PRC Report Series 2019-3 2018-19:7

Treatment seeking behaviour of Tribal population in South

Dr. Oommen P.Mathew Mr. Sachin K.V

Population Research Centre Ministry of Health and Family Welfare Government of University of Kerala 2019

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Foreword

The total Scheduled Tribe population of Kerala is 4.84 lakh which is 1.45 percent of the total population. Tribal population is concentrated in three districts of , Idukki and Wayanad. In most of the other districts it is scattered. Upliftment of the tribal population has been an important objective since independence of both the Central and State Governments which has had its effect. Yet the development plans focused on tribals has been failing for causes unknown. The concern has been more on the success of the programmes to improve the health of the tribal population. The scattered and remote location of the tribal hamlets is believed to be one of the important reasons. On this footing the authors attempt to assess the treatment seeking behavior of the tribal population by carefully selecting the tribal hamlets located in remote locations. So the study was carried out in three districts: Thiruvananthapuram, and Idukki. Edamalakkudy from Idukki, Sayippinkuzhy colony from Pathanamthitta, Podiyam, Anakal and Pattampara from Thiruvananthapauram.

I appreciate the authors of the study Dr. Oommen P Mathew, Research Investigator and Mr. Sachin K.V, Field Investigator of the PRC in successfully completing the study. The findings will definitely be of great use to Planners and Policy makers in understanding the treatment seeking behavior of tribal population in South Kerala.

Kariavattom Dr. P Mohanachandran Nair March 2019 Director-in charge

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CONTENTS

Foreword 2 Executive summary 4 Chapter 1 Introduction 7 Chapter 2 Tribals of Edamalakkudy 15 2.1 Background Characteristics of Edamalakkudy 15 2.2 Treatment seeking behavior 29 2.3 Suggestions to Improve health care system in Edamalakkudy 34 Chapter 3 Sayippinkuzhy Tribal Colony 38 3.1 Background Characteristics 38 3.2 Treatment seeking behavior 42 Chapter 4 Tribal colonies of Thiruvananthapuram 47 4.1 General information about Kani Tribe 47 4.2 Background Characteristics of Hamlets selected for study 48 4.3 General treatment seeking behaviour 52 4.4 Antenatal, Delivery and Immunization care services 54 Chapter 5 Summary and recommendations 62 References 77

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Executive Summary

Kerala, the small southern state of India, is homeland for about 35 tribal communities. Most tribal people live in remote rural hamlets in hilly, forested or desert areas where illiteracy, adverse physical environments, malnutrition, inadequate access to potable water, and lack of personal hygiene and sanitation make them more vulnerable to disease. This study is intended to assess the functioning living condition of the tribal population residing in very interior and remote area of forest. It also envisages to examine the general treatment seeking behavior, antenatal, delivery and postnatal care services received by these tribal population. There are hamlets which are very interior of forests without road connectivity to that hamlets. This study is limited to three southern districts of Kerala: Thiruvananthapuram, Pathanamthitta and Idukki. Edamalakkudy from Idukki, Sayippinkuzhy colony from Pathanamthitta, Podiyam, Anakal and Pattampara from Thiruvananthapauram formed the study area.

Edamalakudy is the only tribal panchayath of Kerala, it has around 28 hamlets with houses in the range 8 to 30 in each hamlets. It was observed during the visit that the physical condition of Valappura, where tribal women stay during menstruation, was of very poor condition in all hamlets. The very poor condition of Valappura is themain reason for staying away from Valappura and avoiding menstruation by unscientific use of contraceptive pills. Modernisation of Valappura is a very important aspect required for Edamalakkudy. One Ayurveda dispensary and one Homeo dispensary are functioning in Edamalakkudy, both started under NHM initiative. Functioning of both these dispensaries are not at all beneficial to the public because of absence of doctor most of days. There is one 4 wheeler Ambulance in Edamalakkudy, but not functioning due to several reasons for the last 1 year. Pregnant women attend the medical camps organised at Society Kudi and other kudies by the CHC . Some of the pregnant women depend on GH for antenatal care services. Due to the irregularity in the conduct of medical camp, pregnant women from far away Kudis are seldom benefited by ANC checkups. The institutional deliveries increased in Edamalakkudi considerably, still delivery in Valapura is common. With the continuous

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effort of two Health department staff nurses of Sub centre, women are aware of the importance of institutional deliveries and the importance of immunisation and are often ready to immunize when medical team arrives in Kudi. It was observed that the immunization programme at Edamalakkudy is not organized in a regular manner, there was no immunisation programme in Society Kudi or any other Kudi for a period of more than 4 months.

Sayippinkuzhy tribal colony is situated in Goodrical forest range of forest division. Most of the families do not have any toilets, electricity is available for some houses, water is mainly from springs / ponds, the non availability of water during summer is the main problem of the sheds. The Medical Officer of Seethathode PHC visits the tribal colony on every Thursday, the doctor attends the sick patients and ANC women at their residence and also provides immunization to children during the camp. Very few pregnant women are utilizing GH Pathanamthitta for Antenatal checkups and antenatal ultra sound scanning. Reaching GH Pathanamthitta at night or odd time is very difficult because of getting vehicle on time, this is one reason for home deliveries and certain women like to deliver in forest rather than in hospital because of their belief.

The selected tribal colonies from Thiruvananthapuram for the study are Podiyam, Pattampara and Anakal. Pattampara and Anakal are the most remote hamlets and no toilet facility is available to houses of these hamlets of Thiruvananthapuram district. Podiyam sub centre of Kuttichal PHC created for the purpose of providing primary health care , antenatal care services and child immunization to the beneficiaries of these tribal colonies, is not functioning in this area for the past several years. Usually people of these hamlets utilize PHC Kuttical on market days, Wednesdays and Saturdays because of comparatively low transportation cost. There is weekly medical camp planned at Podiyam, Pothode, Kunnatheri etc from PHC Kuttichal, but these medical camp is not functioning in regular manner. The visit of the medical team is not regular and no specific time period is followed by the medical team on the day of visit. Even though the education level of women is less, most of them are aware of importance of antenatal check up, institutional deliveries and child immunization. Transportation of pregnant women in emergencies is not at all possible due to the lack of travel facilities. Some of the home deliveries are because of problem to get vehicle on time and some Page 5 of 77

deliveries are carried out in Jeep on the way to hospital. Problem of not getting reimbursement for the travel expense from Tribal department is another major problem in the colonies. There are several reasons for the partial immunization such as lack of immunization camp at Anakal and Pattampara, the information about the date of immunization camp at Pothode or Kunnatheri is not conveyed to the beneficiaries in advance, there is no fixed periodic immunization camp in these area.

Last minute transfer of pregnant women is very tedious and risky one in all the selected hamlets for the study. Maternity stay house is the solution to this problem. Pregnant women along with their bystanders will be able to stay in these maternity house well in advance , say one month before the expected delivery date and one or two weeks stay in these house after delivery. Free nutritious food supply to the inmates of these house also required. The maternity house is required in TH, GH Pathanamthitta and at TH .

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Chapter I Introduction

The tribals are integral part of Indian civilization and possess a very rich cultural heritage. India has the second largest concentration of tribal population after that of the African continent. The Indian tribes are the autochthonous people of the land who are believed to be the earliest settlers on the Indian Peninsula. In India, a tribal is known as Adivasi meaning original inhabitant. There are 450 tribal communities including subgroups among them in India. Tribes in India are not only numerous, but also differ widely in their habitat, level of development, modes of production, exposure to the wider world, traditional values, customs, beliefs, etc. According to the Census of India 2011, population of the scheduled tribe was about 10.45 crores. They constitute about 8.6 per cent of the population of the country, and almost 90 percent (89.97%) of them live in rural areas. . The percentage of the scheduled tribe population varies from one state to another. Though nearly half of the country’s tribal population is concentrated in the three states of Chhattisgarh, Jharkhand and Orissa, a few states like Nagaland, Meghalaya and Arunachal Pradesh are predominantly inhabited by tribals.

Article 342 of the Indian constitution defines ‘tribal folk’ as “People living in a particular place, who enter into marriage relationship among themselves, who have no specific skills in any work, traditionally or ethnically ruled by adivasi leaders, who speak any special language, have own beliefs, customs and tradition”. The criteria of geographical isolation, distinctive culture, primitive traits, shyness of contact with others and economic and social backwardness, are in general, considered relevant in the definition of tribes in India

Kerala, the small southern state of India, is homeland for about 35 tribal communities. These thirty-five different tribes are at different levels of socio-economic strata. As per 2011 census, the total tribal population of Kerala is 4.84 lakhs. It is about 1.45 per cent of the total population of Kerala. The footprints of tribals are found in each and all the

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of fourteen districts of the state, about 36% of the states tribal population is found in the district of Wayanad (1,14,969) of Northern Kerala followed by Idukki (50,269) district.

As the Scheduled Tribes are the first settlers of this country their physical feature, technology, art, religious lore and concepts seem to point to real historical relationship between the tribes of Kerala and Negritos of Malaysia. They are known in different names as 'Adivasies', 'Kattujathi' or 'Kattukurman', 'Vanavasi', 'Girijans', 'Forest dwellers' etc.( L. A. Krishna Iyer 1961). The tribal communities living in different regions in the state may be classified into seven major territorial groups taking into account their historical, ethnic and socio-cultural relations. (P.R.G.Mathur, 1977). They are Kazaragod, Wayanad, Attappady, , Parambikulam, Idukki and Thiruvananthapuram (Mathur 1977)

Tribal health studies in India

There have been a number of studies on the tribes, their culture and the impact of acculturation on the tribal society. But studies relating to tribal health, concept of disease and health beliefs and practices are rather scanty and specific study on this topic with reference to the tribals, covering the different facets is practically non-existent. These studies reveal that tribal health, health behaviour, and health maintenance system is attached with a lot of complexity intertwined with socio cultural beliefs and practices (Chaudhuri 1986).

Tribal health, health behaviour, and health maintenance system is attached with a lot of complexity intertwined with socio cultural beliefs and practices. In tribal societies, the supernatural theory of illness provides an important basis for explanation of beliefs related to state of health and illness. As a result, almost all the tribal communities largely practice magico-religious therapy and ritualistic healing practices. Different cultural groups vary in their perceptions regarding causes of disease. The notion regarding disease causation has been reported by a number of scholars. The causes of ill health as perceived by the tribal communities can be divided into two categories, namely, known and supernatural Choudhury 1994); (Singh 1994; Barth 1956). The Page 8 of 77

tribal people are now exposed to medical pluralism. Prevalence of traditional health care practices and nature and extent of acceptance of modern health care practices among the tribal people in India has been mentioned by various scholars in recent years (Guite and Acharya 2006; Pramukh and Palkumar 2006; Jain and Agrawal 2005; Bhasin 2005). People invariably believe in spirits and other supernatural beings as causes of disease and priority of treatment inclined mostly towards traditional healers. (Devi 2003; Bhasin 2005; Jagga et al. 1996). Every society views health from the perspective of its own culture and responds to them according to the understanding, knowledge, values, attitudes, and beliefs of the people comprising it (Mehta 1992)

Health beliefs and practices in any country are the sum total of people’s reactions, through personal and practical experience, to the health services operating in a community and the way these experiences fit in their frame of reference. This in turn is dependent on the prevailing cultural factors in that community. Any assessment regarding the effectiveness of measures taken to provide health service in a community will have to take this aspect into consideration. Tribal societies like other human social groups have their own health care system using almost entirely the local products in their primitive form mainly plants in their varied forms. This ethnomedicine has survived for centuries until western medicine began to make inroads on to them. Ethnomedicine based on ethno sociology or ethno science is more relevant as it is based on the everyday crisis that the individual faces and which tend to provide response to their health hazards or illnesses on the basis of shared experiences and knowledge made available to them by some competent members of the collectivity (Mehta 1992).

The traditional healers are the carriers of local health tradition and they provide various services to the members of the community. They handle simple ailments like cold as well as urgent situations like snake bite, bone fractures, etc. There are two kinds of healers among the tribal societies i.e.,generalists and specialists. The generalist treats a wide array of illnesses whereas the specialist treats only one or two. In the studied tribal community also there are efficient traditional healers who know and treat various ailments. After getting some education, and experience the advantage of modern medicine the tribals have started using modern medicine for the treatment of new diseases. Thus more than one type of medical system came into practice in the tribal Page 9 of 77

universe. Many of them first rejected this new system of medicine. But with the passage of time they have slowly started accepting it for the treatment of certain diseases.

India’s poor tribal people have far worse health indicators than the general population. Most tribal people live in remote rural hamlets in hilly, forested or desert areas where illiteracy, trying physical environments, malnutrition, inadequate access to potable water, and lack of personal hygiene and sanitation make them more vulnerable to disease.

This is compounded by the lack of awareness among these populations about the measures needed to protect their health, their distance from medical facilities, the lack of all-weather roads and affordable transportation, insensitive and discriminatory behavior by staff at medical facilities, financial constraints and so on. Government programs to raise their health awareness and improve their accessibility to primary health care have not had the desired impact. tribal people suffer illnesses of greater severity and duration, with women and children being the most vulnerable

Young tribal girls enter the reproductive age as victims of undernourishment and anemia, and face greater health risks as a result of early marriage, frequent pregnancies, unsafe deliveries, and sexually transmitted diseases. Women’s low social status makes them more likely to seek treatment only when the ailment is well advanced. Societal attitudes towards pregnancy, which is generally not considered a condition that requires medical treatment, nourishment or care, hinder efforts to deliver antenatal services.

There are several challenges on health of the tribal population. Lack of awareness of health issues : without awareness of health issues, most tribal populations tend to fall ill more frequently and wait too long before seeking medical help, or are referred too late by untrained village practitioners. Lack of health facilities in remote rural areas : coverage health facilities of remote tribal areas was found to be poor, a large number of positions lay vacant, the availability of drugs was inadequate, and vehicles frequently broke down because of poor maintenance. Lack of emergency transportation : pregnant women or sick persons from remote tribal hamlets are unable to make it to health facilities in time for institutional deliveries or emergency medical care for want of easily Page 10 of 77

available and affordable transportation. Discriminatory behavior by health care providers : there are deep-rooted cultural chasms between tribal groups and the largely nontribal health care providers, resulting in insensitive, dismissive and discriminatory behavior on the part of health care personnel. Financial constraints : As most rural tribal populations live below the poverty line, the lack of funds influences how much and what type of health care they receive, and determines whether households are able to maintain their living standards when one of their members falls ill. Poor tribal people often have to borrow money, mortgage land or animals, or pawn jewelry to meet medical expenses, or else let the sick person die. They also cannot sustain the opportunity cost of a doctor’s visit, much less of a protracted hospital stay, often dropping out half-way through a course of treatment as it means leaving their crops, animals, and family unattended. (Improving Health Services for Tribal Populations, http://www.worldbank.org/en/news/feature/2012/02/28/improvinghealthservicesfortriba lpopulations)

It is an accepted fact that the most of the rural areas in India suffer from perilous atmosphere and abysmal living conditions. Unsafe and unhygienic birth practices, unclean water, poor nutrition, subhuman habitats, and degraded and unsanitary environments are characteristics of the rural areas, making the rural habitats the first victim of epidemics. They have no money left to spend on health and are fighting a constant battle for survival and health. Keeping this in view, the GoI launched , “The National Rural Health Mission (NRHM), 2005-12”, to provide effective healthcare to the rural population throughout the country with special focus on 18 states. An important component under NRHM is strengthening of rural health infrastructure including physical infrastructure and buildings, manpower and other facilities. As the tribals constitute a considerable portion of the population of India, to know the status and progress of the Health Infrastructure in the tribal areas, since the 1st issue of the RHS in 2007, the MoHFW dedicates a completes section on the statistics of Rural Health Infrastructure in Tribal Areas.

In spite of the efforts of the government, these Tribal areas continue to suffer from poor maternal and child health services and ineffective coverage under national health and nutrition programmes. Research and data available through surveys have found that Page 11 of 77

infrastructure like Sub-Centres, Community Health Centres (CHCs), Public Health Centres (PHCs) and others are less than required in the tribal areas. Though the population norms for Health resources are lower for setting up of Sub- Centres and PHCs in the tribal areas, still the availability of health workers is insufficient to cater to the needs of the tribals. The availability of Sub Centres, PHCs & CHCs in tribal areas across all states, as on March, 2012, reveal that in the tribal areas of the country, there is a shortage of total 5638 Sub-centres, 1086 PHCs and 268 CHCs. It was also reported that surplus number of PHCs and CHCs are existing in state of Kerala. Availability of doctors at PHCs in the tribal areas is of great significance. Surplus doctors than the required number are found to be in position in the state of Kerala (Statistical Profile Of Scheduled Tribes In India 201343-52)

In Kerala, there are hamlets which are very interior and less connectivity to road and transport system. This study is intended to assess the functioning living condition of the tribal population residing in very interior and remote area of forest. It also envisage into the general treatment seeking behavior, antenatal , delivery and postnatal care services received by these tribal population.

