For the first time since independence, a tribal President has become a reality in India. This is a very positive signal given to the tribal people by the Narendra Modi government. On this International Day of the World’s Indigenous Peoples, let us explore how this symbolic gesture can be turned into a health revolution for the tribal people of India.
Few people are aware that nearly 11 crore tribal people (enumerated as Scheduled Tribes (ST) in the Census of India (2011) live in India. They constitute 8.6% of India’s population, the second largest number of tribal people in any country in the world. The Prime Minister and the national leadership of the Bharatiya Janata Party are aware of this fact, which is one of the reasons why they have chosen a tribal woman for the highest position in the country.
A study published in The Lancet, titled ‘Indigenous and Tribal Peoples’ Health’ (2016), found that India held the inglorious distinction of having the second highest infant mortality rate for the tribal people, next only to Pakistan. This is not an honourable position.
On this day, in 2018, the first national report on the state of India’s tribal people’s health was submitted to the Government of India by the Expert Committee on Tribal Health. The 13-member committee was jointly appointed by the Ministry of Health and Family Welfare and the Ministry of Tribal Affairs, Government of India. I was the Chairman of this committee, with the Additional Secretary and Mission Director of the National Health Mission as the Member Secretary. It took five years of enormous work for the committee to dig out evidence and construct a national picture. The picture was both pathetic and promising. These were some of the few major findings.
Firstly, tribal people are concentrated in 809 blocks in India. Such areas are designated as the Scheduled Areas. However, the more unexpected finding was that half of India’s tribal population, nearly five and a half crore, live outside the Scheduled Areas, as a scattered and marginalised minority. They are the most powerless.
Second, the health status of tribal people has certainly improved during the last 25 years as seen in the decline in the under-five child mortality rate from 135 in 1988 in the National Family Health Survey (NFHS)-1 to 57 in 2014 (NFHS-4). However, the percentage of excess of under-five morality among STs compared to others has widened.
Third, child malnutrition is 50% higher in tribal children: 42% compared to 28% in others.
Fourth, malaria and tuberculosis are three to 11 times more common among the tribal people. Though the tribal people constitute only 8.6% of the national population, half of the total malaria deaths in India occur among them.
Fifth, while malnutrition, malaria and mortality continue to plague tribal people, gradually, the more difficult to treat non-communicable diseases such as hypertension and diabetes, and worse, mental health problems such as depression and addiction leading to cancer and suicide, are increasing. These threaten the health and survival of tribal adults.
Sixth, tribal people heavily depend on government-run public health care institutions, such as primary health centres and hospitals, but there is a 27% to 40% deficit in the number of such facilities, and 33% to 84% deficit in medical doctors in tribal areas. Government health care for the tribal people is starved of funds as well as of human resource. We found them demoralised and inefficient.
Seventh, there is hardly any participation of the tribal people – locally or at the State or national level – in designing, planning or delivering health care to them.
The official policy of allocating and spending an additional financial outlay, called Tribal Sub-Plan (TSP), equal to the percentage of the ST population in the State, has been completely flouted by all States. As estimated for 2015-16, annually ₹15,000 crore should be additionally spent on tribal health. No accounts or accountability exist on this. No one knows how much was spent or not spent.
These issues have persisted as there is no separate data on tribal people’s health, or healthcare or on the money spent.
A road map
The committee was also asked by the Government of India to prepare a road map for the future, which it did. This road map includes a large number of recommendations, but the three most important broad recommendations are the following. Firstly, launch a National Tribal Health Action Plan with a goal to bring the status of health and healthcare at par with the respective State averages in the next 10 years. Second, the committee suggested nearly 80 measures to address the 10 priority health problems, the health care gap, the human resource gap and the governance problems. Third, the committee suggested allocation of additional money so that the per capita government health expenditure on tribal people becomes equal to the stated goal of the National Health Policy (2017), i.e. 2.5% of the per capita GDP.
Four years have already passed. The committee presented its report on August 8, 2018, to J.P. Nadda (who was the Health Minister at that time), the Minister of Tribal Affairs, the Secretaries of the two ministries and the Director General of the Indian Council of Medical Research. Mr. Nadda promised that “this historic report will not lie on the shelf. This government will certainly implement it”. The tribal people of India are waiting.
The Health Minister and the 10 States with a sizable tribal population should take the initiative. The Prime Minister has already signalled his intention by electing a tribal President of India. Let this massive need and the historic opportunity receive an appropriate response. A proposal currently being discussed involves addressing only one disease, the Sickle Cell Disease. Though needed, it will substantially help, at best, five lakh to 10 lakh sickle cell disease patients – merely about 0.5% of the tribal people. The tribal healthcare system is sick, and tribal people need more substantive solutions. We need to move from symbolic gestures to substantive promises, from promises to a comprehensive action plan, and from an action plan to realising the goal of a healthy tribal people.
If actualised, the Tribal Health Mission can be the path to a peaceful health revolution for the 11 crore tribal people. India needs to demonstrate to them that democracy offers a caring solution to their wounds.
Abhay Bang is Director, SEARCH, Gadchiroli