Un met Need for

Public Health-Care Services

in Mumbai, India

The findings of the study very clearly indicate that the potential demand for public health ser vices is very high pro vided that they are conveniently located and afford able.

By T.R. Dilip and Ravi Duggal

 

The rural urban disparities in health outcomes in India are often attributed to urban bias in allocation of resources and location of health-care services. Statistics clearly show that the bed population ratio is higher in urban areas and that those regional inequalities have not seen any significant decline over time (Duggal and others, 1995). This regional imbalance is there in both the public and the private health sector. Further, public spending on health care is also Asia-Pacific Population Journal, June 2004 27

 

* T.R. Dilip, National Consultant, National Health Accounts Cell, Ministry of Health and Family Welfare, New Delhi, e-mail: diliptr@hotmail.com; Ravi Duggal, Coordinator and Senior Scientist, Centre for Enquiry into Health and Allied Themes (CEHAT), Mumbai, India, e-mail: raviduggal@vsnl.com.

 

28 Asia-Pacific Population Journal, Vol. 19, No. 2

Disproportionately higher in urban areas. However, while critiquing the regional bias, it is to be examined whether the urban areas in India, where 22 per cent of the population is residing in slums, has the required number of public health-care facilities. Unlike other urban areas, the matter requires special attention in an urban metropolis in India that is characterized by poor living conditions making the public more vulnerable to diseases, and where poverty levels are likely to be similar, if not worse, than that in rural areas. This could be understood by examining who utilizes those services and for what reasons. Recent all India surveys do not show any large scale rural-urban differentials in proportion utilizing public health-care services in India (NSSO, 1998). According to the survey, those seeking outpatient care services from public sector was 19 per cent and 20 per cent in rural and urban areas and for inpatient care services, it was 44 per cent and 43 per cent, respectively. Out-of-pocket average expenditure incurred on inpatient care treatment was higher in urban areas as compared to rural areas for both public and private sectors and public-private differentials in out of pocket expenditure was also higher in urban areas. Therefore, despite better physical access to health care, the higher average cost for accessing health services makes the urban poor community as disadvantaged as their rural counterparts. This means that there is an emergent need for expansion of public health services even in urban areas so as to reduce the financial burden on the urban poor. What adds to the concern vis-à-vis use of public health services is the declining trend of utilization of both ambulatory and inpatient care from the public health system. The 42nd (1986-1987) and 52nd (1995-1996) Rounds of NSSO surveys amply provide evidence for that – decline in out-patient care from about 27 per cent to 19 per cent and in inpatient care from 60 per cent to 44 per cent (NSSO, 1998). This large decline in use of public health-care services is clearly a function of the decline in public health investment during the same period (Duggal, 1997; GOI, 2002).

 

In the present paper, an analysis of utilization patterns of public health-care services at Mumbai is undertaken from the perspective of inadequate availability of such services in the city. Mumbai, the commercial capital of India is the largest city in the country carrying a population of 11.9 million (DCO, 2001).

 

The high density of population (21,190 persons per square kilometre) has put tremendous pressure on its infrastructure and amenities. About 49 per cent of the population are residing in slums, characterized by shortage of living space, water supply and sanitation facilities. Slums in Mumbai are unique in the sense that only 4 per cent are Kacha1 hutments, while 45 per cent and 51 per cent of houses in slums are Semipucca1 and Pucca1, respectively (IIPS and ORC Macro, 2001).

 

Asia-Pacific Population Journal, June 2004 29

Public health-care services in Mumbai

 

Brihan Mumbai Municipal Corporation (BMC), the largest Municipal Corporation in India, is the major provider of public health-care services at Mumbai. It has got a network of three Teaching Hospitals, 14 Municipal General Hospitals, 26 Maternity Homes across Mumbai (BMC, 2000). Apart from that there are 185 Municipal Dispensaries and 176 Health Posts2 to provide outpatient care services and promote public health activities in the city. In addition, the state government has one medical college hospital, 3 general hospitals and 2 health units, all have a capacity of 2,871 beds (GOM, 2001a).Though there is an urban bias in location of public health-care infrastructure, delivery of those services, especially in metropolitan cities like Mumbai, is again plagued by uneven public preference for health-care services. For example people living close to hospitals use them for minor illnesses, which should actually be treated in dispensaries. This is because there is a lack of an organized referral system and the result is overcrowding of public hospitals with minor ailments and under-utilization of dispensaries where the latter should actually be treated. (Yesudian, 1988). In spite of having better health-care services, there are studies that show people residing in Mumbai are not having proper access to health-care services as 32 per cent of the reported ailments remained untreated (Nandraj and others,

