Background

This 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 areas

Provide insight to those responsible for programming in terms of areas of improvement

Increase the efficiency of the MCGM public health department

Increase the reputation of the MCGM’s health services in the city

Prove as an impetus that demonstrates the MCGM’s priority of the health of the people of Mumbai

Intimate the top-level management as to the priority areas in various departments

Apprise mid-level management of the awareness of the lack of resources

Inform 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 Summary

In 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 assurance

Systems: 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 health

With 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 Dissemination

Ensure 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 Health

Increase 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 NGOs

Ensure 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 Personnel

Increase 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. Infrastructure

Hire staff to fill vacancies of doctors at the primary health care level (Health Posts and Dispensaries) to improve the quality of care

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.

Decrease the gaps in infrastructure (staff, equipment, and training) at the primary and secondary levels of health care

Create 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 all

Revamp 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. Systems

Create 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 Departments

Introduce 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 outbreaks

Improve water supply and sanitation at all slums, this will decrease the amount of diseases in the area.

G. Priorities in Health

Create a department that addresses issues of respiratory health in Mumbai, this should also be a division of the school health department

Utilizing the existing DOTS program, increase the priorities of TB management

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)

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

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 disease

To 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 languages

To know and understand the procedures involved

To 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 continued

To have a comprehensive (various tests, blood work, x-rays, room tarrifs, operations, consulting fees, etc) costs associated with seeking medical care

To receive prompt and courteous care

To be informed about the documentation needed for treatment

To have minimal documentation for emergency cases

To receive Reproductive and Child Health Services free of cost at public health facilities

To receive medications and vaccinations from the local public health post or dispensary

To get medical services which are within the capability of the medical facility

To 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 treatment

To receive the records or a certified copy that gives the details of the disease, treatment, and follow-up necessary at the time of discharge

To refuse the suggested treatment and be informed of the medical consequences thereof

To receive medical care in well-equipped and sanitized conditions

To receive quality care from competent medical professionals

To select doctor’s of one’s choice when possible

To obtain a second opinion

To privacy during medical check-ups

To be assured that all communication and records will be kept confidential

To educational information about medical problems eg. via a library, IEC materials, etc.

To receive a bill cum receipt after the payment is made

To be enabled to pay hospital fees on a payment plan

To 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 feedback

To have adequate waiting space

To 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 medications

You should report the changes in your medical changes

You should ask for clarity if the doctor’s prescription and diagnosis seem unclear

You should follow the doctor’s treatment plan

You should pay your medical bills promptly

You should follow hospital rules and regulations

You should have realistic expectations of what the doctor can do for you

You should help your doctor help you, if something isn’t working, be clear and the doctor can advise alternative care

You 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 mind

You should treat the doctors with respect

You should not ask doctors for false bills or certificates for any reason

I. Recommendations- Expanded

A. Education and Information Dissemination

Ensure that the Patient Bill of Rights and Code of Conduct (attached) is posted in every public health care facility being operated by the MCGM

Action Steps:

Translate the documents into Hindi, Marathi, and other regional languages

Pilot test it with a core group to ensure comprehension of the concept and what it actually would mean

Send around a circular for ALL staff to read and understand the Bill of Rights and Code of Conduct

Post accordingly in all health care facilities in Mumbai

Time line: 2 months

Measure 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 facilities

This should include timings, doctor’s name, and phone number

This map should be updated twice a year by the Public Health Department, once the infrastructure is in place

Time line: 2 months

Measure 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 innovations

Through role plays and consciousness raising, the staff should become aware of the challenges before them

Hold monthly meetings with staff to imbibe aspects of quality assurance throughout the MCGM public health department

Utilizing the health committee formulated, hold trainings for improved quality of care

Provide incentives for randomly conducted surveys of facilities that provide quality care to their patients

Time line: 4 months

Measure 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 sector

Ensure that a wide array of languages are covered in these materials

Time line: 3 months

Measure of Success: Increased patient health education, awareness of preventable diseases

B. Reproductive and Child Health

Increase awareness about institutional deliveries by collaborating with local women’s groups.

Action Steps:

Engage NGOs to help involve Mahila Mandals

Create awareness among leaders in these groups about the hazards of home deliveries

Hold events and public gatherings to raise awareness among these women’s groups

Time 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 NGOs

Action Steps:

Team up with 5 NGO Partners in order to start collecting information that already exists on these topics

Devise a strategy to review these materials and edit/modify as needed

Print and distribute to all women

Time line: Ongoing, but start up will be 2 months

Measure 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 services

Create a public service campaign regarding increasing awareness for these initiatives

Time line: Ongoing campaign, start up will be 2 months

Measure 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 supplements

b. An education campaign should educate women of the value of the proper utilization of these medications before and during pregnancy

Time line: 2 months

Measure 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 NGOs

Action Steps:

Expand job descriptions to include more responsibilities of the CHVs

Increase salary to Rs. 1000 per month

Provide ongoing trainings for them to be more engaged in the work they do

Allow them to collaborate with local NGOs CHW’s as well

Time line: 4-6 months

Measure 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 facilities

Terminate all benefits for those that had such practices

Time line: 1 month

Measure of Success: Discontinuation of private practices for MCGM doctors

De-centralize the management of the primary and secondary health care services

Action Steps:

Allow Medical Officers in each ward to take the lead in decision making

Tell them they have a certain amount of money in the budget and set realistic goals

Encourage them to reach these goals through collaboration and hard work

If 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 months

Measure of Success: Increased job satisfaction and participation in the process

D. Infrastructure

Hire 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 examination

Ample 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 pregnancies

Training in the basics of pre-natal care for community health volunteers

X-ray facilities at certain upgraded facilities

b. Collaborate with medical schools to create incentives for graduating students to commit 2 years to service at the primary or secondary level

c. 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 physicians

Time line: 6 months

Measure 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 objectivity

Put all the data gathered together in a simple report revealing the gaps in services and infrastructure at the primary level

Time line: 3 months

Measure 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 care

Action 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 months

Measure 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 year

Measure 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 departments

The circulars should be stored in a computer as well as hard copy

TCS is also implementing a computerized network, this should be a part of it.

