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This blog by Sweta Das and Parvathy Breeze explores the findings of a health survey in Maharashtra Housing and Area Development Authority. They list the reasons that marginalised community members avoided public health services, instead paying out of pocket for less conveniently located support from the private sector.

In Mumbai, an area with high population density and diverse socio-economic backgrounds, primary healthcare centres play a crucial role in ensuring that cost-effective healthcare services are accessible and equitable. These centres cater to a wide range of people, from children to the elderly, providing essential healthcare services and promoting overall well-being in the community.  Primary health care centres are often referred to as ‘dispensaries’ or, in the context of Mumbai, ‘Suraksha’. They offer a comprehensive range of services, including preventive and curative care such as general check-ups, immunizations for both children and adults, treatment for common ailments, health camps for early disease detection and health education initiatives. They also provide vital maternal and child health services and are key in generating awareness and disseminating information about communicable and non-communicable diseases within the community. Surakshas also provide low-cost treatment, medicines, and even certain diagnostic services. Primary healthcare institutions are essential pillars of hope, ensuring the fundamental right to life and healthcare for every citizen in need.

SPARC and Mahila Milan (a woman led collective) conducted a health survey in a Maharashtra Housing and Area Development Authority (MHADA) colony of Vashi Naka in Mumbai. They found that most residents prefer using private clinics rather than using the nearest public dispensary, even for minor health ailments and services. They do this despite the high out-of-pocket expenditures required to use private services, that in some cases even mean taking out formal loans or borrowing money from friends and relatives.

We looked into why this would be, to gauge if there were any possible interventions that we could assist with. We spoke to various members of Mahila Milan, and spoke to the in-charge and other staff at the public dispensary. We documented the challenges that community members face when accessing the public dispensary, and the issues that hinder the medical personnel from catering to the healthcare needs of community members.

Key factors that discouraged community members from seeking health care at the public dispensary

Long waiting periods

Rekha*, a member of Mahila Milan, said, “This public dispensary in Vashi Naka used to operate between 9am and 1pm only. That is too little time to cater to people from so many areas like Bharat Nagar, Ashok Nagar, Hashu Advani Nagar, Shastri Nagar and Rahul Nagar.”

People often ended up in serpentine queues waiting for hours at a stretch, not just in the outpatient department but also in the emergency rooms. “Community members told me about this one instance when they took a young ailing girl to the emergency room and were asked to wait in a really long queue. They had no idea how long they were supposed to wait,” recalled Rekha. Some people even reported being turned away without a consultation and were asked to return the next day.

Dismissive behaviour from medical staff

People visiting the public dispensary said staff were cold and unapproachable. Some people were yelled at for not maintaining proper queues. Others were met with far more disrespect and indignity. Bharati, a member of Mahila Milan, was told that patients have even heard derogatory remarks like,“Nahaake nahi aate toh bimari hoti toh hai, usme koi badi baat nahi hai,” (When you come here without showering, it is not shocking that you have some disease).

In fact, when we asked Dr. Maya*, the doctor in charge at the dispensary, about such statements, she said, “These people chew tobacco and argue for medicines here. Inke wajeh se bahut zyaada population bhi hai” (they are the reason for the increasing population too). The conversation clearly indicated that the patients were being discriminated against and perceived as slum dwellers living in unhygienic spaces.

Shortage of resources at the dispensary

There are not enough medical staff at the dispensary. Several people left with their children without treatment because there was no paediatrician available.

The dispensary pharmacy lacked medicines, especially for ailments related to blood pressure and diabetes. We found that an elderly patient was denied medicines and treatment for blood pressure, and asked to try again later.

A community leader from Vashi Nak identified the critical need for intervention to improve the dispensary’s conditions. They recognised the need for an intervention when the group attempted to access the TB patient list and identify the whereabouts of these patients. This was done as part of the ARISE project, which focused on identifying and aiding the most vulnerable TB-affected families with ration support. During the team’s initial visit, there was no consulting doctor present. On their subsequent visit, they were denied access to the patient list and instructed to return with a letter from the Medical Officer (Aarogya Adhikari) of the ward. These challenges underscored the urgency of transforming the dispensary to better serve the community’s healthcare needs.

Accountability-seeking initiative

After having heard such narratives from community members and having observed the functioning of the dispensary first-hand, SPARC and Mahila Milan decided to seek accountability from governance actors.  Mahila Milan, with the support of SPARC, wrote a letter highlighting these concerns to the Head of the Department of Brihanmumbai Municipal Corporation (BMC) – the governing civic body of Mumbai.

This resulted in a meeting being held between the health officer of the ward and members of Mahila Milan to discuss the challenges and issues pertaining to the functioning of this dispensary. In the meeting, the Mahila Milan leaders talked about the health camps conducted in different areas and the issues related to the dispensary located in Vashi Naka and Maharashtra Nagar. One of the important aspects discussed by the leaders was the availability and accessibility of a gynecologist in the dispensary. In response, the Medical Health Officer mentioned the ongoing work on the transformation of these dispensaries. As a response the Medical Health Officer asked the leaders to visit Kokriakar dispensary where the in-charge of appointing the gynecologist sits so that they can urge the in-charge to station one in the area. There was a sense of assurance and support that was given by the Medical Health Officer. And asked the leaders to keep conducting the health camps in M east ward.

