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 Table of Contents 
REVIEW ARTICLE
Year : 2020  |  Volume : 9  |  Issue : 12  |  Page : 5872-5880  

Access, utilization, perceived quality, and satisfaction with health services at Mohalla (Community) Clinics of Delhi, India


National Professional Officer, Department of Health Systems, World Health Organization (WHO) Country Office for India, New Delhi, India

Date of Submission02-Aug-2020
Date of Decision20-Sep-2020
Date of Acceptance02-Oct-2020
Date of Web Publication31-Dec-2020

Correspondence Address:
Dr. Chandrakant Lahariya
B-7/24/2, First Floor, Safdarjung Enclave Main, New Delhi - 110 029
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jfmpc.jfmpc_1574_20

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  Abstract 


The first Mohalla or Community clinic was set up in July 2015 in Delhi, India. Four hundred and eighty such clinics were set up in Delhi, since then. This review was conducted to synthesize evidence on access, utilization, functioning, and performance of Mohalla clinics. A desk review of secondary data from published research papers and reports was conducted initially from February–May 2020 and updated in August 2020. Eleven studies were included in the final analysis. Studies have documented that more than half to two-third of beneficiaries at these clinics were women, elderly, poor, and with school education up to primary level. One-third to two-third of all beneficiaries had come to the government primary care facility for the first time. A majority who attended clinics lived within 10 min of walking distances. There was high rate of satisfaction (around 90%) with overall services, doctor–patient interaction time and the people were willing to return for future health needs. Most beneficiaries received consultations, medicines, and diagnostics at no cost. A few challenges such as dispensing of medicines for shorter duration, lack of awareness about the exact location of the clinics, and services available among target beneficiaries, and the incomplete records maintenance and reporting system at facilities were identified. Mohalla Clinics of Delhi ensured continuity of primary care and laboratory services during COVID-19 pandemic in 2020. In summary, Mohalla Clinics have made primary care accessible and affordable to under-served population (thus, addressed inequities) and brought attention of policy makers on strengthening and investing on health services. The external evaluations and assessments on the performance of these clinics, with robust methodology are needed. The services through these clinics should be expanded to deliver comprehensive package of primary healthcare with inclusion of preventive, promotive, community outreach, and other public health services.

Keywords: Community clinics, COVID-19, Health services, India, Mohalla Clinics, primary health care, universal health coverage


How to cite this article:
Lahariya C. Access, utilization, perceived quality, and satisfaction with health services at Mohalla (Community) Clinics of Delhi, India. J Family Med Prim Care 2020;9:5872-80

How to cite this URL:
Lahariya C. Access, utilization, perceived quality, and satisfaction with health services at Mohalla (Community) Clinics of Delhi, India. J Family Med Prim Care [serial online] 2020 [cited 2021 May 11];9:5872-80. Available from: https://www.jfmpc.com/text.asp?2020/9/12/5872/305605




  Introduction Top


The state government Delhi, India had launched Mohalla or Community Clinics “to provide quality primary healthcare services accessible within the communities at their doorstep” and “to reduce the over-crowding of people seeking treatment for common illnesses at hospitals.”[1] The first Mohalla Clinic was launched in July 2015. Four and half years later, by February 2020, a total of 480 clinics were functional across Delhi, India.[2],[3] The details on these clinics and concept behind have already been published in peer reviewed journals in the past.[2],[4] By early 2020, more than a dozen Indian states or cities had either started or were planning to set up community clinics.[5],[6],[7] Yet, much of the public and policy discourse on setting up community clinics is based upon perception and popularity of the clinics, rather than the research and documented evidence. These decisions have also been influenced by media reports, high profile visits of experts and politicians.[8],[9] The research evidence generated on access to services, the pattern of utilization of services, details on beneficiaries attending the clinics, perceived quality of health services and health seeking behavior could be useful for suitable modification of existing facilities and for designing of new facilities by Indian states. Therefore, this review was conducted to synthesize evidence on access, utilization, functioning, and performance of community (Mohalla) clinics of Delhi, India and to assess whether these are fulfilling the stated objectives/purpose to set up these clinics.


