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#8 Call for Volunteers: Designing Digital Infrastructure for Healthcare at National Scale

Why Healthcare?

Interacting even briefly with the healthcare system reveals the issues that plague the sector in India: a severe shortage of high-quality doctors, nurses, or medical supplies (and a lack of information on where the best are); misdiagnoses or late diagnoses; overcrowding and long waits in public hospitals; overpriced and over-prescribed procedures and in private hospitals; a complicated insurance claim system; and significant gaps in health insurance coverage. Those who have worked on trying to improve the healthcare system know the systemic challenges: misaligned incentives in care delivery, a lack of health data to coordinate care, low state capacity, and the political battles between states and the Centre. Yet not one of us is spared bouts of illness or other health incidents over our lifetime. We have no choice but to work with this system. And when it doesn’t function effectively, the largest effects are felt by the poorest: productivity losses and income shocks caused by health issues have a way of spiralling individuals on the cusp of economic well being back into poverty. 

Designing for high quality, affordable, and accessible healthcare in India is a challenging societal problem worth solving, with huge potential spillover benefits.

iSPIRT in Healthcare

At iSPIRT, we have started to develop an approach to dealing with complex societal problems at national scale. Our work on India Stack and financial inclusion taught us that public digital infrastructure can create a radical transformation in social outcomes when designed with a regulated and shared back-end that enables a number of (sometimes new!) private players to innovate on the front end to deliver better services. After all, innovative companies like Uber or Amazon are built on digital infrastructure: the TCP/IP Internet protocol and GPS systems that were both funded by public research. iSPIRT targets societal challenges by setting an ambitious target that forces us to think from first principles and innovate on the right digital public goods – which then catalyses a private ecosystem to help reach the last mile and solve the challenge at scale.

Over the last three years, members of our Health Stack team have been thinking deeply about how to design for a radical transformation in healthcare outcomes. We have developed a trusted working relationship with the National Health Authority and the Ministry of Health to better understand their operations and the issues at play. Our approach to addressing the challenge is evolving every day, but we’ve now developed a hypothesis around a set of building blocks that we believe will catalyse the health system. These blocks of digital infrastructure will, we hope, improve capacity at the edges of the system and realign institutional incentives to solve for long term holistic healthcare for all. 

Health Stack Digital Building Blocks Overview (Work in Progress!)

Some further teasers to our approach are included in the attached writeup which provides an overview of some of the more mature building blocks we hope to implement in the coming year. 

We’re striving for an end state of healthcare that looks something like this (cut by population type on the left):

These ideas were presented by the team recently to Bill Gates in a closed-door meet last month (who said he was excited to see what we could accomplish!)

We need your help!

To help shape our ideas and make them a reality, we need more volunteers — particularly those with the following expertise:

  1. Technical Experts (e.g. microeconomists or engineers): We have a few building blocks with broad design principles that need fleshing out – for instance, a Matching Engine to between individuals and doctors/hospitals. If you are a microeconomist (especially if you have thought about bidding/auction design for a matching engine, and more generally want to solve for misaligned incentives in market structure) or you’re a techie interested in contributing to solve a problem at a national scale, please reach out! Prior expertise in healthcare is not a prerequisite. Also, if you’ve looked through the document and find a block where you think your technical expertise could help us build, certainly let us know. 
  2. Current and Future HealthTech Entrepreneurs: Often, a successful health tech startup requires some public infrastructure to be successful. For instance, a powerful rating and recommendation app need a trusted electronic registry of doctors and hospitals providing core master data. Many of our Health Stack modules are designed to catalyse private sector participation and market potential for better products and services, which in turn produce better outcomes for individuals. If you are interested in helping design public infrastructure that your company could use or are a potential health tech entrepreneur interested in learning more about the ecosystem by building for it, please let us know!
  3. Healthcare Policy/Program Implementation Expertise: Field experience in healthcare delivery is invaluable – it gives us a true sense of the real challenges on the ground. If you’ve worked in delivering healthcare programs before with government, a non-profit, the private sector, an international organisation, or philanthropy and have ideas on what’s needed for an improvement in the sector at national scale, we’d love to hear from you. 
  4. Market making/ Health Stack Evangelisation: Any technology is only as good as its adoption! As some building blocks of the health stack get implemented, we are looking for volunteers who can help evangelise and drive its adoption.

India’s potential in the health sector is tremendous – partly because we have an opportunity to redesign not just the technology foundation (which is a near-greenfield) but also the market structure. With the right team, we hope to orchestrate an orbit shift in the quality and affordability of healthcare across the country.  

To volunteer, please reach out to [email protected] and [email protected] 

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Announcement: iSPIRT Foundation & Japan’s IPA to work together on Digital Public Platforms

Information-technology Promotion Agency, Japan (IPA), Japan External Trade Organization (JETRO), and the Indian Software Product Industry Roundtable (iSPIRT) have shared common views that (i) our society will be transformed into a new digital society where due to the rapid and continued development of new digital technologies and digital infrastructure including digital public platforms, real-time and other data would be utilized for the benefit of people’s lives and industrial activities, (ii) there are growing necessities that digital infrastructure, together with social system and industrial platforms should be designed, developed and utilized appropriately for ensuring trust in society and industry along with a variety of engaged stakeholders and (iii) such well-designed digital infrastructure, social system and industrial platforms could have a great potential to play significant roles to improve efficiencies of societal services, facilitate businesses, realize economic development and solve social issues in many countries. 

Today, we affirm our commitment to launching our cooperation and collaboration through the bringing together of different expertise from each institution in the area of digital infrastructure, including mutual information sharing of development of digital infrastructure, in particular, periodic communication and exchange of views to enhance the capability of architecture design and establishment of digital infrastructure. We further affirm that as a first step of our cooperation, we will facilitate a joint study on digital infrastructure, such as (i) the situation of how such digital infrastructures have been established and utilized in India, Japan and/or other countries in Africa or other Asian regions (the Third Countries) as agreed among the parties, (ii) how the architecture was or can be designed for digital infrastructure as a basis for delivering societal services in the Third Countries and (iii) what kind of business collaboration could be realized, to review and analyze the possibility of developing digital infrastructure in the Third Countries through Japan-India cooperation. We may consider arranging a workshop or business matching as a part of the joint study to figure out realistic use cases.

