AAP changes politics, focus on Healthcare

We five residents of Bengaluru set up a charitable trust in July 2020, rented commercial space in the centre of the city (Shantinagar) in October and opened a clinic to provide free diagnosis, tests and medicines as well as referrals to hospitals for patients. Since it copies the mohalla clinic model of the Aam Aadmi party government in Delhi, it is called the Aam Aadmi Clinic. There are many similarities between this model and the wellness centres run under the Central Government Health Scheme (CGHS) for government employees. Our Clinic is a pilot project to test the suitability of the Aam Aadmi Clinic system for an urban area like Bengaluru and to learn through hands-on experience how it can be set up and how much it will cost. These are our observations and conclusions after running the clinic for six months from 1^st November 2020 to 30^thApril 2021.

Based on the Delhi model, in the Bengaluru clinic, an allopathic doctor (with MBBS qualification) and a nurse examine patients, conduct minor procedures, dispense medicines stocked at the clinic and prescribe tests. A diagnostic centre, with which the clinic has a contract, collects samples for the tests at the clinic itself and provides reports to the doctor. Patients are referred to hospitals and tertiary care institutions as required. We have adopted the lists of tests and medicines used by the mohalla clinics in Delhi. A housekeeper keeps the premises clean and a data entry operator registers patients and maintains medical data (which is recorded both on the computer within the clinic and in books given to patients). The clinic works from 9 am to 1 pm, Monday to Saturday, with 14 public holidays.

The clinic meets requirements prescribed for running free clinics by the Karnataka Primary Medical Establishments Act. It is run on donations made by individual wellwishers and it has obtained approval for tax concessions under 80G of the Income Tax Act. The Karnataka State Pollution Control Board has also registered the vendor who handles the medical waste of the clinic.

FINDINGS FROM THE CLINIC

-there is unmet demand for clinical services

-the mohalla clinic model can identify and treat common ailments and track chronic illnesses

-there is great need for free drugs

-there is even greater need for free basic diagnostic tests

-a mohalla clinic can be set up very quickly

-BBMP has financial capacity to set up a mohalla clinic network in Bengaluru

-a mohalla clinic can be run well with a few staff members

–the mohalla clinic can effectively link patients to referral hospitals and health insurance

-the mohalla clinic can collect comprehensive live data about the health condition of citizens and this can be used to make policy decisions

-the mohalla clinic can link families to important welfare schemes

These conclusions are briefly discussed below.

Demand for clinical services

Our Clinic has been functioning during the Covid pandemic. It opened on 1^st November 2020 when the first wave was waning and it has worked during the spurt in Covid cases and the lockdown imposed from 27^th April 2021. A token system is used on first-come basis to manage patients, with priority being given to emergency cases. These facts prove that there is unmet demand for good quality, free clinical services:

1. The patient footfall at the Clinic rose from 398 in the opening month (November 2020) to 808 by January-February 2021; it fell by end April, because of the ban on public movement after 10 a.m. and the stoppage of public transport during the lockdown; it has gone up again after the lockdown has been eased.
2. Patients queue up before the Clinic two to three hours before opening time to collect tokens for themselves, friends and family members for fear of being turned away when the patient number reaches the 40 plus level; patients suffer great personal inconvenience, break social distancing norms and disturb residents of the locality in their quest for affordable clinical care. The monthly patient footfall was 808 in January and 922 in March; the number of patients visiting the Clinic daily went beyond 50 by the end of February, putting great pressure on staff and services; we are working on how to tackle this issue without turning away patients.
3. Patients who use the Clinic return for further consultations as they are satisfied with the services offered. The share of repeat patients has gone up over this period crossing 70% in April 2021.
4. As news about the Clinic spread, there has been an inflow of new patients who prefer to use the mohalla clinic instead of the primary health centre (PHC) and private paid clinics (for reasons given further on).
5. Patients have shifted to our Clinic from local private clinics (which charge around Rs. 500 per visit) and diagnostic centres.
6. There is a preponderance of women and older dependent patients, which indicates that persons who could not afford clinical care in the past can now access medical attention. Almost two-thirds of the Clinic’s patients are women and around one-fifth are above 60.

