📰 Can a digital ID aid India’s primary health ecosystem?
Without strong health infrastructure, it could amount to putting the cart before the horse
•Following a recent announcement by Prime Minister Narendra Modi on the creation of a digital health ID for every Indian, there has been a renewed debate on the need for a new digital identifier that centralises a citizen’s health records. Two public health experts, Dr. Abhay Shukla and Dr. Suresh Munuswamy, discuss the issue in a conversation moderated by G. Ananthakrishnan . Edited excerpts:
What can a digital health ID do for people?
•Dr. Abhay Shukla (AS):A digital health system can be built only on the basis of a well-functioning health system and integration of data. Integrated management of health data must be based on a larger reorganisation and integration of the health system. Otherwise, it is like putting the cart before the horse. We need to regulate the private healthcare sector, strengthen basic data collection from the primary healthcare level in the public health system, and ensure that this data is used in a manner that is respectful of the citizens’ privacy. Having something like the Data Protection Act in place is essential. In the absence of these preconditions, a digital health ID will be of limited use. And, it definitely cannot substitute for the much wider health system changes required urgently.
What does our experience with digital systems tell about this ID plan?
•Dr. Suresh Munuswamy (SM):As an idea it is great. All the issues are in the execution. You already have an ID, Aadhaar, and several other IDs — PAN card, bank cards, etc. Do they actually serve the purpose? Only with real-time authentication can that be achieved. That is a challenge with Aadhaar also. So, if I take this ID and go to a pharmacy, will it be authenticating me in real time? Is that even a possibility? So, we are just adding another ID.
•There is also an ecosystem. If I again go to a pharmacy, buy medicines, is there a barcode on the medicine? How am I going to even connect the medicine that I’m getting to the centralised database; am I going to manually enter all the data? If I go to a doctor, is the doctor’s data present? Imagine all the prescriptions going to the database. Is the prescription digitally readable or machine-readable? Do we have an e-prescription? These are the challenges.
We want to move towards universal health coverage. With a digital ID as a tool, what is the sequence to achieve that?
•AS:We need at least two or three important elements for building both a robust health system and an effective digital e-health system. The first is certain foundational policies which relate to the larger health system. The second is enabling strategies, which support an integrated information-based system. And then there are the actual e-health applications. So, a foundational change is on the public health Management Information System. We already have an MIS, but it is not functioning adequately. And there is a limited variety of data being received, but a lot of data, especially from the primary healthcare level, is inadequate.
•The second is reporting by the private healthcare sector. There is gross under-reporting of any kind of notifiable disease. In areas like malaria, cases are something like 20 times higher than what is reported by the official system. If you want to have a robust digital e-health system, then we need private practitioners, smaller hospitals, larger private hospitals regularly reporting about their cases.
•And that is linked to the regulation of the private sector. Information is not going to come in isolation. It has to be part of the Clinical Establishments Act and a regulatory framework. Without these, there is no meaning to the e-health platform. Perhaps it will just be limited to secondary and tertiary care and insurance companies. That is the sense that we are getting, that this digital e-health platform is mainly pushed by the providers rather than being pulled by the system.
What potential is there to use the idea for preventive services in primary care?
•SM:If you really want to even pinpoint a specific area where the challenge is, it is in data collection or in writing and reporting. India has a population 10 times or 20 times that of a developed country. We have a shortage of healthcare facilities, shortage of staff.
•Something as simple as identifying a house does not exist on the ground. If you ask the government, there are varying reports on how many houses are there even within a village without very clear data. We don’t have a clear database on nutritional status. Every time I want to dispense medicine or give nutritional advice, I have to weigh a person, measure their height, and arrive at the BMI. These skills are not even existent on the ground.
•You need to have radical new technologies for nutrition, come up with a solution where you could make a simple image to give your height, weight and BMI automatically. Now, that way, you will be able to identify if a person is undernourished or normal. But these are experimental solutions.
Do we have any pilots conducted so far?
•SM:In certain cases, small pilots are fairly successful. But the challenge is in interoperability or integration. Simply because I have one digital thermometer, I cannot transform healthcare. I need to have dozens of devices working in a rural environment, all trying to generate data in a meaningful, rapid way. And then I need to have a back-end platform to collect all the data, make sense of it.
•I need a digital dentistry platform, digital blood screening platform, a digital stethoscope.
