Abstract
This research article is based on a field study conducted in the West district of Delhi during November 2021–December 2021. With the introduction of Mohalla Clinics in Delhi, the supply side of the healthcare system has been affected as those seeking primary healthcare have more choices of public health facilities. This could further affect the utilisation of other government health facilities such as government dispensaries and hospitals. Analysing these effects could be crucial for handling existing bottlenecks of the system such as overcrowding of public hospitals, poor quality of care delivered at public health facilities, etc. This study was intended to uncover the healthcare-seeking pattern of the localities in West Delhi and compare the findings between localities with Mohalla Clinics in proximity and localities without Mohalla Clinics. We also present a comparison of the utilised health facilities on three parameters of accessibility—availability, affordability and acceptability. The sampling of the primary survey was conducted by geographical mapping of health facilities using Qgis software. We find that while Mohalla Clinics are preferred over dispensaries, the choice over government hospitals is seen only in areas where the distance to Mohalla Clinics is lesser vis-a-vis hospitals. It was also seen that the clinics seem to have eased down the barriers to healthcare for females much more than for males. The clinics have fared well in terms of affordability and acceptability but more clinics should be built to scale the effects.
Keywords
Introduction
Primary healthcare has the potential to not just improve health outcomes but also improve health system efficiency and promote health equity (Friedberg et al., 2010; World Health Organization [WHO], 2018). Overcrowding of the district and urban hospitals is one of the major inefficiencies in the current public healthcare system. The secondary health care infrastructure (e.g., public hospitals) taking care of the primary health care needs of the population, is often a result of sub-optimal utilisation of Primary Health Centres (PHCs)/Community Health Centres (CHCs) (Niti Aayog, 2017). Among all the states in India, Delhi has the highest per capita healthcare spending but the healthcare system still suffers from many issues (Economic Survey, 2020–2021). According to a survey by Praja Foundation, it was found that an average Delhi resident spends 9.8% of his household income on health (Praja Foundation, 2019). Despite of availability of many public health facilities in Delhi provisioned by different bodies such as the Municipal Corporation, Delhi Jal Board, etc., affordability in healthcare continues to be a serious concern. Overcrowding of secondary and tertiary care institutions for primary healthcare needs is another major lacuna in the healthcare system of Delhi. The overcrowding at super speciality hospitals like AIIMS for primary healthcare needs leads to delays in the treatment of chronic patients often leading to their deaths. To address these bottlenecks in the healthcare system and optimise the usage of primary healthcare needs, the government of Delhi introduced Mohalla or Community Clinics in 2015.
The healthcare system of Delhi was further reorganised into a four-tier structure of Mohalla Clinics for providing primary health care, Multi-speciality Poly Clinic for providing secondary health care in the form of Outpatient Department (OPD) consultation by specialist doctors including diagnostics, Multi-speciality Hospital for Inpatient Department (IPD) care (earlier called Secondary Level Hospital)and Super-speciality Hospital (earlier called Tertiary Level Hospital) to increase the accessibility of healthcare (Delhi Planning Department, 2019). This restructuring was supported by the increase in the allocation of funds to healthcare from ₹3,300 crores in 2015–2016 to ₹7,484 crores in 2019–2020 (Sahoo & Mahajan, 2020). This reframing is also in coherence with India’s motto of Universal Health Coverage (Ministry of Health and Family Welfare, 2017). National health mission, a central provision of the government has also been targeting improvement in access to health through different policies. In fact, the recent National Health Policy of India (Ministry of Health and Family Welfare, 2017) also states its main goal as
attainment of the highest possible level of health and well- being for all at all ages, through a preventive and promotive health care orientation in all developmental policies, and universal access to good quality health care services without anyone having to face financial hardship as a consequence. This would be achieved through increasing access, improving quality and lowering the cost of healthcare delivery.
The policy further suggests that this attainment 1 is possible by providing free primary care by the public sector (Sundararaman, 2017). Hence in the wake of the goals of National Health Policy 2017 of gaining universal health access, it would be important to understand how the existence of such neighbourhood clinics impact’s the existing barriers to the public healthcare system. Do the clinics reduce the barriers or dissatisfaction associated with the public health system? Are these clinics able to reduce the issue of overcrowding in the public health system and gain public confidence over private counterparts? Could these clinics fulfil the goal of universal health coverage and strengthen the primary healthcare system? Are these clinics improving the access to healthcare for people?
