Draft Outline for MCGM-NGO Council Public Health Policy Project BackgroundThis report started as a discussion between the members of the NGO Council and the MCGM after it was found that there was no existing public health policy document on accessing health care in Mumbai. The NGO Council is a representing body of NGOs in Mumbai seeking to collaborate with local authorities on issues of priority. The NGO council was formed on August 22, 2005. The Council is comprised over 70 organizations with complementary expertise covering all causes and sectors.  The primary objectives of the NGO council is to work with Government, Donors, NGOs, and other third-parties to raise awareness and convene to address the important issues effecting the city of Mumbai.[1] On 12/12/2005, Municipal Corporation of Greater Mumbai (MCGM) has entered into an MOU with the NGO Council, recognizing that an institutionalized partnership between municipal bodies and non-governmental organizations (NGOs) / civil society organizations (CSOs) is critical for promoting Good City Governance. [2] Probable Value of the Report In this section, the author has outlined how the report can be of value to the different existing bodies in the city of Mumbai. The report was not only created for the MCGM, but also for all the other proponents of health care in Mumbai. The following section details to value to each constituency:  MCGM: This report should be seen as an objective analysis of the existing programming at the MCGM. In addition to giving suggestions, the report also highlights the various successes of the MCGM’s health programming. It will be of value in several aspects:Assist lawmakers in allocating funds to priority areasProvide insight to those responsible for programming in terms of areas of improvementIncrease the efficiency of the MCGM public health departmentIncrease the reputation of the MCGM’s health services in the cityProve as an impetus that demonstrates the MCGM’s priority of the health of the people of MumbaiIntimate the top-level management as to the priority areas in various departmentsApprise mid-level management of the awareness of the lack of resourcesInform lower-level staff of the value of their work and increase worker morale NGOs: Non-Governmental Organizations working in Mumbai are working to provide health care to the same citizens that are also the responsibility of the MCGM. This report can help bring the two groups together to not replicate programming in high-need areas and pave the way for NGO-MCGM partnerships. NGO’s can cite the information in the report as representative of the enormous need for improved health care systems in such a large and densely populated city. Donors: With Corporate Social Responsibility representing the progressive era of charitable giving, it is important for donors to also be aware of the issues that are effecting the communities that benefit from their time, money, and resources. 

Citizens: In a city like Mumbai, the average citizen doesn’t think about health care unless it is a situation of urgency or crisis. This report will make citizens aware of the issues in health care that effect all those seeking care through the government health sector. Medical Students, Physicians, and Health Professionals: In light of the recent strike of the doctors in Mumbai, it is also important for policy makers to understand the perspectives of those working on the ground. This report helps shed light on the needs of physicians and avenues for improvement in their occupation. Media: The MCGM health department is often the recipient of negative publicity by the medial. The information in the report can offer some information as to the inner workings of the MCGM health department and what the media can do to support the improvement of these systems.  Overall, the report provides an in-depth analysis of the existing programs, challenges, and successes of the MCGM health department. Looking at the history of health policy in India, it is evident that there has been little emphasis on improving the health of local citizens in recent years. The report attempts to create a common area for discussion and improvement of health systems within this city. With good basic infrastructure, there are many avenues that can be pursued if the aforementioned parties join together to work on a healthy Mumbai.  Conclusions and SummaryIn the last 20 years, there have been few initiatives proposed to improve health for the citizens of India. When looking at the policies and initiatives proposed by the Central Government, there is a clear emphasis on improving rural health. However, with the urban poor population rising, the health needs of the urban poor communities are beginning to exceed those in the rural communities. The health care crisis of the growing urban poor, especially in Mumbai, represents a new challenge in providing health care to the masses. The health care of the urban poor is often worse than or equal to that of the rural poor population. Over 50% of Mumbai’s population of 18 million[3] lives in slums and are part of the growing urban poor. This population is plagued with uneven access to care, malnutrition, and poor maternal and child health. Therefore, it is critical to look at the health of Mumbai on a continuum of urban health.The MCGM (Municipal Corporation of Greater Mumbai) provides medical services through three levels of care, primary, secondary and tertiary. This includes an intricate network of teaching hospitals, secondary hospitals, maternity homes, health posts and dispensaries. Although the infrastructure is complex, there is a multitude of improvements needed to address the health needs of the urban poor population in Mumbai. The various challenges plaguing the MCGM health system are growing as rapidly as the population and need to be addressed urgently. The challenges include:Human Resources: A large amount of vacancies in the public health department of the MCGM lead to the apathy of the staff and patients.Infrastructural:  Lack of equipment and services at the primary and secondary level of care; lack of referral systems to direct patients to the appropriate care level; lack of quality assuranceSystems: Lack of a centralized data system, lack of awareness of existing programs within the MCGM

Ethical: Dilution of the value and faith in the public health system as a facility for all, not just the indigent and underprivileged. This is a phenomenon that affects the patients as well as the staff.Educational: Educational materials for prevention of disease and promotion of health are under-utlilized or unavailable, patients do not understand the complexities of their own healthWith a confident team, collaborations, and an open attitude toward change, there are many options for the MCGM health system to become an accessible service for people seeking quality health care at an affordable price. A no-frills health care system that emphasizes good quality at the lowest possible cost to the consumer will not only benefit the poor, but also those taxpayers whose money is being invested in the government run health care system. Working with existing private providers and NGOs can be beneficial for the MCGM system in terms of decreasing the burden and using best practices of existing programs.Utilizing best practices from cities with similar problems to Mumbai will provide some insight into innovations that could be implemented throughout the existing health systems. While the problems sometimes seem to vast to deal with, it is important to remember that an implementation strategy that works on a step-by-step approach will be the ideal method of slowly improving the system. The MOU between the NGO Council and the MCGM is the critical agreement that should be kept in mind in the difficult stages of planning and implementation. This agreement is meant to bridge the gap between the government and the non profit organizations that provide many needed services to the impoverished. Both have similar goals, it is now time to devise a better strategy through collaboration. Recommendations- Brief A. Education and Information DisseminationEnsure that a Patient Bill of Rights (enclosed) and Patient Code of Conduct are posted in every public health care facility being operated by the MCGM

Create a map of Mumbai (in Hindi, Marathi, English, etc) with locations, timings, and services of each healthy care facility.

Improve primary and secondary health care systems by providing training for quality assurance at all facilities.Ensure that educational materials on ALL illnesses and ailments are available in multiple languages at respective primary and secondary health care levels via posters, pamphlets, and CHVs. B. Reproductive and Child HealthIncrease awareness about institutional deliveries by collaborating with local women’s groups.Develop IEC materials relevant to reproductive and child health as well as other relevant diseases by working with NGOsEnsure all maternal, reproductive and child health services are free of cost.Ensure that all municipal facilities are always stocked with medications for pre-natal care (iron, folic acid etc.) C. Medical and Administrative PersonnelIncrease skills, salaries, and working hours of the Community Health Volunteers and have CHV’s collaborate with health workers from NGOs

Discontinue the practice of allowing doctors to have private practices while employed by the MCGM.De-centralize the management of the primary and secondary health care services D. InfrastructureHire staff to fill vacancies of doctors at the primary health care level (Health Posts and Dispensaries) to improve the quality of careConduct a needs assessment of the infrastructural (both equipment, human resources) gaps in the MCGM public health system via a survey and analysis to apply appropriate solutions.Decrease the gaps in infrastructure (staff, equipment, and training) at the primary and secondary levels of health careCreate a referral system so that people can access the medical services at the appropriate lowest level.Utilize the referral system to minimize costs, patient load, and provide better quality treatment for serious cases.Create management information systems to store and utilize data, statistics, and health records appropriately.Create systems for MCGM circulars to be accessible to allRevamp the ambulatory system completely to provide emergency care as well as transport.De-centralize the laboratory system. Ensure all peripheral hospitals have functional labs.  E. SystemsCreate a patient feedback system to improve policies, procedures, and services for patients and for MCGM staff.Create a Public Health Monitoring Department that meets once in 2 months to plan for upcoming public health issues (i.e. bird flu, leptospirosis). F. Coordinating with other MGCM DepartmentsIntroduce adolescent health education through the municipal school system.   Increase citizen participation through a public health citizen committee in collaboration with the MCGM public health department.Improve disaster management to minimize public health outbreaksImprove water supply and sanitation at all slums, this will decrease the amount of diseases in the area. G. Priorities in HealthCreate a department that addresses issues of respiratory health in Mumbai, this should also be a division of the school health departmentUtilizing the existing DOTS program, increase the priorities of TB managementImplement more programs focused on decreasing IMR and MMR (these should be focused on nutrition, education, and health of the mother as well as the child)Create a city-wide campaign regarding Malaria awareness to be promoted during and before Malaria monthsEnsure that all vitamins and supplements are available to NGOs distributing them to children through various programs

 Patient Bill of Rights Each place posting the Patient Bill of Rights needs to affirm the following statement. "We, the staff and the administration of {health facility} declare the following Bills of Rights for the patients of this medical facility. As per the Municipal Corporation of Greater Mumbai, we declare that staff and administration of {the health facility} have read and understood the following rights of a patient and hereby agree to all the terms listed below. If you have any questions or complaints, please contact {Name of accountable person at health facility} or {name of accountable person at BMC}."  To be treated with dignity irrespective of their caste, class, sex, religion, and diseaseTo have a list of exact services available and corresponding fees (for supplies, bandages, etc)To have a visible map of the hospital (in Marathi, Hindi, English, and other languages)To have a list of emergency services such as blood banks and ambulatory services listed in Marathi, Hindi, English and other languagesTo know and understand the procedures involvedTo be given a reasonable time frame for the treatment and receive a proportional discount in fees for all services after the upper limit of approximation is over and treatment needs to be continuedTo have a comprehensive (various tests, blood work, x-rays, room tarrifs, operations, consulting fees, etc) costs associated with seeking medical careTo receive prompt and courteous careTo be informed about the documentation needed for treatmentTo have minimal documentation for emergency casesTo receive Reproductive and Child Health Services free of cost at public health facilitiesTo receive medications and vaccinations from the local public health post or dispensaryTo get medical services which are within the capability of the medical facilityTo obtain from the doctor complete information concerning the diagnosis, treatment, and prognosis in language the patient can understand.To receive necessary information from the doctor such as long-term effects, side effects etc., before giving any prior consent to a medical procedure and/or treatmentTo receive the records or a certified copy that gives the details of the disease, treatment, and follow-up necessary at the time of dischargeTo refuse the suggested treatment and be informed of the medical consequences thereofTo receive medical care in well-equipped and sanitized conditionsTo receive quality care from competent medical professionalsTo select doctor’s of one’s choice when possibleTo obtain a second opinionTo privacy during medical check-upsTo be assured that all communication and records will be kept confidentialTo educational information about medical problems eg. via a library, IEC materials, etc.To receive a bill cum receipt after the payment is madeTo be enabled to pay hospital fees on a payment planTo have access to a non-hospital staff member appointed to address complaints as soon as possible

To have the contact information of the responsible person (both at the hospital and head office) to register a complaint or give feedbackTo have adequate waiting spaceTo allow relatives to have flexible visiting hours 

Patient Code of Conduct Patients are also responsible for their personal and environmental well-being. The following code of conduct emphasizes the responsibilities of a patient while seeking medical care. As a patient: You should provide the doctor with accurate and complete information about his/her medical history, past illnesses, allergies, hospitalizations, and medicationsYou should report the changes in your medical changesYou should ask for clarity if the doctor’s prescription and diagnosis seem unclearYou should follow the doctor’s treatment planYou should pay your medical bills promptlyYou should follow hospital rules and regulationsYou should have realistic expectations of what the doctor can do for youYou should help your doctor help you, if something isn’t working, be clear and the doctor can advise alternative careYou should participate actively in your own medical care (in terms of awareness and preventions)You should ask the doctor questions to clarify any doubts or misconceptions in your mindYou should treat the doctors with respectYou should not ask doctors for false bills or certificates for any reason 

I. Recommendations- ExpandedA. Education and Information DisseminationEnsure that the Patient Bill of Rights and Code of Conduct (attached) is posted in every public health care facility being operated by the MCGMAction Steps:Translate the documents into Hindi, Marathi, and other regional languagesPilot test it with a core group to ensure comprehension of the concept and what it actually would meanSend around a circular for ALL staff to read and understand the Bill of Rights and Code of ConductPost accordingly in all health care facilities in MumbaiTime line: 2 monthsMeasure of Success: Increased awareness of rights and responsibilities of patients, perhaps greater accountability of staff Create a map of Mumbai (in Hindi, Marathi, English, etc) with locations, timings, and services of each healthy care facility.Action Steps:Hire a group of college students for 2 months to work with the Public Health Department to come up with a map that identifies all the locations of the health facilitiesThis should include timings, doctor’s name, and phone numberThis map should be updated twice a year by the Public Health Department, once the infrastructure is in placeTime line: 2 monthsMeasure of Success: Increased awareness of government facilities, accountability for doctors, less patient load at tertiary care services Improve primary and secondary health care systems by providing training for quality assurance at all facilities.Before implementing any kind of quality measures, the entire MCGM public health department (from the sweeper to the doctor) should understand the need for such innovationsThrough role plays and consciousness raising, the staff should become aware of the challenges before themHold monthly meetings with staff to imbibe aspects of quality assurance throughout the MCGM public health departmentUtilizing the health committee formulated, hold trainings for improved quality of careProvide incentives for randomly conducted surveys of facilities that provide quality care to their patientsTime line: 4 monthsMeasure of Success: Increased patient satisfaction as well as improved attitudes among staff.Ensure that educational materials on ALL illnesses and ailments are available in multiple languages at respective primary and secondary health care levels via posters, pamphlets, and CHVs.Action Steps:Collaborate with the HELP library to create educational materials

Make sure such materials are available at ALL health facilities being run by the government sectorEnsure that a wide array of languages are covered in these materialsTime line: 3 monthsMeasure of Success: Increased patient health education, awareness of preventable diseases B. Reproductive and Child HealthIncrease awareness about institutional deliveries by collaborating with local women’s groups.Action Steps:Engage NGOs to help involve Mahila MandalsCreate awareness among leaders in these groups about the hazards of home deliveriesHold events and public gatherings to raise awareness among these women’s groupsTime line: Ongoing, but start up should be 3 months Measure of Success: Increase in amount of institutional deliveries at the hospitals in the areas where the education has taken place. Develop IEC materials relevant to reproductive and child health as well as other relevant diseases by working with NGOsAction Steps:Team up with 5 NGO Partners in order to start collecting information that already exists on these topicsDevise a strategy to review these materials and edit/modify as neededPrint and distribute to all womenTime line: Ongoing, but start up will be 2 monthsMeasure of Success: Increased awareness of RCH as well as other diseases; may lead to prevention Ensure all maternal, reproductive and child health services are free of cost.Action Steps:Appeal to the budget making entities of the value of free RCH servicesCreate a public service campaign regarding increasing awareness for these initiativesTime line: Ongoing campaign, start up will be 2 monthsMeasure of Success: More urban poor women accessing government health care facilities for prenatal, postnatal, and neonatal care Ensure that all municipal facilities are always stocked with medications for pre-natal care (iron, folic acid etc.)Action Steps: a. Partnerships with pharmaceutical companies can guarantee a constant stock of these very necessary vitamins and supplementsb. An education campaign should educate women of the value of the proper utilization of these medications before and during pregnancyTime line: 2 monthsMeasure of Success: Decreased infant mortality and maternal mortality rates C. Medical and Administrative Personnel

Increase skills, salaries, and working hours of the Community Health Volunteers and have CHV’s collaborate with health workers from NGOsAction Steps:Expand job descriptions to include more responsibilities of the CHVsIncrease salary to Rs. 1000 per monthProvide ongoing trainings for them to be more engaged in the work they doAllow them to collaborate with local NGOs CHW’s as wellTime line: 4-6 monthsMeasure of Success: Increased job satisfaction and output by the CHVs, greater collaboration and raising awareness Discontinue the practice of allowing doctors to have private practices while employed by the MCGM.Action Steps:As an overall initiative, doctors should shut down their private practices at MCGM facilitiesTerminate all benefits for those that had such practicesTime line: 1 monthMeasure of Success: Discontinuation of private practices for MCGM doctors De-centralize the management of the primary and secondary health care servicesAction Steps:Allow Medical Officers in each ward to take the lead in decision makingTell them they have a certain amount of money in the budget and set realistic goalsEncourage them to reach these goals through collaboration and hard workIf they demonstrate leadership skills, there can be incentives for group management of wards (rather than it always having to be cleared through the main office)Time line: 4 monthsMeasure of Success: Increased job satisfaction and participation in the process D. InfrastructureHire staff to fill vacancies of doctors at the primary health care level (Health Posts and Dispensaries)   to improve the quality of care Action Steps:a. Revise the personnel policies for the doctors at the primary health care to improve salaries and make sure the following basic facilities are available at every dispensary:Equipment to sterilize the instruments used for examinationAmple medications for all basic illnesses (diarrhea, cough, cold, flu, and fever)Enough stock of iron, folic acid, for supplying to all women who may come to register their pregnanciesTraining in the basics of pre-natal care for community health volunteersX-ray facilities at certain upgraded facilitiesb. Collaborate with medical schools to create incentives for graduating students to commit 2 years to service at the primary or secondary levelc. Involve current doctors in recruiting of new physicians, offer incentives to those who can find doctors who sign contracts for 2 years or more.

d. Improve the overall image of working for the MCGM improving facilities and systems through a circular highlighting the successes of the primary health care physiciansTime line: 6 monthsMeasure of Success: Decreased vacancies, greater staff job satisfaction Conduct a needs assessment of the infrastructural (both equipment, human resources) gaps in the MCGM public health system via a survey and analysis to apply appropriate solutions.Action Steps:Create a simple survey to assess the equipment, amount of staff, medicines etc.Utilizing the CHV’s (increase their work hours and pay to Rs.1000) to have a basic assessment of equipment, vaccinations, medicines, vitamins etc (each CHV would assess a health post different from their own to maintain objectivityPut all the data gathered together in a simple report revealing the gaps in services and infrastructure at the primary levelTime line: 3 monthsMeasure of Success: A report that identifies the gaps and direct action by the administration. Decrease the gaps in infrastructure (staff, equipment, and training) at the primary and secondary levels of health careAction Steps:Utilizing the assessment in Recommendation 13, assess the needs of each of the primary and secondary health care facilities.The health committee can further lobby the administration about improving the infrastructure at each of these locations.Infrastructure specifies: lab equipment, x-ray facilities, storage for vaccinations, provisions for sterilizing needles, and other needs identified by the survey.Time line: 6 monthsMeasure of Success: Increase in utilization at the primary and secondary levels of health care, increased resources and infrastructure. Create a referral system so that people can access the medical services at the appropriate lowest level.Action Steps:In 5 wards, pilot test the referral system of care described in the Appendix 1, already tried once by the Women Centered Health Project.Using the lessons learned by SNEHA’s CINH program that brings together NGOs and public health systems, implement 3 wards using their methods.Assess the pilots and determine which was most complementary to the needs of the patients that access the MCGM health care system.Time line: 1 yearMeasure of Success: No overcrowding at tertiary hospitals, greater patient understanding of each of the tiers and what they offer.Create management information systems to store and utilize data, statistics, and health records appropriately.This can be a part of the TCS created system.Create systems for MCGM circulars to be accessible to all

