Health services in mumbai

Health Services in Mumbai
Mumbai is one of India's largest cities and an important commercial and industrial centre. Based on the 2001 Census, Mumbai's population in 2003-2004 has been estimated at nearly13million. In the decade 1991-2000, the population has grown at the rate of 2.04% per annum. Despite everyday pronouncements of major breakthroughs and advances in medical and health technology, the basic health needs of a majority of the population in Mumbai are not yet met even in a rudimentary manner. Conventional health services, patterned along the Western lines, have proved inappropriate and far too expensive. Hospitals have become visible symbols of medical care, caring for those who come to it, not necessarily of those who are most affected or most needy. Mumbai has a vast supply of public and private health care services. The services range from the super speciality, tertiary-level care hospitals to the general practitioners. The Central Government has its own dispensaries, which are available only for their employees. Further, there are the Employees' State Insurance Scheme (ESIS) health care services that include hospitals and dispensaries which cater to employees in the organised sector. The various government organisations, such as ports, railways and defence, have their own health care services for their employees. For the general population, the Municipal Corporation of Greater Mumbai (MCGM) provides major facilities in the public sector along with the State Government. 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 Food sanitation and prevention of adulteration of food Control of trades likely to pose a health hazard Impounding stray cattle, immunisation and licensing of dogs Issuance of international health certificates for travelling abroad The registration of birth and deaths is done as per the provision laid down under the Registration of Birth and Death Act, 1969. Each stillborn and live birth and each death has to be registered within 21 days of the occurrence of the event. Thus, certificates of birth or death are issued at the office of the Medical Health Officer of the concerned Ward. There are 174 cemeteries in Mumbai, of which 40 are managed by the MCGM. There are 10 electric crematoria which are open round the clock. The cremation charges for an adult dead body are Rs175/- and Rs100/- per dead body of a child below the age of 12 years. The Executive Health Officer grants the permission of removal of dead bodies outside the city limits. If the dead body has to be taken to a place, which can be reached within 24 hours of the time of death, permission can be taken from the heads of the municipal hospitals. Permission for reopening of the family grave for fresh burial or for bringing a dead body into the city for burial can be taken from the Executive Health Officer, Deputy Executive Health Officer or the Assistant Health Officers. The family welfare and maternal child health programmes are under the supervision of the Special Officer- Maternal Child Health & Family Welfare at F/South Ward. There are 223 centres, including 178 municipal centres, 10 state government centres, 12 centres run by voluntary organisations and 16 service centres belong to private agencies. Male and female sterilisation programmes, copper-T insertions and awareness are carried out, as part of the family welfare programme. Medical termination of pregnancy (MTP) is a facility made available in all municipal hospitals and maternity homes. These centres also conduct programmes of immunisation and prevention of iron deficiency, anaemia and blindness amongst children caused by vitamin A deficiency. School health services are run for children studying in the primary and secondary municipal schools and in the 16 municipal schools for mentally retarded children. These children are examined annually and referred to nearby municipal hospitals if found sick. Children of Standard-I are immunised with Diptheria, Tetanus & Pertussis (DTP) and those in Standard-V and Standard-X are immunised with tetanus toxoid vaccine (TT). Follow up is done by the Assistant Medical Officer (Schools) or the junior health visitors. The BMC has identified 19 diseases as communicable and it is mandatory for all the private practitioners in the Ward to notify the MCGM, if there are cases reported of any of these diseases. Some special services, like the Ophthalmology Hospital at Kamatipura, with an In-Patient Department capacity of 80 are also provided by the MCGM. Special clinics for sexually transmitted infections (STIs) are also run at the maternity home situated at Kamatipura. Free tests are done for detection of syphilis, gonorrhoea, monoiliasis and other STIs. There are 25 voluntary counselling and testing centres (VCTCs) run by the BMC and Mumbai District AIDS Control Society (MDACS) as part of the AIDS control programme. Additionally, there are special centres that deal with specific diseases like Leprosy Hospital at Wadala with peripheral clinics at KEM, LTMG (Sion) and Nair, Tuberculosis Hospital at Sewree and two ENT Hospitals at Bellasis Road and Flora Fountain. Infectious diseases like plague, cholera, jaundice, etc. are treated at Kasturba Hospital at Jacob Circle. Under its programme of providing medical relief, MCGM runs four major hospitals, 16 peripheral hospitals, five specialised 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 10million patients are treated annually in the Out-Patient Departments (OPDs) in the MCGM hospitals. The KEM, which is the largest, alone annually treats 1.2million 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 speciality hospitals. The health posts and the dispensaries are linked to the peripheral hospitals in their respective Wards. These health posts are established with a view to render basic integrated health and family welfare services to the urban poor at a place within walking distance from the slums and other slum-like areas where they live. The facilities available in these MCGM hospitals are, largely, at subsidised rates. For making a case paper, the nominal charges are Rs10/-, for X-rays Rs30/-, ECG at Rs20/-, the ICU beds are charged Rs200/- per day. Fees are charged for the fourth delivery in the municipal maternity homes. Operative procedures are charged as per their categories, either major or minor surgeries, ranging from Rs500/- to Rs5,000/-. A study carried out by Centre for Enquiry into Health and Allied Themes (CEHAT) reveals that while the median cost of treatment in a public hospital for in-patient care is Rs600/-, it is Rs5,000/- in private clinics. In spite of such low charges in public hospitals, if a patient still cannot afford to pay, help can be requested from the social work cell or the Assistant Medical Officer (AMO) for more subsidised rates or for free. Though the city is characterised by sharp contrasts, it has really one of the best public health systems in the country. The total expenditure incurred by the MCGM on public health in 2000-01 was approximately Rs434crore. Some critics say that the infrastructure at municipal hospitals has been stretched to its limits. Public health sector's out-patient care is inadequate or under-utilised because of inconvenient timings or location, long queues, language barriers and rude staff (which, in turn, is because of the over burden of work). Inadequate equipments, poorly maintained equipments, lack of manpower, delay of financial approvals from the bureaucracy, over crowding and the sharp deterioration in the quality of their services have forced many patients to turn to private hospitals. But only a fraction of the population can afford private health care. As much as 46.6% of the population in Mumbai lives in slums, half of which comes under below poverty line (BPL) status, who cannot afford costly health care in private hospitals and, thus, depend on public hospitals. The households in the city largely pay for health care. Even for the subsidised public health care, the poor have to pay extra as bribes due to rampant corruption. The other expenditure is on the medicines, which the public hospitals do not provide, the reason often quoted as “not in stock”, although they are funded to provide medicines. The major chunk of the beneficiaries comprises people belonging to the BPL strata of the society. The lower middle class also utilises certain services like the ICCU or ICU or certain surgeries that are way beyond their reach at a private set up. Generally, there are more male beneficiaries than females in terms of gender utilisation of the health care services in these hospitals. The male OPDs have more number of patients and the In Patient Department (IPD) bed occupancy is as high as 30-35 beds (out of the 40 beds in a hospital ward) compared to female IPD occupancy of 15-25 beds. Males come with more of acute illnesses and females are the ones with more chronic illnesses. In terms of the age group, majority of the medical OPD patients belong to the reproductive and middle ages. The elderly do come for treatment but they are, generally, for cases like hypertension and diabetes for which they require daily medication and they cannot afford it from outside. The tertiary, super specialty hospitals, like King Edward Memorial Hospital (KEM), are one of the best in terms of services in the city. The peripheral hospitals are the ones which are ill equipped. There are no back-ups and, often, they have to depend on private hospitals in the neighbourhood for investigations like CT scan, MRIs and some sophisticated blood tests. Due to excessive patient load in these tertiary-care hospitals, peripheral hospitals have to refer cases that require specialised care to private hospitals. There are often referrals to the government-run hospitals as per the availability of space for admissions. Let us look at the epidemiological profile of the city. The situation is bad; firstly, for data one has to rely on the records of the MCGM, which are insufficient, as they only cater to a small fraction of the population. Secondly, no