CASE STUDY Ayushman Bharat Digital Mission’s Integrated Digital Health Ecosystem is the Foundation of Universal Citizen-centered Health Care in India HEALTH Fragmented health and data systems occur at multiple levels, and a lack of access SYSTEM  to timely information results in reduced quality of medical care. CHALLENGE DIGITAL-IN-HEALTH FLAGSHIP PROGRAM Use of standards based, flexible applications, software solutions, and technologies that work synergistically within the digital ecosystem. These technologies are a SOLUTION  combination of interoperable open-source and proprietary applications that enable access to data and information in a timely manner to meet the unique needs of users. KEY An integrated enterprise architecture through a unified digital health interface TOOL  enables health information exchange across multiple digital health interventions. TIMELINE  2018 till date. RESOURCES Implementation cost is approximately $4.5 million over 3 years. USED  Introduction In the last decade, digital public infrastruc- ture within India has expanded exponentially. The COVID-19 pandemic ushered in the need Several initiatives like the digital identity for accelerated digitization of health care across system known as Aadhaar (for unique identi- the globe. The Government of India amply fication), and the Unified Payments Interface demonstrated their digital prowess in their have become central to India’s public service response to the pandemic by building Digital delivery architecture. The Unified Payments Public Goods (DPGs) that leverage several Interface has transformed heterogeneous standalone initiatives to develop an integrated payment modalities by aggregating them national digital health ecosystem. The aim of under one easy to use, highly secure mobile- this ecosystem is to support Universal Health based system for money transfer. Mobile and Coverage through the provision of real-time internet connections have expanded at a fast data, information and infrastructure using pace and penetrated ever deeper into rural open-source, interoperable, standards-based areas. Currently over 572,000 villages out of digital systems. 597,000 have mobile or network connectivity. AYUSHMAN BHARAT DIGITAL MISSION’S INTEGRATED DIGITAL HEALTH ECOSYSTEM IS THE FOUNDATION OF UNIVERSAL CITIZEN-CENTERED HEALTH CARE IN INDIA There are nearly 1.2 billion mobile subscrib- care services to support this increased ers, 800 million internet users, and 510 million demand and to improve program coverage smartphone users. This expansion can be and enhance quality of care. attributed to the cost of mobile and internet The impact of the pandemic put a spotlight connections dropping substantially, allowing on the benefits of digital innovation, technolo- for increased digital access across the coun- gy-enabled solutions and served to accelerate try. Within the public digital infrastructure, their use. there are 1.24 billion unique Aadhar digital IDs in place, and it is estimated that nearly 10 billion+ eKYC (Know Your Client) transactions The CoWIN platform allowed individuals and 2.64 billion Unified Payments Interface to register on an online portal, schedule transactions take place monthly. This infra- vaccinations at government hospitals, receive DIGITAL-IN-HEALTH FLAGSHIP PROGRAM structure forms the basis of the Ayushman digital vaccination certificates and facilitated Bharat Digital Mission (ABDM). access to vaccinations at private sector hospitals. The platform was viewed positively During the pandemic, India leveraged various by those individuals using it. It gave the digital health interventions to provide contact- government access to valuable COVID-19 data. less health care. Some examples of the Digital Public Goods developed during the pandemic include the COVID Vaccine Intelligence Network Within this short period of implementation, (CoWIN) application, which provided individu- it became clear that a comprehensive digi- als with vaccine certificates, and the Aarogya tal health care ecosystem was necessary to Setu application. Aarogya Setu was originally bring together existing siloed efforts, and a contact tracing app that provided real-time to proactively move towards a more holistic data on active cases, containment zones and and citizen-centric system. The government helped more than 175 million citizens assess responded by creating shared Digital Public risk in their areas. It also facilitated the book- Goods for health care and developed a ing of COVID-19 vaccinations. It has now been framework for a nationwide digital health. transformed into a national health application This initiative was a turning point for health that allows individuals to register for a Digital care in India. The Prime Minister launched Health ID, telehealth consultations, as well as the ABDM on September 27, 2021, under functioning as an Electronic Medical Record so the aegis of the National Health Authority. that individuals can access digital lab reports, Within a year of its launch, the ABDM had prescriptions, and diagnosis. established a robust framework to provide The high volume of over 350 million CoWIN accessible, affordable, and equitable digital registrations prompted India to adopt a health care. With India taking on the G20 completely digital approach to its vaccination presidency in 2023, the Global Initiative on strategy. Telehealth platforms like eSanjeevini Digital Health advocates for a connected and also saw a steep increase in users during the integrated health ecosystem to bring together pandemic, as 85 percent of physicians adopted global efforts on digital health. It also calls telehealth platforms. Use of telehealth was for the best use of technologies for improv- only at 18 percent prior to COVID-19. This ing health outcomes and scaling-up of these emphasized the need to better incorporate technologies as Global Digital Public Goods to cutting-edge digital technologies into health accelerate Universal Health Coverage. Within DIGITAL-IN-HEALTH COMMUNITY OF PRACTICE 2 AYUSHMAN BHARAT DIGITAL MISSION’S INTEGRATED DIGITAL HEALTH ECOSYSTEM IS THE FOUNDATION OF UNIVERSAL CITIZEN-CENTERED HEALTH CARE IN INDIA Digital highways harness data, technology, and connectivity to improve the way the digital architecture is designed, built, operated, and used. This will enable high performing, and faster delivery, and an enhanced customer experience for all. this broad perspective, the ABDM aims to • Workforce: Building a network of support the creation of an integrated digital trained healthcare professionals health infrastructure by developing a digital across the country, but especially backbone. The government will bridge gaps in rural areas. Creating a work- by building digital highways with the aim of force with a focus on distribution, improving the efficiency, effectiveness, and skill mix, and performance transparency of health service delivery in • Affordability: Improving the qual- India for the myriad of different private and ity of public healthcare service DIGITAL-IN-HEALTH FLAGSHIP PROGRAM public stakeholders, that also encompasses delivery to all populations and the alternative medicine, making it a diverse and capacity to meet the demand complex ecosystem to be integrated. • Quality of Care: Improving overall Human Development Service quality and differences in health care Delivery Problem Improvement by improving adherence to treatment guidelines, regulating prescription of opportunities medication, and appropriate use of India’s vision to digitize healthcare started high-end diagnostics and procedures. with the launch of the National Health policy Despite the burgeoning innovations, digitali- in 2017, followed by the NITI Aayog’s National zation of health care in India is challenging. Health Stack in 2018 which formed the basis There are over 5 million health care profes- for the National Digital Health Blueprint sionals, and 1.2 million health care facilities (NDHB) launched in 2019, culminating in serving a population of nearly 1.4 billion