Social Assessment and Tribal Health Nutrition and Population Plan for the HNP Sector Program (2005 to 2010) IPP98

Transcription

1 Public Disclosure Authorized Public Disclosure Authorized Public Disclosure Authorized Public Disclosure Authorized k IPP98 MINISTRY OF HEALTH AND FAMILY WELFARE Social Assessment and Tribal Health Nutrition and Population Plan for the HNP Sector Program (2005 to 2010) November, 2004 A Document Prepared by MOHFW, Government of Peoples Republic of Bangladesh for Public Release

2 i U Pll Abbreviations ADB AIDS ALRI/ARI ANC APR BBS BCC BCG BINP BWHC CAR CBR CC CDR CIET CMMU CPR DDS DGFP DGHS DH DHS DP DPA DPT EIS ELISA EmOC EOC EPI ESP FP FPHP FWA FWC FWV FWVTI GOB HA HDS HEU HIU HIV HKI Asian Development Bank Acquired Immune Deficiency Syndrome Acute (Lower) Respiratory Infection Antenatal Care Annual Program Review Bangladesh Bureau of Statistics Behaviour Change Communication Bacillus Chalmette Guerin (Tuberculosis) Bangladesh Integrated Nutrition Programme Bangladesh Women's Health Coalition Contraceptive Acceptance Rate Crude Birth Rate Community Clinic Crude Death Rate Community Information & Epidemiological Technologies Construction & Maintenance Management Unit (MOHFW) Contraceptive Prevalence Plan Drug and Dietary Supplement Kit Director - General (Family Planning) Director - General (Health Services) District Hospital Demographic and Health Survey (Macro International) Development Partner Direct Program Aid Dipteria/Pertussis/Tetanus Epidemiological Information System Enzyme Linked Immuno Sorbent Assay Emergency Obstetric Care Essential Obstetric Care (Basic / Comprehensive) Expanded Immunization Program Essential Services Package Family Planning Fourth Population and Health Program Family Welfare Assistant Family Welfare Centre Family Welfare Visitor Family Welfare Visitor Training Institute Government of Bangladesh Health Assistant Health and Demographic Survey (BBS) Health Economic Unit Health Information Unit Human Immuno-deficiency Virus Helen Keller International

3 HPSP Health and Population Sector Program HRD Human Resource Development ICDDR,B International Centre for Diarrhoeal Disease Research, Bangladesh IDU Injecting Drug User IEDCR Institute for Epidemiology and Disease Control and Research IMCI Integrated Management of Childhood Illnesses IPH Institute for Public Health IST In-Service Training IUD Intra Uterine Device LD Line Director LE Life Expectancy MAU Management Accounts Unit (MOHFW) MCWC Maternal and Child Welfare Centre MICS Multiple Indicator Cluster Survey (UNIECF) MMR Maternal Mortality Ratio (Number of maternal deaths / 1000 live births) MMRate Maternal Mortality Rate (Number of maternal deaths / 1000 women ag d years) MO Medical Officer MOHFW Ministry of Health & Family Welfare MOU Memorandum of Understanding MSM Men who have Sex with Men MTR Mid Term Review NCES National Coverage Evaluation Survey (for EPI) NGO Non Governmental Organization NID National Immunization Day (for Polio vaccination and Vitamin A) NIPHP National Integrated Population and Health Program (USAID) NNP National Nutrition Programme OBGYN Obstetrics and Gynecology ORS/ORT Oral Rehydration Salts / Oral Rehydration Therapy PFC Project Finance Cell PIP Program Implementation Plan PM Program Manager QA Quality Assurance RHF Recommended Home Fluids (to treat diarrhoea) RIBEC Reform in Budgeting and Expenditure Control Project RPA Reimbursable Program Aid RTI Reproductive Tract Infection SDS Service Delivery Survey SM Syndromic Management STD Sexually Transmitted Disease STI Sexually Transmitted Infection SW Sex Worker TA Technical Assistance TB Tuberculosis TBA Traditional Birth Attendant TFIPP Thana Functional Improvement Pilot Project

4 TFR THC THNNP UHFP UHFWC UMIS UNICEF UPHCP USAID VA VGD VRS WHO Total Fertility Rate Thana Health Complex Tribal HNP Plan Union Health and Family Planning Union Health & Family Welfare Centre Unified Management Information System United Nations Children's Fund Urban Primary Health Care Project United States of America International Development Verbal Autopsy Vulnerable Group Development Programme Vital Registration System World Health Organization

