Assisted Telemedicine for Rural Healthcare Ecosystem

Project Report

Abstract Analyzing, developing and executing pilot runs of an “Assisted Telemedicine” model in rural towards exploring feasibility and designing blue-print of a tele-consultation platform for catering to the rural healthcare needs during Covid-19 and beyond

Project Team E-Health Research Center, IIIT-Bangalore (https://ehrc.iiitb.ac.in) Collaborators: PHIA Foundation (www.phia.org.in), Patharitech Private Limited (www.patharitech.com)

Project Funding COVID-19 Research Funding Programme of Azim Premji University

Report Authors Divya Raj (E-Health Research Center, IIIT-Bangalore) Jhumur Dey (Patharitech Private Limited) Reviewer T.K.Srikanth (E-Health Research Center, IIIT-Bangalore)

Contents

About the document 2 Background 2 Project Objectives 3 Execution Approach 3 Details of Field Trials 5 Location 1 – Community Health Center Kamdara, , 6 Location 2 – Maheshpur village, Angada Block, 10 Location 3 – Kurmul Village, Kamdara Block, Gumla 14 Location 4 – Gankre Village, karra Block, 17 Outcomes 20 Telemedicine Application Overview 20 Technical Solution 25 Summary of Learnings and Observations 26 Relevance in context of Covid-19 pandemic 26 Relevance for non-Covid scenarios 27 Solution Acceptance among Stakeholders 28 Other learnings and observations 30 Conclusion 32 Scope for Enhancements and Future work 32 Summary 33 Annexure 34

Assisted Telemedicine for Rural Healthcare Ecosystem P a g e | 1

About the document

This document is a project report covering details of the work done for “Blue-print for Assisted Telemedicine for Rural Healthcare Ecosystem” project by E-Health Research Center (IIIT- Bangalore) in collaboration with PHIA Foundation and Patharitech Private Limited, under the COVID-19 Research Funding Programme 2020. This includes details of the overall execution approach of the Project, the telemedicine skeletal technical solution created, details on the field work done, the learnings based on field trials of the telemedicine application and also some guidance on feasible approach for scaling up this model for usage during and beyond Covid-19.

Background

With the outbreak of Covid-19 in , seeing the significant benefits of the telemedicine model and the need for quickly increasing the outreach while ensuring social distancing, telemedicine usage in the country got a strong push as the Telemedicine Practice Guidelines were announced by the Medical Council of India in March 2020. These guidelines are designed to serve as an aid and tool to enable Registered Medical Practitioners to effectively leverage telemedicine to enhance health services and access to all in India. This was followed by a rapid launch of numerous telemedicine platforms and apps by private companies and startups, government and semi-government agencies across the country and a huge spike has been reported in the count of telemedicine consultations across the states. Some of the government associated platforms are also offering consultations for free. However, a closer look at the pattern of telemedicine adoption clearly shows that the spread has been limited to the metros and urban regions, and almost negligible adoption in rural parts of the country. Telemedicine in the current model, design and adoption patterns again brings to fore the factors related to “digital divide” across citizens and regions. With the above perspective in mind, with a focus on Jharkhand, efforts were designed and put in by E-Health Research Centre (IIIT-B) along with PHIA Foundation towards exploring the feasibility usage of telemedicine for Jharkhand migrant workers from the rural parts of the states. This was done by leveraging the ecosystem around the Jharkhand Migrants Helpdesk digital platform which had been implemented by PHIA Foundation, E-Health Research Centre (IIIT-B) and Patharitech Private Ltd in collaboration with Government of Jharkhand, and which continues to be operated out of Ranchi (Jharkhand) since the initial announcement of national lockdown in March 2020. Based on the studies involving two key telemedicine platforms (CDAC’s e-Sanjeevani and RIMS e-OPD) and a set of migrant workers it was inferred that the regular telemedicine model involving patients on one end and physicians on the other, posed several challenges n

Assisted Telemedicine for Rural Healthcare Ecosystem P a g e | 2 likelihood of adoption of telemedicine due to multiple technical and non-technical failure points in the entire appointment and consultation process. The same platforms were also tried with few citizens from urban regions of Jharkhand and the results were positive and encouraging. And similarly success was also observed for the cases where new patients were not technology-aware but were assisted by people who were comfortable with the basics of overall processes involved. Lower digital awareness, technical glitches, connectivity and infrastructure issues, apprehensions due to new channels were some of the underlying reasons observed during these studies and field trials. The findings pointed to the need for focused efforts towards designing of new models and applications for telemedicine which are more suited for the rural ecosystem and citizens, while applying the principles of design thinking as the “bottom-up” approach.

