Unique Health Identification and Aadhar: A case for mandatory linkage

All India Institute of Medical Sciences (AIIMS) has requested the Ministry of Health for a mandatory linkage between Unique Health Identification (UHID) and Aadhar. This seems like a simple and a straightforward suggestion but deep down it has major implications for delivery and democratisation of healthcare. I would argue that this linkage should be mandatory for all hospitals, both public and private primarily because it empowers the patients to have access to their own medical records.

As part of the digital initiative, AIIMS issues a UHID to each patient, who visits the hospital for the first time. In subsequent visits the patient is expected to reproduce this number. The UHID plays an instrumental role in documenting the patients entire journey in the hospital. With this it is possible to track, the date and time of the patient visit, the departments where the treatment was offered, the tests and the sub-tests that were undertaken and their results, if the patient was admitted (in-patient) then date and time of the ward in which the patient was admitted, the procedures performed, date and time of discharge, the release description (such as cured, expired etc.) and the diseases codes. Within AIIMS, availability of this data helps the doctor to develop a more accurate medical history of the patient. Also, this significantly reduces the burden on the patient to either produce past medical records or recall all the necessary treatments or procedures done. This has significant impact on quality of care by reducing the risks of medical errors and negligence, better patient management, avoiding unnecessary investigations, etc. In practice, however, there are many patients that are either unable to produce records of their previous visits to the hospital or do not recall the UHID number, as a result of which a new UHID is issued and in the process, precious medical history of the patient is lost. Aadhar has a potential to resolve this issue. Aadhar is a nation-wide unique identification which is used for multiple purposes, therefore, significantly easier for patient to reproduce and if this is linked to the UHID then it is much easier for the doctors to access the medical history without putting any burden on the patient. Moreover, the patient has cheap and reliable access to his own medical records.

A medical record is the property of the patient and just like any property its value depends on proper identification, accurate documentation, easy transferability and the rights to access it. If all hospitals UHID are linked to Aadhar then it has the potential to create a universal health records for the patient. With Aadhar the patient can request the hospital to transfer his medical records to his digital locker which he can access from anywhere at any time. This will lead to democratisation of healthcare delivery.

Let me illustrate this with an example. Consider a patient from a village in Bihar who is visiting a district hospital for an ailment. Under the Digital India initiative, the District Hospitals are expected to maintain a Hospital Management Information System (HMIS) that records the details of patient visits, disease, treatment offered and outcomes (cured, referred, expired, etc.).  If this information was linked to the patients Aadhar, then this could potentially be stored in the patient’s digital locker. Now suppose the patient is referred to a tertiary healthcare such as AIIMS (more than 50 percent patients in AIIMS come from UP and Bihar). With easy access to the digital locker at any time, the patient can transfer all the past medical information to the doctor in AIIMS who will have a far more accurate medical picture than a scenario in which he has to rely only on the testimony and the records of the patient. Such a portability of medical records has significant impact on the quality of care that the patient receives by reducing the risks of medical errors and negligence, better patient management, avoiding unnecessary investigations, etc.

Perhaps in the future it would be possible to link all medical visits, from the primary health centres, community health centres, secondary hospitals to the tertiary care hospitals, to the Aadhar. This will help in the development a comprehensive health record of the patient that is accessible anywhere at any time.

As a first step in the development of a comprehensive health record of the patient it is important that the government makes it mandatory for all the hospitals to link their UHID to Aadhar and give digital access to the patient to their own medical records which can be stored in the digital locker. To achieve this the government must take steps to ensure that basic data on each patient is collected in all hospitals:

1.     Date and time when the patient was admitted.

2.     Vitals of each patient: Weight, Height, BP, Hypertension, Diabetic.

3.     Disease code using the ICD-10 codes.

4.     Date and time stamp when the patient was discharged.

5.     Discharge outcome: Cured, Death, LAMA, etc.

In conclusion, linking UHID to Aadhar allows for the development of the comprehensive health records of the patients. It empowers the patient with the right to access his own medical records anywhere at any time. An important step in the democratisation of healthcare delivery.

Demonetization and its Behavioral Consequences: A Positve Welfare Impact

Demonetization has come as a shock to everybody. The main target of this shock therapy were people dealing with black money and terrorism, nevertheless, it has affected everybody. By and large people have questioned the implementation but very few have criticized the policy and its intention. However, I believe that it will have large behavioral consequences that could have a positive welfare impact. There is no doubt that such a drastic move is pushing people, primarily those in the informal economy, to open bank accounts and actively use them. This might seem trivial and transactional but it has behavioral consequences. Opening and actively using a bank account could potentially lead to behavioral shifts towards decline in wasteful expenditure and increase in savings. Research in behavioral economics has shown that most of us suffer from not taking the right (rational) actions even when we know what is the right thing to do (for example, we keep postponing our decisions to exercise), economist call this time inconsistent behavior. Savings behavior is also subjected to such time inconsistency. To be able to save requires discipline to curtail our present consumption, and save more for tomorrow. Research has also shown that such behavioral issues play an instrumental role in in explaining why people are poor. Fundamentally poor people lack the instruments and the discipline to save. One possible solution to this is to “nudge” people to take the right action, however, demonetization has gone one step ahead to “compel” people to open a bank account and actively use them for savings and expenditure.

