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Chapter IV

CITY PROFILES

Globalization of urbanization is seen as the most important social change in the 21st century.

The trend for the past 50 years is for cities to grow horizontally in the form of urban sprawl,

whether as suburbs in the developed world or peri-urban expansion in the developing world.

This has implications for the efficiency of urban services, including delivery of water and

sanitation, provision of public transport, as well as for access to jobs, education, food and

health services. In many cases, especially in the developing world, the speed of urbanization

has outpaced the ability of governments to build essential infrastructure. Failure to plan for

continued growth results in inadequate health services, water, sanitation, education, and

essential infrastructure.

Cities matter a lot for India. In 2008 an estimated 340 million people are already living in

urban areas representing nearly 30 per cent of the total population. According to the

medium range projections of the United Nations, 41 per cent of India‘s population will live in

urban areas by 2030 (United Nations, 2005). By 2030 Indian cities will have twice the

population of United States of America today. Cities are likely to house 40 per cent of India‘s

population by 2030. The cities will have 270 million people net increase in working age

population. In short we will witness a transformation of our cities that has not occurred in

any part of the world except China.

In India, urban planning can promote healthy behaviors and safety in many different ways,

applicable both to existing and new areas. These would include design for physical activity

in cities, where healthy food is available, safe, accessible and affordable, where affordable

health services for all are provided adequately and where roads are safe. Improvements in

housing and housing conditions, control of pollution and improvement in water and

sanitation go a long way to mitigating health risks. The present research is undertaken in

the four metropolitan cities of India viz. Delhi, Mumbai, Kolkata and Chennai.

Table 4.1. Population Density and Urbanization In Four Metropolitan Cities

INDICATORS DELHI MUMBAI KOLKATA CHENNAI

Area Sq. Km 1483 157 185 174

Density 9340 21190 24760 24231

Urbanization Percentage 93 100 100 100

Source: Census of India, 2001.

As per Table 4.1, of the four major Indian metropolitan cities (Chennai, Kolkata, and

Mumbai being the other three), Delhi is the least densely populated, least urbanized and

covers the largest geographical area (Table 4.1). Kolkata is highly densely populated.


Mumbai Kolkata and Chennai are fully urbanized except Delhi which is 93 per cent

urbanized.

4.1. POPULATION AND THE ECONOMIC STATUS OF INDIAN URBAN CITIES

Among the selected metros, Mumbai has the highest population and Kolkata trailing behind

and Chennai has the least population among the metros (as shown in Table 4.1). In terms

of GDP, Mumbai ranks first followed by Delhi, Kolkata and Chennai. The average

households‘ income is highest in Mumbai followed by Delhi, Chennai and the least in

Kolkata. The household expenditure in Kolkata was found to be Rs. 1,822 per person per

month on average, which is much higher than other metros such as Delhi, Mumbai and

Chennai. Second comes Chennai, with a monthly per capita household expenditure of Rs.

1,570 followed by Mumbai and New Delhi.

Table: 4.2. Economic Status in the Urban Cities

City / Urban area

Population

in 2001 (in millions)*

Population in 2030#

(in millions)

GDP in

$ ID BN

in 2008**

PWC rank in 2008**

Average Households’ Income

(2007-2008)

***

Spending

Propensity

In 2007-

2008 ##

Monthly per capita consumption expenditure in Rs.###

Mumbai 16.36 33.00 $209 29 459,457 54 per cent 1270

Delhi 12.79 25.90 $167 37 408,237 60 per cent 1166

Kolkata 13.22 22.90 $104 61 287,199 65 per cent 1821

Chennai 6.43 11.0 $ 66 87 337,059 58 per cent 1570

Source: * India's national census of 2001

# Population Projection by McKinsey Global Institute Study, 2010

** PricewaterhouseCoopers, UK Economic Outlook, Pages 20-34, November 2009

*** The Next Urban Frontier: Twenty Cities to Watch, an NCAER-Future Capital Research

(of the Future Group), Rajesh Shukla and Roopa Purushothaman, 2008.

## NSSO (2004-2005) Household consumption expenditure as a share of income, per

cent.

### Hindustan Times, Kolkata, 2009.

Most of the households‘ in these cities are employed. Employment status and occupational

characteristics of a population are important aspects of a country‘s level of development,

particularly its economic development. Paid employment of women, in particular, has been

recognized as important for achieving the goal of population stabilization in India (Refer

Appendix 7).


An ongoing study at Indian Statistical Institute (ISI) by Buddhadeb Ghosh (Hindustan

Times, Kolkata, 2009), points out that Kolkata has the highest per capita purchasing power

among all metros. The reason: smaller population and low poverty compared with other

metros. Household expenditure in Kolkata was found to be Rs. 1,822 per person per month

on average, which is way above Delhi, Mumbai, Chennai and Bangalore. Chennai comes

second, with a monthly per capita household expenditure of Rs. 1,570. Hyderabad comes

third, followed by Mumbai, Bangalore and New Delhi. Data for the study was collected in

2004-05 by the National Sample Survey Organization (NSSO). The data collected by NSSO

was adjusted for regional price variations and differences in cost of living in each city. It has

been observed that the spending propensities are very high in the Indian Urban cities.

In order to assess the living standard of the population information on household ownership

of 19 different types of durable goods and four different means of transportation, as well as

possession of a bank account and coverage by health insurance or a health scheme was

done. Households‘ were also asked if they had a Below Poverty Line (BPL) card, which is

issued by the government and identifies households‘ below the official poverty line.

Information was also obtained on whether households‘ had a mosquito net that can be used

for sleeping. Appendix 8, 10 presents information on several of these items which show the

standard of living in the cities.

Urbanization will spread out across India impacting almost every state. India will have 68

cities with population more than 1 million up from 42 today (Europe has 35 today), 13 cities

with more than 4 million people and 6 megacities with more than 10 million or more and at

least 2 cities (Mumbai and Delhi) will be among the 5 largest cities in the world by 2030.

(McKinsey Global Institute Study, 2010).

4.2. SEX RATIO IN THE FOUR METROPOLITAN CITIES

According to the Population Census 2001, Delhi has been noted as the third most populated

city in India. Amongst the four metropolitan cities, Mumbai Urban Agglomeration occupies

the first position with highest population of 16.37 million. Second and Third positions have

been occupied by Kolkata and Delhi Urban Agglomeration with total population of 13.22

million and 12.79 million respectively, whereas Chennai Urban agglomeration is populated

with a population of 6.42 million only. A comparative picture of four metropolitan cities of

India in respect to population and sex ratio has been presented in the following Table 4.3.

The highest sex ratio in Census 2001 has been recorded in Chennai, followed by Kolkata,

Mumbai and Delhi.


Table 4.3. Population and Sex Ratio Of Four Metropolitan Cities In 2001

Sl. No. City/Urban Agglomeration Population Sex Ratio

Person Males Females 1991 2001

1 Delhi Urban Agglomeration 12791458 7021896 5769562 830 822

2 Mumbai Urban Agglomeration 16368084 8979712 7388912 828 823

3 Kolkata Urban Agglomeration 13216546 7072114 6144432 830 869

4 Chennai Agglomeration 6424624 3294328 3130296 932 950

4.3. FAMILY SIZE IN DELHI, MUMBAI, KOLKATA AND CHENNAI

One more impact of urbanization is nuclearisation of families. Nuclearisation refers to the

formation of nuclear families from joint families. Nuclearisation is primarily driven by

employment-related migration and the changing social structure could also be a factor. This

migration is predominantly to urban areas. Nuclearisation, like urbanization, also has twin

impact. It reduces the area per household, but increases overall household formation,

thereby increasing the demand for housing units. As per Indian Census (2001), the urban

household (5.1) size is lower than rural (5.4). The Family size varies in different

metropolitan cities. Delhi has the highest family size of 4.82 whereas Chennai has 4.33

persons. Mumbai has a family size of 3.73 persons but Kolkata has the least family size

among the four metropolitan cities which is of 3.71 persons. We shall look into each city

profile in the following sections.

4.4. NEW DELHI

New Delhi, the capital of Indian Republic, is an imperative commercial centre of South Asia.

