Is the Digital Health ID the one key-card to rule them all?
Inside India’s National Health Stack and the dream of Universal Health Coverage
Among PM Modi’s announcements on the 74th Indian Independence Day, one is a clear winner in terms of its sheer scale of impact. Heralding a new revolution in the healthcare space, the PM announced the launch of the National Digital Health Mission and a new Digital Heath ID for each citizen. Behind this announcement is a much larger project. What is the National Health Stack and why does it hold the promise to be a game changer in public health delivery? We dive in.
What is the National Health Stack?
The National health Stack (NHS) was envisioned in 2018 to create a seamless flow of information across stakeholders in the health ecosystem, bringing patients, health records, hospitals, doctors, insurance providers and government sponsored health schemes on a common, integrative platform.
A technology stack is a set of interconnected yet independent single-purpose technologies — called “platforms” — that work together towards general purpose tasks. Platforms show powerful network effects which can increase access, reduce costs of operation and improve service delivery. Such stacks, when developed by public entities, can serve as public digital infrastructure. Examples from India are India Stack, and the UPI.
NHS for Ayushman Bharat and beyond
In a Strategy Document published by the NITI Aayog in 2018, the two-pronged approach of the Ayushman Bharat Yojna was elucidated. First was the creation of 1.5 lac health and wellness centers. The second was the roll out of the Pradhan Mantri Swasthya Suraksha Yojana (PM-RSSM), which sought to extend financial protection of up to 5 lacs per year per family for the deprived 10 crores plus households towards secondary and tertiary care. Taken together, these were the first steps towards a larger public health plan in the making.
The vision outlined for the NHS was to converge multiple health care schemes into a universal health coverage which is portable (accessible across states), yet decentralised (not stored with a central authority). The NHS was proposed as the digital backbone of the Ayushman Bharat, built as a common public good. It sought to interconnect various government schemes across states, private health and insurance plans and the health information of citizens with a doctor and hospital directory to make healthcare information and services converge on a single plan. This is where the stack comes in.
From Aaadhar to Tele-consultation Services
Four key components make up the NHS . These are the national health electronic registries, coverage and claims platforms, a national health analytics platform and finally, horizontal components like the Digital Health ID.
Built as a common stack, it would cut across primary, secondary and tertiary care, including stakeholders in both the public and private sectors. The NHS, much like the UPI, is a service built around the Aadhaar which constituted its core authentication mechanism. India Stack and JAM enable health information in repositories to be stacked on top, which enables your Digital Health Card to hold your unique health records intact with you, usable across the country. The plan is to create a health stack based on the principles of the India Stack — cashless, paperless and presence-less with a distinct consent layer —like the UPI.
The Open Health Services Network (OHSN) is the interoperable layer of the NHS, the interface which allows private players to host healthcare services on the platform. It governs the relationship between various market players in the healthcare ecosystem such as tele-consultation providers, pharmacies, or diagnostic centres on one side, and government or private apps and platforms on the other side. Teleconsultation services shall be offered through the OHSN, involving an end user, an OHSN gateway and a telehealth service provider.
NHS is designed to facilitate experimentation with policy, detect insurance fraud and create the architecture for private and public to innovate. Set to generate massive amounts of data, the NHS would create the largest health database in the world. The National Health Registries include data on providers, doctors, beneficiaries, family taxonomy, etc. Powered by a set of open APIs, the dream of the Digital Health Mission is to build a host of cloud-based services using common registries. Interestingly, the researcher and policy maker also figure in the policy as users who could use this data for data-driven policy, as well as cutting-edge biomedical research.
What about your Health Data?
Initial efforts into building a privacy framework for the healthcare sector began with the ‘Digital Information Security in Healthcare Act’, proposed by the Health Ministry in 2018. DISHA would enforce privacy and security standards for EHRs. This bill has been now subsumed into a more sector-agnostic framework driven by MeitY with the Personal Data Protection (PDP) Bill that looks at what constitutes personal health records, decision making powers on health data and penalties for breach of consent. The draft law mandates setting up of electronic health data regulators at the national and state level, and it rests the ownership of the data with the patient. As in the case of payments/banking today, the health records will be digitised and stored in a central place in the cloud — a DigiLocker — and accessed remotely by both patients as well as doctors/hospitals/insurance firms, after user consent is provided.It is important to note that to ensure security, the design of the platform seeks to build non-repudiable audit logs and mechanisms for electronic consent.
The Progress so far
Fast forward to 2020, the NHS is set to accelerate Aayushman Bharat, the world’s largest public health scheme. Aayushman Bharat aims to offer Rs 5 Lakh health insurance cover for over 50 crore Indians (40% of the population) for secondary and tertiary healthcare through a network of health care providers. Over 114 million e-cards have been issued in 2019 and the scheme hit the 1 crore treatments mark in May 2020. In the meantime, work on the National health Stack has progressed fast. iSpirt made more APIs and plans public in May this year, and demoed consent manager directories, along with inviting players to build different registries under test conditions. Much of this development has been accomplished with the Swasth Alliance, an alliance of 92 partners across health-tech companies, hospitals, diagnostic labs, insurance companies, tech companies, and venture capital firms. It enlists the Bill & Melinda Gates Foundation, Boston Consulting Group, and iSpirt, among others. 2020 shall see new platforms for tele-consultations, and other digital health services being developed.
The Digital State in India? Changing Dynamics
The digital foundations of a new social security framework are being laid down since the inception of the India Stack itself. If one looks carefully at the initiatives and policy-rollouts in the last four years, the state has woven a web of services, looping in users through Aadhaar and JAM to create a host of platforms and services which make social security- subsidy, education, benefit schemes, loans, and finance increasingly digital. With the coming of the Digital ID, backed by the NHS, the citizen’s engagement with the state will be vastly different from the messy negotiations, delays and poor quality that characterise healthcare service delivery in India.
Taken together, these movements also signal the creation of a digital state in India, not represented by the government office or the sarkari babu, but the linking of one’s data, authentication and service delivery in a more efficient and transparent service-delivery system. Fresh concerns over the centrality of Aadhaar in state-citizen interactions, data privacy and digital rights as well as improvement in delivery of services remain open and contested questions.
Digitalisation though building public infrastructure also helps build state capacity in a rather sluggish, over-stretched Indian state system, bypassing the bureaucracy altogether. All these are signals of a new India, with a fresh set of modes and models, but also a new set of challenges which emerge in the digital era. Let us remember, digital solutions are only as good as the infrastructure they are out to enable. While steps like the Digital ID might be a welcome step in delivery, is it no substitute for what is to be delivered to the people.
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