Indian Healthcare System
Indian Healthcare System
Indian Healthcare System
Review
Special Issue
Privacy-Preserving Computing for Analytics and Mining
Edited by
Dr. Majeed Abdul
https://doi.org/10.3390/inventions6030045
inventions
Review
A Comprehensive Survey on Data Utility and Privacy: Taking
Indian Healthcare System as a Potential Case Study
Prathamesh Churi 1,2 , Ambika Pawar 1 and Antonio-José Moreno-Guerrero 3, *
1 Symbiosis Institute of Technology, Symbiosis International Deemed University, Pune 412115, India;
[email protected] (P.C.); [email protected] (A.P.)
2 School of Technology Management and Engineering, NMIMS University, Mumbai 400056, India
3 Department of Didactics and School Organization, University of Granada, 51001 Ceuta, Spain
* Correspondence: [email protected]
Abstract: Background: According to the renowned and Oscar award-winning American actor and film
director Marlon Brando, “privacy is not something that I am merely entitled to, it is an absolute
prerequisite.” Privacy threats and data breaches occur daily, and countries are mitigating the conse-
quences caused by privacy and data breaches. The Indian healthcare industry is one of the largest and
rapidly developing industry. Overall, healthcare management is changing from disease-centric into
patient-centric systems. Healthcare data analysis also plays a crucial role in healthcare management,
and the privacy of patient records must receive equal attention. Purpose: This paper mainly presents
the utility and privacy factors of the Indian healthcare data and discusses the utility aspect and pri-
vacy problems concerning Indian healthcare systems. It defines policies that reform Indian healthcare
systems. The case study of the NITI Aayog report is presented to explain how reformation occurs
in Indian healthcare systems. Findings: It is found that there have been numerous research studies
Citation: Churi, P.; Pawar, A.; conducted on Indian healthcare data across all dimensions; however, privacy problems in healthcare,
Moreno-Guerrero, A.-J. A specifically in India, are caused by prevalent complacency, culture, politics, budget limitations, large
Comprehensive Survey on Data population, and existing infrastructures. This paper reviews the Indian healthcare system and the
Utility and Privacy: Taking Indian applications that drive it. Additionally, the paper also maps that how privacy issues are happening
Healthcare System as a Potential Case in every healthcare sector in India. Originality/Value: To understand these factors and gain insights,
Study. Inventions 2021, 6, 45. https://
understanding Indian healthcare systems first is crucial. To the best of our knowledge, we found
doi.org/10.3390/inventions6030045
no recent papers that thoroughly reviewed the Indian healthcare system and its privacy issues.
The paper is original in terms of its overview of the healthcare system and privacy issues. Social
Academic Editors: Majeed Abdul and
Implications: Privacy has been the most ignored part of the Indian healthcare system. With India
Chien-Hung Liu
being a country with a population of 130 billion, much healthcare data are generated every day. The
Received: 13 May 2021 chances of data breaches and other privacy violations on such sensitive data cannot be avoided as
Accepted: 17 June 2021 they cause severe concerns for individuals. This paper segregates the healthcare system’s advances
Published: 23 June 2021 and lists the privacy that needs to be addressed first.
Publisher’s Note: MDPI stays neutral Keywords: healthcare; utility; privacy; Indian healthcare; hospitals; EHR; KPI; PDP bill; data
with regard to jurisdictional claims in breach; attacks
published maps and institutional affil-
iations.
1. Introduction
The healthcare industry is an emerging industry. In recent years, the healthcare
Copyright: © 2021 by the authors. industry in developing countries has grown rapidly. In the last few decades, considerable
Licensee MDPI, Basel, Switzerland. efforts have been taken to integrate information and communication technologies (ICT)
This article is an open access article into healthcare practices [1,2]. In E-healthcare, the latest technologies are integrated with
distributed under the terms and medical infrastructures, including continuous monitoring and transfer of health-related
conditions of the Creative Commons problems from the patient-centric environment to respective services providers [2–4]. The
Attribution (CC BY) license (https:// volume of the data generated in the healthcare industry is rapidly escalating. In healthcare,
creativecommons.org/licenses/by/
for highly accurate prediction and early diagnosis of diseases, we must increase healthcare
4.0/).
data utility with the help of various technologies such as machine learning, artificial
intelligence (AI), and data analysis.
According to IBM global business services’ executive report in 2012, the entire health-
care system is being moved from a disease-centric to a patient-centric environment [4,5].
