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1.Introduction and History
World Health Organization (WHO) has defined telemedicine as, “the delivery of healthcare services, where distance is a critical factor, by all healthcare professionals using information and communication technologies for the exchange of valid information for diagnosis, treatment and prevention of disease and injuries, research and evaluation, and for the continuing education of healthcare providers, all in the interests of advancing the health of individuals and their communities.” The word “telemedicine” which gets more popular during the COVID-19 literally translates to ‘healing at a distance’. Telemedicine is the fast paced technique to treat and diagnose patients from anywhere in the globe using communication networks. Telemedicine is the most advantageous technology, which improves long term-health and increases access to preventive care.
Historically, Telemedicine was first used by NASA during the 1985 Mexico City earthquake, and in 1988, during the Soviet Armenia earthquake. This made a mark in history when all other modes of communication became disrupted while satellite technology used in telemedicine proved to be exemplary. In India, the first telemedicine service was established by Apollo Hospital in Aragonda; a village in Andhra Pradesh.
2.Telemedicine in India
With a population of more than 140 crores; the equitable distribution of healthcare services in India has proven to be a major challenge in public health management time and again. In addition to this is the concentration of healthcare facilities in the cities and towns (includes 75% of the doctor’s population), far from rural India, where 69% of the population live. There are very limited primary healthcare facilities for the rural population.
In India, telemedicine offers numerous advantages such as increasing accessibility to healthcare services, improving patient outcomes, and reducing healthcare costs.
1.Convenience & Accessibility: Rural or remote area patients can be directly benefited by telemedicine, where access to healthcare providers is limited. It can also be useful for patients who have mobility issues or disabilities. Patients can receive treatment from the comfort of their own homes, without having to travel long distances or spend time in waiting rooms.
2.Cost benefits: Telemedicine can directly save costs for both patient and healthcare provider. Patients can save money on travel and time off work, while healthcare providers can save on costs associated with maintaining a physical office.
3.Effective patient outcomes: Particularly in areas of chronic disease management, mental health, and prenatal care; telemedicine can lead to an increased outpatient outcome.
4.Time efficient: Telemedicine can save time of patients by avoiding long wait times in doctor’s offices and also of healthcare providers by allowing them to see more patients in less time.
5.Lessen unofficial medical practice: Telemedicine can possibly lessen or stop the unofficial medical practice (Jhola Chaap doctor) which is very much prevalent in rural India.
The regulatory and policy frameworks governing telemedicine in India have evolved tremendously in recent years. The Ministry of Health and Family Welfare in March 2020, issued guidelines for telemedicine practice in India, by providing legal framework for the practice of telemedicine which includes prescription of medicine, legal and ethical standards for telemedicine practice, and providing guidance of issues such as patient consent, privacy , confidentiality, and medical records management. Yet, there are numerous challenges in ensuring equitable access to telemedicine in the country. They have been discussed in detail in subsequent sections.
3.Current Landscape of Telemedicine in India
During the COVID -19 pandemic, there was an increase in adoption of telemedicine in India. To reduce the chances of infection transmission in healthcare facilities; the government encouraged the use of telemedicine. The Indian government has launched a number of initiatives to promote the use of telemedicine in India. One such initiative is the e-Sanjeevani telemedicine platform launched by the Ministry of Health and Family Welfare.
e-Sanjeevani telemedicine: Launched in November 2019, it is one of the largest telemedicine platforms in the world and has a crucial role in expanding access to healthcare services in India, particularly during the COVID-19 pandemic. It is a doctor to doctor telemedicine system implemented under the Ayushman Bharat Health and Wellness Centre (AB-HWCs) Programme. This platform enables patients to consult with healthcare providers remotely by using video conferencing technology. Patients can access the platform using a mobile phone, tablet, or computer with internet access in English and Hindi. It was launched to tackle the issues of uneven distribution of healthcare personnel and infrastructure by bridging the gap that exists between urban and rural, rich and poor population.
The cloud-based e-Sanjeevani platform is implemented in two modes: 1. eSanjeevani AB-HWC (a provider-to-provider telemedicine platform): this variant provides assisted teleconsultations for patients who walk into Health and Wellness Centres (HWCs), community health officers in Health & Wellness Centres facilitate the teleconsultation for the patient who are connected to the doctors and specialists in hubs established in secondary/tertiary level health facilities or medical colleges. This variant is based on a Hub-and-Spoke model. 2. e-Sanjeevani OPD (a patient to provider telemedicine platform): it empowers citizens to access health services in the confines of their homes through smartphones or laptops etc.