Objectives

1. To assess the background characteristics of the tribal population in selected tribal settlement colonies of south Kerala. 2. To assess the general treatment seeking behavior of tribal population selected for study 3. To assess the practice of antenatal care , delivery care and immunization of children of tribal population selected for study 4. To find the unmet need on general and maternal care practices of the tribal population selected for the study

Data and Methodology

It was also reported that surplus number of PHCs and CHCs are existing in state of Kerala. Surplus doctors than the required number are found to be in position in the state of Kerala (Statistical Profile Of Scheduled Tribes In India 2013,43-52). Even though Page 12 of 77

there are sufficient infrastructure facilities and doctors are available in Kerala as compared to other state for the service providing mechanism of rural health, there are pockets where the health care system is very poor. As per the figures of Forest department, there are 725 tribal settlements inside the forest of Kerala. Among these 725 tribal hamlets, there are altogether 20714 families are living. When considering the southern districts of Kerala, there are 129 hamlets in Thiruvananthapuram district, 23 hamlets in district, 25 hamlets in , 14 hamlets in district and 149 hamlets in . The 129 hamlets of Thiruvananthapuram district are located in the 3 forest ranges of Thiruvananthapuram division and 3 ranges of Thiruvananthapuram Wildlife Division of ABP Circle. The 23 hamlets of Kollam spread over 3 Ranges of Thenmala division and 2 ranges of division. The 25 Hamlets of Pathanamthitta district spread over 2 ranges of Konni division and 3 ranges of Ranni division. The 149 hamlets of Idukki spread over 3 ranges of Mankulam division, 5 ranges of Munnar division and 4 ranges of PTR circle. Among the 725 hamlets, 340 hamlets (47 %) were in these 5 Southern district and among the total tribal families residing in forest area, 72 % lives in the forests of southern districts. Majority of these families does not hold any land with deed certificate. Most of these families have agricultural land without deed certificates. There is road connectivity to most of the hamlets of the forest and public transport vehicle available in a major share of the hamlets. There are hamlets which are very interior of forests and no road connectivity to those hamlets.

This study is limited to southern districts of Kerala. Based on the proportion of the hamlets in reserve forest three districts were selected for the study. The selected districts are Thiruvananthapuram, Pathanamthitta and Idukki. Since the aim of the study is to assess the health seeking behavior of tribals living in very remote hamlets, the hamlets were selected with the consultation with officials of forest departments of the concerned divisions. The hamlets selected from Thiruvananthapuram districts after the discussions with range officers are Pattampara, Anakal and Podiyam of Peppara forest range division. Sayippin Kuzhi Tribal colony of Doodrical range of was selected from Pathanamthitta district. The Edamalakkudy Panchayat, the first tribal panchayat consist of 28 hamlets of Munnar forest division was selected from Idukki district. Page 13 of 77

The background characteristics of the hamlets, the facilities such as school, Anganwadis, transportation available in the hamlets, details such as housing structure, water facilities, toilets facilities, availability of electricity etc were collected through structured interview schedule. These details were collected from “Thalivar /mooppan “of the hamlets / person capable of giving information, panchayat member and health staff such as JPHN etc. The general treatment seeking behavior of the hamlets was also collected using structured interview schedules. The data were collected from selected households of the hamlets. The information was also collected from panchayat members and JPHNs. The treatment seeking behavior regarding antenatal care service, delivery care service and immunization of children were collected from pregnant women and women delivered within 2 years of the data of survey using a structured interview schedule. The information such as whether ante natal care service from health facility received, number of antenatal care services received, reasons for not received any antenatal care service, previous obstetric history, distance to the health facility from which received ANC care, amount spent for ANC service, whether JPHN / ASHA visited during ANC period etc were collected. The delivery care details awareness about the importance of institutional delivery, place of delivery, reason for home delivery, expenses during delivery, whether received JSSK / JSY entitlement, problems faced during delivery period etc were collected using interview schedule. The details of immunization received for their children, the awareness of mothers on the importance of immunization, problems experienced for not providing immunization in correct schedule, expense incurred for providing immunization were collected with a structured interview schedule.

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Chapter II Tribals of Edamalakudy

There are 149 tribal hamlets residing inside the forest ranges of Idukki district. These 149 hamlets spread over in 3 ranges of Mankulam division, 5 ranges of Munnar division, 3 ranges of division of high range forest Circle and 4 ranges of PTR forest circle. About 20 percent of the forest hamlets of Kerala is situated within the forest area of Idukki district. When considering the families residing in the forest, nearly 40 percent of families (8179 families) among the 20714 families of Kerala residing in the forest area of Idukki. Most of these hamlets, there is no proper road connectivity and access to public transport system. As per the Census 2011, about 5 percent of the population are tribal. The health service delivery in the public sector in Idukki district is rendered through 2 district hospital, 4 Taluk Hospitals, 13 CHCs, 11 24X7 PHCs, 28 PHCs, 2 UPHCs and 309 SCs. Among the tribal hamlets of Idukki district, the hamlets of Edamalakkudy is most remote in terms of road accessibility, communication, Electricity etc. The hamlets of Edamalakkudi is selected from Idukki district for the present study.

2.1 Background Characteristics of Edamalakudy

Edamalakudy is the only tribal panchayat of Kerala which is located inside the forest and away from the facilities of transportation, communication and electricity. Edamalakudy belongs to Idukki district and is located near Munnar. Edamalakudy, as the name indicates, is situated amidst the mountains, and is surrounded by reserved forest. This panchayat is located in the reserve forest area just close to the Eravikulam National park, a wild life sanctuary. Edamalakudy has around 28 hamlets with houses in the range 8 to 30 in each hamlets. One has to walk 19 kilometers through a narrow trail in the forest to reach the first Kudy. Pettimudy, is the last point accessible by vehicle and is 19 kilometers away from Edamalakkudi. The only tribal population located here is the Muthuvans. Muthuvans are located in other parts of Idukki district too.

Muthuvans : Muthuvans are one of the 36 notified tribes of Kerala. At present, the Muthuvans are scattered across forest area of Idukki District, especially in the

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Marayoor, Suryanelli, Mattupetty, Mankulam, Kuttampuzha, Pooyamkutty and Edamalakudy area of the district. The most secluded Muthuvan settlement is the Edamalakudy; their customs and practices have not yet merged with other tribal or general populations due to their geographic isolation

There are oral histories related to Muthuvans passage to Kerala from one such story. “The Muthuvans who were scared of Pandian warriors fled from their earlier habitat in Tamil Nadu and reached Munnar area with all their belongings and settled in different parts of Idukki district”. Another version goes like this ‘the wrath of Goddess Meenakshi fell upon Madurai and the city was burning. During the time of disorder in Madhurai, the Muthuvans carried the statue of Goddess Meenakshi on their muthuk (shoulder) and reached the Suryanelli area of Idukki and therefore the name Muthuvans. The Muthuvans belonged to Suryavamsham36 and therefore, the place came to be known as Suryanelli”. Another version of the story about the name of their tribe, “There lived Kovalan and his wife Kannaki in Madhurai which was then capital city of the Pandyan king. Once, Kovalan was trapped by a goldsmith in the name of stealing the queen's anklets. The anklet Kovalan possessed was that of his wife Kannaki. Kovalan was punished by the king. Kannaki goes to the kings court, proves the injustice by breaking the remaining anklet she had with her. The anklets of the queen was filled with pearls and while Kannagi's anklets were filled with ruby. The guilt of his hasty decision kills the king. After the death of the king ancestors of Muthuvans left Madhurai with Kannaki. On the way Kannaki could not walk and therefore, they carried her on the muthuku (back/shoulder). And it is therefore, they are known by the name Muthuvan”. These stories therefore, point out the fact that the Muthuvans belonged to the Pandyan dynasty.

The Muthuvans started living in this Edamalakkudy of the Anamudy reserve forest area since 1946. They came from the Chenkulam Kundala the dam reservoir area. The Muthuvans were displaced from the reservoir area during the time of the dam construction. Once, Pattom Thanu Pillai, the then Chief Minister of Kerala, was on his way to Munnar, the Muthuvans present the displacement issue before him. The chief minister agreed to solve the issue and promised to shift the Muthuvans to Edamalakudy area. Initially, seven families migrated to Edamalakudy. There after Muthuvans from , Kanthallur and Kottakkambur area also joined them. Based on the availability Page 16 of 77

of water and other environmental factors, they settled in various parts of the 90 square kilometre area of the reserve forest. Presently there are about 700 families living in 28 kudis. These colonies are connected with narrow pathways of the forest. All four sides of Edamalakkudy are surrounded by hills.

Anamala reserve of Tanil Nadu in the North, Iravikulam National Park in South and Anakkulam range in east, and East, Iravikulam National Park in South, Kodanad and Anakkulam forest range in the west are the boundaries of this panchayat. Wild life animals such as Elephants, bison, Tiger, Leopard, wild boar, venomous snakes etc were seen in this area. The edamalayar and and pooyamkutty river are originating from the forest area of Edamalakkudy

The Geographic map of Edamalakkudy panchayat.

The main livelihood of the people in Edamalakkudy is forest resources and farming. The cardamom, kasthoori turmeric, rice and ragi are mainly cultivated. Especially in this area, cardamom is being grown and maintained on biomedical products, where the market is much cheaper than cardamom in other regions. The traders exploited the farmers during the past several years without earning the right price and make a big profit. The money given by the traders in advance has put the people in debt, causing them to create more dominance of the natives. In addition to agricultural crops, forest produce honey, pearl, pattipoon, wild boar, pepper and paddy are collected in forests. But last year forest department banned traders to enter into Page 17 of 77

Edamalakkudy for trading purposes, so people of Kudis now a days going to Mankulam or Munnar with the agricultural product, hence good price is getting to farmers for their products

Electricity is available in 3 hamlets Idaliparakudi, Society Kudi and shed kudi. There are solar light system is available in all other kudies with the funding of panchayat / forest department. During the last two years, almost all house provided toilets from government schemes. All the families provided ration card, almost all members possess Aadhar card. Ration shop or a sub shop is available in Idalipara kudi, Society Kudi and parappayar kudi. Rice and provisional items are available in these ration shops. Vegetables, fish, meat etc are not available in Edamalakkudi. Under “Jalanidhi”, a world bank assisted Kerala rural water supply and sanitation invested lakhs of amount in Edamalakkudi for providing water in all hamlets. The Mooppan of Ambalappadi kudi and Kavakkattukudi told that not even a single kudi benefited for getting water from the Jalanidhi project so far. Each hamlets found their own water sources (springs) and taking water from there using hoses.

Most of the Muthuvans in Edamalakudy possess their own land. The state government has given them the land for agricultural purposes but without a deed certificate. Some of the families have thirty acres of land and at the same time some others just one acre of land. .The main agricultural crops grown by the them include finger millet, paddy, tapioca and cardamom, pepper. Those who have cardamom cultivation have the shed for the storage purpose as well as for drying the raw cardamom, they take firewood from forest for drying cardamom. Along with agriculture, they collect the wild tubers and honey from the forest. They rear goats and chicken. But, they use neither the milk nor the egg. Muthuvans eat the meat of goat and chicken. Their food timings vary depending on their work. They usually go to work by 10 am in the morning and are in the field up to 3 pm in the afternoon. They avail the rice with the same rate as it is outside the Edamalakudy. For the scheduled tribe provides 22 kg rice in a month for Rs 1 per kg. This has brought changes in their food habit. The place of their staple food ragi is now taken over by rice. They prepare one curry sambar or adaka, a curry prepared out of a green vegetable or its varieties along with rice. They never cook more than one side dish. They rarely use vegetables and mainly use pulses

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like yellow gram and red gram. Women on their way back home from the field collect green leaves, wild vegetables, mushroom and tubers for supper. But, the availability depends on season. Some months they hardly get anything. Especially during the monsoon season with heavy rain and wind they cannot go out to collect anything. Traditionally, the staple food of the Muthuvans was finger millet; which at present is taken over by rice.

Panchayat Office : The decision of the government to form the Edamalakudy grama panchayat is issued under the order 20.05.2010. The decision was taken by the government to form the Edamalakkudy grama panchayat divided by the ward 1 of the Munnar Grama Panchayat. Accordingly, it was divided into 13 wards in Edamalakudy area. The formal opening of the Edamalakkudy Grama Panchayat begins from 01.11.2010.Till date, the panchayat office in Edamalakudy has been working in Devikulam. But a temporary office has been set up in Edamalakudy. There is no staff appointed to this temporary office and one / two staff visits the panchayat office when there is any special function.. The percentage of fund utilization of Panchayat is very less. The functioning of the panchayat office at Devikulam is the main reason for non development of Edamalakkudi. For any development issue or any other representation from the people of Edamalakkudi, have to travel hours to reach Devikulam and submit the issue. There is one akshaya centre near to Panchayat hall, but not functioning. The improper functioning all offices allotted to Edamalakkudi such as Homeo dispensary, Ayurveda dispensary etc is only because of the absence of Panchayat office in Edamalakkudi. For the entire development of the Edamalakkudi, the functioning of Panchayat office in Edamalakkudi is essential.

Schools and Anganwadis : There are 3 Multi-grade Learning Centres (MGLC), single teacher schools in Edamalakkudi. These schools were set up to ensure universal primary education to the children in hamlets. The three MGLC schools are functioning in Idalipara kudi, Meenkuthi kudi and Parappayar kudi. Among these, the functioning of the MGLC school at Idalipara is extremely good. The teacher of the school is from outside of Edamalakkudi, but she has been residing in a small house near to the school. Her work as a teacher is marked as excellent, all the students of kudi are utilizing the sincere effort of the teacher. About 10-15 students are studying in each of these MGLC schools. There are altogether 10 functioning Anganwadis in Edamalakkudi. Anganwadis are available in Vellavara kudi, Parappayar kudi, Idalipara kudi, Andavan

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kudi, Society kudi, Kandathi kudi, Meenkuthi kudi, Irippukallu kudi and Mulakuthara kudi. There are some more Anganwadis but not functioning at the time of our visit.

The entire Edamalakudy has one lower primary school (1-4th class). The school of Edamalakkudi is functioning in Society kudi. The LP school under SSI is functioning in good manner. Two male teachers from are the backbone of the functioning of the school. The first PSC appointment of these male teachers to this school, they are residing in school. Since the functioning of school is extremely good, parents are very interesting to send their children to school regularly. Students of 5-6 neighbouring kudies of school are studying there. The mooppan of Kavukkattu kudi told that 8 children from their kudi is studying Society kudi LP School. In the morning, one or two elder members of Kudi took these children to school and evening elder members pick back children from school. Free food to students thrice a day available in school. Free food is available at morning, at noon and at 4pm. There is one cook appointed from Panchayat for cooking food for students. There are two TTC holders from Andavan kudi and these two are working as teachers in this school on contract basis. The school is going to upgrade as an upper primary school (up to 7th class). A meeting was carried out on 14/2/2019 regarding the up gradation of the school. The people of all kudis are ready to provide all support for the smooth functioning of school, the mooppan of Ambalappadi Kudi was agreed to donate sufficient land near to the school for the up gradation. The world out side Edamalakkudi is not aware of the students of the school, the only vehicle known to them is Jeep. Last year, the staff council decided to bring out these students to outside world of Edamalakkudy, they took students and parents to Munnar and and made the experience of travelling in and saw train in Aluva railway station.

The children has to go out of Edamalakudy for education after primary level of schooling and have to stay in the hostels run by the Government or by the missionaries.

Valappura : There is one Valappura in every hamlets. The women have to stay in Valappura during the menstruation period and usually delivery carried out in Valappura. Women have to stay in Valappura for a period of one month after delivery. This is the traditional custom in all the hamlets. It was observed during the visit to Hamlets that the physical condition of Valappura was of very poor condition. The Valappura is the worst building compared to other buildings of the hamlets. it was Page 20 of 77

observed and understood that there is no proper kitchen in Valappura as compared to the usual kitchen in their homes, they prepare food in choola prepared of three stones in Valappura. There are no toilets attached to it, no electricity, no TV and no other entertainments within Valappura. Men are not allowed to enter in Valappura in any circumstances . When we were in Andavankudy, one snake entered into Valappura, 2-3 women were there during that time and they managed the situation and in such situation also men are not allowed to enter in it. From the interviews, it was marked that women are usually not interested to stay in Valappura as far as possible. When interviewed the couple Chinnappan – Meenavathy of Andavankudi, it was understood that they have no child even after 3 years of marriage. Chinnappan said that women get Mala D and other Oral pills and using it without prescription of doctors or medical staff. When any of the woman went to Munnar for any purpose, purchase sufficient Oral pills for those women who are need and /or asked for it. Hence there is sufficient stock of Oral pills with most of the women in this Kudi. The situation is mot different in other hamlets. Chinnappan said that his wife not staying in Valappura because of absence of menstruation, he said that she might have using pills but not with his permission. From the discussion, it was understood that there are 3 women in this kudi without any child even after 3 or more years after marriage. The very poor condition of Valappura is the main reason for stay away from Valappura by avoid the menstruation by unscientific use of contraceptive pills.

