The State of Tribal Health in Odisha

Abstract

    As Odisha has a large percentage of tribal population and they spread in almost all parts of the state, health development of tribals in Odisha is not only important from the point of view of human development, but also to achieve inclusive development in the state. The paper makes use of both primary and secondary data to analyse the problems. The paper analyses health care services in the tribal areas of Odisha with respect to the accessibility to health facilities. It points out that about half of the villages do not have medical facilities within a distance of 5 km. The absence of transport connectivity in the tribal areas has created adverse condition in efficient health care delivery. Shortage of doctors and lack of other health infrastructure accentuate the problem. Malnourishment is a serious health problem. In some areas such as Banspal Block as much as 90 percent of children are malnourished. All these have translated into high infant and child mortality rate among the tribals. Malaria is endemic in the tribal regions of the state. Primary data collected from Jhumpura Block of Keonjhar district indicate that 80 percent of tribal people take the help of witchcraft method to cure diseases. Further, only 9.38 percent of the deliveries in these areas take place in hospitals as against the state average of 38 percent. A number of suggestions have been put forth in order to get rid of these woes. If adequate attention is focused on awareness creation among the tribals, proper monitoring and supervision of the health programmes, it can go a long way in providing efficient health care delivery to them. Though the PPP mode of health care can be relied upon, it should not put financial burden on the tribals. 

Introduction

    The Neo-Classical economic analysis could not satisfactorily explain economic development in various parts of the world in the mid 20th Century. The ‘Endogenous Growth Theory’ which appeared in the late 1980s focused attention on the use of human capital to stimulate economic development. (Srinivasan, 1998) In formulating the endogenous growth model, a number of economists have considered health as a component of human capital. (Barro, 1991; Mamkiw, Romer and Weil, 1992; Thomas and Strauss, 1997; Bloom et al, 2001) Development thinking and experience of several countries of the world indicate that health has paramount importance in boosting economic development. Overhalt and Margaret have shown the significant influence of health on human welfare and national development. (Overhalt and Saunders, 1996) Amartya Sen has emphasised that social services which includes health reduce mortality and enhance quality of life. (Sen, 2001) Sen characterises unnecessary morbidity and premature mortality as ‘unfreedoms’ that constrain human capability. (Sen, 1999) Sorkin has highlighted the point that the association between health and national development is a two-way phenomenon. (Sorkin, 1976) That health and poverty are associated in a number of ways has been succinctly explained by Hulm and Shepherd.(Hulm and Shepherd, 2003) According to Bloom et al investment in the health of population has contributed to the economic prosperity of South Asia. 

Methodology

    In Odisha, about 22 percent of the people belong to the scheduled tribe community and they live in almost all the districts of the state. It has the largest percentage of tribal population among the Indian states barring the North-eastern states. Out of the 30 districts, nine districts are tribal-dominated. The state has about 47 percent of its area under Scheduled area where more than 50 percent of the population is ST. Access to healthcare by the tribals is important not only for human development, but also for inclusive development in the state of Odisha. An attempt is, therefore, made in this paper to analyse the access of the tribals to health facilities and their health status in different parts of Odisha. Data both secondary and primary are used to analyse the issues. Secondary data as available in published form are used while primary data have been collected from 120 households in eight villages in Jhumpura Block of tribal district of Keonjhar. Anecdotes and photographs reported in various newspapers describing the woe of tribal health are made use of to support conclusions. 

Tribal Health in Odisha

    The undivided districts of Bolangir, Kalahandi, Phulbani, Sundargarh, Keonjhar, Koraput and Mayurbhanj etc. are mostly tribal-dominated. Table 1 presents the distance of the villages from the medical facilities. 

Table 1:    Access to Health Facilities and Transport Connectivity (Within 5 km. Distance)

Source: Das, Sanjukta. (2009), “Health Conditions of the Tribals in Odisha: Analysis of NFHS-II and NFHS-III Data”, Adivasi, Vol. 49, No. 1, June, p. 114.

