Banerjee Thesis

7/27/2019 Banerjee Thesis

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ChildHealthandImmunizationStatus

inanUnregisteredMumbaiSlum

AThesisSubmittedtotheFacultyoftheDepartmentofGlobalHealthand

PopulationHarvardSchoolofPublicHealthinPartialFulfillmentofthe

RequirementsfortheDegreeofMastersofScience.

Boston,Massachusetts

JoyaBanerjee

14May,2010


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Acknowledgements

Thisthesisdrawsuponfindingsfromathree-yearurbanhealthstudy(2009-2011)bytheHarvardSchool

ofPublicHealthandtheIndianresearchcollectivePUKAR(PartnersinKnowledge,ActionandResearch),

supportedbytheRockefellerFoundation.Thestudy,ExploringthePhysicalandSocialDeterminantsof

Urban Health is currently underway in the unregistered urban slum settlement, Kaula Bandar inMumbai, India. My sub-study on urban child health and immunization status was conducted in

collaboration with my research partnerTejal Shitole, from June-August 2009 andDecember-January

2009/10.

IwouldliketothankAnitaPatil-Deshmukh,ExecutiveDirectorofPUKAR,forbeingmysecondthesis

reader,abrilliantmentorandsupervisor,andaboveall,ateacherofformativelessonsthatcouldnever

belearnedfromabookorinaclassroom.IwouldliketoexpressmydeepgratitudetoTejalShitole,

without whom this project would not have been possible, aswell as to Kiran Sawant and Shrutika

Shitole,fortheirstrongcommitmenttotheKaulaBandarcommunity,theirpatience,deepknowledgeof

thecommunity,andcreativenessindevisingsolutionstoentrenchedproblemsinIndiasresource-poor

populations.

DavidBloom,myfirstthesisreader,hasbeenaconstantsourceofinspirationandinsight-thankyoufor

including me in this formidable experience. Adriane Lesser and Heather Lanthorn, HSPH students

workingwithmeduringthefirstpartofthestudyinMumbai,wereincrediblealliesintheirabilityto

applytheirknowledgeandskillstotheproblemsathand,andtohelpmeovercomemanychallenges

andconfusionsduringthe surveydesignandresearchprocess. Iowemysinceregratitudeto Jennifer

OBrien andMarija Ozolins for their diligence, research assistance, logistical support, and continued

feedback.SiddharthAgarwalwaskindenoughtoprovidehiswealthofexpertiseonchildimmunization

inIndiaandgraciouslymadehimselfavailabletomeformymanyquestions.KirtiGheiandSimaShah,

whohelpedturnadauntingideaintoanactionableresearchproject,basedontheirprolificexperiences

studyinghealthsystemsinIndia,wereinvaluablesupporters.

Thisthesishasbeenreadandapprovedby:

__________________________________________________

ProfessorDavidE.Bloom

__________________________________________________

&Dr.AnitaPatil-Deshmukh


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TableofContents

Acknowledgements.............................................................................................................................2

Abstract...............................................................................................................................................4

Introduction.........................................................................................................................................5

I.Urbanizationandthegrowthofslums..............................................................................................6

India:GrowingCitiesandUrbanSlums......................................................................................7

II.ChildHealth&ImmunizationCoverageinIndia..............................................................................10

II.ShortcomingsofUrbanHealthDeliverySystems............................................................................12

BarrierstoAccess....................................................................................................................12

AcceptabilityofHealthInterventionsandHealthEducation....................................................13

IV.TheCaseofKaulaBandar..............................................................................................................14

Methods.................................................................................................................................14

Results:KaulaBandarEthnographyandDemographics...........................................................15

KBDemographics............................................................................................................17

ChildHealthandMothersHealthSeekingBehavior........................................................18

MothersHealthKnowledgeaboutImmunization............................................................20

TheHealthImpactofTenure...........................................................................................22

QuantitativeFindings..............................................................................................................23

Methods..........................................................................................................................23

1)Outcome:ImmunizationStatus...................................................................................24

2)Outcome:Mortality.....................................................................................................25

3)Outcome:MothersHealthKnowledgeaboutImmunization........................................25

V.TheWayForward...........................................................................................................................26

TheEconomicBenefitsofImmunization..................................................................................26

StructuringanEffectiveIntervention.......................................................................................27

Incentives:TheLastMile......................................................................................................29

V.Conclusion.....................................................................................................................................30

WorksCited.......................................................................................................................................31

Exhibit1:ChildHealthSurveyData....................................................................................................35

Exhibit2:TheNotificationProcessandtheImpactofTenureonHealth.............................................37


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Abstract

Asof2007,morethanhalfoftheworldspopulationwaslivinginurbanareas,withaboutone-third

(fully1billionpeople) livinginurbanslums.Indiaalone ishometoroughly170millionslumdwellers,

one-thirdofwhomarechildrenunderfiveyearsofage. Thesqualid,congestedlivingenvironmentof

such slums includes limited access tobasic services such aspipedwaterand improved sanitationwhoseabsenceincreasestheriskofinfectiousdiseaseamongchildren.Thisthesisusesthecaseofan

unregistered urban slum, Kaula Bandar (KB), inMumbai, India, toexaminethe determinants of child

mortalityandimmunizationcoverageusingprimaryquantitativeandqualitativedatafromahousehold

survey(n=226households)andfocusgroups.Resultsindicatethatalthoughimmunizationservicesare

widelyavailableinurbancenters,a knowledge-actiongapkeepsimmunization rates lowandchild

mortalityhighinslumcommunities.Inparticular,lackofknowledgeabouttheprotectivebenefitsof

immunization,lackoftrustedchannelsofinfluence,andsystemicbarrierstoaccessinghealthservices

(suchascost,providerdiscrimination,anddistrustofthesystembynon-tenuredslumdwellersatriskof

losing their homes) leave the majority of urban slum-dwelling children unprotected from vaccine-

preventable diseases. A quantitative analysis of the determinants of childmortality, immunization

status,andmothershealthknowledgeofimmunizationrevealsthatunvaccinatedchildreninKBare3.2timesmorelikelytodiebeforetheageof5thanvaccinatedchildren.Dataonhealthdeterminantsand

outcomes fromchildren ingovernment-registered slums arecomparedwith those from unregistered

communities, revealing profound disparities not just between urban non-slum and urban slum

populations, butalsowithin theslum gradient. Forexample, roughly29%of children inKBare fully

immunized,comparedwith69%ofchildreninregisteredslumsreceivingoutsideservices.Similarly,the

infantmortalityrateinKB(58per1,000livebirths)ismorethandoublethatofregisteredslums(25per

1,000livebirths).Lastly,toaccountfortheuniqueconstraintsfacedbyurban-slumdwellers,thethesis

proposescontextuallyappropriateinterventionsthatcouldincreasevaccinationratesandputIndiaon

thepathtowarduniversalimmunizationcoverage.


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Introduction

Asof2007,morethanhalfoftheworldspopulationwaslivinginurbanareas,andoneinthreecity-

dwellerswas living in anurban slum (UN-HABITAT, 2008/9). Thereare approximately 1 billion slum

dwellersintheworld(UN-HABITAT2006/7),andthisnumberisprojectedtogrowto1.4billionbythe

year 2020 (UN-HABITAT, 2008/9). The growthof cities has had positiveimplications formanyurbancitizens:onaverage,urbanareaspresentgreateremploymentopportunities,increasedaccesstohealth

services, higher-quality educational opportunities, and modern amenities and technologies. These

featureshavecontributedtogreatereconomicandhealthoutcomesamongurbandwellers,including

lowerinfantandchildmortalityratescomparedtoruralregions(NFHS-3,2005/6).

Amidtheprosperityofthegreaterurbanlandscape,however,existsaplethoraofslumsthathavenot

necessarilyreapedthebenefitsofgreatercontemporarycityliving.Thestarklivingconditionsinslums

characterized by extreme population density, poor sanitation, and a lack of access to basic health

servicesencourageahostofhealthchallenges.AccordingtoUN-HABITAT,[s]lumdwellersdieearlier,

experiencemorehunger,havelesseducation,havefewerchancesofemploymentintheformalsector

andsuffermorefromill-healththantherestoftheinhabitantsofcities(UN-HABITAT,2008/9).This

environmentishighlyconducivetothedevelopmentandspreadofinfectiousdiseases,especiallyamong

immunonave populations such as children. Research demonstrates that children living in slums

shoulderadisproportionateburdenofdiseasecomparedtotheiradultcounterparts(Cornia,1987),and

the long-term consequences of these childhood illness can be devastating including permanent

stunting,physicaldisability,andlife-longimpairedcognition(Cornia,1987).

Althoughchildimmunizationhasavertedmorethan2.1milliondeathsannuallyandcountlessepisodes

ofillnessanddisability,20%ofchildrenworldwide,especiallythoselivingonlessthan$1aday,remain

unvaccinated (UNICEF2009).Childhood immunizationprovides an opportunity tomitigate childhood

morbidity and mortality in urban slums through the prevention of a host of infectious diseases.

