npj | digital medicine Comment

Published in partnership with Seoul National University Bundang Hospital

https://doi.org/10.1038/s41746-024-01279-2

India’s evolving digital health strategy

Aditya Narayan, Indu Bhushan & Kevin Schulman Check for updates

India’s evolving digital health strategy leverages citizens, unified interoperable transactions between individuals and busi-
innovative technologies to enhance access to nesses, digital document verification, and the scaffolding regulation sur-
rounding consent in data sharing8.
healthcare services. This paper explores the key The digital identification system, Aadhaar, offers a unique 12-digit
components of India’s digital health transformation, biometric ID to 1.3 billion people and could be leveraged to ensure the
fidelity of public services. Based on these digital identities, the Pradhan
including the Ayushman Bharat Digital Mission Mantri Jan Dhan Yojana (PMJDY) was launched to provide a virtual bank
(ABDM) and India’s integration of biometric account to all Indian citizens free of cost to bring the most underserved
identification and digital infrastructure to improve citizens into the formal economy9. Together, these systems have facilitated
the creation of over 510 million bank accounts and integrated over 98% of
1234567890():,;
1234567890():,;

healthcare delivery. The lessons learned from the population into Aadhaar10. Building upon this foundation, the Unified
India’s large-scale implementation of digital health Payments Interface (UPI) was established. UPI provided a secure and
interoperable digital infrastructure that could facilitate instant fund transfers
provide valuable insights for global health markets via smartphones, leading to 117 billion transactions in 2023 alone11. This
and digital transformations in healthcare systems. system overcame common obstacles such as a lack of interoperability
between public, private, and retail payment systems as well as geographic
India’s healthcare landscape is a vast and interdependent network com- barriers to transferring funds for small businesses. As a consequence of this
prising both public and private sectors, with each playing distinct roles in elegant infrastructure, innovation in the financial markets continues to
delivering medical services to its 1.4 billion population1. The public develop at a rapid pace.
healthcare system is designed to offer free or low-cost services for low-
income and rural populations. However, these public facilities are often Digital health care
overwhelmed as a consequence of inadequate infrastructure, shortages of On the foundation of this success, the government of India turned to the
medical supplies, and a paucity of healthcare professionals2. This gap health sector and committed to “a paradigm shift from the existing silo
between supply and demand for healthcare services is exacerbated in rural systems to a holistic and comprehensive health eco-system, founded on the
areas where nearly 71% of the population resides but where only one-third latest digital architectures and technologies”.12
of the country’s physicians are located3–5. The development of India’s digital health strategy began with a global
The recognition that fragmented governance and unequal access to survey of best practices, in an effort to “leapfrog many of the traps that
healthcare were major impediments to achieving equitable health outcomes bedevil health information systems even in developed economies”.12 The
led to the drive for a cohesive national health strategy. The concept of United States’ HITECH Act, for example, highlighted the importance of a
Universal Health Coverage (UHC) became central to India’s healthcare cohesive data architecture and interoperability. The UK’s NHS Digital
policy, aiming to ensure that all citizens, regardless of income or location, illustrated the importance of developing and deploying integrated digital
have access to necessary health services without facing financial hardship. health platforms that ensure data privacy while enabling efficient health
This push for UHC led to the development of the National Health Policy information exchanges. South Korea’s approach to integrating personal
(NHP) in 2017, which laid the groundwork for leveraging digital technol- health records with national identifiers and Singapore’s “One Patient, One
ogies to strengthen the healthcare system6. Specifically, the National Health Health Record” model offered lessons on the value of ensuring patient access
Policy of 2017 aimed to achieve universal health coverage by increasing to their health data for enhanced care coordination and privacy.
access to quality healthcare services, reducing the cost of healthcare, and Drawing from these global models, India launched the ABDM in 2021
leveraging digital technologies to enhance the efficiency of service delivery. with a focus on creating a secure, integrated digital health ecosystem that
The Pradhan Mantri Jan Arogya Yojana (PM-JAY), launched in 2018 as emphasizes personal health records, ensuring that each citizen’s health data
part of this policy6. PM-JAY is a flagship health insurance scheme providing is accessible, interoperable, and under their control. This ambitious project
coverage of up to INR 5 lakhs per family per year for secondary and tertiary introduced five key innovations designed to enhance the delivery and
care hospitalization (approximately USD 6000), targeting the bottom 50% management of healthcare services across the nation.
of the population by income, or approximately 500 million people7. Central to the ABDM was a unique 14-digit health identifier for every
As the strategy developed, policymakers envisioned a significant role citizen, the Ayushman Bharat Health Account (ABHA). Notably, the
for digital innovation as a means of supporting the overall healthcare ABHA was primarily built upon Aadhaar (although other sources of
strategy. The foundation for this insight was known as “Digital India”—the identification are allowed) - India’s robust biometric identification system,
moniker of an evolving federal government strategy aimed at deploying leveraging its technological underpinnings to securely authenticate and
technology to address the chronic economic and social challenges of India’s manage health records.
diverse population. The technological backbone of Digital India is the India The ABDM mobile application provides individuals with an accessible
Stack, which began in 2009 to digitize government and financial services. electronic personal health record (PHR) that adheres to national inter-
India Stack had four key components: a digital identification system for all operability standards. Unlike traditional Electronic Medical Records

