This is technology’s great trap. By failing to understand context, we end up with incredibly dazzling technology answers for the completely wrong question. We need to keep this in mind when deploying Fourth Industrial Revolution technologies in the real world: Reimagining processes can deliver much greater value than the direct gains afforded by new technology.
The second lesson comes from the learnings in our work that there is no such thing as ‘purely digital’ or ‘purely physical’. All digital solutions interact with and add value to the physical world. We need to maintain an integrated physical-digital perspective, asking how these two realms can complement, rather than substitute for, each other.
This is playing out most starkly in modern retail, where key players from mass market to niche, large incumbents to small upstarts, are all shifting to a seamless multi-channel experience for customers. Online retailers, from the US to China, are increasingly realizing the value of a physical space where customers can experience products. Conversely, incumbent retailers with physical stores realize the value, convenience and efficiencies of an online digital-assist to the customer, whose buying journey increasingly demands the flexibility of this dual approach.
Meanwhile, physical infrastructure will benefit from incorporating digital interfaces and sensors. Everything from oil rigs to farm crops are being integrated into the Internet of Things—machines that ‘talk’ to each other on different kinds of networks. This will inevitably translate to more efficient resource usage in the physical world. Take the case of ‘smart farming’, where GPS data, soil scanning data and other bits of information can be used to make micro-level decisions about fertilizer and pesticide use. These can even take into account variations across the same farm, greatly improving yields and optimizing the use of inputs.
Pitting technology against human work is also a false choice. In analysing the performance of more than a thousand companies across twelve industries, recent global research has found that firms achieve the most significant performance improvements when humans and machines work together. Companies that most holistically embraced the principles of human–machine collaboration saw more than thrice the level of operational performance improvements as those that used AI tools to substitute for workers. In one example, an American healthcare company saved years of R&D work by having software identify dangerous drug combinations. This left its human researchers with safer avenues to explore. 7
As the researchers point out: ‘What comes naturally to people (making a joke, for example) can be tricky for machines, and what’s straightforward for machines (analysing gigabytes of data) remains virtually impossible for humans. Business requires both kinds of capabilities.’ 8
We must see our world as a physical–digital place. A purely ‘physical’ mindset can make us invest in more physical infrastructure when a digital solution could potentially address our needs more efficiently. In the same way, a purely ‘digital’ mindset can make us miss physical constraints and goals. It is only when we combine both perspectives in a complementary way that we will make the most out of existing infrastructure, build new infrastructure to be future-ready, and ensure that technology delivers the results we need from it.
One area where the Tata Group has translated this belief into action is in conducting education and employment testing. In the past, for someone living outside a major metro or state capital, the process of giving an entrance exam began with travelling great distances to the nearest testing centre. Candidates had to go where the testers were. The costs of travel and living were the candidates’ to bear. All this happened because the task of testing was highly centralized and dependent on the physical presence of testers.
TCS iON, a strategic business unit of TCS, reimagined the process of conducting assessments in a physical–digital manner. Turning a physical-only, centralized and sequential task into one that is managed both physically and digitally, allows it to be distributed and managed in parallel by different resources across the country. As a result, exams today look nothing like they did a decade ago. Physical examination centres, connected to a digital platform, proliferate in small cities and towns. A computer adaptive test adjusts difficulty levels to candidates’ performance. Grading, if not automated, is done in a distributed manner by evaluators on the platform. Gaming the system is almost impossible.
Results that took weeks and months previously, are available within a few days, and are more accurate. Access opens up as applicants find assessment centres, previously limited to the big cities, closer home. More than 20,000 jobs have been generated or made more productive, including test centre managers, invigilators and evaluators. The model can scale up to other examinations, evaluators and geographies rapidly. Last year alone, more than 50 million candidates carried out examinations via the physical–digital assessment model, nearly half of whom came from small-town India.
The same can happen in a number of other fields, such as the judiciary, logistics and agriculture.
The third lesson is that we need to grasp the shape and sprawl of technology adoption. The adoption of technology is not only about being able to invent the technology itself; it is also about when the technology becomes affordable enough, and when the social, legal, and political moment is right. Tractors are an example. The potential for farmers all over the world to use tractors has been 100 per cent since at least the 1930s, when they became cost effective. But it was not until 1969 that 80 per cent of farmers in the United States owned tractors. In India, through the 1990s, less than 10 per cent of farms of any size owned a tractor, a mechanized plough or a thresher. The slow adoption of tractors in India was due to their cost and the small size of plots for the most part, but there was also resistance to the new machines from workers and managers.
The spread of automation will take time—it will progress in waves, across different sectors, at different periods, and at different intensities. When it comes to automation in India’s economy, certain sectors, especially high-productivity ones that are integrated into global supply chains, might feel its touch earlier, while the rest of the economy may go without seeing substantial change for years. This is true across different sectors, as it is across distinct geographies. This, in itself, is an opportunity. It allows us to design for the future.
