Public health system capacity of tribal and rural areas in India: a retrospective state-level analysis from 2011 to 2021

Background: India's multi-tiered public health system caters to rural and tribal populations. Previous surveys and small-sample, single-site studies have noted limited access to care among tribal populations. However, a systematic nationwide analysis remains missing. To fill the gap, we retrospectively analysed the primary and secondary public health system capacity in tribal and non-tribal rural parts of India. Methods: We extracted data from the Rural Health Statistics (RHS) reports from 2011 to 2021 on the number of required [as per Indian Public Health Standards (IPHS) guidelines] and functional SCs, PHCs, and CHCs from states with a tribal population >25% of the total state population. Healthcare access was captured using the ratio of functional to required centres for each health facility type separately for rural and tribal areas. We used tribal-to-rural odds ratio values (i.e., ratio of ratios) to understand the relative differences in tribal-rural healthcare access. Results: Nationally, facility-wise tribal health system capacity indices decreased from 0.96 in 2011 to 0.79 in 2021 for SCs, 0.89 to 0.79 for PHCs, and 0.79 to 0.78 for CHCs. The overall tribal health system capacity index fell from 0.95 to 0.79 for India. Most states showed improvement in tribal health system capacity from 2011 to 2021. Tribal-Rural health system disparity index (D) also decreased from 1.15 to 0.98 nationally, indicating increased disparity in the tribal health system. The facility-wise disparity indices decreased for SCs (1.16 to 0.97), PHCs (1.09 to 0.99), and CHCs (1.20 to 1.12), showing an increase in tribal health system disparity nationally. State-level values for facility-wise and overall tribal-rural health system disparity index showed some improvement with the majority of states having higher disparity index values in 2021 than in 2011. Conclusion: The findings highlight limited access to public healthcare in tribal areas across India compared to rural regions, with overall health system capacity declining over the past decade. While some improvement is seen in areas with a higher tribal population, there is a need to address healthcare access for the tribal population nationwide. Future studies should incorporate data on resource availability at healthcare centres to provide a more accurate assessment and develop effective solutions.