5 Table of Contents ABBREVIATIONS.... LIST OF TABLES... EXECUTIVE SUMMARY SECTION I 1 INTRODUCTION CURRENT HNP PROVISIONS FOR TRIBAL PEOPLE INPUTS FOR DEVELOPING THIS TRIBAL PLAN SITUATION OF TRIBAL POPULATION TRIBAL COMMUNITIES AND DIVERSITY DISTRIBUTION OF ETHNIC COMMUNITIES BY LINGUISTIC AFFILIATION SITUATION OF HNP STATUS IN TRIBAL AREAS CONSULTATIONS FOR EVOLVING TRIBAL PLAN, ISSUES RAISED AND SUGGESTED INTERVENTIONS SUGGESTIONS FROM TRIBAL REPRESENTATIVES VIEWS OF TRIBAL WOMEN AND MEN EXPRESSED DURING FGDs SUGGESTIONS FROM WORKSHOP PARTICIPANTS.24 7 ACTIVITIES SUGGESTED FOR IMPROVING HNP STATUS OF TRIBAL PEOPLE..26 SECTION II 8 RATIONALE FOR TRIBAL PLAN GOAL AND OBJECTIVES OF THE TRIBAL PLAN PREREQUISITES FOR DEVELOPING AN ACTIONABLE TRIBAL PLAN STRATEGIES FOR TRIBAL HNP PLAN TRIBAL PLAN FOR FOCUSING RESOURCES AND ACTIVITIES OF HNPSP FOR IMPROVING HNP STATUS OF TRIBAL INTERVENTIONS TO TARGET TRIBAL POPULATION AT UNION LEVEL CULTURALLY AND LINGUISTICALLY SENSITIVE SERVICES (CLSS) TRIBAL PLAN TO TAKE INTO ACCOUNT NEEDS OF TRIBAL PEOPLE IN CHT AND THOSE IN OTHER 61 DISTRICTS VILLAGE LEVEL SUB-CENTRE FOR IMPROVING HNP SERVICES DECENTRALIZATION AND ENSURING LOCAL PARTICIPATION ROLES THAT THE TRADITIONAL LEADERS COULD PLAY FOR INVOLVEMENT OF TRIBAL GROUP ACTIVITIES REQUIRED FOR OPERATIONALISATION OF TRIBAL PLAN DURING HNPSE ACTION PLAN FOR INTEGRATION OF TRIBAL PLAN IN HNPSP INSTITUTIONAL MECHANISM AND IMPLEMENTATION PLAN FOR TRIBAL HNP PLAN 48

6 14 MONITORING AND EVALUATION TIMELINE FOR THNPP IMPLEMENTION BUDGET ANNEX-1 DISTRICTS WITH TRIBAL POPULATION WITH ABOUT 5000 POPULATION (ESTIMATED FOR 2001) ANNEX-2 AN OVERVIEW OF HNP SERVICES IN BANGLADESH....S8 ANNEX-3 LIST OF PEOPLE MET REFERENCES.63

7 I 1 1 List of tables Table 1: Details of FGDs carried out among poor women and men in CHT Table 2: Name of tribal communities and districts where they are found in Bangladesh Table 3: Some available information useful for planning interventions for tribal and tribal are as.19 Table 4: Prerequisites for preparing a plan for providing culturally and linguistically sensitivi-, services (CLSS) to tribal people Table 5: Comparison of HNP sub-components and tribal plan Table 6: Plan of action for successful integration of tribal plan in HNPSP Table 7: Time line for THNPP implementation Table 8: Description of budget line items of THNPP during six financial year Table Al: Tribal population with about 5000 population (estimated for 2001). 55

8 Executive Summary 1. Background Tribal groups in Bangladesh have their own set of languages, social structures, cultures and economic activities. They are at varying level economic and education development. T ey also live in sparsely populated and difficult to access terrains such as forests and hilly regio ns. Any development activity or provision of services needs to take into account these soc iocultural, economic, as well as spatial aspects. For HNP services to be effective in ar as inhabited by tribal groups or to reach HNP services to tribal people, a concerted effort has to be made. Key issue here is how to make HNP services socially and linguistically sensitive, so t hat ethnic groups, such as tribal people, access and utilize the services provided by governme nt. Discussion with tribal people, representatives of tribal groups and experts reveal that tri al depend on native medicine men or tribal healers for health care services. Access to nea est health facility, attitude of providers, language difficulties, and health seeking behaviour of tribal people largely limits effective utilization of HNP services. There is a general consen sus to recognize the need for providing culturally and linguistically sensitive services in tribal ar a. 2. Activities under HNPSP For this purpose a Tribal HNP Plan (THNPP) is suggested here to provide the interface for effective implementation of HNP programme in tribal areas and for tribal people. T P would systematically operationalise a plan to make HNP services culturally and linguistic lly sensitive to tribal needs. The components of THNPP are identifying areas (unions) with 25 per cent tribal population; empowering tribal people to plan for their HNP services and particip ate in stakeholder committees at District, Upazila and Union Level; give a choice for establish ng village level health centres; training of fieldworkers for providing services at these centres or hiring of qualified doctors; training of providers operating at District, Upazila, Union, and C Cs to be sensitive to the needs and expectations of tribal people in that area; developing and implementing a BCC strategy for providers (to bring about attitudinal change) and users (to encourage them to seek appropriate care); an effective monitoring and evaluation process to ensure completion of all these activities with desired outputs and outcomes. Absence of reliable data on proportion of tribal population at union level, ethnographic stud ies as well as non-availability of disaggregated data for tribal (surveys and MIS) is the obstacle for operationalising the THNPP. Therefore, MOHFW would hire agencies to obtain th se information through systematic ethnographic studies, with components of socio-demograpl ic, health, and nutrition for operationalising the tribal HNP plan. 3. Implementation and institutional arrangement: National: Secretary, MOHFW will be responsible for implementation and monitoring of Tribal HNP plan (THNPP). Secretary, together with steering committee shall review the progress of implementation of THNPP during its quarterly meetings. Line Directors (LD) of respective Operational Plan (ESP, BCC, HRD etc.) will include relevant tribal plan activities in

