Feasibility Study of Mobile Medical Unit Operations in Mewat

DOCC PROJECT REPORT

Feasibility study of mobile medical unit operations in Mewat

Helpage India By Charan Puneet Singh (PGP-07-102)

2008

Centre for Development of Corporate Citizenship SP Jain Institute of Management and Research HelpAge India| Fighting Isolation, poverty, neglect

Preface

The project began on 24th March at HelpAge office in New Delhi. At a meeting with the staff of Helpage, I was given the required reference material and was asked to explore possibilities of starting Mobile medical units in Mewat. At the outset, I didn’t even know where Mewat was! It being a new district most maps available don’t show where exactly the place is. Mewat is referred to as land of the Meo-Muslim community spread over Haryana, UP and Rajasthan in the Aravalli region. I started the project with field visit at Gehlap village ahead of Palwal on the Delhi-Alwar Highway. It was an eye opener visit for me. From all the glorious talks about emerging India, rise of Asian powers, world of malls and hyper malls, an easy life and then 40 km outside the capital into an abyss of darkness. Gehlap did not have a doctor anywhere till 9km at PHC Ha- thin. Talking to villagers there, understanding their problems showed me a face of my country I had not seen before. It made me aware of the acute medical, psychological and social problems the aged in rural India have to face. My subsequent visits were to the Primary Health Centres at Hathin, Nagina, Nuh and to the Civil Hospital at Mandi kheda. I visited some NGOs in the region like Chandipur Health As- sociation (Gehlap), MSEDS (Punhana) and Deepalaya (Tauru). I also visited the district col- lector’s office to collect data about the socio economic profile of the district. The project gave me an opportunity to look at rural India closely. I got to see effectiveness of various government policies like the Prime Minister’s road project, the National old age pension scheme, the girl child education scheme and their impact on the real benefactors. I presented my findings and recommendations on the 6th May to Helpage in New Delhi. It was a great exchange of ideas and hopefully Helpage will be starting operations there in the near future. This project under DOCC has given me insights into rural India which have changed my per- ceptions about development. There can be no development if the rural India is not taken along. Also with a rapidly growing aged population, aged rights simply cannot be ignored. Society has to give them their due. Someone once said that India lives in its villages. Now I can truly comprehend the meaning of this small but great statement.

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Acknowledgement

I am grateful to Helpage India for giving me this opportunity to work with them. I would like to thank Mr. Mathew Cherian, Ms. Anupama Dutta , Mr. Manjeet Singh and Mr. Suresh for their constant support, guidance and resourcefulness through the project. I would also like to thank Dr. H.S. Randhawa, chief medical officer, Mewat for taking time out of his busy schedule to listen, guide and encourage us in this project. I would like to acknowledge efforts of Mr. Shiv Kumar in Chandipur Health Association (Gehlap), Dr. Shamim Ahmed (Nuh), Mr. Avinash Pandey (Deepalaya- Ghuspethi) and Dr. Aziz (MSEDS-Punhana) for their hospitality and help extended during field visits. Without their guidance in the field areas, I could not have managed to do this project. Finally I feel indebted to Prof. Nirja Mattoo, Chairperson, Centre for Development of Corpo- rate Citizenship, for identifying this opportunity to work with a great organization like Hel- page. I would like to thank my team mates in the DOCC Committee for their hard work and dedica- tion.

Charan Puneet Singh

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Contents Contents ...... 4

List of Tables and Graphs ...... 8

Executive Summary ...... 9

1. Introduction ...... 10

2. Project Details ...... 11

2.1. Scope ...... 11

2.2. Methodology ...... 11

2.3. Strategy for the Project ...... 12

3. About Helpage India ...... 14

3.1. Mission ...... 14

3.2. Affiliations ...... 15

3.3. History...... 15

3.4. Current Operations ...... 15

3.5. Overview of Major Helpage Initiatives ...... 16

3.5.1. Mobile Medical Units or MMU: ...... 16

3.5.2. Sponsor A Grandparent Project ...... 17

3.5.3. National Small Grants Program ...... 17

3.5.4. Poorest Areas Civil Society (PACS) ...... 18

4. PROFILE OF MEWAT ...... 20

4.1. Historical background ...... 21

4.2. Route Map ...... 24

4.3. District at a Glance ...... 26

4.4. WHY MEWAT IS NOT DEVELOPED? ...... 32

4.4.1. Illiteracy ...... 33

4.4.2. Poor Health ...... 35

4.4.3. Crime ...... 36

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4.4.4. Low Farm Yields ...... 37

4.4.5. Politics ...... 37

4.4.6. No Sops to Investors ...... 37

4.5. Mewat Development Agency, Nuh ...... 38

4.5.1. Introduction ...... 38

4.5.2. Focus areas ...... 38

4.5.3. Work done by MDA ...... 39

5. Health Survey in Punhana ...... 42

5.1. Why Punhana? ...... 42

5.2. Partner NGO: MSEDS ...... 42

5.3. Villages surveyed: ...... 43

5.4. Major Findings from the Survey:- ...... 43

5.4.1. Health ...... 43

5.4.2. Sanitation...... 45

5.4.3 Drinking Water ...... 46

5.4.4. Transport Services ...... 46

5.4.5. Communication ...... 46

5.4.6. Law and Administration ...... 46

5.5 Conclusions ...... 47

6. Recommendations ...... 48

6.1 For Long term Intervention ...... 48

6.2. Short Term Intervention ...... 51

6.3 Medium Term Intervention ...... 51

7. Feasibility ...... 53

7.1. SWOT Analyses ...... 53

7.2. Functional Feasibility ...... 54

7.3. Operational feasibility ...... 57

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7.4. Financial Feasibility ...... 59

8. Case Study: Deepalaya Gram ...... 61

8.1 Introduction ...... 61

8.2. Why Mewat? ...... 61

8.3. Other Projects involved: ...... 62

8.4. About the Project ...... 62

8.5. Mobile Health Unit ...... 62

8.5.1. About the Region ...... 62

8.5.2. Nature of Health Services Offered: ...... 63

8.6. VISION OF THE PROJECT ...... 65

8.7. FUTURE PLANS ...... 65

9. Risk Factors ...... 66

Appendix: A More On MMUs ...... 67

A.1 MMU Collage ...... 67

A.2 MMU India Coverage ...... 68

A.3 North India Operations MMU ...... 68

A.4 A.4. MMU Cost Break Down ...... 70

B. Sponsor a Gran Program- national coverage ...... 71

C. National Age Care Small Grants Scheme- National coverage ...... 72

D. PACS National Coverage ...... 73

E. District Statistics ...... 73

F. More on MDA ...... 75

F.1 Members of Mewat Development Board...... 76

F.2. Members of Mewat Development Agency...... 77

E. Health Survey Punhana ...... 79

E.1. Survey Form Template ...... 79

General Information ...... 79

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Healthcare information ...... 79

Education facilities ...... 80

Water, Sanitation and Infrastructure Facilities ...... 80

F. Field Report – Gehlap Village...... 84

F.2 FIELD VISITS- NUH, MANDI KHEDA, NAGINA ...... 87

Plan of visit: ...... 87

Summary of field visit: ...... 87

Meeting with Dr. Shamim Ahmed ...... 87

Action Points: ...... 89

Talks with Help Age India ...... 89

Meeting with Dr. HS Randhawa, MCO ...... 89

Action Point...... 90

G. Project Plan ...... 91

H. Abbreviation and References ...... 91

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List of Tables and Graphs

Page Num- S.N. Type Title ber

1 chart Block wise Population& Villages 21 2 chart land use mewat-1 26 3 chart land use mewat-2 26 4 chart Population distribution 26 5 chart literacy level comparison 27 6 chart Sex Ratio Comparison 27 7 table block wise Population 28 8 chart Pie distribution-Population 28 9 table Worker distribution 28 10 chart Worker distribution 28 Pensioner Population-block 11 table wise 28 12 chart Pie distribution-Pensioners 29 13 table BPL stats block wise 31 14 chart Pie distribution-BPL Families 31 15 chart MDA Fund allocation 1980-2006 39 16 chart MDA Fund allocation 2007 40 17 table Cost Breakdown-Solution1 50 18 table Medical Team-Deepalaya 63 19 table MMU Operations-North India 69 20 table MMU Cost Breakdown 70 21 table School Enrolment Stats 74 distribution of School Enrol- 22 Chart ment 75 23 Table members of MDB 76 24 Table Members of MDA 77

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Executive Summary

India is a country of 81 million aged people, 33% of whom live below the poverty line, 90% of whom belong to unorganized sector and do not have a social security to rely on and 73% are illiterate. Helpage tries to reach out to these disadvanged elders through different programs focusing on health, finance and emotional aspects. Primarily a fund generation and fund disbursing agency, Helpage supports several NGOs working at grassroots level through technical, financial, legal and consultative intervention. Mobile Healthcare is one program directly implemented by Helpage. A mobile van with a social worker, doctor and a pharmacist on board dispense free medicines and healthcare to disadvantaged old people in rural areas and urban slums where healthcare facilities are remote and inaccessible. The rural healthcare infrastructure based on PHCs is inadequate to meet demands of the aged because of their inaccessibility and limited functionality. Mewat is predominantly a rural district in Haryana. Though adjacent to Gurgaon and Farida- bad, it has remained poor and undeveloped because of various reasons explained further in this report. High illiteracy, poor income levels, high crime rates, few economic or educational opportunities mark this region. The healthcare infrastructure is in bad shape. The 17 PHCs employing less than 90 doctors are inadequate to meet demands of the 12 lakh population spread over 500 villages. Problems become worse for the aged. With breakdown of the joint family system and the youth migrat- ing to economically developed cities, the old Meo have to fend for themselves. Lack of public transport services, cost of healthcare in cities compound their problems. Frustrated, their only hope is the numerous private doctors of dubious qualification. Backwardness, illiteracy and superstitions compound the problems. The Mewat Development Agency, responsible for funding development projects in the region is aware of the health situation, but its focus has been child care and strengthening the existing health delivery mechanism. It is aware of the usefulness of Mobile Healthcare in the region and started operations with partner NGOs in 2003. These were stopped in 2004 due to administrative difficulties. There is a huge need for Mobile healthcare in the region. Three plans have been recommend- ed in this report difference being in cost and time period of intervention. Under first plan, Helpage can use the existing MMU at Faridabad to visit selected villages in Hathin block along the Delhi Alwar highway on few weekdays and on weekends. Referral patients can be sent to Palwal. Under the second plan, Helpage can acquire an MMU and start a medical only MMU service based out of Gurgaon and into Nuh, Tauru and Nagina. Referral patients can be sent to PHCs, private doctors in Gurgaon. Under the third and long term plan, Helpage could coordinate with MDA, use MMU in Pun- hana block for preventive and prescriptive cure. These will use the existing PHCs as base and for referral patients. Helpage could set up training modules for RMPs and prepare multimedia kits for geriatrics care. Coordinate operations with government agencies, PHCs, CHCs and other NGOs in the region.

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1. Introduction

Helpage works for the rights of old people around the world. Helpage India works to improve the lives of old people through various programs like supporting old age homes, running toll- free counseling services, running free mobile medical units etc. It works as a funding agency between NGOs who work directly with people and funding sources which could be private individuals, corporate, agencies or government. The Mobile Medical Unit program is a flagship program of Helpage, running since 1982. A Mobile Medical Unit or an MMU as it is called is an OPD clinic and pharmacist, which tra- vels from village to village in remote areas. Often there are no alternate systems for healthcare deliveries in these regions as these regions are poor, remote and backward. Currently there are 52 such MMUs serving the country in places like Jammu and Kashmir, Sikkim and Kerala. Mewat is a region close to Delhi, populated by Meo community and spread over southern parts of Haryana, over the borders with UP and Rajasthan. Though it is close to the bustling new economy townships of Gurgaon and Faridabad, Mewat is a poor, remote and conservative area. It has a population of 12 lakh, with little in the name of infrastructure for schools and hospitals. This project concerns with the feasibility of starting Mobile Medical Units in Mewat. The feasibility has been discussed with regards to operations, functions and finances.

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2. Project Details

2.1. Scope

The scope of this project is to suggest how Helpage can start MMU Operations in the region. Three approaches have been given: short term, medium term and long term. This report does not include a village by village survey of the region, which would be required before deciding the actual route of the Mobile Unit. Such a survey would require more manpower and time and a similar survey has been done for the health commissioner in Chan- digarh. The report outlines strategic requirement of MMUs in the region through a socio economic analyses, followed by a health survey of selected block and feasibility. A case study has been included about Deeplaya which has been working with children in Mewat for over 5 years and also running a Moble Medical Unit.

2.2. Methodology

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The methodology followed for this report was recursive and can be broadly divided in three phases. Phase 1: Secondary Research: Using the contacts given by Helpage of partner NGOs in the region and telephonic conversations, basic data was collected about Mewat for major towns, villages, approach, etc. This was backed by internet research about Mewat for different NGOs already working in the region, their areas of concern, socio economic make up of the place etc. Phase 2: Field Visits: based on information collected during secondary research, made field visits to NGOs, schools, hospitals, private and government doctors, police officials, eminent social workers in the region. Also a health survey was conducted in a few villages of the Punhana district. Here information was collected on disease pattern, effectiveness of the government apparatus and efforts of NGOs and private healthcare. Phase 3: Analyses: Based on findings from field visits did further research, discussed the findings with Helpage contacts and developed further action plan

2.3. Strategy for the Project

The aim of the project is to study the feasibility of Mobile Medical Units in the Mewat district of Haryana. The feasibility aspect can be looked into three ways:- 1. Operational feasibility 2. Financial feasibility 3. Functional feasibility Under Operational feasibility we address issues like “is it possible to run operations here?” “Is there enough population of aged people here?” “Is it possible to find doctors, paramedical staff here?” “Is there a hospital where locals can be referred to in case need be ?” “Is it possible to run operations within Mewat and not from Delhi or Gurgaon?”