Project Objectives

The objectives of the project were broadly defined as analyzing, developing and doing pilot runs of an “Assisted Telemedicine” model towards designing a blue-print of a Telemedicine platform for catering to the rural healthcare needs during Covid-19. Below activities were outlined to be done as a part this initiative: ● Analyzing the rural healthcare ecosystem in the identified blocks to closely understand the dynamics, constraints and challenges in Covid-19 times ● Analyzing the user personas of doctors in primary healthcare centres (as teleconsultation- providers), community health-workers (as teleconsultation-facilitators) and rural populations (as patients) ● Designing and developing a pilot telemedicine platform aligning to the basic principles of design thinking towards addressing the need for screenings with social distancing, and working around the infrastructure and resource constraints ● Building design features towards enabling longitudinal case history of patients and studying the possibility of leveraging those for their subsequent visits towards ensuring better quality of care and continuity of care at lower costs ● Analyzing design possibilities for incorporating concepts of “family-doctor” and “community- doctor”, integrating the proposed model with effective surveillance mechanism ● Incrementally adding features into the telemedicine platform leveraging the learnings from the trial runs. ● Identifying parameters to be considered for scaling up of the platform at district and state levels

Execution Approach

Assisted Telemedicine for Rural Healthcare Ecosystem P a g e | 3 The project was for studying feasibility and exploring options for leveraging tele-consultation based primary healthcare services to the rural citizens leveraging doctors in primary healthcare centres, while plugging in community health workers and paramedics for assistance. E-Health Research Centre (IIIT-Bangalore) in collaboration with PHIA Foundation and Patharitech Private Ltd did the field work and trials of this platform in Maheshpur village (Angada Block, ), Kurmul Village (Kamdara Block, ) and Ganker Village (Karra Block, ) in Jharkhand. ● The basic telemedicine video-consultation software developed by Patharitech and IIIT-B was leveraged and customized for the technical solution (tab based application) needed for the trials ● The collaborative engagement of the three teams (IIIT-B, PHIA Foundation and Patharitech) in the JIDHAN initiative was leveraged for identification of locations, doctors and field workers needed for the field trials ● The villages and blocks were identified based on following factors: - Covering rural setups with a mix of remote and not-so-remote locations - Availability of effective and enthusiastic field workers for being able to gather patients and try out this new kind of consultation model - Availability of Doctors from government and other hospitals and clinics - Safety and security of the team members and field workers The initial approach of leveraging telemedicine for consultations with Doctors for Covid-19 related diagnosis and treatment had to be adjusted later due to: 1. Reluctance of field workers to do consultation alongside any Covid-19 suspected cases 2. Low Covid-19 incidence rate in Jharkhand, especially in the rural regions the numbers are very low Instead of this, the approach was altered to look for rural citizens who were reluctant to go to hospitals due to Covid-19 scare and arrange a consultation for them with the doctors in the government or non-government setups. In the later stage of the Project, due to challenges faced with limited availability of Doctors in Government hospitals, the team also leveraged a private practitioner in Ranchi (who was paid for each of the tele-consultations) to ensure good amount of time was spent for consultation towards getting the approach validated and get required feedbacks. This was also done to explore the feasibility of scaling up this model in non-government setups. The execution of the project was done in two parallel threads - technical software development on one side and field trials on the other. This helped validate the approach and incrementally add features into the software application. The high-level steps followed for executing the project are shown below:

Assisted Telemedicine for Rural Healthcare Ecosystem P a g e | 4

Figure - Overall Execution Approach (steps in blue boxes were done as a part of current project)

Details of Field Trials

As a part of this project multiple field trials were conducted in the villages across multiple blocks, with the help of ASHA workers, Doctors and other field workers and team-members. The field trials were conducted to get a validation of the tele-consultation based approach for these villages, while also trying to understand the existing healthcare challenges and get inputs from the field work to develop an appropriate digital platform for tele-consultation.

Assisted Telemedicine for Rural Healthcare Ecosystem P a g e | 5 Location 1 – Community Health Center Kamdara, Kamdara Block, Gumla

Figure SEQ Figure \* ARABIC 1: Arhara village, Kamdara Block

Kamdara block is situated at 80 KM South-east from district headquarter, Gumla. It is surrounded by Khunti District Block at its East, at the west, Ranchi District at the North and Bano Block ( District) at its south. Agriculture is the chief occupation of the villagers.

Kamdara has 10 Gram Panchayats, 73 villages and 1 CHC and 19 HSCs, 78 Primary Schools, 43 Middle School, 9 High School and 1 BRCs. It also has a police station and a Block Headquarters.

The populations of Kamdara Block is 63775 and 31664 are male and 32111 are female. The demographic distribution also reveals that the block has a high concentration of people in rural areas which is about 100 per cent of the total population.

Healthcare Profile of the Village/ Block:

Government Healthcare Establishments in the Region: 1. Primary healthcare: Health Sub Centre (HSC), Primary Health Centre (PHC) and Community Health Centre (CHC), together constitute primary healthcare facilities in the district.

Block Name Total HSCs Total PHCs Total CHCs Kamdara 19 0 1 Source: CHC, Kamdara

2. Secondary healthcare: Gumla district has three sub-divisional hospitals (SDH) and one district hospital (DH). This means that the district has the required referral facilities.

Health Staffs in Different Health Facilities in Kamdara Block:

HSC CHC Block ANM ANM Nurse Doctor Kamdara 28 4 2 3

Assisted Telemedicine for Rural Healthcare Ecosystem P a g e | 6 3. Anganwadi Centers: Kamdara block has a total 133 Anganwadi centers. The major functionalities performed by the Anganwadi Centers are- ● Immunization ● Regular Checking of Pregnant women, it includes weight, Blood pressure, Nutrition of mother. ● Educate on Health and Hygiene ● Delivers iron pills to the adolescence girls to prevent iron deficiency. Figure SEQ Figure \* ARABIC 2: Anganwadi Center Private Healthcare Facilities: One private hospital, St Ursula, is situated about 15 km away from the CHC of Kamdara block. In most emergency cases the people are taken to this hospital with the help of ASHA workers. For any minor health related issues or regular checkup people of Kamdara visit the CHC.

