About the author: Rajas Patil is a hardworking and passionate student who is interested in geopolitics and public policy. Growing up in the midst of many different cultures and countries instilled in him a sense of global consciousness and adaptability. He is currently in the 11th grade at the Stonehill International School in Bangalore. In the future, he wishes to pursue his undergraduate studies at the intersection between science and policy.
Abstract
This research paper examines the potential of telemedicine services in addressing healthcare disparities in rural India, where access to quality medical care remains a persistent challenge due to geographical barriers, resource limitations and shortage of healthcare professionals. By utilizing digital platforms to provide remote consultations, diagnostic services and treatment, telemedicine offers a transformative solution to bridge the urban-rural divide. This paper critically examines the current state of telemedicine in rural India, focusing on adoption and scalability. Through a comprehensive literature review, it assesses how telemedicine services have enhanced health outcomes in underserved communities. It also explores the technical, regulatory and infrastructural barriers that limit the expansion of telemedicine. By analyzing implementation cases, this paper provides recommendations for policymakers to optimize telemedicine frameworks to ensure equitable, accessible quality healthcare in rural India. The findings underscore telemedicine’s potential as a vital component of healthcare reforms in India, offering a sustainable path towards achieving universal healthcare coverage in India’s most remote regions.
Introduction
Karnataka, a culturally rich state located in the south of India, is one of the largest and most economically vibrant in the country. Karnataka has grown tremendously in recent years in all aspects; however, healthcare among the rural poor, while improved, has long been a pressing challenge, especially compared to urban areas within the state. Rural regions struggle with a myriad of issues like limited resources, inadequate facilities, and a shortage of healthcare professionals. Remote medical services, also known as telemedicine or e-health, are a scalable way to reduce the difference between health care services in rural and urban areas (Galagali, Ghosh & Bhargav, 2021). These services allow patients to consult with doctors without having to travel.
The healthcare landscape within both Karnataka and India is very polarised, with urban centres like Bengaluru equipped with state-of-the-art centres while rural areas struggle with basic facilities. This problem is not just prevalent in Karnataka but across the country; a report by the United Nations found that 75% of healthcare resources are within urban areas, where only 27% of India’s population lives (Datta, Singh & Mishra, 2023). This leaves the already poorer segment of the population with subpar healthcare, strengthening the poverty trap and divide.
According to the 2011 Census, 62% of Karnataka’s 65 million population live in rural areas. Good public health is essential; it is a fundamental human right and a part of the UN sustainable development goals. Aside from social justice, addressing the issues will lead to the betterment of society, as it allows more and healthier people to contribute to society. If 60% of the population is able to work or live in a more rapid and efficient manner, then the economic benefit would be tremendous, only leading to overall development and allowing the rural poor to break free from the cycle of poverty and illness.
Current Landscape of Healthcare in India
Karnataka follows a 3-tier public health infrastructure system for the rural, primary, secondary, and tertiary. At the primary level, the state has Primary Health Centres (PHCs) and Sub-Centres (SCs). At the secondary level, there are district hospitals (DH), sub-divisional hospitals (SDHs), and community health centres (CHCs), and at the tertiary level, there are medical colleges and specialised hospitals (Agarwal, Jain, Pathak, & Gupta, 2020). The current state of healthcare in Karnataka has both pros and cons; the positives are often overlooked and there have been efforts made by the government to improve healthcare in rural areas through initiatives such as the National Rural Health Mission (NRHM) and eSanjeevani.
The issues are multifaceted, involving social, geographic, and economic factors. One of the most pressing issues is the inadequate healthcare infrastructure. Medical centres need a variety of different equipment, like beds and needles, etc., not to mention the medicines themselves. Furthermore, there are already nearly 2844 government hospitals across the state. However, Karnataka is massive, spanning 190,000 square kilometres, with settlements in every corner (Dash, Aarthy & Mohan, 2021). For this reason, it becomes very hard to build centres near every village, ensuring equal access. Simply building centres is not the end of the story; these centres must also all be provided with quality equipment and staff and be maintained for years to come.
A 100-bed government hospital in Molakalmuru in Karnataka’s Chitradurga district recently gained media attention for its severe electricity issues after a heavy spell of rain forced doctors to treat patients under torchlight (Agarwal et al, 2020). This type of situation is fairly common and represents the state of many health centres. In addition to the lack of equipment, many health centres, especially in rural areas, suffer from poor physical infrastructure. The buildings are often old and dilapidated, as well as far too small to cope with the patients and equipment. Close to one-third of DHs, two-third of SDHs, and half of the CHCs and PHCs rank poor or average (Verma, Krishnan & Verma, 2021). This shows inadequacy in every aspect of human resources, infrastructure, and services.
