12 things to know about Mohalla Clinics and the way these are strengthening Delhi healthcare system

I have been closely following AAP governance in Delhi and their healthcare evolution. The Delhi government is moving towards better and affordable healthcare system. The Delhi healthcare system is world-wide discussed and praised by many other countries. After its implementation in Delhi, many other states in India have also proposed to implement a similar healthcare system. I found a very well written article from Amar Kumar on Quora.com. The article explains the Delhi mohalla clinic system very well and their efficiency level. The article is not a media reporting and can be discarded as fake article. Since I have following mohalla clinic news since beginning, I found all the details in article remains true and are existing on internet either by media reports or ground reports/updates from ministers on their twitter/Facebook accounts. Read the Quora article here.

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Kejriwal’s team has cheated the standards set by National Health Mission.

Yeah this might appear scandalous but that is how the Health Minister Satyendra Jain rolls. Jain’s biggest achievement is to think like an ethical hacker, he breaks many of the existing assumptions and conventions. You might have read 100 articles/posts/tweets about benefits of Mohalla Clinics by domestic media, international media, scientific journals and organizations, but this answer will unveil the actual root causes of these benefitswhich no other article has pointed out. What is so special about it? Why was not this thought of before? Is it all a mirage created by few supporters? Why is head of WHO finding this solution innovative? At the end of the day it is a single doctor sitting in a small room, isn’t it?

<Prologue>
Jain narrates this hilarious incident from his visit to a dispensary. It had a staff of nineteen people, but only one was doctor. So this was the conversation-

Jain- What is the biggest issue at this dispensary?
Employee- Shortage of . . . . . . . . . staff
J- What do you do?
E- I make entries in this register.
J- How many done today?
E- 36
J- What does that guy do?
E- He also makes the entries but in a different register.
Jain - *facepalm*

So the root issue is, as Jain explains, government has never used manpower efficiently. The underlying paradigm is flawed - Trying to solve a problem by throwing money at it and increasing staff. Another example - A 30 bed maternity hospital with 20 doctors and a lot of staff, do you know what was the output? 17 deliveries! Not per day or per week. Mind boggling 17 deliveries per month at a cost to government of Rs 2 Lakh per delivery!Jain closed the hospital. A politician closing a hospital would be termed as suicide by pundits!! But he converted it into polyclinic and today 1500 patients benefit from that polyclinic.

<prologue ends>

So coming back to the original question? What is so special about Mohalla Clinics (MCs)? There are about 12 reasons among two broad categories- Approach taken and Impact created

PART ONE - APPROACH TAKEN

First, Jain ignored the Primary Healthcare Center definition as stipulated by National Health Mission. When the idea was floated then government officers said that if we want to call it PHC then we need to provide all these 8–9 services. Jain said “Fine, lets only cover 6–7 of these and not call them PHCs”. Government officers: “Then it’s OK”. Jain simply ignored the existing standards and created a new standard.[1]Another radical approach was to create 100 “dummy clinics” which are identical to proposed clinics in terms of service but rather in a rented room. All of these will be dismantled later, they only serve the purpose of preparing the backend supply chain for the full scale expansion.[2]

Second, Enormous scale - a model of going from 0 to 1000 clinics in a city, this is one of a kind model across the nation and perhaps even world! Initial target was 500 in first phase and 500 in next. After the feedback, Kejriwal decided to go thousand in one phase.[3]So how come they can envision such a scale? When no other government could think of doing such thing, read the next three points.

Third, Nature of construction - prefabricated “Porta cabin”, a temporary structure.

This implies - faster construction time as they don’t need to dig a foundation or erect any brick walls. This one at Tilak Nagar was constructed in 15 days![4]

Fourth, Bureaucracy circumvented - By the virtue of being temporary structures, they don’t require any of the construction permits. Another factor which enables enormous scale is ability to award bulk tenders. Can a government give out tender of constructing 250 dispensary buildings to one contractor? AAP govt can do so in case of MCs: 4 contractors for 1000 clinics![5]

Fifth, Very low cost i.e. 4% of the earlier budget! - Rs 20 Lakh instead of the usual 5 crore for a full fledged dispensary building.[6]Of course a dispensary will have more space and lifespan, but MCs are almost equal in terms of range of services. In fact MCs are fully air-conditioned and hence more comfortable for visitors.

