India’s National Digital Health Mission: A New Model to Enhance Health Outcomes

Dr. Pallab Saha, Chief Architect, The Open Group

On August 15, 2020, India’s 74^th Independence Day, Prime Minister Modi launched the National Digital Health Mission (NDHM). The NDHM is a comprehensive digital platform that brings together multiple and diverse groups of stakeholders enabled by shared interfaces, reusable building blocks, canonical datasets, and open standards, with a strong foundation of architecture. In a sector that is riddled with administrative and regulatory complexities, coupled with the scale and scope of operations in India, the NDHM aims to revolutionize the healthcare sector. As the largest democracy in the world, that follows a federated structure of governance, the NDHM is unequivocally targeted at improving the patient experience of care, improving the health of the population, reducing the cost of providing healthcare, and enhancing the effectiveness of healthcare providers.

The Blueprint

The digital health platform that NDHM is, is guided by an architectural blueprint called the National Digital Health Blueprint (NDHB), developed a few months earlier. The NDHB has put in place a structure to the thinking and approach. It established the vision and principles, architecture requirements and specifications, applicable standards and regulations, high-priority services, and institutional mechanisms needed to realize the mission of digital health. The NDHB is crafted to unlock enormous benefits for citizens, create new opportunities and financial, productivity, and transparency gains and make a positive contribution to growth, innovation, and knowledge sharing.

Federation as an (Architectural) Goal

A digital platform with a national footprint evokes immediate pushback as it is generally seen to steer the narrative towards centralization. The architecture deliberately and explicitly addresses this ‘concern’ to ensure that India’s overall federated structure of governance is reflected in the architecture as well. In a large country like India, where there are multiple layers of government – national (central), state, local (urban), and local (rural) – the responsibilities are distributed and this is guaranteed by the constitution. In other words, constitutionally India follows a federated structure and this is sacrosanct. Therefore, the federated architecture is governed by the following principles:

• Federated architecture operates collaboratively, where governance is divided between the central authority (National Health Authority), state, and local units, balancing organizational autonomy with enterprise needs
• The central entity’s architecture (NDHB) focusses on the dynamics of economies of scale, standards, interoperability, and the common requirements, while the states and facilities have the flexibility to pursue autonomous strategies and independent processes
• Participating members (states and facilities) can jointly agree upon the common goals and governance of the federation. That joint governance is expressed by the policies governing the roles and responsibilities of membership, resource discovery, and resource access
• There is an administration role (NHA) whereby federation membership, resource discovery, and resource access is granted or revoked according to governance policy
• States and facilities participate in a federation by selectively making some of their resources discoverable and accessible by other federation members
• While the purpose of a federation is to collaborate, and share resources, resource owners retain ultimate control over their own resources
• The design of all the systems in the federation conform to the prevalent laws and regulations

The underlying architecture is compliant with the India Enterprise Architecture (IndEA) Framework, which is based on the TOGAF® Standard, a standard of The Open Group.

NDHM as a Digital Public Good

Comprising of essential standards-based, secure, interoperable, and reusable building blocks available to multiple stakeholders to build and deploy their digital services and applications in a cost-efficient, accelerated, and integrated manner particularly in low-resource settings the NDHM is envisaged to be a Digital Public Good (DPG). As a common digital platform, the intended benefits and value proposition include:

• Demand: Aggregate demands across different sectors, departments, or projects leading to economies of scale and cross-financing (a service can finance another one that uses the same solution but cannot pay for it)
• Commonality: Create common technology assets to enforce reusability and interoperability while reducing overall operational costs
• Flexibility: Build a flexible, customizable, and generic services rather than tailored for one specific need
• Education: Provide users with a more streamlined experience and a trial environment that eases the technology learning curve
• Integration: Provide a basis for integration and data exchange
• Agility@Scale: Build plug-and-play components and solutions to deploy new services rapidly to respond to new requirements
• Alignment: Provide mechanisms to align with the sustainable development goals (SDGs) specific to health domain

All of the above are part-and-parcel of the Agile IndEA approach that will be used in the implementation of the NDHM. Implementation of the minimum viable architecture (MVA) will mean that foundational capabilities will be available quickly, but also create the ability to add newer capabilities progressively.

