Issues and Recommendations on Implementation of Ayushman Bharat – National Health Protection Mission in India

Background

Despite its rapid economic growth, healthcare in India has been an underperforming ecosystem with critically low government expenditure on the area. There is greater acknowledgement and effort being made to ameliorate the situation with the government of India (henceforth, GoI) launching the ambitious Ayushman Bharat – National Health Protection Mission (AB-NHPM), the world’s largest public scheme. While the stride by the government is laudable, India’s lack of focus on healthcare data represents a serious challenge in the implementation of the scheme. To effectively scale services, monitor effectiveness, and ensure accountability of the health schemes, the GoI will have to address the key gaps in its health data system. Some of the key issues identified are as mentioned below:

1. Fragmented and inconsistent data sources: Being a sector that is managed and funded by state governments, there is great variation in quality of care and information amongst the states. Further, even within the states, there is stark differences between public and private health care system and the services provided in rural and urban India. It is important to realize the difficulties in health information exchange that not only impinge effective policy formulation but also increase cost (duplication of tests and labour) and increase the likelihood of medical errors.
2. Inadequate data collection and analysis: India currently relies on sample surveys for tracing health parameters. However, there is a dire need to improve the coverage of these surveys. Even the data that is collected at national or unit level (such as Annual Health Survey) remains under-utilised.
3. Lack of centralised mechanism: Variety of data sets are often produced by multiple sources. However, in the absence of a centralised mechanism to draw linkages across different sources, the system is unable to draw meaningful correlations to support planning and implantation process.
4. Methodological issues: There is little standardization across states and organisations in terms of the information being collected or the definition used. This makes data incomparable and inconsistent with the country, leading to different perceptions of goals and achievement levels. To address the issues mentioned above, this policy memo outlines two broad recommendations that aim to improve collection, maintenance, and access to the healthcare information.

Recommendation

This model emphasises on the need to create a system where information can be stored and share for ease in data flow between various parties, such as physicians and patients or consumers and pharmacies. The electronic health records (EHRs), India’s sweeping effort to digitise database, is currently a largely closed system. There have also been several challenges to its adoption including very high patient volume and poor usability.

Developing a personal health record (PHR) would allow for a patient-controlled database that will allow the patient to provide access to multiple nodes. This can include hospital, laboratories, and even other sources of data generation such as wellness gadgets and web-based diagnostic devices. The PHR would allow for much more customization and development based on context (rural and urban) than an overarching national EHR and give the onus of control to the people. This system would function on blockchain principles, that could allow to record transactions between parties in a verifiable manner and mitigate threats of losing data via cyber-attack.

The access to each, individual account can be built around a unique identification code (Aadhaar or Pan Card). Any entity contributing or retrieving information from the database with require the unique identification code along with an authorization code by the patient. Furthermore, the access provided by the patient to each of these sources can also be in varying degrees and based on pre-authorization, real-time authorization, or a waver in case of emergencies. For instance, laboratories can send the test results to the physician who requested the test and then upload the information onto the individual’s PHR. The individual can then decide on with other physician should receive access, in case she/he goes for a second opinion. There will also be a pre-authorisation that health administrators should have which provides them access to aggregate data for specific zones for monitoring and analysis.

To begin with, the data can be accumulated from the existing fragmented digital information, particularly between the public and the private sector. While most of private sector is yet to be digitised, certain private hospital networks, major diagnostic laboratory and radiology franchises have maintained extensive medical record. In the public sector, data has been collected through several regional or national mandates or via efforts taken up by philanthropic institutions. However, only certain public hospitals have manged to digitize components. Furthermore, the patient can also provide access mobile and web applications that can update the data onto the person’s record and base it on the level of pre-authorization provided.

While it is difficult to ascertain a specific cost model for PHR, a study in 2008 estimated that it would cost the US between $4 billion- $130 billion initial capital (infrastructure and application cost) and between $2 billion- $43 billion (annual cost). However, these expenses would be recouped by $13-$21 billion in annual benefits. India will need to increase its budget proportion from less than 2% to be able to effectively implement this process.

