HOSPITAL BASED URBAN HEALTH CARE SERVICES
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HOSPITAL BASED URBAN
HEALTH CARE SERVICES
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HOSPITAL BASED URBAN
HEALTH CARE SERVICES
Sonya Gill
Lalitha D’Souza
Anagha Pradhan
Dina Patel
rc
The F oundation forEesearch inHommunityHealth
■■
Mumbai/Pune
1999
10628
What is FRCH ?
The Foundation was established in 1975 as a non-profit voluntary organisation to promote the
concept of health care rather than the mere care of illness. This entails the study of health in its wider
perspective, in order to improve the health of our people. The emphasis is on the problems of the
underprivileged sections of our society, especially women and children.
Our staff from various disciplines are engaged in conducting both conceptual research as well
as field studies into the problems faced in achieving Health for All. This is to help in devising alternative
models of health and medical care in keeping with the social, economic and cultural reality of our
country. The aim is to influence government policy and sensitise the people at all levels to the
problems and possibility of achieving good health at affordable cost.
FRCH believes that health is a reflection of the overall quality of life; in fact 80% of the
diseases in India are the diseases of poverty and true health can exist only when there is a positive
improvement in the socio-economic scenario of the country. This can only be achieved through the
people’s own efforts. Hence, FRCH aims to create a People’s Health Movement by demystifying
medicine and increasing public awareness on health, especially at the grassroots, and by strengthening
the age old health culture of our people based on our own systems of health and medical care. This
is to be achieved, by publishing and disseminating information on all aspects of health and related
subjects, by conducting participatory training and interacting with the community.
Community Health Cell
Library and Information Centre
# 359, "Srinivasa Nilaya"
Jakkasandra 1st Main,
1st Block, Koramangala,
BANGALORE - 560 034.
Ph : 2553 15 18/2552 5372
e-mail: chc@sochara.org
fl
HOSPITAL BASED URBAN
HEALTH CARE SERVICES
Sonya Gill
Lalitha D’Souza
Anagha Pradhan
Dina Patel
z
I-*”
H
R
in C ommunityujealth
The! F oundation forEesearch
Mumbai/Rune
1999
Foreword
The present health system has an over-riding emphasis on medical care and that too of a curative
nature, 80% of which in quantity, and even more so in quality, is located in the urban areas.
Three quarters of the health personnel, as also the nation’s health expenditure, is in the forprofit private sector which is almost entirely restricted to curative medicine and caters only
to those who can afford to pay for the services.
The entire load of preventive and promotive health care, as well as curative services for those
who cannot afford the services of the private sector, is borne by the public sector consisting
of government health services (chiefly the PHCs) for the rural population and a combination
of municipal and government services in the urban centres. Even in the public sector, the per
capita expenditure for the rural population who comprise 74 per cent of the total, is Rs.30
while that for the urban is about Rs. 100/-, despite the fact that the health status of the rural
people is twice as poor as that of their urban counterparts.
Due to poor Primary Health Care facilities in dispensaries and health posts, it is the large
hospitals with expensive secondary and tertiary care services that are swamped by patients
who may not require such services. This not only raises the cost of patient care but the tertiary
and secondary care services, including training of students, are over-loaded with problems that
could be adequately catered to at a peripheral hospital.
The aim of this study was to understand the level of care required by the patients attending
the four major speciality departments of one of the most reputed hospitals in the city, namely
the King Edward Memorial Hospital affiliated to the Seth Gordhandas Sunderdas Medical College.
The study reveals that about 30 to 40% of patients daily attending the selected Out-Patient
Departments could have been adequately attended to at Primary Health Care facilities, and that
of the remaining only about 5% required tertiary care services provided by this reputed Institution.
This study could not have been made without the full cooperation of Dr. Pragnya Pai, the Dean,
and the Heads and staff of the concerned Departments. FRCH was also fortunate in having
the dedicated services of Ms. Sonya Gill, Dr. Lalitha D’Souza, Ms. Anagha Pradhan and Ms.
Dina Patel who not only collected but also analysed the massive data which emerged.
It is hoped that the findings of this study will help the Health Authorities of the Municipal
Corporation to look into the reasons why patients do not avail of the primary care facilities
near their homes. Improvement of these facilities will not only reduce the unnecessary load
on the expensive tertiary care facilities. Efficient basic care within easy reach of the people,
with basic facilities such as X-ray and pathology would not only be very welcome but also
highly cost-effective. There is also no reason why Community Health Care Centers with smaller
200 bedded hospitals with broad based medical and surgical speciality services cannot be
established at the 1,00,000 to 2,00,000 population level in urban areas as recommended by
the ICSSR/ICMR report Health for All: An Alternative strategy in 1981. This would provide
a more humanized, personalized and cost-effective service leaving relatively few cases for the
higher secondary and tertiary care institutions. This would result in a far more efficient and
cost-effective public health service in our burgeoning cities, reduce the problems of transportation
and provide a more job satisfying employment to the doctors, nurses and specialists who crowd
our cities. It would also check the proliferation of the private nursing homes by providing
a far more efficient service even for the middle class leave aside the poor.
N.H Antia, FRCS,FACS(Hon.)
Director
(i)
FRCH Research Team
Anagha Pradhan
Dina Patel
Research Officer
Medical Consultant
Junior Research Officer
Research Assistant
Savita Yedekar
Swati Kadam
Asha Vadair
Sushma Jhaveri
Research Assistant
Research Assistant
Research Assistant
Research Assistant
Sonya Gill
Dr. LalithaD’Souza
(ii)
Acknowledgements
The initiative and encouragement to look at the problems of public hospitals goes to
Dr. N.H. Antia, our director. The study, itself, owes its existence to the encouragement, interest
and complete support of the Dean of KEM Hospital, Dr. (Mrs) Pragnya Pai. The Dean and
the Heads of the departments of General Medicine. Paediatric Medicine, General Surgery,
Gynaecology & Obstetrics and Preventive & Social Medicine readily gave their permission
to approach the patients seen by their out-patient units (OPDs). In turn, the Heads of the selected
OPD units and their team of doctors, not only bore our intrusion in the OPDs, but patiently
explained medical conditions and assisted us by recording a diagnosis wherever this was possible.
The same co-operation was extended by the OPD nurses and attendants who managed the patient
flow. Above all, inspite of their illness and the stress of long waiting time, the large majority
of patients and their families willingly answered our questions and gave us time to copy down
the medical notes.
Our efforts to gather data on the health care system in Bombay and the primary care services
in the vicinity of the KEM Hospital were greatly facilitated by the assistance extended by Dr
(Mrs) Alka Karande, the Executive Health Officer of the Public Health Department (Municipal
Corporation of Greater Bombay) and her senior staff. The Medical Officers of the F/s ward
and their staff at the ward office and the dispensaries, too, gave their time and help whenever
it was needed.
Many other people, both outside and within FRCH, gave valuable assistance to this study.
Dr. Apama Narayana undertook the pilot study that helped us to formulate the study design.
Dr J.C. Sharma of Tata Institute of Social Sciences guided us in arriving at the sample size.
The staff of the Medical Records department of the KEM Hospital assisted us with all necessary
background data. M.P. Jardosh of Pristine Cartographers made the maps. At FRCH, Dr. M.W.
Uplekar gave shape to the proposal and remained a sounding board for all medical queries;
Sunil Nandraj helped to formulate the initial questionnaire; Sandeep Khanvilkar, Aditi Iyer
and Aruna Dehpande made valuable inputs in methodology, coding and statistical analysis; and
Sheela Rangan has minutely commented on every draft chapter of the report. Mr. R.S.Thipse
gave library support; and administrative and secretarial help were given by J. Eklahare, Maria
Pinto, Gautam Jadhav, Sashikant More and Pramod More and Nitin Mane, Avinash Pandit and
Sanjay Juvekar. Type-setting and layout by Jayashree and Venu.
CEBEMO, Netherlands provided the financial support for this study.
(iii)
Executive Summary
The most basic indicators of human development point to the relatively better status of
urban residents in India in comparison to the deprivations faced by the rural majority. However,
gross inequalities mark the urban centres. As a result, the urban poor and lower income groups
are highly disadvantaged in their ability to benefit from the better infrastructure and the greater
provision of amenities. The poor condition of public health — high rates of infectious diseases
and malnutrition and an increase in chronic and degenerative diseases — reflect the growing
inequalities in living standards in urban areas. This, in turn, strains the health care services.
The latter are the inevitable recourse of the poor and lower income groups as they cope with
a complex pattern of ill health and premature death.
Until the mid-80s health care services for the urban areas were not seen as an issue.
The urban population was considered highly privileged in its access to a vast supply of medical
and hospital services. However, concern has been expressed whether these services meet the
needs of the urban poor and lower income groups. The growing load on specialist out-patient
services of the public hospitals, poorly organised and underutilised public primary services
and multiple private providers point to the problems in meeting these needs.
The public health care system reaches the underprivileged sections largely through its hospital
services. The present study explores the nature of health needs and problems for which people
seek the out-patient services of the public hospital, the level of care needed for these ailments
and people’s help-seeking behaviour and utilisation of the health care services. In all 1,763
users were interviewed in the out-patient departments (OPDs) of a large public teaching hospital.
The clinical notes recorded on their case papers were also taken down. The OPDs belonged
to the four basic specialities of Medicine, Paediatric Medicine, General Surgery and GynaecologyObstetrics. These were some of the most heavily utilised OPDs and were likely to handle
the widest range of illnesses and disabilities, including common and simple ailments.
Major Findings
1.
There is little systematic information on the socio-economic background of the people
using the public hospital OPDs or the geographical location from which they are drawn. A
large teaching hospital would be expected to have a very wide catchment area that would go
beyond the city in which it is located. Such information would also aid the formulation of
a systematic referral system. Moreover, any discussion of raising additional revenues for the
hospital by imposing user fees must take into consideration the economic condition of those
using the OPD services. Over half the users (54 per cent) belonged to the urban unorganised
sector and two-thirds of the user households had per capita income of less than Rs. 500 per
month. Groups most ‘vulnerable to poverty’ by virtue of an insecure and irregular labour force
status predominantly benefited from the hospital OPD services. However, over half the users
(54 per cent) were drawn from the close vicinity of the hospital itself, with only a quarter
(23 cent per cent) coming from outside Greater Bombay. As a specialist clinic, the Gynaecology
OPD had the widest catchment within the metropolis, utilised equally by women in the suburbs
and the inner city.
2.
In order to strengthen the primary care services and rationalise the load on hospital specialist
clinics, it would be necessary to understand the level of care needed for the illnesses seen
in the OPDs. The hospital OPDs were handling a large load of poverty-related infectious and
(iv)
parasitic diseases. In the range of diagnosed conditions, diseases due to infections took up
over one fourth of all OPD cases, ranging from 40 per cent in Medicine and Paediatric Medicine
OPDs to 20 pqr cent in Surgery to 12 per cent in the Gynaecology OPD. Tuberculosis was
by and large the most common disease among the infectious conditions. The majority of the
people (60 per cent) needed secondary level care, indicating a limited scope for decreasing
the load on public hospitals so long as specialist services are centralised in them. However,
this varied among the OPDs. The Gynaecology OPD was the most optimally used for the secondary
and tertiary level services associated with a teaching hospital. Conditions requiring general
(primary) care were more frequently seen in the Medicine (38 per cent) and Paediatric Medicine
(45 per cent) OPDs, indicating the clear need to strengthen the first contact and general medical
care services. This was all the more necessary as many of the patients needing specialised
services for investigation and stabilisation of dosages could be subsequently referred to a lower
level facility for. follow-up- and long term management.
3.
Public hospitals in Bombay are free and openly accessible facilities. It is often
assumed that people ‘unnecessarily’ use higher level facilities for lower levels of health care.
However, not only \vas, specialist care indicated in about half the cases,, but over two-thirds
(70 per cent) of the users had sought prior treatment. The provider most commonly contacted
(50 per cent) at the onset of the illness was the private practitioner. Long lasting relationships,
close proximity to their residence and convenient timings were some of the reasons for using
private practitioners. Hardly 5 per cent of these users had come to the OPD after using the
municipal dispensaries — the general medical care services available through 159 general
dispensaries in the public sector. There were, however, limits to continuing private treatment.
Lack of quick relief that people associated with minor conditions and the prospects of costly
treatment led them to seek public hospital care. The average cost of Rs. 50 for a short duration
(on an average 3 days) of private treatment ranged from 10 per cent of the monthly per capita
household income of Rs 500 to 17 per cent for those households that were just above the poverty
line. For the destitute poor this amounted to a huge 33 per cent of the household’s monthly
per capita income.
The most common reason for changing the prior provider, especially the private practitioner
(57 per cent), was ‘no relief’. Does this indicate an inadequate handling of illnesses at the
first level of care? No mechanism exists in the current organization of health services to monitor
the care, or update the professional knowledge, of an ever increasing supply of private providers.
Only 28 per cent of all users who had taken prior treatment had cited referrals as a reason
for coming to the hospital. No referral system integrates the huge health care services in
this metropolis despite the existence of the three tiers of public health care facilities. Recorded
data on the utilisation of municipal dispensaries in the vicinity of the hospital showed heavy
load on some facilities and poor utilisation of others. Observations of three dispensaries showed
that there was hardly any interaction between these first level facilities and the hospital specialists
to whom patients were referred. The unplanned expansion of private practitioner services in
the localities served by the dispensaries was highly visible. Estimates based on data published
by the Municipal Corporation found that there was one private practitioner for less than 2,000
people in the municipal ward (4.2 lakh population) in which the hospital is located. In comparison
the dispensary was meant to serve a population of 50,000. The public system could hardly
be expected to match the coverage of the private sector or consider itself the main provider
of first level care. There was an obvious need to review the organisation and performance
(V)
of the public primary care services. At the same time, the development of a referral system
would need to view the existing health care services as a whole, integrating both the public
and private services into a holistic urban health system.
Conclusion
There is no doubt that the health care services need to be integrated within a properly
functioning referral system. Such a system is urgently needed in the urban setting where the
over supply of medical humanpower, duplication of services and increasing competition and
costs of care adversely affect the health care available to the poor and lower income population.
This, however, needs to be done in stages. The access of the poor to the quality services
of the public hospital should not be cut off without providing an adequate alternative at the
first level of care.
(i) Strengthening the first level of services in the public sector based on the dispensaries,
maternity homes, health posts and health centres. All facilities would have a catchment area;
staggered timings that would be convenient for working people; and adequate supply of essential
drugs. To increase the quality of services in these units the first referral specialist clinics and
a wider range of basic investigations could be decentralised to them. These clinics could be
the out-reach services of the local hospital, simultaneously providing the necessary experience
to medical students about conditions and health needs in the community.
(ii) Developing a system of monitoring of private practice patterns and mandatory record keeping
by practitioners. This would form the basis for integrating them within the referral system.
(iii) A properly worked out system of referrals for accessing the hospital, including communication
and referring back the patient to the original doctor.
(iv) Administrative reorganisation of the urban public health departments to achieve co-ordination
and decentralisation.
(vi)
Abbreviations
AFB
ANC
ANM
APD
ARI
BEST
BMC
BP
CGHS
CHV
CNS
CT
Disp.
ESIS
FP
FTMO
G.Surg.
Gen. Hosp.
Govt.
GP
Gy./Gynaec
Hb
HIV
Hosp.
HP
i/c
IMP
IMR
IPP-V
LRTI
MCGB
Municipal
MCH
Med/G.Med.
MO
MOH
MPW
MTP
Munc.
Nurs.H.
Obst.
P.Med.
PHN
PID
PP/Pvt.Pract.
Pvt.
RV fistula
Spl. Hosp.
Spl./Spec.
Tert.
UP
USG
Acid Fast Bacilli
Ante natal care
Auxiliary Nurse Midwife
Acid Peptic Disease
Acute Respiratory Infection
Bombay Electricity Supply and Transport
Bombay Municipal Corporation (now Brihanmumbai
Municipal Corporation)
Blood Pressure (Hypertension)
Central Government Health Scheme
Community Health Volunteer
Central Nervous System
Computerised Tomography
Dispensary
Employees State Insurance Scheme
Family Planning
Full Time Medical Officer
General Surgery
General Hospital
Government
General Practitioner
Gynaecology
Haemoglobin
Human Immuno-deficiency Virus
Hospital
Health Post
In charge
Insurance Medical Practitioners
Infant Mortality Rate
India Population Project - V
Lower Respiratory Tract Infection
Municipal Corporation of Greater Bombay (now
Corporation of Greater Mumbai)
Maternal and Child Health
General Medicine
Medical Officer
Medical Officer - Health
Multipurpose worker
Medical Termination of Pregnancy
Municipal
Nursing Home
Obstetrics
Paediatric Medicine
Public Health Nurse
Pelvic Inflamatory Disease
Private Practitioner
Private
Recto-vaginal fistula
Speciality Hospital
Specialist
Tertiary
Uttar Pradesh
Ultrasonography
(vii)
DEPRIVATION AND HEALTH CONDITIONS IN URBAN AREAS
The most basic indicators of human
development point to the relatively better status of
the urban residents in poor countries such as India
as compared to the deprivations faced by the vast
majority residing in the rural areas. The basic chances
for survival and development reflected in the higher
infant and maternal mortality and illiteracy or the huge
numbers below the poverty line, lag far behind the
conditions in India’s urban centres. The large urban
centres in particular benefited from the investments
in infrastructure as priority was given to building the
industrial and commercial sectors of the economy
after Independence. As a result these urban centers
also held out the promise of employment and higher
purchasing power that would keep the labour force
above the poverty line.
to the Planning Commission, protected water supply
covered 85 per cent while sanitation facilities were
available to 48 per cent of the urban population (Tiwari,
1992). Yet the average water supply available to
slum localities is about 40-50 litres per capita per
day (LPCD) as against the government’s norm of 125200 LPCD. Even this supply is intermittent and of
poor quality resulting in a high load of water borne
diseases and intestinal infections. 3 Exposing the
Government’s claims, the WHO report of the
Commission on Health and Environment found that
only 7 per cent of the country’s 3,119 towns were
partially covered by sewerage and sewage facilities
(Economic and Political Weekly, 1995: 1541). In
poor localities of Bombay, this can mean an average
of 98 persons per toilet which are often in very poor
condition.4 Defecation in the open, uncleared garbage
and overflowing drains are the daily deprivations faced
by the urban poor.
However, deprivation, poverty and precarious
employment mark the urban centres as well. Behind
the aggregate figures of social development lie gross
inequalities. The top 20 per cent of the urban
population consumes five times more than that
consumed by the lowest 20 per cent.1 The poor and
lower income groups are, hence, far more
disadvantaged in their ability to benefit from the better
infrastructure and the greater provision of amenities.
And 86 million (38 per cent) urban people were living
below the poverty line in 1992, a proportion that had
not changed significantly since the 1970s despite
official claims. 2
These deprivations are growing as the rate of
urbanisation (3.14 per cent per annum) remains higher
than the national growth rate (2.13% in 1981-91). In
spite of a low level of urbanisation (26 per cent) the
absolute numbers residing in urban India (217 million)
are larger than those living in cities in the United
States of America.
Within the urban centres, the larger cities (Class
I with one lakh and above population) are absorbing
the greatest growth. The metropolitan cities - over
1 million population - almost doubled in number
between 1981-91 putting severe pressure on their
otherwise better infrastructure (GOI, 1991; Bose,
1995). The urban poor are concentrated in these
metropolises. In 1981 the 12 metropolitan cities
accounted for 43 per cent of the total slum population
(NIUA, 1988: 24).
The large majority of the urban poor and lower
income groups face harsh and dehumanising living
conditions and worsening basic facilities.
Acknowledges the Eighth Five Year Plan, “More than
one quarter of the population in the country now lives
in urban areas. In metropolitan and large cities about
40-50 per cent of the urban dwellers are estimated
to be living in slum areas where the health status of
the people is as, if not worse than, in rural areas.”
(GOI, Planning Commission, 1992: 323)
Small, congested and poorly ventilated slum
tenements are tightly clustered in densely populated
localities with over a thousand people per square
kilometre. These tenements are often labour class
areas that adjoin major industries and are also the
location of small commercial and manufacturing units.
The lower income groups are, therefore, the most
exposed to environmental pollution in their homes,
workplaces and neighbourhoods.
This rapid increase in urban population is
occurring at a time when the Government has initiated
major economic reforms in conformity with the
stabilisation and adjustment programmes mooted by
the International Monetary Foundation and the World
Bank. Aimed at greater liberalisation and market
orientation, the reforms have led to sharp rise in food
prices and further reduced the purchasing power of
the poor and lower income groups (PIRG, 1995: 6391; PIRG, 1994). Public investment in social
infrastructure has declined while prices of all utilities
and civic amenities have been raised.
Compounding these health hazards is the
inequitable distribution of basic services. According
Liberalisation has also intensified the decline
in employment in the organised sector, particularly
1
the urban manufacturing employment. In the first two
years of reform, the share of self-employed and casual
labour increased for urban males at the expense of
regular employment, while female participation in
wage labour rose reflecting the squeeze on family
income (NSS 48th round, quoted in PIRG, 1995: 21).
All new activities in manufacturing and services are
based on contract, casual, temporary or unpaid family
labour or piece-rate and home-based work. Not only
are minimum wages not paid, but also work conditions
are unregulated, unhygienic and variable. There are
very few protective and social benefits to tide over
illnesses, accidents and deaths.
of ill health and premature deaths in urban areas.
Any improvement in the health status of the
urban poor calls for wider action on part of
governments to change the material conditions of
living — the determinants of health. In its absence,
people are inevitably thrown back on the medical and
health care services to cope with illnesses and disease.
Urban Health Care Services
Until the mid-80s health care services for the
urban areas were not seen as an issue. The urban
population was considered highly privileged in its
access to a vast supply of medical and hosp ‘al
services. A quarter of the Indian population was st . ‘d
by 69 per cent of the country’s hospitals and 8( per
cent of its hospital beds. While rural India had still
to achieve the minimum norm of 1 bed per thousand
population in 1992, urban areas —more so the
metropolitan cities — had 2 beds per thousand (GOI,
CBHI, 1993: H7).6 'Hie census in 1981 found that
/j per cent of total allopaths and 4! per cent of the
indigenous practitioners —predominantly private —
were similarly concentrated in urban centres.7
The State of Public Health
The poor condition of public health reflects
these growing inequalities in living standards in
urban areas. Diseases thought to have been controlled
or eradicated in the urban setting have reappeared. The
outbreak of cholera in Delhi, plague in Surat and the
spread of virulent forms of malaria and dengue fever
point to the worsening sanitary conditions (Quadeer
et al 1994). Poor ventilation and overcrowding underlie
the high rates of respiratory infections. There is hardly
any decline in the morbidity caused by TB. Most
alarming are the emergence of new strains of viral
infections and drug resistant strains of diseases that
are rapidly transmitted in congested conditions.
The public sector investment in health services
infrastructure has mainly favoured the urban areas.
Approximately 70 per cent of hospital beds are in
the public sector, particularly in the larger and better
equipped secondary and tertiary segments, making it
the main provider of in-patient care. Around 84 per
cent of public sector beds are located in the urban
centres (Duggal, 1994: 11). Since the 1980s the
growth of public hospitals, the main source of public
health care services in urban areas, has been stagnant
(Baru, 1994). Yet the concentration of medical
services in urban areas continues, as from the mid70s, there has been a rapid expansion in the supply
of private doctors, and small hospitals and nursing
homes (Jesani and Ananthram, 1993).
There is little disaggregated data available on
the differentials in morbidity and mortality among
different socio-economic classes. Microstudies show
that the poor bear the burden of higher rates of
infectious diseases and malnutrition.
An
epidemiological study of four slums in Delhi found
the incidence of diarrhoea among pre-school children
to be 3 - 4 times higher than that of the national average
(Bhatnagar, 1989: 79-80). Water borne infections are
endemic in poorly serviced tenements and slums.
Surveys of different slum localities in Bombay found
that 63 - 68 per cent of children below five years
of age were undernourished which was higher than
the average (46 per cent) reported for urban
Maharashtra ( Geetha et al 1996: 898-899).
Does this huge supply of urban curative services
meet the needs of the poor and lower income groups?
