ISSN (Online) - 2349-8846

Have Delhi's Mohalla Clinics Ensured 'Healthcare for All'?

VINAY KUMAR JHA DIGVIJAY SINGH

Vinay Kumar Jha ([email protected]) and Digvijay Singh ([email protected]) are independent researchers based in New Delhi. Vol. 54, Issue No. 48, 07 Dec, 2019 The authors would like to thank Jean Dreze for his help in conceptualising and designing the study, and also Sushant Kumar Gunjan and Paresh Kumar Lalchandani for their assistance in conducting the survey.

Delhi's mohalla clinics aim to make healthcare accessible by offering free services to all.

According to the Global Burden of Disease (GBD) study, 2015, India ranks 145 out of 195 countries in the Healthcare Access and Quality Index (Lancet 2017). This is a telling indicator, among others, of India’s failure to put in place effective and equitable healthcare services.

The GBD study has noted that, since 1990, there have been improvements in the access and quality of healthcare in India, but these improvements have not been at par with economic growth. Also, the gap in healthcare offered between the leading states (Goa and Kerala) and the laggard states (Assam and Uttar Pradesh) has further widened (Press Trust of India 2018). To some extent, this provides hope that if the political will exists, then the equitable provisioning of healthcare services can be achieved. However, political will is still elusive as the goal of spending 2% of the gross domestic product (GDP) in the National Health Policy (NHP), 2002 is yet to be met (Goel and Khera 2015). The NHP, 2017 has raised the goal of ISSN (Online) - 2349-8846

spending on healthcare to 2.5% of the GDP, to be achieved by 2025 (GoI 2017). In the past few years, there has been a steady increase in the budgetary allocation for healthcare services in India, which now stands at 1.4% of the GDP (Economic Times 2018). The Government of the national capital territory (NCT) of Delhi has also allocated 12.7% of its gross state domestic product (GSDP) on healthcare (India Today 2018). The Delhi government has shown the will to achieve effective and equitable healthcare services, at least in terms of budgetary allocation. It has also embarked on various new initiatives, including the creation of Aam Aadmi Mohalla Clinics (AAMC), to improve accessibility and the quality of healthcare in Delhi, which will be the focus of this article.

The purpose of the AAMC is to provide quality primary healthcare to the communities at their doorstep (Rao 2016). Through this, the Delhi government has added another layer in the hierarchy of healthcare. The first AAMC was inaugurated in Peeragarhi on 19 July 2015 (Lahariya 2016). To date, more than 180 clinics have been opened and the government plans to open a 1000 clinics. According to the Lancet (2016), these clinics “are successfully serving population otherwise deprived of health services.” All services are provided free of charge. To understand the working of AAMCs and their effectiveness, we visited 20 AAMCs located in various areas of Delhi from 5 November 2018 to 1 December 2018. These 20 AAMCs were randomly selected to ensure adequate coverage of different geographical areas and different types of neighbourhoods. Out of the 20 AAMCs we visited, we were able to collect information from 16 of them—two were closed, despite it being a working day, and two AAMCs refused to provide any information. The AAMC Initiative

Accessibility: Patients currently travel 2.5 to 3 kilometres (km) to reach a Mohalla clinic. This distance can be further reduced to 2 km if the target of 1,000 clinics is achieved. For low-income families and daily wage labourers, this reduces transportation costs. AAMCs have also made it easier for senior citizens and differently-abled persons to consult with a doctor. Clinics are open from 8 am to 2 pm, which suits daily wage labourers who can visit the clinic between 8 am and 9 am and then go to work. A major hindrance to these labourers was the waiting time, which has now been significantly reduced (Hazarika et al 2016).

Staffing: The required staff in an AAMC includes: (i) a doctor to check and prescribe medicines; (ii) a pharmacist to disburse the medicines; (iii) a lab technician/phlebotomist to collect blood samples for tests; (iv) an Auxiliary Nurse Midwife (ANM); and (v) a multitasking staff (MTS) to clean and keep the premises hygienic, and to also do some clerical work. However, there is an acute shortage of trained personnel. Due to this, the staff present is overstretched and hence has to work beyond their areas of expertise. The appointment of staff members to AAMCs has been adhoc: at one clinic, all the staff is permanent and had been appointed by the government, while at other clinics we found that most of the staff was hired on a contractual basis. Furthermore, at a few clinics, we found ISSN (Online) - 2349-8846

that the doctors themselves had appointed some of the staff. These variations have arisen because the initiative’s pilot, which was started with different set-ups, was supposed to run for six months, but it continues till date (Basu et al 2018). There are also inconsistencies in instructions communicated by higher authorities. For example, a doctor said that they were told that they would be paid extra if they performed the duties of a lab technician (LT) in addition to their own work. So, some doctors hired external people themselves, on their own terms, to do this job.

Staff punctuality is also an issue. Out of the four clinics we visited between 8 am and 8:30 am, only one was functioning with a doctor present, while another one was closed and opened only at 9:10 am, and the remaining two clinics were open with only one MTS present (Table 1). Furthermore, of the 16 facilities we got responses from, only four said they did not have any problems with staff shortages.

