Bridgital Nation

by N Chandrasekaran

  The Bridgital Transformation

  1

  Flashing Lights

  Nikhil Burman parked his car beside National Highway 37 in Silchar, Assam, turned on the hazard lights, and waited in the darkness. The blinking lights were for the people coming down from distant towns and villages few people could find on a map. He could not see them, but wanted them to see him; they were coming for him.

  While he waited, same as every night at 8.30, a crowd grew around the car. Older women, young men and women, people of all ages, all thrust their papers and their questions at him. His phones rang endlessly. Arriving trains brought more people and more questions.

  His visitors came because they were sick, and deeply in need of anyone who could help. Someone—a friend or relative in their village—had told them of a man who parked his car beside the highway, turned on the flashing lights, and answered questions. That was what brought them out of the hills, across living root bridges a hundred years old, down mountain roads that ran along ravines, and across state lines: Someone who could guide them to the right doctor.

  The surprise was that Nikhil was a driver, and had no medical training at all. His expertise was in helping patients go where they needed to be. Few patients asked him about his qualifications. He seemed to know what he was doing.

  He listened patiently to one caller’s lengthy list of complaints, noting them down on his other phone, an old piece that had a chipped screen and was worn at the edges. He composed reminders to himself on SMS, typing the patient’s name and a code for which test had to be done: SABITA BHOWMIK GC, or RAJIB DAS SKD. He told the caller to not eat because the tests he needed required an empty stomach. Nikhil could not discuss the particulars of the caller’s ailments, but assured him that he would arrange the pickup from Silchar railway station, appointments with doctors, examinations and tests, and even a place to stay. Nikhil was nearly forty, but looked a decade younger. It was his manner—firm, business-like, reassuring—that gave strangers confidence.

  A man stepped out of a rickshaw and walked over to Nikhil. He introduced himself, handed over some papers and, without being asked, bowed to present his head. Nikhil assessed the nature of the lump on the man’s skull with two fingers, like a doctor would. In less than a minute, he concluded which doctor the man had to see. An elderly villager walked up. She was tired, with worry written over her face. This was her first time outside her village. This was the first time she had been so sick. Her stomach hurt, and no one in the village knew what to do. Someone told her about a driver who could lead her to the right treatment, and gave her Nikhil’s number. Now she found herself, a nine-hour train journey later, on a dark highway, in front of a complete stranger, handing over her medical file.

  Nikhil found the woman a place to stay, and prepared her for what would come next. He told her they would drive to Kalyani Hospital the next day, consult doctors, and do some tests. He explained that an operation could follow. The woman listened, but could not stop worrying. She was all alone. To reassure her, Nikhil told her he would buy her medicines from a pharmacy, and take care of any other formalities associated with the surgery.

  ‘But if you die here,’ he remembered to tell her, ‘I will not send your body back to Tripura. I will arrange for you to be cremated here. Understood?’

  In the end, it was a simple procedure to remove a few kidney stones. No complications. Still, Nikhil had worked with patients for a long time. She was older, and he didn’t want to take any chances.

  2

  Playing Roles

  Each evening, Nikhil met with dozens of patients to help them understand what to expect from their visit to Silchar’s hospitals and clinics. On any given day, he estimated, there were usually over two hundred calls from patients in Tripura. 1

  Nikhil’s ‘career’ as a full-time medical coordinator came about entirely by accident. In 2000, soon after he finished school, he began shuttling passengers across Silchar in his father’s auto-rickshaw. One of his frequent customers, a senior doctor at a charitable hospital in the town, found him dependable enough to ask a question: Would Nikhil like to transport patients between the places where they were receiving medical treatment?

  Nikhil agreed.

  Before long, he began to view life through patients’ eyes. Most patients required active help on their arrival in Silchar, having only heard of the place. They arrived bewildered and clutching their medical files, not on a professional’s advice, but on the recommendation of a friend, family member, or neighbour. This meant that few doctors were referring patients to specialists, which, in turn, meant that patients spent time trying to find the right doctor all by themselves. They wandered out of consultations and surgeries, wondering what to do next. They all seemed lost and uneasy this far from home, in an unfamiliar and imposing town that bustled with noise, energy and action.

  Once they did find a doctor, there was the small matter that doctors and patients spoke different languages. Nikhil saw doctors speak in their second or third language to a nurse, who then struggled to translate complex diagnoses and prognoses to patients in a regional dialect. One could only guess how much was lost in translation.

  Nikhil sensed the deep suspicion with which rural patients approached doctors in large hospitals. Beyond the question of whether patients would comply with instructions they only partially understood, he observed a deeper disconnect—of which differences in language was only the most apparent part. It was human nature to be less trusting in a foreign environment, especially if the diagnosis was of life-altering significance.

  When people travelled a long way for medical treatment, the problem was probably a serious one, something that did not have a simple cure. But the shock of a diagnosis was often so great that they refused to trust anything doctors said, and refused to act on medical advice until it was too late. Most had never undergone diagnostic tests, and never been required to understand what reports said. Besides, they were preoccupied with the more mundane concerns: An affordable place to stay in town, transportation, medicine, appointments.

