Chapter 1

Nature, Scope, Objectives and Methodology of

Research

1.1 Introduction

1.2 Significance of the Study

1.3 Scope of the Study

1.4 Objectives of the Study

1.5 Hypotheses of the Study

1.6 Research Methodology

A. Universe
B. Sample
C. Types of Data
D. Tools of Data Collection
E. Presentation of Data
F. Analysis of Data

1.7 Chapterisation

1.8 Limitations of the Study

1.9 Expected Contribution

1.10 Conclusions
 A Comparative Study of Public and Private Health Services in
Mumbai Region Availability and Utilisation Pattern

1.1 Introduction:
Each child born in a country is human resource who will add to the
productivity and prosperity of the nation. However, the responsibility of converting
this latent resource in to an active workforce lies with the Government, private sector
and NGOs. They should be made responsible for health care development in the
country. A child suffering from poor health lacks attendance in the school. Workers
who suffer from childhood malnutrition are less productive than healthy workers.
India has one of the youngest populations in the world. India is experiencing high
growth since a decade. The sustainability of this high economic growth rate requires
huge investment in education and health care of the population.

Government hospitals, some of which are among the best hospitals in India,
provide treatment at taxpayers expense. Before economic reforms in 1991, most
essential drugs were provided free of charge to all patients in these hospitals.
Government hospitals provide treatment either free or at minimal charges. For
example, an outpatient card at AIIMS (one of the best hospitals in India) costs a
onetime fee of rupees 10 (around 20 cents US) and thereafter outpatient medical
advice is free. In-hospital treatment costs in these hospitals depend on financial
condition of the patient and facilities utilised by him but are usually much less than
the private sector. For instance, a patient is waived full treatment costs if he/she is
below poverty line. Another patient may seek for an air-conditioned room, if he is
willing to pay extra for it. The charges for basic in-hospital treatment and
investigations are much less in public hospitals as compared to the private hospitals.
The cost for these subsidies comes from annual financial allocations from the Central
and State Governments. In addition to the network of public and private hospitals,
there are charitable dispensaries and hospitals, many of which provide treatment and
facilities parallel to those provided by private hospitals at highly concessional rates or
in some cases free of costs to the needy population.

Primary health care is provided by city and district hospitals and rural primary
health centres (PHCs). These hospitals provide treatment free of cost. Primary health
care is focused on immunization, prevention of malnutrition, care during pregnancy,
child birth, postnatal care, and treatment of common illnesses. Patients who receive
specialised care or have complicated illnesses are referred to secondary care centres
(often located in district and taluka headquarters) and tertiary care hospitals (located
in district and state headquarters or those that are teaching hospitals).

In post-independence period, India has eradicated mass famines, however the

country still suffers from high levels of malnutrition and disease especially in rural

2
areas. Water supply and sanitation in India are also major issues and many Indians in
rural areas lack access to proper sanitation facilities and safe drinking water. However,
at the same time, India's health care system also includes facilities that meet or exceed
international quality standards. The medical tourism business in India has been growing
in the recent years and as such India is a popular destination for medical tourists who
receive effective medical treatment at lower costs than in the developed countries.

1.2 Significance of the Study:

The role of healthcare in improving a nations wealth and spurring economic
growth is well established. India is among the fastest growing economies in the world
and is poised to become the second largest economy in the world according to a
recent report from the PricewaterhouseCoopers International Limited (PwCIL).1
Indias Human Development Index score, weighed down by poor healthcare
indicators is, however, poor at 0.519, ranking India at 119 out of 169 countries just
ahead of Timor-Leste and Swaziland.2 Several factors that contribute to poor
healthcare indicators in India are:3
(1) Indias healthcare infrastructure is inadequate to meet the huge burden of
disease. India has just 90 beds per 100,000 population against a world average
of 270 beds.
(2) India also has just 60 doctors per 100,000 population and 130 nurses per
100,000 population against world averages of 140 and 280 respectively.
(3) Public spending on healthcare has also been less than 1% of GDP since
independence.
(4) Indias healthcare financing mechanisms are poor with 66% of healthcare
expenditure being out-of-pocket.

Together, these factors result in a poor per-capita spending on healthcare at

US$ 109.4 A slew of reforms are needed urgently to address these concerns.

