Following a recent announcement by Prime Minister Narendra Modi on the creation of a digital health ID for every Indian , there has been a renewed debate on the need for a new digital identifier that centralises a citizen’s health records. Two public health experts, Dr. Abhay Shukla (public health physician and national co-convenor of Jan Swasthya Abhiyaan) and Dr. Suresh Munuswamy (head, Health Informatics and Technology Innovations at the Public Health Foundation of India), discuss the issue in a conversation moderated by G. Ananthakrishnan. Edited excerpts:
What can a digital health ID do for people?
Dr. Abhay Shukla : In principle, having linked electronic health records has certain advantages. However, the context in which it is being introduced, if we keep that in mind, then several questions arise. But the most important point is that a digital health system can be built only on the basis of a well-functioning health system and integration of data. Integrated management of health data must be based on a larger reorganisation and integration of the health system. Otherwise, it is like putting the cart before the horse.
What we need is regulation of the private health care sector, strengthened basic data collection from the primary health care level in the public health system, and [ways to] ensure that this data is used in a manner that is respectful of the citizens’ privacy. Having something like the Data Protection Act in place is essential. In the absence of these preconditions, a digital health ID will be of limited use. And it definitely cannot substitute for the much wider health system changes required urgently, which have been highlighted by the COVID-19 pandemic.
What does the experience with digital systems tell us about this ID plan?
Dr. Suresh Munuswamy: As an idea it is great. All the issues are in the execution. You already have an ID, Aadhaar, and several IDs - PAN card, bank cards... do they actually serve the purpose? Only with real time authentication can that be achieved. That is a challenge with Aadhaar also. So if I take this ID and go to a pharmacy, will it be authenticating me in real time? Is that even a possibility? Currently it is not happening with Aadhaar. Now, if you can enable real time authentication, you can add your data, like driving data, banking data. That has not yet been addressed. So, we are just adding another ID.
There is also an ecosystem. If I again go to a pharmacy, buy medicines, is there a barcode on the medicine? How am I going to even connect the medicine that I’m getting to the centralised database, am I going to manually enter all the data? If I go to a doctor, is the doctor’s data present? Imagine all the prescriptions going to the database. Is the prescription digitally readable or machine readable? Do we have an e-prescription? These are the challenges that need to be addressed.
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At the grassroots level, your driving license, PAN card, Aadhaar is not authenticated in real time. Thankfully, your credit card and debit card is, which is why you have a financial transaction happening. But can we make it that efficient? In which case you need to have resources behind the system. Even if you have those resources, and as Dr. Shukla mentioned, isn’t it a priority to put resources in the health system, rather than in the back end systems first?
We want to move towards universal health coverage. With a digital ID as a tool, what is the sequence to achieve that?
Dr. Abhay Shukla : We need at least two or three important elements for building both a robust health system and an effective digital e-health system. The first is certain foundational policies which relate to the larger health system. The second is enabling strategies, which support an integrated information-based system. And then there are the actual e-health applications. So, a foundational change is on the public health Management Information System. We already have an MIS, but it is not functioning adequately. And there is a limited variety of data being received, but a lot of data especially from the primary health care level is inadequate.
The second is reporting by the private health care sector. There is gross under-reporting of any kind of notifiable disease. In areas like malaria, cases are something like 20 times higher than what is reported by the official system. If you want to have a robust digital e-health system, then we need private practitioners, smaller hospitals, larger private hospitals regularly reporting about their cases.
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And that is linked to the regulation of the private sector. Information is not going to come in isolation. It has to be part of the Clinical Establishments Act and a regulatory framework. Without these, there’s no meaning to the e-health platform. Perhaps it’ll just be limited to secondary and tertiary care and insurance companies. That is the sense that we are getting, that this digital e-health platform is mainly pushed by the providers rather than being pulled by the system, by some digital companies and some providers of e-health applications.
What potential is there to use the idea for preventive services in primary care?
Dr. Suresh Munuswamy: I completely agree that primary health care is where the focus should be. Because secondary, tertiary, all our private hospitals, the really good ones are comparable [to], if not better than the best in the world.