uniform data is available from the private health sector, as the private sector works independent of the public health sector. There is no proper system being followed with regard to the notification of communicable diseases and the interaction has become almost non-existent or only at times of epidemics. Pathological laboratories, which can provide the actual data, are completely left out of this system. The fact remains that the doctors, generally, treat patients symptomatically and do not keep proper records; hence, no reliable data can be collected. Malaria, tuberculosis and polio are some of the diseases that have made a come back in the city with a vengeance in the past few years. New strains of polio virus are brought by migrants from states like UP and Bihar. There has been a constant rise in the cases of malaria in the past years. In fact, deaths have been reported from Falciparum malaria in some parts of the city. Until about a decade ago, this species accounted for only 20% of malaria infections in the city. The remaining 80% of malaria infections was caused by the less lethal plasmodium vivax. However, new data collected at the KEM Hospital and anecdotal evidence from private practitioners in Mumbai and Navi Mumbai indicate that Falciparum now accounts for 30%-40% of malaria infections in the city. Falciparum's resistance to common anti-malarial drugs compounds the problem. Studies from the KEM Hospital indicate that over 50% of plasmodium Falciparum cases in Mumbai are resistant to chloroquine, which is the first-line treatment recommended by the national malaria control programme. In addition, there have been reported cases of Falciparum's resistance to other common anti-malarials, such as artemisinin, primaquine, sulfadoxine and pyrimethamine. Since 1990, a resurgence of tuberculosis (TB) has occurred, characterised by a 70% to 140% increase in the rate of TB-related deaths among adults aged 25-44 years. A vital factor contributing to this phenomenon is HIV infection. A recent review of autopsy reports from Mumbai showed that 85 of 143 adult patients (59%) with AIDS were diagnosed with pulmonary TB, indicating that the disease is the most common opportunistic infection for persons with AIDS. Commensurate with the increase in TB cases is a surge in the prevalence of multi-drug-resistant TB in adult patients. Two reference mycobacterium laboratories in private hospitals in Mumbai have reported a high prevalence of multi-drug-resistant TB strains; 56 of 521 cases (11%) in 1991-1995, and 58 of 100 cases (58%) in 1994-1995. The infant mortality rate (IMR) in the city is 40% and the maternal mortality rate (MMR) is 0.14%. 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 anaemic; this percentage in the slum and non-slum areas is 45.5 and 37.4, respectively. In Mumbai, 50% of children under the age of three are found with elevated lead levels in their blood, due to lead poisoning of the water in the city. 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). The epidemic that has affected the city in the past decade is of HIV/AIDS. There has been a steep rise in the cases of the disease. The figures, though small, are only of those who have voluntarily come forward for the testing at the VCTC. Mumbai has around 0.25 million cases of HIV. Of these, 54% are among prostitutes, 14% among STD patients, 39% among intravenous drug users (IVDU), 16% among homosexuals and 0.75% in the low-risk group. The situation is very complex and multi-dimensional; on the one side is the pitiable situation of health of individuals and, on the other side, is the inadequate and insufficient role played by the State to provide health care for the needy. The third factor adding to this grave situation is the private health sector. This private health sector does take care of the large population's health needs, both in terms of OPD and IPD treatment, but has its own cost burden attached with it. The private sector, as per CEHAT database records, consists of 1,082 private hospitals/nursing homes in Mumbai city run by individuals, co-operatives, corporate bodies, companies, religious bodies, trusts and NGOs. Apart from this, there is a large segment consisting of private practitioners, polyclinics and dispensaries. Recent years have seen plush corporate hospitals mushrooming all over the suburbs to cater to the tertiary ailments of those living in the city. While with the common man, the problem in health continues to be one of tackling infectious and communicable diseases, the “packages” provided by these corporate hospitals cater to the tertiary health care diseases that are due to life-style changes. These new private health care providers are mainly pharmaceutical companies who have their own vested interests. It is well known that the drug industry has an unhealthy influence on the prescription practices of the doctors. The nexus between pharmaceutical companies, private practitioners and chemists is worth studying. Strong medicines are made available without prescriptions.
