Rebooting India: Realizing a Billion Aspirations (27 page)

The fear of being dragged in front of an inquiry committee tends to make bureaucrats risk-averse and in doing so, stifles innovation.
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While it’s all too easy to deride our bureaucracy as being out of step with society, it is important to remember that the incentive structure under which the bureaucracy operates is completely different from what we may encounter in the private sector. In his book,
Bureaucracy: What Government Agencies Do and Why They Do It
, James Q. Wilson explains in wry detail the competing goals that government agencies must meet: they are expected to fulfil an official mandate laid out for them by the government as efficiently as possible while also treating all citizens fairly, maintaining a certain level of responsiveness to citizen
concerns and acting in a fiscally responsible manner at all times since they are accountable to both the government and the public for every rupee spent. These goals can, and do, often clash. Add to this the amount of time that officials must spend securing government support for various initiatives, and it is not surprising that many government projects are executed in a less than ideal fashion. Building a new class of government institutions will remain a pointless exercise unless we also create new ways of staffing these institutions with the best available talent, a point that was addressed in the 2013 report of the Expert Committee on the HR Policy for e-Governance, a committee chaired by Nandan.
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Throughout this book we have discussed the need for a new operational model of government, the National Information Utility, as being essential to implement technology-enabled solutions to the challenges our country faces today. Such a model must necessarily draw on talent from both sides of the public–private divide, and we must understand and appreciate the strengths that both sides bring to the table. Government employees have a deep understanding of procedures, protocols and how government systems work. They are focused on stability, and on executing projects which can stand the test of time after being implemented on a vast scale. They also understand that government projects are designed to be inclusive, providing benefits to as large a section of the population as possible, rather than being designed to provide a very high level of benefits only to a select few.

On the other hand, the private sector has traditionally focused on profit-making as a goal, which has meant the development of a larger appetite for risk and greater comfort with uncertainty and shifting goals. A high value is placed on the ability to understand and employ technology not just to answer today’s problems, but tomorrow’s as well. Academics and those from non-governmental organizations also have their own, equally valuable perspectives. All of these different viewpoints and experiences must be harnessed and integrated to provide holistic solutions, explained in further detail in the diagram that follows. Some of these boundaries are already starting to blur.
Raghuram Rajan, the current governor of the RBI, is a former academic; his appointment was widely hailed and even credited for halting the precipitous slide of the rupee against the dollar.

Drawing as it did upon expertise from both the public and private sector, the UIDAI could be considered an early forerunner of the NIU, and our experiences provide some idea of the ups and downs such an organization could expect to face. We saw first-hand the effect that an ambitious goal can have on bringing people together to work at their best. As Pramod Varma, Aadhaar’s chief architect, puts it, ‘There was respect for each other, there was a larger goal which brought in the purpose. Issues were overlooked because we were there for a larger goal. Because it was a start-up-like environment, even for government officials, the sense of purpose connected people.’ Speaking from the perspective of his government background, Rajesh Bansal adds, ‘The only way to get such projects to succeed in government is getting people to take ownership, and passion is the incentive for that. Government recruitment processes don’t usually focus on passion for the job as a key criterion.’

Inevitably, some friction arose, and resolving these tensions turned out to be an invaluable learning experience in terms of getting the organization to run smoothly. Much of this friction centred around who ultimately had the power to take official decisions within the UIDAI. Ram Sewak Sharma tells us, ‘Government officers felt that this is a government project and they should have full control on policies and decision-making. On the other hand, resources from the private sector felt that they had been hired to deliver and they should also have the ownership.’ Srikanth Nadhamuni explains, ‘The technology team was holding the vendors on a tight leash, but the fact that the payments were coming from the government gave out mixed signals—who was the vendor really working for? It would have been much easier if a government official had been deputed to work in tandem with us for handling the payments angle—we could have worked together to
resolve technical issues as well as the government payments process.’ Of course, this did happen eventually.

