How Sunita Nadhamuni built one of India’s largest healthcare public good portals

Ritu Jha–

Sunita Nadhamuni, a public health technologist who led the Herculean task from Dell of digitizing the Government of India’s program for non-communicable diseases such as hypertension and diabetes, was in Silicon Valley recently. Currently, the chairperson of the Rohini Nilekani-funded Bengaluru-based nonprofit Arghyam, Nadhamuni worked extensively on Dell’s Digital LifeCare, an application used in almost every Indian state, with data of over 238 million Indians. The National NCD portal is listed by the government of India as a “digital public good”.

During her visit to California, Nadhamuni (pictured above; photo by Ritu Jha) shared her journey on building Digital Lifecare at an event held in collaboration with Anurag Mairal, adjunct professor of medicine and director of global outreach programs at Stanford Byers Center for Biodesign, Stanford University. Dr Mairal is also chairman of Entrepreneurs and Professionals in Partnership for Innovation in Healthcare (EPPIC) and FalconX in Milpitas, California.

In an exclusive interview with indica, Nadhamuni shared her experiences with Indian health officials and her field visits on India’s National NCD program.  India, like most other countries in the world, has gone through an epidemiological transition from communicable diseases like cholera, malaria, and typhoid to non-communicable diseases such as heart disease, cancer, and diabetes.
 
According to India’s health data, one in five people in the country suffers from an NCD and over 60% of the deaths are from NCD.

Excerpts from the interview:
Healtcare professionals being trained to use Digital LifeCare. Photo courtesy: Dell

You founded Dell’s Digital LifeCare. Can you share your journey, and why you decided to get into the social impact space?

I’ve always been drawn to working on social issues. At my first job in the Bay Area, I started a voluntary group called Seva with my friends, and we raised money to support rural development projects in India. My interest deepened through interactions with many NGO leaders and field visits during our India trips. After working in technology for 13 years in the Valley, my husband Srikanth and I decided to move back to India to work full-time in the social development sector. I was founder-CEO of Arghyam, a foundation for water and sanitation that Rohini Nilekani and I started with her endowment in 2005. Through our work with more than 100 civil society partners, we saw the transformative power of participatory community approaches to address the basic needs of vulnerable, marginalized rural populations in an equitable and sustainable manner.

In 2009, India started the universal Digital Identity project, Aadhaar, and captured the imagination of the country on how technology adopted in Government programs can be foundational for social transformation at scale. Inspired, I decided to adopt this approach to strengthen the primary health sector and started Digital LifeCare at Dell. This has grown now to the technology platform of India’s National NCD (Non-Communicable Diseases) Program.

What is Digital LifeCare? Who are its users in India and why did Dell decide to focus on India’s National Non-Communicable Diseases (NCD) program?

Digital LifeCare is a digital platform I started at Dell 10 years ago to strengthen primary healthcare for the vulnerable rural population. It consists of mobile and web apps with dashboards for rural health workers, doctors and government program managers to manage, track and support patient journeys for non-communicable diseases like hypertension, diabetes and cancers.

It started as idea with the NGO Karuna Trust. A small pilot at Gumballi village in Karnataka (a southern Indian state of which Bengaluru is the capital) followed, with the first version built by 40 volunteers on their weekends! This led to state deployments in Andhra Pradesh and Telangana two years later. Since 2018, Dell has been the technology partner to the government of India along with Tata Trusts on the National Non-communicable Diseases management program under Ayushmann Bharat. Today Digital LifeCare is called the National NCD Portal and is a mature IT system for the National NCD program reaching hundreds of millions of people. It is one of the largest public health tech initiatives globally today and has been a truly amazing experience for me.

The National NCD portal is now listed as a Digital Public Good (DPG) by Government of India, is used across 32 states and Union Territories, with 230+ million people digitally enrolled, 100+ M screened and more than 225,000 users onboarded as on Jan 31st, 2023.

From left: Murali Chirala, Anurag Mairal, Sunita Nadhamuni

India, like most other countries in the world, has gone through an epidemiological transition from communicable diseases like cholera, malaria, typhoid to non-communicable diseases like heart disease, cancers, diabetes. One in five people in India suffers from an NCD and over 60% of deaths are from NCDs. Since NCDs are silent and chronic, they are much harder to diagnose and manage, resulting in the vulnerable rural communities being disproportionately impacted. Given this nature of NCDs, technology can play a strong role in ensuring universal screening of 350 million people every year, and regular management of every NCD patient. Seeing this potential, the Government decided to have a tech solution for the National NCD program and we were chosen given our prior work in several states for NCD management.

What lessons learned from Arghyam helped you lead such a vast project?