    It is observed that about half of the villages do not have medical facilities within a distance of 5.km in the undivided districts of Bolangir, Kalahandi, Phulbani and Sundargarh. It is further revealed that the highest number of villages in Kalahandi and Phulbani districts are in disadvantageous position as far as accessibility to medical facilities are concerned. It is not only that the villagers lack medical institutions; they also do not have transport connectivity to the medical facilities available at distant places. The situation in other tribal districts is also far from satisfactory. Nearly half of the villages in other tribal districts of Sundargarh, Balangir, Keonjhar etc. neither have medical facilities within their reach nor do they have transport connectivity to the hospitals located in far off places. 

    For instance, the Sukinda block of Jajpur district, which is inhabited by large number of Juangs, has many Juang villages on the hills without proper roads and primary health centres. The villagers have to walk 15 kms to reach the nearest health centre managed by a mining company. The nearest government hospital in Sukinda is 35 kms from the villages. (The Times of India, 17th Dec.2011) The tribal-dominated villages in Tumusingha Gram Panchayat of Kamakshyanagar Sub-Division of Dhenkanal district do not have health facilities within their reach. In case of Mahuldagar and Kiapatrini villages, which are inhabited by as many as 60 families, the villagers have to walk 15 kms inside dense forest to avail health care facilities. A villager Gopi Biruha says “Villagers here are dying of several diseases without proper medical care. No mobile health camp has been organised for years. When we suffer from malaria or skin disease, we have to walk to Anlabereni community health centre which is 14 kilometres and Srimula primary health centre which is 12 kms away by foot”.( The Times of India, 24th Dec.2010). 

    The situation in tribal dominated undivided Koraput district is no better. Twenty percent of the population living in remote forest areas never get medical facilities because of lack of communication. The villagers of Dandabadi, Chipakur, Majhiguda, Dasmantapur, Kolar and Bodaput in Baipariguda Block fail to reach a hospital in need as these villages are not well connected with roads. Similar is the condition for the villagers of Lenja, Bapaliguda, Khandiguda and Muruda villages in Mohuli Panchayat. In the villages of Banamaliput, Tikarpara, Kumbharakandana and Umbel in Lamtaput Block, which are detached from the mainland by the Kolab reservoir, women are unable to avail even the official Safe Motherhood Programme. Kamala is one such woman of Kechala village. She went in to labour and had to be rushed to the district headquarter hospital at Koraput. She had to endure a 45 minute journey in a country-boat and then travelled another 9 kilometres in an auto-rickshaw. After she reached the hospital, she underwent a caesarean operation and gave birth to a baby girl who survived only for two days.( The Times of India, 9th Oct. 2009) Not a single woman of about seven villages having a population of about 3,000, located near Kolab reservoir under Koraput Block, has been benefitted from the “Janani Surakhya Yojana”. To reach these villages, where modern health care facilities are virtually non-existent, one has to cover a distance of about 80 kilometres by road from here or endure a 9 kilometre drive and 45 minutes journey by boat. Padlam Muduli says, “Here we have no health centres. Our area is under the coverage of Mathalput hospital located about 50 kilometres from here. To take our family members to the hospital at Mathalput or Koraput is a real nightmare. Many patients die even before they can be taken to the hospital”. (The Times of India, 9th Oct. 2009) 

    We can now highlight the problem of some of the villages in Keonjhar district where 44 percent of the people belong to the scheduled tribe community. There are large numbers of people belonging to the Bhuyan tribe in Keonjhar district. The remote villages where these tribal people live are surrounded by hills and forest, particularly in Banspal Block. In case there is a medical emergency, a patient is carried in a basket or cot to hospitals situated at a distance of 10 to 20 kilometres. There were occasions when the patient died on the road before reaching either Kanjipani PHC or Banspal CHC. (The Times of India, 19th Nov. 2010) Similarly, Kanheigula village of Harichandanpur Block is inhabited by Juang tribes. It is remotely located in a hilly and forest area. After six decades of independence, a road is yet to be connected to the village. When people are in dire need of health care facilities, they walk 25 to 30 kilometres through the jungle to reach the CHC at Harichandanpur. Often in critical conditions, the pregnant women were carried in bamboo baskets to the Harichandanpur CHC. (Fig.1) The figure depicts how a Juang woman is carried by her relatives in a bamboo basket in a jungle route to the CHC at Harichandanpur in Keonjhar district. These things do not help the patients always. The above cited anecdotes indicate the precarious health care situation of tribal people in Odisha. 

