Social Assessment Of HIV/AIDS Public Disclosure Authorized .

Overall findings from the reviewThere are no specific policies that directly impinge or address the tribal issues but there isenough scope to derive from the various policies that there are areas that can be interpreted tobe applicable to the Tribal people. This has been discussed in the interpretation section of eachpolicy. However, it is concluded that specific issues addressing the requirements of tribalpeople needs to be developed separately drawing from the different policies that are already inplace. This exercise needs to be carried out on a priority basis.6. Institutional Issues A special function at the National and State level needs to be created and positioned todeal with issues relating to policies, coverage and implementation of interventionsamong the tribal people and other socially disadvantaged sections of the populationwho are vulnerable to HIVThe district level planning envisaged during NACP III needs to identify the vulnerableand socially disadvantaged people as well as the tribal people that need to be coveredin the different districts of each stateThe Governing Board and Executive Committee of each SACS can be expanded toinclude members from the Social Welfare Board and Tribal Development departmentsfor better understanding of the requirements of the populations and appropriately planfor intervention and services in those areasThe convergence with RCH II especially in the areas of Tribal Plan, Urban Poor andthe approaches to mainstreaming gender and equity can be attempted in order that theservice availability and service provision can be linked. The policy and goals can bestudied and the same be tied up with in the state PIP for serving the tribal people andother marginalized and socially excluded populationBehavioral studies using a ethnographic approach need to be carried out in differenttribal and rural belts to better understand the risk and vulnerability factors of thespecific population in order to design programme and interventions for thesepopulationsCapacity building of the NACO and SACS staff on the Social Development issues,gender, equity and Social Exclusion needs to be provided in order that the staff aresensitized and appreciate the necessity to include and mainstream such aspects intothe programmeDistrict level structures need to be created for planning the district level HIV/AIDSintervention with evidence for planning and capacity needs to be built on differentaspects of programme planning and management9

7. RecommendationsNational level - Policy Related1.Multi-pronged approach may be adopted to reach out tribal people.2.A policy decision regarding the necessity to intervene with this group needs to betaken.3.Convergence needed to bring about and derive advantages of the synergy betweenNRHM and the HIV/AIDS programme.4.Create a function of Social development, within NACO and SACS to address socialdevelopment activities and to identify, assess and design interdisciplinary researchpriorities and actionable knowledge strategies within SACS and NACO.National Level – Programme Related5.Request the states to carry out a mapping exercise in order to identify tribal belts andto gather information on HIV/STI prevalence among tribal through the sentinel surveys.State level6.Convergence between NRHM and HIV/AIDS control programme should be broughtabout.7.There is a need to have a communication strategy on stigma, discrimination, care andsupport more clearly.8.There is a need to collaborate or co-ordinate with Department of Tourism as thetourists are involved in sexual activities with tribal women.District Level9.The programme should address the gap of non availability of disaggregated data onprevalence rates for different social groups.10.There is need to initiate focused intervention for tribal group.Public-Private Partnership11.Collaboration sought with corporate sector for their involvement in the prevention andeducation programme as well as in provision of services such as STI.12.Advocacy for participation of development and private sector agencies and liaison withinternational and national agencies engaged in developing sustainable livelihoods andreducing vulnerability also need to be thought about.10

