Aam Aadmi Mohalla Clinics (AAMC's) or Neighborhood Clinics were introduced in Delhi four years back to provide free, accessible and quality healthcare to everyone in the state. The Mohalla clinics had an excellent start; its operations were cost-effective, and the concept was welcomed by several leaders, both at home and away, however, it is now struggling to increase its coverage to entire Delhi as planned. The situation presents me with an ideal opportunity to analyze the current performance & identify the challenges that this novel concept is facing using Star Model of Alignment1.
I have divided my paper into three parts:
- the first part introduces the healthcare environment in Delhi,
- the second part analyzes the performance of the existing system through the framework of Star Model of Alignment1
- and the last part identifies the gaps and proposes solutions to address the same by realigning the "points on the star1".
Healthcare system in Delhi
With a population of 16.8 million, Delhi is part of India's wealthiest territory whose population includes a rising number of people in high- and middle-income groups; yet half of its population lives in slums and other substandard housing2. It is this socio-economic variance which is also reflected in the delivery of healthcare services in Delhi. Delhi's healthcare system can be summed up as a "highly fragmented, multiplayer & multilayer system which is poorly accessible and has high variance in cost & quality".
The healthcare facilities in Delhi are either privately owned, state-owned(same) or federally owned (though 25 different types of registered entities exist in Delhi). As on March 31, 2014, collectively, there were 95 hospitals, 1389 dispensaries, 267 maternity homes and subcenters, 19 polyclinics, 973 nursing homes, and 27 specialized clinics in Delhi3. Though state government of Delhi invests about 14% of its budget towards healthcare8 (Federal contribution is 1.16% of GDP), the private sector maintains a dominant position in the delivery of outpatient as well as inpatient health care services, including medical technologies, diagnostic procedures, pharmaceuticals, and hospital construction2.
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Nearly 55% of hospital care in urban areas (national average: 68%) is from private sector4. The Government of Delhi owns almost one-fourth to all one-fifth of all healthcare facilities namely (in a sequential order of level of care) the 221 Aam Aadmi Mohalla Clinics (AAMC's), dispensaries and Primary Urban Healthcare centres (PUHC's), 25 polyclinics, 38 society hospitals and multi/super Specialty hospitals with an overall bed strength of nearly 11,000 beds5.
The health facilities run by the Government of Delhi examine around 33.5 million outpatients and treat nearly 600,000 hospitalized patients every year. All services and medicines at these facilities are offered free of cost, except at some society hospitals, where few services are offered on nominal charges4.
The building blocks, their alignment and performance of the Mohalla Clinics
Despite free services and availability of the highest number of doctors/1000 population, the performance by peripheral health facilities or the primary healthcare system continues to stay poor in Delhi. The poor performance of the system is further supplemented with the unpredictable availability of providers, lack of assured services, medicines, diagnostics, and poorly functioning referral linkage. The combination of the above factors forces a large proportion of people to seek care at the secondary and tertiary level of government health facilities/institutions, even for common illnesses such as fever, cough, and cold. This leads to overcrowding, long waiting hours, poor quality of service delivery, and people being unsatisfied with public health facilities. With this experience –people including poorest quintile of the population find public health facilities too much of hassle4 and end up accessing either nonqualified providers or private providers, even at the cost of out-of-pocket (OOP) expenditure6.
The Strategy & Tasks
To tackle the problem of accessibility, affordability and poor quality of healthcare at the primary care level, the AAP (Aam Aadmi Party) government introduced Mohalla Clinics. They were specifically designed to benefit the low socio-economic communities; however, later, the goal was changed to make quality primary health care services accessible and affordable to all in Delhi, at their doorstep.
The design element of AAMC was targeted with a potential to eliminate unqualified providers, decongestion of higher-level health facilities, making specialists available for those who need them, and thus bringing efficiency in health service delivery4. The principle was based on supply-side financing, providing incentives to the suppliers of health care services in order to improve the accessibility and quality of services for the targeted group7.