Under Financial Feasibility, we addressed issues like “ is it possible to make operations self funded ?”; “ is it possible to get sponsors with interest in development of Mewat?” “ is it possible to get MDA funding for the project?”

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“ Is it possible to use local resources to keep cost of healthcare low to the local populace?”

Under Functional feasibility, we address issues like “ is intervention through mobile medical units likely to make a lasting impact?” “ is helpage the right organisation to intervene in the region?” “ can the operations be made self sustainable in the region?”

Besides this a SWOT analyses was included to identify strengths and weaknesses of Helpage for running such an operation and the threats and opportunities identified in running Mobile Healthcare units in Mewat.

Helpage criteria for Mobile Medical Units:- 1. Target population (60+ people) 2. Population strong enough to support more than 20,000 transactions in a calendar year. 3. There should not be access to similar service offering free or subsidised medical care by government or NGOs. 4. Presence of funding agencies with dedicated budgets on healthcare. Strategy adopted was:- 1. Get rough estimate of the target population in the region. 2. Understand economic health of the target population 3. Understand existing healthcare set up both from sides of consumer and provider 4. Identify whether Helpage criteria can be met in the region 5. Suggest a suitable entry strategy in the region

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3. About Helpage India

HelpAge India features among the leading non-profit organizations of the country. Its activities are oriented toward improving the quality of life for aged persons who are financially inse- cure and lack access to healthcare facilities.

HelpAge India is secular, not-for-profit organization registered under the Societies' Registration Act of 1860. It was set up in 1978, and since then it has been raising resources to protect the rights of India’s elderly and provide relief to them through various interventions.

It works to voice the needs of India‟s 81 million “grey” population, and directly impact the lives of 15 lakh elders through our services every year.   It advocates with national & local government to bring about policy that is beneficial to the elderly.   It makes the society aware of the concerns of the aged and promotes better understanding of ageing issues.   It helps the elderly become aware of their own rights so that they get their due and are able to play an active role in society.  It conducts research in issues related to ageing, and promotes the study of age- care and its related problems.

Promotes Advocacy for:

 Pensions and Social Security

 Geriatrics and Home Care

 Policies Beneficial to elderly

 Barrier Free residential care

 Transportation and Mobility

 Involvement and Recreation

 Safety and Security

3.1. Mission

HelpAge India's mission is to work for the cause and care of disadvantaged older persons and to improve their quality of life.

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3.2. Affiliations

HelpAge India is one of the founding members of HelpAge International, a high profile body having 51 member countries representing the cause of the elderly at the Unit- ed Nations.

It has received a special testimonial from the United Nations for "Dedicated service in support of the United Nations Programme on Ageing".

HelpAge India is also a full member of the International Federation on Ageing.

3.3. History

The origins of HelpAge India go back to the late 1960s when the then speaker of the Lok Sabha visited his counterpart in the House of Commons(UK), who was also honorary secretary of an organisation called Help The Aged. He came back with a vision of setting up something similar in India.

But it took 7 years for this vision to take shape. In March 1974, when Mr. Jack- son Cole, founder of HelpAge International visited India, an intrepid philanth- ropist named Samson Daniel approached him for financial help to set up a member organisation in Delhi. A far-sighted man, Mr. Cole instead offered to train him to raise funds. After a three month training course in London, Mr. Daniel and his wife returned to India and organised a sponsored walk with schoolchildren in Delhi. It was so successful that in 1975 HelpAge Internation- al recruited more staff to cover Bombay, Madras and Calcutta.

In April 1978, HelpAge India was registered in Delhi. Within three months it became autonomous as financial support ceased from UK. Soon after, in July, the Society was awarded Certificates of Exemption under Sections 12A and 80G of the Income Tax Act, 1961, thus indicating general confidence in the Society’s affairs.

3.4. Current Operations

55 million older people in India do not have the luxury of relaxing in their autumn years. Hover- ing at and below the poverty line, they struggle daily to muster basic meals, and so long as they work, they survive. It is for them that HelpAge India exists. It implements a number of programs and services in the areas of rights, social protection, and health care and enables them to live with dignity and independence

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 52 MMUs (Mobile Medicare Units) provided health care at the doorstep of the needy aged. New Units were launched in Raipur & Madurai.  The MMU at Nagpur worked in Vidarbha, providing relief to families affected by farmer suicides.  274 Old Age Homes, 72 Hospitals and 113 Day Care Centres have been supported.  15,985 destitute older people were covered under the Sponsor-A-Grandparent Programme. 230 new senior citizens were included in the fold.  24,500 cataract operations were enabled, through 48 projects.  Helplines for senior citizens began functioning at Chennai (1253) and Delhi (1291) with support from police.

3.5. Overview of Major Helpage Initiatives

3.5.1. Mobile Medical Units or MMU:

What is an MMU? A Mobile Medicare Unit is a moving dispensary, manned with a qualified doctor, pharmacist, social worker and driver. It is fully equipped with medicines. Treatment and medicines are dispensed free of cost or at a nominal rate to needy older people. All MMUs have referral tie- ups with local hospitals for complicated and advanced cases. Promoting health consciousness amongst the elderly and their family members and encourag- ing attitudinal transformation with respect to the well-being of the older persons are integral parts of the programme. Besides providing healthcare, MMUs take on individual initiatives within their areas of work such as: Disaster Relief: During major disasters such as those in Tsunami in southern part of India, Earthquake in J&K and Gujarat, Super Cyclone in Orissa, MMUs immediately got involved in rescue and relief work in the affected areas. Community Development: The MMU staff in MMUs counsel people on hygiene and sanitation, and on the other health related aspects. They also mobilize volunteers to look after older people in their localities. Awareness Camps: Awareness camps are held in rural areas to educate the people on various diseases and their symptoms, and what precautions they should take to ward off illness.

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Specialized Camps: Concentrating on one particular disease, hygiene, cleanliness and nutrition are held in villages. Through these camps it is not only the elderly who are educated but also their careers, guiding them to look out for symptoms etc. Elderly people suffering from the disease are treated and given medication. Referrals are also made for specialized cases to local hospitals. elderly who are educated but also their careers, guiding them to look out for symptoms etc. Elderly people suffering from the disease are treated and given medication. Referrals are also made for specialized cases to local hospitals.

For More on MMU refer Appendix A

3.5.2. Sponsor A Grandparent Project

This program started in 1978, is in partnership with more than 200 NGOs in 25 states of the country and is presently servicing about 16,000 beneficiaries. The program is Community based but also involves old age homes and day care centers across the country.

This program has been etched on a welfare mode, focusing on subsidizing the basic needs of the older people, such as food, clothing, medicines, repair of houses etc who are economically deprived and socially alienated. It also aims to foster independence and dignity, thereby restoring their rightful place in their families and society. Each beneficiary is provided with cash and kind worth about Rs. 500 a month. In 2005, the program underwent a shift from "welfare" to "development". The new approach focuses on the poorest of the poor, and looks at community development rather then individual welfare. For More on above refer Appendix B

3.5.3. National Small Grants Program

The National Age Care Grants program defines the spirit of HelpAge India mission of working for the cause and care of the elderly. Its objectives are:-

1. To support & guide local non government organizations for taking up welfare & development projects for disadvantaged older people

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2. To build the capacity of voluntary organizations on age care, 3. To sensitize the government, media, civil society & general public on ageing issues & concerns of the older people. Under the program, HelpAge India provides limited financial support (grants) to non government organizations for executing time-bound projects aimed at securing an improved quality of life for a given target of older person's population (beneficiaries). The old age specific problems of social, economic, health and emotional security are addressed in this program. The grant support is in the area of old age homes, day care, eye care, special health care, livelihood, research and training, emergency relief, rights of the older people etc. The average grant per project is of Rs. 30,000 and an average life span of one year. Since its inception, HelpAge India has supported over 2300 projects with a value of more than Rs. 880 million touching lives of over 1,000,000 older persons.

3.5.4. Poorest Areas Civil Society (PACS)

The primary objective of the PACS project (Oct 05 - Dec 07) is to strengthen the awareness and capabilities of poor people to demand and use their rights - political, economic, social and human - and services to improve their own lives. The program seeks to achieve this through a network of Civil Society Organization working for the poor. This HelpAge India project is designed to raise awareness amongst the older persons on the relevant rights and social welfare schemes and facilitate access to the same in some of the most backward districts of India. The project is being implemented in partnership with local Civil Society Organizations. A number of Central and State government schemes have been devised to mitigate problems faced by the aged, ranging from pensions to medical aid, travel concessions, preferential interest rates. Further, the destitute aged also qualifies as potential beneficiaries of a slew of poverty reduction/ relief schemes. But there is very little mass awareness on the same. Bene- fits of the scheme rarely ever reach the aged if they are poor and illiterate, if they live in remote backward regions and if they belong to socially oppressed communities. As later mentioned the surveys conducted during the project, plans remain on paper and rarely make an impact on ground. The prevalent poor structures of communication, implementation and enforcement have ex- acerbated the problem of accessibility to these schemes and services. In addition, older per-

HelpAge India| Fighting Isolation, poverty, neglect sons rarely receive support from Panchayat and other formal political institutions; and there are virtually no associations/ institutions working for their interests at the local level. Success of PACS has emboldened Helpage to work stronger in this area and Helpage aims to model itself as a rights based organisation working for benefit of the elderly in the next 10 years. [For more on PACS please use the gallery at http://www.helpageindiaprogramme.org/AgedRightsAdvocacy_imagegallery.html] The focus of the PACS program is Awareness, Access and Advocacy. Recently there has been an attempt to integrate the PACS program with the MMU program. The MMUs through their long lasting and strong relationships with the rural populace enjoy their trust and have been instrumental in increasing awareness about benefits offered by the government to them. They have helped increase penetration of the National Rural Health Mission, Old Age Pension Schemes, National Health Insurance Scheme etc. Though not formally integrated with PACS, efforts have been made in this direction and the future endeavors will work to make this integration stronger.

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4. PROFILE OF MEWAT

At the time of its formation on 1st November, 1966, Haryana State had seven districts. Thereafter 13 new districts were notified from time to time by changing the boundaries of the existing districts. The Mewat district was carved out from erstwhile Gurgoan and Faridabad districts, which came into existence on 4th April 2005 as the 20th district of the Haryana State. The newly constituted district comprises of three sub-divisions namely Nuh, Firozpur Jhirka and Hathin. The district headquarter is located at Nuh. The district comprises of six blocks namely Nuh, Tauru, Nagina, Firozpur Zhirka, Punhana and Hathin. There are 532 villages in the district out of which 27 villages are either uninhibited or are jurisdiction of Municipal Com- mittees.

Geographically, Mewat District is situated between 26-degree and 30-degree North latitude and 76-degree and 78-degree East longitude. Gurgaon district bounds it on its North, while Rewa- ri district lies to its West and Faridabad district to its East. On South, the district shares its boundary with the State of Rajasthan. Mewat district is largely comprises of planes. Inconsis- tency in Mewat topography is evident from its patches of land with hills and hillock of the

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Aravali Mountain on the one hand and plains on the other. Thus, physio-graphically the area is divided into two tracts- upland and low land.

4.1. Historical background

Mewat - Land of the Meos, has its genesis in its tribal inhabitants, the Meo tribals, who are agriculturalist. The area is a distinct ethnic and socio- cultural tract. The Meos, who trace their roots to the early Aryan invasion of Northern India, call themselves Kshatriyas and have preserved their social and cultural traits to a surprisingly large extent, unlike the other tribes of nearby areas.

During the regime of the Tughlak dynasty in the 14th century A.D., these people embraced Islam but till today, they have maintained their age-old distinctive ethno-cultural identity.

Historically, the region has been extremely turbulent and has been subject to repeated invasions and resultant plundering throughout the post-Vedic period, largely due to the situational pe- culiarity of the area and the non-sub-jugative attitude of the people. The destruction and de- vastation over the centuries resulted in backwardness and gross under-development of both the area and its proud people.

According to the Census of India 2001, the total population of Mewat district was 9,93,617 of which 46,122 (4.64%) lived in urban areas and the major chunk 9,47,495 (95.36%) of the population lived in rural areas. Out of the total population of 9,93,617, the district has 5,24,872 males and 4,68,745 females. The SC population in the district is around 78,802. The total numbers of households are 1,42,822 out of which 1,35,253 (95%) are in rural areas and remaining 7569 (5%) are in urban areas. The total number of BPL households in the district are 39667 and APL households are 1,03,155.

