BEEF UP HEALTH BUDGET
SUNIL NANDRAJ
Bombay, the largest urban agglomerate in the country of 12 million people, with four lakh persons added every month, has one of the highest population densities in the world, a humid and warm climate and an grossly inadequate sanitation and garbage clearance system. The situation is an ideal breeding ground for infection and disease.
In Bombay, the public sector has a large network of health care institutions. During 1993-94, the Municipal Corporation of Greater Bombay (MCGB) allocated a budget of Rs. 227.58 crore to the health sector. In addition, the state government spends an estimated Rs.50 crore for the health services in the city.
Yet, the public health service caters to only one-third of users. This, in spite of the fact that the corporation is duty bound under section 61 of the Bombay Municipal Corporation Act to establish and maintain public hospitals and dispensaries and carry out other measures necessary for public medical relief.
Ironically, the expenditure by the MCGB on health care has been dwindling. During '60-61, it spend Rs.5.46 crore on health care, which was 34.45 per cent of its total expenditure; it declined to 25.84 per cent in '85-86 and in '94, the revised estimates indicate that the proportion is even lower at 23.92 per cent.
Further, nearly 37 per cent of the civic health expenditure if Rs.227 crore is accounted for by the three teaching hospitals while the peripheral hospitals, maternity homes, dispensaries, public health programmes get an inadequate allocation.
Further analysis of the corporation and state budgets reveals that the expenditure is highly skewed - establishment/administration costs take away over 60 per cent of the expenditure and it is increasing. On the other hand, expenditure on medicines and diets is around 10 per cent and have declined during he past five years.
Bombay has a huge private health sector-an estimated 40,000 to 50,000 medical practitioners, which includes those from the informal sector like tantriks, faith healers, vaids, etc.
Around 900 institutions provide inpatient care ranging from two-bedded nursing homes functioning from sheds to 750-bedded five-star corporate hospital. In addition to these are the dispensaries, clinics, polyclinics, physiotherapy centers, blood banks, laboratories and diagnostic centres boasting of the latest in hi-tech equipment etc.
This sector caters to one of the largest health care markets in the world, one that is completely unregulated and determined wholly by the supply side. This private market owes to the inadequacy of the public health sector. The functioning of public health services leaves much to be desired. They are overcrowded, lack sufficient drugs, equipment, linen and are unhygienic, corrupt and inefficient.
The hospitals are overcrowded with patients seeking primary care. This is largely because the dispensaries are grossly inadequate in number and insufficiently equipped. The services are starved of funds and the little there is goes for staff salaries and tertiary care hospitals.
Appointments are made on grounds other than merit. Private practice is carried on by government doctors, who use public hospital equipment for private patients.
Barring a few private hospitals and nursing homes, most provide a quality of care that is grossly inferior. Unnecessary surgeries, over-investigations, unethical practices in coronary bypass surgery, kidney transplants, etc. Proliferate. Cut practice inevitably leads to unethical and unnecessary investigations, referrals, hospitalization, high costs, etc. In some hospitals, the pressure to ensure full occupancy of the beds forces doctors to bring in 'business'.
Many private hospitals do not admit patients unless a certain amount of deposit is paid. Doctors and nursing homes charges are often exorbitant and irrational. Many of the bigger hospitals are registered as trust hospitals with a view to getting various state benefits and escaping taxes. In return, 20 per cent of their beds and investigations are meant to be reserved for poor patients. In reality, rarely are poor patients treated at these hospitals.
The private hospitals and nursing homes in the city function without any monitoring and are practically unregulated. It took a writ petition in the Bombay High Court filed by the MFC and Yasmin Tavaria for the BMC for the authorities to admit that the hospitals and nursing homes were indeed functioning without any monitoring.
The court directed the BMC to constitute various committees of experts "to act as a watchdog over the BMC and make appropriate suggestions and recommendations in the regard".
The committee found many of the nursing homes were not registered, functioned from sheds, often dingy, without ventilation, lighting, water, equipment or an operation theatre. Further, they were found to have narrow entrances and passages, were congested and a majority of them were manned by unqualified doctors and nurses. Little progress has been made on the matter and the case is at the moment back in the high court.
On the one hand, we have the public sector which is highly controlled and centralized and the private sector functioning without any monitoring. During the past two decades, there has been a general deterioration in the standard of public health services it the city. It is no coincidence that in these two decades, the private health sector has grown geometrically.
There is an urgent need to strengthen primary care services at the dispensaries and use this as a referral system for secondary and tertiary care. Even the priorities within hospital care development needs to be set as per actual needs, especially of basic specialties as against super-specialties.
This implies vast investment and the government. Though the government and the civic corporation are always complaining about he paucity of funds for the health sector, a lot can be done even with the existing resources provided there is a will.
Additional resources can be generated though rationalization, quality control etc. Further resources can be generated from people with capacity to pay. These people should pay through income and consumption-related taxation and levies and not at the point of delivery of care.
There should be standardization of fees charged, guidelines for all types of hospitals and regular medical and prescription audits.
The Metropolis (Anniversary Special), February 4-5, 1995, pp.1
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