Evaluation MHV Barmer

Health Facilities on Wheels:
Reaching the Unreached

Final Draft
Evaluation of Mobile Health Van Project

in Barmer, Rajasthan
June 2012
Conducted by
HLFPPT
Supported by
CAIRN India
Evaluation of MHV Project
(i)
Study Team
Dr. Shubhra Phillips
Mr. Nadeem Akhtar Khan
Ms. Preeti Upadhyay
Mr. Satyaban Sahu
Mr. Faisal Alam Siddiqui
Ms. Debjani Samantaray
Mr. Azeem Nizami
Ms. Sunita Pandey
Ms. Rita Singh
Mr. Naresh Kumar Mishra
Mr. Ram Rajeev Singh
HLFPPT Corporate Office

Hindustan Latex Family Planning Promotion Trust
B-14/A, Second Floor, Sector 62,
Gautam Budh Nagar, Noida, UP-201307
Tel: 0120-4231060/61/62, 4673673,
Fax: 0120-4231065
(ii)
Abbreviations
Acknowledgement
Table and Figures
Executive summary
1-INTRODUCTION
1.1
Geographical conditions
1.2
Socio economic conditions
1.3
Availability of health services
1.4
Status of health and vulnerable groups
1.5
Mothers and children
1.6
Description of MHV Project
1.7
Experiences of MHV services in the country
1.8
Objectives of the evaluation
1.9
Expected results of the evaluation
1.10
Conclusions
Page no
1
2
2
3
5
5
6
9
10
10
2-METHODOLOGY AND SAMPLE CHARACTERISTICS

2.1
Survey components
2.1.1
Sampling design and implementation
2.1.2
Location of survey villages
2.1.3
Survey tools
2.1.4
Sample size
2.1.5
Transit visit with MHV
2.2
Training and fieldwork
2.3
Data processing
2.4
Characteristics of the sample villages and beneficiaries
2.5
Health infrastructure at the sample villages
11
11
12
12
13
14
14
15
15
16
3-FINDINGS
3.1
OPD services of MHV
3.2
Awareness about OPD services of MHV
3.3
Awareness about health camps
3.4
Relevance of MHV
3.5
Utilisation of MHV services
3.6
Time efficiency of the MHV staff
3.7
Cost efficiency of the MHV services
3.8
Gaps and barriers in utilisation of MHV services
3.9
Impact of MHV services
3.10
Conclusion
18
19
20
21
21
22
24
24
29
33
4- RECOMMENDATIONS
4.1
Provide pathological examination
4.1.1
Test for haemoglobin
4.1.2
Test for malaria
4.2
Enhance basket of services
4.3
Strengthening community mobilisation and public institutions
4.4
Staff composition
4.5
Route planning
4.6
Organising health events
4.7
Referral services
4.8
Develop GIS based MIS
4.9
Document Good Practices
34
34
35
36
37
37
37
38
38
38
38
(iii)
Tables
1.1
1.2
Availability of health services

Age distribution of population
2.1
2.2
2.3
2.4
2.5
Sample size covered

Details of FGD
Characteristics of sample village
Characteristics of beneficiaries
Health facilities at the survey villages
Page no
3
4
13
13
15
16
17
Figures
1.1
1.2
1.3
Scattered settlement of Nagana Village

An old man slowly walking on his sticks to consult the MHV doctor
A mother with her young child
2
4
5
2.1
2.2
3.1
3.2
3.3
3.4
3.5
3.6
3.7
3.8
3.9
3.10
3.11
3.12
3.13
3.14
3.15
3.16
Map of Barmer (Shows the location of 10 survey villages)

Training of Researchers by senior staff of HLFPPT at Barmer
Diagnosis of diseases by North (MPT)
Diagnosis of diseases by south (RGT)
Board of NHV being displayed at a halt point in village
Villagers queue up for MHV before it arrives
Number of health camps by the two regions
Patient load by gender and age
Time spent by MHV by activities
Time spent by doctor with a patient
Monthly patient load by two region
A women turns her head away as doctor gives her instructions
Miles to go to reach a service point
A women in purdah sits at the door step of MHV to talk to doctor
A young child suffering from malnutrition in Nagana village
Kamla Devi of Madpura sani is in her sixties and walks with a stick
Women pleased with the MHV services
People of different background assemble at MHV for consultations
12
14
18
19
19
20
21
22
23
23
24
25
26
27
28
29
31
32
(iv)
Abbreviations
ASHA
ANC
ANM
AWW
CHC
CSR
DLHS
FGD
FRU
HP
HLFPPT
MIS
MHV
MPT
NGO
ICDS
IIPS
NRHM
OPD
PID
PNC
PHC
RCH
RGT
RTI
SC
SMC
ST
STI
TB
UTI
Accredited Social Health Activist

Ante natal care
Auxiliary Nurse Midwife
Anganwadi worker
Community Health Center
Corporate Social Responsibility
District Level Household Facility Survey
Focus group discussion
First Referral Unit
Hypertension
Management Information System
Mobile Health Van
Mangala Processing Terminal
Non Government Organisation
Integrated Child Development Scheme
International Institute for Population Sciences
National Rural Health Mission
Out Patient Department
Pelvic Inflammatory Disease
Postnatal care
Primary Health Centre
Reproductive and child health
Rageshwari Gas Terminal
Reproductive Tract Infection
Schedule Caste
School Management Committee
Schedule tribe
Sexual Transmitted Infection
Tuberculosis
Urinary Tract Infection
(v)
Acknowledgement
We are thankful to Cairn India for providing us an opportunity to conduct an evaluation of

Mobile Health Van Project in Barmer district of Rajasthan. We wish to express our sincere
thanks to Cairn staff for their valuable time and necessary support towards completion of this
assignment.
We would like to acknowledge the assistance provided by Helpage India and Smile Foundation.
The support of the community and healthcare providers contribution is highly appreciated in
making this report possible.
Dr. Shubhra Phillips

Head Strategic Partnerships & Business Development and
In-charge Knowledge Management Division
(vi)
Executive Summary
Introduction
CAIRN Indias vision of health is well-being of all the people around the areas in which it
operates. About two years back, CAIRN initiated a programme, called the Mobile Health Van
(MHV) in two of its operational areas in Barmer district. The first area is called north and is
Mangala Processing Terminal (MPT). The second is referred as South and is Rageshwari Gas
Terminal (RGT). Both of these areas are remote, have difficult terrain and are under served.
This health care initiative of CAIRN intends to make an improvement in health status of the
population by providing preventive and curative services.
This study has been initiated by CAIRN India to evaluate the performance of its two year old
MHV project, and seek recommendations for its future expansion and strengthening. This
chapter presents the background of the area, its prominent features and existing health
services. It discusses the experiences of similar MHV projects in other parts of the country.
Objectives
The objective of this evaluation study is to assess:
1. Relevance of the project in terms of its strategy, approach and interventions of the project;
to test whether they were in tune with the needs, situations and aspirations of the targeted
population.
2. Effectiveness i.e. the extent to which the objectives have been achieved with respect to
improvement in health status of the population.
3. Efficiency of the scheme i.e. in achieving its objectives whether resources have been used
economically and within the specified timeframe.
4. Sustainability of the intervention in term of extent to which the project has been and can
be sustainability on a long term basis.
5. Impact of the scheme i.e. the degree to which the project has helped in improving health
awareness and habits of the villages
Methodology
The study has made use of qualitative and quantitative techniques of data collection. The
respondents included beneficiaries of MHV, key informants, village leaders, ICDS workers,
MHV staff and health providers.
(vii)
The study involved a two-stage sampling design. In the first stage, list of villages covered by
MHV were divided into two service zones namely north (MPT) and south (RGT). All the
villages which were covered by MHV project during the period September 2009 to December
2010, were taken into consideration.
In the second stage, route plan of each MHV was looked at. The villages visited by MHV in one
day were put into a cluster. Thus a total of 10 clusters were prepared. Using Simple Random
Method, one village was selected from each cluster as sample. Equal chance of selection of was
given to all the villages which were covered by MHV Project irrespective of implementing
agency. The sample population for the purpose of the evaluation study comprised of two main
categories:
(a) Service Providers
In-depth interviews were conducted with the District officials and MHV project
functionaries. Focus Group Discussions were conducted among small groups of
community members who were aware of the MHV services being provided, irrespective
of being beneficiary or non-beneficiaries.
In-depth interviews with key informants who were knowledgeable and aware of the
village and its residents.
(b) Beneficiary who availed the services of Mobile Health Van
Data was collected at the village level from adult men, women, elderly population and
youth/adolescent population.
In-Depth Interviews and Focus Group Discussions (FGD): Primary data was collected
through
Participatory activity including Transit Visits
Key recommendations
1. Provide pathological examination
A number of factors identified in the evaluation that can be added in the MHV services. Instead
of only OPD a service, basic pathological test facilitates could be added. Considering high
prevalence of malaria and anaemia in the district, it is recommended that in the first phase
malaria and haemoglobin tests could be taken up, and later increase to tests for blood sugar,
pregnancy, tuberculosis and X-rays.
(viii)
2. Enhance basket of services

