Reimagining the health system from the world view of indigenous communities: a practice model for a health system responsive to the indigenous communities in southern India (rTribe study)

Adivasi (tribal/indigenous) communities in India experience significant health disparities, including limited healthcare access and poor health system responsiveness due to cultural and systemic barriers. We propose the rTRIBE study which will apply state-of-the-art health policy & systems research methods to co-produce knowledge on improving the health system's responsiveness to Adivasi communities in southern India. Guided by the tenets of Indigenous Standpoint Theory will take a multi-method participatory action research approach to reimagine and co-produce transformative solutions for strengthening health systems responsiveness in two Adivasi community settings in southern India. Firstly, we will characterise how Adivasi communities perceive, interact, and relate to the health system in their specific social and historical context. Secondly, we shall describe other health systems actors’ understandings and perspectives about what constrains health systems actors’ ability to, and what will enable them to, deliver culturally responsive care to the Adivasi communities they serve. And finally, we will co-produce a health system responsiveness practice (implementation) model with Adivasi communities, healthcare providers and decision-makers to enhance health system responsiveness for Adivasi communities. Our research approach involves multiple research methods. Qualitative research methods, including in-depth interviews, site-wise participatory workshops, and consultation meetings will be employed to engage Adivasi citizens and community leaders, healthcare providers, and local health system stakeholders. To gain unique visual insights into healthcare access and responsiveness, we will use photo stories created by diverse range of Adivasi citizens. For measuring competencies and assessing the utility of tools developed, we will use survey questionnaires designed to evaluate the cultural competency of healthcare professionals through pre-and post-training assessments. We will use observational and qualitative methods to critically analyse and explain the nature of change seen. The participatory action research approach of iteratively and incrementally gaining insights from multiple cycles of action-reflection will be overlaid on the range of methods used. The study will require 3 years with formative research elements and iterative cycles of intervention development over the first two years, followed by evaluation, ongoing capacity building, and engagement with decision-makers at higher levels (at the district, state, and national levels in India). The study has the potential to profoundly impact action and research on Adivasi communities in India, and beyond. Through co-production of a Practice Model to make the health system culturally responsive to the needs and expectations of Adivasi communities, we aim to develop, test and institutionalize improvements within health services. Beyond local implementation, we plan widespread adaptation and scale-up of the Practice Model, supported by a comprehensive evaluation. Our knowledge translation strategy includes community engagement, state-level stakeholder workshops, peer-reviewed publications, and conference presentations. Our study is built on pre-existing and robust, equitable, trust-based partnerships with Adivasi communities - we will nurture these and build research capacities and advocate for policy changes to advance indigenous health and well-being in India and globally.