Fintech for Health by Access-Health

ACCESS Health Southeast Asia

HealthforSejalMistryand

Access Health Press Fintech

Fintech for Health is based on the white paper, “Breaking the health-poverty trap: How fintech can improve access to healthcare in Asia” published by ACCESS Health International in March 2021, supplemented with field notes from the ground.

First and foremost, we would like to thank MetLife Foundation, ACCESS Health International and Dr. William Haseltine for their support in defining and developing the Fintech for Health Weprogram.aredeeply grateful to all those who took the time share their insight and field experience with Fintech for Health. We have been inspired by your passion for the work and are humbled to be allowed to share that passion with a wider audience. We would also like to thank the editors of this book and are deeply grateful to contributors to the book, in no particular order: Ms Anushruti Adhikari, Dr Mohd. Nasir bin Mohd. Ismail, PhD, Dr. Monica Mittal, Ms Munia Islam, Ms Nabila Khurshed, Ms Nguyen Kieu An, Ms Prashanthi Krishnakumar, Mr Tawfiq Hasan, Ms Tina Ja, Ms Valerie Shelly, Ms Adrienne Mendenhall, Ms Vera Siesjo, Ms Yue Xu and Vriens and Partners. This book is edited by Ms Sejal Mistry and Ms A Vigneswari from ACCESS Health International Southeast Asia, with support from Ms Courtney Biggs, Ms Josephine Gurch, Ms Abegale Escolano and Ms Anushka Maganti.

Acknowledgements

v Contents Preface ................................................................................................................. 1 Breaking the health-poverty trap: Fintech for Health in Asia ..... 4 Foreword ....................................................................................................... 4 Wealth equals health 5 Healthcare Journey is Accompanied by a Financial Journey: The Five Healthcare Challenges ..........................................................................6 Contextualizing financial health and its relation to physical health .............................................................................................9 The opportunity to break the health poverty trap ......................... 11 Fintech for Health should be aligned with Universal Health Coverage goals ............................................................................................... 14 A Framework for Fintech for Health ..................................................... 16 The Fintech Ecosystem ............................................................................... 27 The Application of Fintech to Solve Patient Problems .................. 28 Notes from the field .................................................................................... 34 Bangladesh ................................................................................................. 35 Introduction .................................................................................................... 36 Wage digitization for RMG workers: Advancing financial inclusion in Bangladesh ............................................................................. 37 Mobile financial services in Bangladesh.............................................. 40 Apon – Embedded insurance: meeting the healthcare needs of readymade garment workers ............................................................. 46 China ............................................................................................................. 50 Introduction .................................................................................................... 51 Fintech for health in China: Growing Needs, Unique Opportunities ................................................................................................. 52 Improving accessibility to integrated fintech for health solutions for aging populations in China .............................. 59 India .............................................................................................................. 70 Introduction .................................................................................................... 71

vi Ayushman Bharat Digital Mission ..........................................................72 The Effect of Covid 19 on Healthcare Affordability ........................76 Digital wallets: the genesis, current usage, and future use of healthcare payments in India ...................................................................81 How Fintech for Health partnerships in India provide healthcare financing for cancer patients ....................................................................84 How Fintech for Health partnerships Improve Access to Affordable Healthcare For Hospital Workers in India ...................87 Malaysia LearningsHighlightingViVietnam’sVietnamNepalcompaniesopportunitiesTheinInvestinghealthcareM40Introduc........................................................................................................91tion....................................................................................................92Households:TheforgottengroupinMalaysianfinancing.....................................................................................94forhealth?TimetochangetheparadigmMalaysia.......................................................................................................97risingoutofpockethealthcareexpendituresinMalaysia;forcollaborationbetweenfintechandthehealthcaresector................................................101TheOpportunities......................................................................................104Fintechcanbeusedtoincreasecancerscreenings......................107...........................................................................................................112Introduction.................................................................................................113Nepal’sjourneytowardscashlesstransactions.............................114......................................................................................................118Introduction.................................................................................................119Vietnam’sgrowingfintechindustry:Theopportunitiesformeaningfulpartnershipswithhealthcare......................................120ChallengesandOpportunitiesforFintechforHealthinVietnam124IntroductionandMarketContext124fintechmarket...................................................................127etnam’shealthtechmarket...........................................................129PolicyLandscape........................................................................................131OpportunitiesandRecommendations..............................................145healthtechpotentialinthe“newnormal”........146fromOtherCountries.....................................................151

vii Conclusion..................................................................................................... 164 Contributors ................................................................................................. 165 List of Figures Figure 1. Five Persistent Health Financing Challenges Across Asia ......7 Figure 2. Ibrahim's Journey ................................................................................ 10 Figure 3. Rashida's Journey................................................................................. 10 Figure 4. Binh's Journey ....................................................................................... 11 Figure 5. Xiaoming's Journey.............................................................................. 11 Figure 6. Current Health Expenditure as a Percentage of GDP ............ 15 Figure 7. Proportion of Total Health Expenditures by Financing Sources (OOP, Public and Private) ................................................................... 15 Figure 8. Fintech for Health Framework to Solve Patients’ Health Finance Challenges ................................................................................................. 17 Figure 9. bKash and digital financial inclusion in Bangladesh. Case Study: bKash, mobile wallets in Bangladesh ................................................ 20 Figure 10. Case study 1: Shuidi, An Integrated Donations, Mutual Aid, and Insurance Model ............................................................................................. 25 Figure 11. Case study 2: AffordPlan, An Online Platform to Help People Save for Healthcare 26 Figure 12. Case study 3: Arogya Finance—Alternative Risk Scoring Stimulating Digital Lending for the Underbanked..................................... 27 Figure 13. Case study 4: Apon Wellbeing, a Specialized Marketplace for Workers................................................................................................................ 46 Figure 14. Case study 5: Telenor Health, a Company that Provides Online Health Consultations, Advice, and Insurance ................................ 48 Figure 15. Case study 6: Jianyibao, a Provider that Provides Disease Specific Insurance Plans and Medical Assurance Products ................... 66 Figure 16. Case study 7: Weibao, a provider that provides personalized insurance products 68 Figure 17. The Components of ABDM ............................................................. 73 Figure 18. OOP Health Payments in Malaysian Ringgit ........................ 102 Figure 19. Case study 8. Merchantrade which provides remittance services, teleconsultations, e pharmacy, and insurance ...................... 110 Figure 20. Case study 9: Pasarpolis, an insurtech company............... 154

.................................................................................................................

Figure 21. Case study 10: Halodoc, a teleconsultation company that also provides drug delivery, in-home lab tests, and insurance 156

......................................................

Figure 14. Case study 5: Telenor Health, a Company that Provides Online Health Consultations, Advice, and Insurance ................................48

List of Case Studies

Figure 22. Case study 11: M-tiba, an online health platform that provides a mobile health wallet service 158

Figure 10. Case study 1: Shuidi, An Integrated Donations, Mutual Aid, and Insurance Model 25

.............................................................................

Figure 12. Case study 3: Arogya Finance Alternative Risk Scoring

Figure 19. Case study 8. Merchantrade which provides remittance services, teleconsultations, e pharmacy, and insurance ...................... 110

Stimulating Digital Lending for the Underbanked .....................................27

Figure 15. Case study 6: Jianyibao, a Provider that Provides Disease Specific Insurance Plans and Medical Assurance Products ...................66

Figure 20. Case study 9: Pasarpolis, an insurtech company ............... 154

......................................................

viii

Figure 22. Case study 11: M tiba, an online health platform that provides a mobile health wallet service 158

Figure 16. Case study 7: Weibao, a provider that provides personalized insurance products......................................................................68

Figure 21. Case study 10: Halodoc, a teleconsultation company that also provides drug delivery, in home lab tests, and insurance ......... 156

Figure 24. Case study 13: BIMA, an insurtech company that provides mobile delivered insurance 162

Figure 23. Case study 12: Pro mujer a fintech company that provides preventive care and pay-per-service access to doctors and advanced treatment 160

Figure 11. Case study 2: AffordPlan, An Online Platform to Help People Save for Healthcare ..................................................................................26

Figure 13. Case study 4: Apon Wellbeing, a Specialized Marketplace for Workers ................................................................................................................46

Figure 17. The Components of ABDM .............................................................73

Figure 18. OOP Health Payments in Malaysian Ringgit ........................ 102

................................................................................................................. 160

............................................................................. 162

Figure 23. Case study 12: Pro mujer a fintech company that provides preventive care and pay per service access to doctors and advanced treatment

Figure 24. Case study 13: BIMA, an insurtech company that provides mobile delivered insurance

1 Preface

n 2019, ACCESS Health, with financial and strategic support from the MetLife Foundation, launched the Fintech for Health Innovation platform (F4H). The goal of the F4H initiative is to develop new thinking and new solutions that leverage the growing strength of digital financial services to help everyday people better afford and access healthcare. When we first started talking about “fintech for health,” we elicited polite but confused reactions from both our finance and healthcare peers.

“What do digital wallets, alternative credit scores, and payment gateways have anything to do with healthcare or the improvement of health outcomes?” Or from one healthcare expert several years ago, “What is fintech? Technology from InFinland?”thefinancial services sector, there have been some products designed specifically to cover health care costs – health savings accounts, hospital indemnity, and even loans. But the efforts to bring together the financial services and healthcare sectors have been scarce. This is what we must work on. Technology offers the opportunity to bridge the divide, making it possible for healthcare, governments, and financial providers to co-create and scale new and innovative solutions that address the everrising cost of care and its burden on communities. Technology offers the potential for a faster iteration of ideas, across a much wider geographical and sectoral landscape.

ACCESS Health International and MetLife Foundation have co designed the first-ever regional platform that brings together leading finance and healthcare providers as well as start-ups, I

Fintech for Health 2 with the purpose of finding innovative solutions that increase the affordability and accessibility of healthcare services for lowand moderate income populations. The platform objectives are threefold:

1) Test and scale projects that help people pay for and afford the care they need, using a combination of digitally enabled healthcare and finance solutions, 2) Promote cross sectoral innovation in healthcare access and affordability, and 3) Conduct research on best practices, blending finance and healthcare innovations. Since those initial queries, we have come a long way in finding a common understanding and purpose behind fintech for health and the people whose lives we wish to improve. At its essence, fintech for health is a strategy to weaken the stubbornly strong link between one’s wealth and one’s access to health in most of Asia. With nearly 100 million people in Asia at risk of poverty and out of pocket payments bearing a disproportionate burden on the poor, we realized that more could and should be done.1

We would be woefully ignorant at best and deceptive at worst if we did not acknowledge and assert the strength of Universal Health Coverage its principles and its implementation in breaking the health poverty trap. In every country we have studied, partnered with, and implemented fintech for health solutions, we have done so in the context of a strong political and programmatic commitment to Universal Health Coverage, which asserts the right of every individual to access health services, of sufficient quality, without posing undue financial hardships.

In this book, we provide a series of publications through the Fintech for Health program that has been informed by the knowledge of others academic literature, grey literature, interviews, anecdotes, and our own on the ground experience.

This is just our starting point in the compilation of our knowledge gained on the Fintech for Health domain its uses, its pitfalls, its potential, and its limitations. We hope that this living e book can inform policy and practitioners, the healthcare expert and the finance expert, and anyone else who is interested in this emerging domain.

Resources:

Sejal Mistry

www.fintechforhealth.sgwww.accesshealth.orgwww.metlifefoundation.org

The World Health Organization (WHO) estimates that more than 100 million people around the world are pushed into poverty every year because of healthcare expenditures. The pandemic is erasing years of progress and is exacerbating this push. The World Bank estimated an additional 88 to 115 million people would enter the ranks of extreme poverty by 2021. 2

There have been many efforts around the world to decrease the costs of healthcare, particularly for low-income people –national health initiatives, free clinics, and reduced-priced medicines offered by public, private and non-profit players.

n 2021, the F4H program released a white paper to describe the rationale and existing and potential application of the fintech for health approach in addressing common healthcare challenges. This chapter is adapted from the white paper. The full white paper can be found here.

Breaking the health-poverty trap: Fintech for Health in Asia

Foreword

This white paper seeks to spur further dialogues and actionlocally, regionally, and internationally - around the need, challenges, and opportunities for governments and providers of healthcare, technology, and financial services. The goal of the Fintech for Health program is to forge and support partnerships that can enable low- to moderate-income people to utilize highquality healthcare services in an affordable and timely manner without jeopardizing their financial health. I

A 2020 report5 in The World Bank Research Observer summarizes this financing challenge:

Sejal Mistry 5

Wealth equals health Health is a cherished human right, underpinning our definition of well being and quality of life. In 1946, the World Health Organization set this principle on paper, compelling nations and world leaders to recognize that the “enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being without distinction of race, religion, political belief, economic or social condition.”3 A person’s health and well being are intrinsic to merit. However, if they are viewed merely as functions of economic output, we can be equally satisfied in recognizing that health increases workforce productivity,4 and healthy workforces spur the national economy. Older generations can therefore continue to admonish younger generations with the adage, “Health equals wealth.” For this reason, most societies attempt to provide financial protection against catastrophic healthcare costs most commonly through public financing (subsidized healthcare or social health insurance), private insurance, and charitable endeavors. While these forms of financial protection provide an important foundation for healthcare financing, they leave consistent gaps, causing individuals to bear a large portion of their healthcare expenditure out-of-pocket. For most of the world’s population, the direct link between health and wealth has also meant that good health is bound to good fortune. Healthcare does not necessarily flow to those who need it most, but to those who can afford it most. In short, wealth equals health, deepening this cycle of inequality.

We start with the individual who needs healthcare services now, in the past, or in the future and what their journey looks like in their community. We identify specific points where people are most likely to pay out of their pocket and are vulnerable to high costs. From there, we hone in on where and when fintech solutions may have a role to play across the life Specificcycle.

“Healthcare is different from other budget items in several key ways (cf. Arrow 1963). Its consumption is irregular and unpredictable. This reflects the fact that curative healthcare is valuable only in the event of illness, the timing and nature of which are substantially beyond the control of the individual…The consequent reduction in expenditure on other budget items whether in the current period or other periods is therefore associated with a reduction in welfare rather than an increase, as is the case with other goods and services.” (p.123 124)

types of challenges to affordability and access arise along the healthcare journey. We identified five common attributes of healthcare costs that have prevented many people in Asia from accessing timely and quality healthcare services.

Healthcare Journey is Accompanied by a Financial Journey: The Five Healthcare Challenges

Fintech for Health 6

Sejal Mistry 7 Figure 1. Five Persistent Health Financing Challenges Across Asia

2. Healthcare costs go beyond the cost of health services

There are indirect costs associated with accessing healthcare but not directly linked to the delivery of healthcare services or to the treatment itself. One example is the cost incurred when traveling to a healthcare facility to receive services. People who live in rural and remote areas, where medical facilities, clinicians, and healthcare workers are few and far between, generally have poor access to healthcare. This is particularly evident in South Asia, where 66% of the population live in rural and remote areas, and in East Asia and the Pacific, where 41% live in rural areas.8

1. Healthcare costs are expensive Medical costs are outstripping inflation. While in 2019 the worldwide inflation rate for goods and services was 2.2%,6 the global trend for healthcare costs stood at 7.6%. In the Asia Pacific region, the upward trend in healthcare costs is even more alarming, with a regional average of 7.8% three times the global inflation rate for goods and services.7

Out-of-pocket spending (payments made directly to healthcare providers at the time of service) is one of the greatest threats to the financial security of people around the world. For low- and moderate-income people, the level and unpredictability of healthcare costs that are paid out of pocket impose significant financial vulnerability on the individual and household who may have little savings or assets to pay for the cost of healthcare at the time of service. They may have to raise funds from friends and family, turn to informal lenders and loan sharks, or forego necessary treatments. For this reason, prepayment of healthcare in the form of insurance premiums, taxation, and savings is always preferable. In Asia, out-of-pocket (OOP) expenditure as a proportion of all sources of healthcare financing varies significantly from county to country, with 11% in Thailand to 74% in Bangladesh.9

Fintech for Health 8

3. Healthcare costs are out of pocket.

4. Healthcare costs are unpredictable For most goods and services, prices are known and transparent before purchase. In most cases, prices will not vary markedly from one vendor to another for the same level or quality of goods and services. But in healthcare, individuals are often faced with little information or understanding of the price of a major medical intervention until the point of need. This has significant implications, as the urgency of the medical intervention, combined with the high price of care, puts households in a difficult position without being well informed or having the time to become better informed. The timing, type, and frequency of care are variable within a range by the individual. Two people may have the same disease diabetes, cancer, or cardiovascular

Contextualizing financial health and its relation to physical health A person’s health and financial journey are a unique function of their circumstances. Based on our observations through the Fintech for Health program and informed by our research on case studies, interviews, and discussions with fintech and healthcare organizations around the world, we have developed typical “personas” representing everyday people who experience health financing challenges. Our personas from Malaysia, Vietnam, Bangladesh, and China are representative of many other countries where people face multiple financing challenges that impede access to the care that they need. For low and moderate income people, steady income, robust savings and assets, and adequate health insurance are rarely possible.

Sejal Mistry 9 disease but the treatment needed and, consequently, the costs for each individual can vary significantly.

5. Healthcare costs are not linked to healthcare outcomes. In healthcare, we pay for what we use. In “fee for service” healthcare systems, costs are determined by inputs (i.e. products and services delivered). Outcomes or results are not guaranteed by hospitals or doctors. For the individual, the disconnect between cost and outcome puts tremendous financial pressure on a household and may not result in better health. For those who face severe and life threatening illnesses, this is a gamble that could result in death or bankruptcy and generational poverty.10

The personas describe individuals who face multiple financingrelated obstacles context of their households and communities. It is tempting to find dimensional solutions, but we recognize and build for complexity of real life will fall

one

the

solutions, we

Fintech for Health 10

in the

short. Figure 2. Ibrahim's Journey Figure 3. Rashida's Journey

until

Sejal Mistry 11 Figure 4. Binh's Journey

The opportunity to break the health-poverty trap

Three trends have emerged in the last decade that provides countries with a powerful opportunity to pull people out of the health poverty trap.

Figure 5. Xiaoming's Journey

Fintech for Health 12

Trend 1: Digital transformation is driving health transformation. The use of digital technology has redefined the way we live and interact. As of 2019, 54% of the world has access to the internet,11 around 50% access through a mobile phone,12 and 83% have access to 4G and faster networks.13 We shop online, find jobs online, learn online, find partners online, and now we are seeking healthcare online. The unprecedented scale and pace of technological change have brought innumerable benefits as well as challenges. Digital technology is one of the rare innovations that has been quick to penetrate all income levels and national GDPs. Though not a panacea to poverty—the opposite, if misused—synergy between digital technology and important social and political movements can function as a catalyst in breaking vicious cycles of poverty, inequity, and ill-health.

Trend 2: Fintech is rapidly increasing access to financial and other digital services among the low- to moderateincome segments. Under the premise of financial inclusion, fintech has made remarkable contributions toward increasing access and usage of financial services among low-income people. In the past six years, 1.2 billion people worldwide have gained access to bank and mobile money accounts through digital financial Whiletechnology.14significant gaps remain for underserved segments (e.g. extremely poor, digitally excluded older adults), fintech is moving beyond transactional services to enable targeted,

2. The quality of health services should be good enough to improve the health of those receiving services.

Trend 3: Worldwide, countries are making progress towards universal health coverage. In 2015, world leaders committed to the goal of Universal Health Coverage (UHC) in the landmark Sustainable Development Goals (SDG) meeting of the United Nations. The UHC commitment SDG 3.815 laid out the vision that “all people and communities can use the promotive, preventive, curative, rehabilitative and palliative health services they need, of sufficient quality to be effective, while also ensuring that the use of these services does not expose the user to financial hardship.”16

conveniently delivered financial solutions for low-income Bypeople.leveraging

ABCD (AI, Blockchain, Cloud, and Data) technologies and Open APIs, fintech generates opportunities for partnership and technology integration at a pace, scale, and ease inconceivable a decade ago, with a degree of personalization otherwise impossible.

The three pillars of UHC access, quality, and cost are delineated in the following objectives: 17

3. People should be protected against financial risk, ensuring that the cost of using services does not put people at risk of financial harm.

1. Equity in access to health services— everyone who needs services should get them, not only those who can pay for them.

Sejal Mistry 13

Fintech for Health should be aligned with Universal Health Coverage goals

While UHC is the ideal state for paying for and guaranteeing care, it is not feasible for many countries in the short term. Indeed, the UN General Assembly has set the commitment for all countries to achieve universal health coverage by 2030. Until UHC is achieved, while families face childbirth complications, cancer, diabetes, or a host of other costly diagnoses and medical events, they need trusted and transparent sources of funding that do not rely on selling income-generating assets, or borrowing money from loan sharks, or foregoing care because of costs. In Asia, the health financial protection gap stands at approximately USD 1.8 trillion.18 Low levels of national spending on health, combined with the disproportionate burden on individuals to finance their healthcare at the moment of critical need, leave most people in Asia highly vulnerable to ill health and poverty.

Fintech for Health 14 UHC is an explicit attempt to delink wealth from health and break the health-poverty trap.

Source: The World Bank. (2022). Out-of-Pocket Expenditure (% of Current Health Expenditure). World Bank Open Data.