Our cooperation is consistent with the “Japan-India Digital Partnership” launched between the Ministry of Economy Trade and Industry, Government of Japan and the Ministry of Electronics and Information Technology, Government of India in October 2018. We will work closely together and may consider working with other parties to promote and accelerate our cooperation if necessary.

For any clarification, please reach out to [email protected]

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Bharat Calling In Bay Area

In the first week of October, around Dussehra, a bunch of Indians gathered in the Bay Area. The setting had nothing to do with Dussehra, it had more to do with whether they would be spending their next Dussehra while settled in India or in the Bay Area.

iSPIRT conducted two sessions around opportunities emerging in India, spurred by new digital public goods that are going to create a Cambrian explosion of new software products.

The startup activity in India over the past few years has been noted by Silicon Valley and the attendees had a keen interest to discuss what has been happening on the ground.

There were two primary tracks to the discussion:

  • how India has changed in the past decade or so and 
  • what factors have contributed to that radical change

The largely held view of the ecosystem among those gathered was of the 2008 – 2014 period, when the majority of them were last in India, studying or working.

The concerns raised about starting up were around ease of doing business and culture at the workplace but the consensus was that things are improving in these regards.

The keywords that came up to describe the factors causing the change in India were Jio, Modi and so on. However, the fascinating point to learn for all was about the rise of digital public goods and how they are fundamentally changing the market playground in India.

Many had heard of UPI (Unified Payment Interface) and rightfully so, credited Government for it but what awed everybody was how it came about with the effort of a bunch of volunteers believing in the idea of open-source public good and making India a ‘Product Nation’.

Everyone agreed that a new growth journey lies ahead for India, created by factors such as the rise of internet users, internet penetration with Jio, high data consumption and user education that comes along with it. However, it will get catalysed further when coupled with digital public goods.

UPI has been a success story and it crossed more than a billion transactions last month and had overtaken global volume of American Express months back! A number of successful companies like JusPay and PhonePe capitalised on UPI and similar opportunities now lie ahead with :

We dived into specifics of all these to discuss myriad product opportunities that will emerge, enabling new success stories.

This will further be enabled by :

  • Talent that is more agile and honed to operate in an ambiguous startup environment. This has turned around in the past few years, while a lot of talent was tuned to work in a corporate environment earlier.
  • More access to seed capital as more startup operatives have gained wealth and experience in the past few years
  • And parents are more supportive of the idea to join a startup or start one!

Capitalising on all these would need a new entrepreneur archetype that operates from first principles thinking to dig deep in the market and create viable products and business models taking advantage of unique local factors.

Volunteering with iSPIRT can act as a good channel to understand the market better, to get involved with understanding and building digital public goods that are shaping the times ahead in the country.

It’s the forum to engage with peers that help you learn more about yourself, discover your flow that brings joy and contribute towards a public good.

One attendee summed up the takeaway beautifully –

“In the US, I have created a professional career and learnt lessons by building on top of platforms in the West. Now, there are similar opportunities to build on top of platforms and participate in Indian playground. If I get to become an iSPIRT volunteer, I can not only build on top but also help build the very platforms that are driving India forward.

In my own backyard, I have the local know-how to build for India and should act on it, instead of watching Chinese and Western apps put their stake from Kashmir to Kanyakumari.”

To know more about emerging public goods, iSPIRT Foundation and know our volunteering model, check out www.ispirt.in and write to [email protected]

We would like to thank Jaspreet from Druva, Anand Subbarayan from Lyft for hosting us, Hemant Mohapatra from Lightspeed Partners for helping with the setup and our local volunteer Pranav Deshpande.

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Indian Software Product Registry – All That Product Companies Need to Know

Earlier this year, National Policy on Software Products was rolled out to create a robust, participatory framework to bring together industry, government and academia on a common platform to make India as a global hub for software products development. This is a much-needed initiative to provide holistic and end-to-end support to the Indian software product ecosystem. The registry is the first step among many towards solving the real problems of the industry and nurturing the software product companies. If done right, this initiative will have immense potential and far-reaching impact to benefit the industry.

Under this policy, one of the key initiatives is the set-up of the Indian Software Product Registry (ISPR) through industry ownership. It is a collaborative platform which will act as national coordination, facilitation and inter-connected centre for all activities related to the Indian software product ecosystem.

The main purpose of this policy is to focus towards the promotion of Indian software products which are defined as under for implementation:

  • Indian Company: As per sub-section 26 of section 2 of the Income Tax Act, 1961, “Indian company” means a company formed and registered under the Companies Act, 1956 or Companies Act, 2013,  provided that the registered office or, as the case may be, principal office of the company, corporation, institution, association or body in all cases is in India.
  • Indian Software Product Company (ISPC):  An ISPC is defined as an Indian company in which 51% or more shareholding is with Indian citizen or person of Indian origin and is engaged in the development, commercialisation, licensing and sale /service of software products and has IP rights over the software product(s).

ISPR aims to create a platform to enable discovery of Indian Software Product Companies and their products while simultaneously giving automatic access to the Government e-Marketplace (GeM) platform. This will enable the government to identify Indian companies as part of their buying process. However, more work on specific allocation of government buying and redeveloping of RFP’s in government for products will also be initiated so that the government can finally buy Indian products.

Secondly, by listing on exchange on ISPR will enable MEITY to get a better understanding of the industry so that specific product-related interventions like recurring payments for SaaS companies, credits for R&D to enable Indian companies to invest in research and development, and facilitation of Indian software product industry for providing fiscal incentives, if any, at a later stage among others will also be achieved.

Thirdly, ISPR will also enable Indian Software Product Companies to list their products here and connect to buyers across the world. Since this is a government-backed platform, it provides a high level of trust and authenticity in the global market. 

Indian Software Product Companies can register here.  For any more queries, please feel to reach out on [email protected].