Tribal Action PlanIndia has the second largest concentration of tribal population in the World. Indian tribesconstitute around 8.2 percent of nation’s total population (Census 2001)3 and north easternstates are predominantly tribal-populated States (IDSP 2003)4. Poverty and poor infrastructuraldevelopment in tribal dominant areas have been the main reasons contributing to the inabilityof health programmes in reaching out to tribal populations, which includes the National AIDSControl Programme. The available literature along with findings from the tribal assessmentundertaken by ORG Centre for Social Research in 2006, provide specific evidence to establishthe tribal population in India as being particularly vulnerable to HIV/AIDS and help in identifyingspecific needs of the tribal groups with regard to HIV/AIDS.The assessment reaffirmed that illiteracy, migration and poor access to media makes the tribalpopulation socially vulnerable. With regard to HIV vulnerability, studies have reported that tribalwomen are particularly vulnerable to HIV/AIDS since they commence sexual activity at an earlyage. Sexual practices varied widely, sexual relationships out of wedlock were reported to be avery common phenomenon. Girls and boys staying together before marriage was a sociallyacceptable norm. Couples were also at liberty to divorce and remarry. Males were involved inpremarital or extra marital sex. Condoms were generally not used, as these were disliked.Except in Manipur, by and large, the tribal communities were unaware of STIs and HIV/AIDS.Awareness was lower among women. In all (except Manipur) states the awareness regardingservices for prevention, diagnosis, treatment and care for STIs and HIV/AIDS were lowamongst tribal people. Treatment seeking behavior for most health problems including STIs,revealed initial resort to home remedies or self medication by buying medicines over thecounter from grocery or petty shops (in Manipur), followed by visits to the traditional healers.Other studies have also reported that due to stigma and shame associated with RTIs/STDswomen suffering from RTI / STIs did not consult any physician unless the problem became veryacute. Health facilities like the CHC/PHC were reported to be visited only when the problembecame unbearable. Private health facilities were used, particularly when the location of publicsector facilities was not convenient. Access to health care is yet a problem for tribal people(IDSP 2003) because of scattered settlements and difficult terrain, inadequate accountabilityand monitoring of health service delivery to tribal people, unhelpful attitudes of health servicepersonnel, non availability of manpower at health facilities etc. (THDP 2003)5.No specific interventions had been started among tribals in the study areas by the government,private or public sector collaborators. In Andhra Pradesh, Rajasthan and Manipur, thesepopulations were covered under the interventions designed for the high-risk (CSW andmigrants) and other groups. Very few NGOs, were reported to be working specifically with tribalpeople on HIV/AIDS. NGOs in some tribal areas of Manipur, Rajasthan and Andhra Pradeshwere seen to cover tribal communities under their TI programme. There was a dearth of IECmaterial communicating in local dialect of tribal people.Issues covered under proposed Tribal Action Plan1. Integrate tribal and social development issues in the HIV/AIDS programme at every level3 Census of India. 1991 Part II B (i) PCA- General Population (Vol. I & II). Downloaded l.4Integrated Disease Surveillance Project 2003: Tribal Development Plan. Downloaded fromhttp://www.mohfw.nic.in/TDP.pdf.5 Tribal Health Development Plan. Tamil Nadu 2003. Downloaded from http://www.tnhealth.org/notification/tdp.pdf11