These AAMC's have been envisaged as "box type re-located structures" having 2/3 room fixed setups providing a free consultation, free medicines (109 medicines), and free diagnostics (212 tests) and counselling for people. The AAMC functions for 4 hours between 9-1, Mondays to Saturday8. Currently, there are 221 such clinics which are operational.
Before AAP came to power, public health care services were provided through dispensaries and polyclinics which constituted the primary level, multi-speciality hospitals formed the second tier, and super-speciality hospitals represented the tertiary health care level. The new government has reorganized the health care delivery infrastructure with Mohalla Clinics constituting the base of the pyramid along with existing Primary & Urban Healthcare Centers (PHC's & UHC's) followed by Polyclinics, that form the second tier and are manned by specialist doctors providing outpatient department (OPD) services in primary specialties.
The tertiary health care is delivered through government hospitals, which can be further categorized into multi-speciality and super-speciality hospitals providing specialized OPD and IPD (inpatient department) care. AAMC thus is supposed to act as the first point of contact in a three-tier referral system (Exhibit B). The structure of the AAMC includes the practising physician who substitutes as administrative head and reports to Chief District Medical Officer (CDMO) (Exhibit C). The medicines are being procured centrally by the government, and the lab is outsourced to the private provider (joint partner for all AAMC's).
Human resource/ Reward
Each AAMC consists of a physician (AAMC Chamber doctor), one nurse, one lab technician, one pharmacist and one helper. They are all paid on a "fee for service" basis. The doctor is paid $ .9 /Consultation, and the lab technician/ nurse and pharmacist are paid between $.2- $.4 per patient transaction8.
Information & Decision Support System
The EMR records the basic "demographic and disease profile" of the patients. Using an internet-connected electronic tablet-based protocol, medicines are prescribed and dispensed by the doctor. In some places, the pilot for automated medicine vending machine is currently underway (linked to e-prescription). The biometric listing of patients is maintained along with a list of medicines dispensed. All this data is then stored in a digital cloud and made available to the government. Use of this technology promotes both permanence of records and provides data for further analysis at a higher level9.
The success of AAMC has been attributed to the leadership and political will of AAP, however, using the Star model, it becomes clearer to identify how the reinforcing of the levers of the system design (detailed above) has also contributed to the current success. Being one of the wealthiest states in the country, the policy initiative, in this case, was well supported with the allocation of the funds. The state increased its budgetary allocation to the health by nearly 50% and $ 40 million were allocated immediately towards the development of Mohalla Clinics. Being a priority project, Chief District Medical Officer has been tasked to ensure the success of the project.
The state's existing robust network of secondary and tertiary healthcare facilities have been further strengthened, and it supports the increase in the IPD referral through the Mohalla Clinics. The human resource challenge has been managed through the availability of retired physicians. Lack of employment opportunities has meant that nurses, technicians and pharmacists are generally available. Since these AAMC's have been proposed and launched as community projects in the areas where the people have been otherwise apprehensive of visiting the healthcare facility due to cost barrier, removal of the affordability barrier has changed healthseeking behaviour and made AAMC's a success.
Since opening the first AAMC in 2015, there has been a great response to the concept. Following milestones have been achieved during this time10.
- 221 AAMC's have been opened, employing nearly 1000 healthcare personnel.
- 16.24 million people have utilized Outpatient services
- 1.53 million pathology investigations done
- 27% reduction in OPD in secondary & tertiary care government hospitals
- 66% reduction in the patients visiting "unqualified" doctors (areas where AAMC's introduced) Nearly 40% of the people who have used this service have never accessed a regulated healthcare provider service before in Delhi6
- 80% of patients visiting these clinics have reported that their medical expenditure had declined manifold, attributing it to the commencement of the Mohalla Clinic7.
The gaps, misalignment and the realignment
Thus far the organizational strategy, structure, human resources, incentives, information and decision support system have been mutually reinforcing and have contributed to the initial success; however, AAMC's are now facing multiple challenges to sustain the growth, and this is reflected in the inability of the government to achieve its planned target of opening 1000 clinics by 2019 (Exhibit A).
