The Banyan, the Byte, and the Loom of Care

India’s healthcare story is as ancient as the banyan tree and as futuristic as the byte. Under the long shadows of the banyan, villagers once gathered to share cures and counsel – now their stories are being written in lines of code and pixelated medical records. The Ayushman Bharat Digital Mission (ABDM) and related reforms promise to link every clinic, chemist, and patient in a national web of care. At first glance, this appears to be a grand adventure: widening access, speeding care, and harnessing data for good. Yet like any modern loom, the threads of digital health interweave promise with peril. Does this loom stitch efficiency and equity into the fabric of Indian healthcare, or does it risk tangling the human touch in cold algorithms? In the loom of India’s destiny, will digital health become the golden thread that binds our dreams of equity, or will it snarl the very relationships it seeks to digitize?

The Genesis of Digital Care: From Ayushman Bharat to E-Health

The push for digital healthcare in India is no accident. In 2019–2021, the government launched a sweeping blueprint to modernize health services. NITI Aayog’s National Digital Health Mission (NDHM) strategy envisioned an interoperable national ecosystem with personal health records at its center. In 2021, the Ayushman Bharat Digital Mission was formally launched to make that vision real: a secure, integrated platform where every citizen gets a unique digital health ID (ABHA) and an electronic health ledger. The ABDM application provides each person with an accessible personal health record (PHR) that they control. Patient histories, lab reports, and prescriptions can be linked under a 14-digit ABHA code tied to Aadhaar, enabling truly interoperable data across hospitals, clinics, labs, and pharmacies. The mission also built national registries of providers and facilities, and rolled out the Unified Health Interface (like a “healthcare UPI”) to let startups book appointments or deliver teleconsultations.

These reforms came with great ambition. The COVID-19 pandemic provided a stress test and impetus. The Co-WIN vaccination platform and Aarogya Setu contact-tracing app were early successes that demonstrated digital scale. By August 2024, India had created 568 million ABHA accounts and integrated over 350 million health records into its digital ecosystem. The eSanjeevani telemedicine platform, launched in 2019, facilitated 270 million virtual consultations by mid-2024. The second phase (eSanjeevani 2.0) now even connects home-based diagnostic devices directly into records. In short order, parts of the health system leaped from siloed clinics to a national network. Private sector interest was hot: ABDM created a “digital sandbox” of open APIs so that over 1,000 companies – from labs to hospital IT firms – could plug in services. In principle, this bridge between old clinics and new code promised to make care more efficient, more transparent, and more patient-centered than ever.

The Promises and Perils: Access, Exclusion, and Empathy

The promise of digital health is seductive. Telemedicine and e-consultations can reach a patient in a mountain village with little walking time. An e-pharmacy (online medicine delivery) can serve a sick mother in a remote hamlet at midnight. Automated reminders and AI triage might catch illnesses early. In an economy of scale, digital tools can handle mundane paperwork so practitioners have more time for patients. And the performance gains are real: co-payment caps in Estonia, for example, were managed by tracking e-prescriptions, automatically shielding citizens from extra fees. India hopes for similar efficiency gains.

But stark challenges loom. India’s digital divide remains wide. Official surveys now claim over 85% of households have at least one smartphone and internet access, yet on the ground, many analysts warn that the data masks huge gaps. An Oxfam-backed report notes “over 70 percent of the population in India [has] poor or no connectivity to digital services”. Rural residents, the elderly, women, and the very poor are less likely to own a smartphone or have reliable broadband. Even if a tablet or phone is present, meaningful digital literacy is rare: less than 40% of households have someone who can easily navigate the internet. For these populations, the sophisticated infrastructure of ABDM is an empty promise – an unlit lamp in the night. A scheme is only as inclusive as its weakest link. The same Oxfam report found that digital health expansion “did not improve access to public health services the way it was intended” when large swaths lack basic connectivity.

Legal ambiguity adds to the peril. Many aspects of digital health sit in gray zones. No dedicated statute governs e-pharmacies in India, for example. They must eke by under the colonial-era Drugs and Cosmetics Act and Pharmacy Act, which were designed for shopfronts, not online orders. As one commentary notes, “no legislation in India specifically regulates e-pharmacies,” forcing companies to rely on patchwork rules. This creates uncertainty over storage, shipping controls, and the authenticity of prescriptions. Telemedicine, legalized in emergencies in 2020, likewise runs on guidelines rather than hard law – raising questions about liability, especially when a virtual consultation leads to an adverse outcome. Data privacy is another fog. India’s 2023 Digital Personal Data Protection Act promises to safeguard health data, but critics argue that enforcement will lag behind innovation. Recent events have raised eyebrows: for instance, an online dashboard of India’s health insurance scheme (PM-JAY) briefly published patient names, diagnoses, and bills – ostensibly in breach of even ABDM’s own privacy rules. Such lapses highlight how easily sensitive health details can be exposed when legal norms are still settling.