These clinics are the most peripheral tier in the healthcare structure of Delhi. As per the Indian Public Health Standards (IPHS) Guidelines for Sub-centres, 2012 (Directorate General of Health Services, 2012) a sub-centre which caters to a population of 5,000 in plain areas and 3,000 in hilly areas is considered as the bottommost tier. Despite being at the bottommost level in Delhi’s healthcare structure, the Mohalla Clinics cannot be directly compared to a sub-centre (Sah et al., 2019). Their origin could be traced back to Mobile vans or Mobile Medical Units which used to provide health services in underserved areas through a suitably adopted tempo or other vehicles (Lahariya, 2020).
The existing literature on Mohalla Clinics has studied their effectiveness and many of them have found that the clinics have been successful on the affordability front and have become more accessible for infants, women especially housewives, daily wage workers and old people (Agrawal et al., 2020; Jha & Singh, 2019; Komal & Rai, 2017). While the clinic population ratio was targeted to be 1 per 20,000 people, the government has been able to achieve 1 per every 60,000 people (Aam Aadmi Mohalla Clinic, 2021). It was hypothesised that by bringing these clinics close to the communities, daily wage workers would be less likely to lose their daily wages as the travel time to seek healthcare gets reduced. On the affordability front, it has been claimed that Mohalla Clinics will bring about savings of ₹500–₹2,000/month for an average household of five members (Aam Aadmi Mohalla Clinic, 2021). Besides the positive effects of Mohalla Clinics on the patients, the clinics were also expected to bring a significant change in the healthcare system. There has always been an issue of overcrowding at other public health facilities especially the government hospitals (Indian Express, 2016). With the introduction of Mohalla Clinics, it was expected that the majority of people will now reach the clinics for health conditions that are curable at these clinics resulting in a reduction in hospital footfall. There are very few studies that have identified the effect of Mohalla Clinics on reducing the burden on other facilities (Sah et al., 2019). A primary study by Anand and Dwivedi (2011) has found that 14% of patients who visited private facilities before the Mohalla Clinics are now shifting to Mohalla Clinics. One important factor that induces this shift is the quality of care received at these clinics. People are willing to shift from private health providers to Mohalla Clinics if the quality of care is perceived at par 1 (Komal & Rai, 2017). While these studies have studied the shift in the health-seeking behaviour from Mohalla Clinics to private facilities, there is a lack of evidence on how the shift has occurred within the public healthcare system. There is enough evidence to suggest that the poorly functioning sub-centres, PHCs, and CHCs result in dependence on public hospitals for curative needs thereby stretching the infrastructure at these hospitals to limits (Bajpai, 2014). Hence, understanding how the introduction of Mohalla Clinics has affected the utilisation of public health facilities including the hospitals providing a secondary and tertiary level of care and the dispensaries providing a primary level of care is integral to making this scheme scalable.
The structural change in the healthcare system of Delhi has affected the supply side by introducing a new type of health facility in the presence of already existing public and private health facilities. This could create two kinds of effects. First, on the government dispensaries which are part of PHCs and provide comparable services as Mohalla Clinics. 2 The introduction of Mohalla Clinics might affect the utilisation of public dispensaries, a negative effect on the utilisation of dispensaries might indicate the quality superiority of the clinics over dispensaries (Gage et al., 2018). Second, the government hospitals face issues of overcrowding aggravated by “poorly functioning sub-centres, PHCs, and CHCs resulting in people having to increasingly depend on hospitals for their curative needs” (Bajpai, 2014). Hence, access to Mohalla Clinics could reduce this burden if more people reach out to Mohalla Clinics for basic primary health needs and avoid going to hospitals. These two effects would be better understood if the healthcare-seeking pattern of the individuals is studied well. The demand side, that is, the behaviour of the individuals in need of care needs to be traced out to understand which health facility is used by individuals and the factors affecting this decision. To examine the same, we conducted a primary survey in the West district of Delhi and studied the usage of government dispensaries, hospitals and Mohalla Clinics among the localities of West Delhi. Furthermore, this article contributes to the scarce literature studying the effect of Mohalla Clinics on reducing the burden of other secondary and tertiary healthcare facilities.