9 their operational plans (OP), implement and monitor by compiling report with inputs from unions, upazila and district levels; and send report to steering committee. Annual Progrim Review (APR) will review the progress of THNPP. District and Upazila: Management committees at District, Upazila, and union level would be responsible for monitoring the progress of Tribal HNP Plan. Chairperson of these committ es would include in their monthly meeting agendas activities implemented under Tribal HNP p an and review the progress at union level. 4. Monitoring and evaluation Sampling design of evaluation studies would include tribal districts/unions on a representat ve basis. During the implementation of HNPSP THNNP would monitor increased knowle ge HNP services, importance of seeking HNP services for well being of women, children, ag ed and men, and communities' involvement in managing HNP services at local level. Conmui ity monitoring at village health centre, CCs, UHFWCs, and UJHC, a key issue of tribal plan, wo ild strengthen inputs to M&E by helping to capture information that would have gone unrecor ed due to socio-cultural barriers and gender discrimination faced by communities, especia lly vulnerable groups. These data would demonstrate the extent to which tribal people hz ve participated in and benefited through the implementation of tribal plan. For the purpose of evolving an effective M&E a consultative workshop would be held for finalizing indicators for M&E on obtaining ethnographic information on various tribal grou s, their needs, as well as identification of unions with 25 per cent of tribal population. A basel ne survey using a cluster sampling procedure would establish the values on these identif ed indicators and same would be measured annually to track the progress of THNNP activities as well as impact of HNPSP. Annual independent evaluation would be carried out to assess [he progress of implementation as well as outcome. The following indicators would be monitor d: * Data base on tribal health indicators established and incorporated in MIS by end FY07 * Proportion of tribal utilizing HNP services increased by 50% from the baseline by end FY Budget: Estimated budget for five years during HNPSP ( ) is Taka 155 mill on (about US$ 2.58 Million).

10 Section I I l 11P* I

11 I 1I F1' 1 Introduction Tribal communities of Bangladesh cannot be considered as one homogeneous group. T ey belong to different ethno-lingual communities, profess diverse faith and are at varied/differ ent levels of development- economically, educationally and culturally. There are more than 45 distinct tribal groups in Bangladesh spread across all the districts with varying proportio s. Most of them inhabit difficult to access hilly terrains or forest regions. Many of these tri al groups are also characterized by slow/low growth rate compared to mainstream populati n. There are three predominantly tribal districts (Rangamati, Khagrachhari and Bandarban) wh ere about 14 districts have more than 1 per cent of tribal population; rests of the districts have 1.ss 1 percent of population. A multi-pronged approach is required to address HNP problems. It should be area specific and need based. Since the tribal groups are distributed in varying proportion, characterized by diverse social, cultural and economic situations and at different stages of development a n ed based approach in a geographically contiguous areas would be appropriate. 2 Current HNP provisions for Tribal people Currently health care for tribal in CHT and in other areas are provided through the exist ng network of government health and family planning services and private providers. It is expected that when NNP is scaled up to cover more number of upazilas some of the tribal ar eas and tribal groups are likely to benefit from nutrition programme. The network of facili ies currently available for HNP services in Bangladesh is in the Annexure II. In CHT, GOB has a special development program, which is implemented with UNIC EF support. UNICEF has recruited and trained tribal workers, and in a number of key social ar eas including primary education and primary health care the program has been effective. 1 he recent agreement between GOB and the CHT tribal groups to end a long-standing insurge cy in the area should make it possible to significantly improve implementation of the C HT program. Tribal groups live in areas, which are often difficult to access. In Bangladesh protrac ed insurgency in CHT, difficult terrain, poorly developed communication network hampe red setting up of service networks and their effective functioning. Distinct social, cultural and linguistic aspects further affected utilization of effective services. Information on tri bal groups' perception of HNP services, their specific needs and their preferences have not b Xen considered for improving access and utilization of services. Worldwide tribal have lesser access to services provided by government or private sectors ue to their distinct socio-cultural and language as well as type of physical environment they 1 ve in: forest, hilly terrain, desert, etc. Tribal communities in Bangladesh also share some of th ese issues affecting ethnic groups' in benefiting from existing services.

12 What emerges through discussion with experts and a few micro-level studies is that tribal still depends on tribal healers, private providers, hospitals and clinics run by missionaries alnd NGOs. 3 Inputs for developing this tribal plan Social assessment for HNPSP provided the required inputs for evolving this tribal pl i. Objective of social assessment was to assess the likely impact of the programme on 1he vulnerable population and gain relevant understanding of the social underpinnings End incentives determining behaviors of various stakeholders in the implementation of HNPSP 1. A stakeholder-involved approach guided the process of data collection. Given the time fra ne the following methods were used for obtaining the information required for carrying out the social assessment: i. Secondary data collection ii. Desk review of reports, published and unpublished iii. Focus group discussion with poor women and men iv. In-depths interviews with key informants, and v. Stakeholder workshop Secondary Data Collection: For secondary data collection offices of MOHFW, van us directorates, concerned programme offices of donors, NGOs and research / consulting fi s were visited. In addition to this information were also obtained through internet key w rd search and visiting websites of GOB, UN Agencies, multi -lateral and bi-lateral agencies E d NGOs. Desk Review: The documents collected through this process were reviewed to understand he current situations of Health, family welfare and nutrition in Bangladesh. This review so helped to understand various issues affecting vulnerable groups in utilizing these servi es. Both published and unpublished documents were reviewed. Documents reviewed inc de published books and articles as well as unpublished books, reports, PIP of HNPSP, Operatio al Plans of HNPSP, Policies and strategy documents, and operational research papers. In-depths interviews with key informants: Based on the understanding gained through t is literature a plan was prepared for conducting key informant discussion with a few governm nt functionaries, programme managers / key persons of development partners, researchers at consulting agencies and NGOs. Discussion points varied for each key informant intervie vs. However, the emphasis was in understanding current mechanisms for vulnerable groups, best practices and suggestions for effective implementation to improve coverage and utilization. Specific objective social assessment is to provide inputs for developing intervention ensuring: issues of so ial inclusion, poverty and gender equity and risks to potentially vulnerable segments of the population are consid red and addressed; and that design and social interventions take account of capacity at the community and other le els to enable participation, enhance service delivery, and monitor results.

