ISRO may have sown the seed of telemedicine in India, but it was the Coronavirus-caused pandemic that propelled the widespread adoption of telemedicine and made it an irrefutable need for the present and the future care delivery methods and one that could be exploited to achieve sustainable healthcare solutions for our country’s semi-urban and rural communities. Few organizations and startups mentioned here in this post have gone several extra miles with their efforts to enable telehealth in their own ways.
Rural India has always had poor health infrastructures, and with the second wave of the pandemic hitting the country hard, the acute paucity of care resources further made the people in remote areas become more vulnerable to the virus. The Primary Health Centers (PHCs) have traditionally been ill-equipped with very medical staff and physicians. With no access to quality healthcare, rural citizens are forced to travel to the nearest city and this is usually a long journey made with limited financial resources. Not to mention the already overburdened hospitals in urban India that grapples with limited resources under peak pandemic waves are further burdened with patients from rural quarters.
The problems in rural India are factually known to everybody and this is why telemedicine is seen as the only resolution. It is rather wise to take healthcare to the deprived areas than the citizens go seek for it. This does not mean that taking telemedicine to remote areas is a piece of cake. It demands resources in the form of humans, monetary, and time.
Now, India has never failed to rise up to any situation, nor scale up its capacities. Likewise, tackling the different waves of the pandemic with telemedicine as a major tool has been the best example. Planning, execution, and most importantly persistent toiling combined with overcoming innumerable infrastructure challenges by some of the country’s purpose-driven organizations and startups have made telemedicine a reality to rural healthcare.
ISRO may have sown the seed of telemedicine in India, but it was the Coronavirus-caused pandemic that made telemedicine an irrefutable need for the present and the future care delivery methods and one that could be exploited to achieve sustainable healthcare solutions for our country’s semi-urban and rural communities.
Sensing the need for such tech-enabled healthcare solutions, few organizations and startups mentioned here in this post have gone several extra miles with their efforts to enable telehealth in their own ways.
Highlighting rural India’s major telehealth and telemedicine enablers
Somewhere in the hinterlands of Northern India a van, bearing internet signal receptors, is relentlessly traveling to serve people with essential and prerequisite digital services that are mandatory in this COVID-19 second wave pandemic times. This van, called the Internet on Wheels, is developed and provided by the Digital Empowerment Foundation (DEF). Though launched in 2018, this facility was ramped up during the first wave of COVID-19 in 2020. During the second wave in 2021, as the virus peaked even in rural parts of India, the van was modified to host and provide many more facilities, including awareness on COVID vaccinations.
What I am aware of is that, between April and May 2021, the van has traveled nearly 25,000 kilometers and has served over 200 villages. Each vehicle is equipped with capabilities to facilitate:
- Ration kit distribution
- Vaccine registration
- e-Health on call/video call
- Myth busting
- Mask and sanitizer distribution
- Digital financial services
With these capabilities, the van was welcomed for its timely services and became a super hit among the rural public. The success of this purpose-driven vehicle, in a short time, made DEF scale up to introduce the initiative in 100 new locations using 5 vans, 45 bicycles, and 50 motorcycles.
Osama Manzar, Founder & Director of the Digital Empowerment Foundation believes that in India, despite the elaborate health network, only 13% of the rural population have access to primary healthcare centers, 33% to sub-centers, and 9.6% to a hospital. This, he says, can be increased through telemedicine and can benefit larger Indian populations. As a strong advocate of telemedicine, Manzar says that it can provide solutions to address three basic healthcare issues of awareness, access, and availability in India.
“The DocOnline services developed by DEF provides people in villages with a quick and easy solution to their health problems. DEF’s frontline workers travel from village to village providing medical consultation to people who are unwell via a medical professional on call. This gives people in rural areas the best medical advice without having to leave their houses,” shares Manzar, which is probably the best service for rural areas during the intense lockdowns days.
We are all aware that in India, the doctor-to-patient ratio is 1:10000 (avg) which is 10x higher than what has been set by WHO as 1:1000, which means it is just not possible to match this scale and increase the doctor numbers in a short time but Pankaj Mazumder, COO, Oxyfind Technologies, says it is certainly possible to optimize the operation and efficiency by building remote OPDs and to get people to access to city doctors through telemed applications.