Medical facility : There are three health facilities in the Edamalakkudy panchayat. There is one Ayurveda dispensary in Andavankudi. The Ayurveda dispensary was an initiative by the NHM. All the staff are posted from the NHM and all of them are contract staff. The staff position in the Ayurveda dispensary are one Doctor, one Pharmacist and one attender. The thalaivar of the Anadavan kudi said that the doctor come here once in two weeks and stay within the dispensary for one night . The pharamacist also visit the facility and work there for 2 days in 2 weeks. The doctor is from district and pharmacist from Thiruvananthapuram district. The attender was terminated. Now one lady from the Kudi posted in the dispensary, she serve in the duties of attender, pharmacist etc. She passed 10th class and giving medicine to the people whenever doctor and pharmacist were not available in the dispensary. There is no accommodation facility for doctor or pharmacist attached with the dispensary. When doctor is available, people of nearby kudis utilize the dispensary. Since the functioning of the dispensary is not regular, people of far away kudis not benefited from the dispensary and So, in effect, the functioning of the Ayurveda dispensary is not in desired level.

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There is one Homeo dispensary in Society kudy. The staff was appointed from NHM. There is one lady doctor and one attender. The attender is appointed from the kudi. Since the travel to Society kudi is a tedious one, the doctor reside in the dispensary for 5-10 days in a month. Medicine is available, but the absence of doctor is the major issue. Most of the days doctor is not available . Since the availability of doctor in dispensary is not with pre published days, hence the functioning of the homeo dispensary is not at all benefited to the public.

Ambulance : Travel from Edamalakudy to the nearest hospital in emergencies is the most difficult problem experienced by the people of Edamalakudy. Usually people have to walk from their kudy to pettimudy, a distance ofg18 km by walk, it will take 3-4 hours to reach Pettimudi. From pettimudi have to pick Jeep to reach Munnar. When emergency situation, patients transport by means of temporary stretcher made up of clothes and wood log. A group of 20-50 men of these kudies transport the patients in the temporary stretcher. Usually Pregnant women and sick patients transport by this temporary stretcher. Due to the undue delay in reaching the hospital, several patients died in the past. Since there is no proper road from Pettimudi, only 4 wheel drive jeep can move till Society Kudi. The travel of four wheel drive Jeep to Society kudi is possible only in non-rainy season. In August 2017, “Asrya Charitable Trust - Munnar” sponsored a 4 wheel drive Ambulance to Edamalakkudi. The complete expense such as fuel expense, the salary for driver etc are met by the trust. One driver from Idalipara was appointed as the driver of the Ambulance and the ambulance is parked in Idalippara. People of the kudis reported that the Ambulance was useful for 2-3 months, there after it was not at all for the public when it is needed. The driver appointed for the Ambulances has another job and not available when the ambulance is in need of public. People reported that the Ambulance has to be parked in Society and a driver from Society Kudi is required. The Staff nurses of the sub centre reported that they have no control over the functioning of the ambulance and it is not at all in use for several months. The staff nurse reported that the functioning of the Ambulance is very much necessary for the transportation of emergency cases and the ambulance has to be parked in Society Kudi. Earlier, there was a proposal from NHM to implement a four wheel drive Ambulance suited for Edamalakudy on monthly rent basis. Later on the ambulance service was implemented by the Asrayam Charitable Trust, hence, NHM dropped the proposal

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ASHA : For providing better health service to the beneficiaries and for better coordination between public and health department hamlets ASHAs were appointed in all hamlets. Since these ASHA workers of each hamlet is from that hamlet, the coordination of public health activities of health department is found more are became more easy. Due to several reasons, some of the ASHAs are not working and presently there are only 13 ASHAs are working. The ASHAs provide information regarding medical camp and immunisation session to mothers . All the ASHA workers received 5 day training at panchayat hall of Edamalakkudi. Earlier, mothers skipped to forest with their kid to escape from child immunisation when immunisation team visit kudis. Now women are aware of the importance of immunisation and most of the mothers took the children to immunisation camp. The intervention of ASHA workers have a significant role in enhancing the immunisation coverage in Edamalakkudi.

Primary palliative : Arogyakeralam formulated the Palliative care project in consonance with the Palliative Care Policy of Kerala policy. The initiative under the project aims to identify patients in need, offer guidance for appropriate treatment, provide care at home for the bed ridden, and incurably ill and equip the primary health care system to provide care including medicines. During 2011-12 when the palliative care policy was formulated, setting up of palliative care units in every panchayat was made mandatory. Edamalakkudy Panchayat also implemented the primary palliative care in this panchayat area. Panchayat selected one community nurse and send to for palliative care training. The trained palliative Nurse appointed in Edamalakkudy in August 2017. The palliative nurse is from Munnar. Discussion was made with palliative nurse to assess the palliative care activities in Edamalakkudi. The nurse told that there are only 4 bedridden patients in the entire area. There is one paraplegia patient in Andavan kudi and one bedridden patient in Nenmanikkudi and the other two are old age patients. There are some other old aged patients patients with hypertension and Asthma, she visit them investigate BP and providing medicines. From the discussion, it was understood that all the patients (about 10) including the 4 bedridden patients are from hamlets near to the society kudi. She admitted that not visited the far away hamlets such as Nooradi kudi, Vellavarakudi, Parappayarkudi for the survey of identification of palliative patients. She said that , she contacted the anganwadi workers of the said area and got information that there are no such patients in the area. It is very difficult to

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reach those area without the help of people of those kudis. The palliative nurse told that she work in there for 15 days per month. She told that she came with necessary provision and vegetables and reach Society kudy in Jeep. There are no volunteers for the palliative team, since the path to Edamalakkudi and forest way in between kudies is not suitable for vehicle, palliative nurse has to walk to reach the kudies. The medicine are supplied to patients mainly for BP and these medicine are distributed from the sub centre of Edamalakkudy. The salary for the palliative nurse is Rs. 15000/- pm. Since there is no Ambulance for the palliative, the jeep charge from Munnar to Society kudi and back is reimbursed by the panchayat (Rs. 6000/-) the bill for the provision and vegetables purchase for the stay in Society kudi is also reimbursed by the panchayat (about Rs. 1500/-) per month. It was observed that the palliative nurse spent most of the time in sub centre and disbursing medicine from there to patients. There is one ANM for the Edamalakkudy but the post is vacant and one JPHN of Munnar is in charge of Edamalakkudy and the functioning of ANM is not good, Anganwadi is not functioning in all the hamlets. It is very difficult reach far away hamlets of Society kudi. Because of all these restrictions, the primary survey of identification of palliative patients is not completed even after 1.5 years of functioning of the palliative programme. Hence the functioning of primary palliative is not up to the mark in this Panchayat.

Sub Centre : The health service care of Edamalakkudy is come under Devikulam CHC. There is only one Sub centre in this geographically vast area. Usually one JPHN is in charge of public health activities of the entire population of the sub centre area. The appointed JPHNs were from outside area and travelling to this sub centre is tedious one, hence no effective functioning of the sub centre till 2013. In order to strengthen the functioning of the sub centre, NHM appointed 4 male staff nurses for the sub centre. Since the appointed staff were from outside Edamalakudi and daily travelling to this area is not at all practical, a special order released from government of Kerala. As per the order, number of days per month was fixed as 15 days and the functioning of centre was fixed as 24X7 manner. Since the stay of one staff alone in the centre have so many practical difficulties, hence 2 staff nurses appointed in each duty. After the appointment of these male nurses, the sub centre functioning 24X7 manner. These nurses are providing services such as health check up, BP monitoring and providing medicines to the ill people.

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In 2013, While attending a delivery, the birth attendant called the Nurses for help because of difficulty experience for normal delivery. Males are not allowed to enter Valappura in any situations, since the situation was not under control of birth attendant, she asked the male nurses to enter the Valappura and attend the case. With the help of professional skill of the staff Nurses, the delivery conducted in good manner. After this incidence, all the hamlets permitted these staff nurses to enter Valappura to conduct delivery. The two male nurses of the sub centre is the only approved males to enter Valappura

There is no hospital and doctors in this Panchayat. The two male nurses Mr. Najeeb and Mr. Suresh kumar providing all possible medical assistance, delivery care services and helping to transfer sick patients to nearby hospitals with necessary medical aid. After 2013, the medical support provided by these nurses saved several life, conducted several deliveries at Valappura and transferred several women with complicated delivery to hospitals at Adimali, Munnar and Valppara. Some of the instances

Suresh kumar, Staff Nurse of Sub centre provide support in shifting a pregnant women to hospital

In November 2017, three old women including one traditional birth attendant attended for the delivery of a 21 year old women in Valappura of Iruppukallukudi. When their effort was not attained success, informed the male nurses of sub centre by night. Since it was very difficult to travel to Irippukallukudi from societykudi through forest in night because of wild animal , they started to walk early morning of next day. After 3 hours Page 25 of 77

walking in forest, the male nurses Mr. Najeeb and Mr. Suresh reached Valappura of Irippukallukudi. After the investigations, they found that the condition of the lady is not good for normal delivery and suggested to transfer the lady to hospital. With the help of some of the youth, took the women in temporary stretcher made up of clothes and wood logs and walked through the forest for about 4 hours, crossed the mulakuthara river in a raft and reached GH Valpara hospital by 3pm. During the travel, the nurses monitored the health condition of lady and gave IV fluid. The Gynaecologist examined and the lady delivered by evening, the condition of the neonate was not in good condition and referred to Medical College Palani, these nurses accompanied the mother and neonate to reach MC Palani. The people of the Edamalakkudy told that only because of sincere effort and pain took by these nurses helped to survive the 21 year old lady and her child.

With the medical assistance of staff nurses, crossing Mulakuthara river with a pregnant women using a raft

Another incidence in 2017, a man was attacked by a bison by about 10am. Serious injury happened, a wound of 15 cm width and 13 cm depth, ribs were broken and injury happened to lungs also. After theattach, he informed about the attack to his family through phone. The family members and the male nurses reached there after 1 hour walk through the forest. The nurses tightly wrapped the wounds with pads / cloths. With the help of male Members of kudies, took the patients to sub centre using temporary stretcher made up of clothes and wood logs. Other primary care services provided at sub centre, monitored BP and started IV fluid. With the help of temporary stretcher moved the patient to Idalipara and then transferred to the Ambulance. Since the wheels were

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skidding at the slippery surface at that rainy period, it was very difficult to move the ambulance. Then, about 50 males of the kudies pulled the ambulance with thick rope and reached GH Munnar by 10pm. During these 10 hours the male nurses monitored the BP, gave IV fluids and provided other medical aids with the discussion of medical officers. Since the condition of the patient was poor, transferred to Medical college Kottayam. The patients survived after a serious of surgeries. The kudi members explained this incidence with great gratitude towards the male nurses

Presently Mr. Najeeb and Mr. Suresh kumar are the senior staff nurses appointed by NHM. The other two nurses are passed out students of nursing college Muttom and appointed for one year from NHM. The 24x7 manner functioning of the sub centre is the only dependable medical care for the people of Edamalakkudi and even to provide assistance for delivery at Valappura. There are problems several problems to these staff while working in this centre and these problems raised by these staff were not addressed properly. The low salary is the main problem, the present consolidated salary per month is Rs. 19500/-. This is the salary pattern is admissible to all contractual staff nurses under NHM. These staff nurse have to bring all necessary drugs from Devikulam CHC when they reach to sub centre. Since there is no vegetable stores/ provision store in Edamalakkudi, they have to bring vegetables, provision etc along with the medicines required for sub centre. Since the jeep charge of Rs 3000/- from Munnar to Edamalakkudi is not affordable to them, they reach by share jeep service till pettimudy and walk for 18km to reach Society kudi with the luggage. For the palliative nurse of Edamalakkudi, the jeep charge from Munnar to Society kudi and back is reimbursed by the panchayat (Rs. 6000/-) and the bill for the provision and vegetables purchase for the stay in Societykudi is also reimbursed by the panchayat (about Rs. 1500/-) per month.

PHC: The construction of the PHC is on final stage and expected to start the functioning of PHC in March 2019. Presently there is one Ayurveda dispensary and one homeo dispensary in Edamalakkudy and doctors are posted, but the doctors are available on very limited days per month. The sub centre functioning in 24x7 manner with the 4 contract staff nurses appointed from NHM. There is no doctors in sub centre and the staff nurses providing treatment for all diseases. Presently, MBBS doctors are available in kudi only on the day when the medical team visit, but the programme of

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medical team is not regular in manner. With the opening of the PHC, people are expecting the service of a qualified doctor.

Daily travelling to Edamalakkudy from Munnar is not at all possible. The sub centre functioning with a special order from Government, as per the order, number of working days per month was fixed as 15 days in 24X7 manner. Hence staff nurses residing in sub centre for 15 days and providing service in 24x 7 manner. The attack of wild elephant / bison especially in night, tedious travel to Kudi, difficulty in travel to other hamlets, lack of good accommodation facility, unavailability of hotel, unavailability of vegetables/ fruits/ meat etc for cooking are barriers for staff for residing in Edamalakkudi. The staff has to bring all provision items, vegetables, fruits, meat etc required for the days of stay at Edamalakkudy. An amount of Rs 3000/- is required to reach Edamalakkudy from Munnar in 4 wheel drive vehicle, hence an amount of Rs. 6000/- required only for the travel to Edamalakudy and back per month. The contractual appointment of the staff nurse is the only reason for their stay in centre for 15 days / month with all these limitations in stay.

The staff posted to PHC will be regular staff, hence couldn’t expect to stay in Edamalakkudy as the contractual staff residing there. Unless there is specific special rules to Edamalakkudy, the regular staff posted to Edamalakkudy will get transfer immediately after their joining or will enter into long leave. The following points should be considered for the special rules : 1. Working days per month should fix as 15 in 24x7 manner 2. Special Travelling allowance per month should be there, as the palliative care nurse receive actual travelling expense from panchayat fund. 3. Special priority to the transfer request after 2 years of service in Edamalakkudy.

The present PHC constructed in pathway of wild elephants. All the other official buildings such as sub centre, school, forest station, panchayat office, Akshaya office , ration shop etc situated close to each other and hence the fear attack of wild elephant / bison is comparatively less. Since the PHC is away from those official buildings and PHC is situated in path way of elephants, more security measures are required for the safety of staff residing in the accommodation facility of PHC. The future of sub centre and staff nurse is another question mark after the inauguration of PHC. If the function of Sub centre terminate and the regular staff posted in PHC quit after join either by

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leave or by transfer, the treatment providing system will vanish in this panchayat. Since the people of Edamalakudi is satisfied with the function of the sub centre, the decision regarding the future of sub centre after the functioning of PHC should be taken wisely

2.2 Treatment seeking behaviour

Interview was conducted with the staff nurses of Sub centre and Homeo doctor of the Homeo clinic to identify the major diseases of the area and the management of healthy problems. From the discussion with these persons, it was understood that Hypertension and anaemia are common health problem in the area other than the common fever during rainy season.

The treatment pattern and mode of treatment for general illness is one of the item for the interview schedule for the beneficiaries. The people of Kudies near to the society kudi such as Shed kudi, Andavan kudi, Nadukudi, Ambalathipara kudi, kandathil kudi, kavakkattukudi etc approach the sub cente for almost all type of general illness. Since the sub centre functioning in 24X7 manner, no problem in getting medicine when they reach the sub centre. Some of the family members adopt traditional herbal treatment for minor ailments and some other diseases, if not cured from the treatment depend sub centre.