Delhi is the second-largest city in India with over 12.79 million residents and the 8 largest

metropolis in the world by population. New Delhi has per capita income which is

approximately 2.5 times that of the national average. Among all the States and Union

territories, the National Capital Territory of Delhi is most urbanized with 93 per cent urban

population.

New Delhi`s service sector has expanded enormously due to the presence of large skilled

English-speaking workforce that has attracted umpteen multinational companies. The key

service industries of New Delhi comprise information technology, telecommunications,

hotels, banking, media and tourism. New Delhi`s colossal consumer market coupled with

the easy availability of skilled labor, has attracted foreign investment in the Indian capital in

staggering amounts. New Delhi`s retail industry is also one of the fastest growing industries

in India. 75-80 per cent of households‘ prefer to use private sector treatment in Delhi for


minor and major illnesses. The growing purchasing power of Indian patients is revealed in

the increased business of air ambulance services. Around 365 airlifting worth several million

of rupees happen in Delhi in a year on average. The Planning Commission has computed

the HDI for Delhi and showed Life expectancy at birth (years) 69.6 (All India 62.9); Adult

literacy rate (per cent 15 years and above) of 86.0 (All India 56.5); Combined gross

enrolment ratio (per cent) 73.7 (All India 56 per cent); Human Development Index 0.737

(All India 0.571). A comparison between Delhi and the all-India average reveals that Delhi‘s

HDI value exceeds that of India‘s by almost 30 per cent (Planning Commission, 2002).

4.4.1. Literacy in Delhi

Literacy is a predominant factor of demographic characteristic, which is worked out during

the course of Population Census. According to Population Census, a person is considered

literate, if he or she can read and write with understanding any language. The following

table below gives literacy rate which has increased drastically from 62 per cent to 82 per

cent from 1961 to 2001 Census. Delhi‘s literacy rate (approx. 82 per cent) is higher than

national average of 65 per cent. Delhi has an extensive network of educational institutions.

Table 4.4. Literacy Rate In Delhi During 1961 To 2001 Census

YEAR PERSON ( per cent) MALE ( per cent) FEMALE ( per cent)

1961 61.95 per cent 70.37 50.87

1971 65.08 72.55 55.56

1981 71.94 79.28 62.6

1991 75.29 82.01 66.99

2001 81.67 87.33 74.71

Note: Literacy rates for 1961 and 1971 relate to population aged five years and above. The

rates for the years 1981 to 2001 relate to the population aged seven years and above.

4.4.2. Age Distribution and Dependency Ratio in Delhi

Age wise distribution based on 2001 census has been released by the Registrar General of

India which shows an increase in the dependent population since 1991. Age wise

distribution of Delhi Population for 1991 and 2001 based on sex is given in the table below.

Dependency ratio is defined as the ratio of population below 15 years and above 60 years,

taken together to the population in the age group 15 - 59. It has an important economic

significance. The low dependency ratio of a region implies that a low percentage of


population depends on its working force for economic wealth to consume. In Delhi the

dependency ratio has increased since 1991 and is high.

Table 4.5. Age Distribution and Dependency Ratio in Delhi

Age Group

Age Distribution

1991 2001

Male Female Total per cent of Total

Populatn Male Female Total

Per cent of total

populatn

0-14 1725337 1548145 3273482 34.75 2402701 2090238 4492939 32.44

15-19 518268 396603 914871 9.71 816497 611482 1427979 10.31

20-24 538191 444675 982866 10.43 8146497 612254 1426860 10.30

25-29 517180 439608 956788 10.16 814606 614207 1358925 9.81

30-39 810088 627947 1438035 15.26 744718 1000469 2211006 15.96

40-49 502230 365501 867731 9.21 1210537 618241 1432467 10.34

50-59 283533 220616 504149 5.35 814226 334748 759505 5.48

60+ 236969 202551 439520 4.67 424757 353184 719650 5.20

Age not Stated

23716 19486 43202 0.46 366466 8450 21216 0.15

Total 5155512 4265132 9420644 100.00 12766 6243273 13850547 100.00

Source: Economic Survey of Delhi 2008-2009

4.4.3. Healthcare Scenario in Delhi

According to 'Delhi Human Development Report (2006), the capital of India has a good

network of medical facilities still the hospital-bed-to-population ratio has remained

unchanged at 2.2 for the last 20 years, which is cause for concern. In short Delhi's economy

shines, quality of life remains poor.

Enjoying good health is an essential constituent of human development. Overcoming

avoidable illnesses and leading a long and healthy life are features of good living that all

people cherish. Ensuring people access to good quality healthcare in Delhi calls for much

more than just catering to the needs of nearly 14 million residents of the city. The city-state

has to additionally satisfy the health requirements of many thousands who come from

outside as tourists, daily visitors and specifically in search of specialized medical care. The

city like many growing urban centres attracts a large inflow of migrants from all over India,

especially from Bihar, Haryana, Rajasthan, and Uttar Pradesh. An interesting yet unusual

feature of Delhi is the large floating population of millions of visitors every year. These

short-term visitors are drawn to the city for a variety of reasons including for work and

business, for accessing healthcare, for sightseeing, studying and to visit friends.


Delhi offers among the most sophisticated medical care with latest state-of-the-art

technology for treatment and the best-qualified doctors in the country. In addition to well

reputed Government hospitals, Delhi has a flourishing private sector in health. It is therefore

not surprising that close to one-third of those seeking healthcare as in-patients in Delhi‘s

medical institutions come from outside the city-state. Delhi‘s health network has enabled the

city to record significant achievements. For example: Delhi reports a life expectancy at birth

of 69.6 years—nearly six years higher than the national average. Delhi‘s death rate of 5 per

1000 population is among the lowest in India, Delhi‘s infant mortality rate has fallen steadily

from 43 per 1000 live births in 1990 to 28 in 2003. Delhi reports a Total Fertility Rate of

1.6— well below the replacement rate and lower than Kerala‘s 1.8. Delhi is classified as a

low prevalence state for HIV/AIDS. Nevertheless, Delhi‘s health achievements fall short on

many counts. Such as Delhi‘s Infant Mortality Rate (IMR) is almost three times higher than

Kerala‘s IMR of 11 per 1000 live births. (Kerela is found to have the best IMR indicators in

the country).

The bed-population ratio has remained unchanged at 2.2 for over past twenty years. Efforts

to reduce communicable diseases have been inadequate. According to recent estimates,

almost 21 per cent of outdoor patients and 26 per cent of indoor admissions in hospitals are

treated for communicable diseases. Dengue and malaria remain two vector borne diseases

adversely affecting many lives. Many of the communicable diseases can be traced to the

deteriorating quality of water, increasing problems of poor sanitation, inadequate drainage,

and high levels of environmental pollution. Rest of the 75 per cent patients are treated for

lifestyle diseases.

Delhi‘s overwhelmingly urban population—93 per cent—is spread over 9 districts. The North-

West District spread over 440 square kilometres with close to 2.9 million residents is the

largest; and New Delhi covering a mere 35 square kilometres with around 179,000 residents

is the smallest district. The North-East District is the most densely populated (29,468

persons per square kilometre) and South-West the least (4179 persons per square

kilometre). Accessibility of good healthcare for these people is inadequate and they need to

travel long distances to access a good healthcare center which is an extra burden of cost to

the family.

Corporates provide medical insurance to their employees. This too has led to a spurt in

demand for quality healthcare. With more people buying medical insurance, the average

time spent in the hospital has gone up and are also prolonging their post-operative stay in

the hospital. All this translates into higher demand for hospital beds in all cities. Low-cost

treatment is the ultimate factor in Delhi. Medical care costs only one-fifth of the costs in the

West and due to this 150,000 medical tourists came to Delhi in 2008 which gave rise to

medical tourism. Only 10 per cent of payment is done through insurance so there is a lot of


demand to penetrate the insurance market and rest is through direct payment. This has led

to 62 per cent of healthcare expenditure being financed out-of-pocket. Public health

expenditure by the Government of Delhi, over the past twenty years, has consistently

remained over 6 per cent of the total plan budget. During the Tenth Five-Year Plan period

(2002–07), Delhi allocated 35 per cent of its plan outlay to health—the highest by any state

government in the country. Delhi‘s per capita expenditure on health today is more than

three times the national average.