Looking at the current performance of MCH services, it is recommended that MHV project
should be given an expanded basket of services including pregnancy test, ANC, immunization,
childhood vaccinations and nutrition. The utilisation of public RCH services has been due to
poor connectivity of villages, remoteness of dhanies and non availability of supplies. CAIRN is
rightly positioned to take up this challenge as it has already made in-roads into the villages. It
can fill the gaps that exist in the RCH programme and carry out the programme in partnership
with the government.
3. Strengthening MHV services through convergence with public institutions
CAIRN can present a sound MHV model to the country that is effective, sustainable and
scalable if it engages the communities it works with. Presently the MHV programme is a stand
alone programme to render health services. For these services to be effective that impact is
lasting, it should have local-block-district level linkages including local women group like SHGs,
village leaders and health workers and others. Working in collaboration with community health
workers and public institutions would improve the MHV services. The infrastructural support
for strengthening the performance of PHC and CHCs through coordination with government
would be value addition to CAIRNs CSR initiatives.
A number of centrally and state sponsored programme are ongoing that aim to provide quality
health care like Rajiv Gandhi Mobile health initiated by NRHM-Rajasthan. It is important to
strategically coordinate with the district and block level health official to make MHV efforts
sustainable.
4. Staff composition
Addition of a lady doctor in the staff will add useful service for girls and women. The
community mobilisation also requires full time project staff that makes field visits. The village
level volunteers, especially members of self help groups, who will help in organising health
camps and promote OPD services of MHV.
In the existing set up of MHV, the staff does not get to interact with the local people more
than seeing the patients. This is perhaps the reason that women beneficiaries expressed
difficulty in communicating with the MHV staff. It is recommended that each staff is engaged in
community mobilisation task also, which will sensitise them towards the needs of local people.
(ix)
5. Route planning
It is recommended that the route plan of MHV is redesigned with consideration that it spends
more time at each village. The halt time should never be less than 2 hours per village whether
patients have turned up or not. There is excessive amount of travelling that the staff does
every day, and the services provided by them will not be sustainable.
6. Organising health events
Special attention needs to be paid while organising the health camps. The specialised health
camps need to be organised in regular intervals, which enhance the effectives of health camps.
Organisers must ensure the proper briefing of specialised health professionals prior to
organising the health camps. In order to ensure the quality of services by experts, screening of
symptoms must be done in a planed manner.
7. Referral services
The referral system of MHV has not been put in place properly which explains its complete
ineffectiveness. Since the range of diseases that doctor of MHV encounters can range from
common illnesses to complex situations. With cooperative and well networked system,
complex cases requiring higher range of skills and facilities could be referred. Proper planning is
required so that the patient is referred to keeping in mind geographical factors, time,
affordability and emergency services into consideration. The referral system will only work well
if there is flow of information from both sides. This will require professional help in developing
a proper system so that the patients could be tracked and success of referrals could be
measured.
(x)
Chapter 1
Introduction
CAIRN Indias vision of health is well-being of all the people around the areas in which it
operates. About two years back, CAIRN initiated a programme, called the Mobile Health Van
(MHV) in two of its operational areas in Barmer district. The first area is called North and is
Mangala Processing Terminal (MPT). The second is referred as South and is Raageshwari Gas
Terminal (RGT). Both of these areas are remote, have difficult terrain and are under served.
This health care initiative of CAIRN intends to make an improvement in health status of the
population by providing preventive and curative services.
This study has been initiated by CAIRN India to evaluate the performance of its two year old
MHV project, and seek recommendations for its future expansion and strengthening. This
chapter presents the background of the area, its prominent features and existing health
services. It discusses the experiences of similar MHV projects in other parts of the country.
1.1 Geographical conditions
Barmer district is part of the Thar desert, and is located at the western boundary of the state
of Rajasthan. It is one of the largest districts of the state with hot, dry and in-hostile weather.
As per Census 2001, 92.6 percent population of the district resides in rural areas. The
population is sparse with a population density of only 69 persons per sq km. People in villages
live in dhanies, which are clusters of couple of houses of close relatives. Dhanies are separated
from each other by vast stretches of fields and sand dunes.
In this barren and dry arid land, transport and road connectivity are poor. As per Census 2001,
only 44 per cent of the villages had paved roads. The situation has improved in the last decade
and most villages got connected by pucca road but the Dhanies are generally not connected.
(1)
Nagana, a study village, has a pucca road going up to the primary school. None of the
22 dhanies have a road connection. Settlement pattern is scattered and terrain is tough.
To reach anyone in the dhanies, one has to walk through the desert (Photo 1.1.)
Photo 1.1: Scattered settlement of Nagana village
1.2 Socio economic conditions

Planning Commission has given Barmer status of Most Backward District because of its poor
health status and infrastructure. People are generally poor and their major source of livelihood
is agriculture. The annual rainfall is below 250 mm, and less than 10 percent cropped area is
under irrigation, making it difficult for cultivation. Villages have experienced drought-like
situation almost every second year.
Handicraft making and livestock rearing are other important means of livelihood. The
traditional local crafts are wood carving, block printing on textile, embroidery and leather
carving. Additionally, the male workforce of rural areas seeks daily wage work in the nearby
towns and industrial sites. Poverty is wide spread and people follow sustenance economy.
1.3 Availability of health services
Table 1.1 show the present status of health infrastructure in the three blocks that fall in the
project area of CAIRN India. In spite of the strengthening of health services under the NRHM
programme, there are major gaps.
(2)
TABLE 1.1: AVAILABILITY OF HEALTH SERVICES

Health facility
Baytoo
Block
No. of Sub Centres (SC)

No. of Health facilities above SC but below
block level
No. of PHCs
No. of CHCs
No. of Sub-Divisional Hospitals
No. of District level hospitals
Sindhari
Block
Dhorimanna
Block
Barmer
District
63
1
72
1
77
1
545
6
8
2
0
0
7
1
0
0
8
2
0
0
63
14
1
1
Source: 5th CRM Report, NRHM, Rajasthan
In Barmer district, 7 CHCs are listed as First Referral Units (FRUs) however none of them can
be considered as a functional FRU as the team of required specialists (Gynaecologist,
Paediatrician, Anaesthetist) and Blood Storage Unit are not available in any FRU (Concurrent
Evaluation of NRHM 2009, IIPS). Blood Storage Units have not been set up at the block level.
The district has been ranked low due to inadequate health services. As per the ranking of
districts done by Jansankhya Sthirta Kosh National Population Stabilization Fund
(www.jsk.gov.in), Barmer ranks 581 rank out of 593 districts. Villagers have to travel more than
10 to 20 km to avail public health services. Tough weather conditions, scattered habitations
and diverse population are challenges to any health programme in the district.
1.4 Status of health and vulnerable groups
Barmer district lags behind in health status. Malnutrition, low life expectancy, high maternal and
infant mortality, and high disease burden are some of the problems. While health needs are
high in the area, there are some groups which are more vulnerable than others and in dire
need of health services, as discussed below.
(1) Marginalized communities
The population of Barmer district is close to 19.64 lakhs (Census 2001) comprising mostly of
SC, ST and refugees of Indo-Pak wars. 15.73 per cent of the population is SC and 6.04 per cent
is ST. Muslims form a substantial percentage of the local population (11.80 per cent). Barmer
district has lowest human development indices in the state, with caste and gender
disadvantages (Human Development Report of Rajasthan, 2002). While Rajputs, Jats and
Bishnois are major landowners, the SC and ST communities are a disadvantaged group.
Meghwals, Kolis and Chamars are the three largest SC groups while Bhils, Minas and Gharasias
are the major ST groups. Some of these people form vulnerable group as they face
discrimination in seeking health services.
(3)
(2) Women
The Human Development Report also shows gender gap in education. In 2011, the overall
literacy of the district was 57.49 per cent, while male and female literacy were 72.32 and 41.03
per cent respectively. In rural Barmer, women live in purdah (Photo 1.2). They have relatively
lower social status and decision-making power in their own families. The strong preference for
male child is reflected in the unfavorable sex ratio (900 as per Census 2011). Womens status
has a direct bearing on their health-seeking behavior and the healthcare services available to
them. They form another vulnerable group.
(3) Elderly people
Elderly people require more medical attention that
other age groups, but are often neglected at home.
Table 1.2 shows that 7.1 percent of the total
population in Barmer is that of elderly. A recent
study conducted by CSSO shows that about 19
percent of elderly males and 16 percent of elderly
females self reported some form of illness. They
suffer from visual and hearing problems, senility,
orthopedic disorders, respiratory disorders and
hypertension. In the project area many elderly were
seen with orthopedic disabilities (Photo 1.2).
Walking 8 to 10 km to a PHC is not an option that
they could avail. They need health services close to
their homes.
Photo 1.2: An old man slowly walking on

his sticks to consult the MHV doctor
TABLE 1.2: AGE DISTRIBUTION OF POPULATION
Age group
04
5 14
15-59
60 and above
Total
Source: Census 2001
Number
302215
545120
978039
139461
1964835
Percent
15.38
27.74
49.78
7.10
100.00
(4)
1.5 Mothers and children