2001). Surveys find that seven to eight per cent of deliveries in Mumbai are still home deliveries (CORT, 2000; IIPS and ORC Macro, 2000). All those three surveys showed that the public sector is providing health care to less than 20 per cent of the population. Inconvenient location and timing is suggested as main reasons (CORT, 2000; Nandraj and others, 2001) for not utilizing services of public sector at Mumbai. But the majority of ailments recorded in those surveys were minor (non- hospitalized) ones that could be treated in dispensaries. The role of public sector in providing inpatient care services is quite high, since hospitalization is relatively a rare event and where the cost involved is high enough to push the ailing person’s family into debt (Peters and others, 2002). As far as the utilization of inpatient care services are concerned, the majority of patients use

public hospitals while the lower income groups mainly utilize public health-care services at Mumbai (Yesudian, 1988; Garg, 1994).

 

Moreover, service statistics clearly show that public hospitals are overloaded with patients (GOM, 2001b). Those public hospitals are not only major caregivers for a large section of the population in the city but are also used by persons from rural areas of nearby districts. BMC is also a major health-care provider for women and children at Mumbai. The Reproductive and Child Health Survey (CORT, 2000) has shown that the public sector is a major provider of immunization and family planning services plus a sizeable proportion of the population in this district were depending on public sector for antenatal care services (40 per cent) and child birth (48 per cent). An analysis of BMC dispensaries in two wards at Mumbai showed that an average of 85 patients are treated every day (Duggal, 2000), 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 (Yesudian, 1994).

 

The study and methods

The data analysed here were collected for a demand assessment survey conducted in December 2001, in relation with the BMC’s plan to set up a municipal general hospital in one of it’s wards. This ward is unique in the sense that it is the most populous ward as per the 2001 census (DCO, 2001) in Mumbai with a population of 806,360 (32,938 persons per sq. km.) and yet it does not have a single public hospital within its limits. The only public health-care facilities available within this ward are the 3 municipal maternity homes, 11 municipal dispensaries and 11 health posts. At the same time, there were 114 private hospitals and nursing homes functioning in the area (Nandraj and others, 1998). The utility/need of a public health facility (here a public hospital) can best be understood if one tries to imagine what would happen if that particular facility were not available in the locality. Thus a unique advantage of this data set is that it helps understand this

hypothetical situation to a certain extent. In the study ward, the population has two options for meeting their inpatient care needs; one is to seek care from public hospitals outside their locality or to seek care from private health-care services within or outside the ward.

 

The survey was conducted in three health post areas, which are in the vicinity of the plot for the proposed municipal general hospital. Health posts which are established to render health services to the poor population in urban areas have got administrative boundaries and this facilitates defining the sample frame. Each of those health post areas is divided into sections, each of which is served by two to three health workers. Sections formed the primary sampling units for the study and three sections were selected from each of the health posts that were selected for the study. A total of 120 households were targeted for survey from each section. Thus the present data are on the basis of a rapid household survey which covered 1,035 households in the study area using a stratified systematic sampling procedure (Dilip and Duggal, 2003). The respondents were the head of the household or in their absence, adult members in the household. Here an analysis of households’ preference for health-care services and choice of health-care service from both the public and private sector is undertaken to assess the utility of public health-care services in the metropolitan cities. Similar studies which have used information on the regular source of health care (IIPS and ORC Macro, 2000; Merzel and Howard, 2002) show that socio-economic factors play an important role in gaining entry into the heath-care system.

 

Characteristics of sample households

A brief description of households surveyed is as follows (Dilip and Duggal, 2003). The majority of the households were having four to six members and the average family size was 5.4 members per household. The mother tongue spoken was Marathi in 48 per cent of the sample households, while Hindi and Urdu were also spoken in a sizeable proportion of households. Households mainly belonged to the Hindu (73 per cent) and Muslim (24 per cent) community. Median monthly income of households was reported to be 3,000 rupees (1USD = Indian Rupee 48 at the time of the study), with 52 per cent households in 2,000-4,000 monthly income group. The type of residence was mostly chawls3 (92 per cent).