Disease-centric healthcare systems have the following features (Figure 1):
1. The health data are centrally stored according to diseases (type, symptoms, and
remedial medicines).
2. Electronic health records (EHRs) are assessments and analyses conducted according
to diseases. For example, we can analyze the patient data of the past ten years in a
hospital with diabetes, malaria, or another joint disease.
3. Disease-centric databases present less scope for data analysis because they do not
focus on individual traits and symptoms. Some diseases are related to a person’s
behavior, lifestyle, and geographical location. For example, suppose a person is
treated for two or three similar diseases from different hospitals in the past ten years.
In that case, we must analyze his treatment records, family records, and habits, which
are unavailable in the disease-centric database or may be available in heterogeneous
databases, wherein a combined analysis is complex. Some data values are spread
across multiple datasets maintained separately by hospitals or may have incomplete
values, resulting in inappropriate/wrong prediction. The data quality is questionable
to be used for analysis.
role-based access control, and encryption, are used to hide data. According to [4], data
undergo different phases during its lifecycle: Data storage, transition, transfer, and process-
ing. Existing privacy-preserving techniques remain in the developing stages, and strong
privacy protection is still an open study topic.
With the advent of the technologies mentioned above presenting the problems of
maintaining data privacy, central questions that remain unaddressed in the healthcare
industry field are as follows [10]:
1. Can one pursue high data utility while maintaining acceptable privacy?
2. Because privacy concerns are different for different healthcare organizations, how is
the trade-off between privacy protection and data utility balanced for computing?
Figure 2 illustrates the trade-off between data utility and privacy. In the past years, the
focus was on maintaining patient privacy and maximizing utility by considering patient
privacy [11–13].
With the advent of technology, the number of healthcare markets and assets in India
has been increasing every year. India will have a potential healthcare market shortly. Many
medical institutes are emerging because of a change in government policies. The Indian
government is motivating and encouraging medical colleges to be equipped. Because the
Indian healthcare structure is complex and interdependent, technology implementation and
addressing privacy problems has always been a big question. Therefore, the contributions
of this paper are as follows:
• Provide insights into Indian healthcare systems with applications, trends, and advantages.
• Describe policies that drive Indian healthcare systems
• Specify technological inventions used in Indian healthcare systems.
• List the various privacy issues concerning the Indian healthcare system that needs to
be addressed first.
Structure of Paper
The paper mainly presents the utility and privacy of the healthcare data and discusses
the utility aspect and privacy problems of Indian healthcare systems (Figure 3). To un-
derstand these factors and gain insights, understanding Indian healthcare systems first is
Inventions 2021, 6, 45 4 of 30
crucial. Section 2 presents overall Indian healthcare systems and world health organization
(WHO) indicators that classify sound healthcare systems. Section 3 defines policies that
reform Indian healthcare systems. The case study of the NITI Aayog report is presented to
explain how reformation occurs in Indian healthcare systems. Section 4 describes health-
care applications in India, wherein the advantages of the healthcare system, trends in
healthcare systems, and healthcare startups originated in India are explained. Section 5
presents technologies available for healthcare analytics and Indian papers based on new
machine learning and AI strategies. Section 6 addresses the various privacy problems
discussed in the literature. Section 7 concludes the study.
health system themes [14]. WHO presents some descriptive indicators to define a suitable
healthcare system.
Table 1. WHO indicators for suitable healthcare systems and Indian context.
Table 1. Cont.
√
Healthcare system improvisation can decrease mortality and poverty rates and ac-
celerate economic growth.
Implementing critical, intelligent, and automated health systems can help Indian
people improve health and reduce mortality and poverty rates. The use of AI and machine
learning algorithms in digital Indian healthcare data can enable the early prediction of
diseases and provide remote-level advice from medical experts. Centralization of medical
healthcare records can help rapidly access patient information and increase healthcare
record utility.
√
Unnecessary and non-uniform health sector fragmentation is the main problem of
healthcare industries in India.
Data fragmentation at any level and its granularity are the significant reasons for the
underperformance of India’s healthcare systems. Fragmentation, a myriad of organizations,
institutions (formal and informal rules), management, and administrative arrangements
and entitlements that do not coordinate harmoniously and are often subjected to contradic-
tory incentives, severely hampers the continuity of care and portability benefits [1]. In other
countries, healthcare system fragmentation occurs with uniform policies and rules and has
the same set of roles to access it. Uniform and limited fragmentation of the healthcare data
and users helps:
• Protect the healthcare data from a third-party unauthorized entity;
• Have uniformity in centralized health systems.