  Nurses and doctors were ready to help, of course, but there were endless lines of patients and not enough healthcare providers. They were already doing all kinds of work to keep the hospitals running. Doctors administered injections that nurses otherwise would, and nurses filed documents, made funeral arrangements, and did paperwork for government schemes. Witnessing all this, Nikhil realized that patients longed for guidance from someone who felt friendly and familiar. Someone who could coax and cajole them, as a youth from their village might; someone who could simplify the process of seeking help and alleviate the helplessness they felt.

  The entire edifice of healthcare relies on creating an environment of trust, yet trust was in short supply. Nikhil saw the role he could play. ‘Patients come here thinking they know what ails them and what they might need to do,’ he said. ‘When they receive a different diagnosis, they get overwhelmed. They need guidance, and need to hear their options carefully explained. Navigating the medical system itself should be the least of their problems.’

  Nikhil saw himself primarily as a logistics manager; but while he was careful not to give medical advice, he frequently ended up as a de facto triage nurse, directing patients to certain facilities based on his past experience with cases like theirs. He charged a minuscule daily amount for his services, and fully expected to be haggled down. Several patients needed discounts, and one in five was too poor to pay at all. If someone could not afford even the bargained-down price, Nikhil waived his fee.

  Demand continued to grow, and providing guidance became a full-time business. His fleet of cars grew to seven vehicles. His relatives joined the business, doing what he did. But Nikhil was in it through and through. On occasion, he paused work to donate blood to a customer.

  Seen one way, Nikhil was an entrepreneur, ingenious in finding and serving a market. Across Silchar, their lights blinking in the night, other drivers played a similar role.

  But
seen another way, if India’s systems worked the way they were intended, this market would not exist at all.

  3

  Wrapping Technology around People

  Indians go to spectacular lengths for the most basic things. The graduates who join millions to apply for a few dozen entry-level positions. The rural traveller undertaking an epic journey from home to see a doctor while she worries about her work, her money, her family. When an endeavour is successful, the effort it takes is forgotten. The enormous odds, once they are overcome, gradually seem less daunting. But this success is also a sign of deficiency. Unexceptional tasks are made exceptional only by the difficulty in achieving them.

  We believe there’s a way to make things easier.

  Using technology the right way, with targeted interventions, India can remove long-standing access barriers to vital services. Bridgital wraps technological advances around India’s most abundant resource, its people, to multiply their capabilities and change how they work.

  When we think about the future of technology and work, there are three important distinctions that set India apart from advanced economies, and that make Bridgital a significant opportunity for the country.

  First, India’s lack of markets means access will take precedence over efficiency.

  Advanced economies have a host of mature markets in which digital transformation is focused on increasing efficiency. India doesn’t lack efficient markets, it lacks markets themselves. In the absence of these outlets, people fill in and operate independently—sometimes at the very edge of the law—meeting the unfulfilled demand for healthcare or other basic goods and services.

  This absence of mature markets is evident in financial services. Despite the success of the historic Jan Dhan Yojana, India’s ambitious financial inclusion programme that increased bank account penetration from about 50 per cent to 80 per cent in just three years, there is still work to be done. The country has around 190 million adults without a bank account, making it the world’s second-largest unbanked population after China. Of those who have a bank account, almost half did not use it in 2017, preferring to use cash for spending and saving. 1 New-age financial technology companies are already stepping in with data- and technology-led approaches to meet the demands of the underserved. For example, low-income entrepreneurs, who had never been able to access capital from banks, can do so as companies use analytics to assess their trustworthiness, reducing reliance on collateral and credit scores.

  Building entirely new markets is a different beast to optimizing existing ones. It means prioritizing access, alongside efficiency. Technology adoption will create new markets within the Indian economy. As they are created, and entirely new ecosystems begin to form and spread, there will be demand for people skilled in the ways of these new technologies.

  We believe that Bridgital workers—digitally literate and intermediately skilled workers whose capabilities are complemented by technology—can play a pivotal role in traversing the barriers that have prevented markets from developing. This is an opportunity to create a new category of worker who acts as a bridge, a guide, and a translator. As with cars, planes and computers, where new markets develop, new ecosystems flourish around them. For example, these ecosystems have already grown around the mobile revolution in Africa: Kenya’s largest mobile operator directly employs only around 5,500 people, but has spurred the creation of over 130,000 mobile money outlets to handle the country’s transition from cash to mobile money. 2

  Second, India faces a perennially limited supply of skilled human resources and physical assets.

