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Primary and Reproductive Health in the Slums of Trivandrum City

I. Introduction

1.1

India is the first country to initiate a national family planning programme, integrated in the Primary Health Care system, to contain the rate of population growth. It started as family planning program, expanded into family welfare, covering both maternal and child health (MCH) care and family planning. After the International conference on Population and Development (ICPD)of 1994 in Cairo, it became reproductive and child health, which included services of reproductive tract infection, sexually transmitted diseases and HIV/AIDS. Besides the expansion of services in the post-ICPD era, the basic strategy of the Indian programme changed from target-orientation to a need- based approach, focusing on meeting the needs of the members of the community rather than achievements of certain national demographic goals. In other words, the philosophy of its implementation has undergone a change; it has become a two-step process of assessment of the community needs (CNA) as the first step, and meeting those needs, as the second.

1.1.1 Mainly a rural country, India has 72 per cent of its population living in rural areas (Census 2001a). It was therefore natural that all developmental efforts including those related to health and family welfare focused on rural areas right from the beginning. Successive Five Year Developmental Plans expanded the infrastructure and activities. Today, a reasonable network of health infrastructure has been created in rural areas, providing both reproductive and primary health care services. Focus on rural areas and constraints of resources in the programme led to a slow progress of reproductive and primary health care services in urban areas. It was presumed that better economic status and greater awareness of the urban population and better accessibility of services there will help them to take care of their own health including reproductive health goals. This expectation, fell far short for the slum population groups living in urban areas. This group forms about 40 percent of the large metropolitan areas. It is therefore important that reproductive and primary health care services in the slums receive adequate emphasis. With this backdrop it is felt necessary to undertake a well-designed study on reproductive and primary health care services in urban slums, covering both dimensions of the service needs of people and how they are being met or unmet.. The emphasis of the study should be on policies, programmes and their implementation, and acceptance or non-acceptance by the people. It should ultimately help in strengthening the reproductive and primary health care services in urban areas for meeting the needs for the slum population groups in India. This study was conducted in the city of Trivandrum (also spelt Thiruvananthapuram), the capital of the state of Kerala in India.

1.1.2 India, with a population of one billion, has 28 States administered by their own elected governments and seven Union Territories administered by the Centre. Kerala in the southwest corner of the country is a small state, which takes up 1.27 per cent of the land area and 3.1 percent of the population. The state was formed in 1956 when the states of the country were re-organised on linguistic lines. Till then the state was in three distinct regions. The southernmost region was called Travancore and was ruled by the Maharaja of Travancore till 1947 when the country gained independence from the British. The middle region called Cochin (Kochi) was ruled by another Maharaja. Both these monarchs owed their allegiance to the British monarch who had suzerainty over the whole of India. But the northernmost region called Malabar was directly ruled by the British as part of the Presidency of Madras.

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1.1.3 The state has many features that make it different from the other states of the country. The most striking is the settlement pattern of the people. They live in small homesteads from one end of the state to the other without much of a difference between rural and urban areas. The population density is 819 per Sq. Km. against 324 of India. It has a coastal line of about 600 Kms. along the Arabian Sea and a width of about 60 Kms., bounded by the mountain range of Western Ghats. It has been called a rural-urban continuum where the villages are only administrative boundaries and the towns, a thicker concentration of houses. Most of the villages (85.3 per cent) are well connected by motorable roads against 36.8 per cent in the country. Similarly nearly 95per cent of the Kerala villages have a bus stop within 5 Kms. and a Post Office within 2 Kms. against 64.5 and 70.2 per cent respectively for the country. The difference is even more striking when it comes to telephones. More than 85per cent of Kerala villages have telephone facility within two Kms. whereas only 51per cent of the villages in the country have it (Shariff, 1999). The development of the rural areas has been so good that the urban population has actually declined from 26.39 per cent in 1991 to 25.97 in 2001 (Census 2001a)

1.1.4 The next feature that strikes a casual visitor to the state is the mix of religions. While India’s population is a mixture of 12 per cent Muslims and 2 per cent Christians, most of the others being Hindus, in Kerala Muslims are 21per cent and Christians 20 per cent according to the Census of 1991. On the political front the state is reported to be the first in the world to have an elected communist government. The origins of communism can be traced to the spread of literacy among a people who suffered from the yoke of feudal tyranny in the agrarian sector. Literacy itself owes its origin to the liberal policies of the Monarchs of Travancore and Cochin and the efforts of Christian missionaries. The World Bank’s World Development Report of 1991 cites the Royal Rescript of the Maharani of Travancore in 1817 that commits the state to “defray the entire cost of the education of its people in order that there may be no backwardness in the spread of enlightenment among them”. Initially education was the prerogative of the upper caste Hindus. But social reform movements that started as a protest against the institutionalisation of social exclusion by the upper casts, began demanding education for the backward communities (Vijayachandran 2001). Spread of education has been the prime mover of the development of the state, leading to a literacy level of 91per cent and a female literacy level of 88per cent against the all India figures of 65.4 and 54.2 per cent respectively in 2001.

1.1.5 However, job opportunities in the State are very meagre and large segments of the workforce go outside the state and the country seeking employment. The remittances from these non-resident Keralites are a great source of income for their families at home and keep the economy afloat. In spite of this, it remains one of the poorer states of the country, with a per capita income less than the national average. The Government estimate of per capita income for 1999-2000 is Rs.19461, which works out to about US$ 423 at the current exchange rate (GOK 2000a).

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1.1.6 According to the estimates of poverty by the Planning Commission of Government of India for 1999-2000, the poverty in the state is concentrated in the urban areas with 20.27 per cent of the population living below the poverty line. This means that they do not have the required financial capacity to purchase food, which will fetch 2100 calories for an individual in a day. It is noteworthy that the figure of poverty in the rural areas of Kerala is very low at 9.38 per cent. But for the country as a whole the situation is just the reverse with 27.09 per cent in the rural areas and 23.62 per cent in the urban areas (Narayana 2001). This is a telling example of the quality of life in the rural areas of Kerala.

1.1.7 Though the State is poor, it leads all the other states in every indicator of health. It has often been compared with many advanced countries of the world in its health status. Table 1.1 below gives a picture of the quality of life in the state in comparison with the rest of the country and some other countries of Asia.

Table 1.1 Selected Indicators of Development for Kerala and Some Asian Countries
Country / State Population (million) 1994 GDP Per Capita PPS $ 1994 HPI value (%)
1996
Population below International Poverty line 1985 (one PPS $ /day) Female Literacy Rate (%) 1994 Gross enrolment ratio (1995) in Secondary Schools Life Expectancy Year 1994 Total Fertility Rate IMR 1994
1 2 3 4 5 6 7 8 9 10
Kerala 30.5 1618 15.0 NA 86.3 103 71.7 108 13*
India 918.6 1348 36.7 52.0 39.0 49 61.3 3.0 74
Sri Lanka 18.1 3277 20.7 4.0 86.9 75 72.2 1.7 16
Thailand 58.2 7104 11.7 0.1 90.7 55 69.5 1.8 29
Malaysia 19.7 8865 NA 5.6 77.5 57 71.2 3.4 12
Indonesia 194.6 3740 20.8 14.5 77.1 48 63.5 2.5 53
China 1208.8 2604 17.5 29.4 70.9 67 68.9 1.8 43

* According to National Family Health Survey for 1998-99, the IMR for Kerala is 16.3.
Notes: HPI: Human Poverty Index. This takes into account (i) the survival deprivation in terms of people not expected to survive to age 40, (ii) a composite index of deprivation in economic provisioning indicated by (a) population without access to safe water, (b) population without access to health services, and (c) underweight children under the age of five.
Source: Kannan, 1999.

1.1.8 As can be seen in this table, Kerala with less than a fifth of the income of Malaysia, has achieved about the same levels of life expectancy and infant mortality. In fact in total fertility and female literacy Kerala is much ahead. Only Thailand has a lower Human Poverty Index than Kerala. The annual growth rate of population in Kerala has come down from 2.33 per cent in 1951-71 to 0.9 in 1991-2001 (Census 2001b). With all these statistics UNDP put the human development index for Kerala at 62.79, 20 notches above that for India. Even for China and Egypt, two countries known for their high physical quality of life, the figures are only 60.9 and 61.1 respectively (Srinivasan & Shariff 1997)

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1.1.9 The State has a fairly good health infrastructure in the public sector. The All India pattern of one sub-centre with an Auxiliary Nurse Midwife for 5000 population, one Primary Health Centre (PHC) for 25,000-30,000, and a Community Health Centre for 100,000 dots the Kerala landscape with these institutions. A woman of Kerala has to travel typically only 1.5 Kms. to reach a sub centre for antenatal care or for immunising her child, whereas in the rest of the country the radial distance to a sub centre is 2.7 Kms. A typical PHC in the country covers an area of 143.08 Sq. Kms. with a radial distance of 6.8 Kms. and in Kerala 37 Sq. Kms. with a radial distance of 3.4 Kms. All put together the Government runs 1317 institutions manned by 4367 doctors trained in the modern system of medicine with 45684 beds (GOK 2000). If the institutions and beds in the other systems of medicine (mainly Homeopathy and the Indian System of Medicine called Ayurveda) are added it comes to 2672 institutions and 48258 beds. That is about one bed for 650 persons in the public sector alone. But if we add the facilities in the private sector for all the three systems of medicine there are altogether 1529 institutions and 120182 beds for a population of 31 million which is one bed for every 258 persons, something that not even many developed countries can dream of (Vijayachandran 2001).

1.1.10 However health planners have long been aware of the fact that in this state of high social development there are pockets untouched by all these improvements where malnutrition, poverty and low health status still prevail. Three such islands are mentioned by writers, namely the hilly areas inhabited by tribes, the coastal areas occupied by the fishing community and the slums of the cities. (Ramachandran 1996) this study will explore whether this is true of the slums of the city of Trivandrum.

1.1.11 The city of Trivandrum is situated in the southern tip of the State. The city has a long history behind it. Some historians say that it is mentioned in some literature of the 8th century as the seat of a University. However the modern history of the city starts in the 12th century when the King of Travancore took an interest in the City. Even before that Sree Padmanabha Swami Temple, which was the center of the City, was attracting attention of many travelers. The city was elevated to the status of the official capital of Travancore dynasty in the 18th century. Ever since then it has been the capital of Travancore. When the state of Kerala was formed in 1956 it became its capital.

1.1.12 It has a population of 750,000 spread over 142 sq. kms. The total literacy level for the city is 92.5 percent and for the women 90 per cent. About 12,000 of its people live in 36 identified slums, making up 1.6 per cent of the population. The literacy level in the slums is only 78 per cent. (Census 2001a&b) In October 2000, five rural areas surrounding the city were added on to its administrative limits. These areas, being rural, did not have designated slums; but many slum like settlements.

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1.2 Health Infrastructure

1.2.1 The city is well served by health facilities both by government and private enterprises. There are 25 hospitals in the public sector, the largest being the Trivandrum Medical College, a teaching institution. With 1542 beds and 23 specialties it caters to the education of under graduates and postgraduates in medicine, dentistry, nursing, pharmacy, medical laboratory technology and public health. The women and children section is a separate hospital with 732 beds. Likewise the ophthalmic hospital and mental hospital are separate units. While this is meant for teaching, there is a general hospital meant for clinical services with 747 beds. It has also 12 specialties. On the non-teaching side there is also a separate women and children hospital with 422 beds. Together with other hospitals run by government there are 5246 beds in the public sector in the allopathic system of medicine (GOK 2000). There are about 400 beds each in Homeopathy and Ayurveda. The private sector also provides big and small hospitals in the city, their number being 35, in addition to 41 clinics. Some of these hospitals have specialties of a rare nature and serve in effect as referral hospital to many other institutions. However it may be mentioned here that these hospitals cater not only to the city population but also for patients coming from the rest of the district and the neighbouring districts. The Medical College Hospital serves as a referral hospital for at least three districts of Kerala with a combined population of 7 million. The people from at least two districts of the neighboring state of Tamil Nadu also use this as their referral hospital. Thus it serves about 10 million people.


1.3. Studies on Health in Urban Slums

1.3.1 Some studies are available on the slums of India, which cover several aspects of health care also. The proceedings of a conference on `Health Care of the Villages and Urban Slums’ held on Jan 22-24 1990 in Calcutta, India noted the alarming growth of urban population, which was 3.78 percent per annum between 1971 and 1981 against 2.19 percent of the general population. As much as 47 per cent of the urban growth was constituted by transfer from rural areas. It is the people who come to the city in search of livelihood that squat in the land and create slums. That conference noted that the size of the slum population is directly related to the size of the city. The town with less than 50,000 people had only 10.04 per cent in slums, and as the size of the town went up it steadily increased to 30.78 per cent in the cities over 1 million in 1981 (Sahni & Xirasagar, 1990)

1.3.2 WHO and UNICEF had an interregional consultation on `Primary Health Care in Urban Areas’ in July 1986 in Manila. (UNICEF & EAPRO, 1986) That conference noted that a third of the urban people in Asia lives on slums. It brought out five constraints in dealing with Primary Health Care in slums, namely, (i) the true facts about urban poor are hidden in the aggregated data, (ii) lack of understanding of primary health care among the medical profession, (iii) the policy and the planning capability at the city level is weak, (iv) lack of appropriate community Organisation among urban poor settlements, and (v) lack of resources.

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1.4 Objectives

1.4.1 No study specific to the health care of the slums of Trivandrum could be located. This is probably the fist attempt to study the various aspects of primary and reproductive health care of the slums of Trivandrum city. The major objectives of the study are as follows:

1. To determine what percentage of population in urban slums and non-slum areas are able to meet their various reproductive and primary health care needs and through what sources - public, voluntary and / or private.
2. To understand reasons for preferring one or more of these sources; more particularly, to know why free public sector program services are not utilised.
3. To understand the quality of care they receive, particularly from the public sector program.
4. To determine why reproductive and primary health care needs for certain percentage for population remain unmet, and
5. To relate public sector program policies, programmes and its implementation with its access, acceptance and quality of services and identify gaps at different levels.


1.5 The Plan

1.5.1 The next chapter describes the methodology followed in the survey explaining the sampling procedure, the grouping of the questionnaire, the plan for interviews and the data processing. The third chapter is about the household characteristics of the slums, the non-slums and the suburban areas as captured in the survey. It describes the age, sex distribution and marital status of the sample and goes on to cover their religious affiliation, educational level and occupation. It goes on to present the housing conditions, the possession of durable goods and the basic amenities in the house. An attempt is also made in the chapter to classify the sample by the expenditure and income data, including remittances from migrants.

1.5.2 In Chapter IV the prevalence, incidence and pattern of morbidity are presented, covering also the type of treatment and the expenses involved. An attempt is then made to highlight the financial burden caused by the disease by describing the source of money spent for treatment how it was raised and the loss of wages due to illness. In the same chapter the mortality in the sample population is described, finding out the age and cause of death. The fifth chapter is about reproductive health of women, starting from their menarche, going through marriage, conception, antenatal care, delivery and contraception. While the women in the reproductive age group are the main respondents in this chapter, it also captures some aspects of reproductive health of adolescence girls. Chapter VI is about Child Health. The aspects described are breast-feeding, birth weight, immunisation and nutritional supplements. The story of reproductive health continues in Chapter VII, which focuses on the awareness of HIV/AIDS, sexually transmitted diseases and infections of the reproductive tract. The awareness of mode of transmission, the source of information and misconception about the diseases are covered. Three groups of respondents are involved in this chapter, namely women and men in the reproductive age group and adolescent girls.

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1.5.3 Chapter VIII is about the utilisation of public facilities and the assessment of the quality of service there. Responses on the choice of treatment facility and the reasons for the choice given by various groups are put together in this chapter and the determinants of client satisfaction are explained. In Chapter IX the result of the in-depth interviews with community leaders service providers, programme managers, NGOs, health activists and policy planners are put together. Their suggestions for improvements are grouped under various headings. The last chapter is a brief description of the summary and conclusion.


II. Data and Methodology

2.1 Introduction

2.1.1 This is a two pronged study; the first being a sample survey of residents of the study area and the second, an in-depth enquiry with community leaders, service providers, programme managers, NGOs in the field, health activists and planners and policy makers. We felt that such a two level structure will enable the study to meet our objective more meaningfully and policy recommendations will emerge with better quality.


2.2 Sampling Procedure

2.2.1 The city of Trivandrum consisted of 50 wards covering an area of 74.93 square kilometers till October 2000. The areas outside the city consists of villages divided into administrative units called Panchayats, which have an elected local governments, like the city. Five such Panchayats surrounding the city were added to the city in October 2000. These five Panchayats (details in Annexure 1) were added as 31 wards to the city making the total number of wards 81 and the area 141.74 sq km. The five added Panchayats brought in an additional population of 350,091. The current population of the city is 744,739 (Census 2001a). The old city area had 36 properly designated slums. The newly added areas, being rural in nature till October 2000, did not have such a list. We went through the development plans of these five Panchayats and found that there were really poor areas with slum like conditions in terms of socio-economic status and environmental conditions, some being worse off than the slums of the city. These poor areas were found to be a distinct group, different from the slums and non-slum areas of the old city. We thus decided to treat them as a separate unit, and call them, for want of a better expression, `Suburbs’.

2.2.2 In view of the constraints on resources and the possibility of coming to commonly applicable findings we decided to have a convenient sample of 1000 households from the three areas viz., slums, non-slum areas and suburbs. As our main focus was on the slums, we decided to select one half of the total sample i.e. 500 from there, 250 from the suburbs and for comparison, 250 from the non-slum areas. A uniform sampling procedure was adopted in all the areas. The 36 slums in the old city were divided into 6 groups based on the size of the land area since the sizes of the slums are not uniform. The formulation of the six groups is as follows.
Group I Area <0.2 hectare
Group II 0.2 - 0.49 hectare
Group III 0.5 - 0.9 hectare
Group IV 1.0 - 1.49 hectare
Group V 1.5 – 4.99 hectares
Group VI 5 hectares and above


2.2.3 From each group, two slums were selected using simple random sampling technique, making a total of 12. The total population of each slum was available (given in Annexure I) and the average household size was taken as 5 as this the household size in the district of Thiruvananthapuram according to the Census of 1991. Using this information, we estimated the number of households in each selected slum. The sample size of each slum was determined by the technique of probability proportional to size (PPS). [(Number of HH in the index slum/ total HH) * 500]. The sample households were then selected by systematic sampling method with random start.

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2.2.4 In the five `suburbs’, we found 47 slum-like locations for our study. From each suburb, two localities were selected randomly, making a total of ten. Twenty-five households from each were selected using the same procedure as mentioned earlier. Thus the sample size for the suburban area is 250 households.

2.2.5 Again, 250 non-slum households from the study area were also selected. The corporation area consists of 81 wards currently (see Annexure I). From these wards, 10 were selected randomly and each ward was divided into four segments using topographic maps showing roads, by lanes etc. From these four segments, one was selected randomly. From the selected 10 segments, 25 households were taken using the same sampling procedure followed in the other cases.

2.2.6 As the second major component of our study, apart from the sample of respondents from households, a representative sample of 56 functionaries consisting of community leaders, service providers, programme managers and planners and policy makers were also interviewed for understanding their perceptions, attitudes and suggestions for improving primary health care in slums. (The list of those interviewed in Annexure II) This was done in a hierarchical way. First, the data on qualitative aspects reported by the household respondents were taken up with community leaders to obtain their reactions. The opinions and perceptions of the leaders of the community, NGOs, health activists and the service providers were collected to discuss with the policy makers and programme managers how to formulate and implement strategies for the improvement of health care systems in the slums.


2.3 Questionnaire

2.3.1 The first phase of the survey was intended to collect a variety of information about the households and individuals to study the level of health status in general and the Reproductive and Child Health (RCH) in particular along with the utilisation of public health care system. The field survey used 106 questions grouped into four: on the household, on the burden of disease, on Reproductive and Child Health and on the quality of Public health care service. The questionnaire was prepared in the local language of Malayalam (English translation in Annexure III) and its pretest was carried out in the study area.

2.3.2 The household questionnaire consisted of four sections. In section 1, all usual residents, as reported by the head or an elderly member of household in each sample were listed. For each person, the survey collected information on age, sex, marital status, religion, education, occupation, and relationship with the head of the household. Section 2 collected information on the ownership of the house, materials used for the house construction, electrification of the house and the type of cooking fuel used. Section 3 covered the environmental condition, asking about the toilet facility, the source of drinking water and water for other needs and the provision for wastewater disposal. In order to understand the overall economic status of the sample, possession of household durables, the monthly expenditure on food and other items in the family were elicited in section 4. These points were covered in the first seventeen questions and the 105th and 106th questions, which were the last, tried to obtain information on income of the households including income from remittances from members working outside the state and country.

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2.3.3 The next group of questions was intended to assess the health status of the sample, the pattern of morbidity and mortality and the burden of disease. The questionnaire collected information on the prevalence of disease with a recall period of one month prior to the survey date, the treatment taken, expenditure on the treatment, source of money for that and the income loss due to the disease for each member of the household. Then the questionnaire gathered information on the death of any member in the household within three years of the survey date. The information on age, sex and marital status of the females of the household was used to identify the respondents for administering the women's questionnaire.

2.3.4 The questionnaire on Reproductive and Child Health which was the third group consisted of four sections. The first section collected information from all ever-married women in the reproductive age of 15-49 years. In order to understand the demographic and health behaviour of the sample women, a series of questions (from numbers 35 to 66) were included in this section. The background characteristics such as age, education, occupation, religion etc. of the couples were collected. The details of each pregnancy such as the date of delivery, outcome of pregnancy, sex and survival status of each child, date of death if not living, and details of miscarriages were included in the questionnaire. Questions were also asked about the onset of menstruation, present menstrual status, problems related to menstruation and treatment taken. Details regarding last pregnancy including its outcome, problems, antenatal, natal and postnatal care, place of delivery and breast-feeding behaviour were also gathered. In addition to this all currently married women were asked about their current pregnancy status, use of contraceptives, problems related to the use of a specific method and treatment taken and the reasons for nonuse.

2.3.5 The second section in this group covered Child Health, collecting the details of immunisation against six vaccine preventable diseases and child care of the last child aged two years or less at the time of survey. The age at the administration of each vaccine, the number of doses, the date and place of administration and the reasons for non-immunisation were asked. The details of Vitamin A drops, Iron and Folic acid and Pulse Polio immunisation taken were also collected through this interview schedule.

2.3.6 In the third section, questions were included to assess the awareness of Reproductive Tract Infections (RTI), Sexually Transmitted Infections (STI) and Acquired Immuno Deficiency Syndrome (AIDS) among all ever married women of the selected households and their knowledge about the curability of these diseases.

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2.3.7 The fourth section consisted of questions on adolescent health of the females aged 13-18 years. They were asked about their age at menarche, menstrual cycle, problems related to menstruation, treatment taken, prevalence of white discharge and the treatment for that, awareness of RTI/STI and HIV/AIDS and the prevalence and treatment of RTI.

2.3.8 The fifth was about sexual health of males between 13 and 54 years. Questions related to age, education, marital status, total number of sons and daughters born and living were asked. Then it went on to any problems of sexual health they had before or after marriage, the treatment taken for these problems, reason for not taking the treatment, the effectiveness of the treatment, knowledge about STI and HIV/AIDS, transmission of the diseases and their prevalence.

2.3.9 The last group of questions was about the quality of government health services and client satisfaction. Information on the visit of all ever-married women on any government health facility for the last three months was collected. This questionnaire gathered details of the presence of health staff in the hospital at the time of respondent’s visit, their behaviour towards the clients, availability of medicines, satisfaction about the treatment received etc. Some questions related to client satisfaction of public facilities were put to other respondents also in the context of the burden of disease. But these were taken along with the data gathered in this group for analysis.


2.4 Training and Fieldwork

2.4.1 In order to maintain uniform survey procedure in all the selected areas, a 'Manual of Survey Procedure' dealing with different aspects of the survey was prepared. It consisted of instructions to the interviewers regarding interview techniques, field procedure, method of asking questions and recording answers. It also contained instructions to the editors and supervisors of the survey. The methods for house listing and mapping were also provided in the manual. Most of the interviewers were post-graduates in Social Sciences with some prior experience in household data collection although the minimum educational qualification fixed was a graduate degree in social sciences. All field staff were given two weeks training on the questionnaire, techniques of interviewing, mapping, editing and other aspects of the study by the senior staff of the Population Research Centre, University of Kerala, Thiruvananthapuram. During the training, mock interviews were conducted between participants and the pretest results were also evaluated. The field survey was conducted during February - May 2001.


2.5 In-depth interviews

2.5.1 The second stage of the study began by collecting information about the needs of the community through in depth interview of the leaders of the community. Two Research Assistants, one a Ph.D. in Social Demography and the other a postgraduate in sociology and mass communication, both with several years of experience in conducting such studies, interviewed the local leaders and chiefs of nongovernmental organizations. They enquired with the leaders about their assessment of the health problem of the community, their expectations from the government programmes and what role they played to alleviate these problems. Some of the NGOs interviewed were also providers of some services. After getting a picture of the health and reproductive health needs of the people, the next stage was interviewing the providers of services. These were Government functionaries in health at the cutting edge level, doctors and paramedics of public and private hospitals both non-profit and for profit. In the next stage the programme managers were interviewed with the information collected from the first three groups. These were government functionaries in the city health department and the Health Services of the state who provided the services in the city area. This was to understand program characteristics, program quality, program management and policies and factors that affect them. The next group of informants was health activists who had several ideas about cost effective provisioning of services. All this information was used in interviewing the planners and decision makers like the Mayor of the City Corporation, District Medical Officer, Director of Health services and the Principal Secretary to Government in the Health Department. The information collected from these interviews is used in the appropriate places in the study.

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2.6 Data Processing

2.6.1 All completed questions were edited in the field by the field editor and it was re-edited by the field supervisor. The supervisor checked all skip sequences and responses for consistency. Random checks were conducted by the Research Assistant independently in the field. The data were coded after assigning appropriate codes for open-ended questions. The coded data were entered in computer and analyses was performed using the Statistical Package for Social Sciences (SPSS).


III. Household Characteristics

3.1

This Chapter presents the major characteristics of the sample household population such as age, sex composition, marital status, income, expenditure, household conditions, possession of durable goods, basic amenities and the socio-economic characteristics of the usual residents. The main purpose of this Chapter is to describe the environment in which the study population lives.


3.2 Age and Sex Composition

3.2.1 First we wanted to know the age composition of our sample. The distribution of household population by age and sex composition as recorded in the survey is shown in Table 3.1.

Table 3.1 Age and Sex Distribution of Household Population
Age Group Urban Suburban Total
Slums Non Slums
M F Total M F Total M F Total M F Total
<1 1.1 0.9 1.0 0.6 1.3 1.0 0.8 1.3 1.0 0.9 1.1 1.0
1-4 8.8 5.8 7.2 3.8 4.6 4.2 7.4 7.4 7.4 7.2 5.9 6.5
5-9 9.2 9.1 9.2 7.6 7.1 7.3 7.6 6.8 7.2 8.4 8.1 8.2
10-14 8.2 8.1 8.2 10.4 6.3 8.3 8.0 9.4 8.7 8.7 8.0 8.3
15-19 7.6 10.8 9.3 8.6 8.2 8.4 10.3 8.5 9.4 8.5 9.6 9.1
20-24 9.8 9.8 9.8 7.4 8.8 8.1 10.5 11.1 10.8 9.4 9.9 9.6
25-29 7.9 9.4 8.7 7.2 7.9 7.5 10.5 7.0 8.7 8.4 8.5 8.4
30-34 5.9 7.5 6.8 7.0 8.8 7.9 8.7 9.2 9.0 6.9 8.2 7.6
35-39 9.2 9.4 9.3 8.2 8.8 8.5 7.2 7.4 7.3 8.5 8.8 8.6
40-44 6.7 5.5 6.1 6.6 5.7 6.2 6.3 6.3 6.3 6.6 5.7 6.1
45-49 6.7 5.1 5.9 5.0 5.6 5.3 5.3 5.5 5.4 5.9 5.3 5.6
50-54 5.8 5.8 5.8 3.2 9.2 6.3 2.7 7.7 5.2 4.4 7.1 5.7
55-59 4.3 4.4 4.4 9.4 6.5 7.9 7.6 5.0 6.3 6.4 5.0 5.7
60-64 2.5 3.2 2.9 4.4 4.4 4.4 2.9 2.8 2.8 3.1 3.4 3.2
65-69 3.1 2.0 2.5 4.8 3.3 4.0 2.3 1.7 2.0 3.3 2.2 2.7
70-74 1.6 1.9 1.8 3.0 1.9 2.4 1.5 1.1 1.3 1.9 1.7 1.8
75-79 0.8 1.0 0.9 2.4 0.2 1.3 0.4 0.6 0.5 1.1 0.7 0.9
80+ 0.6 0.3 0.5 0.6 1.3 1.0 0.2 1.3 0.7 0.5 0.8 0.7
Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0
Number 1060 1146 2206 501 522 1023 526 542 1068 2087 2210 4297
Median
age
27.8 27.5 27.5 32.7 32.8 32.7 27.1 28.3 27.7 28.6 28.9 28.7

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3.2.2 The total population surveyed is 4297 distributed in 1000 households. The slum population of the city is 11,667 (Census 2001a). The survey covered 2206 people in the slum, making 18.9 per cent of the total slum population. There are 2087 males and 2210 females, making up a sex ratio of 1059 females for every 1000 males. In a country with a sex ratio of 933, this is indeed remarkable. But the State of Kerala has shown a sex ratio favourable to females in the recent decades, the last being 1036 in 1991 and 1058 in 2001 (Census 2001b). It is significant that in the slums, this ratio is even higher at 1081.

3.2.3 It can also be found that on the whole children below one year comes to 0.9 percent per cent, 1.1 per cent and 1 per cent respectively among the male, female and the total population. Also there is a smaller proportion of children under age five than age five to nine (except suburban) which is in agreement with the ongoing demographic transition in the state from high growth to low growth, as we saw in chapter one. Children in the age group of 1-4 are around 7 per cent in the slums and in the suburbs while they are only 4.2 per cent in the urban areas. The fact that there is no such difference in the 0-1 age group in the three areas indicates that the fertility decline took place earlier in the urban areas and the poorer people in the slums and in the suburbs are only catching up.

