After using Aadhaar on a national scale in the public distribution system at rations shops, the central government now plans to use the biometrics-based Unique Identity system at health facilities from next year. But the scheme has thrown up questions about whether it will create more barriers to access healthcare to those who need it most.

In a significant remodeling of the public health system, Aadhaar numbers will be used as unique patient identifiers in a new electronic health records system, said officials from the Ministry of Health and Family Welfare. National identification numbers will be created and assigned to all health facilities, beginning with public facilities.

“When a patient goes to a health facility, they will be asked to provide their Aadhaar number and either verify themselves by placing their fingerprints on a device kept there, or do a one-time password authentication sent on mobile,” said Sunil Sharma, joint secretary in the health ministry. “Aadhaar authentication will allow the patients access to their own health records, which will be portable and accessible online.”

Sharma added that a procedure will be laid down for doctors and insurance providers to authorise use of health records in cases like accidents where a patient is unable to provide authorisation.

The ministry is already collecting Aadhaar numbers of patients and “seeding” or linking the unique identity numbers to patient records in a few states. It plans to begin implementing the new system by June 2017. Sharma said that if a person does not have an Aadhaar number, then alternate IDs such as ration card, voter identity card will be allowed in the interim.

“No one will be denied medical treatment,” he said.

Pilots in states

Ministry officials say that health records stored in information exchanges will reduce cost and duplication as well as inconvenience to patients when they consult more than one doctor. The electronic record will include previous medical history, procedures undergone, diagnosis, drugs prescribed, and which hospitals visited accessible on a cloud-based e-application.

The health ministry had notified Electronic Health Records standards for India in 2013, which were reviewed by an expert group in 2015. In May this year, the ministry put the revised standards up for public comment and consultation. According to this policy paper, the electronic health records will aim to provide a “summary of various clinical events in the life of a person”. In this system, the paper elaborates, Aadhaar will be the “preferred identifier” when available, but in the absence of an Aadhaar number, two other identities, “local Identifier (as per scheme used by health care service providers)", and any central or state government issued photo identity card numbers may be used.

Under the National Rural Health Mission of 2005, Health Management Information Systems(HMIS) have already been created in states. The new standards, the document notes, aim to facilitate “interoperability”, which means the ability of various systems to share, exchange, and interpret shared data.

The Aadhaar-based programme is being funded under National Health Mission. Following a circular issued by the health ministry, some states are in the process of setting up systems to collect Aadhaar data for patients undergoing treatment in National Health Mission schemes. These include immunisation, maternal health schemes, communicable and non-communicable diseases such as tuberculosis, diabetes, vector-borne diseases, mental health and others.

“We have identified facilities such as Patna Medical College, and a few district hospitals to start the programme,” said Dr Shashi Bhusan Kumar, director of the National Health Mission in Bihar. “We had a one-day training on October 7 for our district data entry operators. We plan to organise a workshop with National Informatics Centre for our staff.”

Kumar said that Aadhaar is currently not mandatory for registering under this system. "But we are emphasising that patients get it," he said. "We are organising camps for patients to register for Aadhaar.”

In Madhya Pradesh, the collection of Aadhaar data of those seeking medical care will be started on a pilot basis in two districts, according to Kiran Gopal, the state's National Health Mission director. “We plan to use Aadhaar as an identifier for the Anmol programme, focused on ante-natal care of pregnant women," he said. "In this, 16,000 auxiliiary nurse and midwives will have an e-tablet which will track the services for pregnant women.”

Dr Saransh Mitter, Chhattisgarh director of National Health Mission, said the state had not yet received any communication on the Electronic Health Record scheme from the centre. “In villages, internet connectivity, and lack of infrastructure will be an issue,” he said.

Besides state departments, Aadhaar data is also being collected for treatment in some national health programmes.

“We are encouraging people living with HIV who come to antiretroviral treatment centres to enroll in Aadhaar,” said Dr R S Gupta, who is deputy director general of the National Aids Control Organisation. “The ART centres will also help link patients who do not have Aadhaar to centers where they can register in Aadhaar.”

Barrier to access?

While the government policy document endorses the use of Aadhaar in the new Electronic Health Records system as an “empowering” tool for those seeking treatment, public health experts expressed concerns over the transition to the new system.

“Right now, the government is not able to set up a basic online transparent cross-facility referral system for free beds in private hospitals for economically weaker section patients who come to Delhi," said Dr Vandana Prasad, a pediatrician and national convener of Public Health Resources Network. "How are they going to create this state-of-the-art facility, from a village in Jharkhand to Delhi? Where are the funds going to come from?”