Staff Nurse Najeeb monitoring BP of 100 year old woman at her residence

When the home remedial measures and treatment from the sub centre is not effective, patients have to shift to other hospital. Shifting of patient to other hospital is a tedious one. They build a temporary stretcher using clothes, sheets and wood logs. Usually 10-

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30 people took the patients in stretcher and walk till pettimudi. It will take about 3-5 hours to reach pettimudi. From Pettimudi, transport to GH Munnar using jeep. Since the four wheel jeep of Asryam charitable society is not available due to several reasons, the only possible way to shift the patient to hospital is using temporary stretcher. Patients from meenkuthi kudi and some other kudies near to it, transport to Anakkulam. Patients from Nooradikkudi , Mulakuthara kudi etc transport to Valppara using these stretchers in emergencies. Since more number of people required to shift patients using stretcher, emergency shifting of patients is usually difficult. Usually, they inform all kudies and males gather for shifting patients, hence time is required to gather people to transport patients. In Sub centre there are two stretchers supplied from NHM, these stretchers are light weight and much easier to transport patients rather than the temporary

Shifting a patient to Munnar using temporary stretcher

Antenatal Care Service : The pregnant women were not interested in antenatal checkups till 5 years back. With the effort from the health department through ASHA workers and the staff nurses of Sub centre, pregnant women attending the medical camps organized at Society Kudi and other kudies. Some of the pregnant women depend Munnar GH for antenatal care services. All medical treatment, antenatal care services and delivery care services were free to the entire population of Edamalakkudi

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till 2 years back. Now the service is limited to people of Idalipara and parappayar kudi. The medical officer provide antenatal care service when the medical team visit the Kudis. If Ultra sound scanning required, pregnant women has to walk 18 km to reach petti mudi, then to Munnar by Jeep service and then to Adimali by jeep or bus. Only because of this tedious journey, usually pregnant women were not interested to proceed with US Scan service. Earlier the pregnant women not interested to visit doctor for ANC check ups during the medical camps. Now hamlets ASHA is available in most of the kudis, with the inspiration of ASHAs and the trained birth attendant Remani, most of the women are going for ANC care check ups during medical camp. Medical camps are designed for once in a month, but from the interviews with beneficiaries revealed that camps are not conducted in regular manner. In some months Camps conducted only in Society Kudi, in that situation pregnant women from far away Kudis such as Nooradi kudi, Irippukallu, Mulakuthara etc were not benefited for ANC check ups. The Staff nurses of the sub centre were usually providing ANC care advice, checkups and IFA/Calcium tablets when the pregnant women were need of it.

Delivery : During the last 5 years, the institutional deliveries increased considerably. Still delivery in Valappura is commonThere is one trained birth attendant (Ramani) in Ambalappadi kudi. In 2008, she and other 4 birth attendant got one month training for conducting safe delivery from TH Adimali. Among these trained birth attendants, Ramani is conducting deliveries in all these kudies and other 4 are not conducting deliveries. According to Remani, she has been conducting deliveries in all the 28 kudies with the support of other birth attendants and helpers. More than 50 safe deliveries conducted so far. She told that if any abnormalities observed during the delivery process, usually call the staff nurses of the Sub centre for their help. If the complication continue, transport the women to pettimudi / Anakkulam using temporary stretcher made up of clothes and wood logs and then to TH Adimali using Jeep. Last year, 3 women were transported to TH by such method and one women delivered in jeep while transporting to Adimali GH. According to Remani, pregnant women of Kudies feel they are comfortable in delivering in Valappura than in hospital, because of the tedious journey to reach the TH. With the continuous effort from the health department, the staff nurses of Sub centre, women are aware of the importance of institutional deliveries. Remani, the trained birth attendant also forces them to deliver in hospital.

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Now a considerable share of the pregnant women with one or more relative move to Adimali during 7th month of pregnancy and reside in kudies of their relatives in and around Adimali and approach to TH Adimali when delivery pain starts. Some women having 2 or 3 children are not interested to move to Adimali for their current delivery at an earlier stage because of no responsible one to take care of other children. The cost incurred with delivery is another factor for avoiding hospital deliveries. There is one ST promoter in Adimali TH and option is there for providing the Jeep charge immediately with the submission of bill with trip sheet, but most of the time beneficiary has to bear the Jeep charge because of lack of fund or some other technical reasons. If any medicine is out of stock at TH, there is provision of purchase it from outside medical shop by ST promoter. Remani reported that, most of the cases the beneficiaries have to purchase medicine from outside with amount from their pocket. According to her, the only benefits received at TH is free food for pregnant and their bystanders. The same responses heard from the beneficiaries interviewed during our visit. There were certain bitter experiences faced by women during delivery at government hospitals and these bitter experiences spread to other kudis, these experiences were found another reason for prefer delivery at Valappura.

Shifting one pregnant woman to hospital using temporary stretcher

Experience of respondents:1) Mrs. X (27 yrs) w/o Neelan from Andavankudi reported that 4 of her 6 delivery were at home. Her first delivery was conducted in Valappura 9 years before date of interview, the second delivery was at TH Adimali in Page 32 of 77

2012, the jeep charge were not provided by the Tribal department, JSY benefits were not received for that delivery. Since the expense for hospital delivery was not affordable, third and fourth deliveries were done at Valappura. As per the advice of health staff , decided for hospital delivery for the fifth child. She went to a relative’s house at Adimaly well in advance of delivery date. When delivery pain started, she and her relative reached TH Adimaly by 1am, since there was no gynaecologist there at that time, they were advised to go to a nearby private hospital (Moonstar hospital). The travelling expense was not provided from the ST promoter. As per the advice, they moved to Moon star hospital, and delivered there immediately. The doctor told that the neonate is sick, so have to stay some more days. After 5 days, they informed that they were not able to t manage the sick neonate and advice to transfer to Medical college Kottayam. An amount of Rs 13,000/- was required for discharge. Her relatives collected the amount from kudi and remitted and discharged from the hospital. In another Ambulance moved to Medical college Kottayam, The disease of neonate cured and discharged from there after several days. The travelling expense to reach Medical college and the travelling expense to Kudi after discharge were not received from the ST promoter of Medical college / no arrangement from ST department or health department for their journey back to Kudi. All the treatment for the sick neonate were free during stay at Medical college and free food received on the days they spent there. She told that she was forced to sell her goats to settle the debts related with her delivery. Due to the bitter experiences, financial limitations and no one in kudi to look after her five kids, decided to deliver in Valappura for her sixth delivery. She delivered her 6th child in Valappura on 14th November 2018. One traditional birth attendant and ASHA worker took the delivery. She informed that all the immunisation of the children were carried out when the medical team reached the Society Kudi. She reported that no immunisation camps conducted in Society kudi after her last delivery till the date of interview (14-2-2019), hence no immunisation given to her last youngest child. 2).Another women (Mrs. Y) from Ambalappady Kudi reported that she delivered 2 years back in GH Munnar (Private Hospital under Corporation). She told that at that time delivery and all kind of treatment is completely free for entire people of Edamalakkudi panchayat. The GH Munnar have all essential facilities and specialist doctors in Gynaecology and paediatrics are available there. Presently, the free treatment at GH is limited to people of 2 Kudis only. This decision from the GH is a big Page 33 of 77

blow to the people of Edamalakkudi. GH Munnar is the nearest hospital to Edamalakkudi and the hospital have all facilities and specialty care services there. The nearest government hospital providing delivery care service is Adimaly, nearly 2 hours journey required to reach there after the reach of Munar.

Immunisation : Five years back, when medical team arrive at Kudi for immunisation, a great share of mothers skip to forest with their kids to avoid immunisation. With great effort from the health department, almost all women were aware of the importance of immunisation and ready to give immunisation when medical team arrive in Kudi. The great acceptance of the two staff nurses among people of Edamalakudi including the permission to enter into Valappura for conducting delivery helped a lot to change their attitude towards child immunisation. There is pre planned schedule to visit medical team from CHC Devikulam in every month. The team divide into three teams and visit all Kudi for medical assistance to patients, antenatal care and for child immunisation. The medical camps are usually organised on the availability of doctors in CHC Devikulam. Since there is shortage / vacancies of medical officers in CHC Devikulam, it was observed that the monthly medical / immunisation camp conducted in irregular manner. During our visit to Edamalakudy on (third week of February), it was observed that the last immunisation camp was conducted in Edamalakkudy on October 8th , 2018. It means that there was no immunisation programme in Society Kudi or any other Kudi for a period of more than 4 months, but 2-3 medical camp conducted during the period. During the interview on 14/2/2019, Mrs. X (27 yrs) w/o Neelan from Andavankudi reported that she delivered a girl child (her 6th delivery) on 14/11/2018. The BCG and other immunisation not given to the infant because of immunisation team visited Society kudi after her delivery. She also reported that all immunisation took for her other five children when immunisation team visit the kudi. Inorder to carry out immunisation programme in regular manner, deep freezer purchased Edamalakkudy. The brand new deep freezer is available in the sub centre for several months, but not installed so far due to some technical reason.

2.3 Suggestions to improve the health care system in Edamalakudy

The functioning of the sub centre is only because of Staff nurse posted for 15 days in month in 24X 7 manner. There is one Homoe dispensary and Ayurveda dispensary in Edamalakkudy and it is not Page 34 of 77

functioning because of several constraints. So, Provide residence facility for staff and appoint one more doctor and pharmacist and rearrange the duty of doctor and pharmacist for 15 days in 24X7 manner.

It is not practically feasible to keep away from the deep-rooted custom of Valappura in Edamalakkudy. The only solution is to this problem is through modernization of Valappura. All the Valappura should be reconstruct and provide all necessary amenities such as usual kitchen facility, clean toilet facility, water facility, electricity, TV and even napkin pad wending machine. Only through modernization of the Valappura, the unhealthy practice of contraceptive pill use can be avoided. The health department noticed the importance of good Valappura and constructed a Valappura in Ambalapparakudi with financial support of NHM fund, but basic facilities such as electricity, water, toilets etc were not provided there and hence its purpose not attained in terms of its utilization.

As Palliative care is mandatory for Grama panchayat in Kerala. So, one palliative nurse appointed for the palliative care in Edamalakkudy. There is no volunteers for palliative care, there is no road facility in Edamalakudy and vehicle is not available for palliative care. It is very difficult to travel through the pathways by alone. Because of all these restrictions, the primary survey of identification of palliative patients is not completed even after 1.5 years of functioning of the palliative programme. Hence there is need of restructuring the function of palliative care in this panchayat by merging the service of sub centre or with the new PHC.

The improper functioning all offices allotted to Edamalakkudi such as Homeo dispensary, Ayurveda dispensary, palliative care etc is only because of the absence of Panchayat office in Edamalakkudi. The full fledge functioning of Panchayat office in Edamalakkudi is essential for the functioning of all the government machineries and for the entire development of the Edamalakkudi.

The present salary of the staff nurses is Rs. 19500/-. This is the salary pattern is admissible to all contractual staff nurses under NHM. There is no additional incentives to these staff nurses. These staff nurse have to bring all necessary drugs from Devikulam CHC along with vegetables, provision required for them. Since the jeep charge of Rs 3000/- from Munnar to Edamalakkudi is not affordable to them, have to walk for 18km to reach Society kudi with the luggage. For the palliative nurse of Edamalakkudi, the jeep charge from Munnar to Society kudi and back is reimbursed by the panchayat (Rs. 6000/-) and the bill for the provision and vegetables purchase for the stay in Societykudi is also reimbursed by the panchayat (about Rs. 1500/-) per month. Page 35 of 77

There should be a special allowance to the staff nurses in addition to the fixed uniform salary of NHM. The travelling from Munnar to Edamalakkudy and back (Rs. 6000/- pm) should be provided as in the case of palliative nurses received from Panchayat

The staff posted to newly constructed PHC will be regular staff, hence couldn’t expect to stay in Edamalakkudy, unless there is specific special rules to Edamalakkudy. The regular staff posted to Edamalakkudy will get transfer immediately after their joining or will enter into long leave. The following points should be consider for the special rules : 1. Working days per month should fix as 15 in 24x7 manner 2. Special Travelling allowance per month should be there, as the palliative care nurse receives actual travelling expense from panchayat fund. 3. Special priority to the transfer request after 2 years of service in Edamalakkudy

The Ambulance provided by the Asrayam Charitable Society is a good ambulance and less than 1.5 years old, but not at all using in emergency situation mainly because of absence of driven when vehicle is needed. So, discussion with Asrayam Charitable Society is essential and resolve the issue. Panchayat or Health department should take initiative to function the Ambulance. If the Ambulance of Asrayam continues with the present situation, NHM should proceed with the earlier proposal of hiring a four wheel drive ambulance and should be under the control of the sub centre of Edamalakkudy.

There are two stretchers at sub centre provided from NHM. These stretchers are light weight and carrying in these stretchers is easy when compared with the stretchers made up of clothes and wood logs. If one such stretcher, provide to each hamlets, it will be much easier to transfer patient to hospital.

The functioning of PHC is expecting soon in Society kudi. One resident doctor is essential in this PHC in 24 X 7 manner for providing ANC care pregnant women of Edamalakkudy. One US scanning machine is essential in the PHC and the doctor should be trained for the operation of machine

Munnar is the shortest place to Edamalakudi and GH Munnar (Private Hospital under Kannan Devan Hills Corporation) is the health facility easily accessible than any other health facilities (private / government). Antenatal care service and Delivery care service were free to all women of the entire Edamalakkudi, but now the free service is limited Page 36 of 77

to members of 2 kudi only. Discussion with the authorities of GH Munnar with district authorities will help to reinstate the free treatment to the entire community of Edamalakudi

With the effort from the health department, the awareness of importance of institutional delivery enhanced among the women. Last minute transfer of pregnant women is very tedious and risky one. Presently some of the women shift to their relative’s house near to Adimali well in advance of delivery and move to TH Adimali when delivery pain start. Maternity stay house is the solution to this problem. Pregnant women along with their bystanders will be able to stay in these maternity house well in advance , say one month before the expected delivery date and one or two weeks stay in these house after delivery. Free nutritious food supply to the inmates of these houses also required. From the district officials, it was heard that construction of maternity stay house at CHC Chithirapuram was completed and inaugurate soon

CHC Chithirapuram is more near to Edamalakkudi and the infrastructure facility of the CHC is good enough to start a delivery point in this centre. A delivery point along with the maternity stay home is more beneficial to the people of Edamalakudi. Hence administrative decision to start delivery point in CHC Chithirapuram is essential

Number of hospital deliveries considerably increased but home delivery is still exist in Edamalakudy due to different reason. Presently there is one trained birth attendant (Remani) in Ambalappady kudi. This trained birth attendant or untrained birth attendants mange delivery in kudis. Since home delivery is a reality in Edamalakkudi, training of traditional birth attendant or ASHA workers will be very much advisable in handling delivery in more scientific manner. There are hamlets ASHAs in Edamalakkudi and some of these ASHA are very sincere and effective in their duties. Training on delivery care service to selected ASHA workers and some of traditional birth attendants are beneficial to manage emergency and unavoidable home deliveries.

Regular monthly immunisation programme with pre planned schedule is essential. Emergency measures required to implement the newly purchased cold chain equipment. Biweekly scheduled fixed plan of immunisation at Society Kudi after the implementation of cold chain to help the immunisation coverage of 5-6 kudies nearer to Society kudi. Page 37 of 77

Chapter III Sayippinkuzhy Tribal colony

There are 25 tribal hamlets residing inside the forest ranges of Pathanamthitta district. These 25hamlets spread over in 2 ranges of Konni division and 3 ranges of Ranni division. There are 1088 families residing in 1579 hectre area of forest in 5 forest range of Pathanamthitta district. Among the 1088 families 548 families possess land in settlement and the others have no land in forest. When compared to hamlets of Idukki, there is road connectivity and transportation facility in most of the tribal hamlets of this district. As per the Census 2011, nearly 1.5 percent of the population of Pathanamthitta district is tribal. The health service delivery in the public sector in Pathanamthitta district is rendered through 3 district hospital, 4 Taluk Hospitals, 12 CHCs, 44 PHCs and 268 SCs. Discussion was carried out the Divisional forest officer of Ranni division to get the idea of Hamlets under Ranni division. As per the discussion, it was observed that Moozhiyar Sayippin kuzhi Colony under Goodrical forest range is one among the hamlets having less amenities and less accessibility to health system. The families of the sayippin kuzhy hamlets are of Malamppandaram nomadic tribal group. The moozhiyar sayippinkuzhi hamlet is selected for the present study from Pathanamthitta district.

3.1 Background Characteristics

Sayippinkuzhy tribal colony is one of the tribal colonies of Ranni forest Division of Pathanamthitta district. This colony situated in Goodrical forest range of Ranni forest division.This sayippin tribal settlement colony come under the Angaamoozhy sub centre of Seethathode PHC. This tribal colony comes under ward 2 of seethathode panchayat. The only tribal population located here is the Malamppandaram.

Malappandaram : The Malai Pandaram or otherwise termed as Hill Pandaram is a scheduled tribe. The Hill Pandaram numbered 1,569 individuals in 1971, and had a population density of 1 to 2 persons per square kilometre. The 2011 Census recorded their population as 2,422. In the region they have a patios referred by others as Pandaram Basha. With others they converse in and educated use the Malayalam script for writing. Presently, the government have allotted plots of forest land to groups in which they have erected their huts and in the remaining area some Page 38 of 77

individuals engage in cultivation, mainly tapioca. The major traditional occupation is hunting and gathering. The Malai Pandaram follow Hinduism. Sastha or is their principal deity. Most of their settlements in Travancore are also located near the Sastha temples like Aryankavu, Achankovil and (https://kirtads.kerala.gov.in/2017/10/11/mala-pandaram/)

The Malai or Mala Pandaram live in the hill regions of Kollam and Pathanathitta districts of Kerala. They primarily occupy the forest ranges of Ranni, Koni, and Achencoil. They also live in Tamil Nadu. They have different customs from other tribes there. The Malai Pandaram have birth and marriage rituals. They bury the dead. The place where the bereaved person lived is destroyed.

