Abstract
The study presents a case study on service operations and service quality aspects of Mohalla Clinics, the public healthcare service setups in the innermost densely inhibited, yet unserved urban neighbourhoods of National Capital Territory of Delhi. It also describes the scalability consideration of public healthcare services. The case presents analysis of operational challenges in delivery of public healthcare services in developing countries. It characterizes the public healthcare service offering by the elements of service package and illustrates the adoption of service blueprint as a tool for service process planning. Additionally, it allows to comprehend the phenomena of quality management in healthcare service delivery and adoption of technology-driven innovations in healthcare service delivery. The case illustrates the challenges of healthcare operations and health service design in the low-cost and high-volume environments.
Introduction and Background
An e-rickshaw driver from Dilshad Garden suburb of National Capital Territory (NCT) of Delhi, Ramesh Kumar was tired of standing in long outpatient queues of the government hospital for the treatment of his prolonged skin infection. This long waiting times had been taking him off the road for long hours and negatively impacting his income. Also, getting treated at a private hospital was not an option due to exorbitant treatment costs. However, Ramesh felt blessed after the opening of a Mohalla Clinic (MC) close to his house in the Dilshad Garden suburb. MCs were set up in Mohallas, the unserved urban neighbourhoods in Delhi under the MC Scheme, 2015, of the State government, with the aim to offer low-cost and affordable primary healthcare. Since the setup of first MC at Peeragarhi relief camp, an urban slum area in North-west Delhi, 300 MCs were functional by January 2020 across 11 districts of NCT offering outpatient services to an estimated 90–100 patients per day (Lahariya, 2017). Located within 5-kilometer distance of underdeveloped localities with a population of 10,000, MCs offered diagnosis, consultation, medicines and pathological testing services. These clinics functioned from portacabins (pre-engineered and movable box-shaped structures) or rented premises and were installed at a miniscule cost of US$28,000 per clinic (Ahmed, 2017). The operational design of the clinic was backed by many healthcare innovations such as fee-for-service payment model for healthcare staff, portable clinic infrastructure and medical technologies for minimizing the patient turnaround time. It was purported that MCs have worked towards reducing household out-of-pocket medical expenditures and reduction in the workload of secondary and tertiary services in the capital state of Delhi (Sah et al., 2019). Nevertheless, the implementation of MC scheme was confronting several operational-level challenges associated with adequate staffing, location and inventory management. Hitherto, many other Indian states expressed their interest in replicating the MC scheme for delivering affordable healthcare to low-income population. Global public healthcare experts had also advocated the extension of Delhi’s MC model to other Indian states and countries underserved dense population and privatized healthcare services (Lahariya, 2017). Like Ramesh, there was a vast urban population in need of an affordable primary healthcare across the various states of the country. Given the current accomplishments and challenges of MC model at Delhi, what remains to be evaluated was whether MC would turn out to be a sustainable solution for delivering primary healthcare to low-income patients falling outside health coverage; and whether MC was a scalable model for primary healthcare delivery across other states?
Public Healthcare System in India: An Overview
The Indian healthcare sector was growing at a compound annual growth rate of 16–17% to reach US$132.84 billion by 2022 (from US$61.79 billion in 2017) (India Brand Equity Foundation, 2019). The sector comprising public and private healthcare providers offered services pertaining to diagnosis and treatment, disease prevention, rehabilitation and health promotion. While the government was the dominant stakeholder of primary healthcare, the private sector was a major contributor to secondary and tertiary healthcare. This was indicated by the fact that 70% of bed capacity and 60% of in-patient care in the country was provided by private service providers. However, the reach of these private healthcare services was limited to middle- and high-income population living in metro and tier-I cities. Low penetration of health insurance (52% of insured population in 2017–2018) could be attributed to the unaffordability of high-priced private healthcare services. Without any medical coverage, most of the Indian population availing private healthcare services relied only on out-of-pocket expenses, which were as high as 61% (US$4,452 billion) of total health spend in 2016 (FICCI & EY, 2019). Thus, a vast Indian population falling under low-income category was dependent on state-provided public healthcare for meeting their primary healthcare needs. Figure 1 shows the trend on out-of-pocket expenditure by Indian households between 2000 and 2018 based on World Bank data.
