National Digital Health Mission (NDHM) was launched with the aim to develop, design, and implement digital building blocks that are essential for an integrated healthcare system.
The Fourth Industrial Revolution is here and set to herald transformation in all industries like energy storage, quantum computing, transportation, agriculture, manufacturing, communications, biotechnology and healthcare. Industrial 4.0 has the potential to connect the world and innovate like no other revolution, the pandemic has especially demanded and accelerated this in the healthcare sector throughout the world and India is no exception. During the pandemic India saw online consultation queries increase by more than 200% and overall telemedicine calls increase by 500% since March as per report published by Practo titled, How India Accessed Healthcare. This may be a sign of India being ready for the digital transformation despite its diverse challenges. Although the per person disease burden, measured as disability-adjusted life year (DALY) rate, dropped in India by 36% from 1990 to 2016, the total disease burden has increased in all states since 1990 because of non-communicable diseases. These include cardiovascular diseases, diabetes, chronic respiratory diseases, mental health and neurological disorders, musculoskeletal disorders, cancers, and chronic kidney disease. India ought to jump on the bandwagon of digital health like the rest of the world to tackle these diseases incrementally faster.
On India’s 74th Independence Day National Digital Health Mission (NDHM) was launched with the aim to develop, design, and implement digital building blocks that are essential for an integrated healthcare system. Health ID (will have history of the patient), DigiDoctor (database of the doctors), Personal Health Records (an electronic record of health-related information of an individual), Health Facility Registry (single repository of all the health facilities in the country to promote standardization of data), telemedicine and e-pharmacy are the services that form part of the digital health mission. A centralized system that can connect the whole country is the first step to a systematic approach to group the siloed healthcare system. The beauty of NDHM is that the data is owned by the individual, it cannot be used without consent. While the government is responsible for creating the ecosystem, the systems and data is open to private players for offering their solutions. This move from the government provides opportunity for innovation in Healthcare and IT. Given that India has the second largest population this is a herculean task, hence a strategic approach is vital. We need to consider questions like what is the plan to train all the doctors to shift from paper based to electronic. How will this be transferred to the patients? Training plans of rural and elderly population. Is there going to be an app? How can this technology be inclusive of the rural, uneducated and the elderly population? Health equity is key to this policy especially when the pandemic is hurting the poor financially hard.
NDHM is a good start for the government to use this mission as an opportunity to set the ground to transition from treatment based healthcare to preventative. That cannot happen unless we solve the current challenges faced by the healthcare sector:
Many patients do not adhere to medications prescribed by the doctors and quit midway due to lack of awareness.
Majority of the Indian population lacks health and technology awareness. A study by Mittal K and Goel MK in Indian journal of community medicine summarised that in urban Haryana found that only 11.3% of the adolescent girls studied knew correctly about key reproductive health issues. A review article on geriatric morbidity found that only 20.3% of participants were aware of common causes of prevalent illness and their prevention. Many patients do not adhere to medications prescribed by the doctors and quit midway due to lack of awareness. All these unnecessarily increase the disease burden and in turn the healthcare costs. Creative health education training programs using digital solutions must be conducted to increase awareness for the poor, uneducated and the geriartic population.
Lower caste and minority religions have decreased access to healthcare given their living conditions which results in poor health outcomes.
Primary Health Centers (PHCs) lack basic infrastructural facilities such as beds, wards, toilets, drinking water facility, clean labor rooms for delivery, and regular electricity. The further one lives from towns – the greater are the odds of disease, malnourishment, weakness, and premature death. Lower caste and minority religions have decreased access to healthcare given their living conditions which results in poor health outcomes. Making provisions that for digital health solutions reach the rural population, providing training to educate the rural population about nutrition and teaching the use of digital solutions is important.
70%-75% of healthcare expenditure comes out-of-pocket. Given that the private sector is prominent in healthcare services and does not have any enforced cap on the billing of medical services, families are forced to choose between life and life savings resulting in households slipping into poverty to meet medical needs. Households with high healthcare needs (SCs/STs, and the poor) are in a more disadvantaged position in terms of spending on health care. Healthcare services are only bound to get expensive, it is time for the government to step-in and spread the financial risk across the entire population equitably.
Enforcing procedures and processes is vital. Succumbing to temptations such as corruption and bribery should be discouraged. While building the processes, NDHM body should proactively involve all the key stakeholders i.e. the doctors, nurses, hospital administration and the patients to understand their pain points. A holistic approach to develop the processes should be applied for successful implementation of the procedures. Regulations for data standardization, validation of processes, cybersecurity standards for controlled supply chain of data are key to ensure accountability and success of the NDHM mission.
Absence of healthcare professionals
India has a shortage of an estimated 6,00,000 doctors and 20,00,000 nurses. India only has one government doctor for every 1,139 people. Right now, the facility is availed mostly by the elite and educated. There are only 0.7 hospital beds per 1,000 people in India with variations across the states, as per World Bank estimates3. Government must simultaneously work on producing more healthcare professionals and deploying telemedicine aggressively to balance the scarcity. Appropriate regulations and education of the poor, uneducated and old in utilizing such technologies has the potential to ease the pressure on healthcare workers.
NDHM should not just focus on processes, especially solutions like DigiDoctor are neither creative nor financially sensible.
Focus on innovation
NDHM should not just focus on processes, especially solutions like DigiDoctor are neither creative nor financially sensible. The Indian Medical Association already houses a database of all the doctors, instead of duplicating and spending resources on something that already exists, NDHM should take advantage of the new Medical Device Regulations and heavily focus on innovation of quality digital health/software products. Innovation in products has numerous advantages – softwares that aid in clinical decisions can improve efficiency and compensate for the scarcity of doctors, innovation in diagnostics can save lives in a timely fashion, apps that measure vital signs like ECG, heart rate, heart rate variability, respiration rate, temperature, oxygen can provide real-time insights into patient’s health for effective treatment, help plan for emergencies better, reduce readmission, hospital bed and labor costs, apps can help with management of diseases by encouraging patients to log in their diet and medications. Developing digital biomarker banks of different diseases for diverse populations while focusing on patient health outcomes both clinically and economically will not only encourage value-based care but also improve patient selection for surgeries and treatments.
The transition from treatment based care to prevention of diseases should start in the first half of this decade and must not be separated from The National Nutrition Mission.
The transition from treatment based care to prevention of diseases should start in the first half of this decade and must not be separated from The National Nutrition Mission. If executed meticulously by engaging all the stakeholders, by diligently complying with the software, cybersecurity, regulatory and quality standards to produce high quality digital health systems India has the potential to become a powerhouse of innovation in both products and processes in a way that healthcare can become patient centric while empowering lifestyle choices and ultimately reducing healthcare costs of the country. That will be a win-win situation!
Nidhi Gani is a Regulatory Affairs Specialist with Smith & Nephew, Boston, USA. She brings over four years of Regulatory experience working with leading companies such as Smith & Nephew, Terumo cardiovascular, specializing in Manufacturing set-up and transfers, New Product Development strategies and Remediation for Medical Devices in international markets such as North America, EU, Asia Pacific, Latin America.