Government comes with its own set of rules and standard operating procedures, many of which are completely unfamiliar to those outside the administrative orbit. Shankar Maruwada says, ‘We had to understand that bureaucrats are primed to follow process and not take risks, which was a big change for us. They have a massive nu mber of rules to follow and we learnt to appreciate the constraints under which they work. We also had to learn that in government, you have to wait for the correct window of opportunity instead of rushing things—the fact that you’re not moving doesn’t mean there’s a lack of progress. Understanding this taught us a lot of patience.’

A common theme was the need to create official positions for those brought laterally into government agencies from the private sector, positions with well-defined powers and responsibilities. As Ram Sewak Sharma puts it, ‘The lesson for me is that we should clearly articulate the roles of people, including the hierarchy, for any government organization in India to work efficiently.’ Ashok Pal Singh adds, ‘You need to provide the flexibility and freedom to function while remaining within the purview of the government.’ This freedom was in evidence at the UIDAI. Pramod recollects, ‘As technologists, we had the kind of large-scale, hands-on product experience that does not commonly exist in government. Members of the initial founding team like R.S. Sharma recognized this and gave us a lot of leeway and support when it came to working out the details.’

Ram Sewak Sharma summarizes it for us, ‘Perhaps we could not achieve perfect harmony between the public and private sector at the UIDAI—five years is a short tenure to change the kind of mental conditioning created by the working environment, whether in the government or outside it. But we need to also remember that this project could not be delivered either by private or by public team alone, and what we did was the only way we could have done it.’

When health is absent, wisdom cannot reveal itself, art cannot manifest, strength cannot fight, wealth becomes useless, and intelligence cannot be applied.

—Herophilus

IN THE SEVEN months of Sarman Siddiki’s brief life, his mother, Moksuda, took him to various government hospitals across the state of West Bengal, trying to get her son’s persistent diarrhoea cured. They lived in a small village two hours away from Kolkata, and Moksuda travelled in trains and buses to get medical care for her child. Many doctors sent Sarman away with prescriptions for medicines; he was admitted to one hospital, sharing a packed ward with children suffering from other contagious diseases. His family spent an entire month’s salary on their son’s treatment, but took him home when it was clear that the overburdened medical staff had little time for him. Sarman’s journey ended at a crowded government hospital in Kolkata, where he became one among forty-one babies who died in a span of six days.
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This is the same city in which the first recorded study of diabetes in India was performed in 1938. At that time, only a thousand of nearly one hundred thousand individuals were found to have the disease; thanks to the twin imperatives of
globalization and urbanization, today over half a million residents of Kolkata are diabetic.
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Nowhere are the paradoxes of India’s rapid economic rise encapsulated better than in the health of its residents. As a nation, we are caught between the devils of our underdeveloped past—malnutrition, high maternal and infant mortality, communicable diseases like tuberculosis and malaria—and the deep sea of sudden prosperity, with an alarming rise in obesity, heart disease, diabetes and other lifestyle-related illnesses. We currently have the world’s second-largest diabetic population, while nearly half of our children continue to be chronically malnourished.
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India has suffered from years of public health policies so inert as to be practically comatose, developments that Nandan traced in
Imagining India
. The situation continues to be grim. As per the Economic Survey of 2013–14, India’s central government spent a measly 1.4 per cent of GDP on healthcare, compared to 3 per cent in China and 8.3 per cent in the United States; our public health spend is among the lowest in the world, and only 33 per cent of this expenditure is funded by public sources.
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The standard of care in government-funded public hospitals varies wildly across the country; the ratio of the number of doctors and hospital beds available to the total population is far below the benchmarks set by the World Health Organization. The lack of easily accessible, high-quality public healthcare has led the private sector to pick up the slack, with private hospitals and clinics mushrooming over the last decade. Faced with ramshackle, poorly staffed and underequipped government hospitals, it isn’t surprising that people make a beeline for private medical facilities even if they are more expensive; over 60 per cent of Indians pay medical costs out of their own pockets.
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For India’s poor, a single health emergency can be sufficient to ensure a lifetime of crippling debt, derailing attempts to overcome poverty; according to the ministry of health, 63 million people every year are faced with ‘catastrophic’ expenditure due to healthcare costs.
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India’s public healthcare system is in desperate need of a massive overhaul. While our existing medical facilities, especially in rural areas,
are inadequate to serve the needs of the population, they are also underutilized by those who prefer private healthcare. Reforming our healthcare system will require changes in policy—including a greater investment from the government—upgrading existing facilities and expanding the reach of public hospitals, clinics and primary care centres.