While AAMC's slow growth can be principally attributed to bureaucratic tussle among the agencies, other performance gaps are also starting to emerge, such as lack of effective integration of AAMC with rest of the system to achieve three-tier referral system, high attrition rate of the physicians and quality variance in the healthcare services offered at these centres. These gaps can be further understood through the misalignment among the "points on the Star Model of Alignment".
I have tried to address these gaps through following tools
- reciprocal (strategic realignment) collaboration with other agencies
- alignment between the rewards and human resources and
- restructuring the decision and information flow system.
Inability to achieve the target of opening 1000 clinics in 5 years
The slow growth of introducing AAMC's is due to the failure of the state government to navigate through the complex governing structure in Delhi. The state government has not been able to secure (buy or get on lease) new properties or land as these assets fall in their jurisdiction of central government agencies who are unwilling to lease it to state government. There are two possible ways to address this issue; both involve the realignment of the strategy with the available resources:
1) State health department would have to find mutual ground with the central government, for example, introducing a central government scheme such as Ayushman Bharat13 concurrently with AAMC, to develop trust and collaboration. This strategic collaboration would, in turn, reduce the cost of health care delivery as the state government can then avoid leasing private land and properties which are more expensive.
2) The second strategic change would be to prevent constructing AAMC in areas where state-run primary healthcare centres or dispensaries already exist. The same structure should be utilized. This will help multiple benefits; It will save the government cost of developing new facilities and also decrease burden of hiring new human resource. The use of existing PHC's would also lead to better information flow as it would benefit from existing horizontal interactions with other PHC's and vertical interactions with district hospitals.
The high attrition rate among the physicians in AAMC
AAMC were to utilize the services of retired physicians and physicians who were keen to work in primary care due to its social value. However, the misalignment between the compensation and amount of work has led to high attrition rate even among these physicians. In community practice, especially in these AAMC's, the physicians examine a new patient every two minutes, and without any "real" assistance, it can be exhausting. The agony is further supplemented by indigent "fee for service" model, which also acts as a deterrent to attract the best talent. These gaps can be addressed by realigning the human resource and the rewards and incentive system.
1) It would be prudent to change the reward system to a minimum capitation plus incentive system. To bear the extra cost, the government can tie-up with private non-healthcare provider corporates, who can attribute these expenses towards CSR activities and thus avail tax benefits (precedent available in Kerala, India).
2) Considering these clinics are only OPD service providers, flexible timings and evening shifts can be considered, and the government can utilize services of postgraduate students and registrars in government health facilities, albeit intermittently. These "locum" physicians can then be incentivized accordingly.
3) Another alternative could be to develop "nurse practitionerled clinics". Non-physicians such as primary care nurses will have to play an increasingly critical role at some point. However, this would require multiple policy changes and several extra hours of training. Though, the move, in the long run, can lower the costs, especially when integrated with technology (telemedicine/ e consulting).
Managing the quality of care provided at AAMC
Currently, the government measures the performance of the clinic based on the number of patients seen by the physician or the number of investigations performed. This basic quantum-based performance metric system does not measure quality improvement, causing misalignment between the information management and the strategic goal of providing "quality" healthcare.
The current system of performance measurement has been somewhat counterproductive in some places as it has led to sporadic incidences of fudging of the data as well as unnecessary consultations (fallacies of fee for service especially when the incentive is so weak). To address this gap, the performance measurement has to be done on the basis of coordinated and quality care-based indicators. Also, the absence of accountability towards attaining quality care is the second reason for falling quality.
In the current system, Chief District Medical Officer (CDMO) is responsible for the polyclinics and dispensaries available in the district (geographical area). However, CDMO is also incentivized for the number of transactions done rather than the quality of care provided. The existing structure (decision-making authority) also inhibits the accountability of the success of the system (Exhibit C). In the proposed realignment there needs to be change in structure, wherein the CDMO should be held accountable for the performance of all the facilities in the district (just like VHA's VISN1system) and should also have decision-making authority (Exhibit D).