All manners of retailers stock all types of medicines. Doctors over-prescribe strong drugs
for minor ailments, reducing future efficacy of the medicine. Pharmaceutical companies
aggressively promote over-prescription in order to promote sales, for which the doctors
are rewarded with gifts and expensive travel for them and their families. Pharmaceutical
companies illegally promote their medicines to the many unqualified quacks. Mixing of
dangerous allopathic drugs in the indigenous medicines is a rampant practice. Last, but
not the least, is the “cut” practice, where the general practitioners are given up to 40% of
the amount collected as fees from the patient. Moreover, many of the private hospitals
employ multi-specialty physicians on a target basis, where they have to achieve a target
in terms of patients if they want to remain attached with these famous hospitals.
The situation will not improve unless some drastic measures are taken. These may
include the halt of privatisation process of the public health services in the city and better
allocation of funds to run these facilities, rather than giving away to the private sector to
run them. There is an urgent need to “tame” the private sector, which is experiencing an
unchecked growth that is leading to exploitation of the population, as they know that
health becomes a matter of prime importance in each individual's life. The focus should
be shifted from the hospitals to the community. Dorothea Sich has described the hospital
as a “self chosen ghetto of the medical profession” and modern doctors as “professional
cripplets” who cannot function without a hospital. Today, commercialisation has
estranged the physicians from their own people. The ablest men and women are not
tackling the most acute and difficult problems. Hence, there should be emphasis on the
involvement of the community to tackle their own problems. As Dr. Mahler said, without
the participation of the community, health becomes a technological mockery.
Role of NGOs
There are a variety of NGOs that are trying to address these diverse problems and concerns in the health scenario in Mumbai. These organisations are involved in providing allied health care services as well as advocacy & lobbying with the Government, patient education and research. Some of these NGOs are : The Society for Nutrition Health Education Action (SNEHA) is an NGO which focusses on issues related to health and empowerment of vulnerable groups. Of SNEHA's many activities, one is medical outreach to street children through its Mobile Hospital and another is a Quality Peri-natal Care project for protecting newborn born babies and mothers that focuses on bringing about changes in attitudes and behaviour as well as enhancing the technical and inter-personal skills of all cadres of health care providers. An NGO like Association for Consumers' Action on Safety and Health (ACASH) has been formed to probe, study, research, assist and deal with health-related consumer issues and to protect the rights of the consumer and the general public. ACASH advocates and campaigns on issues like infant and maternal health and nutrition, tobacco control, doctor-patient relationship, rational drug policy and consumer rights and responsibilities. The Centre for Enquiry into Health and Allied Themes (CEHAT) is involved in research, action, service and advocacy on health. It has a well-stocked and specialised library as well. CEHAT's projects focus on health services and financing, health legislation, ethics
and patients' rights, women's health, etc.
The Health Education Library Programme (HELP) works on patients' education,
conducts awareness programmes on various health issues and runs a library.
A noteworthy feature of most of the NGOs working on health is that they have been
started by health professionals.
Dr. Athar Qureshi, a homoeopath and community health consultant by profession, is the
Joint Convener, EKTA, a committee for communal harmony and peace and a member of
the Humanist movement.
The facts presented and opinions expressed in this booklet are those of the author alone.

Series Editor: Dr Nita Mukherjee


Working Group 4 Report - 2010 Report of the Working Group on the “Global Sickle Cell Disease Network” Chairs Isaac Odame , Hospital for Sick Children, Toronto Hani Atrash , Center for Disease Control, Atlanta Participants : Errol Alden , -American Academy of Pediatrics, Chicago Eiman Abdulramman , Atlanta, Georgia Margaret Bash , National Institute of Health, Bethes

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