A group discussion by the researchers with Attapadi community members [Image Credits: Sunil George]
In 2013, over 50 infants died in Attapadi —a protected area in the Palakkad district of Kerala. This incident, and more deaths in the subsequent years, put the spotlight on the health of the tribal population that lives here. Several underlying health issues, including malnutrition and infant mortality, were identified to be rampant. Both the central and state governments responded with a financial package to provide healthcare and related facilities to these communities free of cost.
Seven years later, a new study has found that free healthcare hasn't solved the problem of poor access to healthcare and high levels of infant mortality. The study, published in the International Journal for Equity in Health, was carried out by researchers from the Health Research Institute, University of Canberra, Australia.
Indigenous communities, across the world, fare poorly on several health indicators like life expectancy, infant mortality and nutrition. Poor access to healthcare worsens this situation. The United Nations (UN) has identified Universal Health Coverage (UHC) as one of the Sustainable Development Goals to address inequality in accessing healthcare. Free universal health coverage ensures that financial constraints do not stand in the way of access to healthcare. However, the researchers of the current study found that the present approach to UHC alone may not yield the desired results. Many factors, including indigenous culture and beliefs, play a vital role in these communities.
Attapadi has 192 villages, inhabited by members of the Muduga, Kurumba and Irula tribal communities. For the study, the researchers interviewed more than 50 people over several months during 2018-2019. These included community members, healthcare workers and experts on UHC and tribal health. They also spent hours conducting observations at both the different villages and healthcare facilities across Attapadi.
Through these interactions, the study aimed to find out if the current healthcare facilities had integrated into people's daily life and solved the problem of poor healthcare in Attapadi. In most indigenous communities, traditional knowledge of health and culture is at crossroads with modern healthcare, alienating them from local health systems.
The study found that the tribal community's approach to health like their counterparts elsewhere, was strongly linked to the environment, their cultural beliefs, and their traditional foods. However, many of these practices were disregarded by the modern healthcare system. For example, the use of medicinal plants is a vital part of their culture.
However, in the guise of providing 'good quality' treatment, healthcare officials often dismissed these traditional medicines and replaced them with modern medicines. They were also generally uninformed about the indigenous cultural practices and beliefs, leaving these people feeling stigmatised and alienated. Thus, although free, the present approach to providing healthcare wasn't successfully integrated with the community and was not meeting their needs.
Forced compliance with specific healthcare programs was another issue. Under the antenatal care program implemented in Attapadi, pregnant women had to visit the tribal speciality hospital at Kottathara village every month for check-ups. This proved to be a challenge as these visits entailed travelling long distances on hilly terrains for several hours. The indigenous community members also expressed apprehension towards going to big town hospitals as navigating the vast, unfamiliar hospital buildings and interacting with unknown doctors was daunting.
The study also revealed some underlying causes for impoverished health conditions of the tribals. Much of their land was lost to settlers from outside. As a result, the nutritious food cultivated by these communities dwindled, resulting in malnutrition, and impacting livelihoods. However, when these issues were brought up by these people, healthcare providers often dismissed them as causes of concern.
The above issues have resulted in a lack of trust in doctors and the healthcare system for the local communities. Although they are aware of free healthcare schemes, they hesitate to access them due to marginalisation and lack of integration with their culture.
"Local communities need to be involved in planning and delivering healthcare services to remedy this situation," says Mr Sunil George, the lead author of the study. "Village chiefs and their councils must have a more expanded and meaningful role in planning and delivering them", he adds.
The researchers also suggest sensitising healthcare workers to the indigenous beliefs and culture and providing most services locally, rather than in hospitals far away.
India is home to a tribal population of over 104 million, and this study highlights why the current implementation of UHC needs to change. Integrating traditional practices, the natural environment, and broader underlying health concerns specific to different communities must be taken into account.
"If interventions to promote UHC are to reach marginalised groups, they must be culturally safe, locally relevant and planned with the active involvement of the community", sign off the authors.
This article has been run past the researchers, whose work is covered, to ensure accuracy.