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According to the UN Department of Economic and Social Affairs, tribal communities report disproportionately high levels of maternal and infant mortality, malnutrition, cardiovascular illnesses, HIV/AIDS and other infectious diseases such as malaria and tuberculosis compared to non-tribal populations. There is an alarming rise in non-communicable diseases among tribal populations globally. Underlying factors like poverty and malnourishment further perpetuate the vicious cycle of such diseases. Often, public health programs are unable to reach tribal populations because of geographic remoteness, and cultural and language barriers. 

The UN Declaration on the Rights of Indigenous Peoples asserts that indigenous people have the right to traditional ways of healthcare-seeking practices and ‘an equal right to the enjoyment of the highest attainable standard of physical and mental health,’ without any discrimination. It is time that the states take progressive and culturally sensitive action toward the improvement of tribal health. 

One-third of the world’s tribal and indigenous population, that is, over 104 million tribal people live in India. (Tribal Health Report 2018) The majority of the tribal population continues to live below the poverty line, have poor literacy rates, suffer from poor health indicators, lack access to equitable healthcare, and are vulnerable to displacement.

As tribal communities need culture-sensitive public health interventions, there have only been a few examples of such organisations: SEARCH has not only transformed the lives of the tribal people in Gadchiroli but also demonstrated the model of home-based neonatal care. Similarly, Jan Swasthya Sahayog in Bilaspur, Chhattisgarh; Ekjut India in Chakradharpur, Jharkhand; Tribal Health Initiative in Sittilingi, Tamil Nadu; SEWA Rural in Bharuch, Gujarat; Tata Steel CSR in Jharkhand and Odisha. Though this is not an exhaustive list, these are some of the organisations that have favourably impacted the health of the tribal communities.

A lack of understanding of tribal culture and imposition of schemes and mechanisms that are culturally alien to the tribal peoples, contribute to the impoverished state of health and nutrition of tribal peoples. (Tribal Health Report 2013) This results in ad-hoc and linear policy measures and government initiatives leading to a lack of community participation. Understandably, despite substantial investment, government-driven research and development programmes are often not able to achieve the desired result. Without active people’s involvement, the government alone cannot steer the programme in the desired direction. (AIRTSC 2015) Inclusive participation helps the government to make any developmental programme more responsive, transparent and accountable.   

Anamaya: The Tribal Health Collaborative

Recognising the need for a collaborative approach, Piramal Foundation, and Bill and Melinda Gates Foundation joined hands to collate learnings, experiences and insights from social organisations and experts working on tribal health issues, government stakeholders at the many levels, and members of tribal communities. This effort resulted in the conceptualisation and launch of Anamaya – the Tribal Health Collaborative by union health and tribal affairs ministries in 2021.

Anamaya, the tribal health collaborative is a multi-stakeholder initiative committed to promoting health, and ending preventable deaths among tribal and marginalised communities in India. It is working towards converging and consolidating efforts of government and non-government organisations, philanthropists, international organisations, academic institutions, civil society organisations, indigenous organisations, and others to carry out its commitment. It aims to build a sustainable, high-performing health ecosystem to address the key health challenges faced by the tribal population of India.

Our collective experience of working with tribal communities, consultations with tribal experts and our current engagement with Anamaya have encouraged us to explore and develop approaches to design sensitive and inclusive tribal health projects. Some of the preliminary approaches are:  

Sustainable Development Goal as a Framework

For tribal communities, traditional ways of life, livelihoods and practices are increasingly under threat owing to a range of factors, including lack of recognition and protection of their rights, exclusionary public policies, and the impacts of climate change. (Dhir 2016) Their livelihoods and beliefs immensely influence their health-seeking practices and behaviour, which needs to be closely studied and understood while developing community health programs. Observing the holistic SDG framework as a criterion provides an opportunity for inclusive development of the health and social aspects of tribal populations.

Sensitivity to Tribal Practices

Tribal health has to be understood by the social, cultural and economic system, geophysical environment, religious beliefs and practices of the people. There is considerable interconnectedness between the treatment of disease and the availability, accessibility, effectiveness, socio-cultural beliefs, awareness level, and attitude of providers. (Islary 2014) There is a dire need to improve health literacy among tribal communities. Behaviour-change-communication interventions that are rooted in tribal culture and involve local influencers receive greater trust and acceptance from the community, rather than the usual one-size-fits-all approach. 

Sustainable Medical Materialist Approach with Scope for Medical Pluralism

The medical materialistic approach of modern medicine has been extremely pathbreaking for curative services in health, but when it comes to public health among indigenous communities more humane approaches should be adopted. (Knibb-Lamouche 2013) The perspective of medical pluralism is crucial as tribal communities for centuries have practised alternative and herbal medicines, and seek care from traditional healers. This needs to be considered when designing public health programs for such communities.

Art and Culture as Enablers of Health

The ‘mandala of health’ concept defines human ecology as the constant interaction of culture and environment. The interactions among culture, community, and family result in variations in lifestyle with special reference to an individual’s interrelated biological, spiritual, and psychological experiences. An individual’s perspective on illness, health, health beliefs, and health practices is shaped by cultural and community contexts. (Lai et.al. 2007) The Repository for Arts & Health Resources underscores that art and culture also weave a net of social connections and provide a sense of safety and belongingness that inspire individuals and collectives.

Engaging with Tribal Communities

There is a unanimous agreement on how crucial community engagement and participation are for a healthcare system to deliver its desired outcomes. There are many existing policies aimed to improve community participation that face implementation challenges and need community-rooted approaches, especially in the context of tribal and marginalised populations. Anamaya focuses on the communitisation of healthcare. Currently, Anamaya is working with some of the key community stakeholders such as (i) local governments (Panchayati Raj Institutions), (ii) self-help groups, (ii) traditional healers (iii) non-governmental organisations (iv) tribal youth groups and (v) community influencers at the local level.

Various research institutions are focusing on the different aspects of the tribal communities, curating, and creating scientific and authentic knowledge on tribal cultures, including their health. The need of coming together from such government institutions, non-governmental bodies, and social groups to make collaborative efforts is now more than ever for India to achieve the SDGs.  

Global Implications: Implementation of a multi-stakeholder framework like Anamaya at a national scale will certainly yield profound learnings about indigenous health and community-rooted public health models that can contribute to enriching the global understanding of inclusive indigenous health. It has the potential to foster multi-country, knowledge-sharing prospects between global universities and institutions that have spearheaded indigenous health research. Lastly, such a magnanimous, long-term public health initiative will widen the scope for global evidence-based policy makings in tribal health. 

Madhu Raghavendra leads the Centre of Excellence, North East India at Anamaya, the Tribal Health Collaborative. He is a public health practitioner, artist and curator, and emphasises leveraging arts and culture for social development. 

Tathagata Basu leads Knowledge Management at Anamaya, the Tribal Health Collaborative. She has worked across issues of education, youth empowerment, gender, and health and closely worked with children and youth at risk, tribal communities, and vulnerable artists.

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