|Year : 2022 | Volume
| Issue : 1 | Page : 18-22
What brings people to government urban primary care facilities? A community-based study from Delhi, India
Nitish Virmani1, Ishaan Mittal1, Chandrakant Lahariya2
1 The Economics Society, Shri Ram College of Commerce, New Delhi, India
2 Executive Director, Foundation for People-Centric Health Systems, New Delhi, India
|Date of Submission||09-Apr-2021|
|Date of Decision||09-Mar-2022|
|Date of Acceptance||10-Mar-2022|
|Date of Web Publication||30-Jun-2022|
B-7/24/2, First Floor, Safdarjung Enclave Main, New Delhi - 110 029
Source of Support: None, Conflict of Interest: None
Introduction: Mohalla or Community Clinics of Delhi, India, provides free primary care services to the general population, with special focus on the underserved and marginalized. This study was conducted to analyze the perception and experience of target beneficiaries and to understand and document the determinants of people visiting these clinics.
Material and Methods: A community-based study was conducted from October 2019 to April 2020. A semi-structured questionnaire was used for data collection. Correlation and comparative analysis were used. Thirty-seven Mohalla Clinics and their catchment areas were visited. A total of 391 respondents (including 35 health staff and 356 community members) were included.
Results: Proximity of clinics, waiting times, age, perceived quality of treatment, and cleanliness at facilities were the factors that influenced the usage of clinics. Lack of first-aid facilities and long waiting time (at a few facilities) were identified challenges. There is a need for wider publicity and awareness about the clinics and regular analysis of data to determine an appropriate mid-course action to further increase utilization.
Conclusion: Community Clinics of Delhi, India, have brought people back to government primary healthcare (PHC) facilities. The popularity of these clinics has encouraged a number of Indian states to set up similar facilities. The factors behind their success need to be studied in detail to derive lessons for making urban PHC accessible in other low- and middle-income countries.
Keywords: COVID-19, India, Mohalla Clinics, primary healthcare, public health, universal health coverage
|How to cite this article:|
Virmani N, Mittal I, Lahariya C. What brings people to government urban primary care facilities? A community-based study from Delhi, India. Indian J Community Fam Med 2022;8:18-22
|How to cite this URL:|
Virmani N, Mittal I, Lahariya C. What brings people to government urban primary care facilities? A community-based study from Delhi, India. Indian J Community Fam Med [serial online] 2022 [cited 2022 Aug 17];8:18-22. Available from: https://www.ijcfm.org/text.asp?2022/8/1/18/349379
| Introduction|| |
Mohalla or Community Clinics were launched in Delhi, India, in July 2015, with one of the stated aims to provide quality primary care services to poor and underserved urban population communities closer to their doorsteps., Soon after the launch, these clinics witnessed higher footfall of target beneficiaries than the other existing health facilities. The details on design and concept behind have already been published in peer-reviewed journals in the past.,, Encouraged by the response, the state government of Delhi had expanded the facilities in 4½ years after the launch of the first clinic. By the beginning of 2020, before COVID-19 pandemic-related disruption of health services started, there were 480 functional Mohalla Clinics in Delhi, India. By early 2020, more than a dozen Indian states or cities had either started or were planning to set up community clinics., As the state governments were planning to scale up and launch similar clinics, this study was planned to understand the perception and experience of target beneficiaries (about these facilities) and to analyze and document the learning for further improvement.
| Material and Methods|| |
This was a community-based cross-sectional study conducted from October 2019 to April 2020, with primary data collection in October–November 2019. Eight of the 11 administrative zones in Delhi were selected purposively. To ensure representativeness, five sampling units from each of eight zones were included. Within each zone, the study units were purposively selected to ensure a mix of both densely and sparsely populated areas. In each zone, urban localities within proximity (i.e., within a 1 km radius) to a Mohalla Clinic were selected. In each sampling unit, 10 respondents were interviewed.
Data collection and study tools
Two separate questionnaires – one for the residents and another for the doctors/healthcare workers staff – were developed and pretested in the study settings. The questions were focused upon health conditions for which people were seeking care, on time taken to reach the clinic and being attended by a doctor, whether medicines were dispensed, and other related aspects, in line with the objectives of the study. All interviews were started with informed consent of the respondents, and anyone who refused to participate was excluded. Data was entered in Microsoft excel sheet and analysis was done using IBM SPSS version 21. The study was approved by Institute Ethics Committee of the research institute.