Key healthcare challenges

1. Kamdara CHC is the major Government hospital which covers the villages around 25 Km of Kamdara Block. Villagers use Public transport like Auto which they can get from the respective villages. In any emergency cases they contact the ASHA workers and arrange private vehicles to take the patient to the Hospital. Ambulance is not present in the CHC. In any emergency villagers have to call ambulance from Gumla which takes more than one hour to reach Kamdara. 2. In any emergency condition of patience ASHA worker has to consult an over call doctor for a suggestion. Many patients who cannot travel to the hospital for consultation have to face difficulties in getting consultation on time. In many cases patients are referred to nearby Mission hospital or RIMS. People who can not afford treatment in private hospitals or face any difficulties in travel to Ranchi tend to terminate the treatment to avoid the difficulties.

Relevance of healthcare tele-consultations

● There are many people who suffer with ailments like hypertension, diabetes etc for which they need to go through regular checkups. In those cases Telemedicine can help the patient to avail an easy way to consult with a doctor.

Assisted Telemedicine for Rural Healthcare Ecosystem P a g e | 7 ● In rural areas (e.g- village Murga, Kamdara Block), where communication is not good people are less concerned about their health as the accessibility to the health care system is difficult for them. Especially for females in villages, health is getting neglected as they have to wait for a male member to take them to the clinic or hospital. In such cases Telemedicine can help the villagers. ● In some cases when the condition of the patient does not come under the specialized area of the doctor patients are referred to any private hospital or Gumla District hospital. In those cases Telemedicine can help the patient to consult with the doctor from their respective village.

Description of field trial Participants 1. Core Project team - Mr. Ravi Shankar( Doctor's end) - Mr.Dilip Shukla - Ms. Jhumur Dey ( ASHA worker’s end) 2. Site Doctor- Doctor of CHC Kamdara 3. ASHA worker 4. Patients Equipment used: ● Tablets- one for ASHA Worker one for Doctor ● Temperature Gun for taking vitals of the patients by ASHA worker ● Pulse Oximeter Steps Followed:  Step1: Identification of patients  Step2: Scheduling appointment with doctor using the portal  Step3: Taking the Vitals by the ASHA worker  Step4: Start Consultation with Doctor

Information about doctor: ● Medical Officer in-charge in CHC Kamdara ● Available in CHC Kamdara from Monday to Saturday from 10 am to 3 pm.

Assisted Telemedicine for Rural Healthcare Ecosystem P a g e | 8

Challenges Faced in Field . ● Poor internet connectivity interrupted the consultation flows in between. ASHA workers had to reconnect. Both the doctor and ASHA worker struggled to conduct a smooth conversation through the platform as the connection was poor which also led to distraction in communication ● Villagers hesitate to disclose their phone numbers, specifically when it is getting recorded using digital platforms. Villagers were hesitant to use such a platform as it was the first time they were introduced to tele-consultation ● The trial was done with available patients in the CHC who have come for consultation with the doctor. Due to time constraints the patients were not willing to appear in such a trial ● The government doctor was committed to many other official works so he couldn't allot sufficient time for the trial.

Observations and Learnings

● The villagers as well as ASHA workers are not experts in using technology. To implement a project like telemedicine, a tangible example of benefits of using in other villages may help to encourage the villagers to welcome such kind of changes in the flow of the existing health care system ● There are no Primary Health Centers in Kamdara Block. All the primary health care facilities are available in Community health Centers and Health sub Centers. ● The CHC provides facilities for OPD, One labour room, laboratory, pharmacy, X-ray room.

Assisted Telemedicine for Rural Healthcare Ecosystem P a g e | 9 ● CHC is well equipped with internet connectivity for performing official tasks like sending documents to the district hospitals. ● CHC does not have its own Ambulance. In urgent need of people of Kamdara block have to call Ambulance from Gulma District Hospital, which takes more than one hour. ● The nearest Private hospital is located in Basia Block which is about 12 km away from Kamdara block ● Private vehicles for commuting are available in the villages. ● Every Thursday ANM visit to Anganwadi and commence the process of vaccination for 0- 3years old children. ● ASHA workers enlist the names of the expected beneficiaries for vaccination on a day before and ● The Village Health Nutrition Day is being organized on any Thursday or Saturday of the month. On that day the ASHA Workers, ANM meets to discuss the health status of the people in the village. ● To make the system a more realistic option for past records uploading will be helpful for both the doctor and the patient.

