When we wrote last year in India Development Review about how neglecting healthcare delivery for India’s 104 million tribal people undermines India's ability to meet the UN's Sustainable Development Goals on hunger (SDG 2) and health and well-being (SDG 3), we had only an inkling of the looming public health crisis to come.

Fast-forward 14 months, and the gaps in healthcare are tragically plain to see. The ongoing onslaught of COVID-19 on rural and tribal populations has underscored the importance of investing not only in preventative and promotive healthcare, but also in robust primary health systems that are responsive to the needs of local communities.

Enter Anamaya, a tribal health collaborative, which was recently launched to "end preventable deaths for tribal and other marginalised communities across India." Anamaya seeks to bridge the large gaps in health and well-being indicators across tribal and non-tribal people in India, drawing on the strengths of collaborative initiatives across government, philanthropy, nonprofits, academic and research institutions, and the private sector.¹

Size and scale of the tribal health issue

Tribal populations across India score consistently lower on health and nutrition indicators and wider determinants of health, according to a compendium of district-level factsheets comparing tribal and non-tribal populations in India, released on April 7 2021.² (An exception is the northeast, whose large, resident tribal populations experience relatively better health than non-tribals.) These factsheets draw on the National Family Health Survey-4 data, as well as data gathered by the International Institute of Population Sciences and the Piramal Swasthya Management and Research Institute. Single district factsheets were developed for districts with at least 200 tribal households Smaller districts were merged geographically (geographically contiguous) to get to 200 tribal households. The compendium seeks to inform better decisions and support district governments in creating customized health interventions for their tribal populations. A few noteworthy national-level findings include:³

• Maternal health: Tribal pregnant women comparatively fare worse than their non-tribal counterparts on a range of maternal health indicators, such as receiving antenatal care in the first trimester (67 percent vs 71 percent), receiving four antenatal care visits (45 percent vs 52 percent), receiving full antenatal care during their pregnancy (16 percent vs 22 percent), consuming 100 iron and folic acid tablets on 100 days or more during pregnancy (26 percent vs 31 percent), delivering in an institution rate (69 percent vs 80 percent). Across all regions of India, a lower proportion of tribal women deliver in an institution. A higher proportion of tribal pregnant women are undernourished (31 percent) and anaemic (58 percent), when compared to non-tribal pregnant women (22 percent and 50 percent, respectively).
• Nutrition of women and children: A higher proportion of tribal children (21 percent) have low birth weight compared to non-tribal children. The prevalence of stunting, severe wasting, and underweight amongst tribal children under the age of five (44 percent, 10 percent, and 45 percent, respectively) is higher compared to non-tribal children (38 percent, 7 percent, and 35 percent, respectively).
• Determinants of health: A lower proportion of tribal households have electricity, a reliable source of drinking water, improved sanitation facilities, toilets, and clean fuel for cooking, compared to non-tribal households. For example, across India, only 19 percent of tribal households use clean fuel for cooking versus 47 percent of non-tribal. About 27 percent of tribal households across India have an improved sanitation facility, compared to 51 percent of non-tribal households. (Only in the northeast do tribal households have better sanitation facilities than non-tribal households.) Across all regions of the country, nearly 64 percent of tribal households do not have access to a toilet facility, compared to roughly 36 percent of non-tribal households. Similarly, literacy rates among tribal women in all parts of India other than the northeast, are far lower (54 percent) than non-tribal women (70 percent). Tribal men are also less literate than their counterparts by almost 10 percentage points.

These considerable differences show that India has not made adequate progress on the health and hunger (which includes nutrition indicators) SDGs for its tribal people. There is urgent need for concerted and inclusive action to improve their health status.

Collaborative action

The Expert Committee on Tribal Health, chaired by Dr. Abhay Bang, issued a report in 2018 which recommended the creation of a functional and sustainable system of healthcare for tribal people by 2022. Drawing on the committee's report, and on learnings from the sector and from consultations with tribal health experts, Anamaya was launched on April 7, 2021, on World Health Day. The collaborative brings together multiple stakeholders that want to create a positive impact on tribal health in India, including the Government, philanthropies and other donors, nonprofits, academic/research organizations, and the tribal community.

Anamaya will have two main roles to deliver improved tribal health outcomes: first, to facilitate implementation of primary health interventions by the Government and nonprofit actors in tribal areas, adopting a health systems approach, and second, to develop and disseminate knowledge specific to tribal health. The collaborative's efforts will be underpinned by an open health technology platform to enable evidence-based decisions and empower health workers and patients.

To facilitate implementation, Anamaya will focus on improving the quality of the following health system components:

• Increasing awareness and generating demand for health services through community participation and ownership. This would involve supporting interventions such as village health, sanitation, and nutrition days, and behaviour change using approaches like participatory learning and action.
• Working closely with public health and other administrative bodies at the district, state, and national level on health processes and standards; operationalizing health and wellness centers, and first referral units; and introducing supportive supervision of health workers.
• Developing the capacity of health human resources, and ensuring leadership and accountability for improved health outcomes.
• Building a robust public health information platform to enhance doctor-patient experience.

The knowledge role seeks to address the large research gaps in tribal health by collating learnings and best practices from the field, creating a repository of standard operating procedures, and developing toolkits for effective primary healthcare delivery. The technology backbone of the collaborative will enable systematic compilation of data and knowledge for effective decision making. The aim is not only to develop new knowledge systems but also to disseminate research and learning widely through peer-reviewed publications, stakeholder convenings, media engagements, and other channels, to inform policy and effect systemic change.

Anamaya's range of partners recognize that no one organization—however well-resourced—can singlehandedly solve India's tribal health challenges. Its core partners such as the Piramal Foundation and the Bill & Melinda Gates Foundation have committed unrestricted funding as well as their expertise and support in designing and governing the collaborative. Other partners include, inter alia, funders, implementing organizations, technical partners, research and knowledge agencies, and monitoring, learning, and evaluation specialists.

As noted by Ajay Piramal, founder of Piramal Foundation, "Collaboration requires a long-term commitment. The problems we face will not be solved in one or two years. Over a 10-year period, Anamaya aims to improve lives of more than 100 million tribal and marginalized people and save more than 500,000 lives across diseases."

Dr. Shailendra Kumar B. Hegde is a senior vice president and head of Public Health Innovations at Piramal Swasthya, a part of Piramal Foundation. In this capacity, Dr. Shailendra takes care of design and implementation of all pilot projects being implemented by Piramal Swasthya, ranging from tribal maternal and child health initiatives to cancer screening. Dr. Shailendra has led Swasthya’s efforts in establishing Anamaya, the tribal health collaborative, to improve the health status of tribal communities in India. He has co-authored over 30 publications in reputed national and international medical journals.

Pritha Venkatachalam is a partner at The Bridgespan Group’s Mumbai office. She has advised governments, donors, philanthropists, and non-profits on a range of global development and social impact opportunities. She is currently leading Bridgespan’s partnership with Piramal Swasthya on designing and implementing the tribal health collaborative. Previously, Pritha established and led Dalberg Global Development Advisors’ New Delhi office. She was also a partner and director at Cambridge Economic Policy Associates (CEPA), UK and set up their first international office in New Delhi. Pritha is an alumna of IIM, Bangalore and the London School of Economics. She has received the Citibank Leadership Award, and has published widely on philanthropy, global health, and development.