Socio-economic status, mortality data, health attitudes, felt needs and utilisation of health services were
studied in 1,313 slum households from a population of 7,109. Poor health status, deficient health attitudes and
knowledge, and the poor utilisation of public sector health services, were some of the findings. Poverty,
unfavourable environment, poor sanitation and a curative health system, are the factors contributing to the
unhealthy conditions in slums. An integrated health system, with community participation, is the alternate
solution to meet the basic health needs of the urban poor.
Dr. (Mrs.) Ancilla Tragler is Project Director—Community Health, and Hon. Paediatriician, Holy Family Hospital,
Bandra, Bombay.
From seven tiny islands inhabited by fishermen, Bombay has grown into a large
metropolis of national and international importance. With a population of less than a
million in 1901, today it has a population of more than 8 million. (8.2 million 1981
Census). It is predicted that its population will be 15 million by the turn of the century.
With this tremendous increase in population, the resources of the city have been
stretched to its limits. Living conditions are appalling, especially in the slums where
more than half the population lives.
What then of the health care in this congested and crowded city? Bombay can boast
of the latest medical technology, and is also saturated with medical facilities. Yet, a
sensitive index like infant mortality is as high as 74. Tuberculosis, hepatitis, polio,
measles, gastroenteritis, are still contributing to high morbidity and mortality. The
poor health status does not stem from the lack of medical facilities which abound in
the city, both in the private government sectors. Under-utilisation of services,
unhygienic housing and environment, ignorance and harmful habits, poverty, and a
predominance of curative health care, all contribute to the poor health picture in the
city, especially in the slums. The present health system belongs to an urban, elite
oriented, top down system of medicine which is as ineffective as it is expensive. A
comprehensive health care system, which meets all the needs of the poor, is now
being advocated. Primary health care, with its long lasting benefits to the community,
has received world wide recognition. It envisages a health package of services with
grassroots level health workers.
In 1979, the Holy Family Hospital started a Community Health project for slums in its
vicinity. The broad based objective was to provide integrated health care to the poor.
Grassroot level health workers were to be involved in delivering primary health care.
The present study was undertaken to ascertain the various factors which affect the
health care of the slum dwellers in the project area. There is a paucity of recent data
regarding the health status in the slums of Bombay. No policy or system is going to
work unless, the population for whom the systems is made, is studied carefully. Based
on this study, a more effective health system for slums in the project was to be carried
out. A pilot project was thus launched for health care to the urban poor in the slums.