The Clinic that we have piloted has become an oasis of affordable care in the urban desert. There is pressure on its services as it attracts patients from all over the city and its suburbs. It is used predominantly by poor families and those whose incomes have fallen during the lockdown. More visits from middle class families could ensure that the services provided at the Clinic are always kept on par with those offered by paid private clinics. One measure that could attract them is an appointments system which gives time slots for consultations and reduces waiting periods; we are trying to develop a method, which can be easily accessed by poor families too.

The current daily patient footfall of between 40 and 50 stretches the capacity of our Clinic between the working hours of 9 am and 1 pm. If BBMP sets up a well-dispersed network of mohalla clinics, a single clinic like ours could comfortably serve a smaller area, since the patient footfall would come down. We believe that the current large unmet demand for medical services could be met by replacing the PHC approach with a network of 2 mohalla clinics per ward. These could run from 9 am to 3 pm six days a week, with a half hour break for lunch and an hour after the clinic is closed to wrap up the day’s activities. Each such clinic could handle up to 1000 patients a month.

Note: Fall in patient footfall by end April is due to the city lockdown; numbers have gone up after the lockdown was lifted.

Suitability of Aam Aadmi Clinic model for urban areas

Our experience proves that a network of free government-run mohalla clinics spread all over the city is essential in Bengaluru to identify and treat common chronic and other ailments. The mohalla clinic approach is a distinct improvement on the existing network of primary health centres (PHCs) in Bangalore, in which one PHC caters to a population of 50000. Patients from within the ward and other parts of the city (some even from beyond city limits) choose to use our Clinic both because of inherent shortfalls of the PHC model (PHCs are too far away, diagnostic tests are not given free etc.), but also because of poor service (PHC timings and services are not displayed, some do not have qualified MBBS doctors, doctors and other staff are not available during working hours, free drugs are not available, premises are not airy and clean etc.). For these reasons, even some govt staff (police personnel, bus drivers and conductors, municipal staff etc.), who often have dedicated medical facilities, prefer to use our clinic instead of PHCs or other govt institutions. We have prepared a social audit proforma which could be used to capture the views of patients and compare the services of our Clinic with those of any PHC. During the lockdown, our Clinic was almost the only free facility available to treat non-Covid complaints, as PHCs and government hospitals were attending solely to Covid cases. Unfortunately, during this period, patients beyond our local area could not access it, since buses and the metro were shut down and private transport was very limited.

The PHC network today is not administratively organized to identify common ailments and analyze patient data for effective policymaking. The patient registration system of our Clinic (discussed further on) has identified some common chronic ailments of Bengaluru city. In the month of April 2021, almost half the patients who visited the Clinic suffered from diabetes, hypertension, hypothyroidism and anaemia, which call for continued monitoring through tests and medication. These conditions may not be curable; they call for management, regular testing and a steady supply of medicines, which can be better organized in urban areas by decentralized mohalla clinics rather than through widely dispersed PHCs.

The PHC is the first point of interaction with a patient; it is expected to have backward links to vulnerable communities through community health workers (ASHAs) and forward links to referral hospitals for further treatment. At present, these links are tenuous: PHCs are too few and too overburdened to follow up patients within their own communities using ASHA workers as well as monitor the cases referred for secondary and tertiary care. In our experience, these functions can be better done through a decentralized network of many small dispersed Aam Aadmi Clinics. (This is discussed further on). In their article “Reconfiguring Urban Primary Health Care”, published in the Economic and Political Weekly (EPW) on 19^th June 2021, Tarun Seem and Sunil Nandraj have also drawn attention to other key advantages of mohalla clinics from the point of view of economy, access to health care, rationality, early detection of illnesses and consequent reduction in treatment costs and greater empathy and compassion for patients . They note that mohalla clinics perform the role of family doctors and help patients to obtain medical services without rushing directly to large, impersonal hospitals. From our Bengaluru experience, we would agree with all these findings.