In the past they lived on hunted food, tubers, roots, and wild fruits and now they use rice as their stable food. They collect Non Wood Forest Produce and barter them in local market for rice and other complimentary things.( Dr. K. Danielkutty)

As with the other forest communities of south India, such as the Paliyan, Kadar, Kannikar, and Mala Ulladan, the Hill Pandaram have never been an isolated community; from earliest times they appear to have had regular and important trade contacts with the neighboring agriculturalists, either through silent barter or, since the end of the eighteenth century, through mercantile trade.The Hill Pandaram have no temples or shrines and thus make no formal ritual offerings to the spirits, leading local villagers to suggest that they have no religion. Nor do they ritualize the life-cycle events of birth, puberty, and death to any great degree.

The Hill Pandaram have two types of residential grouping—settlements and forest camps—although about 25 percent of Hill Pandaram families live a completely nomadic existence and are not associated with any settlement

Settlements are scattered throughout the forest ranges except in the interior forest, which is largely uninhabited apart from nomadic camps of the Hill Pandaram. The majority of the Hill Pandaram are nomadic and the usual length of stay at a particular camping site (or a rock shelter, which is frequently used) is from two to sixteen days, with seven or eight days being the average, although specific families may reside in a particular locality for about six to eight weeks. Nomadic movements, in the sense of Page 39 of 77

shifting camp, usually vary over distances from a half-kilometer to 6 kilometers, though in daily foraging activities the Hill Pandaram may range over several kilometres.

The collection of minor forest produce is an important aspect of economic life and the principal items traded are honey, wax, dammar (a resin), turmeric, ginger, cardamom, incha bark, various medical plants, oil-bearing seeds, and bark materials used for tanning purposes. The trade of these products is organized through a contractual mercantile system, a particular forest range being leased by the Forest Department to a contractor. Through the contractor the Hill Pandaram obtain their basic subsistence requirements: salt, condiments, cloth, cooking pots, and tins for collecting honey. All the material possessions of the community are obtained through such trade. As the contractual system exploited the Hill Pandaram, who rarely got the full market value for the forest commodities they collected, moves have been made in recent years to replace it by a forest cooperative system administered by forestry officials under the auspices of the government's Tribal Welfare Department.

Both polyandrous and polygynous marriages have been recorded, but most marriages are monogamous. Cross-cousin marriage is the norm and marriages emerge almost spontaneously from preexisting kinship patterns, as camp aggregates center on affinally related men. There is little or no marriage ceremony and there is no formal arrangement of marriage partners, although young men tend to establish prior ties with prospective parents-in-law. Marriages are brittle and most older Hill Pandaram have experienced a series of conjugal partnerships during their lifetime.

Sayippinkuzhy tribal colony This colony is situated in Goodrical forest range of Ranni forest division. This sayippin tribal settlement colony come under the Angaamoozhy sub centre of Seethathode PHC. As per the sub centre register the total population of this tribal colonies is 85. Since most of the families are nomadic and no permanent housing structure, the population counted only for the settled houses. This tribal colony is spread over from Kochandy forest check post to Kakki dam site. The ST promoter of Sayippinkuzhi told that there are 22 families in sayippinkuzhi, among these below 10 houses are settled almost in permanent manner and the remaining are in nomadic manner shifting their settlement continuously. During the survey it was observed that, there are 2-3 families about 2 km from Kochandy forest check post , 5-6 families near Page 40 of 77

moozhiyar dam site and 6 families near moozhiyar power house, 2-3 families around KSEB quarters and 5-6 families found near kakki dam. When interviewed the families near Kochandy forest check post, they said that they came to their present area 2 months back and will shift to another place because of shortage of water in the present location. The community is mainly engaged in gathering forest products and NREGS work.

The families do not possess any land with or without deed certificates. The families do not have building number from Panchayat. The families residing near moozhiyar power house have yellow colored ration card (Most economically backward section of society. Antyodaya Anna Yojana Beneficiaries), no ration card to those residing near the dam site. Tribal department provide tarpolin sheet to each family in every year for making of their residence. With these Tarpolin, they make temporary tent with support of bamboo. The sheds of the families near power house was built in some what better manner by using bamboo for walls. The floors of all these tents are prepared with mud. Toilets were provided to 2-3 families residing near powerhouse, all other tents does not have any toilets facility and they are utilizing forest / bush for the purpose. Drinking water is the main problem in all the sheds. The families residing near powerhouse collect water from spring using hose.

The non availability of water during summer is the main problem of the sheds near the settled families near power house. Some of the elder members went to some interior part of forest where pond/ stream wasavailable and settled there till next rainy season. Some elder family members moved to Kakki dam reservoir area where water is available. The families residing near moozhiyar dam using dam water for drinking purpose even though strict orders from officials that not to use dam water for drinking purpose. The main demand from the settlers in Sayippin kuzhi colony is for supply of drinking water throughout the year and not resolved the issue so far.

Electricity is available on all sheds near Moozhiyar powerhouse, the electrification of the houses near pump house by a joint venture of Panchayat and Electricity board. No electricity to the sheds near moozhiyar dam, because they shift their residence occasionally. Two of these family were stayed somewhere in forest, when the head of household died, destroyed the shed and constructed a shed near the dam site. Aadhar card is available to most of the families, and no aadhar card to those residing near dam Page 41 of 77

site. KSEB of moozhiyar gave bed coat and one steel safety box to 21 families and not received these facilities for the nomadic group.

The sayippinkazhy tribal colonies are situated near the road of Pathanamthitta – Gavi road. There are two bus services to moozhiyar. There is one Anganwadi and one school in 40th mile (near KSEB quarters of Moozhiyar). Some of the children are studying in School at moozhiyar where the children of KSEB staff are studying. The education is free to all student studying in KSEB school. The school and Anganwadi are about 6 Km from Moozhiyar power house , one vehicle from Kudumbasree is there to pick the children of colony to school and anganwadi. The vehicle is free for the transportation of the children of colony for the education purpose. The travel of children of colony is free in KSEB vehicle for journey to school. Some of the students are studying in schools outside moozhiyar and residing in tribal hostel.

Malnutrition among women and children of sayippinkuzhy are high. “A survey conducted by the district child protection unit (DCPU) among 11 tribal families in Muzhiyar had revealed that 95 per cent of the children under 18 were under-weight,”. Following the findings, State Commission for Protection of Child Rights (SCPCR) visited the tribal colonies and subsequently the government came up with a programme ‘Subhakshitha Balyam Sundara Balyam’. The school/anganwadi-going children did not have proper food on holidays. “As the elders go to the interior forest, these children take care of the younger siblings at home. As per the programme, breakfast and evening meal are distributed to the children in their school/anganwadis, besides the mid-day meal scheme. On holidays, food was given three times at tribal colonies. The Kudumbashree Mission has been entrusted with the distribution of food. The programme ‘Subhakshitha Balyam Sundara Balyam’ was started in 2016 and the fund for the pilot project for the first six months were borne by the government and through sponsorship. Now the programme took over by Seethathode Grama panchayat and food distributing to about 100 children of Muzhiyar and Gavi region.

3.2 Treatment seeking behaviour

The Sayippinkuzhi tribal colony comes under ward 2 of Seethathode Grama panchayat.

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The sub centre of this area is Angamoozhi sub centre of Seethathode PHC. The sub centre is situated about 15 km from the colony and PHC situated about 19 km away from the colony. The medical officer visit the tribal colony on every Thursday, the doctor attend the sick patients at their residence and provide medicine. The ANM also accompany doctor and vaccination of children also provide on these visits. The doctor visit the patients at dam site location, houses situated near powerhouse and at KSEB quarters area.

One medical team from tribal department visits the sayippinkuzhy tribal colony on every month for the usual medical checkups. The team consists of one medical officer, one pharmacist and one Lab technician. Routine lab tests were carried out by the Lab technician; there is sufficient medicine with the team. Some families are not interested to consult doctor and they usually move to forest with kids when the team arrives in colony. They are not interested in providing immunisation to kids. Some of them were afraid of hospital and injection. These people depend on hospital only when the disease becomes very serious. But, most of the families cooperate with the medical team when they visit the colony. A major share of adult members will be in forest or in Kakki dam area or in interior part of forest collecting forest materials, and may not be available most of the time when the medical team visit the colonies. In case of emergency, they usually approach GH Pathanamthitta using Jeep. Most of the time the jeep charge got it from the ST promoter at GH Pathanamthitta. There is one Ambulance with KSEB. If there is any serious case in the Sayippin colony, the KSEB allow this ambulance for transporting patients to Hospital.

Antenatal care, Delivery and Immunisation: Most of the antenatal women receive antenatal care service during the usual visit of the medical team in Sayippinkuzhy. The medical team provides IFA, Calcium Tablets and TT injection to pregnant women during their visit. Very few pregnant women utilizing GH Pathanamthitta for Antenatal checkups and antenatal ultra sound scanning also carried out there. Some families were not interested for antenatal checkups.

Several years back very less women approached hospital for deliveries and they preferred to deliver in home. With the effort from the health staff, attitude of most of the women changed and now most of them are aware of the importance of institutional

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deliveries. Since the GH is about 40 km away from their residence, there is lot of issues to reach there in time including transportation problem.

Mrs. Z, a respondent reported that out of her five deliveries, 4 were carried out in home. As Doctors and ANM insisted her to deliver in GH, she decided to conduct the ANC care and delivery services at GH. She visited DH Pathanamthitta 8 time for Antenatal care service. Here EDD was marked as 30th June. She visited GH on 31st July, doctor told her to go back and visit back after 2 weeks. After reach home went to Kakki forest for collecting “kunthirkkam” and at that time experience delivery pain and delivered in forest. One traditional birth attendant helped for the delivery. On the next day due to fever, she was transferred to DH Pathanamthitta using Jeep. She spends there for 14 days. An amount of Rs 1400/- towards Jeep charge received from the ST promoter of the DH. She reported that there is no facility to stay and wait for delivery, hence doctor advised to back home, but the day itself delivered in forest. If there is maternity stay home associated with GH Pathanamthitta or at Seethathode PHC, women can stay there with their relatives when reaching delivery time and can avoid home deliveries.

Mrs. A, mother of 1.2 year old child reported that she carried out the ANC checkups in DH Pathanamthitta. About 5 ANC checkups carried out at DH Pathanamthitta and 3 ultra sound scanning were also done. She wanted to deliver in Hospital, but delivery pain started at night (by 10 pm), since there was no vehicle, delivered at home with the help of traditional birth attendant. After delivery, the Ambulance of KSEB arrived and shifted mother and child to DH Pathanamthitta.

Mrs. B, mother of one year old child, presently residing near dam site. She resides in tarpolin tent, no building number, no ration card etc. Earlier she resided in forest and her husband died there, hence destroyed the shed they used there and now residing in dam site area. She never went to DH for antenatal care services and ANM gave her IFA and Calcium tablets. She was afraid of going to hospital and fear of injection. She liked delivery in forest rather than in hospital. She said that they are children of forest, their birth home is forest, all the deliveries of their mother and relatives were in forest and delivery in forest is more comfortable. There are two traditional birth attendant and they believed that delivery with their assistance is safer than delivery in any other place. She delivered in forest with the assistance of the trained birth attendant. The immunization

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given to the child is only BCG; she refused to give further immunisation to her child. There are some other cases delivered in home because of their interest. JPHN reported that some families usually shift their place of residence and now living dam site area is not interested in institution deliveries. They are not interested in antenatal checkups. When medical team reaches there, they will move to forest with their kids. Earlier, Mrs. Z is also with the thought of delivery in home is safer than hospital delivery, after the continuous awareness programme from health staff, ward member and other educated persons understood the importance of hospital intervention on their health. More such programme is required to these women for safe delivery in hospital..

Suggestions :

Drinking ater is the major issue in this colony. They collect water from stream or pond using hose. Water source is a problem when summer starts, the elder members shift to other places where water is available or some members shift to kakki dam area. This nomadic nature is the main reason that hinder the provision of better health care to the people of this colony. Permanent solution to provide water to the families throughout the year is the main demand from the people there.

Both Mrs. Z and Mrs. A wanted to deliver at Hospital. These two women carried out their ANC care checkups in DH Pathanamthitta travelling more than 40 Km by bus. But both had home delivery with the help of traditional birth attendant. Many reasons for the home delivery have been cited which include the distance from home to hospital is more than 40 km, no vehicle readily available for transportation etc. Mrs. Z delivered at home within hours of visit to DH for ANC care checkups.

There are some other tribal colonies in Goodrical and forest range under Ranni division, where public transport facility is limited and very difficult to reach DH within stipulated time. There are no other accessible delivery points other than DH to these people. These incidents indicate the importance of a maternity rest house for trial in Pathanamthitta. If there is facility to stay in maternity homes well in advance say one or two weeks before EDD with one or two relatives, some of them will be ready to utilize the maternity home for safe delivery. After several such institutional deliveries and if they feel comfortable with the maternity homes, more women would opt for safe delivery at these maternity homes. Page 45 of 77

More awareness programme on the importance of ANC Checkups, Institutional deliveries and immuization of children is required in this area. Pear group sensitization will be effective to change the views of some women on delivery and immunisation. Earlier, Mrs. Z was not interested in Hospital delivery, but after sensitization from JPHN, Mrs. Z changed her attitude and decided to go to Government hospital for delivery.

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Chapter IV Tribal colonies of Thiruvananthapuram

There are 129 tribal hamlets inside the forest ranges of Thiruvananthapuram district. These hamlets spread over in 3 forest ranges of Thiruvananthapuram division of Southern Circle and 3 ranges of Thiruvananthapuram Wildlife Division of ABP Circle. There are 3183 families residing in 2442 hectre area of forest in 6 forest range of Thiruvananthapuram district. None of the families have land but agricultural land is there without deed agreement. As per the Census 2011, nearly 1.5 percent of the population of Thiruvananthapuram district is tribal. The health service delivery in the public sector in Thiruvananthapuram district is rendered through 6 district hospital, 7 Taluk Hospitals, 23 CHCs, 85 PHCs and 544 SCs. Discussion was carried out the Divisional forest officer of Wild division office to get the idea of Hamlets under wild life division. As per the discussion, it was observed that some of the tribal settlement colonies of Peppara forest range have no proper roads, no public transport vehicle and less accessibility to public health system. The families of the hamlets of Peppara are of Kanikkar tribal group. The Podiyam, Pattampara and Anakal hamlet were selected for the present study from Thiruvananthapuram district.

4.1 General information about Kani Tribe

The tribal communities in Kerala have been divided into seven major territorial groups taking into account their historical, ethnic, socio-cultural and religious background (P.K .G. Mathur, 1977). The Kanikkar is the major tribal community living in Thiruvananthapuram zone consists of Nedumangad and taluks of Thiruvananthapuram district, and this Tribe is concentrated in Thiruvananthapuram district (90.3%). They are the inhabitants of the area around Agastyakutam. They are a homogenous community without sub tribal groupings. The ethnographic account of Kanis gives their past history; they were formerly settled in Kalakad and Kallidakurchi in of Tamil Nadu. The world famous Arogyapacha (Trychopes zeylanica) was the discovery of the Kani tribes and a product of community wisdom (Iyer 1937). Kani tribes have established distinct systems of knowledge relating to the uses and management of biological diversity on these lands and environments. The Kanis have been historically engaged in agriculture and dependent on the forest Page 47 of 77

products for their livelihood needs, although the pattern of dependence and sustainability levels has changed. The current main livelihood source for the Kanis is from the monoculture of rubber, mixed agriculture, wage labour, and Non Timber Forest Products (NTFPs) collection. The sacred landscape of Agasthyamala is one of the important Biosphere Reserves in the world where the indigenous culture, religion and spirituality are associated with the biological diversity. Kani is the tribal group occupying the Agasthyamala Biosphere Reserve area traditionally for more than 100 years (Darsana et .al, 2018)

‘Kanikkaran’ the word meaning refers to the hereditary proprietor of land. Like many other indigenous groups Kani tribe also did not settle in any place permanently during the very early phase of settlement in Forest .They moved from one place to another after having cultivation for two or three years. Kani tribe settlement system is such that a few families live in a cluster interspersed with the forest. They do limited cultivation of tapioca, banana, millets and cash crops such as pepper, coconut, rubber, areca nut and cashew nut etc., in small plots of land given by the Forest Department. . They derive most of their livelihood from crafts, and gathering and selling of various permitted forest produce. Traditional structure of the community was that of a highly coordinated unit under the control of a tribal chief, called Muttukani. Traditionally, the Muttukani combined the roles of the lawgiver, protector and dispenser of justice, physician and priest. However, with time the traditional system of governance among the Kanis has been eroded to a large extent and the role of the tribal chief is only a token one (Anuradha, 1999). The use of traditional knowledge for herbal medicines among the Kani tribes inhabiting the forests of the region is quite rich.

