Background:
India has significant disparities between rural and urban areas, and when it comes to health care, the disparities are even more pronounced. The elite and middle-class cities have access to some of the best-quality health-care services. About 68.84% of the vast majority of rural residents and vulnerable communities have limited access to quality health care.1 Approximately104 million scheduled tribes constitute 8.6% of India’s population accounted second largest tribal population in the world. Almost 70% of the tribal population in the country resides in rural areas with limited resources.2 Although, major objective of Universal Health Coverage (UHC) is all people have an equal right to access health facilities whenever they need. Hence, to achieve UHC, the impediments faced by vulnerable communities in rural and remote areas to accessing modern healthcare facilities must be overcome. In view of this, even after 70 years of independence, the primary health concerns in developing countries like India are limited access, insufficient availability, inadequate or uncertain quality of health care, and excessive out-of-pocket expenditure (OOPE).3 With a vision of turning UHC-Health for all into reality, the government of India recently launched the Ayushman Bharat scheme to offer accessible and affordable healthcare to all by providing free primary care services from newly updated health and wellness centers (HWCs). Both state and national governments have implemented a range of policies in recent decades to improve coverage of health in India.4 Most notably, the central government set up the National Rural Health Mission5 in 2005 and the National Health Mission6 (NHM) in 2014 and the Rastriya Swasthya Bima Yojana7 in 2010 to provide universal access to rural and marginally backward vulnerable tribes. These policy efforts were accompanied by an increase infrastructure for the health system, such as community and primary health centers.4
Inappropriately, UHC remains an elusive goal, with considerable gaps and vulnerabilities in India's health system in terms of manpower, infrastructure, and service availability in rural and tribal areas. By comparing various health and behavioural indicators with comparator group, Cormier et al. (2019) highlighted the serious public health gaps between indigenous communities, emphasizing the need for community-driven programs and operational research targeting these social and behavioral health determinants.8 Mavlankar (2016) opined that lack of health infrastructure, roads, and extreme poverty compel many needy tribes to ignore their health problems, and thus, understanding the dynamics of health of tribes is a challenge in itself.9 In view of this, current study emphasized the prevailing hurdles in the tribal community in accessing to modern health facilities which available in their areas. The study's theme is to bring the actual problems of the vulnerable community, such as what they think about using government healthcare facilities and how health care providers behave in the community, together with the ground reality of UHC implementations in India in order to achieve the Sustainable Development Goals (SDGs).
Materials and Methods
A community-based cross-sectional quantitative observation was conducted among Saharia vulnerable community in Sheopur district of M.P. during August to October of 2020. The study covered four Primary Health Centers (PHCs); Radep, Durgapuri, Karhal, and Vijaypur. These PHCs were selected using a Probability Proportion to Size (PPS) sampling method. A total of 40 villages were sampled, equally 10 village from each PHC. Characteristics of 10 village; 1 PHC village, 3 SHC/HWC village under the characteristics of health facility villages (located<5 km radius of health centers)10 and 6 non-health facility villages (located>5 km radius of any health centers) were covered. Prior to the interview, the verbal agreement (consent) was taken from the respondents. The whole interview was conducted with the respondents in their local language (Hindi) in a harmonious way. A three-step approach was used to collate the information specific to observe dominated barriers to accessing the healthcare services. To begin, the team enquired on accessing the health facility with grass-root health workers (ASHA, Anganwadi, and ANMs). Second, information was acquired by interviewing community leaders/Sarpanches and traditional birth attendants (TBA). Finally, in the third step, conducted interview with villagers/sufferers. So, we have collected relevant information from 212 respondents, 84 from health facilities and 128 from non-health facilities village as on average 5 respondents from each village. The specific barriers of both type of villages were tabulated in summarize way and comparative for better understanding the barriers and challenges.
Results
The observed barriers were designated in details below;
Reported community barriers in health facility and Non- Health facility villages
The existing community barriers with its full descriptions were analyzed separately according to health facility village and non- health facility villages and level of variation (differential) presented in Table 1. All six identified barriers as ground reality challenges as transportation facilities and road connectivity (1), cultural norms and beliefs (2), lack of awareness (3), child immunization misconceptions (4), health care provider’s behavior (5) and traditional medicine (6) were observed in the villages. The transport facilities and road connectivity & cultural norms and beliefs prevailed among 32.1% and 13.1% individuals in health facility villages respectively while it was higher by 13.2% and 9.5% in non- health facility villages. The lack of awareness (83.3%) about the availability of healthcare facilities is one of the biggest hurdles to accessing healthcare facilities in health facility village and it was observed higher by 5% in non- health facility village. More than fifty percent (55.9) of people are affected by misconceptions about child immunization; they do not prefer child immunization for reasons such as swelling, fever, etc., in health facility village while it was higher by 12.9% in non-health facility village. About 51.2% people prefer to go to private hospitals instead of government hospitals due to inappropriate behaviors of their health staff, it has found similar situation among both health facility village and non-health facility village. About one-third (28.6%) people prefer healing through traditional medicine in health facility village and it was observed 32.8% in non- health facility village by the reason of easily available in their communities.
