Author : Anulekha Nandi

Expert Speak Health Express
Published on Apr 05, 2024

Given the diversity of stakeholders and technical requirements, there is a need for flexible standards to achieve scale and drive the adoption of digital health infrastructure

Building national digital health infrastructures in India

This essay is part of the series titled: World Health Day 2024: My Health, My Right


Access to healthcare in India is riddled with institutional and systemic challenges. These include urban-rural disparities due to the lack of adequate infrastructure and healthcare professionals, financial constraints, and a fragmented healthcare system with a diverse range of actors and standards that prevent the seamless sharing of information. 47.1 percent of the population currently incurs out-of-pocket expenses for healthcare due to issues around affordability, distance from healthcare services, and systemic conditions within the healthcare system that lead to cascading health inequities. The Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (AB PM-JAY) aims to expand universal health coverage through two interrelated components of health and wellness centres and health insurance coverage. The former is based on transforming existing sub-centres and primary healthcare centres to deliver comprehensive primary healthcare covering non-communicable diseases, maternal and child health services, and free essential drugs and diagnostic services. The latter aims to provide health insurance coverage of INR 5,00,000 per family for primary and secondary healthcare, covering 50 percent of the Indian population thus making it the largest public insurance scheme in the world.

The Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (AB PM-JAY) aims to expand universal health coverage through two interrelated components of health and wellness centres and health insurance coverage.

However, the Ayushman Bharat scheme for expanding health coverage relies on a digital backbone—the Ayushman Bharat Digital Mission (ABDM). This involves the effective use of technology to scale the initiative, monitor quality, and ensure accountability. Digital healthcare has the potential to prevent disease and lower health costs while helping people monitor chronic health conditions. It aims to overcome the systemic issues in healthcare by improving access to and quality of healthcare delivery. However, moving beyond piloting and applications, scaling and integration have become one of the key issues. Despite increasing digital penetration, the digital health ecosystem is still at a nascent stage and needs a catalyst to seed the system. While ABDM provides an impetus for this, health data in India is not digitised, standardised, or interoperable and is not readily accessible to researchers, clinicians, and policymakers.

Scaling at the intersection of people and technology 

Building a digital health ecosystem is more difficult than Aadhaar because of the range of stakeholders involved in the process with differing levels of involvement. The ABDM’s architecture is built on India’s cross-domain digital public goods like Aadhar, UPI, DigiLocker, and the Consent Artefact and is intended to be modular and interoperable.  On top of this sits the health data exchange comprising digital registries, health records, and health claims. This is then made available through a Unified Health Interface for telemedicine and other healthcare services for preventive care, diagnostics, and treatment, which provides the platform for public and private innovation and application design.

Source: National Heath Authority, Ministry of Health and Family Welfare

Consequently, the ABDM ecosystem spans a diverse range of stakeholders involving policy-makers like Central and State governments; healthcare providers and professionals like hospitals, clinics, health centres, doctors, labs, and pharmacies; allied private entities like insurance providers; non-profit organisations, and administrators like regulators and programme managers. These diverse stakeholder groups are responsible for the data management, provision, and integration that is needed to drive the digital health ecosystem like electronic health records, and health claims exchange for insurers, drug registries, and hospitals that both generate, use, and process such data. This is further compounded by complex rules governing how health data can be accessed for research, innovation, healthcare improvements and other uses beyond individual patient care. Moreover, building a digital health infrastructure and integration of data and services need vertical consolidation across primary, secondary, and tertiary care as well as horizontal integration across health, community, and social care. 

Persistent tensions exist for scaling i.e. adding new functionalities at the macro level runs counter to the needs of individual users while adapting to localised contextual conditions inhibits the ability to deliver population-scale goals.

Similar initiatives in building national-level health infrastructures in other countries like the United Kingdom (UK) and the United States (US) have faced bottlenecks of inadequate stakeholder engagement, poor communication, and misalignment of interests. Digital transformations in healthcare often occur at the intersection of technology, people, organisations and institutions that co-constitutively drive adoption and change. Digital healthcare settings often present dynamic complexities with multiple technologies and established people, practices, and processes inflected by their related informational needs and concrete features of digital technologies which set the boundaries for what is possible. Persistent tensions exist for scaling i.e. adding new functionalities at the macro level runs counter to the needs of individual users while adapting to localised contextual conditions inhibits the ability to deliver population-scale goals. Consequently, the programme and system design needs to be simultaneously relevant for the innovation and local practices with the former calling for a de-contextualisation and the latter for a re-contextualisation. This requires addressing unmet needs with end-user input from the outset, accompanied by training, engagement, and motivation of stakeholders to implement the new initiative with technical design driven by simplicity, interoperability, and adaptability. Alignment with broader healthcare policy is fundamental as is sustainable funding for long-term growth. 

A way forward 

National digital health integration in other countries has not been able to overcome process and service fragmentation. Despite the expansion of health coverage through Ayushman Bharat, there remain the crucial issues of the ‘missing middle’, i.e. those sections of the population who are not poor enough to be covered by public health insurance and not rich enough to be able to afford private insurance. The ‘missing middle’ constitutes 30 percent of the population with the public health insurance schemes covering 50 percent and 20 percent covered through social health insurance and private voluntary health insurance.

The ABDM architecture proposes a federated, API-enabled, interoperable health information ecosystem that leverages India’s near-universal availability of mobile phones and unique ID systems precluding the storing of all data in a centralised server apart from the health ID, registry of healthcare professionals and facilities to promote interoperability.

Moreover, considerations remain on managing different stakeholder practices and interests and aligning them to new modes of working and organisation driven by digital health integration as well as with privacy concerns about data storage and use. Given the plurality of institutional arrangements, initiatives should be based on flexible standards and processes that are interoperable. The ABDM architecture proposes a federated, API-enabled, interoperable health information ecosystem that leverages India’s near-universal availability of mobile phones and unique ID systems precluding the storing of all data in a centralised server apart from the health ID, registry of healthcare professionals and facilities to promote interoperability. This requires the definition of interoperability standards and interfaces to leverage the intended modular architecture of ABDM as well as harmonisation and integration of data protection imperatives and patient consent management systems across the ecosystem.

Given the diversity of stakeholders involved, planners must account for change management among existing stakeholder groups. This is because such stakeholders might also have existing modes of record keeping and data management that might need to be systematised and structured to be called upon through appropriate APIs and be compliant at a system-level. Scaling ABDM should incorporate a system of feedback loops to ensure stakeholder needs are heard and newer areas of responsibilities and liabilities that might have been introduced by the new system clarified to ensure and drive uptake.


Anulekha Nandi is a Fellow at the Observer Research Foundation

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Author

Anulekha Nandi

Anulekha Nandi

Anulekha Nandi is a Fellow at ORF. Her primary area of research includes technology policy and digital innovation policy and management. She also works in ...

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