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Performance measured thorough "quality, and fiscal based metrics" should determine the budget and incentives for each District Unit team. Another reason for the poor quality is the lack of training in the community based settings. Primary healthcare professionals need to be immersed and trained in community settings. Non-availability of good quality community-based training sites inhibits the production of competent and committed professionals11. Introduction of training or mentoring to current health care providers will not only positively impact the quality but would also increase the retention of staff. The AAMC teams need to be skilled in management and coordination functions as much as clinical skills. The central agency should continuously ensure the up-gradation of the skills (information & decision support system). The same could be delivered either through contact classes or through the use of technology.
The introduction of this new performance-based incentive system would need realignment of other subsystems on the star as the staff would need to be upskilled, the introduction of more resources may be required, and most importantly the development of robust information system to record these metrics would need to be developed.
Lack of integration of AAMC with the system
Lack of proper information management has led to the development of "silos" in the system. As mentioned before, the first step would be to restructure the system and decentralization the decision making; however, this has to be reinforced with the reliable monitoring of the system. The existing AAMC is equipped with registration system (EMR), and the data is available on the cloud; however, the same does not interact with the other systems in the healthcare network rendering the data useless for making critical clinical decision making at different levels of care.
This is a significant information gap that needs to be addressed. The government would have to ensure that the EMR systems interact with each other to achieve its goal of making a functioning "referral system" and building an "integrated care model". The introduction of such a system would again require the staff to be trained to leverage the new system, and perhaps there would be a need even to alter the reward and incentivization system to ensure the acceptability of the new system.
The introduction of Mohalla clinics have certainly helped the government agencies taking an unprecedented step towards achieving universal health coverage. The initial outcomes have also been encouraging, however, as analyzed through this paper, there are several challenges (gaps) that the current system may face (or is facing) which need to be addressed.
As pointed out by Jay Galbraith in his book "the organization must have alignment, but it also needs the flexibility to recognize and respond to the opportunities and threats. Therefore, alignment is best thought of as an ongoing process than a one-time event"12. This holds especially true for AAMC's which are still in the nascent stage of development and would undergo several changes over the period of next 3-5 years. Using the Star Model thus provides a practical and evidence-based approach1 to fine-tune the alignment and solve the shortcomings of Delhi's health care system.
1. Golden, B. R., and R. L. Martin. "Aligning the stars: Using systems thinking to (re) design Canadian healthcare." Healthcare quarterly (Toronto, Ont.) 7.4 (2004): 34-42.
2. Gusmano, Michael K., Victor G. Rodwin, and Daniel Weisz. "Delhi's health system exceptionalism: inadequate progress for a global capital city." public health 145 (2017): 23-29.
3. Government of Delhi. Economic survey 2016-17 Department of Health and Family Welfare, Govt. of Delhi. 2016
4. Lahariya, Chandrakant. "Mohalla Clinics of Delhi, India: Could these become platform to strengthen primary healthcare?." Journal of family medicine and primary care 6.1 (2017): 1.
5. http://health.delhigovt.nic.in/wps/wcm/connect/9cc748004b6f3a1a8a92cb788745c51a/HMIS.pdf ?MOD=AJPERES&lmod=-382194844
6. Chandrakant, L. "Delhi's Mohalla Clinics Maximising Potential." Economic and Political Weekly 51 (2016): 15-17.
7. Sah, Taniya, et al. "Mohalla Clinics in Delhi: A Preliminary Assessment of their Functioning and Coverage." Indian Journal of Human Development 13.2 (2019): 195-210.
11. Mohan, Pavitra, et al. "Designing primary healthcare systems for the future in India." Journal of Family Medicine and Primary Care 8.6 (2019): 1817.
12. Kates, Amy, and Jay R. Galbraith. Designing your organization: Using the STAR model to solve 5 critical design challenges. John Wiley & Sons, 2010.
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