4.4.4. Hospitals in Delhi

There are approximately 646 hospitals and 993 dispensaries within the city and the total

number of beds in the city is 33,000 to 40,000 beds. Delhi has approximately 380 private

hospitals. 120 nursing homes, 38 trust hospitals and 15 government hospitals. Currently

there are 35,200 beds (14,200 beds in the public sector and the rest in private) in Delhi

hospitals and another 32,000 beds will be added by 2012, bringing bed to thousand

population ratio to 3.96. Out of this total, 24,000 beds will be added by private sector and

the rest will be by the government. The medical infrastructure market will grow at 14.5 per

cent. The total investment needed to reach the target of bed to thousand population of 3.96

will be US$2,000 Million (Rs. 10,000 Crores) out of which US$1,500 Million (Rs. 7,500

Crores) will come from the private sector. The revenues currently generated by the private

hospitals in Delhi are US$400 Million (Rs.2,000 Crores) and are likely to increase to US$765

Million (Rs.3,830 Crores) by the year 2012 at a CAGR of 18 per cent.

Figure 4.1. Private hospitals based on Bed Capacity

Source: Delhi Hospital Report, 2010


4.4.5. Demand for number of beds/1000 population in Delhi

Number of beds/1000 population is 2.2 and the world average requirement is 3.96

beds/1000 population but this should increase to 7beds/1000 population with the increasing

population and growing healthcare diseases. So approximately, 31,000 beds needs to be

added in order to reach the ratio of 3.96 beds/1000 population (Delhi Hospital Report,

2010).

4.4.6. Demand for number of patients in Delhi

Average occupancy ratio for private hospitals is 95-100 per cent in most of the good

hospitals. In some hospitals there is a waiting list for patients to get a bed for admission.

With bed strength of 1000 beds, the average number of out-patients visiting the

hospital/day is about 1530, and the number of in-patients admitted/day is 900. With bed

strength of 200 beds, the average number of out-patients visiting the hospital/day is about

350, and the number of in-patients admitted/day is 190. Occupancy ratio of 60-70 per cent

is good enough to break even. So there is a demand to increase the beds and occupancy

ratio which will increase the number of out-patients and in-patients visiting the hospital/day.

4.4.7. Supply and Demand Scenario in Delhi

There are 6400 doctors which works out to 0.4 doctors per 1000 population but requires 1.5

doctors per 1000 population to meet the demand. There are 3200 nurses in Delhi which is 2

nurses per 1000 population will require 3.45 nurses. There are 11,200 physicians which is

0.7 per 1000 population of Delhi but will need 1.8 physicians per 1000 population. In Delhi

there are 35,200 beds which works out as 2.2 beds per thousand population but will require

3.96 beds per 1000 population (Delhi Hospital Report, 2010).


4.4.8. Projected Growth in the number of beds in Delhi

Table 4.6: Upcoming hospitals in Delhi (2009-2012)

Sr.No Name of the hospital No of beds Remarks

1 Rockland Hospital 300 Setting up a hospital in Manesar

2

Rockland Hospital 60 Setting up a hospital in Dwarka-Delhi and to operational by 2010

3 Rockland Hospital 250 Setting up a hospital in Greater Noida and to operational by 2011

4 Pushpanjali Crosslay Hospital 400 The hospital will be operational in 2010. Located at Ghaziabad

5 Fortis Healthcare (Gurgaon Hospital Project)

950 First phase with 350 beds would be ready by the first half of fiscal 2010

6 Fortis - Medicity 800 Located in Gurgaon

7 Manipal 600 Located in Delhi

8 Fortis Healthcare Limited 550 First phase will have 258 beds which will be completed by end of 2009

9 GM Modi Hospital 550

10 DLF Universal Ltd (Gurgaon) 350

11 Paras Hospital 350

12 Max Hospital - Shalimar Bagh 300 Expected to be launched by 2011

13 Max Balaji Hospital (Patparganj,New Delhi)

270 Expected to be launched by August 2009

14 Metro Multispeciality Hospital 250 Expected to be completed by 2009. Located in Delhi

15 Metro Multispeciality Hospital 200 New hospital will be coming up in place of the 80 bedded hospital in Faridabad. The hospital is nearing completion

16 Artemis Health Sciences Pvt Ltd 250

17 Hospital (Jwala Puri) Project 200

18 Hospital (Siras Pur) Project 200

19 Hospital (Madi Pur) Project 200

20 Rajiv Gandhi Super-Specialty Hospital 650 The project is under construction and nearing completion.

21 Metro Multispeciality hospital 200 Expected to be completed by 2009. Located at Greater Noida


#No Name of the hospital No of beds Remarks

22 Hospital (Ashok Vihar) Project 200 Project is currently under construction. Expected to be completed by 2010.

23 Balak Ram Hospital (Timarpur) Project

100 Project is currently under construction. Expected to be completed by 2011.

24 General Hospital 100 Construction to start soon. Expected to be completed in 2012

25 General Hospital 100 Project is currently under construction. Expected to be completed by 2011.

26 General Hospital 100 Project is currently under construction. Expected to be completed by 2011.

27 Guru Harkishan Manipal Hospital 300 Project is currently under construction.Expected to be complted in 2010

28 Paras Hospital 200

29 Wockhardt 170 Expected to be completed by December 2009

30 Max Hospital - Saket South Block 85 Expected to be launched by September 2009

31 RG stone urological research institute n.a Two more hospitals in East and Central Delhi

32 Columbia Asia n.a.

33 Reliance ADAG n.a.

Total supply 9,235

Source: CRISIL Research (2009)

4.4.9. Hospital Bed Ratio in Delhi

Delhi has 646 hospitals, 993 dispensaries, seven primary health centres, forty-eight sub-

centres, and over 250 maternity homes and clinics. Delhi Government‘s Health and Family

Welfare Department is the major provider of healthcare through its network of thirty-two

hospitals. There are more than 190 hospitals which are empanelled by various Insurance

Companies and Third Party Administrators (TPA). According to a recent survey by the

Voluntary Health Association of India (2005) twenty-nine per cent of households‘ use public

medical facilities and 71 per cent use private medical facilities. Fifty-three per cent of

households‘ in Delhi go to a private doctor. Thirty-three per cent of households‘ with a ‗low‘

standard of living use the public medical facilities. Between the years 1982–2004, over a 22-

year period, Delhi added 18,736 new hospital beds. As a result, Delhi‘s bed-population ratio

of 2.2 per 1000 is significantly higher than the national average of 0.7 beds per 1000

persons. Delhi has a high literacy rate of 80.73 per cent and high per capita income of

Rs. 66,000 in 2009. So there is better health awareness and willingness to spend on health.

As per CRISIL research (2009), there will be an additional 33 hospitals adding 9235 beds to

the existing healthcare infrastructure in Delhi.


4.5. MUMBAI

Mumbai, the capital of Maharashtra, is the financial hub and financial capital of India. It is

also proudly one of the world`s fourth largest urban agglomerations. The Mumbai Stock

Exchange is one of the most vital Stock Exchanges amongst the 23 Stock Exchanges of the

country. Mumbai is also the abode of all famous personalities of bollywood, home to one of

the supreme cinema industry of the world. A number of Indian financial institutions have

headquarters based in Mumbai. Mumbai has been ranked as the world`s biggest centres of

commerce in terms of the financial flow volumes in a survey compiled by MasterCard

Worldwide. The McKinsey study (2010) presents the aspirations for Mumbai and its

benchmarking in order to transform to a world class city. Mumbai needs a make a quantum

leap on two fronts: economic growth and quality of life. In order to achieve this vision, the

government must set certain concrete targets. Quantitative aspirations have therefore been

formulated for the six core areas and one of it is healthcare that Mumbai must focus.

4.5.1. Literacy in Mumbai

The approximate rate of literacy in Mumbai is about 77 per cent. The rate of female literacy

in Mumbai is about 71.6 per cent and the rate of male literacy in the city is about 82 per

cent. The Birth Rate, Death rate and Infant Mortality rates have significantly come down

which is a good indicator of health in Mumbai. There‘s also a significant increase in the Per

Capita Income of Mumbai residents.