Table 1
Percent distribution of multiple community barriers among health facility & non-health facility village
Discussions
This study observed that transportation and road connectivity have a bigger barrier in non-health facility villages (45.3%) than to health facility villages (32.1%) in terms of accessing modern health facility. Lack of awareness has surfaced as most significant barrier among Saharia tribe, which affects both health facilities & non-health facility village but it is higher in non-health facility village. Tribal people are unaware of the medical advantages available under several programs of government6, 7 due to a lack of sufficient education and poor socioeconomic conditions. Furthermore, the behavior of healthcare providers also turned out to be another potential barrier in both health facility village & non-health facility village. The local communities were not getting the quality of services from healthcare workers and they also experienced disrespect. The misconception of child immunization further adds up to the list of barriers in community and it has been observed slightly more in non-health facility villages. The local community is very busy in seeking their livelihoods, so they don’t prefer to take child immunizations for the loss of daily wages. Apart from that, they think that their babies get fever and swelling after immunization. In comparison to healthcare facility villages, the cultural norms and beliefs in receiving health care are greatly different in non-health village which emerged as the least significant barrier. Their belief was that illness, diseases and other misfortunes were caused by displeased/unhappy/frightened deities. Tribes' health profiles are inadequate because of a lack of access to health-care facilities as well as community beliefs, cultural traditions. For example, a study conducted among the Baiga tribe in Madhya Pradesh (2009-10) indicated that the tribe have underutilized and low awareness of maternal and child health (MCH), care services.11 Furthermore, a profile of children’s health status revealed that traditional cultural norms are a growing component of Baiga infant morbidity. 12 Since, the place of child birth and its integrated aspects are based on women’s background characteristics and are highly influenced by the family and community. The socio-demographic characteristics of tribes regulate health care decisions and influence the attitudes of women to utilizing modern health care practices. Use of traditional- knowledge, attitude and practice (T-KAP) has been practices majorly by tribe.13 Low level of education, strong cultural believes and traditional culture norms are the strongest community barriers reflected their self-decision-making for not accessing the modern health care facility.14Low birth weight babies as a result of early marriage and stillbirth were major concerns among adolescent tribal girls.15 In tribal regions major gaps are lack of human resources, infrastructure, out of pocket expenditure, etc., are existed so need to develop individuals and community level strategy to overcome the barriers of rural health services.16 Hence, so many barriers in relation to living patterns, knowledge, attitude, belief and perception, etc., among vulnerable communities exist in rural tribal sections of the country, which consequently leads only to solutions of changing the health seeking behavior through information, education and communication (IEC) education campaigning to generate the awareness and healthcare providers may follow the adequate attitude in delivering the health services particularly with vulnerable people.
Conclusions
Lack of awareness, misconceptions about child immunization and healthcare professional behavior were identified as substantial barriers in both types of village (health-facility & non-health facility) whereas transportation and road connectivity were shown to be significant in non-health facility village. The identified barriers/gaps for accessing health facilities in vulnerable communities such as Saharia tribe are facing troubles. These barriers would be minimizing through social activists, researchers and policymakers also things for better health outcomes in context of achieving UHC-health for all everywhere.
Author’s Contribution
DK has generated the idea and concept of manuscript, compilation and data analysis, writing the final version of manuscript. S.S. designed the concept of article and formulates methodology and introduction section, involved in writing the manuscript and also collected data. TS, S Saini and PB involved in data collection and structured the manuscript and NS gave prime opinions and involved in writing the article along with necessary editing. All authors have read the final version of manuscript and agreed to send for publications.
Acknowledgment
We would like to thank Director of the ICMR-NIRTH Jabalpur Institute for their valuable suggestion and encouragement in preparing manuscript on community barriers to accessing the health care services. The manuscript has been approved by the Publication Screening Committee of ICMR-NIRTH, Jabalpur and assigned with the number ICMR-NIRTH/PSC/64/2020.We are also grateful to the grassroots health worker, Saharia community persons who provided relevant information.
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