A 1-minute synopsis
- Coronavirus exposed a gap in the health system: We don’t have the public health function for surveillance, epidemiology, contact tracing or testing for preventive work. In fact, many countries don’t have it.
- The initial instinct behind Swasth app was the short-term impact. No individual organisation or individual acting on their own, would be able to marshal the resources. In order to mount a nationwide response, of course, the government will do what it can, but could a group support the national effort?
- And then gradually, the thought was that if we are indeed making all this effort, can we really make it broad-based, open-source so that it truly becomes a public utility?
The problem to solve
- Indian citizens spend about Rs 10 lakh crore on healthcare—about 4% of GDP. In purchasing power terms, this is enough money. Also, India has the added advantage that we have local medicine manufacturing capacity, we have the ability to train people.
- But we are not seeing good health outcomes because of the high level of fragmentation in the health system. Out of this Rs 10 lakh crore, about Rs 2 lakh crore is spent by the government on healthcare schemes, which have been quite useful. The challenge is the balance of Rs 8 lakh crore. That is distributed in microscopic pieces. Corporate healthcare too is a small portion of this pie.
The collaborative, platform approach
- The Swasth app represents an exploration—can we use an electronic backbone to connect this fragmented system up? Is it possible that we take the smallest of primary care doctors, the largest of hospitals, micro-insurers, the larger insurers, the diagnostic labs, the small pharmacy in a street corner, a large pharmacy chain, and bring them on to one platform? So that patients get comprehensive, quality care.
- Some principles on privacy and data protection are in place. But it’s an area that needs a lot more conversation both within the teams but also vis-a-vis those government bodies and other entities that are thinking about this question.
- The learning: Collaboration is possible. People will come together. You have to have patience, you have to be willing to have the conversation, and accommodate different points of view.
COVID-19 has accelerated the use of telemedicine across the world. Telemedicine reduces the risk of infections due to physical proximity and increases convenience for both doctors and patients. In places with fragmented or inadequate healthcare infrastructure, telemedicine can provide access to healthcare to those who are excluded from the system. Many experts believe that the adoption of telemedicine will continue to gain speed even after the pandemic.
Among telemedicine apps, Swasth, launched in June in India, is exceptional because of the way it was developed. It’s not an app launched by a hospital chain, or a startup or a government. It was launched by a diverse group of individuals and institutions, including hospitals, startups, insurance firms, and experts in public health, technology and policy. An early recognition that the coronavirus pandemic cannot be solved by a single institution, and there is a need for such cooperation, brought them together. Today, it includes hundreds of individuals and institutions in its network, and offers rich lessons for those who aim to solve wicked problems.
Nachiket Mor represents some of that diversity. He was in the top management at ICICI Bank, headed the bank’s foundation through some pioneering work, led the Bill and Melinda Gates Foundation in India, was a member of the Reserve Bank of India board, and is now visiting scientist, The Banyan Academy of Leadership in Mental Health; and Senior Research Fellow, Centre for Information Technology and Public Policy (CITAPP), IIIT Bangalore, among others. He is also a part of the governing council of Swasth App.
Founding Fuel caught up with Mor to understand what went into building the app.
This is the first in a series of conversations on telemedicine in India.
You have spent a lot of time studying Health Systems Design. Can you give us the big picture in the context of coronavirus? What are the three big weaknesses it has exposed and amplified in our health system? And what are the three big strengths that you think can be used to manage and overcome this crisis?
It is not a surprise, it’s not something we didn’t know that health systems in developing countries, even those that are well designed, are not well equipped to deal with the crisis. This is because we don’t know what the eventual infection rates will be. We are talking about anywhere between 20% to 60% of the population. Most health systems, including the ones in developed countries, will have trouble coping. So, I wouldn’t say that our inability to mount an adequate response should be taken as the only indicator of a system that is perhaps not well equipped.
