August 22, 2015

Maternal Health in Tribal Communities of India: Advocacy Dialogue

Maternal Health in Tribal Communities of India: Advocacy Dialogue
organised by
National Alliance for Maternal Health and Human Rights, India
YWCA, New Delhi
Aug 20, 2015 (Day 1)

In an initiative to deliberate upon and voice issues of maternal health of tribal communities through a human rights perspective, a host of Civil society groups, researchers, lawyers, experts and members of Parliament, senior officials from across 13-14 states of the nation congregated in New Delhi  on August 20, 2015 for  a two day  Advocacy dialogue  on maternal health issues of women in tribal areas. The advocacy dialogue was organized by the National Alliance for Maternal Health and Human Rights (NAMHHR).

 Setting the context for the Day 1, Convener of NAMHHR, Jashodhara Dasgupta outlined that the dialogue aimed to draw attention to the condition of the maternal health among tribal communities and present examples of sensitive service provisioning. Along with, it endeavoured to highlight the recommendations of the report of the high level committee (XaXa Committee, 2014) on the status of Tribal Communities in India and it aspired to build a consensus on further policy programme and budgetary recommendations towards addressing healthcare

Sessions on Day 1:

The sessions for the first day in the Advocacy dialogue were divided into five different segments comprising of discussions and sharing of experiences surrounding maternal health of tribal communities. The sessions in the first half of the day presented a situation analysis of the lived experiences of the tribal communities through differnet case studies and the latter half of the day focused upon issues of budget in maternal health and saw deliberations upon the XaXa Committee report.

 The first session for the day which focused upon issue of Availability, Accessibility and Acceptability of health services in tribal areas saw enriching discussions and sharing of studies from Rayagada- (Odisha); Jharkhand besides study on tribal healing practices. The session summed up the discussion that the health system and the health plans have failed to meet the health need expectations of the tribal communities and have had alienating experiences from the health system and there is a quotient of trust deficit in the health system from the community, with cultural, language barriers, remote distance of the communities and other factors cumulatively exacerbating the gaps.   
Experiences from the field also suggested that the tribal medicine though has been existing since times immemorial but has not been accepted in mainstream health systems and has not been documented and validated. Chair for the session Dr. Dinesh Baswal, Deputy Commissioner for Maternal Health, from the MoHFW, while acknowledging the issue of gap in health status of the tribal communities reiterated that it was a complex issue and a concern of all departments.  Co-Chair for the session Dr. Abhijit Das, member of the Advisory Group on Community Action of the NHM, reflected upon evidence building for the margins, as well the need for strengthening the compliance and accountability mechanisms.
A report by NAMHHR, titled Maternal Health in Tribal Communities: A Qualitative  Enquiry into Local Practices and Interactions   with the Health System in Rayagada District, Odisha was also released on the occasion.

The second session saw deliberations premised upon the theme of nutrition and other social determinants of health in tribal areas and highlighted through different experiences of tribal communities that the phasing of traditional sources of livelihood, malnutrition, poverty, migration and non recognition of tribal persons working in stone quarries as scheduled tribes, besides other factors have been detrimental for the health status of the tribal population.  The second session also provided reflections on the issue of vulnerability of the already marginalised tribal women, though the concerns of unnecessary hysterectomies of tribal and Dalit women in private hospitals in Chhattisgarh and the efforts of the state to control the  reproductive health rights of tribal women through sterlization and the government orders for the PVTGs to not adopt permanent family planning methods.

Chair for the session, Biraj Patnaik, a key champion of the Right to Food Writ Petition, proposed some suggestions. He elucidated that the institutional understanding for maternal health has been weak and amongst many issues, food security also need to addressed.  He outlined that some concerns like budget cuts need to be reflected.  Besides the phasing out of Antodhya scheme needs to be stopped and implementation of the Food Security Act needs to be ensured at pan India level as it is currently implemented only in 11 states. 

