India at 75: transforming the health of tribal populations through evidence-based policymaking

After 75 years of independence, we in India have much to celebrate and to rejoice at the stupendous progress made in all the spheres of human endeavour. Besides the largest democracy, we are now the 5^th largest economy in the world1, marching ahead to become in the near future a developed country2. However, the economic growth has been rather uneven and not all sections of the population have progressed at the same pace. Many still suffer from disparities and social inequality and are being left behind in society. Of these, the tribes of India (or scheduled tribes) are the most marginalized, based on economic and social status, as also health-wise3. Less frequently addressed by the policy-makers in the health and development space, this group remains highly vulnerable to disease, disability and premature death.

Challenges faced by tribes of India

According to the 2011 census, tribals were 104 million strong individuals, constituting over eight per cent of India’s population spread across 28 States and seven Union Territories4,5. Each of the 705 tribes is diverse and unique in cultural and life practices. Rich in traditional knowledge, they are among the most resilient and sustainable groups on the planet.

Living in geographically remote and isolated areas, far away from the mainstream, however, they suffer from poverty and poor health infrastructure, which have a profound impact on their health and quality of life. As a result, the Scheduled Tribes (STs) as a group today have the worst social and developmental indicators in health, nutrition, education, etc. among all other social groups in the country6. Infant mortality remains unacceptably high in these groups, life expectancy is shorter by 5-7 years compared to the non-tribal population, maternal mortality is high and child malnutrition too is inordinately high with up to three-fourths of under-five children in some tribal areas suffering from severe or moderate malnutrition7-9.

This must change, if we are to successfully achieve the transformative social and economic change in the country as espoused by the Prime Minister10 and achieve the Sustainable Development Goals (SDGs) by 2030.

Using evidence to policymaking and public health action

In this regard, the first and foremost requirement is the availability of good quality and real-time data on the health conditions of various tribal populations, which presently is scarce, and therefore, not in a position to influence policy and strategy.

The Indian Council of Medical Research (ICMR), as an apex body for the formulation, coordination and promotion of biomedical research in India, has a critical role to play in this context. ICMR is presently investing a fair amount of resources on research among tribal populations and most ICMR institutes are engaged in such research activities.

To commemorate the efforts of such groups this special issue on Tribal Health in the Indian Journal of Medical Research (IJMR) was compiled. I am grateful to colleagues in ICMR and the IJMR for inviting me to be the Guest Editor of this special issue, along with my friend and one of the most distinguished expert, Dr Abhay Bang. I am humbled and consider this as a singular honour.

The ‘Special Issue of IJMR on Tribal Health’ showcases the research being carried out by scientists and researchers from ICMR and other organizations and covers a wide range of tribal health research areas including communicable and non-communicable diseases (NCDs), maternal and child health and nutrition, hemoglobinopathies such as sickle cell anaemia, the undesirable practice of branding and health inequity. Each of these papers has gone through a rigorous review process before finalizing for publication.

Communicable diseases remain a major problem for tribes. For example, some particularly vulnerable tribal groups, such as Saharias of Madhya Pradesh, continue to have the highest TB prevalence in the country11,12. A review included in this issue indicates that although leprosy is declining nationally among STs, it is on the rise. Malaria is an important problem faced by tribals13, and it’s implications on the national malaria elimination drive is discussed as a perspective in this special issue.

At the same time, tribal populations are undergoing an epidemiological transition with the rapid increase in NCDs such as hypertension, diabetes and cardiovascular diseases, as well as associated risk factors such as tobacco use, as shown here14. Mental health, such as depression, is also a concern for tribal populations.

Many studies in this special issue go on to highlight the need to understand the root causes or the social, economic and cultural determinants of diseases responsible for ill-health in tribal populations and using that information to improve their health conditions. Such information is critically useful for health planners and programme managers.

The underlying theme throughout the issue relates to the state of healthcare services in tribal areas, which can be considered abysmally poor in terms of quality and accessibility. This, in part, is due to low per capita expenditure on health, lack of availability of health technologies and life-saving medicines, and to the limited health workforce, as many posts of doctors, specialists and health workers remain vacant. These health system issues must be addressed by respective States, health being the State subject!

Transforming tribal health: Opportunities over the next 25 years

Looking forward to the next 25 years, the following actions are urgently needed:

(i) Transformation of the health system in tribal areas: Greater investments in healthcare with emphasis on quality and access to health services are the key to this social and economic transformation of tribes in India. In fact, the most important lesson from the COVID-19 pandemic was the need to strengthen our health system15 to provide adequate financial and human resources, strengthen the health information system, including epidemiological surveillance data collection and analysis, ensure uninterrupted supply of life-saving medicines, vaccines and diagnostic technologies, and revisit health governance and management capacities in the context of primary healthcare using district health model.

With the district as the administrative unit for programme implementation, a multidisciplinary and multi-sectoral committee at the district level can help oversee the implementation of an annual health plan and fix accountability16. The health and wellness centres are being established by the Government of India for the provision of quality healthcare nearest to where people live, thereby achieving universal health coverage. These centres must be assessed periodically to ensure their proper functioning. Here, the locally elected representatives and the panchayat raj institutions can play a crucial role.

(ii) Investment in research and development infrastructure with institutional capacity building: One of the most alarming aspects of tribal health is the paucity of health data on tribal populations. There has been no attempt made to systematically collect the disaggregated data. In the absence of such data, no evidence-based policymaking or planning is possible. The network of health institutions existing in the country, including medical colleges, can be mobilized to conduct research, for example, to understand the social, economic and environmental determinants of health.

Research is needed that can help better implement national policies and programmes in tribal areas in scaling up proven effective interventions, bringing efficiency and sustainability and ensuring access by the tribal population to these interventions.

(iii) Harness science, technology and innovation: Technology and innovation can help transform tribal health and wellbeing to enhance transparency, information and accountability and to promote efficient delivery of health services. The technologies available can be assessed for their appropriateness for application in tribal areas, given their location and state of health infrastructure available. Efforts can be made to create an enabling environment for the use of technology and innovation.

(iv) Best practices in tribal health: Documentation and dissemination of success stories can motivate others to also try and implement such initiatives and replicate it widely for desired health impact. The traditional wisdom of the population needs to be shared as they have stood the test of time and for centuries in the absence of modern technology. The role that traditional healers can play in disease prevention and advocacy can be facilitated and promoted.

(v) Empowerment and engagement of tribal communities while planning and implementing programmes: Since the majority of the risk factors or disease determinants lie outside of health, sectors beyond health can also be engaged to address health-related issues. To maximize research impact, the tribals can be treated as direct and active participants, issues of relevance to tribal people can be identified and prioritized, tribal peoples’ knowledge and perspectives should be incorporated in processes and findings, and all potential end-users should be engaged from the outset.

It is imperative that the national- and State-level committees dealing with tribal health are adequately represented also by tribal experts/members.

Finally, many believe that the 21^st century will be India’s century17,18! In this endeavour, one may expect not only the tribal populations of India to grow, and prosper as healthy citizens but also to contribute their might in nation building. Only then we shall redeem our pledge of a great nation where all sectors move ahead in an inclusive and sustainable manner and where no one is left behind.