Universal Digital Health ID: Panacea or adveristy?
By Bibhudutta Pani
The policy for universal adoption of Digital Health ID for every citizen of India that was rolled out for implementation of Ayushman Bharat Digital Mission (ABDM) on September 27 is a potential misstep and needs careful consideration and implementation. The big-bang, one-size-fits-all approach of proposing Digital Health ID on a universal basis runs contrary to principles of equity, decentralised and internationally adopted methodology prescribed by the National Health Policy. The policy is vulnerable to unintended outcomes, including fatal exclusions and incentivising an illegitimate/parallel market for healthcare services. ABDM aims to develop the backbone necessary to support the integrated digital health infrastructure of the country and is the mission mode initiative of National Digital Health Blueprint (NDHB), which in turn is the implementation framework of National Health Stack which emerged out of the digital technology adoption initiative of the NHP. Ergo, the objectives intended to be served by this proposal (of Universal Digital ID) have been viewed within the frame of the objectives that were intended to be met by the NHP as well those articulated within the NDHB.
The National Health Policy, 2017 aimed at reducing inequity by minimising disparity on account of gender, poverty, disability and other forms of social exclusion and geographical barriers. However, the initiative of Universal Digital Health ID translates into implementing a common eligibility criterion uniformly, across a vast and disparate populace that is plagued with acute inequality. In this case, it manifests itself in what is known as the digital divide which is a product of inequalities amongst the target group on account of economic means, geography and social hierarchy amongst others. The World Bank estimates (dating back to 2019) that only 41 per cent of population of India have access to the internet. This sparse resource is further skewed in favour of urban areas with rural areas accounting for lower level of access to internet as highlighted in the ICUBE 2020 report by IAMAI and Kantar.
This criterion (of securing Digital Health ID) will act as a gate-keeper (i.e. presumably someone without a Digital ID will not get access to healthcare service, akin to being unable to access air travel without an identity document) and magnify the ensuing damage that will be caused due to the unequal state of affairs, something the national health policy admittedly aims to eliminate in the first place.
The NHP focused on decentralising the decision-making to a level as is consistent with practical considerations and institutional capacity. A decentralised approach for implementing a large scale programme dealing with an essential service such as healthcare does appear to be a sensible approach. However, the proposal to implement a Digital Health ID for all citizens without exception goes against the fundamental basis of a decentralised approach. Further, a binary eligibility/gating criteria for all users can barely be said to empower decision making to a level that is consistent with practical considerations, as is intended under the NHP. In fact, such a step undermines all practical considerations by super-imposing a one-size-fits-all approach.
No international precedents
The National Digital Health Blueprint (NDHB) published in April 2019, by the Ministry of Health and Family Welfare, Government of India aims at furthering the NHP’s emphasis on leveraging digital technologies for enhancing the efficiency and effectiveness of delivery of all healthcare services. To that end, the blueprint recommends creation of Personal Health Records and its access and usage based on international standards.
A study of the UK system indicates that while the framework set out by the National Information Board encourages adoption of digital forms of recording, access and usage of PHR, there is no provision for adoption of a Universal Digital Health ID. In fact, the framework is designed to apply on the healthcare providers who generate and store health records but there are no gating criteria that is imposed on the consumer by mandating something akin to a Digital Health ID.
Similarly, in the US, the Health Information Technology for Economic and Clinical Health (HITECH) Act — the legislation to promote the adoption and meaningful use of health information technology — does not mandate a provision akin to a Health ID. Therefore, while the blueprint recommended adoption of international best practices for the PHR ecosystem, there is no application of that recommendation in adopting the framework for Universal Digital Health ID.
Black market for healthcare
The plan of a Universal Digital Health ID is likely to exclude a sizeable population in India for reasons discussed above. This in turn is likely to create a black/parallel market for healthcare service that is not guarded by this gating criterion of a Digital Health ID. The black market for alcohol spurned by a rather strict licensing regime in the past decades provides a clear glimpse of the outcomes that could arise out of such a step. Healthcare, unlike alcohol, is an essential service, so the incentive for the ecosystem to create a black market is understandably higher. Parallel/illegitimate ecosystem is prone to spurious products/inferior quality, again, an experience from the alcohol ecosystem. The same hazards in the healthcare sector would only increase the hardships manifold.
Workflows enabled by digital technology rely on it being accurate and infallible; when such workflows are embedded into public systems and/or essential subjects, there is an implicit over reliance on such accuracy and/or infallibility as erroneous instances translate into people (often under privileged) being deprived of basic rights/services. Experience (as regards infallibility of technology ecosystem), however, suggests otherwise. Usage of Aadhaar (another flagship digital governance moniker that is being increasingly relied upon by the Central Government) for various public welfare schemes has seen its fair share of erroneous exclusions. The possibility of the Digital Health ID malfunctioning in some cases is a real one and each time that happens, a citizen would be deprived of healthcare service which in some cases could very well be a fatal outcome for the citizen.
Universal adoption of Digital Health ID does not enable grant of universal access of healthcare to all citizens of the country nor does it proliferate usage of electronic medical records. Health records are created, accessed and relied upon by health care providers so an endeavor towards digitisation of health records must be provider-centric (as the framework of HITECH Act sets out) and not consumer-centric (such as digital health ID). Universal Digital Health ID does sound like a grand, large-scale plan with myriad benefits flowing out of it but in reality, it could constrict the intended public benefit in a significant manner. One, therefore, hopes that its deployment will be made in a staged manner keeping practical considerations in mind.
(Bibhudutta Pani is corporate lawyer. He interacts with digital technology-led startup ecosystem).