506 Ancilla Tragler
The study included 1,313 slum households from a population of 7,109 people. A
survey was conducted using a pretested modified interview schedule during the
period 1979-1980. The information was obtained by social workers and trained health
workers. Household visits were made for the collection, of the data. Information was
collected regarding the socio-economic status, literacy levels, people's felt needs,
health attitudes, the health services utilised, and mortality and morbidity. The target
population lived in the slums of Bandra West, Bandra East and the adjoining suburbs.
In Bandra West, slums exist in pockets of 50 to 150 families. In Bandra East, most of
the slums stretch along the Western Express Highway and the railway tracks. A large
section of the slum dwellers have been residents in the slums for long periods of 10
years and more. However, there is a certain amount of continuous turnover in the
slum population. Most of the slums have been provided with basic amenities of
community taps, lavatories, paved pathways and an open drainage system. Health
services are easily available to all these slums from the municipal dispensaries,
hospitals and private physicians.
Urban socio-economic relationships are both more varied and complicated than in
the rural areas. The socio-economic profile of a population affects its life style and
attitudes towards health and disease. Some of these factors include religion, income
and education. A study of these factors can be seen in Tables 1, 2, 3. This slum
population of 7,109 comprises various religions: 55 per cent being Hindus, 21 per
cent Neo-Buddhist, 15 per cent Christian, 4 per cent Muslim and 5 per cent
constituting other group (Table 1). The cosmopolitan nature of the slum population
of Bombay is thus evident. Hindus, however, still constitute the majority. Religious
beliefs and practices affect health attitudes, and this has special relevance in health
education and modification of behaviour. The average family size was 5.4 which
contributes to the overcrowding in slums.
Regarding income, as shown in Table 2, 57 per cent had an income between
Rs. 200/- and Rs. 500/- per month, 16 per cent had an income of more than Rs. 500/-
per month and 27 per cent had an income of less than Rs. 200/- per month. The slum
census of Greater Bombay in 1975 also showed that 79 per cent of slum families have
incomes below Rs. 600/- per month and are in the low income group. Poverty,
resulting in under-nutrition, poor housing and environment, has definite implications
for health. Others (Naidu, 1978:298-312; Muttagi, 1980: 147-156; Ashok Kumar 1983:
1-7) have shown the poor socio-economic status of slum dwellers. Thirty-nine per
cent of the mothers were working mostly as domestic servants, either part-time or full-
time. On the one hand, employment of women improves the socio-economic status as
well as the health of the families. However, the substitute care that is provided to the
children will also reflect on child health. In order to be effective, health education will
have to take into account those providing mother substitute health care.
Literacy was studied in Bandra West in a population of 2,855 where an education
programme was to be started. Of the 2,320 persons above the age of 5 years, 1,598
were adults and 722 were children (Table 3). Overall literacy level was 70 per cent.
Sixty-seven per cent of adults and 73 per cent of children between 5 to 10 years and
78 per cent of children between 10 to 15 years were literate. Fifty-eight per cent of
the women were literate. Literacy for urban areas in India (Ministry of Home Affairs,
1979:7) is reported as 68 per cent. These slums in Bandra show a very high level of
literacy. One of the factors may be that they are well located and in the proximity of
several schools. Though the level of literacy was high, there was a large number of

Health Care In Slums of Bombay 507
dropouts with hardly 10 per cent finishing school. These dropouts from school,
though literate, may still lack education, especially education relevant to health.
In relation to felt needs, the people listed problems like lack of water and sanitation
(25 per cent) unhealthy environment (29 per cent) and inadequate housing (23 per
cent). Only 7 per cent mentioned poor medical facilities. Despite being provided with
basic amenities according to Government regulations, the slum dwellers in this study,
felt the need for better water supply and sanitation. The felt needs of the people are
always important while planning for their welfare. They too see the obvious advantage
of good living conditions which would also lead to better health. Planning for health
must take into account the provision of basic services of water supply, sanitation, and
garbage disposal which are all related to the maintenance of good health. Another
factor, to be taken into account in considering the felt needs, is that some of the slum
dwellers were unaware of their problems and this has to be taken into account, too, in
health education.
Medical treatment was primarily taken from private doctors (56 per cent) municipal
dispensaries 37 per cent and charitable clinics 2 per cent. Despite the availability of
low cost health services from the dispensaries of the Bombay Municipal Corporation
as well as a hospital in the vicinity, the people preferred private medical care.
Compared to the rest of the State, the city spends an enormous amount on health. It
is reported (Bhang, Patel, 1983:10) that the three main cities of Bombay, Nagpur and
Pune consume 80 per cent of the annual health expenditure of the state. Most of this
goes into medical education and curative care services which are under-utilised by
the urban poor. Urban communities living in slums have been found (Yesudian, 1981:
381-392) to have a poor utilisation of services. Apathy of staff, long waiting periods,
shortage of drugs and the lack of knowledge, are some of the reasons for the under-
utilisation of public sector services.
Mortality data were collected for the previous 3 years (Table 4, 5). Death rate was
found to be 9.3/1000 population per year. This rate is lower than that reported for the
city (Annual vital statistics of Maharashtra, 1979) which was 10.3. This may be due to
medical facilities, both in the private and public sector, available in the vicinity of the
slums under study. However, looking at the age distribution, death under five years
constituted 60 per cent of the total deaths. Neonatal deaths were 13 per cent of all
deaths and still-births were 9 per cent of the deaths. Infant mortality was as high as
130 per thousand live births. Preventable causes of death included diarrhoea (16 per
cent), jaundice (5 per cent), accidents (5 per cent), tuberculosis and chronic cough
(16 per cent). Preventable causes of death were more than 60 per cent of deaths.
Despite all the medical facilities available, the health status in these slums is very
poor. In fact, in the private sector, Bombay has a ratio of one doctor for 700
population which is comparable to the Western countries.
Assessing the immunisation status, the coverage was good for smallpox and BCG
with 80 per cent of 782 under five having been covered with these immunisations
(Table 6). However, triple and polio vaccine use was deficient i.e. only 35 per cent of
the children had primary immunisation and 13 per cent had secondary immuni-
sation. Immunisation status of children was inadequate, in spite of these being
well located slums in the proximity of municipal general hospitals and dispen-
saries with immunisation facilities free of cost. Poor health status, inadequate
immunisation coverage and a high incidence of infectious diseases have also