The lessons from Arghyam played a pivotal role in shaping my thinking in leading the technology for the National NCD program. Some of the key takeaways:

• Ensuring universal access to basic needs: The most crucial lesson from my experience at Arghyam was the imperative of ensuring access for the most vulnerable communities. This principle had to be at the core of both program design and the technology solution. No one should be left behind in our pursuit of universal access to basic needs.
• Accounting for Heterogeneity: India’s vast heterogeneity demands a tailored approach. Whether it’s the arid Bhuj region, flood-prone areas like Khagaria, or the mountainous terrain of Tehri Garhwal, the program and technology had to be adaptable and responsive to meet the specific needs of each region.
• Community Mobilization and Local Institution Strengthening: Long-term sustainability hinges on mobilizing communities and empowering local institutions. Engaging the people directly affected by water challenges and reinforcing local structures are fundamental to achieving lasting impact. In addition, recognizing the critical role of frontline workers and building their capacities is of paramount importance for universal reach.
• Engaging Government Stakeholders at All Levels: Collaboration with government stakeholders is vital, not just at the state level but also at the district and block levels. Establishing relationships and alignment with officials at every tier of governance is essential for seamless implementation. For instance, getting an approval from the State’s Principal Secretary isn’t enough; there must be relationships built at the district and block level. Water and health are both complex social issues and cannot be addressed in isolation by just Government or any one organization. Fostering partnerships between committed civil society organizations, research and advocacy groups, and donors is crucial for holistic solutions.

What were the most challenging things while working on Digital LifeCare? How many districts did you visit while working on Digital LifeCare?

I can group the challenges into three buckets: technology, adoption and ecosystem coordination. All of these are manageable when serving up to a million or two people, but at national scale of 500 million people they balloon to enormous proportions.

First, the design and development of technology involves complexity on multiple fronts. For instance, how do you make it attractive for overburdened health workers with limited digital literacy who feel forced into using an app? How do you ensure that the platform can perform consistently well under pressure from 32 states with different languages and administrative needs?

Second, adoption of the technology by users. This was led by our partner, Tata Trusts working with State governments and included training and supporting of more than 100,000 health staff. Health workers, doctors and program administrators all needed to overcome their resistance to technology adoption be convinced of its value. Multiple states ran NCD screening campaigns simultaneously, and they needed daily reports and trouble-shooting of issues faced on the field generating immense pressure for fast response.

And lastly, it was a high-pressure, dynamic environment with diverse stakeholders and perspectives. Working directly with the National Health Ministry of a program of significant importance to the country meant that there was high-visibility and therefore a need to be very agile and quick to respond to changes in policy, in external political & global factors impacting program plans, and in evolving state priorities as they responded to an epidemic or a worker strike.

In the early days when we worked with Andhra Pradesh government in the district of Vizag, my small team and I travelled extensively to every corner of the district that year, and I personally trained more than 500 health workers. Over the last 10 years, I’ve interacted with health officials from almost all the states and gone on many field visits.

With such rich experience in how to run technology projects at scale for Government social sectors in India, what message do you have for people who would like to do similar work?

The first key takeaway when working on such large-scale tech-enabled government programs is how to think about scale. You must design for scale from the beginning but don’t build for 500 million people right away. It’s prudent to take an incremental approach to enhancing the solution progressively as the program matures and new demands arise.

It is critical to develop a deep understanding of the domain – in our case, public health and health systems and how technology can solve the nuanced problems. Without this interdisciplinary approach, it isn’t possible to create a solution that is relevant for the program stakeholders, and earn their trust & respect for true collaboration.

You must invest significant time and effort in ecosystem partnerships, debating and incorporating varying perspectives and ensuring that everyone was aligned on the technology direction.

Most importantly, it’s necessary to adopt a program-first approach. While we were the technology partner, the goal was always the program’s success, and we went the extra mile to do whatever was required to achieve it. It included conducting trainings, working with Ministry on tech policy issues or program guidelines and participating in State reviews to support in the challenges they faced.

What’s your next project? People here say red tape is still there at the government level. How was your experience?

I’m keen to continue my work in improving healthcare especially for NCDs. India’s DPI (Digital Public Infrastructure) approach coupled with working with government for scale can deliver improved healthcare for millions.

Unlike in the private sector, where you can pick your target audience, government needs to deliver services for all, and hence this creates a slow and process driven system. Yes, there are challenges in working with governments, but that is the only way to address the healthcare challenges of the poor and deliver services for all.

My experience of working closely with Government at all levels in the last 10 years has been overall positive. I’ve met many committed individuals working against all odds to push their programs ahead. I find that we’re aligned on the end-goal of ensuring access to care or basic services to every individual.