Comments on the Consultation Paper on Unified Health Interface Submitted to the National Health Authority

1. Background

Pursuant to the National Health Policy (NHP) and the National Digital Health Blueprint (NDHB), the National Health Authority (NHA) now proposes to create a Unified Health Interface (UHI), as a part of the National Digital Health Ecosystem (NDHE).

While the objectives and vision of UHI are well-intentioned, and do well on several counts, such as:

• • Envisioning an Open Network for Digital Health Services as a part of the NDHM;
  • Identifying the incentives and disincentives of joining UHI for different stakeholders;
  • Listing the features and services envisioned to be part of the UHI;
  • Discussing the development, governance and management of UHI; among others.

However, there is scope for improving them further.

NCL expresses its gratitude to NDA for releasing a consultation paper on UHI, which invites responses on various questions posed in the paper. Our response to the same has been given in the subsequent section, along with a few other comments and suggestions.

2. Response to Questions

Q2 As a stakeholder in the health ecosystem, what benefits and risks do you see if an open network approach to digital health services is implemented? Please respond with details.

An open network approach for digital health services will have bring forth various benefits and risks to different stakeholders, which have been captured in the paper, in the form of incentives and disincentives for stakeholders in chapter 4.
As has been acknowledged in this paper, the concept of open networks has been covered under the strategy paper on National Open Digital Ecosystems (NODEs) by the Ministry of Electronics and Information Technology (MeitY). While the guiding principles of NODEs given in it are fairly exhaustive, a few suggestions on some of them are noteworthy in the context of digital health ecosystem. These have been listed below.

Principle 1 – Open and interoperable: In order to make the UHI truly interoperable and open, universal technical standards would require to be framed for HSPs and EUAs. These must be based on Fair Reasonable and Non-Discriminatory (FRAND) monetary and non-monetary terms. These should ensure respect for Intellectual Property Rights (IPRs) also uphold principles of competition law and policy. A transparent, consultative and inclusive process must be adopted while framing them, in order to ensure that non-discriminatory access to all HSPs and EUAs, which will in turn ensure that there are no disproportionate benefits to select players.

Principle 4 – Security and privacy: Given that health data is considered as sensitive personal data, it may be prudent to wait for the enactment of the NPD framework, as well as the passage of the PDPB before allowing processing of health data emanating from the UHI initiative by any stakeholder.

Principle 15 – Grievance redress: Having a robust grievance redress mechanism for UHI is imperative, considering rampant digital illiteracy and inexperience of Indian users in using/employing digital tools and technology in their daily or professional life. Having a single window for grievance redress for UHI related services in may be considered to be more efficient than having individual redress contact points for different grievances, while at the back end the complaint may be forwarded to the relevant team, but the user must not be required to identify and approach relevant team. In case for health services related grievances, users may be pointed towards appropriate grievance redressal avenue.

Q3 The primary stakeholders in the UHI ecosystem are mentioned in section 3.3. While the list is more indicative than exhaustive, are there any other primary or secondary stakeholders that should be considered while building the interface? If yes, please outline their role in the UHI ecosystem.

The list of primary stakeholders mentioned in the paper, cover most of the notable stakeholders. However, the following stakeholders may also be listed in addition to them.

• • While ‘pharmacies’ mentioned in 3.3 may mean to include e-pharmacies as well, the same may be mentioned explicitly, given their rising importance and uptake in times of the Covid-19 pandemic. These also require special attention given the regulatory uncertainty faced by them. Hence, e-pharmacies may be identified as a primary stakeholder of UHI network.
  • One of the objectives of UHI is to ensure that only genuine doctors are able to participate in the UHI network. This would require verification of doctors, which may be done through a two-step authentication system, involving doctors as well as their associations, such as the Indian Medical Association (IMA), and other industry associations. These may therefore be identified as secondary stakeholders of the UHI network.

Q4 The proposed objectives of UHI and UHI Network have been detailed in sector 3.4. Please share your comments on the comprehensiveness of these objectives, methods to ensure these objectives are adhered to. Please comment if there are other objectives which must be included in section 3.4.

