By Genevie Fernandes
In 2015, the Aam Admi Party (AAP), the ruling political power in New Delhi, launched its flagship health initiative of ‘Mohalla Clinics’. To date, 110 Mohalla clinics are functional across New Delhi and have served more than 2 million residents. This primary healthcare network has been lauded by global leaders such as Gro Harlem Brundtland and Kofi Annan as a model for scaling up universal health coverage in urban areas of India and the world.
Mohalla in Hindi means neighborhood or community. Essentially, Mohalla Clinics are health centres that serve as the first point of contact for the population, and offer a basic package of primary health care services including medicines, diagnostics and consultation, for free. These clinics aim to provide timely health services at the community level, thereby reducing the load of referrals to secondary and tertiary health facilities in the state. Many of the Mohalla clinics are equipped with an Android-based tablet called ‘Swasthya Slate’ that can perform a battery of diagnostic tests. This device also ensures health data collection at a population level, which can be aggregated at the state level and analysed for situational analysis and influencing financing decisions. This device is also being used by frontline health workers especially for home visits for antenatal care. Some clinics also have a first-of-its-kind automatic medicine dispenser, installed in collaboration with USAID. Doctors in each Mohalla Clinic are reimbursed Indian Rupees 30 ($0.46) for each patient that they see.
In a country with one of the largest out-of-pocket health expenditures, Mohalla Clinics offer free essential health services to people at their doorstep and reduces the financial burden on low-income households by saving travel costs and lost wages. A strong primary healthcare system can thus help in controlling and preventing infections and diseases at the community level, and also decongest the burden at secondary and tertiary health facilities, thereby helping the state to efficiently manage resources for population health.
While the Mohalla Clinics could be dismissed as a populist political move, it does have the potential meet the basic healthcare needs of the population and help the state advance towards universal health coverage. Furthermore, this model is a classic example where a health initiative has been backed by political will. Funding for Mohalla Clinics relies on domestic resource mobilization. The AAP has increased state health spending by 50%, raised indirect taxes, and ensured reforms and efficiency in budgetary allocations to be able to finance Mohalla Clinics. This initiative thus offers a scalable model for neighboring states and even countries to adopt and adapt, to improve access and availability of essential healthcare.
Despite the strengths of this primary healthcare model, critics including political opponents, health providers and journalists have pointed out operational gaps in some of the Mohalla clinics including lack of staff, medical supplies and diagnostics, and corruption by doctors through over inflation of patient numbers for increased payments. The AAP had set a target of starting 1000 Mohalla clinics by the end of 2016, which it has not met. However, the rush to achieve this target without paying attention to building a system for government stewardship, quality checks, mid-course improvements and continuous financing reforms, can pose obstacles for the AAP in achieving health for all in New Delhi. A comprehensive evaluation of the Mohalla Clinics and dissemination of these lessons is thus much needed.
While the Government of India has for long provided some sort of universal health coverage through its vast, albeit severely underfunded healthcare centres, this primary network has been plagued with challenges including unpredictable availability of providers, lack of services, medicines and diagnostics and poorly functioning referral linkages. As a result, a large proportion of patients seek healthcare even for common ailments, at secondary or tertiary health facilities, leading to overcrowding, long waiting time, and patient dissatisfaction. Many patients then seek health services elsewhere, in private clinics or even with non-qualified providers, increasing their out-of-pocket expenditures on health. The government also launched the Rashtriya Swasthya Bima Yojana, a national insurance scheme for population before the poverty line, however this initiative has not been efficiently managed, making it difficult to achieve its planned objectives.
In March 2017, the Government of India, under the ruling Bharatiya Janata Party (BJP) led by Prime Minister Narendra Modi, approved the National Health Policy, which focuses on preventive and promotive health care and universal access to good quality health care services. The policy aims to increase public spending on health from the current 1.16% of GDP to 2.15%, which was a key recommendation of the 2010 Planning Commission’s High Level Expert Group on universal health coverage (UHC). Given this current political push for UHC at the national level, Mohalla Clinics could actually serve as a replicable model to scale up universal health coverage across India.
However, with the rising tensions between the two political parties – AAP (ruling the state of New Delhi) and the BJP (in charge of the Centre), it remains to be seen if two parties will keep its political differences aside and actually work together to refine and scale the Mohalla Clinic model across other states, and set the stage for achieving universal health coverage for its citizens. After all, health is political, and as Rudolf Virchow said, ‘politics is nothing but medicine at a large scale’.
Further readings on UHC in India:
- Reddy, S. 2015. India’s aspirations for Universal Health Coverage. NEJM.
- Marten et al. 2014. An assessment of progress towards universal health coverage in Brazil, Russia, India, China, and South Africa (BRICS). Lancet.
- Lancet 2011 Series titled India: Towards Universal Health Coverage
- Planning Commission of India. 2011. High Level Expert Group Report on Universal Health Coverage for India.
- Government of India. Press Release – National Health Policy. March 2017.
- Sharma, D. 2016. Delhi looks to expand community clinic initiative. Lancet.
- Khanna, P, and Singh, K. 2016. Mohalla clinic: AAP offers affordable healthcare model at doorstep. Live Mint.
- Dutt, A. 2017. Two years of AAP govt: Are mohalla clinics a game changer in Delhi? Hindustan Times.