Why Tribal Indians See Worse Maternal, Child Health

According to the Census of India 2011, the Scheduled Tribes population, numbering 104 million, constitutes 8.6% of the total population of the country. Madhya Pradesh (MP) has the largest ST population with 14.7% of the total ST population in the country (over 15 million), followed by Maharashtra (10.1% or over 10 million), Odisha and Rajasthan (about 9% or over 9 million each).

More than two thirds of the ST population lives in the seven states of MP, Chhattisgarh, Jharkhand, Odisha, Maharashtra, Gujarat and Rajasthan. However, the concentration of tribal population is highest amongst the North Eastern states, particularly Mizoram (94.4%), Nagaland (86.5%), Meghalaya (86.2%) and Arunachal Pradesh (68.8%).

A comparative analysis of health indicators from National Family Health Survey, 2015-16 and 2019-21 (NFHS 4 and 5) reveals both progress and disparities between tribal and all-India populations.

On progress, experts point out that either one group--that is, the tribal population--has noticeably improved, or the other group has plateaued. “There are two key points when looking at inequity or disparities between groups,” said ​​Rakhal Gaitonde, professor of public health at the Sree Chitra Tirunal Institute for Medical Sciences and Technology. “First, the tribal numbers may have improved. Second, the national average could have plateaued. Both scenarios would reduce inequity.”

Without specific figures, he suggested comparing the rate of change--the slope--between the national average and the tribal population. “My gut feeling is that the national average may be stagnating because reaching higher levels of achievement becomes increasingly difficult,” he said, adding that tribal communities might still be catching up. “The critical question is the rate of improvement--how fast is it? If the national rate is slowing down, that could also contribute to narrowing the gap,” Gaitonde explains. Our analysis bears this trend.

For instance, registered pregnancies among tribals increased from 83.8% to 94.3% during this period, surpassing the national figure of 93.9%. There is a five-percentage-point gap in births assisted by skilled professionals among tribals compared to the national average. The disparity shows up in fewer deliveries performed by doctors, and a higher percentage assisted by Dais or traditional birth attendants.

Overall, institutional deliveries among tribal women rose from 68% to 82.3%, narrowing the gap with all-India levels. While a quarter of deliveries across India were in private health facilities, one in eight among tribals were in private facilities.

“It is particularly important that all births are attended by skilled health professionals, as timely management and treatment can make the difference between life and death for the women as well as for the newborns,” according to the World Health Organization (WHO), as IndiaSpend reported in December 2024.

More tribal women are receiving antenatal care

Antenatal care helps reduce mortality rates among children and mothers. This includes periodic check-ups, immunisation, supplements and ultrasound to detect abnormalities. According to National Health Mission (NHM) guidelines, pregnant women are advised to receive a tetanus toxoid injection, take folic acid tablets for 100 days, and consume milk products and green vegetables.

Antenatal care by skilled workers improved for tribal women (72.9% to 81.8%), but remains below the national average (85.1%). Here again, the disparity shows up in fewer tribal women receiving such care from a doctor as compared to the national average. About two in three pregnant tribal women had undergone an ultrasound, compared to nearly four-fifths of all pregnant women in the country.

The percentage of women who received iron and folic acid supplements for more than 100 days is nearly equal to the national average, as is the share of pregnant tribal women who received tetanus toxoid injections.

Mortality rates fall, but are above national average

Child mortality rates are often used as an overall measure of population health, as well as to determine levels of social and economic development, as IndiaSpend reported in September 2018. The number of young children dying can indicate the ability of communities to access basic healthcare, adequate nutrition and clean water and sanitation.

There has been a decline in mortality rates both in all-India levels and tribal areas; however the rates for tribal areas remain higher than the respective national averages. For instance, one in 20 tribal children died before the age of five years, compared to about one in 25 across India.

Neonatal mortality--or the proportion of children dying in their first month after birth--among tribal populations declined from 31.3 deaths per 1,000 live births in 2015-16 to 28.8, still higher than the national average (24.9).

The infant mortality rate is not only a result of medical factors such as health infrastructure, antenatal care, maternal health, postnatal care, immunisations and the overall preventive health system but also of deeper social problems such as malnutrition and sanitation, we had reported in January 2020.

