Health Service Utilisation and Coping Mechanisms of Urban Slum Dwellers: A Case of Mumbai Slums

Shruti R Pandey^*
*Correspondence: Shruti R Pandey, Assistant Professor, Economics Department, SIES College of Arts, Science & Commerce ( Autonomous), Mumbai University, Mumbai, India, Tel: 9987001928, Email:

Keywords

Health utilisation pattern • Coping mechanism • Out-of-pocket expenditure • Urban poor • Slum dwellers.

Introduction

Health service utilization and health seeking behaviour of a people depend on a number of factors ranging from perception of illness, severity of illness, need for health care, awareness and information about health services, physical, economic and social accessibility of health care services, quality of care, socio-economic structure and the biases of the health care provider. There have been several studies conducted focusing on utilization of health services in India. The studies were conducted in the communities focusing on utilization as part of larger studies that examined morbidity, event related preference for health care and expenditure incurred. Aspects with regard to the general preference for formal/informal, indigenous, private/public type of institutions and services have been studied at length [1]. Some of the study [2-4] was specifically urban based, focusing on how health services are utilised in urban settings.

Economic Burden of Illness

The financial burden of illness is a universal issue, cutting across socio-economic coordinates of households. However, health has often been perceived as a luxury good though it is not. The perception of illness in general and severity of illness in particular has been found to be affected by socio-economic characteristics such as income, age, sex, class and psychological characteristics like stress, co-morbidity condition adding to trauma, cognition abilities of an individual. Therefore, it means that the definition of ailment is not universal. For instance, a rich person may identify a relatively minor indisposition as ailment and go for treatment, while the poor might perceive an ailment only when it is work-disabling in nature. Their subsequent choice of service providers is often in conformity with their respective financial status. Thus, the resultant burden of illness is inherently asymmetrical as far as its nature and origins are concerned. It is the poor, who often continue to bear the burden of illness, even long after it has been cured.

It might be contended that the burden of illness are felt more by the urban poor vis-a-vis their rural counterpart [4,5]. Apart from the higher cost of living and an extremely competitive informal job market, the burden of disease among the urban poor is enhanced, also due to unhygienic living conditions, deplorable status of basic necessities like water and sanitation, increased exposure to accidents and poor environmental condition that increases the vulnerability to indispositions and hence the economic burden. High rate of growth of urban population and consequent increase in population residing in slums has led to over straining of infrastructure and deterioration in public health and wide inequalities in accessing services. Such hostile circumstances coupled with the lack of social network and fall back options, make them more vulnerable to catastrophic cost burden.

India spends about 6 per cent of its GDP on health, but public (Central, State and Local Governments combined) expenditure as a percentage of total health expenditure amounts to a meagre 20 percent of total expenditure on health which is among the lowest in the world. Households account for almost 70 per cent of the total health expenditure, (MOHFW, GOI). Even there imbursements in any form that is availed by households whose members are employed in the formal sector are a minority in India. Given that good health is the most basic of all necessities, such high levels of out-of-pocket spending by the households have certain adverse implications. While for some, access to health care is reduced considerably, others who opt for treatment face catastrophic burden of health care expenditures and are in danger of becoming impoverished.

Health utilization pattern in Mumbai

Mumbai is having a well-developed infrastructure and a vast supply of public and private health care services. The services range from the super specialty tertiary level care hospital to general practitioner [6-8]. The central government has its own dispensaries which are available only for their employees. Further there is employees State insurance Scheme catering to the organized sector employees. The various departments such as the ports, railways, defence etc have their own health care services and hospitals catering to their employees. For the general people the Bombay Municipal Corporation provides the major care in the public sector along with the state government. There are six teaching hospitals, fifteen peripheral hospitals, 26 maternity homes, 159 dispensaries and 76 health posts run by the BMC. In the private sector, the CEHET database records 1082 hospitals and nursing homes run by various agencies.

Methodology

In the present study, utilization of health services implies all health care services and facilities. Utilization was defined as services taken from the health facilities referring any institution, BMC, private, tradition, charitable, subsidized, recognized and unrecognized in the event of falling sick. Treatment of sickness includes medical advice, examination, diagnosis, cure and care of illness. Non-treatment is when the sickness was reported during the recall period and where no action was taken to alleviate the symptoms. Self-medication and home remedy from any local health service provider were also included to cover the entire gamut of utilization of health care services by the households to understand the factors and aspects of health seeking behaviour. (Studies in urban areas show same trend in greater utilization of private facilities NCAER (1992) conducted study at India level indicated that for all states barring Himachal Pradesh, Assam, Orissa and Karnataka, the preference for private sector health provider is high. Even in a state like Kerala, which has a well-developed public health infrastructure, there is greater reliance on the private sector than the public sector. Public sector health service utilization ranges from 9% to 36% [9,10].

