India delivered the first dose of the Covid-19 vaccine to 76% of its adult population by the first week of November. But 48 districts are lagging behind with the first dose coverage yet to reach the half-way mark.

Half of these districts are tribal-majority. Twenty of them lie in the northeastern states of Nagaland, Arunachal Pradesh and Meghalaya.

According to the Ministry of Tribal Affairs, communities that are classified as Scheduled Tribes live in 558 districts of India. In 90 districts, they account for more than half the population, as per the report of an expert group tasked with studying healthcare in tribal areas.

Of these 90 districts, 24 fall in the list of 48 districts identified by the Centre with low vaccination coverage.

Among tribal-majority districts across India, Senapati in Manipur has the lowest second dose coverage, according to data from CoWIN, the government portal for vaccination registration. Only 3.8% of its population had received the second dose of Covid-19 vaccine till November 6. That day, for instance, only 78 doses were administered in the entire district.

Other districts reporting low vaccine coverage include Kurung Kumey in Arunachal Pradesh, Ukhrul and Tamenglong in Manipur, East Garo Hills in Meghalaya, and Kiphire in Nagaland. Outside of the North East, the lowest vaccination coverage is tribal areas is in Gumla in Jharkhand and Narayanpur in Chhattisgarh.

Most of the tribal districts in the North East saw a surge in vaccinations in June and July, soon after the second wave of Covid-19 peaked. But the vaccinations began to drop starting August.

Dr Sunil Kaul, who runs Action NorthEast Trust, a non-profit based in Assam, said that apart from a few urbanised pockets, most of the North East is sparsely populated and has seen barely any Covid-19 cases. “It is mostly in urban areas that we saw cases,” he said. As a result, the demand for vaccines has been low.

“In March and April, there was pressure from the government, so people got vaccinated. That pressure eased eventually,” Kaul added.

But it isn’t just lack of demand. Gugu Haralu, an activist in Nagaland, attributed the low vaccination coverage to mistrust of the health system and misconceptions about vaccines. “Every hospital was testing every incoming patient for Covid since the pandemic began and people were scared this is a scam,” she said. Some religious leaders advised people against vaccination, deepening vaccine hesitancy, she added.

Outside of the North East, in states that have a substantial Scheduled Tribes population – Chhattisgarh, Jharkhand, Maharashtra – the vaccination coverage is lower in tribal regions compared to other rural or urban districts. But it is better than the tribal districts of the North East.

“The spike in June and July could be because resistance to vaccination had been broken to some extent and tribal people had decided to get jabbed,” said Dr Dileep Mavalankar, director, Indian Institute of Public Health. The subsequent decline in Covid-19 cases across India could have eventually diluted the urgency of vaccination, he said.

Data offers some evidence in support of Mavalankar’s contention. calculated the first and second dose coverage in the 24 districts with a gap of 50 days, between September 13-15 and November 5-6. While the second dose coverage improved in the districts in the 50 days, the first dose coverage remained nearly stagnant. This suggests people who got their first dose were walking in for the second, but a newer pool was not coming to get vaccinated.

A vaccination awareness road show held in Shillong in May. Photo: National Health Mission

Low stock, low awareness in early days

Public health experts say it is not surprising that tribal-majority districts lag behind others in vaccination coverage.

“If you look at family planning, or any other vaccination campaign, tribal areas take a few decades before their resistance goes away,” said Dr Abhay Bang, founder of SEARCH, a non-profit in Gadchiroli, Maharashtra, and chairman of the expert health group commissioned by the tribal affairs ministry. He said rumours and misconceptions spread fast and take deep root in Adivasi communities. For instance, in southern Gadchiroli, Adivasis refused to get jabbed fearing impotency.

Dr Shashikant Shambharkar, district health officer, Gadchiroli, said, “In initial months if our health workers would visit, they would hide in their huts and refuse to come out.”

In addition to hesitancy, in the early months after the vaccination drive was launched, vaccine supply was erratic. “Intermittently, drives for vaccination were stopped because there was no supply,” Bang said, adding that low vaccine availability deterred health workers from widely raising awareness.

Since doses were distributed based on daily district performance, low vaccination numbers also meant the supply to tribal districts further shrunk. “If supply is not smooth, we cannot plan future vaccination drives or raise awareness in villages,” Shambharkar said.

In Nandurbar, a district in north Maharashtra with more than 70% Scheduled Tribe population, 27% of total population was jabbed with the first dose by September 15. This rose to 38% over 50 days till November 6 – still, nearly half of the state average of 72.3%.

“Initially, tribal people were resistant to vaccination,” said former Nandurbar district health officer Dr Nitin Borke. “We started immunising local leaders and government staffers to show villagers that vaccines were safe. But when people started coming forward, we faced supply issues.”

The district was immunising 1,500-3,000 people a day until July. In August, the supply improved and the daily numbers jumped to 8,000-9,000. In the last fortnight, however, daily vaccinations have dropped to 5,000-6,000 doses per day, despite adequate supply since there are zero active Covid-19 cases in the district.

State-wise disparity

Not all tribal-majority districts have low vaccination coverage.

In Himachal Pradesh, 95% of the adult population have received the first dose of the Covid-19 vaccine. Kinnaur not only has 89% first dose coverage, it has managed to fully immunise 71% of its population by giving them two doses.

In Sikkim, the North Sikkim district has 69% first dose coverage.

In contrast, in several districts of Jharkhand (Lohardaga, Gumla, West Singhbhum) and Chhattisgarh (Surguja, Bastar, Narayanpur, Bijapur), the first dose coverage is below 40%, CoWIN data till November 6 shows.

In Mizoram, even as first dose coverage is over 50% in most districts, immunisation officer Dr Lalzawmi said the hilly terrain and scattered population has made it difficult to reach the last mile. “People don’t travel to vaccination centres. We have to travel to reach them,” she said.

Dr Shrey Desai, from NGO Sewa that works for tribal health in Gujarat, said the government must draw a list of unvaccinated people and counsel them one-on-one. For child immunisation programmes, he said “immunisation officers would visit homes to counsel parents”.

“The government has to move beyond hoardings and advertisements to counsel tribals on benefits of vaccination,” he argued. “Local politicians have scope to do more on this.”

This reporting was supported by a grant from the Thakur Family Foundation. Thakur Family Foundation has not exercised any editorial control over the contents of this article.