The article has been arranged into seven sections. The first section is giving the introduction and presents some results from the literature. The second section lists the objectives of the study. The third section describes the data on government health facilities in the western district of Delhi and discusses the methodology used for the survey. Further, the fourth section lays out the descriptive profile of the sample and the fifth section begins with the results on morbidity, disease profile and healthcare use pattern. This section also examines the accessibility of health facilities in three aspects: availability, affordability and acceptability. In this article, the relevant results and discussions are presented in an integrated manner. The sixth section presents a comparison between the use pattern of Mohalla Clinics vis-a-vis other government health facilities. The last section draws on the conclusions and policy recommendations.
Objectives
The broad objective of the study is to evaluate the effectiveness of the Mohalla Clinics Model from users’ perspective in the West district of Delhi. This has been achieved by studying the healthcare usage patterns and comparing the utilisation of Mohalla Clinics vis-a-vis government dispensaries and hospitals. The sub-objectives of the survey are as follows:
To identify the morbidity rate, and disease pattern across socio-economic factors and identify the prevalence of primary and chronic ailments in the West district of Delhi. To trace the health facility usage pattern, that is, which facility (with emphasis on government hospitals and dispensaries) is used by people in episodes of sickness and its relationship with socio-economic factors. To assess the accessibility of healthcare facilities on three parameters: physical access, affordability and quality of care. To study the use pattern of Mohalla Clinics and its relationship with the usage of government dispensaries and hospitals.
Methodology and Data
Health Facilities in West Delhi
There are 11 districts in Delhi. Each district has sub-divisions. Our study district, that is, the West district has three sub-divisions—Patel Nagar, Punjabi Bagh and Rajouri Garden. Among all the districts in Delhi, West Delhi has the highest number of PHCs and second highest number of sub-centres 3 (Ministry of Health and Family Welfare, 2019). West District is the third most populous district of Delhi capturing 15.15% of the total population of Delhi. As per Census 2011, the sex ratio of the west district is 875 (Office of the Registrar General & Census Commissioner, 2011)
Delhi’s health network is controlled by different agencies. In the West district, there are 35 Delhi Government Allopathic Dispensaries & Seed PUHCs which are under the control of the Department of Health Services, Govt. of NCT of Delhi. Some allopathic dispensaries and state hospitals also have Homoeopathic, Unani and Ayurvedic dispensaries running on the same premises which come under the Department of AYUSH. There are six government state hospitals which are controlled by the Department of Health & Family Welfare. Besides these, there are some health facilities such as allopathic dispensaries, Maternal and Child Welfare Centres, and Maternity Homes being controlled by the Municipal Corporation of Delhi (MCD). The west district has parts from the west zone, that is, Karol Bagh, Narela, Rohini, zone of MCD. Some facilities are also operated by institutions such as Employees’ State Insurance (ESI), Central Government Health Scheme (CGHS), Delhi Transport Corporation (DTC), Delhi Jal Board (DJB) and so on. 4
List of Mohalla Clinics, West Delhi
As per the Delhi Government’s list of functional Mohalla Clinics in the West district of Delhi 5 , there are a total of 21 Mohalla Clinics in rented premises, 13 in porta cabins and 1 is owned by Delhi Urban Shelter Improvement Board (DUSIB). In our dataset, details of 22 Mohalla Clinics are provided (Table 1). We have matched the identity of these facilities with the administrative data provided by the government of Delhi. All 21 facilities are operational in rented premises and 1 is owned by DUSIB. Most of the facilities in our dataset opened by June 2016 except 3 which opened in 2017.
List of Mohalla Clinics in the Sample.
Mapping of Health Facilities
Firstly, we map the geographic locations of all the government health facilities of the West district of Delhi (Figure 1). The address of all state government dispensaries, state government hospitals and MCD health facilities were collected from the administrative data and using the Smart Monkey Geocoded Tool of Google Spreadsheet, geocoding of all the addresses was done. Next, for confirming the locations on the map, manual verification was also conducted.
