As India witnesses a downward trend in covid-related fatalities, we must ensure that the digital public goods created during the pandemic continue to gain traction once the threat subsides. One such public good is eSanjeevani, the government’s telemedicine platform, which had achieved 1 million cumulative tele-consultations till December 2020.
The platform was developed by the Centre for Development of Advanced Computing, and launched in November 2019 by the ministry of health and family welfare to improve access to health services that had severely been curtailed during the pandemic by lockdown restrictions and the redirection of healthcare resources towards tackling covid. While the government reacted with commendable alacrity and agility to ensure that health services were available in remote areas, the eSanjeevani platform faces three big hurdles, or the three ‘A’s discussed below.
Abuse: Many private telemedicine platforms in India have seen incidents of sexual harassment of women doctors, with abusers making lewd remarks or flashing themselves on the pretext of seeking advice. The patient verification process of registration for eSanjeevani is similar to that of private platforms, which makes it susceptible to similar abuse. To simplify registration, no proof of identity is requested while signing up and a simple OTP verification process is employed.
One way to address this issue is to use Aadhaar verification for registration, where an OTP would be sent to the mobile number registered against the person’s Aadhaar. However, this would complicate the registration process. Also, many do not have their Aadhaar linked with their mobile numbers, and they would not be able to use the platform. Another way to address abuse would be to match doctors and patients algorithmically, based on gender. This could reduce attempts to abuse the platform.
Availability: Doctors, particularly women, who have faced abuse on these platforms may decline online consultations in the future. This would reduce the availability of healthcare professionals necessary for such platforms to function effectively. eSanjeevani already struggles with a shortage of doctors, which is evident in the time it takes for a patient to receive relevant advice after a request is put in. Patients recount experiences of doctors not being readily available, resulting in long waits. Some say that it sometimes takes over an hour to consult a doctor, with no indication of the time it would take for one to become available.
Although the portal provides patients with an option to select specialist consultation services through a drop-down menu, patients often receive a message stating that the selected service is closed. Patients then try to avail of a general service, though the doctor may not be qualified to diagnose the problem, which can result in an unsuccessful consultation. This is suboptimal , and could discourage them from trying to use the platform again. Apart from taking aboard more doctors, the platform could provide an option for patients to record their symptoms or ailments when they first seek a consultation. The patient could either type it in a chosen language or record an audio message. Using natural language processing (NLP), the platform could then initiate an algorithmic match between a doctor and a patient. This would raise the success rate.
Access: While the telemedicine practice guidelines released jointly by the Medical Council of India and Niti Aayog allow for video, audio, text-based, and asynchronous modes of communication for teleconsultation, eSanjeevani is available as a video-based mobile and web application. This requires the patient to have a smartphone or a laptop with an internet connection. However, this does not solve the problem of access faced by half our population that remains digitally excluded. These are people who either have feature phones or no device with which to log onto the internet.
Moreover, knowledge of the English language is necessary for people to make use of eSanjeevani, as its registration forms and instructions are available only in English.
To ensure that such services are accessible to all, governments should set up functional teleconsultation helplines, auto-diallers, text messages, and other asynchronous channels. These modes are permissible under the country’s telemedicine guidelines. To enhance access, the government can also use community-based local centres equipped with mobile devices or tablets, such as panchayat offices (i.e., the offices of village-level governments) and self-help groups. Governments that do not make adequate investments in these channels risk excluding large segments of their population, thereby depriving them of online access to healthcare. We do not want a situation where the most vulnerable populations are left out of this programme.
Besides strengthening eSanjeevani along the lines of the three ‘A’s discussed above, India should take the current opportunity to scale eSanjeevani as a world-class teleconsultation platform. eSanjeevani could be integrated with the country’s larger healthcare ecosystem, connecting hospitals, clinics, pharmacies, laboratories, diagnostic centres and doctors offering in-person consultations. This would allow for the provision of a well-diversified range of service offerings, and this goal could be pursued by the National Digital Health Mission. However, the platform must first address the three ‘A’s of abuse, availability and access.