Health in spite of Poverty -
the story of the Slums of Trivandrum in India

-V.Vijayachandran
Former Principal Secretary to
Government of Kerala, India

I. Genesis

Here is a city whose slum population lives nearly as healthy as their well off neighbors. That is Trivandrum or Thiruvananthapuram, the capital of the state of Kerala in India. This state on the southern tip of India facing the Arabian Sea, is a paradox of high health amidst poverty and stands out among the twenty eight states of the country in their peoples health. Its thirty two million people have an average life expectancy of 72 against 66 for the one billion in the country and an infant mortality rate of 16 against country's 72. The census of 2001 revealed that the annual growth of its population has come down from 2.3 percent in 1961-71 to 0.89 in 1991-2001, while the country is still growing at 1.8 percent per annum. But the state's per capita income was lower than the average for the other states for several years and just crossed the average in the last few years with about 423 dollars.

However, the health thinkers have been suspicious of these averages and believed that there would be pockets of ill health tucked away in these statistics. They pointed to three such possible areas, the first the tribal population in the hills, the second the fishermen in the coasts and the third the poor in the slums of the cities. Studies have found this suspicion to be true in the case of the first two. But no field study appears to have been done to test this hypothesis about the third. Our study showed that this is not true about the slums of the city of Trivandrum with some notable exceptions, which we will come to. It would not be far wrong to suggest that it is not true about the slums of the other urban areas of the state, as they are similar in characteristics of housing, education health infrastructure, nutrition and the like.

II. Methodology

Our study had two parts, the first, a survey of one thousand households and the second a set of in-depth interviews. The sample of 1000 households had 4297 members and was considered adequate for the city's population of 750,000 living in 141.74 square kilometers. There are thirty-six identified slums in the city where about 12,000 people live. We grouped these slums according to size and selected 500 households from them for our survey following the techniques of systematic sampling with a random start and 'Probability Proportion to Size'. In October 2000 five rural areas surrounding the city were added to the city and these had no designated slums. Therefore we went about identifying the poor areas among them that had characteristics of slums like crowded housing, poor sanitation etc. We found 47 slum-like settlements. As they were rural till recently and were only semi-urban in their nature, we called them suburbs and selected 250 households among these settlements following the same techniques. Similarly, we selected 250 households from the rest of the city to provide the foil. Thus we got the slums, the suburbs and the non-slums for our survey. Eight well-trained investigators of both the sexes approached the 1000 households with a well designed and pre tested questionnaire, aided by a manual and closely supervised by experts, from February to May 2001. The results of the survey were processed and analyzed using the Statistical Package of Social Sciences.

The second part of the study was in depth interviews. Armed with the findings of the survey, an experienced social demographer with an expert in mass communication and sociology conducted in-depth interviews with fifty six functionaries who were carefully selected from community leaders, service providers, programme managers, policy makers, non-governmental organizations and health activists. The Professor of Demography in the University of Kerala who is also the Director of the Population Research Centre, the Deputy director of that Centre who is a PhD in Statistics and this author spent several days drawing conclusions, validating them with the available literature and writing the report consisting of 120 pages divided into ten chapters.

III. Profile of Slums

Looking at the demographic aspects of the sample, we found the slums to share all the characteristics with the non-slums and suburbs, and indeed, with the rest of the State. For example Kerala is the only state in the country with a sex ratio favorable to the female. In this state there were 1058 females to 1000 males in 2001. This biologically natural phenomenon is reversed in the other states by higher infant mortality among females and other causes. But in the slums of Trivandrum we found this to be even higher at 1081. No wonder, the proportion of female-headed households in the slums at 23.4 per cent is much higher than the 16.4 per cent in the non-slums.

