INTRODUCTION

The Government of India, through its flagship program Ayushman Bharat Digital Health Mission (ABDHM), has embarked on a transformative journey to enhance healthcare accessibility and delivery in rural areas. ABDHM aims to transform 150 000 sub-centres into Health and Wellness Centres (HWCs) with the addition of telemedicine services. This is being achieved by using a hub and spoke paradigm with the help of ‘eSanjeevani’ digital platform.1

eSanjeevani’s inception in November 2019 marked a pivotal step towards realizing the telemedicine vision outlined under ABDHM. Accelerated by the Covid-19 pandemic restrictions, eSanjeevani swiftly expanded its reach to approximately 124 500 HWCs, serving as spokes, and over 15 656 hubs across India.2 Additionally, the Ministry of Defence has facilitated a national outpatient department on the eSanjeevani platform, staffed by over 100 veteran doctors, thereby augmenting healthcare accessibility on a national scale.3 eSanjeevani provides a free teleconsultation service, promotes digital health equity by offering a multilingual interface, and facilitates access to both allopathic and Ayush health services. This comprehensive approach caters to both the urban and rural populations, contributing in a major way to the overall goal of achieving universal health coverage (UHC).

The increasing use of eSanjeevani underscores its pivotal role in improving healthcare access, particularly in rural and hard-to-reach areas, as seen during the Covid-19 crisis. Thus, eSanjeevani plays a crucial role in facilitating the patient and doctor connection in both rural and urban settings.3

Our study focuses on understanding Community Health Officers (CHOs) perception towards the use of eSanjeevani in the rural setting and the challenges faced by them in the process.

METHODS

This was a descriptive cross-sectional study to assess the CHO’s perception of eSanjeevani. The research was conducted across rural areas of Maharashtra where trained CHOs were stationed in diverse locations across the state.

We included 120 participants who completed CHO training at a tertiary medical college between March and August 2020. Data were collected in September 2022, at which time they had 2 years of experience following their training. A Google form questionnaire was sent to all participants. Upon completion, they were interviewed for their opinions and suggestions for improvement of the quality of eSanjeevani. Subsequently, the data obtained through the Google form were compiled and analysed.

The primary outcome was the perception of eSanjeevani among the CHOs. Secondary outcomes included factors influencing their perception, such as ease of use and effectiveness. Descriptive statistics were used to analyse the compiled data. Frequency distributions and percentages were calculated to summarize the CHOs’ perception of eSanjeevani.

We adhered to ethical guidelines of the institution conducting the research (Approved by the Ethics Committee of Bharati Vidyaeeth Deemed University and Medical College, Pune, number BVDUMC/IEC/33A), ensuring confidentiality and voluntary participation of the CHOs.

RESULTS

Of 120 CHOs, 106 (88.3%) responded to the questionnaire. The CHOs included nursing graduates (38.7%) and postgraduates (4.7%), Ayurveda graduates (48.1%), Unani graduates (3.8%), and others (4.7%). Over half (53.8%) of the CHOs used the eSanjeevani application on a daily basis, while 30.2% used it intermittently, and 16% used it infrequently.

eSanjeevani was effective in supporting CHOs’ management of various health conditions. Notably, it was perceived as very valuable for non-communicable diseases like diabetes (39.6%) and hypertension (38.7%). Interestingly, skin conditions (50.9%) also showed a major benefit from teleconsultation, followed by paediatrics (45.3%) and maternal health (42.5%). Conversely, eSanjeevani appeared less effective in managing psychiatry cases (25.5%) and other health conditions (21.7%). CHOs reported that the platform helped in generating prescriptions and advising treatment (Table 1).

TABLE 1. CHOs’ perceptions of resource availability and patient experience with eSanjeevani teleconsultation

Perception parameter All the time (%) Sometimes (%) Never (%) Are you able to generate a prescription based on advice? 44 (41.5) 50 (47.2) 12 (11.3) Are you able to give treatment based on the advice given on the app? 30 (28.3) 60 (56.6) 16 (15.1) Are drugs advised by specialists available in the centre? 3 (2.8) 69 (65.1) 34 (32.1) Are investigation facilities recommended to be available? 5 (4.7) 54 (50.9) 47 (44.3) Are patients comfortable with the concept of teleconsultation? 9 (8.5) 65 (61.3) 32 (30.2)

A fair proportion of CHOs reported that, in their view, patients received early diagnoses and comprehensive treatment plans through eSanjeevani (Table 2). However, CHOs also encountered several hurdles while utilizing eSanjeevani, such as the absence of specialists (58.5%), network connectivity issues (27.3%), and extended waiting periods where 15.1% had a waiting time of over 90 minutes (Table 3).

