ABSTRACT
Background:
The well-known phenomenon of tribal disadvantage in India requires constant monitoring to ensure diligent attention to equitable protection of tribal people’s right to life.
Methodology:
This study, based on an analysis of secondary data from the National Data Analytics Platform database in different tribal communities in Indian states, charts the differential progress of tribals by establishing a gap.
Results:
Huge differences were observed in the total fertility rate among the tribal population across the states, with the lowest in Sikkim (1.02) and Delhi NCT (1.24) and the highest in Bihar (2.98) and Meghalaya (3.07). Similarly, family planning is a matter of great concern as contraceptive usage showed wide disparities with the tribal women of Meghalaya (28.0%) and Mizoram (30.9%) on one end of the spectrum and that of Uttarakhand (77.9%) and Delhi (75.7%) on the other end. An association was demonstrated between the literacy gap in any state and the percentage of ST population below the poverty line. The patriarchal social structure in mainland India and matriarchal structure in North-Eastern India were also evident in tribal population. Financial independence ranged from 29.5% in Andhra Pradesh to nearly 67% in Karnataka. Similarly, mobile phone penetrance among tribal women ranged from 25.8% in Madhya Pradesh to nearly 90% in Sikkim.
Conclusion:
While many households in these tribes still lack basic amenities, notable differences regarding maternal child health, education, health insurance, and overall empowerment were identified, supporting arguments for devising more sophisticated differential forms of intervention.
Keywords: Inequity, maternal child health, NFHS-5, tribal health
Introduction
The creation of an equitable society is among the top priorities of any civilized nation. In the Indian context, equity still seems a distant dream, considering the diverse races, ethnicities and linguistic sub-groups and the unequal distribution of resources among them. Family physicians are often the first point of contact between the population and the health system. They can encounter a wide range of beneficiaries, ranging from the upper socio-economic strata to the lower. Family physicians practicing in tribal-predominant areas need to be abreast with the nuances of tribal health, and their unique vulnerability to disease and disability. Among the vulnerable groups in India, the Scheduled Tribes (STs) are among the most disadvantaged socio-economic groups in India.[1] For much of the period of British rule in the Indian subcontinent, they were known as the depressed classes.[2]
The STs comprise about 8.6% of India’s population (according to the 2011 census).[3] The Constitution Order, 1950 lists 744 tribes across 22 states in its first schedule. Even within the STs, there are inequities among the tribes residing in various regions, based on race, gender, and religion.
This is the Decade of Action that calls for accelerating sustainable solutions to the world’s biggest challenges—ranging from poverty and gender inequality, climate change, marginalization, and closing the finance gap.[4] International standards were adopted in the Sustainable Development Goals (SDG) index for nine indicators, including the World Health Organisation (WHO) target of 50% reduction of anemia in women of reproductive age by 2025. Two goals—two (zero hunger) and five (gender equality)—demand special attention, as the overall country score is below 50.
India is a country with many tribes, all having diverse ethnicities, races, and religions. But inequities exist in the health, education, employment, and empowerment status of these diverse tribes based on socio-economic status and other factors. The inequity based on gender is well evident, and religion and race further lead to social exclusion. Many tribal communities are closely associated with forests and difficult-to-reach areas and have worse-off health and nutritional indicators.[5] Appropriate attention should be given to how these social determinants interplay in generating and sustaining inequity when designing policies and programs to reach equitable progress toward improved tribal health. Education is a key indicator for the socio-economic development of any community, social group, and society at large. Education and women empowerment are inter-related to each other. No doubt, education is the only means which would bring change in socio-economic and political rights of the tribal people.
The National Rural Health Mission launched in 2005 had identified eight states as Empowered Action Group (EAG) states with high population growth and poor indicators related to Maternal Child Health.[6] These states are Bihar, Chhattisgarh, Jharkhand, Madhya Pradesh, Orissa, Rajasthan, Uttarakhand, and Uttar Pradesh. These along with the eight North-Eastern states and Jammu and Kashmir and Himachal Pradesh have been given special focus to ensure the greatest attention where needed.[7] A similar grouping of states based on their tribal population and tribal health indicators is envisaged by the current study.
