Country’s healthcare system in a nutshell

The Indian constitution mandates that the government ensure the "right to health" for everyone, and each state is responsible for providing free access to healthcare services. However, the Indian healthcare system has consistently been underfunded, and the private healthcare sector is predominant in India's healthcare landscape. Many healthcare expenses are in effect borne directly out of pocket by patients.

Historically, the government has introduced various health insurance schemes targeting specific groups, with different levels of coverage across states, but these have not significantly reduced out-of-pocket expenses. For example, in 2017-18, only around 37% of the population had any form of health coverage.

Other barriers to accessing healthcare include long wait times, perceived poor quality of public health services, and significant shortages in healthcare infrastructure and workforce. (Tikkanen et al., 2020)

According to the most recent data from 2010, This coverage encompasses both those who are members of health insurance schemes and those who have free access to state-provided healthcare services

NITI Aayog (the National Institution for Transforming India) reported in 2021 that approximately 70% of India's population have some form of health insurance coverage, encompassing State Government schemes, social insurance programs, and private insurance (NITI Aayog, 2021). This represents a significant increase from 2010, when only 12.5% of the population in India were covered by health insurance (Our World in Data, n.p.).

Open

Source: https://data.worldbank.org/indicator/SH.XPD.OOPC.CH.ZS?locations=IN

Public vs private

Open

Source: The World Bank.
The pink column refers to the public expenditure as a % of the country’s total healthcare expenditure. The blue dot is the country’s expenditure on health per capita, expressed in international dollars at purchasing power parity.

 The national infrastructure

The Indian National Health Policy (NHP) 2017 aimed to achieve the highest possible level of health and well-being for all ages through preventive and promotive health care and universal access to quality health services without financial hardship.

To support this goal, the Ministry of Health and Family Welfare established a committee led by Shri J. Satyanarayana to develop an implementation framework for the National Health Stack. This committee created the National Digital Health Blueprint (NDHB), which provides the foundation and action plan for digital health implementation.

The NDHB document outlines the context, rationale, scope, and implementation arrangements for a nationwide digital healthcare ecosystem, referred to as the Ayushman Bharat Digital Mission (ABDM). Published in 2019, the NDHB aims to establish a comprehensive digital health ecosystem, reduce out-of-pocket expenses, and achieve Universal Health Coverage (UHC).

The key objectives and proposals of the NDHB were:

1. Federated Architecture: this enables seamless information flow across different healthcare players. This model allows decentralised management of data at national, state, and facility levels, ensuring interoperability and flexibility;

2. Interoperability and Open Standards: Emphasis is placed on adopting open standards and open-source software to ensure interoperability among diverse health systems. This approach aims to integrate existing health information systems and new digital health initiatives smoothly;

3. Patient-Centric Approach: The blueprint ensures citisens have full control over their health data. Data protection and privacy are embedded in the system's design, with stringent security measures for data processing and storage;

4. Core Building Blocks: Key components include Health ID, Health Data Dictionaries, Electronic Health Records (EHR), and Personal Health Records (PHR). These building blocks are designed to be minimalistic for easy adoption and are critical for creating a unified health information infrastructure​;

5. Integration of Health Services: The NDHB aims to integrate various health programs like Ayushman Bharat, Reproductive Child Healthcare, and NIKSHAY (for tuberculosis) onto a unified IT platform. This integration seeks to enhance service delivery efficiency and ensure timely healthcare access;

6. Stakeholder Collaboration: The blueprint encourages feedback and participation from all stakeholders, including healthcare providers, technology developers, and the general public, to refine and implement the digital health strategies effectively​;

(Ministry of Health & Family Welfare, 2019)

ABDM is an healthcare transformation project of the Government of India that aims to develop the backbone necessary to support the integrated digital health infrastructure of the country.

As Forbes remarked, ABDM is a very interesting case: because of the large population of India, any precedent for data management in the ABDM will establish a model for other national health programs to study (Dans, 2020).

ABDM encompasses health registries like ABHA(a 14-digit patient identifier), HPR (Health Professional Registry), and HFR (Health Facility Registry). It will also soon include drug registries, allowing manufacturers to update and verify drugs through health authorities, so that patients can check whether a drug is unlicensed.

