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Name of Student: Siddhesh Govind Bhandari

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Name of Guide: Prof. Smita Dalvi

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Type of Document: Dissertation

2.0 Urbanization in Mumbai
Urbanization is one of the challenges faced by all the cities of the world. Mumbai has urbanized over the past 60 years. Since 1971, there has been a persistent growth in the population from 8 million to 21 million now.
2.1 Factors for Urbanization
Some of the factors for urbanization are:
• Industrialization
• Social factors
• Employment opportunities
• Modernization/ better infrastructure.

2.2 Migration from rural to urban
Migrations are caused due to various social, political or economic factors. Few of them are:
• Marriage is one of the social factors for migration
• Employment: People come to urban areas in search of better jobs.
• Education: People from rural areas migrate to urban areas for higher education
• Security: Political disturbance also causes people to move out.
• Healthcare: People often come to urban areas for getting better treatment.

2.3 Problems due to migration
Due to large migration, there is a shortage of residences in the city. Most of the migrants are un skilled and get low waged jobs. The cost of residence is expensive due to economic growth. So these people cannot afford their own house.
This gives rise to illegal settlements and slums, which is one of the major issue in urban areas.
2.4 Urban stress and health
The fast paced city life has effects on the psychological as well as the physical health of the residents. As we are getting urbanized, people are getting more stressed to cope up with the world resulting in poor mental health.

2.4.1 Urban poor and stress
About 50% of the population in Mumbai is poor and lives in crowded shanties without proper sanitation and basic amenities. Migrant population forms a large proportion of urban areas, and are vulnerable to health issues, but are not able to access the public health facilities.
2.4.2 Factors of stress among poor
Poor population get stressed due to various tangible and intangible factors:
• New area of stay
• Staying alone without family
• Improper working conditions
• Improper living conditions
• Income
• Lack of jobs and employment
2.4.3 Effects on physical health
Our physical and psychological health is inter-related. Deterioration of one can affect the other. These stress factors can have an adverse effect on the mental health of the people.
People with psychological distress often tend to get drawn to substance abuse and smoking.
These factors in turn have negative impact on the physical health of the person.
Improper living conditions and
un-hygienic spaces can deteriorate health. Emotional and social stressors often lead to increase in crimes in such spaces.
2.5 Stressed spaces
Majority of the population in our city resides in slums. Slums are the outcome of lack of affordable housing in the city.
The density of population in such areas is high.
Problems with such spaces are:
• Lack of safety
• Lack of sanitation
• No proper water supply
• Overcrowding
• Lack of privacy

2.5.1 Urban mental health
People with poor financial conditions face stressors when they do not have opportunities to fulfil their needs. These stressors can lead to depressive disorders among such people. Poverty means unemployment and lack of proper housing,
Is more likely to lead to psychiatric illnesses such as depression and anxiety.
Healthy environments need to be provided to people staying at such spaces.

2.5.2 Mental health in India
1. One out of five Indian is suffering from mental disorder.
2. 50% of corporate India is under chronic stress.
3. WHO says India is the most depressed country in the world
4. Suicide is the largest cause for deaths in 15-35 year olds
5. India spends just 0.06% on mental healthcare.
6. Upto 50% mental health problems begin a younger ages.
7. About 200 men and 100 women commit suicide every day.
8. Atlast 20% of young India experience some kind of mental illnesss
9. Only one in 10 people are thought to have received treatment. (htt1)