During the Covid pandemic, our Clinic has publicized essential general and ward-specific information about the precautions, guidelines and instructions of BBMP and links to help lines, PHCs, control rooms, frontline Covid staff, Covid care centres and hospitals. Patients with Covid like symptoms have been isolated and swiftly sent to the nearest BBMP contact points under intimation to them. We have actively promoted vaccination and given patients with comorbidities appropriate medical advice. We believe that mohalla clinicshave an important role in identifying new illnesses and their prevalence and alerting the hospital system and health authorities. Their role in providing essential clinical services during pandemics is a matter that needs to be discussed.

Demand for free medicines

Non-availability of prescribed medicines at government hospitals and PHCs is a frequent complaint of the patients at our Clinic. Patients with prescriptions from government institutions sometimes visit us for medicines and are then examined and treated by the doctor at the Clinic. Our Clinic has succeeded in managing medicine stocks to avoid such situations; prescribed medicines are always available. Patients with chronic ailments receive regular supplies after they are tested under medical supervision. At our Clinic, drugs needed by patients are estimated based on past trends,stocks are closely watched and timely indents placed on suppliers. The availability of free medicines at our Clinic supplied under the supervision of a qualified doctor is a major attraction for patients who need continuing medication as well as those with fresh complaints.

Need for free basic diagnostic tests

Our Clinic offers more than 70 common diagnostic tests (including blood and urine tests, X rays and ECG) on the pattern of the Delhi mohalla clinic. As in Delhi, under an MoU executed with a reputed diagnostic centre, samples are collected at the Clinic by a phlebotomist, who then gets tests done at the centre and brings reports back to the doctor within a day’s time. For X rays, ECG etc, patients visit the same nearby diagnostic centre with an authorization from the Clinic and reports are brought to the doctor by the phlebotomist for interpretation and diagnosis. In the government sector, free facilities for diagnostic tests are only available in some specialized PHCs, while in many government hospitals, tests are given free only to poor patients holding BPL (below-the-poverty-line) cards or income certificates showing very low annual incomes. In some institutions, even the poorest patients have to pay to get tests done. At the Aam Aadmi Clinic, we frequently get patients who have been asked by PHCs to get tests done and those who have been refused free tests by government hospitals. Some patients come to the Clinic with prescriptions for diagnostic tests given by other private and government doctors (some doctors even refer their poor patients to us for tests!). In all cases, tests are given only after patients are examined by the Clinic doctor. The high costs of diagnostic tests in private centres are a huge burden on the common man. Government has no plans to set up its own diagnostic centres or provide free tests to all patients. This demand can be met only under the Delhi mohalla clinic model.

Time needed to set up a mohalla clinic

Our experience shows that a mohalla clinic can be set up very quickly. At least 145 sq. ft. of carpeted area (in a well lit and ventilated commercial space) for a reception area, consultation room and medicine store is needed according to Annexure 1 of the Clinical Establishments Act of Govt of India for a clinic with diagnostic support services. Our Clinic is located on 1200 sq. ft. of rented area with rooms for the doctor, for examining patients and storing medicines, spaces for registration and internal discussions, separate toilets for men and women and a yard where patients can gather outside Clinic hours. We were able to open the Clinic on 1^st November 2020, just a fortnight after the premises were taken over on 14^th October, after making a few small repairs, ensuring light, electricity and ventilation, installing the furniture and equipment prescribed in the Clinical Establishments Act at Annexures 2 and 3 (and other needed items), putting up the signs and notice boards prescribed in this Act as well as posters giving important information about local medical facilities, Covid requirements etc., adding other essential items like CCTV cameras, invertors, Ipads and internet connections, finalizing MoUs for diagnostic testing and disposal of medical waste (after completing the registration prescribed by the KSPCB), purchasing essential drugs, notebooks to maintain patient records, drinking water cans, masks, sanitisers and other consumables, publicizing the date of opening of the Clinic and its facilities among local residents and recruiting Clinic staff (a qualified doctor, nurse, housekeeper and data entry operator with aptitude for their jobs). In subsequent months, other essential items-a wheelchair, an oxygen concentrator, PPE kits and scrubs for staff, portable fans, tanks to store water when municipal supplies fail etc.-have been added as needed. A token dispensing machine could be added for greater efficiency. When a mohalla clinic network becomes operational, government could link up with public or private ambulance facilities to transport emergency cases to and from clinics. Our Clinic handles emergency transport needs with voluntary assistance.

