Abstract
Mohalla clinics have not been engaged so far in dealing with the COVID-19 crisis, though they have emerged as an important segment of the primary healthcare infrastructure and services in Delhi. In this article, we argue that these clinics could have played a significant role in tackling the virus by carrying out COVID testing and creating awareness among the public about the virus. The states such as Kerala and Himachal Pradesh, which have successfully mitigated the corona crisis, in comparison, have effectively employed their well-developed primary healthcare system during the pandemic. Drawing from these experiences, we conclude with policy suggestions to make the mohalla clinics an integral part of the strategy to fight this public health crisis in the national capital.
Introduction
The COVID-19 pandemic has brought to the fore the supremely important but oft-ignored issue of healthcare in India. States such as Maharashtra, Tamil Nadu, Delhi, Karnataka and Andhra Pradesh are leading the bandwagon of states with the highest positive cases of COVID (Ministry of Health and Family Welfare, 2020). Delhi has been one of the major hotspots of COVID-19 in India, starting from the time of the lockdown, and its trajectory has continued along the same lines in the post-lockdown phase as well. The national capital, which is an important medical tourism destination in India for people from various parts of the country as well as abroad, is clearly struggling to deal with the corona crisis. This is despite the fact that the Delhi government has assigned health a top priority in its budget and allocated a significant chunk of its monetary resources in the improvement and development of healthcare facilities in the city. Health expenditure as a percentage of total state expenditure in Delhi is 11.4%, which is one of the highest in India (National Health Profile, 2019) as compared to the appallingly low national average of 1.15% of the GDP (Ministry of Health and Family Welfare, 2018a). Delhi has a clearly etched-out three-tier healthcare system with mohalla clinics being the lowest rung of the pyramid providing primary health care. The second tier comprises polyclinics, whereas tertiary healthcare is delivered through multi-speciality and super-speciality hospitals (Sah et al., 2019). Despite the presence of a well-developed and continuously improving network of mohalla clinics and polyclinics, the high number of positive COVID cases in the city has highlighted the fact that these are not being optimally utilised and the burden of healthcare has fallen on the government hospitals, which are notorious for their crumbling physical and human infrastructure and function beyond their optimal capacity even during normal times.
In this article, we attempt to see how the primary healthcare system in Delhi comprising mohalla clinics can help contain the COVID pandemic. From telephonic conversations with two field monitors of mohalla clinics and visit to a clinic in person, we find that these have not been given any mandate to deal with the corona crisis. Also, from literature, we make a comparative assessment and show that Kerala and Himachal Pradesh have effectively employed their well-developed primary healthcare system in controlling the spread of the virus. We conclude that empowerment and inclusion of primary healthcare can be an effective way of fighting the coronavirus battle in Delhi.
COVID-19: The Story of Delhi
We try to analyse some data related to total cases of COVID in Delhi, the number of deaths due to the virus and the recovery rate in the city. Figure 1 shows the total confirmed and recovered cases of COVID in Delhi. The data are from 2 March until 13 July 2020. We see that the number of cases started increasing in the city from around April and have risen continuously over the months, crossing the one-lakh mark in July. Similarly, the number of recovered cases has also increased over the months, although it still remains below the total confirmed cases. The gap between the total number of confirmed cases and recovered cases shows that the remaining patients either have yet not fully recovered from the disease or have succumbed to the virus.
The number of new and recovered cases of COVID in Delhi has been shown in Figure 2. The graph shows that while the recovered cases have increased in recent times, so has the number of new cases of COVID in the city. Despite the fact that strict lockdown was in place in the city, and later, containment zones were identified to cordon off the areas with COVID cases, the continuous increase in the number of new cases gives weight to the community-transmission hypothesis in the city.
We show the number of deaths attributed to COVID and recovery rate in Delhi in Figures 3 and 4, respectively. We see that morbidity has been on the rise, particularly after mid-May, which could be due to increase in non-institutionalisation of COVID patients, poor treatment in the hospitals and lack of an effective cure. While the number of deaths has increased, the recovery rate has also improved after witnessing a rock bottom in April. This could be explained by measures such as increase in COVID testing, mandatory institutional and home quarantine for people with travel history or COVID, quick identification of COVID hotspots and marking them as containment clusters and so on.
Despite an impressive recovery rate which can be seen as a silver lining, the number of COVID cases in Delhi are increasing by the day. The public healthcare system is overwhelmed with government hospitals in Delhi being closed fully or partially, to exclusively treat the COVID patients. This has put many patients with critical ailments at a high risk as there are no doctors to monitor their health.
