Introduction

India’s healthcare landscape is a vast and interdependent network comprising both public and private sectors, with each playing distinct roles in delivering medical services to its 1.4 billion population1. The public healthcare system is designed to offer free or low-cost services for low-income and rural populations. However, these public facilities are often overwhelmed as a consequence of inadequate infrastructure, shortages of medical supplies, and a paucity of healthcare professionals2. This gap between supply and demand for healthcare services is exacerbated in rural areas where nearly 71% of the population resides but where only one-third of the country’s physicians are located3,4,5.

The recognition that fragmented governance and unequal access to healthcare were major impediments to achieving equitable health outcomes led to the drive for a cohesive national health strategy. The concept of Universal Health Coverage (UHC) became central to India’s healthcare policy, aiming to ensure that all citizens, regardless of income or location, have access to necessary health services without facing financial hardship. This push for UHC led to the development of the National Health Policy (NHP) in 2017, which laid the groundwork for leveraging digital technologies to strengthen the healthcare system6. Specifically, the National Health Policy of 2017 aimed to achieve universal health coverage by increasing access to quality healthcare services, reducing the cost of healthcare, and leveraging digital technologies to enhance the efficiency of service delivery. The Pradhan Mantri Jan Arogya Yojana (PM-JAY), launched in 2018 as part of this policy6. PM-JAY is a flagship health insurance scheme providing coverage of up to INR 5 lakhs per family per year for secondary and tertiary care hospitalization (approximately USD 6000), targeting the bottom 50% of the population by income, or approximately 500 million people7.

As the strategy developed, policymakers envisioned a significant role for digital innovation as a means of supporting the overall healthcare strategy. The foundation for this insight was known as “Digital India”—the moniker of an evolving federal government strategy aimed at deploying technology to address the chronic economic and social challenges of India’s diverse population. The technological backbone of Digital India is the India Stack, which began in 2009 to digitize government and financial services. India Stack had four key components: a digital identification system for all citizens, unified interoperable transactions between individuals and businesses, digital document verification, and the scaffolding regulation surrounding consent in data sharing8.

The digital identification system, Aadhaar, offers a unique 12-digit 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 Mantri Jan Dhan Yojana (PMJDY) was launched to provide a virtual bank account to all Indian citizens free of cost to bring the most underserved citizens into the formal economy9. Together, these systems have facilitated the creation of over 510 million bank accounts and integrated over 98% of the population into Aadhaar10. Building upon this foundation, the Unified Payments Interface (UPI) was established. UPI provided a secure and interoperable digital infrastructure that could facilitate instant fund transfers via smartphones, leading to 117 billion transactions in 2023 alone11. This system overcame common obstacles such as a lack of interoperability between public, private, and retail payment systems as well as geographic barriers to transferring funds for small businesses. As a consequence of this elegant infrastructure, innovation in the financial markets continues to develop at a rapid pace.

Digital health care

On the foundation of this success, the government of India turned to the health sector and committed to “a paradigm shift from the existing silo systems to a holistic and comprehensive health eco-system, founded on the latest digital architectures and technologies”.12

The development of India’s digital health strategy began with a global survey of best practices, in an effort to “leapfrog many of the traps that bedevil health information systems even in developed economies”.12 The United States’ HITECH Act, for example, highlighted the importance of a cohesive data architecture and interoperability. The UK’s NHS Digital illustrated the importance of developing and deploying integrated digital health platforms that ensure data privacy while enabling efficient health information exchanges. South Korea’s approach to integrating personal health records with national identifiers and Singapore’s “One Patient, One Health Record” model offered lessons on the value of ensuring patient access to their health data for enhanced care coordination and privacy.

Drawing from these global models, India launched the ABDM in 2021 with a focus on creating a secure, integrated digital health ecosystem that emphasizes personal health records, ensuring that each citizen’s health data is accessible, interoperable, and under their control. This ambitious project introduced five key innovations designed to enhance the delivery and management of healthcare services across the nation.

Central to the ABDM was a unique 14-digit health identifier for every citizen, the Ayushman Bharat Health Account (ABHA). Notably, the ABHA was primarily built upon Aadhaar (although other sources of identification are allowed) - India’s robust biometric identification system, leveraging its technological underpinnings to securely authenticate and manage health records.

The ABDM mobile application provides individuals with an accessible electronic personal health record (PHR) that adheres to national interoperability standards. Unlike traditional Electronic Medical Records architectures, the PHR is managed, shared, and controlled by the patient themselves with the ability to make records visible or invisible to providers. This architecture is a unique feature of the ABDM program.