2.6 Health care in Mumbai
Mumbai, the capital
city of Maharashtra is the most populous city in our country.
It is also 4th most populated city in the world and one of the most populated urban regions in the world.
In India, we are faced with the unique problem of over burdened Public hospitals, as well as, increasing cost of surgeries in the Private hospitals. Also, there is a fast emerging group of jet-setting executives and business men, who do not have the time to ‘waste’ in hospitals, and are looking for fast recovery, enabling they to get back to work as early as possible. The answer lies in the proper and complete utilization of Day Care surgery.
According to the latest government estimates, the doctor-patient ratio is 1:1800 and the hospital bed-patient ratio of 1:1259. There is an estimated shortage of 42,000 beds in just the government hospitals which cater to 60% of the population.
India’s healthcare infrastructure is inadequate to meet the burden of disease. India has just 90 beds per 100,000 population against a world average of 270 beds that is approx.1 bed for 1000 people.
Mumbai, the commercial capital of the country has a population of about 21 million. The density is also quiet high. (htt7)
The population density of Mumbai is about 30,000 people per square kilometer.
• With such large population, the city faces problems in the field of proper housing and healthcare for all.
• Mumbai city has hospitals and dispensaries which are run by the municipal corporation of greater Mumbai. It is the greatest corporation in our country and provides healthcare facilities in Mumbai.
• It has a network of 4 teaching hospitals,5 specialized hospitals, 16 peripheral hospitals,28 municipal maternity homes,14 maternity wards attached to municipal hospitals.
• Apart from this, 185 dispensaries and 176 health posts provide outpatient services.
• The state government has 1 medical college hospital, 3 general hospitals, and 2 health units having a total capacity of 2871 beds.
• There are 70 government hospitals in the city which are owned by different government agencies.
• Mumbai’s existing health infrastructure was planned between 1950 and 1980 to cater to 5.2 and 7 million people, while the facilities are currently used by about 13 million people, said a World Bank study. (htt2)
3.1 Introduction to outpatient care
Outpatient care is a medical care that allows patients to return home on the same day of the treatment. Such centers can be a part of hospitals or can be individual units.
With the rapid advancements in the technology in the Indian health industry, approximately 60% of the surgeries can be done without overnight hospitalization.
These services are provided at facilities like hospital outpatient departments, outpatient clinics, dialysis centers etc.

3.1.1 Formats of outpatient care
1. Integrated with the hospital
2. Hospital autonomous centers
3. Stand-alone centers
4. Day care centers – small scale
5. Individual consultants

Integrated centers share the operation theaters (OT), outpatient departments (OPD) and healthcare staff with the hospital.
Standalone units have pharmacies, diagnostic labs, operation theaters, OPDs, workforce and consultants of their own.
Centers specializing in ophthalmology, dialysis and oncology have a setup similar as outpatient care center.

3.2 Global market review
As of 2018, more than 60% of the surgeries are performed on day case or short stay basis. The global ambulatory care market is predicted to reach INR 242 Tn by 2024, from INR 155 Tn in 2016 with a grown rate of 6%.
Aging population, unaffordable healthcare, high government expenditure on these facilities being the major factors for the market growth.

India to have huge potential for outpatient surgery centers: Medical experts
In the United States, 75% of the surgeries are carried out at the outpatient surgery centers. The model is affordable and provides better quality of care than hospitals.
“The outpatient centers provides accessibility and affordability of surgery to common patient and has a huge potential in India,” – Dr. Ranawat, orthopedic surgeon. (htt3)
3.2.3 Indian market review
• The outpatient surgery has lot of potential to grow in our country, the country is burdened with more than 20% of the diseases of the world but only has 6% of the hospital beds.
• Outpatient surgery can reduce the treatment cost by 70% as compared to the cost of inpatient treatment. There has been a significant increase in such surgery centers in the field of ophthalmology, gastroenterology and orthopedics.
• It is expected that 75% of the surgeries in our country will be outpatient by the year 2020 as compared to 43% in 2016.

3.2.1 Scope of outpatient centers in India
• In India, due to shortage of healthcare capacity, and availability of surgeons, the outpatient center can play a better role in giving surgical services.
• The outpatient centers require less area to set up than a hospital facility.
• The outpatient centers can provide services at 20% less cost than other hospital facilities.
• The chances of getting infections from the hospitals is also less.
— Dr. Girish Rao, CEO Nova medical center

3.2.4 Key Growth factors of the market
• Improvement in the technologies in healthcare
• Cost-effectiveness
• Less accessible public healthcare facilities in India.