A country-wide survey of utilisation of health services
showed that both the urban arid rural people approached
private practitioners for three-fourths of all routine
illness care.8 The public sector handled only onefourth of general (ambulatory) care, with the bulk
provided by the out-patient departments of the public
hospitals. In other words, the public health system
and particularly the public first level (primary) services
— emphasising both curative and preventive-promotive
care —were handling only a tiny proportion of people’s
day to day health problems. On the other hand, 60
per cent of hospitalisations —the more expensive
services— were handled by public hospitals especially
Alongside the load of infectious morbidity,
there is a substantial rise in chronic and degenerative
diseases. Very high levels of air pollution in Bombay
have led to a 10 per cent increase in cases relating
to breathlessness, cough, chest pain and high blood
pressure between 1983-95 (Times of India, January
24, 1995). 5 Heart attacks and heart diseases and
accidents are becoming the major cause of mortality
in urban areas. Occupational hazards and the morbidity
related to the burden of work, though poorly
investigated, contribute greatly to this complex pattern
2
This is all the more urgent today as major policy
reforms are being put forward in a piece-meal manner.
The reorganisation of urban health services considered
by a government committee in 1982 remained limited
to reaching out very selective preventive services —
family planning and immunisation— to the urban slums
(GOI, MOHFW, 1982). All other first level care
services are by default to be left to the private sector,
except for the small number of under-utilised public
dispensaries or the overcrowded hospital OPDs.
for the poorer classes.
Public hospitals have a major role in serving
the poorer strata and as a result, in the current pattern
of a poorly organised health system, these carry a
dual burden. They manage huge out-patient
departments which are overloaded with patients seeking
the entire range of care from minor, self limiting
ailments to serious diseases. The out-patient
attendance in Bombay —one of the most overprovided
cities — ranges from 5,000 daily outpatients in the
biggest teaching hospital, to an average of 1,700 in
the four major general hospitals, to 700 in the ten
smaller peripheral hospitals.9
The public health authorities have at no time
looked at the condition of the private sector and its
implications for public health. Health reforms
visualise a major role for the private sector (GOI,
Planning Commission, 1992: 324). The few studies
that exist, however, raise serious doubts on the quality,
practice patterns, high costs and lack of regulation
that characterise a sector on which a majority are
highly dependent (Duggal and Nandraj, 1991; Bhat,
1993; Nandraj, 1994; Phadke, 1994).
This is, however, secondary to their role of
providing in-patient care. Unlike private hospitals,
these are also called upon to handle emergency,
medico-legal and high-risk care services. Often their
bed utilisation goes beyond 100 per cent as they have
to accommodate large numbers of seriously ill
people.10 While such high levels of utilisation
severely strain the hospital resources, especially at
a time when public health budgets are stagnant, the
overcrowding and patient queues and centralisation of
services are extremely inconvenient for ill people.
As urban centres expand, people would need to travel
longer distances and spend greater time in accessing
public hospital services. Moreover, the expansion of
public hospitals is hardly likely to keep pace with
either the growing urban periphery or the saturation
of population in the settled poorer neighbourhoods.
At the same time, alternative methods of
funding public hospitals and curtailing their ‘excessive’
use are being considered. These include levying or
raising user fees on hospital services and charging
higher rates to those who lack referral from a lower
level public facility (World Bank, 1993; GOI, Planning
Commission, 1992). There is, however, little
systematic information on the socio-economic
background of the people that public hospitals serve
nor on the nature of health needs for which people
crowd the OPDs. As a result, such reforms may only
restrict the access to needed services without providing
any alternative source of good and affordable general
(primary) care.
As many public health analysts have pointed
out, urban areas need planned and integrated primary
health services providing the whole range of basic
curative, preventive and promotive care. In such a
system, hospital services would provide referral,
technical support and teaching facilities.
As
experiences of other countries have shown, the health
services need to be planned as a whole and based on
a well functioning referral system (Gupta, 1995:153161). The need for a referral system was to a limited
extent reflected in the recommendations of early
government committees but was never implemented
(Murthy et al 1983:31).
The problems of the public hospitals, poorly
organised public primary care services and the quality
and affordability of private care —these are the factors
that determine whether the health care needs of the
urban poor are being adequately met. The current
study focuses on the day-to-day health problems seen
in the out-patient departments (OPDs) of a large public
hospital in an attempt to understand the functioning
of the urban health services as a whole.
Notes:
1 The NSS data for 1992 showed that in urban areas the lowest 3 deciles or consumption classes spent 13 per
cent of the total private consumption expenditure, the middle 4 deciles spent 32 per cent while the share of the
top 3 deciles was 55 per cent. The share of the lowest 20 per cent (lowest 2 deciles) was 8 per cent and this was
equivalent to the share (9 per cent) of the lowest 20 per cent in total private consumption expenditure in the
rural areas. NSS, 1992, Consumer Expenditure and Employment Survey. Quoted in S.P. Gupta, 1995.
2 S.P. Gupta, 1995: 1296 & Table 3. This estimate is based on the NSS data using the methodology recommended
by the Expert Group on Estimation of Proportion and Number of Poor set up by the Planning Commission in
3
1989 The Planning Commission, however, continues with the old method of estimating poverty levels. The
official estimate of urban poverty was 13% for 1992. However, both methods showed a trend towards increase in
poverty from 1990-91 onwards, both for urban and rural areas, reflecting the adverse impact of the policies of
economic reform and structural adjustment.
3 BMRDA 1989 survey data, quoted in C. Sengupta, 1991; for inequalities in coverage, see
S. Gokhale, 1996: 5; for micro-level data on quality of water supply and sanitation, see M. Swaminathan, 1994.
137-138.
4 Based on 1981 census data on 619 notified slums in Bombay. Quoted in M. Swaminathan, 1994: 138.
5 Data collected by Dr A.A. Mahashur, Prof, of Chest Medicine, KEM Hospital., Bombay
6 See GOI, Planning Commision, Seventh Five Year Plan 1985-90, vol. II: 274 for the minimum population
norm for bed strength and distribution of different sizes of hospitals.
7 GDI Registrar General, Census of India ML A. Jesani (1991: 8) calculated the population coverage in 1981
ivo
was 1 allopath per 817 urban residents as against 1 per 7,189 rural persons. The combined coverage of all
allopaths and indigenous practitioners came to 1 per 408 urban and 1 per 1,917 rural persons.
8 NSS 42nd round on Morbidity and Utilisation of Medical Services. GOI, NSSO, 1992: 69-70.
9 Average total OPD attendance calculated from the data for 1995-96 on 14 Peripheral Hospitals belonging to
the MCGB. Data obtained from MCGB, Public Health Department.
10 (Dr) Pragnya Pai. ‘Health Care Scenario in Public and Private Sector with special reference to the Municipal
hospitals of Bombay’. Lecture presented to the Bombay Management Association.
4
STUDY DESIGN AND METHODS
This study explores the problem of overloading
of the public hospital out-patient services in the
metropolis of Bombay. This problem is seen from
the perspective of those who use these services —
their social background and their health needs and
ailments that have brought them to the out-patient
department. The choice of providers used by them
for the initial treatment of their problem and thenreasons for changing over to the hospital out-patient
service help to pinpoint the problems of the wider health
services infrastructure in Bombay. The study suggests •
some of the measures that could help to rationalise
the load on the public hospitals OPD services.
the study. Built in 1925, the hospital is located in
Parel in south-central Bombay. Parel and the adjoining
neighbourhoods constitute the old industrial areas of
cotton textile mills. The KEM hospital is the largest
public sector hospital in Bombay in terms of the bed
strength, the number of departments, the number and
range of specialist and superspecialist clinics
conducted every week and the total attendance of out
patients seen in a day (Appendix B Table 1). It has
a strength of 1,800 beds and a total of 28 departments
belonging to the basic and superspecialities. These
departments conduct a total of 64 out-patient clinics.
On an average, 5,000 people daily attend the out-patient
departments (OPDs) in the hospital.
Health care services are organised at different
levels of care. The first level, termed as the
‘peripheral’ or ‘primary’ care level, is the point at
which people should come in contact with the health
services. The first level services are located in health
posts, dispensaries, General Practitioner clinics and
maternity homes. These are meant to handle the most
frequently occuring conditions for which simple
technologies for prevention and cure exist. The bulk
of health care needs in a community can be handled
at this level. The more complex and serious conditions
needing specialised investigations and treatment are
seen by specialist medical professionals at the
‘secondary’ level facilities such as the General
Hospital. The rare and serious cases would need the
care of superspecialists based in ‘tertiary’ care
facilities, equipped with sophisticated medical
technology. The public teaching hospitals are sought
for all levels of health care which is a major factor
in overcrowding in these hospitals.
The KEM Hospital is also one of the four public
teaching hospitals in the metropolis. It is attached
to the Seth Gordhandas Sundardas Medical College,
— one of the three medical colleges with affiliated
tertiary care hospitals that are owned and administered
by the Municipal Corporation of Greater Bombay
(MCGB). (The fourth medical college and teaching
hospital belongs to the State government, the
Government of Maharashtra.)
Sampling for the Survey: The study focused
on the users of out-patient departments (OPDs)
belonging to the basic specialities only. These users,
or outpatients, referred to all patients living at home
who were coming to the hospital for treatment. Four
basic specialities were selected, namely, General
Medicine, Paediatric Medicine, General Surgery and
Gynaecology-Obstetrics. These specialities are the
most commonly available services at any secondary
level hospital and constitute the first level referral
services in a health care system. These were amongst
the first seven most heavily utilised specialist OPDs
in the KEM hospital (Appendix B, Table 2).
Objectives
1. To study the socio-economic profile, morbidity
and help-seeking pattern of the users of
the
out-patient services of a public teaching hospital in
Mumbai.
The selected OPDs were also the most likely
to handle a wide range of illnesses, disabilities and
maternal care needs, including common and simple
problems. This would allow us to explore the
possibility of categorising the conditions into the three
levels of care mentioned above.
2. To broadly assess the level of care needed for
the illnesses seen in the out-patient departments,
3. To study the hospital based out-patient care in
terms of accessibility, convenience and costs.
A pilot study, conducted in June 1993, had
focussed on the morbidity profile of 250 users in
five out-patient departments (OPDs) of the KEM
Hospital. It was undertaken by a MBBS doctor who
had assessed the level of care needed by the sample
users in terms of the percentage needing primary,
secondary and tertiary level care. A statistical
formulal was applied to the findings of the pilot study
4. To review the peripheral levels of the public health
care services in Mumbai and to identify interventions
needed to rationalise the load on the public hospital.
Study Design
Study Area : The King Edward VII Memorial
(KEM) Hospital, Bombay was selected as the site of
5
k.
I
to derive the sample size of 1,763 out-patient users
for this study.
The components of information covered by the
interview schedule included (i) general information
and socio-economic background of the patient and the
patient household; (ii) duration and nature of
symptoms of the current episode; (iii) prior selfmedication and utilisation of health care services for
the current episode, the costs incurred and reasons
for changing the providers;
(iv) the reasons for
The entire sample was distributed over the
selected departments in proportion to the share of
their out-patient load in the total out-patient attendance
of the hospital (ie. using the proportionate probability
sampling (PPS) method). The distribution of the
sample is given in the chart below.
Total OPD Users Sample
n = 1,763
Medicine
OPD
n = 747
General Surgery.
OPD
n = 521
New
n=504
New
n=346
Male :
Female :
Old
n=243
454
293
Old
n=175
Paediatric Medicine
OPD
n = 206
New
n=122
355
166
Old
n=84
113
93
Gynaecology
OPD
n= 190
Obstetrics
OPD
n = 99
New
n=120
New
n=26
Old
n=70
190
Old
n=73
99
Period of Data Collection in OPDs :
Round 1 : Jan 94 283
Round 2 : Apr 94 216
Round 3 : Jul-Aug 248
Feb-March 94
January 94 : 81
April
94 : 66
July-Aug 94 : 59
In order to get accurate and complete morbidity
profile of these OPDs, the sample for each OPD was
further devided into new and old patients and male
and female users. This was based on the pattern of
attendance recorded in the previous year (1993). The
ratio of new to old patients was approximately 2:1
with the pattern being reversed in the Obstetrics OPD.
Male patients were double the female patients in
General Surgery OPD with differentials narrowing over
Medicine and Paediatric Medicine OPDs. All relevant
data on out-patient attendance was obtained from the
medical records department of the hospital.
June-July ‘94
choosing KEM hospital and the costs and waiting time
involved; and (v) the overall knowledge and use of
the municipal dispensary or any other primary level
facility in the public sector; and (vi) the utilisation
of health care services in general by the user and the
household members. At the end of the interview
schedule there was space to take down the clinical
notes and diagnoses, if any, recorded on the patient’s
medical case paper by the attending doctor in the OPD
(Appendix C).
The researchers were also instructed to record
any narrative details that might be provided by the
users during the course of the interview. They were
also expected to record their observations of the OPD
setting and of the incidents and situations that arose
from the crowded conditions.
Techniques and Tools of Data Collection: The
constraints of the OPD setting such as the fixed
timings, ill people and a moving queue necessitated
the use of a quantitative approach to data collection.
A survey method based on brief interviews and fairly
specific questions was considered the most appropriate
technique of data collection. However, since this was
an exploratory study some open-ended questions for
qualitative information were also included in the
schedule.
After the first hundred schedules were'
completed the socio-economic, morbidity and help
seeking data were listed. This enabled the researchers
to identify the gaps in the information and refine
the guidelines for data collection accordingly. The
research team did not have access to comparable
studies and these listed responses became the basis
for developing the codebook.
(a) Quantitative Method: The survey of OPD
users, therefore, relied on semi-structured interviews.
6
Table 2.1: Size and Distribution of Daily Sample
OPD
Av. no. of
interviews/day
Male
New cases
Male
Old cases
Female
New cases
29
12
5
6
4
14
7
7
4
7
4
3
3
11
6
2
7
General Medicine
Paediatric Medicine
General Surgery
Gynaecology
Obstetrics
16
31
17
9
(b) Secondary Data Collection: The study was
supplemented by secondary data on the health care
services in Greater Bombay available with the Public
Health Department of the Municipal Corporation
(MCGB). The network of peripheral health facilities
provided by the municipal corporation in the F/South
Municipal Ward within which the KEM Hospital is
located, was profiled. The focus was on the first level
curative facilities located in the municipal dispensaries
rather than on the outreach preventive services of the
health posts.
8%
26%
12%
18%
8%
variations in conditions likely to be seen in the Surgery
and Gynaecology OPDs.
Field work was carried out by women research
assistants. For each department depending on the size
of the total sample two or three days per week were
fixed for data collection. The same days of the week,
and therefore the unit of doctors responsible for
running the clinic on that day. were retained during
the entire period of fieldwork for each department.
The selection of the units was random. The
researchers had to complete a fixed sample of daily
interviews. The daily sample was divided into new
and old cases and within these into the male and female
users (Table 2.1).
Data on the morbidity recorded at, and the
attendance load of, the municipal dispensaries was
collected from the F/South Ward Public Health
Department. Brief visits were made to three of the
better utilised dispensaries in this ward. The qualitative
insights gained through discussions with the staff and
the observations of the researchers were recorded.
The profile of the ward level services and insights
into their functioning suggested the need for a larger
systematic study of the public peripheral services in
Bombay which was outside the scope of the present
research.
The data was collected in two phases, i.e. before
and after the user had seen the doctor. The research
assistants started their interviews half an hour before
the OPD began as soon as the registeration desk
opened. The early patients, after collecting their
stamped case papers, would queue up on the long
benches in the main hallway outside the out-patient
clinic. Separate queues were maintained for male and
female patients in the Medicine OPD whereas the
Paediatric Medicine OPD had separate queues for the
new and old cases. In the rest, there was only a single
queue.
Conduct of the Study
The Survey - Data Collection in the OPDs:
The out-patient departments selected for the study
function on six days of the week. The Medicine,
Surgery and Gynaecology OPDs work from 8.30 a.m.
to 12 noon while the Paediatric Medicine and
Obstetrics OPDs work in the afternoon from 1.30
p.m to 4.00 p.m. Each clinic is conducted by a unit
of specialists and resident doctors. Separate units of
the respective departments conduct the OPDs on
different days of the week.
The day’s interview began with the first patient
in the queue. The respondents were selected in as
random a manner as was possible. The OPD setting
presented several constraints that made it difficult for
a systematic selection of the respondents. There
was no serial order stamped on the case paper nor
was any token system used to regulate the flow of
patients into the OPD. Any casualness on the part
of the doorkeeper would see the queue break up as
soon as the ward boy or ayah opened the OPD doors
to collect a batch of case papers or let in some
patients.
Within the OPD there could be several
queues depending on the number of cubicles and the
sitting arrangements for the doctors.
For each speciality OPD the period of data
collection was fixed as four to six weeks. For General
Medicine and Paediatric Medicine OPDs, the user
sample was divided into three rounds of interviews
in order to arrive at the morbidity profile across the
different seasons. Such a procedure was not used
for the other two OPDs as the existing literature on
morbidity and health utilisation surveys did not suggest
Efforts were made to select every fourth patient
in the Medicine OPD, every fourth patient in the
7
L
Female
Daily sample as
Old cases proportion of
average daily
attendance
■i!
Paediatric Medicine OPD, every seventh male and
every eighth female patient in General Surgery and
every fourth in the Gyneacology OPD. Such a
systematic procedure could be managed only unevenly
as it meant a great deal of co-ordination among the
investigators who had to select old and new
respondents separately and within these the male and
female respondents.
Almost all the information was recorded while
the respondent waited to go into the clinic or stood
m the queue in the clinic itself. Each interview took
between 15-20 minutes. The help of accompanying
relatives was sought when the respondents were
children, old persons or diffident women. Almost
no respondent refused us an interview although a small
number of women were highly diffident about talking
to unknown persons. However, there were certain
items of information that some women respondents,
youth or accompanying female relatives could not
provide such as the break-up of income of earning
members in the household or costs of prior treatment.
In the case of old patients with multiple visits,
die notes of the first day, the investigations conducted
in the course of the various follow-up visits and the
diagnosis, if any, were recorded during this first phase
of the interview itself.
entire sample of respondents.
Data Analysis: All responses to the closed
questions were coded and entered on the computers,
e data were analysed using the Fox Pro2 and SPSSPC packages. The open-ended responses were listed
and categorised and used to illustrate the quantitative
data.
Methodological Issues and Limitations
A major component of this study was to
categonse the morbidity data into different levels of
care. However, the profile of illnesses and ailments
seen m the OPDs relied mainly on the trend shown
by confirmed diagnoses. Diagnoses constitututed a
little over a third of all morbidity recorded for the
User sample. As a result, the categorisation of the
levels of care was based on the management of the
condition by the attending doctors themselves. These
being specialist clinics a bias towards secondary level
care was present. The exception was the General OPD
managed by the Department of Preventive and Social
Medicine which screened the new patients in the
Medicine OPD.
The rest of the morbidity data has been
presented as symptoms reported by the patients
themselves and have been classified as the ‘main
symptom or the ‘most disturbing symptom’. This
needs to be analysed further to get s detailed picture
of the conditions that can be effectively handled at
the first (primary) level of care.
As each interview continued, the researcher
would simultaneously watch out for the respondents
interviewed earlier. After they had seen the doctor,
the researcher would once again approach the
respondent and take down the doctor’s clinical notes
and diagnosis, if any, from the case papers. This
The accessibility and convenience of using
procedure demanded a great deal of concentration on
hospital services could be studied only in a limited
part of the researchers who had to wait a long time
way. The data on expenditure on drugs and
before the respondents were able to get their turn
investigations towards the treatment in the hospital
at the doctor’s desk. By that time the respondents
has many limitations. This data could only be collected
were in a rush to leave in order to queue up at the
for the old patients where recall was a major problem.
pharmacy or undergo tests before the pathology closed.
It was particularly difficult to keep track of the users
The discussion of the municipal dispensaries and
of the Gynaecology OPD as there were three separate
health post were based on brief visits and preliminary
observations which need to be developed into a detailed
cubicles which the users could enter at random. As
study.
a result clinical notes could not be recorded for the
Note:
1
n
d2
Where Z = normal value 1.96
P = probability of the KEM out-patient needing secondary care
(based on findings of a pilot study)
q = (1-P)
d = 10% of p
S.K. Lwanga & S. Lemeshow, 1991: 1.
in loJheTahbOVe f°TUla Was ap^lied tO the findinl!!i °fa pilot study conducted in six OPDs in this hosoital
patients.
‘ ’M1"
StUdy
WUh the teVet Care retluired by ‘he sample of out-
8
s
I;
THE USERS OF PUBLIC HOSPITAL OPDs
Who are the main users of the crowded out
patient clinics of the public hospital in a metropolitan
city? What are their socio-economic characteristics?
Hospital clinics handle the larger load of routine out
patient care in the public health system. Are these
clinics serving a larger proportion of the city’s poor?
do not come within the perview of protective
legislation (CRD,1994:32-33).2
It is this
constellation of deprivation and vulnerability that
constitute the character of the poor and lower
income groups in Bombay.
Bombay: The Urban Poor As India's foremost
industrial and commercial centre, Bombay is easily
the most affluent city in the country. Occupying
a tiny area of land (603 sq. kms), the population
of Greater Bombay (9.9 million in 1991) and its
adjoining urban periphery is set to become one of
13 megalopolises in the world. Greater Bombay,
itself, consists of three zones comprising the island
city, the western and eastern suburbs. It is
administered by the Municipal Corporation of
Greater Bombay which has divided the district into
23 municipal wards.
The out-patients of the specialist clinics at the
public hospital were mostly the younger workers in
the early or mid-occupational stage, new entrants into
the workforce, women household workers and young
dependents. Over three-fourths of them lived in
Greater Bombay (76 per cent) itself or in its
metropolitan region (7 per cent urban Thane).
The OPD Users
Ramesh, 22 year old vendor of betel
leaves, had studied upto Std. 10 and
lived with four family members in a
single room chawl (tenement) at Wadala
in Central Bombay. He approached the
Surgery OPD complaining of stomach
pain. He had been experiencing pain
in the left side of his abdomen for the
last 4-5 years but this had got
aggravated in the past two years. The
last four days had been particularly
uncomfortable and he had stopped
working, losing his daily earnings of Rs.
30/- to 40/-, as well as the Rs 200/- he
had invested in the stock of betal leaves.
In the absence of his earnings the family
was dependent on his mother’s daily
earnings of Rs. 55/- from selling
bananas on the footpath.
Despite the strong economic base, glaring
disparities exist between different sections of the
population. By 1991 an estimated 55per cent to
68per cent of the people lived in slums that occupy
only 6 percent of the total land area (CRD,1994:7475; Swaminathan,1994:136). Another 2 lakh
people were living on the footpaths without any
amenities and 4 lakh resided in dilapidated and
unsafe tenements in the inner city area (Sengupta,
1991:22). The enormous profits in real estate and
construction industry has put decent housing beyond
the purchasing power of the large majority. As many
micro studies have shown, the people in these areas
face enormous deprivation from the environmental
squalor, inadequate amenities and very high levels
of air pollution. 1
Mahindra was a peon with a private
export unit dealing in carpets and
furniture. He earned Rs 1500/- per
month out of which he sent Rs. 200/to his parents, both agricultural
labourers in Belgaum
district,
Karnataka, and gave Rs. 500/- to his
athiya (father’s sister) with whom he was
lodging for four years at the BDD
chawls in Worli, another locality in
Central Bombay. In late 1993 he began
to have acute spasms of pain in the right
side of his chest and rib cage. Initially
he did nothing, but as the pain increased
relatives suggested that he have a check
up at the hospital. He was diagnosed
as a case of lung tuberculosis and put
on treatment .
Not only do the lower income groups face
declining conditions of living, they are also
confronted by a deterioration in the employment
situation. The expansion in employment slowed
down considerably during the 1980s, with almost
negligible growth in industrial and manufacturing
jobs (secondary sector). This sector had initially
attracted the enormous migration of the labour force
to the city. By 1991, the services sector had
overtaken the industrial sector to become the main
source (60per cent) of employment. More and more
people are today engaged in non-financial services
and trade which provide little protection, no benefits
and poor wages. In the production sector, jobs are
increasingly
concentrated
in
the
small
establishments —the urban informal sector— that
(Profiles constructed from the schedule)
9
Age
Profile
Three quarters of the users interviewed in the
Medicine, General Surgery, Gynaecology and Obstetrics
out-patient departments (OPDs) belonged to the
economically active age group of 15-45 years. Over
half of them were the youth and young adults between
26 to 30 years of age. The women coming for Obstetrics
care were younger (median 23 years) while children
in the Paediatric OPD had an average age of 4 years.