The NHI initiative appears to be focussing on health services availed by citizens in future. However, it has seemingly ignored the already availed medical consultations and tests, as well as presently consumed medications by consumers. Consumers should be encouraged to digitise and upload such medical history as well.

Secondly, another objective of the UHI could be to raise awareness amongst users on various issues such as debunking Covid-19 vaccine hesitance, prevalence of fake doctors in rural areas, precautions to be taken with respect to seasonal illnesses, important vaccines for children, nutritional needs of women and children etc. most importantly, there is a need for raising awareness amongst users on avenues for grievance redressal available to them, in case of service deficiency.

Q5 UHI will support a range of digital health services and is expected to evolve with time. How should the digital health services be phased in the upcoming versions of UHI?

The NHA may consider adopting a phased approach in implementing or launching the various envisaged services as a part of the UHI. The proposed phasing in this regard, along with the possible timelines, has been given below.

• • Phase 1 may focus upon fair discoverability and verification of entities. This stage would require compiling and creating an online database of HSPs, in a manner which conforms with principles of platform and HSP neutrality, and also ensures that only verified entities are onboarded on the UHI network. Appropriate filters for searching relevant HSPs may also need to be incorporated at this stage. Parallelly, HSPs may be requested to pursue the sandbox approach for seamless integration of their services with the UHI, for consumers. This phase may extend upto a year, from the finalisation of the UHI framework.
  • Phase 2 of the rollout may integrate HSP services with the UHI, in an interoperable and secure manner. This would include chasing objectives of enabling service fulfilment and financial settlements. It is expected that the Personal Data Protection Bill 2019 (PDPB), currently being deliberated upon by a Joint Parliamentary Committee (JPC) would be finalised and enacted by this time. This phase may last for six months, after Phase 1.
  • Phase 3 may delve into creating user feedback loop (ratings and comments on particular HSPs), and also creating consumer’s grievance redressal mechanism on the UHI network itself, so that consumers are not forced to get their grievances resolved offline after chasing individual HSPs. This phase may be implemented within a period of three months.

Q6 Have all incentives / disincentives for various stakeholders to participate been covered in chapter 4? If not, please provide the list and mention the role and description of the stakeholder.

The paper has already covered most of the disincentives for various stakeholders of the UHI. However, a few missed ones have been given below.

• • The paper acknowledges that UHI would be disruptive for existing End User Applications (EUAs). Accordingly, adequate provisions may need to be made to secure their existing investments made for raising awareness amongst users regarding their services.
  • HSPs may need to invest in technology led solutions for integrating their services and online platform with the UHI network, in an interoperable manner, for which adequate incentives may need to be made for them.

Q7 For the disincentives mentioned in chapter 4 and the ones provided as an answer to the question above, please provide details on possible mitigating measures that may be taken to minimize the impact of said disincentives.

In order to ensure that the disincentives for HSPs and EUAs do not outweigh the corresponding incentives emanating from the UHI initiative, the NHA may consider conducting a Cost-Benefit Analysis (CBA). This will ensure that the disincentives of participating in the UHI, would not outweigh its incentives.

Q8 In the proposed discovery model in section 5.1.3.1, EUAs are expected to present all responses returned by the Gateway to the user and allow the user to choose the HSP. Should any alternate models be allowed? If yes, provide details.

The service discovery component of the UHI should be available to users in real time, i.e., users should be able to browse and book consultation, tests and order medicines immediately, or at their convenience, instead of having to wait for HSPs to revert on their queries/requests. Furthermore, HSPs should not be encouraged to respond to general users’ requests (unless directed to them particularly), since it may result in information overload, and unnecessary disturbance to users. Accordingly, it is suggested that filters should be provided to users for them to themselves shortlist relevant HSPs based on certain associated parameters. This will enable user convenience by not adopting a multi-step process for service discovery.

Secondly, the paper on multiple instances has relied upon proximity as a major consideration for users choosing a particular HSP. For instance, it mentions discover the ‘closest’ lab, or ‘closest’ ambulance service. While this certainly could be an important parameter for choosing a particular HSP, it surely is not the only parameter. Users may also consider other parameters like quality, trust, price, among other parameters while choosing a particular HSP. Also, HSPs may be requested to mention the radius catered to by them, while uploading their service on the UHI network, so that only available HSPs may be shown to users. Accordingly, the NHA may consider refraining from over-emphasising on proximity as a parameter for choosing an HSP.

