|Year : 2021 | Volume
| Issue : 2 | Page : 209-212
Challenges and prospects in india's digital health journey
Nachiket Gudi1, Theophilus Lakiang2, Sanjay Pattanshetty3, Suptendra Nath Sarbadhikari4, Oommen John5
1 Postgraduate Student, Department of Health Policy, Prasanna School of Public Health, Manipal Academy of Higher Education, Manipal, Karnataka, India
2 Independent Researcher, India
3 Associate Professor, Department of Health Policy, Prasanna School of Public Health, Manipal Academy of Higher Education, Manipal, Karnataka, India
4 Independent Consultant, Digital Health, George Institute for Global Health, India
5 Senior Research Fellow, George Institute of Global Health, University of New South Wales, New Delhi, India, Prasanna School of Public Health, MAHE, Manipal, India
|Date of Submission||16-Dec-2020|
|Date of Decision||19-Jan-2021|
|Date of Acceptance||19-Apr-2021|
|Date of Web Publication||14-Jun-2021|
The George Institute of Global Health
Source of Support: None, Conflict of Interest: None
| Abstract|| |
India's journey in the digital health arena and its contribution to the landmark resolution on digital health by the World Health Organization has been recognized globally. India has demonstrated its commitment to leverage digital health as a health system strengthening intervention, as outlined in the National Digital Health Blueprint based on which, the National Digital Health Mission (NDHM) is currently being piloted by the National health authority. Further, the Sandbox environment of NDHM is actively encouraging all the ecosystem partners to familiarize with the evolving national digital health infrastructure. The strategy to enhance the India's progress in implementation and scale-up of digital health interventions are drawing attention to workforce capacity building, harnessing health data to facilitate research and development, evidence-informed development of policies, sustaining efficiency and quality of system through appropriate monitoring, and periodic evaluation informed by frameworks specific to digital health or those adapted to evaluate health informatics applications.
Keywords: Challenges, digital health, health information management, human resource, implementation, India
|How to cite this article:|
Gudi N, Lakiang T, Pattanshetty S, Sarbadhikari SN, John O. Challenges and prospects in india's digital health journey. Indian J Public Health 2021;65:209-12
|How to cite this URL:|
Gudi N, Lakiang T, Pattanshetty S, Sarbadhikari SN, John O. Challenges and prospects in india's digital health journey. Indian J Public Health [serial online] 2021 [cited 2021 Jul 30];65:209-12. Available from: https://www.ijph.in/text.asp?2021/65/2/209/318362
| Introduction|| |
Digital health as a phenomenon is defined as “the cultural transformation of how disruptive technologies that provide digital and objective data accessible to both caregivers and patients leads to an equal level doctor-patient relationship with shared decision-making and the democratization of care." It has been pivotal in enhancing health care and improving the economy across nations as it brought communities closer to seeking health care through different modalities. With growing population resulting in large gap between the number of health-care professionals and patients, increasing cost of health care, investing in technology to enable health-care delivery was the stimulus to digitalize public health in India. The use of digital health interventions in primary care has provided good results in cessation programs, maternal health education, addressing mental health issues, and maintaining vaccine supply chains, thus making digitalization of public health imperative in India. India's journey in the digital health arena has been recognized globally and of particular note is India's leadership of the landmark resolution on digital health for health systems strengthening by the World Health Organization (WHO) and was adopted during the 71st World Health Assembly.
On August 15, 2020, the honorable Prime Minister of India launched the National Digital Health Mission (NDHM), which envisions to ensure connected health services through its health card with a health ID for every citizen. Before the launch of the NDHM, India has made efforts in this direction through its National Health Policy (NHP) and the national digital health blueprint (NDHB). In this article, we trace the journey of NDHM and enlist the potential implementation challenges while outlining the strategic opportunities in India's digital health journey.
| The Journey from the National Health Policy to the National Digital Health Mission|| |
The NHP 2017 laid emphasis on “ensuring a district-level database on information on health system components, strengthening surveillance system and establishing registries, establishing federated integrated health information architecture, health information exchanges, and National Health Information Network by 2025." The NHP not only advocated for an Integrated Health Information System to enhance private sector participation and facilitate interoperability but also recognized the role of technology in health-care delivery by establishing a National Digital Health Authority which will facilitate in regulating, developing, and deploying digital health across the continuum of care. The NHP also stated the use of digital tools for AYUSH system of medicine and promoted the development of information database to foster research.