The current study aimed to document the inequities in maternal and child health, education, insurance, and empowerment among tribal population in various states of India.
Methodology
Ethical approval was waived off as the study involved only secondary data from publicly available databases. Further, the data has no identifying information and is freely available on the Internet, so further use and analysis is implied.[8] The database used was the National Data Analytics Platform (NDAP) developed by the National Institution to Transform India (NITI) Ayog, for giving easy access to all public data to the general population.[9] The first dataset used was the percentage of the total population below the poverty line (BPL) and it was merged with the dataset containing percentage of ST population BPL. A composite bar chart was created which showed both the datasets together. The next two datasets that were merged were: percentage of ST population BPL in 2009–10 and literacy rate of all population, ST population and gaps: Census 2011.
For the demonstration of health inequities in the tribal population, the dataset used was National Family Health Survey-5 (NFHS-5) state reports. Although the NDAP did not provide the needed granularity for filtering the data pertaining to tribal population, the state reports available on the NFHS-5 website did provide the needed information. The variables selected for the demonstration of health inequities were total fertility rate (TFR), percentage of pregnant women registered for pregnancy and receiving antenatal care from a doctor, contraceptive prevalence rate and unmet need for family planning, percentage of stunting, wasting, underweight and anemia among tribal children and health insurance coverage among adult tribal population in various states.
Educational inequities were demonstrated by comparing pre-school and school attendance among children from tribal households in different states. This dataset was also obtained from the NFHS-5 state reports for various states, as NDAP portal did not provide the needed granularity.
A heat and bubble map was created using the NDAP portal to demonstrate the relationship between poverty and the literacy gap in various states. The dataset on the percentage of ST population BPL was merged with the dataset containing the literacy gap of ST population for the creation of the heat and bubble map. The social and empowerment inequities among tribal females was demonstrated by the following variables from NFHS-5 state reports: percentage of tribal women making their own decision, owning a mobile phone, having their own money, and facing violence from spouse. A line chart was created using the percentage of ST seats in state legislative assemblies from the SDG Index by the NITI Ayog database merged with the proportion of the tribal population in any state from the 2011 census database. Another line chart was created using two different variables of the SDG Index NITI Ayog datasets on women empowerment: crime rate against women per 1,00,000 and cruelty against women by spouse per 1,00,000 women population.
Mean differences in continuous variables, proportions in categorical variables, and relative risks including odds ratios accompanied by their confidence intervals were computed using Statistical Package for Social Sciences (SPSS) software package version 26.
Results
The poorest states in India with the highest percentage of general population BPL were Chhattisgarh (36.4%), Jharkhand (34.2%), Bihar (33.0%), Madhya Pradesh (29.5%), Assam (28.8%), Uttar Pradesh (28.6%), and Odisha (28.5%). On the other hand, the states having the highest percentage of ST population BPL included Odisha (51.6%), West Bengal (47.3%), Madhya Pradesh (43.8%), Maharashtra (42.5%), Jharkhand (40.2%), and Chhattisgarh (43.9%). This clearly demonstrated that even prosperous states like Maharashtra and West Bengal have a sizeable BPL tribal population. The gap between these two percentages clearly demonstrated a disadvantage toward the ST population and was highest in West Bengal (28.2%), Odisha (23.1%), Maharashtra (25.6%), and Kerela (20.2%) [Table 1 and Figure 1].
Table 1.