4.2 Background Characteristics of Hamlets selected for study

Three tribal colonies are under the Podiyam sub centre of Kuttichal PHC,which comes under the CHC of Vellanad were selected for the study. The selected tribal colonies for the study are Podiyam, Pattampara and Anakal. All these colonies come under ward 7 of Kuttichal Grama panchayat. The JPHN of Podiyam sub centre reported that there are altogether 27 tribal settlement colonies under the sub centre. All these tribal colonies are remote area and public transport facility is not available in any of the centre. The people of these tribal colonies have to walk kilometers to get public transport to reach any one

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health facilities. The Podiyam sub centre was created for the purpose of providing primary health care, antenatal care services and child immunization to the beneficiaries of these tribal colonies and thus the strengthening of the public health activities of these areas. There is one community hall in podiyam and sub centre started its functioning in that building. The functioning of the sub centre in this building stopped after several months. This sub centre is not functioning in this area for the past several years. The functioning of the sub centre is presently in the official record only. Anakal and Pattampara are the most remote tribal settlement colonies of these 27 tribal colonies and these are the most remote and interior tribal colonies of the entire Trivandrum District. Podiyam tribal settlement colony is the colony where the sub centre was instituted. So these three tribal colonies were selected to study the general treatment seeking characteristics, antenatal care, delivery care and immunization of children of the beneficiaries residing in these colonies.

Podiyam: Podiyam comes under ward 7 of Kuttichal Panchayat. This tribal settlement colony is under peppara forest range of Thiruvananthapuram wildlife division of Thiruvananthapuram. As per the official records there are 26 tribal families residing in 75 hectors of land in reserve forest of Peppara range. Most of the family possesses their own land.

The state government has given them the land for agricultural purposes but without a deed certificate. The families have agriculture land of 1 Acre to 6 Acre. Most of the families have constructed concrete houses with the financial aid of tribal department/ grama panchayat/ block panchayat. Some families are waiting for financial aid for house construction and now residing in sheds made up of bamboo and bamboo leaves. The houses have house numbers from Kuttichal grama panchayat. Almost all the houses received toilets from local self government scheme. The drinking water source for these families is springs and ponds, and families took water from the spring using hoses. Electricity is available for all families in this hamlet. There is no public transport facility to the hamlet. The nearby place where public transport is available is Kottoor, which is about 10 km from Podiyam. The road is available till Valippara, which is about 4 km from Podiyam. The road towards Podiyam from Valippara is capable of travel in vehicles such as Jeep, Auto and bikes. Some of the families own bikes and auto and one family own one jeep. Page 49 of 77

Anganwadi is available in Valippara, which is about 4 Km from Podiyam and school is available in Utharamcode about 10 km from Podiyam. One LP School is available in Podiyam. There is arranged Jeep from Tribal department for the travel of students from Podiyam tribal colony to Anganwadi and school at Utharamcode. The travel is free of cost. Some of the students from Podiyam are residing in tribal hostels for their study at high school and higher secondary level education.

Pattampara: Pattampara is the most remote tribal colony in the Peppara forest range. There are 6 tribal families residing in 14 hectors of land in reserve forest of Peppara range. The families possess land for agricultural purposes but without a deed certificate. The nearby place where public transport is available is Kottoor, which is about 17 km from Pattampara. The road is available till Valippara, which is about 15 km from Pattampara. There is jeep road till Kunnatheri, and 5 km walk from there through forest is required to reach Pattampara. Either walking of 30min to reach Kunnatheri or 3 Hour walk through forest required to reach Valippara to get jeep to travel Kottoor . The roof all the houses are made of bamboo leaves, walls are made of bamboo and floor are of mud. All the houses have number form panchayat. Electricity is available in all sheds. No toilet facility available to these houses. The drinking water source for these families is springs, and families took water from the spring using hoses.

House of Mooppan of Pattampara tribal colony

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Anganwadi is available in Valippara, one LP school at podiyam. One high School is available in Utharamcode and there is Jeep service for the travel of students to reach school from Tribal department. The jeep service reaches till Kunnatheri. Certain students of this tribal colony are residing in tribal hostels at Kottoor / Nedumangad for their study at high school level education. Jeep services are available from Kunnatheri to Kottoor on all Wednesdays and Saturdays, people of nearby colonies utilize jeep service to sell their agricultural product at Kottor and purchase all provisional and vegetables from Kottoor. The charge for travel to Kottoor from Kunnatheri is Rs. 100/- per trip.

Anakal: Anakal is one of the most remote tribal colonies in the Neyyar forest range of Thiruvananthapuram wild life division. There are22 tribal families residing in this tribal colony. The families possess land for agricultural purposes but without a deed certificate. The nearby place where public transport is available is Kottoor, which is about 15 km from Anakal. The road is available till Valippara, which is about 15 km from Anakal. There is jeep road till Pothode, from Pothode, 3 km has to walk through forest to reach Anakal. About 30 minute walking is required to reach Anakal from Pothode. The roof all the houses are made of bamboo leaves, walls are made of bamboo and floor are of mud. All the houses have number form panchayat. No one received house from Life mission or under panchayat scheme. Electricity is available in almost sheds, still there are sheds without electricity. No toilet facility available to these houses. The drinking water source for these families is springs, and families took water from the spring using hoses.

Interview with respondents at Anakal colony Page 51 of 77

Interview with respondents at Anakal colony

There is one LP school in Pothode , about 10-12 students of this settlement studying in Pothode LP School. Some of the students of this tribal colony are residing in tribal hostels at Kottoor / Nedumangad for their study at high school level education. Jeep services are available from Pothode to Kottoor on all Wednesdays and Saturdays, people of nearby colonies utilize jeep service to sell their agricultural product at Kottor and purchase all provisional and vegetables from Kottoor. The charge for travel to Kottoor from Kunnatheri is Rs. 100/- per trip.

4.3 General treatment seeking behaviour

Podiyam: The people of this tribal colony depend on Kuttichal PHC and Nedumangad Taluk hospital for treatment of general ailment. Some of the families depend on traditional herbal treatment for minor ailments and depend on health facilities, if not cured from the treatment. On Wednesdays and Saturdays there is jeep service to Kottoor in morning and back to Podiyam in the evening. This jeep service is for transporting their agricultural and forest resources to kottoor. On these days, people can travel to Kottoor by this jeep for a charge of Rs. 30/- for a trip. On other days, they have to walk half an hour to reach Valippara to get public vehicle to reach hospital. In emergency cases, people of Podiyam have to pick auto or jeep to reach in PHC or Taluk hospital on other days, the expense for reach these health facilities by hiring Jeep or Auto varies from Rs. 1000 to Rs. 1800/-. There is weekly medical camp at Podiyam from PHC Kuttichal, the medical camp is organized every Monday. One Medical Officer, JPHN of the sub centre / Staff nurse are the members of the medical team. The medical camp is conducted in community hall of Podiyam.

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From the interview with beneficiaries, it was observed that the medical camp is not organized in regular manner. The camp was not conducted for the last 4 weeks to the day of interview. During the camp no investigations were carried out, the facility for BP check, glucose level checking facilities also were not there with the team. The doctor examines the patients and provides medicine if medicine is available with the team otherwise they prescribe for medicine. Usually the team reaches between 11 am and 12 Noon and examination is carried out for those who had been waiting for the team and they leave immediately after examination of patients who were waiting there. Most of the time immunization was conducted with the medical camp and no specific schedule for immunization in this medical camp.

The weekly medical camp is not at all useful for the people of Podiyam and nearby colonies because of the following reasons :

1. there is no specific time period followed by the medical team on the day of visit,

2. the visit of the medical team is not regular and not with prior intimations and

3.the vaccination of children is not available during all of the visits.

Pattampara: The people of this tribal colony mainly depend on herbal treatment for health issues. Usually people of this colony depend on hospital only for diseases which were not managed by herbal treatment, mainly because of financial constraints. In emergency, the people of Patrtampara colony mainly depend on PHC Kuttichal or TH Nedumangad. To reach these hospital have to walk 30-45 minute to reach Kunnatheri, and then jeep journey till Kottoor and public transport to Government facility. The travel from Kunnatheri to Kottor is Rs. 100/- only on Wednesday and Saturday morning, otherwise the amount will raise to Rs. 1700/- 2000/-.Since the amount required is much more than affordable to the very poor people of Pattampara, some of them forced to walk for 3 hours to reach Valippara to get public transport.

Mrs. C (50Yrs) said that they tried for Jeep to transport his wife because of severe stomach pain as she was not relieved even after several days of herbal treatment, the Jeep arrived after several attempts and they spent Rs. 5400/- as travel expense and the amount was not reimbursed from the tribal department. Mr. D (60 years) told that he

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went to Nedumangad TH using hired jeep for treating severe abdomen pain 3 months back. Appendectomy was carried out there and he spent 7 days there. An amount of Rs. 5800/- was spent towards travel expense and treatment. He travelled to Tribal department office at Nedumangad for 3 times to get the amount, each time an amount of Rs. 300/- was spent as travelling expense for each journey to Nedumangad, only Rs. 4000/- has been received so far and Rs. 1800/- is still pending. There is no visit by any medical team in Pattampara. For immunization also they have to travel too much distance.

Anakal : The people of this tribal colony mainly depend on herbal treatment for health issues. Usually people of this colony depend on hospital only for diseases which were not managed by herbal treatment and because of financial constraints. In emergency the people of Pattampara colony mainly depend on PHC Kuttichal or TH Nedumangad. To reach these hospital have to walk 30-45 minute to reach Pothode, and then jeep journey till Kottoor and public transport to Government facility. The travel from Kunnatheri to Kottor is Rs. 100/- only on Wednesday and Saturday morning, otherwise the amount will raise to Rs. 1700/- to 2000/-. Since the amount required is much more than what is affordable to the very poor people of Anakal, most of them wait till next Wednesday and Saturday for their treatment at PHC / TH. There is planned medical camp at Pothode LP school, but the medical camp is not carried out regularly and there is no specific time slot for the medical team at Pothode. When the medical team looks after the patients who have been waiting there, they leave the place immediately. There is no medical camp at Anakal. The people of Anakal have to walk through the forest for 30 minutes to reach Pothode. If the medical camp is pre planned and regular and the time slot of the camp at Pothode is fixed, it will be very useful for the poor people of Anakal.

4.4 Antenatal, Delivery and Immunization care services

Podiyam : The women in this area are aware of the importance of antenatal care checkups. Most of them depend on PHC Kuttichal and TH Nedumangad for the ANC care checkups. When medical camp visits podiyam, JPHN provides IFA tablets and calcium tablets to the pregnant women. Usually pregnant women approach TH Nedumangad for delivery purpose. It is not much difficult to get Jeep at night as compared to other colonies of this area. So they take the pregnant women to TH

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Nedumangad when delivery pain starts. Hence no home delivery was reported during last year in this colony. Interviews with women brought out certain issues in this regard.

Mrs. D (23 Yrs) reported that they went to TH Nedumangad 3 months (in September 2018) before the date of interview for delivery. When delivery did not happen after admission, they proceeded for LSCS. After LSCS, Gynecologist asked them to give Rs. 2000/- for anesthesia doctor. But they were not ready to pay and complained to Medical Superintendent, but no action was taken on it. She told that this type of bad practice is there in TH Nedumangad. She replied that JSY amount was not received after delivery. This reflects the out of pocket expenditure.

Mr. E (25 years) reported that, 2 years back his wife had delivery pain at night. There is great difficulty in getting a jeep. After several attempts they got one jeep. But his wife delivered in the Jeep on the way to TH Nedumangad. Delivery in Jeep in not a rare situation in this area.

Pattampara : There are only 6 families in this tribal colony and most of the women are illiterate or less educated. Five – ten years back there is no practice of antenatal check up and all of the deliveries were conducted at home. Now situation has changed, even though the education level of women is less, most of them are aware of importance of antenatal check up. From the interviews with beneficiaries, the views on the importance of ANC check up and their practice were assessed.

Mrs. F (23 yrs) W/o Mr. F is illiterate and living in Pattampara, a very remote tribal colony with no vehicle access. Jeep service at low rate of Rs. 100/- to from Kunnatheri to Kottoor is available only on Wednesday and Saturday. On other days, amount of Rs. 3000/- is required to hire Jeep to reach TH Nedumangad or PHC Kuttichal. Under PMSMA, one gynecologist is available at PHC for antenatal consultation on 9th of every month. Usually this day may not be Wednesday or Saturday, hence no jeep service is there from Kunnatheri to Kottoor on these days. Because of financial crisis, she walked 3 hours to reach Valippara the place at which public transport facility is available and travelled to TH Nedumangad on 9th for antenatal care service. She visited more than 7 times for the antenatal checkups and for all these travel she walked 6 hours through forest (to and fro). As per the advice of the Gynecologist at TH Nedumangad, US scan Page 55 of 77

carried out three times and each time Rs. 750/- was spent for scanning, no reimbursement was received either from Hospital or Tribal department. She complained that JPHN or ASHA worker never visited her during antennal period, JPHN called her 3 times during ANC period.

She told that she was interested to deliver in Government hospital, but her delivery was carried out at home due to several reasons including financial crisis to pick jeep. When delivery pain started, it was very difficult to walk for more than 30 minute to reach Kunnatheri and male members were not there to take her in stretcher, hence decided home delivery. One traditional birth attendant took the delivery. The delivery happened in December 2018.

With 2 month old child after home delivery

She informed the JPHN after delivery through phone, then she began to scold her for not going to Hospital. On next day, JPHN reached Kunnatheri with a van from hospital. She walked through forest for 2 hours to reach Kunnatheri. She was admitted for 5 days in Nedumangad TH, after discharge she was dropped back in Kottoor by car. From Kottoor she reached Kunnatheri by Jeep and an amount of Rs. 1700/- was spent for the travel which was not reimbursed from tribal department. She told that she was fine after home delivery but from the pressure from health staff she was admitted hospital after a tedious walk of 2 hours on the next day of delivery. But with the hospitalization,

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an amount of Rs. 1700/- had to be spent for travel expense. This amount was not really bearable to them at that time. This incidence shows the failure of JSSK, which is aimed for the out of pocket expense for institutional deliveries.

The birth doze immunization was taken from TH Nedumangad, there after no immunization was given, because of tedious travel with kid to PHC. JPHN asked her to take child to PHC, but because of difficulty in walking with child for 3 hours she did not travel to PHC. The penta 1 immunisation was pending at the time of interview. She suggested, it will be convenient if one immunization schedule was conducted at Kunnatheri, which is 30 minute walkable distance from their residence. She told that if there was any facility to stay at TH Nedumangad for one or two before delivery, definitely she would have utilized the facility.

Anakal : Most of the women of Anakal are illiterate or less educated. Greater shares of women are aware of the importance of ANC cares service and institutional deliveries. But the utilization of ANC care service from hospital and institution delivery is comparatively low because of financial constraints and tedious travel to reach the health facility. Hence the home delivery is comparatively high in this tribal colony. There are no planned health camps in this very remote tribal area. The medical camp is usually conducted at Podiyam and Pothode, but that camp is also not regular and ndo ot maintain a stipulated time slot. There was only one woman having a child below 1 year in Anakal during our visit to the place. The experience of the women is given below.

Mrs. G (26 years), w/o Binu is a resident of Anakal tribal colony. She has two kids, elder is one year old and second one is just 4 days old . During her first pregnancy, she went for ANC care service in PHC Kuttichal. Going to PHC is a tedious journey, has to walk about half an hour through forest and travel in Jeep on market days (Wednesdays and Saturdays). She also visited JPHN at medical camp at Podiyam to get IFA and calcium tablets. Her husband is a resident from . If at Anakal, it would have been very difficult to move to hospital in emergency situation, hence moved to her husband’s home at Amboori. When delivery pain started, they moved to Nedumangad by jeep. She delivered her first child at Nedumangad on 23/1/2018. The travel cost of Rs. 3500/- was reimbursed from the ST promoter office of Nedumangad Hospital. Since the child was low birth weight, the baby was referred to SAT Medical College

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Thiruvananthapuram. She stayed at SAT for 8 days, since most of the medicines were not at hospital she had to buy from outside medical stores. About ten thousand rupees was spent during the sty at SAT for medicine and for the stay of bystander there. After discharge, free transportation was arranged from Tribal department to reach Amboori.