One way to reach underserved and remote rural areas is by providing medical services over the internet or by phone. India’s private sector has already seen the implementation of telemedicine facilities across hospital chains, allowing doctors to directly interact with and diagnose patients sitting thousands of kilometres away.
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Such facilities can serve as the first point of contact for patients with the healthcare system, and can help to address the problem of building and staffing healthcare clinics in hard-to-reach parts of the country. Another exciting development that must be harnessed is the ability of smartphones to function as diagnostic devices. A cursory search through the online app stores of mobile telephone systems reveals a profusion of apps designed to allow people to monitor their heart rates, track how many calories they’ve burned, and help them manage chronic conditions such as diabetes. A new wave of research is now focused on developing small, mobile phone-compatible sensors that can be used to measure physical parameters, such as a person’s blood glucose level. By simply plugging the sensor into one’s phone, the relevant data can be stored, analysed and transmitted as needed to healthcare professionals. An entire suite of such plug-and-play sensors can allow for multiple health parameters to be monitored simultaneously, and given the size of India’s cellphone user base, could convert even the most basic of primary health care centres into rudimentary diagnostic laboratories.
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While broadening the reach and quality of medical facilities within the country, a second priority for our healthcare system must be focused on lowering costs. A report from the consulting firm Deloitte estimates that between the years 2005 and 2015, the economic impact
of heart disease, stroke and diabetes on the Indian economy was to the tune of over $200 billion in losses—an amount equivalent to 1 per cent of our GDP, putting an enormous strain on our finances.
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The best way to allow for efficient, low-cost patient management is through the creation of electronic health records (EHRs). Today, the average person’s medical history is usually encapsulated in a bulging file full of doctor’s notes, test results, X-rays and scan reports stretching back several years. Medical service providers usually have their own internal data storage systems, which operate completely independent of each other, so it is impossible to track the progression of a particular patient through the medical system.

The surgeon and author Atul Gawande describes an interesting experiment carried out by Jeffrey Brenner, a physician in Camden, New Jersey.
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Brenner started monitoring the flow of patients into Camden’s hospitals, and focused his attention on those patients who cost insurers the most money. As it turns out, these were not people having complex medical procedures or being given expensive medicines—they were people whose illnesses were not being managed correctly, like the man who wasn’t taking his blood pressure pills and was headed for kidney failure as a result. Something as simple as checking to make sure he took his medicines on time was sufficient to improve his health and save the insurers from paying thousands of dollars in dialysis costs.

In the Indian context, Brenner’s model has plenty of applications. For instance, the indiscriminate use of antibiotics and the failure to follow treatment plans has led to the emergence of drug-resistant forms of tuberculosis and other ‘superbugs’, a looming crisis that we are completely unprepared to handle, both medically and financially. If one could monitor all the antibiotics that a person has been prescribed over time, and make sure they have been taken correctly, the problem of antibiotic resistance might be averted. This kind of health monitoring is only possible if every patient has an EHR in a common, standardized and interoperable format. Pioneering initiatives already exist in India, such as the EHRS system implemented by the Apollo chain of hospitals.
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What are the benefits of creating a common, nationwide platform for healthcare? Patients can have easy access to their medical history, without having to save every scrap of paper from every doctor’s visit. After putting in place rules governing privacy, data sharing and access, this data can now be made available to all healthcare providers who can make better-informed decisions. Machine-learning algorithms can be applied to come up with new insights and develop a customized treatment plan for every patient. This data can also be mined to understand larger trends in public health across the country.

In terms of its physical design, we envision that an Electronic Medical Record System (EMRS) will be a service provided by multiple technology service providers. Every provider will conform to a set of interoperability guidelines, allowing users of the platform to pick a vendor of their choice, as well as making it easy to move from one service provider to another. The EMRS will provide interfaces to all stakeholders: hospitals, pharmacies, clinics, insurance companies, diagnostic labs, and so on. For example, a pharmacist can pull up a prescription, doctors can pull up diagnostic test results from labs online, and insurance companies can provide customized quotes based on prior history. The Aadhaar number can serve as the natural patient identifier in this system, and a base level of information can be shared automatically, while the release of additional information will require patient consent—a ‘part public, part private’ model.