Gap between the total population and ST population BPL
| State | Percentage of ST population BPL (%) | Percentage of the population BPL (%) | Gap (%) |
|---|---|---|---|
| Andhra Pradesh | 18.1 | 8.7 | 9.4 |
| Assam | 24.5 | 28.8 | −4.3 |
| Bihar | 34.8 | 33.0 | 1.8 |
| Chhattisgarh | 43.9 | 36.4 | 7.5 |
| Gujarat | 33.3 | 16.1 | 17.2 |
| Himachal Pradesh | 6.8 | 7.0 | −0.2 |
| Jammu and Kashmir | 9.7 | 9.7 | 0.0 |
| Jharkhand | 40.2 | 34.2 | 5.9 |
| Karnataka | 32.3 | 20.2 | 12.0 |
| Kerala | 27.3 | 7.1 | 20.2 |
| Madhya Pradesh | 43.8 | 29.5 | 14.3 |
| Maharashtra | 42.5 | 16.9 | 25.6 |
| Odisha | 51.6 | 28.5 | 23.1 |
| Rajasthan | 31.6 | 13.8 | 17.7 |
| Tamil Nadu | 19.8 | 11.2 | 8.6 |
| Telangana | 18.1 | 8.7 | 9.4 |
| Uttar Pradesh | 21.7 | 28.6 | −7.0 |
| Uttarakhand | 18.8 | 11.1 | 7.7 |
| West Bengal | 47.3 | 19.1 | 28.2 |
Figure 1.
Percentage of total and ST population BPL in 2009-10 and 2011-12 in various states (Tendulkar Method)
Health inequities
TFR measures the number of children a woman would have in the course of her life if the fertility rates observed at each age in the year in question remained unchanged.[10] It is evident that huge differences are observed in the TFR among the tribal population across the states, with the lowest in Sikkim (1.02) and Delhi NCT (1.24) and the highest in Bihar (2.98) and Meghalaya (3.07) [Figure 2].
Figure 2.
Inequities in total fertility rate among tribal population in various states
The inequities in maternal health were demonstrated using the NFHS-5 data on antenatal check-ups by a doctor and percentage of tribal mothers registered and having Mother Child Protection card. The inequities were evident with the lowest tribal pregnancy registration in Manipur (77.9%) and 100% registration in the southern states of Kerela, Goa, and Tamil Nadu [Figures 3 and 4]. Similarly, family planning is a matter of great concern as the contraceptive usage showed wide disparities with the tribal women of Meghalaya (28.0%) and Mizoram (30.9%) on one end of the spectrum and that of Uttarakhand (77.9%) and Delhi (75.7%) on the other end [Figure 5]. As a rule, it was observed that higher the contraceptive prevalence rate, lower the unmet need for family planning.
Figure 3.
Inequities in antenatal care among tribal pregnant women in various states as demonstrated by their registration status
Figure 4.
Inequities in antenatal care among tribal pregnant women in various states as demonstrated by the percentage of women receiving antenatal care from a doctor
Figure 5.
Inequities in family planning among tribal pregnant women in various states as demonstrated by contraceptive prevalence and unmet need.
The inequities in child health were demonstrated by the wide range of stunting, wasting, underweight, and anemia prevalence among tribal children in various states [Figure 6].
Figure 6.
Inequities in child health among tribal children in various states as demonstrated by the prevalence of stunting, wasting, underweight, and any anemia
Lastly, the gender inequities in health insurance coverage were demonstrated which showed wide variation in coverage ranging from 6.8% among tribal males in Uttar Pradesh to 86.8% among those in Goa [Figure 7].
Figure 7.
Gender inequities in health insurance coverage among tribal adults in various states
Educational inequities
It is well known that tribal children have poor school attendance as compared to their normal peers. The pre-school attendance ranged from 11.1% in Uttar Pradesh to nearly 80% in Andhra Pradesh. Similarly, the school attendance among tribal children varied from 71.4% in Madhya Pradesh to 96.2% in Himachal Pradesh [Table 2].
Table 2.