She shifted to Amboori when she was pregnant for the second time. The ANC care services received from Mayam PHC near Amboori and free USG scan received from Karakkonam Medical College. Since the expense during first delivery was not a bearable amount to them, and due to severe financial crisis, she & her husband decided for home delivery and shifted to Anakal tribal colony. She delivered at her home on 25/2/2019 , one traditional birth attendant was there for the delivery. After delivery, she informed about the delivery to JPHN, but none visited her till our visit (29/2/2019) to the colony. This incident also shows the failure of the programmes like JSSK. This woman is illiterate but aware of the importance of antenatal care and institutional delivery. JSSK has been implemented in the state to avoid out of pocket expenses. An amount of Rs. 10000/- was spent as out of pocket expense during her first delivery. Even though she was interested in institutional delivery, she opted for home delivery only because of the anticipated out of expenses. So, she purposefully shifted to Anakal for home delivery.

With 4 day old child after home delivery

She told that the immunization of children of Analkal is another major problem. There is no immunization camp at Anakal. There is camp at Pothode but they are not informed about the date of camp in advance hence they were not able to give immunization to Page 58 of 77

their kids. She was aware of the importance of immunization, so took her son’s immunization at PHC after tedious journey. She asked for immunization service at Anakal or at pothode on pre published time and date.

Under PMSMA scheme, one Gynecologist from Nedumangad is working in Kuttichal PHC on 9th of every month. Pregnant women of these area are asked to visit the PHC on these days, since 9th is not necessarily a Wednesday or Saturday, women of these tribal settlement area have to hire jeep to reach PHC on these days. The rate for hiring a jeep will be more than 2000/- and most of the time there is no reimbursement from the Tribal department, hence women have to walk 2-4 hours to reach Valippara, where public transport service is available. Due to weakness of body to walk or due to financial constraints, most of the women were not utilizing the opportunity.

There are 12 tribal colonies under the forest range of Kottoor, 13 tribal colonies under Peppara range and 17 tribal colonies under Neyyar range. The public transport facility is not available in most of these tribal colonies. Jeep / auto are available in most of these tribal colonies. We visited tribal colonies Pothode and Warila of Peppara range, Thenmala, Kombai and Ayiramkala of Neyyar forest range. The general treatment behavior and antenatal and delivery care are similar to the colonies visited by us. Jeep on hire is available in almost other tribal colonies except Anakal and Pattampara. The problem of reimbursement of travel expense from the tribal department is the main issue raised by the people of other tribal colonies.

Suggestions :

Podiyam is declared as a sub centre of the PHC Kuttichal to provide better health care service to the poor people of 8-10 tribal colonies this remote area. Presently Podiyam is only a sub centre in government official records, and no separate sub centre is functioning in this area. The service to the public is limited to the camps days organized at these tribal areas. People of Podiyam colony reported that the medical camp at podiyam is fixed on Mondays. The people complained that the camp is not regularly organized. There is no fixed time for camp on the day of visit. The medical team leaves the place immediately after the service is provided to those wait for service. The sub Page 59 of 77

centre Podiyam should be made functional as a sub centre in Podiyam itself, The service of JPHN and JHI should be available on all days, if so it will be beneficial for about 5- 10 hamlets. Medical camp should be conducted on tribal colonies with a pre published time schedule. Such camps should function on specific time slot on the day of visit.

The JPHN of Podiyam Sub centre told that 8-10 medical camps per month was conducted at various tribal colonies and immunization service is also provided in these camps. But most of the beneficiaries reported that the immunization is not given at tribal colonies and have to travel with kids to PHC / TH Nedumangad. Immunisation programme should be incorporated with the pre published camp schedule and the mothers of child whose immunization is due should be informed in advance.

ASHA is not effective in these areas, which is another reason for poor service of public health activities, so steps should be taken to strengthen ASHA in these areas. Immunization outreach should be done at the remote tribal colonies such as Anakal, Kunnatheri, Pothode etc. and prior intimation should be given to the beneficiaries.

Earlier Jeep charge was received from ST Promoter of TH Nedumangad, when the trip sheet is submitted. Now, the amount is transferred to account. The time of sanctioning amount is much more. The beneficiaries have to go Nedumangad Tribal office several times to get the amount. Since there is no public transport vehicle from Podiyam and other tribal colonies, the expense is much more to reach Nedumangad to enquire about the status of application. So, measures are required to get the amount from the hospital. Now the payment of amount is through bank account, which is a problem to some families who do not possess any bank account.

The jeep charge to reach PHC Kuttichal or TH Nedumangad is above Rs. 2000/-, most of the cases the amount is not reimbursed due to several reasons such as lack of amount, technicalities etc. Jeep drivers are not even ready to pick these patients due to these formalities. So measures are required to resolve the issues.

Delivery in jeep is not a single incident in these colonies. On call Jeep / ambulance service from Health department or Tribal department is essential for beneficiaries in these very remote colonies such as Pattambara, Anakal, Pothode etc. An amount of

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about Rs. 2000/- is essential to reach GH Nedumangad by Jeep at emergencies. Because of lack of such a big amount, they were forced to deliver in home.

Maternity stay home at Nedumangad is essential. It is very difficult to pick pregnant women to Nedumangad TH from Anakal / Pattampara etc when the delivery pain starts. The beneficiaries reported that they would have stayed in Nedumangad TH for one or two weeks before the delivery date for safe delivery, but such a facility is not available there.

The market at Kottoor is on Wednesdays and Saturdays. People for all colonies of Peppara, Neyyar and Kottor forest range arrive at Kottoor with their agricultural product on these days, sells these product and purchase all necessary items for their household from market of Kottoor on these days. The travel to Kottor on these days are affordable (varies from Rs. 30/- to Rs. 100/-) to the people of these tribal area on these days. Medical camp at Kottor on these days will be useful to the public of all the tribal colonies of the Thiruvananthapuram wild life division.

Presently One Gynecologist under PMSMA is working in PHC Kuttichal on 9th of every month. But it is very difficult and more of a economic burden to the beneficiaries to reach PHC on the specified day. If PMSMA / or the service of a gynecologist is implemented in Kottoor on one Wednesday or Saturday per month, it will be very useful for all pregnant women of the colonies of Neyyar, Kottor and Peppara range.

Earlier the OP registration was manual in PHC Kuttichal, then priority was there for the tribal people from these colonies. Now, electronic token system has been implemented, hence more time is required to wait for medical care service at PHC. Priority for tribal people is required for OP care at hospitals. So some sort off measure s are required in this regard.

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Chapter V Summary and recommendations

Kerala, the small southern state of India, is homeland for about 35 tribal communities. These thirty-five different tribes are at different levels of socio-economic strata. As per 2011 census, the total tribal population of Kerala is 4.84 lakhs. It is about 1.45 per cent of the total population of Kerala. Tribal health, health behaviour, and health maintenance system is attached with a lot of complexity intertwined with socio cultural beliefs and practices. In tribal societies, the supernatural theory of illness provides an important basis for explanation of beliefs related to state of health and illness. The traditional healers are the carriers of local health tradition and they provide various services to the members of the community. In the studied tribal community also there are efficient traditional healers who know and treat various ailments. Most tribal people live in remote rural hamlets in hilly, forested or desert areas where illiteracy, trying physical environments, malnutrition, inadequate access to potable water, and lack of personal hygiene and sanitation make them more vulnerable to disease. This is compounded by the lack of awareness among these populations about the measures needed to protect their health, their distance from medical facilities, the lack of all- weather roads and affordable transportation, insensitive and discriminatory behavior by staff at medical facilities, financial constraints and so on. Government programs to raise their health awareness and improve their accessibility to primary health care have not had the desired impact. Young tribal girls enter the reproductive age as victims of undernourishment and anemia, and face greater health risks as a result of early marriage, frequent pregnancies, unsafe deliveries, and sexually transmitted diseases. Women’s low social status makes them more likely to seek treatment only when the ailment is well advanced. They have no money left to spend on health and are fighting a constant battle for survival and health. Keeping this in view, the GoI launched, “The National Rural Health Mission (NRHM), to provide effective healthcare to the rural population throughout the country. In spite of the efforts of the government, these Tribal areas continue to suffer from poor maternal and child health services and ineffective coverage under national health and nutrition programmes. This study is intended to assess the functioning living condition of the tribal population residing in very interior

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and remote area of forest. It also envisages into the general treatment seeking behavior, antenatal, delivery and postnatal care services received by these tribal population.

As per the figures of Forest department, there are 725 tribal settlements inside the forest of Kerala. Among these 725 tribal hamlets, there are altogether 20714 families are living. Among the hamlets, 47 % were in Sothern district and 72 % of tribal families living in the forests of southern districts. Majority of these families does not hold any land with deed certificate. There are hamlets which are very interior of forests and no road connectivity to those hamlets. This study is limited to southern districts of Kerala; three districts were selected for the study. The selected districts are Thiruvananthapuram, Pathanamthitta and Idukki. Since the aim of the study is to assess the health seeking behavior of tribals living in very remote hamlets, the hamlets were selected with the consultation with officials of forest departments of the concerned divisions. The hamlets selected from Thiruvananthapuram districts are Pattampara, Anakal and Podiyam of Peppara forest range division, Sayippin Kuzhi Tribal colony of Goodrical range of Pathanamthitta district and Edamalakkudy Panchayat of Idukki district. The background characteristics and the infrastructural facilities of the selected hamlets were assessed through discussions with elder members of hamlets and also using structured interview schedules. The general treatment seeking behavior of the hamlets was also collected using structured interview schedules. The treatment seeking behavior regarding antenatal care service, delivery care service and immunization of children were collected from pregnant women and women delivered within 2 years of the data of survey using a structured interview schedule.

Among the tribal hamlets of Idukki district, the hamlets of Edamalakkudy are most remote in terms of road accessibility, communication, Electricity etc. Edamalakudy is the only tribal panchayat of Kerala, it has around 28 hamlets with houses in the range 8 to 30 in each hamlets. The only tribal population located here is the Muthuvans. Electricity is available in 3 hamlets, all the families have ration card and almost all members possess Aadhar card. Each hamlet found their own water sources (springs) and taking water from there using hoses. Most of the Muthuvans in Edamalakudy possess their own land. The state government has given them the land for agricultural purposes but without a deed certificate. The panchayat office in Edamalakudy has been working in Page 63 of 77

Devikulam. A temporary office has been set up in Edamalakudy, but no staff appointed to this temporary office. The absence of functioning of the panchayat office at Edamalakkudy is the main reason for the improper functioning all offices allotted to Edamalakkudi. There are 3 MGLC single teacher schools, 10 functioning Anganwadis and one LP school in Edamalakkudy. There is one valappura in every hamlet, women have to stay in Valappura during the menstruation period and usually delivery carried out in Valappura, and it was observed during the visit that the physical condition of valappura was of very poor condition in all hamlets. The very poor condition of Valappura is the main reason for stay away from Valappura and avoiding menstruation by unscientific use of contraceptive pills. There is one Ayurveda dispensary in Andavankudi and one Homeo dispensary in Society kudy, both are started from the initiative of NHM. Medicine is available in these dispensaries, but due to absence of doctor in most of days, hence the functioning of both these dispensaries are not at all benefited to the public. Travel from Idamalakkudy to the nearest hospital in emergencies is the most difficult problem experienced by the people of Edamalakudy. In August 2017, “Asrya Charitable Trust - Munnar” sponsored a 4 wheel drive Ambulance to Edamalakkudy and complete expense such as fuel expense, the salary for driver etc are met by the trust. People reported that the functioning of the ambulance is very much necessary, but not functioning due to several reasons for the last 1 year.

Under NHM, ASHAs were appointed in all hamlets, presently there are only 13 ASHAs are working. There is one primary palliative nurse in Edamalakkudy, but the functioning of primary palliative is not upto the mark in this Panchayat. Inorder to strengthen the functioning of the sub centre, NHM appointed 4 male staff nurses for the sub centre in 2013.Four staff nurses were appointed and number of days per month was fixed as 15 days. After the appointment of these male nurses, the sub centre functioning 24X7 manner. The construction of the PHC is on final stage and expected to start its functioning soon. The staff posted to PHC will be regular staff, hence couldn’t expect to stay in Edamalakkudy as the contractual staff residing there, unless there is specific special rules to Edamalakkudy. Working days per month should fix as 15 in 24x7 manner, special Travelling allowance per month should be there and special priority to transfer after a certain period of service in Edamalakkudy. The people of Kudies near to the society kudi approach the sub center for almost all type of general illness. Some of the family members adopt traditional herbal treatment Page 64 of 77

for minor ailments and depend on sub centre if not cured from the treatment. Shifting of patient to other hospital is a tedious one. They build a temporary stretcher using clothes, sheets and wood logs. Usually 10-30 people took the patients in stretcher and walk till pettimudi. It will take about 3-5 hours to reach pettimudi. From Pettimudi, transport to GH Munnar using jeep. Since more number of people are required to shift patients using stretcher, emergency shifting of patients is usually difficult. With the effort from the health department through ASHA workers and the staff nurses of Sub centre, pregnant women attending the medical camps organised at Society Kudi and other kudies. Some of the pregnant women depend on Munnar GH for antenatal care services. All medical treatment, antenatal care services and delivery care services were free to the entire population of Edamalakkudi till 2 years back. The medical officer provide antenatal care service when the medical team visit the Kudis. If ultra sound scanning required, pregnant women has to travel Adimali. Earlier the pregnant women not interested to visit doctor for ANC checkups during the medical camps. Medical camps are designed for once in a month, but from the interviews with beneficiaries revealed that camps are not conducted in regular manner, due to the irregular pattern in medical camp pregnant women from far away Kudis such as Nooradi kudi, Irippukallu, Mulakuthara etc were not benefited for ANC checkups. The Staff nurses of the sub centre were usually providing ANC care advice, checkups and IFA/Calcium tablets when the pregnant women were need of it.

During the last 5 years, the institutional deliveries increased considerably. Still delivery in Valappura is common. There is one trained birth attendant (Ramani) in Ambalappadi kudi. Ramani is conducting deliveries in most of kudies with help of others in emergencies. More than 50 safe deliveries conducted so far. She told that if any abnormalities observed during the delivery process, usually call the staff nurses of the Sub centre for their help. If the complication continue, transport the women to pettimudi / Anakkulam using temporary stretcher made up of clothes and wood logs and then to TH Adimali using Jeep. Last year, 3 women were transported to TH by such method and one women delivered in jeep while transporting to Adimali GH. According to Remani, pregnant women of Kudies feels they are comfortable in delivering in Valappura than in hospital, because of the tedious journey to reach the TH. With the continuous effort from the health department, the staff nurses of Sub centre, women are Page 65 of 77

aware of the importance of institutional deliveries. There are several other factors to select Valappura for delivery such as not getting Jeep charge form ST department, most of the cases the beneficiaries have to purchase medicine from outside hospital with amount from their pocket, the expense of bystanders and self and some bitter experiences from hospital etc. Five years back, when medical team arrive at Edamalakkudy for immunisation, mothers usually skip to forest with their kids to avoid immunisation. With great effort from the health department and the two staff nurses of sub centre, almost all women were aware of the importance of immunisation and ready to give immunisation when medical team arrive in Kudi. It was observed that the immunization programme at Edamalakkudy is not in regular manner. It was observed that the last immunisation camp was conducted in Edamalakkudy on October 8th , 2018. It means that there was no immunisation programme in Society Kudi or any other Kudi for a period of more than 4 months, but 2-3 medical camp conducted during the period. Inorder to carry out immunisation programme in regular manner, deep freezer purchased for Edamalakkudy. The brand new deep freezer is available in the sub centre for several months, but not installed so far due to some technical reason.

Sayippinkuzhy tribal colony is one of the tribal colonies of Ranni forest Division of Pathanamthitta district. This colony situated in Goodrical forest range of Ranni forest division. This sayippin tribal settlement colony come under the Angaamoozhy sub centre of Seethathode PHC. The only tribal population located here is the Malamppandaram. There are 22 families in sayippinkuzhi, among these below 10 houses are settled almost in permanent manner and the remaining are in nomadic manner shifting their settlement continuously. The families does not possess any land with or without deed certificates. The families does not have building number from Panchayat. Some families have yellow colored ration card and no ration card to those residing near the dam site. Tribal department provide tarpolin sheet to each family in every year for making of their residence. With these Tarpolin, they make temporary tent with support of bamboo. Most of the families do not have any toilets, electricity is available for some houses, and water is mainly from springs / ponds. The non availability of water during summer is the main problem of the sheds hence elder

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members goes to some interior part of forest where pond/ stream are available and settles there till next rainy season and some families shift to Kakki area. There is one Anganwadi and one school in 40th mile, education is free to all students from colony, free transport facility to these students. Since Malnutrition among women and children of sayippinkuzhy are high, a programme ‘Subhakshitha Balyam Sundara Balyam’ was implemented in this area. As per this scheme breakfast and evening meal are distributed to the children in their school/anganwadis, besides the mid-day meal scheme. On holidays, food were given three times at tribal colonies. This programme took over by Seethathode Grama panchayat and food distributing to about 100 children of Muzhiyar and Gavi region.