States with more educated women show better health outcomes for children, IndiaSpend reported on March 20, 2017. A child born in the wealthiest 20% households was about three times more likely to survive early childhood as compared to a child born in the poorest 20% families, IndiaSpend reported in January 2019.

“There has been significant improvement in basic health services, particularly in areas like antenatal care and immunisation, which have a major impact when mortality rates are high,” said Rakhal Gaitonde.

He pointed to maternal mortality as an example, explaining that when rates range between 150-300 per 100,000 live births, antenatal care can drastically reduce deaths. “However, once rates drop to around 70, as in Tamil Nadu a decade ago, more advanced interventions like skilled birth attendants are needed,” he said. When mortality falls below 30, intensive care becomes essential, requiring a shift in medical strategies at each stage.

Gaitonde also stressed the role of inequity in health outcomes. “The causes of a disease differ from the causes of its distribution,” he said. He cited tuberculosis as an example, noting that while it is caused by bacteria, its higher prevalence among poor communities stems from factors like hunger, immune suppression, and stress. “Understanding this distinction is crucial,” he added.

Vaccination rates on par

Between 2015-16 and 2019-21, immunisation coverage among tribal children aged 12–23 months improved, narrowing the gap with all-India averages. The percentage of fully vaccinated tribal children rose from 55.8% to 76.5%, compared to an increase from 62% to 76.5% nationwide.

Tribal children achieved near parity with all-India figures even for specific vaccines, such as the three doses of Hepatitis B, Penta/DPT, and polio vaccines. Coverage of the measles vaccine also improved, reaching 86.7% among tribal children compared to 87.9% nationally.

“High child mortality can be addressed through basic interventions like immunisation, regular schooling, and access to meals from ICDS (even if not at 100% coverage),” says Gaitonde. “These measures have a definite impact on reducing mortality, and we are already seeing the results. This progress builds on decades of development efforts, particularly since the National Rural Health Mission (NRHM) era which ensured consistent funding for sub-centers and PHCs, encouraging people to rely on public health services. More recently, initiatives like Mission Indradhanush have further contributed to these consistent efforts in reducing mortality rates.”

Nutritional status

Stunting--where a child is short for her age--among tribal children declined (43.8% to 40.9%), but remains above the national average (35.5%). Similarly, the prevalence of wasting--where a child has low weight for their height--among tribal children also declined.

India’s healthiest children are in states that provide the best maternal healthcare, IndiaSpend reported in January 2016. Further, the poor quality of health infrastructure, antenatal care, maternal health and postnatal care jeopardise the lives of children, we reported in January 2020.

“Stunting is a proxy for overall cognitive and physical underdevelopment,” according to a September 2017 report by the Bill and Melinda Gates Foundation, as IndiaSpend reported in January 2018. “Stunted children will be less healthy and productive for the rest of their lives, and countries with high rates of stunting will be less prosperous.”

Adults who were stunted at age two spent nearly one year less in school than non-stunted individuals, according to this study conducted by University of Atlanta in 2010, as IndiaSpend reported in July 2016.

Similarly, a study of Guatemalan adults found that those stunted as children had less schooling, lower test performances, lower household per capita expenditure and a greater likelihood of being poor. For women, stunting in early life was associated with a lower age at first birth and more pregnancies and children, according to this 2008 World Bank study.

A 1% loss in adult height due to childhood stunting is associated with a 1.4% loss in economic productivity, according to World Bank estimates. Stunted children earn 20% less as adults compared to non-stunted individuals, we had reported.

Further, experts say that early childhood malnutrition increases the risk of developing non-communicable diseases such as hypertension, diabetes and heart disease in adult life, as IndiaSpend reported in October 2019.

Anaemia prevalence rose across the country, both among children and in adults. A condition characterised by a deficiency in the number or quality of red blood cells--responsible for carrying oxygen throughout the body--anaemia can lead to symptoms such as fatigue, weakness, and shortness of breath.