The less mobile dependent persons over 60 years, who
otherwise have higher health needs, did not seem to
be frequent users of these OPDs (Table 3.1).
males had reached the secondary level (Std. VIII-X),
although few had successfully completed it. Only
18per cent of the users were non-literate. About 14per
cent had qualifications beyond the secondary level but
graduates and professionals were very few (Table 3.2).
Other surveys, too, have noted the trend towards
secondary level educational attainment among the
younger generation belonging to low-income families
in Bombay. One survey, carried out nine years ago,
covered the Naigaum maternity home area adjacent
to the hospital. The chawl and slum dwellers in this
area were almost evenly distributed into the non-literate
category and the primary, secondary and higher secondary
Table 3.1: Age-Wise Distribution Of OPD Users
Age
Group
Male
n=805
Female
n=730
Total
n=1535
Age
Group
Male
n=113
Female
n=93
Total
n=206
(years)
%
%
%
(years)
%
%
%
<14
4
2
3
0- 1
15
24
19
15-29
51
56
54
1-5
38
42
40
30-44
25
29
27
47
34
41
45-64
16
12
14
>65
4
1
3
Median
26
26*
4
• Note: Only respondents included.
♦Excludes users of Obstetrics OPD (median age 23 years).
Table
Adults in the 16-35 years range emerge as the
biggest group in baseline surveys of poor localities
in Bombay. One of the reasons for this may be the
presence of young migrants in these localities. The
proportion of the elderly has been found to be low
either due to a shorter life-span, the movement back
to the village after retirement or retrenchment from
job, which has increased in the last decade with the
decline in the formal manufacturing jobs. Children,
on the other hand, make up one-third of the population
in these localities (Yesudian and Parsuraman,
1990:38). More males, rather than females, avail of
the Medicine, Surgery and Paediatric OPD services.
This differential was built into the sample for the
survey and does not emerge as a finding of the study.
Education
3.2: Education Profile Of OPD Users
Education of
Patient
Non-Literate
Level
Reflecting the overall higher literacy levels and
access to education in Bombay, the average female
users had middle level schooling (Std. V-VII) while
Male
n=806
%
12
Female Total
n=744 n=1550
%
%
18
23
Primary (Stds. I- IV) 9
11
10
Middle (Stds.V-VII)
19
27
23
Secondary
(Stds.Vffl- IX)
43
29
36
High Sec.\Dipl\Tech\
Undergraduate
12
8
10
Graduate\Professional
5
3
4
Note: Only respondents included.
Excludes users of Paediatric Med. OPD
10
Occupational Profile
levels of scool education (Yesudian,1988a:43). 3
However, this trend is uneven due to the high drop
out rate among children studying in the schools
run by the municipal corporation which overwhelmingly
cater to the low - income groups.
Employment
Over half the economically active users (54
per cent) worked in the urban unorganised sector,
either as wage workers or as self-employed (Figure
3.1; Appendix A Table 2). A major metropolitan
economy such as that of Bombay, is nevertheless
highly heterogeneous and unequal. People’s command
over resources is greatly determined by their status
in the labour force. It is groups most “ vulnerable
to poverty” by virtue of an insecure and irregular
labour force status that predominantly benefit from
the hospital OPD services.4 This is borne out by
the concentration of the economically active patients
in mainly four occupational groups.
Status
Around 41per cent of the users were
economically active as wage workers or self-employed
(table 3.3). Working men, and more so, working
women used the Surgery and Gynaecology-Obstetrics
OPDs respectively, in larger proportion to their share
in the workforce(Appendix A Table 1). On the other
hand, 58per cent of the users were economically
dependent on their households as they were women
household workers, children and unemployed men
(Table 3.3). Among all the OPDs, General Surgery
was utilised by a higher proportion of both the
economically active and the unemployed, ie.
predominantly male workers. This is probably a
reflection of the greater expense of these services
in the private sector.
Table
Figure 3.1: Occupational Profile of OPD users
n = 710 (working patients)
Seif Employed
Primary Sector
17 %
13%
3.3
Employment Status Of OPD Users
White Collar
10%
Employment
Male
Female
Total
Status
n=922
n=839
n = 1761
%
%
%
60
20
41
Organised Sector
19%
Unorganised Sector
41%
Earners
Wage earners/
Self employed
Unorganised sector workers:
Income from rent,
The largest group of users (19 per cent) were
the lower level service workers. These were peons,
watchmen, gardeners, lift operators in private
establishments and housing societies; salespersons,
shop assistants and counter workers; small hotel and
canteen workers; compounders; domestic workers;
theatre extras; telephone operators and xerox
assistants. The majority worked on a contract basis
while a small proportion (3 per cent) were selfemployed.
pension, savings,
2
1
2
job due to illness
3
1
2
Unemployed
13
1
8
part-time work
Non-Earners
Not earning/ Lost
Household workers
1
63
30
Students/ Children*
19
15
17
Retired
3
<1
1
The non-factory skilled workers, in wage or self
employment, constituted the second largest (13 per
cent) group. These were the laboratory assistants; taxi,
rickshaw and truck drivers; electricians, carpenters,
masons, painters working in the construction industry;
tailors and embroidery workers; machinery fitters, and
mechanics; barbers and others. The third largest group
(12 per cent) consisted of the semiskilled workers.
These were mostly in small and medium private
manufacturing units such as pharmaceuticals,
garments, leather, cassettes and printing presses. A
Note : Only respondents included
♦Refers to users of Paediatric Medicine OPD
11
much smaller proportion of the users (6 per cent)
were the very poor vendors, hawkers and stallkeepers.
But other marginal workers — rag pickers, garbage
sifters, women home-based workers — did not appear
to access to the OPD services in large numbers.
Among the self-employed, 4 per cent of the
users had small retail businesses or were shop owners
and traders. These are relatively secure activities and
have been excluded from the discussion of the
unorganised sector. The expanding unorganised sector
within Bombay’s economy implies insecure and
irregular work, varying wages and complete lack of
protective legislation or social security. This sector
is set to expand greatly under the current liberalisation
policies.
White collar workers:
A small proportion of the lower level white
collar employees, mainly clerks, accountants,
municipal school teachers, computer operators,
supervisors, also used these OPDs. A larger
proportion of these were women using the
gynaecology and obstetrics services (Appendix A,
Table 2). The higher income professional groups
were hardly found using these services in the public
hospital.
Rural groups:
Apart from the urban workforce, a small but
significant proportion of the OPD users (13 per cent)
belonged to the cultivating groups of cultivators. Even
among them the low-income and vulnerable sections
of small and marginal farmers, and to a lesser extent,
agricultural labourers largely utilised the city’s public
hospitals. In the Gynaecology OPD 18 per cent of
the women workers belonged to these sections.
Organised sector workers:
The working patients from the organised sector
(19 per cent) formed a smaller proportion of the OPD
users. Among these, the lower level workers in public
utilities, formed the single largest (10 per cent) group.
Income level nf Iker Households
These were mainly employees of the municipal
corporation for whom the municipal hospital is the
The overall labour class background of the urban
main facility. Blue collar workers in the organised
users is reflected in the income levels reported by
sector did not appear to utilise these OPDs. Special
them for the earning members. In the Bombay-Thane
hospital facilities are available for the organised sector
region, an average household of six members was
workers under the Employees State Insurance Scheme
supported by two earners. Two-thirds (64 per cent)
(ESIS) or employer schemes. These facilities are
of the urban households had a per capita income of
also concentrated in south-central Bombay and would
less than Rs. 500 per month (Table 3.4). Among these
explain the very small utilisation of the OPDs by these
11 per cent constituted the abject poor with monthly
sections.
Table 3.4: Monthly per capita income of User Households
Per capita
Income
Med
OPD
G. Surg
OPD
Gynaec
OPD
Obst
OPD
P. Med
OPD
Total
(Rs.)
n=522
n=386
n=131
n=70
n=171
n=1280
%
%
%
%
%
. < 150
12
10
10
9
16
11
151-300
26
24
16
21
32
25
301-500
30
26
24
24
31
28
501-1000
24
29
32
26
17
26
1001-2000
7
10
15
17
4
9
>2000
1
2
2
3
Median PC (Rs)
400
450
531
500
313
415
Median HH (Rs)
2,000
2,100
2,225
2,000
1,818
2,000
.Note:
2
Only respondents included .
PC - per capita per month; HH - household per month.
Excludes households belonging to agricultural (primary) sector. Average household size for Bombay- Thane sample was 6 (range 1 - 23) and the average number of earners was 2 .
For the non-Bombay / Thane households, the average size was 7 (range 1 - 32) and average number of
earners was 2.
12
in Maharashtra, with the adjacent Thane district
contributing 9per cent of them. The common
metropolitan public transport system, location of jobs
in Bombay and visits to relatives were some of the
reasons for people in the far-flung suburbs and urban
centres of Thane to resort to a city hospital. A small
proportion (4 per cent) belonged to other states,
particularly Uttar Pradesh, Bihar, Madhya Pradesh,
Rajasthan and some southern states, all of which have
contributed considerably to the workforce in Bombay.
Among the basic specialty clinics, General Surgery
had a higher utilisation by non-Bombay users.
per capita income less than Rs. 150.5 A larger
proportion of the poor used the Paediatric Medicine
(median household per capita income of Rs. 312) and
Medicine (Rs. 400) OPDs. In comparison, a larger
proportion of the Gynaecology-Obstetric OPD users
reported relatively better levels of income (median
Rs 500).
The need for two incomes is again apparent
in the occupational background of the households of
the non-earning users. Overwhelmingly, their earning
members were concentrated in the unorganised wage
and self-employed sectors (Appendix A, Table 3).
The majority of these users (81 per cent) had
come to the city specifically for treatment. The rest
were people who had fallen ill while on a visit to
relatives and had been brought to the hospital for
treatment. In all 14per cent of these users belonged
to rural areas.
The official definition of poverty based on the
income norm is inadequate as a measure of deprivation
experienced by low - income groups in Bombay.
Poverty lines estimate purchasing power or
expenditure levels that only just allow households to
meet their survival needs. As Swaminathan points out,
this excludes any discussion or estimate of
expenditures on other basic needs such as housing,
clothing, education and health (Swaminathan,
1995:134). Apart from these essential expenditures,
urban poverty has the added dimension of
environmental degradation that poses serious health
hazards for people residing in slums and congested
neighbourhoods. Even though incomes show wide
differentials among the labouring groups, the small
surpluses are hardly sufficient to change the quality
of their housing or the insanitary and polluted
condition of the environment. Added to this is the
lack of job security and social benefits in the growing
unorganised sector.
Catchment area of the KEM Hospital out-patient
clinics:
The majority of the users, around 58 per cent,
were from the city zone of Greater Bombay, while
17 per cent belonged to the suburbs and extended
suburbs. As a highly specialised and technologically
well equipped facility, the teaching hospital is meant
to serve a large geographical area. Since the concept
of a catchment or referral area has not been developed
in planning for hospital services, these can be openly
accessed by the general public residing anywhere in
the metropolis or outside of it.
In the case of these OPDs, a little over half
the users (54 per cent) were drawn from the close
vicinity of the hospital itself, municipal wards namely
the F (south and north) and G (south and north) of
south-central Mumbai (map 1; Appendix A Table 5).
Densely populated with 51,000 to 61,000 population
per sq. km. respectively, these four wards account for
1.85 million people. Even within these, the utilisation
was predominantly from the labour class residential
areas.
Residence of OPD users
Three fourths of the users (76 per cent) were
from Greater Bombay (Figure 3.2; Appendix A Table
4). Another 20per cent had come from other districts
Figure 3.2: Residence of OPD Users
n = 1,760
L
3)
Etntey
Thme
■ Utm
As a specialist, clinic the Gynaecology OPD
had the widest catchment with a relatively higher
proportion of utilisation (28 per cent) by women
residing in the suburbs (map 2). This, as shown by
the morbidity profile of this OPD, is due to its
relatively greater use as a secondary and tertiary
facility.
Medicine, Paediatric Medicine and Obstetrics
OPDs were more heavily utilised by residents from
the near-by localities. Historically, these localities
have had a large concentration of the Bombay working
class and are the locus of the early labour tenements
built for the textile mill workers around 1920s.
Lttnadira Qherd^s
□ Rid
13
GREATER
BOMBAY
0i
3 km.
K
Ar
uj
UJ
N
Ct
o
UJ
X
X
N.
M
more than 270
D
90 to 270
B
30 to 90
. 10 to 30
less than 10
• K.E.M. Hospital
PN-Fnorth
GN-Gnorth
Fs-F south Gs-Gsouth
2.
M A ’p*
GREATER BOMBAY
3 km
0I
K
Uj
LU
N
cc
o
111
%
4.
X
M
in
no. of Gynaec
patients per ward
0
• K.E.M.Hospital
10
20
30
40
FN-Enorth
GN-fcnorth
______ .__________ ^3-F south
G$-G south
The central part of the Bombay city region was
favoured for the location of the textile mills in the
early phase of Bombay’s industrialisation. The need
for a captive labour force encouraged the building of
labour tenements close to the mills, thereby effectively
segregating labour class areas from the better
ventilated elite residential localities along the western
seaboard (Crook et al, 1989; Ramasubban and
Crook, 1992). These are some of the areas worst
affected by industrial pollution and congested
neighbourhoods. Local industries and the textile mills,
as well as the polluted air from the petro-chemical
industry in the east, contribute to the high levels of
air pollution (Crook et al., 1989: 43). Along with
this area forms the old inner city localities that have
a high proportion of decaying tenements.
Although the study did not elicit information
on the conditions of housing and the provision of basic
amenities available to the users, it was evident from
the addresses that the overwhelming majority lived
in old, often dilapidated, one-room tenements or
‘chawls’, newer single-room housing board residential
blocks and slums (CRD, 1993:72-73). A similar
pattern of shanty dwellings and single-room tenements
characterised the people residing in the suburbs. The
hutment colonies are more widespread in the suburbs
of Greater Bombay.
Although large sections of the population in
the inner city areas live in ‘pucca’ chawls, a single
building houses around 100 households where large
families live in a single room of 120 to 150 sq.
feet. These do not have a separate cooking area or
bathing place. Despite water connections and provision
of taps, whether common or private, the water supply
is in short supply. The number of common toilets
are totally inadequate and poorly maintained, drainage
systems are often choked and garbage is removed
irregularly (Yesudian, 1988a: 43-54). The
environmental conditions are even more degraded in
the slum areas. A large number of the users were
residing in the congested slum colonies located in
the Sewree - Wadala belt.
Discussion:
The specialist out-patient clinics of
the public teaching hospital were being used mainly
by the younger workers, overwhelmingly urban, largely
male and belonging mainly to the unorganised
workforce. On the other hand, over half the users
- women, children and the unemployed - were
economically dependent on their mainly labour class
households. They were mainly residing in the labour
class residential areas in the vicinty of the hospital
Since the largest section belonged to the unorganised
workforce, these users lacked social security or
coverage of protective legislation and the public
hospital’s quality services was one of the few safety
nets available to them.
Notes:
1 See Madhura Swaminathan, 1994 for a discussion of the living conditions among the homeless and the
slum dwellers of Bombay and the health risks faced by them. See C. Sengupta, 1991 & S. Gokhale, 1996
for an overview of the living conditions of the poor in Bombay.
2 The deterioration in the employment situation accelerated in the 1980s, according to the Socio-economic
Review of Greater Bombay. The expansion in employment slowed down considerably from 2.7 per cent
growth per annum in the 1960s and 1970s to 1.8 per cent in the 1980s. This was mainly due to the negligible
growth of secondary sector jobs—0.6 per cent per annum in 1980s as against 2.5per cent in 1970s. It
is estimated that only a third of Bombay's workforce is in the organised public and private sectors. Almost
46 per cent of all workers in the 1990 (as compared to 27.4 per cent in 1971) were employed in establishments
with less than 10 workers. CRD, 1994: 32-33.
3 See also Yesudian & Parsuraman, 1990: 43. The 1991 census shows the literacy rate in Bombay to
be 82.5 per cent (male - 87.8 per cent; female - 75.8 per cent) while urban Maharashtra and urban allIndia rates are 79.2 per cent and 73.1 per cent respectively. The 1989 BMRDA survey^ of^ slums in the
(C. Sengupta, 1991:
Bombay metropolitan region found only 22per cent of the slum dwellers were illiterate
i
28).
4 Studies have shown that the character of the urban poor is hetrogenous. The destitute, or those below
the poverty line and officially designated as the poor, constitute a subgroup. According to Rodgers, “many
more will be vulnerable to poverty by virtue of an insecure or irregular labour force status: for instance,
many types of casual workers, or the erratically self - employed" (1989: 5).
5 The Expert Group of the Planning Commision had given Rs. 162.2 as the per capita monthly poverty
line expenditure in 1989-90 for urban areas (EPW, 1994 : 1233). The estimates of poverty in Bmbay based
on the official income norm is lower than for other urban areas. L. Deshpande et al estimated that 16per
cent of Bombay's population was below the poverty line in 1983 (1990 : 52-53). According to the 1989
household survey by ORG, 27per cent of households in the Bombay Metropolitan Region had a household
income of less than Rs. 1,290 per month (at 1989 prices), the income level taken as the cut-off to identify
poverty in 1989.
16
AILMENTS AND THE NEED FOR HOSPITAL OPD SERVICES
What are the health conditions for which the
lower income users seek hospital out-patient care?
Are these ailments and illnesses of a minor nature?
Could a large proportion of these have been handled
by a primary care provider or facility?
On the other hand, there has been a decline
in deaths due to diarrhoeal diseases, and among
infants due to causes of peri-natal mortality. Infant
mortality at 48 per 1000 live births is lower than
the urban -all-India (65 in 1990-92 period) and
urban Maharashtra (52/1000) levels. However, this
is unacceptably high for the country's premier
industrial city. It, in turn, reflects the vast disparities
between different social classes. This is evident from
the large variations in the infant mortality rate
(IMR) among different localities.
Bombay: Mortality and Morbidity Reliable and
systematic information on disease conditions and
morbidity is almost totally lacking for Greater
Bombay. The major causes of mortality are, however,
fairly well recorded as registration covers 90per
cent of all deaths. Mortality has been declining over
the past three decades but is currently higher (7.6
deaths per 1000 population in 1990-92) than the
urban all-India (7 per 1000) and the urban
Maharashtra (5.7) levels (MCGB, 1991 & 1992-93;
Economic and Political Weekly,1994b:1302). Within
this declining trend, deaths due to degenerative
conditions, specifically ‘heart diseases' and ‘heart
attacks', have been intensifying. At the same time,
deaths caused by major infectious diseases of the
respiratory tract — pulmonary tuberculosis,
pneumonia and broncho-pneumonia — have hardly
shown any decline in the last decade (Fig. 4.1.
MCGB,Public Health Department, 1980,1987 &
unpublished data for 1991). These diseases together
are responsible for the higher than average
mortality in the city zone (10.5 per 1000 in 199092) as against the suburbs (7/1000) and extended
suburbs (6\1000.) MCGB, Public Health Department
1991 & 1992-93).
Higher than average infant deaths continue
to take place in the highly congested industrial
wards, such as Chembur (M/E) in the eastern
suburbs with a rate of 65 per 1000 in 1993 and
Parel (F/S)in the city zone (60/1000). In contrast,
the elite western suburb of Bandra (H/w) and
Malabar Hill (D) in the city had a low rate of 31
infant deaths (MCGB, Public Health Department,
Unpublished data for 1993). At present the focus
of public health concern in the Bombay Municipal
Corporation appears to be almost exclusively on
child survival (and family planning) as a result of
the India Population Project-V (IPP-V) funded by
the World Bank. The Socio-economic Review also
argues that any improvement in mortality levels in
Bombay will depend upon reductions in infant
and maternal mortality (0.5 per 1000 live births)
(CRD, 1994:17). 1
Figure 4.1 : Leading Causes of Mortality in Greater Bombay
25
20 .
15 .
10 .
5 .
0
1978
1984
1991
■ Tuberculosis
■ Pneumonia/BronchoPneumonia
■ Perinatal Mortality
■ Bronchi tis/A st hama
□ Heart Attacks/Heart Diseases
II Malignancy
■ Diarrhoea) Diseases
17
illnesses seen in Dispensaries, nevertheless, points
to a large load of infective and parasitic diseases
and respiratory disorders ( Appendix B Table 3).
More recent records from eight dispensaries in the
F/S ward within which KEM Hospital is located
shows no change in the pattern of illnesses for which
people, and largely the poor and low income groups,
are seeking basic care. Such institutional morbidity
data can be used to improve preventive services in
the locality served by a dispensary; for instance,
the huge load of diarrhoeal diseases should direct
public health activities towards improving the
sanitation and water supply in the low-income
neighbourhoods. The application, if any, of this
data to direct the local (ward-level) public health
measures is not indicated in the annual reports arid
bulletins of the public health department.
It is obvious that the pattern of mortality is
a mixed ohe. ThFre is a growing share of
degenerative conditions and a continuing large load
of communicable diseases and infections arising out
of highly congested and polluted work and living
environments. Acute respiratory infections (ARIs)
were also the largest cause of infant deaths in 1991.
There are 'dlso large differentials between the poor
and affluent sections of the population although this
can be judged only on the basis of mortality pattern
according to wards.
A much greater focus on the health needs of
the urban poor is required from the public health
authorities. As pointed out by Rammasubban et
al., the decline in mortality has not led to an
equalising in the different mortality levels in
different localities. Large differentials exist in TB
and heart disease mortality. In 1991, the deaths
due to TB were four to five times higher in the worst
affected inner city E (Byculla) and F/S (Parel) wards
compared to the less affected localities on the
western seaboard (H/w. P/S and R/S wards). Even
in the case of heart diseases considered as a disease
of affluence, the industrial wards (E, F/S and F/
N) had mortality levels comparable to the elite
localities (D, K/W and H/W). The range in infant
mortality between the worst and the best wards is
dboUt two to one.
HThese are substantial
differentials when one considers that we are
recording them by ward, not by social class, and
that wards consist of very large population: from
300,000 in the H West to 560,000 in M, for
example. "(Ramasubban and Crook, 1992:23-24).
However, since the majority utilise private
practitioners for their basic and short-term care,2
the data from public dispensaries may not capture
the range of conditions for which people need
primary and secondary care. The presence of a
large private medical sector handling the bulk of
out-patient care complicates the collection of
morbidity data. Leave alone statistics on general
morbidity, even the load of communicable diseases
is probably under represented in the official
statistics. The rising cases of malaria in recent years
has highlighted the neglect of private practitioners
in notifying these to the Public Health Department.
Under the BMC Act 21 diseases have to be notified
to the municipal authorities to enable them to
undertake prevention and control measures.
Morbidity Profile of Hospital OPD Users
Alongside the focus on child survival, a
greater urgency is needed in tackling the large
load of communicable and respiratory diseases.
Unfortunately, there is very little data on the
changing trends in morbidity. There have been no
large community surveys designed to document
morbidity patterns. Some trends are shown in studies
on utilisation of health care services in Bombay.
For instance, a survey of 1,257 households (8,015
population) spread over three municipal wards,
covering Mahim-Dharavi and Bandra, was
conducted in 1989. It showed that, on an average,
there were 5 to 6 new illness episodes (of short
duration) per 100 persons in the community every
14 days. About 89per cent of these short-duration
illnesses consisted of fevers, cold and other infectious
conditions and aches and pains (Yesudian, 1990).
The specialist OPDs of public hospitals do not
maintain any medical records and little is known about
the morbidity profile of these clinics. The present
study looked at the range of ailments, diseases and
disabilities for which people approached the specialist
out-patient services of the public hospital. Institutional
morbidity data helps to identify the prevalent problems,
illnesses, disorders and emergencies for which the
urban poor and lower-income groups seek health care
(Bannerji D., 1984).3 Self-reported and self-perceived
illnesses define the actual demand for health care
services, including the public hospital out-patient
care.To meet this demand effectively, specialist out
patient services in the hospital need to act as support
and referral services within an integrated health care
system. A common perception about the public
hospital out-patient services is that they are heavily
utilised by people with minor ailments or problems
needing good general care.
