Mumbai is a veritable healthcare Mecca. It boasts of some of the best hospitals, both public and private, and some of the finest doctors. The public health system, run by the Municipal Corporation of Greater Mumbai (MCGM) is unique and has no parallel in any city in the country. It provides healthcare at negligible costs at all levels, from primary care at its 168 dispensaries, to super-speciality services such as cardiac care and neurology at its three medical colleges.
What are the challenges that the city faces with respect to health?
Mumbai is one of the most populous cities in the world, home to 22.2 million people. It has grown rapidly in the last three decades, and healthcare services have not kept pace. The government’s district survey data for 2013-2014 cites five hospitals and 236 beds per 100,000 people. A majority of the tertiary care hospitals are confined to the old city limits, leaving the rapidly growing eastern and western suburbs comparatively underserved.
The private sector has grown indiscriminately, raising the cost of care to astronomical prices. Over 60 per cent of our people live in densely-populated slums where poor or non-existent sanitation means additional health risks, a clear and present danger. Frequent migration within the slums, and to and from them from outside the city, makes it difficult for many government programmes, including immunisation, to reach all the population. Among the poor, 80 per cent of health expenditure is out-of-pocket, and a single major hospitalisation can push a family from poverty to below the poverty line.
In 2015, there were 1,74,902 births in the city and 94,706 deaths. Over 90 per cent of deliveries took place in hospitals, although the percentage of home deliveries would be much higher in the slums. Over 50 per cent of infant mortality was neonatal deaths in the first four weeks of life.
The five major causes of death in the city are heart disease, respiratory diseases (tuberculosis, pneumonia, and chronic bronchitis), cancer, infections, and accidents, which, between them, account for 66 per cent of the deaths. The city needs to pay special attention to TB and non-communicable diseases.
Mumbai struggles to meet the needs of patients within its municipal borders, and has the additional burden of a large number of patients coming in other parts of the state and country, and even from abroad. Healthcare, to put it plainly, is out of reach for many of our citizens.
What should the focus on fixing health be? How can we ensure equitable, high-quality healthcare for all?
We need a plan. Too often, decisions on where and how health services are provided is the result of commercial interests, political pressure, or knee-jerk reaction to emergencies and epidemics. Mumbai needs a comprehensive plan that brings in all players and ensures that every patient in any part of the city has access to care. The city plan describes what type of services are required in which suburb, and depending on the need, space and permissions should be allocated to both the public and private sector.
Newer hospitals must include centres for cancer, tubercolosis, infectious diseases, and dialysis. There is a dearth of beds for patients with mental illnesses, which must be also addressed. Planning for intensive care beds, Neonatal Intensive Care Unit (NICU) beds, and beds for the growing number of geriatric patients should be kept in mind.
Healthcare for the poor also needs particular attention. The public sector must provide free services to the poorest and most vulnerable, and the National Health Mission should be rolled out on an emergency basis. Schemes such as insurance for the poor and the Rajiv Gandhi Jeevan Dayi Yogana, which offers free surgical and intensive care facilities for the poor, need to be streamlined and monitored.
Better primary healthcare
Hospitals and hospitalisation are necessary only for a small fraction of seriously ill patients, or those requiring surgery. A majority of illnesses can be diagnosed and treated by a good general practitioner. In fact, early diagnosis and treatment of many diseases — for example, respiratory ailments, diarrhoea, and malaria — can avert hospitalisation and death. Regular monitoring and treatment of blood pressure and diabetes can prevent complications. (Unfortunately, general practitioners are a diminishing breed: most young doctors opt for specialisations these days.)
Additionally, the city needs more dispensaries, and with hours that accommodate a working population. Currently, the MCGM has a total of 168 dispensaries — grossly inadequate for the existing population — many of which close by 4 pm. With the lack of options, the poor, in particular, resort to the services of unqualified doctors or charlatans. These quacks are easily found in the slums, and they are inexpensive too. But they are also responsible for, at best, late diagnosis, or worse, misdiagnosis and irrational treatment, leading to delayed hospitalisations.