Action Steps:Using a computerized system, circulars should be sent out to all departments, and not just specific departmentsThe circulars should be stored in a computer as well as hard copyTCS is also implementing a computerized network, this should be a part of it.Time line: 6 monthsMeasure of Success: Improved record-keeping and awareness of all the programs/updates going through the MCGM system.Revamp the ambulatory system completely to provide emergency care as well as transport.Action Steps:Create a public-private company willing to partner with the MCGM on issues of ambulatory careCreate minimum qualification guidelines of those operating the vehiclesEnsure the vehicles are well equipped with supplies and equipment for saving livesCreate a free call system for people to call this number 24 hours a dayCost? Should be further discussedTime line: 6 monthsMeasure of Success: Decreased deaths due to the scarcity of quality ambulatory care, perhaps some benefits from the public-private partnership De-centralize the laboratory system. Ensure all peripheral hospitals have functional labs.Action Steps:Using the infrastructure survey, it is important to assess which areas are lacking proper labsThese labs should be equipped to test for TB, AIDS, and conduct all other necessary blood work on siteThere should be no additional user fees associated with this serviceTime line: 4-6 monthsMeasure of Success: Decreased load on the 3rd tier lab systems, better facilities for patients to access blood work results   E. SystemsCreate a patient feedback system to improve policies, procedures, and services for patients and for MCGM staff.Action Steps:Through a screening process, select non-hospital staff to field the concerns of patientsEnsure the person is competent in mediation and can handle high pressure situationsThe person will then bring the issue to the hospital administration team to be addressed within a certain time frame depending on the emergencyEnsure this process is well documented with appropriate attention from administration for complaint managementTime line: Ongoing, set up time 3 monthsMeasure of Success: Decreased frustration among patients and staff alike, decreased attacks on doctors 

Create a Public Health Monitoring Committee that meets once in 2 months to plan for upcoming public health issues (i.e. bird flu, leptospirosis) and acts a citizen body to represent the concerns of the locals.Action Steps:Review examples of Porto Alegre and other participatory/citizen committeesMCGM’s public health department should set up an open house day to invite all interested parties to learn more about how the MCGM works.The main role of the committee should be monitoring upcoming health issues and creating a forum for discussion and preparedness (i.e. avian flu, monsoon related illnesses)Utilize media partners to help support and promote the outputs of this collaborationTime line: 6 monthsMeasure of Success: Increased citizen participation and actual change as a result of the participation.    F. Coordinating with other MGCM DepartmentsIntroduce adolescent health education through the municipal school system.     Action Steps:Work with the Niramaya Health Foundation which just launched SPARSH, an adolescent health education initiativePilot this initiative at some of the schoolsReplicate and disseminateTime line: 6 monthsMeasure of Success: Increased awareness in adolescent health, increased awareness among children on life skills and personal health Improve disaster management to minimize public health outbreaks Action Steps:Work closely with the disaster management cell and the NGO Council to start to address some of the issues related to disaster managementEducate the city through the LACGs on the importance of preparednessEnsure the release of it before onset of monsoon seasonTime line: 4 monthsMeasure of Success: Increased confidence in the public health system, increased preparedness for individuals and families Improve water supply and sanitation at all slums to decrease the amount of diseases in the area.To be further developed. G. Priorities in HealthCreate a department that addresses issues of respiratory health in Mumbai, this should also be a division of the school health departmentAction Steps:

Conduct an in-depth analysis of the respiratory health of MumbaiWork with NGOs to create greater awarenessCreate a cell within the school department so children can be screened for respiratory issuesFurther follow up will be needed by the public health and the school departmentTime line: 6 monthsMeasure of Success: Increased awareness of respiratory health, greater initiatives to address them Utilizing the existing DOTS program, increase the priorities of TB managementAction Steps:Given the numbers of cases and deaths reported in the Mumbai health profile, it is critical that there be more initiatives to address TB in MumbaiCreate a commission to address why there are still so many cases despite the presence of DOTsEnsure that people suffering from TB are not building up a resistance to the medication.If that is the case, there needs to be further concentration of a public health strategy in this area  Time line: 1 yearMeasure of Success: Decreased deaths and cases reported due to TB in Mumbai Implement more programs focused on decreasing IMR and MMR (these should be focused on nutrition, education, and health of the mother as well as the child)Action Steps:Work with NGOs like SNEHA and CCDT to look at how they are improving systems to support better Reproductive and Child HealthUtilize the benefits of the new RCH II policy that was released as an impetus for improving the health services provided to women and childrenTime line: 6 months, ongoingMeasure of Success: Decreased IMR and MMR (at least by 30-40%) Create a city-wide campaign regarding Malaria awareness to be promoted during and before Malaria monthsAction Steps:Given the fact that Malaria is a major problem in climates like those of Mumbai, it is critical that the Public Health Department address this issueTeach the public about increasing awareness about the dangers of malaria and how to prevent itProvide citizens with information through the LACG meetingsInformation should be circulated in all newspapersNGOs and the MCGM can collaborate on this campaignTime line: OngoingMeasure of Success: Decreased cases and deaths by Malaria Ensure that all vitamins and supplements are available to NGOs distributing them to children through various programs Action Steps:Every month the MCGM should conduct an inventory of the stockNGOs should submit requests for vitamins 2 months in advance

Stock should always be ensured and monitoredTime line: 3 monthsMeasure of Success: Increased availability of critical nutrients necessary for the development of children II. Executive Summary

IntroductionThis report started as a discussion between the members of the NGO Council and the MCGM after it was found that there was no existing public health policy document on accessing health care in Mumbai. The NGO Council is a representing body of NGOs in Mumbai seeking to collaborate with local authorities on issues of priority. The NGO council was formed on August 22, 2005. The Council is comprised over 70 organizations with complementary expertise covering all causes and sectors.  The primary objectives of the NGO council is to work with Government, Donors, NGOs, and other third-parties to raise awareness and convene to address the important issues effecting the city of Mumbai.[4] On 12/12/2005, Municipal Corporation of Greater Mumbai (MCGM) has entered into an MOU with the NGO Council, recognizing that an institutionalized partnership between municipal bodies and non-governmental organizations (NGOs) / civil society organizations (CSOs) is critical for promoting Good City Governance. [5] The relationship between the NGO Council and MCGM has been utilized in various Solid Waste & Local Area Citizen Group initiatives. This report was initiated to maximize the output of the public health system. This report is an in-depth policy analysis into Central and Municipal policies pertaining to health via an analysis of existing programs, successes, challenges, personal interviews, conclusions, and recommendations. The purpose of the report is to highlight what is working and offer suggestions for where improvements can be made. This report serves as an initial policy document necessary to begin conversations on trends in public health in Mumbai. As India becomes a major player in the global economy, it is critical that local governments understand the global repercussions of a weak health system in light of a strong economy. Since Mumbai already has an existing infrastructure to catalyze these efforts, it is in this spirit that we propose that the MCGM and NGO Council work together to address the issues in health in Mumbai. 2. National Policies in Health Care in India National Health Policy 1982The first national health care policy was written in 1982 by the Central Government. This policy was created to set a primary objective of Health Care for All by 2000. The establishment of efficient and effective primary health care systems, especially for the vulnerable: the underprivileged, women, and children were critical elements of achieving health care for all by 2000. The GOI had set an ambitious agenda for improvement of health of the Indian citizen. An integrated network of evenly spread specialty and super-specialty services was specified in the draft.  Since implementation of NHP-1983, the national health program was able to achieve some successes in health care. Smallpox and Guinea Worm Disease have been eradicated from the country; Polio is on the verge of being eradicated; Leprosy, Kala Azar, and Filariasis can be expected to be eliminated in the foreseeable future. There has been substantial drop in the Total Fertility Rate and Infant Mortality Rate. The life expectancy has gone from 36.7 to 64.6 in 50 years. The Infant Mortality Rate (IMR) has been cut in half since 1951.

 Fifty years later, the achievements of this policy only represent a fraction of the need that exists in India. Ironically, with a hike in user charges, proposals of privatization of government hospitals, and increasing healthcare costs, the year 2000 represented a dynamic turn in the intended goals of NHP-1983.[6 ] The burden of cost of care subsequently has shifted from being the responsibility of the government to becoming a burden on the patient seeking care. A retrospective analysis of the NHP-1983 alludes to the fact that the policy may have been over ambitious considering the infrastructure that existed at that time. National Health Policy 2002The next National Health Policy was written in 2002, when public health investment was at an all time low, 1.3% of the GDP in 1990 to .9% of the GDP in 1999 (GOI, 2002).  The aggregate expenditure in the Health sector is 5.2 percent of the GDP. Out of this, about 17 percent of the aggregate expenditure is public health spending, the balance being what ends up being out-of-pocket expenses.[7] The central budgetary allocation for health over this period, as a percentage of the total Central Budget, has been stagnant at 1.3 percent, while that in the States has declined from 7.0 percent to 5.5 percent. NHP 2002 expounds that country wide, less than 20% of the population which seeks OPD services, and less than 45% of those that seek indoor treatment, avail services such as public hospitals. This low incidence of seeking OPD (Out-Patient Dispensary) treatment is due to unsatisfactory factors like time, workday loss, lack of faith in medication as also the outside medical prescriptions  The NHP 2002 firstly stresses the aspect of vertical programming in current public health services provided by the government; keeping in mind that horizontal programming (health programming that works within several sectors to accomplish similar goals) would be more cost effective for the kind of health needs of the population on India. Secondly, there is an imperative need to upgrade the national and statewide Disease Surveillance Network.Overall, the NHP-2002 document envisions the existence of an organized primary health care structure. Since the physical features and needs of urban settings are different from rural areas, there is a need to set a different set of measurable criteria for urban health care. In addition to improved ambulatory and emergency care, in urban settings, the NHP-2002 emphasizes a 2 tiered healthcare system:Primary Health Care: 1st Tier; serve a population of 1 lakh, dispensary for OPD and essential medicationsSecondary Health Care: 2nd Tier; a government hospital, where a referral is made from the primary health centre[8] Although the NHP-2002 document is quite thorough, it covers just basic objectives in urban health care for the poor, which are the upcoming communities that will need the attention of the government. The aforementioned objectives are part of the mandate for improved services in public health services in an urban setting.National Population PolicyThe National Population Policy (NPP), drafted in 2000, also includes the critical aspect of urban health care and its effect on population policy. The NPP 2000 affirms the commitment of government towards voluntary and informed choice and consent of citizens while utilizing

reproductive health care services, and continuation of the target free approach in administering family planning services.[9] The NPP 2000 provides a policy framework for advancing goals and prioritizing strategies during the next decade, to meet the reproductive and child health needs of the people of India, and to achieve net replacement levels (or Total Fertility Rates) by 2010. It is based upon the need to simultaneously address issues of child survival, maternal health, and contraception, while increasing outreach and coverage of a comprehensive package of reproductive and child heath services by government, industry and the voluntary non-government sector, by working in partnership.[10] The NPP document emphasizes the importance of connecting population policy to health care systems “it is as much a function of making reproductive health care accessible and affordable for all, as of increasing the provision and outreach of primary and secondary education, extending basic amenities including sanitation, safe drinking water and housing, besides empowering women and enhancing their employment opportunities, and providing transport and communications.[11] Report of National Commission on Macroeconomics and HealthThe Ministry of Health and Family Welfare, a division of the Government of India, submitted this report in 2005 with the intention of taking an informative look at the health of the nation. The terms of reference of the National Commission on Macroeconomics & Health (NCMH), included among others, a critical appraisal of the present health system — both in the public and the private sector — and suggesting ways and means of further strengthening it with the specific objective of improving access to a minimum set of essential health interventions to all. It was also intended that the Commission would look into the issue of improving the efficiency of the delivery system and encouraging public-private partnerships in providing comprehensive health care.[12 ] According to the NCMH report, the public health system in India is currently overwhelmed by the co-existence of communicable and infectious diseases, alongside an epidemic of non-communicable diseases (Cardiovascular diseases, cancer, diabetes, etc). Even with existing interventions, communicable diseases are expected to decline, but there are further risks with the emergence of new infections and non-communicable diseases that will need to be addressed as well.As the report is focuses on the macro-economic perspective of health, the NCMH postulates the three major drivers of health care costs as[13]: Human Infrastructure: Cost of staffing the health needs of the countryDrug Regime: Cost of drugs is an issueTechnology Used: Advancing health care to suit the countries needs through the use of technologyWorld Health Organization Country ProfileThe World Health Organization Country Profile gives an overview of the health of the country. The World Health Organization has also analyzed the health of India. According to a report on India by the World Health Organization (WHO) there are approximately 501,900 doctors in the country, which equals 5.2 docs per 10,000. This is important as these doctors not only look after a large population in urban pockets and many are even employed by many private hospitals. The number of nurses/midwives are about 607, 376.[14] Other problems in health resources include a

shortage of funds and government medical training and there are many vacancies in lab techs, radiologists, for diseases like malaria and tuberculosis. Overall, the health policies of India seem to overlap in areas such as access to health, nutritional deficiencies, lack of resources, high rates of infant and maternal mortality, lack of primary health care services, lack of expenditure as per the state governments, and the presence of communicable, non-communicable, and infectious diseases all at the same time. However, through the NHP-2002, NPP-2002, the NCMH report, and the country health profile of the WHO collaboratively offer various solutions to the aforementioned challenges in country-wide health care. While it is clear that there have been initiatives to address health in India, it has primarily been from a rural perspective. A closer look at the changing population intimates us that the urban poor are the ones suffering from a new illness: access to health care. 3. Urban Poor and HealthAlthough the focus of many of the Central government initiatives for health have been focused on the rural sector, it is critical to now start exploring the gaps in urban health care. Rapid and unplanned urbanization is a marked feature of Indian demography during the last 40-50 years. According to the 2001 census, India’s urban population currently accounts for almost 30% of the population (approximately 285 million). This represents a 100 times increase in the past century and nearly 40% increase during the last decade. The population and the amount of urban poor are rapidly increasing and contributing to a significant strain on resources. The unabated growth of the urban poor is leading to what is currently being called the “2-3-4-5 Phenomenon of Population Growth”, which states that the Urban Population is India is currently at 285 million[15], urban poor are estimated at 70[16]-90[17] million, and the estimated annual births among the urban poor are 2 million.[18] The health conditions of the urban poor are similar to or worse than the rural population and far worse than urban averages. High infant and maternal mortality, malnutrition, lack of access to services, sub-optimal health behaviors, and inadequate public sector reproductive and child health services. The Environmental Health Project (EHP), a project of USAID has re-analyzed the (NFHS) National Family Health Survey (1998-1999) in 2003 and found that the health of the urban poor has been under-estimated up to this point. The tables below have been adapted from the EHP website. A closer comparison between the problems of the rural population versus the urban poor gives greater insight into the upcoming challenges in urban health. As the country shifts to the urban areas, evidence demonstrates the need for more of a focus on improving (access to) urban health care.Urban health care in MumbaiIn Mumbai, a city of approximately 18[19] million people, over 50% of the population lives in the slums. With a city’s population expanding at a rate faster than infrastructure to address it, health is likely to be impacted severely, with the underprivileged communities being the hardest hit. In Mumbai, urban poverty manifests into informal settlements and slums which have little or no access to sanitation, water supply, education, and health infrastructure. This dramatic increase in the population of cities in developing countries has put enormous pressure on services like water, sewerage, housing and transport.The infant mortality rate (IMR) in the city is 40% and the maternal mortality rate (MMR) is 14%. The survey conducted by Reproductive and Child Health (RCH) and Centre for Operations

Research and Training (CORT) in 1999 states the sex ratio in the city as 872 females per 1000 males, net migration has contributed 19% to the population growth of the city. The crude birth rate (CBR) in the city is 16.6 per 1000 and the general marital fertility rate (GMFR) is 108.7 per 1000. Nearly 76% of the children and 42.1% of women in the city are anemic; this percentage in the slum and non-slum areas is 45.5 and 37.4, respectively. Nearly 50% of the children under three years are underweight (measured in terms of weight-for-age), 40% are stunted (height-for-age) and 21% are wasted (weight-for-age).[20] According to the Maharashtra Economic Survey 2004-05, the incidence of poverty in the rural areas of the State dropped from 58% per cent in 1973-74 to 24% per cent in 1999-2000. In the same period, in urban areas it dropped from 43.9 per cent to 26.8 per cent. At present, the incidence of poverty is higher in urban areas than in the rural areas. Of the 2,38,247 children weighed in June 2005 at various anganwadis in Mumbai, 1,066 were severely malnourished, according to government figures. In 2002, a study conducted by Neeraj Hatekar and Sanjay Rode of the University of Mumbai's Department of Economics, projected a floor estimate of least about 750 children dying of malnutrition in Mumbai alone each year. [21] Further, the rates of malnutrition are higher in the urban poor than the rural average. When looking at access to health services, the presence of infrastructure seems to make little difference in how the poor seek health care.  Table 3.1 indicates that despite the presence of infrastructure (hospitals, health posts), only about 43% of the urban poor actually access health services. Mumbai is a good example of challenges of health care access for the urban poor. With some of the finest health care institutions in the country, the urban poor often face health problems that are similar to those effecting the rural population. The next section provides insight into the existing health infrastructure in the city of Mumbai. Existing Infrastructure in MumbaiThe MCGM’s existing public health system is a stark contrast in infrastructure and utilization. Under its programs for public health care, the MCGM runs four major hospitals, 16 peripheral hospitals, five specialized hospitals, 168 dispensaries, 176 health posts, and 28 maternity homes with a staff of over 17,000 employees. The Corporation also runs three medical colleges. Of the total 40,000+ hospital beds in the city, the MCGM run hospitals have about 11,900 beds. As many as 10 million patients are treated annually in the Out-Patient Departments (OPDs) in the MCGM hospitals. The largest hospital, the King Edward Memorial Hospital and Medical College, alone annually treats 1.2 million patients in its OPD. The state government has one medical college, three general hospitals and two health units with a total of 2,871 beds. Each of the peripheral hospitals is linked to one of the four super specialty hospitals. The health posts and the dispensaries are linked to the peripheral hospitals in their respective Wards. These health posts were established under the World Bank Funded project called IPP-V, and resulted in the set up of the Health Posts which were meant to serve as the primary link between the citizen and the government.[22] MCGM Facilities and Programs

