PRESENTER – Dr MANISH TAYWADE

Modrator- Dr Amol Dongre

Frame work of Seminar

HISTORYBritish enumerated and classified- India’s population into

groups and categories one of which was the category of the tribal or adivasi (indigenous people).

The word “tribal” half-naked men and women, arrows and spears in their hands, combined with myths of savagery and cannibalism

This group has social, cultural, economic, and political traditions and institutions distinct from the mainstream or dominant society and culture

The tribes were greatly dependent on the forest for their daily needs, including food, shelter, instruments, medicine, and even clothing.

INTRODUCTIONIn India, Adivasis in Hindi and are recognized as STs.Article-342 of the Constitution defines a tribe as-

“an endogemous group (marrying within themselves),with an ethnic identity; who have retained their traditional, cultural,

identity; who have distinctive language or dialect of their own; they are economically backward and live in seclusion governed by their own social norm, and largely having a self contained economy”

Professor Majumdar:Tribe-as social groups with a territorial affiliation, endogamous,with no specialization of functions ruled by tribal officers,herediatry or otherwise,united in language or dialect,recognising social distance with others tribes or caste,following traditionl beliefs and costums.

Geographical distribution of tribes

The Fifth Schedule covers Tribal areas in 9 states of India:State Areas

AndhraPradesh

Visakhapatnam, East Godavari, West Godavari, Adilabad, Srikakulam,Vizianagaram, Mahboobnagar, Prakasam (only some mandals are scheduledmandals)

Jharkhand Dumka, Godda, Devgarh, Sahabgunj, Pakur, Ranchi, Singhbhum (East & West),Gumla, Simdega, Lohardaga, Palamu, Garwa, (some districts are only partly tribal blocks)

Chhattisgarh Sarbhuja, Bastar, Raigad, Raipur, Rajnandgaon, Durg, Bilaspur, Sehdol,Chindwada, Kanker

HimachalPradesh

Lahaul and Spiti districts, Kinnaur, Pangi tehsil and Bharmour sub-tehsil inChamba district

MadhyaPradesh

Jhabua, Mandla, Dhar, Khargone, East Nimar (khandwa), Sailana tehsil in Ratlam district, Betul, Seoni, Balaghat, Morena

Gujarat Surat, Bharauch, Dangs, Valsad, Panchmahl, Sadodara, Sabarkanta (parts of thesedistricts only)

Maharashtra Thane, Nasik, Dhule, Ahmednagar, Pune, Nanded, Amravati, Yavatmal,Gadchiroli, Chandrapur (parts of these districts only)

Orissa Mayurbhanj, Sundargarh, Koraput (fully scheduled area in these three districts),Raigada, Keonjhar, Sambalpur, Baudakondmals, Ganjam, Kalahandi, Bolangir,Balasor (parts of these districts only)

Rajasthan Banswara, Dungarpur (fully tribal districts), Udaipur, Chittaurgarh, Siroi (partlytribal areas)

NFHS 3 (2005-2006) Data indicates that health outcomes for Tribals:Indicator India Average

In percentScheduled Tribe

In percentScheduled Caste

In percent

Women age 20-24 married by age 18 (%) 44.5 55.5 52.7

Total Fertility Rate 2.68 3.12 2.92

Women age 15-49 using any method ofcontraception

56.3 48.0 55.0

Women receiving 3 ANC visits during lastpregnancy (%)

50.7 40.2 44.3

Institutional birth (%) 40.7 19.6 35.1

Children 12-23 months fully immunized (%) 43.5 31.4 39.7

Women 15-49 whose BMI is below normal (%)

33 46.6 39.5

Children 6-35 months who are anemic (%) 79.2 85.1 82.3

Women 15-49 who have heard of AIDS(%) 57 34.6 50.9

Different RCH indicators for the SCs/STs against the rest of the population is given below: source;NFHS II(1998-99)

Health Indicator ScheduledCastes

ScheduledTribes

Rest ofPopulation

IMR 83.0 84.2 61.8

Under 5 Mortality 119.3 126.6 82.6

% Children underweight

53.5 55.9 41.1

% Children with ARI

19.6 22.4 18.7

% Children with diarrhoea

19.8 21.1 19.1

% Women with anemia

56 64.9 47.6

Health Problems common to all Tribes:Marked lack of Health and Medical Services-High degree of inbreeding and therefore high prevalence of genetically

inherited diseasesMost of the tribes have high prevalence of goitre, among women of child

bearing age groups, habitation in hilly area and lack of access to sea foodsMost of tribes studied by anthropologist and voluntary organisation appears to

have a few common practices regarding maternal and child care; Expectant mothers are expected to restrict there diet and quantity as there is a common fear that if the baby is too large, delivery would be difficult and might lead to death of the mother

Among most of the tribes, gastrointestinal disorders, particularly dysentery and parasitic infection are very common leading to morbidity and malnutrition, diarrhoea, dysentery, skin diseases respiratory diseases.

Nutritional problems are also a big issue in these tribe areas, vitamins A,C,B complex deficiencies , under-nutrition of mothers along with anaemia due to food taboos, protein energy under-nutrition and few cases of vitamin deficiencies in children due to general lack of awareness of child care and infant feeding practices

Health Problems common to all Tribes continue…. Indebetness: rampant poverty and deficit economy.

