INTRODUCTION
Globally, the on-ground anti-COVID-19 strategy has been driven by urban local bodies:[1] they conduct tests, set up isolation facilities, and assist medical practitioners in treating patients. As COVID-19 infection numbers soared across India beginning March 2020 and hospitals reported shortages in beds and medical staff, local authorities began setting up isolation centres and makeshift health facilities in their jurisdictions.
Mumbai, India’s financial centre and one of the world’s most densely populated cities, struggled to handle the pandemic like many other metropolises. The city could not sufficiently provide for its residents’ public health needs, exposing the already overburdened processes and systems that have plagued urban local bodies, which have been mandated by the Constitution to ensure adequate public health infrastructure and services. The Municipal Corporation of Greater Mumbai (MCGM) had to rely on private hospitals and set up quarantine facilities in sports centres and open grounds to tackle the outbreak.[2] Mumbai has since created temporary systems to deal with the pandemic.
This paper makes an assessment of the capacity of Mumbai’s development plans (DPs) to provide for the city’s health needs. It studies the current 2034 DP and its predecessor (1991 DP) through an urban planning lens. Urban planning is concerned with integrating various physical, social and economic functions over a particular space,[3] to reduce imbalances in these functions in the areas being planned and distribute the benefits of urbanisation across the population for minimal disparities in access to resources.
Urban local bodies are tasked with preparing DPs for cities. DPs are statutory and include detailed strategies and proposals based on the people’s socio-economic needs and aspirations and the available resources and priorities.[4] The plans calculate the amenities required by the city population as per the available area, and reserves spaces or create provisions for amenities like health facilities.
According to the 2014 Urban and Regional Development Plans Formulation and Implementation (URDPFI) Guidelines,[5] DPs should account for the provision of hospitals, health centres, nursing homes, dispensaries, clinics and health posts. The URDPFI also lays down the norms for providing such facilities based on the population size and ease of access.[6]
URBAN HEALTH PLANNING IN MUMBAI
Mumbai reported a high number of COVID-19 cases daily between April and June 2020.[7] During this time, shortages of public hospital beds and other medical facilities were widely reported,[8] highlighting the deficiencies in the city’s public health infrastructure, the development of which is part of the city’s DP. The MCGM prepares 20-year DPs for Mumbai—the 2034 DP is currently in force (since September 2018) and the previous plan, the 1991 DP, was in effect for nearly 30 years.[9]
To determine the amenities that should be included in the DP, the MCGM adheres to the functions listed in the Twelfth Schedule of the Constitution, which details the powers, authority and responsibilities of municipal bodies, including the provision of “public health, sanitation conservancy and solid waste management” facilities.[10] Additional duties are also determined by the Mumbai Municipal Corporation Act 1888 (MMC Act)[11] and the Maharashtra Regional and Town Planning Act, 1966 (MR&TP Act).[12]
Section 22 of the MR&TP Act discusses the provision of land for public amenities, such as for education, health, social and cultural purposes; for public entertainment and government use; as open spaces and for sports facilities; for transport and communication purposes; as community facilities; or for industrial and commercial functions.[13] Section 61 of the MMC Act lists the MCGM’s obligatory duties, including “measures for preventing and checking the spread of dangerous diseases” and “establishing and maintaining public hospitals and dispensaries and carrying out other measures necessary for public medical relief”.[14]
However, Mumbai’s DPs have failed to account for emergencies and other events that could dictate development trends beyond the primary mandate of reserving land for medical (and other) amenities. In health emergency like the COVID-19 pandemic, protocols detailed in the National Disaster Management Plan (NDMP) are followed. The goal of the NDMP is to “make India disaster-resilient, achieve substantial disaster risk reduction, and significantly decrease the losses of life, livelihoods, and assets — economic, physical, social, cultural and environmental — by maximising the ability to cope with disasters at all levels of administration as well as among communities”.[15] However, this vision is disconnected from the various aspects of planning and is thus tough to achieve.
Although Mumbai is spread over a 603 square kilometre area, the MCGM oversees only 458 square kilometres and plans for only 415.05 square kilometres.[16] The rest of the Mumbai land is under the jurisdiction of multiple authorities, such as the Slum Rehabilitation Authority, the Special Purpose Authority (SPA) set up for Dharavi redevelopment, the Mumbai Port Trust, the Mumbai Metropolitan Region Development Authority and the Maharashtra Industrial Development Corporation, as well as the central government.[17] However, the MCGM’s policies apply to all of Mumbai’s approximately 12.4 million people.
