Kerala study reveals health amidst poverty

A study conducted in the slums of Kerala shows good general health even in conditions of povety. V Vijayachandran gives an account of the study and suggestions to improve public health system

Here is a city whose slum population is nearly as healthy as its affluent neighbours. Trivandrum is a paradox of high health amidst poverty and stands out among the 28 states of the country. Its 32 million people have an average life expectancy of 72 against 66 for the one billion in the country and an infant mortality rate of 16 against country’s 72. The census of 2001 revealed that the annual growth of its population has come down from 2.3 per cent in 1961-71 to 0.89 in 1991-2001, while the country’s is still growing at 1.8. But state’s per capita income was lower than the average for states for several years and just crossed the average in the last few years with about 423 dollars.
However, the health thinkers have been suspicious of these averages and believed that there would be pockets of ill health tucked away in these statistics. They pointed to three such possible areas, the first the tribal population in the hills, the second the fishermen in the coasts and the third the poor in the slums of the cities. Studies have found this suspicion to be true in the case of the first two. But no field study appears to have been done to test this hypothesis about the third. Professor of Demography, University of Kerala, also the director of the Population Research Centre, Deputy director of that Centre who is a PhD in Statistics and this author conducted a study to prove that this is not true of slums in Trivandrum (with some notable exceptions).

It would not be wrong to suggest that it is not true about the slums of the other urban areas of the state, as they are similar in characteristics of housing, education health infrastructure, nutrition and the like. The study had two parts, the first, a survey of one thousand households and the second a set of in-depth interviews. The sample of 1000 households had 4297 members and was considered adequate for the city’s population of 750,000 living in 141.74 square kilometres. There are thirty-six identified slums in the city where about 12,000 people live. We grouped these slums according to size and selected 500 households from them for our survey following the techniques of systematic sampling with a random start and ’Probability Proportion to Size’. In October 2000 five rural areas surrounding the city were added to the city and these had no designated slums. We found 47 slum-like settlements. As they were rural till recently and were only semi-urban in their nature, we called them suburbs and selected 250 households among these settlements following the same techniques.

Similarly, we selected 250 households from the rest of the city to provide the foil. Thus we got the slums, the suburbs and the non-slums for our survey. Eight well-trained enumerators of both the sexes approached the 1000 households with a well designed and pre tested questionnaire, aided by a manual and closely supervised by experts, from February to May 2001. The result of the survey were processed and analysed using the Statistical Package of Social Sciences.

The second part of the study was in depth interviews. Armed with the findings of the survey, an experienced social demographer with an expert in mass communication and sociology conducted in-depth interviews with fifty six functionaries who were carefully selected from community leaders, service providers, programme managers, policy makers, non-governmental organisations and health activists. The study revealed that slum dwellers do not lag behind the others in general and reproductive health. In fact, in the incidence of morbidity in the slums and suburbs at 128 and 121 per thousand are lower than the non-slums at 145.

Out of the 274 persons in the slums who went for treatment during the month previous to the interview, 85 lost their wages and 147 had to raise money from other sources for treatment, most of them borrowing and some pledging or even selling assets. Against the backdrop of the revelation in a study of the World Bank that hospital expenses alone push 2.2 percent of India’s population below the poverty line every year, this data assumes great importance and emphasises the need for a health insurance for the poor.

When we come to the reproductive health of women we notice the same trend as in general health - the standard quite high, but lower than the non-slums. The survey found the menstrual health of both married women and adolescent girls to be good. The fact that more of them in the slums and suburbs had more than one abortion than in the non-slums is a matter of concern. Nearly all of them had antenatal check up in the previous or current pregnancy, mostly starting in the third month. The number of antenatal visits is about 7, the slums showing no let up.