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The Global Stack: A Manifesto

In 1941, soon after he had secured an unprecedented third term as President of the United States, Franklin D. Roosevelt mobilised the US Congress to pass the Lend-Lease Act. Its context and history are storied. British Prime Minister Winston Churchill famously wrote to FDR requesting material assistance from the United States to fight Nazi Germany — “the moment approaches when we shall no longer be able to pay [to fight the war]”. FDR knew he would not get the American public’s approval to send troops to the War (Pearl Harbor was still a few months away). But the importance of securing the world’s shipping lanes, chokepoints, manufacturing hubs and urban megalopolises was not lost on the US President. Thus, the Lend-Lease Act took form, resulting in the supply of “every conceivable” material from the US to Britain and eventually, the Allied Powers: “military hardware, aircraft, ships, tanks, small arms, machine tools, equipment for building roads and airstrips, industrial chemicals, and communications equipment.” US Secretary of War Henry Stimson defended the Act eloquently in Congress. “We are buying…not lending. We are buying our own security while we prepare,” Stimson declared.

The analogy is not perfect, but FDR’s Lend-Lease Act offers important lessons for 21st century India’s digital economy. Our networks are open; our public, electronic platforms are free and accessible to global corporations and start-ups; our digital infrastructure is largely imported; and — pending policy shifts — we believe in the free flow of information across territorial borders. India has made no attempt, and is unlikely in the future, to wall off its internet from the rest of the world, or to develop technical protocols that splinter its cyberspace away from the Domain Names System (DNS). While we have benefited immensely from the open, global internet, what is India doing to secure and nourish far-flung networks and digital platforms? The Land-Lease Act was not just about guns and tanks; a quarter of all American aid under the programme comprised agricultural products and foodstuff, including vitamin supplements for children. The United States knew it needed to help struggling markets in order to build a global supply chain that would serve its own economic and strategic interests. Indeed, this was the very essence of the Marshall Plan that followed a few years later.

In fact, India’s digital success story itself is a creation of global demand. When the Y2K crisis hit American and European shores, Indian companies stepped up to the plate and offered COBOL-correction ‘fixes’ at competitive rates. In the process, Western businesses saved billions of dollars — and Y2K made computing ubiquitous in India, which in turn, added great value to the country’s GDP. 

Therefore, there are both security-related concerns and economic consequences that should prompt India to develop “digital public goods” for economies across Asia, Europe and Africa. Can India help develop an identity stack for Nigeria — a major source of global cyberattacks — that helps Abuja mitigate threats directed at India’s own networks? Can we develop platforms for the financial inclusion of millions of undocumented refugees across South and Southeast Asia, that in turn reduces economic and political stress on India and her neighbours when confronted with major humanitarian crises? Can we build “consent architecture” into technology platforms developed for markets abroad that currently have no data protection laws? Can we nurture the creation of an open, interoperable and multilateral banking platform that replaces the restrictive, post-9/11, capital controls system of today with a more liberal regime — thus spurring financial support for startups across India and Asia? Can India — like Estonia — offer digital citizenship at scale, luring investors and entrepreneurs who want to build for the next billion, but do not have access to Indian infrastructure, markets and data? These are the questions that should animate policy planners and digital evangelists in India. 

The Indian establishment is not unmindful of the possibilities: in 2018, Singapore and India signed a high-level agreement to “internationalise” the India Stack. The agreement has been followed up with the creation of an India-Singapore Joint Working Group on fintech, with a view towards developing API-based platforms for the ASEAN region. As is now widely known, a number of countries spanning regions and continents have also approached India with requests to help build their own digital identity architecture. 

But the time has come to elevate piecemeal or isolated efforts at digital cooperation to a more coordinated, all-of-government approach promoting India’s platform advancements abroad. The final form of such coordination may look like an inter-ministerial working group on digital public goods, or a division in the Ministry of External Affairs devoted exclusively to this mission. Whatever the agency, structure or coalition looks like within government, its working should be underpinned by a political philosophy that appreciates the strategic and economic value accrued to India from setting up a “Global Stack”. In 1951, India was able to successfully tweak the goals of the Colombo Plan — which was floated as a British idea to retain its political supremacy within the Commonwealth — to meet its economic needs. Working together with our South Asian partners and like-minded Western states like Canada, we were able to harvest technology and foreign expertise for a number of sectors including animal husbandry, transportation and health services. India was also able, on account of skilful diplomacy, to work around Cold War-era restrictions on the export of sensitive technologies to gain access to them.

That diplomacy is now the need of the hour. The world today increasingly resembles FDR’s United States, with very little appetite to forge multilateral bonds, liberal institutions, or rules to create effective instruments of global governance. It took tact and a great deal of internal politicking from Roosevelt to pry open the US’ closed fist and extend it to European allies through the Lend-Lease Act. India, similarly, will need to convince its neighbours in South Asia of the need to create platforms at scale that can address socio-economic problems common to the entire region. This cannot be done by a solitary bureaucrat working away from some corner of South Block. New Delhi needs to bring to bear the full weight of its political and diplomatic capital behind a “Global Stack”. It must endeavour to create centripetal digital highways, placing India at the centre not only of wealth creation but also global governance in the 21st century.

The blog post is authored by Arun Mohan Sukumar, PhD Candidate at The Fletcher School at Tufts University, and currently associated with Observer Research Foundation. An edited version of this post appeared as an op-ed in the Hindustan Times on October 21, 2019.

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#7 Healthcare leapfrog – but where is the problem?

When was the last time you skipped a movie for a workout, or chose a salad over a pizza? Or, actually got your annual tests done – annually? Or, visited a doctor without seeking a second opinion? Or, took your pills without constant reminders?
These are problems even for someone who can afford the time and access to read blogs online. Now let’s move on to Bharat (i.e., all Indians except the affluent ~30 million families). 

Remember the Gorakhpur hospital deaths last year? Or, the recent Bihar encephalitis crisis? Here are some more boring stats – more than half the doctors in the country practise without any medical qualification, less than 20% of our population has access to secondary and tertiary care, more than 7% get pushed into poverty because of expenditure on healthcare every year. Be it tuberculosis, diabetes, anaemia or cancer – India shares one of the highest, if not the leading, burden of disease globally.

So, where is the problem? It’s everywhere! 

Let’s step back a little. There are constraints, and then there are problems. Problems are those that can and should be addressed. Constraints, however, are things that are almost impossible to change. For example, there just aren’t enough qualified doctors in the country. Or, a single-payer and provider system (i.e., our public health system) simply cannot address all the healthcare needs of the country. It is impossible to create a large pool of doctors in a short amount of time. Similarly, we are bound to have multiple payers and providers, each of whom has fundamentally misaligned incentives. These constraints are inherent in the system.

The question is – can problems be solved while operating under these constraints?