4.5.2. Age Distribution and Dependency Ratio in Mumbai

In Mumbai there are 6.6 per cent of people who are above 60 years of age with

dependency. Mumbai‘s dependency ratio is high compared to other cities.

Table 4.7. Age Distribution in Mumbai

Age Distribution – Mumbai

Mumbai Suburb Mumbai City

Age Group Persons Males Females Persons Males Females Total

0-14 27.24 26.06 28.68 23.54 21.99 25.54 50.78

15-34 40.25 41.68 38.51 41.15 43.67 37.91 81.4

35-59 26.4 26.65 26.09 27.47 27.64 27.26 53.87

60and above 6.03 5.53 6.64 7.7 6.56 9.18 13.73

99.92 99.92 99.92 99.86 99.86 99.89 199.78

Source: Maharashtra Census 2001


4.5.3. Healthcare scenario in Mumbai

The Mumbai Human Development Report gives a clear picture of healthcare scenario in

Mumbai. Due to better spread healthcare facilities in Mumbai the common understanding is

that Urbanization is strongly linked to and higher levels of education and delayed marriages

and smaller families. Good birth control is there in Mumbai. Yet early marriages seem to be

the trend in the city despite high levels of urbanization. This paradox should cause concern.

The average life expectancy is the average number of years a person is expected to live

assuming that the current mortality rates continue. The average life expectancy at birth in

Mumbai is 56.8 years in 2007 (Life Expectancy for India is 67.7 as per Human Development

Report, 2007-2008). With economic growth the death rate (Crude death rate in 2000 was

7.6 in 2000 and came down to 7.1 in 2003) declines but because of better health facilities,

birth rate remains same, therefore the increase in population of Mumbai.

Heart attacks caused the maximum deaths in Mumbai. Increased number of heart disease is

due to sedentary life styles with lack of exercise and poor eating habits in Mumbai. Non

communicable diseases dominate over communicable diseases. Tuberculosis which is widely

known as poor man‘s disease also has a very high incidence due to poor unhygienic

conditions.

Infant mortality rate (IMR) in Mumbai is 36.66 in 2007 an increase from 2003 which was

34.57 (37.5 for Maharastra and National average is 57). Maternal mortality occurs due to

complications during pregnancy and child birth and is related to the availability and access

to institutional and skilled personnel at the time of delivery. A higher number of institutional

births actually reduces the instances of maternal mortality and this is what is happening in

Mumbai, Statewide and nationally. Adequate nutrition is critical for health and productivity

of the people. Malnutrition can result in greater susceptibility to infections, risk of adverse

pregnancy outcomes for women and growth retardation among children. 45.4 per cent of

children below 5 years of age had stunted growth. 32.6 were underweight. More than half

of children between the age 6-35 months and pregnant women are anaemic.

Against this backdrop of birth rate, death rate, infant and maternal mortality rate and

nutritional status of the population a review of the provision of health services in Mumbai

would be seen. The public healthcare system falls woefully short when it comes to issues of

quality and responsiveness of service. A large part of this is explained by the considerable

over-burdening of the 20 or more municipal hospitals. At the same time, utilization of

primary healthcare facilities (i.e., around 150 municipal out-patient dispensaries and


maternity homes) is abysmal. To correct this imbalance, the Municipal Corporation of

Greater Mumbai (MCGM) needs to upgrade primary healthcare facilities (e.g., ensure that an

adequate stock of medicines is available, as are anesthetists) while discouraging patients

from going directly to the municipal hospitals (e.g., by significantly increasing the difference

in case-paper fees between municipal hospitals and primary healthcare facilities). In

addition, the Government should encourage public private partnerships in hospitals and

should hand over a few hospitals to reputed trusts and NGOs, without withdrawing any

funding and by putting in place more appropriate user charges.

Mumbai is a strong contender for promoting medical tourism owing to its potential strength

of experts‘ across various disciplines. Although Mumbai has a stronghold in secondary and

tertiary healthcare it has witnessed limited development in the sector. With a focused

approach the inherent strength of Mumbai can be directed to promote development of

health city and a slew of new hospitals that would support medical tourism. Within the

existing framework and with limited modifications, the MCGM should exploit this potential to

develop a Health city in the suburbs. To develop capacity, it could also grant public hospitals

the autonomy to enter into public-private partnerships and become global centers of

excellence in important fields such as cardiac care and diabetes.

The yearly per capita health expenditure of Municipal Corporation in Mumbai is Rs. 210. It is

greater than the per capita expenditure in Maharastra which is at 142.62 as per 2004 -05

figures but less than per capita national expenditure of Rs. 275.

4.5.4. Hospitals in Mumbai

There are altogether approximately 539 hospitals in Mumbai and 48 per cent of these are

the nursing homes, followed by private hospitals which are 28 per cent whereas 21 per cent

are trust hospitals and only 3 per cent are government hospitals. As per Table 4.9 there are

approximately 35,595 beds in Mumbai.


Table 4.8: No. of beds in Mumbai in 2008

Hospitals with no. of beds No of hospitals Total no of beds

>= 1000 beds 6 8,290

500 to 999 beds 15 8,711

300 to 499 beds 19 6,884

200 to 299 beds 15 3,721

100 to 199 beds 31 4,025

50 to 99 beds 25 1,594

25 to 49 beds 39 1,314

< 25 beds 64 1,056

Total no. of beds 214 35,595


4.5.5. Demand for number of beds/1000 population in Mumbai

Number of beds/1000 population is 2 and the world average requirement is 3.96 beds/1000

population but this should increase to 7 beds/1000 population with the increasing

population and growing healthcare diseases. So approximately 35,000 beds needs to be

added in order to reach the ratio of 3.96 beds/1000 population.

4.5.6. Demand for number of patients in Mumbai



With bed strength of 1000 beds, the average number of out-patients visiting the

hospital/day is about 1600, and the number of in-patients admitted/day is approximately

950. With bed strength of 200 beds, the average number of out-patients visiting the

hospital/day is about 400, and the number of in-patients admitted/day is 200. Occupancy

ratio of 40-45 per cent is good enough to break even. So there is a demand to increase the

beds and occupancy ratio which will increase the number of out-patients and in-patients

visiting the hospital/day.


4.5.7. Projected Growth in The Number Of Beds

Table 4.9: 2009-2012 — Names of Upcoming hospitals: Mumbai

#No Name of the hospital No.of beds

Remarks

1 Seven Hills Hospital 1,500 Expected to start operations in July 09. 300 beds would be operational in the first phase

2 Lilavati hospital 300 Planning to set up a new hospital in Mumbai

3 Apollo Hospital 550 Located at Navi Mumbai.Its first phase would have 400 beds

4 Hinduja hospital 138 New multispeciality hospital is under construction

5 Global Hospital 500 Tertiary care hospital at Lower Parel. Expected to start operations by Dec-09

6 Government hospital 120 under implementation. Expected to be completed by 2010

7 Apollo Hospital 250 Entered into a Joint venture to set up a hospital in Thane

8 Apollo Hospital 250 Entered into a Joint venture to set up a hospital in South Mumbai

9 Wockhardt- Versova 492

10 Adams Wylie Hospital (Wockhardt) 340 Located in South Mumbai near Nair Hospital

11 Shatabdi Hospital 500 Planning to set up a new hospital in Govandi

12 Kohinoor City Hospital 150 Would be commissioned in 2009

13 Hiranandani Hospital 100

14 Singapore-based Pacific Healthcare n.a

Total supply 5,190

Source: CRISIL Research (2009) n.a.: Not available.

4.5.8. Hospital Bed Ratio in Mumbai

Inadequacy of healthcare infrastructure can be deciphered from the proportion of

population per hospital bed in the city. A higher population bed ratio indicates over crowding

in the hospitals and consequently inadequacy of health service delivery. In municipality

hospitals there are 10,147 people per bed and in private hospitals its 487 people per bed.

The availability of hospital beds in comparison to the total population in different parts of

the city is also disproportionate. Majority of the population living in the eastern and western

suburbs has to rely on inadequate facilities available nearby or travel to the island city for

medical care, further adding to their costs with respect to the choice.