Mazumder rightly says that a patient from a rural place has to spend a lot of time on travelling and waiting to get a 10- or 20-mins consultation time from a city doctor. If a remote OPD is implemented that too at a very low capital expenditure compared to a physical infrastructure, it would save first the life of the patient, second time and lastly the much needed – saving money that is involved in commuting and treatment for a financially constrained rural citizen.
Oxyfind has developed a technology where it is possible to build remote OPDs in remote locations of India. Mazumder says that this tech is possible with the redundant fiber infrastructure of telecom companies where video conference streaming in HD or 4K resolution has been made possible without internet dependencies.
“Delivering healthcare solutions under low internet availability conditions is Oxyfind’s USP. Oxyfind’s telemedicine application is named OXYPHONE. This application works on peer-to-peer technology, which means the need for any cloud infrastructure is negated in between to render or deliver the videos. Oxyfind has tied up with WISTECH (www.wistech.in) to establish a point-to-point link between the two locations (city hospital and rural remote OPD). Once the link is established, we run our OXYPHONE application on top making it less- or non-dependent on the internet. As it is an enterprise solution, it is possible to scale up healthcare at very low capital expenditure,” says Mazumder.
In partnerships with the Governments of Eastern India, Oxyfind has delivered COVID-19 health care and has even taken up COVID-19 vaccination drives. Oxyfind is in talks with NHM (National Health Mission) GoA (Govt of Assam) to organize or optimize the rush in vaccination centers with its Oxyfind Smart Screen (OSS) solution. OSS turns a phone into a real-time appointment slot tracking device, where the patient can track his/her appointment slot in real-time, which can potentially result in less crowd in those vaccination drives.
Commenting about the feature, Mazumder says, “We are already aware of the huge queue and crowd in the vaccination centers and we believe at Oxyfind we can minimize it to a great extent with our technology. Also, we are offering this technology free of cost to the Govts, NGOs, and non-profit entities who are organizing the vaccination drive.”
As Oxyfind and DEF are doing their part successfully, there is another interesting organization that works to deliver telemedicine and one that cannot be failed to mention here that is Intelehealth ― a technology non-profit organization brought out by a team of engineers, clinicians, management, and public health experts.
Intelehealth takes pride to have developed an innovative open-source telemedicine platform, that’s improving access to primary health care in underserved regions of the world. Intelehealth has partnered with organizations such as Johns Hopkins University Center for Bioengineering Innovation and Design, Ekal Arogya Foundation, Govt. of Gujarat, Healing Fields Foundation, Department of Health – Philippines, Syrian American Medical Society, and UNICEF to name a few. The organization has been recognized by the World Economic Forum and by the Government of India’s – NITI Aayog as an innovative solution provider for continuing the delivery of essential services during the COVID-19 pandemic.
Partnering with the State Government of Gujarat, Intelehealth deploys its telemedicine solution in rural clinics (called Health and Wellness Centers HWCs) in Morbi district. The solution connects Community Health Officers (CHOs), these are nurses or AYUSH practitioners, with remote doctors located at the nearest government hospital. The CHOs will deliver telemedicine-based management for high-risk pregnancies, childhood illnesses, NCDs, cancer, geriatric care, and dermatological conditions.
Neha Verma, Chief Executive Officer/co-Founder of Intelehealth, who is also pursuing her PhD in Health Informatics at Johns Hopkins University, says that patients can get appropriate advice for home-based care and appropriate referrals for management via telemedicine at the HWC level itself. The organization also works with the government to create a pool of volunteer specialists (gynecologists, pediatricians) from the private sector as these posts are vacant within the government system.
Spearheaded by Verma and many other founders, the organization’s objectives do not stop at just setting up telemedicine services but have also conducted online training for 160 doctors in telemedicine-based care delivery and has also helped them orient to India’s new Telemedicine Guidelines.
Another notable service by Intelehealth is its comprehensive outpatient care through micro-entrepreneurs: The Chikitsa Sahayta Kendra Project (Health Outreach Center) in tribal villages in Odisha and Jharkhand in India. This project is using a comprehensive care delivery model to identify, treat, and manage patients with high-quality care for primary health. It uses a micro-entrepreneurship approach to create women health workers who provide doorstep health services. They charge the patient a nominal amount for consultation and at the same time can earn for a livelihood. The project currently implemented in Odisha and Jharkhand is scaling to 1200 health workers, reaching out to 3.6 million people.
