Tribes Health in India

The term "Scheduled Tribes" first appeared in the constitution of India. Article 366 (25) defined scheduled tribes as "such tribes or tribal communities or parts of or groups within such tribes or tribal communities as are deemed under Article 342 to be Scheduled Tribes for the purpose of this constitution". The list is state/UT specific and a community declared as a scheduled tribe in one state need not be so in another state.

Over 104 million tribal people live in India spread across 705 tribes, and account for 8.6 per cent of the country's population (1). Tribal people have remained marginal-geographically, socio-economically, politically and therefore, health and healthcare in tribal areas remained unsolved problem.

Demographic Profile

The tribal population are largely concentrated in ten states and in 8 North-East states. Nearly 90 per cent of the tribal population live in rural areas. Numerically, Madhya Pradesh has the largest tribal population (15 million), followed by Maharashtra (10 million), Odisha (9 million) and Rajasthan (9 million). However the concentration of tribal population is highest amongst the North-East states. They mostly live in hilly and forested areas.

The population of tribal males is 52.5 million and females is 52.0 million. The total fertility rate is 2.48, which is within reasonable limit and the decline in total fertility rate is comparable to other populations in some major states. The sex ratio in 2011 was 990, which is higher than the national average of 943. The child sex ratio of STs in 0-6 years age group has declined from 972 in 2001 to 957 in 2011 census, but still it is higher than the general population at 914 girls to 1000 boys (2).

Literacy rate: As per census data, literacy rate for STs in India has improved from 47.1 per cent in 2001 to 59 per cent in 2011. The male literacy rate has increased from 59.2 to 68.5 per cent and female literacy rate increased from 34.8 per cent to 49.4 per cent during the same period. Table 1 compares the literacy rate in STs and all India population.

Life expectancy

The life expectancy at birth for ST population in India is 63.9 years, as against 67 years for the general population (1).

Reproductive, maternal, new-born, child health and adolescent (RMNCH+A) strategy (1):

No recent estimates for maternal mortality among tribal women are available separately. Early marriage, early child

Table 1: Literacy rate among STs and All India Population

Year	All India - Persons	All India - Males	All India - Females	Scheduled Tribes - Persons	Scheduled Tribes - Males	Scheduled Tribes - Females
1961	28.30	40.40	15.35	8.53	13.83	3.16
1971	34.45	45.96	21.97	11.30	17.63	4.85
1981	43.57	56.38	29.76	16.35	24.52	8.04
1991	52.21	64.13	39.29	29.60	40.65	18.19
2001	64.84	75.26	53.67	47.10	59.17	34.76
2011	73.00	80.90	64.60	59.00	68.50	49.40

birth, low BMI and high incidence of anaemia are known factors for high maternal mortality. The 68.0 per cent rate of institutional delivery is much lower than the national average of 78.9 per cent. 71.5 per cent deliveries are conducted by skilled health personnel. Coverage of post-natal care remains poor. Only about 37 per cent tribal women reported receiving any postnatal care within 48 hours after home delivery.

As per NFHS-5, the estimated infant mortality rate for scheduled tribe was 41.6, 1-4 year child mortality rate was 9.0, under five mortality rate 50.3, and neonatal mortality rate 28.8 per 1000 live births. The time trend shows a major improvement in the mortality rates.

Immunization coverage of the tribal children remains lower than the total population as shown in Table 2.

The percentage of stunting, wasting and underweight in tribal children has reduced but malnutrition (micro-malnutrition and macro-malnutrition) is still higher than in all population children as shown in Table 2.

The burden of disease in tribal community

Epidemiological transition is taking place in tribal areas also, as in rest of country. The health care needs of the tribal people is much more than RMNCH+A. The tribal population in the country faces a triple burden of diseases. While malnutrition and communicable diseases like malaria and tuberculosis continue to be rampant, rapid urbanization, environmental distress and changing lifestyles have resulted in a rise in the prevalence of non-communicable diseases like cancer, hypertension and diabetes. To add to this is the third burden i.e. of mental illnesses, especially the addictions.