Time line: 6 months

Measure 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 care

Create minimum qualification guidelines of those operating the vehicles

Ensure the vehicles are well equipped with supplies and equipment for saving lives

Create a free call system for people to call this number 24 hours a day

Cost? Should be further discussed

Time line: 6 months

Measure 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 labs

These labs should be equipped to test for TB, AIDS, and conduct all other necessary blood work on site

There should be no additional user fees associated with this service

Time line: 4-6 months

Measure of Success: Decreased load on the 3^rd tier lab systems, better facilities for patients to access blood work results

E. Systems

Create 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 patients

Ensure the person is competent in mediation and can handle high pressure situations

The person will then bring the issue to the hospital administration team to be addressed within a certain time frame depending on the emergency

Ensure this process is well documented with appropriate attention from administration for complaint management

Time line: Ongoing, set up time 3 months

Measure 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 committees

MCGM’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 collaboration

Time line: 6 months

Measure of Success: Increased citizen participation and actual change as a result of the participation.

F. Coordinating with other MGCM Departments

Introduce adolescent health education through the municipal school system.  

Action Steps:

Work with the Niramaya Health Foundation which just launched SPARSH, an adolescent health education initiative

Pilot this initiative at some of the schools

Replicate and disseminate

Time line: 6 months

Measure 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 management

Educate the city through the LACGs on the importance of preparedness

Ensure the release of it before onset of monsoon season

Time line: 4 months

Measure 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 Health

Create a department that addresses issues of respiratory health in Mumbai, this should also be a division of the school health department

Action Steps:

Conduct an in-depth analysis of the respiratory health of Mumbai

Work with NGOs to create greater awareness

Create a cell within the school department so children can be screened for respiratory issues

Further follow up will be needed by the public health and the school department

Time line: 6 months

Measure of Success: Increased awareness of respiratory health, greater initiatives to address them

Utilizing the existing DOTS program, increase the priorities of TB management

Action 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 Mumbai

Create a commission to address why there are still so many cases despite the presence of DOTs

Ensure 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 year

Measure 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 Health

Utilize the benefits of the new RCH II policy that was released as an impetus for improving the health services provided to women and children

Time line: 6 months, ongoing

Measure 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 months

Action 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 issue

Teach the public about increasing awareness about the dangers of malaria and how to prevent it

Provide citizens with information through the LACG meetings

Information should be circulated in all newspapers

NGOs and the MCGM can collaborate on this campaign

Time line: Ongoing

Measure 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 stock

NGOs should submit requests for vitamins 2 months in advance

Stock should always be ensured and monitored

Time line: 3 months

Measure of Success: Increased availability of critical nutrients necessary for the development of children

II. Executive Summary

Introduction

This 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 1982

The 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 2002

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.[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: 1^st Tier; serve a population of 1 lakh, dispensary for OPD and essential medications

Secondary Health Care: 2^nd 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 Policy

The 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 Health

The 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 country

Drug Regime: Cost of drugs is an issue

Technology Used: Advancing health care to suit the countries needs through the use of technology

World Health Organization Country Profile

The 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 Health

Although 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 Mumbai

In 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 Mumbai

The 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 Mumbai

Tuberculosis Program: To address, treat, educate and eradicate TB

Universal Immunization Program: An initiative to provide children and families in Mumbai with proper immunizations

Polio Eradication Program: To immunize, treat, and eradicate Polio

National Malaria Control Program: To address and treat Malaria

Mumbai District AIDS Control Society: Educate, disseminate information, provide counseling and treatment, blood safety, monitoring and evaluation

School Health Program: The SHP aims to provide in school health care for children attending the schools run by the MCGM

Successes

Managing 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.

Challenges

All 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 care

Primary health care services are weak in resources and manpower, this leads the general public to seek healthcare at the tertiary level of care

Secondary Hospitals and Maternity Care are also not well-equipped and suffer from centralized decision making systems that prevent administration for taking decisions

Tertiary 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 systems

Inconvenient timings, locations, and a high amount of vacancies have lead to a great degree of dissatisfaction with the MCGM run services

Lack of emphasis on quality assurance results in apathy from staff as well as patients

Lack 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 level

Reporting 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 rationale

Competition from the private sector (practitioners and hospitals) also poses a considerable barrier for underprivileged folks to access the public health system

Lack 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 Dissemination

Reproductive and Child Health

Medical and Administrative Personnel

Infrastructure

Systems

Coordinating with other MCGM departments

Priorities in Health

The 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 Mumbai
Conclusions and Summary

In 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 assurance

Systems: 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 health

With 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 Dissemination

Ensure 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 Health

Increase 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 NGOs

Ensure 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 Personnel

Increase 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. Infrastructure

Hire staff to fill vacancies of doctors at the primary health care level (Health Posts and Dispensaries) to improve the quality of care

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.

Decrease the gaps in infrastructure (staff, equipment, and training) at the primary and secondary levels of health care

Create 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 all

Revamp 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. Systems

Create 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 Departments

Introduce 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 outbreaks

Improve water supply and sanitation at all slums, this will decrease the amount of diseases in the area.

G. Priorities in Health

Create a department that addresses issues of respiratory health in Mumbai, this should also be a division of the school health department

Utilizing the existing DOTS program, increase the priorities of TB management

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)

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 Background

Through 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 Act

8. 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 infec