I must also mention Intelehealth’s efforts to enable the Health and Wellness Centers to meet their service-delivery goals under Ayushman Bharat Yojana. The roll out of eSanjeevaniOPD (Govt. of India’s largest Teleconsultation Platform) in Jharkhand has been Intelehealth’s bespoke project.
Verma, commenting about this project said, “The Jharkhand state has implemented eSanjeevaniOPD, but the number of people using the system is less, likely because they don’t know how to use it. Telemedicine was made for the most difficult areas however this application is not reaching them. Intelehealth along with Transform Rural India, National Health Mission and Center for Development of Advance Computing (C-DAC) have a common mission and investment into improving the health access for patients in Jharkhand.”
Although, another service not directly relevant to India, it’s worth a mention here. Intelehealth has actively participated in the Telemedicine Policy & Consulting for UNICEF and the Ministry of Health of The Kyrgyz Republic. Integrating the findings from the study of current projects and existing policy frameworks, Intelehealth facilitated capacity-building workshops for key stakeholders to draft a telemedicine policy for the country. The organization conducted a series of program design workshops to develop an implementation plan for telemedicine-based care management for children with disabilities at the primary care level in rural areas, a key focus area for UNICEF.
Coming back to Intelehealth’s services in India, the organization set up IVR helplines to reduce the overloading of hospitals in the districts they have undertaken, and also, they hold trainings on addressing the issue of Vaccine Hesitancy for the rural population.
Another interesting feature of Intelehealth is its telemedicine platform with a novel digital assistant called Ayu, which contains evidence-based protocols for delivering high-quality health services and improved patient outcomes. Ayu supports task-shifting of complex protocols such as clinical history taking, physical examination, screening, etc., to local health workers like nurses, midwives, and community health workers. For conditions beyond the capacity of the health worker + digital assistant, she can connect with a virtual doctor over telemedicine to develop a management plan for the patient. Through a digital assistant + telemedicine, Intelehealth ensures that the right medical expertise is made available, even when the expert can’t physically be present.
Sharing more details about Ayu, Verma says the app has history taking and baseline screening examination protocols covering 88 conditions and 143 basic examinations. Additionally, Ayu supports the integration of low-cost portable point of care diagnostic equipment. Health workers can facilitate teleconsultations with primary care physicians and specialists & then connect the patient with a nearby pharmacy for medications, significantly reducing the patient’s time, distance, and money to access care. The app is available in multiple languages, can work offline and in very low bandwidth, which is most needed in areas that have low internet supply.
Doubling India’s digital infrastructure and moving in direction of better policies
A report released, last year, by McKinsey Global Institute (MGI) had estimated that the implementation of telemedicine technology could save India $4 billion to $5 billion every year and replace half of in-person outpatient consultations in the country. The report titled ‘Digital India: Technology to transform a connected nation’ highlighted that the growth of smartphone ownership and spread of broadband internet connectivity are creating a large untapped market for telemedicine consultations.
MGI found that if telemedicine replaced 30 to 40% of in-person outpatient consultations, India could save up to $10 billion and improve care for the poor and those living in remote areas. Telemedicine could replace half of in-person outpatient consultations in India, and an accelerated implementation plan could enable the country to tap 60 to 80% of this potential by 2025.
But the success of telemedicine rests largely on digital infrastructure. While India has made great progress in the field of telecommunication in the last two decades, a large proportion of rural areas have yet to receive benefits of the digital revolution. Though progress is seen waxing in the penetration of internet post the onset of the pandemic.
The ‘ICUBE 2020’ report by IAMAI and Kantar indicates that the Internet usage in India continues to grow. Internet users are estimated to grow by 8% in 2020. As of 2020, the estimated number of Internet users who have accessed the Internet in the last one month is around 622 million. The number of Active Internet Users (AIU) are expected to grow and reach 900+ million by 2025. In Urban India, AIUs have grown by 4% over last year to reach 323 million, while in rural it has increased by 13% over last year to reach 299 million. Clearly, these numbers suggest that India’s digital revolution continues to be propelled by the rural masses.