Table 1 Comparison of some MCH indicators in ST and all population (2019-2021) ST-Scheduled Tribe Source: (3)

1. Communicable diseases

The tribal population bears a disproportionate burden of communicable diseases. These include tuberculosis, malaria, leprosy, sexually transmitted diseases, AIDS/HIV, skin infections, diarrhoeal diseases, hepatitis etc.

a. Tuberculosis:

The estimated prevalence of pulmonary tuberculosis in tribal community is significantly higher than in the rest of the country, i.e., 703 against 256 per 100,000 population (1). RNTCP provides free diagnosis and treatment to all the patients. The programme has started the newer interventions like active case finding to improve the case detection rate in hard to reach areas. Around 40,000 tribal patients have been diagnosed and treated under RNTCP since 2015 (4). To improve access to tribal and other marginalized groups, there is provision for: (a) Additional TB Units and Designated Microscopy Centres (DMC) in tribal/difficult areas; (b) Compensation for transportation of patient & attendant in tribal areas; (c) Higher rate of salary to contractual staff posted in tribal areas; (d) Enhanced vehicle maintenance and travel allowance in tribal areas; and (e) Provision of TB Health Visitors (TBHVs) for urban areas.

The programme would intensify its case finding activities through systematic active TB screening among clinically and socially vulnerable population in campaign mode. Here the tribal districts of the state are mapped among vulnerable population and door to door case finding efforts are carried out. Phase 1 of the campaign was executed in January, 2017 and the 2nd Phase was implemented in July-August 2017. During this campaign, the programme screened more than 72,000 target tribal population across the country and diagnosed 27 additional TB cases.

The most significant aspect of the project is the deployment of the Mobile TB Diagnostic Van (MTDV) equipped with X-ray facilities and Sputum Microscopy facilities which offer diagnostic services for Tuberculosis at the doorstep of the patient's home in difficult to reach areas of the tribal populations. This project has been initially undertaken in 5 States (Madhya Pradesh, Gujarat, Chhattisgarh, Rajasthan and Jharkhand) in 17 districts. 35 MTDVs have been fabricated for this purpose.

The project covers a total population of approximately 17.65 million. This intervention is expected to improve the 'Standard of Care among the extremely deprived populations. The efforts are expected to improve early seeking of care, reduction in out of pocket expenditure of individual patients and curbing of individual patients being directed to multiple providers for treatment which results in huge economic burden to patients and their families.

b. Leprosy:

Under the national leprosy eradication programme, state wise disaggregated data of tribal population is collected on monthly basis. During the year 2016-17, out of 1,35,485 new leprosy cases detected, 25,474 (18.90%) were scheduled tribes and 25,449 (18.78%) were scheduled castes.

Facilities for Scheduled Castes and Scheduled Tribes: Leprosy services are uniformly available to all including scheduled castes & scheduled tribes population irrespective of caste and religion. Under the programme, funds are allotted to NGOs, who are encouraged to work in tribal areas for providing services like IEC, prevention of deformity and follow up of cases. Intensified IEC activities have been taken up through various media including the rural media under which population residing in remote, inaccessible and tribal areas is being covered.

c. Malaria and other vector borne diseases Although tribal communities constitute only about 8% of the national population, they account for about 30% of all cases of malaria, more than 60% of P. falciparum, and as much as 50% of the mortality associated with malaria.

