Lok Sabha Question No. 1080 (UNSTARRED), answered on 2021-12-03
Subject: Communicable Diseases in Tribal Areas
Ministry: HEALTH AND FAMILY WELFARE
Asked by: Achyutananda Samanta

## GOVERNMENT OF INDIA MINISTRY OF HEALTH AND FAMILY WELFARE

## DEPARTMENT OF HEALTH AND FAMILY WELFARE

## LOK SABHA UNSTARRED QUESTION NO. 1080 TO BE ANSWERED ON THE 03 rd  DECEMBER, 2021

## COMMUNICABLE DISEASES IN TRIBAL AREAS

## 1080. SHRI ACHYUTANANDA SAMANTA:

Will the Minister of HEALTH AND FAMILY WELFARE be pleased to State:

- a) whether the National Expert Committee on Tribal Health in its report has stated that tribal people  face  triple the  burden  of  diseases,  and  bear  a  'disproportionate  burden'  of communicable diseases like tuberculosis and malaria;
- b) if so, the details thereof;
- c) whether the Government has taken any steps to address this, if so, the details thereof and if not, the reasons therefor;
- d) whether there is limited access to healthcare and more severely access to medicines in such areas, if so, the details thereof;
- e) whether  the  Government  is  taking  any  steps  to  ensure  better  access  to  healthcare  for  the tribal people, if so, the details thereof, if not, the reasons therefor; and
- f) whether  the  Government  is  considering  bringing  forth  a  comprehensive  tribal  healthcare policy to tackle such issues and if not, the reasons therefor?

## ANSWER THE MINISTER OF STATE IN THE MINISTRY OF HEALTH AND FAMILY WELFARE (DR. BHARATI PRAVIN PAWAR)

- (a) & (b): The Expert Committee on Tribal Health, in its report, has stated that, tribal people face a triple burden of diseases and bears a disproportionate burdenofcommunicablediseases,  primarily  those  that  are  often  referred  to  as  diseases  of poverty and underdevelopment, which includeMalaria, and Tuberculosis. While malnutrition and communicable diseases like malaria and tuberculosis continue to be high, rapid urbanization, environmental distress and changing lifestyle have resulted in a rise in the prevalence of non-communicable diseases like cancer, hypertension and diabetes.

(c) to (f):  'Public Health and Hospital' is a State subject, the primary responsibility of ensuring availability  of  healthcare  facilities  including  access  to  healthcare  in  tribal  areas  lies  with respective State/UT Governments.

Under  the  National  Health  Mission  (NHM),  government  of  India  provides  financial and technical support to States/UTs to strengthen their health care systems including support for  communicable  diseases  management,  setting-up/upgrading  public  health  facilities  and augmenting health human resource on contractual basis for provision of equitable, affordable healthcare  to  all  its  citizens  particularly  the  poor  and  vulnerable  population  including  tribal population  based  on  requirements  posed  by  the  States  in  their  Programme  Implementation Plans (PIPs).

Government  has  taken  a  number  of  steps  to  address  the  challenges  related  to Communicable Diseases  like,  Malaria  and  Tuberculosis,  in  tribal  areas  and  the  access  to healthcare.

Under  the  National  Tuberculosis  Elimination  Programme  (NTEP),  in  tribal,  hilly  and difficult areas, special provisions have been made to expand diagnostics and treatment centres, programme management units, to improve access to TB patients and coverage of TB services, as under:

-  TB Programme Management Unit (TB Units) - 1 for every 1 lakh population as against 1 for every 2 lakhs general population.
-  Microscopy Centres  for  diagnosis  of  TB  -  1  for  every  50,000  population  as  against  1  for every 1 lakh population.
-  Travel Allowance - Rs. 750 is provisioned for TB patients notified from designated tribal areas to support travel to access TB diagnosis and treatment centres.

Key interventions and activities to address Malaria in tribal areas -

- i. Long Lasting Insecticidal Nets (LLINs) are distributed to the families for protection from Malaria
- ii. Indoor Residual Spraying (IRS) - undertaken extensively to control 'endophilic' malaria vectors
- iii. Expanding the testing facilities to ensure early diagnosis and treatment by extensive use of Rapid Diagnostics Kits (RDK), through ASHAs, and ANMs
- iv. Promoting use of Gambusia Fish to control the larvae in the water bodies.

Besides above, various other interventions that are being implemented for strengthening of healthcare system for improved health outcomesin beneficiaries in tribal areas are as follows;

-  Health  and  Wellness  Centres  (HWCs)  are  established  by  transforming  the  SHCs  and PHCs, as part of the Ayushman Bharat - the flagship programme of Government of India, to improve the health care delivery.  In the current financial year, over 80466 HWCs have

been operationalized till 28th November, 2021. Of this 13636 AB-HWCs are operational in 177 tribal districts (as on 28 November 2021).

