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Public Health
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Original Research

Monetary burden of health impacts of air pollution in

Mumbai, India: Implications for public health policy

A.M. Patankar a,*, P.L. Trivedi b

a
K.J. Somaiya Institute of Management Studies and Research, Vidyavihar (East), Mumbai 400077, India
b
Department of Humanities and Social Sciences, Indian Institute of Technology, Bombay, India

article info summary

Article history: Objectives: Mumbai, a mega city with a population of more than 12 million, is experiencing
Received 20 January 2010 acute air pollution due to commercial activity, a boom in construction and vehicular traffic.
Received in revised form This study was undertaken to investigate the link between air pollution and health impacts
20 October 2010 for Mumbai, and estimate the monetary burden of these impacts.
Accepted 10 November 2010 Study design: Cross-sectional data were subjected to logistic regression to analyse the link
between air pollution and health impacts, and the cost of illness approach was used to
measure the monetary burden of these impacts.
Keywords: Methods: Data collected by the Environmental Pollution Research Centre at King Edward
Air pollution Memorial Hospital in Mumbai were analysed using logistic regression to investigate the
Morbidity link between air pollution and morbidity impacts. The monetary burden of morbidity was
Logistic regression estimated through the cost of illness approach. For this purpose, information on treatment
Concentrationeresponse costs and foregone earnings due to illness was obtained through the household survey and
coefficients interviews with medical practitioners.
Cost of illness Results: Particulate matter (PM10) and nitrogen dioxide (NO2) emerged as the critical
pollutants for a range of health impacts, including symptoms such as cough, breathless-
ness, wheezing and cold, and illnesses such as allergic rhinitis and chronic obstructive
pulmonary disease (COPD). This study developed the concentrationeresponse coefficients
for these health impacts. The total monetary burden of these impacts, including personal
burden, government expenditure and societal cost, is estimated at 4522.96 million Indian
Rupees (INR) or US$ 113.08 million for a 50-mg/m3 increase in PM10, and INR 8723.59 million
or US$ 218.10 million for a similar increase in NO2.
Conclusions: The estimated monetary burden of health impacts associated with air pollu-
tion in Mumbai mainly comprises out-of-pocket expenses of city residents. These expenses
form a sizable proportion of the annual income of individuals, particularly those belonging
to poor households. These findings have implications for public health policy, particularly
accessibility and affordability of health care for poor households in Mumbai. The study
provides a rationale for strengthening the public health services in the city to make them
more accessible to poor households, especially those living in the slums of Mumbai.
ª 2010 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved.

* Corresponding author. Tel.: þ91 98205 01438; fax: þ91 22 25157219.

E-mail address: archana.patankar09@gmail.com (A.M. Patankar).
0033-3506/$ e see front matter ª 2010 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved.
doi:10.1016/j.puhe.2010.11.009
158 p u b l i c h e a l t h 1 2 5 ( 2 0 1 1 ) 1 5 7 e1 6 4

