IFF has submitted its comments on the National Digital Health Mission’s consultation paper on the Unified Health Interface. In our comments, we have focused on five key issues, namely: the need for more diverse feedback, the risk of market capture by the private sector, the risk of digital exclusion, financial exploitation and service pricing, and the need for public digital infrastructure.
Health data is becoming increasingly important today. Pre COVID-19, rapid digitalisation was leading to the burgeoning use of health apps. This has only increased after the pandemic. Furthermore, healthtech has diversified to include not just health apps but also other services such as telemedicine and e-consulations, which have registered exponential increases in usage over the past 1.5 years.
Concomitantly, the government has tried to introduce regulations and policies to regulate the sector, as a result of which it launched the National Digital Health Mission (NDHM) on 15th August, 2020 to “usher in a new revolution in Health Sector”. Subsequently, several new programmes have been introduced, such as the Universal Health ID programme to integrate the health data of citizens across different applications and portals. The government has also notified a Health Data Management Policy (HDMP) to regulate the storage and processing of health data.
Now, while some of these may prima facie sound beneficial, there are some pressing concerns about these interventions that are yet to be satisfactorily addressed. For example, we have pointed out issues of privacy, exclusion and administrative coercion in the current Health ID programme, and yet health IDs continue to be created for those who have received vaccine shots, generally without permission. With respect to the NDHM’s HDMP, we had provided our comments on the policy during the consultation on the policy. Along with the Centre for Health Equity, Law, and Policy, we also wrote a paper analysing the HDMP, highlighting problems with respect to consent and confidentiality, data privacy and security, exclusion, and private sector access to healthcare data.
The Unified Health Interface
On 23rd June, 2021, the NDHM released the consultation paper on the Unified Health Interface (UHI). The UHI will be the main foundation for the NDHM, and is envisioned to “expand interoperability of health services in India through open protocols”. The aim of implementing this system is to “unleash a digital health tech revolution with innovations and various services for citizens.”
The UHI will adopt an open protocol model where a set of shared technical standards will be shared with everyone in the system, with the aim of ensuring that patients and health service providers can interact with each other seamlessly even on different applications. The UHI will help implement the architecture for the NDHM having four main layers:
- Digital Public Goods: The NDHM will have an interface with several digital public goods such as Aadhaar, Jan Dhan Bank Accounts, and Mobile, UPI, eSign, Digilocker, etc.
- Health Data Exchange: This is the layer at which the key information will be stored and processed, including the Health ID, the Healthcare Professionals Registry and the Health Facility Registry, Health Information Exchange and Consent Manager, Health Data Standards.
- Unified Health Interface: This will be the network of end user applications and health service provider applications, where users can access multiple health services such teleconsultations and appointment bookings.
- User Applications: These will be the actual end user applications and platforms, developed by the government or the private sector, that interact with the users.
The rollout of the various pillars of the NDHM has been wracked by inadequate consultations and unaddressed issues. This stems from a perspective that seems to view the existence of information asymmetries in the health sector as the primary concern, in lieu of which it prescribes the use of emerging technologies to remedy such problems. Such an approach may result in other issues, given the extractive model of data collection envisaged under the NDHM mission. Other concerns, such as the commoditization of citizens’ data in the absence of a robust data protection legislation, also abound and may have wide-ranging implications for data security and exclusion from welfare entitlements. Unfortunately, the UHI consultation paper seems to have been written in the same vein.
Thus, we have the following recommendations:
- Need for more diverse feedback: The current UHI framework seems to exclude public health groups and civil society as stakeholders. These bodies can provide valuable information not only provide key insights into ground level and policy level challenges to implementing the UHI, but also help to furnish real time feedback from the main users of the UHI - the citizens of India.
- Risk of private sector capture: Existing healthcare apps that have already captured some amount of market share may have an unfair advantage. Thus, there is an urgent need for a government app to exist in the space to ensure market competitiveness. This would involve further integration of existing government apps such as the National Health Portal and Mera Aspataal. Furthermore, during service discovery, public sector options must always be included in search results.
- Risk of digital exclusion: A significant digital divide persists in India: TRAI data states that India has 795.18 million internet subscribers, which indicates an internet penetration rate of only 58.51%. Rural-urban disparities prevail, as indicated by the rural penetration rate of 34.69%, with 308.17 million rural internet subscribers, which is not even one third of the urban penetration rate of 103.98%, with 487.01 million urban internet subscribers. In such a scenario, it is likely that many citizens of India may not be able to adequately navigate the UHI and so may end up being excluded from the NDHM environment. Thus, we recommend that the creation of digital infrastructure be ramped up on a mission mode basis. Additionally, the scale of digital literacy schemes must also be increased, while the quality of the training imparted must be improved.
- Financial exploitation and service pricing: The proposed pricing scheme may result in exorbitant costs for accessing healthcare services. Thus, out of the three components of the pricing scheme, the end user application fee component must be capped for all essential services, at least during the gestation period. This will ensure that citizens, especially in times of dire need, are not exploited by end user applications.
- Need for public digital infrastructure: Using the private sector to develop the software for the UHI gateway may result in increased costs for citizens. Thus, it is recommended that the government develop the UHI gateway itself, and then subsequently charge health service providers and end user applications a fee for participating in the UHI environment, which can be harmonised with the cap mentioned on end user application fees. This would also allow the government to implement comprehensive protocols for security and consent.
- NDHM’s consultation paper on the Unified Health Interface (link)
- IFF’s submissions on the Unified Health Interface Consultation Paper (link)
- Previous blogpost titled ‘Analysing the NDHM’s Health Data Management Policy: Part 2’ dated 15th July, 2021 (link)