As in a federal country, the accountability of public healthcare delivery system in India was quite fragmented. It was being administered by multiple agencies functioning under the centre, state and Local governments. Operating under the purview of Center government, the Ministry of Health and Family Welfare (MoHFW) was responsible for the implementation of national level program for family welfare and prevention of communication diseases. At state-level, Department of Health and Family Welfare (DoHFW) worked for the governance and operations of public healthcare facilities in the state. Other healthcare services with wider effects such as medial education and quality control of drug and pharmaceuticals were governed by both State and Center governments. Additionally, the local municipal corporations shared the responsibility of local health and sanitation in their respective constituencies. Figure 2 shows the public healthcare administration system in India. Despite government’s commitment towards public healthcare sector, the spending on healthcare was merely 1.15% of gross domestic product in 2018. It was much lower than that in many low- and high-income group countries (average 6.3% in 2016) (World Health Organization, 2019).
A Multi-tiered Approach to Community Health 1
A multi-tiered system of community-level primary healthcare facilities had been established as an effective and low-cost approach for reaching out to greater number of people in the developing countries (Hussein & Collins, 2016; WHO, 2016). As per WHO estimates, most of the serious health problems faced by developing countries were either preventable or curable by the provision of simple, inexpensive and timely healthcare provided through community-level healthcare facilities (WHO, 2016). For a developing country such as India, providing an assured nation-wide access to healthcare was challenging for the Federal government. Thus, to bring primary healthcare closer to the underserved population of the country, a three-tiered system for the provision of healthcare was adopted. Figure 3 shows the three-tiers of Indian healthcare system. At the first level were the sub-health centres or sub centres (SCs), while primary healthcare centres (PHCs), community healthcare centres (CHCs) and district hospitals (DHs)/sub-divisional hospitals (SDHs) were functioning at the secondary level, and research institutes/medical colleges (second-level referral unit) were working at the tertiary level.
SCs and Urban PHCs
SCs were the initial points-of-contact established in semi-urban and rural areas with a population of 5,000, primarily for extending the coverage of the public healthcare system. These community-level health facilities administered by the MoHFW were modestly equipped to offer maternity and family welfare services. They are typically staffed by locally recruited community health workers called Accredited Social Health Activists (ASHAs) and Auxiliary Nurse Midwife (ANM), who were trained for six months to 2 years for antenatal care and health programme. These health workers provided immunization services, care of newborn, midwifery, supervision of pregnancy, care for endemic diseases and emergency care for minor injuries. They were dependent on PHCs and DHs for guidance and trainings. Nevertheless, in 2019, there were only 160,751 functional SCs against the Indian Public Health Standards (IPHS) expectation of 240,155. Problems with this inadequate number were exacerbated by an acute shortage of healthcare workers at these centres (27,964 vacant positions of ANMs in 2018) (FICCI & EY, 2019).
Urban PHCs comprised the dispensaries and polyclinics functioning in urban areas with population of 30,000. These were maintained by DoHFW with the purpose of diagnosis and treatment. As per IPHS guidelines, these centres were staffed with a medical officer and supported by nurses and other paramedics (MoHFW, 2012). These were equipped to provide out-patient services as well as limited in-patient services (4–6 beds). These acted as the referral unit for 5–6 SCs operating in the block. However, not only were 37% of these PHCs active, but they were also severely unstaffed (FICCI & EY, 2019). The shortage in the capacity of public healthcare at primary-level was creating excessive workload on the secondary-level service centres, resulting in long waiting time, poor service quality and, eventually, high dissatisfaction among patients.