Q9 Are there any challenges to the proposed approach to pricing of services detailed in section 5.1.3.2? Please suggest other alternate pricing models that must be supported by the Gateway.

It is true that running the UHI would be resource intensive, and a mechanism for recovering its costs must be devised. However, adding UHI gateway charges over, would only increase the price of services for users. Such costs on users may be avoided to encourage adoption of the UHI, atleast for the initial few years. UHI may raise funds for its functioning through other means such as: seeking government support, selling advertisement space on UHI, imposing penalties on HSPs and EUAs in case of defaults or deficiency in services etc.

Q10 Are there any other areas that must be supported by the Gateway for service fulfilment in section 5.1.3.3? If yes, provide details.

While the UHI will not participate in service delivery, and rightly so, it may however, provide an avenue to users to seek any queries/clarifications they may have pre or post the service. This may include: any ambiguity in the prescription provided by the HSP, or clarification needed before/after any lab test etc. A chat box may be created for this purpose, which is integrated with respective HSPs.

Q11 Post-fulfilment, as described in section 5.1.3.5, covers ratings and grievances. Are there any other areas that must be supported by the Gateway for post service fulfilment in section 5.1.3.5? If yes, provide details.

As has been mentioned previously, raising awareness on grievance redressal avenues available to users must be undertaken by UHI. Accordingly, this may form a part of post service fulfilment grievance redressal, wherein appropriate information may be available to users, for pursuing any service-related grievances.

Q12 The proposed approach for allowing users to share ratings for the HSPs as well as EUAs has been laid out in 5.1.3.5. Please comment on the same and share any other approach that might be adopted.

It is suggested that only verified users of UHI may be allowed to rate HSPs and EUAs, i.e., only those users who have availed the services of the respective HSP and/or EUA should be allowed to provide ratings to them. Notably, many large e-commerce platforms have adopted such a model for user rating of different products purchased by them. Such ratings may be supplemented with publicly sourced ratings as mentioned in the paper. However, clear demarcations may need to be provided in such ratings, so as to inform the user of the different sources of ratings.

Q13 What approaches, other than the ones mentioned in chapter 6, should be considered for managing and governing the UHI gateway? Please provide details.

Section 6.1 of the paper provides for NDHM to appoint a committee of technical experts to design the initial UHI open protocols. However, no indication has been given as to the process to be followed for selecting its members, or the qualification of the possible members, or composition of the committee. Similarly, no guidance has been given with respect to inviting experts to form an expert consultation group. The following indicative procedure may be followed in this regard.

• • A document stating the procedure to be followed for selecting from possible candidates should be prepared.
  • The procedure must be fair, transparent and efficient.
  • Advertisements may be made informing the public about the vacancy and the procedure for selecting candidates to attract the attention of suitable candidates.
  • Candidates who have not applied may also be considered, after recording reasons for considering such candidates.
  • Selection procedure should be completed within ninety days of being commencement.

Notably, a detailed procedure to be followed for selecting members for a committee has been given in the draft Indian Financial Code.2 Inspiration may be taken from the same as well.

Furthermore, given that users will be the ultimate beneficiaries of the UHI network, it is imperative to take a bottom-up approach, instead of a top-down approach. Accordingly, one must understand a user perspective on product design, user friendliness, convenience etc. while building services linked to the UHI network. Undertaking user surveys would be useful in this regard.

Q14 What should the UHI Gateway charge in the initial few years of operation? How can this model evolve over time?

As has been mentioned previously, it may not be appropriate to burden users with UHI gateway charges, in the initial few years of its operation. Other modes of raising funds for the functioning of UHI may be explored.

3. Other Comments/ Suggestions

Apart from the responses to the questions posed by the paper, given below are a few specific suggestions, as well as broad comments.

3.1 Specific suggestions

Given below are certain section-specific suggestions on the paper.