Even in the components of the check up neither the overall sample nor the slums showed any shortfall. No wonder, the vast majority of them did not have any problems during pregnancy. As one would expect from a literate population living in a city with good health infrastructure, most of the deliveries took place in institutions, slums falling slightly behind the other two areas. But even in the home delivery in the slums, doctors or paramedics were present in most of the cases. Again, the majority of them had normal deliveries without any problems resulting in live births, whether in the slums, suburbs or non-slums.

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

The awareness of AIDS, Sexually Transmitted Diseases (STI) and Reproductive Tract Infections (RTI) is an important aspect of reproductive health of women, adolescent girls and men. Our study revealed that among all these groups awareness is quite high, with some differences in degree. The awareness about HIV/Aids is the highest among girls, followed by men and married women. But while about 77 per cent of the married women in the slums are aware of HIV/Aids only 55 per cent are aware of RTI and 52 per cent of STI. This gap is noticed in the suburbs and non-slums as well as in the slums and is true about men and adolescent girls also. Government of India has special programme for increasing the awareness of HIV/Aids through the National AIDS Control Organisation, which seemed to have had its impact.

But the same vehicle could have been easily adapted to spread the message about the other two important groups of conditions. Alas, this was not to be! Aids is handled by the Department of Health while the other two are by the department of Family Welfare, though both constitute the Ministry of Health and Family Welfare headed by one Minister of Government of India. The health activists who were interviewed were very critical of this lack of coordination. Our next probing was about the utilisation of public health facilities and their opinion about it. Usually there is a lot of criticism in the media about the inadequacy of public facilities and the impression one gathers is the people are dissatisfied with the services and they do not resort to it in need. But to our surprise, we found about two thirds of the sample utilised them. In fact, for reproductive and child health care it is even higher. They are not driven to public facilities by poverty, as the figure is the same in the non-slums. Among the one third who did not utilise them, distance and lack of faith were the dominant reasons, other reasons like delay, bribery and lack of cleanliness lagging far behind. Nearly three fourth of the married women are fully satisfied with the quality of service provided, even the women from the non-slum areas.

When we met the respondents from various groups with these findings for in-depth interviews about their opinion on public health provisioning in the city, some of them refused to believe the veracity of the findings, as they were so much exposed to the gloomy picture of public facilities projected by the media. The scientific nature of the survey had to be explained to convince them.

The study group’s views about the problems that beset the public health system and suggestions for improvement are listed below:

• Shortage of drugs and consumables in the hospitals: Allocate more funds in the State budget for health. Its share has come down from over 16 per cent in 1974-75 to under 12 in 2000-01. At least retain the old proportion. Also improve logistics of supplies.
• Shortage of manpower: Stop the practice of granting long leave to medical personnel for taking up employment abroad.
• Environment hazard in the slums: Drainage and waste removal must be attended to as priority. If the City cannot maintain public toilets, pay-and-use toilets may be introduced and the upkeep entrusted with private agencies.
• Introduction of user fee collection from those who can afford will fetch the much-needed revenue to the system and reduce the overcrowding. A small experiment is already in place where the Hospital Development Committees are allowed to charge user fees and utilise them for the development of the hospital. This should be expanded. Another suggestion is to develop a partnership with the private sector, which is well developed in the State.
• Poor facilities for the aged: With the demographic transition and increased longevity, the proportion of the aged has increased in the State. The number of people above 70 has gone up from 3.4 per cent in 1971 to nearly 5 per cent in 2001. Geriatric care should be introduced in the medical curriculum and NGOs encouraged and assisted to set up old age homes and provide home nursing. q Poor health awareness of the people: Better health education is called for. Community based organisations and NGOs should be roped in for this.
• Financial burden of illness: This can be addressed only by an appropriate health insurance scheme that protects the poor against the financial risks from catastrophic illness. The city and the State with near 100 per cent literacy are ideally suited for introducing such a scheme. It can be thrown open to the private sector, but the need for regulating their practices and protecting the poor cannot be overemphasised.

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

(The author was the principal secretary to Government of Kerala for health, family welfare, sports and youth affairs. He may be contacted at vijaychandran@rocketmail.com)