In 2019, India placed the NDHB for public opinion. The blueprint in its aims outlined leapfrogging to the digital age through the provision of a wide range of digital health services and was pivoted on the recommendations of NHP 2017, which emphasized the use of digital technology for achieving Universal Health Coverage. It has used a layered approach which encompasses principles, building blocks, standards and regulations, applications, services, institutional structure which falls into health, and technical domains. It adopts the principle of “think big, start small, and scale fast,” with an action plan for implementation.
| Implementation Challenges|| |
One of the major challenges in implementing digital health across India is that health is a state matter, where the states are responsible for on-the-ground implementation while policy directions are centrally directed, and therefore, the individual states are legally entitled to vary from central health directives.
In terms of implementation capacity, the WHO states that efficient operation of public and private health sectors is affected due to lack of leadership and management capacity. Evidence suggests that India has had a shortage of human resources for health and their inequitable geographical distribution from a long time.,,, Lack of dedicated personnel to manage health information for various information gathering portals has also been highlighted, thus drawing attention to developing curriculum around public health informatics and mainstreaming of Health Information Management (HIM) professionals.,,
In this article, we further draw attention to the lack of trained workforce for handling health information and health information systems, digital platforms working in silos due to limited interoperability, noncompliance to standards, and lack of data governance frameworks. To realize the prospects of data monetization and its potential contribution, digital economy is a far-fetched aspiration in the absence of optimal data governance mechanisms. At present, India has an acute shortage of trained workforce with competence in handling the health-related data that could be generated through the successful implementation of NDHM. The paradigm shift in the information capturing mechanisms and citizen-centric tools can also see reluctance for widespread uptake. To enable this, empowering the end users through citizen-centric digital health awareness programs are required. There are a limited number of educational institutes that are currently training students in HIM and health informatics as a specialization and only one of them is a government sponsored university. Although the model curriculum for HIM was published in 2016 by the MoHFW, the blueprint has not given due recognition to the role of HIM professionals as opposed to hospital administrators and Health IT professionals. Other ethical challenges of health data in digital formats include weak data protection policies resulting in unrestricted access to patient data for commercial firms. Thus, to counter this, the Ministry of Electronics and Information Technology tabled the Draft Personal Data Protection Bill, 2018, which when passed offers to set up National Data Protection Authority to regulate access to those who collect data, thereby ensuring privacy protection.
It is of paramount importance to understand the usability from an end user's perspective and there is an immense scope for integrating existing portals in India to offer a seamless experience. There is a paucity in literature on concrete efforts towards integrating digital health tools and this requires the collaborative efforts of UI/UX designers, administrators, human-computer interaction scientists, and the end users, with these platforms being developed through a participatory co-design approach. Although different models from South Korea and NHS Digital in England have been referred to in the blueprint, the Indian context is unique with high patient load and poor participation from private health-care providers towards health data aggregation which could be attributed to low digital literacy. The blueprint also recommends incentive-driven governance mechanisms at the health facility level for maintaining facility registry, but the existing programs function through delegation of responsibilities thus forcing the nursing staff in health-care establishments and frontline health-care workers in primary care contexts to devote a significant amount of their time for data entry than rendering health services.
| Emerging Opportunities|| |
The NDHM envisions to “create a national digital health ecosystem that supports universal health coverage," but there are operational areas that need capacity building without which the exercise might prove costly in terms of acceptance, usability, and data aggregation. The capacity building activities should be implemented considering the intrinsic and contextual factors. The operational areas and opportunities for capacity building are highlighted in [Table 1].
