Sejal Mistry heads up the Southeast Asia arm of ACCESS Health International – a healthcare NGO – and leads innovative health financing and digital technology projects. Before that, Sejal was a researcher and a policy adviser, focusing on the global HIV/AIDS epidemic. She has also acted as the senior international health adviser on health financing and strategic purchases for the South Korean government.

Welcome to Payments Powerhouses, Sejal. How did you go from being a researcher to getting involved in health financing?

Sejal: There have been a lot of steps in between on my career trajectory — moving from research, the first essential step was moving into policy and really understanding how we bring scientific evidence to decision-makers. At the start of my career in HIV/AIDS, I focused on getting people the treatment they needed and working out what we could do for those who couldn't afford it. The world of patents and price protections became a very important area for me because I realised even if we accumulated as much evidence as we could in scientific papers and publications, nothing would get done unless we worked with the people who can affect those programs and policies.

Now, on my way from HIV/AIDS to health financing, there was a pivotal moment for me in Korea. Besides K-pop and Korean dramas, one of the great innovations of Korea is its healthcare system; they've done an incredible job of forming a single-payer system for healthcare, with one large state-owned insurer. And they have used digital technologies to take data-driven approaches to facilitate the purchase of health services, the delivery of health services, and healthcare payments.

During my time as a Korean civil servant, I was blown away by how far ahead the country was in leveraging technology for the healthcare ecosystem; they've done incredible things. And that got me really thinking about health financing. While cancer, diabetes, and HIV/AIDS are important, they are somewhat niche topics. However, when you talk about money, it affects everybody, regardless of the health sector. Money is a sort of oil that drives the machinery. So, when you start understanding how financing works for healthcare systems, you start understanding the type of decisions that policymakers are faced with when allocating resources.

What are your key responsibilities in your role at ACCESS Health International?

As the Regional Director for ACCESS Health for the Southeast Asia region, I cover the ASEAN countries. But increasingly, because of the work we're doing – in fintech and financial innovations in particular – we're getting a lot of requests to start looking at bringing together fintech and technologies for health financing in all parts of the world. And part of the reason this is happening is that we're not going to the US, UK or Europe to find those innovations; a lot of those innovations are driven by Southeast Asia and Asia in general. And I think that's what's really exciting.

So, we do research articles, white papers, and reports. But one of the most gratifying aspects of our work is bringing together ‘unconventional’ partnerships. We bring bankers, healthcare providers, and hospitals to the same table. It's not uncommon for us to have a ministry of finance or a central bank together, or a ministry of health with DBS, Pfizer, Roche, or startups. That's where the magic happens: when parties who don't normally talk to one another come together to take an out-of-the-box approach.

Has it been challenging to get ‘traditional’ partners on the same page?

To set some context: Before COVID-19, we launched a program called FinTech for Health, and we were lucky to get a grant from the MetLife Foundation. We explained to the Foundation the core healthcare financing challenges faced by people in this part of the world, and they agreed that this would be a great opportunity for us to understand the vulnerability of people when it comes to healthcare costs.

When we launched the program, I remember introducing ourselves to digital wallet companies in Vietnam, saying, “We're doing FinTech for Health; we’re a healthcare NGO.” And they couldn’t understand what we were doing there; getting people's attention at the beginning was hard. But we explained that regardless of what sector you’re in – healthcare, transport, energy, or commerce – we all know someone who has had a major health event and may have struggled to pay for it. And when we told those in the financial services sector that they have a role to play, we got some traction. Then, COVID-19 happened, and everyone realised healthcare does affect business, and it paved the way for a lot more work, interesting conversations, and potential partnerships.

You pointed out that there have been a lot of innovations in this region. What are some examples, and why do you think these are emerging from here and not the West?

Unsurprisingly, Indonesia, the home of many fintech unicorns, has a couple of examples.

HelloDoc and Alodokter focus on digital health, providing teleconsultation services. They have been working increasingly with major platforms – Gojek, Grab, and others – to bring medical services to the wider market that FinTech companies can typically reach.

We’ve gotten used to making transactions online, and there has also been a shift in the healthcare experience, which is a fantastic example of how the pandemic has brought so much opportunity, in terms of digital technologies' role. If I use any existing telemedicine platforms – including Doctor Anywhere, MyDoc, and Speedoc – I’d have a really good consumer experience. There are potential cost savings and convenience for patients and providers, and they also help triage non-severe cases that may be blocking hospitals or GPs.

PasarPolis is an insurer tech aggregator bringing easy-to-understand, simplified, and affordable insurance products for the masses, not solely for healthcare. I believe this could be a big game-changer. Traditionally, private insurance caters to wealthy, formal sector workers, but innovations in Indonesia, India, and China are redefining insurance and how it's delivered.

It's not to say that nothing is happening in the US and Europe; the US will remain a centre of innovation. But there is, in my opinion, the sense that necessity breeds invention. In this part of the world, with its resource-constrained settings, the power of digital technology and cheaper labour costs, you can do pretty amazing things.

