How the Aam Aadmi Party’s Mohalla Clinics changed public healthcare in Delhi

Sixty-four-year-old Chaman’s cardiovascular problems would never have been diagnosed were it not for the free Aam Aadmi Mohalla Clinic, 500 metres from his electronics shop in Panchsheel Vihar, New Delhi. “I would not have had the time or money to go to another doctor farther away from the shop,” said Chaman, who uses only his first name.

When Chaman went to the clinic, the doctor detected heart problems and recommended an angiography at the government-run Safdarjung Hospital. “Today, I am sitting here alive” because of the guidance I got at the clinic, he said, adding that he could have had a heart attack if his condition had remained undiagnosed or worsened.

Mohalla clinics are one of the foremost healthcare initiatives of the Aam Aadmi Party, which assumed office in February 2015. From then until February 6, 2019, it has set up 450 such neighbourhood healthcare clinics to provide free health-check ups and medicines, thereby making public healthcare more affordable and accessible.

With Delhi elections slated for February 8, 2020, we visited three clinics in Khirki Village, Panchsheel Vihar and Kalkaji area of southern Delhi. Many residents we spoke to, especially the poor, said they had benefited from these clinics. Data shows that more residents have accessed healthcare since these clinics were established.

Critics, however, point out that the majority of Mohalla Clinics were established just ahead of elections – 152 in January 2020 and 100 in the last quarter of 2019. One public health expert who has studied Mohalla Clinics said the plan to open 1,000 such clinics by March 2020 was excessive and aimed at garnering votes, adding that Delhi does not need so many clinics.

Improved access

Many visitors to Mohalla Clinics said that earlier, they only visited a doctor when they felt very unwell or had debilitating symptoms of disease. With Mohalla Clinics, which are free and accessible, they have started visiting for more regular check-ups and flu-like symptoms.

Globally, a person visits the hospital three times a year on average, compared to one visit a year in India, according to the research paper published in January 2020 in the Journal of Family Medicine and Primary Care. After Mohalla Clinics were set up in Delhi, a person visited the doctor 5.6 times per year, on average, the paper found.

The number of visits has risen even after accounting for an increase in population, said Chandrakant Lahariya, a public health expert who co-authored the paper. “This shows a need for better healthcare services. If the services are made accessible for people, they will benefit from it,” he said, adding that women, who hesitate to visit hospitals because of money or distance, are visiting neighbourhood clinics on their own now.

Each Mohalla Clinic serves a population of 10,000 to 15,000, and 70-100 patients visit a Mohalla Clinic every day on average. Here, they can get 212 kinds of free diagnostic tests done from empanelled laboratories, and get 109 free drugs from the essential drug list of the Delhi government.

“I have benefitted a lot,” said 42-year-old Meenu Verma, who lives in South Delhi’s Sheikh Sarai and has been visiting the Mohalla Clinic every 20 days for the past two years for thyroid and asthma medicines. “I called all my sisters also to get check-ups done. The doctor tested us for iron, vitamin D, calcium, everything.”

Mohalla Clinics provide basic medical care and treatment for common illnesses such as fever, diarrhoea, skin problems, respiratory problems, and first aid for injuries and burns. They refer patients to bigger government hospitals such as the All India Institute of Medical Sciences or Safdarjung Hospital for tests or procedures that they do not themselves conduct. Bigger hospitals might also refer patients to a Mohalla Clinic for basic diseases such as diarrhoea.

These clinics are set up either in portacabins or in rented properties, and are open from 8 am to 2 pm, Monday to Saturday. Some also work a double shift from 7 am to 7 pm. Each clinic has a staff of four –a doctor, a nurse, a pharmacist and an office assistant.

Other government services

Government healthcare centres and hospitals provide free-of-cost or subsidised care and medicines to those below the poverty line across India, but these are often overcrowded, have low-quality facilities and care.

Delhi has 38 state hospitals, seven Municipal Corporation of Delhi hospitals, 258 state dispensaries, 92 MCD dispensaries, four New Delhi municipal council dispensaries, and 10 chest clinics, which also provide free health services. These facilities examine around 33.5 million outpatients and treat nearly 600,000 hospitalised patients every year, according to a research paper published in 2017 in the Journal of Family Medicine and Primary Care.

“We come here [to the Mohalla Clinic] to get medicines for fever, cough, cold, blood pressure, sugar, everything,” said 60-year-old Kiran Singh, who lives in Khirki Village. “Earlier, we used to go to private hospitals. The government hospital is too crowded and far so we didn’t go there.”

“We had to start queuing from 7 am in the morning for our turn at the OPD [outpatient department] at bigger hospitals,” said 55-year-old Remi Thapa, another resident of Khirki. “Here, the doctors are nice, they give us regular medicines and lifestyle advice on what to eat and how to exercise.”

Thapa goes to the local clinic once every month to get his blood pressure medicines. He would earlier go to Madan Mohan Malviya Hospital or Safdarjung Hospital, the two government hospitals located 4-5 km from his home.

Proximity is one of the biggest attractions of these clinics, most visitors we spoke to said. “I can come here alone because it is near,” said 90-year-old Dharmnath, who was at the Khirki Mohalla Clinic to get a cough syrup. “Earlier, I had to wait for my son to take me to a dispensary or hospital.”

Cost-effective

Delhi residents spent 9.8% of their household income on health every year on average, according to a report by the non-profit Praja published in November 2019. One of the reasons is the lack of health insurance, due to which 90% of India’s poorest pay for medical expenses from their own pocket, IndiaSpend reported in December 2019. The average medical expenditure per hospitalisation in a private hospital – Rs 31,845 – is seven times that in a government hospital – Rs 4,452.