Fig. 1

    A Juang Pregnant Woman of Kanheigola Village in Harichandanpur Block of Keonjhar District is carried in Bamboo Basket for Treatment through a Jungle Route

Source: Samaj

    The medical facilities per sq. km could be a good indicator to analyse people’s access to health facilities. In case of the tribals of Odisha, the criterion i.e. facilities per square kilometre is more useful as the tribals live in hilly and remote areas. In these areas people live in scattered places without having road and transport connectivity. Table 2 presents the poor access in tribal dominated districts. It is found that there are twelve districts where the medical facility per sq. km is higher than the state average. Out of these twelve districts nine are tribal dominated. On the contrary, majority of the non-tribal districts have lower area / medical institution ratio. Similar trend is also noticed in the area / allopathic medical institutions (MIs) in 2004. Higher area/ medical institution ratio of the remote tribal dominated districts indicate higher transport cost of visiting the medical institutions for seeking medical assistance. This is also reflected from the data of the districts’ percentage of woman received antenatal care.

Table 2:    Availability of Medical Facilities (Area wise)

Source: Das, Sanjukta (2009), “Health Conditions of the Tribals in Odisha: Analysis of NFHS-II and NFHS-III Data”, Adivasi, Vol.49, No. 1, June, p.114.
Note: a –Allopathic Institutions under the Health and Family Welfare department.

    For various reasons, the infant and child mortality rate are found to be very high among the tribals. A comparative study of IMR, child mortality and under five mortality rate among ST, SC and other categories of people in the NFHS-II and NFHS-III results reveal the following things. There is no gainsaying the fact that IMR, child mortality and under-five mortality have decreased among various categories of people in the NFHS-III period (2005-06) as compared to the NFHS-II. It is found that IMR has declined from 98.7 to 78.7 among ST population, while this decline is from 79.1 to 53.1 among the general category people. Despite the decline in IMR among scheduled tribe people in Odisha, it is still much higher as compared to state and national averages. Similarly, child mortality rate was 62.5 among the STs according to NFHS-III while it was only 44 during NFHS-II. This implies that there has been an increase in child mortality among the STs in Odisha. The under-five mortality rate was 136.3 among the STs, while it was 96.6 for the entire state as a whole during NFHS-III. (Table 3) The tribal-dominated Kandhmal district has earned the dubious index of being the district with the highest under-five child mortality rate in the country. For every one thousand children born in the district, 145 die before the age of five (Govt. of India, 2011). While the average under-five mortality rate among boys is 138 in Kandhamal, it is 153 among girls. On the other hand, the average under-five mortality in Odisha is only 82. The tribal dominated Bolangir district in Odisha figures among the second worst district for death of children within one year of birth. As many as 100 children per 1,000 births in Bolangir die before celebrating their first birth day which is close to the worst such district of Shrawasti in Uttar Pradesh with an IMR of 103, according to the Annual Health Survey Bulletin, Govt. of India, 2010 - 11. In some of the tribal districts like Malkangiri, IMR has increased over the years. The district has about 57 percent tribal population. The IMR in the district that was 55.2 per 1,000 live births in 2005 has increased to 62.5 in 2006 and 67 in 2007 and further to 70 in 2008. Though the government is taking steps to check infant deaths, the infant deaths of Banspal Block of Keonjhar district seems to be out of control. The cases of child mortality are alarming in spite of different health programmes which have been launched to prevent infant deaths and malnutrition. It is reported that the number of infant deaths was 268 during 2009-10 which was 276 during 2008-09. The IMR of this block is calculated as 118.61 during 2008-09, 115.87 during 2009-10 and 104.96 during 2010-11. In most of these cases, the families were poor and fail to give the children nutritious food. Unavailability of doctors, medicines, blind faith and health service at doorstep in remote hilly areas are also said to be the reasons for infant deaths. Blind faith like bathing the child and shaving the head immediately after the birth, use of traditional medicine, late coming to medical due to lack of communication during pregnancy and lack of awareness are also said to be the causes of infant deaths. Not only Banspal, the situation of tribal- dominated Telkoi, Harichandanpur, Ghatagaon, Sadar, Jhumpura and Joda block area, the infant death is also acute. According to the Health Department in Keonjhar district, a total of 3,441 infants died in the district between 2008 and 2010. Though the number of infant death is declining as per official record, the actual death will be much higher. (The Times of India, 17th Dec.2011) Table 4 depicts the various health indicators of tribal people in Odisha with that of other categories of people in the state as well as in the country. It is found that child mortality among the STs is much higher than the national average while in case of under-five (U-5) mortality among the ST people in Odisha the figure is nearly twice that of the national average.