2. Systematize knowledge management on HIV/AIDS among Tribal people for developinginterventions among them3. Increase accessibility of the range of services under the NACP to tribal people4. Work with development partners and public and private sector enterprises to improveHIV/AIDS prevention and control among vulnerable and tribal peopleFramework considered for the planIn Tribal Action Plan, against each of the above issues, a set of actions have been suggestedunder the column of “Actions to be undertaken”; the organizations who are expected to beoverall responsible for undertakeing the suggested actions under the column of “agencies thatcan effectively undertake activities”; the steps involved in implementation of these activitiesunder the column of “Implementation Process”; the suggested time of iinitiation of theseactivities under column “ Time duration and the frequency of the activities to be undertaken”;the process and output indicators to assesss the extent of successful implementation ofsuggested actions under the column of “Possible monitoring mechanisms/indicators” has beenmentioned. In the following paras, an attempt has been made to summarize the suggestionsmade in the action plan.1. Integrate tribal and social development issues in the HIV/AIDS programme at everylevelIntegration of tribal and social development in HIV/AIDS programme at every level would callfor some actions to be taken in the intial period of NACP-III. The actions include (i) ensuringinclusion of socio-economic and cultural dimensions of tribal people in the existing NACOpolicies and programmes. (ii) integrating HIV/AIDS programmes with NRHM and TribalDevelopment Programmes at all the three levels. (iii) advocacy for sensitizing officials andfunctionaries of Health and Tribal departments on issues of HIV, social development with aspecial reference to vulnerable and tribal groups. These actions may be taken in the intialperiod of NACP-III (iv) training ‘action-agents’ at every level for effective communication andimplementation of the Tribal Action Plan.2. Systematize knowledge management on HIV/AIDS for developing strategicinterventions among tribal peopleDuring NACP I and NACP II efforts have been made in HIV high prevalence states and someof the High-risk states including Gujarat and Delhi wherein communication strategies wereformulated and disseminated with the help of IEC collaborative media products (TV, radio andprint) in collaboration with various government and non-government agencies at national andinternational level. This needs to be extended to the tribal communities in particular to get amulti-pronged and multi-faceted effect of the communication interventions on HIV/AIDSprevention and control as also to generate and disseminate evidence base on vulnerability oftribals to STIs and HIV/AIDS in order to develop strategic interventions among them. In thisregard, in the initial period of NACPIII, formative research for developing interventions amongtribal groups may be formulated which would further consolidate the efforts on dissemination ofevidence based information. Mass media centric programmes have proved to have limitedacceptability in the past, while the quality of IPC efforts suffered to a large extent. Tribalpopulations are quite close knit and at the same time very distant from the new, globalisedIndia. Hence, Inter-personal communication (IPC) has a major role to play in dissemination ofinformation among this population, which has had limited exposure so far.12

In year 2, a “KNOWLEDGE CENTRE” at NACO for consolidating and disseminating knowledgeon sexual health and HIV/AIDS issues pertaining to tribal groups may be formulated.Subsequently, to identify factors that increase “HIV/AIDS vulnerability” amongst vulnerable andtribal populations, it is imperative to support more research studies. There is also a need toreview and document ongoing interventions and related research among vulnerable and tribalgroups from time to time as an ongoing activity under NACP-III. Lack of focus and prioritizationof messages has lead to a very close-ended behaviour change. It is important to avoiddissemination of fragmented information, which most often leads to spread of ‘mis-information’rather than ‘information’. Information disseminated through the Knowledge Centre should alsofocus on other areas of behaviour change to lead to a significant change in the society. Tribalpopulations are geographically as well as culturally ‘difficult-to-reach’ as compared tocommunities in the non-tribal areas. Hence, a comprehensive package of masscommunication and IPC is imperative to target behaviour change among this population. Also,monitoring and follow-up of these efforts forms an important part of this package, as also, theefforts should be more synergised and continous rather than event based. Establishment of anentity like the Knowledge Centre can ensure this happens.3. Increase access to the range of services under the NACP for tribal areaAwareness plays a critical role in access of services by the target groups.Poor physical access of tribal population to diagnosis and treatment under the NACP has beenreported due to factors like difficult terrain and sparsely distributed tribal population in forestand hilly regions, locational disadvantage of primary health institutions (PHIs); longer distancesto travel to reach to VCTCs and PHIs and weak primary health care infrastructure includingVCTCs. Considering the fact that awareness is a major limitation for access of serviceswherever these are available, advocacy efforts in the tribal areas should focus on creatingawareness of mere presence of diagnostic and treatment facilities in the vicinity. This could bedone by involving the local leaders, anganwadi centres and schools and by strengthening thecapabilities of ‘change-agents’ at grass root levels. Some actions to increase acess to therange of services may be taken in the year 2 and 3 of programme, for example, TargetedInterventions (TIs) among most vulnerable tribal groups may be extended, ICTCs (stationary/mobile) catering tribal areas may be established and their effective functioning would also needto be ensured. Services like condom promotion, nutrition awareness and hygiene and healtheducation should be extended among tribals. Access to effective IEC/BCC for HIV preventionand referral systems to increase the utilization of HIV/STI/RTI services may be improved and itwould be an ongoing process.4. Work with development partners and public and private sector enterprises to improveHIV/AIDS prevention and control in tribal peopleOperationalising capacity of communication programmes varies considerably with states andhence, the need for IPC to strengthen efforts through IEC and BCC, could be made possiblethrough hand holding with development partners who have strong hold at grassroot level aswell as segment specific targeted communication. Public private partnerships could be a link tostrengthen operationalising capacity within tribal communities, involving positive people’snetworks. A vital step would be develop synergies between NACO and SACS, betweenpartner ministries and departments and between different media channels like mass media,mid media to strengthen advocacy activities and ensure effective dissemination of IEC material.The in-flow of funds needs to be monitored and outflow channelised so as to make significant,effective and complete utilization of available resources.13

