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Delhi looks to expand community clinic initiative
World Report
Delhi looks to expand community clinic initiative
Narayan Das used to run a roadside bicycle repair shop near a slum in Sultanpuri, northwest Delhi. He was not aware of his high blood sugar levels until he collapsed at work and had to be admitted to hospital. “After my diabetes was diagnosed, I began spending about 200 rupees every month on medicines and regular blood tests. This was a heavy burden as I had retired from work”, he recalls. Now, he does not have to worry as he gets regular medication and blood sugar tests done for free at a mohalla clinic (community clinic) not far from his home. The clinic was opened as part of a flagship programme by the Delhi Government launched in July, 2015. The initiative is aimed at expanding the reach and range of health services in unserved and underserved areas such as slums. In a unique model, all services—consultation, medicines, and diagnostic tests—are offered in one place and are free for people from all income groups. In existing staterun dispensaries and hospitals, people have to visit three different places for these services and make more than one trip. Doctors and paramedics are also overworked and absenteeism is high. To circumvent such problems, compensation for doctors and staff in mohalla clinics is linked to the number of patients they see. “We get patients from nearby areas, about 100 to 120 patients every day. Earlier they would go to a government facility located far off or to private providers in the vicinity, spending a good amount of money in both cases”, notes Ramesh Bansal, the doctor in charge of the Sultanpuri mohalla clinic. There are 106 such clinics in Delhi and close to 1·5 million patients have visited them in the past year. Delhi state, with a population of 16 million, has a fragmented www.thelancet.com Vol 388 December 10, 2016
health system run by multiple state and central government agencies and municipal corporations, as well as a range of private providers. The health system of the Delhi Government alone has 36 hospitals (10 000 beds), 185 dispensaries, and dozens of other facilities, catering for 33 million outpatient visits every year. Four municipal corporations run their own networks of dispensaries. Yet many areas remain underserved, some facilities remain under used or poorly staffed as the different health systems are not inter-linked.
“...increasing access to publicly financed primary care is the best way to accelerate health coverage’...” Although mohalla clinics have added another layer to the existing system, they offer key advantages. “They provide an assured package of services, facilitate access to basic services, with potential for referral linkage, and make it all affordable by reducing indirect costs like travel and lost wages”, said Chandrakant Lahariya, a New Delhibased public health specialist who was involved in designing the concept. Additionally, he says, the project could help address problems of unqualified providers and overcrowding at tertiarycare facilities. Chandrakant Pandav, a community medicine expert at the All India Institute of Medical Sciences in New Delhi, points out that “a serious limitation is the focus on curative care and neglect of preventive and promotive care. Under pressure from populist politics, these clinics are ending up equating holistic health care with curative care”. Pandav, however, feels preventive outreach services, linkage with existing health facilities, and monitoring and
quality assurance of diagnostic services could help improve the services being provided by the clinics. The High Level Expert Group on Universal Health Coverage established by the central government had recommended in 2011 a substantial increase in public health financing to provide universal access to free primary care services including essential medicines and diagnostic tests. “Mohalla clinics appear to be putting this strategy into operation. There is already a good case for scaling this up in Delhi and potentially in other Indian states because people seem to like these services. Evidence from around the world shows that increasing access to publicly financed primary care is the best way to accelerate health coverage”, commented Robert Yates, Senior Fellow at Chatham House, London, UK, after a recent visit to a clinic in Delhi. Although some states have studied the model and are keen to replicate it, scaling it up in Delhi to 1000 clinics by the year-end has been caught up in a political dispute. The Delhi health minister Satyendar Jain has accused the central government of creating roadblocks to the expansion plan. India’s ruling Bharatiya Janata Party has alleged that Jain preferentially rented premises for the clinics from his party members. “The clinics during the pilot stage were opened in rented premises. Now we want to install portable cabins on public land but central government, which controls all [of the] land in Delhi, is cold to the idea”, a state health official said. The plan to use parts of government school buildings is also facing bureaucratic hurdles. Without political consensus on the benefit of the clinics, efforts to improve health coverage in Delhi could well stall.
Dinesh C Sharma
A local government scheme to provide better primary care coverage in India’s capital territory is proving popular with residents, but not central government. Dinesh C Sharma reports from Delhi.