In India, annually 22 lakh infants and children die from preventable illnesses;
1 lakh mothers die during child birth, 5 lakh people die of Tuberculosis. Diarrhoea
and Malaria continue to be killers while 5 million people are suffering from
HIV/AIDS.5 In context of poverty, access to public health systems is critical. Since
1990s, the public health system has been collapsing and the private health sector has
flourished at the cost of the public health sector. Health policy in India has shifted its
1
PricewaterhouseCoopers International Limited (PwCIL) (2010), Report on Indian Growth, India.
2
United Nations Development Programme (2010), Human Resource Development Report, New
York, Oxford University Press.
3
Krishnakumar, Sankaranarayan (2011), Budget 2011-12: The Healthcare Sector Wishlist, PwC
India, February.
4
World Health Organisation (WHO) (2010), World Health Statistics, Geneva.
5
Gangolli, Leena V. and et.al. (2005), Review of Healthcare in India, Centre for Enquiry into Health
and Allied Themes (CEHAT), Mumbai, January.

3
focus from being a comprehensive universal healthcare system as defined by the
Bhore Committee (1946) to a selective and targeted programme based healthcare
policy with the public domain being confined to family planning, immunization,
selected disease surveillance and medical education and research. The larger
outpatient care is almost a private health sector monopoly and the hospital sector is
increasingly being surrendered to the market. The decline of public investments and
expenditure in the health sector since 1992 has further weakened the public health
sector thus, adversely affecting the poor and other vulnerable sections of society.
Introduction of user fees for public health services in many states has further reduced
their access to health services.6 The time has come to reclaim public health and make
a paradigm shift from a policy-based entitlement for healthcare to a right-based
entitlement. For this healthcare has to become a political agenda.

Again there are disparities in healthcare services in rural and urban areas and
in public and private healthcare services. 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 these regional inequalities have not seen any significant
decline over time. The regional imbalance in health care facilities is there in both the
public and the private health sector.

Considering the above dichotomy, there is a strong need to have an effective

National Health policy to provide timely and cost effective health care services to
masses and develop vast medical tourism potentials of India. Considering the
locational aspect that 63% of our population lives in rural areas and lack hospitals,
hospitals without doctors, shortage of medicines, etc., this research work may attract
the attention of policy makers to have an effective distribution of health measures
through proper designing and effective implementation of health policies and
programmes of the government, so, as to reach the benefits of healthcare to the
maximum numbers in maximum areas. In urban areas, many needy and deserving
people do not avail health care services of public hospitals due to time and cost
wasted in travelling from their place of residence to the hospital, where they have to
wait for hours at the cost of their daily subsistence. Again these hospitals prove costly,
when a patient, referred to private labs for test and evaluation, is made to pay user fee
and made to buy medicines from private vendors for the want of adequate quota of
essential medicines with the hospital.

Given all these constraints and deficiencies, India is poised to become a

popular destination for medical tourism. Medical Tourism (a.k.a. Health Tourism) is a
developing concept whereby people from world over visit India for their medical and

6
Dilip T.R. and Duggal Ravi (2004), Unmet Need for Public Healthcare Services in Mumbai, India,
Asia-Pacific Population Journal, Bangkok, Thailand, June.

4
relaxation needs. Most common treatments are heart surgery, knee transplant,
cosmetic surgery and dental care. The reason why India is a favourable destination, is
because of its infrastructure and technology in which it is at par with those in the
USA, the UK and Europe. India has over 150000 medical tourists each year and this
figure is rising at a high pace. Mumbai is becoming a main centre of medical tourism
with 282 private general hospitals, 14 multi specialty hospitals and three super
specialty hospitals.7 There are special hospitals in Mumbai as well five for cancer
care and four heart institutes. Still the overall standard of healthcare facilities in India
in general and in Mumbai in particular is poor.

From macro-perspective also there are several reasons for promoting public
health care facilities in India:
(1) Higher growth improves health status and better health status reinforces trends
and income growth.
(2) Medical care is price sensitive goods. 1% increase in income is associated
with 1.4% increase in medical care.
(3) Improved health reduces poverty. Out-of-pocket medical cost alone may push
2.2% population below poverty line in one year in India.8

Against this background, the present study compares and contrasts the
standard of healthcare services provided by a public sector and private sector hospital
in the city of Mumbai.

1.3 Scope of the Study:

The present study is restricted to the network of the healthcare facilities in the
city of Mumbai. Mumbai, the commercial capital of India, is the largest city in the
country carrying a population of 12.5 million people. The density of population in
Mumbai is very high. Mumbai has a Population density of 30,000 persons per square
kilometer which is relatively high.9 The following table outlines the demographic
characteristics of Mumbai as per the Census 2011.
Table No. 1.1
Demographic Characteristics of Mumbai
Population, Density, Literacy and Sex Ratio 2011
Parameters
Population as per 2011 1,24,78,447
Density of Population (per sq. Km.) 30000
Literacy Rate 89.7
Sex Ratio (Number of females per 1000 males) 848
Source: Population Statistics 2011, Government of India, New Delhi.