Outline of the study area

It is important to understand the geographical and demographic feature of the area under the study. The study comprises of a sample of 300 households selected at random from three slum parts of the area Kurla (L), Chembur (M) and Bhandup (S) in Mumbai city. The Brihann Mumbai Municipal Corporation (BMC) divides the city into 24 Wards(Table 1). The above-mentioned regions are among the top five wards of Mumbai's slum population. The data from the 2011 census shows that nearly 41.3% of the city's population lives in slums. Dharavi, which had the distinction of being largest slum of Asia, is a part of G north ward and its population is 5.82 lakh with nearly 60% slums [11-13]. Dharavi is no longer Asia’s largest slum. It is now dwarfed by four other slum clusters of Mumbai and suburbs namely, Kurla-Ghatkopar (70%-80% slum population), Dindoshi (80% slum population), Bhandup (70% slum population), and Mankhurd- Govandi (95% slum population).

Source-Mumbai HDR (2009)

A mixed method approach using quantitative and qualitative techniques was adopted to make use of the advantages of each method and to enable triangulation. Data were collected at community level through a household survey and interviews with key informants. A simple random sampling was used with 300 households [14]. The care was taken to interview only those household which have faced illness in the past month. Using a pretested questionnaire, data was collected from the household members. Recall Period for illness reported data was taken as 1 month in case of common disease and 6 months for hospitalization treatment(Table 2). For interpretation of data, graph and simple diagrams have been used and for comparative and analytical study tabular presentation has been practiced.

The rationale behind the selection of these slum areas arises from the fact that as per BMC reports, four wards in the city K east (Andheri), L(Kurla), G south (Elphinston), E (Byculla and Chinchpoly) have been notified as high risk areas since 2010, where presence of slums, continuous construction activities and demographic conditions have led to high incidence of morbidity.

Discussion

The cases of seeking treatment is quite high as 94% of household accepted that they have taken the advice of health professionals as against 6% who did not seek any treatment mainly due to cost factor or illness was not severe enough. This shows increased awareness among the poor population regarding health problems and also the realization of a proper diagnosis at early stages rather than to ignore the health condition. This finding is important as it implies that now health is not so widely considered as a luxury but as an investment for better working life. Good health status implies regular working days which mean more income to family. But if this finding is related with the actual rate of continuing treatment or forgoing the institutional care by replacing it with traditional means due to some economic constraints, the cost and access factor regarding health care becomes important. Thus, household are denied of proper health care not because they are not aware of health benefit but because they cannot afford it.

Awareness about the government policy and schemes are critical. Most of the respondents agree that even if few of people in their locality are aware about the program, they can well spread the knowledge. According to some of the respondents, following are common problems faced, while seeking to health care services,

Most of the times health workers at hospital do not provide adequate information.

They do not inform them regarding health cost coverage schemes.

The medicine provided at the BMC run hospitals are of low cost but also of less value in terms of benefits (which may be a bias, as some of the respondents were happy with the treatment got in public hospitals) Non-availability of drugs, hence, people have to depend on private sellers for antibiotic and other branded medicines, which prove to be costly and burdensome.

During the course of survey, it was observed that the people attach more importance to education than health. Health cost is something that may incur or not, but education is something that is needed even to understand health and wellbeing. Therefore any health programs must be accompanied with educational attainment on which the success of preventive care depends. Reliance on relatives and friends is the most sought after coping strategy for these people. They are under permanent debt trap. People also resort to intra house labor substitution and not happy with this state of affair as they lose their daily wages. This labor substitution occurs in the form of working without cash or kind for the person from whom the loan has been taken. A high level of opportunity cost is attached with intrahousehold- labor substitution. The households seeking treatment incur costs that force them to cut spending on other basic needs or to adopt coping strategies that put them into debt or deplete their assets. The poorest were, in particular, less likely to seek treatment and were less able to cope with cost burdens because they could not obtain loans and had no assets to sell.

There is growing interest in the impact on households of the costs of illness and of health service utilization. At the same time, it is also being increasingly recognized that these costs can lead to household impoverishment and create increasing pressure on the demand for health care facilities in the urban slums.

Conclusion

Therefore the main objective of the study was to study how illness perception and treatment seeking behavior are influenced. The health infrastructure of the country is not adequate and accessible equally to all sections of population. Urban poor which forms a large percentage of informal worker live in vulnerable situation, therefore more prone to sickness and consequently face catastrophic burden of health care cost. The role of government in primary health care in terms of free and cheap service is non-substitutable as far as poor people are concerned. But there exists a wide gap between quality needed and quality provided.

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