The young mother and their children require many health services that have not reached them
reflecting in high MMR and IMR. In the last decade there has been a marked improvement in
the health indicators of this region, however much needs to be achieved in terms of nutrition,
immunization, family planning, institutional deliveries, new born care and childhood diseases.
Some of the other health indicators show that:
(1)
Institutional deliveries are still quite low:

a. 21.3 per cent (DLHS 3)
b. 38.2 per cent (Concurrent Evaluation of NRHM 2009, IIPS)
(2)
Immunization programme has not been able to achieve the targets:

a. 51.0 per cent (DLHS 3)
b. 64.2 per cent (Concurrent Evaluation of NRHM 2009, IIPS)
(3)
Breastfeeding practices are poor

a. Per cent of currently married
women reported to have breastfed
youngest surviving child within 1
hour of delivery 30.09 per cent
(Concurrent Evaluation of NRHM
2009, IIPS)
b. Per cent of currently married
women
exclusively
reported
breastfed
to
have
youngest
surviving child for first six months
Photo 1.3: A mother with her young child
48.7 per cent (Concurrent Evaluation of NRHM 2009, IIPS)

(4)
The family planning coverage by modern methods is around 52 per cent, which is quite
low (DLHS 3). The fertility rate is high and the average household size is 6.34 persons.
This district therefore has many vulnerable groups and communities that are hard to reach.
The general population also has a high disease burden, specially malaria, diarrhea,
gastrointestinal infections, tuberculosis, leprosy and respiratory disorders. Young girls and
women suffer from anemia and their problems remain unattended.
1. 6 Description of MHV Project
CAIRN flagged off the MHV project on September 2009 to provide preventive and curative
healthcare in the project area. One of the major focus areas for the MHV was prevention,
applied through a Comprehensive Awareness Programme. As the project progressed, lacking
(5)
healthcare facilities and poor health conditions of villagers served as the inspiration to expand
to curative services. The objectives of the MHV project are:
Accessibility to and provision of preventive healthcare and curative medication for
treatment.
Provision of medical check-up facilities.
Need-based referral and diagnostic services.
Sensitization regarding geriatric care.
The project is being implemented through experienced NGOs- Helpage India and Smile
Foundation. Both NGOs have experience of carrying out grass root work in the villages.
Presently there are two MHVs, each covering 20 villages in 5 days. This way each of the 40
villages gets one visit of MHV every week. The primary function of the MHV is to provide
diagnostic, preventive, curative healthcare and referral services. Each MHV is staffed with a
qualified doctor, a pharmacist and a driver, and is equipped with essential medicine and
equipments.
1.7 Experiences of MHV services in the country
The concept of MHV services evolved due to challenge of covering remote villages in far flung
areas with poor health infrastructure and transport network. Mobile health service emerged as
the only feasible answer for such situations. The concept of mobile health services came
decades back when philanthropist and hospitals extended health services to those who could
not reach them. Health camps and blood donation camps have been regularly held. However,
these initiatives have not been taken up at big scale, and did not offer OPD or diagnostic
services.
In the last one decade that there has been a spurt in MHV based activities. It is a result of
corporate sector accepting the big challenge of healthcare, especially in rural areas. Many such
projects have been funded under the CSR initiative, and implemented with the help of NGOs.
Some of the well known projects are detailed here
(1) Lepra India
Lepra India has been successfully working for the last two decades in the health segment, with
major focus on HIV, malaria, leprosy and tuberculosis. Their work area is Orissa, Madhya
Pradesh, Jharkhand, Andhra Pradesh and Bihar.
(6)
Their Mobile Health Clinic project has been running since 2006 and has served population of
18 villages in Andhra Pradesh. Various components of the project are: mobile health van,
awareness meetings, exhibitions and sensitization programmes.
This is a highly rated project with sound linkages and networking with the existing health
facilities and programmes, as well as effective monitoring.
(http://www.iadho.org/includes/mhcAnnaulReport2010.pdf).
(2) DLF Foundation with CII

DLF Foundation has recently sponsored a Lifeline Express with CII. A train with 5 coaches has
been equipped with diagnostics, medical and surgical interventions to the disabled and post
operative care.
On the similar lines, DLF is initiating a Mobile Medicare Van to reach out to remote villages of
Maharashtra. Target is remote villages and construction workers.
The van is equipped to carry basic diagnostics, OPD and outreach services. It has In-built Lab
and X-Ray facilities. Each van is manned by a Gynaecologist and a General Physician. The
Mobile Medicare Vans provide Free OPD Services with subsidized medicines (free for those
below the poverty line).
(3) Wockhardt Foundation
Wockhardt Foundation has undertaken an ambitious project covering 40 districts of
Maharashtra and Gujarat. The mobile health van are well equipped with stet scope, BP
machine, nebulizer, oxygen cylinder, splints etc. It is manned by doctor and has medicines and
consumables. They supply antibiotics, pain killers, vitamins, anti allergic medicines etc. Each van
has a GPS tracking system installed which help effectively monitor the programme.
(4) MHV project in Uttarakhand (HLFPPT)
The state of Uttarakhand has perhaps the most significant mobile health project in the country.
The initiative was taken under NRHM, is called Mobile Health Clinic (MHC) and was piloted in
Chamoli district in the year 2004. It has been extended to Garhwal district. The
implementation has been done by HLFPPT under the Public Private Partnership (PPP) model.
This project also called Sehat Ki Sawari provides high quality, affordable Reproductive Child
Health services to the community besides OPD services.
(7)
MHC is well equipped with medicines and is operated by a team comprising of Medical Doctor,
two ANM Nurse, Laboratory Technician, Driver, Helper, MHC Van Coordinator and one
Village Link Worker. The MHC carries visits Fixed Service Delivery Points (FSDP) which are
10 in each of the districts. Each FSDP covers an average of 5-7 villages. Each FSDPs is served
twice in a month. The major services provided are general OPD, prevention, diagnosis and
cure of:
Minor ailments and acute infections
Diseases of national importance like- TB, Malaria, Measles etc
Diseases relevant to pediatric age group: like diarrhea, ARI, Meningitis etc
Skin disorders e.g. Scabies, fungal infections
Respiratory diseases e.g. Asthma, Chronic Obstructive Pulmonary diseases, Tuberculosis,

Occupational respiratory problems e.g. Coal workers - pneumoconiosis
Locally prevalent diseases e.g. Iodine deficiency diseases, worm infestations and vector
borne diseases.
Renal disorders e.g. Urinary tract infections,
ENT disorders e.g. Throat infections, ear infections etc.
Early identification of suspect cases of genital/breast cancer by examination
Antenatal services
Early identification of pregnancy by urine test
Nutritional counseling
Prophylactic and therapeutic IFA distribution
TT immunization
Early identification of high risk cases
Advice for delivery by trained worker/personnel
Importance of spacing
Infants and Child Monitoring
Neonatal/Newborn care
Immunization coverage- BCG, DPT and OPV, Measles, MMR, TT immunization.
Early diagnosis and treatment of childhood Acute Respiratory Infections and starting
treatment.
Diarrhea case detection and early institution of Oral Rehydration Therapy
Identification of complications in minor ailments e.g. Fever, pneumonia and diarrhea for
quick referral.
(8)
Inter Personal Counseling activities for prevention and early detection of congenital
disorders.
Adolescent and Reproductive Health:
RTI / STI Preventive Counseling
Promoting Healthy Sexual Behaviour
Menstrual hygiene
Promoting of delaying age at marriage
Clinical investigations including lab tests
Hb examination
BG and Rh typing
Blood Sugar F/R/PP
Urine test for sugar and proteins
Urine pregnancy test
Other services depending on the field requirement and epidemiological situation
Since inception this project has catered to nearly a lakh people. It is envisioned that the entire
project would work towards strengthening the public health system of the state and address
the health needs of the people on sustainable basis. The MHC endeavors to enhance health
seeking behavior of the people in the rural and hilly terrain by creating awareness and provide
quality RCH services accessible to the people at an affordable price. Advocacy done to enhance
the health seeking behavior among the people bore fruits as larger numbers of people are
reporting for seeking health services. Village Link Workers contributed substantially to the
success of this outreach activities even though their involvement was short lived.
1.8 Objectives of the evaluation
The objective of this evaluation study is to assess:
1. Relevance of the project in terms of its strategy, approach and interventions of the
project; to test whether they were in tune with the needs, situations and aspirations of
the targeted population.
2. Effectiveness i.e. the extent to which the objectives have been achieved with respect to
improvement in health status of the population.
3. Efficiency of the scheme i.e. in achieving its objectives whether resources have been
used economically and within the specified timeframe.
(9)
4. Sustainability of the intervention in term of extent to which the project has been and
can be sustainability on a long term basis.
5. Impact of the scheme i.e. the degree to which the project has helped in improving
health awareness and habits of the villages
1.9 Expected results of the evaluation:
Documenting best practices, gaps, learning and challenges
Identifying specific program components need to be strengthened in order to improve