Table 3    Premature Mortality Situation among the Tribals in Odisha

Source: Das, Sanjukta (2009), “Health Conditions of the Tribals in Odisha: Analysis of NFHS-II and NFHS-III data”, Adivasi, Vol. 49, No.1, June, p. 110.

Table 4:    Health Characteristics of Tribals vis-a-vis Other Social Groups in Odisha and India

Source: Patra, Sudhakar and K. K. Sahu. (2012). “Health Status of Tribes in Odisha: Reflection on Critical Issues and Problems” in L. N. Dash, (ed.) Health and India’s Economic Development: Challenges and Opportunities, New Delhi: Synergy Books.

    Malnutrition continues to be a cause of serious health problems among the tribal people of Odisha. The hill and forest surrounded tribal-dominated Banspal block is reported having high malnutrition in the district of Keonjhar. It is reported that 90 percent of children of Banspal block are suffering from malnutrition for various reasons. Malnutrition is also found to be very high among the primitive tribes such as Bonda, Didayi, Juang and Kutia Kandha. According study conducted by the Regional Medical Research Centre (RMRC), Bhubaneswar, 66 percent of primitive tribal population in the age group of 6-15yrs in Mayurbhanj and Sundargarh districts were found to be malnourished (ICMR Bulletin, 2003). Similarly, the chronic energy deficiency was found to be very high among Lanjia Soura (89.4 percent) and Kutia Kandha (88.9 percent), two primitive tribes of Rayagada district. Many belonging to the Bonda, Didayi, Kandha and Juang, primitive tribes of Odisha have different levels of anaemia as an important outcome of malnourishment. Similarly, 85 percent of Paudi Bhuyans, a primitive tribe of Sundargarh district, were found to be suffering from different levels of anaemia. Malnutrition also stalks the tribal children of Koraput district. The tragedy of persistent child malnutrition in the district presents a dismal picture of future of the human development in Odisha.

    Odisha is a high disease burden state so far as malaria load is concerned. Not only does it account for 23 percent of total malaria cases in India, the state also has dubious distinction of 70 percent death and lion’s share of plasmodium falciparum (Pf ) incidence. According to available data, 66 percent of malaria deaths are reported from tribal areas. More than 60 percent of tribal population of Odisha lives in high risk areas of malaria. In a study conducted in undivided Koraput district, it was observed that the district is endemic for malaria and is hyper-endemic in top hills where Bonda primitive tribes live (ICMR Bulletin, 2003).