4.6. KOLKATA

Kolkata is the capital of West Bengal and also touted artistically as the `City of Joy`, making

it India`s third-largest city and urban agglomeration. The urban agglomeration of Kolkata

covers several municipal corporations, municipalities, city boards and villages and is the

third largest urban agglomeration in India after Mumbai and Delhi. The city is also classified

as the eighth largest urban agglomeration in the world. As per the census of 2001, the

urban agglomeration's population was 13,216,546 while that of the city (Municipal

Corporation of Kolkata) was 4,580,544. Kolkata city's population growth has been pretty low

in the last decade. It is the main business, commercial and financial hub of Eastern India.

Kolkata is a multicultural, cosmopolitan city. Kolkata witnessed an economic decline from

the late sixties till the late nineties. The city's economic fortunes turned the tide as the early

nineties economic liberalization in India reached Kolkata‘s shores during late nineties.

Kolkata is home to many industrial units, of large Indian corporations, whose product range

is varied and includes - engineering products, electronics, electrical equipment, cables, steel,

leather, textiles, jewellery, frigates, automobiles, railway coaches, wagons. Several industrial

estates like Taratolla, Kalyani, Uluberia, Dankuni, Kasba, Howrah are spread throughout the

urban agglomeration. A huge leather complex has come up at Bantolla. An export

processing zone has been set up in Falta. Specialized setups like the country's first Toy Park,

and a Gem and Jewellery Park have also been established. The city is the major business,

commercial and financial hub of eastern India and also of the north-eastern states. India`s

second largest bourse - the Kolkata Stock Exchange is based here. Some notable companies

and business magnets established in Kolkata are ITC Limited, Bata India, Birla Corporation,

Coal India Limited, Damodar Valley Corporation, United Bank of India, UCO Bank, Allahabad

Bank and Vijaya Bank.

Size of population and its distribution over space play a very significant role in spatial

planning. According to 2001 Census, 13.22 million people were distributed over 1851.41 sq.

km. of Kolkata Metropolitan Area (KMA) forming an overall density of 7950 persons per sq.

km. Area category-wise distribution: Kolkata Municipal Corporation (KMC), the largest

component of KMA with 197.54 sq. km. of area, accounts for 10.6 per cent of KMA‘s area

and with 45.73 lakh residents accounts for 31.1 per cent of KMA‘s population. Other two

municipal corporations viz. Chandannagore and Howrah extend over 3.9 (1.2 + 2.7) per

cent of KMA‘s land accounting for 7.9 (1.1 + 6.8) per cent of KMA‘s population. The 38

municipal towns of KMA extend over 33.2 per cent KMA‘s land and shelter 45.1 per cent of

KMA‘s residents. The 77 CTs occupy only 10.8 per cent of KMA‘s area providing home to 6.7


per cent of KMA‘s population. A vast chunk of KMA‘s land i.e. 40.3 per cent is rural in nature

accounting for only 8.7 per cent of KMA‘s population. The accessibility of care to these areas

is always a problem. There are inadequate tertiary care facilities in these areas outside

Kolkata Municipal area. They need to travel long distances to avail quality care which leads

to cost burden on the family. If Home Care services are started, it will be a boon for them.

4.6.1. Kolkata's literacy rate

Kolkata has a very good literacy rate of 81 per cent which exceeds the all-India average of

66 per cent. With high literacy rate and high per capita income there is high health

awareness and the willingness to spend more.

4.6.2. Age Distribution and Dependency Ratio in Kolkata

Dependency ratio is defined as the ratio of population below 15 years and above 60 years

taken together to the population in the age group 15 - 59. It has an important economic

significance. The low dependency ratio of a region implies that a low percentage of

population depends on its working force for economic wealth to consume. The dependency

ratio for KMA and KMC are found to be 0.53 and 0.49 respectively. The dependent

population is very large.

Table 4.10. Age Distribution in Kolkata

Age Pyramid - Kolkata 2005

Age group (Years) Male

Female

Number Percentage Number Percentage

0 to 4 132,500 5.32 per cent 124,400 6.02 per cent











80+ 29,500 1.18 per cent 29,200 1.41 per cent

Total 2,492,400 100.00 per

cent 2,067,500 100.00 per

cent

Source: CIA Factbook 2007, USA


4.6.3. Healthcare Scenario in Kolkata

The Human Development Indices for Kolkata is as follows: Health Index 0.82; Income Index

0.73; and human development index of 0.78 which is the highest in West Bengal. Kolkata

ranks first in human development ranking of West Bengal.

Several outcome indicators for health and nutrition suggest that while average conditions

could have improved more rapidly, there is substantially more equality of access across the

population than in other parts of India. In the context of the high population density in the

city, the extent of reduction of the decennial growth rate of population in West Bengal has

been quite impressive at nearly 7 per cent as compared to the Indian average of 2.5 per

cent. This has occurred in a scenario of both birth rates and death rates declining quite

rapidly. The improvement in the sex ratio in West Bengal has been considerable, at the rate

of 1.86 per cent as compared to the average Indian improvement of 0.6 per cent. Sex ratios

also show district wise differences, with Medinipur being the best and Kolkata being the

worst. Of course, high rates of male in-migration into Kolkata may explain this difference to

some extent; however, the sex ratio for 0-6 years is also the lowest in Kolkata.

Kolkata has improved on Infant Mortality Rate (IMR) and Maternal Mortality Rates (MMR) as

compared to West Bengal which ranks third in India with respect to infant mortality rates.

Even in terms of reduction over time, between the 1982-1992 period and the 1992-2002

period West Bengal appears to have done much better than India as a whole, which clearly

suggests a gradual improvement in health facilities over the years in the state. Infant

mortality is nearly 42 per cent of the deaths occur within the first week, the control of early

neonatal mortality would lead to a much improved IMR.

The data on nutrition overall indicates that the average level of nutrition in the city, and

especially among women, is low by several criteria. However, malnutrition among children is

lower than the national average, and severe malnutrition is also low, suggesting that

distribution is better than in most other states. The overall anaemia status of children in

Kolkata and West Bengal is very poor as it ranks as low as nineteenth among 25 states. The

proportion of children with anaemia (78 per cent) is higher compared to the Indian average

of 74 per cent. In the rural areas, 82 per cent of children are estimated to have anaemia,

compared to 64 per cent in urban West Bengal and 60 per cent in Kolkata. Severe anaemia

is also higher in rural West Bengal, at 5.3 per cent compared to 4.6 per cent in the urban

areas and 0.7 per cent in Kolkata.


The incidence of anaemia among women is much higher than in many other parts of the

country. Compared with the national average of 52 per cent Kolkata has high incidence of

Anaemia. Once again, rural women tend to be worse off in terms of anaemia, although the

incidence of severe anaemia shows the opposite pattern, being the lowest in the rural areas

at 1.4 per cent, compared to 1.8 per cent in all urban areas and 2 per cent in Kolkata.

The data on morbidity among the general population indicate very high incidence of asthma

and jaundice. These are diseases which are affected by the extent of atmospheric pollution

and the availability of safe water and sanitation, so these are clear areas for public health

intervention. More of lifestyle disease than communicable disease are showing up gradually.

The public hospitals in Kolkata, such as Kolkata Medical College or Nil Ratan Sarkar Medical

College, were a melting pot for the best clinical acumen and a crucible for medical treatment

and research, in the heydays of 1960s, which set new benchmarks for other institutes. Not

just West Bengal, but patients from Bihar, Orissa, and the seven North Eastern states

flocked to Kolkata for treatment. However, in the period from '70s to the '80s, healthcare

services in Kolkata began a downward spiral from their position of strength. As political

turmoil and union uprisings derailed development and complacency set in, the overloaded

public healthcare system failed to cope with the enormous inflow of patients. While the

South emerged as a hub for medical care, public hospitals in Kolkata started lagging behind

in technology and clinical acumen.

