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Availability of Health Infrastructure and Accessibility to Health Services in the Urban Slums of Kolkata: A Contextual Exploration

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Indian Journal of Health Social Work

(UGC Care List Journal)

Availability of Health Infrastructure and Accessibility to Health Services in the Urban Slums of Kolkata: A Contextual Exploration

Shreya Chatterjee1 & Subhashree Sanyal2

1Research Scholar, Department of Social Work, Visva-Bharati University, Sriniketan 731236, Bolpur, West Bengal 2 Assistant Professor, Department of Social Work, Visva-Bharati University, Sriniketan 731236, Bolpur, West Bengal.

Correspondence: Shreya Chatterjee, email: chatterjeevb@gmail.com

ABSTRACT

Health is one of the important pillars for the development of every individual which plays an important role in ensuring a good quality of life as well as longevity. Urban slums in India and across the globe are increasing and are mostly without any basic amenities to life, such as no proper housing conditions, lack of drainage and sanitation facilities, poor educational facilities and lack of safety and security. Therefore, the urban population in these slum and squatter settlements are living without adequate facilities for life. Prevalence of such inappropriate and inadequate parameters of life in these slums highlights poor living conditions with a lack of accessibility to health, education and other components of life. Aim: This paper analyses the health infrastructural availability, accessibility and state of urban health services in the urban slums of Kolkata, India; also concerning child health services. Prevalence of hazardous physical location of the slums with lack of health infrastructural facilities have a greater incidence of diseases among the slum dwellers and children. Materials and Methods: The sample households were selected purposively for the study. Both qualitative and quantitative data were collected from the sample households to determine the objectives of the study. The present analysis is based on the primary data collected among two (02) slum zones (4 slums) from Kolkata, India which includes 52 households. Results and Conclusion: Results highlight the lack of government health facilities in the slums of Kolkata, high expenses for medical facilities, problems faced in accessing the medical facilities in government hospitals, and poor availability of maternity benefit schemes with the prevalence of home delivery in the urban slums of Kolkata. Therefore, together these insufficiencies of the basic amenities of health infrastructural facilities indicate the vulnerability of these slum dwellers and children which needs to be addressed to ensure better living with desired health conditions for them.

Keywords: Health, Infrastructural facilities, Accessibility, Slums, Kolkata.

INTRODUCTION

The growth of the slums has led to a greater incidence of diseases in the slums and squatter settlements. The slums are the major place for the breeding of infectious diseases and their way of transmission. This is due to increased rural-urban migration, poor and hazardous environment and lack of basic services such as proper drinking water, lack of sanitation facilities, overcrowded etc., which has steered to poor indicators of health with the spread of several infections and diseases such as tuberculosis, cholera HIV/ AIDS, meningitis, and malaria, diarrhoea, and respiratory infections. Consequently, the slum residents and the children are vulnerable to several diseases like malaria, cholera, pneumonia, diarrhoea, etc (Roy et al., 2014), (Ernst et al., 2013).

