Mohalla Clinics trying to fill the ‘Health for All’ gap in Neoliberal times | Priyanka Yadav

by Priyanka Yadav *

FOR YEARS OUT-OF-POCKET expenditure on health care has been the highest among the total health expenditure in India. The National Health Accounts Estimates 2018-19 observed that the total health expenditure was 3.2 per cent in the year 2018-19, whereas out-of-pocket expenditure in the same year was 48.2 per cent for an average Indian. It is a given that the individual aims to avail of the best health services he can afford. After all, today, health is a commodity.

Although there was a decline in the out-of-pocket-expenditure for four years, from 2014 to 2018, the figure continued to be high due to structural reasons. Health services in India are provided by private health players, and government expenditure on health care directly or through spending on insurance schemes has been low. Health care also involves personal preferences and costs depend on that too. A May 2020 study found that ‘medicines contributed the largest share of OOPE. Nonmedical costs were a significant component of health expenditure. Annual outpatient expenditure on medicines, diagnostic tests, and nonmedical costs was higher than annual inpatient expenditure’. Two years of the Covid pandemic has only helped reiterate this finding.

This reality, however, contradicts the fundamental promise of the Indian constitution, which guarantees health as a primary right under article 21 (right to life). The discourse has shifted from rights to commodities, as privatisation has led to negligence by governments in providing all primary and affordable health care. Indeed, this contradiction in theory and practice is nothing but the denial of fundamental rights and in opposition to the Alma Ata promise, ‘Health for All’. The Bhore Committee Report of 1946, the Alma Ata Declaration 1978, and The National Health Policies of India have all emphasised the need for universal health and ‘Health for All’’. However, the importance of this goal has not been realised yet.

The Idea of Mohalla Clinics 

Since India’s participation at the healthcare conference in Kazakhstan, Public Health Centres in villages and urban areas has been the model the government has officially supported. Today there are 50,000 PHCs in the country offering basic healthcare. Obviously, this is not enough, nor adequate for 1.4 billion people and expensive private healthcare has thrived.

The Aam Aadmi Party’s innovative intervention since 2015, called the Aam Aadmi Mohalla Clinic, aims to meet the ‘Health for All’ target in the national capital city of Delhi, with a population of 20 million. These clinics provide primary care facilities in communities at affordable rates and within accessible reach. At the time of writing this article, there are more than 520 such clinics spread across Delhi. The Aam Aadmi Party claims that once they achieve their full target of 1000 operational Mohalla Clinics, these will be instrumental in decluttering government hospitals, which can enable government hospitals in Delhi to focus on in-patient care.

Certain features of these porta cabin-structures have attracted national and international attention, like Accessibility. These clinics are located within the community/locality, serving a specific population size, making access hassle-free and smooth.

Affordability: As mentioned earlier, India’s healthcare expenditure is high. Private hospitals charge much higher than government hospitals for treatment of the same ailment, and higher charges do not assure better quality. AAMC’s services of free medicine, free diagnosis and free lab tests have enhanced their impact within communities. A total of 212 lab tests are provided for free, and a good stock of nearly all sorts of primary care medicines and a trained pharmacist, lab technician and qualified doctor are available at these health facilities.

Access For Women: Another extremely crucial dimension of AAMCs is that it has made access to medical services for women hassle-free. This point has to be understood a little more elaborately. For women dependent on their family or spouse, it is difficult to reach out to a hospital or health centre independently unless their problem has not been aggravated. Moreover, stay-at-home wives/mothers usually cannot find the time to wait long hours at hospitals, which only prevents them from availing of critical intervention when needed. When the ailment becomes acute, the women take the pain of reaching out to a health facility. However, with the advent of Mohalla Clinics in the neighbourhood, women are confident of reaching out to this facility independently and avail health services in a manner such that any major ailment gets nipped in the bud. Therefore, Mohalla Clinics have indirectly helped in the medical empowerment of women.