The darkness that engulfed the healthcare vista of the city for two decades started clearing

only by the mid-'90s with the advent of hospitals like Peerless Hospital, Ruby Hospital, AMRI

and BM Birla (the cardiac wing of GP Birla group that was already running CMRI). The city's

healthcare landscape got a further boost in the decade beginning 2000 with the

establishment of hospitals like Apollo Gleneagles, Wockhardt (now Fortis), Bhagirathi Neotia

Woman and Child Care Centre, Desun, Sankara Nethralaya and Columbia Asia.

4.6.4. Hospital Beds in Kolkata

There are approximately 200 hospitals within the city and the total number of beds in the

city is 20,000 to 25,000 beds for an estimated population of 51 Lakh. Out of these 72 per

cent are in private sector, 20 per cent are trust hospitals, 15 per cent are government

hospitals and only 10 per cent are nursing homes.


Table 4.11: No. of beds in Kolkata in 2008

Hospitals with no. of beds No of hospitals Total no of beds

>= 1000 beds 5 7,252

500 to 999 beds 6 3,371

300 to 499 beds 6 2,067

200 to 299 beds 14 3,181

100 to 199 beds 16 2,005

50 to 99 beds 22 1,406

25 to 49 beds 38 1,328

< 25 beds 19 328



4.6.5. Demand for number of beds/1000 population in Kolkata

Number of beds/1000 population is 1.2 and the world average requirement is 3.96

beds/1000 population but this should increase to 7 beds/1000 population with the

increasing population and growing healthcare diseases. So approximately 18,000 beds

needs to be added in order to reach the ratio of 3.96 beds/1000 population.

4.6.6. Demand for number of patients in Kolkata



With bed strength of 700 beds, the average number of out-patients visiting the hospital/day

is about 1200, and the number of in-patients admitted/day is 650. With bed strength of 200

beds, the average number of out-patients visiting the hospital/day is about 350, and the

number of in-patients admitted/day is 190. Occupancy ratio of 70 per cent is good enough

to break even. So there is a demand to increase the beds and occupancy ratio which will

increase the number of out-patients and in-patients visiting the hospital/day. Growth rate is

highest in Cardiac and Cancer and will grow at 14 per cent. There are more than 100

hospitals which are empanelled by various Insurance Companies and Third Party

Administrators (TPA). (Kolkata Hospital Report, 2010)


4.6.7. Projected Growth in the number of beds in Kolkata

Table 4.12: 2009-2012 — Names of Upcoming hospitals: Kolkata

No. Name of the hospital

No. of beds

Remarks

1 Global Hospitals 700 Global Hospitals has tied up with the Surekha group for the project. Expected to come up in two phases of 350 beds each. Project is still at a planning stage.

2 AMRI Hospitals 500 500 Bed Hospital at New Town Rajarhat. Land acquisition is underway.

3 Medica Synergie Pvt. Ltd.

500 Construction of the 500 bed project located on EM Bypass is underway.

4 Neotia Elbit Healthcity

500 Project at planning stage, to be located at chakgheria on EM Bypass.

5 Wockhardt Hospital 342 Expected to specialise in cardiology and cardiac surgery besides urology and nephrology. Construction is underway.

6 Ruby General Hospital Limited

300 Plans to set up a 300-bed unit for oncology and neurology spread over 2.5 acres adjacent to its building on EM Bypass

7 AMRI Hospitals 275 275 bed hospital to be located at Mukundpur Road. Construction is underway.

8 Tata Memorial Cancer Hospital

150 Located near New Town Rajarhat, the facility is expected to become operational in 2009.

Total supply 3,267

n.a.: Not available


4.6.8. Hospital Bed Ratio in Kolkata

With population served per bed ratio being at 1.88 as against three to four beds per 1,000

populations in developed countries extra beds are required urgently. The city just does not

cater to the city's population alone. The catchment area is the entire state, neighboring

states and neighboring countries like Bangladesh, Nepal, and Bhutan as well. Kolkata is

projected to face a massive shortage of 13,735 beds in 2011(Express Healthcare, July

2010).


4.7. CHENNAI

Chennai, formerly Madras, is the capital of Tamil Nadu and is located on the Coromandel

Coast of the Bay of Bengal. Its the fourth largest metropolitan area of India. The urban

agglomeration of Chennai has an estimated population over 6.43 million in the year 2001,

making it one of the largest urban agglomerations in India. The city is a large commercial

and industrial centre, and is known for its cultural heritage and temple architecture.

Approximately 40 per cent of the automobile industries have their base in Chennai and

hence the place is proudly recognized as the Automobile Capital of India. Major software

companies like Accenture, Cognizant Technology Solutions (CTS), Infosys, Satyam, Sun

Microsystems, Symantec, TCS (Tata Consultancy Services Ltd.), Verizon, Wipro have

development centres in the city. The city is now the second largest exporter of Information

Technology (IT) and IT Enabled Services in the country after Bangalore.

4.7.1 Literacy Levels in Chennai

Census figures indicate that the literacy rates in Chennai City and the CMA are more or less

equal and these figures compare favorably with the overall literacy rate in urban Tamil

Nadu. The literacy rate has been increasing since 1961 from 55 per cent to 74 per cent. The

table below gives the comparative picture.

Table 4.13: Literacy Levels in CMA in percentage

1961 1971 1981 1991 2001

City 59.47 62.01 68.68 72.54 76.81

CMA 54.82 58.64 66.56 70.32 76.09

Urban TN 21.06 30.92 40.43 51.33 73.51

Source: Chennai Demography 2009

4.7.2. Age Structure and Dependency Ratio in Chennai

Age structure of a population in a city / metropolis plays a major role in urban planning. It

gives an idea about dependent population, working population, jobs to be created, the

present and future requirements of educational, health and other facilities and amenities. It

depends on birth rate, death rate and also migration. Age structure of population in CMA as

per Census 1971 to 2001 is given in the table below where the dependent population is

seen to be increasing.

As per Table 4.15 the dependent ratio is 479 and is having a disability percentage of 2.2.


Table 4.14. Age Structure in CMA in per cent

Age Group 1961 1971 1981 1991 2001

0-4 13.2 12.51 11.03 8.68 7.31

5-9 12.39 11.74 10.35 9.56 7.97

10-14 10.64 10.97 11.37 10.51 8.95

15-19 8.66 9.97 10.61 10.22 9.55

20-24 10.73 11.05 10.68 11.14 10.47

25-29 10.21 9.29 9.61 10.2 10.33

30-34 7.98 7.15 7.46 8.06 8.46

35-39 6.69 6.99 6.66 7.48 8.04

40-44 5.49 5.14 5.36 5.68 6.19

45-49 4.15 4.33 4.7 4.98 5.5

50-54 3.65 3.51 3.7 3.92 4.37

55-59 2.1 2.46 2.73 2.9 3.1

60-64 2.06 2.3 2.4 2.64 2.83

65-69 1.1 1.15 1.37 1.51 1.96

>70 1.2 1.65 1.97 2.33 3.02

not stated 0 0 0 0.18 1.93

Total 100 100.21 100 100 100

Source: Chennai Demography 2009

Table 4.15. Percentage of population in broad age groups (0-14, 15-59 and 60+)

and dependency ratio, 2001

City 0-14 years 15-59 years 60+ years Dependency ratio

Male Female Male Female Male Female

Chennai 11.9 11.5 33.7 31.9 4.0 4.1 479

Source: Census of India 2001, Director of census operations, Tamil Nadu

4.7.3. Healthcare Scenario of Chennai

Due to better spread healthcare facilities in Chennai the common understanding is that

Urbanization is strongly linked to and higher levels of education and delayed marriages and

smaller families. As per C.Ramanujam J, Joseph Durai Selvam, R.Ramasamy (2007)

developmental indicators at district level in Tamil Nadu in 2005-2006 where the Total

Fertility Rate (TFR) in Chennai is 1.8 (2004). The registered birth rates in Chennai City in

1981 were 31.20 and varied from 38.6 to 24.06 during 1981-91 and have reduced to 22.62

in the year 2003. Similarly the death rate also reduced to a considerable extent from 9.20 in

1981 to 8.01 in 2003. The rate of natural increase declined from 22.00 in 1981 to 14.61 in

2003.


