Mainstreaming telemedicine is the most transformative change hospitals have made to provide healthcare in the post-coronavirus disease (Covid-19) world without compromising on quality of care and outcomes. The Board of Governors in supersession of the Medical Council of India (MCI) issued Telemedicine Practice Guidelines on March 25 to strengthen delivery in a post-Covid-19 world, with a focus on Health and Wellness Centres (HWCs) that provide preventive and primary healthcare within a 5 km radius at the grassroots level.
“We had already put in six months of work into the guidelines and when the coronavirus pandemic happened, we expedited it. Technology platforms were something available and being used, but were not regulated, which exposed both patients and providers to challenges. These guidelines provide guidance material for reference, that can be refined before they become an annexure to the MCI Act, enabling regulation,” said Dr Nikhil Tandon, professor and head of the department of endocrinology and metabolism, All India Institute of Medical Sciences (AIIMS), who is a member of the Board of Governors in supersession of the MCI that drafted the regulation.
Telemedicine is being used by doctors to connect with patients, and by mid-level provider/health workers to connect patients with doctors without patients having to physically visit a hospital or clinic.
Telemedicine has already helped decongest AIIMS, which moved its out-patient department services online from April 8 to enable patients access treatment and care during lockdown.
“Even post lockdown, it will help reduce the burden on the secondary hospitals and improve documentation, data-collection, diagnosis and care without risking the safety of the patients or the health workers. It is already being used with success in some states for reproductive and child health and tuberculosis notification and outreach,” said an epidemiologist in the health ministry, requesting anonymity.
There is a persistent shortage of doctors, health workers and hospital beds in the country, especially in rural areas and densely populated underserved states. India has 1.1 million allopathic doctors registered with the Board of Governors/State Medical Councils in December 2019, according to the National Health Profile 2019.
India’s public health expenditure is just 1.28% of its GDP, with the per capita public health expenditure being Rs 1,657 in 2017-18. The rising cost of treatment has led to inequities in access, with people in underserved rural areas and urban slums among the worst hit. For people living in rural areas completely dependent on government hospitals and clinics, the government allopathic doctor-patient ratio is 1:10,926, shows NHP 2019 data.
“Assuming 80% availability, it is estimated that around 9.26 lakh doctors may be actually available for active service,” said minister of state for health and family welfare Ashwini Kumar Choubey in the Lok Sabha last year. The availability is always lower because some retire, some stop working, move to hospital administration, while others go overseas without getting their names struck off the register.
For a population of 1.36 billion, this makes the doctor-population ratio 1:1,457, which is lower than the WHO recommended norm of 1:1,000. In addition to doctors, India has a little more than two million registered nurses and midwives, many of whom need infection control training to care for patients with communicable diseases, such as Covid-19 and tuberculosis.
“Mobile apps, telemedicine, digital health are all great and welcome, but cannot help any country leapfrog fragile and under-resourced health systems,” said Prof Madhukar Pai, Canada Research Chair in Translational Epidemiology & Global Health, and Director, McGill Global Health Programs, McGill University, Montreal.
“I can see that working in a robust healthcare system. How can it work in settings with poor internet access, illiteracy and extreme poverty? We simply cannot code our way out of the healthcare mess we are in. Digital tech simply cannot replace a functional, robust public healthcare system,” said Dr Pai.
Over the past two years, community health officers (CHO) have emerged as the first point of preventive and primary healthcare for an increasing number of people in rural India at HWCs, where telemedicine is an integral part of outreach and health services. They offer primary health services such as measuring blood pressure and doing simple pinprick tests for malaria, blood glucose levels and haemoglobin, and dispensing over-the-counter medicines for fever and pain.
Since CHOs are usually qualified nurses or practitioners of alternative systems of medicine with additional training in community medicine, they cannot prescribe medicines, change prescription treatment or give injections, but can also ask patients to continue prescribed medication – such as for diabetes, hypertension, among others — after a video consultation with the doctor at the nearest primary or community health centre.
Before these guidelines, there was no legislation or guidelines on the practice of telemedicine through video, phone, and online platforms, which include the web, apps, chats, etc. The existing provisions under the MCI Act, 1956, MCI Regulations 2002, Drugs & Cosmetics Act, 1940 and Rules 1945, Clinical Establishment Act, 2010, Information Technology Act, 2000 and the Information Technology Rules 2011 primarily governed only the practice of medicine and information technology.
“There are challenges, including connectivity, but the reach and support telemedicine provides is tremendous. Since April 8, the endocrinology department reached at least 60% patients who needed follow-up advice, without their needing to visit the hospital or doctor during the lockdown,” said Dr Tandon.
Telemedicine can increase reach, but it cannot replace a strong primary health system, which is dependent on competent health systems and providers. “I hope the biggest issue with public health delivery post-Covid is the recognition that universal health coverage is critical for any country to face a pandemic. Many countries are learning that you cannot build healthcare capacity during a crisis. It takes time and investment to build a good public health system. India has failed to invest in health for decades and this must change post-Covid19. Health spend must at least increase to 2.5% of GDP, at a minimum,” said Dr Pai.