Aam Aadmi Mohalla Clinic: A paradigm shift in India's healthcare system

Aam Aadmi Mohalla Clinic, Zakir Nagar

Last week, when I took my roommate suffering from high fever to a Doctor in a nearby private clinic in Safdarjung Development Area, New Delhi, he charged Rs. 800 just to write paracetamol as prescription. She had to pay Rs.1500 for the blood test. The cost of the whole treatment of viral fever was around Rs. 3000. While, she can afford to pay this amount, there are many who try to avoid going to a doctor until things become very serious. Treatment of a single member suffering from a life threatening disease causes a big hole in family budget. In our country where the private hospitals/clinics are slammed for charging extremely high and the government hospitals for their lethargic service, the common man is left with no option. One can only pray to die without any ailment.

I heard about Aam Aadmi Mohalla clinics few days back and I was curious to visit there and check how this new healthcare initiative is working. Before I get into the details of the clinics that I visited, here is a quick analysis of the concept of Mohalla clinic:-

What is Aam Aadmi Mohalla clinic?
Aam Aadmi Mohalla clinic is a pilot project of Aam Aadmi Party to make primary healthcare more accessible to people. More than 100 Mohalla clinics are opened across the length and breadth of Delhi. The locations for the clinics are purposely chosen to cater the poor and downtrodden. Medication and tests are done free of cost. The timings of the clinics are between 9 am to 1 pm from Monday to Saturday. The project is based on PPP model which involves the PWD (Public Works Department), WISH (Wadhwani Initiative for Sustainable Healthcare) Foundation for technical assistance and other private players whose tenders get selected.

How does a Mohalla clinic work?
The staff in a Mohalla clinic includes a Doctor appointed by the CDMO (Chief District Medical Officer), an ANM (Auxiliary Nurse Midwife) , a pathologist and a multi-tasker. As the clinic opens, the patients seek token from the ANM on First Come First Serve basis. Then the Doctor calls them serially. The Doctors are required to record the patients' details in a register as well as in an app provided to them. The details include - picture, name, age, gender, address, mobile no. , symptoms, diagnosis, prescription, provisional diagnosis and reference. 

The picture below depicts the home page of the app where the facility to register a new patient, patient's history (follow up), attendance of the staff, inventory (medicine stock), patient's list of the day, lab record and account is provided. As soon as the doctor enters the medicine in the prescription field of the app, the medicine count in the inventory decreases. This maintains the medicine stock in the clinic. The Doctors are required to sync the day's patient list with the server at the end of the day i.e. 1 pm after tallying it with the entries made in the register. The procedure is mandatory as the doctors, pathologist and multi-tasker are paid according to the number of patients they serve.

What is the salary of the staff?
The Doctor is paid Rs. 30 per patient, the pathologist is paid Rs. 8 per patient, the multi tasker Rs. 2 per patient while the ANM is paid a fixed salary. She is supposed to reach the clinic by 8 am and leave by 2pm. There is one ANM over every 10,000 people and under her works five ASHA workers. 

What is the average number of patients visiting the clinic everyday?
An average of 100 patients visit each Mohalla clinic everyday including senior citizens, kids, teenagers and middle-aged people. The number was 20 initially then increased to 70 and now it has reached 100. The number is bound to double in coming months. 

What are the demographics of the patients?
The patients are largely poor labour class people from immediate neighbour of the clinics. As the clinics are located deep inside the congested lanes without any sign board anywhere except on the building where it exist, therefore, the people knowing about these clinics are utterly few. It is only the word of mouth which is increasing the number of patients day by day. Many patients who come from far flung areas are mostly relatives and friends of the people living around the clinic. 

What is the limit of a Mohalla clinic?
Mohalla clinic is aimed at providing primary healthcare. Therefore, there are many diseases which the clinics are not equipped to deal with like the facility of ultrasound, X-ray, Pregnancy test (in some clinics), etc. The patient in such cases are referred to polyclinics or nearby government hospitals.

I had no idea about the location of these Mohalla clinics. I searched it on the Internet but couldn't find any address. I asked my hostel's security guard and mess workers, but they were clueless. In fact, their reaction to this term was worth capturing. Then, I read a few articles written so far on Mohalla clinics and found the mention of the area of these clinics. With the exact address still not available, I decided to ask the locals once reaching that area.