the launch of the Ayushman Bharat Digital people. Bringing such a large number of mission in 2021 (Sharma, R. S et al., 2023). stakeholders onto a single digital health The vision supported by previous invest- system managed by the government in a ments in foundational technologies provided single step was not viable, due to both the the groundwork for creating an integrated sheer volume, and the extremely varied digital health ecosystem, the aim of which is needs. Although there has been rapid digi- to provide quality healthcare using accessible tization in other sectors, such as finance and affordable digital technology. and banking, travel and tourism, and the As detailed in the policy documents, some of hospitality sectors, it must be acknowledged the envisioned digital health interventions for that digitizing health data is more nuanced addressing health service delivery reforms and requires a more granular and involved include: approach. Health care data is more complex as it consists of numerous different types • Infrastructure: Strengthening of files, requires stringent data protection healthcare infrastructure and help- and security regulations, and includes an ing to reach the underserved infinite number of medical terminologies and particularly in rural areas. definitions which are not universally under- • Access to Care: Reducing dispari- stood. These include radiological images, lab ties that exist in access to healthcare reports, prescriptions, and outpatient and between urban and rural areas in-patient records. In addition, all of these DIGITAL-IN-HEALTH COMMUNITY OF PRACTICE 3 AYUSHMAN BHARAT DIGITAL MISSION’S INTEGRATED DIGITAL HEALTH ECOSYSTEM IS THE FOUNDATION OF UNIVERSAL CITIZEN-CENTERED HEALTH CARE IN INDIA are written using different standards and Finally, the program uses an evidence-based formats. More importantly, health care data approach to inform its design and implementa- is highly sensitive and personal in nature and tion to ensure that the technology is effective, poses greater risk. Therefore, the digitization efficient, and cost effective. Together all of health care is more complex and challeng- these building blocks can be scaled as well ing when compared to other sectors. as sustained to meet the growing needs of the program as it expands and evolves over time. Technology Principles A federated architecture has been adopted The ABDM is a platform based an open using six core building blocks that have been Application Programming Interface (API), developed using a minimalistic approach and meaning it is flexible and allows both open- are maintained centrally at the national level DIGITAL-IN-HEALTH FLAGSHIP PROGRAM source and proprietary technologies to plug in. (Figure 1). All the other building blocks are It is an ecosystem where all the building blocks designed to be operated in a federated model and components of the ABDM are designed to that allows regional, state-level and institu- be interoperable to facilitate the exchange of tion-level platforms and systems to function data. The platform makes use of open stan- independently, but in an interoperable fashion. dards and data exchange protocols to ensure that different systems can communicate with An API provides a way for two or each other effectively. They work together more computer programs to seamlessly, regardless of the application or communicate with each technology provider used. other. It is a software interface, offering Security and privacy are recognized as top a service to other priorities underpinning the design and devel- pieces of software. It opment of the APIs, and all systems need to enables multiple software comply with relevant data protection and secu- components to “talk to each other” using a rity regulations1. It was imperative that robust set of definitions and protocols, such as a measures are put in place before deployment data dictionary. APIs are an accessible way to protect data from unauthorized access and to extract and share data within and across theft. organizations. Building blocks refers to software The systems are designed based on user-cen- code, platforms, and applications, tered design principles and consider the needs that are interoperable, provide and preferences of health care providers, basic digital service at scale patients, and other stakeholders. The plat- and can be reused for multiple form utilizes evidence-based approaches to use cases and contexts. It serves inform its design and implementation. as a component of a larger system or stack, and can be used to facilitate the delivery of digital public services via functions for e.g., registration, scheduling, ID authen- 1 At the time of writing, India’s new Digital Data tication, messaging, etc. The building blocks Protection Bill 2023 (https://www.meity.gov.in/ can be combined and adapted to be included writereaddata/files/The%20Digital%20Personal%20 Data%20Potection%20Bill%2C%202022_0.pdf) had as a part of a stack of technologies to form a not been promulgated. Adjustments to the system Digital Public Infrastructure. https://digitalpub- described in this case study may need to be made licgoods.net/DPI-DPG-BB-Definitions.pdf depending on the Bill’s final form, as adopted as law. DIGITAL-IN-HEALTH COMMUNITY OF PRACTICE 4 AYUSHMAN BHARAT DIGITAL MISSION’S INTEGRATED DIGITAL HEALTH ECOSYSTEM IS THE FOUNDATION OF UNIVERSAL CITIZEN-CENTERED HEALTH CARE IN INDIA OPEN-SOURCE APPLICATIONS are built on publicly available source codes that can be accessed, modified, and distributed by anyone, are free to use, encourage collaboration, and contribute to innovations by allowing developers to contribute to the code base. They can be used by developers to build new solutions that leverage the health stack (initiative by government of India to improve digital health infrastructure) or other open-source tools, and they can be customized to meet the needs of different health care providers and patients. PROPRIETARY APPLICATIONS: Proprietary applications, on the other hand, are built on a code that is owned and controlled by a particular company or organization. They are typically sold as commercial products, and users may be required to pay licensing fees or subscription costs to access them. In the context of ABDM, proprietary applications may be used by health care providers or insurers to manage patient data, billing DIGITAL-IN-HEALTH FLAGSHIP PROGRAM information, or other aspects of their operations. While proprietary applications may not be as open or customizable as open-source solutions, they can still play an important role in the digital ecosystem by providing specialized features or services that are not available elsewhere. While open-source applications may encourage collaboration and innovation, proprietary applications may provide specialized services or features that are not available in open-source alternatives. Main components of the digital health ecosystem enabled by ABDM: • Hospital Management Information System (HMIS): A comprehensive information system that collects, stores, and analyzes data related to health service delivery and utilization • Health Insurance: Ayushman Bharat provides health insurance coverage to eligible households in India through the Pradhan Mantri Jan Arogya Yojana (PM-JAY) scheme (a public health insurance scheme) • e-Governance: Digital platforms are used to manage various aspects of the health care delivery system, such as enrolling beneficiaries, managing claims, and monitoring program performance • Telehealth: The program includes the provision of telehealth services to rural and remote areas, allowing patients to access medical consultations and advice from specialists • Use of both Open Source and Proprietary Software and technological applications • Health Information Exchange: A platform that enables the exchange of health information between health care providers and stakeholders, such as patients, insurance companies, and public health agencies. • Electronic Health (EHRs): EHRs are maintained for each