Introduction

• Tribals constitute around one per cent of Tamil Nadu’s population
• Tribals are settled mostly in 12 districts. They are spread in 2860 villages located in 63 blocks
• A total of 173 PHCs and 611 health centers serve this population
• Tribal communities have not enjoyed adequate healthcare services - inaccessibility and cultural factors are the main causes

As one of the main aims of the Tamil Nadu Health Systems Project is to increase access to quality healthcare for poor and disadvantaged people, the Project undertook the task of improving healthcare services to tribal communities in Tamil Nadu.

Laying the foundation for better tribal healthcare

Adopting a systematic approach in tackling the challenge of providing healthcare services to tribal communities, initially, a tribal development plan was created. This plan was based on consultations with members of tribal communities, non-governmental organizations, and tribal development consultants. The plan was also influenced by studies done on burden of diseases involving the tribal communities, and health seeking behavior of tribal communities.

As a result of this plan, TNHSP undertook six interventions, including:

• Mobile outreach services to improve accessibility
• Diagnosis and treatment of sickle cell anemia
• Providing peer counselors
• Promotion of institutional deliveries
• Provision of bed grants and
• Activities to Inform, Educate and Communicate (IEC)

Taking healthcare to the tribals, ensuring utilisation and better health

The Project has carried out the following activities in each of the six interventions listed above.

• Mobile outreach services to improve accessibility
  To overcome accessibility issue, mobile outreach services were provided in partnership with non-governmental organizations in the districts of Nilgiris, Coimbatore, Dharmapuri, Krishnagiri, Vellore, Salem, Namakkal, Dindigul,
  Kanyakumari, and Villupuram. The services were monitored by the district administration. Vehicles equipped with a doctor, nurse, lab technician, and a pharmacist would visit difficult-to-access areas once in 15 days. In Nilgiris district, three vans were provided as it has a higher concentration of tribal population.

  Apart from out-patient services, the mobile outreach services also provide ante-natal and post-natal
  checkup. and newborns are provided vaccination. Laboratory services and IEC services are also provided. the
  expenditure for this programme is provided by the National Rural Health Mission.

• Diagnosis and treatment of sickle cell anemia
  Sickle cell disease is characterized by a mutation in the shape of the red blood cell from a smooth, donut-shape to a crescent or half moon shape. The cells lack plasticity and can block small blood vessels, impairing blood flow. This condition leads to shortened red blood cell survival, and subsequent anemia, often called sickle cell anemia. Poor blood oxygen levels and blood vessel blockages in people with sickle cell disease can lead to chronic acute pain syndromes, severe bacterial infections, and necrosis (tissue death). In Tamil Nadu, sickle cell anemia is prevalent mostly among tribal communities in the Gudalur and Pandalur taluks of the Nilgiris district. According to the studies done by ICMR and NAWA in this area, there is an estimated 500 patients with sickle cell disease, considering the current population of 25,000.

  In order to prevent and treat this disease, various interventions were undertaken. The approach was to combine screening and identification of sickle cell patients, along with counseling and treatment. Two NGOs, Ashwini Hospital, Gudalur and Nawa Hospital, Kotagiri, run these sickle cell anemia centers. A standard management protocol in diagnosis and treatment was developed and is followed in these hospitals. This consists of the following:
  1. A survey was done to find how many people had sickle cell anemia, and how many were likely to get the disease, so that interventions could be provided accordingly. Treatment cards were issued to positive patients.
  2. Premarital counseling was provided to ensure that two people with sickle cell anemia did not marry to ensure that any offspring they may have would not contract the disease.
  3. Out-patient services such as vaccination are provided against pneumococci and treatment for minor ailments
  4. During emergency, which occurs during a sickle cell crisis, blood transfusions are provided
  5. Hydroxy urea tablets are provided throughout the lifetime of a sickle cell anemia patient

• Providing peer counselors
  Counselors from tribal communities were appointed at 30 healthcare centers (25 hospitals, 5 primary healthcare centers) to increase the comfort-levels of the members of tribal communities accessing the hospitals. As these counselors are from tribal communities, they instill confidence and help in removing fears and apprehensions the tribals faced over the years. These counselors will assist patients from the tribal communities visiting hospitals and also maintain detailed records of their visits. The counselors were given training in HMDI Salem in November 2008 and reorientation training in March 2009. This intervention has helped increase attendance of members of tribal communities in hospitals.

• Promotion of institutional deliveries
  Women in tribal communities shy away from institutional deliveries because of inhibitions and other cultural factors, which leads to a higher preventable maternal and neonatal mortality and morbidity. To address this, a pilot programme was implemented by TNHSP in four primary health centers where expectant mothers are brought in from their place of residence to a PHC three days before their expected delivery date. The cost of shelter, medical attention, and food is taken care of by the State for the mother and an attender. Soon, this will be expanded to all tribal districts through the National Rural Health Mission.

• Provision of bed grants
  In two hospitals as a pilot program all the costs associated with inpatient care for tribals are reimbursed. This is administered through NGO partnerships. These hospitals are Aswini Hospital in Gudalur, Nilgiris, and NGO Hospital of Nilgiris Wayanad Tribal Welfare Society.

• Activities to Inform, Educate and Communicate (IEC)
  Sensitization workshops were conducted for leaders of the tribal communities on healthcare services provided, in CMC Vellore in May 2009 at Chennai. Apart from tribal leaders from 10 districts, this workshop was attended by NGO partners and other officials. Apart from healthcare issues, education and economic concerns were discussed.

  The recommendation from this workshop, and another consultative workshop conducted at Ooty in April 2009 have been shared with World Bank. It was decided that TNHSP along with other departments such as NRHM , DMS, and DPH will take care of the tribal healthcare issues. A committee with officials from various departments has been planned to tackle other issues.

Programme Brochure