7
http://www.mumbaidoctors.co.in/list-of-hospitals.html.
8
Jain Kalpana (2004), Debt Trap: Stuck in a Private Hospital, Mumbai, Times of India, 19th November.
9
Government of India (2011), Population Census of India, New Delhi.

5
 About 49% of the population of Mumbai are residing in slums, characterised by
shortage of living space, water supply and sanitation facilities. Slums in Mumbai are
unique in the sense that only 4% are Kacha hutments, while 45% and 51% of houses in
slums are semi-pacca and pacca houses respectively.10 The health and sanitation
conditions in slums are poor and the proportion of people falling sick is very large.
Providing adequate, timely and cost effective health care services to such a huge ailing
population from slums, which is highly susceptible to all types of diseases, is a
challenge indeed. This requires a comprehensive and well planned health policy that
can co-ordinate the plans and programmes of the various public health care providers
such as the government, private hospitals and clinics and NGOs in India.

Mumbai city has hospitals and dispensaries run by Municipal Corporation of

Greater Mumbai (MCGM), state government and private trusts. MCGM, the largest
Municipal Corporation in India, is the major providers of public health care services
in Mumbai. It has a network of four teaching hospitals, five specialised hospitals, 16
peripheral hospitals, 28 municipal maternity homes and 14 maternity wards attached
to municipal hospitals with around 17000+ employees attached to these hospitals.11
Apart from that, there are 185 municipal dispensaries and 176 health posts to provide
outpatient care services and promote public health activities in the city. In addition,
the state government has one medical college hospital, three general hospitals and two
health units and all together they have a capacity of 2871 beds.12

The scope of the present study is restricted to the public and private sector
healthcare service providers and also charitable dispensaries and hospitals in Mumbai
and the total population of Mumbai city who is the consumer of these services. The
study covers data for a period ranging from 2001-2002 to 2010-2011.

1.4 Objectives of the Study:

Health promotes development through increase in efficiency and productivity
and therefore, improvement in the health status of people is essential for social and
economic development of a nation. Improved health reduces poverty through
improvement in productive capacity of a labour. Good health enables a person to earn
more and create additional resources to maintain and improve his/her health.
Economic growth requires not only capital accumulation and progress in technology
but also investment in social sectors such as education and health and alleviation of
poverty. Therefore, it is essential to promote economic welfare through fair
distribution of health services to poor population who are the masses of India.
10
International Institute of Population Sciences (IIPS) and ORC Macro (2001), Life in Slums of
India, Mumbai.
11
Municipal Corporation of Greater Mumbai (MCGM) (2009), Records of Municipal Corporation of
Greater Mumbai.
12
Government of Maharashtra (2009), Directorate of Health Services.

6
 The topic of the thesis is A Comparative Study of Public and Private Health
Services in Mumbai Region Availability and Utilisation Pattern. It is the study
related to the inequality in the distribution and usage of Public and Private Health
services in the city of Mumbai. It brings out an in-depth analysis of availability and
accessibility of public health care services to the poor population that constitutes
almost half the population of the city. This study aims to document and analytically
understand the constraints experienced by poor while accessing public health care
facilities, the extent to which these services are used by needy and poor population
and expenditure pattern of poor population on health care services in the city of
Mumbai. The availability of healthcare services in urban areas is currently inadequate
due to rising population and increasing rate of immigration. The economically poor
population of urban areas tend to have higher unmet need for healthcare due to
poverty, inconvenient location of public hospitals, poor quality services, higher user
fee and inconvenient timings of public hospitals, leaving many of the reported
ailments untreated. In spite of having better healthcare services, there are studies that
show people residing in Mumbai are not having proper access to health care services
as 32% of the reported ailments remained untreated.13

The study attempts to understand the problems faced by poor population in

seeking healthcare services provided by the government in general and private
hospitals in particular. The study reviews relevant academic work relating to the
determinants of health care services and the impact of poor health of poor masses on
the state economy. This research also attempts to study the broad determinants of
health care expenses of poor in the context of rising morbidity among adults, children
and more among women. The study also focuses on the need to have a disaggregated
study by selecting Mumbai as a sample population to arrive at meaningful policy
alternatives. The study also questions; why the poor spend on private health services
instead of seeking free of cost public health services provided by the government?
Too often, services fail poor people in access, in quality, and in affordability.

Against the above background, the study seeks to achieve the following broad
objectives:
(1) To compare and contrast the differences in healthcare standards and healthcare
facilities in private and public sector hospitals in the city of Mumbai.
(2) To study expenditure pattern of urban poor towards healthcare sector and their
inclination towards private or public sector and reasons thereof.
(3) To examine the problems faced by poor people in accessing public healthcare
services.
(4) To examine whether any gender bias exists in health expenses of poor families
in urban areas.
13
Duggal Ravi and et.al. (1995), Health Expenditure across States PartI Economic and Political
Weekly, Mumbai, vol. 30, No. 15, pp. 834-844.

