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1. Introduction
With the objective of strengthening the accessibility and equity of health services, the Ayushman Bharat Digital Mission was launched in 2021. The mission will leverage IT and its associated technologies to support existing health systems with a ‘citizen-centric’ approach. The vision of ABDM is to create a digital health ecosystem for the nation which can support universal health coverage in an efficient, accessible, inclusive, affordable, timely and safe manner. The mission is expected to improve the efficiency, effectiveness and transparency of Health service. It will provide a choice to individuals to access both public and private health services, while healthcare professionals will have better access to patients' medical history to provide better healthcare.
Reference - ABDM Website
Since 2005, most of the healthcare capacity added in India has been in the private sector, or in partnership with the private sector. Now, The private sector consists of 58% of the hospitals in the country, 29% of beds in hospitals, and 81% of doctors.
According to the National Family Health Survey-3, the private medical sector remains the primary source of health care for 70% of households in urban areas and 63% of households in rural areas. The study conducted by IMS Institute for Healthcare Informatics in 2013, across 12 states in over 14,000 households indicated a steady increase in the usage of private healthcare facilities over the last 25 years for both Out-Patient and In-Patient services, across rural and urban areas.
The Covid-19 Pandemic has underlined Fundamental Loopholes in our Health Infrastructure; according to the Human Development Report of 2020, India has just 5 beds and 8.6 doctors for every 10,000 people. Further, the Rural Health Statistics of 2020 states that— a shortfall of 46140 Sub Centres (24%), 9231 Primary Health Centres (29%) and 3002 Community Health Centres (38%) across the country. In these circumstances, We believe that the Digitisation of Healthcare in India is a game changer. Emphasis on Telemedicine and Digital Health Ecosystem will allow an Equitable Distribution of resources and reach out to the last human standing in line.
The success of the ABDM and the fulfilment of its overarching mission of a singular, unified healthcare ecosystem is largely dependent on the participation of extant private healthcare institutions in its network. However these institutions on an organizational level have little incentive to participate and integrate its systems as part of the ABDM due to outdated systems and infrastructure and potential loss of revenue.
This paper aims to identify key points of resistance preventing the private health sector in India from expediting its participation in the ABDM, potential concerns and risks in how the ABDM is implemented and policy incentives that can expedite the adoption of ABDM standards across the Private sector. This paper also attempts to broadly discuss the scope and structure of the ABDM to get an overall picture of the long term potential and benefits of a unified digital healthcare system in India.
2. The Vision
Ayushman Bharat Digital Mission aims to utilize the existing public digital infrastructure—including that related to Aadhaar, Unified Payments Interface, and wide reach of the Internet and mobile phones (JAM trinity), for establishing the building blocks of ABDM. The existing ability to digitally identify people, doctors, and health facilities, facilitate electronic signatures, ensure non-repudiable contracts, make paperless payments, securely store digital records, and contact people provide opportunities to streamline healthcare information through digital management will further help in the advancement of our healthcare sector.
Researchers will also greatly benefit from the availability of aggregated information as they will be able to study and evaluate the effectiveness of various programs and interventions. Better quality of macro and micro-level data will enable advanced analytics, usage of health-biomarkers, and better preventive healthcare. ABDM has the potential to greatly benefit citizens, doctors, hospitals, pharmacies, laboratories, and health tech companies apart from aiding the ‘Digital India’ campaign.
The vision is to create a state-of-the-art network of digital health solutions, provide ease of living and a simplified hospital system, to enable people living in the remotest areas of the country to avail virtual consultations from doctors of big hospitals in cities. While ABDM is a relatively new program, it does have to overcome certain challenges as discussed before. Proper planning and implementation can go a long way in making it a huge success
3. STRUCTURE OF THE NDHM ECOSYSTEM
ABDM aims to develop an ecosystem that digitally connects all the healthcare players across the country with each other in a citizen-centric manner (cite image of NDHM ecosystem). The Mission’s strategy is to build an ecosystem that leverages India’s extant digital public infrastructure; specifically, the JAM Trinity consisting of UPI, Aadhar, and the growth of mobile and Internet usage. This strategy will streamline the flow of healthcare information by leveraging existing capabilities from these public goods such as identification of individuals, facilitation of e-signatures, paperless payments, and non-repudiable contracts.
