A strong digital health system will also address the inefficiencies in healthcare delivery
By Dr Devendra Kumar Punia
With India launching its most ambitious healthcare scheme ever in the form of Ayushman Bharat or Pradhan Mantri Jan Arogya Yojana (PMJAY), there is both excitement and apprehension over its future. Excitement stems from the huge benefits it promises to deliver towards realising our goal of universal healthcare while apprehension surrounds our ability (or the lack of it) to make this mammoth project a success. A programme that aims to provide substantial health coverage to as many as 10 crore households can be a game-changer if it is rolled out successfully. Not only does it make healthcare more accessible for millions of deprived Indians, it also promises to radically improve primary and preventive healthcare by building 1.5 lakh health and wellness centres.
As our country works towards achieving a uniform and standardised health coverage system, key to its success is building a strong capability in digital health. Digital health is essentially a paradigm that converges healthcare delivery with digital tools in a way that empowers us to better track, manage, and improve our health so that we are able to lead better and more productive lives. A strong digital health system will also address the inefficiencies in healthcare delivery, make healthcare more accessible and cost effective.
Niti Aayog has already envisioned and announced plans to create a National Health Stack (NHS) as a futuristic health system for all citizens of the country. How it streamlines the delivery of healthcare and uses the available country wide data to work towards better health outcomes is something to watch out for.
An enabling digital infrastructure for PMJAY Understandably, a programme that envisions provision of paperless and cashless treatment for the poor across a large network of public and private hospitals faces multiple challenges. Earlier initiatives in India like Rashtriya Swasthya Bima Yojana (RSBY), Rajiv Arogyasri in Telangana, Yeshasvini in Karnataka and others faced challenges in implementation:- poor enrolment of entitled beneficiaries, low participation by service providers, poor fraud detection, lack of reliable and timely data and analytics, etc. The other major challenge has been portability of health services across the country, as health is a state subject and there is large migration of citizens for employment.
National Health Stack (NHS) envisages to provide the shared digital infrastructure to address these challenges. NHS is being built upon the India stack which makes use of Jan Dhan, Aadhar and Mobile. The India stack has proved itself useful in developing a foolproof and fraud proof system of accessing relevant information and checking identities in banking, telecom, other Government service delivery.
On top of this strong technology foundation, NHS will have healthcare domain focused services like induction of private hospitals and private practitioners into the primary and secondary healthcare ecosystem; focus on Non-Communicable Diseases (NCD); disease surveillance; health schemes management systems; nutrition management; school health schemes; emergency management; e-learning platform for health, LMS, tele-health, tele-radiology; diagnostic equipment; health call centre(s), etc.
Why digital infrastructure?
A nationwide reach with such massive coverage would need a truly digital, paperless and cashless service delivery with an IT backbone that successfully converges disparate systems and scattered data to make the healthcare experience seamless and hassle free for the poor beneficiaries while serving to bring down costs of health protection by leveraging the benefit of health data.
Experts say that previous health coverage schemes initiated by different Governments have failed to take off because of a series of factors such as low enrollment of entitled beneficiaries, low participation by service providers, lack of reliable data and analytics as well as poor fraud detection. If Ayushman Bharat has to succeed, the digital spine behind it has to function in a way that it plugs all these above loopholes. Availability of reliable healthcare data is one of the most important requisites for health insurance providers to assess the healthcare scenario of a region, the dominant diseases and risks. Unfortunately, statistics on health are highly unreliable in India with most experts agreeing to the fact that disease prevalence is significantly under-reported, especially among poorer populations.
The NHS must become not just a tool to share information between various stakeholders of the scheme but also a reliable repository of data on health. With time, this consolidated data can provide sufficient information to insurance providers to be able to offer more cost-effective coverage.
At the same time, cyber security and safety from leakages and data theft must also be accorded top priority. A highly ambitious National Programme for Information Technology in the UK was initiated in 2002 with an objective to create a centralised, digital healthcare record for patients. However, the scheme had to be scrapped in 2011 after coming under constant fire for its ill management and excessive expenditure, as well as concerns over privacy and security of data. We must learn from this experience and ensure we do not repeat the mistakes of that experiment.
Improving accessibility in primary healthcare It is common knowledge that shortage of doctors and other medical staff is a critical problem that bedevils India’s healthcare sector. This problem is particularly acute in rural areas and public hospitals. According to data, 7% of primary health centres (PHC) across India were functioning without a doctor as on March 31, 2017. The shortfall of specialists was 81% in community health centres (CHC). Together, CHCs and PHCs had a 22% shortfall of pharmacists and a 40% shortage of laboratory technicians. No healthcare scheme, howsoever ambitious, can succeed in its goals without addressing these problems. The proposal to establish 1.5 lakh new health and wellness centres look very appealing on paper, but will require extensive investments and efforts in not only creating the physical infrastructure but also the workforce.
Digital health tools are critical in realising this goal. We will have to use tools such as telemedicine and digital health applications to cover up the shortage of human resource. Establishing telemedicine centres where patients can interact with doctors and seek consultation virtually must be done at every primary health centre. The government and private sector must also invest in building digital applications that help monitor nutrition levels among rural populations, and send automated vaccination reminders to parents.
This will also require extensive efforts to improve digital literacy in the country. According to a report by the Internet and Mobile Association of India (IAMAI), urban India with an estimated population of 455 million already has 295 million people using the Internet. However, rural India, with an estimated population of over 900 million has only 186 million internet users. This clearly tells us about the digital literacy gap in India which needs to be bridged.
Big data analyses for better outcomes
Availability of clinical data on health has been a major problem for medical researchers in India. Digitisation of medical records paves the way for creation of a huge database of disease related statistics which can be utilised for medical research and analysis, thereby helping improve public health outcomes at large. With low-cost access to rich longitudinal data on large populations for epidemiologic research, researchers can use data analytic techniques and predictive analyses to arrive at solutions to public health problems and evolve epidemiologic theory. The large sample sizes and diverse information available in a large database can be very useful for population health research and for overall benefit of public health.
Earlier experiences with platforms and systems in the cases of income tax, GSTN and others have shown that NHS like platform can be really useful and critical to the success of Aayushman Bharat. All the stakeholders need to come onboard to make the vision of cashless care with improved access to ensure the protection for the poor.