In the absence of healthcare services and lack of transportation, vulnerable tribes are deprived of timely healthcare facilities
Insecure livelihoods and lack of access to government services have significantly impacted the health of these tribes. Photo: Aishwarya Mohanty. Raja Kirsani (name changed) lost two kids, aged three and four, from 2018-2020. The elder child had suffered a high fever one night when Kirsani set out on foot to reach the hospital, more than 10 kilometres from his village. The journey through the forest seemed endless as he kept asking his son to stay up and breathe. By the time Kirsani reached the hospital, his son was declared dead.
“His body was burning with high temperature. He had been down with fever for the past couple of days and we opted for local remedies but that night his condition deteriorated. I had to take him to the hospital,” Kirsani said.
Two years from then, history was to repeat itself. His daughter felt uneasy due to severe pain in her stomach. By night, he undertook the same arduous journey to the hospital again as she was unable to bear the pain, but his daughter died on the way.
In both cases, the ailments remained undiagnosed. Kirsani belongs to the Bonda tribe, a Particularly Vulnerable Tribal Group (PVTG) of Odisha. The PVTGs reside in remote hilly terrains and qualify as vulnerable because of their stagnant population, low literacy level and pre-agricultural level of technology.
While health parameters remain a major area of concern, in many PVTG villages, remote geography and limited communication access also impact their healthcare-seeking behaviour. The insecure livelihoods and lack of access to government services have significantly impacted the health of these tribes.
For Kirsani and nearly 70 others from Sanuguda village of Badadural Gram Panchayat of Odisha’s Malkangiri district, reaching a medical facility has been out of bounds.
The village is accessible in two ways: One includes three minor rivers and narrow, barely-walkable passages through fields and a jungle. Another is an approach road that can accommodate only one two-wheeler at a time and poses high risks during monsoons. The latter, however, is a longer distance. The nearest medical facility is still 12 km away.
Kirsani said:
It usually takes us over three hours to cover the distance on foot. There is no other option. Ambulances can not reach us and we have to cover the distance on our own.
Odisha has 13 PVTGs, residing in 541 PVTG habitations with a population of 0.134 million, spread across 89 Gram Panchayats.
Some 127 of the total 541 habitations are completely inaccessible, according to data accessed from Odisha PVTG Empowerment and Livelihoods Improvement Programme (OPELIP).
“For geographically remote villages, we intend to reach them through approach roads but these are not all-weather roads. Almost 90 per cent of the villages have been covered through approach roads and we are planning to cover the remaining villages in the months to come,” said P Arthanari, OPELIP project director.
“In the absence of healthcare services and lack of transportation, vulnerable tribes are deprived of timely healthcare facilities,” stated a 2017 report by the Comptroller and Auditor General (CAG) of India.
Tribal groups — more vulnerable to disease and malnutrition than the rest of the population — cover a distance of five to 80 km to reach a community or district health centre, it further stated.
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In Tanda village of Odisha’s Rayagada district, 30 Dongria Kondh households live on a remote hilltop. As a daily livelihood practice, men and women trek down to Boriguda village to sell their daily local produce like fuelwood, turmeric and millets.
The trek down, which starts in the early morning, usually takes an hour and a half. After selling their produce in the local markets, they return home by early evening. The route cutting through the hill, with narrow carved-out paths, small and large boulders and thick trees, is a traditional route used by the villagers.
An alternate approach road has been carved out only recently but is yet to be completed. The villagers still opt for the traditional route. At times of healthcare emergencies, the route becomes a challenge.
“We do not go to hospitals. During an emergency, reaching a health facility is next to impossible from here. It is extremely rare that we go to hospitals,” said one of the villagers, Kuduji Jakasika.
These tribal groups also fall under the high burden category of infant and maternal mortality rate as well as a high risk of malaria and diarrhoea.
“In case of pregnancies, most deliveries happen at home. How can a pregnant woman climb up and down a hill? But if they want an institutional delivery, they first trek down to one village, rest for a night and resume again the next day. It is a rather long process,” she added.
Pregnant women are also carried on foot for long distances with the help of cots and makeshift carriers.
In Tanda, like most of the remote villages in forested areas, the primary source of livelihood is non-timber forest produce. Men and women travel to dense forests accompanied by their children, mostly toddlers, exposing them to risks of non-communicable diseases.
The lack of stable income, low nutrition, limited access to childcare centres and rising food insecurity also impacts health-seeking behaviour.
“In the absence of roads and connectivity, if we have to travel with a sick person, it also adds to an increased expenditure not only on transportation but also food and other logistics, in addition to physical stress,” said Maladi Nisika, a villager from Tanda.
Road connectivity significantly contributes to shaping the health of the sub-populations since the access and coverage of any health programme depends on it, as does the inhabitants’ health-seeking behaviours, observed a 2015 study by the Asian Institute of Public Health and the Scheduled Castes and Scheduled Tribes Research and Training Institute.
Above 40 per cent of the PVTG population perceived road connectivity and above 30 per cent perceived that service availability in the health facilities was the major obstacle to accessing public health services.
Bonda Ghati in Malkangiri district, home to nearly 7,000 people from the Bonda tribe, has only one health and wellness centre catering to the entire population. In 2013, it was taken over by a local non-profit under the public-private partnership model.
The centre has one Ayush doctor and two MBBS doctors. It has facilities for blood tests and deliveries, but for an ultrasound or X-Ray, one needs to travel nearly 20 km to another hospital. From there, they are further referred to the district health headquarters and then to the neighbouring district of Koraput.
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“People do come to us from time to time, but for aged people, it’s an issue. In case of emergencies we refer them to the block health centre in Khairput,” said Dr Prafulla Parida, in charge at the centre.