The term healthcare infrastructure is an encompassing term for the facilities and services that benefit a population’s health. The term can be understood as not only physical buildings and equipment but also the distribution and availability of quality healthcare professionals (Malhotra, Ramachandran, Chauhan, Soni & Garg, 2020). The shortage of trained healthcare professionals is another critical issue that plagues rural areas in particular. In 2023, the high court of Karnataka initiated a public interest litigation (PIL) on the matter of the shortage of medical staff. The vacant job positions are not only large in number but are varied, where the scarcity encompasses a wide range of roles, highlighting the extensive nature of the issue.
Rural regions are often characterised by tough geography that exacerbates the existing problem of equal healthcare, like the expansive Western Ghats range covering the vast majority of the state’s west coast. These hilly wet regions have poor transportation networks, which make it difficult to both build and service facilities. This forces households to travel far for healthcare, coming at a great personal and financial cost. Many people don’t have health insurance to help with the cost either. 68% of Indians have inadequate health insurance coverage, with 27% having less than ₹5 lakh in coverage (Bakshi & Tandon, 2022).
There are other non-infrastructure-related barriers present as well; social and cultural factors further “complicate” the landscape. 50.6% of Indians do not trust doctors. For centuries, traditional ayurvedic and traditional healers have been the norm, an estimated 400,000 traditional healers practice medicine in India, making up 57% of rural medical care (Verma et al, 2023). Modern healthcare is seen as an alien, unreliable entity, leading many to reject modern medicine despite the opportunity.
Previous policies
Other telemedicine services already exist in India and are probably better as of now, Practo and 1mg; however, the key difference is that these services require money to be spent, shutting off the majority of telemedicine demographic. Similar services have also been implemented in China, a country in a similar position historically to India. China’s largest telemedicine platform, with 373 million registered users has helped the vast ageing population, especially in the west of the country, to access quality healthcare with relatively short wait times in a non-disruptive manner (Stoltzfus et al, 2023). China has a completely different socioeconomic landscape from Karnataka and India, but they have proven that telemedicine is an extremely promising initiative and has the potential to solve the issues of traditional healthcare methods in Karnataka.
Over the past years, Karnataka has introduced a range of new policies and programs aimed at enhancing healthcare access in rural areas. These initiatives are part of a broader national and state effort to meet the healthcare needs of rural communities (Singh et al, 2022). Although such policies and initiatives have achieved some level of success, challenges continue to persist, especially in effective implementation and sustainability.
One of the key initiatives at the national level, aimed at providing health services to rural areas, is the eSanjeevani scheme. Launched in 2019 under the Ayushman Bharat Digital Health Mission (ABDM), the scheme has been very effective in Karnataka, as it has efficiently adopted and implemented it. The eSanjeevani scheme operates in two main models; the first, eSanjeevani Ayushman Bharat and Health and Wellness Centres (AB-HWCs), aims to bridge the rural and urban healthcare divide by giving teleconsultations completely free of charge (Maroju et al, 2023). These (AB-HWCs) are smaller clinics in rural areas acting as the first point of contact. The model is set up through a hub and spoke model, where the HWCs are the spokes, which lead to the hub comprising more well-trained healthcare professionals at a zonal level (Singh & Dev, 2021). Patients can receive basic health care, and those who require specialised advice can do so easily. According to the Ministry of Health and Family Welfare, this model throughout India has been implemented in 1,09,748 AB-HWCs and 14,188 Hubs, totalling 71,158,968 teleconsultations (2022).
Improving all aspects of healthcare infrastructure across the entire state is costly and impractical for now; hence, this online approach has been so successful. These large numbers are possible due to this online nature, reducing burden on physical infrastructure and overworked professionals.
Policy Recommendations
Addressing the aforementioned challenges through telemedicine is paramount to fostering a conducive environment for growth and development. To overcome these barriers, Karnataka and India as a whole must adopt new effective strategies to improve health care from a telemedicine angle, specifically.