Two AAMCs were also unduly closed on a working day. At one of them, there was a leaflet stuck on the outside wall with the message reading “Clinic will remain closed on 7th and 8th November.” Upon contacting the district cell administrative authority of that AAMC, we were told that no such instruction was given to any AAMC to remain close. All the staff are from Delhi NCT, and most of them did not demands residential facilities for themselves, even though some doctors and staff members come from places as far as 30 km away from the clinics. However, a few doctors complained that they are not getting posted to clinics near to their homes, despite repeated requests.

Table 1: Staff Appointments and Attendance (in %) Present (at time of arrival during Appointed Vacant working hours) Doctor 100 0 56 Pharmacist 40 60 100 ANM 93 7 100 Staff Nurse/Nursing 47 53 86 Orderly Lab 56 44 89 technician/Phlebotomist Safai karmachari-cum- 50 50 88 clerk/MTS

Source: Prepared by authors

Facilities: Most of the clinics we visited during the survey had basic technical tools required for their day-to-day functioning. Instruments like drip stands, microscopes, and sterilisers were unavailable as the nature and purpose of these clinics do not necessitate the need for them.

There are two types of structures, portable cabins and rented apartments, from where ISSN (Online) - 2349-8846

AAMCs function. Most of the portable cabins are uniform, but rented premises vary in structure. The portable cabins consist of two rooms where one room is for the doctor to consult patients and the other room is for the rest of the staff, which also includes waiting area for patients. Rented premises had no uniform set-up. Every clinic was fitted with equipment like an air conditioner, fridge, etc. Of all the clinics we visited, 75% had continuous water supply, while the remaining 25% did not (Table 2). One doctor told us that the clinics did not have water supply due to a tussle between the Jal Board and the New Delhi Municipal Corporation (NDMC). The clinics with water supply had functional toilets, and only one clinic did not have toilet facilities. The rest of the clinics had non-functional toilets. Every clinic had regular supply of electricity. Three (18.75%) of the clinics even had electricity back-up.

Table 2: Proportion of Clinics with Selected Facilities (%) Facilities/Instruments Functional (in %) Cold storage facility (Eg. Fridge) 100 Kitchen/cooking facility 6 Running water supply 75 Electricity connection 100 Electricity back up 19 Regular electricity supply 100 Toilet 81 Examination table 100 Blood pressure instrument 100 Gloves 100 Adult weighing scale 100

Source: Prepared by authors

Patients: Given the services offered, AAMCs attract a large number of patients on a daily basis. On an average, there were 684 patients per week (114 a day). Patients from super- speciality hospitals also visit AAMCs to get tests conducted. This reduces the workload of these hospitals and does not substantially increase the workload of AAMCs as the patients get divided into various AAMC facilities. Not only migrants, but patients from the bordering states of Uttar Pradesh and Haryana also visit the AAMC facilities. Doctors provide free consultation and prescribe medicines to them. However, they cannot get diagnostic tests done as they do not have a Delhi Aadhaar card.

Medicines: As noted, Mohalla clinics disburse free medicines as per need. These clinics have 109 types of essential medicines that cover general ailments. According to the respondents, medicines come on demand and not on a fixed frequency, which helps ensure the all-time availability of the medicines. Most of the medicines are prescribed for the period of 3 days to the patients. ISSN (Online) - 2349-8846

Bookkeeping: We observed that bookkeeping was being done in a methodical manner. Bar one AAMC, we saw that records of patients, medicines distributed, etc, were instantly logged in a register. At the clinic where records were not being instantly maintained, we were informed that records would be updated at the end of the day. Some AAMCs maintained a digital record, but this was not a universal practice.

There have also been reports of fudging the number of patients as well as unnecessarily calling back a patient to inflate the numbers (Dutt 2018). At one clinic, we found that the doctor was marking the entry of those patients who had only come to collect reports.

Emergency Services: AAMCs do not have ambulances, but the doctors and the senior–most respondents interviewed said that they do not anticipate a problem in getting an ambulance on request. No doctor, however, had ever called an ambulance before.

Tests Conducted: We found that no two clinics conducted the same set of tests. There are clinics that offer all of the tests listed by the Delhi government, while there are some AAMCs where no tests are conducted. Other AAMCs are selective in the tests conducted—one doctor told us that they did not conduct urine and stool tests as containers were unavailable. One clinic collected sputum to test for tuberculosis (TB), while all of the other AAMCs referred TB–related cases to directly observed treatment short course (DOTS)[1] centres.