The third session titled effective approaches to health service delivery for tribal communities reflected upon the examples of advocacy by civil society groups for maternal health through collective initiatives like that of mobile text community reporting amongst tea tribes in Assam, involving a trained cadre of tribal health workers to reduce the health status gaps in Chhattisgarh and raising community voices in Gujarat.
 Parliamentarian T N Seema, who chaired the session deliberated that health status of the situation of the tribal population was same across the nation. While citing example of her home state, Kerala, she reflected that though Kerala is an outlier in the health and education but there are differentials within the state in health situation of the tribal relative to the state at large. She suggested upon the need for integration of different departments and ensured for taking up the issue of the health status of the tribal communities with fellow Parliamentarians and in the Parliamentary Standing Committee on Health & Family Welfare. Co-Chair for the session Amar Jesani, Member of Mission Steering Group of the NHM, suggested for  the need for advocating health care as a right on lines similar to Right to education, right to Foos Security Act.

The fourth session of the day reflected upon the key concerns around Policy recommendations on budgets for maternal health in tribal communities and the emerging priorities surrounding the Tribal Sub Plan (TSP).

It was highlighted that the TSP was a very narrow approach and does not plan for targeted improvement of specific social sectors there was a need to strengthen state planning and the coordination, monitoring and evaluation function of Ministry of Tribal Affairs for the TSP.

 The fifth session for the day highlighted the Key Findings and Recommendations of high level XaXa Committee report. Prof. Usha Ramanathan, who has been a part of the committee and key note address outlined that the report reflected the socio-economic status of the tribal population and the context was the education, health and livelihood of the tribal population.

She said that while compiling the report and interacting with several tribal communities it discerned that, migration, mass displacement, malnutrition were some of the visible issues of the tribal population.  Discussant in the session Shiraz Bulasara suggested that there was a need to ensure the basic minimal facilities in the health institutions. Co-discussant Madhuri Krishnaswamy stressed upon creating nursing colleges and medical colleges for tribal communities near tribal district hospitals, so that the trained cadre of tribal health workers can be created to bridge different gaps in health status of the tribal communities. 
It was also suggested in the session that the XaXa Committee report did not apply to the North East Tribes and tribal communities from Ladakh and Lahaul &Spiti as these were very different and diverse contexts. 
The first day of the Advocacy Dialogue closed on a very positive note as Parliamentarian and Chair of Parliamentary Standing Committee on Tribal Welfare, Fagan Singh Kulaste promised to take the health issue of tribal community at different platforms and voice concern on the issue vehemently in the Committee. 

Aug 21, 2015 (Day 2)

The two day Advocacy dialogue  on maternal health issues of women in tribal areas organized under the aegis of the National Alliance for Maternal Health and Human Rights (NAMHHR) in New Delhi, on its second day, saw the  development of further call to action and draft recommendations as culled out from the previous day discussions, presentations and deliberations.

Draft Recommendations and Call to Action

 Sana Contractor, representative of NAMHHR and Convener of NAMHHR, Jashodhara Dasgupta highlighted upon the draft recommendations of the National Alliance and elaborated that the recommendations were still in a draft stage and would be refined after more discussions with other stakeholders and sent to the MoHFW Committee on Tribal Health for consideration. They reflected that through the day one presentations of studies and discussions, it discerned that the exclusion and marginalisation of tribal communities was not limited to their geographic isolation only, other factors like poverty, hunger, migration, lack of identity, displacement, loss of traditional sources of livelihood etc. too were instrumental aggravating health gaps of the tribal communities. It was stressed that there is a need to address the deprivation among the tribal population.