Location 2 – Maheshpur village, Angada Block, Ranchi

Figure SEQ Figure \* ARABIC 3: CHC Kamdara

Figure SEQ Figure \* ARABIC 4: Maheshpur Village of Ranchi district has a total population of 112,759 as per the Census 2011. Out of which 56,841 are males while 55,918 are females. In 2011 there were a total of 22,572 families residing in Angara Block. The Average Sex Ratio of Angara Block is 984. The block consists of a total number of 21 panchayats and 83 villages. Maheshpur Village I situated 5 km away from the sadar of Angada block, comes under Sirka panchayat. Total population of Maheshpur is 2467. The village is divided into three hamlets. It has a total of 3 Aganwadi centers, one for each hamlet.

Assisted Telemedicine for Rural Healthcare Ecosystem P a g e | 10 Healthcare profile of the village

Government Healthcare Establishments 1. Health Sub Center: Maheshpur Health Sub Center provides the preliminary health care support to the villagers. Major facilities of Maheshpur sub center are- ● Outpatient department ● Medicine corner ● Vaccination

2. Primary Health Center: The nearest Primary Health Center of Maheshpur is in Getalsud Panchayat which is around 7 Km away from Maheshpur village. There is no PHC in Sirka panchayat.

3. Community Health Center : Community Health Center is the primary source of health care support for the villagers of Maheshpur.

● Minor operation is done in CHC, for major operation villagers have to find another hospital. ● The infrastructure of CHC is poor, it has no electricity backup most of the time they don’t have electricity. ● CHC has one ambulance which is available for emergency service. As the number of available ambulances is very less than the demand most of the people have to arrange vehicles by their own in case of any emergency.

Private Healthcare Facilities One private hospital named Shalini Hospital is located within 5 km of the village, it has inpatient facility, operation room but the villagers cannot avail the facilities due to the high treatment cost

Key healthcare challenges 1. Availability of medicine: Villagers have to face an access medicine corner as there are no pharmacies nearby. The nearest medicine corner in the Health Sub Center is 1 km away from the village but all types of prescribed medicine is not available in the sub center.

2. Accessibility: The CHC Angada is around 5km from the village. No public bus is available for travelling. Public auto rickshaws are available in limited numbers. For any special treatment villagers have to visit Sadar hospital Ranchi which is 25-30 Km the village.

Assisted Telemedicine for Rural Healthcare Ecosystem P a g e | 11

Relevance of healthcare tele-consultations

● In the village many people are suffering from chronic illness who need to go for regular checkup. In those cases telemedicine will ease treatment procedures. ● This will help to save time and money the villages has to spend on travelling for visiting a hospital ● In the villages limited health care are available in PHC, for extent health care services like treatment of skin problems, ulcers prefer to visit Ranchi Sadar Hospital.

Description of field trial Participants 1. Core project team - Dilip Shukla (Doctor’s side) - Rahul Kumar ( Doctor’s side) - Jhumur Dey (ASHA worker’s side) 2. Doctor of Ranchi Sadar Hospital 3. ASHA worker 4. Patients

Equipment used ● Tablets- one for ASHA Worker one for Doctor ● Temperature scanner for taking vitals of the patients by ASHA worker ● Pulse Oximeter

Step followed

 Step1: Identify some patients for telemedicine trial  Step 2: Introduce them about the platform and inform them of the objectives of the trial.  Step 3: Provide ASHA worker a brief orientation about the functionalities of this telemedicine platform.  Step 4: Complete registering the patient  Step 5: Start video consultation one by one.

Doctor chose to have Telemedicine consultation from his home.

Information about Doctor:

Assisted Telemedicine for Rural Healthcare Ecosystem P a g e | 12 ● On deputation at Sadar Hospital Ranchi ● Posted at CHC , Specialization – Anesthesia, Was one of the 8 doctor team members posted at Paras Hospital Dhurwa during Covid 19 pandemic

Total Five patients from the village took part in the trial of video consultation. ASHA workers started to register patients by 10.30 am. The consultation started at 11.30 am. The doctor and patient were connected by the web. The doctor asked about the current condition of the patients, past medical history similarly he does in face to face consultation. Each consultation continues at least for 10 minutes. Challenges faced in the field: From ASHA worker’s end ● Due to lack of proper information regarding the current pandemic and the approaches taken for testing of Covid, the many villagers were not willing to participate in this trial. ● Getting medicine is the major challenge for the villagers so instead of consultation they were more concerned about availability of medicine. ● Unstable internet connectivity sometimes hinders the flow of consultation. From Doctor’s end ● If the medicine prescribed by the doctor is not available then how will they choose an alternative or how they will consult about this with the doctor through this platform? ● Doctor needs to inform the patient every time he sends a prescription. There is no option to understand by the patient automatically that the doctor sent the prescription. ● Doctors need to inform the patient each time after modifying the sent prescription. ● As we asked the patient to click a picture of their prescription, one of the patients did not have a mobile to click a photo during the consultation.

Observations and learnings:

From ASHA worker’s end ● The ASHA worker is comfortable to use technology. She is willing to learn about technology which can help the villagers to access the health care system easily. ● Most of the villagers don’t have access to technology because of that they are afraid of such kind of inclusion of technology in the healthcare system. ● Infrastructural set up was unavailable for the current trail. So the ASHA worker had to hold the Tab which was difficult for her. In this situation during consultation ASHA worker’s hand may touch any button in the tab can lead to termination of consultation in between.