    A study conducted by RMRC, Bhubaneswar during 2000-03 in Malkangiri, Kandhamal and Keonjhar districts shows malaria positive rate of 14.2 per cent in Bonda, 14.4 per cent in Didayi, 10.5 per cent in Kandha and 9.5 per cent in Juang population. The malaria death in the tribal dominated Keonjhar district is also very high. Despite the various programmes undertaken for malaria eradication, 108 people died of malaria in 2000 which decreased to 68 in 2001, 35 in 2003 and it stood at 31 in 2007. During the period from 1997 to 2007, a total of 617 people died of malaria in this district. It is also found that malaria death is also rising in the other tribal districts of Kalahandi, Malkangiri and Bolangir.

    The data collected from the 120 households in eight villages of Jhumpura Block of Keonjhar district also reveal the fact 80 percent of the people take the help of witchcraft method to cure diseases, and only 7.5 percent people visit government hospitals. For not visiting the government hospitals, the main reasons ascribed are distance of the hospitals, poor health services and health personnel absenteeism in the hospitals. Only 9.38 percent of the deliveries among the tribals in these villages take place in hospitals as against the state average of 38 percent. Similarly, the practice of antenatal checkup (12 percent) and seeking health advice from the doctor during pregnancy (32.5 percent) are abysmally low. 

    A number of factors are ascribed to the high rate of death and disease in the tribal districts of Odisha. Shortage of doctors and inadequate infrastructure has hit health services in the tribal districts. For example, in 2009 the district of Keonjhar had only126 doctors in 84 hospitals against the official requirement of 203 doctors. Out of the 84 hospitals, 68 are PHCs, 8 CHCs, 2 sub-divisional hospitals, one upgraded hospital in Ghatgaon, 1 urban health centre in Barbil and the district headquarters hospital. There are no doctors in many single-doctor primary health centres. Only 126 doctors are catering to 16 lakh people in the tribal dominated district which is reeling under various health hazards due to rise in air, water and noise pollution. Malaria, diarrhoea, anaemia and tuberculosis have hit the tribal districts hard. Every year hundreds fall prey to these diseases due to inadequate health facilities. Instances of infant and maternity deaths in Keonjhar are common. Many doctors are reluctant to work in the interior hospitals because of inadequate infrastructure. Consequently, people in these remote villages continue to depend on quacks resulting in deaths due to wrong diagnosis and treatment. Further, out of the 56 Ayurvedic dispensaries in the district 17 were without a doctor, Lack of awareness also cost the tribal people dear. Because of this factor, the tribal-dominated Koraput district has earned the dubious distinction of being the third after Ganjam and Cuttack and first among the tribal districts to have the highest number of HIV/AIDS cases in the state. As many tribal people are not aware of the various government health programmes, many of them do not know about the “Janani Surakhya Yojana” (JSY), a programme seeking to support safe motherhood. It is reported that since 2007 none of the 17 mothers of Sanamajhiguda village in Borigumma block, who deliver their babies at their homes in the presence of their village ANM have received the money they are entitled to under JSRY. Basanti Gouda of this village alleges “I gave birth to my son in October 2007 and the village ANM was present. I filled up the required forms the next day and submitted them to concerned authorities. But I am yet to receive the money. My husband has approached the officials several times, but without luck”. (The Times of India, 6th Sept., 2009) Surprisingly, the tribal areas of the State have adequate sub-centres and PHCs in comparison to many other states of the country. 

Conclusion

    From the discussion above it is clear that apart from increasing government health expenditure, there is a need to increase health awareness among the tribals. A number of health programmes have been implemented in Odisha in general and in the rural areas in particular. But they have not yielded the desired result. Therefore, what is more important is the proper monitoring and supervision of these programmes for efficient health care delivery to the tribal people. In order to check health personnel absenteeism in the remote hospitals in tribal areas, different types of incentives should be extended to them. As the public health care system has failed to deliver the required service to the poor tribal people, the PPP model of health care delivery which has been initiated in Odisha can be extended to the tribal areas of the state. However, the PPP model should be tuned in such a way that there should not be any financial burden on the poor tribal people. 

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