beneficiary enrolled under PM-JAY, and they contain a complete record of all medical treatments received by the patient • Health Analytics: The data collected through HMIS and EHRs is analyzed to identify patterns, trends, and opportunities for improvement in the health care delivery system These building blocks work together to create a comprehensive digital health ecosystem, aimed at improving access to quality health care for all Indians, particularly the most vulnerable and marginalized communities. DIGITAL-IN-HEALTH COMMUNITY OF PRACTICE 5 AYUSHMAN BHARAT DIGITAL MISSION’S INTEGRATED DIGITAL HEALTH ECOSYSTEM IS THE FOUNDATION OF UNIVERSAL CITIZEN-CENTERED HEALTH CARE IN INDIA As defined by ABDM, the data is federated Federated Architecture is a pattern in enterprise and stored close to the point of generation. architecture which allows interoperability and All the registries and other master databases information sharing between semi-autonomous of ABDM are built as a ”single source of truth” decentralized organized lines of business on different aspects and are backed by strong (LOBs), information technology systems data governance principles which includes and applications that share a common clear ownership, roles and responsibilities and vision. It works well in heterogeneous environments where a central one-fits-all dedicated data governance structures estab- approach cannot be applied; and provides lished at both the central and state levels. high flexibility and agility to the various autonomous (and interlinked) compo- Figure 1 is a representation of the architec- nents within the system for coordinated ture of the Ayushman Bharat Digital Mission DIGITAL-IN-HEALTH FLAGSHIP PROGRAM sharing and exchange of information. formerly known as the National Digital Health There is no centralized repository of Mission. health care records either in one place or in one system; and can be stored in The key objectives of these overarching tech- multiple places as per the choice of nology principles are to ensure that: hospitals, doctors, and patients. This is known as a federated architecture • Patients can securely store and in IT or digital system. Only the data access their medical records, such collected through registries such as Health ID registry, Health care Professional as prescriptions, diagnostic reports, Registry and Health care Facility Registry and discharge summaries, and share is stored centrally because these them with health care providers for datasets are essential in providing assured and appropriate treatment interoperability, trust, identification, and single and follow-up. In addition, patients source of truth across different digital health can access accurate information on systems. both private and public health facilities, and service providers can access health services remotely through advanced analytics, and usage of health tele-consultation and e-pharmacy biomarkers in diagnosis, which enables geographic and demography-based • Health care professionals have full program monitoring and the use of access to a patient’s medical history, preventive health care. This facilitates after obtaining informed consent, informed decision making to improve to ensure they can prescribe the policy design, strengthen program right interventions. This integrated implementation, and increase the ecosystem facilitates an improved accountability of health care providers continuum of care, digitizes insurance claims that can be processed for • Researchers can use aggregated data faster reimbursement, and overall to study and evaluate the effectiveness enhances service provision of various programs and interventions, and this facilitates a comprehensive • Policy makers and program feedback loop between researchers, managers have access to better policymakers, and providers. quality macro and micro-level data, DIGITAL-IN-HEALTH COMMUNITY OF PRACTICE 6 AYUSHMAN BHARAT DIGITAL MISSION’S INTEGRATED DIGITAL HEALTH ECOSYSTEM IS THE FOUNDATION OF UNIVERSAL CITIZEN-CENTERED HEALTH CARE IN INDIA Figure 1  Technology Architecture of the Ayushman Digital Health mission DIGITAL-IN-HEALTH FLAGSHIP PROGRAM Source: NHA Annual Report 2021–2022_d4f624f7b5.pdf, page 86. Major implementation milestones • Health care professionals (Health care Professionals Registry) The ABDM was launched in 2020 to acceler- • Health care facilities, including but not ate the digitalization of health care across limited to hospitals, laboratories, and India by building digital highways to promote pharmacies (Health Facility Registry) connectivity between disparate existing digital health systems, developed prior to COVID-19, In these registries, each individual entity is and integrate existing digital health solutions assigned a Unique Identifier (UID), which to support the creation of interoperable plat- is used across the entire ecosystem. This forms, bringing them all together under one helps to establish linkages through APIs and comprehensive and holistic ecosystem. The enhances accessibility of information. The aim key milestones that led to the launch of the is to digitally empower individuals, patients, ABDM are illustrated in Figure 2. doctors, and health facilities to streamline the delivery of health care services and related Since its launch, the foundations for a robust information. Some of the key implementation public digital health infrastructure are being milestones since the ABDM’s inception in 2018 laid through core registry building blocks or include: modules of: 1. Launch of a real-time HMIS through • Individuals/citizens/patients an online portal. The HMIS is a dig- (ABHA ID registry) ital initiative under the Ministry of DIGITAL-IN-HEALTH COMMUNITY OF PRACTICE 7 AYUSHMAN BHARAT DIGITAL MISSION’S INTEGRATED DIGITAL HEALTH ECOSYSTEM IS THE FOUNDATION OF UNIVERSAL CITIZEN-CENTERED HEALTH CARE IN INDIA Health, and Family Welfare (MOHFW), obtaining the patients consent, a digital which collects, stores, and analyzes version of the health record is uploaded health service delivery and utilization to the ABHA account to create a seam- data. The HMIS portal uses all appli- less online platform that allows users, cable government standards, such insurance companies and hospitals as standardized facility UIDs, entity across the country to access and share names, geographic boundaries (up to EMRs through the web application. The the level of villages), population data ABHA also enables citizens to compile a and other relevant information, includ- comprehensive medical history across ing Geographic Information System various health care providers, thereby (GIS) based layers that are used in improving clinical decision-making. the Integrated Health Information As of August 2023, nearly 442 mil- DIGITAL-IN-HEALTH FLAGSHIP PROGRAM Platform. APIs link it to other programs lion ABHA numbers, were generated, and 293 million patient health records 2. Creation of individual ABHA were linked to the individuals’ ABHA Numbers and health accounts as accounts (ABDM Dashboard, 2023) a basis for a seamless online plat- form. ABHA numbers are comprised of 3. Creation of UIDs for service pro- a randomly generated 14-digit iden- viders. Using a similar approach to the tification number are created either UIDs for individuals, 14-digit UIDs are using the individual’s/patient’s mobile generated for both the Health Facility number or Aadhar number. This enables Registry and the Health Professional each person to get a unique health Registries. The Health Facility Registry account, an Ayushman Bharat Health is “a single centralized repository of all Account (ABHA) linked to their ID. After the health facilities in the country” to Figure 2  Key milestones leading to the launch of the Ayushman Bharat Digital Mission May 2018 Sept 2018 Jan 2019 Aug 2020 Sep 2021 National Health Pradhan Matri-Jan National Health National Digital Ayushman Bharat Agency Arogya Yojana Authority Health Mission Digital mission Speci c goals for Components for Implementation Notable Policy digital