Figure 6. Current Health Expenditure as a Percentage of GDP

Sejal Mistry 15

Figure 7. Proportion of Total Health Expenditures by Financing Sources (OOP, Public and Private)

Source: The World Bank. (2022). Current health expenditure (% of GDP). World Bank Open Data. Retrieved 13 July https://data.worldbank.org/indicator/SH.XPD.CHEX.GD.ZS2022.

World Bank Open Data. Retrieved 13 July ;https://data.worldbank.org/indicator/SH.XPD.GHED.CH.ZS2022.TheWorldBank.(2022).

;https://data.worldbank.org/indicator/SH.XPD.OOPC.CH.ZS2022.TheWorldBank.(2022).

Domestic private health expenditure (% of Current Health Expenditure)

. World Bank Open Data. Retrieved 13 July transformation,barriersdoctorinstitutionsWhen;https://data.worldbank.org/indicator/SH.XPD.PVTD.CH.ZS2022.patientslacksufficientfundswhetherpublicorprivatetopayforcare,theyalsolackaccesstothehealthandfinancialthathighincomepeopleenjoy.Asnotedabove,duetotherapidadoptionofmobiletechnologies,lowtomoderateincomepeoplemayhavebetteraccesstoamobilephonethanaorabank.FintechforHealthaimstoovercomethesewhileleveragingthethreetrendsofdigitalfintech,anduniversalhealthcoverage.

Domestic general government health expenditure (% of Current Health Expenditure)

A Framework for Fintech for Health

Retrieved 13 July

To delineate a framework for Fintech for Health, we found it useful to subdivide fintech solutions into three components: digital financial solutions, key digital enablers, and the channel to healthcare services. We developed and refined this framework through successive iterations and discussions with fintech and healthcare providers to attempt to reach a common understanding of the challenges they face.

Fintech for Health 16

Sejal Mistry 17 Figure 8. Fintech for Health Framework to Solve Patients’ Health Finance Challenges

Key Digital Enablers

We recognize that the array of fintech solutions is vast and beyond what we have presented here and that it will continue to expand as technology and business models evolve. We propose a starting point to look specifically at solving health financing challenges where the burden on paying for care falls heavily on the individual. We recognize that fintech also has a significant role to play in lowering the overall cost of care by making healthcare backend systems more efficient and affordable, including universal health coverage systems.

Source: ACCESS Health International Southeast Asia Team

Digital technologies have the potential to make healthcare and finance more targeted, affordable, scalable, and convenient. In many under-resourced countries, technology provides additional infrastructure for delivering healthcare that is

affordable, efficient, and increasingly aligned with users’ preferences and behaviors. Through fintech for health, these countries have an opportunity to leapfrog legacy finance and health systems.

Four main digital technologies enable Fintech for Health models: information, analytics, e-wallets, and digital identification. These rest upon a digital platform that integrates multiple functions and services. The Foundation: Digital platforms Forming the foundation of our fintech for health model, digital platforms have been reshaping the way we interact with, choose, pay for, and receive goods and services, offering convenience, affordability, and reach. Digital platforms assume a multitude of forms, from websites to e commerce sites, payments apps, ridesharing platforms, health messaging apps, medical claims systems, or e governance platforms. Many are now evolving into “superapps”. Digital platforms facilitate convenient deployment of Fintech for Health solutions by connecting financial solutions and healthcare providers to individuals. In China, WeChat and AliPay tapped into their large consumer payments base to offer healthcare services and healthcare specific financing options. The Grab and PingAn joint venture Good Doctor was designed to combine a superapp with a telemedicine platform to offer digital health services across Southeast Asia. There are four main “component enablers” that form the digital platform base: information, analytics, e-wallet, and digital ids.

Fintech for Health 18

Ataccessible.theindividual level, analytics has yielded unprecedented personalization and customization of loans and insurance plans.

Enabler 1: Information

Importantly, data analytics has led to the emergence of entities providing “alternative risk scoring” that uses non traditional means of assessing creditworthiness. With one billion people in Asia unbanked, these services have become important for unlocking credit and capital, in addition to providing point of care loans to individuals and families in their time of need.

Sejal Mistry 19

The availability of information aggregated, tailored, and interpreted for individual needs empowers people to make better decisions for themselves. In the sphere of fintech, price comparison sites allow people to choose the most appropriate and affordable insurance, loan, or bank account, increasing transparency and user autonomy. In healthcare, the availability of information is critical to guiding decision-making, from finding the right doctors to researching available treatment options. Increasingly, private insurance and pharmaceutical patient support programs are offering bundled solutions with digital health and healthcare “concierge services.”

Enabler 2: Data analytics

At the societal level, policymakers and industries are using data analytics to shape our healthcare environment and experience. Using the data derived from Fintech for Health models, policymakers and health systems planners can assess health

In healthcare, as in finance, data analytics is driving innovations in personalized risk assessments, market insights, and societal decision making that can make healthcare financing more

Fintech for Health 20 seeking behavior at the community level by processing billing, procurement, and income data. Furthermore, finance technologies may overcome some of the ongoing challenges that arise in aggregating information across fragmented and rudimentary electronic health record systems.

Enabler 3: Digital wallets Digital wallets give users an opportunity to receive wages and timely outside payments (e.g., family, government, employers), eliminate distance, store value, make payments, and apply for other transaction services, such as lending. Digital wallets create an avenue for social insurance payments and timely claims reimbursement without requiring users to open a formal bank account.

Figure 9. bKash and digital financial inclusion in Bangladesh. Case Study: bKash, mobile wallets in Bangladesh Enabler 4: Digital ID

Digital identification allows governments and private sector enterprises to authenticate a person’s identity and deliver services in an efficient, private, and secure manner. The World Bank refers to digital ID as a “game-changer” and provides an

Healthcare Delivery Channels

The linkage of digital financial services to traditional (brick and mortar clinics, hospitals) and digital (telemedicine) health delivery channels are helping to address the challenge of immediate financial needs for emergency or high cost healthcare services. Moreover, digital financial services for health provides a seamless, convenient, and affordable way for people to access healthcare. Traditional healthcare organizations have a significant role to play in making new financing models accessible for their patients. These systems, or networks of systems, have the capability to counsel patients in their communities and refer them to relevant resources. In person clinics, pharmacies, and hospitals are increasingly integrating telemedicine into their practices. This integration gradually gained traction over the last five years and has accelerated under COVID 19, as patients struggle to reach brick

Sejal Mistry 21

opportunity for developing countries to leapfrog their developed counterparts by creating more efficient and modern systems.19Digitalidentification uses biometrics, such as electronically captured facial features, iris patterns, and fingerprints, to establish a unique identity. It replaces paper data with digital datasets, offering security, transportability, and efficiency. By using digital ID, governments can issue digital tokens that can be used to record financial data, health data, and eligibility for social benefits, thereby increasing access to these systems both online and offline,20 particularly for underserved populations for whom these services would otherwise be out of reach.

Additionally, fintech platforms and digital wallets, including bKash and Pathao in Bangladesh, MoMo in Vietnam, and Tencent in China, are offering telemedicine services and insurance products directly on their platforms, which are promoted through their distribution networks. Digital payment companies have a significantly larger reach and customer market than digital health companies and can bundle telemedicine and e pharmacy services onto their payment platforms.

Fintech for Health 22 and-mortar providers and fear further exposure to the SARSCoV-2 virus. The regulatory landscape followed suit, allowing greater insurance coverage of telemedicine consultations and paving the way for innovative partnerships.

Digital Financial Services Archetypes Health delivery channels help link key digital enablers to digital financial services. We have defined four main archetypes of innovative health financing solutions that can be offered to unbanked or underbanked consumers using technology: digital health savings, digital lending, crowdfunding, and insurtech. These financing models are not mutually exclusive; the most practical and impactful models will combine two or more archetypes. Service Archetype 1: Insurtech Insurtech and digital insurance have expanded the ways in which people purchase insurance and the types of insurance available to them. Insurtech extends the reach of financial protection through underlying digital technologies (data analytics, blockchain, artificial intelligence) that are deployed for enhanced underwriting and risk assessment, claims management, improved customer experience, and distribution.

Service Archetype 2: Crowdfunding

PolicyBazaar22 in India features several family health insurance plans that cover children, parents, and grandparents for hospital fees and give discounts on products and services, all for one Withpremium.large unbanked populations, a growing middle class, and a traditionally low penetration of private insurance in China, India, and parts of Southeast Asia, there are enormous opportunities for the application of insurtech to address the low levels of financial protection in the region. A study by Swiss Re estimates that by 2029, the Asia Pacific region will account for 42% of the global insurance premium, and China will become the largest insurance market by mid 2030.23

Sejal Mistry 23

Crowdfunding has grown as a financial model that pools donations from many people to fund individual causes, enterprises, and projects through community campaigns, either through direct donations or through mutual aid programs that provide a degree of financial protection for catastrophic care. Crowdfunding platforms, such as Give.Asia, rely on donations to

Insurtech has also enabled a diversification of insurance offerings. Microinsurance offers an affordable but limited form of financial protection to individuals who cannot afford traditional insurance and is typically offered as an add on to other financial transactions or services. Companies like Digital Healthcare Solutions (DHS) in Bangladesh are offering microinsurance to Grameenphone subscribers in Bangladesh, while the Vietnam Women’s Union offers credit life insurance to its Definedmembers.21group models provide insurance to small groups of people, such as family units, rather than individuals.

Thisevent.model incentivizes people to pay for financial protection through micro contributions that are far lower than traditional insurance premiums. According to the Research Institute of Ant Financial’s “Online Mutual Aid White Paper,” mutual aid in China is projected to cover 450 million people, almost one third of its population, by 2025.24 These programs expanded in 2020 to start offering insurance programs such as Shuidibao (Figure 10), showing that mutual aid can be a stepping stone to full financial protection.

Crowdfunding platforms provide a direct way for beneficiaries to let people in their network and beyond know about their need for financial assistance while also giving the broader population the ability to donate charitable funds. In China, the crowdfunding model has expanded to provide additional basic financial protection through mutual aid platforms, which collect very small amounts of money per person (e.g., 10 RMB or $1.30 per month) from a very large population towards a fund that its members can draw upon in the event of a catastrophic health

Fintech for Health 24 cover large hospital bills or treatment costs that a family cannot afford. While perhaps no other model points to systemic failures more than donation based crowdfunding, which tells stories of individuals and families facing extraordinary healthcare expenses and heart rending circumstances, they are still a health financing band aid when no other immediate solutions exist.

Archetype 3: Digital savings

A digital version of a traditional savings account, digital savings accounts are a feature that most large banks around the world now offer. Digital savings accounts have several advantages over traditional savings accounts, including easy access to one’s savings when and where a person needs them. Importantly, digital savings are now being provided to vulnerable sections of society such as informal and low wage workers, women, and marginalized groups who were previously excluded from or unable to use traditional banking services.

Sejal Mistry 25 Figure 10. Case study 1: Shuidi, An Integrated Donations, Mutual Aid, and Insurance Model Service

One of the most well known examples of the use of digital savings for health is the M TIBA initiative by CarePay, which was created as a joint venture between PharmAccess and the mobile network operator, Safaricom in Kenya. M TIBA conveniently helps people save small amounts of money for anticipated health expenses such as maternity care or elective surgery.

Fintech for Health 26

AffordPlan offers mobile health savings accounts (mHSAs) and patient centered communication tools that enable integrated care and address challenges linked to high out of pocket payments and low quality services.

The M-TIBA model is now the gold standard for blended public and private financing. Subscribers can save, send, and receive funds for medical treatment through apps on their phones.

Subscribers can pay for medical treatment at any M TIBA approved healthcare provider and clinic using their phones and can use funds to pay premiums for registered health insurance

Archetype 4: Digital Lending

Digital lending offers credit through digital platforms and, combined with alternative risk scoring technology, provides affordable loans to someone without a credit history. Lending services can be provided by a single company, like Arogya

Donors can send subsidies or vouchers to beneficiaries.

Inpolicies.25India,

Figure 11. Case study 2: AffordPlan, An Online Platform to Help People Save for Healthcare Service

Figure 12. Case study 3: Arogya Finance Alternative Risk Scoring Stimulating Digital Lending for the Underbanked

The fintech ecosystem consists of government regulators, start ups, telecommunications companies, banks, financial service organizations, and fintech associations. Each of these organizations has a role to play in driving sector wide innovation, creating desirable products, negotiating partnerships, and creating sustainable infrastructure and regulatory pathways.

Sejal Mistry 27 Finance (see Figure 12), or as an intermediary platform between banks and individuals. Digital platforms also allow individuals to lend money via peer to peer payments technology securely and safely without requiring cash withdrawal or wire transfer service. Microfinance institutions provide short term loans that can be used in conjunction with microinsurance to cover a person’s out of pocket healthcare expenses while waiting for insurance reimbursement.

The Fintech Ecosystem

The maturity of the ecosystem, and in particular regulations on fintech and financial services, determines the speed at which Fintech for Health models can be launched and scaled to deliver impact. In response to the COVID 19 pandemic, a time of sudden loss of income and limits on movement, regulations in financial services around the world have changed rapidly to increase financial inclusion and life saving access to digital financial Theservices.fintech ecosystem prioritizes low income people who lack access to traditional financial institutions and services.

The Application of Fintech to Solve Patient Problems

Fintech for Health 28

In this section, we describe different but common health journeys in Asia and what a Fintech for Health approach may look like. These illustrative solutions are informed by our research on case studies and interviews, as well as the projects we are currently working on to forge partnerships between the fintech and healthcare sectors in the six countries studied.

Solving for Ibrahim: Reducing the out-of-pocket burden and increasing financial protection Though Malaysia boasts one of the strongest public health financing systems across middleincome countries in Southeast Asia, the out-of-pocket (OOP) costs of chronic disease management remain substantial for ordinary Malaysians like Ibrahim who has Type II Diabetes. With a low monthly income, Ibrahim finds OOP costs of tests, health visits, counseling sessions, and treatments related to diabetesrelated complications as a large financial burden. Nonetheless, Ibrahim can receive little to no cost services from nearby hospitals and clinics in Malaysia. A Fintech for Health

Sincealtogether.2020,

“Diabetes insurance” policies have emerged as a growing trend. Instead of excluding people with diabetes, these insurance packages protect diabetics against the costs of worsening illness. As an incentive, people who manage their condition well receive favorable premiums. For example, MSIG Gluco SafeGuard24 insurance in Malaysia has partnered with a health tech company to provide diabetes management support to patients healthier and lower claims by up to 40%).26 The insurance policy is also geared towards protecting those at risk, such as Ibrahim’s daughter, who recently discovered she is pre diabetic.

Rashida’s situation is not unique, nor is the exploration of teleconsultation for improved antenatal care. Throughout the region, public and private initiatives are focusing on upskilling workers through teleconsultations and telemedicine. Thanks to local teleconsultation, Rashida does not have to choose between expensive visits to the city or foregoing antenatal care

Access to Information (a2i), a program of the Government of Bangladesh that catalyzes citizen-friendly public service innovations by simplifying governance and bringing services closer to people, has been exploring the introduction of

Solving for Rashida: Delivering high-quality and affordable antenatal care virtually For her first pregnancy, Rashida saw a local midwife for basic check-ups and delivered her baby at the hospital. However, for her second child, she found out through her local community health worker that she is eligible not only for government financial support, but antenatal care delivered virtually, as depicted in an illustrative solution in Figure 8.

Sejal Mistry 29 approach would allow Ibrahim to manage both his condition and payments care not already covered.

teleconsultations for antenatal care. The program expands services otherwise inaccessible to women like Rashida. In 2017, the government of Bangladesh, in collaboration with the World Bank, launched a G2P cash assistance program, which is digitally paid every quarter, to support pregnant women.

Solving for Binh: Paying for the better option for health and reproductive needs In Vietnam, discussions between fintech and healthcare providers enabled through the Fintech for Health initiative, examine the use of digital lending and other fintech solutions to help women access the immediate financing required to pay the upfront costs of contraception by way of an installment-based repayment plan tailored to their financial situation. An illustrative solution among these partners is depicted in Figure 8. Solving for Xiaoming a young man unexpectedly diagnosed with lung cancer In China, access to cancer treatment reached a tipping point in 2018 with the release of “Dying to Survive,” a comedy film about a leukemia patient who smuggles cheap, counterfeit cancer medication. The unlikely box office hit set off a national debate about the dire choices people face in China when faced with catastrophic illnesses like cancer and the resulting financial calamity. In parallel with shifts in public sentiment, a rising tide of digital players providing insurtech solutions spawned a proliferation of innovative financing options.Fromproviding mutual aid to personalized insurance products catered to specific conditions, illnesses, and individual financial situations, these solutions are expanding the ability of ordinary Chinese to pay for care typically out of reach. In Figure 8, we look

Fintech for Health 30

Sejal Mistry 31 at the case of Xiaoming, who at 25, unexpectedly faces tough decisions about his cancer diagnosis. In 2020, there were 815,563 new cases of lung cancer in China, and 62 million people were at risk of getting lung cancer.27 For Xiaoming, and millions like him who are vulnerable to unexpected cancer diagnoses and high costs of treatment, new fintech solutions are emerging. To help them, mutual aid companies like Shuidihuzhu and insurtech companies like Meditrust are providing important options. Figure 8 lays out an illustrative path for Xiaoming to receive the care he needs. The problems faced by Rashida in Bangladesh, Xiaoming in China, Binh in Vietnam, and Ibrahim in Malaysia are multilayered, self-reinforcing, and complex. We aim to illustrate how a Fintech for Health approach could help address multiple healthcare access and financing challenges. It is tempting to seek out silver bullets and one-dimensional solutions, but until we recognize and build for the complexity of real life situations, we will fall short of providing true solutions to the problems they Asface.novel solutions emerge at the intersection of finance and healthcare, one pattern we have seen is that partnerships between healthcare, finance, and other ecosystems are vital. Very few actors can bring the full range of services required to meaningfully help patients along their healthcare journey. However, through the deliberate alignment of vision, incentives, and business models between stakeholders, we have seen that much can be achieved. These illustrations of solutions provided to our personas allow us to highlight several principles which are critical for the

With these principles in place, the Fintech for Health approach naturally lends itself to solutions that:

include:1.Designing solutions that encompass the entire lifecycle of the healthcare journey, rather than a specific point on the pathway.

1. Allow flexibility to mix and match and combine fintech, digital, and healthcare services to provide a bundled value proposition.

2. Address the unique needs of the individual and the environment he or she lives in. 3. Build for the masses while solving for the poor. Fintech for Health will not entirely overcome the challenges of rising healthcare costs and is not a replacement for universal health coverage. However, we recognize that people’s health cannot wait, and neither can their access to financing. By 2030, the deadline for the achievement of the Sustainable Development Goals (specifically SDG 3.8), millions in Asia will be

3. Providing a package that addresses the three main needs for a person’s care: the healthcare intervention, a way to pay for this care, and the information needed for the person to fully understand their situation and make informed decisions (e.g. education, literature).

Fintech for Health 32 success of the fintech for the health approach. These principles

2. Maintaining a patient-centric approach by valuing people’s behaviors, values, and habits are just as much as their healthcare and financing needs.

Sejal Mistry 33 diagnosed with cancer, diabetes, and other chronic diseases which will still pose a significant financial burden on low- and moderate income people. Multilateral development organizations such as the World Bank and the International Finance Corporation Alliance for Financial Inclusion have long studied and promoted financing innovations to spur societal development. The use of Fintech for Health solutions should be considered in the international toolbox of strategies to strengthen and reinforce universal health coverage

Theglobally.inspiration for new strategies lies not just with governments, but with entrepreneurs and communities. Fintech for Health is not a top-down, or governmental, approach to health financing. It fills the gaps in and between national programs, traditional private insurances, banking, and the health sectors. It represents the identification of societal needs and market opportunities and the way to provide solutions for everyday problems for ordinary people. When these ideas and opportunities are taken to scale, we have the opportunity to not just create solutions, but to have an impact. The impact we hope that Fintech for Health will achieve is to remove the burden of having to make the terrible choice between catastrophic health and catastrophic costs.

Notes from the field ore than documenting case studies and expounding on the theoretical potential of Fintech for Health, the F4H program was conceived with the goal of making a direct impact on the lives of low- and middle-income people in Bangladesh, China, Malaysia, India, Thailand, Nepal, and Vietnam. We examined problem statements of public health importance where financing (or the lack thereof) determined who received access to appropriate prevention, care, and treatment services and who was left behind. While Universal Health Coverage systems of tax based financing or social insurance played a critical role in providing financial protection against catastrophic healthcare costs, we observed that people in all the target countries still bore a significant degree of healthcare costs on their own. In the following notes from the field we examine where fintech for health can and has helped – where there is potential for these solutions, but has not yet been realized.

35 Bangladesh

Introduction Bangladesh is a country of 164.7 million people in South Asia, bordered by India, Nepal, and Pakistan. The capital city, Dhaka, is a thriving urban center that accounts for nearly 14% of the population. While ranking consistently on the lower end of global health systems development, Bangladesh has made significant strides in recent years. The infant mortality rate has decreased from 63.09 in 2000 to 25.4 in 2019, while maternal mortality has dropped from 434 deaths per 100,000 live births in 2000 to 173 deaths per 100,000 live births in 2017. In the following series of notes, Mr Tawfiq Hassan and Ms Nabila Khurshed evaluate the potential for fintech to improve access to healthcare in Bangladesh. Mass implementation of fintech often begins with the digitization of payments. In Bangladesh, the decades-long rise in mobile-based services, coupled with the more recent pandemic-driven push to move services to online platforms, has paved the way for cashless transactions in a heavily cash-based society. Two case studies, featuring the company Apon and Digital Health Solutions….. which offers affordable products and services for industrial workers in Bangladesh, illustrate the impact of specialized marketplace products on ready-made garment workers. As early as 2016, Digital Health Solutions (formerly Telenor Health) was a pioneer in integrating fintech and healthtech solutions with the “Tonic” program that provided affordable microinsurance and teleconsultations.