In addition to the hospitals run by the MCGM there are secondary hospitals, maternity homes, health posts, and dispensaries that are under their jurisdiction. There are 168 dispensaries and 176 health posts set up in Mumbai. The health posts were set up from a World Bank Initiative called IPP-5 (India Population Project 5) which sought to set up primary health care centers in Mumbai from 1988-1996.The health posts provide medications for DOTS as well as medications for basic ailments (cough, cold, fever, gastrointestinal issues) while the dispensary has a doctor that is there to provide medical check ups. These dispensaries and health posts often don’t function at maximum utilization rates due to large scale vacancies, disconnect of the staff and the community, and general ignorance toward quality. While there are always exceptions, due to the overall lack of facilities and resources given at the primary level, health posts are not universally utilized to access primary health care. There are 28 maternity homes run by the MCGM. Maternity homes were meant to be a referral point from the primary health care systems. In an ideal situation, if a pregnant woman went to a dispensary for prenatal care, a doctor there would refer her to a maternity home or peripheral hospital for institutional delivery. However, the maternity homes are suffering under severe neglect due to lack of equipment, on the site decision making, and quality of care. Additionally, the controversial practice of charging fees for reproductive and child health has led to an apathetic view of maternity homes. Municipal hospitals are meant to be the secondary and tertiary points of care for the patient seeking healthcare in Mumbai. These hospitals also should be used as referral points, but when patients have a free range of choices, as is in the MCGM health system, most of the primary infrastructure is bypassed. There are four major hospitals, 16 peripheral hospitals and five specialized hospitals. The four major hospitals are also medical colleges which infuse them with a greater amount of financial resources and recognition than in the peripheral hospitals. The peripheral hospitals should be a secondary referral point from the primary health care centers; however, it is also plagued with low resources, centralized decision making, and little attention on quality of care. If an urgent case is brought to a secondary hospital, it tends to be transferred to a major hospital, and due to problems in ambulatory care, patients have little chance of survival.The various programs include:Leprosy Program: An initiative to address and contain Leprosy in MumbaiTuberculosis Program: To address, treat, educate and eradicate TBUniversal Immunization Program: An initiative to provide children and families in Mumbai with proper immunizationsPolio Eradication Program: To immunize, treat, and eradicate PolioNational Malaria Control Program: To address and treat MalariaMumbai District AIDS Control Society: Educate, disseminate information, provide counseling and treatment, blood safety, monitoring and evaluationSchool Health Program: The SHP aims to provide in school health care for children attending the schools run by the MCGMSuccessesManaging such a complex system of health infrastructure has yielded successful initiatives. The School Health Program and Polio Eradication Programs are 2 of them. The main reasons for

success can be communicated through de-centralization of management, networking with families, creating community understanding around a certain illness and strong leadership. Among these few successes, there are many areas that need to be improved throughout the MCGM public health system. ChallengesAll of the aforementioned programs are run in synergy through the jurisdiction of the Public Health Department. Many of the reasons the public chooses not to access the care is:The MCGM Health Budget: The budget of the MCGM Health Department (over Rs. 800 Crores) lacks equity in terms of distribution of resources to the secondary and primary levels of carePrimary health care services are weak in resources and manpower, this leads the general public to seek healthcare at the tertiary level of careSecondary Hospitals and Maternity Care are also not well-equipped and suffer from centralized decision making systems that prevent administration for taking decisionsTertiary Hospitals are on the receiving end of the high monetary assistance and have to bear the burden of overcrowding and higher expectations of patients due to the weakness in the secondary and primary care systemsInconvenient timings, locations, and a high amount of vacancies have lead to a great degree of dissatisfaction with the MCGM run servicesLack of emphasis on quality assurance results in apathy from staff as well as patientsLack of referral systems also lead to a misunderstanding of which services are offered where and create too much of a free market system for patients that results in overcrowding at the tertiary levelReporting and data collection, as evident from the Mumbai health profiles needs to be improved and expanded with up to date data as well as accurate descriptions of rationaleCompetition from the private sector (practitioners and hospitals) also poses a considerable barrier for underprivileged folks to access the public health systemLack of public health disaster systems as well as adequate water sanitation and supply also contribute to problems in access to health care Overall, the report looks at various successes and challenges of the MCGM public health system. Through there are many challenges, the good news is that Mumbai has an existing infrastructure that can  contribute to the improvement of how people in the city access the public health care system. This report gives various recommendations in terms of:Education and Information DisseminationReproductive and Child HealthMedical and Administrative PersonnelInfrastructureSystemsCoordinating with other MCGM departmentsPriorities in HealthThe primary step that will be taken will be the initiation of a Bill of Rights for Patients as well as a Code of Conduct to help education and inform people accessing ALL health care in Mumbai as to what their rights are and what the expectation is of their behavior. 

This report serves as an initial document to signify the NGO Council’s and the MCGM’s commitment to the health care of the people of Mumbai. This document can be utilized by practioners, administration teams, doctors, nurses, medical students, NGOs and more. An in-depth analysis of the MCGM’s health care system can give all those involved in the field some insight into the inner workings of Mumbai’s premier public health system in addition to citing specific areas for improvements. A healthier community can contribute to the overall wealth of Mumbai, making it healthy, wealthy, and wise. Accessing Healthcare in MumbaiConclusions and SummaryIn the last 20 years, there have been few initiatives proposed to improve health for the citizens of India. When looking at the policies and initiatives proposed by the Central Government, there is a clear emphasis on improving rural health. However, with the urban poor population rising, the health needs of the urban poor communities are beginning to exceed those in the rural communities. The health care crisis of the growing urban poor, especially in Mumbai, represents a new challenge in providing health care to the masses. The health care of the urban poor is often worse than or equal to that of the rural poor population. Over 50% of Mumbai’s population of 18 million[23] lives in slums and are part of the growing urban poor. This population is plagued with uneven access to care, malnutrition, and poor maternal and child health. Therefore, it is critical to look at the health of Mumbai on a continuum of urban health.The MCGM (Municipal Corporation of Greater Mumbai) provides medical services through three levels of care, primary, secondary and tertiary. This includes an intricate network of teaching hospitals, secondary hospitals, maternity homes, health posts and dispensaries. Although the infrastructure is complex, there is a multitude of improvements needed to address the health needs of the urban poor population in Mumbai. The various challenges plaguing the MCGM health system are growing as rapidly as the population and need to be addressed urgently. The challenges include:Human Resources: A large amount of vacancies in the public health department of the MCGM lead to the apathy of the staff and patients.Infrastructural:  Lack of equipment and services at the primary and secondary level of care; lack of referral systems to direct patients to the appropriate care level; lack of quality assuranceSystems: Lack of a centralized data system, lack of awareness of existing programs within the MCGMEthical: Dilution of the value and faith in the public health system as a facility for all, not just the indigent and underprivileged. This is a phenomenon that affects the patients as well as the staff.Educational: Educational materials for prevention of disease and promotion of health are under-utlilized or unavailable, patients do not understand the complexities of their own healthWith a confident team, collaborations, and an open attitude toward change, there are many options for the MCGM health system to become an accessible service for people seeking quality health care at an affordable price. A no-frills health care system that emphasizes good quality at the lowest possible cost to the consumer will not only benefit the poor, but also those taxpayers whose money is being invested in the government run health care system. Working with existing private providers and NGOs can be beneficial for the MCGM system in terms of decreasing the burden and using best practices of existing programs.Utilizing best practices from cities with similar problems to Mumbai will provide some insight into innovations that could be implemented throughout the existing health systems. While the

problems sometimes seem to vast to deal with, it is important to remember that an implementation strategy that works on a step-by-step approach will be the ideal method of slowly improving the system. The MOU between the NGO Council and the MCGM is the critical agreement that should be kept in mind in the difficult stages of planning and implementation. This agreement is meant to bridge the gap between the government and the non profit organizations that provide many needed services to the impoverished. Both have similar goals, it is now time to devise a better strategy through collaboration.  Recommendations- Brief A. Education and Information DisseminationEnsure that a Patient Bill of Rights (enclosed) and Patient Code of Conduct are posted in every public health care facility being operated by the MCGMCreate a map of Mumbai (in Hindi, Marathi, English, etc) with locations, timings, and services of each healthy care facility.Improve primary and secondary health care systems by providing training for quality assurance at all facilities.Ensure that educational materials on ALL illnesses and ailments are available in multiple languages at respective primary and secondary health care levels via posters, pamphlets, and CHVs. B. Reproductive and Child HealthIncrease awareness about institutional deliveries by collaborating with local women’s groups.Develop IEC materials relevant to reproductive and child health as well as other relevant diseases by working with NGOsEnsure all maternal, reproductive and child health services are free of cost.Ensure that all municipal facilities are always stocked with medications for pre-natal care (iron, folic acid etc.) 

C. Medical and Administrative PersonnelIncrease skills, salaries, and working hours of the Community Health Volunteers and have CHV’s collaborate with health workers from NGOsDiscontinue the practice of allowing doctors to have private practices while employed by the MCGM.De-centralize the management of the primary and secondary health care services D. InfrastructureHire staff to fill vacancies of doctors at the primary health care level (Health Posts and Dispensaries) to improve the quality of careConduct a needs assessment of the infrastructural (both equipment, human resources) gaps in the MCGM public health system via a survey and analysis to apply appropriate solutions.Decrease the gaps in infrastructure (staff, equipment, and training) at the primary and secondary levels of health careCreate a referral system so that people can access the medical services at the appropriate lowest level.Utilize the referral system to minimize costs, patient load, and provide better quality treatment for serious cases.Create management information systems to store and utilize data, statistics, and health records appropriately.Create systems for MCGM circulars to be accessible to allRevamp the ambulatory system completely to provide emergency care as well as transport.De-centralize the laboratory system. Ensure all peripheral hospitals have functional labs. E. SystemsCreate a patient feedback system to improve policies, procedures, and services for patients and for MCGM staff.Create a Public Health Monitoring Department that meets once in 2 months to plan for upcoming public health issues (i.e. bird flu, leptospirosis). F. Coordinating with other MGCM DepartmentsIntroduce adolescent health education through the municipal school system.   Increase citizen participation through a public health citizen committee in collaboration with the MCGM public health department.Improve disaster management to minimize public health outbreaksImprove water supply and sanitation at all slums, this will decrease the amount of diseases in the area. G. Priorities in HealthCreate a department that addresses issues of respiratory health in Mumbai, this should also be a division of the school health departmentUtilizing the existing DOTS program, increase the priorities of TB managementImplement more programs focused on decreasing IMR and MMR (these should be focused on nutrition, education, and health of the mother as well as the child)Create a city-wide campaign regarding Malaria awareness to be promoted during and before Malaria months

Ensure that all vitamins and supplements are available to NGOs distributing them to children through various programs 1. Introduction and BackgroundThrough an initiative between the Municipal Corporation of Greater Mumbai (MCGM) and the NGO council in Mumbai, health was identified as a major priority. This policy report was written in order to have a better perspective on health in Mumbai. The NGO Council is a representing body of NGOs in Mumbai seeking to collaborate with local authorities on issues of priority. The NGO council was formed on August 22, 2005. The Council is comprised over 70 organizations with complementary expertise covering all causes and sectors.  The primary objectives of the NGO council is to work with Government, Donors, NGOs, and other third-parties to raise awareness and convene to address the important issues effecting the city of Mumbai.[24] On 12/12/2005, Municipal Corporation of Greater Mumbai (MCGM) has entered into an MOU with the NGO Council, recognizing that an institutionalized partnership between municipal bodies and non-governmental organizations (NGOs) / civil society organizations (CSOs) is critical for promoting Good City Governance. [25] The MCGM was formed in 1873 as Mumbai’s civic body. Through the multifarious civic and recreational services that it provides, the MCGM has always been committed to improve the quality of life in Mumbai.[26] It was under this spirit that the MCGM and part of their team took the initiative to come into an agreement of partnership with the NGO Council.  The MCGM has signed a Memorandum of Understanding with the NGO Council to begin to discuss the critical issues, one of the major ones being health.The general responsibilities in Public Health for the MCGM are specified on the website:Public Health and Medical Relief Services[27]The following functions are performed by the staff in the wards under the supervision and guidance of the Executive Health Officer, the Deputy Executive Health Officer, 4 Zonal Assistant Health Officers and the Epidemiologist.1. Prevention and control over communicable diseases.2. Maintenance of vital statistics regarding births, deaths and occurrence of diseases.3. Maternity and child welfare services.4. Medical relief through dispensaries including mobile dispensaries.5. Regulation of the places for the disposal of the dead.6. Prevention of adulteration and misbranding of articles of good.7. Licensing and controlling trades dealing in food and coming under the purview of sections 394 and 412A of the Bombay Municipal Corporation Act8. Licensing and controlling trades (Other than food establishments)9. Controlling places of public amusement from public health point of view, namely, cinema houses, drama theatres, etc.10. Registration and inspection of Nursing Homes.11. Licensing of Nurses Establishments.12. Expansion programme of public health and medical relief services.13. Other miscellaneous functions 

For the efficient discharge of these functions, Greater Bombay has been divided into Wards

which, have been grouped into six zones. Each zone is in charge of each of four Assistant Health Officers. The table below is an organogram of the current hierarchy at the MGCM Public Health Department.Table 1.1 Organogram for the MCGM Public Health Department For the purpose brevity and focus of this report, we have chosen to focus on very specific aspects of health care and delivery systems. This includes primary health centers, peripheral hospitals, maternity homes, health posts, dispensaries; communicable, non-communicable and infectious diseases; health and hygiene, sanitation, access to water, and environmental health. This report will exclude registrations of births and deaths, stray cattle, disposal of the dead, and such issues such as licensing. While all issues are important, this report will only cover the aforementioned issues as they are directly linked with access to public health care facilities.  2. National Policies in Health Care in IndiaThis section will identify the various policies that have come in surrounding health care initiatives in India. It is important to look at the national initiatives before we focus on Mumbai, because these policies can provide the MCGM and the NGO Council with some insight on national health policy standards and how good governance can help the city move forward to adherence.2.1 National Health PolicyThe Government of India (GOI) first drafted a National Health Policy in 1983 (NHP-1983). This policy was created to set a primary objective of Health Care for All by 2000. The establishment of efficient and effective primary health care systems, especially for the vulnerable: the underprivileged, women, and children were critical elements of achieving health care for all by 2000. The GOI had set an ambitious agenda for improvement of health of the Indian citizen.An integrated network of evenly spread specialty and super-specialty services was specified in the draft.  Since implementation of NHP-1983, the national health program was able to achieve some successes in health care. Smallpox and Guinea Worm Disease have been eradicated from the country; Polio is on the verge of being eradicated; Leprosy, Kala Azar, and Filariasis can be expected to be eliminated in the foreseeable future. There has been substantial drop in the Total Fertility Rate and Infant Mortality Rate. The life expectancy has gone from 36.7 to 64.6 in 50 years. The Infant Mortality Rate (IMR) has been cut in half since 1951. The success of the initiatives taken in the public health field are reflected in the progressive improvement of many demographic / epidemiological / infrastructural indicators over time – (Table 2.1).[28]Table 2.1 : Achievements Through The Years - 1951-2000 [29]

Indicator 1951 1981 2000

Demographic Changes      

Life Expectancy 36.7 54 64.6

Crude Birth Rate 40 33 26

Crude Death Rate 25 12 8

IMR 146 110 70

Epidemiological Shifts      

Malaria (cases in million) 75 2 2

Leprosy cases per 10,000 population

38 57 4

Small Pox (no of cases) >44,887 Eradicated  

Guineaworm ( no. of cases)   >39,792 Eradicated

Polio   29709 265

Infrastructure      

SC/PHC/CHC 725 57,363 1,63,181

Dispensaries &Hospitals( all) 9209 23,555 43,322

Beds (Pvt & Public) 117,198 569,495 8,70,161

Doctors(Allopathy) 61,800 2,68,700 5,03,900

Nursing Personnel 18,054 1,43,887 7,37,000

The table above highlights the progression of health infrastructure, demographics, and epidemiology through 50 years.These achievements only represent a fraction of the need that exists in India. Ironically, with a hike in user charges, proposals of privatization of government hospitals, and increasing healthcare costs, the year 2000 represented a dynamic turn in the intended goals of NHP-1983.[30] The burden of cost of care subsequently has shifted from being the responsibility of the government to becoming a burden on the patient seeking care. A retrospective analysis of the NHP-1983 alludes to the fact that the policy may have been over ambitious considering the infrastructure that existed at that time. The next National Health Policy was written in 2002, when public health investment was at an all time low, 1.3% of the GDP in 1990 to .9% of the GDP in 1999 (GOI, 2002).  The aggregate expenditure in the Health sector is 5.2 percent of the GDP. Out of this, about 17 percent of the aggregate expenditure is public health spending, the balance being what ends up being out-of-pocket expenses.[31] The central budgetary allocation for health over this period, as a percentage of the total Central Budget, has been stagnant at 1.3 percent, while that in the States has declined from 7.0 percent to 5.5 percent. The current annual per capita public health expenditure in the country is no more than Rs. 200.[32]Table 2.2: Public Health Spending in select Countries [33]

  %Population with income

%Health Expenditure

%Public Expenditure on

of <$1 day to GDP Health to Total Health Expenditure

India 44% 5% 17%

China 19% 3% 24%

Sri Lanka 7% 3% 45%

UK - 6% 97%

USA - 14% 44%

The table above demonstrates the public health spending in select countries. India, China, and America spend the least amount on their public health expenditure. These statistics indicate why we are at quality level that does not deliver services at a desirable standard. Under the constitutional structure, public health is the responsibility of the States. The general expectation is that the State will give the principal contribution to public health care, with the supplemental support from the Central government. In this backdrop, the contribution of Central resources to the overall public health funding has been limited to about 15 percent. According to NHP 2002, the fiscal resources of the State Governments are known to be very inelastic. This is reflected in the declining percentage of State resources allocated to the health sector out of the State Budget. In order to significantly improve the decentralized public health system in the country, there needs to be more resource allocation from the Central Government budget. If the State public health services, which are a major component of the initiatives in the social sector are not supplemented with additional support, the changes in National Health Care will be slow and lack universal access at best. The NHP-2002 has been formulated taking into consideration these ground realities in regard to the availability of resources.[34] NHP 2002 expounds that country wide, less than 20% of the population which seeks OPD services, and less than 45% of those that seek indoor treatment, avail services such as public hospitals. This low incidence of seeking OPD treatment is due to unsatisfactory factors like time, workday loss, lack of faith in medication as also the outside medical prescriptions  The NHP 2002 firstly stresses the aspect of vertical programming in current public health services provided by the government; keeping in mind that horizontal programming (health programming that works within several sectors to accomplish similar goals) would be more cost effective for the kind of health needs of the population on India.Secondly, there is an imperative need to upgrade the national and statewide Disease Surveillance Network. Without accurate disease surveillance and monitoring, the public health system will not be able to ascertain the accomplishments and challenges of current and past initiatives. Thirdly, there is a greater need to have more specialists in public health and family medicine, with an emphasis on public health nursing and access to medication. 