Indian healthcare policies are growing and are adaptive and structured. Several
problems of healthcare systems required to secure the systems are addressed.
according to the IBEF report [15]. The Infographics (Figure 5) describe each segment in-
volved in the Indian healthcare system.
Table 3. Comprehensive overview of ‘trends and privacy implications in the Indian healthcare system.
Table 3. Cont.
Table 4. Cont.
• Exogenous Data
The data obtained from medical and wearable devices such as pacemakers, fitness
bands, and intelligent watches are categorized as exogenous data. Because data are col-
lected from devices and sensors, they are stored in the cloud and are considered to have
sensitive information such as heart rates and blood-related information; such data are
breaches to privacy issues [25,26]; the details are presented in the next section of the paper.
• Genomic Data
The data relating to people’s genes and genetic structures are classified as genomic
data. The data are susceptible but simultaneously highly complex to understand as far
as their analysis is concerned. The genomic data analysis helps scientists and medical
practitioners to predict remedies accurately and preventive methodologies for patients
with a particular lifestyle, that have similar genetic make-up, or are exposed to similar
environmental conditions [27,28].
for identifying the relationships among various symptoms with similar causes of
particular diseases.
• Regression: Regression is used to find the correlation among various attributes de-
fined over a particular function. For regression, a mathematical model is constructed
with the training data with dependent and independent variables. Regression can be
linear and nonlinear. Linear regression identifies the relationship between a depen-
dent variable and one or more independent variables. Logistic regression, a nonlinear
regression type, can accept the categorical data and predict the probability through
the logit function.
5.4.2. Artificial Intelligence, Machine Learning, and Deep Learning in Indian Health Data
Big data plays a vital role in Healthcare, bioinformatics, and health informatics in
recent years [35–38]. The comprehensive data generated in healthcare in 2009 are 44 times
higher than that generated now, and sometimes, processing the data for analytics, predic-
tion, and accurate visualization is difficult. AI has gradually been evolving in healthcare.
According to an article in Wired, in India’s Aravind eye care system, ophthalmologists
and computer researchers work together to test and deploy an automated image classifi-
cation system to screen millions of retinal photographs of diabetic patients [39–41]. The
technologies including AI and deep learning have potential applications in the healthcare
industry such as medical imaging, radiology, cancer prediction, diabetes and heart disease
prediction, pathology, genome interpretation, and patient monitoring.
Moreover, AI is used in fraud detection in the healthcare field. Fraud can be committed
by service providers or healthcare insurance companies in billing and treatment or other
report generation [42].
Definition 1. “The state of being alone or the right to keep one’s matters and relationships secret”—
definition obtained from the Cambridge dictionary [81].
Definition 2. “No one shall be subjected to arbitrary interference of their privacy, family, home, or
correspondence or attacks upon their honor and reputation. Everyone has the right to the protection
of the law against such interference or attacks”—article 12 universal declaration of human rights.
Definition 3. “privacy can be divided into several separate, but related, concepts:”
- Information privacy involves establishing rules governing collecting and handling personal
data such as credit information and medical and government records. It is also known as
data protection;
- Bodily privacy concerns the protection of people’s physical selves against invasive procedures
such as genetic tests, drug testing, and cavity searches;
- Privacy of communications covers the security and privacy of mail, telephones, e-mails, and
other forms of communication; and
- Territorial privacy concerns the setting of limits on intrusion into the domestic and other
environments such as the workplace or public space. This includes searches, video surveillance,
and ID checks—Australian law reform commission.
Definition 4. “Privacy is the right to be let alone or freedom from interference or intrusion.
Information privacy is the right to have some control over how your personal information is collected
and used”—the international association of privacy professionals.
Privacy plays a vital role in the healthcare field because healthcare data contain
sensitive information about patients and related stakeholders. As stated in the introduction,
most healthcare fields have changed their operations from disease to patient-centric. The
records of people are stored according to their characteristics, personal and emotional
behavior, and geographic information. Central storage of electronic medical data across
highly configured servers is one of the most suitable options for data analysis [82,83].
It prevents the use of duplicated or redundant data because of its central storage and
maintenance. The amount of healthcare data is significant, and in India, the data are also
unstructured. Furthermore, this can lead to privacy and data breaching because of its
storage- and transformation-related concerns.