Thus, our experience proves that a mohalla clinic can be opened a fortnight after a building is occupied. This period can even be reduced to a week when an existing PHC is converted to a mohalla clinic.

Cost of running a mohalla clinic

Our Clinic was set up and is being run by donations from individual wellwishers. Some of the furniture and equipment was donated in kind and other items and services bought at market rates. Operating costs consist of salaries of staff, rent for the premises, payments for utilities like water, electricity and miscellaneous consumables, medicine costs and diagnostic tests.

The monthly operating cost for our Clinic in a standard working month is between Rs. 4 lakhs and Rs. 5 lakhs. The per patient cost computed against the patient footfall at the Clinic over the first six months works out to around Rs. 500.The itemwise cost breakup for the typical month of March 2021 is given below:

We pay market rates for goods and services used to run the Clinic. The doctor is paid the BBMP rate for contract doctors. The qualified nurse, a housekeeper (who cleans the premises and assists other staff members) and the data entry operator (who registers patients and maintains data) are paid at market rates. The housekeeper is expected to get the Clinic cleaned and open before 9 am and staff stay on when the Clinic closes at 1 pm (or later after attending to all waiting patients) to put things in order for the next day.

At present, medicines are bought from reliable suppliers by making indents when drug supplies fall below the critical levels fixed for each item. We have begun estimating the monthly requirement of medicines at the beginning of every month on the basis of past experience of patient demand and the medical conditions of repeat patients, particularly those with chronic ailments. We are exploring other avenues, like purchase from government outlets (where the medicines we need may not be available or be sold in bulk). There may be scope for tieups with reputed medicine manufacturers to get regular supplies at the best rates. Brand differentiation and the variety of marketed packaged drugs result in medicine suppliers delivering items which are different from the indented products. We are trying to streamline drug stocks and payments by focusing on the most-needed medicines. As for diagnostic tests, the centre which has signed an MoU with our Clinic offers a bulk discount of 25% on the total bill, as a part of its business practices.

If a stand-alone clinic is replaced by a mohalla clinic network, the cost per clinic will reduce due to economies of scale as government can inter alia

-use its own premises or get better rents on leased premises

-buy bulk drugs and get larger discounts from drug suppliers

-set up diagnostic centres (this will result in substantial savings on the costs of tests) or have a tie-up with a centre which can provide the required facilities at convenient locations.

Diagnostic tests account for half the operating costs. This figure can be drastically cut if government opens its own labs and places aphlebotomist to collect samples in each mohalla clinic (or ties this up with a private centre). 3 mohalla clinics can be run by BBMP within a budget of Rs. 1 crore.

If two clinics are opened in each ward, Bengaluru will require 396 mohalla clinics for its 198 wards. 141 PHCs operating in the city can be converted into mohalla clinics with minor adjustments and 255 new clinics have to be set up. This can be done with a budget of Rs. 85 crores a year. The cost of opening own diagnostic centres will be more than absorbed by reduction in the costs of tests in clinics. These savings have been factored into our estimates. BBMP has budgeted Rs. 84 crores under Health (Medical) in 2021-2122, which is less than 1% of its total budget of Rs. 9287 crores. This is an underestimate as it does not cover PHCs in the city which are run by the State government and budgeted under zilla parishads or fully account for funds released under the National Urban Health Mission (NUHM) scheme of the Central government. By opening mohalla clinics, the budgeted outlay will increase to 1.8% of the total budget, which is within BBMP’s capacity. At present, one-third of the Central government’s allocation to Karnataka under the NUHM scheme is not utilized. This amount should be drawn fully to fund the mohalla clinic network. In such an arrangement, the per patient cost could come down to Rs. 350.

