The way forward for Delhi’s clinics

As per the plans of the Delhi government, the state should have had 1,000 mohalla or community clinics in place by end-2016. However, only onetenth the promised number had come up by the end of last year, despite health being at the top of the agenda of the elected state government.

Mohalla clinics aim to make select health services available and accessible to poor and underserved communities. As per an official report released in August 2016, nearly 800,000 people availed themselves of the health services, and 43,000 pathological tests were conducted over a period of five months. During the dengue and chikungunya outbreak in Delhi in SeptemberNovember 2016, laboratory tests were done and doctors examined people with symptoms at mohalla clinics, contributing to less crowding and panic at hospitals.

The concept has received acceptance across the political spectrum and several states (Punjab, Maharashtra, Gujarat and Karnataka, for example) and a few municipal corporations (Pune) have shown interest in launching a variant of these clinics.

This is not surprising, as primary health care infrastructure is largely non-existent in urban India. People have to go to big hospitals, which are usually overcrowded and far from their homes. They have to wait long hours, losing their daily wages, with no assurance of health care services. Alternatively, people delay seeking health care, which leads to a worsening of their health condition.

To address this, the Union government in 2013 launched the National Urban Health Mission (NUHM), which aims to have a doctor at an urban primary health centre (U-PHC) for every 50,000 people. In contrast, mohalla clinics aim to provide a doctor and a slightly lower range of services for every 10,000 people.

Until now, the lowest contact point for people to see a doctor in the health system was the 370-odd allopathic dispensaries run by the Delhi government. However, while these dispensaries have good infrastructure, utilisation of their services has remained low owing to lack of clarity on the scope of service provision, lack of human resources, and other factors.

While the design of mohalla clinics is cost-effective, their success will depend on effective implementation. Moreover, having been set up within the community with the availability of a qualified doctor, these clinics could help in eliminating unqualified practitioners. These also provide an opportunity for community participation in health care delivery.

Mohalla clinics in Delhi have been set up through a number of innovative approaches, including doctors on contract on a “fee-for-service” basis, use of rented premises, and flexible and variable clinic timings to ensure convenience. However, in recent months, there have been hiccups in setting up additional clinics, such as delays in land allotment, official approval procedures, and infighting between the Delhi government and municipal corporations over land.

While the mohalla clinics initiative had two important ingredients for success — political will and financial resources — apparently not enough was done for timely implementation. There could have been improvements in three areas.

First, no operational plan was prepared for almost a year. Had there been a road map from the beginning, the challenges might have been identified, understood and addressed. A few independent technical experts believe that the target of setting up 1,000 mohalla clinics in such a short period was extremely ambitious, unrealistic and reflected political naiveté and disrespect for processes.

Second, this was projected as a flagship state government scheme. Engagement with other stakeholders, such as municipal corporations, was not thought through. Health facilities run by the state government in Delhi serve nearly half of all people who go to any public health facility. However, allotment of land is controlled by a separate body, and getting land for these clinics had become a tug of war. The core concept of mohalla clinics as an efficient referral linkage to the next level of health facility works best when there is coordination among all agencies providing health services. Engagement with both health and non-health stakeholders is essential for success.

Third, though political parties would like to continue to be in power forever, the reality is different; following a change in government, the flagship initiatives of the previous government tend to suffer. The current government should engage with other political parties and seek to build a consensus in order to ensure political as well as financial sustainability for the programme.

Though the timeline for the setting up of these clinics has been shifted, lessons need to be learnt. The government should engage with all stakeholders; develop a detailed road map and operational blueprint, shared and agreed with stakeholders; and explore mechanisms for political sustainability.

Mohalla clinics have generated hope among the poorest of gaining access to quality health care, and have the potential to improve the way people seek health services. Above all, the success of the initiative in Delhi could focus attention on restructuring and revamping primary health care across states. That would be the real contribution of mohalla clinics to India’s health care system.

The Delhi government should develop a detailed road map and operational blueprint for the mohalla clinics initiative, and explore mechanisms for political and financial sustainability