If we were to look at the problems, they would broadly be classified as the following:

  1. Supply (quality, affordability and accessibility): Improving quality, affordability and accessibility is indeed a necessary first step. While it is important to strengthen the existing infrastructure, certain initiatives and technologies can help accelerate this process. For example, the Ayushman Bharat Yojana is already addressing affordability at secondary and tertiary care levels for the vast majority of the population. Similarly, the combined use of low-cost screening and diagnostic devices, telemedicine and clinical decision support systems can enable even minimally trained professionals to deliver care, especially at the primary care level – making it good, affordable and accessible.

  2. Demand (health-seeking behaviour for preventive care and adherence): Even an excellent care delivery system would fail if people didn’t avail the services or didn’t stick to the recommendations offered as part of these services. This is precisely the problem in healthcare. Very few people actually engage in preventive care or adhere to the recommendations or treatment plan prescribed by a caregiver. It would require a very savvy use of point-of-care devices (that enable convenient at-home/doorstep testing, monitoring and instant diagnosis at affordable prices) and behavioural economics hacks (nudges) to bring about this behavioural change.

  3. Misaligned incentives (between provider-provider and payer-provider): An eye-care provider that I spoke to explained this to me. Even though this provider focused on cataract surgeries, it often ended up carrying out screening camps and post-op follow-up care for its patients. This was because of a lack of referrals – even if small providers/ general practitioners detected disease in the patient, they would not refer the patient upward for fear of losing to another provider. In other words, upward referrals don’t happen because downward referrals don’t happen. Similarly, the fundamentally misaligned incentives between payer and provider (which we talked about at length in this post) result in issues like procedure inflation and delayed intervention. How can this be addressed?

What’s missing?

As mentioned in one of our previous posts, we think the answer might lie in the concept of care intermediaries. As the name suggests, these will be new types of independent entities that are different from payers and providers. They will act as agents of the patient and aid in decision making. Specifically, they will play the following roles: (a) aggregation, (b) nudges, (c) referrals, (d) audits. With care intermediaries in the picture, let us understand what the new normal would be:

  1. The care intermediary predicts preventive care-seeking behaviour, disease incidence and adherence patterns. It uses this intelligence to distribute appropriate gamifier policies to customers. As an aggregate buyer of these policies, it is able to provide them at reasonable costs to the end consumers while also providing for its own sustenance.
  2. Every person who has a gamifier policy is now nudged by the care intermediary to seek preventive care. The care intermediary also carries out appropriate screening and diagnostic tests for its consumers.
  3. For the consumers identified with a need, the care intermediary then becomes a part of the referral workflow, and makes recommendations to the patient for both procedure and provider selection. 
  4. Lastly, the care intermediary facilitates downward referrals and nudges the patients to adhere to the prescribed post-treatment care plans. 

There could be many manifestations of the care intermediary – for example, it may partner with local community health workers to carry out screening and adherence management. Or, it could partner with primary caregivers for providing the actual referral recommendation to a patient. In other cases, such as seeking a major tertiary care treatment like surgery, the patient may directly consult the CI for recommendations.

What’s next?

What will the business model of a care intermediary be? How will it make credible recommendations?  Who will it partner with? What are the checks and balances required? What is needed from a privacy perspective?

The idea of a care intermediary is new, and a lot still needs to be worked out!
If you would like to share feedback or volunteer with us to help with this effort, please reach out to me at [email protected].

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Fireside Chat: Vinod Khosla and Nandan Nilekani in Conversation with Sharad Sharma

Join us for a conversation with Vinod Khosla and Nandan Nilekani. Together with Sharad Sharma, our fireside chat host, they will talk about what it means to be an entrepreneur in India today and how these entrepreneurs can solve the hardest problems of India.

Vinod Khosla and Nandan Nilekani are arguably two of the most influential thinkers and innovators of our time when it comes to transformation, entrepreneurship, and large scale impact. Born within 6 months of each other, both graduated for IITs, created iconic companies, become billionaires in the in aprocess and continue to innovate and transform the world.

What better opportunity than to hear these icons of industry at a fireside chat discussing the most intriguing aspects of startups, entrepreneurship, digital transformation and India’s growth towards a multi trillion dollar economy.

About Mr. Vinod Khosla

Vinod Khosla is the founder of Khosla Ventures, a premier Silicon Valley venture capital firm, and a member of the 2018 Midas List. His firm, Khosla Ventures, invests in a wide variety of startups ranging from Healthcare, Sustainable Energy, Food/Agriculture to Space, AI and Robotics. He co-founded Sun Microsystems in 1982 after which he spent 18 years at venture capital firm Kleiner Perkins Caufield & Byers before launching his own fund.

About Mr. Nandan Nilekani

Nandan Nilekani is the co-founder of tech giant Infosys and currently back as a non-executive chairman affecting a remarkable turnaround. In 2009, he was made a Cabinet Minister and Chairman of UIDAI – India’s mammoth National ID project – Aadhaar.  After Aadhaar, Nandan has actively supported India’s digital transformation through the IndiaStack initiatives in payments, digital locker, eSignature and other services. Nandan has also backed startups in the India ecosystem.

About Mr. Sharad Sharma

Sharad Sharma is the co-founder of iSPIRT and has worn many hats as CEO of Yahoo India R&D, Chair of NASSCOM Product Forum and as intrapreneur at AT&T. He is a passionate evangelist and an active investor in the software product ecosystem in India.

When?

2nd of August, 2019 from 18:00 – 19:30 hrs.
Venue to be disclosed. 

How to participate?

You can be a part of this Fireside Chat by registering here. Confirmed participants will be intimated by the 28th of July via email. 

Please note, due to limited seating at the venue we will not be able to accommodate everyone who applies.

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Data Empowerment and Protection Architecture Explained – Video

More commonly known as the ‘Consent Layer of the India Stack’, Data Empowerment and Protection Architecture (DEPA) is a new approach, a paradigm shift in personal data management and processing that transforms the currently prevalent organization-centric system to a human-centric system. By giving people the power to decide how their data can be used, DEPA enables the collection and use of personal data in ways that empower people to access better financial, healthcare, and other socio-economically important services in a safe, secure, and privacy-preserving manner.