health, higher productivity and better quality of life for the

Introduction residents. This empirical study was undertaken to examine
the relationship between air pollution and respiratory and
Urban air pollution is a matter of concern among policy cardiovascular symptoms and diseases for the residents of
makers, organizations, donor agencies and people across the Mumbai. The study developed concentrationeresponse (CR)
world due to its adverse consequences for human health and coefficientsd based on locally obtained data, and estimated
the environment. The dynamics of economic growth, indus- the monetary costs of the health impacts caused by
trialization and urbanization coupled with population growth increases in air pollution in the city. The findings of this
are primarily responsible for air pollution. In urban areas, air study have wider policy implications for pollution control
pollution is a serious problem due to the concentration of programmes and provision of public healthcare facilities
people, both as perpetrators and victims of pollution. World- in Mumbai.
wide, it is estimated that urban air pollution causes 800,000
deaths annually and the loss of 4.6 million life-years, two-
thirds of which occur in the developing countries of Asia
Methods
alone.1 Air pollutants such as particulate matter, sulphur
oxides, nitrogen oxides, ozone and carbon monoxide are
Epidemiological studies conducted in different parts of the
responsible for a range of acute and chronic morbid effects
world have demonstrated a wide range of acute and chronic
and premature mortality in urban areas. Pollutants such as
health impacts due to air pollution.4 Some notable examples
greenhouse gases (e.g. carbon dioxide, methane, nitrous oxide
are studies conducted in Jakarta,6 Santiago,7,8 Mexico City,9
and chlorofluorocarbons) have transboundary impacts such
Shanghai,10 Taiwan11e13 and China.14 Similar studies have
as ozone depletion and global warming which affect the
also been carried out in India in Mumbai,15e18 Delhi,19e21
health and livelihood of millions of people, particularly in the
Hyderabad22 and Chandigarh.23 The studies conducted in
poor and developing countries. Air pollution is, thus, a global
Mumbai have either examined the health effects of air
‘public bad’ that imposes massive economic and social costs
pollution on the basis of CR functions extrapolated from other
at local, regional and global levels.
studies, or have investigated the prevalence of respiratory
In developing countries, millions of urban residents are
morbidity but not its causal link with air pollution.
exposed to acute levels of air pollution.2 The emerging econ-
The main objective of this empirical study was to examine
omies of China, India and the Latin American countries are in
the relationship between air pollution and morbidity in
a transition phase with increased life expectancy, changes in
Mumbai by developing CR functions and estimating the
lifestyles and influx of population into urban areas. Cities such
monetary burden of health effects. This study focused on
as Mumbai, Delhi, Beijing, Shanghai, Manila, Bangkok, Mexico
morbidity effects alone and not premature mortality related to
City and Santiago are facing acute air pollution due to indus-
air pollution, since morbidity is felt at regular and short-term
trial activity, population growth, construction booms for
changes in air pollution, unlike mortality which is a rare and
housing and infrastructure, increased vehicular traffic, con-
extreme occurrence. Similarly, this study was only concerned
gested streets, poorly maintained vehicles, limited access to
with the human health effects of air pollution. Welfare effects
clean fuel and lack of effective control programmes.1,3,4
(e.g. effects on property and vegetation) and ecological effects
Mumbai is one of the largest mega cities in the world with
were not included in the scope of the study.
a population of more than 12 million. The city has a sizable
industrial, commercial and trading base, and plays host to
Data sources
pharmaceutical, thermal power and fertilizer companies,
along with oil refineries and engineering, electronic and
A dataset provided by the Environmental Pollution Research
electrical businesses. The average per-capita income in the
Centre (EPRC), attached to the Department of Chest Medicine
city is 69,000 Indian Rupees (INR) or US$ 1725 (2004e2005
at King Edward Memorial (KEM) Hospital in Mumbai, was
prices),c which is three times that of the national per-capita
used to examine the relationship between air pollution and
income.5 In recent years, industries have closed down or
respiratory and cardiovascular morbidity in Mumbai. The
moved out of Mumbai, making way for large residential
EPRC team carried out a survey in six areas of Mumbai
complexes, thus leading to rapid expansion of suburbs and
(Worli, Borivali, Khar, Bhandup, Andheri and Maravali)
changing the land use pattern. Service sector activities,
between February 2003 and April 2004 to create a represen-
particularly information-technology-enabled services, have
tative environmental health profile of the residents. More
also increased sizably, contributing to more vehicular traffic
than 1800 individuals residing within 1 km of the air quality
and a boom in construction.
monitoring stations located in the six areas were adminis-
Given the economic pre-eminence of Mumbai, the fact
tered the questionnaire. The survey gathered information on
that more than 50% of the city’s residents still live in slums
socio-economic profile, occupation, travel pattern, and
and face a life stricken by poverty, malnutrition and unhy-
gienic surroundings cannot be ignored. The authors felt the
d
need to examine the health consequences of air pollution for CR function is the relationship between air pollution and
Mumbai from the point of view of planning for better public human health effects determined through epidemiological
studies. It empirically explains the variations in the number of
cases of illness or death in the population for changes in the
ambient concentrations of air pollutants and other explanatory
c
Conversion to US$ done at the exchange rate 1 US$ ¼ INR 40. factors such as age, gender, diet, smoking habit, occupation, etc.
 p u b l i c h e a l t h 1 2 5 ( 2 0 1 1 ) 1 5 7 e1 6 4 159