 

Only 4.5 per cent were residing in apartments, while the remaining 2.6 per cent were residents of slum/kacha structures. It was found that 75 per cent of dwellings were occupied by owners themselves while the remaining were occupied by tenants. Information on years of stay in the dwelling showed that the majority (about 75 per cent) had been staying in them for more than 10 years, with average number of years of stay in the same dwelling being as high as 23 years.

 

In brief, the study area is a mix of lower class and a lower middle class community, depicting a typical poor settlement in a metropolitan city. Type of housing and years of stay hints that the location was essentially a slum which got transformed into chawls with extended years of stay, a phenomenon which is common in cities like Mumbai. Moreover housing characteristics show that the community is well settled and this is important from the access perspective because such communities have a stake in the city.

 

General source of health care for the household

Health-seeking preferences of the household is studied by asking the respondents about the major source of health care for the household for treating ailments requiring inpatient and outpatient care services. About 54 per cent (table 1) reported that they generally took inpatient treatment (if required) from the private sector. Another 40 per cent reported that they preferred services provided by BMC for treatment of ailments involving hospitalization. This in fact is quite high considering the fact that the study area or the nearby locality does not have a BMC owned public hospital. “Other public facility” are the state government owned and ESI/Insurance related facilities which account for only 4.5 per cent of preference for such hospitals.

 

 

Table 1. Percentage distribution of reported source of
health care for the households
Type of health facility	Inpatient care	Outpatient care
BMC facility	40.3	14.4
Other public facility	2.3	2.0
ESI/Insurance related	2.2	0.5
Private sector	53.8	82.4
Charitable institutions	1.4	0.6
Others	—	0.1
Total	100	100
Number	1,029	1,033

 

Public preference for outpatient care services from a BMC facility 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 per cent). 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.

 

Reasons for preferring public/private sources of treatment

The respondents who reported about health-seeking preferences as public/private sector were further queried about the major reasons for seeking care from that corresponding source (public or private) of treatment. Results (table 2) show that “Cost is affordable” as the major reason (65 per cent), which makes them prefer services in public sector for inpatient care services. The main reason reported for choosing private hospital was it being the “Nearest facility” (45 per cent). It should be noted that another 30 per cent reported “no other option” as a reason for preferring treatment from private hospitals; this indicating that if a convenient public option were available, preference for it would increase for about one third of the people who currently use private hospitals. Interestingly in terms of quality of service, the public hospitals seem to be scoring over private ones in people’s preference ratings.

 

 

Table 2. Percentagea/ of respondents citing selected reasons reported for preferring to take treatment from a particular source
	Inpatient care treatment		Outpatient care treatment
Reason reported
	Public sector Private sector		Public sector Private sector
Nearest facility	8.4	44.6	55.0	78.6
Convenient timing	5.1	17.4	14.9	11.0
Offers good quality service	32.6	23.3	24.6	13.6
Cost is affordable	64.5	10.8	31.5	1.4
Availability of medicines	1.4	1.8	1.2	1.6
No other option	6.8	29.6	6.3	15.6
Others/Missing	1.5	3.2	2.9	2.4
Number	463	569	175	858

a/ Percentages do not add up to 100 because of multiple responses in some cases.

 

For outpatient care services where 82 per cent (table 1) preferred services in private sector, 78 per cent among them reported “nearest facility” as a reason for doing so. Among those utilizing services in public hospital, it can be seen that “nearest facility” (55 per cent) “cost is affordable” and “good quality service” as reasons for seeking care from a public sector. All those indicate that outpatient care services in the public sector are mostly utilized by the population residing near the public facility and by those with limitations in paying for health care. This also means that if physical access to OPD facility improves, then more users will shift to the public sector.

 

Choice of health care

As mentioned earlier, proximity/distance is the major reason for choosing

services (table 2). Therefore the respondents were asked about the choice of health care if both the public and private health-care facilities were made available to them. In such a situation, 83 per cent and 88 per cent reported that they would prefer to utilize services in the public sector for outpatient and inpatient care, respectively (table 3).