It gives every Indian control over their data, democratizes access and enables the portability of trusted data between service providers. This architecture will help Indians in accessing better financial services, healthcare services, and other socio-economically important services.The rollout of DEPA for financial data and telecom data is already taking place through Account Aggregators that are licensed by RBI. It covers all asset data, liabilities data, and telecom data.

We, at iSPIRT, organised a learning session on the 18th of May, to give relevant and interested stakeholders a detailed primer on DEPA. We had 60-odd very animated and engaging people in the audience. The purpose of the session was to understand the technological, institutional, market and regulatory architecture of DEPA, it impacts on existing data consuming businesses and how people could contribute to this new data sharing infrastructure that’s being built in India.

The session was anchored by Siddarth Shetty, Data Empowerment And Protection Architecture Lead & Fellow, iSPIRT Foundation (Email – sid@ispirt.in). Please feel free to reach out to him for any queries regarding DEPA.

For other queries, please write to [email protected].

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#6 Healthstack session at LetsIgnite

We had the chance to conduct a discussion on the National Health Stack during the LetsIgnite event organized by the LetsVenture team on 15th June at the Leela Palace. The audience comprised of early stage healthcare startups along with angel investors and venture capitalists having keen interest in healthcare investments. Some notable attendees included Dr. Ramesh (senior cardiologist, MD Endiya Partners) and Mr. Mohan Kumar (Partners, Norwest Venture Partners).

Sharad Sharma (co-founder, iSPIRT), Dr. Santanu Chatterjee (Founder, Nationwide Primary Care), Dr. Ajay Bakshi (Founder Buddhimed Technologies, ex-India CEO Parkway Pantai) and Arun Prabhu (Partner, Cyril Amarchand Mangaldas) had been invited to lead the session, which was moderated by Anukriti Chaudhari and Priya Karnik, both core volunteers at iSPIRT championing the health stack initiative.

The context was set by an interactive talk by Sharad who began by giving a glimpse of the underlying philosophy of the iSPIRT Foundation – the idea of building public goods as digital technology stacks which can be leveraged by private players to serve Bharat. . Sharad described societal change in India being a Jugalbandi between digital public infrastructure, market participants and policy makers to achieve the same. He mentioned how the India Stack was changing the face of fintech in India and that the Health Stack could do the same for healthcare. The audience was more than startled to hear that a day prior to the session, the number of UPI transaction in India were already one-sixth of what MasterCard had done worldwide. ( UPI has only been around for 33 months! ). Sharad then went on to explain the different layers of the Health Stack comprising National Registries, standardised health information flows, an insurance claims management software built upon a standard Policy Markup Language and a gamifier policy engine. He didn’t miss reminding the audience that the Health Stack was being built to solve for the healthcare needs of ‘Bharat’and not the privileged 30 million Indian families already being well-served by the healthcare conglomerates in urban areas.

With the context in place, Anukriti took over to give a background of the healthcare landscape in India. India struggles with a 1:1600 doctor to patient ratio with more than 60% of doctors and hospitals concentrated in urban regions. To add to that, the public expenditure for healthcare is just 3.9% of our annual GDP (compared to 18% in the US) and it’s not surprising that most deaths in public healthcare facilities happen because of poor quality of care. Health insurance penetration barely touches 20% with OOP expenditure dominating the healthcare spending in India. With a huge underserved population, the need of the hour is to leap-frog to scalable solutions that can reach the masses instead of incremental linear growth solutions to address the Indian healthcare challenges. The different layers of Health Stack make it much easier for innovators (both public and private) to develop radical solutions.. While funding in healthcare startups has increased over the last 5 years, it still significantly lags behind areas like fintech, e-commerce, ed-tech, etc. Moreover, the bulk of healthtech investments have been focused on the consumer tech sector. Anukriti ended her views with a futuristic optimism regarding the innovations that Health Stack could open, to make healthcare truly affordable, accessible and high quality.

We were fortunate to have Dr. Santanu and Dr. Bakshi give insights about the Health Stack with their on-ground experiences in healthcare spanning over decades. Dr. Santanu mentioned that for primary care, the national registry of care providers was very fundamental to ascertain ‘which stakeholder provides what’ given that almost every provider is somewhere involved in primary care. On top of that, he stressed about the need for Artificial Intelligence backed clinical support systems that seamlessly integrate with the doctor’s workflow. This is of particular relevance for rural healthcare settings wherein, despite various efforts, there aren’t enough doctors to setup shops in villages . A standardized health information layer, along with data transfer mechanisms, could be the driving force for this. He was, however, wary of how well standard insurance schemes would work for primary care as the insurance business model falls apart given that almost everyone needs access to primary care at some point or the other. Priya resonated with his views and further suggested that for ‘Bharat’, micro insurance policies could be the key mechanism to drive insurance adoption at the consumer level. Such a system could potentially be facilitated by a claims engine platform build upon a standard policy markup language to ‘almost-automate’ (auto-adjudicate) the claims addressal process.

Dr. Bakshi contended that for a stable society, healthcare and education are a must, as the former secures our ‘today’ while the latter secures our ‘tomorrow’. Having worked as the CEO of three major hospital chains in India, he accepted (without an iota of political correctness) that as a nation, we have failed miserably in providing either. Healthcare is a social good and nowhere in the world has it been solved by private players alone (given the way private incentives are aligned). The public sector in India hasn’t stepped up which is the reason that private players dominate the quality healthcare delivery which could lead us (or is perhaps already leading) to following the footsteps of the US. This is an alarming trend because in the short and medium term, India cannot afford to outsource the entire healthcare delivery to private players. Dr. Bakshi remarked that to set things on the correct track, the Health Stack is a very important initiative and congratulated the iSPIRT team for working ardently to make it happen. He however suggested all stakeholders to be privy of the fact that while fintech transactions are linear (involving the payer and the recipient), a healthcare ‘transaction’ involves multiple aspects like the doctor’s opinion, investigation, drugs, nurses, ward boys and many other layers. This underlying multidimensionality would make it difficult to replicate an India Stack kind of model for the healthcare setting. At the core of the healthcare transaction lies the ‘doctor-patient’ interaction and it is imperative to come but with some common accepted standards to translate the healthcare lingo into ‘ones and zeroes’. He lauded the health information flows  of the Health Stack for being a step in the right direction and mentioned that in his individual capacity, he is also trying to solve for the same via his newly launched startup Buddhimed Technologies.