Staffing a mohalla clinic network

Our Clinic is running successfully with an allopathic doctor, a qualified nurse, a data entry operator and a housekeeper. The staffing pattern is similar to the Delhi model. A community health worker (ASHA) should also be added to the staff as indicated earlier. A clinic requires supervision and back office support. In our Clinic, this is being done by volunteers. In a government network, a unit of six clinics can be monitored by a supervisor, who should visit one clinic every morning to solve operational problems relating to infrastructure, medicine supplies, referrals and other matters and ensure that quality standards are maintained. The supervisor can be attached to one of the clinics of the area. Reserve medical, nursing and other staff are also needed to substitute for regular appointees when they go on leave. Providing qualified locums for the doctor and nurse and managing tasks when other staff are on leave (without affecting clinical services) has been a constant challenge at our Clinic. In a BBMP network of mohalla clinics, a short list of locums could be prepared, drawing on retired or other available persons. In our experience, registration and data entry can be taken over by the nurse during a leave emergency.

Delhi mohalla clinics are run on staff contracts, under which suitable persons are empanelled and remunerated with a basic minimum payment for treating 50 patients daily combined with per-patient payments for additional persons treated. In our view, this may not be a sustainable long term model. We recommend that posts in mohalla clinicsshould be filled by permanent staff recruited through normal channels. The process may take some time, but it is desirable to extend the benefits of permanent employment to clinic staff to improve service reliability and morale. Supervision and disciplinary control must be maintained so that quality standards are maintained. Qualified doctors and nurses are available to occupy clinical jobs under the government. The post of supervisor should be filled by promoting experienced, qualified nonmedical staff of mohalla clinics. Mohalla clinic doctors will have limited promotion possibilities to posts in BBMP hospitals. But, the clinical experience will attract fresh recruits; government could also give some preference for service in mohalla clinics for admission to postgraduate courses. A satisfactory retirement package could be worked out for mohalla clinic doctors who leave after years of service.

Referral to hospitals and insurance providers

As mentioned earlier, we believe that PHCs are too widely dispersed and too overburdened to follow up referrals and help patients to reap the full benefits of government’s insurance policies. This can be best done through decentralized mohalla clinics. Although not a part of the government medical network, our Clinic is in close touch with PHCs and all government medical institutions and uses the Aarogya Mitras located in government and private hospitals under the Aarogya Karnataka insurance scheme to monitor the treatment of referred patients. Our Clinic also connects with the charitable wings of private hospitals. We would like to add a full-time community health worker to provide advice and medicines for chronic illnesses at the community level itself, monitor the treatment of repeat patients, identify early disease symptoms, follow up referrals and link patients to government insurance and relevant welfare programs. We also wish to start IAC work through publicity, home visits and campaigns. We recommend that a community health worker should be added to the core staff of mohalla clinics in Delhi too.

Management and use of clinic data

In our view, the data management systems of a mohalla clinic should satisfy the following principles. Information received at the clinic should be available to the patient, the primary physician and referral doctors. After ensuring patient confidentiality, policy makers and managers should be able to use anonymous broad data categories to identify existing and emerging problems and change policies. There should be systems in place to automatise routine clinic administration. Data collection must never disturb the working of the clinic; it should assist and improve the work.

Several Health MIS systems are used today by private and government institutions, but there is no effective network in Bengaluru linking together PHCs (and private clinics and hospitals) to generate live or even current data on health and morbidity indicators. Stand alone systems also do not seem to be in place in BBMP PHCs.

In our Clinic, the most essential data about patient identity and occupation and key biometric indicators is collected during registration and recorded on an Ipad in a google sheet, which is available to the doctor for diagnosis, prescription and referral. A hard copy is simultaneously given to the patient as a personal medical book which can be used for visits to other medical institutions. The unique patient code number is tied to the date of first visit to the Clinic so that the record in the computer can be easily located during later visits. Patients use the procedure willingly and bring their records to the Clinic for each visit. This is similar to the procedure used in CGHS wellness centres. Within the Clinic, drug stocks and diagnostic test costs are tracked on excel sheets. These basic documents developed by a volunteer have helped us to keep track of the treatment of patients on a continuing basis and generate live information about trends in illnesses and demands for tests and medicines. Such data is currently not being systematically collected or analysed in PHCs or within BBMP itself.

