ISSN (Online) - 2349-8846 Delhi’s Mohalla Clinics Hold the Potential to Significantly Improve Access to Quality Healthcare ARNAV SETHI POOJA SHARMA TANISHA AGRAWAL SHUBHRO BHATTACHARYA Arnav Sethi is an M Phil research scholar and Junior Research Fellow at the Department of Sociology, Delhi School of Economics. Pooja Sharma completed her master's in public policy from St Xavier's College, Mumbai. Tanisha Agrawal and Shubhro Bhattacharya are master's students in economics at Université Paris 1 Panthéon-Sorbonne, Paris, France. Vol. 55, Issue No. 40, 03 Oct, 2020 In 2015, the Aam Aadmi Party-led Delhi government introduced “Aam Aadmi Mohalla Clinics” to provide affordable basic healthcare to marginalised sections of society at their “doorsteps.” This paper evaluates the effectiveness of the programme based on a survey of 493 respondents. We found that while AAMCs partially meet their stated objectives, several areas need urgent attention including lack of information about clinics, casteism by doctors and property owners, and availability of services. In 2015, the Aam Aadmi Party-led Delhi government introduced “Aam Aadmi Mohalla Clinics” (AAMCs) to provide affordable primary healthcare to marginalised sections of society at their “doorsteps.” Specifically, the initiative sought to provide free medical consultations, medicines, and diagnostic services. One mohalla clinic was intended to serve a population of 10,000 low-income and poor residents within the vicinity of two to three kilometres (Lahariya 2016). AAMCs sought to bring about a radical shift to a more ISSN (Online) - 2349-8846 decentralised four-tier system from a three-tier system (Raju 2019): 1. Primary healthcare: AAMC 2. Secondary healthcare and Outpatient department (OPD) services: multi-speciality poly clinics 3. Inpatient department (IPD) care: multi-speciality hospitals 4. Tertiary healthcare: super-speciality hospitals In the previous three-tier system, primary healthcare was delivered through dispensaries, secondary healthcare was delivered through multi-speciality hospitals, and tertiary healthcare services was delivered through super-speciality hospitals. Government dispensaries performed the function of the first two tiers of the four-tier system and were overburdened. Moreover, the cost of setting up a dispensary is Rs 3 crore, whereas the cost of setting up a mohalla clinic is just Rs 20 lakh (Rao 2016). This paper seeks to evaluate the programme’s effectiveness in meeting the needs of beneficiaries on parameters including perceptions about quality of healthcare and services provided and waiting time. Primary Research As of June 2018, 158 mohalla clinics were functional (Directorate General of Health Services 2018). We conducted surveys from June–August 2018 at 25 clinics (that were chosen based on a weighted sampling method).1 We visited the nearest urban poor settlement to each of the 25 clinics respectively and interviewed about 20 respondents (all ever-married women) at each settlement. We used a convenient sampling method to identify respondents, and took informed verbal consent from every participant. The study was finally concluded with a sample size of 493 ever-married women. We choose ever-married women because our pilot survey revealed that male respondents were usually not available at home in the daytime due to their employment in both formal and informal jobs. Based on our findings, two key factors impacted the accessibility of clinics: the distance between clinics and households, and the availability of information about the location, functioning and operating time of clinics. Of the respondents to our survey, only 66% had heard about the clinics, about 55% were aware about the services provided by clinics and around 40% had ever visited a clinic. These results are dismal, especially considering the fact that almost 80% of the 25 settlements we studied were situated within a kilometre distance from clinics. Among respondents who had heard about the clinic, almost 40% had said that they had not visited the clinic because of the lack of information. Some assumed AMMCs were administrative offices of local municipalities, while others thought they functioned as offices for the AAP. Even those who believed they were medicine dispensaries were not aware that qualified doctors were present in the clinics. The Delhi government needs to be more effective in sharing key information about the clinics among the intended beneficiaries. This is underscored by the finding that after learning about the scheme through our survey, ISSN (Online) - 2349-8846 almost 60% of the respondents who had never visited AAMCs indicated that they were willing to visit a clinic. Two of the main objectives of the AAMCs are to ease the burden on public hospitals