If this ID is going to be used to profile health status and the commercial risk that individuals carry and that is used to discriminate, would you say legal changes must precede anything else?
•AS:Yes, that is a big concern, because health data is very sensitive. And you see that the Aadhaar data has been hacked into. The NITI Aayog said that they will be making available some of the data, and even to private players. That is the front door, and the back door can be hacked into. So, imagine if this data becomes available to employers. That the following person has diabetes, they will not employ her. Or to insurers. They will either charge a much higher premium or on some pretext they will not insure. If a person has HIV, which is confidential, and that data becomes available to colleagues or people in the immediate environment, he may be stigmatised. We don’t have a Data Protection Act yet in this country.
•The other issue is about regulation. Today, we don’t even know how many private hospitals are there in a particular city. There is no reliable source of information on how many beds are available. The government is actually struggling in the COVID-19 epidemic to find out. We don’t even have a comprehensive list of private practitioners. From that level, we’re saying that we will digitise all the data. Regulation includes mandatory information, which needs to be accessed from private providers. Many States still don’t have an effective Clinical Establishment Act.
Will the private tertiary care segment be happy with the idea of a digital ID?
•AS:Definitely. It is my hunch that it is the insurance industry, along with segments of the IT industry, which are pushing this whole idea. The insurance industry wants to know the background, the previous illnesses and previous procedures, to improve its own business.
•And, of course, private hospitals will also benefit to some extent. But, for patients, it has to be linked with an assurance that the care being provided through such an integrated system is more rational, more standardised, and rate-regulated.
•Similarly, rates. You’ve seen in the COVID-19 epidemic how patients have been grossly overcharged in certain private hospitals. So, you know, if it leads to standardisation, of quality of care or rationality of care, and regulation of rates, then that kind of digital health platform will be of some use to the patient. Whatever I have read about the digital health stack, which is a kind of precursor to this digital [move], these aspects do not seem to be very much fore-fronted. With a public health expenditure of 1.2% of the GDP, there is no way you can have a robust universal health system. So, just thinking about a digital platform is not really going to help.
Can some elements of personal identity be masked and health advice given to individuals using an ID?
•AS:Anonymised data for public health surveillance may be of some use for certain kinds of illnesses, especially non-communicable diseases. Especially blood glucose levels and lipid profiles for population-based public health decision-making. But a large proportion of illnesses are communicable diseases, perinatal and maternal health conditions, where laboratory investigations are of limited value and a lot of clinical interaction is still required. What we need to do is strengthen front-line and primary health care workers.
A report on universal health coverage by the erstwhile Planning Commission said a small percentage of GDP can provide all citizens with free essential medicines. Can that be a demand with the digital ID?
•AS:We already have the technology, we don’t need a new ID for that. The Tamil Nadu Medical Services Corporation model, which has been replicated in Kerala and Rajasthan, has shown that essential medicines can be made available across the State in each healthcare facility, provided there is a demand-driven supply and a willingness to make the procurement and distribution system transparent, accountable and free of corruption. Of course, some more technology will help.
Should not a digital ID confer a right to medicines for all?
•AS:It is not going to make a big difference. What we need first is an expansion of primary health services in the public sector through health centres. Then we need to engage local private practitioners and bring them into the system. Then, digital health will help strengthen it, make information available, and deliver medicines. In chronic illnesses like diabetes, high blood pressure, arthritis and cardiac ailments, digital health platforms could make available regular, low cost, quality medicines, especially for elderly patients who cannot go to a health centre, in a regulated system.
•SM:What the T.N. model said was, when you centralise purchases a lot of things can be taken care of. You have this efficient way of delivering medicines up to the primary health centre level. Again, the challenge is, you are only tracking the secondary packages. You don’t know if the person is getting the medicines. You need to have the real time authentication of the person.
Judges must ponder and pursue the old norms that earned them respect and public confidence
•As I read media accounts about the Supreme Court decision convicting Prashant Bhushan of contempt of court, I was reminded of another case of alleged contempt which my father Brahma Nath Katju always recalled with a chuckle. It took place in the early 1950s when he was a junior lawyer in the Allahabad High Court. A villager from Uttar Pradesh had written postcards making allegations against a magistrate. The magistrate complained to the High Court. The court sent a number of notices to the villager to appear in court but he ignored them. Finally, non-bailable warrants were issued and the police produced the villager in court.
