Bridgital Nation

by N Chandrasekaran

Everywhere Entrepreneurship Could Lift 45 Million Indians into Productive Employment

  The power of everywhere entrepreneurship is that it is possible for these types of entrepreneurs to exist in every community around the country. They can help meet local needs and develop local resources, spurring development in the communities where they operate. Because they can be ubiquitous, they can—in the aggregate—produce far more employment than the small size of any individual firm might suggest. These everywhere entrepreneurs are also more likely to expand their businesses and make the investments in technology that improve the productivity of their firms and workers.

  The twin challenges you have been reading about in these chapters—jobs and access—call for a plan for the twenty-first century that Indians can get behind. Fundamentally, this plan should renew the focus on entrepreneurship to move the needle towards formal employers; it should make paid work attractive for women in order to address the participation gap; and ultimately, this plan will need to be anchored by a Bridgital approach that marries the gap between skills and jobs.

  Done with purpose and urgency, India can transform the lives of hundreds of millions, unleash huge productivity gains in concert, and tap into vast reserves of undiscovered economic fuel. The gains of the Bridgital approach aren’t theoretical. A taste of this promising future exists today, beyond the rocky hills 60 kilometres east of Bengaluru, near the gold fields of Kolar.

  Bridgital in Action

  34

  New Aims

  On visiting the All India Institute of Medical Sciences (AIIMS) in New Delhi in 2016, K.R. Ramesh Kumar, then the health minister of Karnataka, had braced himself for disorder. This was where the country’s finest doctors gathered to be pressure-cooked by the nine thousand patients who arrived at the hospital’s forty-eight outpatient departments every day. Hundreds would wait hopefully for an elusive appointment slot, visiting multiple times a day or over weeks until they got one. Patients lay on beds anywhere and everywhere. Everybody had questions, and nobody had answers.

  But the minister was befuddled. There were queues and quiet. There were electronic displays, token numbers and tablets. Things moved quickly.

  The orderliness was by design. The AIIMS Transformation project was a venture by TCS to streamline patient movement through the hospital. The average waiting time after getting an appointment fell from six hours to two. Four in five patients arrived with appointments, up from one in five. There was a new class of workers he hadn’t seen before—they coordinated between doctors and patients. The adjustments and larger changes made to achieve such a system were many, but at its heart was a simple offering: Clear information for doctors and patients alike. It hadn’t required a miracle, or vast investments in building something new and untested. The system used what was already available. Just differently.

  Minister Kumar wanted to transform healthcare in Karnataka. He knew that out in the countryside, where most of India lived, healthcare needed some kind of order. He knew, all too well, that patients ignored the primary health centres made for them and headed straight to hospitals. He wanted to give them something better.

  In August 2017, Minister Kumar met with the Tata Group to build on the system he had seen at AIIMS. Only this would not be confined to a building, but spread over an entire district in Karnataka. They would begin in his constituency, the rocky outpost named Kolar.

  Kolar is neither rich nor poor. Its income level is close to the national median. Its literacy rate is only marginally lower than the rest of Karnataka, but it has more children who drop out of school. Once known for its gold fields, Kolar is now famous for its tomatoes. It is not uncommon, in certain years, to see farmers destroying unwanted tomatoes by leaving them on the highway and letting passing cars do the rest. 1

  The town bustles with markets and traffic, but at the edges, it thins and turns quiet. Roads become single lanes on the town’s outskirts. Among the hills that resemble giant rock piles, there are even narrower paths of mud to villages hidden somewhere in the distance. Bus stops are remote, and simply reaching them means walking a long stretch, or taking a ride over bumpy terrain. For people who sit in wait in the tree shade to hail a ride or catch sight of a bus, crossing these distances is a decision measured in money and time. If their destination is the district hospital in Kolar, their calculations include the possibility of malfunctioning machines and missing doctors. A day gone to waste.

  The future of Kolar’s healthcare, it was decided, would begin at one edge of the town, in a sanatorium where langurs and wild horses strolled through the corridors. An unused room was set aside for the system, which by now had a name—Digital Nerve Centre, or DiNC.

  The DiNC model worked in two ways, just as the AIIMS transformation did. By redefining certain roles and responsibilities, and creating a new class of Bridgital workers, time-consuming administrative pressures were taken off valuable medical staff. And with the added mesh of technology, the system sorted patients at the very beginning, and brought more people into healthcare’s purview.

  The team from TCS that built the system for AIIMS knew about healthcare systems and processes. They were dealing with practices that had calcified so long ago that few understood how strange things had become.

  When the team looked at how specialist doctors—oncological surgeons, to be precise—spent their days, it came as a surprise to know that only around half their time was spent treating people. The rest of it involved non-clinical work: Filing paperwork, developing checklists, writing notes for the operation theatre, and explaining the modalities of diagnostic tests to patients. It was work someone else could be doing. Even clinical time often included patients with basic ailments who would have been better served if they had visited a primary or secondary health facility.