According to the National Family Health Survey (NFHS) data, in India, the infant mortality rate is also very high with 54.6 per 1000 live births for the urban poor while the urban national average is 41.7 per 1000 live births. Similarly, the rate of HIV infection along with child mortality is also high in the slums of Kibera, Africa. The slum children in India below the age of five years are victims of respiratory disorders and infections due to the use of biofuel with improper burning and fire way out facility. (Roy et al., 2014).
Children residing in the urban slums are malnourished and are vulnerable to a higher risk of diarrhoea, fever, cough, low birth weight, infant death and malnutrition (Goel et al., 2017), Awasthi and Agarwal (2003), Sen (1994). Zerbo et al., (2020) in their study also highlighted the increasing health risks for children such as the prevalence of communicable and non-communicabl e diseases, malnourishment, mental health problems, accidents, injuries, etc., due to urbanization, lack of basic services to life, and overcrowding hou ses in the inform al settlements of Sub-Saharan Africa.
UN-HABITAT in their report highlights that the condition of the urban slum dwellers is a worse condition, which is poor than the rural areas. The report also provides evidence from a tale of two cities within one city that the urban population living with all benefits of life and the other part of the city where these slum dwellers reside are living under poor conditions of life. Hence these poor and worst living conditions of life among these slum dwellers create an environment that hampers their health and other parameters of life and is also likely to die earlier that the other urban city population. Recently, reports have highlighted that in India the urban health infrastructure is inadequate, not up to the mark, and consequently has not been able to meet the needs of the urban population. It has been reported that there are 1083 Urban Family Welfare Centres (UFWCs), and 871 Health Posts (HPs) which cater to the health needs of 377 million people living in the urban areas in the country. This translates to one UFWC/HP per 192,992 urban populations, compared to the norm of one centre for every 50,000 persons, indicating severe accessibility issues. Other estimates indicate the need for an additional requirement of 500 urban health and family welfare centres to meet the current needs of the urban poor (Gupta and Guin, 2015).
In a similar context, the access to health services is less in urban slums which are predominant by private clinics. This is because government funding in health care infrastructure is limited in slums (Ernst et al., 2013). (Banerjee et al., 2012) also observed that the nearest government hospital was more than 5 km from the residence.
A study conducted by Gupta & Guin, 2015, highlighted the status of health among the slum dwellers in four Indian cities of Jaipur, Ludhiana, Mathura and Ujjain. The study revealed a scarcity of government facilities and services and a preference for private health facilities which has led to the high expenses in private as well as public health facilities. Inadequate and insufficient availability of basic amenities like sanitation, garbage disposal and potable water has highlighted the reason for the prevalence of acute illness. The study also reported that about 40% of the slum dwellers have to travel more than 5 km for accessing the hospital facility Therefore, the lack of availability of government health facilities in the slum vicinity revealed the continuous vulnerability of the urban poor.
Sajjad, 2014 in his study stated that the health condition of non-notified slums of Meerut city is in poor conditions than in notified slums. These non-notified slums lack several basic resources like proper housing conditions, no drinking water, sanitation facility, and lacks a waste management system. Thus, these problems of inadequacies lead to the onset of several diseases such as typhoid, cholera, dysentery, plague, yellow fever, etc. This is because the household and environmental conditions prevailing in the slums are much better in notified slums.
Similarly, another study conducted by Firdaus, 2012, on the 10 selected slums of Aligarh city revealed that these slums lack basic amenities of life like drinking water facilities, sanitation, proper drainage system and garbage disposal facilities. The absence of these basic facilities for life leads to the onset of diseases, and infections such as respiratory infections, tuberculosis and diarrhoea/dysentery among the slum dwellers.
Sur et al., 2004 in his study highlighted that there are several factors which affect the health conditions of slum dwellers. The study was conducted across Ward 29 and 30 of the Kolkata Municipal area on diarrhoea cases. The factors which regulate the choice of healthcare services for diarrhoea treatment were based on the severity of the disease, cost of treatment, and reputation of the care provider in the urban slums of Kolkata.
Bhadra and Bhattacharya, 2018 in their study highlighted the conditions of the slums concerning the health and sanitation of western and southern Kolkata are in a deplorable state with poor access to health care services in the slums. This is because the slums are situated along the major drains, railway lines and garbage disposal sites which leads to the onset of several diseases like asthma, arthritis, diabetes, cold and cough, diarrhoea, dengue etc. Hence, due to the poor sanitation and poor environmental conditions in the slums, the slum dwellers especially the female and children are affected by several diseases and as a result, 70% of the slum households spent about 10 to 20% of their monthly income on medical expenses.
Hence, these insecure settlements of Kolkata are in deplorable conditions with a prevalence of overcrowding, lack of healthcare facilities, presence of several infectious diseases and poor nutritional status. Therefore, it i s imperative to conduct a study on the availability of health infrastructural facilities and their accessibility to health care services in the Urban Slums of Kolkata.
The present study attempts to understand the availability of health infrastructure in the slums of Kolkata. This study also attempts to explore the accessibility of child health care services in the slums of Kolkata and finally, the study provides suggestive measures for improving the condition of health infrastructure in the slums of Kolkata. Hence the objectives of the study: are (i) to understand the availability of health infrastructure in the slums of Kolkata and (ii) to explore the accessibility of child health care services in the slums of Kolkata. The indicators for the above objectives are the prevalence of diseases in the slums of Kolkata, access to primary health centres, distance to the nearest health care service, type of hospitals visited by the slum dwellers, problems faced by them in accessing them, availability of health insurance cards, immunization of children and availability of birth registration certificates etc.

METHODS AND MATERIALS

The study area is the Metropolitan city of Kolkata, West Bengal. For the present study slums of Kolkata have been divided into five zones i.e., Central, East, West, North and South. Two slum zones, the Central and the North zone were selected and from each zone, two slums were selected for detailed study. The slums selected for the study include Park Circus and Dhapa Dhipi from the Central zone and from the North zone the slums are Narkeldanga and Dakshindari. This comprises 52 households from the slums which include interviews with the slum dwellers to explore the availability of health infrastructure and accessibility of child health services in these slums. The sample households were selected purposively for the study. Both qualitative and quantitative data were collected from the sample househo lds to determine the objectives of the study.

