Dr Budhaditya Gupta, Healthcare Expert and Professor D.V.R. Seshadri, Indian School of Business (ISB) highlights that well-designed and context-appropriate teleconsultation models can indeed make a significant impact in addressing the healthcare equity challenge for rural/semi-urban India
The COVID-19 pandemic has resulted in growing popularity and increased adoption of telemedicine as the lockdowns prompted large number of people to seek teleconsultation services. In India we saw telemedicine being accepted and supported by key institutional stakeholders such as the Medical Council of India, the Insurance Regulatory and Development Authority of India, and the Ministry of Health and Family Welfare. Indeed, telemedicine is an exciting proposition for India given that most of the population, particularly those in semi-urban & rural areas, have little or no access to quality healthcare. This healthcare access challenge in the rural hinterland, which accounted for about 70 per cent of India’s population, has been in part due to a shortage of an estimated 600,000 doctors in the country based on the World Health Organization (WHO) recommendation of doctor to population ratio of 1:1000 and the fact that most doctors prefer to be based in urban areas.
Telemedicine models for rural/semi-urban India
Over the last two years we have witnessed a few private organisations, both for-profit and not-for-profit, engage in the development or launch of telemedicine-based services for the semi-urban and rural population. These services are essentially built on staff-assisted operating models where the patient meets a local medical practitioner in person and the local practitioner then supports the tele-consultation session between the patient and a remotely located city-based doctor. The local practitioner, typically an unaccredited healthcare provider or a trained nurse, plays a key role in this model, given the poor digital literacy and telecom network access challenges, by supporting the patient-doctor interactions during the teleconsultation session. This emerging model is indeed a welcome development given the much-discussed care access challenge in semi-urban and rural India, particularly when patients need access to clinical specialists. It is important to note that telemedicine models without the involvement of local medical practitioners tend to be unsuccessful in these markets, particularly in rural areas, given the trust deficit, technology access challenge, communication barriers and the preference for local and affordable healthcare providers, including quacks, who have been part of the local community over the years.
Challenges related to rural/semi-urban telemedicine model
There is broad acknowledgement of challenges related to telemedicine-based care models in developing countries such as India. These include but are not limited to unclear clinical and regulatory guidelines, low digital literacy, poor network connectivity and bandwidth, as well as lack of (or insufficient) rigorous efficacy studies. However, the current discourse often tends to ignore the fundamental challenge of accurate assessment and effective care provisioning via teleconsultation; this is particularly true for staff-assisted teleconsultation model for the semi-urban and rural patients. Below we list select points to elaborate this challenge.
- City-based doctors are embedded in a vastly different socio-economic context compared to that of the local medical practitioner and the rural/semi-urban patient and in many cases the doctor has limited/no experience of the rural/semi-urban context. This makes effective communication a challenge. If a doctor ends up catering to remote patients from across the country, the problem of context is magnified, as it is impossible for a doctor to be so versatile that she is able to tune in to the contextual realities of all patients referred to her in a heterogeneous and diverse country such as India.
- The doctors might not be able to communicate in the local dialect with the rural/semi-urban patients and local practitioners. Moreover, they often have an inadequate understanding of the norms, values, behaviors, diets, etc., of the rural/semi-urban population. Finally, patients in rural/semi-urban areas often do not have the language proficiency, health literacy and confidence to engage with remote city-based doctors effectively.
- The complexity is further exacerbated in situations where the rural/semi-urban patient is a migrant worker from another part of the country. Many small towns in Western and Southern India have substantial number of migrant workers from states like Bihar, Orissa and West Bengal.
- City-based doctors might have limited/no awareness of diseases common in the rural/semi-urban population segments. For example, this can negatively impact the diagnosis process when the city-based doctor consults workers in stone cutting industry suffering from silicosis or farmers suffering from prolonged exposure to pesticides.
- One cannot underestimate the cultural context of the rural patients. Lack of trust and comfort with city-based doctors makes engagement challenging, as there are concerns that tele-consultation sessions might be recorded and used to harass at a later point. This is particularly true for female patients and high-stigma clinical conditions such as mental health, sexual health, etc.
- Small-town and rural patients often have natural apprehensions related to differences in religion, caste, and gender differences; in such cases they might avoid tele-consultation sessions altogether or engage superficially with the doctors even if they attend these sessions.
High-quality doctor-patient interactions that involve detailed discussion of patient history and a thorough physical examination have long been and continue to be the fundamental element of effective primary care delivery, as it allows the doctor to listen to the patient carefully, ask questions, diagnose the underlying cause and arrive at the appropriate treatment approach. However, despite much excitement about potential of telemedicine for rural/semi-urban India, the current staff-assisted telemedicine model is not ideal for desired physician-patient interaction and will lead to sub-optimal clinical outcomes and consequent unsatisfactory patient and doctor experience. Indeed, such sub-optimal quality of doctor-patient interaction during tele-consultation is not a challenge limited only to the rural/semi-urban patient segment; this is a common theme for all teleconsultation services across socio-economic segments and geographies. However, the challenge tends to be most acute for rural/semi-urban patients given the contextual differences via-a-vis city-based doctors, as discussed above.
Way forward
Well-designed and context-appropriate teleconsultation models can indeed make a significant impact in addressing the healthcare equity challenge for rural/semi-urban India. Given the challenges discussed with the current approach, entrepreneurs and NGOs need to adopt a human-centered design approach while establishing telemedicine care models for rural/semi-urban India to ensure that these models are context appropriate. Furthermore, the design of these models will benefit from following considerations.
- Near-remote doctors: We recognise that the core advantage of telemedicine is that it allows for remotely located doctors to provide care to patients. In fact, the geographic distance between the doctor and patient is not an issue if the overall macro-contexts for the doctor and patient are similar. For example, Australian-trained medical practitioners living overseas in countries such as Canada use telehealth to treat rural and regional patients in Australia, since their contexts are similar. But how far can the remote doctor be for the Indian rural/semi-urban patient? Our view is the Indian tele-health doctor for a rural/semi-urban patient should ideally be located at the closest city, preferably in the same state or territory, to minimise differences in language, diet, cultural norms, etc., and improve the doctor’s understanding of the patient’s socio-cultural context.
- Training of local practitioners and remote doctors: Local medical practitioners at rural/semi-urban locations should be trained in soft-skills critical to support effective engagement between the doctor and patient. The local practitioner role needs to go beyond technology and clinical support and the emphasis should be on establishing a robust communication channel between the doctor and the patient. Failure to realise this will constrain the rural/semi-urban teleconsultation models from achieving their true potential. In addition, the remote city-based doctors should be trained on how to assess and diagnose patient conditions during the tele-consultation and how to best work with the local practitioner to navigate anticipated challenges and knowledge gaps.
- Intelligent matching algorithms: Finally, as telemedicine models for rural and semi-urban locations mature over time, the embedded algorithms determining which doctor sees a particular rural/semi-urban patient needs to be improved. These algorithms over time need to go beyond considering only the patient clinical conditions while deciding on the appropriate consultation doctor. Instead, the algorithms matching patients to doctors must explicitly consider other attributes such as socio-cultural factors, location proximity, language, gender, religion, prior patient consultation history, reported past patient experience, etc.