  In simpler terms, doctors’ capacity was severely hamstrung. They found that when just one of their tasks—operation theatre notes—was shifted, it created enough time for them to see more patients. On just this one task among the dozens that India’s oncologists performed every day, the shift translated to nearly 4,000 extra doctor-hours every year. 2 Numbers were on their side. Given India’s size, the slightest improvement would make a huge difference.

  The TCS team had reimagined the processes of India’s largest public hospital, and created a national network that linked cancer hospitals. But the task of helping supplement primary healthcare meant dealing with public infrastructure, organizing government doctors and nurses, and reordering entrenched processes. Unexpected surprises were inevitable.

  They didn’t have to wait long. While the rest of the sanatorium had electricity, it took two months for DiNC to finally have access to the power they required. In the meantime, in the western extension of the building, they began to arrange clusters of desks where nurses and doctors would sit, making phones calls, receiving questions. Unlike call centres aimed outside India’s borders, this centre’s focus would be deeply local. The team’s members began to train local recruits in the art of primary healthcare outreach.

  There was no better way to do this than to enlist community health workers, one of India’s great public health successes.

  35

  ASHAs

  ‘What, Ammi, still doing homework at this age? When will you stop?’

  Aminah Sheikh grinned at her thirteen-year-old son and kept working. She hadn’t yet changed out of her pink saree, the uniform that told people from a distance that she was a health worker. As always, it was lined with dust from the day’s exertions: Walking from hut to hut, asking questions, offering guidance, taking notes. She sat on the floor of her own hut and prepared a report about the house visits on her tablet. The connection kept breaking, and she stepped out to wave the tablet in the darkness until it caught a signal.

  Aminah had turned thirty in the past year. She raised her children alone in Juhalli, a village in Kolar. She had studied until seventh grade, was married by sixteen, and divorced at twenty. She took on tailoring jobs for a living, but
gave it up because ‘everyone in the village knows how to sew. Everyone makes their own clothes at home.’ Ten years ago, she signed up to become an ASHA during a recruitment drive. 1 There was no salary, but there was an honorarium, and there were commissions for every child they got immunized, and every new and expectant mother they sent to a doctor or followed up on.

  She had met Geetha, a fellow ASHA, then, and they had been inseparable ever since. Between them, they covered Kannada and Urdu, the languages of the villages they had been assigned. All the better to tell off the drunk and belligerent men they encountered on occasion. ‘Having someone else with you is better in such cases. You don’t feel unsafe,’ Aminah said. Once out in the field, they accompanied pregnant women for delivery, ensured that babies were immunized, checked up on antenatal and prenatal cases, and distributed medicines to tuberculosis patients.

  Lately, their roles had been expanded as part of a new project. They had recently been trained to screen people for non-communicable diseases that included diabetes, heart disease and cancer. They were also paid to register people on the healthcare system their tablets were connected with. Each new registration earned them a rupee over the monthly ₹3,500 ($50) they now earned. The tablet in their hand had made access into households easier, Aminah said. ‘It makes people curious. They have not seen something like this before. They think it is a big deal having their details on this device. So, now they flock to us with their Aadhaar cards to get registered.’

  The tablets were an extension of DiNC’s efforts to enrol residents across Kolar. ASHAs were among the first to experience the change. ‘There are some things that are different now, which we like,’ Geetha said. Aminah agreed. (They usually agreed with each other.) ‘Earlier, we would have to wait for a weekly visit from a nurse to the primary health centre for screenings. We didn’t have any means of helping people get appointments at the hospital. Now, we do this screening ourselves and people think well of us because we can establish contact with the hospital.’

  ‘I think,’ Aminah said, ‘our status in society has improved.’

  36

  The Clinicograph

  After the introduction of ASHAs nearly a decade and a half ago, India’s maternal and child health parameters improved dramatically. ASHAs came from the community they worked in, spoke the language, and knew its concerns. They encouraged expectant mothers to visit doctors, and kept following up.

  ASHAs were also tasked with gathering data. But the records they maintained were on paper, with all the difficulties the medium possessed. Information was updated irregularly and difficult to audit. With the government’s approval, TCS team members taught ASHAs to register new patients on tablets, ask questions that could identify undiagnosed illnesses, and record data about the people they met almost instantly. ASHAs would lead the charge in building a registry of patients beyond existing registries, the most important step in making primary healthcare functional.

  When DiNC was finally operational, ASHAs spread out to enrol the locals. From then onward, any interaction they had with the public healthcare system in Kolar added to a clinical medical history that doctors on the system could access. Patients no longer required paper records. Every time they met with or spoke to a doctor on the system, their central health record was updated.

  Their records were viewable on an app called the Clinicograph, which provided doctors a comprehensive view of a patient’s medical history. The Clinicograph arranged a patient’s health data in chronological order, with the most recent reports on top. It was accessible anywhere, by anyone authorized to do so.

