The United Kingdom’s celebrates 70 years of the National Health Service (NHS) this year. The NHS was a pioneering experiment in providing universal healthcare free of cost to all residents (not just citizens) in the UK.
From personal experience, I can say with some degree of confidence that access to healthcare is independent of socio economic status and based solely on need - a strict triage based entirely on medical needs so that even though one may have a shattered thumb as a result of a weekend cricket adventure, one had to manage with some tape and over the counter pain killers for a few days while those who had more serious and life threatening injuries were treated in the trauma care department of a major London hospital.
Why is this relevant to India and to every Indian today unless like me you are easily overcome by schadenfreude and distracted by others’ miserable stories in far away lands?
On 6th July this year, the NITI Aayog published a consultation paper on the National Health Stack, which it calls the “NHS”. To avoid confusion with the NHS as it is globally known, I prefer to refer to it as the NITI Aayog Health Stack (NAHS, for short). So what is the NAHS?
It is an ambitious technology platform and national IT infrastructure to digitise all our health records and have it available on the cloud to various service providers. What it is not, is national health care or universal healthcare, which makes one wonder why the reference to the “NHS” was necessary.
It may surprise most people to know that the NAHS concept is not unique and the use of the term NHS by the NITI Aayog is a cryptic clue. The UK had the “NHS Connecting for Health” touted as the “world’s biggest civil information technology programme”, which was virtually identical to the NITI Aayog concept - a central database of personal health records accessible centrally so that patients can access healthcare services anywhere in the UK.
After almost 10 years and £20billion, the project that had the best global consultants and technologists (IBM, Accenture and Cerner) was finally shelved! So, in a small country where there already exists free universal healthcare and a high level of digitisation of health records, the concept of digital network to connect 30,000 doctors and 300 hospitals was a failure. Yet the NITI Aayog believes that it will work in India!
Under our federal constitution, healthcare is a state subject, which means that the central government does not DIRECTLY provide ALL healthcare to Indians BUT it does however extensively fund health programmes in states. This includes state government health insurance projects (like Rajiv Arogyasri in Telangana and Yeshasvini in Karnataka) under various “schemes” like the Rashtriya Swasthya Bima Yojana (RSBY), Aam Aadmi Bima Yojana (AABY), Janashree Bima Yojana (JBY) and Universal Health Insurance Scheme (UHIS) and these have had varying degrees of success.
HOWEVER, the NAHS seems to be a model for getting free access to healthcare records of the poor as quid pro quo for health insurance coverage. The objective of NAHS seems to be to create a national healthcare record database, which will be used to price health insurance!
There have already been op-ed pieces in anticipation of a push for universal health insurance during the budget season and again in the last week supporting the need for a national health database so that the poor can receive appropriate medical care nationally. But there has been little discussion on the concept, structure and risks of this NAHS platform, which is surprising since we have had recent experience with Aadhaar on the extent of the fundamental Right to Privacy and there has been a healthy debate on the fundamental right to healthcare over the last few years spurred by civil society.
We know that health insurance companies have not been able to sell as many policies as they would have liked and the “penetration” into the market has been less than promising, after the dream of a large untapped population was aggressive sold. Currently, the insurance coverage is limited to hospital costs and excludes several procedures, including pregnancy related costs and pathetic claims settlement process and ratios, which are in stark contrast with vehicle insurance where even minor dents and scratches are covered.
Rather than trying to understand why health insurance is not popular, the government and insurance companies have found a novel model to “force” health insurance on the population. This year the National Health Protection Scheme or the Ayushman Bharat Health Insurance Scheme, was widely publicised as “Modicare” by the Prime Minister himself.
If the NAHS project is implemented,
- there is a risk that access to healthcare will be subject to participating in the insurance scheme;
- the government will no longer be responsible for healthcare but will outsource this responsibility by buying insurance (Modicare and policies issued by health insurance companies) and expecting its people to access private healthcare providers linked to insurers;
- The US model of healthcare linked to expensive insurance which has very few supporters outside the obvious corporate beneficiaries will have infected us taking us further away from a welfare state and in breach of the government’s constitutional duties and responsibilities.
- Taxpayers’ money will be used to fund a database that benefits health insurance companies and hospitals.
Perhaps the NITI Aayog believes that we will be better than the UK at large scale IT projects using the public-private-partnership (PPP) model and safer than the Singapore model, which went offline after a massive security breach. The Washington Post announced that 2015 was the ‘Year of the Healthcare Hack’ to highlight the number of security breaches. That may be a record that the NITI Aayog is aiming for India to beat in 2019.
If the NITI Aayog is really confident that this model will transform healthcare in India, here is a suggestion - let it be implemented for the Central Government Health Scheme (CGHS) initially. After all, the CGHS ticks all the boxes that the NITI Aayog identifies as key requirements and objectives:
- every person has a unique identity that can be matched to their health records;
- there would be a clear benefit from a central database of their health records so that they can be accessed wherever they are posted or choose to settle down once they retire;
- the government already knows the cost of the healthcare provided under the CGHS and can therefore shift to an “insurance model” very easily;
- analytics using AI and big data will ensure that steps are taken to monitor health and identify trends and risks at a very early stage;
- quality of healthcare improves as a result of more data being available on the cloud for analytics;
- the huge database of a million or more patients will help with research on various diseases and treatments;
- as a good representative sample of the population, it will help fine tune the NAHS system before it is rolled out to the rest of the population; and
- it will have “skin in the game”; a chance for policy makers to demonstrate that they are so confident of their policies that they are willing to risk their lives and those of their families.
Once success is demonstrated, this project can be rolled out to those who are covered by the Employee State Insurance Scheme (ESIC), where the model as applicable to the CGHS seems to fit. If that succeeds, expand the programme to public sector units (PSUs), railways, banks and finally the armed services, which should be the easiest since it is a closed network of hospitals and patients.
After all, they tick all the boxes in terms of the requirements and objectives and can be “quick and easy wins” - they are ready for digitisation and they will benefit immensely from it. All those state governments that are interested could start by implementing this model for all government servants and public servants like ministers, members of legislative assembly (MLAs), judges, and state public sector undertaking employees.
I for one, fulfilling my patriotic duty in the interest of the nation, do not mind being last in the queue for the benefit of the NAHS in India. This may be one where being last may not be a bad thing at all!
(Murali Neelakantan is Principal at amicus. He is a dual qualified (English solicitor and Indian advocate) and has previously worked on the “Connecting for Health” project in the UK.)