Despite factors such as nutritional deficiencies, seasonal migration, erratic meal timings and a myriad of other factors elucidated in my earlier blogs that result in the proliferation of malnutrition in the tribal villages and districts, the issue of malnutrition can relatively be easily controlled to a great extent with adequate delivery of healthcare services and provision of affordable and accessible healthcare in the tribal areas. I will touch upon the major aspects of tribal healthcare services, its links with the issue of malnutrition and inherent limitations of the same to counter the issue. In the process, I have also made an attempt to make some suggestions with respect to each of these factors that contribute in the spreading of malnutrition.
Tribal Hospitals – Links to nutrition
Most tribal hospitals can prove to be lifesavers with respect to the life threatening health problems faced by tribals in the villages in Maharashtra and elsewhere in India. The single biggest factor that leads to malnutrition is the lack of proper food and nutrition. Part of the problem is also the lack of awareness regarding the importance of balanced diet and other daily dietary and nutritional requirements. For this, perhaps, if the tribal hospitals in these regions can be equipped with a nutrition rehabilitation unit, then a very critical source of this life threatening issue can be curbed. The nutrition rehabilitation units could help address the nutritional imbalances in the daily food intake of the tribal population suffering from malnourishment. The purpose of these nutrition units could be to dole out special therapeutic foods that contain macronutrients such as proteins, fats and carbohydrates and also very important micronutrients such as the essential vitamins and minerals. The therapeutic food can be made from local food sources and using local manpower itself. In addition to this, the primary health centre (PHC) too must be equipped with specialised child healthcare treatment centres that provide this essential therapeutic diet to the malnourished (target) population.
Paucity of Primary Health Centres
Primary health centre (PHC) or public health centre is the backbone of healthcare service delivery in India, especially urban slums and rural areas. PHCs are the basic structural and functional unit of public health services. The main objective behind a PHC is to provide accessible, affordable and available primary healthcare to the rural population. The numbers of PHCs in rural India and especially in tribal areas are themselves not adequate. At present, there is only one PHC serving approximately 35,000 tribals, on an average. The lack of adequate number of PHCs relative to the tribal population in these areas is quite alarming. In an ideal situation, one PHC can serve a population of around 10,000 people only and covering an area of 5-8 kilometres, at most. However, at present, a tribal has to travel up to 20-25 kilometres to reach the nearest PHC.
The State government must ensure adequate number of PHCs at an approximate 8-10 kilometre radius of the tribal village. CHCs (Community Health Centre) and PHCs need to be made more accessible for the villagers. In case a specialised CHC and PHC cannot be erected at all the required locations, then the Government must ensure at least one health sub-centre in all the tribal villages.
Non-availability of Doctors and Nutrition experts
Even with these PHCs in place, healthcare service delivery in tribal areas faces other major problems. That is, extreme shortage of medical personnel. Medical doctors, nurses, nutrition experts and other medical personnel are unwilling to relocate to tribal areas in order to practice medicine and serve the tribals. In the tribal belt of Maharashtra, the doctors are not ready to go and work in the hospitals in these areas. So, most of the hospitals in the tribal areas remain under-staffed most of the times. There is particular scarcity of maternal and child health (MCH) specialists and other medical specialists such as paediatrician, nutritionists, anaesthetics, among others, in the tribal hospitals. Further, due to severe lack of paediatricians in government hospitals and PHCs in such tribal areas, if the infant/child is suffering from chronic malnutrition, the risk of the child succumbing to death during the first 1,000 days (of birth) increases manifold. Thus, there is definitely a strong correlation between lack of trained medical specialists and malnutrition deaths.
We are well aware of one of the age-old superstitions related to pregnancy and food intake. That is, the tribal women follow the practice of low food intake during pregnancy for easy and comfortable delivery of the newborn (resulting in anaemia among mothers and malnourishment among the infants). The intake of nutritious diet is the least among women when they actually need the most!
Another critical hurdle that healthcare faces are that the local population usually don’t want to admit their children to hospitals due to superstition, cultural barriers and various other socio-economic factors. Since these tribals often don’t admit their malnourished children to hospital, children are dying at home.
The state governments can perhaps start a home based ‘Child Healthcare Program’. For instance, I think the government of Delhi has done well by introducing Mohalla clinics. This is a very clear signal of why primary healthcare must be delivered as close to home as possible.
In such aforementioned programs, the respective malnutrition cases can be treated in the comforts of their home and village by a trained female health worker. This female health worker could focus on special healthcare needs of a pregnant woman; help provide ante-natal care (ANC), post-natal care (PNC), provide guidance and assistance to young mothers, newborn and infants. Perhaps, the Maharashtra Government can start such a program wherein all the underserved rural areas, especially the tribal areas, are provided essential maternal and child health care facilities. Here, government health officials and staff such as the Accredited Social Health Activist (ASHA) workers, Integrated Child Development Service (ICDS) scheme workers, Auxiliary Nurse Midwives (ANM), among others, can be roped in to provide such dedicated and specialised care to the focus groups.
Furthermore, health counsellors can be roped in to advocate and promote the provision of institutional deliveries. The counsellors can ensure 24 hour care and counselling services, especially in the most underserved tribal regions. The state governments can invest and develop such ‘Health Counselling Programs’ via the support of local Non-Governmental Organisations, etc. This will further ensure affordable, accessible and equitable health care delivery among the rural and tribal populace.
Government Failures – Under-reporting of malnutrition cases
Under reporting of malnutrition and child deaths is a very big issue. The average Infant Mortality Rate (IMR), that is, the number of child deaths per thousand live-births, is close to around 60 in all tribal areas. But this is reported as less than 40. Similar condition is for reporting of the severe acute malnutrition (SAM) cases. The prevalence of SAM is approximately 20% of the total malnourished children, which is very high. But as per government figures, it is regularly reported as less than 10%! In essence, suppose there are 1000 children who are severely malnourished, but only half of them are reported as SAM cases. The remaining (estimated around 50 percent) children suffering from SAM thus get excluded from specialised care and treatment, if any. These are essentially the ‘missing SAM’ cases. These excluded/missing/neglected children are thus more prone to succumbing to death in the absence of the much needed care.
Thus, correct statistics, correct recording of the facts and figures and correct reporting can go a long way to at least move in the right direction and thereby to solve the severe malnutrition prevalent in these tribal areas. This will ensure proper planning, implementation and execution of targeted treatment and care for both the severely and moderately acute malnutrition cases in the tribal villages.
In conclusion, I would like to lay greater emphasis on the present health systems in place at the central, state, village, and district and block level to work in tandem rather than independently. There is a dire need to strengthen the linkages and synergies of all the major stakeholders of heath care in India, especially in the most underserved rural and tribal regions of our country. The State government needs to commit greater investments towards the tribal healthcare ecosystem. Tribal hospitals need to be equipped with state of the art facilities, focussing especially on the most vulnerable sections of the society such as the young mothers, pregnant and lactating women (PLW) and newborn and infants and children below the age of 5 years. Furthermore, there is an urgent and persistent need to devise formal behaviour change communication (BCC) and community mobilisation (CM) strategies by the CHC, PHC and health sub-centres to comprehensively address the cultural barriers prevalent among the tribal population.
Lastly, relationships between tribal cultures, behaviours, government interventions (such as subsidies), health system and policies and malnutrition need to be studied in detail. The solution to address such a huge problem like malnutrition cannot be generalised. That is because the demographics of the tribal community very dynamic and varies region wise. Thus, focussed ingenuous interventions need to be carried out at the micro level, specific to that very district, that very block and that very village or hamlet.