Under National Vector Borne Disease Control Programme, services for prevention and control of Malaria, Kala-azar, Filaria, Japanese Encephalitis, Dengue/Dengue Haemorrhagic Fever (DHF) and Chikungunya, are provided to all sections of the community without any discrimination. However, since vector borne diseases are more prevalent in low socio-economic groups, focussed attention is given to areas dominated by the tribal population in North Eastern States and parts of Andhra Pradesh, Chhattisgarh, Gujarat, Jharkhand, Karnataka, Madhya Pradesh, Maharashtra and Odisha. Additional inputs under externally assisted projects from Global fund to North Eastern states and from World Bank to other states, especially for control of Malaria are provided. For Kala-azar elimination in the states of Bihar, Jharkhand and West Bengal, World Bank support is also being provided. In addition, North Eastern states are being provided 100% central assistance for implementation of the programme (6).

2. Non-communicable diseases

The evidence of an early epidemiologic transition in tribal areas and associated increase in the incidence of non-communicable diseases is being observed.

(a) Hypertension:

One out of every four tribal adults suffer from hypertension. Further the prevalence of hypertension increases significantly with age, consumption of tobacco, alcohol and a sedentary lifestyle. Yet two out three tribal adult men and women did not know the signs and symptoms of the ailment. Only 5 per cent men and 9 per cent women suffering from hypertension knew their hypertensive status.

(b) Blindness and visual impairment:

The national programme for control of blindness and visual impairment is a centrally sponsored scheme (60:40 in all states and 90:10 in NE states) with the goal to reduce the prevalence of blindness to 0.3 per cent by 2020. The benefits of the scheme are meant for all including SC/ST population as per the need. The following initiatives have been implemented under NPCBVI, keeping in view the needs of NE states including Sikkim, which are tribal predominant (6):

• Assistance for construction of dedicated eye units in North-Eastern states including Sikkim and other hilly states, • Appointment of contractual ophthalmic manpower (ophthalmic surgeons, ophthalmic assistants and eye donation counsellors) to meet shortage of ophthalmic manpower in states, • Assistance for setting up of multipurpose district mobile ophthalmic units for diagnosis and medical management of eye diseases for coverage in difficult areas, • Besides cataract, assistance for treatment and management of other eye diseases viz. diabetic retinopathy, glaucoma, refractive transplantation, vitreo-retinal surgery and childhood errors corneal blindness, is provided. •

3. Genetic disorders

The prevalence of sickle cell disease (anaemia and trait together) and thalassaemia - another genetic disorder - varies between 1-40 per cent in different tribal communities. However, most of the prevalence is due to the heterozygous form of the disease. Sickle cell anaemia, the more serious form, is prevalent in 1 in 86 births among tribal communities in central India (1).

Another genetic disease prevalent in many tribal groups in India is the G6PD deficiency. Among the 14 primitive tribal populations from four different states showing a high frequency of sickle gene, the prevalence of G6PD deficiency varied from 0.7 to 15.6 per cent (1).

4. Mental health and addictions:

Almost 72 per cent of the tribal men in 15-54 years age group use tobacco as compared to 56 per cent non-tribal men and about 50 per cent tribal men consume some form of alcohol (5). Tobacco and alcohol, both are risk factors for non-communicable diseases and cause serious diseases, and increases mortality. They reduce productivity and increase poverty, disrupt family harmony and generate law and order problems.

5. Animal attacks and violence in conflict areas

As tribal areas are often surrounded by forests, animal bites from snakes, dogs and scorpions are common.

Health care infrastructure and tribal development

Tribal development has been a challenge to the planners and policy makers since independence. This is mainly on account of their traditional life styles, remoteness of habitation, dispersed population and displacement. Tribal sub-plan (TSP) strategy now known on Scheduled Tribal Component (STC), was adopted in 5th Five year plan for accelerated development of tribal people. Ministry of Tribal Affairs and Ministry of Health and Family welfare are making efforts through tailored educational, infrastructural and livelihood schemes for the improvement in terms of various indicators relating to literacy, health and socio-economic status etc. However, there is still significant gap in human development indicators between scheduled tribes and all category group (2).

