Having over 12 million people as residents besides a floating population of about 6 million people, India’s biggest metropolitan city Mumbai has quite a lot on its platter to cope up, especially in terms of healthcare. The onus to manage it lies on the Municipal Corporation of Greater Mumbai (MCGM), Sandeep Datta and Harshal Yashwant Desai of Elets News Network (ENN) explore the Herculean endeavour.
MUMBAI AT A GLANCE
Described commonly as India’s financial capital, Mumbai has a large commercial and trading base. It hosts corporate offices of industries, multinational companies and headquarters of key financial institutions.
The city is divided into 24 administrative divisions (wards) with population of 8-10 lakh each. The Mumbai island city plus the Mumbai suburban district comprise what is now called as Greater Mumbai It is under the administration of the Municipal Corporation of Greater Mumbai (MCGM).
MCGM AND THE HEALTH DEPARTMENT
Among the notable departments of Municipal Corporation of Greater Mumbai is the Health Department. It not only provides basic healthcare facilities but also manages other aspects related to preventive and social or community medicine.
The city follows the three-tier system of healthcare. At the primary- level of healthcare, it provides maternity and child care, family planning, control of communicable diseases, immunisation and services for non-communicable diseases through a network of 208 primary health posts, 175 dispensaries and 28 maternity homes in addition to outreach health services.
At the secondary-level, specialised health services are provided through 17 peripheral hospitals and five specialty hospitals. Tertiary care is provided through four medical colleges. The total annual outpatient department load in peripheral hospitals is 57 lakhs.
MCGM HEALTH BUDGET
Municipal Commissioner of Municipal Corporation of Greater Mumbai Ajoy Mehta recently presented the budget for 2019-20, while giving due attention to improve healthcare delivery within its hospitals and institutions.
MCGM has allocated Rs 4,151.14 cr for new hospitals and upgradation of equipment. The budget for health department has been increased by over 13 percent. Besides provision for major hospitals, the corporation will spend on basic infrastructure and equipment. There is a separate provision for building construction of proposed Hinduhriday Samrat Balasaheb Thackeray Medical College and repairing Nair hospital.
According to Mehta, budget primarily focuses on the health of Mumbaikars. The health budget has been increased by Rs 400 crores as compared to last year to Rs 4,151 crores for the health sector in the city. The corporation is very much focussed on improving its peripheral hospitals with newer upgradation to convert them into super specialty hospitals so that the pressure on major civic run hospitals is reduced.
THE GAMUT OF CHALLENGES
Some prominent challenges in healthcare service delivery at all levels include rising population, migration, undernutrition, poor housing, overcrowding and increasing risk factors of non-communicable diseases (NCDs) like obesity, eating habits, smoking and drinking and physical inactivity.
In the light of challenges and increasing demand, there are gaps in healthcare delivery. Hence, the MCGM in recent years embraced new innovations to provide healthcare, for example, in providing extra beds.
MCGM has been consistently making efforts to strengthen and revamp the three-tier system and public health infrastructure including preventive healthcare system.
MCGM’S LANDSCAPE OF INITIATIVES PPP POLICY FOR STRENGTHENING PATIENT SERVICES
Public-private partnerships (PPPs) can be viewed as an effective way to expand access to higher-quality health services by leveraging capital, managerial capacity, and know-how from the private sector.
There is a constant need to bring together the private health sectors such as medical colleges, hospitals, industrial/corporate hospitals, nursing homes, NGOs and practicing doctors/ specialists for the success of public health programmes.
MCGM has a PPP policy revised in 2018 under which these premises are being utilised for provision of services such as maternal and child services and also other specialty services to the citizens.
STRENGTHENING OF PRIMARY AND SECONDARY HEALTHCARE SERVICES
STRENGTHENING DIAGNOSTIC SERVICES THROUGH “AAPLI CHIKITSA”
In major hospitals, 50% of the patient load is due to diagnostics (e.g. KEM hospital sees 3,000; 50% of total patients) referrals for diagnostics on everyday basis.
Therefore, Aapli chikitsa, an innovative solution to provide “free pathological diagnostic services” to patients at the peripheral level is being introduced.
Under the initiative, the laboratory services will be outsourced in 16 municipal peripheral hospitals, five Specialty Hospitals, 28 Maternity Homes and 175 Dispensaries on public private partnership basis.
PROVIDING FREE CANCER SERVICES THROUGH PPP
India reports over 1.5 million new cancer cases annually, that’s about 100 cases per 1,00,000 people as compared to 300 in the US.
According to data collated by the Indian Cancer Society, the Mumbai Cancer Registry recorded 13,564 cases in 2014 compared with the 12,090 in 2010.
Screening of cancer becomes an utmost prevalent public health action, for the purpose MCGM partnered with Cancer Patients Aid Association (CPAA) in 1998 to undertake early screening of breast cancer through mammography.
MCGM under the PPP policy allotted Naigaon Maternity hospital to the Cancer Patients Aid Association (CPAA), who runs the centre with the help of corporation and donor funds. This was a true model of public private NGO partnership.