The Public Health Department of the
Municipal Corporation also publishes data on the
symptoms and conditons recorded for new patients
seeking treatment at the General Dispensaries.
Keeping in mind the very uneven quality and
reliability of these records, the pattern of fresh
The present study explored both these issues.
It identified the illnesses and disabilities most
18
commonly handled by these OPDs. It also broadly
assessed the level of health care — ie. basic general
care, specialist and super-speciality care — needed
to treat these conditions.
Among the diagnosed conditions, tuberculosis ranked
first in Medicine (31 per cent) and Paediatric
Medicine (26 per cent) and third in General Surgery
(11 per cent). An overview of the major conditions
seen in these OPDs is presented in Table 4.1. A
detailed discussion of the profile of conditions seen
in each OPD follows in the next section.
Morbidity and the level of care needed: There
were over two hundred different symptoms which were
being considered by the doctors attending the out
patient departments of Medicine, Surgery, Paediatric
Medicine and Gynaecology - Obstetrics. For each
OPD, a profile of the main symptom or condition
for which people sought treatment has been developed
on the basis of the person’s own description. This
is complemented by the profile of confirmed
diagnoses available from the patient’s case sheets.
Being a teaching hospital, the case sheets had lucid
clinical notes, confirmed diagnoses were available for
one-third (33 per cent) of all patients interviewed and
in its absence, ‘impressions’ or ‘provisional diagnosis’
were put down in another 26 per cent of cases.
The level of care needed to treat the problems
seen in the OPDs was also assessed (Table 4.2). This
was based on the actual management of the patients’
condition by the attending doctors themselves
(Appendix A, Table 7). Each OPD was handled by
a unit of specialists and resident doctors of the
concerned department. The only exception was the
General Medicine OPD. In the latter all new patients
were being handled by a General OPD managed by
the Department of Preventive and Social Medicine.
The former screened all new patients in an effort to
reduce the load on General Medicine and ensure
speedy treatment and accurate referrals.
The hospital OPDs handle a large load of
poverty-related infectious and parasitic diseases. In
the range of diagnosed conditions, diseases due to
infections took up over one-fourth (27 per cent) of
all OPD cases (Appendix A, Table 6). These ranged
from about 40 per cent in the Medicine and Paediatric
Medicine OPDs, to 20 per cent in the Surgery OPD
and 12 per cent in the Gynaecology OPD.
Tuberculosis was by and large the most common
disease among the infectious conditions. It was
confirmed in as many as 20 per cent of the patients
who were given a diagnosis. It was also the most
frequently investigated condition (17 per cent of all
provisional diagnosis). This points to the magnitude
of tuberculosis cases being diagnosed and treated in
the public hospitals.
People needing specialist (secondary) or
tertiary care were all those who (a) underwent higher
level investigations, (b) were hospitalised or (c) were
referred to other clinical specialities and
superspecialties in the hospital. Those users who were
only given treatment were assessed as needing basic
(primary) curative care. Basic medical care is available
in the municipal dispensaries or provided by private
general practitioners. The majority of these cases
were treated and disposed at the first visit itself. Also
included in this category were a small proportion of
people who underwent basic (1st level) investigations
(Appendix A, Table 9). Only a few of these routine
tests are available in the upgraded municipal
dispensaries.
Table 4.1 : Ranking of Confirmed Diagnoses in OPDs
OPD
First
Second
Third
General Medicine
Tuberculosis
Hypertension
Lower Respiratory
Tract Disorders
Paediatric Medicine
Tuberculosis
Seizure Disorder
Lower Respiratory
Tract disorders
General Surgery
Minor Surgical
Conditions
Anorectal
Conditions
Tuberculosis
Gynaecology
Infertility
Pregnancy
Menstrual Disorders
19
Table 4.2 : Level of Care Needed by OPD Users
Level of
Care
Medicine
OPD
n = 700
%
Paed. Med
OPD
n= 190
%
G. Surgery
OPD
n = 459
%
Gynaec.
OPD
n= 158
%
All
OPDs
n = 1507
%
Primary
Secondary
Tertiary
38
57
5
45
42
13
25
67
7
8
68
23
32
60
9
(primary) care were more frequently seen in the
Medicine and Paediatric Medicine OPDs. These
conditions added to the overloading of the specialist
OPDs, which could hamper the doctors in spending
sufficient time on serious cases. Ill patients were
severely inconvenienced by the long waiting time and
the consequent tensions in the waiting areas.
The majority of the people seen in these OPDs
needed secondary level out-patient care. This was
also evident from the pattern of diagnosed conditions
in each OPD, as discussed in the following section.
A closer scrutiny of the clinical notes showed that
many of the patients needed specialised services for
investigation and stabilisation of dosages. These
patients could be subsequently referred to a lower
level facility for follow-up and long term management.
Hardly 5per cent of the patients were admitted from
the OPDs (Appendix A Table 7). The latter were
functioning as consultant clinics which, in the public
health system, are centralised in the hospitals. Until
some decentralisation is undertaken, public hospitals
will be burdened with a heavy load of out-patients
seeking treatment for major diseases and disablities.
A General OPD was established in the Medicine
OPD by the Department of Preventive and Social
Medicine to redress some of these problems. This
OPD was able to reduce the load on the Medical
specialists by screening all new patients. One third
(34per cent) of the new cases were given treatment
and disposed at the first visit. Another 29per cent
were referred to the other clinical departments in the
hospital (Appendix A Table 8). Only 6per cent of
all referred cases needed to see the medical specialist.
This pattern confirms the need for a referral system
to relieve the load on the specialist services.
Overall, 9 per cent of the patients required the
opinion of superspecialists and sophisticated (3rd
level) investigations. The Gynaecology OPD was the
most frequently used for tertiary level services
associated with a teaching hospital.
1. General Medicine and General OPD
People reported to the General OPD and
General Medicine OPDs with a wide range of
symptoms. Over half (59per cent) of the complaints
The level of care provided varied among the
different OPDs.
Conditions requiring general
Chart 4.1: Symptoms and Related Diagnoses
(in ranked order)
Chest Pain
Cough
(including cough with fever & cough
cough with breathlessness)
Fever
Abdominal
Pain
(7%)
(16 %)
(14 %)
(9 %)
Tuberculosis
Tuberculosis
Tuberculosis
Tuberculosis
Lower Respiratory
Tract Infections
Upper/Lower Respiratory
Tract Infections
Upper/Lower
Respiratory
Tract Infections
Acid Peptic
Disease
Hypertension/
Ischamic Heart Dis.
Asthama/ Chronic
Obstructive Pulmonary Dis.
Malaria
20
Figure 4.2: General Medicine
Main Symptoms
n = 747
Chest pain
Cough
Fever
Abdomen pain
Joint pain
Headache
Weakness
Breathlessness
Swelling body/ft
Loose motion/vomiting
Bodyache
Fits & seizures
Parasthaesia
Asymptomatic
Others
% to total
■
■
■
■
■
■
■
H
■
■
■
|
H
■
B
MM 16
15
■ 9
7
7
6
5
4
3
2
2
2
2
3
16
u
4
2
0
12
10
8
6
16
14
Others include oedema, injuries, urinary complaints, eye complaints and lumps.
Confirmed Diagnoses
n = 196
% to total
■ 38
Communicable Dis I
21
Cardiovascular Dis
16
Resp. Tract Dis
CNS Dis.
6
GI Tract Dis.
Endocrine Dis
Urinary Tract Dis.
Dis. of bones & joints
12
Others
x
0
5
10
15
20
25
30
35
40
Others include SLE, injuries, anaemia, varicose veins, mental illness
I
being sought in the Medicine OPD is presented in
Figure 4.2 (Appendix A Table 10). Even among other
cases in which the diagnosis was not clinically
confirmed, the trend of illnesses largely followed the
same pattern as the diagnosed ailments. Surprisingly,
the cases of diarrhoeal diseases in these OPDs were
low as compared to the prevalence in the city and,
particularly, the large numbers recorded at the
municipal dispensaries.
related to chest pain, cough, fever, abdominal pain,
and aches and pains (Figure 4.2). The most common
illnesses diagnosed in the case of these symptoms
are presented in the chart below (chart 4.1).
Overall 47 per cent of the patients were
accorded one or more diagnosis, although
confirmation was available for 35 per cent of the
people. The range of diseases for which help was
21
to the hospital OPD. The remaining complaints such
as ‘hole in the heart’, ‘hole in the palate’, ‘inability
to walk’, ‘failure to thrive’, ‘small head’, ‘big head’,
‘high blood pressure’ \Vere fewer in number; yet they
indicate the wide range of problems affecting children
using the OPD services of the public hospital.
The trend in the illnesses remained the same
over the different seasons. However, among some
of these conditions variations occurred. For instance,
people reporting with chest pain related to upper and
lower respiratory tract problems were maximum in
the winter (January) season and least during the
monsoons (July-August); on the other hand, fever cases
due to malaria were highest in the rainy season.
Diarrhoeal diseases hardly showed up during the latter
season.
Overall 37 per cent of the paediatric patients
had a confirmed diagnosis. The range of diagnosed
conditions is presented in figure 4.3 (details in
Appendix A, Table 11). The morbidity pattern shows
a large load of infectious conditions (44 per cent)
and respiratory problems along with chromosomal and
congenital conditions, malignancies and seizures.
l^vel of care : From a range of almost one hundred
ailments varying from infectious and degenerative
disorders to nutritional diseases, injuries and
congenital disorders, a little over one-third (38 per
cent) of the people needed primary level care. These
were patients who were only given treatment, were
following-up at the OPD for collection of drugs
and all those who underwent only first level
investigations. For instance, among the new cases
(39 per cent) that were sent for investigations, only
10 per cent underwent first level investigations. The
ailments needing primary level care included upper
respiratory tract infections, skin diseases, worms, acid
peptic disease and cases of fever (Appendix A, Table
7). Among all the new cases, 34 per cent were only
given treatment and disposed by the General OPD.
The infectious conditions seen in this OPD
showed some seasonal variation. Gastro-enteritis was
significant in April (the summer season) while mumps
and whooping cough were reported only in the
monsoon season. Respiratory tract infections were
highest in the colder season.
Level of Care : The Pediatric Medicine OPD was
very similar to the Medicine OPD in that it handled
the full range of conditions requiring primary,
secondary as well as tertiary level care. One-third (32
per cent) of the children were checked and given
treatment without being investigated or called for a
follow-up. These children, including those advised only
first level investigations (13 per cent), mostly needed
primary level care for conditions like upper respiratory
tract infections, diarrhoeas, worm infestations and
common skin ailments such as scabies. Other
conditions that required only basic care were
constipation, urinary tract infection and nutritional
disorders.
Just 5 per cent of the patients (both old
and new) needed tertiary level care in the form
of super-specialist opinion and third level of
investigations. These were cases of Systemic Lupus
Erythmatosus (SLE), Aquired Immuno-deficiency
Syndrome (AIDS), coronary heart disease (CHD),
seizure disorders, transient ischemic attacks (TLA) and
complicated cases of ischemic heart disease (IHD).
A small number of children required tertiary
level care. They constituted 13 per cent of all patients
with the diagnosed conditions ranging from
chromosomal, congenital and hereditary disorders, to
seizure disorders and infections such as toxoplasmosis
and HIV. The wide range of higher (3rd) level
investigations ordered in this OPD reflects the above
pattern of diagnosis. It is obvious that the Pediatric
Medicine OPD was having to handle a very wide range
of complex cases even though the number of patients
requiring tertiary level care was small.
Only 2 per cent of the patients were
hospitalised. The majority (59 per cent) of the people
needed secondary level out-patient care offered by
this OPD. However, after investigations, consultant
opinion and stabilisation in the hospital OPD, more
than half these cases could be followed up at a general
medical level facility, such as the municipal dispensary.
2. Paediatric Medicine OPD
Children between the ages of one month to
12 years were brought to this afternoon OPD by their
parents, mostly mothers. They came with complaints
ranging from cough and fever (47 per cent of all
symptoms) to seizures (9 per cent), lumps, mostly
in the neck (6 per cent), diarrhoea and abdominal
complaints (figure 4.3). Again the numbers of
diarrhoea and vomiting were small. These constituted
hardly 5 per cent of the complaints, despite the effort
to document seasonal variations in illnesses. It would
appear that these health problems did not entail a visit
.Less than half the children seen in this OPD
(42 per cent) needed secondary level care. Chest
X-rays and Mantoux test were the most commonly
advised investigations. There was an obvious concern
and awareness among the attending doctors about the
magnitude of TB among children. About 15 per cent
of the cases needing specialist care could be followed
up at a lower level facility (dispensary) after the OPD
doctors had confirmed the diagnosis and stabilised
the treatment regimen.
22
Figure 4.3: Paediatric Medicine
Main Symptoms
n = 206
% to total
33
Cougl
14
Fever
9
Fits
5
Lumps
Loose motions
4
Abdomen pain
4
Weakness of limb?
4
Boils/ ulcer*
4
2
Urinary complaints
Others
20
0
5
10
15
25
20
30
35
Others include chest pain, headache, eye complaints. Swelling of body/ limbs, rashes
constipation, loss of appetite, failure to thrive and feeding difficulty
Confirmed Diagnoses
n = 70
% to total
44
Communicable Dis.
21
CNS Dis.
19
Resp. tract Dis.
Cong, /chromosomal Dis.
Cardiovascular Dis.
Others
20
0
10
20
30
40
50
Others include abscesses, boils, cellulitis, ulcer, nutritional diseases,
prematurity, vitamin deficiency, sepsis
who directs patients to one or another OPD. As
abdominal pain was collectively the most common
symptom over all the four OPDs, the related diagnoses
in the different OPDs is given in the chart below (chart
4.2). Lumps in the neck, axilla, groin, scalp, breast,
abdomin and extremities were the second most
common complaint followed by injuries and bums
3. General Surgery
Over half (55 per cent) the people visiting this
OPD came with complaints of abdominal pain and
lumps (figure 4.4). The prominence of the complaint
of ‘abdominal pain’ in the Surgery OPD is largely
due to the level of knowledge of the enquiry clerk
23
Figure 4.4: General Surgery
Main Symptoms
n = 521
% to total
33
Abdominal pain
Lumps
22
Injuries
8
Rectal pain/ bleeding
4
Chest pain
Urinary complaints
Joint pain
Inguino-scrotal pain
■■ 2
■■ 2
Boils/ ulcers
Flatulence/ indigestion
Swelling of body L— 2
Others
12
30
25
20
15
10
5
0
35
Others include cough, headache, vomiting, fits/ seizures, constipation, weakness of limbs
Confirmed Diagnoses
n = 163
% to total
20
Communicable Dis .
20
Minor surgical cond.
17
Gastrointestinal Dis.
17
Ano-rectal Dis.
9
Dis. of male genitalia
Hernia
6
4
Peripheral vasular Dis.
Dis. of urinary tract
2
Goitre
Malignancy
2
Injuries
2
2
12
Others
0
10
5
15
20
25
Others include lower respiratory tract infection (LRTI), gangrene, cervical/ other
lymphadenitis, fibroadenosis,ovarian cysts
one or more impressions marked on their case paper).
Figure 6 shows the pattern of morbidity (based on
diagnosed conditions) that characterises the General
Surgery OPD (see Appendix A, Table 13).
which were mostly of a minor nature. Although less
common, rectal bleeding, chest pain and urinary
complaints were significant and indicated specific
conditions.
Level of care: One fourth (25 per cent) of the patients
for conditions
such
required only primary level care f~.
---------- —
Overall 36 per cent of the patients had a
confirmed diagnosis (although nearly three-fourths had
24
Chart 4.2: Symptom ‘Abdominal Pain’ and Related Diagnoses In All OPDs
(in ranked order)
General Surgery
OPD
(33%)
General Medicine
OPD
(7%)
Paediatric Medicine
OPD
(4%)
Amoebiasis
Tuberculosis
Acid Peptic Diseases
Appendicitis
Hernias
Gastritis
Calculus
Tuberculosis
Acid Peptic Diseases
Worm infestation
Gastritis
Urinary tract infection
as amoebiasis, worm infestation, gastritis, acid peptic
disease, middle ear infection, minor injuries,
constipation, malaria, anxiety and neurosis. These
cases were treated and disposed off without
investigations or referral, or only underwent first level
investigation. No more than 7 per cent of the patients
in this OPD needed tertiary level surgical management.
These were mainly cases of malignancy,
cryptorchidism and thyroid nodule.
Gynaecology
OPD
(18 %)
Ectopic pregnancy
Cystitis
Cholecystitis
OPDs, this OPD was providing a larger amount
of superpecialist care and treatment. This was
indicated in 23 per cent of the conditions including
the treatment of infertility, primary amenorrhoea and
toxoplasmosis. Primary level care was needed in a
mere 8 per cent of cases while the proportion needing
secondary level care (68 per cent) was the same as
in the Surgery OPD. As a teaching hospital department,
the Gynaecology OPD was the most optimally used
for secondary and tertiary level care.
A relatively larger number of people seen in
this OPD (62 per cent) needed specialist opinion and
care. Surgery was advised in 8 per cent of all
diagnosed conditions and consisted of an equal number
of major and minor surgical procedures. 4
OBSTETRICS
All women were registered with this OPD
for their deliveries. The majority (75 per cent) of
the pregnancies were normal. Less than a third (31
per cent) of the women reported one or more
complaints. These included abdominal pain, fatigue
and weakness, aching limbs, anorexia, urinary
complaints and vaginal discharge.
4. GYNAECOLOGY OPD
The single most common and specific
complaint for which young women were approaching
this OPD was the inability to conceive (16 per cent).
An equally large number of complaints related to
menstrual problems such as menstrual irregularities,
heavy bleeding and painful menses. These conditions,
along with the need for a check-up for ‘missed period*
and the general symptom of ‘stomach pain’ constituted
two-thirds of the complaints for which women sought
the OPD services (figure 4.5).
Very few (4 per cent) had an additional
diagnosis other than pregnancy. However, 25 per cent
of the women had either a bad obstetric history, mainly
repeated abortions and still-births, or were having
problems with their current pregnancy such ^s heavy
bleeding.
The largest (60 per cent) proportion of women
had registered with the hospital in their 2nd trimester
of pregnancy, mainly in the fourth or fifth month
(Appendix A, Table 14). As 75 per cent had come
directly to the hospital, this was the average duration
of first contact for ante-natal care. One-fourth (26
per cent) had come in their first trimester (1-3
months) while a smaller number (14 per cent) had
first ANC contact in the last trimester (7-9 months)
of pregnancy. The utilisation of ANC services among
these users is an improvement over the pattern for
poor households in Bombay as a whole. A 1990
baseline survey of slum localities spread across the
city found that 74per cent of the women had registered
Diagnosis was available for 39 per cent of all
the women interviewed. Among these almost onethird needed treatment for primary and secondary
infertility (Figure 4.5; Appendix A, Table 12).
Pregnancy was confirmed in 21 per cent of the women,
the majority of whom had approached the OPD to
terminate their pregnancy. Only a small proportion
of the women (12 per cent) had sought the OPD
services for infectious conditions of the reproductive
tract, mainly lower reproductive tract infections and
pelvic inflammatory disease (PID).
Level of care: In comparison to the other three
25
Figure 4.5: Gynaecology
Main Symptoms
n= 190
% to total
Abdominal pain
Inability to conceive
16
Menstrual compl.
16
12
Missed period
7
For MTP
5
Urinary compl.
4
Lumps
3
Vaginal discharge
19
Others I
f
0
5
15
10
20
Others include recurrent obortion, repeated stillbirths, menses not began, vaginal irritation,
joint/ limb/ backache
Confirmed Diagnoses
n = 62
% to total
Infertility L
21
Pregnancy
10
Menstrual Disorder
6
Prolapse ■■■
For tuboplasty
6
■■■■
5
Ovarian cyst
5
Lower genital infs. ■■■■
Ectopic pregnancy
3
PID
3
19
Others
I .......
0
5
15
10
20
/
25
30
Others include TB, toxoplasmosis, abscesses, RV fistula, diabetes, hypertension, chromosomal
disorder, still-birth
I
26
35
for ANC in the last trimester of their pregnancy. As
many as 11 per cent did not have any ante-natal care
(Yesudian and Parsuraman, 1990: 80-81).
disease among both the diagnosed cases and those
under investigation. The substantial use of the OPDs
for the diagnosis and treatment of the long-term
communicable diseases highlights several concerns,
namely (a) a need to assess the performance of the
national programmes and disease control activities
being implemented by the public authorities in
Bombay; and (b) the role of public hospitals in
implementing the national programmes such as TB
control.
Discussion: The public teaching hospitals were set
up in the city region of the old Bombay city between
the 1840s and 1960s. They functioned as both general
and super-speciality hospitals. Today they centralise
a vast range of services — secondary and tertiary
care— under one roof. The current study has looked
at the morbidity profile of selected specialist OPDs.
These OPDs on the one hand, are the more commonly
used first level referral services. On the other hand
they also help to refer patients to the tertiary services.
Besides tuberculosis, respiratory tract
infections, chronic disorders and certain non communicable ailments — acid peptic diseases
(APDs), hypertension, seizures, menstrual disorders
and sterility —constitute a large load of the problems
handled by these OPDs. Some of these conditions
need specialised services for investigation, consultant
opinion and stabilisation of dosages. Subsequently,
these could be referred to a lower-level facility for
follow-up and long-term management.
The load of out-patients attending the hospital
has been increasing every year. As the study showed,
these OPDs cater to the entire range of conditions.
Among these about a third of the conditions could
be handled by a peripheral health unit or a general
practitioner. This would ease the overloading of the
Medicine and Paediatric Medicine OPDs in particular.
These OPDs, barring the Gynaecology OPD,
play only a small role in referring patients to the
tertiary care services. These are functioning as
specialised services for the majority of illnesses but
are also having to handle a fair number of simple
ailments. This indicates the need to strengthen the
first level of care and to establish a well functioning
referral system.
However, more than half the people seen in
these OPDs needed consultant opinion. This indicates
a limited scope for decreasing the load on public
hospitals so long as specialist services are centralised
in them. Infectious conditions formed a substantial
load of illnesses, with tuberculosis being the dominant
Notes:
1.
In 1984 the under-5 child mortality accounted for 26% of total deaths. In 1993 its share had come
down to 14%. There is no data at present to show that this decline is due to the control of vaccine
preventable diseases targeted by the Universal Immunisation Programme (UIP) and the control of
diarrhoeal diseases. Around three-quarters of these deaths (73% in 1991 and 77% in 1993) occur
within the first year of life. In 1991 the main causes of infant deaths were prematurity of the new
born (30% of total infant deaths), APIs (16%) and diarrhoeal diseases (6%). Except for some health
education programmes for the latter disease, the current child survival programme of the public health
department hardly addresses the other main causes. With 44% of all infant deaths concentrated in
the first week (perinatal mortality) and a high rate of still births (19 and 23 per 1000 live births
respectively), it is obvious that maternal health, quality of ante-natal care and availability of good
institutional facilities for child deliveries need to be addressed. (Unpublished data for 1993 obtained
from the Public Health Department, MCGB).
2.
See the following section on Utilisation of Health Services by OPD Users.
3.
Institution based data tends to miss out the unarticulated health needs of marginalised groups such
as women, the elderly and the abject poor.
4.
Major surgery was advised for hernia, hydrocele, appendicitis, cholecystitis, gall stones, cryptorchidism
and goitre. Minor surgery included piles, paronchia, abcess, cysts and small benign tumours of the
skin/ subcutaneous tissue such as lipoma and exterior ganglion.
27
FROM ONSET OF ILLNESS TO SEEKING THE OPD
A very wide range of health problems had
brought people to the hospital OPDs. How did these
people handle their illness or discomfort at the onset
of their problem? Did they seek general medical care
before turning to the hospital specialists?