The move from cash to digital payments in the ready-made garment industry in Bangladesh has opened new doors in the digital ecosystem for low-income earners. The digitization of wages creates a multitude of opportunities, from empowering women to have more financial autonomy to enhancing the overall quality of life of workers and their families. It also lays the foundation for advancing financial inclusion for low- and moderate-income workers in Bangladesh. Bangladesh is the world’s second-largest apparel maker and seller, backed by a robust ready-made garment industry (RMG). For several years, many development programs have advocated for the digitization of RMG workers’ wages to further the financial inclusion agenda and gain credibility in the international market. Thanks to the persistent interest of international donors, buyers, and local DFS players, around 1.5 million workers received digital wages at the beginning of 2020. This was still less than half of the total RMG workforce (4.1

4. Digital Health Solutions providing low cost health insurance with bundled teleconsultation for Bangladeshi families Wage digitization for RMG workers: Advancing financial inclusion in Bangladesh

3. Apon Embedded insurance: meeting the healthcare needs of readymade garment workers

2. Mobile financial services in Bangladesh

Sejal Mistry 37 Topics 1. Wage digitization for RMG workers: Advancing financial inclusion in Bangladesh

Having access to financial services ensures a regular inflow of funds (salaries) into accounts. Many individuals’ wages have been digitized due to the central bank’s order. Since then, several healthcare organizations have reached out to collaborate with Bangladesh Garment Manufacturers and Exporters Association (BGMEA), the trade body that governs factories. Several of these healthcare players proactively seek partnerships with the RMG industry including Praava Health, Common Health, Maya, and Inspectorio. In a country like Bangladesh, the importance of

The journey to digital has been fast tracked by the COVID 19 pandemic as Bangladesh Bank ordered all factories to digitize wages in two weeks. By the end of April, 1.92 million new mobile financial services (MFS) wallets were created to receive factory wages. The move can be considered the most transformational one in Bangladesh’s digital financial inclusion narrative so far.

All major MFS providers in Bangladesh namely bKash,29 Rocket (DBBL),30 and Nagad31 were gearing up to onboard workers onto their platforms when the government imposed movement restrictions due to the COVID 19 pandemic.32 Additionally, they took up the challenge of ensuring liquidity at agent points. The regulator then enacted special cash out fees for RMG workers (0.4%, slashed down from 2%) so that accessing the funds does not become costly for them. Though banks are not part of this accelerated inclusion, some have already extended payroll services for RMG workers.

Fintech for Health 38 million). The Access to Information (a2i) program of the ICT division and Better than Cash Alliance (BTCA) had pledged that by 2021, 90% of RMG workers will be receiving salaries digitally.28

What does this mean for Fintech for Health?

Sejal Mistry 39 fintech and healthcare working together to solve health financing challenges cannot be overstated, as the public policy does not yet prioritize the agenda of Universal Health Coverage.

Currently, on-site medical services in most Bangladesh factories are inadequate, limited to basic screening and first aid. They are not robust enough to prevent and treat occupational health injuries. With so many occupational hazards and so few on-site services, workers fall victim to the health poverty trap, where poor health leads to poor productivity, leading the individual into a descent into poverty.

Historically, buyers and labor rights advocates have made it mandatory for factory owners to adopt safe labor practices, since protecting the long-term health of workers benefits all involved. Last year, Pragati Life Insurance piloted a health insurance model and found that positive health-seeking behaviors of the workers increased when they enrolled in the program. In addition, factory owners’ return on investment in workers’ health had a positive impact on workplace productivity and Improvingefficiency.financial inclusion for women is an important principle of Fintech for Health, as women are often the glue holding families together. Eighty percent of RMG sector workers in Bangladesh are women. Daily, they bear the physical and emotional burden of the around-the-clock labor needed to support their families, maintain their households, and care for their children. Ensuring affordable healthcare for these women will bring about manifold benefits most importantly, economic stability for the entire family.

There are ample opportunities to design innovative health financing solutions in Bangladesh. Though the COVID-19 pandemic has caused an economic slowdown, we must be prepared to act as the economy gears up in a post-COVID world. In addition to piloting health financing solutions, actors should consider bundling health services with other supports for workers’ wellbeing, such as retail and housing. Employee transaction histories can help in providing credit indexing that allows for immediate healthcare loans that can be paid back in manageable installments.

The well-being of workers in Bangladesh’s export-oriented industry has received major international attention during the past decade. Slowly but surely, the workers are benefitting from various interventions designed to improve their quality of life and ease their financial burdens. Access to digital technology, innovative financial solutions, health education, and financial literacy services will play a crucial role from here on out. Together through Fintech for Health, we can address these needs through patient centered, scalable, customized interventions that improve the quality of life for RMG workers in Bangladesh.

What are the opportunities?

The Government of Bangladesh, through the Ministry of Information and Communications Technology, supports the

Fintech for Health 40

Authors: Ms Nabila Khurshed, Independent Consultant, ACCESS Health International Mobile financial services in Bangladesh

implementation of Digital Bangladesh, also known as Vision 2021. Digital Bangladesh leverages technology to drive economic growth, measuring impact through indicators such as education, health, poverty reduction, and unemployment rates. For more than a decade, Bangladesh has made advancements in integrating technology across various sectors and streamlining good governance practices and affairs. One key ingredient for accelerating digital development is the country’s 171+ million cellphone subscribers, among them 112+ million internet subscribers.33 Services such as digital bill payments, online tax returns, academic institution registrations, digital health services, and online banking systems have allowed greater opportunities for financial inclusion and technology adoption. However, despite increasing reliance on newer technologies, a gap remains in digital literacy and access.

The push to digitize Bangladesh during COVID-19 Vision 2021 went into effect at the start of COVID-19 in order to rapidly digitize and utilize platforms, especially for vulnerable, underserved communities. Though mobile financial services (MFS) were already growing quickly in Bangladesh, the practice of using MFS to access and execute financial services was not broadly anchored across the nation. Throughout the COVID 19 pandemic, there has been an increased dependence on digital solutions focusing on user experiences in product and service design in order to adapt to the “new normal.” Further, there has been an increased adaptation to MFS due to the guidelines set and enforced by expert health agencies (e.g., the World Health Organization) recommending cashless transactions whenever possible to control the spread of COVID-19. The increased use of digital

Sejal Mistry 41

Having convenient access to financial services allows customers to keep money in their mobile wallets and send and receive money at any time, from anywhere, to anyone. During the pandemic, when people were encouraged or required to remain in their homes, MFS offered services beyond individual to individual money transfers. Communities now habitually buy groceries and other daily necessities online, often paying through mobile wallets. [JG comment: Using a collective wallet?]

Due to the convenience of paying MFS, from February to November 2020, utility bill payments nearly doubled from Tk 4.41 billion to Tk 8.31 billion. Additionally, the Government of Bangladesh provided direct cash support to 5 million COVID 19 affected families through four major MFS operators. The combination of fintech innovation, technological development, and increased access to mobile phones creates a range of opportunities for customers. Salaries are now disbursed through mobile wallets, most notably in the ready made garment (RMG) industry and for other unbanked populations such as informal workers. In July 2020, 87% of garment workers were brought under the digital wage system. However, in November 2020, digital wage payments dropped to 54% due to receded incentive of the government stimulus, lagging integration of digital wage systems in the factories, and lack of workers’ education and confidence about mobile

Fintech for Health 42 transactions as a form of financial inclusion has accelerated and strengthened the foundation of digital financial services globally. Bangladesh is no exception with MFS providers experiencing a tremendous upturn in the number of customers; from March 2020 to November 2020 alone, around 10 million clients were added, taking the number of registered clients now to 96.4 million.

Sejal Mistry 43 financing and banking. Donations are now more effectively distributed to marginalized communities and Zakat money is increasingly sent through MFS to various welfare foundations. The remittance, payments for government services, toll payments, credit card bill payments, insurance premiums, and payments for digital healthcare services, among others, are also taking place more often through digital platforms.

Currently, 15 banks in Bangladesh are providing MFS with over 1.03 million agents countrywide. The pioneering MFS operator, bKash, has been operating under the authority of Bangladesh Bank as a subsidiary of BRAC Bank Limited. bKash has brought in approximately 10 million new customers, bringing its total customer base to 50 million and daily transactions over Tk 10 billion. The popularity of the bKash platform is due to the diversity of services provided, such as sending or adding money, mobile recharge, cash out, payments, tickets, news, and partner offers with recent additions during the pandemic to cover donations and pay bills (e.g. utility bills, government fees, education, credit card, etc.).

Nagad, a joint venture launched in 2019 and operating under the Bangladesh Post Office, is the country’s fastest growing mobile financial service operator and currently serves over 2.5 million customers. Rocket, a mobile banking application by Dutch Bangla Bank Limited, is the third leading MFS operator in the country. With cooperation between central banks and government entities, Bangladesh has made tremendous progress in the MFS sector. In order for the spread of MFS to continue, regulatory environments must promote sandboxes and other mediums to test and implement guidelines and regulations that increase MFS opportunities and protect consumer interests.

Fintech for Health 44

The emergence of the mHealth Sector

digital health leaders are learning to better address the health and financing needs of the patients they serve. However, these companies still encounter many regulatory hurdles. For example, the companies providing digital health services fall under the Ministry of Health but may also need authorization by the Information and Communication Technology (ICT) division and other authorities depending on licenses obtained, whereas the financial services sector is regulated under the Ministry of Finance. The National Digital Health Strategy initiated in 2019 and recently revised in December 2020 provides guidelines for digital technology used to strengthen health systems. As the focus continues to be on digital health, the need for Fintech for Health partnerships is increasingly important. Future of MFS in Bangladesh The opportunities to leverage fintech to support health wallets are many. The modern digital healthcare experience has been shaped by MFS through continued usage of daily cashless experiences and refined user experiences, particularly in the

Digital health services were gaining traction before the pandemic, but it was quarantine measures that propelled their growth. Digital health leaders in Bangladesh include Digital Healthcare Solutions, Praava Health, and Maya Bangladesh, who are currently addressing challenges to healthcare access, affordability, and education. Digital health services have had innovative solutions that have been able to remotely diagnose, cloud-based monitoring of health systems, and rapid dissemination of information to patients and medical Throughprofessionals.keypartnerships,

Sejal Mistry 45 health sector for medical expenditures. In March 2021, patients used discount and special bundled offers through the partner health system Square Hospital, in the form of making payments for their healthcare packages. Payments are also accepted through digital transactions at United Hospital through Dutch Bangla Bank Limited. This is just the beginning of the Fintech for Health story in Bangladesh. Through further conversations between sectors, partnerships, and the continued evolution of payments and health behaviors, the future of MFS in healthcare will become all the more promising.

Authors: Mr Tawfiq Hasan, Senior Partnership Consultant, ACCESS Health International Southeast Asia Ms Munia Islam, Independent Consultant, ACCESS Health International

Fintech for Health 46 Apon Embedded insurance: meeting the healthcare needs of readymade garment workers Figure 13. Case study 4: Apon Wellbeing, a Specialized Marketplace for Workers

Sejal Mistry 47

Fintech for Health 48 Figure 14. Case study 5: Telenor Health, a Company that Provides Online Health Consultations, Advice, and Insurance

Sejal Mistry 49

50 China

2. Improving accessibility to integrated fintech for health solutions for aging populations in China

3. Fintech for Health: People with Chronic disease

Topics 1. Fintech for health in China: Growing Needs, Unique Opportunities

With the first largest population and the second largest economy in the world, China has spurred the growth of some of the world’s most innovative and widespread applications of fintech for health in the world. Of the six focus countries, China has the most well established fintech for health models, particularly in insurance and digital health integration. China’s digital growth was accelerated over the course of the COVID-19 pandemic when these applications were rapidly scaled as part of the country’s robust health systems response. Through a series of articles composed by ASK Health consultants Ms Yue Xu and Ms Tina Ja, we examine how the intersection of robust technology and supportive regulatory action allows innovative solutions to be brought to market and when successful and appropriate, disseminated at scale. Despite the steady growth and success of the Chinese market, we shed light on populations who have long been vulnerable to the costs of healthcare and how finance and technology solutions are mitigating the disproportionate burden.

Introduction

The rise of fintech in China has penetrated the health industry, particularly in health financing, posing unique opportunities for solving complex public health issues. To meet the growing demand for quality healthcare for an aging population, it will be crucial for China must consolidate its preliminary universal health coverage system by using fintech to further relieve people’s medical financial burden.

Since the launch of major healthcare reform in 2009, China has expanded social health insurance for all. The majority of the population is now covered by medical insurance. This insurance

The core layer: Basic medical insurance system

Fintech for Health 52

Health Finance in China: Medical Security System Overview

This layer includes government support and private donations, catering primarily to people living in extreme poverty and serving as a financial safety net for their basic medical needs. The accessibility of the medical assistance system has grown significantly since its nationwide establishment and implementation in 2008. In 2018, the system benefited a population of 120 million with an expenditure of 39.97 billion RMB.34

The bottom layer: Urban and rural medical assistance system

Fintech for health in China: Growing Needs, Unique Opportunities

China has implemented universal health coverage under a multilayered medical security system, which consists of three main layers.

Sejal Mistry 53 is mainly composed of basic medical insurance for urban residents, and the new type of rural cooperative medical care. The basic medical insurance system includes (1) the New Rural Cooperative Medical Scheme (NRCMS) plan, (2) Urban Resident Basic Health Insurance (URBMI) plan, and (3) Urban Employee Basic Medical Insurance (UEBMI) plan, with NRCMS and URBMI chiefly financed by government subsidies, and UEBMI co-funded by the government and employers. By the end of 2019, NRCMS and URBMI have merged into one unified resident medical insurance system for most regions in China.35 Critical disease insurance, a crucial part of the basic medical insurance scheme, was created to protect patients from a catastrophic financial burden. At least 50% of the medical reimbursement is provided for insured critical disease patients, and the reimbursement rate within the scope of critical disease insurance has gone up to 60% after URBMI merged with NRCMS. The private sector has also been encouraged to launch insurance products that cover critical diseases. More than one hundred kinds of critical disease insurance products have reached consumers, making it one of the most important health insurance categories on the market.

The supplementary layer: Private sector (Commercial health insurance and beyond) The private sector plays an essential role in filling funding gaps left by public health insurance. Currently, over one hundred insurance companies are offering around 5,000 commercial health insurance products in China. Innovative models such as mutual aid and charitable crowdfunding platforms have also flourished. Embedded in the digital ecosystem of apps/miniprograms, and bolstered by the immense active user base of WeChat, these models have spread virally, offering families a

Problem

Fintech for Health 54 more accessible and affordable way to gain necessary financial assistance. Statement: Existing Challenges

A research study conducted in Shandong province showed that as many as 52% of cancer patients experience some kind of

“On the one hand, the problem of uneven medical resource distribution persists. Many residents have to move across regions and provinces to obtain better medical services, which not only is time-consuming but also generates high costs in travel, accommodation, and other resources not directly related to health care; On the other hand, innovative treatments and drugs are not easy to obtain under the current Chinese medical system, and the supply chain cost is relatively high. These two aspects have led to high costs of obtaining medical services.”

Despite the progress of implementing universal health coverage, populations in rural areas and low socio income still struggle to access high quality healthcare. Three key challenges are: The high financial burden for patients with critical disease Death due to malignant tumors has become a major public health concern, accounting for 23.91% of total deaths in China and costing more than 220 billion RMB.36 Patients with critical diseases like cancer face grim challenges in receiving timely and affordable medical treatment, which is worsened by the uneven distribution of health resources and limited coverage of basic medical insurance in terms of innovative drugs.

ACCESS Health Partner from Ping’An Medical Insurance Technology

statistics of the State Council Poverty Alleviation Office in 2016, 42% of the total poverty-stricken households in China – more than 7 million people – became poor or were forced back into poverty due to illness. 38 A study on the health expenditures of end-of-life cancer patients in China revealed that the proportion of family income allocated to health expenditures and OOP expenses was twice as high for lowincome quintiles than for high-income quintiles.39

As a proportion of total health expenditures, out of pocket payments in China have declined dramatically from 59% in 2000 to 29% in 2017. But the effects of OOP payments remain significant at the individual level.41 Limitations on medication, type of medical services, health organization, and

Sejal Mistry 55 financial difficulties in seeking treatment related to cancer, out of which 10% have forgone some kind of treatment due to unaffordable medical costs.37

Under-privileged populations are more vulnerable to a medical financial Accordingburdentothe

The vicious cycle of poor health leading to poverty makes the underprivileged population especially vulnerable to a medical financial burden. Not only are they disproportionately prone to illnesses due to regional disparities in available health resources and preventive measures, but many of them also lack access to crucial financial protection services such as commercial health insurance. The CHI purchase ratio of people with an annual income below 10,000 yuan is only 14.2%, and high premium prices remain a major hurdle.40

Basic Medical Insurance Coverage remains insufficient in practice

Fintech for Health 56

The combination of the internet, technology, and insurance changed the landscape of commercial health insurance, making it much more accessible in everyday life. It provides highly accessible insurance services and can personalize protection schemes based on treatment fields and consumer types. Among the myriad of new insurance products, two types of products stand out: Inclusive insurance/Supplementary medical insurance

Potential Solutions: Thriving Fintech Trends

Fintech fundamentally transformed the lives of many in China. Some of these thriving fintech innovations show great potential in addressing the health financing issues analyzed above.

Insurance technology

reimbursement rates restrict the utilization and protective effect of basic medical insurance. For example, inpatient medical care requires 10 20% of OOP co payments under the two urban insurance schemes (UEBMI & URBMI) and can be as high as 35% for the rural plan (NRCMS), which imposes a substantial financial burden even on the insured population.42 Furthermore, basic medical insurance can only cover limited innovative drugs and treatments, preventing poorer households from accessing quality treatment in time and further driving up costs as advanced stage disease and complications set in.

This type of insurance is the product of collaboration between insurance companies and the government, with features including low premiums and relatively limited compensation. Low premiums result in easier entry and higher accessibility for most residents, with the aim to include as many residents in a city as possible.

Outcome-based insurance Outcome-based insurance is highly aligned with the new market trend of “value-based care,” which emphasizes quality of medical care over quantity. Outcome-based insurance based on drugs or medical devices is a model that links therapeutic effects to insurance compensation. Usually, medical device companies or pharmaceutical companies, and fintech companies jointly design products, which are underwritten by cooperative commercial insurance companies. In this model, after using drugs and medical devices bound to insurance items, insured patients will be paid if they fail to reach the pre established curative effect target within a certain treatment time.

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Many insurance companies are accelerating their development of technology. Insurance technologies include cloud computing, big data, artificial intelligence, the Internet of Things, blockchain, and other technologies. This will allow insurance companies to obtain greater promotion in product development, cost control, risk management, customer service, and so on. Chinese insurance giant Ping’An, for example, is deploying an AI risk management system backed by linked user databases to automate claim management. Taikang, on the other hand, is building an entire health cloud ecosystem to improve the patient experience, with data integrated from thousands of nursing homes, clinics, and hospitals.43 Mutual aid and crowdfunding platforms Mutual aid and crowdfunding are two models which have gained traction recently. Mutual aid refers to a large number of funds shared by designated members, while crowdfunding refers to fundraising initiated due to medical expenses that the individual or family cannot afford. Mutual aid platforms like Shuidi and

The fintech industry has transformed people’s lives in China with digital technology. The preliminary fintech solutions, such as supplementary medical insurance and mutual aid platforms, have shown initial success in providing residents with broader healthcare service coverage and financing channels. In the near future, we look forward to more fintech innovations, helping

Qingsong help people who lack access to or can’t afford commercial health insurance to meet their financial health needs, filling the funding gap between low incomes and high medical expenses. Mutual aid plans are low cost and easy to access via WeChat. If one participant on the plan becomes critically ill and needs help with medical care, everyone in the plan will share the cost equally. This model has achieved great success, particularly in underdeveloped areas. As of 2019, 80 million users have subscribed to the Shuidi Mutual Aid Plan. More than 70% are from third tier cities and rural areas.

Summary In the past few decades, the Chinese government has developed a multi layered medical security system that drives economic development by protecting the workforce from catastrophic spending and catastrophic health outcomes. The medical security system has also played a role in achieving universal health coverage in China. However, the economic development and improvement of living standards drive demand for healthcare services, and the growth rate of healthcare expenditure has far exceeded that of household income. These factors, along with demographic shifts brought on by an aging population and widespread urbanization, are posing major challenges to supplying and funding treatment to an already overburdened healthcare system.

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Sejal Mistry 59 solve health financing challenges, and developing the multilayered medical security system in China.