technologies digital health Implementation milestones • Registries • Electronic registries guidelines • Pilot on Aug. 15, • Claims performs • Layered framework 2020 • Federated • Building blocks • National rollout on architecture • Personal health Sept. 27 • Data standards & records • Standards and • Approved by Union electronic health • Federated regulations Cabinet on Feb. 26 records architecture • Institutional framework • Health analytics Source: Adapted from NHA_Annual_Report_2021_2022_d4f624f7b5.pdf page 82. DIGITAL-IN-HEALTH COMMUNITY OF PRACTICE 8 AYUSHMAN BHARAT DIGITAL MISSION’S INTEGRATED DIGITAL HEALTH ECOSYSTEM IS THE FOUNDATION OF UNIVERSAL CITIZEN-CENTERED HEALTH CARE IN INDIA facilitate storage and exchange of stan- which is a flagship health insurance dardized data from both the public and scheme, launched in September 2018 private health facilities in the nation. to provide health insurance coverage Health facilities would have provision of to eligible households. To ensure timely electronic processing of documents for insurance payments, EHRs are main- various purposes like for empanelment, tained for each beneficiary enrolled claims processing, e-signature etc. The under PM-JAY. A dashboard has been Health Professional Registry is also created that has both aggregated and a commonly known as the Digi Doctor drill-down view of various datasets, and Platform or Doctors Directory. Digi it provides real time reports of trans- Doctor Platform is “A single, updated actions and analyzes utilization trends. repository of all doctors enrolled in The PM-JAY also has in place hospital DIGITAL-IN-HEALTH FLAGSHIP PROGRAM nation with all the relevant details of registration, beneficiary identification, doctors such as name, qualifications, and transaction management system(s) name of the institutions, qualifications, specializations, registration number 5. Expansion and integration of with State medical councils, years of Telehealth Services “eSanjeevani” experience, etc. Doctor’s Directory is with ABDM. The program has tele- one of the essential building blocks health services available, allowing of the national e-health architecture patients in rural and remote areas to access digital medical consulta- These provide verified digital identities tions to solicit advice from specialists. to large and small public and private health facilities and professionals. This List of Digital services provided include: serves as a single source of truth for (A) Citizen/Patient Services: (i) Single, Secure verified health care provider related Health Id to all citizens, (ii) Personal Health Record, information and connects them to the (iii) Single (National) Health Portal, (iv) App central digital ecosystem. The Health Store, (v) Specialized Services for Remote Areas/ Facility Registry and Health Provider Disadvantaged Groups, (vi) NDHM Call Centre, Registry help improve the identification/ (vii) Digital Referrals & Consultations, (viii) Online discovery of health care facilities and Appointments, (ix) e-Prescription Service, (x) Digital allow health professionals to build an Child Health, (xi) National “Opt-out” (for privacy); online presence and offer their ser- (B) Services by/for Health care Providers/ vices more effectively. In addition, a Professionals: (xii) Summary Care Record, (xiii) Drug Registry is also being designed Open Platform to access Emergency Services, (xiv) to create a single, up-to-date, cen- Technology for Practitioner (GP) Transformation, tralized repository of all approved (xv) Digital Referrals, Case Transfers (xvi) Clinical drugs across all systems of medicine Decision Support, (xvii) Digital Pharmacy & pharmacy Supply Chain, (xviii) Hospital Digitization, 4. Integration of EHRs for Pradhan (ix) Digital Diagnostics; Mantri Jan Arogya Yojana (PM-JAY). (C) Technical Digital Services: (xx) Architecture As of August 2023, a total of 110 digital & Interoperability, (xxi) Health Information health services/applications have been Exchange, (xxii) Standards, (xxiii) Health Network, integrated with ABDM. (National Health (xxiv) Data & Cyber Security, (xxv) Information Authority and ABDM, 2023). The EHR Governance. forms an important part of the PM-JAY DIGITAL-IN-HEALTH COMMUNITY OF PRACTICE 9 AYUSHMAN BHARAT DIGITAL MISSION’S INTEGRATED DIGITAL HEALTH ECOSYSTEM IS THE FOUNDATION OF UNIVERSAL CITIZEN-CENTERED HEALTH CARE IN INDIA The integration allows existing users is taken and logged, and only after of eSanjeevani to create an ABHA that are the health records shared account, manage their existing health records, such as prescriptions 7. Implementation of health ana- and lab reports, and to share these lytics. The data collected through with the doctors on eSanjeevani for both the HMIS and EHRs is being better clinical decision-making and analyzed to identify patterns, trends, to support the continuum of care. and opportunities for improvement As of August 2023, eSanjeevani ser- in the health care delivery system vices have reached over 145 million Figure 3 highlights the different components of Indians (eSanjeevani website, 2023) the ABDM and how these are linked in terms DIGITAL-IN-HEALTH FLAGSHIP PROGRAM 6. Launch of Health Information of their functionality and use. Exchange and Consent Manager (HIE-CM): The HIE-CM platform was Institutional and strategic launched to facilitate the exchange of alignment to implement change health information between health care providers and other stakeholders, such Under a partnership between the Ministry as patients, insurance companies and of Health and Family Welfare and the public health agencies. This system Ministry of Electronics and Information ensures that the identity of persons Technology, the National Health intending to share information is first Authority has been identified as the lead verified, consent of the person/patient Figure 3  Overview of the functioning of ABDM HEALTH HEALTH INFORMATION ABHA INFORMATION PROVIDERS HIP USERS HIU Health Public Health Information Information Public Health Programs Providers (HIP) ) users (HIU) Programs Doctors & Doctors & Hospitals Health Information Hospitals Exchange (Gateway) & Content Manager Diagnostic Diagnostic Centre Healthcare Centre Professionals Registry Health Health Facility Health Locker Registry Locker Viewing/Sharing of Health Records after consent Entities providing or using information could be same or di erent Source: ABDM Handbook (2022). DIGITAL-IN-HEALTH COMMUNITY OF PRACTICE 10 AYUSHMAN BHARAT DIGITAL MISSION’S INTEGRATED DIGITAL HEALTH ECOSYSTEM IS THE FOUNDATION OF UNIVERSAL CITIZEN-CENTERED HEALTH CARE IN INDIA implementing agency. The National Health • Coordinating with the Ministry of Health Authority has been entrusted with: and Family Welfare and States/Union Territories to resolve technical and • Administrative and technical leadership operational issues and capacity building • Building the technological infrastructure The National Health Authority works in • Creating a national digital close coordination with other ministries health ecosystem and government departments, the private • Developing models for self- sector and civil society organizations. The financing within the ABDM multi-stakeholder mechanism through which the program operates includes the following: The National Health Authority DIGITAL-IN-HEALTH FLAGSHIP PROGRAM is also tasked with: 1. The National Health Authority is the implementing agency for PM-JAY and is • Implementing policies and decisions responsible for the overall management approved by the Mission Steering and program performance. It provides Group and Empowered Committee technical support to the States/Union • Developing strategic partnerships with Territories on program implementation private sector and civil society bodies Figure 4  ABDM Stack–Modular and Interoperable USER PRIVATE SOLUTION APPLICATIONS PUBLIC AND INDIVIDUAL APPS HEALTH PROVIDER APPS Diverse user Arogya Setu | E-sanjeevani LIMS | HIMS experience and Other Apps innovative solutions UNIFIED HEALTH