4.Healthcare infrastructure in rural India
The healthcare infrastructure in rural India has 3 tiers. The detailed breakdown of these tiers are as follows:
However, despite the aforementioned minimum staff requirements, there is an acute shortfall in many states of the country. When it comes to health workers and nursing staff, Uttar Pradesh tops the chart with a shortage of 2,288 ANMs and 2,134 nursing staff in 2021-22 respectively. Rajasthan, where our research was based, has a relatively smaller shortfall of 173 ANMs and no shortfall of nursing staff. In many states like Uttar Pradesh, despite the natural expectation that the rural healthcare system would have been reinforced in light of the devastation caused by the COVID-19 pandemic, the shortfall in rural health staff had increased.
When it comes to doctors in CHCs, the situation is far worse. Over the years, there has been a significant increase in the number of PHCs and CHCs in the country. There has been an increase of 1904 PHCs and 2,135 CHCs from 2005 to 2021. However, this increase in infrastructure has not been supplemented with a proportionate increase in manpower.
As we can see from the table above, in 2021, there was a 66.1% shortage of male health workers in PHCs. The objective of setting up CHCs in the country was to provide referral as well as specialist health care for the rural population. Yet, there is a nearly 80% total shortfall of specialists in CHCs across the country. The shortfall is not uniform across states, with some states, especially the larger ones like UP, Rajasthan, Gujarat and MP registering a disproportionately high shortfall of specialists.
5.Scope and limitations of study
We conducted interviews with 30 households and 3 medical officers across 3 villages in rural Udaipur (10 households & 1 medical officer/village). Udaipur is a district which ranks among the lowest in terms of HDI in the country. Rural Udaipur is mostly inhabited by people belonging to the Meena, Bhil, Garasiya, Charpota and Ninama tribes. Due to the hilly terrain, villages are not densely populated and commuting to and from the city and even a given village tends to be difficult and time consuming. For example, it takes an hour and a half to commute between one of the villages we surveyed and the largest government hospital in the city by public transport, even though they are just roughly 30 km apart. Similarly, in another village, it takes roughly 45 minutes to an hour to commute between the local PHC and the farthest village ward, hiking over steep hills and rocks.
Most adult males from these villages are engaged in daily wage labor in Udaipur city or seasonally migrate to far-off cities like Ahmedabad, Himmatnagar, Jaipur etc. in search of work. While most households engage in seasonal agriculture, they are constrained by small landholdings and unfavorable terrain. Thus, the household income of most households is precarious.
6.Primary research findings
6.1Household expenditure on healthcare continues to be significant
The median income of the households we interviewed was INR 8,500 per month. 85.7% households which had at least a member falling ill, visited a hospital/clinic and/or consulted a doctor.
The median household expenditure on healthcare in the previous year was INR 3,000. This amounts to nearly 3% of the total annual income of the family being spent on healthcare. This despite healthcare being free end-to-end in government facilities and free health insurance of up to INR 5,00,000 being provided under Rajasthan’s flagship Mukhyamantri Chiranjeevi Bima Yojana. In the previous year, roughly 1/4th of the expenditure was spent on managing chronic illnesses like hypertension, high blood sugar, chronic pains and aches etc.
When respondents visited private hospitals/clinics, the median expenditure on doctor consultation was INR 1,100. The median expenditure on medicine was INR 3,000. Although medicines in government hospitals are provided free of cost, 5 out of 15 households who exclusively visited government hospitals reported that there was a shortage of prescribed drugs which forced them to purchase them from private pharmacies. The median expenditure on traveling to a hospital/clinic in the city was INR 1000.
The median greatest household expenditure on a single illness that had befallen the household was INR 15,000, with 8 households spending over INR 1,00,000.
only 23 out of 30 households reported significant expenditure on a single illness.
6.2Healthcare preferences of most rural Indians is still govt. led services
19 out of the 30 households interviewed showed a preference towards government hospitals for initial treatment and diagnosis. However, this preference doesn’t translate into satisfactory resolution in the majority of cases. While 56.7% respondents visited the local PHC or CHC initially for most of their ailments, only a minority i.e. 35.3% of respondents had satisfactory resolutions. Most of these respondents reported that they had to consult a private practitioner for an illness that can be termed as common.