That said, clearly, good health systems are founded on the foundations of good primary care. And countries that have been able to respond well, and within India, those states that have been able to respond well—states like Kerala, for example—have a strong public health tradition on top of a primary care tradition.
If one were to ask overall what is the gap that has become visible is the absence of a strong public health function—and this is different from primary care—one could argue we could integrate with it. But we don’t have the kind of public health function for surveillance, for epidemiology, for contact tracing or testing for preventive work of the type that is needed.
Many countries don’t have it. I’m not going to tell you we are the exception. But indeed, that’s an important issue in any epidemic, in particular in COVID-19. In terms of our response to it, one is, of course, in a public health sense, can we contain, can we move forward? Dharavi, for example, is one of the examples now of where a good public health response seems to be visible on the COVID-19 issue, perhaps a little bit late, perhaps concentrated on Dharavi and not necessarily around the city of Mumbai or across the country. But, these are responses that one could have seen, perhaps earlier in crises and many states that are still at early stages of crises, they could benefit from understanding what such mechanisms might look like and what they might want to do.
In terms of overall weaknesses in the health system, obviously this is a much larger topic than we can cover in our small discussion. And there are several components that one needs to examine. But if you were to link back towards where we are going—Swasth app—in which a particular aspect of the weakness we are thinking about, I would say, is the high level of fragmentation.
If you look at the health system, give or take, about Rs 10 lakh crore is spent by the citizens of the country on healthcare. Many would argue that this is not adequate, we should, as a country, be spending more money. Rs 10 lakh crore amounts to maybe 4% of GDP. People talk about closer to 8% or 7% as being adequate. But there are many countries which at 4% of GDP have been able to deliver good health systems.
And India has the added advantage that, unlike many developing countries, we have local medicine manufacturing capacity, we have the ability to train people that other countries don’t have. And therefore, if I look at it in purchasing power terms, this Rs 10 lakh crore is much larger than a mere nominal conversion to dollar value might imply. So, one could say Rs 10 lakh crore—one could make the argument is enough money.
But then the question you might ask is, ‘well, if it’s enough money, how come we are not seeing good health outcomes in the country?’ Out of this Rs 10 lakh crore, again depending on how you count it, about Rs 2 lakh crore is spent by the government through taxes on healthcare using a number of schemes. The National Health Mission is a scheme. The Prime Minister’s Jan Aarogya Yojana is a scheme. There are many schemes the government has and clearly in some areas like maternal child health, in the public health domain, these schemes have been quite useful. I wouldn’t say they are a complete response yet, as we discussed earlier, but they have been quite useful and one should not scoff at the fact that somewhere near 60-65% of the babies that are delivered in this country—we deliver two-and-a-half crore babies a year—are delivered by government employees and delivered safely I may add. Yes, one could argue that we lose about seven to eight lakh babies a year when the true number should be closer to 10% of that. And therefore this 90% of numbers are, quote-unquote “excess deaths”. So I’m not, therefore, telling you that this is a perfect outcome that we have but I wouldn’t also want to go to the other extreme and say that we are delivering no value.
The challenge is the balance of Rs 8 lakh crore. That Rs 8 lakh crore is distributed not even in tiny pieces but in microscopic pieces.
The largest healthcare provider in the country, corporate healthcare, has a Rs 5,000 crore topline in an Rs 8 lakh crore market. And the next one is half that. If you aggregate all corporate, they don’t cross [Rs] 20,000 [crore]. If you aggregate all insurance, that doesn’t cross [Rs] 30,000 [crore]. So, in some ways, unlike in many other sectors in India—look at steel, power, cement, airline, banking, corporate sector there is a large informal sector in banking for example, for the corporate sector is a reasonable portion of that sector—not true in the Indian health system.
Now, one could go in two directions with that.
One is to say why don’t we identify those corporates that have a reasonable size, work with them and see if we can build an aspiration to take a Rs 5,000 crore health system, corporate health system, and find a way to get into a Rs one lakh crore system. That could be an interesting aspiration. And I would say that’s an interesting pathway that I wouldn’t want to dismiss.