The main occupation of the people of Mewat district is agriculture and allied and agro-based activities. The Meos (Muslims) are the predominant population group and are completely

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agriculturists. They perceive themselves as such, with a sense of pride. The agriculture in Mewat is mostly rain fed except in small pockets where canal irrigation is available. Agricul- ture production measured in terms of crop yield per hectare in Mewat is comparatively low to the other districts of the State. Animal husbandry, particularly dairy is the secondary source of income for people of Mewat and those who live closer to the hilly ranges of Aravali also keep a few sheep and goats. Milk yields are not so low in the district, however, due to heavy indebtedness most of the farmers are forced to sell the milk to the lenders at lower than normal price, which drastically reduces their income from the milk. The poultry population in Mewat district is much less in comparison to other districts of Haryana State.

Mewat has remained a region of backwardness even after independence. The area lags behind the rest of Haryana on almost every yardstick of development indices, even though the farthest point of Mewat is no farther than 145 Km. from the National Capital of India.

SOIL

The soil of the district is light in texture, particularly sandy, sandy loam and clay loam. The upper hills are mostly barren.

AGRICULTURE

The total population of district Mewat according to the 2001 Census was 993617 of which 46122 i.e. 4.64% was urban and 947495, i.e. 95.36% was rural. The average household size in rural Mewat was 7. The Meos (Muslims) are the predominant population group and are virtually completely agriculturist. They perceive themselves as such, with a sense of pride. The agriculture in Mewat is mostly rain fed except in small pockets where canal irrigation is available. Agriculture production measured in terms of crop yield per hectare in Mewat is comparatively low.

ANIMAL HUSBANDRY

Animal husbandry is the secondary source of income. Those who live closer to the hilly ranges of Aravali also keep sheep and goats. Milk yield is not so low, but due to heavy indebtedness the income from the' milk is much reduced, as many farmers have to sell the milk to the lender at lower than normal price. The poultry population in Mewat is much less than in rest of Haryana.

CLIMATE

Mewat falls under the Sub-Tropical, Semi-arid climatic zone with extremely hot temperature in summer. Dryness of air is standard feature in Mewat except during the monsoon season. May & June are the hottest months of the year with the temperature ranging from 30 C to 48 C, January, on the other hand is the coldest month with temperature ranging between 4 C to 25 C. Strong dusty winds are conspicuous during summer.

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RAINFALL

The annual rainfall varies considerably from year to year. The maximum rainfall is experienced during the monsoon season, which reaches its peak in the month of July. The principal precipitation occurs during monsoon period from June to September when about 80% of the rainfall is received. The average rainfall varies from 336 mm to 440 mm in the district.

HUMIDITY

Humidity is considerably low during the greater part of the year. The district experiences high humidity only during the monsoon period. The period of minimum humidity (less than 20%) is between April and May.

WIND

During the monsoon, the sky is heavily clouded, and winds are strong during this period. Winds are generally light during the post-monsoon and winter months.

REGION SPECIFIC WEATHER PHENOMENA

Mewat experiences a high incidence of thunderstorms and dust storms, often accompanied by violent squalls (andhar) during the period April to June. Sometimes the thunderstorms are accompanied by heavy rain and occasionally by hailstorms. In the winter months, fog sometimes appears in the district.

LITERACY

The literacy rate in Mewat is appallingly low, particularly in case of females. For Muslim women in Mewat, the literacy rate ranges 1.76 % to 2.13 %, the lowest in the country. The literacy rate for men also falls below the National average and ranges 27 % to 33 %.

SEX RATIO

The Male: Female sex ratio is also lower than the National average. In Mewat there are only 894 females to each 1000 male as against the national average of 927 females per l000 males. Infant mortality rate in Mewat indicate similar backwardness rising up to 85 per 1000 in Punhana block, which has 80% Muslim community, as against the national average of 72 and 75 for the State of Haryana. Maternal mortality rates are not available, but considering the poor health facilities, large family size and the adverse sex ratio, it can be safely assumed that maternal mortality is high.

Recent Investments:

a) Classic Golf Resort

Classic Golf Resort is a wholly owned subsidiary of ITC Limited, one of India’s leading corporate organizations. The golf course comprises of 27 holes of 3 nines each (The Ridge, The Valley and The Canyon), which bear witness to the Master’s virtuously and golfing

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skills. It has been designed by Jack Nicklaus. It is located off the Delhi-Jaipur Highway and only 35 kms away from the International Airport and about 75 miles drive from Central Delhi.

The investment is important because it shows the faith ITC has put in Mewat by investing in the region. A good location, near the airport and on the tourist map can bring prosperity to the region.

4.2. Route Map

The map shows way to Tauru, Nuh and Nagina from New Delhi.

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b) Country Club

The Best Western Resort Country Club is situated near Manesar on the Delhi Jaipur High- way. The Resort is only 25 kilometers from Nuh District Headquarter (Mewat). Pink City (Jaipur) and Taj Mahal (Agra) are only 200 kilometers away. Vrindavan and Mathura are 150 kilometers. Other nearby attractions are Tijara Jain Temple (60 kilometers) and Neemrana Fort (70 kilometers). The Resort is only 25 kilometers from sprawling Gurgaon Shopping Mall.

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4.3. District at a Glance [Source: 2008 Statistical Data, Additional DC Office, Nuh]

1. Graph1:

Land use indicates that region is predominantly rural, with most area being dedicated to agriculture. Only 70% of cultivated land is irri- gated area.

2. Graph2:

Even though farming is a common practice in the region, yields are low and income from farming is low. Most farmers have secondary oc- cupations as well.

3. Graph 3:

Even though Mewat borders Gur- gaon and Faridabad, which have faced rapid development over the past decade, it represents a stark contrast. More than 95% of the 10 lakh people live in villages.

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4. Graph 4:

Mewat has low literacy levels, lower than neighbouring districts in Haryana, Ra- jasthan or UP. There are many reasons for this including conservative atti- tudes, lack of access etc. This has compounded other problems in the region like health, female foeticide etc.

5. Graph 5:

The sex ratio for Haryana is skewed as against the national average. The figure for Mewat is better than for Haryana. Though a positive sign, it is more because health facilities in Me- wat are not advanced enough and people cannot afford sex determination tests at labs more than any other reasons.

6. Family Size: 7.5 Average 7. Economy: Agriculture Based, Rainfed Agriculture and Animal Husbandry. People living in Aravalli are used to rearing sheep and goats and cattle, selling milk and occasionally meat for subsistence during the non-crop months. Milk sellers do not command good rates as transport services are remote and products cannot reach Gurgaon or Delhi. Recently real estate prices in Tauru and Nuh have gone up, due to construction boom in the Gurgaon region. 8. Number of Sub Divisions: 3 9. Number of Tehseels: 5 10. Number of Blocks: 6

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11. Number of Villages : 531 12. Number of Panchayats: 355 13. Number of Muncipal Committees: 3 14. Number of Police stations: 6 15. Number of Police Posts: 6 Number of Police Personel :100 [ Mewat has high crime rates. Many gangs frm the region operate in Delhi and on the Delhi-Alwar and Delhi-Mathura Highway. The police force of 6 cars and 100 police is inequipped to control crime in the region.] 16. Length of roads: 800km including Hathin 17. Blockwise population distribution

S.N. Block Population 1 Nuh 212855 2 Tauru 126169 3 FP Jhirka 243868 4 Punhana 206858 5 Hathin 203867

Graph 6:

Ferozepur Jhirka is most populated. The Mewat region actually spreads out between Haryana, UP and Rajasthan and there is significant floating population of Meo who keep moving from place to place for trade or in search of livelihood. Since the conditions are even worse in neighboring states Meo flock to Mewat for medical treatments etc.

18. Worker Distribution

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S.N. Employment Number 1 Cultivator 175794 2 Agriculture Laborer 61136 3 Household Industries 7629 4 Other Workers 151647 Graph 7

Among Other Workers, daily wage earners like drivers, construction workers, etc. A lot of these workers work at construction sites in Gurgaon and Faridabad. The place also has large number of truck drivers and taxi drivers working in nearby states.

19. . Population of Pensioners in Mewat Region (Block wise)- 2008 list

SN Tehseel / Block Pensioners 1. BDO Nuh 7970 Sec Nuh 331 2. BDO Tauru 4385 Sec Tauru 490 3. BDO Punhana 8430 4. BDO Nagina 4340 5. BDO Ferozepur Jhirka 5290 Sec Ferozepur Jhirka 542 6. BDO Hathin 10470 Sec Hathin 523 42,771

The difference between the BDO – block development officer and Secretary Count is that the BDO list accounts for rural and the Secretary list accounts for the towns. Sum of both is taken for the whole region

Graph 8: Distribution reflecting above table

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The government estimates number of pensioners in rural villages to support people above the age of 60 in rural areas. However the exact population of 60+ in the region is estimated to be in range of 1 to 1.2 lakh. It is because in most villages half to a third of all elders are registered to receive pensions

20. Health Infrastructure Of Mewat District

Above graphic illustrates the government run medical apparatus in the district designed as under the National Rural health Mission. The Health commissioner at State ministry

of health is the administrative head of the apparatus and is represented by the MCO at the district level.

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12. BPL Data [Source: Additional DC Office, Nuh. 2008]

BPL Survey Distt. Mewat( 2002 ) Blocks No. families

Tauru 3179

Nuh 6725

Nagina 5653

Punhana 10195

FP Jhirka 4452

Hathin 6025

total 33229

Graph 10: BPL families

As per the figures collected in 2002 there were 33,229 BPL families in the region. These figures are higher if we account for the floating population of Meo from neighbouring states. The people in this category are mostly aged, illitrate, unable to take of themselves and their dependents. Punhana bordering UP on the Delhi-Mathura Highway has the highest number of the BPL families as opportunities for income generation are limited here.

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4.4. WHY MEWAT IS NOT DEVELOPED?

Mewat is close to Delhi and shares border with Gurgaon, a district which has seen the fastest growth in real estate prices in the world, and is seen as the hub of Indian IT revolution. However, Mewat continues to face fundamental problems like any other remote rural district in India where female feticide is rampant, deaths at child birth stand highest, electricity runs for a couple of hours a day, villages have never received clean drinking water, crime rates are high, opportunities for education and jobs are low and the future seems bleak. At least this was the picture till a few years ago. The government then created a Mewat De- velopment Agency, an independent body, headed by an IAS officer, to look into the needy areas, allocate funds and foster development in association with local agencies and outside NGOs. The MDA has done significant work in the area. The report first looks at the factors because of which Mewat has remained an under developed district as compared to its peers in Haryana.

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4.4.1. Illiteracy As per the government statistics the literacy rates for men in Mewat stood at 45% and for women at 17.5% while the average for Haryana district stood at 77% and the national average is 78%. There are various reasons for this. Access to education is one of them. Earlier, most villages in the district did not have schools. For a long time after independence, no new schools opened in the district and there were few educated people who wanted to make their children study. Coupled with a low capacity to pay, it became a dormant case of no demand and no supply. The people also did not have the resources or the inclination to send the kids to school in neighboring villages. Most Meo kids as such get married early and start earning as farmers or as semi-skilled laborers. Graph 9 (Refer Appendix E) gives the latest enrolment stats declared by the MDA. The drop- out rates and the number of primary schools also reflect a trend. The number of primary schools is 600+, and enrollment is highest, and as the level increases, number of school stu- dent decreases sharply, mentioned as drop-out rate, which is as high as 85% from primary to middle level and 75% from middle to high school level. This means if more schools are opened, situation can definitely become better. Another problem is the conservative mindset. 85% of the Meo people are Muslims and do not like Modern education, which they see as an attempt by government to undermine their belief and society. For the Muslim women, literacy rates were as low as 2% in the 2002 census. These mindsets are changing slowly due to the effort of government, MDA and NGOs like Dr. Aziz’s MSEDS ( Mewat Social and Economical Development Society, Punhana). Mewat has mosques and madrassas dotting the landscape and most kids do not attend school, prefer- ring to attend the madrassas. There are 215 madrassas in the region with several having separate class rooms for women. However the quality of instruction here is questionable as they are meant primarily for religious instruction. In recent years, there has been a spurt in number of schools including girl schools because of favourable government policies. Starting with the mid day meals scheme and free books, bag and uniform for kids in primary school kids, enrolment statistics are high. However, in the field trips undertaken to villages across blocks for this project, no kids could be seen attend- ing any kind of government school, nor were they in uniform. The quality of education received in these schools is thus doubtful. The school enrolments are at an all time high, especially after cash remunerations offered by the government for the girl child under the scheme. In fact at a village Naseempuri in Punha- na district, the sarpanch proudly told us that the local primary school has higher enrolment for

HelpAge India| Fighting Isolation, poverty, neglect girls than boys. Not a small feat considering the conservative Meo society where women have had a status akin to a servant and a birth giving machine (Most households that were visited had women with 15 to 23 kids). In fact Dr. Aziz, a Meo educationist and social worker refers to the mindset change that has come about with regard to education. There was a local saying here which said, “ thoda pada to kam chhuta, bada pada to gaon chhuta”, can be translated to “some education, will make you disinterested in field work and excess education will render you disinterested in village life, so why study?” This was a reason why children dropped out of school early to work in fields, become daily wage earners in Delhi or Faridabad etc. Now private education institutes offering professional courses and distance education learn- ing centres of famous universities have come up in Nuh , besides there is an ITI for vocational training and a planned medical college at Mandi Kheda.