TELEMEDICINE APIs LAB & DRUG APIs OTHER HEALTH INTERFACE SERVICES APIs Discover doctor Discover doctor APls for Health Book appointment Discover pharmacy Discover bed availability Services Discover hospital facilities Teleconsult... Available services .. Take Decisions ... DIGITAL REGISTRIES HEALTH INFORMATION HEALTH CLAIM ABHA healthcare EXCHANGE STANDARDS HEALTH DATA professionals Health information eClaims standard DIGITAL PUBLIC INFRASTRUCTURE EXCHANGE Health facilities exchange & consent Health claims Streamlining ow manager of patients, health Drugs ... Platform policy markup information and Health document language money standards (diagnostic reports prescriptions) Bill markup language Aggregated health data & analytics JAM & OTHER DIGITAL PUBLIC GOODS Cross domain Aadhaar, UPI, e-RUPI, e-Sign, Digilocker, Consent Artefact... generic building blocks Source: ABDM Handbook (2022). DIGITAL-IN-HEALTH COMMUNITY OF PRACTICE 11 AYUSHMAN BHARAT DIGITAL MISSION’S INTEGRATED DIGITAL HEALTH ECOSYSTEM IS THE FOUNDATION OF UNIVERSAL CITIZEN-CENTERED HEALTH CARE IN INDIA 2. State Health Agencies have been 5. Technology providers are responsible set up by each state and have full for developing and implementing the operational autonomy and respon- platform being used for the program, sibility to ensure that the program such as mobile apps and web portals, is effectively implemented which serve to ensure seamless imple- mentation and reduce the chances of 3. Insurance companies are responsible fraud and abuse. These partners are for providing health insurance cover- mainly from the private sector and are age to beneficiaries, managing claims recruited at competitive market rates and reimbursement process(es). They are selected through bidding and are Figure 5 highlights the range of stake- paid a premium by the government holders present within the ABDM network, for providing insurance coverage. their roles in supporting patients and cit- DIGITAL-IN-HEALTH FLAGSHIP PROGRAM izens to get comprehensive health care. 4. Health care providers: Private and public health care providers, such as hospitals and clinics, are eli- Scaling considerations and gible to participate in the program sustainability and provide health care services to The ABDM was launched as a pilot on 15th beneficiaries. They are required to August 2020 in six Union Territories of India, follow the standard treatment pro- namely Andaman & Nicobar, Chandigarh, Dadra tocols and the quality standards set & Nagar Haveli, and Daman & Diu, Ladakh, by the National Health Authority Lakshadweep and Puducherry, with the aim of Figure 5  Stakeholders in the ABDM Network Source: ABDM, 2023. DIGITAL-IN-HEALTH COMMUNITY OF PRACTICE 12 AYUSHMAN BHARAT DIGITAL MISSION’S INTEGRATED DIGITAL HEALTH ECOSYSTEM IS THE FOUNDATION OF UNIVERSAL CITIZEN-CENTERED HEALTH CARE IN INDIA Strategic alignments as a part of service delivery reform and to implement change: • Distributed: Health care delivered not only in fixed facilities, but also in workplaces, communities, and people’s homes by a wider cadre of health workers, including patients themselves and their caregivers • Connected: Share data with each other and systems outside of health care and be available to health workers and patients on mobile devices • Continuous: Health care to serve people during the 5,000 waking hours of the year, not only the 15 minutes they spend in a fixed facility • Human centered: Health care to put the patient and their caregivers at the center and empower health workers DIGITAL-IN-HEALTH FLAGSHIP PROGRAM • Decentralized: Decision-making to be less concentrated and put more into the hands of local leaders, health workers, and ultimately patients • Collaborative: Health care to seamlessly combine the insights of non-experts, experts, and non-human agents • Responsive: A system that automatically adapt itself to new data and new diseases Digitalization is a key ingredient of this transition within the health system to ensure better service delivery and to strengthen core public health functions establishing a national digital health ecosys- on central principles of ABDM, national poli- tem by creating an online platform, enabling cies, regulations, and standards. The state is interoperability of health data within the health responsible for the capacity building of health ecosystem to create longitudinal electronic care professionals to enable them to be able health records of citizens and facilitate delivery to lead and implement, as well as conducting of health services through this digital health the overall monitoring and evaluation of the ecosystem. To date, three key registries program in their respective states. A total of namely the Health UID, Health Professional 31 states are making steady progress towards Registry, Health Facility Registry, and digital building a comprehensive digital health eco- infrastructure for data exchange have been system. As of August 2023, about 293 million developed and implemented in these Union digital health records have been linked to the Territories with an estimated budget of $6.4 ABHA accounts of individuals and 442 million million. citizens have generated their unique ABHA allowing them to access and manage their To enhance program coverage, the 2023 digital health records anytime, anywhere. budget allocation to NHA has been increased They can also access paper-less digital health by 70 percent, and each State Digital Health services under ABDM. The digital linking of Mission has been tasked with implementing individual’s health records with ABHA is being ABDM within their respective territories. The carried out extensively across different health State level scale-up plans were/ are in the facilities of the country with the support of process of being developed and they include State Governments. the development and/or updating of state spe- cific technology and infrastructure that builds DIGITAL-IN-HEALTH COMMUNITY OF PRACTICE 13 AYUSHMAN BHARAT DIGITAL MISSION’S INTEGRATED DIGITAL HEALTH ECOSYSTEM IS THE FOUNDATION OF UNIVERSAL CITIZEN-CENTERED HEALTH CARE IN INDIA To ensure greater uptake and sustainability, enrollment of beneficiaries, reim- the government intends to conduct public bursement of claims, and monitoring awareness campaigns to encourage indi- of program’s performance; (iii) EHRs viduals to enroll in the program. These will used by health care providers to store target those living in rural and remote areas, and manage the health information of and the economically weaker percentiles. To beneficiaries, including their medical ensure those who are unconnected, margin- history, treatments received, and test alized, remote, tribal, and digitally illiterate results; (iv) information systems like are reached by ABDM, specialized systems ‘e-Hospital’, which is a cloud-based and offline modules are planned. The network Hospital Management Information of Panchayati Raj (local government) institu- System to connect patients, hospitals tions with support from the frontline health and doctors on a single digital platform; DIGITAL-IN-HEALTH FLAGSHIP PROGRAM workers, Accredited Social Health Activists and and ‘e-Shushrut’, incorporates an inte- Anganwadi workers will facilitate this last mile grated computerized clinical information outreach. In addition to the necessary infra- system for improved hospital adminis- structure, the program will require an increase tration and patient health care. It also in the number of digitally trained health care provides an accurate electronically providers and insurance companies to provide stored medical record of the patient; quality care to the increased number of indi- (v) telehealth and remote consulta- viduals. Improved partnerships with private tion services which includes video and health care providers are planned to reduce tele-consultations and e-Sanjeevani (a the financial burden on the government and web-based comprehensive telehealth to improve the quality of care provided under solution that facilitates doctor to doctor, the