Author: Ms Yue Xu, Assistant Director for Strategic Partnership and Impact Programs, ASK Health

Improving accessibility to integrated fintech for health solutions for aging populations in China

China’s population has been aging rapidly over the last two decades. Swift economic development and improvements in healthcare have led to an increase in life expectancy and a decrease in mortality. The United Nations projects that there will be 366 million older Chinese adults by 2050 which represents an increase of adults aged 65 years and older from 12% of the population to an estimated 26%. An aging demographic shift on this scale is unprecedented and raises dire concerns about the health and well being of older adults in China. Furthermore, the elderly population in China is facing an increased chance of developing health issues. These include higher rates of depression, difficulty with activities of daily living, body pain, and Withhypertension.ariseinaging populations, combined with the onset of chronic diseases and other aging related illnesses, comes an increase in demand for medical care solutions, creating considerable challenges for the health system. The weight extends to families, as they are usually the primary source of caregiving for older adults in China. At the same time, China’s rapid economic growth and urbanization have also led to a growing number of young adults in China moving from rural to

Digital financial and health solutions

As a result, the need for accessible and affordable elder care and healthy aging solutions has become significant. This is especially critical for the elderly living at home with their adult children, as well as ones who live on their own. The need for solutions is observed not just in China, but across the globe, as the world is facing an accelerating aging society.

To address the rise in the need for healthcare solutions, emerging efforts and innovations have been observed through financial technology across various regions. Through fintechenabled healthcare solutions such as health management via telemedicine, digital payments for health services, and aging-inplace, the elderly population can access affordable healthcare services. The solutions ultimately allow them to receive appropriate care while remaining independent and feeling empowered to make their own health decisions. Shenzhen, an insurtech company based in China, focuses on offering solutions for the aging population. Its mission is to help older adults seek care, and empower younger adults to take care of their parents’ health. Its main aim is to provide fee-based health services such as customized medical check-up products and family health consultants for the middle-aged and elderly population.

Fintech for Health 60 urban areas for employment opportunities. The share of the population living in urban areas increased from 19% in 1980 to 60% in 2019. This trend has separated millions of older adults from their adult children, leaving many older family members alone, unattended, and uncared for. The growing prevalence of age-related health issues, if unmanaged, will result in an increased need for care and costly treatments.

Author: Ms Tina Ja, Director for Strategic Partnership and Impact Programs, ASK Health

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Utilizing its nationwide health service network, Shenzhen provides customized health management solutions and system operation support for enterprises. It offers third party administrative services to provide insurance companies with medical and behavioral data on middle aged and elderly customers and assess risk control measures to empower insurance product designs. It also offers risk reports for elderly policyholders and embeds more tailored and targeted health management services into insurance products. Ultimately, Shenzhen focuses on two parts, health management services, and insurance payments, establishing a closed loop of “customized medical examination health management health insurance”. Conclusion With the growing aging population, the need for solutions to enable early prevention, health management, and aging in place is imminent. Fintech-enabled healthcare solutions are becoming increasingly more integrated, accessible, and financially viable for the elderly, crossing regional and cultural barriers. Moreover, the solutions provide security, allowing elders to feel more independence, and at the same time, stay connected to their loved ones.

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Innovations in technology and its intersection with the financial sector have driven fintech growth into a global industry. Innovations such as mobile money, blockchain, and artificial intelligence within the financial sector have drastically improved convenience, inclusiveness, and access. The applications of fintech have steeped into various sectors, particularly healthcare. In earlier publications, the Fintech for Health China team focused on fintech empowering healthcare for healthy and underserved populations, including low-income, elderly, and patients with rare diseases. In this article, we hone in on the growing population living with chronic illness.

Fintech for Health: People with Chronic disease

As with many countries in Asia, where the aging population has caused a societal change, China has reached a tipping point where the burden of health conditions has transitioned from infectious diseases to chronic diseases. Research published in Frontiers in Public Health that focuses on chronic illness, and aging reports that almost 80% of deaths in China in people aged 60 years and above are from chronic diseases, with the most burdensome being Ischemic Heart Disease, Stroke, Chronic Obstructive Pulmonary Disease (COPD), and Type 2 Diabetes.44 Behavioral risks, including smoking, alcohol consumption, sedentary behavior, and poor dietary intake contribute significantly to these conditions. Chronic disease, if left unchecked, requires expensive and frequent treatments, increasing the financial burden for the patient. There is an increasing need for better management and treatment of chronic diseases, starting with prevention, early intervention, and monitoring.

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Fintech and health tech-based solutions have proven to help alleviate various healthcare management needs, particularly in chronic disease management, telemedicine, and purchasing drugs, as well as self management for maintaining independence and quality of life. The following are a few examples of chronic disease management solutions that arise from the integration of digital therapeutics (DTx), health management, and insurtech. Improving medical adherence for chronic diseases with digital therapeutics and InsurTech Miao Health, China and Wellthy Therapeutics, Singapore Miao Health is one of China’s largest digital health platforms that utilizes behavior data and artificial intelligence. It is a subsidiary of China Pacific Insurance Company, (CPIC), one of the largest insurance companies in China. With a digitalized health management platform, Miao Health uses artificial intelligence and big data to offer services that help manage health, provide medical treatment and medicine, alert users, and healthcare providers to potential future issues, and collect data to improve health risk assessments. The platform has incorporated over 7,000 scientific documents, that enable the recognition of more than 3,000 unusual indicators. It compiles guidance that helps users mitigate over 100 key risk factors, and sends pre emptive health alerts for over 1300 diseases. Since its launch in 2015, over 100 million users have registered for Miao Health.

Miao Health offers a series of solutions for both corporations and individuals. It works with insurance partners to build joint digital platforms, designing tailored solutions for different population groups. It also designs personalized group insurance for corporations, as well as offers health management services

Wellthy Therapeutics is a leading digital therapeutics company that operates in Mumbai and Singapore and caters to populations in Europe and Asia. Its mission is to bridge the gap of episodic care patient interactions only during physician visits or hospital stays and enable continual care for better health outcomes, by enabling digital care for complex clinical conditions. Wellthy collaborates with insurance partners, creating a tool that allows users to better engage and manage patients, improve health outcomes, providing value based care. This integration between Wellthy’s digital therapeutics solution and insurtech allows insurers to measure the risk behavior of the users more accurately by collecting patient data using wearable devices and sensors, and monitoring elements such as lifestyle habits, treatment receptiveness, and medical adherence. Studies have shown that therapeutic interventions mediated by artificial intelligence technology result in positive outcomes for patients and policyholders with chronic diseases. This combination further reduces the frequency and duration of hospitalization and minimizes claim costs for insurers who have partnered with digital therapeutics companies.

Building a Health Management Ecosystem – JD Health, China JD Health is an online pharmacy, medical appointment booking platform, and provider of telemedicine and other healthcare

Fintech for Health 64 for the employees. Lastly, Miao collaborates with pharmaceutical companies for better chronic disease management. Ultimately, through the combination of AI, online + offline service models, lifestyle management, and chronic disease medication purchases, Miao Health can offer a full range of health management solutions.

Sejal Mistry 65 services. It is a subsidiary company of JD.com, China’s secondbiggest e-commerce company following Alibaba. JD Health has launched its first health insurance product, “Family Doctor Insurance” which integrates health management services with insurance and relevant services, from claims settlement to disease management and prevention. This solution offers insured family members aged between 28 days to 70 years old full access to JD Health’s “Family Doctor” telemedicine services for timely health advice and management support. Patients’ medical expenses will be covered according to the insurance plans designed by JD Health and its insurance partners, such as Allianz JD and Fosun Health.

The Family Doctors team covers five main areas including internal medicine, surgery, gynecology, pediatrics, and traditional Chinese medicine with more expert support from 18 special medical centers which specialize in cardiovascular, psychosocial, diabetes, nephropathy, tumor related diseases, and more. Conclusion The intersection between fintech and health tech has become commonplace to broaden and bridge the accessibility and affordability gaps in health care Integrating fintech solutions can perfect this approach and improve patient health and quality of life. Fintech and health tech integration has allowed healthcare to become more personalized, by integrating insurance, medicine, and health management into a solution and those affected by chronic disease, to have a better sense of security and control over their wellbeing.

Fintech for Health 66 Author: Ms Tina Ja, Director for Strategic Partnership and Impact Programs, ASK Health Figure 15 Case study 6: Jianyibao, a Provider that Provides Disease Specific Insurance Plans and Medical Assurance Products

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Fintech for Health 68 Figure 16. Case study 7: Weibao, a provider that provides personalized insurance products

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70 India

Introduction With over 1.38 billion people, 19 states, and 2 union territories, India is arguably a federation of countries with unique and often vastly different linguistic, economic, and political contexts. In the context of healthcare, the state level differentiation is quite significant, as the Indian Constitution endows the states, rather than the central government, with the power to interpret and implement national health policies. In 2018, the government of India launched the Ayushman Bharat scheme, aimed at providing universal health coverage for the entire Indian population. While state level health financing schemes remain important, Ayushman Bharat is unique in that it is a unified initiative. In a series of articles by Sireesha Perabhatina and Prashanti Krishnakumar, we explain how the Ayushman Bharat digital mission aims to develop the technological backbone for integrated digital health infrastructure and create unique health identification for all individuals. A unique health ID allows Indian citizens to access and integrate core government services into their daily lives. Complementing public sector initiatives, the Indian private sector has made tremendous gains in digital penetration and innovation gains that can be leveraged by Fintech for Health. We look at the penetration of fintech and the uptake of digital wallets in India. An estimated 52% of the Indian population has adopted fintech solutions, compared to the global average of 33%. The financial inclusion of underbanked and unbanked individuals is an important step to help people access and pay for their healthcare expenses, known as out-ofpocket payments. With over 54.78% of all health expenditures in India paid by individuals, access to legitimate and ethical sources of financing and financial protection is critical.

2. Effect of Covid 19 on Healthcare affordability

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3. Digital wallets: the genesis, current usage, and future use healthcare payments in India

Another Fintech for Health partnership with Entitled, a platform that helps employees [ARM5] easily access financial products and services, saw the creation of the Sanjeevani health card for frontline allied health workers to provide a bundled financial package of pre approved health loans, microsavings, and accident coverage.

Topics 1. Ayushman Bharat Digital Mission

4. How Fintech for Health partnerships in India provide healthcare financing for cancer patients

We highlight the partnership between D-code and Arogya Finance that was brokered by ACCESS Health through the Fintech for Health Initiative. The combination of a doctor discovery platform to source affordable healthcare services for critical illnesses and a low interest medical loan is helping underbanked people reduce and mitigate their financial burdens.

Ayushman Bharat Digital Mission

What is the Ayushman Bharat Digital Mission (ABDM)?

The Government of India launched the Ayushman Bharat Digital Mission (ABDM) on 27th September 2021. ABDM is a flagship digital health initiative that aims to develop the technological backbone for an integrated digital infrastructure in the Indian health system. The government launched a pilot project of the ABDM in the six Union Territories of the country last year.

The vision of ABDM is to create a unified online platform for India that will provide easy access to treatment records and enable faster and more effective treatment. ABDM seeks to offer a wide range of data, information, and infrastructure services, based on open, interoperable, standards-based digital systems while ensuring the security, confidentiality, and privacy of health related personal information. The genesis of the program was the National Health Policy (NHP) 2017. NHP 2017 presented a vision of health and well being for all of all ages, emphasizing the need for a continuum of healthcare. Based on this policy directive, the government developed the National Digital Health Blueprint (NDHB), the guiding document that provides the architectural vision, guiding principles, and data standards to create an integrated digital health infrastructure for India. The ABDM is designed and deployed in alignment with the guiding principles of the Blueprint. What are the components of ABDM? Figure 17. The Components of ABDM

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The Health ID promises to reduce inefficiencies and improve clinical outcomes. Health professionals can access the entire digital medical record of their patients, better understand past health episodes and conditions, and design more effective treatment protocols. The Health ID will also be the reference for other stakeholders in the health system, such as diagnostic laboratories, insurance companies, and government-sponsored health insurance programs. The Healthcare Professionals Registry will bring all health staff, such as doctors, nurses, and paramedics, onto a single platform.

What are the implications of ABDM?

One of the critical components of the ABDM includes the creation of a unique health ID for every citizen. Personal health records are linked to the ID, creating a longitudinal health record for the person which can be viewed with the help of an application: the PHR. The creation of the health ID is voluntary, and the personal health record will comply with security and privacy principles. ABDM will also provide unique identifiers for all healthcare professionals and create a Healthcare Professionals Registry and a Health Facility Registry.

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The Health Facility Registry will be a database of all health facilities updated in real-time, which will bring further ease of

The Health ID will help citizens do away with cumbersome safekeeping and carrying paper based medical records while navigating the health system. Through the PHR, an individual can share prescriptions, diagnostics reports, and other medical history documents with healthcare providers, irrespective of where and when they were generated. In addition, as old records will not be lost but saved digitally, the patient can avoid needless duplication of tests and procedures.

Sejal Mistry 75 doing business for all health system stakeholders. ABDM will ensure interoperability and bring together the digital health solutions across all hospitals onto a single platform.

The ABDM will also impact the health financing sub-system of healthcare stakeholders, thereby providing timely access to affordable healthcare. In addition, the insurance industry will have valuable data for proper underwriting of policies. ABDM will also digitize the claims process, enable auto adjudication of claims, and reduce the time needed to provide reimbursement. In conclusion, the ABDM is an enabling digital framework for the entire healthcare system. The creation of health ID and record repositories is the early stage of a more extensive digital health transformation envisioned in a National Digital Health Ecosystem.

Consolidating a person’s medical record is an opportunity for telemedicine, preventive health and wellness, and other varied healthcare solutions to grow. While the individual will be the sole owner of their health record, anonymized and aggregated population level data will fuel advanced analytics, the use of biomarkers, and the development of preventive healthcare. The population data will aid geography and demography based monitoring, improve disease surveillance, and support evidence based policymaking.

Author: Ms Prashanthi Krishnakumar, Technical Specialist, ACCESS Health International

The Effect of Covid 19 on Healthcare Affordability

India is a large market for fintech to serve. The penetration of mobile networks across population segments has nearly doubled from 2015 (27% of the population) to 2020 (50% of the population). India also has the epidemiological bonus of youth constituting about 33% of the population in 2020.48 An unbanked population of 190 million adults presents a sizeable

Enablers for the growth of fintech in India

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The healthcare technology market in India is booming and is estimated to reach USD 21 billion in 2025. However, largely due to COVID 19, investments in Indian health tech dipped by 11%, from USD 512 million in 2019 to USD 455 million in 2020.45 Like the rest of the economy, the fintech industry has been affected by COVID-19. Lending-based firms have been especially affected due to the inability of customers to make timely repayments. Fintech still seems to be better positioned than most other startups. The findings from a FICCI IAN Survey of 250 startups in India showed that fintech reported the least operational disruptions from the pandemic.46 Digital wallets and other e payment options have seen a surge in their user base as digital shopping for essential commodities and increased preference for no contact deliveries led to a shift away from cash Thetransactions.national average adoption rate of fintech by Indians is 52%, which is higher than the 33% global average. The adoption rates are 66% in metros, 51% in tier II and III cities, and 33% in rural areas.47 As India comes out of the peak COVID 19 period, fintech is well poised to aid the economic recovery and support people’s ability to afford their health needs.

Fintech’s contributions to healthcare in India

Fintechs are addressing multiple healthcare affordability challenges in the country. Digital lending is possibly the most prolific space. Arogya Finance is a longstanding player, present in 70 cities across 14 states, providing loans exclusively for healthcare. Arogya Finance uses psychometric tools to assess

Sejal Mistry 77 market opportunity.49 The Reserve Bank of India (RBI) has a target for banking penetration set at 90% by 2021.50 The government’s push for financial inclusion helps digital lending platforms target previously underserved customer segments.

Small and Medium Enterprises have emerged as an important sector of the Indian economy, employing over 80 million people and contributing 8% to India’s Gross Domestic Product (GDP). However, they are often held back by the lack of credit support offered by traditional financial institutions. fintech promises solutions to the bottlenecks that are inherent in the traditional financial systems. The algorithms used by fintech also bring days of processing time taken by traditional institutions down to a few minutes, while the entire process is managed online. Many factors have created an enabling environment for the growth of fintech in recent years. Nonbanking payment institutions such as mobile wallets and payment banks have grown. Artificial Intelligence (AI), blockchain, and the Internet of Things (IoT) have brought greater innovation and security to financial transactions.51 The RBI has taken progressive policies for providing loans to fintech. A host of government initiatives also enable technology based offerings, including identity formalization through the Aadhaar card, the Digital India initiative, the United Payments Interface (UPI), and the National Digital Health Mission (NDHM).52

ImpactGuru and Ketto are two leading crowdfunding platforms for health needs that allow users to start their fundraisers within minutes. Impact Guru, founded in 2015, leverages the power of WhatsApp and Facebook for mobilizing funds. With the tagline, ‘Why Wait for a Medical Loan? ImpactGuru Can Raise Funds,’ this firm has helped raise over USD 200 million through its platform and global partners and helped more than 10,000 patients directly and over 100,000 through its nonprofit partners.58

Fintech for Health 78 the creditworthiness and interest rate of unbanked borrowers.53

The loans are processed within 3 to 48 hours and pay for medical bills in partner healthcare facilities. Arogya Finance also issues preapproved health cards.

Credihealth sanctions small ticket-size loans of 30,000 to 50,000 rupees within 24 hours. CareCover loan cards allow users to secure instant cash for medical emergencies. Their zero percent interest rate EMO option also covers pre existing illnesses that are usually not covered under private health insurance.54 Firms like MyShubhLife and Paisa Dukan use machine learning to determine credit worthiness and provide a set of offerings including medical loans.55,56,57

ImpactGuru was awarded the Winner for Best Use of Technology to Drive/Execute CSR Initiative in Digital Social and Economic Empowerment by the Internet and Mobile Association of India in Marketplaces2021.for health related insurance are helping users easily understand, compare, and access products that traditionally took longer to enroll. A major player in the insurance marketplace is Policy Bazaar. The platform showcases a range of insurance products, including health insurance policies, and provides an end to end solution to tracking policies

Fintech supporting Government initiatives in India

The Digital India initiative by the Government of India has snowballed a set of efforts for financial inclusion in the country. Easy banking facilities for all through the Pradhan Mantri Jan Dhan Yojana, simplification of procedures relating to financial instruments, unique identification process of Aadhaar, and simplification of tax procedures through the goods and services tax (GST) are some significant measures.61 The proliferation of fintech options like easy loans has aided the government’s dream of financial inclusion.

Another recent program, the Pradhan Mantri Street Vendor's AtmaNirbhar Nidhi (PM SVANidhi), launched in June 2020, aims to provide collateral free working capital loans to street vendors. Under the program, 3 million loans have been approved, of which only 1.1 million loans have been disbursed. This exposes a wide efficiency in the program that can be addressed by fintech. MAKSPay has developed an application that helps street vendors easily enroll for the program and avail of the loan in a record time of 15 minutes, compared to the 30 days required for the traditional route. The app has important features, like the pooling of data from the applicant’s multiple IDs to auto-populate the application, and options for daily autorepayment in affordable amounts such as Rs 50 or Rs 100 instead of a single monthly payment option.

Sejal Mistry 79 and claims assistance. Over 100 million visitors use the website annually and the company recorded nearly a million sales transactions monthly. In 2020, PolicyBazaar accounted for about 32% of life and retail health insurance policies in India.59 Saveo

Healthtech is an e commerce marketplace for pharmacies that aims to organize and aggregate the retail pharmacy market.60

Alongside the development of futuristic products, fintech should partner with the government to promote financial literacy and awareness among the people. 2021 is a landmark year as the world is getting vaccinated for COVID 19 and recovering the losses to both the economy and the health and morale of the people. Fintech has a great role to play overall, and specifically in improving healthcare affordability in India.

Fintech for Health 80 In the health space, the Government launched the National Digital Health Mission in August 2020. The program has proposed to create a health ID for every citizen to access a federated Personal Health Record or repository of all health related data and a registry of doctors and health facilities. NDHM has fashioned a Sandbox environment that enables the testing of new products and technologies for a defined period to ultimately ensure the successful deployment of tested products in the market. Healthcare service providers, hospitals, healthcare software vendors, and anyone who wants to build NDHM APIs (application programming interface) can access the Sandbox.62

Fintech can avail the opportunity of such government initiatives to build products for bringing access, affordability, and quality within reach of all Indians. Limited financial literacy is a key factor for the slow rate of financial inclusion in the country.63

Author: Ms Prashanthi Krishnakumar, Technical Specialist, ACCESS Health International

What are digital wallets?

A digital wallet or e-wallet is software that enables users to make payments electronically, using a computer or mobile device.66 Digital wallets are primarily accessed through mobile applications and have improved safety and convenience in transactions as one need not carry cash, debit, or credit cards to make payments. In financial terms, digital wallets are a form of Prepaid Payment Instrument (PPI), which facilitates the purchase of goods and services, including the transfer of funds, against the value available on the PPI. The value available refers to the amount paid for by the user through cash, from a bank account, credit card, or other PPIs.67 PPI options for digital payments have been around in India since 2002, but their use was restricted to gift cards, forex cards, meal reimbursements, etc. However, the introduction of digital wallets has led to the country's surge in digital payments in prepaid instruments.68 Oxigen wallet is the first ever e wallet in

Globally, the digital wallet market size was valued at USD 1,043.1 billion in 2019 and is projected to reach about USD 7,580 billion by 2027, growing at a Compounded Annual Growth Rate (CAGR) of 28.2% from 2020 to 2027.64 In 2019, India had 73.9 million people using digital wallets. The estimated value of mobile transactions in 2020 across India was INR 36.5 trillion, equivalent to USD 4.9 trillion. The value is expected to more than triple by 2024.65 The increased penetration of the internet and smartphones and targeted government initiatives have spurred growth in digital payments in India.