The neonatal mortality rate is 7.2 in 2004. The average life expectancy is the average

number of years a person is expected to live assuming that the current mortality rates

continue. The average life expectancy at birth in Chennai is 67 years for Males and 69.8 for

females in 2001 (Life Expectancy for India is 67.7 as per Human Development Report, 2007-

2008). With economic growth the death rate declined but since better health facilities birth

rate remains same therefore the increase in Population of Chennai. Between the years

1991-2001, Chennai had a decadal growth rate of 13.07 with a life expectancy of 74.2 in the

year 1997. Chennai ranked first in Human Development Rank and Gender Development

Rank in Tamil Nadu.

In 2005-2006, Heart attacks (8487) caused the maximum deaths. Increased number of

heart disease is due to sedentary life styles with lack of exercise and poor eating habits in

Chennai. Deaths due to Cancer were 677 and Diabetes 296. Non communicable diseases

dominate over communicable diseases. Deaths due to Cholera were 13 and due to Jaundice

908. Prevalence rate of Tuberculosis in one lakh population is 311 and for Malaria its 78.

Tuberculosis which is widely known as poor mans disease also has a very high incidence

due to poor unhygienic conditions.

Infant mortality rate (IMR) in Chennai is 13.73 in 2005-2006 (In 2002 it was 44 for Tamil

Nadu). Maternal mortality occurs due to complications during pregnancy and child birth and

is related to the availability and access to institutional and skilled personnel at the time of

delivery. A higher number of institutional births actually reduces the instances of maternal

mortality and this is what is happening in Chennai, Statewide and nationally. The maternal

mortality ratio (Number of maternal deaths due to pregnancy causes occurring during

pregnancy within 42 days after termination of pregnancy per one lakh live births) of Chennai

is 0.4 (In 2002 it is 112 for Tamil Nadu) only.

Adequate nutrition is critical for health and productivity of the people. Malnutrition can result

in greater susceptibility to infections, risk of adverse pregnancy outcomes for women and

growth retardation among children. 51.9 had good 90 per cent of standard weight but the

other percentage of 49.9 per cent of children had between 60-90 per cent of standard

weight. 96.5 per cent of adolescent girls were having anaemia in 2002-2004.

Against this backdrop of birth rate, death rate, infant and maternal mortality rate and

nutritional status of the population a review of the provision of health services in Chennai

would be seen. The summary of all the health indicators is given as a comparision between

these cities in Appendix 11.

There are 15 Government hospitals and a large number of private hospitals which provide

medical and healthcare. The Government General hospital, popularly referred to as "G.H.",

is the biggest government run hospital in the city. There are many large private hospitals,

http://en.wikipedia.org/wiki/Government_General_Hospital

http://en.wikipedia.org/wiki/Government_General_Hospital


among which many are multi-specialty hospitals. Some of India's well-known healthcare

institutions such as Apollo Hospitals (the largest private healthcare provider in Asia),

Sankara Nethralaya, Madras Medical Mission(MMM),Frontier Lifeline and K.M. Cherian heart

foundation and Sri Ramachandra Medical Centre are based in the city, making it one of the

preferred destinations for medical tourists from across the globe.

4.7.4. Supply and Demand of Healthcare in Chennai



Considering the longevity in life, improved health conditions predicated, it is assumed that

the number of beds required maybe at the rate of one in a 500 population. The beds

required for the projected population for the year 2011 is 17700, 2016 its 19900, 2021 its

22400 and 2026 its 25100. Some nine lakh patients are admitted every year to the nearly

500 hospitals and nursing homes in Chennai. There are 20, 508 beds in total. More than five

lakh patients come from outside Tamil Nadu (Draft Master Plan – II for Chennai

Metropolitan Area, 2007). Some 50 per cent of hospital beds and 40 per cent of doctors are

in the private sector in Chennai, compared to 21 per cent and 29 per cent respectively in

Tamil Nadu as a whole and 35 per cent and 30 per cent respectively in the country (Asha

Krishnakumar, 2003).

Table 4.16: Total no. of beds in Chennai in 2008

No. of beds in hospitals No of hospitals Total number of beds

>= 1000 beds 4 6,751

500 to 999 beds 8 5,211

300 to 499 beds 5 2,110

200 to 299 beds 12 2,746

100 to 199 beds 17 2,002

50 to 99 beds 20 1,258

25 to 49 beds 10 362

< 25 beds 4 68



4.7.5. Hospital Bed-Population Ratio

The ratio of hospital beds to the population, usually expressed as the number of available

hospital beds for every 1,000 population. The hospital bed population ratio in Tamil Nadu is

http://en.wikipedia.org/wiki/Apollo_Hospitals

http://en.wikipedia.org/wiki/Sankara_Nethralaya

http://en.wikipedia.org/wiki/Sri_Ramachandra_Medical_College_and_Research_Institute

http://en.wikipedia.org/wiki/Medical_tourism


only 0.35 beds per 1,000 people, against the minimum of seven beds for every 1,000. The

bed population ratio in Chennai city was only 1.5 beds per 1,000 people. Theres lot of

overcrowding in the Public hospitals and the private hospitals are scattered. Accessibility and

affordability is a common problem for most of the people. The Municipalities and Town

Panchayats have experienced higher growth rate than that of the City. The density pattern

indicates that the City has the highest gross density of 247 persons/ha, whereas the

average gross density in CMA is only 59 persons/ha. The gross density in most of the

municipal areas and Town Panchayats is very low, indicating that these areas offer high

potential for growth and would be the receiving residential nodes in future. There are plans

to increase overall density of the Chennai Metropolitan Area from the present 59 persons

per hectare to 105 persons per hect.; while doing so the density of Chennai will increase

from 247 persons per hect. in 2001 to 333 persons per hect. in 2026, while in the rest of

CMA the average density will go up from the present 27 persons per hect. to 67 persons per

hectare. Till then people living in these areas have to travel long distances to get good

tertiary care which causes extra burden of cost. It is estimated that CMA would house a

population of 126 lakhs by 2026, of which Chennai City alone would account for 58 lakhs. As

shown in Table there will be eight new hospitals by 2012 adding an extra 1800 beds to the

existing healthcare infrastructure of Chennai which is not sufficient at this rate of expansion

of city. The healthcare infrastructure would further be burdened if corrective measures are

not taken.

4.7.6. Projected Growth in the number of beds

Table 4.17: Upcoming supply: Chennai (2009-2012)

# No Name of the hospital No. of beds

1 Madras Medical Mission 200

2 Apollo Hospital 150

3 Sundaram Medical Foundation 150

4 Hiranandani Hospital 100

5 Madras Institute of Orthopaedics and Traumatology (MIOT) 450

6 Deepam hospitals 200

7 Hinduja Group 250

8 Manipal Hospitals 300

Total supply 1,800



4.8. DISEASE PREVALENCE IN DELHI, MUMBAI, KOLKATA and CHENNAI

Urban dwellers are more prone to some diseases, such as diabetes, asthma, and goitre and

other thyroid disorders. Interviewed women and men were asked if they have any of these

diseases. The household respondent was asked whether anyone in the household suffers

from tuberculosis. The prevalence of these diseases is presented in (Appendix 1) and

summarized below.

Diabetes

Diabetes, commonly known as ‗sugar‘ illness, is often related to a sedentary lifestyle,

obesity, and stress. It is fast emerging as an important health problem in urban areas. A

person has diabetes when the body fails to produce or properly use insulin to convert sugar,

starch, etc., into energy. National Family Health Service -3 (NFHS-3) shows that, diabetes is

more prevalent in urban areas than in rural areas. In general, the prevalence of diabetes in

the four cities is higher than the national average both among women age 15-49 (881 per

100,000) and men age 15-49 (1,051 per 100,000). In these cities, the prevalence of

diabetes among women varies from 1,124 per 100,000 to 3,874 per 100,000 in Chennai.

Kolkata and the other cities have more than 2 per cent of women who suffer from diabetes.

The prevalence of diabetes among men ranges from 430 per 100,000 to 2,516 per 100,000

in Chennai. The prevalence of diabetes among poor women and men is the lowest in every

city, probably because they are less likely to have sedentary lifestyles or to be overweight or

obese. Nevertheless, in Chennai, even among poor women, 2,666 women per 100,000

suffer from diabetes and in Kolkata 1,608 poor men per 100,000 suffer from diabetes.