13 Focus Group Discussion with poor women and men: To sutpplement the information obtained through literature review and key informant interviews, 16 FGDs were conducted amongst poor women and men in rural areas. The details of the FGDs carried for given below: Method: Focus Group Discussion Tool: FGD guideline Respondent Categories: 1. Poor Women; and 2. Poor Men Number of Districts : Four Districts. Tribal population and lower performance in hea th, family planning and nutrition indicators were considered for selecting two districts. Remain ng two districts were selected in such a way to cover the CCs currently managed by Community Management Group supported by NGOs Number of Villages in each District: Two Villages to be selected in a Union in each district: 1. One village locate close to UHFWC 2. One remote village located away from UHFWC but close to a CC. Number of FGDs in each village: I FGD among poor men and 1 FGD among poor women. Details of FGDs carried out: Table 1: Details of FGDs carried out among poor women and men in CHT Division District Upazila Union Village Poor Total Women _ Chittagong Khagrachha Khagrachhar Bhaibon Headman para ( ri i Chara Kms) Village close to UHFWC Kaladhan Bara para (5.5 Kms). Remote village located away from UHFWC but close to a CC. Charafra (7 K.Ms from UHFWC and CC is located in the village) Remote village located away from UHFWC but close to a CC. (NGO working in this village is BORD) l Raja Rampur ( Kms) Remote village located away from UHFWC but close to a CC.

14 Stakeholder workshop: The draft report was shared in stakeholder workshop. In addition the participants are discussed in small groups on issues pertinent for refining the social assessm9nt for HNPSP. The themes discussed during the stakeholder workshop were: * Tribal plan for health, nutrition and family planning. * Plan for vulnerable groups (Poor, women and disabled persons) * Health, nutrition and family planning in disaster prone areas, and * 'Voice' and stakeholder participation in preparation, implementation and monitoring of HNPSP * Functional coordination for health, family planning and nutrition service delivery * Plan for making CCs functional 4 Situation of Tribal Population Kibriaul Khaleque, a Sociologist has done detail literature review highlighting inadequ te information available on tribal communities in Bangladesh. Paucity of information of tri bal communities' points to the fact there has been no systematic efforts to understand tri bal cultures, their distinct traditions, worldview and needs. Most of the recent information is anecdotal. Given below is an excerpt from an article written by Khaleque, which as published by Society for Environment and Human Development (SEHD), Dhaka, Bangladesh. "The earliest sources on the tribal communities of Bangladesh consist of a few bo ks written by British Government officials during the period between the middle of 1 th century and the first quarter of 20th century. These classical sources include: Dal ton (1872), Gait (1895), Gurdon (1907), Hodson (1908), Hunter (1876), Hutchin on (1906), Lewin (1869; 1870; 1873), Playfair (1909), Riebeck (1885), Risley (1891), zaid Smart (1866). Census Reports and District Gazetteers compiled during the British rle contain valuable information about the ethnic communities and hence these docume nts may be regarded as good sources. Such official documents had been updated in he subsequent period. But except for a continuation of the old tradition of preparing th ese documents, no significant research had been done in the post-british period... the Government documents prepared during the Pakistani rule ( ) contain v ery little new information. These were basically a reproduction of the older sources. "he same is the case with the only book, "Pakistaner Upajati" (1963), published by the Pakistan Government. Besides the above sources, we find a few books and artic les published during the middle of 20th century. These sources contain the findings of a ew foreign anthropologists who did field research or at least had visited the ethnic ar as during this period. Thus mention may be made of the works of Bernot (1957; 19 58; 1964), Bessaignet (1958; 1960), Brauns (1973), Kauffman (1962), Levi-Strauss (195 a; 1952b), Sopher (1963; 1964). Most of these studies were concerned with the eth nic communities of the CHT and a very few on the ethnic groups living in the north rn borders of Bangladesh. Among the recent sources, there are a few books written by a Bangladeshi amateur writer (see Sattar 1971; 1975; 1978). The facts presented in th ese books are based either on the classical sources, or on the hearsay, and/ or the superfic ial knowledge gained by the author through his occasional visits to the ethnic areas. The

15 author has neither any background in anthropology or sociology (d. Maloney 1984:9), nor does he have any training in research methodology. As a result, the contents of these books suffer from many shortcomings. A recent book, "Tribal Cultures of Bangladesh" (Qureshi 1984) may be regarded as a good source. Some of the articles in this book had been contributed by professio nal anthropologists, some by students of anthropology or sociology who were engaged in research on ethnic communities at the time of writing their article, while some artic les by persons well informed in ethnic affairs. However, this book also contains a f ew articles written by amateur writers. Among the most recent journal articles written by professional anthropologists End social scientists, we may include: Bertocci (1984), Islam (1981), Jahangir (19 9), Khaleque (1983a, 1983b, 1984, 1985, 1988), Mey (1978), Montu (1980), and ZanLan (1982). There are also some mimeographs (see for example, Chowdhury 1979), and theses and dissertations (Khaleque 1982, 1992; Rahman 1985) which contain valua le recent data on some ethnic communities. The most recently published ethnographic accounts on specific ethnic communities of Bangladesh that I came across are: The Paharias by Gomes (1988) and Banglades her Garo Sampradai (in Bengali) by Jengcham (1994). The former is based on the auth r's research among the Paharia people, while the latter is based on the author's observat on of his own society and culture" (Khaleque, 2001). In Bangladesh there are about 45 tribal communities. In 1991 there were about 1.2 mil on which is about 1.13 per cent of the country's total Population 2. Tribal forums claim about 2.5 million as the current population size. Assuming a decadal growth rate of about 1.47 he current estimated tribal population based on 1991 Census, would be about 1.9 milli Dn. Proportion of tribal population in the 64 districts varies from less than one per cent to ab ut 55.6 percent in Rangamati district in Chittagong Hill Tracts (CHT). Khagrachhari (48.9 %) and Bandarban (48 %) are the other two districts in CHT accounting for sizable tribal population. According to 1991 Census about 82 per cent of tribal were living in rural areas and 18 per cent in urban areas. Very high proportion of tribal follows Buddhism (37 %), follo ed by Hinduism (21 %), Islam (18 %), Christianity (11 %) and other belief system (13 %) (Cen sus 1991). They speak a variety of languages, have their own distinct cultures and bound by t eir own customary laws. Tribal community representatives dispute the census figures in 199. Some of the scholars Ind private census carried out by missionaries show that for some groups census figures falls far below than the number estimated at the community level. The 1991 Census Report un der "other" might include the smaller sections or sub-divisions of some of the Tribal communi ies as well as the ex-tribal groups. These additional groups (cf. Maloney 1984) could be: "Banj gi (similar to Pankho and Kuki,), Dalu or Dulai or Dalui (a section of Garo), Hadi (a Hindui ed group), Ho (a section of Munda), Kachari or Kacari (a Hinduized group), Mahili (a s b- division of Santal), Mikir (a Hinduized group), Paliya (a branch of Rajbansi), Pathor (a 2 Latest Census 2001 yet to publish the population figures separately Tribal communities.