CHCs and DHs/SDHs
Serving as the first referral unit at the block-level for the neighbourhood 4–5 PHCs, CHCs were designed to offer routine and emergency care services in medical specialties such as medicines, paediatrics, gynaecology and surgery to both outpatients and inpatients. They also had the responsibility to promote national health programmes within states and union territories (UTs). Other services of CHCs were school health services (including health screening of school going children, immunization and midday meal), adolescent health care (counselling and services related to pregnancy and contraception) and blood storage facilities. Governed by the State governments, these centres were equipped with diagnostic and investigative facilities such as operation theatre, labour room, X-ray machines and pathological labs. They were staffed with a physician, specialists, nurses and paramedic staff. Impeded by the high demand for primary care, there was a 30% shortfall of operational CHCs with large number of vacant staff positions including nurses, radiologists, lab technicians and pharmacists (FICCI & EY, 2019).
DHs or SDHs also served as a secondary referral unit operating at the district-level and offered curative, promotive and preventive healthcare services. Along with the services for family planning and immunization, these hospitals offered critical healthcare services, that is, round-the-clock emergency obstetric care including surgical interventions and anaesthesia, newborn care, accident & trauma care, blood storage and dialysis services. Depending on the population of the district, a DH had 75–500 beds for inpatients as well as OPD services for various specializations including dentistry and ENT (MoHFW, 2012). The seasonal outbreak of non-communicable diseases and limited capacity of primary-level healthcare services was creating excessive demand pressures on DHs and SDHs in various states/UTs.
Medical College Hospitals (MCHs)
The tertiary level of healthcare services comprised the referral hospitals attached with DHs/SDHs to offer specialized services at subsidized prices. There were 235 medical colleges funded and controlled by agencies under State government. These medical colleges also functioned as referral hospitals (Porter, 1985). Additionally, there was a group of nine autonomous public MCHs named as All India Institute of Medical Institutes (AIIMS). Other agencies running MCHs were operating for the Ministries of Defence and Railways.
Evolution of Mohalla Clinic: The Base of the Primary Healthcare in NCT
The NCT of Delhi, which comprised 11 districts, had an estimated population of 2 29 million in 2019 with an urban population density of 93% (9,000 persons/sq. km) against the national average of 25% (350 persons/sq. km). One of the reasons of this overwhelming high urban population in Delhi was the immigration of people from other states in search of work opportunities. This additional share of inhabitants residing in slums and other substandard housing was putting additional pressure on public healthcare services of the capital city. Contemplating the growing burden on the public healthcare facilities in Delhi, State government significantly increased the per capita expenditure on public healthcare. According to Delhi Economic Survey (2018–2019) the per capita expenditure on healthcare was US$34.66 against US$29.41 in 2014–2015. The number of beds per 1,000 of population was 2.99 in 2017–2018 against 2.68 in 2014–2015. The health infrastructure in the state included 17 MCHs, 88 DHs/SDHs, 178 polyclinics, 230 maternity homes, 1,160 nursing homes and 1,298 dispensaries (Delhi Planning Commission, 2019). Nevertheless, the per capita expenditure on public healthcare in Delhi was much lower than many Indian states. For instance, this expenditure was US$71.26 in Sikkim and US$71.97 in Arunachal Pradesh, resulting in higher household out-of-pocket spending in Delhi. Table 1 provides a summary of public healthcare governance, agencies and services functioning at NCT of Delhi.