The slum dwellers do not lag behind the others in general and reproductive health. In. fact, in the incidence of morbidity the slums and suburbs at 128 and 121 per thousand are lower than the non-slums at 145. While there is not much difference in the causes of illness and its duration, the cause of death shows significant difference. In the non-slums more than 36 percent die of old age and its related ailments while in the slums and suburbs it is only about 24 per cent. No wonder, the people in the slums and suburbs die earlier, their mean age at death being 56 and 58 respectively while for the non-slums it is 64.

The reasons for this and other differences we highlight elsewhere are to be sought in the education level, the housing condition, the income and standard of living of the slums and the suburbs. Health economists have tended to attribute the good health status of the State to the high level of literacy, especially among the female. This theory finds some validation in our study. Though we did not capture literacy per se, we found the proportion of people who did not go to school to be the highest in the slums at 21 per cent, against 20 in the suburbs and only 14 in the non-slums. Similarly only about 10.5 per cent in the slums and suburbs are matriculates while 21 per cent in the non-slums are. In fact, among the females of the slums and suburbs matriculates are only 8 and 6 per cents respectively, while it is 19 per cent in the non-slums.

But when it comes to housing this difference is more telling. Twenty-three per cent of the houses in slums are two-room tenements and nearly 6 per cent single rooms, while it is negligible in the non-slums. In the coconut growing state of Kerala, the leaves of this tree are the cheapest building material though it is the least durable. A significant proportion of the slum dwellers use them for their roofing (45 per cent) and walls (21 per cent), while only 26 per cent and 5 per cent of the suburbs and 5 per cent and less than one per cent of the non-slums use them for roofs and walls respectively. The story of flooring also tells the poverty of the slums. Beaten earth is the floor of 17 per cent of the houses in the slums, while it is just 4.4 per cent in the non-slums. Traditionally, such floors are plastered with cow dung, which makes it more livable. Four per cent of the slums could not even afford that. Putting these facts together one can safely conclude that about a fifth of the people in the slums of Trivandrum live in perishable houses that will not stand the fury of the monsoons. Only one in twenty of the suburbs suffer like this, while the non-slums seem to have largely escaped this fate.

It is not only in the nature of housing but also in the amenities that slum houses lag behind. Only less than a fourth of them have running water at home, while 68 per cent of the non-slum homes have it. But it is in the toilet facilities that the difference is appalling. Thirty five percent of the slum households do not have toilet facilities driving them to open grounds or public toilets that are very ill kept. And only a negligible proportion of those who have the toilets have flushing facility.

Thus the slum dwellers have to put up with poor and unhygienic housing conditions. They cannot afford anything better. While we did not rely on their statement of income because of the tendency for understatement, the expenditure data revealed that about 60 per cent of the slums and suburbs spend less than Rs.1500 a month. The amount estimated for the slum households (family size of 4.3) to cross the poverty line is Rs.1600 a month. Keeping in mind the fact that the total expenditure includes non-food items also, it is reasonable to assume that about two thirds of the slums and suburbs do not have enough nourishment to fetch them 2100 calories in a day. This is a startling figure, considering the fact that only 20.3 per cent of the urban population of the State is below the poverty line according to official estimates.

Illness strikes them as a catastrophe. Those who were unlucky enough to be stricken had to spend money out of their meager income, as there are no insurance schemes worth the name. Out of the 274 persons in the slums who went for treatment during the month previous to the interview, 85 lost their wages and 147 had to raise money from other sources for treatment, most of them borrowing and some pledging or even selling assets. Against the backdrop of the revelation in a study of the World Bank that hospital expenses alone push 2.2 percent of India's population below the poverty line every year, this data assumes great importance and emphasizes the need for a health insurance for the poor.

IV. Comparative Reproductive Health Profile

When we come to the reproductive health of women we notice the same trend as in general health _ the standard quite high, but lower than the non-slums. The survey found the menstrual health of both married women and adolescent girls to be good. But one interesting piece of information that came out is that nearly 19 percent of the women in the city get married before the legal age of 18, the proportion being nearly 20 per cent in the slums and suburbs. One would not have expected this, given the comparatively high status of education in the city.