Multiple Providers, No Integration or Planning of
Services: The metropolis has an abundance of
curative facilities and medical providers. The public
health care sector has a large presence, having
benefited from the investment made by the most
wealthy municipal corporation in the country, as
well as the State and Central Governments.' This
investment has translated into 47 general and
restricted public hospitals and a network of lower
level outpatient facilities and community outreach
services (Appendix B, Table 4)
Among all the cities, although the profile of
services for these have not been documented
systematically, Greater Bombay probably has the
largest network of public services. Within the public
sector the Bombay Municipal Corporation (BMC)
is the dominant provider, spending 10 per cent of
its total revenue expenditure on public health.
Seventy per cent of this public health budget is
spent in providing patient care services, including
primary preventive care, and the control of
communicable diseases.
This is a statutory
responsibility and also includes a smaller
component of regulatory activities to ensure public
health and safety and the control of air pollution
(Appendix B, Table5). Water supply and sanitation
are administered by separate departments of the
corporation.
dispensaries and 176 health posts (Appendix B,
Table 4). No referral system integrates this
extensive network of public medical facilities. In
the BMC and state government facilities, almost
all levels of care except for a few tertiary care
services, can be openly accessed by the general
public. Open access to free and subsidised services
is meant to serve the medical needs of the poor
and lower income groups.
The weakest component of the public system
are the first level care services. Only 15 per cent
of the public health budget is spent on dispensaries,
health posts and maternity homes. These, in turn,
lack co-ordination and do not have active back-up
support and linkages with the hospital system. 2
The greater load of patient care is borne by the
public hospitals in Bombay. Another problem facing
the public health services isthat of meeting the needs
of the rapidly expanding suburban population. This
has led to the expansion of small 100-bed general
hospitals and health posts rather than organising
a comprehensive provision of primary health
services.
The bulk of curative care is, however,
concentrated in the private sector consisting of the
private practitoners, nursing homes and the large
trust hospitals. Very little data is available on the
number and types of the private practitioners
practising in Bombay. These are the largest and
most visible private health services, are used widely
by all sections of the population and are known
to vary greatly in the quality and standards of care
provided. However, the regulatory powers of the
state medical councils and the local authorities are
ineffective leaving the people, particularly the poor,
to bear the brunt of uncertain quality and
commercialised practice patterns (Duggal and
Nandraj 1991:5-7; Yesudian, 1995).
The public health care services conform to
the three levels of care. At the top of the health
care services hierarchy are the five teaching
hospitals (medical and one dental) and attached
medical colleges, four of which are owned by the
BMC. There are also five special and infectious
diseases hospital of the Corporation, as well as
hospitals belonging to the State and Central
Governments and the Employees State Insurance
Scheme (ESIS). A large number of the latter are
restricted to occupational and employee groups
largely belonging to the organised sector workforce,
and run parallel to the general services.
By 1995, 96 per cent of all in-patient facilities
and 49 per cent of beds were privately owned
(Appendix B, Table 4). Even this data is a gross
underestimate of the rapidly growing nursing home
sector. The majority are very small nursing homes
with a capacity of 4 to 10 beds operating out of
residential areas.3 Criticising the complete lack of
regulation and monitoring of private hospital
services by the BMC, Duggal and Nandraj point
out that many of these facilities operate without
being registered.
These exist in unhygienic
conditions, operate without basic amenities and
equipment and lack qualified staff (Duggal and
The intermediate and lower level facilites for
the general public are provided by the municipal
corporation. These include 15 secondary or
•Peripheral’ hospitals in the eastern and western
suburbs, 27 maternity homes, 159 general
Nandraj, 1991:5-7).
28
I'
Only an estimated 21 private hospitals have
a bed strength of over 100 beds. Among these are
the very expensive hospitals owned by business
houses but registered as public trusts and research
centres, reflecting the trend towards the
corporatisation of health care in urban centres.
Along with this is the increasing capital intensity
of health care as advanced medical and diagnostic
technology is concentrated in these hospitals and
the growing numbers of diagnostic centres, without
any planning or assessment of need (Jesani and
Ananthram, 1993). Their services are unaffordable
for the majority of the population — the poor and
low-income groups.
drug therapy. Very few (3 per cent) mentioned
medicating themselves or using home remedies.
Barely two or three said that they had used traditional
healers or cultural and ritual practices. The
proliferating drug stores, private practitioners,
pathology laboratories and nursing homes in the urban
setting and a growing presence of practitioners in rural
areas would appear to have strengthened the appeal
of modern medicine. Young workers in unorganised
sector jobs would seek strong drugs giving quick relief
as they had little protection against the loss of income
or employment due to illness. Unable to improve
their work and living conditions, the urban lower
income groups depended on medical care to cope with
frequent infections and environmental hazards.4
Undoubtedly the poor in Bombay have access
to one of the best developed health care
infrastructures in the country. In fact 28 per cent
of total beds in the state of Maharashtra are located
in Bombay which accounts for only 13 per cent of
the state’s population. Yet their ability to benefit
fully from these services varies greatly. The rapid
and haphazard expansion of private services has
escalated the cost of health care and the scope for
malpractices. Health care as a business has also
marginalised the public sector services as medical
professionals and para medical staff, trained at
public expense, are skimmed off by the private
services. It has entrenched a dual health care system
whereby the public teaching hospitals which
constitute the apex facilities of a health care
infrastructure are viewed as services only for the
poor. This affects both the quality of care as well
as the capacity of the public hospitals to play
effectively the role of back-up referral and support
centres.
Prior medical treatment: Only a little over
two-thirds (70 per cent) of the users had taken
treatment before approaching the hospital OPD (Figure
5.1). The majority (49 per cent of all users) had
sought general —basic or primary— care. The overall
pattern was to use a single practitioner or facility and
then change over to the hospital OPD. A smaller
proportion (16per cent) had also used higher level
providers, such as specialists, hospitals and nursing
homes, or undergone investigations (14 per cent of
those with problems lasting upto a year) prior to the
OPD.
Shifting between a variety of providers was not
common. Only 10 per cent of the users had
approached more than two providers prior to the
hospital OPD. Access to a reputed, well-equipped
public hospital appeared to reduce the experimentation
with providers and thereby,enabled them to manage
the costs of private care. 5
Duration of the problem: The average
(median) duration of symptoms at the first OPD visit
ranged from nine days in paediatric cases to one to
two months, respectively, in the medicine and surgery
or gynaecology cases. How ever people from outside
Bombay had come with conditions and symptoms that
had been persisting for four to six months (Appendix
A, Table 14).
Utilisation of Health Care Services by the OPD
Users
Pattern of Health Care Seeking
Priority to curative care: The people we met
in the long queues outside the hospital OPDs had
sought fairly quick treatment and relief for their
current ailments. Most parents had approached a
medical provider within a day of their child falling
ill. The adult users had sought treatment within three
to five days of the onset of their illness. These were
either, fresh episodes and new problems or the
aggravation of a chronic condition The exceptions were
women with gynaecological problems from outside
the Bombay Metropolitan area. They had waited upto
one and half months before they tried to have their
problem attended to (Appendix A, Table 14).
Providers at First Contact, Costs and Reasons for
Change of Facilities
Direct Use of the hospital OPD
Despite the extensive network of the urban
public health services almost a third (32 per cent)
of the Bombay-Thane users had come directly to the
KEM hospital OPDs for their current problems.
Among the people residing outside Bombay and Thane
who had come directly to this hospital, most were
People apparently preferred medical care and
29
and sending money back to the village,
private treatment for a serious illness
would be expensive. Without consulting
anyone Ajit Kumar decided to directly
approach the Medicine OPD. He was
put on a seven day course of antibiotics
for his urinary infection by the General
OPD. A chronic smoker, he was also
treated for the next one and half months
for chronic obstructive pulmonary
disease by the medical specialist to
whom he was referred. By the sixth visit
Ajit Kumar had recovered. Although he
had escaped the expense of prolonged
private care, he nevertheless had to buy
medicines worth Rs 250 apart from
foregoing wages of Rs 40 each time he
attended the OPD.
visiting relatives or temporarily residing in the city
when they had fallen ill and were brought to the OPDs
(Figure 5.1).
The direct use of the hospital out-patient
services was higher amongst the paediatric (37 per
cent) and gynaecology cases (39 per cent). Parents,
whose children were bom in this hospital or who had
been treated satisfactorily in the past, reported having
developed strong bonds with particular doctors and
becoming long term users of this OPD. Women
said they had often followed the advice of relations
and friends in seeking out the gynaecology OPD
as the department had a reputation for treating
specific conditions such as infertility (Appendix A,
Table 15).
On the other hand, residence in the vicinity
of the hospital, i.e. the F/S and the adjoining labour
class localities of F/N wards, was a significant factor
in the direct use of the Medical OPD and, to some
extent. General Surgery. The availability of a ‘free
hospital close to their residence did not necessarily
mean regular use of the OPDs. Many people
distinguished between minor and more serious
ailments and chose providers accordingly.
(Constructed from the interview schedule)
There were others who had little idea of the
recurring nature of their stomach pain. They had tried
various providers in the past and during the current
episode of their chronic ailment had decided to try
out the hospital services. Another acute bout of
gastritis or amoebiasis, and they might go to some
other practitioner suggested by friends.
Experiencing burning micturation and
pain in the chest Ajit Kumar was sure
that this was a “major” ailment. For
minor illnesses like cough, cold, fevers
this young tailor in the Gopal Hager
basti, Worli, was used to seeking
treatment from a private “family” doctor
of long standing. But this seemed
serious, needing a proper check-up. For
someone earning Rs 2,000 per month
For others, the aggravation of the chronic
condition would come at a time when their finances
were low and they would try out the free services
of the hospital. Another recurring condition was fever.
Those who had been treated for malaria in the recent
past sought out the hospital, anxious that the problem
had not been adequately treated.
Figure 5.1: Provider At First Contact (for the current problem)
Other Users
Bombay-Thane Users
266
n= 1392
Pvt. Practitioner
Pvt. Practitioner
56%
51%
.
Pvt Spl./
Hospital
Mudc. DispJ
Public
13%
6%
KEM
Hospital
MuncV Govt.
Pvt. SplJHosp.
Hospital
19%
Public Dispensary
6%
5%
4%
KEM Hospital
MuncTGovt.
Hospital
32%
8%
30
Poor utilisation of public primary care facilities:
others who had.
Many of the simpler chronic conditions
and short term infections could be handled cheaply
and, probably, more effectively at the primary level
facilities such as the municipal dispensaries. It would
allow for quicker follow-up compared to the hospital
OPD where people returned only after a week to
consult the unit that first saw them. It would also
allow for a sustained relationship with a doctor who
would be in a better position to explain the problem
to the patient. Educating people to control their
condition, along with giving them drugs to relieve their
symptoms, would be easier at this level of care.
However, the primary care facilities in the public
sector did not figure prominently among the providers
people had initially approached. Hardly 5 per cent
of the OPD users had approached the municipal general
dispensaries at the onset of their problem. Neither
did the utilisation of this facility increase among those
who changed a number of providers before reaching
the public hospital.
This is despite the fact that 55 per cent of the
users in Mumbai-Thane were aware of a municipal
or government dispensary in the vicinity of their
residence. Most of them could even identify the
location of the dispensary and 40 per cent said that
it was within walking distance from their home. Not
only did they know of this facility, but 41 per cent
also said that they had used the dispensary for
themselves or for family members sometime in the
past (Appendix A, Table 16).
A little under half the urban users (45 per cent)
were either unaware of such a facility or said that
no dispensary was located close to their place of
residence.
Obviously, it is not the public primary services
that are offloading their users on to therowded public
hospital OPDs. At the same time little is known about
the utilisation and erformance of the urban primary
care units in Mumbai’s public health sector. In terms
of utilisation, a survey of households in the vicinity
of theKEM hospital i.e. the Naigaum matemityhome
area, found hardly 3-4 per cent of the people using
dispensaries for their short-term or long-term
illnesses. The majority used private clinics, public
hospitals and the ESIS facilities (Yesudian C.A.K.,
1989a).6
The peripheral health units such as public
dispensaries can handle the bulk of the health needs
of the community in which they are located. However,
there is hardly any information on how these units
are functioning. We present a profile of the network
of primary services available at the level of the
municipal ward in the next section.
Even among those coming from outside
Mumbai, hardly 6 per cent had contacted the rural
primary health centre or a government dispensary. As
other surveys have shown, the hospital clinics and not
the primary care units are the main source of treatment
for all those who turn to the public health services
for their health needs (Government of India, National
Sample Survey Organisation, 1990). 7 Overall 43per
cent of all users had first contacted the public sector
health services with the overwhelming preference
being for the hospital OPDs.
Very few, however, ventured any opinion about
this facility which gives free treatment and drugs (if
available). Some of the reasons people mentioned
for using or not using dispensaries are given below.
The negative perceptions were voiced by many who
had not used the dispensaries themselves but who knew
Use Dispensaries:
- for "minor illnesses" such as cough. Colds,
fevers, scabies, skin infections, ear problems
- for "minor injuries” like cuts, wounds,
rat bite
- for joint pains
- for breathlessness
- for children’s illnesses
- for immunisation of children
- for collecting TB drugs
- for injections
Do Not Use Dispensaries:
- medical care is unsatisfactory
a) medicines are ineffective
b) do not check properly
c) medicines not available
d) doctors not qualified
- no equipment, no facilities, very small
- long waiting time, too crowded
always a queue
- dispensaries are dirty
- timings are inconvenient; dispensaries
are not open after 4 p.m.
- distance is the same for the dispensary
and KEM,
31
100
1 H
1UU
9
o
al., 1993). Most OPD users (61 per cent), too,
maintained that they and their families depended on
private (general) practitioners for their routine care
and minor illnesses. “Always go to the private” was
the common response of even those who had come
directly to the hospital OPD for the current problem.
Dependence on private practitioners
The provider most commonly contacted by both
the urban and rural users (50 per cent) was the
ubiquitous private practitioner. In the brief period
of our interview, it was difficult to ascertain the
qualification of these practitioners or the system of
Most people
medicine that they practised,
distinguished between the ‘ordinary’ (general) doctor
whom they frequently approached for their ailments
and minor problems and the ‘big’ (specialist) doctor
to whom they were sent for investigations by their
practitioner. The majority (34 per cent) had come
to the OPD after using a single (general) practitioner.
Only a few had changed to a second practitioner (8
per cent) or higher-level private and public providers
(7 per cent) prior to the OPD.
A significant minority had built up long term
relationships with particular practitioners. These were
called the ‘family doctor’ or referred to as the ‘same
doctor’ and, invariably, the practitioners’ names were
cited. Among the rest who said they “always go to
the private” the pattern of using this provider varied
widely. Some only made a single contact and one
time payment for medicines before changing over to
the hospital OPD.
Feeling feverish, Rajesh had gone
immediately to a local practitioner in
the Mahim bazaar where he worked as
a cleaner of glass. The latter charged
him Rs 18/- for some tablets which
provided him a "little rest but then the
same problem recurred". Within three
days Rajesh had approached the
hospital. At the General OPD, he was
put on malaria treatment and sent for
the malaria parasite smear test.
On the other hand , less than 6 per cent of the
users from Bombay and Thane had initially approached
a private specialist or nursing home, although a larger
proportion (13 per cent) of those coming from outside
had depended on this source of care.
Several studies have shown the extensive use
of private practitioners, rather than the public health
facilities, in treating short-term illnesses. This trend
cuts across all socio-economic groups (Duggal and
Amin, 1989; Yesudian, 1988 & 1990; Kannan et. al.,
1991; GOI, NSSO, 1990; NCAER, 1992; George et.
Table 5.1: Reasons for Changing the Provider Last Used (prior to OPD)
Reasons Cited
by Users
Referred
(bearing a letter)
Second opinion/
investigations
(advised or sought)
No Relief
Problem recurred
Financial Problems
Simultaneous treatment
Others
Private Sector
n = 959
Spec. Nurs. Oth.
Pvt.
Hosp
pract
n=769 n=83 n=95 n=12
Munc.
Disp.
n=86
Public Sector
n = 203
Tert. Total
Gen/Spl ESIS/
CGHS Hosp
Hosp
n= 24 n=l 1 n=1162
n=82
%
%
%
%
%
%
%
%
%
25
33
36
42
33
29
63
<1
28
13
13
13
25
16
21
13
57
39
33
17
38
32
33
5
3
11
19
8
7
2
5
2
1
11
4
13
4
4
6
14
64
50
<1
6
4
18
7
Note: Multiple responses. Only valid respondents included.
Pvt. Prac: private practitioner; Spec.: private specialist; Nurs. H: nursing home; Oth: other
Munc. disp: mu nicipal dispensary; Gen/ spl H: General/ special hospital; Tert: tertiary.
Other reasonsinclude change of residence, timings unsuitable, no specific reason, etc.
Other private providers include public sector doctors practising privately.
32
Rekha, studying in Std. 12, had also
gone immediately to her "family doctor”
in Sewree when the fever rose. He gave
her tablets and syrup for a day’s
treatment, charging her a fee of Rs 22
Only the previous month she had been
treated for malaria by him. Worried that
malaria had recurred Rekha decided to
have a check-up at the hospital. By then
the OPDs had closed. She was seen in
the casualty department and asked to
come to the General OPD the next day.
As for the municipal dispensary, she
vaguely knew of one at Ram Tekdi
(actually an independent health post)
but had never used it.
loose motions. This is despite the fact
that “both the Ambewadi and the
Zakaria Bundar (Abhyudaya Nager)
dispensaries (were) within five minutes
walking distance”.
The latter is an
upgraded dispensary. It could have put
the child on the same initial treatment
as the OPD specialist except that the
basic investigations available at the
primary care facility does not include
the Mantoux test.
(Constructed from the interview schedule)
The single most common reason for leaving
the practitioner was “no relief’, “only partial relief’
or “felt better and stopped the treatment but the
problem recurred” (Table 5.1). The expense of the
treatment was not directly voiced. People paid up
in the expectation of a quick cure. A small number
(8 per cent) had undergone investigations ordered by
the practitioner. About 8 per cent had used two
practitioners before seeking out the OPD.
(Constructed from the interview schedule)
Others depended on various practitioners that
were abundantly available in the neighbourhood,
changing to the public system when they were referred
or when they lost confidence in the practitioner’s
treatment.
Yet the prospect of a slightly prolonged
private treatment and an uncertain outcome was
a financial burden to them. And investigations were
decidedly expensive. The range of costs people had
incurred with practitioners even in the short duration
of one month of the onset of illness clearly shows
the difficulties in sustaining private treatment (Table
5.2). Almost two-thirds (62 per cent) of the OPD
users belonged to households with per capita monthly
income of less than Rs 500 (Table 3.4). The average
cost of Rs. 50 for a short episode of treatment ranged
from 10 per cent of the monthly per capita income
of Rs 500, to 17 per cent for those just above the
poverty line. For the destitute poor this amounted
to a huge 33 per cent of the household’s monthly
per capita income.
Little Meena had been referred to the
Paediatric Medicine OPD by the local
GP to get investigations done for fever,
cough and congestion that were
persisting for a month. The harried
father, a postman commuting daily to
Bandra for work from his residence in
the sprawling Jeejamata Nager
zopadpatti at Kalachowki,
used
“whichever doctor is open” at the time
of the onset of the illness. He had spent
Rs.35 on Dr Amit’s “syrup and tablets”
before being referred to the hospital.
The previous month he had spent Rs 70
to 80 on a neighbourhood specialist for
treating her for an episode of fever and
Table 5.2: Cost of Prior Private Practitioner Care
(OPD users with one month duration of illness)
No. of
PPs Used
Nature of Treatment
Only consultation
Treatment with medicines
(‘syrup, tablets, capsule’)
Injections with or without medicines
Investigations with or without medicines
Average Total Cost
Note: Only valid respondents.
* No drugs dispensed, or treatment taken on credit.
33
Cost Incurred (Rs)
Median
Range
22
183
0*
40
00-
40
800
101
23
329
65
350
50
018 0-
800
735
800
The cost of private specialist care was four
folds that of the ordinary practitioner. For the majority
(72 per cent), this entailed an outlay of 50 per cent
to 100 per cent of their monthly per capita income
on a single ailment. Private specialists’ care involved
investigations, expensive injections and, in some cases,
a few hours of- bed stay for observation and
administration of a drip.
It was at this point that people pressurised
practitioners to advise a public facility and even give
them a referral note or practitioners themselves
advised people to go to the public hospital. One fourth
of the users had brought referral letters from private
practitioners. The majority, however, had given up the
earlier treatment, and guided by friends or their own
past experience decided to approach the hospital OPD
(Appendix A, Table 15).
Four persons had undergone prior
hospitalisation in private nursing homes, incurring very
large expenditure. These were emergency admissions
in cases of angina, heart attack and an episode of
focal convulsion. The costs were catastrophic in
comparison to the household’s financial status.
Costs of Prior treatment
Among the people who had approached the four
OPDs with ailments that were less than a month old,
66 per cent gave details of the costs of prior
treatment.8 This expenditure was almost wholly on
private sector care (Table 5.3). On an average, the
private (general) practitioner’s treatment had been used
for three days and involved about two visits. Some
users had not paid any charges as they had, either,
made a brief contact without taking drugs dispensed
by the practitioner or had taken the treatment on credit.
The worst affected were the people who had to depend
on the private sector for long term treatment.
Public Primary Care Services in Bombay:
Municipal Dispensaries and Health Posts
General medical care and preventive services
are provided by a variety of public sector agencies
in Bombay. The municipal corporation (MCGB), the
Central Government Health Scheme (CGHS), railways
and police services organise the first level care through
dispensaries. The ESIS has both dispensaries and
private medical practitioners (IMPs) contracted to the
scheme. Freely accessible to all are the 159 general
dispensaries, 176 health posts and 27 maternity homes
run by the municipal corporation (Appendix B, Table
4).
Shaila was treated for tuberculosis by
the local GP She had spent Rs 500 on
injections and tablets in a period of a
month. This amounted to one fourth of
her family's monthly income which was
dependent on three people's wages. Not
surprisingly she had left treatment as
soon as she had felt better. When her
condition worsened again the GP
referred her to the hospital with a note
of irregular and incomplete treatment.
Structure of the municipal primary care
services: As single doctor clinics, each municipal
dispensary is expected to serve a population of 50,000
or people residing within a radius of 1.5 kms. In
the densely populated city zone, it would be possible
for such a large number of people to access a
dispensary within a kilometre of their residence. In
(Constructed from the interview schedule)
Table 5.3: Cost of Prior Treatment - all providers
(OPD users with onp month duration of illness)
Facilities /Providers
No. of
Users
Average Costs (Rs)
Median
Range
Duration of Use
(median days)
Private Sector
Private Practitioners
329
50
0-800
3
1
730
Specialists
Nursing Homes / Hospitals
21
4
250
20-1100
1500-7660
4
1
1
11
8
Public Sector
Municipal Dispensary
39
0
0-90
3
1
730
Secondary Hospitals
20
0
0-1000
5
1
30
Note:
Only valid respondents.
♦ Investigations done privately.
** On and off treatment. New episode of a long-term problem.
34
Chart 5.1: Municipal Primary Care Facilities
Primary Care Facility
Staffing
Functions
Dispensary
(ordinary)
Medical Officer
(MO i/c)
Pharmacist
Dresser (cumregistrationclerk)
Labourer
Basic curative care & drugs. Clinic based care.
85per cent function at
Preventive care:
a stretch from 9 am
Immunisation.
Passive malaria surveillance. to 4 PM.
Treatment of TB patients ref Registration stops
1/2 hour prior to
erred by Area TB Clinic:
closing.
Injections lunch time and
Drugs distribution
Malaria worker & TB
organiser belonging to the
Referrals:
upgraded dispensaries
vertical programme
attached to dispensaries.
hospital specialist OPDs.
Upgraded
Dispensary
MO i/c
Pharmacist
Lab. Technician
Dresser
Labourer
Curative and Preventive
services as given above.
Routine investigations:
Blood - Hb, CBC, ESR
Urine - routine
Stool - routine
Same as above.
Conduct routine investiga
tions.
Dental clinics attached to
three city dispensaries.
Health Post
Full-time MO
Pharmacist
PHN
ANMs (4)
MPWs (4)
Clerk
Attendent
CHVs (25)
Outreach of FP services,
with emphasis on MCH,
birth spacing & temporary
contraceptive methods.
Increasing the immunisation
status of children.
Registration of unregistered
births & deaths.
Record maintenance.