Indonesia, India, and China are really exciting markets, given the size of their populations. Players like Alipay or WeChat getting into the business of healthcare have completely disrupted the market, and we’re also starting to see more copycat solutions in places like Indonesia or Vietnam. We're looking at bringing awareness to the financial services sector and technology companies of the major role they have in making healthcare accessible and affordable.

Healthcare costs are generally high and mostly paid out of pocket. How can it be made cheaper and more accessible?

Overall structural trends make it hard to mitigate healthcare costs because the burden will fall on the individual or the government. One reason is that populations are living longer, and with age comes more conditions and more chronic diseases. Ageing is not a bad thing – we want people to live longer, but we want people to live longer and be healthy. Singapore and Thailand have some of the fastest-ageing populations in the region, which means more healthcare needs and higher medical care costs. The rate of medical inflation in the region stands at about 8%, which outstrips your regular inflation for goods and services.

The cost of healthcare is going up, as well as the demand for healthcare. There is an increasing sense of desire for better quality care, especially among the emerging middle class. Everyone's gotten used to seamless e-commerce and payment experiences, so why can't the healthcare experience be similarly seamless? Anyone who's visited a hospital knows how frustrating the experience can be. But there are a lot of factors that make it hard to do cost containment.

Healthcare isn’t going to get cheaper; in fact, I think we're going to see it get more expensive really quickly, but there are things we can do to mitigate the burden. One opportunity for cost containment lies in bringing digital technologies in fintech to the backend of billing and payment systems, which can bring about a lot of efficiencies. Healthcare is one of those sectors where a lot of money is wasted on operations. So, there's a tremendous opportunity for cost savings if we can make the delivery of healthcare services, healthcare provider payments, or insurance more efficient through backend technologies.

Every person's healthcare journey has a financial decision behind it. At ACCESS Health, we take an ecosystem approach – our role is to be the glue, bringing different partners together to find ways to resolve financial pain points in the healthcare journey, by offering solutions that make it more affordable, more convenient, more transparent, and simple. There has been a lot of value in bringing these partners together, but it hasn’t been easy; bringing different sectors together is very challenging.

When selecting partners to work with, do you have a list of potential names, or does it depend on the particular challenge and the need in a market?

Fintech for health is a very new area; few have looked into leveraging fintech to ease the individual burden of financial costs. We take a multi-pronged approach, and have had to evolve along the way. We would look at some major public health challenges that a population might face in a country, if there is a health financing challenge, and if there is a role for fintech.

For example, one of the first projects we started working on was in Vietnam, where the public health issues were, or remain, a large number of abortions and a lack of access to reproductive healthcare services. Women who move from rural to city areas are particularly vulnerable; they’re away from their families and perhaps have an active sexual life, and it's still not quite culturally accepted to admit that and get contraception. When they do get contraception, these are short-term options with high failure rates. A better option is to have long-term contraception, which is cheaper than short-term contraception over time, but it comes with a high upfront cost. So we worked with a local NGO and other partners to develop a digital lending solution for women, where they could get access to long-term contraception in a way that's discrete, transparent, and with a financing plan behind it.

I loved the idea, but we couldn't get it off the ground. Two main challenges were that the fintech regulatory environment in Vietnam is still pretty conservative; many clinics that offer these kinds of products are still largely cash-based. Also, we can’t talk about digital lending solutions unless we first address the problem of digital payments acceptance in Vietnam and get these clinics to provide a non-cash payment gateway.

Fintech could be the right solution, but the infrastructure needs to be ready. In looking into incentivising health savings by having a digital wallet, there are a lot of concepts that we're playing around with in places like India, Bangladesh, Vietnam, Malaysia, etc. But this is still a very new topic, and it’s not an easy story to sell in many places.

Are there any technology trends, solutions, or use cases of particular interest to healthcare providers now?

Getting more frontline healthcare providers – private practitioners and GPs – onto digital payments platforms is important in enabling healthcare access. We can build up from digital transactions to offer financing solutions. In the US, there are even discussions about Buy Now Pay Later (BNPL) for healthcare, which can be tricky, but I think it's a fascinating trend and something that addresses a pain point.

Not everyone has high liquidity. Particularly for low and middle-income people and those who don't have insurance, high healthcare costs could drive people into poverty, drive them to loan sharks, and drive them to sell their assets.

We are looking at integrating payment platforms into hospital and clinic systems. Digitising insurance and providing an avenue for people to understand and buy insurance through insurer tech distribution platforms is also very exciting.

Another area governments are exploring is cashless transactions that can be made through people's healthcare wallets. By cutting out the middleman, you're driving efficiency. So, we're exploring ways to get maternal health vouchers issued by the government to people via their mobile phones, which they can use at healthcare providers without any exchange of cash. There’s a real opportunity for access and optimisation of systems – that makes it really exciting.

When I worked in the US, the healthcare system seemed rather complex. Whenever I visited a doctor or a specialist, I didn’t know how much the medical bill was until weeks later, which got me questioning why things worked that way.