Dispensaries and primary care facilities need to be increased, and located closer to vulnerable slums. They must operate for longer hours, especially early morning and evening. They also need to be staffed with trained and qualified medical practitioners and nurses. Quacks need to be regulated, and must be prevented from practising. For unserviced slums, mobile medical dispensaries should be regularly deployed, and private hospitals can be required to adopt nearby slums and offer free services.
Prevention: still better than cure
Prevention saves both lives and money. Many diseases, including diarrhoea, typhoid, cholera, and jaundice (infective hepatitis), can be prevented by ensuring supply of safe water and food, proper sanitation and following hygienic practices. Malaria and dengue, for example, are the result of breeding of mosquitoes in both fresh and stagnant waters. Others diseases can be prevented with simple home quarantines, foremost among them common infectious diseases of childhood, like diphtheria, measles, etc.
There are vaccinations that can prevent hepatitis and some forms of cervical cancer. Complete immunisation rates in the age group of 12 to 23 months are 47.89 per cent (NFHS 2014-15). These need to be enhanced to over 70 per cent. Mumbai also faces the dual burden of malnutrition. On the one hand, there is undernutrition in childhood, with 25.8 per cent of children underweight, and 23.04 per cent stunted. On the other hand, we have increasing obesity in later life, a harbinger of diabetes and heart disease.
Provide basic services to slums, including providing safe drinking water and proper sanitation and mandating hygienic food practices and handling.
Improve city planning and contingency management to prevent waterlogging and flooding. Crucial to preventative health measures is improved access to information for mothers, including the promotion of early, exclusive breastfeeding and guidelines for appropriate nutrition. Hospitals should be made baby-friendly to provide essential neonatal care.
Create awareness campaigns around the dangers of junk food and sweetened sodas to help curb childhood obesity.
Information, and information technology
Premature babies die in taxis, or outside the hospital, for want of NICU beds. Heart attack, stroke, or accident victims often do not reach the appropriate hospital in time.
Health information centres to give citizens real-time access to information about essential healthcare services in the city, including the availability of a bed, approximate costs of care, and even traffic conditions en route to the nearest hospital. Information technology can help. But IT solutions need to account for the city’s socio-economic diversity. That is, health apps and other ‘smart’ services are welcome, but there should also be a health services hotline at the press of a button. There a number of helplines already in use and these could be integrated.
You. Yes, you.
A pertinent question: does the average Mumbaikar take responsibility for her or his own or family’s health?
What food do we eat? Are we responsible for introducing junk food to our family? What is our attitude to smoking and tobacco chewing and driving drunk? Do we check our homes, our societies, our neighbourhoods, for potential breeding ground of mosquitoes? Have we ensured immunisation not only for our own children but also the children of our maids and drivers? Do we make sure the food and water served by street food vendors is hygienic and safe?
Local Advance Locality Managements (ALMs) should also function as health protection committees. Each ward must have a health committee, which includes the local elected representatives, the medical officer, and ALM representatives that will focus on health issues pertaining to the ward. The public sector and corporates should work together to create a health awareness. The public sector and voluntary organisations have an opportunity to collaborate on raising community awareness in slums.
ABOUT THE AUTHOR
Armida Fernandez has been working in the health sector in Mumbai for over four decades. She was the dean of the Lokmanya Tilak Muncipal Medical College, and started the country’s first human milk bank. Post retirement, she founded the Society for Nutrition, Education and Health Action, a not-for-profit that works on issues of health, nutrition and violence across the slums of Mumbai and neighbouring corporations. She is currently medical director of Holy Family Hospital at Bandra.
Points to ponder
The public sector must provide free services to the poorest and most vulnerable
Dispensaries and primary care facilities need to be increased, and located closer to slums. They must and operate for longer hours
Slums also need basic services such as safe drinking water and sanitation
Health information centres must give citizens real-time access to information about essential health care services in the city. There should also be a health services hotline
The Mumbaikar must take responsibility for her own and her family’s health.