Do we need it at all? How many ‘missions’ do we need for every sector to make improvements in coverage and quality of service delivery?

21/09/2020 

P JOY OOMMEN AND K R ANTONY

Those who have gone on surveys to rural households have noted that it is much easier to retrieve a colour-coded ration card for PDS than a Mother-Child Immunisation Card. Colour of that card also indicates whether you are privileged as BPL or Antyodaya beneficiary. Next important record many hold is their caste certificate. 

 A decade ago, they got another card with their face photographed for the first time, to be used for voting during elections. Voters’ ID  bestowed on them some sense of importance once in a few years. Many state and national leaders visited them and the local politicians gave or promised many goodies and often some much-needed cash.

Later, Aadhaar card with photograph came in to their lives which went on to occupy a pre-eminent position as the magic key that could open many doors. It is another matter that even today, it is officially optional except for the income taxpayers. And soon enough, even non-income tax-paying poor households realised that whether to register for MNREGA, to get/renew a ration card, open a bank account, get their land and property registered or even for booking a rail ticket, you needed an Aadhaar card.

The Rashtriya Swasthya Bima Yojana (RSBY) insurance holders got another card but had to get them Aadhaar-linked. In turn, you discovered a surprising bonanza of healthcare benefits – of up to Rs 30,000 per family even in private hospitals. For those going on short or longer-term migration to other states, Aadhaar was the only card which helped them for anything at all.  Some empathetic state governments used the Aadhaar card to give benefits to the migrants. Banks too stopped asking for their ration cards to open new accounts.

And now, the announcement of a new chip-embedded digital health card! Announced from the ramparts of the Red Fort on Independence Day by Prime Minister Narendra Modi himself (how much more important can it get?) as part of a new mission called National Digital Health Mission (NDHM).

Some worries and doubts arise. To start with, do we need a new card at all? An associated question is how many ‘Missions’ do we need for every sector to make improvements in coverage and quality of service delivery?  Do I benefit more with this card if I already hold a PM-JAY (Jan Arogya Yojna) card backed by a powerful Aadhaar card?

Nationwide controversies on the Arogya Setu app and apprehensions of leakage of data from social media app led to the new mission giving an upfront assurance that it would be optional, that the consent of the card holder would be mandatory to digitally transfer any information and that data would be stored in a decentralised manner.

Haven’t we heard these assurances earlier too with many other schemes though creeping invasions in to one’s life became a norm rather than an exception – with or without expressly granted consent.  Consent clause gives no comfort to a patient who stands virtually naked and helpless in front of the medical practitioner or the hospital staff who says ‘sign here to give your consent’. The consent comes clearly out of worries about the consequences of not giving consent.  

In the process, some others – the previous doctor and hospital and the diagnostic centres too stand exposed. It becomes a dilemma for all doctors and the hospital managements to decide how truthful and factual they can afford to be. 

‘Why were particular diagnostic tests ordered, why were certain medicines prescribed and why such procedures are undertaken’ by them? Do we assume that all practitioners of different systems of medicines and their establishments, large or small and across the public and private sector in rural or urban areas have the technical and infrastructural capabilities to record the patient history relating to them? Who will ensure that the entries are error-free and that there are no mischievous entries to avoid possible liabilities in future? 

Future litigations

Will practitioners or hospital managements become obsessive about additional diagnostic tests to avoid future litigations or allegations of inadequate care? Can this kind of an all-encompassing digital backbone offer solutions or substitute existing gaps in infrastructure and current inadequacies in the system? How effectively are we utilising the currently available data for our policy decisions? What is the missing data that we are looking for?  

We already have the Health Ministry’s management information system under NHM and Integrated Disease Surveillance Project (IDSP). We have separate district-wise and state-wise data on most communicable diseases. We have data generated by name about every pregnancy, birth and children up to six years.  For determining coverage benefit and for pan-India portability, only the minimum general details as were available in the PMJAY card is enough. 

Many hospitals of repute in the public and private sectors have already switched over to electronic health records for improving their internal management and efficiency strictly ensuring privacy and data security. They also give a detailed discharge summary and reports of investigations in case of shifting to another hospital seeking a second opinion. 

Even if the quality of data generation and retrieval are unsatisfactory in the private sector hospitals, can the introduction of a government health card solve it? Imagine electronically capturing the voluminous real-time data of medical history, diagnosis and treatment of a billion. 

 Do governments need sensitive, personalised information on a public platform though supposedly protected by a password? There is no data protection law in our country as on date and as such, little accountability exists for privacy protection leave alone penal action for breach of it. Insurance companies will get access to data directly or indirectly affecting the premium and conditionality of health insurance policies. There are far too many unanswered questions to inspire confidence in this mission for your data. 

(Oommen is retired Chief Secretary of Chhattisgarh; Antony is a Paediatrician and independent Public Health Consultant based in Kochi)

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