India’s vast population faces the critical challenge of a fragmented healthcare system that is not accessible from all cities, towns, and villages equally. Part of the challenge is the sheer size of the country and its population which will require the government to mobilize humungous resources at a cost that is not always feasible and bound to leakage. Despite this, it was interesting to see that the Government of India was able to provide treatment to a vast number of cases during the ongoing COVID-19 pandemic. They were also able to vaccinate nearly 98% of the population of 1.3 billion people with one dose and 83% with both doses in a span of 2 years.[1] This was partly thanks to the digital elements that were put in place by the Ministry of Electronics and IT (MeitY) in collaboration with the Ministry of Health and Family Welfare (MoHFW).
The Government of India has a capacity to innovate quickly, at scale, and effectively to reach its massive population. This was proven during the COVID-19 pandemic by the early release of Aarogya Setu app (in April 2020)[2], and the COVID Intelligence Network (CoWIN) (in January 2021)[3]. Both these applications formed the digital backbone of the massive containment and later vaccination efforts. Interestingly, the lessons learned from these experiences have strengthened government’s ongoing efforts to digitize healthcare in India.
Looking back, the government enacted National Health Policy in 2017, which put forward the goal of digitizing the entire healthcare ecosystem in India. In July 2018, the NITI (National Institution for Transforming India) Aayog released its first proposal for the National Health Stack, which was to form the foundation of India’s digital health mission. After reexamining the proposal, NITI launched the National Digital Health Blueprint (NDHB) report in April 2019, enumerating the steps to be taken to make this goal achievable. Fast forward to September 2021, the blueprint has manifested into the Ayushman Bharat Digital Mission (ABDM), launched by Prime Minister Narendra Modi. The initiative aims to develop an integrated digital health infrastructure for the country. In 2022, the national Budget spelled out clear policy direction towards nationwide implementation of ABDM, which was widely welcomed by stakeholders in the healthcare sector.[4]
The ABDM which falls under the National Health Authority (NHA) has adopted a collaborative approach to bring in innovative digital healthcare solutions. The key building blocks of ABDM are the Ayushman Bharat Health Account (ABHA), the Healthcare Professionals Registry (HPR), the Health Facility Registry (HFR), and the Health Information Exchange and Consent Manager (HIE-CM). Currently, there are over 800 participants integrated with ABDM’s registries and enabling health data exchange through the HIE-CM. The NHA is actively attracting interest of and solutions from developers to further improve the Unified Health Interface (UHI), the Health Claims Platform (HCP), software-as-a-service (SaaS) based solutions for information systems developed for hospitals and labs, and other open-source solutions.[5]
Currently, the government is looking to revise the Health Data Management Policy which has included a security and privacy by design approach and aims to shape the National Digital Health Ecosystem (NDHE) through the principle of federated architecture, which allows for interoperability between independent and decentralized information systems.[6] The government plans to assign a unique health account number to each individual, which can be verified using their Aadhaar card, and will be accessible across the ecosystem. While participation is optional, once the account is created, citizens can link their health records with the account, and share the same after consent through a health information exchange (HIE).[7]
Given the tremendous success of the government in creating the Aadhaar ecosystem for identification, Unified Payments Interface (UPI) for payments and FAST Tag for national electronic toll collection on roads and highways, the ABDM aims to create a scalable electronic health records system that flushes out duplicity of health records and inefficiency in access to and quality of healthcare in India. While critics have questioned the possibility of successfully implementing the program in a sector with such vast inequalities in infrastructure and resources, it doesn’t look like the government is worried or hesitating.
Firstly, India’s digital health mission aims to achieve an important milestone by bringing into the ecosystem previously invisible entities who were responsible for providing healthcare in some form. India has a large number of private healthcare facilities that are well-resourced and of high quality, combined with the public healthcare facilities that are not well-funded and offer poor quality healthcare service. Although the distinction is not always so stark, since there are some very good public healthcare facilities as well. It is also important to note that most healthcare facilities in India today do not communicate with one another, health records are not unified and not accessible or shareable between two or more hospitals. The NDHE will solve this problem, by allowing citizens to efficiently share their health records across the system.
Secondly, ABDM will allow for the healthcare data to be put to use more productively, as is seen globally in case of electronic health records. The data being stored, shared, and reused, will allow healthcare providers and institutions to elicit more value out of the data, which otherwise was largely being held idle, deleted or expired. This means that patient data, if made available with their consent, can advance a new wave of healthcare research in the country, and can help doctors make more informed treatment decisions.
Lastly, the government is aiming to give patients control of their data, which they can edit and share as per their convenience and requirement. This allows for patients to access healthcare as per their needs and without having to go through the gruesome process of resubmitting health records on paper at every point of healthcare delivery. This saves time which in turn can be used to better plan treatment for the patient and allows doctors better visibility of the patient’s condition.
However, critics have pointed out some concerns. India has yet to enact the Data Protection Bill and there are signs that it is still in advanced stages of discussion. As a result, experts feel that health data at this point is prone to cyber threats. They believe that the health data management policy should wait for the data protection law to be enacted so as to provide adequate security. They also suggest a tiered structure of grievance redressal to enhance user trust and improve feedback loops. From a systems perspective, they also observe that digital health IDs could cause exclusion, if citizens are asked to link their health IDs with other IDs like Aadhaar, for example. Moreover, there is a need to generate consensus on anonymization standards for health data, so that sharing it does not lead to breach of privacy. Lastly, primary and secondary uses of data should be clearly spelled out for the user to give consent to, otherwise it is observed that data can be misused after sharing takes place.[8]
Despite these concerns, there is a lot to look forward to from India’s digital health mission, since it aims to address important complexities in a diverse and highly unequal healthcare system. We can expect the initiative to continue to evolve dynamically over the coming years, as stated in the policy, as it makes the various elements of it more visible[9], the various stakeholders more responsible, and for the government to get a better picture of the pain points which they can ameliorate through reforms. Interestingly, as seen in many other countries, digitization of healthcare is also a great opportunity to bring in more investment. The same may also happen in India, which has tremendous demand for healthcare services and an insatiable need for infrastructure, doctors, nurses, and tools to expand access to the remotest parts of the country.
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