Digital Health Credentials in India and Africa: Are COVID-19 Travel Passes Catalyzing New Tech Innovations?

This transcript was generated using AI and may contain inaccuracies. If you notice an error, feel free to email [email protected].

CHAPTERS 

[00:00:00]: Digital health credentials & the COVID travel pass challenge 

[00:02:45]: India's CoWIN/DIVOC system: scale, design, and domestic use 

[00:05:45]: Key design decisions: multilingual, phygital, and offline verification 

[00:07:33]: Africa's AU Trusted Travel System: history and PanaBIOS origins 

[00:13:51]: Capacity building and training across 21 countries 

[00:17:45]: Interoperability challenges; the case for a global standard 

[00:19:51]: India & Africa working toward mutual compatibility 

[00:22:28]: WHO, G20, and the path toward a federated global system 

TRANSCRIPT 

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Hello and welcome to Moving Beyond Pandemic, the podcast from the Migration Policy Institute that looks at how COVID-19 is reshaping all aspects of human movement, from tourism and business travel to labor migration and mobility. I'm Meghan Benton, Director of the International Program at the Migration Policy Institute. COVID checks in borders and travel have ebbed and flowed across the course of

[00:00:25.560] 

the pandemic as governments have sought to adapt to outbreaks of variants, evolving case counts, hospitalization and death rates, and vaccination and treatment coverage. But they faced one key challenge. They slow cross-border movements down transport carriers, airlines. They can't easily check if each passenger is vaccinated or tested without reading each person's paperwork. So administering vaccination or testing requirements at school scale is tricky. That's where digital tools come in as they help with automatic verification of health and vaccination records. Digital health credentials have been used during the course of the pandemic to help reopen economies and global mobility. And today we're going to hear about two major innovations in this regard, the Indian Dialog System and the African Union Trusted Traveler System. Both of these are interesting because they're examples of how the pandemic fueled important positive spillover effects in regions that had lower levels of digital penetration, lower capacity at borders, a more nascent health system and more limited resources, of course. And how COVID became a catalyst for major digital innovation that set the standard for new ways of managing mobility and health that could outlast the pandemic. I was very happy to bring together three experts to discuss these issues.

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Dr. Pramod Varma Is the chief architect of India's digital identity program and of its COVID pass system, DIVOC. Dr. Edem Adzogenu Is the co-chair and founder of the Afro Champions Initiative, a public private partnership that's helped drive a coordinated and digital response to COVID-19 on the continent, especially on digital testing certificates. And Lawrence Huang is an Associate Policy Analyst with the Migration Policy Institute and author of the report Digital Health Credentials and COVID-19: Can Vaccine and Testing Requirements Restart Global Mobility? Welcome Pramod, Edem, Lawrence, it's great to

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have you all on the podcast today.

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Great to be here.

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Thank you.

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Thanks.

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I wanted to start with a question to Pramod. Could you tell us a bit about digital verification of the COVID vaccine in India? How is the CoWIN Pass being used right now?

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Six months before India started our vaccination drive, the enormity of it was daunting because we have a billion people and two doses and maybe a booster after that. We sort of knew that's going to be a long attempt at it. And so there were two aspects of vaccine drive. One, the physical vaccine availability and capacity building across the country to be able to actually do vaccination. But at the same time we knew that alone is not enough. Because the value, most value of vaccination is not merely getting vaccinated. Of course that's a big value, not falling sick, but having the economy come back and having the ability for people to get back to work. And that was immediately visible to us. And that necessity that people must get back to work is, was very, very important for us. While global travel was only a small amount, small number of people, the domestic we are a high service industry and we have, you know, very, very high service industry and require people to be able to vaccinate and sort of show that to be able to get back. So we started the effort on DIVOC, which is open source effort.

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We built the entire credentialing platform and we adopted W3C specification because it was perfect timing that they had standardized that. And of course we worked with WHO to get the data, basic data elements standardized as well. So India adopted both W3C as well

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as WHO.

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And how is the CoWIN pass being used in India right now?

