With Covid-19 cases in India crossing the 3 million mark on Saturday, scaling up the digital health ecosystem to improve access and quality of care is as critical as strengthening systems to optimize healthcare delivery.

“India’s response strategy remains the same. Our focus is on trying to bring down mortality to less than 1%. To do that, we will continue with… the test, trace, track and treat strategy and an aggressive vaccination strategy to prevent infection…,” said Union health minister Harsh Vardhan.

Experts agree that India’s case count is bound to increase over the next few months, given its 1.3 billion population, and the way forward remains diagnosis, containment, and treatment. “No new response is needed beyond trace, test, isolate and treat [strategy],” said Dr Anurag Agrawal, director, Council of Scientific and Industrial Research- Institute of Genomics and Integrative Biology.

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The health system strengthening as part of India’s Covid-19 response will be further boosted by the National Digital Health Mission (NDHM) announced by Prime Minister Narendra Modi on Independence Day. Pilots have rolled out in the Union Territories of Chandigarh, Ladakh, Dadra and Nagar Haveli and Daman and Diu, Puducherry, Andaman & Nicobar Islands and Lakshadweep.

“The NDHM aims to create a digital health ecosystem that encompasses private and public health systems to deliver improved healthcare services across the country in a highly inclusive, equitable, and secure manner. The systems built are completely digital, patient-friendly, and totally interoperable,” said Vardhan.

The four key components of NDHM are national health identity, personal health records, Digi-Doctor, and health facility registry. “Every Indian who wishes to participate has to create a unique Health ID, which will be valid across states, hospitals, diagnostic laboratories, and pharmacies, and will be linked for seamless flow of health information. All digital health records issued will be automatically-linked to the respective Health IDs,” he said.

Health records, both legacy and new, will be accessible electronically only with the consent of the patient. This framework will create a longitudinal health track of every patient to assist the clinician in decision-making and give patients access and control of their health data.

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In a move to increase access, transparency, and accountability, the system has the Digi-Doctor option. The option allows doctors from modern and AYUSH systems of medicine from across the country to register, get authenticated, share data on a web portal, and to write prescriptions with digital signatures.

NDHM will next be scaled up to take e-pharmacy and telemedicine services to all states.

The health facility registry component in NDHM will be a certified and standardised repository of all health facilities in the country, including hospitals, medical colleges, diagnostic labs, pharmacies, and health and wellness centres to ensure the quality of care through regular audits, tracking outcomes and collecting feedback.

“The registry will be centrally maintained, and will store and facilitate the exchange of standardized data of both public and private health facilities in the country,” said Vardhan.

“All products have been built with the highest standards of security checks. The applications are hosted on a highly secure Government Community Cloud. Access to the cloud is restricted with permissions, and an advanced level of security is implemented. All applications, as well as infrastructure, go through rigorous security audit before utilization over the public domain,” said Vardhan.

Additionally, individuals can choose where to keep their data. “There is no mandate to keep data on Government servers only,” said Vardhan. Patients also have the option of choosing the time period for which they want to grant consent.

NDHM will take India another step closer to universal health care. India’s public health expenditure is 1.28% of its GDP, with per capita public health expenditure being ~1,657 in 2017-18. For people living in rural areas completely dependent on government hospitals and clinics, the government allopathic doctor-patient ratio is 1:10,926, according to the National Health Profile 2019, leading to inequities in access.

Mainstreaming digital health and telemedicine is the most transformative in healthcare delivery post-Covid-19, but it cannot replace a strong primary health system and connectivity. For that, we need motivated healthcare workers and an enabling infrastructure, which must be equally high on the government’s priority list.