Digital Health in India–Its Advent and Rise

The government of India launched the Digital India campaign in 2015 in a bid to transform the country into a knowledge economy, with on-the-go access to information, governance and services. This had positive repercussions in a sector much needed to help tackle issues of access, affordability and quality: health care. The National Health Policy (NHP) 2017 for India was released on 17 March 2017. The last NHP was framed in 2002 and this recalibration came after a gap of 15 years to address the emerging challenges necessitated by the changing socio-economic, technological and epidemiological landscape.

The NHP 2017 focused on extensive deployment of digital tools to improve the efficiency and outcome of the health care system. Implementing the policy faced several operational challenges, and the benefits were localized and fragmented. While health service providers did not have an aggregate view of the data for providing services, the government did not have reliable data for policy analysis and planning. All this meant an increase in the burden on the citizen seeking health care.

Given below are some specific references that were made to integrate digitization or “Information Technology” in the NHP 2017 to address the issues:

S. No	Section in Policy	Reference to deployment of IT
1	Primary Care Services and Continuity of Care	This policy denoted an important change from a piecemeal to comprehensive primary health care package which includes geriatric health care, palliative care and rehabilitative care services. Within this, to ensure that primary care is a reality, every family would have a digital health card that links them to a primary care facility and further be eligible for a defined package of services anywhere in the country at higher levels of facilities. This would also necessitate upgradation of the existing sub-centers and reorienting PHCs to provide comprehensive set of preventive, promotive, curative and rehabilitative services. The potential of digital health systems would be leveraged to form systemic linkages between primary, secondary and tertiary levels to ensure continuity of care.
2	Mental Health	The policy mentioned the need to leverage digital technology (telemedicine) when access to qualified psychiatrists is difficult.
3	Supportive Supervision	For supportive supervision in more vulnerable districts with inadequate capacity, the policy mentioned introducing innovative measures such as use of digital tools and HR strategies.
4	Medical Education	The policy recommended and recognized the need to expand the number of tertiary super specialty AIIMS like centers to include in it a National Knowledge Network. These networks are envisaged to be used for tele-education, tele-CME, tele-consultations and access to digital health library.
5	Human Resource Governance and leadership development	The policy recognized that human resource management is critical to health system strengthening and service delivery. The policy supported measures aimed at continuing medical and nursing education and on the job support to providers, especially those working in professional isolation in rural areas using digital tools and other appropriate training resources.
6	Health Technology Assessment	The policy stressed on the fact that health technology assessment is required to ensure that the technology choice for programs is participatory and is guided by considerations of suitability, scientific evidence, safety, cost effectiveness and social values. The NHP had committed to the development of an institutional framework and capacity development plan for health technology assessment and adoption.
7	Digital Health Technology Ecosystem	The policy articulated that a National Digital Health Authority (NDHA) will be set up to regulate, develop and deploy digital health across the continuum of care. This is in recognition of the integral role of technology (eHealth, mHealth, cloud, Internet of things, wearables, etc.) in the health care delivery space. The policy advocates extensive deployment of digital tools for improving the efficiency and outcome of the health care system (Delivery of better health outcomes in terms of access, quality, affordability, lowering of disease burden and efficient monitoring of health entitlements to citizens) and aims at an integrated health information system which serves the needs of all stakeholders and improves efficiency, transparency, and citizen experience. This national health information architecture also envisaged to roll-out and link systems across public and private health providers at State and national levels consistent with Metadata and Data Standards (MDDS) & Electronic Health Record (EHR), which will be supported by this policy. The policy suggested exploring the use of “Aadhaar” (unique ID) for identification. Creation of registries (i.e., patients, provider, service, diseases, document and event) for enhanced public health/big data analytics, creation of health information exchange platform and national health information network, use of National Optical Fibre Network, use of smartphones/tablets for capturing real time data, are key strategies of the National Health Information Architecture.
8	Application of Digital Health	The policy advocated scaling of various initiatives in the area of teleconsultation to ensure linking tertiary care institutions (medical colleges) to District and Sub district hospitals which provide secondary care facilities and specialist consultations. The policy promoted utilization of National Knowledge Network for tele-education, tele-CME, teleconsultations and access to digital library.
9	Leveraging Digital Tools for AYUSH	Digital tools would be used for generation and sharing of information about AYUSH services and AYUSH practitioners, for traditional community level health care providers and for household level preventive, promotive and curative practices.