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So the usage is pretty much mostly domestic and people like us of course use use it internationally when we travel, but otherwise majority of the people, so again I think this was very important for us. India is very diverse in our language structures, access to phone, access to Internet. So we needed few critical decisions which is also why W3C and the actual DIVOC implementation was very key. One is multilingual. That means we cannot have only English. We needed multilingual for people to be able to read it. Second phygital, that means it's digitally natively verifiable, but doesn't mean it's digitally carrying. And that means people need not have a smartphone to carry our certificate. They can actually print out the certificate with a digitally signed QR code. So people who have no phones could also carry this. But still digitally verifiable. So. So it's very subtle, right? So it's digital inside, physical outside, right. So that was very key for us because 300 million people have no phones. So we still needed to make sure smartphone is not a necessity for us to be able to do. And the third was offline verification because we also needed that lot of times Internet, while Internet is cheap and connected In India, pretty large 95 plus percentage is connected.

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The reliability of, you know, in a metro underground, for example, reliable connection is still doubtful and we making it necessary for Internet connection to verify would have been an issue. So we made sure the vaccine certificate is self contained and actually offline. Verifiable means digitally verifiable, that it's not tampered with, it is not fake. So we can still verify it's not fake, it's not tampered with, you, it's indeed the real certificate. Completely without Internet by the way. So that was the underlying architecture and of course it's used everywhere because most of the service industry, cabs delivery, food delivery and COVID, of course all this gig economy literally went up. Number of jobs went up. Crazy. After the first lockdown, when it opened up, pretty much most of the people stayed home. That actually meant the service industry boomed in terms of actually coming home. In fact, I get my hair cut at home, in India for example. Everything is home. So that actually meant they all had to carry their certificate either physically or on their smartphone or to their employer or the gig platform to which they are connected to. And they had to prove that they are vaccinated.

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So it's used everywhere.

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It's use is really normalized. It's used everywhere. Right, Interesting.

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Everywhere. Because that's how most of the service industry folks get back to work.

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Yeah, great, thank you, that's fascinating. And Edem, could I turn to you next? The African Union trusted travel system hasn't received much attention, at least not in the United States. But it was one of the earliest digital responses to the pandemic. I was wondering if you could tell us a little bit about the history and then the same question, how it's being used in practice.

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Well, thanks. And indeed this is a recurring theme in global digital technology trends in contemporary times. For example, long before the fintech boom materialized in the West, Africa was already doing very cutting edge things in digital finance. Eventually, when M-Pesa became a byword for African adaptive thinking. The interesting thing is that even after the fintech boom took off in the Europe and and in the us more Africans today utilize the latest in mobile banking services than Americans. We are seeing a similar trend play out in digital health as well. Now the U.S. for instance, has been talking for decades about radical redesign of what is a very expensive healthcare system with new technologies. And yet, it is in Africa that medical drone deliveries are happening at scale. It is in Africa that electronic health insurance systems are attempting to focus on the masses with mobile-based health insurance products that reward preventive behavior, etc. So I'm sketching this background because COVID tech is no different. The African Union trusted travel system was actually preceded by trials of the DABIT protocol, DABIT being the Digital African Biosecurity and Bioscreening, Biosurveillance and Bioscreening for International Travel.

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This protocol led to the AU initiative that created PanaBIOS, the Pan African Bio Surveillance System. It initially was piloted in Ghana and the first world or the world's first integrated digital contact tracing system saw the entire process of case identification, samples collection and transport, testing and results delivery managed end to end through a digital application. Now this was way back in May 2020, barely three months from the onset of the pandemic. And then in June, the first contingent monitoring and exposure notification system was put in place to allow mass registration of voters to happen without worsening the COVID infection rates in Ghana. Just prior to the elections, the presidential elections. In January 2021, Kenya became one of the first countries in the world to actually verify the authenticity of COVID-19 test results using a digital platform. Now, the rationale for all these is identical. Africa has had to be very risk tolerant in its adoption of technology because unlike in the West where these solutions are seen as incremental shifts to elaborate pre existing mechanisms, in the case of Africa they often involve, as you would imagine, building brand new infrastructure. And architects like Pramod said earlier, therefore have to do much more quicker in terms of novelty and social acceptance by configuring solutions that are adaptive to our reality.