RESULTS
PHYSICAL LOCATION OF THE SLUMS

For the present study, we have selected two slums from the Central zone of Kolkata i.e. Park Circus (railway line jhupripara) and Dhapa Dhipi. Park Circus (railway line jhupripara) is a non-registered squatter slum situated along the railway track connecting to Sealdah station and is majorly surrounded by the commercial area. The physical location of the slum along the railway line is a deterrent to the existence of the slum dwellers. Dhapa Dhipi is a registered slum situated along the side of the major drain (nallah) of the city of Kolkata and is surrounded by a residential area. This location of the slum, near the high drain (nallah), carries waste out of the city, hence exposing the slum dwellers and children to several health hazards.

Similarly, from the northern zone of Kolkata, two slums were selected i.e. Narkeldanga and Dakshindari. Narkeldanga, this non-registered slum is situated along the side of the major drain (nallah) of the city of Kolkata and is located by the m ajo r road transpo rt alignment. The physical location of the slum along the major drain (nallah) often exposes slum dwellers and children to the occurrences of several diseases and several accidents take place as the slum is situated along the major transport way. Dakshindari, the registered slum is also situated along the side of the railway line connecting to Sealdah railway station. The Sealdah station is one of the busiest and major stations of the southeastern railway connecting to the other states of India. This physical location of the slum is a challenge for the existence of the slum dwellers and children because many accidents and illegal activities take place due to the presence of railway lines.
Prevalence of Diseases in the slums:

Inadequate basic amenities for life, the hazardous physical location of the slums, filthy sanitation, drainage system and prevalence of poor environment in the slums of Kolkata are the reasons for the suffering of the slum dwellers as well as the children from various infectious, communicable and no ncommunicable diseases. Diseases range from fever, cold and cough, asthma, diarrhoea, typhoid, other digestive diseases, rheumatism or other bone-related ailments , cardiovascular/blood pressure, mental health problems, tubercul osis, diabetes, skin diseases, dengue, malaria and other seasonal problems etc.

Type of health facility in the slums:

The slum dwellers when asked about the existence and type of health facilities in their slums, reported the absence of any primary health centres in the slums from the slum zones of Kolkata. Although in one of the slums in the central zone there are only private health clinics, which are hardly accessed by the slum dwellers. Furthermore, these slum dwellers also reported that they mostly prefer governmental health facilities to private ones. This is due to the high cost involved in accessing these private health care facilities, whereas the services provided by the government hospitals are free of cost and are much cheaper than the private clinics.

Distance of health services

The absence of primary health centres is another obstacle in promoting desired health indicators, which is faced by these slum dwellers in the slums of the central zone. The data collected from the slums revealed that the distance that the slum dwellers have to travel from their homes to get health services is about 4-6 km and 1-2 km respectively for both the slums of the central zone i.e. Dhapa Dhipi and Park Circus. Thus, the distance of the government hospital from the central zone is within the vicinity of 6 km away from the slum areas, and the lack of any health centres in the slums has increased the load of patients at Chittaranjan hospital which is frequently accessed by the slum dwellers of this zone. Similarly, in the north zone, there is a lack of availability of primary health centres in the slums of this zone. Thus, the distance which the slum dwellers have to travel from their homes to avail the health services is about 4- 6 km and 1-2 km respectively for both the slums of the north zone, i.e. Narkeldanga and Dakshindari.

Hospital visited by the slum dwellers

Figure No. 1 highlights that 77% of the families in the central zone visit the nearby government hospitals for accessing healthrelated services, while only 23% of them visit private doctors and hospitals. Similarly, in the northern zone, the figure depicts that about 54% of the families are opting for government health services whereas 46% of them visit private doctors or hospitals.

Expenses on Health issues

Figure No. 2 shows the amount of expenditure that the slum dwellers of the slums of Kolkata incur on the account of several health-related issues. Therefore, it can be observed that in the central zone, 46% of the families spend Rs. 5000-10,000 on health issues, followed by 38% spent more than Rs.10, 000, 8% spend Rs.2000-5000 and the rest 8% incur expenditure within Rs.1000-2000 respectively. Followed by in the north as shown in the
figure, highlights that 31% of the families spent more than Rs.10,000, followed by 31% of the families spent Rs.5000-10,000 on their health problems, 23% and 15% of the families spent about Rs.2000-5000 and Rs.1000-2000 respectively on their health problems. Hence, it is evident that there are incidences of health problems in the slums of Kolkata which increases the expenditure incurred on several health issues.

