Nagpur (Maharashtra): On 21 July 2022, India chose its first tribal President, representing more than 110 million of its most disadvantaged community.
Former Jharkhand governor Droupadi Murmu sailed through presidential elections, creating history, as she defeated the opposition candidate and former union finance minister Yashwant Sinha, in being elected India’s 15th president since 1950.
Murmu’s victory was significant, as the National Democratic Alliance (NDA), led by India’s ruling Bharatiya Janata Party (BJP), looks to consolidate its political grip on tribal India by riding on the political symbolism of anointing a tribal woman leader as the head of the republic.
Murmu is a Santhal from Odisha, home to 9.5 million tribals. The move to nominate a tribal woman for the presidential election also split the opposition and forced some parties of the opposition United Progressive Alliance (UPA) to vote for her.
It was difficult for most parties to go against a tribal candidate when India’s Adivasis are scattered over a fifth of districts, or 150 of 773, and influence electoral outcomes in several parliamentary constituencies: 47 of 543 Parliamentary seats are reserved for scheduled tribes (STs), and 151 districts have an ST population of at least 25%, enough to affect electoral outcomes.
Yet, the government of Prime Minister Narendra Modi has taken no action on a key report submitted five years ago by what remains the only post-independence expert inquiring into the status of tribal health and healthcare.
Indeed, some government agencies, often, did not cooperate with the committee, said its head, Abhay Bang, MD (medicine), PhD, 72, a practising doctor and founder and head of the nonprofit Society for Education, Action and Research in Community Health (SEARCH). He and his wife Rani, a gynaecologist, have been providing medical services to Adivasis since the late 1980s.
“Frankly, the tribals probably don’t count politically, and we don’t count them,” Bang told Article 14. “National priorities don’t count tribals. The health system does not count what happens to the tribal health. Therefore, our major emphasis is that we must create a separate tribal health account.”
Apart from Bang, there were 11 other committee members from the government and national research institutes. When Bang’s committee began their work, they found counting tribals and collecting data on them was not easy.
After “repeated requests (from the committee and also the health ministry between 2013 and 2018)”, the census commissioner met the committee,” said Bang. “But we could not get any data on tribal health or healthcare. It was simply incomprehensible to us why the Sample Registration System (SRS) could not have possibly given us that data, because the data are computerised.”
In a 300-page report submitted in 2018, the Bang committee constituted jointly by the ministries of health and family welfare and tribal affairs, said that, among other issues, the state of tribal health “has significantly improved over the past 25 years, and yet, it is worst compared to other social groups”; there was a lack of data; lack of healthcare in what are called scheduled areas, where Adivasis live; and a lack of financing and accountability within “tribal sub plans”, a 48-year-old strategy for focussed development of tribal areas.
In 2018, the health minister at the time, J P Nadda (now BJP national president), tribal affairs minister Jual Oram and their secretaries, top officials from the Indian Council of Medical Research (ICMR), “the entire machinery”, as Bang put it, accepted the report. It was endorsed by the NITI Aayog, the government’s think tank, and the Prime Minister’s Office asked the health ministry to prepare a roadmap for implementation.
“On the face of it, everyone endorsed it, but there seems to be no movement on it,” said Bang, who speculates that Modi’s “big bang” Ayushman Bharat programme of national health insurance pushed the tribal health plan aside. Then came the Covid-19 pandemic.
Bang, who lives on the SEARCH campus Shodhgram, about 20 km from the eastern Maharashtra town of Gadchiroli, and is a well-known voice on community healthcare particularly in the tribal areas, said the committee sifted through scattered datasets to weave together the story of tribal health and healthcare in India.
The picture the committee put together was not rosy.
Tribals make up 8.6% of India’s population, but half of all those who die from malaria are tribal; the prevalence of tuberculosis is three times higher among tribals; and malnutrition is 50% higher among tribal children, the committee reported.
“Health problems in tribal India are not unique, but are at a much higher frequency with consequent higher mortality,” Bang told Article 14. “But, the healthcare system is either vacant or weak or inefficiently functioning.”
The committee recommended structural, institutional, governance, finance and data-related reforms to make rapid improvements to healthcare among marginalised tribal populations. The Centre has not yet worked on any of these recommendations.