This is a significant public health issue in India, affecting various demographics, particularly women and children as per the WHO definition. Anaemia among tribal women aged 15-49 years rose from 59.9% to 64.6%, exceeding the all-India increase (53.1% to 57%).

"Sickle cell anemia is prevalent among Warli women (a tribe in Maharashtra and Gujarat), yet many do not seek treatment despite experiencing chronic fatigue and low haemoglobin levels. Additionally, 23% of women do not consume folic acid and iron tablets during pregnancy due to misconceptions about side effects like yellow urine," says Roshini Alphanso, assistant professor at Nirmala Niketan and member of the Jan Swasthya Abhiyan, who conducted her research among the Warli community. Poverty, cultural practices, lack of nutrition awareness, and nutrition migration are among major factors contributing to anaemia in the community, Alphanso found.

Changing disease burden

Tribal populations are also seeing an increase in lifestyle diseases such as hypertension and high blood sugar.

“In Kerala, using NFHS data, we see that conditions like hypertension are increasing among the Adivasi community,” said Rakhal Gaitonde. He pointed to small studies conducted in regions like the Nilgiris and Gudalur in Tamil Nadu, and Thrissur in Kerala among others, which have found a high prevalence of stroke among certain tribal communities. “These rapid changes are concerning,” he said.

While governments continue to focus on traditional health indicators such as mortality, antenatal care, and immunisation--measures that remain critical--Gaitonde argued that emerging health challenges driven by lifestyle changes need greater attention. “Communities that once relied on forest produce are now consuming polished rice from the PDS, leading to significant issues like diabetes, hypertension, and obesity,” he said.

“So, while it’s encouraging to see reductions in child mortality, the rising burden of non-communicable diseases cannot be ignored,” he added.

Lack of healthcare infrastructure and personnel

India has only 0.7 physicians per 1,000 people, and most citizens must travel around 20 kilometres to access a hospital, as per World Bank data. As of November 2024, India has 1.4 million registered allopathic doctors, and assuming 80% availability along with 614,000 AYUSH doctors, the country’s doctor-population ratio stands at approximately 1:811—surpassing the WHO standard of 1:1000, according to a Rajya Sabha reply.

But these overall figures conceal disparities within the country. While health worker vacancies are on par with national averages, tribal areas have fewer specialist doctors, government data show.

“In the absence of health care services and lack of transportation, vulnerable tribes are deprived of timely health care facilities,” according to a 2017 report by the Comptroller and Auditor General (CAG) of India, as IndiaSpend reported in September 2019. Tribal groups have to cover a distance of five to 80 km to reach a community or district health centre, the 2017 CAG report said. Across India, people have to cover an average distance of 13.55 km to reach a community health centre, we had reported.

Poor infrastructure, including bad roads, limited transport, weak ambulance services, and unreliable phone networks, along with shortages of health personnel, inadequate equipment, language and social barriers, long waiting times, and poverty, severely hinder healthcare access in tribal regions, as per a report by the Expert Committee on Tribal Health constituted by the Ministry of Tribal Affairs and the Ministry of Health and Family Welfare.

Vacancies for doctors in primary health centres (PHCs) in tribal areas rose from 17.2% to 23.3%. Further, vacancies for nursing staff and auxiliary nurse midwives (ANMs) in PHCs and CHCs increased in tribal areas, with vacant ANM positions rising from 10.8% to 14.6% in tribal areas, compared to a decline in rural areas (27.1% to 18.4%).

The shortage of human resources in tribal health centres is driven by poor working conditions, inadequate facilities, lack of social infrastructure, and limited professional growth, leading to frustration due to weak systems, unfair transfers, and insufficient financial incentives. Despite measures like postgraduate reservations, additional marks for tribal service, higher pay, and compulsory rural service bonds, poor implementation and non-compliance have left the gap in health personnel unaddressed, with motivation and quality of care remaining serious concerns, as per a report by the Expert Committee on Tribal Health.

Moreover, doctors, specialists and other health workers are often missing, absent, ill-trained or ill-equipped to work in tribal areas, which are regarded as punishment postings thanks to poor infrastructure, absence of facilities and lack of avenues for personal and professional growth, as per a report by the expert committee on tribal health.

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