Due to the nature of healthcare within Karnataka, telemedicine is the only sustainable and scalable method to offer healthcare to rural areas. The eSanjeevani scheme has no doubt been effective in its implementation; however, an underlying problem prevents the initiative from reaching its full potential. A study in 2023 about telemedicine awareness and preferred digital healthcare tools conducted a survey in a village in rural Karnataka. Only 2.2% of the participants actually knew about the eSanjeevani scheme, and none of them actually utilised its services in the past year. Furthermore, only 56% of the participants said they would be willing to use the services. 82.5% said that the reason for the unwillingness was a lack of familiarity (Venkataraman et al, 2024).
The masses, especially in rural areas, must be made aware of these great facilities that are available through public awareness campaigns. Posters and billboards are common methods of doing so. But advertisements on TV and social media are the most efficient way. Close to 60% of India’s population has access to the internet, but this number is rising exponentially, especially in rural areas. 82% of Indians engage with TV advertisements (D’Souza et al, 2021). Creating advertisements that educate communities about the benefits of the eSanjeevani initiative and how to access it is a sure way to quickly increase awareness. As these campaigns are a reflection of the government, they should be made regarding local culture and sensitivities; for example, the advertisements in Karnataka should be in Kannada.
Telemedicine services exist, but there is a shortage of doctors who actually attend eSanjeevani regularly. The demand is simply too much for the current status quo, meaning that the supply has to increase. Working long hours online is not favourable to workers so there must be incentives given for these postings. However, monetary compensation at this large scale is not feasible, as the government cannot redirect enough capital. A very practical and efficient strategy is utilising medical students and recent graduates, either voluntarily or by conscription (Gupta, 2023). This not only addresses the shortage but also gives experience to future healthcare workers. This resource-constrained environment is very different from what most students are trained in, developing clinical and problem-solving skills necessary for the profession. Most telemedicine consultations are elementary in nature and do not require a deep understanding, and an early exposure to the reality of rural healthcare can create a sense of responsibility and motivate the students to help the country (Nagaraja et al, 2024).
Across 2018 to 2012, an average of 780,000 students passed the National Eligibility cum Entrance Test (NEET) for admission in undergraduate medical programs. However, there are only 80,000 government, private institutions, and medical college seats. Other factors, like the price of education and reservations, limit the seats for many (Delana et al, 2023). The government has almost doubled the number of undergraduate medical seats, yet the disparity still remains large. This mismatch is ironic considering the shortage of doctors, especially in the government sector. The data shows there is fierce competition between students, so those who participate in the scheme would be offered credits or other career advancement opportunities. This advantage would attract masses of students to volunteer for telemedicine roles, all trying to gain an edge.
Increased awareness and labour will be futile unless eSanjeevani’s services themselves are not very efficient and helpful. A large concern is that there are long waiting lists. A team of Metrolife reporters surveyed people in Karnataka; one patient was on a waiting list; after 10 minutes, the patient gave up. The following day, she logged in with a new token number and waited for 10 more minutes, and a doctor was assigned, but he couldn’t hear properly so he placed the patient on hold again and she went back to the waiting list. This sort of situation is fairly common (Gupta, 2023). However, the contribution of students in theory should reduce this problem by increasing the supply to meet demand. More doctors would reduce the workload on each doctor, so eSanjeevani could provide more detailed, efficient healthcare, leading to easier follow-up consultations and lower waiting times.
The actual meetings between patients and doctors are negatively impacted due to connectivity issues. India’s network coverage has improved exponentially in recent years. India has more than 820 million active internet users now, of whom more than half come from rural parts of the country. However, internet penetration in rural India is only around 41%, where it is often unreliable and slow (Sageena, Sharma & Kapur, 2021). This causes the teleconsultation to be slow and laggy, wasting the patients and doctors time and potentially blocking lifesaving advice. Developing network coverage is crucial to pulling 61% of the rural population out of digital darkness, opening up not just better telemedicine but a plethora of opportunities.
Conclusions
The lack of quality widespread healthcare is one of the greatest challenges that Karnataka and India as a whole face, particularly prevalent in rural areas. Efficiently implementing telemedicine through the eSanjeevani initiative would overcome tough geographic, infrastructural, and systemic issues. By expanding digital infrastructure, training more healthcare workers, and raising awareness about telemedicine services, leading to a more developed and happy nation. The successful implementation and adoption of telemedicine in Karnataka will serve as an example to the rest of the country. Based on the socioeconomic status quo of a particular region, approaches can be tailor-made to suit best. Continued investment and collaboration between the government and rural areas will eventually provide all with the healthcare they deserve. Better health and reduced sickness will develop living standards, boost the economy, and propel India to better days.
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