Immunizationhasresultedinlarge-scalereductioninchildmorbidityandmortality,encouragingmany

tocategorizeitasoneofthegreatestachievementsinthehistoryofpublichealth(CDC,1999).Still,despitethepromiseofchildhoodvaccination,coverageamongurbanIndianchildrenremainslow,with

only69%ofchildrenaged12-

23 months considered as

fully vaccinated in Mumbai

(NFHS-3, 2005/6). Data

suggest that coverage rates

among urban poor children

largely living in slums are

approximately 40%, even

lowerthantheurbanaverage

of 58%. (Ghei et al, 2010).Figure 1 shows large

differences in immunization

status between urban poor

and non-poor, and also that

urban and rural rates are

verysimilar.

Figure1:IndiasChildImmunizationStatus

(UrbanHealthResourceCenter,2007)


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InIndiaalone,thereare169millionslumdwellers(IIPS,2009)andthecountryishometo17%ofthe

worldsslumdwellers(UN-HABITAT2008/9).AsthenumberandsizeofIndiasslumscontinuestogrow,

the number of children living in conditions conducive to infectious disease will also increase. This

upward trajectory encourages concentrated efforts to increase coverage of childhood immunization

acrosstheurbanlandscape.

Thisthesiswillusethecaseofanunregisteredurbanslum,KaulaBandar(KB)inMumbaitoexaminethe

determinantsofchildhealthandimmunizationstatus.Itwillexaminetheimpactof:

Barrierstoaccessinghealthinformationandservices Relevanceandacceptabilityofexistinghealthinterventions Landtenure Householdfactors(income,levelofeducation,religion,age,etc.) Healthknowledgeandhealth-seekingbehavior.

DrawingonprimarydatacollectedfromahouseholdsurveyinSummer2009,thisthesiswillassesschild

healthstatusinKBusingthefollowingindicators:childmortalityrates,immunizationstatusofchildren

underfiveyearsold,andmothershealthknowledgeandhealthseekingbehavior.ThecaseofKBwill

alsobeused toexamine theroleof tenurestatusindeterminingimmunizationcoverage;specifically,

dataonhealthoutcomesinKB,anunregisteredslum,willbecomparedtooutcomesfromregistered

slumsbasedoncensusdata,anddatafromtheNationalFamilyandHealthSurvey(NFHS-3,2005/6).

Lastly,throughananalysisofbarrierstoaccessingservices,thisthesiswilloffercontextuallyappropriate

interventionstoscale-upchildhoodimmunizationandimprovechildhealthinIndiasurbanslums.

I.Urbanizationandthegrowthofslums

TheUnitedNationsdefinesslums as communities characterized by insecure residentialstatus,poor

structuralqualityofhousing,overcrowding,andinadequateaccesstosafewater,sanitation,andother

infrastructure (UN-HABITAT,2003).From2000to 2030,theworldsurbanpopulationisprojectedto

grow at anannual growth rate of 1.8%,nearly double the rate of total population growth. In less-

developedareas,theurbangrowthratecurrentlyaverages2.3%(UNPopulationDivision,2005),andfor

slums,therateisdramaticallyhigher,atupto6%peryear(Chatterjee,2002).95%ofthisgrowthinthe

next 40yearswillbe indeveloping countrycities (UN-HABITAT,2008/9). The rapid growthof slums

represents a fundamental transformation of thephysical and social environmentof urban life and

humanhealth(Unger&Riley,2007).

Whereasonlytwocenturiesago,urbanareaswerehotbedsofinfectiousdiseaseandhighmortality,

todayscitiesareonaveragehealthierthanruralareas(UN-HABITAT,2006/7).Themodernizationof

citiesbringsincreasedaffluence,widespreadavailabilityofgoodsandservices,highqualityeducationandinfrastructure,andgreateremploymentopportunitiesforbothwomenandmen( Ibid).Inareport

onurbanhealth ineightIndiancities, theInternationalInstituteofPopulationSciencesnotesthat,It

was often assumed that the heavy concentration of health facilities and personnel in urban areas,

particularlyintheprivatesector,wouldautomaticallytakecareoftheincreasingurbanpopulationand

its health needs (IIPS, 2009). However, because the majority of urban growth has occurred in

developingcountriesthatarealreadystrugglingtomeetthebasicneedsoftheirpopulations,thereare

notenoughphysicians,drugsandfacilitiestomeetthedemandofthelargenumberofpatients.


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Becauseslumsareoftencentersof highmobilityandmigration,a continuous influxofnewpoolsof

infectious agents combined with high population density puts slum dwellers at high risk of

contracting communicable diseases (Agarwal, Sangar & Ghei, 2005). Numerous social determinants

cause poorhealthin slums aswell, including hiddenand hard-to-reach slumpockets, aweaksocial

fabric,socialexclusion,classdiscriminationtowardslumdwellers,alackofcoordinationamongvarious

stakeholdersandapaucityofpoliticalwillandconsciousnesstoaddressthehealthneedsofIndiasmost

marginalized(Agarwal,etal.2005).

UngerandRileypointoutthathealthservicesavailableinslumsareoftencomprisedofaninconsistent

patchwork ofpublic,private, andcharity-based providers. Inadequateor inappropriate care at these

places permits the progression of preventable diseases (Unger & Riley, 2007). Given barriers to

accessinghealthservicessuchascostandproximity,manyslumdwellersoftenwaituntilhealthcareis

absolutelynecessarybeforeseekinghelp.Riley,etal,addthat,theformalhealthsectorencounters

slumresidentsonlywhentheydeveloplate-stagecomplicationsofpreventablechronicdiseases(Riley

etal,2007).

Accordingto theInternational Instituteof PopulationSciences(IIPS),notallslumsarecreatedequal,and striking variability exists across these growing communities (IIPS, 2009). The five shelter

deprivationsUN-HABITATusesasindicatorsofslumstatussanitation(properdisposalofhousehold

andindustrialwaste,andsewagesystems),accesstowater,adequatelivingspace,durablehousingand

thesecurityoftenurediffergreatlywithinandbetweenslumcommunities(UN-HABITAT2006/7).

Oneofthegreatestdifficultiesinimprovingslumhealthistoprovideservicesinareaswhereresidents

are illegally occupying private land. According toUN-HABITAT,up to one-third of theworldsurban

population is constantly threatenedby forced eviction and insecurityof tenure.Many of the largest

slums intheworld,suchasKibera inKenya,KhayelitshainSouthAfrica,OrangiTowninPakistan,and

Dharavi in India, began as illegalsettlements (Peopleof Kibera,2010, Slum RehabilitationAuthority,

2007).Land tenureand landsecurity issues cancreate insurmountable bureaucratic obstacles to theprovision of basic rights,amenities andhealth services, since communities are frequently bulldozed.

Governmentsfearlegitimizing theillegaloccupationof privatelandbyprovidingbasic services.The

uncertainty of land rights significantly deters investments in housing, sanitation, infrastructure and

healthservicesinslumcommunities.

India:GrowingCitiesandUrbanSlums

Indias rapid industrialization, recurring famines,droughts, andcrop failures havespurred large-scale

migration to urban areas, where the burgeoning middle class and affluent elites provide prolificemployment opportunities in Indiasmassive serviceandmanufacturing industries. Figure2 charts a

steadyincreaseinthesizeofIndiasurbanpopulationoverthepastcentury.Infact,2009wasthefirst

year that Indiasmanufacturingoutputovertookagricultural output (Economist,2009).Areas ofhigh

population density are also those where jobs tend to cluster, drawing hundreds of thousands of

migrantseachyeartourbanhubs.Yeta2010studyonthedeterminantsofhealthinurbanslumsargues

that,[t]hecontinuedinfluxofindividualstoacommunityseverelylimitedbytenuredisputessuggests

thatmanymigrantsencouragedbythepromiseandprofitofcitiesareactuallyencounteringapotential


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povertytrap(PUKAR&HSPH,2010).

Upon arrival, many destitute rural migrants

findthattheycannotaffordtheastronomical

housingcostsofmegacitiessuchasMumbai,

and resort to taking up residence in

unregistered urban slums (Sadiq, 2008).

Thereisasevereshortageoflegal,affordable

housing for those at the lowest end of the

wealth spectrum in the largest cities (Ibid).

What little affordable housing is available

tends to be located outside of city centers,

suchthatthecostoflong,arduouscommutesisintroduced(upwardsofthreehoursdaily).

Thelackofurbanplanningleavesaffordable

areassuchasKBisolatedwithlimitedaccess

totransportation,schoolsandservices.Thus

in Mumbai, the second largest city in the

worldwithapopulationofalmost14million

residents, 56%ofMumbaikars1live in slums

(IIPS,2009).OfMumbaispoor(thoseinthe

lowest wealth quartile), almost 80% live in

slums,whichcoveronly6%ofthecitysland

(IIPS, 2009). Figure 3 outlines Indias slum

conditions.

The International Institute of Population

Sciences(IIPS),thebodythatconductsIndias

National Family and Health Survey (NFHS),

defines slums according to characteristics

1ResidentsofMumbai

Figure2:UrbanGrowth

(IIPS,2009)

Figure3.

