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Indian Journal of Community Medicine

The Status of Familly Welfare Services in Tribal Areas: Highlights of the Evaluation Process

Author(s): Prasanta Kumar Saha

Vol. 28, No. 3 (2003-07 - 2003-09)

C Stat (UK), Fellow of RSS (UK), Deptt. of Family Welfare, Govt. of India, New Delhi

The Tribal societies in India are undisputedly considered as the weakest sections of the population in view of common socio-economic and socio-demographic factors like poverty, illiteracy, lack of developmental facilities, lack of adequate primary health facilities etc due to, perhaps, demographic phenomenon, tribal population constitutes a very small segment of the total population of India. Up to 1941, share of tribal population in the total population was about 3% which has increased to about 8% in the recent period. There is no comprehensive study on demographic model depicting scientifically the demographic pattern of the tribal population in India. Though Government of India has conducted surveys on socio-economic aspects of tribal population, economically they live in abysmally poor economic conditions for years. Millions of these people are surviving in a most inhuman environment. Plenty of such scenarios are found in tribal districts of M.P., Bihar, Orissa, etc. Tribal population in India is found predominantly high in a number of districts of Assam, Bihar, M.P., Maharashtra, Manipur, Orissa, Rajasthan, Sikkim, Tripura, Andaman & Nicobar Islands and Daman and Diu. This segment of population comprises about 460 different tribal groups showing different social and cultural characteristics.

In the context of Reproductive and Child Health (RCH) Programme undertaken by the Govt, of India, the basic needs of health care of tribal women mainly relate to nutritional deficiency, child bearings, reproductive health and hygiene, unwanted pregnancies, abortions, RTIs and HIV. Pregnancy related risks and complications among tribal women in particular and various types of mortalities among the tribal population in general are high.

It is a striking feature that though the Tribal women in India suffer from high levels of female morbidity and mortality, they do not seek generally medical facilities from health centres. They simply neglect the serious health problems like, RTIs/STDs, menstrual disorders and unwanted pregnancies primarily due to lack of awareness and generally due to lack of accessibility to health facilities proper information and guidance.

Health Infrastructure in Public Sector:

Government of India and State Governments have established a country wide network of Sub-Centres (SCs) and Primary Health Centres (PHCs) with differential norms of population coverage:

Population per Health Centre
  Tribal Area Non-Tribal Area
SC 3,000 5,000
PHC 20,000 30,000

As in mid-1999, the total number of Sub-Centres (SCs), Primary Health Centres (PHC) and Community Health Centres (CHC) in Tribal areas were 20770 (15% of total SCs), 3289 (14% of total PHCs) and 541(18% of total CHCs) respectively.

According to the information readily available, about 20% of the posts of Medical Officers were vacant in tribal areas compared to 15% in non-tribal areas. Similarly, in tribal areas about 15% of posts of pare-medical staff were vacant compared to about 10% in non-tribal areas in recent period. The lack of infrastructure in the health sector in tribal areas in well known. This predominantly discouraging social factor calls for correct assessment and evaluation of the existing facilities. This issue of optimal structure of health care in an age-old neglected segment of population may naturally lead to proposing a different strategy for providing best quality of RCH services up to the satisfaction of the tribal people in general and tribal women and children in particular.

Management of progress of RCH programme:

Reproductive and Child Health (RCH) programme was launched by the Government of India (Department of Family Welfare) in October, 1997 all over the country. RCH programme is to provide need-based, demand-driven, high quality health and family welfare services to the mothers and children and to ensure client's satisfaction which needs improving the existing facilities and creating new facilities. Implementation of RCH programme was preceded by historic policy reform undertaken by the GOI in 1996-97 which focuses on two basic and most significant initiatives which are (a) Decentralized Participatory Planning and (b) Bottom-up approach for programme implementation dispensing with decades old target oriented approach for implementing family welfare programme. Both the initiatives are to be taken care of under the innovative approach called Community Needs Assessment Approach (CNAA). Therefore, under RCH programme building up of an efficient machinery of management particularly for monitoring of progress and evaluation of effectiveness of the programme is treated as one of the most important thrust areas. It is an encouraging fact that there is a permanent system of evaluation of the health care services under the Family Welfare Programme and currently under RCH programme. The existing system of evaluation in the field of FW programme comprises the following components:

  1. Quantitative evaluation through verification of the reported performance to check the authenticity of records and identification of interventions for improvement.
  2. Qualitative evaluation to assess the skills of different health personnel, facilities available, utilization of available health services, clients satisfaction etc.

In fact, under the current process of programme implementation, emphasis is supposed to be laid more on quality of health and family welfare services than the quantitative approach for sheer numerical achievements which were followed previously under the target oriented approach in implementing the family welfare programme which reportedly led to inflated figures thus highlighting drawbacks of the quantitative aspects.

Evaluation process:

In order to assess the veracity of both the status of the services provided to the family planning acceptors, of different methods reported by the State governments, a system of continuous statistical verification has been in vogue in this country for the last about 3 decades. The evaluation process (which is not supposed to be optimum in its implementation) is being carried out regularly every month both by the Centre and State Government machineries. Based on the findings of these field sample checks, regular feed back is sent to the concerned State Governments urging them to take suitable remedial measures obviously with a view to improve the quality of the Family Welfare services.

In the public sector there are three agencies which are undertaking sample verification of mainly family welfare programme. These are stated as below:

  • Eight Regional Evaluation Teams located in Bangalore, Bhopal, Calcutta, Chennai, Delhi, Lucknow, Patna and Pune which are functioning under the guidance and supervision of Govt. of India and under the administrative control of the concerned Regional Health Offices.
  • 17 Regional Health Offices of Ministry of Health and FW, Govt. of India.
  • 17 Demographic and Evaluation (D&E) Cells located in State Family Welfare Bureau of 17 States.