npj Digital Medicine | (2024)7:284 1

npj | digital medicine Comment

architectures, the PHR is managed, shared, and controlled by the patient vaccinations for citizens. Alongside this platform, a mobile health applica-
themselves with the ability to make records visible or invisible to providers. tion, Aarogya Setu, emerged as a means of conducting remote COVID-19
This architecture is a unique feature of the ABDM program. contact tracing13. ABHA numbers were created rapidly through the CoWIN
The Healthcare Professionals Registry and Healthcare Facilities Reg- initiative, leading to 130 million new accounts while ensuring efficient
istry catalog enrolled healthcare professionals and facilities nationwide. By record keeping14. For patients, the ability to readily access personal health
creating standardized, accessible databases of healthcare providers and records allowed for rapid verification of vaccination status, exemplifying the
institutions, the ABDM facilitated easier verification and provider cre- potential of digital tools in managing public health emergencies14.
dentialing processes, which in turn helped patients make more informed As of March 2024, the country has seen the creation of 568 million
choices about their healthcare. ABHA accounts and the integration of over 350 million health records into
Finally, the Unified Health Interface is the patient-facing platform the digital ecosystem13. The program’s reach, encompassing over 230,000
supporting healthcare transactions. It was designed as an “open protocol for health facilities and 285,000 registered providers, underscores the scale of
various digital health services,” including, but not limited to, appointment the effort14.
bookings, teleconsultations, and patient service delivery. Its open network Telemedicine has evolved along with the ABDM program. The
structure allows for the integration of End-User Applications—such as data eSanjeevani telemedicine platform, launched by the Ministry of Health and
from health apps used by patients—and Health Service Provider applica- Family Welfare in 2019, facilitated over 270 million teleconsultations as of
tions—digital tools used by hospitals, clinics, and laboratories to manage August 202415. eSanjeevani was initially designed for physician-to-physician
patient data or facilitate operations. consultations, facilitating collaborative care. However, in response to the
Of note, the ABDM concept was conceived as a catalyst for private COVID-19 pandemic, it expanded rapidly into a physician-to-patient ser-
investment in the digital health sector. Accordingly, ABDM has put in place vice, known as eSanjeevani OPD (outpatient). Notably, eSanjeevani scaled
a “digital sandbox” that provides access to APIs from ABDM registries to healthcare delivery during the pandemic, with 57% of beneficiaries being
private sector digital application developers aimed at providing novel ser- female and 12% senior citizens15. The second phase of this effort, eSanjee-
vices for patients and providers. To date, ABDM has integrated over 1,000 vani 2.0, integrates information from Point of Care Diagnostic devices for
private companies into the ecosystem13. Examples include diagnostics rapid diagnosis.
companies that allow patients to link lab results (e.g., TB tests, blood tests,
urine drug screens) with their ABHA records. Further, a range of Hospital Challenges in implementation. One of the most persistent challenges to
Management Information Systems allow hospitals to link patients’ ABHA the scale-up of India’s digital healthcare ecosystem is the uneven techno-
records to data management platforms, which offer monitoring of patients’ logical and infrastructural landscape across the country. While urban areas
health status, secure telemedicine channels, organized appointment book- have largely benefited from improved connectivity and digital literacy,
ings, and other “quality of life” upgrades. rural regions continue to struggle with limited access to the internet and
necessary IT infrastructure16. Although there are over 400 million internet
Scale and adoption subscribers in rural areas as of 2024, the quality and reliability of this
The COVID-19 pandemic served as a catalyst for the ABDM, accelerating connectivity often fall short of what is needed to sustain robust digital
the deployment of digital health technologies. A prime example of this health services17.
acceleration is the CoWIN platform, a federal digital platform designed to Data privacy and security concerns also loom large over the adoption of
facilitate the registration, scheduling, and management of COVID-19 ABDM18. The digitalization of health records necessitates stringent data