Data collection is done at our Clinic using two I pads and an internet connection. Data heads are occasionally modified according to need; for example, data regarding Covid vaccination has been added in recent months. There is no extra burden on the doctor or delay in patient services due to data collection, as only essential personal and medical data is recorded. On the other hand, our basic formats and standard operating procedure (SOP) have improved work efficiency and assisted staff to perform all the tasks of the Clinic (diagnosis, prescription, dispensing of drugs, conducting tests and making payments to suppliers) systematically. Google sheet data is shared between the doctor, nurse and data entry operator at the Clinic and three back-end managers (one of whom is the volunteer data specialist). Essential dashboards are periodically prepared to track critical parameters like patient footfall, costs, illnesses, diagnostic tests and drug drawals; we hope to auto-generate them by end July. As the system works on google sheets, patient confidentiality and data security are ongoing issues. Nevertheless, we believe that this is the minimum data collection and analysis mechanism that every Clinic must use from the beginning, so that records are always up-to-date with no extra effort. Clinics should transit to a different platform when the mohalla clinic network is established and the government develops a suitable platform. Policy makers and health managers in BBMP and the government should use the essential live data in the dashboards generated by clinics for rapid response to evolving issues and for effective policymaking. In our view, collection and analysis of health data in PHCs fails today because data management disturbs urgent clinical work. Data collection should, therefore, be done painlessly and in the course of regular activity; long formats should not be used to collect information not directly connected to work.

How to provide simultaneous access of patients to data collected at the Clinic is a major challenge. At present, during registration and diagnosis, information is recorded two times-it is written in the medical book and then entered into the computer. A passbook system could replace this to a single activity. Patients who have access to IT tools, could also be allowed to log in to view and print out data maintained in clinics, with appropriate safeguards. Such systems are already used in hospitals in Bengaluru. The data network also needs external links to referral hospitals, insurance providers and maybe even to government portals dealings with issues like BPL or ESI cards which determine the charges to be paid in referral hospitals. If desired, there could be links to private charitable facilities too.

Connecting patients to other government schemes

Some patients at our Clinic need help under related government schemes. For example, Clinic staff try to connect them to pension schemes for the poor, widowed or disabled, to domestic violence and child protection help lines etc. We have even linked patients to private charities. Mohalla clinics would need to perform such services too.

CONCLUSION

Shortfalls of the existing health system and the present low levels of investment in clinical care in Bengaluru have become front page news, particularly after the start of the pandemic. But, BBMP has no plans to open mohalla clinics on the lines proposed here. There has been an announcement that around 20 new PHCs will be opened in wards which do not have a PHC. We have discussed in detail why this is not a satisfactory solution. There has also been a report that BBMP will open mohalla clinics. What is contemplated, however, is to run “mohalla clinics” on public-private-partnership (PPP) basis, that is through NGOs or other private bodies. The nature of these clinics and the relationship between BBMP and the agencies who will run them are not clear. We do not know if the clinics will be run under corporate CSR funds or any other arrangement. We believe that this is a bad idea. Basic clinical care is a fundamental duty of government which it should perform directly. The Delhi government has already done this successfully. At our Clinic, we have discovered that a mohalla clinic meets the needs of urban population, that it can be opened quickly and that a network of such clinics can be run by an affordable increase in the BBMP budget (and better utilization of unspent funds from schemes like NUHM). With a comfortable capacity to handle at least 1000 patient footfalls/clinic/month, the mohalla clinic network we have proposed could treat 48 to 50 lakh cases in a year. When community health workers spread out from these institutions to tackle chronic complaints within local communities, this would mean a coverage of even 60 to 70 lakh complaints. If this is done, there is no doubt that the health and morbidity indicators of Bengaluru city will improve dramatically. We strongly advocate this proposal and hope that it will be adopted, now that we have shown the way.

By Rani Desai, V. Gopal. S. Hariharan, Renuka Viswanathan, Sanchit Sawhney