that there was no existing public health policy document on accessing health care in

Mumbai. The NGO Council is a representing body of NGOs in Mumbai seeking to collaborate with local authorities on issues of priority. The NGO council was formed on August 22, 2005. The

Council is comprised over 70 organizations with complementary expertise covering all causes and sectors. The primary objectives of the NGO council is to work with Government, Donors, NGOs, and other third-parties to raise awareness and convene to address the important issues effecting the city of Mumbai.1 On 12/12/2005, Municipal Corporation of Greater Mumbai (MCGM) has entered into an MOU with the NGO Council, recognizing that an institutionalized partnership between municipal bodies and non-governmental organizations (NGOs) / civil society organizations

(CSOs) is critical for promoting Good City Governance. 2

Probable Value of the Report

In this section, the author has outlined how the report can be of value to the different existing bodies in the city of Mumbai. The report was not only created for the MCGM, but also for all the other proponents of health care in Mumbai. The following section details to value to each constituency:

a. MCGM: This report should be seen as an objective analysis of the existing programming at the MCGM. In addition to giving suggestions, the report also highlights the various successes of the MCGM’s health programming. It will be of value in several aspects: 1. Assist lawmakers in allocating funds to priority areas 2. Provide insight to those responsible for programming in terms of areas of improvement 3. Increase the efficiency of the MCGM public health department 4. Increase the reputation of the MCGM’s health services in the city 5. Prove as an impetus that demonstrates the MCGM’s priority of the health of the people of Mumbai 6. Intimate the top-level management as to the priority areas in various departments 7. Apprise mid-level management of the awareness of the lack of resources 8. Inform lower-level staff of the value of their work and increase worker morale

b. NGOs: Non-Governmental Organizations working in Mumbai are working to provide health care to the same citizens that are also the responsibility of the MCGM. This report can help bring the two groups together to not replicate programming in high-need areas and pave the way for NGO-MCGM partnerships. NGO’s can cite the information in the report

1 www.karmayog.org, See website for MOU 2 http://www.karmayog.org/bmcngocouncil/bmcngocouncil.htm 4 as representative of the enormous need for improved health care systems in such a large and densely populated city.

c. Donors: With Corporate Social Responsibility representing the progressive era of charitable giving, it is important for donors to also be aware of the issues that are effecting the communities that benefit from their time, money, and resources.

d. Citizens: In a city like Mumbai, the average citizen doesn’t think about health care unless it is a situation of urgency or crisis. This report will make citizens aware of the issues in health care that effect all those seeking care through the government health sector.

e. Medical Students, Physicians, and Health Professionals: In light of the recent strike of the doctors in Mumbai, it is also important for policy makers to understand the perspectives of those working on the ground. This report helps shed light on the needs of physicians and avenues for improvement in their occupation.

f. Media: The MCGM health department is often the recipient of negative publicity by the medial. The information in the report can offer some information as to the inner workings of the MCGM health department and what the media can do to support the improvement of these systems.

Overall, the report provides an in-depth analysis of the existing programs, challenges, and successes of the MCGM health department. Looking at the history of health policy in India, it is evident that there has been little emphasis on improving the health of local citizens in recent years. The report attempts to create a common area for discussion and improvement of health systems within this city. With good basic infrastructure, there are many avenues that can be pursued if the aforementioned parties join together to work on a healthy Mumbai.

Conclusions and Summary

In the last 20 years, there have been few initiatives proposed to improve health for the citizens of

India. When looking at the policies and initiatives proposed by the Central Government, there is a clear emphasis on improving rural health. However, with the urban poor population rising, the health needs of the urban poor communities are beginning to exceed those in the rural communities. The health care crisis of the growing urban poor, especially in Mumbai, represents a new challenge in providing health care to the masses. The health care of the urban poor is often worse than or equal to that of the rural poor population. Over 50% of Mumbai’s population of 18 million3 lives in slums and are part of the growing urban poor. This population is plagued with

3 www.wikipedia.com/wiki/Mumbai 5 uneven access to care, malnutrition, and poor maternal and child health. Therefore, it is critical to look at the health of Mumbai on a continuum of urban health.

The MCGM (Municipal Corporation of Greater Mumbai) provides medical services through three levels of care, primary, secondary and tertiary. This includes an intricate network of teaching hospitals, secondary hospitals, maternity homes, health posts and dispensaries. Although the infrastructure is complex, there is a multitude of improvements needed to address the health needs of the urban poor population in Mumbai. The various challenges plaguing the MCGM health system are growing as rapidly as the population and need to be addressed urgently. The challenges include:

 Human Resources: A large amount of vacancies in the public health department of the

MCGM lead to the apathy of the staff and patients.

 Infrastructural: Lack of equipment and services at the primary and secondary level of

care; lack of referral systems to direct patients to the appropriate care level; lack of quality

assurance

 Systems: Lack of a centralized data system, lack of awareness of existing programs within

the MCGM

 Ethical: Dilution of the value and faith in the public health system as a facility for all, not

just the indigent and underprivileged. This is a phenomenon that affects the patients as well

as the staff.

 Educational: Educational materials for prevention of disease and promotion of health are

under-utlilized or unavailable, patients do not understand the complexities of their own

health

With a confident team, collaborations, and an open attitude toward change, there are many options for the MCGM health system to become an accessible service for people seeking quality health care at an affordable price. A no-frills health care system that emphasizes good quality at the

6 lowest possible cost to the consumer will not only benefit the poor, but also those taxpayers whose money is being invested in the government run health care system. Working with existing private providers and NGOs can be beneficial for the MCGM system in terms of decreasing the burden and using best practices of existing programs.

Utilizing best practices from cities with similar problems to Mumbai will provide some insight into innovations that could be implemented throughout the existing health systems. While the problems sometimes seem to vast to deal with, it is important to remember that an implementation strategy that works on a step-by-step approach will be the ideal method of slowly improving the system.

The MOU between the NGO Council and the MCGM is the critical agreement that should be kept in mind in the difficult stages of planning and implementation. This agreement is meant to bridge the gap between the government and the non profit organizations that provide many needed services to the impoverished. Both have similar goals, it is now time to devise a better strategy through collaboration.

Recommendations- Brief

A. Education and Information Dissemination 1. Ensure that a Patient Bill of Rights (enclosed) and Patient Code of Conduct are posted in every public health care facility being operated by the MCGM 2. Create a map of Mumbai (in Hindi, Marathi, English, etc) with locations, timings, and services of each healthy care facility. 3. Improve primary and secondary health care systems by providing training for quality assurance at all facilities. 4. Ensure that educational materials on ALL illnesses and ailments are available in multiple languages at respective primary and secondary health care levels via posters, pamphlets, and CHVs.

7 B. Reproductive and Child Health 5. Increase awareness about institutional deliveries by collaborating with local women’s groups. 6. Develop IEC materials relevant to reproductive and child health as well as other relevant diseases by working with NGOs 7. Ensure all maternal, reproductive and child health services are free of cost. 8. Ensure that all municipal facilities are always stocked with medications for pre-natal care (iron, folic acid etc.)

C. Medical and Administrative Personnel 9. Increase skills, salaries, and working hours of the Community Health Volunteers and have CHV’s collaborate with health workers from NGOs 10. Discontinue the practice of allowing doctors to have private practices while employed by the MCGM. 11. De-centralize the management of the primary and secondary health care services

D. Infrastructure 12. Hire staff to fill vacancies of doctors at the primary health care level (Health Posts and Dispensaries) to improve the quality of care 13. Conduct a needs assessment of the infrastructural (both equipment, human resources) gaps in the MCGM public health system via a survey and analysis to apply appropriate solutions. 14. Decrease the gaps in infrastructure (staff, equipment, and training) at the primary and secondary levels of health care 15. Create a referral system so that people can access the medical services at the appropriate lowest level. 16. Utilize the referral system to minimize costs, patient load, and provide better quality treatment for serious cases. 17. Create management information systems to store and utilize data, statistics, and health records appropriately. 18. Create systems for MCGM circulars to be accessible to all 19. Revamp the ambulatory system completely to provide emergency care as well as transport. 20. De-centralize the laboratory system. Ensure all peripheral hospitals have functional labs.

8 E. Systems 21. Create a patient feedback system to improve policies, procedures, and services for patients and for MCGM staff. 22. Create a Public Health Monitoring Department that meets once in 2 months to plan for upcoming public health issues (i.e. bird flu, leptospirosis).

F. Coordinating with other MGCM Departments 23. Introduce adolescent health education through the municipal school system. 24. Increase citizen participation through a public health citizen committee in collaboration with the MCGM public health department. 25. Improve disaster management to minimize public health outbreaks 26. Improve water supply and sanitation at all slums, this will decrease the amount of diseases in the area.

G. Priorities in Health 27. Create a department that addresses issues of respiratory health in Mumbai, this should also be a division of the school health department 28. Utilizing the existing DOTS program, increase the priorities of TB management 29. Implement more programs focused on decreasing IMR and MMR (these should be focused on nutrition, education, and health of the mother as well as the child) 30. Create a city-wide campaign regarding Malaria awareness to be promoted during and before Malaria months 31. Ensure that all vitamins and supplements are available to NGOs distributing them to children through various programs

Patient Bill of Rights

Each place posting the Patient Bill of Rights needs to affirm the following statement. "We, the staff and the administration of {health facility} declare the following Bills of Rights for the patients of this medical facility. As per the Municipal Corporation of Greater Mumbai, we declare that staff and administration of {the health facility} have read and understood the following rights of a patient and hereby agree to all the terms listed below. If you have any questions or complaints, please contact {Name of accountable person at health facility} or {name of accountable person at BMC}."

 To be treated with dignity irrespective of their caste, class, sex, religion, and disease  To have a list of exact services available and corresponding fees (for supplies, bandages, etc)  To have a visible map of the hospital (in Marathi, Hindi, English, and other languages)

9  To have a list of emergency services such as blood banks and ambulatory services listed in Marathi, Hindi, English and other languages  To know and understand the procedures involved  To be given a reasonable time frame for the treatment and receive a proportional discount in fees for all services after the upper limit of approximation is over and treatment needs to be continued  To have a comprehensive (various tests, blood work, x-rays, room tarrifs, operations, consulting fees, etc) costs associated with seeking medical care  To receive prompt and courteous care  To be informed about the documentation needed for treatment  To have minimal documentation for emergency cases  To receive Reproductive and Child Health Services free of cost at public health facilities  To receive medications and vaccinations from the local public health post or dispensary  To get medical services which are within the capability of the medical facility  To obtain from the doctor complete information concerning the diagnosis, treatment, and prognosis in language the patient can understand.  To receive necessary information from the doctor such as long-term effects, side effects etc., before giving any prior consent to a medical procedure and/or treatment  To receive the records or a certified copy that gives the details of the disease, treatment, and follow-up necessary at the time of discharge  To refuse the suggested treatment and be informed of the medical consequences thereof  To receive medical care in well-equipped and sanitized conditions  To receive quality care from competent medical professionals  To select doctor’s of one’s choice when possible  To obtain a second opinion  To privacy during medical check-ups  To be assured that all communication and records will be kept confidential  To educational information about medical problems eg. via a library, IEC materials, etc.  To receive a bill cum receipt after the payment is made  To be enabled to pay hospital fees on a payment plan  To have access to a non-hospital staff member appointed to address complaints as soon as possible  To have the contact information of the responsible person (both at the hospital and head office) to register a complaint or give feedback  To have adequate waiting space  To allow relatives to have flexible visiting hours

10 Patient Code of Conduct

Patients are also responsible for their personal and environmental well-being. The following code of conduct emphasizes the responsibilities of a patient while seeking medical care.

As a patient:

 You should provide the doctor with accurate and complete information about his/her medical history, past illnesses, allergies, hospitalizations, and medications  You should report the changes in your medical changes  You should ask for clarity if the doctor’s prescription and diagnosis seem unclear  You should follow the doctor’s treatment plan  You should pay your medical bills promptly  You should follow hospital rules and regulations  You should have realistic expectations of what the doctor can do for you  You should help your doctor help you, if something isn’t working, be clear and the doctor can advise alternative care  You should participate actively in your own medical care (in terms of awareness and preventions)  You should ask the doctor questions to clarify any doubts or misconceptions in your mind  You should treat the doctors with respect  You should not ask doctors for false bills or certificates for any reason

11 I. Recommendations- Expanded A. Education and Information Dissemination 1. Ensure that the Patient Bill of Rights and Code of Conduct (attached) is posted in every public health care facility being operated by the MCGM Action Steps: a. Translate the documents into Hindi, Marathi, and other regional languages b. Pilot test it with a core group to ensure comprehension of the concept and what it actually would mean c. Send around a circular for ALL staff to read and understand the Bill of Rights and Code of Conduct d. Post accordingly in all health care facilities in Mumbai Time line: 2 months Measure of Success: Increased awareness of rights and responsibilities of patients, perhaps greater accountability of staff

2. Create a map of Mumbai (in Hindi, Marathi, English, etc) with locations, timings, and services of each healthy care facility. Action Steps: e. Hire a group of college students for 2 months to work with the Public Health Department to come up with a map that identifies all the locations of the health facilities f. This should include timings, doctor’s name, and phone number g. This map should be updated twice a year by the Public Health Department, once the infrastructure is in place Time line: 2 months Measure of Success: Increased awareness of government facilities, accountability for doctors, less patient load at tertiary care services

3. Improve primary and secondary health care systems by providing training for quality assurance at all facilities. h. Before implementing any kind of quality measures, the entire MCGM public health department (from the sweeper to the doctor) should understand the need for such innovations i. Through role plays and consciousness raising, the staff should become aware of the challenges before them

12 j. Hold monthly meetings with staff to imbibe aspects of quality assurance throughout the MCGM public health department k. Utilizing the health committee formulated, hold trainings for improved quality of care l. Provide incentives for randomly conducted surveys of facilities that provide quality care to their patients

Time line: 4 months

Measure of Success: Increased patient satisfaction as well as improved attitudes among staff.

