Bridgital Nation

by N Chandrasekaran

  ‘I contacted a pregnant woman in a remote rural area,’ she recalled. ‘She was severely anaemic and both she and the baby could have been compromised. In addition, the family was opposed to her taking supplements because they feared losing the baby.’ Karuna counselled them constantly, eventually bringing them around. ‘The woman received treatment for anaemia, and the delivery was safe. At another time, such a patient would have probably died, or left the baby with a slim chance of survival.’ Anaemia was a common topic for Karuna, given that one out of two Indian women is anaemic. 1

  The other part of DiNC could be found at Sri Narasimharaja (SNR) district hospital, a crowded facility a few kilometres from the sanatorium. Chanda, in her late twenties and a resident of Bangarpet, a sleepy little town full of fields of ragi and tomato plantations, arrived for work at 9 a.m. Her job, as a patient care coordinator, was to liaise between the various doctors, hospital departments and staff, so that patients moved smoothly and quickly through the hospital. The care coordinators were sorters of a kind. They recorded basic information and guided patients to the right doctors and testing labs. They also maintained order while some patients arrived with referrals and appointments, and others showed up without notice. In their absence, these tasks would have fallen to doctors and nurses, or to informal entrepreneurs like Nikhil Burman.

  Mornings were a rush. They began with checking in at DiNC’s new videoconferencing facility, which connected SNR’s doctors with patients at distant health centres (when Internet connectivity was available). She then toured the wards and OPDs, taking stock of the appointments for the day, and checking the availability of doctors. ‘I love my work,’ she said. ‘Some of the doctors are very strict and you need to check with them before having a word, but some of them are more relaxed. It is great to be able to help patients and to guide them.’

  The DiNC job was very different from anything Chanda had done before. ‘I like the fact that I have to move around a lot here. I hate being in one place all day. And meeting so many people is the best part of the job.’ She walked around with a tablet in her hand, attracting the attention of patients who gave her their details, and allowed themselves to be led by her.

  Chanda began as one of six care coordinators who worked at the hospital, each with their own beats to manage. Her salary was ₹12,000 ($170) a month, double what she earned answering calls for a car dealership. Within months, her enthusiasm and capability were widely recognized, and she was promoted to manage and train new patient care coordinators. Six care coordinators now reported to her, and she would be the first person to approach for any escalations within the system.

  The promotion came with a salary spike. She now earned ₹18,000 ($260), and was the primary breadwinner of her family. ‘Almost 90 per cent of the household expenses are borne by me,’ she said proudly.

  ‘We were barely able to make ends meet,’ said Chanda. ‘But with the promotion, we will now be able to put some money away in savings. I am going to treat my entire family when my first salary as an implementation specialist comes.’

  38

  Recovery

  Shireen Junaid, a mother to two daughters, staggered into a primary health centre in Kolar. She was pregnant, and quite unwell. It was February 2018, and the primary health centre looked nothing like the government medical facilities she knew. The place smelled of new paint. Nurses held electronic tablets. There were rows of metal chairs lined against the walls. A green-coated attendant handed her an appointment slip. Minutes later, she was ushered into a consulting room where a doctor brought up a scanned image of her recent medical history, and wrote down her symptoms. Then the doctor placed a call, and another doctor appeared on a screen behind him.

  Dr Kumar, the man on the screen, pulled up Shireen’s records. He noticed that her haemoglobin count was already severely low, at 6.40 grams per decilitre, and the delivery was just a few months away. She had a rare blood type—O negative—so finding a donor or supply for a blood transfusion would be difficult. The longer they let her blood count stay low, the greater danger she and the baby would be in.

  Kumar recommended that Shireen receive injections of iron—as many doses as they could manage before the delivery. He advised her to visit the district hospital for these injections. Shireen was not interested. She said the hospital made her wait for hours she didn’t have. The travel time, on top of the half-day spent jostling to see a doctor, filled Shireen with dread. Her children would have to come along too. Her husband worked two restaurant shifts, and her parents lived hours away.

  The doctor assured her that things had changed now, and told her to expect a phone call.

  Later that day, a few hours after she left the Kolar centre, her phone rang. The caller asked if they could book her an appointment at the hospital the next day. The approach surprised Shireen, who was unused to being checked on. The next morning, within minutes of entering the hospital, Shireen was sent into a consulting room where a doctor administered an injection. A nurse told her there would be two more. Altogether, she had spent no more than half an hour at the hospital. Shireen grew used to the calls, the people at the other end fixing her appointments for her, reminding her of this or that. Each time she visited the hospital, the speed at which she was served and discharged surprised her. By the time Shireen went into labour, the treatment had worked. Her recovery had been helped in part by encouragement and advice from callers she had never met.

