Coercion marks digital health promotion in India

On September 27, the Prime Minister launched the Aayushman Bharat (ABDM) digital mission to create a seamless online platform that enables interoperability within the digital health ecosystem.

According to the statement of the Prime Minister, “from now on, every citizen receives a health card and his files are digitally protected”.

ABDM is the government’s latest attempt to digitize service delivery in India as part of its flagship Digital India mission, launched in 2015.

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The ABDM is the successor to the National Digital Health Mission (NDHM), which was launched by the Prime Minister in August 2020. The introduction of the NDHM (and now ABDM) has raised critical questions about the integrity and security of an individual’s data. , as well as accessibility for marginalized and impoverished communities. It has also raised fears that people without a health card could become targets for exclusion in health matters.

Attempting to answer these questions requires a historical understanding of the government digitization process and how ABDM fits into it. This shows that digitization may be a necessary step to prepare our governance systems for the future, but it is currently hampered by legal, infrastructural and barrier-free obstacles.

The history of the digitization of the public sector dates back to the National Plan for Electronic Governance (NeGP) of 2006. The plan aimed to expand digital infrastructure in remote areas of the country and ensure that government services are easily accessible.

Initially, he focused on governance programs such as banks, land registers, issuance of pensions and passports. With the introduction of the Digital India Mission in 2015, however, the realm of digitization has been broadened to include almost all interactions between the state and citizens such as healthcare, education, and transportation.

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Meanwhile, examples such as the introduction of Aadhar have highlighted the inadequacies of the conception of digitization as the silver bullet for the delivery of social services nationwide.

The use of Aadhar over the past 10 years has been fraught with privacy, data security and exclusion issues, all of which now apply to the case of ABPM.

No legal framework

In most cases, the digitization of public distribution services has taken place in the absence of a legal framework. Rather, they were carried out primarily through a series of administrative orders with minimal judicial and legislative control. ABPM is no exception.

The government first announced the NDHM policy in the six Union Territories in 2020, then extended ABDM to the whole country, all in the absence of clear laws. The State may refer to the “Health Data Management Policy” to justify such directives. However, a directive cannot replace a law passed by parliament.

It is also important to note that the scope of these digitization measures, which range from the PM-JAY program to the ABDM, has been implemented and extended in the absence of a coherent data protection law in the country. The 2019 law on the protection of personal data is pending before the Joint Parliamentary Committee.

In addition, states such as Delhi and Tamil Nadu have also announced the introduction of health cards for residents of their states in certain jurisdictions; and there is little to no clarity on the relationship between the state and the central maps.

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No informed consent

The health data management policy recognizes that the health ID “requires the express consent of an individual before it can be created.”

However, several reports have indicated that health identifiers are also generated for citizens who have used their Aadhaar card to register for their Covid-19 vaccines on CoWIN. This process appears to have been carried out without prior attempt to inform citizens that the use of aadhar would result in the creation of a health card.

The Ministry of Health and Family Welfare announced in its response to an RTI request submitted by Medianama that as of August 16, 2021 05/11, 42,794 health identifiers had been created through the CoWIN platform. This is in addition to the health identifiers generated in the six territories of the Union.

Inadequate infrastructure

The pandemic has underscored the importance of a health system that is both quality and affordable. The digitization of the health system will play a decisive role here, provided it is based on a robust technological device.

A report by the Department of Electronics and Information Technology titled “Adoption of Electronic Health Records: A Roadmap for India” noted that state hospitals and pharmacies have very little ICT infrastructure and that only a few large public hospitals have computers and connectivity.

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According to the results of another study, in addition to poor infrastructure and poor connectivity, there are also issues related to low spending / budgets for information technology in hospitals. Compared to many countries that spend almost 5% of the total hospital budget on IT, Indian private hospitals typically only spend 2.5% of the total hospital budget on IT. The corresponding proportion is significantly lower in public hospitals.

Data security, data exchange

The government has stressed that the health card is voluntary and that its absence cannot be used as a justification for a failure to provide health services. As was shown during the vaccination campaign, the realities of introducing a new identity card may differ from the required state. For example, although Aadhar is not a mandatory requirement for vaccination, there have been instances where hospitals have refused to accept any form of identification other than Aadhar. The concern, therefore, is that there will be a similar separation in the case of Health ID.

Due to the sensitive and private nature of information associated with Health ID, concerns remain about its security and the extent to which it may be disclosed. The health management policy defines the security measures to be taken when processing this data; Although there have been previous reports of Aadhar data leakage, such measures are far from foolproof, especially when the data is shared by a number of entities.

The directive also allows for the sharing of anonymized health data for research purposes and for the formulation of guidelines.

However, the policy does not identify the appropriate anonymization methods that would be required for such disclosure. This, combined with the lack of a clear framework for handling non-personal data, can create confusion as to the extent to which information is anonymized before it is disclosed.

The Covid-19 pandemic has shown and clarified what role a well-functioning public health system plays in health management.

And while the digitalization of the healthcare system is necessary and can help address some challenges such as transparency, large and bulky patient record keeping, physician access to older patient records, it shouldn’t be. do so at the expense of solving the fundamental challenges of access. to a large part of the population facing affordable and effective health care.

To this end, any attempt at digitization must be very specific, limited in scope and have adequate safeguards to ensure that individuals are not excluded.

And such a process needs to be part of a much larger health strategy that primarily aims to ensure that existing systems are strengthened and improved, rather than being replaced by technology.

(Aman Nair is Policy Officer at the Center for Internet and Society, Pallavi Bedi is Policy Officer at the Center for Internet and Society)

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