4. Ensure that educational materials on ALL illnesses and ailments are available in multiple languages at respective primary and secondary health care levels via posters, pamphlets, and CHVs. Action Steps: m. Collaborate with the HELP library to create educational materials n. Make sure such materials are available at ALL health facilities being run by the government sector o. Ensure that a wide array of languages are covered in these materials Time line: 3 months Measure of Success: Increased patient health education, awareness of preventable diseases

B. Reproductive and Child Health 5. Increase awareness about institutional deliveries by collaborating with local women’s groups. Action Steps: p. Engage NGOs to help involve Mahila Mandals q. Create awareness among leaders in these groups about the hazards of home deliveries r. Hold events and public gatherings to raise awareness among these women’s groups Time line: Ongoing, but start up should be 3 months

Measure of Success: Increase in amount of institutional deliveries at the hospitals in the areas where the education has taken place.

13 6. Develop IEC materials relevant to reproductive and child health as well as other relevant diseases by working with NGOs Action Steps: s. Team up with 5 NGO Partners in order to start collecting information that already exists on these topics t. Devise a strategy to review these materials and edit/modify as needed u. Print and distribute to all women Time line: Ongoing, but start up will be 2 months

Measure of Success: Increased awareness of RCH as well as other diseases; may lead to prevention

7. Ensure all maternal, reproductive and child health services are free of cost. Action Steps: v. Appeal to the budget making entities of the value of free RCH services w. Create a public service campaign regarding increasing awareness for these initiatives Time line: Ongoing campaign, start up will be 2 months

Measure of Success: More urban poor women accessing government health care facilities for prenatal, postnatal, and neonatal care

8. Ensure that all municipal facilities are always stocked with medications for pre-natal care (iron, folic acid etc.) Action Steps: a. Partnerships with pharmaceutical companies can guarantee a constant stock of these very necessary vitamins and supplements b. An education campaign should educate women of the value of the proper utilization of these medications before and during pregnancy Time line: 2 months

Measure of Success: Decreased infant mortality and maternal mortality rates

C. Medical and Administrative Personnel 9. Increase skills, salaries, and working hours of the Community Health Volunteers and have CHV’s collaborate with health workers from NGOs

14 Action Steps: x. Expand job descriptions to include more responsibilities of the CHVs y. Increase salary to Rs. 1000 per month z. Provide ongoing trainings for them to be more engaged in the work they do aa. Allow them to collaborate with local NGOs CHW’s as well Time line: 4-6 months

Measure of Success: Increased job satisfaction and output by the CHVs, greater collaboration and raising awareness

10. Discontinue the practice of allowing doctors to have private practices while employed by the MCGM. Action Steps: bb. As an overall initiative, doctors should shut down their private practices at MCGM facilities cc. Terminate all benefits for those that had such practices Time line: 1 month

Measure of Success: Discontinuation of private practices for MCGM doctors

11. De-centralize the management of the primary and secondary health care services Action Steps: dd. Allow Medical Officers in each ward to take the lead in decision making ee. Tell them they have a certain amount of money in the budget and set realistic goals ff. Encourage them to reach these goals through collaboration and hard work gg. If they demonstrate leadership skills, there can be incentives for group management of wards (rather than it always having to be cleared through the main office) Time line: 4 months

Measure of Success: Increased job satisfaction and participation in the process

D. Infrastructure 12. Hire staff to fill vacancies of doctors at the primary health care level (Health Posts and Dispensaries) to improve the quality of care Action Steps:

15 a. Revise the personnel policies for the doctors at the primary health care to improve salaries and make sure the following basic facilities are available at every dispensary:

 Equipment to sterilize the instruments used for examination  Ample medications for all basic illnesses (diarrhea, cough, cold, flu, and fever)  Enough stock of iron, folic acid, for supplying to all women who may come to register their pregnancies  Training in the basics of pre-natal care for community health volunteers  X-ray facilities at certain upgraded facilities

b. Collaborate with medical schools to create incentives for graduating students to commit 2 years to service at the primary or secondary level

c. Involve current doctors in recruiting of new physicians, offer incentives to those who can find doctors who sign contracts for 2 years or more.

d. Improve the overall image of working for the MCGM improving facilities and systems through a circular highlighting the successes of the primary health care physicians

Time line: 6 months

Measure of Success: Decreased vacancies, greater staff job satisfaction

13. Conduct a needs assessment of the infrastructural (both equipment, human resources) gaps in the MCGM public health system via a survey and analysis to apply appropriate solutions. Action Steps: 1. Create a simple survey to assess the equipment, amount of staff, medicines etc. 2. Utilizing the CHV’s (increase their work hours and pay to Rs.1000) to have a basic assessment of equipment, vaccinations, medicines, vitamins etc (each CHV would assess a health post different from their own to maintain objectivity 3. Put all the data gathered together in a simple report revealing the gaps in services and infrastructure at the primary level

Time line: 3 months

16 Measure of Success: A report that identifies the gaps and direct action by the administration.

14. Decrease the gaps in infrastructure (staff, equipment, and training) at the primary and secondary levels of health care Action Steps: hh. Utilizing the assessment in Recommendation 13, assess the needs of each of the primary and secondary health care facilities. ii. The health committee can further lobby the administration about improving the infrastructure at each of these locations. jj. Infrastructure specifies: lab equipment, x-ray facilities, storage for vaccinations, provisions for sterilizing needles, and other needs identified by the survey.

Time line: 6 months

Measure of Success: Increase in utilization at the primary and secondary levels of health care, increased resources and infrastructure.

15. Create a referral system so that people can access the medical services at the appropriate lowest level. Action Steps: kk. In 5 wards, pilot test the referral system of care described in the Appendix 1, already tried once by the Women Centered Health Project. ll. Using the lessons learned by SNEHA’s CINH program that brings together NGOs and public health systems, implement 3 wards using their methods. mm. Assess the pilots and determine which was most complementary to the needs of the patients that access the MCGM health care system.

Time line: 1 year

Measure of Success: No overcrowding at tertiary hospitals, greater patient understanding of each of the tiers and what they offer.

16. Create management information systems to store and utilize data, statistics, and health records appropriately. This can be a part of the TCS created system. 17. Create systems for MCGM circulars to be accessible to all 17 Action Steps: nn. Using a computerized system, circulars should be sent out to all departments, and not just specific departments oo. The circulars should be stored in a computer as well as hard copy pp. TCS is also implementing a computerized network, this should be a part of it.

Time line: 6 months

Measure of Success: Improved record-keeping and awareness of all the programs/updates going through the MCGM system.

18. Revamp the ambulatory system completely to provide emergency care as well as transport. Action Steps: qq. Create a public-private company willing to partner with the MCGM on issues of ambulatory care rr. Create minimum qualification guidelines of those operating the vehicles ss. Ensure the vehicles are well equipped with supplies and equipment for saving lives tt. Create a free call system for people to call this number 24 hours a day uu. Cost? Should be further discussed Time line: 6 months

Measure of Success: Decreased deaths due to the scarcity of quality ambulatory care, perhaps some benefits from the public-private partnership

19. De-centralize the laboratory system. Ensure all peripheral hospitals have functional labs. Action Steps: vv. Using the infrastructure survey, it is important to assess which areas are lacking proper labs ww. These labs should be equipped to test for TB, AIDS, and conduct all other necessary blood work on site xx. There should be no additional user fees associated with this service Time line: 4-6 months Measure of Success: Decreased load on the 3rd tier lab systems, better facilities for patients to access blood work results

18 E. Systems 20. Create a patient feedback system to improve policies, procedures, and services for patients and for MCGM staff. Action Steps: yy. Through a screening process, select non-hospital staff to field the concerns of patients zz. Ensure the person is competent in mediation and can handle high pressure situations aaa. The person will then bring the issue to the hospital administration team to be addressed within a certain time frame depending on the emergency bbb. Ensure this process is well documented with appropriate attention from administration for complaint management Time line: Ongoing, set up time 3 months

Measure of Success: Decreased frustration among patients and staff alike, decreased attacks on doctors

21. Create a Public Health Monitoring Committee that meets once in 2 months to plan for upcoming public health issues (i.e. bird flu, leptospirosis) and acts a citizen body to represent the concerns of the locals. Action Steps: ccc. Review examples of Porto Alegre and other participatory/citizen committees ddd. MCGM’s public health department should set up an open house day to invite all interested parties to learn more about how the MCGM works. eee. The main role of the committee should be monitoring upcoming health issues and creating a forum for discussion and preparedness (i.e. avian flu, monsoon related illnesses) fff. Utilize media partners to help support and promote the outputs of this collaboration

Time line: 6 months

Measure of Success: Increased citizen participation and actual change as a result of the participation.

19 F. Coordinating with other MGCM Departments 22. Introduce adolescent health education through the municipal school system. Action Steps: ggg. Work with the Niramaya Health Foundation which just launched SPARSH, an adolescent health education initiative hhh. Pilot this initiative at some of the schools iii. Replicate and disseminate Time line: 6 months Measure of Success: Increased awareness in adolescent health, increased awareness among children on life skills and personal health

23. Improve disaster management to minimize public health outbreaks

Action Steps: jjj. Work closely with the disaster management cell and the NGO Council to start to address some of the issues related to disaster management kkk. Educate the city through the LACGs on the importance of preparedness lll. Ensure the release of it before onset of monsoon season Time line: 4 months Measure of Success: Increased confidence in the public health system, increased preparedness for individuals and families

24. Improve water supply and sanitation at all slums to decrease the amount of diseases in the area. To be further developed.

G. Priorities in Health 25. Create a department that addresses issues of respiratory health in Mumbai, this should also be a division of the school health department Action Steps: mmm. Conduct an in-depth analysis of the respiratory health of Mumbai nnn. Work with NGOs to create greater awareness ooo. Create a cell within the school department so children can be screened for respiratory issues

20 ppp. Further follow up will be needed by the public health and the school department Time line: 6 months Measure of Success: Increased awareness of respiratory health, greater initiatives to address them

26. Utilizing the existing DOTS program, increase the priorities of TB management Action Steps: qqq. Given the numbers of cases and deaths reported in the Mumbai health profile, it is critical that there be more initiatives to address TB in Mumbai rrr.Create a commission to address why there are still so many cases despite the presence of DOTs sss.Ensure that people suffering from TB are not building up a resistance to the medication. ttt. If that is the case, there needs to be further concentration of a public health strategy in this area Time line: 1 year Measure of Success: Decreased deaths and cases reported due to TB in Mumbai

27. Implement more programs focused on decreasing IMR and MMR (these should be focused on nutrition, education, and health of the mother as well as the child) Action Steps: uuu. Work with NGOs like SNEHA and CCDT to look at how they are improving systems to support better Reproductive and Child Health vvv. Utilize the benefits of the new RCH II policy that was released as an impetus for improving the health services provided to women and children Time line: 6 months, ongoing Measure of Success: Decreased IMR and MMR (at least by 30-40%)

28. Create a city-wide campaign regarding Malaria awareness to be promoted during and before Malaria months Action Steps: www. Given the fact that Malaria is a major problem in climates like those of Mumbai, it is critical that the Public Health Department address this issue

21 xxx. Teach the public about increasing awareness about the dangers of malaria and how to prevent it yyy. Provide citizens with information through the LACG meetings zzz.Information should be circulated in all newspapers aaaa. NGOs and the MCGM can collaborate on this campaign Time line: Ongoing Measure of Success: Decreased cases and deaths by Malaria

29. Ensure that all vitamins and supplements are available to NGOs distributing them to children through various programs

Action Steps: bbbb. Every month the MCGM should conduct an inventory of the stock cccc. NGOs should submit requests for vitamins 2 months in advance dddd. Stock should always be ensured and monitored Time line: 3 months Measure of Success: Increased availability of critical nutrients necessary for the development of children

II. Executive Summary

Introduction This report started as a discussion between the members of the NGO Council and the MCGM after it was found that there was no existing public health policy document on accessing health care in

Mumbai. The NGO Council is a representing body of NGOs in Mumbai seeking to collaborate with local authorities on issues of priority. The NGO council was formed on August 22, 2005. The

Council is comprised over 70 organizations with complementary expertise covering all causes and sectors. The primary objectives of the NGO council is to work with Government, Donors, NGOs, and other third-parties to raise awareness and convene to address the important issues effecting the city of Mumbai.4 On 12/12/2005, Municipal Corporation of Greater Mumbai (MCGM) has entered into an MOU with the NGO Council, recognizing that an institutionalized partnership between

4 www.karmayog.org, See website for MOU 22 municipal bodies and non-governmental organizations (NGOs) / civil society organizations

(CSOs) is critical for promoting Good City Governance. 5

The relationship between the NGO Council and MCGM has been utilized in various Solid Waste

& Local Area Citizen Group initiatives. This report was initiated to maximize the output of the public health system. This report is an in-depth policy analysis into Central and Municipal policies pertaining to health via an analysis of existing programs, successes, challenges, personal interviews, conclusions, and recommendations. The purpose of the report is to highlight what is working and offer suggestions for where improvements can be made. This report serves as an initial policy document necessary to begin conversations on trends in public health in Mumbai. As

India becomes a major player in the global economy, it is critical that local governments understand the global repercussions of a weak health system in light of a strong economy. Since

Mumbai already has an existing infrastructure to catalyze these efforts, it is in this spirit that we propose that the MCGM and NGO Council work together to address the issues in health in

Mumbai.