program. and patient to doctor teleconsultations); (vi) Payment systems used to manage Enablers and Challenges the payments to insurance companies, health care providers, and technol- Enablers contributing to the success of the ogy providers, for example Paytm and ABDM include: Unified Payment Interface (vii) ‘Scan and share’ uses a QR code-based token 1. Creation of innovative technologies system to manage queues at hospital and leveraging these to enhance counters and streamline the outpatient quality of care and health service registration process in large hospitals. delivery. The ABDM’s digital eco- system includes a set of digital tools, In addition, there are several other systems, and platforms that are used user friendly and clinical decision to implement and manage the health support systems that are under program. These tools include a vari- development and have the potential ety of: (i) Mobile Applications used to overhaul the health care sector for beneficiary identification, eligi- of India. Some of these include the bility verification, and for accessing Internet of Medical Things to digitize health services; (ii) Web Portals: used and connect all critical care units of a by health care providers, insurance hospital such as the ICUs, operating companies, and government agen- rooms, ventilators, navigation sys- cies to manage the program, including tems and artificial intelligence with DIGITAL-IN-HEALTH COMMUNITY OF PRACTICE 14 AYUSHMAN BHARAT DIGITAL MISSION’S INTEGRATED DIGITAL HEALTH ECOSYSTEM IS THE FOUNDATION OF UNIVERSAL CITIZEN-CENTERED HEALTH CARE IN INDIA advanced diagnostic capabilities and of the digital registries, ABHA numbers, remote diagnosis, 3D printing tech- consent framework, and others that aid nology, robot assisted diagnosis and in universal access to health facilities. treatment of diseases, including min- imally invasive surgeries, wearable 3. Development of succinct policies, health care devices, etc. is planned. strategy, regulations, and stan- The ABDM leverages these emerg- dards for a unified digital health ing technologies by using Block Chain ecosystem. A series of policies, technology and tracks their develop- guidelines, regulations and standards ment and updates via the Innovation across all levels and core components Wing in the National Health Authority. of the ABDM have been developed and operationalized/deployed and DIGITAL-IN-HEALTH FLAGSHIP PROGRAM 2. Establishment of a standardized are regularly updated with a view to digital health care ecosystem that strengthening the digital health care supports stakeholders to connect infrastructure. Some of these include: in a trusted environment. The digital ecosystem under the ADBM provides a • ABDM Strategy Overview and conducive and interoperable platform Action Plan: presents the broad for all the above-mentioned applications context, scope, rationale, key to work together seamlessly via differ- constructs or building blocks, ent digital pathways through the Unified implementation strategy, outcomes, Health Interface. The Unified Health and institutional structure for Interface enables all health care service developing a digital ecosystem for providers and end-user applications to health care services in the country interact with each other on its network • National Digital Health Blueprint and provides a seamless experience lays out the framework of key for service discovery, appointment building blocks essential for the booking, teleconsultations, ambulance evolution of the National Digital access, and more. The Unified Health Health Ecosystem. It recommends Interface is based on open network a Federated architecture, Universal protocols and can address the current Health ID, Electronic Health records, challenge of different digital solutions Metadata and data standards, Health being unable to communicate with each informatics standards, Registries other. Moreover, it gives the stakehold- for Non-Communicable Diseases ers a trusted environment, promotes (NCDs), Directories of Providers, innovations to enhance quality of care professionals and paramedical(s), in an efficient, transparent manner. The Legislation and Regulations on Data Government of India has also routinely Management, with focus on privacy allotted a sizable budget for technolog- and security, and data analytics ical advancement and digitization in the health care sector. Digitization of health • Guidelines and strategies related care records is key for making the to the digital infrastructure benefits of the new technology more across the different levels of health scalable, and the Union Budget has care. These guidelines ensure that made provisions for a planned rollout DIGITAL-IN-HEALTH COMMUNITY OF PRACTICE 15 AYUSHMAN BHARAT DIGITAL MISSION’S INTEGRATED DIGITAL HEALTH ECOSYSTEM IS THE FOUNDATION OF UNIVERSAL CITIZEN-CENTERED HEALTH CARE IN INDIA the requisite digital infrastructure and efficiently, and it is used is in place, is regularly maintained to improve the quality of care and upgraded. There are policies provided in line with the privacy related to the availability of and security data standards technology and the connectivity of health care providers, for example Apart from developing policies specifi- cally for the digital health architecture, • Development of technical additional guidelines and regulations standards and regulations are developed by the health sector to ensure that the technology to ensure that quality of care meets and different applications used the PM-JAY standards. Some of this meets the required standards for includes standards for health care DIGITAL-IN-HEALTH FLAGSHIP PROGRAM security, reliability, and privacy providers, insurance companies, tech- nology providers, and for the quality of • Hardware guidelines for states care provided to beneficiaries. There and health care institutions are also policies related to the financial sustainability of the program, effective • Interoperability guidelines and efficient use of resources, preven- to ensure that digital tools tion of fraud and abuse, monitoring used under the program can the performance of health care provid- communicate and exchange data ers, insurance companies, technology with other digital health systems providers, and program evaluation. used for e.g., EHR etc. This Together these policies and regula- helps to promote innovations, tions help to ensure the transparency, contribute to quality of care, and accountability, and efficiency of pro- long-term program sustainability gram. These are continuously reviewed and updated to ensure that they are • Data protection and privacy aligned with the ever-evolving needs policies and strategy outlines the of the beneficiaries and the program. minimum standards for data privacy protection to be followed by all Public-private partnership is the 4. participants/stakeholders of ABDM. nucleus of the ABDM and has There are a set of robust laws to played a pivotal role in its evolve- protect digital data for e.g., Health ment. The private sector plays a Data Management Policy. These pivotal role in the establishment laws help to promote and implement of the ABDM’s comprehensive and e-health standards, protect patient interoperable digital architecture. The privacy and security, and regulate private sector has joined hands with the storage and sharing of EMRs the National Health Authority and is involved in the following ways: • Data Management policies and regulations ensure that • Technology providers: The data generated is stored, used, private sector through “small shared, and managed securely start-ups” and “developers” is DIGITAL-IN-HEALTH COMMUNITY OF PRACTICE 16 AYUSHMAN BHARAT DIGITAL MISSION’S INTEGRATED DIGITAL HEALTH ECOSYSTEM IS THE FOUNDATION OF UNIVERSAL CITIZEN-CENTERED HEALTH CARE IN INDIA involved in the development and Some of the key challenges faced implementation of the technology under the ABDM include: platform, and other innovative • Uncertainty related to private applications like the mobile apps, sector