Will Delhi's mohalla clinics be a viable replacement for overcrowded government dispensaries?

Any visitor to the Aam Aadmi mohalla clinics being set up in Delhi will be left in no doubt that they have been established by the ruling Aam Aadmi Party. At the entrance of each clinic, visitors are greeted with a massive board bearing the faces of Delhi Chief Minister Arvind Kejriwal and Health Minister Satyender Jain.

These mohalla clinics are the first level of the Delhi government’s "three-tier public health roadmap" to make healthcare accessible to all, and to reduce crowding at government hospitals. Since the plan was introduced last year, 100 clinics have been opened. They are expected to offer primary healthcare like basic consultations and medicines. The second tier will consist of polyclinics offering specialist care and a wider spectrum of diagnostics including X-Ray and ultrasound. Patients who need surgery or hospitalisation are referred to the final tier – government hospitals.

Health a priority

Health Minister Jain said that his party was serious about healthcare. The Delhi government has allocated 16% of its total budget for health as compared to just about 1.5% in the Union Budget.

Despite this, the Delhi government’s planned per capita public health expenditure for 2016-'17 is less than the amount recommended by the Planning Commission (Rs 3,800) but more than the 2013-'14 figure (Rs 1,775). "According to the Delhi budget 2016-'17, the per capita public health expenditure is about Rs 2,600,” said Ravi Duggal, country coordinator, International Budget Partnership.

Some states and Union Territories particularly Sikkim (Rs 4,090), the Andaman and Nicobar Islands (Rs 5,154) and Lakshadweep islands (Rs 6,665) score better in terms of per capita public health expenditure in years 2013-'14.

Ambitious plans

A mohalla clinic as envisioned by the Aam Aadmi government, is different from the government dispensary, which is usually a bigger space with a waiting area and several rooms. While a dispensary costs about Rs 3 crore to set up, a mohalla clinic can be set up with just Rs 20 lakh. The Delhi government uses pre-fabricated, semi-permanent portable cabins that can be assembled anywhere for these clinics.

So far, three are in government premises, while the others are in rented spaces. AAP aims to set up 1,000 such clinics by the end of the year. “For every dispensary which targets 50,000 people, there must be five mohalla clinics,” said Dr Arun Banerjee, additional director, planning, Directorate General of Health Services, Delhi. Similarly, there are 150 polyclinics planned, of which 22 are already operational.

If the mohalla clinic experiment works, the government has decided to do away with dispensaries completely.

For the mohalla clinics, the government has empanelled private doctors who are paid Rs 30 per patient. “We targeted doctors who want to do social service, or maybe women who stopped working after marriage, and now want to work,” said Jain.

Medical officers employed by the state government have been placed in the three permanent mohalla clinics in Peera Garhi, Nathupura village and Mandavali.

Gynaecologist Surupa Ranjan, who works at the Krishna Nagar mohalla clinic, also has a private practice in Dilshad Garden in northeast Delhi. She decided to take up the mohalla clinic job as she always wanted to “serve the public”. She spends at least five to seven minutes on each patient. “If the infrastructure is as good as it is now, it will work,” said Dr Ranjan. “They have to keep up with the supply of medicines and have enough staff to help us out.”

In Munirka village in South Delhi, Dr Shoebul Haque, is a recent medical school graduate. He signed up for the mohalla clinic here as it gave him some time to study for his post-graduation (the clinic runs only one shift from 8 am to 1 pm.)

New wine in old bottle?

Few public health activists agreed to comment on the Aam Aadmi Party’s approach to primary healthcare because the initiative is still new.

But Dr Chandrakant Lahariya, a public health expert who advises the government on mohalla clinics, said it was the need of the hour.

“There is no comparable example anywhere in the world in case of mohalla clinics,” said Dr Lahariya. “But the underlying principle is similar to primary healthcare. Primary healthcare means health servicing that should be available at the doorstep of people for the needs of people at an affordable cost with sufficient participation of the community. It need not be high cost or high technology. There are many ways you can achieve this. Mohalla clinics are one of them.”

In his opinion, dispensaries are standalone facilities, so patients prefer to visit tertiary care [hospitals] or private clinics. He added that since most of India’s health sector was private, it was crucial to rope in private doctors.

However, public health experts said that a public-private partnership had its risks. For one, "involving the private sector usually tends to increase expenditure", said Duggal.

But Dr Amit Sengupta, national convener of the Jan Swasthya Abhiyaan, an umbrella network of public health organisations, questioned why all solutions for public healthcare needed to be rooted in public-private partnership.

“Why is there a total barrier to hiring full-time staff?” asked Dr Sengupta. “If the system is capitation based, there are both pros and cons. There could be a conflict of interest. The clinic could become a way in which doctors get patients [for their private practice]. We need procedures to guard against this.”

Dr Sengupta said that the Aam Aadmi Party’s attitude towards healthcare was a classic instance of do-gooders without a plan. “By introducing mohalla clinics, they are creating a new tier of healthcare delivery without looking into the existing one,” said Dr Sengupta. “What do we do about the existing tiers? Why not strengthen the dispensary itself?”

Duggal concurred: “Completely replacing the dispensary would involve additional capital expenditure.”

But Dr Sengupta added: “At least they are doing something.”

This is the concluding article of a two-part series on public healthcare in Delhi. The first article can be read here.