The facilities are located at the ward level, the smallest administrative unit of Census India. For the analysis, we wanted to capture the geographical areas around each government dispensary and hospital that are approachable or accessible from the respective facility. These areas would include localities which are most likely to use these health facilities. Further, to find the catchment area of each state government dispensary, we created a buffer circle of a radius of 500 m keeping each dispensary as the centre of the circle. This was done using QGis Software (Figure 2). Some of these circles enclose Mohalla Clinics in their buffer zone while others do not. Out of the 32 state government dispensaries, 19 dispensaries have 1 or more Mohalla Clinics in the catchment area while the rest of the 13 dispensaries have no Mohalla Clinic in their catchment area. The same process has also been done for the 6 state hospitals in our study sample (Figure 3). Out of the six state hospitals, four have one or more Mohalla Clinics in the buffer zone and two do not have any clinics. The facilities with at least 1 Mohalla Clinic face direct competition with Mohalla Clinics as the individuals residing in these buffer zones have geographic access to both Mohalla Clinics and other government health facilities. Hence, we expect to uncover the effect on utilisation of other government health facilities vis-a-vis the Mohalla Clinics by comparing the catchment area having at least one Mohalla Clinic and areas having no Mohalla Clinics.
As per Census 2011, the West District of Delhi has an area of 129 km², with a population density of nearly 14,000 persons per km². The population of 2,543,243 consists of 1,356,240 males and 1,187,003 females. Children between 0 and 6 years are 203,528 consisting of 109,526 boys and 94,002 girls. 99.75% of the district’s population lives in urban areas (Department of Economic Affairs, Ministry of Finance, 2019).
For our study, we are using Cochran’s formula to calculate the desired sample size. We have chosen a 95% confidence interval and a standard deviation of 0.5 and a confidence interval (margin of error) of ± 6.5%. Using the following formula, yields a sample size of roughly 210.
where z is the standard normal variate corresponding to the chosen confidence interval, p is the (estimated) proportion of the population which has the attribute in question and e is the desired level of precision or margin of error. Here, z is 1.96 (corresponding to a 95% confidence interval) and p is assumed to be 0.5 for maximum variability.
For sampling, we divided the entire district spatially into 38 buffer zones (32 and 6 buffer circles for state dispensaries and state hospitals respectively). We have used stratified random sampling to form the sample. The buffer circles at the dispensary and the hospital level were categorised as strata(s). The strata(s) differ from each other in the number of Mohalla Clinics enclosed in them. For example, strata one will have zero Mohalla Clinic, strata 2 will have one Mohalla Clinic and so on. Table 2 presents the categories of strata and the number of buffer circles within each stratum. Since we wanted to form a representative sample, at least 50% of the total buffer circles within each strata level were chosen. For example, if a particular stratum has 10 buffer circles, at least 5 of them were selected randomly. From a total of 38 buffer circles, 21 have been selected for sampling (Table 2). From each chosen buffer circle, 10 individuals were selected randomly at different geographical distances from the health facilities (the centre point of the buffer circle) to maintain the wide coverage of the sample attributes. While the survey was strictly following a pre-tested questionnaire, some group discussions and subjective answers were also recorded to understand the rationale behind the decisions of a citizen seeking healthcare.
Description of Strata(s) and Buffer Circles in Survey.
The field survey was completed during November 2021–December 2021. We used a convenient sampling method to identify respondents and took informed verbal consent from every participant.
Descriptive Statistics of the Sample
The demographic analysis of the sample is presented in Table 3. In comparison with the census data of West Delhi, some close similarities between our sample statistics and population aggregates can be seen. For example, the sex distribution of the chosen sample closely resembles the population distribution. The percentage of females in the sample is 45.24% and that in census data is 46.67%. The corresponding values for male population in the sample and census are 54.76% and 53.32% respectively. The sex ratio of the district in the census data is 875 while our sample sex ratio is 826. Furthermore, the child proportion, that is, the percentage of children in the age category 0–6 is 9.30% in the sample and 11.35% in the census.
Comparison of Survey Statistics with Census 2011.
More than half of the sample is aged between 16 and 50 years. The second highest age group in the sample is the elderly population, that is, above 51 years of age. Among the younger population, 0–6 years have a higher presence as compared to 7–15 years. The prominent religion followed is Hinduism which is around 80.09% in our sample and 82.07% in the census. This is followed by Islam, Sikhism and others. The distribution seems to be close to what the census data suggests. The occupation structure of the sample shows that most of the interviews were conducted with daily wage workers or homemakers with 26.67% and 20.95% respectively. This is followed by students (12.38%) and salaried professionals (8.10%).