Educational and gender inequities among tribal population in various states
| State | ST Households (%) | Pre-school attendance among 2-4 years (%) | School attendance among 6-17 years (%) | ||||
|---|---|---|---|---|---|---|---|
|
|
|
||||||
| Male | Female | Total | Male | Female | Total | ||
| Arunachal Pradesh | 76.8 | 17.9 | 19.8 | 18.8 | 92.4 | 90.8 | 91.6 |
| Andhra Pradesh | 4.1 | 69.5 | 69.6 | 69.5 | 80.2 | 80.4 | 80.3 |
| Assam | 13.0 | 39.3 | 38.9 | 39.1 | 92.3 | 92.7 | 92.5 |
| Bihar | 3.8 | 29.9 | 31.4 | 30.5 | 80.3 | 76.8 | 78.6 |
| Chhattisgarh | 30.3 | 23.2 | 23.7 | 23.5 | 78.2 | 80.2 | 79.2 |
| Goa | 8.8 | NA | NA | 54.6 | 95.2 | 93.7 | 94.6 |
| Gujarat | 15.5 | 52.0 | 53.6 | 52.8 | 78.7 | 75.3 | 77.0 |
| Haryana | 1 | 17.1 | 13.6 | 15.1 | 74.4 | 77.2 | 76.3 |
| Himachal Pradesh | 5 | 62.9 | 62.8 | 62.8 | 95.7 | 96.8 | 96.2 |
| Jammu and Kashmir | 7.2 | 15.6 | 19.7 | 17.7 | 93.3 | 88.1 | 88.4 |
| Jharkhand | 28.2 | 12.5 | 14.9 | 13.7 | 88.8 | 78.1 | 79.3 |
| Karnataka | 10.8 | 34.9 | 42.4 | 38.5 | 92.9 | 87.4 | 89.1 |
| Kerela | 1.8 | 58.6 | 57.2 | 58.3 | 94.3 | 86.5 | 90.0 |
| Madhya Pradesh | 21.2 | 22.3 | 21.8 | 22.0 | 77.5 | 70.8 | 71.4 |
| Maharashtra | 11.0 | 59.7 | 64.1 | 61.8 | 84.8 | 81.5 | 83.3 |
| Manipur | 27.9 | 42.0 | 40.8 | 41.4 | 93.9 | 94.1 | 94.0 |
| Meghalaya | 89.3 | 25.2 | 27.9 | 26.6 | 88.0 | 92.8 | 90.4 |
| Mizoram | 94.6 | 36.5 | 30.8 | 33.6 | 95.0 | 92.2 | 93.7 |
| Nagaland | 91.5 | 14.4 | 19.1 | 16.8 | 90.0 | 92.0 | 91.0 |
| NCT Delhi | 1.6 | 35.5 | 35.5 | 35.5 | 87.6 | 83.7 | 85.9 |
| Odisha | 24.3 | 40.9 | 43.6 | 42.2 | 75.7 | 72.4 | 74.1 |
| Punjab | 0.6 | 29.6 | 32.9 | 31.1 | 78.3 | 85.1 | 81.5 |
| Sikkim | 35.3 | 53.3 | 64.7 | 58.4 | 95.0 | 93.5 | 94.1 |
| Rajasthan | 14.0 | 20.5 | 20.9 | 20.7 | 92.2 | 84.8 | 85.1 |
| Tamil Nadu | 1.9 | 37.7 | 15.1 | 28.9 | 84.1 | 84.1 | 84.1 |
| Telangana | 8.2 | 61.4 | 67.8 | 64.3 | 93.0 | 86.7 | 88.0 |
| Tripura | 27.5 | 45.2 | 41.8 | 43.4 | 95.1 | 88.4 | 88.7 |
| Uttar Pradesh | 1.7 | 12.1 | 10.2 | 11.1 | 72.6 | 75.3 | 75.0 |
| Uttarakhand | 2.9 | 37.8 | 31.0 | 33.9 | 87.3 | 85.0 | 86.1 |
| West Bengal | 5.9 | 52.7 | 50.4 | 51.6 | 93.9 | 85.4 | 86.1 |
Education is one of the foremost interventions for bringing out any socio-economic transformation. A literate person has a much better quality of life as compared to an illiterate person and also has better prospects for employment and livelihood opportunities. The literacy gap among the ST population is the difference between the literacy rate of the state and that of the ST population in the state. An association was demonstrated between the literacy gap in any state and the percentage of the ST population below the poverty line (as per the Tendulkar Method) [Figure 8].