3.2.4 Young population (0-14 years) constitutes nearly one fourth (24 percent) of the total for both sexes. One has to view this in the context of India and Kerala where the corresponding figures are 36.1 per cent and 27.6.per cent respectively as revealed in NFHS –2 (IIPS and ORC Macro 2001) . In the non-slum areas, the young population constitutes 20.8 per cent, while it is much higher in the suburbs at 24.3 per cent and slums at 25.6at 25.6 per cent. This adds one more piece of evidence to the observation in the previous paragraph that fertility decline has been delayed in the slums and suburban areas. There is a larger number of the population in the younger age group than in the older age groups of each sex in all the study areas. Among the total population 55 per cent are in 15-49 age group. The highest proportion (56.9 per cent) of this age group is in the suburban area followed by slum (55.9 per cent) and non-slum (51.9 per cent). Moreover women outnumber men at the oldest ages (80+) except with a slight difference in the slum. Women are generally believed to be more likely to survive to older ages leading to a higher expectation of life for them. Though the difference appears negligible at present, it is quite likely that the gap will widen in course of time when demographic transition becomes universal.

3.2.5 The median age of the population shows the youthful character of the population of the study area. For the total population it is 28.9 years. The median age for females is higher by 0.3 years. This, again, is in tune with a higher expectation of life at birth for females.

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3.2.6 In order to find the dependency ratio in the sample we extracted the data from Table 3.1 and put it in Table 3.2.

Table 3.2 Households by Age
Age Group Urban Suburban Total
Slum Non-slum
< 15 25.5 20.8 24.3 24.1
15-64 68.9 70.5 71.2 69.8
65+ 5.6 8.7 4.5 6.1
Total 100 100 100 100
Dependary Ratio (%) 45.1 41.8 40.4 43.3

3.2.7 The distribution of population by broad age groups shows that the largest share of nearly 70 per cent is in the age category of 15-64 years and the lowest share of 6 per cent is in the age group 65 years and above. The age distribution of population in suburban and slum are quite similar. The dependency ratio indicates that for every person in the productive age group there are 0.4 persons under age 15 or age 65 and above. The dependency ratio in the slums at 45.1 is higher than in the other areas.

3.3 Marital Status
3.3.1 Table 3.3 describes Marital Status of household population at the time of the survey.

Table 3.3 Marital Status by Household Population
Marital
Status
Urban Suburban Total
Slum Non-slum
M F Total M F Total M F Total M F Total
Single 52.1 43.3 47.5 46.1 38.5 42.2 51.4 42.1 46.6 50.5 41.8 46.0
Married 44.7 40.9 42.7 49.3 45.2 47.2 44.9 42.8 43.8 45.8 42.4 44.0
Widow 1.8 11.9 7.0 3.2 10.7 7.0 2.8 10.7 6.5 2.4 11.3 7.0
Divorced 0.3 0.3 0.3 0.0 0.2 1.0 0.0 0.2 0.1 0.1 0.2 0.2
Separated 1.1 3.7 2.4 1.4 5.4 3.4 0.9 4.2 2.6 1.1 4.2 2.8
Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0
Number 500 250 250 1000

3.3.2 It is observed that overall 44 per cent of the population is currently married, 7 per cent widowed and another 3 per cent per cent divorced or separated. In all the three areas, males outnumber females both in the never married and married categories. However, in widowhood women outnumber men in all the three areas. In the suburbs and slum areas, the proportion of never married was more than married. But this trend was reversed in the non-slum area.

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3.4 Household Composition

3.4.1 Table 3.4 provides the percent distribution of households by sex of head of households and other members, size and relationship structure.

Table 3.4 Household Composition
Details Urban Suburban Total
Slum Non-slum
Household Headship
Male 76.6 83.6 78.4 78.8
Female 23.4 16.4 21.6 21.2
Total 100.0 100.0 100.0 100.0
Relationship M F Total M F Total M F Total M F Total
Head 36.1 10.2 22.7 41.7 7.8 24.4 37.3 9.9 23.4 37.7 9.6 23.3
Wife 0.0 31.6 16.4 0.0 37.0 18.9 0.0 33.7 17.1 0.0 33.4 17.2
Husband 0.4 0.0 0.2 0.4 0.0 0.2 0.9 0.0 0.5 0.5 0.0 2.5
Son 49.9 0.0 24.0 46.5 0.0 22.8 49.8 0.0 24.5 49.1 0.0 23.8
Daughter 0.0 34.2 17.8 0.0 39.3 20.0 0.0 35.2 3.6 0.0 35.7 18.3
Grandchildren 16.6 10.8 8.8 5.0 5.4 5.1 7.2 5.4 4.4 6.4 8.2 7.3
Son-in-law 4.3 0.0 2.1 4.6 0.0 2.2 3.4 0.0 2.7 4.2 0.0 2.0
Daughter-in-law 0.0 7.9 4.0 0.0 3.8 1.9 0.0 5.4 2.7 0.0 6.3 3.2
Parent 0.5 1.8 1.1 0.8 2.1 1.5 0.0 2.8 1.4 0.4 2.1 1.3
Other 2.2 3.4 6.6 1.0 4.6 2.9 1.4 7.6 4.7 1.6 4.6 3.3
Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0
Number 1060 1146 2206 501 522 1023 526 542 1068 2087 2210 4297

3.4.2 As one would expect in a typical household group in India, the large majority of households (78.8 per cent) is headed by males. The proportion of female-headed households is more in slums (23.4 per cent) compared to the suburbs (21.6 per cent) and non-slum areas (16.4 per cent) areas. Female-headed households would have limited resources, which would be one contributory factor for the relative poverty of these areas. About 24 per cent of the population is sons and 18.3 per cent daughters of the head of household. Grandchildren constitute 7.3 per cent.

3.4.3 On an average, there are 4.3 persons in a household in our sample; 4.1 persons in non-slum households, 4.3 in the suburbs and 4.4 in the slums. This compares with 5.1in Kerala State and 5.4 in India (NFHS -2).

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3.5 Religion

3.5.1 India is predominantly a Hindu country with 82 per cent of the population professing this faith, 12 per cent Islam, 2 per cent Christianity and 4 per cent others in 1991. Kerala throws up a different picture with 57 per cent Hindus, 21 per cent Muslims and 20 per cent Christians (Census, 1991). Our sample shows yet another mix. Table 3.5 gives the distribution of households by major religious groups.

Table 3.5 Distribution of Households by Religious Affiliation (%)
Religion Urban Suburban Total
Slum Non-slum
Hindu 46.6 70.4 82.0 61.4
Muslim 9.0 14.4 18.4 10.2
Christian 44.4 15.2 9.6 28.4
Total 100 100 100 100
Number 500 250 250 1000

3.5.2 Hindus are even higher than in the state. But what is interesting is that the Christians constitute the second largest religious community with 28.4 per cent. Muslims with 10.2 per cent are only about half the average of the state. Though Hindus are the predominant group in all the three areas, the slums present a different picture. There, Hindus and Christians are more or less equally represented. One could venture an explanation in the fact that many slums in our sample are inhabited by the fishing community (not necessarily engaged in fishing) and there is a higher proportion of Christians among them.


3.6 Education

3.6.1 Education has been identified as the cornerstone of development as it affects almost all aspects of human life and leads, among other things, to better health outcomes. In a country with a total literacy rate of 54.16 per cent (Census 2001b) Kerala flaunts itself as a 100 per cent literate state and many writers attribute its high health outcomes and demographic achievements to an early attainment of literacy especially among the females.

3.6.2 The information on educational attainment was collected for every member of the household. Since basic education is starting at age six, only those above six have been considered here. Table 3.6 provides the distribution of male and female household members by the level of education obtained.

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Table 3.6 Distribution of Population by Education Level (%)
Level of Education Urban Suburban Total
Slum Non-slum
M F Total M F Total M F Total M F Total
No Formal Education 20.7 21.4 21.1 11.5 16.3 13.9 16.8 23.0 19.9 17.5 20.60 19.10
Primary
(Standards 1-4)
18.3 18.0 18.1 8.9 8.1 8.5 14.8 18.1 16.5 15.2 15.60 15.30
Middle
(Standards 5-7)
21.0 21.2 21.2 9.2 9.0 9.0 17.6 19.2 18.4 17.2 17.70 17.40
Secondary
(Standards 8 & 9)
21.9 27.7 24.8 11.6 12.5 12.1 26.7 27.6 27.2 20.5 24.00 22.30
Matriculation 12.9 8.1 10.4 23.3 18.8 21.0 15.2 6.0 10.5 16.0 10.20 13.00
Under Graduate 3.9 2.5 3.2 10.8 13.1 12.0 3.2 3.0 3.1 5.4 5.20 5.40
Degree 0.6 0.6 0.6 12.3 13.3 12.8 1.1 3.0 2.1 3.6 4.30 4.00
PG and above 0.7 0.4 0.6 12.3 8.9 10.6 4.6 0.0 2.3 4.6 2.40 3.50
Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0
Number 945 1039 1984 471 480 951 475 496 971 1891 2015 3906


3.6.3 It shows that 19 per cent of the sample did not have any formal education, 17.5 per cent males and 20.6 per cent females. This does not mean that all of them are illiterate. Some would have become literate as a result of the literacy mission, which was a big movement in Kerala in the Nineties. Various reports of the mission have shown that it had its impact in Trivandrum district also. However the state figure for formal education is 92.8 percent for males and 85.1 per cent for females. This figure is bettered in the urban area with 88.5 per cent males and 83.7 per cent females (I-2). But when it comes to our sample it is worse with 82.5 per cent for males and 79.4 per cent for females.

3.6.4 The overall level of education attained is generally low among slum dwellers. On the whole a very small proportion (7.5 per cent) of males and females have received higher education leading to a university degree and above. Moreover, there is a notable difference in educational attainment between the groups. People living in non-slum areas have considerably more education than those living in other areas. While 21 per cent of the non-slum areas have completed the school education only 10.5 per cent in the suburbs and 10.4 per cent in the slums have reached that stage. When it comes to women it is still lower with 8 per cent in the slums and 6 per cent in the suburbs. Thus one could say generally that the people in the slums are less educated than their counterparts in the non-slum areas.

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3.7 Occupation

3.7.1 After age, religion and education, we probed into the nature of the occupation of the sample population. Table 3.7 shows the distribution of occupational profile of the sample household members.

Table 3.7 Distribution of Population by Occupation (%)
Occupational
Status
Urban Suburban Total
Slum Non-slum
M F Total M F Total M F Total M F Total
No Job 19.4 17.6 18.5 23.9 16.6 20.1 10.2 18.4 14.4 18.2 17.6 17.9
Govt. employee 4.0 3.1 3.5 16.2 7.4 11.6 4.5 2.2 3.3 7.1 3.9 5.5
Coolie 6.4 5.0 5.7 2.3 0.7 1.5 12.5 11.5 12.0 6.9 5.5 6.2
Business
24.4 5.0 14.1 10.5 0.9 5.6 46.1 1.2 23.5 26.5 3.1 14.3
Pensioner 16.5 1.0 8.3 9.0 5.0 6.9 15.5 1.0 8.2 14.4 2.0 7.9
Student 5.1 19.5 12.7 21.9 17.1 19.4 3.0 17.7 10.4 8.7 18.5 13.8
Housewife 0.0 40.8 21.7 0.0 48.7 25.3 0.0 43.7 22.0 0.0 43.5 22.7
Driver 5.3 0.3 2.7 1.3 0.0 0.6 3.2 0.0 1.6 3.8 0.2 1.9
Skilled 5.5 4.0 4.6 5.4 1.9 3.6 4.0 2.9 3.5 5.1 3.2 4.1
Non-skilled 2.2 2.8 2.6 1.3 1.2 1.2 0.7 1.2 1.0 1.6 2.1 1.8
Fishing 11.2 0.7 5.6 8.2 0.5 4.2 0.2 0.0 0.1 7.6 0.4 3.9
Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0
Number 770 873 1643 389 421 810 401 407 808 1560 1701 3261

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3.7.2 Only those who were 15 years and above were considered here. Of the total respondents nearly 18 per cent reported that they have no work. Among non-slum population, this is 20.1 per cent. Nearly 27 per cent of the male respondents are engaged in business, much more (46 per cent) in the suburbs. Next to business, the largest proportion of males (14.4%) is pensioners. Government employees constitute 7.1 per cent of males. Nearly 8 per cent are engaged in fishing. Around 7 per cent are coolies. We can attempt to find the daily wage earners by adding three categories, namely, coolies, non-skilled workers and those engaged in fishing. On the whole 11.9 per cent of the people are daily wage earners, the slums leading the pack with 13.9 per cent and the suburbs with 13.1 and non-slums with 6.9 following.

3.7.3 Regarding female respondents, the largest proportion (61.1 per cent) is either housewives or unemployed. 18.5 per cent are students. Of the remaining, coolies came to 5.5 per cent, government employees 3.9 per cent, business (petty vendors or running small shops) 3.1 per cent and pensioners 2 per cent.


3.8 Condition of Housing

3.8.1 The household questionnaire obtained the information on housing conditions and household possessions. The data are helpful in assessing the standard of living, the socio-economic status of the household and environmental conditions in which the respondents live. Table 3.8 presents the distribution of households by housing conditions like type of roof, wall, flooring and the number of rooms apart from the details of ownership of the house.

Table 3.8 Distribution of Households by Housing Characteristics (%)
Characteristics Urban Suburban Total
Slum Non-slum
I. Ownership

Ownership 88.2 84.8 78.0 83.7
Rent 11.8 15.2 22.0 16.3
II. Roof
Concrete 24.4 59.6 21.2 32.4
Tiled 17.8 32.4 46.0 28.5
Thatched 45.4 4.8 25.6 30.3
Sheet 12.4 3.2 7.2 8.8
III. Wall
Coconut leaves 21.0 0.8 4.8 11.9
Mud 8.6 3.2 10.4 7.7
Exposed Brick 9.6 4.4 18.0 10.4
Brick with Cement Plaster 60.4 91.6 66.8 69.8
Sack 0.4 0.0 0.0 0.2
IV. Flooring
Marble 0.4 4.0 0.0 1.2
Ceramic Tiles 1.2 3.6 1.2 1.8
Mosaic Tiles 2.0 26.0 7.6 9.4
Cement 79.0 62.0 68.4 72.1
Mud plastered with Cowdung 13.4 4.0 20.4 12.8
Exposed mud 4.0 0.4 2.4 2.7
V. Number of Rooms
One Room 5.6 3.2 6.0 5.1
Two Rooms 23.0 1.6 6.4 13.5
Three Rooms 31.8 8.4 30.0 25.5
Four or Five Rooms 34.6 48.4 46.0 40.9
Six and above 5.0 38.4 11.6 15.0
Total 100.0 100.0 100.0 100.0
Number 500 250 250 1000

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3.8.2 For the purpose of this survey, the owner of a house is the person living in the house without paying rent. Data indicate that among the total households 83.7 per cent own their houses and the remaining 16.3 per cent pay rent. In the urban area there were 15.2 per cent households who were paying rent for their houses compared to 7.6 per cent in suburban and 11.8 per cent in the slums. It may be noted here that there were instances where some slum dwellers complained that they do not have title over the land they occupy. But urban squatting, which is the major source of the creation of slums, does not appear to be a major problem here unlike in the big cities of India and the rest of the third world.

3.8.3 Coming to roofing, two materials, which give permanent nature to it, are reinforced cement concrete and tiles. By this standard 58.8 per cent of the houses in the sample have permanent roofing, 32.4 per cent with concrete and 28.5 per cent with tiles. 30.3 per cent had roofs thatched with cadjan coconut leaves, which is a common roofing material for the poor in Kerala. Nearly 9 per cent of the houses were roofed with sheets of various materials like asbestos, aluminium and PVC. Only people with a reasonable means of livelihood can afford to put concrete on top of their houses. Only 21.2 per cent in the suburban areas and 24.4 per cent in the slums could do this while 60 per cent in the non-slums could afford it. Next in status and cost would come tiled roofing. Transformation of roofing from tiles to concrete is also an indication of the urbanization of the households. This impression is borne out by the fact that 46 per cent of houses in the suburbs have tiled roof while it is only 32.4 per cent in the non-slums. But when it comes to the slums, the most popular roofing material is coconut leaf thatch, covering 45.4 per cent of houses as against 25.6 per cent in the suburbs and 4.8 per cent in the non-slum areas. Houses that have sheet roof constitute 12.4 per cent in the slums, 7.2 per cent in the suburbs and 3.2 per cent in the non-slum areas. These two types of roofing are of a temporary nature and are used by those who cannot afford the other two. Thus, 57.8 per cent of the houses in the slums and about 33 per cent in the suburbs are of a temporary nature, going by the roofing material. This can be taken as an indicator of their access to resources.

3.8.4 Overall, the walls of a large proportion of households are made up of bricks plastered with cement (69.8 per cent). One out of ten houses have their walls made of bricks without plastering. These two types of walls can be considered of a permanent nature. Coconut palm leaves provide the walls of 12 per cent of the houses and mud of 7.7 per cent. Sack is the wall material of 0.2 per cent of the houses, all of which are in the slums. Thus 19.8 per cent of the houses have temporary walls. While this constitutes only 4 per cent of the houses in the non-slum area and 15.2 per cent in the suburbs, it makes up a substantial 30 per cent of the houses in the slums. It is safe to assume that the walls of a temporary nature with materials like leaves, mud and sack do not have permanent roofing, as it will not be supported by the walls. Thus out of the 57.8 per cent of the houses in the slums with temporary roofing 30 per cent have temporary walls also, making them insecure for living and liable to perish in the heavy monsoons of the state. This also points to the prevalence of poverty in the slums.

3.8.5 The type flooring used is another indicator of the economic status of the occupant. Of the six types, marble is the most expensive. No house in the slums has it. But 4 per cent of the houses in the non-slum areas have it, while only a negligible number (0.4 per cent) in the suburbs use it. The next high-cost item is ceramic tiles, which is used by 3.6 per cent of the houses in the non-slum area and only 1.8 per cent in the slums and suburbs. The most commonly used flooring material is cement, covering 72 per cent of the houses. While nearly 92 per cent of the houses in the non-slum areas are of this type, only 66.8 percent in the suburbs and 60.4 per cent of the slums belong to this group. The traditional flooring in the state is beaten earth covered with cow dung, which has to be re-applied every now and then. This prevails to some extent in the rural areas of the state. It is therefore not surprising that more than 20 per cent of the houses in the suburbs have this kind of flooring. This decreases to 13.4 per cent as we go to the slums and to 4 per cent in the non-slum areas of the city. But there are some people who are too poor to afford even the cow dung covering for the mud floor. They have just the beaten mud as their floor. Four per cent of the houses in the slums and 2.4 per cent of the suburbs are of this type. It is negligible in the non-slum areas.

3.8.6 The information on the number of rooms that a household has, gives a measure of crowding. While most of the respondents in urban areas (86.8 per cent) live in fairly adequate space with four or more rooms, 53.2 per cent in the suburban areas and much less (39.6 per cent) in the slums live with such convenience. On the other hand, an overwhelming proportion of respondents in slums (44.1 per cent) and in the suburban areas (42.4 per cent) live in limited space with three rooms or less, against only 13.2 per cent in the non-slum areas. The proportion of households that live in single room and two-room tenements in the slums are 5.6 and 23 per cent respectively, giving a picture of their overcrowding. With all these features, it would not be far off the mark to infer that about 30 per cent of the people in the slums are too poor to afford houses that keep the minimum standards.

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3.9 Household Durable Goods

3.9.1 In order to obtain additional information on the economic status of households, the respondents were asked about the possession of certain domestic items. Table 3.9 shows the percentage of households having certain durable goods.

Table 3.9 Distribution of Households by Possession of Durable Goods (%)
Possession Urban Suburban Total
Slum Non-slum
Telephone 14.4 56.8 16.4 25.5
Refrigerator 11.4 52.0 10.0 21.2
Washing Machine 2.0 26.0 0.0 7.5
Television 56.8 89.2 51.2 63.5
VCR/VCP 5.0 29.6 2.4 10.5
Water pump 3.6 11.2 1.6 5.2
Grinder 7.6 51.2 4.0 17.6
Fan 60.2 94.0 45.6 67.7
Radio 37.4 61.6 24.0 41.9
Sewing Machine 15.0 21.6 6.8 15.2
Tape Recorder 3.8 5.6 1.2 0.3
Electric Mixer 26.3 25.9 15.0 23.5
Computer 0.0 2.8 0.0 0.2
Number 500 250 250 1000

3.9.2 The data indicate that almost 68 per cent of the households have fans (94 per cent in urban, 46 per cent in suburban and 60 per cent in slum) and 64 per cent own a television (89 per cent in urban 51 per cent in suburban and 57 per cent in slum). A little more than one fourth of the households have a telephone. The proportion is high in the non-slum area (56.8 per cent) than the suburbs (16.4 per cent) and slums (14.4 per cent). About one fifth of the households also possess a refrigerator. The distribution is more than half in the non-slum areas (52 per cent) followed by 11.4 per cent in the slums and 10 per cent in the suburbs. On the contrary, it was observed that the percentage of households possessing electric mixer is more in the slums (26.3 per cent) than in the other two areas. But it may be noted that 51.2 per cent of the houses in the non-slum areas have grinders. Probably the function of electric mixer is also carried out by the grinders. Only 2.8 per cent of the households possess a computer, none in the slums or suburbs. Ownership of household durables varies tremendously between the areas. A comparison of the extent of material possessions reveals that its degree is higher in the non-slums than in the other two areas. The non-slum differential is particularly strong for telephones, refrigerators, television, VCR/VCP, fan and radio.

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3.10. Ownership of Vehicles

3.10.1 Table 3.10 provides the percentage of households owning certain vehicles.

Table 3.10 Distribution of Households by Ownership of vehicles (%)
Vehicle Urban Suburban Total
Slum Non-slum
Car 0.2 12.4 0.4 3.3
Scooter 9.2 33.2 16.4 17.0
Auto rickshaw 0.2 0.8 2.8 0.2
Cycle 22.2 24.4 13.6 21.5
Boat with Engine 1.0 0.0 0.0 0.1
Number 500 250 250 1000

3.10.2 Those who have one type of vehicle or the other are less than half. More than a fifth of the households own a bicycle (24.4 per cent in urban, 13.6 per cent in suburban and 22.2 per cent in slums). Next to bicycle, scooter is the most commonly owned mode of transport. On the whole 17 per cent of the households possess a scooter. The proportion is 33.2 per cent in the urban area, 16.4 per cent in the suburbs and 9.2 per cent in slums). Overall only 3.3 per cent of households possess a car. Only one household in the slum possesses a boat with engine, which is used for the purpose of fishing.


3.11 Basic Amenities

3.11.1 Besides the nature of houses, living conditions are influenced by the basic amenities available. The presence of certain facilities affects the health as well as the quality of life of the people. Here an attempt is made to find out the availability of these amenities, which include electricity, fuel, drinking water, water for other needs, toilet facility, drainage facility etc. These physical characteristics of the household have an important bearing on exposure to environmental pollution as well as reflecting household economic condition. Table 3.11 provides information regarding the household amenities available.

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Table 3.11 Households by Basic Amenities (%)
Basic Amenities Urban Suburban Total
Slum Non-slum
I. Electricity
Yes 74.8 97.2 85.6 85.9
No 25.2 2.8 14.4 14.1
II. Fuel
Wood 75.4 32.0 84.0 66.7
Kerosene 9.0 2.0 1.6 5.4
Gas (LPG) 15.6 66.0 14.4 27.9
III. Drinking Water
Tap at Home 24.2 68.0 12.0 32.1
Public Tap 66.2 8.8 39.2 45.1
Own Well 8.6 23.2 30.0 17.6
Public Well 1.0 0.0 18.0 5.2
IV. Water for other needs
Tap at Home 22.0 66.0 11.2 30.3
Public Tap 51.8 9.2 26.0 34.7
Own Well 24.8 24.4 39.6 28.4
Public well 0.8 0.4 20.4 5.6
Pond 0.4 0.0 0.0 0.2
Stream/River 0.0 0.0 2.8 0.7
Bore well 0.2 0.0 0.0 0.1
V. Drainage Facility
Without Cover 20.0 4.4 2.4 11.7
With Cover 14.0 34.4 0.0 15.6
Pit 0.4 2.0 0.0 0.7
No Facility 65.6 59.2 97.6 72.0
VI. Stagnation of Water
Yes 23.6 7.6 23.2 19.3
No 76.4 92.4 76.8 80.7
VII. Toilet Facility
No Facility 34.6 1.6 24 23.6
With Flush 6.7 45.5 8.9 19.8
Without Flush 78.4 50.4 72.7 67.9
Pit 14.9 4.1 18.4 12.3
Total 100.0 100.0 100.0 100.0
Number 500 250 250 1000
No Facility
Public Toilet 46.2 0.0 10.0 36.3
Open Ground 53.8 100.0 90.0 63.7
Total 100.0 100.0 100.0 100.0
Number 173 4 16 237

3.11.2 Electricity is widely available in the study area. Overall 85.9 per cent of the households have this facility. Electricity is much more common in non-slums, 97.2 per cent of households having it, compared to 85.6 per cent in the suburbs and 74.8 per cent in the slums. It is observed that about one fourth of the households in the slums is deprived of electricity while in the non slums it is less than 3 per cent.

3.11.3 Wood is the main source of fuel for cooking. Overall 66.7 per cent of the households use this fuel, 27.9 per cent use LPG and 5.4 per cent kerosene. While two thirds of the households in the non-slums have LPG as their fuel, wood is the fuel for three fourths of the households in the suburbs and slums.

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3.11.4 Access to water and sanitation is an important determinant of disease free living. Water is generally supplied to all by the Government. But only some have plumbing in their homes. Others depend for drinking water on the public tap in the street or on wells, some their own and some public. The majority (45 per cent) depends on street tap, only a third (32.1 per cent) having taps in their homes. But the position changes grossly when we disaggregate this data. Sixty eight per cent of the non-slum people have piped water in their homes while only 24 per cent of the slum dwellers and 12 per cent of the suburbans have this luxury. As one would expect in a rural like setting, 48 per cent of the households in the suburbs depend on well water, 30 per cent on their own wells and 18 per cent on public wells. But even within the non-slum areas of the city, 23.2 per cent of the households depend on wells for drinking water. It is noteworthy that only 9.6 per cent of slum dwellers depend on well water for drinking.

3.11.5 Availability of water for other needs is also important. A variety of sources of water are available in the study area. We have seen that 45 per cent of the people take their drinking water from public taps. While this is the source of water for other purposes also, the proportion is only 34.7 per cent. This is probably because of the difficulty in fetching the water from the street tap, or due to their reluctance to use unprotected water for drinking. Only a negligible proportion of households is dependent on other sources like public well, river, pond and bore well.

3.11.6 Another facility that has an equal bearing on health and disease- free living is the drainage system for wastewater. Table 3.11 provides information regarding the type of drainage system in the study area. A majority of the households (72 per cent) has no drainage system operating in their locality. It was found that most of the of households (97.2 per cent) in the suburbs have no drainage facility, followed by 65.6 per cent in the slums and 59.2 per cent in the rest of the urban area.

3.11.7 The respondents were asked whether there was any stagnation of water around their houses. On the whole, more than 80 per cent said that there was no stagnation of water within the premises of their houses and hence it was not a problem for them. This is surprising in the face of the fact that 72 per cent of the houses do not have drainage facility. The lack of stagnation is probably because of the undulating terrain of the city. Trivandrum is fortunate enough to have been built on a complex of hills. Most of the remaining 20 per cent of the households which have the problem of water stagnation are in the slums and suburbs. The proportion is almost similar in both areas. Another factor that reduces the stagnation of water in the slums is that many of the slums are close to the sea where the sandy soil percolates the water down quickly. Only 7.6 per cent of the households in urban area have the problem of water stagnation.

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3.11.8 Table 3.11 also provides the information on the kind of toilet facilities used by the sample households. It is found that 76.4 per cent of the households have toilet facility. It is to be noted that in the slums only 65.4 per cent of the households have this, while 76 per cent have this in the suburbs and nearly all in the urban area.

3.11.9 Nearly 88 per cent of households have modern facility. Out of this only19.8 percent have flushing facility. It is quite disturbing that in the slums and suburbs 14.9 per cent and 18.4 per cent of the households respectively use pit latrines. In the crowded settlements of the slums where 10 per cent of the houses use well water for drinking, 15 per cent using pit latrines is not a healthy sign. A similar health hazard is posed by those who use the open ground as toilets. The two surveys carried out by Kerala Sastra Sahitya Parishat (KSSP) had revealed that the open defecation in the state had come down from 51.1 per cent in 1987 to 27. 6 per cent in 1996 (Kunhikannan and Aravindan, 2000) But one would have expected this to be nil in a city like Trivandrum which is known for its cleanliness. Therefore it is surprising that more than 63 per cent of those who do not have toilets use open ground as toilets. This is a whopping 15 per cent of the households in the sample area where 22.8 per cent of the people take drinking water from wells. However the use of open ground is negligible in the urban area where the dependence on open wells for drinking water is substantial (23.2 per cent). Fortunately only 48 households (9.6 per cent) in the slums use drinking water from the wells where the use of open ground for toilet is by 93 houses (53.8 per cent of houses with no facility), which makes 18.6 per cent of the slum population. In the suburbs 21.6 per cent use open ground for toilet and 48 per cent depends on wells for drinking water.

3.11.10 The reluctance to use public toilets was probed informally by the enumerators and covered in the interview with community leaders. The common complaint is that the number of public toilets is not adequate and their maintenance is also poor. The doors of some of them are broken or missing. In the absence of Corporation sweepers, they are not cleaned frequently. In some cases, slum dwellers have employed their own sweepers and tried to keep the toilets clean. Inadequate facilities for latrines and their overuse in the absence of cleaning have made them not only unserviceable but also extremely unhygienic. The practice of pay-and-use toilets adopted in some other cities in India and abroad is worth trying here.