•The Bench asked the villager why he had not responded to the notices. He said he could not afford the railway fare and as the police had brought him to court, he did not have to pay a paisa for the journey. The judges conferred with each other and decided that his allegations would not shake the administration of justice in the State; a warning would be sufficient. So, they warned him to not make such allegations and told him that he could go back home. “How will I go home? I have no money,” the villager told the judges. That flummoxed them but they quickly recovered and decided to personally pay the fare! A senior advocate who was there to assist the court offered to ensure that the villager was given a meal and dropped to the railway station.
Qualities of a judge
•Now, the times are very different. A magistrate is a lowly cog in the great judicial machine and not a judge of a superior court. But the personal qualities that were then required of judges and shown by those two Allahabad High Court judges are no different from those expected of present-day judges. Apart from integrity, in all its aspects including intellectual, and impartiality, the one word which comes readily to mind on the qualities of judges is sobriety.
•Indeed, sobriety in a judge is so significant that it is part of the simile ‘as sober as a judge’. Sobriety is not greyness or humourless grimness but a characteristic that denotes balance and connotes a desire to shun the limelight. It is the opposite of flamboyance which is in itself not a negative personal attribute and perhaps even appropriate for some callings, but is it so in judges? Judges in the past and most now too avoid being flamboyant. Sobriety and flamboyance are relevant in the Prashant Bhushan case but have not received any focus. This is because the Supreme Court has avoided any comment on the Chief Justice of India (CJI)’s photograph which has been, in a manner, the origin of the present action.
•In paragraph 62, the court in the Bhushan judgment notes: “The first part of the first tweet states, that ‘CJI rides a 50 lakh motorcycle belonging to a BJP leader at Raj Bhavan, Nagpur without a mask or helmet’. This part of the tweet can be said to be a criticism of the CJI as an individual and not against the CJI as CJI”. It thereafter proceeds to mention the second part of the tweet where Mr. Bhushan says, “at a time when he keeps the SC in a lockdown mode denying citizens their fundamental rights to access justice”. The court holds that the second part of the tweet was critical of the CJI as CJI and was contemptuous.
•As the court has itself categorically opined that any comment on the photograph of the CJI cannot attract contempt, citizens are safe from being hauled up for contempt if they draw inferences as long as they do not make that a basis for making adverse comments about the the CJI’s role in the administration of justice in the country. This fortifies citizens to make observations on the photograph as well as the changing nature of conventions regarding the personal conduct of the judges of the superior courts so long as they do not imply any criticism of the judges’ functioning as judges. There too the court has discussed at great length how fair and constructive criticism of judicial functioning and of court judgments without attribution of motives is healthy for the functioning of Indian democracy.
•A reputed wire service reported that people who were knowledgeable about the incident said that the CJI did not know who owned the motorcycle and that he merely wanted to get a feel of it. It also claimed that he wants to buy a motorcycle after his retirement. The fact is that the photograph was unique for never has a superior court judge, leave alone a CJI, been seen astride a motorcycle. The question is whether the CJI was wise to do so while occupying the august office he does or whether he should have curbed his enthusiasm till he had retired. What would he feel if many judges and magistrates follow his example, and photographs of them getting a feel of objects of their enthusiasm — for example, sports cars — appear? This is a question only he can answer after giving it the thought it deserves. I will only add that he himself knows that many lawyers on elevation to the bench have to curb their enthusiasm, change some habits and become sober in their conduct.
Shunning the limelight
•In the immediate aftermath of independence, judges also maintained a tradition of aloofness. They did not seek public attention; indeed, they avoided it. For instance, unlike politicians and officers of the executive branch, they moved without pilots and escorts or sirens and red lights on their cars. It may now come as a surprise but it was only in the 1980s that High Court judges were provided with official cars. Till then, at least in the Allahabad High Court, many judges drove to the court themselves.
•At some stage judges began to seek to be equated with executive officers and politicians in terms of some perks and privileges. This does not imply that the standards of judicial work were compromised but it did mean that they came more in the public eye. This led to a weakening of the strong norms of aloofness. The limelight was shunned. Official cars with sirens and red lights were symptomatic of the changing mores.
•There was yet another tradition that most judges strictly adhered to. They mainly confined themselves to their judicial work and only spoke through their judgments. This does not mean that they did not pursue their hobbies and write on non-judicial subjects in which they had expertise but they avoided issues of public policy which may come before the courts. Certainly, they did not give their views on controversial political and social issues. Largely this tradition continues to be pursued.