IndiasUrbanSlumConditions:

APortraitinNumbers

Approximately40%ofIndias1.2billionpeople

liveinurbanareas(IIPS,2009)

UrbanpoorconstitutenearlyathirdofIndias

entireurbanpopulationwithnumbersthatare

growingatthreetimestherateofnationalpopulationgrowth(Agarwaletal.,2005)

Indiaishometo63%ofallslumdwellersin

SouthAsia,amountingto169millionpeople,

or17%oftheworldsslumdwellers(UN-

HABITAT,2006/7)

1in10childrenbornamongtheurbanpooris

notlikelytoreachhisorherfifthbirthday

(Agarwal,etal.2005)

UrbanareasinIndiahavelessthan4%of

governmentprimaryhealthcarefacilities( Ibid)

Thereis,onaverage,onlyonehealthfacility

forevery150,000peopleinIndiaslargest


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such as dilapidated and infirm housing structures, poor ventilation, acute overcrowding, faulty

alignment of streets, inadequate lighting, paucityof safe drinking water,water-logging during rains,

absenceoftoiletfacilities,andnon-availabilityofbasicphysicalandsocialservices(IIPS,2009).

TheofficialIndianCensusdefinesslumsasacompactareawithapopulationofatleast300orabout

60-70 households of poorly built, congested tenements, in an unhygienic environment usually with

inadequate infrastructure and lacking in proper sanitary and drinking water facilities (IIPS, 2009).

However,thelegaldefinitionofslumsdiffersfromstatetostate.Bothdefinitionsarevague,makingit

difficulttoenumerateslumpopulationsorcomparehealthoutcomesbetweenslumsandwiththeurban

non-slumpoor. The distinction between urban poor and urban slum dwellers (as defined below) is

important because there are large disparities in health and living conditions between the two

populations.

Itisoftenassumedthatslumdwellerslivebelowthepovertyline.However,whileslumsandpoverty

arecloselyrelatedandmutuallyreinforcing,therelationshipisnotalwaysdirectorsimple(UNHuman

SettlementsProgram,2003). IncitiessuchasDelhiandMumbai, someslumdwellerspresent income

levelsthatputthemwellabovethepovertyline(Singh,2001).Nevertheless,slumshavethehighest

concentrationsofpoorpeopleandtheworstlivingconditionsinurbanareas(IIPS,2009).

Aslumis consideredtobegovernment-recognized,legal,andpermanentwhenitisnotifiedtobea

registeredslumbyacompetentadministrativeauthority(IIPS,2009).Designatingparticularslumsas

notified allows for government investment in civic and municipal services such as water, trash

removal,andproperlypipedwater.However,unregisteredslumsinhabitedbymigrantworkers,new

ruralmigrants, or long-term slum residents who find it difficult to find formal housing within their

earningcapacity,arenotenumeratedwithincensus figuresandhaveextremely lowreachof services

andcivicfacilities(IIPS,2009).Forthepurposesofthisthesis,notifiedslumswillrefertoregistered,

permanent slums that receive government services such as pipedwater, sanitation and anganwadi

centers.2Unregistered slums will refer to non-tenured, informal, unauthorized colonies occupying

privateor otherwise non-residential land, resettlement colonies, squatter settlements, etc. Exhibit 2providesadiagrammaticillustrationofthenotificationprocessandtheimpactoftenureonhealth.

AforthcomingmanuscriptbyPUKARandHSPHonthedeterminantsofurbanhealthinKBfoundthat,

[i]nIndia,tenure(i.e.legallandownership)stronglyshapesthecontoursofthe slumgradient,which

oftenbeginswithsquattercommunitiesandendswithformallegalization(PUKAR,2010).Slumsthat

haveexisted formanyyears often become notified slums, (i.e. they become permanent, officially

registered by government authorities). However, a constant influx ofmigrants from rural areas has

increasedthenumberofillegal,unregisteredsettlements.Infact,NFHS-3foundthatapproximately

one-quarterofIndiancitydwellersdidnotfeelsecurefromeviction(NFHS-3,2005/6).

Given that residents of untenured slums are ineligible to receive municipal services from the

government, theymustinsteadseek outalternative sources. Toobtain these basic necessities, slum

dwellerspayastronomicalpricesandoftenreceivepoorquality,intermittentservices.Becauseof the

constantthreatofforcedeviction,householdinvestmentremainslow.Thisresultsinapoorstandard

of living, which can reinforce and ingrain the cycle of poverty (PUKAR & HSPH, 2010). If these

2Anganwadicentersarecommunity-basedfunctionariesofthe

IntegratedChildDevelopmentScheme(ICDS)a

GovernmentofIndiaprogramstartedin1975,toprovidechildeducationhealthandnutritionservices(Gheietal,

2010).


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communitieswereabletoobtainlandtenureanditsaccompanyingservices,theirdailycostsof living

and their disease burden would fall, and household investment would increase, accelerating their

escapefromthepovertycycle( Ibid).

HSPHandPUKARarguethat[p]olicyinterventionsthatmovesettlementstothelegalendoftheslum

spectrum can disrupt the poverty cycle by assuaging land security fears and ushering inmunicipal

servicessuchas pipedwaterandtoilets.Together,landsecurityandimprovementsinbasicamenities

canpromotehouseholdinvestment,aspeopleanticipateandplanformorepermanentstaysintheir

householdsandcommunities.(PUKAR&HSPH,2010).

InIndiasrecentpast,destructiveslum-clearingpolicieshavehastenedthepushforresidentsofillegal

settlementstoachievelegalstatusandreceiveservices.Forexample,initsefforts tomakeMumbaia

world class city theMaharashtra state governmentenacteda slum-clearing campaign in2004 and

2005thattoredownmorethan90,000shanties.(UN-HABITAT,2006/7).However,urbanslumgrowth

rates suggest that the number of unregistered settlements will only continue to grow,making this

approachuntenableandunsustainable.ThegovernmentofIndia(GOI)oftenresettlesslumdwellersto

tenements on the fringes of cities, destroying close-knit slum communities and dividing large, joint

family residences into nuclear units residing in separate flats. Unsurprisingly, it is very common forresettled slum dwellers to sell their new property and return to the slums (Mehta, 2004). The civil

societyorganizationAshainterviewedresettledslumdwellersin2006,whoreportedthatontheone

handtheywerehappytohavesecuretenureandaccesstobasicservicesbutontheotherhandthe

resettlementlocationofferedfeweremploymentopportunitiesandledtoincreasedtravelcosts.(Asha,

2006).

II.ChildHealth&ImmunizationCoverageinIndia

Highinfantandchildmortalityandmorbidityarerevealingindicatorsofthepervasive,negativehealthoutcomes ofovercrowding, poorenvironmentalconditions,sub-standardhousingconditions,and the

lackofaccesstoquality,affordablehealthcare.Childhealthandimmunizationstatusinparticular

areausefullensthroughwhichtoassessoverallslumpopulationhealth.

Childrenareatparticularriskofcontractingdebilitatingandoftenfatalcommunicablediseases.In

2008aloneinIndia,outof27millionlivebirths,therewereover1.5millionneonataldeaths(WHO,

2008).AccordingtoNFHS-3,Indiasurbanunder-fivemortalityrate(U5MR)was74deathsper1,000live

births,comparedtotheaverageof48amongIndiastotalpopulation(IIPS,2009).InMumbai,theinfant

mortalityrate(IMR)variesfrom30-43deathsper1,000,whichmeansthat3-4%ofchildrendiebefore

reachingtheirfirstbirthday(IIPS,2009).Theneonatalmortality rate (NMR),IMRandU5MRaremuch

higher among the urban poor than the urban average, and are equally as poor as their ruralcounterparts(Agarwaletal.,2005).

Table1:ChildandInfantMortalityinMumbaiSlums

(IIPS,2009)

(Deathsper1,000livebirths)

InfantMortality 24.9

Under5Mortality 32.7


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Measles inparticular isamajor killerof slum-dwelling Indianchildren dueto prolongedexposure to

infected siblings in very small living spaces with several family members dwelling in a single-room

household (Banerjee & Shitole, 2009/10). According to the NFHS-3, more than one in five poor

householdshasatleastsevenpersonssleepingperroom(IIPS,2009).

TheWHO/UNICEF Expanded Programme on Immunization (EPI, provided by the Indian government)

includes one dose of BCG vaccine to prevent tuberculosis, three doses of DPT vaccine to prevent

diphtheria,pertussis,andtetanus, threedoses oforal polio vaccine (OPV),andonedose ofmeasles

vaccine(WHOandUNICEF,2005).Achildshouldbefullyimmunized(i.e.shouldhavereceivedalltheEPI

vaccines)byageone.

The Indian government provides free immunization services to all children in government health

facilities.However, ratesamongsturbanpoorchildren remainlowerthan theurbanaverage:roughly

69%ofurbanchildreninIndiaages12-23monthsarefullyimmunized(IIPS,2009)comparedtoonly

44%ofurbanpoorchildren(Banerjee,A.&Duflo,2008).Thisnumberlikelyoverlooksthechildrenliving

inunregisteredslums,whoseimmunizationcoverageappearstobemuchlowerbasedondatafromKB.

Thefirstimmunization(BCG)isgivenatbirth,andbyinferenceitseemsmorelikelythatahospital-born

babywill be immunized forBCGthan a home-delivered child.Among theurbanpoor, almost three-

quartersofbabiesaredeliveredathome(Agarwaletal,2005),asignificantcauseoflowerimmunization

ratesinthispopulation,aswillbedemonstratedbyprimarydataonKBinsectionIV.