3.12 Monthly Household Expenditure

3.12.1Information has been elicited on expenditure for measuring the economic status of the household population.

3.12.2Table 3.12 shows the distribution of the sample households according to monthly expenditure.

Table 3.12 Monthly Expenditure of Households
Monthly Expenditure (in Rs.) Urban Suburban Total
Slum Non-slum
<500 13.6 0.8 6.4 8.6
500-999 24.6 5.2 30.0 21.1
1000-1499 23.0 12.0 27.2 21.3
1500-1999 22.0 18.4 16.4 19.7
2000-2499 9.2 14.8 7.6 10.2
2500-2999 4.4 16.4 5.6 7.7
3000-3499 1.8 11.6 4.0 4.8
3500-3999 0.8 7.6 1.6 2.7
4000-4499 0.4 6.0 0.0 1.7
4500-4999 0.0 2.0 0.4 0.6
5000+ 0.2 5.2 0.8 1.6
Total 100.0 100.0 100.0 100.0
Number 500 250 250 1000
Median 1257 2459 1250 1477

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3.12.3 On the whole, the average monthly expenditure of more than half of the households (51 per cent) in the sample was below Rs.1500. Poverty line in the urban area is defined as having enough to consume to get 2100 calories per day. The amount required for that at current prices is Rs. 372 per capita per month (Oommen, 1999). For the family size of 4.3, the expenditure required to cross the poverty line is Rs.1600. However our data is in intervals of Rs500 and we can take Rs1500 as the cut off expenditure. If we follow this criterion we can see that as high as 61.2 per cent in the slums and 63.6 per cent in the suburbs are below the poverty line, while only 18 per cent in the non-slum area come in this category. However we recognize that this data is only a quick measure of poverty, which has other dimensions. Households with monthly expenditure above Rs.1500 and below Rs.5000/- constitute about 47.4 per cent. The number of households with expenditure more than Rs.5000 was extremely low at1.6 per cent.. It can also be seen that the largest group of 18.4 per cent in the non-slum areas spends in the range of Rs.1500 to Rs.2000, whereas in the suburbs and slums it is 16.4 and 22 per cent respectively. . If we take the expenditure below Rs500 as a rough and ready measure of people living in abject poverty, there are 13.6 percent of the people absolutely poor in the slums and 6.4 per cent in the suburbs whereas in the non-slums it is only less than one per cent. The median expenditure for the sample is Rs.1477. For the slums it is Rs.1257, for the suburbs Rs.1250 and for the non-slum area Rs.2459.

3.12.4 The questions on total expenditure were not asked straight away. Item wise expenditure was asked and then added to get the total. This gave more reliability to the data. The item wise break up is given in Table 3.15.It reveals that the largest proportion of the people in the slums (29.4 per cent) and in the suburbs (28 per cent) spend in the range of Rs.1500 to Rs. 2000 on food. In the other parts of the city the largest group (20.8 per cent) spent in the range of Rs.3000 to Rs.3500 on food.

3.12.5 Coming to utilities, while all spent some amount on fuel, nearly 63 per cent did not spend anything on water and nearly 20 per cent did not spend on electricity. Most of the others in all the three areas spent less than Rs.50 on water and less than Rs.150 on electricity. The expenditure on fuel also came to less than Rs.50 for most people.

3.12.6 But huge differential is noticed in the expenditure towards rent. It is noteworthy that most of the people (88.6 per cent) did not have to pay any rent. Ownership of houses seems to be the ruling pattern across the three areas. The majority of those who stay in rented buildings in the slums and in the suburbs pay less than Rs.350 a month, while in the non-slum areas the majority pays more than Rs.1050 per month. It is interesting that at least 2 families in the slums also pay more than Rs.1050.

3.12.7 When it came to education more than half the people did not have to spend anything. This could be due to a variety of reasons like having no school-going children at the time of the survey, getting the benefit of free education from the government which is available for large sections of the population, support from service organizations for books etc. Nearly a fifth of the households in the slums and suburbs spent less than Rs.150 a month, while 22.8 per cent in the non-slum areas spent up to Rs.350.

3.12.8 The next item queried was clothing. More than a quarter of the households in the slums and suburbs spent only less than Rs.50 a month on this item. More than half in these areas spent up to Rs.150, whereas in the urban areas more than half spent up to Rs.750 on clothing.

3.12.9 As far as expenditure on treatment is concerned, 54.6 per cent of the total reported no expenditure. It is to be noted that more than three fourth of the households in the non-slum area did not have to spend anything on this. Nearly 30 per cent in the slums and a fourth of the people in the suburbs spent less than Rs.150 a month on treatment. The expenditure on treatment for the episodes of illness in the previous month is dealt with separately in Chapter IV.

3.12.10Thirty seven per cent in the slums and 40.4 per cent in the suburbs spent up to Rs.150 a month on travel, while more than a third in the non-slum areas spent up to Rs.350. When it came to entertainment, the picture changed. The vast majority (83 per cent) answered that they do not spend anything on entertainment. Nearly 13 per cent spent below Rs.150 a month with some slight variations across the areas. Probably they watch Television, nearly two thirds having it at home (see Table 3.9). The expenditure on TV being of a capital nature would not figure in the monthly expenditure. The items grouped as miscellaneous include donations, gifts, charity etc. Half the people do not have any expenditure on this and more than a third spent less than Rs. 150 a month with some variations in the areas.

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Table 3.13 Distribution of Households by Item wise Expenditure (%)
Item wise Expenditure (in Rs.) Urban Suburban Total
Slum Non-slum
Food
<500 2.8 2.0 2.4 2.5
500-999 10.4 1.2 11.6 8.4
1000-1499 9.6 4.0 9.2 8.1
1500-1999 29.4 10.4 28.0 24.3
2000-2499 14.8 12.0 16.4 14.5
2500-2999 1.8 6.8 1.2 2.9
3000-3499 24.0 20.8 18.0 21.7
3500-3999 1.8 8.4 4.4 4.1
4000-4499 1.0 9.6 1.2 3.2
4500-4999 2.6 8.8 3.6 4.4
5000+ 1.8 16.0 4.0 5.9
Water
<50 18.0 39.6 8.0 24.2
50-149 6.2 25.2 4.0 12.1
150-249 0.0 2.0 0.0 0.5
250-349 0.0 0.4 0.0 0.1
350-449 0.0 0.4 0.0 0.1
450+ 0.0 0.4 0.0 0.1
None 75.8 32.0 88.0 62.9
Electricity
<50 29.0 18.8 49.6 31.6
50-149 30.0 36.4 22.0 29.6
150-249 9.0 22.4 6.4 11.7
250-349 2.6 10.4 0.8 4.1
350-449 1.2 5.6 0.4 2.1
450-549 0.4 0.8 0.0 0.4
550-649 0.0 0.4 0.0 0.1
650-749 0.0 0.0 0.0 0.0
750+ 0.4 2.0 0.4 0.8
Not Paying 27.4 3.2 20.4 19.6
Fuel
<50 82.4 36.0 84.8 71.4
50-149 9.6 23.6 7.6 12.6
150-249 2.4 3.2 1.2 2.3
250-349 5.6 36.0 6.0 13.3
350-449 0.0 0.4 0.4 0.2
450-549 0.0 0.8 0.0 0.2
Rent
<50 0.0 0.0 0.0 0.0
50-149 2.6 0.0 0.0 1.3
150-249 1.6 0.4 0.8 1.1
250-349 2.6 1.2 2.8 2.3
350-449 1.2 0.8 1.2 1.1
450-549 1.0 0.8 0.0 0.7
550-649 1.0 0.8 0.0 0.7
650-749 0.0 0.0 0.0 0.0
750-849 0.6 0.4 0.4 0.5
850-949 0.2 0.0 0.0 0.1
950-1049 0.6 1.6 1.2 1.0
1050+ 0.4 9.2 0.0 2.5
None 88.2 84.8 93.2 88.6
Education of Children
<50 5.2 0.0 6.8 4.3
50-149 14.4 7.2 11.2 11.8
150-249 9.2 9.2 8.4 9.0
250-349 5.8 6.4 2.4 5.1
350-449 2.2 6.8 2.8 3.5
450-549 1.6 8.4 3.2 3.7
550-649 0.8 2.0 0.4 1.0
650-749 0.4 0.8 0.0 0.4
750-849 0.6 1.6 0.4 0.8
850-949 0.4 0.0 0.0 0.2
950-1049 0.8 3.6 0.0 1.3
1050+ 2.2 4.0 1.2 2.4
None 56.4 50.0 63.2 56.5
Cloth
<50 26.4 5.6 26.8 21.3
50-149 33.0 9.2 34.4 27.4
150-249 21.8 6.0 9.6 14.8
250-349 9.4 9.2 11.2 9.8
350-449 3.0 11.2 3.2 5.1
450-549 3.0 5.2 2.4 3.4
550-649 0.0 2.4 0.8 0.8
650-749 0.4 3.6 0.8 0.8
750-849 0.6 22.4 4.4 7.0
850-949 0.0 0.0 0.0 0.0
950-1049 1.4 8.0 3.6 3.6
1050+ 1.0 17.2 2.8 5.5
Treatment of Diseases
<50 5.8 0.0 8.0 4.9
50-149 24.6 10.8 16.8 19.2
150-249 10.8 4.8 9.2 8.9
250-349 4.6 2.8 4.8 4.2
350-449 1.4 0.0 0.8 0.9
450-549 5.0 2.8 2.8 3.9
550-649 0.6 0.4 0.8 0.6
650-749 0.0 0.0 0.0 0.0
750-849 0.4 0.4 0.0 0.3
850-949 0.0 0.0 0.0 0.0
950-1049 1.2 1.2 0.8 1.1
1050+ 1.0 1.2 2.4 1.4
None 44.6 75.6 53.6 54.6
Travel
<50 5.0 0.0 6.4 4.1
50-149 32.0 11.2 34.0 27.3
150-249 7.2 10.4 10.0 8.7
250-349 6.6 13.2 6.0 8.1
350-449 1.4 1.6 0.4 1.2
450-549 3.8 16.8 4.0 1.2
550-649 0.8 0.8 0.8 0.8
650-749 0.2 0.0 0.0 0.2
750-849 0.4 0.0 0.0 0.2
850-949 0.2 0.4 0.0 0.2
950-1049 0.4 1.2 0.8 0.7
1050+ 0.0 1.6 0.8 0.6
None 42.0 42.8 36.8 40.9
Entertainment
<50 2.8 0.4 7.6 3.4
50-149 7.4 14.8 8.4 9.5
150-249 1.0 6.0 1.6 2.4
250-349 0.4 2.4 0.4 0.9
350+ 0.6 1.6 0.0 0.7
None 87.8 74.8 82.0 83.1
Miscellaneous
<50 19.2 0.0 12.8 12.8
50-149 19.6 31.2 22.4 23.2
150-249 5.6 13.2 4.0 7.1
250-349 2.4 5.2 2.4 3.1
350-449 0.4 0.8 0.4 0.5
450-549 0.8 2.0 0.4 1
550+ 1.2 3.6 0.8 1.7
None 50.8 44.0 56.8 50.6

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3.13 Monthly Household Income

3.13.1 Income is the most difficult information to get in surveys as people have a feeling that they will get some benefit if the income is reported low. This is not surprising because many welfare schemes of the government are targeted to low-income groups and there is no foolproof system of means testing. In order to reduce this bias of understatement, the questions on expenditure were put in the beginning of the survey and after covering aspects like morbidity, reproductive and child health, quality of government services etc, income was asked as the last question.

Table 3.14 Distribution of Households by Monthly Income (%)
Monthly Income Urban Suburban Total
Slum Non-slum
<1500 18.00 2.80 20.80 14.90
1500-2999 37.00 10.40 35.60 30.00
3000-4499 24.60 22.80 28.80 25.20
4500-5999 12.00 12.40 6.00 10.60
6000-7499 4.20 12.00 4.00 6.10
7500-8999 2.20 8.80 2.00 3.80
9000-10499 1.60 8.00 1.20 3.10
10500-11999 0.00 1.60 0.40 0.50
12000-13499 0.40 4.40 0.40 1.40
13500-14999 0.00 1.60 0.00 0.40
15000-16499 0.00 5.60 0.00 1.40
16500-17999 0.00 1.20 0.00 0.30
18000-19499 0.00 1.60 0.40 0.50
19500-20999 0.00 1.60 0.00 0.40
21000-22499 0.00 1.20 0.00 0.30
22500-23999 0.00 0.40 0.00 0.10
24000-25499 0.00 3.60 0.40 1.00
25500+ 0.00 0.00 0.00 0.00
Total 100 100 100 100
Number 500 250 250 1000
Median 2797 6200 2730 4762

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3.13.2 Monthly income of about 15 per cent of the members of the household is below Rs.1500/-. (Urban 2.8 per cent, suburban 20.8 per cent and in slum 18 per cent). 30 per cent of the members have reported their monthly income is between Rs.1500 and Rs.3000/-. A little more than one fourth households have income between Rs.3000 and Rs.4500/-. Only 1 per cent earn more than Rs.24000/-. The data shows that the lowest monthly income of Rs.1500 or less is found to be considerably more among the households in suburban area (20.8 per cent) followed by slums (18 per cent) and the least in the non-slums (2.8 per cent). These differences are significant and reveal the gravity of economic problems prevailing in the slums and suburbs. However, largest group of households that has a monthly income ranging from Rs.1500 to Rs.3000 can be found in slum (37 per cent) followed by suburban 35.6 per cent and urban 10.4 per cent. However it is to be noted that nearly one fifth of the slum dwellers have income above Rs. 4500 while in the suburbs it is only less than 15 per cent. When the income slab goes up further, the number of houses in the non-slum areas increase while the others decline. The median income is Rs.4762 for the total, Rs.2797 for the slums, Rs. 2730 for the suburbs and Rs. 6200 for the non-slum areas.

3.13.3 Questions were put on the source of income, dividing it into land, business, salary, pension, wages, rent, help from relatives and help from institutions. Data in Table 3.15 shows that the large majority of the households in the slums (75.6 per cent) and in the suburbs (74.8 per cent) have their income from wages. Salary and pension together constitute the majority (54 per cent) in the urban areas. However it may be borne in mind that several households have income from multiple sources.

Table 3.15 Distribution of Households by Source of Income (%)
Item Urban Suburban Total
Slum Non-slum
Land 0.6 5.6 2 2.2
Business 7.8 17.2 6.8 9.9
Salary 17.8 35.6 11.6 20.7
Pension 4.6 18.4 5.6 8.3
Wages 75.6 37.6 74.8 65.9
Rent 2.0 2.4 2.0 2.1
Help from Relatives 7.0 7.6 3.6 6.3
Help from Institution 1.0 0.5 0.8 1.0
Number 500 250 250 1000

Note: The percentages may add to more than 100 as there are multiple sources of income

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3.14 Migration

3.14.1 Migration has been noted by many researchers as having a positive influence on the development process of the State and its population growth. Every decade since 1950 witnessed decrease in the population growth rate in the state. The impact of migration on the decrease has been steadily rising ever since out migration from the state started exceeding in migration. As a result of migration, the proportion of population below poverty line has declined by 12 per cent. The number of unemployed persons has come down by more than 30 per cent (Zacharia, 2000). However, the volume of migration in the sample is very low, only 49 houses having migrants. This section provides major socio economic and demographic characteristics of the migrants of the study area. Table 3.16 presents the percentage distribution of migrants in the households in the study area.

Table 3.16 Distribution of Households by Migrants (%)
Number of Migrants Urban Suburban Total
Slum Non-slum
One 73.3 93.3 100.0 81.6
Two 23.3 6.7 0.0 16.3
Three 3.3 0.0 0.0 2.0
Total 100.0 100.0 100.0 100.0
Number 30 15 4 49

3.14.2 Of the 1000 sample households, 49 households (4.9 per cent) have members working outside Kerala. Of the 49 households, 8 households have two migrants each and one has three. Thus there are 59 migrants in total.

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3.14.3 The background characteristics of the migrants are presented in Table 3.17.

Table 3.17 Background Characteristics of Migrants (%)
Characteristics Urban Suburban Total
Slum Non-slum
I.Relationship with Head of Household
Husband 25.6 25.0 0.0 23.7
Son 41.0 31.3 75.0 40.7
Daughter 2.6 6.2 0.0 3.4
Son-in-law 30.8 25.0 0.0 27.1
Brother 0.0 6.2 25.0 3.4
Sister-in-law 0.0 6.2 0.0 1.7
II. Age
<25 7.7 6.2 0.0 6.8
25-29 30.8 25.0 50.0 30.5
30-34 28.2 18.8 0.0 23.7
35-39 25.6 6.2 25.0 20.3
40-44 5.1 18.8 0.0 8.5
45-49 2.6 18.8 0.0 6.8
50+ 0.0 6.2 25.0 3.4
III. Sex
Male 97.4 87.5 100 94.9
Female 2.6 12.5 0 5.1
IV. Education
illiterate 5.1 0 0 3.4
7th to 9th Standard 25.7 6.2 0 18.6
Matriculation 46.1 37.5 25 42.4
Under Graduate 5.1 25 75 15.3
Degree 7.7 12.5 0 8.4
Technical Qualification 10.3 18.7 0 11.9
V. Occupation
Government Service 5.1 12.5 0 6.8
Business 35.7 25 25 32.2
Driver 17.9 18.8 50 20.2
Servant 5.1 0 0 3.4
Salesman 2.6 12.5 25 6.8
Electrician 12.8 18.8 0 13.6
Semi-skilled 18.1 6.2 0 13.6
Others 0 6.2 0 1.7
VI. Duration of Stay
Less than 1 year 7.7 0.0 25.0 6.8
1-5 years 58.9 31.2 25.0 6.8
6-9 years 12.9 25.0 0.0 15.2
10-15 Years 12.8 18.8 25.0 15.2
16-20 years 7.7 12.5 25.0 10.2
Above 20 years 0.0 12.5 0.0 3.3
VII. Monthly Remittance
<1000 12.8 18.8 25 15.3
1000-2499 51.3 0 0 33.9
2500-3999 15.4 12.5 25 15.3
4000-5499 7.7 37.5 25 16.9
5500-6999 12.8 12.5 0 11.9
7000+ 0 6.2 0 6.7
VIII. Place of Stay
Europe 0 6.2 25 3.4
Middle East 79.5 93.8 75.0 83.0
South-East Asia 7.7 0 0 5.1
Outside State but within India 12.8 0 0 8.5
Total 100.0 100.0 100.0 100.0
Number 39 16 4 59

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3.14.4 Of the total population, 40.7 per cent of migrants are sons and 3.4 per cent are daughters of the heads of households. Approximately, 23.7 per cent are husbands of the head. About 27.1 per cent of the migrants are sons-in-law and 1.7 per cent sisters-in-law of the head of the family. Around 3 per cent are brothers of the head of household.

3.14.5 Age distribution of the migrants reveals almost one third (30.5 per cent) of migrants belong to 25-29 age group. Nearly one fourth of the migrants (23.7 per cent) belong to 30-34 age group. Another 20.3 per cent of the migrants are in the age group of 35-39 years. These age groups together constitute almost 75 per cent of the total migrants. This shows the age selectivity of migration.

3.14.6 Regarding sex, there is a clear predominance of males in migration. Of the total, 95 per cent are males.

3.14.7 Educational level of the migrants shows that around 43 per cent of migrants are matriculates. More than 15 per cent are under graduates and 8 per cent graduates. Nearly 12 per cent have technical qualifications like Certificate or Diploma in Engineering, Teachers Training Certificate or Computer Training. Only 2 persons(3.4 per cent) are illiterate.

3.14.8 Occupational breakdown of the total migrants shows that the larger proportion of migrants (32.2 per cent) is engaged in business. Next to business, the majority of migrants (20.2 per cent) are employed as drivers. Similar proportion (6.8 per cent) of migrants are working in Government service and as Salesmen. Electricians and semi skilled workers constitute 13.6 per cent each. More than three per cent work as servants.

3.14.9 Around 7 per cent of migrants have duration of service less than one year. Almost 65 per cent have service between one year and 10 years. More than one fourth has service between 10 years and 20 years. 3.3 per cent have worked more than 20 years.

3.14.10 Remittances, no doubt, improve the standard of living of the migrants’ family. The survey also collected information on the volume of remittances sent by migrants. Almost 34 per cent of the migrants sent between Rs.1000/- and Rs.2500/- monthly. More than 15 per cent sent between Rs.2500 and Rs.4000. Nearly 17 per cent sent between Rs.4000/- and 5500/-. Monthly remittance of only 5 per cent is Rs.10,000/- and above.

3.14.11 Table 3.17 also shows the place where the migrants work at the time of survey. Countries of the Persian Gulf occupy first place in receiving migrants from the study area, nearly 83 per cent working there. Around 5 per cent work in South East Asia and 3.4 per cent work in Europe. The remaining 8.5 per cent is employed outside the state but within India.

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3.15 Summary

3.15.1 The picture that emerges is that the slums and the poor areas in the suburbs have many characteristics in common, which make them distinct from the non-slum areas. The slums have a sex ratio more favourable to the females than the rest of the city and the state. The fertility decline has taken place in the slums later than the other areas. There is a higher dependency ratio in the slums. Generally males head the households. But in the slums nearly one fourth of the households have female heads. The religious mix shows that the study area has more Christians and less Muslims than the state. In the slums the proportion of e Christians is almost equal to Hindus. In the matter of education, the slums trail behind the rest of the city. Only a tenth of the people in the slums and suburbs completed high school education successfully. Business is the most common occupation, the suburbs leading the other two groups. About 12 per cent of those employed are daily wage earners, the slums leading with 14 per cent. Nearly a third of the houses in the slums are of purely temporary nature with thatched roof and walls, and only less than a fourth has running water inside. More than a third of the houses in slums do not have toilet facility and among them more than half use the open field for this. About a fourth of the houses in the slums are not electrified. Going by the expenditure data, more than 13 per cent of the slum dwellers are absolutely poor which is not so in the suburbs or the rest of the city. Another 25 per cent are moderately poor.


IV. Morbidity and Morality

4.1

The State of Kerala is well known for its fast achievement of demographic and health transition among the states of India. The low level of fertility and mortality, especially infant mortality, compares well with many advanced countries. However, the prevalence of morbidity is reported high in spite of continuing low mortality. This apparent paradox has caught the attention of several health economists and population scientists. Information on morbidity and mortality is highly relevant for identifying population groups, which require attention by health care planners. With this backdrop our study aimed to collect data on the incidence of sickness and of death in the sample.

4.1.1 To find out the incidence, prevalence and pattern of morbidity, questions were put to the respondents. The incidence of morbidity works out to 42 per thousand with the previous month as the reference period . We limited the reference period to one month in order to avoid recall lapse and related errors. This was comparatively lower in the slums at 38 and higher in the suburbs at 49. There is some difference in the prevalence of morbidity among the three groups. Out of 500 households surveyed in the slums, 246 had at least one member who was ill at the time of the survey. Out of the 250 surveyed in each of the other two areas, 129 in the non-slum areas and 111 in the suburban areas had one member sick. Some households had 2 and some three, making the total ill 282 in the slums, 148 in the non-slum areas and 129 in the suburban areas. The sample sizes in the three areas are is 2206, 1023 and 1068 respectively. Thus the prevalence of morbidity works out to 127.8 per thousand in the slum areas, 144.7 in the non-slum areas, 120.8 in the suburban areas and 130.1 in the entire study area. A comparison of this with the morbidity of the state for different years available in other surveys is given in Table 4.1

Table 4.1 Morbidity Rates in Kerala and Trivandrum City
Disease Kerala Trivandrum City 2001
NSS 1974 KSSP 1987 KSSP 1996 NCAER 1993 (Urban) Urban Suburban Total
Slum Non Slum
Acute 71.2 206.4 121.9 210.0 127.8 144.7 120.8 130.1
Chronic 83.7 138.0 114.6

Source: Kunhikannan & Aravindan (2000) for columns 1 to 4
Shariff 1999 for column 5
Note:
The recall period of the three other surveys is two weeks.

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4.1.2 In the present survey a clear distinction between chronic and acute diseases has not been attempted. However, the general picture that emerges is that the prevalence of morbidity in Trivandrum City is not much different from the state. Morbidity is the lowest in the suburban areas. This is understandable as these were villages till recently and were added on to the city for administrative convenience. They carry the characteristics of a village in some respects and city in some others. But it is surprising that more people in the non-slum areas fall ill than in the slum areas. An explanation for this may have to be sought in the perception of illness among people at different levels of social development.

4.1.3 It is generally observed that among people with low economic status and poor health indicators, the morbidity is also very low. This is because the surveys look at the perceived morbidity and poor people may not perceive some small episodes of illness as significant enough to seek treatment and recall and report. This question has been agitating some writers like Johanson S Ryan and Riley. The latter who reviewed the morbidity trends in Japan, United States, Britain and Hungary found that sickness prevalence has moved in a direction opposite to the death rate for most of the age and sex groups (Riley 1990). This is well illustrated in Indian states as well. Surveys have shown repeatedly that Kerala which has very good health indicators as we saw in Chapter I, has the highest prevalence of morbidity. It was 163 per thousand in 1994 against an all India figure of 94. A state like Bihar with an IMR of 67 and life expectancy of 60 had only the prevalence rate of 91 per thousand in the same survey (NCAER 1994). The picture about major morbidity is not different, showing Kerala with a major morbidity prevalence rate of 73.2, India 45.8 and Bihar 38.2 (Sharif 1999). When one bears this dimension in mind it need not be surprising that the people with better education, and income, living in the non-slum areas have a more intense perception about morbidity, recall minor ailments which the slum dwellers might ignore.


4.2 Pattern of Morbidity

4.2.1 Communicable diseases constitute a major burden of disease in India, accounting for 50 per cent of the burden compared to only 18 per cent in China, a country very similar, and 43.8 per cent in low and middle income countries in 1998 (WHO, 1999). With this background, a specific question was put whether the respondents had any communicable diseases during the recall period. Only 9 out of the 4297 persons questioned reported that they had communicable diseases. However as can be seen in Table 4.2, many had fever, some of which like typhoid fever would be communicable. It is quite likely that the respondents did not recognize them as communicable. Therefore this data on communicable diseases is not conclusive.

4.2.2 Out of the 559 people who were ill, 130 (23.3per cent) were down with fever, cold, headache etc. making the incidence rate of this common complaint 232 per thousand. This omnibus group is the largest group of ailments in the KSSP Survey also, being 118 in 1987 and 68 in 1996 over a two-week recall period. Not much difference is observed among the three areas about the incidence of this group of illnesses as can be seen from Table 4.2

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Table 4.2 Nature of Disease (%)
Disease Urban Suburban Total
Slum Non-slum
Pneumonia Fever, Severe cold, Headache, Migraine, Toothache etc. 20.6 26.4 25.6 23.3
Blood Pressure, Heart Problems 24.8 16.9 10.9 19.5
Asthma, Cough, Breathing Difficulty 22.0 12.8 16.3 18.2
Paralysis, Stroke, Arthritis, Rheumatism 10.3 12.8 12.4 11.4
Diabetes, Kidney Trouble, Urinary infection, Uterus complaint 3.9 13.5 7.0 7.2
Dysentery, Gas Trouble, Vomiting Stomach ache, Ulcer in the GI Tract, Jaundice Appendicitis 5.7 5.4 6.2 5.7
Allergy & Skin Diseases 2.1 2.7 7.0 3.4
Eye problem, Hearing impaired 1.8 3.4 3.1 2.5
Accident 3.5 0.7 1.6 2.3
Cancer, Tumour 1.1 2.0 3.1 1.8
Mental Problem, Retarded Growth, Epilepsy 1.4 2.0 1.6 1.6
Tuberculosis 1.8 0.0 1.6 1.3
Goiter, Thyroid problem 0.7 0.7 0.8 0.7
Filariasis 0.4 0.0 0.8 0.4
Measles 0.0 0.7 0.8 0.4
Chickenpox 0.0 0.0 1.6 0.4
Total 100 100 100 100
Number 282 148 129 559

4.2.3 After fever, cardio-vascular problems seem to be the highest, nearly 20 per cent suffering from that. It is interesting to note that nearly 25 per cent of the sick in slums suffer from this, while in the non-slum it is only 17 per cent and in the suburbs only 11 per cent. One would expect this group of life style related ailments to be more prevalent among the richer group of non-slums. But here the picture is different.

4.2.4 The next group of common ailments is asthma, cough and breathing difficulty, afflicting about 18 per cent of the ill. This, again, is more in the slums with 22 per cent, while it is only about 13 in the non-slum areas and 16 in the suburbs. The fourth group of ailments is nervous disorders like paralysis, stroke, etc. affecting 11.4 per cent. In this, the slums are better placed with only about a tenth suffering from this, against about an eighth in the other areas. Another finding of interest is that though only 2.3 per cent of the ill were accident victims, their proportion in the slums is 3.5 per cent against less than one in the non-slums and 1.6 in the suburbs

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4.3 Duration of illness

4.3.1 The intensity of illness is indicated, among other things by its duration. The responses to the questions on this are presented in Table 4.3.

Table 4.3 Duration of Illness (%)
Duration Urban Suburban Total
Slum Non-slum
1 month and less 29.8 29.1 40.3 32.0
2 months 4.3 4.1 3.9 4.1
3 months 3.5 2.7 2.3 3.0
4 months 2.1 2.0 1.6 2.0
5 months 1.1 0.7 1.6 1.1
6 months 3.2 2.7 1.6 2.7
7 month 0.7 0.7 1.6 0.9
8 months 0.4 1.4 1.6 0.9
9 months 0.4 0.7 1.6 0.7
10 months 0.7 1.4 0.8 0.9
12 months 2.8 3.4 0.8 2.5
4 Years 20.6 22.3 19.4 20.8
9 Years 14.5 12.2 8.5 12.5
Above 10 years 12.1 14.2 14.0 13.1
Period not specified 2.5 2.7 0.8 2.1
No data. 1.4 0.0 0.0 0.7
Total 100 100 100 100
Number 282 148 129 559

4.3.2 Out of the 559 persons reported ill 32per cent were ill for less than a month and 48.5per cent for more than a year. Illness lasting less than a month can be assumed to be of a minor nature. The percentage of people with less than one month’s illness in the slum is 29.8 and in the non-slums 29. However, it is quite high at 40.3 per cent in the suburbs. This shows that more of the sick in the suburbs suffered from illness of a minor nature. This is in tune with our earlier observation that the incidence of sickness in the suburbs is the lowest (Table 4.1). Those who were ill for more than a year is 49.7 per cent in the slums 51.4 in non-slum areas and 42.6 in the suburban areas. Here also the suburbans fare better than the other two resident groups. Enquiries were also made to find out whether the diseases are still prevailing and if not how long it lasted. No significant difference could be noticed in this. (Table not given)

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4.4 Treatment

4.4.1 Most of those who were ill (96.6 per cent) went in for treatment. There is very little variation among the three areas in this. The reasons for not seeking treatment are given in Table 4.4.