proxies for indoor and outdoor exposure to air pollution. The

Table 1 e Average monthly concentration of pollutants
health condition of the respondents and the prevalence of during survey period (in mg/m3).
symptoms and illnesses were diagnosed or confirmed by the
Pollutant Name of ward
medical team during the survey. A subset of 1542 respon-
dents from the EPRC survey was selected for this study. This Worli Borivali Khar Bhandup Andheri Maravali
included individuals above 11 years of age who were SPM 269 55 427 342 293 579
administered the entire questionnaire by the EPRC team. The PM10a 153 31 243 195 167 330
health effects diagnosed in the survey were symptoms (e.g. SO2 39 9 23 31 22 39
cough, phlegm, breathlessness, wheezing and cold) and NO2 51 24 83 64 55 127
diseases [e.g. bronchitis, asthma, upper respiratory tract NH3 29 28 43 48 48 149
infections (URTI), cardiac, other chest illnesses, allergic SPM, suspended particulate matter; PM10, particulate matter less
rhinitis and chronic obstructive pulmonary disease (COPD)]. than 10 mm in size.
Diagnosis of acute symptoms was based on the health Source: APMRL, MCGM (2008).
condition prevailing at the time of the survey, as well as the a PM10 is calculated as 57% of SPM based on the average range
reported frequency of the symptoms during the year prior to found in the literature (45e70%).