2. National Policies in Health Care in India

National Health Policy 1982

The first national health care policy was written in 1982 by the Central Government. This policy was created to set a primary objective of Health Care for All by 2000. The establishment of efficient and effective primary health care systems, especially for the vulnerable: the underprivileged, women, and children were critical elements of achieving health care for all by

2000. The GOI had set an ambitious agenda for improvement of health of the Indian citizen. An integrated network of evenly spread specialty and super-specialty services was specified in the draft. Since implementation of NHP-1983, the national health program was able to achieve some successes in health care. Smallpox and Guinea Worm Disease have been eradicated from the

5 http://www.karmayog.org/bmcngocouncil/bmcngocouncil.htm 23 country; Polio is on the verge of being eradicated; Leprosy, Kala Azar, and Filariasis can be expected to be eliminated in the foreseeable future. There has been substantial drop in the Total

Fertility Rate and Infant Mortality Rate. The life expectancy has gone from 36.7 to 64.6 in 50 years. The Infant Mortality Rate (IMR) has been cut in half since 1951.

Fifty years later, the achievements of this policy only represent a fraction of the need that exists in

India. Ironically, with a hike in user charges, proposals of privatization of government hospitals, and increasing healthcare costs, the year 2000 represented a dynamic turn in the intended goals of

NHP-1983.6 The burden of cost of care subsequently has shifted from being the responsibility of the government to becoming a burden on the patient seeking care. A retrospective analysis of the

NHP-1983 alludes to the fact that the policy may have been over ambitious considering the infrastructure that existed at that time.

National Health Policy 2002

The next National Health Policy was written in 2002, when public health investment was at an all time low, 1.3% of the GDP in 1990 to .9% of the GDP in 1999 (GOI, 2002). The aggregate expenditure in the Health sector is 5.2 percent of the GDP. Out of this, about 17 percent of the aggregate expenditure is public health spending, the balance being what ends up being out-of- pocket expenses.7 The central budgetary allocation for health over this period, as a percentage of the total Central Budget, has been stagnant at 1.3 percent, while that in the States has declined from 7.0 percent to 5.5 percent.

NHP 2002 expounds that country wide, less than 20% of the population which seeks OPD services, and less than 45% of those that seek indoor treatment, avail services such as public hospitals. This low incidence of seeking OPD (Out-Patient Dispensary) treatment is due to unsatisfactory factors like time, workday loss, lack of faith in medication as also the outside

6 Health Care for All Who Can Afford It, The Lawyers Collective, Mumbai 2000. 7 National Health Policy, Government of India, 2002. 24 medical prescriptions The NHP 2002 firstly stresses the aspect of vertical programming in current public health services provided by the government; keeping in mind that horizontal programming

(health programming that works within several sectors to accomplish similar goals) would be more cost effective for the kind of health needs of the population on India. Secondly, there is an imperative need to upgrade the national and statewide Disease Surveillance Network.

Overall, the NHP-2002 document envisions the existence of an organized primary health care structure. Since the physical features and needs of urban settings are different from rural areas, there is a need to set a different set of measurable criteria for urban health care. In addition to improved ambulatory and emergency care, in urban settings, the NHP-2002 emphasizes a 2 tiered healthcare system:

 Primary Health Care: 1st Tier; serve a population of 1 lakh, dispensary for OPD and

essential medications

 Secondary Health Care: 2nd Tier; a government hospital, where a referral is made from the

primary health centre8

Although the NHP-2002 document is quite thorough, it covers just basic objectives in urban health care for the poor, which are the upcoming communities that will need the attention of the government. The aforementioned objectives are part of the mandate for improved services in public health services in an urban setting.

National Population Policy

The National Population Policy (NPP), drafted in 2000, also includes the critical aspect of urban health care and its effect on population policy. The NPP 2000 affirms the commitment of government towards voluntary and informed choice and consent of citizens while utilizing reproductive health care services, and continuation of the target free approach in administering family planning services.9

8 National Health Policy, Government of India, 2002. 9 National Population Policy, Government of India, 2000. 25 The NPP 2000 provides a policy framework for advancing goals and prioritizing strategies during the next decade, to meet the reproductive and child health needs of the people of India, and to achieve net replacement levels (or Total Fertility Rates) by 2010. It is based upon the need to simultaneously address issues of child survival, maternal health, and contraception, while increasing outreach and coverage of a comprehensive package of reproductive and child heath services by government, industry and the voluntary non-government sector, by working in partnership.10 The NPP document emphasizes the importance of connecting population policy to health care systems “it is as much a function of making reproductive health care accessible and affordable for all, as of increasing the provision and outreach of primary and secondary education, extending basic amenities including sanitation, safe drinking water and housing, besides empowering women and enhancing their employment opportunities, and providing transport and communications.11

Report of National Commission on Macroeconomics and Health

The Ministry of Health and Family Welfare, a division of the Government of India, submitted this report in 2005 with the intention of taking an informative look at the health of the nation. The terms of reference of the National Commission on Macroeconomics & Health (NCMH), included among others, a critical appraisal of the present health system — both in the public and the private sector — and suggesting ways and means of further strengthening it with the specific objective of improving access to a minimum set of essential health interventions to all. It was also intended that the Commission would look into the issue of improving the efficiency of the delivery system and encouraging public-private partnerships in providing comprehensive health care.12 According to the NCMH report, the public health system in India is currently overwhelmed by the co-existence of communicable and infectious diseases, alongside an epidemic of non-communicable diseases

(Cardiovascular diseases, cancer, diabetes, etc). Even with existing interventions, communicable

10 National Population Policy, Government of India, 2000. 11 National Population Policy, Government of India, 2000. 12 Report of the National Commission on Macroeconomics and Health, Ministry of Health and Family Welfare, 2005. 26 diseases are expected to decline, but there are further risks with the emergence of new infections and non-communicable diseases that will need to be addressed as well.

As the report is focuses on the macro-economic perspective of health, the NCMH postulates the three major drivers of health care costs as13:

1. Human Infrastructure: Cost of staffing the health needs of the country

2. Drug Regime: Cost of drugs is an issue

3. Technology Used: Advancing health care to suit the countries needs through

the use of technology

World Health Organization Country Profile

The World Health Organization Country Profile gives an overview of the health of the country.

The World Health Organization has also analyzed the health of India. According to a report on

India by the World Health Organization (WHO) there are approximately 501,900 doctors in the country, which equals 5.2 docs per 10,000. This is important as these doctors not only look after a large population in urban pockets and many are even employed by many private hospitals. The number of nurses/midwives are about 607, 376.14 Other problems in health resources include a shortage of funds and government medical training and there are many vacancies in lab techs, radiologists, for diseases like malaria and tuberculosis.

Overall, the health policies of India seem to overlap in areas such as access to health, nutritional deficiencies, lack of resources, high rates of infant and maternal mortality, lack of primary health care services, lack of expenditure as per the state governments, and the presence of communicable, non-communicable, and infectious diseases all at the same time. However, through the NHP-2002,

NPP-2002, the NCMH report, and the country health profile of the WHO collaboratively offer various solutions to the aforementioned challenges in country-wide health care. While it is clear that there have been initiatives to address health in India, it has primarily been from a rural

13 Report of the National Commission on Macroeconomics and Health, Ministry of Health and Family Welfare, 2005. 14 India Country Health Profile, World Health Organization, 2001. 27 perspective. A closer look at the changing population intimates us that the urban poor are the ones suffering from a new illness: access to health care.

3. Urban Poor and Health

Although the focus of many of the Central government initiatives for health have been focused on the rural sector, it is critical to now start exploring the gaps in urban health care. Rapid and unplanned urbanization is a marked feature of Indian demography during the last 40-50 years.

According to the 2001 census, India’s urban population currently accounts for almost 30% of the population (approximately 285 million). This represents a 100 times increase in the past century and nearly 40% increase during the last decade. The population and the amount of urban poor are rapidly increasing and contributing to a significant strain on resources. The unabated growth of the urban poor is leading to what is currently being called the “2-3-4-5 Phenomenon of Population

Growth”, which states that the Urban Population is India is currently at 285 million15, urban poor are estimated at 7016-9017 million, and the estimated annual births among the urban poor are 2 million.18

The health conditions of the urban poor are similar to or worse than the rural population and far worse than urban averages. High infant and maternal mortality, malnutrition, lack of access to services, sub-optimal health behaviors, and inadequate public sector reproductive and child health services. The Environmental Health Project (EHP), a project of USAID has re-analyzed the

(NFHS) National Family Health Survey (1998-1999) in 2003 and found that the health of the urban poor has been under-estimated up to this point. The tables below have been adapted from the

EHP website. A closer comparison between the problems of the rural population versus the urban poor gives greater insight into the upcoming challenges in urban health. As the country shifts to

15 2001 Census of India 16 Public Private Partnerships for Improving the Health of the Urban Poor, Dr. Siddharth Agarwal, 2005. 17 Public Private Partnerships for Improving the Health of the Urban Poor, Dr. Siddharth Agarwal, 2005. 18 Laveesh Bhandhari and Shruthi Shesth, Health of the Poor and the subgroups in Urban Areas, June 2003. 28 the urban areas, evidence demonstrates the need for more of a focus on improving (access to) urban health care.

Urban health care in Mumbai

In Mumbai, a city of approximately 1819 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).20

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.

19 MCGM Health Profile, 2004 says the population is 12.6 million. Wikipedia.com quotes the population at 18 million and growing. 20 Health Services in Mumbai, The Bombay Community Public Trust, 2004. 29 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. 21

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.

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

21 Mumbai’s Invisible People, The Hindu, November 2005 30 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.22

MCGM Facilities and Programs

In addition to the hospitals run by the MCGM there are secondary hospitals, maternity homes, health posts, and dispensaries that are under their jurisdiction. 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.

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. These dispensaries and health posts often 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.

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,

22 Health Services in Mumbai, The Bombay Community Public Trust, 2004. 31 the controversial practice of charging fees for reproductive and child health has led to an apathetic view of maternity homes.

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 various programs include:

1.) Leprosy Program: An initiative to address and contain Leprosy in Mumbai

2.) Tuberculosis Program: To address, treat, educate and eradicate TB

3.) Universal Immunization Program: An initiative to provide children and families in

Mumbai with proper immunizations

4.) Polio Eradication Program: To immunize, treat, and eradicate Polio

5.) National Malaria Control Program: To address and treat Malaria

6.) Mumbai District AIDS Control Society: Educate, disseminate information, provide

counseling and treatment, blood safety, monitoring and evaluation

7.) School Health Program: The SHP aims to provide in school health care for children

attending the schools run by the MCGM

Successes

Managing such a complex system of health infrastructure has yielded successful initiatives. The

School Health Program and Polio Eradication Programs are 2 of them. The main reasons for 32 success can be communicated through de-centralization of management, networking with families, creating community understanding around a certain illness and strong leadership. Among these few successes, there are many areas that need to be improved throughout the MCGM public health system.

Challenges

All of the aforementioned programs are run in synergy through the jurisdiction of the Public

Health Department. Many of the reasons the public chooses not to access the care is:

1.) The MCGM Health Budget: The budget of the MCGM Health Department (over Rs. 800

Crores) lacks equity in terms of distribution of resources to the secondary and primary

levels of care

2.) Primary health care services are weak in resources and manpower, this leads the general

public to seek healthcare at the tertiary level of care

3.) Secondary Hospitals and Maternity Care are also not well-equipped and suffer from

centralized decision making systems that prevent administration for taking decisions

4.) Tertiary Hospitals are on the receiving end of the high monetary assistance and have to

bear the burden of overcrowding and higher expectations of patients due to the weakness in

the secondary and primary care systems

5.) Inconvenient timings, locations, and a high amount of vacancies have lead to a great degree

of dissatisfaction with the MCGM run services

6.) Lack of emphasis on quality assurance results in apathy from staff as well as patients

7.) Lack of referral systems also lead to a misunderstanding of which services are offered

where and create too much of a free market system for patients that results in overcrowding

at the tertiary level

8.) Reporting and data collection, as evident from the Mumbai health profiles needs to be

improved and expanded with up to date data as well as accurate descriptions of rationale

33 9.) Competition from the private sector (practitioners and hospitals) also poses a considerable

barrier for underprivileged folks to access the public health system

10.) Lack of public health disaster systems as well as adequate water sanitation and supply

also contribute to problems in access to health care

Overall, the report looks at various successes and challenges of the MCGM public health system.

Through there are many challenges, the good news is that Mumbai has an existing infrastructure that can contribute to the improvement of how people in the city access the public health care system. This report gives various recommendations in terms of:

 Education and Information Dissemination

 Reproductive and Child Health

 Medical and Administrative Personnel

 Infrastructure

 Systems

 Coordinating with other MCGM departments

 Priorities in Health

The primary step that will be taken will be the initiation of a Bill of Rights for Patients as well as a

Code of Conduct to help education and inform people accessing ALL health care in Mumbai as to what their rights are and what the expectation is of their behavior.