With regard to this, public private partnership for IEC, BCC and prevention strategies thatincludes promotion of condoms, mobile vans, referral services, adoption of ICTCs and trainingof medical staff and use of electronic media in media dark areas, may be ensured oncontinuous basis during the entire span of the programme.The implementation process for each of the suggested actions and their possible monitoringindicators under above mention four areas has been illustrated in the detailed action plan givenbelow.14

Tribal Action PlanGoal: Reduce vulnerability of tribal people to HIV/AIDS through ensuring equitable access to comprehensive care and support under the NACP IIIPOLICYObjectivesIntegrate tribal andsocial developmentissues in theHIV/AIDSprogramme at everylevelActions to beundertakenEnsure inclusion ofsocio-economic andcultural dimensionsof tribal people in theexisting NACOpolicies andprogrammesIntegration ofHIV/AIDSprogrammes withNRHM and TribalDevelopmentProgrammes(National, State andDistrict Level)Agencies that caneffectivelyundertakeactivitiesNACO & SACS NACO &MoHFW SACS & Deptof Health DAPCU &District HealthSocietyImplementation Process Formation of TCSG* at NACO for the entire duration of NACPIII Associate an official preferably Jt Dir (IEC) at NACO and hiscounterpart at SACS to address issues of tribal and socialdevelopment Ensure identification of vulnerable tribal people by states andprioritize coverage in phased manner Plan stakeholder consultations at regional level involvingSACS for preparing state/district specific strategies DG (NACO) to be a special invitee in the steering committeemeetings of NRHM to discuss the ways and means ofintegration PD SACS to be a special invitee in the meetings of State RuralHealth Mission The Point person at the state level to liaise with healthdepartment, tribal welfare and social welfare Deptt., civilsociety organizations at state and district level Consider existing socio-cultural dimensions among tribalpeople across the regions while planning interventions Point person in consultation with National and State NGOAdvisor to identify and engage mother NGOs working inHIV/AIDS Capacity Building of NGO/CBOs (working on HIV and non-HIVissues) in tribal areas by mother NGOs.Time duration and thefrequency of theactivities to beundertaken In the initial period ofNACP-IIIIn the initial period ofNACP-IIIPossiblemonitoringmechanismsNACO policiesand programmesmake adequatementioning ofspecificvulnerable groupsincluding tribals Guidelinesavailable tointegrateHIV/AIDSservices withNRHM for thetribal areas15

ObjectivesActions to beundertakenAdvocacy forsensitizing officialsand functionaries ofHealth and Tribaldepartments onissues of HIV, socialdevelopment with aspecial reference tovulnerable and tribalgroups.Agencies that caneffectivelyundertakeactivities NACO & SACS* TCSG (Tribal Consultative and Support Group):Implementation Process Point person to develop budget line items / have a provision ofpooling funds from concerned deptt. in light of coverage oftribal people Point person in consultation with TCSG to formulate strategiesfor advocacy among officials an

Ms Ranjana Saradhi Dr. Seema Kaul Dr. G. Balasubramanian Dr. Sheela Rangan Dr. Kabir Sheikh Core Team Mukesh Chawla (Principal Coordinator) Sumit Kumar Maji (Co-ordinator-West Bengal and Manipur) Pallavi Karnick (Co-ordinator -Maharashtra) Daksha Solanki (Co-ordinator - Chh