National Digital Health Blueprint 2020 needs a review?

With an aim to fix the ailing healthcare facility of the country, Indian government (like other sectors – Finance, Public Distribution System etc.) has opted for digitization as a solution. In January, 2020, the government released a National Digital Health Blueprint which sets out a comprehensive framework for “Federated National Health Information System”. In March, soon enough the COVID-19 pandemic struck the country and underlined the importance of having the National Digital Health Blueprint in action. However, the pandemic situation has also highlighted the many areas of improvement for the Blueprint and the need for urgent action on such improvements. This blog post will put forth the author’s views on the need of studying the Blueprint again and including the concepts like digital therapeutics, digital diagnostics and telemedicine in its scope. The blogpost will also aim to present a picture of the diverse elements of a futuristic digital health ecosystem for India and the role that science, scientists and technology can play in establishing such an ecosystem.

Introduction

It seems like that Indian government has developed a formidable belief that technology is solution for all the deep-seated problems which are haunting the country’s socio-economic growth since independence. In 2015, the ambitious Modi government launched the “Digital India” programme with an aim to transform India into a knowledge economy, empowered with on-the-go access to information, governance and essential services. This ambition quickly received a reinforcement in the form of JIO’s success, which resulted in increasing the smartphone penetration rate and making India the second-fastest digital adopter in the world. Around the same time, the image of India’s healthcare remained pitiful and harrowing. In the Healthcare Access and Quality (HAQ) Index, India ranked below what can be considered as dismal position – 145th out of 195 countries.

India significantly lacks in implementing most of the World Health Organisation’s (WHO) recommendations regarding the adequacy in terms of doctors, nurses, medical technicians and healthcare facilities as required to cater the population. Owing to such inefficiencies, the country’s healthcare policy has been inconsistent such that India is overburdened with the task of eradicating infectious tuberculosis disease. It is only in this decade that India was able to get the polio-free status for itself. Our country is also facing exponential rise in cases of lifestyle disorders ensuing the endemic of diseases like diabetes and clinical depression. Simply put, these statistics are omen for India as a contender to be in the league of top three fastest growing economies of the world. The government of India itself has noted that in order to realize the real growth potential, the country has to fix the health systems on priority basis by investing adequate finance and manpower. Presently, Indian labor workforce is performing far below its optimum productivity due to many ill-health issues.

Therefore, the government, considering the nation’s emerging forte in digital space, has decided to go digital in healthcare reforms as well in order to analyse the consumption of health services by the population. As per the GoI, the future is technology, and India cannot accomplish its goal of ‘Health for All’ in the absence of digitization of health infrastructure and delivery. India is seeing Artificial Intelligence or Machine Learning as the foundation of accessible, affordable and quality health solutions at the intersection of technologies like biotechnology, robotics and computer science. The digital approaches for upgrading the conventional healthcare infrastructure could definitely be an antidote for the frail healthcare infrastructure given the nation’s population  is increasingly on-boarding various digital platforms. It can also be a great overall strategic direction for India to shape its influence in terms of policy-making in the context of global health. It is indeed a possibility given India’s competitive position in technology innovations and the fact that health-tech market is in a nascent stage, with all the countries almost on level playing field.   

The National Digital Health Blueprint 2020 (NDHB)

The ruling government is envisioning the digital health infrastructure as a system that will fit well or accurately with its larger aim to modernize (specifically ‘digitize’) the public health welfare system. In this line, the missions that have been already initiated by government are Ayushman Bharat, Swachh Bharat, Digital India, and Make in India.

The Ministry of Health and Family Welfare of India (MoHFW), pursuant to its afore-mentioned digital health policy initiatives, released NDHB in January 2020. This is the only detailed official explanation of PM Modi’s proposed National Digital Health Mission. It provides a picture of the entire framework of a “Federated National Health Information System”. It elaborates that the envisioned framework will inter-link systems of private and public health provider organisations serving across primary-, secondary- and tertiary-healthcare services. As the blueprint specifies, this is clearly in alignment with one of the objectives envisaged under the National Health Policy of 2017 i.e., to create an integrated health information system for all stakeholders in the health system, to improve efficiency, transparency and citizen experience.

The NDHB is indeed a well drafted document as it comprehensively shows the way the reformers have to tread in order to carry out the colossal task of developing an extensive database of electronic health records, which will be available as single source repository of health data per unique patient within India. Beyond this, state-wise datasets containing information of health-workers (doctors, nurses, paramedics) and health facilities, disease registries, inventories, and insurance claim records will also form the essential element in federated system. The blueprint provides that the database hub and key facilities will be hosted by the Health-Cloud (H-Cloud). Similar to the Aarogya Setu’s API release, the federated system will also be interoperable to allow seamless data exchange.