Prior to demonetization I had conducted a survey of new age “taxi aggregators” drivers to understand why they were giving up a regular job at traditional taxi companies and joining these new companies for variable income. Though most of them were joining to make more money but they also valued the payment policy of these new companies. The drivers in these new companies are not paid in cash but every week money is deposited in their bank account. They said that this led to reductions in wasteful expenditure and also building a bank balance became a matter of pride. The drivers placed a high value on this and credited the new age companies for inculcating this discipline. Many of them believed that they were saving lot more than before when they were working in traditional taxi companies which paid in cash. What this highlights is that if informal workers were to rely more on banks as a method of receiving their wages and making payments, it then has the potential to resolve behavioral issues related to savings and consumption. Unfortunately, behavioral issues cannot be resolved easily, sometimes coercion is required to do the right thing.

Land Acquisition: The Clash of Ideologies – “Negative” Congress vs. “Positive” BJP

The political difference between Congress and BJP over land acquisition is fundamentally a clash of ideologies between two concepts of individual liberty: the negative liberty versus the positive liberty. (This is from an essay “Two Concepts of Liberty” by Isaiah Berlin (1958)). The notion of negative liberty refers to defence of the individual “freedom from” other individuals or the state. It consists in the “negative” aim of guarding the individual from interference, in particular, by the state. While the positive notion of individual liberty consists in the “positive” aim – the individual to be his own master or the “freedom to” do what one wills. These two concepts of individual liberty are ideologically very different and their clash is at the heart of the great political battle between the Congress and the BJP.

In 2013, the UPA government headed by the Congress party repealed the draconian Land Acquisition Act of 1894 by passing The Right to Fair Compensation and Transparency in Land Acquisition, Rehabilitation and Resettlement Act. The primary objective of the act was to defend individuals right to property and work from arbitrary invasion by the state. Through this act the Congress attempted to defend the “negative” notion of individual liberty. In essence the act made it extremely difficult for the government or the state to coercively or forcefully acquire individual property no matter how lofty or noble the purpose might be. The act introduced several impediments, such as, the “consent” clause where for private and for the PPP (public private partnerships) projects consent of 80% and 70%, respectively of the affected families, which included both the owners of the land and those working on the land, was required prior to acquisition. Moreover, the act also required a preliminary investigation of the social impact and the public purpose of the land acquisition. This would happen in consultation with local political representatives at the panchayat or the municipal level. Last but not the least the act repeatedly emphasises that in the event of land acquisition “the absolute bare minimum extent needed for the project” is acquired. The act was historical in defending the individual independence from interference by the state and it went far beyond the simple issue of increasing compensation. By adhering to defend the negative notion of individual liberty I refer to the congress as the “negative” congress.

In 2014, BJP came to power by promising governance, growth and development. According to the BJP poverty and backwardness are a big impediment to individual “freedom to” be the master of their own will. They fundamentally believe that every individual irrespective of their race, religion and creed is united in their aspiration to growth and progress and therefore, the single most important objective of the government is to create an enabling environment where every individual has a fair chance to grow, develop and progress. However, the ground reality might be very different. In particular what should the state do with those individuals who do not aspire to grow or are not willing to sacrifice their property for the larger national interest of growth and progress? It is in this context that one must view the amendments that BJP introduced. In essence the amendments makes it easier for the government to coercively acquire land for larger national interest by removing the consent clause and social impact assessment. The philosophical justification for this is that in case of those individuals, who voluntarily do not sacrifice their right to land and work for the larger national interest of growth and progress, are not fully aware of what it means to be free and therefore the state has the right to coerce such individuals to be free. This is precisely BJP’s defence – ad nauseam they have argued that the amendments are in national interest for growth and progress of poor people who are not fully aware of what it means to be free. BJPs primary argument, therefore, is that it is all right for some individual freedom to be sacrificed for more freedom in the future because if individuals voluntarily gave up their right to land and work for larger national interest then the issue of coercion and land acquisition would not arise. Therefore, in the context of land acquisition BJP is an adherent of “positive” notion of liberty, hence I refer to the BJP as the “positive” BJP. Broadly speaking BJP has taken a very similar stance of defending national interest by imposing draconian measures on the liberty of individuals or group of individuals, such as, by deplaning a Greenpeace activist, questioning or banning non government organisations (NGOs), or targeting civil right activists.