|Table 1: National Digital Health Mission components and opportunities for capacity building|
Click here to view
A recent report suggests that a strong governance is the key to Digital Health Investments and advocates for the use of governance frameworks such as the Health ICT Governance Architecture Framework 2.0 and Control Objectives for Information and Related Technologies 5 (COBIT-5). Lessons from other countries have identified cross-cutting challenges such as sustainable funding, training of users, and establishing credibility in information handling. Engaging all the actors (boundary spanners and gatekeepers) in the digital health sphere in small and digital India mission at large thereby optimizing processes, with due attention given on “what to govern” and how to deploy digital governance (top-down and bottom-up) across various levels of health care would bring us a step closer to the holistic digital health ecosystem in India.
The Sandbox environment at the NDHM will allow one to integrate and validate the software systems by partnering with the NDHM (application programming interfaces [APIs]). Enrolment is invited and open to Healthcare Service Providers, Hospitals, Healthcare Software Vendors, and anyone who wants to build NDHM APIs. Health Information Providers, Health Repository Providers, Health Information Users, or Health Lockers should integrate with NDHM APIs. [Table 2] shows the digital building blocks hosted by the sandbox.
|Table 2: The sandbox hosts the following digital building blocks that are useful for anyone who wants to create software services and products integrated with National Digital Health Mission services|
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| Conclusion|| |
Emergence of digital health in India can narrow the existing inequities in accessing health care, as the blueprint emphasizes on the use of digitally enabled outreach services, particularly telemedicine, thus acknowledging the low doctor-to-population ratio in most parts of the country. Thus, the strategy to enhance India's progress in implementation and scale up the digital health interventions are drawing attention to workforce capacity building, frameworks for clinical and operational data collection, collation and governance to facilitate research and development, evidence-informed development of policies, sustaining efficiency and quality of system through appropriate monitoring, and periodic evaluation informed by frameworks specific to digital health or those adapted to evaluate health informatics applications.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Meskó B, Drobni Z, Bényei É, Gergely B, Gyórffy Z. Digital health is a cultural transformation of traditional healthcare. Mhealth 2017;3:38.
Asi YM, Williams C. The role of digital health in making progress toward Sustainable Development Goal (SDG) 3 in conflict-affected populations. Int J Med Inform 2018;114:114-20.
Hamilton C, Maw A, Gill A, Brahmbhatt M, Phaal R, Pickard J. Paediatric neurorehabilitation: Finding and filling the gaps through the use of the Institute for Manufacturing strategic roadmapping method. BMJ Innov 2017;3:137-43.
Kumar N, Anderson RJ, editors. Mobile Phones for Maternal Health in Rural India. Proceedings of the 33rd
Annual ACM Conference on Human Factors in Computing Systems; 2015.
Gonsalves PP, Hodgson ES, Kumar A, Aurora T, Chandak Y, Sharma R, et al.
Design and development of the “POD Adventures” smartphone game: A blended problem-solving intervention for adolescent mental health in India. Front Public Health 2019;7:238.
Gurnani V, Singh P, Haldar P, Aggarwal MK, Agrahari K, Kashyap S, et al.
Programmatic assessment of electronic Vaccine Intelligence Network (eVIN). PLoS One 2020;15:e0241369.
Ministry of Health and Family Welfare GoI. Delhi: National Health Policy; 2017.
Sarbadhikari SN. Digital health in India – As envisaged by the National Health Policy (2017). BLDE University J Health Sci 2019;4:1.
Government of India. National digital health blueprint. In: Ministry of Health and Family Welfare e-HS, editor. New Delhi: Government of India; 2019. p. 76.
Hazarika I. Health workforce in India: Assessment of availability, production and distribution. WHO South East Asia J Public Health 2013;2:106-12.
