Three-quarters of Indians live in rural areas (68.8% as per the last census), only 25% of qualified doctors are located there. From a policy and welfare distribution perspective, this is foundational health inequity. Simply put, there aren’t enough doctors for every Indian close to where they live.
In 2020, the Covid-19 pandemic added an unprecedented burden on an already burdened healthcare system. The pandemic underscored India’s fragmented health system, and it raised an urgent need for innovative models to create resilience and a robust public health response system for healthcare emergencies. Since the onset of the pandemic, social distancing norms, lockdowns and overburdening of the physical health infrastructure has collectively pushed telecare/telemedicine into the mainstream of health provision. Or so it seems, but how much of India’s health infrastructure and services deficiencies have Telemedicine been able to address? How much can it be expected to do?
Telemedicine is hardly a new idea but is still one of the most innovative in all its avatars. Using telephony for medical care was first piloted in India in 2001 – having existed for nearly two decades. In 2001, the Indian Space Research Organisation (ISRO) initiated a nationwide telemedicine programme and provided the necessary infrastructure for 384 hospitals with 60 speciality hospitals connected to 306 remote healthcare facilities. However, there was neither a concerted effort by the providers nor an urgent response from Indian residents. Telecare (later called Telemedicine) stayed on the fringes of healthcare and the public health system for almost two decades.
Early into the pandemic, India launched the telemedicine practice guidelines that regulate medical prescriptions given via telephony and prescribe detailed procedures on conducting follow-up care for chronic diseases, thereby enabling patients to consult doctors from home. An indigenously developed telemedicine initiative, ‘e-Sanjeevani‘, offered a range of telemedicine services via the hub and spoke model through a ‘Health and Wellness Centres’ network under the flagship Ayushman Bharat programme Government of India. E-Sanjeevani catered to 0.8 million telemedicine consultations across India within six months of its launch last April.
Other governments and partner organisations have also funded and promoted Telemedicine in the wake of the pandemic. As an emergency Covid 19 response, USAID has invested in telecare through several partner organisations. Through USAID funding Jhpiego, the Nishtha project runs a telecare program with an estimated reach of 41 million beneficiaries in Nagaland and other states of the Northeast of India. In Southwest India, SMRC has forged partnerships between livelihood development goals for Persons with Disabilities (PWDs) by training PWD women on basic Telemedicine; this initiative saw 273 participants from Gujarat, Odisha and Telangana.
The private sector, too, has shown keen interest in the field. A few major Indian private sector players in Telemedicine include Narayana Hrudayalaya, Apollo Telemedicine Enterprises, Asia Heart Foundation, Escorts Heart Institute, Amrita Institute of Medical Sciences, and Aravind Eye Care. India’s civil society networks have also engaged with Telemedicine. For instance, a volunteer-led programme by a group of Indian health start-ups, supported by 7000 healthcare professionals, developed a telemedicine platform named the project ‘StepOne’ offering tele-triage for COVID-19.24 In partnership with 16 state governments in India. Several private corporations either established new toll-free numbers or managed the existing emergency health helpline numbers that governments were using for ambulance services both for their employees and the public at large.
While data on the reach of telecare is limited, it is believed that the potential reach of telecare can be estimated based on the distribution curve of smartphones and the internet. With only 50% of the urban population and less than 25% of the rural population having access to the internet, the poor and marginalised are far less likely to get the benefits of telecare than the more privileged. The following factors add to the challenges of equitable health care:
Urban-Rural Divide:
With a population of over 120 crores, India is the second-most populous country in the world. The number of doctors and health professionals are insufficient. Added to that is the mismatch of concentration of health facilities and professionals in urban and rural populations.
Despite this, the digital penetration in rural India is deepening, and telecare often presents itself as the only viable solution (in terms of cost-effectiveness and one-to-many reach) for this population. However, slow clinical acceptance, resistance from doctors, the unreliability of internet connectivity and poor bandwidth, a lack of digital literacy and an attendant lack of standards, especially of telecare services coupled with unfriendly technological design, continue to hamper the prospects of Telemedicine.
Gender Divide:
While Telemedicine is emerging as the alternative for ‘in-person visits’ to the health facility, a deeper exploration of the digital divide, digital gender divide, and social norms needs careful consideration. The National Family Health Survey (NFHS 5) reveals a significant digital divide in the country, with rural women right at the bottom. The data demonstrates that only 42% of Indian women surveyed have ever used the internet, compared to 62% of men. In Indian cities, the percentage is slightly higher, with 56% of women and 73% of men ever having gone online. The GSMA report presents the top barriers for internet use among women as literacy, relevance, affordability and safety in that order.
Social Norms:
Cultural and social norms dictate the behaviours and digital use patterns for women. Men have been the primary gatekeepers for access to digital technology as well as health uptake. Safety, protection and respect in the community are the most often provided justifications for these norms.
For instance, a village in Gujarat has reportedly banned women from using or possessing mobile phones – with the threat of fines for those caught in the act. These deep-seated norms where women need permission from their husbands, fathers or brothers to reach services, including the use of technology, has been a major barrier. It is only recently that research has demonstrated some ways past these barriers for women customers of telecare – for example, we now know that women prefer IVR services with a female voice over other forms of connection.
While telecare presents an opportunity for the health system to reach the most vulnerable and augment the primary health system, we will need to fast track digital literacy and internet access among the vulnerable for a more equitable uptake of telecare. In addition, a renewed focus on gender norms and belief systems that inhibit health-seeking behaviours will have to be addressed for an equitable healthcare system.
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