ABHA is a 14 digit unique identifier. Patients also create an ABHA address, which has a gmail-like structure. They can create multiple ABHA addresses to maintain their healthcare data but the patients are uniquely identified in the healthcare ecosystem through their ABHA. While sharing the healthcare record with the patient, the doctor links it with the ABHA address preferred by the patient to make it a part of their longitudinal record history.

ABHA leverages Aadhaar, which is a 12-digit unique identifier for citizens of India. Most of the bank accounts leverage Aadhaar infrastructure as a KYC service.

While there are multiple ways to create an ABHA e.g. using driving license, however, Aadhaar provides a seamless way to create an ABHA in seconds digitally. Other methods require additional verification and authentication.

Then, providers have their own organisational ID for each patient

• HPID (Health Professional ID): The HPID identifies the care provider uniquely in the healthcare ecosystem.

Gateways and protocols that drive interoperability with open standards are 3:

1. Unified Health Interface

User applications for UHI are: HSPA (Health Service Provider Applications), EUA (End User Application)

2. Health information exchange Consent Manager (HIE-CM):

   1. Health Records: Health Data sharing with consent, Health document collation (diagnostic, reports, prescription), Aggregated Health data for policy & analytics

User applications for HIE-CM are: PHRs (Personal Health Records Applications) and HMIS/LMIS (Hospital Management Information Systems)

3. Health claims exchange (HCX):

   1. Health claims: cClaims standard, Health claims platform, Policy markup language, Bill markup language

National health authority (NHA) is the body mandated with steering ABDM. It provides a certification framework for PHR applications. To build a National Health Authority-licenced system there are 3 stages of compliance

• Milestone 1 (M1) is the verification and creation of ABHA.

• M2: HIP (Health Information Provider) can share record to another party using APIs and patient consent

• M3: HIU (Health Information User) can pull data and show it

  • Request from the doctor to pull data goes to the system with the record to show a consent request to the app

  • Request from patients to pull their own data from providers’ systems linked to the Abha

National PHRs

This is the list of PHR platforms that have been approved by the National Health Association (NHA) for Ayushman Bharat Digital Mission (ABDM) roll-out (list can be found at this linkhttps://abdm.gov.in/our-partners/PHR ):

• Plus ninety one by Plus 91

• Driefcase, by Driefcase Health Tech Pvt Ltd

• Eka.care by Orbi Health Private Limited

• Paytm by Paytm

• Raxa by Raxa Health

• Arogya Setu by Arogya Setu

• Bajaj Finserv Health by Bajaj Finserv Health

• Parchaa by Panscience AI Healthcare Pvt Ltd

• Health-e by Anahat Solutions Pvt Ltd

 Statistics

Here are insights about ABDM : https://dashboard.abdm.gov.in/abdm/

Bibliography:

Ang, A., 2022. PHR app DRiefcase connects with India's ABDM. Healthcare IT News, 3 February. Available at: https://www.healthcareitnews.com/news/asia/phr-app-driefcase-connects-indias-abdm (Accessed 11 January 2024)

Dans, E., 2020. How India’s National Digital Health Mission Is Set To Revolutionize Healthcare. Forbes, updated 17 August. Available at: (Accessed 11 January 2024)

Driefcase Health-Tech, n.d. FAQs. Available at: (Accessed 11 January 2024)

Driefcase Health-Tech, n.d. Homepage. Available at: https://www.driefcase.com/ (Accessed 11 January 2024)

Ministry of Health & Family Welfare, Government of India, 2019. National Digital Health Blueprint. Available at: https://abdm.gov.in:8081/uploads/ndhb_1_56ec695bc8.pdf (Accessed 20 July 2024)

National Health Authority (NHA), Government of India, n.d. Ayushman Bharat Digital Mission (ABDM). Available at: (Accessed 11 January 2024)

NITI Aayog, 2021. Health Insurance for India's Missing Middle. Available at: https://www.niti.gov.in/sites/default/files/2021-10/HealthInsurance-forIndiasMissingMiddle_28-10-2021.pdf (Accessed 20 August 2024)

Tikkanen, R., Osborn, R., Mossialos, E., Djordjevic, A., & Wharton, G.A., 2020. International Health Care System Profiles: India. The Commonwealth Fund. Available at: (Accessed 26 July 2024)