From the Margins to the Centre
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From the Margins to the Centre A study on the health inequities among the tribal communities in selected districts of Chhattisgarh, Jharkhand and Odisha Research by Sama – Resource Group for Women and Health Supported by National Human Rights Commission This research was conducted between 2017 and 2018 by Sama – Resource Group for Women and Health B-45, 2nd Floor, Shivalik Main Road, Malviya Nagar, New Delhi 110017 Email: [email protected] Website: http://www.samawomenshealth.in Sama, a Delhi-based resource group for women and health, was initiated in 1998 by a group of feminist activists from the autonomous women’s movement. Sama advances an understanding of health from a gender, caste, class and rights perspective, and seeks to locate the concerns of women’s health in the context of socio-historical, economic and political realities. Sama believes that equality and empowerment, can be ensured only when poverty, curtailment of capabilities, lack of livelihood rights, lack of health services and access to health care, illiteracy and multiple forms of discrimination based on caste, class, gender religion, ethnicity, sexuality, disability and many other rubrics are structurally challenged. Sama is committed to integrate gender, caste, class and rights analysis within the wider context of other social relations in order to emphasize the complexity of existing power relations that work towards exclusion and marginalization. Through its work, Sama seeks to bridge the gap between community voices and policy outcomes as well as facilitate understanding and action on health through inter-sectoral and inter-movement linkages. The research has been supported by National Human Rights Commission Contents Acknowledgements 4 Abbreviations 7 Chapter 1 Introduction 11 Chapter 2 Methodology 27 Chapter 3 Profile 46 Chapter 4 Social determinants and health 52 Chapter 5 Specific health problems and illnesses 67 5.1. Communicable diseases 5.1.1 Malaria 68 5.1.2 Tuberculosis 83 5.1.3 Leprosy 100 5.2. Non-communicable diseases 105 5.3. Mental health and well being 115 5.4. Women’s health related issues 5.4.1 Maternal health 121 5.4.2 Uterine prolapse 144 5.4.3 Access to abortion services 146 5.4.4 Contraception 153 5.5. Undernutrition 158 5.6. Acute respiratory infections 176 5.7. Haemoglobinopathies 180 5.8. Epilepsy 188 5.9. Snakebites, dog bites and other animal attacks 192 Chapter 6 Availability and utilisation of health services 199 Chapter 7 Conclusion and Recommendations 230 Annexures 257 3 Acknowledgements The Research Team Overall coordination of the Research: Sarojini N, Deepa V and Rizu State level field work: Rizu, Adsa Fatima, Sarojini N, Ruchi Bhargava, Susheela Singh with Kalyani Badola, Geetika Vashist (both were formerly with Sama during the field work) and Mr. Gouranga Mohapatra (Jan Swasthya Abhiyan, Odisha) Analysis and writing: Sarojini N, Deepa V, Rizu, Adsa Fatima, Ojaswini Bakshi, Ruchi Bhargava, Oshin Siao Bhatt, Prathibha Sivasubramaniam with Ranjan De. Local Investigators: Mr. Pranaya Kumar Panda, Nuapada; Ms. Kusum Rajwadi, Koriya; Mr. Md. Arif Ansari, Gumla; Mr. Prasan Tirkey, Latehar. Other research support: Megha Kain Acknowledgments We would like to thank, first of all, the women, men and children and their families who participated in the research and generously shared their experiences regarding their health problems. This report is dedicated to them. Our sincere thanks to the participants from the focus group discussions in the villages. We hope that their voices and concerns, reflected here, will inspire introspection and action towards the fulfilment of the rights of tribal communities. We hope that the recommendations will be considered by the Centre and State governments towards achieving right to health of tribal communities in the country. We extend our sincere thanks to the National Human Rights Commission (NHRC) for their unstinting support that has not only made this research possible, but also strengthened Sama’s overall engagement with the issue. Special thanks to the Chairperson, Hon’ble Justice H. L. Dattu, Mr. Ambuj Sharma (Secretary General, Chief Executive Officer of the Commission), Dr. M. D. S. Tyagi Jt. Director (Research), Dr. Ranjit Singh (Joint Secretary for P and A), Mr. Nishchith and Ms. Priyanka from NHRC. We also thank NHRC’s technical and administrative staff for their cooperation. We are grateful to Mr. J. S. Kochher (former Jt. Director, Research, NHRC) for his support and also for contacting district officials to make arrangements for our stay in places where it was not available. Thanks to Dr. Savita Bhakhry (formerly with NHRC) for encouraging Sama to take up this important Study. We are extremely grateful to our advisor – Dr. Yogesh Jain, Jan Swasthya Sahyog (JSS) for his support throughout the study, and for his guidance, inputs to the various sections of the report, suggestions to the recommendations that have shaped this research and analysis. 