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Leapfrogging India’s Healthcare: Lessons from the past 15 years

It's astonishing when you are self-aware; you question your every action. Recently, I discovered that while walking stairs (which I do most of the time even though there is a lift in my apartment), I take two steps at a time rather than, like most humans, taking one step at a time. This nature of mine, I can recall from a very long time. This habit of skipping steps is not only my nature but also the nature of our nation (India), a subconscious effect! I know you are wondering how these two are connected, and for that, you need to read this essay. Meanwhile, do you have the same habit of taking two steps? If you don't walk stairs, start doing it; it is good for your health, irrespective of your age. :) 


If we review India's growth story - especially infrastructure-wise, digitally - we can sense that as a nation, we have been fortunate to leapfrog on multiple occasions. Here are a few examples: 


"Most probably, you might know these leapfroggings hence skip and move to the next section of the essay which starts with the review of the USA’s healthcare evolution".


  • Cashless Society: Indian society took less than 10 years to become a cashless society, compared to the USA, which took almost 200 years. Here, too, the progress of Western society took one step at a time: Bank Accounts, Cheque Payments, Credit Cards, and Real-time Payments. However, in India, all these happened simultaneously. In fact, a significant percentage of Indians opened bank accounts for real-time payments (UPI). 

  • Communication and Internet Evolution: In the USA, communication evolution moved to mobile phones after the saturation of receiver-based phones. However, in India, it directly jumped to mobile without the saturation of receiver-based phones. Hence, a different evolution of Internet penetration and digital adoption: USA's Internet adoption was from Desktop to Mobile, taking around 30+ years, while India jumped directly to mobile, skipping the desktop in the middle, and today, 75% of Indians are on the internet. This took around 10 years, thanks to large-scale Digital Public Infrastructure.


We have been skipping steps and achieving these exponential growths due to technological development, with Indian businesspersons and entrepreneurs dreaming big and utilizing large-scale digital public goods, making products and services affordable for a larger Indian population. Here is a list of levers that made skipping these steps possible:


  • The affordable smartphone and cheap data packs were two of the biggest levers behind internet penetration. 

  • The availability of smartphones and cheap data, along with large-scale digital public identity (Aadhar), eliminated the obstacles of digital identification, hence no problem in opening bank accounts, hence no problem in creating UPI, hence going cashless.


An important point to consider is that when private players like Jio, owned by Reliance, were making data packs cheap, digital public goods such as Aadhar, DigiLocker, UPI, etc., made sure the scale of the impact could touch every Indian.


This has been the story behind India's growth, seemingly the most suitable where there is a contribution by both parties - Public and Private. In Rohini Nilekani’s language: Sarkaar (Government) and Bazaar (Market). 


We have been working on healthcare with a mission to make quality healthcare affordable for 1.2 billion Indians. We have experimented, piloted, and talked to all the stakeholders and fundamentally believe India's healthcare might leapfrog, similar to the ones mentioned above.


To understand this, we need to take a look at the evolution of the USA’s healthcare system and India’s current healthcare system. 


So, if you look at the USA's healthcare progress, it was something like this: Like everything, the healthcare delivery system was mostly based on physical tests (subjective), and as the progression of technology took place, the healthcare delivery system started taking place through health bio-markers (utilization of all the diagnosis tools, yearly body check-ups etc). Now, it seems to be shifting to DNA-based sequencing. I have explained this through an example below. 


Let's term the above evolution as Medicine 1.0, Medicine 2.0, and Medicine 3.0 (Referenced from Peter Attia's book: Longevity). In terms of functionality, Medicine 2.0 focuses on treatment/cure once the validation of a medical condition is proven through diagnosis using the representation of bio-markers (health indicators). The shift from Medicine 1.0 to Medicine 2.0 was due to the advancement and innovation of drugs, technology, and chemicals, among which anti-biotech was one of them.


Medicine 2.0 saved millions of lives and cured many diseases such as HIV, Hepatitis C, Tuberculosis (TB), etc. In fact, today's Medicine 2.0 is capable of curing/treating even Cancer, which was considered untreatable just a few decades back. What we all have achieved with Medicine 2.0 is remarkable.


Unfortunately, Medicine 2.0 cannot be the solution for the scale and complexity of a country such as India. Especially in the case when the numbers are staggeringly high and India lacks physical infrastructure. Also, the problem with Medicine 2.0 is that it can only be utilized once the identification part is validated using technology through bio-markers (health indicators). Hence, we need Medicine 3.0, which doesn't wait for the medical condition to appear in the first place. For example, Medicine 3.0 doesn't wait for a patient's diabetic condition to let the blood glucose cross 135 mg/dl; rather, it takes steps when the blood glucose is 98 mg/dl.  