Aam Aadmi Mohalla clinic, Munirka 

The first Mohalla clinic I visited was in Munirka. I reached Munirka Bus stop and asked a vegetable vendor about Mohalla clinic. Even he was also not aware about the term. Then, I elaborated stating the name of Aam Aadmi Party, Arvind Kejriwal and free medicines. He directed me to a narrow lane beside him. It was dark due to converging buildings on either sides of the road, leaving little space for illumination. Although, it was luckily dry due to the sunny weather that day. I was consulting from every passer-by so that I could find at least one person who knew the place. I found a woman who was a regular visitor of the Mohalla clinic and knew it by name. She accompanied me till the gate of the Mohalla clinic. Meanwhile, I discussed about the clinic with her. She was satisfied with the medication. There was a big board on the clinic's roof bearing pictures of Delhi CM Arvind Kejriwal and Health Minister Satyendra Jain. Well, looking at the board, one might wonder whether it is a clinic or a party office. I opened the filmed glass door and to my surprise there was no place to walk to the doctor. I somehow managed to reach there. The room was well furnished and air conditioned (probably the reason why I was not feeling suffocated in the crowd). The Doctor, Shoebul Haque and his team were cooperative. An average of 100 patients visit the clinic everyday and about 20 blood tests are done. I talked to a few patients there--

Dhupcharan, 22, who migrated from Madhya Pradesh two years back, works at the Indira Gandhi International Airport, Delhi. He lives in Vasant Vihar Jhuggi with his family. Last week, he discovered difficulty in breathing, high fever and tight stool. He got himself checked in Swastic Clinic, a private clinic which recommended a blood test which cost him Rs. 470/-. He bought the prescribed medicines for three days at Rs. 236/-. Today, he has come to consult the doctor at the Munirka Mohalla clinic with the hope to get the same expensive medicines prescribed by the private hospital free of cost. He was given a paracetamol, ORS satchet and a medicine along with a cough syrup. He was not satisfied with the given medicines as they are different from the one prescribed by the private clinic. Dhupcharan came walking to the clinic along with his father Lakhan, 45.

Shweta, 26, a resident of Munirka migrated from Bihar 10 years back. She is now married and has three kids of age five, four and two. Five days back, she came to the Munirka Mohalla clinic to get herself and her eldest kid treated for fever. The medicine had resulted in pain, itching and allergy on their hands. Today, the doctor at the clinic has asked her to get the urine test done and show the reports next day.

Mohani, 67, lives in RK Puram. She is facing persistent stomach ache since last few days. The doctor at the Mohalla clinic has referred her to a government hospital to get ultrasound test done as the clinic lacks the facility. She is afraid of what will happen next. 

Aam Aadmi Mohalla clinic, west Patel Nagar, Patparganj

While I was standing in the queue like other patients, a middle-aged woman suddenly  came pushing everyone to get inside the doctor's room. The patients standing in the queue started shouting at her for breaking the line. She responded that she was standing there but went back to her home because she had forgotten the files. A heated argument started between the people waiting in the queue and her as it is not allowed to break the queue. The deadlock ended after Dr. Ranjana Saxena, the in-charge of this Mohalla clinic intervened to allow her to get in.

Sharmila Begum, 45, a resident of Vinod Nagar, suffering from Hypo thyroid, was standing in the queue since last 45 minutes for her turn to get the blood test done. She complains about the long duration that a patient has to wait, with an empty stomach, just to get the blood test done. She recommends a separate line for blood tests.

Well, the kids of this generation are blessed to have seen the healthcare facility at their doorstop so early. Sunny,12, lives nearby. He got hurt two days back while playing in the school. Today, he has come to the clinic to know if the wound is healing or not.

Sunita, 26, missed her periods last month, she is afraid of being pregnant. She doesn't want another kid. She came to the clinic with her sister-in-law and a three years old son. But the doctor has referred her to ASHA workers as the pregnancy test and contraception facility is not available at this clinic. Sunita did not understand what the doctors told her and the two ladies walked out with a bad impression of the clinic. 

Parvati, 45, a domestic help in Vinod Nagar colony recently slipped while working which resulted in minor fracture in her legs. The Doctors asked her to get the X-ray done from Lal Bahadur Shastri hospital a few days back. The poor woman went to the hospital alone in a rickshaw which charged Rs 80/- one side. She came to show the reports to the doctor here. The Doctor prescribed her medicines and pain relief gel. Parvati is not able to earn since last week and wants to get back to her work as soon as possible. She feels X-ray machine should be set up in the clinic.