engagement: ABDM has and web portals to ensure seamless provided guidelines for public- implementation and reduce the private partnerships. In this short chances of fraud and abuse implementation period, though the private sector and insurance • Health care providers: Private companies have worked well within health care providers, such as the ABDM network, there are some hospitals and clinics, are eligible concerns on the inclusion of private to participate in the program and DIGITAL-IN-HEALTH FLAGSHIP PROGRAM sector beyond the technology provide health care services to related companies and startups. beneficiaries. They are required Clarity is needed on how to increase to follow the standard treatment the engagement of private sector protocols and the quality standards hospitals, and integration of small set by the National Health Authority. clinics and independent doctors The private sector also plays a role in into the ABDM ecosystem. While building the capacity of health care there are many advantages to providers and improving the quality the partnerships with technology of care. This process is currently companies and start-ups, there have a bit slow with only 5 percent of been several implementation and private sector hospitals participating. technical challenges encountered. Data security concerns relating to Some of these issues include data the use of sensitive and confidential security, data privacy, and challenges data from HIV, AIDS, and TB integrating ABDM with private patients, for example, there is a sector hospital software persists, reluctance to participate in ABDM incentives for the private sector • Private insurance companies: to merge with the ABDM and the provide health insurance need for a legislative framework coverage, manage claims and to ensure their cooperation in a the reimbursement process. national mission are required They are selected through a • Need to strengthen data privacy bidding process and are paid a and cybersecurity across premium by the government for the ecosystem: It is widely providing insurance coverage acknowledged that the program has Through a stakeholder engagement strong multiple gateways to ensure plan, the ABDM informs, data privacy and cybersecurity. At communicates and problem solves the entry point, the 14-digit UID with the private sector in an format is the same for individuals, efficient and consultative manner. service providers and health DIGITAL-IN-HEALTH COMMUNITY OF PRACTICE 17 AYUSHMAN BHARAT DIGITAL MISSION’S INTEGRATED DIGITAL HEALTH ECOSYSTEM IS THE FOUNDATION OF UNIVERSAL CITIZEN-CENTERED HEALTH CARE IN INDIA facilities. This format makes it help detect patterns, trends and difficult for hackers to penetrate; used for other statistical analysis and even when a theft is successful it would be difficult to gauge the • Need for incentives to enhance type of data. Additional steps that compliance: According to a recent have been put in place include strong report titled ‘Leapfrogging to a data privacy and cybersecurity laws Digital Healthcare System (FICCI, and regulations that specify that 2020)’, it is estimated that there health data should not be stored in a are over 500 software providers government owned cloud or server. who provide HMIS software to The data stays at its original source hospitals and the adoption of EHR and can be retrieved as and when in India is less than 10 percent and DIGITAL-IN-HEALTH FLAGSHIP PROGRAM needed, but only after obtaining is characterized by fragmentation the patient’s consent. Despite all and low digital penetration. Adopting these robust data privacy and ABDM requires doctors to write cybersecurity safeguards, there is prescriptions on their laptops/ concern among private sector service computers/tablets, which is a providers that the health insurance huge behavioral change. Given the companies can still access patient workload on them, incentivizing them information simply by virtue of being to use computers and laptops is a big in the ecosystem, analyze disease challenge that needs to be addressed trends, and then use this information through awareness campaigns. The to increase insurance premiums. To same is true for other healthcare ensure additional safety, there is professionals like nurses, pharmacy also a need to encrypt stored data, etc. In such campaigns, efforts are distribute this data across various being made to show the doctors and independent servers to prevent the healthcare staff the advantages of original sensitive data from being ABDM: time saved due to prefilled recovered by hackers and tag the prescriptions, ability to quickly look encrypted data to ensure proper at records chronologically rather than authentication and consent from searching paper records. To address the concerned authorities. Though this issue a Digital Health Incentive the consent of an individual is being scheme has been developed to taken to access and store data it provide financial incentives to health must be made mandatory, and facilities, diagnostic laboratories, additional consent needs to be taken and Digital Solution companies to to anonymize personal information enhance adoption of the ABDM so that it can be included in public • Need to address inequities: In datasets. The consent for sharing many hospitals, particularly small anonymized data needs to be taken hospitals, there is lack of investment at grassroots levels, such as at the in computer hardware and digital health care facility, and service storage space in health facilities, provider levels. These anonymized which are prerequisites for ABDM. indices can then be made public to DIGITAL-IN-HEALTH COMMUNITY OF PRACTICE 18 AYUSHMAN BHARAT DIGITAL MISSION’S INTEGRATED DIGITAL HEALTH ECOSYSTEM IS THE FOUNDATION OF UNIVERSAL CITIZEN-CENTERED HEALTH CARE IN INDIA At some remote places, internet 2. India has adopted an incremental connectivity issues also exist and a phased approach to implement ABDM. This approach allows for feed- • Financial sustainability: There back loops and lessons learned from is a perception that the ABDM is each phase, are utilized, monitoring expensive, and it is not clear if the results and experiences of the early government can bear the cost of adopters for further improvements the entire program rollout, hence the financial sustainability of the 3. Instead of one standardized, centralized program remains an area of concern system, a multi-stakeholder approach has been adopted and the national In short, additional work is needed to e-health system is flexible to adapt DIGITAL-IN-HEALTH FLAGSHIP PROGRAM secure public trust for more citizens to the needs of the various stake- to continue to enroll into the program holders at all levels yet weaving them allowing it to reach critical mass together under one common platform and offer better value for money. 4. A national strategy exists that guides Advice for others the adoption and implementation of the Mission. This strategy is tailor-made ABDM is an ambitious program that has the for each region and considers their potential to revolutionize health care access in strengths, weaknesses and adapts India. During its short implementation period, well to areas which are remote and/ the mission has brought to focus several effi- or have poor digital connectivity. ciency related concerns to the fore that create Furthermore, the strategy recog- challenges the health system and were exac- nizes that digitization process will take erbated by the pandemic. The program has many years and has scope to incor- been able to bring about large-service deliv- porate new advances in technology ery reform and has overhauled the country’s health care data systems. Some of the key 5. The government has invested in lessons learned from ABDM’s short implemen- establishing the required digital eco- tation period include: system, such as information system architecture, clinical coding and stan- 1. It is a voluntary scheme and relies on dards, process harmonization and the trust and consent of its citizens. information