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4.4.2. Poor Health As per discussion with Dr. H. S. Randhawa , the chief medical officer of the Mewat district, a major cause of the diseases the Meo people suffer from is the lack of awareness, lack of education, lack of balanced diet and the resulting low hemoglobin content. The low hemoglobin content contributes to complications during pregnancies and weak health of new born children, as well as several problems for the older people. The common diseases prevalent in the region are skin problems like Scabies, heart problems like Hyperten- sion, eye problems like myopia etc. Mortality rate is 85 per 1000 births in Punhana district which also has the highest number of BPL families. The poor health means lesser life expectancy for people in the region. The life expectancy for women is lesser than for males. This is because women have a more difficult life than men. The average age of women getting married in the area is 13. They have their first child by 14 or 15. An average woman in Mewat will have around 18 pregnancies. Abortion or use of contraceptives is not welcome by the Meo society. By the time a woman reaches middle age, her health is in shambles because of unusually high number of pregnancies and their impact on the body. When a woman is not heavily pregnant she is supposed to do household work, farm work and take care of family. A pregnant woman is not given any special diet. A common practice is to make a pregnant woman spread eagled on a stove of boiling water, supposedly to help make the child develop better. Also after the delivery, child and mother are fed only jaggery and kept in a dark room laced with cow dung, for a week. Such practices seem to have been inspired from dark ages. In old age, women often face problems moving about because of joint problems; complain about eye problems, body pains, skin problems etc. Rarely do the women get enough healthcare in old age in lieu of the hard work they do all their life. Healthcare is also not accessible to most villagers. Though there are 17 Primary Health Cen- ters, which are supposed to have all facilities and cater to a captive population of over 50000, we found that people often don’t trust doctors here. Medicines which are supposed to be given free of cost, are almost never available. Most villages do not have chemists. There are several quacks practicing openly without restriction, and draw crowds of eager patients. Men suffer from poor health because of bad diet and habits like smoking tobacco and coal based Hookah have health problems starting from middle age (40 onwards). They complain of incessant cough but cannot stop hookah, back pains because of tough life of a farmer and

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skin problems like Scabies because of exposure to infected animals. Poor health affects their productivity and ability to earn.

4.4.3. Crime

Mewat is one of the most dangerous districts around Delhi and robberies along the Delhi- Alwar highway and Delhi-Mathura Highway are not uncommon. The two are some of the busiest highways which see thousands of vehicles pass everyday to world famous tourist places like Taj Mahal and Neemrana Fort. However, due to high crime instances, private investors do not feel safe in investing in the region. Also, the Mewat region has over the years become a breeding ground for such gangs that in- dulge in a wide range of crimes in Delhi and the satellite townships of Gurgaon, Faridabad and Noida. Right from cheating, robbery and burglary to motor vehicle thefts, these gangs have proved to be a tough nut to crack for the police. According to senior police officers, a large number of people from this region take to crime for sustenance. There are certain gangs operating from Rajasthan that cheat people on the pretext of selling them "gold". Mewat gangs have gained international attention because what police calls a traditional game for gangs from the region. During a meeting with Mr. Alhawat, an Inspector with the Punhana Police Station, he re- vealed that Mewat is a difficult posting for police officers. It is because Meo are very conservative and prefer the good old ways of settling disputes. Gun culture is rampant. The district has low prosecution rates because there are long running family disputes and each family will pile up trivial cases against each other, to trouble the other. More recently, with real estate boom in Gurgaon , property dealers often use uneducated Meo youth to settle scores and do shady deals. With 6 police stations and a staff of less than 100, the police in Mewat is unequipped to take care of more than 500 villages spread over Mewat. It is stretched and is tested to limits by soaring crime graphs.

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4.4.4. Low Farm Yields

The Mewat district has no natural source of water like lakes or river. It depends on rain water and ground water to irrigate its crops and sustain farming. Average land holdings are small, as divisions between successive generations has lead to division of farms. The farmers thus have low income levels and often have a secondary source of income to sustain their families through the year. Some rear animals, some open shops, some become truck drivers or do labour at construction sites in Gurgaon. Unlike Punjab and neighboring Haryana districts, these farmers are not rich.

4.4.5. Politics

An uneducated voting populace is a blessing for our elected leaders. Only this can explain why this region was ignored for almost 3 decades, after independence. Even after MDA was created in 1980, little has changed on the ground. There have been vested interests at work in keeping this area the way it has been, so that those in power do not face any questions, any consequences of their actions. An uneducated, conservative and backward community which doesn’t think and question its own conditions is a coveted political base in a democratic set up.

4.4.6. No Sops to Investors

Districts like Faridabad and Gurgaon in Haryana owe their economic boom to investors like Hero motors, Suzuki motors, DLF group etc which were offered land at throwaway rates and tax concessions and other sops which allowed industries to flourish. However, Mewat seems to have missed the bus. Though surrounded by industrial complexes of Gurgaon, Faridabad in Haryana and Mathura in UP, Mewat has not seen much industrialization so far.

Even transport within the district is not well developed. If there is a good incentive scheme offered to investors, it could open up avenues for the people of Mewat. There have been attempts to open an industrial estate in Nuh, but the uptake by industries has been rather slow.

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4.5. Mewat Development Agency, Nuh

4.5.1. Introduction

The main idea behind creation of Mewat Development agency was to bring acceleration in development, for which creation of basic infrastructure is most vital thing viz. education, agriculture, irrigation, drinking water, livestock management, health; housing, industrial training and community works attracted foremost consideration of the government. MDA’s role is to plan, coordinate and administer Mewat. The MDA has done good work by attracting several funding agencies like the IFAD, Rome and Indian and multinational NGOs for the benefit of Mewat. The IFAD sponsored a decade long program spanning all aspects of community development worth US $22.23 million.

4.5.2. Focus areas

The focus areas of these programs were:- 1. Child Care 2. Women Emancipation 3. Income Generation The program now sustains through a smaller version focused exclusively on promotion of Self Help groups in the region. MDA supports over 400 SHGs which are run mostly by women in villages and support income generation, micro finance, child healthcare and education. The MDA also gives out contracts to NGOs to run target based projects in fields of healthcare, education etc. This has helped some local NGOs like MSEDS ( Mewat Social and Eco- nomical Development Society) run by Dr. Aziz in Punhana do some good work in the region on a sustainable bases. Also NGOs like SPYM, Shahid Foundation, Brahmjyoti etc have worked on MDA contracts in the region and contributed to development.

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4.5.3. Work done by MDA

The following graphic shows the budget spend of MDA in the region. The spend distribution outlines the kind of project MDA has undertaken. Besides The IFAD, the MDA also gets financial support for its projects from Haryana Government, Central Government, and other international agencies from time to time. Though primary socio economic indicators have shown progressive development, the area remains remote and ill developed. For detailed information on the projects taken up by MDA, the programs sponsored and the timelines can refer the MDA website at http://mda.nic.in/MADP.htm Graph 11:

From the above graphic it is apparent that the focus areas for MDA have been :-

 Socio Economic development of the region

 Gender Self reliance on a sustainable basis

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 Broad range economic opportunities

For details on the projects sponsored under the different schemes in the above period, information can be obtained from http://mda.nic.in/MADP.htm and Appendix part F

For the year 2007-08 the MDA has following budget allocation:-

For the current year the MDA budget -spend is concentrated on the following sectors:- 1. Education:- through:-  Expansion of primary school education  Expansion of adult education program  Expansion of college education  Introduction of the Open school concept 2. Community works:-  Construction of Village roads  Construction of drains and storm water ponds  Village development programs 3. Health:-  Maintenance of Medical Infrastructure  Health Camps  Delivery Hut schemes

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 Mobile medical Unit  Pulse Polio Mission

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5. Health Survey in Punhana

5.1. Why Punhana?

Punhana block is a remote block of the Mewat district, sharing borders with UP along the Delhi Mathura national highway. The area is notorious for robberies and being a den of crim- inal gangs operating in Noida, Delhi and Gurgaon. Punhana was selected for the health survey because of the following reasons:- 1. Highest number of BPL families in the district 2. One of the most populated regions in the district 3. Distance from NCR areas like Gurgaon and Faridabad is higher than blocks like Tau- ru, Nuh or Hathin. 4. Identified as a tough area to work in by the government medical surveys because of various reasons like:- a. High concentration of the Sunni Meo people, who view government attempts to provide healthcare or other development programs with suspicion b. High crime rates like vehicle thefts c. Problems like absenteeism by teachers in schools and doctors in hospitals d. Problems faced during the Pulse Polio program where religious figures from Deoband and Jamia-Hamdard University had to be brought in to this region to restore faith; Meo had fears that Pulse Polio drops were attempts to make the people impotent and threaten their race. e. High illiteracy in the region compounding problems of health workers f. One of the highest instances of female feticide. Also infant mortality rates are among the highest in the region.

5.2. Partner NGO: MSEDS

The Mewat Social and educational development society MSEDS, is a registered voluntary society which works in areas populated by the Meo community like Mewat in Haryana, Bha- ratpur in UP and Alwar in Rajasthan. It has a clear goal of organizing rural communities with

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a focus on child development, women empowerment, education enhancement and poverty alleviation programs. The society has headquarters in Bisru village of Punhana and 90% of the staff belongs to the operational area. This helps in understanding the problems of the region, establish good rela- tionship with the local people and run community driven projects in the region.

Major activities of MSEDS are:- 1. Socio Economic Development 2. Health, Sanitation and Medical care 3. Education for girl child 4. Agriculture and Horticulture development 5. Animal Husbandry and dairy development 6. Organizing rural women for active and equal participation in projects for income generation, promotion of rural art, provision of drinking water etc.

5.3. Villages surveyed:  Shahpur Chowkha

• Owtha

• Naseempur

• Pinangwa

• Sultanpur

• Teher

• Thet

5.4. Major Findings from the Survey:-

5.4.1. Health

1. Common diseases in the area include Scabies, Dry Cough, eye problems, heart problems, Joint pains etc. There are seasonal diseases like malaria and flu which usually strike in mon- soons or during summers.

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2. Most villages do not have a doctor; some large villages have a chemist shop. Almost every village has one RMP (rural medical practitioner). These men are barely qualified and attend a six month course run by government in basic healthcare. RMPs are meant to address common problems like fevers, pains, cold, and cough and to help patients in villages till they can reach out for a proper medical care. 3. A big problem is lack of paramedical workers in the region, there are no institutes for training paramedical workers in the region, and outside workers have little incentive to work in the region, it being poor and unapproachable and crime ridden. 4. People do not trust the government doctors in PHCs and CHCs. They prefer visiting more expensive private doctors with dubious qualifications. They visit the PHCs (though they are free) only if their private doctors fail to address their pains, or in case of accidents. This is against the widely held notion that poor people will prefer free healthcare. A doctor’s fee is a common criterion among locals to measure quality of his services. The more expensive the better. 5. People often travel all the way to Faridabad, Palwal and even Delhi to get proper medical care. But those who cannot afford the travel have little option. Cost of transport is a large component of the cost of medical care. 6. The government doctors in Mewat also are not happy. The postings in Mewat district are considered as punishment postings and doctors try everything to avoid being posted here. There is little scope for private practice here, there is no quality of life, education opportunities for children are limited and the place is crime ridden. Government doctors are thus not inspired to work here. In spite of this, there is always a rush at the PHCs which are usually teeming with patients. 7. There is little understanding of geriatric care among society. It is considered quite normal for an aged person to be ill, irrespective of whether the problem can be medically addressed or not. 8. Investing in an aged person’s care is considered a burden on family. Even for kids, Meos average family size is 9. So it is not possible for a family to look well after them. Usually if the kid is a male, he is likely to have a better chance at healthcare. 9. Mewat lacks doctors. There is 1 civil surgeon, the Chief medical officer, Dr. Randhawa himself, and no gynecologist, no eye surgeon, no cardiac surgeon in a district with population of 12 lakh. 10. Besides the health infrastructure, Mewat being a backward place is quite remote in terms of attitude to healthcare. Ancient practices like child marriage still prevail. Girls get pregnant

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after marriage at early age. They are not given a balanced diet till during pregnancy or after child birth. Men sit at home and smoke hookah, which causes coal to deposit in lungs and breathing tract. 11. The Sub centers are usually do not have any facilities and the PHCs are either short of staff or short of medicines or both. There are few chemist shops and a problem of genuine medicines is acute. 12. Government’s current health policy focuses on organizing health camps in the region. A health camp had advantages that large number of patients are taken care of, doctors from outside can be involved, people in other villages can be informed in time. However, problem with health camp is that because they are organized with pomp and show, with ministers at- tending and using them as a political tool, there is little effectiveness. Also there is no scope for follow up checks. For heart ailments etc, only diagnoses can be done, and patients can be referred to big hospitals outside. 13. MDA’s health focus has been on kids and women. This is because child deaths are common during child birth. Efforts are on to make sure that child deliveries occur in safe and clean surroundings and women can get counseling for pre and post natal care. The Sub center mechanism and Delivery Hut schemes are used for this purpose. The Sub centers are extensions of medical services into remote villages employing trained Medical workers. These medical workers get 6-month training in healthcare at the civil hospital in Mandi-Kheda. The Delivery Hut scheme is meant to provide pick and drop services to pregnant women in time of delivery. A toll free cell number is used and a back office in Nuh receives the call. The nearest delivery Hut van which is a RTP, rural transport vehicle, is stationed at nearby PHCs is sent to collect the patient from the village and bring her to the PHC for delivery.