Geographically, Mumbai is divided into Greater Mumbai in the south (island city), and the western and eastern suburbs in the north (suburban Mumbai). The Bombay City Improvement Trust was established in the aftermath of the 1898 plague epidemic and created the DP that extended the main city into the suburbs by joining the seven islands that now constitute Mumbai.[18]
Mumbai is divided into two district zones led by the Mumbai island city and Mumbai suburban collectorates, and further into 24 wards (nine under the island city limits and the rest in suburban Mumbai). Of the 458 square kilometres under the MCGM’s jurisdiction, including areas under some SPAs, 387 square kilometres is in suburban Mumbai and the rest in the island city area. While 24 percent of the population resides in the island city area (which makes up for 15 percent of the total area), 76 percent live in suburban Mumbai.[19] Suburban Mumbai has seen rapid development and the DPs have been unable to keep pace with the changing needs of this area.
The MCGM provides primary level care through health posts, dispensaries and postpartum centres; secondary care through maternity clinics, peripheral and speciality hospitals; and tertiary care through hospitals, including medical colleges. Private dispensaries, nursing homes and hospitals make up for the deficit in the public health facilities. The total daily patient count is 35,600 in all corporation-run public hospitals (peripheral, major and specialised), 16,505 in dispensaries, and 1,600 in maternity homes.[20]
Mumbai’s Development Plans: A Survey
The 1991 DP, based on the 1996 URDPFI Guidelines, came into force during India’s economic liberalisation. It did not prepare for Mumbai’s unprecedented growth and was widely criticised for its conservative population projections for 2001 (Census year)—while it planned for a projected population of 98.07 lakh people, Mumbai’s population grew to 119.78 lakh by 2001.[21]
The DP proposed that the city’s new wave of development be triggered by creating residential and commercial growth centres in the suburbs and the required amenities, including health, be planned differently for the island city and suburban Mumbai (see Table 1).
Table 1: Medical space provision standards under the 1991 DP
|
Island city |
Suburban Mumbai |
| Population |
3085411 |
9356962 |
| Proposed reservation dispensary |
0.013 square meters pp |
0.013 square meters pp |
| Proposed reservation Maternity Home |
0.021 square meters pp |
0.042 square meters pp |
| Proposed reservation Hospital |
0.167 square meters pp |
0.33 square meters pp |
| Space specification for dispensary |
1 dispensary/50,000 population – Area of site 668.9 square meters, covering an area of 1.5 km radius |
1 dispensary/50,000 population – Area of site 668.9 square meters, covering an area of 1.5 km radius |
| Space specification for maternity home |
50 beds/ 1,00,000 population -Area of site, 41.8 square meters/bed |
50 beds/1,00,000 population- Area of site,83.61 square meters/bed |
| Space specification for hospital |
4 beds/1,000 population- Area of site- 41.8 square meters |
4 beds/1,000 population- Area of site- 83.61 square meters/bed |
Source: Municipal Corporation of Greater Mumbai health department[22]
Although the planners were able to achieve some balance in providing medical infrastructure across the city, they were “unable and unwilling to address the reality in front of them” of the growing population and appeared to be “planning for an alternate, utopian/ideal future outcome”.[23] This meant that the amenities and infrastructure eventually proved insufficient to cater to the growing population. The shortcomings of 1991 DP became more evident after the 2012 existing land use (ELU) study,[24] which the 2034 DP has attempted to address.
2012 Existing Land Use
At the start of the planning process, urban local bodies conduct ELU studies to map and describe the amount of land in each land use category (residential, industrial, commercial) and the distribution of uses throughout the study area.[25]
The 2012 ELU revealed that only 271.17 square kilometres (65.34 percent) of the 415.05 square kilometres of the MCGM’s planning area was developed. Medical amenities were made available only on 31.84 kilometre—or 1.17 percent—of the developed land, amounting to 0.77 percent of the total planning area.[26] Provisions were made for private hospitals on 62.97 hectares of land (0.63 square kilometres) as opposed to 56.05 hectares (0.56 square kilometres) for municipal hospitals, and municipal and government hospitals in suburban Mumbai were allotted less land than in the island city (see Table 2).
Table 2: Break up of actual land used for medical amenities (in hectares)
| Type |
Total land |
Island City |
Suburban Mumbai |
| Municipal Hospital |
56.05 |
32.7 |
23.35 |
| |
|
|
|
| Private Hospital |
62.79 |
20.55 |
42.23 |
| |
|
|
|
| Government Hospital |
58.57 |
54.18 |
4.39 |
Source: 2012 Existing Land Use[27]
In instances of public land being reserved for private hospitals, the MCGM grants several concessions, such as providing additional floor space for construction. In turn, the private hospitals are expected to provide free medical treatment to patients from economically weaker sections (to at least 20 percent of its total bed capacity) and treat at least 10 percent of people in its out-patient department free of cost.[28]
A study mapping the medical amenities in the MCGM’s planning area[29] against the standards prescribed by the National Urban Health Mission (NUHM)[30] highlighted the shortage of medical facilities in the city—Mumbai currently has a 70 percent deficit in health posts and dispensaries, a 79 percent deficit in maternity homes and a 55 percent deficit in hospitals (see Table 3). Of these facilities, the MCGM operates 26 maternity homes, 160 dispensaries, 183 health posts and 24 small and big municipal hospitals, peripheral and specialised hospitals and medical colleges.
