THE UPI MOMENT FOR HEALTH CARE

The launch of the India health stack sets the stage for access to affordable health care anytime, anywhere. EPISODE #43

Dear Reader,

A very happy Monday to you.

Little under a month ago, the launch of the Account Aggregator (AA) framework to tap the business of personal data had caught my attention. It was dubbed as ‘The 'UPI Moment for Personal Data’. So you may wonder as to why I have chosen to repeat the headline in the context of the launch of the Digital Health Mission.

The reasoning is very simple. The tech stack developed indigenously and one which allows for inter-operability is the foundation for both. And the consent layer in the tech stack actually links the two initiatives. And like in the case of AA, this initiative too is packed with potential for achieving scale.

What the NDHM proposes to do is unlock the health data locked away in silos of various health care providers and labs and combine them for public good—for the benefit of both the consumer as well as the health ecosystem. Together with Ayushman Bharat, the ongoing health insurance scheme for 600 million Indians at the bottom of the pyramid, the health stack provides an opportunity to reimagine India’s health infrastructure by ensuring access to affordable and effective healthcare.

Separately, on 7 October Prime Minister Narendra Modi will complete 20 years as the head in public office, a journey that began as a chief minister in Gujarat. Ahead of this Open magazine published a special issue capturing this moment. It includes a superb interview with PM Modi, which, among other things provides terrific insights into the governance approach of the National Democratic Alliance (NDA). For anyone who is curious, including critics and investors, both domestic and foreign, it is a must read. To read the interview please click here.

The special issue also includes a column from me on the technology driven inclusion framework powering the new development strategy being pursued by the NDA. I argue that leaning on a nimble and indigenously developed technology backbone built on the foundation of Aadhaar, the new inclusion framework favours empowerment over entitlement—a very significant shift which teaches people how to fish, instead of giving them fish for free. It overlaps with the topic of Capital Calculus this week. To read the column please click here.

This week’s picture is taken by Swarnavo Chakrabarti. I picked it from the offerings at Unsplash as it captured a slice of reality in Indian health care.

A big shoutout to Gautam, Ashu, Nimesh, Premasundaran, Vandana, Rahul and Aashish for your informed responses, appreciation and amplification. Gratitude also to all those who responded on Twitter and Linkedin. Reader participation and amplification is key to growing this newsletter community. And, many thanks to readers who hit the like button 😊.

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Photo by Swarnavo Chakrabarti on Unsplash

THE HEALTH CARE RESET

Last week the country formally launched the National Digital Health Mission (NDHM), though officially it goes with a different moniker: Ayushman Bharat Digital Mission.

Another government initiative that is not short on ambition: This time to take affordable health care to those who need it; and once again by employing a digital backbone. In short it is India’s big fix of it sell-past-the-date health infrastructure. NDHM will essentially permit all of those volunteering to opt for a unique digital health-ID to enable portability of their medical history—at the least it will reduce enormous friction for out-station patients seeking consultation through tele-medicine or looking to tap specialists across the country—and a health registry of verified medical personnel.

Most importantly it uses the very same open digital architecture deployed so successfully for the Unified Payments Interface (UPI) which has revolutionised payments in the country; and also the Account Aggregator (AA) framework designed to monetise personal data—launched in the first week of September. Based on the phenomenal success of UPI, it is only logical to expect similar results with the NDHM over time. Like we have seen with FinTech it should encourage innovations around NDHM.

At the same time this is also an implicit vote of confidence in the India Tech stack—something that is winning rave reviews globally.

The Plan

The NDHM project began in 2018 when the Niti Aayog published a report on the Health Stack. Thereafter it went through several iterations, both through public consultations and internal conversations within government.

It essentially seeks to unlock the health data locked away in the silos of hospitals, laboratories and the existing health network. By getting the data to talk to each other, NDHM is seeking to exploit it for the benefit of both consumers and the health ecosystem, particularly public health care. Look at it like building a top class highway; almost overnight it will connect habitats and the resulting economic conversation is called development. Similarly, the end objective of NDHM is to make health care affordable and thereby more accessible. Like I said earlier it is the big fix to India’s existing healthcare woes.

The enabling digital ecosystem for this is already in place. At this point of time there are an estimated 1.3 billion (or 130 crore) holders of Aadhaar, the unique 12-digit ID issued to all residents of India; 1 billion (100 crore) plus cell phone connections of which 400-600 million (40-60 crore) are using smart-phones; 600-800 million (60-80 crore) Internet users; and, 430 million (43 crore) Jandhan no-frill bank accounts owned by the poor.

The new information technology highway brings all these parts together. Exactly why we have seen the new tech backbone, India Stack, leverage this digital infrastructure to its advantage and make UPI and direct benefits transfer (DBT) an outstanding success. This is now proposed to be extended to health care.

To make this work, the NDHM has envisaged two voluntary actions that will provide for the Unified Health Interface (UHI), the tech backbone powering NDHM.

One, a patient registers for a unique digital health-ID, which may or may not be linked to their Aadhaar.

