A Better Public Health Policy Planning for Universal Health Coverage

The biometrics underpinning the Aadhaar system have enabled it to become the foundational tool for identity verification in India, leading to it becoming increasingly integrated into the delivery of healthcare services by the government. Yet, the biometric system still does not cover anyone under the age of 5 due to the (once considered) insurmountable challenge of accurately detecting early childhood fingerprints. However, recent technological advances have meant that India should now actively consider early childhood (ages 1-5) biometrics to buttress healthcare delivery, especially for the underserved.

Fingerprints as a stable marker of identity

It has been demonstrated that the fingerprints of children, even newborns, do not deviate substantially from their fingerprints as adults. Moreover, superficial damage to the epidermis cannot change fingerprint patterns—although intense manual labour can (temporarily) wear away the patterns while deep, permanent scars can disrupt them. Consequently, capturing the fingerprints of young children and newborns has been a heavily researched area due to the benefits it offers as a stable marker of identity, especially in developing countries where individuals may lack other forms of documentation.

Hurdles in capturing the fingerprints of young children

Nevertheless, in practice, capturing the fingerprints of children younger than age 5 has been a major challenge due to the issues encountered with inadequate technology and infant behaviour.

Firstly, while the basic patterns of a child’s fingerprints do not change over time, from an imaging perspective, large changes are seen. Given that each fingerprint consists of ridges and valleys that form this unique pattern, as the child grows, the spaces between the ridges enlarge non-uniformly, making it harder for technology to match the new fingerprint pattern with the original pattern recorded. This challenge is exacerbated by the tendency of quick skin peeling seen in newborns in the weeks after birth.

Secondly, existing fingerprint recognition technology for adults generally uses a ‘platen’ (the glass surface against which the fingers are pressed). This is problematic for young children because pressing their fingers against the hard glass surface can obscure some of the patterns due to their soft, malleable skin and poorly-defined ridges.

Finally, behaviourally, it can be a challenge to get a young child to keep their finger on the plate long enough and with the appropriate orientation and level of pressure to get a usable fingerprint scan. Reportedly, in infants, this is exacerbated by the early childhood grasp reflex (where they grasp objects that they are in contact with) which further distorts the pattern seen on the platen.

Early childhood fingerprint technology: Making its way to mass market

Consequently, over the years, much technological innovation has gone into developing systems that can accurately capture childhood fingerprints, especially for children below age five. For instance, a much higher resolution scanner (>1000 PPI vs 500 PPI for adults) must be used for younger children as they have smaller and more poorly-defined fingerprints vis-à-vis adults. This is sometimes used alongside software that will correct for print distortion (such as smudging or inappropriate finger position).

Alternatively, to deal with the issue of ‘platen’-linked distortion, emerging technologies have sought to use non-contact imaging where an image of the fingerprint is captured without having to press it against a solid surface. These methods have, in research settings, demonstrated that accurate early childhood fingerprint detection is achievable with current technology.

Alternatively, to deal with the issue of ‘platen’-linked distortion, emerging technologies have sought to use non-contact imaging where an image of the fingerprint is captured without having to press it against a solid surface.

More recently, the Japanese corporation NEC, a British startup (Simprints) and GAVI collaboratively developed a system that uses a high-resolution fingerprint scanner with software correction, with a self-reported 99 percent accuracy. In September 2022, a trial was initiated for 4,000 children (aged 1-5) in Bangladesh. The fact that large development organisations are now initiating trials should be a strong indication that this technology is beginning to mature (with costs potentially coming down) and should spur a relook from the policymakers.

Baal Aadhaar and healthcare delivery

In the Indian context, the Baal Aadhaar (Aadhaar for minors) currently mandatorily requires the registration of fingerprints at age 5 and subsequently, an update at the age of 15. It is now time for the government to actively consider collecting biometrics for children older than six months or a year—either by licensing existing technology (such as via GAVI) or by actively developing this in-house through partnerships with Indian technology firms. This would not only ensure that the Aadhaar biometric scheme remains at the forefront of identity verification but also have major benefits for healthcare delivery.

It is now time for the government to actively consider collecting biometrics for children older than six months or a year—either by licensing existing technology (such as via GAVI) or by actively developing this in-house through partnerships with Indian technology firms.

Currently, the healthcare infrastructure in India (as in many countries), is extremely decentralised: healthcare records for a patient cannot be transferred when treatment is sought at a different site. Consequently, for the ~600 million internal migrants in India, many from poor, rural backgrounds who have moved to urban/industrial/agricultural hubs for work, paper records for their children can often be lost, damaged, or incomplete.

Additionally, parents/caregivers may not have the medical literacy to explain their child’s medical history in full (previous tests, diagnoses, prescriptions) which hinders medical management. For example, in the 2022 measles outbreak in Mumbai/Thane which primarily affected the urban poor and migrant population, the loss of paper vaccination records by parents greatly impeded municipal authorities in identifying zero-/missed-dose children, with one study estimating that ~75 percent of under-five cases did not have vaccination cards available.

Some of these issues may be resolved to some extent with the ongoing gradual rollout of the U-WIN portal that aims to store all UIP vaccination records on one platform, linked to an ID proof. Similarly, the Ayushman Bharat Digital Mission (ABDM) is creating a dedicated architecture for the sharing of medical records between healthcare facilities.

Nevertheless, these systems would be enhanced with the addition of fingerprint-based identity verification, which delivers better outcomes for children than Electronic Medical Records (EMR) or document-based identity verification alone. For instance, parents may not be aware that their child has a U-WIN ID and may register them with a different document each time (or may accidentally or fraudulently have generated multiple Baal Aadhaars), leading to a complex web of incomplete records. This problem can be exacerbated by the fact that individuals (and especially children) may have different name spellings in different documents, which is a common issue observed in the Indian context. With biometric identification, matching of healthcare records (e.g. treatment/vaccination records) to child beneficiaries can be done with greater accuracy, enabling the provision of appropriate care.

Nevertheless, these systems would be enhanced with the addition of fingerprint-based identity verification, which delivers better outcomes for children than Electronic Medical Records (EMR) or document-based identity verification alone.

Further, documentary proof of identity risks inadvertently excluding certain groups within society such as children given up for adoption/abandoned, those who are homeless and those who come from families that tend to move very frequently—as many of these individuals might lose medical documents/vaccination cards and face difficulties acquiring identification like Aadhaar cards.

The way forward

Capturing biometrics for children (aged 1-5), including in the Baal Aadhaar, will aid the process of achieving Universal Health Coverage (UHC) by providing greater access and continuity of healthcare to children from vulnerable populations, whilst also aiding healthcare providers/authorities who face challenges in collecting comprehensive medical histories and identifying zero-/missed-dose children.

This will also have longer-term benefits, with the government being able to identify and target child beneficiaries better (with less leakage) for welfare schemes, as is currently done for adults. Moreover, this will be a further building block towards the eventual goal of capturing infant (ages 0-1) fingerprints within days of birth that will allow the government to substantially improve the accuracy of birth registries and maintain better population data—with concomitant benefits to public health policy planning.

Pulkit Athavle is a 2nd year MBBS undergraduate student at Nanyang Technological University, Singapore.

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