How we use this long runway matters a great deal. Since Bridgital is all about marrying people with technology, those employed in Bridgital roles will gain vital skills in working and interacting with new-age technologies. ‘Bridgital graduates’, armed with these transferable technology skills, can galvanize productivity across sectors. In a future of work transformed by the Fourth Industrial Revolution, where every sector adopts technology to a lesser or greater degree, these skills will allow employees of Bridgital projects to move diagonally to other sectors. This will create the essential ramp we need for people to move from the informal sector to the formal, from unskilled to skilled. As Bridgital graduates go on to join other sectors with higher demand and rewards for their skills, less qualified workers can get on the Bridgital ramp. In this vision, the future of training and skilling will be less about specific industries and roles, and more about digital skills (understanding how to interact with technology), twenty-first-century skills (such as critical thinking, creativity and collaboration), and lifelong learning.
Given the need for a large number of jobs for India’s incoming workforce, the country should use the opportunity that technology provides to generate gainful employment, instead of investing blindly in labour-substituting automation.
We should also attempt to bridge the increasingly split nature of India’s economy, which has a high-productivity formal sector and a low-productivity informal sector, but is missing a middle of intermediate-productivity, mid-skill work. Many workers in the informal sector are trapped in low-wage, low-productivity employment. They struggle to find jobs in which new skills can be learned, skills that can grant them opportunities in the formal sector. Meanwhile, companies struggle to fin
d the skilled workers they need. The repercussions of the ‘missing middle’ are increasingly visible. India needs a bridge between the two—a bridge by which lower-qualified workers can acquire the digital skills required to participate in the growth story.
This is the opportunity before us, the chance to solve some of our most intractable problems. But it needs our collective intervention, and active participation, to boost jobs and train our workforce for a digital future.
WHAT IS BRIDGITAL?
At its heart, Bridgital addresses access challenges through a reimagining of the tasks and processes that make up a job, and complementing this with technology that enhances and supports workers. Its innovations span three elements.
Bridgital processes
Redefine what exactly is needed to deliver a service or solution, especially in a manner that prioritizes the challenges of those without access. As this takes place, a lot of activity currently in the purview of the informal sector is brought into the formal fold.
Rethink conventional approaches to who-does-what in the value-chain of service delivery.
Bridgital technology
Digital technology and low-cost service delivery models that push the limits of how efficiently we can make use of valuable assets such as physical infrastructure, and the time of high-skill workers.
Bridgital workers
Digitally literate and technology-augmented workers take on tasks of higher value carved out for them. These range from tasks currently performed by more highly qualified workers, to tasks that mediate likely user challenges in implementing solutions or adopting new services.
Augmented capabilities of all levels of workers improve the quality, transparency and standardisation of service delivery.
The healthcare system showcases the transformative potential of the Bridgital approach. We cover it in depth in the sections ‘The Access Challenge’ and ‘Bridgital in Action’.
The Access Challenge
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Calculations
Another phone call. Dulal Pal was fifty years old. A doctor in Tripura recently diagnosed him with jaundice. He wanted to come to Silchar for further consultations right away. Nikhil asked Pal to meet him at the car beside the highway.
At 10 p.m. the next day, Pal and his wife joined the long queue that ended at Nikhil. One psychiatry appointment, one neurology consult, three kidney stones, one stomach problem, and three transportation bookings later, it was Pal’s turn to explain what ailed him. The symptoms didn’t look like jaundice to Nikhil, but in keeping with his self-imposed rules he didn’t offer a diagnosis. Instead, he organized Pal’s tests and appointments, and arranged a meeting with a doctor at Cachar Cancer Hospital. Nikhil’s brother arrived to drive Pal and his wife to a hut with bamboo walls, reserved for them for ₹120 ($1.70) a night.
The following day, Nikhil took Pal to the diagnostic centre, but the CT scanner wasn’t working. A replacement tube was on the way from Guwahati, three hundred kilometres away. The journey would take three days. Nikhil estimated that eight days would pass before all of Pal’s reports were ready. Pal was unprepared for this delay. He had shut his shop back home to seek treatment, and was losing money each day he spent in Silchar. Still, he had little choice but to wait.
The diagnosis confirmed Nikhil’s hunch. Pal had a tumour in his abdomen. But the patient was just as worried about the money he was losing. Between the shop and his cancer, Pal decided to go home, get the business running again, and then decide what he would do. Weeks later, he called Nikhil. ‘So how much money do you think I will need for my treatment? What are the chances of being cured?’ he asked. ‘How many more years will I live? Does it come back?’
Pal’s was one of three cancer diagnoses among patients that arrived for Nikhil from Tripura in the last week of July 2018. All of them returned home after the diagnosis—to balance their budgets, protect their cashflows, weigh potential outcomes, and decide whether to take up the course of treatment their doctors advised. Nikhil knew which way cases like these usually went. Confronted with the prospect of long periods of hospitalization, whose cost was compounded by the days of lost income, patients chose to skip treatment altogether.