5.4.2. Sanitation

1. Very few villages have drainage facilities, storm water ponds, paved roads or street lights. 2. Almost 95% of the villagers do not have access to toilets. They use open forests and farms to relieve themselves. This becomes a problem for aged men and women who find it difficult to travel 2 to 3 km outside the village during winters and in rainy season. 3. Meo people do not bathe regularly or follow hygiene practices like washing hands.

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5.4.3 Drinking Water

Few villages have access to clean drinking water. The pipes laid down for water supply have rusted and are broke. Most villages depend on ground water for drinking, washing and cook- ing needs. Usually it is water from the same source which is used for all three. No one boils water for drinking. Water is stored in earthen containers. Women often walk long distances outside the city to fetch water and also for washing and bathing. For photos refer Appendix E

5.4.4. Transport Services

As shown in the pictures in Appendix E, state of public transport in the region is bad. There is almost no public transport. The autos and tempos run between major towns like Nuh and Punhana,often overcrowded. However for travel between the villages, the roads are narrow, often muddy and chief transport options are horse carts. Recently private taxis like Tata Sumo are also running between major villages. The cost of transport between villages is low, Rs 2 to neighboring villages. It is high for Palwal, Farida- bad or Delhi. During the field visits undertaken, patients were found who were in desperate need of medical attention, which refused to travel outside and see a doctor because the difficulties and costs of travelling! Roads between major villages are good and motor able, others between smaller villages were muddy. Under the Prime Ministers Road Project, MDA has done good work in providing a lifeline to these villages.

5.4.5. Communication

Penetration of Cell phones in the region is strong. Lying between important industrial clusters like Faridabad and Gurgaon, this is an asset to Mewat. Cell Phones have helped connect the place to outside community.

5.4.6. Law and Administration

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Child marriage is another social malice that is prevalent in the region. In almost all villages, girls between 13 and 16 years of age are married off to grooms between 17 and 19 years. Dowry is not a common practice in Muslims but Meo Muslims, probably because they are surrounded by Hindu communities in the nearby areas of Mathura, Bharatpur and Alwar, ac- cept and demand a huge dowry. Like in other parts of Haryana, women are rated as second-grade citizens here. Women work in the fields, at home, fetch water and do all the chores, while men just sit around the chaupal, smoke and play cards. This was witnessed in course of field visits while visiting to villages in the peak harvesting season. Groups of young men were to be found loitering while no woman would be in sight as they would toil away their day in fields. The role of the community is strong, and decisions taken by the village, pal or Khaap Pan- chayat are binding on all people. The police or civil administration has rarely interfered. The police and the state government had decided to crack down on those indulging in trade of women but in the wake of stiff opposition from the community leaders, the police did not take punitive action against those who were involved in the buying and selling of minor girls.

5.5 Conclusions

1. There is a tremendous need for mobile healthcare services in the Mewat region. 2. Besides the prescriptive care, there is also a need for preventive care. Medicines alone cannot help improve the health standards in the region. 3. For preventive care, winning the confidence of local community has to be the first step. 4. There is a need to make the community sustainable in terms of its own healthcare needs. 5. The existing health infrastructure is in state of disuse and disarray. However, MDA is interested in using Public-private partnership for maximum benefit of people. 6. There is a significant population of aged people, who cannot travel or afford private healthcare, to sustain the momentum of a new MMU launched in the region. 7. Organizations like Deepalaya have proven that Mobile Units can succeed in the region if backed by a proper referral system.

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6. Recommendations

6.1 For Long term Intervention

• Strengthen existing healthcare delivery mechanism in Punhana-

– Train RMPs (rural doctors), village doctors, and ayahs. Even with MMUs it is possible to cover villages once a week or once a fortnight. Training the RMP who live in these villages and coordinating medical care with them will help serve communities better. Also creating an alternative to the services of quack doctors in the region which draw hordes of people.

– Use Primary Health Centres, Community Health centres spread over Mewat as base stations to run Mobile Medical Units. There are 17 PHCs in the region and there is no private hospital with comparable facilities. It is not possible for the MMU to refer patients to hospitals outside Mewat because of cost considerations. Using PHC and CHC as bases, we can use whatever facilities have been provided by the MDA in the region. This will reduce chaos at PHCs, increase density of cases coming with MMU referrals, increase efficiency of the modern systems being acquired by MDA. It is suggested that this mechanism be used as bases for improving the PHC system through the public -private partnership in future.

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– Make supply chain for genuine medicines effective by tying up directly with Pharma companies to deliver medicine for Mobile Units. The Mobile Medical Units can supply medicines in bulk to be disbursed through RMPs in the villages. This will reduce the incentive for quacks selling fake drugs in the region.

– Prepare modules on geriatrics (care of aged) in local language using interactive multimedia tools like CDs, which can be used to train medical workers of Sub Centre Clinics. Multi media is being used heavily for promotion of Pulse Polio, Aids awareness and birth control. However, used intelligently it can be used to create awareness of the sad state of elders in the local language.

• Bring co-ordination in works of different agencies-MDA, MSEDS SHGs, NGOs like Venu’s Eye Clinic, Fortis Healthcare, Deepalaya, CSR divisions like Escorts, Ford Foundation etc because though on paper every agency has done great work, little has changed on ground in

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Mewat in last few years. Coordinating efforts of different agencies will bring synergies and consolidation of efforts.

• Use Mobile Medical Units to reach out to tough areas and engage the elderly in community development. This may involve using social workers from Jamia Hamdard, or Wakf board or Deoband communities to encourage safer health practices like avoiding hookah, tobacco and alcohol, using contraceptives, avoiding marriage at young age etc.

• Build health awareness through healthier habits, make local communities self sustainable in their healthcare through better diet, better lifestyle and awareness of treatable diseases

• Create awareness of government run schemes for the aged like old age pension, senior citizen rights, geriatric care initiatives

• Support income generation activities for the aged through MMUs, by disbursing medicines locally in village or supporting MMU operations locally

• Create Help lines for the Meo to give information about MMU, Healthcare in Mewat region. This helpline will also give information on basic healthcare, availability of specialist care in and around Mewat and save time and money spent on travel.

EXPECTED TIME PERIOD FOR OPERATIONS: 5 TO 1O YEARS

EXPECTED COSTS: 30 lakh per annum

No Cost Head Amount

1 MMU Operations 13 2 Training RMP 2 3 Preparing Multimedia kits 1 4 Engaging Social Workers 4 5 Help Line Operations 2 6 Marketing costs 0.5 7 management costs 5 Sum 27.5

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6.2. Short Term Intervention

• Area: Hathin • Intervention Plan:-

– For one day in a week, the existing Faridabad MMU can cover villages bordering Palwal in the Hathin Block of Mewat. – Doctors from Palwal-have supported Helpage Healthcampsand can be recruited for once a week trip to the Hathin Area – Referrals can be forwarded to PHC Hathin and Govt Hospital / Guru Nanak Hospital in Palwal – Coordinate with the CMO, SMO and the local supporting NGO for route plan, Health focus areas, referral patients etc

• Benefits

– Close to Delhi-Easy monitoring and control – Hathin more safe for operation than Punhana – Easier to get paramedical staff for Hathin: staff can up-down from Palwal or Ballagarh on the Delhi-Alwar highway. – Separate MMU acquisition not required – Facilitate coverage of Mewat on pilot bases before full time operation in neighboring areas – Less start up time and Low start up costs – Target 10 villages on a weekly or 20 on a fortnightly bases-Acquire 5000 to 10000 patients accordingly-costs to go up by-50000 to 1 lakh per month accordingly

6.3 Medium Term Intervention

• Area: Hathin and Nuh

• Plan:

– I MMU running fortnightly operations based out of Gurgaon into Nuh and Tauru, and out of Faridabad into Hathin and Nagina

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– A dedicated MMU running in Mewat every day in villages in Nuh, Hathinand Tauru. – Training RMPs and Village doctors in old age care – Penetration of old age schemes, sanitation practices in target villages – Target 50 villages per week, with upto10 villages each day – Coordinated field trips with PHCs and commercial hospitals in the area, share information on disease pattern and kind of intervention required, referrals etc. – Tap donors from Gurgaon and Faridabad – Use facilities available in Gurgaon and Faridabad to train local doctors, RMPs and aayis

• Benefits

– Tap Captive population of over 5-6 lakh in Nuh, Hathin and Nagina – Lesser risk to Operational staff and property-operate out of Gurgaon and Faridabad – Can act as an eventual bridge for Helpage into the region; can look to target more remote areas in near future. – Cost : 15 lakh per annum

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7. Feasibility

7.1. SWOT Analyses

The purpose of this analyses is to identify the Strengths, weaknesses of Helpage as an organisation and compare them to the opportunity and threat arising out of running the Mobile Medical Operations in Mewat

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7.2. Functional Feasibility

 MMUs cannot by themselves eliminate health problems of the aged in the target region. They have to be a part of the overall health strategy in the region. As suggested, they can be best used in coordination with the PHCs and the Sub centres and the RMPs acting as parts of a value chain delivering healthcare services to the people of Mewat.

 Can act as an instrument of social change, inspire them to a better and healthier life, primarily because several diseases can be avoided with simple precautions, and these ways are much more effective than providing cure through medicines. This will also be an opportunity to bond with the local community elders and engage them in this task. It is difficult but achiev- able and has been attempted in past for Pulse Polio mission.

 Results will not be quick, long term intervention is required. Any organisation cannot look at a timeframe of less than 5 years in the target region. Enabling self reliance will need some measures and a plan to discontinue operations eventually when suitable success has been achieved.

 Need to meaningfully engage the target audience through a concerted campaign directed at

– Gender equality,

– Aged rights,

– Economic self reliance without angering local sentiments.

• Burn out rate of NGOs in the area is high, hence cooperation with other NGOs , MDA and medical fraternity a must.

In 2003 when the MDA engaged different NGOs to run Mobile medical units in different blocks, Helpage also started operations in Nuh. The operation was a success as it did 28000 transactions that year. However, with change of management in MDA, policy changed and funding

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was discontinued in 2004. Helpage had to shut operations there and look at interventions in shape of occasional health camps organised through the local partner NGO. However these issues should be included when launching operations and a long term contract of 3 to 5 years should be agreed on before launch of operations.

• Independent operations involving distributing free medicines without creating an awareness of issues will lead to short-term success but long-term loss, because the local community will become even more dependent on outside intervention for its self sustenance.

In the rural areas, quality of care is often measured with cost of care. While interacting with the people in villages, a patient would often mention the amount he spent on his treatment, and not mention about what treatment he underwent. Similarly for the doctors, their fee is a used by patients as a measure of comparison of skills. Hence it makes sense to charge a nominal amount to the villagers in this area. Even if people cannot afford it, and are in a bad state, medicines can be given on credit and credit can be separately accounted for at the end of year. This will give transparency in accounts and a project a “ not for charity” attitude to the recipients.

• The presence of multitude of agencies presents a unique opportunity to work in the area

Talking to Dr. Randhawa, the chielf medical officer in the region, it came out that there are many stakeholders interested in the benefit of Mewat. The government has tried but has its limitations. The doctors in PHCs are not a happy lot. The government doctors do not enjoy confidence of local people as much as private doctors do. There is a severe dearth of doctors in the region, there being less than 100 government doctors for a population of more than 12 lakh. The Mobile Medical Unit can address this problem in a unique way which has not been attempted before. It provides an opportunity to pool efforts of various organisations, government and private to create a model which is best suited to Mewat.

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Essentially the model suggests;- 1. Use PHC as base of operations for mobile medical units 2. Use Sub Centres as local access points for remote villages for the MMUs 3. Use RMPs as agents of the MMU in the region 4. Shift the MMU base at each day / alternate day / bi weekly/ weekly to a different operational base to cover the most needy areas and cover as many number of villages as decided. 5. Refer patients to PHCs for further treatment, with referral from MMU. 6. Evolve a feedback mechanism to escalate issues if any in the value chain to the MCO, who will be responsible for smooth operations

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7.3. Operational feasibility

To decide the operational feasibility, following parameters were identified:- 1. Sustainability of operations over a long period 2. Quality of infrastructure 3. Security of staff and property Sustainability over a long period can be achieved if following points are kept in mind:- a) Confidence of the local community lies with our organisation. b) Confidence of the Mewat Development agency, and local doctors lies with our organisation c) Doctor and para-medical staff from within the community, work with our MMU, or the ability of MMU to engage local people in community development. d) Operations are made self funded eventually, to make them replicable in other parts of the region and inspire competition to emerge with similar models. Quality of Infrastructure: a) Quality of roads; there are no roads in many interior villages in Mewat. Also because the neighbouring villages in Rajasthan face heavy mining activity, the dumper trucks running in the region cause heavy wear and tear of the roads. These roads need to be repaired every year. MDA has budget for it and does good work, but the need far outweighs the efforts. b) Village development works: If villages have open drains and sewers, which continue to breed disease causing insects, there is little which intervention through MMUs can achieve. Villages need to have proper drainage and clean environment. Security of Staff and Property: The cases of Mewat based gangs engaging in crime are common. However one needs to note that there are organisations in the region which have done good work for a number of years without being harassed. Example is Deepalaya gram in Gusbethi in Tauru block of Mewat which has done great work infield of education, health and community development in this region. It has worked well in the region considered tough even by standards of the local administration. General precautions will have to be kept in place like limiting the visiting hours till 6pm in summers and 5pm in winters and keeping the village sarpanch and the local police aware of the MMU movement in the area.

