Social audits can encourage community participation, reduce instances of exclusion, and encourage the adoption of digital health services
Representational image. AP
On 27 September 2021, the Central government launched the Ayushman Bharat Digital Mission (ABDM) to enable digitisation of medical records, which patients can then access on their smartphones. It will allow Indians to control the flow of their health data and share it with doctors, insurance companies, or fitness apps. The latter can then use it to create new products and services that improve health outcomes.
Setting up and scaling an integrated health care system is likely to be a decade-long project, if not a multi-decade one. The vast majority of hospitals and health facilities are not digitised, and many that have some digital capacity are not digitised end-to-end. In addition, most people are not enrolled in ABDM yet. Even if they wanted to be, the digital nature of the project means that many without internet connectivity and smartphone access risk being underserved. Moreover, individual consent may not truly be meaningful considering widespread illiteracy.
How we reconcile these ground realities of India with the bold digital vision of ABDM will determine the future of our healthcare system. One such complex issue is the accuracy of health records – better records avoid last-mile exclusion, enable meaningful innovation, and ensure that the database is real-time and robust. While doctors and other healthcare professionals can be trained appropriately, this will likely be a herculean task in a sector that is highly decentralised and expansive.
Therefore, continuous auditing is vital to ensure that the data is updated, accurate and devoid of any errors.
The ABDM’s first draft of the Health Data Management Policy (‘HDMP’) already has some provisions for this. For example, Section 24 of the HDMP provides for health facility auditors ‘to verify that the services offered by the health facility are the same as claimed by such facility during the registration process, and that such health facility is operational at the time of its listing and is located at the address as claimed by such health facility.’ The latest version of the HDMP also discussed the need for implementing independent audit mechanisms. Moreover, the ABDM’s documents suggest that health practitioners and facilities could be made open for user reviews.
A third path that lies somewhere is between formal auditors and user feedback. Social audits were first developed as a mechanism to uphold accountability in government schemes and evaluate whether ground realities matched with findings published by the government. They are most commonly conducted at the local levels of governance, such as the gram panchayats. The community collects primary data (i.e., data provided by stakeholders) and secondary data (i.e., data provided by the government) to publish an ‘audit report’. The report compares the data ‘on the ground’ against the government data to provide a detailed analysis of the scheme’s shortcomings, areas that need improvement, identifying successful models that can be applied elsewhere, etc. The audit report is made public to encourage people to participate in local governance and to enhance transparency.
Social audits are now an essential part of many regulators’ toolkits, considering the low health budget and the massive population it is spread across. In April 2017, for example, Meghalaya passed the Meghalaya Community Participation and Public Services Social Audit Act, which is, by all accounts, enjoying public participation and results. Social audits were also used as part of the National AIDS Control Organisation (NACO) in achieving a massive reduction in HIV-AIDS cases across India in record time. They are used every day as part of MGNREGA as well.
More importantly, however, social audits mobilise people on the ground and spread awareness about the benefits of digitisation of healthcare. They make communities part of the journey towards progress and leverage their proximity to issues in a manner that an expert auditor can never accurately capture. To create a successful social audit framework, it must be institutionalised in the relevant ministry.
Encouraging a more consultative process will also allow the audit report to publish directly actionable interventions, which will also help improve the systems through a feedback loop as the program is implemented. Communities can also use these reports to increase awareness regarding the ABDM and understand how the system works. Breaking information down into easily digestible formats will positively impact rates of adoption across communities.
Only when such community involvement becomes a part of the day-to-day workings of ABDM, will we truly unlock its transformative potential. When that happens, every Indian will not only become a user of the system, but its custodian and steward. It will match the boldness of our vision with the inclusivity of our approach.
The author is Founding Director, The Dialogue. Views are personal.
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