But there’s another possibility, which is where I think the Swasth app represents an exploration. It will be hard to say whether we will eventually get there or not. Can we use an electronic backbone to connect this fragmented system up so that as far as the patient is concerned, because fragmentation or defragmentation in itself is not value, it’s valuable only if it delivers value to the patient? It’s possible that if we can use our unique strengths, of technology, of communication, is it possible that we take the smallest of primary care doctors, the largest of hospitals, microinsurers, the larger insurers, the diagnostic labs, the small pharmacy in a street corner to a large pharmacy chain, bring them on to one platform. So that the patient journey then becomes closer to what one would imagine is an ideal journey with quality control, with protocols, with comprehensive care.
A lot of this has to be explored. I don’t want to suggest to you that we have today the answer to these questions, but since you say where might the future lie? Let’s start with the big picture. This could be a possible direction we could go.
Can you take us through the genesis of the idea of Swasth? When did you first recognise that, hey, this is going to be a big problem, probably far exceeding the healthcare capacity? Can you take us through the early days and by early days, it’s probably around April.
Now, I wouldn’t say this was my idea at all. We have another group called ACT Grants that was set up to raise money from startups, from investment houses, from philanthropists so that a small—given the size of the crisis, hundred crore is not a large number. But a pool of funds will be available that would allow a group like this to use its unique skills of evaluation of management teams, checking in what’s going on, mentorship to identify where are the critical opportunities where gaps can be filled. Is it in PPEs [personal protective equipment], is it in ventilators, is it in HFNC [high-flow nasal cannula] devices [used for delivering oxygen]? It’s a separate story that you might want to look at to see how well this group has done to identify these gaps and rapidly move to fill them and how they’ve used their unique capabilities as investment managers, as private equity players, that allow startup entrepreneurs to have a far bigger impact than a routine Rs 100 crore fund might have.
In those conversations, particularly led by people like Mukesh [Bansal] of Curefit, it started to become apparent—and I was a member of that group as well, I still am—that despite all the steps we are taking, the crisis could go into a mode that is significantly larger and this was well before any of these numbers for Mumbai and Chennai and Delhi. In fact, at that point, it seemed almost that we were not going to face the crisis at all. So I think it might even have been before April that the discussions began. But I think it’s a tribute to this group that they felt they may be wrong. But what if they are right, and the crisis indeed snowballs, there was a sense that any individual organisation or any individual acting on their own, would not be able to marshal the resources. And that, in order to mount a nationwide response, of course, the government will do what it can, but if there was a group that wanted to support the government and the national effort, it would have to be a group that would come together. Individually, people chasing ideas and assignments might not get us.
I would say that would be the genesis of this. What was amazing to me is how quickly people came together, recognised and started. Again, I want to point out the role Mukesh played in talking to people, making sure that they understood what the level of the crisis was, how by joining hands, sometimes, what’s obvious, still needs to be communicated. And I think that’s how the Alliance initially came together. Then, of course, as more people joined both the short-term and the long-term vision, I think the initial instinct was the short-term impact.
And then gradually, the thought was that if we are indeed making all this effort, wouldn’t it be a good idea to try and understand what the long term might hold? So, then the question of how do we govern it in a way that it doesn’t look like a small club of people trying to prove something. Can we really make it broad-based, open-source so that it truly becomes or acquires the character of a public utility, where everybody is free to contribute, but nobody has a unique role?
Taking a couple of steps back, clearly there were two different paths that you could have taken and there is probably a case to be made for a single organisation doing it. If you look at large platforms—Uber, Amazon—they are single companies which still managed to get diverse people on the platform and scale up very fast. What seems to be very unique about Swasth is different people coming together. What were the discussions around what is the best path to take? Does taking this path actually close doors for the others? Can you take us through some of the key points that were debated?
Obviously, this was the core issue at hand. Is it necessary to create a group of people that would be needing to do it because there’s certainly a loss of efficiency? When you try to coordinate, as you discuss, try to build consensus, that takes time.