7
 (5) To draw attention of policy makers to lacunae in the public healthcare system
and make suggestions for the betterment of healthcare system in the city.

1.5 Hypotheses of the Study:

On the basis of the above broad objectives, the study proposes to test the
following hypotheses:
(1) Poor families prefer private health services due to convenient timings,
convenient location, quality services and user-friendly charges.
(2) Public health services in the city of Mumbai are inadequate in relation to
market demand. Hence, poor are compelled to access private health services.
(3) In Mumbai, transport cost to access public health service is much higher than
the user charges.
(4) Poor families avoid treatment to save loss of their subsistence wages. They
survive on Over the Counter medicines available conveniently at cheaper cost.
(5) There is a gender bias in the share of health expenses in families.

1.6 Research Methodology:

Various components of research methodology for the present research work
are as under:
A. Universe:
All public, privates and charitable hospitals and dispensaries located in the city of
Mumbai and the entire population of Mumbai constitute universe for the present study.
Table No. 1.2
List of Government Hospitals in Mumbai
Sr. Name of Hospital Location Phone
No. No.
(1) Jagjivan Ram Hospital (Railway) Agripada 23095801
(2) E. S. I. S. Hospital Andheri 28367207
(3) MIDC Hospital Center Andheri (E) 26343772
(4) Kasturba Hospital Arthur Road 23083901
(5) K. B. Bhaba Hospital Bandra 26422775
(6) Harilal Bhagwati Municipal General Hospital Borivali (W) 28932461
(7) Central Railway Hospital Byculla 28726588
(8) J. J. Hospital Byculla 23739031
(9) Municipal Eye Hospital Byculla 23082632
(10) St. George Hospital C.S.T. (V.T.) 22620248
(11) B.A.R.C. Hospital Chembur 25563140
(12) Mangal Anand Hospital Chembur 25224845
(13) RCF Hospital Chembur 25563397
(14) Smt. Diwaliben Mehta Municipal Hospital Chembur 25220333
(15) Bhabha Hospital Chembur 25520333
(16) Family Planning Hospital Colaba 22611654
(17) G. T. Hospital Crawford Mkt. 22621464

8
(18) B. J. Sangar Hospital Deonar 25563137
(19) Cama Albless Hospital Dhobi Talao 22611654
(20) E.S.I.S. Hospital Dhobi Talao 22042526
(21) Godfrey Clinic Fort 22613093
(22) Seth A.J.B. Municipal ENT Hospital Fort 22042526
(23) Rajawadi Hospital Ghatkopar 25115066
(24) Sant Muktabai Municipal General Hospital Ghatkopar 25153771
(25) Siddharth Hospital Goregaon 28766885
(26) Centenary General Hospital Govandi 25564069
(27) Haji Ali Childrens Orthopedic Hospital Haji Ali 24920030
(28) Cooper Hospital Juhu 26207254
(29) E.S.I.S. Hospital Kandivali 28877501
(30) Centenary General Hospital Kandivali (W) 28050882
(31) Khar T. B. Hospital Khar 26482353
(32) Bhabha Hospital Kurla 25113144
(33) Agarwal Trust Eye Hospital Kurla (W) 25143616
(34) K. B. Bhabha Hospital Kurla (W) 26500144
(35) M. W. Desai Municipal General Hospital Malad 28777857
(36) S. K. Patil Municipal General Hospital Malad (E) 28894381
(37) E.S.I.S. Hospital Marol 28320752
(38) E.S.I.S. Hospital Mulund 25645521
(39) Municipal Hospital Mulund (E) 25616225
(40) Swatantra Veer Sawarkar Municipal General Hospital Mulund (E) 25686225
(41) Manasdevi T. Agarwal Municipal General Hospital Mulund (W) 25640767
(42) B.Y.L. Nair Charitable Hospital Mumbai Central 23081490
(43) Police Hospital Nagpada 23075909
(44) Police Hospital Naigaon 24111666
(45) INHS Asvini Navy Nagar 22151666
(46) Health Unit (Railway) Hospital Parel 24225966
(47) K.E.M. Hospital Parel 24131763
(48) M.G. Memorial Hospital Parel 24132575
(49) Tata Hospital Parel 24161413
(50) Tata Memorial Hospital Parel 24146750
(51) Wadia (Female) Hospital Parel 24129786
(52) Wadia (Children) Hospital Parel 24129787
(53) I.I.T. Hospital Powai 25782316
(54) Naval Dockyard Hospital Powai -
(55) Mumbai General Hospital Santacruz (E) 26182081
(56) V. N. Desai Municipal General Hospital Santacruz (E) 26182081
(57) Sewree T. B. Hospital Sewree 24139784
(58) Lokmanya Tilak Municipal General Hospital Sion 24076381
(59) Sion Hospital Sion 24092020
(60) E.S.I.S. Hospital Thane 25823434
(61) Mental Hospital Thane 25320728
(62) Turbhe Hospital Turbhe 27631827
(63) K. M. J. Phule Municipal General Hospital Vikhroli (E) 25782283
(64) Acworth Municipal General Hospital for Leprosy Wadala 24147256