  There were other stories too. From Guwahati, a panicked cancer patient barred from boarding a flight home called DiNC with an urgent request for a doctor’s note. Within fifteen minutes, DiNC produced a note that allowed him to board the flight. From Chennai, a doctor received a frantic call from a patient driven to thoughts of suicide due to pain. By looking at the patient’s Clinicograph, and speaking with the patient, the doctor was able to identify that he had not taken the prescribed pain medication, and duly counselled him to do so.

  The stories were validation for a new approach to healthcare—one that emphasized staying in touch with patients. In this system, the effect of well-timed phone calls was crucial. The system did not wait for patients to act on their own; it accounted for human nature, for limitations of time and money. The calls indicated to their recipient that someone was looking out for them, smoothing their visits to doctors and hospitals, removing the hurdles they found so dispiriting. All this was to overcome the deep mistrust patients had of the public healthcare system from which they expected so little.

  Slowly but surely, patients turned up at the primary health centres in greater numbers. Between February and July 2018, the primary health facilities covered by DiNC saw a 55 per cent increase in visiting patients from the previous year. By November 2018, more than 500 patients had undergone virtual consultations at public health facilities. On balance, 40 per cent of virtual consultations were to ensure that a patient visiting a primary health centre did not have to return without seeing a doctor, while the rest were to ensure that a patient could consult with a specialist at their nearest health centre, without having to travel to visit a specialist.

  The figures were from a single district. But it was enough to provide a glimpse of what was possible.

  39

  The Bridgital Model

  In 2018, we set out to understand the impact of Bridgital on jobs, wages, productivity and access to services in India.

  We initially turned to a global study: A McKinsey Global Institute model that quantified the impact of automation on workforces globally. 1 To do this, they first broke down industries into a series of occupations, and each occupation into a series of tasks. They then broke down each task into five sets of skills—physical and manual, basic cognitive, higher cognitive, social and emotional, and technological—and assessed when technology could achieve the capabilities of a worker in a given skill category. Then, they estimated when that technology might become financially viable.

  When technologies are able to replicate skills at a low enough cost,
specific tasks start to be automated. When most of the tasks within an occupation can be automated, that occupation itself is considered automated. The dependence on the type of skills involved, the level of skill required and worker remuneration, all help explain why sectors automate at a different pace from one another. It’s why the progress of automation varies from one economy to the next. While stylized, this reflects quite well the broad thrust of how automation is likely to progress.

  In a country where labour is relatively scarce, skilled and so expensive, companies may be early technology adopters, automating large parts of their workforce. On the other hand, in a country like India, it may be a while for technology to be inexpensive enough to compete with the low cost of labour. McKinsey’s model estimates that, for India, 9 per cent of current work hours will be automated by 2030—much lower than the 23–24 per cent impact estimated in the US and Germany.

  Demystifying Work

  We modified this model, applying the Bridgital approach to incorporate what we saw on the ground in India. We saw not a binary choice between automation or no automation. Instead, we saw a world in which work was demystified—disaggregated and redistributed through the aid of the cloud, AI and related technologies. In this world, lower-wage, digitally augmented workers are able to take on tasks previously done only by experts and specialists. This frees up time and capacity for the latter to use their skills optimally. Technology allows the seamless transfer of the freed-up time and capacity—mediated by digitally augmented workers in the last mile—to cater to the needs of the underserved. The result is an enhanced system since the specialized workers focus on what they do best and other workers take on new, more productive tasks. Most importantly, it is more inclusive.

  The right tools could take a load off junior doctors, nurses and health associates. Many pre-diagnosis activities, for instance, could be turned into a checklist programmed onto a kiosk, a handheld tablet, or even a smartphone, and then be used by someone without clinical training. The data they collect could be analysed almost instantly by medical software, and be made available for a doctor to consult whenever they wanted. The software could be programmed to highlight potential problems, signal improvements, or even suggest treatment approaches.

  Specialist doctors are able to conduct virtual consultations with patients well beyond where roads end, where the choice to access healthcare is a major life decision. This is where the benefits of the Bridgital approach meet the road.

  Bridgital Addresses India’s Twin Challenges of Jobs and Access: The Healthcare Example 2

  Bridgital Healthcare

  India currently has about 700,000 practising doctors. To reach a standard considered acceptable by the World Health Organisation, it will need more than it can currently produce. By 2030, when it will need a bare minimum of 1.5 million doctors, there will instead be just over a million. 3

  By our estimate, a Bridgital transformation of the entire Indian public health system—automating and reassigning tasks—could free up the equivalent of 370,000 full-time doctors by 2030. 4 Added to this, Bridgital approaches could create a million new jobs in healthcare, and make another million more productive. With gains in productivity will come wage gains—on average, digitally augmented workers should see a 15–20 per cent rise in their wages.

  Bridgital Notably Addresses the Doctor Supply Gap

  40

  Bridgital More Broadly

  The transformations at AIIMS and Kolar are real-world demonstrations of applying Bridgital in healthcare. But the principles that underpin Bridgital can be applied anywhere, by anyone, at any time. We discuss a few sectors below and in the charts on the following pages.