Public Healthcare in National Capital Territory, Delhi
MCs served as the fourth tier (base) of the three-tier public healthcare system of Delhi. Each MC offered basic curative and some preventive healthcare services within 5-kilometer radius of underdeveloped urban areas in Delhi. It evolved from the established concept of mobile health services (called as mobile medical units or MMUs) initiated by the Center government to deliver clinical healthcare services to marginalized communities. Such communities were cut off from the established healthcare system on account of their geography or affordability. However, MMUs were falling short of serving as an effective base of the healthcare services pyramid in Delhi. High dependency on external factors such as transport and road infrastructure along with administrative and procedural complexities had made MMUs an ad hoc solution for primary healthcare. Hence, to offer a sustainable alternative for affordable primary healthcare services to a large urban population residing in Jhuggi Jhopri (slums), and other migrant communities, MC initiative was kickstarted. The scheme was managed by Delhi Healthcare Corporation, an agency enacted by DoHFW under the supervision of Principal Secretary for Health. Propelled by high political ownership, 106 MCs were set up by December 2016. The financing for MC relied on domestic resource mobilization (Lahariya, 2017). Further, NCT of Delhi had the advantage of greater budgetary allocation for healthcare, which was 16% against the 1.5% in the union budget. Thus, a dedicated budget of US$2.86 billion, amounting to 4% of overall health budget (US$73.11 billion) of the state, was allocated for setting up 1,000 MCs all across the state (Delhi Planning Commission, 2019). Among the services offered were out-patient consultation for seasonal illnesses (cough & cold, fever and allergies to name a few), first-aid for minor injuries, pathological tests for chronic diseases (such as Diabetes, Blood pressure and Thyroid), routine immunization and family planning. It also provided referrals to empanelled private clinics for specialized diagnostic services such as computed tomography or CT scan. Yet, a fully functional referral system to secondary and tertiary healthcare services in the state was also the desperate need of the hour. Since their inception in 2015, MCs had been serving 16.24 million patients, belonging to low-income group. They worked on easing the patient traffic flow towards secondary and tertiary healthcare services in the NCT (Sah et al., 2019). They also reduced the number of illegal clinics and laboratories run by unqualified practitioners in underdeveloped parts of the national capital. Additionally, they facilitated in reducing the out-of-pocket medical expenditures of uninsured urban households. Figure 4 shows the current status of MC.
Affordable Primary Healthcare Through Mohalla Clinic
To provide an affordable primary healthcare alternative to the vast urban neighbourhoods of NCT, many technological innovations were integrated in the service design of MC. These innovations were incorporated in the supporting facilities and systems for waiting line management and workforce management at the clinic.
Supporting Facilities
The potential sites for establishing MCs were identified across the 11 districts of Delhi. The key criteria for selecting sites were proximity to dense localities of underserved and migrant population (within 2–3 km radius), connection to all-weather road (within 400 m walking distance from main road), right size of the land (minimum 50–60 sq. meter) and zoning requirement of public works department (PWD). These sites either included or ensured proximity to a government school and a metro station to ensure high approachability of these locations (Sah et al., 2019). To start with, in 2015, 105 locations were selected based on survey of residents and resident welfare associations by officials of DoHFW and PWD.
For cost effectiveness, MCs functioned from portable cabins or rented premises. These portable cabins were prefabricated modular structures with insulated sides and roof made from glass wool. These cabins were assembled and installed by PWD at a cost of US$28,000/cabin (Ahmed, 2017). Owing to the small assembly time of these structures, the cost and speed of establishing an MC was phenomenal. Typically, an MC facility had a built-up area of 50–60 sq. meter in a plot of about 100–150 sq. meter. The facility included two to three rooms. The layout of the facility was designed keeping in mind optimal space utilization as well as the privacy of patients. One of the rooms was dedicated to out-patient consultation and examination, while the other two rooms housed the laboratory equipment and medicine vending machines. Some area of the facility was earmarked for waiting patients considering the extreme weather conditions of Delhi, which made it challenging to have an open waiting area. While basic amenities of clean drinking water and toilet were provided in all MC facilities, a few were even air-conditioned and had a television in the waiting area (Sah et al., 2019). Each clinic had vibrant surroundings with many informational displays (such as list of medicines and pathological tests) on the walls.