  From the perspective of patients, it was easy to see the benefits. They did not need to travel long distances to find medical advice, nor did they have to maintain medical reports. They did not have to recall their medical history for a doctor each time. Regardless of where they sat, doctors had access to the same records. Based on what they saw, distant specialists could consult on a course of treatment to local doctors. At a moment’s notice, they could find test results, notes by previous doctors, and recordings of conversations—all of which, taken together, could yield vital medical clues. Anything could be relevant, so the Clinicograph’s back-end system, the Concentric Data Repository (CDR), vacuumed it all: Maternity cards that patients kept in physical form, scanned images of past doctor prescriptions, test results on paper.

  This sort of ‘unstructured’ information would have been difficult to use in the past. But technology’s advances have unlocked new ways of finding meaning. With machine learning and AI, the value in old medical documents can be extracted more easily. Automated processes mine the system’s database to understand whether a particular patient has done certain laboratory tests just by ‘reading’ the scanned images of test documents in the database, and checking for the patient’s name and the name of the laboratory test. New technologies allow such ‘reading’ and ‘processing’ algorithms at scale, identifying patterns and insights from vast troves of data in a fraction of the time it would take healthcare personnel. It might even—when it is advanced enough—decipher doctors’ handwriting.

  This analysis of data, repeated thousands of times over a wide geographic area, could potentially understand the ebb and flow of the health of individuals, neighbourhoods, districts and entire countries. It could better understand how citizens seek health, understand what health practices are more effective, provide disease patterns and predict outbreaks, and improve the health system’s efficiency by identifying shortages.

  The possibilities are endless. The technological platform is receptive to innovation; it is possible to plug in a range of devices and complimentary services. One such invention, a camera backed by AI that assesses images for pre-cancerous lesions within seconds, was plugged into the DiNC’s platform. Doctors then took over.

  Doctors and other professionals used the platform to provide services, such as Lamaze classes, or educated patients in techniques that were commonplace at high-end urban hospitals, but infinitely rarer in rural India. All of this happened in Kannada, a language local residents understood.

  The platform’s flexibility also made it easy to scale. Technology innovations at the back-end make light work of the kryptonite of healthcare digitization so far—the array of disparate systems that are used across various healthcare facilities. A single hospital may have a different information system for its patients, its diagnostic laboratory and its radiology department. The platform streamlines the tangle of ‘structured data’ coming from various legacy health systems, using a combination of medical expertise and technology. The costs, time and effort to implement are estimated to be far lower than that of equivalent approaches—Health Information Exchange technologies, for instance—used in the developed world.

  DiNC’s technology elements are a harbinger to what is possible when the combination of data, connectivity and AI is deployed in context. But with Bridgital, technology is only part of the story. Truly solving India’s healthcare access challenge needs the right mix of people and processes as well.

  37

  Ubayakushalaopari

  To Minister Kumar, the DiNC’s approach to healthcare reminded him of a Kannada letter-writing custom before the advent of email. ‘Traditionally the first sentence in a letter was, “We are all safe here, we are anxious to know and by the grace of God we believe that you are all safe there.”’ This was called Ubayakushalaopari, he explained. ‘The well-being of both of us.’

  Every morning, in the large bright room in the sanatorium that housed the DiNC, nurses, doctors and coordinators sat in silos and phoned people across Kolar. Their workspaces were marked by signs that dangled above: ‘DiNC coordinator’, ‘Mother and childcare coordination’, ‘DiNC nurse’, ‘Non-communicable diseases coordination’, and ‘Speciality care coordination’. The callers wore hospital coats. With their headsets on, and toggling windows on the DiNC platform, they introduced themselves to patients who were mostly pleasantly surprised to be asked after. The callers br
owsed through the records of each patient, looking up their history in notes that had been written and uploaded. ‘Anaemia’, some notes were titled, and expanding them presented a more detailed picture. The notes were a guide, a way to catch up and record more information.

  Sister Karuna, one of the callers, had been a nursing professor at a college in Bengaluru, and supervised nurses at a local hospital. She joined DiNC in February 2018 on the suggestion of the district health officer, and took to it immediately. She trained ASHAs and coordinated with patients and families to bring them into the system’s fold. Karuna had found dealing with patients she could not see disorienting at first, but grew used to the system. Months after she began, when we watched her work at Kolar, she thought nothing of calling up people and chatting with them casually to make them open up. ‘At a hospital, you can only serve those who turn up. But the poor mostly don’t visit hospitals for several reasons. They think they cannot afford treatment. They are unaware of relevant government schemes. They live very far from large hospitals and losing money and time to visit a hospital does not suit them,’ Karuna said.

  One of the big challenges of her job, she said, was in helping people overcome their superstitions. ‘Sometimes pregnant women tell me that they don’t have milk with their coffee. They think it will affect their baby. I tell them that it is nothing like that.’ The area was filled with deeply held beliefs about how good health could be attained. The good news, sister Karuna said, was that when she called with medical advice, at least they listened.

  The calls were supposed to last no more than ten minutes, but several of them went on for twice as long. With a concerned voice at the other end, people unloaded their questions. Sister Karuna took questions about getting exercise, and informed someone that a government health card would cover their medical expenses. For a family that couldn’t afford food with iron, she advised a switch from sugar to jaggery.