One UID, One EHR: Beyond cash transfers, LPG and vote bank politics

Is nuance dead? Do we live in the time of binary debates?

While reporting for the UIDAI story in Forbes India less than a fortnight ago and now looking at the reactions to the story, mostly on Twitter, it seems as a society we are fast losing our taste for nuances. In general, people look at Aadhaar with a black or white lens. As in climate change, GM crops, or as my colleague Rohin Dharmakumar says the birth control debate in the US, issues where people make up their mind about which side of the debate they want to be in and then process information to perpetuate that point of view, Aadhaar has fallen into that category.

When the story How Nandan Nilekani took Aadhaar past the Tipping Point went live on the website, some readers even accused us of “propaganda”.

Propaganda, really? Our editor tweeted on Tuesday: “Am not a fan of Aadhaar, but the Forbes India article shows how Nandan Nilekani overcame the system to get his way on UID.” Then there were four of us reporting on it. What propaganda are people talking about? We went looking for truth and we’ve written what we found.

Just like most innovations, Aadhaar implementation is messy on the ground. To cite just one example, as of August 2013, in one of the pilot districts in Rajasthan, less than 20-25 percent of direct bank transfers for various programmes were happening through Aadhaar seeding. If in some places scanning devices are not present, in others existing devices don’t work. Limited access to bank is a pullback too. In the bargain, a lot of people are given a run around. “The system will be dumped as far as cash transfers are concerned; it might work to track train and airline travelers and bank transactions etc,” says Nikhil Dey of NCPRI, a vocal critic of Aadhaar.

What services will Aadhaar be used for is the real thing, now as well as in future. Yet people are confusing the platform for the end product/service. Ashish Rajadhyaksha, a fellow at the Centre for the Study of Culture and Society in Bangalore, who has recently published a book In the Wake of Aadhaar after extensive research in eight Indian states, says there’s lot of confusion in the minds of people. Some think it’ll get them ration; others think it’ll grant them some kind of protection if they get caught in a legal suit.

His book argues that Aadhaar is just a cog, at best a huge cog, in the giant wheel of digital governance in India. He thinks the benevolent, democratic idea of Aadhaar will eventually be shaped by the service (and the ideology of its provider) that is mounted on it. And there lies the caveat. He cites the example of microfinance crisis in Andhra Pradesh. After the MFI Bill of 2010, when the state government cracked down on MFIs in the state, it is now working to establish banking correspondents by primarily using Aadhaar. “It is by no means clear that this will lead to any change in the sort of chronic indebtedness that the MFI explosion had created across several regions of the state,” says Rajadhyaksha.

He raises a valid point but Aadhaar was never meant to be the message; it is the messenger and, as wisdom says, you don’t shoot the messenger if you don’t like the message. Even the cash transfer debate has taken the tone that it has because politicians started to take credit for it even before it was sufficiently widely rolled out and its implementation adequately evaluated.

But going beyond the vote bank politics, there’s one use-case in healthcare which nobody is talking about publicly. (It’s understandable. When time is short and maximum bang for the buck has to be made, why waste time in healthcare where results will show only over time.)

Assuming that the data protection policy comes into effect soon, by linking each UID number to a person’s electronic health record (EHR), India can leapfrog health management. Nobody in India maintains EHR worth its name. However, two months ago the Union health ministry approved the national EHR standards. The idea is to have a country-wide rollout of EHR for all government hospitals. Private hospitals follow some minimal record keeping but most of them don’t lodge patients’ medical records and none provides an EHR which a patient can access remotely. With UID database residing in the cloud, even a rudimentary EHR linked to it and stored in the cloud along with critical information, say, about blood group, allergies, chronic illness, long term medication, etc, can go a long way not only in better healthcare delivery but even gathering epidemiological data.

The Centre for Development of Advanced Computing (C-DAC) in Noida has built a hospital information management system which can be seamlessly linked to UID. In states like Rajasthan and Maharashtra, where the state govt is rolling C-DAC’s HMIS, it is already linked to the UID database. Even if the UID number is not available (forgotten or lost), the HMIS can retrieve the UID number using the patients’ biometrics. Keeping privacy concerns in mind, says executive director BK Murthy, the management system is designed to give roll-based access at every level and no data can be shared without the patient’s and doctor’s consent.

Once the data protection policy is in place, which qualifies what patient rights are, more private companies in healthcare and IT will come forward to implement EHR. Vijaya Verma, founder and chief executive of Yos Technologies, which among other things provides IT solutions connecting care providers and patients, says “privacy is not a big deal” for patients today. Patients don’t get it and they sign the consent form even without reading it which ensures that we have the consent but it’s not informed consent, she says. Yos provides electronic medical records to hospitals (to be kept within the hospital) and electronic health records to patients (to be accessible over the cloud) which includes discharge summaries and prescription data.

Verma believes once the National Identification Bill is passed and the data policy comes into effect, UIDAI should use its permanent enrollment centres to update Aadhaar by adding some basic health data about individuals.

But that maybe too ambitious, both in terms of saddling UIDAI with additional work and exacerbating privacy concerns.

I’ve argued earlier why healthcare is not on the election agenda of Indian politicians but I hope the UIDAI and the rest of the bureaucracy find a compelling use-case in EHR.