Overall, the NHP-2002 document envisions the existence of an organized primary health care structure. Since the physical features and needs of urban settings are different from rural areas, there is a need to set a different set of measurable criteria for urban health care. In addition to improved ambulatory and emergency care, in urban settings, the NHP-2002 emphasizes a 2 tiered healthcare system: Primary Health Care: 1st Tier; serve a population of 1 lakh, dispensary for OPD and essential medicationsSecondary Health Care: 2nd Tier; a government hospital, where a referral is made from the primary health centre[35] Although the NHP-2002 document is quite thorough, it covers just basic objectives in urban health care for the poor, which are the upcoming communities that will need the attention of the government. The aforementioned objectives are part of the mandate for improved services in public health services in an urban setting. 2.2 National Population PolicyThe National Population Policy (NPP), drafted in 2000 also includes the critical aspect of urban health care and its effect on population policy. The NPP 2000 affirms the commitment of government towards voluntary and informed choice and consent of citizens while utilizing reproductive health care services, and continuation of the target free approach in administering family planning services.[36] The NPP 2000 provides a policy framework for advancing goals and prioritizing strategies during the next decade, to meet the reproductive and child health needs of the people of India, and to achieve net replacement levels (or Total Fertility Rates) by 2010. It is based upon the need to simultaneously address issues of child survival, maternal health, and contraception, while increasing outreach and coverage of a comprehensive package of reproductive and child heath services by government, industry and the voluntary non-government sector, by working in partnership.[37] The NPP document emphasizes the importance of connecting population policy to health care systems “it is as much a function of making reproductive health care accessible and affordable for all, as of increasing the provision and outreach of primary and secondary education, extending basic amenities including sanitation, safe drinking water and housing, besides empowering women and enhancing their employment opportunities, and providing transport and communications.[38] The health related goals of the NPP are defined in a socio-demographic context and include critical aspects of urban health care:Address the unmet needs for basic reproductive and child health services through supplies and infrastructureMake school education compulsory until age 14Reduce IMR to 30/1000Reduce MMR to 100/100,000Achieve universal immunizationPromote delayed marriage age100% birth, death, and marriage registration

Attain 80% institutional deliveries, 100% by trained personsUniversal access to information and counseling regarding reproductive healthContain AIDSPrevent and control communicable diseasesIntegrate systems in medical education and careEstablish family normsSocial sector and family welfare should be mergedPromotion of family norms The NPP seems to critically look at population policy and health as an integrated system that needs to be improved in synergy. Social and health problems contribute to the high population rates which will effects health care systems adversely. These goals also have some degree of overlap with the goals of NHP-2002. The NPP has also has set forth some recommendations for improvements in urban health:Finalize a comprehensive urban health strategyFacilitate service delivery centers in urban health slums to provide comprehensive basic health, reproductive and child health services utilizing relationships with NGOs, private sector organizations, and corporate housesPromote networks of retired doctors and para/non-medical personnel who may serve as providers for clinical and non-clinical services for remunerationStrengthen social marketing programs for non clinical family planning products and services in urban slumsSpecially targeted information, education, and community campaigns for urban slums on family planning, immunization, ANC etc, and other reproductive health servicesAggressive integration of health education programs with medical and health programs in environmental health, personal hygiene, nutrition education, and population educationPromote inter-sectoral coordination between departments and municipal bodies dealing with water and sanitation, industry, housing, transport, education and nutritionStreamline referral systems and linkages between primary and secondary levels of care in the urban arenaLink provision of continued facilities to urban slum dwellers in compliance with the small family norm. These recommendations fall under the purview of the central and state governments, with both parties taking some type of responsibility for continued access to health care for the urban poor. 2.3 Report of National Commission on Macroeconomics and HealthThe Ministry of Health and Family Welfare, a division of the Government of India, submitted this report in 2005 with the intention of taking an informative look at the health of the nation. The terms of reference of the National Commission on Macroeconomics & Health (NCMH), included among others, a critical appraisal of the present health system — both in the public and the private sector — and suggesting ways and means of further strengthening it with the specific objective of improving access to a minimum set of essential health interventions to all. It was also intended that the Commission would look into the issue of improving the efficiency of the delivery system and encouraging public-private partnerships in providing comprehensive health

care.[39 ] According to the NCMH report, the public health system in India is currently overwhelmed by the co-existence of communicable and infectious diseases, alongside an epidemic of non-communicable diseases (Cardiovascular diseases, cancer, diabetes, etc). Even with existing interventions, communicable diseases are expected to decline, but there are further risks with the emergence of new infections and non-communicable diseases that will need to be addressed as well. The NCMH report estimates (based on current data) that by 2015, the number of AIDS cases will be approximately three times the current level and will be roughly equal to the cases of tuberculosis (85 lakhs).[40] Additionally, cardiovascular diseases, diabetes, and cancers will increase by 25% and mental health issues will affect 6.5% of the population.[41] According to the NCMH report, prevention is the key solution for countries like India that suffer from a lack of resources. For example:Integrated approaches for vector control through de-centralized systems are known to reduce water-borne diseases.Access to clean water reduces cases of gastroenteritis and diarrheaImmunizations reduces onset of diseases caused by lack of immunizationVitamin supplementation prevents certain illnesses such as blindness As the report is focuses on the macro-economic perspective of health, the NCMH postulates the three major drivers of health care costs as[42]: Human Infrastructure: Cost of staffing the health needs of the countryThere is currently not enough engagement of Community Health VolunteersSpecialists such as pharmacists, paramedics, and lab technicians are largely unavailableThe reproductive health sector (Nurses, midwives) is underdeveloped and is not able to meet the demandDrug Regime: Cost of drugs is an issueDrugs need to come under price controlThe industry is largely un-regulated in IndiaThere are no patent laws to protect the consumer and innovatorTechnology Used: Advancing health care to suit the countries needs through the use of technologyTechnological advances in health should be included as part of the budgetUse of modern technology can greatly influence how illnesses are treated in IndiaThe NCMH report discusses the challenges and successes of the state of health care in India, and cites the following failures in the national health policy:Weak management: Key factors include centralized decision-making, problems in project management, low budgets, large scale absenteeism, absence of performance based monitoring, and conflicting job roles.Poor governance and role of state: There is very little accountability at the state level and this leads to lack of good governance.Lack of strategic mission: There is very little information out there that sets goals for where the state of national health care should be.Vertical programming: The preponderance of vertical programming is an enormous waste of resources and time.

 All these aspects of health in India contribute to the lack of access to health care for the citizens of the country. However, the NCMH report also suggests a way forward, to improve health care access in India. The various methods they suggest in the report include:Promoting equity for access by reducing household expenditure on health by experimenting with different types of funding (health insurance, public-private partnerships etc).Restructuring the primary health care program to make it more accountableReduce disease burden and level of riskEstablish institutional framework for improved qualityInvest in technology and human resourcesThe guiding principles should be based on accountability, responsibility, accessibility, adaptability, courtesy and participation.  2.4 World Health Organization Country ProfileThe World Health Organization has also analyzed the health of India. According to a report on India by the World Health Organization (WHO) there are approximately 501,900 doctors in the country, which equals 5.2 docs per 10,000. This obviously does not include a large number of doctors qualified in othe systems like Ayurveda, Homeopathy, Unani or Siddha. This is important as these doctors not only look after a large population in urban pockets and many are even employed by many private hospitals. The number of nurses/midwives are about 607, 376.[43] Other problems in health resources include a shortage of funds and government medical training and there are many vacancies in lab techs, radiologists, for diseases like malaria and tuberculosis. Further, the external analysis helps assess the major challenges in the health programming. While overall mortality has decreased, the report states, the living standards are amongst the poorest in the world. This is primarily due to:Lack of resourcesLack of a integrated multi-sectoral approachInsufficient IEC materialPoor involvement of the NGO sector (collaboration rather)Inadequate lab servicesManually operated health management systemPoor surveillance and poor responseDealing with non-communicable diseasesGender disparities:Decline in female/male ratio:In 1999 and 2001, the ratio went from 927 to 923.Violence (domestic and social)Nutritional deficiencies56 % children under 5 said to have Iron DeficiencyIntegrated Child Development Service is supposed to cover all but is slated to reach 54 million pre-school children, pregnant and lactating women through mid-day meal programs and emphasis on nutrition.Stereotypes and discriminationIncrease in lifestyle diseases for certain populations[44]

 A critical issue that is not discussed often is Environmental Health:Emissions leading to greater degree of respiratory diseasesAgricultural problemsAll these increase the risk of vector born diseasesSignificant environmental degradation leads to destruction of natural resources Environmental health is largely not discussed due to the prevalence of non-communicable and infectious diseases in India. However, environmental health covers a broad range of issues such as unsafe drinking water; unhygienic sanitation and air pollution significantly contribute to the burden of disease, particularly in urban settings.[45] In the same country profile, WHO asserts that in 1998, approximately 5.1% of the GDP was spent on health care. Overall public expenditure on health was 18% and the WHO assessment of the problem asserts a situation of getting the funds to the right places. The WHO Country Profile supports the information on national health policy as reported in this paper. The external analysis added value through its future vision for health care in India. The goal is to achieve optimal health for the people, which would allow them to lead socially and economically productive lives and be in keeping with the principles of a Health for All Strategy. The health care system envisaged would have a public-private mix, with the latter encouraged to take a greater share of secondary and tertiary health care services.[46] Overall, the health policies of India seem to overlap in areas such as access to health, nutritional deficiencies, lack of resources, high rates of infant and maternal mortality, lack of primary health care services, lack of expenditure as per the state governments, and the presence of communicable, non-communicable, and infectious diseases all at the same time. However, through the NHP-2002, NPP-2002, the NCMH report, and the country health profile of the WHO collaboratively offer various solutions to the aforementioned challenges in country-wide health care. While it is clear that there have been initiatives to address health in India, it has primarily been from a rural perspective. A closer look at the changing population intimates us that the urban poor are the ones suffering from a new illness: access to health care. 

3. The Urban Poor and HealthAlthough the focus of many of the Central government initiatives for health have been focused on the rural sector, it is critical to now start exploring the gaps in urban health care. The next section discusses the future of the urban poor population and access to health care. 3.1 Urban Population growthRapid and unplanned urbanization is a marked feature of Indian demography during the last 40-50 years. According to the 2001 census, India’s urban population currently accounts for almost 30% of the population (approximately 285 million). This represents a 100 times increase in the past century and nearly 40% increase during the last decade. The population and the amount of urban poor are rapidly increasing and contributing to a significant strain on resources. The unabated growth of the urban poor is leading to what is currently being called the “2-3-4-5 Phenomenon of Population Growth”, which states that the Urban Population is India is currently at 285 million[47], urban poor are estimated at 70[48]-90[49] million, and the estimated annual births among the urban poor are 2 million.[50] 3.2 Health ConditionsThe health conditions of the urban poor are similar to or worse than the rural population and far worse than urban averages. High infant and maternal mortality, malnutrition, lack of access to services, sub-optimal health behaviors, and inadequate public sector reproductive and child health services. The Environmental Health Project (EHP), a project of USAID has re-analyzed the (NFHS) National Family Health Survey (1998-1999) in 2003 and found that the health of the urban poor has been under-estimated up to this point. The tables below have been adapted from the EHP website. A closer comparison between the problems of the rural population versus the urban poor gives greater insight into the upcoming challenges in urban health. As the country shifts to the urban areas, the evidence below demonstrates the need for more of a focus on improving (access to) urban health care. Given the fact that government doctors are only 12% of the RCH services, it is clear that the increasing problems in urban health demonstrate the need for further study and training of issues in urban health care.As the urban population expands and health care needs of the urban poor increase, it is critical for the city and state governments to start focusing efforts on the health of the urban poor. Mumbai is a perfect example of the growing need for the right to basic health care for the urban poor population. 4. Mumbai, MaharashtraUrbanization is one of the most significant processes found in developing countries today. Maharashtra is one of the most urbanized states in the country with more than 42% of the population living in cities and towns[51].The population of Mumbai has grown from less than four million at India's Independence fifty years ago, to about 18[52] million today. The population of Mumbai is about 18 million, with a density of 4,205 persons per square kilometer. The overall literacy rate of the city is 77%, which is higher than the national average (82% of adult males and 71.6% of adult females are literate). The religions represented in Mumbai include Hindus (68% of the population), Muslims (17% of the population), and Christians and Buddhist (4% each). The remainders are Parsis, Jains, Sikhs, Jews and atheists.[53]

Mumbai contributes to a large portion of growth and wealth in India. Mumbai contributes 10% of all factory employment, 40% of all income tax collections, 60% of all customs duty collections, 20% of all central excise tax collections, 40% of India's foreign trade and Rupees 40 billion (US$ 9 billion) in corporate taxes. A number of Indian financial institutions have headquarters in downtown Mumbai, including the Bombay Stock Exchange, the Reserve Bank of India, the National Stock Exchange of India, the Mint, and numerous conglomerates (the Tata Group, Godrej and Reliance etc).[54] As economic prosperity sets in early 2006, the public health of Mumbai is starting to suffer due to neglect.4.1 Health in Mumbai, MaharashtraIn Mumbai, a city of approximately 18[55] million people, over 50% of the population lives in the slums. With a city’s population expanding at a rate faster than infrastructure to address it, health is likely to be impacted severely, with the underprivileged communities being the hardest hit. In Mumbai, urban poverty manifests into informal settlements and slums which have little or no access to sanitation, water supply, education, and health infrastructure. This dramatic increase in the population of cities in developing countries has put enormous pressure on services like water, sewerage, housing and transport.The infant mortality rate (IMR) in the city is 40% and the maternal mortality rate (MMR) is 14%. The survey conducted by Reproductive and Child Health (RCH) and Centre for Operations Research and Training (CORT) in 1999 states the sex ratio in the city as 872 females per 1000 males, net migration has contributed 19% to the population growth of the city. The crude birth rate (CBR) in the city is 16.6 per 1000 and the general marital fertility rate (GMFR) is 108.7 per 1000. Nearly 76% of the children and 42.1% of women in the city are anemic; this percentage in the slum and non-slum areas is 45.5 and 37.4, respectively. Nearly 50% of the children under three years are underweight (measured in terms of weight-for-age), 40% are stunted (height-for-age) and 21% are wasted (weight-for-age).[56] According to the Maharashtra Economic Survey 2004-05, the incidence of poverty in the rural areas of the State dropped from 58% per cent in 1973-74 to 24% per cent in 1999-2000. In the same period, in urban areas it dropped from 43.9 per cent to 26.8 per cent. At present, the incidence of poverty is higher in urban areas than in the rural areas. Of the 2,38,247 children weighed in June 2005 at various anganwadis in Mumbai, 1,066 were severely malnourished, according to government figures. In 2002, a study conducted by Neeraj Hatekar and Sanjay Rode of the University of Mumbai's Department of Economics, projected a floor estimate of least about 750 children dying of malnutrition in Mumbai alone each year. [57] Further, the rates of malnutrition are higher in the urban poor than the rural average. When looking at access to health services, the presence of infrastructure seems to make little difference in how the poor seek health care.  Table 3.1 indicates that despite the presence of infrastructure (hospitals, health posts), only about 43% of the urban poor actually access health services. Mumbai is a good example of challenges of health care access for the urban poor. With some of the finest health care institutions in the country, the urban poor often face health problems that are similar to those effecting the rural population. The next section provides insight into the existing health infrastructure in the city of Mumbai. 

4.2 Existing Infrastructure in MumbaiThe MCGM’s existing public health system is a stark contrast in infrastructure and utilization. Under its programs for public health care, the MCGM runs four major hospitals, 16 peripheral hospitals, five specialized hospitals, 168 dispensaries, 176 health posts, and 28 maternity homes with a staff of over 17,000 employees. The Corporation also runs three medical colleges. Of the total 40,000+ hospital beds in the city, the MCGM run hospitals have about 11,900 beds. As many as 10 million patients are treated annually in the Out-Patient Departments (OPDs) in the MCGM hospitals. The largest hospital, the King Edward Memorial Hospital and Medical College, alone annually treats 1.2 million patients in its OPD. The state government has one medical college, three general hospitals and two health units with a total of 2,871 beds. Each of the peripheral hospitals is linked to one of the four super specialty hospitals. The health posts and the dispensaries are linked to the peripheral hospitals in their respective Wards. These health posts were established under the World Bank Funded project called IPP-V, and resulted in the set up of the Health Posts which were meant to serve as the primary link between the citizen and the government.[58] Mumbai’s health is reported through the yearly report “The Mumbai Health Profile”. Information from profiles dating 1997-2004 has been used in the following analysis. The first and most important aspect of Mumbai is the population and its growth. The chart below represents the growth of the population from 1997-2004.Figure 4.1 Growth in the Population of Mumbai[59] According to this analysis, the population has been growing at a rate of (to be added).The birth rates and death rates are often indicative of the population growth. The reason for over population remains the high birth rate. Despite the fact that the birth rate has decreased, the death rate has also decreased. The decrease in death rate can be contributed to better health (for some), increased nutrition, the growing economy and general evolution of the population. However, the rate at which the death rate decreased is still not equal to the birth rate. Mumbai’s birth versus death rate is illustrated in the figure below:  The high birth rate is often correlated with a high infant mortality rate (IMR). Although the IMR has significantly decreased in the last 50 years, it still remains a major problem for those who cannot access health care during pregnancy and after birth of a child. Some parents feel the need to have a safety net in case on or two children die along the way. The figure below represents the IMR rate in Mumbai:

 This table shows that the IMR rates in Mumbai have decreased over the last 7 years. The current IMR reported by the MCGM is at 35% per 1000 births. However, this is merely the tip of the iceberg as neo-natal deaths are often under-reported and death rates of children under 5 years old are not evaluated by the MCGM. The infant deaths below 1 year of age for the years 1997-2004 are indicated in the table below: Table 4.1: Infant deaths of children below 1 year (1997-1999 data unavailable)

2001 2002 2003 20047255 7142 7403 6505

 Although the numbers are decreasing, it is unclear according to the data, which intervention has played the largest part in slowly bringing down the IMR. The Maternal Mortality Rate (MMR) is an indicator of how many mothers are dying after childbirth. Add information about maternal mortality. The figure below indicates the MMR in Mumbai. As Mumbai comes into a new age of economic prosperity, one can postulate that the health of the city as a whole has suffered in this process. As the urban middle and upper classes have more choices on where they seek care (mostly high specialty, private institutions) the checks and balances that kept the MCGM public health department running efficiently are no longer applicable. 

5. Services in DetailHealthcare in Mumbai is run under the jurisdiction of the MCGM. It functions to provide health care to the citizens in affordable and accessible manner. Mumbai’s health care system is probably one of the most elaborate urban health systems in the country. It is unique because it provides care at three different levels, and functions to (hopefully) provide health care at a minimum cost to the consumer. 5.1 Functions of the Public Health DepartmentThe Public Health Department of the MCGM not only provides basic health care facilities but also manages other aspects related to preventive and social or community medicine. The Department is divided into zonal set-ups for administrative purposes. There are five such zones, which cover 23 Wards (nine city Wards, eight western suburban Wards and six eastern suburban Wards). The Deputy Municipal Commissioner handles each zone. Each Ward has a separate Ward Office and the Ward Medical Health Officer (MHO) heads the Public Health Department in that Ward. The Department carries out the following activities:• Registration of births and deaths and maintenance of statistics• Regulation of places for disposal of dead• Maternity and child welfare and family welfare services, school health services• Control of communicable diseases• Food sanitation and prevention of adulteration of food• Control of trades likely to pose a health hazard• Insect and pest control• Impounding stray cattle, immunization and licensing of dogs• Regulation of private nursing homes• Medical relief through hospitals• Issuance of international health certificates for traveling abroad• Ambulance and hearse services• Treatment of contagious diseasesThis section is an overview and analysis of the existing MCGM structure in relation to services and access to health care. 5.2 Dispensaries and Health PostsThere are 168 dispensaries and 176 health posts set up in Mumbai. The health posts were set up from a World Bank Initiative called IPP-5 (India Population Project 5) which sought to set up primary health care centers in Mumbai from 1988-1996. When the World Bank pulled out, the MCGM took the responsibility of the health posts and dispensaries. However, due to various issues in budgeting, prioritization at the MCGM, and other reasons that are not well-documented, the quality of services offered at these health posts and dispensaries is not quite meeting the needs and demands of the public that accesses this system. The health posts provide medications for DOTS as well as medications for basic ailments (cough, cold, fever, gastrointestinal issues) while the dispensary has a doctor that is there to provide medical check ups. Unfortunately, these dispensaries and health posts don’t function at maximum utilization rates due to large scale vacancies, disconnect of the staff and the community, and general ignorance toward quality. While there are always exceptions, due to the overall lack of facilities and resources given at the primary level, health posts are not universally utilized to access primary health care. 