Table 3: Proportion of Clinics Offering Select Tests (in %) Haemoglobin (Hb) 81 Blood type 81 Blood Sugar Level 81 Urinalysis 75 Pregnancy test 69 Stool examination 63

Source: Prepared by authors

Quality of Healthcare Provided: As mentioned earlier, there is a significant patient load on the clinics. On average, 114 patients visit a single AAMC in a day. Generally, the examination time available to doctors is about five hours. Even though the clinics are open from 8 am to 2 pm, most doctors come in late and also take long breaks (for tea, etc) during the day. Doctors are incentivised to see as many patients as possible, as those who are on contract are paid on a per-patient basis. On average, a patient receives two to three minutes of consultation, which includes the time taken to write prescriptions. This limited amount of consultation time may lead to a misdiagnosis and the overprescription of medicines. This will not only weaken the trust that patients have with doctors, but in the long run, may also lead to increased drug resistance. India already has a high antimicrobial resistance (AMR) to common antibiotics, one of the highest in the world (Chowdhury et al ISSN (Online) - 2349-8846

2018). These issues could defeat the very purpose of AAMCs.

A majority of patients in AAMCs are from lower middle-class backgrounds, and are vulnerable as receiving treatment from quacks has made them gullible and inclined towards taking medicines for any symptom. These habits are being reinforced in AAMCs as doctors do not spend enough time treating patients. Patients from this socio-economic strata tend to feel that if a doctor does not prescribe them medicines, then they have not been properly checked. We questioned a few patients at each of the 16 clinics, and most said their expectations were being met. Only one patient was unsatisfied, their reason being that they were no longer being prescribed the same medicines they received in another hospital. There is a possibility that the patient load will substantially decrease once all of the envisaged 1,000 AAMCs are operational, but the Delhi government needs to meticulously plan the functioning of these clinics to be able to effectively treat patients.

Political Meddling: A few doctors said they are pressured by politicians from the party in power to show as many patients as possible in the register. We were unable to verify this, but, as mentioned earlier, it is in the doctors’ interest to see as many patients as possible. Some locals also told us that, at times, workers affiliated from opposition parties create a ruckus in an attempt to disturb the proper functioning of the clinic. The clinic staff, however, were unsure if these people were party workers. Nonetheless, this creates a security problem.

Another issue brought to our attention by one of the doctors was how doctors of the central government and state government have separate agendas, which affects the functioning of the clinics. This doctor said that he was not being remunerated properly, and dues were not being cleared on time. Ananya Basu (2018) has noted that despite the Delhi government playing a crucial role in the healthcare system, it does not have the proper say even in policy terms.

Compulsory Aadhaar for Tests: To avail free tests offered by an AAMC, it is compulsory to produce an Aadhaar card. This is an issue for migrants as more often than not, they do not have a Delhi Aadhaar card. Thus, they cannot avail AAMC services. On inquiry, a doctor told us that the private labs, which conduct the tests do not provide reports if the samples are not linked with an Aadhaar card. This goes against the Supreme Court’s ruling. The feasibility of extending AAMC services to all Delhi residents, including those without a local Aadhaar card, is worth examining.

Quacks: Despite being a metropolitan city, Delhi has a number of quacks operating in its midst. Their clients are mostly people who do not have much knowledge and means. Some patients who used to visit quacks are now visiting AAMCs instead, as they know that a government institution will have certified doctors, coupled with the fact that AAMCs are at their doorsteps. This has led to substantial decrease in practice as well as numbers of quacks (Rao 2016). However, a more detailed study in this regard is needed. ISSN (Online) - 2349-8846

The AAMC Impact

The Delhi government’s AAMC initiative has won appreciation from various leaders across the world. This initiative has the potential to revive citizen’s faith in public healthcare, but many improvements are required. The AAMC initiative can improve government accountability to provide healthcare as a basic necessity. Furthermore, other state governments like Maharashtra, Gujarat, and Karnataka, among others, are also planning to start clinics along the lines of the AAMC (Lahariya 2017). This can be seen as one of the biggest achievements of the AAMC, as it has brought healthcare into the mainstream political discourse and has made state governments (on whose mandate the health services fall) more serious towards healthcare.

However, much remains to be improved. AAMCs need greater uniformity in staffing, services and functioning. As far as possible, staff members should not be hired on a contractual basis as this dilutes their overall responsibility, and thereby denies patients proper care. The Delhi government should also bring the services of family planning including prenatal care, postnatal care, and the the distribution of contraceptives within the AAMC, fold. Also, the clinics can be used for other health-related services after the timings of clinics. Another aspect that needs to be taken care of is to increase the visibility of the AAMC, which would in turn increase the reach of this initiative among masses. We spoke to many people from various places who lived around an AAMC's vicinity and realised that most of them had no idea about their location.

The provision of having mandatory Aadhaar Card of Delhi NCT goes against the principle of universal healthcare for all citizens, and other accredited ID should be equally valid. The Delhi government has a laudable target of opening a 1,000 clinics but the number should not derail its commitment to provide quality healthcare services. While setting up new clinics, the government should ensure adequate resources, including a qualified staff.

End Notes:

[1] A commonly-used strategy to control tuberculosis efficiently and in a cost-effective manner.

[2] HMIS is a health database that keeps all health related data of patients. It helps doctors and decision-makers in taking effective decision for managing the health problems.

[3] In Antimicrobial Resistance bacteria modifies itself in a way that it reduces or eliminates the effectiveness of the medication which earlier was effective in treating the bacteria- related ailments.

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