Table 4.4 Reasons for not Taking Treatment (%)
Reasons Urban Suburban Total
Slum Non-slum
1. Financial cost 55.6 66.7 50.0 57.9
2. Not believing in treatment 1.1 0.0 0.0 5.3
3. Self-treatment 33.3 33.3 50.0 36.8
Total 100.0 100.0 100.0 100.0
Number 9 6 4 19

4.4.2 More than a third (7 persons) resorted to self-treatment and 58 per cent did not go for treatment because of the cost involved. However these are too small numbers to draw any meaningful inference.

4.4.3 Most of those who took treatment resorted to allopathic system and only 8.7 per cent of them chose other systems like homoeopathy and Ayurveda . The percentage of non-slum ill who took to other systems of medicine treatment is 14, whereas the percentage of slum ill is only 5.5 and that of suburban ill 9.6.

Table 4.5 Type of Treatment (%)
Type of Treatment Urban Suburban Total
Slum Non-slum
Allopathy 94.5 85.9 90.4 91.3
Homeopathy 1.8 8.5 2.4 3.7
Ayurveda 3.7 5.6 7.2 5.0
Total 100.0 100.0 100.0 100.0
Number 273 142 125 540

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4.4.4 An interesting light is shown on the health system seeking behavior of different groups. Probably, the higher level of education among the non-slum people make them more conscious of the side effects of modern medicine and willing to experiment with the other systems. Generally, in India, reliance on traditional system of medicine is very high among the rural poor because of questions of physical and financial access. The survey shows that once the barriers to access are removed, the poor people would like to go for the sure shot of modern medicine. It is the better off people who are more conscious of the side effects who would like to try out alternate systems of medicine. In the Bellagio Conference on Good Health at Low Cost (1985) the prevalence of traditional medicine is identified as one of the common features of China, Sri Lanka and Kerala, which were three of the four regions considered as models for low cost health care (Halstead et al 1985). It appears that the poor are apparently losing faith in the alternative systems. Perhaps they cannot afford to spend more time on recovering from illness which the alternate systems entail and would like to get back to their work as early as possible as otherwise they would lose income. The gains in preventive medicine and cost effective health care provided by the alternate systems of medicine seem to be getting eroded. What this will lead to and what are the implications on public health requires to be further studied.

4.4.5 The type of hospital they went to and the reasons why some did not go to public facilities are dealt with in Chapter VIII.

4.4.6 Next we tried to find out if they had any difficulty in accessing the facility for treatment. Out of the 540 patients, 6.7 per cent visited health facilities within a kilometer and 29 per cent within two kilometers as seen in Table 4.6.

Table 4.6 Distance to the Hospital (%)
Distance in Km. Urban Suburban Total
Slum Non-slum
<1 9.1 3.5 4.8 6.7
1 19.7 32.6 15.2 22.0
2 and 3 23.8 18.4 14.4 20.1
4 to 9 26.1 21.3 32.8 29.3
10 14.6 15.6 14.4 14.8
11 to 19 4.8 6.4 13.6 7.2
20 plus 2.2 2.1 4.0 2.6
No Data 0.0 0.0 0.8 0.2
Total 100.0 100.0 100.0 100.0
Number 273 142 125 540

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4.4.7 More people in the slums visited facilities within one kilometer, while those who went to facilities within two kilometers are more in the non-slum areas (36 per cent). In the suburban areas it is less at 20 per cent. However, the fact that 25per cent of the patients had to travel more than 10 kms. to the health facility in a city like Trivandrum is surprising. 1.7 per cent had to travel more than 20 kms. But it has to be borne in mind that this distance is to the hospital they chose to go to and not to the nearest hospital.

4.4.8 The data on distance to the hospital of choice is corroborated by the fact that 23.3 per cent of the patients walked to the hospital (Table 4.7). This means a large majority of those who went to the facility within two kms. did not have to engage any means of transport.

Table 4.7 Mode of Conveyance (%)
Mode Urban Suburban Total
Slum Non-slum
By Walk 23.7 24.8 20.8 23.3
By Bus 48.9 2.6 55.2 48.7
By Auto Rickshaw 27.0 24.8 23.2 25.6
By Car 0.4 7.8 0.8 2.4
Total 100.0 100.0 100.0 100.0
Number 273 142 125 540

4.4.9 Only 2.4 percent had to go by car. More than 22 percent did not have to spend anything at all on transportation to the hospital, broadly corroborating the figure of 23 per cent who went by walk.

4.4.10 As seen in Table 4.10, 53 per cent had to spend only less than Rs.15/- on transport to the hospital. This is a very small amount. There is no significant difference among the three groups in this regard.

Table 4.8 Expense for the Journey (%)
Expense in Rs. Urban Suburban Total
Slum Non-slum
Nil 23.7 24.8 16.8 22.4
1-15 53.3 46.8 58.0 52.7
16-25 12.1 8.5 16.8 12.2
26-30 4.5 9.2 1.6 5.1
41-45 3.3 3.5 1.6 3.0
66-70 1.4 1.4 4.0 2.0
76+ 1.8 5.7 1.6 2.8
Total 100.0 100.0 100.0 100.0
Number 273 142 125 540

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4.5 Expenses for Treatment

4.5.1 Regarding the expenses for treatment of the illnesses that occurred during the previous month, it may be seen from Table 4.9 that, out of the 540 patients 451 (83.5 per cent) incurred some expenditure.

Table 4.9 Expense for Treatment (%)
Expenses in Rs. Urban Suburban Total
Slum Non-slum
1-100 34.6 28.2 40.6 34.4
101-200 20.2 19.7 15.1 18.8
201-300 11.8 8.5 8.5 10.2
301-400 6.1 11.1 6.6 7.5
401-500 8.3 15.4 5.7 9.5
501-600 2.2 5.1 3.8 3.3
601-700 0.0 2.6 5.7 2.0
701-800 1.8 2.6 5.7 2.0
801-900 0.4 0.0 0.0 0.2
901-1000 5.3 5.1 5.7 5.3
1001+ 9.2 1.7 4.7 6.2
Total 100 100 100 100
Number 282 148 129 559
Median expenditure in Rs. 178 216 158 185

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4.5.2 Out of the spenders, a third spent only less than Rs.100 a month. The largest proportion of patients in all the three areas belongs to this group. In the suburbs it is nearly 41 per cent. Those who had to spend between Rs.100 and 200 are nearly 19per cent. If we take these two groups together we can see that the majority of the people (53.2 per cent) had to spend less than Rs.200 on treatment. Nearly 55 per cent of the slum patients and 48 per cent of the non-slum patients and 56 per cent of the suburban patients belong to this group. Thus, overall, the expenses for treatment do not appear to be high in the majority of cases. However, it is significant that 9.2 per cent of the slum patients and 4.7 per cent of the suburbans had to spend more than Rs.1000. The median expenses for treatment work out to Rs.185 for the total. The fact that the non-slum dwellers have a higher median expenditure implies, perhaps, a higher burden of chronic diseases.

4.5.3 It may be noted that the expenditure for treatment given in Chapter III refers to the average expenditure for all households, whereas here we are dealing with the expenditure incurred only by those who underwent treatment during the previous month.

4.5.4 The total expenses as seen in Table 4.10 was gathered by adding up the expenses for the purchase of medicine, fee for the doctor, the investigations and x rays and other miscellaneous expenses. It would be interesting to find out the expenses for the purchase of medicine alone. Table 4.12 shows that the median expenditure for purchasing medicines is Rs.93, the highest being in the non-slum areas with Rs.104. this is to be expected as they have a higher burden of chronic disease.

Table 4.10 Expense for the Purchase of Medicine (%)
Expenses in Rs. Urban Suburban Total
Slum Non-slum
Nil 28.1 29.8 23.2 27.4
1-25 4.1 21.2 24.0 13.3
26-50 17.8 6.1 24.0 16.3
51-75 9.1 4.0 3.1 6.4
76-100 22.3 17.2 18.8 20.2
101-150 10.2 12.1 6.3 9.7
151-200 14.2 16.2 7.3 13.0
201-250 2.5 5.1 3.1 3.3
251-300 15.2 8.1 9.4 12.0
301+ 4.6 10.1 4.2 5.9
Total 100 100 100 100
Number 197 99 96 392
Median expenditure in Rs. 97 104 67 93

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4.5.5 Out of the 540 patients who took treatment, 148 (27.4 per cent) did not have to spend anything at all, 28per cent in the slums, nearly 30per cent in the non-slums and 23per cent in the suburbs. The patients who went to Government hospitals are 67 per cent, as we will be seeing elsewhere in Chapter VIII. The free distribution of drugs is only in the public facilities and there is perennial complaint about its shortage in the Government hospitals. In this study, we observe that while about two-thirds of the patients go to Government hospitals, only a little over 27 per cent get the medicines free. This means that only 40 per cent of those who go to government hospitals get free medicine confirming the general impression about the shortage of drugs in government hospitals. This assumes that only government hospitals give medicines free. Another interesting information is that 65 of the 540 patients (12 per cent) paid some fees to the doctor. Private practice is allowed for government doctors in the state. Very often there are complaints that without paying fees to the doctor privately no proper treatment will be available in government hospitals. In Kerala there is no practice of levying separate fees by the doctor in private hospitals. Therefore one could reasonably conclude that the payment was to government doctors in their private consultation. Even then, it is not a sizable proportion as more than two thirds went to government hospitals for treatment and those who paid money to doctor are only 65 in number. On the assumption that all this money was paid to government doctors, the percentage of the patients who paid money to government doctors works out to 17 per cent only. However some private doctors who run only outpatient clinics and not hospitals would be collecting fees. Therefore the proportion of patients who paid fees to government doctors is likely to be even less than 17 per cent.

Table 4.11 Fee for Doctors (%)
Expenses in Rs. Urban Suburban Total
Slum Non-slum
1-25 6.5 8.0 0.0 6.2
26-50 22.6 48.0 11.1 30.8
51-75 3.2 0.0 0.0 1.5
76-100 61.3 24.0 55.6 46.2
101-150 0.0 4.0 11.1 3.1
151-200 3.2 4.0 0.0 3.1
201-250 0.0 0.0 0.0 0.0
251-300 0.0 0.0 0.0 0.0
301+ 3.2 12.0 22.2 9.2
Total 100 100 100 100
Number 31 25 9 65

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4.5.6 Among those who paid, about 40 per cent paid only less than Rs.50, the proportion being more than half in the non slum areas and much less in the other two. It may be noted that most of them (84.7 per cent) paid Rs.100 or less as doctor’s fee. An interesting piece of information is that it is in the slums that more people paid between Rs. 75 and 100, followed by suburbs, while in the non-slums more people paid between Rs 25 and 50. The reasons for this are not clear.

4.5.7 The source of money was the next question put to them.

Table 4.12 Source of the Money for Treatment
Particulars Urban Suburban Total
Slum Non-slum
No. % No. % No. % No. %
No need for money 26 9.5 18 12.8 33 26.4 77 14.3
Own 101 36.9 79 56.0 33 26.4 213 39.4
Other Sources 147 53.6 44 31.2 59 47.2 250 46.3
Total 274 100.0 141 100.0 125 100.0 540 100.0

4.5.8 Out of the 540 patients who took treatment, only 39.4 per cent could find their own money and 46.3 per cent had to find money from other sources. The largest proportion of those who had to find money from outside is in the slums with 53.6 per cent. The suburbs with 47.2 per cent and non-slum with 31.2 follow it. Thus the proportion of ill in the slums who had to raise money is much higher than in the other two groups. This speaks of the high financial burden that a disease casts on the slum dwellers.

4.5.9 The heaviness of the burden becomes more apparent when we look at the loss of wages due to illness.

Table 4.13 Wage Loss Due to Illness (%)
Amount lost Urban Suburban Total
Slum Non-slum
1-150 2.4 10.5 7.7 4.9
151-300 8.8 0.0 2.6 5.6
301-450 1.2 0.0 5.1 2.1
451-600 8.2 15.8 15.4 11.2
601-750 4.7 0.0 7.7 4.9
751-900 1.2 0.0 0.0 0.7
901-1050 18.8 21.1 2.6 14.7
1051-1200 0.0 5.3 0.0 0.7
1201-1350 1.2 0.0 0.0 0.7
1351-1500 7.1 5.3 12.8 8.4
1501-3000 8.2 10.5 7.7 8.4
3001-4500 2.4 0.0 7.7 3.5
4501-6000 2.4 0.0 0.0 1.4
6001-7500 2.4 0.0 0.0 1.4
7501-9000 3.5 5.3 2.6 3.5
9001 2.4 26.3 2.6 5.6
No Data 25.9 0.0 25.6 22.4
Total 100.0 100.0 100.0 100.0
Number 85 19 39 143

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4.5.10 Out of the 540 patients, 143 (26.5 per cent) suffered loss of wages due to illness that occurred in the previous month. This is 31 per cent in the slums and suburbs. But in the non-slum area this percentage is only 13.5. As can be seen from Chapter III more people in the slums and suburban areas are daily wage earners and, therefore, this is not surprising. Out of the 143 patients who suffered financial loss due to illness, 22.4 per cent could not furnish any data about the amount of loss. The others reported losing varying amounts of income. When the amounts were grouped into intervals of Rs.150, the group that had the largest number of people was found to be Rs.901 to Rs.1050/-. Nearly 15 per cent of the patients suffered a loss in this range. While the proportion was 21 per cent in the suburbs and non-slums, it was nearly 19 per cent in the slums. Some people had to lose more than Rs.9000/-. Those in the non-slum area belonging to this category are 26.3 per cent. However, it may be borne in mind that the sample size is very small.

4.5.11 Table 4.16 shows how the sick raised money for treating themselves.

Table 4.14 How the Money was Raised (%)
Particulars. Urban Suburban Total
Slum Non-slum
Borrowed 81.6 75.0 76.3 79.2
Selling of land 2.7 15.9 23.7 10.0
Selling of Gold 3.4 4.5 0.0 2.8
Pledging of Gold 4.8 4.5 0.0 3.6
From Church 2.0 0.0 0.0 1.2
Help from relatives 5.4 0.0 0.0 3.2
Total 100 100 100 100
Number 147 44 59 250

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4.5.12 Nearly 80 per cent of those who had to raise money from outside borrowed it, more in the slums than in the other two areas. About one-eighth of the patients had to liquidate assets like land and gold ornaments, 23.7 per cent of in the suburbs, 20.4 per cent in the non-slum areas and only 6.1 per cent in the slums. On the whole the slum dwellers could rely more on borrowing and the need for liquidating assets was much less. Perhaps they do not have much assets to liquidate. A total of 4.4 per cent relied on help from relatives and religious organizations. It is noteworthy that 5.4 per cent in the slums could get help from relatives while none in the other two areas could manage it. Perhaps the slum dwellers living closely together as a community has better access for borrowing from friends and relatives.

4.5.13 A recent study by the World Bank has shown that more than 40 per cent of the hospitalized Indians had to borrow money or sell assets to meet the cost. (World Bank, 2001) Though our study is not limited to hospitalization, the finding is not much different. Out of the 540 persons who underwent treatment 250 had to raise money from outside. If we leave the small proportion who got help from relatives and religious institutions, the number of those who had to borrow or sell assets is 239, making a percentage of 44.2. The World Bank continued the enquiry and found that hospital expenses alone push 2.2 per cent of Indians below the poverty line. Our study did not have in its scope this particular line of enquiry. However, we have seen in Chapter III that 15 per cent of the people reported a monthly income of less than Rs.1500, which is the amount, required for crossing the poverty line. The proportion is substantially higher in the slums and suburbs at 21 per cent and 18 per cent respectively. The ill in the slums who had to spend upto Rs.200 for treatment are nearly 55 per cent and in the suburbs more than 55. About a tenth of the people suffered a wage loss upto Rs.300. Ignoring the small cost of transportation, these two amounts will be pushing some people below the poverty line in the slums and suburbs. It is certainly worth studying this separately.


4.6 Mortality

4.6.1 Mortality rate is often considered a proxy for the health status of a community. The State of Kerala has already achieved a low level of mortality with a crude death rate of 6.4 per thousand and Infant Mortality Rate of 16 per thousand live births (Census 2000b). Although our study does not permit the computation of mortality rates, we have attempted to study the mortality in the last three years and its causes.

4.6.2 During the last three years, the total sample population experienced 92 deaths: 62 per cent men and 38 per cent women. This ratio is maintained in the slums and non-slums and slightly changed in the suburban areas as is evident in Table 4.15.

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Table 4.15 Mortality within 3 Years (%)
Particulars Urban Suburban Total
Slum Non-slum
Male 63.6 66.7 53.8 62.0
Female 36.4 33.3 46.2 38.0
Total 100.0 100.0 100.0 100.0
Number 33 33 26 92

4.6.3 A rough estimate of Crude Birth Rate during the last three-year period works out to 7.3, which is higher than the state average.

4.6.4 The age distribution of deaths shows that most of the people died of old age, which is a reflection of population aging. Table 4.16 shows that the total percentage of people who died after 65 is 45.6 per cent.

Table 4.16 Age at Death (%)
Age in Years Urban Suburban Total
Slum Non-slum
10-14 6.1 0.0 7.7 4.3
15-19 3.0 0.0 7.7 3.3
20-24 0.0 0.0 3.8 1.1
25-29 3.0 3.0 0.0 2.2
30-34 9.1 0.0 0.0 3.3
35-39 0.0 0.0 0.0 0.0
40-44 6.1 9.1 3.8 6.5
45-49 6.1 9.1 3.8 6.5
50-54 9.1 6.1 7.7 7.6
55-59 3.0 6.1 7.7 5.4
60-64 6.1 9.1 7.7 7.6
65-69 3.0 0.0 7.7 3.3
70-74 21.2 12.1 23.1 18.5
75-79 12.1 6.1 0.0 6.5
80-84 9.1 18.2 11.5 13.0
85-89 3.0 6.1 0.0 3.3
90+ 0.0 9.1 3.8 4.3
Total 100.0 100.0 100.0 100.0
Number 33 33 26 92
Mean age at death(Years) 55.7 64.0 57.7 59.3
Standard deviation 20.89 17.91 22.03 20.6

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4.6.5 The average life expectancy of the state is 72 years. In our sample more than a fifth of the people have lived beyond the age of 74. If we look at the proportion of people who died in different age groups in the three areas, we can see that the largest proportion (18.5per cent) died between 70 and 74 years. More than 21 per cent of the deaths in the slums and more than 12 pr cent in the non-slums and 23 per cent in the suburbs occurred in this age group. Generally it is the people in the non-slum areas that live longer, the mean age at death there being the highest at 64 followed by suburbs at 57.7 and slums at 55.7. The tables do not include one infant death that occurred in the slums.

4.6.6 Regarding the causes of death, in a little over 3 per cent the cause was not diagnosed.

Table 4.17 Causes of Death (%)
Cause Urban Suburban Total
Slum Non-slum
Not Diagnosed 6.1 3.0 0.0 3.3
Geriatric ailments 24.2 36.4 23.1 28.3
B.P., Heart Attack 15.2 24.2 19.2 19.6
Suicide 21.2 0.0 19.2 19.6
Cancer 6.1 12.1 7.7 8.7
Diabetes, Kidney problems 6.1 0.0 15.4 6.5
Asthma 6.1 9.1 3.8 6.5
T.B. 0.0 6.1 7.7 4.3
Paralysis, Brain stroke 3.0 3.0 3.8 3.3
Jaundice 6.1 0.0 3.8 3.3
Ulcer 3.0 3.0 0.0 2.2
Total 100.0 100.0 100.0 100.0
Number 33 33 26 92

4.6.7 It can be seen in Table 4.19 that 28.3 per cent of the deaths were due to geriatric ailments, the highest proportion (36.4per cent) being in the non-slum areas. Though cardio vascular diseases are the major cause of morbidity in the slums, afflicting about 25 per cent of the sick, its fatal blow is felt more in the non-slums with more than 24 per cent of the deaths caused by it. This is much higher than the rate of 14.3 reported for the state in the KSSP survey of 1996 (Kunhikannan and Aravindan 2000). It is quite disturbing that suicide is the second largest killer in the slums, accounting for 21.2 per cent of the deaths. It is nil in the non-slum areas and less than 4 per cent in the suburbs. This is also much higher than the state figure of 2.8 per cent of the KSSP study. This ought to be a matter of serious concern. Kerala has one of the highest suicide rates in the country with 28 per 100,000 against the country’s average of 8 (various reports of the Kerala State Mental Health Authority). The reasons for concentration of this in slum areas have to be investigated without delay and interventions sought. We saw in Table 4.1 that the morbidity due to accidents is the highest in the slums at 3.1 per cent and it is only 1.6 per cent in the suburbs. However, the mortality due to accidents is 5.4, almost the same as 5.7 in the KSSP study. It is the highest in the suburbs at 11.5 per cent whereas in the other two areas it is only 3 per cent. Diabetes and kidney problems accounted for 6.5 per cent of the deaths. If this is combined with blood pressure and hearth attack, which commonly constitute the diseases of life style, we can observe that 25.8 per cent of the deaths are due to this group of diseases. In the slums it accounted for 21.3 per cent and in the suburbs 34.6 per cent. In the non-slums there was no death due to diabetes or kidney problem and therefore, the percentage is that of BP and heart attack (24.2). Cancer caused 8.7 per cent of the deaths in our study sample and almost the same in the state at 8.6 in the KSSP study

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4.7 Summary

4.7.1 We find that the incidence of morbidity in the study sample is 130 per thousand and higher in the non-slum areas. This is higher than the figure for the state reported in various studies. But it is nothing to be alarmed about as we saw that perceived morbidity goes up and not down with improved development. Among the causes of morbidity, if we take away fever and related common ailments, cardio vascular diseases take the highest place in the slums afflicting more people there than in the other areas. Acute respiratory infections are the most common disease among the suburbans. Though the share of accidents is small, slums take the lead in this.

4.7.2 About the duration of illness the suburbans take the lead over the others with more short duration illnesses. Most of them went for treatment, choosing the allopathic system. Mostly they went to health facilities nearby, walking to it or taking a ride by bus or auto rickshaw, spending small amounts for transportation. Most of them had to spend some money for the treatment, the amount being less than Rs.200 in the majority of cases with little difference among the three resident groups. Only about 40 per cent of those who went to government hospitals got all the medicine free. But only 12 per cent of the patients had to pay fees to the doctor, the amount being in the range of Rs.25 to 100 in the majority of cases. Nearly half of those who spent money for treatment had to raise it from other sources. Most of them borrowed it. Nearly a fourth in the suburbs and a fifth in the non-slum areas had to sell their land or gold to defray the expenses for treatment, while in the slums only a little more than a twentieth had to do so. A little over a fourth of the sick had to lose their wages also due to the illness. Thus the financial burden caused by morbidity on the poor appears to be substantial, calling for further investigation.

4.7.3 The Crude death rate for the sample is found to be 7, not much different from the figure of 6.4 for the state. A good number of people live longer than the average life expectancy of 72 for the state. Though the average age of death is 60, people in the slums die younger at about 56 against 64 in the non-slums. Geriatric ailments are, quite naturally, the most common cause of death. After that, the greatest killer is cardio vascular disease, accounting for about a fifth of the deaths. But in the slums this place is taken by suicides.

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V. Reproductive Health of Women

5.1 Introduction

5.1.1 India, the second most populous country in the world crossing the one billion mark in May 2000, is one of the first to introduce programmes to control the runaway growth of population. At the initiation of the programme in 1952 it was primarily a clinic-based family planning programme. This was transformed into an extension programme in 1963 integrating it with Maternal and Child Health care (MCH). 1992 saw the launching of the Child Survival and Safe Motherhood (CSSM) programme with greater emphasis on the reduction of maternal and infant mortality. Until 1996, a target-oriented approach was followed so as to maximise the level of family planning acceptance. After the International Conference on Population and Development (ICPD) in Cairo 1994 the Population Programme was given a different emphasis encompassing within its fold the entire reproductive and Child Health of Women and Men. The target-based approach has given way to the Community Needs Based Assessment in India. The programme of Reproductive and Child Health launched in 1996 puts this emphasis into practice. The New Population Policy adopted by the Indian Parliament in February 2000 outlines the strategy for achieving replacement level of fertility by 2010 and stabilisation of population by 2045 (GOI 2000). This Survey had, as one of its major components, questions about reproductive health status of 855 ever-married women between 15 and 49 years. Detailed probing was done into the status of their reproductive health starting from puberty and encompassing marriage, pregnancy, childbirth and contraception.


5.2 Menstrual Cycle

5.2.1 We began at the commencement of the reproductive health with questions on puberty. Table 5.1 shows the distribution of age at menarche of ever-married women between 15 and 49 years and adolescent girls by residential status.

Table 5.1 Age at Menarche (%)
Age Urban Suburban Total
Slum Non-slum
EMW AG EMW AG EMW AG EMW AG
Less than 11 0.7 18.2 0.5 41.5 0.5 17.8 0.6 22.0
11-12 23.0 58.5 24.2 48.8 22.5 43.9 23.1 54.4
13 and Above 76.3 20.8 75.3 9.8 77.0 39.0 76.3 22.1
Not Started 0.0 2.5 0.0 0.0 0.0 0.0 0.0 1.6
Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0
Number 456 159 190 41 209 41 855 241
Mean 13.3 12.5 13.1 11.6 13.2 12.9 13.3 12.4

Note: EMW: Ever Married Women (15-49 years)
AG: Adolescent Girls ( 13 – 18 years)

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5.2.2 One look at the table tells the story of age at menarche advancing with the passage of time. While only less than 1 per cent of the married women attained puberty before 11years, 22 per cent of the girls attained it at that time. This huge differential persists irrespective of the area of residence. This is probably due to the improved nutritional status of the girls compared to women. This presumption gets strength when we note that in the non-slum areas where the girls are likely to be better fed, 41.5 per cent of them attained puberty before 11 while it is about 18 per cent in the other two areas. More than half the girls attained puberty between 11 and 12, while more than three fourths of the married women attained it after 13. There is little difference among the areas in this. But the upper age in the case of slum women went up to 19 years, suburban to 18 years and non-slum to 17 years (data not shown). The mean figure for the married women and the girls reconfirms the fact of the latter attaining puberty earlier, the difference being about a year.

5.2.3 The next enquiry was about the regularity of menstrual cycle and the problems during their periods. Both ever married women and adolescent girls (AG) were separately asked about it. The responses are presented in Table 5.2

Tables 5.2 Regularity of Menstrual Cycle (%)
Regularity Urban Suburban Total
Slum Non-slum
EMW AG EMW AG EMW AG EMW AG
Regular 80.3 92.8 91.6 96.5 83.3 97.2 83.5 94.1
Irregular 19.7 7.2 8.4 3.5 16.7 2.8 16.5 5.9
Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0
Had Problem 8.8 23.6 6.8 29.0 8.6 11.2 8.3 22.2
No problem 91.2 76.4 93.2 71.0 91.4 88.8 91.7 77.8
Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0
Number 456 159 190 41 209 41 855 241

Note: EMW: Ever married Women ( 15- 49 years)
AG: Adolescent Girls ( 13- 18 years)

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5.2.4 As one would expect, with the advancement of age, more of the married women had irregular cycles than the girls. However, one common feature is that the irregularity is more in the slums than the other two areas, whether they are married women or adolescent girls. This is one indicator which would suggest that the female reproductive health status is lower in the slums. Irrespective of the regularity of the cycle, some women had problems associated with their periods. But about 92 per cent of the married women and 78 per cent of the girls had no problem. The non-slum areas lead the other two in this.

5.2.5 The majority of those with problems took some treatment as can be seen in Table 5.3.

Table 5.3 Treatment for Menstrual Problems (%)
Treatment Received Urban Suburban Total
Slum Non-slum
EMW AG EMW AG EMW AG EMW AG
Yes 60.0 20.1 76.9 27.3 44.4 0.0 59.2 20.4
No 40.0 79.9 23.1 72.7 55.6 100.0 40.8 79.6
Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0
Number 40 37 13 12 18 5 71 54

Note: EMW: Ever married Women ( 15- 49 years)
AG: Adolescent Girls ( 13- 18 years)

5.2.6 While only a fifth of the girls sought treatment for their menstrual problems, about 60 per cent of the married women did so. The suburban girls seem to take menstrual problems in their stride, with none going for treatment. Even among their women only 44.4 per cent went in for treatment. The facility they visited for treatment is dealt with in Chapter VIII.

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5.3 Marriage

5.3.1 The analysis of nuptiality and associated factors are important because age at marriage has an important bearing on family building activity and the level of fertility. Presumably, a rise in the marriage age shortens the reproductive span and implies a higher education before marriage. It is true that upward shift in marriage age depresses fertility level and increases average age of child bearing. One of the important factors responsible for high population growth rates in most of the developing countries today is the low level of age at marriage (Goyal, 1998). Age at marriage has been found to be the most significant determinant of declining fertility in Kerala (Zachariah, et al 1994). We tried to find out the age at marriage of wives and husbands. The results are in Tables 5.4 and 5.5.