Table 1 | Barriers and Facilitators of ABDM Adoption

Facilitators Barriers
Governmental support and policy frameworks Infrastructure challenges
Public initiatives like the Digital India campaign and Ayushman Bharat Digital Limited internet connectivity and digital infrastructure, particularly in rural areas
Mission (ABDM)
Variations in access to electricity and other essential services
Robust digital infrastructure Regulatory challenges
The success of Aadhaar as a biometric identification system, laid the foundation for Complexities in enforcing data privacy and security across India’s diverse and
unique digital identification federated healthcare system
Unified Payments Interface (UPI) facilitating secure financial transactions Challenges with cross-border data transfers under the Digital Personal Data
Protection Act (DPDPA)
Public–private partnerships Digital literacy and socio-cultural barriers
Incentives and collaborations between the government and private sector to Low levels of digital literacy, particularly in rural and underserved areas
innovate and scale
Development of user-centric digital health solutions Socio-cultural preferences for in-person consultations over digital health services
Patient empowerment and education Financial constraints
Increased awareness and education on the benefits of digital health tools High costs associated with establishing and maintaining digital health tools
like EHRs
Tools such as personal health records (PHRs) enable patient control over health data Limited public health spending (1–2% of GDP), which hampers widespread
adoption

npj Digital Medicine | (2024)7:284 2

npj | digital medicine Comment

protection measures to safeguard sensitive patient information, particularly 10. Aadhaar Dashboard. UIDAI. https://uidai.gov.in/aadhaar_dashboard/index.php (2023).
given the scale of ABDM. To this end, the Digital Personal Data Protection 11. National Payments Corporation of India. UPI Product Statistics. NPCI. https://www.npci.org.in/
what-we-do/upi/product-statistics (2023).
Act (DPDPA) of 2023 represents a step forward in India’s efforts to regulate 12. Ministry of Health and Family Welfare. Final Report on National Digital Health Blueprint (NDHB).
the processing of personal data and ensure data privacy19. https://main.mohfw.gov.in/sites/default/files/Final%20Report%20-%20Lite%20Version.
While the Federal government has direct control over the financial pdf (2019).
13. National Health Authority. Aarogya Setu: COVID-19 Contact Tracing and Self-Assessment
sector and could implement the India Stack strategy, the responsibility for Mobile App. Ministry of Health and Family Welfare. https://www.mohfw.gov.in/aarogyasetu.
oversight of the health sector is a state responsibility. The states of Andhra html (2022).
14. ABDM-Insights. National Health Authority. https://dashboard.abdm.gov.in/abdm/ (2024).
Pradesh and Karnataka have made notable progress in the adoption of
15. eSanjeevani. Ministry of Health and Family Welfare. https://esanjeevani.mohfw.gov.
ABDM. Karnataka, in particular, has seen higher engagement from private in/#/ (2024).
healthcare centers, offering valuable lessons on provider onboarding and 16. Campanozzi, L. L. et al. The role of digital literacy in achieving health equity in the third
millennium society: A literature review. Front Public Health 11, 1109323 (2023).
navigating provider concerns regarding increased accountability14. A
17. Roy, A. How India is using the Internet. Economic Times. https://economictimes.indiatimes.
summary of facilitators and barriers to ABDM may be seen in Table 1. com/tech/technology/how-india-is-using-the-internet/articleshow/108354854.cms?from=
mdr (2024).
18. Sharma, R. S., Rohatgi, A., Jain, S. & Singh, D. The Ayushman Bharat Digital Mission (ABDM):
Looking forward making of India’s Digital Health Story. CSI Trans. ICT 11, 1–12 (2023).
The ABDM is an exciting initiative for India and offers a vision for a national 19. Government of India. Digital Personal Data Protection Act 2023. Ministry of Electronics and
digital health architecture. Importantly, after assessing the utilization of Information Technology. https://www.meity.gov.in/writereaddata/files/Digital%20Personal%
20Data%20Protection%20Act%202023.pdf (2023).
electronic health records in the US and globally, India has made significantly
different strategic choices on how a digital health strategy can be accom-
plished. Specifically, the backbone of their strategy is the development of a Acknowledgements
The authors wish to thank Krishna Reddy MD of Access Health India and Suhel Bidani of the Bill and
set of unique patient identifiers, and the implementation of a personal health Melinda Gates Foundation for their help in collating data for this article. No specific funding was
record architecture to collect data and provide digital health services for received for this work.