Referral services.
ANM/MPW - 6,000 to
8,000 population each
Survey catchment
householdsfor enlisting
target groups:
protected/unprotected
eligible couples;
immunisation status
of children (<5 yr.);
pregnant women.
Follow-up home visits with/
by CHVs (2,000-3,000 pop
each) for promoting
immunisation, FP, health /
nutrition education, ANC
registration, vitamin
supplementation.
Mobilisation for above.
Inform FTMO about any
case of TB Leprosy,
(50,000
Population)
(50,00065,000 pop.
in slums/
chawls)
Source:
Activities
MCGB, Public Health Department.
Except for the two Unani and three Ayurvedic
dispensaries, all others are staffed by MBBS doctors.
Sixty four of the 159 dispensaries have been upgraded
to provide laboratory facilities. These handle very
basic routine investigations. Some of these also have
dental clinics attached to them (Chart 5.1).
the suburbs, however, this size of population would
have to travel 2 -3 km to reach a dispensary. Such
a population norm for dispensaries is completely
unrealistic. Even accounting for the section of the
labour class that is covered by ESIS and other public
sector services, a single facility can hardly handle
7,000 to 9,000 households. It is not surprising,
therefore, that there is an overloading of public hospital
OPDs or that people have come to depend extensively
on private practitioners.
Patients are referred to the nearest BMC
hospital for specialist opinion and investigations. In
the case of some long-term ailments like diabetes,
35
Table 5.4 (a): Utilisation of Municipal Dispensaries in Bombay
1984
1989
1990
f992
1994
No. of dispensaries
155
n.a.
162
159
159
Total Attendance (millions)
4.38
3.97
4.51
4.54
5.28
Daily average per dispensary
94
89
92
106
Total New Attendance (millions)
1.31
1.51
1.86
n.a.
Daily average new attendance
28
30
37
Source:
1.37
MCGB, Annual Report of the Executive Health Officer 1984, 1989
MCGB, Civic Health Bulletin 1990, 1992-93.
MCGB, Outline of Civic Finances 1994-95
Table 5.4 (b): Utilisation of Dispensaries in the F/S Ward
Dispensaries
Type of
facility
New Attendance
(average per day)
Total Attendance
(average per day)
1992
1994
1992
1994
Parel Dispensary,
F/S Ward office, Parel
Upgraded
Health Post
148
137
444
480
Sewree Cross Road Disp.
Sewree
A.D. Marg Dispensary
Parel
Ambewadi Dispensary
Kalachowki
Abhyudaya Nager Disp.
Kalachowki
Ordinary
42
45
140
151
Ordinary
49
51
114
145
Ordinary
41
50
135
143
Upgraded
Health Post
Dental Clinic
39
48
85
73
F/S Ward Average
(excl. Parel Disp.)
Ordinary - 6
Upgraded - 3
Equipped with
HP - 4
Single HP- 3
33
39
93
107
Kidwai Nager Dispensary
Wadala
Gautam Nagar Dispensary
Dadar
Naigaum Dispensary,
Naigaum Maternity Home
Triveni Sadan Dispensary
Curry Road
Ordinary
Health Post
Ordinary
41
39
91
87
33
31
100
89
Upgraded
Health Post
Ordinary-
12
22
35
66
18
21
75
99
Note:
Computed from total attendance figures.
HP - health post.
Source: Public Health Department, F/S Ward, Parel.
36
*
arrangements can be made at the dispensaries to
distribute drugs for diabetes to patients whose
treatment regimen has been set by the hospital.
However, there is no data on the utilisation of
dispensaries for follow-up and management of long
term and chronic illnesses. In the absence of a referral
system, hospitals do not refer patients back to the
dispensary nor communicate their opinion to the
dispensary doctors.
within which the hospital is situated the average daily
attendance for eight dispensaries ranged from 66 to
151 people in 1994. Clearly some dispensaries are
moderately utilised while others are overloaded
although the reasons for such variations are not
documented. The Parel dispensary located in the ward
office building undertakes a wider number of activities
and is, therefore, better known and highly utilised
(Table5.4 b).
Municipal dispensaries account for a tiny 3 per
cent of the total spending on health by the BMC and
even this has been showing a declining trend. From
3.6 per cent in 1989-90, the share of expenditure on
dispensaries has declined to an estimated 2.9 per cent
in 1994-95 (Appendix B, Table 5).
Strengthening the first level of care: There is a
clear need to review the functioning of municipal
dispensaries from the point of strengthening the first
level of care. Observation of an upgraded dispensarycum-health post and two ordinary dispensaries
(referred to as A, B, & C respectively) helped to
identify some issues.
Since 1988, 176 health posts have been set
up under the World Bank funded India Population
Project-V (IPP-V). These are located in a variety
of premises including dispensaries that have sufficient
space, independent premises, old urban family welfare
centres and a handful of private voluntary organisations.
Health posts were mooted by the Committee on
Revamping Urban Health Services for the Urban Poor
(Krishnan Committee, 1984). The outcome of this
exercise has been the revamping of the urban family
welfare and MCH services along the lines of the rural
primary health care delivery system. Using paramedics
and local women community health workers, the health
posts give greater outreach of selective preventive
services. These are almost wholly focused upon family
planning and child immunisation as the main objective
is to reduce the population growth rate (MCGB, IPPV, 1990). The BMC put 5 per cent of its public health
expenditure into the health post programme in 199394. This is further supplemented by grants from the
state government.
1. Condition of dispensaries: The dispensary
premises ranged from a large old building, to a
spacious structure of five rooms covered by an
asbestos roof, to a two-room shop space with
partitions. All were modest in appearance and the
two ordinary dispensaries located among a row of
crowded shops and vendors were hardly noticeable.
Their small, faded sign boards shrank into the
background in sharp contrast to the prominently
displayed, large, brightly painted signboards and
gleaming exteriors of small private clinics surrounding
them.
The interiors were large, modestly furnished
and slightly fading. Yet, these dispensaries B and C
were spotlessly clean and their equipment, intruments
and furniture were well-maintained. On the other hand,
the large premises of the dispensary A appeared to
be in a state of neglect. Peeling paint, discoloured
interiors, cobwebs and dust gave the impression of
premises that had not been maintained for several
years. The apparatus in the laboratory - slides, pipettes,
test tubes, rubber tubing -, were old and worn-out.
Similar was the condition of the instruments on the
doctor’s table, while the mattress on the examination
bed and rexene covers were stained and shabby. For
the past five years this dispensary was earmarked for
shifting to a large new building across the yard, but
the sanction was still awaited.
In a slum or slum-like area (chawls) one health
post serves 50,000 to 65,000 population whereas in
a mixed locality, it exists for one lakh population.
The main function of the health post staff is to survey
the catchment population, enlist eligible couples,
pregnant and lactating women and children below five
years of age. Increasing contraceptive use mainly
targeted at low income women, increasing the
immunisation status of children and advising women
to register for ANC are the most common activities
undertaken.
It is not surprising that even a small number
of poorly maintained facilities can result in a public
impression of dispensaries being rudimentary and
giving poor quality care. The urban poor and lower
income groups, therefore, consider them as facilities
of last resort, targeted at the destitute and totally
impoverished sections. Even the better maintained
dispensaries face major bottlenecks in managing the
maintenance and repairs of their premises and larger
equipment. In dispensary C, a refrigerator of 1959
vintage had been certified by the maintenance
Utilisation of dispensaries:
The location of
dispensaries in the labour class neighbourhoods makes
them easily accessible for the poor. For Bombay
as a whole, however, the attendance levels show low
and stagnating utilisation (Table 5.4 a).
On the other hand, the attendance at different
dispensaries varies greatly. In the municipal ward
37
problems most frequently seen by her. Diarrhoeal
diseases were mainly seasonal and not a large problem.
At the well utilised dispensary B, the commonly
presenting conditions mentioned by the doctor were
malaria, scabies and minor injuries, especially in
children. In the latter, malaria cases were on the
increase in comparison to the previous year. In the
first three weeks of that month 185 fever cases were
tested of which 23 were positive. In dispensary C,
222 people were tested and 51 were found to be
positive. The sole task of the malaria worker posted
in these dispensaries was to make a slide of the malaria
parasite smears from every case of fever, which were
then examined at the central laboratory at the ward
office. It could take 3-5 days for reports to come
back and those who tested positive would be followed
up by the field malaria workers in their homes.
However the majority of these cases were first going
to the private practitioners, turning to the dispensaries
when the condition recurred. Needless to say, private
practitioners were treating malaria symptomatically.
department of the ward as ‘unserviceable’, ‘to be
scrapped and replaced’. No action had been taken
for the past 4-5 years and the dispensary was depending
upon the neighbouring health post for its supply of
vaccines. Similarly the steriliser had been scrapped
but not replaced for the past three months.
Drug supplies were reportedly being
streamlined. The Medical Officer Health (MOH) of
the ward would co-ordinate with dispensaries to loan
drugs to the facility facing shortages. However,
bottlenecks persisted. There was a delay of two
months between placing an indent request and the
delivery of drugs. And indenting for drugs was
circumscribed by a falling drug budget. The most
commonly needed drugs like paracetamol could be
in short supply at a time when the cases of fevers
were increasing. Such bottlenecks and shortages lower
the credibility of the public facilities. In people’s
perception, free drugs differentiate the public
dispensary from the private practitioner. Having to
buy drugs is as good as seeking practitioner services
as the fee is, ostensibly, for the drugs dispensed by
the latter.
It was difficult to ascertain the load of
investigations undertaken at the upgraded dispensaries,
but it would appear that the laboratory visited by us
was under-utilised. It did not undertake the most
commonly needed malaria parasite smear test and AFB
sputum examination despite the large prevalence of
these diseases reported by the doctor. The number
of TB patients registered with these dispensaries was
also small. Twenty-six patients were registered with
dispensary A. These, along with another 120 at a
nearby ordinary dispensary were handled by a single
TB organiser belonging to the vertical programme
(City TB Control Programme).
2. Level of care sought at the dispensaries:
In order that dispensaries handle a larger range of
illnesses in the community and take the load off the
hospital OPDs, it is important to understand the level
of care being sought at these dispensaries. The
morbidity record for new' patients submitted by each
dispensary to the ward public health department is one
indication but the information is not completely
reliable (Appendix B, Table 3).
Our observations showed that attendance was
very heavy on certain days. On a Monday at dispensary
A, the doctor had seen 45 new and 61 old patients
within two hours of starting work. Most of them were
women, children and the elderly - the less mobile
sections of the neighbourhood. Similarly, at dispensary
B the doctor had seen 30 patients in just one hour.
Since all three dispensaries were being handled by
women doctors the overall utilisation had increased,
particularly from women in the neighbourhood.
Apparently, neither the dispensaries or their
laboratory facilities, nor the elaborate infrastructure
belonging to the different communicable diseases
control programmes are currently effective in
reducing the load on the hospital OPDs. In turn the
public hospitals have little contact with the primary
care units. The dispensary doctors received no
feedback from hospitals and therefore no professional
inputs, regarding the patients referred for
investigations and specialist opinion. It was only when
people came for a new episode of illness, did the
doctor get to know about the diagnosis and treatment
given at the hospital.
Many of the illness conditions were very minor
such as common colds and small wounds especially
in small children. Many of the old cases needed the
doctor only for the routine sanctioning of either drugs
or a change of dressing. A smaller number of cases
needed greater attention and examination, such as the
cases of high fevers with headache and chills or people
who seemed to have been inadequately treated for
malaria by private practitioners.
The study of the hospital OPD users shows
a very wide range of ailments for which people
seek care. These include minor infections and major
communicable diseases to a host of noncommunicable disorders and chronic conditions.
Conventionally, the public health departments have
given priority to the notifiable communicable diseases,
family welfare and child survival programmes. Is this
At dispensary, A the medical officer cited TB,
respiratory problems due to the proximity of textile
mills, common colds, malaria and malnutrition as the
38
approach sufficient to address the complex health
situation in urban areas?
underestimate, there are 260 indigenous and allopathic
practitioner clinics in the F/S Ward (MCGB, Public
Health Department, undated: 138-142; 147-150). In
comparison to the 50,000 population norm for the
public dispensary, there is one private practitioner for
less than 2,000 people in this ward. The public system
can hardly match this coverage or consider itself as
the main provider of first level care. Moreover, private
practitioners, unlike dispensaries, are available late
in the evenings which is convenient for working people.
3. Clinic-based role without community
outreach: There is no catchment area for any
dispensary although health posts have defined areas
to look after. Dispensary services are clinic based,
catering to anyone who seeks them. In the absence
of a system of registration of the target population
with a dispensary, people tend to move between
dispensaries which are closely located to each other.
■
i
-f
The unplanned expansion of the private
practitioner services was apparent from the visit to
the dispensaries. According to the dispensary staff,
25 private practitioner clinics could be found on the
small stretch of road, hardly 15 minutes walking
distance, on which dispensary B is located. The
informal catchment population of 57,000 for
dispensary A consists of slums (47 per cent) and low
income housing colonies and chawls (53 per cent).
According to the map in the health post, there are
40 private practitioner clinics within this locality.
Some of these have diagnostic and nursing home
facilities.
Dispensary doctors do not make home visits
and have no role to play in the environmental
conditions of the locality within which the dispensary
is located. Dispensaries are only curative centres.
These notify the ward office about any increase in
cases of the main infectious diseases after which the
ward’s epidemiological officer takes over. The
minimum role of ensuring environmental sanitation,
cleaning of overflowing drains or removal of garbage
around the dispensary is restricted to informing the
ward Medical Officer Health. The latter can only
notify the concerned conservancy, maintainace or
drainage departments but has no authority to get the
work implemented.
On the other hand, several studies have shown
that the quality of care provided by practitioners varies
widely.
This is especially the case with their
prescribing patterns, inappropriate use of antibiotics
and injections and poor knowledge of recommended
drug regimens for treating TB and leprosy (Uplekar,
1995; Nandraj, 1994). The problem of quality is
further complicated by the presence of many
unqualified persons practising largely in poor
neighbourhoods.
Neither the dispensary nor the health posts are
involved in monitoring the condition of basic services
in their area. Within the health services itself, the
role of dispensaries is limited by the existence of
separate vertical programmes. Suspected TB cases
are referred to the Area TB Clinics (Acts) for
investigation and initial treatment.9 The detection
and treatment of malaria patients is shared with that
programme’s infrastructure and workers. Another
verticle programme has been added to the existing
ones in the form of the outreach services of the health
posts. How does the existence of separate vertical
programmes managed by different administrative
authorities in the public health department impact upon
the role of the dispensary? What is the nature of
co-ordination between the dispensary and the health
posts? In fact,. greater funding and priority to the
health post programme appears to have further
undermined the role of dispensaries in the public health
system.
This once again highlights the greater
responsibility and leadership role of the public sector
in ensuring access to good basic care. The
fragmentation of health services among multiple
providers dec;. ??ot allow the public sector to exercise
effective leadership at the first level of care.
Discussion: The felt need of the OPD users’ was
curative care. They were prompt in seeking treatment
from the widely available providers in their
neighbourhood. Almost three-fourths had sought
treatment, largely basic care, prior to approaching the
public hospital OPD. The provider most commonly
contacted at the onset of the illness was the private
(general) practitioner.
The existing organisation of the public health
services at the first level (primary) of care needs to
be reviewed.10
Unless an integrated and
comprehensive approach to health care of the people
is evolved based on the dispensary, people will
continue to seek the better curative facilities of the
public hospitals.
People had learned to distinguish between their
minor ailments and the more serious illnesses that
would need longer treatment. For the former they
depended on the local practitioners, with many people
reporting long-lasting relationships with them. Hardly
5 per cent of these users had come to the OPDs after
using the municipal dispensaries. There were, however,
limits to continuing private treatment. Lack of quick
4. Dominant position of private providers:
The beneficiaries of a weak public primary care system
are the private practitioners and poly .links. According
to the data published by thr BMC, itself an
39
relief that people associated with minor conditions,
and prospects of costly treatment led them to seek
higher care: check-up from highly qualified doctors
and investigations. The open-access public hospital
was their safeguard against uncertainty about their
health and the costs of prolonged care.
There is a need to review the organisation and
performance of the public primary care services. This
review should address both the varied health problems
of urban low-income groups and the appropriate
use of the different tiers of the health care services.
Notes:
1.
The combined spending of the Bombay Municipal Corporation (BMC) and the State Government
(Maharashtra) on health care services and activities was over Rs. 300 crores in 1994. Duggal and
Nandraj estimated the share of the State Government to be Rs. 50 crores, i.e. about 16.6 per cent
with the major share of spending being undertaken by the local authority (1994:37-38). The Central
Government expenditure is in addition to this Rs 300 crores. In 1994, the BMC spent an estimated
Rs. 253.21 crores on public health. Spending on health in the seven year period since 1988 has
formed 22 per cent to 23 per cent of the main budget (Budget A) and about 10 percent of the total
revenue expenditure on all services. The bulk of the health budget (86 per cent-87 per cent) is spent
on curative care (including some preventive services) and medical education. See Appendix B,Table
5 for the details of expenditure on public health borne by the BMC.
2.
See C.A.K. Yesudian, 1991 for a discussion of the compartmentalised approach to primary health
care in Bombay's public health system.
3.
According to the Public Health Department (MCGB), the number of nursing homes had increased
to 1,208 by 1996. Of these 622 nursing homes had a strenght of 1-10 beds only (Personal
Communication).
4.
See N. Crook et al., 1989: 317-318 for the findings of a cross-sectional house-hold survey that showed
substantial recourse to modem curative medicine among the entire range of poor and marginalised
population in Bombay.
5.
Since the study did not follow up the patient after the OPD visit, it is difficult to say whether
they engaged in any experimentation after the hospital for the same episode.
6.
According to this study the pattern of utilisation of the health care services in this area was private
practitioner clinics (63 per cent), public hospitals (19 per cent), ESIS hospital and facilities (11 per
cent), municipal dispensaries (3-4 per cent) and private hospitals (1 per cent).
7.
The survey on morbidity and utilisation of medical services conducted by the National Sample Survey
Organisation (NSSO, 42nd round) found that only about one-fourth (26 per cent rural and 27 per
cent urban) of the total routine out-patient care in the country was handled by the public sector.
And over three-fourths of this care was accounted for by the OPDs of the public hospitals (23
per cent in urban India and 19 per cent in urban Maharashtra). Urban public dispensaries in
Maharashtra handled 3 per cent of illness episodes and rural primary health centres took care of
10 per cent of out-patient care. The single largest provider of out-patient care was the private practitioner,
who was utilised for 50 per cent of routine care (GOI, NSSO, 1990 : 69-70).
8.
The survey asked information on cost of prior treatment from every person interviewed. However,
accurate recall becomes difficult for long duration of treatment. Therefore a reference period has
been used in analysing the cost data. Only the costs reported by users with symptoms of upto one
month duration at the time of interview have been included. Even within this limited reference period,
there were women and students who had spent on the current episode but could not give details
as they had not handled the payments themselves. Therefore only valid respondents are included.
The costs refer only to direct expenditures such as fees, medicines and injections, and admissions.
9.
See S. Rangan, 1995 for a discussion of problems posed by the existence of multiple public health
facilities for TB patients.
10.
See C.A.K. Yesudian, 1995 (op. cit.).
40
HOSPITAL BASED OUT-PATIENT SERVICES
In the large hall outside the out-patient
clinics, the patients would start queuing up from
early in the morning in order to get a quick turn
with the doctor. Only the Gynaecology OPD had
its own waiting room. In the case of the Medicine,
Surgery and Gynaecology OPDs, the registration
desk opened at 8.00 am. Stamped case papers were
issued and the patients would begin their long wait
on the wooden benches in the waiting area. The
housemen, registrars and lecturers came in by 8.30
am, followed by other senior doctors. Periodically
bunches of case papers would be collected by the
ward attendant and distributed randomly on the
desks of the doctors. By 10.00 a.m., with only half
an hour for the registration desk to close, the OPD
attendance was at its peak strength.
treatment prior to coming to the hospital (Table 5.1).
It was observed that the quality of referrals varied
widely. Some referral notes carried details of
investigations performed, possible diagnosis and the
course of treatment prescribed. Others were small
letterheads that did not even give the qualification of
the referring practitioners and only asked the attending
doctor in the OPD “to do the needful”. Often the
patients, finding no improvement in their condition,
had themselves asked for a note for the hospital.
Referrals are not honoured in the current
hospital set-up. The patients observe the same queue
and have to undergo the full check-up and
investigations. At the most, the fact of prior treatment
may find mention in the clinical notes recorded by
the OPD doctor.
The Paediatric Medicine OPD functioned in
the afternoons. Ailing children accompanied mostly
by their mothers and often with siblings in tow,
would start arriving by 1.00 p.m. All OPDs officially
worked for three to three and half hours — between
8.30 - 12.00 in the morning and 1.30 - 4.30 in the
afternoons. The Medicine and Surgery OPDs,
however, continued at least an hour longer due to
the heavy rush of patients. During the year that
the study was conducted (1994), the average daily
attendance in General Medicine was 350 out
patients, General Surgery had 200, Paediatric
Medicine ranged between 70-90 children while
Gynaecology/Obstetrics OPDs were visited by
approximately 80-100 women each day.
The reputation of the hospital, especially the
assurance of friends and relatives who had used it or
had a contact among the staff (36 per cent), and
satisfactory treatment in the past (24 per cent) were
the main reasons given for the current use.
Accessing the OPD services
Travel costs: One-third (34 per cent) of the new
patients had spent nothing on travelling to the
hospital (Table 6.1). The majority had walked 10 to
20 or 25 minutes from the neighbourhoods in the
F/S and adjoining F/N and G wards. This included
undernourished mothers with infants in their arms who
came to the Paediatric Medicine OPD. Some suburban
users were train pass holders for whom the hospital
was close to their place of work. Others were visiting
relatives in the vicinity and could walk over to the
hospital OPD.
Referrals
Less than one-fourth of all users (21 per cent)
cited referral as a reason for coming to the hospital
(Appendix A Table 15). The proportion hardly varied
across the OPDs. The number of referred persons
went up to 28 per cent among those who had sought
Table 6.1:
The availability of a mass transport system
easily enabled the patients and accompanying persons
Cost of IVavel for New OPD Users (single round trip)
Costs of
travel
City Zone
Suburbs
Outside
Gr. Bombay
Total
(Rs)
n = 608
(%)
n = 176
(%)
n = 221
(%)
n = 1006
(%)
Nil
< 10
11 - 50
> - 51
46
41
12
19
36
36
9
Note: Valid respondents only.
41
11
12
42
36
34
34
23
10
crowding as patients were let into the
OPD in batches of five. A new batch
went in only when the last patient from
the previous batch was on the
examination table. The sister-in-charge
who took the initiative and supervised
the staff should be given credit for this
welcome change.
to access the hospital from all over the city. Higher
costs were incurred by those who came from outside
Greater Bombay as well as those who used a taxi or
a mixed public-private transportation.
Direct costs of care: The hospitals belonging to the
BMC are meant to provide free services. Case papers
are supplied free and there are no charges for routine
investigations. All drugs should also be supplied by
the hospital. People, however, had to purchase drugs
and materials whenever these were in short supply.
Among the old patients 60 per cent reported buying
drugs (Appendix A, Table 17). In case of some old
patients the case papers showed that on some visits
all drugs were not supplied while others were able
to recall such expenditure. The average expenditure
was Rs 20 per visit. In the General Medicine OPD,
people reported expenditures of Rs 300 and above
on the purchase of anti-TB drugs, thyroid problems
and Herpes. The treatment of primary sterility and
PID were mainly responsible for the higher
proportion of women spending on treatment in the
Gynaecology OPD.
Just three days back the situation was
different. The patient load was high and
the OPD had started a little late. When
the door opened people rushed inside
and formed queues in front of the
doctors' desks. On hearing that one of
the doctors was absent, the queue in
front of the empty table broke up and
people tried to get into the other queue.
The room was crowded, chaos abundant
and a petty argument threatened to
develop into a big fight. As usual the
staff were nowhere to be seen. Finally
when a patient complained to a senior
doctor, the staff was summoned and all
people sent back to the hall outside.