Table 5.4 Age at Marriage of Wives (%)
Age of marriage Urban Suburban Total
Slum Non-slum
Less than 15 3.5 3.7 3.4 3.5
15-17 16.0 7.9 18.7 15.1
18 & 19 28.3 21.6 33.5 27.8
20-24 40.8 41.6 32.4 39.0
25-29 9.4 21.5 11.0 12.5
30+ 2.0 3.7 1.0 2.1
Total 100.0 100.0 100.0 100.0
Number 456 190 209 855
Median 19.7 21.5 18.7 19.1

5.3.2 The table shows that 18.6 per cent of the marriages have taken place in the study area even before the legal age of eighteen. This is higher in the slums at 19.5 percent, the highest being in the suburban area with 22.1 per cent. It is not a happy state of affairs that in spite of a fairly high degree of education among women, about a fifth of them contract marriages which are illegal. Three and a half percentage has got married below the age of 15 years among the three sample groups. This is less than the figure of 5 per cent for the state (NFHS -2) 15-19 years seems to be the most popular age for marriage for women, 42.9 per cent choosing it. This is only 29.5 per cent in the non-slum areas, while it is 52.2 per cent in the suburbs and 44.3 per cent in the slums, probably an effect of their higher education. We have seen in Table 3.6 that in the non-slum area more than half the women are matriculates and above, while in the other two areas they are only about 12 per cent. Only a small percentage got married at the age of 30 and above. On the whole the women in the suburbs get married very early as indicated in their median age at marriage, which is 18.7. The next comes the slums with 19.7. The non-slum women have a median age of 21.5 They are the only ones having a higher median age at marriage than the state for which the median is 20.2. The other two groups can however, take consolation in the fact that they have a higher median than the country’s, which is 16.4 according to NFHS –2.

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Table 5.5 Age at Marriage of Husbands (%)
Age of marriage Urban Suburban Total
Slum Non-slum
15-19 4.1 2.2 6.1 4.2
20-24 34.5 23.2 42.1 33.8
25-29 43.3 33.8 35.1 39.2
30-34 15.6 30.9 12.7 18.3
35-39 1.8 7.7 2.5 3.3
40+ 0.7 2.2 1.5 1.2
Total 100.0 100.0 100.0 100.0
Number 456 190 209 855
Median 25.8 28.1 24.7 25.9

5.3.3 The most popular age for marriage for men is 25 – 29 years, nearly 40 per cent of them getting married in that interval. However, this holds good only in the slums and non-slum areas with 43.3 per cent and 33.8 per cent respectively. In the suburbs the popular age is 20 – 24 years, more than 42 per cent getting married at that age interval. The non – slum areas show their preference for higher age at marriage among the men also, with about 10 per cent getting married after 35, while in the suburbs it is only 4 per cent and in the slums only 2.5.This is in tune with the general impression that age at marriage in the urban areas is high. At the all India level while urban men get married at 26.5 years, rural men get married at 24.2 years on an average (NFHS - 2) The median ages at marriage of husbands show the same relationship as in the case of wives. The present age of husbands and wives were also taken. But the tables are not given, as they do not seem to be of any material significance for our study. The median current ages of wives and of husbands are 23.5 and 38.7 respectively, showing a difference of about 15 years. (Table not given).

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5.4 Conception

5.4.1 The next question asked to ever-married women in the reproductive age was about their conception.

Table 5.6 Conception (%)
Whether Conceived Urban Suburban Total
Slum Non-slum
At least once 90.5 87.9 92.3 90.9
Not conceived 9.5 12.1 7.7 9.1
Total 100.0 100.0 100.0 100.0
Number 456 190 209 855

5.4.2 As can be seen in the table, 9.1 per cent of them did not conceive. Among the total number of women, 90.5 per cent had experienced at least one birth, 67.8 percent had two births and 28.2 had three births. Out of the total births, about 2 per cent were stillbirths. The incidence of stillbirths is slightly higher in the slums. Overall, no sex preference is observed in the distribution of live births irrespective of birth order (data not given.)

5.4.3 After enquiring about the onset of pregnancy, the next probing was about the incidence of abortions, both induced and spontaneous. Out of the sample of 855 women, 123 had abortions. Table 5.7 gives the details of abortions that occurred to ever-married Women.

Table 5.7 Abortions (%)
Abortion if any Urban Suburban Total
Slum Non-slum
Yes 12.3 15.8 17.7 14.4
No 87.7 84.2 82.3 85.6
Total 100.0 100.0 100.0 100.0
Number 456 190 209 855
Number of abortion
One 57.1 83.3 62.2 65.0
Two 39.3 10.0 32.4 30.1
Three 3.6 6.7 2.7 4.1
Four 0.0 0.0 2.7 0.8
Total 100.0 100.0 100.0 100.0
Number 56 30 37 123

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5.4.4One out seven women had at least one abortion in their lifetime. However among slum dwellers only one out of eight had it.

5.4.5 When it comes to the number of abortions, nearly two thirds of those who had abortions had only one. The non-slum areas take the lead in this with more than 83 per cent. In the non-slum area, the number of women who had more than one abortion is also quite less. Only three women there had two abortions and two had three. In the slum area, out of 56 women who had abortion, 22 had two abortions and two women had three.

5.4.6 Altogether 123 women had 173 abortions, implying an average of 1.4 abortions per woman. Forty-three of them had 2, six had 3 and one had 4 abortions. We did not find much difference in the months of occurrence of different order of abortions. Therefore all the abortions were put together in one table to show their months of occurrence.

Table 5.8 Months of Occurrence of Abortions (%)
Month Urban Suburban Total
Slum Non-slum
First 20.7 2.6 13.2 14.4
Second 36.6 44.7 26.4 35.3
Third 31.7 34.2 39.6 34.7
Fourth 6.1 10.5 9.4 8.1
Fifth 4.9 7.9 7.6 6.4
Sixth 0.0 0.0 3.8 1.1
Total 100.0 100.0 100.0 100.0
Number 82 38 53 173

5.4.7 Out of 173 abortions, 70 per cent have taken place in the second and third months of pregnancy. The fact that 6.4 per cent of the abortions took place in the fifth month should invite the concern of health providers. There were two abortions in the sixth month, one of it was first abortion and the other was the second for the same woman.

5.4.8 Information on the problems related to abortion shows that nearly 12 per cent had some kind of problems associated with it.

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Table 5.9 Problems Associated with Abortion (%)
Problems if any Urban Suburban Total
Slum Non-slum
Yes 16.1 3.3 13.5 12.2
No 83.9 96.7 86.5 87.8
Total 100.0 100.0 100.0 100.0
Number 56 30 37 123
Problems
Back pain 44.5 100.0 40.0 46.6
Lower abdominal pain 33.3 0.0 60.0 40.0
Excess Bledding 11.1 0.0 0.0 6.7
High Fever 11.1 0.0 0.0 6.7
Total 100.0 100.0 100.0 100.0
Number 9 1 5 15

5.4.9 Most of the women had no problems associated with abortion. Out of 123 who had abortions only 15 had problems, one in the non-slum area, 5 in the suburbs and 9 in the slums. In the problem cases 47 per cent had back pain. Three each in the suburbs and slums suffered from lower abdominal pain. One woman suffered from excessive bleeding and another from high fever.

5.4.10 The next probing was about any stillbirths they would have had. It came out that only 8.2 per cent of the sample had stillbirths.

Table 5.10 Stillbirths (%)
Still Birth Urban Suburban Total
Slum Non-slum
Yes 12.3 6.3 1.0 8.2
No 87.7 93.7 99.0 91.8
Total 100.0 100.0 100.0 100.0
Number 456 190 209 855

5.4.11 The proportion of women who had stillbirths is 12 percent in the slums, and 6 percent in non-slum areas. The higher proportion in the slums is perhaps an indication of the lower nutritional status of women, especially in the light of the fact that antenatal care was adequate among them as we see in the following section. The suburban women had the lowest number of stillbirths at 1 percent.

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5.5 The last Pregnancy

5.5.1 The ever-married women were questioned in detail about their last pregnancy. If they were pregnant at the time of questioning, the previous pregnancy was taken as the last.

5.5.2 Antenatal checkup refers to pregnancy related health care provided by a doctor or a health worker in a health facility or at home. The safe motherhood initiative proclaims that all pregnant women must receive basic, professional antenatal care. All pregnant women are expected to have physical check up before delivery. ANC can reduce maternal morbidity and mortality. A minimum of three checks up is recommended by the health department so as to ensure safe pregnancy and delivery.

Table 5.11 Antenatal Care (%)
Antenatal checkup during pregnancy taken Urban Suburban Total
Slum Non-slum
Yes 92.6 92.1 89.4 91.7
No 7.4 7.9 10.6 8.3
Total 100.0 100.0 100.0 100.0
Number 408 164 189 761

5.5.3 The table reveals that 92 per cent in the total had received ante-natal checkup during their pregnancy, the same per cent in the slums and non-slums and 89 per cent in the suburbs. As for the reasons for not going for check up see Table 5.12.

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Table 5.12 Reasons for Not Availing of ANC (%)
Reason Urban Suburban Total
Slum Non-slum
Lack of Knowledge of Service 30.0 0.0 5.0 15.9
Did not feel necessary 36.7 69.2 70.0 53.9
Not customary 0.0 7.7 0.0 1.6
Financial cost 30.0 15.4 10.0 20.6
Distantly located 0.0 7.7 0.0 1.6
Not permitted to go 0.0 0.0 10.0 3.2
Others 3.3 0.0 5.0 3.2
Total 100.0 100.0 100.0 100.0
Number 30 13 20 63

5.5.3 More than half the mothers who did not go for antenatal checkup felt it to be unnecessary. This points to the need for strengthening IEC activities in this area. About16 percent of them reported lack of knowledge of service as the reason, and nearly 21 per cent financial cost. Thirty per cent of the slum mothers reported lack of knowledge and another 30 per cent financial problems. It is important to note that two suburban women were not allowed to go for antenatal check up by their families. One in the non-slum area did not do antenatal check up, as it is not customary.

5.5.4 The survey further investigated the time of antenatal check up and its components. The timing of the visits for the antenatal care is given in Table 5.13.

Table 5.13 Timing of Antenatal Care (%)
Month of first ANC Urban Suburban Total
Slum Non-slum
First 7.4 9.3 10.7 8.6
Second 15.6 26.5 8.3 16.2
Third 38.6 48.3 45.0 42.3
Fourth 15.9 6.6 16.0 13.9
Fifth 11.9 4.7 13.5 10.8
Sixth 2.4 2.0 1.8 2.2
Seventh and above 8.2 2.6 4.7 6.0
Total 100.0 100.0 100.0 100.0
Number 378 151 169 698
Mean month of starting ANC 3.5 3.0 3.4 3.3

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5.5.5 More than 42 percent of the overall sample had their first visit for ANC in the third month of pregnancy, 48 per cent in the non-slums, nearly 39 per cent in the slums and 45 per cent in the suburbs. It speaks well of the awareness of the pregnant women that nearly a fourth of them had their first checkup before the end of the second month of pregnancy with some differences showing in the three areas. As one would expect, more expectant mothers in the non-slum area went earlier for checkup than in the other areas. However it is to be noted that even in the slums nearly two thirds of the expectant mothers had gone for checkup before the end of third month. The mean month of first ANC is 3 or 3 plus in all the areas. But about 23 per cent of slum women had started their antenatal visit in the fifth month only. This also calls for concerted action by the health providers among the underprivileged sections of the society.

5.5.6 The number of antenatal checks up and the timing of the first check up are important for the health of the mother and the outcome of pregnancy. The conventional recommendation for normal pregnancies is that once pregnancy is confirmed ante natal check up should be scheduled at four weeks intervals during the first seven months, then every two weeks until the last month and weekly thereafter (MacDonald and Pritchard, 1980). Four ante natal checks up, one each during the third, sixth and ninth month of pregnancy have been recommended as the minimum necessary (Park and Park, 1989). Table 5.14 provides the information on the number of visits for ANC.

Table 5.14 Number of Visits for ANC (%)
Number Urban Suburban Total
Slum Non-slum
1-3 9.3 4.6 9.5 8.3
4-6 31.5 12.6 33.1 27.0
7-9 46.3 30.5 46.7 43.0
10-12 12.2 36.4 6.5 16.1
13-15 0.5 15.2 3.6 4.4
16-18 0.2 0.7 0.6 0.3
Total 100.0 100.0 100.0 100.0
Number 378 151 169 698
Mean 6.9 9.5 6.7 7.4

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5.5.7 Forty three percent of the expectant mothers had between 7 and 9 visits, but in the non-slum area more than 36 per cent had 10 to 12 visits. The proportion that had only 1 to 3 visits is very low at 8.3 per cent in the overall sample and more than 9 in the slums and suburbs. Twenty seven per cent of all the expectant mothers had 4 to 6 visits. More than 12 visits are rare, coming to less than 5 per cent; but quite high at 15.2 per cent in the non-slums. The mean visits are high for non-slum women than the other two areas.

5.5.8 Regarding the components of ANC, we asked the mothers about four items, namely measuring the weight, checking the blood pressure, administering iron and folic acid tablets and tetanus toxoid injections. The responses are presented in Table 5.15.

Table 5.15 Components of ANC (%)
Weight measured Urban Suburban Total
Slum Non-slum
Yes 90.5 92.7 91.7 91.3
No 7.7 7.3 8.3 7.7
Don't remember 1.8 0.0 0.0 1.0
Blood Pressure checked or not
Yes 90.5 92.7 91.7 91.3
No 7.7 7.3 7.1 7.7
Don't Remember 1.8 0.0 1.2 1.0
Iron Folic Acid Received or not
Yes 98.4 100.0 98.8 98.9
No 1.6 0.0 1.2 1.1
TT Injection
Yes 91.6 91.1 92.3 91.5
No 8.4 8.9 7.7 8.5
Total 100.0 100.0 100.0 100.0
Number 378 151 169 698

5.5.9 It can be seen that most of the expectant mothers who went for checkup had all the four components done. More than 91 per cent had weight and blood pressure taken, nearly 99 per cent were given iron and folic acid tablets and 91.5 per cent had anti-tetanus injections. Very little differential is noticed among the three areas.

5.5.10 When we come to the breakup of the components, we see the number of iron and folic acid tablets and TT injections given in Table 5.16.

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Table 5.16 Intake of Iron and Folic Acid Tablets and TT (%)
Number of Tablets Urban Suburban Total
Slum Non-slum
10-50 tablets 22.5 14.3 23.6 20.8
51-100 tablets 65.7 60.7 54.3 62.1
101-150 tablets 3.7 15.0 10.7 8.0
151-200tablets 4.1 10.0 5.3 5.6
201 and above 4.0 0.0 6.1 3.5
Total 100.0 100.0 100.0 100.0
Number 372 151 167 690
Number of TT Injection given
One 2.4 1.4 5.0 2.8
Two 24.2 23.4 26.2 24.5
Three 71.8 75.2 67.4 71.5
Four Times 1.5 0.0 1.4 1.2
Total 100.0 100.0 100.0 100.0
Number 378 151 169 698

5.5.11 Sixty two per cent of the expectant mothers had between 50 and 100 tablets of iron and folic acid and 71.5 per cent had 3 TT injections. It may be borne in mind that the requirement is 100 tablets and at least two TT injections. The area wise figures show that the highest was in the non-slum areas followed by slums and suburbs.

5.5.12 The expectant mothers were asked about the health problem they had during pregnancy. The result is in Table 5.17.

Table 5.17 Problems During Pregnancy (%)
Problem Urban Suburban Total
Slum Non-slum
Yes 9.9 6.5 11.3 9.5
No 90.1 93.5 88.7 90.5
Total 100.0 100.0 100.0 100.0
Number 378 151 169 698

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5.5.13 Nearly 91 per cent did not have any health problem. However 11.3 per cent in the suburbs and nearly 10 per cent in the slums had some problems. The nature of the problem is given in Table 5.18.

Table 5.18 Nature of the Problem During Pregnancy (%)
Nature of Problem Urban Suburban Total
Slum Non-slum
High B.P. 27.0 60.0 14.2 29.5
Bleeding 32.4 20.0 42.8 32.8
Pain in the abdomen 8.1 0.0 0.0 4.9
Urinary infection 0.0 10.0 7.3 3.3
Vomiting 16.2 0.0 14.2 13.1
Suffocation 8.1 0.0 14.2 8.2
Associated with contraception failure 8.1 10.0 7.3 8.2
Total 100.0 100.0 100.0 100.0
Consulted Doctors/Health workers 85.7 100.0 87.5 88.5
Number 37 10 19 66

5.5.14 As can be seen from the table, nearly a third of those who had problems had bleeding and about 30 per cent high blood pressure. The latter occurred to 60 per cent of the sample in the non-slum areas. All of them in the non-slums consulted doctors or health workers and less than 90 per cent in the slums and suburbs.


5.6 Delivery

5.6.1 As far as delivery is concerned, the most important question was if it took place in an institution or at home. Table 5.19 shows that 93.4 per cent of the deliveries took place in the institutions. This is the same figure for the State as a whole as revealed in NNFHS -2. However the corresponding all India figure is only 34 per cent (IIPS &ORC Macro 2001).

Table 5.19 Place of Delivery
Place of Delivery Urban Suburban Total
Slum Non-slum
Institution 90.9 96.1 96.2 93.4
Home 9.1 3.9 3.8 6.6
Total 100.0 100.0 100.0 100.0
Number 378 151 169 698

5.6.2 In the slums institutional deliveries are 91 per cent, in the suburbs and non-slums 96 per cent. It is a matter of concern that in the slums, 9.1 per cent of the deliveries took place at home.

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5.6.3 However nearly 61 per cent of the home deliveries in the slums were attended by trained personnel such as doctor, nurse, ANM and Trained Birth Attendant (TBA). Only 23 per cent of the home deliveries in slums were attended by relatives and friends, whereas it was 50 per cent in the non-slum area.

Table 5.20 If Home Delivery, Who Attended
Attended by Urban Suburban Total
Slum Non-slum
Doctor 39.3 0.0 0.0 33.3
Nurse/ANM 12.5 0.0 0.0 10.6
TBA 8.9 50.0 0.0 12.1
Untrained TBA 16.1 0.0 0.0 13.6
Relatives/ Friends 23.2 50.0 100.0 30.3
Total 100.0 100.0 100.0 100.0
Number 34 6 6 46

5.6.4 Regarding the nature of the delivery, 83 per cent had natural delivery with very little variation among the three areas. The remaining 16.6 needed some assistance.

Table 5.21 Nature of Delivery and Problems (%)
Nature of Delivery Urban Suburban Total
Slum Non-slum
Normal 82.0 83.0 87.3 83.4
Assisted 18.0 17.0 12.7 16.6
Total 100 100 100 100
Problem during delivery
Yes 11.4 7.8 12.5 10.8
No 88.6 92.2 87.5 89.2
Total 100.0 100.0 100.0 100.0
Number 378 151 169 698

5.6.4 Of the total deliveries, 10.8 per cent had some medical problems, 12.5 per cent in the suburbs, 7.8 per cent in the non-slums and 11.4 in the slums.

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5.6.5 The largest group (31 per cent) had the problem of premature labour. None in the non-slum area had it, while 42 per cent in the slums and 15 per cent in the suburbs suffered from this problem. Prolonged labour was the next, covering nearly 24 per cent.

Table 5.22 Nature of the Problems During Delivery (%)
Nature of the Problem Urban Suburban Total
Slum Non-slum
Premature labour 42.2 0.0 15.0 30.9
Obstruced labour 7.8 15.4 5.0 8.3
Prolonged labour 20.3 30.8 30.0 23.7
Breach presentation 7.8 23.1 25.0 13.9
Excessive bleeding 14.1 7.7 10.0 12.4
Umbilical cord around neck 1.6 0.0 0.0 1.0
B.P. 6.2 23.1 15.0 10.3
Total 100.0 100.0 100.0 100.0
Number 43 11 21 75

5.6.6 The outcome of the last pregnancy is shown in Table 5.23.

Table 5.23 Outcome of the Last Pregnancy (%)
Outcome Urban Suburban Total
Slum Non-slum
Live Birth 97.8 91.6 96.5 96.1
Still Birth 1.0 1.1 0.5 0.9
Induced Abortion 0.5 2.8 1.0 1.1
Spontaneous Abortion 0.7 4.5 2.0 1.9
Total 100.0 100.0 100.0 100.0
Number 417 179 196 792

5.6.6 Outcome of the last pregnancy shows that 96 per cent ended in live births, nearly one per cent ended in stillbirth, another one per cent in induced abortion and two per cent in spontaneous abortion. It is noticed that the non-slum women had more induced abortions than the others. It may be noted that the data here is only about the last pregnancy whereas the data previously given about abortions and stillbirths pertain to all women in the reproductive age group.

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5.6.7 We asked those who had induced abortions why they did so. The answers are given in Table 5.24.

Table 5.24 Reasons for Termination of Last Pregnancy (%)
Reasons Urban Suburban Total
Slum Non-slum
Child is too young 50.0 60.0 0.0 44.4
Can't afford another child 50.0 40.0 100.0 55.6
Total 100.0 100.0 100.0 100.0
Number 2 5 2 9

5.6.8 The table shows that 60 per cent of the non-slum women had done it because their child was too young. Five of the nine women who had terminated their last pregnancy did it due to the fact that they could not afford another child.

5.6.9The month at which the last pregnancy was terminated is in Table 5.25.

Table 5.25 Month of Termination of Pregnancy (%)
Month in which terminated Urban Suburban Total
Slum Non-slum
One 50.0 0.0 50.0 22.2
Two 0.0 20.0 50.0 22.2
Three 0.0 20.0 0.0 11.1
Four 50.0 40.0 0.0 33.3
Five 0.0 20.0 0.0 11.1
Total 100.0 100.0 100.0 100.0
Number 2 5 2 9

5.6.10 It shows that 60 per cent of the non-slum women had terminated their last pregnancy at fourth month or onwards and 40 per cent terminated it in the second and third month of gestation. One woman in slum did it in the fifth month of gestation. Only two women (one in non slum and one in slum) reported that they had some problem related to termination of pregnancy. However, the sample is too small to attempt any inferences. The non-slum woman suffered from excessive bleeding and the slum woman suffered from back pain/body pain. Only one of the two went for treatment (data not given).

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5.7 Current Pregnancy

5.7.1 Besides asking the ever-married women about their last pregnancy we also asked if any were pregnant at the time of the survey. Thirty of the samples of 855 were pregnant, 20 in the slums and five each in the other areas. We asked them if they had antenatal check up. The result is in Table 5.26.

Table 5.26 ANC of Current Pregnancy (%)
Whether consulted for checkup Urban Suburban Total
Slum Non-slum
Yes 90.0 80.0 100.0 90.0
Number of checks up
1-2 22.2 50.0 80.0 37.0
3-4 33.3 0.0 0.0 22.2
5-6 38.9 25.0 20.0 33.3
Above 6 5.6 25.0 0.0 7.4
Month of first check up
1st Month 44.4 50.0 80.0 51.9
2nd Month 16.7 25.0 20.0 18.5
3rd Month 27.8 25.0 0.0 22.2
4th Month 5.6 0.0 0.0 3.7
5th Month 5.6 0.0 0.0 3.7
Taken T.T. Injection or not
Yes 65.0 40.0 40.0 56.7
How many T.T. Injections
One 30.8 0.0 100.0 35.3
Two 53.9 100.0 0.0 52.9
Three 15.4 0.0 0.0 11.8
Total 100.0 100.0 100.0 100.0
Number 20 5 5 30

5.7.2 All the suburban women and 90 and 80 per cent of the slums and non-slums had had their checks up. Regarding the number of checks up, 50 per cent of the non-slum women, 80 per cent of the suburban women and 22.2 per cent of the slum women had 1-2 checks up. About a third of the slums had 3-4 checks up. Taking up the month in which they had gone for consultation, 50 per cent of the non-slum women, 80 per cent of the suburban and 44.4 per cent of the slum have had their check up at the first month of their pregnancy.

5.7.3 Among the pregnant women, 40 per cent each in the non-slum and suburban had taken T.T. injection and 65 per cent in the slums. All of them in the non-slum area took two TT injections and all of suburban region had one dose, while in the slum, 30.8 per cent had taken one injection, 53.9 per cent two injections and 15.4 per cent three injections.

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5.8 Contraceptive Use

5.8.1 In the early years of the population programme in India, the most popular contraception was vasectomy. As female sterilisation came into vogue, the use shifted to that, nearly two thirds of current contraception in India depending on it (IIPS & ORC Macro 2000).

5.8.2 The focus of this section is our enquiry into various aspects of contraceptive practice adopted by currently married women like current and previous use of contraception, duration of use, reasons for non-use, discontinuation, etc.

5.8.3 Of the total 813 currently married women, 30 are pregnant and thus have no need for contraception at the time of the survey. Table 5.27 shows the percentage distribution of the others by current use of contraception.

Table 5.27 Contraceptive Prevalence (%)
Status Urban Suburban Total
Slum Non-slum
Current Users 61.2 48.9 65.1 59.4
Non-users 38.8 51.1

34.9

40.6
Total 100.0 100.0 100.0 100.0
Number 415 176 192 783

5.8.4 Of the 783 women who constitute the potential for the need for contraception, 59.4 per cent have adopted it. This Contraceptive Prevalence Rate of 59.4 per cent is lower than the prevalence rate of 66 per cent in the urban areas of the state as revealed in NFHS -2 (IIPS & ORC Macro 2001). But it is noteworthy that the prevalence rate in the slums (61.2 per cent) is higher than non-slum areas (48.9), and that the highest is in the suburbs (65.1). This speaks well of the awareness of the women in the poorer sections of the society.

5.8.5 When we probed the reasons for nonuse of contraception, the answers we obtained are presented in Table 5.28.

Table 5.28 Reasons for Non Use of Contraception (%)
Reasons Urban Suburban Total
Slum Non-slum
Want children 58.6 65.5 76.0 64.8
Desire for male child 6.8 8.9 6.0 7.2
Desire for female child 6.8 6.7 3.0 6.0
Fear about operation 3.1 2.2 0.0 2.2
Fear about side effects 10.6 10.0 3.0 8.8
Costs too much 0.0 4.4 3.0 1.9
Youngest too young 10.6 0.0 3.0 6.0
None to care after 1.2 0.0 0.0 0.6
eligious objection 1.2 2.2 6.0 2.5
Total 100.0 100.0 100.0 100.0
Number 161 90 67 318

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5.8.6 Two thirds of the women do not use contraception because they want children. Probably this answer is given by those who do not have any children yet or the desired number. What is significant in this table is that only 7.2 per cent gave the desire for a male child as the reason. This is matched by 6 per cent who want a female child. This is another proof to the fact that there is no significant sex preference for children in the state, unlike in the rest of the country where stories of female foeticide abound, in spite of the law against sex determination of foetus. Nearly 9 per cent cited the fear about side effects as the reason. There is need for health workers to play a better role in doing away with this fear.

5.8.7 We probed the popularity of the different methods of contraception. The distribution of women by the method used is given in Table 5.29.

Table 5.29 Current use of Contraceptive Method (%)
Reasons Urban Suburban Total
Slum Non-slum
Female Sterilisation 97.6 94.1 96.0 96.6
IUD 0.8 1.2 1.6 1.1
Oral pill 0.0 0.0 0.8 0.2
Condom 0.0 2.3 0.8 0.6
Rhythm/ Periodic abstinence 1.6 2.3 0.8 1.5
Total 100.0 100.0 100.0 100.0
Number 254 86 125 465

5.8.8 Among the current users 98.5 per cent are using methods like sterilisation, IUD, oral pills and condoms, which are, classified as modern methods. Female sterilisation is the most popular method, with 96.6 per cent of the women preferring that. It is much higher than the preference of 76 per cent by the women users in the state and 71 per cent in the country (IIPS &ORC Macro 2001). This preference is the highest in the slums at 97.6 per cent followed by the suburbs with 96 per cent. In the non-slum areas there are some couples, though very few, preferring IUD, condoms and rhythm, which are quite unpopular in the slums and suburbs. It is not surprising that the poorer couples in the slums and suburbs opt for a terminal method. This is in tune with the NFHS–2 data for the state, which showed an inverse relationship between standard of living and preference for female sterilisation (IIPS & ORC Macro 2001).

5.8.9 Sterlisation is not only popular but also being adopted at an early age as seen in Table 5.30.

Table 5.30 Women’s Sterilisation by Age (%)
Age Urban Suburban Total
Slum Non-slum
<19 4.4 3.7

5.0

4.4
20-24 43.1 33.3 41.6 41.0
25-29 32.7 44.4 40.0 36.7
30-34 10.9 17.3 10.0 11.8
35-39 6.5 1.2 1.7 4.2
40-44 2.4 0.0 1.7 1.8
Total 100.0 100.0 100.0 100.0
Number 248 81 120 449
Mean 23.7 25.9 24.0 24.1

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5.8.10 It shows that 82 per cent of those who adopted sterlisation are less than 30 years old with not much difference in the three areas. A greater proportion of women in the slums (43.1 per cent) and the suburbs (41.6 per cent) belong to the age group of 20–24, while in the non-slums 44.4 per cent belong to the age group of 25–29. This confirms the impression that the poor sections go for terminal methods very early in their reproductive span. This impression gets reinforced when we look at the mean age of sterilisation, which is 23.7 and 24 in the slums and suburbs respectively, whereas it is 25.9 in the non-slum areas.

5.8.11 The current users were also asked about their previous use of contraceptive methods. The response is given in Table 5.31.

Table 5.31 Previous Use of Contraceptives by Current Users (%)
Method Urban Suburban Total
Slum Non-slum
IUD 95.0 50.0 83.3 82.4
Oral pill 5.0 12.5 0.0 5.9
Condom 0.0 0.0 16.7 2.9
Rhythm/ Periodic abstinence 0.0 12.5 0.0 2.9
Withdrawal 0.0 25.0 0.0 5.9
Total 100.0 100.0 100.0 100.0
Number 20 8 6 34

5.8.12 The most important information from the table is that out of the 465 current users, only 34 (7.3 per cent) had any previous experience of contraception. This implies that most of the women (92.7 per cent) go for the terminal method of sterilisation as soon as the need for preventing further birth is felt. There is some slight variation in the three regions in the proportion of women who used contraception previously, it being 7.9 per cent in the slums, 9.3 in the non-slums and 4.8 in the suburbs (not in the table). The interesting point is that 82.4 per cent of the previous users had preferred IUD. The pattern appears to be that most of the women go for female sterilisation as soon as they feel the need for limiting the family size and most of the others try out IUD first and then opt for sterilisation. However, there is some preference for oral pill and rhythm in the non-slum areas and for condoms in the suburbs among previous users.