In2000,IndiasNationalPopulationPolicypledgeduniversalimmunizationcoveragebytheyear2010.

However,accordingtoSiddharthAgarwal,aleadingexpertonchildhealthinIndianslums,[a]lthough

coverage hasincreasedsubstantially inrecentyears,largenumbersofslum-dwellingchildren remain

incompletely immunized. Also, dropout rates remain problematic for immunization programs that

require multiple injections before the vaccine schedule can be completed. As of 1993, the Indian

MinistryofHealthandFamilyWelfareestimatedthatdropoutratesforDPTandOPVwereashighas70% of participating children (Pande & Yazbeck, 2003). This is important given that the failure to

complete vaccine regimens can leave childrenat risk and pave the way for resurgent epidemics of

infectiousdisease.

The impact of the failure to achieve universal coverage on childhood mortality and morbidity from

vaccine-preventableillness(VPI)isdifficulttoestimate.Since71.8%ofinfantandchilddeathsoccurat

home, causesofdeathcannotbe effectivelydetermined (Awasthietal.,2003).Additionally,in2003,

94.5%ofchildhospitaldeathsdidnothaveadeathcertificateandphysiciansoftentimesfailtodiagnose

their patients conditions (Ibid). Physicians frequently prescribe medications without providing a

diagnosis,oranyaccompanyinghealthinformationprevention,treatmentorcare(Banerjee&Shitole,

2009/10).

Based on this unreliable data, Indias Integrated Children Development Scheme (ICDS) system

underreporteddeathsin2003byone-third(Awasthietal.,2003).Itisalsodifficulttofindreliabledata

oninfantandneonatalmortalityrates, sincedataarecollectedstatewideandareonlydisaggregated

intourbanvs.ruralcategories,excludinginter-populationheterogeneityandsignificantdisparitiesbased

onsocioeconomicstatus,caste,ethnicbackgroundandplaceofresidence(Vaid,etal.2007).


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II.ShortcomingsofUrbanHealthDeliverySystems

Indiahasfallendismallyshortofits2001goalofuniversalimmunizationcoverageby2010.Thereforeit

is necessary to identify specific barriers to scaling up immunization coverage in urban slum

environmentsinordertodesignandimproveviablehealthinterventionsthatwillmakeuniversalaccess

a realisticpossibility.Challenges foruptakefall into twomaincategories:barriers toaccessinghealthservices by slum-dwellers, and a lack acceptability of immunization services due to the absence of

adequatehealtheducationefforts.

BarrierstoAccess

Starkdifferencesexistbetweenthemorbidity andmortality ratesofdisenfranchised Indiansliving in

registeredslums(suchasJogeshwariandDharavi)versusthoselivinginunregisteredslumswherethere

islittletonoprovisionofhealthservices,water,orsanitation.Manyoftheseunregisteredslumsdonot

fall on the radarofgovernment agenciesor NGOs (someonpurpose, toavoid the threatof forced

eviction).Thelackofadequatecityplanningandmappingleadstoaconcentrationofhealthservicesinasmall number of areas, and oftentimes duplication of services leads to repeated interventions in

registeredcommunities,whileunregisteredslumshaveatotallackofaccess(Agarwal,etal.2005).

Investments inhuman resources for public health have not increased in response tourbangrowth.

Giventheimmensevolumeofpatientsandthelimitedresourcesofgovernmenthospitals,healthcare

providersareoverwhelmed. InlargeIndiancities suchasMumbaiandDelhi,governmenthealthcare

workers (for example, staff atanganwadi centers, community-based institutions that provide basic

healthservices)facenumerouschallengesthatdecreasemoraleandharmrecruitmenteffortsfornew

workers.Payislowandopportunitiesforprofessionaldevelopmentorpromotionarescarce.Ageneral

lack of effective management in many institutions results in ineffective outreach efforts and poor

programoutcomes.LongandarduouscommutesonIndiancitiespoorpublictransportcantake3hoursormoreoutofahealthworkersday(Agarwal,etal.2005).

Beyondtheproblemoftoofewtrainedhealthworkersandfacilities,othersignificantbarriersprevent

parents (most oftenmothers) from bringing their children tohealth clinics for treatment of illness,

immunization,orroutinecheck-ups.Clinichoursoftencoincidewithworkinghours,havelengthywait

times,oraresimplytoofaraway andunaffordable. Inurban slums, thepreferredhealthprovideris

mostoftentheclosestone;parentsoftentakechildrentoNGOhealthproviders(Awasthi etal.,2003),

local pharmacists and chemists, bhagats (traditional healers) and local doctors who may not be

qualified practitioners (Banerjee & Shitole, 2009/10). For treatment or immunizations that require

multiplevisits,mothersfinditdifficulttomakerepeatvisits,ormakethiseffortonlyformalechildren

(Gaudin&Yazbeck,2006).3Injoint-familysituations,parentsandin-lawscanexhibitpowerfulresistance

when it comes to a young mother spending time and household income on doctor visits and

immunizations(Ibid).

3ThiswasnotthecaseinKB.Mothersshowedapreferenceforfemalechildrenandhealthoutcomesforboth

genderswereverysimilar.


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13

AcceptabilityofHealthInterventionsandHealthEducation

Oftentimes specific urban slum-dwellingcommunities hold strong traditional and/or religious beliefs

againstimmunization,ordonotunderstandthebenefitsofimmunization.Forexampleapproximately

halfof KBspopulation consists ofmigrantsfromBiharandUttarPradesh (U.P.) (Banerjee&Shitole,

2009/10).Inthesetwoareasthereis apervasiveurbanmyththattheoralpoliovaccine(OPV)causessterilityinmen.GivenIndiasnefarioushistoryofSanjayGandhisforcedsterilizationofpoorpeopleand

ethnic/religious minorities (predominately Muslims) in the 1970s, such fears are not historically

baseless and gave rise to a distrust of the medical establishment by Indias poor (Gwatkin, 1979).

However,therefusaltotakeOPVhasadangerouseffect:Indiaisoneofonlyfourcountrieswherepolio

hasnotbeeneradicatedintheworld(WHO,2006).

Whilepatientscanseeandappreciatethedirectbenefitofcurativehealthservicestothemselvesandto

their children, the long-term, preventive benefits of immunization to both the child and to the

communityarelesstangible.Mothersoftendonotunderstandwhytheyshouldputupwithacranky

childwithasorearmforaweekwhens/hewashealthytobeginwith(Banerjee&Shitole,2009/10).

Additionally,serviceproviderswhohaveanegativeanddiscriminatoryattitudetowardslumdwellers,or

whocauseinjuryorinfectionthroughpoorvaccinationprocedurescaninhibitwomenfromcompleting

theirchildrensseriesandbringingtheirsiblingsatall(Agarwal etal.,2005).

Agarwalalsopointsout that evidence suggests that poor uptakeof immunizationin urban areas is

associated withmothers unawareness about repeat visits to achieve complete immunization rather

thanoverallvaccineawareness(Agarwal,etal.2005).Asaresult,halfofurbanpoorchildrenwhobegin

theirimmunizationserieseventuallydropout(Ibid).

For womenwho had their childrenin the village before migration tourban areas, unreliable health

servicesareamajordeterrentforaccessingimmunizationservices.AbhijitBanerjeeandEstherDufloof

MITs Jameel Poverty Action Lab conducted a randomized controlled trial on child immunization to

evaluate theimpactofincentiveson increasinguptake.Throughweeklyvisitsof healthfacilities,theyfoundthat45%ofthestaffin chargeof immunizationswereabsentonanygivenworkday,andthere

wasnopredictablepatterntotheirabsence(Banerjee,A&Duflo,2008).Banerjeesays,[g]iventhata

fullimmunizationcourserequiresatleastfivevisitstoapublichealthfacility,theunreliabilityofthe

[healthserviceproviders]maydeterfamiliesfromtakingtheirchildren tothesub-center tocomplete

thefullimmunizationschedule.(Banerjee,A&Duflo,2008).

BecauseantibioticsareoftengivenasinjectionsinIndiaratherthanpills,itiscommonformarginalized

women to failto differentiatebetweeninjectionstotreat illness ratherthan vaccinationsto prevent

illness.Womenwhoparticipatedinfocusgroupsreportedthatdoctorsinthetwoclosestgovernment

hospitals openly discriminate against poor patientswhom they assume are uneducated and will be

non-compliant.Women said they were shouted at and blamed for childrens illnesses or infectedinjectionwounds.Theyweretoldtoboiltheirwater,washtheirhands,andtonoturinateordefecatein

commonoropenspaces.GivenKBandotherslumsconstraints,suchpublichealthmessagesarelargely

useless(Banerjee&Shitole,2009/10).

Othersreportedbeingturnedawayfromimmunizationservicesbecausetheydidnothavetheirchilds

birthregistrationdocument(whichisagainstgovernmenthospitalpolicy(Jaju,2009).Thediscriminatory

attitudeofhealthproviderswasidentifiedasamajordisincentivetoavailingofhealthservicesamongst


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14

women infocusgroupsonbarriers toaccessinghealthservicesandchallengestotheacceptabilityof

immunization(Banerjee&Shitole,2009/10).