Assisted Telemedicine for Rural Healthcare Ecosystem P a g e | 13 From Doctor’s end ● Since all the patients participated were on medication but patients’ past medical history, reports are not available. ● For some cases where some tangible examination or observation is required for a doctor. In those cases video consultation is challenging. E.g-One of the patient had infection developed on her leg and she was hesitant to show as it was not continent to

show the infection through the system, On Figure SEQ Figure \* ARABIC 5: Doctor consulting which the doctor commented “Good to use whenpatient physical from his examination place is not required” ● Patients were worried about receiving prescriptions. ● In order to convince the villagers to appear in the trial awareness about the healthcare facility and benefits is very important. ● One of the key functionalities to make the project successful is to map the healthcare needs of the villagers. ● Only tele-consultation will not help the villagers to get complete health assistance. The major challenge for the villagers is to get the medicine. ● Device Galaxy Tab A (14.94cm*24.52*0.75cm) inch is optimum to use the portal. The entire screen covers all the features without scrolling.

Location 3 – Kurmul Village, Kamdara Block, Gumla

Village Kurmul is located around 8 km away from the main Kamdara town. Kurmul Village It comes under Kurmul Panchayath. It is located 53 KM towards East from District headquarters Gumla. 6 KM from Kamdara. 68 KM from State capital RanchiTotal population is 383 and

Assisted Telemedicine for Rural Healthcare Ecosystem P a g e | 14 number of houses are 70. Female Population is 48.0%. Village literacy rate is 83.3% and the Female Literacy rate is 37.6%.

Healthcare profile of the village:

1. Government Healthcare Establishment The nearest health care center of the village is Kamdara Community Health Center which is about 9 km from the village. The nearest health sub center of the village is Ramtolia Sub Center which is also 7-8 km away from the village. The anganwadi center performs vaccination, growth monitoring, for children below the age of five years. 2. Private Healthcare Facilities: There is one medicine shop where the villagers can purchase medicine apart from CHC/PHC. One private hospital is situated around 5 km away from the village which is frequently visited by the villagers when doctor is not available in the CHC.

Key Healthcare Challenges:

● Availability of medicine: The main source of medicine for the villagers is the Kamdara CHC where the medicine is available free of cost. But due to unavailability of medicine and long distance villagers have to visit private medicine corner near by their village for which they have to spend from their earnings. Because of these challenges villagers developed the habit of avoiding visiting CHC. ● Accessibility: People face difficulties in getting public transport to visit the Hospital as the village has no direct connection with the main city. The public auto rickshaw is available only on Thursday and Sunday (market day) in a week. On any other day villagers have to walk 3-4 km to reach the main road where they can get a public transport. In case of any emergency or urgency villagers have to reserve a vehicle which costs around Rs. 250 for one way. ● Awareness regarding health facilities Most of the villagers do not hold Ayushman Bharat cards. Many villagers do not have Ration Cards too, due to which they are unable to apply for Ayushman Bharat Card. ● People who have Ayushman Bharat Card can get free treatment in private hospitals but people who don’t have Ayushman Bharat card cannot get the benefits. ● Lack of knowledge regarding the benefits received from the health care schemes and the process of availing the benefits makes them demotivated for making a health card.

Assisted Telemedicine for Rural Healthcare Ecosystem P a g e | 15

Relevance of healthcare tele-consultations ● People tend to neglect health issues as the accessibility to healthcare services is challenging for them. Some of the health problems are generally ignored by the villagers. ● There is no private practitioner available nearby. If they need to consult about any day to day health issue they visit the nearby pharmacy and rely upon the medicine suggested by the pharmacist. ● People showed interest in the video consultation model and realized and acknowledged that a platform like this will reduce the villagers’ effort for paying visits to the hospital.

Description of field trial Participants 1. Core Project team - Mr. Divya Raj(Doctor's end) - Ms. Jhumur Dey (ASHA worker’s end) - Block coordinator Kamdara block (Doctor’s end) 2. Site Doctor- Doctor of CHC Kamdara 3. ASHA worker 4. Patients Due to poor internet connectivity and other technological problems related to portals, the consultations could not be completed end to end successfully using the app. However the ASHA worker and some patients were introduced to the system and oriented about the functions of the web portal.

Challenges faced in field ● Mobilizing people for field trials was difficult as the people of the village were busy in their own work and not willing to spend time for the trial. ● For doctors also finding time for trial was a tough job as they are occupied in many other activities. ● Internet connection is not so strong to conduct a video consultation. Many times it lost the signal and had to resume the consultation.

Observations and learnings

Assisted Telemedicine for Rural Healthcare Ecosystem P a g e | 16 ● People are not much used to with smartphone, technology. ASHA workers need proper guidance to handle devices for such a kind platform. ● People of the village do not want to visit CHC to get medicine due to unavailability of medicine in CHC. They went to the nearest pharmacy and consulted with the pharmacist for medicine and treatment.

Location 4 – Gankre Village, karra Block, Khunti

Figure: Gankre Village

Gankre is a remote village of Karra block of Ranchi, which is situated 5 km away from the Karra town. The villagers depend on agriculture for their livelihood. 91.70 % of laborers depict their work as Main Work (Employment or Earning over 6 Months) while 8.30 % were associated with Marginal action giving occupation to under a half year. Of 241 specialists occupied with Main Work, 208 were cultivators (proprietor or co-proprietor) while 6 were Agricultural workers. Ganrke is a medium size village located in Karra Block of Khunti district, Jharkhand with a total 96 families residing. The Ganker village has a population of 535 of which 280 are males while 255 are females as per Population Census 2011.