5.8.13 This surmise can be further verified if we look at the age of women who used contraception previously

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Table 5.32 Age of Women Who Used Contraception Previously (%)
Age Urban Suburban Total
Slum Non-slum
<19 5.0 0.0 0.0 2.9
20-24 60.0 50.0 66.6 58.9
25-29 35.0 37.5 0.0 29.4
30-34 0.0 12.5 16.7 5.9
35-39 0.0 0.0 16.7 2.9
Total 100.0 100.0 100.0 100.0
Number 20 8 6 34

5.8.14 It can be seen from this table that those between 20 and 24 years who did not directly go for sterlisation but tried out a temporary method first are more in the poorer areas of the slums and suburbs.

5.8.15 We can also check how long the women used temporary methods before coming to the terminal method in table 5.33

Table 5.33 Duration of Previous Use of Temporary Methods (%)
Duration Urban Suburban Total
Slum Non-slum
One month 0.0 5.0 0.0 2.9
Two month 0.0 5.0 0.0 2.9
Three month 12.5 5.0 16.7 8.9
One year 12.5 25.0 16.7 20.6
Two year 37.5 15.0 33.3 23.5
Three year 25.0 35.0 33.3 32.4
Four year 12.5 5.0 0.0 5.9
Five year 0.0 5.0 0.0 2.9
Total 100.0 100.0 100.0 100.0
Number 8 20 6 34
Mean months 24.9 25.9 21.5 24.5

5.8.16 This table adds one more element to the story, namely, that most women who used temporary methods prior to sterlisation try it out for a period of three years. It has to be remembered that the effect of an IUD insertion would normally last for five years. The IUD users seem to be discontinuing it before the end of its effective period.

5.8.17 When it comes to the reasons for abandoning the previous use, the desire to have another child stands out as the most prominent.

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Table 5.34 Reasons for Discontinuation of Contraceptive Method by Previous Users (%)
Reasons Urban Suburban Total
Slum Non-slum
Effectiveness over 15.0 0.0 16.7 11.8
Want next child 40.0 75.0 33.3 47.0
Side effects 30.0 12.5 33.3 26.5
Became pregnant 5.0 0.0 16.7 5.9
Bleeding 10.0 12.5 0.0 8.8
Total 100.0 100.0 100.0 100.0
Number 20 8 6 34

5.8.18 The next major reason is side effects, which 26.5 per cent reported. This is an important pointer. Did the IUD users remove the insertion prematurely because of the side effects? But it is worth pursuing this question, as it will point to the effectiveness of IUD as a contraceptive. Though the size of the sample here is very small, it throws some light on the behaviour of contraceptive use of the women who currently have adopted contraception, mainly sterilisation.


5.9 Source of Motivation

5.9.1 Motivation and it source are important factors in the realm of family planning programmes. The data on the sources of motivation of contraception from our sample are presented in Table 5.35.

Table 5.35 Distribution of Women by Source of Motivation (%)
Source Urban Suburban Total
Slum Non-slum
Self 57.7 63.0 66.1 61.0
Husband 33.6 29.8 26.6 30.9
Relatives 3.7 3.6 2.4 3.3
Friends 2.9 1.2 4.0 2.9
Doctor/ANM/Health worker 2.0 1.2 0.8 1.6
Media 0.0 1.2 0.0 0.2
Total 100.0 100.0 100.0 100.0
Number 254 86 125 465

5.9.2 It speaks highly of the women’s awareness of the need to limit the size of families that most of them (61 per cent) were motivated by their own desire, slightly less in the slums. We have seen in Chapter III that most of them have a fairly high level of education. Approximately 31 per cent of the women were motivated by their husbands, more in the slums than in the other two areas. Thus the decision to go in for contraception mostly ends in the family, the husband and wife taking it together in about 92 per cent of the cases. It is to be noted that motivation by the health staff is only 1.6 per cent.

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5.10 Summary

5.10.1 On the whole we see a fairly good status of reproductive health among the sample women. It is only slightly lower in the slums and suburbs than the non-slum areas of the city. Starting with menstrual cycle we note that there is not much of a difference in the age at menarche. However, so far as the regularity of menstrual cycle is concerned, more women have irregular cycles in the slums and suburbs than in the non-slum areas. Though the number of women with problems in their periods is very small in the three regions, more of them in the non-slums go for treatment. Regarding the age at marriage comparatively more women in the slums and suburbs get married before the legal age of 18. Generally, women in these two areas get married earlier than in the non-slum areas. The median age of women is, obviously higher in the non-slum areas, that is, 21.5 years, as against 19.7 and 18.7 respectively in slums and suburbs.

5.10.2 There is not much difference in the number of conceptions among women in the three areas. But abortions, whether spontaneous or induced, are highest in the suburbs followed by the non-slums. But among those who had abortions, a higher number of women in the slums had more than one. In the timing of abortion the suburban women are worse off than in the other areas with the number in the fourth, fifth and sixth months higher. More women in the slums and suburbs had problems with abortion than in the non-slums. But in the matter of stillbirths, the suburban women have the lowest problems. It is a matter of concern that the outcome of one eighth of the pregnancies in the slums ended in stillbirths.

5.10.3 Antenatal check up is a widely prevalent practice in all the three areas, though slightly less in the suburbs. The very few who did not avail themselves of ANC cited lack of knowledge of the service and not feeling the need as the major reasons. In the timing of ANC and its components there is not much difference among the areas. But in the number of visits non-slums take the lead with an average of 9.5 over the others with about 7. It is to be noted that it is in the slums that the least number experienced problems with their pregnancies.

5.10.4 Institutional delivery appears to be the norm, with only 6.6 per cent taking place in the homes. This is higher in the slums. However, the saving grace is that the home deliveries in the slums were mostly attended by doctors or other trained personnel. Most deliveries were normal in all the three areas. But more in the slums and suburbs had medical problems like premature or prolonged labour.

5.10.5 As far as the outcome of the last pregnancy is concerned, most of them had live births in all the areas. But induced and spontaneous abortions were more in the non-slums. Talking about current pregnancy, it is noteworthy that it is the suburbs that take the lead in going for ANC, followed by the slums.

5.10.6 Thus the slum women are not behind the others in matters of reproductive health. In fact in the matter of current use of contraception they fare even better. More women in the slums and suburbs are current users than in the non-slums. Most of the non-users gave desire for children as the reason. There is very little gender preference for children in our study area. Most of the women have adopted a permanent method of sterilization as in the rest of the state and country. Only a very small proportion of these women had used contraception previously. Among those who had, there was a preference for IUD. Other temporary methods are popular only in the non-slum areas with a small proportion preferring condoms in the suburbs. The terminal method is adopted by more women in the slums and suburbs before the age of twenty-four, whereas the popular age in the non-slums is between 25 and 29. The decision to adopt contraception seems to be taken between the wife and husband, the former getting self-motivated in a majority of the cases.

5.10.7 The picture that we get is of a set of women who are quite aware of their reproductive health needs and who get the needs met when they decide. . But the slum and suburban women are slightly behind their better educated counterparts in the non-slums in a few aspects, though in the use of contraception they are ahead.

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VI. Child Health

6.1 Introduction

6.1.1 Child Health is one of the key indicators of the health status and quality of life of a country. In most of the developing countries, the level of child health is not satisfactory as indicated by high deaths among infants and children below five years, which constitute half of the total deaths in these countries. Hence improvement of child health is an important aspect of any country’s health care system. The most quoted indicator of child health is infant mortality rate. While it has steadily improved for the country to 68 per thousand from 112 in, the States other than Kerala have to go a long way to reach its figure of 16. In the matter of child mortality (under 5) also the state leads with 18.8 per thousand whereas the country lags behind with 94.9 (Misra et al, 2001).

6.1.2 We have seen in Chapter V that most of the deliveries in the study area take place in the hospitals and even when it takes place in the homes it is mostly attended by doctors or trained paramedical personnel. This ensures, to a great extent, the survival of the mother and child. Out of 792 last pregnancies in our sample, 24 ended in abortions either induced or spontaneous and 7 in still births. Thus the sample size of children we have is 761.


6.2 Birth Weight

6.2.1 The first point of enquiry was about the weight of the baby, whether it was taken and, if so, whether there were low birth weight babies. The results are presented in Table 6.1.

Table 6.1 Birth Weight (%)
Birth weight taken Urban Suburban Total
Slum Non-slum
Yes 87.9 94.1 93.3 90.6
No 12.1 5.9 6.7 9.4
Weight of the Baby
< 2500 gram 29.0 18.6 39.4 29.1
2500-2999 > 44.8 36.3 29.1 39.0
3000-3499 17.8 27.4 17.0 19.9
3500 and above 8.5 17.7 14.6 12.0
Total 100.0 100.0 100.0 100.0
Number 408 164 189 761

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6.2.2 The birth weight was taken for most of the children immediately after the birth. This is not surprising as institutional deliveries are the norm. But in the urban areas of the state all babies born within three years prior to 1998-99 were weighed according to NFHS - 2, a great improvement on 76 per cent of NFHS – 1 of 1992-93. Thus the figure is lower in the city. It is no consolation that in urban India only 60 per cent was weighed, according to NFHS II – 2 (IIPS & ORC Macro 2000 and 2001 and IIPS – 1995). The figure is even lower in the slums with 88 per cent.

6.2.3 Low birth weight is a major cause of childhood morbidity and mortality. The desired minimum birth weight being 2500 grams, the proportion of low birth weight babies is 29.1 per cent. This is higher than the figure for Kerala, which was estimated to be 13 per cent by KSSP (Kunhikannan and Aravindan–2000). 18 per cent by NFHS – 2 (IIPS & ORC Macro 2001). In our study only the non-slum data agrees with the state data. In the other two areas the percentage of LBW babies seems to be much higher than the state figure and even the figure of 21 per cent for urban India (IIPS & ORC Macro 2000). It is alarmingly high at 39.4 per cent in the suburbs. This is a matter of concern and calls for immediate intervention. However it would appear that no intervention is possible in this regard. Ramankutty (2001) who conducted an exploratory study about the reasons for the high prevalence of low birth weight babies in Kerala supported the assumption that the demographic causes of LBW such as teenage pregnancies, high birth order (beyond three), very short birth interval and pregnancy among elderly women have been eliminated on account of the demographic transition that has taken place in the state. He concludes that the principal risk factors relate to the mother’s nutritional status before pregnancy: her weight and height, the tendency of first born children carrying an inherent chance for LBW, premature birth etc. are the possible reasons. Therefore long term measures are required to improve the nutritional status of adolescent girls and eliminate the causes of premature delivery.


6.3 Breast Feeding

6.3.1 The next question was about the practice of breast feeding. The responses are presented in Table 6.2.

Table 6.2 Details Regarding Breast Feeding (%)
Breast Feeding Started Urban Suburban Total
Slum Non-slum
Same day 95.0 96.1 95.2 95.3
1-3 days 3.1 3.3 3.0 3.1
No breast feeding 2.0 0.6 1.8 1.6
Whether feeding at present
Yes 1.9 0.6 2.4 1.8
Duration of breast feeding
Less than 12 months 14.2 14.4 15.4 14.3
12-17 months 2.0 0.0 0.6 1.2
18-23 months 72.2 83.0 77.2 74.8
24-29 months 10.2 2.6 6.8 7.5
30+ months 1.4 0.0 0 0.7
Total 100 100 100 100
Number 408 164 189 761

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6.3.2 Breast feeding appears to be the norm with more than 95 per cent of the mothers doing it the same day. According to NFHS -2, only 42.9 per cent of the mothers in the state and 15.8 per cent in the country started breast feeding the child within one hour of birth. However those who started the same day is 92 per cent in the state and 37.1 per cent in the country (NFHS-2). Thus there is not much difference between the state and the city whether it is the slums, the non-slum areas or the suburbs. Adding those who started it within three days of birth, it comes to 98.4 per cent. Little difference is noticed between the areas.

6.3.3 Regarding the durations of breast feeding two years appears to be the most popular one with nearly 75 per cent of the mothers breast feeding their babies for that period. More mothers in the non-slum areas did so. However the proportion of mothers stopping at one year is not very small, it being a little over 14 per cent. There are more mothers in the slum than in the other two areas who breastfed their babies for more than two years.


6.4 Immunisation

6.4.1 In India, child immunisation is an important component of child survival programme. The National Policy Document of children accepts the responsibility of the State to children both before and after birth and during the period of growth to ensure their full physical, mental and social development. The Expanded Programme of Immunisation was started in 1978 with the objective of providing free immunisation services to all eligible children and expectant mothers. Immunisation against polio was introduced in the programme in 1979-80. BCG immunisation against Tuberculosis was also brought under the Expanded Programme of Immunisation in 1981-82. The latest addition to the programme was vaccination against measles in 1985-86. In order to step up the pace of immunisation, the Universal Immunisation Programme was introduced in 1985-86 and is being implemented in the state through the existing network of the primary health care system.

6.4.2 An important means of improving the survival of young children consists of immunising them against the principal child diseases – tuberculosis, diphtheria, pertussis, tetanus, poliomyelitis and measles. Hence, it would be significant to study in this survey the immunisation services utilised by the children of the sample households.

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6.4.3 One dose of BCG and measles vaccines and three doses of polio and DPT vaccines are needed to establish immunity to the above major childhood diseases. BCG Vaccination protects children against tuberculosis. This vaccination is given at birth or at six weeks. DPT is administered in 3 doses at 45 days interval from birth. This protects them against diphtheria, pertussis and tetanus. To protect the children against poliomyelitis Oral Polio Vaccine (OPV) is given at birth as zero dose and three times later every 45th day. Antimeasles vaccine is given in the ninth month. The latest wisdom is that a child can be considered fully immunised only if he has been given all the prescribed doses and the booster doses which for polio and DPT goes on till the fifth year. This means that only after 5 years of age we can assess the immunisation status. However the primary immunisation is completed by the ninth month by which time the measles vaccine and all the doses of polio and DPT vaccines are given, except the booster doses.

6.4.4 Generally the surveys of immunisation status are about the primary immunisation only and for that they cover all the children from 12 to 24 months. They exclude the 0-12 months age group since most of them would not have completed all the required doses. However, we decided to capture the details of partial coverage of immunisation also in the study area by including children of 0-12 months. We collected information on whether each living child within the age group of 0-24 months ever received a vaccination during the reference period. There were 95 children in this age group. The details were obtained either from the immunisation cards available or from the statements of the respondents.

6.4.5 For finding out the full coverage of primary immunisation we grouped the children into two categories, those below 9 months and those above as the ninth month is the cut off point for completing all the doses of primary immunisation. Table 6.3 gives the immunisation coverage of all children in the age group of 9-24 months. There were 73 children in this group. Children were classified as fully immunised if all available vaccines in the required doses were received.

Table 6.3 Distribution of Children (9–24 months) by Immunisation Coverage (%)
Immunised Urban Suburban Total
Slum Non-slum
Full 72.2 68.8 66.7 69.9
Partial 27.8 31.2 33.3 30.1
Total 100.0 100.0 100.0 100.0
Number 36 16 21 73

6.4.6 From the table it can be seen that, only 70 per cent of the children in the age group of 9-24 months have been fully immunised. According to NFHS-2, 79.7 per cent of children between 12 and 23 months in Kerala have received all doses of all vaccines. This variation can be explained partly by the difference in the age group considered here.

6.4.7 When it comes to partial immunisation the picture is shown in table 6.4.

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Table 6.4 Immunisation Status (%)
Status Urban Suburban Total
Slum Non-slum
BCG 96.3 100.0 100.0 97.9
DPT 1st Dose 59.2 78.9 79.2 68.0
2nd Dose 59.2 78.9 79.2 68.0
3rd Dose 48.1 57.9 58.3 52.6
POLIO 1st Dose 75.9 89.5 87.5 81.4
2nd Dose 75.9 89.5 87.5 81.4
3rd Dose 74.1 78.9 83.3 77.3
Measles 90.7 94.7 91.7 91.7
Number 53 18 24 95

6.4.10 All the children had received BCG Vaccination except 2 in the slum. Thus BCG vaccination is almost complete. It may be due to the fact that it is a single dose and is administered soon after birth. Even then in the state only 96.2 per cent of the children have received BCG and in the country 71.6 per cent (IIPS and ORC Macro 2001).

6.4.8 DPT is administered in 3 doses. Only 52.6 per cent of the children in the age group 0-24 months have received all the three. But about 68 per cent have received two doses. It is reasonable to assume that they will receive the final dose as they age.

6.4.9 However in the case of Polio, more than 77 per cent are fully immunised. Government of India in 1995 introduced Pulse Polio Immunisation for achieving total eradication of poliomyelitis from India by 2000. It envisaged the administration of oral polio vaccine to all children 0-3 years of age on one single day. This is repeated 4-6 weeks later. The intention is to eliminate the virus from the community. Accordingly, the State Department of Health Services with the assistance of UNICEF organised immunisation camps on 1st December 2000 and 21st January 2001. Mothers were asked if their children were administered polio vaccine in the camps. Most of the children (83.5 per cent), irrespective of previous immunisation status, were again immunised in the above camps.

6.4.10 Measles can be a serious problem among children. A child is expected to get measles vaccinations when it is nine months old. About 89 children (91.7%) had received the vaccination against measles. This is the only vaccination where the figure for the city is better than the figure for the State, which was 84.6 per cent as, reported in NFHS-2. 6.4.13 Reasons for not vaccinating at all are or not completing the vaccination schedule were collected during the survey. There were many reasons for not immunising a child. Table 8.4 presents the distribution of children in the age group of 0 - 24 months at the reference period of the survey who did not receive immunisation or not fully immunised by reason and type of immunisation.

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Table 6.5 Reasons for Non-immunisation
Reasons Urban Suburban Total
Slum Non-slum
No. % No. % No. % No. %
Child is too young 1.3 30.2 6 66.7 9 56.2 28 41.2
Not aware of all doses 1 2.3 2 22.2 0 0.0 3 4.4
Child is ill 19 44.2 0 0.0 6 37.5 25 36.8
Family problem 0 0.0 0 0.0 0 0.0 0.0 0.0
Vaccine not available 0 0.0 0 0.0 0 0.0 0 0.0
No specific reasons 9 20.9 1 11.1 1 6.2 11 16.2
Financial problem 1 2.3 0 0.0 0 0.0 1 1.5
Total 43 100.0 9 100.0 16 100.0 68 100.0

Note: The total here will be more than the partially immunised and non-immunised children in 6.3 as the same parent would give different reasons for different doses.

6.4.11 The reasons for failure to complete the immunisation schedule fully show that “child is too young” is the foremost reason pointed out by 41.2% of the mothers. These children may not have attained the age prescribed by the health authorities for receiving the remaining doses. For 36.8% of the mothers, the leading reason is “child is ill”. Some other reasons mentioned by mothers for not completing the immunisation are “not aware of all doses” and “financial problem”. More than 16% of the mothers have no specific reason to mention.

6.4.12 It is the responsibility of health personnel to advise mothers to give all types of immunisation to children since mothers may tend to neglect vaccination, though it is very important. We tried to probe what was the source of motivation for getting the children immunised. It was found that a good majority (87.6%) of the mothers were motivated by doctors or nurses to immunise their children (table not given). The role of the health worker does not seem to have been important.

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6.5 Nutritional Supplement

6.5.1 After immunisation, the other items of health care for the children are the administration of vitamin-A and iron and folic acid tablets. Vitamin-A deficiency is a leading cause of blindness. Moreover it is also linked with increased susceptibility to severe infections and malnutrition. In order to prevent Vitamin A deficiency, supplementation programmes are implemented under National Programme on Prevention of Blindness in which oral doses in the form of tablet/liquid of Vitamin-A are administered every 6 months to vulnerable groups of age 1–5 and lactating mothers. In our sample of children below 24 months, only about 32% have received Vitamin-A drops. While the proportion is more or less the same in the non-slum area and high at 41.7% in the suburbs is quite low at 27.8% in the slums. The figure is much lower than that for the entire state which was 43.6% for children below three years the figure for the slums is lower than the all India figure of 29.7% (IIPS & ORC Macro.2000).

Table 6.6 Administration Vit.A and IFA to children (%)
Details Urban Suburban Total
Slum Non-slum
Vitamin-A 27.8 31.6 41.7 31.9
Don't know 11.8 0.0 0.0 6.4
IFA 22.2 31.6 16.7 22.7
Number 54 19 24 97

6.5.2 Children are given Iron and Folic Acid tablets for iron supplementation. It is found that around 31.6% of children in non-slum area 16.7% in suburban and 22.2% in slum got IFA tablets/liquid. On the whole 22.7% of children are given IFA tablets for iron supplementation.

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6.6 Summary

6.6.1 Though the state boasts of a very low infant mortality rate, the status of immunisation in the city leaves much to be desired. This calls for concerted efforts on the part of the health authorities. One of the reasons for the low figure could be that the private hospitals may not be giving adequate emphasis for this. This is the impression gathered in the interview with some community leaders NGOs and providers of public services. There is scope for a more meaningful partnership with the private sector in this.


VII. Awareness of RTI, STI and HIV/AIDS

7.1 Introduction

7.1.1 Among different dimensions of Reproductive health care, Reproductive Tract Infections (RTI), Sexually Transmitted Infections (STI) and HIV/AIDS occupy a distinct position. AIDS fell as a bombshell on the Indian scene in 1986 when the first aids case was discovered in a sex worker in Chennai (Madras). A quick survey of more than a hundred female sex workers of that city showed that more than 10 per cent of them were infected with HIV. Since then other areas have been found and many cases discovered. The National AIDS Control Organisation (NACO) estimates that 3.86 million people in India are infected with HIV and 20304 full blown AIDS cases have been officially reported (NACO 2002). Tamil Nadu, Maharashtra, Karnataka, Andhra Pradesh, Manipur and Nagaland are the states where the infection has crossed one per cent in antenatal women. According to the sentinel surveillance of antenatal women of Kerala carried out in August – October 2001 the prevalence rate among them is 0.09 per cent (Information collected from the State AIDS Cell, Kerala). Based on this, the experts estimate the HIV positive population of Kerala to be 70,000. In a population of 3.1 million, this works out a prevalence rate of 0.26 per cent. This chapter deals with the awareness of RTI, STI and HIV including their mode of transmission and the preventive measures among married women, adolescent girls and men in the reproductive age group. We have already dealt with the problems of reproductive health of married women in chapter V.

7.1.2 The Governments both at the Centre and the States have launched Information, Education and Communication (IEC) programmes through mass media and other means to increase awareness about these diseases. In the second section of this chapter, we try to analyse the knowledge about RTI, STI and AIDS and the transmission and preventable measures of these among ever-married women of all ages. In the three study areas, 1262 women, 241 adolescent girls and 998 males were interviewed. The responses about the three diseases are put together in one table each to make it easy for comparison and to avoid monotony.

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7.2 Ever Married Women of all Ages

7.2.1 Altogether 633 married women were questioned in the slums, 325 in the non-slum areas and 304 in the suburbs.

7.2.2 This section deals with the awareness of RTI, STI and HIV/AIDS among ever-married women, the sources of knowledge, awareness of the modes of transmission and curability. Table 7.1 presents the level of awareness of the three conditions among them.

Table 7.1 Awareness of RTI, STI and HIV among Married Women (%)
Awarenees and Source of Knowledge RTI, STI and HIV Urban Suburban Total
Slum Non-slum
RTI STI HIV RTI STI HIV RTI STI HIV RTI STI HIV
Awareness 54.8 52.1 77.4 68.0 64.6 86.2 43.8 41.1 72.7 55.6 52.7 78.6
Source of Knowledge
Television 39.2 38.6 57.0 61.5 59.1 78.2 36.5 30.3 24.3 44.3 41.8 62.4
Radio 15.6 14.1 19.8 29.2 28.6 33.2 15.1 16.8 56.9 19.0 18.5 24.3
Print Media 21.0 21.0 30.9 75.1 76.0 92.9 57.2 16.1 23.3 33.9 34.0 45.1
Slogans/Pamplets/Poster 3.5 3.3 5.9 24.0 26.8 31.4 4.0 4.0 7.9 8.0 9.5 12.9
Doctors 3.0 2.8 3.8 4.0 3.7 5.2 3.3 2.6 4.3 3.3 3.0 4.3
Health Worker 4.7 4.6 6.8 0.9 0.9 0.9 0.7 0.7 1.0 2.8 2.7 3.9
School Curriculum and Teacher 0.8 1.0 2.4 3.7 2.5 3.4 2.6 2.6 8.9 1.9 1.8 4.2
Community Meetings 8.7 8.1 11.7 2.5 0.9 0.9 4.9 3.6 4.0 6.2 5.2 7.1
Friends/Relatives 12.3 11.7 20.7 22.2 19.4 23.7 9.5 8.9 17.8 14.2 12.7 20.8
Husband 1.9 1.7 2.8 1.9 2.8 3.1 1.6 2.0 3.0 1.8 2.1 2.9
Number 633 633 633 325 325 325 304 304 304 1262 1262 1262

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7.2.3 Overall more than half the married women are aware of RTI and STI and more than three fourth about HIV/AIDS. We have seen in chapter III that nearly 80 per cent of the women in the sample had formal schooling (Table 3.6) The female literacy in Kerala is 87.86 per cent in 2001 (Census 2001b). The level of awareness of diseases that infect the reproductive system is not commensurate with the level of education and literacy. The awareness is the poorest among the suburbs, the slums faring better, followed by the non-slum areas. It is not a happy state of affairs to know that about half of them in the slums and suburbs are not aware of RTI and STI and nearly a quarter of them about HIV, though they are reasonably well educated. They lack this information, which is crucial for their sexual health. NACO has put in a massive effort in IEC activities on HIV and that seems to have had its impact. But the IEC work on RTI and STI have not been that intensive in spite of these being given importance in the Reproductive and Child Health (RCH) programme launched by Government of India and the State Governments. It is surprising how in the two massive programmes run by the Government both with the help of World Bank and other donors, one could be very effective and the other not so. This points to the lack of co ordination among the people who run the two programmes. While NACO is under the Department of Health in Government of India, RCH programme is run by the Department of Family Welfare. Though the Union Minster for Health and Family Welfare heads both these Departments, two separate Secretaries run them. It is not difficult to include RTI and STI in the IEC activities on HIV and make it a campaign on sexual health. But probably the compartmentalization of the two Departments stands in the way. Many researchers have pointed out this lack of co ordination between the two. This is yet another pointer to it.

7.2.4 While there is a multiplicity of sources of knowledge for the same individual, Television appears to dominate all the others. This is not surprising as nearly two thirds of the households have TV sets, the percentages in the slums and suburbs being 56.8 and 51.2 (see Table 3.9). For nearly two thirds of the married women the awareness about HIV/AIDS came from TV and for more than 40 per cent of them, about RTI and STI. The next is the print media, about a third of the women giving credit to it for RTI and STI and about 45 per cent for HIV. In the suburbs this is the major source of information for RTI with more than 57 per cent acknowledging it. However for the other two diseases TV dominates even in the suburbs. The social interaction between friends and relatives contribute only nominally to the propagation of knowledge about these diseases, more in the non-slum areas than in the other two areas. Schooling does not appear to have done much to spread the awareness of these diseases. Those who came to know of them from the school curriculum or the teachers are only less than 2 per cent for RTI and STI and 4.2 for HIV. It appears that the role of health workers is very weak in all the three areas in providing knowledge, only less than 3 for RTI and STI and less than 4 for HIV. Community meetings also contributed marginally to the awareness, only about 6 or 7 per cent of the married women getting the information through them. However it is noteworthy that in the slums this has played a marginally bigger role than in the other two areas, contributing more than 8 per cent for RTI and STI and more than 11 per cent for HIV. There appears to be better community activity in the Slums.

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Table 7.2 Awareness of Transmission of RTI, STI and HIV among Married Women (%)
Awarenees of Mode of Transmission of RTI, STI and HIV Urban Suburban Total
Slum Non-slum
RTI STI HIV RTI STI HIV RTI STI HIV RTI STI HIV
Aware of mode of Transmission 68.4 68.4 68.4 83.1 83.1 83.1 61.2 61.2 61.2 71.7 71.7 70.9
Hetero-Sexual Intercourse 88.6 97.2 98.4 92.3 99.0 99.6 89.7 92.0 93.3 90.1 96.8 97.1
Needles/Blades/Skin puncture 35.4 38.5 59.4 62.8 74.6 78.1 51.3 52.7 54.6 48.4 54.3 64.0
Transfusion of infected Blood 26.8 27.5 48.0 51.7 61.7 70.3 29.9 31.3 38.3 36.3 40.5 52.2
Mother to Child 5.5 6.1 12.4 26.6 36.8 36.4 14.5 17.0 16.8 14.9 19.3 21.8
Homo-sexual Intercourse 0.8 1.2 2.8 1.0 1.5 1.9 14.5 15.2 12.9 3.6 4.1 5.9
Lack of Personal Hygiene 13.4 7.3 0.7 18.8 4.5 0.7 5.1 1.8 1.0 13.7 5.2 0.8
Others 0.0 0.0 0.0 1.0 0.0 0.0 0.0 0.0 0.0 0.3 0.0 0.0
Number 633 633 633 325 325 325 304 304 304 1262 1262 1262

7.2.5 A striking similarity is observed about the proportion of married women knowing about the mode of transmission of the three diseases, it being over 70 per cent in all the three. But there are differences among the areas. Only about two thirds of the married women in the slums and suburbs know how they are transmitted while over 83 per cent in the non slum areas know it. Heterosexual intercourse is the most commonly acknowledged mode, about 97 per cent crediting it for STI and HIV and over 90 per cent for RTI. It is quite heartening to see about 98 per cent of the married women in the slums acknowledging this as the mode for STI and HIV and 88.6 for RTI. The second place for all the three diseases is taken up by needles, blades and skin punctures; 64 per cent crediting it for HIV, 54.3 per cent for STI and 48.4 per cent for RTI. Transfusion of infected blood occupies the third place with 52.2 per cent for HIV, 40.5 per cent for STI and 36.3 per cent for RTI. The similarity about the mode of transmission among the diseases continues and transmission from mother to child takes the fourth place. About 15 per cent state that this is a mode of transmission of RTI and about 20 per cent of STI. Only 21.8 per cent of the respondents acknowledged the transmission of HIV from mother to child. Though the major mode of transmission of HIV in India is heterosexual in the course, accounting for 82.6 percent, at least 1.8 percent is accounted for by the prenatal route (NACO 2002). It is known that the chances of an HIV infected mother passing it on to the child are quite high. Therefore, one would expect this to be mentioned as a mode by a large majority of educated women. Even in the non slum areas only 36.4 per cent stated this as a mode of transmission. Perhaps the IEC activities on HIV do not emphasize this mode and that could be the reason. When it comes to fifth place the similarity ends and quite rightly. Homosexual intercourse is the fifth place in HIV. But only about 6per cent of married women acknowledge this as a mode of transmission of HIV. Probably the awareness of the married women of the existence of this practice itself would be very limited, given the societal mores. Workers in the AIDS prevention programmes have found it difficult to locate practitioners of homosexuality in Trivandrum city as they are very few (Various reports of State AIDS Cell and interview with community leaders). Lack of personal hygiene occupies the sixth place for the other two diseases. About all these modes the awareness seems to be higher in urban non-slums than the slums and suburbs.

