Manoswini Sarkar, Associate - Reducing Inequalities Program
Picture Credit: Press Trust of India
The COVID-19 crisis has highlighted the importance of prioritising healthcare services and infrastructure throughout the world and the need for countries to invest in modern healthcare facilities. The United Nations Development Programme has highlighted huge disparities that exist among countries in their ability to cope and recover from the crisis. Better health is the cornerstone of development and is a key indicator of a country’s progress.
However, developing countries face significant problems in the implementation of health programs due to a multitude of reasons - lack of resources, widespread poverty and in many cases, an absence of a sustained political will. Thus many countries, including India, have shown poor progress with respect to health on the route to sustainable development.
In India, several measures have been undertaken by the government to improve the health of its people by introducing national and state health and family welfare programs, such as the National Health Mission which was launched in 2013 with the aim of establishing a universal, affordable and decentralized health delivery system. These programs have helped improve healthcare access and delivery, control and eradication of many diseases, improvement in drinking water supply and sanitation among others. Even though India has made significant strides in improving the health of its population, it is still lagging behind in several health indices.
With rapid population growth and migration of people from rural areas to urban areas due to urbanization, the primary health care system is getting overburdened with this rise in demand for healthcare services. There are insufficient healthcare facilities (in the form of clinics) and the ones available are severely understaffed and inaccessible with long hours of waiting time. This has led to some patients consulting private medical practitioners rather than government health centres due to the poor infrastructure, overcrowding as well as poor quality standards of public health centres.
The National Health Mission established by the Ministry of Health and Welfare encompasses the National Urban Health Mission (NUHM) and the National Rural Health Mission (NRHM). Each Urban Primary Health Centres (UPHC) established under the National Urban Health Mission aims to cater to around fifty to sixty thousand people and a rural PHC aims to cover around twenty to thirty-thousand people, in contrast to Europe and Asia where similar primary healthcare centres typically cater to around 2,500 to 5,000 people. The actual number of centres present in both urban and rural areas is disappointingly low. These centres are also located in remote settings which necessitate long hours of travel and the standard 9-5 timing doesn’t suit the poor daily wage labourers or migrants.
This brings to fore the need for decentralisation of healthcare, which can contribute towards healthcare being equitably accessible to everyone, especially in the urban areas due to the rising demand for better facilities. A significant step taken in this direction is the introduction of Mohalla clinics (meaning neighbourhood or community clinics) launched in July 2015 in the city-state of Delhi in India. The idea originated from the success of mobile medical units (MMUs) or mobile vans and following this, 1000 such centres were planned to set up across the national capital, with each being staffed with a doctor, auxiliary nurse midwife, pharmacist, and support staff with some variations across the centres.
The aim of the Mohalla clinics is to provide basic healthcare services such as consultations, diagnosis and consultations to underserved regions and marginalised people in the urban areas, for free. Each clinic panders to a population of about 10,000 people, which significantly increases the availability of doctors and the geographic distance to access these clinics by manifold. The initiative has reduced travel time significantly and the average time to visit a doctor and seek advice on an ailment has reduced to half an hour as the clinic is situated in their own neighbourhood within 1000 meters from their houses. The timings of some of the facilities have also been expanded to address a huge load of patients so everyone could access the facilities. A token system is introduced in each of these clinics which leads to people being served fairly with no preferential treatment being accorded to anyone. Additionally, it has also encouraged people to get diagnosed at the early stage of the illness when many illnesses can be treated without referring them to secondary or tertiary health centres.
Furthermore, innovative techniques using ICTs are offered in these clinics such as the use of an Android-based tablet called ‘Swasthya Slate’, which can perform up to 33 common medical tests including blood pressure, blood sugar, blood haemoglobin, urine protein and also tests for common diseases such as dengue, malaria hepatitis, HIV, and typhoid. Each test only takes around a couple of minutes and the device uploads its data to a cloud-based medical-record management system that can be accessed by both the patient and the doctor to get access to their medical history.
In the months of September and October of 2016, when a Dengue and Chikungunya outbreak became pervasive in Delhi, healthcare centres were overburdened with patients, the Mohalla clinics helped alleviate the crisis to some extent as patients could get easily examined and laboratory tests for free.
