-- PRADIP MAZUMDER
Introduction
Prime Minister Narendra Modi’s much lauded announcement of setting the National Digital Health Mission (NDHM) in motion, during his address on the occasion of 74th anniversary of India’s independence, is a hope that swings in despair. While delivering his speech from the Red Forte the Prime Minister said, “This will bring a new revolution in India's health sector and it will help reduce problems in getting treatment with the help of technology.” However, such assertion without evidence may raise the eyebrows of the expert critiques. In contrast, a mere fideism without substantiation may also be misleading. Therefore, it is better to scrutinize NDHM to test its proficiency under the scanner of a handful of questions. This paper is aimed at understanding the NDHM from its policy perspective.
According to the government sources, the vision of NDHM is to create a nationwide digital interconnected system in which all citizens would be provided with inclusive, affordable, and safe healthcare. Such digital health system should significantly improve the efficiency of health service delivery with adequate transparency. The sources claimed that NDHM will be a major stride towards achieving the United Nations Sustainable Development Goal of Universal Health Coverage including financial risk protection. Besides, India will be placed at the forefront of the global medical research with the largest anonymised health databases. It will also reduce the cost of healthcare through improved fraud detection. The Union Minister of Health & Family Welfare, Dr. Harsh Vardhan, has termed the scheme as “game-changing”. He informed that after a pilot launch in the Union Territories of Chandigarh, Ladakh, Dadra and Nagar Haveli, Daman and Diu, Puducherry, Andaman & Nicobar Islands and Lakshadweep; the Union government will work in partnership with the States to launch NDHM.
Under the scheme,
every citizen’s health will be mapped through a new Aadhar-like health ID which
will store the individual's medical records, including diseases, the line of
treatment and medicines prescribed. The ID will become essential for all
treatment related issues, from the appointment of a doctor to hospitalization. This
will also integrate the facilities like telemedicine, e-pharmacy, etc.
The National Health Policy-2017 proposed a new National Digital Health Authority. The National Digital Health blueprint was released by a Committee in July, 2019 which recommended the setting up of the National Digital Health Mission (NDHM), a governmental organization with complete functional autonomy. The blueprint recommended to create a system of personal health records in accordance with the international standards which should be easily accessible to the citizens and, based on citizen’s consent, such personal data will be available to the service providers. The blueprint suggested that NDHM should manage the core digital health data and establish the infrastructure required for seamless exchange.
The blueprint actually recommended two building blocks: (i) Personal Health Identifier (PHI) and (ii) Health Master Directories & Registries. With Aadhar-ID at the centre, these building blocks will look after the requirements of unique identification of persons, facilities, diseases and devices.
Amid such well articulated jargon, one cannot let the deficiencies in India’s basic healthcare facilities go. India’s inadequate health delivery system with its insufficient infrastructure cannot be hidden under the veil of digitization. While the mission’s details are still being awaited, let’s inspect NDHM point by point.
With the given statements and recommendations, there are multiple issues and concerns that require in depth analysis to understand the possible outcome of NDMH:
1. India’s
present health infrastructure
India’s
digital gap despite a digital leap
Experience
of using digital identification for healthcare
Challenges
of data privacy
Monopolization
of healthcare in private hand
Some
Unequivocal Elaborations
India’s present health infrastructure:
With an estimated 1.3 billion in 2015, India has the world's second-largest population. But, the country’s existing healthcare infrastructure is deficient to cater to the needs of the population. Despite universal healthcare services, free treatment and essential drugs provided by the state and the central governments, the government hospitals are understaffed and under-financed and, therefore, forcing patients to visit private medical practitioners and hospitals. For every 10,000 people, India has nearly 8.5 hospital beds and 8 physicians. Japan and South Korea have over 100 beds for the same population. Majority of India’s population, who lives below the poverty line (BPL), can spend Rs 47 and Rs 32 per day in urban and rural areas respectively. Therefore, they have no other alternatives but to rely on the public sector healthcare system which is under-financed, short-staffed and cannot meet their needs.
There is also disparity between the rural and urban health services. According to the government’s health and family welfare statistics, India is 81 percent short of specialists at rural Community Health Centers (CHCs). Primary Health Centers (PHCs) are short of more than 3,000 doctors, with the shortage up by 200 per cent over the last 10 years to 27,421. Rural areas remain underserved since the majority of healthcare professionals are concentrated in urban areas where patients have higher paying capacity. India’s number of physicians meets the global average; but 74 percent of its doctors cater only to 33 percent of the urban population. (Firstpost; April 2019)
The Union Budget should boost rural development, infrastructure and macroeconomic stability to enhance for better healthcare facility. Although India’s health budget has been increasing in percentage but, it should commensurate intimately with the government's ambitions, especially while managing inflation and new health programme announcements like NDHM. Unfortunately, there has been always a mismatch between the means and the desire.