the survey.
Air pollutants included in the analysis as explanatory
variables were particulate matter less than 10 mm in size
(PM10), sulpur dioxide (SO2), nitrogen dioxide (NO2) and
ammonia (NH3). These pollutants are regularly monitored by
the roof-top monitors in the six areas (selected in the EPRC
survey) by the Air Pollution Monitoring and Research Labo-
ratory (APMRL) of the Municipal Corporation of Greater
Mumbai, and the monthly averages are reported.e The APMRL
records the levels of suspended particulate matter (SPM) in
Mumbai. PM10 was calculated as 57% of SPM in Mumbai, as the
literature on air pollution indicates the range of PM10 in SPM
varies from 45% to 70%.6 The pollution records were taken
from the APMRL to obtain the levels of pollutants for the
analysis, as indicated in Table 1, based on the months in
which the EPRC survey was carried out. Other explanatory
variables selected from the EPRC data and used as controlling
factors in all the variants of the regression model were age,
gender, smoking habit, distance travelled to place of work,
occupation, width of road adjacent to residence, presence of
polluting industry near residence, hours spent in kitchen,
quality of kitchen ventilation and type of the cooking
fuel used.
For estimating the monetary costs of the health impacts
related to air pollution, a survey of 150 households was carried
out by the researchers in five areas of Mumbai (Borivali,
Andheri, Dadar, Chembur and Colaba) to obtain information
on the cost of treatment and lost wages due to restricted and
e
In Mumbai, ambient air pollution levels fluctuate depending
on seasonal and climatic factors. Generally, air pollution levels
are low during the monsoon season (JuneeSeptember) and are
quite high during winter (DecembereJanuary). Levels of pollut-
ants vary significantly between areas, with Borivali recording
the lowest levels of pollutants and Maravali recording the
highest levels of pollutants. The difference between minimum
and maximum monthly averages of pollutants within areas is
also quite large during the year. For instance, the SPM levels
in Maravali range from 150 mg/m3 to 650 mg/m3. In Borivali,
the fluctuations in monthly averages are from 55 mg/m3 to
288 mg/m3. NH3 is not a criteria pollutant, but it is monitored in
Mumbai due to the high levels experienced in parts of the city
due to proximity to a fertilizer factory. There are large fluctua-
tions in NH3 levels from 33 mg/m3 to 1200 mg/m3 in Maravali
during the year.
total inactivity days related to the considered symptoms and
diseases.f Similar information was also obtained from doctors
in public and private hospitals, and general practitioners in
the city. Information obtained from households and medical
practitioners was used to calculate the total monetary costs of
health impacts associated with changes in air pollution levels
in Mumbai.
Research methods
The cross-sectional survey design used by the EPRC team
influenced the choice of regression model employed in this
study. Logistic regression is generally used when the dependent
variable is binary or dichotomous. The regression model was
used to test the null hypothesis which proposed no significant
relationship between air pollution and respiratory and cardio-
vascular morbidity in Mumbai. The dependent variables in the
model were symptoms and diseases. All the regression model
variants used the controlling factors (i.e. age, gender, smoking
habit, etc.) as outlined earlier. The data allowed the authors to
test the incidence or occurrence of a particular symptom or
disease against air pollution levels across different areas. The
regression output yielded log odds ratios, which were used to
predict changes in the odds of occurrence of a symptom or
disease due to changes in air pollution levels. The coefficients
corresponding to the significant odds ratios were used for
further analysis as the CR coefficients in the study. Similar
methodology can be found in cross-sectional studies conducted
in Beijing,24 Guangzhou, Wuhan and Lanzhou,25 Benxi,26
Taiwan12,13 and four cities in China.27 Using the CR coeffi-
cients, changes in the health effects for given changes in air
pollution concentrations were estimated using the US Envi-
ronmental Protection Agency methodology.6
f
The areas selected for this survey differ from the areas origi-
nally targeted by the EPRC survey. Since household income is one
of the most important factors in Mumbai to determine the choice
of healthcare service (public vs private), areas were targeted
depending on the baseline information available about the socio-
economic status of households. For instance, households
belonging to lower income strata were targeted in areas of
Chembur and Colaba. Households in Dadar and Borivali were
predominantly middle-income families and those targeted in
Andheri belonged to higher income strata.
160 p u b l i c h e a l t h 1 2 5 ( 2 0 1 1 ) 1 5 7 e1 6 4

Monetary costs of the health effects were estimated using
the cost of illness approach, which comprises the cost of
treatment for illnesses and lost earnings due to missed work
days or restricted activity days. Similar methodology has been
used for estimating the monetary burden of health effects in
studies conducted in Mexico City9,28 and Santiago.29 For this
study, the household survey was carried out by the
researchers in five areas of Mumbai to obtain information on
the cost of treatment, including cost of medicines, equipment
and consultation charges of doctors, as well as restricted and
total inactivity days due to illness. The households were asked
to give details about the type of treatment, service provider,
cost of treatment, restricted activity days, total inactivity days,
and loss of wages or salary per day for each symptom and
disease listed in the questionnaire. Furthermore, a survey
questionnaire was administered to the medical practitioners
engaged in public and private health facilities, as well as
general practitioners in the city. This survey obtained infor-
mation on the outpatient and inpatient costs of treatment in
public and private healthcare facilities, type of treatment,
days of hospitalization required for symptoms and illnesses,
days of restricted and total inactivity, and average number of
missed work days for each symptom and disease listed in the
questionnaire. The proportion of people using public and
private healthcare services, the average wages of such indi-
viduals, and the symptoms and diseases requiring hospitali-
zation were based on information obtained from the EPRC
data and previous studies. A summary of the range of esti-
mates obtained for symptoms and diseases is given in Table 2.
study. The dependent variables, presence (or absence) of
cardiovascular and respiratory symptoms and diseases, were
used in the logistic regression framework to examine their
relationship with the explanatory variables. In order to
examine the link between air pollutants and morbidity
outcomes (symptoms and diseases), the odds ratios for the
four pollutants (PM10, NO2, SO2 and NH3) were obtained using
multipollutant variants of the regression model. PM10 and NO2
were not considered together in the same variant of the model
due to their high correlation. However, PM10 and NO2 were
considered separately in different variants of the regression
model as their sources in Mumbai are different. PM10 mainly
has domestic or area sources, including construction activity,
and NO2 is produced by vehicular and industrial emissions.8
The results of the regression model were obtained and inter-
preted on the basis of the significance tests used in the
empirical literature in this research arena.30 The regression
output showed statistically significant relationships between
air pollutants and specific health outcomes, thus invalidating
the null hypothesis. The regression results yielded the log
odds ratios, which were used to predict changes in the odds of
occurrence of a symptom or disease due to changes in air
pollution levels. The coefficients corresponding to the signif-
icant odds ratios were the CR coefficients used in the study to
estimate changes in the health effects for given changes in air
pollution concentrations, similar to the methodology used in
studies conducted in Taiwan.12,13
Estimation of health effects