Table 3: Shortage of medical facilities in Mumbai in numbers
| |
Health posts and Dispensaries |
Maternity homes/wards + post-partum centres |
Hospitals (Municipal + State-run) |
| Island City |
118 |
13 |
12 |
| Suburban Mumbai |
225 |
36 |
16 |
| Greater Mumbai |
343 |
49 |
28 |
| NUHM standards |
1197 |
239 |
62 (50 General hospitals and 12 speciality hospitals) |
| Deficit (Units) |
854 |
190 |
34 |
| Deficit (Expressed as %) |
70% |
79% |
55% |
Source: MCGM preparatory study and ELU 2012 survey, UDRI, NGO Praja Report, NUHM[31]
There are also widespread discrepancies in health infrastructure planning for the island city and suburban Mumbai. Although only 24 percent of Mumbai’s citizens reside in the island city, they have access to 12 public hospitals, while the 76 percent who live in the suburbs have access to only eight such hospitals.[32] This is grossly inadequate to meet the economically weaker section’s needs, given that 76 percent of the total urban population is concentrated in suburban Mumbai[33] and heavily reliant on public health facilities. Only 31 percent of Mumbai’s total population accesses public medical facilities, and 65 percent of the economically weaker section are forced to use private and charitable health facilities.[34]
Merely allocating space for medical facilities is insufficient. “The mere use of demographics can lead to overestimation or underestimation of required bed numbers. Therefore, in addition to demographic changes, the impact of technological advances, periodic crises, emerging diseases, and epidemiology must be accounted for” in urban plans.[35]
The 2034 DP was formulated through a participative process to determine the needs of the city.[36] Meetings and interactions with health, education, social welfare, gender, housing and other experts were held to make the plan more integrated.
It did away with having separate provisions for the island city and suburban Mumbai and determined these based on the per capita benchmarks and the new population projection of 12.79 million for entire Mumbai. This ensures that high-density areas will have a greater provision of health amenities.
The DP also considered that several private dispensaries, maternity homes and consulting clinics are located on a single floor of a building used for residential/commercial purpose,[37] which was not considered and accounted for in the 2012 ELU. This is important because such facilities cater to the population and must be accounted for to get a realistic picture of medical facilities.
It identified a health infrastructure provision of 0.419 per square metre per person to ensure that all amenities across the city get an equal reservation. Maternity homes have a fixed provision of 0.045 square metres per person, hospitals have 0.360 square metres per person, and dispensaries 0.014 square metres per person (see Table 4). To meet this requirement, Mumbai will need 537 hectares of land (121.18 hectares in the island city and 415.88 hectares in the suburbs). However, the 2034 DP earmarks only 403 hectares for health amenities, a shortfall of 134 hectares.[38]
Table 4: Medical amenity provision in 2034 DP
| MEDICAL AMENITIES (0.419 square meters pp) |
| Dispensary |
0.014 square metres per person |
| Maternity home |
0.045 square metres per person |
| Hospital |
0.360 square metres per person |
Spatial gaps are apparent when the provisions determined in the 2034 DP are compared to existing health amenities and projected demand (see Table 5). The gap analysis highlights what is required to meet the minimum health standards of 0.419 square meter per person of health amenities.