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Also a case in point is presence of retail networks of multi national consumer good companies like coke, Pepsi and the Indian-oil run petrol pumps in the region. There is a strong recommendation here that if approached correctly, the region can meet all above requirements. Besides the above points, the operational issues like finding out the optimum path can be done once a complete survey is done of the target area and every village is thoroughly surveyed. The health commissioner convened such a survey in the region and 100 villages out of 500 villages in the district have been identified in the region as difficult. Most of them lie in the Punhana block. It is not possible to meet requirements of 100 villages, so it will be better if we start with a target of 25 villages in Punhana block. These can be finalised in consultation with health commissioner or the medical chief officer.

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7.4. Financial Feasibility

The aspects under financial feasibility looked at are:-

1. Potential partners and sponsors 2. Self sustainability 3. Cost cutting measures

The cost structure of running an MMU is in Appendix A.4 The running cost of an MMU is 9 lakh per annum.The acquisition cost of an MMU is 4.5 lakhs. Converted Rural Transport Vehicle or a 4* 4 Tata sumo depending on the type of geography we are looking at. In the given case the roads in villages, in remote regions are very bad and a 4 * 4 vehicle is required. Estimated running costs are likely to be around 10.5- 11 lakh per year. Since the area is populated and there is no service in Punhana, a captive population of 2.4 lakh is assumed. Even if the MMU can capture 10% market in its first year of operation and charge a basic amount ( equal to that charged by most RMPs), Rs 30, the amount is Rs 7.2 lakh. This means most of the running costs can be met even if helpage charges a basic amount currently paid to RMPs.

Benefits to Helpage through self funding are:-

1. Less dependence on sponsors for sustaining the operations 2. More respect for paid services than free services 3. Lower chances of misuse of medicines 4. Can be made target specific for staff; can be inspiring and competitive 5. Can refer patients with diagnoses to PHCs

Benefits to villagers are:

1. Get qualified doctors, pharmacist and genuine medicine at doorstep 2. Do not have to bear travel costs 3. Freedom from quacks

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4. Need not travel to PHCs and wait for OPD; can produce diagnoses from MMU.

The operations can be made completely self reliant by raising the fee, but we have to consider the ability to pay of people as well. We suggest Helpage seek funding on per transaction bases from MDA or donor agencies active in the region. This would mean even if the transaction cost is 45 Rs per patient, 30 is borne by patient and 15 by the donor. Exact figures can be identified only after staff has been appointed, route has been fixed and all cost heads are known.

Among the sponsors identified are some agencies which have worked in the area and are aware of its complexities. These are:

1. Aga Khan Foundation 2. Ford Foundation and its local concern Meo Foundation 3. Haryana Wakf Board 4. Escorts Motors 5. MDA

For medicines, Helpage can get subsidised medicines from Pharma companies like Ranbaxy, Dr. Reddy’s Labs etc.

COST CUTTING MEASURES

1. Use local doctors and local paramedical staff. Retaining outside doctors will be difficult because of higher costs involved 2. Use local base stations to run the operations, do not run operations from Delhi or Gurgaon.

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8. Case Study: Deepalaya Gram

8.1 Introduction

Deepalaya initiated the Chameli Dewan Rural Health Clinic and Mobile Unit under this backdrop with support from the Dewan Foundation for providing health services to the rural poor of Mewat region in Haryana.

8.2. Why Mewat?

The region is located 60 km from Delhi, nearly 35 km from Gurgaon, which is a developing metropolitan city. It is, for the most part, rural with a population of 8, 00,000 with nearly 500 villages dominated by Meo-Muslims (Converted Hindus). Following findings were found after surveying the area:

 Immunization of children very low with large number of children affected by poli- omyelitis.  Diarrhea amongst children very high and the villagers are ignorant about its means of prevention.  Infant and childhood death common due to pneumonia.  Awareness of antenatal care very low and routine checkup negligible.  Access to public sector services is limited as well as there is lacking of female provid- ers.  Adolescent young people at the threshold of marriage and adulthood have no life education as any topic related to sex and sexuality is a taboo.  Poverty and superstitious beliefs also indirectly plays an underlying factor behind other factors cause of diseases.

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 Social and religious issues act as constraints for females to access reproductive health services.

8.3. Other Projects involved:

 Deepalaya is involved with the formation of Self-Help Groups comprising women covering nearly 150 villages of the region to improve their financial status by setting up micro enterprises through micro finance, using savings and loans from banks. Training and awareness are also held for the womenfolk in leadership, community development, vocational skills and literacy.  Deepalaya has established Deepalaya Gram with a School, Vocational Training Insti- tute and a well furnished Transit Home (Hostels) for working and street children of Delhi.

8.4. About the Project

The Chameli Dewan Rural Health Clinic and Mobile Unit was established in 2005 in collaboration with St. Stephen’s Hospital, Delhi to bring about long-term changes in health which would help in development and capacity building of the community. St. Stephen’s Hospital provides the necessary technical/professional inputs in running the community outreach program. Doctors, Training program as well as Participatory planning exercises are provided by St. Stephen Hospital.

8.5. Mobile Health Unit

Deepalaya’s goal in initiating the project was to offer better accessibility in health care in Mewat region. At present we are able to provide health services to 14 villages i.e. Pipaka, Tavru, Re- hari, Shikarpur, Chahlaka, Soondh, Sabras, Bissar, Dhidhara, Bhango, Nizampur and Jaurasi and a cluster of villages surrounding the out patient clinic viz. Gusbethi, Kirori, Patuka, and Bhutlaka through our clinic and mobile unit.

8.5.1. About the Region

The area is pre-dominantly composed of Meo Muslims i.e. converted Muslims who depend largely in farming for livelihood. As agriculture cannot sustain everybody some work in stone quarries, some drive trucks, and other vehicles to transport goods and humans. Migration is very limited as any outside influence is, eyed suspiciously. Thus it is a very common sight to see young men unemployed and women trying to scrape together a living. In most of the villages the would be mothers are primis i.e. teen mothers and the nearest hospital to provide institutional delivery is at Tauru where in event of a caesarean the Surgeon has to be called from elsewhere. Almost all deliveries are conducted at home by local old woman. After parturition the baby is not given the colostrums but the newborn is given „Desi ghuti’ (local medicine) believing that it would help in digestion. This practice is not advisable by

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medical terms. Postnatal women are given jaggery syrup for 2-3 days instead of any solid food, assuming that she will not be able to tolerate food. This leads to the vicious cycle of lack of mother’s milk, lack of hygiene, gastroenteritis and malnutrition. The average children borne by mothers here are eight to ten. Women are keen to use methods of spacing, but have to face considerable opposition for the same.

8.5.2. Nature of Health Services Offered:

8.5.2.1. Clinical Check-Up

The clinic and mobile unit operates from 9.30 - 17.30 hrs for 5days a week. Two lady doctors are deputed for the clinical checkups. One lady doctor is available for all the days while the other is available for 3 days a week. The mobile van follows a schedule to visit the villages. The doctor, a pharmacist, Nurse goes with the mobile unit to the village that has been schedule for the day.

Medical Team

Full Time Doctor – 1 Part Time - 1 Health Coordinator 1 Nurse/ANM 1 Community Health Workers 3

Pharmacist 1

Community Health Volunteers 15 1, acts also as community Driver cum Health Worker health worker when needed Data Entry Personnel 1 Driver 2 Ayah 1

The Registration Process The beneficiaries are charged nominal fee for health check -up. New patients are charged Rs. 5 at the time of registration and in the succeeding visits they are charged Rs.2. Medicines are provided with 50 % discount of the exact cost. The clinic also provides few medicines, which are necessary at the time of pre-natal and postnatal care free of cost.

Status of Patients Visiting the Clinic and Mobile Clinic

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Month Male Female Old New D.S. T.H. ANC October 177 350 323 223 70 78 129 November 219 496 395 308 98 55 187 December 174 399 312 254 34 21 183 January 112 397 269 240 25 27 193 February 153 436 351 238 57 46 203 Total 835 2078 1650 1263 284 227 895

From October to February, the Clinic treated 2913 Patients with the majority of 2078 females, in contrast to only 835 men as shown the table above. 284 Children from the Deepalaya School at Deepalaya Gram and 227 Children from the Transit Home were treated as well. Many patients were referred to other medical institutions.

8.5.2.2. A dental health camp Awareness Programmes by the health team To create and raise health awareness in this area, health workers, doctors and volunteers hold regular community meetings with the villagers. In the meetings the health team discusses about the prevailing health problems. Other topics are like having nutritious food, hygiene and vitamins. An important topic is always the precautions woman should take within a pregnancy to ensure the health of the baby. In a poor area, where many of the children are malnourished, it is important that the clinic has a Malnutrition program. The doctors took weight and height of several children of the villages. The health team guided the parents which had undernourished children and demonstrated some remedies. After the intervention of Deepalaya the children showed great improvement in their appearance and in general health. Deepalaya’s health staff is trained at regular intervals to enhance their knowledge and their skills. In doing so, Deepalaya is ensuring a good health care and a well trained health team. Besides the training, new A.N.M. and health worker joined the team to deal with the growing number of patients caused by the higher acceptance within the villages. Now more and more villagers are medicated by the mobile clinic, because these villagers saw how good the treatment of the Chameli Dewan Rural Health Clinic and Mobile Unit was in the past. Even former skeptical patients from Muslim villages adopted the methods of family planning, the doctors offered.

8.5.2.3. A health camp

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The health team in regular intervals organizes health camps, awareness campaign in the villages. Within these camps better nutrition, hygiene and illness and disease prevention is teached. The Clinic is providing health service to the Deepalaya Gram in Gusbethi. The doctors regularly examine the health of the children. The health team tests eyesight by using eye charts and takes the weight and the nutritious status of the children.

8.5.2.4. Referral System

In creating an effective local referral system, Deepalaya is working close together with the doctors at PHC-Tavru, GH-Sohna and Mandikhera and the medical institutions within this area. The referral system includes patients for sputum tests, X-rays and treatment for Tuber- culosis, Hansen’s disease and ophthalmic examination. Deepalaya is trying to get in touch with more institutions in this area, to offer the best medical treatment as possible.

8.6. VISION OF THE PROJECT

Through the Chameli Dewan Mobile Health Clinic, Deepalaya aims to provide quality health services to the unserved at affordable costs in Mewat region. The Clinic is also an important part of the Deepalaya Gram as it offers good health care to the children.

8.7. FUTURE PLANS

1. Expansion of the Clinic to provide better health service 2. Campaign for Awareness Programmes and organize more health camps 3. Reaching out to larger population of Mewat Region

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9. Risk Factors

• Security of staff and property will be a risk. High crime rates in the region mean there will be a pressure to provide adequate safety measures and precautions. This could mean avoiding certain routes, informing local police about Mobile unit schedule and restricting operating hours.

• Trust of local community is important especially at the start up stage. The community is backward, attempts to promote healthier lifestyle and promotion of women welfare could alienate the locals.

• Sustaining interest of MDA / Donor. As regards to MDA, policy changes happen with change in management (the officer in charge) and changes in ruling political parties. Funding through MDA is thus not reliable if it is on a year-to-year bases. Sponsor should be ready to support on a long term bases.

• Employing Manpower for Mewat. There is a shortage of qualified manpower in Mewat, for doctors and paramedical workers. Getting workers from outside a challenge because Helpage cannot afford paying higher than market for such a program.

• Finding a reliable local partner. Most local agencies are focussed on local needs and are not mature to scale up to a region level. This means Helpage may need to identify multiple local partner NGOs for its operations in Mewat.

• Management of Public private partnership a challenge. Though not impossible, it has not been achieved so far in field of healthcare delivery in Mewat, even though numerous NGOs have worked with the MDA at different times.

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Appendix: A More On MMUs

A.1 MMU Collage

MMU Operations shown in above pictures from Helpage website. For more please log on to http://www.helpageindiaprogramme.org/mmu_imagegallery.html

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A.2 MMU India Coverage

A.3 North India Operations MMU North India Operations -MMU

Mentioned below are average number of treatments taken up by Helpage MMU. Each MMU covers a group of Urban villages or rural villages where parallel healthcare facilities are not available.

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State District Treatment Delhi Delhi Unit 1 22024 Delhi Unit 2 20782 Punjab Chandigarh 18238 Amritsar 21109 Jallandhar 16866 Moga 23568 Haryana Jagadhari 18095 Faridabad 18910 J & K Jammu 20344 Baramulla 3358 Rajasthan Jaipur 14632

Udaipur 20215 Bikaner 20081 Kota 16159 Uttar Pradesh Lucknow 20308 Kanpur 26540 Ghaziabad 18663 Mathura 27919 Varanasi 8186

TOTAL 355997

Note: Average 12 sites are covered by each MMU

[Reference : http://www.helpageindiaprogramme.org/mmu_nr_state&district.html]

Above statistic is useful because Helpage considers an average of 20000 annual treatments as breakeven limit for each of its Mobile Medical Units. The operations which have reached a maturity stage are well over this figure. Low treatment density can be described for operations yet to reach mature state.