Whereas, if you’re operating on your own in a single company structure, you can move rapidly and clearly there is a pro and con to something like this.
I think early on, there was a realisation that COVID-19 is the crisis that will stretch the resources of every single company in the system—and something we need to be conscious about is that unlike in e-commerce or in rideshare, or in any other sector, the formal healthcare sector in India is a small portion, even if you add everybody together of the larger system, and no individual company or hospital system [is large enough]—as I said, the largest is Rs 5,000 crore. There are no hundred thousand [crore] companies. One could say if you had a power crisis, there might be a credible set of companies that say, “I can take care of it. I don’t need to come together with others. We are large enough.”
Whereas here, I think it was much harder to make that argument. So, there was kind of the practical pragmatism to it that we are all relatively small players. If we are really going to address this crisis, we’re going to have to come together and also the sense that the crisis is just so large that even large players might find it troublesome.
How did you go about organising the team? I read in Business Standard that there were seven different teams, one looking at governance, product development and so on...
It’s a very organic process. Each company that joined initially said that they will contribute engineers and code, they’ll contribute whatever they can, some people contributed HR resources, some contributed technology people, some people contributed operations people—I’m amazed at the range of volunteers that are working in this.
The platform was constructed in such a way that anybody is free to come. There is no restriction so long as you have an interest in something and you have something to add as a value. For example, we are, as we speak, in the process of constructing a group to focus on mental health services.
Now, currently, everybody’s worried about the disease, and those types of machinery are out there, treatment, etc, moving forward, but there are already groups working on things that we might roll out maybe 15 days or a month from now, or we may discover that there isn’t enough momentum for us to roll it out at all.
It’s a very open style that is really more driven by your passion and your interest rather than saying that ‘Oh, no, no, this is meant only for a small club.’
So, then it will take several members or group administrators and they can add anybody that they think can add value.
I see that there has to be a balance between some things that everyone has to accept—probably privacy, data protection would come under that. And there are some initiatives that are driven by the passion of the group or the opportunities they see. So, coming back to privacy and data protection, and it’s a major issue when it comes to healthcare, and a lot of organisations have burned their fingers, Google included. How did you think about it? Given that India doesn’t have a data protection law yet, how did you go about thinking about it to make sure that it will comply with a law that might come maybe next year?
This is very much a topic of ongoing debate and discussion as to what is the right way. The current approach that the platform has taken is, the platform is merely a gateway. It does not store data, it does not wish to serve customers based on data sets that it has. It’s a partner-driven platform. What it enables is, if you are a patient and say that “I’m in this geography. I need a home quarantine solution,” I will quickly help you find and then it’s between you and the provider.
The providers are carefully chosen to make sure there’s no exclusion. It’s more “Do you meet minimum standards? Are you prepared to work?” For example, we are working on oxygen therapy as an issue. First level low flow oxygen. There is a protocol. Are you prepared to follow the protocol? If you don’t like the protocol, you’re free to present to the group of doctors. There is a medical group as well, that comprises doctors that reviews everything that comes up.
If you say that you have a credible plan to meet these guidelines, you are able to join. Then the question is when a patient comes in, does the app seek to collect and store data about the patient and then offer services to the patient?
I don’t know about the future product development pathway that might take place, but as of now, that is not what the platform does. It’s simply a pass-through gateway. If you sign on as a user, you will get a sense of how that platform works.
Now, in the longer run, some of these questions will have to be answered. It’s an area that I think needs a lot more conversation both within the teams but also vis-a-vis those government bodies and other entities that are thinking about this question.
I don’t think this is a solution that can be evolved entirely separately. Is it possible that our vision of the future might be that there is indeed a central data repository, which is owned, controlled, managed by a public utility of some sort. And a platform like this one simply enables, under patient control and the patient direction providers, to access that information for as long as they need it and as long as the patient authorises. And the minute that that process is over, does it smoothly disconnect the patient?