the implementation of programme in future
Identifying role of MHV project in enhancing the community relation with Cairn India
Understanding the extent of need based services reached by Mobile Health Van project
Finding of the evaluation would manifest best practices, understanding gaps that need to
be address and recommendations shall help in formulating the improved health
intervention in the districts to take project forward.
1.10 Conclusions
Barmer is an economically backward district with scattered habitations and poor health
infrastructure. It has lowest human development index in the state of Rajasthan. People of
Schedule Caste and Schedule Tribe caste, young girls and women, and elderly are more
vulnerable people. Due to poor connectivity of dhanies, there is a need to augment health
delivery system to effectively reach out to people. Presently even FRUs are ill equipped and
short of trained staff. Family planning and RCH programmes have lots more to achieve.
(10)
Chapter 2
Methodology and Sample Characteristics
This chapter presents a brief overview of the methodology used in the study. It also discusses
the characteristics of the sample villages and respondents. The evaluation is a cross section
descriptive study that allowed assessing the impact of MHV Project in 10 selected villages.
2.1 Survey components
The study has made use of qualitative and quantitative techniques of data collection. The
respondents included beneficiaries of MHV, key informants, village leaders, ICDS workers,
MHV staff and health providers.
2.1.1 Sampling design and implementation
The study involved a two-stage sampling design. In the first stage, list of villages covered by
MHV were divided into two service zones namely north (MPT) and south (RGT). All the
villages which were covered by MHV project during the period September 2009 to December
2010 were taken at this stage.
In the second stage, route plan of each MHV was looked at. The villages visited by MHV in one
day were put into a cluster. Thus a total of 10 clusters were prepared. Using Simple Random
Method, one village was selected from each cluster as sample. Equal chance of selection of was
given to all the villages which were covered by MHV Project irrespective of implementing
agency.
(11)
2.1.2 Location of survey villages
Figure 2.1 shows the location of 10 survey villages.

Fig 2.1: Location of Survey villages
Chandaniyo ki
Nangana
Madpura Sani
Khatiyon ka Talla
Harpuniyo ki Dhani
Bhakharpura
Maliyon ki Dhani
LEGENDS
Sara
North (MPT)
South (RGT)
Mangle ki Beri
Goliya Garwa
2.1.3 Survey Tools
The evaluation tools comprised of structured schedules and guidelines for FGDs, as described
below. The interview guidelines were translated in Hindi.
(a) Beneficiary Schedule: Data was collected at the village level from adult men, women, elderly
population and youth/adolescent population.
(b) In-Depth Interviews and Focus Group Discussions (FGD): Primary data was collected
through In-depth interviews with key informants who were knowledgeable and aware of
the village and its residents. Additionally, in-depth interviews were also conducted with the
District officials and MHV project functionaries. FGDs were conducted among small groups
of community members who were aware of the MHV services being provided, irrespective
(12)
of being beneficiary or non-beneficiaries.

2.1.4 Sample size
The study is based on structured interviews conducted with the village leaders, beneficiaries,
key informants, staff of CAIRN India and Helpage India. The table below shows the sample size
by respondent groups. In each of the villages, first the Sarpanch was interviewed, followed by
interviews with other respondents. A total of 62 beneficiaries were interviewed, of which
nearly 42 percent were women (Table 2.1). Amongst the key informants, a large number were
village functionaries like ANM, ASHA and Anganwadi Workers (AWW).
TABLE 2.1 SAMPLE SIZE COVERED
Village Leaders (Sarpanch)
Beneficiaries
Male
Female
Total
Key informants
ANM/ASHA
AWW
Ward members
Teachers
Others
Cairn India Staff / Helpage India staff
District health officials/Key Informants
9
36
26
62
7
6
2
7
22
4
7
Table 2.2 shows the details of FGDs held in the villages with groups of men and women.
TABLE 2.2: DETAILS OF FGD
Date
30.5.2012
30.5.2012
31.5.2012
01.6.2012
02.6.2012
03.6.2012
03.6.2012
04.6.2012
04.6.2012
05.6.2012
06.6.2012
Name of village where FGD was

conducted
Madpura Sani
Madpura Sani
Harupechiyon Ki Dhani
Khatiyan Ki Tala
Chandoniyon Ki Dhani
Maliyon Ki Dhani
Maliyon Ki Dhani
Bhakharpura
Bhakharpura
Sara
Goliya Garwa
Type of
FGD
Male
Female
Female
Male
Female
Male
Female
Male
Female
Male
Male
No. of participants
Men
Women
6
7
7
8
6
7
13
8
7
9
8
(13)
A participatory activity carried out by the researchers was the organization of some interactive
games and activities with the groups of local inhabitants. This was undertaken to seek pertinent
feedback on health issues and perspectives from the local population.
2.1.5 Transit visit with MHV
Two Transit Visits were conducted during which one researcher went in MHV for the whole
day. Information was collected on the time spent on different activities, and observations were
made on the nature and manner of services provided by the MHV staff.
2.2 Training and fieldwork
Senior professionals of the HLFPPT first made preliminary visit to Barmer. The purpose of this
visit was to understand the functional aspect of MHV project at ground level as well as to
interact with Cairn staff placed at Barmer. This helped in making field plan and arranging
logistics for fieldwork.
The training consisted of classroom training, demonstration and practice interviews, as well as
actual field practice. The classroom training included instructions on interviewing techniques
and field procedures, a detailed review of each item in the questionnaires and instruction and
problem solving of participants. It also included training on research ethics.
Photo 2.2: Training of researchers by senior staff of HLFPPT at Barmer
Special invitee from Cairn was also present in the training programme at Barmer. Two teams
conducted the main fieldwork in each of the selected villages. Each team consisted of one field
supervisor, one male and female research investigators. A Field team In-charge was present
(14)
throughout the fieldwork. The fieldwork was carried out during May-June 2012.
2.3 Data processing
Completed survey tools were collected and scrutinized. The data processing was done through
conventional method which consisted of coding, data entry and machine editing.
2.4 Characteristics of the sample villages and beneficiaries
The population of ten survey villages is shown in the table below. The survey villages have
scanty rainfall, desert terrain, limited availability of water and poor infrastructure. Other
characteristics that aggravate the challenge of accessibility are the lack of roads connecting
dhanies, transport facilities, irregular electric supply and telecommunication. Table 2.3 gives
village wise number of households and percentage of BPL.
Table 2.3
Village Name
Area: MPT North
1. Harpuniyo ki Dhani
2. Madpura Sani
3. Khatiyon ki Talla
4. Chandaniyo ki Dhani
5. Nagana
Area: RGT South
1. Mangle ki Beri
2. Maliyon ki Dhani
3. Bhakharpura
4. Goliya Garwa
5. Sara
Households
79
868
106
190
185
199
144
316
130
496
Source: Sarpanch Schedule
Table 2.4 shows the profile of the beneficiaries who were covered during the primary survey.
The sample has a good representation of gender, religious background, marital and economic
status of people.
(15)
TABLE 2.4: CHARACTERISTICS OF BENEFICIARIES

Characteristics
N
Age
< 15
15-59
> 60
Religion
Hindu
Muslim
Gender
Male
Female
Marital status
Married
Unmarried
BPL status
BPL
APL
Number
62
Percent
100.00
5
47
10
8.06
75.81
16.13
58
4
93.55
6.45
36
26
58.06
41.94
55
7
88.71
11.29
37
25
59.68
40.32
Source : Beneficiary data
2.5 Health infrastructure at the sample villages

Table 2.5 shows distance of public health facilities from each of the 10 survey villages. It is clear
that the health infrastructure in the district has improved rapidly under the NRHM. There are
many Sub Centres, PHCs and CHCs present in the area. However from many villages PHC or
CHC are more than 10 km away. For vulnerable population, covering this distance to seek
timely medical help may not be possible.
(16)
TABLE 2.5: HEALTH FACILITIES AT THE SURVEY VILLAGES

Survey village
Mangle ki Beri
Maliyon ki Dhani
Bhakharpura
Goliya Garwa
Sada
Harpuniyo ki Dhani
Madpura Sani
Khatiyon ka Talla
Chandaniyon ki Dhani
Nagana
Distance of health facilities from village

