Connecting the Unconnected is a monthly column by the Digital Empowerment Foundation (DEF) that explores how technology can drive inclusion and governance in India. The column focuses on how the digital divide impacts communities differently and advocates for equitable, citizen-informed solutions that ensure technology empowers rather than excludes.
India’s delicate healthcare system has long been hindered by chronic underinvestment, with public health expenditure remaining a mere 1.85% of the national budget. This has led to a system progressively dominated by private entities, a nearly broken primary healthcare network, and rural regions struggling with insufficient facilities and unresolved social health challenges.
Telemedicine, which had been an underexplored idea in public policy, emerged as a potential solution to bridge healthcare gaps in India. In November 2019, the Ministry of Health and Family Welfare launched eSanjeevani, a telemedicine platform developed as part of the Digital India initiative. Its goal was to connect doctors, specialists, and super-specialists with people residing in remote locations. This system proved helpful during the COVID-19 pandemic, when face-to-face appointments decreased to 32%. At the same time, online consultations surged by nearly 300%, positioning the platform as an essential resource, and integrating an innovative digital approach into a system that has long faced pressure.
By 2021, the Indian government expanded its health objectives through the Ayushman Bharat Digital Mission (ABDM), which aimed to establish an integrated system linking public and private health sector providers. Despite these efforts, post-pandemic, the telemedicine service in rural India has remained uneven and mostly disappointing. The use of telemedicine soared dramatically between 2021 and 2022 in regions, only to drop again in 2023, underscoring the fragility of relying on digital methods in rural healthcare.
A study by the Digital Empowerment Foundation (DEF) across nine sites in different states, namely Alwar (Rajasthan), Barabanki (Uttar Pradesh), Bharatpur (Rajasthan), Chirala (Andhra Pradesh), Choutuppal (Telangana), Gazipur (Uttar Pradesh), Kollegal (Karnataka), Nuh (Haryana), and Vizag (Andhra Pradesh), shows the significant challenges faced in access to the national telemedicine service.
At the core of DEF’s model are the ‘soochnapreneurs’ (Information Entrepreneurs) community members, trained in skills to help locals access telemedicine services and play a subset role as ‘healthpreneurs’. These facilitators act as connectors, translating tools to help communities connect with digital health services, ensuring beneficiary support for diagnosis, prevention, and timely care. Despite the availability of eSanjeevani and preventive digital health services, the research reveals that telemedicine uptake is uneven and varies across regions.
During the course of the study, it was observed that significant gender disparities remain evident at most of the sites. In Kollegal and Nuh, men used telemedicine services more frequently than women, reflecting entrenched mobility restrictions for women in preventive healthcare. In Barabanki and Nuh, telemedicine utilisation targets were met earlier than planned, suggesting that the limitations of existing face-to-face healthcare may have compelled people to rely on digital alternatives due to pressing necessity. In Gazipur, active community involvement through healthpreneurs significantly increased women’s willingness to participate.
The study highlights the fact that telemedicine goes beyond mere convenience and serves as a final option when healthcare services are inaccessible or inadequate. Residents in the study regions pointed out that the long distances to Primary Health Centres (PHCs), Community Health Centres (CHCs), and district hospitals are an important barrier to accessing preventive healthcare. This distance was more than an inconvenience and presented a barrier to obtaining timely medical attention. For daily wage workers, visiting a hospital could mean losing a day’s wages, whereas for households reaching health facilities during emergencies was often impractical without their own vehicles.
There were scenarios where eSanjeevani’s guarantee of linking patients to a specialist within minutes was crucial. Residents of the study regions stated that telemedicine spared them the need for hospital visits and long queues. It also partially alleviated doctor scarcity by allowing patients to access specialists across states. However, this convenience also introduced challenges. Users reported that a typical teleconsultation involved waiting an average of 15-20 minutes before connecting via audio or video with a doctor. Further, the lack of mechanisms for patients to reconnect with the same doctor for follow-up consultations makes continuous care nearly impossible.
Technological barriers compounded the difficulties encountered. Southern states like Telangana and Andhra Pradesh achieved better outcomes partly because doctors fluent in the local language were more readily available. Users also faced issues such as dysfunctional OTP login systems, limited chat features, and poorly designed data entry screens. Additionally, location mismatches were common, with individuals residing in Gazipur, Uttar Pradesh, consulting doctors from Bihar while unable to access healthcare professionals in their home state. Unavailability of doctors to attend to patients online has forced state officials to issue instructions requiring doctors to be online from 9 am to 5 pm.
Youth is often a catalyst for accessing telemedicine services in rural regions. Equipped with digital literacy and access, they act as bridges for seniors or rural residents without proficiency to utilise the telemedicine platform. The adoption of telemedicine typically expanded via family circles, our study found. Those familiar with it motivated relatives to try the service, widening the circle of confidence surrounding health tools. Nevertheless, the digital divide was evident among adults. Many people encountered difficulties due to restricted health literacy, struggled with virtual appointments, and showed a strong preference for face-to-face interactions.
The challenges of telemedicine access extends past consultations. Complimentary drugs from PHCs are only accessible through doctor log-ins at Health and Wellness Centres (HWCs). This is crucial, as there are profound issues with the availability of doctors and system accessibility. As a result, after receiving a consultation patients are forced to buy medicines from private pharmacies. This is an expensive burden, given that out-of-pocket spending on medications accounts for half of total health expenditure. For rural households, this compromises one of telemedicine’s main advantages: affordable healthcare.
India’s current integrated healthcare system also imposes a load on frontline healthcare staff. ASHA workers and primary care staff members who are already responsible for preventive measures, primary responses, awareness creation, and data entry tasks now must also handle teleconsultations. Telemedicine involves managing data, and the shift to healthcare has increased expectations on personnel without addressing staffing shortages or lack of training.
Achieving health equity in India is not about expanding telemedicine availability. It necessitates addressing the limitations of health systems while guaranteeing that medications, follow-up care, and financial protections are integrated into health sector offerings. On the other hand, telemedicine continues to hold promise for the future despite these constraints. Research consistently shows that online consultations are cost-effective, time-efficient and particularly helpful for disease prevention. It has the potential to alleviate pressure on healthcare facilities and provide access to specialists who might otherwise be out of reach for rural populations.
However, telemedicine does not function independently. It requires strengthening health infrastructure, digital infrastructure, protecting data privacy, ensuring cybersecurity, and enhancing digital literacy. Its effectiveness also depends on addressing inequalities such as language, caste, gender, and financial hurdles. Bridging this digital health divide will require not only technological expansion but also socially inclusive policy implementation, political will, and a commitment to ensuring that the digital future of healthcare leaves no one behind.
Suruchi Kumari is a senior researcher and communication practitioner at Digital Empowerment Foundation. She has a PhD in Geography from Jawaharlal Nehru University. Her research areas lie at the intersection of digital rights and citizenship in India, particularly in the context of welfare delivery.
Views expressed are the author’s own.