Another tension is efficiency vs empathy. A teleconsultation might save travel time, but does a doctor on a screen truly see the patient’s fear? Will a rural patient trust a video doctor when first-generation frontline workers in villages still ask for personal advice? Will an automated symptom checker misdiagnose the faint elderly widow who cannot describe her pain well? These questions speak to the human element. Technology can triage and route patients efficiently, but caring for the person as a whole requires empathy that algorithms do not feel. Without safeguards, digital health risks reduce patients to data points. Accessibility cuts both ways: while a smartphone could summon a doctor, the absence of one bars entry entirely, creating a new digital “health literacy” caste.

There are also systemic challenges. The push for digital health has spurred a boom of private health-tech companies and startups. In theory, this innovation brings more options; in practice, it raises worries about profit motives. Will patient data become a commodity? Who owns and monetizes the vast health data lake? Already, global tech giants eye India’s market (Apple’s health apps, Google’s AI initiatives). While oversight is meant to protect patients, the lines between public health goals and commercial interests can blur. Balancing these forces – ensuring that e-health initiatives do not become pipelines for corporate profit at the expense of public welfare – is a delicate political challenge.

The Constitutional and Legal Compass

India’s digital health ambitions must be navigated by our constitution. Health, though not explicitly a fundamental right, is woven into India’s basic law. The Supreme Court long ago interpreted Article 21 (right to life) to include “the right to health and medical care”. Similarly, Article 47 (a Directive Principle) obliges the State to “regard the raising of … the standard of living and the improvement of public health as among its primary duties”. On these grounds, every Indian can claim that governance should improve health access and infrastructure. Thus, digital health is arguably not just a policy choice but a mandate of dignity. If health is life, then preserving the privacy of health data also falls under personal liberty. In Puttaswamy (2017), the Supreme Court confirmed that privacy is an intrinsic part of Article 21. By extension, individuals have a constitutional stake in how their personal health data is handled. This is no abstract concern: the law (now the DPDP Act 2023) must respect informed consent and confidentiality, as envisaged in the NDHM framework itself.

Federalism further shapes the terrain. In India’s Seventh Schedule, “Public health and sanitation; hospitals and dispensaries” sit in the State List. This means states are primarily responsible for healthcare delivery. At first glance, a national digital initiative might seem to encroach on this domain. However, the NDHM strategy explicitly invokes “cooperative federalism”: the Centre sets standards and builds the backbone, but actual care and records are generated by state-run clinics and private practitioners. In practice, this split creates both opportunity and friction. States like Kerala and Tamil Nadu, which have strong public health systems, may customize how they integrate ABDM IDs and telemedicine services. Others may need more central help. The Constitution’s silence on digital privacy means laws like the DPDP Act, drafted by the central government, now establish ground rules for everyone’s data. In effect, the Centre is governing an activity (data processing) that overlaps health records – a gray area in classical constitutional terms.

Judicial precedents also cast light. In Paschim Banga (1996), the Court said “denial of timely medical treatment in a government hospital” violates Article 21. One could argue: if a citizen is digitally disenfranchised by these reforms, could that breach the “right to health” core of life? And if a hack or data leak occurs, does that injury become a threat to life and liberty? These are unsettled but essential questions. The law also distinguishes health from, say, banking; unlike financial data, personal health data does not yet enjoy iron-clad regulation (the old draft Healthcare Data Act of 2018 never passed). So, in the absence of clear sectoral rules, digital health often relies on intersecting laws like the IT Act, telecom rules, and generic privacy norms. This ambiguity adds to stakeholders’ worries: tech entrepreneurs need clarity on compliance; patients wonder who to sue for a privacy breach – the doctor, the platform, or the government?

Finally, digital health must reckon with existing regulations. The Telemedicine Practice Guidelines (2020) relaxed rules on online consults during the pandemic (they say registered doctors may consult via video/phone). E-pharmacies too got ad-hoc green lights in 2020, but many states like Maharashtra and Tamil Nadu declared them illegal, leading to courtroom fights (the Drugs Controller filed cases against them). In short, India’s legal ecosystem is still catching up. Meanwhile, constitutional values – health as dignity, federal cooperation, privacy as a right – set an aspirational compass. Policymakers must ensure that NDHM and related schemes are implemented in a way that honors these principles. The Constitution imagined a welfare state; digital tools must serve the realization of that vision, not undermine it.