This report serves as an initial document to signify the NGO Council’s and the MCGM’s commitment to the health care of the people of Mumbai. This document can be utilized by practioners, administration teams, doctors, nurses, medical students, NGOs and more. An in-depth analysis of the MCGM’s health care system can give all those involved in the field some insight into the inner workings of Mumbai’s premier public health system in addition to citing specific

34 areas for improvements. A healthier community can contribute to the overall wealth of Mumbai, making it healthy, wealthy, and wise.

Accessing Healthcare in Mumbai

Conclusions and Summary

In the last 20 years, there have been few initiatives proposed to improve health for the citizens of

India. When looking at the policies and initiatives proposed by the Central Government, there is a clear emphasis on improving rural health. However, with the urban poor population rising, the health needs of the urban poor communities are beginning to exceed those in the rural communities. The health care crisis of the growing urban poor, especially in Mumbai, represents a new challenge in providing health care to the masses. The health care of the urban poor is often worse than or equal to that of the rural poor population. Over 50% of Mumbai’s population of 18 million23 lives in slums and are part of the growing urban poor. This population is plagued with uneven access to care, malnutrition, and poor maternal and child health. Therefore, it is critical to look at the health of Mumbai on a continuum of urban health.

The MCGM (Municipal Corporation of Greater Mumbai) provides medical services through three levels of care, primary, secondary and tertiary. This includes an intricate network of teaching hospitals, secondary hospitals, maternity homes, health posts and dispensaries. Although the infrastructure is complex, there is a multitude of improvements needed to address the health needs of the urban poor population in Mumbai. The various challenges plaguing the MCGM health system are growing as rapidly as the population and need to be addressed urgently. The challenges include:

 Human Resources: A large amount of vacancies in the public health department of the

MCGM lead to the apathy of the staff and patients.

23 www.wikipedia.com/wiki/Mumbai 35  Infrastructural: Lack of equipment and services at the primary and secondary level of

care; lack of referral systems to direct patients to the appropriate care level; lack of quality

assurance

 Systems: Lack of a centralized data system, lack of awareness of existing programs within

the MCGM

 Ethical: Dilution of the value and faith in the public health system as a facility for all, not

just the indigent and underprivileged. This is a phenomenon that affects the patients as well

as the staff.

 Educational: Educational materials for prevention of disease and promotion of health are

under-utlilized or unavailable, patients do not understand the complexities of their own

health

With a confident team, collaborations, and an open attitude toward change, there are many options for the MCGM health system to become an accessible service for people seeking quality health care at an affordable price. A no-frills health care system that emphasizes good quality at the lowest possible cost to the consumer will not only benefit the poor, but also those taxpayers whose money is being invested in the government run health care system. Working with existing private providers and NGOs can be beneficial for the MCGM system in terms of decreasing the burden and using best practices of existing programs.

Utilizing best practices from cities with similar problems to Mumbai will provide some insight into innovations that could be implemented throughout the existing health systems. While the problems sometimes seem to vast to deal with, it is important to remember that an implementation strategy that works on a step-by-step approach will be the ideal method of slowly improving the system.

The MOU between the NGO Council and the MCGM is the critical agreement that should be kept in mind in the difficult stages of planning and implementation. This agreement is meant to bridge the gap between the government and the non profit organizations that provide many needed

36 services to the impoverished. Both have similar goals, it is now time to devise a better strategy through collaboration.

Recommendations- Brief

A. Education and Information Dissemination 30. Ensure that a Patient Bill of Rights (enclosed) and Patient Code of Conduct are posted in every public health care facility being operated by the MCGM 31. Create a map of Mumbai (in Hindi, Marathi, English, etc) with locations, timings, and services of each healthy care facility. 32. Improve primary and secondary health care systems by providing training for quality assurance at all facilities. 33. Ensure that educational materials on ALL illnesses and ailments are available in multiple languages at respective primary and secondary health care levels via posters, pamphlets, and CHVs.

B. Reproductive and Child Health 34. Increase awareness about institutional deliveries by collaborating with local women’s groups. 35. Develop IEC materials relevant to reproductive and child health as well as other relevant diseases by working with NGOs 36. Ensure all maternal, reproductive and child health services are free of cost. 37. Ensure that all municipal facilities are always stocked with medications for pre-natal care (iron, folic acid etc.)

37 C. Medical and Administrative Personnel 38. Increase skills, salaries, and working hours of the Community Health Volunteers and have CHV’s collaborate with health workers from NGOs 39. Discontinue the practice of allowing doctors to have private practices while employed by the MCGM. 40. De-centralize the management of the primary and secondary health care services

D. Infrastructure 41. Hire staff to fill vacancies of doctors at the primary health care level (Health Posts and Dispensaries) to improve the quality of care 42. Conduct a needs assessment of the infrastructural (both equipment, human resources) gaps in the MCGM public health system via a survey and analysis to apply appropriate solutions. 43. Decrease the gaps in infrastructure (staff, equipment, and training) at the primary and secondary levels of health care 44. Create a referral system so that people can access the medical services at the appropriate lowest level. 45. Utilize the referral system to minimize costs, patient load, and provide better quality treatment for serious cases. 46. Create management information systems to store and utilize data, statistics, and health records appropriately. 47. Create systems for MCGM circulars to be accessible to all 48. Revamp the ambulatory system completely to provide emergency care as well as transport. 49. De-centralize the laboratory system. Ensure all peripheral hospitals have functional labs.

E. Systems 50. Create a patient feedback system to improve policies, procedures, and services for patients and for MCGM staff. 51. Create a Public Health Monitoring Department that meets once in 2 months to plan for upcoming public health issues (i.e. bird flu, leptospirosis).

F. Coordinating with other MGCM Departments 52. Introduce adolescent health education through the municipal school system. 53. Increase citizen participation through a public health citizen committee in collaboration with the MCGM public health department.

38 54. Improve disaster management to minimize public health outbreaks 55. Improve water supply and sanitation at all slums, this will decrease the amount of diseases in the area.

G. Priorities in Health 56. Create a department that addresses issues of respiratory health in Mumbai, this should also be a division of the school health department 57. Utilizing the existing DOTS program, increase the priorities of TB management 58. Implement more programs focused on decreasing IMR and MMR (these should be focused on nutrition, education, and health of the mother as well as the child) 59. Create a city-wide campaign regarding Malaria awareness to be promoted during and before Malaria months 60. Ensure that all vitamins and supplements are available to NGOs distributing them to children through various programs

39 1. Introduction and Background

Through an initiative between the Municipal Corporation of Greater Mumbai (MCGM) and the

NGO council in Mumbai, health was identified as a major priority. This policy report was written in order to have a better perspective on health in Mumbai. The NGO Council is a representing body of NGOs in Mumbai seeking to collaborate with local authorities on issues of priority. The

NGO council was formed on August 22, 2005. The Council is comprised over 70 organizations with complementary expertise covering all causes and sectors. The primary objectives of the NGO council is to work with Government, Donors, NGOs, and other third-parties to raise awareness and convene to address the important issues effecting the city of Mumbai.24 On 12/12/2005, Municipal

Corporation of Greater Mumbai (MCGM) has entered into an MOU with the NGO Council, recognizing that an institutionalized partnership between municipal bodies and non-governmental organizations (NGOs) / civil society organizations (CSOs) is critical for promoting Good City

Governance. 25

The MCGM was formed in 1873 as Mumbai’s civic body. Through the multifarious civic and recreational services that it provides, the MCGM has always been committed to improve the quality of life in Mumbai.26 It was under this spirit that the MCGM and part of their team took the initiative to come into an agreement of partnership with the NGO Council. The MCGM has signed a Memorandum of Understanding with the NGO Council to begin to discuss the critical issues, one of the major ones being health.

The general responsibilities in Public Health for the MCGM are specified on the website:

Public Health and Medical Relief Services27

24 www.karmayog.org, See website for MOU 25 http://www.karmayog.org/bmcngocouncil/bmcngocouncil.htm 26 http://www.mcgm.gov.in/forms/grindex1.aspx 27 http://www.mcgm.gov.in 40 The following functions are performed by the staff in the wards under the supervision and guidance of the Executive Health Officer, the Deputy Executive Health Officer, 4 Zonal Assistant

Health Officers and the Epidemiologist.

1. Prevention and control over communicable diseases.

2. Maintenance of vital statistics regarding births, deaths and occurrence of diseases.

3. Maternity and child welfare services.

4. Medical relief through dispensaries including mobile dispensaries.

5. Regulation of the places for the disposal of the dead.

6. Prevention of adulteration and misbranding of articles of good.

7. Licensing and controlling trades dealing in food and coming under the purview of sections 394 and 412A of the Bombay Municipal Corporation Act

8. Licensing and controlling trades (Other than food establishments)

9. Controlling places of public amusement from public health point of view, namely, cinema houses, drama theatres, etc.

10. Registration and inspection of Nursing Homes.

11. Licensing of Nurses Establishments.

12. Expansion programme of public health and medical relief services.

13. Other miscellaneous functions

41 For the efficient discharge of these functions, Greater Bombay has been divided into Wards which, have been grouped into six zones. Each zone is in charge of each of four Assistant Health Officers.

The table below is an organogram of the current hierarchy at the MGCM Public Health

Department.

Table 1.1 Organogram for the MCGM Public Health Department

For the purpose brevity and focus of this report, we have chosen to focus on very specific aspects of health care and delivery systems. This includes primary health centers, peripheral hospitals, maternity homes, health posts, dispensaries; communicable, non-communicable and infectious diseases; health and hygiene, sanitation, access to water, and environmental health. This report will exclude registrations of births and deaths, stray cattle, disposal of the dead, and such issues such as licensing. While all issues are important, this report will only cover the aforementioned issues as they are directly linked with access to public health care facilities.

42 2. National Policies in Health Care in India

This section will identify the various policies that have come in surrounding health care initiatives

in India. It is important to look at the national initiatives before we focus on Mumbai, because

these policies can provide the MCGM and the NGO Council with some insight on national health

policy standards and how good governance can help the city move forward to adherence.

2.1 National Health Policy

The Government of India (GOI) first drafted a National Health Policy in 1983 (NHP-1983). This

policy was created to set a primary objective of Health Care for All by 2000. The establishment of

efficient and effective primary health care systems, especially for the vulnerable: the

underprivileged, women, and children were critical elements of achieving health care for all by

2000. The GOI had set an ambitious agenda for improvement of health of the Indian citizen.

An integrated network of evenly spread specialty and super-specialty services was specified in the

draft. Since implementation of NHP-1983, the national health program was able to achieve some

successes in health care. Smallpox and Guinea Worm Disease have been eradicated from the

country; Polio is on the verge of being eradicated; Leprosy, Kala Azar, and Filariasis can be

expected to be eliminated in the foreseeable future. There has been substantial drop in the Total

Fertility Rate and Infant Mortality Rate. The life expectancy has gone from 36.7 to 64.6 in 50

years. The Infant Mortality Rate (IMR) has been cut in half since 1951. The success of the

initiatives taken in the public health field are reflected in the progressive improvement of many

demographic / epidemiological / infrastructural indicators over time – (Table 2.1).28

Table 2.1 : Achievements Through The Years - 1951-2000 29

Indicator 1951 1981 2000

Demographic Changes

Life Expectancy 36.7 54 64.6

Crude Birth Rate 40 33 26

28 National Health Policy, Government of India, 2002. 29 National Health Policy, Government of India, 2002. 43 Crude Death Rate 25 12 8

IMR 146 110 70

Epidemiological Shifts

Malaria (cases in million) 75 2 2

Leprosy cases per 10,000 38 57 4 population

Small Pox (no of cases) >44,887 Eradicated

Guineaworm ( no. of cases) >39,792 Eradicated

Polio 29709 265

Infrastructure

SC/PHC/CHC 725 57,363 1,63,181

Dispensaries &Hospitals( all) 9209 23,555 43,322

Beds (Pvt & Public) 117,198 569,495 8,70,161

Doctors(Allopathy) 61,800 2,68,700 5,03,900

Nursing Personnel 18,054 1,43,887 7,37,000

The table above highlights the progression of health infrastructure, demographics, and epidemiology through 50 years.

These achievements only represent a fraction of the need that exists in India. Ironically, with a hike

in user charges, proposals of privatization of government hospitals, and increasing healthcare

costs, the year 2000 represented a dynamic turn in the intended goals of NHP-1983.30 The burden

of cost of care subsequently has shifted from being the responsibility of the government to

becoming a burden on the patient seeking care. A retrospective analysis of the NHP-1983 alludes

to the fact that the policy may have been over ambitious considering the infrastructure that existed

at that time.

30 Health Care for All Who Can Afford It, The Lawyers Collective, Mumbai 2000. 44 The next National Health Policy was written in 2002, when public health investment was at an all time low, 1.3% of the GDP in 1990 to .9% of the GDP in 1999 (GOI, 2002). The aggregate expenditure in the Health sector is 5.2 percent of the GDP. Out of this, about 17 percent of the aggregate expenditure is public health spending, the balance being what ends up being out-of- pocket expenses.31 The central budgetary allocation for health over this period, as a percentage of the total Central Budget, has been stagnant at 1.3 percent, while that in the States has declined from 7.0 percent to 5.5 percent. The current annual per capita public health expenditure in the country is no more than Rs. 200.32

Table 2.2: Public Health Spending in select Countries 33

%Population %Health %Public with income Expenditure Expenditure on of <$1 day to GDP Health to Total Health Expenditure

India 44% 5% 17%

China 19% 3% 24%

Sri Lanka 7% 3% 45%

UK - 6% 97%

USA - 14% 44% The table above demonstrates the public health spending in select countries. India, China, and America spend the least amount on their public health expenditure.