Problems faced by the slum dwellers in
accessing health services

Figure No. 3 shows the various problems faced by the slum dwellers from the slums of Kolkata while accessing health services from both government and private health sectors. The problems faced by the slum dwellers are 40% of them had to stand in a long queue for several hours for accessing health services from the hospitals, followed by 27% reported that the doctors not taking care of the patients properly, 3% of them reported of financial problems (especially accessing health services from private sectors and 30% of them did not report any such problems faced in accessing health services. Similarly, in the slums of the north zone, as the figure no highlights that 44% of the slum dwellers had to stand in a
long queue for several hours for accessing health services from the hospitals, and 9% of them reported that the doctors did not take care of the patients properly, 6% reported of several financial problems,21% reported other problems (like taking leave from their jobs to visit the health centre), and about 20% of them did not report any such problems faced in accessing health services.

Availability of health insurance cards

Figure No. 4 highlights the availability of health insurance cards among the slum dwellers of the slums of Kolkata. Therefore, it can be observed that in the central zone, 92% of the families do not have health
insurance cards while only 8% of them have health insurance cards. Similarly, in the north zone, as shown in the figure, highlights that none of the families have a health insurance card.

Immunization and Availability of Birth Registration Certificate

This secti on highl ights the status o f immunization and the availability of birth registration certificates among children in the slums of Kolkata. Data was collected from the families for the central zone, and figure no. 5 highlights that 74% of the children are immunized whereas 26% of the children are not immunized. Again, it can be observed from the figure that in the north zone, 86% of the children are immunized whereas only 14% of them are not immunized.

Birth Registration Certification is one of the mo st important a nd first sources o f identification of any child. It can be observed from figure no.6 that in the central zone, 82% of the children have received their birth registration certificate while 18% of the children did not have their birth registration certificate. Followed by the north zone, the data reveals that 70% of the children have their birth registration certificates while 30% of the children do not have their birth registration certificates.

Followed by the availability of maternity
benefit scheme, that the central zone, as
figure no.8 highlights only 8% of the women
could avail of the maternity benefit scheme
rest 92% of these women did not avail benefit
from the maternity benefit scheme.
Furthermore, in the northern zone, 96% of
the women did not receive any maternity
benefit scheme while only 4% of them could
avail the benefit from the maternity benefit
scheme.

Several interviews with lactating mothers of
these slums reported the lack of awareness
of the importance of institutional delivery as
well as the availability of a maternity benefit
scheme. Inferences can be drawn that
institutional delivery is higher in the slums of
the central zone than in the northern zone.
But the majority of the women from the slums
of Kolkata did not avail of any maternity
benefit scheme. For the present study,
interviews with the women reflected that only
a few among them had the information they
utilized whereas a few of them did not utilize
it. They also reported that the procedure
involved in accessing the maternity benefit
scheme involves a long process which they
can hardly make through it.

Child Birth-Place of Delivery-Institutional or Home and Availability of Maternity benefit Scheme

Family welfare programmes are the most emphasized ones in India, and it was important to explore the availability of the services by these slum dwellers. Accordingly, data was collected related to the place of delivery and the availability of the maternity benefit scheme in the slums of Kolkata. Figure no.7 reveals that in the central zone, the percentage of hospital delivery is 68% while 32% had home delivery. Followed by the north zone, the percentage of hospital delivery is only 41%, whereas 59% of the women had home delivery of their children.

Followed by the availability of maternity benefit scheme, that the central zone, as figure no.8 highlights only 8% of the women could avail of the maternity benefit scheme rest 92% of these women did not avail benefit from the maternity benefit scheme. Furthermore, in the northern zone, 96% of the women did not receive any maternity benefit scheme while only 4% of them could avail the benefit from the maternity benefit scheme.
Several interviews with lactating mothers of these slums reported the lack of awareness of the importance of institutional delivery as well as the availability of a maternity benefit scheme. Inferences can be drawn that institutional delivery is higher in the slums of the central zone than in the northern zone. But the majority of the women from the slums of Kolkata did not avail of any maternity benefit scheme. For the present study, interviews with the women reflected that only a few among them had the information they utilized whereas a few of them did not utilize it. They also reported that the procedure involved in accessing the maternity benefit scheme involves a long process which they can hardly make through it.
DISCUSSION