The core building blocks of ABDM are as follows:
a) Digital Registries
a.i) A Universal Health ID to standardize the process of identification across healthcare providers by providing each individual with a unique ID created using an existing Aadhar or driver’s license. Further, the system registers certain basic details of the individual, including demographic, location, family/relationship, contact details, etc. The UHID will uniquely identify individuals, authenticate them, and link and / or their health records (only with informed consent) with multiple healthcare systems and various stakeholders
a.ii) A Healthcare Professionals Registry - a comprehensive repository of all healthcare professionals across both modern and traditional systems of medicine.
a.iii) The Health Facility Registry - a comprehensive repository of all healthcare professionals across both modern and traditional systems of medicine.
b) Health Records: this includes three distinct bits - standards to build a health record, records exchange and consent manager, macro opportunities for anonymisation and aggregation of data for public health analytics.
c) Health Claims: this is primarily made up of a claims exchange, claim standards and payment mechanisms.
d) Personal Health Record-System (PHR) - which will enable individuals to manage complete information about his/her healthcare. The information would include the longitudinal record, consisting of his/her health data, lab reports, discharge summaries, treatment details, across one or multiple health facilities.
4. ABDM Today
For the past few years, the focus on health facilities has been on the rise. To be precise, the National Health Policy 2017 and Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (AB PM-JAY) have led the way to achieve the vision of Universal Health Coverage (UHC).
Recently, the Ayushman Bharat Digital Mission (National Digital Health Mission) was launched with the aim to ease business processes for doctors, hospitals and other health care providers. ABDM was initially rolled out in six states and union territories in August 2020. Through this programme, all health care services from across the country will now be available online through a digital network of hospitals. The National Health Authority under the Ministry of Health and Family Welfare is the implementing agency.
During the launch, the PM was all in praise for the scheme and asserted that this mission is a potential game-changer in our health sector. Many health experts have lauded this initiative. However, critics claim that infrastructure facilities available in public healthcare facilities, especially in rural areas, will cause hurdles. They also raise concerns over privacy issues and a possible increase in workload for healthcare workers.
Within a year, the programme has registered considerable success. As of 12th Sep 2022 according to ABDM website, an impressive over 24 crore ABHA numbers have been created with 1,44,371 Health Facilities and 69,312 Health professionals having registered, along with over 7 lakh health records App downloads. In a similar vein, by July this year, as many as 52 digital health services/applications have integrated with ABDM including 32 private entities. This includes a range of technology stakeholders including Hospital Management Information Systems (HMIS), Personal Health Records (PHR) apps and Healthtech apps. Furthermore, as reported till late July, there are as many as 919 healthtech innovators who are participants in the ABDM Sandbox, a digital space for experiment of integration before a digital app or health product is made live for the actual use.
While the over 24 crore ABHA numbers may already constitute one-sixth of India’s population, the truth remains that a large part of the healthcare value chain remains outside the government-driven ABDM initiative. According to the government’s own data, of nearly 12 lakh healthcare facilities, a mere 1.4 lakh have joined the ABDM platform. Similarly, of the 50 lakh healthcare professionals today, only 69,000 joining the platform is again an insignificant number. According to the National Health Profile 2019, only 65% of primary health centers in rural India have computers. And the fact that over 65% of rural India still has no internet as of now doesn’t quite paint a very bright picture for the future. Add to this the digital discomfort if not illiteracy for a substantial number of people even today.