On a visit to the dispensary a few months later, Mahila Milan found some of the necessary changes had been made. Mahila Milan member Bharati said, “Now the working hours of the dispensary have been extended until night, with two shifts of the out patient department services in mornings and evenings. They have also made arrangements for the waiting patients to be seated instead of standing in the queue.” She also found that a list of doctors and their designated consultation time was put on public display, a diagnostic lab was introduced and the pharmacy was better stocked.

Dr. Maya also corroborated these improvements as part of the new upgrade scheme called  HBT (Hinduhridayasamrat Balasaheb Thackeray) which targets the effective working of the dispensaries, which began on the 2nd of Oct 2022. by the BMC. She said, “We have newly recruited specialist doctors like paediatricians, dentists, gynecologists, and dermatologists. We also have separate doctors appointed for the out patient department services.”

Perspectives of the medical personnel

While we wanted greater accountability from governance actors for better functioning of the dispensary, we felt it was equally crucial to hear the perspectives of the medical personnel as well.

Ramesh, a staff nurse at the public dispensary, told us that the lack of adequate staff hindered their ability to properly manage and treat the large number of patients visiting the dispensary. “But, some patients also create chaos and make things difficult for us. Some of them fight in the queue with each other and with the staff. Some of them just refuse to maintain silence. And, then there are also the ones that spit tobacco on the premises of the dispensary. This is all very triggering for us here,” he explained. For him, this could be the reason behind some of the health staff behaving indifferently towards the patients.

Dr. Maya told us in an interview, “The working hours of our dispensary have been extended to two shifts and a diagnostic centre is also set up now. This is all part of a new State government scheme for effective working of public dispensaries.”

Services provided at the dispensary now include out patient department services, specialist consultations with gynecologists, dermatologists, dental services, paediatrics, dieticians, a low-cost general diagnostic laboratory, pharmacy, dressing room, and a DOTS centre. Medical staff present in the dispensary now include one Medical Officer in charge, a GNM (General Nursing and Midwifery), a multi-purpose health worker (MPW), a data entry operator, a lab technician, and a pharmacist. Even the evening shift is now staffed properly with one doctor in charge, GNM, MPW, lab technician, and pharmacist.

When questioned about the major challenges faced by the medical staff, Dr Maya said, “So far, the biggest issue is catering to such a large population with just one doctor and so few medical personnel here.”

With not enough dispensaries in the vicinity to cater to the population in the area, they face a large crowd of patients every morning. “It’s overwhelming for us doctors as well. I have to handle more than 150 patients a day,” she said. She also explained that the doctors at the dispensary are overburdened with a plethora of tasks like attending to patients, record keeping, attending various meetings and training and even visiting other institutions when needed.

In more than two decades of experience in healthcare institutions in Mumbai, Dr. Maya has seen a gradual increase in the number of dispensaries and their working hours. “It is great to see that, for sure. But, this has been a slow process because of the lack of space and funds allotted for construction and upgrading of dispensaries. I believe we have a long way to go before the number of doctors and dispensaries is made proportional to that of the patients,” she explained.

She said the extension of the working hours of this dispensary in Vashi Naka is beneficial for the patients, especially for women as they often tend to be busy with household chores in the mornings. Women are also relieved that this dispensary now has a gynecologist available twice a week.

The lack of resources, such the shortage of medicines at the pharmacy, equipment in the dispensary, and frequent power cuts affect their ability to meet the needs of the patients. “Patients shout at us when they do not get medicines from the pharmacy here. How do we even make them understand that there is an acute shortage of medicine?” said Dr Maya. “We also have our own limits in terms of providing facilities and services. Sometimes, the way patients behave with the staff and get impatient, it gets overwhelming for us. And, there are no security personnel for us,” she added.

“I have been raising these concerns and issues to the higher authorities because I strongly feel a resolution would help us make the dispensary a lot more effective and efficient,” she said.

She acknowledged that dispensaries act as the primary point of contact for the communities to address their health needs. Without accessible and affordable dispensaries that can duly cater to the community’s needs, the spread of private multi-specialty hospitals is inevitable, and consequently so is the rise in out of pocket expenditure for the community.

Conclusion and the way forward

Conversations with medical staff, community members, and members of Mahila Milan revealed the many structural and systemic problems that hindered the proper functioning of this public dispensary. However, problems like a lack of dispensaries, poor ratio of medical staff to patients, lack of funds for resource-based needs, improper and/or discriminatory behaviour towards patients, inadequate attention to patient needs like medicines and diagnostics, are not specific to this dispensary alone. These, unfortunately, characterise the broad range of problems that plague most public health care systems.

Without systemic interventions and political will to improve public healthcare systems, the socio-economicly marginalised are being pushed to penury by accessing healthcare services at private clinics. Dispensaries like this one in Vashi Naka act as the primary point of contact in terms of healthcare, and timely solutions will help the community access good, low-cost healthcare facilities and services. Our experiences and conversations at the dispensaries and with the community tell us that it is not enough to just build more dispensaries or allocate more resources.