Healthcare Profile of the Village

Government Healthcare Establishment

Assisted Telemedicine for Rural Healthcare Ecosystem P a g e | 17 Community health center is the nearest healthcare center for the villagers. The CHC karra is 6 Km away from the village. The karra CHC provides services for – Out Patient department, Test lab, X- ray (payable), Pharmacy. Every day one doctor is available in the CHC from 10 am to 3 pm. Private Healthcare Facilities Two pharmacies are located around 6 -7 Km in Karra which are the main source of medicine for the villagers when they failed to get medicine in CHC. There are no practitioners available for consultancy.

Key Healthcare Challenges 1. Unavailability of medicine: People of the village have to face difficulties to receive the medicines. The CHC is not equipped with all the medicine prescribed by doctors. Many times medicines are not available in the pharmacy too. 2. Accessibility: There is no transportation between the village and the main town. Only on Wednesday (on the day of market) public transport is available. On other days of the week villagers have to travel 5-6 km on foot or by cycle to reach the hospital. For any emergency situation villagers have to hire a vehicle, mostly they arrange vehicles from the village.

Description of Field trial Participants: 1. Core Project team - Mr. Shwet Rajan ( doctor’s side) - Jhumur dey ( ASHa worker’s side) 2. Private practitioner 3. ASHA worker 4. Patients

Doctor: Ex. CMO, Mecon Hospital, Ranchi Specialization: General Physician

Steps followed Figure SEQ Figure \* ARABIC 7:Doctor consulting the patient from his chember

Assisted Telemedicine for Rural Healthcare Ecosystem P a g e | 18 Step 1: Identified village and doctor to conduct the trail. Step 2: Identified ASHA worker, and discussed with her to arrange and coordinate with patients for the trial Step 3: ASHA workers informed all the patients in the village and checked their availability for the trial a day before the trial. Step 4: Took the details of available patients scheduled their visit using the portal by ASHA worker Step 5:Visited more houses and invited others who are willing to visit a doctor. Step 6:Scheduled the patient for tele-consultations Step 7:ASHA workers filled the vitals of the patients Step 8:Started the consultation once Doctor was available

Challenges faced in field: ● Restricting the time duration of the consultations was tricky as sometimes villagers felt the need to prolong the conversation with the doctor. ● It took a long time to get a prescription after the consultation ended. The patient had to wait for the doctor to complete writing the prescription who took longer time due to new way of doing it and also due to lack of suitable keyboards for typing in the tab ● Patients and their family members were not having test reports or past prescriptions with them.Figure This SEQ was Figure also because \* ARABIC there 8: Consultation is limited from the village awareness about the importance of maintaining longitudinal history of patients as every consultation is most of the time taken in silos. For uploading past records people were unable to find their past records.

Observations and Learnings: From ASHA worker’s end: ● The ASHA worker is not comfortable in English typing in Tab. It took a long time to enter names and other details for scheduling the patients. Proper guidance and assistance can facilitate in operating the tab. ● Felt very happy and satisfied after using this tool for video consultation with a doctor. ● Villagers show their eagerness and appreciation towards possibility of these kinds of facilities in their village.

Assisted Telemedicine for Rural Healthcare Ecosystem P a g e | 19

From Doctor’s end: ● After the first consultation, the doctor became comfortable and could easily navigate through the application thereafter. ● As the patients were from rural areas, the doctor in addition to the prescription was also suggesting the patients the activities to be followed with the prescriptions using local dialect.

Outcomes

Telemedicine Application Overview

The technical solution for enabling Tele-consultation from Field-workers’ (or Patients’) end and Doctors’ end comprised of the following:

1. A tablet device compatible cloud-based software application for doing tele-consultations with other required provisions and functionalities 2. Tablet devices for health workers and doctors ends for launching the internet based telemedicine applications - Samsung Galaxy Tab A 10.1 3. Internet connectivity for the tablet devices

Functional Flow of Telemedicine application

The functional flow of the cloud-based Telemedicine application created for the project is outlined below:

Assisted Telemedicine for Rural Healthcare Ecosystem P a g e | 20

Due to limited time available and also to retain focus on the key research aspects of the application flow, the steps for registration of doctor and ASHA workers were handed from backend as and when needed for the trials. This worked well as for all the rounds of trials the details of Doctors and field workers were known in advance.