With two stalwarts of healthcare sitting beside her, Anukriti grabbed the opportunity to put forth the controversial concept of ‘doctors being averse to technology’ which could possibly be a hindrance for Health Stack to take off. Dr. Santanu and Dr. Bakshi were quick to correct her with the simple example of doctors using highly technical machines in providing treatments. They coherently stated that doctors hated Information Technology as it was forced upon them and suggested that IT professionals could do a better job by understanding the workflows and practical issues of doctors and then develop technologies accordingly. This is an important takeaway – as various technologies are conceptualized and built, doctors should be made active participants in the co-creation process.

The idea of a common public infrastructure for healthcare definitely caught the attention of both investors and startup founders. But amidst the euphoria emerged expected murmurs over privacy issues. That was when Arun Prabhu, the lawyer-in-chief for the session, took the lead. He reiterated Dr. Bakshi’s point of the doctor-patient relationship being at the core of the healthcare transactions. Such a relationship is built upon an element of trust, with personal health data being a very sensitive information for an individual. Thus, whatever framework is built for collating and sharing health information, it needs to be breach proof. Arun cited the Justice Srikrishna report to invoke the idea of consent and fiduciaries – a system wherein individuals exercise their right to autonomy with respect to their personal data not by means of ownership (which in itself is an ambiguous term), nor by regimes of negligence or liability but by the concept of a coherent consent mechanism spread across different stakeholders of the healthcare value chain. Moreover, the consent system should be straight-forward and not expressed via lengthy fifty page documents which would make it meaningless, especially for the India 2 and India 3 population. Lastly, he mentioned that just like physical and tangible assets have certain boundaries, even data privacy can have certain realistic limitations. If an information point cannot be specifically identified or associated with a particular individual but can have various societal benefits, it should be made accessible to relevant and responsible stakeholders. Thus, while it is imperative to protect individual health data privacy, there should be a mechanism to access aggregated anonymized health data. There is tremendous value in aggregating large volumes of such data which can be used for purposes like regional analysis of disease outbreaks, development of artificial intelligence based algorithms or for clinical research. Priya added that such a system was inherent in the Health Stack via the Population Health Analytics Engine and the framework for democratisation of aggregate data.

Overall, the session amalgamated various schools of thought by bringing together practitioners, CEOs, CIOs, lawyers, startups and investors on one common discussion platform. This was perhaps an example of the much-needed Jugalbandi that Sharad had mentioned about. A public good is conceptually ‘by the stakeholders, for the stakeholders and of the stakeholders’. This necessitates its active co-creation instead of isolated development. Needless to say, multi-way dialogue is the DNA of such a process. Staying true to that philosophy, we look forward to conducting many such interactive sessions in the future.

Ravish Ratnam is part of the LetsVenture Team – a platform for angel investing and startup fundraising.

He can be reached on [email protected]

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#5 What is the Federated PHR Component of the Health Stack?

PHR – Personal Health Record – is a mechanism to access a longitudinal view of a patient’s health history and be able to use it for different purposes. It is a component of the health stack:


It relies on two building blocks – (a) registries, to know the source of the data; and (b) health identifier, to know whom the data belongs to. Separating out the building blocks with each serving singular functions helps design a more scalable and sustainable system. We follow certain principles for both of these building blocks:

1. Registries are master databases with information about different entities in the healthcare ecosystem, for example, of hospitals, doctors, care beneficiaries, etc. There should be checks and balances built to ensure correctness of data (such as digital signatures, audit trails, etc.), and this information should be made accessible for different use cases (through open APIs, and consent). Opening access to this information will have a positive effect of increased demand, thus improving quality and leading to convergence towards singular sources.

2. Health identifier is a mechanism to integrate a patient’s health records. This identifier should incorporate the following features:

  • The identifier need not be unique. This means that a patient should have the ability to create multiple health identifiers for different health records – think of different digital folders for mental health cases and cancer cases (a common practice in the physical world).
  • The power to unify health records should lie with the patient. In the physical world, this would translate to the patient having the right to either keep two folders or merge them into one. The same should be allowed digitally.
  • Patients should be allowed to use any identifier to verify themselves. However, since we are creating an electronic system of health records, it is important that these be digitally verifiable – such as mobile number, email ID or Aadhaar.

3. Electronic consent, as specified by MeitY, is a mechanism to give consent electronically in a manner that follows the ORGANS Principles – Open, Revocable, Granular, Auditable, Notifiable, Secure.

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With these building blocks in place, we come to features of the PHR architecture:

1. Federated – instead of having a centralised repository of all health records, we propose a federated framework where data resides at the source of generation. This has many benefits – (i) ease of operations, as data is not stored with a single entity (ii) lower costs, as no additional repository is being built (iii) better security, as data is stored at different nodes; and (iv) patient empowerment, as data is being shared directly with the patient.

2. Schema level standardisation – we believe that only standardising the schema without enforcing codification standards (which require a significant behavioural shift) should be sufficient for a number of use cases. Since this standardisation is at an IT systems level, it only requires a one-time mapping and does not require any change in clinical workflows.

3. Health data access fiduciaries – these would be entities that would route the consent and data requests between information users and information providers. In doing so, they would play the role of privacy protection, consent management and user education.

4. Health data vault – this is an option for the patient to store his/ her records in a personal storage space. While most hospitals that capture data continue to store it for a long period of time,  an individual might still choose to store this information separately (for long-term access, trust-deficit between patient and provider, etc.). In such a case, the patient can request a copy of the record to be pushed to his/her health data vault.

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Proposed architecture:

Workflow:

Patient goes to a healthcare provider. At the time of issuance:

Option 1: patient shares mobile number/ email id/ aadhaar no.
1. Provider authenticates user using one of the digital identifiers
2. (a) Provider sends a link to patient for downloading the report. Patient can later link these records with his/ her HDAF; or
2. (b) Patient can sign up with HDAF and search for provider to link records

Option 2: patient shares HDAF ID
1. Provider links patient records to the HDAF

Post linkage, patient can approve requests from data consumers through the HDAF for different use cases.

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We believe that building PHR as a public good will enable interesting use cases to come to life, that would together improve the healthcare ecosystem. While we will continue our quest for these, we would love to receive feedback on our thinking! If you work in this space and have comments, or would like to understand how this could help your product, please drop me a line at [email protected].