When it came to government hospitals as a whole, inclusive of big government hospitals in the city or nearby towns, there was a strong preference (63.3%) for them over private hospitals. When we consider the factors that influence a household’s choice of hospital, it becomes clear why this is the case.
Most households reported a combination of factors that influenced their choice of hospital. Primary among these were cost (13 responses), quality of treatment (11 responses), distance (10 responses) and amenities (7 responses). The cost factor is inclusive of consultation fees, medicine, diagnostic tests, travel and caretaking costs. Due to government hospitals at all levels being free for poor households, they are favored over private hospitals.
For most respondents, quality of treatment included perceived efficacy like doctor’s reputation, dose, type and number of medicines prescribed. For instance, most households had a belief that most illnesses cannot be cured without prescribing injections. They were also of the opinion that a doctor needs to physically touch and inspect a patient in order to diagnose their illness. At the same time, real efficacy indicators like time taken to heal and a doctor’s/hospital’s ability to diagnose/treat formed an important part of the consideration of quality. Amenities included availability of adequate medicines, beds, availability of specialist doctors. In this regard, we observed that PHCs generally had a reputation for being suitable for minor illnesses like common cold and stomach aches only. This reputation was formed by PHCs lacking specialist doctors, doctors prescribing minimal medication and diagnosing without properly inspecting patients. The lack of specialist doctors could be seen in the village having a CHC as the doctor-in-charge at the hospital reported that they just had 2 doctors posted at the hospital, one anaesthesiologist and one gynecologist. Additionally, doctors’ working hours were fixed during the day and they commuted from the city, thereby rendering emergency consultation improbable. Moreover, the opportunity cost for most households of consulting during the day was high as they were engaged in daily labor. However, when it came to big government hospitals in the city or neighboring towns, the quality of treatment provided and availability of amenities was mostly held in good regard. The only deterrent for many households in this case were the long queues, bureaucratic processes and frequent unavailability of prescribed medication.
6.3Telemedicine awareness is negligible
No household that we surveyed had ever accessed teleconsultation of any kind. 90% of households were unaware about the Ayushman Bharat DIgital Health Mission (ABDM) or the eSanjeevani OPD. Even those who were aware about the existence of the said policy weren’t informed about how they were to be accessed. 83.3% of households did not know whether their local PHC or CHC was equipped with eSanjeevani assisted telemedicine service.
Only 6 respondents (20%) reported that no member in their household owned a smartphone. Majority of respondents and their respective family members who owned a smartphone could use it for calls (66.7% & 100%), messaging (50% & 94.1%) and social media (54.2% & 94.1%). However, only 1 respondent and 1 respective family member had ever used any government service/app on their smartphone (4.2%).
6.4Ease and efficiency will drive telemedicine uptake
Majority of households (53.3%) that were interviewed responded positively to the use of teleconsultation if it were made available, while 40% households were uncertain. However, there were a few crucial factors which respondents said will affect their decision to use teleconsultation service. The primary factor is efficiency in terms of time (14 households), followed by ease of use (11 households) and efficiency in terms of cost (10 households). Households were willing to avail teleconsultation services if it would save them time that is spent traveling to the city/town and standing in queues at the big government hospitals. Similarly, they were willing to use teleconsultation if it would be provided free of cost or at minimal cost. However, due to the lack of confidence around their own digital capacity, households were concerned about the service being easy to use and/or someone being present to assist them while using this service. Surprisingly, despite quality of diagnosis/treatment being a major factor affecting one’s choice of hospital in the status quo, only 5 households were concerned about the quality of teleconsultation. As discussed earlier, physical interaction weighed considerably on respondents’ evaluation of quality. Thus, 26 respondents (86.7%)were of the opinion that teleconsultation could only be used for initial diagnosis of minor illness, mostly an upgrade over the quality of care they received in PHCs today.
7.Challenges for implementing telemedicine services in rural areas
The challenges that need to overcome in order to ensure equitable access to telemedicine services in rural areas of the country can be summarized as follows:
1.Digital literacy and connectivity: India has 759 million users who use the internet at least once a month. The number is expected to grow to 900 million by 2025. 399 million of current users are from rural India, which witnessed 14% growth in the number of users in the last year. Yet, as we discussed earlier, the state of digital literacy in the country is extremely low with 80% of the population not possessing adequate digital literacy to use the internet. Despite the advent of 5G, around 50% of the population across the country have poor to no internet connectivity. Additionally, most PHCs do not have a resource person who can help people access teleconsultation services.