India and the World: Global Comparisons

India is not alone in wrestling with e-health. Consider Estonia, a pioneer in digital governance. Nearly 99% of Estonians’ medical data and prescriptions are already digital. There, patients routinely access records online, and doctors use national health portals. Importantly, Estonia’s e-health system is known for data security, built on a strong e-ID infrastructure. This gives India a distant target: high penetration and user control. However, Estonia’s small, wealthy population and unified system differ greatly from our context.

In the United Kingdom, the NHS has long sought digital integration. Patients in England can view their GP records (via the NHS app) – indeed, “most adult patients… have access to their primary care electronic record, including free-text notes”. This has improved patient engagement and reduced paperwork. But the NHS’s digitization has not been smooth; costly IT projects sometimes failed, and high-profile data privacy debates (e.g., sharing records with Google DeepMind) have made British patients wary. The UK teaches us that centralization brings standardization but can also breed bureaucratic inflexibility. The NHS is also grappling with how much personal control to give versus how to protect.

In Kenya, digital health has taken a different path as a lower-middle-income country. Kenya’s 2016–2030 eHealth policy emphasizes telemedicine and mobile health (mHealth) to improve rural access. For example, Kenya has deployed national health information systems and is experimenting with SMS-based health alerts. Like India, Kenya faces uneven connectivity, but it has leveraged high mobile phone usage and public–private partnerships (e.g., mobile money for health micro-insurance). The Kenyan strategy shows the value of a long-term plan: it explicitly ties digital health to Vision 2030 development goals, focusing on infrastructure and standards. The lesson: even resource-limited countries can advance e-health by tailoring technology to local needs.

Other countries offer snippets of wisdom. Singapore’s “My Health 365” program integrates health data across hospitals, but even it safeguards privacy through strong consent frameworks. Australia has a national My Health Record system, yet it was met with public resistance (the government had to make it opt-in rather than automatic after privacy concerns). The USA’s fragmented approach (with HITECH Act incentives for electronic records) shows how a lack of central coordination can leave interoperability low despite high spending. In short, every model involves trade-offs. No one country has found the perfect formula. Some emphasize efficiency (like Australia’s central rebate system), others autonomy (like Canada’s province-led systems), or privacy (like the EU’s GDPR standards).

For India, the comparative view is clear: balance is key. We must pick lessons that fit our diversity. Our sheer size and heterogeneity – “neither as centralized as Australia nor as decentralized as the US,” as one observer put it – means we need a hybrid path. As we adopt digital health, we should safeguard what these examples highlight: patient access to data (Estonia, UK), privacy protections (EU), and inclusive access (Kenya). We also must avoid what others have shown can go wrong: don’t crowdsource patient data into the wild (USA insurance pitfalls), and don’t impose top-down systems that people reject (early failures of Australia’s My Health Record). In navigating these global currents, India can forge a system that is efficient yet empathetic, standardized yet adaptable to local languages and customs.

Political Currents: Federalism and Reform

Digital health policy in India is now as much political economy as technology. At the Center, digital healthcare is a flagship reform – an emblem of “Digital India” and wellness. The ruling party touts ABDM as a visionary game-changer. Opposition parties and civil society raise alarms about privacy and central oversight. States with strong health systems (e.g., Tamil Nadu, Kerala) are cautiously embracing ABDM but also asserting their own data systems and concerns about patient confidentiality. In practice, the Centre has pursued cooperative federalism – involving states in planning – but states remain wary. For instance, after a limited pilot in six Union Territories, the government launched ABDM nationwide in 2021 without publicly sharing detailed results. Critics feared this was hasty: “Without public disclosure of evidence or lessons from the pilot, the national roll-out can be interpreted as a hasty decision”. This points to a trust gap: states want assurance that one-size digital IDs truly work for their patients before blindly adopting them.

Moreover, the power balance is shifting. Traditionally, public health data was the purview of local hospitals and state registries. Now, a central mission is aggregating data across the country. Questions arise: Who “owns” the data – the patient, the hospital, the state, or the Centre? The government has insisted that data stays in India and will be used only for health; yet many officials stress that a unified system is needed to unlock economies of scale. This tension between central authority and regional autonomy is a classic federal dilemma. Centralizing data can drive national planning and equity (much like the GST built a unified market), but it can also ruffle the feathers of states that see it as encroachment.

At the same time, political economy shapes incentives. Private insurers, pharmaceutical firms, and tech companies all stand to benefit from a digital health infrastructure. The government’s “sandbox” approach explicitly invites private innovators. But socialists worry about market capture of a public good. Can regulators ensure that data isn’t sold to the highest bidder? And who will maintain the backbone systems – the government’s digital health authority or outsourced agencies? These questions are being played out quietly in boardrooms and policy debates.