For adherents of “negative” notion of individual liberty, the “positive” notion of individual liberty merely represents a “specious disguise of brutal tyranny.” It is this clash of ideology between the negative and the positive notion of individual liberty that is at the heart of the political battle between the “negative” Congress and the “positive” BJP.

(Published in The Shillong Times on 16th May 2015)

In Defence of the Pursuit of Power

It is important to remind our self that the only driving force for a political leader is quest for power. There are no other higher ideals or purposes. This is the fundamental truth about leaders in any forms of government, whether it is a democracy, dictatorship or an authoritarian rule. However, there is a subtle but an important difference between a democracy and other forms of government. In a democracy it is the anonymous “unknown” citizens of the country who elect the political leaders while in other forms of government it is the select few “known” citizens. Therefore, a political leader in a democracy in order to acquire and retain power is compelled to cater to the needs of the public at large while in other forms of government a political leader only needs to cater to a select few, perhaps at the expense of large section of the society. An important implication of this is that a political leader in a democracy will have to be a relentless campaigner to woo the public to elect him to power. His foreign policy, socio-economic policy and national security policy will by and large be shaped by the demands of the public that will elect and re-elect him to power. If the campaign ends then so will the political life. The campaign must go on. Because it is this relentless campaign that connects the leader to the masses, it is this campaign that disciplines the leader to work in the interest of the public.

In a recent article Mr. P Chidambaram, a veteran Congress leader, candidly and critically mocked, that the Prime Minister Mr. Narendra Modi, unlike the prime ministers in the past, is always in “campaign mode”. Well there is an important lesson for the Congress party to be learnt here – to be relevant it will have to campaign.  In 2004 and 2009, relentless campaigning by the Congress party brought them to power and in 2014 the lack of it resulted in the worst ever defeat for the Congress party – it could not even muster enough seats to claim the leadership of the opposition. The lacklustre campaign in the recently concluded Delhi assembly elections is the single most important reason for the complete wipe out of the Congress party where 62 of its candidates lost their deposits. Had the Congress party lost due to lack of performance it would have been understandable but the truth is that it actually performed. In 1998 the Delhi infrastructure was crumbling, the economy was stagnant, life in general was old and sluggish but in 2013 there was a world-class metro, flyovers, local economy booming, life in general vibrant and young. For some inexplicable reason the Congress party did not feel a need to communicate this to the public.

When did the Congress party stop campaigning? I believe it happened with the anointment of Mr. Rahul Gandhi as the Vice President of the Congress Party on January 19^th, 2013. Rahul Gandhi’s summary rejection of the quest of power ended the Congress’s campaign. Perhaps not having to struggle for power led him to a naïve belief that he can be politically relevant without the quest for power. In his maiden speech as Vice President Rahul emotionally talked about what his mother told him “power that many people seek is poison” and “we should not chase power, but use it to empower others.” Rahul Gandhi was very sincere and genuine in what he said but unknowingly his childlike detachment from the quest of power took away the only reason to be a political leader. And without a political leader the Congress party did not have a campaign and, therefore, ceased to be relevant. Rahul Gandhi forgot the basic tenets of democracy - the only “antidote to power” in a democracy is that to get power one needs the consent of the people – and it is the seeking of this consent that “empowers voices”. Paradoxically, the political leaders in democracy who quest for power are more grounded in reality in terms of what people actually need while those who detach themselves from power live in a narrow, make belief world of what they think the people want. Such leaders, unfortunately, have a paternalistic approach to the betterment and empowerment of society and therefore, for good reasons are rejected by the people. This is precisely what happened to the Congress party in the recent Lok Sabha elections.

Well for the sake of Indian democracy it is extremely important that the Congress party is revived. The disciplining mechanism of democracy is effective only if people have alternatives. Otherwise it is a matter of time before power corrupts and absolute power corrupts absolutely. The resurrection of the Congress party is in national interest and it can only happen if the animal spirits for quest of power are rekindled in the Congress leadership, particularly in Mr. Rahul Gandhi. In this regard there is a lot he can learn from his grandmother, Indira Gandhi, who had an unquenchable thirst for power. She derived her strength and power directly from the public and that made her a mass leader. She was on a perpetual campaign mode. In more recent times, Mr. Narendra Modi and Mr. Arvind Kejriwal have emerged as populist mass leaders, like Indira Gandhi, they have direct connect with the people, and the hunger and the drive to be in power, and so they campaign hard for it and the masses love and cheer them for it. Their politics of directly appealing to the anonymous “unknown” citizens to get power is a refreshing change from the “(a)dharma” of coalition politics of more recent times where only a few “known” elected representatives are appeased to retain power. For the sake of democracy the Congress party must rise to the new era of mass politics and it needs to remind itself that the quest for power is the only driving force for political survival.

(Published in the Hindu February 22nd, 2015: http://www.thehindu.com/opinion/op-ed/comment-in-defence-of-the-pursuit-of-power/article6917332.ece)