In telehealth, scaling up the Indian advantage

There are lessons from the pandemic that can be applied usefully to how health care can be delivered

Published - February 17, 2021 12:02 am IST

In the novel coronavirus pandemic, health-care providers have been reassigned from other specialties to COVID-19, restricting high quality care for other conditions. Simultaneously, lockdowns and fear of transmission have dampened demand for non-emergency care. A survey conducted by the World Health Organization (WHO) in 105 countries in July 2020 ( showed that essential services were disrupted in the majority of countries, with immunisation, antenatal and childcare services among the most widely affected. About 45% of low-income countries incurred at least partial disruption of over 75% of services, relative to only 4% of high-income countries. Almost 60% of services were at least partially disrupted in South East Asian countries.

COVID-19 impact

In India, detection of tuberculosis cases was down by 50% in April-December of 2020 relative to the same period in 2019, and antenatal care visits were down by 56% in the first half of 2020. With stoppage of routine follow ups, blood sugar control for diabetics was at risk, increasing the chances of adverse events requiring hospitalisation, including worse outcomes in the case of COVID-19 infection. Cancer care has been badly affected in many countries, as well as diagnosis and treatment of other non-communicable diseases.

Further, the pandemic has exacerbated inequalities — people living in rural and remote areas were further disadvantaged by not being able to travel to cities to seek specialist care. The pre-existing shortage of specialists in many rural areas led to care being delayed or not happening at all.

Enhance technology use

The acceleration in the use of digital technologies has mitigated the impact of COVID-19 to some extent. Virtual consultations avoid the risk of COVID-19 transmission and are helping to bridge this socio-economic divide.

The Indian government’s eSanjeevani platform offers both provider-to-patient interactions and provider-to-provider interactions, where patients visit smartphone-equipped community health officers in rural health and wellness centres; these in turn connect to general practitioners and specialist doctors through a hub-and-spoke model. Private providers and non-governmental organisations have also expanded virtual access to underserved populations.

Yet, given the scale of unmet demand, there is an urgent need to increase the efficiency and effectiveness of every minute spent in virtual care interactions. There are lessons we can learn from the pandemic that can be applied usefully to how we deliver health care.

Remote-shared medical appointments in which multiple patients with similar medical needs meet with a clinician at once, remotely, and where each receives individual attention, can greatly increase telehealth capacity by eliminating repetition of common advice.

Utilising shared appointments

Remote shared medical appointments essentially virtualise in-person shared medical appointments (SMAs) which have been offered successfully in the United States for over 20 years. Patients get more time with their clinician, albeit not in private. SMAs enable peer support and peer-to-peer learning. Providers who have offered SMAs have found them to improve both productivity and outcomes for many conditions, notably diabetes. SMAs could help tackle India’s widespread “sugar” problem.

The Aravind Eye Hospital in Puducherry has successfully trialled in-person SMAs for patients with glaucoma, a disease that causes gradual, irreversible blindness. Glaucoma progression can be slowed through regular follow up and taking prescribed medications. The eye hospital found that in shared appointments, patients spur one another to engage more and ask more questions. Such (virtual) peer interaction could be welcome in the current paradigm of social distancing.

eSanjeevani and other telehealth platforms could consider offering virtual shared medical appointments. Patients in different villages, with similar conditions can be seen at once remotely by a generalist or specialist, during the pandemic. Once transmission risk subsides, seeing patient groups within each village centre will help build supportive bonds, enable sharing of local knowledge, and likely attract supplementary providers (physiotherapists, optometrists, etc) due to scale.

Testing and vaccine adoption is stymied by misinformation. Providers can offer virtual group information sessions accessible via smartphone in which a health-care worker explains the benefits of COVID-19 testing and vaccination and answers questions, reaching potentially quite large audiences. Engaging in real time with a care provider in an interactive format will likely encourage safe behaviours to a greater extent than if the same information is provided without interaction.

Switching to radically different care delivery models requires rigorous testing combined with mentoring, training and behaviour change for both patients and providers. Adoption of in-person shared medical appointments has been slow. The unique telehealth capacity crisis which COVID-19 has created is drawing interest to virtual SMAs. Training platforms such as ECHO, which train primary-care providers in many States through an online platform — can accelerate adoption and should also guide implementers on how to gather data that can be used to scientifically validate this care model.

Patients who choose to attend an in-person SMA often like the experience and return for more. This is likely for virtual SMAs too. Trialling and acceptance of this model could amplify the impact of health systems both during the pandemic and beyond.

The plusses

Relative to other nations, India is well poised to ramp up telehealth. Data plans are cheaper in India than anywhere. It is possible to get 1.5GB of data a day for a few hundred rupees a month, and Indians from all socioeconomic groups regularly enjoy group video chats with friends and relatives. Having a group interaction with a care provider on an appropriately secure platform is certainly conceivable.

WHO’s Global Strategy on Digital Health, adopted by the World Health Assembly, is a call to action providing a road map for nations to rapidly expand digital health services. With innovation in systems thinking, learning and adaptation, new digital tools bring an opportunity to leapfrog into a reality of ‘Health for All’.

Kamalini Ramdas is Deloitte Chaired Professor of Innovation and Entrepreneurship at London Business School. Dr. Soumya Swaminathan is Chief Scientist at the World Health Organization. This article draws on an article by the same writers that appeared in the January 2021 issue of Nature Medicine;

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