They reflected that the common approach was that the tribal population was resistant to modern medicines, however through the studies and discussions it came forth that wherever the tribal population could access these health services they were not averse to it. It was also mooted that decentralization, flexibility in budget was required in monitoring and planning to address the local tribal needs.  The tribal blocks were underserved, lacked in staff and infrastructure and home deliveries were largely conducted amongst these communities. Malaria, sickle cell anemia were recognized to be rampant among the tribal communities silicosis and TB were identified as the occupational hazards the tribal communities faced. Lack of blood transfusion services, and emergency obstetric care were identified as the major areas of intervention for maternal health of tribal communities.

They further elaborated that it emerged through the discussions and presentation that the Tribal Sub Plan has not worked well and the emphasis has been on the demand side. The tribal health systems were quite sophisticated however there had been no recognition of the healing practices or the practitioners.

  Based on these observations the National Alliance has drafted recommendations broadly in four major areas. 

These included strengthening of the health system, within which some of the aspects include providing clean labour rooms, provision of emergency obstetric care, qualitative health services, employment of skilled workforce, and support for home deliveries with adequate transport and telecommunication services besides other aspects. The recommendations also highlighted for massive training of tribal communities to create a skilled health force and increase their ownership and also stressed upon the need for the sensitization of health service providers. Within the set of recommendations convergence of different departments was stressed for along with the need for disaggregated data tribal health. The draft recommendations stressed for a robust food security network to combat malnutrition and chronic hunger which has a manifestation on tribal maternal health status per se and tribal health status. It called for immediate universal implementation of maternal health benefits and the need to involve local millets, oils and other local available nutrition sources. The   set of draft recommendations called for study on healing tribal practices, midwifery practices, and recognition of the tribal practitioners, besides validation and documentation of the vast tribal health practices.

Abhay Bang-(Chair of the MoHFW Committee on Tribal Health) responses to the draft recommendations of the Alliance 
 Abhay Bang, Chair of the MoHFW Committee on Tribal Health who was present for the Advocacy dialogue appreciated the recommendations of the National Alliance and said that the Call for Action has provided rich inputs and these would be taken seriously by the CommitteeHe outlined that maternal health was ‘Like A Tiger in the Ecosystem’ which was indexical of the overall tribal heath system. He reflected that the issue of effect of alcoholism on tribal maternal health also needs to be elaborated upon. He also highlighted that the Panchayat Extension Scheduled Area (PESA) has not been implemented ideally. There were few concerns which need to deliberated, he said, like have we reduced maternal health to JSY; what should be the centre of decision making , designing and planning in tribal health, what role do tribal  Gram Sabhas have in planning when PESA is seen as a governing instrument etc.  Bang added that the committee report on the tribal health provides information on current status of tribal health in India and it provides a rich data, through ICMR, National Institution of Nutrition, Census and SRS and now the committee is further delving into report on the current status of health care of tribal population.

 Roadmap for 2nd generation recommendations for Maternal Health Programme, a publication of NAMHHR was also launched on the occasion.

Manoj Jhalani, Joint Secretary (Policy) Ministry of Health & Family Welfare outlined that certain questions remain pertinent as how do we ensure sensitivity of health service providers towards the tribal communities. He highlighted that the government has decided upon some steps to bridge the health gaps like ‘Time to Heath Care Approach’ in hilly and tribal areas at sub-centre with mid level service providers, amongst other steps. Jhalani elaborated that the NFHS will now be done every three years at district level also and this will help in providing disaggregated data.  

Parliamentarian Jairam Ramesh, chair delineated that there were disparities in the health status of the tribal population. He outlined that the fundamental problem starts with tribal administration and advocated for adoption of models like ITDA, and suggested that though it is not an universal solution but partnership with civil society groups in provision of health services in tribal areas can be looked out as options. 

 The second day of the Advocacy dialogue ended with a renewed energy among different stakeholders of the Alliance and on a promising note with Chair of the MoHFW Committee on Tribal Health, Abhay Bang promising to take the recommendations in the high level report and Parliamentarian Jai Ram Ramesh assuring to take up the aspects of tribal health in Parliamentary Standing Committee and other platforms.