The clinic at your doorstep: How the Delhi government is rethinking primary healthcare

Posted on May 25 2016 - 8:18pm by admin

Does eating spicy food give you rashes? Aarti, 12, wanted to know. She looked at her older sister waiting near the door of the doctor’s room at the mohalla clinic, in Nathupura village, Burari, North Delhi.

Dr CM Gupta, on duty during the evening shift, smiled at them and said, “No.” Aarti gestured to her sister, as if saying “I told you so.” The rashes were a result of a mild infection, the doctor explained. Humming a tune, he wrote out the prescription. The pharmacist handed over the medicines to the girls.

Aarti, a school-going girl, did not spend more than 15-20 minutes in the clinic. She actually sauntered in while running another errand and did not spend a paisa.

Aarti would not dream of going to a government hospital for a rash. If she had, she would have spent the whole day in at least three queues – one to register for an appointment, another to see the doctor, and one more to get medicines. Many skip the last line out of sheer frustration.

Clinic at your doorstep

Last month, the Aam Aadmi Party government in Delhi opened 100 mohalla clinics, targeting a population of 10,000 people each, on a pilot basis. Three of them – in Peera Garhi, Nathupura, and Mandavali – are permanent clinics that run between 7 am and 7 pm and are manned by doctors from the State Health Department. The rest function out of rented premises, where the Delhi government has hired private doctors, who see patients between 8 am and 1 pm.

People come to mohalla clinics for all kinds of minor health problems including fever, headaches, nagging coughs or colds, and skin ailments such as rashes, pimples, ulcers in the mouth, toothaches and check-ups for diabetes and blood pressure.

Patients walking into the clinic are given a token number from a token dispensing machine. When one’s turn comes, the patient meets the doctor, who examines him or her and writes a prescription. Some doctors use an electronic tablet that records essential information, including a photograph, of each patient. The prescription is printed on a slip, which is handed to the pharmacist who dispenses medicines free of cost.

The tablet and prescription that some mohalla clinic doctors are equipped with.

The tablet and prescription that some mohalla clinic doctors are equipped with.

Besides a doctor, each clinic has an auxiliary nurse and midwife, a pharmacist, and a lab technician.

The mohalla clinic at Peera Garhi, in West Delhi, which was set up last year, is also equipped with a Swasthya Slate, an Android-based tablet, that can test blood pressure, blood sugar, heart rate, electrocardiogram, body temperature with immediate results. However, the clinic has been using it sparingly (mostly for haemoglobin tests, the doctors said).

Clinic vs dispensary

There are 270 dispensaries in Delhi, the majority of which are run by the Delhi government.

But how are mohalla clinics different from these dispensaries?

Traditionally, a dispensary is a bigger premise as compared to a clinic. While dispensaries have a waiting area and several rooms and cost about Rs 3 crore to set up, a mohalla clinic can be built with just Rs 20 lakh, claim state officials.

The pharmacy at the Peera Garhi mohalla clinic.

The pharmacy at the Peera Garhi mohalla clinic.

“Some of our dispensaries have three floors with 25-30 rooms,” said Dr Avnish Bhargava, officer on special duty, Directorate General of Health Services, Delhi. “A primary health centre need not be run from such large structures. We are using Portacabins to build our mohalla clinics. These are pre-fabricated semi-permanent structures which can be assembled and also can be relocated easily.”

While medicines are supposed to be free of charge in dispensaries, AAP functionaries, including Health Minister Satyender Jain, said that the dispensaries often ran out of medicines.

The idea behind mohalla clinics is to decentralise primary healthcare even further. “We want to create 1,000 mohalla clinics. For every dispensary that targets 50,000 people, there must be five mohalla clinics,” said Dr Arun Banerjee, additional director, planning, Directorate General of Health Services, Delhi.

Dr Pankaj Kumar, who is on the evening shift at the Peera Garhi mohalla clinic in West Delhi, used to work at a dispensary at Khyala, another area in West Delhi.

“When we used to start work [at the dispensary], there would be a long line of people outside,” said Dr Kumar. “You can’t chat at leisure with a patient as you know there are about 150 to 200 people waiting. Yaha kaam karne main maza aata hai. (I enjoy working here). At its peak, there is a crowd of about eight to 10 people waiting.”

However, not every dispensary is crowded. For instance, the dispensary in Chattarpur, South Delhi, that this reporter visited, seemed to have a steady flow of patients, with a wait of about 15-30 minutes at the most. The dispensary at Rohini, in Northwest Delhi, was also not too crowded, and it took patients about half an hour to get treatment and pick up medicines from the pharmacy.

Minimum expense

A government hospital or a dispensary can be very intimidating place. The bigger the unit, the more difficult it is to navigate, especially for an illiterate or a semi-literate person.

Before the mohalla clinic was set up in Nathupura, Suman, 48, who runs a vegetable mart in the village would go to private doctors whenever she had a health problem. “The nearest hospital is Hindu Rao Hospital, at least half an hour to 45 minutes away,” said Suman. “I would spend at least Rs 100 on travelling first by an auto-van and then by bus. It was easier for me to see private doctors.”