The medical officer of Seethathode PHC visit the tribal colony on every Thursday, the doctor attend the sick patients at their residence and provide medicine. The ANM also accompany doctor and vaccination of children also provide on these visits. One medical team from tribal department visit the sayippinkuzhy tribal colony on every month for the usual medical check ups. The team consist of one medical officer, one pharmacist and one Lab technician. Routine lab tests were carried out by the Lab technician, there is sufficient medicine with the team. Some families are not interested to consult doctor and they usually move to forest with kids when the team arrive in colony. Some of them were afraid of hospital and injection. In case of emergency, they usually approach GH Pathanamthitta using Jeep. There is one Ambulance with KSEB. If there is any serious case in the Sayippin colony, the KSEB allow this ambulance for transporting patients to Hospital.

Most of the antenatal women receive antenatal care service during the usual visit of the medical team in Sayippinkuzhy. Very few pregnant women utilizing GH Pathanamthitta for Antenatal checkups and antenatal ultra sound scanning also carried out there. Some families were not interested for antenatal checkups. Several years back very less women approached hospital for deliveries and they preferred to deliver in home. With the effort from the health staff, attitude of most of the women changed and now most of them are aware of the importance of institutional deliveries. Reaching GH Pathanamthitta at night or odd time is very difficult because of getting vehicle in time, this is one reason for home deliveries. If there is maternity stay home associated with GH Pathanamthitta or at Seethathode PHC, women can stay there with their relatives when reaching Page 67 of 77

delivery time and can avoid home deliveries. Certain women liked to delivery in forest rather than in hospital. According to them, they are children of forest, their birth home is forest, all the deliveries of their mother and relatives were in forest and delivery in forest is more comfortable. JPHN reported that some families, usually shift their place of residence and now living dam site area are not interested in institution deliveries.

The selected tribal colonies for the study are Podiyam, Pattampara and Anakal. All these colonies comes under ward 7 of Kuttichal Grama panchayat. All these tribal colonies are remote area and public transport facility is not available in any of the centre. Pattampara and Anakal are the most remote hamlets of Thiruvananthapuram district. In Podiyam, Most of the families have constructed concrete houses with the financial aid of tribal department/ grama panchayat/ block panchayat. All the houses of Pattampara and Anakal are kutcha houses, the roof all the houses are made of bamboo leaves, walls are made of bamboo and floor are of mud. Electricity is available in all sheds of these three hamlets. The drinking water source for these families in all these three hamlets is springs / ponds, and families took water from the spring using hoses. No toilet facility available to houses of anakal and Pattampara. Anganwadi is available in Valippara, which is about 4 Km from Podiyam and school is available in Utharamcode about 10 km from Podiyam. Pattampara is the most remote tribal colony in the Peppara forest range. There are 6 tribal families residing in this hamlet. There is jeep road till Kunnatheri, and 5 km walk from there through forest is required to reach Pattampara. Jeep services are available to Kottoor on all Wednesdays and Saturdays, people of these colonies utilize jeep service to sell their agricultural product at Kottor and purchase all provisional and vegetables from Kottoor. The charge for travel to Kottoor varies from Rs. 40/- to Rs. 100/- per trip.

Podiyam sub centre of Kuttichal PHC created for the purpose of get general medical assistance, antenatal care services and child immunization to the beneficiaries of these tribal colonies. There is one community hall in podiyam and sub centre started its functioning in that building. The functioning of the sub centre in this building stopped after several months. This sub centre is not functioning in this area for the past several years. The functioning of the sub centre is limited in the official record only. Some of the families of these three hamlets depend on traditional herbal treatment for minor Page 68 of 77

ailments and depend on health facilities, if not cured from the treatment. On Wednesdays and Saturdays there are jeep service to Kottoor in morning and back in the evening. Usually people of these hamlets utilize PHC Kuttical on these days because of comparatively low transportation cost. On other days, jeep charge will by between Rs. 1000/- to Rs. 3000/- to reach hospital.

There is weekly medical camp planned at Podiyam, Pothode, Kunnatheri etc from PHC Kuttichal, the medical camp assigned on every Monday and Thursdays. One medical officer, JPHN of the sub centre / Staff nurse are the members of the medical team. From the interview with beneficiaries, it was observed that the medical camp is not in regular manner. The camp was not conducted for the last 4 weeks to the day of interview. The weekly medical camp is not at all useful for the people of Podiyam and nearby colonies because of the following reasons :1. There is no specific time period followed by the medical team on the day of visit, 2. The visit of the medical team is not regular and the absence of the visit was not with prior intimations and 3.the vaccination of children is not available during all of the visits.

Most of the women are illiterate or less educated. Five – ten years back there is no practice of antenatal check up and all of the deliveries were in home. Now situation changed, even though the education level of women is less, most of them are aware of importance of antenatal check up and went to PHC Kuttichal on 9th of every month or at Nedumangad TH for antenatal care service. Transportation of Pregnant women in emergencies is not at all possible due to the lack of travel facilities. Some of the home deliveries are because of problem to get vehicle in time and some deliveries carried out in Jeep on the way to hospital. Some of pregnant women preferred home delivery only because of financial constraints. The problem of not getting reimbursement for the travel expense from Tribal department is another major problem.

Women are aware about the importance of child immunization. There is partial immunization in these tribal colonies. There are several reasons for the partial immunization such as no immunization camp at Anakal and Pattampara, the information about the date of immunization camp at Pothode or Kunnatheri is not passed to the beneficiaries in advance, there is no fixed periodic immunization camps in Page 69 of 77

these area, the travel to PHC / TH Nedumangad is tedious journey with kids for immunization etc. Hence not able to give immunization of their kids.

Recommendations :  The functioning of the sub centre is going on in smooth manner only because of Staff nurse posted for 15 days in month in 24X 7 manner. The Homeo dispensary and Ayurveda dispensary is not at all beneficial to the people of Edamalakkudy because of absence of doctors and staff most of the time. A suggestion would be to provide resident facility for staff and appoint one more doctor and pharmacist and rearrange the duty of doctor and pharmacist for 15 days in 24X7 manner.  The Valappura is the worst building compared to other buildings of the hamlets. Women are usually not interested to stay in Valappura as far as possible. The very poor condition of Valappura is the main reason for staying away from Valappura and they avoid menstruation by unscientific use of contraceptive pills. The only solution is to this problem is through modernization of Valappura. All the Valappuras should be reconstruct ed and provided with all necessary amenities such as usual kitchen facility, clean toilet facility, water facility, electricity, TV and even napkin pad wending machine.  The primary survey of identification of palliative patients is not completed even after 1.5 years of functioning of the palliative programme. There are only 4 identified bedridden patients. Hence there is need of restructuring the functioning of palliative care in this panchayat by merging the service of sub centre or with the new PHC.  Presently the Panchayat office of Edamalakkudy functions at Devikulam. The full fledged functioning of Panchayat office in Edamalakkudi is essential for the functioning of all the government machineries and for the entire development of the Edamalakkudy.  The present salary of the staff nurses of Edamalakkudy Sub centre is Rs. 19500/. This is the salary pattern admissible to all contractual staff nurses under NHM. There is no additional incentives to these staff nurses. These staff nurse have to bring all necessary drugs from Devikulam CHC along with vegetables, provision required for them. Since the jeep charge of Rs 3000/- from Munnar to Page 70 of 77

Edamalakkudi is not affordable to them, they have to walk for 18 km to reach Society kudi with the luggage. For the palliative nurse of Edamalakkudi, the jeep charge from Munnar to Society kudi and back is reimbursed by the panchayat (Rs. 6000/-) and the bill for the provision and vegetables purchase for the stay in Societykudi is also reimbursed by the panchayat (about Rs. 1500/-) per month. The service of these staff nurses are well appreciated and this is the only facility in Edamalakkudy providing service in 24X7 manner on all days. There should be some special allowance to the staff nurses in addition to the fixed uniform salary of NHM. The travelling from Munnar to Edamalakkudy and back (Rs. 6000/- pm) should be provided as in the case of palliative nurses received from Panchayat.

 The regular staff posted to Edamalakkudy PHC either get transfer immediately after their joining or will enter into long leave. Special rules for staff for PHC is essential for the regular posting of staff in PHC. The following points should be considered for the special rules: 1. Working days per month should be fixed as 15 in 24x7 manner 2. Special Travelling allowance per month should be there 3. Special priority to the transfer request after 2 years of service in Edamalakkudy

 The Ambulance provided by the Asrayam Charitable Society is a good ambulance and less than 1.5 years old, but not at all used in emergency situation mainly because of absence of driver when vehicle is needed. So, discussion from district officials with Asrayam Charitable Society is essential to resolve the issue. Panchayat or Health department should take initiative to function the Ambulance.  Earlier, there was a proposal from NHM to hire a 4 wheel drive ambulance on monthly rent basis. If the Ambulance of Asraayam continue with the present situation, NHM should proceed with the earlier proposal of hiring a four wheel drive ambulance and should be under the control of the sub centre / PHC of Edamalakkudy.  There are two stretchers at sub centre Edamalakkudy provided from NHM. These stretchers are light weight and carrying in these stretchers is easy when compared with the stretchers made up of clothes and wood logs. If one such

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stretcher, provide to each hamlets, it will be much easier to transfer patient to hospital in case of emergencies.  The functioning of PHC is expecting soon in Society kudi. One resident doctor is essential in this PHC in 24 X 7 manner.  The pregnant women of Edamalakkudy have to go at TH Adimali to get US scan during the pregnancy. Because of the tedious journey and the cost of transport, most of them were not interested to proceed with scanning. One US scanning machine is essential in the PHC and the doctor should be trained for the operation of machine.  Munnar is the shortest place to Edamalakudi and GH Munnar (Private Hospital under Kannan Devan Hills Corporation) is the health facility easily accessible than any other health facilities (private / government). Antenatal care service and Delivery care service were free to all women of the entire Edamalakkudi, but now the free service is limited to members of 2 kudi only. Discussion with the authorities of GH Munnar with district authorities will help to reinstate the free treatment to the entire community of Edamalakudi  With the effort from the health department, the awareness of importance of institutional delivery has improved among the women. Last minute transfer of pregnant women is very tedious and risky one. Presently some of the women shift to their relative’s house near to Adimali well in advance of delivery and move to TH Adimali when delivery pain starts. Maternity stay house is the solution to this problem. Pregnant women along with their bystanders will be able to stay in these maternity house well in advance, say one month before the expected delivery date and one or two weeks stay in these house after delivery. Free nutritious food supply to the inmates of these house also required. From the district officials, it was heard that construction of maternity stay house at CHC Chithirapuram was completed and inaugurate soon.  CHC Chithirapuram is more near to Edamalakkudi and the infrastructure facility of the CHC is good enough to start a delivery point in this centre. A delivery point along with the maternity stay home is more beneficial to the people of Edamalakudi. Hence administrative decision to start delivery point in CHC Chithirapuram is essential.

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 Number of hospital deliveries considerably increased but home delivery still exist in Edamalakudy due to different reason. Presently there is one trained birth attendant (Remani) in Ambalappady kudi. This trained birth attendant or untrained birth attendant’s manage delivery in kudis. Since home delivery is a reality in Edamalakkudi, training of traditional birth attendant or ASHA workers will be very much advisable in handling delivery in more scientific manner. There are hamlets ASHAs in Edamalakkudi and some of these ASHA are very sincere and effective in their duties. Training on delivery care service to selected ASHA workers and some of traditional birth attendants are beneficial to manage emergency and unavoidable home deliveries.  Regular monthly immunisation programme with pre planned schedule is essential. Emergency measures are required to implement the newly purchased cold chain equipment. Biweekly scheduled fixed plan of immunisation at Society Kudi after the implementation of cold chain to help the immunisation coverage of 5-6 kudies nearer to Society kudi  Drinking water is the major issue in sayippinkuzhy colony. The people collect water from stream or pond using hose. Water source is a problem when summer starts, the elder members shift to other places where water is available or some members shift to kakki dam area. This nomadic nature is the main reason to provide better health care to the people of this colony. Permanent solution to provide water to the families throughout the year is the main demand from the people there.  One of the main reason for home delivery in Sayipinkuzhy colony is the poor transport facility to reach Pathanamthitta especially in odd times. There are no other accessible delivery points other than DH to these people. If there is facility to stay in maternity homes well in advance say one or two weeks before EDD with one or two relatives, some of them will be ready to utilize the maternity home for safe delivery. After several such institutional deliveries and if they feel comfortable with the maternity homes, more of the women will opt for safe delivery at these maternity homes.  Some women are interested for delivery in forest because they believe that they are children of forest, their birth home is forest, all the deliveries of their mother and relatives were in forest and delivery in forest is more comfortable. There are Page 73 of 77

two traditional birth attendants and they believed that delivery with their assistance is safer than delivery in any other place. Some women changed this attitude and were ready to deliver in government hospital after sensitization by JPHN and some other educated members. More awareness programme on the importance of ANC Checkups, Institutional deliveries and immunization of children is required in this area. Pear group sensitization will be effective to change the views of some women on delivery and immunisation  Podiyam is declared as a sub centre of the PHC Kuttichal to provide better health care service to the poor people of 8-10 tribal colonies this remote area. Presently podiyam is one sub centre in government official records, but no separate sub centre functioning in this area. The sub centre Podiyam should be made to function as a sub centre in Podiyam itself, The service of JPHN and JHI should be available on all days, if so it will be beneficial for about 5-10 hamlets.  People of Podiyam colony reported that the medical camp at podiyam is fixed on Mondays. The people complained that the camp is not regular in manner. There was no fixed time for camp on the day of visit. The medical team leave the place immediately after te service is provided to those who wait for service. Medical camp should be conducted on tribal colonies with a pre published time schedule. Such camps should be functional on specific time slot on the day of visit.  The JPHN of Podiyam Sub centre told that 8-10 medical camps per month was conducted at various tribal colonies and immunization service is also providing in these camps. But most of the beneficiaries reported that the immunization is not conducting at tribal colonies and have to travel with kids to PHC / TH Nedumangad. Immunisation programme should be incorporated with the pre published camps and should inform mothers of child whose immunization is due.  ASHA is not effective in Podiyam, Anakal area, which is another reason for poor service of public health activities, so steps should be taken to strengthen ASHA in these areas.  Immunization outreach should be done at the remote tribal colonies such as Anakal, Kunnatheri, and Pothode etc. with prior intimation to the beneficiaries.

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 Earlier Jeep charge was received from ST Promoter of TH Nedumangad, when the trip sheet is submitted. Now, the amount is transferred to account. The time of sanctioning amount is much more. The beneficiaries have to go to Nedumangad Tribal office several times to get the amount. Since there is no public transport vehicle from Podiyam and other tribal colonies, the expense is much more to reach Nedumangad to enquire about the status of application. So, measures are required to get the amount from the hospital. Now the payment of amount is through bank account, problem to some families do not possess any bank account  The jeep charge to reach PHC Kuttichal or TH Nedumangad is above Rs. 2000/-, most of the cases the amount is not reimbursed due to several reason such as lack of amount, technicalities etc. Jeep drivers are not even ready to pick these patients due to these formalities. So measures are required to resolve the issue.  Delivery in jeep is not a single incident in these colonies. On call Jeep / ambulance service from Health department or Tribal department is essential for beneficiaries in these very remote colonies such as Pattambara, Anakal, and Pothode etc. An amount of about Rs. 2000/- is essential to reach GH Nedumangad by Jeep at emergencies. Because of lack of such a big amount, they were forced to deliver at home.  Maternity stay home at Nedumangad is essential. It is very difficult to pick a pregnant women to Nedumangad TH from Anakal / Pattampara etc when the delivery pain start. The beneficiaries reported that they would have stayed in Nedumangad TH for one or two weeks before the delivery date for safe delivery, but such a facility is not available there.  The market at Kottoor is on Wednesdays and Saturdays. People for all colonies of Peppara, Neyyar and Kottor forest range arrive at Kottoor with their agricultural product on these days, sells these product and purchase all necessary items for their household from market of Kottoor on these days. The travel to Kottor on these days are affordable (varies from Rs. 30/- to Rs. 100/-) to the people of these tribal area on these days. Medical camp at Kottor on these days will be useful to the public of all the tribal colonies of the Thiruvananthapuram wild life division. Page 75 of 77

 Presently One Gynecologist under PMSMA is working in PHC Kuttichal on 9th of every month. But it is very difficult and more of an economic burden to the beneficiaries to reach PHC on the specified day. If PMSMA or the service of a gynecologist is implemented in Kottoor on one Wednesday or Saturday per month, it will be very useful for all pregnant women of the colonies of Neyyar, Kottor and Peppara range.  Earlier the OP registration was manual in PHC Kuttichal, then priority was there for the tribal people from these colonies. Now, electronic token system has been implemented, hence more time is required to wait for medical care service at PHC. Priority for tribal people is required for OP care at hospitals. So some sort of measures are required.

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Reference

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