16 Hinduized group), Pnar (a sub-division of Khasi), Riang{ a section of Tipra), and Shendu (a branch of Khami). The list of ethnic communities given by Maloney (1984) includes anot ier 10 groups: Bede, Bhuimali, Bhuiya, Ganghu, Jaliya (Kaibartta), Kukamar, Kurmi, Ma to, Malla (Mallo), Namasudra. These groups are, in fact, ex-tribal groups. Maloney is aware of this fact, but he has included them in the list of tribes to identify the Indo-Aryan speaking s all ethnic groups". (Khaleque, 2002) Khaleque further commenting on the size of tribal population in Bangladesh, Khaleque in iis article mentioned that: "In fact, the ethnic population might be more than the figure given in the Cen sus Report. There are reasons for supposing so. It has been observed that the ethnic peo ple who were converted to Christianity are often listed in the Government offi ial documents under the category "Christian," while those who use Bengali names sim lar to the typical Hindu names are often grouped under the category "Hindu." ill b th cases, ethnic people are excluded from the groups where they belong to. One can ea ily make such mistakes if one does not have adequate knowledge about the ethnic peo ple and their ethnic, religious, and linguistic background" (Khaleque. 2002) The largest groups of tribal, collectively known as "Jumma" live in the three hill district: - Rangmati, Khagrachari and Bandarban - of CHT. CHT is located in southeastern part of Bangladesh. Tribal population also found in plains areas, especially in the border districts. The table below shows the details of distribution of tribal community and districts in which they are found compiled by Khaleque in his article (2002): Table 2: Name of tribal communities and districts where they are found in Bangladesh S.No. Name of tribal communities Districts 1 Assam Rangmati, Sylhet 2 Bagdi Kustia, Natore, Jinaidaha, Khulna, Josore 3 Banai Mymensingh, Sherpur, Jamalpur 4 Bawam Bandarban 5 Bedia Sirajganj, Chapainababganj 6 Bhumiji Dinjapur, Rajshahi 7 Chak Bandarban, Cox's Bazaar 8 Chakma Rangmati, Khagrachari, Bandarban 9 Dalu Mymensingh, Sherpur, Jamalpur 10 Garo Mymensingh, Tangail, Sherpur, Netrakona, Gazi ur, Rangpur, Sylhet, Sunamganj, Moulabi Bazaar 11 Gorkha Rangmati 12 Hajong Mymensingh, Sherpur, Netrakona, Syl liet, Sunamganj 13 Kharia Sylhet 14 Khasi Moulabi Bazaar, Sylhet, Sunamganj 15 Khyang Bandarban and Rangamati 16 Khondo Sylhet 17 Khotrio Barman Dinajpur, Rajshahi, Gazipur

17 S.No. Name of tribal communities Districts 18 Khumi Bandarban 19 Koch Mymensingh, Tangail, Sherpur, Netrakona, Gazipur 20 Kole Rajshahi, Sylhet 21 Karmarkar Rajshahi, Chapainababganj 22 Lushai Rangamati, Bandarban 23 Mahali Rajshahi, Dinajpur, Bogura 24 Mahato Rajshahi, Dinajpur, Pabna, Sirajganj, Bag ra, Jaypurhat 25 Malo Dinajpur, Rajshahi, Nogaon, Bog ra, Chapainababganj, Rangpur, Panchagargh, nat re, Thakurgaon, Pabna 26 Manipuri Moulabi Bazaar, Sylhet 27 Marma Rangmati, Khagrachari 28 Munda Dinajpur, Rajshahi, Nogaon, Bog a, Chapainababganj, Rangpur, Panchagargh, Nat re, Thakurgaon, Sylhet 29 Muriyar Rajshahi, Dinajpur 30 Mro Bandarban 31 Musohor Rajshahi, Dinajpur 32 Oraon Dinajpur, Rajshahi, Nogaon, BogU a, Chapainababganj, Rangpur, Panchagargh, Nat re, Thakurgaon, Pabna 33 Pahan Rajshahi 34 Paharia Dinjapur, Rajshahi, Nogaon, Bog ra, Chapainababganj, Rangpur, Panchagargh, Nat re, Thakurgaon, Pabna 35 Pangkho Bandarban 36 Patro Sylhet 37 Rai Rajshahi, Dinajpur 38 Rajbongshi Mymensingh, Rajshahi, Gazipur, Dinajpur, Tang ail, Khulna, Josore, Faridpur, Kustia, Dhaka, Sherpur 39 Rajuar Raj shahi 40 Rakhain Cox's Bazaar, Barguna, Patuakhali 41 Santal Dinjapur, Rajshahi, Nogaon, BogI ra, Chapainababganj, Rangpur, Panchagargh, nat -re, Thakurgaon, Sylhet, CHT 42 Singh Pabna 43 Tanchangya Rangamati, Bandarban, Khagrachari 44 Tripura Rangamati, Bandarban, Khagrachari, Sylhet, Rajb i, I Chandpur, Comilla, Chittagong 45 Turi Rajshahi, Dinajpur 4.1 Tribal communities and diversity