Implications and Other Sectors

The NDHM will accelerate India’s move towards a digital society. Digital platforms democratize data, so will NDHM. The areas and issues that have received special attention in the design of the platform include a strong overarching framework and compliance to strict data protection and privacy standards; a regulatory framework to provide for the governance and establish specific rules for neutrality, transparency, data accessibility, interoperability, and fairness for all platform participants; a proactive approach towards raising the digital competency of citizens-at-large; and discouragement of unfair practices stemming from network-effects and data-based economies of scale, specifically focussing on innovation-barriers and technological lock-in effects.

The UN SDGs do not exist in isolation. Purely from a national development outcome perspective, the NDHM will also act as precedence to other such similar initiatives covering important sectors like education, agriculture, commerce and industries.

A Game Changer

Undoubtedly, NDHM is a game changer for many reasons, the three key ones being:

1. The unprecedented scale, scope, and complexity of an initiative that impacts one-seventh of humanity in a domain as critical as health generates automatic global interest
2. Following intense periods of preparation and development, an announcement by Prime Minister Modi symbolizes support from the highest levels, which is imperative for anything of this nature
3. This is the first sectoral architecture implementing a digital platform, that will act as an exemplar for other critical sectors like education, agriculture, commerce, and industries

The NDHM includes actions to transform the health sector into an open, collaborative, interconnected ecosystem structured around an architecture of integrated digital services that are personalized, paperless, presence-less, proactive, perceptive and pervasive. Simplifying processes, reducing administrative burdens, promoting interoperability, and strengthening data and knowledge management is an integral part of the transformation process, all of which culminate into better health outcomes for all.

About the Author:

As Chief Architect at The Open Group, and President, Association of Enterprise Architects (India), Dr. Saha has been identified as a Thought Leader by IBM Smart City Connect, and featured by the Forbes Magazine. A MeitY-NeGD Senior Lead Expert in Enterprise Architecture and a Visiting Professor of Digital Architecture at the Indian Institute of Management, Visakhapatnam, Dr. Saha advises various Ministries and States on matters pertaining to government-wide architecture initiatives. He has been a key contributing author of the India Enterprise Architecture (IndEA) Framework and the Digital Service Standard (DSS), and the co-author of the Agile IndEA Framework playing a critical role in these being notified as national standards. He has been a member of the high-level committee involved in the development of India’s National Digital Health Blueprint for the Ministry of Health and Family Welfare, Government of India. His work has been used as a primary reference for the SDG Digital Investment Framework by the International Telecommunication Union (ITU), and has authored ITU’s thematic report on Digital Transformation. Previously, as Head of Wipro’s Government and Public Sector Architecture Practice, he was selected as an elite Distinguished Member of Technical Staff (DMTS). Dr. Saha has published five books on enterprise architecture. His work has been translated into Arabic, Mandarin, Korean, Russian, and Polish. Dr. Saha was the Chief Architect to Andhra Pradesh State Enterprise Architecture (ePragati) taking it to international prominence. He is a two-time recipient of the Microsoft research grant supported by the UN, and a joint recipient of the Innovation Fund by the Land Transport Authority of Singapore. His work has been cited by the United Nations, ITU, World Health Organization, US Department of Defense, Open Technology Foundation, Info-Tech Research Group, Carlsberg and has contributed to the World Bank EA Guidelines for Mongolia, Vietnam & Bangladesh. He has been an examiner for research degree to the UNSW, a visiting researcher to the UN University, an expert reviewer to the Association of Computing Machinery (ACM) EA Tech Pack. and an invited faculty at the Carnegie Mellon University. He is instrumental in introducing enterprise architecture into the post-graduate (MBA) curriculum in IIM Visakhapatnam and IIT Delhi.