9
 (65) B.P.T. Hospital Wadala 24129684
(66) E.S.I.S. Hospital Worli 24933142
(67) Mata Bal Sangopan Hospital Worli -
(68) Poddar Hospital Worli 24933533
(69) Police Hospital Worli 24940303
Source: Compiled from the records of Mumbai Mahanagarpalika.

Mumbai is the commercial capital of India and supports large population.

Since years, there has been no expansion in the public healthcare facilities in the city
with ever-rising population. Mumbai houses the largest number of slum dwellers in
the world with numerous health issues, both due to pollution and fast-moving
lifestyle. More than half (54.5%) the population of Mumbai dwells in slums.14 The
following table shows the ward-wise distribution of slum population in Mumbai city.
Table No. 1.3
Ward Wise Distribution of Slum Population in Mumbai City, 2001
No. of Name of Ward Total Slum Slum Population (in
Wards Population %)
(1) (Ward A) Colaba 60,893 28.88
(2) (Ward B) Sandhurst Rd. 18,746 13.33
(3) (Ward C) Marine Lines Nil Nil
(4) (Ward D) Grant Road 38,077 9.95
(5) (Ward E) Byulla 52,230 11.86
(6) (Ward F/S) Parel 141,653 35.76
(7) (Ward F/N) Matunga 304,500 58.07
(8) (Ward G/N) Mahim/Dadar 324,886 55.82
(9) (Ward G/S) Elphinstone Rd. 151,506 33.08
(10) (Ward H/W) Bandra 138,541 41.06
(11) (Ward H/E) Khar Santacruz 457,622 78.79
(12) (Ward K/E) Andheri (E) 472,226 58.30
(13) (Ward K/W) Andheri (W) 316,065 45.11
(14) (Ward P/S) Goregaon 210,591 48.10
(15) (Ward P/N) Malad 508,435 63.65
(16) (Ward R/S) Kandivali 326,235 55.30
(17) (Ward R/C) Dahisar 173,160 33.75
(18) (Ward R/N) Borivali 169,662 46.63
(19) (Ward L) Kurla 658,972 84.68
(20) (Ward M/W) Chembur (W) 283,557 68.48
(21) (Ward M/E) Chembur (E) 523,324 77.55
(22) (Ward N) Ghatkopar 435,009 70.21
(23) (Ward S) Bhandup 593,300 85.83
(24) (Ward T) Mulund 116,250 35.21
Total 24 Wards 6,475,440 54.06
Source: Directorate of Census Operation, Maharashtra, Census of India 2001.

14
Singh D. P. (2006), Slum Population in Mumbai, Published by IIPS Mumbai, ENVIS Centre,
Volume 3, No. 1, March.

10
 According to the ward-wise break-up of the slum and non-slum population as
of 2001, S ward in the eastern suburbs, comprising Bhandup, Nahur, Vikhroli and
Kanjurmarg, has the highest concentration of slum dwellers at 85.8 per cent. It is
followed by L ward (Kurla) with 84.7 per cent, H/East ward (Santacruz, Mahim) with
78.8 per cent and M/East (Govandi, Mankhurd) with 77.5 per cent. The entire
population of the Mumbai city and all slum dwellers and public and private hospitals
and dispensaries constitute universe for the present study.

Justification for Selecting Mumbai as a Research Area:

Mumbai is the financial capital of India. People from different parts of the
country have migrated to this city and thus, the city is inhibited by people of diverse
linguistic and religious groups. Mumbai is one of the most crowded cities of the world
in terms of density of population (30000 persons per sq. km.). The city experiences all
the problems of growing urbanisation such as increasing population, pollution, rising
slums, dearth of health facilities, fast moving life, poor awareness among masses about
health issues and to add to it, indifferent attitude of the government towards
development of health facilities. Although health facilities in the city have improved in
recent years, they are not just enough, especially in the public sector. This has paved the
way for the development of healthcare services in the private sector. All these factors
collectively make Mumbai an ideal place for conducting research on the present topic.