Health is primarily a major challenge in slums due to poor environmental conditions, poor sanitation, drainage system etc. Hence, this filthy environment in the slums prohibits the slum dwellers to attain a better quality of life. The present study highlights the vulnerable physical location of the slums of Kolkata which are mainly situated near the major drain (nallah) and a railway track. Consequently, this filthy environment is a deterrent to the health condition of the slum dwellers as well as children. This leads to the onset of several diseases which are both communicable, noncommunicable as well as infectious among the slum dwellers due to the lack of several basic facilities of life and the filthy physical location of the slums. Hence, the deplorable condition of the slums with overcrowded settlements, dilapidated dwellings, and lack of other civic ameni ties highlig hts the unhealthy environment of the slums as the major reason for the high prevalence of the disease among inhabitants living in slums. This highlights that the families from the slums of Kolkata are susceptible to several diseases and as such spent a considerable amount of their income on their health issues increasing their expenditure.

The findings of the study also highlight the absence of any health centres in the slums of Kolkata. The slum dwellers have to travel a distance of 6 km to access health care services for themselves. The establishment of primary health centres in the slums would be able to cater for the needs of these slum dwellers of Kolkata. Furthermore, the slum dwellers are much inclined to visit the government hospitals and as the services provided by these government hospitals are free of cost and are much cheaper than private health care services. Apart from the absence of primary health centres in the slums, the study also highlights several other problems faced by these slum dwellers in accessing the health care services such as standing in a long queue for hours in the hospital, doctors do not take care of the patients properly, financial problems faced by the families etc.
As the study reveals the prevalence of several diseases like dengue and malaria in these slums which requires proper timely treatment. Awareness of health and cleanliness-related services during the occurrence of such diseases should be conducted and implemented through several awareness programmes and promote the concept of cleanliness in the slum areas of Kolkata.
The study also highlights the lack o f availability of health insurance cards among the families of the slums of Kolkata. They have no information about the benefits of health insurance. Thus, initiatives by the NGOs, Civil Society Organizations operating in these slums need to be taken to create awareness of the benefits of health insurance cards and accessing health insurance would be an incentive for these poor slum dwellers to incur the cost of expensive health services whenever required.
Further, the findings of the study highlight that the majority of the children from the slums are immunized and have their birth registration certificates. Although there are children from both the slum zones who are still to be immunized and need the issuance of a birth registration certificate. Thus, the health workers need to address this issue to complete the immunization process for each child and also help these children to get the birth registration certificate from the municipality for ensuring the rights of the children and provide them with an enabling environment for them to grow and develop. For the present study as the data collected also highlights the prevalence of home delivery in the slums of Kolkata and very few women are availing of the maternity benefit scheme. Most of the slum dwellers are unaware of the facilities of the maternity benefit scheme and the importance of institutional delivery. Hence, there is a need to conduct awarenes s programs related to the importance of institutional delivery and the procedure of availing maternity benefit schemes among these slum dwellers.
Finally, one of the major areas to thrust upon to create a better living among these slum dwellers is education and awareness. There is a need to educate the slum population regarding the knowledge of keeping the environment clean and ways to combat several contagious diseases. This will directly improve the socio-economic condition of the families as well as impact their health conditions also. Moreover, since the health conditions of these slum dwellers and children are very much affected by the surrounding ambience of the slums, lack of proper sanitation, drainage system and prevalence of poor environment of these slums as the physical location of the slums is adjacent to the nallah (drains) which is one of the frequent areas for garbage disposal. This hampers the health condition of the children as well as the women. Therefore, there is an urgent requirement for the cleaning of the slum areas by the Kolkata municipality to avoid the problem of garbage disposal, poor sanitation and drainage conditions. Furthermore, improving the socio-economic condition of the families of these slums of Kolkata is important as this will help to improve the health condition of the families facing financial problems in accessing health care services. For the present study, the data collected highlights that the health condition of the slum dwellers and poor accessibility of the health care services prevalent in the slums of central and north Kolkata make it wrecked and inappropriate for them to reside. Therefore, strengthening the role of NGOs, civil societies and other organizations working in these slum areas, promoting participatory planning with community participation, proper utilization of the available res ources and proper coordination with the governmental allied departments to ensure proper implementation of the programmes to address these issues of poor access to health services in the slums and provide proper medical facilities to these urban population.

CONCLUSION

In conclusion, the study highlights several aspects of poor he alth infrastructural availability and accessibility in the slums of Central and North Kolkata. Thus, it is very evident that the slum dwellers and the children in these slums are very much affected due to the inappropriate conditions of the health infrastructure and also due to the insufficiencies of several other conditions which are important to life in these slums of Kolkata.

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Conflict of interest: None
Role of funding source: None
ISSN: 2582-1393 (Online)
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