Barely a week old, Mangala's baby sleeps in a cloth cradle, off a main road in Jogeshwari, suburban Mumbai. Though her home is on the dug-up sidewalk, the still-to-be-named baby girl is lucky. She was born in a local hospital, a registered birth that will feature on the Government's radar and will be useful for the child to obtain services later in life. Her two older brothers, aged 4 and 2 years, though, have not been as lucky, born as they were in informal surroundings and their births are not registered. Their young mother Mangala (who does not know her own age) is from Amravati in Maharashtra, and her husband works as a cleaner in Mumbai. Still sleepy from possibly a late night looking after the newborn, she introduces her boys from the small gang of kids gathered around her.

A health-post, or a Government centre that dispenses basic care and medicine, is a couple of minutes' walk from where Mangala and her family live. But it was not till recently that Mangala agreed to visit it, and that too only because of persuasive health-workers.

Familes like Mangala's, the urban poor and homeless, are the worst-hit as they are not comfortable going to a Government primary healthcare set-up, says Vaibhavi Padave from the non-government agency Aakar Mumbai, instrumental in getting Mangala to overcome her misgivings about visiting the health-post. No one pays much attention to such people at a hospital and that makes them uncomfortable, she says, adding that even the political class ignore them because they consider them migrants from another State, when in fact they are from Maharashtra.

Under-utilised Facilities

The nearby satellite health-post (as primary healthcare centres are called in urban areas) is run by the Brihanmumbai Municipal Corporation (BMC)), among the richest municipal corporations in the country. But this centre is an extremely modest set-up with pale-yellow walls and little sunlight coming in. Heading it is Kanchan Ganghurdhe, who explains that her staff help in educating the neighbouring areas on family planning, malaria, and immunisation. And the centre is equipped with deep freezers, ice-packs and so on to keep medicines in the right storage conditions, especially when the electricity goes off, she adds.

Leprosy and tuberculosis are also monitored here, and more recently they have started counselling young girls too, says Kanchan who has been a BMC employee for 22 years. Her colleague shows the well-packed TB drugs and explains the rigour they put into getting patients to take their medicines as required, over a six-month period. But the monitoring and record-keeping is manual and members of the staff write down details of people who visit. A task easier said than done when you consider that this number runs into several thousands and gets complicated in illnesses like TB, where patients who show resistance to the first level of medicines need further follow-up.

A short drive away, at a maternity-oriented health post, there appears to be still less activity. It is after lunch hour, and the young doctor there says they handle the basic ailments of people from the neighbourhood, though the centre is dedicated to maternity. There are separate rooms to handle HIV/ TB and so on, but the infrastructure is basic, though the building is large. Medicines are stored in little cartons, some are even lying open and exposed. At the upper level, there are beds and a few patients – this health-post could definitely do with more doctors, patients and activity.

The picture is slightly different in the upmarket suburb of Oshiwara, where there is a larger health-post. Its corridors have rows of women seated on the floor waiting to meet a doctor. And one young doctor running to balance his patient appointments and lunch takes a breather to say that more doctors are sorely required.

Stereotypical Approach

The primary level of healthcare services in the country sticks to the stereotype – under-staffed and grossly under-utilised. That is because they are under-funded, says veteran health expert Dr Anant Phadke of Centre for Enquiry into Health and Allied Themes (CEHAT). In rural areas, the primary levels of healthcare come under some system and authority. In urban areas, while they come under rich municipal corporations, there are no rules of standardisation on how these posts need to be run. So each municipality runs its own show, he says, adding that the demand for a Central and State policy standardising operations at health-posts and centres has been pending for a while now.

These centres could do much more in educating and dispensing healthcare services than just focussing on the few programmes such as immunisation, family planning and so on rolled out by the Central Government. Across the country, health-posts tell similar stories of neglect, except in Goa and Mizoram where centres are better run, Dr Phadke points out.

The health-post at Bhandup nestles in a residential area in suburban Mumbai. It is an imposing, multi-level structure with an open space in front, security guards, and so on – but it is almost empty post-lunch. Locals say the place teems with people earlier in the day. But post-lunch, more beds are occupied by relatives of patients than patients themselves. It is visiting hours, we are told, and perhaps that explains the presence of many family members. This empty healthcare facility is a shocking contrast to regular private hospitals or clinics in the city, for instance, that would be teeming with people.

Healthcare Crisis

Be it urban or rural, there is a healthcare crisis at our doorsteps, says Arvind Singhal, Chairman of Technopak Advisors. In the Tier II and III cities, which he defines as semi-urban and rural areas, people travel about 77 km to get to a healthcare centre. These would be in locations like Sangli in Maharashtra or Mathura in Uttar Pradesh, he points out. The 77 km number was arrived at through actual ground work, during earlier research for aid agencies, he says.

The country needs to break away from the model of large hospitals and focus instead on smaller, accessible and affordable speciality centres where basic diagnostics and services are taken care of – like daycare centres that provide smaller procedures, eye care, dialysis, and so on. The bigger hospitals are under pressure to get a return on their investments and that opens the door to malpractices as, for instance, patients are asked to take tests that are not required, he says.

Given the shortages in medical staff, the Government needs to think outside the box to make healthcare affordable and train several levels of people to help support the main doctor's work. Technology, for example, can be used more effectively, to connect remote rural centres with doctors at well-known hospitals.

A universal healthcare project is set to be rolled out in the country involving increased Government spending on health. The Government can further tackle pricing by talking to producers of consumables, medical equipment, medicines and so on, and get them to lower prices for publicly-funded healthcare projects, says Singhal. Healthcare is a Government responsibility, and only if the Government stays active and involved will medical services reach not just marginalised people like Mangala, but others who require it as well, say health workers.