B. Sample:
Considering the ward-wise slum and non-slum population as per the Census
2001, the researcher has selected the following five areas for the purpose of data
collection and analysis and establishing hypotheses and achieving objectives of the
research. Most of these wards have very high concentration of slum population as per
the Census 2001:
(1) (Ward H/W) Bandra
(2) (Ward H/E) Khar, Santacruz
(3) (Ward P/N) Malad
(4) (Ward L) Kurla
(5) (Ward S) Bhandup (Including Nahur, Vikhroli and Kanjurmarg)

The government hospitals, private hospitals and trust-run hospitals which are
generally visited by people in the above areas for their health-related problems are:
Government Hospitals:
(1) M. W. Desai Municipal General Hospital, Malad (E),
(2) K. B. Bhabha Hospital, Bandra (W), and
(3) K.M.J. Phule Municipal General Hospital, Vikhroli (E).
Private Hospitals:
(1) Samarth Hospital, Vikhroli (W),
(2) Shanti Nursing Home, Bandra (W),
(3) Sanjeevani Hospital, Malad (E),

11
Trust-run Hospitals:
(1) Sanjeevani Chandrabhan Agrawal Charitable Trust Hospital, Malad (E).
(2) Mahavir Medical Research Centre, Khar (W).

A sample of 300 respondents has been selected randomly from the above areas
to seek responses of people, especially slum dwellers, on healthcare facilities provided
by the public hospitals vis--vis private hospitals and dispensaries in their areas.
Table No. 1.4
Table Showing Distribution of Sample
Sr. No. Ward Number of
Respondents
(1) (Ward H/W) Bandra 20
(2) (Ward H/E) Khar, Santacruz 32
(3) (Ward P/N) Malad 57
(4) (Ward L) Kurla 88
(5) (Ward S) Bhandup (Including Nahur, Vikhroli & Kanjurmarg) 103
Total 300
Source: Researchers Field Survey.

A sample of 100 in-patients and out-patients selected randomly from three

government sponsored hospitals in the areas was interviewed to have in-depth
investigation and analysis of the problem under consideration. The following table
gives the details of the sample selected from these hospitals:
Table No. 1.5
Distribution of Patients Selected for Personal Interview from the Selected Government
Hospitals in the Areas under Study
Name of the Hospital In-patients Out-Patients Total
Respondents
M F T M F T M F T
M. W. Desai Municipal General 4 5 9 11 14 25 15 19 34
Hospital, Malad (W)
K. B. Bhabha Hospital, 6 5 11 10 12 22 16 17 33
Bandra (W)
K.M.J. Phule Municipal General 4 5 9 9 15 24 13 20 33
Hospital, Vikhroli (E)
Total 14 15 29 30 41 71 44 56 100
* An in-patient is a person who is admitted to the hospital and stays overnight or for an
indeterminate time, usually several days or weeks
** An outpatient is a patient who is not hospitalized for 24 hours or more but who visits a
hospital, clinic, or associated facility for diagnosis or treatment.
Source: Researchers Field survey.

The researcher found it difficult to collect information from illiterate and

some aged respondents. Some respondents refused to part with information due to

12
their severe and prolonged illness. Thus, wherever respondents refused to part
with information or where the researcher found it difficult to extract information,
such respondents were substituted with other respondents, having similar profile.
The technique used to collect sample for the present research was random
sampling technique.

Justification for the Sample:

The sample for the present study is justified on the following grounds:
(a) The sample size is large and adequate. Again responses generated from the
patients and vulnerable groups have been cross checked by generating
responses on the same issues from the doctors and policy makers.
(b) Sample fairly represents the population under study. The universe for the
present study is homogenous in nature and therefore, the sample of 300
respondents from the area selected for the present study is quiet adequate.
(c) The sampling technique used for the present study is random sampling
technique. Considering the largeness of sample size, the question of bias can
be minimized.

C. Types of Data:
The present research study is based on data collected from both primary as
well as secondary sources.

Secondary data was collected from published reports of the Government of

India, Statistical data from Census reports, data from different rounds of surveys
conducted by the National Sample Survey Organisation (NSSO), the Sample
Registration System (SRS), and the National Family Health Survey (NFHS), Planning
Commission Reports and similar other Government publications. For international
data, sources were reports published by international bodies such as the World Bank
publications; World Development Report (WDR), Human Development Report
(HDR), World Health Organisation (WHO) and such others. Extensive literature
review of published books, research articles and studies published in national and
international journals and publications has also been undertaken. For the current
trends, the websites and internet were also explored.