 

 

Table 3. Type of facility preferred by households if both public and private health facilities were available to them
Percentage preferring
Public facility Private facility			Total (N)
Outpatient care services	83.4	16.6	100 (1,001)
Inpatient care services	88.1	11.9	100 (1,008)

 

 

Table 4. Percentagea/ of respondents citing selected reasons reported for preferring to take treatment from public/private if both services were available to them
Reason reported	Inpatient care treatment		Outpatient care treatment
	Public Private		Public Private
	facility facility		facility facility
Nearest facility	29.3	59.9	11.9	30.9
Convenient timing	6.5	11.4	5.1	19.2
Offers good quality service	20.0	25.2	20.3	44.4
Cost is affordable	57.5	6.6	72.0	4.1
Availability of medicines	1.5	3.6	4.7	7.5
No other option	4.1	2.4	6.6	5.8
Others/Missing	5.1	3.6	5.2	8.4
Number	841	167	882	119

a/ Percentages do not add up to 100 because of multiple responses in some cases.

 

The reasons for such a reversal in choice of health care are presented in table 4. Here also affordability appears as a major reason for choosing public sector if it is available to them. The reason that “Cost is affordable” has been reported by 58 per cent and 72 per cent of respondents as their choice for public sector for inpatient and outpatient care services, respectively. It hints that non-availability of public facility in the locality is a major factor that drives the community to seek care from the private health sector. Owing to a lack of public health-care services in the locality, there exists a sizeable section of the population who are forced to seek care from the private sector. That clearly points to the need to strengthen public health-care services. Further, enhancing user charges could prove fatal for the public health system since people reported “Cost affordable” as a major advantage of the public health-care system.

 

Unmet need for public health facilities

From the previous section one notes that a large section of the population are seeking health-care services from the private sector even if they are not interested in doing so. Here, an attempt has been made to find out the intensity of this problem in the population under study. The need for a public/private facility is considered to have been met, if the “current choice” for source of health care for the household matches with the “preference” for source of health care, if both public and private facilities were made available to the household. If those two responses do not match, then there is an unmet need for a public/private health-care facility in the population.

 

 

Table 5.	Unmet need for public/private facility for inpatient and outpatient care services in the population (figures are in percentages)
Inpatient careservices			Outpatient careservices
Current choice public and preference also public(met need for public health facility)		43.7	16.0
Current choice public but preference is private (unmet need for a private health facility)		1.2	1.0
Current choice private but preference is public (unmet need for a public health facility)		44.4	67.4
Current choice private and preference also private(met need for private health facility)		10.7	15.6
Total		100.0	100.0
Number		999	1,006

 

Table 5 indicates that the unmet need for inpatient care services from public facility is 44 per cent in the population, that is that 44 per cent of the population are forced to seek inpatient care services from the private sector. For outpatient care services, the unmet need for public facility is even higher at 67 per cent. At the same time, the unmet need for inpatient care services and outpatient care services from the private sector was negligible (only about 1 per cent). It has been mentioned previously that 114 private hospitals and dispensaries are already functioning in the study area (Nandraj and others, 1998). Hence, residents in the area are least likely to benefit from any further addition in the number of private health-care facilities. This has policy implications for regulating the spread of the

private health-care sector on a geographical basis and at the same time for considerable expansion of public health-care facilities. Also, there exists a segment of the population who solely depend on public health care services, which comes under the “met need” category, that is 44 per cent for the expensive inpatient care and 16 per cent for outpatient care which is relatively cheaper.

 

Utilization of public health-care services and unmet need

for public facility by income level

As in the case of any other population in India, a higher proportion of poorer sections were reported to be preferring to seek treatment from public healthcare providers in the public sector. About 57 per cent of the population belonging to the “less than 2,000 rupees” income category reported to seek inpatient care from public sector, while only 33 per cent in the highest income category reported the same. The income- wise differentials in households preference for outpatient care services also showed a similar trend. However, the situation is likely to change if both the public and private health-care facilities were made available to them.