5 0 8 Ancilla Tragler
been the findings of others (Desai and Pillai, 1972; Chansoria, Taluja et al. 1975: 879-
Attitudes to family planning and infant feeding were also studied. Thirty-seven per
cent of the families were practising some method of family planning. Most of these
were families with 3 or more children. Sterilisation of mothers was the most common
method of family planning (90 per cent). A random sample of 100 children was
studied for practises regarding breast feeding and introduction of solids in the diets of
In the first 6 months of life, breast feeding was almost universally practised, that is, 92
per cent breast fed. By one year, 64 per cent of children were still being breast fed.
However, 30 per cent of children were bottle fed at some time or the other, mostly as
supplementary feeds, while others used cup and spoon. So, though breast feeding is
still being practised, there is evidence of penetration of non-human milk and bottle
feeding in the diet of infants. This may be related to mass audio visual media
propaganda of these baby foods and milk bottles in urban areas, or due to inadequate
supply of the milk of the mother. Sixty-nine per cent of the children had solid food
added to their diet only after one year, and barely 8 per cent started on solids by six
months. Similar findings were also obtained in another study (Bapat, 1982: 19-20)
regarding breast feeding and supplementary foods in a study in the slums of Pune.
Women were found to be lacking in knowledge regarding the causes and spread of
diseases, nutritional practices and the hazards of environment to health. Eighty per
cent of the women were ignorant as to the cause of diarrhoea and scabies. Myths and
beliefs were also prevalent. Worms were most commonly thought to be caused by
eating sweets. Colds were said to be due to eating banana, citrus fruits or cold foods
like ice cream and curds. Many foods like eggs, papaya, and jaggery were believed to
be heat producing and were avoided during pregnancy and the summer. Expensive
foods were claimed to be nutritious foods. Red coloured foods like beetroots were
said to increase blood formation. Health awareness was thus found to be significantly
lacking in the mothers.
Literacy in women has been associated with better health. The State of Kerala boasts
of high literacy in women, 54 per cent, and also of low infant mortality, 55 per
thousand live births. In this study, child health is poor in spite of the higher number of
literate women. This may be due to lack of health-relevant education in the school
curriculum as well as from the mass media and health care personnel.
Poverty alone is not the root cause of poor health in slums. Deficient health-relevant
education, poor living conditions in slums together with a curative oriented health
system, all contribute to the poor health status. Substantial improvement in health
care is a long term task and would involve improving the economic status and
environmental sanitation together with a wider dissemination of health awareness and
knowledge. Health education, especially with respect to hygiene, prevention of
illness, nutrition, child care and family planning, can very successfully pave the way
for better care. This has been universally accepted (Kenneth, 1975—WHO; Ghosh,
1983: 235-242). The present curative and hospital based system has been found to be
incompatible with the concept of "Health for AU" in both the rural and urban areas
(Indian Council of Social Sciences Research and the Indian Council of Medical