The blueprint obviously lists the standards for maintaining the privacy and security of the digitized health data (The next blogpost on the National Digital Health Mission will exhaustively deal with privacy and security related aspects – we also have interesting classified updates for you in that post). Project implementation will not be gradual or stage-wise, but it will follow the scheme of technology sandbox to test and roll-out the massive data-management infrastructure. The infrastructure will be further used for tracing the real-time stats related to population-wide health status. The customized and timely interventions will be made if the predictive analytics of the stats forecast community outbreaks or disease spread propensity by region. The running algorithms will be deployed to optimize data analysis and allocate scarce resources at district and state level, and more.

It has to be kept in mind, and can be inferred from the blueprint, that there are three prerequisites for successfully initiating the exercise that the NDHB proposes:

Uniform internet and telecommunications availability across the country;

An extensive network of primary healthcare centres for service delivery; and

Trained health workforce.

Presently, all these three are work in progress in India wherein Second and Third points really require a special focus.  Internet penetration in India has picked up a good rate but healthcare on field is definitely lacking. The government has to create a solid foundation through uninterrupted support, spirit and funding.

The envisioned integrated national-health data hub will be a vital asset to run process and analyze all the complex health data, which can be leveraged for creating accurate policy-designs and well-gripped implementation control. For example, through algorithms, timely automated intervention within the health system will increase cooperation. As soon as certain stat will touch a determined threshold, the notifications will trigger the appropriate health-crisis management authorities. The entire process will include relaying of targeted messages within the population, automated stock and inventory management warnings, and virtual medical training and research, to create a strong foundation for affordable and efficient healthcare. Once operational, the database is expected to connect and expedite India’s slow-moving fragmented health system. While this will not immediately fix the system entirely, it is surely a step towards making it efficient and future-ready.

Is everything right with the Blueprint?

The Blueprint definitely mentions about the great plan of futuristic healthcare infrastructure. However, it is still far from being an “all-encompassing vision document” which is needed to provide solution to two-fold issues: (a) A launch pad for India’s digital health ambition, and (b) Need of resolving the deeply entrenched issues with healthcare that persist for years now. Therefore, it is needed to trace specific to context use cases recognizing the problems that are unique to India.

Even the WHO’s guidance has made the point that digital-health interventions must be treated as supplements, not substitutes, for functioning health systems. The Blueprint requires major upgrades to its dimensions- which means priority push for digital policy on therapeutics, diagnostics and medicine.

Policy action needed to reform therapeutics and diagnostics in India must be aligned with the broader AI policy of India. The current version of India’s AI policy provides “healthcare” as one of the most promising areas but admits the obstacles it will face in creating a new path. India is not alone in this predicament. Recognizing best practices around the world and picking out unique use-cases, the following points must be considered to strengthen the policy in terms of therapeutics and diagnostics:

1. Promoting indigenous innovation in health-tech while maintaining technological sovereignty;

2. The use-cases with respect to healthcare must be selected keeping in mind the inherent infrastructure limitations and resource shortages;

3. While going digital, it is important to keep patient safety as priority through adopting regulatory frameworks that mandate scientific and clinical validation of products/services;

4. One thing that is essential to the traditional doctor-patient relationship is trust. The approach must invest in creating a reliable infrastructure.

5. Real-world transparency, data confidentiality, cyber security and ethics should be the foundational principles when an innovator envisages a health-tech innovation. Proper guidelines for medical software developers and policy on transparent data-sharing agreements wherein, rights of patients are protected must be rolled out at the earliest.

Conclusion

Therefore, it is important to say it again, the Digital Health is not the immediate relief given the limitations of the India’s healthcare, i.e. inadequate infrastructure and resource shortages. However, one thing we have learnt for sure is that a better-connected and digitized nation is better-prepared to achieve sustainable development goals if policy’s approach is inclusive in real sense, and to face unprecedented black swans of magnitude like Covid-19 pandemic. Digital health adoption will bring many changes in the functioning of the current system across the value chain. The benefits of public goods, products and services under this category must be maximized, with minimum disruption to the society. If all goes well i.e. policy implemented properly and limitations checked promptly, the NDHB could be a chance for India to get rid of its ailing healthcare infrastructure.

(These are personal views and opinions of the author and do not necessarily reflect views of any organisation)