Sunday, June 22, 2014

Mumbai’s Healthcare – Looking Back for its Future

written for Health Action's 25th Anniversary special issue
When Health Action emerged on the scene 25 years ago Mumbai’s public healthcare system was one of the most robust in the country delivering near universal access healthcare not only to Mumbaikars but also to many from across the country and many other neighbouring countries. But post nineties the neoliberal economic reforms had adverse consequences for the public health sector. Since then this primacy of Mumbai’s public healthcare system has unfortunately withered away and today it stands at the cross roads neglected and undernourished.
This situation also generally applies to public healthcare across the country wherein public health commitment in the budgets under the Minimum Needs Program post 6th Five Year Plan which had seen substantial increases and peaked around 1988 to 1.5% of GDP saw a reversal and over the last 25 years have been hovering around 1 percent of GDP despite political commitments during the UPA decade of reaching 3% of GDP. While NRHM may have brought in a bit more resources and some improvements the public healthcare services are nowhere close to in its reach and access of what it was 25 years ago. With huge global changes where an increasing number of countries from amongst developing countries are investing towards establishing universal access to healthcare, there is no reason why India should lag behind. In India we have a strong civil society build up towards demanding universal access to basic healthcare. Jan Swasthya Abhiyaan and its various state level initiatives amongst others have actively been pushing for right to healthcare and now with a new government at the helm it is an opportune moment to push harder for right to healthcare. Even the pages of Health Action over the years have discussed this and advocated for appropriate changes. Here we discuss briefly how the public health services of Mumbai have been decimated over the last two decades.
The present status of public health services in Mumbai, as also countrywide, is both unacceptable and unpardonable. For a city which is India’s financial capital and contributes over one-third of all national taxes, the healthcare deal for the Mumbaikar is unjust. This must change in the coming years. For this to happen the Brihan Mumbai Municipal Corporation (BMC) would have to more than double its health budget. Mumbai may have the wealth that any world class city has (percapita income over Rs. 2 lakhs per year) but its public health doesn’t match up. Filth, malnutrition, communicable diseases, life-style diseases, sanitation, hygiene and environmental health are all close to the bottom of comparable cities globally. Public health facilities are under-financed, lack human resources and are in a state of disrepair.
A peep into history tells us that the situation was not always like this. Infact right upto 1991 public health and healthcare services were quite robust with the BMC spending between 25 to 35 percent of its budget on healthcare (see Table 1). Until then most Mumbaikars, the poor, the middle classes and even the rich (for super specialty care) used the public health system ranging from health posts and dispensaries to maternity homes, hospitals and teaching hospitals.  This was possible because a reasonable proportion of budgetary allocations were made, most staff was in position, medicines and diagnostics were adequately provided for, even though there was overcrowding and wait lists. The tertiary hospitals of the BMC and the state government were leaders in the country and were endowed with the most recent medical technologies and equipment.
From 1991 with the new economic policy under structural adjustment reforms the funding for healthcare contracted to an unbelievable level of 15% of that of BMC’s total budget by 1995 and since then has been on a downward slide bottoming at 8.8 percent of the budget in 2012-13. The new economic policies also brought in health insurance and the rising incomes of the middle classes facilitated often by employers buying health insurance cover for organized sector employees leading to their migration to the private health sector. The consequence of this was that the aggressive voice of the middle classes disappeared from the public health system making it a health system for the poor. And anything meant for the poor becomes a poor system as it gets neglected.
Post nineties we saw the public healthcare system in Mumbai deteriorate. The declining commitment of resources (Table 1) was the first blow. This created shortages of supplies like medicines and diagnostic consumables, inadequate maintenance, embargo on new recruitments, and curtailment of new investments for setting up additional public facilities to cater to an increasing population of the city. All this contributed to affecting the credibility of the public health system. In the meanwhile the private health sector began to boom under the liberalized economy, as also corporates entered in a big way setting up hospital and diagnostic chains. At the same time with health insurance being opened up most employers and middle class professionals opted for health insurance and the latter facilitated migration of the middle classes to the private health sector. This was the second blow to the public health system. Before the turn of the new millennium public health services introduced user charges for most services under the World Bank sponsored health sector reforms project and this alienated the poor patients too. This was the third blow. With persistent under-financing leading to deteriorating quality of public health services the staff, especially doctors and nurses, had to face the angst of the patients and this led to widespread frustration within the system. With the private health sector expanding rapidly doctors and nurses from the public system found new opportunities and began to exit from public hospitals and dispensaries. This was the final blow, the proverbial last straw that broke the camel’s back.
So looking forward to the future of public healthcare in Mumbai we actually need to look back into its history and revive the public health system we had and we were proud of. We would have to return to an expenditure level of atleast 25% of the BMC budget and this will help improve the healthcare facilities, bring back the doctors and nurses and also the patients from all classes. The middle classes who have migrated to insurance based financing and the use of the private health sector are not very happy with either. They get a raw deal, are subject to irrational therapies, malpractices and frauds. Healthcare is a public good and we need to re-establish that. For this we have to go back to the time when Health Action started and rebuild the public health system from where we left it 25 years ago. Infact, Health Action is one of the few magazines that has recorded the ups and downs of the public healthcare system, among other health issues, and discussed options of how to change the situation for the better. Mumbai has the resources and can take the lead to show that we can get back on the path towards universal access to a good quality of public healthcare services. The rest of the country will follow. And Health Action will be a witness to the changes we want to see.
Table 1: BMC’s Health Expenditure Trends 1960-61 to 2013-14 Rs. Crores
Health Expenditure
Total BMC Expenditure
Percent Health
2012-13 RE
2013.14 BE

Expenditures include revenue and capital. Source BMC budget documents various years


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