(under development)

(under development)

Referral Health Centres

Seva Mandir helps operate 2 Referral Health Centres, in Kochla (Jhadol block) and Kojawada (Kherwara block). These RHCs provide both primary care and laboratory investigations. Kojawada hospital also has beds for 11 in-patients.

Monitoring and Evaluation of Government Health Services

Under the auspices of the Rajasthan Voluntary Health Association (Jaipur), Seva Mandir conducted the evaluation for the Udaipur district to assess the impact of the Village Contact Drive (VCD). The VCD is a campaign launched by the Rajasthan Health Systems Development Project to increase people’s awareness of and access to health services through targeted visits to the villages. The findings revealed that while the overall effect of the VCD appears to have been positive, the gains accrued are not commensurate with what was originally hoped for. For example, an average of 65% of the households in a village were not aware either of the visits or their purpose and only 41% of respondents were aware about the benefits of having a BPL card and 73% of respondents were unaware of the free facilities available in the Community Health Centres. A sustained interaction stressing these elements might prove to be more effective.

In addition to this, Seva Mandir undertook an evaluation of a recent capacity building initiative under the NRHM for various stakeholder groups (ASHAs, panchayat members, block level officers and community members) conducted by Calcutta-based consultancy, I-Land Informatics, under the NRHM. The evaluation revealed varied levels of understanding across the different stakeholder groups. Some topics appeared to have been given more attention (e.g. JSY and immunization) than others. Overall the ASHAs seemed to be best informed (though this could be due to the fact that they had also participated in previous trainings). Substantial information gaps were found amongst the key government functionaries and these need to be addressed urgently.

Finally, Seva Mandir has been involved in facilitating community based monitoring of Government Health Centres at all level as part of a PFI (secretariat) and PRAYAS (state nodal agency) initiative being carried out across 9 states. The work was carried out across 15 villages of three PHCs in Kotra block (Mamer, Bikarni, Mandwal). It began with the formation of village level health and sanitation committees and training the committees on monitoring and dialogue at the PHC at block level. Seva Mandir’s own staff also participated in a TOT on community monitoring to enhance their capacity to take this work forwards.

Action Research

Immunisations

The action research on immunisation (for mothers and children) that Seva Mandir had been conducting in collaboration with the MIT Poverty Action Lab came to a close this year. The research was being conducted in collaboration with the government and entailed ensuring the regularity of the immunization camps and providing incentives to parents for getting their children immunized. Incentives included 1 kg of dal for each shot and a complete set of cooking utensils for full immunization. Although these incentives are only given for children under the age of 2, the camps are open to children up to the age of 5. The action research indicated positive results and Seva Mandir has decided to continue the activities as part of its mainstream health programme.

Improving Reliability of Government Sub Centers

This intervention aimed at improving the reliability of availability of services at the government sub centres. The objectives were to (a) ensure the availability of the ANMs at the selected sub centres, and see its impact on the care seeking practices of the community; and (b) Assess the effect of care seeking from a qualified provider on the health status of the communities.

The research was carried out from Dec'05 – Dec'07 in a randomised treatment-control design with 48 sub centres serving as the treatment group, and 52 centres as control. A Memorandum of Understanding (MOU) was signed between Seva Mandir and District Health Department to monitor the presence of the Additional ANMs (placed at sub-centres in tribal areas since December 2004, as per order by the state Government) at 48 sub centres, 3 days of the week; and capacity building of these ANMs through periodic trainings. Ultimately, monitoring was only carried out at 41 sub-centres. Of these, the Government had appointed an Additional ANM in only 16, which were monitored three days a week. The remaining 25 sub-centres with single ANMs were monitored only on Mondays as the District Collector had issued orders for all ANMs to be at their sub-centres on all Mondays. The presence of the ANMs was monitored using specialized date and time stamps and random checks.

Monitoring Results – from Date & Time Stamps

The presence of the ANMs during the baseline study conducted between January 2002 and August 2003 was 44%. As the intervention started, it seemed that the presence was improving however soon enough it plateaued and, some months later, it even fell. The presence in the additional ANM centres went as low as 27% in some months. However, the absence days were also not increasing. A new category of "exempt days" seemed to explain the non-increase in both presence and absence. Exempt days referred to those days when the ANM was officially allowed to be away from the sub centre for other tasks like monthly meetings, camps, visits for cases of sterilization etc. It is difficult to verify whether the ANM actually went for these tasks/meetings. For example, verifying whether the ANM went for home visits or not would not be possible even for the Medical Officer. Hence it is possible that the increase in exempt days is due to both conflicting orders from the senior health authorities as well as collusion between the ANM and her seniors.

Addressing Iron-Deficiency Anaemia through Fortification of Flour

Seva Mandir has been conducting another action research intervention to explore an innovative solution to addressing the high levels of anaemia in its work area by enhancing dietary intake through village-level iron-fortification of flour. Since most villagers get their grains milled at the local village miller (known as a chakki), the introduction of a simple iron-rich compound to the flour at the time of milling could help to increase consumption of iron. Mixing machines and a regular supply of iron-mix were provided to chakkis in 68 treatment hamlets. 66 control hamlets were selected for comparison. Bimonthly meetings were conducted with the selected chakki owners to orient them and monitor performance. The chakkis’ performance was reviewed and their honorarium adjusted accordingly.

A midline evaluation shows an average increase of 0.65gms/dl amongst the treatment group. The study came to an end later in the year and chakkis were given the option of continuing with the fortification if the were interested. 23 chakkis are still continuing in this mode. In Kherwara block, the research is still ongoing and 30 chakkis are continuing with the fortification. The future strategy will depend on the end-line results. During the present period, the scope of introducing pre-packaged, iron-fortified salt as an alternative to fortification at the village chakki was also explored but due to issues in procurement, it was not possible to take this endeavour forward.