India’s digital gap despite a digital leap:
With 560 million internet subscribers in September 2018, India is one of the largest and fastest-growing markets for digital consumers and the digital services are also growing in parallel. (Noshir Kaka et al; March 2019) Indians downloaded 12.3 billion apps in 2018, second only to China. The government’s mass financial-inclusion program, Jan-Dhan Yojana, has increased the share of Indian adults by more than double who have at least one digital financial account. Globally, India stands among top two countries on many key dimension of digital adoption. However, in terms of Country Digital Adoption Index, a McKinsey study, India scored low; just 32 on a scale of 100 in case of digital foundation, digital reach and digital value.
During 2020, there are around 687 million internet users in India. Despite the large base of internet users, India’s internet penetration rate was just around 50 percent. Although, the internet penetration rate has increased by nearly two times in last five years, internet accessibility and use in India largely varied for gender and socio-economic divide. In 2019, there were more male internet users in the country compared to female users. Moreover, the gender gap was increased further between the remote villages and the urban metros. Against an estimated 337 million urban internet users, there were 290 million internet users in rural India. Despite the availability of 4G networks, increased availability of cheap data plans and various government initiatives under the Digital India campaign; just around 29 percent of the country’s total population were mobile internet users in 2018. (Sandhya Keelary; July 2020)
Since 2014 India is digitizing in a faster pace. Still, 90 percent of all retail transactions, by volume, are made through cash, though many people have digital bank accounts. E-commerce revenue is growing by almost 30 percent per year; but only 5 per cent of trade in India is done online, compared with 15 percent in China during 2015.
As we have seen earlier, India has very few doctors, not enough hospital beds,
and a low share of government spending on healthcare; it is said that digital
solutions can help overcoming such challenges by making doctors and nurses more
productive. Telemedicine, for example, will enable doctors to see overall more number
of patients and shall help the doctors in cities to serve patients in distant rural
areas which will also reduce consultation costs by about 30 percent. If
telemedicine can reduce in-person outpatient consultations cost by 30 to 40
percent, it is estimated that, with digitization in overall healthcare
industry, India would save up to $10 billion in 2025.
However, these are ambitious statements having little or no relevance with ground realities. With the existing gap in digitization drive in India, the idea of creating a nationwide digital interconnected system through NDHM is nothing but a day-dream.
Digital identification, to cater to healthcare services, is not a new initiative in India. It started much before Narendra Modi assumed power at the centre. According to the UNESCAP 2010, India’s Ministry of Health and Family Welfare (MoHFW); Ministry of Communication and Information Technology and state governments along with some tertiary level hospitals with specialties have acted since 1999 in developing e-health project and telemedicine activities which had been carrying out tele-education and tele-healthcare. (Basher and Roy; May 2011)
One such flagship e-governance project of the government of India, after piloted in Delhi and thereafter launched nationwide in 2015, was Online Registration System (ORS) for e-Health which linked the Hospital Management Information Systems (HMIS) of various hospitals to an Aadhaar-based registration and appointment system for patients. The ORS system was adopted in over 1,100 departments in 131 hospitals throughout the country that had digitized their HMIS. However, the available data as of January 2018 showed that only a little over 1.2 million appointments could have been booked through the ORS. (Julia Clark et al; 2018) This has certainly been statistically insignificant for a populous country like India.
Beside the unique identification of patients, Aadhaar platform was used to uniquely identify and monitor the performance of health workers and to incentivize them to indirectly benefit the patients with better quality of care. In March 2017, MoHFW asked all Accredited Social Health Activists (ASHAs) and other contractors with the National Health Mission (NHM) to register their Aadhaar numbers in the employee database which would enable the deposition of performance-based incentives and other payments directly into their bank accounts through the Aadhaar Payment Bridge System (APBS). Even after three years, as on today, the details of Aadhaar seeding in the ASHA database and payments through APBS are not available in the public domain. Therefore, the outcome of the project cannot be meticulously reviewed.
