Health Systems Strengthening for Vulnerable Populations: Case study using south Indian Adivasi Health experience

Based on a plenary talk delivered at the 2nd State Conference of the Indian Association of Preventive & Social Medicine (IAPSM) at Yenapoya Medical College, Mangalore, Karnataka held on October 21 & 22, 2022

1. Health systems strengthening for vulnerable populations Lessons from working with Adivasi/ST communities (Kar, KER & Arunachal) Dr. Prashanth N Srinivas MBBS, MPH, PhD (Public health) Faculty & DBT/ Wellcome Trust India Alliance Fellow in Public Health (2017-22) Director, Institute of Public Health Bengaluru iphindia.org Recognised by Ministry of Science & Technology, Government of India as a Scientific Research Organization

2. Our 30-min journey Positionality & influences Social origins of disease & ill-health & locating “vulnerability” Public health research(er)’s engagement with social inequalities & identifying an agenda for transformative knowledge Role of health policy & systems research in deriving transformational knowledge Charting a research & health systems strengthening agenda for vulnerable populations 2 2nd State Conference of Indian Association of Preventive & Social Medicine ( Yenapoya Medical College, Mangaluru )

3. Positionality & Influences Medical doctor with entirely rural & community health practice Health policy & systems researcher with a conviction that public health knowledge (research) has to be transformative in terms of equity & social justice Critical realist in my perspective on nature of reality vis-à-vis its knowability Heavily influenced by community engagement and participatory action research as opposed to expert-oriented evidence (practice-based evidence & co-production) Non-Adivasi; born into urban socio-economically secure household due to father’s employment as a defense scientist with early (privileged access) to private English medium school 2nd State Conference of Indian Association of Preventive & Social Medicine ( Yenapoya Medical College, Mangaluru ) 3

4. Social origins of disease & ill health ” … physician, anthropologist, pathologist, prehistorian, biologist, writer, editor, and politician, known for his advancement of public health. “ 2nd State Conference of Indian Association of Preventive & Social Medicine (Yenapoya Medical College, Mangaluru) 4

5. What is vulnerability? T he extent to which an individual, community, place, structure, or organization is exposed to threat(s) Affects wellbeing multi-dimensional and differential (varies across physical space, among, and within social groups) scale dependent (with regard to time, space and units of analysis such as individual, household, region, system) dynamic (the characteristics and driving forces of vulnerability change over time) Source: Vogen & O’Brien, 2004

6. Dimensions of vulnerability Source: Huq & Hussain, 2015

7. Where does “disadvantage” or Vulnerability lie? Unfair localizing of blame on individuals – “blaming victims” “Vertical transmission” of social drivers – not only pathogens Invisibilising the service and the system Neighborhoods – the forgotten locus of interface with disease 7 2nd State Conference of Indian Association of Preventive & Social Medicine ( Yenapoya Medical College, Mangaluru )

8. How do we meaningfully engage with social inequalities as public health professionals/researchers? Reflections from work in partnership with Soliga and other Adivasi communities & collectives in southern Karnataka Identifying systemic entry points Reflexive practice – our own unconscious biases, norms and values uncritically embraced by our (colonial?) training, listening to other points of views….. Illustrations from our ongoing work on health inequities at IPH Bengaluru 8 2nd State Conference of Indian Association of Preventive & Social Medicine ( Yenapoya Medical College, Mangaluru )

9. “… behind everyone, everywhere ”* MMH Soliga photo Bhargav 9 * Anderson et. al 2016 The Lancet Bhargav Shandilya/ PLA Project Gaze 2nd State Conference of Indian Association of Preventive & Social Medicine (Yenapoya Medical College, Mangaluru)

10. 10 Lenses 2nd State Conference of Indian Association of Preventive & Social Medicine (Yenapoya Medical College, Mangaluru)

11. Bringing in theory & history 11 2nd State Conference of Indian Association of Preventive & Social Medicine (Yenapoya Medical College, Mangaluru)

