Supporting the Government of Delhi to improve primary healthcare via the mohalla clinic programme

The urban poor in India have low access to affordable and high-quality primary healthcare. This leads to poor health outcomes and makes them more vulnerable to health-related financial shocks. Between January and June 2019, IDinsight worked closely with the Department of Health and Family Welfare, part of the Government of Delhi, focusing on local primary healthcare clinics called “mohalla clinics” which were designed to provide low-cost high quality services to India’s urban poor. This post outlines our main findings including what’s working with the mohalla clinics, what challenges the program faces, and our recommendations to address these challenges ahead of scaling up the program. These lessons or approaches may also be applicable for other low-cost health solutions targeted at low-income urban residents.

Background

In June 2019, 189 primary healthcare clinics, called Aam Aadmi Mohalla Clinics, were set up locally in neighbourhoods across Delhi. These clinics provide free consultations, medicine, and diagnostic tests, all in the same location, in an effort to make healthcare easier for residents to access. Since their creation in 2015, they have provided more than 10 million consultations. Other Indian states are also now looking to adopt Delhi’s mohalla clinics model to provide primary healthcare to their residents. In our study, we found that most patients visit one of the mohalla clinics because it is the closest facility to their home and because it offers free services.

As the Government of Delhi scales the program to 1000 clinics, we supported them to better understand three aspects of the program – awareness, usage, and service delivery. We conducted two sample surveys to understand their effectiveness. One survey (“the exit interviews”) sampled more than 1700 patients at existing mohalla clinics. The other survey (“the general population survey”) sampled more than 1400 households of intended beneficiaries, it targeted those living within 1 or 2 kilometers of the clinic. Through these sample surveys, we aimed to answer three key questions:

1.       What proportion of the general population are using these clinics?

2.       What additional services do the intended beneficiaries want to receive at the mohalla clinics?

3.       Are mohalla clinic patients satisfied with the care they receive? How can the clinic be improved to make patients more satisfied?

Figure 1 below shows the location of all clinics in whose catchment area we conducted the general population survey, and Figure 2 shows the location of all clinics where we conducted the exit interviews. For each type of survey, we randomly sampled mohalla clinics from the list of all clinics, ensuring coverage from all assembly constituencies that had at least 1 clinic.

Figure 1: Sample size and details of the general population survey in the catchment area of the clinic

Figure 2: Same size and details of exit interviews conducted with Mohalla clinic patients

Below, we outline a simple theory of change for how the mohalla clinics could improve patient satisfaction and ultimately health outcomes in the city. Our theory of change indicates that once residents know about the proximity and free consultative services that Mohalla clinics provide, they will service them more regularly for their primary healthcare needs.

We structure our findings to provide insights on the last three links – awareness, usage, and service delivery – in the “steps to a satisfied patient” figure below.

Figure 3: A simple depiction of the theory of change from setting up of mohalla clinics to increased patient satisfaction, with the ultimate objective of improving health outcomes for Delhi residents

A summary of our takeaways highlights a missed opportunity among patients to use primary care at mohalla clinics

1.    Only about 40% of respondents in the catchment area of clinics were aware that there was a mohalla clinic in their neighborhood. Most of them had become aware of the clinic because they saw the clinic and word-of-mouth.

2.    Of respondents who had accessed healthcare facilities in the last three months, 36% could have used a mohalla clinic but had not done so. We estimate this based on the percentage of residents in the catchment area who visited another healthcare facility in the last three months and reported a set of nine symptoms (specified below) that could have been treated at mohalla clinics.

3.    Once the patients visited a mohalla clinic, though, they reported receiving services that were either at par or better than other public or private medical facilities.

Key takeaways

1.    Lack of awareness of Mohalla Clinics

About 40% respondents in the catchment area of clinics were aware of a mohalla clinic near them. Respondents who lived farther away from the clinics were less likely to be aware that they exist.[1] Of those who were aware, a majority had either heard about the clinic from their friends or acquaintances or had seen the clinic from outside.

Figure 4: Channels through which respondents learned about mohalla clinics

To increase awareness, we recommend that the Government use localized campaigns in the areas where these clinics are established.

2.    A shift towards Mohalla Clinics instead of other facilities

About 74% of respondents who accessed healthcare in the last three months visited a government healthcare provider. Of these, about 40% had visited a government hospital, 17% a government dispensary and only about 15% had visited a mohalla clinic. Patients who reported the same symptoms reported visiting either mohalla clinics or providers at another healthcare facility, indicating that they weren’t taking advantage of the low-cost alternative at the mohalla clinics. The most common reported symptoms, such as fever and cough-cold, are the kinds of symptoms the mohalla clinic is well placed to handle.

Figure 5: Type of government health care provider visited by respondents in the last three months

We further estimate that 36% of respondents who accessed healthcare from another facility during the past three months could have used mohalla clinics but did not. The estimate calculates the percentage of respondents who visited another private or public health facility for the following 9 symptoms – fever, cough/cold, vomiting, diarrhea, body pain, abdominal pain, blood pressure, diabetes. In particular, respondents without a formal education in our sample were more likely than respondents without a formal education to use private or other government health facilities, as compared to mohalla clinics.

Figure 6: Healthcare facilities used in the last three months by respondents without a formal education

Within the public healthcare system, only a small proportion of those living in the catchment area have shifted from using government hospitals to mohalla clinics for primary healthcare. A larger shift can come from greater awareness, trust, and superior service delivery at the mohalla clinics. Our recommendation here is for the government to test different interventions such as incentives for doctors who refer patients to mohalla clinics or posters at hospitals to nudge patients to use mohalla clinics instead of other public facilities for primary care.

3.    Increased patient satisfaction at mohalla clinics

Many services at mohalla clinics were reported as either at par or better than other facilities[2], and 97% of mohalla clinic patients stated that they would return for treatment. However, there is still scope to improve the quality of care and clinic infrastructure: Ten percent of the respondents said medicines were unavailable at mohalla clinics at least once in the last three months; Twenty-three percent of respondents found the clinic to be somewhat clean; whereas 2% found it not clean. Forty percent of respondents suggested improvements to the mohalla clinics in terms of regular availability of staff, diagnostic tests, medicines, or clinic infrastructure like drinking water and waiting area size.

Figure 7: Service quality at mohalla clinics compared to other facilities

Emerging recommendations

While patient satisfaction with mohalla clinics is generally high, some challenges persist with awareness creation and further shifting patients towards using medical services at these clinics. The government can also make small improvements in services at the clinics to further increase satisfaction. As the government scales up the mohalla clinic programme, we recommend the following actions to strengthen the program: [3]

1.       Increase awareness of mohalla clinics in the area through localized campaigns or by making it easier to locate clinics using their geo-coordinates.

2.       Test interventions that can shift people towards mohalla clinics from other higher-cost primary health care facilities

3.       Further patient satisfaction at mohalla clinics through regular monitoring of quality of care and improving infrastructure at the clinics.

Figure 8: Key takeaways and emerging recommendations

Views expressed here do not reflect those of the Government of Delhi.

Footnotes

[1] We test the hypothesis by regressing awareness of clinic on distance of the household from the clinic, while accounting for clinic level effects. The coefficient is significant at 5% significance level.

[2] We asked about 1700 patients exiting from mohalla clinics about their experience, satisfaction and areas for improvement at the clinic. Similar questions were also asked to those living in the catchment area of the clinics and visiting other healthcare facilitates.

[3] We are working with the Government of Delhi to help implement some of our recommendations, and exploring a scope of work for a future engagement.