But, it would be incorrect to say that we have a clear position on this. All I can say is it’s an issue that is front and centre in any conversation on any application that is developed.
What has been the experience of the hospitals that have joined in early? What are some of the early lessons that came from offering the service that’ll be useful to the kind of hospitals and doctors, professionals who come in later.
In terms of value to the patient, the current application that is being used the most, is the telemedicine application. In that space, all of these players already have something that they’re doing on their own. This is, of course, free to the patient. And to the extent that they have signed on and made commitments when they partnered with this platform, they are serving the same patients using the exact same infrastructure that they have.
Right now, I wouldn’t say there’s a lot of new learning to them on that. As we are developing new solutions, like the home point solution, like the oxygen therapy solution, how does one build out a service that is driven by protocol, that is driven by a collective conversation, understanding of for-profit, non-profit, all kinds of providers coming in? My suspicion is, in whatever conversation I’m a part of, there is a lot more new learning what each one can provide. Also, a lot of these companies are more familiar with tier 1 cities, maybe somewhat familiar with tier 2 cities.
How does one think about a broader space? Again, there is new learning there because there are newer partners that are more familiar with those spaces that are contributing their ideas and their thoughts. To this process, also planning ahead for scale, planning ahead for providing services to government entities—these are things some of the partners have done as a matter of routine. Some have learned something new—what does it involve? What are the challenges? What are the opportunities? And how can one really go about?
Inclusion, given the digital divide?
Currently the goal is to try and build the service in a way that every last person can look at the telemedicine platform. It’s not simply a smartphone-based platform. You can also call. And you can have a discussion with somebody. Somebody may say I wish to see somebody physically. As the membership network evolves, the full expectation is that there will be individual doctors that will sign up, that you may be able to find just like you can find a local place for a home quarantine institution, you could find a primary care doctor that is right next to you, that is willing to serve you.
And then the technology serves the doctor, and not necessarily serves the patient directly. So, like right now, in the design, the phone is the default. So, you don’t necessarily need to have a smartphone, you can just call and many people seem to be familiar with doing that. We’re also developing assisted modes—somebody may say, I don’t want to talk to a doctor but my nurse or somebody else that I’m working with, could they talk to the doctor on my behalf? These are all ways but the intent very much is to find a way to get it out to as broad an audience as possible and in a way answering those questions also helps understand, is the long term vision at all even a possibility, or is this alliance useful for here and now, but may not really be that useful? Because it can’t really answer the questions of the type that you’re asking.
I asked a similar question earlier. But, this is for the system in general. Are there any major lessons from the entire exercise starting with, not only this very specific app but also, from a more systemic perspective? Are there any big lessons that can be useful in case we want to replicate it in our own country or if other developers countries want to replicate a similar existence.
The lesson to me if you ask me personally is that collaboration is possible. People will come together. You have to have the patience, you have to be willing to have the conversation, you have to be willing to accommodate different points of view.
There will always be sceptics in the environment, you have to take on board their concerns, not react to them. You have to work with the assumption that they have good intentions, that they’re asking these questions not because they mean poorly, but they want something good to come out of it.
And patience, conversation, discussion, allowing more people to join in. You know, somebody is upset. Let them join a conversation, rather than keep them out. Bring them in. I think these are very good lessons.
I must say coming from a classic corporate or NGO type background where, as an operator/manager, you don’t have the experience of building this coalition. That’s why it’s called the Swath Alliance and as broad-based as possible, the expectation that they’ll have one lakh members. Now, how will they all feel included but also make sure that they are aware that they are included but as are others?
It’s not about “I get what I want. But then I keep others out”. But I think this is an evolving journey. If I can say right now this early in the journey because right now laser focus is on COVID-19. Making sure we are providing services that respond to the immediate need. And that’s what’s really brought the coalition. The longer-term ideas are there, but we have to see how we can convert this energy and this enthusiasm and proceed beyond the immediate challenges.