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Digital wallets: the genesis, current usage, and future use of healthcare payments in India

 Closed wallets - issued by a company to a user to buy goods and services exclusively from that company. Examples are Amazon Pay and Ola Money.71

 Open wallets include all features offered by semi closed wallets and can also be used to withdraw money from ATMs. This type of wallet is issued only by banks, which have partnered with other banks.72

 Semi-closed wallets users can transact with listed merchants and stores through online and offline payments. Examples are Paytm and Airtel Money.

How are digital wallets facilitating healthcare payments in India? The evolution of digital wallets has made health finance easy, informative, and comprehensive. The COVID-19 pandemic has prompted many industries to re-evaluate their operations Especially in the health sector, digital wallets allow patients to self-manage their medical expenses and access vital information. 73 An international example is M-TIBA, a digital wallet by PharmAccess and Safaricom that facilitates inclusive healthcare in Kenya. It is a three-way platform that connects patients, healthcare providers, and healthcare payers. It enables the

Fintech for Health 82 India, launched in July 2004. In 2006, the media firm Times Group, in association with YES Bank, introduced Wallet365.com.69 But, the use of digital wallets really picked up pace after the launch of Mobikwik in 2009. In addition, Paytm, Google Pay, PhonePe, Amazon Pay, and Airtel Money have captured the country's digital wallet market in recent years.70

There are three types of digital wallets

Online booking and payment for diagnostic tests saw a 60 to 70% increase in tier 1 cities since the COVID 19 outbreak.75

Every kind of healthcare product and service provider in India today has a mobile wallet option. We can see this with online consultation providers such as Practo and Lybrate, Apollo 247, or online pharmacies like Netmeds, MedPlus, and PharmEasy.

Sejal Mistry 83 exchange of money and data between these three parties, allowing financing within the healthcare sector.74

Diagnostics providers also provide the option to transact through digital wallets. Digital wallets have also been used to purchase other healthcare products and essentials, from masks to health insurance policies. Thus, digital wallets have enabled fast, convenient, and secure payments for healthcare in India. What is the future of digital wallets?

Future trends in mobile wallets are the enhancement of loyalty rewards, security and simplicity, artificial intelligence, and cryptocurrency. 76 Companies that have investments in mobile wallets have been devising ways to expand their reach in rural areas, which could significantly impact development across India. The government also has encouraged private and public partnerships to increase the volume of mobile wallet transactions 77 In May this year, the Reserve Bank of India issued a regulatory guideline for all PPIs, including digital wallets, to become interoperable by April 2022. Interoperability removes the limitation of using the amount in one wallet only on expenses made through the same wallet. Users can send money from one mobile wallet to various other wallet brands and withdraw cash from point-of-sale machines. 78, 79

Fintech for Health 84 Other digital payment modalities have also disrupted the financial payments landscape in India. Possibly the largest is the Unified Payments Interface (UPI). In Quarter 1 of 2021, around 1.13 billion transactions were made through mobile wallets, while UPI based payments numbered around 2.3 billion. The value of the transactions was about INR 411.75 billion for mobile wallets and crossed INR 5 trillion for UPI.80

Author: Ms Prashanthi Krishnakumar, Technical Specialist, ACCESS Health International How Fintech for Health partnerships in India provide healthcare financing for cancer patients

While supporting a family of four his wife, child, and widowed mother Raman barely makes ends meet each month. He has already spent $544 out of pocket for preliminary diagnostics to determine his mother’s cancer status. He is told the rest of her tests will cost between USD 270 and USD 350. The treatment, which includes surgery to remove a tumor found in her right breast, will cost around USD 4,762. Raman has basic insurance coverage from his employer for himself, his wife, and his child, but his mother remains uncovered. The treatment in a public hospital would be less expensive, but public hospitals are overcrowded with a waitlist of 6 to 8 weeks for cancer surgery. In addition to this, government hospitals often lack the specialized infrastructure

Raman anxiously awaits his mother’s test results at one of the leading private hospitals in Bangalore. Working as a clerk for a small commercial business, Raman earns USD 476 per month.

Additionally, treatment for about 40% of cancer hospitalization cases is financed mainly through loans, the sale of assets, and contributions from friends and family.83 In essence, having a cancer patient in your family in India can mean a lifetime of a physical, emotional, and financial burden for the whole family. Raman not only faces a financial challenge but also the difficulty of navigating the complex healthcare system. Fighting against time, he struggles to find high quality care for his mother that is also affordable. Tired and frustrated, Raman searches the internet for support options for cancer patients and finds DCode DCodeCare.

helpless. Without the right financing solution, he might lose his mother to cancer. This is the story of many in India, where breast cancer is the most common cancer. Every 4 minutes one woman is diagnosed with breast cancer and every 13 minutes, one woman dies of breast cancer. A typical cancer patient spends over USD 50081 in a public hospital on medical treatment alone, half the average annual income of $1,029 per person.82 In a private hospital, out of pocket spending for inpatient care is about four times that of public hospitals.

Sejal Mistry 85 required for cancer diagnosis and treatment, leaving patients to turn to private diagnostic facilities that operate at market prices. The social insurance scheme launched in 2018, Pradhan Mantri Jan Arogya Yojana (PM JAY), covers the poorest section of society, but Raman and his family do not meet the eligibility Ramancriteria.feels

Care is a discovery platform for critical illness patients looking for the right treatment at the best price.84 More specifically, it assists cancer patients in finding suitable doctors and hospitals and helps them negotiate price points for the latest

Fintech for Health 86 treatments. Raman leaves a message on the DCode platform and soon receives a return call from the team. They connect Raman to an oncologist working at a 60 bed private hospital with rates substantially lower than the health system where Raman’s mother was previously being cared for. The cache of hospitals onboarded by DCode includes smaller, private hospitals with qualified oncologists, where they outsource most of their diagnostics, keeping in house prices for surgery and clinical treatments low. The final test Ramen’s mother needs costs less than $81 through this facility, which is less than half the cost charged by the previous hospital. However, Raman’s mother still requires expensive surgery, to the tune of about $3,000. The Dcode Care team intervenes at the request of Raman and helps him negotiate the surgery cost down to $2,450. After spending on the diagnostics, Raman still needs $1,088 for the surgery. Believing he is left with no other choice, Raman decides to sell his mother and wife’s gold jewelry. Before partnering with Fintech for Health, the DCode Care team could do little to support Raman at this juncture. But now they collaborate with Arogya Finance agents. Arogya Finance is a non banking financial institution providing loans to meet the healthcare needs of the lower income population.85 Arogya Finance and DCode Care together assist in navigating the healthcare system, negotiating medical bills, and accessing financing for healthcare services. DCode Care introduces Raman to an Arogya Finance team member. Arogya Finance’s supportive network of partners works together to back loans for the patient or their families. Through the use of alternative credit scoring tools, Ramen is deemed eligible for a 0% interest loan for the remaining amount needed for his mother’s tests, her surgery, and all postoperative and rehabilitation out of pocket

Sejal Mistry 87 expenses. Raman’s mother was treated successfully and is now recovering well. The success of Raman’s medical and financial journey through the healthcare system was made possible by Fintech for Health, a project run by ACCESS Health International and Metlife Foundation which aims to create partnerships that broker accessible, affordable healthcare financing options for low- and moderate income populations in Asia. Under Fintech for Health, we aim to guide partners to collaborate in this way and support many other Ramans in their healthcare journeys.86

Authors: Dr Monica Mittal, ACCESS Health International

How Fintech for Health partnerships Improve Access to Affordable Healthcare For Hospital Workers in India Amogha is a nurse at the CARE Cardiac Center at Durgabhai Deshmukh Hospital. She is cheerful, kind, empathetic, and wellliked by all her patients. However, what her patients do not realize is that Amogha is responsible for family members with multiple illnesses and experiences much of the same pain and stress. Unable to continue paying for her family’s health expenses, Amogha believes she is out of options. This is the case for many frontline healthcare workers in India. Six hundred million Indians almost half the country's population are categorized as middle-class. The lower middleclass lives on $2-$4 per person per day while the upper-middle class lives on $6-10 per person per day.87 Many lower-middleincome workers are unaware of and have limited access to suitable health financing options. As more Indians move from

Fintech for Health 88 the lower to the middle class, it is even more important for them to have options to save and pay for their healthcare services, as even just one unexpected health event can plunge them back into the cycle of poverty.

Entitled88 aims to enable access to financial services for more than 34 million workers in India. Entitled partners with factory and industry employers to provide access to emergency funds, rewards, discounts on healthcare and daily essentials, savings programs, and counseling for their employees. Entitled’s B2B2C model allows them to reduce risk and lower the distribution cost, opening up the opportunity to reach a large, underserved base of workers, a segment of the population that typically does not have reserve funds for health emergencies. In April 2021, Entitled, in partnership with ACCESS Health International, launched the Entitled Sanjeevani health card for the employees of the CARE Cardiac Center at Durgabhai Deshmukh Hospital in Hyderabad. The Sanjeevani health card is a bundled financing product for lower to middle income employees and is customized to the income level and choice of the staff. The health card offers a combination of pre approved health loans, micro savings, and accident coverage. The Sanjeevani card has a host of useful features for employees and is available at zero cost to the employee and the employer. The card entitles them to a pre-approved credit limit of up to twice their monthly salary for health and wellness expenditures which can be used for all family members. The credit limit of up to INR 7,500 (~ USD 103) for out of pocket expenses such as pharmacy bills, lab tests, and up to INR 50,000 (~ USD 685) for hospitalization expenses. The loan comes at a flat interest rate of

Entitled also dedicates one local staff to regularly visit the hospital to educate employees and easily clarify issues with enrollment or availing benefits through the Sanjeevani card. Through the Fintech for Health program, ACCESS Health supported Entitled to identify a willing healthcare provider, co designed features and limits suited to the provider, and communicate regularly with staff at CARE to address their questions and receive feedback. Through this partnership, ACCESS Health facilitated Entitled’s foray into serving the healthcare worker segment, thereby supporting nurses, security guards, and housekeeping personnel. ACCESS Health continues to work with Entitled, connecting them to more healthcare partners such as clinics and health device manufacturers so more low and middle income healthcare workers can benefit from this bundled financing product. Amogha now has easy access to an emergency health fund and her family has term life insurance of INR 100000 (USD 1370)

Sejal Mistry 89 1.75% per month and a flexible repayment structure ranging from 3-12 months, through a digital EMI option. The employee can avail of telemedicine services and discounts of up to 30% on out-of-pocket expenses on medicines and diagnostics at a monthly membership of INR 99 (~USD 1). Addon options include term life insurance and hospital cash plans. In the beginning stages of the project, the most well-received feature has been the micro saving option, offering the flexibility to save for health during certain months of the year and the option to withdraw instantly in case of a health emergency. The users will have access to an emergency fund by investing as low as INR 200 (~USD 3) in a liquid mutual fund plan, which is a low risk plan with an average annualized return of around 6%.

Author: Ms Prashanthi Krishnakumar, Technical Specialist, ACCESS Health International

Fintech for Health 90 within just two months of receiving the Sanjeevani card. The collaboration between Entitled and CARE Cardiac Center was made possible through Fintech for Health.

91 Malaysia

Introduction Over the last five decades, Malaysia has enjoyed a steady increase in economic growth and social development and is projected to become a high income country in the next 5 to 8 years. In the Southeast Asia region, Malaysia has one of the strongest health systems, having long provided universal health coverage for all Malaysians with access to quality and affordable health However,services.inthe context of rising medical inflation, chronic diseases, and aging and migrant populations, current health financing measures are straining to maintain the balance of high quality and affordable healthcare for all people. The Malaysian government has enacted a series of measures to address the growing demand for more costly and chronic health services and to mitigate the burden of chronic diseases on the average household.InMalaysia, almost 38% of healthcare payments are out of pocket.89 This means Malaysians spend an average of RM1700 per person paying out of pocket for their healthcare services in 2017 alone. This can be extremely taxing, especially for those in the B40 (bottom 40th percentile) income group and even M40 (41st percentile to 80th percentile) income group. Apart from that, only 22% of Malaysians own medical insurance.90 Hence it is not surprising to know that a series of initiatives were launched by the government of Malaysia to target the B40 and M40 populations. At the federal level, PeKa B40 has been established to help B40 Malaysians to get access to medical devices.91 This initiative also intends to increase healthcare screening among this population. Furthermore, it even provides a transport incentive and

Sejal Mistry 93 treatment completion incentive for the B40 Malaysians to increase their adherence to healthcare treatments. Similar incentives have also been established by various state governments to help the B40 individuals in their states such as the Peduli Sihat scheme which was developed by the state of Selangor.92 This similar strategy of allocating funding for preventive and primary care has been widely employed in other countries93 and is seen as an important strategy to minimize patients ending up in hospitals for much more expensive Despitetreatments.94these strategies, much more still needs to be done to help Malaysians, especially the B40 and M40 Malaysians. In this series of articles, consultant Dr. Nasir Ismail, explains how fintech for health can support the financial burden of healthcare costs when public sector resources are not enough. He highlights a new concept that the Fintech for Health program is exploring the use of investment vehicles to save (with stronger returns) on healthcare expenses. A case study on Merchantrade Asia, one of the largest homegrown remittance providers in Malaysia, also details the role the company is playing in providing financial protection to the B40 and migrant populations. Topics 1. M40 Households: The forgotten group in Malaysian healthcare financing 2. Investing for health? Time to change the paradigm in Malaysia 3. The rising out of pocket healthcare expenditures in Malaysia; opportunities for collaboration between fintech companies and the healthcare sector don’

using their income to pay for the rising healthcare costs in Malaysia and only 22% of Malaysians who purchase health insurance, healthcare costs will be a major burden for those in the M40 group. This is especially true given that 48% of M40 households received their outpatient healthcare services in private healthcare settings in 2019. This is compared to 30% among the B40s and 62% among the T20s.

M40 Households: The forgotten group in Malaysian healthcare financing

The income classification “M40” refers to Malaysians who make RM 4850 to RM 10,959 (USD 1,170-2,635) per month and are the group that benefits least from government health financing programs.

Fintech for Health 94 4. Fintech Should Be Used to Increase Cancer Screening

While those in the B40 group (i.e., those earning at the bottom 40% of household incomes) receive government support such as PEKA B40 which funds surgeries and medical equipment, or MySalam which provides limited healthcare insurance coverage, Malaysians in the M40 group are excluded. In states such as Selangor and Terengganu, M40 households are also excluded from subsidized healthcare programs such as Peduli Sihat, causing them to rely heavily on their income to pay for

Withhealthcare.81%ofMalaysians

A third of these M40 Malaysians were admitted to private hospitals compared to 15% among the B40s and two thirds of T20 Malaysians (those earning in the top 20% of household incomes). This means M40 Malaysians are seeking healthcare outside of public healthcare facilities, ultimately paying out of pocket for these services.

One solution is to divide the M40 group into three categories lower, middle, and upper based on their household income thresholds. National healthcare programs should be expanded to reach this segment of the population. For example, MySalam insurance could be provided at a higher, but still affordable, premium than for the B40s. With incomes not much higher than the B40 income groups, wider coverage would allow the lower M40 segment more options in accessing affordable healthcare Fintechservices.can also be used to provide additional safety nets for the M40 group. For example, insurance products customized to the needs of this group could be offered on Malaysian insurtech since 43% of Malaysians cannot afford to purchase health insurance, providing additional avenues for them to seek out affordable health insurance could solve this major barrier. Even in the United States of America, rising insurance premiums and deductibles are putting tremendous pressure on middle class Americans so this issue is not uniquely limited to Malaysia. Additionally, the government of Malaysia could provide expanded tax credits to help M40 Malaysians to cover their healthcare insurance premiums and deductibles. In addition to these expanded programs, awareness needs to be raised about the importance of owning healthcare insurance. The percentage of monthly household incomes spent on healthcare had risen to 5.1% in 2019 so it is crucial for more Malaysians, especially those who are seeking care in private hospitals, to own health insurance. With almost half of M40 Malaysians utilizing private hospitals, health insurance is increasingly important. Currently, topics on health insurance have been incorporated as part of the national curriculum. But much more could

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Tosubsidies.ensure

Fintech for Health 96 be done to educate M40s on the importance of owning health insurance. In the last two years, the COVID-19 pandemic was said to heighten the awareness of the need of having health insurance providing the much needed fertile ground to plant awareness of the need for owning health insurance in middle income However,populations.healthinsurance is not the only solution, and buying health insurance in Malaysia is still difficult. The current rules do not allow Malaysians to buy health insurance if they have a pre existing condition, excluding many Malaysians in the M40 group. Additionally, the age limit imposed by some health insurance companies means M40 Malaysians would only have health insurance as a safety net until a certain age. In the United States of America, the Affordability Care Act has tried to reduce one of these limitations by removing the exclusion based on pre existing conditions. Similarly, the government of Malaysia should play an active role in expanding health insurance coverage for M40 Malaysians with pre existing conditions by deploying regulatory interventions or providing financial they avoid debt from medical expenses, safety nets in the form of government subsidies and affordable private insurance plans must be made available for this group. National healthcare programs should expand to include middle income Malaysians who also experience the heavy burden of out of pocket healthcare expenses.

Authors: Dr Mohd. Nasir bin Mohd. Ismail, PhD, Independent Consultant, ACCESS Health International

Investing for health? Time to change the paradigm in Malaysia

The personal costs of healthcare have caused many Malaysians severe financial problems, and in some cases even led to bankruptcy. In 2017, Malaysians paid RM21.5 billion or 38% of the total amount of healthcare expenditures in out of pocket payments. It is projected that by 2027, this will rise to RM55 billion. Through the Fintech for Health program, we are exploring how investing money in diverse products created by fintech companies will brace the Malaysian people for rising out of-pocket payments and alleviate financial hardship. First, we must address the possible risks involved when paying for healthcare costs through investment. With investment comes risk, and with risk, there is always fear that individuals might lose some, if not all, of their healthcare savings. Investing is often seen as a long term strategy and as such, can be considered unsuitable for short term withdrawals to pay for healthcare costs. If healthcare costs rise unexpectedly, investors must quickly turn their investment into cash flow. Given the potential risks, one might question whether it would be wise to use this strategy of investing to help pay for rising healthcare costs, especially for out-of-pocket payments. I advocate that it is a practical and wise decision to invest money in fintech companies to pay for out of pocket healthcare costs. Comparable to investing for retirement and education, it should be a cultural practice in every society. In Malaysia, the presence

Sejal Mistry 97

Investing in healthcare is about changing a paradigm. With the emergence of fintech companies, Malaysian investors now have access to the latest technology to minimize investment risk, earn returns, and prepare for rising out of pocket payments. This is a powerful alternative to what Malaysians have had in the past.

Fintech for Health 98 of universal healthcare and access to private medical insurance products might prevent Malaysians from embracing the culture of saving and investing in healthcare. This is why introducing a new culture of investing is crucial in preparing Malaysians for the expected rise in healthcare costs in years to come.

Changing Paradigm and democratizing investments

It is imperative to recognize that investing in healthcare should not be seen as a T20 (top 20% of Malaysian household income earners) strategy alone. Fintech companies are actually democratizing investment through the use of robo advisory or algorithms and minimum fees. Now more than ever, the B40 (bottom 40% of Malaysian household income earners) and the M40 (middle 40% of Malaysians household income earners) can register and invest their money in fintech products. Investment in healthcare is no longer a strategy exclusive to the wealthy. It has become viable for all strata of society. Fintech companies can encompass the full range of needs required by investors, by allowing investors to adjust the level of risk they are willing to take. This means investors could opt for minimum risk to invest their money to pay for shorter term healthcare costs. As all investments involve risk, the ability to tailor risk level is one of the great benefits of using fintech companies’ products. Investors using the robo advisory app can easily adjust the level of risk they are willing to take for their investment.

The Benefits of Investing for Healthcare

Sejal Mistry 99

Secondly, investing in healthcare can be a mid-term investment strategy for healthcare plans such as a pregnancy or dental braces, as well as a long-term investment strategy for aging individuals, in parallel with investing in retirement. While it is true that many healthcare costs can be unexpected, many elective and non-urgent surgeries and treatments still need individuals to have access to financial resources.

Thirdly, individuals who are currently putting their money into savings for future healthcare costs take no risks and do not allow their money to work for them. While this may be a safe bet for some individuals, the inflation of healthcare costs will surpass the value of their savings. As savings generate little to no interest, they are unable to keep up with inflation and would consequently demand an increasing amount of money to be put aside, ultimately forcing individuals to allocate a larger percentage of their income to healthcare savings.

In the long term, using savings for healthcare costs is not sustainable.

This is where investing can play a big role, since putting money into viable investment products allows individuals to catch up to, or at least keep up with, the inflation of healthcare costs. In this way, investing in healthcare is a crucial strategy to beat inflation. For example, the medical

The major benefit of investing in healthcare is the availability of a personal fund to pay for healthcare costs. The possession of this fund will help Malaysians access and afford healthcare without fear of debt. Malaysians with investment funds will now be able to access healthcare screenings and prevention in private healthcare centers, in turn lessening the burden of public healthcare facilities.