These statistics indicate why we are at quality level that does not deliver services at a desirable standard. Under the constitutional structure, public health is the responsibility of the States. The general expectation is that the State will give the principal contribution to public health care, with the supplemental support from the Central government.

31 National Health Policy, Government of India, 2002. 32 National Health Policy, Government of India, 2002. 33 National Health Policy, Government of India, 2002. 45 In this backdrop, the contribution of Central resources to the overall public health funding has been limited to about 15 percent. According to NHP 2002, the fiscal resources of the State Governments are known to be very inelastic. This is reflected in the declining percentage of State resources allocated to the health sector out of the State Budget. In order to significantly improve the decentralized public health system in the country, there needs to be more resource allocation from the Central Government budget. If the State public health services, which are a major component of the initiatives in the social sector are not supplemented with additional support, the changes in

National Health Care will be slow and lack universal access at best. The NHP-2002 has been formulated taking into consideration these ground realities in regard to the availability of resources.34

NHP 2002 expounds that country wide, less than 20% of the population which seeks OPD services, and less than 45% of those that seek indoor treatment, avail services such as public hospitals. This low incidence of seeking OPD treatment is due to unsatisfactory factors like time, workday loss, lack of faith in medication as also the outside medical prescriptions The NHP 2002 firstly stresses the aspect of vertical programming in current public health services provided by the government; keeping in mind that horizontal programming (health programming that works within several sectors to accomplish similar goals) would be more cost effective for the kind of health needs of the population on India.

Secondly, there is an imperative need to upgrade the national and statewide Disease Surveillance

Network. Without accurate disease surveillance and monitoring, the public health system will not be able to ascertain the accomplishments and challenges of current and past initiatives. Thirdly, there is a greater need to have more specialists in public health and family medicine, with an emphasis on public health nursing and access to medication.

34 National Health Policy, Government of India, 2002. 46 Overall, the NHP-2002 document envisions the existence of an organized primary health care structure. Since the physical features and needs of urban settings are different from rural areas, there is a need to set a different set of measurable criteria for urban health care. In addition to improved ambulatory and emergency care, in urban settings, the NHP-2002 emphasizes a 2 tiered healthcare system:

 Primary Health Care: 1st Tier; serve a population of 1 lakh, dispensary for OPD and

essential medications

 Secondary Health Care: 2nd Tier; a government hospital, where a referral is made from the

primary health centre35

Although the NHP-2002 document is quite thorough, it covers just basic objectives in urban health care for the poor, which are the upcoming communities that will need the attention of the government. The aforementioned objectives are part of the mandate for improved services in public health services in an urban setting.

2.2 National Population Policy

The National Population Policy (NPP), drafted in 2000 also includes the critical aspect of urban health care and its effect on population policy. The NPP 2000 affirms the commitment of government towards voluntary and informed choice and consent of citizens while utilizing reproductive health care services, and continuation of the target free approach in administering family planning services.36

The NPP 2000 provides a policy framework for advancing goals and prioritizing strategies during the next decade, to meet the reproductive and child health needs of the people of India, and to achieve net replacement levels (or Total Fertility Rates) by 2010. It is based upon the need to

35 National Health Policy, Government of India, 2002. 36 National Population Policy, Government of India, 2000. 47 simultaneously address issues of child survival, maternal health, and contraception, while increasing outreach and coverage of a comprehensive package of reproductive and child heath services by government, industry and the voluntary non-government sector, by working in partnership.37 The NPP document emphasizes the importance of connecting population policy to health care systems “it is as much a function of making reproductive health care accessible and affordable for all, as of increasing the provision and outreach of primary and secondary education, extending basic amenities including sanitation, safe drinking water and housing, besides empowering women and enhancing their employment opportunities, and providing transport and communications.38

The health related goals of the NPP are defined in a socio-demographic context and include critical aspects of urban health care:

1. Address the unmet needs for basic reproductive and child health services through supplies

and infrastructure

2. Make school education compulsory until age 14

3. Reduce IMR to 30/1000

4. Reduce MMR to 100/100,000

5. Achieve universal immunization

6. Promote delayed marriage age

7. 100% birth, death, and marriage registration

8. Attain 80% institutional deliveries, 100% by trained persons

9. Universal access to information and counseling regarding reproductive health

10. Contain AIDS

11. Prevent and control communicable diseases

12. Integrate systems in medical education and care

13. Establish family norms

37 National Population Policy, Government of India, 2000. 38 National Population Policy, Government of India, 2000. 48 14. Social sector and family welfare should be merged

15. Promotion of family norms

The NPP seems to critically look at population policy and health as an integrated system that needs to be improved in synergy. Social and health problems contribute to the high population rates which will effects health care systems adversely. These goals also have some degree of overlap with the goals of NHP-2002.

The NPP has also has set forth some recommendations for improvements in urban health:

1.) Finalize a comprehensive urban health strategy

2.) Facilitate service delivery centers in urban health slums to provide comprehensive

basic health, reproductive and child health services utilizing relationships with

NGOs, private sector organizations, and corporate houses

3.) Promote networks of retired doctors and para/non-medical personnel who may

serve as providers for clinical and non-clinical services for remuneration

4.) Strengthen social marketing programs for non clinical family planning products and

services in urban slums

5.) Specially targeted information, education, and community campaigns for urban

slums on family planning, immunization, ANC etc, and other reproductive health

services

6.) Aggressive integration of health education programs with medical and health

programs in environmental health, personal hygiene, nutrition education, and

population education

7.) Promote inter-sectoral coordination between departments and municipal bodies

dealing with water and sanitation, industry, housing, transport, education and

nutrition

49 8.) Streamline referral systems and linkages between primary and secondary levels of

care in the urban arena

9.) Link provision of continued facilities to urban slum dwellers in compliance with the

small family norm.

These recommendations fall under the purview of the central and state governments, with both parties taking some type of responsibility for continued access to health care for the urban poor.

2.3 Report of National Commission on Macroeconomics and Health

The Ministry of Health and Family Welfare, a division of the Government of India, submitted this report in 2005 with the intention of taking an informative look at the health of the nation. The terms of reference of the National Commission on Macroeconomics & Health (NCMH), included among others, a critical appraisal of the present health system — both in the public and the private sector — and suggesting ways and means of further strengthening it with the specific objective of improving access to a minimum set of essential health interventions to all. It was also intended that the Commission would look into the issue of improving the efficiency of the delivery system and encouraging public-private partnerships in providing comprehensive health care.39 According to the NCMH report, the public health system in India is currently overwhelmed by the co-existence of communicable and infectious diseases, alongside an epidemic of non-communicable diseases

(Cardiovascular diseases, cancer, diabetes, etc). Even with existing interventions, communicable diseases are expected to decline, but there are further risks with the emergence of new infections and non-communicable diseases that will need to be addressed as well.

The NCMH report estimates (based on current data) that by 2015, the number of AIDS cases will be approximately three times the current level and will be roughly equal to the cases of tuberculosis (85 lakhs).40 Additionally, cardiovascular diseases, diabetes, and cancers will increase

39 Report of the National Commission on Macroeconomics and Health, Ministry of Health and Family Welfare, 2005. 40 Report of the National Commission on Macroeconomics and Health, Ministry of Health and Family Welfare, 2005. 50 by 25% and mental health issues will affect 6.5% of the population.41 According to the NCMH report, prevention is the key solution for countries like India that suffer from a lack of resources.

For example:

 Integrated approaches for vector control through de-centralized systems are known to

reduce water-borne diseases.

 Access to clean water reduces cases of gastroenteritis and diarrhea

 Immunizations reduces onset of diseases caused by lack of immunization

 Vitamin supplementation prevents certain illnesses such as blindness

As the report is focuses on the macro-economic perspective of health, the NCMH postulates the three major drivers of health care costs as42:

1. Human Infrastructure: Cost of staffing the health needs of the country

. There is currently not enough engagement of Community Health Volunteers

. Specialists such as pharmacists, paramedics, and lab technicians are largely

unavailable

. The reproductive health sector (Nurses, midwives) is underdeveloped and is

not able to meet the demand

2. Drug Regime: Cost of drugs is an issue

. Drugs need to come under price control

. The industry is largely un-regulated in India

. There are no patent laws to protect the consumer and innovator

3. Technology Used: Advancing health care to suit the countries needs through

the use of technology

41 Ibid. 42 Report of the National Commission on Macroeconomics and Health, Ministry of Health and Family Welfare, 2005.

51 . Technological advances in health should be included as part of the budget

. Use of modern technology can greatly influence how illnesses are treated in

The NCMH report discusses the challenges and successes of the state of health care in India, and cites the following failures in the national health policy:

 Weak management: Key factors include centralized decision-

making, problems in project management, low budgets, large scale absenteeism,

absence of performance based monitoring, and conflicting job roles.

 Poor governance and role of state: There is very little

accountability at the state level and this leads to lack of good governance.

 Lack of strategic mission: There is very little information out there

that sets goals for where the state of national health care should be.

 Vertical programming: The preponderance of vertical programming

is an enormous waste of resources and time.

All these aspects of health in India contribute to the lack of access to health care for the citizens of the country. However, the NCMH report also suggests a way forward, to improve health care access in India. The various methods they suggest in the report include:

1.) Promoting equity for access by reducing household expenditure on health by

experimenting with different types of funding (health insurance, public-private

partnerships etc).

2.) Restructuring the primary health care program to make it more accountable

3.) Reduce disease burden and level of risk

4.) Establish institutional framework for improved quality

5.) Invest in technology and human resources

The guiding principles should be based on accountability, responsibility, accessibility, adaptability, courtesy and participation. 52 2.4 World Health Organization Country Profile

The World Health Organization has also analyzed the health of India. According to a report on

India by the World Health Organization (WHO) there are approximately 501,900 doctors in the country, which equals 5.2 docs per 10,000. This obviously does not include a large number of doctors qualified in othe systems like Ayurveda, Homeopathy, Unani or Siddha. This is important as these doctors not only look after a large population in urban pockets and many are even employed by many private hospitals. The number of nurses/midwives are about 607, 376.43 Other problems in health resources include a shortage of funds and government medical training and there are many vacancies in lab techs, radiologists, for diseases like malaria and tuberculosis.

Further, the external analysis helps assess the major challenges in the health programming. While overall mortality has decreased, the report states, the living standards are amongst the poorest in the world. This is primarily due to:

o Lack of resources

o Lack of a integrated multi-sectoral approach

o Insufficient IEC material

o Poor involvement of the NGO sector (collaboration rather)

o Inadequate lab services

o Manually operated health management system

o Poor surveillance and poor response

o Dealing with non-communicable diseases

o Gender disparities:

2. Decline in female/male ratio:

 In 1999 and 2001, the ratio went from 927 to 923.

43 India Country Health Profile, World Health Organization, 2001. 53 3. Violence (domestic and social)

4. Nutritional deficiencies

 56 % children under 5 said to have Iron Deficiency

 Integrated Child Development Service is supposed to cover all but is

slated to reach 54 million pre-school children, pregnant and lactating

women through mid-day meal programs and emphasis on nutrition.

5. Stereotypes and discrimination

o Increase in lifestyle diseases for certain populations44

A critical issue that is not discussed often is Environmental Health:

. Emissions leading to greater degree of respiratory diseases

. Agricultural problems

. All these increase the risk of vector born diseases

. Significant environmental degradation leads to destruction of natural resources

Environmental health is largely not discussed due to the prevalence of non-communicable and infectious diseases in India. However, environmental health covers a broad range of issues such as unsafe drinking water; unhygienic sanitation and air pollution significantly contribute to the burden of disease, particularly in urban settings.45

In the same country profile, WHO asserts that in 1998, approximately 5.1% of the GDP was spent on health care. Overall public expenditure on health was 18% and the WHO assessment of the problem asserts a situation of getting the funds to the right places. The WHO Country Profile supports the information on national health policy as reported in this paper. The external analysis added value through its future vision for health care in India. The goal is to achieve optimal health for the people, which would allow them to lead socially and economically productive lives and be 44 India Country Health Profile, World Health Organization, 2001. 45 National Health Policy, Government of India, 2002. 54 in keeping with the principles of a Health for All Strategy. The health care system envisaged would have a public-private mix, with the latter encouraged to take a greater share of secondary and tertiary health care services.46

Overall, the health policies of India seem to overlap in areas such as access to health, nutritional deficiencies, lack of resources, high rates of infant and maternal mortality, lack of primary health care services, lack of expenditure as per the state governments, and the presence of communicable, non-communicable, and infectious diseases all at the same time. However, through the NHP-2002,

NPP-2002, the NCMH report, and the country health profile of the WHO collaboratively offer various solutions to the aforementioned challenges in country-wide health care. While it is clear that there have been initiatives to address health in India, it has primarily been from a rural perspective. A closer look at the changing population intimates us that the urban poor are the ones suffering from a new illness: access to health care.

46 India Country Health Profile, World Health Organization, 2001. 55 3. The Urban Poor and Health

Although the focus of many of the Central government initiatives for health have been focused on the rural sector, it is critical to now start exploring the gaps in urban health care. The next section discusses the future of the urban poor population and access to health care.