Quality professionals: A long-time problem in India’s healthcare system has been the success ofunderqualified, unprofessional and untrained doctors. AAMC has filled this gap by providing quality services, medicines and lab tests free of cost. However, a much more detailed study in this regard is needed. Delhi Government hires Doctors for Mohalla Clinics on a contractual basis after going through a walk-in-interview process. The candidates who appear for the interview are not just retired doctors or candidates looking for part-time work but serious candidates willing to serve at these clinics. Transparency and accountability of the doctors are maintained by the reimbursement policy fixed by the government.

AAMCs Reduce the burden on tertiary care sector: Health systems and infrastructure work at three levels in India: Primary, Secondary and Tertiary Care facilities. In practice, India does not have a strong primary care infrastructure for various reasons like scarcity of funding, lack of infrastructure, poor access in remote locations and lack of human resources. These constraint have led to poor and pathetic conditions of primary health care structures in India and, by default, this burdens the tertiary and secondary care centres. Mohalla clinics have helped enormously by providing primary care in this problem scenario. AAMCs are located within the community; they provide basic primary care for minor and serious illnesses. All sorts of medicines are available here, and basic lab testing facilities are available free of cost. Most of the problems are addressed at the primary level, and only ailments which require tertiary attention reach bigger hospitals. AAMCs help in filtering patients who require primary care from the ones who need tertiary care, thereby reducing the burden of bigger hospitals.

Referral Services: As primary care unit, AAMCs provides every kind of basic health care facility; however, sometimes, there is a requirement for advanced medicines, tests or diagnoses for which one looks up to the tertiary or secondary care unit. Doctors at Mohalla Clinics not only guide the patient for tertiary care but can make a referral to any polyclinic or government hospital in Delhi.

Provides Primary Care: Mohalla Clinics function as primary care units to provide all basic minimum health care facilities to the respective community. A structure, to be regarded as primary care unit, needs to fulfil a certain criterion. It should cater to a certain number of people and have a basic ‘minimum’ care facility for minor and serious ailments. It should be located within the community and not only provide curative but preventive care in a manner that not only serves the health of the individual but also of the community at large. Mohalla Clinic, for now, fulfil all these criteria except for facilitating preventive care. So Mohalla Clinics are structures of primary care serving people within a locality.

Quality Infrastructure: Mohalla Clinics are located in porta cabins or rented apartment structures. With a waiting area for patients, a cabin for doctors, and space for lab tests and pharmacists. The clinics have utilised the campus area well in some areas for beautification and medicinal purposes. The cost of having a Mohalla Clinic is lesser than establishing a brick-and-mortar structure of a hospital or clinic. Mohalla clinics are located well within the community, clearly visible and accessible.

Doctor-Patient Rapport: These patients who visit the clinic are recurring patients whose patient history is well known to the serving doctors. This mechanism helps maintain a doctor-patient rapport where the doctor can understand the root cause of the problem and prescribe treatment according to each patient’s health condition, which is an effective method of health care delivery, similar to general practitioners in the United Kingdom under the NHS.

Limitations

No model can be absolutely perfect. Working models grow out of policies amended and improved in stages. They grow gradually if they accommodate their limitation. There are certain shortcomings of the Mohalla Clinic structure too.

 Infrastructure: It is praiseworthy to see how these clinics function in porta cabin structures and rented properties. However, these structures have certain limitations; for instance, the rented properties are too small and congested and lack patient waiting area, with no space to even stand. Fieldwork at these clinics in the rented property revealed that there was space only for stock and the staff to sit; patients either crowded near the doctor’s cabin or queued up on the road before the cabin. Porta cabins were relatively spacious; however, the patient waiting area was still small. Some clinics extended outside without a proper shed or wall, making it difficult for the patients to access the clinic during monsoon or peak summers.

Healthcare Facility: As of now, most clinics are equipped with almost every kind of primary medical facility. The field survey, however, found increasing demand for gynaecological and health services for women and child care.
Security/Safety: Many Mohalla Clinics were located in a remote locations with stocks of medicine, expensive medical instruments and other furniture, without any security or safety. One clinic reported many instances of theft. In some cases, theft was reported of syringes and other medicine, facilitating illegal activities like drugs and addiction.