If you really want to even pinpoint a specific area where the challenge is, it is in data collection or in writing and reporting. India has a population 10 times or 20 times that of a developed country. We have shortage of healthcare facilities, shortage of staff.
Something as simple as identifying a house does not exist on the ground. If you ask the government, there are varying reports on how many houses are there even within a village without very clear data. We don't have a clear database on nutritional status. Every time I want to dispense medicine or give nutritional advice, I have to weigh a person, measure the height, arrive at the BMI. These skills are not even existent on the ground.
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You need to have radical new technologies for nutrition, come up with a solution where you could make a simple image to give your height, weight and BMI automatically. Now that way you’ll be able to identify if a person is undernourished or normal. But these are experimental solutions.
Do we have any pilots conducted so far? What is this new digital ID based on?
Dr. Suresh Munuswamy: I will go back to what Dr. Shukla mentioned. A lot of these things are being pushed by the providers, primarily for the top hundred million or 200 million population. Let’s say services like Amazon, or all these banking services, delivery services, they are primarily targeted at the top hundred million or 200 million. For the bottom 800 million or even the bottom billion, we need fundamentally different services.
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In certain cases, small pilots are fairly successful. But the challenge is in interoperability or integration. Simply because I have one digital thermometer, I cannot transform healthcare. I need to have dozens of devices working in a rural environment, all trying to generate data in a meaningful, rapid way. And then I need to have a back end platform to collect all the data, make sense of it. I need a digital dentistry platform, digital blood screening platform, a digital stethoscope.
If this ID is going to be used to profile health status and the commercial risk that individuals carry and that is used to discriminate...would you say legal changes must precede anything else?
Dr. Abhay Shukla : Yeah, that’s a big concern, because health data is very sensitive. For the data to be accessible to others, it could be a disaster. And you see that the Aadhaar data has been hacked into. The NITI Aayog said that they will be making available some of the data, and even to private players. That is the front door, and the back door can be hacked into.
So, imagine if this data becomes available to employers. That the following person has diabetes, they will not employ her. Or to insurers. They will either charge a much higher premium or on some pretext they will not insure. If a person has HIV, which is confidential, and that data becomes available to colleagues or people in the immediate environment, he may be stigmatised. We don’t have a Data Protection Act yet in this country.
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The other issue is about regulation. Today, we don’t even know how many private hospitals are there in a particular city. There is no reliable source of information on how many beds are available. The government is actually struggling in the COVID-19 epidemic to find out. We don’t even have a comprehensive list of private practitioners. From that level, we’re saying that we will digitise all the data. Regulation includes mandatory information, which needs to be accessed from private providers. We have the Clinical Establishments Act 2010, which, 10 years down the line, is yet to be fully implemented. The standards have not been notified. Many States still don’t have an effective Clinical Establishment Act.
Will the private tertiary care segment be happy with the idea of a digital ID, as everything goes on the record and the asymmetry is, in a sense, removed?
Dr. Abhay Shukla : Definitely. It’s my hunch that it is the insurance industry along with segments of the IT industry, which are, pushing this whole idea. The insurance industry wants to know the background, the previous illnesses and previous procedures, to improve its own business. And, of course, private hospitals will also benefit to some extent. But, for patients, it has to be linked with an assurance that the care being provided through such an integrated system is more rational, more standardised, and rate regulated.
Today, irrational care is rampant in the private sector. Unnecessary Caesareans, hysterectomies, so many bypass operations and angioplasties are going on. Is this going to be checked? Not automatically just by putting up a digital platform.
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Similarly, rates. You’ve seen in the COVID epidemic how patients have been grossly overcharged in certain private hospitals. So, you know, if it leads to standardisation, of quality of care or rationality of care, and regulation of rates, then that kind of digital health platform will be of some use to the patient. Whatever I have read about the digital health stack, which is a kind of precursor to this digital [move] these aspects do not seem to be very much fore-fronted.