In India, Privacy is not treated as a serious concern. Privacy issues in healthcare,
specific to India, are caused by prevalent complacency, culture, politics, budget limitations,
large population, and infrastructures. Due to these factors, data security requires a backseat
that allows easy access to confidential information. Furthermore, the prevalent culture
affects healthcare disclosure in India. In many cultures, disclosing sensitive personal
healthcare data is considered ill-mannered. This leads to discrepancies in the recorded
healthcare data and a decrease in the level of treatment meted out. The results and statistics
of treatments given do not match the records due to inaccurate data reporting.
India is a democratic country with a large population, and maintaining a standard
infrastructure is a problem for implementing privacy models in India. The cost required
to implement a privacy model is substantial and requires funding from the government
Inventions 2021, 6, 45 18 of 30
and people. Making the privacy model a success involves the work of specialists in the
Privacy and healthcare fields. Budget constraints may cause an ineffective model to be
implemented, which cannot be secure and safe from attacks.
According to the recent news, the Indian health ministry has proposed a law to govern
data security (personal data protection bill) that would provide people complete ownership
of their data. People can access, share, and deny sharing the records available at the
server. The health ministry proposed digital information security in the healthcare act
on March 11, 2018. The committee suggested the following key points and developed a
privacy framework:
• The law must be flexible and adhere to changing technologies.
• Law must be applied to public and private sector entities.
• Entities controlling the data should be accountable for data processing.
• Consent must be structured and genuine.
• Data processing and analysis must be minimal.
• A high-powered statutory authority should enforce the data protection framework.
The Indian healthcare data are considerably diverse and collected from different
heterogeneous sources (public and private sector hospitals and health insurance). No
regulations are enforced over the health data authorship, due to which any third party
can access the sensitive data and misuse the data for its benefit. The proposed law has
guidelines and technological aspects for preserving healthcare data privacy.
Cyber Attacks on Data Gathering Phase Cyber Attacks at Network Phase Cyber Attacks at Storage Phase
Phishing attack Eavesdropping of health record Cross-site scripting attack
Log access attack Man-in-the-middle attack Weak authentication attack
Social engineering attack Data tampering
Denial of the service attack
SQL injection attack.
Brute force attack (on passwords) Data interception
Spoofing and sniffing attack
including breaching the Indian health data stating that because the Aadhaar card contains
sensitive information, it cannot be used as a mandatory document in fields such as banking,
the insurance sector, and mobile servicing [92].
H. Culture
Cultural interventions are other challenges faced by the Indian healthcare industry.
Most cultural communities do not allow people to share or disclose their personal informa-
tion due to predefined cultural restrictions, resulting in the recording of false information.
The discrepancy in health records results in inaccurate analyses and an inaccurate treatment
that is meted out [93].
I. Prevalent Complacency
Complacency is widespread in Indian healthcare. A large amount of work, planning,
cooperation, and communication among multiple departments is required to make the
privacy and security of healthcare in India a success. However, due to slackness, the
probability of the privacy model implemented in India is poor [94].
J. Cost
Implementation of the privacy model with suitable infrastructure is costly. The Indian
government faces other problems such as poverty and corruption that are given high
priority, and privacy model implementation is given the least priority. Small organizations
do not have enough assets to protect their employees.
Table 9 presents the privacy problems of the healthcare system of India as mentioned
above. Table 10 explains how each privacy problem is being addressed in different health-
care structures in India.
Table 10. Privacy issues stated in the Indian healthcare system (continued).
7.1. Key Performance Indicators in the Context of Privacy in the Indian Healthcare System
Key Performance Indicators (henceforth termed as a KPI) are very important as they
measure privacy concerns that need to be addressed first. According to the research done
in [100,101], the following KPI is related to privacy issues; however, they are applicable for
social media photos and video sharing in the existing research. Since privacy issues exist
everywhere, in every field, KPI is applicable in the Indian healthcare context as well. The
list of KPIs and their details are given below:
• Forced Trust vs. Control: A forced trust is a trust in which an individual has no
choice but to trust any healthcare system. On the other hand, control is a systematic
view of obtaining trust and assuring each individual that their sensitive personal data
will not be shared with the third party without any consent. In the Indian healthcare
context, the ratio of forced trust to control is high. People tend to have less trust in any
healthcare system because of constitutional limitations. This is one of the significant
KPIs in the context of Indian Healthcare privacy.