Due to this confusion people who had
quietly observed the queue and waited
outside lost their turn. As one patient
said, “We usually go to a private
practitioner. My small children feel
extremely harrassed here and my wife
cannot cope with waiting for hours on
end with them."
Investigations were performed free (70 per
cent), except where dyes, needles and other material
inputs had to be purchased. About 4 per cent of
the old users were advised sophisticated investigations
such as CT Scan and ultrasonography (USG) which
attract charges, although at lower rates than that
charged in private clinics and hospitals (Appendix A,
Table 18).
Waiting time: In the absence of a referral system
the public hospital has no control over its workload.
It provides care to anyone who approaches the
specialist clinics. Easily the most irksome aspect
of using the OPDs for the patients was the long waiting
time. On an average people saw the doctor after
queuing up for one and half hours to two hours
(Appendix A, Table 19). After the check-up they would
have to rush to get their investigations done before
the pathology or radiology departments closed as well
as collect drugs from the pharmacy. It meant foregoing
a half day’s work and for some, a loss of the day’s
wages (Appendix A,Table 20). If they were late for
investigations, they would have to return the next day.
Another patient however took a different
view. He had come from Bihar and
despite the delay and chaos, found the
hospital far superior to the public
hospitals in his home state. The problem
here in Bombay was the very long
waiting time but he overlooked it as
“proper attention is given and there is
a thorough examination. In Bihar, the
doctors do not even care to examine the
patient and the prescription is ready
even before the patient has finished
describing his complaints." As for the
noise and crowding, according to him,
if a facility meant for five people was
used by fifty than this was bound to
happen,
(Observations of the investigator)
The pressure of numbers and the long
waiting time would often lead to chaotic
conditions. This was most often caused
by the inability of the non-medical staff
to systematically and sympathetically
maintain the queue system in the waiting
area..
The OPD moved even more slowly on days
when doctors had to instruct students. This increased
the crowding enormously, and was harassing for the
seriously ill who waited in the same general queue
along with those with more minor ailments.
Today the OPD was quiet and well
managed. There was no chaos and
Problems in continuity of care:
42
People followed
up with the same unit that had initially examined them
on the first visit. This allowed for some continuity,
but it meant a full week’s gap before the patient could
approach the OPD. This procedure was strictly
followed and patients who came in-between were asked
to return. Often this would mean an inappropriate
use of the casualty services if the patient needed to
see a doctor again.
care. On the other hand reputation of the hospital
was a prominent reason for attending the OPD. The
fact that all investigations were available under one
roof and doctors were highly trained, were the main
reasons for seeking the public hospital OPD despite
the overcrowding and long waiting time.
Discussion: Long waiting time, overcrowding
and patient stress and shortages of both common and
expensive drugs are the common associations people
have about public hospitals. These inconveniences
are only partially compensated by the perceived quality
of medical care and the availability of all investigations
under one roof. Undoubtedly, hospitals need to
function as referral facilities supporting
comprehensive first level (primary) services closer
to people’s residences itself.
Ease of use: In a huge and impersonal facility
patients were often at a loss as to whom to ask for
guidance or directions. Considerable time was spent
in searching out departments to which they were
referred by the OPD.
Perceived quality of medical care: People
seldom voiced an adverse opinion about the medical
43
CONCLUSION
The load of users on the out-patient services of
the apex teaching hospital located in the city zone of
Bombay district continues to grow. Some of the most
heavily used hospital out-patient departments belong to
the basic specialities of Medicine, Paediatric Medicine,
Surgery and Gynaecology-Obstetrics. These are also
the commonly used first level referral services. Does
the crowding of the OPDs reflect a casual attitude on
part of the users? Given the free and openly accessible
facilities, are people ‘unnecessarily’ using higher level
facilities for lower levels of health care?
As the study showed, 40 per cent of the users were
earners with the large majority being the younger
workers, mainly male and more than half of them
belonging to the urban informal sector. The rest of the
users - women, children and the unemployed - were
economically dependent on their mainly labour class
households. Over half the users were drawn from the
labour class residential areas in the close vicinity of
the hospital itself encompassing Parel (F/S ward),
Wadala (F/N), Worli (G/S) and Dadar-Naigaum (G/N
ward). Since the largest section belonged to the
unorganised workforce, these users lacked social
security or coverage of protective legislation and the
public hospital’s quality services was one of the few
safety nets available to them against the health hazards
created by their living and work environment.
sought the services of the municipal dispensaries, the
first level facilities providing general care in the public
health sector in Bombay. However, lack of quick
recovery, the uncertainty that the problem was serious
and mounting costs of prolonged private treatment made
them change over to the hospital out-patient services.
Over half those who had used the private practitioners
cited lack of relief and recurring symptoms as the main
reason for changing the provider. On an average the
patient came after four weeks of being ill. Hardly 28
per cent of those who had sought prior care carried a
referral letter. It is therefore not surprising that a little
over half the users were provided secondary level care
at the OPDs.
Emerging issues: The findings throw up a number of
issues about the effective functioning of the health care
services and their ability to meet the needs of poor and
lower income groups. Firstly, the morbidity seen in
these specialist OPDs could be indicative of inadequate
handling of the illnesses at the first level of care. Yet
no mechanism exists in the current organisation of
health services to monitor the care provided by the
private providers. In the absence of a referral system,
treatment patterns cannot be scrutinised. Nor are
hospitals tied into a system of providing professional
support, continuing education or training to the lower
level providers.
A broad assessment made of the management
of patients by the OPD doctors themselves revealed that
about a third of the patients could be handled by a
peripheral health unit or a general practitioner. The level
of care needed by patients varied considerably among
the OPDs. Conditions requiring general (primary) care
were more frequently seen in the Medicine and
Paediatric Medicine OPDs, indicating the clear need
to strengthen the first contact and general medical
services. Yet more than half the people seen in these
OPDs underwent investigations and further referrals.
The study indicates that there is a limited scope for
decreasing the load on public hospitals so long as
specialist services are centralised in them and there is
no system of referrals between hospitals and the first
level services.
Secondly, till date no effort has been made to
systematically study the <causes of poor utilisation of
the public primary health services, particularly the
municipal dispensaries. Unlike other urban centres,
Bombay has a three level organisation of public health
services. However, the priority in terms of funding
lies with the hospital sector, particularly the teaching
hospitals, and in terms of public health action, with the
selective services—family
planning
and
immunisation—of the health posts. On the other hand
the felt need of the people is for curative care. A
reorganisation of urban health services towards
providing comprehensive first level services that
combine good medical, preventive-promotive care
and first level services has not been considered by
the public health system.
The majority of the users — over two-thirds —
had sought prior care. People appeared to distinguish
between minor and more serious ailments. For the
former, they used private practitioners in close
proximity to their residences. Many users cited having
developed long term familiarity with these practitioners.
They considered it cumbersome to use hospital services
on a regular basis. Hardly 5 per cent of the users had
Thirdly, no referral system exists — not even a
limited one covering the public sector — to integrate
and co-ordinate the multiple providers and the diffcrcm
levels of the health care services.
Towards a referral system: The role of a
hospital, according to the WHO, is to provide referral
services, technical support and training inputs for lower
44
i.
level facilities. A referral system, however, has to be
based on integrated and good quality first level services.
Otherwise, it would only serve to cut off the access of
the poor and lower income patients to quality services
of the hospital without giving them an adequate
alternative. Developing a referral system could be done
in stages:
(1)
Strengthening the first level services in the
public system including the dispensaries, maternity
homes, health posts and health centres would have to
precede the referral system. All facilities would have
a catchment area and staggered timings that would be
convenient for working people. These centres could
provide outreach services for special and vulnerable
groups.
planned and based on an assessment of the area’s need
so as to avoid duplication and unnecessary
competition.
(3)
Functioning of hospitals only as referral
facilities would require patients to carry tandardised
referral slips giving all information of the previous
treatment. The referral
system would need to
function in both directions with hospital specialists
referring
back the patient to the original doctor for
follow-up. Only then would there be
continuity
of care and the possibility of sustained relationships
with specific providers.
(4)
The setting up of a referral system would also
need administrative re-organisation.This would be
needed to co-ordinate the functions of the hospital
administration and the Public Health Department in the
municipal corporation.
To increase the quality of services in these units,
specialist clinics and a wider range of investigations
could be decentralised to them. These clinics could be
handled by hospital based specialists, especially the
peripheral units falling within the hospital’s
catchment area. For instance, the informal catchment
area of the OPDs under study
would have at least
12 dispensaries in three municipal wards that could be
supported
by the hospital. The dispensary setting
could provide necessary experience to medical
students about the conditions and health needs in the
community, as well as professional inputs from hospital
doctors for the dispensary and health post doctors.
General OPD in the hospital- a short term
solution: Faced with the pressure of out-patients
needing all levels of care, the hospital had considered
an internal referral system. This would consist of a
General OPD handled by residents from the basic
specialities which would screen all new patients, make
appropriate referrals to the specialist clinics and treat
all those needing general care and some basic
investigations. A small experiment in the form of a
General OPD screening all new patients attending the
General Medicine OPD is going on.
(2)
Improving the first level services would also
need to integrate the large numbers of private
practitioners and consultants. These vary widely in their
qualifications and quality of care offered. To
integrate them within the referral system would require
a system of monitoring as well as mandatory record
keeping for them. In the long run, the
expansion
of public or private services would need to be tightly
Apart from rationalising the patient load on the
specialists, the usefulness of a General OPD would be
enhanced if it led to a specialisation in family practice.
Rather than residents, properly trained family
practitioners could handle this OPD. This would also
aid in reorienting medical education towards general
practice.
45
APPENDIX -A
Table
Employment Status
G.Med
OPD
n=746
%
'V
1: Employment Status of OPD Users
Gynaec
OPD
n=i89
%
G.Surg
OPD
n=515
%
Earners
Wage earners/Self
employed
47
58
25
Income from rent,
pension, savings &
Part-time work
3
1
Not earningXLost job
3
due to illness
2
12
Unemployed
9
1
Non-Earners
27
22
69
Home worker
4
4
Student /Children*
9
2
Retired
1
1
Note : Only respondents included
Refers lo the users of Paediatric Medicine OPD.
Obst
OPD
n=99
%
PMed
OPD
n=206
%
Total
n=1761
%
14
41
2
1
2
8
83
30
17
100
1
1
Table 2 : Occupational Profile of OPD Users
Occupation
White collar
Professional
Clerical
Organised Sector
Skilled worker - manufacturing
Semi-skilled worker - manufacturing
Skilled worker - Public utiiides
Semi-skilled worker Public utilities
Semi-skilled worker - Other services
Unorganised Sector
Skilled worker - manufacturing
Semi-skilled worker - manufacturing
Contract worker with organised sector
Skilled worker - service sector
Semi-skip: / worker - service sector
Domestic'.' servant
Heavy manual worker
Home based worker
Self Employed
Artisan /Skilled worker
Shop owner /Small business /Retailer
Worker rendering other services
Petty trader .■Vendor
Primary Sector
Big farmer (>15 acres)
Middle farmer (5.1 to 15 acres)
Small farmer (2.6 to 5 acres)
Marginal farmer (<2.6 acres)
Marginal fanner cum agri, labourer
Agricultural labourer
Other cultivator (land holding rot known)
G.Med.
OPD
n=351
%
10
9
1
19
2
c
1
9
1
42
5
12
1
8
12
2
2
<1
18
6
3
3
6
11
1
1
1
4
1
1
3
G.Surg.
OPD
n-300
%
7
1
6
23
2
4
2
12
2
40
3
8
I
9
13
2
3
IS
4
4
4
6
12
1
<1
3
1
<1
4
Gynaec. Obst
OPD
OPD
n=14
n=47
%
%
17
29
2
15
29
4
7
4
7
Total
n=712
%
9
I
8
19
2
4
2
10
40
57
9
2
2
4
21
21
2
15
2
4
2
6
23
2
11
6
2
2
7
2!
7
2
41
4
11
1
8
12
4
2
<1
7
7
17
5
4
4
6
13
1
1
2
4
1
1
3
Note : Only respondents included
46
J
Table 3: Occupational Profile of Households of Non-earning OPD Users
Occupation
I
Household
workers
n=522
%
White collar
Professional
Clerical
15
Students/ Unemployed
children*
n=298
n=123
%
%
2
16
2
12
14
Organized Sector
Skilled worker - manufacturing
Semi-skilled worker - manufacturing
Skilled worker -Public utilities
Semis-skilled worker - Public utilities
Semi-skilled worker - Other services
39
2
13
3
20
38
Unorganized Sector
Skilled worker - manufacturing
Semi-skilled worker - manufacturing
Contract worker with organized sector
Skilled worker - service sector
Semi-skilled worker - service sector
Domestic servant
Heavy manual worker
Home based worker
53
3
2
7
23
5
5
Self Employed
Artisan /Skilled worker
Shop owner /Small business /Retailer
Worker rendering other services
Petty trader /Vendor
28
7
8
4
9
22
5
9
3
5
24
4
Primary Sector
7
Big farmer (>15 acrea)
Middle farmer (1.5 to 15 acres)
Small farmer (2.6 to 5 acres)
1
Marginal farmer (<2.6 acres)
<1
Marginal farmer-cum-agri. labourer
Agricultural labourer
Other cultivator (land holding now known) 6
11
17
2
10
6
19
16
1
13
4
2
2
43
6
16
2
20
39
2
13
4
20
<1
59
4
55
19
1
17
1
1
2
2
1
1
4
Note: Only respondents included
All earners included (multiple responses)
♦Refers to users of paediatric medicine OPD
47
n=943
%
16
6
19
1
54
2
11
Total
3
15
<1
7
21
3
5
11
2
7
11
19
4
4
25
6
9
3
8
10
<1
3
9
2
2
<1
<1
6
5
Table 4:
Medicine
OPD
n=747
%
Locality
77
61
16
7
1
Bombay
City
Suburbs
Thane
Rural
Urban
Maharashtra
Rural
Urban
Other states
Rural
Urban
6
11
9
1
4
3
1
Place of Stay of OPD Users
G.Surg
OPD
n=519
%
Gynaec
OPD
n=190
%
Obst
OPD
n=99
%
P.Med
OPD
n=205
%
Total
70
56
14
12
3
9
12
74
45
28
11
2
9
11
8
2
91
71
80
19
20
7
76
58
17
9
2
7
11
9
1
4
3
1
10
2
6
3
1
60
2
1
6
9
2
6
5
5
1
1
4
1
1
8
1
4
1
1
Table 5: Localities in Bombay Showing Higher Utilisation of
n=1760
%
OPDs
G. Med
OPD
n=578
(%)
G. Surg
OPD
n=365
(%)
Gynaec
OPD
n=140
(%)
Obst
OPD
n=90
(%)
P.Med
OPD
n=163
(%)
Total
City
PareVLalbaug
Sewri/Kalachowki
Dadar/Naigaum/Bhoi wada
Worli/Prabhadevi
Wadala
80
17
80
14
10
8
13
4
61
14
79
15
23
75
9
17
11
5
8
5
5
77
15
12
8
7
5
Western Suburbs
Kandivali/Malad
Bandra
Goregaon
13
2
3
2
11
3
1
19
7
2
9
4
1
7
4
3
2
3
Eastern Suburbs
Bhandup/Vkhroli
Chembur
Kurla/Ghatkopar
8
2
1
2
9
3
1
2
20
5
4
5
15
2
7
2
16
4
3
5
Locality
10
8
5
6
7
10
14
Note: Localities contributing less than 2% of OPD users are omited from the above table.
48
n=l336
(%)
12
3
2
2
11
2
2
2
Table 6 : Confirmed Diagnoses - All OPDs excluding Obstetrics
Total Respondents = 1,507
Confirmed Diagnoses = 492 (33%)
Nature of Diagnosis
n=492
___ %
27
20
2
2
1
1
Infectious and Parasitic Diseases
Tuberculosis
Amoebiasis
Worm Infestation
Malaria
Filaria
STDs
Others
1
1
Disorders of Gastro-intestinal Tract
Anorectal Diseases*
Acid Peptic Disease
Hernias
Appendicitis
Gastroenteritis
Others
18
Diseases of the Circulatory System
Hypertension
Ischaemic Heart Disease
Rheumatic Heart Disease
Congenital Heart Disease
Other Cardiovascular Diseases?
Varicose Veins
TAO/Peri Artia Disease
Others
12
6
5
2
1
1
Disorders of the Female Genital Organs
Infertility
Infectious conditions
Ovarian Cyst
Prolapse
Tubal Ligation
Menstrual Disorders
Primary Amenorrhoea
Fibroadenosis-Breast
Others
6
2
1
1
1
1
<1
11
4
1
1
1
1
1
1
<1
2
Diseases of Skin, Subcutaneous tissue and Nails
Minor Surgical Conditions
Infectious and Fungal conditions
10
8
2
Disorders of the Respiratory System
Lower Respiratory Tract-Infectious
-Non infectious
Upper Respiratory Tract -Infectious?
10
Disorders of the Central Nervous System
Seizures\ Epilepsy
Cerebrovascular Accident
Others
6
4
1
1
49
6
4
3
3
n=492
----- %3
2
1
Nature of Diagnosis
Metabolic and Endocrine Disorders
Diabetes
Thyroid disorders
3
2
1
Disorders of the Male Genital Organs
Hydrocele
Phimosis
Epididymo-orchitis
Ante Natal Care
Pregnancy
<1
3
3
Non Specific Diagnosis
General Weakness
Muscular Disorder/Myalgia
Cervical /Other Lymphadenitis
Pyrexia of Unknown Origin
2
1
Disorders of Urinary Tract
Nephrotic Syndrome
Others-Infectious
-Non infectious
1
<1
1
Nutritional Disorders
Nutritional Anaemia
Others
Disorders of the Skeletal System other than Fractures and Dislocation
Arthritis
Others
2
1
1
1
1
1
1
<1
<1
<1
Injuries/Fractures/Burns
Injuries
Fractures
Others
1
1
<1
1
<1
<1
Mental Illnesses
Anxiety
Neurosis
Congenital Disorders
Cleft Palate/Lip
Others
Malignancies
Ca Abdcmen/Oesophagus
Others
Neonatal Disorders
Prematurity
Neonatal Sepsis
Diseases of Ear
Middle Ear Infection
Disorders of Blood and Blood forming Organs
Haematological Disorder
Disorders of the Connective Tissue
Systemic Lupus Erythmatous
1
<1
<1
<1
<1
<1
<1
<1
<1
<1
<1
<1
<1
Chromosomal Disorders
Note :
2
1
1
1
<1
Multiple response.
Diagnoses presented in "anked order.
50
Table 7:
Management
of
Patients
Management
of Patients in OPDs
G.Med
OPD
n=700
%
P.Med
OPD
n=190
%
Referred.
- to Super specialist OPDs
- to specialist OPDs
24
2
23
12
4
8
29
4
25
27
5
22
22
Investigated.
1st level.
2nd level
3rd level
49
11
51
14
55
10
35
3
30
41
66
3
40
8
53
10
37
5
23
6
Hospitalised
2
5
6
15
5
Given treatment only*
27
32
15
5
22
Note :
Total
n=1507
%
25
3
Multiple responses. Percentages are calculated on number of valid cases ie the patients for
whom medical notes were available. Response rate varied from 83% in Gynaecology to 94%
in General Medicine.
* Given a course of medicine only.
Table 8:
Management
Of
Patients
Referred
Investigated
Hospitalised
Given treatment only
Note:
Gen.Surg Gynae.
OPD
OPD
n=459
n=158
%
%
G. Med
OPD
n=471
%
Management
of New
Patients in OPDs
P. Med
OPD
n=110
%
G. Surg
OPD
n=299
%
Gynaec
OPD
n=120
%
29
14
45
27
55
2
34
6
31
46
6
28
39
16
42
19
8
5
28
Total
n= 975
%
43
Multiple responses. Percentages are calculated on total number of valid cases.
Response rate 89%.
51
7;
pH-IOO
1 11 buo
)< 1
IJ
Table 9: Investigations Ordered for OPD Users
Investigations
1st level
Blood group
Blood sugar
Complete Blood Count (CBC)
Erythrocyte Sedimentation Rate
(ESR)
Haemoglobin estmation (Hb)
Peripheral Smear for Malarial
Parasite
Urine Bile salts/Bile pigments
Urine routine microscopy
Sputum Acid Fast Bacteria
Stool routine examination
Mantoux test
Note:
2nd level
Alkaline phosphate
Anti Streptolysine O titre (ASLO)
Blood Urea Nitrogen (BUN)/
Creatinine/ Urea
Lipid profile
Liver function tests(Bilirubin, SCOT,
SGPT)
Platelet count
Renal Function Tests (RFT)
Routine Blood Chemistry
Serum electrolytes
Veneral Diseases Research Laboratory
test (VDRL)
Widal
Urine culture & Antibiotic Sensitivity
Test (AB ST)
Urine pregnancy test
Barium meal/enema
Chest X-ray
Direct Retrograde Urethrography(DRU)
Hystero-salpingography (HSG)
Intravenous pilography (IVP)
Intravenous urethrography (FVU)
Mass Miniature Radiography (MMR)
Plain X-ray abdomen/Kidney Ureter
Bladder (KUB)
Ultrasonography (USG)
X-ray other part
Fine Needle Aspiration Cytology
(FNAC)
Other histopathology
Peritoneal fluid tap & culture
Pleural tap
Vaginal smear & Cystology
Dialatation & curratage (D & C)
Gastroscopy
Electrocardiogram (ECG)
3rd level
2-D Echo
Barr bodies
Chromosomal study
Colonoscopy
CT scan/ other scan
Cystogram
Cystoscopy
Doppler
Electroencephalogram(EEG)
Endoscopy
Fistulogram
Folicle Stimulating
Harmone (FSH)
HIV test
HSA
Immunoglobulin assay(IG)
Laproscopy
Magnetic Resonance
Imaging (MRI)
Micurating.Cystomethrogram
Prolactin
Serum Leutinising
Harmone (LSH)
Serum Testosterone
Test for Toxoplasmosis
,Other sexually
transmitted
diseases,Rubella,Cytomegalo
virus and Herpes simplex
(TORCH)
Thyroid function test
(T3/T4/TSH)
Venogram
This was compiled from the medical notes of the patients included in the study.
Only a limited number of the first level investigations listed in this chart are provided at upgraded
dispensaries; the first level curative facilities provided by the Bruhanmumbai Municipal
Corporation.
52
Table 10: General Medicine OPD - Confirmed diagnoses
Total Respondents = 700
Confirmed Diagnoses = 196 (28%)
Nature of diagnosis
n=196
%
Infectious and Parasitic Diseases
Tuberculosis
Malaria
Others *
Cardiovascular Disorders
Hypertension
Ischaemic Heart Disease
Rheumatic Heart Disease
Others
Respiratory lYact Disorders
Lower Respiratory Tract disorder
Upper Respiratory Tract disorder
Endocrine Disorders
Diabetes
Others
Central Nervous System Disorders
Seizures \ Epilepsy
Cerebrovascular accident
Others
G I Tract \ Liver disorders
Gastritis
Others
Urinary Tract Infections
Nephrotic syndrome
Others
Disorders of Bones and Joints
Arthritis
Others
Others 2
39
31
3
5
21
12
5
3
2
16
11
5
5
4
2
7
4
2
1
6
3
3
3
2
1
3
2
2
12
Note: Multiple responses. Percentages are calculated on number of valid cases.
1. Filaria, leprosy, Aquired immuno-deficiency syndrome(AIDS), worms, amoebiasis,
candidiasis
2. Systemic lupus erythmatous (SLE), injuries, anaemia, varicose veins, mental illness
53
Table 11: Paediatric Medicine OPD Confirmed Diagnoses
Table 13: General Surgery OPD - Confirmed
diagnoses
Total Respondents = 459
Confirmed Diagnoses = 164 (36%)
Total Respondents - 190
Confirmed Diagnoses =70 (37%)
Nature of diagnosis
n=70
%
Nature of diagnosis
n=164
%
Infectitious and parasitic diseases
Tuberculosis
Others 1
Respiratory tract disorders
Lower Respiratory Tract disorder
Upper Respiratory Tract disorder
Central Nervous System disorders
Seizures \ Epilepsy
Others
Congenital \Hereditary \Chromosomal
disorder
Cardiovascular disorder
Others 2
44
26
19
19
10
9
21
19
3
Infectious and Parasitic Diseases
Tuberculosis
Others1
Minor surgical conditions
Abscess \ Pyoderma \ Ulcer
Sebaceous cysts
Corns
Others
Ano-Rectal Diseases
Piles
Fissures in anus
Peri-anal fistula
Others
G I Tract \ Liver diseases
Acid Peptic Diseases
Peptic Duodenal Ulcer
Appendicitis
Gastritis
Gall stone \ Cholelithiasis
Others
Surgical conditions of male genitalia
Hydrocele
Others
Hernias
Inguinal hernia
Others
Peripheral vascular diseases
Varicose veins
Peripheral vascular diseases
Others
Goitre
Injuries
Malignancies
Others2
20
7
4
20
Note: Multiple responses. Percentages are
calculated on total number of valid
cases.