3.1 Urban Population growth

Rapid and unplanned urbanization is a marked feature of Indian demography during the last 40-50 years. According to the 2001 census, India’s urban population currently accounts for almost 30% of the population (approximately 285 million). This represents a 100 times increase in the past century and nearly 40% increase during the last decade. The population and the amount of urban poor are rapidly increasing and contributing to a significant strain on resources. The unabated growth of the urban poor is leading to what is currently being called the “2-3-4-5 Phenomenon of

Population Growth”, which states that the Urban Population is India is currently at 285 million47, urban poor are estimated at 7048-9049 million, and the estimated annual births among the urban poor are 2 million.50

3.2 Health Conditions

The health conditions of the urban poor are similar to or worse than the rural population and far worse than urban averages. High infant and maternal mortality, malnutrition, lack of access to services, sub-optimal health behaviors, and inadequate public sector reproductive and child health services. The Environmental Health Project (EHP), a project of USAID has re-analyzed the

(NFHS) National Family Health Survey (1998-1999) in 2003 and found that the health of the urban poor has been under-estimated up to this point. The tables below have been adapted from the

EHP website. A closer comparison between the problems of the rural population versus the urban poor gives greater insight into the upcoming challenges in urban health. As the country shifts to

47 2001 Census of India 48 Public Private Partnerships for Improving the Health of the Urban Poor, Dr. Siddharth Agarwal, 2005. 49 Public Private Partnerships for Improving the Health of the Urban Poor, Dr. Siddharth Agarwal, 2005. 50 Laveesh Bhandhari and Shruthi Shesth, Health of the Poor and the subgroups in Urban Areas, June 2003. 56 the urban areas, the evidence below demonstrates the need for more of a focus on improving

(access to) urban health care.

Table 3.1 MCH Health Conditions of the Urban Poor vs. Rural Population

Health Conditions of the Urban Poor vs Rural Population

120 103.7 101.3 100 73.3 80 63.1 66 Rural Average 60 47 46.7 Urban Average 31.739.1 40 Urban Poor 20 0 Under 5 Mortality Infant Mortality Neonatal Mortality Mortality per 1000 births R e - A n a l y s i s o f N F H S - 2 ( 1 9 9 8 - 9 9 ) b y E H P 2 0 0 3

This table shows that the urban poor have similar under 5, infant and neonatal mortality when compared to the rural population.

Table 3.2 Malnutrition in the Urban Poor vs. Rural Population

57 Rates of Malnutrition

60 56 49.6 50 38.4 40

0 Rural Average Urban Average Urban Poor **Weight for age <-2 SD R e - A n a l y s i s o f N F H S - 2 ( 1 9 9 8 - 9 9 ) b y E H P 2 0 0 3

This table shows that the urban poor have higher rates of malnutrition than the rural average population.

The tables above give a dismal picture into the healthcare of the urban poor. The high rates of under 5, infant, and neonatal mortality in the urban poor are rising to the level of the rural population.

58 Table 3.3 How the Urban Poor Access Health Services

Poor Access to Health Services

70 60.5 60 50 42.9 36.6 40 30 20 10 0 Rural Average Urban Average Urban Poor Complete Immunization by Age 12-23 Months R e - A n a l y s i s o f N F H S - 2 ( 1 9 9 8 - 9 9 ) b y E H P 2 0 0 3

This table shows that the urban poor access health services just about the same way the rural average do.

59 Table 3.4 Inadequate Public Sector Reproductive Child Health Services

Inadequate Public Sector RCH Services

5% 12%

Government Doctors Private Doctors Chemists Other

This pie chart shows that private doctors comprise about 82% of the healthcare in India.

Given the fact that government doctors are only 12% of the RCH services, it is clear that the increasing problems in urban health demonstrate the need for further study and training of issues in urban health care.

As the urban population expands and health care needs of the urban poor increase, it is critical for the city and state governments to start focusing efforts on the health of the urban poor. Mumbai is a perfect example of the growing need for the right to basic health care for the urban poor population.

4. Mumbai, Maharashtra

Urbanization is one of the most significant processes found in developing countries today.

Maharashtra is one of the most urbanized states in the country with more than 42% of the population living in cities and towns51.The population of Mumbai has grown from less than four million at India's Independence fifty years ago, to about 1852 million today. The population of

Mumbai is about 18 million, with a density of 4,205 persons per square kilometer. The overall

51 Issues in Social Infrastructure, Health Infrastructure in Mumbai, Mumbai Transportation Unit, 2005. 52 Wikipedia.com reference 60 literacy rate of the city is 77%, which is higher than the national average (82% of adult males and

71.6% of adult females are literate). The religions represented in Mumbai include Hindus (68% of the population), Muslims (17% of the population), and Christians and Buddhist (4% each). The remainders are Parsis, Jains, Sikhs, Jews and atheists.53

Mumbai contributes to a large portion of growth and wealth in India. Mumbai contributes 10% of all factory employment, 40% of all income tax collections, 60% of all customs duty collections,

20% of all central excise tax collections, 40% of India's foreign trade and Rupees 40 billion (US$ 9 billion) in corporate taxes. A number of Indian financial institutions have headquarters in downtown Mumbai, including the Bombay Stock Exchange, the Reserve Bank of India, the

National Stock Exchange of India, the Mint, and numerous conglomerates (the Tata Group, Godrej and Reliance etc).54 As economic prosperity sets in early 2006, the public health of Mumbai is starting to suffer due to neglect.

4.1 Health in Mumbai, Maharashtra

In Mumbai, a city of approximately 1855 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

53 Wikipedia.com reference 54 http://en.wikipedia.org/wiki/Mumbai 55 MCGM Health Profile, 2004 says the population is 12.6 million. Wikipedia.com quotes the population at 18 million and growing. 61 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.

56 Health Services in Mumbai, The Bombay Community Public Trust, 2004. 57 Mumbai’s Invisible People, The Hindu, November 2005 62 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 Mumbai59

58 Health Services in Mumbai, The Bombay Community Public Trust, 2004. 59 Mumbai Health Profiles, 1997-2004, MCGM, Mumbai. 63 Population of Mumbai (1997-2004)

2004 12.6

2003 12.3

2002 12.1 r a

e 2001 11.9 Y 1999 11.3

1998 11.1

1997 10.9

10.0 10.5 11.0 11.5 12.0 12.5 13.0 Population (In Millions)

This table shows population growth in Mumbai from 1997-2004. (Other sources dispute these numbers).

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:

Figure 4.2 The birth rate versus the death rate in Mumbai60

60 Mumbai Health Profiles, 1997-2004, MCGM, Mumbai. 64 Birth Rate vs Death Rate in Mumbai

20 17.7 18 15.8 16 15.2 15.1 14.7 14 e

g 12 a t Birth Rate n

c Death Rate r

e 8 7.2 7.13 6.9 7.1 6.8 P 6 4 2 0 1999 2001 2002 2003 2004 YEAR

This table shows the increase/decrease patterns of the birth rates and death rates.

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:

65 Figure 4.3 Infant Mortality Rates Mumbai61

Infant Mortality Rates Mumbai

38.8 39 38.7 38 38

37 36 IMR 36 35.02 35

33 1999 2001 2002 2003 2004 Year

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.

Figure 4.4 Maternal Mortality Rates in Mumbai 1997-2004

61 Mumbai Health Profiles 1997-2004, MCGM, Mumbai. 66 Maternal Mortality Rates in Mumbai

t 16 n e

c 15 MMR r e P 9 10 8

0 1999 2001 2002 2003 2004 Year

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.

67 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 68 • 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. 69 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 Program62

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 62 The information on the Leprosy Control Program has been from the Mumbai Health Profiles (1997-2004), MCGM, Mumbai. 70 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 Mumbai63

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.

63 Mumbai Health Profiles, MCGM, 1997-2004 64 Mumbai Health Profile 2003-2004 71 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

72  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

deaths66 in Mumbai. The table below represents the cases and deaths in Mumbai of

hepatitis:

65 Mumbai Health Profile, MCGM, 2004. 66 Mumbai Health Profile, MCGM, 2004. 73 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% 67rate 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

67 Mumbai Health Profile, MCGM, 2004. 74 the community and treat them immediately. In addition to health awareness to people,

the NMCP also utilizes 3 methods of surveillance68:

 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 2369, 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

68 Mumbai Health Profile, MCGM, 2004. 69 Mumbai Health Profile, MCGM, 2004. 75  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 Mumbai70

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

70 Mumbai Health Profile, MCGM, 1997-2004. 71 Mumbai Health Profiles, MCGM, 1997-2004 76 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

72 Conversation with Dr. Usha Ubale, former AHO of the School Health Program, January 2006. 73 Conversation with Dr. Usha Ubale, former AHO of the School Health Program, January 2006. 77 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

74 http://ajrccm.atsjournals.org/cgi/content/full/158/2/547#DISCUSSION 75 http://www.oasisngo.org/ 76 Environment status of Greater Mumbai, 2004-2005, MCGM. 78 This only underscores the imperative need for more of a focus on respiratory care for a population that is literally choking on its environment.

79 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.

77 Interview with Dr. Usha Ubale, MCGM. 80 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.

81 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

82 o Population Education

o Information, motivation about family planning

o Health Education

. Environmental sanitation

. Personal Hygiene

. Communicable diseases

. Nutrition

. M.C.H. & E.P.I

 Preventive Services

o Immunization

o Ante-natal, Post-natal and infant care

o Prophylaxis against anemia

o Prophylaxis against Vitamin A deficiency

o Presumptive treatment of malaria

o Identification of suspected cases of leprosy and tuberculosis

o Filariasis

o Infant Feeding

 Family Planning Services

o Nirodh, conventional contraceptives and oral pills

o I.U.D. insertion

o Sterlization and other M.T.P. Services via referral to hospital or through mobile

 Curative

o Fist aid during accidents and emergencies

o Treatment of simple ailments

83  Supportive Services (Referral)

o High risk maternity cases

o Sterilization and M.T.P.

o Diagnosis and treatment of tuberculosis and leprosy

o Laboratory services for diagnosis o malaria matter requiring doctors

services/hospitalization

 Reports and Records

o Preventive services

o Family planning acceptors

o Vital events

o 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

84 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 Plant and Revenue Works (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

hospitals79:

Rs. In Crore Hospital Name Revenue Total KEM Hospital & GSM College 114.1 137.5 LTMG Hospital & College 93.2 124.1

78 Issues in Health Infrastructure, Mumbai Transformation Support Unit, 2005. 79 Issues in Health Infrastructure, Mumbai Transformation Support Unit, 2005.

85 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 funding80:

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

80 Issues in Health Infrastructure, Mumbai Transformation Support Unit, 2005. 86 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

81 Issues in Health Infrastructure, Mumbai Transformation Support Unit, 2005.

87 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

88 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 untreated82.

The MCGM’s described functions for dispensaries and health posts are described below:

Functions of Dispensaries:

1. Clinical management on OPD basis.

2. Immunization- polio, DPT, Measles, Tetanus, Toxid, Typhoid.

3. Preventive services.

4. In upgraded dispensaries- Laboratory services- Urine, stool, HB blood, and Malarial

parasite. (Out of 163 dispensaries- 60 are upgraded).

5. Health Education to the patients attending the dispensaries.

82 Duggal, R et al, Unmet Need for Public Health Care Services in Mumbai, India, June 2004. 89 6. Medical examination of Municipal employees. On the whole, dispensaries, preventive,

curative services to the patients.

Functions of Health Posts:

1. Conducting baselines surveys of the community (of about 65,000 population) residing with

in the given geographical area.

2. Enlisting the eligible couples, motivating them for adoption of small family norms and

providing them with outreach services for contraception.

3. Immunizing children against the 6 vaccine preventable diseases viz. children tuberculosis,

diphtheria, tetanus, pertussis, poliomyelitis and measles through fixed center based and

camp approaches.

4. Preventing and treating case of nutritional anemia in mother and children by distributing

iron-folic acid tablets & syrup.

5. Vitamin A syrup to all children as prophylactic doses for Vitamin A deficiency.

6. Oral Rehydration salt packets to children of under-five age group suffering from diarrhea

7. Conducting Growth Monitoring Program for children of under-five age group.

8. Giving health education to all slum-dwellers.

9. Detection and treatment of cases of Leprosy, Tuberculosis, AIDS and Malaria.

10. Registration of unregistered births and deaths.

11. Detection of new home births and the motivation of such mothers to get their babies

immunized.

12. Establishing effective Management Information System including proper record keeping

and timely reporting.

13. Developing and efficient referral system.

90 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.

83 Report of the National Commission on Macroeconomics and Health, Ministry of Health and Family Welfare, 2005. 84 Independent Research conducted by the author of the report, 2006 85 Duggal, R et al, Unmet Need for Public Health Care Services in Mumbai, India, June 2004. 86 Author interview on December 26, 2005 91 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

87 Dr. Janaki Desai, Founder and Director of the Niramaya Health Foundation 88 Dr. Janaki Desai, Founder and Director of the Niramaya Health Foundation 89 Duggal, Ravi et al, “Unmet need for public health care services in Mumbai, India”, Asia Pacific Population Journal, 2004. 92 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 inefficiencies91

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

90 Duggal, Ravi et al, “Unmet need for public health care services in Mumbai, India”, Asia Pacific Population Journal, 2004. 91 Author Interview with Dr. Sanjay Nagral, January 2006. 93 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

92 http://www.kem.edu/hospital.htm 94 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

93 http://www.kem.edu/college/fees.htm

94 Research Conducted by the author, included in Appendix 1. 95 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.

96 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 survey95 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.

95 The details of this study are attached to this report as an Appendix 2 97 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.