Key Considerations

In order to effectively launch the PHR, there are certain key aspects that need to be targeted at. These steps can also greatly benefit the healthcare system in India, even with the current mechanisms present. The suggestions are as follows:

To facilitate information collection and dissemination at hospitals and laboratories, investment must be made in equipping the public health care facilities with the required hardware and software. The implantation of the National Optical Fibre Network (NOFN) across all villages will certainly simplify this.

It is crucial to bring on board the private sector health care facilities and other mobile or web-based applications. This can be achieved by first, devising the policy in a way that there is immense consumer demand for the scheme and business are compelled to join the system. Second, by providing incentives such as free-open source software to update information on the PHR.

The new bill proposed by the MoHFW on the Digital Information Security in Health Care Act in a promising step forward in deterring misuse or loss of health data. The bill must also include guidelines on PHR that strictly state the protection and use of personal health information such as easy but consented flow of information and giving supremacy to right to privacy. The patient should be explicitly made the ultimate decider, even in the face of a conflict between the patient and the healthcare facility or government authorities. However, a precondition must be the moral obligation to provide basic access as anonymous users to allow the government to monitor and evaluate data.

While PHR will facilitate collection and storage of data, there must be focused investment on training and developing human resource and software to monitor, analyse, and evaluate all the data being collected. The PHR system will provide an opportunity to form correlations between varied aspects, which can be used to trace casual linkages for targeted government action.

Strengthening Data Collection

To ensure the success of Ayushman Bharat and the PHR recommendation, it is essential to address certain fundamental structural aspects related to data collection. These include the following:

Often being entangled as a state and a central subject, there is an overlap in the data collected by the ‘central sample’ and the ‘state sample’. This overlap leads to considerable wastage of resources. Pooling in the data will not only enhance the data set but also provide a method the accuracy of the information. It will also provide the option of identifying gaps in the data collected.

Standardising definitions across states and ministries will help being out a comprehensive set of comparable data. This will also be crucial in pooling in the data and avoid discordance in information provided by different departments. For instance, the analysis presented but MoHFW on whether India will achieve the targets of Millennium Development Goal 5, on maternity mortality ratio, was varied from the Ministry of Statistics. For this purpose, the strategy should be to collaborate with the essential ministries such as Ministry of Home Affairs, Ministry of Statistics and Program Implantations, MoHFW, Niti Aayog, and other state and district level offices. While creating a single integrated data-based system with shared information across ministries still has a long way forward, establishing guidelines for definitions and collection is an important first step.

There are data gaps present in the current population health coverage, particularly for specific groups. Those who live in remote areas or are working in the informal sector are generally missing from the larger data set. Identification of the extent of coverage that takes place by age, gender, socio-economic class, and place of habitation is key to get a holistic perspective. This is needed not just for policy formation but also to see the effectiveness of a policy for the marginalised communities.

Data on “preventive, promotive, rehabilitative and palliative services” remains insufficient. This is essential to map service accessibility and availability and to monitor needs. Special emphasis must be placed to bridge the missing data which could possibly involve small scale but extensive studies.

A large part of data collected by surveys depends on the questionnaire prepared and the person collecting the information. It is thus important to invest resources in equipping the officials collecting the data with the right kind of skills to conduct interviews, transcribe them, and file the information collected. With the country increasingly moving towards digitisation, special training sessions must also be provided in the specific health information hardware and software that will be adopted.

None of the above recommendations can be achieved to this optimum capacity without an increase investment in health budget and specific emphasis on data collection. Even the low budget that has been allocated does not often get released in time. The announcement of Ayushman Bharat presents the perfect opportunity to push for these reforms and prepare a case for increased funding. Increased investment will also be testimony towards India’s commitment to the SDGs and its global commitment to provide quality healthcare.