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#4 Reimagining Cancer Care

In the last few months, I have had the opportunity to work closely with the National Cancer Grid – a network of 150+ cancer centres in India – and in the process, better understand the workflows involved in different medical processes and the requirements of medical professionals. I have closely observed care delivery, interviewed cancer patients and oncologists, learnt about current challenges and about initiatives being undertaken by NCG and other organisations to tackle them.

This blog post is an evolved version of an earlier post, where I had talked about the use cases of health data and the implementation of a PHR (Personal Health Record). Of these, I believe that the biggest use of health data will be in improving the quality of care in complex medical cases (either acute like surgical procedures, or chronic like cancer). In this post, I will use cancer care to exemplify this.

Core idea
Let us visualise a specific application for cancer care, with oncologists as its primary users. There are only around 1000 trained oncologists in India, so let’s assume that all of them are users of this application. Let us also assume that clinical data of all patients treated by these oncologists is conveniently accessible through this application (with due privacy and security measures). What will these users do now?

Expert consultation
I attended a Virtual Tumour Board run by the National Cancer Grid – a weekly remote consultation program run on Saturday mornings where teams of doctors voluntarily join to discuss well-documented cases and their potential treatment plans. VTBs are run separately for each speciality (like head & neck tumour, gynaecology, neurology, etc.), which means that it takes up to 4-6 weeks for one’s turn. Doctors usually do not have the luxury of such long waiting periods, and therefore turn to individual consultations which are often not documented, depend on informal connects and are sometimes made with incomplete data. Formalising this process and making it asynchronous can be of huge benefit to all medical professionals.

Care team collaboration

Complex medical procedures often involve a team of doctors and other medical professionals, working responsibly for a given patient. A significant percentage of all deaths due to medical negligence is caused by lack of communication between the care team members. The communication process today is paper-based and unstructured, leading to accidents that can, in fact, be prevented – especially with the growing use of IoT devices and voice-based inputs. (I saw one such application at Narayana Health being used by their ICU teams).

Performance evaluation

Lack of organised data, changing patient care-providers and long feedback loops make it difficult for medical professionals to monitor their performance. Can we empower them with tools to do so? Doctors today lack visibility on the outcome of the treatment given and rely on intuition, experience or techniques tested in developed countries for care delivery. Such a tool would not only help doctors improve their performance, but also improve the trust equation with their patients.

User Experience
There are three crucial elements for enabling a good user experience:

Data input – Most EHR systems require text input to be typed in by doctors. This makes it difficult to use. Other input techniques for automated data transcription like touch, voice, or other innovative methods for data capture will need to be explored. Additionally, interoperability across all systems and devices will be key in enabling access to all data.

Data interpretation – Sorting through a patient’s health records takes up a substantial amount of time of a physician, especially when the data is unstructured. Developing intelligence to sort the relevant records as per the case in question will significantly enhance the user experience of the product.

Safety and Privacy– All solutions should ensure complete privacy of patients. This could mean access controls, electronic consent, digital signatures, digital logs, tools for data anonymisation, etc. it might also be important to perform basic verification of users of the platform.

Value Discovery
The value of the platform will increase as more and more physicians become a part of it. For example, an endocrinologist might need to consult a cardiologist in a case of disease progression, or an ENT specialist might need to consult an oncologist to confirm a diagnosis. More importantly, the platform will also drive innovation, i.e., other use cases can be developed on top of it. For example, the expert opinions mentioned above can also be used for consulting patient remotely, pre-authorising claims, forming medical peer review groups, etc. Similarly, working care groups can also simultaneously enrol staff for upskilling (as practised today in an offline setting), and information about treatment outcomes can help guide better research.

Next steps
We remain on a quest to find use-cases for PHR since we believe technology pilots alone would not be enough to drive its adoption. In that context, we are looking for partners to experiment with this in different healthcare domains. If you are interested, please reach out to me at [email protected]!

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#3 What does the Health Stack mean for you?

The National Health Stack is a set of foundational building blocks which will be built as shared digital infrastructure, usable by both public sector and private sector players. In our third post on the Health Stack (the first two can be found here and here), we explain how it can be leveraged to build solutions that benefit different stakeholders in the ecosystem.

Healthcare Providers

  • Faster settlement of claims: Especially in cases of social insurance schemes, delay in settlement of claims causes significant cash-flow issues for healthcare providers, impacting their day-to-day operations. The claims and coverage platform of the health stack is meant to alleviate this problem through better fraud detection and faster adjudication of claims by insurers.
  • Easier empanelment: The role of facility and provider registry is to act as verified sources of truth for different purposes. This means a convenient, one-step process for providers when empanelling for different insurance schemes or providers.
  • Quality of care: The use of personal health records can enable better clinical decision making, remote caregiving and second opinions for both patients and medical professionals.

Insurers

  • Faster and cheaper settlement of claims: claims and coverage platform, as described above
  • Easier empanelment of healthcare providers: registries, as described above
  • Diverse insurance policies: In addition to the above benefits, the policy engine of the healthstack also seeks to empower regulators with tools to experiment with different types of policies and identify the most optimum ones

Researchers and Policymakers

  • Epidemiology: the analytics engine of the healthstack can be helpful in identifying disease incidence, treatment outcomes as well as performance evaluation of medical professionals and facilities
  • Clinical trials: a combined use of analytics and PHR can help in identifying requirements and potential participants, and then carrying out randomised controlled trials

How can it be leveraged?

While the healthstack provides the underlying infrastructure, its vision can be achieved only if products benefitting the end consumer are built using the stack. This means building solutions like remote second opinions using health data from healthcare systems, as well as developing standard interfaces that allow existing systems to share this data. In the diagram below, we elaborate on potential components of both of these layers to explain where innovators can pitch in.

If you are building solutions using the health stack, please reach out to me at [email protected]!

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Decoding the Aadhaar (Amendment) Bill – PMLA Amendment

The amendment made by way of the Aadhaar and Other Laws (Amendment) Bill, 2018 to the Prevention of Money Laundering Act,2002 gives true effect to the intention of the Hon’ble Supreme Court as set out in their judgment of September 2018.

It is clear from the judgment that the objective was to empower the individual and allow for the resident to be able to uniquely identify herself to avail of every service of her choice while ensuring that there are adequate protections for such use under the force of law.