5.3 Maternity HomesThere are 28 maternity homes run by the MCGM. Maternity homes were meant to be a referral point from the primary health care systems. In an ideal situation, if a pregnant woman went to a dispensary for prenatal care, a doctor there would refer her to a maternity home or peripheral hospital for institutional delivery. However, the maternity homes are suffering under severe neglect due to lack of equipment, on the site decision making, and quality of care. Additionally, the controversial practice of charging fees for reproductive and child health has led to an apathetic view of maternity homes. 5.4 Municipal HospitalsMunicipal hospitals are meant to be the secondary and tertiary points of care for the patient seeking healthcare in Mumbai. These hospitals also should be used as referral points, but when patients have a free range of choices, as is in the MCGM health system, most of the primary infrastructure is bypassed. There are four major hospitals, 16 peripheral hospitals and five specialized hospitals. The four major hospitals are also medical colleges which infuse them with a greater amount of financial resources and recognition than in the peripheral hospitals. The peripheral hospitals should be a secondary referral point from the primary health care centers; however, it is also plagued with low resources, centralized decision making, and little attention on quality of care. If an urgent case is brought to a secondary hospital, it tends to be transferred to a major hospital, and due to problems in ambulatory care, patients have little chance of survival. The aforementioned case is especially true in the cases on deliveries and post-partum emergencies.5.5 ProgramsThe MCGM runs a complex set of programs to address the major health issues of the Mumbai. A government run health department is important for two major reasons:Controlling Infectious Disease: If public health sector does not work, diseases like malaria etc will increaseAccess to Public facilities: such as ambulatory care and emergency servicesThe following section describes these programs in detail and provides some insight into how they are addressed by the MCGM Public Health Department.5.5.1 Leprosy Control Program[62]The Leprosy Control Program was started in 1890 and is based out of the Acworth Municipal Hospital in Mumbai. The services provided by the hospital include inpatient services, out patient services, peripheral clinics, field work, re-constructive surgery, training, and research. The Leprosy Control Program has achieved a significant amount of success in Mumbai over the years and is demonstrated in the table below:Table 5.5.1.a: Cases and Deaths: Leprosy in Mumbai[63]

  1997 1998 1999 2001 2002 2003 2004Cases 4966 423 629 310 4297 3384 1651Deaths 4 11 10 11 7 5 5

This table shows that the cases and deaths by Leprosy have decreased significantly in Mumbai due to the availability of medication. Though there is no explanation for the fluctuation in numbers over the years, it can be postulated that treatment and detection methods for leprosy have been improved and implemented by the MCGM. The decrease in number of deaths demonstrates that treatment programs are working

and there are adequate detection methods in place to address leprosy in Mumbai. This has just been derived from observation, as there is little conclusive information in the Mumbai Health Profiles 1997-2004.             5.5.2 Revised National Tuberculosis (TB) Control ProgramThe Revised National Tuberculosis Program (RNTCP) is a national initiative that is run under the provision of the Mumbai District Tuberculosis Control Society (MDTCS) since 1999 for the effective control and smooth implementation of the TB control program. [64] For the implementation of this program, the MCGM has established:Six District Tuberculosis Officers119 Microscopic Centers have been established at municipal dispensaries, hospitals, and TB clinics903 DOTS Centers (Directly Observed Treatment, Short-Course- a WHO program) have been established to help TB patients seek care for TB.The RNTCP conducts many health awareness activities including health awareness month, World TB Day, community meetings, street plays and more. MCGM also collaborates with private providers in their PPM (Public Private Mix) Project. This project was started in 2002 with 2 zones and now covers 5 zones. This program consists of a public- private partnership between the MCGM and private providers to implement the DOTS and RNTCP. According to the Mumbai Health Profiles, the following tables represent the cases of TB that were reported:        Table 5.5.2.a: Cases and Deaths: TB in Mumbai

  1997 1998 1999 2001 2002 2003 2004Cases 44536 37707 14424 38238 40009 24620 25888Deaths 9339 10583 8750 9345 8998 8929 8774

This table shows that the cases and deaths by TB. The number of cases has decreased while the number of deaths has stayed relatively constant. It is unclear from these numbers what intervention contributed to the change in cases reported. The drastic change in numbers is not analyzed as per the Mumbai Health Profiles. It could be attributed to the implementation of the RNTCP initiative, but does not explain the dramatic drop in the rates of cases reported in 1999. This calls for further investigation of the results to take a closer look at the reasons for the changing numbers. The number of deaths attributed to TB has been on the decline since 2001. The decline rate is (To be added later).             5.5.3 Universal Immunization ProgramThe Expanded Program of Immunization was launched in the year 1978 for covering all children up to five years. In 1985, the Universal Immunization Program was launched in 1985 to cover all the children under one year with all vaccines to achieve the following targets:Elimination of Neonatal Tetanus by the year 1995Eradication of polio by 2000Reduction of 90% cases of measles by 1995Specific activities include:Vaccine distribution and maintenanceCollecting data and informationPerformance reports

Extended coverage evaluation surveyExtra activities as neededThe chart below takes a closer look at the immunization evaluation report for the BMC for the most recent year (2004). [65]

Vaccine Target Achievement PercentageHepatitis B 200591 61,002 30.41%DPT III (Diptheria, Polio, Tetanus)

200591 196526 97.97%

Polio III 200591 196114 97.96%BCG (TB Vaccine) 200591 203397 101.39%Measles 200591 174009 86.74%T.T. (M) (Tetanus) 220650 173249 78.51%D.P.T. (B) 192570 163325 84.81%Polio (B) 192570 167531 86.99%D.T. (5) (Diptheria) 226754 156443 68.99%T.T. (10) 226754 184694 81.44%T.T. (16) 226754 146324 64.52%

The table above shows the target and achievement rates, clearly, while some met and exceeded the target, others felt quite short.    The interpretation of these numbers demonstrates that while there are some significant successes in the MCGM Universal Immunization Program (UIP), there are still some gaps in targets that are yet to be reached.For example, in 2004, there were 4584 cases of Infectious Hepatitis (reported) and 92 deaths[66] in Mumbai. The table below represents the cases and deaths in Mumbai of hepatitis:                  Table 5.5.3.a: Cases and Deaths: Hepatitis in Mumbai

  1997 1998 1999 2001 2002 2003 2004Cases 3455 2929 2526 3627 3810 3488 4584Deaths 207 192 184 135 78 51 92

           This table shows that the cases and deaths by Hepatitis in Mumbai. It is unknown if it is Hepatitis A or B. These deaths could have been prevented if the achievement rates of Hepatitis B vaccines were better. (Will clarify if we are talking about Hep A or Hep B) Although the deaths are not so high, the number of cases is enough to create concern and demand some type of intervention. It should be noted that this initiative was started in March 2003 and needs some time to actualize its goals. Clearly, the UIP has achieved some significant success in the areas of DPT (Diptheria, Polio, Tetanus), Polio, and BCG (Tuberculosis vaccine), but still needs to meet international standards for Hepatitis, Tetanus and others. 5.5.4 Polio Eradication ProgramThe Polio Program is a part of the Universal Immunization Program. The Pulse Polio Program (PPP) has achieved a 97.6% [67 ] rate for vaccinations. The Pulse Polio Program is an administration of extra Oral Polio Vaccine does to all children irrespective of their immunization

status if they are below 5 years of age. This program has achieved significant success due to an aggressive media campaign and drive.                        5.5.5 National Malaria Control Program (NMCP)       The NMCP pursues malaria control through parasite control (surveillance branch) and vector control. The purpose of the surveillance branch is to detect malaria cases from the community and treat them immediately. In addition to health awareness to people, the NMCP also utilizes 3 methods of surveillance[68]:Active: House to house survey of fever patientsPassive: Blood samples of all fever cases are taken by medical personal of the MCGMMass Surveillance: Looking at high risk communities more broadly Although in 2004, malaria deaths were cited at 23[69], the number of reported cases was 13,522. This cites a need for greater action in prevention, not just in monsoon season, but in all seasons. 5.5.6 Mumbai District AIDS Control Society (MDACS)MDACS is a program that was started in 1998 as an initiative of the MCGM. MDACS functions as an over-seeing body to all the programs related to HIV/AIDS in the city of Mumbai. MDACS has several activities including:Establishing and tracking of STI/RTI servicesCondom PromotionTargeted InterventionIECYouth and AIDSVoluntary Counseling and Testing Centers (Confidential)Prevention of Parent to Child Transmission (PPTCT)Blood SafetyCare and SupportTraining and SurveillanceMonitoring and EvaluationInter-sectoral Collaboration: Work Place Intervention Through MDACS there are clearly a large amount of interventions focused to address and control HIV/AIDS in Mumbai. The tables below give some indication of cases and reported deaths according to the health profiles of the MCGM:                   Table 5.5.6.a: Cases and Deaths of AIDS reported in Mumbai[70]

  1997 1998 1999 2001 2002 2003 2004Cases 180 384 3682 1909 2018 4445 3190Deaths 25 66 100 178 179 889 278

This table shows that the cases and deaths by AIDS in Mumbai. The cases and deaths remain inconsisten with little explanation.           These numbers also seem to bring about some questions as to why there is such a fluctuation of reported deaths between 2002-2004. The WHO reports that HIV has a 0.9% prevalence in India.

The numbers from Mumbai do not corroborate with the national statistics for many reasons. (Explain reasons here) 5.5.7 School Health Program (SHP)[71]The SHP is a critical component of community health care. As school-going children comprise approximately 20% of the population, it is important to promote health awareness amongst them and their families. The objectives of the school health program include:Promotion of positive healthPrevention of diseasesEarly diagnosis, treatment, and follow-up of defectsAwakening of health consciousness in childrenProvision of a healthy school environmentTo achieve these objectives, the SHP provides a mix of health assessments, curative services, rehabilitation, follow-up, healthy child and school competitions, child to child/family/community programming, immunization, first aid and emergency care, statistics, training and other activities. These programs reach approximately 5 lakh children per year through Std. 1, 3, 5, 7, 9.[72] The school health program is run jointly under the health department (which is responsible for administration) and the education department (which is responsible for logistics).[73] Each year, the SHP plays a critical role in helping children access health care. Through parent/teacher/community meetings, the idea of community health is re-enforced in these children to underscore the important role everyone plays in a healthy community. Additionally, due to the nature of follow-up in the SHP, children are able to get treatment without creating a stressful situation in their family. The SHP works with 7 special school clinics at Nair, Nair Dental, K.E.M., Sion, Cooper, Rajawadi, and Bhagwati hospitals. During 2003-2004, the SHP program has admitted between 41,980 and 35,991 children into these specialty clinics, respectively. The SHP has also been beneficial for the screening of TB and Polio and picked up such rare conditions such as Rheumatic and Congenital Heart Disease and such illnesses. Additionally, the extensive health education program reached out to parents, teachers, nurses, and awarded health trophies to deserving children and schools. The School Health Program is an innovative method of providing healthcare to children who are from impoverished populations. 5.5.8 Respiratory System DiseasesOne omission from the MCGM health programming is Respiratory Systems Disease, which, as demonstrated in the table below, are presenting an increasing health threat for residents of Mumbai

Deaths Reported                1997 1998 1999 2001 2002 2003 2004Respiratory Disease

7270 7377 7332 7223 2412 8293 8174

This table shows the deaths reported by respiratory disease from 1997-2004. The table above illustrates a disturbing trend in the city, the rapid rise of deaths of respiratory problems. Due to the fact that there are many infectious and communicable/non-communicable

diseases that need to be addressed, respiratory disease has been reported, but there are no interventions reported in the Mumbai Health Profiles. It is important to note that, these are the deaths reported, and most likely represents a fraction of the actual cases of respiratory disease. By respiratory diseases, we are specifically referring to asthma, bronchitis, upper respiratory infections, etc. According to a study conducted in the D-West ward by the American Journal of Respiratory and Critical care medicine, the asthma prevalence in the Mumbai sample (3.5% based on physician diagnosis, but 9 to 12% when including symptomatic subjects without diagnosis).[74] With an under-reported 9 to 12 prevalence (number of cases of the disease at a specific time) of respiratory ailments, there is a greater need for some intervention by the MCGM. An NGO called the Oasis Foundation claims the air is so bad in Mumbai, it is equivalent to smoking 40 cigarettes per day.[75]In another report by the Environmental Health Department of the MCGM, it was estimated that 43.3% of the population has reported some type of a respiratory illness (this can be asthma, bronchitis, allergic rhinitis, and chronic obstructive pulmonary disease).[76] This only underscores the imperative need for more of a focus on respiratory care for a population that is literally choking on its environment. 

6. Successes6.1 School Health ProgramThe School Health Program (SHP) is a good indicator of a successful initiative of the MCGM. One of the main indicators of their success is the fact that they have a very long vacancy rate. Out of 37 positions, only 5 are vacant.[77] This statistic seems acceptable compared to the high rates of vacancies at the MCGM at this time. There are several other reasons that contribute to the success of this program.Decision-Making Process: Since this program falls under the jurisdiction of the Public Health Department as well as the Education Department, it enjoys a more independent decision-making process. This helps management take the lead in certain situations and can lead to greater innovations within the programStaff Continuing Education: The SHP encourages doctors to continuously be learning throughout their employment process. Staff are encouraged to go to workshops, trainings, and courses. This keeps staff stimulated and helps them apply new strategies to the way they treat their patients.Immediate Follow-Up: If a child is not well and needs urgent care, the doctors are able to refer them to clinics immediately. There is no worry about the family taking the time and care to go to a hospital, wait, and seek care there itself.Administration Team:  The administration team seems to be up to date with everything. Weekly reports are required in addition to meetings, updates, and follow-up. When staff feel accountable to someone, they are more likely to perform their job well.These are just a few of the examples of what works in the School Health Program. Overall, it seems that de-centralized decision making, continuing education, timely follow-up and strong leadership can make a program that sees up to 5 lakh children per year a success. 

6.2 Polio EradicationThe eradication of polio was also a successful initiative of the MCGM. Through the National Pulse Polio Campaign, Mumbai has achieved success due to the publicity and easy dosage. The Pulse Polio Campaign asserts that any child, regardless of immunization status, should receive a drop of polio. Community Health Volunteers (CHV’s) have been a critical aspect of this campaign, by going door-to-door in various communities to ensure that everyone is receiving the required dosage. The national emphasis has made a difference to bring together the entire nation around the focus of polio eradication. The same amount of dedication, for other illnesses, could also be utilized to eradicate other preventable diseases in Mumbai. 

7. ServicesIt has been quite challenging to find clear outlines of the range of services and programs provided by the MCGM. According to the Executive Health Officer (EHO), the MCGM is constructing guidelines for provisions of health services in the following areas:1 dispensary/health post per 50,000 people within 1.5 km.1 facility with a maternity ward for every 150,000 people within 3 km.1 general hospital for every 350,000 people within 5 km.Each of these facilities corresponds to the three-tiered (primary, secondary, tertiary) healthcare system initiated by the Government of India. The dispensary, the primary health care center, is expected to provide treatment for fever, cold, etc. and provide outreach services, MCH vaccinations. The following guidelines are recommended for areas with a population of 25,000 - 50,000:1 female doctor1 public health nurse3-4  nurse midwives3-4 male M.P.W1 Class IV (woman)1 computer/clerk1 voluntary women health workers – 1 for every 20,000 peopleLaboratorySterilization, M.T.P, vaccinesAreas with populations greater than 50,000 need to be divided into two areas with populations of under 50,000 in each. According to the same report, primary health care consisted of the following services:Outreach servicesPopulation EducationInformation, motivation about family planningHealth EducationEnvironmental sanitationPersonal HygieneCommunicable diseasesNutritionM.C.H. & E.P.IPreventive ServicesImmunizationAnte-natal, Post-natal and infant careProphylaxis against anemiaProphylaxis against Vitamin A deficiencyPresumptive treatment of malariaIdentification of suspected cases of leprosy and tuberculosisFilariasisInfant FeedingFamily Planning ServicesNirodh, conventional contraceptives and oral pillsI.U.D. insertion

Sterlization and other M.T.P. Services via referral to hospital or through mobile vansCurativeFist aid during accidents and emergenciesTreatment of simple ailmentsSupportive Services (Referral)High risk maternity casesSterilization and M.T.P.Diagnosis and treatment of tuberculosis and leprosyLaboratory services for diagnosis o malaria matter requiring doctors services/hospitalizationReports and RecordsPreventive servicesFamily planning acceptorsVital eventsMorbidity and Mortality in respect of:MalariaTuberculosisLeprosyDiahrroeal diseasesMaintenance of family cards for population coveredThrough various policies and guidelines, the MCGM realizes the urgent need for having accessible and community based services for those that access public health care. However, when it comes to implementation of these services, there are several challenges that impede the utilization of municipal-run health care facilities. The following challenges are some of the major barriers to the provision of equal distribution of health care services to the underprivileged population of Mumbai. 7.1 MCGM Health BudgetAs per the Municipal Corporation Act, the MCGM is primarily concerned with providing preventive health care services in the city. However, the current focus seems to be leaning toward curative care in a major way. In the following budget, it is evident that the majority of funding goes to tertiary and secondary care.[78]

        Rs. In Crore

  RevenueCapital Works (Civil)

Plant and Machinery Total

1. Public Health Department 98.4 3.7 75 102.1

2. Medical Relief and Education (Including Medical Relief and Medical Education)

599.4  (537 Medical Relief)(62.4 Medical Education) 62.7 45.6 707.4

3. Measures to Control Environmental Air Pollution 3.7 11.2 69.3 4.4

Total 701.5 66.3 46.2 813.3 Clearly, the budget illustrates the above point as the budget for curative services and medical education are nearly 7/8ths of the entire budget of the MCGM health program. The cost of medical relief is greater in comparison with the cost of preventive services. However, for the sake of the budget, it all falls under the category of “Medical Relief”. Additionally, because medical education is mainly subsidized, many colleges can not collect revenue from the medical colleges, as may be the case in other countries. This point can be validated when looking at the top four 3rd-tiered hospitals[79]:        Rs. In Crore  Hospital Name Revenue TotalKEM Hospital & GSM College 114.1 137.5LTMG Hospital & College 93.2 124.1BYL Nair & TNM College 70.9 111.7Nair Hospital & Dental College 7.4 9.7Total of Major Hospitals   383

 When we look further at the budgets of the special and periphery hospitals, we get a better idea of where the priorities lie in the funding of medical institutions:  Name of Special & Peripheral Hospitals Rs. In Crore1 Bhajekar Hospital 1.42 ENT Hospital 3.03 Eye Hospital 1.74 K.B. Bhabha Hospital Bandra 15.95 K.B. Bhabha Hospital Kurla 8.46 Mun. General Hospital Ghatkopar 19.97 Bhagwati Hospital 14.48 MTA Mun General Hospital 8.99 Cooper Hospital 21.810 DN Mehta Hospital Chembur 4.111 VN Desai Hospital, Santa Cruz 8.912 MW Desai Hospital, Malad East 4.613 VD Savarkar Hospital, Mulund 3.414 MGH Barvenagar Hospital 3.615 SK Patil Hospital Malad East 1.716 Centenary Hospital, Kandivali 3.717 Centenary Hospital, Govandi 6.718 Mahatma Jyotiba Phule Hospital, Vikhroli 4.719 Siddhartha Nagar, Goregaon 3.420 BSES Mun Gen Hospital, Andheri West 2.7  Total 138.9

 

Many of the peripheral and secondary hospitals listed above are located in the suburbs, while the 4 major hospitals are located on the south side of Mumbai. This presents many challenges for those that end up having to seek care at secondary and primary institutions. Infectious Disease and Tuberculosis hospitals also do not get priority in terms of funding[80]:  Name of Hospital Rs. In Thousands1 Katsurba Hospital 14,37,072 GTB Hospital 17,65,483 RDTB Clinic Dadar 41,704 Shamaldas Gandhi Marg TB Clinic 30,745 Balaram Street TB Clinic 23,336 TB Clinic, Khar 93,047 Nawab Tank, TB Clinic 27,168 Acworth Leprosy Hospital 1,40,03  Total 35,58,55

     And finally, the category of “others” which loosely covers health posts, maternity homes, and dispensaries is at the bottom of priority list.[81]  Name Rs. In Thousands1 Maternity Homes, Children Welfare Services etc 59,03,212 Dispensaries 20,58,713 CHMS (PH) 3,544 Central Analytical Lab 29,02  Total 79,94,406 Public Health Department 98,39,607 Measures to Control Environmental Air Pollution 3,69,70

 The figures above demonstrate that there are several gaps in terms of priority in funding to the various health initiatives of the MCGM. A close look at the budget shows a major gap in the primary, secondary and tertiary levels of care.A budget analysis can demonstrate the trends in fund allocation and expenditure as part of the MCGM. Budget analysis: Source- Budget Estimates A, 2005-2006, as prepared by Municipal Commissioner, BMCAppendices to Budget Estimates A, Revenue Income and Expenditure (combined) 2005-2006, as prepared by Municipal Commissioner, BMCFor- Public Health Dept., comparisons being made between budgeted estimates of 2004-2005 and 2005-2006The increase in income for the budget estimate from 2004-2005 to 2005-2006 is given as Rs. 252.47*, whereas the increase in expenditure for the budget estimate from 2004-2005 to 2005-2006 is Rs. 443.53. Deficits for sure with exp. almost double the amount of income.