With a public health expenditure of 1.2% of the GDP, there’s no way you can have a robust universal health care system. So just thinking about a digital health platform is not really going to help. And another apprehension is that PMJAY [PM-Jan Arogya Yojana], which is the previous big idea of this government proved to be a non-starter in the COVID-19 epidemic. It’s actually the public health system and public hospitals across the country which have stepped up.
Delhi has community mohalla clinics. Is it worthwhile looking at something like that with an ID?
Dr. Suresh Munuswamy: We all seem to agree that in some way mohalla clinics made a difference. Delhi itself is a very unique model. It is a highly populated fairly small State where the numbers seem to be adding up. If you provide any service, and if you even collect 10 rupees or 15 or 30 rupees, where each service is billed, the money that a healthcare service provider makes in a day seems to be meaningful.
If I replicate the same thing in a different State, the density of population reduces. In one square kilometre Delhi would have around 100,000 or half a million people living whereas in Telangana or Andhra, where they actually want to replicate the services, the density is much less. If I get 100 cases or 200 cases and then for the same area, I seem to be getting only 20 cases or 30 cases...this seems to be a challenge.
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If you want to roll out some kind of a two-wheeler based service where people can actually go around and increase the population coverage, maybe provide core services, maybe increase the costs that you’re actually charging, probably the same model can be implemented implemented in other States. But this is where you need new technologies. Like point of care devices, diagnostic devices to test, blood or urine or any other samples at the home.
Can some elements of personal identity be masked and health advice given to individuals using an ID?
Dr. Abhay Shukla : Anonymised data for public health surveillance may be of some use for certain kind of illnesses especially non-communicable diseases. Especially blood glucose levels and lipid profiles for population based public health decision-making. But a large proportion of illnesses are communicable diseases, perinatal and maternal health conditions, where laboratory investigations are of limited value and lot of clinical interaction is still required. What we need to do is strengthen frontline and primary health care workers.
Disease surveillance is a prime area, where digital or e-health will help. If you look at the Integrated Disease Surveillance Programme, if you look at their website, it is completely outdated and the outbreaks information is from 2012. And in outbreaks, every day the situation changes.
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The erstwhile Planning Commission report on Universal Health Coverage said a small percentage of GDP can provide all citizens with free essential medicines. Can that be a demand with the Digital ID?
Dr. Abhay Shukla : We already have the technology, we don’t need a new ID for that. The Tamil Nadu Medical Services Corporation model which has been replicated in Kerala and Rajasthan, and which has shown that essential medicines can be made available across the State in each health care facility provided there is a demand-driven supply and a willingness to make the procurement and distribution system transparent, accountable and largely free of corruption. Unfortunately, most other States have not adopted the Tamil Nadu model yet, for political reasons, and not due to lack of technology. Of course, some more technology will help.
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Should not a digital ID confer a right to medicines for all?
Dr. Abhay Shukla : Yes, it is true that the primary health system is inadequate and people go to private medical practitioners and private medical stores. But the digital ID is not going to make a big difference. What we need is a combination of expanding primary health services in the public sector through health and wellness centres or mohalla clinics. This can act as an arm of the public health system for free care. Engage local private practitioners and bring them into the system under regulation. Then digital health will help strengthen it, make information available, deliver medicines. In chronic illnesses like diabetes, high blood pressure, arthritis, cardiac ailments, digital health platforms could make available regular, low cost, quality medicines, especially for elderly patients who cannot go to a health centre, in a regulated system.
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Dr. Suresh Munuswamy: Before the Tamil Nadu model, each District Medical Officer was purchasing medicines and it led to a lot of corruption. So what the TN model said was, when you centralise purchases a lot of things can be taken care of. You have this efficient way of delivering medicines up to the primary health centre level. Again, the challenge is, you are only tracking the secondary packages, not primary medicines. You don’t know if the person is getting the medicines. You need to have the real time authentication of the person.
Dr. Suresh Munuswamy is head, Health Informatics and Technology Innovations at the Public Health Foundation of India; Dr. Abhay Shukla is a public health physician and national co-convenor of Jan Swasthya Abhiyaan