Abstract
An e-rickshaw driver from Dilshad Garden suburb of National Capital Territory (NCT) of Delhi, Ramesh Kumar was tired of standing in long OPD queues at the government hospital for the treatment of his prolonged skin infection. This long waiting times was taking him off the road for long hours and negatively impacting his income. Also, getting treated at a private hospital was not an option due to exorbitant treatment costs. However, Ramesh felt blessed after the opening of a Mohalla Clinic (MC) close to his house in the Dilshad Garden suburb. MCs were the primary healthcare service setups started in the Mohallas, 1 the innermost densely inhibited, yet unserved urban neighbourhoods of NCT of Delhi. Established under the Mohalla Clinic Scheme, 2015, by the State’s government, there were 300 such clinics offering free of cost diagnosis, consultation, medicines and pathological testing services to low-income patients without a formal health insurance coverage. The healthcare operations of MCs had been backed by many innovations such as fee-for-service payment model for healthcare staff, portability of clinic’s infrastructure and adoption of innovative medical technologies for minimizing the patient turnaround time. These clinics had successfully reduced the out-of-pocket medical expenditures for the targeted households besides reducing the workload of secondary and tertiary service centers in the national Delhi. MC had earned recognition from global public healthcare experts as a scalable and sustainable healthcare model by achieving its goal of providing universal health coverage (UHC). Many other Indian states have expressed their interest in replicating the MC model of state-provided healthcare service delivery. Service package framework from analysing the service attributes of MC is presented in Figure 1.
The Proposed Solution.
MC model had proved to be an effective health- care reform towards achieving the goal of UHC in the NCT. The model had gained appreciation from public health experts functioning at both national and international level. These experts had even recommended the replication of the MC model to other Indian states as well as to other countries struggling to achieve health coverage for population lying in the low-income segment. Some prominent medical periodicals also studied this MC model and reported the aptness of the model for scaling- up public healthcare in countries with privatized and inequitable healthcare scenario and vast population without health insurance. However, the sustainability and scalability of MC schemes were dependent on how effectively the current implementation challenges were handled by the administration. Additionally, the other scalability considerations for expansion of this community healthcare scheme to other states of the country were the socio- economic status of community, political ownership in the states, budgetary considerations and suitable quality control mechanisms. While Ramesh got benefitted from primary healthcare including consultation for seasonal illnesses, first-aid for minor injuries, pathological tests for chronic diseases, routine immunization and family planning offered by MCs, it remained to be seen whether MC scheme could prove to be a solution for primary healthcare for low-income patients falling outside health coverage. What remains to be seen is whether:
Would MC present a model for delivery of state-provided primary healthcare with a scalability potential across the country? Would MC be a sustainable solution for delivering primary healthcare to low-income patients falling outside health coverage?
India Public Healthcare System
Strengths, weaknesses, opportunities and threats or SWOT analysis of Indian public healthcare system:
Strengths:
A population-based three-tier network of healthcare services.
Network-integration using a well-functioning referral system.
Weakness:
Shortage of primary healthcare infrastructure and resources.
Fragmented accountability of public healthcare service administration.
Demand pressures on secondary and tertiary level services.
Poor service quality.
High out-of-pocket medical expenses of households.
Opportunities:
Government’s commitment to improve healthcare services.
Threats:
Dominance of private healthcare service providers.
Lack of political ownership towards public healthcare services.
Service Blueprint of Outpatient Services
A service blueprint is a process chart that not only illustrates the key steps of service delivery process, but also visualizes the customer contact points and the customer evidence of service delivery. A typical service blueprint shows the following aspects of a service delivery system:
Physical evidence: These are the tangible elements of a service delivery process, which influence the customer perception of a service. For instance, clinic reception or waiting area are the physical evidences of a MC. Customer actions: These are the steps of the service delivery process carried out by a customer in a service environment. As an example, a patient/ caretaker enters biometric details on Swathaya slate in a MC. Line of interaction: A line that divides the customer actions from the service provider’s actions in a service environment. On-stage employee contact: These are service provider’s actions, which are visible to the customer. For instance, nurse in the clinic records patients’ vitals. Line of visibility: A line that separates service provider’s actions that are visible to the customer from those that are invisible. Back-stage employee contact: These are the service provider’s actions, which are invisible to the customer. One such example is the creation of electronic medical record. Line of internal interaction: A line that separates the back-office actions of a service provider from its front-office actions. Support processes: These are the service provider’s actions to support the service delivery process. For instance, lab courier picks up the specimen for processing.
Service Package of Mohalla Clinic
Service packages constitute the bundle of product/service attributes of the service offering. The elements of service package are supporting facilities, facilitating goods, information, implicit services and explicit services.
Supporting facilities: It includes the physical resources, which are essential for the service delivery. For instance, the supporting facilities for a restaurant can be accessible location, layout, building, interior décor and furniture.
Facilitating goods: These are the materials consumed during the service delivery. For instance, food and beverages are the facilitating goods for a restaurant service.
Information: This element is accurate and timely information, which is critical to the success of service delivery.
Explicit and implicit services: While the element of explicit services is about the observable benefits, the implicit services pertain to the psychological benefits received by the customers as they consume the service. For instance, for the restaurant service, the explicit services are presentation of the food, variety of food options in the menu, taste, aroma and price of food, some or all of which customers observe for evaluating the service. On the other hand, a sense of convenience, privacy and security created among customers by the friendly and caring attitude of restaurant staff are the implicit elements of restaurant service.
Implementation Challenges of MC Scheme
Challenges associated with the weak operational planning and administrative structure are as follows:
Mechanisms for monitoring and control of service quality. Forward linkage with secondary and tertiary healthcare facilities for patient referrals. Proper staffing and technical guidelines. Coordination with other healthcare programme and agencies.
Action points for overcoming these challenges are as follows:
Use of surveillance technologies like closed-circuit television for the purpose of monitoring. Information technology-based inventory tracking for medicine stock management. Collaborate with local skill-training institutes for training community health workers.
Footnotes
Declaration of Conflicting Interests
The author declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article.
Funding
The author received no financial support for the research, authorship and/or publication of this article.