Prasad pointed out that despite a Health Management Information System being created in all states 10 years ago under the National Rural Health Mission, no proper system of referral existed within states. Basic data such as on births and deaths of infants and number and location of pregnant women was not maintained at district and village level because of shortage of staff and infrastructure.

"The main problem patients from economically poor sections face is not duplication, but lack of access to good quality health facilities," said Prasad. "They are sent from pillar to post without proper treatment, there are staff shortages and basic laboratory technicians are not hired. Most staff is contractualised, not paid on time, not trained. How will one Aadhaar number change all that?"

State officials who spoke to said that health departments planned to implement the new system with their existing staff working on collecting and entering data on Aadhaar numbers. This, though, may burden already short-staffed facilities.

As per health ministry data from 2014-'15 on health facilities in rural areas, which include public health centres, community health centres and sub-centres, there was a shortfall of 1.84 lakh staff of 4.92 sanctioned posts. That is a 37% shortage of health staff who are not doctors. These staff include auxiliary nurses and midwives, health workers, radiographers, laboratory technicians, pharmacists and nurses. Across India, 5,053 sub-centres or 3% of all facilities function without a auxiliary nurse and midwife or a health worker.

Health activists say infrastructure and staff should be provided for the transition to the new electronic records system to be smooth.

Prasad added that there was no problems with creating unique identifiers for patients per se, but it could lead to exclusion if it the identifier is made mandatory, creating a barrier to access. "In ration system too, the government started by saying Aadhaar is not mandatory but they have made it mandatory, despite Supreme Court orders that it cannot be made mandatory. They started by saying it is voluntary, then insist on it as mandatory saying their backend systems require it."

Other experts pointed out that currently, health systems do not require proof of identity from those seeking treatment and have documented instances where the need for identification had prevented the poor from getting medical aid.

Chhaya Pachauli, senior programme coordinator with Prayas Centre for Health Equity in Rajasthan cited a fact-finding report prepared by the organisation on the case of Phulmati Devi, a migrant brick kiln worker, who gave birth to twins on April 7 in Bardoli Char village in Bharatpur.

"On April 7, she visited the Khedali community health center in Alwar but was denied a tetanus injection because she was not able to produce a 'mamta card', which is given when a pregnant woman registers at a local health facility," said Pachauli. "On her way out from the center, Phulmati gave premature birth to twins on the road, and was denied care a second time just hours later at the Mahila Jila Chikitsalaya in Bharatpur despite an emergency-like situation because her husband Avdesh's Aadhaar card showed a Uttar Pradesh address."

Prayas has also documented several instances of exclusion from health services in Rajasthan's state health insurance scheme which requires enrolling in the "Bhamashah" scheme, a state-level database of beneficiaries built using Aadhaar database.

"The only condition of treatment should be if a patient is unwell and needs care," said Pachauli. "Targeting on the basis of proofs of identity makes it harder for people seeking treatment."

Aadhaar authentication failures

Public health activists also expressed concerns over evidence of exclusion of beneficiaries who faced Aadhaar authentication errors in other schemes such as the public distribution system.

In Andhra Pradesh, the first state to start using Aadhaar in ration system, government officials said Aadhaar authentication did not work for 4%-5% of all beneficiaries. But in Rajasthan, the second state to start use of Aadhaar authentication at all ration shops, principal secretary of food and civil supplies department has said that 63% of beneficiaries were able to collect their grains after Aadhaar authentication as per data from August.

"If 37% are being turned away when their fingerprints do not work on device, or there are data entry errors, or electricity and connectivity problems, the biometrics-based system is very error prone and leading to large scale exclusion and hassles for beneficiaries,” pointed out Dipa Sinha, a member of the National Alliance for Maternal Health and Human Rights. “In ration system, you can tell someone, 'come another day, your fingerprint authentication did not work today, or the electricity has failed,' but can you afford to do that at health facilities?”

Hanja Devi in Daulatpura in Masuda in Rajasthan's Ajmer is an elderly ration beneficiary for whom fingerprint authentication shows errors. Photo: Anumeha Yadav

Sinha pointed out that the evidence from Rajasthan, Jharkhand, Delhi also showed that the most vulnerable groups, such as the elderly and migrant workers who do manual labour, were also having the greatest difficulty in accessing benefits after biometric authentication.

“If biometrics cannot be collected for children below five in Aadhaar, and if elderly and migrant workers face frequent problems in fingerprint authentication, then biometrics is not the most appropriate technology for public health," she said. "The government should be looking at alternate technology too, such as smart cards, which already exist under Rashtriya Swastha Bima Yojana .”