While the Delhi government cannot do much in terms of curative care in the battle against COVID-19, there is a lot that could have been done when it came to preventive healthcare. The mohalla clinics could have been a key resource and contributed in stemming the virus by virtue of their availability, affordability and accessibility. As per a report by the Health Ministry, 73% of the COVID deaths in India can be attributed to comorbidities (Livemint, 2020). A recent study of 12 mohalla clinics in Delhi (Sah et al., 2019) found that about 21% of the patients visit mohalla clinics for chronic ailments such as hypertension, diabetes, renal disease and so on. Since people with these ailments are at a higher risk of contracting COVID, mohalla clinics could have used their medical data of patients to trace, test and isolate the potential corona carriers, thus breaking the chain of transmission of the virus.
As per the National Health Profile 2019, the number of government hospitals and beds in Delhi are 109 and 24,383, respectively, as on 1 January 2015. WHO recommendation for the bed–population ratio is five beds per thousand population, while the same figure for Delhi is only 2.99 (Economic Survey of Delhi 2018–2019). The city’s health infrastructure was crumbling even before the coronavirus pandemic. There was an acute shortage of manpower in healthcare facilities in Delhi, with 34% shortage of medical staff (doctors, surgeons and specialists), 29% shortage of paramedical staff and 22% shortage of nurses as on 31 December 2018 (Report on State of Health in Delhi, 2019). While the Delhi government has increased the bed capacity, the acute shortage of health workers and manpower continues. In such a bleak scenario, mohalla clinics could have played a decisive role in ensuring the well-being of people in the city. Since the bulk of the institutional COVID cases in Delhi are being handled by government hospitals, their OPD departments have witnessed a sharp decline in the number of patients. However, these people require an affordable and accessible alternative to the government hospitals. Mohalla clinics could have been the best-possible substitute for these government hospitals as they provide treatment of most of the basic ailments along with the provision of free medicines and tests. This could have helped in easing the pressure off the government hospitals which could have exclusively focused on the treatment of COVID patients.
Under-utilisation of Mohalla Clinics amidst COVID 1
We conducted telephonic conversations with two field monitors who are responsible for supervising the functioning of mohalla clinics in their area. We also visited a mohalla clinic in person to assess the situation on the ground and see if mohalla clinics were doing anything to curb the spread of COVID. The mohalla clinic we visited was located in the Mayur Vihar area of East Delhi. We were told by the doctor that since its inauguration in early 2020, the footfall had never been high—primarily because it was located in an economically well-off area where people preferred to visit private clinics. Despite fewer footfalls, the clinic had continued to function during the lockdown. Also, because the locality was an educated one, the people practised home-isolation and social distancing. Thus, no potential COVID cases were brought to the doctor’s notice, and the only ailments that patients reported were cough and cold. We enquired what steps, if any, were taken by the clinic to create awareness among the people about COVID and were told that during the first few weeks of the lockdown, the Delhi government had asked them to distribute some pamphlets that listed the essential do’s and don’ts to ward off the virus. These pamphlets were given only to the patients who visited the clinic. After a few weeks, the pamphlets stopped arriving and then there were no further orders from the government.
In the telephonic conversations with the two field monitors, we were told that the mohalla clinics in Northeast Delhi that one of them was in-charge of were functional during the lockdown. However, the footfall was very erratic. Although the crowd were mostly the regular patients who needed their quota of medicines, there were certain cases when people panicked, fearing that they had symptoms of COVID. On being asked whether mohalla clinics were equipped to handle such potential COVID cases and what the course of action adopted by the doctor and staff was in such cases, we were told that the patients were mostly sent back to their homes with paracetamol. Also, the clinics could do nothing in such cases, except refer the patients to hospitals for COVID tests. To the questions of whether the government was providing PPE kits to the doctors and staff at mohalla clinics and whether the clinics were sanctioned to conduct tests, the answer to both was ‘no’. We also asked the field monitor if the clinics were providing free sanitisers and masks to patients. Again, we were told that there had been no such order from the government.
The second field monitor who supervised 11 mohalla clinics in Northwest Delhi told us that when the first case of COVID-19 at a mohalla clinic made headlines, many patients became wary of visiting clinics. The footfall of patients also plummeted in clinics within the containment clusters. Though the clinics under his supervision did not shut down, both the doctors and the patients had apprehensions about visiting the clinics. He noted that there was still a lack of PPE kits for doctors and staff and they worked with regular surgical masks and gloves. The field monitor believed that the government could have used mohalla clinics to contain the spread of COVID-19, primarily by using their widespread presence in semi-urban clusters to carry out rapid testing.
Role of Primary Healthcare in Containing the COVID Crisis in Kerala and Himachal Pradesh: A Comparative Overview
While mohalla clinics have been praised for their trend-setting role in the urban healthcare of Delhi, they remain largely neglected in the COVID pandemic. On the other hand, states such as Kerala and Himachal Pradesh have garnered appreciation for handling the corona crisis in a prudential manner, by effectively employing their primary healthcare structure as foot soldiers.