 

 

Table 6. Percentage of households preferring treatment from publichealth-care sector and percentage of households having unmet needfor public health-care facility by level of household income
			Per cent		Per cent
Monthly income ofhousehold (in Rupees)			preferring publicsector for		having unmet need forpublic facility for
			Outpatient Inpatient		Outpatient Inpatient
			care care		care care
			services services		services services
Less than 2,000			22.8	56.5	63.2	37.1
2,000-4,000			18.3	46.3	66.1	42.7
4,000 and above			10.0	32.5	72.0	53.3
Total			16.9	44.8	67.4	44.4
Note: US$ 1	=	Rs. 45.55.

 

The proportion experiencing unmet need for public health-care services increases between the lowest and highest income groups from 63 per cent to 72 per cent, and from 37 per cent to 53 per cent for inpatient care services and outpatient care services, respectively. This gives a clear indication of the fact that given a choice even the relatively higher income groups would prefer public services.

 

Furthermore, it appears that the level of unmet need for public health-care services depends on household’s potential to seek treatment from alternate sources of care. Poverty is driving households belonging to lower economic groups to public health

facilities located at far of places to meet their health-care needs, since they do not

have the necessary purchasing power to seek treatment from the private sector.

 

Discussion

The study brings out how a largely poor urban community in the biggest

metropolitan city in India is lacking access to public health-care services. The

non-availability of a public hospital within or in close proximity to their locality

and an inadequate number of public dispensaries makes life difficult, especially for

the poor who too are forced to seek care from the private sector. The findings of the

study clearly indicate that the potential demand for public health services is very

high provided they are conveniently located and affordable. In fact, given the

choice, a large proportion of users of private health services would prefer making

use of public health services.

 

The population under study being from the lower and lower middle class and their disposable incomes being very limited, it is natural that they have overwhelmingly indicated that, given the choice, they would prefer using public health services. This is so, because that is clearly the less costly option, while it also does not give rise to unnecessary medication, diagnostics and procedures. This would be true at the larger level across the country given the overall context of poverty. Thus the role of the State in such a context becomes very crucial and hence the public health services have to be geared towards meeting the demands being made on them. In today’s scenario, with declining public investments and expenditure in healthcare and the introduction of user charges, the expectations of people, especially the poor, are being belied. The people have great faith in the public system and expect social support from the state for services like health, education and housing – the three critical elements of social security.

Given the responses on the unmet need expressed by respondents, it is evident that if public health services were in easy access range and well provided, then 88 per cent and 83 per cent of the population would use public health services for hospitalization and ambulatory care, respectively. This is in sharp contrast to the actual utilization pattern within the same community. This gap reflects the inadequacies within the public health-care system, both with respect to numbers or physical access and in terms of adequacy of resources and quality of care. By contrast, the private health sector fulfils those expectations yet at a tremendous cost to the patient.

 

Therefore, the State must assume a more proactive role in strengthening access and quality of care of its health services for its citizens. That would mean not only more resources to be allocated for health care in its budgets but also increased efforts into improving allocative efficiencies so that resources are better and more effectively utilized. For instance, even from the existing budgets, if more resources are allocated to dispensaries, if dispensaries and health-posts are integrated, if a referral system for hospitals is put in place and graduates passing out of public medical schools compulsorily put in three to five years of public service as a return for the virtually free medical education they have received, and other similar measures, then the effectiveness of the public health-care system will improve tremendously and it will regain the esteem and respect it enjoyed until recently.

 

Acknowledgements

We take this opportunity to thank Brihan Mumbai Municipal Corporation (BMC) for entrusting CEHAT to undertake this study. Thanks are also due to the anonymous reviewers from the Board of the Asia-Pacific Population Journal for their stimulating comments, which has contributed significantly to improving this paper.

Endnotes

1. The classifications Kachha, Semipucca and Pucca are on the basis of the type of house construction.

Kachha are the ones made from mud thatch or other low quality materials, Semipucca are made from partly high and partly low quality materials, and Pucca are made with high quality materials.

2. “Health Posts” are set up in the community to deliver preventive and promotive health-care services and is expected to cover a population group that has 40 per cent of its constituents living in slum or slum-like localities. Each Health Post covers an average of 50,000 population.

3. Chawls are pucca and semipucca a set of houses with common walls and shared toilets and bathrooms.

4. Cross practice refers to ayurvedic, unani and homeopathic practitioners who also prescribe allopathic medicines.

 

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