and reduce overcrowding (Sharma 2016). Around 50% of the respondents who visited AAMCs had previously been visiting public healthcare facilities for their primary healthcare needs. To reduce the burden on secondary and tertiary healthcare facilities, AAMCs should strengthen the referral mechanism. Indeed, in our sample, only 26 out of 193 respondents (about 13.5%) were referred to either a private or a public healthcare unit for advanced treatments. A popular way to access primary treatment—apart from private facilities near settlements—was from unqualified practitioners, who are operating under the colloquial name of “Bengali doctors.” While such practitioners are prohibited from practising under Section 27 of the Delhi Medical Council (DMC) Act, 1997, almost 30% of the respondents had visited or continue to visit these clinics. Another disturbing finding is that nearly 47% of respondents who were visiting unqualified practitioners were prescribed unlabelled medicines which could contain harmful substances. A positive finding is that about 17% of the respondents switched to AAMCs from unqualified practitioners, suggesting that the scheme has the potential to reduce the dependence on unqualified practitioners. Proximity Impacts Accessibility We found that distance was the main reason people shifted to AAMCs. Forty-five percent of respondents who had heard about the clinics learned about them because of their proximity to their households. Indeed, AAMCs were located in closer proximity than public facilities for 90% of the respondents. Almost 57% of the respondents singled out proximity as a factor for shifting to AAMCs from their previous healthcare facilities for primary healthcare. One justification for this preference is that travel expenses and time spent are usually determined based on distance to healthcare facilities. Our findings, therefore, underscore the importance of having healthcare facilities in close proximity to marginalised groups, especially women because their mobility is restricted and regulated due to patriarchal norms. Figure 1: Reasons for shifting to mohalla clinics ISSN (Online) - 2349-8846 Source: authors’ research based on a sample of 493 respondents How Well Are Clinics Functioning? Waiting time: Almost 91% of the respondents said they experienced shorter waiting times during their visits to AMMCs compared to other public healthcare facilities. However, 51% and 53% of the respondents said they experienced longer waiting times during their visits to AMMCs compared to private clinics and unqualified practitioners, respectively. Doctor’s performance: Between 65%–67% of the respondents who were visiting other public centres, private centres, or unqualified practitioners conceded that doctors at AAMCs performed better than or at par with the facilities they previously accessed. This suggests a step towards the right direction in establishing trust with the programme’s intended beneficiaries. However, a proportion of respondents are unhappy with the services. Indeed, our findings suggest that about 23% of respondents are either not sure or are unwilling to visit the clinic in the future. The social and economic status of patients impacts the doctor–patient interaction and quality of healthcare they receive. Respondents reported incidents where AAMC doctors refused to touch patients or use a thermometer because such doctors believed in casteist notions of purity and pollution. Health practitioners overwhelmingly and disproportionately belong to upper and middle castes (George 2015). They often assert a pattern of dominance. Ensuring adequate representation of doctors from oppressed castes can enhance the accessibility of healthcare for marginalised caste groups. There were also instances of large-scale segregation within slums, most notably against Dalits, particularly Valmikis and Chamars. This has also led to discrimination in terms of healthcare access since some upper-caste houseowners stopped people from oppressed castes from entering clinics that were operating on their property. Porta-cabins and rented apartments: The Delhi government had initially planned to set ISSN (Online) - 2349-8846 up porta-cabins2 adjacent to notified informal settlements. However, this plan became increasingly difficult to implement because of a lack of availability of space, and a prolonged tussle between the central and state government on land acquisition. Thus, the Delhi government began renting apartments and retrofitted them with the necessary infrastructure. Out of the 25 clinics that were a part of this study, we selected 12 porta- cabins and 13 rented apartments. While on paper, both types of property are supposed to function the same way, our findings suggest a difference in their services (Directorate