5. CONCERNS
a) Patient Consent - Confidentiality and trust are among the key components that determine a patient's relationship with his/her healthcare provider. Especially in India it is very common for families or individuals to have a preferred doctor that serves as a primary point of contact for any healthcare related concerns. Sensitive medical history and healthcare data is uniquely personal and the storage and maintenance of this information is done through the informed consent of the patient.
In a health record system which will make personal health data easily accessible across healthcare providers, institutions and private players with access to your health ID, how the government regulates patient consent to share their information across the various stakeholders who access your health data is yet to be addressed.
b) Participation of private players- Despite the potential benefits that private healthcare providers can achieve through improved discovery of health services and availability and faster and low-cost incurred on cashless insurance claims. There is still little incentive for their participation due to the already high rate of health facility utilization which is increasing steadily.
Additionally they would be incurring significant capital and operational costs for standardization of the existing systems and system integration. Furthermore they would incur training costs and potential loss of testing and diagnostic revenue due to greater competition and choice.
Small healthcare providers like charitable hospitals, clinics, diagnostic labs, pharmacies, or nursing homes are less inclined to participate because of the significant costs involved.
The cost to these healthcare providers, who are most likely in various stages of digitisation, is the number of man hours required to digitize their health records and other data. The actual financial cost of upgrading or altering their digital health systems to meet basic required standards to participate in the ABDM and the UHI can be a severe deterrent.
Given a history of non-compliance of the private sector with public programmes, particularly its reluctance to share data and information, and the myriad conflict of interests that prevail, ABDM is unlikely to succeed in creating a comprehensive database of healthcare providers and professionals. Additionally, The voluntary nature of participation in the ABDM has led to a significant portion of private healthcare providers opting to not participate in the universal programme nor integrate into the UHI.
c) Balancing clinical and business decisions - ABDM documents invoke patient choice as a key goal. The argument is that information on the performance of providers would allow patients to choose the most efficient provider, enhance competition, bring down prices and increase efficiency. But there are problems in trying to equate clinical decisions with business decisions. Healthcare sector experiences multiple forms of market failures which makes establishing conditions of competition virtually impossible.
Most research shows that consumers seldom apply choice for seeking healthcare (Glide and Smith 2013). The UK introduced a Choose and Book programme in 2004, to allow patients a choice of doctor appointments and hospitalisations. But very few patients and doctors used the system, a phenomenon termed as "clinical resistance" (Greenhalgh 2013).
Patients seldom act as rational consumers because they do not have adequate information about the need or timing of healthcare, or the possible outcome of the healthcare sought. They depend on the decision of the physician. The physician, guided by the Hippocratic Oath and aided by clinical information and skills, acts as an agent of the patient (the principal) to choose an appropriate mode of healthcare. Trust in the physician’s judgment becomes a crucial driver when the ability to choose is limited. The more complex healthcare gets, the more is the gap between the patient’s knowledge and that of the physician. The physician enjoys a monopoly over clinical decisions.
So long as this principal-agent relationship is guided by trust and the physician’s interest is aligned with that of the patient, healthcare provisioning works on a rational basis. The moment the physician is governed by commercial interests, patients are subjected to potential maleficence and unnecessary modes of treatment. Healthcare costs increase, resources get diverted to those who can afford care, and access is denied to the poor and needy.
Markets address this problem of information asymmetry between the patient and the physician through insurance. Here the physician and providers become agents of the insurance provider, who in turn is the agent of the patient. Yet, even as governments and insurance companies try to curb unnecessary use of services (induced demand), information asymmetry continues to prevail and induced demand deceives the eyes of
most regulators. More resources are thrown in to heal the symptoms, without trying to address the fundamental problem.
d) The Private Insurance Industry - The big data analytics envisaged by ABDM suits a particular type of health financing and delivery system: private voluntary insurance schemes. ABDM becomes a prerequisite for the expansion of such schemes, as envisaged by plans for financial protection for the non-poor in the informal sector. Voluntary insurance schemes operate on principles of risk rating. People who are judged to have a higher risk of falling ill have to pay higher premiums. Thus, information about the health status of enrolled people becomes crucial in deciding premium prices, co-payment rates, as well as denying claims.
