It is 11 a.m. Muhammad Shahid, a tailor, is waiting outside Mohalla Clinic set up by the Aam Aadmi Party government in B-Block Nihal Vihar, west Delhi. His child has mild fever. A headcount shows there are 12 patients sitting inside the clinic. After waiting for one and a half hours, Shahid’s name is announced. A few minutes later, he comes out holding a clutch of medicines. “All the prescribed medicines were available,” he says.
“I used to go the Delhi government dispensary nearby. Now, there is this clinic,” he adds. This is Shahid’s first visit to a Mohalla Clinic. When asked if he sees a difference between the dispensary and the clinic, he says “no”.
Everyone has a story to tell about their misgivings concerning the health care system in India – profit motive of the private sector and inefficiency of the public sector, the twin traits which set them apart. This is what the AAP government in Delhi wants to change. Mohalla Clinics is one of its major interventions to increase access to the public health care system of the Capital.
The intent was matched with the publicity campaign mounted by the AAP government. State-of-the-art Aam Aadmi Mohalla Clinics (AAMC) and their efficiency were advertised in both print and television media. A reality check on the ground reveals a story of the challenges that lie ahead as the project scales.
According to the Economic Survey of Delhi 2014-15, the number of medical institutions in the city has increased at a slow pace. The reasons mentioned are varied: non-availability of land, shortage of manpower and multiplicity of agencies. A total of 260 dispensaries – primary health care – fall under the Delhi government. Each intends to look after 50,000 people.
“We will create 900 new Primary Health Centers (PHCs)”, the AAP wrote in its 2015 election manifesto. Mohalla Clinics are an extension to the existing 260 government dispensaries, which are also meant to provide primary health care. While dispensaries cater to 50,000 patients, Mohalla Clinics aims to reach 10,000 patients. The aim is clear: bringing health care to citizen’s doorstep.
Speaking to The Hindu , AAP leader and Chandni Chowk MLA Alka Lamba said: “There were virtually no provisions for conducting tests in government dispensaries. In Mohalla Clinics, you can get around 200 tests done on the spot and you get the report right away. Lab technicians are present at the clinic only.”
Majnu Ka Tila
However, when The Hindu visited the Mohalla Clinic in her constituency, located at Majnu Ka Tila, the reality was slightly different. Tests were indeed conducted, but there were no ‘instant tests’, as claimed. There was no lab technician. “The tests have been outsourced to a private laboratory Unipath. We collect blood samples from 9 to 11 am every day. A person comes from the lab, collects the samples and gives us the report on the following day,” the doctor at the clinic explained.
It was noon and 160 patients had already visited the clinic. “This is fever season, the number of patients is at its peak,” the doctor said.
Less than a kilometre away, at a lonely corner of the locality, lies a dispensary functioning under the Delhi government. It is a large spacious building, with more than 5 rooms.
When inquired, the AAP MLA wasn’t aware of the dispensary.
“The Delhi government has decided to not interfere with the functioning of dispensaries until the target of setting up 1,000 Mohalla Clinics is not completed. People are not going to these dispensaries. No tests are being done there. There is a shortfall of medicines there. Perhaps the previous government wasn’t as serious about Mohalla Clinics as the AAP government is,” Ms. Lamba said.
But the staff said that the Mohalla Clinic was, in fact, dependent on the dispensary: all the drugs to the clinic were delivered by the dispensary.
The dispensary does have the provision for conducting tests. Not 200 though. “Around 20 tests can be done here itself. It is not outsourced as is the case in Mohalla Clinics,” another staff member mentioned.
But there were no patients around. The staff opened the OPD register to show that over a hundred patients had visited the place before we arrived. “The doctor has just left, with permission.”
The Mohalla Clinic has a four-member staff – a doctor, a young lady helper who acts as a compounder making the list of patients coming to the clinic, a man who collects blood samples for tests and a pharmacist to give medicines.
The pharmacist, however, isn’t trained for distributing medicines. She is an Auxiliary Nurse Midwife (ANM), earlier posted at the stated government dispensary. ANM looks after immunisation and Antenatal Care (ANC), a key component of primary health care – not available at this Mohalla Clinic. Now, she distributes medicines, raising questions. Dr Usha, who serves here, is a retired government doctor.
This Mohalla Clinic is one of the 105 such centres opened up by the AAP government this year. Unlike the “fancy” model clinic set up in Peeragarhi last year, most of the new ones are set up in rented or rent-free accommodations, with private doctors engaged to manage the clinic as self-contained institutions. The doctors are paid Rs. 30 per patient as consultation charges.
These new clinics are pilot projects. “In order to develop the understanding for the work flow and methods in the management of the Mohalla Clinics, a pilot project of AAMC to be run through private doctors in rented/rent free locations is proposed by the government. At present, the project may be executed for six months and later extended/ expanded as per requirement,” a government note on Mohalla Clinics mentioned.
Six months have passed since the clinics were started. The AAP has promised 1,000 clinics by this year-end, which means around 900 more clinics would have to be set up in three months.
The Raghubir Nagar Mohalla Clinic is housed in a yellow building with a park in front in a predominantly low-income population area. As is the case with other Mohalla Clinics, large photographs of the Chief Minister and Health Minister hang outside the clinic. There is also a blue board stating, “Free medicines, free consultation.”