This case study stemmed from the conversations that happened during the health survey undertaken by SPARC and Mahila Milan. Our learnings, observations, and recommendations then coalesced into intervention efforts for an improved functioning of the dispensary. And, while we acknowledge that our letter to the governance actors is far from being the only factor that paved the way for the changes noticed in the dispensary, we do think this sheds light on the possibilities for how health systems could see significant improvements when civil society organisations and communities come together to identify challenges and then seek accountability and/or advocate for improvements.

*The names used in the blog are pseudo-names to protect the individuals’ identity

Earlier this month colleagues from across the consortium attended the International Conference on Urban Health in Atlanta, USA. The team pulled together a fascinating panel presentation that looked at intersectional analyses from across the ARISE consortium. The panel consisted of colleagues from across the consortium, and our four focus countries and was well attended by delegates from across the world.

The panel was chaired by Dr Surekha Garimella of The George Institute for Global Health, India. Surekha started the session by outlining how globally, more than half of all people live in urban areas and 60% are projected to do so by 2050. She explained that one in three urban dwellers now live in precarious, marginalised areas, including informal spaces; an estimated 881 million people in low- and middle-income countries. She also spoke about how the nature of informality and the unequal power relations present in society deny people their human rights and entitlements and result in structural violence.

Surekha said, “Within ARISE we want to focus on tackling the social and political systems that shape these issues, ultimately addressing issues of structural violence.” She explained how one of the consortium’s core principles is using an intersectional approach to understanding health and wellbeing, moving beyond the single axis framework that is dominant and drawing inspiration from African American colleagues and activists that developed this approach.

Surekha went on to explain how people are shaped by their simultaneous membership of communities and the interaction between these interactions and connected systems of power. That power manifests in many ways and actions, and recognition of the inequality of power is central to our understanding of intersectionality. Throughout the presentations from colleagues we shared examples of multiple forms of vulnerability and how we make sense of it all.

As a consortium, we really wanted to make sure we brought the voices of the communities we work in, and the co-researchers we work with, to international gatherings such as ICUH. Surekha’s introduction was followed by videos from co researchers in Bangladesh, Kenya, and India, sharing their experiences and telling their stories. We heard from Miriam Abwanda, a deaf woman living in Kenya; Sanjoy Kumar Sanz, a male co-researcher working with us in Bangladesh; and Rupa Khatri, a female waste worker in Shimla, India.

Samuel Saidu from COMAHS, Sierra Leone talked about his PhD research around the health seeking behaviours of young people living in informal settlements in Freetown. He also centred the voices of his co researchers and community members. A young man from Moyiba, discussing how he would define health and wellbeing said, “I think [a young boy’s] health is defined as the state in which I can care for myself when I am sick and when I have no diseases or bacteria affecting my body.” While a young woman from Cockle Bay said, “Wellbeing is when I can do everything myself especially when I am not struggling to pay school fees or what I should eat for the day. I can do everything for myself without getting others involved with my burden.”

Inayat Singh Kakar of The George Institute then spoke about the experiences of women waste workers in Shimla, India. She explained how, despite women making up the majority of the door-to-door waste workforce, decisions on demands and strategy are largely taken by men, with issues specific to women often missing from the demands of the collective. Inayat spoke about how ARISE worked to create spaces where women could lead, through consistent dialogue between women workers and researchers and exposure visits and interactions with collectives led by women.

We then heard from Kenyan colleagues, with Linet Okoth presenting on behalf of her LVCT health colleagues Inviolata Njoroge and Robinson Karuga. The presentation focused on the experiences of people with disabilities (PWDs). Linet explained that approximately 5% of Kenyans are PWDs, that health inequities arise from unfair conditions faced by persons with disabilities, and health access for PWDs is even more constrained due to limited resources. The experiences of PWDs were further explored through the community based participatory research approach Photovoice.

Next, we heard from Bachera Aktar from the BRAC James P Grant School of Public Health at BRAC University in Bangladesh. Her presentation focused on the intersectional gender analysis of factors influencing access to healthcare among women living in informal urban settlements undertaken by ARISE. Bachera spoke through the methodology and key findings, as well as the intersectional factors influencing women’s access to healthcare, weaving in the voices of respondents.

A community researcher in Kollyanpur said, “Many girls in our area suffer from genital infections and menstruation-related problems but are hesitant to discuss with their parents, and cannot also seek treatment because of embarrassment. As a result, those minor problems gradually become major health risks over time.”

Finally we heard from Abu Conteh from Sierra Leone Urban Research Centre on his PhD research looking at how infectious disease and non-communicable diseases (NCDs) impacting the poor, particularly in fragile settings. Abu also discussed the impact of COVID-19 in areas already under pressure, and how health outcomes are already precarious in informal settlements; influenced by intersecting inequities.

We are so glad to have had the opportunity to share our work with an international audience, and have been able to centre the voices and experiences of our co researchers and communities and highlight the importance of an intersectional analysis of inequity and marginalisation.