This study found a significant relationship between PM10 and

Results NO2 with symptoms such as cough, breathlessness, wheezing
and cold, and illnesses such as allergic rhinitis and COPD. SO2
The cross-sectional survey design used by the EPRC team was found to be significantly associated with cardiac ailments
influenced the choice of regression model employed in this and other chest illnesses, and NH3 was related to phlegm and

Table 2 e Range of estimates obtained for symptoms and diseases.

Nature of Cost of treatment Daily cost of treatment in Days required Days of Days of total Frequency per
illness (non-hospital) hospital (in Rs)a in hospital restricted inactivity person per yeard
a
(in Rs) activity

Symptoms
Cough 200e700 e e 2 1 3
Phlegm 200e700 e e 2 1 2
Breathlessness 300e700 1000e3000 4 2 2e4b 1e2c
Wheezing 300e700 1000e3000 4 2 2e4b 1e2c
Cold 100 e e 1 e 8
Diseases
Bronchitis 250e1000 1000e3000 6 8 6 1e2c
Asthma 250e1000 1000e3000 6 8 6 1e2c
URTI 100e1000 e e 2 1 2
Allergic 100e1000 e e 2 1 2
rhinitis
COPD 1000e5000 5000e10000 7 10 5e7b 1e2c

URTI, upper respiratory tract infection; COPD, chronic obstructive pulmonary disease. Data obtained from household survey and doctors.
a Lower values in the range are the costs of treatment in public OPDs and public hospitals, and higher values are the costs of consulting
specialist physicians or private hospitals.
b Lower value shows total inactivity days without hospitalization and upper value shows inactivity days with hospitalization.
c Lower values show the frequency of hospitalization per year and upper values show the frequency of outpatient treatment per year.
d Frequency indicates the number of times a person suffers from the symptom or disease per year.
 p u b l i c h e a l t h 1 2 5 ( 2 0 1 1 ) 1 5 7 e1 6 4 161

Table 3 e Concentrationeresponse (CR) coefficients and incidence of health effects for Mumbai.
Health effect Pollutant CR coefficient (%)a,b Change in health Estimated incidence Estimated incidence
effect (%)c per 1 lakh populationd for Mumbaie

Symptoms
Cough PM10 0.007 0.35 350 42,000
NO2 0.021 1.05 1050 126,000
Phlegm NH3 0.012 1.20 1200 144,000
Breathlessness PM10 0.009 0.45 450 54,000
NO2 0.028 1.40 1400 168,000
Wheezing PM10 0.006 0.30 300 36,000
NO2 0.020 1.00 1000 120,000
Cold PM10 0.006 0.30 300 36,000
NO2 0.018 0.90 900 108,000
Diseases
Cardiac SO2 0.118 2.36 2360 283,200
Other chest illnesses SO2 0.162 3.24 3240 388,800
NH3 0.024 2.40 2400 288,000
Allergic rhinitis PM10 0.014 0.70 700 84,000
NO2 0.046 2.30 2300 276,000
COPD PM10 0.014 0.70 700 84,000
NO2 0.023 1.15 1150 138,000