Aam Aadmi Mohalla clinic, Dallupura

Against my expectations, Dallupura village has got one Government hospital in Vasundhara, one dispensary and two Aam Aadmi Mohalla clinics. The area has got no roads but two Mohalla clinics. The area seems to be politically active as I saw boards bearing the photos of the members of AAP and BSP all around. Big SUVs with the BSP  stickers passed through those narrow dingy lanes twice while I was walking to reach the clinic. The Mohalla clinic is pretty spacious and the doctor is responsive. The owner of the house where the Mohalla clinic is rented, Virender Singh, works as a multi-tasker in the clinic. The clinic mostly works till 3 pm. The average number of patients visiting the clinic are 100. The patients are largely satisfied with the doctors and their medication.

Khushboo, 10, studies in 5th standard in Nagar Nigam School in Dallupura. She had visited the clinic twice before with her parents. Today, she has come alone to get herself checked for the stomach ache bothering her since the last few days.  

Ram Das, 52, a farmer had lived in Dallupura village for 20 years. Three years back he shifted to Kanpur. There, he was diagnosed for diabetes and could not afford the treatment there. So, he came back to Dallupura upon hearing from his relatives about the Mohalla clinic. 

BB Singh, 58, owns a multi purpose shop adjacent to the Dallupura Mohalla clinic. He is pursuing vitamin D3 deficiency treatment from the clinic. He is happy with his treatment and finds no fault there.

Aam Aadmi Mohalla clinic, Harijan basti, Dallupura 

The patients of the area complained against Dr. Sunita Wardhan, stating that her behaviour is discriminatory with them. She checks the patients from a significant distance  without touching them even if it is required sometimes. When I went to check the clinic, everything described about the doctor was true. I had to literally ask her to move a little towards the patient so that I could capture them in one frame. 

Vimla Devi, 50, housewife, lives in front of the Mohalla clinic since last 35 years. She complains about the arrogant and discriminatory behaviour of the doctor. She said, " Yeh doctor ekdum haraman hai, hum logo ko dur se dekhti hai, haath bhi nahi lagati. Hum toh yahan ab nahi jaate." (The doctor is bad. She checks us from a distance, doesn't even touch us.  We have stopped going to this clinic now.)

Aam Aadmi Mohalla clinic, Sanyog Vihar 

The ANM of the clinic who is temporarily placed few days back in replacement complains against the extra work the ANMs are required to do at these Mohalla clinics. They are required to reach the clinic at 8 am, complete the vaccination task, fill in enteries in the app/registers and leave around 3 pm. There is one ANM appointed over 10,000 people and five ASHA workers work under her. They are paid a fixed salary by the government. Well, all ANMs I met in the Mohalla clinics don't share a similar opinion. Others don't find their job a burden. The Doctor at the clinic, Dipa Arora, told me about how the people complained  against her to the MLA for asking Aadhar card from the patients which was one of the required field to be filled in the app. She added that most of the patients don't have mobile number. So, on the basis of their mother's name, it becomes very difficult to follow up a patient.

The Doctor also told me about Neelam Tyagi, 32, a resident of Jain colony who joined the clinic two months back to assist them free of cost. She helps in labelling the blood samples, dispatching the medicines from almirah and distributing reports to the patients. She is a housewife and has two kids, one in class 8th and other in class 11th. Despite having no experience in this field, she works efficiently. With the desire to work for people, she manages her family and social work at the clinic.

Shiv Nath, 85, owns a cycle repairing shop in the area which his sons run now. He has visited the clinic for the second time. Prior to the opening of the Mohalla clinic, he used to go to the Deen Dayal government hospital in Sector 10/12. He says, " Yeh bahut acha hai, thoda aur bada clinic hota toh majja hi aa jata." (The clinic is very good. Had it been more spacious, it would have been great).

Aam Aadmi Mohalla clinic, Ajay Park 

Dr. G.R. Arora, the in-charge of this clinic made several recommendations for improving the working of the Mohalla clinics. Only a single almirah is allocated for storing the stock of medicines in the clinic. This forces them to keep the medicines on the floor where they get mixed with other medicines and leads to the error of handing over the wrong medicine to the patients. Dr. Arora adds that the examination table can't be put to use as it has neither got a screen nor a ladder to get on. The PWD is supposed to provide these facilities but he hasn't received them yet. Many patients with the complaint regarding their ears come to him but he then refers them to poly clinics and hospital due to unavailibility of wax drops. Anti-diarrheal and anti-vertigo medicines are also not supplied in the clinic. The Doctor pointed towards the lack of coordination between the Mohalla clinics and the hospitals where he refers his patients. The hospitals don't pay due attention to the referred patients. 