Averages, percentages, correlation, and comparative analysis were used for data analysis, as per the stated objectives.
| Results|| |
A total of 391 respondents (356 community members and 35 were doctors and other health staff at Mohalla Clinics) included in the study. The average age of the respondents was 41.6 years, 49% were males, while 82.2% were from the low-income groups [Table 1]. Ninety three percent of the respondents were aware of the location of Mohalla Clinics and 73.5% of the respondents had ever visited a clinic at least once. Awareness about the clinics increased with the age of the respondents, and around 97% of the respondents aged above 40 years were aware of these facilities [Table 2]. Most reported to have received services within 1 h, and around 17% of the respondents reported waiting time between 1 and 2 h.
|Table 1: Descriptive information and profile of respondents in the study|
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|Table 2: Awareness and utilization of Mohalla Clinics by different age groups|
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Nine of every 10 respondents found doctors to be cooperative and gave an average rating of 4.1 out of five. Forty-nine percent of the respondents had at least one test conducted from these clinics, and more women were advised to undergo a test than men (55% for women vs. 41% in men). Three-fourth of all respondents reported that they had access to clinics within 10 min of walking distance.
The government had announced providing a tablet to each Mohalla Clinic for record-keeping; however, only 18% of facilities had any such tablets. Majority of these clinics maintained a register for record-keeping. Cleaning and sanitation of facilities was rated as good, by respondents, in most of the clinics; with the exception of a few clinics that were poorly maintained. At a few places, toilet facility for patients was not available. It was noted that the poorly maintained clinics had lower average daily visits having a negative correlation. The average waiting time decreased considerably, with an increase in the staff having a negative correlation of −0.632. Even the slightest difference in average staff strength resulted in a dramatic change in the waiting time. Around 90% of the zones which had an average staff strength of 4 had average waiting times between 15 and 20 min, while all zones with average staff strength less than 4 had waiting times upward of 25 min. The average age of the patients was found to be positively correlated with the number of visits [Table 3].
| Discussion|| |
The provision of primary healthcare (PHC) services through community clinics with doctors, nurses, and other staff as health team, for every 2000–7000 population, is a widely practiced norm in many countries.,,,, However, in India, one urban PHC facility is located or available for every 50,000 people., Therefore, setting up Mohalla Clinics in Delhi increased the availability of health facilities with doctors fivefold. The selection of the sites for these clinics was also in those areas which were underserved till then. This increased the availability and accessibility of health services by poor and underserved people. This indicates that the provision of the health services as per the needs of the population and closer to the people can result in increased utilization and bring people back to government healthcare facilities.
The study found sustained high attendance at nearly all the clinics. However, the sustained and high demand for services and the high average attendance at many of these clinics in due course meant that there was an increased waiting time for people attending the facilities. This had countered one of the advantages of these clinics, which was of reduced waiting time and early access. Recognizing the challenge, the state government made the facilities with average daily attendance of 150 or more per day into two shifts per day, with separate staff for each shift. Such approach is indicative of responsiveness of policymaking to meet the needs of the people. The fact that majority of the people who started visiting a Mohalla Clinic were earlier attending private (formal or informal) healthcare providers indicates that if health services are provided by the government with assured provision and good-quality services, people would start the using these services.
The utilization of Mohalla Clinics has been higher among the older people as in line with the fact that majority of health conditions increase with age. Moreover, distance and long waiting time discourage older people from attending healthcare facilities. Therefore, these clinics are partly addressing health needs of elderly and women, who otherwise are dependent upon adult members of family for decision-making on health needs.
There is still untapped potential through these Mohalla Clinics. As an example, the need for mental health services in India is increasingly being recognized, which has been further increased after COVID-19 pandemic. Most of the mental healthcare services are available at larger facilities and specialty centers in large towns. In the absence of sufficient services, the pathway adopted by patient is long and start with informal and unqualified providers. Similarly, the urban migrants and underserved have informal employment and are at risk of occupational and environmental health challenges., Yet, services for these are not available closer to the people and primary care providers have not adequately been trained and equipped in offering such services. A number of countries such as Thailand and South Africa in recent years have rapidly expended the delivery of occupational and environmental health services through primary care system services. As other states consider such clinics, the provision of such specialized services of mental health and occupational health should be considered through these primary care facilities.
