Tribal people make for about 8 percent of India’s population. However, they account for over a quarter of the country’s poorest people. Although these groups have seen considerable progress over the years – poverty among tribal groups declined by more than a third between 1983 and 2005 – nearly half the country’s Scheduled Tribe remains in poverty, due to their low starting point.
Medical camps have proved to be very popular with number of beneficiaries ranging from 500 to 4,000 | Three World Bank-supported State Health Systems Projects – in Rajasthan, Karnataka, and Tamil Nadu adopted a number of innovative strategies to improve the health of tribal groups. Given the wide diversity among these groups and their various levels of socio-economic development, the interventions adopted were multipronged and area-specific.
Bringing medical services in remote areas
While medical camps have often been conducted in the past, there was an overwhelming need for mobile medical camps to reach remote tribal populations. All three projects, therefore, sought to improve outreach, through state-sponsored medical camps in Rajasthan, and through NGO-run mobile health clinics in Tamil Nadu and Karnataka.
Rajasthan
Medical outreach camps: In Rajasthan, the project brought medical outreach camps to nine desert and tribal districts where brick-and-mortar health facilities were dysfunctional. Six outreach camps were conducted every month in each district. Each camp was followed by two smaller camps to dispense lab reports and medicines and provide follow-up care. Populations were drawn to these camps through door-to-door canvassing by Accredited Social Health Activists (ASHA) and Auxiliary Nurse Midwives (ANM), as well as loudspeaker announcements, banners and pamphlets. The range of free medical services provided was widened to include pediatric, gynecological, and general medical services, in addition to free immunization, basic lab tests, free medicines for a full course of treatment, and referral of the more complex cases to advanced facilities. Doctors were brought in on a rotational basis from satellite hospitals that had lighter patient loads as well as from higher health facilities to ensure that no facility was left unattended for long. With the number of beneficiaries at each camp ranging from 500 to 4000, outreach camps have proved to be extremely popular and the uptake of services by underserved populations has been consistently encouraging.
The number of camps increased from 15 camps catering to some 9400 tribal beneficiaries over a six-month period in 2006 to 433 camps catering to some 45,000 tribal people over a similar period in 2008.
Mobile health clinics are very popular, especially for women and children’s illnesses | Tamil Nadu and Karnataka
Mobile health clinics: In Tamil Nadu and Karnataka, the projects introduced mobile health clinics to bring basic health services to tribal populations in underserved parts of the state, and contracted NGOs to run them. Each mobile health clinic consisted of a large vehicle staffed with a qualified doctor, two ANM/nursing staff, a pharmacist, a lab technician and a male and female support staff. The vehicle was equipped with an oxygen cylinder, IV lifelines, emergency drugs and plenty of information materials. Medical staff treated common illnesses and provided first aid and maternal and child care services, as well as family planning services. They also helped raise awareness of health issues and collected data on the disease profile of tribal populations. The Mobile Health Clinics have proved to be very popular, especially for women and children’s illnesses. In Tamil Nadu, some 17,000 villages were serviced by tribal outreach vans between May 2008 and September 2010, with medical benefits accruing to over 630,900 beneficiaries. In Karnataka, over 250,000 tribal patients availed of the services of mobile outreach vans between June 2008 and May 2011.
Providing emergency transportation for expectant mothers
All three states of Tamil Nadu, Karnataka and Rajasthan have used Public-Private Partnerships (PPPs) to provide emergency transportation to take pregnant tribal women to health facilities for obstetric care. While not all hamlets have access to tarred roads, the emergency ambulance services reach the nearest motorable point to pick up patients in all three states.
All three states have used Public-Private Partnerships (PPP) to provide emergency transportation for pregnant tribal women | Tamil Nadu – ambulances for pregnant women
With the project paying for 385 well equipped, state-of-the-art ambulances, free emergency transportation is now available to take pregnant tribal women to primary and higher health centers.
Lessons learnt from the poor management of multiple NGOs contracts for ambulance services led the state government to revise its strategy and contract a single professional agency to provide free emergency transportation services in health, fire, and police emergencies across the state. An additional 200 ambulances are being supported by the project to effectively address the increasing demand. To encourage institutional deliveries amongst tribal groups, another scheme provides full boarding and lodging facilities at PHCs in tribal regions for the mother and a maximum of two attendants for 10 days at a cost of Rs.100 per day. The scheme has proved promising and has been expanded by the Department of Medical Services to over 15 PHCs that cater to remote tribal populations. NRHM too has expressed interest in the scheme and has set aside a budget to expand it to 43 PHCs in the neediest tribal areas.
Employing health workers from tribal communities
As tribal populations find it difficult to navigate through the complexities of medical facilities, all three health projects have made provisions to help them. In partnership with local NGOs, counselors who are often from tribal communities themselves have been placed at district hospitals to guide patients, explain doctors’ prescriptions, help patients take advantage of welfare schemes, and counsel them on preventive and promotive health behaviors.