During 1999-2000, these evaluation machineries covered 26 tribal districts for undertaking assessment of status of RCH services. These districts were: Srikakulam, Vizianagram, Krishna, Adilabad, Nizamabad in Andhra Pradesh; Satna, Surat, Banaskantha in Gujarat; Rajandagaon, Durg in Madhya Pradesh; Ahmednagar, Bhandara, Nagpur, Chandrapur in Maharashtra; Midnapore, Hoogly, Bankura, Birbhum in West Bengal; West Sikkim, South Sikkim in Sikkim; West Champaran, Deogarh in Bihar; Chittourgarh in Rajasthan; Vellore in Kerala and Kanya Kumari and Palakhad in Tamil Nadu.

Status of RCH Services in the Tribal Districts:

The evaluation process had highlighted a few shortcomings during the sample verification of RCH services in 95 Districts including 26 Tribal Districts in the country. Some of the important findings related to these Tribal districts are summarized below

  1. Facilities relating to infrastructure at Sub-Centers are lacking in the tribal areas. The Auxiliary Nurse Midwives (ANMs) who are posted in tribal areas
  2. Medical Officers and Health Officers posted in tribal areas are practically working in non-tribal areas due to lack of basic conveniences in the tribal areas for their stay.
  3. Tribal population is generally scattered in hilly areas or in other difficult terrains. Vis-a-vis this geographic constraint, about 15 to 20 villages are kept under the jurisdiction of one ANM. This situation constrains heavily the ANMs from providing adequate services to the people for ANC, post-natal care, safe delivery, immunization to children, etc.
  4. Delivery in tribal areas is generally conducted by the relatives. Such practice leads to higher order of Infant Mortality Rate (IMR), Still births and Maternal Mortality Ratio (MMR). These mortality factors are, therefore, responsible for an unusual attitude on the part of the concerned couples for giving birth to 7 or 8 children with the belief that ultimately 2 to 3 children may survive.
  5. It is a notable feature that Institutional deliveries are too low and the rate of still births is very high as mothers are , brought to Primary Health Centers (PHCs) and the Community Health Centers (CHCs) for delivery in a very critical condition at the last moment. In respect of home delivery by Dais, it is well known that the Dais in tribal areas are not trained.
  6. Minimum number of medical equipments and other essential equipments are not available in may health centers.
  7. A good number of posts were found vacant in the health centers thus affecting the implementation of family welfare programme.
  8. General conditions of the sub centers located in the Tribal Districts are very poor.
  9. Medical and Paramedical staff obviously need necessary training on RCH Programme particularly under decentralized planning.
  10. Recording of service particulars is very unsatisfactory particularly maintenance of the eligible couple registers (ECR).
  11. There is lack of follow-up services for health care in the health centers of many tribal districts.

Hypothesis of absence of discrimination:

In view of the observations stated above, one important issue emerges that is, the Government of India (and also the State Government) do not follow an adversely discriminatory sentiment towards tribal people in India regarding provision of primary health care to them. It is significant to point out here that almost all the deficiencies as mentioned above are equally true for most of the non-tribal districts also. One of the real practical problems faced and recorded by the evaluation machinery is that the tribal population lives in geographically scattered areas and in areas which are not easily accessible. Therefore, the hypothesis of absence of discrimination against tribal population is some how acceptable in the existing set up.

Special measures for tribal districts:

The Government of India is chalking out separate and special strategies for meeting basic needs of primary health care and reproductive and child health care for the tribal population in the phase-II of the RCH programme. In this regard it is important to mention that under the historic policy reform of Target Free Approach and the Community Needs Assessment Approach (CNAA) undertaken by the department of Family Welfare, Govt. of India since 1996-97, the programme of assessment of the needs of RCH services at the grass root level is being implemented in majority of the districts of majority of the States including the tribal districts through objective household as well as institutional surveys.

Conclusions:

The overall scenario in the tribal areas as depicted through the evaluation machinery under the on-going evaluation process shows that the tribal people are now eager to accept, for instance, the terminal methods of family planning and other modern services. However, due to lack of these facilities, they are deprived of these valuable services which they really need. It may, therefore, call for a differential strategy to be adopted for bringing about the improvement in the Health and Family Welfare services in desired scale in the tribal areas of the country. These strategies will be framed under a holistic approach of improving roads and transport systems, communication, sanitation and arranging safe drinking water. At the same time building up the infrastructure of sub centres (e.g. constructing buildings), posting skilled manpower and reducing the population norm to about half the present norm per health centre seem to be essential.

References:

  1. Tribes as Indigenous People of India - by Mr. Virginias Xaxa, Economic and Political Weekly, Dec. 18, 1999.
  2. Annual Report, 1999-2000, Ministry o ' Health and Family Welfare, Government of India.
  3. National Family Health Survey (NFHS-II), 1998-99.
  4. Manual on Community Needs Assessment Approach in Family Welfare Programme, department of Family Welfare, Ministry of Health and FW, Govt, of India.
  5. Year Book, 1998-99, Deptt. of Family Welfare, Ministry of Health and FW, Govt. of India.
  6. The Reproductive and Child Health Programme Schemes for Implementation, October 1997. Deptt. of Family Welfare, Ministry of Health and FW, Govt, of India.
  7. Relevant Reports of Census of India, 1991 and 2001.
  8. Population Policy of India, 2000, Deptt. of Family Welfare, Ministry of Health and FW, Govt. of India.
  9. Rural Health Statistics, Dec. 2000, Ministry of Health and FW, Govt. of India.
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