12. Social construction of remoteness & disadvantage 12 Neighborhood disadvantage and access to healthcare - The case of sickle cell disease in two Adivasi communities in central and southern India Experience of remoteness in diverse socio-geographical settings in southern Karnataka 2nd State Conference of Indian Association of Preventive & Social Medicine (Yenapoya Medical College, Mangaluru)

13. Healthcare experience & patient rights 13 How adverse healthcare experience shapes Adivasi communities’ health-seeking behaviour in secondary & tertiary hospitals? Preliminary work on notions of patient rights among Adivasi communities Meena Putturaj Mahadevamma 2nd State Conference of Indian Association of Preventive & Social Medicine (Yenapoya Medical College, Mangaluru)

14. Driven by the problem/phenomenon 14 Asha George, Kerry Scott, Veloshnee Govender WHO Alliance for HPSR/HRH Reader 2nd State Conference of Indian Association of Preventive & Social Medicine (Yenapoya Medical College, Mangaluru)

15. 15 Why are systems failing in tribal health Common thread from NGO/social movement work in tribal areas: drivers of poor health status are pre-dominantly social, structural….systemic So, why & how are systems (not only services) failing tribal health? Source: CHC/SOCHARA Reframing the question systemically 2nd State Conference of Indian Association of Preventive & Social Medicine (Yenapoya Medical College, Mangaluru)

16. 2nd State Conference of Indian Association of Preventive & Social Medicine (Yenapoya Medical College, Mangaluru) 16 However, vulnerability is not only about large populations and natural disasters; individuals or households too can experience vulnerability due to various psychosocial, familial or other life circumstances. In either case – be it individuals or populations – an experience of vulnerability is almost never exclusively due to the individual’s own choices . A large body of work from social sciences, as well as stories and narratives of people who have dealt with vulnerabilities in their life, demonstrates that this experience is almost never caused in isolation. Prashanth N S (2018) Vulnerability as a threat. The Journal of the Christian Medical Association of India 33(3): 7-9

17. 2nd State Conference of Indian Association of Preventive & Social Medicine ( Yenapoya Medical College, Mangaluru ) 17 Vulnerability as a social construct Pregnancy as biological/physiological condition and pregnancy as a contextual bio-psycho-social event in a specific socio-geographical setting Menstrual pain as a biological condition vs menstrual pain experienced in diverse workplace, household & adverse/gender-blind settings Bereavement Anxiety about events….

18. 2nd State Conference of Indian Association of Preventive & Social Medicine (Yenapoya Medical College, Mangaluru) 18 Implications for systems that equalize rather than equitise … Primary health care Anganwadis Disease-control programs Ayusman Bharat – Arogya Karnataka …..

19. 2nd State Conference of Indian Association of Preventive & Social Medicine (Yenapoya Medical College, Mangaluru) 19

20. Transformative action on tribal health: Interventions & policy engagement 20 Transformative action on tribal health: Interventions & policy engagement Youth engagement through sports clubs (9) & inclusive public “platforms” 2nd State Conference of Indian Association of Preventive & Social Medicine (Yenapoya Medical College, Mangaluru)

21. Transformative action on tribal health: Interventions & policy engagement 21 Transformative action on tribal health: Interventions & policy engagement Healthcare navigation at secondary & tertiary care for Adivasi patients 2nd State Conference of Indian Association of Preventive & Social Medicine (Yenapoya Medical College, Mangaluru)

22. Transformative action on tribal health: Interventions & policy engagement 22 Transformative action on tribal health: Interventions & policy engagement Comprehensive action plan for GoK ST welfare on systemic gaps in tribal health 7 recommendations of which all accepted & funding secured; at least 2 implemented Tribal health research cell in medical colleges guidelines being written Representation of Solega & Koraga in national Adivasi platforms Policy engagement with Koraga & Solega social moment (ADEQUATE Project) Madesh Thammayya Susheela Kenjoor 2nd State Conference of Indian Association of Preventive & Social Medicine (Yenapoya Medical College, Mangaluru)

