India’s landmark telemedicine initiative needs a revamp if it is to fulfil its potential

In the spring of 2020, I left Cambridge, England, to return home to Kolkata and found myself in the midst of a strange predicament.

During my last few weeks working at Addenbrooke’s Hospital in Cambridge, we had begun to hear of stray cases of a new viral infection in China, and much to my annoyance, my father had begun sending a barrage of precautionary text messages from India.

Needless to say, the profound implications of those early reports were yet to dawn upon me and “pandemic” was only a word whose definition one had to learn – in series, after “endemic” and “epidemic” – before appearing for community medicine examinations while working towards an MBBS degree.

However, within days of my return home, the World Health Organization had characterised Covid-19 as a pandemic, and the world as we knew it changed forever. On March 23, 2020, India went into lockdown, drawing the shutters on all the grand plans for which I had quit my job and returned from the United Kingdom.

As I sat at home, enjoying the downtime and coming to terms with the new order of life, the novelty of the first few days soon wore off and natural instincts honed by years of medical training took over. On March 29, I set up a Facebook page called “Lockdown Medical Aid”, offering free medical advice to anyone who was stranded at home and needed a consultation. Within days, around 30 colleagues spread over eight cities in India had joined the effort and we started a website rather ambitiously named “Doctors for India”.

For most of the medics consulting out of that page, this was perhaps the first tryst with telemedicine. Certainly, none of us thought much of the initiative other than that it was a temporary means of public service and an escape from monotony. But over the next few weeks, we provided consultations to hundreds of patients, one of whom was diagnosed with acute cholecystitis and eventually underwent a life-saving surgery at a government medical college hospital.

In hindsight, that was perhaps the first time I reflected on the potential of telemedicine, if scaled up and supported by the right tools.

Telemedicine in India has certainly evolved since then, supported by important initiatives such as the release of the telemedicine practise guidelines in 2020 and the Ayushman Bharat Digital Mission in 2021. In fact, the national telemedicine service, eSanjeevani, was launched in 2019, before the pandemic, based on a “hub and spoke” model, in which patients in relatively remote health centres, or spokes, could access online consultations with specialists at larger centres, such as medical college hospitals, or hubs.

With the outbreak of Covid-19, the government accelerated the rollout of eSanjeevani, enabling more patients to access online consultations in the middle of lockdowns. I had first-hand experience with the system after I joined the Institute of Post-Graduate Medical Education and Research in Kolkata in 2021 and started providing teleconsultations on the platform as part of hospital rotas in 2022.

On paper, eSanjeevani seems like a resounding success – as of August 2024, more than 276 million consultations had been provided on the platform.

However, multiple studies originating out of states such as Karnataka and Jharkhand have raised questions about its usefulness, as has an analysis of over 60 million consultations nationally by an MIT-based study. Indeed, a story in this publication flagged concerns that referring units, such as sub-centres, were being assigned “targets” for how many referrals to make per day to doctors higher up in the healthcare system. It also noted that there was evidence that the number of patients using the system had dropped once the peak of the pandemic had been passed.

In a recent Lancet Southeast Asia paper, my colleagues and I have pointed out fundamental deficiencies in the design of the eSanjeevani pathway, its referral protocols, and the staffing and training of healthcare workers in the system, all of which lead to inappropriate and sub-optimal referrals.

This, in turn, results in unsatisfactory consultations, from which patients do not derive any actual benefit. These conclusions draw on reports at the state and national levels, as well as from my personal experience while consulting on the eSanjeevani platform for nearly three years.

For instance, during this period, nearly a third of all patients referred to me had no complaints related to my specialities of obstetrics, gynecology and reproductive medicine. In fact, nearly one-fifth of patients referred to me were males! A majority of female referrals were based on complaints completely unrelated to my specialties, ranging from knee pain to earache and cough.

Finally, more than 90% of referrals were not for audio or video call consultations, as the designers of eSanjeevani had intended they should be, but came in the form of written requests – that is, notes describing patients’ symptoms, and requesting medical advice.

These notes are logged as consultation requests but often consist of only a word or two, providing precious little detail about patients’ conditions, making it difficult to safely and ethically prescribe any treatment, in line with medico-legal guidelines.

It seemed clear that the health workers at the spokes of eSanjeevani had had little or no training in effective triage and referral. This led to consultations that were a waste of time for both the doctor at the hub as well as the patient at the spoke. Moreover, there seemed to be a complete absence of general practitioners within this referral chain, though the design of eSanjeevani envisions them playing a key role in the system.

There also appeared to be no standard operating protocols in use for triage and referral, or for competency assessment of health-workers before they were allowed to operate the system, or audits of their performance in using the system. It also appeared that there hadn’t been any qualitative audit of the usefulness of the service as a whole beyond mere counting of referral numbers.

eSanjeevani was a landmark initiative, and has the potential to serve as a blueprint for a healthcare system that delivers universal healthcare to India’s vast and varied population. If it is to fulfil this potential, it needs, and deserves, a thorough revamp of its referral pathway, standard operating protocols and audio and video technology infrastructure and use.

Other key changes that would improve the system would be the integration of general practitioners into it to address relatively simple patient complaints before they are referred to specialist physicians, the training of healthcare workers in optimal triage and referral, and the integration of algorithmic and artificial intelligence tools into the platform to match patients to appropriate specialists.

In 2020, we managed to save at least one life working out of a hastily made Facebook page. I remain convinced that supported by the right tools, protocols and processes, eSanjeevani has the potential to save millions and set an example to the rest of the world.

Dr Biswanath Ghosh Dastidar is presently Research Director at GD Institute for Fertility Research and Assistant Professor at the Center of Excellence in Assisted Reproductive Technology at IPGMER & SSKM Hospital, Kolkata. He can be reached at [email protected]