PROVIDING COMPREHENSIVE THALASSEMIA CARE, PAEDIATRIC HEMATOLOGY, ONCOLOGY AND BONE MARROW TRANSPLANT SERVICES FREE TO PATIENTS
Considering the need of an intervention in this area, MCGM established the “Comprehensive Thalassemia Care, Paediatric Hematology-Oncology & BMT Centre” in 2017 with expertise from LTM Sion Hospital as a satellite centre.
The centre is well-equipped with all major facilities such as indoor facility, ICU, day-care chemotherapy unit, bone marrow transplantation unit, day care transfusion unit, pre- natal diagnosis and operation theatre for bone marrow transplantation procedures.
Laboratory services are also available with all basic investigations; ultrasonography, electrocardiogram and 2D echocardiography machines, audiometry, apheresis machine, an ophthalmology unit with slit lamp and fundoscopy and the blood irradiator. The centre also provides diagnostic procedures such as bone marrow aspiration, biopsy, lymph node and other tissue biopsy.
STRENGTHENING CT SCAN AND MRI DIAGNOSTICS SERVICES IN PERIPHERAL HOSPITALS
The contracting mechanism was adopted and the services were started on PPP model wherein the PP partner brings in the equipment, staff and maintains the services throughout in the MCGM premises.
MCGM patients receive services at MCGM rates whereas the PP partner can also take private patients on paid basis.
BOOSTING INTENSIVE CARE SERVICES IN PERIPHERAL HOSPITALS
The shortage of ICU beds combined with an insufficient number of trained professionals pose challenges to the delivery of effective critical care services across the city.
MCGM is set to share 180 intensive Care Unit (ICU) beds under public- private partnership (PPP) to cater to ICU patients because there is dearth of intensivists in peripheral hospital.
A contracting mechanism was adopted on the basis of per bed per day rates (Rs. 2,200 per bed/day) and intensivists were appointed to provide round the clock services in ICU. At any given time, one post graduate intensivist and other with M.B.B.S. qualification and five years ICU experience.
STRENGTHENING DIALYSIS SERVICES AT PERIPHERAL LEVEL
MCGM evolved a model wherein non- governmental organisation (NGO) backed by charitable dialysis units, either in an established hospital or as free standing units, were set up.
Mumbai has 112 dialysis centres, of which 12 are housed in MCGM and rest of them are in private sector.
As per the model, the NGO enters into a public-private partnership with the MCGM which provides space for the unit in MCGM hospital or the permission is obtained under Reservation Accommodation policy and the NGO runs the charitable dialysis unit by installing all equipment.
INCREASING THE BED CAPACITY THROUGH CHARITABLE TRUST HOSPITALS
A total of 1,762 beds are being made available for weaker and needy patients in 77 hospitals. As part of the process, the economic status of patient is verified by MSW of hospital and is referred to the charitable hospital; thus, reducing the out-of-pocket expenditure of patients.
Bed, RMO services, nursing care, food, linen, water, electricity, routine diagnostics and housekeeping services are non-billable and to be provided free to weaker and indigent patients by charitable hospitals.
STRENGTHENING OF MATERNAL CARE IN MATERNITY HOMES THROUGH SPECIALISTS
MCGM evolved a model where case- based approach has been adopted. A panel of anesthetics, sinologist, and paediatrician has been created.
Case-based payment has been fixed for managing each patient which makes it easy to make these specialists available at every centre.
• 28 anesthetics, 28 sonologists, 7 pediatricians, and 4 gynecologists have been appointed on the panel for specialized services
• Out of 28 maternity homes, five maternity homes are identified zone-wise as sentinel centers as first referral unit with services of sentinel neonate care unit
A MODEL OF PRIVATE SECTOR ENGAGEMENT IN TUBERCULOSIS
Tuberculosis (TB) is one of the top ten most common causes of death worldwide.
In 2013, a comprehensive strategic plan “Mumbai Mission for TB Control” was formulated by MCGM in response to the growing concern over the spread of TB and increasing incidence of drug-resistant TB in the city. As a part of this mission, private sector involvement was an important strategy in order to improve quality of diagnosis, treatment and patient care at all levels of private sector.
The project was implemented in 2015 through a donor agency and was later transitioned to private provider support agency (PPSA) in the year 2018 to be fully implemented by MCGM (Mumbai District TB control society).
PROVISION OF GENERIC MEDICINES THROUGH PRADHAN MANTRI BHARTIYA JANAUSHADHI KENDRA
Following the need assessment, it was decided that MCGM shall be making arrangements to build up an area for setting up of Pradhan Mantri Bhartiya Janaushadhi Kendra (PMBJK) under PPP Model.
The said premises shall be handed over to the service provider for a period of five years on care taker basis. In the initial phase, three hospitals were shortlisted to begin the services and later on the services are to be expanded to other peripheral hospitals as well.