Screenshots of the key screens of the Telemedicine application are shown below:

Assisted Telemedicine for Rural Healthcare Ecosystem P a g e | 21 Figure SEQ Figure \* ARABIC 9: Log in page Figure: Login page for the Telemedicine App

Figure: Searching old patient with last name and phone number

Assisted Telemedicine for Rural Healthcare Ecosystem P a g e | 22

Figure: Patient's Registration form

Figure: Provision for Recording of Patient’s Vitals by ASHA Worker

Assisted Telemedicine for Rural Healthcare Ecosystem P a g e | 23

Figure: ASHA worker's screen during consultation

Figure: Doctor’s screen during consultation

Assisted Telemedicine for Rural Healthcare Ecosystem P a g e | 24

Figure: Doctor can see the past records of patient

Technical Solution

The technology stack for the solution developed was entirely based on open-source technologies and is shown in the figure below:

Figure: Technology Stack used for Tele-consultation app

The solution architecture diagram for the technical solution used is shown below:

Assisted Telemedicine for Rural Healthcare Ecosystem P a g e | 25

Figure: Technical Solution Diagram for Tele-consultation app

Summary of Learnings and Observations

The field trials, the discussions with the villagers, doctors, health workers and other stakeholders provided a first hand insight into the healthcare ecosystem and services in the villages where the trials were undertaken. On one hand these insights validated some of the existing understanding, and on the other hand it also provided several new learnings and observations. While some of these inputs, observations and learnings were incorporated into the tele-consultation app itself, these are also being specified in this section of the report.

Relevance in context of Covid-19 pandemic

● While villagers were aware of Covid-19 pandemic and the emphasis of wearing masks and taking sanitary precautions, usage of masks was very rare to observe due to a very low Covid-19 incidence rate in these villages or surroundings. Health workers were found to be carrying masks possibly due to their job expectations however its usage was found very occasionally ● Assisted-Telemedicine based approach for arranging consultations with Doctors for Covid-positive or Covid-suspected cases was challenging as the health-workers (who are

Assisted Telemedicine for Rural Healthcare Ecosystem P a g e | 26 supposed to play telemedicine-assistants) would need to facilitate this in proximity to the patients which was a genuine reason of apprehensions. ● Many people were also apprehensive about the trials due to the pandemic measures they had been hearing about, and denied disclosing any health problems fearing it may get associated with corona test and may be forcibly taken to hospitals later. They denied measurement of their temperature and oxygen levels. In this situation using the tele- consultation of Covid suspected cases using this platform is less relevant ● However the designed approach and model looked relevant and promising in the pandemic situation once it was directed to focus on other ailments, towards helping the non-Covid patients avoid commute to the nearest healthcare centers in the Covid-19 situation. This approach helped get better responses and more open-ness from villagers for the field trials and consultations. Focussing on children, elderly and other vulnerable sections of the villagers can be more effective during and after Covid-19 pandemic as well.

Relevance for non-Covid scenarios

● Accessibility for healthcare services for the residents of these villages, which were typically located more than 6-7 km from the nearest government healthcare establishments, was very limited . The accessibility was found to be even more difficult because of non-availability of public transport. The socio economic background of the villagers constrains them from owning or hiring personal vehicles to travel to hospitals. In this context, Telemedicine based consultations can help the villagers to consult doctors or any other qualified practitioners from the village itself. Adoption of this approach was found to have a good appeal for the villagers ● In many cases health-issues are neglected in villages due to hassles involved in getting basic consultations and non-availability of public transport for going to the hospitals. Especially when a child or a woman faces any minor health issue instead of visiting a doctor they often tend to ignore the problem which may lead to serious health issues later. Tele-consultations can help to get timely assistance in such cases. ● Sometimes the patients are referred to other doctors or to hospitals in cities like Ranchi. The patient has to depend on many other factors like - availability of doctor, travelling cost, companion for visit the hospital, lack of information and experience etc. In such cases as well, the solution can be very helpful if the referred Government doctors can provide an initial online consultation and guide on next steps. ● The tele-consultation based model can be very relevant for consultation of the aged people, those who are unable to travel due to health conditions, suffer from chronic illness like diabetes, high blood pressure and need routine checkup ● There is a strong need to focus on the health of women as it was an easy observation that female health is generally neglected in villages due to dependency for visiting doctors.

Assisted Telemedicine for Rural Healthcare Ecosystem P a g e | 27 ● This also has a potential relevance for time to time guidance for maternity related cases. While such a platform can not be a replacement for face to face consultations with the Doctors it may be explored as an option to connect with the Auxiliary Nurse Midwives (ANMs), who are typically based out of sub-centers or hospitals, for time-to-time guidance ● The model also has a relevance for malnutrition prevention efforts. This could facilitate remote consultations with Doctors or experienced supervisors of Malnutrition Treatment Centers (MTCs) towards assessing the health of the children in the remote villages and guiding the appropriate cases to come to MTC in a timely manner ● A growing incidence of non-communicable diseases (NCDs) was also observed. Many aged people in villages who are suffering from hypertension, diabetes, cardiovascular disease and other geriatric health issues have to go for regular treatment. As travel to hospitals will be even more challenging for the elderly tele-consultation model has good relevance for such cases as well ● However availability and affordability of prescribed medicines is a challenge not to be ignored for any transformations to succeed. The model needs to be extended to provide forward linkages with provisioning of medicines as well without which there will be very limited efficacy of the model.