Sub centre is in the village; the next nearest health facility is CHC
Gudamalani, at a distance of 22 kms.
Distance of Sub centre and CHC Gudamalani are 3 kms and 11 kms
respectively.
PHC is in the village; distance of CHC Gudamalani is 10 kms.
Sub centre is in the village; distance of CHC Gudamalani is 8 kms.
Sub centre is in the village; distance of PHC Paylakalan is 8 kms; the
nearest CHC is at Sindhari and is about 18 kms away.
Nearest PHC is at Kawas, at a distance of 4 km; nearest CHC is at
Baytoo and nearly 25 kms away
Nearest of PHC is at Kawas,at a distance of 1 km; nearest CHC is at
Baytoo, which is 22 kms away.
The nearest PHC is at Kawas at a distance of 8 km; CHC is at Baytoo
which is 31 kms away
Nearest PHC is at Kawas, at 12 kms distance; CHC is at Baytoo which is
34 kms away
Nearest of PHC is at Kawas, at 8 km; CHC is at Baytoo which is 30 kms
away
(17)
Chapter 3
Findings
The MHV project has nearly completed two years. This chapter looks at how many patients
have come to MHV for medical consultation, awareness people have about MHV, what is its
impact, relevance and efficiency. This chapter also presents the barriers of using the MHV
services and the gaps that exist.
3.1 OPD services of MHV
Since inception, a total of 39,939 beneficiaries of North (MPT) and 55,265 beneficiaries of
South (RGT) came to MHV for OPD. This is a significant achievement considering it has been
only two years since the programme started.
Fig 3.1 shows percent distribution of disease pattern diagnosed by North (MPT) MHV during
March 2011 to May 2012. Data on disease pattern indicates that 26 percent were diagnosed of
fever and 15 percent of skin infection. Other prominent diseases are chronic obstructive
pulmonary disease (9 percent), osteoarthritis (8 percent), gastritis (7 percent) and dyspepsia (7
percent). Irritable bowl syndrome, eye infection, diarrhea, scabies, constipation and
hypertension related diseases have been diagnosed in less than 5 percent cases. Malaria has
been diagnosed in 1 percent cases, which appears to be highly under reported because Barmer
is known to be malaria infected.
Fig. 3.1: Diagnosis of Diseases by North (MPT)
(April 2010 - May 2012)
Any ot her
14%
Chronic Obst rict ive

P ulmonary disease 9%
Ost eo art hrit is
8%
Skin Infect ion

15%
Gast rit is
7%
Dypepsiea
7%
Irrit able Bowl syndrom
4%
Fever
26%
Eye Infect ion

3%
Malaria
0%
Hypert ension
1%
Const ipat ion

1%
Scabies
2%
Diarehhea
3%
(18)
Fig 3.2 shows distribution of diseases in the South (RGT) for the period April 2010 to May
2012. Data shows 21percent cases of skin infection and 12 percent cases of Dyepsiea.
Fig. 3.2: Diagnosis of Diseases by South (RGT)
(April 2010 - May 2012)
Dypepsiea
12%
Fever 8%
Skin Infect ion

21%
Ost eo art hrit is

8%
Malaria
5%
Eye Infect ion
4%
Diarehhea
4%
Any ot her
26%
Scabies
3%
Irrit able Bowl syndrom

1%
Hypert ension
1%
Const ipat ion

1%
Gast rit is
3%
Chronic Obst rict ive

P ulmonary disease 3%
3.2 Awareness about OPD services of MHV

The concept of mobile health van was new to the people of Barmer two years back. When it
was introduced in the villages, people saw faces of foreigners in the van, and they started calling
MHV Goro ke Gadi. Now it is popularly known as Dawai Vali Gadi.
The Dawai Vali Gadi is a household name
now. Everyone knows about it, whether
they use it or not. Hariram Bishnoi,
Sarpanch of Mangle Ki Beri said As the
MHV enters a village, driver blows the
siren loudly. People living in far off dhanies
can hear it. They recognise that the gadi
has come.
The board at the halt point prominently
announces the presence of MHV and the
names of programme organisers (Photo
3.3). The halt points of MHV are usually
Photo 3.3: Board of MHV being displayed at a halt

point in village
village schools, which provide good visibility. Researchers observed that at all the halt points,
there were people queuing up much before the arrival time of MHV (Photo 3.4) showing high
level of awareness about the services rendered.
(19)
Photo 3.4: Villagers queue up for MHV before it arrives
3.3 Awareness about health camps

While the OPD services of MHV are well known in the villages where it operates, health
camps fall far behind in popularity. Nukkad Natak, movies and puppet shows attracted crowd
but the recall of the messages was poor. When asked about the camps held in their village,
very few remembered any messages or service given through health camps. Only 11 out of 62
beneficiaries had knowledge of the health camps organised in their village.
The responses of village leaders and health functionaries about services of MHV were
lukewarm. A few of them complained that they were not aware of any of these programmes.
A health camp was held in Harponion ki dhani village, nearly a year back. According to the
staff that organised the camp, it was an awareness drive for breast feeding, immunization,
sanitation and hygiene. However the village leaders and people did not recall anything
about the camp. Mr. Bhara Ram, a Mukhi (Chief) of the village is also the school SMC
Chairperson, expressed his unhappiness in these words I do not know of any health camp
organised in my village. They (organisers) did not inform us about any such programme.
On the other hand, government healthcare officials learned about these health camps, often
through media. They also declined their participation in these programmes because they were
not invited. They suggested that these events could be organised jointly with government for
better community support and impact.
The low awareness levels about the health camps being organized is perhaps to do with the
low frequency of camps in recent times (Fig 3.5). From this data we can deduce that merely
(20)
one or two camps were held in the last one year. The beneficiaries could not recall information
disseminated, thereby nullifying the purpose of organizing health camps.
Apr-12
May-12
Mar-12
Jan-12
Feb-12
Dec-11
Oct-11
Nov-11
Sep-11
Jul-11
Aug-11
Jun-11
May-11
Apr-11
Mar-11
Jan-11
Feb-11
Dec-10
Nov-10
Oct-10
Sep-10
Jul-10
Aug-10
Jun-10
May-10
5
4
3
2
1
0
Apr-10
number of health camps
Fig. 3.5: Number of health camps by the two region
month
North
South
3.4 Relevance of MHV

Discussions with the villagers and feedback from healthcare service providers show that the
MHV has provided useful service. People are appreciative of these efforts. The common
diseases in this area are arthritis and asthma amongst elderly people; dysentery and viral
infections amongst children; and seasonal fever, gastro-intestinal infections, skin diseases and
eye problems in the general population. The MHV addresses these health problems well, and
most of all it has filled an important gap that existed in the healthcare outreach.
3.5 Utilisation of MHV services
People in most villages visit the MHV in large numbers, and are regular. There are always a few
patients waiting even before it arrives. This exhibits that the local population has received the
MHV services quite well.
To analyse the target group availing the MHV services, February 2012 data obtained from MIS
was analysed (Fig 3.4). The graph below shows that it is largely young and very old people who
have benefited most from the MHV project.
(21)
Fig. 3.6: Patient load by gender and age (Feb 2012)

400
350
300
No. of patients
250
200
150
100
50
0
< 2 year >=2 to <6 >=6 to
year
<14 year
>=14 to
<18 year
>=18 to
<25 year
>=25 to
<40 year
>=40 to >=55 year

<55 year
age of male & female

Male
Female
Discussions with village leaders show that the village to village variations in the utilisation
pattern of MHV services are quite significant. While in some villages up to 70 per cent patients
avail the services of the MHV, in others it may be much lower. In Budhraniyo ki Dhani village,
the patient load remains below 20. Utilisation of services by villages requires more in-depth
analysis of data and a more updated MIS.
3.6 Time efficiency of the MHV staff
The team of researchers went in MHV with the Helpage India team on two different dates. The
researcher observed the practices of the team and noted down the time taken in different
activities. The results are shown in the Fig 3.7.
It shows that MHV staff spends about 7 to 8 hours in the field. Since MHV travels to four
villages everyday, it is not surprising that about 35 percent of the time is taken up in travel
alone. Close to 7 percent goes in rest and wastage. The time spent in consulting the patients is
about 58 percent.
(22)
Fig 3.7: Time spent by MHV by activities
9.00
0.22
8.00
7.00
0.82
Time (hours)
6.00
4.78
5.00
3.82
4.00
3.00
2.00
2.83
2.37
MHV-1
MHV-2
1.00
0.00
Travel time
Patient consultation time
Rest time
The time spent by doctor on individual patients was noted down for 54 cases and is shown in
Fig 3.8. For a few cases time spent is zero. These are likely to be repeat cases in which doctors
send them for extending the already prescribed treatment. For the vast majority of patients,
the time spent is somewhat less than a minute.
The time per patient is quite low and requires attention. Looking at this data in the light of the
requests from villagers to stop MHV for a longer time in each village, one should consider
reducing the number of villages to be covered everyday and redesigning the travel path. This
way time given by doctors and staff per patient will increase, making services more time
efficient. However, collection of larger data set will provided more reliable conclusions.
Fig. 3.8: Time spent by Doctor with a patient
210
180
Time150
(in seconds)
120
90
60
30
0
1
9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43 45 47 49 51 53
Patient number
Time sent by Dr.with the patient (in sec.)
(23)
3.7 Cost efficiency of the MHV services