In sum, the supporting facilities in the form of cost-efficient, prefabricated portable cabins or rented premises offered a quick and easy way of starting up an MC in a densely populated area—typical to each city and town in India, and various other developing nations. Moreover, with this setup the monthly maintenance costs were lower than a no-frills basic clinic of equivalent capacity.
Managing Waiting Lines Through Technology
A typical MC either operated between 8 am and 2 pm in a single shift or between 7 am and 7 pm in double shifts on six days of a week excluding Sundays. While the average daily patient footfall at a MC was 90–100, it went as high as 250 per day during outbreak of seasonal illnesses. Since a vast majority of patients visiting these clinics were daily wagers and their housewives (especially mothers of young children), quick service was the key to patient satisfaction.
To manage the problem of waiting lines, MCs attempted to enhance the patient co-creation in service delivery process by employing many service innovations (Lahariya, 2017). Like banking services, MCs also used token-based queuing system. A token vending machine with reusable tokens was installed in the waiting area to serve patients on first-come, first serve basis and avoid long queues. For medical record management, a mobile medical device called Swathaya slate was available at each MC. This sensor-based device created and stored the medical record, including biometrics and medicines/tests prescribed, of the patient’s health using a cloud-based storage. This facilitated the medical officers to refer patient’s medical history for accurate diagnosis from any of the clinics equipped with the device. Additionally, the health data collected by the device also facilitated in analysing the progress of healthcare situation in an area. The device had a prescription writing and printing software for reducing the overall cycle time of patient diagnosis. To prevent out-of-pocket expenses on common laboratory test, these clinics were equipped to conduct 212 tests, with more than 33 of these common medical tests performed on Swathaya slate itself (Sah et al., 2019). In case of a complex test, the lab specimen was collected from an MC and processed at the nearest district hospital lab, and results were notified the following day. For the quick distribution of medicines, each MC had a medicine vending machine. Working like a small pharmacy, these vending machines used sensor technology to allow the patients to dispense medicines as per their prescription, thereby eliminating the need for a full-time pharmacist. A total of 109 essential medicines could be dispensed on prescription through these machines. These innovations inherent to the service design and delivery of MCs contributed to reduction in the patient waiting time from almost half a day at other public healthcare setting to 30 minutes per patient at a neighbourhood MC (Shostack, 1984). It also shrunk the non-clinical activities of medical officers, leaving them with more patient interaction time, aiding in patient satisfaction.
Therefore, with technological innovations in the service design and delivery, the patient throughput of an MC was higher than a normal SC or a PHC, making the model highly efficient and sustainable.
Managing Costs of Healthcare Staff
To curtail the costs as well as dependency on permanent healthcare staff, MCs adopted the staff payment model of ‘fee for service’. Each MC was run by an empanelled physician or doctor with professional degree in medicine or surgery, an ANM, a pharmacist and a helper or multi-task worker on need basis. Physicians running private practices were empanelled based on well-defined guidelines. As per these guidelines, the service quality of these empanelled physicians was monitored and controlled by the chief district medical office of the district, in which the MC falls. Empanelled for a year, these physicians were remunerated on per-patient basis (at the rate of US$0.56 per patient with a minimum limit of 75 patients per day). Working in single shift of 4–6 hours, the responsibility of a doctor was to manage the outpatient clinic, which involved attending patients, conducting minor surgical procedures (such as dressing of wound), maintaining patient records, timely reporting for the replenishment of medicines and consumables and maintaining a log of patient complaints. The paramedical staff was also appointed on per-patient renumeration basis by the DoHFW as per prescribed guidelines (Lahariya, 2017). Figure 5 shows the distribution of common health problems of MC visitors.
Thus, the specific guidelines for the engagement of private sector in the healthcare delivery, helped in achieving the MCs objective of low-cost and affordable healthcare. Furthermore, the return-on-investment focused human resource cost management was an innovative way to ensure the popularity and longevity of MC model. Table A1 provides summary of healthcare services offered by MC.