Isn't it odd how much we've accepted that as a norm in healthcare? I think there's a lot that healthcare can learn from the digital transformation in financial services and other sectors, where information sharing is increased.

There's a common concept in healthcare around information asymmetry – doctors and providers have all the knowledge, and patients are basically at their mercy. You don't know what items in your bill or your treatments that you actually need. We need to start using these technologies to bring more information to people. During the pandemic, a digital wallet in Vietnam began to provide COVID-related information, and these examples are very exciting and much needed for the environment.

Speaking of digital wallets, how are they enabling patients across the region to better manage their medical expenses? Have you come across any effective examples?

We're working with a company called BIMA that takes an ecosystem approach to affordable insurance and teleconsultations. They were primarily focused on Africa and have now moved to Asia, and we've been working with them in Bangladesh, launching one of the first health savings wallets. What's exciting about this is we’re helping people to pay for their healthcare services, and save for healthcare expenses, which is not too different from Singapore’s Medisave. This also enables them to receive money from a government transfer into their health savings wallet, be it a maternal voucher, which is very common in Bangladesh, or a P2P transfer. And these transfers can be done through the healthcare wallet instead of calling up friends or family to get cash transferred immediately. That's the thing – in healthcare, there's that urgency aspect.

On top of that, it’s the ability to bundle digital wallets with teleconsultations, the delivery of drugs, and other things. If you have a big platform, like a banking platform, that might be a great place for people to get their healthcare services, book their doctor appointments, etc. Despite the plethora of healthcare apps out there, almost no one downloads it, whereas everyone's got some sort of banking app, and many people in many countries have digital wallets. This is particularly true for underbanked and unbanked people. So, when we first started out, we were trying to bring finance to healthcare. Instead, we decided to bring healthcare to financing platforms, where people are, and make things easy, such as getting a loan for a healthcare expense on that same app.

Is there anything governments or central banks can do better in fintech and healthcare?

When we started, we focused on bringing these partnerships and new models into the healthcare experience and patient journey. We realised very quickly that there isn’t a regulatory roadmap for how finance and healthcare work together. In many countries, the startups and partners that we work with would share that they’d try things until they got a slap on the hand from a regulator or were told to shut down.

So what we started doing is having conversations with regulators. Whether they were insurance regulators or central banks, Ministries of Finance and Ministries of Health, we started bringing them to the table to find ways to facilitate payment transactions for healthcare services. For example, we’d look into the regulatory permissions that fintech platforms would need to offer a healthcare service component. Whether central banks realised it or not, they were starting to be called upon to make these decisions, such as who to give lending and insurance licences to.

During the COVID-19 pandemic, we saw the importance of digitising wages, which became a key topic for us – this is a challenge that we see in Asia and all over the world. So, we've been working on a paper that looks at the global landscape of digital financial service models for healthcare and the role of central banks. Recently, we attended a policy forum in Jordan where we talked to central banks about what they can do, albeit healthcare isn’t in their remit.

We need to create a regulatory environment where central banks and other regulators can come together and spur innovation while providing some guardrails and making sure we're still protecting the consumer interest.

The combination of healthcare and fintech is a relatively new niche sector. What are the other areas you would like to call more attention towards?

What's been really exciting for us is looking at underbanked and unbanked people in places like the region and the tools and technologies that can get them access to ethical, high-quality financial sources. For example, if an individual doesn't have a rich credit history or a formal bank account, how do you assess their creditworthiness? That’s where technologies like alternative credit scoring come in. If we look at places like India and Indonesia, people who need healthcare services and insurance are not a tiny sliver of the population; they probably make up the majority of the population.

We’re now looking at alternative datasets, talking to insurers or reinsurers, and trying to refine their actuarial calculations for these populations we have almost little to no data on. This will help us start creatively developing good solutions with strong market potential for many businesses while serving the needs of people who have often been left out of the formal financial sector and thereby not getting the healthcare they need.

Have you identified any specific technological areas, players, or companies that can help your agenda?

One example we like to talk about is a social enterprise based out of India called Arogya Finance, which provides point-of-care lending using psychometric testing. They've developed a proprietary technique to assess the creditworthiness of people and their families in Asia – within a few days, individuals can be assessed, provided a loan, and have the amount transferred directly to the provider. Arogya Finance has also done a lot of outreach to build up that trust with healthcare providers, who would be rightly suspicious of lending companies, to develop a network of hospitals and clinics that accept financing from Arogya Finance.

There have been many occasions where people find out about Arogya Finance at the hospital's office, which can be very empowering. For example, a doctor who wouldn’t want to prescribe a certain treatment because they know a patient can’t afford it can now offer more expensive options that come with a financing plan. That's what we're trying to do – giving people opportunities to get the treatment they need without having to sell off their assets.

Finally, do you have any health tips or advice that you stand by?

Wash your hands!

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Payments Powerhouses is a monthly editorial series interviewing the movers and shakers of the payments and wider fintech industry in Southeast Asia and beyond. If you’d like to be featured on Payments Powerhouses, reach out to us here.