Given the sensitivity of the data it holds, an EMRS system must be highly secure and must meet all requirements of patient privacy and data confidentiality. Given the emergence of big data and cloud computing, all records can simply reside online in the cloud, allowing for easy storage and access. The design of the entire EMRS must respect the fact that the medical data of a patient belongs to them, and they can take it with them wherever they want, or download it for personal use. EMRS providers that focus on customer convenience
through such services as smartphone access, offer a simple user experience, have a good track record, and offer competitive pricing, will end up winning the patients’ trust and their wallets.

There are natural questions about what data is stored, and who is allowed to access it. A strong data regulator is essential. In the US, the Health Insurance Portability and Accountability Act (HIPAA), 1996, regulates data sharing and privacy; we need a similar data regulatory body to be set up by the government, whose duties would include the preparation of legislation to govern data sharing and privacy, the laying down of interoperability guidelines and file formats for data sharing based on global standards (such as the HL7 and DICOM standards that govern medical data), and the monitoring of EMRS providers for compliance on an ongoing basis.

The EMRS will be a treasure trove of ‘big data’ that can be mined using analytics to identify public health trends, collect statistical data, perform disease surveillance and detect epidemic outbreaks. Eventually, this information can be combined with other social and environmental data to drive the sort of holistic approach to preventive healthcare that helped to improve quality and cut costs in Camden.

India’s government-run medical facilities are notorious for the absenteeism of staff; a World Bank survey reported that an estimated 40 per cent of primary health clinic staff were missing in action at any given time.
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EMRS would help to monitor the attendance and performance of government healthcare workers in primary health centres and hospitals, as well as Accredited Social Health Activist (ASHA) and Anganwadi workers and other paramedical staff. The EMRS can also be used to track government-run insurance schemes (the Rashtriya Swasthya Bima Yojana scheme is a prime example) by collating data from the EMRS and empanelled insurance providers.

This is an idea that Nandan had mooted with several health secretaries during his time at the UIDAI, but it failed to gain any traction within the administration.

Building an EMRS is a long-term investment, requiring the creation of new legislation, new regulatory bodies and perhaps a new National Information Utility (NIU). In our road map to a healthy India, we envision this NIU to take the form of a National Health Information Network (NHIN), a common platform to bring all players in the health ecosystem under one digital umbrella, paving the way for the creation of a paperless national health network. Given the proliferation of health-linked smartphone apps and wearable diagnostic devices, the NHIN should function as a resource to promote further innovation in these fields by acting as the central repository for all health data in the country.

As all government hospitals and primary healthcare centres come online, the government will be the first driver of t he NHIN, while other players can enter the system over time—an asynchronous design that allows the NHIN to be launched rapidly without having to spend an interminable amount of time ensuring that every single participant is enrolled prior to the launch. In the same way that Aadhaar-linked bank accounts can be used to disburse government payments, the Aadhaar-linked NHIN can be used by the government for health-related payments to individuals, such as benefits through the Janani Suraksha Yojana or incentives for ASHA workers.

Eventually, we expect the payment horizon to encompass the private sector as well; for example, insurance companies that need to pay health service providers under the terms of an insurance policy can use the NHIN to do so. Skilled professionals who understand both medicine and technology will be key in the implementation and rollout of such a system. The ministry of health can create a new department to house a dedicated team with the mandate to build the NHIN ecosystem.

We as a nation can no longer afford to be blasé about short-sighted policies, lopsided development and inadequate funding when it comes to healthcare. With public facilities in a shambles and private facilities unaffordable to the poor, simultaneously afflicted with diseases of
poverty and diseases of affluence, our economy is being insidiously weakened by a workforce that is growing sicker. Piecemeal solutions will no longer work, and we must harness the ability of technology to give us the big-picture view essential to solving our most pressing health crises.