There can be the reference to a number of health insurance schemes that had begun registration and authentication through Aadhaar link with an objective of extending the maximum benefit. The Janani Suraksha Yojana or JSY (literally meaning Maternal Protection Scheme) has been one such scheme. JSY had been started as part of the National Rural Health Mission (NRHM) on 12 April 2005 with an objective of reducing maternal and neonatal mortality. During 2016-17, the scheme had registered 10.4 million beneficiaries. (The Gazette of India; 2017) Seven years after the launch of the Aadhaar linked JSY scheme, a study published in the Journal of Tropical Pediatrics (Oxford Academic) in December, 2017 concludes that a substantial burden of infant and maternal mortality still exists in India and a high proportion of such deaths are avoidable. The study findings indicate the need for specialized newborn care, emergency obstetric care, efficient ambulance transport system, promoting health-seeking behaviour, better knowledge of danger signs and strengthening community–facility linkages. (Tripathy and Mishra; December 2017)
The experience, as of now, from the widespread coverage of Aadhaar and its integration into healthcare services shows that, a mere digitization will not facilitate the Indians to access to a number of social and health-related programmes such as Integrated Child Development Service (ICDS) scheme, immunization campaigns, primary healthcare, preschool education and food for the children under six and their mothers.
Through NDHM push, government has an ambitious plan to digitize health records of all Indians by 2022. This is in accordance with an approach paper published by the National Institute for Transforming India (NITI Aayog) in July 2018, titled as the National Health Stack: Strategy and Approach.
Because of its sensitivity, privacy of personal health data must be protected. Data privacy and protection are keys to both well-managed health systems and to identification systems more broadly. However, such systems may also create risks related to data protection and privacy. Unauthorized access to or misuse of personal information can reduce trust, undermine individual rights to privacy and consent, and in some cases, put vulnerable groups at a serious risk of harm. (World Bank; 2018) In its report titled “The Role of Digital Identification for Healthcare: The Emerging Use Cases”, the World Bank has cautioned that the risks of misuse of personal data may be pronounced in the health context, particularly if unique identifiers are linked to health records or other potentially sensitive data such as medical conditions and past treatments.
While responding to the question on vulnerability of Aadhaar data security in Rajya Sabha (Question No. 3293), the Minister of State for Electronics and Information Technology had informed, “UIDAI data is fully secured/ encrypted at all the times i.e. at rest, in transit and in storage. For further strengthening of security and privacy of data, security audits are conducted on regular basis, and all possible steps are taken to make the data safer and protected.” (Rajya Sabha; 2018)
However, there was a complete mayhem in 2018 and the government was defenseless when the cyber-security issue with Aadhar card was brought to the limelight. Around 200 official government websites accidentally made personal Aadhaar data public. One could access thousands of government databases with confidential information simply by Googling it. Government of India resorted to blocking around 5,000 officials since Aadhaar data was being accessed by unauthorized personnel working for the government. (Jain M; 2019) The situation was so grievous that the Supreme Court had to put its observation on the issue. The apex court clearly mentioned that “vulnerability of biometric data for Aadhaar is violation of rights.” (Business Standard; Sep 2018)
From
the experience of Aadhar data abuse, there has to be disbelief on the process
of dealing with data protection, privacy and security in the context of unique
ID in the NDHM systems. Moreover, there are reasons to be more skeptical since
Indu Bhushan, Chief Executive Officer, National Health Authority (NHA) said
that Personal Health Record (PHR) and Electronic Medical Record (EMR) solutions
can be developed by private players as well while taking care of security,
privacy and standards of the NDHM ecosystem. Will the profiteering private
players show any respect towards data privacy?
Monopolization of healthcare in private hands:
By definition, healthcare is the set of services provided for the treatment of an ill person. Ideally healthcare services should be catered by the State to its people. However, in the neo-liberalized free market economy, health is also a commodity and healthcare is one of the most heftily paid services. During post liberalization, healthcare has become one of India's largest and the most profitable sectors in terms of revenue. Healthcare sector comprises hospitals, medical devices, clinical trials, outsourcing, telemedicine, medical tourism, health insurance and medical equipment. (IBEF; July 2020) The Indian healthcare sector is growing at a brisk pace and it has emerged as a robust industry.
