Introduction

With the rapid spread of the Coronavirus and the growing population, monitoring public health is a herculean task for governments worldwide, opening avenues for information technology-based solutions within the health space. Thus, the public health sector requires the aid of information technology, now more than ever. Given the burden on public healthcare around the globe, digital health data has ensured timely tracking of the spread of the COVID-19 pandemic.¹ Most nations have already initiated digitising medical records.  However, there is yet room for further collaboration of public healthcare systems and information technology that remains unexplored in certain countries.

Taiwan has been lauded worldwide for its management of the first wave of the COVID-19 pandemic with robust digital democracy, ensuring participatory governance. The nation saw its first case as early as January 2020 and measures were put in place to monitor and screen visitors coming to Taiwan.2 This effective preparedness of Taiwan was evident from their policies that utilise present digital health infrastructure and moulding it to combat the COVID-19 crisis.  

Digitised health infrastructure of Taiwan

One of the four Asian Tigers with about 23 million citizens, Taiwan boasts of a robust government ministered insurance-based healthcare mechanism.3 To improve the efficiency of several small healthcare schemes and bring them under a singular umbrella, the government introduced the National Healthcare Insurance system (NHI) in 1995, providing health coverage nationwide and using digital media to support its health infrastructure.  In 2017, Taiwan spent $37.5 billion USD on healthcare, accounting for 6.4 per cent of the GDP, out of which 53.7 per cent was dedicated to NHI.4 To access the benefits under the NHI, every citizen is provided with an NHI IC card (integrated circuit smart card), which is used to identify the person, store a brief medical history, and bill the national insurer.  Another aspect of the digitised healthcare system in Taiwan is MediCloud.5 It started as PharmaCloud in 2013 and was renamed NHI MediCloud. This patient-centric information system allows healthcare workers to access patient data regarding tests ranging from X-ray imagery to ultrasounds.6 The NHI Card provides this system with real-time information to track the patient records and progress whenever necessary.7

The critical components of the healthcare system are the National Health Command Center (NHCC) and Central Epidemic Command Center (CECC), which played a crucial role in the COVID-19 pandemic. The NHCC, with its information exchange mechanism that surveys and exchanges real-time data from all health-related and media databases with each other, allows it to monitor national health emergencies at all times and facilitate quick action.8

Response to the Pandemic

With a robust healthcare infrastructure in place and the experience of dealing with epidemics such as SARS in 2003 and H1N1 in 2009, Taiwan was better positioned to tackle a public health emergency that came its way, even the deadly COVID-19 pandemic. The nation was the first to warn WHO on December 31, 2019, and mobilise experts against COVID-19 on January 5, 2020.9

Taiwan deployed the policy of contact tracing, testing, and monitoring patients using an information-based health system MediCloud integrated into the pandemic control system linking real-time data with immigration.10 This move was undertaken soon after the outbreak in Wuhan to monitor the constant influx of visitors to Taiwan from China. It enabled all health providers to access patients’ travel history, occupation, contact history, and clustering at mass gatherings in real-time, leading to accurate health assessments.Assisting in precise testing and tracing instead of mass testing, a digital system like MediCloud enabled the government to use its resources effectively and meticulously. The laws governing the privacy of this collected data are specific and formulated so that violations of any individual medical regulations by health institutions carry a maximum fine of hundreds of millions of yuan.11 As a result, many hospitals have set up mechanisms to ensure they follow the law.12 Furthermore, a GPS-based information system, a collaboration of the CECC and mobile phone companies, called Intelligent Electronic Fences System (IEFS), was introduced to monitor and trace people in quarantine using their mobile phones.13

Open data dashboards were also being used to monitor the supply of masks in the pharmacies and grocery stores across the country. VTaiwan, a platform used for open discussions on policy formation, was extensively used to ensure real-time health policies were formulated by the government based on the inputs by the civil society. Agile response, information transparency, and targeted campaigns to tackle misinformation have ensured that the citizens actively participate in combating the pandemic. As a result, Taiwan reported a meagre 514 positive cases till September 30, 2020.14

India’s healthcare infrastructure

Healthcare has been the least invested sector in India, with a mere 1.8 per cent of the GDP spent on it in 2020-21.15 A mix of public and private healthcare service providers form the Indian healthcare system. Being the second-most populous country in the world with a population of 1.3 billion, the public healthcare infrastructure struggles to cater to the needs of the vast population. The concentration of healthcare services is very high in urban areas, with the dominance of private services in the health landscape. This leads to high out-of-the-pocket expenses for people.  To ensure affordable healthcare, the Rashtriya Swasthya Bima Yojana (RSBY) was launched in 2008 to cater to the health of Below Poverty Line (BPL) citizenry of the country and introduced the use of smart cards to utilise the benefits of the scheme and cashless transactions.16 In 2018, the RSBY was subsumed and relaunched as Ayushman Bharat.17

The National eHealth Authority (NeHA) was proposed to be set up in 2015 as a regulatory and standard-setting organisation in the Indian healthcare sector. The main objective of NeHA was the development and promotion of digital health services in India cost effectively and transparently.18 In the absence of a data protection policy, the plans of launching NeHA have been delayed.  

Indian Response

The pandemic has accelerated investment and innovation in healthcare infrastructure. For effective contact tracing, the government pioneered an app, Aarogya Setu, for contact tracing, which uses Bluetooth and GPS data for self-assessment of individuals for COVID-19 using a known infection database.19 Another app, CoWin, was launched as a prerequisite for COVID-19 vaccination to ensure systematic delivery of vaccination to the citizens, though now the mandate has been removed.  However, there have been instances where concerns regarding the data collection, safety, and privacy on the apps were raised by experts and civil society.20

Doctors provided telemedicine to patients suffering from mild cases of COVID-19. The National Digital Health Mission (NDHM) was launched in August 2020 to bring all healthcare stakeholders under one umbrella and ensure seamless health services.21  However, the mission is still in its pilot stage, and it would be too early to speculate on its success or failure in the absence of any data in the public domain. In the absence of a robust digital health policy framework, India had reported 63,10,267 positive cases till September 30, 2020.22

Conclusion

The innovation in the digitisation of the public health sector in India has been sporadic.  Technologies like AI and cloud-based supply chain management, among others, will help India effectively combat the pandemic. However, obstacles like digital illiteracy, misinformation, lack of trust in health services have to be tackled for the growth of digitized health facilities in India. Those factors have been instrumental in Taiwan’s fight and success against COVID-19. Such digitisation is supported by special personal data protection laws being put into force.23

On the other hand, with a data privacy policy gap and ambiguity in security measures, the privacy issues continue to create a lack for applications like Aarogya Setu.24 The Personal Data Protection Bill, 2019, includes the health data under sensitive personal data. Issues like lack of judicial representation in the Data Protection Authority to raising the cost of compliance for start-ups have resulted in the bill being pending for around three years. A clear data protection policy that ensures data safety is the need of the hour, in the absence of which any attempt to use information technology is futile. These steps will go a long way to build a resilient digital healthcare ecosystem in India.  

(This article was written by Sanjana Kulkarni & Ruchita Tamgadge under guidance of Dr. Swapna Jambhekar, CPPR Research Consultant)

Image Courtesy: analyticsijndiamag.com

References : 

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Aarogya Setu’s 6 Major Privacy Issues Explained. (2020, May 12). HuffPost. https://www.huffingtonpost.in/entry/aarogya-setu-app-privacy-issues_in_5eb26c9fc5b66d3bfcddd82f

Views expressed by the author are personal and need not reflect or represent the views of Centre for Public Policy Research.

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