India’s 110 million Indians, according to the 2011 census, are spread across 705 tribes, and nearly 50% live in “scheduled” or demarcated tribal areas, the other half scattered nationwide beyond the scheduled areas.
On a rainy July day, Article 14 met Bang in his office on SEARCH campus in Gadchiroli, a district that is over 38% Adivasi, against the backdrop of the buzz created locally around the BJP’s tribal presidential nominee.
We spoke to Bang before Murmu was elected, revisiting the context of the expert committee’s constitution by the union government, its key findings, the roadmap it suggested to improve tribal health and healthcare, with the aim of eventually closing the healthcare gap with India’s non-tribal populations.
Excerpts from the interview.
Dr Bang, why does India need to look at tribal health and healthcare exclusively? And why, in your opinion, did the Centre constitute such a committee in 2013?
Keshav Desiraju, the then health secretary, and then tribal secretary, Vibha Puri Das, came to SEARCH in 2012. They spent two days, wanting to understand why tribal health needs a separate focus and the nuances of the issue. Two months later, Desiraju called to inform us that the government of India had decided to constitute an expert committee and asked me to chair it. There were 12 members, and Manoj Jhalani, the then joint secretary of the ministry of health and family welfare, was our member secretary. The committee was constituted in 2013.
There must have been a realisation within the government that tribal health administration needs to be addressed differently because these regions, regardless of the states such as Gujarat, Rajasthan, Jharkhand, Chhattisgarh, were dragging down the national trends for the IMR (infant mortality rate) or CMR (crude mortality rate) for the non-tribal populations.
This became the first effort really to find out the status of tribal health and healthcare in India. It took us 63 long years to ask some pertinent questions.
What was the mandate of the committee? Tribal health and healthcare has to be located within the larger milieu of tribal India. And was it expanded as the study progressed?
I won’t go into the details, it’s all there in the report. Broadly, the committee was tasked to answer two questions: 1) What is the present status of health and healthcare in tribal areas and why the gap? 2) What should be the roadmap for the future to bridge this gap rapidly? We had a wide scope: to review and do the diagnosis of the state of tribal health and various programmes and recommend a blueprint for betterment.
The committee had experts from various areas, some of them had been practitioners, as well as academicians, administrators, and tribal scholars; and we could manage to do an honest inquiry.
After the initial few meetings, we mapped out the steps, created sub groups and sub sub-groups to dive into different and specific aspects; we conducted state visits, especially the states with large tribal populations. A national workshop on innovative practices on tribal health by government and non-governmental organisations was held here in SEARCH with the support of the government of India in which 22 different best practices were presented as part of our search for good and viable alternatives. Suggestions were invited electronically.
What were the main challenges you confronted? After all, this was a humongous task.
Foremost, there was hardly any segregated national data on tribal health. What was available in the census and others reports was data on tribal population, their distribution, etc. But nothing on the status of tribal health in tribal blocks. We identified from the census data that there are 809 blocks that are tribal majority blocks; there are 151 districts where tribal population is more than 25%. This is the real core.
There was another surprising finding: 55% of the tribal population lives outside of these blocks. This is a vast and scattered tribal population. Visual imagery about tribal India is that tribals live in scheduled areas but we found it’s not completely true.
This half of the tribal population that lives outside the tribal blocks or scheduled areas is more marginalised and disempowered. Because in the scheduled areas, tribal communities are in collectives, they have access to forest resources, have some protection of laws such as PESA [Panchayats (Extension to Scheduled Areas) Act, 1996], so they have natural social advantages. But the scattered tribal populations don’t enjoy these social and economic advantages. For example, the scattered ST (scheduled tribe) populations in urban or rural areas are mostly landless or work as footloose labourers on construction sites or in domestic sectors.
They have no information about the government programmes or schemes nor do they have access to natural resources; they don’t have the collective community power either. Many of them are people displaced from their villages and land due to development projects or have lost their lands and turned landless. They are the most marginalised and disempowered people, nearly 50 to 60 million.
What did the lack of data indicate or mean?
I will give you two examples about how severe the lack of data on tribal health is.
India’s census commissioner also heads the sample registration system or SRS that operates under the home ministry and is headed by the Registrar General of India, who is also the census commissioner and is an IAS (Indian Administrative Service) officer. The job of the SRS is to collect regular information on a random sample of population in urban and rural areas in 700 blocks, about 10,000 people per block; total sample size being about 7 million people, selected randomly every year from the entire country.
