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.
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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.
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.
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.
Source: The Hindu