Budget estimates for the yr. 2005-2006 have increased w.r.t. 2004-2005, but mostly under salary and administrative component. For example- General Superintendence- almost doubled; under Rabies Control, Licensing of dogs; under Medical Relief and Education for King Edward Memorial Hosp. Figures on page H-158 gives a better picture for it. The wages since 1999-00 until now have increased by almost 100% and form the major chunk of total exp. when compared to others (other budget analysis tools can be employed to highlight the above point). Page- H-159 shows ‘wages’ under the head of “Controllable Expenses” that have actually grown in an uncontrollable fashion, whereas the increase in “Obligatory Expenses” mentioned above it has not been much.Budgeted estimates for repairs (as part of General Superintendence, under Rabies- increase by ten times); for Medicines, Instruments and Inoculations (under Epidemics) and for Equipment (under Medical Relief and Education for King Edward Memorial Hosp.- increase by 100%)have also increased significantly. The thing to be noted is that while all these increments are being made on paper, are they also being materialized or do they continue to be on paper only.The budgeted amount to be invested for equipment (under Vector, Pest and Rodent Control) has been reduced by almost Rs. 200, 000.Budgeted amount under Rabies Control for ‘payment for sterilization of dogs’ has gone down by Rs. 300,000.The exp. under has decreased from Rs. 200,000 to a mere figure of Rs. 30,000.The summary and concise form of detailed estimates given at page no. H-160 clearly shows that the estimates for 2005-2006 when compared to that of 2004-2005 have been on a decline for most of the elements of Public Health Expenditure, though it has also increased for others. To mention a few heads where it has declined- Epidemics; Vector, Pest and Rodent Control; Laboratory; Dispensaries (under Medical Relief and Education) etc. Examples where the increase has taken place- Rabies Control; Life Guard Services at Juhu, Versova, Hospitals, Maternity Homes etc. 7.2 Primary Health CarePrimary care is supposed to be the first point of access for the citizen. If primary health care institutions are at the bottom of the priority list, then they will be treated similarly by the consumer or patient. In Mumbai, the major issues around utilization of the public health care system are quality of care, convenience, costs, distances, apathy among staff, and wide-spread vacancies. As a result, people living Mumbai fail to access primary care services and proceed to the tertiary level hospitals and private vendors for all their care, even that which is normally addressed at the primary care level. This leads to overcrowding at the city’s third tier hospitals, which have comprehensive services and better quality of care. According to a study conducted by CEHAT (Centre for Enquiry into Health and Allied Themes) demonstrates that despite having better health care services, people residing in Mumbai do not have proper access to health care as 32% of ailments remained untreated[82]. The MCGM’s described functions for dispensaries and health posts are described below:Functions of Dispensaries:Clinical management on OPD basis.Immunization- polio, DPT, Measles, Tetanus, Toxid, Typhoid.Preventive services.

In upgraded dispensaries- Laboratory services- Urine, stool, HB blood, and Malarial parasite. (Out of 163 dispensaries- 60 are upgraded).Health Education to the patients attending the dispensaries.Medical examination of Municipal employees. On the whole, dispensaries, preventive, curative services to the patients.   Functions of Health Posts:Conducting baselines surveys of the community (of about 65,000 population) residing with in the given geographical area.Enlisting the eligible couples, motivating them for adoption of small family norms and providing them with outreach services for contraception.Immunizing children against the 6 vaccine preventable diseases viz. children tuberculosis, diphtheria, tetanus, pertussis, poliomyelitis and measles through fixed center based and camp approaches.Preventing and treating case of nutritional anemia in mother and children by distributing iron-folic acid tablets & syrup.Vitamin A syrup to all children as prophylactic doses for Vitamin A deficiency.Oral Rehydration salt packets to children of under-five age group suffering from diarrhea Conducting Growth Monitoring Program for children of under-five age group.Giving health education to all slum-dwellers. Detection and treatment of cases of Leprosy, Tuberculosis, AIDS and Malaria.Registration of unregistered births and deaths.Detection of new home births and the motivation of such mothers to get their babies immunized.Establishing effective Management Information System including proper record keeping and timely reporting.Developing and efficient referral system. According to leading public health experts, improving primary care is the best method to promoting health and preventing disease in countries with high populations and low resources.[83] During a non- research based study of a primary health center in Chembur, Mumbai, the author found that the majority of the patients coming there were either coming for TB medication (42%) or basic health problems 53% (fever, cough, cold). Out of 19 people surveyed, only one person complained about the process of sending a patient to a hospital, then health post/dispensary, then hospital again. The majority of patients (73%) were satisfied with the quality of health care because the doctor was good.[84] This comment was most always in relation to the doctor and the effectiveness of the medicines. An analysis of MCGM dispensaries in two wards at Mumbai showed that an average of 85 patients are treated every day, 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.[85] It is clear that the public health services in Mumbai are certainly utilized; however, it is the quality of the care that should be addressed. While the research demonstrated that the people going to the dispensaries and health posts were satisfied by the services, there are other wards

that are plagued with vacancies at curative level positions. For example, an interview of the K east Ward Officer (also a doctor) revealed that out of 11 positions for medical officers, there are currently 9 vacancies.[86] Staff dissatisfaction is high among the Community Health Volunteers (CHV’s). The CHV’s were retained after IPP-V ended to serve as the “eyes and ears” of the MCGM- performing such duties as immunization campaigns, home visiting, family planning education, and more duties as required. Of the CHV’s I met, all of them complained of salaries that were too low. These CHVs make up to Rs. 900 per month, which in contrast to the onus of their work is too low, and if the burden of community health outreach must fall upon them. Other examples of challenges at health posts and dispensaries include a visit of Dr. Janaki Desai to a dispensary on Antop Hill with a group of foreign visitors. “I saw the doctor use a dirty, old, un-sanitized needle to give the patient an injection. On top of that they were asking the visitors for money to help support the health post”.[87] Dr. Desai heads the NGO the Niramaya Health Foundation. The organization’s main focus is to provide health education and promote the concept of prevention. “Due to the inadequate services provided by the MCGM, our clinics have turned into the OPD’s instead of centers for promotion of good health and prevention of disease. We hope to work more collaboratively on these issues.”[88] Dr. Desai also mentioned that their NGO provides iron supplements (supplied by the MCGM) to young women, and these vitamins have been “unavailable” for the last 6 months. The challenges of utilizing the public health system is currently presenting a challenge for those who are trying to work within the system. In contrast, in other wards and areas of Mumbai, some citizens prefer to access care by a private provider. In the K East Ward, public preference for outpatient care services from a BMC facility in the CEHAT study “Un-met Need for Public Health Care Services, in Mumbai, India” 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 percent). 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.[89] The reasons cited in this study for choosing private care cited “offers good quality service” as the main reason. However, in terms of affordability, the same respondents said they would prefer to go to a public facility- however, due to lack of doctors and general unavailability; they had to seek care at a private practitioner.[90]Clearly, while the primary health care system does have many strengths, it is plagued with issues of quality and access due to inconvenient timings, widespread vacancies, and lack of motivation of staff. 7.3 Challenges at Secondary Hospitals and Maternity HomesAs is evident in the MCGM budget, the secondary (also referred to as peripheral hospitals) and maternity homes do not receive adequate resources to support their respective institutions. The budgeted allocation of 20 secondary hospitals is equal to the entire budget of KEM Hospital. In a city that is expanding toward the suburbs, it is critical that the peripheral hospitals are also

prioritized in terms of development and offering of services. According to Dr. Sanjay Nagral, a physician at Jaslok and Bhabha Hospital (Bandra), certain systems create inefficiency at secondary hospitals. One is, despite the service, the perception is that government related health services are always bad. Secondly, part of the problem is the bad attitude of the staff:They think the patients are poor, so they deserve bad treatmentSenior staff reinforces this problemStaff is genuinely inefficientThis is very true at the peripheral hospitalsEven proper seating arrangements at the OPD could ease the tension that is created by long waiting time and staff inefficiencies[91]Maternity homes are also not utilized properly, as surveys from the CEHAT study found that seven to eight per cent of deliveries in Mumbai are still home deliveries. About 40% of the population utilizes the public sector for antenatal services. According to Dr. Armida Fernandez, founder of SNEHA, an organization working collaboratively with the MCGM to improve public health care for Maternal and Child Health, According to Dr. Fernandez, the IMR in Mumbai is 40/1000 and the amount of neonatal deaths: 25/1000. Shockingly, the MMR in India is equivalent to that in Mumbai (410/100,000). Clearly, there is a greater need for improvement of care at the secondary level as well as the primary health care level. 7.4 Third Tier HospitalsThe third tier sector hospitals, KEM, Nair, Sion, and Nair Dental are known world wide for the breadth and depth of their services. KEM is the flagship institution of medical education and public facilities in Mumbai. These institutions provide comprehensive care, from general medicine to cardiac surgery under their care. On the website for KEM, it states “The medical college (school) provides training to about 2000 students in undergraduate, postgraduate and super-specialty medical courses; in undergraduate and postgraduate physical and occupational therapy; Masters and PhD courses in various allied specialties. A nursing school is also maintained by these institutions. With about 390 staff physicians and 550 resident doctors, the 1800 bedded hospital treats about 1.8 million out-patients and 68,000 in-patients annually and provides both basic care and advanced treatment facilities in all fields of medicine and surgery.”[92] Clearly, colleges and hospitals of this caliber benefit greatly from the subsidization of their services by the MCGM. As is evident from the MGCM budget, the majority of the financial resources of the public health department are allocated to these four major hospitals. In fact, their endowment makes up approximately 7/8th (86%) of the entire public health budget. It is important to note that because these are also medical colleges, the government in part, is also subsidizing the medical education of students attending these colleges. Subsidizing medical education is hardly a new phenomenon; however, the chances of the future physicians from these colleges integrating into the community to fill the much needed gaps are minimal. The table below illustrates how minimal the medical education fees truly are:ALL FEES ARE FOR A TERM OF 6 MONTHS at Seth GS Medical College:[93]

First MBBS Rs.10,100

Second and Third MBBS Rs. 8,100

Postgraduate Medical degree courses (MS,MD,MCH,DM etc) Rs.14,800

Postgraduate Medical diploma courses (DVD,DMRD etc) Rs. 14,800

BSc Rs. 1750

MSc Rs. 5475

PhD Rs. 6275The table above demonstrates how minimal the fees are for medical students.Although KEM and the other medical colleges are quite competitive at the entrance point, the fees are not really a barrier for those seeking medical education; even the completely poor fall into various scholarship categories. As a result, the medical education or the cost of it is not a critical point of contention for the student. Additionally, students and residents have their own opinions about the state of the public health system:“The secondary hospitals have no facilities.”“We cannot practice without proper equipment and that is the major problem with the health posts and dispensaries”.“I would not prefer to work at a government facility if I had the choice”.[94] These were the words of the residents interviewed at a general OPD in a hospital/medical school by the author. The residents spoke of the challenges they had heard from the field and implied that they would rather go into private practice or a fellowship than stay to practice in health clinics. When asked how much they spent on their medical education, many stated that between scholarships, waivers, and government quotas, many of them did not have to pay anything for their medical education. Clearly, there is a gap between curative medicine and preventive medicine in the Indian medical system. It is known among doctors and faculty that Preventive and Social Medicine (PSM) is like the step-child of Indian medicine. PSM is not widely developed or even understood by the doctors who have that qualification. Additionally, the financial value of a doctor practicing PSM is also quite low. Therefore, the idea of PSM, which is essentially public health, is brushed aside for more curative services. However, the value of such a practioner, especially in communities and clinics, would be invaluable for improving the health indicators of the urban community at large. The undervaluing of PSM has led to a great divide between preventive and curative medicine at the practical level at 3rd tier hospitals and medical colleges. Another aspect that has paralyzed the public hospital system, especially at the 3rd tier, is the opportunity for professors to have a private practice in addition to their work at the hospital. This not only takes away precious time that could be spent in the community or doing trainings, but it sets a bad example for young residents and interns about the purpose of a publicly funded healthcare system. Additionally, as beneficiaries of the public system, their profits should not be utilized for personal purposes. While the original creators of the policy may have been thinking otherwise, this policy ultimately can be detrimental to the public health system.Also on the website, is the list of salaries for the various posts at the hospital:

Position SalaryResident Rs. 6500-8000 per month

Lecturer Rs. 15,000 per month

Associate Professor 

Rs. 18,000 per month, provisional quarters may be provided.

Professor Rs. 25,000 per month, provisional quarters may be provided.

 With salaries lower than what most people make at the bustling call center industry, it is no wonder that doctors are not opting for government positions in health.Finally, the biggest challenge at the third tier is not just the low school fees, private practices, lack of emphasis on PSM, or low salaries- it is the lack of a referral system that leads to the overcrowding of these hospitals. These hospitals are overcrowded with people coming for simple ailments (cough, cold, fever, backache) that can be addressed at the primary care level.Another non-scientific survey[95] was conducted in the general OPD of KEM hospital by the author of 20 people visiting the GOPD for health care. Sixty-five percent came from areas that had government hospitals and facilities: Wadala, Ullhasnagar, Malad, Bhyendar, Andheri, New Mumbai, Bhandup, Sewri, and Govandi. Patient’s less serious ailments were cold and cough, high blood pressure, acidity, dizziness, fever due to no access to cleaning water, and respiratory infections. These conditions could easily have been cured at the primary health care level, at a municipal dispensary or health post. When asked why they chose to KEM over their local public health post or dispensaries, the answers varied from not knowing about local services to dissatisfaction with quality of care. Overall, the majority of those coming to KEM came because the doctors were good and the treatment was effective.“Good Doctors, and good facilities for patients”, Housewife, Wadala“I went to a private hospital and the doctors were rude. I came here and the doctors spoke to me   nicely”, Housewife, Ullhasnagar“Doctors and facilities are good. Those who leave here, leave well” Male, Parel“Treatment is done well, and they take time and do good. In the village, they give an injection, and it doesn't work well. It is good. Its not easy to handle that many people”, Driver, Rajapur Village“If you come 1-2 times you get better relief. The procedure has become a little complicated, it used to be better when people were prioritized based on illness”, Saleswoman, Bhayendar. She also added that she is unaware of the public services offered near her home. Overall, there was a major lack of awareness of the existing public health services offered near their home, and a major perception that the doctors treated them with more respect at KEM than anywhere else. The average amount of money spent going there for just travel averaged at about Rs. 56 per person. This can be half of one day’s wages for daily laborers, and the waiting time can surely cost them another day’s pay. Of course, this does not include the amount of money they may have spent seeking health care from alternative sources of treatment. One woman claimed to have spent Rs. 1000-1200 on her care in a private facility to no avail, and then someone recommended she come to KEM. This study was conducted to get a sense of why people chose to come so far to seek care. At the end of everything, more than the actual treatment, it was the fact that the doctors were attentive, focused, spent time listening to each patient, and generally had an affable manner about them. 

Although this is quite similar to what was observed in the municipal dispensary, some of the interviewees’ biggest complaints were that the doctors in the dispensaries did not treat them with respect and dignity. The affable manner can be related to several different issues:The residents are fairly young and were able to work with peers of a similar age groupKEM has each and every facility that is required for a doctor to come up with a proper diagnosisThe residents expressed that the emphasis on quality came from the senior management, underscoring the administration’s commitment to quality of careThere was a good team environment where the work was distributed evenly and senior doctors were very supportive to the juniorsThrough this observational analysis, it seems that most people want someone who can speak to them nicely and help them out with whatever ailment they are having. They don’t mind waiting, or traveling for days, they just want respect and affability. The other side of this survey is that due to timing problems, many of the doctors were present during the interviews. This could have skewed the results of the survey as perhaps the patients did not want to seem ungrateful. In fact, some of these patients arrive at the hospital so desperate, any form of care that results in better health is helpful. While the responses do show a positive image of the hospitals, it is important to remember the conditions under which the survey was conducted. It is also important to remember that this was just a small survey of the patients and is not meant to be indicative of the entire population that utilizes it. While this example is just of one of the best institutions in Mumbai, another municipal teaching hospital- Sion (and LTMG Medical College) often bears the geographical brunt of the influx of patients bypassing the primary health care system. Since Mumbai is an island city and has developed toward the suburbs, the majority of the 3rd tier hospitals ended up in the southern part of Mumbai. This creates major barriers to access in care due to the distance and time involved in reaching these hospitals from the suburbs. Sion hospital provides a break in that geographical barrier from the suburbs to “town-side”. As a result, Sion hospital bears the burden of most emergency cases, transfers from peripheral hospitals, casualties, and most aspects of urgent care. As a result, Sion’s services are compromised due to work-overload on physicians, scarcity of resources, and difficulty in managing overcrowding. Clearly, there are many complicating factors regarding efficiency and access at municipal hospitals in Mumbai. Even though services are of high quality at 3rd tier hospitals, they are still plagued by issues of overcrowding, lack of referral systems and non-utilization of primary health care services. It is important to understand the detrimental effect an uneven distribution of services ends up having on the entire public health system. Indeed, due to some of the compromised conditions (financial and otherwise) at primary and secondary levels, the system itself encourages uneven access to health care.    7.5 Inconvenient Timings