  Materials and Methods Top


Desk review of secondary data from published research and reports was conducted in February–May 2020. The research papers and reports, based upon primary data, published between July 2015 and May 2020 were included. A combination of key words “Mohalla Clinics,” “Community Clinics,” Delhi, India and Neighborhood clinics were used for conducting the searches on PubMed, EmBase, and Google scholar and other internet sources. Research article published in peer reviewed journals and reports available at the official websites or any other official sources were included. The unpublished research work was excluded from the analysis. The full text of articles identified were collected, read, and information extracted in excel sheet, which were used to develop tables and boxes, and then interpreted. The literature review was updated in August 2020. This was a secondary analysis based upon desk-review and was exempted from the need for approval by an institutional ethics committee.


  Results Top


A total of 11 published research articles and reports, based upon inclusion criteria, were identified and included in the analysis. Four were published as research articles in peer-reviewed journals.[10],[11],[12],[13] Five studies based upon primary data collection were published as part of reports including a qualitative case study on Mohalla Clinics.[14],[15],[16],[17],[18] The summary reports of two population-based surveys, which focused on health and Mohalla clinics, were also included.[19],[20] [Table 1].
Table 1: Summary description of studies and reports included, with sample size and key findings[10],[11],[12],[13],[14],[15],[16],[17],[18],[19],[20]

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There were many common findings in the studies and surveys included in this review.[10],[11],[12],[13],[14],[15],[16],[17],[18],[19],[20] Mohalla clinics are very popular, catering to nearly 10–20% of the total outpatient attendance at government healthcare facilities. The clinics have increased accessibility and affordability to outpatient services to target beneficiary and most received services at zero cost or at far lower cost than the other healthcare facilities where the beneficiaries attended similar services. The time taken to be attended by doctor had also reduced drastically from upto a few hours to less than 30 min. The cost of transportation had reduced in majority of cases as these clinics were in walking distance. The studies have documented that a majority of beneficiaries were elderly and children, women, those who otherwise did not have access to health services. For example, a study[17] found 65% of patient surveyed at Mohalla clinics were female. It was found that most patient received the free medicines and diagnostics. There was high level of satisfaction among beneficiaries across all studies, which went up to 97%. Another study found that 85% of those attending Mohalla clinics gave satisfaction rate average or above; which was far higher than 55% for hospitals sample. Nearly two-third of all responded rated these clinics 5 out of five[17] [Table 2]. These or similar findings have been reported from other studies included in this paper.[10],[11],[12],[13],[17]
Table 2: Comparative performance of hospitals and Mohalla clinics, 2017[18]

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One of the key findings from various studies identified as part of this research was that presence of a few other clinics in vicinity gave beneficiaries a choice to select a facility. For example, when women were uncomfortable attending a clinic where a male doctor was posted, they could make a choice of going to another nearby clinic, where female doctor was posted.


  Discussion Top


The provision of primary healthcare services through community clinics with doctors, nurses, and other staff as health team, for every 2000–7,000 population, is a widely practiced approach in many countries[21],[22],[23],[24] [Box 1]. However, in India, the first contact between a doctor at government health facility and community is through primary health centres (PHCs). Each PHC is planned for every 20,000–30,000 population in rural area and 50,000 people in urban areas. The actual availability of PHCs is for much higher population per facility.[21] Therefore, setting up Mohalla clinics in Delhi increased the availability of health facilities with doctors by fivefold in urban setting.



Soon after setting up Community Clinics, each facility was being attended by an average of 100–150 people between 8 am and 2 pm. Thus, government increased the timing in two shifts from 7 am to 7 pm, for those clinics, which had more than 150 patients on average.[25] The findings from the studies included in this review validates what was often said by political leaders and reported in media that more women, elderly, and children attending these facilities. These findings underscore the unmet need of health services among the poor, under-served and migrant populace in major cities.