Fintech for Health 100 inflation rate in Malaysia is reaching 14% per year, while investing in robo-advisor would provide an interest rate of 3 to 10%, thus allowing the investors’ money to grow alongside the rate of inflation and ultimately helping to fight rising healthcare

Individuals will now have enough time to liquidate their investment and turn it into cash flow, as robo advisory companies offer easily accessible rapid transition to liquidity via their app. For some robo advisory companies, the transition from investment to cash can take place in fewer than 7 business days. The ease and speed of transition make it even more appealing to utilize investments to pay for healthcare costs.

Lastly, the fear of liquidity is no longer an issue as the movement toward cashless healthcare in Malaysia means that individuals can pay for their healthcare using credit cards or small loans.

Ascosts.healthcare costs are predicted to increase by seven-fold in 20 years’ time, it is increasingly important to help Malaysians prepare for any healthcare payments by capitalizing on these investment products. Take a normal delivery for a pregnancy as an example. By 2040 the price tag could rise to RM42,000. Likewise, the healthcare costs for a knee replacement are projected to rise from RM18,000 to RM121,000. This means an investor who is preparing him or herself for a knee replacement surgery in 2040 might need to save RM18000 in 2020 and keep saving RM300 per month for 20 years with 3% return on investment to be able to afford their knee replacement surgery. If the risk is increased to 6%, that investor would only need to put aside RM160 per month for the coming 20 years, a dramatic decrease. Therefore, the risk level determines the amount needed to be invested each month.

Investing in fintech companies to prepare for any-and-all healthcare costs can be an important strategy to fight the rising out of pocket payments seen in Malaysia.

Author: Dr Mohd. Nasir bin Mohd. Ismail, PhD, Independent Consultant, ACCESS Health International

The rising out-of-pocket healthcare expenditures in Malaysia; opportunities for collaboration between fintech companies and the healthcare sector Malaysia provides universal health coverage for its citizens. Despite this, the private healthcare sector is growing rapidly, with 49% of total healthcare expenditure in Malaysia spent in the private sector in 2017 alone.95 Malaysians often utilize private healthcare services to receive curative or diagnostic treatments96 or when there are long wait times97 to receive healthcare treatments from public facilities. Appointment slots, especially those for specialty services, are frequently booked six months out, prompting Malaysians to use private clinics, often at their own expense. Out of this situation, a dual tiered healthcare system has emerged in Malaysia, with an astonishing 77% of healthcare expenditure in the private sector coming from out of pocket payments. Out of pocket (OOP) payments are defined as payments paid by patients or their family members that are not reimbursable by third parties. In 2017, OOP health expenditure in Malaysia was RM21.5 billion, or 38% of the total health expenditure. The graph below shows the trend of out of pocket payments in Malaysia from 1997 to 2017. OOP payments have grown at the

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Putrajaya: Malaysia National Health Accounts Section. (p. 87). Why Should Fintech be Interested in Healthcare?

Fintech for Health 102 rate of 10% every year and if this trend continues, total OOP expenditure is projected to reach RM55 billion by 2027. Figure 18. OOP Health Payments in Malaysian Ringgit

Fintech organizations can play a bigger role in solving the OOP payment crisis in Malaysia, employing technology to make financial transactions faster, easier, affordable, and efficient.

Fintech is a relatively new concept for many in the Malaysian healthcare system but as interest grows, it has the potential to address many healthcare challenges through health savings accounts, point-of-care lending, crowdfunding, and innovative insurance plans. By bringing together fintech companies and healthcare institutions, Fintech for Health aims to define the many opportunities for addressing high OOP costs in Malaysia.

Source: Ministry of Health Malaysia. (2019). Malaysia National Health Accounts: Health Expenditure Report 1997 2017.

Additionally, Malaysia strives to be a key player in medical tourism, aiming to generate up to USD 675 million through their healthcare sector alone and up to USD 2.5 billion in total revenue through medical tourism.104 The majority of medical tourists coming into Malaysia are from Indonesia, presenting the need to ensure fast and smooth financial transactions between these Fintechcountries.can also play an important role in addressing the rising OOP payments incurred by the 80% of Malaysian households who are in the B40 (bottom 40th of household income) and M40 (middle 41st to 80th of household income) groups. Together these groups represent almost 6 million households in Malaysia.105

The 3 million household members in the B40 group earn from below poverty level income to RM4849 per month, whereas the other 3 million household members in the M40 group earn from RM4850 and up to RM11000 in household income per month. Additionally, there are 2.2 million documented migrant workers currently not covered for their outpatient care.106 The B40, M40, and documented migrant workers pay OOP to receive treatment in private hospitals, clinics, pharmacies, dentists, and other alternative healthcare

Sejal Mistry 103 These collaborations are crucial as Malaysia aims to be a cashless society.98 With 70% of Malaysians99 supporting this cashless initiative, public hospitals in Malaysia have a goal to be completely cashless by the end of 2021.100 Given this, financial payment technology would have access to 145 public hospitals, 994 health clinics, 1,800 community clinics, 91 child and maternal clinics, 3,421 Malaysian government clinics, and 240 private hospitals in Malaysia.101,102 In other words, fintech companies would have access to almost RM128 billion worth of healthcare transactions by 2027.103

The Opportunities

As Malaysia embarks on a mission to create a completely cashless society, there are many opportunities for fintech and healthcare organizations to team up. 60% of Malaysians now own smartphones, providing an excellent foundation for creating a digital payments ecosystem in the country.107 In this ecosystem, there are many opportunities for innovative financing solutions such as lending, crowdfunding, investments, and insurance models that aim to address high OOP payments in Malaysia.

Lending Malaysians in the B40 and M40 groups experience barriers in seeking healthcare treatment in private centers because they lack the immediate financial resources needed to pay for the fees. Point of care lending solutions can provide immediate, affordable, and targeted loans to those struggling to pay up front costs at private facilities. These loans would improve this population’s access to the private healthcare sector and outpatient clinics, avoiding the long wait times and discontinuity in care experienced at public facilities. Opening up the private healthcare system to the wider population also lessens the burden on the public system. One opportunity for fintech companies includes the chance to build customer lending profiles using historical financial transactions to determine creditworthiness. This could then be used by patients or their

Fintech for Health 104 facilities. The “bottom of the pyramid” carries much of the burden of OOP payments, with the B40 group paying RM1 to RM5 to see a doctor at public hospitals, despite the coverage from social insurance plans.

Sejal Mistry 105 family members to acquire funds to pay for other OOP payments or necessities.

Crowdfunding Crowdfunding is another innovative financing model that can address high OOP payments. Typically, the P2P model is used as the crowdfunding source in Malaysia. This platform could be used to help Malaysians pay healthcare expenses quickly as the funds come from multiple individuals at the same time.108

Raising the funds can be rapid or slow, allowing users the flexibility to use the funding according to the treatment they need. Health Savings Until now, many Malaysians have not had much incentive to save for their OOP or catastrophic healthcare costs. In the B40 and M40 groups, saving is even rarer and often not financially feasible. Simple digital health savings accounts (HSA), whether linked to one’s bank account or in the form of a digital wallet for the under or non-banked, provide Malaysians a way to set aside money each month for their healthcare payments. These accounts allow Malaysians to put in small or varying sums of money each month to save for healthcare costs. Future opportunities for fintech companies lie in the area of incentivizing saving through products and services that bolster the HSAs and through programs that make it easier for Malaysians to pull from these accounts for healthcare services as soon as it is needed. In the future, Fintech for Health projects in Malaysia will delve more into conversations about what can be done to make these HSAs more attractive and saving for healthcare services easier for B40 and M40 populations.

Additionally, the lack of affordable, customized healthcare insurance products for recent graduates means young graduates are dependent on poor quality public health facilities or are forced to pay OOP in private healthcare facilities. These curated insurance products might help to further reduce the OPP payments, improve access to care for Malaysians and reduce the burden on public health facilities. The opportunities for fintech and healthcare to come together to create solutions to the high OOP payments in Malaysia are vast. With the market open and eager to find innovative solutions,

Fintech for Health 106 Insurance Fintech companies could also play a role in creating curated insurance products that are affordable for large segments of the population. Affordability has been cited by 43% of Malaysians as the reason why they did not have healthcare insurance.109 Currently, only 22% of Malaysians are covered by personal health insurance.110 Through designing and offering innovative insurance models, fintech companies could customize insurance products and packages for young married couples, women, recent graduates, retired elderly, or students in higher learning institutions, among others.

Currently, fintech companies are designing these insurance products from healthcare insurance companies without specifically targeting populations that might benefit from them the most. For example, one-fifth of all birth deliveries in Malaysia, or about 100,000 deliveries take place in private healthcare facilities every year; however, there are no curated insurance products that target newly married couples or pregnant couples leading to Malaysians spending from RM300 million to RM600 million in OOP payments for birth deliveries.111

Sejal Mistry 107 now is the right time to hold these conversations. The key is identifying the best, most effective solutions for the B40 and M40 populations in Malaysia who experience the worst outcomes due to high OOP payments.

Author: Dr Mohd. Nasir bin Mohd. Ismail, PhD, Independent Consultant, ACCESS Health International Fintech can be used to increase cancer screenings Fintech, or financial technology, can and should be used to increase the prevalence of cancer screenings among the Malaysian population. In Malaysia, the government has been proactive and forwardthinking when it comes to pushing for the adoption and expansion of fintech products among Malaysians. The ePenjana cashless payment initiative is just one way the government has expedited the adoption of digital wallets among Malaysians. The cashless initiative benefited up to 15 million Malaysians who are now using a multitude of e wallet platforms.

In addition to making payments easier for a larger segment of the population, digital wallet platforms act as a conduit between the government and its citizens. Qualified Malaysians can download stimulus money by entering their unique national identity card into their smartphones. This eliminates the need for Malaysians to queue in government offices or crowded post offices to receive benefits and stimulus packages. The success of ePenjana is an example of how fintech platforms can have an extremely wide reach among Malaysians, begging

Fintech for Health 108 the question: how can fintech be adapted for the healthcare sector as a tool to increase cancer screenings? Through fintech platforms, the government of Malaysia can disburse cancer screening vouchers/credits quickly and effectively to increase the number of cancer screenings performed, as well as to help cover the personal costs incurred for such procedures.

One effective tool and cost efficient for colon cancer screening is the Fecal Occult Blood Test (FOBT), which has been shown to reduce colon cancer mortality by up to 16%. This screening method is quite affordable, costing between RM20 and RM30. The government of Malaysia, or any other interested state governments and non governmental bodies, could use fintech platforms to distribute the RM20 to RM30 needed for the cancer screenings. Malaysians can download the vouchers/credits and

Colon cancer screenings specifically are extremely important for the Malaysian population, as it is the second leading cause of death for those with cancer in Malaysia and is most common among males. Over 3500 Malaysians were diagnosed with colon cancer in 2018 alone, with most diagnosed in the later stages of cancer. Roughly 64% of Malaysians with colon cancer were diagnosed during stages III and IV. In a recent survey, only 3% of Malaysians have gone through colon cancer screening and it was identified as a direct barrier to reducing colon cancer mortality. Furthermore, colon cancer treatments are very costly and can range from RM13000 for stage I, to RM30000 for stage IV. The 5 year survival rate of Malaysians with colon cancer recently dropped from 79% in stage I to 19% in stage IV. It is abundantly clear that colon cancer screening is important not only to save lives but to reduce the burden of healthcare costs for both the patients and the public healthcare system.

As demonstrated, the fintech platform can be a very powerful tool to prompt and encourage the behavioral change that is needed to increase cancer screenings among the general population. The impact it can have should not stop at colon cancer screenings but be expanded to increase the prevalence of breast cancer and prostate cancer screenings, among others. Fintech, as the latest innovation in financial technology, should be considered a highly powerful solution in our fight against cancer.

Authors: Dr Mohd. Nasir bin Mohd. Ismail, PhD, Independent Consultant, ACCESS Health International

Sejal Mistry 109 pay for colon cancer screenings in public and private healthcare Throughsettings. this system, colon cancer screenings would be made available to the general population, and as a result, colon cancer would be identified at an earlier stage. This will not only save lives but also reduce healthcare costs.

In addition, the same fintech platforms that house e-wallets could be further utilized to raise awareness about colon cancer and the importance of colon cancer screening, while also being used for the disbursement of vouchers and credits. In this way, Malaysians who download the vouchers and credits could then become a positive example to their friends and family members to take part in colon cancer screenings.

Fintech for Health 110 Figure 19. Case study 8. Merchantrade which provides remittance services, teleconsultations, e pharmacy, and insurance

Sejal Mistry 111

112 Nepal

Inpeople.1132015,to

resolve its geographical hurdles, its government transformed into a three-level federal government: a federal level, seven provinces and 753 local governments.114 It has since achieved improvements of overall health: the human development index value increased to 0.602 in 2019, mortality rate during childbirth decreased to 186 out of 100,000 in 2017, mortality under the age of 5 decreased to 32.2 per 1,000 live births in 2018, and life expectancu rose to 71.5 in 2018.115,116,117

Nepal, a landlocked country home to the world’s highest mountains and rugged terrain, has long faced geographical hurdles in accessing goods and services, including healthcare. Its diverse topographical and sociological state results in periodic epidemics of infectious diseases, epizootics and natural hazards such as floods, forest fires, landslides, and earthquakes.112

Currently, majority of its healthcare expenditure is from domestic private health providers, 63.28%,118 but out-of-pocket expenses remain a large portion of it, 57.91%.119 Its health expenditure is only 4.45% of its GDP.120

Around 22% of Nepalis do not have access to basic health facilities, and only 61.8% have access to health care within a 30minute radius. This is partly caused by a shortage of human resources for health with only 0.67 doctors and nurses per 1,000

Compared to the other countries in the Fintech for Health program, Nepal’s digital and fintech environments are still nascent. Its room and potential for growth, given the ability of digital technologies to transcend geographical barriers, should not be underestimated.

113

Introduction

Fintech for Health 114

Topics 1. Nepal’s journey towards cashless transactions

Nepal’s journey towards cashless transactions

How it Started In the last decade, Nepal has made great strides toward implementing digital banking services. Historically a country whose citizens are most comfortable using cash, the move to paperless digital transactions is now a reality. With an internet penetration rate of over 72%121 most of which can be attributed to internet use on mobile phones the willingness and ability to use digital banking services is higher than ever.

In this section, consultant Ms Anushruti Adhikari describes how Nepal is laying the basic infrastructure to move towards digital payments in a society where cash has long dominated. To understand the context and opportunities for fintech in Nepal, consultant Ananda Raj Khanal takes a deep dive into Nepal’s policy landscape in the following in depth report.

The year 2002 saw Nepal’s first e banking services, followed soon by SMS banking services accessible on mobile phones in 2004. Despite slow moving and often restrictive government regulations, there are now over 8 million mobile banking customers in Nepal.122 The jump from digital banking to habitually using digital transactions has been painfully slow. Again, near sighted government regulations, such as policies forcing a low maximum limit for daily and monthly digital transactions, hindered the growth of digital payments in many sectors. In addition to this, these services often only reach the young, urban population,

Sejal Mistry 115 leaving those in rural areas with little to no options for digital banking and payments.

How it’s Going Digital payments and banking companies have only in the last fifteen years emerged to become key players in Nepal’s developing payments market. Launched in 2009 by fintech startup F1 Soft, the mobile wallet eSewa123 aims to “simplify payments, promote digital payments and expand financial inclusion for Nepalese people.”124 Its license in 2017 from the country’s central bank, Nepal Rastra Bank, paves the way for other banking services companies. The platform is simple and easy, with users making payments either online through the app or SMS or a registered eSewa agent. Other companies such as Khalti125 and FonePay126 have followed the same pathway to integration, presenting more opportunities for Fintech for Health partnerships in Nepal. Digital Nepal Framework One of the biggest barriers to digital payment companies has always been low adoption rates, especially in rural areas. There is a general lack of trust due to recent data breaches and individual digital literacy remains low. To address these concerns and implement consistent national policies, Nepal has created the 2019 Digital Nepal Framework.127 This framework is designed to enable Nepal to harness its growth potential by leveraging disruptive technologies and driving socioeconomic growth. The framework identifies eight key sectors among them healthcare on which government resources and focus will be placed to unlock innovative digital solutions to address growing challenges.

Fintech for Health 116 National Payment Gateway

The ongoing pandemic shines a light on the necessity of digitization. Hit particularly hard by COVID 19, the Nepalese people have adapted to better function in our new normal by using more digital services. Both rural and urban citizens now use digital wallets for more than just ticketing and online payments, with wallets now seen as the safest method of paying for groceries, courier services, electricity bills, and ridesharing. Since the start of the pandemic, eSewa has seen a 35% increase in users, bringing its entire user base to 3.5 million people.130

Another mobile wallet, IME Pay,131 saw a growth of 25% between March and August 2020, with more than 60% of these new users coming from semi-urban and rural parts of Nepal.

The Impact of COVID-19

The framework also serves as an overall roadmap for making government-related, and in time all payments, cashless in the near future. With the reins handed over to Nepal Rastra Bank (NRB), the implementation of the national payments system is slow-going and wrought with bureaucratic struggles.128 However, the information technology infrastructure has already been put into place and at least five major banks will be linked to the system. In addition, Nepal Clearing House has recently created ConnectIPS129 to enable government-related payments as well as funds transfers. While a national system is still in the works and its reach to remote areas is expected to be poor, stakeholder engagement and buy in are high and implementation of a national gateway is now in sight.

Opportunities Presenting Amid the Pandemic

As seen in many countries, digital payments have proven to be a safe and easy way to transact when it comes to paying for everyday items and services. As a result of the pandemic, the ease of using these platforms has quickly improved in Nepal. For example, surcharges were dropped for use of ATMs, Real Time Gross Settlement Services, ConnectIPS, and e-banking and mobile banking services. In addition, NRB has increased transaction limits for daily and monthly mobile transfers in an effort to minimize health risks and make digital transactions a more normal way of life for the Nepali people. Stakeholders should capitalize on these changes which should remain in place even after the pandemic.

Authors: Ms Anushruti Adhikari, Nepal Institute for Policy Research

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Ms Valerie Shelly, ACCESS Health International

Looking to the Future In Nepal, we are just now discovering the many opportunities for Fintech for Health. In a country still defining the parameters of digital banking and payments, the possibilities for healthcare entities to collaborate with fintech toward the goal of equitable, affordable, accessible healthcare for all can now be realized. As the pandemic subsides, we can see where when time, energy, focus, and finances are put to work necessary and effective advances can be made to make healthcare more accessible and affordable. In alignment with Digital Nepal Framework and with the promise of a National Payment Gateway, we hope Fintech for Health moves forward in Nepal with eagerness and excitement.

118 Vietnam

119

Fintech-based solutions in Vietnam can bridge the growing gap in access to treatment, which requires continuous or complicated care. The fintech sector is growing rapidly. In a nation of over 90 million people, over 67% have access to a mobile phone and around 19.2 million held a digital wallet.133,134

Introduction In the last three decades, the rate of economic growth in Vietnam has been one of the most remarkable in Southeast Asia Between 2002 and 2021, per capita GDP rose 3.6 fold, and poverty (<USD 2k/day) dropped to below 2% for nearly a third of the population. During this time, Vietnam also made significant strides in healthcare with infant mortality dropping from 22 per 1000 live births in 2002 to 17 in 2020 and life expectancy increasing from 73 in 2002 to 75 years in 2020. The government of Vietnam had also committed to Universal Health Coverage in 2014 with approximately 91% of the population covered by social health insurance.132 Like many of its other Southeast Asia counterparts, Vietnam is experiencing a significant rise in chronic diseases due to increased life expectancy as well as lifestyle changes. The significant demand for healthcare resources is also contributing to the rise in healthcare costs in line with the trend seen worldwide.

A robust digital environment provides a strong basis for bringing fintech to improve access, convenience, affordability, and quality in Vietnam. In an article by independent consultant Nguyen Kieu An, we look at the importance of digital transformation and cashless payments as an enabling factor for accessing healthcare. In our multiple attempts to bring fintech solutions to healthcare problems in Vietnam, we realized that the regulatory landscape has been one of the most critical factors in their uptake, speed,

Fintech for Health 120 and penetration. To understand the context and opportunities in Vietnam, we also commissioned Vriens and Partners, a government advisory think tank, to take a deep dive into Vietnam’s policy landscape and potential in an in depth report. Topics1. Vietnam’s growing fintech industry: The opportunities for meaningful partnerships with healthcare

5. Vietnam’s Healthtech Market 6. Policy Landscape

In May 2020, a video of a crying Vietnamese woman went viral. She was trembling tearfully, repeatedly thanking a man next to her. She had lost a bundle of cash sent from relatives to pay for her mother’s dialysis treatments and the young man had found the packet and returned it to her. Unknown to him, this small act of kindness likely allowed the woman to avoid months and perhaps years of financial hardship. Among the many advances Vietnam has faced in the last two decades, the relatively rapid shift from cash based to digital payments is one of the most recent. Though the government mandate was already in place, COVID 19 has propelled the

Vietnam’s growing fintech industry: The opportunities for meaningful partnerships with healthcare Escaping a cash-only culture

2. Challenges and Opportunities for Fintech for Health in Vietnam 3. Introduction and Market Context 4. Vietnam’s Fintech Market

Sejal Mistry 121 process forward, creating the foundation for a vast digital ecosystem for Vietnamese consumers. With much of the infrastructure in place, where does healthcare fit in and how can we capitalize on this progress by creating innovative fintech solutions for low and moderate income people?