The public health system in our country has been in distress due to underfunded health clinics and hospitals.
The medical tourists from the rural areas coming to the metropolitan cities and lack of hospital beds has led to the establishment of day care surgery. It is noted that there are only 0.9 beds in hospitals for thousand people in our country.
3.3 Requirement of outpatient centers in India
• Our country has shortage of healthcare facilities for a number of diseases like cataract, cancer and acute kidney disorders along with others.
• As of 2016, about 0.2 million people needed dialysis treatment in India, But only 0.4 dialysis centers per million people were available.
• In our country 95 percent of the medical colleges do not give cancer care which includes, surgeries, consultation, diagnostics and treatment departments in one single campus.
• Thus more outpatient centers should be established to meet the demands for these health issues in our country. (htt3)
The outpatient care center can work supplementary to large hospitals, through which it can carry some minor and some major surgeries in general surgery, obstetrics, gynecology, orthopedics, ENT, ophthalmology, plastic and cosmetic, urology and gastrointestinal procedures.
In the next decade it is expected that all major hospitals will build their outpatient centers in India.
– Dr. Anil Ranawat, Surgeon.
By the end of 2020, it is expected that more such centers will be established in the cities of India.
Day case surgery market in India was approximately INR 250 Bn and has a growth rate of 15 percent. (htt6)
Importance of outpatient services in India
There are large chunks of population who have no accessibility to medical care, even outpatient.
According to available statistics.
• About 25-35 inpatients are given care per bed in India
• With 8,70,160 beds in our country, 2.7-3 crore in-patients are served in India per year.
• About 600 patients are treated on outpatient basis per bed in India.
• 52 crore patients are given treatment on outpatient basis. (htt9)

It is patient’s first point of contact into any healthcare delivery system.
It contributes in reduction of morbidity and mortality.
It’s a first step to disease prevention and promotion of good health.
It reduces the number of admissions to inpatient department, thus conserving the available beds. (htt9)

3.5 Essential factors for Outpatient care
The speed with which the services must be provided marks the biggest difference between inpatient and outpatient care. Every thing is immediate.
1. Convenience
2. Easy access
3. User friendliness
4. Accessibility for all
5. Family centered care
6. Separate facilities for children and adolescents
7. Separation of healthy and sick children

3.5.1 Easy access
• The facility should be well connected to highways or modes of public transport.
• The individual clinics should be within short walking distances from the main lobby.
• Decentralize waiting rooms in specialty clinics provide more intimate spaces than that of large waiting rooms.

3.5.2 Accessibility for all
• Everyone should have the ease to access the facility
• Not just the physically disabled, accessibility is important for the elderly population.
• Ramps should be provided where ever necessary.
• The places should be accessible by a wheelchair.
• Handicap toilets should be provided.

3.5.3 Family centered care
• Buildings designed for outpatient care must consider the needs of entire family.
• Appropriate seating must be designed for the adults and play areas for the children.

3.5.4 Convenience
• The proximity to home or easy of accessibility is an important factor.
• Childcare services should be provided. (Ambulatory Care)

3.5.5 Way finding
• In such facilities the corridors, entrances and exits should be clearly defined, both inside and outside the building.
• Way finding becomes critical with larger buildings.
• Avoiding unnecessary walks and turns in the corridors by keeping the shapes simple.
• A central atrium creates a landmark for the people to find their ways in the building.
• The building can be arranged in vertical and horizontal axial corridors with all the clinics located on this axes and the intersection would naturally be the lobby, registration areas, dining areas or other public activity spaces.

3.5.6 Separation of the well from the sick
• It is advisable to separate the sick children from the well children, in the pediatric waiting rooms
• This is generally done by providing sick and well waiting rooms on either side of the reception desk.
• Three sided reception desks are used for this purpose so as to allow the clerks to have a visual contact to both the waiting rooms as well as the new patients that enter the facility. (Hospital Interior Architecture)

3.6 Advantages of outpatient care
• Outpatient surgery patients are not sick, they are just candidates for elective procedures. In a hospital their families may have a to share a common waiting room with inpatients families which can have a devastating psychological effect on their mind.
• Psychological stress is always experienced by the people while entering a hospital. Stress is heightened after having unexpected sights such as a patient arriving in an ambulance.
• Outpatient surgery provides better utilization of hospitals facilities and hospital beds.
• It also reduces the cost of treatment. The major saving is due to elimination of hospital stay.
• These patients can continue their routine work with the health care continuing in the background on outpatient basis.