One of the impacts of these clinics has been that a number of Indian states have started a variant of community clinics,, or started on other initiatives to strengthen PHC. As an example, soon after the release of India's National Health Policy 2017, to strengthen PHC system, an initiative by the name of Health and Wellness Centre (HWC) was launched in April 2018. This aims to extend the package of services and mental health services through PHC system. Therefore, both HWCs and Mohalla or other community clinics in India are important opportunities to expand and deliver a wide range of occupational and environmental health-related services, as per the health needs of a specific population. Both initiatives also focus upon nonmedical needs such as cleanliness of facilities, proper waiting areas, running water, and clean toilets for use by the patients as well. This will make health services responsive and has potential to increase the use of government PHC facilities in India.
Yet, community clinics are not without limitations and challenges. There are areas for further improvement, which should be given attention for corrective measures. These include the need for rationalization of workload, attention to improve the quality of service, wider publicity and awareness in local communities to increase the use, and regular analysis of data to determine an appropriate mid-course action.
While conducting a literature review, it was found that there is very limited primary research and assessments on Mohalla Clinics of Delhi and other community clinics in India. One aspect is that health systems and policy research in India are often underfunded, and at times, there is limited and insufficient expertise. This, on the one hand, underscores the need for establishing institutional mechanisms for such research. Alongside, it is proposed that while starting such clinics, the policymakers 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 due to the factor that most of the research capacity is based at tertiary-level facilities and academic institutions and the physicians working in PHC are not always involved in the health research. The capacity building of PHC providers in design and implementation of health services and research through institutional mechanisms needs to be streamlined and sufficiently funded.
The importance of the community clinics as hub for PHC services was further recognised when in the ongoing coronavirus (SARS-CoV-2) or COVID-19 pandemic has been extensively recognised. These facilities had played an important role and points of entry for many patients to healthcare services as well as to offer the COVID-19 testing services as well. However, 2 years into the COVID-19 pandemic, as all other services had been disrupted, some of the functioning of Mohalla Clinics had been disrupted. This is a reminder that we also need rework and strengthen all type of health facilities and services.
| Conclusion|| |
Community Clinics of Delhi, India, are making health services available, accessible, and affordable for poor and marginalized. These facilities have resulted in increased utilization of government primary care facilities by many of the people who were earlier attending private (formal or informal) providers. Part of higher utilization of these government facilities can be attributed to these being responsive to the health needs of population. These facilities could be a good model for urban settings in other low- and middle-income countries.
This work was conducted as part of “Project Jaankari” of the Economics Society, Sri Ram College of Commerce, New Delhi. It could become possible because of team efforts and the authors would like to thank a number of colleagues who directly or indirectly contributed (names listed in alphabetical order, by the first name): Aadithya Sumod, Aaradhya Daga, Aastha Gaur, Akshit Gupta, Amogh Sangewar, Amrit Chadha, Anshdeep Singh Chadha, Anudhii Sundaram, Anurag Juyal, Arham Mehta, Arpita Rathi, Aryaman Dhiman, Divyam Gupta, Eeshita Verma, Himanshu Chhabra, Hrithik Gupta, Ishika Daga, Ishita Desai, Keshav Ahuja, Khushi Srivastava, Krittika Chowdhury, Madhumanti Adhikary, Mahir Dhariwal, Nakul Gupta, Pankhuri Srivastava, Parth Chowdhary, Rohan Kohli, Saksham Singh, and Sarvesh Agrawal. We are also thankful to all health staff and respondents who were extremely vital for successful conduct of this study.
Financial support and sponsorship
Conflicts of interest
CL was a staff member of the World Health Organization (WHO) at the time of completion of this study. The views expressed in this article are personal and do not necessarily represent the decisions, policy, or views of WHO. Other two authors (TA and SB) have no conflicts of interest.
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[Table 1], [Table 2], [Table 3]