-  The population norms for setting up Health Facilities in vulnerable areas including tribal areas are relaxed. Against the population norms of 5,000, 30,000, and 1,20,000 for setting up of Sub Centre, PHC and CHC, the norm is  3,000, 20,000 and 80,000 respectively in vulnerable areas including tribal areas.
-  Under NHM, relaxed norms are there for Mobile Medical Units for tribal areas; extra one MMU if it  exceeds  30  patients  per  day  against  60  patients  per  day  in  plain  areas  for bringing healthcare delivery to the doorsteps of the population.
-  To minimize the Out of Pocket Expenditure incurred on health services, National  Free Drugs and Diagnostic Service Initiative has been rolled out. The medicines are provided adequately to all health facilities, including the health facilities in tribal areas, as per the essential medicines lists for respective levels of facilities. Special focus is given to ensure that  there  are  no  interruptions  in  availability  of  medicines  in  health  facilities  in  tribal areas.
-  The ASHA programme guidelines provide for recruitment of ASHA at habitation level, in hilly,  tribal  and  difficult  areas).  Consequently,  ASHAs,  have  been  put  in  place  at habitation  level  (well  below the  national  norm  of  one  ASHA  at  a  population  of  about 1000).
-  Government  of  India  is  supporting  states  in  implementation  of  National  Ambulances Services under NHM for free transportation of sick patients to the health facilities. This service  is  extended  to  remote,  rural  and  tribal  areas  also.  States  are  free  to  place  these ambulances  at  a  lower  population  norm  or  as  per  time  to  care  approach  so  that  these ambulances are easily accessible by all.
-  Further,  all  tribal  majority  districts  whose  composite  health  index  is  below  the  State average have been identified as High Priority Districts (HPDs) and these districts receive more resources per capita under the NHM as compared to the rest of the districts in the State.  These  districts  receive  higher  per  capita  funding,  have  enhanced  monitoring  and focussed  supportive  supervision  and  are  encouraged  to  adopt  innovative  approaches  to address their peculiar health challenges.

Due to above interventions under NHM, there has been 73% increase in Health Facilities available in Tribal areas as compared to 10% increase in all India.

| Type of Facility   | All India   | All India   | All India   | Tribal Areas   | Tribal Areas   | Tribal Areas   |
|--------------------|-------------|-------------|-------------|----------------|----------------|----------------|
| Type of Facility   | RHS 2005    | RHS 2020    | % Increas e | RHS 2005       | RHS 2020       | % Increase     |
| SHCs               | 1,42,655    | 1,55,404    | 9%          | 16,748         | 29,745         | 78%            |
| PHCs               | 23,109      | 24,918      | 8%          | 2,809          | 4,203          | 50%            |
| CHCs               | 3,222       | 5,183       | 61%         | 643            | 1035           | 61%            |
| Total              | 1,68,986    | 1,85,505    | 10%         | 20,200         | 34,983         | 73%            |

-  States are encouraged to adopt flexible norms for engaging specialists for public health facilities by various mechanisms like 'contracting in' and 'contracting out' of specialist services under National Health Mission. NHM provides for following types of incentives and  honorarium  to  staff  for  ensuring  service  delivery  in  rural  and  remote  areas  in  the country
-  Honorarium to Gynecologists/ Emergency Obstetric Care (EmoC) trained, Pediatricians & Anesthetist/ Life Saving Anaesthesia Skills (LSAS) trained doctors for conducting C Sections.
-  Hard  area  allowances  and  special  packages  are  provided  to  attract  health  HR, especially medical officers and specialists, to remote and difficult areas.
-  Incentives  like  special  incentives  for  doctors,  incentive  for  ANM  for  ensuring timely ANC  checkup and recording, incentives for conducting Adolescent Reproductive and Sexual Health (ARSH) activities etc
-  States  have  also  been  allowed  to  offer  negotiable  salaries  to  attract  Specialists including flexibility in strategies such as ''You quote, we pay".

In addition, non-Monetary incentives such as preferential admission in post graduate courses for staff serving in difficult areas and improving accommodation arrangement in rural areas have also been introduced under NHM.

M/o Health & Family Welfare and M/o Tribal Affairs has prepared a Joint Action Plan for addressing  Tuberculosiss  in  Tribal  Areas  articulating  the  steps  to  be  taken  by  the  State/UT Government's. The key strategies being implemented under this initiative are as under:

- 1) gap analysis for increasing access to diagnosis and treatment
- 2) Vulnerability assessment and Active Case Finding
- 3) Community  engagement  for  improving  health  seeking  behaviour  and  intensified  IEC activities for reducing stigma and increasing demand for services
- 4) Strengthening recording and reporting systems
- 5) Contact tracing and intensifying surveillance of TB cases

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