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Because most people don't have smartphones, they have feature phones, people hardly even have phones. And also the fact that they have to come at no cost to be able to get acceptance. So to the specific answer to your question about, you know, how many countries there are 21 countries that have now deployed different levels of the trusted travel and trusted vaccine systems, either directly with the African Union and PanaBIOS, or through regional economic communities like the West African Health Organization.

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You mentioned testing as being one of the main motivations. Could you just talk a little bit about how the trusted travel system is being used to verify testing as people move across borders, for instance?

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Well, what we had to do was to basically integrate the various chains within the ecosystem of biosurveillance. So labs were registered on the platform, we had to register portal, also the national health systems or public health institutes had their national repositories also interlinked. And then we had to connect airlines, we had to connect immigration, and we had to connect the airlines as well. I've mentioned, I mean, aviation authorities. Now, why this was important was because we wanted to remove the burden of verification from the individual themselves, who may not even have phones. So with their ID, the labs upload their test certificates. It runs through the AU PanaBIOS platform, picks up codes and alphanumeric codes in the case of people who have no mechanism to verification of QR codes, alphanumeric codes, or even the numbers that could be written on their travel documents for verification. And any of these institutions that are on the platform who are authorized and have accounts, because this is a closed system, are able to go in there and with the number able to retrieve the test certificate and be able to do the verification. So a lot of the labs were connected onto this platform.

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Accounts were created for lab managers. Port health officials also had accounts. And this spread across the entire 21 countries that have signed onto the platform and done end to end integrations.

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And that sounds like a massive undertaking. I mean, you mentioned the registry of trusted testing providers, but also the implications for capacity of border officials and airport staff and transport carriers. Did that require a lot of capacity building and training to building up of infrastructure to be in a position where they could do that verification?

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Yes, indeed. A lot of the training was done virtually and, and in regimes. So first was getting the lab technicians and the lab admins trained and then they would then go on and train their staff. Then we go on. And then that normally would take two, three days, either virtually by zoom or physically, depending on the circumstance. And then we had also the port health officials that also went through two, three days of training. And again, the training just requires them having accounts, how to open and assess the accounts and how to do verification. And then we'll run demos and then after that the aviation authorities. And once that is done, the country, the Ministry of Health of that respective country will now issue a travel advisory with respect to entry and exit requirements of the country and the digital verifications that were so required.

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Fascinating. Thank you. And Lawrence, let's zoom out a little bit here.

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How does this compare to the picture worldwide? You know, is this similar to what's happening in other regions? How many countries have digital health credentials right now and what are they using them for? Is it mostly a domestic issue or international travel? Give us the global picture.

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Let's start with what they're used for. So digital health credentials, they allow us to verify somebody's vaccination status, their test result, or if they've recovered from COVID-19 and almost all systems, they include vaccination Fewer of them include test results and fewer still cover recovery status. And there are basic two basic use cases for digital health credentials. First, international travel, and second, domestic access to services and venues, like going to the pub and taking a taxi, although they can potentially be used for routine healthcare things like immunization records. So, first, on international travel, the latest data I saw was that as of mid March 2022, 65 countries are requiring proof of vaccination for travel and many more requiring proof of a negative test result. And it certainly seems like the trend is towards countries either requiring proof of vaccination for entry or doing away with restrictions entirely. One good indication is the EU digital COVID certificate, which is probably the system with the widest geographic reach. As of May 2022, it covers all the EU countries, as well as 37 countries and territories outside the EU and even the United States, which is one of the few large countries without a national system.

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It has a set of state and private sector alternatives, in particular the smart health card. So these are certainly common systems. Now, the problem, of course, is that they're not compatible, which is making travel complex and less safe than it could be. The second major use of these systems is domestically. And almost all countries really developed digital health credential systems for domestic use to let people enter restaurants and museums and concerts. And even though by now they are less commonly used, I would just point out that it's. It's hugely important from a migration perspective that migrants and travelers are able to prove their vaccination status in their destination country. So if I'm a migrant worker who just moved to a country that requires proof of vaccination to enter health facilities or public housing or basic social places like the pub, I need to be able to convert my existing proof of vaccination into one recognized by the destination country. And this has proved an issue throughout the pandemic, for example, with Australians unable to enter museums in Italy because our proof of vaccination isn't compatible with theirs. So both uses, international and domestic, they are increasingly common, and they were quite important within the pandemic, even if perhaps the international use case is the one that gets the most attention.