governance as a core The mission is built on principles of foundation before moving on to the fundamental rights and other legisla- implementation of the technology tion such as the IT Act 2008, and the Aadhar Act. The Digital Personal Data 6. Instead of focusing on the devel- Protection Bill 2023, under discussion opment of an IT system, the digital in the Parliament, will provide safe- health program is linked to the Primary guards for personal data protection Health Care system and focuses and processing. It is also informed by on the end goal of delivering qual- core democratic principles of coop- ity health services for all. Changes erative federalism and is presided are made to clinical protocols, insti- over by Supreme Court judgements tutional culture, and administrative workflows with digitalization DIGITAL-IN-HEALTH COMMUNITY OF PRACTICE 19 AYUSHMAN BHARAT DIGITAL MISSION’S INTEGRATED DIGITAL HEALTH ECOSYSTEM IS THE FOUNDATION OF UNIVERSAL CITIZEN-CENTERED HEALTH CARE IN INDIA 7. A network of stakeholders across all created is encrypted and cannot be the core components were engaged altered), and Cloud Computing are in the design and implementation of also being explored to make the ABDM the ABDM using a public-private part- more efficient and effective. Unlike the nership model. Under this model, the partnerships with technology compa- roles and responsibilities of each stake- nies that are more well established, holder in the whole ecosystem are partnerships with private sector hos- clear and well defined. Stakeholders pitals are still in their nascent stages include the government themselves, and will continue to evolve with time. policymakers, private health providers, allied private entities like health tech- 9. The UIDs for individuals, service pro- nology companies, doctors, NGOs, and viders and health facilities are the key DIGITAL-IN-HEALTH FLAGSHIP PROGRAM various administrators like program to interoperability across the entire managers and regulators. This arrange- digital health ecosystem. It also serves ment addresses some of the earlier as the first step in ensuring data pri- challenges that the government had vacy. To further enhance security, the with the private sector regarding pay- government has developed data man- ments. The government, through the agement and sharing standards which involvement of multiple stakeholders are governed by a robust legal system and the private sector, has now estab- 10. Under the ABDM, all digital services are lished effective payment mechanisms available in various regional languages across the ABDM platform to reconcile and have been designed in ways to bills and pay health care providers make them accessible and user friendly 8. Public-private partnerships with tech- 11. The government is currently work- nology companies, startups and private ing on a mass awareness raising hospitals are an integral piece of the campaign to promote the use of ABDM’s strategy to streamline health ABDM and generate demand care processes. Technology companies play a pivotal role in innovation and the 12. The expansion in health insurance creation of new digital health solutions. coverage to reach over 500 million The ABDM keeps the platform up to people makes PM-JAY one of the larg- date which means it complements the est health insurance programs in the private sector technology that plugs world. It is critical to providing finan- in to it. This technology is regularly cial protection for the economically updated and upgraded, but issues of weaker sections of the society in case data privacy and cybersecurity still of medical emergencies. It alleviates need to be addressed from time to poverty stemming from high out of time. Newer technologies like Artificial pocket health expenses. The scale of Intelligence, the Internet of Things, the program is extremely impressive Block Chain (Blockchain Technology and other countries have much to learn can guarantee that the data that is from this huge mobilization effort. DIGITAL-IN-HEALTH COMMUNITY OF PRACTICE 20 AYUSHMAN BHARAT DIGITAL MISSION’S INTEGRATED DIGITAL HEALTH ECOSYSTEM IS THE FOUNDATION OF UNIVERSAL CITIZEN-CENTERED HEALTH CARE IN INDIA References ABDM. (2023). Retrieved from https://abdm.gov.in/ National Health Authority. (2022). Draft Revised abdm. Health Data Management Policy. Retrieved from https://abdm.gov.in/publications. ABDM Dashboard. (2023). Retrieved from https:// dashboard.abdm.gov.in/abdm/. PIB Delhi. (2022). Press Information Bureau (PIB), MOHFW. Government of India accessed on 20th Bajpai, N., Wadhwa, M. (2020). CSD Working Paper Feb 2023. Retrieved from https://www.pib.gov.in/ Series – India’s National Digital Health Mission. PressReleasePage.aspx?PRID= 1884387. In. Towards a New Indian Model of Information and Communications Technology-Led Growth and Saha, P. (2020). India’s National Digital Health Development. Retrieved from https://csd.colum- Mission: A New Model to Enhance Health bia.edu/sites/default/files/content/docs/ICT%20 Outcomes. The Open Group. Retrieved from India/Papers/ICT_India_Working_Paper_36.pdf. https://blog.opengroup.org/2020/08/19/ DIGITAL-IN-HEALTH FLAGSHIP PROGRAM indias-national-digital-health-mission-a-new- Bajpai, N., Wadhwa, M. (2020). India’s National model-to-enhance-health-outcomes/. Digital Health Mission. ICT India Working Paper # 36. CSD Working Paper Series: Towards a New Sharma, A. (2022). India’s progress in digital Indian Model of Information and Communications health care ecosystem: Evolution of Policy Technology-Led Growth and Development. regulations and future. Business World India. Retrieved from https://csd.columbia.edu/sites/ Retrieved from https://www.businessworld. default/files/content/docs/ICT%20India/Papers/ in/article/India-s-Progress-In-Digital-Health ICT_India_Working_Paper_36.pdf. care-Ecosystem-Evolution-Of-Policy-Regula- tions-And-Future/24-06-2022-433956/. Bargnagarwala, T. (2022). How India is creating digital health accounts of its cit- Sharma, R. S., Aishwarya Rohatgi, Sandeep Jain, izens without their knowledge. Retrieved and Dilip Singh. 2023. “The Ayushman Bharat from https://scroll.in/article/1031157/ Digital Mission (ABDM): Making of India’s Digital how-india-is-creating-digital-health-accounts-of- Health Story.” CSI Transactions on ICT, March. its-citizens-without-their-knowledge. https://doi.org/10.1007/s40012-023-00375-0. eSanjeevani website. (2023). Retrieved from Singh, A. (2022). Strengthening Ayushman Bharat https://esanjeevani.mohfw.gov.in/#/. Mission through AI adoption. Centre for Strategic and International studies. Retrieved from https:// National Digital Health Mission. (2020). Strategy www.csis.org/blogs/new-perspectives-asia/ Overview Making India a Digital Health Nation strengthening-ayushman-bharat-through-ai- Enabling Digital Health care for all. Ministry of adoption. Health and Family Welfare (MOHFW), Ministry of Electronics and information technology and Sudan, P. (2022). A digital health revolution to national health authority. Retrieved from https:// empower citizens. The Tribune. Retrieved abdm.gov.in:8081/uploads/ndhm_strategy_over- from https://www.tribuneindia.com/news/ view_1aebd4820e.pdf. comment/a-digital-health-revolution-to-empow- er-citizens-373953. National Health Authority. (2022). A brief guide on Ayushman Bharat Digital Mission and its various building blocks. Retrieved from https://abdm.gov.in:8081/uploads/ABDM_ Handbook_19_10_2022_24c5078481.pdf. DIGITAL-IN-HEALTH COMMUNITY OF PRACTICE 21 AYUSHMAN BHARAT DIGITAL MISSION’S INTEGRATED DIGITAL HEALTH ECOSYSTEM IS THE FOUNDATION OF UNIVERSAL CITIZEN-CENTERED HEALTH CARE IN INDIA © International Bank for Reconstruction and Development / The World Bank 1818 H Street NW, Washington DC 20433 Internet: www.worldbank.org; Telephone: 202 473 1000 This work is a product of the staff of the World Bank with external contributions. Note that the World Bank does not necessarily own each component of the content included in this work. 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