The newly opened government clinic at BJR Nagar of the Malkajgiri area of Hyderabad may have helped save 55-year-old P Satya’s life. On April 13, Satya went to the clinic to get his two-month-old injuries checked. The skin on one thumb and near his toes had turned black and looked dead. The clinic is one of three hyperlocal clinics called basti dawakhanas that the Telangana government has opened in the city.
Satya has diabetes, a disease that causes nerve damage, and any injury to extremities can lead gangrene. If a doctor catches it in time the injury can be treated even if a limb has to be amputated. If left untreated, such injuries can be fatal.
Satya had been avoiding going to hospital even though his regular diabetes medicines were not helping his wounds heal.
“It is gangrene, said Dr N Prathyusha, the doctor in charge at basti dawakhana who saw Satya a few minutes later. “It hasn’t spread too much.”
The doctor gave Satya antibiotics for his wounds and advised him on a course of treatment and follow-ups. Satya did not have to pay anything for the treatment or consultation.
Satya had been putting off going to a doctor because of his fear of large hospitals.
“I would have gone to the Gandhi hospital (a tertiary hospital) for treatment, but it reminds me of my daughter who died there last year,” he said. “We had delayed the visit due to not being able to take time off and she died due to a brain-related problem. There are doctors there, but the size of the hospital and the severity of my ailments left me with no courage.”
Other patients at the clinic also talked about their fear of visiting bigger hospitals and how they prefer to deal with afflictions on their own.
“I know many people who didn’t survive a visit to the bigger hospitals,” said one patient.
It is this fear and the general lack of access to healthcare services that the Telangana government is trying to change with the basti dawakhana experiment.
The basti dawakhanas are the latest in the efforts at upgrading primary healthcare made by some states in India. The Delhi government opened mohalla clinics in 2016 and Kerala launched better versions of primary health centres last year. Even the Niti Aayog, the central government’s policy think tank has lauded the mohalla clinic model and wants it to be adopted for the Modi government’s ambitious plan of setting up health and wellness centres across the country as part of the new Ayushman Bharat initiative announced in the budget this year.
The basti dawakhana initiative is being jointly managed by the National Health Mission and Greater Hyderabad Municipal Corporation to provide free primary health services. The Telangana government hopes to reduce out-of-pocket healthcare expenses for the poor. By making sure poor patients can get treatment for their ailments at these clinics early, they may avoid more serious and therefore more expensive to treat health complications.
Three basti dawakhanas were inaugrated on April 6 in the BJR Nagar, Gaddi Annaram and Hashimabad localities of Hyderabad. These clinics operate six days a week from from 9 am to 4 pm. Staffed with one doctor, one nurse and one maintenance worker, these clinics are supposed to cater to roughly between 5,000 and 10,000 people.
The doctors and the staff nurses have been hired on a contract basis and we will continue with this model,” said Sikta Patnaik, additional commissioner for health and transport.
Each clinic has three rooms – a waiting hall, a pharmacy and an examination room.
A basti dawakhana provides outpatient consultation for minor ailments, screenings for blood sugar, blood pressure, anaemia, provide basic diagnostic services, provide antenatal and postnatal care. The clinic also organises immunisation drives, dispenses contraceptives, provides family planning information and conducts health awareness promotions.
Each of these clinics has been provided with a three-month stock of 144 essential medicines that are dispensed to patients free of cost. These include medicines for hypertension, diabetes, malaria, dengue and allergies and infections. The clinic also has nonsteroidal anti-inflammatory drugs, vitamin supplements, and calcium, iron and folic acid tablets.
Preventing self-medication
By 1 pm on April 12, less than a week after it opened, the Hashimabad clinic had about 80 patients. The patients had a range of ailments. Apart from seasonal fevers, coughs and colds, many had joint pains, anaemia, skin allergies, diabetes, hypertension and workplace injuries.
The duty doctor was on leave and the medical officer from the nearby Maisaram Urban Primary Health Care Centre Dr Jaipal Reddy was attending to the patients.
Nishath Fathima walked in during the lunch break. “I have a lot of pain near the back of my neck and in my upper body,” said the 35-year-old, who has been taking pain-killers from a pharmacy near his house.
Hashimabad residents like Fathima earlier had to spend a whole day to go to the primary health centre at Barkas, which is four km away, or at Maisaram, which is six km away. Many resorted to treatments from private doctors in their areas.
“That was a very conducive environment for unqualified medical practitioners or for self-medication,” said Dr Reddy. “This is risky because the symptoms of a heart attack might be misread as gastritis. A clinic like this, if used properly, not only reduces the need for self-medication but also helps detect serious ailments at an early stage.”
Dr Prathyusha at the BJR clinic also had patients like Surendra Kumar who were medicating themselves. Sixty four-year-old Kumar has had joint pains for more than two years. “A private practitioner told me that my ankle bone is extended and that it can’t be treated,” he said. “Thereafter, I kept taking pills from the local pharmacies.”
Kumar tried to retrieve an old message on his mobile with the details of the medicines he had been taking. The doctor asked him to return to the clinic with the details, prescribed new medication and recommended that Kumar start eating more eggs. Kumar then went to the pharmacy to get the his medicines. All in all, he spent about 15 minutes inside the clinic.
Referral system
If they function well, the basti dawakhanas can ease the burden on the health system, especially larger hospitals that currently receive many patients with minor ailments. Each basti dawakhana is equipped to perform 19 diagnostic tests such as haemoglobin count, blood grouping, blood sugar, tests to check dengue and malaria – all available to patients free of cost.
Before the launch of the basti dawakhanas, the 112 operational primary health centres of the 145 sanctioned for the city were the first level of healthcare services. Each primary health centre has a medical doctor and a staff of at least six members and caters to 50,000 to 75,000 people. Officials believe that once the 50 planned basti dawkhanas are operational, the outpatient burden on the primary health centres will decline.
“We are seeing a steady inflow of between 60 and 100 patients at each of these clinics,” said G Srinivas Rao, chief program officer of the National Health Mission for Telangana. “On some days, the Hashimabad clinic saw even 120 patients. So, we are effectively cutting down at least 50-60 patients from each primary health centre, which is great because the medical officers can focus more on the critical patients.”
A patient who cannot be treated at a basti dawakhana is referred to either a primary health centre, or one of 13 community health centres, or one of five area hospitals that are smaller hospitals that district hospitals. More severe cases go to the district hospital and the 10 tertiary hospitals available for the more than 7.7 million population living in the Greater Hyderabad Municipal Corporation limits. The tertiary hospitals are overcrowded on most days with outpatients from the city and referrals from the other districts of Telangana too.
“We plan to work on improving the referral mechanism too and not waste precious resources,” said Rao. “In our study of the outpatient data at tertiary hospitals, we saw that around 30-40% of the patients come with minor ailments. We aim to take this burden off the tertiary clinic, and help the patient too by providing the service at their doorstep.”
Another 14 centres are ready for operations and waiting to be inaugurated. By the end of May, Hyderabad should have 50 such clinics across the city, said health officials. The clinics are currently being run out of buildings owned by local administrative bodies.
“As of now, the focus is to use the community halls for the purpose, where the local community is willing and supportive. This ensures quick and successful beginning,” said Patnaik.