Even popular politics enters the fray. Rural voters wonder if digital health is real health or just an urban elite’s buzzword. Marginalized groups ask whether caste, class, or language barriers will be coded into algorithms. Campaign promises around “free data” or “Internet for all” have boosted smartphone use, but reformers must convert that connectivity into real care, or risk losing public trust. The pandemic made telemedicine necessary; now it is becoming political. Will every party agree that health records must be digital, or will it become a wedge issue about surveillance? So far, leaders on both sides claim support for digitization in principle. But they compete over how much oversight to grant citizens versus corporations, and how to share authority between Delhi and the states.

In these political currents, one thing is clear: digital health in India will not be decided by technocrats alone. It is a democratic project. It touches on federalism, economic justice, and fundamental rights. Its success will depend on balancing efficiency with empathy. Every step – mandating a health ID, funding rural telemedicine kiosks, or legislating data protections – must be justified not only by technical metrics but by ethical and constitutional values. The stakes are high, and the journey will demand the wisdom of both Silicon Valley and Preamble.

A Call for Balanced Reform

India stands at the cusp of a healthcare transformation as profound as any in our history. Like the implementers of GST 2.0 before us, we face “the grand promise and threat that reforms bring.” Digital health can indeed become a force for great equity, but only if we steer wisely. We must ensure that in the race to digitize, no citizen, no community, and no state is left behind. The gadget in the city that tracks health vitals is worthless if it means a rural grandmother cannot summon a doctor. The appeal of a unified health ID is hollow if it tramples on the patient’s right to privacy.

The solution lies in balance. We need efficiency woven with empathy, just as our Constitution combines Fundamental Rights with Directive Principles. Health data systems should be central enough to allow interoperability and public health planning, yet federal enough to let states innovate in local languages and contexts. Patients’ records must be digitally available, but only with informed consent and ironclad privacy, honoring the spirit of Article 21 and the Puttaswamy judgment. Technology must serve human dignity, not override it.

Internationally, nations teach us that neither blind centralization nor anarchy suffices. Australia found success with a national system by carefully rolling it out; Canada empowered provinces but created interoperable standards; the EU operates on voluntary data-sharing principles; the USA wrestles with its fragmentation. India’s path is between all these. Our reform must capture cooperative federalism in spirit, not just on paper. The Centre and States must truly collaborate – pooling resources for hard problems (like rural connectivity) while respecting local expertise. In rural India, for instance, a common telemedicine protocol could exist alongside traditional health workers versed in local languages.

Above all, our mission must be values-driven. This is not merely a technical upgrade, but a reaffirmation of what we stand for as a society. Digital health should be a bridge, not a barrier. It should empower the doctor at the village panchayat, the community nurse in the outpost, and the patient at their bedside. It should bind our strengths – our Constitution’s commitment to health as a duty of the state, our pluralism, and our innovation – into a common fabric.

Let us adopt reforms that are founded on equity as well as efficiency. Imagine every Indian having continuous, confidential access to their medical history, and every provider being better informed. Imagine data helping to predict outbreaks before they happen, but never being misused to discriminate. Those are achievable ideals, but they rest on collective will. The hour has come for India to demonstrate that technology and democracy can go hand in hand. We must make digital health the means to extend compassion, not replace it; to expand rights, not erode them.

In the loom of India’s future, let each digital thread reinforce the strength of the whole. Only then can this grand experiment fulfill its promise: not just a more efficient system, but a more humane and just one, true to the best of our ideals.

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References:

• Haripriya, G., Harigovind, P. C., & Rakesh, P. S. (2025). Emerging e-pharmacy sector in India: Ethical and regulatory concerns. Indian Journal of Medical Ethics. Advance online publication. https://doi.org/10.20529/IJME.2025.041
• Khanna, V., & Kotwal, A. (2025). Examining the significance of the Digital Personal Data Protection Act, 2023, in the context of the healthcare industry: A comprehensive analysis. Discover Public Health, 22, Article 381. https://doi.org/10.1186/s12982-025-00757-6
• National Institute for Transforming India (NITI Aayog). (2023). National Digital Health Mission: Strategy Overview. Government of India.
• Narayan, A., Bhushan, I., & Schulman, K. (2024). India’s evolving digital health strategy. npj Digital Medicine, 7, 284. https://doi.org/10.1038/s41746-024-01279-2
• World Health Organization. (2025). Using digital solutions to protect people from user charges for health care: lessons from Estonia. Regional Office for Europe.
• Government of India. (2023). Digital Personal Data Protection Act, 2023 (Act No. 12 of 2023). Ministry of Electronics and Information Technology.