The imposition of lockdown in India has contributed to the popularity of telemedicine in the last year. The Government of India’s tele-consultation platform eSanjeevani, which connects patients with Government doctors in 28 states and Union Territories has crossed over a million consultations since its launch in April 2020. Private technology platforms and aggregators of doctors like Practo for example have recorded a 500% jump in online consultations towards the end of 2020.
The pandemic has repositioned telemedicine as a crucial medium for healthcare delivery. While associations like the Indian Medical Association initially opposed telemedicine, raising concerns of possible unhealthy fallouts in patient care and the likelihood of medico-legal issues, they have now come out in support of telemedicine, provided there are safety checks and mechanism to prevent fraud.
The growing demand for telemedicine and the lack of proper regulatory framework prompted the Government of India to notify the Telemedicine Practice Guidelines in March 2020. Additionally, the Economic Survey Report 2021 vouched for harnessing telemedicine to its fullest but also stated that its success depended on internet penetration in all parts of the country. Yet, stakeholders including the Government and private players need to do more to ensure telemedicine is inclusive and robust.
COVID-19 – a catalyst for Telemedicine
Telemedicine has been around for a considerable time, the Indian government has in the past run pilots and studied the benefits of Information and Communication Technology on healthcare delivery, including Indian Space Research Organization’s (ISRO) first SATCOM-based telemedicine network project at Aragonda, Andhra Pradesh in 2001. There was a common understanding that this could revolutionise access to healthcare provided infrastructure was in place.
However, the use of private platforms in delivery teleconsultation in urban areas was opposed by bodies like state medical councils – the Karnataka Medical Council for example issued a statement warning doctors against online consultation in May 2019, only to reclarify its stand through a circular dated 27 March 2020 allowing the operation of telemedicine platforms in light of COVID-19.
The shock to the health sector during the onset of COVID-19 in India saw resources being diverted to mitigate COVID-19, which came at the cost of outpatient visits to hospitals, hospitalisations for Non-Communicable diseases (emergencies) and the country’s immunisation drives. This also exacerbated inequalities, particularly the poor and people living in rural and remote areas who were cut off from healthcare due to existing shortage of practitioners, especially specialists leading to stagnation of healthcare delivery in rural India.
These factors only accelerated the popularity of teleconsultation platforms and forced the government to accelerate its deployment through policy interventions and investing in its own platforms like e-Sanjeevani.
Strengthening Telemedicine Policies and Structure
Digitising healthcare has been attributed to overcoming manpower shortage, numerous private hospitals and platforms have capitalised on providing distance telehealth facilities including, tele-ICU facilities in partnership with smaller hospitals in rural India. However, tele-ICU has not been regulated and is beyond the scope of the Telemedicine Practice Guidelines as it only focuses on the practice of outpatient telemedicine. There is a need to broaden the scope for telemedicine and include inpatient care, which is currently lacking in India.
The popularity of e-Sanjeevani shows that trust in the public healthcare system is growing and the demand is bound to increase with its expansion to the rest of the country. It is therefore important to ensure that the time of teleconsultation is optimised to the fullest and that patients are screened to be presented to appropriate doctors or specialists who are more likely to address their symptoms. It could also be designed to ensure a seamless referral system, where if one doctor is unable to diagnose a problem, the patient is referred to a specialist within a short span of time. This could prevent repeated login or visits to dedicated telehealth facilities, and prevent repeated advice from doctors.
Network Connectivity and Telemedicine
Access to smartphones and internet is crucial to access personalised telemedicine facilities, the economic survey report proposed strengthening BharatNet Optic Fiber Network in the Gram Panchayats (GP) across India. While access to internet is crucial to the success and inclusivity of telemedicine, the goal to connect all 2,50,000 GPs in India remains slow with repeated extension of deadlines leaving many GPs left without broadband connectivity. Internet penetration is still sub-optimal, with a large proportion of Indians dependent on mobile network than broadband.
Far more glaring is the gender disparity in accessing the internet – in 2019, the IAMAI reported that the breakup between male and female users with respect to access to internet in India level is 67% and 33%, respectively, the breakup in urban areas is 62% and 38%, respectively. In the rural areas, the gap is wider with men accounting for almost two-thirds of the internet users at 72%, while women account for a mere 28%. This pretty much means that a large majority of women, will either have no access to telemedicine facilities or remain dependent on male relatives who have access to smart phones.
In order to overcome the disparity in access to internet and address common ailments, e-Sanjeevani can be strengthened to have internet equipped wellness centres offer shared consultation or follow-ups services for individuals with common illness or ailments. Additionally, public health centres should also look a including those without smartphones, especially those still dependent on features phones. Over 33% of phone users in India are feature phone users. Ensuring they are registered into the public health systems with regular automate messages for follow up consultation and dial in features to access practitioners could be incorporated.
The pandemic has accelerated the deployment and proliferation of telemedicine for primary healthcare and can overcome India’s challenges owing to shortage of manpower and last mile challenges to healthcare delivery. Yet its scope needs to be broadened to truly make it accessible and successful, this includes broadening the scope of telemedicine and tele-health to include in patient healthcare and also ensuring that connectivity is bolstered across the country. It is also important to ensure that the e-Sanjeevani platform evolves to connect patients with little or no internet connectivity.