When governments purchase coverage on behalf of citizens, like under the Prime Minister Jan Arogya Yojana (PMJAY), health records of population groups become a crucial tool in negotiating premiums. When providers are to be paid, exhaustive information about their performance becomes essential in deciding package rates. The profits of the insurance industry thus depend crucially on the availability of health records of individuals. But the Indian health system currently neither has exhaustive data on the health profiles of individuals nor rigorous information about healthcare providers, the kind of data required by insurance companies, the payers, or for PMJAY. Both PMJAY and ABDM are thus part of a larger project towards the greater commercialisation of healthcare.
Thirty-six percent of insured individuals in India have private coverage, which covers only hospitalizations. In the year 2016, the NSSO released the report “Key Indicators of Social Consumption in India: Health” based on its 71st round of surveys. The survey carried out in the year 2014 found out that, more than 80% of Indians are not covered under any health insurance plan, and only 18% (government funded 12%) of the urban population and 14% (government funded 13%) of the rural population was covered under any form of health insurance.
e) Weak infrastructure and Digital Divide - The experience of the pandemic has shown us how weak our data systems are. Even when public programmes collect enormous
volumes of data, using significant resources — often at the cost of delivery of healthcare — the health system does not make appropriate use of data to make informed decisions. Policies often contradict or ignore evidence, and data is used selectively to further vested interests. The health system often does not collect the data we need, hides data that exposes faults, and seldom analyzes the data it collects. We do not even know how many hospital beds we have in our country, how many health professionals are there, where they are located and what services they provide. Even basic data like death registration is far from complete, making it difficult to measure death estimates. Epidemiologists and mathematicians have pointed out that incomplete death registration has led to considerable under-counting of Covid-19 deaths (Guilmoto 2021). Using digital technology to make healthcare choices would benefit only a small affluent section of the society and systematically leave out the vulnerable sections. Only 15% of women and a fourth of men in India use the internet in India (Nikore 2021). This digital divide has created barriers to economic opportunity for a large part of the vulnerable section of society.
The experience with the COWIN app for booking Covid-19 vaccination slots is instructive. Large sections of the population found it difficult or even impossible to book their vaccination using the app — in particular, the elderly, people with poorer educational backgrounds, women, people working in the informal sector, and rural residents, found it difficult to access vaccines. This added to the chaos of the early phase of vaccination.
f) Unreliable health-care facilities - in both the government and private sectors - currently there are significant issues of unreliability of the availability of beds and doctors in a hospital
6. RECOMMENDATIONS
a) Centralized collection, digitisation, and storage of health data could end up establishing unprecedented dominance by big capital and the state and curbing the rights of citizens. In centralized systems, where governments retain data gathered by private entities on a central server, it is harder to protect the data from being shared for commercial use or human rights abuses. Such attempts need to be resisted and an alternative health system needs to be created. Such a health system would necessarily be democratic, decentralized, people-centric, and non-commercialised.
We recommend that data storage be done on a local level with access to a centralized network for on-demand data requests outside the locality. This would immensely increase the availability and security of private data. Such an alternate system would also need data, but such data would be locally managed and not centrally stored, and hence less vulnerable to breaches, threats and commercial misuse. Here the emphasis would be more to have robust and comprehensive health system data, rather than an expensive centralized system for electronic health records.