Morbidity, Disease Profile and Healthcare Use Pattern
Morbidity Rate
Out of the total sample, about 54.3% reported having fallen sick in the last 6 months from the date of the survey. The highest prevalence of disease can be seen in the child population and elderly population, that is, 0–6 years and above 51 years. Both age groups are dependent age groups. The prevalence is further found to be higher in females as compared to males. In females, the highest prevalence is in the 16–50 years age group whereas in males the highest prevalence is in 0–6 years. If we look at the age and gender together, the most affected groups are females in the 16–50 age group (71.15%), males in the 0–6 category (64.29%) and males above 51 years old (62.96%).
Type of Disease: Primary or Chronic?
More than half (63.16%) of the sample reported suffering from an acute condition whereas 36.84% faced a chronic condition (Figure 4). Among males, 59% and 41% are reported to have been suffering from acute and chronic conditions respectively. The prevalence of the acute conditions is much higher in females with about 68% and 32% reported to have been suffering from acute and chronic conditions respectively. Across all age categories, more than 50% of the sample seems to suffer from acute conditions. While 0–6 years are reported to be patients of acute diseases, 7–15 years and 16–50 years share a similar ratio of 3:2 across acute and chronic ailments.
Where Are People Going for Treatment?
In our survey, we asked people about the facility used for treatment if they have fallen sick in the last 6 months. Six options, that is, government hospital, government dispensary, MCD dispensary, private facility, Mohalla Clinic and self-treatment were given. From the results, it turns out that the maximum number of people go to government hospitals. Between Mohalla Clinics and government dispensaries, a higher proportion of people go to the former over the latter (Figure 5).
Gender: If we look at the gender-wise usage of different facilities, while most of the females are going to Mohalla Clinics, more than one-third of the males are going to government hospitals. Mohalla Clinics is the second choice among the male sample. This indicates the higher usage of Mohalla Clinics across females vis-a-vis males (Figure 6). During qualitative discussions, it was found that the males are mostly working and would visit the health facility near their workplace as opposed to females who would want to visit a health facility close to their place of residence. Since the Mohalla Clinics are situated in residential localities, females tend to find them more accessible. It was also found that some of the males who were rickshaw pullers were comfortable travelling some distance to reach a health facility.
Age: The sample has been divided into four age categories: 0–6, 7–15, 16–50 and above 51. Each of these age groups has unique health needs and hence a significant reason behind the choice of health facility. Government dispensary is the most prominent choice among the 0–6 years old with 50% of this age group visiting dispensaries (Figure 6). Mohalla Clinics do not provide immunisation services or child-specific care while the government dispensaries provide the same. It was found the women would find it difficult to visit a dispensary which is often located at a significant distance from their homes but because of the lack of child-specific care at Mohalla Clinics, they had to resort to dispensaries. The dependent or elderly age group, that is, above 51 years of age are using the government hospitals, Mohalla Clinics and private facilities. While Mohalla Clinics are a choice of many, people who can afford to go to private facilities do not trust the government facilities. The elderly population visiting the government hospitals were majorly the ones suffering from chronic ailments which are not curable at primary health centres like dispensaries or Mohalla Clinics.
Type of disease: Further, which facility is used for primary and chronic conditions was identified through the data. Since Mohalla Clinics are set up at the primary level, their usage is expected to be highest for primary ailments which are verified by the results. About 32% of the sample are visiting Mohalla Clinics, 25% are visiting government hospitals and 21% are visiting government dispensaries if they suffer from any primary condition (Figure 7). It is interesting to see that only a small 2.8% are using private facilities for primary level of care. In contrast to this, more than half of the sample suffering from any chronic condition are going to private facilities for treatment, government hospitals are the second highest used facilities. It seems that while the government-private divide still exists when people suffer from chronic ailments, the divide is almost non-existent when people suffer from primary ailments. Among the government facilities, government hospitals are the significant players in Delhi. A significant share of people uses government hospitals for both primary and chronic ailments. This often leads to the problem of overcrowding and lack of quality care provided at these facilities. One of the objectives of Mohalla Clinics was to reduce this burden on government hospitals. Although the Mohalla Clinics seem to be successful to some extent, there is still a huge scope for change.