One of the impacts of these clinics has been that a number of Indian states have started a variant of community clinics[6],[7],[11] or done other primary healthcare reforms.[26] The health and wellness Centres (HWCs) component under Ayushman Bharat program started by national government of India is an initiative focused on delivery of comprehensive PHC services.[27] There seems a high relevance of community clinics in India, which has the triple burden of diseases/health issues–communicable, non-communicable and maternal and child health issues.[28] Specially, where nearly 20% of adult population is affected by either diabetes or hypertension and need regular care and management. However, setting up community clinics should be considered only a part of broader healthcare reforms. The situation demands that such primary care system should not be doctor centric only and few tasks of following up the cases of chronic conditions and providing preventive and promotive health advices, the nurses and other category of staff need to be empowered. In fact, that approaches of team-based service delivery and task shifting is the “standard of care” in many middle and high-income countries.[21],[22] Countries such as Japan, United Kingdom, and New Zealand have systematically made efforts to empower general physicians, adopt team-based approach in health service delivery.

It is intriguing that in spite of 5 years in operation, there are very limited studies based upon primary data collection and to assess the performance of these clinics. Even the available studies have variable methodology and small sample sizes of 3–6 facilities. In contrast, even a few newspaper stories are based upon more visits and interactions with more number of facilities.[29] There is need for more rigor in these type of survey and analysis. This lack of enough primary research, in spite of large number of medical colleges and academic research institutions in Delhi state, need to be further examined. One possibility is that health systems and policy research in India is most often under-funded and at times there is limited and insufficient expertise. This on one hand underscores the need for establishing institutional mechanisms for such research. Alongside, it is proposed that while starting such clinics, the policy makers and program managers should proactively make provision of funding for conducting assessment and evaluation of new policy initiatives, to support evidence informed decision making. The lack of research on primary care initiatives can also be because of the factor that most of the research capacity is based at tertiary level facilities and academic institutions and the physicians working in primary healthcare are not always involved in the health research. The capacity building of primary healthcare providers in design and implementation of health services and research through institutional mechanisms need to be streamlined and sufficiently funded.

A few experts have argued that India is rapidly evolving as in hospital oriented, technocentric healthcare system, fueled by private sector providers[30] and the focus and attention from primary healthcare is seemingly lost. The top 20% of population often seek care at high end hospitals for even primary healthcare needs; however, this trend is trickling down to poor as well, where they also wish to seek services at large facilities, even for basic healthcare needs. Mohalla Clinics with primary care focus seems to have been reversing that trend of over-utilization of hospitals for basic need, which is unsustainable and unaffordable for the country, in long run. Mohalla clinics seems to have potential to shift the focus from specialist care to a general physician-based health services. These clinics are bringing the attention back on the role primary healthcare physician can play in a system which has excessive attention on super-specialist care. Healthcare system in Japan is an example where in spite of most modern and advanced technologies, health services focus, and importance of primary care physicians is fully understood. The practitioners of primary healthcare are rarely recognized. A few analyses have pointed out that of prestigious Padma Awards in India, of awardees from the field of medicine less than 2–3% were primary healthcare physicians or public health workers.[31],[32] Mohalla and other community clinics provides opportunity to reclaim primary healthcare space in times when technocentric and specialist care get more attention.

Setting up community clinics is not enough and to make process lasting and sustainable, a few additional steps are needed for empowerment of healthcare providers in primary care settings. The representation of primary care providers need to be ensured in the decision-making bodies such as medical council and other national level health policy and program making committees. The primary healthcare physicians and nurses need to be adequately empowered and invited to join policy high table and process of decision making. The voice of primary healthcare providers and public health specialist need to be sought beyond consultations with them, by having them as regular part of these processes.

As a number of Indian states are setting up community clinics and reforming their primary healthcare system, it will be useful if learnings from these clinics is used and widely shared. A common feature of most such clinics in India is curative care focus, with limited attention on public health services. There is need to expand the benefit package offered through these clinics to deliver comprehensive primary healthcare services including preventive, promotive, rehabilitative, and public health services.