“The clinic is of great help to my family. Earlier, we had to go the hospital,” said Om Prakash, a tailor whose house is situated just next to the clinic. His wife jumped in, “Not just us, everyone is happy. The doctor talks sweetly and listens to us. Her medicines work.”
The infrastructure may not be fancy, but the reasons for Om Prakash’s elation become clear as you enter the clinic.
At the entrance, a lady asks the patients their name, phone number, age and other details and gives them a handwritten slip. With that paper, patients form a queue, which extends outside the clinic, as there is no space inside.
The doctor examines the patients in an open room. She is is no hurry; she takes her time to diagnose the problem. “Prepare a daily chart of your activities and show it to me on your next visit. A healthy lifestyle is very important,” she tells a young adult. “You went to Ganga Ram before? Show me the prescription. I will take it forward from there,” she tells another. “Take the medicines for three days. If it doesn’t work, come back. We will get your tests done here.”
In the announcement of the second phase of the clinics, the Delhi government said in a note” “Patients shall be examined using an Internet-connected electronic tab based protocol and medicines prescribed and dispensed by the doctor. The biometric listing of patients will be maintained along with the list of medicines dispensed.” This was indeed a reality at Raghubir Nagar Clinic.
After seeing the doctor, patients go to the nearby room where a man is sitting with a tablet. He clicks photographs of the first-timers and asks for their phone numbers. Every detail is recorded, including prescription and diagnosis. But this facility is being used only at this clinic among the few The Hindu visited.
With the marked slip, the patients go to the lady distributing medicines. She also collects blood samples for tests. At least 25-30 people are inside the clinic. For over an hour the staff works without taking a break. “We take a five-minute break for tea at noon. This is fever season, patients are plenty. There is no time,” a staffer says.
Pramod, a fruit seller, has 103-degree fever. He doesn’t look well and gets prioritised to go to the front of the queue. No one complains.
“I have come here two-three times. Blood test reports are available on the second day. Today, I have come for my daughter,” says Raj Kumar, as he waits outside the clinic for his daughter.
Almost everyone who The Hindu spoke to across five Mohalla Clinics said that prescribed medicines were available in the clinics.
The Peeragarhi clinic, the first one to be set up, serves to showcase the best that the AAP government promises in health care. Set up in a porta cabin, it is fully air-conditioned and quite unlike a public facility in the popular imagination. Also, at a corner a water dispenser and a suggestion box are installed on the wall.
People enter the clinic, use the dispensing machine to get a token, and wait outside for their turn. At other clinics, this is done manually. Thanks to the token system, there is no chaos.
But there is no IT-based cloud management technology present in this clinic. Registration is manual. A lab technician is posted full-time and hence tests are conducted within the clinic – not outsourced as in others. The Swasthya Slate – a diagnostic device that was credited in Western media for the success of these Mohalla Clinics – is missing. Reports suggest that its results were not accurate.
Around 250-300 patients visit here every day, and this clinic runs in two shifts, unlike the 100 others which just run in the morning.
Dr Alka Choudhary, the in-charge of that clinic, is back after conducting a survey of the slum area where the clinic is set up. Her major worry is the presence of quacks. Minutes away from the Mohalla Clinic, inside a small fruit shop, operates a Bengali Doctor. “He may give anything, but we have faith in his medicines,” says a patient sitting outside the Bengali Doctor’s clinic.
Few come in and directly ask for a particular medicine or get a specific test done. “Please prescribe a blood test,” a patient asks the doctor. “But for what?” Dr. Choudhary asks.
A justifiable refusal to grant the medicine they want doesn’t make them happy. And that could be the reason why 30-year-old Amir Chand is not satisfied. “Satyendra Jain (Delhi Health Minister) has provided amazing facilities. But what are these doctors doing?”
The nearest grocery shop owner opens and shows a box full of medicines like Paracetamol. “If this is all they have to give, I can do so too,” he says, claiming that people at times come to him as they know what the doctor will prescribe.
Unfortunately, the clinic is surrounded by open drains, making it the perfect breeding ground for mosquitoes. Complaints were made to the municipal corporation, residents said, but no action for a long time. At the peak of the crisis, when a visit was made to the clinic again, thankfully, the area was cleaned up.
A government official associated with the Mohalla Clinics project expressed displeasure about the scaling plan of the government; concerned if quality is being compromised for quantity, in order to fulfill the ambition of setting up 1,000 Mohalla Clinics. “Intentions are great. But they shouldn’t be in a hurry.”
“The new pilot clinics are just running OPDs. If family planning services and immunisation are not provided, the burden falls back on the dispensaries,” the official said.
Outside the Nihal Vihar clinic, with a saffron scarf wrapped around his neck, Rajesh Chand jumps in between people discussing the politics of Delhi’s ongoing health care crisis. “It is unfair to blame (Prime Minister Narendra) Modi or (Chief Minister Arvind) Kejriwal. What can they do? It is the public which is responsible. We don’t take care of ourselves. Even after multiple advertisements on TV and posters all around, we, the public, continue to avoid basic precautions. Unless that happens, the current crisis will continue,” Chand says philosophically.