Loss of tribals rights over land forests Primitive mode of agriculture Ignorance Expenditure beyond their means Adherence to panchayat decision

Land alienationShifting cultivation:12% of Indian tribes, northeastern region and central

India, leading to soil erosion, flood in river, ecological imbalance.Bonded labour: Bonded labour act in 1976 and child labour act 1987.Lack of education Industrilization and problems of tribesProblem of tribal forestCommunication

Problems of accessibility and poor utilization of health services in tribal areas:o Difficult terrain and sparsely distributed tribal population in forests and

hilly regions.o Locational disadvantage of sub-centers, PHCs, CHCs.o Non availability of service providers due to vacant posts and lack of

residential facilities.o Lack of suitable transport facility for quick referral of emergency cases.o Lack of appropriate HRD policy to encourage/motivate the service

providers to work in tribal areas.o Inadequate mobilization of NGOs.o Lack of integration with other health programs and other development

sectors.o IEC activities not tuned to the tribal: idioms, beliefs and practices.o Services not being client friendly in terms of timing, cultural barriers

inhibiting utilization.o Non involvement of the local traditional faith healers.o Weak monitoring and supervision systems.

RCH Programme:Goal:To improve the health status of the tribal community Objective: The main objective of the program is to develop integrated and sustainable

system for primary health care services delivery in the tribal areas of the country.

Strategy: To attain the above goals and objectives, the strategy will be to:Assess the unmet needs of RCH services in different tribal areas and

different tribes.Provide integrated and quality RCH Services Improve service coverage, accessibility, acceptability and its utilization.Promote community participation and inter-sectoral coordination.Promote and encourage tribal system of medicine.Develop a sufficient number of first referral institutions capable of tackling

emergencies including obstetric emergencies.Provide associated supplies, management and information

Type of Services Tier Service

Community

Level

Community based worker /ASHA to work as social mobiliser, educator & provider of non-

clinical services and to work as Depot holder for contraceptives.To act as DOTs provider

for the revised National TB Control Program, to take malaria slides, store and distribute

antimalaria drugs, create awareness about sanitation, safe drinking water and participate in

the other health care programs.

Sub

Centre

ANC&PNC services, IFA distribution, delivery by skilled attendant, referral for

institutional delivery, contraceptive distribution and referral for terminal methods,

immunization, management of childhood illness, deworming, nutrition and health education

for mothers, treatment of minor aliments including RTI/STI, services under national

programme like DOTS, NMCP, counseling services.

PHC All above + dispense ayurvedic, home opathic, Unani and Tribal system of medicines.

Block

PHC/CHC

All above+Terminal method of FP EOC+ elective abortion 1stTrimester, MVA, screening

and clinical based services for sickle cell anaemia, Thalasemia, G-6 PD deficiency and Lab

services.

Tribal RCH IN MAHARASHTRAFive districts have special programmes for tribal as far as family welfare

sector is concerned.

The Navsanjivani scheme is being implemented in all tribal areas.Special schemes are prepared for tribal areas-

1) Matutva Anudan Yojana2) Continous Medical education through Dai Meeting2) Pada Volunteer Scheme3) Mobile Medical Squad4) Compensation for loss of daily wages

5) Water Quality Monitoring

Flow of fund in tribals

GOI

state

district society/Zilla Panchayat

Block PHC MO/ Block Panchayat

Public Private PartnershipNGOs mapping should be carried out in the tribal areas and credible

NGOs especially with clinical services backup should be encouraged to take the total responsibility of managing the RCH and health services in the sub-centre/PHC/CHC where public health system is deficient/inadequate.

NGOs and corporate sectors should be encouraged to take up CBD projects covering minimum a block population and could coordinate mobile health services, counseling, referral transport, awareness creation and social mobilization.

NGOs and private nursing homes/hospitals may be involved in the program including service delivery through a frame work of partnership.

Accreditation methods can be followed for private and NGO operated facilities. All facilities within the framework should follow uniform reporting system and referral system.

Outsourcing/franchising of discrete services (such as diagnostics) to NGOs/Private Sectors.

Constitutional safe guard for TribalsArticle 46 of the constitution, ”The state shall promote, with special care the

educational and economic interest of the weaker sections of the people, and in particular of ST and SC,and shall protect them from social injustices and all forms of exploitation”.

Article 15 prohibits discrimination on grounds of religion,race,sex and place of birth.free access to temple,hotels,schools and public places.

Article 16 provide equal oppurtunities for employment and appointment in public sector and Government service.Article 16(4) provides reservation for jobs 7% for ST.

Article 17 provides untouchability abolition.

VECTOR BORN DISEASESTribals constitute only about 8% of the 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

ISSUES

a) Inadequate Access to Services

b) Poor Service Delivery

c) Lack of Demand for Services

d) Lack of Consultation

Sickle cell Anemia:Sickle cell anemia is rampant in the tribal population, the prevalence of

homozygotes for the sickle gene calculated to be over 20% with an estimated five million individuals predicted as carriers.

consanguineous marriage practices, there is a dangerously high prevalence of genetic disorders among tribal populations.

Along with amino acid irregularities, Glucose-6-Phosphate Enzyme Deficiency, a fatal and genetically carried deficiency in a blood enzyme, is present in about 15 million tribals, who reside in primarily high-incident malaria zones such as Madhya Pradesh, Maharashtra, Tamil Nadu,Orissa, and Assam states.

References:Association for Health Welfare in the Nilgiris & Tribal India Health

Foundation Sickle Cell Disease Center, OPERATIONS REPORT VERSION 1.7

Website http://www.tihf.org/PROJECT IMPLEMENTATION PLAN FOR VULNERABLE GROUPS

UNDER RCH II: December 2004. Government of India Department of Family Welfare Ministry of Health & Family Welfare.

Sahni A,Xirasagar S.Health and Development of the Tribal People in India:Indian society of health adminastrators.1990

Deogaonkar SG. Tribal administration and development. New Delhi:1994Concepts In Social Sciences And Some Important Issues In Indian Society,

Culture And Economy.4th ed. Department of Extra Mural Studies:International Institute For Population Sciences.2003.

http://www.mahaarogya.gov.in/projectandschemes/itdpnavsanjivani/default.htm