Since the 1970s, Kerala has been internationally as well as domestically admired and researched for its achievements in health outcomes and health infrastructure despite its medium economic growth. The backbone of the state’s notable health standards is the state-wide infrastructure of primary health centres. Along with this, the spread of education has heightened people’s health consciousness and awareness (Varatharajan et al., 2004). Since the formation of the state, health has been one of the highest priorities of the state government (Nabae, 2003). In view of delivery of services and care, the grassroots organisations of the state are strong and their network is widespread. Both Community Health Centres (CHCs) and Primary Health Centres (PHCs) strive to reduce the health inequality of the rural–urban divide. This decentralised healthcare system not only withstood devastating floods, but also the recent outbreak of Nipah virus, by making better use of voluntary and active public engagements (The Guardian, 2020). During the COVID crisis, Kudumbashree, a grassroots network of local organisations and women’s self-help groups in Kerala, came forward to help contain the outbreak by producing two million masks and 5,000 litres of hand sanitiser in the initial phase of the nationwide lockdown. The state also established 1,200 community kitchens to help feeding indigent and unemployed. In this initiative, Kudumbashree served 300,000 meals per day (The New Indian Express, 2020). The state maintained regular communication with the public about the hazards and risks of this novel disease, disseminating precautionary messages through official channels to dispel fake news (The Guardian, 2020).
Another state that can be considered doing reasonably good in the COVID pandemic, if the low number of positive corona cases and fatalities can be considered indicators of it, is Himachal Pradesh. With a three-tier rural primary healthcare system, the state has a surplus of SCs, CHCs and PHCs for the population. The health system of the state is decentralised in the form of relegation of duties to Panchayat Raj Institutions as well as Health and Family Welfare Advisory Committees (PARIKAS). These PARIKAS are responsible for the functioning of the SCs and women participation is actively encouraged in these (Welschhoff, 2007). Besides, data from NFHS 2005–2006 show that the highest utilisation of government health facilities in the country is done by the households in Himachal Pradesh, with the figure standing at an impressive 83% (Goel & Khera, 2015). In their study, they also find that Himachal Pradesh has a high patients utilisation rate (PUR), which is defined as the number of patients served per thousand population in the last seven days. The authors find that the PUR for sub-centres in Himachal Pradesh in the study is 8.6% as compared to 4.4% for sub-centres in Bihar. Similarly, for PHCs in Himachal Pradesh, the PUR is 11.7% in comparison to an abysmal 1.1% for Bihar. Another study (Powell-Jackson et al., 2013) developed a quality of care indicator in the delivery of primary health services by employing six factors: 24-hour availability of services; presence of clinical staff; training in the past five years; status of basic infrastructure and availability of equipment and essential drugs. In the study, Himachal Pradesh ranks in the high-performing states with Kerala, Tamil Nadu and so on. In the context of the COVID pandemic, the state’s success in containing coronavirus cases can be attributed to its superlative primary healthcare infrastructure and a novel initiative—active case finding (ACF). The ACF campaign started in April when 16,000 basic health personnel, ASHA, Anganwadi workers and auxiliary nurse midwives (ANMs) trekked all the way to the most remote and distant places of the state, to reach every single house in order to collect data on the travel history and health indicators of every family member and upload these to an online database. A large number of COVID-positive cases were identified in Himachal Pradesh in the lockdown phase due to the ACF initiative that saw an active role of the primary healthcare personnel, thus diluting the possibility of chain transmission of the virus and also helping in easing off the pressure on the civil hospitals (Rediff.com, 2020).
While Kerala has been appreciated widely for successfully flattening its COVID curve, Himachal Pradesh remains an unsung story. The reason these states have managed to smoothly fare through the corona crisis is because of not only their strong and resilient primary health system, but also its timely and effective utilisation, clear risk communication and community participation. On the contrary, Delhi, despite housing some of the best medical facilities in the country, and the advantage of a well-developed primary health system, failed to do so.
Conclusion and Policy Suggestions
In this article, we have shown how a well-developed network of primary healthcare can play a decisive role in curbing the COVID pandemic, as is evident from the examples of Kerala and Himachal Pradesh. We also show that Delhi has completely ignored its network of mohalla clinics in checking the pandemic. This is validated from our visit to a mohalla clinic as well as telephonic interviews with two field monitors of mohalla clinics.
The following suggestions can be taken up to increase the role of mohalla clinics in the battle against COVID in Delhi.
In conclusion, it can be said that mohalla clinics can be a game-changer in the battle against COVID. These have proved to be hugely effective in curing basic ailments hitherto. These clinics can play a decisive role in promoting preventive health care amongst the people of Delhi. The Delhi government should galvanise more resources into their functioning in terms of human, physical and financial capital. This will also help in ameliorating the deplorable condition of the higher-level government hospitals.
Footnotes
Acknowledgements
We would like to express our gratitude to the field monitors who agreed for telephonic interviews.
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article.
Funding
The authors received no financial support for the research, authorship and/or publication of this article.