The MCGM’s timings for health posts and dispensaries are generally 9am-4pm. This is often an inconvenient time for people who are employed. Leaving work and spending an unspecified amount of wait time can contribute to the frustration with public health facilities. 7.6 LocationsAs it was alluded to previously, the major 3rd tier hospitals are located in the southern part of Mumbai, while the city has expanded toward the suburbs in the north and east. This is common urban phenomenon known as urban sprawl, is leading to compromised access to public health care and is increasing the market for private practitioners (both qualified and un-qualified).  In the surveys conducted of the KEM OPD ward, many of the patients that came from various distances were unaware of the locations or services offered near their home. Apart from the ones who had a negative perception of it, many claimed to not know the locations of the government health facilities. This happens for many reasons:Due to extremely large populations to be covered by community health volunteers (1 per a population of 60,000), each home that is supposed to be visited is often notSince word of mouth is the most common method of reaching out to communities, the lack of awareness propitiates throughout the communityIf people know of a 3rd tier hospital that is effective, they will bypass the primary health care system regardless of proximity.Additionally, there was no map of Mumbai that had explicitly drafted the locations, timings, and doctors at each health facility. A pamphlet of that nature would be useful to promote the availability of government health care services. 7.7 VacanciesWide spread vacancies continue to plague the MCGM health system. In K East Ward, as mentioned previously, there are nine vacancies out of eleven positions for Medical Officer’s of Health. This is in an area that already suffers because of the lack of the municipal hospital in the ward. When the survey was conducted at KEM General Out Patient Department, the residents working there also mentioned that they were not interested in working at municipal dispensaries due to lack of resources and facilities. The general disposition of the MCGM public health department seems rather apathetic in relation to the high rates of vacancies. It seems to be an acceptable norm that should just be accepted. This further complicates the case for expecting patients to seek primary health care. If a patient goes once or even twice and the doctor is not there or has left early, it becomes a dysfunctional health care center for them. Further, due to a hiring freeze due to budget problems a few years ago, there were no positions filled. There are several reasons for wide-spread vacancies at MCGM. First, the salaries for doctors are not at a standard of living that would be appealing to many young doctors and the older doctors that have been MCGM position for years often wait to retire to get benefits. Secondly, there are no incentives for working at a community service level. Thirdly, there are hardly enough facilities at primary and secondary level that make a doctor feel like they can diagnose/treat a condition without having to refer the patient to a tertiary institution for further investigation.Finally, given the financial remuneration is so limited for doctors, many would prefer to start their own practice or work in a private institution. 7.8 Quality Assurance

Quality Assurance or quality of care does not mean sophisticated or exclusive care, but is concerned with fully meeting the needs of those who need the service the most, at the lowest cost to the organization, within limits set by higher authorities. Quality of care is cited as the main reason the interviewees at the KEM GOPD chose to travel to KEM for their care. One hundred percent of the patients mentioned the doctors are facilities were good. The doctors spoke to them nicely and the treatment was effective. One woman mentioned that it was “very clean” as compared with other hospitals she had been to. These correlated with the residents’ comments that the facilities and resources available to them helped them serve the patients better. Additionally, the presence of systems and availability of “one stop servicing” is extremely beneficial. Because KEM has everything from X-ray facilities to MRI’s, patients don’t need to seek care elsewhere.In summary, Quality Assurance, as a concept is a systematic way of ensuring and maintaining “quality” of services and has proved useful globally. Quality of care has 3 dimensions:Client’s perspective: What do clients expect from the health services?Professional’s perspective: Do services follow health care provider’s professional standards?Management or Administrative perspective: Are the resources being used productively? Are the services efficient?Through a collaborative initiative between the MCGM and XXX project, an action research project was implemented in 2 wards: H East and G North. This included 17 health posts, 16 dispensaries, 2 maternity homes, and 1 secondary hospital. The focus of the project was to look at providers as agents of change. The project was limited in terms of its interaction with the community, primarily because the project was aiming to reach the community through the providers. The overall goal was to ensure quality health services for women within the context of reproductive rights and health. The objectives were:Improve, strengthen, and increase quality and range of health care services for women at all levelsEnable women to have access to gender sensitive and user friendly servicesDevelop and build capacity of staff at 2 wards, training, monitoring and evaluation, and health of womenThis project worked closely within the MCGM structure with senior decision makers and health managers in planning and intervention. Also the project focused on the capacity building of staff in counseling, communication skills, training skills etc. The project also promoted quality assurance and monitoring and evaluation.This quality assurance system was implemented over 4 years and the team took every initiative to ensure proper planning and implementation:Workshops, planning, experimentations and interventionsAdvocacyResearchAnd in order to make sure everyone felt involved in the process, they established committees to serve as links to the system, conducted participatory research and gave feedback, took all efforts to ensure administrative support, and involved key persons from the MCGM. The main issues that needed to be addressed were:Information needs of clientsAttitudes of staff toward clientsCommunication process between staff and clients

Diagnosis and prescriptions given by CHVs and ANMs (Auxilliary Nurse Midwives)Training and supervision of staffReferral processUse of routine dataThis project was very well planned, but was not accepted by the staff and administration teams as it was thought of as a foreign concept. The project was opposed from many sides, and most people claimed to not receive enough support from senior staff. The project did accomplish some formidable goals, including two manuals for clinical guidelines in reproductive health for both makes and females and a referral process that is described in the next section. 7.9 Referral SystemsThe nature of the way people in Mumbai access public health care facilities would be greatly improved if there were a referral system in place. In most countries, if a patient needs to see a provider for a specialty, they must go through their primary care provider first. However, in a system where the public is free to access health care at any level, the primary health care system in bypassed and the patient heads straight to the tertiary or specialty care. When patients choose to seek care at their own discretion, resources for primary and tertiary care are wasted and tertiary resources are exhausted. This was evident in the KEM General OPD survey, where many of the patients came for such common health issues such as fever, cold, cough, backache and dizziness. If these patients had gone to their primary health care facility, it would have saved both the hospital and the patients time and money. A referral system was tried and tested at MCGM by the Women Centered Health Project. The process is described below: An effective referral system would ensure optimum utilization of the three tier health care delivery system of the MCGM and therefore use the available resources:            I. Objectives of the Referral System:To ensure appropriate utilization of available resourcesTo ensure accessible, affordable health care servicesTo ensure patient and provider satisfactionII. Pre-Requisites of an idea referral system:Well defined levels of health care services based on availability of specialty servicesStandard referral protocolsAdministrative guidelines agreed upon by appropriate authorities governing various levels of health care facilitiesA well defined and well implemented feedback systemFocus on client and client centered in natureInvolvement of public as well as private sectorStrategies to enforce compliance II. The proposed system for MCGMThis was looking at a well defined three tiered system with health posts and dispensaries at the primary level, secondary hospitals, maternity homes and post partum centers as secondary and teaching hospitals. The way it was proposed to work was that the priority would be given to the referred patient. Patients being referred were getting a specially designed slip and would be afforded benefits at the primary level. 

This entire process did not work in the end because some of the staff were not clear about the referral slips, this led to further patient dissatisfaction, people were unclear about how the system was supposed to actually make things better. This process is also being implemented through an NGO called SNEHA (Society for Education, Health and Action for Women and Children). CINH (City Initiative for Neonatal Health) is a collaborative initiative between the SNEHA, the International Perinatal Care Unit (IPU), UK and the Bombay Municipal Corporation (BMC), CINH uses participatory techniques to involve community members in urban slums and municipal health service providers to achieve:• Improvements in maternal and newborn care practices and care seeking• Provision of high quality antenatal and postnatal care at public health posts• Continuous quality improvements for maternal and neonatal services at maternity homes and hospitals CINH has three essential components:Improving public health systemsImproving maternal and neonatal health outcomes at the community-level Developing these supply and demand interventions into a replicable model for urban slum settings A four-pronged approach will address these essential components: Improvement in the quality of maternal and neonatal health care in all levels through the development of a formal referral system in the BMC. This includes implementation of clinical and administrative protocols for referral and transfer. To ensure sustained change, the Appreciative Inquiry model will be used in addition to supportive supervision techniques. The participatory development of antenatal, postnatal and neonatal (APN) service package for health posts was developed to build support at the community level. The use of action-research cycles with community groups to improve maternal and neonatal health outcomes.  This low-cost intervention trains local facilitators to lead community groups through a process of identifying local challenges in maternal and neonatal health and evolving workable strategies.  The development of evidence-based models for urban slums by building action research projects with a strong evaluation component.  Each intervention is participatory and includes capacity building for sustainability. [96]As CINH is being implemented throughout various public health care facilities in Mumbai, it is important to look at it as a replicable model that can be utilized universally throughout the system. Such a model can lead to greater efficiency as well as increased quality assurance throughout the process. 7.10 Lack of AwarenessLack of awareness covers a range of categories, lack of awareness of the patients regarding the availability, locations, and timings of government services; lack of awareness within the staff about quality assurance and quality of care; and lack of awareness of the multi-dimensional

aspect of the MCGM’s programming. There is no availability of a map in of the health services being offered in each area. This leads to the general lack of awareness of services offered by the MCGM. Patients feel there is a free range for them to access services anywhere, regardless of the inconvenience. Staff are also largely unaware of the overall goals for quality services and perform on a “fire-fighting” strategy, in which only the exigent issues are addressed, and there is little adherence to ongoing strategy planning and setting up goals and work plans. Finally, it just seems that there is a great disconnect between the different aspects of MCGM programming. While some programs get national level priority (Polio and TB), some of the other programs like environmental health and primary health care delivery through the CHV’s is not set as a priority for funding. Although these programs are multi-dimensional and could be inter-sectoral, the programming tends to run in a vertical fashion, all working toward goals without thinking of the benefits of a more horizontal approach toward programming. 7.11 Public Health Disaster ManagementIn light of the recent outbreak of avian influenza, the MCGM needs to have a separate cell that deals with public health disasters and outbreaks of diseases. If there is a cell that monitors public health outbreaks around the world and tracks them before they reach Mumbai. Having a team whose expertise is public health disaster management would be beneficial to the public health department. This team would consist of media persons, public health experts, hospital administration team, doctors, nurses, pharmacists, and community health workers. In this situation, the outbreak needs to be attacked through a multi-dimensional approach:A media person can be in charged of the reports that go out to the press. In its current state, the communication between the media and the MGCM is antagonistic with plenty of skirting the blame.Public health experts can help figure out medical and preventive strategies to address the outbreak. Currently, various staff from many departments have been pulled from other work to address this issue. There is no real assessment of how far Mumbai bas been affected, thus creating a state of panic and fear.A hospital administration team is critical to setting up an operation to deal with the possibility of a public health outbreak. The hospital beds to be used for quarantine as needed should be decided beforehand as well. This team can be responsible for carrying out administrative and laboratory tests as needed.Doctors and Nurses are needed to help any urgent needs related to people who have already contracted the illness. These providers should be vaccinated (if possible) before hand to all illnesses that pose a threat.Pharmacists can ensure that medications needed for the outbreak are available and not expired. They should ensure enough stock just in case an outbreak is likely.Finally, community health workers are needed to help keep the community educated and not panic; especially the communities that live in large slum populations. The MCGM has put out pamphlets regarding the Avian Flu, however, they are only in Hindi and Marathi, thus excluding a large part of the slum-dwelling populations and impoverished communities.Addressing issues during a time of disaster are never smooth, no matter how well planned out the process is. However, adequate planning and team preparation can help decrease the “learning” that happens along the way. In other words, disaster management teams should be adequately prepared beforehand so that while some things may require thinking on the spot, other processes can go according to standard procedure. 

 7.12 Water supply and sanitationTo be added   7.13 Challenges from the Private SectorAccording to a World Bank Study, nearly 82 per cent of all health spending in India is private.[97] The increasing competition of the private sector of health care combined with a larger disposable income of the middle class has resulted in loss of patients from the public to the private sector.These patients cannot necessarily afford the exorbitant cost of the private health care facilities, but are willing to go into debt or risk their financial security to seek care in the private sector. The reputation of public health services, unfortunately have become so negative that those who can, and even those who can’t, will opt to seek care in a private facility. According to Dr. Sanjay Nagral, “this was not the case 20-25 years ago, because back then people did access the BMC services”. At that time, the private sector was also not as developed. This also helped keep the system in check, as everyone from politicians to plumbers were accessing the system. Today the average middle-class person or upper class person doesn’t think to use the BMC’s services. Even the poor re-consider it at times. Even though there are segments of the private sector which are too expensive for the average middle class to afford, they will still seek care there. According to Lokshahi Hakk Sanghatana, a democratic rights organization, said in its report, `Creeping Privatization in Public Hospitals in Mumbai — Private Profit, People's Loss'[98], that public hospitals come forward and administer care during times of social strife such as natural calamities, riots and outbreak of diseases, while private hospitals do not. The report claims that the MCGM is moving toward privatization at most of the municipal health facilities. According to the report, privatization of health facilities has been taking place in many ways — hospitals, services such as blood banks, dialysis centers and intensive coronary care units (ICCUs) have been handed over to NGOs or private entrepreneurs. If there are no private funds available, the report says, and then the expansion projects are generally unavailable. The MCGM collaborates with some private practitioners for tuberculosis treatment, but other private practioners do not report having the same treatment regimen across the board for TB treatment. These types of partnerships need more transparency and communication so the health outcomes of the patient are not affected negatively. Further, out of approximately 40,000 hospital beds in Mumbai, the MCGM holds about 10,000, which means that over 3/4ths of the beds are under the jurisdiction of the private sector. Newer complications are due to arise out of the latest trends in medical tourism. With foreigners investing their dollars and pounds in private health care in India, the hospitals will make a lot of money, no doubt, but again the poor will remain without quality or quantity in terms of available services. According to a report in the Hindu magazine, “Only seven years from now, the most optimistic industry forecast posits, medical tourists hosted by India can pump Rs. 10,000 crores into our economy. An estimated 1,50,000 such visitors a year already spend about Rs. 1,500 crores in India for treatment.”[99] The major question everyone is asking is, what does this mean

for the impoverished citizens of Mumbai. Although private hospitals have obligations for their not-for-profit status under the Public Trust Act to provide healthcare free to the extent of 20 per cent of their resources, there is no accountability or follow-up for this provision. As a result, the poor don’t even see private care as an option, thus the frustration ends up coming out on the public healthcare system. 7.14 Reporting and Data CollectionThe Mumbai Health Profile is put out every year (approximately) in order to give an update of the health programming and accomplishments. What is missing from the report is an analysis of the numbers reported. It seems very haphazard that the numbers are just reported without any indication of what could have led to an increase or decrease. For example, there are no explanations for why the TB numbers have fluctuated so much over the years.  One can assume that the different policies that have been implemented may have contributed to it, but the report itself does not make a connection between the interventions and the numbers. The reporting process is a critical part of showing the successes and challenges of the MCGM. Another aspect of the MCGM that needs to be revised is data collection. For example, the School Health Program is a successful intervention, but the data is not centralized so that there can be effective epidemiological monitoring of growth, malnutrition, rates of TB and other illnesses, and follow up. In order to decrease the paper burden, it is important to establish a global information system that allows staff to input data and allows universal access to it from all MCGM facilities. A centralized, computerized data system could result in increased efficiency of the process. This would in turn improve the reporting process as well. 

8. Appendicesa. Patient Bill of Rights Each place posting the Patient Bill of Rights needs to affirm the following statement. "We, the staff and the administration of {health facility} declare the following Bills of Rights for the patients of this medical facility. As per the Municipal Corporation of Greater Mumbai, we declare that staff and administration of {the health facility} have read and understood the following rights of a patient and hereby agree to all the terms listed below. If you have any questions or complaints, please contact {Name of accountable person at health facility} or {name of accountable person at BMC}." To be treated with dignity irrespective of their caste, class, sex, religion, and diseaseTo have a list of exact services available and corresponding fees (for supplies, bandages, etc)To have a visible map of the hospital (in Marathi, Hindi, English, and other languages)To have a list of emergency services such as blood banks and ambulatory services listed in Marathi, Hindi, English and other languagesTo know and understand the procedures involvedTo be given a reasonable time frame for the treatment and receive a proportional discount in fees for all services after the upper limit of approximation is over and treatment needs to be continuedTo have a comprehensive (various tests, blood work, x-rays, room tarrifs, operations, consulting fees, etc) costs associated with seeking medical careTo receive prompt and courteous careTo be informed about the documentation needed for treatmentTo have minimal documentation for emergency casesTo receive Reproductive and Child Health Services free of cost at public health facilitiesTo receive medications and vaccinations from the local public health post or dispensaryTo get medical services which are within the capability of the medical facilityTo obtain from the doctor complete information concerning the diagnosis, treatment, and prognosis in language the patient can understand.To receive necessary information from the doctor such as long-term effects, side effects etc., before giving any prior consent to a medical procedure and/or treatmentTo receive the records or a certified copy that gives the details of the disease, treatment, and follow-up necessary at the time of dischargeTo refuse the suggested treatment and be informed of the medical consequences thereofTo receive medical care in well-equipped and sanitized conditionsTo receive quality care from competent medical professionalsTo select doctor’s of one’s choice when possibleTo obtain a second opinionTo privacy during medical check-upsTo be assured that all communication and records will be kept confidentialTo educational information about medical problems eg. via a library, IEC materials, etc.To receive a bill cum receipt after the payment is madeTo be enabled to pay hospital fees on a payment planTo have access to a non-hospital staff member appointed to address complaints as soon as possible

To have the contact information of the responsible person (both at the hospital and head office) to register a complaint or give feedbackTo have adequate waiting spaceTo allow relatives to have flexible visiting hours b. Patient Code of Conduct Patients are also responsible for their personal and environmental well-being. The following code of conduct emphasizes the responsibilities of a patient while seeking medical care. As a patient: You should provide the doctor with accurate and complete information about his/her medical history, past illnesses, allergies, hospitalizations, and medicationsYou should report the changes in your medical changesYou should ask for clarity if the doctor’s prescription and diagnosis seem unclearYou should follow the doctor’s treatment planYou should pay your medical bills promptlyYou should follow hospital rules and regulationsYou should have realistic expectations of what the doctor can do for youYou should help your doctor help you, if something isn’t working, be clear and the doctor can advise alternative careYou should participate actively in your own medical care (in terms of awareness and preventions)You should ask the doctor questions to clarify any doubts or misconceptions in your mindYou should treat the doctors with respectYou should not ask doctors for false bills or certificates for any reason  

c. Probable Value of the Report In this section, the author has outlined how the report can be of value to the different existing bodies in the city of Mumbai. The report was not only created for the MCGM, but also for all the other proponents of health care in Mumbai. The following section details to value to each constituency:  MCGM: This report should be seen as an objective analysis of the existing programming at the MCGM. In addition to giving suggestions, the report also highlights the various successes of the MCGM’s health programming. It will be of value in several aspects:Assist lawmakers in allocating funds to priority areasProvide insight to those responsible for programming in terms of areas of improvementIncrease the efficiency of the MCGM public health departmentIncrease the reputation of the MCGM’s health services in the cityProve as an impetus that demonstrates the MCGM’s priority of the health of the people of MumbaiIntimate the top-level management as to the priority areas in various departmentsApprise mid-level management of the awareness of the lack of resourcesInform lower-level staff of the value of their work and increase worker morale NGOs: Non-Governmental Organizations working in Mumbai are working to provide health care to the same citizens that are also the responsibility of the MCGM. This report can help bring the two groups together to not replicate programming in high-need areas and pave the way for NGO-MCGM partnerships. NGO’s can cite the information in the report as representative of the enormous need for improved health care systems in such a large and densely populated city. Donors: With Corporate Social Responsibility representing the progressive era of charitable giving, it is important for donors to also be aware of the issues that are effecting the communities that benefit from their time, money, and resources. Citizens: In a city like Mumbai, the average citizen doesn’t think about health care unless it is a situation of urgency or crisis. This report will make citizens aware of the issues in health care that effect all those seeking care through the government health sector. Medical Students, Physicians, and Health Professionals: In light of the recent strike of the doctors in Mumbai, it is also important for policy makers to understand the perspectives of those working on the ground. This report helps shed light on the needs of physicians and avenues for improvement in their occupation. Media: The MCGM health department is often the recipient of negative publicity by the medial. The information in the report can offer some information as to the inner workings of the MCGM health department and what the media can do to support the improvement of these systems. Overall, the report provides an in-depth analysis of the existing programs, challenges, and successes of the MCGM health department. Looking at the history of health policy in India, it is

evident that there has been little emphasis on improving the health of local citizens in recent years. The report attempts to create a common area for discussion and improvement of health systems within this city. With good basic infrastructure, there are many avenues that can be pursued if the aforementioned parties join together to work on a healthy Mumbai.