There is no doubt that investing in “critical digital infrastructures like information systems, connectivity, cybersecurity, and tools to collect and analyze data are fundamental to a digitally enabled system,” a fact the Vietnam government knows well.135 Building on the National Financial Inclusion Strategy, The State Bank of Vietnam (SBV) governor highlighted non cash payments, digital banking, and green banking as the top three priorities for the industry from now until 2025. The country has also loosened regulatory restrictions around cashless payments and built up the technological infrastructure needed to create an ideal digital payment ecosystem. A plan for extending these services to small businesses and those in rural areas are now also in view.

In the last few years, Vietnam witnessed a surge in funding for fintech companies and startups, ranking second in terms of the total investment for fintech in the region, with much of these investments going to payments companies. The number of fintech startups in Vietnam grew by more than 179% between 2017 and 2020 with the payments sector representing 31% of all fintech startups. In addition, the total value of digital transactions in Vietnam increased 124% in the first quarter of 2020 compared to 2019. Building on the digital foundation In healthcare, a strong digital payments ecosystem can serve as a first step to unlocking new pathways for access to financial

Fintech for Health 122 services for people who have traditionally been left out (the unbanked and underbanked). These populations are particularly vulnerable to the shocks of healthcare costs that are not sufficiently covered by social insurance (e.g. innovative medicines for cancer care). Outside of social insurance, most do not hold private insurance and do not have sufficient savings for a major health illness or event. This is a problem in a country, such as Vietnam, where out of pocket spending for health services remains high (41% of total health expenditure). In addition, about a third of the population borrows money including for healthcare needs from unofficial lenders who impose high interest rates, making it next to impossible for low to moderate income people to pay back these loans.

The Vietnamese government, in an effort to address these issues, has made it a priority to digitally enable all healthcare systems in the country. According to SBV, more than 30 hospitals have introduced systems for electronic hospital fee payment. However, it is worth noting that this number has not changed since 2019, and the national goal of digitizing 50% of the hospitals in major cities by 2019 has not been reached. There have been many obstacles to implementation such as low rates of adoption and buy in, connectivity troubles with banking software, and communication and compatibility issues between intermediary services and hospital information systems. Further regulatory advances such as considering integrating the national ID system to sign up for digital banking services instead of requiring in person signatures should also be considered. In addition, these services should be extended to rural areas and the benefits of adopting the cashless system are adequately explained to businesses and consumers with low digital literacy.

The opportunities With this changing digital culture, what are the opportunities for fintech and healthcare to come together to address high out-ofpocket payments? A good place to start is by utilizing Vietnam’s growing digital infrastructure to develop new tools that provide access to financial services to underbanked and informal sector workers to help address their health needs. For example, can a fintech-enabled health savings accounts help a person set aside small amounts of money that can be put specifically towards these Second,costs?what unique partnerships need to be made that integrate health and fintech services? Last year, MoMo and Viet Duc University Hospital signed an agreement to integrate MoMo’s payments platform onto the hospital’s payments system, allowing users to pay for their outpatient and inpatient healthcare services via the app’s e-wallet. By going cashless, Viet Duc aims to reduce wait times, simplify processes, and altogether eliminate the need for cash. Momo’s e-wallet users are ubiquitous and collaborations such as this one can allow even the unbanked to easily pay for their healthcare needs when and where they want. Finally, in addition to payments, we look at how services like insurtech (such as Papaya), peer-to-peer lending, health savings accounts, and crowdfunding (like Betado) can take advantage of this movement towards digitization in hospitals. Can they extend the health system’s digital reach into rural areas and have a positive impact on out of pocket spending? The Fintech for Health program is exploring these opportunities.

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The road ahead The progress made in 2020 uncovers how much ground there is still yet to cover in the area of fintech for health. Within one lifetime, an emerging economy is shifting from a cash-based society to taking a multi-sectoral, whole-of-government approach to implementing widespread digital payments. Through an increasingly digital Vietnam, we have an opportunity to leverage innovations in finance to create healthcare solutions. Partnerships between healthcare and fintech can help the country achieve its goal of more accessible, affordable healthcare for those who need it most.

Authors: Ms Nguyen Kieu An, Independent Consultant, ACCESS Health International Challenges and Opportunities for Fintech for Health in IntroductionVietnam and Market Context

Framing fintech for health in Vietnam

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Over the past two decades, Vietnam’s economy has grown rapidly, averaging 6.18%136 annually, placing it among the most dynamic economies in Southeast Asia and the Asia Pacific region more generally. The population also remains relatively young, with the 16 30 age group accounting for 25% of the population,137 but the country is entering the final decade of its demographic ‘golden period’. Despite the ongoing potential for demographics based growth, it is increasingly necessary for Vietnam to position itself now for sustainable growth once its demographic advantages end. If Vietnam fails to do so, it risks

Sejal Mistry 125 getting ‘stuck’ in its current lower-middle-income status or expected middle-income status. The government has focused on further industrial development as the way out of this predicament, seeking to leverage a technological revolution to achieve ‘Industry 4.0’: an economy both technologically advanced and industrial. Such an economy requires investment and development in both technological capacity and industrial base. For the latter, industrial zones have grown rapidly in recent years and continued manufacturing expansion & development are among the Government’s highest priorities. For the former, Vietnam is becoming a tech hub and investment darling, but there remain many questions on whether its policy environment will enable sustained tech development. Across tech subsectors, policy and regulation are in a nascent stage compared to more developed regional peers, progress on the development of a policy ecosystem has been slow and cautious, and there is a continued risk of restrictive policies taking root.

Vietnam’s focus on the industry also presents a particular set of healthcare challenges, reflective of gender and of industrial employment itself. These will evolve and be exacerbated as the country’s populations get wealthier and older, driving expanded non communicative disease burdens. While many of Vietnam’s industry workers are resident near their employers, there is a huge number of laborers migrating from other localities across Vietnam to work and reside in factory areas. Migrant industrial workers face a range of challenges in accessing social services, with healthcare presenting a particular challenge, especially for women.

Fintech for Health 126 From a gender perspective, of the approximately 3.83 million workers who are recorded as directly employed in the country’s industrial zones (the real number is likely higher)138, around 60% are women.139 For these workers, access to reproductive healthcare services in industrial zones is a growing problem. Existing sexual and reproductive healthcare services, including contraception, mostly target married couples (industrial workers are less likely to be married) while income and access challenges also prevent women from being able to work near a healthcare facility. A further complication is the hộ khẩu (household registration book) and national health plan systems which states that one shall receive less insurance reimbursement when using healthcare services out of their registered place of origin. Accessibility to high quality healthcare is further limited as even patients with access to public health services have higher medical costs when they visit a top level hospital without referral documents from medical institutions of a lower tier140. Given that many women working for factories in industrial zones are migrant laborers who earn around USD 250 to USD 350 per month on average141, private sector care is not an option.

Separately, rapid industrialization and urbanization in Vietnam in the past few decades have driven major changes to both the environment and human behavior. Deteriorating air and water pollution, combined with sedentary lifestyles and evolving diets toward higher calories, has made non communicable diseases (“NCDs”) emerge as the biggest cause of death in Vietnam, accounting for roughly 70% of all illnesses. 142 As Vietnam’s population is forecast to continue aging in the next decades, the challenges presented by NCDs will only grow.

A fast growing, investment attracting sector

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In this context, innovation in healthcare accessibility and affordability is sorely needed. Though Vietnam has a public healthcare system that provides widespread access and a national health insurance program designed to provide affordable services, these structures are already straining to deliver the healthcare people need. As industrial workforces grow and demand better healthcare, as the burden of NCDs expands, and as more and more Vietnamese citizens gain access to financial services, there is a clear opportunity to leverage innovative financial tools to support access to healthcare. Against this backdrop, a key question is whether the Vietnamese Government is able to design a policy and regulatory framework that enables effective collaboration between fintech solutions and affordable health services.

Vietnam’s digital economy has boomed in recent years. Alongside the growth of social media platforms, online platforms for the purchase of goods and services quickly emerged. While previously inaccessible, Vietnam’s high internet usage rates now provide merchants with a large customer base. The result was a rapid rise in digital commerce and accompanying clarity that Vietnam’s historic reliance on cash transactions was not sufficient. Thus, technology solutions that facilitate swift and convenient payments on such platforms started to emerge in Vietnam, including homegrown startups such as Momo, Moca, and VNPay. That also explains why the first regulations that laid out a legal framework for the fintech sector in Vietnam placed a strong emphasis on cashless payments and intermediary

Vietnam’s fintech market

Up until 2020, the Vietnam government took a (somewhat) more laissez-faire approach to governance of the fintech sector from both regulatory and investment perspectives, leaving new fintech models peer to peer lending (“P2P lending”) or insurtech, for instance to operate in a regulatory grey area. However, this led to growing concerns about bad credit and foreign ownership. These concerns have come to the fore in recent years and the pace of new or reformed regulation has slowed while inspections and restrictions on business activities has expanded. A revision of Decree 101 has been repeatedly delayed, for example.

Fintech for Health 128 payment services (“IPS”), such as Decree 101/2012/ND-CP on Cashless Payments (“Decree 101”) 143 and Circular 39/2014/TT NHNN guiding intermediary payment services (“Circular 39”). 144

In part, this shift has been driven by the rapid expansion of foreign investment into fintech startups in the Vietnam. Foreign investors present in more than one third of the licensed payment services and about half of these fintech corporations now having majority foreign ownership. While access to foreign capital is clearly a vital growth driver, it has created government/regulatory concerns regarding foreign control of a key sector. These concerns are particularly acute when it comes to potential Chinese investment and ownership. As a result, regulatory reform has included significant policy debate within the government on whether to include foreign ownership caps or restrict foreign fintech investment activity in other ways. Vietnam’s fintech market is one of the fastest growing in Southeast Asia, with the number of fintech startups rising from 44 to around 120 companies between 2017 and 2020. 145 These

 Insurtech: A newly emerged segment combining insurance and technology, insurtech occupies 4.5%148 of the total fintech scene. Papaya is currently one of the major tech platforms for health insurance in Vietnam.

Vietnam’s healthtech market

 Intermediary Payment Services (IPS): Payments remain the largest segment, accounting for roughly 33%146 of the fintech scene in Vietnam. Prominent IPS providers including Momo, VNPay, Payoo, Moca, Zalo Pay, and SmartPay offer users various payment options ranging from e wallets to payment gateways.

P2P lending: This emerging segment remains the second largest, as companies providing this lending service Fiin Credit, Interloan, and Money Bank, to new a few - take up 15.5%147 of all fintech startups.

Early stages of development with great potential Vietnam’s young population has been a factor driving economic growth and foreign investment in recent years however, over the next two decades the aging of Vietnam’s population is expected to accelerate and overall population growth slow. In addition to aging, growing affluence will continue to increase demand in the health sector. As the middle class in Vietnam continues to expand, this segment of the population is expected to seek out high quality healthcare services, which have traditionally been available primarily at the top tier government-run hospitals in the major urban areas. Healthcare



Sejal Mistry 129 companies provide users with a wide variety of financial solutions IPS, lending, insurance, crypto, etc.

 Distribution services: Pharmacity and Thuocsi are currently among the biggest e commerce platforms for drugs and medical equipment.

 Innovative solutions: Many tech startups have created platforms to facilitate medical service appointment booking, improve patient engagement, and telemedicine, such as JioHealth, eDoctor, and YouMed.

Rising demands for healthcare services in the past few years have increased pressure on the medical facilities in Vietnam, especially state-run hospitals and clinics in urban areas. These institutions are often overcrowded because of their high quality treatment while hospitals in rural areas struggle with the lack of medical supplies and trained doctors. This opens opportunities for innovative technology solutions to tackle challenges and improve patients’ experience with the healthcare services, indicating huge potential for growth of the healthtech market in the coming future.

Fintech for Health 130 is among the top spending priorities and fastest-growing sectors in Vietnam which accounted for 6.6 percent of total GDP in 2019. Spending on healthcare per capita is expected to triple from US$161 in 2018 to US$408 in 2028. 149

 IT solutions: As the number of people seeking medical care is increasing, hospitals need up-to-date IT systems to facilitate patients’ data storage, scheduling, transactions, and so on. Large technology companies in Vietnam, such as FPT Information system, VNPT Software, and Viettel Business Solutions have been entrusted by many clinics and hospitals to build internal IT systems, data center operations, and other integrated solutions for medical activities.

Policy TechnologyLandscapeinhealthcare

To date, fintech and healthtech startups have partnered together mostly in the payment sector to enhance users’ experience. Given the growth of IPS in the past few years, the majority of healthtech apps and platforms – including the largest companies such as Pharmacity, JioHealth, or BuyMed – allow users to pay for services and products through e-wallets or payment gateways. Aside from these partnerships, the number of fintech companies providing other types of financial services in the health sector is limited in large part due to the lack of a regulatory structure and clarity for start-ups on where Government policy is likely to go.

Where fintech meets healthtech

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With public services dominating the healthcare sector, government policy and its direction by the Communist Party of Vietnam (“CPV” or “Party”) play particularly key roles in determining the priorities and trajectory of healthcare provision and how it is paid for. For several years both CPV and the government have sought to bring about modernization and change to Vietnam’s healthcare services, including universal health coverage public health service quality improvements and encouraging innovation. However, these efforts have been hamstrung by structural challenges facing the healthcare sector, slowing reform and innovation. At the top level of policy, in 2017 the Party’s Central Committee released Resolution No. 20 NQ/TW (“Resolution 20”) 150 which defines Vietnam’s strategic view on improving citizens’ healthcare and health protection. Twenty five years after the

Fintech for Health 132 first policy (Resolution No. 04-NQ/TW on urgent issues in the public health sector), Resolution 20 lays the groundwork for an updated approach to healthcare and for the first time defines the “application of information technology” as a key enabling factor in meeting healthcare objectives. While, as with all Party directions, implementation directives are thin, the Resolution does explicitly provide a top level political foundation for the Government and the Ministry of Health to leverage technology in pursuit of a modern and effective healthcare system. However, the language of the Resolution also indicates a limited embrace of innovation for ‘how’ such technology might be brought to bear. For example, for improving disease prevention and control, CPV suggests information technology systems be used on health records or for insurance payments. Information technology is also encouraged in hospitals’ internal management systems as well as medical activities. Under the auspices of Resolution 20, and as the Government’s first step to implementing the strategy laid out by the Party, Decision No. 1092/QD TTg (“Decision 1092”)151 was signed, approving a Vietnam Health Program. As with Resolution 20, Decision 1092 stresses the application of information technology as an ‘innovative solution’ for the challenges facing healthcare and health service quality, though provides little direction for implementation. Following these higher level policies, the Ministry of Health (“MOH”) sought to implement healthcare reforms. Working groups, regulatory authorities, and local health authorities have all been tasked to improve the health sector in line with the targets laid out. These efforts have been effective, with some health institutions moving forward on digital health records, pilot programs leveraging remote access to care, and, gradually,

Barriers to Policy Reform

The first of these structural challenges is the conservativeness inherent to healthcare regulators. Officials are very reluctant to introduce policies or regulations that have any risk of negative outcomes (either process or health outcomes) or could be later viewed as enabling corruption. Given this, every regulation and policy is scoured for downside risk and provisions that might prove challenging for officials to implement or manage in the future are frequently removed. The second structural risk is corruption and Vietnam’s ongoing anti corruption crackdown. Corruption and crackdowns in Vietnam’s healthcare sector are endemic as highlighted by the

Sejal Mistry 133 a regulatory structure being developed for tech in healthcare. Among these are planned revisions to the Law on Medical Examination and Treatment152 which is anticipated to provide a clearer structure for the remote provision of diagnosis and sharing of health records between medical institutions. On the tech side, MOH has begun to develop a policy framework starting with 2019’s Decision No. 4888/QD-BYT (“Decision 4888”) 153 on smart and health technology solutions. Decision 4888 recognizes the benefits of technology applications in health, such as the Internet of things, artificial intelligence, and blockchain so provides some policy direction for public and private companies to follow. While these policy initiatives are important, and the expected development of legal structures in the form of legislative updates are promising, these adjustments have not addressed many of the key structural challenges that limit reform effectiveness and inhibit innovation.

Fintech for Health 134 multi-year VN Pharma case that recently saw the indictment of a serving vice Minister and the ongoing Viet A COVID testing scandal affecting dozens of local Departments of Health. Most recently, as of April 2022, Minister Nguyễn Thanh Long and several other MOH officials have been linked to the Viet A scandal.154 Legitimate as corruption crackdowns can be and are, this environment further slows and reduces risk tolerance in policy making, particularly when the subjects of policy development are not comprehensively understood by policymakers, as is the case with many innovative tech solutions

Finally, cost concerns are a central driver for policymakers. With Vietnam’s aging population and social insurance costs already stretching the state budget, new costs to the system are avoided. Such costs include both new pharmaceutical or health technology based treatments and the expense of structural reform either in the form of health infrastructure, including services or building human capital. Though Vietnam has shifted focus and resources towards non communicable diseases (with a growing effort to target prevention), conservatism in state budget investment in healthtech, digital health, and financial technology poses real challenges. Digital Finance Vietnam’s finance sector has undergone rapid changes in recent years as a result of technological developments. Though still, a predominantly cash-based economy compared to more developed regional economies, Vietnam has seen a sharp rise in non-cash transactions, both with cards and more recently with the increase in digital payment options. While these have driven impressive growth for the emerging fintech community, these new products and services are popular mostly among the young

Formerplatforms.Prime Minister Nguyễn Xuân Phúc sought to address the financial inclusion challenge in part via 2020’s Decision No. 149/ QD TTg (“Decision 149”)155 approving Vietnam’s National Strategy on Financial Inclusion. The policy was designed to improve access to financial services by licensed credit institutions. Specifically, Decision 149 encourages the expansion of credit institutions and distribution channels of financial services to those who have limited experience with such services. In order to achieve that goal, this Decision explicitly reflects the Government’s push for digitalization and innovation in the design of financial services and products to make sure they could reach a wider range of users, including rural and vulnerable communities. However, the focus on licensed credit institutions does limit the options available and reflects some of the conservatism within the Vietnam Government when it comes to pure play digital financial services. In another effort to gradually strengthen the legal framework for fintech. In 2020, the Government issued Resolution No. 100/NQ CP (“Resolution 100”)156 paving the way for a fintech regulatory sandbox. Once fully developed, this regulatory sandbox is expected to allow new fintech services, such as P2P lending, to develop within defined boundaries. The Government’s goal is that this will enable innovation while controlling the growth of the fintech subsector and support effective policy decision making to bring successful innovation under a formal regulatory umbrella.

Sejal Mistry 135 and middle-aged communities in urban areas. There remain real gaps in financial inclusion for rural and remote areas and the policy environment continues to privilege expanding traditional banking services rather than total reliance on digital payment

Fintech for Health 136

On April 1, 2022, the State Bank of Vietnam (“SBV”) released the Draft Decree on the regulatory sandbox for financial technology in the banking industry for public consultation for two months.157

The release of the Draft Decree for the fintech regulatory sandbox has been delayed for several years and is welcome news to those in Vietnam’s fintech sector. According to the Draft Decree, six types of fintech solutions are permitted to participate in the regulatory sandbox model, namely (1) credit extension via a technology platform, (2) credit scoring, (3) application programming interface (“API”), (4) peer to peer lending (“P2P Lending”), (5) blockchain and distributed ledger technology (“DLT”), and (6) other technology solutions. Fintech solution providers must apply for a license that is effective for up to two years and which can be renewed multiple times. Notably, the requirements for P2P lending are more stringent than those of other fintech services, including requirements that all transactions be conducted through a licensed credit institution or intermediary payment service providers, due to concerns over fraud and black credit. While SBV plays a central role in appraising application dossiers and overseeing fintech regulatory sandbox operation, several other government agencies, including the Ministry of Public Security and Ministry of Justice, also participate in the process, reflecting SBV’s cautious approach to approving activities within this fintech regulatory sandbox. Within the existing regulatory structure, fintech is mostly guided by the regulations from the State Bank of Vietnam (“SBV”). The most relevant laws and regulations governing fintech are defined in the box below:

 Banking activities: The Law on Credit Institutions provides for the establishment, organization, and operation of credit institutions defined as either domestic or foreign entities performing at least one banking activity including deposit acceptance, credit extension, and provision of payment services conducted through bank accounts. This applies to many fintech stakeholders, particularly partner banks.

 Payments: Decree 101 on cashless payments is the primary regulation for all digital payment activities, setting out the requirements (including licensing requirements) for payment services such as e-wallets and payment gateway. It is supported by Circular 39 guiding the Decree

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Fintech Regulatory Governance

 Lending: The SBV takes a very conservative approach to the provision of any kind of credit, as such activities are restricted to those licensed specifically to offer loans (under the Law on Credit Institutions. In this closed environment, even ‘pay-later’ digital models have struggled to gain traction as SBV has generally defined them as offering a line of credit. That said, IPS providers are becoming more innovative and SBV is beginning to recognize that some form of regulated digital lending activity is almost unavoidable going forward. For now, models for ‘lending-like’ activities such as installment payments, an option recently becoming popular on e-commerce platforms, remain governed by consumer lending regulations. Even though fintech companies providing P2P lending services have already

Fintech for Health 138 entered the market, regulations for this sub-sector have yet to be developed.