IV.TheCaseofKaulaBandar

Toprovideacomprehensiveassessmentofthedeterminantsofchildhealthandimmunizationstatusin

bothunregisteredslums(usingtheexampleofKB)andregisteredslums,thisthesiswilldrawuponthree

datasources:

1) TheprimarydatasourceisahouseholdsurveyonchildhealthandimmunizationstatusinKB4,(asub-studyoftheHSPHandPUKARstudyonthedeterminantsofurbanhealth),

2) A2008/9householdsurvey 5todemonstratehowthelackoflandtenureandbasicutilitiesimpactsthehealthandwealthoftheKBcommunity,

3) The2001Censusdataonurban,notifiedslums(supplementedbyNFHS-32005/6findingson8Indiancities

6

)

Methods

TheHSPHandPUKARstudyassessedfivedomains:

Childhealth&immunization, Maternalhealth, Water&sanitation, Healthnetworks, Smallenterprise.

This sub-study on child health and immunization was designed and administered amongst 226

householdsinKB,interviewingthemothersof258childrenunderfiveyearsold.Thewomenchosento

participateinthehouseholdsurveyreflectthebroadspectrumofcommunitieslivinginKBthatdefine

themselvesaccordingtoreligion,language/ethnicgroupand/orincomelevel.Thesurveywasconducted

inHindi/ Urdu, Tamil and Marathi, and obtained informed consent with signatures or thumbprints.

Findingsweresupplementedwith17 filmedfocusgroupsandone-on-one interviews.Forchildhealth

histories,therecallperiodforquestionsaboutseriousillnessesandfrequentlyoccurringsymptomswas

oneyear,toaccountforthesmallsamplesize.

4Studydesigned,translatedandadministeredbyJoyaBanerjeeandTejalShitole.DataanalysisbyJoyaBanerjee5ByPUKAR,2008/9,supportedbytheFordFoundation

6NFHS-3teamsupervisorsdecidedtoincludebothnotifiedandunregisteredslums,basedontheCensusdefinition

ofslumsprovidedonpage7.However,theNFHS-3doesnotprovideinformationonwhatpercentageoftheslums

wereunregistered,andthereforeitisnotpossibletodrawaccurateconclusionsontheimpactoflandtenureon

healthstatusfromthesedata.NFHS-3usedverysimilarmethodologytotheCensus,choosingrepresentative

samplesof2,000from8Indiancities(1,000slumand1,000non-slumindividualseachrepresentingahousehold).

Stateweightscorrectedforoversampling,sothatindicatorsbasedonthesedatawererepresentativeatthecity

level,aswellasforslumandnon-slumareaswithincities.


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15

Surveyparticipantswereselectedusingrepresentativesamplingbasedonthegeographicallocationof

their household in the slum, which is divided into distinct ethnic communities, self-defined by

inhabitantsaccordingtolanguage,religion,homelandandothercharacteristicspeculiartothecultural

groupsinIndia.Forexample,MuslimfamiliesfromBiharoccupiedonemainsectionoftheslum,while

TamilboatrepairmenwhosefamilieshadbeeninKBfordecadesoccupiedanother.Theslumsitsupona

wharf and has one main road, with narrow, perpendicular lanes that denote separate communities

(Figure6).Participantswerechosenfromeveryotherlane,andbasedonwhichmotherswereavailable

forinterviewsondaysthesurveywasbeingconducted(includingnon-workweekdaysandtimes).

Thestudysobjectiveswere:

Toascertainthedeterminantsofchildmorbidityandmortality, Toassessthehealthknowledgeandhealth-seekingbehaviorofKBmothers, Tocollectdemographicinformationoneachhousehold(focusingprimarilyonthemother), Toobtainhistoriesofthehealthofchildrenunderfive.

Methodsforthequantitativecomponentofthestudyareonpage23.

Results:KaulaBandarEthnographyandDemographics

KBisan unregisteredslumsettlementontheeasternwaterfrontofMumbai,hometo18,000-25,000

residents (PUKAR,2008/9). TheKBcommunity ismadeup primarily of Tamil boat-repairing families,

someofwhomhavebeenthereforover40years,andmigrantlaborers(whoaremuchmorerecent

arrivals, mostly from Bihar andU.P.) (Banerjee& Shitole, 2009/10).Seventypercentof KB residents

reportthattheyinitiallycametotheareainsearchofemployment(PUKAR,2008/9).Thewharfthat

theyliveon(picturedinFigure6)isownedbytheBombayPortTrust(BPT).TheBPThasbeentryingto

forciblyremoveresidentsforfourdecades.

Figures4-6:SituatingKaulaBandar(GoogleMaps,2010)


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BecauseKBresidentsareoccupyingBPTslandillegally,theyhavenoaccesstocleanwater,sanitation,

electricityorbasichealthservicesguaranteedtoall Mumbaikarsthatownorrenttheirhomeslegally.

Thousandsoftinyone-roomhomessitperchedoneatopanotheramidstlanessonarrowtheyoften

requireinhabitantstowalksinglefile.KBhasanextremelyhighpopulationdensity (Table2),a factor

thatgreatlyincreasestheriskofcontractingcommunicabledisease.Consequently,tuberculosis,measles

andothercommunicablediseasesareverycommonamongstbothchildrenandadults.

Table2.Populationdensitycomparison

(PUKAR,2008,WorldGazetteer,2008,USCensusBureau,2008)

Population Landarea(km2) Populationdensity(peopleperkm

2)

KaulaBandar 18,000-25,000 0.08 230,769-320,512

Mumbai 13,830,884 603 22,937

NewYorkCity 8,363,710 789.4 10,452

TheuseofunwieldyandflammablematerialsinthebuildingofhomesputstheKBcommunityatgreat

riskoffiredamage.InFebruaryof2010,afiresweptthroughthecommunityanddestroyed251homes.

Thelackofpipedwaterandtheinaccessibilityofslumhomesmeantthatthefirebrigadetookhoursto

arriveandtodousetheflames.

To obtain water for bathing, drinking, cooking and cleaning, homes would tap into the Bombay

MunicipalCorporation(BMC,thelocalagencyresponsibleforprovidingbasicamenitiestoMumbaikars)

watersupplypipes.However,approximately20yearsago,theBMCbecameawareoftheillegalusageof

waterbythecommunity.Theysubsequentlydestroyedtheundergroundpipingbygoingtoeachhome

inKBanduprootingthepipingsystem(PUKAR&HSPH,2010).However,fivehouseholdsweremissed,

andcurrentlythesefivesupplywatertotheentireKBcommunitythroughanintricatesystemofrubbertubingat excessive costs. FortenuredMumbaikars,theBMCchargesamonthlyfeeofRs.30

7per

householdforaccesstoaproperwatertap.However,inKB,anaverageresidentpaysbetweenRs.150-

2998,a5-10folddifference(PUKAR&HSPH,2010).Thefirebrigadepipesareoldanddamaged,allowing

the surroundingseawater, garbage, fecalwasteand othertoxins to leak into the pipedwater.Only

59.6%ofhouseholdsusedanymethodofwaterpurificationsuchasboiling,waterpurificationtabletsor

drops,etc.

Only3%ofKBhouseholdshadaccesstoatoiletintheirhome,andthemajorityofsurveyrespondents

reported that there are less than five public toilets in the community, for between 18,000- 25,000

people(PUKAR,2009).Observeddatasuggestthatresidentsmakefrequentuseofthesurroundingsea

asa toiletandgarbage-dumpingsite.TherubbertubingsystemthatsupplieswatertoKBhomesrunsdirectlythroughthiscontaminatedseawater.Thelackofdrainageandsewagesystemsexacerbatethe

spreadofwater-borneillnessesandcommunicablediseases,especiallyduringmonsoonfloodingseason

(Banerjee&Shitole,2009/10).

7$0.66USD

8$3.31-$6.60USD


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Because the majority of KBs tightly packed

homes lackwindows orproper ventilation, and

Mumbai temperatures can reach over 40C

(104F)duringthecityshottestseasons,children

frequently swim in the surrounding,

contaminated seawater to cool off. They have

nowhere else to play except for a small,

abandoned boat yard full of rusty pipes.

Consequently, skin infections, parasites and

tetanus are common childhood causes of

morbidity.

KBDemographics9

ThemajorityoffamiliessurveyedwereMuslims,

an observation closely supported by the PUKAR

2008/9surveyaswell, whichfound that51% of

respondents were Muslim, 42.9% were Hindu,

3.8%Christian,and2.1%other(Figure7).

When asked to report which languages they

speak, some respondents distinguished Hindi

fromUrdu,butitwas laterdiscoveredthatsome

considered them to be the same language.10

Therefore Figure 8 masks the true number of

Urdu speakers who may have reported beingHindi speakers, since Hindi is one of the two

lingua francas of Mumbai (the other being

English).

Figure9showsthatthemajorityofrespondents

earned between Rs. 3,000- 5,000 per month11

andsubstantialpercentage,12%,earnaboveRs.

5,000 per month12. The per day equivalent

would be Rs. 100- 16713, signifying that the

average KB resident earns above the global

povertylineofRs 57 per day,or $1.25 per day(PPP). When women from these families were

9AllsubsequentfindingsinthissectionarefromthechildhealthstudybyBanerjee&Shitole,2009/10.

