In the last one year, the mohalla or community clinics of Delhi have received a lot of interest. These clinics can arguably be credited to place health higher in the mainstream political discourse. In a year of functioning, from 100-odd clinics an estimated 26 lakh people reportedly availed of health services. The patient footfall was termed as success by the ruling party, while opposition parties used the same numbers to argue the failure.
At a rate of 50-70 patients per day for 25 working days a month per clinic, these have fairly performed in providing healthcare. On the other hand, there is need and scope for more government health facilities, especially for outpatient-based primary care. As per the NSSO 71st round, 80% of people (outpatient consultation) go to private providers. There are direct and indirect costs associated with care in public and private sectors; however, if for a private provider, the costs double.
People need more outpatient health services than hospitalisation. Nearly 70-80% of health needs can be addressed through consultation, without consulting specialist doctors, by general physicians. Increasing access to a medical doctor close to people could be considered an ‘intuitive approach’ for efficient health services delivery. Most countries with limited financial and human resources have made sustained efforts and investment on such a design and improved health outcomes.
Health experts have opined that the design of mohalla clinics has the potential to strengthen primary healthcare. These clinics come with an explicit commitment from political leadership and commensurate financial allocation in the state budget—the sine qua non for implementing any health initiative.
Their success or failure in Delhi could provide useful guidance to policymakers. In India, public spending on health is nearly 1.16% of GDP, the country is placed tenth from the bottom in the world. To avail health services, people have to pay from their pockets, directly to the providers, and this expenditure is one of the highest in the world. An estimated 6 crore people fall below poverty line due to health-related expenditure.
A major proportion of limited government funding goes into setting up large hospitals and strengthening district hospitals. So, the primary healthcare system remains underfunded and weak across India.But investment on primary care brings cost-effectiveness and efficiency. At an investment of Rs 200 crore per annum, or 4% of total health budget of Delhi, mohalla clinics have the potential to cater to 1.5-2 crore people, or 8-10% of all patients. The total cost of running 1,000 clinics is less than one-tenth of the annual budget of a large medical institute and affiliated hospitals in Delhi state. The state can use the following complementary measures.
One, strengthen existing facilities. The concept of mohalla clinics is good, but these cannot be a panacea for all maladies in health services delivery in Delhi. Even a full-scale implementation of 1,000 mohalla clinics will address up to 10% of health needs in the city state. That isn’t enough. The existing 1,600 dispensaries, which are functioning at suboptimal levels, are in urgent need of revamp—making them efficient can provide additional 20-30% of outpatient services.
Two, establish functional referral linkage and ‘continuum of care’ between different levels of facilities. Mohalla clinics should become the first point of contact between the community and medical doctor. Only referrals should go to the next level.
Three, increase the share of primary care in future financial allocation to health. The recently released National Health Policy (2017) aims to increase government funding to health to 2.5% of GDP by 2025. The goal of the government should not be to set up a specific numbers or types of clinics. Thus, mohalla clinics should be the means to an end—improving access to quality primary healthcare services (or universal health coverage) through government system—and not an end in itself.