Occupation: The majority of students, homemakers and retired individuals are going to government hospitals. Private facilities and Mohalla Clinics are the prominent choices among the daily wage workers with 36% and 28% of the sample visiting them respectively (Figure 8). During some group discussions on the field, it was found that daily wage workers are afraid of losing their wages for the days when they fall sick and hence their preferred choice is rarely government hospitals. Mohalla Clinics often have less waiting time as compared to hospitals and hence are preferred by this category. Among this category, some individuals cared about the better quality of care and interaction with the doctor and hence went to private facilities. This was also the case in areas where Mohalla Clinics were not present in the vicinity of the communities.
Accessibility of Health Facilities
In this section, we will try to assess the accessibility of the health facilities in Delhi on the following three parameters. This analysis is conducted for individuals who used any health facility in the last six months i.e. 54% of the total sample.
The first important aspect of access to healthcare begins with the geographical availability of health facilities. On average, the time taken to reach a government hospital is twice the time taken to reach a Mohalla Clinic. This relationship between a government hospital and a Mohalla Clinic also exists in waiting time. On a typical visit to a government hospital, an individual has to wait for 27 minutes to meet the doctor and the same is reduced to 12 minutes when an individual visits a Mohalla Clinic. In terms of geographical access, government dispensaries and Mohalla Clinics are close to each other in terms of travel time but the waiting time at the former is higher than the latter. This might explain the greater percentage of individuals choosing to go to Mohalla Clinics rather than the dispensaries. The average waiting time at a Mohalla Clinic is only 3 minutes more than at a private facility. In terms of travel time, the average time taken to reach a Mohalla Clinic is 4 minutes less than a private facility. In terms of availability, Mohalla Clinics seem to be giving good competition to the existing private facilities in Delhi.
Expenditure on Consultation and Medicines across Type of Facility.
Usage of Mohalla Clinics and Utilisation of Other Health Facilities
One of the major objectives of setting up the clinics was to enhance the accessibility of healthcare by catering to the nearby localities or the neighbourhood. Through this survey, we also try to assess the success of these clinics. To begin with, we look at who are using these clinics in the following subsection:
Use Pattern
From the results (Figure 10), it is indicated that females have reported to come to clinics more than males. 64% of the sample coming to the clinics are females in comparison to 36% of males. While 16–50 is the dominant age category, the second most frequent visitors come from the age category above 51 years. The purpose of clinics to take healthcare to unserved target groups especially the women and elderly seems to have been covered to an appreciable extent.
Usage of Different Facilities by Buffer Circles
We have categorised the buffer circles with different intensities varying from 0 to 6. The intensity of the buffering circle is determined by the number of Mohalla Clinics lying within the boundaries of the buffering circle. Analysing the effect of the presence of Mohalla Clinics on the usage of other government health facilities is essential to map the success of these clinics. In Figures 11 and 12, the y coordinate depicts the percentage of sample using different health facilities, and the x coordinate represents the intensity of buffer circles. Figure 11 is a combined graph of all health facilities whereas in Figure 12, there are five sub plots created for each health facility across different intensity of buffer circles. From Figure 11, it can be seen that government hospitals are used by the majority of the sample in buffer circles with no Mohalla Clinic. The proportion of the sample using the Mohalla Clinics increases with the increase in the intensity of buffer circles. The usage of private facilities seems to be increasing with the increase in buffer circle intensity, but it drops for intensity greater than four clinics (Figure 12). Government/MCD dispensary is not a choice of many even when the buffer circle intensity is low. It seems that the sample is divided between government hospitals and private facilities as their preferred choice when the Mohalla Clinics are not in their choice set. In circles with a higher number of Mohalla Clinics, the clinics stand as a tough competition to other health facilities indicating accessible and quality care from the Mohalla Clinics.