10UrduisconsideredtobeamorepureformofHindi,andisspokenpredominatelyinMuslimcommunities.The

twousedifferentalphabetsbutareessentiallythesamelanguage,barringsomedissimilarvocabulary.11$67.79-$112.86USDpermonth

12112.86USD

13$2.26-$3.76USD

Figure7

Figure9

Figure8


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askedwhytheydonotusetheirhigherearningstoseekoutimprovedlivingconditionsinotherlocales,

someparticipantsrespondedthattheydidnotwishtoleavetheirfamilyortight-knitcommunity.

TheaverageKBhomehas6.15residents(Table3) andisapproximately2.5mx2.5m(8x 8).Bathing

andcooking(overkerosenefires)areconductedinsidethehomeorimmediatelyoutside,inthelanes,

causingfrequentrespiratoryinfectionsinchildren.

Thegreaternumberof children perMuslimhouseholdcould beexplained by themuch higher total

fertilityrates(TFR)andlowerlevelsoffemaleeducation(whicharesignificantlycorrelatedwithfertility

rates)(Bloom&Canning,2006)inthestateswheremostMuslimfamiliesmigratedfrom.InBihar,the

TFRis4.3and74.6%ofurbanpoorwomenhavenoeducation.InU.P.,theTFRis 4.1birthsper1,000

womenand67.7%ofwomenhavenoeducation(UrbanHealthResourceCenter,2007).Overall,almost

halfofwomeninKBhavenoeducation(Figure10).

Onesurprisingfindingisthatonly10.9%ofwomenare

employed, even counting home-based production or

servicework. Therecentproliferation ofmedia about

another Mumbai slum, Dharavi14, has created the

commonimpressionthattherearethousandsofmicro-

industries booming in Indias slums. The surveyinstrument asked, Do you have a job for which you

earn money? and interviewers gave examples that

includedin-homeworksuchastailoring.Ofthe10.85%

who are employed, women reported working as

servants,tailors,cooks,andshopkeepers.

ChildHealthandMothersHealthSeekingBehavior

InKBonly29%ofchildrenarefullyvaccinated,comparedto69.8%ofchildreninMumbaiasawhole,and68.7%innotifiedslums(IIPS,2009).Freevaccinationisavailableatgovernmenthospitalsthatare

reachablebytrainortaxi.Thecostof transporttotheclosesthospitals(Rs.415foraone-way,second-

classtrainride,andapproximatelyRs.40-6016bytaxitoJJHospitalorCamaHospital,respectively)was

14WherethefilmSlumdogMillionairewasfilmed

15$0.09USD

16$0.89-$1.34USD

Table3:HouseholdComposition

Mean Standard

Deviation

#ofpeopleperhousehold 6.15 2.58

#ofchildrenperhousehold 2.91 1.53

#ofchildrenperHinduhousehold

2.86 1.37

#ofchildrenperMuslimhousehold 3.17 1.62

Figure10:


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consideredtobeadisincentive forsomemothersto seekingcareina healthcarefacility,certainly to

makingmultiplevisitstocompletetheentireimmunizationschedule.

Womenreported seeing local doctors inKB for most of their childrens healthcare needs, and only

taking them to hospitals (most often government hospitals) in serious conditions (such as excessive

vomiting and diarrhea, persistent fevers and coughs, etc.) Table 3 provides a breakdown of which

healthcarefacilitiesaremostcommonlyutilized.ItisunclearwhattrainingthedoctorsinKBhave,but

interviewswiththemrevealedthattheydonotofferimmunizations,butdotreatcommonchildhealth

issues.Womenreportedthatthemostcommonseriousillnessestheirchildrenhaveexperiencedare:

Pneumoniaandotherrespiratoryinfections, Tuberculosis, Malaria, Typhoid, Tetanus, Jaundice, Measles.

Itisimportanttoconsiderthatbothwomenandphysicians(inKBandatfourgovernmenthospitals)

reportedthatphysiciansdonotnormallydiscussdiagnoseswithwomen,becausetheyassumetheyare

uneducated and will not understand. They merely assess the childs symptoms and prescribe

medication, which women pick up from the medico or chemist (small pharmacies where

certificationstatusofpharmacistsisunknown).Themedicationcomesintheformofloosepillswrapped

in foil or plastic, with no identifying information. Side effects from interactions are consequently

common.

Womenjudgetheeffectivenessofaproviderbasedonthetimeittakesfortheirchildrentorecover.If

theyaredissatisfiedwiththelengthoftherecoveryperiod,theyseeanotherdoctorandgivetheirchild

adifferentmedication.Table4showsastrongpreferencefordoctorsinKB,andinfocusgroupswomen

cited the reason for the preference as low cost and proximity. Women also said that doctors in

governmenthospitalsseethemonlyforafewminutesanddonotconveyanypreventiveorcurative

healthinformation.Withregardtoimmunization,somephysiciansinstructedwomenthattheinjections

givenwereforthepreventionofillness,andthatitwasveryimportanttosavethechildsvaccination

card(butdidnotexplainwhyitwasimportant).Only29%ofwomenstillhavetheirchildsvaccination

Table4:MothersHealthSeekingBehavior

SourceofHealthcare %

DoctorinKB 44.2

DoctoroutsideKB 8.5

Privatehospital 7.8

Governmenthospital 16.7

Bhagat(traditionalhealer) 0.8

Treatathome 3.5

Notreatmentsought 17.4

Noresponse 1.2


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card(andthereforedataonimmunizationarelargelybasedonmothersrecallof


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21

Only29.1%ofchildrenwerefullyimmunized

in KB (Figure 12). Child immunization status

seemedtodependlargelyontheconvenience

factorformothers,meaningthatiftheservice

was provided, for free, without the mother

havingtotravelortaketimeoutofherday,

immunization rates would be high. For

example,88.8%ofchildrenweregivenBCG,a

vaccinegivenatbirth,atimewhenawoman

delivering in a health facility has access to

immunization services. Similarly, Oral Polio

Vaccine(OPV)ratesarethehighestoutofany

vaccination, at 95%. This is because the

government Pulse Polio door-to-door

campaign is highly effective and reaches

almost every household in KB, with workersgoing from lane-to-lane givingdrops toeach child, and

returningtothehomeifthechildwasnotpresentinitially.ComparetheseratestoMeasleswith31.78%

coverage,avaccinegivenbetween9-12monthsthatrequiresthemothertovisitahealthfacility.

SomeKBmothersreportedthatthelocalDockyardHospitalhasbeenorganizingimmunizationcampsin

KB.Therearemixedfeelingsaboutthecamps:manywomenreportedthattheinjectionsitesontheir

children became swollen and infected. Several developed cysts that required costly operations (at

approximately Rs. 1,00017, one-third of monthly income). This might suggest improper sanitizing

practicesorperhapsthere-useofneedles.However, infocusgroups,womenbyand largeseemedto

knowtheimportanceofusinganewneedleforeachpatient,andthatHIVinfectioncouldresultfrom

usingthesameneedleonmultiplepatients.Manywomenreportedwatchingtomakesurethedoctor

usedanewneedleduringimmunizationprocedures.

17$22.36USD

Figure12


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22

Table5.ComparisonofKBtoNotifiedSlumsandPoorestWealthQuartile18

Oneveryindicator inTable5exceptfordeliveriesassistedbyhealthpersonnel,KBfaredmuchworse

than both notified slums, and inmost casesworse than the poorest quartile aswell. The numberssuggestthatKBspopulationisunusuallydisenfranchisedcomparedtothoselivinginnotifiedslumsand

theurbanpoor,especiallywithregardtoeducation,tenure,infantmortalityrate,andtheincidenceof

diarrhea.

TheHealthImpactofTenure

Toassessthevalidityofthesefindings,andtocompareKBanunregisteredslumtonotifiedslums,

datafromKBarecomparedtoCensusdataonthesamehealthindicatorsinTable6.Itisimportantto

note thattheCensus iscarriedoutonlyonceeverydecade,and sothedata are from2001.Whereavailable,NFHS-3datafrom2005/6(usingsimilarmethodologyto theCensus) isusedtosupplement

Censusfindings,whichmaybeoutdated.Censusdataweredisaggregatedintocity,slum,non-slumand

18Someindicatorsarehighlightedbecausetherecallperiod(past1 year)maymakethesedataincomparableto

those fromtheCensus(2weeks).Thesurveyinstrumentaskedwomenaboutcommonillnesseswithinthepast

year;2weekswouldnotberepresentativeofKBgiventhesmallsamplesize.However,observationaldataandthe

qualityofKBsconditionssuggestthatthesedatamayverywellbeaccurate.

IndicatorKaulaBandar

(unregistered)

Census(notified

slums)

Census

(poorest

quartile)

NFHS-3(both)

%ofwomenemployed 10.9% 27.1% 27% 27.9%

%ofwomenwithnoeducation 45.4% 19.3% 46.2% 19.9%

%ofwomenwith


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23

poorest wealth quartile. For the purposes of accurate comparison, only slum and poorest wealth

quartileareincludedhere.