Rao M, Rao KD, Kumar AK, Chatterjee M, Sundararaman T. Human resources for health in India. Lancet 2011;377:587-98.
Garg S, Singh R, Grover M. India's health workforce: Current status and the way forward. Natl Med J India 2012;25:111-3.
Rao M, Kadam S, Sathyanarayana T, Shidhaye R, Shukla R, Ramachandra SS, et al
., editors. A Rapid Evaluation of the Rajiv Aarogyasri Community Health Insurance Scheme in Andhra Pradesh, India. BMC Proceedings; 2012.
Gera R, Muthusamy N, Bahulekar A, Sharma A, Singh P, Sekhar A, et al.
An in-depth assessment of India's Mother and Child Tracking System (MCTS) in Rajasthan and Uttar Pradesh. BMC Health Serv Res 2015;15:315.
Wholey DR, LaVenture M, Rajamani S, Kreiger R, Hedberg C, Kenyon C. Developing Workforce Capacity in Public Health Informatics: Core Competencies and Curriculum Design. Front Public Health 2018;6:124.
Centre for Health Informatics (CHI) NIoHaFWN, Ministry of Health and Family Welfare (MoHFW), Government of India. National Health Portal: Centre for Health Informatics (CHI), National Institute of Health and Family Welfare (NIHFW), Ministry of Health and Family Welfare (MoHFW), Government of India; 2015. Available from: https://www.nhp.gov.in/health-informatics_pg#Institutes%20Offering%20Courses
. [Last accessed on 2016 Dec 05].
MOHFW. In: Section AH, editor. Model CurriculumHandbook-Health Information Management: New Delhi 2016.
Prasad M D, Menon CS. The Personal Data Protection Bill, 2018: India's regulatory journey towards a comprehensive data protection law. Int J Law Inform Technol 2020;28:1-9.
Nedungadi PP, Menon R, Gutjahr G, Erickson L, Raman R. Towards an inclusive Digital Literacy Framework for Digital India. Education+ Training; 2018.
Dehury RK, Chatterjee SC. Assessment of health management information system for monitoring of maternal health in Jaleswar Block of Balasore District, Odisha, India. Indian J Public Health 2018;62:259-64.
] [Full text]
Loomis GA, Ries JS, Saywell RM Jr., Thakker NR. If electronic medical records are so great, why aren't family physicians using them? J Fam Pract 2002;51:636-41.
Singh A, Jadhav S, Roopashree MR. Factors to overcoming barriers affecting electronic medical record usage by physicians. Indian J Community Med 2020;45:168-71. [Full text]
Baubie K, Shaughnessy C, Kostiuk L, Varsha Joseph M, Safdar N, Singh SK, et al.
Evaluating antibiotic stewardship in a tertiary care hospital in Kerala, India: A qualitative interview study. BMJ Open 2019;9:e026193.
Tillu G. AYUSH research for New India: Vision and strategies. J Ayurveda Integr Med 2018;9:240-4.
Manchanda RK. Medical pluralism, regulations and pharmacopoeia: A perspective. Indian J Res Homoeopathy 2017;11:85. [Full text]
Kumar A, Tripathy NR, Bhaskar A. Central government health services (CGHS) in perspective of beneficiaries' satisfaction. Int J Health Sci Res 2016;6:401-9.
Marcelo A, Medeiros D, Ramesh K, Roth S, Wyatt P. Transforming Health Systems Through Good Digital Health Governance. Asian Development Bank: Philippines;2018.
Development BCFS. Digital Health: A Call for Government Leadership and Cooperation between ICT and Health 2017.
Okeke U. The Role of Governance Mechanisms on the Diffusion of Innovation in Healthcare Networks PhD diss., University of the West of England, UK, 2018.
Balsari S, Fortenko A, Blaya JA, Gropper A, Jayaram M, Matthan R, et al.
Reimagining health data exchange: An application programming interface-enabled roadmap for India. J Med Internet Res 2018;20:e10725.
[Table 1], [Table 2]