Thus, it is the SRS that gives us an idea of IMR or CMR or other data for the entire country, because information collated from the states is inadequate. The SRS is a good system set up in the 1970s to collect data directly in different states. Despite some delay, we get the IMR/CMR data, separately for rural and urban India. So, if we know that the IMR of India is 30 today, that figure has come from this SRS data.
We officially asked the SRS commission to give us the IMR/CMR for the tribal population. We were informed that they don’t keep segregated data on tribal populations.
Now this was perplexing: We said since you have data on 7 million random samples, you might also have the data for ST population. For, all they needed to do was give us segregated data for tribal populations because they would naturally have tribal populations in their random samples.
Despite our repeated requests (from the committee and also the health ministry), we could not get any data on tribal health or healthcare from the SRS. The SRS, the best of the government system, could not give us IMR/CMR for the tribal population. Now, this was in a way revealing because while we intuitively know that the indices are worse off in the tribal areas, this lack of data was an indication that India did not have a focus to find out what the tribal IMR/CMR is. Nobody ever asked for an estimate of a separate tribal IMR.
Same thing happened in the states. In Jharkhand for instance, we met the health secretary. In MP, which has the highest tribal population in absolute sense (these are also states where tribal population is more than 10 million), they told us that they never treat tribal population as a separate focus for data collation. This is not any criticism of them, but it took us 63 years to ask this simple question: What is the status of health and healthcare in tribal India?
So, all our policies and programmes concerning tribals are framed without any specific data?
No, not entirely. Some data comes from the census. We know for example what is the infrastructure development in scheduled areas, how many PHCs (public health centres) exist etc. But we don’t have data on how many tribal people actually have access to healthcare or avail of the facilities.
I will give you a second example: Regarding the Planning Commission guidelines for SC and ST (peoples), two marginalised and backward communities for whom we have a constitutional commitment. The guidelines are that while budgetary allocation should be equally distributed to all the districts, there would be a special tribal sub plan to be spent on the scheduled areas over and above the regular budget outlays. Ditto for the SC populations. Now if Maharashtra has 9.4% ST population, the state government has to take out 9.4% of funds from the overall health outlays for the Tribal Sub Plan, to be spent exclusively on tribal (communities). For the country the entire TSP would be about 8.6% commensurate with the tribal population.
We asked the tribal and health ministry for data on how much is the allocation for TSP for the entire country and how much of it was actually being spent on tribal health.
Again, we were told there is no separate account for tribal health.
Which means we don’t know how much of the Tribal Sub Plan (TSP) component goes on tribal health?
We get data on how much TSP funds are allocated, but how much of it was on health? The national accounting system does not have segregated data on tribal health within the TSP.
Lack of account keeping means lack of accountability. I don’t know if this was really not kept or the ministry had no good picture to share, whatever the reasons, the committee was informed that this data was not available.
The committee then accorded the responsibility to the National Health System Resource Centre (NHSRC), a para organisation under the health ministry, to estimate how much should be the TSP health budget for each state and nationally. That’s because the tribal population varies state-wise, so we needed an estimate of the health plan in each state’s TSP, and then a cumulative national estimate. So how much is the overall health budget; how much is the tribal population of respective states, and so, how much should be the share of the health budget to be spent on the tribal health component—we needed to know. At that time (2015-16), the NHSRC came up with an estimate: That tribal health plan would be Rs 15,600 crore per year for India. This money should have been additionally spent on tribal health—each year.
Specifically for tribal health under TSP…
Yes, Rs 15,600 crore, based on the 2015-16 budget outlays.
There was and is no separate accounting of this money. Whether this much was or is being spent, and if so, under what heads…what was the outcome.
So where did the bulk of your data come from?
We were helped by two major sources: One, the National Family Health Surveys (I to 4) because NFHS-5 was yet to happen then. The NFHS is conducted by the Indian Institute of Population Sciences or IIPS (IIPS director Dr Faujdar Ram was a member of the committee). We requested the IIPS to give us segregated data from the NFHS data pertaining to the under-five IMR for the ST population. They derived that from the NFHS-1 to 4 from 1990 to 2015 – the tribal population and their mortality rates, so that was good data that came from the NFHS data.