d. Training Activity for the BMC Organizing and Managing Urban Health Services: Identify the guiding principles of the municipality- If they are not explicit, they should be drafted.Example: Is the guiding principle equity of access, ensuring a simple, basic minimum package of health care is accessible to all?Is collaboration between health and other sectors, such as education a guiding principle? Purpose of the Municipality:Is it to provide appropriate and affordable primary health services for the entire city population?Or is it to provide for the poor, and to facilitate private service provision for higher income groups? Assess the internal environmentAre the resources available? (Staff, money, infrastructure)The current structure and stated function of the government servicesVarious service tiersNeeds careful delineating Evaluate the External EnvironmentCurrent national policy, with direct respect to direct provision of service compared with promoting and regulating the private sectorDirection of decentralizationNational policy for health sector financingNational norms setting service standards or configurationsLevel of flexibility within the BMC in interpreting these policies Goals and ObjectivesUse these to formulate a strategic planBroad objectivesOperational objectivesKey areas to consider:Current decentralization policies altering government and administrative structures,The debate over government health service tiersRelationship between government and private sectorInstitutional development to improve managerial capacity in government health services *Private sector notes:            -The quality of care of private providers varies a lot from very high to very low.            -In low income areas, care is often of low quality            -Even if private providers are more polite, the quality of care is not necessarily better            -Private providers are driven by market forces            -Preventive measures are often neglected 

*Governments have a definite responsibility to ensure a minimum quality of care to protect the population from the adverse effects of healthcare:            Healthcare is important because it relieves suffering            Healthcare is dangerous, especially if inappropriate therapies are given.            Governments can consider voluntary accreditation of the private sector. e. Integrating public health issues into the LACGs With the recent success of the LACG’s for the littering rules and other community issues, it is important to use this resource to address issues of public health as well. The type of activism coming from these groups can be well-utilized as a springboard for other community problems that need the focus and energy of an organized constituency. The following ideas can be incorporated:Circulate a brief summary of the Public Health Policy DocumentEach LACG can identify its area of priority and take up a particular issue in health (i.e. child health/school health, health of pregnant mothers etc)This can be a yearly campaign for the LACGs to work with the local MCGM health centers/dispensariesThe Bill of Rights and Code of Conduct can be promoted through these groups as well f. Apex Health Committee Possible Members: Dr. Ratna Magotra, Former Cardiac Surgeon at KRMDr. Janaki Desai, Niramaya Health FoundationMs. Dipika Banerjee, Program Director, AVSAR  Role of Committee: The role of the committee will be focused on:Promoting the relevant recommendations in the reportBeing the voice for public health issues for the NGO CouncilApproving appendices and annexures for other health topics not yet covered in the report (mental health, sanitation & water issues, etc)Meeting once a month to monitor progress of the MCGM on proposed issues (i.e. new programming, follow up, recommendations etc.) 

g. Author’s Note Although the concept of public health dates back to ancient times, the practice is something relatively new and upcoming in the world space. The idea of conducting an analysis of the health care system in Mumbai was not only challenging, but a part of this growing awareness of public health as a critical force in the medical/health world. The challenges I encountered while writing this report taught me a lot about public health and its applications in India, a nation with so much potential. Going through all the health policies of India, identifying the key areas of importance, summarizing 200-400 page reports, meeting with people that were either very willing to help or willing to make it harder and finally meeting the patients who came the hospitals, health posts etc to seek medical care. The challenges greatly outweighed the benefits of writing such a report. The most important question we should ask at this point is: why wasn’t a report like this written years ago? Unfortunately, this seems to be a trend in global public health, with decreased funding and low priority given to health systems and public health. All things are inter-connected here- how 26 July 2005 effected health to the recent striking doctors- in terms of the long-term affect of negligence on the importance of providing high quality medical care for the masses. I hope that this report can add value to the hard work of NGOs, MCGM, and all the other groups involved in bringing health care to the masses.  Overall, this project was of great value to me and I hope it serves as a springboard for those wishing to promote the benefits of good public health systems in Mumbai and all over the world. Thank you for entrusting me with such a task. Meenakshi VermaMarch 2006

Appendix 1QuestionnairesMumbai Public Health Policy Framework Questionnaire for Utilization of Tertiary Health Care Services Date:

1. Age 

 

2. Location 

 

3. Address 

 

4. Occupation/Education  

 

5. Why did you come here for your medical services?  

 

6. What stopped you from seeking care close to your house?  

 

7. How much did it cost you to come here today?  

 

8. If the services were closer to your home, would you access them?

 

9. If you feel comfortable, can you share your health problems with us? 

 

10. What do you like about the care here? 

 

    Comments or Concerns: Data Number:_____     Entered:_________                   Mumbai Public Health Policy Framework Questionnaire for Utilization of Primary Health Care Services

 Date:

1. Age 

 

2. Location 

 

3. Address 

 

4. Occupation/Education  

 

5. Why did you come here for your medical services?  

 

6. Do you ever seek care at a hospital, why?  

 

7. How much did it cost you to come here today?  

 

8. If you feel comfortable, can you share your health problems with us? 

 

9. What do you like about the care here? 

 

10. How long was your waiting time?   Comments or Concerns:     Data Number:_____     Entered:_________                 

Appendix 2Health Post Survey Results- Vashi Naka Health Post, Chembur 

  Age

Sex Location

Occupation

Education

Q1 Q2 Q3 Q5 Q6

A 35 Female

VNHP housewife

none cold, fever, cough

goes to Mah hospital sometimes

Free Medicine is good

Waited for 1/2 hour

B 12 Male VNHP Student 4th TB Only diagnosis was there

Free Everything is good

No wait time

C 18 Female

VNHP Student 11th comm

fever, cough

No Free Medicine and check up is good

Waited for 1 hour

D 55 Male VNHP Business 10th 4 year old child has TB

Went to shetabdi hospital and felt kicked around feels he doesn't know what is going on medically with the child and no one is giving him a straight answer

Free Gave medicine but waiting to see if it works

Waited for 1/2 hour

E 20 Female

VNHP Makes ganpati statues

5th Boil on neck

No Free Medicine is good

Waited for 1/2 hour

F 17 Female

VNHP None 10th TB no Free Medicine is good

Waited for 1 hour

G 25 Female

VNHP None 12th fever, cough

Goes to private doctors sometimes

Rs. 10

Medicine is good

Waited for 1 hour

H 17 Female

VNHP None 7th vomiting, diarreah

no Free Medicine is good and it works

Waited for 1 hour

I 27 Fema VNHP None 10th children comes to Free Doctor is Waited for 1/2

le have fever

dispensary first, then to hospital

good, medicine is perfect

hour

J 29 Male VNHP None 5th TB no Free Medicine makes a difference

No wait time

K 55 Male VNHP None none TB Goes to Shetabdi sometimes

Free Facility is good

No wait time

L 35 Male VNHP Plumber 6th TB No Free Doesn't know

No wait time

M 26 Female

VNHP None 6th stomach illness and fever of children

No Free Everyone here is good

waited for 2 hours

N 22 Female

VNHP None none Fever, cough, cold

Private providers

Rs. 20

Its ok No wait time

O 64 Male VNHP None 5th TB Somaiya Free Good because he gets his medications on time

No wait time

P 18 Male VNHP None none TB No Free Doesn't know

No wait time

Q 26 Female

VNHP None 5th Children are not well

Rajawadi Hospital

Free 1st time here, if it works, she will come back

No wait time

R 7 Female

VNHP None none Girl has a huge boil

Went to Sion Hospital and they told him to come here

Free Care is better

No wait time

S 15 Female

VNHP None 10th TB No Free Medicine is good

No wait time

T                    Appendix 3KEM General Out Patient Department Survey Results 

Age Sex Address

Occupation

Education Q1 Q2 Q3 Q4 Q5 Q6

N/A

Female Wadala Housewife N/A

No cure despite repeated medicines No relief 20 No

Fever, Backache

Good Doctors, and good facilities for patients

N/A Male Wadala Carpentar 9th

Referred by a private doctor

Not improved despite treatment 30 No

Fever, no access to clean water

Believes KEM cures Malaria better than other centers, good investigation services

13Female Worli N/A 7th

Patient had already taken treatement from a BMC health post but was not cured.

Not improved despite treatment 16 Yes

Cough, vomiting, fever and chills

Good doctors and lots of good facilities are available

30Female

Ullhasnagar Housewife 5th

Went to Goyal hospital, didn't make a difference, although it was a private hospital, it didn't make a difference, also the doctor spoke rudely

No health facilities close to home (that she was aware of) 50 Yes

Chest pain, fainting

Doctors spoke to her nicely

N/A

Male Sakinaka, Andheri (E)

Embroidery Worker

N/A local doctor advised him to go to the big

Did not know if there are BMC facilities

30 Yes N/A Doctors, and he doesn't know about the investigation facilities

hospitalclose to his home

24Female

Grant Road

Not workin 6th

Went to Nayyar hospital, but that was not helping, so she came to KEM

Services not good at health post, the problem was more severe than they could handle 20 Yes

Migrane headaches

She came here from other people telling her it was good, Nayyar was good but the medicine was not working

32 MaleNew Mumbai

Shipping Company 12th

Company friend said to come to KEM

Doesn't know any other facilities 70

Indira Gandhi hospital is there, but the facilities are not so good Hernia

Everything is good here. Good people and doctors

46 Male ParelFactory Worker N/A

He had a fever and a cold

No health posts near his home (that he was aware of) 0 No

Fever, cold

Doctors treated him well, his mother also comes here

36 MaleRajapur (Village) Driver 10th

In the village, his BP went up and he had to come to KEM for further tests. Jijaji sent him.

Not many health services in the village (475 km from Mumbai)

256

Yes, there are not many services in the village. Even if someone gets sick, they have to travel 95 km BP

Treatment is done well, and they take time and do good. In the village, they give an injection, and it doesn't work well. It is good. Its not easy to handle that many people.

30Female

Bhayendar

Saleswoman 12th

Tried at 2-3 private hospitals, nothing helped

No public care (that she is aware of) 20

Yes, left home at 7am, nothing close to her house Acidity

If you come 1-2 times you get better relief. The procedure has become a little complicated, it used to be better when people were prioritized based on illness

40Female Andheri

Housecleaning 7th Dizziness

Municipality hospital is there, but they don't give enough attention 50

Yes. There is a doctor at the municipal hospital, but he hardly comes

Lymph nodes

Treatment is effective and doctors are good

50Female

Matunga Road

Works for a company 11th Dizziness

Feels Sion and KEM are the same. 8

Yes, all the current ones are private

Dizziness, frozen shoulder

Doctors are good and money is saved

45 MaleLower Parel

Bus conductor 10th

Lump in finger

This is closest to his house 0

Primary health center is just for basic care

Lump in finger Doctors are good 

59Female Bhandup

Not workin 7th

Lives in the village, but came here for care N/A 0 No

General pains in knee, hip, and chest

Everyone talks well and I like the hospital

60 Male Parel Not working

10th Shoulder pain and stomach problems

Came from the village, so doesn't

400

No Shoulder pain and stomac

Doctors and facilities are good. Those who leave here, leave well

know about PHC

h problems

29 Male Sewri Driver 8th Headache

There are municipal hospitals, but no doctor facilities but not gone there 10

Services currently are good, but doctors are not available

Headache, dizziness Treatment is good

30Female

Elephistine

Not working 7th Backache

There is a clinic on Saini Road, but only goes there for immunizations 0 No

Backache

Doctors are good, cleanliness, and care is good. Other hospitals Nayyar and Sion are not clean

35Female Worli

Not working 10th

Health is not good

There are (Facilities) but small. Its ok. 10

Doctors are better here, rupees are complete here

Cough and Pnemonia

Full treatment is good

48 Male Malad Tailor 5th

There is a KEM branch in Malad, but medicine is not available,

 went to the PHC in Borivali but there were problems

100

Yes I would. There is an ease to the services here

Baby has a respiratory infection

Doctors are good, except sometimes the care is compromised

 

II. Best PracticesUtilizing best practices from other cities with similar challenges in terms of healthcare can improve the health outcomes of the city of Mumbai. The following section further analyzes several of these best practice models. a) Participatory Budgeting in Porto Alegre, Brazil[100]Until the beginning of the 1980s, Porto Alegre experienced accelerated population growth, which left one third of its population with only marginal access to urban infrastructure. In 1989 a large proportion of the population lived in non-legalized areas, in shacks without drinkable water, sewerage systems or paved streets. Local government decided on all municipal investments, without any consultation of residents. However, the city's income, which was based on taxes collected, was not adequate to finance even a minimum of public works needed to sustain development. Participatory budgeting was introduced as part of the political platform of the Labour Party in 1989 to involve the residents in setting priorities for public works; ensure a more equitable distribution of municipal investment; promote transparency in municipal activities and reduce opportunities for corruption; and increase popular participation in municipal government. Following its introduction the program gained strength as the public gained more experience in decision making and as tax reforms strengthened municipal finances. The program has developed into an international model of participatory government. The general rule that applies is that there is a direct connection between the spending in the local neighborhoods and what motivates people to attend meetings. If you don’t attend a meeting for your district, chances are that your road light won’t be working. Since participatory budgeting began in Porto Alegre in 1991, over $700 million has been invested in basic urban infrastructure, including water supply, sanitation, road improvements and public lighting. An opinion survey at the end of 1997 showed that 85 percent of city residents either had been active in the budgeting process or considered the investments to be highly relevant to their circumstances. In 1990, when the program started, people thought it wouldn’t work, so only 1000 people participated. In 1999, over 40,000 people were participating. The concept is simple, Porto Alegre is divided into 16 districts for purposes of the budget. A council is created in each district as a space for citizens to meet and discuss spending priorities. Meetings are open to anyone who would like to attend.  Citizens set two priorities: district and citywide spending. District spending focuses on specific public works projects in the neighborhood, such as paving streets or improving sewer systems. Citizens identify three priorities, with funds allocated based on population size and need. Need-based allocation of funds means that poorer neighborhoods receive more money than wealthy ones. World Bank study found substantial quality-of-life improvements in Porto Alegre:Between 1989 and 1996, the percentage of the population with access to water services rose from 80% to 98%.Those served by the municipal sewage system increased from 46% to 85%.The number of children enrolled in public schools doubled.In poorer neighborhoods, 30 kilometers of roads were paved annually.

Tax revenue increased by nearly 50 percent, a fact the World Bank attributes to “transparency affecting motivation to pay taxes.”The MCGM is plagued with issues of transparency and disclosure regarding how decisions are made in the domain of health. It may be worthwhile to explore small levels of participatory budgeting and see how that might be of value to the citizens that utilize the public health sector. b) Cambodia’s Non Profit Path to Health CareCambodia’s public health care system was plagued with some of the same issues that limit the potential of the MCGM Public Health Department. Large scale absenteeism, vacancies, and corruption caused massive under-utilization of the public health care system. However, the government decided to take a low-cost approach to improving health care for the poor by contracting international or local non profits to run the health centers and hospitals at a fraction of the cost. The approach is catching on in a growing number of poor countries around the world, from Bangladesh and Afghanistan to Congo and Rwanda, to Bolivia and Guatemala, reaching tens of millions of people. These contracted services have allowed international donors and concerned governments to cut through dysfunctional bureaucracies - or work around them, and to improve health care and efficiency at modest cost.  In Cambodia, the nonprofit groups - all of them international - are instilling discipline and clarity of purpose in a health care system enfeebled by corruption, absenteeism and decades of war and upheaval. They have introduced incentives to draw Cambodia's own doctors and nurses back into the system. Patients, especially the poorest ones, have followed in droves. The international NGOs are paid based on performance, based on their ability to achieve immunization targets, decrease Infant Mortality Rates, and make sure women are getting prenatal care and following up with institutional deliveries.Although Mumbai does not seem to be at the same level as Cambodia at this time, there can be potential benefits to having foreign NGOs setting up and running operations to improve efficiency and subsequently transitioning to a local team.  c) Subsidized Health Care in the Philippines[101]The Makati Health Program (MHP) was designed to provide residents of the city of Makati in the Philippines earning monthly incomes less than US$156 access to quality health care. However, when the program was evaluated in 1986, they found that people in that income bracket were unable to afford the health care provided by the MHP. The local government of Makati partnered with the private sector partner, Makati Medical Center and two NGOs.The program has afforded beneficiaries access to services such as major surgeries in one of the best private hospitals in the Philippines. In 2000, over 50,000 cardholders were treated at the Makati Medical Center, with bills totaling US$ 3.3 million. Under the terms of the expenses sharing scheme, the city government of Makati shouldered US$1.9 million while Makati Medical Center contributed US$1.4 million.Together with the local government's initiatives in preventive health care, the Makati Health Program has contributed to declines in the mortality rate and improvements in morbidity rates across all ages. Makati is one of the few cities in the Philippines that provide subsidized quality health care to its constituents.

The idea of health subsidies can be a good idea for the MCGM Public Health System. Utilizing the networks of private hospitals in the city, there can be value added if both the government and the private sector actively participate in improving health care for all. All the different initiatives mentioned above are merely suggestions for improving aspects of the MCGM health systems. Clearly, the process of implementing different strategies is going to be a challenge, but the use of best practices from other institutions should be a good starting point for those positive about changing the system.

Works Cited  Understanding our Civic Issues, The Bombay Community Public Trust, Health Services in Mumbai, 2004. Public Private Partnerships for Improving Health of Children in Urban Slums, Dr. Siddharth Agarwal, Urban Health Resource Center, 2005. “Unmet needs for Public Health Care Services in Mumbai, India”, T.R. Dilip and R. Duggal, Asia-Pacific Population Journal, 2004. “Mumbai’s Invisible People”, The Hindu, November 2005. “Maternal Care in India Reveals Gaps Between Urban and Rural, Rich and Poor”, Population Reference Bureau, July 2003. “The USAID/India Urban Health Program: An evaluation of activities to date and recommendations for the future”, October 2005. World Health Organization South-East Asia Regional Office, Vol. 3 Issue 2, September 2003 Health Concerns and Organizing Health Care Delivery to Urban Slums, Dr. Siddharth Agarwal, Urban Health Resource Center, 2005. Health Delivery and Health Wants In Mumbai Slums, India, Centre for Water Policy and Development, University of Leeds, Date Unvailable. Country Health Profile- India, World Health Organization, 2002. National Family Health Survey, Maharasthra, March 2000. Report of the National Commission on Macroeconomics and health, Government of India, 2005. US AID Health Report, 2002. Personal Interviews with Dr. Sanjay Nagral, Dr. Khandare, Dr. Ambe, Dr. Thanekar, Dr. Usha Ubale, Dr. Janaki Desai, Dr. Armida Fernandez, Ms. Leena Joshi, Mr. Ravi Duggal, Dr. Ratna Magotra National Health Policy 2002 & 1983 Moving Toward the Right to Health Care, CEHAT, 2005/ BMC Health Profiles 1997-2004. 

National Health Policy 2002. http://phm-india.org/pdf/hungerwatch/draft_guidelines_starvation.pdf

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