Digital health education shouldn’t lose sight of equity, social justice

Soham Bhaduri

Health Policy Expert

ONE of the most conspicuous ways in which the Covid-19 pandemic transformed healthcare was through an unprecedented mainstreaming of digital health. What was earlier commonly thought to be a substantive adjunct or the ‘next big thing’ at best has now secured a strong foothold in healthcare delivery in the country. Recognising its potential to improve healthcare access amid stringent mobility restrictions, the government issued the Telemedicine Practice Guidelines in March 2020. This was followed closely by the launch of the eSanjeevaniOPD, proclaimed to be the world’s largest national telemedicine service, in April that year. But perhaps the most momentous turn was when it made inroads into national health insurance, which stands to decisively shape the future of public healthcare delivery. The Ayushman Bharat Digital Mission, a Union Government initiative that is spearheading the digital health transformation in the country, was launched in the aftermath of the pandemic and is steadily heading towards achieving a thorough digitalisation of health records. Nearly 58 crore Ayushman Bharat Health Accounts (ABHA) have been created so far. And nearly 35 crore health records have been linked with ABHA.

If healthcare is seen as a complex system straddling multiple sub-systems, it is impossible to ignore the system-wide ramifications that digital health is likely to have, ranging from provider payment methods to medical education. Global evidence attests that the effectiveness of digital health rollout is strongly contingent on healthcare personnel, one of its primary stakeholders. In the Indian context, this suggests that reforms in medical education are unavoidable, not just in professional education that produces new healthcare workers but also in continuing education for the existing pool of practising personnel. Maharashtra’s recent decision to commence a foundation course in digital health for medical students, the first of its kind in the country, is a notable development. There have been steady calls for its nationwide adoption as well as a stronger, more integrated emphasis on digital health in the medical curriculum. As the discourse gathers steam, one should visit some guiding principles that must be remembered along the way.

The emphasis on digital health in the medical curriculum, consequential as it is, cannot outpace the contemporaneous state of digitalisation of the country’s healthcare. These two elements exist in a natural, dynamic equilibrium. It has to reflect the national health realities and priorities of the present day. Digital health cannot be imbibed in its fullest unless integrated at every step of medical training, but overzealous measures in this direction will be wasteful. Rather, its presence in the curriculum must grow steadily as digital health catches on, and given the nature of medical training, this will be inevitable.

It is apt here to identify three broad competencies when it comes to digital health education: knowledge, skills, and attitudes and ethics. In most parts of the developing world, knowledge and skills related to digital health modalities among healthcare personnel have been less than optimal. This has likely improved in the aftermath of the pandemic.

At the same time, evidence from China, Saudi Arabia, Iran and India demonstrates an overall positive attitude of healthcare personnel toward digital health. Importantly, knowledge has an understandably direct and substantial impact on attitudes. Given the current phase of digital health in the country, the predominant emphasis of curricular reforms must be on knowledge and attitudes while also allowing for basic skills. This is particularly important in order to ensure a steady and sustainable expansion and adoption of digital health in the foreseeable future. This shall also prevent an abrupt overburdening of an already crammed medical curriculum, as the emphasis on skills grows hand in hand with the evolution and maturation of the digital health landscape. Maharashtra’s incremental approach is laudable and can serve as a paradigm for other states to emulate. A similar approach must be adopted in continuing medical education, with the need to steadily move towards making digital health competencies a part of licensure requirements.

There is evidence lending credence to the idea that hard skills in digital health practice, particularly for doctors, may not be as pivotal as many of us may be inclined to think. Doctors work in inter-professional teams with other crucial cadres of medical and allied personnel, and this is only more likely to accentuate with the evolution of digital health. In such a scenario, teamwork and distributed leadership competencies become all the more crucial. Medical education has traditionally been individualistic in its outlook, and doctors in general rarely do well outside hierarchical power structures. Another idiosyncrasy of medical education and practice, that of a physician-driven relationship, is likely to undergo a noticeable shift with the mainstreaming of digital health. At bottom, the digital health movement is about empowering the patient, and the concomitant levelling of power relations may not at first be very congenial to physicians. It is here that a stronger emphasis on attitudes, ethics and communication in medical education becomes the key. It is aptly said that unlike some skills, which may depreciate in significance with the advent of digitalisation, leadership and managerial competencies will only tend to become more crucial.

Finally, educational reforms reflecting a systemic expansion of digital health cannot ignore equity and social justice considerations, apart from the ethical considerations arising in personalised practice. Digital health is understood to be an equally effective perpetuator of health inequities unless due caution is exercised right from the design stage. These range from simpler aspects like digital health literacy to subtler ones, such as AI-based tools based on poorly representative datasets exacerbating health inequities. Emphasis on these will be particularly significant for preparing the next generation of health policymakers. 

Join Whatsapp Channel of The Tribune for latest updates.