Facilities for scheduled tribes under National Health Mission (5)

Health Care Infrastructure

As per the present norms, tribal and hilly areas should have one Health Sub-centre (HSC) per 3,000 population, one Primary Health Centre (PHC) per 20,000 population, and a Community Health Centre (CHC) per 80,000 population. Data on 'required versus shortfall of sub-centres, PHCs and CHCs in tribal areas of 18 states and three UTs was studied. Data in 18 states showed:

Sub-centres: In seven states no shortfall in number of HSCs against the required number was observed. In the remaining 11 states, a shortfall of 4,996 sub-centres i.e. 27 per cent of the required numbers in these states was noted.

PHCs: No shortfall existed in 11 states. In the remaining seven deficient states a shortfall was noted of 1,023 PHCS which was 40% of the required number in these states.

CHCs: In eight states, there was no shortfall. In the remaining 10 states a shortfall of 209 CHCs was observed. The shortfall accounted for 31% of the required number of CHCs in these states.

Among the UTs an 8% shortfall in Sub-centres and of 1 CHC (against the requirement of 1) was reported from Dadra and Nagar Haveli. No other shortfall was noted at any level. Thus in about half of the states, the health institutions in tribal areas were deficient in number by 27 to 40 per cent as compared to the present norms.

Health Human Resource (HHR)

A huge gap in human resources in health centres in tribal areas is attributed to reasons such as limited scope for professional interaction or growth for the staff, a feeling of social and professional isolation, weak human resource policies, poor working conditions and environment in the government health institutions, limited social infrastructure, etc. Various states have tried different measures to overcome this shortage of doctors, but the problem persists. Several states have introduced a bond for compulsory rural service, but it is flouted by most of the doctors completing MBBS. The medical education and the health departments seem unwilling or unable to enforce the execution of the bond.

The Ministry of Health and Family Welfare (MoHFW) and the Ministry of Tribal Affairs (MoTA), in October 2013, jointly constituted an expert committee on tribal health, under the chairmanship of Dr. Abhay Bang. It had as its members prominent academicians, civil society members and policy makers who have long been working with the tribal people. The expert committee suggests following measures to improve human resources for tribal health (5):

1. Features of tribal society demand that the health care provider, as far as possible, should be a local tribal. The present health workforce pattern is opposite of this. 2. The only way of effecting a vibrant, responsive and accessible health workforce in the tribal areas in a sustained manner, is by ensuring that local tribal people are trained and deployed in the health force. 3. It is important to place the centre of gravity of the workforce not at the top the specialists and doctors -but closer to the communities.

The ASHA in tribal areas should have an expanded role. Eight type of functions and total 4 hours of work per-day is expected from tribal ASHAs. Mid-level care providers should be created through bridge courses and placed at the sub-centres. To attract doctors to work in tribal areas, the total salary of MOs needs to be substantially increased. To provide doctors dedicated to work in tribal areas, the committee recommended creation of dedicated medical colleges in tribal districts, exclusively for tribal students in the scheduled areas.

References

1. Govt. of India, Report of the Expert Committee on Tribal Health, Tribal health in India, Bridging the gap and a roadmap for the future, Executive Summary and Recommendations, Ministry of Health and Family Welfare, New Delhi and Ministry of Tribal Affairs New Delhi. 2. Govt. of India (2018), Annual Report 2017-2018, Ministry of Tribal Affairs New Delhi. 3. Govt. of India (2022), National Family Health Survey-5 Report, Ministry of Health and Family Welfare, New Delhi. 4. Govt. of India (2018), Annual Report 2017-2018, Ministry of Health and Family Welfare, New Delhi. 5. Govt. of India, Tribal Health in India, Policy Brief, Report of the Expert Committee on Tribal Health, Bridging the gap and a roadmap for the future, Ministry of Health and Family Welfare, New Delhi and Ministry of Tribal Affairs, New Delhi. 6. Govt. of India (2020), Annual Report 2019-2020, Ministry of Health and Family Welfare, New Delhi.