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I mean, in a way, it sounds like both of those use cases have the same challenge at their core, which is that if you have systems that aren't interoperable, they're not compatible with one another, then people on the move, whether they're crossing borders or whether they're living in a country as a migrant worker or whether they're just visiting, might have challenges proving their status. So Pramod, can you talk a little bit about how has India been working with other countries on. On interoperability or on mutual verification? What are there any issues there in terms of people visiting India or any concerns about people carrying the COVID pass able to move globally outside of India?

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Yeah, this is an excellent question. Just before we jump into that, a couple of things that what we are doing to further expand there is significant domestic usage itself and then there is international. So I think our value, we are deriving a lot more value domestically than internationally. I think that's why I think couple of things we did further beyond COVID. The problem if you do it only for COVID is that it is reasonably, you know, time bound and people get back and then they think everything is normal and then the need for it, as Lawrence is saying now these days, asking in the restaurants and so on, it's pretty much almost gone, right? People are stopped asking many of this and suddenly the value of digital credentialing goes away because the underlying platform, of course the vaccination was useful. But the idea of digital credentialing cannot be limited only to COVID because the health credentialing is a much larger topic and must be done. So one of the things India is doing is already expanded to all the tests. RTPCR test was a starting point. So many of the tests are now digitally verifiable certificates and now we are, in the next few months you will see entire immunization efforts, all the child immunization, polio vaccination, all those efforts are going to use the same platform that is actually providing digital credentials for children and parents and so on because that is much more long term value because when they go to school, when they get into admission and even when they go to college, right.

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They need to carry their, the childhood immunization records and so on. So it's a much bigger efforts that is getting done on top of what we have already built. So that is very valuable to not think of just COVID. That's important to think about beyond COVID as a sustainable digital credentialing effort across the health domain. That's what India is doing on the international side. Like both Edem and Lawrence were saying they were parallel efforts, right? EU had their own, African Union has their own. All of them doing exactly same thing, verifiable digital formats and Australia had and so on. Right. So that's where your question is how much have we done to embed? So two things we did: One is to allow our users, Indians who are traveling out to export from coWIN in a EU format. So if you go to coWIN certificate portal for Indians to download, not only you can get a DIVOC format for domestic purposes, but you can actually get an EU format or ICAO format. And Edem, and we have been talking between us to actually bring African Union compatibility as well. So it's a technical thing, it's quite straightforward.

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And both tech platforms can easily provide sort of export as feature, export as EU format, export as ICAO. Why? Because people need to travel and they can export it in the way they wish to export. And that's a very important step without waiting for diplomacy to kick in. And if you don't do this and wait for the countries to have a diplomatic level talk that's long and we have seen that's a point you are asking how much have we done to talk? These country level discussions have been slow, frankly, very slow, painful. And it takes a lot of push and pull.

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Edem, I wanted to ask you the same question. So how is the AU trusted travel system working? You know, can you travel to Australia or Singapore and you know, pull out the trusted travel system and get your vaccination or testing results verified easily? And then, you know, by contrast, can someone visiting Africa easily get vaccination certificates from elsewhere verified?

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Oh yes, they can, using a piece of technology called Polyglot, developed with partners like the United Nations Development Program and PanaBIOS through our Global Haven partnership. But the African Union suite of trusted health platforms can generate travel certificates on demand for the likes of Singapore, the UK and Australia. And as Pramod said, we are currently working closely with this team to cover the DIVOC countries like India and the Philippines. It's important to note that in the design of the trusted travel system, it was also clear to us that we had to take advantage of COVID to sort of build the backbone, the digital backbone infrastructure that the African continent needed. Imagine 55 countries, fragmented, siloed, each one using different systems, some commercial, some government, not talking to each other. We've had experiences in the past where yellow card certificates from one country traveling to another country on the continent where, you know, people were not accepted because they didn't trust the authenticity of the certificate. They imagined that these were people who just probably bought them on the roadside or printed it on their computer. And so for us this was the opportunity to begin to digitize, not just necessarily for COVID, but starting with COVID extending to the yellow cards, children, immunization cards, student trouble, health credentials, all of these things for us had to start at home, and that's why we call it the trusted system.