One of the limitation of specialist based and hospital-based health systems is doctor–physician relations become transactional, which is often bereft of personal touch and empathy. The amount of time doctors spend with every patient is often less than a minute. Studies have noted that time spent by doctors with patient at Mohalla Clinics was higher than other facilities and was associated with higher satisfaction. This is fully in consonance with global evidence where smaller clinics have been found to be associated with higher patient satisfaction, better treatment compliance, regular follow–ups, and improved clinical outcomes.[33],[34] The longer and personalized patient–doctor interaction time at Mohalla Clinics could clearly have been associated with regular use of these clinics as well as return visits.

There are reports where doctors at Mohalla clinics of Delhi have been involved in mediating social issues of domestic violence and problem of alcoholism. This has created a connection between doctors and other healthcare providers and communities being served. This provides a very conducive opportunity and environment, which should be effectively used for increased people's participation in health, deliver preventive and promotive health services (people are more likely to be receptive) and address social determinants of health (i.e,. improved sanitation, improved water supply, etc.). This personal touch between doctors and patients and communities can results in better health outcomes and reflects the potential of these clinics.

There are a few aspects of clinics, with scope for improvement. A large proportion of people were not aware about location of these clinics or services provided. There is need for awareness generation about these clinics in target populations through localized campaigns and by engaging community members and civil society organizations. The regular assessment and patient satisfaction survey can contribute to further improvement in quality of these clinics and this will be essential as more clinics are being set up. Despite India being considered as an Information and communication technology (ICT) hub, the use of ICT at these clinics has been found very limited. An adaptation of Mohalla clinics in Telangana state of India as Basthi Dawakhana has effectively used ICT platforms including the tele-medicine for consultations, which indicates the possibility and potential of ICT in improved health service provision.[6]

Mohalla Clinics at times are criticized for not delivering comprehensive primary healthcare services. While true, this criticism is unfair as these clinics were designed for a specific type of services, which these are delivering. Therefore, these clinics should be assessed against the objectives these were set up. The officials in state government of Delhi have repeatedly indicated that Mohalla clinics would be linked to appropriate facilities to make services provision comprehensive; however, that had not happened till March 2020. (Later, the COVID-19 pandemic had changed the priority actions and the focus at present is on response to pandemic).

In year 2018, nearly 15–20% of total patients who attended government health facilities for outpatient consultations attended Mohalla clinics. This may appear a small proportion; however, in that years only around 200 such clinics were functioning. Since then, by February 2020, around 480 Mohalla clinics were functioning in Delhi and everyday around 50,000 patients were being attended at these clinics. This number makes a significant proportion of all patients attending outpatient services at all government facilities. This number would understandably increase as and when the planned 1,000 such clinics would be set up.

One of the stated goals of these clinics was to reduce the overcrowding in government hospitals. By early 2020, the clinics did not seem to have achieved this objective. Possible explanation is that the initial care seeker at these clinics were those who were either not attending any health facility (pent-up demand for services) or were going to private (qualified or unqualified) providers. Whichever is the case, the government provision of such clinics has increased health services access and utilization and improved affordability of health services for poor and underserved populations. These clinics, clearly contributing to India's journey toward universal health coverage as envisaged countries latest national health policy.[34] There is need to make active and targeted interventions to shift people from hospitals to Mohalla clinics. Approaches such setting up screening OPDs at large hospitals and then giving preferential treatment for consultations at larger facilities to those who have attended and been referred from Mohalla clinics to next level of facility.

