“... the health situation of the tribal population can be improved and... as things stand today, a lot of work needs to be done. There is need for urgent action. Applying the principles of Equity and Antyodaya, this committee has no hesitation in saying that tribal health must receive the first and the highest attention.” This statement in the country’s first ‘Tribal Health Report’ submitted by an Expert Committee on Tribal Health constituted by Union Ministry of Health and Family Welfare, and Union Ministry of Tribal Affairs, sums up how important it is to implement the recommendations in the report. Sadly, despite the report being submitted to the Government of India in 2018, precious little has happened.

 

“Two things have happened since submission of the report -- nothing much, and realisation that there is lack of a group to give political push to the issues of tribal health,” says ‘Padma Shri’ Dr Abhay Bang, Founder and Director of Society for Education, Action and Research in Community Health (SEARCH), and also Chairman of the Expert Committee on Tribal Health. Dr Bang told ‘The Hitavada’ that nothing much had happened on the recommendations in the report because of competing priorities. Government launched Ayushman Bharat Scheme, due to which Government machinery got engaged in its implementation, elaborated Dr Abhay Bang. COVID-19 also sapped a lot of attention of the Government. “So, in sum, no one opposed the report but there has been no implementation either. Time has come when it must dawn upon the authorities concerned that without improving tribal health, national average cannot improve. For, one section will be left behind every time while making an attempt to improve national average,” he observed. According to Dr Bang, there is absence of unified political voice for tribals. As a result, there was lack of political push for tribal health and related matters.

 

There is a little story behind ‘The Report of the Expert Committee on Tribal Health: Tribal Health in India – Bridging the Gap and a Roadmap for the Future’. Noted economist and Nobel laureate Prof Amartya Sen calls meeting of a group called ‘Kolkata Group’ to which the experts from India and Bangladesh, bureaucrats, social workers, leaders etc are invited. “I, too, was invited. During travel from hotel to the venue of the meeting, the then Health Secretary Keshav Desiraju was sitting next to me. During the conversation, I told him that needs of tribal and rural areas were different as far as health issues were concerned. So, I stressed, there has to be different response to addressing these needs in case of tribal areas and other rural areas,” recalled Dr Bang. Two months later, Desiraju took efforts to understand the work in the domain and visited SEARCH with the then Tribal Affairs Secretary Vibha Puri Das. They spent time in understanding the ground situation from close quarters. On their return, they constituted an Expert Committee to prepare what is known as Tribal Health Report. However, preparing the country’s first such report was a daunting task. The report came into being after five years of hard work put in by the committee. The darkness of information was astounding. The committee chief said, “We had to extract, derive, and collate the requisite data from various data-sets. We realised that since Independence, the Government had ‘solved’ issues pertaining to tribal health without even an estimation of the problem.”

 

The committee found that the healthcare services in tribal areas, apart from being ‘deficient in number, quality and resources, suffer from major design problems of inappropriateness to tribal society and lack of participation’. Further, the tribal people suffer from ‘triple burden of disease’. As per the report, one set of burden is malnutrition and communicable diseases, another set is rapid urbanisation-environmental distress-changing lifestyle resulting in rise in prevalence of non-communicable diseases (cancer, hypertension, diabets), and the third burden is mental illnesses especially addiction. Tribal communities in the country have poorer health indicators, greater burden of morbidity and mortality, and very limited access to healthcare. Further, there is ‘near complete absence’ of data on the health situation of different tribal communities.

 

The expert committee submitted the report to the Government in 2018. The then Health Minister J P Nadda welcomed the report and promised action through implementation. NITI Aayog and Prime Minister’s Office also wrote to the Ministry of Health. However, sadly, nothing much has happened on ground. So, ‘what next?’ Dr Abhay Bang gave a very interesting reply: “Well.. It is said that Shiva had cursed the ‘Swara’ (melody) that its existence would be momentary. In today’s era, data has this curse. Any data can be of no use after some time. For, there may be several variations in the conditions, and especially time, in which the data was collected. Passage of time reduces the utility of data.” Still, he said, when there is no data, whatever data is compiled for the first time has its relevance. For, this data becomes benchmark for the future endeavours. Similar is the case with Tribal Health Report. According to the globally renowned health expert, the data compiled in the report will serve as benchmark, whenever in future, the Government decides to implement the recommendations. 

 

Some of the findings Some findings of the report deserve serious and urgent attention. For instance, though life expectancy at birth for Scheduled Tribe (ST) in India is 63.9 years as against 67 years for general population, the life expectancy for tribal people is likely to be an ‘over-estimate’ because child deaths are ‘under-reported’ amongst tribals. Dealing with various aspects of tribal health, the report points out that almost 50 per cent adolescent ST girls in the age-group of 15-19 years are ‘under-weight’ or have a body mass index or BMI of ‘less than 18.5’. As many as 27 per cent tribal women still deliver at home, the highest among all population groups. “This could in part be attributed to the unfriendly attitude of health workers, language and understanding gap, and the lack of trust in an alien system. More importantly, maternal health services provided by the Government are often not in tune with the health beliefs and practices of the tribal people,” states the report. “The infant mortality rate in ST in India was the highest in the world among the indigenous populations, next only to the Federally Administered Area in Pakistan. India cannot be proud of this,” the report points out. Though there has been a major improvement that the tribal infant mortality rate has halved over a period of 26 years -- from 1988 to 2014, the annual rate of reduction in tribal IMR after peaking in 2004, declined during the 10 years -- 2004-2014. The report goes on to bring out several such points to ponder over for the Government, policy-makers, and health sector.

 

Key recommendations As part of the objective of the report to develop a national framework and roadmap to improve appropriateness, access, content, quality and utilisation of health services among tribal populations, the committee has made several recommendations. One key recommendation is to launch Tribal Health Mission with space for say of tribals through participation in its structure and design. Another recommendation is to appoint 1,000 Tribal Health Officers (THO). “At present, tribal healthcare is low on quality and resource-starved. One THO per 809 blocks in the country and District THO must be appointed, on the lines of IAS cadre. Further, there should be a mechanism of Tribal Health Council and Directorate to improve service delivery,” Dr Bang added.

 

‘Increase total public expenditure on tribal health to Rs 2,447/- per capita’ As far as financing the whole effort for improvement in tribal health is concerned, the report mentions that there has to be ‘strict adherence’ to Tribal Sub-Plan guidelines ensuring additional allocation by Central and State Ministries of Health to public health allocation and expenditure in tribal areas, in proportion to the share of ST population -- to a total of Rs 15,676 crore, and ensuring that 70 per cent of this is spent on primary healthcare. Further, it presses for increasing the total public expenditure on tribal health to Rs 2,447/- per capita, to bring it to the level equivalent to 2.5 per cent of national GDP, matching the goal of the new National Health Policy-2016. As far as Maharashtra which has 9.40 per cent of ST population is concerned, the report expects allocation for tribal health in the health budget to be Rs 948 crore. “Sadly, there is no systematic account available about funds spent on tribal health. At best, this is feigned helplessness. Hence, we have recommended efficient fund flows from the Government matched by transparent accounts, financial monitoring and reliable data,” Dr Bang added.