STANDARDISATION OF HEALTHCARE INFRASTRUCTURE
With the growing disparity and no standard protocol available for standardisation of infrastructure for peripheral hospitals, it has been proposed to give uniform aesthetic look to all the peripheral hospitals which will include both exteriors and interiors of hospitals.
As part of the standardisation process, the internal arrangement in the wards, OPDs and casualty should be as per the Airborne Infection Control (AIC) norms.
PRIMARY PREVENTION FOR COMMUNICABLE AND NON- COMMUNICABLE DISEASES
SOCIAL CAMPAIGN FOR DENGUE CONTROL USING MASS AWARENESS IN MUMBAI
The existing strategies adopted by MCGM for dengue control involve work place interventions, contact tracing, and various interventions in non-slum areas and involvement of housing societies along with massive awareness campaigns.
• Representatives from PLAN International (India chapter) and health officials conducted a series of meetings to undertake a pilot project in five of high risk wards of MCGM
• Based on the available data at epidemiology cell, five high risk wards were identified for this pilot project
• A total of 100 volunteers (20 for each ward) were trained by PLAN’s insecticide department regarding common domestic, peri-domestic breeding sites, how to identify the larvae, adult mosquito etc. for the door to door awareness activities
PROVISION OF COUNSELLING SERVICES TO BEAT DIABETES (NCD CONTROL)
Non-communicable diseases (NCDs) are a growing concern worldwide and as per Indian Council of Medical Research, prevalence of diabetes in Mumbai is 10% and that of pre- diabetes is 15%.
• The pilot project was initially started in 28 dispensaries and as a next step these services are now being expanded to 72 dispensaries from 1st December 2018 for a period of six months
• A joint initiative of MCGM & Indian Dietetic Association (IDA) which was initially implemented in four select ward dispensaries to test the efficiency & efficacy of this model
As part of the intervention, patients who need counseling are referred to dietitians appointed by IDA. Patient is then provided lifestyle solutions on individual basis and is followed up on weekly basis
STOP DIABETES BLINDNESS — A STRATEGY TO PREVENT DIABETES MELLITUS RELATED BLINDNESS
Diabetes is a lifelong disease and has immense long term effects where it affects other organs like the eyes, kidney, and nerves along with other essential body organs. The retina of diabetic patients gets affected over course of disease which may lead to blindness.
PROCESS OF IMPLEMENTATION
• A joint initiative of MCGM & Aditya Jyot Foundation for Twinkling Little Eyes (AJFTLE)
• Initially, the intervention was implemented at 47 MCGM dispensaries in select dispensaries
Since the beginning of the programme in August 2018, 629 diabetic patients were screened for ophthalmic examination in 14 dispensaries, of which 56 showed cataract (8.9%), 50 showed retinopathy changes (7.9%) and other ailments were seen in 34 patients (5.4%).
STRENGTHENING AIRBORNE INFECTION CONTROL PRACTICES IN HEALTHCARE INSTITUTIONS
An AIC Unit (AICU) model was established by Municipal District TB control Society in collaboration with U.S Centers for Disease Control and Prevention (CDC) and SHARE India in 2016, which is one of the unique initiatives in India.
It provides technical and operational guidance on environmental controls to reduce the risk of transmission of airborne pathogens for example Tuberculosis.
STRENGTHENING OF TERTIARY HEALTHCARE SERVICES PROVIDING TELEMEDICINE SERVICES AT PERIPHERAL HOSPITALS
Telemedicine essentially combines state-of-the-art electronics, ICT and associated applications in the field of healthcare delivery and also helps in providing education to patients and healthcare professionals.
MCGM recognised that the use of telemedicine can greatly aid in dealing with the shortage of healthcare staff and improving the penetration of healthcare infrastructure and resources in underserved healthcare facilities.
MGGM is in the process of setting up telemedicine facility wherein 16 peripheral hospitals (patient node) will be connected with four major hospitals (specialist node) through outsourcing mechanism.
The services will also include real time screening with portable integrated medical devices, examination camera and store and forward image automation software, digital stethoscope to improve utilisation of healthcare services.
INNOVATIONS IN FACILITY MANAGEMENT
Health Management Information Systems (HMIS), one of the six building blocks essential for health system strengthening, is a data collection system specifically designed to support planning, management, and decision-making in health facilities and organisations.
MCGM does not have a single online platform to store electronic version of patient files.
HMIS will help store patient’s information in digitised form at one place making patient records particularly patient history easily and readily available at all levels.
PROCESS OF IMPLEMENTATION
The HMIS is in process and will be rolled out in a phase-wise manner. Some of the major features of HMIS in process include patient management, data generation and a special feature to convert speech to text for data entry into OPD sheets.
The connectivity providers will be MTNL & TATA and the scope covers four major hospitals, five specialty hospitals, 18 peripheral hospitals, 28 maternity homes, 161 dispensaries, 183 health posts.
The scope covers 34 modules under; patient registration / admission, OPD, IPD, emergency, administrative, allied services, diagnostic & investigation.