Conclusions and Policy Recommendations
While the introduction of Mohalla Clinics in the health system of Delhi has affected the health use pattern of the communities, the effect varies as per the health facility. From the survey conducted in the West district of Delhi, it seems that people in the communities still hold a significant preference for government hospitals. While the hospitals still face heavy footfall, government dispensaries and MCD dispensaries are the choices of very few, especially in communities which have access to Mohalla Clinics. This could be because of the better quality of care provided at Mohalla Clinics vis-a-vis the dispensaries (IDinsight, 2019). But this transition from government dispensaries to Mohalla Clinics can only be seen in areas where the latter are geographically accessible. It was proposed that 1,000 Mohalla Clinics will be set up but the target has not been met yet (Delhi Govt, 2020). This creates large variations in the geographic accessibility of these clinics across localities within the same district. There were some areas where people were unaware of what a Mohalla Clinic is and was only aware of traditional options like hospitals and dispensaries. So, in communities (buffer circles) which do not have any or few Mohalla Clinics, government hospitals are the dominant option people have. It was found that waiting time and travel time to a government hospital are twice that of a Mohalla Clinic. So, if geographical access to clinics could be improved by setting up more clinics, people could seek care without spending a lot of time travelling and waiting. In terms of availability, Mohalla Clinics prove to be a counterpart to private facilities. They could save the huge Out of Pocket Expenditure that an average individual spends in private facilities. The potential of Mohalla Clinics vis-a-vis the government hospitals and private facilities is immense but the geographical availability is an issue that needs to be looked upon to benefit the localities equally.
Further, it was also seen that the clinics seem to have eased down the barriers to healthcare for females much more than for males. Since a significant proportion of females are using the facilities, the government could think of introducing reproductive and child healthcare (RCH) services, especially for this group. While the AAP government has recently introduced the “Mahila Mohalla Clinics” (Indian Express, 2021) on the same line, it seems that adding another type of clinic might add to the confusion already existing among the communities about the dispensaries and clinics. It would be better if the RCH services could be integrated with the original Mohalla Clinic model itself. Agrawal et al. (2020) found that the gender of the doctor plays a crucial role in deciding the utilisation rate of women, that is, usually a female patient does not feel comfortable with a male doctor and hence the attendance at such clinics tends to be poor for women. Hence, for better targeting of clinics for women, policymakers should also consider the gender of the doctor at the clinics meant to provide women-specific services. From our results, it also seems that people prefer to go to Mohalla Clinics over government dispensaries. RCH services are provided at the dispensaries but not at the clinics yet. Hence introducing these services at the clinics might make the dispensaries obsolete eventually if access to Mohalla Clinics is widespread.
The affordability of government health facilities is undoubtedly remarkable as all of them provide free consultation and medicines. While there were some cases of ill-treatment and consultation charges reported at other government health facilities, no such case was found at Mohalla Clinics. People who have used Mohalla Clinics once prefer going to them again in any health episode. This reflects the success of clinics in building a social connection with the local communities. A larger credit for this success goes to the doctor of these clinics. In the qualitative interactions with the communities, it was found that a friendly doctor has played a crucial role in the success of Mohalla Clinics. While affordability has not been a concern, the unavailability of medicines and laboratory tests at some clinics has been a discomfort for the individuals. During qualitative interactions, it was found that patients would be asked to come another day for medicines or visit another dispensary for the same. Hence, maintaining enough stocks of medicines by introducing a proper accounting mechanism could eliminate such issues.
Mohalla Clinics have been a novel idea in context to the current healthcare needs. The success of these clinics ise dependent on true accessibility of them, the spirit with which they were introduced. The model is appreciated internationally as well as internally this idea has also been replicated in other states of India in the name of Basti Dawakhana in Andhra Pradesh, Atal Clinics in Jharkhand, Janta clinics in Rajasthan and Sanjeevni Clinics in Madhya Pradesh. There is a need to increase the number of clinics to witness the benefits on a large scale. These clinics could have become change-makers during the recent health crisis of the COVID-19 pandemic but remained ill-equipped largely (Business Standard, 2020). Hence, missing out on an important health event like this was a disappointment. The potential is large and could change the health scenario in Delhi. From our study, it seemed that the model is scalable as the benefits attained in communities closer to Mohalla Clinics are greater as compared to others.
Footnotes
Acknowledgements
We would like to express our gratitude to Dr Shaleen Mitra, NCT Government and Ms Kamakshi from the Delhi Secretariat office for providing their support before and during the primary survey. Thanks to the team that helped us to collect the data for this study, Aakash, Sakshi, Dyuti, Vishal and field supervisors Gauri and Anmol for extending their support.
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.