4 Our special thanks to Dr. Indranil Mukhopadhyay (JSA, Jindal Global University) for contributing to the chapter on Health Systems. We are extremely grateful to Mr. Samir Garg, State Health Resource Centre (SHRC), Chhattisgarh for his suggestions, inputs to the recommendations and also introducing us to the Mitanins. We sincerely acknowledge Ms. Sulakshana Nandi and Ms. Deepika Joshi of Public Health Resource Network (PHRN) and Chaupal, for sharing their experiences of working with tribal communities, relevant documents and their inputs. We thank Dr. Prabir Chatterjee, SHRC for his prompt suggestions on specific technical parts. Special thanks to Ranjan De for his meticulous review of the drafts, editing and for the layout of the report. Without his support the report would not have been completed in such a short period. We would like to thank Dr. Mamta Bhushan Singh, Professor, Neurology, All India Institute of Medical Sciences (AIIMS), Ms. Malini Ghose, Adv. Veena Johari and Mr. Vivek Divan for their comments and inputs on specific sections of the report. Thanks to Ms. Meena Seshu, Ms. Aarti Pai and Dr. B. Subhasri for providing valuable inputs on certain recommendations. We also thank Ms. Malini Sood and Ms. Oshin Siao Bhatt for editing a few sections of the report within a tight schedule. We are grateful to Ms. Jashodhara Dasgupta, Dr. Rakhal Gaitonde for sharing the reports, studies on maternal health among tribal women; conflict and health. We acknowledge the contribution of Prof. Padmini Swaminathan, Ms. Philomena Vincent, Prof. Rama Baru, Dr. B. Subhasri, Ms. Prabha Nagaraja and Ms. Vrinda Marwah (all Sama Board members) for their initial observations and inputs. We acknowledge Ms. Noyana Khatoniar (Sama) for helping with the data compilation for the profile section and Ms. Pallavi Gahlaut (Sama) for her support. Thanks to Mr. Ashok Yadav, Mr. Chandan Prashad and Mr. Antony Kurien for their support with finances and administration. We would like to thank Mr. Kishor Goswami for the initial layout. Special thanks statewise In Odisha We are grateful to Mr. Gouranga Mohapatra, JSA for his contribution, contacts and support for conducting the research in Nuapada and Rayagada in Odisha. Thanks to Mr. Abani Panigrahi from Lokdrushti for his inputs on issues particularly on migration and also providing local investigators for the research. We would like to thank the team at Chale Chalo for sharing their work. Thanks to Haridas from Youth for Action and Research, Maagriha and Mr. Kuturam Sunani for providing us support and helping with contacts. 5 A special thank you to Dr. John Cherian Oommen and his team at Christian Hospital, Bissam Cuttack, Rayagada for their inputs and suggestions. We are extremely grateful to Nuapada District Collector and District Magistrate Dr. Poma Tudu, and Additional District Magistrate (ADM) and Mr. Trilochan Minz providing us all the support during the visit, and also for introducing the research team to the CDMO. A big thank you to Dr. Jagdish Mahanand, CDMO and other doctors from the District Hospital, staff nurses, para medical staff who remained available to us during the entire duration; for their cooperation and for providing all the necessary data without any hassle. Special thanks Mr. Prashant Kumar Baral, Deputy Manager, RCH for providing all the data, information and accompanying us to the field along with other members of NHM team. Special thanks to Mr. Biswa Kumar Behera, DPM (NHM) for sharing the data and information. The staff at Komna and Khariar CHCs, PHCs, SCs, the ASHAs, ANMs, AWWs, DAMAN teams in the area deserve a big thank you. Without their support, the fieldwork would have been incomplete. Thanks to Dr. Dibakar Ojha, in charge-CBDA, Nuapada for sharing the information on CBDA. Thanks to Ms. Vidyawati and Mr. Basudev Panda in Rayagada who helped the team in translation from Kui and Odiya language during the interview and discussions on field. Thanks also to Mr. Bhubaneshwar Raut, Mr. Sadhuram Podh, Mr. Prakash Kumar Bandichhor, and Mr. Himanshu Panda for their help during field work; and to the Panchayat Pradhans in the villages that the team visited. Chhattisgarh Thanks to the staff of Jan Swasthya Sahyog, Bilaspur for sharing their reports and other relevant documents. Thanks to Sister Elizabeth Nalloor, RAHA, Jashpur; Ms. Rekha Shivhare, Phulwari Coordinator, Koriya; Thanks to Ms. Roshini, Mitanin District Coordinator, Mitanin Programme, and Sukhmani, Block Coordinator, Mitanin Programme and the other Mitanins for their cooperation and support during the visits to Koriya and Jashpur. Thanks to the staff at the SCs, PHCs and CHCs visited and also the DH officials. Thanks to all the AWWs, ANMs. Jharkhand Thanks to the Ekjut team members in Gumla and Latehar, who provided us inputs about the areas; Sister Anjana and Sister Sujata from Nazareth Health Center, Mahuadanr, Latehar; Dr. Vasavi Kiro, Torang Trust; NAWO; Mr. Balram, Right to Food Campaign and Mr. Haldar Mahto, member, Jharkhand State Food Commission. Thanks to all the Medical Officers and the other staff at PHC sand CHCs, Sahiyas, ANMs, AWWs for sharing their experiences.