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7.2.6 Even though many of them are aware of HIV/AIDS and a part of them about the mode of transmission, still there are certain misconceptions existing in the society about this. An individual identified as HIV +ve is ignored and isolated by everybody in the society and many of them do not touch or even go near the patient due to the misconception that it may be transmitted by touch, air, sharing clothes and vessels etc. Questions were put about each of these commonly perceived misconceptions.

Table 7.3 Misconceptions about Mode of Transmission of HIV/AIDS among Married Women (%)
Misconception Urban Suburban Total
Slum Non-slum
Shaking hands 13.7 13.5 22.4 15.8
Embracing 14.4 13.5 22.7 16.2
Kissing 19.1 15.4 23.4 19.2
Sharing Clothes 16.1 14.8 22.0 17.2
Sharing vessels 15.8 14.5 22.4 17.1
Through urine, faeces etc. 17.7 16.6 24.3 19.1
Insects like Mosquito 23.9 21.2 25.4 23.6
Number 633 325 304 1262

7.2.7 Overall the misconception appears to be harboured by only about a fifth of the women. This is a great improvement on the state figure revealed by a survey on behavioural surveillance conducted by NACO in 2001. According to that survey 44.8 per cent of females in Kerala had no incorrect knowledge on the transmission of HIV, suggesting that 55.2 per cent had correct knowledge (NACO). The married women of Trivandrum appear to be much better in this. Shaking hands as a mode of HIV transmission was mentioned by 13.5 percent urban non-slum respondents, 22.4 percent suburban respondents and 13.7 slum dwellers. Embracing and hugging an HIV +ve patient is a misconception for 16.2 percent on the whole. ‘Transmission is possible through kissing’ was mentioned by 19.2 percent in total while it is 15.4 percent among urban non-slum women, 22.4 percent in the suburban and 16.1 percent slum respondents. Sharing vessels and clothes do not have much difference in all the three areas and it is almost the same (around 17) when taken as a whole. Chances to get transmitted by contact with urine and faeces of the patient scored 19.1 percent in the total, 16.6 percent from the urban non-slum, 24.3 percent from sub-urban and 17.7 percent from slum areas. It is to be noted that the misconception is the highest among the suburbans, each of the modes scoring about 22 per cent points. Slums and non-slums do not show much difference. The IEC activities seem to have had their impact in the old city area with an even spread while in the newly added suburbs the impact is not that strong. More intensive efforts are called for removing the misconceptions.

7.2.8 HIV is a disease brought about by the individual’s actions nearly in all cases. Though there is a no cure for it, it is almost preventable. Therefore the knowledge about prevention is of paramount importance in combating the infection. Questions were put on this to the married women. Their response is tabulated in Table 7.4.

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7.4 Knowledge of Prevention of HIV/AIDS among Married Women (%)
Knowledge about Prevention Urban Suburban Total
Slum Non-slum
Using condoms during sexual intercourse 8.1 19.0 17.7 13.4
Safe Sex 98.8 99.6 92.7 97.7
Checking blood prior to transfusion 41.7 67.6 41.2 49.7
Sterilising needles, syringes before injection 53.0 73.5 46.9 57.6
Avoiding Pregnancy while having HIV 4.8 15.8 9.4 9.0
Avoid any type of relation 0.7 0.4 0.5 0.6
Do not know 2.1 0.0 11.4 3.8
Number 633 325 304 1262

7.2.9 Most of the married women seem to have adequate knowledge about the method of prevention as nearly 98 per cent of them mentioned safe sex as the method. The 13 per cent who mentioned use of condoms also would be included in this category. There is not much difference among the three areas; In the urban non-slum and slum areas all the women have this impression, while in the suburbs it is nearly 93 per cent. Almost 19 per cent of women in the urban non-slum said that condom usage can prevent HIV transmission to a certain extent while only 8.1 per cent in the slum said so. It is around 18 per cent in the suburban area. The next highest group nearly 58 percent mentioned sterilizing needles, syringes etc. Nearly half the married women mentioned checking blood prior to transfusion. Almost 68 per cent in the urban non-slum area, 41.2 percent in the suburban and 41.7 per cent from the slums subscribe to this view. Avoidance of pregnancy while having HIV was supported by 15.8, 9.4 and 4.8 per cent of women in the urban non-slum, suburban and slum areas respectively. Though there are misconceptions about HIV positive patients leading to their ostracisation from the society, only a negligible proportion of respondents stated that avoiding contacts would prevent HIV infection. It is encouraging to find that most of the people, especially in the slums have correct knowledge about the modes of prevention of HIV.

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7.2.10 A crucial factor about the campaign in HIV is the emphasis that the infection is not curable. Very expensive drugs are available only for reducing the viral load in the infected person’s blood thereby enabling him to live with the virus reasonably free from opportunistic infections. Therefore the impression about curability is very much a determinant in the adoption of preventive measures. Questions were put on this to the married women and it is quite shocking that nearly 15per cent said that it is curable and only 54per cent said it is not curable, 31per cent being not sure. Probably the advertisements from quacks about cure for AIDS have contributed to this. This is especially surprising because nearly all are aware of HIV and have nearly correct knowledge about the mode of transmission and prevention. This shows the IEC activities have to go a long way in emphasizing the non-curability of HIV. The slogan ‘not curable but nearly 100per cent preventable’ does not appear to have caught on.

Table 7.5 Knowledge of Curability of RTI, STI and HIV among Married Women (%)
Curability Urban Suburban Total
Slum Non-slum
RTI STI HIV RTI STI HIV RTI STI HIV RTI STI HIV
Curable 36.8 39.3 14.8 54.2 57.8 9.3 33.5 37.8 20.6 40.6 43.7 14.7
Not curable 12.5 11.1 54.0 4.9 3.7 64.3 6.3 2.3 43.1 9.0 7.1 54.1
Do not know 50.7 49.6 31.2 40.9 38.5 26.4 60.2 59.9 36.3 50.4 49.0 31.0
Number 633 633 633 325 325 325 304 304 304 1262 1262 1262

7.2.11 About RTI and STI, nearly half the married women said they do not know if these are curable or not, more in the suburbs than slums or non-slums. Knowledge of modern medicine’s ability to cure these diseases does not appear to have spread among married women. But it is to be noted that only less than 10per cent said it is not curable. The misconception about curability about RTI an STI is high among the suburban as in the case of HIV. This again, points to the need for strengthening IEC activities in this direction.

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7.3 Female Adolescents

7.3.1 This section deals with the reproductive health of adolescent females between the age group 13 and 18 years. The total number of respondents is 241, out of which 159 are from slums and 41 each from non-slum and suburban areas. We have already dealt with the age at menarche in Chapter V.

Table 7.6 Menstrual Problems among Adolescent Girls ( %)
Menstrual problems Urban Suburban Total
Slum Non-slum
Regularity of menstrual cycle
Regular 92.8 96.5 97.2 94.1
Irregular 7.2 3.5 2.8 5.9
Discomfort during menstruation 23.6 29.0 11.2 22.2
Abdominal pain 82.4 63.6 100.0 79.6
Head Ache 2.9 36.4 0.0 10.2
Excessive bleeding 14.7 0.0 0.0 10.2
Went for treatment
Government Hospital/Consultation 2.9 18.2 0.0 6.1
No consultation 79.9 72.7 100.0 79.6
Percent who are taking Medicines 20.6 18.2 50.0 22.4
Number 159 41 41 241

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7.3.2 Most of adolescents (94 per cent) have their menstrual cycles regularly. Irregularity of the cycles is rare, the highest being about 8 per cent, which is among the slum dwellers. Discomfort during menstruation was reported by 22.2 per cent of the total respondents. It was insignificant among slums and suburban girls. Among the urban non-slum respondents it was felt by 29 per cent. So far as the nature of discomfort is concerned, nearly 80 percent of the respondents had abdominal pain. Excessive bleeding constituted 10.2 per cent of the total.

7.3.3 It comes out that 79.6 percent of the respondents who had discomfort did not undertake any treatment. Out of the treatment-seeking respondents, 14.3 per cent went to Government hospitals while 6.1 per cent consulted private doctors. About 18 percent of slum dwellers depended on Government hospitals as could be expected, while an equal proportion in the urban non-slums consulted private doctors. Almost 18 percent of urban non-slum girls took medicines while 50 percent in the suburban area and 20.6 per cent in the slums also took it.

7.3.4 The respondents were asked about other problems of the reproductive tract. The only common problem encountered by the adolescents was white discharge. Therefore questions were put on this. The result is shown in Table 7.7.

Table 7.7 Adolescent Girls with Reproductive Tract Problems (%)
Problems Urban Suburban Total
Slum Non-slum
Do not have problem 40.0 15.6 15.8 32.3
Have white discharge 60.0 84.4 84.2 67.7
Consulted doctor 1.0 0.0 0.0 8.7
Took medicine 17.2 0.0 16.7 15.9
Number 159 41 41 241

7.3.5 About one third of the total respondents have this problem, while in the slums the proportion is 40 per cent. In spite of this being a major reproductive health problem, only less than one per cent went in for consultation and less than 16 per cent took any treatment.

7.3.6 It is important for adolescent girls to know about STI and HIV. Questions were put to them about this. The results are in Table 7.8.

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Table 7.8 Awareness of STI among Adolescent Girls (%)
Awareness Urban Suburban Total
Slum Non-slum
Aware of STI 50.7 43.8 31.6 46.4
Gonorrhea 94.9 93.3 100.0 95.2
Syphilis 2.5 6.7 0.0 2.8
Aware of Mode of Transmission 87.2 93.3 76.9 86.8
Sexual intercourse 94.1 92.9 90.0 93.5
Needle/Blades 67.1 64.3 50.0 68.1
Transfusion of infected Blood 49.3 50.0 80.0 52.7
Number 159 41 41 241

7.3.7 Though only 46.4 per cent of the girls are aware of STI, all of them have heard about HIV (see Table 7.9 below). This shows that while the IEC campaign has been effective on HIV, its efficacy on STI has been far from satisfactory, as we saw in the case of married women as well. But it is encouraging to note that more than half the girls in the slums have heard about STI, while not even 44 per cents in the non-slums areas have heard about it, and not even a third in the suburbs. The awareness of STI consists almost entirely of the awareness of gonorrhea, 95.2 per cent being aware of it and only less than 3 per cent knowing about syphilis. Other infections do not appear to have entered their realm of thinking.

7.3.8 Among those who have heard about STI, 86.8 percent know about the mode of transmission, which is constituted by 93.3 percent from urban non-slum, 76.9 percent from suburban and 87.2 percent from slum areas. Most of them (93.5 per cent) mentioned sexual intercourse as a mode of transmission. Transmission through needles/blades was acknowledged by 64.3 per cent urban non-slum adolescents, 80 percent of suburban and 67.1 percent slum adolescents. Spread of STI through transfusion of infected blood scored 52.7 percent in the total constituted by 50 from urban non-slum, 80 percent from sub-urban and 49.3 from slum areas. Only 7.7 percent of the total respondents mentioned that transmission is possible from mother to child, which was not mentioned by any respondent from the urban non slum area. About 12 percent of suburban slum adolescents and 9 from slum areas supported it. On the whole the knowledge about modes of transmission is encouraging.

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Table 7.9 Awareness of HIV among Adolescent Girls (%)
Awareness Urban Suburban Total
Slum Non-slum
Aware of HIV 100.0 100.0 100.0 100.0
Aware of Mode of Transmission HIV 67.3 65.9 65.9 66.8
Sexual intercourse 84.1 87.5 92.1 86.0
Needle/Blades 72.3 74.1 71.4 76.2
Transfusion of infected Blood 59.5 63.0 62.9 60.6
Mother to Child 9.0 0.0 11.1 7.7
Source of Knowledge of HIV
School 39.3 19.1 32.3 35.3
Friends/Relatives 5.4 0.0 9.7 5.5
Television 56.3 61.9 57.3 57.9
Newspaper/ Magazines 19.6 38.1 3.2 18.9
Community Classes 2.7 0.0 0.0 1.8
Parents 0.9 0.0 3.2 1.2
Number 159 41 41 241

7.3.9 Though all the girls have heard about HIV, only two thirds of them are aware about the mode of its transmission, the three areas showing not much difference. Among those who know about the mode of transmission of HIV, only 86 per cent acknowledged sexual intercourse as the mode, 87.5 percent in the non-slum areas, and 84.1 percent in the slums. The suburban girls fare better with 92.1 per cent. Transmission through needles and blades was known to a little over three fourths of the girls and through blood transfusion to less than a third of them, the three areas showing not much variation. Mother to child transmission is acknowledged not even by 8 per cent and by none in the non-slum areas. With the entire sample knowing about HIV, one would expect all of them to know about its transmission also. An awareness of HIV without its mode of transmission is not very effective in preventing the infection. This again points to the lack of focus in the IEC campaigns on HIV.

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7.3.10 As in the case of married women, Television dominated as the source of knowledge among adolescent girls, but to a much less extent. Nearly 58 per cent acknowledged it with very little variation among the areas. It is quite heartening to see that the school has played an important role in creating the awareness of HIV, more than a third giving credit to it. However, among the non-slum girls only less than 20 per cent acknowledged it. Nearly a fifth of the girls mentioned magazines as a source of information. Kerala is a state where a large number of magazines get circulated. Some of the largest circulating magazines in the country are in the state’s language of Malayalam. (Various newspaper reports). It is widely known that there is a great readership of these magazines among women. Table 7.1has shown that more than 45 per cent of the married women acknowledge the print media as a source. Therefore a fifth of the girls acknowledging it is not a surprise. But the inter – area difference calls for some surprise with only a little over 3 per cent of the girls of the suburbs giving credit to it, while more than 38 per cent in the slums did so. But the size of the sample being only 41 such differences may not be significant. Another similarity with the women is that in the slums the girls get information through community classes, though only less than 3 per cent. This source is totally absent in the other two areas. This confirms the view that there is more community activity in the slums. Parents as a source information contributed only 1.2 percent to all the girls. The suburban areas fared better with 3.2 percent, while in the slums it is not even one percent. Parents, especially mothers, can play a better role in educating the children about HIV, especially in the face of the fact that more than 78 per cent of the married women are aware of HIV (See Table 7.1).


7.4 Men (13 – 54 years)

7.4.1 In order to know about the sexual health and related aspects of the males, men from 13 to 54 years from the sample households were interviewed. A total of 998 men were interviewed out of which 149 were from urban non-slum areas, 262 from the suburban areas and 587 from the slums. We have already seen the characteristics of men of all ages in Chapter III. Here we study only men in the reproductive age group.

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Table 7.10 Education and Marital Status of Male Respondents (%)
Characteristics Urban Suburban Total
Slum Non-slum
Education
No Schooling 4.6 0.0 1.5 3.0
Primary 15.3 1.3 17.5 13.8
Secondary 27.4 14.2 28.5 25.8
Matriculation 45.4 51.5 49.8 47.5
Undergraduates 3.9 12.1 1.2 4.5
Degree and above 2.2 12.1 1.5 3.5
Technical Diploma or Certificate 0.7 7.5 0.0 1.4
Professional 0.5 1.3 0.0 0.5
Marital Status
Single 39.7 64.4 37.4 43.8
Currently married 58.8 35.5 61.8 56.1
Widower 0.2 0.0 0.0 0.1
Divorcee 0.3 0.0 0.0 0.2
Separated 1.0 0.0 0.8 0.8
Number 587 149 262 998

7.4.2 Men who had no schooling are only 3 per cent while in the general population it is 19 per cent (Table 3.6). This would suggest that it is the women who constitute the bulk of this category. Nearly half the men are matriculates, predominantly in the non-slums. About an eighth of the non-slum men are degree holders where as it is only about 2 per cent in the other two areas. The upper hand of the non-slum areas is seen in all the levels of education.

7.4.3 Regarding marital status, the bulk of the men (nearly 62 per cent) are currently married. The proportion of married men in the general population is only 44 (Table 3.3), which is natural as the men below 15 are also included in that.

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7.4.4 Questions were put to the respondents about their sexual health problems before and after the marriage. The number who had problems is too small to give in a table. Only 6 of the 998 respondents stated that they have or had sexual health problems before marriage, three from the slums, two from suburbs and one from the non-slums. The problems were, difficulty in urination, fungal infection and sore on the penis. All these respondents had taken treatment and it was effective. Incidence of sexual disease after marriage was also rarely reported. Only 11 respondents had problems, 8 in the slums, 2 in the suburbs and one in the non-slum areas. Five in the slums had infertility and one sexual disability. All others had fungal infection. Out of the 11 who had problems 8 persons took treatment, all of them from the slums.

Table 7.11 Awareness of STI and HIV among Males (%)
Awareness Urban Suburban Total
Slum Non-slum
Education
Aware of HIV 90.5 100.0 88.9 91.5
Aware of STI 77.2 94.0 79.8 80.4
Syphilis 7.5 32.9 14.5 13.2
Gonorrhea 4.6 22.9 5.7 8.1
Fungal infection 0.6 2.1 1.4 1.1
Do Not know 1.9 1.4 0.0 0.8
Aware of Mode of Transmission
Sexual Intercourse 68.4 94.3 58.9 70.5
Sexual contact with sex workers 14.4 8.6 16.8 14.0
Sharing of needles/blood transfusion 20.1 41.4 25.4 25.2
Mother to child 6.2 2.9 4.8 5.2
Do not know 13.9 10.7 10.5 12.5
Knowledge about prevention
Avoid sexual intercourse with sex workers 23.4 14.3 14.8 19.6
No sharing of needles/syringes 10.2 17.9 17.2 13.3
Using condom 28.3 53.6 24.4 31.7
Safe Sex 22.5 43.6 27.3 27.4
Do not know 20.3 21.4 19.6 20.3
Knowledge of place of treatment
Government Hospital 25.6 35.7 23.0 26.7
Private hospital 52.3 57.9 56.9 54.5
Aids cell 22.1 3.4 18.7 18.5
Do not know 0.0 0.0 1.5 0.4
Number 587 149 262 998

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7.4.5 More men know about STI than married women and adolescent girls. While the proportions among the first two are 52.7 and 46.4 per cent respectively, among men it is as high as 80.4. The same trend is seen about HIV also. More than 91 per cent men know about it, while the married women who know are only 78.6 per cent, though all the adolescent girls know about it. According to the behavioural surveillance survey conducted by NACO in 2001 (NACO 2002), the proportion of men in the urban areas of Kerala who had ever heard of HIV is 99.5 and women 98.6. Though this is variant with the result of our study, the general trend is the same, namely, that a substantially high percentage of men and women know about HIV. This is probably due to the fact that they get information from the schools also, which only some in the sample of men would get. Introduction of awareness of HIV in the schools is a recent phenomenon. Among the three areas of the study, urban non-slums with 94 per cent scores the highest in the awareness of STI. Though the general awareness about STI is good across the areas, when it comes to the awareness of particular diseases like syphilis, gonorrhea or fungal infection the knowledge is confined to a very small proportion; 13.2 per cent about syphilis, 8 per cent about gonorrhea and only 1 per cent about fungal infection. It would appear that generally men do not have adequate information to suspect STI when they get some symptoms. More men in the urban non-slum areas know about these than in the other two areas. This calls for more intensive IEC activities on this front.

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7.4.6 About the transmission of STI and HIV, more than 70 per cent acknowledged sexual intercourse as the mode, while among married women nearly 97 per cent selected this (Table 7.2). Somehow the women appear to know more about STI and HIV transmissions than men. Even in the non-slum area, only close to 95 per cent men acknowledged this, while 99 per cent of married women did so. More than 94 percent of the urban non-slum respondents, 58.9 percent of the suburban and 68.4 percent of the slum respondents mentioned about sexual intercourse. Only 8.6 percent in the urban non-slum area, 16.8 percent in the suburban and 14.4 percent in the slum areas mentioned that it may be transmitted by having sexual intercourse with sex workers. Since the major carriers of STI are sex workers, this again calls for more intensive educational efforts Transmission through blood transfusion and sharing of needles was reported by 41.4 percent urban non-slum respondents, 25.4 percent suburban respondents and 20.1 percent in the slum areas. Mother to child transmission was known to 2.9 percent, 4.8 percent and 6.2 percent in the urban non-slum, suburban and slum areas respectively. A good proportion have mentioned that they do not know the mode of transmission. It is around 10.7 percent in the urban non-slum, 10.5 percent in the suburban and 13.9 percent in the slum regions.

7.4.7 The knowledge about preventive measures appears to be inadequate among men. Not even a fifth of the respondents mentioned avoiding sexual intercourse with sex workers. According to a survey carried out by the State AIDS Society of Kerala, the HIV prevalence among female sex workers of Trivandrum is 2.6 per cent (Collected from State AIDS Cell Trivandrum). They being the major source of infection, it is quite surprising that only less than 20 per cent of the men suggested avoiding sex with them as a preventive measure. Though the men in the slums fare better in this with more than 23 per cent suggesting it, not even 15 per cent in the other two areas suggest this as a means of prevention. When it comes to the sharing of needles and syringes, the ignorance is appalling. In spite of the widely acknowledged fact that this is one sure way of spreading HIV, only a little over 13 per cent of the men stated avoiding sharing of needles and syringes as a means of prevention. In the slums, it is only a tenth of the men who mentioned this. The slightly better figure for the non-slums and suburbs do not help in reducing the shock. Though the transmission through this in India is only 4.2 per cent (NACO, 2002) the people are expected to know of it. The shock deepens when it comes to safe sex and the use of condoms. Not even a third of the men mentioned use of condoms and only a little over a fourth mentioned safe sex in general. Though the distinction between these two is blurred, the respondents did not take them to be mutually exclusive. Even if we add up the two, giving the benefit of doubt, it is only less than 60 per cent. With more than 93 per cent of men aware of HIV this is not a happy state of affairs. Equally shocking is the fact a fifth of the men do not know how to prevent HIV and STI. The fairly intensive IEC campaign on HIV does not appear to bring home the messages about prevention among men, who are the main culprits in its spreading.

7.4.8 Responses on the knowledge about the place of treatment for STI shows that 35.7 percent in the urban non-slum area, 23 per cent in the suburban region and 25.6 per cent in the slum areas mentioned Government Hospitals. A significant proportion have mentioned private hospitals i.e. around 57.9 per cent in the urban non-slum, 56.9 per cent in the suburban and 52.3 per cent in the slum areas. Treatment through AIDS cell was reported by 6.4, 18.7 and 22.1 per cent respondents in the urban non-slum, suburban and slum region respectively.

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7.5 Summary

7.5.1 This part of the survey reveals that the awareness about RTI, STI and HIV is fairly high among married women, adolescent girls and men in the reproductive age group. The awareness of HIV is substantially higher than that of STI among the three groups. This shows that the IEC campaign of NACO could not carry with it effectively the messages on STI as well. The lack of coordination between the department of Health which overseas the work of NACO and the department of Family Welfare which is responsible for Reproductive and Child Health in the same Ministry is perhaps responsible for this state of affairs. There are some variations in the degree of awareness among the three groups and the three areas of the study. Generally the awareness about HIV is the highest among girls followed by men and married women. But in the case of STI the adolescent girls are in the lowest rung, the first and second being taken by men and women. Among all the three groups of individuals, those living in the suburban area are slightly less aware than those in the slums and non-slums. More women and girls living in the slums are aware of these deceases than those living in the other two areas.

7.5.2 The similarity among the three groups continues in the mode of transmission also, with the girls showing the highest awareness about the transmission of STI and women about HIV. More women living in the non-slum areas know about transmission than those in the other areas. Only less than a fifth of the women harbour misconceptions about the transmission of HIV. Though a higher proportion of men are aware of STI and HIV than women, when it comes to the preventive measures they woefully lag behind. Not even three fourth of them recognize sexual intercourse as a mode, though nearly all the women recognize it and though it accounts for 82.6 per cent of the transmissions in India. It is indeed shocking that only less than the fifth of the men mentioned avoiding intercourse with sex workers as a method of prevention. Safe sex as a means of prevention has appealed only to a little over a fourth of men As the main culprits of the transmission of the infection, the men need to know much more about prevention. IEC activities have a long way to go in this.

7.5.3 Speaking of IEC, the best source of information is proven to be television. About two thirds of the women, and more than half of the girls acknowledged this medium. The role of the health worker in spreading the message appears to be marginal. Of late, the contribution to awareness from the schools has become more evident as more than a third of the girls have acknowledged it, though among the elder women it is insignificant. Community meetings are a source of information to a very small extent. This is better in the slums showing better community activity there.

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7.5.4 Coming to the reproductive health of adolescent girls, the age at menarche is between 11 and 13 for more than half concentrated in the middle. Most of them have regular periods and some have slight problems like abdominal pain and some, white discharge. Only a few take treatment for this. Combined with a generally high awareness of STI and HIV one could say that the reproductive health of adolescent girls are generally satisfactory with no significant variation among the three areas.

7.5.5 Most of the men in the sample have completed their educations at various levels, higher in the non-slum areas followed by the suburbs and slums. A majority of them are married. Their general standard of reproductive health is fairly high. Those who had problems before or after marriage are too small to be considered. But with the wrong notions about the prevention of HIV, they are in the danger of losing their standard of sexual health.


VIII. Utilization and Assessment of Quality pf Public Facilities

8.1 Introduction

8.1.1 In India health care is expected to be the responsibility of the Government. In the days of the Kings, health care was a Dharma of the monarch, meaning his duty. But the Sanskrit word Dharma has also the connotation of giving free as charity. Health care is also supposed to be given free to the people by the government, as the latter’s duty. But in modern times, when costs are rising, this concept of duty and charity cannot be easily put into practice. But still the general expectation is that it is the duty of the government to provide health care to all at all times. The people tend to adjudge the quality of services provided by public health facilities against this expectation.

8.1.2 In the State of Kerala where there is a higher awareness of health needs, there is also a higher demand for quality services by the government. Among the states of India, Kerala has been consistently spending more than the average on health on a per capita basis. The average for all states in 1980-81 was Rs.24 when for Kerala it was Rs.32 and in the budget estimates of all states in 2000-01 it was Rs.146 for all states and Rs.198 for Kerala (GOK, 2000a). Even then large sections of people resort to private health care, as the public facilities do not come up to their expectation. KSSP Survey of 1987 has revealed that 58 per cent of health seekers go to the private facilities and 28.6 per cent to government, the balance treating themselves (Kunhikannan and Aravindan, 2000).

8.1.3 With this background an attempt was made to find out the degree of utilization of public health facilities in the city of Trivandrum, the reasons for not utilizing it and the level of satisfaction. Questions were put in different parts of the survey questionnaire to the entire sample population on the treatment for general illness and to ever married women on the treatment of complaints specific to them

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8.2 General Population

8.2.1 In Chapter IV we saw that out of the 4297-sample population, 559 people were afflicted with various ailments during the month prior to the survey and 540 of them took treatment. They were asked where they went for treatment. Table 8.1 below shows that, contrary to the general impression, two thirds of them went to the public facilities for treatment.

Table 8.1 Choice of Facility by General Population (%)
Facility Urban Suburban Total
Slum Non-slum
Government Hospital 63.4 62.7 80.0 67.0
Private Hospital 33.7 35.9 19.2 30.9
Doctor's Home 1.8 1.4 0.8 1.5
Mobile Hospital 1.1 0.0 0.0 0.6
Medical Store 0.0 0.0 0.0 0.0
Total 100.0 100.0 100.0 100.0
Number 273 142 125 540

8.2.2 But it has to be noted that in the slums, only about 63% of the ill-used public facilities, whereas 80% in the suburban areas did so. Trivandrum is a city well provided with Government and private health facilities including well-reputed super specialty hospitals. The total number of health facilities in the private sector is 71 as reported by the Health Department of the City Corporation. The people in the suburban areas seem to have greater confidence in public health facilities than the others. It is significant that none of the respondents went to medical store for treatment, although 7 of them had taken self-treatment. With a large number of medical stores in the city, one would have expected at least some patients to go to medical stores and consult the pharmacists and shop assistants on what drugs to take. In many backward states consulting the Pharmacy Store Assistant on minor ailments is a common practice. This does not appear to be the case in Trivandrum city. This speaks well of the awareness of the people on health matters.

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8.2.3 When queried as to why they did not make use of public facilities, nearly half of them mentioned poor quality (mentioned as good quality in private facilities and lack of confidence in Government facilities) as the reason, as seen in Table 8.2. This is the reason given by 52 per cent of the slum ill, 59 per cent of the non-slum ill and only by 33 per cent of the suburban ill. This strengthens the impression that the suburban people have better faith in public facility.

