Deteriorating public healthcare in Mumbai
10 July 2012
Mumbai’s public healthcare sector is approaching exhaustion. The Municipal Corporation of Greater Mumbai (MCGM), despite its untiring efforts to provide affordable healthcare through its general hospitals and peripheral centres, has had to compromise on consistency, responsiveness and quality, owing to the huge disease burden. The fact that over 62% of the city’s population resides in slums with inconsistent water supply and poor sanitation and garbage disposal systems makes the task of ensuring good public health in India’s commercial capital even more difficult.
Despite its noteworthy achievement in combating malaria and an increased focus on overhauling the city’s public health infrastructure by developing an enabling policy framework, MCGM continues to face major challenges in ensuring an effective, affordable and accessible health system for the city’s 1.24 crore people.
Against this backdrop, experts from the medical and peripheral fields, NGOs, consumer groups and media gathered at ORF Mumbai on June 22, 2012 to discuss the challenges confronting public health services in India’s commercial capital. The roundtable discussion ’Healthcare in Mumbai’ was organised by ORF in collaboration with Rosa Luxemburg Stiftung (RLS), one of the largest political education institutions in Germany.
"We live from one emergency to another," said Dr. Armida Fernandez, Founder Trustee and Chairperson, SNEHA and former Dean, Sion Hospital, lamenting the inadequate follow-up on the two-year-old promise made by MCGM to prepare and implement a long-term public health policy for Mumbai. Comprehensive public health planning must account for up to 90% of promotive and preventive health services, but instead, we have focused on curative services. "Such an approach has kept large sections of the society vulnerable to preventive diseases," she said. She highlighted that Mumbai had in place an extensive three-tier public health system comprising the MCGM-run community-based primary health posts and dispensaries, post-partum centres, maternity homes, etc. at the base, which expanded to its next-tier of secondary health infrastructure, and finally the third tier of tertiary general hospitals. Besides this, Mumbai also has a large presence of the state-run anganwadis and dispensaries; a plethora of charitable and private health services at all levels; and an army of general practitioners and even non-qualified medical practitioners.
"Unfortunately, there is a lack of coordination among these players," she rued. As a result, there is absolutely no importance accorded to basic necessities like health education, proper nutrition, provision of safe supply of water and better solid waste management and sanitation services, immunisation, maternal and child health, prevention and control of endemic diseases, appropriate treatment of common diseases and injuries and the provision of essential drugs.
Several participants made a strong argument for MCGM to integrate the inseparable aspects of 1) Health education, 2) Promotion of proper nutrition, 3) Safe supply of water and 4) Better solid waste management and sanitation services in all its future health planning.
Nutrition and health go hand-in-hand, said Ms. Priya Agrawal of SNEHA. She pointed out that in Mumbai, as in the rest of the country, provision of healthcare is the MCGM’s concern, while ensuring provision of nutrition, especially for the poor women and children, remains the responsibility of the state government. Ms. Shilpa Kamble of the Navnirman Samaj Vikas Kendra, an organisation working closely with the government for the implementation of the DOTS programme for TB control, highlighted the poor infrastructure at MCGM’s primary health posts.
Several other discussants at the roundtable also urged MCGM to recognise the crucial role played by non-qualified doctors - especially in slums - and integrate their services with the public health infrastructure planning by ensuring skills’ development programmes and certification programmes. Several participants called for the need of integration of the AYUSH doctors in the mainstream public health planning.
Dr. Praful Barvalia, Chairman of Dr. Barvalia Foundation, gave the example of the Panchmahal district in Gujarat, which experienced a high rate of malaria mortality. Given the lack of registered doctors, the government invited AYUSH doctors, trained them in the programme and gave them specific mandates to implement the drive. This helped in not only bringing down the prevalence of malaria, but reduced the death rate by 93 per cent. He urged MCGM to prepare a policy framework which would facilitate such integration. Mr. Anthony Samy, CEO, Alert India, an organisation which is working with leprosy patients, pointed out that his organisation has trained AYUSH doctors who are currently working at leprosy referral centres run by the various state governments across 95 districts.
Ms. Neha Madhiwalla of Sahyog, an NGO working for medical ethics, questioned the failure of the government in providing quality healthcare at the primary level which, she said, was ’the lowest of the low-cost interventions’. There is no reason why primary healthcare, which does not deal with hi-tech care or cost intensive interventions, must have such a large presence of private players, she said. Maybe it’s time to reflect on whether such a scenario is inevitable or whether there is a tacit understanding that primary health is one sector where the state should not intervene in the manner in which it could and should, she said.
Mr. Ashok Kalbag of Pune-based Vigyan Ashram said that a top-down approach will not work as health issues are different in different pockets of the community. Basic health and hygiene education among slum children will eventually lead to such best practices becoming a norm, at least in some slum communities. Dr. Barvalia enumerated his experience with malaria control measures in the slums of Shivaji Nagar in Mankhurd and Govandi, where ORF Mumbai and Barvalia Foundation had helped the MCGM with its anti-malaria campaign in 2010-11. The campaign included day-long ’Fight the Bite’ workshops for women who were given certificates of participation at the end of the workshop. As a result, each woman who participated is till today the best messenger for prevention of malaria in those slum neighbourhoods. Empowering the local community can give remarkable and sustainable results, Dr. Barvalia remarked.
Dr. Anita-Patil Deshmukh, Executive Director, PUKAR described the successful work done by PUKAR at the Kaula Bandar slum in Mumbai, underscoring the importance of community engagement in ensuring better health and overall development of slum residents. Giving examples of lack of basic statistics like annual mortality figures with the MCGM health department at ward offices, she urged for decentralisation of public health governance and management, coupled with regulation of the private sector health services. Sandeep Kapila, co-founder, Swasth India, a social venture working towards improving the health of low-income segments, urged the need for creating city-wide health information systems.
A presentation on ’Tapping the PPP Potential for Urban Health Care’ was given by Mr. Narinder Nayar, Chairman, Bombay First. He said that the empowered committee of Bombay First’s Health Mission has presented its final report and recommendations to the government in June 2012. Bombay First has recommended a PPP model where the government can bring in capital investments, operational support, professional skill services and high-end technology support, while the private sector can chip in with volumes, share of revenues, greater footprint and visibility.
The participants voiced the need for ORF to approach the MCGM with a detailed report of the event and also highlight the key recommendations that emerged from the discussions.
Earlier, the organisers of the Roundtable Discussion welcomed the participants and gave opening remarks. Dr. Leena Chandran Wadia, Senior Fellow, ORF Mumbai, highlighted the key areas of research undertaken by ORF Mumbai in public health sector, which includes an ongoing study on improving mental healthcare and, a recently published extensive report recommending reforms in medical education. She flagged the key challenges and opportunities facing the MCGM, setting the agenda for the discussions to follow. She also underlined the current goals of the Government of India for providing ’Universal Health Coverage’. Dr. Rumi Aijaz, Senior Fellow, ORF, spoke about ORF’s long-standing collaboration with RLS and the objectives of the ongoing joint study series. "Healthcare statistics on different indicators in urban India including life expectancy, infant mortality, diseases, etc., are quite alarming. Primarily, living and working conditions of the people in India’s rapidly urbanising scenario and the failure of the State to provide basic healthcare to a burgeoning population in cities are the key reasons for many of the prevalent health challenges," he said.
(This report is prepared by Dhaval D. Desai, Research Fellow and Programme Coordinator, ORF Mumbai)