3.7 Facilities provided by such centers
• Cardiology
• Psychology
• Dental
• Dermatology
• Endocrinology
• Surgery
• Pediatrics
• Plastic surgery
• Pain management
• Psychiatry
• Urology
• OT
• Nephrology
• Gynecology
• Oncology
• Ophthalmology
• Orthopedics
• Neurology
• Gen. Physician
• Gastroenterology
• Hematology
• Homeopathy

3.8 Patient flow
• The patient’s first visit may be a few days before the procedure, to fill the preadmission forms, have laboratory tests and receive instructions on diet.
• The patient arrives to the facility few hours before the scheduled time with a family member. Lab tests are conducted if required. The patient is moved to the preparation area, where their cloths are changed to surgical cloths.
• Some facilities have private prep rooms and exam rooms whereas others have dressing rooms and lockers for storage of patient’s cloths.
• The patient may be wheeled or walked into the operative rooms
• Anesthetic induction takes place in the operating room.
• Post-surgery until the patient is stabilized and conscious, they are moved to the recovery area.
• Patients remain there after dressing and have something to eat while their family member has arrived.
• Instruction for the post-operative care may be given here. (Ambulatory Care)
3.9 Dental health unit
3.9.1 Description

3.9.2 Functional areas
The dental component has the following zones:
1. Reception
2. Waiting area
3. Office for administration
4. Dental surgery rooms
5. Labs, sterilizing , x-ray processing areas

3.6.3 Functional relationship
This unit must be placed with other outpatient facilities
Should be in close proximity with the entrance, waiting area and public facilities. (Indian Health Facility Guidelines, July 2014)
3.10 Outpatients unit
The outpatients unit refers to the entity that provides facilities on same-day basis.
The following facilities may be provided in the outpatients unit.
• Multi-disciplinary consultant and treatment clinics.
• Day-only surgery
• Day only medical facilities
• Dental
• General medicine
• Medical imaging
• Mental health
• Pathology
• Pharmacy
• Radiotherapy
• Rehabilitation
• Ophthalmology
Functional areas
This unit can contain many sub units. It can range from a minor stand-alone facilities to large multispecialty units.
The core unit has these functional zones
• Reception and admission zone
• Waiting and treatment (patient zone)
• Staff zone

3.11 Day surgery/ procedures unit
3.11.1 Description
A day surgery unit is used for performing operative or endoscopic procedures. Admission, procedure and discharge occurs on the same day. It has one or more operating theatres with a provision for anesthesia and a post operation recovery zone for patients. (Indian Health Facility Guidelines, July 2014)
The range of procedures that can be performed in this unit can include:
• Surgical procedures, predominantly dental, plastic surgery, ENT and eye care.
• Endoscopy
• Minor procedures, infusions.

2.12 Operating department
2.12.1 Description
A operating unit gives an harmless and precise environment for operative procedures of people who are experiencing diagnostic and surgical procedures under the effect of anesthesia. It also provides pre-operative care and post operation recovery. (Indian Health Facility Guidelines, July 2014)
2.13 Dental health unit
Dental health units may be attached to the healthcare facility or can be individual units outside the hospital setup. When attached to a healthcare setup, the dental unit shares the facilities with the healthcare unit.
• The dental unit may be located close to other outpatient services and should have access to the public facilities, entry and exits. (Indian Health Facility Guidelines, July 2014)
2.14 Radiation Oncology Unit

The main purpose of this unit is to provide services for treatment of people by emitting radiation. The unit may contain one or more electron beam and radiation rooms.
Radiation oncology may also be referred as radiation therapy (Indian Health Facility Guidelines, July 2014)


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