1 Lumps, worms, amoebiasis, scabies,
candidiasis, gastroenteritis
2 Abscess, boils, ulcers, vitamin
deficiency, protein energy malnutrition
(PEM), prematurity, constipation, sepsis
Table
12: Gynaecology OPD- Confirmed
diagnoses
Total Respondents = 158
Confirmed Diagnoses = 62 (39%)
Nature of diagnosis
Infertility
Primary .
Secondary
Pregnancy
Menstrual disorders
Prolapse
For tuboplasty
Lower genital tract infections
Ovarian cysts
Ectopic Pregnancy
Pelvic inflamatory disease (PID)
Others 1
n=62
%
32
27
5
21
10
7
7
5
5
3
3
20
Note:
11
9
20
7
4
3
7
17
11
3
3
1
17
3
3
2
1
1
6
9
6
3
6
5
1
4
2
1
1
3
2
2
12
Multiple responses.
1. Worms, amoebiasis, filariasis, sexually
transmited diseases (STDs).
2. Lower respiratory tract
infectionLRTI),constipation, gangrene,
hypertension,arythmias, congestive
cardiac failure,anxietyovarian cysts,
dysmenorrhoea, middle ear infection,
muscular disorders,cervical \
other lymphnode,fibroadenosis
Note: 1 Tuberculosis, toxoplasmosis, piles,
abscesses,diabetes, hypertension,
rectovaginal fistula, chromosomal
disorders, abortions,still births.
54
Table 14 : Patterns
Health care
Pattern of
Seeking
Statistics
Onset to 1st. n
provider used Median
(days)
Range
Total no. of
n
facilities used Median
prior to KEM Range
Duration of
n
symptoms at Median
1st. Opd visit Range
(days)
of Health
G.Med
OPD
Care
Seeking Behaviour (New cases)
BB
Oth
G.Surg
OPD
BB
Oth
326
2
59
3
0-730
213
5
0-730
418
1
84
65
1
281
1
0-7
0-7
0-8
0-7
0-730
412
30
1-7300
45
6
93
1
0-730 0-730
62
120
2-6205
Gynaec
OPD
BB
Oth
Obst.
OPD
BB Oth
11
4
72
16
19
8
45
120
0-120 0-730 0-545 0-240
105
1
0-5
1
82
273
182
60
1-5475 1-7300
P.Med
OPD
BB
Oth
17
1
0-2
101
1
0-5
19
1
0-2
4
0-180
22
0
0-1
4
0-1
100
77
92
19
21
4
9
30
60
180
Hnd.
0-2555 0-43801-2737 0-3620 1-3 1-3
Note: Only valid cases included
BB - Bombay & Thane users Oth - Other users
Duration of symptoms recorded in days for all OPDs
except Obstrectics.
For Obstrectics OPD duration is in trimester.
Table 15:
Reasons
Referred
Internal Referral
Suggested by Doctor incl.
for investigation
Reasons for Choosing KEM Hospital
Med
OPD
n = 737
%
G.Surg
OPD
n=515
%
P.Med
OPD
n = 204
%
Gynaec
OPD
n = 187
%
Obst
OPD
n = 99
%
21
1
24
2
21
1
23
1
3
1
21
7
10
7
5
1
8
24
17
13
12
40
9
9
10
2
24
7
15
24
13
11
39
23
42
45
36
8
8
15
16
10
12
19
11
14
13
Satisfactory treatment in past/
Long term users
22
Inexpensive
13
Near place of residence
11
Suggested by friends/relatives or
based on reputation
34
As KEM staff/relative or Govt/BMC
worker
9
Others (incl. attending ill relatives
and emergency)
13
Note: Multiple responses. Percentage calculated on number of valid cases.
55
Total
n=1742
%
1
Table 16: Knowledge, Use & Accessibility of the Municipal Dispensaries
Awareness of OPD Users
G.Med
OPD
n=604
%
G.Surg
OPD
n=403
%
P.Med
OPD
n=172
%
Gynaec
OPD
n=139
%
Total
Users
n=1318
%
Munc. Disp. near residense
Munc. Disp. used atleast
once by self/family
Munc. Disp within walking
distance
_
57
50
70
44
55
56
24
43
19
41
56
23
39
17
40
Note:
Respondents include only Bombay-Thane residents
Only valid respondents.
Table 17:
Spending on Drugs (old patients)
Costs of
Drugs
(Rs)
Medicine
OPD
n = 189
(%)
Paed. Med
OPD
n = 69
(%)
Gen. Surg
OPD
n = 123
(%)
Gynaec
OPD
n = 39
(%)
Nil
< 50
51 - 100
101 - 500
>500
40
29
7
20
4
51
20
12
15
3
37
24
19
16
4
33
18
15
28
5
Note:
Obst
OPD
n=52
(%)
Total
39
23
17
19
2
40
25
13
18
4
n= 472
(%)
Valid respondents were only 73% of total old cases.
Table 18: Cost of Investigations
at Hospital (Old
cases)
n=156
%
Paed.Med
OPD
n=56
%
Surgery
OPD
n=l 15
%
Gynaec.
OPD
n=51
%
Obst
OPD
n=46
%
Total
OPD
n=424
%
79
11
3
8
77
4
11
9
65
19
6
10
59
28
2
12
59
37
4
70
17
5
8
Expenditure
on
Investigations
(Rs.)
Medicine
Nil
Upto 50
51 - 100
>100
Note: Only respondents included
56
Table 19: Waiting Time in OPDs
Time spent
waiting at
the OPD
(hours)
< */2
Vl - 1
1 - 2
2 - 3
>3
Medicine
OPD
n=638
%
P. Med.
OPD
n=173
%
Surg.
OPD
n=404
%
Gynaec.
OPD
n=143
%
Obst.
OPD
n=83
%
Total
10
1
3
5
15
39
32
8
10
43
31
7
5
12
5
13
38
31
24
38
17
11
13
30
32
33
11
n=1441
%
36
30
18
Note: Only respondents included.
Table 20: Wages Lost Due to OPD Visits (New cases)
Wages lost
(Patient and /or
relative)
(Rs.)
Medicine
OPD
n=196
%
P. Med.
OPD
n=28
%
Nil
Upto 50
51 - 100
> 100
55
28
9
8
61
69
18
23
14
7
6
Surgery
OPD
n=190
%
2
Note: Only respondents included.
Response rate 87%.
57
Gynaec.
OPD
n=26
%
Obst.
OPD
n=l
%
35
50
12
4
Total
n=441
%
60
1
26
9
5
APPENDIX - B
Table 1: Public Teaching
Hospital
and General Hospitals in Bombay 1995
Bedstrength
Maternity
Total
I. Teaching Hospitals
1. King Edward VII Memorial Hospital
2. Bai Yamunabai L Nair Hospital
3. Sion Hospital
4. Sir J J Hospital
1,800
1,071
1,404
1,377
HA. City General Hospitals - J J Group
1. Gokuldas Tejpal Hospital
2. St. George Hospital
521
487
• * . Major
I1B. Peripheral Hospitals^B Bhabha Hospital, Bandra
1. K
1---2. Dr. R N Cooper Hospital, Juhu
Bhagwati
Hospital, Borivali
3.
Rajawadi
Hospital,
Ghatkopar
4.
436
520
365
640
• ’ • Minor
IIC. Peripheral Hospitals
V
N
Desai
Hospital,
Santacruz
5.
M
W
Desai
Hospital,
Malad
6.
S
K
Patil
Hospital,
Malad
7.
,Kandivali
Centenary/ Hospital .Kandivali
8.
K
B
Bhabha
Hospital,
Kurla
9.
MAA
Hopsital,
Chembur
10.
11. Centenary Hospital, Govandi
12 Sant Muktabai ospital, Barvenagar
13. Munich Gene’ral Hospital Mulund
Hospital. Mulund
14. M T Agarwal Hospital,
251
162
100
120
356
74
192
104
100
213
Note:
Daily Utilisation
No. of
OPD
Inpatient
Departattendance admissions
ments
209a
120b
234
5,132a
743b
1,492
232
93
193
133
28
25
14
72
90
17
17
14
15
2,396
1,326
541
1,853
94
79
58
88
11
11
9
12
12
9
12
7
11
933
421
289
1,093
1,125
891
836
435
551
923
46
33
60
164
70
40
30
60
10
30
40
30
18
a
[994
b
1996
Excluded- special hospitals and hospttals serving p
14
occupational groups in public
sector.
. Medical Records DepanreM. King ^wari VR
JSRfSW: Dir.»»
« IL
mcgb^
58
6
25
31
10
35
13
12
19
Table 2: Average Daily Attendance in OPDs - 1994
Basic specialities
OPD
No. of
Super specialities
New
old
Total
219
121
83
122
75
49
21
44
115
140
161
70
59
34
54
23
334
261
244
192
134
83
75
67*
OPD
Clinics
per week
G.Medicine
Orthopaedic
Opthalmology
G.Surgery
Skin
Gynaecology
Obstetrics
Paediatric Medicine
Note:
Source:
6
6
6
6
6
6
6
6
*1993 figures.
No. of
New
clinics
per week
Cardiology
Plastic Surgery
Thoracic Surgery
Neurosurgery
Nephrology
2
1
4
6
2
110
186
17
13
10
Old
Total
253
128
74
26
21
363
314
91
39
31
Average attendance estimated from total recorded attendance in respective OPDs.
Medical Records Department, KEM Hospital, Mumbai.
59
Table 3 : Morbidity Profile of New Cases Seen in Municipal Dispensaries
_ Pattern of Morbidity
Greater
1984
Bombay
1989
F/s
1992
Ward----1994?
1,319,7241
%
1.372,997’
%
119,254’
%
131,779’
%
G’k;
110
29**
Infective and parasitic diseases
Diarrhoeal diseases
' Tuberculosis
Worm innfestation
Vaccine preventable diseases
Herpes
Mumps
Malaria
STDs
Viral Hepatitis
33
29
1
2
<1
<1
<1
<1
1
26
17
4
3
<1
<1
<1
<1
<1
22
15
1
2
Disorders of the resiratory tract
Upper Respiratory Tract
Common cold
Tonsilitis
Influenza
Pharyngitis
Lower Respiratory Tract
Bronchitis
Bronchopneumonia
Pneumonia
16
9
6
1
1
1
7
7
1
<1
14
9
5
2
1
1
5
4
22
18
13
2
1
2
4
3
<1
26
<1
<1
Unspecified fevers
9
11
16
12
Nutritional disorders
5
7
10
12
Injuries and accidents
2
6
12
12
Disorders of ENT
2
5
11
19
Diseases of skin
Scabies
RingWorm
3
1
2
5
19
23
4
1
12
4
12
6
Minor surgical conditions and njuries
7
4
0<
1
Disorders of Gastro Intestinal TYact
Dyspepsia
Ulcers
Piles
Fistula in anus
Disordes of the circulatory system
Disorders of the nervous system
Urinary tract infections
Opthalmic conditions
ANC \ PNC
Other conditions
Other causes
3
2
1
2
1
1
<1
<1
1
2
1
0
<1
<1
2
1
0
<1
<1
2
<1
<1
<1
<1
<1
<1
1
1
<1
2
<1
4
12
1
<1
<1
<1
2
14
60
'r:I
3
C2 •
1
1
<1
2
<1
1
<1
1
<1
1
1
<1
3
4
1
2
18
11
1
1
1
8
6
2
6
1
1
4
Note:
1 Total new cases.
Published data for all dispensaries in Greater Bombay (Bruhanmumbai) is available only upto
1989. More recent data is available with the public health department of each ward; hence the
difference in the years.
The above morbidity data from dispensaries has been re-classified according to the distribution
of diseases based on physiological systems (as in the WHO ICD). The format currently used
by the Public Health Department for recording the morbidity data is at least 20 years old.
Secondly, by restricting such rcords to only new cases, the
the dispensary
dispensary morbidity
morbidity data
data is
is largely
largely
symptoms based. As such ‘diarrhoea and dysentry’, ‘fevers’, ‘common cold’, ‘injuries and accidents’
are □the
hoe«fOU
fourfr hhighest
’ghestjrankin
ranking8 conditions for which dispensary treatment is sought (accounting
for 38% of all conditions in 1989).
°
* Data for 8 out of 9 dispensaries.
**
A single dispensary has reported 20,000 new cases of dysentry which has doubled the share
of diarrhoeal diseases in new cases reporting to dispensaries in F/s ward in 1994. The range
for the other 7 dispensaries was 4,000 to 6, 000 cases. The above data is not tenable as it
means that 6-7 new patients
]
would be seeking treatment only for dysentry, which is not borne
out by the daily utilisation data.
Source:
MCGB, Public Health Dept._ Annual Report of the Executive Health Officer- 1984 &1989,
Table 56.
F/s ward, Public Health Department.
61
Health
Services Infrastructure in Greater Bombay 1995
City
Zone
No
Beds
Western Suburbs
Suburbs
Extended
No
Beds
No
Beds
Table 4:
Sector
Eastern Suburbs
Suburbs
Extended
No
Beds
No
Beds
Greater Bombay
No
Beds
4
5
4,305
2,160
3,733
993
PUBLIC
Municipal Corpration of Greater Bombay
(MCGB)
Teaching Hospitals
Infectious Diseases and other Special Hospital
General Hospitals
Maternity Homes
Special Clinics
Dispensaries
Ordinary
Upgraded
Dental clinics
Health Posts
Government of Maharashtra
Teaching Hospitals
Special ./General Hospitals
ESIS Hospitals
ESIS Dispensaries
Central Govt./ Public Sector Undertakings
Hospitals
CGHS Dispensaries
Total Public
PRIVATE (1994)
Hospitals/ Nursing Homes
4
5
4,305
2,160
317
8
38
34
4
51
2
1,352
1,715
1,150
5
2,033
1
6
3
6
7,725
747
136
5
4
1,366
92
2
3
15
15
17
5
15
9
8
3
35
36
38
16
1
400
1
14
162
25
7+
159
93
66
4
176
1,885
1,283
3,676
273 3,114
500
1
400
4
234
413
30
1
- 13,032
307
4
4
1,207
248
299
2,683
1,341
1,833
2,450
9
36*
2,011
19,147
1,075
1,757
170
1
7
5
14**
81
1,109
1,065
18,307
20,832
5,561
4,397
4,440
2; 184
37,454
Grand Total
Bed : Population Ratio
1:152
1:367
1:434
1:418
1:434
1:265
62
Note:
Approximate figures for bed capacity as data varies according to sources.
City zone - includes the area from Colaba in the south upto Mahim in the West and Son in the east (Municipal wards A to G).
Western Suburbs - are the neighbourhoos noth of Mahim. The suburbs stretch from Bandra to Andheri (wards H and K) and theextended
suburbs as from Jogeshwari to Borivali (Wards P&R).
Eastern Suburbs - lie north of Sion. The suburbs include the localities from Kurla to Vikhroli (Wards L,M) and Chembur (WardM), and the
extended eastern suburbs refer to Bhandup and Mulund (Wards S and T).
*Zone-wise distribution not available (two new maternity homes established in 1996).
♦Includes TB, STD & Leprosy clinics.
♦♦Additionally 1,550 Insurance Medical Practitioners (IMPs) are 'available' for 95,877 families.
Source: MCGB/Govt. of Maharashtra, Respective Medical Colleges.
MCGB, Public Health Dept. Performance Budget 1994-95
MCGB, Director Peripheral Hospitals.
MCGB, Public Health Dept., Civic Health Bulletin 1992-93.
MCGB, Public Health Dept.., List of Dispensaries, Health Posts, Private Hospitals.
Govt, of Maharashtra, Public Health Dept., Performance Budget 1993-94, pp.34,36.
GOI, CBHI, Health Information of India 1994, Table 13.01.
63
Table 5: Bombay Municipal Corporation- Revenue Expenditure on Public Health 1988-89 to 1994-95
(Rs. in thousands)
1988-89
1989-90
1990-91
1991-92
1992-93
1993-94
Revised
Estimates
1994-95
130,740
(13.08)
151,293
(13.57)
172,666
(12.88)
199,938
(12.86)
244,106
(12.21)
269,898
(12.13)
320,110
(12.64)
862,185
(86.26)
956,689
(85.85)
1,160,520
(86.58)
1,345,904
(86.60)
1,744,931
(87.30)
1,939,574
(87.22)
2,198,230
(86.81)
a) Hospitals
579,625
(57.99)
643,505
(57.75)
778,208
(58.06)
906,130
(58.31)
1,193,398
(59.71)
1,285,863
(57.82)
1,450,600
(57.28)
b) Medical Education
77,673
(7.77)
89,645
(8.96)
122,394
(9.13)
126,260
(8.12)
149,346
(7.47)
160,738
(7.22)
176,350
(6.96)
c) Maternity Homes &
Child Wei. (incl. FW)
48,399
(4.84)
57,981
(5.80)
84,628
(6.31)
119,426
(7.69)
163,534
(8.18)
208,785
(9.38)
245,630
(9.70)
d) Dispensaries
33,170
(3.31)
36,327
(3.63)
41409
(3.09)
48,867
(3.15)
63,136
(3.16)
67,236
(3.02)
75,720
(2.99)
e) Others*
1,23,319
(12.33)
1,29,231
(11.59)
1,33,881
(9.99)
1,45,221
(9.35)
1,75,517
(8.78)
2,26,953
(10.21)
2,26,953
(9.87)
6,549
(0.64)
6,369
(0.57)
7,103
(0.53)
8,162
(0.53)
9,596
(0.48)
14,227
(0.63)
13,729
(0.54)
999,474
1,114,351
1,340,289
1,554,004
1,998,633
2,223,699
2,532,069
Actuals
Heads of Expenditure
I Public Health
II Medical Relief &
Education
HI Environment Air Pollution
Control
Total
Note:
Source:
(I+II+III)
Include the expenditure on leprosy clinic, grant-in-aid and statutory contributions to government public institutions and public institutions
and debt charges.
1) Municipal Corporation of Greater Bombay, Out Line of Civic FinaOfiS—1994-95.» Mumbai, December 1994.
2) Municipal Corporation of Greater Bombay, Budget Estimates A 1995-96 . Mumbai, January 1995, pp. 90-93.
64
APPENDIX - C
Round Number
HOSPITAL BASED URBAN HEALTH SERVICES IN BOMBAY.
USERS STUDY
STUDY OF THE OUTPATIENTS AT THE K.E.M. HOSPITAL.
1. Socio-Economic Information about Patient and his/her household
Information about the Patient
Name
Education
Address
Occupation
□□□
OPD
Respondent: Self
HH Size
Schedule Number
D
Other(Specify)
Information about the Other Earners of the Household
Relation with patient
Education
Occupation
Income
E
NE
Age
Sex
M
Income
T
/F
2A. Information about the Current Episode of Illness
Old Case
Duration
New Case
Visit Number
Whether K.E.M. is the 1st
facility approached
Reason : For check-up • To collect reports
for visit of investigations
•
To show the reports •
to the doctor
Follow up •
Yes
No
2B. Prior Help-seeking
Facility used
Cost of treatment
Order
Time Gap
Duration
No Treatment
Self Medication
Religious Practices
Pharmacist
Private General
Practitioner
Private Specialist
Private Hospital/
Nursing Home
Municipal
Dispensary
Mun. Sec. Hosp./
Govt. General Hosp
SEIS /CGHS
Any Other
KEM
65
Nature of Treatment
Reason for change of treatment
3. Reasons for choosing K.E.M. Hospital
Referred by Gen. | |
Practitioners
Referred by [ |
Mun. Disp.
Earlier doctor
unsatisfactory
New staff member |
at KEMH
Suspected by
No other reason
Referred by
DGHS/SEIS
|
No Relief from | |
earlier treatment
Referred
- ' • by<
Mun.
J'
— Sec. ’Hosp.
Satisfactory Rx [^Inexpensive
in the past
EZJ Near place of
of residence
EZJ
Got fed up with Q
earlier treatment
Suggested by
friends/relatives
No other reason (specify) Q
5. Knowledge about and accessibility to Municipal Dispensaries
6. Waiting time at KEMH
.4. Costs incurred at KEM till now
Municipal Dispensary near residense ? Yes
Item
Drug
No
Cost (Rs.)
Location /Address of the Dispensary
For investigation/s
Material
Investigation
To see the doctor
Time taken to reach it
Travel (Toft Fro, for
patient and
accopanying person/s)
Has it been used (for self or others)?
Admission charges
Other Information
For drugs
Yes
No
Other
Tips
Surgery
Wage* lost (Pt. &
accompanying
person/s)
Date of i terview
Name of the investigator
Any other
Total
7A. Clinical Notes (General Medicine, General Surgery, Paediatric Medicine OPDs
66
7B. Gynaecology OPD Clinical notes:
1. History CC
SMW.
Age
7. Vagina] Discharge
8. Bowels
O.P.D.
Micturation
9. Clinical Findings
PA.
2. Past History
P.V. - Ga.
Ut
3. Menstrual History
F.M.P.
Pa.M.C.
PrM.C.
L.M.P.
Fa.
PS.
PR.
4. Marital History
Sterility
Sexual frgidity
5. Obsteric History
F.T.N.D.
Abortions
Dysparcunia
10. Other Systems
Use of contraceptives
11. Investigations
Total number of confinemenu
Abnormal F.TD.
Puerperal infection
Premature labours
Date and nature L.D.
6. Previous Operation
Vaginal Smear
Cervical Smear
Endometerial Biopsy
Rubin's Test
A. Z. Test
B. S.R.
Blood K.T
Blood Sound
Urine
Seminal Fluid
Hysteriosalpingograph
Cystoscopy findings
12. Follow up
7G Obstetric OPD Clinical Notes
Information regarding previous pregnancies
1
FTND
3
2
4
5
6
(Y« /No)
Place of delivery
Home
Attended by
Relative/ Neighbour
Trained Dai
Doctor
Private
Maternity home/
Hospital
Public
Immunisation (2IT)
Chart as per Obstetrics OPD case paper
Date Weight B.P.
Urine Fundal Ht
Abd. Girth
Presentation
Ant
position and
shoulder
condition of P.P.
67
F.H.S.
Pallor Oedema Hb%
Systems and
complaints
Advice and
summary of
treatment
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Health Resources, Investment and Expenditure. A
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Household Health Expenditure in Two States: A
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NGOs in Rural Health Care
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Health Research Studies in India: A Review and
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Urban Tuberculosis Control: Problems and Prospects
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Ralegan Siddhi: A Model for Village Development
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ABOUT THIS BOOK
Until the mid-80s health care services for the urban areas were not seen as a major issue.
The urban population was considered highly priviledged in its access to a vast supply of medical
and hospital services. However, concern has been expressed whether these services meet the
needs of the urban poor and lower income groups experiencing declining conditions of public
health and growing inequalities in living standards. The health care services are the inevitable
recourse of the poor and lower income groups as they cope with a complex pattern of ill healh
and premature death.
The public health care system reaches the underpriviledged sections largely through its
hospital services. The current study focuses on the day-to-day health problems seen in some of
the most heavily utilised out-patient departments (OPDs) of the metropolitan tertiary public
hosital. It documents the socio-economic background of the people that crowd these OPDs,
their help-seeking behavior and utilisation of the primary health care services. It explores the
nature of health needs and problems for which people seek hospital OPD care and assesses the
level of care that these problems require.
The study argues the hospital services need to be integrated within properly functioning referral
system: Hospitals would be the referral and technical back-up to comprehensive primary health
services providing the whole range of basic curative, preventive and promotive care.
ISBN 81-87078-20-0
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