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We had to generate trust first among ourselves. Most land borders on the continent still are closed. They're beginning to open. What we are doing currently is digitizing test certificate, I mean digitizing RDTs and antigen test kits to be used for the purpose of land border crossing with the sole objective of providing the kind of forensic tools that will ensure that test certificates or test regimes can be validated. You know the source, you know which lab it came from, which actual test kits you can track and trace. And then with that, now you're able to speak to the rest of the world and Africa doesn't need to get marginalized. And so this is of course, as you said earlier, massive undertaking. But we are committed to making sure that we build that infrastructure, we get countries working closely. And the same way as India is doing, the public infrastructure is being built to enable startups, private sector innovators, engineers now to be able to build other solutions on top of it. So we are evolving from trusted travel to trusted vaccines. And now we're evolving into what we are calling trusted health, where we know exactly, we're interlinking with genomic centers, understanding how variants are moving across the continent, how they're moving into the continent.

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I mean, you've all seen the instances where South Africa was penalized when it came up with the discovery of the Omicron variant. And then there was a pushback that, no, it came from other parts of the world because it comes to South Africa now with the kind of infrastructure we're putting in place, we'll be able to know who is coming from where. Because once you start connecting test data to travel data to genomic data, mobility data and vaccine data begins to give you massive information on not how variants are moved on the continent, but also beginning to understand the immunity thresholds of our people on the continent and beyond.

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I mean, Lawrence, does it matter? You know, we have these, these huge systems that are working well within their regions and that's sort of expanding in different ways to be exportable or to be verifiable by different countries. Does it matter that we don't have a kind of global standard or interoperability?

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That's a really good question. One place to start is the fact that we have gotten this far into the pandemic without a global system for interoperability. And it's had many challenges, but it has functioned so far. So it's important to point out that for now, interoperability is the exception, not the norm. So right now we're talking about mutual recognition, which is, I think, like Pramod said, you take your vaccination certificate to the border, you show it to an airline official, as long as it looks vaguely legitimate, it's accepted. But this is, this is susceptible to bias. It's really cumbersome, and it's really easy to let in fake, okay, documents. On top of that, the system, it's deeply inefficient, especially during the travel process itself. So in most cases, because we have to give them, like an airline official, this document, they're checking your name, your birthday, your photo, and then they have to also check the type and the date of the vaccination, whether you're boosted. And all of this is adding extra minutes into each person's travel process. And that all adds up to make it really chaotic when you're trying to process travelers through an airport, for example.

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And if we get the technical and policy decisions right now so that we have this infrastructure in place, it will be much easier for us to kick start it the next time we have to. For the next COVID-19 I mean,

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you mentioned a little bit preparing for the next pandemic, and of course, that's the way that Pramod and Edem mentioned that they're thinking about things in their countries and regions. You know, this is the infrastructure that you're building for future health needs and also potentially for pandemic response. But Lawrence, what does this mean, for instance, for the UN system in terms of pandemic preparedness? You know, you mentioned that there had been no single coordinator. But is the, is the WHO trying to coordinate these efforts more for the next time as part of its pandemic preparedness thinking?

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Absolutely. It seems like that the WHO had had initial plans to pilot a digital credential early in the pandemic. Then it stepped back and issued some guidance instead on digital proof of vaccination and testing. But now it's working on a potential pilot of a global system within the G20 and with the support of the OECD. And this would see it taking on much more of a coordinating role. So instead of having one single global credential, it would basically be a federated system. So each existing system can continue to exist, but the WHO would hold the essential digital information necessary for interoperability, and it would develop a universal verifier so that there's an app which can verify any credential within this WHO network. And it's important that both the WHO and the G20 are working on and calling for this global digital infrastructure to be part of the negotiations for both a new pandemic instrument and the revisions of the international health regulations. And it very much remains to be seen whether this will happen. As of May, there hasn't been a lot of willingness from member states to fully talk about and cover the border and mobility aspect in these negotiations.