• Content Viewed by Whom: Though there is limited access to any EHR and only
authenticated people can view or access the sensitive data, there is still the possibility
that unauthorized entities may access health records. Weak passwords, inappropriate
security policies, conflict in access controls, and sharing passwords to untrusted
persons are the possible reasons sensitive data may be misused. In India, the healthcare
system is not very structured and centralized. Local hospitals keep their records on
local servers, which are highly vulnerable to various attacks. Data breaching primarily
happens in tier 2 and tier 3 cities and village hospitals.
• Tacit Knowledge: Even if the healthcare system ensures maximum protection against
data breaches for healthcare data, the metadata or tacit information may reveal more
information than basic health information. Using reverse engineering techniques
or social media analysis, it is easy to gain personal information. In India, there
are many cases reported against criminals who seek sensitive information through
social media accounts. Unfortunately, there is no control over the protection against
such information.
• Laws and Regulation: Limited regulation and law in the constitution are essential
KPI in the Indian healthcare field. As per the latest data of 2019, Indian healthcare
generates 1021 gigabytes of data per year. Managing such a massive amount of data
by protecting sensitive content must prioritize the Indian government.
• Use of new Data Protection Technologies: The newer technologies like blockchain,
two-factor authentication, machine learning, AI, and attribute-based anonymization
is only implemented in high-end industries or healthcare organizations. Small sector
health organizations, village, or tier 3 hospitals do not have funds to support the
protection of such data, and hence newer technologies cannot be used.
• Researcher’s Satisfaction: Since there is a massive generation of healthcare data, it
is an excellent opportunity to analyze the data for research purposes. Healthcare
analytics is the emerging field of computing and is rising exponentially in India. More
restricted and policy-imposed data are not suitable for analytics purposes, and data
quality gets degraded.
• Industry-academia collaboration exists for privacy preservation mechanisms: There
is a huge gap between industry and academia in India. Despite having good re-
searchers in the privacy field, their work is not reaching the industry.
It is also noted that all these KPI are not treated with the same priority. In order to
priorities KPIs, the different stakeholders are taken into consideration. This paper’s contri-
bution is to summarize the ratings given by stakeholders directly or indirectly involved in
managing or accessing healthcare data.
The following stakeholders are chosen:
Inventions 2021, 6, 45 24 of 30
Table 11. Ratings of KPIs defined over privacy issues by healthcare stakeholders.
no regulations over the authorship of the health data, due to which any third party can
gain access to the sensitive data and misuse the data. The reidentification attack is the
most common attack of health data wherein, with the help of a group of some identifiable
entities (called quasi-identifiers), individuals’ identities can be easily determined. The
proposed law mentioned in the above section has guidelines and technological aspects
of preserving healthcare data privacy. The proposed research will be the outcome of the
privacy framework developed by the Indian government in the PDP bill. The primary
constituents of the PDP bill are drawn in Figure 10.
Figure 10. Personal Data Protection bill entities adopted from [101].
Figure 10 presents the essential elements of the data protection bill adopted in India.
The data owner is called a data principle in GDPR; they are also called a data custodian.
The data fiduciary can be any company, organization, group of people, or individual who
determine the purpose of the data use and dissemination. They can be a data holder in the
context of GDPR. A data processor is a third-party entity that is involved in the processing
of data. In some situations, the data fiduciary and data processor roles can be the same,
and the whole depends upon a particular situation. The Data Protection Authority of India
(DPAI) is the statutory body that can define rules and regulations about data protection.
reidentification, and many more. As per the framework (Figure 10), the data fiduciary and
the data processor shall implement the necessary methods such as anonymization and
de-identification during data processing to implement appropriate security and safeguard
in the system. They also can define what level the privacy can be maintained by keeping
the utility of the data. Privacy by Design (PbD) is one of the solutions suggested by DPAI
in the PDP bill.
Author Contributions: The author P.C. and A.P. wrote the initial draft of the manuscript. A.-J.M.-G.
proofread and gave constructive comments towards improving the quality of the paper. He also
handled the major revisions in the paper. All authors have read and agreed to the published version
of the manuscript.
Funding: This research received no external funding.
Institutional Review Board Statement: Not applicable.
Informed Consent Statement: Not applicable.
Data Availability Statement: This research work is an extensive review of past published papers,
and hence no specific data/dataset applies to this research work.
Acknowledgments: The authors would like to thank the anonymous reviewers and editors who
have been involved in examining this manuscript.
Conflicts of Interest: The author declares no conflict of interest associated with this research work.
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