Section 5.2.1: Patient experience

Patients have been empowered to receive online prescriptions from doctors. It has been observed, that in many instances doctors provide hand-written prescriptions to patients, which are not always legible. Accordingly, use of typed prescriptions may be encouraged/mandated.

Section 3.5: Trust and privacy in UHI and UHI network

Aggregated and anonymised data may be made available to the policy makers and programme managers to ensure more informed decision making by the Government. It is to be noted that India lacks a Non-Personal Data (NPD) governance framework.

Furthermore, the section also relates to privacy and protecting personal data. While it mentions that the UHI protocols will be built on the principle of privacy by design, it is to be noted that the country currently awaits a dedicated personal data protection law. UHI also envisages to build health bots for consumers, which would have access to their personal data.

Given that health data is considered as sensitive personal data, it may be prudent to wait for the enactment of the NPD framework, as well as the passage of the PDPB before allowing processing of health data emanating from the UHI initiative by any stakeholder.

Section 6.3: Onboarding of participants

While it lays down efforts for onboarding public and private HSPs and EUAs, it misses out on creating a roadmap for encouraging users to start availing the UHI network. A robust plan must be prepared for raising awareness amongst users, as well as building their capacity to use the UHI network upto its full potential.

3.2 Broad comments

Apart from the specific suggestions given above, NHA is urged to also consider the following broad comments while finalising the UHI framework.

On-ground implementation

No matter how noble the proposed UHI initiative appears on paper, it will only bare fruit, if it is complemented by in-spirit on-ground implementation. This will require the following, among other steps.

• • Skill development: This is not only necessary for technology development and maintenance, but also for public and private HSPs and EUAs to hand hold them in integrating their services with the UHI network. Also, users of the UHI network would need basic skill development with respect to digital literacy to enable them to avail the digital health services.
  • Enhancing cyber-security: India has been prone to numerous cyber-attacks, and has witnessed many government owned digital assets being attacked. Significant investment in training, and developing security infrastructure may need to be made, in order to secure the UHI network.
  • Infrastructure and connectivity constraints will also need to be addressed to increase reliance on digital systems. This may require special attention in rural areas, for rural users to gain access to digital health services.

Encourage e-clinics

E-clinics are known to have enabled access to essential primary healthcare services to the presently underserved populace. They have begun gaining popularity and acceptance among rural users, becoming a low-cost and effective alternate mode of providing primary healthcare services in remote locations. E-clinics, therefore have the potential to accelerate the efforts of moving towards achieving the objectives of United Nations (UN) Sustainable Development Goal (SDG) 3 on ‘Good Health and Well-Being’.

However, e-clinics in India face various challenges, such as: lack of adequate physical and digital infrastructure, trust deficits amongst users, inadequate government support, unsupportive regulations, human resource constraints, ack of skills among first time or new users, low level of awareness among potential users, among others. Accordingly, there is a need to overcome such challenges, to promote the uptake of e-clinics.

Optimal regulation of e-pharmacies

The role and importance of e-pharmacies, especially in times of the Covid-19 pandemic is well documented.5 However, the industry is trapped in a regulatory bottle, unable to grow upto its true potential. They key issue requiring to be addressed is the existing regulatory uncertainty in defining/promoting e-pharmacies. Prevailing laws such as the Drugs and Cosmetics Act, 1940, Pharmacy Act, 1948, Information Technology Act, 2000, Drugs and Cosmetics Rules, 1945, have not defined regulations for online sale and monitoring of pharmaceutical medicines adequately.

While the government had proposed certain amendments to the Drugs and Cosmetics Rules, 1945, for defining/regulating e-pharmacies in August 2018; However, those are yet to see the light of day.6 The absence of clear rules pertaining to e-pharmacies in India, has fuelled legal battles on the validity of operating e-pharmacies in the country. Accordingly, it becomes imperative for the government to notify the proposed amendments to the Drugs and Cosmetics Rules, 1945, as a first step towards unleash the potential of e-pharmacies in India.

4. Conclusion

As has been discussed above, there is substantial scope for improving the UHI, as a building block of the NDHE. NCL looks forward to DoCA considering and adopting the recommendations given above.