Table 8.2 Reasons for Not Resorting to Public Facilities by General Population (%)
Reasons Urban Suburban Total
Slum Non-slum
No Confidence 25.0 15.7 20.8 21.5
Distance 35.9 27.5 41.7 34.1
Lack of cleanliness 0.0 3.9 0.0 1.2
To avoid delay 1.1 2.0 12.5 3.0
Heavy rush 1.1 9.8 4.2 4.2
Good quality in Private 27.2 37.3 16.7 28.7
Known Doctor in Private 2.2 0.0 0.0 1.2
Bribery in Govt. Hospital 2.2 2.0 0.0 1.8
Relatives influence 3.3 0.0 4.2 2.4
Medicines to be taken from outside 2.2 2.0 0.0 1.8
Total 100.0 100.0 100.0 100.0
Number 92 51 24 167

About one third of them chose the private facility because of the proximity to their homes.

8.2.4 The general population were also asked about mortality and the results were given in Chapter IV. We saw in that chapter that all were given some treatment before their death, either at home or in one of the hospitals. This was followed up by a question on the type of hospital they were taken to whether it was private or public. The result is shown in Table 8.3.

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Table 8.3 Choice of Facility for Treatment for Fatal Illness by General Population (%)
Facility Urban Suburban Total
Slum Non-slum
Government 42.4 9.1 19.2 23.9
Private 45.5 57.6 57.7 53.3
Home 9.1 30.3 23.1 20.7
Abroad 3.0 3.0 0.0 2.2
Total 100.0 100.0 100.0 100.0
Number 33 33 26 92

All those who died had undergone treatment for fatal illness; nearly 24 per cent in Government hospitals, 54.3 percent in private hospitals and 20.7 per cent at home.

8.2.5 We have seen in Table 8.1 that when people were sick, about two thirds went to government hospitals; but in the mater of treatment which ultimately led to death only 24 per cent went to government hospitals. In the latter case the illness would have been grave. This indicates that they do not trust government hospitals when the complaints are of a serious nature. However, a larger proportion in the slums (42.4 per cent) took their seriously ill patients to the government hospitals. In the non-slum area only less than 10 per cent did that and in the suburbs nearly 20.


8.3 Ever Married Women of All Ages

8.3.1 This study has a specific focus on Reproductive and Child Health. The ever married women (EMW) of all ages were questioned in detail about their general and reproductive health. It may be noted here that the recall period with EMW was three months and not one month as in the case of the general sample, since one month recall was not felt sufficient to capture the reproductive health status adequately. The total sample size of ever-married women of all ages was 1262. Out of them, 398 went in for treatment for some ailment or the other. It is noteworthy that, not withstanding the common complaint about public facilities, 278 of them went there for treatment, making about 70 per cent.

Table 8.4 Choice of Facility by Ever Married Women of All Ages for General Illness (%)
Facility Urban Suburban Total
Slum Non-slum
Government 71.9 50.0 78.0 69.8
Private 28.1 50.0 22.0 30.2
Total 100.0 100.0 100.0 100.0
Number 221 68 109 398

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As in the case of general population, the popularity of public facilities is the greatest in the suburbs followed by slums. In the non-slum area only half the EMW made use of them for their general illness.

8.3.2 Most clients judge a health facility by the quality of overall service they receive – how they are treated and what they experience during their visit. The dissatisfied clients would hesitate to visit the same health facility again. Several factors which can give satisfaction to the clients like a well equipped health facility manned by trained medical personnel, with less waiting time, with the patient examined in a place of privacy, with supportive staff, sufficient medicines provided with right advice of how to administer etc. play a key role in deciding the pattern of utilisation of health services. If 70 per cent of the women seek treatment in government hospitals, there could be only two reasons: either they are satisfied with the services or, even if dissatisfied, they cannot afford to go to a private facility. We saw in Chapter III that the majority of the people are not so poor as not to be able to afford treatment for their illness. Therefore, the fact that they went to government hospitals can only show that they are not unhappy with the services available there. In order to understand the client satisfaction, the components of satisfaction were broken down into a series of questions and were posed to the clients. Table 8.5 reveals the factors that influence client satisfaction.

Table 8.5 Determinants of Client Satisfaction of Ever Married Women who used Public Facilities (%)
Determinants Urban Suburban Total
Slum Non-slum
Service time convenient Yes 93.1 100.0 95.3 94.6
No 6.9 0.0 4.7 5.4
Easy to reach Yes 90.6 76.5 81.2 86.0
No 9.4 23.5 18.8 14.0
Whether Doctor/ Nurse Available Yes 96.9 100.0 97.6 97.5
No 3.1 0.0 2.4 2.5
Privacy Yes 67.9 88.2 84.7 75.5
No 32.1 11.8 15.3 24.5
Staff supportive/friendly Good 82.4 100.0 95.3 88.5
Poor 17.6 0.0 4.7 11.5
Quick attention Yes 21.4 29.4 32.9 25.9
Long wait 78.6 70.6 67.1 74.1
Availability of medicine Yes 32.7 20.6 30.6 30.6
No 67.3 79.4 69.4 69.4
Received Instructions to use
medicine
Yes 96.9 100.0 98.8 97.8
No 3.1 0.0 1.2 2.2
Treatment effective No 13.2 8.8 12.9 12.6
Can't say 36.5 32.4 34.2 35.3
Consulting fee paid Yes 17.6 20.6 8.2 15.1
No 82.4 79.4 91.8 84.9
Good enough to recommend to others Yes 84.3 97.1 94.1 88.8
No 15.7 2.9 5.9 11.2
Total 100.0 100.0 100.0 100.0
Number 159 34 85 278

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8.3.3 The data above indicate that as high as 95 per cent found the timing to be convenient, 86 per cent the facility to be within easy reach, the proportion being the highest in the slums (90.6 per cent), and about 98 per cent found the nurse and doctor to be available when they visited the health facility. About three fourths were satisfied about privacy in the examination room, 89 percent about the behaviour of the staff and 98 per cent about the instructions given by the staff for taking medicine. A majority (52.3 per cent) found the treatment to be effective. In spite of the common complaint that the Doctors in government hospitals would not give proper attention without paying fees, the data reveal that 85 per cent did not pay fees to the doctor. A whopping 89 per cent would recommend public facilities to others. As far as negative feedbacks are concerned, around three fourth (74.1 per cent) found the waiting time to be long andnearly 70 per cent did not get all the medicines.

8.3.4 The survey also collected information on the reasons for not seeking medical help from public health facility. Out of the sample of 1262 women 398 sought treatment and, as stated above, only 120 of them went to private hospitals, making 30 per cent. These persons were asked the reasons for not going to public facilities. The response is given in Table 8.6.

Table 8.6 Reasons for Not Using Public facility by Ever Married Women
Reasons Urban Suburban Total
Slum Non-slum
Not conveniently located 19.4 17.7 20.8 19.2
Timings not convenient 4.8 0.0 0.0 2.5
Poor quality of service 38.8 14.7 29.1 30.0
Heavy rush 6.4 2.9 8.3 5.8
Non-availability of Doctors 0.0 0.0 0.0 0.0
Rare availiability of Doctors 0.0 0.0 4.2 0.8
Doctors do not examine properly 4.8 8.8 4.2 5.8
Medicines not/rarely given 3.2 0.0 8.3 3.3
Medicines are of bad quality 1.6 2.9 4.2 2.5
Doctor/staff do not behave properly 0.0 0.0 0.0 0.0
Services are charged 3.2 0.0 12.5 4.2
Prefer Private Doctors 17.8 52.9 4.2 25.0
Others 0.0 0.0 4.2 0.8
Total 100.0 100.0 100.0 100.0
Number 62 34 24 120

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8.3.5 The largest group (30 per cent) was driven to the private hospital by the poor quality in public facilities, more in the slums (39 per cent) than in the other two areas. This is not much different from the general population where this group was found to be 34 per cent (Table 8.2 above). It is to be noted that only about 15 per cent in the non-slums gave poor quality as the reason. The next largest group is 25 per cent who simply prefer private doctors, a very high proportion (53 per cent) in the non-slum areas. This can be compared with the group of 21 per cent of the general population who expressed lack of confidence in public facilities. Nearly 20 per cent were driven by the distance, less in the non-slums, whereas among the general population it was 34 per cent. Heavy rush has driven only 5.8 per cent of the women to the private facility and 4.2 per cent of the general population.


8.4 Ever-Married Women (15-49 Years)

8.4.1 So far we have considered the question whether public facilities met the needs for general ailments by all and by Ever Married Women of all ages. As our focus narrows to reproductive health we also narrow the sample to Ever Married Women in the reproductive ages. The questioning on reproductive health started with their menstrual problems. We saw in Chapter V that out of the total of 855 only 71 women had menstrual problems and out of them only 42 went for treatment. It is noteworthy that 31 of them (73.8 per cent) went to public facilities.

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Table 8.7 Choice of Facility for Menstrual Problems (%)
Facility Urban Suburban Total
Slum Non-slum
Government 66.7 80.0 87.5 73.8
Private 33.3 10.0 12.5 23.8
Others 0.0 10.0 0.0 2.4
Total 100.0 100.0 100.0 100.0
Number 24 10 8 42

8.4.2 The reasons why others did not go are in Table 8.8. The size of the sample is too small to draw inferences.

Table 8.8 Reasons for Not Choosing Public Facilities for Menstrual Problems (%)
Reasons Urban Suburban Total
Slum Non-slum
Not nearby 12.5 0.0 0.0 9.0
Poor quality 37.5 50.0 100.0 45.5
Others 50.0 50.0 0.0 45.5
Total 100.0 100.0 100.0 100.0
Number 8 2 1 11

8.4.3 We also saw in Chapter V that 761 of the sample could be asked about their last pregnancy and found that 698 had gone for antenatal check up. As can be seen in Table 8.9, public facilities were the choice of 81 per cent of women.

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Table 8.9 Place of Ante-Natal Check up (%)
Facility Urban Suburban Total
Slum Non-slum
Government Hospital 84.1 57.0 92.9 80.3
Government Dispensary 0.8 0.0 0.0 0.4
Government Sub center 0.5 0.0 0.0 0.3
Private Doctor/Hospital 14.6 43.0 5.9 18.7
Doctor's House 0.0 0.0 1.2 0.3
Total 100.0 100.0 100.0 100.0
Number 378 151 169 698

8.4.4 This again shows that public facilities are quite popular. When we probed the reasons for not using public facilities the answers we obtained show that the largest group (42.4 per cent) did so due to the poor quality in public facilities. We can reasonably club this with the 16.7 per cent of them who gave the better quality in the private facility as the reason. Together this makes 59.1 per cent. In the non-slums it is nearly 57 per cent. This is higher than the previous two samples. Inconvenient location was the factor that drove 21.2 per cent of the pregnant women to the private sector for antenatal check up.

Table 8.10 Reasons for Not Going to Public Facility for Antenatal Check up (%)
Reasons Urban Suburban Total
Slum Non-slum
Not conveniently located 25.9 18.4 15.4 21.2
Poor quality of Service 51.9 69.2 38.4 59.1
Fees should be remitted 22.2 3.1 7.7 11.4
Non-availiabilty of service 0.0 0.0 7.7 0.7
Did not feel necessary 0.0 3.1 23.1 3.8
Unhygienic condition 0.0 6.2 7.7 3.8
Total 100.0 100.0 100.0 100.0
Number 54 65 13 132

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8.4.5 Generally, the reasons are not much different from those put forward for general ailments by men and ever-married women. However, a new reason has come up, namely `fees have to be remitted`. On further probing this answer was found to mean the long procedure and the waiting for remitting the fees rather than the amount of fees, which is quite small.

8.4.6 Some women had other health problems during pregnancy. A total of 64 of them went in for consultations. As can be seen in Table 8.11 about two thirds of them went to government doctors and facilities. The reasons for going to others were not probed.

Table 8.11 Consultation for Problems During Pregnancy (%)*
Reasons Urban Suburban Total
Slum Non-slum
Government Doctors and facilities 69.0 40.0 78.6 68.0
Private Doctor 31.0 50.0 21.4 32.1
Total 100.0 100.0 100.0 100.0
Number 36 10 18 64

Note: One person (10 per cent) in the non-slum visited doctor at home. Adding this, it will be 100 per cent. But many in the other categories visited doctors at home also, which is not included in the table.

8.4.7 We continued this probing on the utilization of public services into the next step, namely deliveries. Here also the proportion was substantial, with nearly three fourths utilizing them.

Table 8.12 Place of Delivery (%)
Place of Delivery Urban Suburban Total
Slum Non-slum
Government Hospital 76.1 63.4 83.7 74.9
Private Hospital 14.8 32.7 12.6 18.4
Home 9.1 3.9 3.8 6.6
Total 100.0 100.0 100.0 100.0
Number 378 151 169 698

8.4.8 The reasons for not going to government facilities are the same as in the other cases, poor quality and distance dominating them.

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Table 8.13 Reasons for Not Going to Government Hospital for Delivery (%)*
Reasons Urban Suburban Total
Slum Non-slum
Not conveniently located 30.7 24.0 52.2 31.7
Poor quality of Service 33.3 62.0 39.1 44.9
Delivery attended by male 11.1 2.0 0.0 5.9
Costs involved 15.9 0.0 0.0 7.4
Unhygienic conditions 0.0 6.0 0.0 2.2
Others 9.6 6.0 8.7 8.1
Total 100.6 100.0 100.0 100.2

Interestingly, about 6 per cent opted out of government facility because the delivery is attended to by male doctors, more than 11 per cent in the slums. Nearly 16 per cent in the slums mentioned the costs involved as the reason. This would refer to the informal payments to be made to the staff and the expenses for buying medicine etc and the procedure for payment. It is not that public facilities are costlier than private ones.
8.4.9 Out of the total of 855 ever married women, 813 were currently married. Thirty of them were pregnant. The remaining 783 were asked about their contraceptive use and the results are discussed in Chapter V. A total of 449 currently married women have undergone sterilization. Of them 425 accepted it in public facilities and 24 in private hospitals (Table 8.14). The percentage of women who did not use public facilities is only 5.3.

Table 8.14 Place of Sterilisation (%)
Facility Urban Suburban Total
Slum Non-slum
Government 98.0 82.7 95.8 94.7
Private 2.0 17.3 4.2 5.3
Total 100.0 100.0 100.0 100.0
Number 248 81 120 449

8.4.10 As for the reasons for not going to public facilities, the picture is not much different from the other uses. Nearly 71 per cent were deterred by the distance, 16.6 per cent by the unhygienic conditions and about an eighth by poor quality.

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Table 8.15 Reasons for not using Public Facility for Sterilization (%)
Reason Urban Suburban Total
Slum Non-slum
Poor quality of service 20.0 7.1 20.0 12.5
Not convenient 80.0 64.2 80.0 70.8
Unhygienic 0.0 28.6 0.0 16.6
Total 100.0 100.0 100.0 100.0
Number 5 14 5 24


8.5 Children Below 2 Years

8.5.1 The only question pertaining to public facility probed about children was the place of immunization. A total of 95 children were immunized (fully and partly), 68 of them in public facilities, the percentage being 71.5. The reasons for not seeking public facilities were not probed in this case.

Table 8.16 Place of Immunisation (%)
Reasons Urban Suburban Total
Slum Non-slum
Government Hospital 63.5 63.2 66.7 64.2
Primary Health Centre 3.8 0.0 8.3 4.2
Immunisation Camp 3.8 0.0 0.0 2.1
Sub Centre 1.9 0.0 0.0 1.0
Private Hospital 25.0 36.8 20.8 26.3
Don't Know 1.9 0.0 4.2 2.1
Total 100.0 100.0 100.0 100.0
Number 52 19 24 95

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8.6 Summary of Choice

8.6.1 If we summarise the responses from these various groups on where they went for their health needs and why, we can see that a large majority of them went to public facilities.

Table 8.17 Summary of Choice of Treatment Facility (%)
Group Number Government Private Others
All samples for general illness 540 67.0 30.9 2.1
All samples for treatment for fatal illness 92 23.9 53.3 22.9
Ever married women of all ages for general illness 398 69.8 30.2 0.0
Ever married women (ages 15-49) with menstrual problems 42 73.8 23.8 2.4
Ever married women (ages 15-49) for antenatal check up 698 81.0 19.0 0.0
Ever married women (ages 15-49) with problems during pregnancy 64 68.0 32.0 0.0
Ever married women (15-49) for delivery 698 74.9 18.4 6.6
Ever married women (15-49) for sterilisation 449 94.7 5.3 0.0
Children for immunisation 95 71.5 26.3 2.1
Total 3076 75.3 22.0 2.7

8.6.2 It reiterates the inference that public facilities are quite popular. Except for illnesses which ultimately led to death, more than three fourths of the sample and its sub groups have gone to public facilities for general illnesses and problems of reproductive health. It is as high as 95 per cent for female sterilization. Overall about three fourths used public facilities. This negates the general impression that public facilities are run badly and people would avoid them. In fact when the women were asked whether they were satisfied about the services provided by public facilities, nearly three fourths of them answered in the affirmative (Table 8.18). Even most of the others were partially satisfied.

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Table 8.18 Level of Satisfaction by Ever Married Women of All Ages (%)
Level Urban Suburban Total
Slum Non-slum
Fully satisfied 71.0 73.5 79.1 73.3
Partially satisfied 25.8 23.5 20.8 24.2
Not satisfied 3.2 3.0 0 2.5
Total 100.0 100.0 100.0 100.0
Number 62.0 34.0 24.0 120.0

8.6.3 However, a rider is in place here. Trivandrum is the capital of the state and is better served, medically. The Government runs a super specialty teaching hospital with about 1200 beds and four other big general hospitals, 1154 beds in two facilities out of this are exclusively for women and children. It is not like a rural area where there is only a sub centre with an Auxiliary Nurse-Midwife for a population of 5000, a Primary Health Centre with at least one doctor for 25,000 and a Community Health Centre with at least four doctors for 100,000. Some of this infrastructure is also available in the City. For finding out the type of public facility used we asked the ever-married women of all ages what type of facility they went to. More than 91 per cent answered that they went to Hospitals. Only about 9 per cent used the other rural-like infrastructure, as can be seen in the table below. Therefore the response in this survey cannot be taken as the representative opinion of consumers of public health facilities in the State.

Table 8.19 Choice of Public Facility for General Illness by EMW of All Ages (%)
Place of Treatment Urban Suburban Total
Slum Non-slum
Government Hospital 93.7 91.2 84.7 90.7
Community Health Centre 1.2 0.0 3.5 1.8
Primary Health Centre 3.1 8.8 11.8 6.5
Sub Centre 1.9 0.0 0.0 1.1
Total 100.0 100.0 100.0 100.0
Number 159 34 85 278

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8.6.4 We tried to find out whether it is poverty that drives people to public health facilities where the services are practically free. But we saw in Chapter III that if we go by expenditure pattern, those who spent below Rs.500 a month are only 8.6 per cent. If we go by income, only 15 per cent are with less than Rs.1500 per month. As about three fourths of the people use public facilities, the reason would not be lack of affordability. In fact, we saw in Table 8.18 that most of the women are satisfied with the quality of services and about 90 per cent would recommend it to others Thus, there appears to be genuine reasons of acceptance for using public facilities. However there is a significant proportion of people who do not go to public facilities and for them distance and poor quality are the two major reasons. The factor of distance, as appearing in various tables, should be considered cautiously. The perception on distance is relative and can vary among different population groups such as total population, ever married women of all ages and of reproductive age.

Table 8.20 Summary of Reasons for Choice of Facilities
Reason All sample EMW for all illness Menstrual Problem ANC Delivery Sterilisation
Disrtance 34.1 19.2 9.0 21.2 31.7 70.8
Poor quality 28.7 30.0 45.5 59.1 44.9 12.5
No confidence 21.0 25.0 0.0 0.0 0.0 0.0
Lack of cleanliness 1.2 0.0 0.0 3.8 2.2 16.6
Others 15.0 25.7 45.5 15.9 21.2 0.0
Total 100.0 100.0 100.0 100.0 100.0 100.0
Number 167 120 10 132 128 24

8.6.5 Lack of cleanliness and lack of confidence in the ability of the facility to cure the patients form the next two reasons. Other reasons vary among the groups and include items like heavy rush, bribery, relatives’ influence, non-availability of medicine etc as given in the individual tables in the relevant paragraphs. In the next chapter we deal with the suggestion for the improvement that came up in the in-depth interviews with community leaders, health activists etc.

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IX. Suggestions forImprovement of Public Health Facilities

9.1

This study envisaged in-depth interviews with community leaders, providers, programme managers, health activists and decision makers also with a view to validating the data on qualitative aspects provided by the household respondents and to enlist the opinions as well as suggestions of the former. In this endeavour, the information from various groups of respondents from households was used as the reference material. There were several suggestions and opinions commonly expressed by belonging to different groups. We have analysed various suggestions and collated them under specific issues.


9.2 Shortage of Drugs

9.2.1 The community leaders were of the impression that because of the general dissatisfaction with public health facilities, slum dwellers were not going to the nearby Government hospitals and health Centres for treatment. They were surprised to know that the vast majority of slum dwellers and others went to public facilities and that most of the women expressed satisfaction about the services there. Some community leaders even doubted the veracity of the responses. It took an explanation of the methodology and of the detailed fieldwork involved, to convince them. But one suggestion they all had in common was that more medicines should be made available in the government facilities. When this was taken up with the Director of Health Services and the Principal Secretary to Government for Health and Family Welfare they both pointed to the perennial shortage of funds in the Department. The Health Department spends about Rs.500 million on the purchase of drugs alone. But due to the ways and means position of the Government, they are not able to release this fund (like all other departments) in time and therefore the drug suppliers are not being paid their bills. This interrupts the supplies.

9.2.2 Some of those interviewed doubted whether shortage of funds is the only problem. According to them, sometimes drugs lie undistributed in the medical stores while there is acute shortage in the hospitals. According to them, this is more of a problem in the rural areas. The logistics of distribution have to be streamlined. Some of the leaders pointed out the system in the neighbouring state of Tamil Nadu where a separate corporation has been formed by the Government for drug distribution. But the Principal Health Secretary to Government stated that the success of the Tamil Nadu system depended on the funds for drug purchase being given to this corporation at the beginning of the year itself. No doubt, there are many things in the Tamil Nadu system that can be introduced in Kerala. But unless funds are made available no system will work. Thus the crux of the problem is the financial crisis the state is passing through.

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9.3 Shortage of Manpower

9.3.1 The second major deficiency pointed out by the community leaders, providers and programme managers is the shortage of manpower in hospitals and other facilities. The shortage is so acute that sometimes one nurse has to cater to more than one ward and samples have to be taken to the private labs outside for investigation. Many of those interviewed stated that the visits to public facilities by patients will be even higher if there are doctors, lab technicians and nurses in adequate number. While probing to find out the reasons, it came out that the procedure of recruiting manpower through an independent statutory body is a long drawn out one. The time lag between requisitioning the staff and getting them in position is 2-3 years. Advance planning can be done only for vacancies caused by retirement. But a large number of people go on leave. The practice of granting leave upto fifteen years for taking up other jobs abroad and even within the country came in for very sharp criticism from the health activists. This practice may be appropriate in other sectors where there are plenty of people to work. But in the health sector where there is a perennial shortage of doctors, nurses, lab technicians, pharmacists etc, this is totally illogical. But in spite of the political leaders agreeing with the illogicality0 of granting leave in the face of shortages, successive governments by different political affiliations have done nothing about it. Thinking people pointed out that pressure from the unions of employees is the reason.


9.4 Environmental Issues

9.4.1 The third issue that came up is the need to emphasize on preventive care. Many of those who interviewed brought to light the health hazards to which present day living in crowded environment exposes people. Many suggestions came up on this. The foremost was the need to provide drainage, sanitation, waste removal and protected water in the slums. We saw in Chapter III that 72 per cent of the households do not have drainage facility, nearly two-thirds of the houses in the slums, nearly 60 per cent in the non-slum areas and almost all in the suburbs. Trivandrum used to be called the cleanest city in the country earlier. However the claim to this distinction looks dubious in the face of the lack of drainage. It is due to the topography of the land that there is not much stagnation of water. The danger of outbreak of epidemics cannot be ruled out. A priest near one of the slums in the coastal area brought to our attention the outbreak of malaria in that locality in the first half of 1996. The cases were initially imported but soon it spread to large areas threatening to blow into an epidemic. It was the concerted effort of the health department, the Church and other non-governmental agencies that put an end to this. Such situations can develop again in the city with such poor drainage.

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9.4.2 We also saw in Chapter III that 24 per cent of the households do not have latrines, 35 per cent in the slums. The majority of them use open ground as toilets, the use of public toilets being confined to a third of them. The community leaders blamed the city authorities for the bad upkeep of public toilets. However, some health activists suggested that it would be better to introduce pay-and-use toilets, which have been found to be very successful in some other parts of the country. This is worth pursuing.

9.4.3 Waste removal was pointed out by the respondents, the community leaders and by nearly all others as the major problem in sanitation. Nearly every respondent complained about it. The city authorities stated that they have found a solution to this problem by erecting a garbage treatment plant nearby. However, the residents around the newly erected plant have been objecting to the transportation of garbage to that area and its treatment there as it poses a health hazard to them. The current position is that this expensive new plant does not get enough garbage, which continues to accumulate in the streets and slums, and the removal is as unsatisfactory as before.


9.5 Safe Drinking Water

9.5.1 The next suggestion for preventive care was the provision of protected water in all the homes. We saw in Chapter III (Table 3.11) that only a third of the houses have running water inside and two-thirds of the houses in slums bring water from the public tap in the street. This situation can be remedied only by investment in a water augmentation scheme.

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9.6 Strengthening of Primary Centres

9.6.1 The major problem in government hospitals pointed out by all, is the heavy rush of patients. This is more so in the specialty hospitals. At the same time the utilization of centers for maternity care and primary health care is very poor. The people tend to rush to tertiary hospitals and overcrowd them. Many leaders said that this is because the quality of service in the primary centers is very poor. The answer is to staff them adequately, make drugs available and keep them clean. After doing this, the specialty hospitals can be made truly and strictly referral hospitals facilitating a two-way reference for the patients.


9.7 Cost Recovery

9.7.1 A question arises whether the Government can provide all services to all free. If there is improvement in quality, the people who get attracted to public facilities are those who have been paying for their care in private facilities. At the same time the quality cannot be kept low for fear of serving the rich. This can be described as the Public Health Conundrum. Purely from an objective standpoint, poor quality is a self-targeting mechanism as only those who cannot afford better quality will go to a poor facility. But it is totally an anti-egalitarian move as the poor have an equal right to good quality services as the rich. The only way out of the conundrum is to charge the rich who use public facilities. The Principal Health Secretary pointed out the attempts have been made by the health department for charging fees from those who can afford and keeping the money in the Hospital Development Committee for improving the facilities in the hospital. While a proper mechanism for means testing is still to be evolved, this system has helped in stretching the health budget and providing improvements not possible under the budget. He showed the example of the teaching hospital in the city, which has a Hospital Development Committee where political parties and public men are represented. They are allowed to collect user fee and keep it with them. They also run a medical store. The money collected has been used for improving facilities like putting up a Cardiac Catheter Lab, appointing security staff, etc. The budgeted expenditure for running this hospital in 1998-99 was Rs.330 million and the income of Hospital Development Committee was about 30 million. The state Government intends to make the other hospitals follow this example.

9.7.2 However the need for support from the state budget was emphasized by all. They reminded us of the importance given by the Monarchs of the state for health and education which is the primary reason for the present high status in both. But there is some complacency now and the share of health in the state budget has steadily come down from 16.27 per cent in 1974-75 (Panikar and Soman, 1984) to 11.41 in 200-01 (GOK, 2000b). Our subjects here took strong exception to this. This is a dangerous trend and has the potential of undoing the gains of the past. They are of the view that at least the status quo ante should be restored. After all, the need of the hour in a state like Kerala is to improve the quality of population, especially the health status of women and

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9.8 Partnership with Private Sector

9.8.1 In the context of the declining share of health in the state’s budget and the rising expectation of the people about modern healthcare, some pointed to the need for seeking a partnership with the private sector. In India, more than 80 per cent of the health expenditure is in the private sector and the picture in Kerala is not different. Instead of keeping such a major provider of health care at arms length, the government should rope in their help in public health programmes as well as in general health care. However, many also spoke of the need for regulating the conduct of the private sector when it touches the boundaries of ethics.


9.9 Geriatric Care

9.9.1 The need for geriatric care was emphasized by many. With a successful demographic transition, the number of the elderly has risen fast in the state. Against an all India figure of 7.9 per cent, Kerala has 10.0 per cent of its people above 60 (IIPS and ORC Macro 2001) The population above 70 has gone up from 3.41 per cent in 1991 to 4.95 in 2001 in the State (Rajan 2000) Families have become nuclear and with 2.05 million people working outside the state (Zacharia et al.1999), the elderly are left to fend for themselves. There is need for old age homes, geriatric wards and starting geriatric medicine as a speciality in the medical curriculum. There is also the need for encouraging NGOs to provide home nursing for the elderly.


9.10 Organisational Aspects

9.10.1 The next problem raised by city leaders and program managers is the dichotomy in the organization of health services in the city. The responsibility of health care in the city is with the Director of Health Services who runs the general and other hospitals and the Director of Medical Education who runs the teaching hospital. The city corporation which has a health department headed by a medical doctor is more or less confining its health activity to sanitation. Some of the city councilors who were interviewed were of the opinion that the city can take care of the health of the people in its entirety. But the health administration in the state Government and the health activists who were interviewed were of the view that such a change in the organization of public health provisioning is not called for as it will not bring any benefit to the public.

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9.11 Autonomisation of Hospitals

9.11.1 Another important suggestion was about the need of introducing greater autonomy to the major hospitals in fund utilisation and generation. Currently, the Superintendents of hospitals have to go through a cumbersome procedure for purchase equipments and consumables. It is so long- drawn that in many years, huge chunks of allocated funds go unutilized.

9.11.2 If the heads of the departments of major hospitals and the medical superintendents are given more autonomy in the utilisation of funds, this could be avoided. Each department can be made a budget centre and they can also be permitted to recover costs as much as possible without impinging on social equity. Such an innovative step could go a long way in motivating them in generating the much needed additional resources. A successful case is that of the Regional Cancer Centre Trivandrum, which was originally the Radiotherapy department of the Government Medical College and was transformed into an autonomous society in 1981. Though the bulk of the finances still come from the state budget, it now raises substantial resources externally from agencies like WHO and research organizations and internally from patients who can afford payment. More than half of its running cost is r