Human Resource: Mohalla Clinics in prime locations received a good number of patients daily; sometimes 150 patients would visit a clinic during one shift. However, the staff available at these clinics is limited and cannot really handle the rush. Clinics that receive higher footfall can be equipped with increased staff to handle matters effectively.

Reimbursement: At Mohalla Clinics, doctors are recruited on a contractual basis with no fixed salary but reimbursement. They are paid according to the number of patients seen per day, which is 40 rupees per patient, which is less than a government clerical job rate. This payment per patient is a complex policy to maintain and a data entry is needed to keep account.The pharmacist and the multitask workers have fixed salaries; however, they do not have leave provisions.

 Cleaning/Maintenance: These clinics do not have cleaning staff who can look after daily cleaning and hygiene at the clinic. A multitask worker is present, but cleaning remains undefined and thus is left undone in many places. In some areas where the doctor and staff are responsible, they take care of it, but cleaning is not a priority at other facilities. This is a matter of concern, especially during pandemic time. A similar situation is observed with the maintenance staff, and the facility is provided with many electronic and medical devices; however, there is no provision for repairing appliances or electronics in case of emergency. No institution or person is deployed for this task, making it difficult for the staff members to operate.

Improved facility for Recording Patients’ Medical History: These clinic function in a defined area, dealing with a limited number of populations. Most of the patients come again and again. It is easier for doctors working at AAMCs to track the patient’s medical history than for doctors at more prominent hospitals. However, most of the time, doctors at these clinics are not equipped or trained to record patient medical history. Some doctors are in such practices at facilities, purely due to their interest and primarily rely on their memory. If the arrangement to record patient medical history is improved, with specific equipment and human resources, it can bring a good change in dealing with specific populations and community health care challenges.

Conclusion 

The reasons which make AAMCs a unique model have been listed with its limitation. These combinations of factors have led to the success of AAMCs in Delhi, with other States looking forward to replicating the same model. Apart from being a policy success, AAMCs have strengthened the larger goal of ‘health for all’ in this Indian city. Moreover, it has extended Article 21 of the constitution, which is the Right to Life, to every citizen in an institutional manner.

Right to health is an undefined right but has been evoked repeatedly under Article 21. Post-liberalisation, this right has been compromised severely by the government and private players equally. The worst-affected group has undoubtedly been the underprivileged and the marginalised. The commodification of health care post-neo-liberalisation has denied many underprivileged their fundamental right to health which is constitutionally their due. AAMCs have been able to make critical interventions in this area. By providing quality care at affordable costs or no cost at all, AAMCs have improved the quality of life for the vulnerable section of society, thereby ensuring respectable life and health for all.

While the party and clinic have done well in this regard, the Aam Aadmi Party (AAP) needs to have a clear social vision which becomes the primary anchor in the functioning of this health policy. If the party aims to run this service model effectively, becoming a key player in the health system, it needs to think of a working strategy even if it is not Delhi’s ruling party. They need to address the limitations and work on them seriously rather than focus on increasing the number of clinics. It is for the party to ensure that quality is not compromised in search of quantity. Moreover, a crucial intervention like this should become instrumental in bringing a revolutionary change in healthcare. If these limitations are not accommodated well by AAP, then fear of this policy becoming history or losing its quality will persist.

(Author: Priyanka Yadav is a research scholar at the Centre for Political Studies JNU. Her area of interest ranges from political economy, political theory, political philosophy and thought. Currently, she is doing a case study of the Aam Aadmi Mohalla Clinics for her PhD.)

(Conflict of Interest Disclaimer: This article is based on independent and academic work and has not in any way been supported by any entities related to Aam Adami Party)

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  This cross-sectional study of 43 781 inpatients and 8914 outpatients found that medicines accounted for 29.1% of inpatient and 60.3% of outpatient OOPE; nonmedical costs, such as travel, lodging, and food, accounted for 23.6% of inpatient and 14.6% of outpatient OOPE; share of OOPE from doctor consultation and diagnostic test charges increased with socioeconomic status; and annual outpatient costs were a greater proportion of annual income of households than annual inpatient costs.
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[This article was edited by Papri Sri Raman]