2.Lack of information and awareness: The lack of awareness is at two levels. First, there is an acute lack of information about many facets of accessing healthcare. Second, there is massive unawareness about what constitutes teleconsultation and how it is to be implemented. There are numerous factors that contribute to this lack of awareness and inability to access information. It is difficult for everyone to learn about how medicine and diagnosis work. Due to lower levels of education and lack of access to information, the situation is even more precarious for people in rural areas. At the same time, even slight inaccuracies or anomalies in providing healthcare can have dire consequences. Thus, while people trust healthcare providers and put their full faith in them to get cured, this trust becomes a double edged sword which results in patients forming dogmatic assumptions about them and their methods when they don’t work. All the examples discussed above about needing physical interaction to properly diagnose illness, syringes being more effective than oral medication point towards this phenomenon. Thus, while creating awareness about teleconsultation is important, it has to be complemented with creating awareness about basic facets of healthcare delivery.
3.High dependency on existing healthcare infrastructure and personnel: For teleconsultation to work well, proper examination and transparency with regards to information sharing are necessary. For proper examination, local HWCs need to be equipped with adequate testing facilities and manned by personnel who are trained in carrying on the examinations ordered by the consulting doctor. Thus, it is uncertain how illnesses more serious than those being entrusted by villagers to PHCs in the status quo would be diagnosed without building the capacity to carry on the necessary examinations. Additionally, the onset of teleconsultation in rural areas might also warrant stocking up on a wider variety of medications for it to truly save time and cost by patients not having to travel to the city/town. Given the responses around shortage of medication even in larger government hospitals in cities and towns, limited supply might prove to be a hindrance in truly realizing the potential of teleconsultations.
4.Shortage of doctors: As we discussed earlier, there is an acute shortfall of specialist doctors employed by the government in status quo. While teleconsultation will result in better distribution of manpower among existing government facilities, government doctors already are overstretched and overburdened with their current workload.
5.Insurance coverage: The ABDM envisions bringing together private healthcare providers to provide teleconsultation. Given cost of healthcare is a major factor affecting one’s choice of hospital, it would be difficult to effectively implement teleconsultation services in rural areas without bringing them under the purview of insurance coverage. However, there exists widespread apathy towards government provided health insurance policies from private practitioners and healthcare providers as witnessed through the recent protests in Rajasthan against the state’s Right to Health Bill which sought to bring all private health services under the ambit of government provided insurance.
6.Data privacy: Due to limited digital literacy, rural populations are highly vulnerable to breaches of data privacy. Health data is highly sensitive data. While the latest Data Privacy and Data Protection Bill is a step in the right direction to provide stringent protection against data breaches, recent experiences in the country pertaining to digital health points towards a great deal of ambiguity around consent and classification of data on the ABDM platform.
8.Recommendations
Based on the challenges identified above, it will require a systematic effort to successfully ensure equitable access to quality telehealth services in rural India. Due to limited digital penetration and digital literacy levels, focus should be on scaling and strengthening the e-SanjeevaniAB-HWC module in rural areas. A few recommendations in that regard are as follows:
1.Capacity building: Capacity building needs to happen at two levels. First, the capacity of community health centers need to be built to handle telemedicine. Currently, there is a shortage of nearly 17,400 doctors in CHCs across the country. For providing accessible telemedicine services, it is essential to bridge this gap as much as possible. As telemedicine services don't require doctors to be at the hospital for shifts, private practitioners can be hired on a part time basis. Second, healthcare providers at local PHCs should be trained on using the module for teleconsultation. This could be done by leveraging National Institute of Electronics & Information Technology’s (NIEIT) expertise in providing technical training to improve governance. There should be a dedicated resource person in each PHC to help patients access teleconsultation services. With eSanjeevani 2.0 being rolled out in March 2023, the use of Point of Care Devices (PoCD) should be encouraged and taught to healthcare providers. PoCDs provide results of various clinical tests including physiological parameters within minutes of taking a test, thereby facilitating rapid diagnosis and quick decisions. These devices could prove to be a cheap and effective alternative to equipping PHCs with full-scale infrastructure for diagnosis, thereby encouraging people to visit PHCs for even complex diagnoses.