23. Transformative action on tribal health: Interventions & policy engagement 23 Agenda-setting on health and healthcare within the Solega & Koraga social movements Examining role of secure forest rights in health/healthcare Strengthening existing federeated Sanghatane among the Solega Total 105 FRC strengthening meetings conducted in Chamarajanagar district with1086 Adivasi membership. C.Madegowda 2nd State Conference of Indian Association of Preventive & Social Medicine (Yenapoya Medical College, Mangaluru)

24. Transformational Knowledge Lay Knowledge Organized knowledge Forest protection staff on ground Policymakers: Social welfare & health departments at state level Implementers District & taluka health managers Public health training Primary Health Care Epidemiologists Community-based organisations & tribal groups Wildlife biologists & Ecologists Social Science Hard Science 2nd State Conference of Indian Association of Preventive & Social Medicine (Yenapoya Medical College, Mangaluru) 24

25. Long-term Engagement through field station (Why is this left to NGOs?) 2nd State Conference of Indian Association of Preventive & Social Medicine (Yenapoya Medical College, Mangaluru) 25 Next steps

26. Deepening and expanding 26 2nd State Conference of Indian Association of Preventive & Social Medicine (Yenapoya Medical College, Mangaluru)

27. 27 27 Yogish CB Nityashri SN Sabu K U Sumanth M M Yogish C B Mahantesh S K Nandini Velho Julee Jerang Tanya Seshadri Mahantesh SK Collaborators : C Madegowda & ಜಿಲ್ಲಾ ಬುಡಕಟ್ಟು ಗಿರಿಜನ ಅಭಿವೃದ್ಧಿ ಸಂಘ, ಚಾಮರಾಜನಗರ , Deepa Bhat, (JSS Medical College) Giridhara Babu (Public Health Foundation of India), M D Madhusudan, Nandini Velho, Sumanth M Majigi (Mysore Medical College & Research Institute, Mysore), Tanya Seshadri (Vivekananda Girijana Kalyana Kendra & Institute of Public Health Bengaluru), Bruno Marchal (Institute of Tropical Medicine, Antwerp, Belgium) Mentors : H Sudarshan, Sundari Ravindran, Rakhal Gaitonde, Kishore Kumar Our team 2nd State Conference of Indian Association of Preventive & Social Medicine (Yenapoya Medical College, Mangaluru)

28. Acknowledgements India Alliance Grants Administrators: Sachin Sharma and Mahesh Reddy Upendra Bhojani , Pragati Hebbar , Tanya Seshadri, N Devadasan and Akshay Dinesh and several others among IPH staff & well-wishers; Devaki Nambiar, Sundari Ravindran & Rakhal Gaitonde; Giridhara Babu, Sumanth M M, Deepa Bhat, M D Madhusudan & Nandini Velho Vivekananda Girijana Kalyana Kendra (BR Hills) & Zilla Budakattu Girijana Abhivruddhi Sangha, Chamarajanagar District Administration and Zilla Panchayat of Chamarajnagar , particularly DHO Dr. Vishweshwarayya Department of health & family Welfare & ST Welfare departments in Chamarajanagar district Health, Forests & Environment, Rural Development and Panchayati Raj Department & ST Welfare departments, Government of Karnataka Forests and tribal affairs departments in Kerala Friends and colleagues from IPH Bengaluru Health equity cluster & other IPH Bengaluru colleagues 2nd State Conference of Indian Association of Preventive & Social Medicine (Yenapoya Medical College, Mangaluru) 28 THETA team (former and current; in alphabetical order of first names): Anika Juneja , Bhagya, Jose Thomas, Julee Jerang , Mahadevamma , Mahantesh Kamble , Madesh Thammayya , Mahesh, Shivamma , Nandini Velho, Nagesh, Nityasri S Narasimhamurthi , Pande Gowda, Puneet, Sabu K Kochupurackal , Santosh Sogal , Shekar, Susheela Kenjoor , Yogish Channabasappa