The challenges brought out the need for a uniform standardized data warehousing system and in 2018 a vision for a digital stack for health was laid out by Niti Aayog, the premiere think tank of the country, with key objectives and principles that echoed with the NHP 2017. Subsequently, the National Digital Health Blueprint was developed in 2019 by the ministry of health.

National Digital Health Mission

The Prime Minister of India finally launched the National Digital Health Mission (NDHM) in August 2020 while addressing the nation from the Red Fort on India’s 74th Independence Day. The NDHM is the outcome of an iterative and consultative process involving stakeholders such as medical providers, policy makers, private sector, health tech companies, insurance providers and civil society members, among others, to ensure all of the above tenets captured in the NHP 2017 see the light of day. It aims to develop the backbone necessary to support the integrated digital health infrastructure of the country and bridge existing gaps amongst different spokes of the health care ecosystem through digital highways.

The NDHM comprises six key building blocks or digital systems— HealthID, DigiDoctor, Health Facility Registry, Personal Health Records, e-Pharmacy and Telemedicine—that will enable access to timely, safe and affordable health care through a citizen-centric approach. In the real world, this would mean synthesis of the several digitized existing legacy systems, like the mother- child tracking system (MCTS), the integrated disease surveillance program (IDSP) into one big platform. The center has some of these unidirectional information systems, in addition to the states which operates their own digital initiatives, either independently or in partnership with central government, a not-for-profit or corporate entity.

Currently, digitization is limited to unidirectional software—an advanced form of excel spreadsheets, where data collected on paper based legacy systems is entered manually into basic software for data collation and sending it further. Unfortunately, at the moment, the analysis is limited to development of graphs and diagrams using non-variate or bi-variate analysis. To evolve into a digital space, where real time data is captured and analyzed to generate outputs which will support decision making, technology interfaces will need to be at all levels from health care consumers to the frontline workers and the private health care institutions. Electronic medical records have become popular in private tertiary and secondary care center, but they often function in silos without appropriate linkages with each other or with the legacy systems in the government. Data from the consumer side, is still not available as digital literacy and access to technology is low.

To facilitate effective monitoring of policy implementation and to achieve the vison of technology empowering and supporting health care services at all levels, digitization and real time monitoring are important tools. Electronic health records linking all system, and thereby making available a huge data warehouse for analysis, would be required. The digital health card for each family seems to be an effort envisaged in this direction. Reduction in cost of access to technologies, reducing cost of entering the marketplace, focus on digitalization via unique identity system, advocating for Indian version of HIPPA with increased focus on consumer protection and confidentiality, and standardizing technology standards could provide starting grounds for more digitalized health care in India.

The vision that NDHM promises augurs well for a futuristic India which has learnt well from global best practices across the world. Some initiatives that state governments have already initiated like E-Olakh, collaborations with ISRO and others are paving the way for other states to adopt and follow. Lastly, in spite of the challenges that still linger within the health care delivery system, including lack of skilled medical and paramedical staff, poor infrastructure, poor uptake of insurance services and low budgetary allocations to name a few, digitization of health is non-negotiable.

Access to high speed internet, mobile phone penetration, leveraging IoT for wearables, telemedicine, use of AI in health care programming, precision medicine, robotic assisted surgery, m-health, regulated health care aggregator platforms, e-pharmacies if allowed to function in a conducive and well-regulated ecosystem could offer possible solutions to the age-old issues of access, quality, privacy and confidentiality in health care in India.