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IT for Change warns that proposed interface under NDHM might establish oligopoly in digital health

ITfC drew comparisons with the current UPI ecosystem to make a key point about the government’s proposed health interface.

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“..Unrestricted access to the UHI may also have adverse effects on the digital healthcare market, potentially enabling its dominance by a few market players,” Bengaluru-based IT for Change (ITfC) said in its submission to the National Health Authority (NHA) on the proposed Unified Health Interface (UHI). This quote largely formed the premise of ITfC’s submission regarding the NHA’s consultation paper on UHI.

The NHA proposed the UHI on July 23, inviting comments from stakeholders on what would form the second-last layer of the National Digital Health Mission – the Indian government’s attempt at creating a digital health ecosystem. The proposed UHI decides how digital health services will be integrated with the NDHM – including how NDHM data will be accessed by healthcare service providers while ensuring quality control. 

In its submission, ITfC raised privacy concerns and concerns that the UHI might potentially lead to an oligopoly in healthcare, based on the current situation in the similarly-designed Unified Payment’s Interface (UPI).

ITfC’s submissions to the NHA

1. On the Open Network Approach

The NHA proposed that an Open Network Protocol could be used for dispensing digital health services that are based on shared technical standards which will allow healthcare service providers as well as patients to use one platform. 

What ITfC said:

In response to the NHA’s question on benefits and risks foreseen in an open network protocol/approach to UHI, the ITfC drew comparisons with the UPI ecosystem, from which the NHA has self-admittedly drawn design inspiration.

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“In the case of the UHI, a similar scenario is likely to play out in the absence of clear rules of access. Moreover, the problem may be exacerbated by the significant value offered by healthcare platforms and the projected long-term growth of digital healthcare” — ITfC

To prevent such an oligopoly from capturing the market share, ITfC recommended:

Pre-emptive market share caps like in UPI: Apps on the UHI should be allowed to expand their market share only up to a certain level.

FDI regulations: ITfC called for FDI caps and additional scrutiny for foreign players building upon the NDHM to prevent private capital monopolising ‘publicly provisioned network infrastructure’.

Data Access conditionality: Under this, technology service providers involved in the UHI need to share certain high-value data sets they collect, in line with the recommendations of the Expert Committee on Non-Personal Data constituted by the Ministry of Electronics and Information Technology (MeitY).

Rules for developing apps on UHI: For certain health services, it should be required that private sector players apply in partnership with a public entity and be subject to technology transfer conditionalities after a certain number of years.

2. Pricing

The NHA proposed a three-part pricing mechanism: Health Service Provider (HSP) price for service + UHI Gateway charges (if any) + End-User Application (EUA) service charges. It also said that in the long run, it could consider charging HSPs or EUAs for access to the UHI.

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What ITfC said:

The NGO raised the issue that the proposed charge on health service providers for access to the UHI Gateway as well as the proposed pricing mechanism could –

  • Prohibit not-for-profits and public sector entities from delivering services on the platform – this could further decrease the options available for marginalised communities and community health workers.
  • Push the costs over to the consumers making healthcare more expensive.
  • Promote monopolisation by large or international technology companies – this is because they can absorb costs, even offer discounts as they did in the case of cashback in UPI.

To counter these impacts, IFtC recommended:

Tiered-pricing model: This would provide access to the UHI gateway, however, it will exempt non-profit and public sector agencies from usage costs. 

Differentiated prices: ITfC recommended different prices for smaller private platforms and large, dominant platforms.

3. UHI Gateway

The NHA proposed that the NDHM will manage a UHI gateway that service providers can use to link up with the rest of the health ecosystem to deliver services. Initially, one gateway will be operational and once the initial stages are completed, scaling to multiple gateways will be considered.

What ITfC said:

ITfC cautioned against the creation of multiple UHI gateways, saying that this could lead to the creation of a digital health infrastructure beyond the oversight of the government, and without the accompanying transparency requirements. According to them, this would make it difficult to regulate overpricing or other exclusionary practices that may affect citizens adversely if an alternate digital infrastructure were to achieve dominance in the field.

Further, they pointed to a recent representation ITfC had made along with other civil society organisations against the NUE (New Umbrella Entity) license being granted to Amazon. This representation said that “infrastructures are one of society’s richest mines of data, and access of MNCs to such a data mine would compromise India’s data sovereignty”. An NUE could be similar to a potential UHI with multiple gateways.

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ITfC recommended:

No multiple gateways for now: UHI gateway remains under the government’s oversight. Any future expansion to multiple gateways should be considered after taking into account lessons learned from operating the ecosystem over a duration of time.

4. Privacy

On data sharing, the NHA proposed that the UHI network will not have access to which HSPs and patients had consultations, and said that the system will have a rating system and will share aggregated data for policy-making and research.

What ITfC said:

On aggregated data use and personal data protection: ITfC said that it is unclear how personal data protection will extend to re-use and subsequent processing of aggregate data generated through the usage of the applications developed on top of the UHI.

Granular consent: ITfC said that is vital for the UHI to support fine-grained models of health data representation that will allow a patient to provide informed consent at granular levels from within coarse health records.

Mandatory name disclosure in rating system: The NHA had said that mandatory disclosure of names may be included in the rating system proposed for health service providers on the interface. ITfC said that this could raise the possibility of retaliation to a reviewer negatively impacting their experience on the system and could potentially allow aspects of patient data to be inferred, such as their locality of residence and/or socio-economic attributes.

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ITfC recommended:

Implementing data protection guidelines: Pending personal data protection bill be implemented before the designing of the UHI and meanwhile, in the interim, the NHA should come out with personal data protection guidelines for the UHI network ecosystem.

What ITfC didn’t say anything on

ITfC in its submission responded to 6 out of 15 questions in the NHA’s consultation paper, and while it is unclear why it did not respond to the rest, here are all the other questions:

1. The NHA asked if there were any changes needed to the guidelines to ensure the adoption of telemedicine and e-pharmacy.

2. 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.

3. The NHA asked if the listed UHI objectives were comprehensive enough, if there should be any other objectives added, as well as for methods to ensure these objectives are adhered to.

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4. UHI will support a range of digital health services and is expected to evolve with time. What digital health services should the initial version of UHI focus on?

5. 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?

6. Whether all incentives/disincentives for various stakeholders were covered or not and if not a list of those not covered with a mention of the role and description of the stakeholder?

7. 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.

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

9. 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 fulfillment in section 5.1.3.5? If yes, provide details.

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The consultation process so far

The UHI is just one of many layers in the NDHM.  So far, the NHA has conducted consultations on the Health Professionals RegistryHealth Facility RegistryNDHM draft implementation strategy, NDHM blueprint, data policysandbox framework guidelines, and others.

In July, it held public consultation meetings on the Health Professionals Registry and  Health Facility Registry. It had conducted consultations on the draft implementation strategy and Health Data Policy consultation last year as well and is expected to release multiple other documents for further consultation.

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Written By

I cover health and education technology for MediaNama. Reach me at anushka@medianama.com

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