Counselors from tribal communities have played a major role in facilitating better services |
Rajasthan
Patient counselors: Initially patient counselors were placed at all facilities which had 100 beds or more, in partnership with local NGOs. As these counselors proved quite popular, qualified counselors were directly recruited and placed at all facilities with 50 beds or more.
Round-the clock Citizens Help Desks have been set up to address complaints | Tamil Nadu
Tribal counselors: NGOs were contracted to train and place counselors from tribal populations in government hospitals and PHCs in 12 tribal districts. These counselors also pay weekly visits to tribal hamlets to raise awareness about health issues and promote healthy behaviors. Attendance by tribal groups has increased at health facilities. The project is now expanding this service to other tribal districts.
Karnataka
Increasing local expertise through tribal ANMs: For the first time in Karnataka, tribal ANMs were recruited and trained to bring health care closer to tribal settlements. In every batch of ANM trainees, ten seats were reserved in each district for tribal girls who have passed Class 10 and are willing to work in tribal settlements where no ANMs are posted and where accessibility to health services is poor.
Citizens Help Desks: Citizens Help Desks have been established to provide round-the-clock assistance to tribal and other vulnerable groups in selected district and taluk level hospitals. These help desks also address complaints by mediating between consumers and service providers. Nineteen of these desks are supported through the World Bank-financed project, with NRHM expressing interest in expanding these services to other health facilities in the state.
Changing the behavior of health care providers
The Tamil Nadu and Rajasthan health projects supported behavior change communications campaigns amongst the clinical, paramedical, and lower staff, as well as mechanisms to obtain feedback.
Rajasthan
A behavior change communications campaign was conducted in medical facilities in six districts. The campaign sought to instill patient-friendly behavior among health care providers and helped them develop team spirit and pride in their work. Pre-and post-training evaluations as well as independent surveys indicate that the training was greatly valued by lower-level staff who have the most contact with patients and that it has indeed improved their attitudes and behavior patterns towards tribal patients.
Consumer feedback and complaint redressal pilot: A consumer feedback and complaint redressal initiative is being piloted that logs patient feedback and complaints through both anonymous and open channels. Action taken on complaints is publicly disclosed for greater awareness.
Tamil Nadu
A Training of Trainers model in Tamil Nadu helped build substantial capacity within the state’s health department to hold heterogenous and homogenous group trainings in behavior change communication. The objective of inculcating team spirit, pride in work and client friendliness was central to these workshops. This method ensured these skills remained available with the state long after the agency completed its assignment, making it possible to conduct refresher courses at no additional cost to the state.
A campaign to install patient-friendly behavior among health care providers proved successful |
Providing financial support
While most innovations have included the provision of free medical services to poor tribal populations, a few pilots have sought to ease the financial burden of inpatient care on these groups.
Tamil Nadu
Bed grant scheme: Lack of reliable public health care services in certain underserved tribal areas prompted the project to partner with NGOs for the provision of free inpatient care to tribal populations.
All costs pertaining to minor ailments and surgeries are reimbursed by the project. The scheme has been well received by tribal populations and uptake has improved. For instance, the number of inpatients at the hospital facility run by the Nilgiris Wynaad Tribal Welfare Society increased from 7 per month to 47 per month over the two-and-a-half-year period between 2008 and 2010.
Tamil Nadu
Mortuary van services: The project procured forty two mortuary vans and contracted an equal number of NGOs to run them at pre-defined competitive rates. The vans were stationed at the larger public facilities. They were also promoted actively by counselors stationed at facilities. The project is now moving towards a comprehensive mortuary van service with the International Red Cross Society, to be supported by a centralized call center facility, a unique toll free number, and trained staff.
Ensuring sustainability
Taken together, these activities in Rajasthan, Karnataka and Tamil Nadu have significantly contributed to better access to health care by poor, underserved tribal populations.
Government is making an effort to sustain initiatives introduced under these Projects | Given the limited scope, scale and duration of World Bank projects, all three projects made specific efforts to ensure that the capacities built, initiatives supported, and systems institutionalized with the projects’ support remained sustainable.
This was done through a constant dialogue with the states’ Directorates of Health and the National Rural Health Mission (NRHM) to ensure there was no duplication of effort and that the innovations introduced would continue after Bank financing was over. For instance, in Rajasthan, where the project introduced mobile health clinics in remote tribal and desert regions, the state government is planning to take these over. Similarly, in Tamil Nadu and Karnataka, the state NRHMs have built the capacity to manage the public-private contracts with the NGOs to run the Mobile Health Clinics and the Citizens’ Help Desks. The Tamil Nadu project also plans to dovetail the efforts of the wide range of stakeholders working on tribal development issues – both government and non-governmental – into an integrated state tribal development plan.
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