Figure 8.
Heat map of India showing association between poverty and literacy gap in ST population in various states
Social inequities
The percentage of ST women who usually make specific decisions relating to their life ranged from 56.6% in Telangana to 95.2% in Nagaland. The patriarchal social structure in mainland India and matriarchal structure in North-Eastern India were also evident in tribal populations. Financial independence ranged from 29.5% in Andhra Pradesh to nearly 67% in Karnataka. Similarly, mobile phone penetrance among tribal women ranged from 25.8% in Madhya Pradesh to nearly 90% in Sikkim [Table 3].
Table 3.
Social and empowerment inequities in tribal women among various states (NFHS-5)
| State | Women who usually make specific decisions (%) | Women who have money that they can decide how to use | ST women have a mobile phone they themselves use | Emotional, physical, or sexual violence |
|---|---|---|---|---|
| Madhya Pradesh | 77.9 | 48 | 25.8 | 34.5 |
| Odisha | 76.4 | 45.6 | 33.4 | 35.5 |
| Uttar Pradesh | 67 | 53 | 41.3 | 43.5 |
| Haryana | 71.9 | 57.2 | 50.4 | 21.1 |
| Gujarat | 75.3 | 56.3 | 33.8 | 27.1 |
| Bihar | 75.6 | 40.6 | 42.1 | 39.6 |
| Chhattisgarh | 77.2 | 52.7 | 36.7 | 29.1 |
| Jharkhand | 78 | 46.5 | 40.8 | 38 |
| Andhra Pradesh | 66.5 | 29.5 | 45.1 | 38.0 |
| Punjab | 79.6 | 57.2 | 61.2 | 13.3 |
| Maharashtra | 63.1 | 47.3 | 33.2 | 39.5 |
| Tamil Nadu | 89.1 | 52.6 | 54.7 | 40.3 |
| Rajasthan | 62.8 | 45 | 34 | 30.3 |
| NCT Delhi | 72.1 | 56.6 | 73.8 | 25.8 |
| Uttarakhand | 81.4 | 39.6 | 52.4 | 18.9 |
| West Bengal | 71.8 | 52.9 | 32.1 | 37.8 |
| Telangana | 56.6 | 31.7 | 46.6 | 45.8 |
| Jammu and Kashmir | 68.4 | 41.6 | 59.8 | 15.8 |
| Tripura | 81 | 55.5 | 46.4 | 29.1 |
| Karnataka | 65.7 | 66.9 | 51 | 50 |
| Kerela | 71.5 | 47.6 | 66.1 | 14.1 |
| Meghalaya | 85.4 | 50.5 | 67.5 | 21.5 |
| Nagaland | 95.2 | 40.9 | 82.5 | 10.9 |
| Arunachal Pradesh | 77.9 | 53.5 | 79.2 | 26.3 |
| Assam | 81.1 | 32.3 | 59.5 | 33.9 |
| Mizoram | 87 | 33.2 | 82.4 | 12.5 |
| Manipur | 78.4 | 39.9 | 74.7 | 35.7 |
| Sikkim | 89.1 | 65.8 | 89.6 | 12.4 |
| Goa | 72.2 | 60.1 | 83.8 | NA |
| Himachal Pradesh | 63.6 | 63.8 | 74.7 | 6.5 |
The number of seats reserved for ST in the legislature is directly proportional to the proportion of ST out of the total population. This relationship is clearly visible from the line diagram [Figure 9]. In addition, close concurrence was seen in crime rates against women and rates of spousal cruelty [Figure 10]. The percentage of tribal women experiencing emotional, physical, or sexual violence at the hands of their husbands ranged from 6.5% in Himachal Pradesh to 50% in Karnataka.
Figure 9.
Line diagram showing close correspondence between the proportion of STs in a state compared to the percentage of seats reserved in the legislature for STs
Figure 10.