Each MHV can cover 150 patients in OPD everyday. This translates to nearly 3000 patients
every month. The graph (Fig. 3.9) below shows that for most of the months the target are not
met and during the summer months of April to August and festival months of October
November it is much below the target. Low patient turnout could be tackled by improving the
social mobilisation programme. During the lull period, MHV staff could be used for awareness
generation work, promoting ANC, PNC, immunization, health and hygiene and promoting
preventive measures.
Fig. 3.9: Monthly patient load by the two region
3000
2500
Patient
load
2000
1500
1000
500
0
Aug-11
Jan-12
Jan-11
Dec-11
Feb-12
Sep-11
Dec-10
Sep-10
Feb-11
Nov-11
Nov-10
Jul-11
Jul-10Aug-10
Oct-11
Jun-11
Jun-10
Oct-10
Mar-12
Mar-11
Apr-12
Apr-10
Apr-11
May-12
May-11
May-10
month
North
South
3.8 Gaps and barriers in utilisation of MHV services

While the services offered by CAIRN India are much appreciated by the villagers, the general
view amongst them is that the MHV can service minor health ailments like fever, cough and
cold, and a few geriatric problems. For any serious ailments, patients should be taken to CHC.
If the ailment persists and situation demands serious attention, then patients are taken to
Gujarat, where the best healthcare services are available. This perception is detrimental to the
MHV programme and inhibits many patients from availing its services.
(1) Cultural and language barrier: Care has been taken by NGOs in engaging local staff,
still villagers feel difficulty in communicating as stated by a woman beneficiary The doctor does
not understand what we illiterate women tell him in our Marwari. We do not understand everything
that he tells us. We have to guess as to what he might be advising. A similar comment came from
an Anganwadi worker The MHV staff is of urban origin and finds it difficult to connect to the local
villagers. In some places lack of communication with villagers, due to cultural and language
differences, appears to be a problem and needs to be addressed. The field staff has to mingle
(24)
with people, understand their problems and relate to them. Thus only the cultural and language
barrier will be overcome.
Photo 3.10: A woman turns her head away as Doctor gives her instructions
(2) Marginalised community: Some village people do not avail the MHV services because of
their lower caste status. Bhils is one such community. It has a distinct culture and its people do
not mingle with people of other communities easily. They remain un-served by all such
services. This was observed in the Bhil dominated dhanies of Maliyon ke Dhani and Sada
(3) Perception of cheap and low quality service: CAIRN has extended low priced health
services to people, which is unfortunately getting associated with low quality. This is a
dangerous perception that requires a quick correction. Those who are well off in the project
area did not hesitate in saying that MHV is a cheap option, and is only meant for very poor
people. One of them added free medicines do not work because they are of low quality. Many a
respondents said that doctors of MHV are not able to give proper medication because they are
unable to diagnose the illness properly. They do not have facility for pathological tests. Some
complained that doctor did not even use stethoscope (alaa) to check the patient.
Doctors give a lot of medicines but their diagnosis is not sound. Ramdeo a respondent said,
Doctor is treating my brother for last six months. His fever continues and medicine is ineffective.
No pathological tests have been done and doctor is taking a blind shot at the disease. Another
patient said Doctor do not even have injections. How can their medication be effective?".
On the other hand, Doctors also feel tied down to a narrow range of medicines. They cannot
(25)
ask patients to buy medicines from the open market. Many a times there is a need to apply
special ointment, which may not be in MHV. These are some of the short comings in the
programme which does affect the quality of service.
Doctors in MHV are retired and are quite old. About one doctor many people complained that
he was hard of hearing. Many of the patients said they had difficulty in talking to him. Fitness of
the doctor is imperative and critical for running the health service. Since some of the
complaints are not unfound, there is a need to work towards delivering quality service.
(4) Distance within the village: Distance of dhanies is a big barrier in most of the villages.
Some of the dhanies are as far as 5 to 8 kms away from the Halt Point of the MHV (Photo 3.4).
Most people who come for the OPD consultations at the MHV are from nearby dhanies only.
Option of spreading out Halt Points to those dhanies from where demand arises, may ease the
situation and give a larger reach to the programme.
Photo 3.11: Miles to go to reach a service point
(26)
(5) Lack of privacy: Patients require privacy which

an open van does not provide (Photo 3.12). The data
on diseases diagnosed has shown that reproductive
and sexually transmitted diseases are not reported
perhaps for the same reason. Feedback from young
people and the age profile of patients (Fig 3.6) shows
that problems of young people (14 to 40 year old)
have not been so well addressed, especially the sexual
disorders. The
syndromic
doctors of
management
of
MHV
can
perform
reproductive
tract
infections, which is based on symptoms and clinical

signs but patients do not turn up due to stigma
attached to these diseases. They require anonymity
and privacy. Since MHV does not offer that, they turn
to quacks or self medication.
Photo 3.12: A woman in purdah sits at

the door step of MHV to talk to doctor
(6) Absence of lady doctors: Women expressed that they suffer from anaemia and
gynaecological problems like white discharge, itching and menstrual disorders. But they hesitate
to consult the male doctor of MHV. In Barmer, women follow Purdah system and they remain
covered under veil as a symbol of modesty. Amongst Rajput women it is just not acceptable
that women go to MHV where there are no lady doctors.
(7) Frequency and timing of the MHV: MHV visit falls at odd hours in some villages. One
Sarpanch said that MHV comes to his village at noon, a time when people are having lunch. The
vehicle hardly waits because it has to go to four villages every day. It is unable to keep precise
timing at all places. Therefore patients end up having a long wait.
Frequency of MHV is once a week, which is very low. Sometimes patients have to wait for a
week or more to consult doctor, which is too long. People demand that the van should visit
each village atleast two or three times per week. The stoppage time of MHV works out quite
low. Sometimes it is less than an hour in a village. People complained that by the time they
reach MHV, it moves out of village. There is need to increase stoppage time and increase
frequency of visits.
MHV stands in a village for a very short period. Maitni Devi of Sada village registered her
complaint in these words Within 10 to 15 minutes of coming, the MHV driver starts
telling it is time to go. Once I objected to this. He got angry with me. Now he makes me
wait and does not make my health card easily.
(27)
(8) Emergency needs: The emergency services in the project area are non existent.
Rajasthan has one of the highest MMR because often women are unable to reach medical
facility in obstetric emergencies. Poor people have no option in such situations but to rely on
local dais and jhola chaap doctors. It will be a great service to the people if emergency services
are made available on call.
There should be a lady doctor in the MHV because the young women of our village cannot share
their sexual and reproductive problems with male doctors
Suwa, 45 years old, Village Bhakarpura She was talking about the health seeking behaviour of the
women of her community.
(9) Narrow range of service: There are many diseases that are prevalent, but not handled
by MHV. Tuberculosis is one of them which is a prominent diseases. 9 out of the 62
beneficiaries interviewed demanded diagnostic and treatment facilities of tuberculosis in the
van. Inability to treat such widely prevalent diseases is a barrier to the services offered.
(1)
(2)
(3)
Reproductive and Child Health services are critically
(4)
important here, but not offered by MHV. There are

many children who are victims of low immunization and
poor nutrition (Photo 3.13). Panno Devi, an anganwadi
worker in Harponio ke dhani, said MCH facilities are
poor in our villages. Immunization of infants, ANC and
PNC of women if made available at the village level, will
have major health impact.
The secondary data also confirms the opinion of health
providers that the breastfeeding practices are quite poor.
ANC and immunization are still low. There is a need to
address some of these issues through expanding the
basket of services.
Photo 3.13: A young child suffering

from malnutrition in Nagana village
(10) Lack of coordination with the public health providers: One of the biggest
drawbacks of the programme is that it is not synchronised with the public health programme of
NRHM. For it to be effective, and there should be coordination and dialogue between the
coordinators of MHV and public health service providers. The health camps will also have a
better appeal if they are conducted jointly with government programmes.
(28)
3.9 Impact of MHV services