See Editorial page 2837
Dinesh C Sharma 2855
Delhi looks to expand community clinic initiative
Narayan Das used to run a roadside bicycle repair shop near a slum in Sultanpuri, northwest Delhi. He was not aware of his high blood sugar levels until he collapsed at work and had to be admitted to hospital. “After my diabetes was diagnosed, I began spending about 200 rupees every month on medicines and regular blood tests. This was a heavy burden as I had retired from work”, he recalls. Now, he does not have to worry as he gets regular medication and blood sugar tests done for free at a mohalla clinic (community clinic) not far from his home. The clinic was opened as part of a flagship programme by the Delhi Government launched in July, 2015. The initiative is aimed at expanding the reach and range of health services in unserved and underserved areas such as slums. In a unique model, all services—consultation, medicines, and diagnostic tests—are offered in one place and are free for people from all income groups. In existing staterun dispensaries and hospitals, people have to visit three different places for these services and make more than one trip. Doctors and paramedics are also overworked and absenteeism is high. To circumvent such problems, compensation for doctors and staff in mohalla clinics is linked to the number of patients they see. “We get patients from nearby areas, about 100 to 120 patients every day. Earlier they would go to a government facility located far off or to private providers in the vicinity, spending a good amount of money in both cases”, notes Ramesh Bansal, the doctor in charge of the Sultanpuri mohalla clinic. There are 106 such clinics in Delhi and close to 1·5 million patients have visited them in the past year. Delhi state, with a population of 16 million, has a fragmented www.thelancet.com Vol 388 December 10, 2016
health system run by multiple state and central government agencies and municipal corporations, as well as a range of private providers. The health system of the Delhi Government alone has 36 hospitals (10 000 beds), 185 dispensaries, and dozens of other facilities, catering for 33 million outpatient visits every year. Four municipal corporations run their own networks of dispensaries. Yet many areas remain underserved, some facilities remain under used or poorly staffed as the different health systems are not inter-linked.
“...increasing access to publicly financed primary care is the best way to accelerate health coverage’...” Although mohalla clinics have added another layer to the existing system, they offer key advantages. “They provide an assured package of services, facilitate access to basic services, with potential for referral linkage, and make it all affordable by reducing indirect costs like travel and lost wages”, said Chandrakant Lahariya, a New Delhibased public health specialist who was involved in designing the concept. Additionally, he says, the project could help address problems of unqualified providers and overcrowding at tertiarycare facilities. Chandrakant Pandav, a community medicine expert at the All India Institute of Medical Sciences in New Delhi, points out that “a serious limitation is the focus on curative care and neglect of preventive and promotive care. Under pressure from populist politics, these clinics are ending up equating holistic health care with curative care”. Pandav, however, feels preventive outreach services, linkage with existing health facilities, and monitoring and
quality assurance of diagnostic services could help improve the services being provided by the clinics. The High Level Expert Group on Universal Health Coverage established by the central government had recommended in 2011 a substantial increase in public health financing to provide universal access to free primary care services including essential medicines and diagnostic tests. “Mohalla clinics appear to be putting this strategy into operation. There is already a good case for scaling this up in Delhi and potentially in other Indian states because people seem to like these services. Evidence from around the world shows that increasing access to publicly financed primary care is the best way to accelerate health coverage”, commented Robert Yates, Senior Fellow at Chatham House, London, UK, after a recent visit to a clinic in Delhi. Although some states have studied the model and are keen to replicate it, scaling it up in Delhi to 1000 clinics by the year-end has been caught up in a political dispute. The Delhi health minister Satyendar Jain has accused the central government of creating roadblocks to the expansion plan. India’s ruling Bharatiya Janata Party has alleged that Jain preferentially rented premises for the clinics from his party members. “The clinics during the pilot stage were opened in rented premises. Now we want to install portable cabins on public land but central government, which controls all [of the] land in Delhi, is cold to the idea”, a state health official said. The plan to use parts of government school buildings is also facing bureaucratic hurdles. Without political consensus on the benefit of the clinics, efforts to improve health coverage in Delhi could well stall.
Dinesh C Sharma
A local government scheme to provide better primary care coverage in India’s capital territory is proving popular with residents, but not central government. Dinesh C Sharma reports from Delhi.
See Editorial page 2837
Dinesh C Sharma 2855