Additionally standardization of hospitals data governance and storage standards can be accomplished faster on the state level than on a national level. As a result the infrastructure costs borne by the healthcare providers would be significantly lower.
b) Patients should have the capability to manage and delete complete information about his/her healthcare including his/her health data, lab reports, discharge summaries, treatment details, across one or multiple health facilities through a common government platform accessible through the individual health ID. The individual should be able to allow or deny access of this information to institutions/organizations linked with ABDM. This can be enabled by enforcing transparency and standardization of data management, storage and privacy policies across member healthcare service providers.
c) The increased access to health information benefits private players and public insurance agencies linked with ABDM but 80% of Indians are unlikely to benefit from better insurance given the current state of health insurance coverage. Policies such as
“Modicare” should be expedited as the ABDM infrastructure grows to provide basic insurance coverage to the rural population who currently have no means of benefiting from the increased digitization and commercialization of healthcare in India.
d) For individuals, enrolment should be voluntary. But if healthcare professionals and providers fail to enroll, it would defeat the whole purpose. After all, to choose between healthcare providers, we need comprehensive real-time data from all providers. ABDM should make the sharing of health records by establishments empanelled under publicly funded and organized programs like PMJAY, Employees' State Insurance Corporation, or Central Government Health Scheme.
e) Leverage the existing digital healthcare infrastructure Many States have already connected the National Rural Health Mission (NRHM) and National Health Mission through the IT network connected to most public health centers even in tribal areas. All larger health facilities generate and store computerized patient data also for planning treatment, procurement of medicines and consumables. The cards created under the Rashtriya Swasthya Bima Yojana and the Ayushman Bharat Pradhan Mantri Jan Arogya Yojana are used for pan-India portability or for determining insurance cover.
f) Electronic Health Records (EHR) is the basic foundation for this mission. The NDHM should focus its resources on standardization and infrastructure advances in the public sector. The success of the ABDM rests upon the strength of the digital infrastructure supporting it.
Meet The Thought Leaders
Karan Patel (he/him) is a mentor at GGI an undergraduate from IIT Madras. He is correctly employed with Teachmint, an ed-tech start-up in their strategy team. Prior to Teachmint, he worked at Dalberg Advisors as an analyst where he worked with multi-laterals and international foundations on gender, education and energy sectors. He has also interned in MIT Sloan, Qualcomm and IIM Ahmedabad giving him a plethora of experience in the corporate and academic world. He also started his own venture in hyperlocal air-quality monitoring. Karan is an avid sport-person and masala chai fanatic.
Meet The Authors (GGI Fellows)
Shankar is an engineering graduate who completed his BTech in Electronics and Communication from NIT Trichy and has nearly 3 years of experience in the finance sector. He has 2 years of experience as a data analyst in a global bank and currently works as a data engineer at a centralized
cryptocurrency exchange. Shankar has been selected as a GGI Fellow in 2022 and is deeply passionate about solving problems and creating meaningful change. In his free time Shankar enjoys reading, sports and is an avid fan of mixed martial arts.
Shalini Kapoor is the consultant for Future of Impact Collaborative at Atma and has close to 3.5 years of experience in the impact sector. Her experience and learning from being a teaching Fellow and spearheading the implementation of education programs with state governments and communities
directly provided her with the foundation for building meaningful relationships, non-profit management, fundraising, and hands-on experience in managing and coordinating multi-stakeholder projects that create holistic ecosystems. She has also been selected as a GGI Fellow in 2022 and is deeply passionate about creating a positive social Impact. She is a certified PADI open water Scuba diver and loves to explore the ocean. In her free time, you can find her binge-watching shows/movies/documentaries with a bowl full of chocolate ice cream and sipping cold coffees.
Nikhil Shah is an entrepreneur currently working with his family to set up a cardiac hospital in Coimbatore. Nikhil is driven by his curiosity and passion to learn through experiences. This curiosity, along with his background in Economics and experience working in credit and lending is what enables him manage a large hospital project without any formal experience in healthcare or construction. Following 3yrs, Nikhil has begun construction of the hosptial as at 12/22. Following the establishment of the hospital, Nikhil plans to venture into the health-tech space given the immense opportunities around healthcare awareness, access, and quality in India. In his free time, Nikhil enjoys reading (currently exploring Huxley and Maria Popova), watching films and hiking in the surrounding Western Ghats.
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