Perhaps it is poverty that drives the parents to lighten the burden earlier. Most of the married women have conceived at least once, but about 14 per cent in the overall sample had abortions. The fact that more of them in the slums and suburbs had more than one abortion than in the non-slums is a matter of concern. Nearly all of them had antenatal check up in the previous or current pregnancy, mostly starting in the third month. The number of antenatal visits is about 7, the slums showing no let up. Even in the components of the check up neither the overall sample nor the slums showed any shortfall. No wonder, the vast majority of them did not have any problems during pregnancy. As one would expect from a literate population living in a city with good health infrastructure, most of the deliveries took place in institutions, slums falling slightly behind the other two areas. But even in the home delivery in the slums, doctors or paramedics were present in most of the cases. Again, the majority of them had normal deliveries without any problems resulting in live births, whether in the slums, suburbs or non-slums.

The next issue probed was the prevalence of contraception among married women. As the capital of the state well known for bringing down the growth of population in a relatively short period, one would have expected most of the women to use some form of contraception. But only about 59 per cent in the overall sample use them, slightly higher in the slums. This is even lower than the contraceptive prevalence rate of 66 per cent in the urban areas of the state as revealed in the National Family Health Survey conducted in 1998. The reason for this lower prevalence was the desire to have children and not lack of knowledge. But surprisingly, the desire for male child was not a great reason and was evenly matched by the desire for female child unlike in the other states. But why 41 per cent of the women of Trivandrum do not use contraception in spite of knowing about it remains a mystery.

The preferred method for the majority of those who go in for contraception is female sterilization and that too at the early age of about 25. Before adopting this terminal method some have tried out IUD, only very few going for oral pill, rhythm etc. Use of the once popular condom seems to be very negligible, evidencing the shift of the burden of contraception from the male to the female over the years. Another interesting piece of information that came out of the survey is that there is very little motivation from outside. Most women are self-motivated and some by their husbands. Thus motivation comes from within the nuptiality. One could say confidently that family planning has come of age even among the slum dwellers.

The same degree of mature awareness is discernible in bringing up the child. Nearly all of them get the birth weight of the baby taken and start breast feeding the same day. But it is a matter of concern that the low birth weight babies are about 29 per cent, which is even higher than for the rest of urban India as revealed in the National Family Health Survey of 1998. Our survey did not measure the nutritional intake during pregnancy. Perhaps that would have thrown some light on this. But the fact we saw earlier, that about two-thirds in the slums may not be having adequate intake of calories may be a pointer to this. When it comes to immunization, the mothers show their concern. About 70 per cent in the overall sample had taken all the required doses of immunization in the first nine months. It is heartening to see that in the slums it is even higher at 72 per cent. Among the laggards the illness of the child came out as the predominant reason. However, the importance given to immunization does not appear to be given to the administration of nutritional supplements like Vitamin A and iron and folic acid, only about 32 per cent adhering to the schedule, even less in the slums, though these are given free by the State like immunization.

The awareness of AIDS, Sexually Transmitted Diseases (STI) and Reproductive Tract Infections (RTI) is an important aspect of reproductive health of women, adolescent girls and men. Our study revealed that among all these groups awareness is quite high, with some differences in degree. The awareness about HIV/AIDS is the highest among girls, followed by men and married women. But while about 77 per cent of the married women in the slums are aware of HIV/AIDS only 55 per cent are aware of RTI and 52 per cent of STI. This gap is noticed in the suburbs and non-slums as well as in the slums and is true about men and adolescent girls also. Government of India has special programme for increasing the awareness of HIV/AIDS through the National AIDS Control Organization, which seemed to have had its impact. But the same vehicle could have been easily adapted to spread the message about the other two important groups of conditions. Alas, this was not to be! AIDS is handled by the Department of Health while the other two are by the Department of Family Welfare, though both constitute the Ministry of Health and Family Welfare headed by one Minister of Government of India. The health activists who were interviewed were very critical of this lack of coordination.