patients. This massive experiment at scale should provide important

insights into the digital transformation of the United States and global Author contributions
A.N. conceived the paper idea, conducted the primary writing, and contributed to the analysis of
healthcare markets. available data and policy documentation. I.B. provided policy expertise, specifically regarding the
National Health Plan and universal health coverage, and contributed to critical revisions of the paper.
Aditya Narayan 1, Indu Bhushan2 & Kevin Schulman 1,3,4 K.S. supervised the project, provided strategic guidance on the content, and critically revised the
1 paper. All authors (A.N., I.B., K.S.) have read and approved the final version of the paper.
Stanford University School of Medicine, Stanford, CA, USA. 2India
National Health Plan, New Delhi, India. 3Clinical Excellence Research
Competing interests
Center, Stanford University, Stanford, CA, USA. 4Graduate School of The authors declare no competing interests.
Business, Stanford University, Stanford, CA, USA.
e-mail: [email protected]
Additional information
Received: 25 April 2024; Accepted: 18 September 2024; Correspondence and requests for materials should be addressed to Kevin Schulman.

Reprints and permissions information is available at

http://www.nature.com/reprints
References
1. World Health Organization. India Data. World Health Organization. https://data.who.int/ Publisher’s note Springer Nature remains neutral with regard to jurisdictional claims in published maps
and institutional affiliations.
countries/356 (2023).
2. Balarajan, Y., Selvaraj, S. & Subramanian, S. V. Health care and equity in India. Lancet 377,
505–515 (2011).
3. Pengpid, S. & Peltzer, K. Rural-urban health differences among aging adults in India. Heliyon 10, Open Access This article is licensed under a Creative Commons Attribution-NonCommercial-
e23397 (2024). NoDerivatives 4.0 International License, which permits any non-commercial use, sharing,
4. Banerjee, S. Determinants of rural-urban differential in healthcare utilization among the elderly distribution and reproduction in any medium or format, as long as you give appropriate credit to the
population in India. BMC Public Health 21, 939 (2021). original author(s) and the source, provide a link to the Creative Commons licence, and indicate if you
5. Menon, G. R. et al. National Burden Estimates of healthy life lost in India 2017: an analysis using modified the licensed material. You do not have permission under this licence to share adapted
direct mortality data and indirect disability data. Lancet Glob. Health 7, e1675–e1684 (2019). material derived from this article or parts of it. The images or other third party material in this article
6. Ministry of Health and Family Welfare. National Health Policy 2017. https://mohfw.gov.in/sites/ are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to
default/files/9147562941489753121.pdf (2017). the material. If material is not included in the article’s Creative Commons licence and your intended
7. Bajaj Finserv. Ayushman Bharat—Pradhan Mantri Jan Arogya Yojana (PMJAY). Bajaj Finserv. use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain
https://www.bajajfinserv.in/insurance/ayushman-bharat-yojana (2023). permission directly from the copyright holder. To view a copy of this licence, visit http://
8. IndiaStack. IndiaStack—Technology for 1.2 Billion Indians. India Stack. https://indiastack. creativecommons.org/licenses/by-nc-nd/4.0/.
org/ (2023).
9. Government of India. PM Jan Dhan Yojana. PMJDY. https://pmjdy.gov.in/ (2021). © The Author(s) 2024

npj Digital Medicine | (2024)7:284 3