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A.4 A.4. MMU Cost Break Down

ANNUAL BUDGET FOR AN MMU Budget Heads Particulars Amount

(a) Human Resources 4,27,400 Doctor 1,17,900

APO/SW 1,38,000

Pharmacist 92,500

Driver 79,000

(b) Infrastructure and Equipment 68,000 Insurance 4,000

Road Tax 3,000

Fitnes 2,500

Fuel 42,000

Miscellaneous 2,000

Vehicle servicing/maintenance 13,400

Base Office Furniture and Civil Works 1,100

Printing and Stationery 8,600

(e) Administration 76,000 Local conveyance 12,500

Advertisement (recruitment) 1,000

Bank charges 500

Depreciation 26,000

Electricity and Water Expenses 1,000

Insurance Expenses 800

Misc Camp Expenses 4,000

Misc Exes 5,000

Staff Welfare 7,200

Rent, Taxes, Rates 9,700

Office Stationery, Books & Periodicals 300

Mobile, Telephone, Communication 5,700

Postage & Telegram 1,600

Audit, legal & Professional charges 700

TOTAL 9,00,000

The heads for fuel and local conveyance are shaded to indicate that these costs could be higher and depend on the distance covered and where the staff is sourced from. These calculations

HelpAge India| Fighting Isolation, poverty, neglect represent the average cost from the 52 MMUs running all over India.

B. Sponsor a Gran Program- national coverage

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C. National Age Care Small Grants Scheme- National coverage

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D. PACS National Coverage

For more pictures on PACS please use the gallery at

http://www.helpageindiaprogramme.org/AgedRightsAdvocacy_imagegallery.html

E. District Statistics 1. Nagina- Govt. College, Industrial Training Institute

Nuh- Yasin Meo Degree College

Ferozepur Jhirka- Shanti Sagar Kanya Maha Vidyalaya, Industrial Training Institute

Tauru- Seth Hardwari Lal

Hathin- ITI, Govt Polytechnic

2. Primary Schools : 622

3. Middle School : 74

4. High School: 55

5. Senior School : 30

6. College: 3

7. Polytechnic :1

8. ITI / VEI: 7

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9. Bal Bhavan: 3

10. Teacher Training Institute: 1

11. Enrollment Statistics at Gov. Schools in Mewat

Total students

Boys Girls Total Drop Out rate

1 Primary 87474 61414 148888

2 middle 14905 6261 21116 86%

3 High 3667 1264 4931 77%

4 Senior Sec 3113 936 4049 18%

The primary school infrastructure has been in a dilapidated state. Only recently the MDA has refocussed on improving the facilities available in schools . Drop out rates remain high especially for girls as they get married off early.Girls as young as 12-13 get married. Even opportunities for education after Primary level are low, as few villages have middle schools and even fewer have high schools, forcing some children to abandon education mid wat through. Illetracy compounds the problems of the region.

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F. More on MDA

Mewat Development Agency DC Office, Nuh

Additional DC Office, Nuh

In the year 1980, Govt. of Haryana with a commitment to deliver social and economic justice to the backward and under-privileged sections of society, constituted Mewat Development Board (MDB) headed by His Excellency, the Governor Haryana, Ministers and Secretaries of important sectors viz. Finance, Irrigation, Power, Industries, Agriculture, Animal Husbandry, Cooperation & Development and all the M.Ps & MLAs of Mewat region and also few other eminent persons of the region as official & non official members. Its executing agency at field level, Mewat Development Agency (MDA) was also formed simultaneously and its Go- verning Body comprises of Commissioner, Gurgaon Division, Gurgaon as Chairman, D.C Mewat as Vice Chairman, CEO, MDA Member Secretary, Financial Commissioners, Reve- nue & Finance or their Representatives, Additional Deputy Commissioner, Mewat and heads

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of concerned line departments as members. The role of MDA was one of planning, coordination and administration.

F.1 Members of Mewat Development Board

S.N. Name of Members/Special Invitees Members/Special Invitee 1. His Excellency, the Governor Haryana Chairman 2. The Chief Minister, Haryana, Chandigarh Senior Vice Chair- man 3. The Finance Minister, Haryana, Chandigarh Member 4. The Revenue Minister, Haryana, Chandigarh Member 5. The Agriculture Minister, Haryana, Chandigarh Member 6. The Industries Minister, Haryana, Chandigarh Member 7. The Development & Panchayats Minister, Haryana, Chandigarh Member 8. The Cooperation Minister, Haryana, Chandigarh Member 9. The Irrigation Minister, Haryana, Chandigarh Member 10. The Animal Husbandry Minister, Haryana, Chandigarh Member 11. The Power Minister, Haryana, Chandigarh Member 12. Sh. Avtar Singh Bhadana, Member of Parliament, Faridabad Member 13. Sh. Azad Mohammad, MLA, Ferozepur Jhirka Member 14. Sh. Habib-Ur-Rehman, MLA, Nuh Member 15. Sh. Harsh Kumar, MLA, Hathin. Member 16. Sh. Sahida Khan, MLA, Taoru Member 17. The Chief Secretary to Government, Haryana, Chandigarh Member 18. The Financial Commissioner & Principal Secretary to Govt., Haryana, Member Revenue Department, Chandigarh 19. The Principal Secretary to Chief Minister, Haryana Member 20. The Financial Commissioner & Principal Secretary to Govt., Haryana, Member Irrigation and Power Department, Chandigarh 21. The Financial Commissioner & Principal Secretary to Govt., Haryana, Member Animal Husbandry Department, Chandigarh 22. The Financial Commissioner & Principal Secretary to Govt., Haryana, Member Finance Department, Chandigarh 23. The Financial Commissioner & Principal Secretary to Govt., Haryana, Member Agriculture Department, Chandigarh 24. The Financial Commissioner & Principal Secretary to Govt., Haryana, Member Industries Department, Chandigarh 25. The Financial Commissioner & Principal Secretary to Govt., Haryana, Member Education Department, Chandigarh 26. The Financial Commissioner & Principal Secretary to Govt., Haryana, Member Health Department, Chandigarh 27. The Financial Commissioner & Principal Secretary to Govt., Haryana, Member

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Technical Education Department, Chandigarh 28. The Financial Commissioner & Principal Secretary to Govt., Haryana, Member Women & Child Development Department, Chandigarh 29. The Commissioner & Secretary to Govt., Haryana, Public Health Member Department, Chandigarh 30. The Deputy Commissioner, Mewat at Nuh Member 31. The Chairman-cum-Managing Director, Haryana Vidyut Prasaran Nigam Member Limited, Panchkula 32. Sh. Fazruddin Besar S/o Sh. Suleman R/o Village Sakras, Tehsil Fero- Member zepur Jhirka 33. Sh. Shakur Khan S/o Sh. Umed Khan R/o Village Kairaka, Tehsil Nuh, Member District Mewat 34. Er. Mohammad Israil, House No. 35, Sector-14, Gurgaon Member 35. Smt. Veena Eaglton, IAS (Retd.) J-5, South City, Phase-I, Gurgaon Member 36. Sh. Tayyub Hussain R/o Village Bhimseka, Tehsil Hathin (Mewat) Member 37. The Vice Chancellor, Maharshi Dayanand University, Rohtak Special Invitee 38. The Vice Chancellor, Haryana Agriculture University, Hisar Special Invitee

F.2. Members of Mewat Development Agency S.N. Name/Designation of Officer Members 1. Commissioner, Gurgaon Division, Gurgaon Chairman 2. Deputy Commissioner, Mewat Vice Chairman 3. Chief Executive Officer, MDA Member Secretary 4. Additional Deputy Commissioner, Mewat, (Nuh) Member 5. The Special Secretary to Govt. Haryana, Revenue Department, Member Chandigarh through his representative not below the rank of Joint Secretary. 6. The Special Secretary-II to Govt. Haryana, Finance Department, (F.D.- Member Branch), Chandigarh through his representative not below the rank of Joint Secretary. 7. Peoples representatives—6 (one each from six Panchayat Samities in Members the Mewat area)

(i) Chairman Block Samiti-Nuh

(ii) Chairman Block Samiti-Taoru

(iii) Chairman Block Samiti-Hathin

(iv) Chairman Block Samiti-Nagina

(v) Chairman Block Samiti-Punhana

(vi) Chairman Block Samiti-F.P. Jhirka

Special Invitees

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8. The Sub Divisional Officer (Civil), Nuh. Special Invitee 9. The Sub Divisional Officer (Civil), F.P. Jhirka Special Invitee 10. The Sub Divisional Officer (Civil), Hathin Special Invitee 11. The Superintending Engineer, Public Health, Gurgaon Special Invitee 12. The Superintending Engineer, Irrigation, Faridabad Special Invitee 13. The Superintending Engineer, Ranney Well, Palwal. Special Invitee 14. The Superintending Engineer, DHVBN, Gurgaon. Special Invitee 15. The Civil Surgeon, Nuh (Mewat) Special Invitee 16. The Deputy Director Agriculture, Mewat. Special Invitee 17. The Deputy Director, Animal Husbandry, Mewat. Special Invitee 18 The District Horticulture Officer, Mewat. Special Invitee 19 The Divisional Soil Conservation Officer, Gurgaon/ASCOs, Mewat. Special Invitee 20 The Executive Engineer, Panchayati Raj, Nuh. Special Invitee 21 The District Forest Officer, Mewat. Special Invitee 22 The District Education Officer, Mewat Special Invitee 23 The District Elementary Education Officer, Mewat Special Invitee 24 The Project Officer, ICDS, Gurgaon. Special Invitee 25 Three Representatives of NGOs in rotation to be nominated by Chair- Special Invitee man, MDA.

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E. Health Survey Punhana

E.1. Survey Form Template

General Information

Q1. Village Name:

b) Village population:

c) BPL families’ population

d) Pensioners population

Q2. Name of Person

Q3. Age

Q4. Occupation

Q5. Income

Q6. How long have you lived in the village?

Q7. How many kids do you have?

Healthcare information

Q8. Do you have any healthcare facilities in your village?

Q9. If no, please mention in case of illness, where do you go? How far is it from your village?

Q10. How much do you usually spend on medicines / healthcare?

Q11. In case of emergencies like accidents what do you do?

Q12. What are the common diseases in the village?

Q13. Is there any healthcare program run by government / NGO / private organisation in your village / neighbouring village?

Q14. Please mention if any awareness program has been run in this village, like about clean drinking water, use of toilets, healthier food habits etc.

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Education facilities

Q15. Do you have a school in your village?

Q16. If yes, then what level:

a. Primary b. Middle c. Senior Secondary

Q17. Do you send girls in your family to school?

Q18. Are you aware of the government schemes like free education and cash incentives to girl students?

Water, Sanitation and Infrastructure Facilities

Q19. Do you have a toilet in your home?

Q20. Is there a community toilet in your home?

Q21. Where do you dispose of your household garbage?

Q22. Do you have a rainwater harvesting system (Called “ dhalao” in Hindi) in your village?

Q23. Do you have a community centre, a Panchayat ghar or a day care centre ( “Aanganwadi”) in your village ?

Q24.What are the facilities for drinking water in your village?

Q25. What is the condition of drainage in your village?

Q26. Whom do you approach in case of drainage problems, flooding, disease outbreak etc ?

Q27. What are the transport facilities available to villagers here?

Q27. Any other suggestions?

Pictures from Survey:-

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Pic1. Men smoke Hooka in Punhana

Pic2: Few villages have access to clean drinking water. The pipes laid down for water supply have rusted and are broke. Most villages depend on ground water for drinking, washing and cook- ing needs.Women often walk long distances outside the city to fetch water and also for washing and bathing.Women in Teher, wash utensils as children watch. Women live like second class citizens, rear children, work in fields, do household work and cook while men idle away time.

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Pic 3: An Overloaded Auto in a Mewat Town: Nuh

Pic 4: The unofficial Mewat Transport: Horse cart

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Pic 5. Collage of Health Survey.

Deepalaya Mobile Health Unit at Ghusbethi, Tauru

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F. Field Report – Gehlap Village

Field Visit Report 1 The purpose of this report is to report findings from field visit of village Gehlap in Mewat district of Haryana while studying the feasibility of starting mobile medical van service in the region. *All figures quoted in this report are based on interviews and observations and have not been validated from any standard source. Executive Summary

Village Gehlap is one of the 230 villages in Mewat district. It has a population of 8500 to 9000.The general diseases found in the target group here are breathing problems, eye problems, joint problems, heart ailments and seasonal problems like diarrhea, fever and flue. The villagers face problems due to lack of access to medical facilities, the problem being more acute for elders who cannot support themselves or are immobile. Target Group Strength There are around 8500 people in Gehlap village. There are 550 registered pensioners, and applications have been filed for another 1200 people. This indicates that approximate age of people above 60 years of age is likely to be around 1000 or 10% of the population. Out of this there are 118 widows and 12 handicapped people. Widows generally refer to those who have lost their spouse due to old age. Talk- ing to people in Gehlap, similar demographics exist in the neighboring villages. Economic Profile Gehlap is mainly an agriculture-dependent village. Nearly 10% people have more than 3 acres of land. Most people have land holdings of size between 1 and 3 acres. Some 5% of the people are those with no land of their own and work on others land to make a living. As per government data there are 647 people below the poverty line in the village (the yellow card holders). There are 150 people which are even below this minimum standard and come under red card holders or known as poorest of the poor. There are less employment opportunities for the youth because of small size of farm holdings and low disposable income among villagers. As an indicator of economic state, number of TV sets per hundred households was 40. Same figure for fridge was 15. There are 2 cars in the village. Socially, Gehlap is one of the more developed villages In the area, with paved streets, good drainage and local administrative infrastructure. There is now a school till class 12th and a girl’s school in the village. Disease Pattern Based On Our Survey, main problems affecting elders in Gehlop area are:-

1. Eye Problems 2. Asthma or Breathing Problems

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3. Joint Pains / Back Pains 4. Heart Problems 5. Skin Related Problems 6. Seasonal Problems like Flu etc.