Nikhil answered the questions as best he could. He did not expect to hear from Pal again.
In 2017, an informal survey of patients living on the streets outside Tata Memorial Hospital found that they had lost an average of ₹55,000 ($786) in foregone wages during the course of their treatment. Nearly half of the patients had worked as daily-wage labourers. When they returned home, there was no guarantee they would find such work again. 1
So many Indians live on the edge of poverty that it only takes one adverse health event to tip them over. Every year, as many as 49 million Indians are pushed into poverty by medical expenses—over half of the 97 million people around the world who fall into poverty when a catastrophic health event occurs. 2 The cost of healthcare can lead to a spiral of debt. Their standard of living falls, opportunities vanish, and a vicious cycle that may span generations sets in. The full cost to India, especially in terms of the incredible potential that goes undeveloped and unrealized as a result, can only be described as a national tragedy.
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The Great Medical Migration
Set against India’s rapid economic growth, its healthcare record is bleak. In 2016, the country’s communicable diseases death rate was starkly higher than the global average. There are more tuberculosis patients per 100,000 people than in Uganda, Afghanistan and Haiti. India has much higher maternal and infant mortality rates than countries in the region such as Mongolia, Sri Lanka and Vietnam. 1
Much of this is because India’s public health system is understaffed and underfunded. This is especially the case in rural India’s network of primary and community health centres. 2 The lack of reliable access to doctors and medicines at rural public health facilities leaves patients seeking care from sources they trust, such as family, elders and local healers, rather than trained doctors. And when trusted sources fail, patients travel, often great distances—not just to the large, super-speciality hospitals in the big metros, but to public hospitals in every state capital, and even tertiary hospitals in district capitals. This is the great medical migration: Millions of people travelling great distances to large urban hospitals that end up bearing the load of primary and secondary health centres.
Tata Memorial Centre in Mumbai mapped the location of 75,000 patients and found that over half travelled more than a thousand kilometres to get access to reliable cancer treatment. Granted, patients the world over may have to travel to access specialized care for cancer. Innovative models have emerged in response to these challenges, such as the distributed cancer control model pioneered by Tata Trusts. 3 In India today, however, many are travelling with more routine complaints. Delhi’s All India Institute of Medical Sciences sees 9,000 patients at its outpatient clinics every day. Some may have nothing more serious than a viral infection or fever, which could easily be addressed at a primary care clinic. The large numbers are not easily served. They stretch India’s hospitals—already brimming with patients and renowned for their efficiency—to breaking point, and force them into innovation of a different kind. ‘We admit a patient here only if she agrees to share her bed with another patient,’ a staff member at the Government Medical College in Dehradun says. ‘We don’t have enough beds, but they keep pouring in.’ 4
In the mind of patients exposed to India’s medical system, there is either the most basic healthcare, or large hospitals. Between these, there is nowhere else to go.
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Twice Exceptional
Between 2018 and 2019, we and our team of researchers travelled frequently to India’s north-east, which has among the highest cancer rates in the country (largely linked to the widespread use of tobacco). We focused on Barak Valley in Assam to understand how hospitals were coping with a constant flood of patients. 1
The valley is twice an exception: It is in a region st
ruck by exceptional rates of cancer, and is also shaped by exceptional and dedicated healthcare providers. Nowhere is this more apparent than in the city of Silchar, a place overrun with patients and a commercial ecosystem that serves all their needs. There are pharmacies at every corner. Off the busy Meherpur Road, a string of hospitals cater to the rich and the poor. A billboard for a healthcare brand features an illustration of a pawn toppling the king on a chessboard. ‘One right decision can conquer cancer,’ it reads.
Cancer makes healthcare more complex, and also exposes its limits. The illness demands consistent engagement with a higher level of expertise, found mostly in the formal health system. This means that patients have to overcome social, physical, financial and geographic hurdles before they meet a doctor who can help. The constraints are multilayered, and often prohibitively high.
How patients and medical staff in the north-east cope with cancer provides some insight into India’s larger healthcare challenges.
We first visited Kalyani Hospital, which resembled, on the outside, an ordinary two-storey building. It was late in the afternoon, and the sky was quickly turning dark. There were hundreds of tired patients thronging the halls on every floor. We went up to the second floor to meet Dr Das, who had asked Nikhil to transport the hospital’s patients years ago. Upstairs, we waited in a consultation room with desks and plastic chairs while his secretary explained that he was performing a surgery. We had arrived on a day booked for operations. Dr Das and his staff assembled in the operating theatre before 9 a.m., and ended work twelve hours later. Each doctor performed up to ten operations a day. This was why the staff looked exhausted, his secretary explained apologetically.
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