Aadhaar Act Amendment

This is clearly set out in the now amended Section 4(3) of the Aadhaar (Targeted Delivery of Financial and Other Subsidies, Benefits and Services) Act, 2016 (the “Aadhaar Act”) as follows:

Section 4(3) – Every Aadhaar number holder to establish his identity, may voluntarily use his Aadhaar number in physical or electronic form by way of authentication or offline verification, or in such other form as may be notified, in such manner as may be specified by regulations.

Explanation-For the purposes of this Section, voluntary use of the Aadhaar number by way of authentication means the use of such Aadhaar number only with the informed consent of the Aadhaar number holder.

And further in Section 4(4)-

An entity may be allowed to perform authentication if the Authority is satisfied that the requesting entity is-

  1. Compliant with such standards of privacy and security as may be specified by regulations; and
  2. (i) permitted to offer authentication services under the provisions of any other law made by Parliament; or

(ii) seeking authentication for such purpose, as the Central Government in consultation with the Authority and in the interest of the State may prescribe.

With the above amended provisions, it is clarified that (a) the objective is to ensure that the Aadhaar number holder is empowered to establish her identity voluntarily with informed consent (b) Entities that may be permitted to offer authentication services will do so pursuant to a law made by Parliament or by way of Central Government direction in consultation with the UIDAI and in the interest of the State.

PMLA Amendment

The amendment to the Prevention of Money Laundering Act,2002 (the “PMLA”) seeks to give clear direction to the above-enunciated ideas.

The newly inserted Section 11A of the PMLA provides for the manner in which a Reporting Entity may verify the identity of its clients and beneficial owner (conduct KYC). This is by way of offline verification of Aadhaar or where the Reporting Entity is a banking company- online verification of Aadhaar.

However, it is further clarified (in tandem with the aforesaid amendments to the Aadhaar Act) that upon satisfaction of standards of privacy and security, the Central Government may, in consultation with the UIDAI and appropriate regulator provide for online authentication for Reporting Entities other than banking companies.

And it is further explicitly clarified that in the scenarios as contemplated in this provision, nobody will be denied services for not having an Aadhaar number, i.e: ensuring that the presence of Aadhaar number is not mandatory but purely enables and eases the availing of services.

As next steps on this front, distinct Reporting Entities, including NBFCs, Mutual Fund Houses and other financial institutions need to approach the Central Government with requests for access to online Aadhaar authentication services.

Organisations such as DICE would be useful in mobilising groups of different financial institutions in approaching the relevant regulators and Central Government authorities for Aadhaar authentication access.

Saranya Gopinath is the co-founder of DICE (Digital India Collective for Empowerment)- an industry body representation across emerging technology sectors.

She can be reached on [email protected]

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Scaling Good Advice In India’s Startup Ecosystem – A Research Paper On PNGrowth Model

In January 2016 iSPIRT ran the largest software entrepreneur school in India, called PNgrowth (short for Product Nation Growth).  The central vision of PNgrowth was to create a model of peer learning where over 100 founders could give each other one-on-one advice about how to grow their startups. With peer learning as PNgrowth’s core model, this enterprise was supported by a volunteer team of venture capitalists, founders, academics, and engineers.  See iSPIRT’s volunteer handbook (https://pn.ispirt.in/presenting-the-ispirt-volunteer-handbook/)

However, unlike a regular “bootcamp” or “executive education” session, the volunteers were committed to rigorously measuring the value of the peer advice given at PNgrowth. We are excited to announce that the findings from this analysis have recently been published in the Strategic Management Journal, the top journal in the field of Strategy, as “When does advice impact startup performance?” by Aaron Chatterji, Solène Delecourt, Sharique Hasan, Rembrand Koning (https://onlinelibrary.wiley.com/doi/10.1002/smj.2987).

TLDR: Here’s a summary of the findings:

1. There is a surprising amount of variability in how founders manage their startups.  To figure out how founders prioritized management, we asked them four questions:

“…develop shared goals in your team?”
“…measure employee performance using 360 reviews, interviews, or one-on-ones?”
“…provide your employees with direct feedback about their performance?”
“…set clear expectation around project outcomes and project scope?”

Founders could respond “never,” “yearly,” “monthly,” “weekly,” or “daily.”

Some founders never (that’s right, never!) set shared goals with their teams, only did yearly reviews, never provided targets, and infrequently gave feedback. Other, super-managers were more formal in their management practices and performed these activities on a weekly, sometimes daily, basis. Not surprisingly, the supermanagers led the faster-growing startups.  Most founders, however, were in the middle: doing most of these activities at a monthly frequency.

2. Since PNGrowth was a peer learning based program, we paired each founder (and to be fair, randomly) with another participant. For three intense days, the pairs worked through a rigorous process of evaluating their startup and that of their peer. Areas such as a startup’s strategy, leadership, vision, and management (especially of people) were interrogated. Peers were instructed to provide advice to help their partners.

3. We followed up on participating startups twice after the PNgrowth program. First ten months after the retreat, and then we rechecked progress two years afterwards.

We found something quite surprising: the “supermanager” founders not only managed their firms better but the advice they gave helped their partner too.  Founders who received advice from a peer who was a “formal”  manager grew their firms to be 28% larger over the next two years and increased their likelihood of survival by ten percentage points. What about the founders who received advice from a laissez-faire manager? Their startup saw no similar lift. Whether they succeeded or failed depended only on their own capabilities and resources.

4. Not all founders benefited from being paired up with an effective manager though. Surprisingly, founders with prior management training, whether from an MBA or accelerator program, did not seem to benefit from this advice.

5. The results were strongest among pairs whose startups were based in the same city and who followed up after the retreat. For many of the founders, the relationships formed at PNgrowth helped them well beyond those three days in Mysore.

So what’s the big take away: While India’s startup ecosystem is new and doesn’t yet have the deep bench of successful mentors, the results from this study are promising. Good advice can go a long way in helping startups scale.   iSPIRT has pioneered a peer-learning model in India through PlaybookRTs, Bootcamps, and PNgrowth (see: https://pn.ispirt.in/understanding-ispirts-entrepreneur-connect/).

This research shows that this model can be instrumental in improving the outcomes of India’s startups if done right. If peer-learning can be scaled up, it can have a significant impact on the Indian ecosystem.