How India is moving from an 'ego-based' to an 'ecosystem-based' digital health system

Lav Agarwal, the Joint Secretary of India’s Ministry of Health and Family Welfare, is a big believer in the country's new Ayushman Bharat Digital Mission, which translates roughly as the Long Live India Digital Mission.

The initiative aims to create a platform for longitudinal electronic health records for all of India’s 1.3 billion people. Piloted in August 2020, and launched nationally in September 2021, the system will establish national health IDs, a registry for facilities and providers, and national digital health records to improve patient care and outcomes.

We spoke with Agarwal about his hopes for the innovative project.

What is the origin of the Ayushman Bharat Digital Mission?

Agarwal: India has been using digital health applications and related data tools for quite a long time, about eight to 10 years, for multiple programmatic interventions. For example, we have applications for reproductive and child health, TB patient monitoring platforms, non-communicable disease applications, etc. We also had multiple digital applications for supporting our field health workers, Asha workers, etc.

We realized, however, that while all these applications were helping in some form, we weren’t taking full advantage of these digital tools since there were multiple sets of data, not talking to each other. We knew we needed to remove silos within the health data system.

There are a lot of insights that can be obtained when multiple data sets are connected. Digital health can be a great enabler in two ways. One, a digital health system can support the delivery of health services. And two, a digital health system can ensure effective monitoring of the delivery of health services.

In 2017, the government adopted a new national health policy that promoted the idea of a unified digital health system. It laid out the vision for this and talked about creating a national data health information architecture.

India chaired the world’s biggest intergovernmental partnership on digital health, the Global Digital Health Partnership, for two years. Taking the ongoing challenges and learnings into consideration, and after extensive consultation with all stakeholders including IT companies, startups, industry associations, academia and health care providers, and other stakeholders in the health sector for a period of 6 months, we developed a National Digital Health Blueprint.

The National Digital Health Blueprint talked about the principles that needed to be followed as we broke down data silos. It also talked about the implementation mechanism. In the past, we had come up with approaches and goals for digital health. But the blueprint specifically prioritized taking a mission-mode approach for implementation through the Ayushman Bharat Digital Mission, which was initially called the National Digital Health Mission. It talked about data privacy, data security, data ownership, interoperability standards, and data ownership principles.

I like to think that a unified digital health system removes barriers that impede communication and collaboration. I think of the ego between human beings that impedes communication. This moves us from an ego-based digital health system to an ecosystem-based digital health system.

What problems will the initiative address?

Agarwal: There are two major issues it is trying to address: program management and service delivery. Who are the stakeholders involved in these challenges? They include the patients, providers, facilities, government policymakers, and researchers. To be successful, we have to ensure that the initiative addresses critical challenges faced by each of these five major stakeholders.

For patients, it creates a system that can track the longitudinal health of every citizen in the country. It supports their access to services, access to information, access to data, and provides quality services across all levels through interventions like telemedicine, etc. For healthcare professionals, it ensures they have access to the data they need to serve their patients. It allows them to manage and monitor compliance. For health facilities, it ensures discoverability and supports the delivery of online services. For researchers, it allows them to access critical aggregate data, undertake research, and allows for the creation of a loop to inform policymakers. Also, this data can help save a lot of time in clinical trials.

This information in turn allows policymakers to fine tune their interventions and be more precise in targeting not only curative but preventive and promotive aspects of health care.

How does the initiative help improve patient care?

Agarwal: The National Digital Health Mission ensures better access to services and better service delivery. This is about making health systems more efficient.

To give an example, let’s look at a patient with diabetes. Generally, patients with diabetes don’t receive medication based on their blood sugar levels on the particular day they are visiting the doctor. Instead, they receive prescriptions based on the last five or six months of their blood sugar levels and other data. If doctors don’t have access to that data, they can’t properly treat the patient. Now, all of that data is online and accessible. So doctors can see this information, not just a datapoint from today, to guide their decision making about medication and dosage.

India created a telemedicine platform during Covid-19, eSanjeevani which has already provided 33 million video consultations to patients across the country in the last year. We serve on average 200,000 telemedicine calls per day wherein patients from rural and remote areas can get quality medical advice from the confines of their homes, free of cost.

India has in fact undertaken multiple initiatives to improve access to care under the overarching theme of Ayushman Bharat.

These include launching 150,000 Ayushman Bharat Health & Wellness Centers to provide primary health care across the country and Ayushman Bharat Jan Arogya Yojana for cashless, paperless health insurance to provide 500 million citizens free secondary and tertiary health care.

How did the initiative impact access to care and government health services during COVID?

Agarwal: Data-driven insights have been our biggest support for managing Covid-19. We created the Covid-19 portal to monitor the trajectory of cases and available hospital infrastructure, and its usage across all states and districts in the country on a real-time basis. Through a testing portal and app, all tests – RT-PCR and RAT – were monitored across the country, and crucial parameters like total tests conducted and test positivity across the country is monitored. The data from more than 3,000 labs all came into a single database.

We monitored case trajectory and important parameters to develop projections on the requirements of hospital infrastructure. Telemedicine-supported health care delivery during periods of restrictions when people could not visit hospitals out of fear of infection. And when vaccination was launched on January 16th, 2021, we also launched Co-WIN, an IT platform to monitor vaccinations. More than 1.9 billion doses have been administered so far and their details are monitored through Co-WIN. We can remind patients to get their booster. We can see where people are getting vaccinated and where they are not, to understand where communications or interventions might be needed. The data gives us tremendous insights.

How did COVID impact the initiative?

Agarwal: COVID aided in terms of accelerating the acceptance of digital health initiatives across the spectrum, by providers and citizens alike. I mentioned eSanjeevani, which supports telemedicine. It is the biggest telemedicine platform presently in the world.

What did you learn during the pilot phase and what had to be adjusted as a result of those learnings?

Agarwal: We worked during this period on creating a communication strategy to involve all stakeholders, providers at all levels, and citizens at large. We created IT platforms which will manage the registry of patients, providers and facilities, and created a sandbox environment for integrating existing applications with the ABDM framework for its wider usage and adaptability.

What is the status of registration in the digital health system right now?

Agarwal: Currently, we have about 11,000 doctors who have registered, 26,000 health facilities, and more than 210 million Indians who have created their unique health IDs under the Ayushman Bharat Digital Mission. This number is growing as we speak.