Sixth, In-house testing capabilities - Of the 200 free tests many can be conducted few meters away from the doctor’s table which is unique on this scale. For other tests patients just needs to visit one more time.[7]

Seventh, Zero employees in 1000 clinics: Whole staff is “empaneled” and none are hired as state government employee. Advantage is that government can quickly recruit as many as they want, the process of hiring permanent employees can take decades. Doctor is paid less per patient than a cobbler makes per customer!, still many of them ends up making more than 1 Lakh per month for 4 hours of duty![8] As a result of such incentive structure doctors behave nicely with every patient so that they keep visiting. Some instances of fake patient billing have been noticed, but such issues won’t remain for long as analytic algorithms can be used to detect abnormal patterns and blacklist such criminals.

Eighth, Cutting edge digital technologies - Doctor enters all the details via a tablet. Now patient will not have to carry their medical records, even if they visit another clinic. In the pic below you can see another innovation- Medicine vending machine, patient shows the prescription and machine dispenses the required medicine.[9]

PART TWO - IMPACT GENERATED due to the above mentioned 8 approaches

Ninth, Proximity. As it is a small structure with minimal construction time, it can be erected bang in the middle of most populous areas. It doesn’t matter if it is a slum or unauthorized colony. In fact the very first one was constructed in a illegal colony with barely any streets, forget about roads.[10]This factor of proximity creates many more additional impacts like the next few reasons.

Tenth, Doctor visit is no longer a four day mission for poor. In earlier scenario

Elders and ladies needed an accomplice to travel.
If the bread winner had to accompany then he would miss his daily wage
If there is a need for tests he would miss wages 2 more times -for tests, for collecting test results and then second doc visit.
Additional expense for travel - Auto/Bus
Additional expense for tests
Additional expenses for medicines

Due to all these issues even a labourer would directly go to nearby private doc or resort tounqualified quacks (colloquially known as Bangali Babas) who usually prescribes steroids to suppress the symptoms rather than curing the issue.[11] Now this 4 day saga has drastically reduced to mere 15 minutes-

Rupandeep Kaur, 20 weeks pregnant, arrived at a clinic looking fatigued and ready to collapse. She was taken to see a physician who reviewed her medical history, asked several questions, and ordered a series of tests. These tests revealed that her fetus was healthy but Kaur had dangerously low hemoglobin and blood pressure levels. The physician ordered an ambulance to take her to a nearby hospital.

All of this, including the tests, happened in 15 minutes. The entire process was automated — from check-in, to retrieval of medical records, to testing and analysis and ambulance dispatch. The hospital also received Kaur’s medical records electronically. There was no paperwork filled out, no bills sent to the patient or insurance company, no delay of any kind. Yes, it was all free. Had she not received timely treatment, she may have had a miscarriage or lost her life. [12]

Eleventh, Hidden patients are being discovered: Earlier scenario for poor people:

Wait for the problem to appear
Wait until it’s unavoidable
Wait more
Finally visit the doc as mentioned in the point above and after 2–3 days of running around get the final prescription
Take it or leave it (in case prescribed med is costly)
Keep on going till the body fails again [13]

Today, even if they don’t have any serious problem, they are visiting for minor symptoms e.g. elders visiting for back pain are getting the BP/sugar checked along with the consultation. Many are detecting shocking level of type 2 diabetes/ hypertension for the first time. If these “non-urgent” patients are treated earlier, then will save govt a lot of efforts at a later stage, like this doc caught few cases of typhoid and early stage canceramong MCs visitors.

Twelfth, Incredible cure rate - Clinics were predicted to have cure rate of 85% but surprisingly the actual cure rate turned out to be 97%!![14] This will reduce the crowds in hospitals. Right now, it is becoming difficult to differentiate between crowded railway platforms and hospitals.

All these 12 factors are one of a kind, hence many countries/states are intrigued by the concept of MCs. If you are interested in knowing more details then watch this documentary. MCs is a minor achievement of Delhi health dept there is much more, read this answer to get an idea on how Jain is on his way to create a Scandinavian system in a third world country.

How freaky is this. 10 days after I mentioned Scandinavia in my original answer. This lady from Norway said “The health reforms in Delhi strike me as an excellent strategy to build an inclusive health system in India” [15]

Why is garnering such feedback from this lady extraordinary?

Norway is Ranked one i.e. best nation on the planet as per Human Development Index
She has been three time Prime Minister of Norway,
It gets bigger - She was Director General of WHO, this post is like Health minister of planet earth

Finally, why doesn’t media focus on positive aspects like these? Why no prime time discussions over Health agenda? Is all of media biased and paid? NO! The actual cause of this state of media is you, the viewer. Positive news like these are boring, they don’t bring much TRP and as a result low revenue. We humans are wired like this, we might hope for positive news but we give our attention to negative/sensational news only.

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Watch Mohalla Clinic video here explaining its facilities, test and efficiency.