The Healthcare Professionals Registry and Healthcare Facilities Registry catalog enrolled healthcare professionals and facilities nationwide. By creating standardized, accessible databases of healthcare providers and institutions, the ABDM facilitated easier verification and provider credentialing processes, which in turn helped patients make more informed choices about their healthcare.

Finally, the Unified Health Interface is the patient-facing platform supporting healthcare transactions. It was designed as an “open protocol for various digital health services,” including, but not limited to, appointment bookings, teleconsultations, and patient service delivery. Its open network structure allows for the integration of End-User Applications—such as data from health apps used by patients—and Health Service Provider applications—digital tools used by hospitals, clinics, and laboratories to manage patient data or facilitate operations.

Of note, the ABDM concept was conceived as a catalyst for private investment in the digital health sector. Accordingly, ABDM has put in place a “digital sandbox” that provides access to APIs from ABDM registries to private sector digital application developers aimed at providing novel services for patients and providers. To date, ABDM has integrated over 1,000 private companies into the ecosystem13. Examples include diagnostics 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 Management Information Systems allow hospitals to link patients’ ABHA records to data management platforms, which offer monitoring of patients’ health status, secure telemedicine channels, organized appointment bookings, and other “quality of life” upgrades.

Scale and adoption

The COVID-19 pandemic served as a catalyst for the ABDM, accelerating the deployment of digital health technologies. A prime example of this acceleration is the CoWIN platform, a federal digital platform designed to facilitate the registration, scheduling, and management of COVID-19 vaccinations for citizens. Alongside this platform, a mobile health application, Aarogya Setu, emerged as a means of conducting remote COVID-19 contact tracing13. ABHA numbers were created rapidly through the CoWIN initiative, leading to 130 million new accounts while ensuring efficient record keeping14. For patients, the ability to readily access personal health records allowed for rapid verification of vaccination status, exemplifying the potential of digital tools in managing public health emergencies14.

As of March 2024, the country has seen the creation of 568 million ABHA accounts and the integration of over 350 million health records into the digital ecosystem13. The program’s reach, encompassing over 230,000 health facilities and 285,000 registered providers, underscores the scale of the effort14.

Telemedicine has evolved along with the ABDM program. The eSanjeevani telemedicine platform, launched by the Ministry of Health and Family Welfare in 2019, facilitated over 270 million teleconsultations as of August 202415. eSanjeevani was initially designed for physician-to-physician consultations, facilitating collaborative care. However, in response to the COVID-19 pandemic, it expanded rapidly into a physician-to-patient service, known as eSanjeevani OPD (outpatient). Notably, eSanjeevani scaled healthcare delivery during the pandemic, with 57% of beneficiaries being female and 12% senior citizens15. The second phase of this effort, eSanjeevani 2.0, integrates information from Point of Care Diagnostic devices for rapid diagnosis.

Challenges in implementation

One of the most persistent challenges to the scale-up of India’s digital healthcare ecosystem is the uneven technological and infrastructural landscape across the country. While urban areas have largely benefited from improved connectivity and digital literacy, rural regions continue to struggle with limited access to the internet and necessary IT infrastructure16. Although there are over 400 million internet subscribers in rural areas as of 2024, the quality and reliability of this connectivity often fall short of what is needed to sustain robust digital health services17.

Data privacy and security concerns also loom large over the adoption of ABDM18. The digitalization of health records necessitates stringent data protection measures to safeguard sensitive patient information, particularly given the scale of ABDM. To this end, the Digital Personal Data Protection Act (DPDPA) of 2023 represents a step forward in India’s efforts to regulate the processing of personal data and ensure data privacy19.

While the Federal government has direct control over the financial sector and could implement the India Stack strategy, the responsibility for oversight of the health sector is a state responsibility. The states of Andhra Pradesh and Karnataka have made notable progress in the adoption of ABDM. Karnataka, in particular, has seen higher engagement from private healthcare centers, offering valuable lessons on provider onboarding and navigating provider concerns regarding increased accountability14. A summary of facilitators and barriers to ABDM may be seen in Table 1.

Table 1 Barriers and Facilitators of ABDM Adoption
Full size table

Looking forward

The ABDM is an exciting initiative for India and offers a vision for a national digital health architecture. Importantly, after assessing the utilization of electronic health records in the US and globally, India has made significantly different strategic choices on how a digital health strategy can be accomplished. Specifically, the backbone of their strategy is the development of a set of unique patient identifiers, and the implementation of a personal health record architecture to collect data and provide digital health services for patients. This massive experiment at scale should provide important insights into the digital transformation of the United States and global healthcare markets.