Savitri, 70, a resident of Deepak Vihar and wife of a retired Army personnel, comes to the clinic regularly for the treatment of her arthritis problem. She is contented with the treatment which is providing her relief. 

Aam Aadmi Mohalla clinic, Gali no. 5, Gopal Nagar, Najafgarh 

The clinic neither has any sign board outside its building nor in the adjoining lanes. Dr. Priya, 36, is one of the youngest doctor of the Mohalla clinics and this is the reason why she is hounded by the local MLAs every now and then on influential patients complaint for not treating them first or for any other trivial reason. 
A new Medicine Vending Machine (MVM) is recently installed at the clinic, yet not operational. The MVM is installed at 10 Mohalla clinics so far but operational at only two places. The machine will enable automatic dispatch of the medicines after reading the bar code available on the prescription slip. 

Chameli, 83, has been living in the area since her marriage. She never expected that a clinic will be opened right in front of her house. For all these years, she had to travel a long distance to reach the government hospital. She has a deep sense of belongingness with the clinic and fights with anyone who tries to bully the doctors or patients there. When I went there to enquire about the work done by the doctors, I had to literally convince her that I am not here to close the clinic. 

Aam Aadmi Mohalla clinic,  Shiv Vihar

The clinic is visited by the patients from the nearby Phool ki Jhuggi where the temporary labour resides.  Before the Mohalla clinic was opened in the area, the patients used to visit the Chawla dispensary. The Doctor complains that some patients misuse their right by forcing them to carry out tests which are not required to be done. They create chaos in case of denial of the tests. 
HIV counselling is given at the clinic and a patient regularly visits for the same.

Aam Aadmi Mohalla clinic, Qutub Vihar

This clinic has got an unique set up, the clinic and Aam Aadmi Party office being in the same plot. Dr. Swati Agarwal mentions about the hindrance she and her staff faces due to the unnatural situation of the clinic. The senior citizens, if not seen first, hounds her by the name of the MLA, Gulab Singh. Mostly, the residents of the area takes the medicines from the quacks (Gollachap) and then come for rectifying them. The biggest trouble she faces is the tab handed over to her to fill in the details of the patient, which she finds time consuming. The multi-tasker also was not

given adequate training before handing over the job of filling the data in the app. There is always discrepancy in the number of patients in the app and in the register which leads to confusion. Although the Pregnancy test facility is not available at the clinic, family counselling is done here. She complains that medicine for vomiting (syp. Domperidone) and loose motions (Syp. Metrogyl) were never provided which is a common problem with the patients. She faces no problem in the follow up of the patients but only the last four visits of the patients are made available. Although the past visits can be downloaded from the server on request. She said that they face security issues when the patients get out of control at times when their reference to the MLA is not entertained and also the area is situated near to the fields which makes it difficult for them to walk alone.

Aam Aadmi Mohalla clinic, Gali no. 6, Zakir Nagar, Joga Bai extension

Yet another area where people are not aware of the name 'Mohalla clinic': the auto dropped me outside the congested lanes where it couldn't enter. Well, it was easy to find Gali no. 6. But it really got difficult to find the clinic. There were multiple short lanes emerging after every ten steps. Every person I asked was giving me a new direction. I was tired of walking and asking the same question from every passer-by. After I asked a small shop owner about the clinic near the Nooh Masjid, he showed me the way from where I was coming. This made me angry and I told him that I am coming right from that place and hadn't seen any clinic there. I also told him not to advice any direction if he wasn't aware of it. He replied, "Madam, main wahan ilaah karane jata hun, jhooth nahi bol raha. (Madam, I go there for my treatment and I am not lying). I apologised him for being rude and asked him about the working of the clinic. He said, "the medicines are effective and the doctor is good."

As I entered the clinic, I found less rush than other clinics I had visited. I sat among the patients waiting for their turn. The lady near me asked me to take a token from inside,  I asked her about the clinic. She gave me a good review. I talked to few more and gathered that the patients, especially women, are not happy with the ANM, Ms. Madhu and the pathologist, Ms. Sushma Bahuguna whom they find rude and discriminatory. Even the tokens that were given to the patients that day were not serially arranged but the patients were called serially, creating confusion and discontent among the patients. Pregnancy test and contraception facilities are not available in this clinic and the women strongly feel that it should be availed soon. When required, the patients are referred to Batla house dispensary where Ayurvedic, Homeopathic and Allopathic treatments are provided. On talking to the pathologist, I gathered the area is prone to dengue due to high number of mosquitoes. She said even the clinic is not free of mosquitoes and added that the clinic is not cleaned on a daily basis and the dustbins of the lab are not emptied every day. 