MHV has served thousands of people. It has brought smiles on the faces of elderly people.
Women throng to the MHV in large numbers to consult the doctor. A bond of trust is
beginning to form. The paragraphs below
show the impact it had on the lives of
people.
(1) Bringing smiles on the faces of
elderly
Old people have been one of the biggest
beneficiaries of the programme (Photo
3.14). They tend to ignore their health
problem in the beginning, and go for
consultation only when disease took
serious form. Some faced neglect of family
members. Many of them suffered from
Photo 3.14: Kamla Devi of Madpura Sani is in her

sixties and walks with a stick.
geriatric diseases like asthma and arthritis. MHV came as a boon to them. One sees elderly,
often on their sticks, slowly walking to see the MHV doctor.
(2) Making health services affordable
Due to MHV villagers have experienced reduced cost of travel and treatment. A beneficiary
named Teja Ramji Mali of village Maliyon ke Dhani said When MHV was not here, I used to
travel about 5 km to Nagar where there is a Sub Centre and a private doctor. It takes one
hour to walk there. Conveyance which costs Rs 200 and treatment cost was not less than Rs
300. If problem persisted we used to go to CHC Gudamalani which was 13 km away from our
village. It never costs less than Rs 1000 per visit.
The village Madpura Sani is dominated by people of OBC and Brahmin caste. Ketaram is
Meghwal, and belongs to schedule caste. He worked as a wage labour in a nearby PoP
factory. He suffered from lung infection and was coughing continuously.
He rushed to PHC Kawas, but there doctors do private practice. They charged him fees and
made him buy expensive medicines from open market. He said There was no relief inspite of
spending money. Then I switched to a local private doctor. That was expensive too and gave
me no relief. At the end, on recommendation of one of his relatives, he went to the doctor in
MHV. He got free treatment. This medicine was so effective that now Ketaram recommends
MHV to all his friends and relatives now.
(29)
(3) Service at the door step

Before MHV came, there was hardly any health service in the neighbourhood. People had to
travel to PHC, CHC or the District Hospital. Going to PHC Kawas used to be big waste of
time. I used to lose one day wage in the process. Now we consult the MHV doctor first before
rushing out of village, said Surendra Kumar, a villager of Harpornio ke Dhani. Same is the
story for most of the beneficiaries. Health services at their door step means saving precious
time and not losing that days wage.
Moona Devi of Nagana is 70 year old. She is sitting under shade of tree and is eagerly waiting
for the MHV to arrive. Lately her health has gone down and she suffers from fever and loose
motions. This has made her very fragile. No one is free in her house to take her to a doctor.
Nearest PHC is Kawas that is 10 km away. She felt very weak and became fragile.
Now that MHV has arrived, she walks slowly with her stick, to the school where MHV will
come. Last week she got the medicine and her loose motions came in control. She is quite
happy today and said with a smile The Dawai Gadi is a God sent gift to old people like us.
(30)
Photo 3.15 : Women pleased with the MHV services
(4) Changing lives, changing health seeking behaviour

MHV and other programmes have made people aware about common diseases, and they seek
preventive and curative options. During an FGD in Khatiyan Ki Tala people said earlier people
went for jhad phoonk when they had fever. Now they know it could be malaria. They rush to
PHC for test or consult private doctors. The wait time has surely reduced. People have begun
to use mosquito nets now. All these changes have taken in the last few years only and MHV
could partially take the credit for this achievement. Hari Ram Bishnoi, Sarpanch of Mangle ki
Beri said people are more aware about their health now. The Neem Hakim (jhad phoonk)
shops have fast disappeared from our village neighbourhood. Now people go to MHV, and for
anything serious go to Barmer or Gujarat. Sarpanch of Maliyon ki Dhani said now the village
compounder, who did private practice and cheated people, has stopped coming to our village.
This is a big achievement of MHV.
Now people have become aware about need of clean drinking water. Many of them told during
interviews that the water table in their village is polluted. They are aware about fluoride in
water. Many villagers have forwarded their demand to Cairn India and their village Sarpanch to
install filter machine in hand-pumps. One of the respondents demanded that their drinking
water problem should be addressed We are getting sick because our drinking water has become
polluted. MHV people should solve our drinking water crisis instead of treating the diseases. People
are hopeful about CAIRN and the services it offers.
(31)
Ramchandra Bishnoi was standing at the village Bus Stop in Goliya Garwa and got attracted
to sounds coming from the village school. He walked over there to find a Health Camp has
been organised by Cairn India. He sat there for sometime and listened to doctors advising
people to have clean drinking water. He was suffering from stomach problem for about a
year and had already spent more than Rs 2000 to consult doctors at CHC Gudamalani,
which is around 20 km from his village. He learnt at the health camp that if drinking water is
not clean, it can cause several health problems including stomach problems. He was told that
the water in his village is salty and has fluorides, which are harmful for health.
On advice of the doctors at the health camp, he started getting drinking water boiled at his
house. Everyone takes boiled water in his family now. Ramchandra tells that all his stomach
problems disappeared like a magic. He has now taken all the advice that the MHV doctors
had given regarding heath and hygiene. He says MHV has changed his life.
(5) Bringing equality

A typical village of Rajasthan is known for caste ridden social system. Interestingly, MHV has
been a big caste equaliser. People of different castes stand in a queue to consult doctor. The
researchers examined the phenomenon closely and came to the conclusion that there is no
caste barrier in consulting MHV. This is not a mean achievement.
Photo 3.16: People of different backgrounds assemble at the MHV for consultations
To sum up, MHV has provided very good service. In the words of a villager MHV is like Ganga
river. When Ganga water comes to your home, everyone touches it. Same with MHV. It is free
and good.
(32)
3.10 Conclusion
CAIRN has been able to provide health service to a very large number of people through the
OPD services of MHV project. It is a cheaper alternative for people, and is available closer to
their homes. The elderly and very poor have been especially benefited by the programme. It
has given them hope and brought smiles on their faces. The services rendered are relevant to
people because MHV has served the most unserved population.
The programme has several gaps, which if filled will make MHV more effective and efficient.
Villagers are unhappy with the time and frequency of van. They have demanded 2 to 3 visits of
MHV every week. On the other hand, the general perception is that MHV staff does not have
the expertise to treat serious illnesses. They can only handle cough, cold, fever and may be skin
allergies. Some people do perceive MHV services to be of low quality- doctors neither give
them sufficient time for clinical check-up, nor has any facility for pathological examination;
without a lady doctor, women hesitate in sharing their gynecological problems; the medicines
are limited and doctors do not give injections. The health camps have been too infrequent to
have a substantial impact.
The programme could become more efficient if MHV movement plan is redesigned and given
more halts in a village to cover the unserved dhanies. The basket of services could b`e
expanded to include MCH services, specially immunization and nutrition, as well as pathological
testing. To improve outreach there is a strong need to work with the existing government
machinery and synchronise with the ongoing NRHM programme.
(33)
Chapter 4
Recommendations
The public health care set up in Barmer district faces challenges to cater the large rural
population. The FRUs are ill equipped thereby not handle emergencies. Immunization, Family
Planning, Breastfeeding and ANC drives have immense scope to achieve the desired impact.
MHV has filled some of these gaps and made a positive impact on the lives of people.
The findings show that people availing the MHV services. The project reach and effectiveness
could be increased by making a few additions. Based on study findings and analysis, the
following recommendations are suggested:
4.1 Provide pathological examination
A number of factors identified in the evaluation that can be added in the MHV services. Instead
of only OPD services, basic pathological test facilitates could be added. Considering high
prevalence of malaria and anaemia in the district, it is recommended that in the first phase
malaria and haemoglobin tests could be taken up, and later increase to tests for blood sugar,
pregnancy, tuberculosis and X-rays.
4.1.1 Test for haemoglobin
Iron deficiency is a wide spread problem in the population and has some very serious
consequences. Hb test provides proper detection of the problem. By adding the Hb test in the
MHV, the doctors will be able to suggest therapeutic measures to patients and do timely
intervention. The major women beneficiaries will be pregnant women, lactating mothers,
menopausal women, school going children and others.
(1) Measurement
The most suitable method to measure Hb for such community applications is a HemoCue
machine. It is a portable devise for carrying out haemoglobin tests based on photometry. The
blood is drawn from patient and put into a micro cuvette by capillary action, which is then
inserted into HonoCue photometer. The machine gives results within 45 to 60 seconds.
(34)
(2) Supplies
The test requires purchase of disposable microcuvettes which come in a box with fixed expiry
dates. The other items required are disposable sterile lancets, batteries and other supplies such
as disinfectant, gauze pads, alcohol, band aids and latex gloves.
(3) Training requirement
The person required to carry out the test should be atleast Class 12 pass, and undergo training
to operate the machine. SDM Hospital at Jaipur provides one week training and certificate.
(4) Cost of test
The initial cost of machine is Rs 35000 to Rs 40000. The cost of microcuvetee is the tune of Rs
30 per piece. Thus the cost of carrying out one test comes out to be close to Rs 40.
(5) Benefits
The machine portable, light and handy. It can easily be transported to the field. The
tests are performed in the field without a need to transport blood samples to
laboratory.
This is a rapid test for which results are available immediately. The MHV doctors can
suggest treatment based on the test results.
The machine does not require electricity and is run on batteries.
There is no need for refrigeration.
The operation of the machine is simple and an Intermediate pass student could be given
one week training for him to operate the machine properly.
The test is USFDA approved and has reported high sensitivity.
(6) Risks
The cost per test is higher than the traditional methods.
Any error in the test process may raise adverse image of MHV
4.1.2 Test for malaria
Malaria has one of the most serious health problem, as reported by the health practitioners in
Barmer. It is reported to have highest mortality and morbidity amongst all diseases. There are
frequent seasonal outbreaks of malaria in the target area. Providing screening test to detect
malaria is a need of the hour.
(35)
(1) Measurement
Rapid Diagnostic Test (RDT) is a quick method to diagnose malaria infection by detecting
specific malaria antigens in a person's blood. The blood sample can be taken using finger prick
method. The test is available in different formats such as dipstick, strip, card, pad and cassette.
The diagnosis requires application of a very small quantity of blood on the test card, along with
a reagent. After 15 minutes, specific bands appear on the test card window which indicate if the
patient is infected by Plasmodium falciparum or one of the other 3 species of human malaria.
(2) Supplies and manpower required
The test does not require any capital investment or electricity.
(3) Training requirement
Anyone with little training will be able to perform this test.
(4) Cost of the test
The cost of malaria detection using RDT works out in the range of Rs 20 Rs 35 per test.
(5) Benefit
It is a quick test
Does not require any laboratory, equipment, electricity, refrigeration facility and capital
investment.
Can be performed at Point-of-Care
(6) Risk
Low sensitivity reported when low concentration of malaria parasites
Better sensitivity for P. faciparum but not for non P. falciparum
Microscopy is cheaper method with higher sensitivity
4.2 Enhance basket of services

