Unmet Need for Public
Health-Care Services in Mumbai, India
findings of the study very clearly in dicate that the potential
demand for public health ser vices is very high pro vided
that they are conveniently
located and afford able.
By T.R. Dilip and Ravi Duggal
The rural urban disparities
in health outcomes in India are often attributed to urban bias in
allocation of resources and location of health-care services. Statistics
clearly show that the bed population ratio is higher in urban areas
and that those regional inequalities have not seen any significant
decline over time (Duggal and others, 1995). This regional imbalance
is there in both the public and the private health sector. Further,
public spending on health care is also disproportionately higher
in urban areas. However, while critiquing the regional bias, it
is to be examined whether the urban areas in India, where 22 per
cent of the
population is residing in slums, has the required number of public
health-care facilities. Unlike other urban areas, the matter requires
special attention in an urban metropolis in India that is characterized
by poor living conditions making the public more vulnerable to diseases,
and where poverty levels are likely to be similar, if not worse,
than that in rural areas. This could be understood by examining
who utilizes those services and for what reasons.
Recent all India surveys do not show any large scale rural-urban
differentials in proportion utilizing public health-care services
in India (NSSO, 1998). According to the survey, those seeking outpatient
care services from public sector was 19 per cent and 20 per cent
in rural and urban areas and for inpatient care services, it was
44 per cent and 43 per cent, respectively.
Out-of-pocket average expenditure incurred on inpatient care treatment
was higher in urban areas as compared to rural areas for both public
and private sectors and public-private differentials in out of pocket
expenditure was also higher in urban areas. Therefore, despite better
physical access to health care, the higher average cost for accessing
health services makes the urban poor community as disadvantaged
as their rural counterparts. This means that there is an emergent
need for expansion of public
health services even in urban areas so as to reduce the financial
burden on the urban poor. What adds to the concern vis-à-vis use
of public health services is the declining trend of utilization
of both ambulatory and inpatient care from the public health system.
The 42nd (1986-1987) and 52nd (1995-1996) Rounds of NSSO surveys
amply provide evidence for that – decline in out-patient care from
about 27 per cent to 19 per cent and in inpatient care from 60 per
cent to 44 per cent (NSSO, 1998). This large decline in use of public
health-care services is clearly a function of the decline in public
health investment during the same period (Duggal, 1997; GOI, 2002).
In the present paper, an analysis of utilization patterns of public
health-care services at Mumbai is undertaken from the perspective
of inadequate availability of such services in the city. Mumbai,
the commercial capital of India is the largest city in the country
carrying a population of 11.9 million (DCO, 2001).
The high density of population (21,190 persons per square kilometre)
has put tremendous pressure on its infrastructure and amenities.
About 49 per cent of the population are residing in slums, characterized
by shortage of living space, water supply and sanitation facilities.
Slums in Mumbai are unique in the sense that only 4 per cent are
Kacha1 hutments, while 45 per cent and 51 per cent of houses in
slums are Semipucca1 and Pucca1, respectively (IIPS and ORC Macro,
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