Table 5: Spatial data on health amenities
Source: 2034 DP, Census 2011, 2012 ELU[39]
The following inferences can be made from the spatial data (Table 5):
- Mumbai has a 134-hectares spatial gap for health amenities, even after creating space for new health amenities in the 2034 DP
- Suburban Mumbai has a deficit in health amenities. It requires 192 hectares of space to meet the medical needs of its population but currently has only 115.32 hectares. In contrast, the island city needs 58 hectares and has designated 161.2 hectares, almost double the land required for health amenities
- The existing developed area for health infrastructure is about 51 percent of the 2034 DP requirement
The 2034 DP has provided new locations for hospitals and institutes of medical research and has suggested that the “health services of the city will fare better if they are supported by greater space allocation to older nationally reputed hospitals or more branches at fresh locations in the city where space is available. The city should also encourage newer entrants in areas in which Greater Mumbai is deficient”.[40]
Importantly, although private hospitals were previously allotted land on the condition of setting aside 10 percent of their beds for the economically weak, this has not been monitored.[41] Another issue impacting the implementation of the DPs and the augmentation of medical amenities is the unattractive land policies for private owners, such as the accommodation reservation rule,[42] which stipulates that a private landowner be adequately compensated for giving out part of their land for public use. If all reservations mentioned in the DP (59.43 million square metres) are to be acquired, the civic body will need to spend INR 12,198 billion (at 2013-14 prices).[43]
However, according to the 2034 DP, “reservations were still viewed as a negative imposition” by private owners. It added: “Since reservations are for the purpose of public amenities enjoyed by the entire city population at the cost of the reserved landowners, it is only fair and equitable that the reserved landowners get adequately compensated,” but an “adequate compensation formulae had not been worked out by the policymakers making it difficult for land acquisition”.[44]
Additionally, the costs required to acquire land for asset building are out of the reach of most urban local bodies in the country, including the MCGM since most of its funds are earmarked for wages and other administrative expenses.[45] Regulations such as the Rent Control Act (1947) and Urban Land Ceiling Act (1976) exacerbated land demand and saturated housing stocks, resulting in the city having the world’s 16th highest residential property rates.[46]
Urban Budgets
An examination of the MCGM’s three most-recent civic budgets shows that there were minor changes in revenue and capital expenditures related to public health facilities (see Table 6). In 2020-21, the civic body allotted INR 4260 crore (13 percent of its total budget) to run existing public health facilities, INR 3211 crore has been allotted for revenue expenditure (primarily administrative expenses) and INR 1049 crore for capital expenses (permanent repairs, purchasing equipment).[47]
Since 2018-19, despite an increase in the demand for facilities, almost the same percentage of financing has been allotted, leading to severe shortfalls in provision (as exposed during the COVID-19 crisis).
Table 6: A three-year expenditure evaluation for public health in the MCGM budget
|
2020-21 |
% of total expenses |
2019-20 |
% 2019-20 |
2018-19 |
% 2018-19 |
| Revenue expenditure for public health |
3211 |
17 |
3345 |
17 |
2905 |
16 |
| Capital expenditure for public health |
1049 |
7 |
806 |
7 |
732 |
8 |
| Total MCGM budget |
33441 |
|
30692 |
|
27258 |
|
| Public health expenditure as a % of budget |
13 |
|
13 |
|
13 |
|
Source: MCGM budget 2020-21[48]
An analysis of the MCGM budget shows that barely 17 percent of the city budget’s total revenue is directed to expenses related to health amenities, which makes up only 7 percent of the asset creation in terms of capital expenses. This has been an important contributor to the poor implementation of the city’s spatial health provisions.
The city and state governments must focus on improving Mumbai’s health infrastructure to meet global standards and cater to the demands of the rapidly growing migrant population. Mumbai’s private healthcare sector is of superior quality, and the governments must consider promoting it for health tourism to reap economic dividends. This will require additional funds to support the city, but recent changes to taxation laws[49] and policies have hit the city’s revenue streams.[50]
The existing budgets need to be adequately complemented with a special investment fund to enhance Mumbai’s health infrastructure[51] through public-private partnerships or health bonds.
Poor Implementation
While funding remains a major challenge in achieving health infrastructure planning targets in cities, the implementation of DPs is another serious challenge. While there is great emphasis on planning, little attention is paid to the implementation process. An analysis of the 1991 DP reveals that only 33.65 percent of the actual plan was implemented; health amenities, which fall under social infrastructure, saw only 31.29 percent implementation (see Table 8).[52]
Table 8: DP 1991 implementation
| SECTOR |
AREA RESERVED (Ha) |
IMPLEMENTED |
% IMPLEMENTED |
| Physical infrastructure |
1150 |
453 |
39.39 |
| Social infrastructure |
3195 |
1000 |
31.29 |
| Others |
5338 |
1806 |
33.83 |
| TOTAL |
9683 |
3259 |
33.65 |
Source: Revised Draft Development Plan Report 2014-34[53]
According to the 2034 DP, the poor implementation is attributable to two main factors—the inability to fund the implementation of the DP, and the disengagement of the DP from the annual budget formulation exercise. The “lack of resources for DP or disregard of DP leading to sizeable amenity deficits will only lead to [a] progressive drop in quality of life”.[54]
Although the 2034 DP has identified a more robust source of funding for its implementation (the accommodation reservation rule), this will also not suffice to meet the city’s growing demands and fulfil the health targets.
DPs are the outcome of a multi-layered process, with several revisions at the urban local body and state government level. The 2034 DP was adopted in September 2018 after a four-year delay. The 1991 DP also saw similar setbacks. A separate assessment of the finalisation process must be conducted to eliminate causes for delays in the spirit of the 74th Amendment of the Constitution.
In 2018, the MCGM proposed establishing a separate cell to oversee the DP’s implementation, recruit professionals from the planning and geospatial sectors, create a databank and provide inputs to the MCGM’s planning team.[55] However, no progress has yet been made on this front.
CONCLUSION
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