18 i III IT I I Tribal communities in Bangladesh are known for their distinct culture, belief system, econormic activities, political system, customary laws, and spoken languages. Some of the smaller tribal communities are still animists. They practice 'Jhumming' shifting cultivation. Land is ow Led communally. Men and women work in the field and engage in various livelihood activities. They have been depending on the traditional medicine men for their health. Local beliefs and customs influence what food is consumed during pregnancy and given to newborn and children. Hence, tribal communities in Bangladesh cannot be clubbed together as ( ne homogenous group. The socio-economic needs, health-seeking behaviour, perception of family planning, practi es affecting nutritional intake and aspirations vary from one tribal community to another. Re ch of development programmes are not even. Same can be said of health, population and nutrit on services. Tribal women are less educated compared to their male counterparts as well as compared to national figure of 32.4 per cent in 1991 Census. Literacy level among vari us tribal communities is also uneven. From the programme point of view diversity of tri bal community in a geographically contiguous area introduces another challenge. It would not be uncommon to find in one mouza one finds four different tribal communities speaking f ur different languages, practicing four different religions, varying levels of developme nt, variations in educational attainment and having their own sets of worldview. 4.2 Distribution of Ethnic Communities by Linguistic Affiliation There is a high degree of variations in the languages spoken and scripts used by the tribal communities in Bangladesh. Tribal spoken languages belong to different language families A distribution of the tribal communities by language categories (d. Maloney 1984; Grier on 1903) is given below. Tribal communities in Bangladesh, as is the case with tri bal communities elsewhere, did not have any written script. Many of these communities on con act with missionaries and non-tribal adopted other language scripts. "Thus Burmese script was adopted by the Chakma and Marina, Bengali script by the Tipra and Manipuri, and Ron an script by the Garo, Lushai, Santal, and some others" (Khaleque, 2002). Language Family Branch Ethnic Communities Tibeto-Burmese Kuki-Chin Bawm, Chakma, Khami, Khyang, Lushai, Manipuri, Marina, Mro, Pankho, Sak, Tanchangya (Other groups: Banjogi, Shendu) Bara Garo, Hajong, Koch, Mrong, (Bodo) Rajbansi, Tipra (Other groups: Dalu, Hadi, Kachari (kacari), Mikir, Paliya, Pathor, Riang) Austro-Asiatic Khasi Khasir (other group: Pnar); Munda Munda, Santal (Other groups: Mahili, Ho) Dravidian Oraon, Paharia

19 Indo-Aryan Bede, Bhuimali, Bhuiya, Ganghu, Jaliya-Kaibarlla, Kukamar, Kurmi, Mahato, Malia, Namasudra Note: "Other groups" mentioned in parentheses, as well as the groups listed under the Ind o- Aryan language family were found in some sources, but not in the 1991 Census Report. 5 Situation of HNP status in tribal areas Efforts have been made to collect available literature on situation of tribal health, nutrition ad population. However, information available is limited and available studies are fragmentary in nature. Regional and national level studies do not provide disaggregated data for tribal. T]lis provides a limitation on correctly understanding current tribal situation in terms of health, nutrition and population situation. Given this scenario some of the district / divisional level data are presented here. This reflects general overall low performance of the regions inhabited by tribal on various indicators. Although the infant mortality and child mortality rates were low for Khagrachhari, maten al health indicators, such as antenatal care visit, assistance during delivery by medically trairned personnel and post natal care for mother were lower than that of national or divisional figures - 30 per cent, 9.9 per cent and 6.6 per cent. For Rangamati assistance during delivery by medically trained personnel (15 %) was higher compared to national (11.6 %) and divisio lial (11.4%) percentages. Reported antenatal care visit was lower (41.4 % compared to 47.6 % for the country). Though postnatal care received for mother in Rangamati (16.1%) was hig] er compared to Chittagong Division (9 %), it was higher only by a fraction compared to that of national percentage (16.7 %) Table 3: Some available information useful for planning interventions for tribal and tribal areas Variables for planning interventions for tribal and tribal areas Division / Districts % of tribal Poorest Antenatal Delivery Any M ternal household * Care assistance Postnatal Mc rtality population to Visit (At by care R total lease one medically trained received for population # Visit)* personnel* mother* Bangladesh CHITTAGONG DIVISION Bandarban Brahmanbaria Chandpur Chittagong Comilla Cox's Bazar

20 Variables for planning interventions for tribal and tribal areas Division I Districts % of tribal Poorest Antenatal Delivery Any Maternal household * Care assistance Postnatal MO9rality population to Visit (At by care total lease medically received one trained for population # Visit)* personnel* mother* Feni Khagrachhari Lakshmipur Noakhali Rangamati CHITTAGONG 325 DIVISIONAL SYLHET DIVISION Habiganj Maulvibazar Sunamganj Sylhet SYLHET DIVISIONAL DHAKA DIVISION Dhaka Faridpur Gazipur Gopalganj Jamalpur Kishoreganj Madaripur Manikganj Munshiganj Mymenshingh Narayanganj Narsingdi Netrokona Rajbari Shariatpur Sherpur