Table 6 revealsstriking discrepancies

in immunization coverage. These

couldbeduetothefactthatnotified

slums have health interventions

specificallyforchildrenandmothers,

such as the Integrated Child

Development Scheme (ICDS) which

operates through 40,000 anganwadi

centers nationwide, where

community health workers offer

immunization, child health services

andantenatalcare(IIPS,2009).Therearealsomanyurbanhealthcentersinorincloseproximityto

notifiedslums.Thereisaproliferationofslum-focusedNGOs,especiallyinDharavi,thatprovidehealth

informationandservices,andencourageimmunization.

TheoneinconsistentfindingisthatOPVincidenceinKBismuchhigherthaninnotifiedslums.Thiscould

beduetothegeometriclayoutofKB(Figures4-6)whichmakesiteasiertovisiteveryhomeinaslum,

comparedtootherslumssuchasDharaviwithserpentinelanesandanun-plannedlayoutforanever-

growingnumberofhomes.

QuantitativeFindings

Methods

A predictive logistic regression model was built from the retrospective cohort study data using

backwardselimination(p


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DurationofresidenceinKB(continuous), Birthplacecityhospital,villagehospital,andwith/withoutadai.21

1)Outcome:ImmunizationStatus

Table7:PredictionofImmunizationStatus

Parameter Estimate

LikelihoodRatio95%

ConfidenceLimits Pr>ChiSq

Intercept 0.6467 -1.5047 2.8183 0.5537

Language:Other -0.6222 -2.0043 0.8590 0.3842

Language:Urdu -1.9730 -3.5340 -0.4711 0.0102

Notemployed 2.2913 0.8493 3.7545 0.0016

Notbornincityhospital -2.2980 -3.6995 -1.0877 0.0005

#Peopleinthehouse 0.3341 0.0636 0.6526 0.0253

Table7showsthatsignificantpredictorsofimmunizationstatusarethecovariateslanguage,

employmentstatus,birthlocationandthenumberofpeopleinthehousehold .

Language:Urduspeakersare1.97timeslesslikelytogetimmunizedcomparedtoHindispeakers,holdingallothervariablesconstant.(Hindi=referencegroup)

22Thismaybebecause

mostUrduspeakershavemigratedfromresource-poorareassuchasU.P.andBiharwhichhave

notoriouslylowhealthandeducationoutcomesparticularlyforwomen,whoaremore

marginalizedintheseregionsthaninotherpartsofthecountry(UrbanHealthResourceCenter,

2005/6).23

Employment:Womenwhoarenotemployedare2.29timemorelikelytohaveimmunizedtheirchildrencomparedtothosewhoareemployed,holdingallothervariablesconstant.Infocus

groups,whenaskedtoexplainthisfinding,womenrespondedthatthosewhoareemployeddo

nothavetimetotaketheirchildrentothehospital,waitinlongqueues,andsacrificeadays

wages.

Birthlocation:Childrenborninavillagehospitalorathome(villageorurban)are2.30timeslesslikelytobeimmunizedthanchildrenborninacityhospital(governmentorprivate).Village

hospitalshaveinconsistentqualityofcare,unreliableprocurement,highratesofabsenteeism

amongpersonnel,andfrequentshortagesofsupplies.Basedonresponsesinfocusgroupswith

21Askilledbirthattendant.

22Languagegroupdatawasincludedtoexaminebehavioralpatternswithindistinctethnicgroups,whichare

demarcatedlargelybylanguageinIndia.However,thesurveyaskedparticipantswhichlanguagestheyspeak

(multipleoptionswerepossible),andnotwhattheirprimarylanguageis.ThusifaTamilresidentlearnedHindi

duringhisorhertimeinMumbai,itwouldappearasthoughtherearemoreHindispeakersthanthereactuallyare,

andthiscouldbiasthefindings.23SeediscussionoflanguagegroupsinprevioussectionKBDemographics


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KBmothers,womenwhodeliverathomearelesslikelytomakethevisittoahospitallaterto

immunizetheirchildren.

Numberofpeopleinthehouse:Perincreaseofonepersoninthehousehold,amotheris0.33timesmorelikelytogetherchildimmunized,holdingallothervariablesconstant.(6.15=

referencegroupwithastandarddeviationof2.58)Itisunclearwhythismightbe;perhapswith

eachsuccessivechildamotherismorelikelytolearnofimmunizationthroughdoctorvisitsorfromfamilyandneighbors.However,thiscontradictsthelaterfindingthatperincreaseofone

childinthehousehold,amotheris0.39timeslesslikelytohavecorrectknowledgeofthe

purposeandbenefitsofimmunization.

2)Outcome:Mortality

Table8:Predictionofchildmortalitystatus

Parameter Estimate

LikelihoodRatio

95%Confidence

Limits Pr>ChiSq

Intercept -1.7337 0.0473 3.4830 0.0447

Immunizationstatus

(dichotomous)

-3.2177 1.9683 4.5386 ChiSq

Intercept 0.0579 -1.4363 1.5249 0.9386

Mothersage 0.0583 -0.0053 0.1253 0.0786

Income:


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StructuringanEffectiveIntervention

Given the unprecedented growth of Indias slums, it is imperative that the GOI devote increased

resources specifically toward the health of urban slum dwellers. Interventions should take into

consideration the specific challenges faced by urban slum dwellers without tenure, which may be

distinct from the more general category of urban poor. Unger and Riley argue that [a]ppropriateinterventionsandtreatmentsareonlyeffectiveonceprovidedinthecontextofaccessibleandutilized

healthcareservices(Unger&Riley,2007).

India is making progress by including slum dwellers and other marginalized urban dwellers in its

eleventhFiveYearPlan(2007-2012).TheplanincludestheintroductionoftheNationalUrbanHealth

Mission(NUHM)forinclusivegrowth,coveringallcitieswithapopulationofmorethan100,000(IIPS,

2009).Itmustnowassesstherelevanceandimpactofcurrenthealthprogramsaffectingslumdwellers,

andcraftnew interventions thatbettermeetthepopulationsuniqueneeds.Earlierplans since2001

shifted away from slum-clearing policies, instead focusing onslumsasanintegral part of the urban

landscape. Thepolicies recognized slums as contributors to city economies throughboth their labor

market contributions and informal production activities (Asha, 2006). Insteadof treating slums as aproblemtobesolved,newpolicieswerebasedonthepremisethatlocalbodiesshouldaccommodate

slumsandrecognizetheircontributionsthroughprovidingaffordablehousingandservices.

Indiahasalreadyshowedthatitiscapableofimplementingalarge-scalehealthinterventioninaslum

populationwithnear-universalcoverage.IndiasPulsePolioCampaignofferingdoor-to-doororalpolio

vaccination,reached94.96%ofchildreninKB.Suchsuccesspointstotherealpossibilitythatuniversal

accesscanbewithinIndiasreachifadequateresourcesaremobilizednow.It isclearthatnewhealth

carefacilities,anddrugandvaccinestockpilesareneededtomeetthegrowingdemandofurbanslum

populations.AsthefindingsfromKBdemonstrated,theexpansionofprimaryhealthcareinfrastructure

into areas now overlooked will improve the immunization status of slum-dwelling children and, by

corollary,long-termoverallpopulationhealthandproductivity.(Agarwaletal.,2005).

Inorderto createacceptabilityofanddemandforimmunizationservices,slumdwellersmustbe

providedwithaclearunderstandingofthebenefitsofvaccines,theimportanceoffollowingthrough

withallscheduleddoses, informationonpotentialsideeffects, theunderstanding thatothersin their

communityaretakingadvantageofthefreeservice,and incentivestoovercomebarrierstoaccessing

health services. Interventionsmust be cost effective,geared toward changing behavior in thetarget

population,andmustbemeasurableandscalable.

TherearefivenecessarystepstoworktowardsuniversalvaccinecoverageinIndia:

1) Identify all slums (notified and unregistered) usingmappingand vulnerability assessment as a

planning tool. By understanding which areas are endemically weak and assessing adequacy the ofinfrastructure,itwillbecomeclearwherenewfacilitiesareneeded,andprimarylevelfacilitiescanbe

re-definedtoreachleft-outareas(Agarwal etal.,2005).

2) Strengthened and regular immunization services, particularly for areas with poor access.

Immunization strategiesmust focusonproviding the complete series and making sure that women

knowwhyitis crucialforthemtoreturn,ratherthansimplyimmunizingasmanychildrenaspossible

withoutregardtofollow-up.


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3) Because of the unique role women play in safeguarding the health of their children, slum-

dwelling women should be trained as community health and outreach workers. Community

participationiswellknowntoincreasebehaviorchangeandtheacceptanceofmanydifferenttypesof

healthinterventionsthroughthecreationoflocalownership.Itcanincreasetrustandawarenessofthe

benefits of immunization programs, and this knowledge is likely to spread toother households and

communities given the close-knit nature of slum communities. Community health workers should

emphasize theimportanceofretainingvaccinecards,proofof vaccinationanddateswhen theywere

given(evidencethatiscrucialtoevaluatingtheefficacyofanintervention).

The KB child health study found highly correlated patterns of health-seeking behavior, health

knowledge, and incidence of communicable disease based on which lane houses are situated in

(Banerjee&Shitole, 2009/10).ThusKBslane-basedbehaviormaybea highlyeffectivedistribution

channel for immunization health information. 56% of KB women already know the purpose of

immunizationandthesewomencanbemobilizedas apowerful resource inefforts toincreasehealth

education.