Health Care in Slums of Bombay 509
Research, 1980). Community based health centres have to be established, and
community involvement, together with grassroots level health workers must be
ensured. In an urban slum situation, the effectiveness of such a system has been
documented (Tragler, 1984). In planning for health care in urban areas, an integrated
health system, that is geared to meet the basic health needs of the urban poor, is
Ratna Naidu
"A Study of Slum in Hyderabad and Secunderabad". Indian
Journal of Social Work, Vol. XXXIX, No. 2: 298-312
P. K. Muttagi
"A Socio-economic Profile of the Project Area". Indian Journal
of Social Work, Vol. XLI, No. 2: 147-156.
Ashok Kumar
"A Study of Factors Affecting the Status of Slum Dwellers", Indian
Journal of Social Work, Vol. XLIV, No. 1:1-7
Meera Bapat
Determinants of Health in Low Income Communities. A Case
Study of Pune.
Office of Registrar General:
Survey on Infant and Child Mortality
Ministry of Home Affairs,
New Delhi
C. A. K. Yesudian
"Differential Utilisation of Health Service in Metropolitan City",
Indian Journal of Social Work, Vol. IXLI, No. 4: 381-392
Abhoy Bhang
Health Care Which Way to Go, Medico Friends Circle; 167
Ashiv PateI
Desai A. R.
A Profile of Indian Slum, Bombay University Press
Pillai S. D.
Maya Chansoria
"A Study of Immunisation Status in a Defined Urban Population"
Indian Paediatric 20: 235-242
Howel W. Kenneth
Health by the People, W.H.O.
Shanti Ghosh
"Primary Health Care in Developing Countries". Indian Paediatrics
20: 235-242.
Indian Council of Social
Health for All: An Alternative Strategy
Indian Council of Medical
Research, 1980
Director of Health Services,
Annual Vital Statistics of Maharashtra
Govt. of Maharashtra,
Ancilla Tragler
"The Role of a Health Worker in an Integrated Health Programme
in Slums", Indian Paediatrics, 2 1 : 287-293.

5 1 0 Ancilla Tragler
Table 1
Figures given in parentheses are percentages.
Table 2
Figures given in parentheses are percentages.

Health Care in Slums of Bombay 5 1 1
Table 3
5-10 years
191 151 45 48 93 146 103 249
(55.84) (44.16) (23.56) (31.79) (27.19) (76.43) (68.21) (72.80)
10-16 years
181 199 33 52 85 148 147 295
(47.63) (52.36) (18.23) (26.33) (22.36) (81.76) (73.86) (77.63)
752 846 172 355 527 580 491 1071
(47.05) (52.94) (22.87) (41.96) (32.97) (77.12) (58.03) (67.02)
1124 1196 250 455 705 874 741 1615
(48.44) (51.55) (22.24) (38.04) (30.38) (77.75) (61.95) (69.61)
Total Literacy 70% = 62% Females
= 78% Males
Figures given in parentheses are percentages
Table 4
(Three Year Period)
Bandra East Bandra West Extended Total
7 10 1 18
(10) (13) (2) (9)
7 11 9 27
(10) (14) (17) (13)
1 mth—1 year
12 9 14 35
(18) (12) (27) (18)
1 year—5 years
10 15 16 41
(15) (19) (31) (21)
5 years—15 years
12 4 2 18
(18) (5) (4) (9)
2 0 29 10 59
(29) (37) (19) (30)
68 78 52 198
(100) (100) (100) (100)
Under five
36 45 40 123
(53) (58) (77) (62)
10 9 9 9.3
Population N.
2300 2855 1954 7109
Figures given in parentheses are percentages

5 1 2 Ancilla Tragler
Table 5
(Three Year Period)
Figures given in parentheses are percentages.

Health Care in Slums of Bombay 5 1 3
Table 6
Under five Smallpox BCG Vaccine Primary Triple Secondary Triple &
Vaccine Polio Vaccine Polio Vaccine
Bandra West
130 104 104 33 13
(80) (80) (25) (10)
Bandra East
350 273 287 147 53
(78) (82) (42) (15)
Bandra West
127 108 89 25 13
(85) (70) (20) (10)
Extended Suburbs
145 116 116 58 22
(80) (80) (40) (15)
752 601 596 263 101
(80) (80) (35) (13)
Figures given in parentheses are percentages.