  It is widely known that India does not have enough skilled resources and expertise. Accompanying this is a lack of infrastructure and physical resources as well. India has only half the number of doctors recommended by the World Health Organisation. The availability of hospital beds is even more problematic, with around two-thirds fewer beds than the global average. A citizen in rural India experiences even greater deprivation than the overall figure suggests, because resources tend to agglomerate in large cities. More than 60 per cent of hospitals are in urban India, where only about a third of India resides. With a population of 1.3 billion and growing, India does not have enough physical infrastructure—hospitals, roads, schools, warehouses, testing centres—to match the challenges posed by its scale. 3

  India is making gains on these metrics, but will continue to be a stretched society. It will need to make the most of what resources it does have, through a combination of both people and technology.

  Third, India’s demographics demand a different approach to automation and AI.

  Developed economies are well into middle age. China and the US will have a median age over thirty-eight by 2020 (Japan’s will be over forty-eight). 4 The older that countries get, the fewer workers they have available. This shortage drives them to develop technologies that can substitute for labour. As ageing economies have automated, they have transformed production practices, making them leaner and more efficient. The choices they’ve made are about efficiency, a response to their particular concerns.

  In contrast, the median age of India’s population will be twenty-eight by 2020, and thirty-one by 2030. The problem India has is not of age or numbers; it is skills and qualifications. Therefore, India’s approach to automation has to be distinct from China, the US and Japan; it has to focus on technologies that augment and raise people’s skills.

  India will not be able to simply cut and paste China’s (and much of Asia’s) development path. It will need to forge a new path and bring the twentieth-century growth model of manufacturing-led development into the twenty-first century. This new growth model requires an alternative strategy: Boosting a range of labour-intensive, intermediate economic activities that take care of India’s vast unmet demand and shift people towards more formal characteristics of work. Bridgital is a way of doing just this.

  In the early 1980s, there was no playbook for what came to be known as outsourcing. Tata Consultancy Services (TCS), India’s first IT services firm, was then a far smaller organization. It had to convince hesitant clients that India had the brightest engineers, and that they could meet every business demand. Back then, it was common for representatives of large US and European companies to attend meetings, listen attentively, and politely decline to have a part of their work handled thousands of kilometres away. At one meeting, the head of a credit card company listened to a visiting TCS team distractedly, and then, at the end of the meeting, said, ‘I don’t believe you guys can do it. I’m not risking it. This has never been tested.’ To this, the leader of the TCS contingent replied, ‘I hope you will call me back.’

  Within months, the company head called back. In a short while, other calls followed: From the city of Detroit for software for its police force, from a company in New York that wanted its banking software serviced, from Phoenix, Sydney, Venezuela. They were all participants in the Third Industrial Revolution, a period marked by the proliferation of computers and the development of information technology. It eventually led to the adoption of business models like global supply chains and business process outsourcing that are commonplace today, but were unthinkable at the time.

  Technology’s upheavals are constant, however, and no sooner was the third over than the Fourth Industrial Revolution began. Even so, keeping an eye on the future requires learning from the past. Three key lessons, learned from building lasting businesses that ride the waves of technology’s disruptions, serve us well when thinking about Bridgital.

  The first lesson: Technology alone does not solve difficult problems. But when technology is applied in context with reimagined processes, the results can be magical.

  Consider the case of electricity. When this new stream of power started to replace the steam engine and water wheels as the primary source of energy, the first twenty years (up to 1920) registered just small improvements in productivity. It was only between 1920 and 1935, when businesses changed to take advantage of the new technology, t
hat factories achieved an immense growth in productivity. 5 Before electricity, factories were designed around the constraints of the single, fixed, power source, which dictated where immovable machines would be placed. There wasn’t much choice. The product of those machines—half-finished articles—were wheeled around the factory and moved from machine to machine.

  Electricity, with its ease of distribution, allowed for a more logical arrangement of machines, making the process faster, more efficient, and reducing waste. In the final calculation, the indirect gains from changing factory processes far outweighed the direct benefit of the lower energy costs electricity offered.

  Still, technology alone tempts us time and again, and so solutions to pressing problems are seen only in technological terms. This explains why India has no dearth of advocates for ‘stacks’ and platforms for agriculture, education, the judiciary, and health. Yet applied in isolation, technological solutions can end up wasting time and money.

  The husks of digital-only thinking are all around us. One of the more well-known examples is the Aakash tablet programme, whose objective was to make education accessible to over five million students by digitizing content and making it freely available on low-cost tablets. The ambition was there, the foundation wasn’t; an initial trial revealed issues with the device’s battery, screen and sound. The programme focused too heavily on developing an affordable device, and not enough on the content or how a tablet could change students’ educational experience. Nor was there any clarity on which textbooks would be digitized. In class, teachers shunned the device. Aakash ended up being just a low-cost device that could run a few apps and handle a few different file formats. The programme was shut down in March 2015, having fallen short of its laudable intentions: ‘What really crippled the programme was not the operational delays or logistical failures, but the . . . assumption that placing a tablet in a student’s hands would solve everything,’ a critic of the programme wrote. ‘What the tablets would ultimately do was become, for those who couldn’t afford to maintain and use them, a burden.’ 6