The medical emergency of the urban poor

From InfoChange India, September 2008

By Kalpana Sharma

A man who works as a driver in Mumbai discovered recently that his wife, who complained of breathlessness, had a heart problem. She has a blocked artery and a faulty heart valve. Like others of his ilk, this man lives in a slum. His salary as a driver is not enough to rent, leave alone buy, an apartment anywhere in Mumbai. So he lives in a ‘regularised’ slum, which cannot be demolished, and which is, ironically, located on the most expensive real estate in Mumbai, in the upscale neighbourhood of Malabar Hill.

This preferred location, however, makes little difference to him when facing a health crisis such as this. The choices before him are stark. If he does nothing, because he cannot afford to get his wife treated, then she will die. If he chooses to get her treated, then he faces lifelong indebtedness.

In a city with some of the most expensive and modern healthcare facilities, millions of lower income and poor people face the dilemma of this driver. As opposed to their rural counterparts, even poor people living in cities are well aware of the medical interventions that are possible to prolong life and to deal with life-threatening conditions. But they also know that such interventions are out of their reach in an increasingly privatised healthcare market. The public healthcare systems that exist are simply not enough to meet the demand even for ordinary health conditions, leave alone for specialised care.

Mumbai is actually better served than most other Indian cities with public health facilities. The Brihanmumbai Municipal Corporation (BMC) runs four teaching hospitals, five specialised hospitals, 16 peripheral hospitals, 28 maternity homes and several hundred dispensaries and health outposts. Out of the estimated 40,000 hospital beds available in Mumbai, around a quarter come under the BMC. In addition the state government runs one medical college, three general hospitals and two health units with a total of 2,871 beds. The Central government also runs one hospital.

Yet, despite the availability of these services, people who cannot afford to spend on private healthcare still do not necessarily see public services as the first choice. Several studies have shown that as many as 77% in urban areas and 63% in rural areas turn to private practitioners for outpatient care because the public facilities are either too far, or their procedures are too bureaucratic and take too long to access. Even amongst poor people who cannot afford private care, the percentage of those who use it is over 60%.

However, for in-patient care, the poor seek out public facilities, even if they are at some distance from where they live, because they are the only ones that are affordable. It is evident that these are inadequate to meet the demand. The overcrowding seen in every public hospital is a stark reminder of the shortage of affordable beds in a city where the majority of people cannot afford expensive healthcare. Furthermore, the big hospitals in Mumbai serve as referrals for people from across the state and other states.

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