Looking at the current performance of MCH services, it is recommended that MHV project
should be given an expanded basket of services including pregnancy test, ANC, immunization,
childhood vaccinations and nutrition. The utilisation of public RCH services has been due to
poor connectivity of villages, remoteness of dhanies and non availability of supplies. CAIRN is
rightly positioned to take up this challenge as it has already made in-roads into the villages. It
(36)
can fill the gaps that exist in the RCH programme and carry out the programme in partnership
with the government.
4.3 Strengthening MHV services through convergence with public institutions

CAIRN can present a sound MHV model to the country that is effective, sustainable and
scalable if it engages the communities it works with. Presently the MHV programme is a stand
alone programme to render health services. For these services to be effective that impact is
lasting, it should have local-block-district level linkages including local women group like SHGs,
village leaders and health workers and others. Working in collaboration with community health
workers and public institutions would improve the MHV services. The infrastructural support
for strengthening the performance of PHC and CHCs through coordination with government
would be value addition to CAIRNs CSR initiatives.
A number of centrally and state sponsored programme are ongoing that aim to provide quality
health care like Rajiv Gandhi Mobile health initiated by NRHM-Rajasthan. It is important to
strategically coordinate with the district and block level health official to make MHV efforts
sustainable.
4.4 Staff composition
Addition of a lady doctor in the staff will add useful service for girls and women. The
community mobilisation also requires full time project staff that makes field visits. The village
level volunteers, especially members of self help groups, who will help in organising health
camps and promote OPD services of MHV.
In the existing set up of MHV, the staff does not get to interact with the local people more
than seeing the patients. This is perhaps the reason that women beneficiaries expressed
difficulty in communicating with the MHV staff. It is recommended that each staff is engaged in
community mobilisation task also, which will sensitise them towards the needs of local people.
4.5 Route planning
It is recommended that the route plan of MHV is redesigned with consideration that it spends
more time at each village. The halt time should never be less than 2 hours per village whether
patients have turned up or not. There is excessive amount of travelling that the staff does
every day, and the services provided by them will not be sustainable.
(37)
4.6 Organising health events

Special attention needs to be paid while organising the health camps. The specialised health
camps need to be organised in regular intervals, which enhance the effectives of health camps.
Organisers must ensure the proper briefing of specialised health professionals prior to
organising the health camps. In order to ensure the quality of services by experts, screening of
symptoms must be done in a planed manner.
4.7 Referral services
The referral system of MHV has not been put in place properly which explains its complete
ineffectiveness. Since the range of diseases that doctor of MHV encounters can range from
common illnesses to complex situations. With cooperative and well networked system,
complex cases requiring higher range of skills and facilities could be referred. Proper planning is
required so that the patient is referred to keeping in mind geographical factors, time,
affordability and emergency services into consideration. The referral system will only work well
if there is flow of information from both sides. This will require professional help in developing
a proper system so that the patients could be tracked and success of referrals could be
measured.
4.8 Develop GIS based MIS
The present MIS is not comprehensive in terms of information it tracks. It is taking the staff
long time to update it. The project could improve its efficiency if a GIS based MIS system is
developed to track the movement of vehicles and measure the halt time. It is recommended
that the MHV is powered with solar panel and is provided with long-range broadband wireless
internet facility to send the online data to the server at head Office as well as to the referral
centres. If the MIS is properly developed and systems are in place, performance of the project
can be easily tracked.
4.9 Document Good Practices
CAIRN project on MHV can provide useful lessons and insights to other programmes running
in rural and under served areas in the country, and outside. It is recommended that the Good
Practices and success stories are documented, using professional expertise.
(38)
References
1. Government of India, Framework for Implementation (2005-2012), National Rural
Health Mission-Meeting peoples Health Needs in Rural Areas, Ministry of health and
Family Welfare, New Delhi-2005.
2. Government of India, National Rural Health Mission (2005-2012) Mission Document,
Ministry of Health and Family Welfare, New Delhi, 2005.
3. NRHM-The progress so far. http://mohfw.nic.in/nrhm
4. NRHM-The Medical Mobile U nits. http://mohfw.nic.in/nrhm
5. National Institute of Health and Family Welfare, New Delhi and UNFPA An
Assessment of functioning of Mobile Health Units in Jharkhand, 2008-09
(39)

Evaluation MHV Barmer

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Evaluation MHV Barmer

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Health Facilities on Wheels:

Reaching the Unreached

Evaluation of Mobile Health Van Project

Evaluation of MHV Project

HLFPPT Corporate Office

2-METHODOLOGY AND SAMPLE CHARACTERISTICS

Evaluation of MHV Project

Availability of health services

Sample size covered

Scattered settlement of Nagana Village

Map of Barmer (Shows the location of 10 survey villages)

Evaluation of MHV Project

Accredited Social Health Activist

Evaluation of MHV Project

We are thankful to Cairn India for providing us an opportunity to conduct an evaluation of

Dr. Shubhra Phillips

Evaluation of MHV Project

Evaluation of MHV Project

2. Enhance basket of services

Evaluation of MHV Project

Evaluation of MHV Project

Evaluation of MHV Project

Photo 1.1: Scattered settlement of Nagana village

1.2 Socio economic conditions

Evaluation of MHV Project

TABLE 1.1: AVAILABILITY OF HEALTH SERVICES

No. of Sub Centres (SC)

Source: 5th CRM Report, NRHM, Rajasthan

Evaluation of MHV Project

Photo 1.2: An old man slowly walking on

Evaluation of MHV Project

1.5 Mothers and children

Institutional deliveries are still quite low:

Immunization programme has not been able to achieve the targets:

Breastfeeding practices are poor

surviving child for first six months

Photo 1.3: A mother with her young child

48.7 per cent (Concurrent Evaluation of NRHM 2009, IIPS)

Evaluation of MHV Project

(2) DLF Foundation with CII

Evaluation of MHV Project

Minor ailments and acute infections

Diseases of national importance like- TB, Malaria, Measles etc

Skin disorders e.g. Scabies, fungal infections

Respiratory diseases e.g. Asthma, Chronic Obstructive Pulmonary diseases, Tuberculosis,

Renal disorders e.g. Urinary tract infections,

ENT disorders e.g. Throat infections, ear infections etc.

Early identification of suspect cases of genital/breast cancer by examination

Early identification of pregnancy by urine test

Prophylactic and therapeutic IFA distribution

Early identification of high risk cases

Advice for delivery by trained worker/personnel

Infants and Child Monitoring

Immunization coverage- BCG, DPT and OPV, Measles, MMR, TT immunization.

Diarrhea case detection and early institution of Oral Rehydration Therapy

Evaluation of MHV Project

Adolescent and Reproductive Health:

RTI / STI Preventive Counseling

Promoting Healthy Sexual Behaviour

Promoting of delaying age at marriage

Clinical investigations including lab tests

Blood Sugar F/R/PP

Urine test for sugar and proteins