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But it's an ongoing process to. So we'll have to wait and see. But it does seem to me that because we know we're going to have future public health breakouts, outbreaks, it is the time for us to put in the efforts and the financial investments into creating an interoperable digital system for the future.

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Thank you. And I wanted to ask, well, a similar question to Pramod and Edem Pramod first. How do these investments in digital infrastructure, how might they shape responses to future outbreaks or future pandemics?

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Yeah, I think Lawrence brought an extremely important point. I think being in the industry for 30 years and I have never seen a global unified effort on anything. Okay. It's very hard to assume they will exist. One system that actually works across the world, right? Geopolitical issues, just, you know, speed issues, different concerns and cares. Different part of the different contextualization issues is different context. It works differently. So I think they will exist. I think as an architect, I always assume they will exist. Multiple systems, period. And the real question is that that G20 discussion Lawrence was bringing is about a coordinated effort to allow that federated system to coexist.

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Edem, same question. How do these massive investments and, you know, this huge undertaking, how will it shape the African region's response to the next outbreak or the next pandemic?

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Well, so as you know, Africa has had its share of pandemics. We had Ebola in the past. We're dealing with COVID now. There are varying waves. We've got, you know, still a lot of zoonotic diseases still lurking around. So the investment was made with the view of ensuring that we build systems that solve our siloed issues, digitize our infrastructure, leapfrog in a way that enables us to connect so that when the pandemics of this nature happen again, we don't have to go to ground zero and start all over again. We're able to strengthen roots or cut out roots or areas that we feel need interventions. And yes, indeed, there's low uptake now because of. Most people assume COVID is gone, it's moved on and people are trying to get to normalcy as possible, but we cannot take a chance with diseases like say Ebola, for example, if there was a breakout of that, you really want to know if that lab, that test took place, whether it took place in a genuine lab, whether it was an accredited lab. You want to know whether the piece of paper the person has genuine. These systems, either forensic, technological and the policies that go with them have to be tested.

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Thank you so much all of you. This has been such a rich discussion. Thank you very much.

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Wonderful to be here. It was great speaking with all of you.

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Thank you so much. Meghan.

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Thank you.

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The policy discussion has so far often focused on the European Union and its EU digital COVID certificate or on the work the World Health Organization has been doing around digitizing the yellow card. We heard today about two regions that did incredibly innovative and impactful work and on a huge scale. DIVOC covers a fifth of the global population, as we heard, which is just an amazing achievement. These initiatives were in many ways bolder because the African Union and India lack the same digital and border capacities as the European Union because both are being used to rethink cross border health systems beyond COVID. So as we heard from Edem, this was a big capacity building and infrastructure undertaking that Africa CDC set up a whole continental registry of labs that can verify test results. They'll be able to use this for future pandemics, outbreaks of Ebola, other pathogens, and the spillover benefits are also great. India's already using the DIVOC system to look at routine immunization so every person can have digitally verifiable proof their polio vaccines. The other lesson here is that digital health credentials need to be part of conversations about pandemic preparations preparedness so that we don't dismantle everything once it feels like the pandemic is over, but we build dormant but prepared systems that can be reactivated for future public health crises.

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If you want to find out more, you can look at Lawrence's paper: Digital Health Credentials in COVID-19; Can Vaccine and Testing Requirements Restart Global Mobility? Which is available at migrationpolicy.org/topics/coronavirus. You can also find our other work on pandemic preparedness there. And if you want to hear more, please subscribe to this podcast Moving Beyond Pandemic wherever you find your podcasts or through our website migrationpolicy.org/podcasts I'd like to thank my colleagues Lisa Dixon, Michelle Mittelstadt and Yoseph Hamid for producing this podcast. The music you heard on today's episode was Juno in the Space Maze by Loopop. I'm Meghan Benton, and I'll see you next time.