It is no surprise, then, that most visitors to Mohalla Clinics are poor or middle-income, as the January research paper found.

At the same time, the Mohalla Clinics are not expensive to set up, when viewed in light of their benefits, experts said. It takes Rs 20 lakh to set up a Mohalla Clinic in a porta cabin, while the recurrent costs of medicines, supplies and salaries are between Rs 5 lakh and Rs 7 lakh a month, Lahariya estimated. The total cost of setting up 1,000 clinics would be about Rs 200 crore – equivalent to 0.3% of the total Delhi government budget in 2019-’20 – and the cost of running them would be around Rs 50 crore to Rs 70 crore per month.

Combining the municipal and state budgets, Delhi spent Rs 8,549 crore on health in 2018-’19. Of this, Rs 403 crore or 4.71% was for Mohalla Clinics. The following year, 2019-’20, the Delhi government spent Rs 8,400 crore – 14% of its Rs 60,000-crore budget – on health. Of this, 6.9%, or Rs 375 crore, was allocated for Mohalla Clinics.

Not all services available

These clinics do not provide complete antenatal care as ultrasound tests are not permitted here. “Examining pregnant mothers is not a part of our job, but there is also not any strict restriction. If a pregnant woman comes to the hospital I always conduct a basic examination,” said a Mohalla Clinic doctor, when asked why Mohalla Clinics do not offer antenatal care. “I give them iron and folic acid, and ask them to get vaccines. What more can we do?”

The government plans to provide more services including immunisation, the Hindustan Times reported in July 2019, quoting a Delhi government official.

Government doctors, who spoke on condition of anonymity, said there are separate government programmes for immunisation. Providing vaccines at Mohalla Clinics every day would not be feasible as vaccine vials need refrigeration and proper storage, Lahariya explained.

Patients said that the 109 free medicines disbursed for free at Mohalla Clinics do not cover all ailments, and they have to buy other medicines at full price from private shops.

“I do save money. I regularly take my blood pressure medicines from here but all my medicines are not available here,” said Thapa, the patient from Khirki Village. He had a back injury, for which he had to take painkillers costing Rs 145 per 10 tablets. These are not available at the clinic, he said.

The list of essential drugs is also restrictive for doctors because sometimes they cannot prescribe better-suited salts or medicines not on the list, they said. “We have to prescribe medicines only from this list, even if we know that a certain medicine will work better for a patient,” said a Mohalla Clinic doctor.

Further, clinics have limited stocks of medicines. “We see most patients for diabetes, thyroid, and hypertension. We give them a 20-day dose in one visit as we only have that much stock,” said 26-year-old Neha Singh, a pharmacist in South Delhi’s Panchsheel Vihar Mohalla Clinic. “We often run out of these medicines because demand for these is always high.”

Digitising records

Mohalla Clinics are trying to digitise patient records with the help of the Wadhwani Initiative for Sustainable Healthcare, or WISH, Foundation. The clinics try using tablet computers for registering patients, recording diagnoses, generating e-prescriptions, budgeting, inventory and human resource management.

Maintaining proper health records would be important for preventive care and treatment during disease outbreaks, experts said. “If major diseases can be identified in various pockets of the city, it will make their targeted prevention and treatment possible,” Lahariya said.

But currently, clinics are not maintaining these data. Praja, the nonprofit, filed a request under the Right to Information to know the 10 most reported diseases at Mohalla Clinics, but only three of the Union Territory’s 11 districts had provided this information by February 6, 2020, they said.

City-wise disease surveillance would not be possible without every clinic maintaining patient records in the right format, the Praja report said. For instance, in response to the RTI request, one of the districts provided data disease-wise while the others only provided the total count of OPD patients.

Hits and misses

Seven states in India, including Telangana, Karnataka, Rajasthan, Madhya Pradesh, Jharkhand, Jammu and Kashmir, and Maharashtra, have started working on a similar network of centres modeled on Mohalla Clinics, the January 2020 research paper said.

Delhi itself has 450 such clinics currently operational, though the target was to have one every 5 km, which would take their number to 1,000. “When 1,000 clinics were projected as a number, it was a political statement and has always been an unrealistic figure,” said Lahariya, “These many clinics are not required and would probably also not be set up.”

Despite the proximity of Mohalla Clinics, as of July 2019, 41% of Delhi residents still relied completely on private healthcare services and 12% accessed both government and private services in 2019, found a report by Praja. Nevertheless, this was an improvement over 2017, when 47% of Delhi residents relied completely on private healthcare services, while 21% accessed both.

Part of the reason why many people do not visit Mohalla Clinics is that these clinics are, by design, equipped to provide curative and diagnostic services only. For services such as immunisation and antenatal care, for instance, patients have to visit government health centres. In fact, one critique of Mohalla Clinics is that they provide very little preventive care, no rehabilitative care, no family planning, and no education or awareness, Lahariya said.

IndiaSpend reached out to the Aam Aadmi Party but they refused to comment, saying the elections were too close and they were busy.

Despite their shortcomings, the Mohalla Clinic rollout has focused political attention on healthcare like never before, Lahariya said. “People have started feeling that providing primary healthcare is the government’s job, and this is a huge transformation. Till now healthcare was being designed from the government’s point-of-view, from the provider’s perspective. Mohalla Clinics have changed the concept of healthcare by bringing peoples’ perspectives and their needs at the centre.”

This article first appeared on HealthCheck, a publication of the data-driven and public-interest journalism non-profit, IndiaSpend.