Healthcare industry in India is projected to reach $372 billion by 2022. The hospital industry in India, accounting for 80 per cent of the total healthcare market, is growing at a Compound Annual Growth Rate (CAGR) of 16-17 per cent and expected to reach $132 billion by 2023. India is expected to rank among the top 3 healthcare markets in terms of incremental growth by 2020. The healthcare information technology market is expected to grow by 1.5 times. The diagnostics market is expected to grow at a CAGR of 20.4 per cent to reach $32 billion by 2022 from just $5 billion in 2012. The Indian telemedicine market is expected to grow at a CAGR of 20 per cent to reach $32 million by 2020. Over $200 billion will be spent on medical infrastructure in India by 2024. Foreign Direct Investments (FDI) are allowed cent per cent under the automatic route for greenfield projects while FDI in brownfield projects are permitted up to 100% under the government route. (Invest India; August 2020)
In
a growing market, where free flow of capital from both the domestic and foreign
origin is encouraged and, then, protected by government policies, the NDHM is nothing
but a push towards concentration of capital in a very few private hands by
integrating all individuals, groups and organizations under one umbrella. The
Prime Minister said in his Independence Day speech that every Indian will get a
Health ID card and every time they visit a doctor or a pharmacy, or a lab, all
details will be registered in this health card; ranging from doctor appointment
to the medication prescribed, medical tests, when were they done. Every bit of
detail will be available in someone’s health profile. Thus, NDHM will reduce
the existing gap between various stakeholders such as doctors, hospitals and
other healthcare providers, pharmacies, insurance companies, and citizens by
bringing them together and connecting them in an integrated digital health
infrastructure. (Sharma Neetu C; Aug
2015)
The NDHM comprises six key building blocks or digital systems namely, HealthID, DigiDoctor, Health Facility Registry, Personal Health Records, e-Pharmacy & Telemedicine. According to the CEO of NHA, the core building blocks of NDHM shall be owned, operated and maintained by the Government of India. However, the private stakeholders will have an equal opportunity to integrate with these building blocks and create their own products for the market. This makes it amply clear how the government is facilitating the process of concentration of capital in private hands. Two examples would substantiate such claim.
First of all, let’s talk about the hospital industry which accounts for 80 per cent of the total healthcare market. According to the findings of nation-wide survey on “Household Social Consumption related to Health” during the period July 2017 to June 2018, private hospitals across the country were accounted for 55 per cent of the in-patient hospitalization cases while the share for public hospitals was 42 per cent. The remaining 3 per cent of the surveyed household were treated by medical charitable trusts. The survey was conducted by the National Statistical Office (NSO), Ministry of Statistics and Programme Implementation, as a part of 75th round of National Sample Survey (NSS). This clearly indicates a higher reliance on private healthcare services. (The Indian Express, Nov 2019) Through NDHM, patients having HealthID will consult DigiDoctors from private hospitals via Telemedicine route for which the internet services will be provided by a private owner and the medicines prescribed in “generic” (where neither the doctor nor the patient will have any choice) will be dispensed through e-pharmacy which will also be owned by the monopoly capital. All these steps will hardly have any government control. Government will only prepare the data base at the cost of public revenue for the benefit of private and corporate capital. The above activities will also be very much urban centric as there are more number of people who can afford to pay which we have discussed earlier in this paper.
Second example will be the health insurance sector. According to the Oxford Economics, revenue earning from health insurance premiums will reach $3.5 billion by 2021, representing a growth of more than 12 per cent annually since 2006. (Oxford Economics; 2018) This is despite the fact that only 14 per cent of the rural population and 19 per cent of the urban population reportedly have health expenditure coverage. (The Indian Express, Nov 2019) Among the insured public, only 13 per cent of rural and 9 per cent of urban population were covered by government sponsored health insurance schemes. According to the global data report, public sector insurance companies in India are accounted for 45.8 per cent of the market, which is a substantial decline from the 54.8 per cent in 2014-15. The total premium collected by private insurers in 2018-19 was $11.9 billion, higher than that of the public sector companies. (Global Data; Feb 2020) In such private player dominated market, Prime Minister Narendra Modi launched one of the biggest publicly-funded healthcare insurance schemes, the “Ayushman Bharat” programme in 2018 with an aim of covering 500 million people below-poverty-line (BPL) and offering Rs. 5 lac to every BPL family per annum for institutional treatment. (Nirula et al; June 2019) Union Budget 2020-21 has an allocation of Rs 6,400 crore for the country’s flagship health insurance scheme. The experts from the field of health believe that, the private health insurance players will garner the benefits of Ayushman Bharat programme and will enhance their wealth at the cost of public money.
NDHM is allegedly a scheme that will help the corporate insurance companies to access to the readymade data bank of national health which will be prepared at the government’s expenditure. While processing the claims, the corporate insurer will get the benefit of the integrated healthcare system that brings all stakeholders, from patients to hospitals, under one umbrella.
Conclusion:
Exploring completely the best practices and their use of foundational identification in healthcare is beyond the scope of this paper. However, the points of the above discussion involve key areas of the foundational identification of an improved healthcare system which can be leveraged to make healthcare outcomes better for people at large. The foundational systems which involve India’s healthcare infrastructure and its overall socio-economic developments including the digital services should be made robust and inclusive. There should be enough measures in place for security of personal data. The risks and challenges in planning and integrating healthcare facilities are to be appropriately dealt with. A healthcare scheme should be designed and implemented only as a public welfare rather than a corporate good. Otherwise, NDHM will remain as a distant hope that swings in despair.