Collection of primary data is done through the personal interviews of adult

members of poor households whose family income was Rs. 10000 and less per month
(70% of the respondents). Three hundred (300) men and women were interviewed.
Most of them were employed with unorganised sector with irregular income.
Selection of household is based on accessibility. The households were chosen at
random with the assistance of the local chiefs. Patients in the hospitals were
interviewed through permission of the hospital authorities. The questionnaire,
included questions about personal and family characteristics of the respondents and

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their expenditure pattern and utilisation of health services provided by the public and
private sectors. In some cases, women were the main supporting member to the
family as man counterpart in the family spent his entire earning on liquor. In many
families, children above 15 years of age were school dropouts or did not attend school
due to poverty. In most cases, children of this age group were found to be working to
support their families.

Personal interviews of doctors working in Government hospitals were

conducted. In-patients and out-patients in Government hospitals were also
interviewed (total sample size 100). Opinions were sought from these respondents on
health care facilities for prolonged illness and attitude of doctors and hospital staff
towards patients.

D. Tools of Data Collection:

Survey method was used to collect primary data from 300 respondents, all of
whom were the residents of the selected slums in the city of Mumbai. Considering the
nature of respondents, the following tools of collecting primary data were used:
Table 1.6
Tools of Data Collection
Tools Utility Justification
Questionnaire: Close-ended questionnaire was Questionnaire is the most
used to generate specific commonly used tool for the
responses from patients about collection of specific information
the health facilities in public about the problem under
sector and private sector consideration.
hospitals in the city.
Opinionnaire: Opinionnaire has been used to Opinionnaire checks the
collect opinions, attitudes and authenticity and relevance of data
views of stakeholders such as collected through questionnaire and
doctors, general public, policy provides greater insight in the
makers, etc. on the responses problem under consideration.
obtained through questionnaire.
Interview Interview schedules have been Interview schedule helps to derive
Schedule: used to generate expert views specific conclusions on the basis of
on the problem under data generated through
consideration. questionnaire and opinionnaire.

E. Presentation of Data:
For interpretation of data, graphs and simple bar diagrams have been used. For
comparison and analytical study, tabular presentation has been used. Bivariate tables
have been used for applying statistical tools like chi-square for establishing
hypotheses and achieving objectives of the research.

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F. Analysis of Data:
Data collected from primary sources have been analysed through appropriate
statistical tools such as averages and chi-square test to establish the hypotheses under
consideration.

1.7 Chapterisation:
The present study has been divided in the following six chapters:
Chapter - 1
The Chapter One outlines the background of the problem under
consideration, its significance in the present scenario, the scope of the study,
objectives the research intends to achieve and hypotheses to be established. It also
includes a detailed methodology of conducting research on the issue under
consideration and various components of research design such as the universe, the
sample, types of data, tools of data collection, presentation of data and methods
use to analyse data. It gives the chapter schemes of the research report and outlines
contents of each chapter in short.

Chapter - 2
The Chapter Two undertakes the review of literature related to the present
topic of study and tries to define the problem under consideration in a proper way.
Firstly, the chapter defines important terms and concepts in a proper way to give
readers an understanding of various terms in the research report. Secondly, it critically
reviews the health programmes and policies of the government. Thirdly, the chapter
touches healthcare financing in India and compares it with the selected countries.
Fourthly, the chapter highlights economical, social, gender and regional disparities in
accessing healthcare in India. The Chapter also sums up status of healthcare in rural
and urban India and concludes with the recent development in Indian healthcare
market. The chapter identifies the research gaps between the problem under
consideration and the available literature on the issues and strongly recommends
further exploration on the problem.

Chapter - 3
The Chapter Three defines the concept of health economics and highlights
its significances in the present scenario. It also conceptualises the term health and
emphasises health as a fundamental right as per various international and national
Covenants, Acts and Rules. The Chapter justifies need for health expenditure and
investment in the healthcare sector. It highlights the burden of diseases in India
and a number of committees and commissions appointed by the Government to
suggest reforms in healthcare sector and make it available to all at affordable
costs. The Chapter concludes with Indias move towards recognition of the Right
to Health.

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Chapter - 4
The Chapter Four outlines the phases in the development of healthcare sector
in India, Indias healthcare system and health care delivery in India. The Chapter is
completely dedicated to healthcare status in India, Maharashtra and Mumbai city. It
highlights the problems of slums in India in general and slums in Mumbai in
particular. It has also detailed the health infrastructure in India, Maharashtra and
Mumbai. The researcher has also collected data on the various diseases which mainly
affect slum dwellers in Mumbai and their proximate causes. It also analyses the
expenditure pattern of slum dwellers in Mumbai. The chapter ends with various
initiatives of the government to boost healthcare industry in India.

Chapter - 5
The Chapter Five analyses the responses of the respondents (majority slum
dwellers) selected for achieving objectives of the research and establishing
hypotheses. The researcher had designed a closed-ended questionnaire to seek
responses on the problem under consideration. The said questionnaire has two
parts part I deals with the profile of respondents while Part- II deals with
responses of respondents on various questions asked during the field survey. The
Chapter also justifies how various objectives of the present research have been
achieved. The researcher has used chi-square test to establish the various
hypotheses formulated at the beginning of the study. Almost all the objectives and
all the hypotheses, except one, have been established.