4) Simply offering immunization series is not enough. A comprehensive intervention requiresproximate health facilities, affordable services, adequate supplies, vaccine efficacy, correct

administration,postadministrationcounseling,followupwithleft-outchildrenanddrop-outs,andsafe

disposalofvaccinesyringes;butalsobymeasuringtheinterventionsimpactonslum-dwellingchildrens

morbidity andmortality fromvaccine-preventablediseases, througha systemof rigorousmonitoring

and evaluation. This will require improved disease surveillance, especially in areas of low reach.

(Agarwal,etal.2005)

Agarwalsuggestsholdingregularimmunization/outreachcampsthatarepublicizedwell,andoccurina

convenient,fixedlocationonaregularschedule(Agarwal,etal.2005).Campsmustobtainthesupport

oflocalstakeholderssuchasslumcorporators,religiousleaders,teachers,maleheadofhouseholdsand

motherinlawsinordertohavewidelocalbuy-inandtoensurethatallpotentialbarriersareaddressedina culturallyappropriate, relevantmanner.Slumschoolsandmadrassahs,communityworshipareas

suchastemplesandmasjids,anganwadicenters,andprivatedoctorsclinicsareconvenientandtrusted

locations tohostsuch camps.Agarwalalsosuggests that healthcareworkers candistributepictorial

cardsorleafletsindicatingtheappropriateagesfordifferentvaccinesandreinforcingthesignificanceof

timelyimmunizationwhenchildrenvisithealthservicesforconsultation.Thesewillencouragefamilies

togettheirchildrenimmunizedevenwhentheymigratetootherareas.

5) Foranyofthistobeeffective,theremustbea convergenceofstakeholdersinordertobuild

political momentumand tomanage resources effectively. The wide range of stakeholders who can

influence the success of an immunization intervention should not be underestimated. Stakeholders

couldincludegovernmentofficials,privateproviders,communityoutreachworkers,NGOs,faith-based

organizations,donoragencies,religiousleaders,teachers,andtheslum-dwellersthemselves.Traditional

birthattendants,dais,couldbeparticularlyhelpfulinidentifyingthehomeswheretheyhaverecently-

deliverednewborns(deQuadros,2008).

Toreducetheduplicationofservicesandtoensurecoordinationbetweenmultiplestakeholdersatthe

citylevel,allstakeholdergroupsshouldmeetregularlytoidentifyeachotherscomplementaryrolesand

capacities.Theyshouldworktogether tocreatea time-boundplanfor scaling immunizationservices

withmeasurableoutcomesandarigorousmonitoringandevaluationcomponent.


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Incentives:TheLastMile

BanerjeeandDufloconductedarandomizedcontrolledtrialinIndia(n=1640)inwhichtheyexamined

theefficacyofnon-cashincentives(insteadofcashgivingonekiloof daalorlentilsandasetofbowls)

onimmunizationrates.Onegroupoutofthreehamletsinvolvedinthetrailreceivedwellpublicized,

regularlyoccurringimmunizationcamps.Thesecondreceivedthecampsaswellasthesmall,non-cashincentive of daal, worth Rs. 40.

24The third group was the control and did not receive camps or

incentives(BanerjeeA&Duflo,2008).

Duflounderscoredtheimportanceofincentivesinaninterviewinwhichshesaid,evenwhenyoufully

fixthesupplyproblemandimmunizationservicesareavailable,youstillneedtonudgepeopleabit.You

needtoprovideanincentivefortheparenttobringthechildandyouneedtoprovideanincentivefor

the service provider to be there aswell (Duflo & Banerjee, 2008). Banerjee and Duflo tested the

hypothesisthatimprovingreliabilityofservicesimprovesimmunizationrates,andsmall,non-financial

incentiveshavelargepositiveimpactsontheuptakeofimmunizationservicesinresource-poorareas

(Ibid).Banerjeenotesthat:

IninterventionA,evenwhenaccesswasgoodandasocialworkerconstantlyreminded

parentsofthebenefitsofimmunization,morethan80percentdidnotgettheirchildren

fullyimmunized.Morethan75percentobtainedthefirstshotwithouttheincentive,but

thenstoppedattendingthecampsonlyafter2or3shots.Thisshowsthattheparentsdo

nothave strongobjections to immunization, but that they arenotpersuaded enough

about itsbenefits to overcome thenatural tendency to delay a slightly costly activity

(Ibid).

Anumberofpreviousstudieshaveshownthatuptakeofpreventivebehaviorsisverysensitivetosmall

incentives or small costs, suggesting that incentives can play a role in promoting preventive health

services(Kremer,2007;Cohen,2007;Thornton,2005).However,otherresearchershavesuggestedthat

inresourcepoorsettings,ensuringareliablesupplyofhealthservicesandeducatingparentsaboutthebenefitsofpreventivecarearemoreimportantthanprovidingincentives.(Morris,etal.,2004)

BanerjeeandDuflosfindingssupportthecaseforprovidingincentives:Whilecontrolhamletshadafull

immunization rate of 6.2%, hamlets inwhicha reliablecampwas held showed ratesof16.6%, and

addingtheincentivepushedratesto38.3%,astatisticallysignificantincrease.Moreover,whileacamp

without incentives increased immunization ratesonlyin thehamletwhere it tookplace,campswith

incentivesalsoincreasedratesinneighboringvillages(BanerjeeA&Duflo,2008).

SimilarincentiveschemeshavebeenhighlysuccessfulinMexico(formerMinisterofHealthJulioFrenks

conditionalcashtransferprogram,Oportunidades,andNewYorkMayorBloombergsOpportunityNYC

program.

AparticipantinoneofKBsfocusgroupsmentionedthatinherhomevillageinU.P.,thereisanincentive

schemethatprovidesconditionalcashtransferstofamiliesthatbringtheirchildreninforimmunizations

andwhocompletethevaccineschedule.Shesaid,Theygiveyoumoney,sonoweveryonegoes.A

cash(ornon-cash)transfercouldbeapowerfulincentiveforKBwomentoimmunizetheirchildren.In

24$0.88USD


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fact,womenwerepartiallyincentivizedtoparticipateinthefocusgroupdiscussionsbyreceivingakilo

ofriceeach.

V.Conclusion

The link between immunization and child mortality is well known. However, prior studies on

immunizationinIndiadidnotestablishhowchildmortalityratesandimmunizationcoveragediffereven

within thesame social,medicalandhealth care systems.Access tocarewithin thesamemetropolis

variesgreatlydependingonmanyfactorsthatdeterminesocietalinequityincludingincome,migration

status,ethic/religiousgroup,geographiclocation,etc.Indiasdiseasesurveillancesystemmusttakeinto

accountthesedifferencesbyconsistentlydisaggregatingitsdatainfuturecensuses.

Withincreasedinvestigation into utilizationof immunizationservices,qualityof care, followupvisits

andimpactonchildmorbidityandmortality,itwillbefurtherestablishedthatunregisteredslumshave

farlessaccesstoservicesthannotifiedslumsreceivingoutsideinterventions.Equityinhealthaccess

requiresurgentattentiontotheimprovementofbothaccessandqualityofcare.

Focused,cost-effectiveandmeasurableimmunizationinterventionsthattakeintoaccountthecontext,

needsanddesiresofthetargetcommunitywilldramaticallyimprovetheimmunizationhealthstatusof

slum-dwelling children. In the words ofUnger and Riley, slums are complex, and our effortsmust

matchthiscomplexity(Unger&Riley,2007).Meaningfulinvolvementofcommunitymemberswillgive

communities local ownership and help make the program more relevant and likely to succeed.

Immunization confers enormous health benefits on the individual; but also, overall, long-term

populationhealthandproductivitywillimproveduetothedeclineincommunicabledisease.Vaccines

have existed for decades, and yet vaccine-preventable diseases still kill hundreds of thousands of

children in developing countries every year. With the rich and growing body of evidence around

successfulprograminterventions,thereisnoreasonwhyIndiacannotattainuniversalcoverageinthenearfuture.


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Exhibit1:ChildHealthSurveyData

Table10:ChildHealthHistories

(n=258childrenunder5yearsoldin226households)

Number %ChildsAge


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Table11:ImmunizationStatus

Immunizations # %

None 29 11.24%

Fullyimmunized 75 29.07%Donotremember 105 40.70%

Hasvaccinationcard(listingdatesofeach

vaccine) 75 29.07%

Nocard(databasedonrecall)* 59 22.87%

OPV 245 94.96%

NoOPV 13 5.03%

BCG 229 88.76%

DPT1(6weeks) 127 49.22%

DPT2(10weeks) 116 44.96%

DPT3(14weeks) 104 40.31%

Measles(9-12months) 82 31.78%


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Exhibit2:TheNotificationProcessandtheImpactofTenureonHealth.

(Takenfromtheforthcomingmanuscript,PUKAR&HSPH2010,asadaptedfromMahadevia&Shah,

2009)

Figure13.Theevolutionofslumliving

Figure13.Consequencesofinsecuretenureonhealthandwellbeing


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Figure14.Consequencesofinsecuretenureonhealthandwellbeing

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