Asthma

Asthma, a chronic respiratory disease, is often mistaken for tuberculosis because the

symptoms are similar. Among the four diseases covered in NFHS-3, with few exceptions,

asthma is the first or second most common health problem in these cities. The prevalence

of asthma among women varies from 591 per 100,000 in Delhi to 3,133 per 100,000 in

Kolkata. Among men, the prevalence of asthma is also very high in Kolkata (3,269 per

100,000, respectively). The number of Acute Respiratory infections is also shown in

Appendix 4.

Goitre or other thyroid disorders

Goitre is usually caused by an iodine deficiency, which leads to an enlargement of the

thyroid gland. The only symptom in many cases is a swelling in the neck. As shown in

(Appendix 1), the prevalence of goitre is much higher among women than men in every


city. Among men, the prevalence of goitre or other thyroid disorders is highest in Kolkata

(730 per 100,000). The prevalence of goitre among women ranges from 482 per 100,000 to

as high as 4,199 per 100,000 in Kolkata. In Chennai, almost 3 per cent of women suffer

from goitre or other thyroid disorders. There are far greater differences in the prevalence of

goitre or other thyroid disorders between slum and non-slum areas among women than

men. The prevalence of goitre or other thyroid disorders is exceptionally high among

women in non-slum areas of Kolkata (5,139 per 100,000). In almost every case, poor men

and women are less likely than other men and women to have goitre or other thyroid

disorders.

Tuberculosis

The extreme crowding conditions, lack of proper sanitation, and environmental pollution in

very large cities exposes residents, particularly slum dwellers, to a high risk of contracting

tuberculosis, which is a highly contagious disease. It is also caused due to poor hygiene

conditions with congested housing. In recent years, tuberculosis has re-emerged as a major

public health problem in many parts of the world, often as an opportunistic illness related to

HIV/AIDS. The disease spreads through droplets that can travel through the air when a

person with the infection coughs, talks, or sneezes. In NFHS-3, the household respondent

was asked whether any usual resident of the household has tuberculosis. For each

household member with reported tuberculosis, the household respondent was asked

whether the person received medical treatment for the TB.

Appendix 1 presents the prevalence of medically treated TB, i.e., the number of de jure

females and males of all ages per 100,000 suffering from medically treated TB. The number

of females suffering from medically treated TB varies from a low of 240 per 100,000 in Delhi

to a high of 667 per 100,000 in Mumbai. The prevalence of medically treated TB among

women is higher in slum than in non-slum areas in every city.

A wide range of serious diseases, including several types of cancers and heart and lung

diseases are associated with tobacco use. Tobacco use among women can cause a variety

of reproductive health problems, such as difficulty in becoming pregnant and an increased

risk of infertility, pregnancy complications, premature births, low-birth-weight babies,

stillbirths, and infant deaths. Similarly, frequent use of alcohol is related to several health

and social-psychological problems. Appendix 6 presents the proportion of women and men

who smoke cigarettes or bidis, who use tobacco in any other form, and who consume

alcohol. In India, tobacco is used in several forms, such as smoking of cigarettes or bidis,

chewing of paan masala or gutkha, and applying tobacco to the teeth or gums. Smoking

and tobacco use, particularly smoking cigarettes or bidis, is not common among women.The

usage of tabocco and alcohol is also a strong indicator for the disease prevalence. It has


been observed that all these cities have a fair number of these categories of people

(Appendix 6). Poor housing and living conditions in the cities of developing countries,

particularly in slums, is a matter of great concern. Dilapidated and infirm housing and lack

of such basic services as safe drinking water, improved toilet facilities, and clean cooking

fuel expose slum residents to a variety of infections. This section examines some important

indicators of housing and living conditions in slum and non-slum areas and in poor

households‘. environmental health indicators, such as the source of drinking water, the type

of sanitation facilities, the availability of a separate kitchen in the house, and the main type

of cooking fuel used. There are many infectious disease still prevalent in the cities due to

these conditions (Appendix 9). The prevalence of like Diarrhea and Fever in these four cities

is also high as shown in Appendix 4.

In India, the Reproductive and Child Health Programme of the Government of India aims to

provide key maternal and child health services to women during the antennal period, during

delivery, and during the postnatal period. Antenatal care (ANC) refers to pregnancy-related

healthcare, which is usually provided by a doctor, an ANM, or another health professional. It

is recommended that women receive at least three antenatal check-ups during pregnancy.

The antenatal check-up should include a weight and blood pressure check, abdominal

examination, immunization against tetanus, iron and folic acid prophylaxis, as well as

anaemia management. The first antenatal check should take place during the first trimester

of the pregnancy. The programme also recommends that all deliveries should be conducted

in institutions or under the supervision of a health professional. All women should receive a

postnatal check-up within two days of delivery. In every city except Meerut, more than

three-quarters of women had at least three antenatal care visits for their most recent birth

during the five years before the survey. Almost all women in Chennai had at least three

antenatal care visits, followed by Mumbai (91 per cent each). The percentage of women

who received antenatal care in the first trimester of their pregnancy ranges from 58 per

cent in Kolkata to 88 per cent in Chennai. In Mumbai, about 70 per cent of women received

their first antenatal check-up during the first trimester. Ninety per cent of women or more

received at least two tetanus toxoid injections during their most recent pregnancy in all

cities. In Chennai slightly more than half of women consumed iron and folic acid (IFA)

tablets during their pregnancy for at least 90 days. In the other six cities, the percentage

following the standard recommendation ranged from only 29 per cent in Mumbai and to

around 40 per cent in the other three cities. These comparision tables are available in

Appendix 5 and 11.


4.9. USAGE PATTERNS OF PUBLIC HEALTH FACILITIES IN DELHI, MUMBAI,

KOLKATA AND CHENNAI

The citizens in each of these four cities depend on public and private healthcare facilities

when a member of the family is sick. It‘s important to know how these facilities are utilized

since it gives an estimate of how the public and private hospitals are functioning.

Table 4.18. Percentage of households’ using public health facilities in selected cities, India, 2005-06

# Region

Percentage of households using public

health facilities

Percentage of households using private

health facilities

1 Delhi 28 72

2 Mumbai 21 79

3 Kolkata 17 83

4 Chennai 31 69

Source: National Family Health Survey (NFHS-3)2005-06

Table 4.18 shows the distribution of households‘ by the source of healthcare. The private

medical sector is the primary source of healthcare for the majority of households‘ in every

city in slum and non-slum areas (Appendix 2). With the exception of Chennai, a majority of

even poor households‘ usually seek treatment from the private medical sector in case of

illness of a household member. In Chennai, almost two-thirds of poor households‘ (63 per

cent) seek treatment from the public medical sector. In most cities, public sector medical

facilities are more likely to be utilized by poor households‘ than slum households‘ or other

households‘.

In households‘ that generally do not seek healthcare from government sources when

household members fall sick, the household respondent was asked why household members

do not generally use government health facilities. In almost all cases, the three most

commonly reported reasons for not using government facilities are the poor quality of care,

the lack of a nearby facility and excessive waiting times at government facilities (See

Appendix 2). The reason for not using government facility due to no nearby healthcare

facility is highest in Mumbai (44 per cent), Delhi (37.9 per cent), Chennai (30.6 per cent)

and the least is in Kolkata at 21.4. We can take Mumbai as a special case of its highest non

use of health facility.


Table 4.19. Choice of Healthcare Provider by Income and the reason for the Choice

As per the study carried out by World Bank (2003) focused on the choices regarding the

healthcare facilities. 35 per cent of poor households‘ earning less than Rs. 5000 per month

uses the municipal hospitals. On an average 21 per cent of the people use Public hospitals

and the rest goes to the private hospitals costs notwithstanding. Such choices were

determined by costs, distance, quality and other reasons. With increase in incomes there is

a dramatic change of preference to private hospitals and they also prefer quality services.

For low income group accessibility and affordability is a more important consideration than

quality. 75-80 per cent of households‘ prefer to use private sector treatment in Mumbai for

minor and major illnesses.

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