2.Building awareness: Under the aegis of the National Health Mission (NHM), there has been great progress in creating awareness about health and wellbeing by ASHA workers in villages. Yet, certain less-informed beliefs about methods of diagnosis and treatment as discussed earlier might hinder the buy-in of communities into telehealth services. Trust is key in making public health initiatives work. Large scale awareness programs utilizing the vast network of existing ASHA workers and targeted education programs aimed at community leaders from underserved communities can help build trust in communities upon the efficacy of telehealth services, the benefits and procedure of creating the Ayushman Bharat Health Account (ABHA) card/ID and breaking down myths about different facets of healthcare.
3.Leveraging network effects: Some of the major benefits of connecting a large number of hospitals/health centers, medicine suppliers/pharmacists, diagnostic services and individual practitioners are the network effects that can be derived out of it. The following network effects need to be leveraged for telemedicine to be successful in rural India:
a. Knowledge sharing - sharing of best practices between stakeholders at different levels of the healthcare delivery system to ensure quality, timely diagnosis, monitoring and treatment.
b. Efficient allocation of services - depending on availability, telehealth operators could have the liberty to connect to required practitioners, hospitals, diagnosticians or pharmacists.
c. Greater choice for patients - with ABDHM’s vision of encouraging private practitioners to join the telehealth network, patients in rural areas should have the liberty to opt for consulting private practitioners and allied services from their villages.
d. Health mapping - with ASHA cards/IDs ensuring patients’ health data could be stored online, efficient health mapping could take place which would in turn result in better understanding of health problems and behavior among people,risk and intervention evaluation chalking out clustered intervention strategies for maximum efficacy and efficiency.
e. Telepharmacy service - in order for people to save time and money traveling to cities, there needs to be sufficient supply of medication in village PHCs. This can be ensured when their stocks are mapped online and restocking happens according to demand.
4.Providing insurance cover for telemedicine services: With people in rural areas being price sensitive about healthcare services, it is essential that government health insurance cover, like that of the Chiranjeevi Swasthya Beema Yojana in Rajasthan, is provided for availing telehealth services, end to end, especially for services by private providers. This will require a substantial amount of confidence building among private healthcare providers due to the reputation for government health insurance coverage being difficult to process and claim for these providers. Efficient grievance redressal systems can help build trust among private service providers.
5.Permitting inter-state practice: ESanjeevani currently only permits patients to consult doctors from within the state they reside in. In order to address the disproportionate shortage of doctors across states and ensure timely access, inter-state practice needs to be permitted.
6.Incentivising R&D for greater implementation of RPA & AI: Implementation of RPA and AI solutions in telehealth can further propel the growth of this industry. Administrative tasks, prescription management, diagnosis management, insurance claims and patient data sharing, all can be processed with more agility and accuracy than ever before. AI algorithms can not only enhance the accuracy and speed of diagnosis but also assist doctors in detecting high-risk conditions. Predictive AI/ML-enabled automation can be used to improve remote patient monitoring by automatically screening medical needs or detecting emergencies and alerting providers.
7.Forming clear guidelines and regulations: Guidelines and regulations need to be formed to qualify patient-physician interactions, create an accountability framework to tackle medico-legal negligence, malpractice and liabilities, procedures for gaining consent from patients, use of data, follow-up care and integrating technology and medical practitioners’ procedures.
Meet The Thought Leader
Vamsi is a mentor at GGI, and has a diverse background that includes being a former McKinsey employee and a graduate of IIT Madras. He possesses a broad skill set encompassing strategy and operations, gained from his various roles and industry exposure.
Meet The Authors (GGI Fellows)
Vivek is currently a Ph.D. candidate at Case Western Reserve University, Ohio, United States. He completed his Masters in Organic Chemistry from National Institute of Technology, Warangal, India securing a Gold medal. He was also selected for the Erasmus Mundus Scholarship to do research at Freie Universtat Berlin, Germany. He is passionate about driving change in medicine and life science in the interest of public health. He has strong interests in scientific advocacy and and public health policy.
Subham is a lawyer, working to impact the lives of adolescent students from underserved communities by building their capacity for leadership and resilience in the 21st century. He is passionate about helping state and non-state actors maximise their impact in the realms of education, public health, minority rights and local governance.
If you are interested in applying to GGI's Impact Fellowship program, you can access our application link here.
Resources
International Journal of Pharmaceutical Research and Applications Volume 8, Issue 3 May-June 2023, pp: 1373-1380
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https://www.cdc.gov/museum/pdf/cdcm-pha-stem-mapping-public-health-lesson.pdf
https://www.amazon.in/Poor-Economics-Radical-Rethinking-Poverty/dp/1610390938