Challenges Faced by Mohalla Clinic
Even as the MC scheme made primary healthcare services accessible exclusively to the uninsured urban households residing in Delhi, the implementation of the scheme suffered many challenges.
Narrow Scope for Preventive and Promotive Healthcare Services
While the urban PHCs, which included dispensaries and polyclinics operating in the underserved urban areas, enrolled pregnant women for antenatal care and were a part of national immunization programme for infants, MC were not equipped to offer any of the preventive and promotive healthcare services (Bhuvan et al., 2019). The scope of MC was limited to curative and diagnostic healthcare services, which inadequately met the needs of uninsured urban households.
Poor Linkage with Secondary and Tertiary Healthcare Services for Referrals
Though, the MC model was designed to be based on a system of referrals through a tiered approach to healthcare services, this system was not fully operational. There were multiple departments and agencies of Union, State and Local government, which controlled the functioning of secondary and tertiary services in the NCT. Disagreements between Center and State government, lack of clarity on the governance of MC and paucity of ownership were some of the causes of lack of a robust patient referral management.
Weak Administration and Maintenance
The MC was launched as the State government’s flagship scheme to set up 300 clinics till January 2020. However, without a detailed operational planning, the administration and maintenance of these clinics became a formidable task (Bhuvan et al., 2019). A weak operational planning resulted in issues related to recruitment of adequately trained doctors and other staff, dissatisfaction among staff, management of medicine stock, accessibility to utility services, routine upkeep and availability of land for setting up new clinics.
Conclusion
MC model had proved to be an effective healthcare reform towards achieving the goal of universal health coverage in the NCT. The model had gained appreciation from public health experts functioning at both national and international level (Lahariya, 2017). These experts had even recommended the replication of the MC model to other Indian states as well as to other countries struggling to achieve health coverage for population lying in the low-income segment. Some prominent medical periodicals also studied this MC model and reported the aptness of the model for scaling-up public healthcare in countries with privatized and inequitable healthcare scenario and vast population without health insurance (Sharma, 2016). However, the sustainability and scalability of MC schemes were dependent on how effectively the current implementation challenges were handled by the administration. Additionally, the other scalability considerations for expansion of this community healthcare scheme to other states of the country were the socio-economic status of community, political ownership in the states, budgetary considerations and suitable quality control mechanisms. While Ramesh got benefitted from primary healthcare including consultation for seasonal illnesses, first-aid for minor injuries, pathological tests for chronic diseases, routine immunization and family planning offered by MCs, it remained to be seen whether MC scheme could prove to be a solution for primary healthcare for low-income patients falling outside health coverage.
Footnotes
Declaration of Conflicting Interests
The author declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article.
Funding
The author received no financial support for the research, authorship and/or publication of this article.
Appendix 1.
Relevant Readings
Fitzsimmons, J. A., & Fitzsimmons, M. J. (2006). Service management: Operations, strategy and information technology (Chapter 3, 5th ed.). McGraw-Hill.
Metters, R. D., Pullman, M., & King-Metters, K. H. (2009). Successful service operations management (Chapter 5, 2nd ed.). Cengage Learning.
Goldstein, S. M., Johnston, R., Duffy, J., & Rao, J. (2002). The service concept: The missing link in service design research. Journal of Operations Management, 20(2),121–134.
Edvardsson, B., & Olsson, J. (1996). Key concepts for new service development. Service Industries Journal, 16(2), 140–164.
Shostack, G. L. (1984). Designing services that deliver. Harvard Business Review, 62(1), 133–139.
Hussein, T., & Collins, M. (2016). Why big health systems are investing in community health. Harvard Business Review.
Additional Materials
NDTV Special Projects (2016, March 18). Mohalla Clinic – Health within reach. YouTube video, 9:39.
NDTV (2017, October 26). Mohalla Clinic: Work in progress. YouTube video, 9:24.