Based on medical records at Hateem Government hospital, the major treatments were given for following diseases:-

1. Scabies- a skin disease caused by access to affected animals 2. URI- Upper Respiratoty tract Infection 3. Joint Problems 4. Anaemia

Health Infrastructure The doctors also mentioned that the Haemoglobin content of the patients is very low and people are generally weak. This is because of the diet habits in the region. Even though the diet is heavy in milk such conditions exist. Habits like consumption of Hookah may accentuate the prevalence of dry cough , liver and URI infections. The medical infrastructure of the village consists of 5 RMPs and 1 nurse. There is a government run Primary medical center in village. There are no registered chemists or pharmacists. There are some stockists selling drugs illegally in the village. There is no check if the drugs sold are genuine or not. RMPs also dispense drugs worth Rs 80000 annually to the village (Refer A1). RMPs see 30-35 patients in a day, of which 33% are elders. In season, that is September and June, the figure is up to 100 patients a day. These are basic drugs like pain killers, for fever, congestion etc. Main job is to give immediate relief and refer to doctors in the CSU at Hathin (6 KM away). The CSU at Hathin serves a population of 240000 or 96 villages with strength of 5 doctors including one on contract. The Hathin Hospital has limited beds and refer patients to bigger hospitals in Mandi Khera or Palval as required. It is also supposed to dispense drugs to villagers but the large numbers means it is perennially short of essential drugs. In 2007 Hateem hospital saw 18000 new patient registrations and served another 15000 patients. The purpose of the PMC in village is to assist the village women during and after pregnancy and to help distribute drugs for general purpose. However it doesn’t enjoy much faith in the village as it is usually out of stock and there is little to offer in way of guidance beyond conventional wisdom. It has four nurses but the deliveries are handled at Hateem based hospital through use of an ambulance. For all emergencies and serious ailments people in Gehlap visit the private hospitals in Palval (18 km away) or Mandi Khera (35 KM away). This is because even the government hospitals in Hathin and Palval do not have spe- cialists or required medical infrastructure. At Mandi Khera all medical facilities including X ray, den-

HelpAge India| Fighting Isolation, poverty, neglect tal etc are available.( as claimed by the SMO Hathin, Dr. PK Sharma. An Organization based out of this village, Chandipur Health Association has done some good work in the village. They have from time to time organized medical camps to diagnose diseases, refer patients and distribute medicine in collaboration with organizations like the Red Cross, Fortis Hospital and Helpage.

The Panchayat at Gehlap has marked a 2 acre land for a medical assistance centre and has applied to Help age and Fortis hospital to help establish and run the center.

CHCs in Mewat District:-

1. Nuh

2. Ferozepur Jarka

3. Punhana

4. Hateem

5. Tauru

Primary health centers under CSU Hateem

1. PHC Mindkola

2. PHC Nangal Jat

3. PHC Uttawal

Contacts: Dr PK Sharma (SMO) – Ph: 986856189 Dr HS Randhawa (CMO)- Ph 951268273010 Rajender (Pharmacist )- Ph 9896258914 Shiv Kumar- contact person- Chandipur Health Association - Ph 09813244916

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F.2 FIELD VISITS- NUH, MANDI KHEDA, NAGINA

Plan of visit: To visit Nuh tehsil, the DC office, the MCO office and the civil hospital at Mandi Kheda and Dr. Shamim Ahmed at Nuh to collect secondary data about the Mewat district with a view of selecting saml villages for survey. Summary of field visit: 1) Met the chief medical officer of the district and discussed health situation at a macro level, agreed to meet again for a detailed discussion with regards to current assignment 2) Collected substantial data about mewat district pertaining to the socio economic health of the district from the DC office and the additional DC office 3) Collected information about different NGOs active in the Health area in the Meat region and Nuh region, the problems faced and the likely areas for intervention by Helpage. 4) PHC Nagina Field Visit Meeting with Dr. Shamim Ahmed 1. Mewat has 451 villages; population of 12 lakh; government stats put it at 10 lakh, but need to include people of Mayo community in nearby states of Rajasthan who also depend on Mewat for medical care etc. Problems in state include illiteracy, ignorance, lack of education facilities, superstitions but above all apathy of government. Even today, Nuh tehsil with 44 villages and a population of 50000 doesn’t have a government school till class 12 th. 2. Health among other infrastructure woefully inadequate as planned by the government; one civil hospital at Mandi Kheda, inaccessible, hence a lot of dependence on the work done by NGOs like Red cross and help age such as organizing medical camps, eye care camps etc. 3. Mewat development agency has been trying to do right things, it has right plans and the funds, but due to some reasons the efforts have not borne fruits. In 2003, the MDA started the Mobile Medical Unit scheme with a number of partner NGOs in different Mewat districts, by disbursing money to these NGOs and providing Vans. This scheme lasted 1.5 years and in Nuh region alone 27000 cataract surgeries were performed. However scheme was stopped and vans not used later. 4. Government started with Delivery Hut scheme where they provide ambulance for pick and drop of pregnant women for delivery in CHC or PHC. The scheme re-used the Vans lying unused since the closure of the Mobile medical van scheme. 5. The government has a huge budget for health and the preferred mode of expense is through medical camps which are organized every month by selecting a village at random. These are

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generally inaugurated by the Chief minister or governor and a lot of money goes in the band- o-bast for organizing and publicity of these events. Also selecting a village at random reduces the effectiveness as there are always other areas with a more urgent need of attention. The theme of government organised camps is also random and not need based. Also there are 451 villages in the Mewat area, even if we take big villages say above 10000 population the number is close to 100, if a camp is organised in a village its turn will come again after 6 years, which means no follow up or post surgical care. 6. The effectiveness of the Mobile Medical Unit lies in the fact that there is a doctor who comes every week in the village leading to development of trust with the local people. Trust is a big problem in the villages of Mewat region because of illiteracy and superstitions. The female literacy rate is 1.5%, among lowest in the world, while that of Haryana is above 60%.This illiteracy and a minority mindset is exploited by rumour mongers to further jeopardise the efforts at development. Recently in the Pulse Polio Operation of the government, families were hiding there infants fearing that the polio drops would make their kids impotent later in life. Such a crises in confidence also exists about facilities in the PHCs, CHCs and even Mo- bile Units. It is also a responsibility of the agency which offers medical care to win confidence of people and make them understand their own need for better health care. The Mewat Region has highest instance of deaths during child birth, infant mortality, besides high prevalence of diseases like TB, polio, scabies, respiratory tract infections. 7. Numerous NGOs are operating in the region. The major ones include; 1. Deepalika Foundation / Diwan foundation: - Mobile Medical Units in Tauru, Schools throughout Mewat ; orphanage, computer training, vocational training center and a 100 bed hospital in Tauru. Based at 46, institutional area, Janak Puri, D Block 2. Shahid Foundation: Mobile Medical Units and hospital in Punanah district.Based out of surajkund in Delhi. 3. Red Cross has presence through DC ; DC is the district head of red cross; how is it working in the area is not known; 4. Sehgal Foundation has started Mobile Medial Units in Hateen area in 2003; were discontinued later; know big presence through work in SHGs and adult education. 8. There is an NGO Brahmjyoti foundation which is involved with running and maintenance of the mobile delivery van infrastructure this year onwards.

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9. Helpage and Dr. Shamim have been talking about the Mobile Medical units in Nuh for some 4 years now, with main concern of helpage being that Nuh is far from delhi and it will be difficult to maintain the buses. But need to discuss tis Action Points:

1. Talk to different NGOs present in the health / Mobile Medial unit operations and find out about the scale and coverage of their schemes and their long term plans. 2. Talk to CMO about the problems mentioned above and find out how government plans to counter these. 3. Talk to Brahmjyoti foundation 4. Need to talk to Helpage about what previous discussions or agreements have been made with Dr. Shamim or in Mewat district. Talks with Help Age India

Helpage plans to become a rights based organisation instead of a welfare organisation. It wants to change its delivery model to a more wellness based model where elder citizens are made aware of their rights as senior citizens, the facilities provided to them by the government, to help them claim these benefits through legal, political and social lobbying if required. The transition is based on premise that welfare model, based on making available free healthcare is not sustainable in the long run, if the people of the rural populace are not made aware of their rights . Pension is provided to all people above the age of 60 by the government of In- dia. How many people in this age group in rural parts of India are even aware of their right to claim tis income? Money is doled out all right but it hardly reaches the targeted beneficiaries because of various reasons such as illiteracy, lack of awareness, backwardness of region, Panchayat politics etc. Helpage has been doing work in rural India for last 20 years. It has won the confidence of rural populace in areas it has served. It has also tried to help by improving the health infrastructure by creating awareness of these rights by campaigning for better health practices, pension claims, training village RMPs and aashas. However the focus on MMUs has created short sighted goals for the organisation and taken the organisation away from its main goals. This has lead to a rethinking in terms of long term strategy and under its new program called the Helpage vision 2013 it has set new targets for itself and its key stakeholders. Meeting with Dr. HS Randhawa, MCO

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The meeting with the MCO, Dr. Randhawa was at the Civil Hospital at Mandi Kheda. The hospital has a beautiful and expansive building with all facilities a modern hospital could ask for. The building was built through funds donated by the Sultan of Oman. In 1994 the hospital was closed for want of doctors and other qualified paramedical staff. However, the government acquired the building in 1998 with a view to further equip the hospital and offer better medical services to Mewat people. Today the hospital also functions as the office of the MCO who makes the plans and budgets outlays for health annually. 1. Dr. Randhawa expressed concern that inspite of so many stakeholders in Mewat’s development, NGOs, Governor, MDA, State government, Central government there is no progress on the ground for so many years. In short, he was apprehensive about what new could Help Age do? 2. A new Medical Van service started in March covered 13 villages, plan to cover 26 next month. This year there are plans to appoint a special doctor, a pharmacist and a nurse to travel to villages in the Nuh district and perform OPD and also small surgeries. The Bus donated for the purpose is equipped with all modern facilities and has been lyng with the civil hospital for last 6 months. 3. About what areas they can look at- need to think, about government plans and budget- not discussed, about what NGOs present in the area- many but don’t know exactly what they are doing and what they plan to do. He said Helpage needs to find out exactly what they can do in this area and how can they contribute; say if it involves running of the current bus by the government- as in since the government is incurring expense in medicines and it has already outsourced maintenance of delivery hut and this bus to Brahmjyoti , how can Helpage contribute here? Action Point

1. Need to discuss with Helpage above situation before next meeting with Dr. Randhawa. I essentially set out to do a needs analyses with the CMO, however, I am having to do marketing for Helpage which I am not equipped to handle with what background information I have; Need cost structure of the medical division; any other direction I can lead the discussion to for intervention by HelpAge; Does HelpAge have any other interests other than just serving the people in Mewat---- attracting government funds meant for Health budget???

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G. Project Plan

13 Jul 2008 20 Jul 2008 27 Jul 2008 ID Task Name Start Finish Duration 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 1 2

1 Appointment of Project Manager 02-06-2008 06-06-2008 1w 02-06-2008

Liasoning with MDA,local NGOs and 2 09-07-2008 22-07-2008 2w 09-07-2008 CMO, local doctors Seek Sponsors, Prepare Tentative 3 06-06-2008 03-07-2008 4w 06-06-2008 Project Plan

4 Organise Board Meeting 03-07-2008 16-07-2008 2w 03-07-2008

Finalise Project Plan, Route, 5 16-07-2008 22-07-2008 1w 16-07-2008 Responsibilities and Goals

6 Aqcuire MMU, Make appointments, 25-07-2008 31-07-2008 1w 25-07-2008

7 Start Operations 04-08-2008 02-09-2008 4.4w 04-08-2008

8 Review Meeting, Track Progress 01-08-2008 01-08-2008 .2w 01-08-2008

H. Abbreviation and References Abbreviations

CHC Community Health Center CMO Chief Medical Officer

DOCC Center for Development of Corporate Citizenship PACS Poorest Area Civil Society

PHC Primary Health Center MDA Mewat Development Agency

MMU Mobile Medical Unit MSEDS Mewat Social and Economic Development Society

SMO Senior Medical Officer

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SWOT Strength Weakness Opportunity Threat

References

www.helpageindia.org

www.indiango.org

www.haryanaonline.nic.in

www.mda.nic.in

www.tribuneindia.com

www.deepalaya.org

www.helpageprogrammes.org

www.helpage.org

UN Report on Aged Rights

Planning Commission Report on Mewat

National Rural Medical Mission

National Policy on Aging- A report by Institute of Economic Growth

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