21 Variables for planning interventions for tribal and tribal areas Division / Districts % of tribal Poorest household * Antenatal Care Delivery assistance Any Postnatal 3ternal M 9rtality population to Visit (At by care R total lease one medically trained received for population # Visit)* personnel* mother* Tangail DHAKA DIVISIONAL KHULNA DIVISION Bagerhat Chuadanga Jessore Jhenaidaha Khulna Kushtia Magura Meherpur Narail Satkhira KHULNA DIVISIONAL BARISAL DIVISION Barguna Barisal Bhola Jhalokati Patuakhali Pirojpur BARISAL DIVISIONAL RAJSHAHI DIVISION Bogra Dinajpur Gaibandha Joypurhat Kurigram

22 Variables for planning interventions for tribal and tribal areas Division / Districts % of tribal Poorest household* Antenatal Care Delivery assistance Any Postnatal Maternal M qrtality population to Visit (At by care Ratio ( total lease one medically trained received for population # Visit)* personnel* mother* Lalmonirhat Naogaon Natore Nawabganj Nilphamari Pabna Panchagar Rajshahi Rangpur Sirajganj Thakurgaon RAJSHAHI 223 DIVISIONAL Source: # 1991 Census, BBS, Government of Bangladesh * District Level Socio-Demographic and Health Care Utilization Indicators, 2003 (The data for this cc mes from the 2001 Bangladesh Maternal Health Services and maternal Mortality Survey Bangladesh Maternal Health Services and Maternal Mortality Survey, 2001 Generally, and despite the efforts of the government and NGOs, an efficient and effect ve health network, in terms of accessibility, reach and quality care, is lacking. Not hav ng adequately trained medical personnel, drug-supply and health infrastructure puts sev sre constraints upon effective health care in sparsely populated regions inhabited by tribal people. 6 Consultations for evolving tribal plan, issues raised and suggested interventions It is imperative to assess to what extent existing provision of services is considered accessi le and utilized by tribal. Understanding social, cultural, economic and physical barriers affect ng full utilization of services is essential for evolving a suitable framework to provide appropri ate services to tribal groups in Bangladesh. Inputs from tribal and representative of tri bal community, who could articulate HNP needs of the people and visualize mechanisms fr m improving access and utilization, were sought for preparing this tribal plan. As mentior ed

23 elsewhere, men and women, discuss some of the issues pertaining to HNP services for them, during FGDs conducted in two CHT villages. Sanjeeb Drong, General Secretary of Bangladesh Indigenous Peoples' Forum was interviewed to obtain insights into problems fa ed by tribal community as such and suggestions for improving HNP conditions of tribal people in CHT and those living in other districts. In addition, a small group of experts discus led components of tribal plan, which would be useful for taking HNP services close to tri al people and improved its utilization. The inputs obtained through FGDs, interview and s all group consultation are presented subsequently. 6.1 Suggestions from tribal representatives On issue of improving HNP the following suggestions were provided: * Special programmes to reach effectively the tribal in districts other than C T, especially in north and eastern part border districts which have substantial tri al population * HNP services to be available for every 500 households. This would help in reach -he tribal adequately who live in sparsely populated area. * Adequate communication network in areas inhabited by tribal areas, which would h lp in reaching the facilities * Different set of beliefs governs practices of health, family planning and nutrit on (during pregnancy, lactation, etc.), which needs to considered for evolving appropri te programmes. * Tribal people speak different language and appropriate information should be availa ble in the language spoken by tribal people * Recruit and appoint tribal women and men for various post in HNP services, wh ch would help in providing tribal friendly services * Educational and training facilities to impart required skill to tribal people to serve in facilities run by government * Recognition and promotion of tribal system of medicine * Improve water and sanitation situation in tribal in habitation 6.2 Views of tribal women and men expressed during FGDs Views of tribal men and women spoken to during FGDs are presented below Main problems affecting provision of health care Respondents were also asked to key problems affecting provision of health care in their ar a. Listed here are the key problems mentioned during the FGDs: * Inadequate supply of medicines in the government facilities, * Non-availability of private qualified practitioners, * Worst communication system, * Lack of health consciousness,

24 * 1I1ID * Lack of awareness of health problems, especially that of maternal and child healtl 1, * In ability to use health facilities for delivery, * Clean water supply, and * Lack of sanitation facilities. Many of the tribal dwellings do not have government facilities in the vicinity, some of the respondents felt that non-availability of private qualified practitioner as one of the m in problems. Transport was next important problem and lack of health consciousness was a so mentioned. Interestingly respondents were also mentioned of institutional delivery, in the context of their inability to use health facilities due to distance and lack of transport. As he households of tribal dwellings are dispersed how to reach outreach activities such as fa ily planning service, as well as provision of nutritional supplements to all the households havy to be considered Suggestions for improving health care services During the discussion respondents also considered ways and means by which existing H NP services could be improved: * Qualified doctor at UHFWC * Adequate supply of medicines at government facilities * Developing health consciousness through health education * Improving communication system * Immunization of children * Providing better maternal health to stop maternal deaths * Attention to health care needs of aged * Special arrangement for aged in government facilities (to reduce waiting time, etc.) * Ensure good behaviour of the staff towards the patients * Adequate attention from doctors to alleviate suffering of the patients when t ey approach doctor for health care delivery * To do away with malpractice in the form of bribe (which the patients have to p y) in the government health centres, and * Equip UIHFWC with pathological testing facilities, operation theatre, x- -ay machines, etc., to ensure quality services to people in the rural areas. 6.3 Suggestions from workshop participants The participants attending the workshop came up with the following suggestions on the b sis of a small group discussion: 1. dedicated tribal plan based on needs of different groups 2. accessible and functional health facility (for every population) in tribal ar -as or areas with tribal population 3. increase hardship allowance or other benefits 4. mobile and satellite services

25 5. train tribal health practitioners in modem medicines - trained tribal health practitioners to work as paramedicals or referrals 6. include tribal representatives in national, district and upazila level stakeholder committees, so that they can review progress of tribal plan 7. collect data of tribal health indicators 8. developing BCC according to tribal culture and language 9. actionable HIV/AIDS programme in tribal, especially in CHT.