98 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.

99 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.

100 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 101 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:

1. Client’s perspective: What do clients expect from the health services?

2. Professional’s perspective: Do services follow health care provider’s professional

standards?

3. 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

102 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.

103 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

104  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:

1. Improving public health systems 105 2. Improving maternal and neonatal health outcomes at the community-level

3. Developing these supply and demand interventions into a replicable model for urban slum

settings

A four-pronged approach will address these essential components:

a. 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.

b. The participatory development of antenatal, postnatal and neonatal (APN) service package

for health posts was developed to build support at the community level.

c. 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.

d. 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.

96 SNEHA CINH Project Summary, 2005. 106 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:

107  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.

108 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

97 “Are we ready for medical tourism?” The Hindu, Sunday April 17, 2005. 98 “NGO slams public health system in Mumbai”, The Hindu Business Line, Wednesday, November 16, 2005. 109 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

99 “Are we ready for medical tourism?” The Hindu, Sunday April 17, 2005. 110 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.

111 8. Appendices a. Patient Bill of Rights

Each place posting the Patient Bill of Rights needs to affirm the following statement. "We, the staff and the administration of {health facility} declare the following Bills of Rights for the patients of this medical facility. As per the Municipal Corporation of Greater Mumbai, we declare that staff and administration of {the health facility} have read and understood the following rights of a patient and hereby agree to all the terms listed below. If you have any questions or complaints, please contact {Name of accountable person at health facility} or {name of accountable person at BMC}."

 To be treated with dignity irrespective of their caste, class, sex, religion, and disease  To have a list of exact services available and corresponding fees (for supplies, bandages, etc)  To have a visible map of the hospital (in Marathi, Hindi, English, and other languages)  To have a list of emergency services such as blood banks and ambulatory services listed in Marathi, Hindi, English and other languages  To know and understand the procedures involved  To be given a reasonable time frame for the treatment and receive a proportional discount in fees for all services after the upper limit of approximation is over and treatment needs to be continued  To have a comprehensive (various tests, blood work, x-rays, room tarrifs, operations, consulting fees, etc) costs associated with seeking medical care  To receive prompt and courteous care  To be informed about the documentation needed for treatment  To have minimal documentation for emergency cases  To receive Reproductive and Child Health Services free of cost at public health facilities  To receive medications and vaccinations from the local public health post or dispensary  To get medical services which are within the capability of the medical facility  To obtain from the doctor complete information concerning the diagnosis, treatment, and prognosis in language the patient can understand.  To receive necessary information from the doctor such as long-term effects, side effects etc., before giving any prior consent to a medical procedure and/or treatment  To receive the records or a certified copy that gives the details of the disease, treatment, and follow-up necessary at the time of discharge  To refuse the suggested treatment and be informed of the medical consequences thereof  To receive medical care in well-equipped and sanitized conditions  To receive quality care from competent medical professionals  To select doctor’s of one’s choice when possible  To obtain a second opinion  To privacy during medical check-ups  To be assured that all communication and records will be kept confidential  To educational information about medical problems eg. via a library, IEC materials, etc.  To receive a bill cum receipt after the payment is made  To be enabled to pay hospital fees on a payment plan  To have access to a non-hospital staff member appointed to address complaints as soon as possible  To have the contact information of the responsible person (both at the hospital and head office) to register a complaint or give feedback  To have adequate waiting space  To allow relatives to have flexible visiting hours 112 b. Patient Code of Conduct

Patients are also responsible for their personal and environmental well-being. The following code of conduct emphasizes the responsibilities of a patient while seeking medical care.

As a patient:

 You should provide the doctor with accurate and complete information about his/her medical history, past illnesses, allergies, hospitalizations, and medications  You should report the changes in your medical changes  You should ask for clarity if the doctor’s prescription and diagnosis seem unclear  You should follow the doctor’s treatment plan  You should pay your medical bills promptly  You should follow hospital rules and regulations  You should have realistic expectations of what the doctor can do for you  You should help your doctor help you, if something isn’t working, be clear and the doctor can advise alternative care  You should participate actively in your own medical care (in terms of awareness and preventions)  You should ask the doctor questions to clarify any doubts or misconceptions in your mind  You should treat the doctors with respect  You should not ask doctors for false bills or certificates for any reason

113 c. Probable Value of the Report

In this section, the author has outlined how the report can be of value to the different existing bodies in the city of Mumbai. The report was not only created for the MCGM, but also for all the other proponents of health care in Mumbai. The following section details to value to each constituency:

g. MCGM: This report should be seen as an objective analysis of the existing programming at the MCGM. In addition to giving suggestions, the report also highlights the various successes of the MCGM’s health programming. It will be of value in several aspects: 1. Assist lawmakers in allocating funds to priority areas 2. Provide insight to those responsible for programming in terms of areas of improvement 3. Increase the efficiency of the MCGM public health department 4. Increase the reputation of the MCGM’s health services in the city 5. Prove as an impetus that demonstrates the MCGM’s priority of the health of the people of Mumbai 6. Intimate the top-level management as to the priority areas in various departments 7. Apprise mid-level management of the awareness of the lack of resources 8. Inform lower-level staff of the value of their work and increase worker morale

h. NGOs: Non-Governmental Organizations working in Mumbai are working to provide health care to the same citizens that are also the responsibility of the MCGM. This report can help bring the two groups together to not replicate programming in high-need areas and pave the way for NGO-MCGM partnerships. NGO’s can cite the information in the report as representative of the enormous need for improved health care systems in such a large and densely populated city.

i. Donors: With Corporate Social Responsibility representing the progressive era of charitable giving, it is important for donors to also be aware of the issues that are effecting the communities that benefit from their time, money, and resources.

j. Citizens: In a city like Mumbai, the average citizen doesn’t think about health care unless it is a situation of urgency or crisis. This report will make citizens aware of the issues in health care that effect all those seeking care through the government health sector.

k. Medical Students, Physicians, and Health Professionals: In light of the recent strike of the doctors in Mumbai, it is also important for policy makers to understand the perspectives of those working on the ground. This report helps shed light on the needs of physicians and avenues for improvement in their occupation.

l. Media: The MCGM health department is often the recipient of negative publicity by the medial. The information in the report can offer some information as to the inner workings of the MCGM health department and what the media can do to support the improvement of these systems.

Overall, the report provides an in-depth analysis of the existing programs, challenges, and successes of the MCGM health department. Looking at the history of health policy in India, it is evident that there has been little emphasis on improving the health of local citizens in recent years. The report attempts to create a common area for discussion and improvement of health systems within this city. With good basic infrastructure, there are many avenues that can be pursued if the aforementioned parties join together to work on a healthy Mumbai. 114 d. Training Activity for the BMC

Organizing and Managing Urban Health Services:

1.) Identify the guiding principles of the municipality- If they are not explicit, they should be drafted. a. Example: Is the guiding principle equity of access, ensuring a simple, basic minimum package of health care is accessible to all? b. Is collaboration between health and other sectors, such as education a guiding principle?

2.) Purpose of the Municipality: a. Is it to provide appropriate and affordable primary health services for the entire city population? b. Or is it to provide for the poor, and to facilitate private service provision for higher income groups?

3.) Assess the internal environment a. Are the resources available? (Staff, money, infrastructure) b. The current structure and stated function of the government services c. Various service tiers d. Needs careful delineating

4.) Evaluate the External Environment a. Current national policy, with direct respect to direct provision of service compared with promoting and regulating the private sector b. Direction of decentralization c. National policy for health sector financing d. National norms setting service standards or configurations e. Level of flexibility within the BMC in interpreting these policies 5.) Goals and Objectives a. Use these to formulate a strategic plan b. Broad objectives c. Operational objectives Key areas to consider: a. Current decentralization policies altering government and administrative structures, b. The debate over government health service tiers c. Relationship between government and private sector d. Institutional development to improve managerial capacity in government health services

*Private sector notes: -The quality of care of private providers varies a lot from very high to very low. -In low income areas, care is often of low quality -Even if private providers are more polite, the quality of care is not necessarily better -Private providers are driven by market forces -Preventive measures are often neglected

*Governments have a definite responsibility to ensure a minimum quality of care to protect the population from the adverse effects of healthcare: Healthcare is important because it relieves suffering Healthcare is dangerous, especially if inappropriate therapies are given. Governments can consider voluntary accreditation of the private sector. 115 e. Integrating public health issues into the LACGs

With the recent success of the LACG’s for the littering rules and other community issues, it is important to use this resource to address issues of public health as well. The type of activism coming from these groups can be well-utilized as a springboard for other community problems that need the focus and energy of an organized constituency.

The following ideas can be incorporated: 1.) Circulate a brief summary of the Public Health Policy Document 2.) Each LACG can identify its area of priority and take up a particular issue in health (i.e. child health/school health, health of pregnant mothers etc) 3.) This can be a yearly campaign for the LACGs to work with the local MCGM health centers/dispensaries 4.) The Bill of Rights and Code of Conduct can be promoted through these groups as well f. Apex Health Committee

Possible Members:

1.) Dr. Ratna Magotra, Former Cardiac Surgeon at KRM 2.) Dr. Janaki Desai, Niramaya Health Foundation 3.) Ms. Dipika Banerjee, Program Director, AVSAR

Role of Committee:

The role of the committee will be focused on: a. Promoting the relevant recommendations in the report b. Being the voice for public health issues for the NGO Council c. Approving appendices and annexures for other health topics not yet covered in the report (mental health, sanitation & water issues, etc) d. Meeting once a month to monitor progress of the MCGM on proposed issues (i.e. new programming, follow up, recommendations etc.)

116 g. Author’s Note

Although the concept of public health dates back to ancient times, the practice is something relatively new and upcoming in the world space. The idea of conducting an analysis of the health care system in Mumbai was not only challenging, but a part of this growing awareness of public health as a critical force in the medical/health world.

The challenges I encountered while writing this report taught me a lot about public health and its applications in India, a nation with so much potential. Going through all the health policies of India, identifying the key areas of importance, summarizing 200-400 page reports, meeting with people that were either very willing to help or willing to make it harder and finally meeting the patients who came the hospitals, health posts etc to seek medical care. The challenges greatly outweighed the benefits of writing such a report.

The most important question we should ask at this point is: why wasn’t a report like this written years ago? Unfortunately, this seems to be a trend in global public health, with decreased funding and low priority given to health systems and public health. All things are inter-connected here- how 26 July 2005 effected health to the recent striking doctors- in terms of the long-term affect of negligence on the importance of providing high quality medical care for the masses. I hope that this report can add value to the hard work of NGOs, MCGM, and all the other groups involved in bringing health care to the masses.

Overall, this project was of great value to me and I hope it serves as a springboard for those wishing to promote the benefits of good public health systems in Mumbai and all over the world.

Thank you for entrusting me with such a task.

Meenakshi Verma March 2006

117 Appendix 1 Questionnaires

Mumbai Public Health Policy Framework

Questionnaire for Utilization of Tertiary Health Care Services

Date: 1. Age

2. Location

3. Address

4. Occupation/Education

5. Why did you come here for your medical services?

6. What stopped you from seeking care close to your house?

7. How much did it cost you to come here today?

8. If the services were closer to your home, would you access them? 9. If you feel comfortable, can you share your health problems with us?

10. What do you like about the care here?

Comments or Concerns:

Data Number:_____ Entered:______

118 Mumbai Public Health Policy Framework

Questionnaire for Utilization of Primary Health Care Services

Date: 1. Age

2. Location

3. Address

4. Occupation/Education

5. Why did you come here for your medical services?

6. Do you ever seek care at a hospital, why?

7. How much did it cost you to come here today?

8. If you feel comfortable, can you share your health problems with us?

9. What do you like about the care here?

10. How long was your waiting time?

Comments or Concerns:

Data Number:_____ Entered:______

119 Appendix 2 Health Post Survey Results- Vashi Naka Health Post, Chembur

Age Sex Location Occupation Education Q1 Q2 Q3 Q5 Q6 A 35 Female VNHP housewife none cold, fever, goes to Mah Free Medicine is good Waited for 1/2 hour cough hospital sometimes B 12 Male VNHP Student 4th TB Only diagnosis Free Everything is No wait time was there good C 18 Female VNHP Student 11th fever, cough No Free Medicine and Waited for 1 hour comm check up is good

D 55 Male VNHP Business 10th 4 year old Went to shetabdi Free Gave medicine Waited for 1/2 hour child has TB hospital and felt but waiting to see kicked around if it works feels he doesn't know what is going on medically with the child and no one is giving him a straight answer E 20 Female VNHP Makes 5th Boil on neck No Free Medicine is good Waited for 1/2 hour ganpati statues F 17 Female VNHP None 10th TB no Free Medicine is good Waited for 1 hour

G 25 Female VNHP None 12th fever, cough Goes to private Rs. 10 Medicine is good Waited for 1 hour doctors sometimes H 17 Female VNHP None 7th vomiting, no Free Medicine is good Waited for 1 hour diarreah and it works

I 27 Female VNHP None 10th children have comes to Free Doctor is good, Waited for 1/2 hour fever dispensary first, medicine is then to hospital perfect J 29 Male VNHP None 5th TB no Free Medicine makes No wait time a difference K 55 Male VNHP None none TB Goes to Shetabdi Free Facility is good No wait time sometimes L 35 Male VNHP Plumber 6th TB No Free Doesn't know No wait time M 26 Female VNHP None 6th stomach No Free Everyone here is waited for 2 hours illness and good fever of children N 22 Female VNHP None none Fever, cough, Private providers Rs. 20 Its ok No wait time cold O 64 Male VNHP None 5th TB Somaiya Free Good because he No wait time gets his medications on time