What the SRS could not, the NFHS did, as regards information you sought.
Yes. Similarly, the National Nutrition Monitoring Bureau at the National Institute of Nutrition (NIN), Hyderabad—unfortunately, now the Centre has disbanded this institution—used to sequentially do population surveys on nutrition status. The NIN was the apex organisation in India for assessing nutrition standards. They had done a large sample on ten states on nutrition status among tribal population and the latest survey available to us was from 2009: the nutrition in tribal areas of India, these data were systematically collected.
So, we got mortality rates from NFHS data and we got nutrition status from NNMB data. And then various disease-specific data came from individual ministries or departments. We also got good data from several independent studies. Because we had also appealed to the people to share any meaningful information or data, and we got some 600 responses that were useful to us.
One of the recommendations of your committee was, therefore, to collate and streamline this data (see the executive summary), apart from the financial or structural reforms or new institutional set up that you recommended is also important is the upkeep of the data.
Yes, you are right because unless you have data you can’t plan anything, and the tragedy of tribal health is that we severely lack credible data. You cannot assess anything unless you have good data.
Otherwise, you can do merely the indicative newspaper stories, but if you want to go beyond breaking news and formulate meaningful policies, you need data. There is no reason why separate data should not be kept for the 11 crore (110 million) of the most-marginalised ST population. To keep the data and monitor it constantly is probably the first and most important step.
This takes me back to that fundamental question: why should we have a separate approach for tribal health?
See, we all say health is a product of social, economic, geographic, climatic and cultural conditions. Now for tribal people, all these five variables are different. Their social set up is different, it is more communitarian; their economic condition is backward and to a large extent dependent on forest-economy; their climate is different because again these scheduled areas are forested or hilly, and therefore geographical set up is different; there are long distances between habitations with low population density; their education status is low; culture is different and to a large extent tribals rely on traditional knowledge and even belief in supernatural forces. If these factors are different for them, it is but natural that health outcomes will be different. So, that is one reason why tribal health situations would be different and unique to deal with.
Second reason: Obviously diseases are not unique to tribal areas, or that tribal biology and tribal diseases remain universal, but their frequency, prevalence and gravity differ.
You mention in the report that tribal people rely almost entirely on the public healthcare system because private healthcare is mostly non-existent in these areas or very expensive.
It is the National Sample Survey Organisation (NSSO) data that say that 75% of healthcare—I mean even the OPD (out-patient department) level consultation—is provided by the private sector in the rest of India. In tribal India, 50% of healthcare is provided by the government sector. So, tribal people depend more either on traditional systems or public health systems. Private care is relatively less developed in the predominantly tribal areas, and that’s why the public health system becomes very important to tribal people. But as I said it is either vacant or inefficient, the report mentions the prevailing gaps on infrastructure, less human resource etc.
Now, this is a feature of tribal India, and it’s not unique: the public health system is inefficient everywhere or vacant, but its severity is more in the scheduled areas. Seriousness and severity are the hallmarks of tribal health and healthcare.
Combine all these things together: one, their different socio-economic, demographic, climatic, geographical and cultural settings; second, the disease prevalence, which is much higher that elsewhere; third, the inefficient public healthcare system; fourth, the lack of financing; and, the fifth and the most important feature, that we don’t count them so, there are no data, and thus no accountability.
These five things together really make up the picture of tribal health and healthcare in India.
You grappled with data gaps, but if you were to state two or three major findings, what would they be? The report mentions, for instance, that tribal India is witnessing a transition to non-communicable diseases. What are the areas that require urgent attention?
If you see the wording of the report, we have been very cautious; we say the non-communicable diseases have also started emerging. Otherwise very easily an impression could be gathered that the old problems have perished. The main problems of tribal India remain malaria, malnutrition, and mortality. There is a box of our major findings. We suggested a nine-point programme (read the key recommendations here). We suggested a population-based approach for the scheduled areas and family-centric programmes for the scattered tribal populations beyond the scheduled areas, particularly in the urban areas. So that you target ST families wherever they are.
Like a kind of universal health coverage for tribal populations.
We suggested giving ST populations not living in the scheduled areas health cards and appointing dedicated social workers. These social workers could facilitate access to various programmes meant for STs, their health monitoring, access to healthcare and schemes, and keep a tab on the key health indicators.