Saira Bano, 47, came to the clinic with her mother-in-law, Akhtari, 75, from Joga Bai area near Isla Masjid. She had visited the clinic six to seven times before and today came to take medicine for her mother-in-law's fever and consult her kid's report and medication from a private hospital. 

Nisar Khan, 69, and Moh. Jammal, 52, residents of Zakir Nagar have come to the Mohalla clinic today for the first time after their neighbours recommended them. Prior to the opening of this clinic, they used to go to Batla house and Safdarjung hospital, pretty far from their residence. 

Taranum,19, has brought her mother Shabnam, 45, to the clinic to get her blood test done. She complains that she came to the clinic twice for the same but was denied. Now, when her mother's situation has worsened, she is allowed for the test.

Aam Aadmi Polyclinic, kanti Nagar

 

The polyclinic looks no less than a hospital. It had Dermatology OPD, ECG Room, Minor OT, Gynae, peadiaric OPD, Breast cancer screening room, ICTC Counselling among many others. While there is no indoor facility, the clinic is equipped to handle diverse ailments. Many teenagers were seen among the patients. On asking them, I gathered that they were seeking skin treatment there.

Anamika Sharma, 19 and Pooja Mathur, 20, both second year student of Political Hons. from the nearby college live in Yamuna Vihar. They come regularly to the polyclinic for treatment of pimples. The medicine given here is effective. Their college mate from Kanti Nagar recommended the treatment from this clinic.

Veerwati, 25, wife of a tailor has come to seek treatment of her two months old kid from Seelampur in a mini bus. The kid first had some problem in stomach for which he was referred to Karkardooma hospital. Now, the hair of the kid are falling in bulk everyday. She met Dr. Anwer Aslam, pediatric, who sent her to the Dermatology section from where she was referred to the Chacha Nehru hospital. She was clueless about what was happening. I went to the Doctor and asked what happened to the child. He informed me that the child is suffering from 'Alopecil Areata' which they are not capable of handling.

Sanju, 40, who migrated 10 years back from Bihar tells about how these clinics are of no use to her. Her son Vikas, 17, a tailor in Kanti Nagar used to have extreme stomach ache few months back. When she brought her to the polyclinic for treatment, he was referred to Hedgewar for ultrasound. When she got those reports, the doctors referred her to GB Pant hospital from where she was again referred to Arban hospital. Till date, her son has got no relief from stomach ache and the poor fellow is wandering from one hospital to other.

To sum up, Mohalla clinics are a big hit. The people at the clinic were mostly happy and satisfied. Even after instigating them, nobody spoke against this facility. Probably, this is the first government project which is benefiting the common man of the city. All the clinics are set up in backward areas catering to poor labour class section of the society. In fact, at some clinics, people from slums are availing this health care service. Many patients at these clinics were first timers who came on recommendation of their neighbours. Few even travelled from a different city to Delhi where their relatives live to seek the treatment from the Mohalla clinic. The increasing rush is creating chaos among patients and decreasing the doctor to patient time. Patients feel that there should be two separate queues, one for regular patients and other for those who visit with an empty stomach for their blood test. The app is highly rebuked both by the doctors as well as the patients. The Doctor's time and attention is diverted in filling the entries in the app rather than examining the patients in three to five minutes' duration allotted to each patient. The clinics lacks few medicines catering to some common problems of the patient like diarrhea, vomiting, loose motions and ear issues.
 
Well, one need to understand the limitations of Mohalla clinics and the fact that they are tier one in primary healthcare. The basic aim of the clinic is to serve smaller health issues of a common man. 
 
It is interesting to watch the people getting more health conscious in a sense that they make sure their Blood pressure and sugar test is done twice in a week. The kids are at the top who come to the clinic alone in case of any trouble they face -- be it getting a first aid on the wound, stomach ache, fever or acne problem. Pregnancy test and contraception are mostly not available at the clinics and the patients are referred to the ASHA workers. No publicity is done for the Mohalla clinics. In fact at some clinics, no board is placed for the people to identify the clinic. Even the board has only Mr. Kejriwal's and Satyendra Jain's picture which confuses the place with the party's office. 
 
The clinics are working well and with some improvements, the Mohalla clinics will be more efficient. There is no doubt that these clinics have brought about a sea change in the delivery of government health care service to a common man. The day is not far when people from other states of the country will begin demanding such facility in their states too.