A recent study had listed these clinics as one of the potential model for expanding primary healthcare in India.[25] Many have argued that these clinics have placed health higher on the political agenda, as was noted in recent national and state level elections in India, a potential which can be further harnessed with engagement of community and civil society organizations.[35] The concept of Mohalla Clinics is being widely accepted by additional Indian states. In end September 2020, one more Indian state proposed to set up Mohalla Clinics.[36]

During the COVID-19 pandemic in early 2020, the clinics played a major role in assured provision of essential primary healthcare services in New Delhi. While the larger facilities and hospitals had suspended the outpatient consultation services, Mohalla clinics continued to provide the services. This was very useful where service continuity was assured yet risk of transmission was minimized. At later part of pandemic response in July onwards, select Mohalla Clinics of Delhi had also started offering COVID-19 laboratory testing services. Many of the staff posted at these clinics proven useful in fulfilling various activities related to COVID-19 including contact tracing. In August 2020, many of the Mohalla Clinics served as facility for expanded COVID-19 testing in Delhi.[37] These clinics once again proved that primary healthcare facilities can be essential for effective health services, in normal situations as well as during the health emergencies.

More than 9 months into the pandemic, it has become amply clear that high end super specialty facilities and technology driven solutions are useful but not sufficient in itself. The COVID-19 response success stories have emerged from countries such as Vietnam and Thailand.[38] Much of the success in COVID-19 pandemic response has been reported and emerged from the countries, which have over the years invested in stronger primary healthcare system as well as in public health services.[39],[40],[41]

One of the limitations of the finding in this review is that a few of the included studies were based upon smaller sample size of 3–6 facilities. None of the study except two published in peer reviewed journals were comparable in study design. The type of questions asked in each of these researches varied and there was no standardization. These limitations suggest the need for caution in generalization and interpretation of results. There is need for regular assessments and evaluation of community clinics in Delhi. A few comprehensive external evaluations and assessment, with robust research methods are needed to objectively assess accessibility, utilization, and quality of services provided and whether it has made an impact on the out of pocket expenses. The learnings and evidence can not only help Indian states but also the other low and middle income countries focusing on similar initiatives.


  Conclusion Top


Mohalla Clinics and the similar community clinics from Indian states have made primary care accessible and affordable to under-served population. These facilities have brought attention of policy makers in strengthening and investing on health services. These clinics have arguably placed health services, higher on the political and policy agenda in India. There is need to utilize this opportunity and develop mechanisms to ensure that community clinics results in delivery comprehensive package of primary healthcare services with inclusion of preventive, promotive, community outreach and other public health services. India's national health policy 2017 has proposed to strengthen primary healthcare for advancing toward Universal Health coverage and the community clinics are expected to accelerate this journey.

Key messages

  • Mohalla (community) clinics of Delhi, India are highly attended by target beneficiaries. These clinics have made primary care services accessible, available, and affordable to so far under-served populations.
  • These clinics are contributing to address inequities in health services utilization as more women, children, elderly, migrants and those who had no access to health services are attending health services at government facilities, free of cost.
  • Most of the beneficiaries who attended these clinics reported high rate of satisfaction. A findings also corroborated by high rate of repeat visits by the target beneficiaries for next health condition.
  • There are areas for further strengthening such as improved provision of medicines, better data recording and reporting system and increasing awareness about the location of these facilities.
  • Mohalla clinics played important role in continuity of essential non-COVID-19 health services during the COVID-19 pandemic period, even when large facilities were temporarily closed. The staff at these clinics contributed to surge capacity for COVID-19 response. The facilities doubled up as COVID-19 testing centers.
  • Indian states, which are setting up Community Clinics on the similar concept can learn from the experience and learnings from Mohalla Clinics of Delhi. The state government of Delhi should consider a detailed and scientific evaluation on functioning of these clinics.
  • The health services provision through Mohalla Clinics should be expanded to a broad range of comprehensive primary healthcare services. Each clinic should be linked with facilities providing public health services, to ensure people in catchment area received entire range of health services.


Disclaimer

Author is the staff member of the World Health Organization (WHO). The views expressed in this article are personal, and do not necessarily represent the decisions, policy, or views of the WHO.

Financial support and sponsorship

Nil.

Conflicts of interest

Author was involved in the design and scale-up of Mohalla Clinics of Delhi, India, in personal and honorary capacity.



 
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