Though a higher proportion of men are aware of STI and HIV than married women, when it comes to the preventive measures they woefully lag behind. Not even three fourths of them recognized sexual intercourse as a mode of transmission though it accounts for nearly 83 percent of the transmission in India, and though all women recognized it. It is indeed shocking that only less than a fifth of the men mentioned avoiding intercourse with sex workers as a method of prevention. Safe sex as a means of prevention appealed only to a fourth of the men. There is very little difference in the three areas in this. As the main culprits of the transmission, men need to know much more about prevention. The publicity activities need to focus on this.

V. Utilization of Public Health System

Our next probing was about the utilization of public health facilities and their opinion about it. Usually there is a lot of criticism in the media about the inadequacy of public facilities and the impression one gathers is that people are dissatisfied with the services and they do not resort to it in need. But to our surprise, we found about two thirds of the sample utilized them. In fact, for reproductive and child health care it is even higher. They are not driven to public facilities by poverty, as the figure is the same in the non-slums. Among the one third who did not utilize them, distance and lack of faith were the dominant reasons, other reasons like delay, bribery and lack of cleanliness lagging far behind. Nearly three fourth of the married women are fully satisfied with the quality of service provided, even the women from the non-slum areas.

VI. Gaps and Recommendations

When we met the respondents from various groups with these findings for in-depth interviews about their opinion on public health provisioning in the city, some of them refused to believe the veracity of the findings, as they were so much exposed to the gloomy picture of public facilities projected by the media. The scientific nature of the survey had to be explained to convince them. As mentioned earlier, this group included community leaders, providers, health activists etc. Their views about the problems that beset the public health system and suggestions for improvement are listed below:

1. Shortage of drugs and consumables in the hospitals ---- Allocate more funds in the State budget for health. Its share has come down from over 16 per cent in 1974-75 to under 12 in 2000-01. At least retain the old proportion. Also improve logistics of supplies.

2. Shortage of manpower ---- Stop the practice of granting long leave to medical personnel for taking up employment abroad.

3. Environment hazard in the slums ---- Drainage and waste removal must be attended to as priority. If the City cannot maintain public toilets, which many in the slums depend on, pay-and-use toilets may be introduced and the upkeep entrusted with private agencies.

4. Heavy rush in the hospitals, especially in the secondary and tertiary units ---- The services being virtually free, all tend to rush to the secondary and tertiary units, while the primary ones lie unutilized. Attempts at making the former referral units have failed. No government can provide all services to all at all times. Providing free services to the rich is only depriving the poor of opportunities of better service. Introduction of user fee collection from those who can afford will fetch the much-needed revenue to the system and reduce the overcrowding. A small experiment is already in place where the Hospital Development Committees are allowed to charge user fees and utilise them for the development of the hospital. This should be expanded. Another suggestion is to develop a partnership with the private sector, which is well developed in the State.

5. Poor facilities for the aged ---- With the demographic transition and increased longevity, the proportion of the aged has increased in the State. The number of people above 70 has gone up from 3.4 per cent in 1971 to nearly 5 per cent in 2001. Geriatric care should be introduced in the medical curriculum and NGOs encouraged and assisted to set up old age homes and provide home nursing.

6. Poor health awareness of the people ---- Better health education is called for. Community based organizations and NGOs should be roped in for this.

7. Financial burden of illness ---- This is the gravest problem and can be addressed only by an appropriate health insurance scheme that protects the poor against the financial risks from catastrophic illness. The city and the Sate with near 100 per cent literacy are ideally suited for introducing such a scheme. It can be thrown open to the private sector, but the need for regulating their practices and protecting the poor cannot be overemphasized.

Thus we found the slums and suburbs to have nearly the same general health and reproductive health status with some notable exceptions explained by poverty, lower education level and housing and environmental conditions. Our in-depth interviews revealed that the situation is remediable if there is political will.