The dispensary closest to Peera Garhi’s Rajiv Gandhi Punjabi colony relief camp is the one at Pashchim Vihar, about a kilometre away. A sick person would have to take a rickshaw, or brave the Rohtak road to reach the dispensary. It is open only between 8 am to 1 pm, but is extremely crowded. The wait there, people from the relief camp said, is a minimum of two hours.

Waiting for treatment also costs money, as people lose their day’s earnings. “In a hospital, a patient has to spend two to three hours waiting for the doctor, then again wait to take medicines, and then come again the next day to collect test reports,” said Delhi Health Minister Satyender Jain. “If you consider the patient’s lost time and the money he or she spends to reach the hospital, it would be about Rs 500 to Rs 600. How will a poor man spend so much? We wanted to build a clinic that people can walk to.”

Dispensaries see about 300-350 patients in the six hours they are open, while mohalla clinics see about 100-150 patients in the same time.

A doctor examines Munna Singh, a physically handicapped person, outside the Krishna Nagar clinic.

A doctor examines Munna Singh, a physically handicapped person, outside the Krishna Nagar clinic.

For a physically challenged person like Munna Singh, it is even tougher to go to a public hospital. Whenever he fell sick, the 48-year old resident of Krishna Nagar in East Delhi would get his wife to take him to Dr Hedgewar Aarogya Sansthan, a secondary district level hospital, in Karkardooma.

Singh was employed as a mason when he fell from a roof in 2000 and lost the use of his legs. He now moves around in a makeshift wheelchair. When Singh visited the Krishna Nagar mohalla clinic for the first time, he found that the rented premise was not wheelchair-friendly. However, he was surprised to find that the doctor on duty was willing to examine him on the road.

He was suffering from cough, fever, and body ache for nearly a week. This was his follow-up visit. He complained of fever despite the earlier treatment.

The doctor examined him and changed his prescription. “Earlier I had to go to the hospital for every small ailment,” said Singh. “My wife works as a house-help and she would have to take a day off to take me there. Now, someone has to just lift me and put me on the wheelchair. I can come to the clinic by myself.”

Free medicines and diagnostics

In the four clinics that visited, medicines were freely available, except for a shortage of one particular formulation at the Krishna Nagar clinic.

Unlike many general practitioners who give out open tablets in small packets, at these clinics, the strips of medicines are cut to give patients the exact number of tablets prescribed. Many patients complained of cough, and were liberally given bottles of cough syrup.

Apart from rapid diagnostic tests such as digital blood pressure monitors and glucometers (for random blood sugar tests), lab technicians in these clinics collect samples for more than 212 tests that are conducted free of cost. Many patients come to the clinic not for treatment, but just for the tests.

Aakash Raj, 25, who was suffering from fever and vomiting, had visited the Charak Palika Hospital in Moti Bagh, South Delhi, but was unable to get tests done at that hospital. Raj, who lives in Munirka, then decided to try out the new mohalla clinic near his home for his tests, and got them.

Quacks out of business

Mohalla clinics are set up in slums or villages, which have less access to primary healthcare, despite needing it the most. The areas Scroll.invisited were either highly congested or polluted. Nathupura, for instance, has open sewage lines, while Munirka village is very congested with small-scale enterprises running inside the residential colony.

Many people are daily wage workers who may not want to travel to a far-off dispensary or a hospital. The only option they had before mohalla clinics was to go to a private doctor, many of them with nonexistent, or dubious, degrees.

In Nathupura, and Munirka, private clinics, and laboratories flourish because of the lack of medical facilities for the poor in the area. Some areas like Peera Garhi had plenty of quacks and practitioners of a controversial system of medicine called Electropathy. In Peera Garhi’s Punjabi clinic, these so-called doctors admitted that the mohalla clinic was taking away their patients.

AK Sharma prescribes medicines, including antibiotics, despite not having a medical degree.

AK Sharma prescribes medicines, including antibiotics, despite not having a medical degree.

A few minutes’ walk from the Peera Garhi mohalla clinic is the practice of self-styled doctor AK Sharma, who has studied upto Class 12. He said he trained under an Ayurvedic doctor for 10-15 years before he opened his clinic in Punjabi colony. There are plenty of medicines on his shelves, which he dispenses to his patients. He said that he gave paracetamol for cold-cough, and augmentin (an antibiotic) for fever. “Clinic se bahut farak pada hai (The clinic has reduced my business),” said Sharma. “Earlier, there would be 70-75 patients each day. Now I get 10-12 patients a day.”

A midwife, Sudesh Nayyar, handles pregnancies in the area. In her air-conditioned room which also serves as a clinic, saw many hormonal pills that are given to women during pregnancy. “I do the work of first aid. I only give desi dava (medicines),” said Nayyar.

Earlier, people had no option but to visit these clinics. “My two children were delivered with Sudesh only,” said Shalu Kohli, a Punjabi colony resident. “I was lucky to not have complications, like some other people I know. Now, we have better options.”

This is the first part of a two-part series on public healthcare in Delhi. The next article will run tomorrow.

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