Also, mobile phones are omnipresent as these instruments remain the most used device for accessing internet with almost 100% of the active internet users opting for mobile phones to access internet. 17% of the AIU accesses internet using a personal computer and 6% chooses to access internet using other devices such as tablet, streaming device, smart speaker, smart TV. Cheaper and faster data plans, availability of the content in Indic languages have trigged the universal usage of mobile phones by AIUs to access internet content in both urban and rural India, cites the ICUBE 2020 report.
Well, although the internet penetration in rural India is very evident, DEF’s Osama Manzar is convinced that overcoming several barriers is critical for telemedicine’s success in rural India. He says, “We are living in a digital age. This pandemic has made sure if it was not clear to some that the internet is a basic right to everyone. In urban India, while the digital literacy rate is 61%, in rural India the digital literacy rate is just 25%. There are three kinds of barriers that are causing the digital divide in India. First being Infrastructural barriers. These stem out of lack of connectivity and network infrastructure, lack of data towers across regions. Second, are the economic barriers. These stem from economic reasons and are impacted by device affordability, income influence on owning devices, regional (urban-rural) divides. Lastly are the normative barriers which are stemming from norms, customs, traditions, and local contexts. These impact the relationship and interaction that citizens have with technology, its usage, and how they leverage it for their daily activities. For example, gender or caste dictates agency in India and control over resources leading to the gap between the haves and have nots. This gap has to be filled as priority.”
Further Manzar, exhorts that, “Policies need to be framed around telemedicine. Telemedicine is coming as potential healthcare provider to rural as well as urban areas. It mainly uses technology for remote diagnosis and monitoring. The government must revamp the rural health infrastructure. It must equip all PHCs with qualified and able doctors and the necessary equipment. Following this, it should enable these doctors with digital devices that allow them to serve the patients that are unable to visit the center. This is a long-term goal. In the short term there is an urgent need to deploy frontline workers who will travel to every village in the country and provide people with medical consultation at their doorstep through a medical professional on call. It should assign the duty of being on call to good quality doctors so that the rural population gets the good quality healthcare they deserve.”
With all this understanding it is clear that all solutions should be focused on increasing connectivity. Building digital infrastructure will help ease the burden on healthcare. If people could get basic help online or through telemedicine, it will stop long queues at the OPD centers and hospitals will have their resources more focused on serious issues. For that doctors need to be digitally trained. Digital resources and infrastructure have to be built at the ground level and training people to access these facilities will become critical.
Many more organizations like Intelehealth, DEF, and startups like Oxyfind should be made to establish a stronger foothold in rural India as the masses can benefit from telemedicine. Obviously, all of those infrastructure and resources and trainings are pointless, if connectivity is not improved by the Government of India. The pandemic has proved how important it is to invest in digital technologies at the ground level keeping a ‘bottom to top’ approach in consideration. Government programs to extend optic fiber to remote areas need to be coupled with linking the smallest administrative and healthcare units like the Public Health Centres (PHCs) and Health & Wellness Centres (HWCs), with larger hospitals and medical college hospitals. For the medium term, objective evaluation is essential.
It is timely to evaluate functioning telemedicine programs, both public and private, including eSanjeevani, which has completed over 60 lakh consultations since November 2019. Evaluation results should inform evolution of the guidelines and of the legal framework. In the short term, it is training of medical practitioners that merits urgent attention. Telemedicine ‘crash courses’ or continuing medical education modules can raise awareness among them and help practitioners to keep abreast with technological, ethical, and legal concerns and advances.
As India’s ambitious phase 3 of rural broadband project, BharatNet, expands across the country, the telemedicine ecosystem will definitely get a major push in delivering healthcare through teleconsultation and electronics prescription. The government of India is also taking multiple other initiatives in this space, such as the National Health Stack (NHS) and National eHealth Authority (NeHA), which are the digital framework to support healthcare across India. The major goal of these initiatives is to compile digital health records for all citizens by 2022 to leverage the benefits of telemedicine and e-health for Indians.
However, telemedicine cannot be the answer to all problems and surely cannot replace in-person consultation or emergency medicine. It can definitely make a substantial contribution to cope with the current pandemic of Covid-19. Furthermore, its wider acceptance and implementation will help India prepare better for any future pandemics, thus reiterating and emphasizing the fact that if health is the motive, then digital is the sole instrument.