COPD, chronic obstructive pulmonary disease; PM10, particulate matter less than 10 mm in size.
a The coefficient represents percentage change in the prevalence rate of morbidity outcome per mg/m3 change in pollution concentration.
b Coefficients obtained in the regression model controlling for factors such as age, gender, smoking habit, distance travelled to place of work,
occupation, width of road adjacent to the residence, presence of polluting industry near residence, hours spent in kitchen, quality of kitchen
ventilation and type of cooking fuel used.
c Incidence of health effects estimated for 50-mg/m3 increase in PM10, 50-mg/m3 increase in NO2, 20-mg/m3 increase in SO2 and 100-mg/m3
increase in NH3.
d 1 lakh ¼ 100,000.
e Incidence for Mumbai city calculated for the population of 12 million as per 2001 Census.

other chest illnesses. The CR coefficients corresponding to
significant odds ratios were used to estimate the incidence of
health effects for given changes in air pollution concen-
trations,g as shown in Table 3.
Estimation of monetary burden
The figures shown in Table 2 were used to estimate the
monetary burden of the health outcomes. Certain assump-
tions were made for estimating the health costs. For instance,
based on the EPRC data and empirical findings,31e33 it was
assumed that 25% of city residents use public health facilities
and have a daily wage of approximately INR 200. For the
remaining city residents, the daily wage was assumed to be
approximately INR 500 and they were assumed to use private
health facilities. Based on the information gathered from
medical practitioners, it was assumed that 20% of cases of
breathlessness and wheezing and 50% of cases of COPD would
require hospitalization. Table 4 shows estimates of the inci-
dence and total monetary costs of illness for Mumbai.
The monetary estimates shown in Table 4 indicate out-of-
pocket expenses of individuals, which include the cost of
g
The incidence of health effects was calculated based on the US
Environmental Protection Agency methodology using the
following equation: DHjp ¼ bjp  POPj  DAp, where DHjp is the
change in health effect j due to pollutant p, bjp is the CR coeffi-
cient for health effect j related to pollutant p, POPj is population at
risk of health effect j, and DAp is change in the concentration of
pollutant p.
treatment and foregone earnings (lost wages) due to illness.
Table 5 shows the out-of-pocket expenses on treatment of
health outcomes as a proportion of annual personal income.
In order to determine the total monetary burden of illness
caused by air pollution, personal expenses towards cost of
treatment and foregone earnings, government expenditure
incurred in public healthcare facilities, and societal costs due
to loss of productivity were considered. The total burden of
illness estimated here was, thus, the sum of personal costs,
government or public expenditure, and societal costs as seen
in Table 6. Government or public expenditure on health care
was only relevant for cases treated in public dispensaries or
hospitals, and hence was considered likewise. The cost to
society is the loss of productivity, which was assumed to be
equivalent to the lost wages on account of restricted activity
and total inactivity days due to illness.
The monetary burden of health impacts is likely to increase
in future as the cost of treatment and wages increase.
Therefore, the authors attempted to estimate the future
trends in monetary burden, assuming an increase in the pri-
ces of medicines and consultation charges by 9% per annum,
and an increase in wages by 5% per annum based on
Consumer Price Index trends.34 Government expenditure in
public healthcare facilities has remained more or less stag-
nant in percentage terms over the years in Maharashtra state
and Mumbai, and per-capita expenditure has actually
decreased.32 The authors assumed that this trend will
continue in future. They further assumed that Mumbai’s
population will increase at a rate of 1.87% per annum based on
past growth rates.35 Given these assumptions, future trends in
162 p u b l i c h e a l t h 1 2 5 ( 2 0 1 1 ) 1 5 7 e1 6 4

Table 4 e Incidence and total cost of illness for Mumbai (in million Indian Rupees).
Nature of Pollutant Estimated People using Total cost in People using Total cost in Estimated total
illness incidence in public health public health private health private health burden for
Mumbaia care care care care Mumbai