Chapter - 6
The Chapter Six summarises the findings of the study and conclusions derived
thereof. The research has also made some valuable suggestions to make healthcare
services in the city of Mumbai Accessible, Available and Affordable to poor masses.

1.8 Limitations of the Study:

The present study is constrained by the limitation of time and cost. The study
is restricted to the public, private and charitable hospitals and dispensaries in the city
of Mumbai. At the same time, individual capacity of researcher in exploring a crucial
social sector, i.e. healthcare economics is a challenging task.

Despite all constraints and limitations, the findings and conclusions derived
thereof and suggestions and recommendations given at the end of the study would go
a long way in improving and enhancing health care facilities in the city. These
suggestions will guide the health care policies of not only the Government of
Maharashtra but also the State Governments of the other states in the country. At the
same time, the results of the study will open new frontiers for young researchers to
carry this study further to other regions and states of the country.

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1.9 Expected Contribution:
Health is a constitutional right; denial of it may interfere with the social justice
and equity. It is the indicator of human development of a nation. The greater
inequality in the attainment of health services can adversely affect the human
development index of the country. As the concept of human development has become
more important than economic development; health, education, social and gender
equality are significant subjects of study. The objective is to recommend some
improvements in health policies to obtain social and economic justice for all.

Since countries are composed of states, any countrys growth rate will depend
on the growth of its different states. Similarly, cities, towns and villages are the parts
of a state and the country. They are broadly governed by the same legal system; they
have same broad health policy devised by the Central Government and have the same
constitution. Health is a State subject and state policies would have important bearing
on the public health expenditures in India. Therefore, Mumbai, a metro city of India,
has been chosen for the purpose of the present study which shares common culture
with various other states of the country. It is, sometimes, referred to as a mini-India as
it houses people from different regions, ethnicity, cultures, religions, economic
backgrounds and status. This study examines the expenditure pattern of poor families
on health services in relation to the availability of health services provided by the
Government. The analysis of problems in one representative area and suggested
reforms can be the guiding role models for other areas of the country.

Like in other developed countries, healthcare expenditure in India is also

increasing steadily. However, public health expenditure has been grossly inadequate
in relation to demand. The government has been spending less than private
expenditures on health. The Bhore Committee report (1946) stated that per capita
private expenditure on health was Rs. 2.50 compared to a state per capita health
expenditure of just Rs. 0.36 which is 1/7th of private expenditure.15 Even today the
proportion of public expenditure on health to GDP in India is only 0.9 per cent of
GDP while the average public spending of less-developed countries is 2.8 per cent of
GDP.16 Only 17 per cent of all health expenditure in India is borne by the
government, the rest being borne privately by the people, making it one of the most
highly privatised health care systems of the world.

Besides the main objectives of the study, the research also addresses the
following questions:
(1) What should be the role of different levels of government in financing
health and managing health expenditure?

15
Bhat, Ramesh and Jain, Nishant (2004), Analysis of Public Expenditure on Health using State Level
Data, Indian Institute of Management, Ahmedabad, June.
16
Government of India (2007), Tenth Five-Year Plan Document, Planning Commission, New Delhi.

17
 (2) Why do poor avoid health care?
(3) Whether there is any discrimination in the share of health expenses in
families?
(4) What are the determinants of the health expenses in family budget?

1.10 Conclusions:
Researchers findings are based on the population earning up to Rs. 10000 and
less per month (70% of the respondents). Many of these respondents live in slums and
chawls. Although the overall condition of air, water and land in these areas is poor,
the effects of those are severe due to congestion and poor hygiene in the slums. Slum
dwellers are exposed more often to toxins in the air, water and soil due to open
sewers, unpaved lanes, weak house structures and the use of common toilets and
water taps. Living in slums adversely affects the health of all individuals regardless of
gender, age and work status. The findings of the present study clearly show that in
Mumbai, in spite of having some of the best public health care facilities in the
country, most of the people are not able to access them due to unplanned locations
and inadequate infrastructure and their poor maintenance in public hospitals. The
study found a very high utilisation of the private health services and the limited role
played by the public sector in the city in providing healthcare services to poor and
needy population.

The study also identifies the factors that lead to non-utilisation of public health
services in the city, which has more public health facilities compared to any other
parts of the country. This raises the question that although the services may be
available, the access to them is determined by several other factors. In short, the
results present a forceful plea for greater attention to the allocation and quality of
public health care services for poor and needy, accessible at an affordable cost.

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