Second, the medical infrastructure—of doctors, nurses, hospitals, labs—is included in a registry, providing a data base of verified health providers. Once the consent of the patient is obtained—which in turn ensures that control remains with the consumer—the health information can be shared on this digital backbone.

This too now becomes part of the public digital infrastructure which already includes Aadhaar, UPI, the JAM (Jandhan, Aadhaar, Mobile) trinity. NDHM can now uniquely identify patients, doctors and medical facilities. And then, like in the case of UPI, potentially undertake seamless and paperless transactions using UHI.

Underlying both digital public goods, UPI and UHI, is the India Stack. It is the technology base which combines a set of Application Programming Interface (APIs)—the tech bridge that allows two software applications to talk to each other—permitting businesses, government or any developer to tap into the digital infrastructure built on the foundation of Aadhaar.

It is able to do this by leveraging four pillars: Presence-less (digitally access and verification using Aadhaar); Paper-less (digital records allowing portability); Cash-less (one interface allowing for inter-operable payments between bank accounts and wallets); Consent (permits entities to access an individual’s data).

The potential of NDHM was summed up pithily in a piece published in Times of India on Saturday by Nandan Nilekani, the man who spearheaded Aadhaar.

“Today, you simply use any UPI app to pay anyone without worrying about what app or bank they use. Similarly, the vision is to use any UHI app to connect with any doctor, book an appointment, make a payment, share health records and get the prescription added to health records. Doctors will also have the choice to use the best UHI app (like we choose between various wallets on offer to make our payments digitally) that helps them manage their patients’ interactions digitally. Interoperability will accelerate digital adoption. This will be a boon to Bharat as a lot of our healthcare talent is still in the cities.”

The Benefits

Given the short yet impressive history of UPI, some of the advantages underlying the health stack are obvious. I have placed them in four buckets:

First, the health stack with its digital audit trails and health registry increases transparency. This is particularly relevant in the health sector where the trust quotient is plumbing lows. Alongside, the data base so generated can be tapped to track the spread and incidence of diseases—like say in the case of covid-19—ensuring better public health care management.

Second, flowing from the above and the fact that sharing of data is consent-based it ensures that the patient is in control of their data. It also secures their health records. I recall how a detailed physical file compiled by me capturing my father’s deteriorating health history was nicked at night from the hospital ward where he was admitted; it was probably a junior resident looking to do a research paper. Worse than the theft of personal health data, my father’s health history developed huge gaps thereafter.

Third, the UHI, like it has happened with UPI, will facilitate market innovation involving private players. Like it has happened with FinTech. At the least it will optimise expenditures on public health by minimising leakages; giving more bang for the buck. Once again a public digital good is looking to create an inter-operable platform for public-private collaboration in the environment of a rules-based regime.

Fourth, the platform approach to UHI ensures low-cost onboarding and high volume, enhancing its use. UPI which was launched in 2016 is at present logging nearly 3 billion transactions a month.

Global Attention

The ‘New India’ playbook relying on open digital ecosystems to deliver solutions of scale is finally beginning to get global attention.

In a rare departure from its compulsive doom scrolling about India, the Financial Times published an opinion piece on 1 October by Merryn Somerset Webb, editor-in-chief of MoneyWeek.

Webb took note of the “technological revolution” saying:

“However, there are two new things to watch in India. The first is its technological revolution. India’s open-minded young tend to be early adopters, says India Capital Growth’s David Cornell and the rollout of the world’s largest 4G network combined with lockdowns, low-cost data and widespread smartphone usage (1.1 billion users) has massively accelerated the advent of e-commerce and digital banking. In India, 99% of all online activity happens on phones.”

And then added that this trend was yet to get captured in the stock markets indices, implying that the current bull run is just the beginning:

“This transformation is not yet reflected in the stock market: the digital and technology sector makes up only 1% of market capitalisation versus 30% in the US. That is about to change. There is, says Mick Gilligan of Killik & Co, a “wave of IPOs coming down the tracks”. In other words, the unicorns are coming.”

If indeed Webb’s prophecy does pan out this will turn out to be a much bigger story than just about stock market returns. Since we are talking about scale (already, the size of India’s middle class tops the population of most countries.) the network effect of this transformation driven by technology is going to be enormous. India can leapfrog its way to a new growth trajectory. Undoubtedly it has the potential to cause an unprecedented trading-up in living standards, resulting in even more consumer demand to power the Indian economy.

Given the history of India’s missed opportunities one can only hope that this is the one moment when the law of averages catches up. In a good way that is. Fingers crossed.

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Recommended Viewing

Staying with the theme of this week I came across this unmissable conversation on NDHM and hence the share.

Varad Pande, a partner in Omidyar, teams up with Kiran Anandampillai, Advisor, Technology at the National Health Authority, to educate us on the new paradigm of Open Digital Ecosystems (ODE) that underlie the indigenous technology backbone powering revolutionary ideas like Aadhaar, UPI, AA and now NDHM. It is just under an hour long and brilliant. Happy viewing.

Till we meet again next week. Stay safe.