  Agriculture: If agriculture, the source of livelihood for nearly half of India’s workforce, underwent a Bridgital makeover, it would centre around agriculture extension workers. The traditional role of an extension worker has been to disseminate new knowledge to farmers. 1 These workers have the advantage of local language and dialect, coupled with knowledge of specific cultural contexts. However, low penetration rates and vacancies limit the potential impact of the extension worker role today. For extension workers, the transformation could be in the form of digital platforms that offer information and farming insights based on granular data—things farmers currently lack access to, limiting their productivity. Roles would change here too. Extension workers could collect data by testing soil and water. They could help farmers sign on to online marketplaces that offer everything from credit to trucks. Depending on how many of India’s 1.6–1.7 million farm holdings adopt agricultural services, augmented extension workers could range between 500,000 to one million in number. 2

  Logistics: A Bridgital approach in logistics would make the perilous job of a truck driver simpler, safer and more productive. A platform could train drivers, insure them, remind them of safety measures, provide real-time guidance on routes and driving behaviour and direct them to the nearest place where they could get a good night’s sleep. It would also include infrastructure that makes this a reality, such as rest stops with proper food, sanitation and dormitory facilities in critical locations.

  Platforms would turn long-distance transport into a relay-type task, breaking up a cross-country journey into multiple day-long trips by a succession of drivers. And yet things would move faster: Truck fleets would be on the road continuously, reducing transit time by 50 per cent or more. 3

  Judiciary: A Bridgital effect on the judiciary would make more efficient use of judges’ time, lowering the 30-50 per cent of time taken up by administrative and procedural hearings. Augmented ‘courtroom managers’ could help reduce the workload of judges and also tide over the 5,800 courtroom vacancies currently. Records would be digitized, case summaries would be supported by AI, and courts would know instantly if the same case was being heard by courts in different locations.

  If the spectrum of transformation includes agriculture, logistics, the judiciary, education, and financial services as well, we believe that a Bridgital approach will directly impact 30 million workers by 2025—in the form of new jobs, as well as augments to existing ones. Wages for these workers will likely increase around 10-20 per cent. It will expand the size of the formal economy. At the same time, more than 200 million citizens will experience improved access to services. 4

  Bridgital: 30 Million Gainful Jobs, across Six Sectors by 2025

  These are conservative estimates, and cautious numbers. Bridgital isn’t a miraculous solution. It’s a leap from where we are, and a step towards where we could be. These numbers speak of the slow, painstaking, yet ultimately rewarding path of incremental change that lies ahead as the future of work becomes our present.

  So how can India make it possible for everyone, no matter where they are, to apply Bridgital principles?

  To begin with, data privacy—the foundation of any Bridgital approach—is a necessity. India is in the process of recognizing individuals’ right over their personal data. As it does this, it needs to ensure that data can be accessed only by people who are authorized to do so, but without stifling researchers who need it. At the same time, India requires an authority that can provide redress for unauthorized access to data. There’s a range of models to pick from: The China model, which restricts most forms of access; the US model, where firms set the terms on which they access data; and the EU model, which is conservative but balanced.

  Second, industries and organizations would benefit from freedom to experiment with existing roles and create new ones. For example, there are certain tasks that only doctors are permitted to do, such as prescribing certain drugs, and administering life-saving injections. This is something an advanced nurse practitioner—a role already mainstreamed by the National Health Service in the UK—could do just as well. What’s needed is some more lightness of touch when India limits what its professionals are permitted to do.

  Third, technology can help overcome old apprehensions by redefining how services are delivered. Currently, a doctor mu
st be physically present in the same room as the patient to write them a prescription. In another time, this was a precaution against fake prescriptions being used to create a black market in prescription medication. Now, with digital signatures and remote consultations becoming the norm, the precaution is a hurdle to better ways of functioning. There are very likely similar instances of well-meaning regulations in other industries that have outlived their purpose.

  Fourth, digital skilling needs official recognition. By certifying the knowledge that augmented workers gain in the course of their work, India will encourage its people to improve their skills, knowledge, and productivity. This feeds into a virtuous cycle where workers will build on technical knowledge and twenty-first-century skills, such as collaboration and creativity. When it comes to twenty-first-century skills, we need to design our educational approach in new ways. Creativity, for instance, is a natural human tendency—but we can study the circumstances under which it flourishes, and design our educational system in ways that offer such opportunities to every student. Collaboration, which appears like a basic task, can be perceived as progression through stages of learning and mastery over dozens of skills including negotiation and conflict resolution. Critical thinking requires a change in mindset, from passive transmission of knowledge to learning by questioning and testing hypotheses.

  Reaching this state will involve novel approaches, like the use of regulatory sandboxes—experimental settings where new rules are tested, their impact studied, and then used to formulate new policies for the entire sector. At the same time, the shaping of data rules must be as collaborative as possible, with the participation of all stakeholders—start-ups, academia, civil society, small and large private companies.