Photo credit: Sadhika Tiwari
SUSTAINABILITY OF THESE CLINICS
The Mohalla Clinics have been lauded nationally and internationally by global leaders such as Former UN Secretary-Generals Kofi Annan and Ban Ki-Moon among others as having been regarded as a major step towards universal health coverage and reducing the burden from primary health centres.
Owing to the success of these clinics in addressing primary health care requirements, it is important to ensure the sustainability of Mohalla clinics. For that, it needs to continuously upgrade itself and introduce new measures to keep up with the demands of the neighbourhood and its people. For example, these clinics could’ve been used during the COVID-19 pandemic as the first contact point for testing people showing visible symptoms of the disease. Based on the reports of the test, if positive, the person would’ve been sent immediately to a treatment facility at a specialised hospital. Due to the localised information available on the Swasthya Tablet, the people who were in contact with the infected could also have been traced and quarantined immediately or referred for testing/treatment, thereby significantly controlling the spread of the disease.
The private sector using public-private partnerships can also be engaged to strengthen the system, make operations smoother and make it even more accessible to people. Mechanisms to monitor and evaluate the system needs to improve which can be done by establishing a proper grievance redressal system. One of the major reasons this succeeded in the state of Delhi is due to the higher budgetary capacity towards allocation of additional resources. If governments plan to follow a similar model in their respective states, the budgeting for the additional services needs to be estimated and a detailed plan has to be created. Other issues which are closely related to health such as drinking water, sanitation, hygiene also need to be addressed.
A MODEL OF DECENTRALISATION?
Taking a cue from the Mohalla clinics in Delhi, in April 2018 the state government of Telangana announced the plan to set up 200-500 Basthi Dawakhanas throughout the city of Hyderabad and has already set up around 58 Basthi Dawakhanas in association with National Health Mission to make quality medical and healthcare services accessible and free to the doorsteps of the urban poor. Following the success story of these clinics, similar healthcare centres can be established in other urban areas of the country with the help of the respective state governments and the National Health Mission. Many other states such as Maharashtra, Karnataka, and Madhya Pradesh have already expressed an interest to follow suit. In cities such as in Mumbai, Kolkata and Chennai, where there is a significant amount of population living in slums, resettlement and refugee colonies, these clinics can massively help in increasing accessibility to health services, which could, in turn, help people save up on transport costs and lead to a reduced waiting time. The free medicines disbursed as per need will help people immensely and will encourage them to visit these centres more often for the symptoms for which people hesitate to visit primary health centres and which have the potential to turn into serious illnesses later. Not just in India, but a similar model could be followed in other metropolitan cities of the world in developing countries where people are deprived of healthcare services, so clinics could be established which could each pander to 2000-5000 people. This would majorly help in cities where healthcare centres are overburdened and help in reducing health inequities.
A worker sprays disinfectants on a mohalla clinic in New Delhi. Photo: PTI/Ravi Choudhary
One of the criticisms of the Mohalla clinics has been that it is a populist move by the government of Delhi. However, what cannot be overlooked is its potential to reform the healthcare system of the country by providing basic healthcare services to the millions of marginalised people in the urban settings and taking them under the umbrella of universal healthcare coverage at an affordable cost. It can also contribute positively to the health-seeking behaviour of people residing in marginalised areas. Urban health has to be seen in a multisectoral way and broader interventions are necessary for not just the public health field but also in the economy, environment, sanitation, education and food security. Therefore, these clinics need to be supplemented by overall healthcare improvements, among other fields, which can contribute towards a holistic advancement and improvement in the health of the people.
The questions we need to ask is if the state governments of India and of other countries have a similar political will, leadership and resolve to introduce a similar holistic approach towards healthcare services. How can these clinics be equipped to deal with relatively unknown viruses such as COVID-19? How can other issues which are closely related to health such as hygiene, health and sanitation be addressed via these clinics? What role can civil society organisations play so as to generate awareness regarding health issues? Only by answering these questions can we make the idea of decentralised healthcare more widespread which can address issues of availability, accessibility, affordability, efficiency, quality assurance and equity of healthcare services to all.
Manoswini Sarkar is a final year master's student of Political Science and International Relations at Jadavpur University, Kolkata. She is also an SYLFF research fellow at the Tokyo Foundation for Policy Research. She has extensive experience in non-profit work with several organizations in different capacities.