Frankly, the tribals probably don’t count politically, and we don’t count them. National priorities don’t count tribals. The health system does not count what happens to the tribal health. Therefore, our major emphasis is that we must create a separate tribal health account.
For example: for every survey, we ask for gender information, similarly whether it is NSSO, NFHS, or SRS, or immunisation drive, we should enumerate the ST population: what is the institutional delivery to STs? Or what is the proportion of their immunisation? All tribal data should be segregated; this report happened after 63 years, but this has to happen frequently. The government does not have to do anything different but merely include ST as one variable in the data collection and analysis. That’s it.
You have suggested a new institutional set up, a national tribal health council (NTHC). Why?
We already have the National Health Council. The NTHC, we recommended, should be a part of it. Reason is simple. Tribal health does not receive its due attention. So, we have to create a separate governance structure for it, as an imminent step towards improving the tribal health scenario. Because this whole thing is also a failure or rather the lack of governance. (For the detailed governance structure recommended by the committee, see page 34 of the executive summary here)
In our report, we have suggested a dedicated tribal health directorate within the ministry of health and family welfare, on the lines of institutions or departments for HIV control or a separate ministry for Ayush. This directorate will monitor all data, programme performance, allocation of money and progress, and report to the NTHC, which will be a political body. We have suggested the constitution of such directorates at the central, state, and lower levels too. A separate directorate will ensure that tribal health receives its due attention.
Governance structure is important. Because the problems pertaining to tribal health are not merely the high prevalence of diseases but poor governance as well. You need some kind of reforms to improve poor governance, and that is why governance reforms, finance reforms, data reforms and healthcare service delivery reforms form part of our key recommendations.
Another major recommendation in the report: most often, decisions on tribal health and policies are taken without tribal people, so we have suggested that in 151 districts where tribal population is more than 25%, there should be separate tribal health councils or committees. Right from the Gram Sabha to the district level.
Let me give you an example. Take Gadchiroli district: we recognize it as a tribal district but the district tribal population is only 38%; 62% live in non-tribal areas. Naturally, the district health administration would be more concerned about the 62% population and treat the tribal health in the same manner as the rest of the population. Within the district health plan there needs to be a separate tribal health plan. Predominantly tribal blocks of Gadchiroli should have a different plant that suits these blocks. Also, they need a new governance plan and participation of locals in deciding priorities, planning, and programme delivery.
You see how the Covid vaccine delivery is lagging in tribal areas: because they have not heard of Covid, so the vaccination will lag too. It took 100 years for modern health reforms to penetrate the tribal parts of India.
It will be a digression from our subject, but there is an interesting anecdote that I would like to narrate. In 1940, a British officer travelling to Bhamragarh (a remote area of south Gadchiroli) found a very high prevalence of a sexually transmitted disease called yaws. He ordered the setting up of a government dispensary there for its treatment. So, even the British realised that tribal health priorities were different; you won’t know if there is no ground touch. Now, if we were to define priorities of tribal health and healthcare while sitting in New Delhi or Mumbai with local people having no voice in it, priorities would not address the main questions of tribal India. We at SEARCH recently conducted a survey in about 20 Gadchiroli villages; malaria remains the key priority of the people, we found. So, there has to be participation of local people in the priority-mapping. We have specifically mentioned in the report that local is central to tribal India.
You think there is no participation of local people in mapping the priorities? Local public representatives?
No. There is no participation at all. There is a tribal advisory council in Maharashtra; it’s a constitutional authority. The governor has special powers to map the priorities and this council is supposed to advise him on that. But it does not function; it does not meet regularly, or when it does, its focus is on trivial issues that diverts attention from the broad picture.
Which are the worst districts in terms of indices, and did the committee see any reflection on tribal health of the long-drawn armed conflicts or displacement and migration? On mental health, you also point out that issues in north-east India require a different approach.
No, like I said, the committee could not have launched new studies and had to depend on the available data and studies. There are gaps in the study or areas that need focused inquiry, and we have mentioned those aspects in our report. Like we felt there must be an independent study on the growing mental health challenges in tribal India.
On the health and healthcare status in the north-eastern states, there is a separate chapter. The situation there is different from the rest of India. In most of the states tribal people are in a minority even though in some states their absolute population is over ten million, but in the northeast, tribal people are in a majority so their situation politically, demographically etc. is peculiarly different. The committee suggested a different roadmap for tribal health and healthcare in those parts.