P 18 Male VNHP None none TB No Free Doesn't know No wait time Q 26 Female VNHP None 5th Children are Rajawadi Hospital Free 1st time here, if it No wait time not well works, she will come back R 7 Female VNHP None none Girl has a Went to Sion Free Care is better No wait time huge boil Hospital and they told him to come here S 15 Female VNHP None 10th TB No Free Medicine is good No wait time

T Appendix 3 120 KEM General Out Patient Department Survey Results

Age Sex Address Occupation Education Q1 Q2 Q3 Q4 Q5 Q6 No cure despite repeated Fever, Good Doctors, and good facilities N/A Female Wadala Housewife N/A medicines No relief 20 No Backache for patients Fever, no Not improved access to Believes KEM cures Malaria Referred by a despite clean better than other centers, good N/A Male Wadala Carpentar 9th private doctor treatment 30 No water investigation services Patient had already taken treatement from Cough, a BMC health Not improved vomiting, post but was not despite fever and Good doctors and lots of good 13 Female Worli N/A 7th cured. treatment 16 Yes chills facilities are available Went to Goyal hospital, didn't make a difference, although it was a private hospital, No health it didn't make a facilities close difference, also to home (that Chest Ullhasnag the doctor spoke she was aware pain, 30 Female ar Housewife 5th rudely of) 50 Yes fainting Doctors spoke to her nicely local doctor Did not know if Sakinaka, advised him to there are BMC Andheri Embroidery go to the big facilities close Doctors, and he doesn't know N/A Male (E) Worker N/A hospital to his home 30 Yes N/A about the investigation facilities Services not good at health Went to Nayyar post, the hospital, but that problem was She came here from other people was not helping, more severe telling her it was good, Nayyar Grant so she came to than they could Migrane was good but the medicine was 24 Female Road Not workin 6th KEM handle 20 Yes headaches not working Indira Gandhi hospital is there, but the Company friend Doesn't know facilities New Shipping said to come to any other are not so Everything is good here. Good 32 Male Mumbai Company 12th KEM facilities 70 good Hernia people and doctors No health posts near his home Factory He had a fever (that he was Fever, Doctors treated him well, his 46 Male Parel Worker N/A and a cold aware of) 0 No cold mother also comes here Yes, there are not many services in the village. In the village, his Even if Treatment is done well, and they BP went up and Not many someone take time and do good. In the he had to come health services gets sick, village, they give an injection, to KEM for in the village they have and it doesn't work well. It is Rajapur further tests. (475 km from to travel 95 good. Its not easy to handle that 36 Male (Village) Driver 10th Jijaji sent him. Mumbai) 256 km BP many people. Yes, left home at If you come 1-2 times you get 7am, better relief. The procedure has Tried at 2-3 No public care nothing become a little complicated, it private hospitals, (that she is close to her used to be better when people 30 Female Bhayendar Saleswoman 12th nothing helped aware of) 20 house Acidity were prioritized based on illness 40 Female Andheri Housecleani 7th Dizziness Municipality 50 Yes. There Lymph Treatment is effective and ng hospital is is a doctor nodes doctors are good there, but they at the don't give municipal 121 hospital, but he enough hardly attention comes Yes, all the Feels Sion and current Dizziness, Matunga Works for a KEM are the ones are frozen Doctors are good and money is 50 Female Road company 11th Dizziness same. 8 private shoulder saved Primary health center is Lower Bus This is closest just for Lump in 45 Male Parel conductor 10th Lump in finger to his house 0 basic care finger Doctors are good General Lives in the pains in village, but came knee, hip, Everyone talks well and I like the 59 Female Bhandup Not workin 7th here for care N/A 0 No and chest hospital Came from the Shoulder Shoulder pain village, so pain and and stomach doesn't know stomach Doctors and facilities are good. 60 Male Parel Not working 10th problems about PHC 400 No problems Those who leave here, leave well There are Services municipal currently hospitals, but are good, no doctor but doctors facilities but not are not Headache, 29 Male Sewri Driver 8th Headache gone there 10 available dizziness Treatment is good There is a clinic on Saini Road, but only goes Doctors are good, cleanliness, Elephistin there for and care is good. Other hospitals 30 Female e Not working 7th Backache immunizations 0 No Backache Nayyar and Sion are not clean Doctors are better here, There are rupees are Health is not (Facilities) but complete Cough and 35 Female Worli Not working 10th good small. Its ok. 10 here Pnemonia Full treatment is good Yes I would. There is a KEM went to the There is an Baby has branch in Malad, PHC in Borivali ease to the a Doctors are good, except but medicine is but there were services respiratory sometimes the care is 48 Male Malad Tailor 5th not available, problems 100 here infection compromised

122 II. Best Practices

Utilizing best practices from other cities with similar challenges in terms of healthcare can improve the health outcomes of the city of Mumbai. The following section further analyzes several of these best practice models.

a) Participatory Budgeting in Porto Alegre, Brazil100

Until the beginning of the 1980s, Porto Alegre experienced accelerated population growth, which left one third of its population with only marginal access to urban infrastructure. In 1989 a large proportion of the population lived in non-legalized areas, in shacks without drinkable water, sewerage systems or paved streets. Local government decided on all municipal investments, without any consultation of residents. However, the city's income, which was based on taxes collected, was not adequate to finance even a minimum of public works needed to sustain development.

Participatory budgeting was introduced as part of the political platform of the Labour Party in

1989 to involve the residents in setting priorities for public works; ensure a more equitable distribution of municipal investment; promote transparency in municipal activities and reduce opportunities for corruption; and increase popular participation in municipal government.

Following its introduction the program gained strength as the public gained more experience in decision making and as tax reforms strengthened municipal finances.

The program has developed into an international model of participatory government. The general rule that applies is that there is a direct connection between the spending in the local neighborhoods and what motivates people to attend meetings. If you don’t attend a meeting for your district, chances are that your road light won’t be working. Since participatory budgeting began in Porto Alegre in 1991, over $700 million has been invested in basic urban infrastructure,

100 Case Study 2 - Porto Alegre, Brazil: Participatory Approaches in Budgeting and Public Expenditure Management

123 including water supply, sanitation, road improvements and public lighting. An opinion survey at the end of 1997 showed that 85 percent of city residents either had been active in the budgeting process or considered the investments to be highly relevant to their circumstances.

In 1990, when the program started, people thought it wouldn’t work, so only 1000 people participated. In 1999, over 40,000 people were participating. The concept is simple, Porto Alegre is divided into 16 districts for purposes of the budget. A council is created in each district as a space for citizens to meet and discuss spending priorities. Meetings are open to anyone who would like to attend. Citizens set two priorities: district and citywide spending. District spending focuses on specific public works projects in the neighborhood, such as paving streets or improving sewer systems. Citizens identify three priorities, with funds allocated based on population size and need.

Need-based allocation of funds means that poorer neighborhoods receive more money than wealthy ones.

World Bank study found substantial quality-of-life improvements in Porto Alegre:

 Between 1989 and 1996, the percentage of the population with access to water services

rose from 80% to 98%.

 Those served by the municipal sewage system increased from 46% to 85%.

 The number of children enrolled in public schools doubled.

 In poorer neighborhoods, 30 kilometers of roads were paved annually.

 Tax revenue increased by nearly 50 percent, a fact the World Bank attributes to

“transparency affecting motivation to pay taxes.”

The MCGM is plagued with issues of transparency and disclosure regarding how decisions are made in the domain of health. It may be worthwhile to explore small levels of participatory budgeting and see how that might be of value to the citizens that utilize the public health sector.

124 b) Cambodia’s Non Profit Path to Health Care

Cambodia’s public health care system was plagued with some of the same issues that limit the potential of the MCGM Public Health Department. Large scale absenteeism, vacancies, and corruption caused massive under-utilization of the public health care system. However, the government decided to take a low-cost approach to improving health care for the poor by contracting international or local non profits to run the health centers and hospitals at a fraction of the cost. The approach is catching on in a growing number of poor countries around the world, from Bangladesh and Afghanistan to Congo and Rwanda, to Bolivia and Guatemala, reaching tens of millions of people.

These contracted services have allowed international donors and concerned governments to cut through dysfunctional bureaucracies - or work around them, and to improve health care and efficiency at modest cost. In Cambodia, the nonprofit groups - all of them international - are instilling discipline and clarity of purpose in a health care system enfeebled by corruption, absenteeism and decades of war and upheaval. They have introduced incentives to draw

Cambodia's own doctors and nurses back into the system. Patients, especially the poorest ones, have followed in droves. The international NGOs are paid based on performance, based on their ability to achieve immunization targets, decrease Infant Mortality Rates, and make sure women are getting prenatal care and following up with institutional deliveries.

Although Mumbai does not seem to be at the same level as Cambodia at this time, there can be potential benefits to having foreign NGOs setting up and running operations to improve efficiency and subsequently transitioning to a local team.

c) Subsidized Health Care in the Philippines101

101 http://www.bestpractices.org/bpbriefs/social_services.html

125 The Makati Health Program (MHP) was designed to provide residents of the city of Makati in the

Philippines earning monthly incomes less than US$156 access to quality health care. However, when the program was evaluated in 1986, they found that people in that income bracket were unable to afford the health care provided by the MHP. The local government of Makati partnered with the private sector partner, Makati Medical Center and two NGOs.

The program has afforded beneficiaries access to services such as major surgeries in one of the best private hospitals in the Philippines. In 2000, over 50,000 cardholders were treated at the

Makati Medical Center, with bills totaling US$ 3.3 million. Under the terms of the expenses sharing scheme, the city government of Makati shouldered US$1.9 million while Makati Medical

Center contributed US$1.4 million.

Together with the local government's initiatives in preventive health care, the Makati Health

Program has contributed to declines in the mortality rate and improvements in morbidity rates across all ages. Makati is one of the few cities in the Philippines that provide subsidized quality health care to its constituents.

The idea of health subsidies can be a good idea for the MCGM Public Health System. Utilizing the networks of private hospitals in the city, there can be value added if both the government and the private sector actively participate in improving health care for all.

All the different initiatives mentioned above are merely suggestions for improving aspects of the

MCGM health systems. Clearly, the process of implementing different strategies is going to be a challenge, but the use of best practices from other institutions should be a good starting point for those positive about changing the system.

126 Works Cited

1.) Understanding our Civic Issues, The Bombay Community Public Trust, Health Services in Mumbai, 2004.

2.) Public Private Partnerships for Improving Health of Children in Urban Slums, Dr. Siddharth Agarwal, Urban Health Resource Center, 2005.

3.) “Unmet needs for Public Health Care Services in Mumbai, India”, T.R. Dilip and R. Duggal, Asia-Pacific Population Journal, 2004.

4.) “Mumbai’s Invisible People”, The Hindu, November 2005.

5.) “Maternal Care in India Reveals Gaps Between Urban and Rural, Rich and Poor”, Population Reference Bureau, July 2003.

6.) “The USAID/India Urban Health Program: An evaluation of activities to date and recommendations for the future”, October 2005.

7.) World Health Organization South-East Asia Regional Office, Vol. 3 Issue 2, September 2003

8.) Health Concerns and Organizing Health Care Delivery to Urban Slums, Dr. Siddharth Agarwal, Urban Health Resource Center, 2005.

9.) Health Delivery and Health Wants In Mumbai Slums, India, Centre for Water Policy and Development, University of Leeds, Date Unvailable.

10.) Country Health Profile- India, World Health Organization, 2002.

11.) National Family Health Survey, Maharasthra, March 2000.

12.) Report of the National Commission on Macroeconomics and health, Government of India, 2005.

13.) US AID Health Report, 2002.

14.) Personal Interviews with Dr. Sanjay Nagral, Dr. Khandare, Dr. Ambe, Dr. Thanekar, Dr. Usha Ubale, Dr. Janaki Desai, Dr. Armida Fernandez, Ms. Leena Joshi, Mr. Ravi Duggal, Dr. Ratna Magotra

15.) National Health Policy 2002 & 1983

16.) Moving Toward the Right to Health Care, CEHAT, 2005/

17.) BMC Health Profiles 1997-2004.

18.) National Health Policy 2002.

127 19.) http://phm-india.org/pdf/hungerwatch/draft_guidelines_starvation.pdf

20.) http://www.maharashtra.gov.in/english/ecoSurvey/ecoSurvey1/economySurveyShow.php

21.) www.blonnet.com/2005/11/16/stories/2005111601821300.htm

22.) www. hindu .com/2006/01/01/stories/2006010104671200.htm

23.) www. hindu .com/the hindu /mag/2005/04/17/stories/2005041700060100.htm

24.) www. worldbank .org/

25.) www.earthinstitute.columbia.edu/images/TheLancet_ slum _ dwellers .pdf

26.) www.hindu.com/2005/11/03/stories/2005110304381100.htm

27.) www.mezomorf.com/ health /news-19949.html

28.) www. indianpediatrics .net/feb2004/137.pdf

29.) Urban Health Resource Center: http://www.uhrc.in/

30.) WHO Newsletter: http://w3.whosea.org/extrelations/pdf/vol3-2/RD%20mess.pdf

31.) www.swissre.com/INTERNET/pwswpspr.nsf/alldocbyidkeylu/BMER-5GBLEN? OpenDocument

32.) www. wikipedia .org/wiki/Mumbai