The Delhi government planned to set up 1,000 mohalla or community clinics in the state by end-2016, but only one-tenth of the target was met in the proposed timeline. In this article, public health expert Chandrakant Lahariya contends that in the success or failure of this initiative, at stake is the future of the efforts to reform the health system and strengthen primary healthcare in urban areas across Indian states.
As per plans of the Delhi government, the state should have had 1,000 mohalla1 or community clinics2 in place by end-2016. However, only one-tenth (106, to be precise) of the promised number had come up by the end of last year. In the 18 months since the first clinic in Peeragarhi area of Delhi was opened on 19 July 2015, there was one more spurt in March 2016, when 100 additional clinics were started.
This happened in spite of health being at the top of the agenda of the elected state government. There were promises of reforms in the way health services are organised, including creation of referral linkages through a four-tier system3; establishing 150 polyclinics4; and setting up screening OPDs (out-patient department) in hospitals, to name a few. Essentially, the mohalla clinics were a ‘front’ for a series of health-system reforms which the state government has initiated; the other reforms received relatively limited attention.
The clinics seem to have met the health needs of the target population; and as per an official report released in early August 2016, nearly 800,000 people had availed of the health services, and 43,000 pathological tests were conducted over a period of five months. On average, every clinic was catering to 70 to 100 patients per working day. During the dengue and chikungunya outbreak in Delhi in September-November 2016, mohalla clinics served as a facility where laboratory tests were done and doctors could examine people with symptoms. This contributed to lesser crowds and panic at hospitals.
The concept has received acceptance across the political spectrum and a number of Indian states, example, Punjab, Maharashtra, Gujarat, and Karnataka, and a few municipal corporations (Pune) have shown interest in launching a variant of these clinics. However, the delay in setting up the targeted 1,000 such clinics in Delhi is worrisome and one needs to think of steps that could be taken by the state government to meet the target.
State of primary healthcare infrastructure in urban India and need for mohalla clinics
Primary healthcare infrastructure is largely non-existent in urban India. People have to either go to a big hospital, which is usually overcrowded and far from their homes. Consequently, they have to wait for long hours, losing their daily wages, with no assurance of healthcare services. Alternatively, people delay seeking healthcare services, which leads to worsening of health conditions and development of complications.
The primary healthcare infrastructure in urban India has been weak, partially due to traditional focus on the rural health system. In 2013, the Government of India launched the National Urban Health Mission (NUHM), which aims to strengthen urban primary healthcare. However, implementation has remained suboptimal and programme managers are reported to have limited capacity to implement NUHM at the district level. Financial support has remained suboptimal, and infrastructure has not been developed on account of a multitude of reasons.
Under the NUHM, the community’s first contact with a medical doctor is at urban primary health centres (U-PHC), which have been proposed at the level of 1 for every 50,000 population. In contrast, the mohalla clinics aim to provide a medical doctor and a slightly lower range of services for every 10,000 people.
Till now, the lowest contact point for people to see a medical doctor in the health system was 370-odd allopathic dispensaries, run by the Government of Delhi. However, while these dispensaries have good infrastructure, utilisation of their services has remained poor because of no clarity on scope of service provision, lack of human resources, and other factors. Moreover, the geographical distribution of these dispensaries is not optimal and often these are located close to other specialised health facilities, which are preferred by people. Therefore, the dispensaries, at least in current form, have proven largely inefficient and ineffective (though it would not be correct to generalise).
While the design of mohalla clinics is cost-effective, their success would depend on effective implementation. Moreover, having been set up within the community with the availability of a qualified doctor, these clinics could help in elimination of unqualified doctors. Clinics being in the community also provide an opportunity for community participation in healthcare delivery.
However, there is far too much attention on curative services (apparently by design); and the government should use these clinics for addressing the emerging challenge of non-communicable diseases and provide public health services as well.
Lessons from Delhi’s experience with mohalla clinics
Mohalla clinics in Delhi have been set up with a number of innovative approaches, including doctors on contract on a ‘fee-for-service’ basis; use of rented premises; and flexible and variable timing of clinics to ensure convenience. However, in the last few months, there have been many hiccups in setting up of additional clinics such as delay in the allotment of land for the clinics, official approval procedures, and infighting between Delhi Government and municipal corporations for land. Finally, in September 2016, the Delhi Government announced that the timeline of setting up 1,000 clinics by end 2016 could not be met.
While the initiative of mohalla clinics had two important ingredients for success, that is, political will and financial resources, apparently not enough was done for timely implementation. The following areas could have been improved:
- No operational plan was prepared for almost a year. Even the officials to whom the task had been assigned had limited clarity on what was expected from them. It was only in mid-2016 that a small team started working on a roadmap. Had there been a roadmap from the beginning the challenges might have been identified, understood, and addressed. A few independent technical experts believed that the target of setting up of 1,000 mohalla clinics in such a short period was extremely ambitious, unrealistic and reflected political naiveté and disrespect for the processes.
- This was projected as a flagship state government scheme. Engagement with other stakeholders such as municipal corporations was not thought through. Health facilities run by the state government in Delhi serve nearly half of all people who go to any public health facility. However, allotment of land is controlled by a separate body, and getting land for these clinics had become a tug of war. The core concept of mohalla clinics to work as an efficient referral linkage to the next level of health facility would work best when there is coordination among all agencies providing health services. Engagement with both health and non-health stakeholders is essential for success.
- Though political parties would like to continue to be in power forever, reality is different. The likely sufferer following a change in government becomes the flagship initiatives of the previous government. The current government should engage with other political parties and seek to build consensus in order to ensure political as well as financial sustainability for the programme. These efforts might facilitate establishment of these clinics in an accelerated manner as well.
Though the timeline for setting up of these clinics has been shifted, lessons need to be learnt. The Government should engage with all stakeholders; develop a detailed roadmap and operational blueprint for mohalla clinics, shared and agreed with stakeholders; and consider finding mechanisms for political sustainability.
For the Delhi government, at stake is their credibility and the issue of moral responsibility to fulfil their electoral promises. Mohalla clinics have generated hope among the poorest of having access to quality healthcare, and have the potential to improve the way people seek health services. Above all, the success of the initiative in Delhi could bring attention on restructuring and revamping primary healthcare in all Indian states. That would be the real contribution of mohalla clinics to the Indian healthcare system.
- Mohalla means neighbourhood.
- Mohalla clinics aim to make select health services available and accessible to the poor and underserved communities. These clinics have become immensely popular and have received widespread acclaim, both nationally and internationally.
- The first tier is usually clinics and primary health centres. Second tier is polyclinics and community health centres, where a limited range of specialist services are available. Third tier is large hospitals with full range of specialist services. The fourth tier comprises medical colleges and apex hospitals with super speciality services and referral-only services.
- While there is one doctor in the mohalla clinic, polyclinics have doctors from specialties such as orthopaedics, gynaecology and paediatrics. These are second-tier of healthcare service delivery.