Of note is SBV’s acknowledgment in an official letter to credit institutions and banks that P2P lending is an existing practice and may have a role in enhancing access to financial services. While not a regulatory structure in itself, this suggests one may be forthcoming that legalizes some form of P2P Lending. As with healthcare, however, the structural conservatism of the SBV has slowed and limited the Vietnam Government’s embrace of digital financial services. Apart from the cost factor, the drivers of this conservatism are similar. There is an added concern, though, regarding security and fraud, including national security implications. The SBV and ministries with security mandates are extremely cautious regarding policies that could provide a foreign entity with excessive influence over the financial sector including digital lending. Policy assessment Given the above, despite slow progress on policy development

Vietnam’s government agencies in finance and in healthcare have been generally supportive of digitization and seek ways to leverage digital capabilities. At least partially as a result of these efforts, Vietnam has emerged as a major growth market for startups and technology companies. However, these policy efforts have not (yet) translated into clear frameworks that enable next generation technology solutions. They also do not address the cross sector nature of the use of fintech in health, where a multisectoral understanding of how fintech can support healthcare is required for Government to develop effective supportive policies.

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Within fintech, the crystalizing regulatory framework provided by Decree 101 played a crucial role in supporting the rapid expansion of IPS companies. However, since then SBV’s regulations on fintech have not really developed, constricting fintech to a focus on payments. Other aspects of fintech, such as P2P lending, cryptocurrency or blockchain, are not enabled by current regulation at least until the new sandbox model is finalized. As a result, most fintech chose to invest in payment services and target large scale markets e commerce platforms for example to minimize risks including regulatory risks. Within the health sector, MOH’s recent policies reflect a determination to digitize the health sector through the application of technology in diagnosis, treatment, health insurance, patients’ data storage, and other supportive services. However, MOH has no specified policies focused on healthtech that would provide an enabling regulatory environment for telemedicine services. The ambiguous nature of health technology regulations can make private sector stakeholders more hesitant to engage with startups, which partly explains why healthtech startups in Vietnam remain nascent. Combining fintech and healthech remains outside the current view of policymakers and there is not yet a clear forum for the relevant State agencies to discuss how policies that encourage innovation in fintech could be leveraged to support healthcare provision.

Fintech for Health 140

StakeholdersNoAgency

II. Government 2

Mandate/ Relevance

GovernmentLeadership

I. National Assembly 1 Committee on EnvironmentandTechnology,Science, The Committee on Science, Technology, and Environment is commissioned to review draft regulations, supervise the implementation of regulations, and submit proposals in the fields of science, technology, and the environment. This Committee is generally more open and receptive to innovative technologies that can provide a positive societal impact than other parts of the Vietnamese governance system. However, its ability to drive policy change is limited.

The Government is the primary policy driver of Vietnam and the executive branch of the political system. Prime Minister Chinh oversees all activities that fall under the mandate of the Government. In addition, the Prime Minister has the authority to approve sector specific national master plan or strategy, such as the national strategy on the protection and improvement of citizen’s health or national financial Theinclusion.4Deputy Prime Ministers assist the Prime Minister in supervising specific fields, including social issues, healthcare, technology, finance, and so on. Each Deputy Prime Minister also directly oversees relevant government bodies, such

Operating under MOH, EHA supports MOH leadership in performing state management functions that are related to the application of technology in the health sector. As such, EHA is the focal point for the development of strategies or planning for technological applications within healthcare.

HealthElectronicAdministration(“EHA”)

MOH is a government body performing state management functions in the healthcare sector, including preventive medicine, drug administration, food safety, medical appliances, etc.

Sejal Mistry 141 No Agency Mandate/ Relevance as the Ministry of Health, State Bank of Vietnam, etc.

The Ministry currently is undergoing internal turmoil as several previous officials have been found guilty of corruption charges. As a result, it is likely that ministry leadership, as well as leaders of specialized departments, will take very cautious steps in the policymaking process for the time being, which is a challenge to organizations seeking engagements with Nonetheless,MOH. during the COVID 19 outbreak, MOH has shown signs of openness to cooperation with the private sector as the Ministry has partnered with several technology companies to build health monitoring apps.

3 LeadershipMOH

III. Ministry of Health (MOH)

5 Department InternationalofCooperation

General Office for PlanningandPopulationFamily

Department of ChildrenHealthMaternaland

Fintech for Health 142 No Agency Mandate/ Relevance

The General Office for Population and Family Planning is mandated to oversee the fields of population and family planning, including demographic records, family planning services, etc. As the use of safe contraceptive measures to prevent unwanted pregnancy among the female workers' community is also part of family planning, the General Office for Population and Family Planning is likely to be interested in solutions that improve

The Department of International Cooperation is in charge of establishing and maintaining MOH’s external affairs with foreign partners. This is the agency that receives requests for cooperation from foreign organizations and then reports to MOH leadership for further guidance.

The Department of Maternal Health and Children oversees the fields of reproductive health, maternal health, and pediatrics through the promulgation of national strategies or masterplan addressing the issues under the Department’s mandate. Reproductive health, especially reproductive healthcare services for female workers in industrial zones, is an important item on the Department’s agenda. The Department often collaborated with the local Department of Health to conduct training sessions on reproductive health for female workers in industrial zones in provinces.

access to quality reproductive health services.

8 Department of InsuranceHealth

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SBV Leadership

DepartmentPayment

As the state agency specialized in overseeing the national health insurance system, the Department of Health Insurance is mandated to develop solutions to keep the system wellbalanced, such as adjusting fee ranges, introducing new payment methods, etc.

IV. State Bank of Vietnam (SBV)

SBV performs the state management of monetary and banking activities and foreign exchange, aiming at stabilizing the value of Vietnamese currency, ensuring safe and sound banking operations and the system of credit institutions, ensuring safety and efficiency of the national payment system, and contributing to socio-economic development.

No Agency Mandate/ Relevance

The Payment Department assists the Governor in overseeing the payment sector in Vietnam. This is the agency that reviews application dossiers of IPS and issues regulations guiding the fields of payments and settlements. The current leader of the Payment Department was originally an experienced

Despite SBV’s current push for digitalization of the banking sector, the newly appointed Governor developed her career at the Department of Monetary Policy suggests that she will likely adopt a balanced and cautious approach to policymaking, especially when it comes to digital innovation.

As lots of new fintech models possess potential risks to both cybersecurity and social security for example, the risk of black credit from P2P lending A05 will

A05 is an agency under MPS that specializes in cybersecurity and hightechnology crime prevention.

LeadershipMPS MPS perform the state management functions in national security, and social order and safety, which covers cyber security, intelligence, crime prevention, and so on. Besides SBV, MPS also reviews application dossiers submitted by IPS to make sure these services do not pose harm to the security of Vietnam. Given the nature of its mandate, MPS generally adopts a conservative approach when it comes to policy making.

Department of Cyber Security and Hi tech (“A05”)PreventionCrime

V. Ministry of Public Security (MPS)

Fintech for Health 144 No Agency Mandate/ Relevance official at the Information Technology Department. Such background suggests that he has a good understanding of new technology trends and is likely to be supportive of digital transformation within the payments sector.

A05 is not unopened toward foreign ideas on management, and they do cooperate with international firms on certain issues such as raising public awareness of cybersecurity and training for government agencies. However, they are also impacted by their internal conservatism and tend to be conservative when introducing new regulations in managing cyberspace.

13 LeadershipMOF

(“ISA”)AuthoritySupervisoryInsurance

Sejal Mistry 145 No Agency Mandate/ Relevance likely stay cautious of the expansion of financial service activities.

Opportunities and Recommendations

Building a strong partnership foundation for the use of fintech in Vietnam’shealthcaremobile communication technologies and internet are robust, with telecommunications services covering almost the entire country. Eighty nine percent of rural Vietnamese own mobile phones, with an average rural user spending

ISA is a state agency operating under MOF and overseeing the insurance sector of Vietnam. This is the agency that grants certificates allowing the operation of insurance businesses. For instance, ISA recently granted Medici, a start-up providing insurtech service, the insurance broker license in July 2021.

VI. Ministry of Finance (MOF)

MOF is the state agency taking charge of national finance and budget. With that said, the fields regulated by MOF include but are not limited to the state budget, state reserves, insurance, fees, etc. The Minister of Finance is generally seen as a strong and decisive leader. He has proven adept at maintaining good relationships with other high level leaders. However, as an administrator, he tends toward the bureaucratic and is prone to creating additional and sometimes burdensome procedures.

Ongoing cooperative activities between the Vietnam Government and other governments, development agencies, IFIs, and local banks also seek to support startups with loans, technical training, as well as business mentorship. Some of the biggest programs include the SpeedUp fund established by Ho Chi Minh City’s Department of Science and Technology, the Startupcity.vn platform launched by Hanoi’s People Committee, and the Mekong Business Initiative co founded by the Asian Development Bank and the Australian Government.

Quarantine and travel restriction orders during the COVID pandemic resulted in increasing demand for healthtech applications in Vietnam, most of which are telemedicine platforms that allow patients to receive consultation from

Fintech for Health 146 approximately three hours on the internet158. Startups and the tech industry also enjoy favorable policies from the government, with numerous funds at State and provincial/municipal levels.

At the same time, there does not appear to be a strong government/public sector platform for bringing fintech to bear on health outcomes. In Vietnam’s context, there is huge potential here but a lot of work to do with Government to develop their understanding of the needs and opportunities. Especially when the Fintech Regulatory Sandbox is approved, there will be clear opportunities to develop pilots and build partnerships. Starting with developing a strong partner and knowledge foundation in Government will help put programs such as Fintech for Health1 on key agencies’ ‘mental map’ as interested stakeholders continue to develop programs with private sector partners.

Highlighting healthtech potential in the “new normal”

Sejal Mistry 147 doctors online. The introduction of such platforms not only contributes to increasing access to health services but also leads to the future of convenient and safe medical care. This context presents opportunities to leverage a widespread understanding of the benefits of comparatively ‘simple’ healthtech to deepen support for its further development.

Framing Workshop Vietnam’s Ministry of Health is interested in solutions that increase access to affordable healthcare services. The Ministry is working to complete a regulatory framework for telemedicine as well as financing options for this practice (e.g., including

Given that the application of fintech solutions to ensure universal access to healthcare services is still rather new in Vietnam and the regulatory landscape for both fintech and healthtech are under development, interested parties should closely monitor upcoming policy developments while engaging policymaking bodies, especially the MOH and the SBV.

Framing for engagements with key stakeholders

The first step for public sector engagement will likely be the identification and selection of a potential partner. The right partner provides opportunities to educate government stakeholders on best practices and the potential for Fintech for Health, while also presenting the chance to influence policies shaping the future of how fintech can support health outcomes.

Looking at how healthtech can be enhanced to support vulnerable populations, e.g., workers at factory zones particularly hard hit by COVID 19 will be a strong way to build a supportive network of government stakeholders and educate them on the possibilities of bringing fintech into the picture.



Fintech for Health 148



 Establish



telemedicine into the list of medical practices eligible for national health insurance benefits). This is reflected in the Draft Law amending the Law on Medical Examination and Treatment currently under development and a series of other regulations on telemedicine. As such, identifying the right agency partner within the MOH and then sharing relevant international experience, via a workshop or a seminar, would be the first concrete step in a public sector outreach initiative. Such a workshop might be framed as: Sample workshop with the MOH Theme: The importance of partnership between fintech and e-health in Vietnam Objectives: Create a forum where stakeholders may exchange perspectives on how innovative fintech solutions and e health services can work together to improve universal access to healthcare in Vietnam and/or strengthen working relations between the MOH and interested parties (e.g., startups, NGOs, business associations, etc.) Method of organization: Keynote speeches followed by a panel discussion Partner organizations: A relevant agency within the MOH and an NGO/ business association



Participants: Officials from the MOH and other relevant agencies (e.g., SBV), representatives from the healthtech and fintech sector, and media. Possible agenda:



Opening remarks by a representative from the MOH and an NGO/ business association Keynote speeches related to the selected theme Panel discussion joined by policymakers, experts, and representatives from businesses

CSR Initiatives

A second possible way forward focuses more on fintech and would seek to leverage the recent release of the Draft Decree defining the regulatory sandbox. Based on the Draft Decree’s current language, the SBV is taking a cautious stance towards fintech solutions due to concerns of risks to users e.g., ‘black credit’ in the form of P2P lending. Against this backdrop, initiatives to communicate international experience and best practices with policymakers are important. The first step would, of course, be formal written comments on the Decree. However, given the newness of the fintech sector, trust building via a Corporate Social Responsibility (CSR) program would help demonstrate the sector’s prioritization of providing ‘safe’ fintech Assolutions.such,a CSR program by P2P lending platforms helping to raise users’ awareness of ‘black credit’ can be seen as the next strategic step for the fintech sector to improve their image in the SBV’s perspective and lay the groundwork for future advocacy Framingplans. for a CSR program to engage with the SBV Program theme: Avoiding black credit risk from P2P lending services Objectives:



Sejal Mistry 149 



Fintech for Health 150  Raise users’ awareness of imminent risks in P2P lending  Showcase P2P lending service providers’ efforts in addressing user risks, thus improving the image of P2P lending from both users’ and policymakers’ perspectives  Method of organization: A series of training sessions for a group of the target audience (e.g., workers in industrial zones)  Partner organizations: Local authority and/or relevant NGO  Participants: Representative from SBV, local authority, NGO/ international organization, target user groups, etc.  Suggested agenda:  Opening remarks by a representative from the SBV, local authority  Training sessions jointly conducted by fintech solution providers, NGO/ international organization Authors: Vriens and Partners

Case study 11: Jianyibao, a Provider that Provides Disease Specific Insurance Plans and Medical Assurance Products Case study 7: Weibao, a provider that provides personalized insurance products

Fintech for Health: People with Chronic disease

Case study 10: Telenor Health, a Company that Provides Online Health Consultations, Advice, and Insurance China



Fintech for health in China: Growing Needs, Unique Opportunities



Sejal Mistry 151 Learnings from Other Countries Bangladesh  Wage digitization for RMG workers: Advancing financial inclusion in Bangladesh  Mobile financial services in Bangladesh  Apon Embedded insurance: meeting the healthcare needs of readymade garment workers  Digital Health Solutions providing low cost health insurance with bundled teleconsultation for Bangladeshi families 

Case study 9: Apon Wellbeing, a Specialized Marketplace for Workers

Improving accessibility to integrated fintech for health solutions for aging populations in China



Fintech for Health 152 India  Ayushman Bharat Digital Mission  Effect of Covid 19 on Healthcare affordability  Digital wallets: the genesis, current usage, and future use healthcare payments in India  How Fintech for Health partnerships in India provide healthcare financing for cancer patients Malaysia  M40 Households: The forgotten group in Malaysian healthcare financing  Investing for health? Time to change the paradigm in Malaysia  The rising out-of-pocket healthcare expenditures in Malaysia; opportunities for collaboration between fintech companies and the healthcare sector don’  Fintech Should Be Used to Increase Cancer Screening  Case study 12. Merchantrade which provides remittance services, teleconsultations, e-pharmacy, and insurance Nepal  Nepal’s journey towards cashless transactions Vietnam  Vietnam’s growing fintech industry: The opportunities for meaningful partnerships with healthcare

Sejal Mistry 153  Challenges and Opportunities for Fintech for Health in Vietnam  Introduction and Market Context  Vietnam’s Fintech Market  Vietnam’s Healthtech Market  Policy Landscape

Fintech for Health 154 Figure 20. Case study 13: Pasarpolis, an insurtech company

Sejal Mistry 155

Fintech for Health 156 Figure 21. Case study 14: Halodoc, a teleconsultation company that also provides drug delivery, in home lab tests, and insurance

Sejal Mistry 157

Fintech for Health 158 Figure 22. Case study 15: M tiba, an online health platform that provides a mobile health wallet service

Sejal Mistry 159

Fintech for Health 160 Figure 23. Case study 16: Pro mujer a fintech company that provides preventive care and pay per service access to doctors and advanced treatment

Sejal Mistry 161

Fintech for Health 162 Figure 24. Case study 17: BIMA, an insurtech company that provides mobile delivered insurance

Sejal Mistry 163

164 Conclusion

intech for Health” is a rapidly evolving field that we hope can help to improve health services for all people. Although much of the work highlighted here revolves around “fintech,” we do not lose sight that the sole purpose of this program is centered on the words, “for health.” Ideally, the use of fintech and other technologies may be so thoroughly integrated, that they simply become part of a robust health system without the need to delineate a separate domain. In highlighting the articles, case studies, and notes from our ACCESS Health team we aim to share what we are learning and continue to learn about the integration of digital financial services for health care and health systems. This is the beginning of our journey, and we invite you to write to us to contribute your experiences in Fintech for Health, your viewpoints, and even to debate and refine our thinking. Feel free to reach out at info@accessh.org.

In the end, ACCESS Health International is committed to the vision that “all people, no matter where they live and what their age, have the right to access high quality and affordable healthcare and to lead healthy and productive lives.” Everything we do is in service to that vision.

Dr Mohd. Nasir bin Mohd. Ismail, PhD, Independent Consultant, ACCESS Health International

Dr Monica Mittal, ACCESS Health International

MsInternationalNabilaKhurshed, Independent Consultant, ACCESS Health

MsInternationalNguyenKieu An, Independent Consultant, ACCESS Health

Ms Munia Islam, Independent Consultant, ACCESS Health

1 World Health Organization, & The World Bank. (2017). Tracking Universal Health Coverage: 2017 Global Monitoring Report (English). Geneva: WHO Document Production Services

Vriens and Partners

MsInternationalPrashanthi

165 Contributors

Ms Yue Xu, Assistant Director for Strategic Partnership and Impact Programs, ASK Health

Krishnakumar, Technical Specialist, ACCESS Health International

Ms Anushruti Adhikari, Nepal Institute for Policy Research

Mr Tawfiq Hasan, Senior Partnership Consultant, ACCESS Health International Southeast Asia

Ms Tina Ja, Director for Strategic Partnership and Impact Programs, ASK Health Ms Valerie Shelly, ACCESS Health International

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108 Securities Commission Malaysia. (2019). New ECF, P2P Financing Operators And Property Crowdfunding Framework Announced At Sc Fintech Roundtable. https://www.sc.com.my/resources/media releases and announcements/new ecf p2p financing operators and property crowdfunding framework announced at sc fintech roundtable. 109 National Institutes of Health. (2019). National Health and Morbidity Survey 2019: Non communicable diseases, healthcare demand, and health literacy. Ministry of MS_2019_https://iptk.moh.gov.my/images/technical_report/2020/4_Infographic_Booklet_NHHealth._English.pdf 110 Ibid. 111 Tahrani, P. K., Sivasampu, S., Goh, P. P., Faizah, A., Hisham, A. N. (2010). National Healthcare Establishments & Workforce Statistics 2010. Institute for Clinical

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142 Ministry of Health. (2021). Thứ trưởng Bộ Y tế: Cứ 100 người Việt tử vong, có đến 77 ca do bệnh không lây nhiễm (Vice Minister of Health: In every 100 deaths in Vietnam, 77 cases are due to non communicable diseases). Ministry og Health Portal. Retrieved February 12, 2022 from https://moh.gov.vn/hoat dong cua lanh dao bo/ /asset_publisher/TW6LTp1ZtwaN/content/thu truong bo y te cu 100 nguoi viet tu vong co en 77 ca do benh khong lay nhiem.

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140 Ministry of Health, UN Migration, World Health Organization, and the Nippon Foundation (2020). Situation Analysis of Migration Health in Vietnam. Retrieved February 12, 2022 from https://publications.iom.int/system/files/pdf/sa migrant health viet nam.pdf.

141 Báo Điện tử Chính phủ (2020), Thu nhập bình quân của công nhân lao động tăng 35% (Workers’ average income rose by 35%) Báo Điện tử Chính phủ. Retrieved February 5, 2022 from https://baochinhphu.vn/print/thu-nhap-binh-quan-cua-cong-nhanlao dong tang 35 102284874.htm.

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39 2014 tt nhnn%253a guidance on payment intermediary service.html.

145 Fintech News Singapore (2020), Vietnam Fintech Report 2020. Retrieved February 12, 2022 from https://fintechnews.sg/wp content/uploads/2021/01/Vietnam Fintech Report 2020.pdf.

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152 The Government of Viet Nam. (2011). Law on Medical Examination and Treatment. Viet Nam Social Security. Retrieved April 15, 2022 https://vss.gov.vn/english/legal/pages/default.aspx?ItemID=3551from

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156 The Government of Viet Nam. (2021). Resolution No. 100/NQ CP approving the proposal of the development of a regulatory sandbox for fintech (in Vietnamese). Retrieved April 17, 2022 https://chinhphu.vn/default.aspx?pageid=27160&docid=203985from

158 Mobile Marketing Association and Google (2019), The State of Mobile in Rural Vietnam Report. Think with Google. Retrieved from ural_Vietnam_Report.pdfhttps://www.thinkwithgoogle.com/_qs/documents/7268/The_State_of_Mobile_in_R,February13,2022.

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Fintech for Health

Articles inside

Vietnam’s growing fintech industry: The opportunities for meaningful partnerships with healthcare Challenges and Opportunities for Fintechfor

Nepal’s journey towards cashless transactions

The Opportunities

companies and the healthcare sector

M40 Households: The forgotten group in Malaysian healthcare financing

Introduction

Introduction

Mobile financial services in Bangladesh

Introduction

A Framework for Fintech for Health

Ayushman Bharat Digital Mission

to physical health

The Fintech Ecosystem

Improving accessibility to integrated fintech for health solutions for aging populations in China

Wage digitization for RMG workers: Advancing financial inclusion in Bangladesh