Is India’s public healthcare system ready for digital infrastructure?

Budgetary allocations to health care indicate a shift in state priorities for health care in India. What impact will this have on access to health?

The need for a stronger role of the state in the health sector has never been felt so deeply as in the past two years of the pandemic. Amid rising COVID-19 cases, inadequate infrastructure in public hospitals, and little government regulation, private hospitals were charging exorbitant fees. Given the magnitude of this problem, it was expected that the government would become aware of the lack of infrastructure in public health care, and measures to correct the problem would be reflected in this year’s budget. However, the budget reflects different priorities.

Reduced role of the state in health services

The allocation of funds to the health sector this year was INR 83,000 crore, or just 0.33% of India’s GDP. The 2017 national health policy, meanwhile, provides that the government should devote at least 2.5% of GDP to health to achieve its goal of universal health coverage. Inadequate allocation of funds has further led to underfunding of several flagship health programs.

The budget for the National Health Mission – a program aimed at strengthening the public health system, including infrastructure, human resources, medicines and equipment – recorded an increase of only 1.8% compared to forecasts budgets for the previous year. This is when the government’s own data showed that a rural sub-centre serves 5,729 people, primary health centers (PHCs) serve 35,730 people and community health centers (CHCs) serve 1,71,779 people in general areas against the national target of 5,000 people for sub-centres, 30,000 people for CSPs and 1,20,000 for CSCs respectively. A similar deficit is documented in terms of personnel and equipment in the public health sector where a deficit of 6.8% of allopathic physicians in CSPs and 76.1% of specialists in CSCs has been reported.

Another program that was announced in the 2021-2022 fiscal year and hailed as a health capacity building program has also been overlooked: the Pradhan Mantri health infrastructure mission. This program has been allocated a budget of INR 64,180 crore for a period of five years, with a specific spending target for each year. The total expenditure for this program was INR 900 Crore (ER or Revised Estimates) in FY 2021-22 and INR 5,156 Crore (BE or Budget Estimates) in FY 2022-23. While the absolute numbers may have increased in the space of two years, the total expenditure for this program is not even half of the target that has been set for each of those two years.

Programs focused on building and strengthening infrastructure in the public health space have been grossly underfunded. This suggests that the state is not trying to create a greater role for itself in the provision of health services.

Moving from physical to digital infrastructure

The highlight of this year’s budget was the focus on building a digital health ecosystem. Although the Minister of Finance began her speech by acknowledging the need to strengthen health infrastructure, the focus was on building digital rather than physical infrastructure. The National Digital Health Mission (NDHM) has been allocated INR 200 crore, more than six times more than the BE of the previous year. The NDHM offers a technology-driven solution to improve the efficiency of the healthcare system. It is based on two key building blocks:

1. Generate unique health identifiers for all citizens
2. Maintain a digital registry of all healthcare providers

While unique health identifiers will be linked to patient medical records, the digital health registry will serve as an online repository of basic information about the workforce and the various institutions involved in the delivery of health services. Unique health identifiers have been introduced to maintain an effective digital health record of a patient’s medical history and are mandatory for anyone receiving government health plan benefits. However, experiences from past programs suggest that when such ID cards are made mandatory, they often act as an additional barrier for patients. Taking the example of Pradhan Mantri Jan Arogya Yojana, a Hindi daily reported in 2019 that Uttar Pradesh’s health department received eight to ten complaints daily about hospitals refusing to treat patients even after they produced an Ayushman Bharat identity card. . Such cases were not confined to Uttar Pradesh alone; the states of Madhya Pradesh, Rajasthan and Delhi have also witnessed such cases. Even in the case of Aadhaar, which has a well-established exception handling mechanism, patients were denied COVID-19 treatment due to non-production of the card or issues with its online verification. With little government regulation and lack of appropriate infrastructure, cards linked to a patient’s proof of identity, when made mandatory, can prevent rather than enable them from seeking care. medical.

The NDHM requires healthcare providers to act as data trustees in which they are responsible for maintaining a digital copy of inpatient and outpatient medical records and then linking them to patient health identifiers. This data, which includes both personal (relating to a specific individual) and non-personal (aggregated and anonymized) health records, is highly sensitive and of great market value. In 2019, cybercriminals stole 68,000 records from an India-based healthcare website that contained patient information as well as personally identifiable information and physician information. This data is likely to end up with insurance companies, among others, and could therefore increase insurance premiums. This data is also an attractive target for big pharma competing to increase their profits. In a scenario where digital health records are prone to cyber theft and no appropriate sanctions are in place for data breaches, these health records remain highly vulnerable.

The NDHM also provides for the sharing of data collected by trustees with health information users (HIUs) – agencies that could view these health records with patient consent. However, the program fails to determine precisely which agencies qualify as HIUs. He mentions that these can be doctors, apps providing advice to patients, the government and its agencies involved in medical research, healthcare providers or any other entity interested in viewing the records. This broad definition of HIUs can lead to sharing of sensitive health data between different types of entities and lead to further data compromise.

Other building blocks of NDHM include DigiDoctor, Online Pharmacy, and Telemedicine, all of which require strong technical expertise to build and maintain their digital ecosystem. A report published in 2016 pointed out that with the exception of some large public hospitals, most public hospitals and clinics have very little information and communication technology infrastructure. As the private sector is better placed in terms of digital infrastructure, it is called upon to take center stage. But the private sector emerging as the primary entity in the provision of health care presents another set of problems, notably that of high out-of-pocket expenses for patients. The literature on PMJAY, the public health insurance scheme, reveals that private hospitals engage in abusive practices such as “double billing” whereby they claim the cost of a service from the insurance company in addition to billing patients or asking them to buy drugs or diagnostics. from outside. During the pandemic, a team from Down to Earth visited nine states that reported high hospitalization rates and told several stories about how government insurance plans had failed to provide a financial cushion to patients. .

Programs such as NDHM can reinforce the dominance of the private sector in the healthcare delivery space and further diminish the role of the state. The announcement of a nationwide mission to digitize health records as the human, financial and physical resources of the public health sector are stretched raises several questions, the most pertinent of which is whether the health sector in India is at an appropriate stage for the government to focus on digital healthcare solutions.

This article originally appeared on India Development Review



The opinions expressed above are those of the author.


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