Data shows Mumbai citizens' healthcare costs spiralling; authorities must ensure last-mile service delivery by strengthening dispensaries

A white paper on healthcare released recently in Mumbai by NGO Praja Foundation has shown that people in the city spend an enormous percentage of their household incomes on accessing basic health services.

According to the data released, on an average, people spent 9.7 percent of their annual income on healthcare in 2019. If we take the per capita income of the city to calculate actual expenditure on health, we see a drastic increase in overall health spending from Rs 19,209 crores in 2017 to Rs 27,795 crores in 2019 (a 45 percent rise in two years). It is crucial to examine the reasons behind this state of affairs.

One clue in this regard is provided by data for government-run OPDs (Out-Patient Departments) in Mumbai in 2018. The numbers show that 76 percent of the total OPD patients went to government hospitals while only 24 percent went to dispensaries. It is worth pondering as to why people seem to prefer hospitals over dispensaries for accessing basic healthcare services.

In Mumbai, dispensaries managed by the Municipal Corporation of Greater Mumbai (MCGM) are meant to serve as primary health care units. Mumbai has a total of 181 municipal and 12 police dispensaries. However, the worrying aspect is that there is only one public dispensary for 64,468 people. Although the National Urban Health Mission (NUHM) states that there should be one public dispensary for every 15,000 persons, none of Mumbai’s administrative wards meet this requirement. In fact, in four wards (Andheri West (K/W), Malad (P/S), Dahisar (R/N) and Mulund (T), there is only one dispensary for more than one lakh people.

It is important to note that most public dispensaries offer allopathic services only, while there are only four ayurvedic, one unani and no homeopathy dispensaries in the city. A majority of the working population is unable to access public primary healthcare since municipal dispensaries function only from 9 am to 4 pm (with a one-hour lunch break).

Consequently, people either access government hospitals or private health facilities for their basic health needs. Of the 20,187 households surveyed by the Praja Foundation, almost half (49 percent) of the respondents use private healthcare facilities. Those who cannot afford private healthcare have to commute to government hospitals for accessing out-patient services.

At the national level, the Ministry of Health and Family Welfare announced 1.50 lakh ‘Health and Wellness Centres’ (HWC) to be set up as public primary health units under the Ayushman Bharat scheme by 2022. For the same, an amount of Rs 250 crores was allocated for the urban sector. However, little improvement has been seen in the city’s public health system.

Further, the MCGM spent 74 percent of the revenue health budget in 2017-18 on hospitals while only 26 percent was spent on dispensaries. In terms of human resources in municipal dispensaries, there was only one medical staff member per dispensary, while there were 48 medical staff members available per municipal hospital. There is also a significant percentage of sanctioned posts that are yet to be filled in municipal dispensaries (19 percent) and hospitals (26 percent) in 2018, clearly suggesting that dispensaries are understaffed to serve the population.

All this does not present a good public health picture. The city’s maternal mortality ratio is still double that of the target to be achieved by 2030. Fifteen people in the city died of tuberculosis every day in 2018. There were 374 cases of tuberculosis per 1 lakh population, while the target to be achieved is zero cases per 1 lakh population.

The issue at hand is not merely one of achieving targets, but also of realising the goal of affordable, accessible and quality healthcare for all. Healthcare systems across the world have succeeded by focusing on the base – building a strong preventive and primary care at the community level. For example, Cuba has an effective multi-specialty community-based polyclinic for primary healthcare. Similarly, Sri Lanka improved its health indicators through timely preventive and primary care.

It is, therefore, important that primary health care (dispensaries) is revamped for a holistic change in the functioning of the healthcare system. The recommendations of the National Health Policy, 2017 for Health and Wellness Centres (municipal dispensaries, rechristened) as the platform to deliver comprehensive primary healthcare and commitment of two-thirds of the health budget to primary healthcare needs to be implemented in spirit.

Availability of public health care at the level of the citizens’ locality needs to be ensured by better coverage, and also accessibility through improved timings (such as from 8 am to 10 pm).

There is a dire need to increase the number of personnel in government facilities, to ensure effective delivery of health services. This can be done by not only allocating more than one general doctor per dispensary but also through visiting specialist doctors. The MCGM dispensary thus needs to be converted into a multi-specialty clinic, with a focus on AYUSH services as well. Special courses for skill-based learning of doctors and nurses need to be conducted to enable them to provide preventive and primary care for different ailments.

For this, all the dispensaries need to be similarly upgraded with the required equipment. Schemes such as ‘Aapli Chikitsa’, which aim to provide diagnostic services such as blood tests at the dispensary level need to be strengthened. Dispensaries can also act as local-level agencies to monitor the health status in a locality/community.

While insurance schemes act as a buffer to prevent catastrophic health expenditures at the secondary and tertiary level, they can neither be a substitute for providing subsidised primary care nor can they drastically reduce citizens’ out of pocket expenditures. What we need is to invest in creating a health system, that stands on an effective and robust base - the public primary health care unit.

Praja Foundation is a non-partisan organisation working towards enabling accountable governance

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