A bike ambulance has been provided in one of the villages for emergencies.
In Niyamgiri hills, home to the Dongria Kondh PVTG, the community health centre in Kurli Gram Panchayat caters to the entire population atop the hill. The centre has one Ayush doctor, one nurse and one peon. When Down To Earth visited the centre, only the peon was present as others were on leave. In the absence of qualified medical practitioners, he prescribes and provides medicines for basic ailments like fever, cough, headache and stomach ache.
Among the PVTG villages, 61 villages (2,955 households comprising a population of 13,048) have their health sub-centres outside a 10 km radius, according to the data accessed by Down To Earth.
Governments must take up special measures such as regular health check-ups, monitoring of education, arresting malnutrition and child marriages, institutional rehabilitation of physically and mentally challenged tribal children, and providing regular mobile health services for remotely located PVTGs who are on the verge of extinction, recommended a 2018 report on tribal health by the Ministry of Tribal Affairs.
Usually, the infrastructure and associated healthcare facilities are made available to villages or areas that meet population criteria. But it is a pity that most of the PVTG habitations do not meet the population criteria, as a result of which they get deprived of such facilities to be set up, said Dr AB Ota, former director of Odisha State Tribal Research Institute.
“Therefore, one of the single largest initiative government should do in PVTG areas for providing facilities is to relax population criteria to facilitate such provisions,” Ota added.
The state’s health and family welfare department implemented specific health system-strengthening initiatives regarding the management of human resources and primary care provision.
“In hard to reach places, diagnosis and testing becomes a challenge for any ailment. We have tied up with non-profits as well for these pockets wherein they become the first point of contact apart from our ASHA and auxiliary nurse and midwives (ANM),” said Dr Bijay Mahapatra, director of Public health, Odisha.
These partnerships help to mobilise resources, enhance service delivery, and raise awareness of the PVTG communities’ health needs.
Deployment of mobile healthcare units is another strategy, but difficult terrains make this harder as well. Similarly, another approach of telemedicine and using technology to remotely diagnose and treat patients also proves challenging in the absence of proper network connectivity in most of these habitats.
Given the dispersed settlement patterns and poor connectivity, there is a need for reflexivity in approaches to human resource deployment.
Experts contend that training community health workers from within the villages can be an effective approach to providing basic healthcare to these villages. This is based on the consideration that involving communities in the process will help identify and implement appropriate and culturally sensitive solutions.
“One strategy is to educate and equip community health workers (CHW) from within the PVTG communities. These CHWs can provide services such as first aid, care for mothers and children and disease prevention and help educate the community on health and hygiene practices,” said Dr KC Sahoo, a public health specialist focusing on PVTG healthcare.
The government can play an important role in addressing the lack of access to healthcare in remote PVTG villages. “The government can allocate more funds to healthcare, construct healthcare facilities in remote areas and provide financial assistance to healthcare professionals who work in these areas,” he added.
Reiterating the same, another public health specialist Dr Biswajit Modak also suggests the appointment of community-based health officers per village.
Community health officers (CHO) are basically nursing officers with a degree (B.Sc / General Nursing and Midwifery) in nursing. But in case we are not able to find a qualified workforce, then we may select ANM as CHO, Modak said.
“They can be trained like CHOs with basic services like common ailments, reproductive, maternal, neonatal, child, adolescent health and nutrition and non-communicable diseases. They could be trained on these three aspects,” Modak added.
He further added that such community-based health officers could only be allowed to dispense medicines and not for prescription or to diagnose chronic diseases.
“In case of diagnosis, it should be referred to the nearest primary health centre or community health centre. And for this referral, there should be a government transportation system,” he added.
Some healthcare officials have also manoeuvred creative ways to reach out to these villages. Pratima, a GP nutrition coordinator in Kandhamal’s Belghar, faces difficulties in reaching out to one specific village under her Gram Panchayat, which requires crossing seven minor water bodies.
Belghar is home to the Kutia Kondh tribe. The village is also inaccessible through phone networks, but Pratima still manages to communicate with them on a daily basis.
“I visit the village, but it is not possible to do so every time. But the villagers travel to the local weekly markets every week that has become our meeting point. I keep track of expecting mothers, the aged or someone with a chronic disease,” Partima said.
In that case, it becomes easier to monitor. Not in emergencies, but we are still prepared for certain cases and their health is monitored, added.
Ambedikola, a small village in Bilamala Gram Panchayat of Belghar, continues to be inaccessible. A 7 km downhill road leading to the village remains non-motorable and can only be accessed on foot. The village with only 11 households has no network, making it difficult to convey any important message. The nearest healthcare centre is 20 km from here.
There is no way to reach them. I travel to that village once in a month or meet them and take updates when they visit the panchayat office to buy food from the public distribution system, said Pruthybash, a GP nutrition manager.
“Because there is no other option left for them, they rely heavily on traditional health practitioners referred to as ‘Gunia’ in local parlance. They are the first resort for anyone seeking healthcare in these villages,” he added.
This dependence is also highlighted in a study which states that the degree of geographic difficulties and cultural dynamics decide the ‘perceived’ isolation and interaction with healthcare providers in hard-to-reach areas. This ultimately leads to impacting the utilisation of the facilities. In extremely remote areas, health needs are mainly fulfilled by traditional healers and ethnomedical practices. In the absence of healthcare infrastructure and accessibility, people continue to depend on traditional practices.
This is the second of a three-part series. Read the first part here. The last part of the series explores whether and how traditional medicinal practices and modern medicine practices converge for the PVTGs.
This article was supported by Health Systems Transformation Platform as a part of HSTP — Health Journalism Fellowship 2022.
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