The success or failure of any national flagship programme depends on where it sits. This in itself becomes the big prize. The National Digital Health Mission (NDHM) has been dragging for years due to inter-ministerial turf wars created by various interests, some wanting it to sit with the Ministry of Health & Family Welfare (MoH&FW) and others with Ministry of Electronics and Information Technology (MeitY). SKOCH Group – the only citizen’s advocacy platform – has argued for years that the only place for such a mission is at the National Health Authority (NHA) which is neutral to all influences and good for the people of India because of its demonstrated success in Ayushman Bharat. We are grateful to the Prime Minister for this decision.

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On 29 November 2019, SKOCH Group had organised the India Economic Forum (IEF) wherein some of the brightest and best of India’s technocrats and domain experts from across 85 cities and 28 states had gathered to delve on the state of the economy and deliberate on a future roadmap.

Given the 2019 issue of INCLUSION magazine Ayushman Bharat: Lifeline of the Poor wherein SKOCH had undertaken an assessment of the scheme’s performance by the National Health Authority (NHA), which also included an extensive field study of how the scheme is performing on the ground in various states including those in North-Eastern states. Some of the pre-stated discussion areas for the India Economic Forum were of proactively de-risking Ayushman Bharat through:

1. Recognising the great performance as a global best practice.
2. Arguing for the convergence of all health schemes into Ayushman Bharat.
3. Putting Infrastructure provisioning and scaling under the National Health Authority.
4. Using the momentum of Ayushman Bharat to promote Indian pharma industry and capturing highest possible intellectual property value in India.

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SKOCH Group – the only citizen’s advocacy platform – has argued for years that the only place for such a mission is at the National Health Authority (NHA) which is neutral to all influences and good for the people of India because of its demonstrated success in Ayushman Bharat. We are grateful to the Prime Minister for this decision.

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The discussion on Welfare Economics had thrown up the following recommendations, which went as SKOCH’s official recommendation to the government including Prime Ministers’ Office, Minister of Health and various other stakeholders:

1. A National Health Stack should be created. There is need for development of an integrated system for healthcare across the country.
2. Ayushman Bharat has largely addressed the demand side issues. Supply side is yet to respond. There is need to build a large number of hospitals to address the demand.
3. Ayushman Bharat (NHA) could work as an umbrella organisation for delivery of the integrated health services across the country. This would make financing, monitoring and delivery of services inclusive, smoother and efficient.
4. There is need to revamp and develop outcome-based statistical system. Technology can play a critical role in this endeavour.
5. Evidence based policy making is critical for making an impact at the grassroots. The success or failure of the scheme should not be judged by the input but by the outcome. This will happen only if there is reliable outcome-based data.
6. Market principles in welfare scheme. Introduce competition, accountability and innovation in welfare schemes. These terms are normally associated with the market economy. But they are now equally relevant for the implementation of welfare schemes.
7. There is a need to develop a robust independent evaluation mechanism for effective and regular evaluation of welfare schemes.
8. For-profit private hospitals can play a big role in creating the required healthcare infrastructure. Conducive environment needs to be created to attract private investments in the sector, especially in the rural India.
9. Social welfare schemes in other areas like education, sanitation, poverty eradication and livelihood creation should also be integrated with respect to their focus areas.

On 15 August 2020, from the ramparts of the Red Fort – Prime Minister Narendra Modi announced a gamechanger initiative for the lives and health of every Indian citizen in the form of a National Digital Health Mission (NDHM), which seeks to put healthcare data of all citizens within the hands of the citizens.

This vision of the National Digital Health Mission is:
1. To create a National Digital Health Eco-system.
2. Support Universal Health Coverage in an efficient, accessible, inclusive, affordable, timely, and safe manner.
3. Provision of data, information, and infrastructure services.
4. Leverage open, interoperable, standards-based digital systems.
5. Ensure security, confidentiality, and privacy of health data.

The objectives of the National Digital Health Mission are:
1. Citizen-centric Digital Health Ecosystem.
2. Establish state-of-the-art digital health systems and managing health data.
3. Improve the quality of health data collection, storage and dissemination.
4. Provide a platform for the interoperability of health care data.
5. Fast track creation of updated and accurate health registries for the entire country.
6. Create provision to measure quality of care, progress against policy initiatives and Sustainable Development Goals.

The mission envisages providing a unique Health ID to all citizens which will be linked to their Patient Health Records (PHR). This unique 14-digit ID, which will also contain a QR Code will make it easier for each citizen to have access to their historical health data be it diagnostic or lab reports, prescriptions, discharge and procedural summaries to be easily accessed in one digital location to be able to provide quick and easy medical service facilities to all citizens.

This will not only empower citizens but also allow hospitals, doctors and insurance companies to easily access patient health records and drastically reduce costs and processing times for delivering their services.

India will be the first such country to implement a transformational change of this magnitude and deliver interoperability of health systems with healthcare service providers, hospitals, patients and medical/health insurance providers – government or private.

The principle behind this is that of data being a digital public good with ease of access to all within the ecosystem for cheaper and seamless delivery of health services through digital public infrastructure. The key guiding principles behind the NDHM are:

1. Voluntary Participation
2. Privacy and Security by Design
3. Inclusivity
4. Seamless Portability
5. Educate and Empower
6. Wellness-centric

The NDHM operates on the following technology principles:

Infrastructure

• Core Framework: NDHM shall be developed adopting India Enterprise Architecture Framework (IndEA).
• All building blocks and components to conform to open standards; open source software product; open source development and shall be interoperable.
• Adoption of a Federated Architecture: Core building blocks developed and maintained centrally. All other blocks to be operated on federated model that factors in interoperability.

Legacy Systems

• Step 1: Compliance of legacy systems to the Blueprint principles and Agile IndEA principles will be assessed through an appropriately designed assessment tool
• Step 2: Evaluate the current conformance and effort required to integrate them with NDHM.
• Step 3: Only those legacy systems that cross the bar will be allowed to operate within the eco-system.
• Step 4: The data about healthcare providers, labs, patients available in the legacy applications shall be leveraged and utilised to the extent possible, leading to savings in time and effort.

The opportunities available for doctors are as follows:

• Identity management for qualified doctors: Enable real-time determination of identity online.
• Consent-based access to patient health records: From anywhere across the country.
• Provision for e-sign on Clinical Notes: Can sign e-prescriptions, diagnostic reports, discharge summaries and e-Claims from their phone or web and go completely paperless.
• Profile enhancement: Sharing their specialisation, work hours and availability online making it convenient for patients to book appointments.
• Provision for Telemedicine: Offer tele-consulting services online and sign e-prescriptions.
• Other service benefits for Doctors: Can purchase services such as medical insurance online.

The opportunities for councils are as follows:

• Efficient workflows – Minimised efforts (Cost, time and resources) without any usurpation of their authority/domain.
• Improved regulation of practice and tracking.
• All attributes to be digitally signed and have a trail record on different clinical documents.

The opportunities for doctor aggregators include:

• Verified and authenticated database of healthcare providers.
• Access to a major denominator for various analytical activities.
• Increased transparency in services.