TABLE 2. Usefulness of specialists’ teleconsultation for patient management

Usefulness parameter Nursing graduates* AYUSH practitioners* (n=47) number (%) (n=55) number (%) Early diagnosis 42 (89.4) 39 (70.9) Better investigations 42 (89.4) 40 (72.7) Better treatment 44 (93.6) 41 (74.5) Referral services 39 (83.0) 40 (72.7) Improved access to specialist care in the rural community? 42 (89.4) 36 (65.4)

TABLE 3. Challenges faced by CHOs while using eSanjeevani

Challenge faced Frequency* (%) Specialists not available 62 (58.5) Network issue 29 (27.3) Long waiting time (minutes) 0–30 66 (62.3) 30–60 15 (14.2) 60–90 9 (8.5) >90 16 (15.1) Patient not cooperative 2 (1.9)

The CHOs, recommended various modifications that could further enhance eSanjeevani’s quality. An analysis of their responses to open-ended questions revealed the following key themes:

Doctor availability and wait times. This was the most prominent theme, where many CHOs complained about long wait times (37.7%) and lack of specialists (41.5%). A number of CHOs recommended the inclusion of more specialists at the hub, improving appointment scheduling, and prioritizing specialists.

Target reduction. A concerning finding was that 20.7% of CHOs resorted to fraudulent calls to meet the daily high targets. This suggests a need to re-evaluate the current target structure.

Expanding functionality for emergency care. Some CHOs (6.6%) recognized the potential benefit of eSanjeevani in handling emergency cases. This suggests a need to explore adaptations to the platform that could make it more suitable for emergency teleconsultations.

Technical issues. Connectivity problems and network limitations are concerns. CHOs reported network issues (8.5%) and desired offline functionality (2.3%).

Patient records and communication. CHOs also addressed the lack of features for managing patient information and communication with patients (8.5%).

DISCUSSION

We investigated the CHOs’ perspectives on the use of eSanjeevani in rural Maharashtra. We found that the patient-to specialist communication has improved in rural areas, and such findings have also been reported in rural America.4 Such access to specialist care, which used to be very difficult in rural areas due to reasons such as travel time, high out-of-pocket expenditure, and low awareness, may now be possible.5

The study emphasizes the importance of telemedicine in facilitating early diagnosis and comprehensive investigations, which helps in providing effective healthcare. CHOs reported that teleconsultations were perceived as very useful for facilitating early diagnoses and recommending investigations. This suggests that while telemedicine cannot replace face-to-face consultations entirely, it can play a crucial role in enhancing healthcare outcomes by promoting timely diagnosis and comprehensive treatment. Previous studies6 have demonstrated telemedicine’s potential to facilitate early diagnoses of conditions like cardiovascular diseases and breast cancer through direct patient outcome measures.

However, the study also identifies challenges faced by CHOs when using eSanjeevani. These limitations fall into two main categories. First, resource constraints within the healthcare system restrict their ability to carry out specialists’ recommendations. This includes a lack of facilities for investigations and providing necessary medications at HWCs. Second, challenges related to the functionality and user experience of the application compromise its effectiveness. These include limited specialist availability (58.5%), network connectivity issues (22.6%), and extended waiting times (16.0%). Over 20% also reported making fraudulent calls to meet the high daily targets. This results in misuse of the platform and thus creates a negative connotation of the healthcare system. These obstacles resonate with findings from other telemedicine studies, which emphasise the need for improved infrastructure and training to optimise the use of such technologies.7

It is crucial to acknowledge our study’s limitations. First, the findings are primarily based on the CHOs’ perceptions, not direct patient outcome data. Therefore, observed ‘effectiveness’ is based on their assessments rather than quantifiable clinical improvements. Second, the cross-sectional design limits our ability to establish causal relationships. Third, the study’s regional focus in Maharashtra may limit generalizability to other areas. Finally, reliance on self-reported data from CHOs introduces potential bias.

While our study focuses on CHOs’ perceptions, it aligns with broader research that has demonstrated measurable improvements in healthcare outcomes and increased patient satisfaction through telemedicine implementation.8,9 Additionally, the study underscores the importance of storing patient data digitally, which can streamline healthcare delivery by ensuring easy accessibility to patient information.