Cough PM10 42,000 10,500 6.30 31,500 53.55 59.85

NO2 12,600 31,500 18.90 94,500 160.65 179.55
Phlegm NH3 144,000 36,000 21.60 108,000 183.60 205.20
Breathlessness PM10 54,000 13,500 23.22 40,500 188.73 211.95
NO2 168,000 42,000 72.24 126,000 587.16 659.40
Wheezing PM10 36,000 9000 15.48 27,000 125.82 141.30
NO2 120,000 30,000 51.60 90,000 419.40 471.00
Cold PM10 36,000 9000 1.80 27,000 9.45 11.25
NO2 108,000 27,000 5.40 81,000 28.35 33.75
Allergic rhinitis PM10 84,000 21,000 10.50 63,000 126.00 136.50
NO2 276,000 69,000 34.50 207,000 414.00 448.50
COPD PM10 84,000 21,000 424.20 63,000 2709.00 3133.20
NO2 138,000 34,500 696.90 103,500 4450.00 5147.40

COPD, chronic obstructive pulmonary disease; PM10, particulate matter less than 10 mm in size.
a Incidence for Mumbai city calculated for the population of 12 million as per 2001 Census, and incidence estimated for 50-mg/m3 increase in
PM10, 50-mg/m3 increase in NO2 and 100-mg/m3 increase in NH3.

the monetary burden of illness due to air pollution were
estimated as depicted in Fig. 1.
Discussion
The findings of this study have revealed a significant rela-
tionship between air pollution and morbidity outcomes for
Mumbai. Among the four pollutants considered in the study,
PM10 and NO2 emerged as the most significant pollutants
and have a significant relationship with symptoms such as
cough, breathlessness, wheezing and cold, and diseases such
as allergic rhinitis and COPD. The results also indicate that
NO2 has relatively greater health impacts in terms of inci-
dence and costs. The major source of NO2 in Mumbai is diesel-
and gasoline-based vehicles. There has been a substantial
increase in the number of vehicles in Mumbai over the last
decade. With expanding suburbs, rapid development in
neighbouring districts, growing affluence and availability of
affordable personal vehicles, this number is going to increase
manifold in the near future. Thus, programmes and initiatives
are urgently required to control the NO2 levels.
Substantial economic costs are associated with the
increase in incidence of these health outcomes with increases

Table 5 e Out-of-pocket expenses as proportion of annual personal income.

Nature of Cost of illness without hospitalization Cost of illness with hospitalization
illness
Cost of illness Frequency Cost as % Cost of illness Frequency Cost as %
(in INR) per yeara of annual (in INR) per person of annual
incomeb per year income

Public healthcare facilities

Cough 600 3 3.0 e e
Phlegm 600 2 2.0 e e
Breathlessness 900 2 3.0 5000 1 8.3
Wheezing 900 2 3.0 5000 1 8.3
Cold 200 8 2.7 e e
Allergic rhinitis 500 2 1.7 e e
COPD 3000 2 10.0 37400 1 62.3
Private healthcare facilities
Cough 1700 3 3.4 e e e
Phlegm 1700 2 2.3 e e e
Breathlessness 2200 2 2.9 14500 1 9.7
Wheezing 2200 2 2.9 14500 1 9.7
Cold 350 8 1.9 e e e
Allergic rhinitis 2000 2 2.7 e e e
COPD 10,000 2 13.3 76000 1 50.7

COPD, chronic obstructive pulmonary disease; INR, Indian Rupees.

a Frequency based on the information obtained from doctors.
b Annual income of those in public health care is INR 60,000 and those in private health care is INR 150,000.
 p u b l i c h e a l t h 1 2 5 ( 2 0 1 1 ) 1 5 7 e1 6 4 163

Table 6 e Total burden of illness for Mumbai (in million Indian Rupees).
Nature of Pollutant Incidence for Total burden Total burden Total burden Total burden
illness Mumbaia in public health in private health of disease for in million
services service Mumbai US$b