26 7 Activities suggested for improving HNP status of tribal people Based on the review of available literature, one-to-one consultations and inputs from a stakeholder workshop the following activities are suggested for HNPSP. They are applica le to both CHT and non-cht areas. * Recognizing social, economic, cultural and linguistic differences of tribal communiti es, to ensure reach of services a tribal plan may be considered to channelize the resour es and implementation of HNPSP * Redesigning of service delivery model in tribal areas and for tribal groups. Doors ep delivery of services may have to be encouraged. As the tribal population live in arc as with low density, which means smaller population spread across larger geographi al areas, and considering the fact that they live in hilly regions and forest areas, th re could be one trained health visitor and family welfare visitor for every 500 household s. * Reviewing of coverage of CCs in tribal areas. For households at a distance of m re than 3 Kms or cut off by stream/river or steep slope, satellite clinics or mobile clin ics should be considered to extent the coverage. If required possibility of setting up of village health centre (VHCs) to provide basic curative care by an NGO or by community with support from government or DPs may be considered. * Institutional Strengthening to put in place a strong management structure for effici nt implementation of the programmes by MOHFW. * Support to infrastructure and service delivery in the public sector to fill in gaps and make the services more user friendly. Supplement the public sector service delivery by engaging the private sector and NGOs at all levels, more so at the community level. * Manpower development by way of better recruitment, training and rewards syster ns. Preference to be given for recruiting individuals from tribal community, as tt ey understand their community and needs. * Strengthening training and manpower development in for the staff in tribal areas. * Training and working with other systems of medicine and tribal system of medic ne practitioners * Developing a need based and culturally sensitive Communication Program * Integration with other departments to promote better resource utilization (for est department, education department as well as NGOs working on inter-sect ral programmes) * Operations Research to identify alternative strategies to improve tribal health * Development of a referral system for institutional deliveries, emergency obstetric c e and terminal method of family planning. * Service delivery through mobile vans to sparsely distributed tribal population. * Involve NGOs/Private Sector in the provision of Primary Health Care Services and a so as part of the referral system. * Reorganizing and restructuring of the existing service delivery infrastructure to beco ne an integral part of the proposed system. * Provide and encourage tribal system of medicine. * Adequate resource outlay for operationalising these interventions

27 Section II I 1 1 1

28 i W ~ 1111 ID] l l~~~~~~~~~~~~~~~~~~~~~~~~~~~ 8 Rationale for tribal plan Centrally administered projects / programmes designed on a nation wide basis provided HNP services across the country. Additional components such as satellite clinics, EPI, family welf are outreach activities, and nutritional centers provided within the framework to improved ser ice delivery. Whilst such an approach was useful in taking the service close to patients/consum rs, utilization of services remained low for various other reasons, arising out behavioural aspects of provider and users. Organic growth of services, in response to perceived importance of cer ain issues, resulted in less attention to quality of services, HRD, equity and sustainability. All th ese initiatives being part of broader plan, at times they are at variance with ground level realit es, affecting HNP status. Difficult terrain, locational disadvantages of health facilities, non-availabi ity of service providers, lack of appropriate HRD policy to encourage /motivate service provider to work in remote areas and weak monitoring and supervision systems are some of the barriers to access. Insurgency situation in CHT with predominant tribal population also contribu ted significantly to development of basic infrastructure, including provision of HNP services. Lack of information 3 on tribal groups, especially their HNP status, health-seeking behaviour, and ne eds (health, population, nutrition, and communication) limits the utility of any plan interventi ns planned. Moreover, there are no safeguards for diversion of resources. Return on the invest ent remains low as the input planning is normative and often fails to address special requirements b th in terms of investments and management structures. Formation of NGOs/CBOs by tribal gro ips has been slow or non-existing in tribal areas. All these point to the relevance of develop ing culturally and Linguistically Sensitive Services (CLSS), which takes into account location spec fic situation and needs of the people. Such a plan would, therefore, depend on decentrali ed mechanism with broad directives and guidelines. Adequate provision of resources, capa ity building and reviewing of existing modalities of service provisions become imperative. 9 Goal and objectives of the tribal plan Goal: To improve HNP status of the tribal community by provision of need based high qua ity integrated primary health care, family welfare and nutrition services with a view to achieve he socio demographic goals envisaged in PRSP and MDG. Objective: Main objective of the tribal plan is to develop integrated and sustainable system of provision for HNP services through primary health care services delivery model in ar as inhabited by tribal in sizable proportion. Here primary health care services will incll de programmes like family welfare, reproductive and child health care, immunization, vari us disease control programmes, curative as well as referral services, along with associa ted supplies, human resources, management structures and information (to patients/consumers 'nd providers). To attain this, the specific objectives will be to: 3 Most of the information available are outdated or pertain to tribal groups inhabiting North Eastern Part of undivided subcontinent, prior to independence. Available information is unreliable and fragmentary.