However, thanks to the digital healthcare infrastructure such as ABDM, progress in DNA-sequencing, and LLM-based AI, India might, most probably, leapfrog from Medicine 2.0 to Medicine 3.0. I would say that is the only way to solve the massive healthcare epidemic we will face in the next few years. 


The brilliant aspect of India's Medicine 3.0 is that two out of the three components are available at scale at a fraction of the cost. 


  1. LLM-based models are already commoditized and available for dirt-cheap prices. 

  2. India's National Health Stack - ABDM - is scalable to a billion users, considering it is doing well with half a billion ABHA and billions of health records attached to these ABHA. 


The third component essential for enabling Medicine 3.0 in India involves technology related to DNA sequencing and its logistical considerations. Although the current cost of DNA sequencing devices is in the thousands of dollars, ongoing biological advancements are in the engineering stage hence we can expect the cost decline. Thanks to the increasing computational capacity of AI-enabled computers, they can synthesize our billions of cells, bringing the magic of Medicine 3.0 to billions of Indians at just a fraction of the cost. This hyper-personalization, tailored to individuals' DNA and genes, will make precision medicine a reality—a groundbreaking step toward improving the lifespan and healthspan of billions.


Addressing the shortfall of Medicine 2.0, where yearly health checkups remain underutilized among Indians, despite access to smartphones and ABHA, which auto-attaches health records directly from providers (if on the ABDM network). There's a high probability that India's healthcare delivery will shift from physical tests to DNA sequencing.


Consider the MinION, a genome-reading device that can be plugged into a laptop. It can read an entire human genome of 25,000 genes in a few days, costing a mere hundred dollars. Contrast this with the first version of the same genome device, which costs billions to read just one letter of the DNA (A, G, C, or T) of the human genome. The MinION can also provide indications of DNA methyl markers, revealing biological age—a testament to the progress made in the field of bioengineering. 


Genome information is poised to become the method to treat and optimize human health and ageing issues. Discovering genes and molecules related to anti-ageing, combined with health records attached to individual ABHA, will generate evidence-based protocols. DNA sequencing, as a cornerstone of Medicine 3.0, promises a breakthrough in human health and longevity.

Consider the impact of DNA sequencing on early cancer detection. Until now, no diagnosis or test effectively identified cancer in its super early stage, where the odds of survival could improve significantly. Cancer cells might originate in one part of the body, such as the breast, and if not eliminated on time, they may spread to other vital organs like the lungs or heart disturbing the regular functioning of the human body. 


Unlike normal cells, cancer cells grow continuously without getting destroyed—a unique feature termed "Cell-free DNA." While traditional diagnostic tools and bio-markers struggle to identify this differentiation, DNA sequencing can discern Cell-free DNA. Conducting DNA sequencing at intervals and creating an average of the growth and destruction pattern of human cells may provide insights similar to the Diabetic control biomarker Indicator H1Abc, indicating average blood glucose levels. 


Computation of billions of cells and the complex nature of human DNA necessitate the assistance of AI and biotechnology. Thanks to these advancements, we will have a tool in future to identify cancer cells at the super early stage, potentially saving millions of human lives. Companies like Grail employ multi-cancer early detection (MCED) blood tests, analyzing DNA shed by all cells into the bloodstream, to identify abnormal methylation patterns on cell-free DNA fragments indicating the presence of cancer. While this method remains costly, ongoing technological progress suggests a more affordable version in the future.


The logistical aspect of DNA sequencing poses challenges, as conventional digital forms and individual image-based systems might prove insufficient. Considering that Indian Health Insurance is still in its early stages, incorporating a system to eliminate potential cancer risks into claim reimbursement is vital. These are aspects to figure out to ensure Medicine 3.0 accessibility nationwide, similar to UPI.   


When this transformation occurs, a significant percentage of Indian health tech and healthcare companies may become redundant. This consideration is pivotal before delving into the final solution to avoid succumbing to the Sunk Cost Fallacy.


In that scenario, a counter-intuitive question arises: with so many changes, what aspects of healthcare will remain constant despite massive technological and physical developments? In part 2 of the essay, we will explore these constants and delve into understanding why there cannot be a PhonePe of Healthcare (a notion previously contemplated) based on the "Jobs to be done" framework.


Before I conclude this essay, now you tell me whether I and our nation (India) both have a nature to skip or not - taking multiple steps? :)


Thanks for reading, Part 2 of this essay is in development. I shall see you all the next week :) 


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