Similarly, we have to think differently to cater to the health problems of the Particularly Vulnerable Tribal Groups (PVTGs), or for the endangered tribal populations of the Andamans.Similarly, we have to think differently to cater to the health problems of the Particularly Vulnerable Tribal Groups (PVTGs), or for the endangered tribal populations of the Andamans.
The committee could not spend a lot of time on these issues but we say in our report that these sections and regions need radically different approaches to addressing their problems.
What about mental health issues?
Tribal areas have three disease patterns: old communicable diseases, malnutrition or maternal health; emerging non communicable diseases such as high blood pressure; and mental health issues and addiction, which remain the least recorded area. We assume that because tribal people live in natural habitat, they would be happy, but our ongoing study shows high prevalence of depression or suicidal tendencies etc. tribal people do have serious mental health issues but are rarely acknowledged. Malnutrition gets recorded but not mental health at all; mental health issues and addiction. There is a need for a different policy to address rising addiction.
During the Emergency, the Indira Gandhi-government had moved a separate policy called the excise policy for the scheduled areas, which barred commercial sale of alcohol in tribal areas because of the disastrous consequence it would have; it acknowledged that tribal people easily succumb to commercial alcohol, so no shop should be licensed or allowed to sale commercial alcohol the in scheduled areas, but the policy also said that their traditional home brewing tradition should not be legally banned; and that such a tradition should be reduced through awareness and education. There was a consensus within the Centre and among the states then. Today, no one knows about the existence of such a policy for scheduled areas.
Our report mentions that such a policy exists but needs implementation. This policy should be earnestly implemented in tribal areas.
Why then has there been no action from the Centre yet on your report, five years on? There has been virtually no acknowledgement from the Centre about this report or its recommendations
Let me state the facts as they happened. We submitted this report in 2018 to the government of India. J P Nadda, the then health minister (and now the BJP national president), along with the then tribal affairs minister (Jual Oram), and their secretaries, top ICMR officials, the entire machinery was present when we submitted the report. Mr Nadda accepted this report and promised earnest implementation of our recommendations. At that time, I had said the report had come out after 63 years and it took us five years to finish the work, so it should not take another 63 years for it to be implemented. Nadda promised an action plan to be in place within five years. The ministry of tribal affairs, which had jointly commissioned this study, endorsed it. NITI Aayog endorsed it. The report went to the PMO (Prime Minister’s Office), which asked the health ministry to prepare a roadmap.
On the face of it, everyone endorsed it, but there seems to be no movement on it. It’s a reality. We had suggested a 10-year roadmap, 2018-2027, so that by 2027 the health status in tribal India could be brought on par with the rest of the population in the respective states. Objectives, goals etc. were set, but since there was no beginning, there can’t be any achievement at all.
Why did this happen? It’s only my conjecture. The health ministry priorities changed when the PM announced the Ayushman Bharat programme (in September 2018). It was such a big-bang programme that the tribal health got pushed behind. After that, the Covid-19 pandemic unfolded, so the health ministry had no time for this issue. And unfortunately, the tribal people make no noise in the Parliament or the media. Then who cares?
Now that we are likely to have a tribal woman as the president of India, do you think this is a time to relook at and implement this committee’s report. What’s the way ahead?
Tribal health must receive its due attention now if a tribal woman is going to be the President of India, and this is the right time. My observation is that health ministry wants smaller measures, like small tinkering in tribal health, like a panacea for snake bite, or something on sickle cell anaemia; 20-25% people carry a sickle gene, which protects against malaria, but only 1-2% suffers from homozygous sickle cell anaemia. I am not saying we should not fund or float disease-specific, area-specific programmes, but we need larger reforms.
We need to fix the governance gaps, financing, man-power, priorities, delivery system and lack of accountability. Instead of touching all these major issues, small one or two improvements would be like tinkering with fragments.
We need a holistic redressal of the tribal health and healthcare systems
I think our Prime Minister should propose a comprehensive tribal health mission for the 110 million tribal people of this country, to bring about the desired structural reforms.
(Jaideep Hardikar is based in Nagpur, Maharashtra. He is a journalist and author of the book “Ramrao: The story of India’s farm crisis”.)