Challenges aplenty for digital health mission

Soham D Bhaduri

Health Policy Expert

Around the world, the ideal of public monopoly in healthcare provisioning and financing has lately come under the scanner. Even the staunchest proponents of public sector healthcare have come to acknowledge that public sources of healthcare finance, such as general taxation, are unable to keep pace with the rising healthcare demands across the globe.

With this realisation comes the tangibly increased leaning towards private sources of finance and various forms of public-private partnerships (PPP), albeit without impairing health equity as much as possible.

Recently, the Centre announced the nationwide rollout of Pradhan Mantri Digital Health Mission (PM-DHM), which is in its pilot stage in six UTs. The hallmark of this initiative is the provision of a health ID card and a 14-digit unique health identity number that will serve as a personal digital health account of an individual — apart from other features like healthcare facilities registry and healthcare professionals registry to facilitate easy access to health centres and personnel.

Aspects like easy exchange and interoperability of health data, access to a more comprehensive range of useful medical information, and the possible boost to evidence-based health policymaking in the long run, which are the obvious benefits stemming from this initiative, have been widely discussed.

And, so have been the possible cons such as breach of privacy and confidentiality.

However, the larger picture lies in the subtler aspects, which go hand-in-hand with the Centre's ambitious plan to expand insurance-based healthcare coverage over the medium and long terms.

The PM-DHM was launched on the third anniversary of the Centre's flagship health programme, the Ayushman Bharat Mission (ABM). Starting from the bottom, the ABM aims to gradually expand healthcare access to all Indians via the insurance route, through public-private partnership. For such a large-scale public-private partnership to be justifiable, engagement with the private sector has to be strategic. The cornerstone of such strategic purchasing is the availability of good quality data, not just for the government to assess the performance of private players, but also for private players to operate optimally and gainfully.

This requires a robust health IT infrastructure to be laid, block by block, as ambitious plans to expand insurance-based healthcare unfold alongside. The PM-DHM is, thus, a central pillar of the current Central dispensation's plans to expand and cement a stronger role for private players and insurance companies in the country's healthcare landscape, which need not entirely be to the detriment of Indian healthcare. Any benefits that accrue to individual patients is actually incidental.

The second most important aspect meriting discussion is the administrative barrage that this likely to accompany this initiative, which warrants to be minimised as much as possible in the interest of the country's frail healthcare infrastructure and human resources. Experience from the US indicates how such a digital health framework could entail formidable sums in administrative costs.

In the Indian context, where public funds for healthcare are perennially short, every extra rupee spent on administrative expenses raises ethical concerns, since these costs don’t directly contribute to improving the health of the population. This does not downstate the significance of rolling out the digital health framework. Nor does this imply that the same should be deferred until funds for health are bountiful.

However, there is a need for striking a balance between the competing concerns. We must also not ignore the rise in the administrative workload of physicians and other healthcare personnel that this initiative might result in, which would be more acutely felt, given that health manpower is in short supply. Data literacy is often poor, even among qualified medical personnel. Also, Internet connectivity is still precarious in large parts of the country. Although these issues must not deter the initiative, working around them will be imperative.

Another important aspect of the initiative is its inherent linkage with the insurance model of healthcare, more precisely the ABM. The precursor of the Pradhan Mantri Jan Arogya Yojana (PMJAY, the insurance component of ABM), namely the Rashtriya Swasthya Bima Yojana (RSBY), was replete with alleged reports of insurance fraud, such as fake beneficiaries. The PMJAY has not been free of them either.

With the health IT system unprecedentedly expanding health data availability, it becomes a double-edged sword of sorts, as data could be used both to instigate as well as to deter insurance fraud. This merits caution as the weak regulatory environment in the country may tip the balance towards the former.

Secondly, it is worthwhile to note the beneficiary profile of the PMJAY, which is currently 40 per cent poorest population, which, moving forward, could be expanded to 85 per cent of the population (including the large informal sector) on a contributory basis. This population is very likely to lack the most in data literacy, exacerbating ethical concerns surrounding consent and privacy.

It is also to be noted that expanding contributory health insurance to the large informal sector is in itself an administratively challenging exercise forecasting large, and likely to be wasteful, administrative costs. Concerns have also been raised regarding the large-scale availability of health data which could facilitate market expansion of the private sector as well as a gainful segmentation of the patient population.

However, such data could also be of great use in building fruitful public-private partnerships, and it is for the government to ensure that things are steered down the right lane.

Finally, undertaking a cost-benefit analysis of the initiative is called for. The overall costs, including the indirect costs of laying the digital health framework, could be substantial and crowd out investments in other essential areas of public health.

The immediate benefits would mainly come in the form of better patient experience and management, which is unlikely to reflect significantly at the population level. Over the medium and long terms, a boost to strategic private sector engagement and more effective public health policymaking can be the possible benefits, but neither of them is guaranteed and would require strong government stewardship.

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