Cough PM10 42,000 11.55 85.05 96.60 2.42

NO2 12,600 34.65 255.15 289.80 7.25
Phlegm NH3 144,000 39.60 291.60 331.20 8.28
Breathlessness PM10 54,000 34.70 269.73 304.43 7.61
NO2 168,000 107.94 839.16 947.10 23.68
Wheezing PM10 36,000 23.13 179.82 202.95 5.07
NO2 120,000 77.10 599.40 676.50 16.91
Cold PM10 36,000 3.60 16.20 19.80 0.50
NO2 108,000 10.80 48.60 59.40 1.49
Allergic rhinitis PM10 84,000 21.00 189.00 210.00 5.25
NO2 276,000 69.00 621.00 690.00 17.25
COPD PM10 84,000 476.18 3213.00 3689.18 92.23
NO2 138,000 782.29 5278.00 6060.79 151.52

COPD, chronic obstructive pulmonary disease; PM10, particulate matter less than 10 mm in size.
a Total incidence of health effects is estimated for the 12 million population of Mumbai as per 2001 Census figures for 50-mg/m3 increase in PM10,
50-mg/m3 increase in NO2 and 100-mg/m3 increase in NH3.
b 1 US$ ¼ 40 Indian Rupees.

in PM10 and NO2. If personal costs, governmental costs and
societal costs are included, the total monetary burden esca-
lates further. However, it should be noted that the costs
calculated in this study are for morbidity effects alone. If the
mortality effects of the pollutants are also taken into account,
the monetary burden is likely to increase substantially. Hence,
the costs estimated here provide conservative lower bound
estimates of the costs of air pollution for Mumbai city, and the
actual costs are expected to be much larger.
Most of the monetary burden comprises out-of-pocket
expenses borne by the suffering individuals and families. As
the estimates show, these expenses represent a significant
proportion of the annual income of people, particularly for
those belonging to poor households. There are, thus, tangible
costs of health impacts which can no longer be ignored by
policy makers and citizens. The huge burden on individuals
also reflects the inadequacy of the public health facilities
available in the city. The findings of this study call for
strengthening of the public health infrastructure to cater for the
health needs of those who cannot afford expensive treatment.
The personal costs of health impacts are mainly paid
through individuals’ incomes. There is no system of private
health insurance or social insurance which can adequately
protect individuals from such costs. Currently, the coverage of
the health insurance schemes is negligible. There is no social
insurance scheme in place in the entire country. Thus, the
health consequences are entirely faced by individuals and
families themselves, sometimes through the sale of assets or
loans to fund the medical expenses. Efforts are urgently
needed to put in place a system of health insurance which
eases the burden of disease on people.
A significant issue emerging from this study is the stagnant
health expenditure of the Government and its consequences
for the population. There is an acute need to strengthen the
public healthcare system in Mumbai in terms of accessibility,
affordability and quality in order to help poor households.
This assumes more relevance since half of Mumbai’s pop-
ulation lives in slums with greater exposure to all types of
pollution, and a life stricken by poverty, malnutrition and
unhygienic living conditions.

18000
16000
14000
12000
Million INR

10000
8000
6000
4000
2000
0
2008 2009 2010 2011 2012 2013 2014 2015
Burden due to PM10 Burden due to NO2 Total burden of illness

Fig. 1 e Future trends in burden of illness for Mumbai city. INR, Indian Rupees; PM10, particulate matter less than 10 mm in
size.
164 p u b l i c h e a l t h 1 2 5 ( 2 0 1 1 ) 1 5 7 e1 6 4
Ethical approval
None sought.
Funding
None declared.
Competing interests
None declared.
Acknowledgments
The authors wish to thank Dr. Amita Athavale, Head of the
Department of Chest Medicine and EPRC at KEM Hospital,
Mumbai for providing the dataset, without which this study
would not have been feasible.
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