Line diagram showing the similarity in the crime rates against women and rates of domestic violence in Indian states
Discussion
The literature is replete with studies demonstrating health, education, and economic depravity among the tribal population in India.[11,12] Family medicine includes the newer areas of tribal health in which the unique idiosyncrasies and vulnerabilities of the tribal population are studied. Some of the diseases with a higher burden in the tribal population include tuberculosis, malaria, cataract, sickle cell disease, etc.[13–16] A previous study had compared the ST and non-ST inequality patterns at a fine-scale level in Karnataka, Arunachal Pradesh, and Madhya Pradesh.[17] The authors concluded that the absence of health inequalities in Madhya Pradesh indicates a uniform socio-geographical disadvantage while poor healthcare utilization by ST people in Karnataka indicates health inequities. The current study also reported gaps in tribal and non-tribal population in various states, and various patterns emerged which should guide the policymakers in the respective states. Programs addressing the health inequalities of STs need to consider site-specific assessments of socio-geographical and health system factors.
Another study from Kerela demonstrated that the predicted prevalence of underweight is 31 and 13% points higher for Paniya and other ST members, respectively, compared to their normal peers 18–30 years old (27.1%).[18] According to another study, there are issues like drop-out among tribal girls after upper primary level because of the critical issues like their early marriages and financial constraints.[19] Keeping in view their educational backwardness, low rate of enrollment, and high drop-outs after upper primary level among tribal girls, governments have to swiftly launch targeted policies and programs for their education and empowerment.
As per the recent data from NFHS-5, nearly one-third of the ever-married women reported to have experienced spousal violence, ranging from 10% in Himachal Pradesh to 48% in Karnataka.[20] Similar pattern of spousal violence was demonstrated in the current study among tribal women, ranging from 6.5% in Himachal Pradesh to 50% in Karnataka. In general, violence among tribals is less as compared to the general population. Another study from tribal areas of East India had demonstrated that the respondents from tribal areas had a better perception regarding gender equity compared to non-tribal respondents.[21]
According to the 2011 census, the tribal population constitutes almost 8.6% of the total population of the country, and the demographic statistics reveal that they have been underprivileged for many decades because of the mass number of the tribal population residing in different rural zones.[22] Like other social groups, tribal women have been facing problems related to reproductive health, economic backwardness, and education. Full immunization coverage is lowest among the ST population (56%) as compared to the national average of (62%) in India.[23] Understanding the bottlenecks and addressing the inequities to bridge the gaps is one of the mandates of UNICEF. The current study also highlighted the wide variations in child nutritional parameters among the tribal children like stunting, wasting, underweight, and anemia.
The current study explored the state-wise inequities in various indicators related to health, education, and empowerment among the tribal population in 2021. The study highlighted the wide range of values in health indicators like TFR, antenatal care, pregnancy registration, health insurance coverage, and under-five child nutrition. It is hoped that the states lagging in these indicators should devise tribal-focused initiatives to bridge the gap and bring the tribal population on par with those residing in other states. Education is a powerful means of bringing socio-economic upliftment to tribal population. The study clearly demonstrated the relationship between education gap and poverty. Finally, socio-economic determinants are deep-rooted with factors like gender equity, women empowerment, and financial independence indirectly influencing the disparities in health.
The study was one of its kind as it utilized the publicly available data on NDAP portal (NITI Ayog) and tried to deduce patterns of inequities in various domains. Other novel findings of the study include high rates of child malnutrition in better-off states like Maharashtra, Gujarat, and West Bengal, higher unmet need for family planning among states like Punjab and Sikkim despite higher contraceptive usage, poor ANC coverage by doctors in some EAG states indicating poor doctor population ratio, and lesser prevalence of spousal violence in tribals as compared to the general population.
It is hoped that this study which compares the tribal health among different states of India unwraps realities and paves way for state-specific action plans to address inequities for tribal welfare. The study emphasizes the need to focus on regions with poor health, education, and social empowerment to achieve universal health coverage by 2030.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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