•All in all, judges of the superior courts must, even in these changing times, ponder deeply the old norms that earned them respect and public confidence, and pursue them. There is no surer foundation for the judicial branch of the state.
📰 Borrow from RBI to bridge GST gap, Centre tells States
Pandemic an act of God, says Sitharaman; States given 7 days to consider options
•The Centre on Thursday acknowledged that States are likely to face a GST revenue gap of Rs. 3 lakh crore this year, as the economy may contract due to COVID-19, which Finance Minister Nirmala Sitharaman termed an unforeseen “act of God”. Compensation cess collections are only expected to bridge 22% of this gap. Of the remaining Rs. 2.35 lakh crore, the Centre said only Rs. 97,000 crore was due to GST implementation itself, rather than caused by the impact of COVID-19. At the GST Council meeting, it claimed that this Rs. 97,000 crore is the portion “hardwired” into the compensation law.
•The Centre then offered States two options for borrowing to meet the shortfall, Ms. Sitharaman told journalists after the meeting. The States have seven working days to decide their option, she added.
•“A special window could be provided, in consultation with the RBI, so that the States can get this Rs. 97,000 crore at a reasonable rate of interest, and this amount can be repaid after five years through the collection of cess,” said Finance Secretary Ajay Bhushan Pandey. “Another option is that this entire gap of Rs. 2.35 lakh crore can be met by the borrowing by the States. There also, arrangement could be made with the RBI and certain facilities could be provided.”
•Ms. Sitharaman added that for States choosing the first option, she would be willing to remove conditions around a further 0.5% relaxation in their borrowing limits under the FRBM Act.
📰 Restoration of peace on LAC key to ties, says India
•“ And putting the border issue in an appropriate position, avoid misjudgment, keep divergences from escalating into disputes, and take concrete steps to bring the bilateral relations back to the right track.” In Delhi, the Ministry of External Affairs made clear that both sides needed to take “reciprocal actions” to restore peace. Spokesperson Anurag Srivastava said, “complete disengagement requires re-deployment of troops by each side towards their regular posts on their respective sides of the LAC”, adding that “it is important to bear in mind that achieving this requires agreed actions by both sides.”
•“The two sides had also agreed to continue their engagements — both through diplomatic and military channels,” he added, quoting the recent remarks of External Affairs Minister S. Jaishankar that “finding a solution... must be predicated on honouring all agreements and understandings… and not attempting to alter the status quo unilaterally”. In India’s view, complete disengagement and a full restoration of the status quo prior to May’s transgressions remains far off. Chinese troops still remain on India’s side of the LAC at Pangong lake and are disrupting Indian patrols in the Depsang plains, while a build-up of forces remains elsewhere along the LAC.
📰 India, ASEAN must shed non-tariff barriers: Goyal
‘Need to fix declining trend of trade’
•Business communities of India and the ASEAN should work to resolve their differences, remove non-tariff barriers, ensure sanctity of rules of origin and open markets to expand two-way trade, Commerce and Industry Minister Piyush Goyal said on Thursday.
•Addressing the ASEAN-India Business Council, Mr. Goyal said both sides needed to work together to further this relationship as two-way trade was witnessing signs of decline, from $81 billion to $77 billion, “probably the first time we saw a 5% de-growth.”
•He said India and ASEAN (the Association of Southeast Asian Nations) have not been able to harness the full trade potential for various reasons, but that now was the time to expand trade, address concerns and resolve differences.
•“It is important that businesses on both sides work to resolve differences, work to create a more valuable and trusted regional value chains, remove non-tariff barriers on both sides, ensure sanctity of rules of origin, and open markets to expand trade,” opined Mr. Goyal.
•“We will have to work together and we can create a resounding sound which will be heard by the whole world. But if each one of us only remains committed to themselves and does not look to further this relationship , our trade which is already seeing signs of falling from USD 81 billion to USD 77 billion...can at times move into the downward spiral,” Goyal added.
•The minister said the two sides have not yet been able to start the review of free trade agreement in goods.
•He added that businesses can play the role of a bridge to help resolve the issues “amicably and quickly“.
•He said problems that do not resolve in a quick time frame have the risk of expanding and “sometimes growing beyond control, beyond repair”. So businesses of both the sides should work together, embrace each other, and embrace each others’ problems to resolve them.