Solution Acceptance among Stakeholders

Video-based consultation with a doctor using the Telemedicine app was a completely new experience for the villagers who are habituated to face to face consultation with doctors, and have not come across this tele-consultation based model. Villagers rely upon treatment through physical examination by the doctor and a fiduciary relationship with the doctors. The project team had an apprehension regarding the likely response of all the stakeholders (Villagers, ASHA/other health workers and Doctors) for this new technology-based remote consulting model. Villagers ● During the trials, there was some initial apprehension among villagers with respect to possible linkages to pandemic based measures being introduced everywhere. However on providing a clear orientation and objectives of the exercise a lot of openness was seen among the villagers for this new model and there was a very positive response during the trials. ● Several villagers initially showed uneasiness for appearing in video consultations. After experiencing the trial they realized it can help them in saving time as well as expenses in comparison to the regular conventional model in which they need to travel to physically for a doctor consultation.

Assisted Telemedicine for Rural Healthcare Ecosystem P a g e | 28 ● During the trials, after the initial few patients had registered, many other people came forward on their own to register their name for consultation with a doctor ● There was an overall positive response about the model and how it can be useful for the needs and the challenges being faced. Some explicit positive feedbacks have been recorded in earlier section of this report

ASHA/Health Workers

The ASHA workers who were part of the trials were happy to use the platform to consult with doctors. ASHA workers felt it will help them in assisting the patients in the villages and this will also help in reducing their effort in cases where immediate consultation is needed. ● In general the ASHA workers were found to be happy to see this technology based model. Several of them expressed their appreciation towards the likelihood of introduction of this technology based transformation in their villages. ● Several of them were not comfortable in using technology however given the simplicity of the app it could be assessed that with some training and hand-holding they would be able to use it. ● Auxiliary Nurse Midwife (ANM) can also be an alternative option for the role of telemedicine-assistant however they often have very limited time and typically they are available in villages only around vaccination drives ● While having the applications screen headings and labels in helped, ASHA and other field workers need to be further trained for using the Google’s Hindi keyboard typing options more swiftly as it was taking time for them to enter the basic details for each patient

Doctors:

● Doctors showed a positive reception to the new model and were fine to try that out based on their availability. ● Doctors seemed to be having limited time availability due to their current responsibilities and schedules ● Doctors appreciated the usefulness of the platform to conduct a primary consultation, and were in general found to be open to this new model and usage of technology. They also provided specific inputs to help cater to the consultation needs more effectively ● After the first round of trial, based on Doctor’s input features for upload of past prescriptions and for providing follow-up instructions to ASHA workers were included. This also highlighted their strong needed and emphasis on getting longitudinal history of

Assisted Telemedicine for Rural Healthcare Ecosystem P a g e | 29 patients which is becoming even more important due to significant rise in cases of non- communicable diseases like diabetes ● Challenges could also be seen in Doctors having to type the medicine names and other prescription details into the application using the keyboard option available in the tab. ● While a tab device is better from a portability perspective, looking at usability angle and considering the fact that Doctors will have regular workstations, a laptop may be a better option for using the Telemedicine app from the Doctors’ ends. ● Any larger screen options on both the ends shall definitely be a more effective one from the perspective of effectiveness of consultation as well as likelihood of adoption by stakeholders. ● Seeing their limited time availability and often tight schedules it is recommended to get this aspect studied further to identify right technology infrastructure options (both hardware and software) towards facilitating easier entry of details and ensuring greater acceptance of the solution. ● Doctors in Government hospitals commented that villagers would be expecting free medicines as well through Government channels if the consultations are being provided by Doctors in Government hospitals ● Doctors engaged in private clinics were very receptive to usage of the model possibly due to the monetary benefits this model can bring in for them. While typing in the initial consultations took some time, once comfortable the turnaround time for an end to end consultation improved.

Other learnings and observations

Few noteworthy learnings and observations regarding lifestyle, healthcare systems, and challenges in accessing health for the villagers of these pilot villages are listed below:. ● Even today technology plays a very limited explicit role in the lives of most of these villagers. Most of the villagers still do not use phones. Typically, only the youth have phones with them and even they have very limited expertise in using smartphones. ● Many people are not willing to disclose their phone number. They assume their number may be misused by the authority (!) ● People in these villages seemed to be open to developmental changes if they are apprised beforehand about the benefits which can be expected through some orientation sessions, instead of any sudden announcements being made for any changes ● There is a strong need for sensitization of the villagers regarding preventive healthcare and avoiding negligence of health issues.

Assisted Telemedicine for Rural Healthcare Ecosystem P a g e | 30 ● While there is an awareness about the Golden Card and Ayushman Bharat scheme a significant proportion of the villagers still do not have the Golden Card which is needed for coverage of treatments under Ayushman Bharat ● There is severe lack of understanding about the benefits of Ayushman Bharat, processes and other details which seems to one of the key reasons for very limited utilization of the Ayushman Bharat scheme in these villages ● The villagers are comfortable to consult with a doctor who is known or trustworthy. Doctors available in CHC, nearby pharmacists or other non-qualified practitioners have the trust of the villagers and understand the local health and non-health issues, lifestyle, mindset etc. For such reasons the quacks and nearby pharmacists are often the first options for these villages due to the trust they have been able to build over the years, and are referred by most of the villagers as “Doctor”. ● These non-qualified practitioners typically also know the individuals occupations, lifestyles, their family members and any family health issues as well. Hence they are able to play a “family doctor” kind of role. Having a model which can cater to that can help in improving its adoption. Telemedicine-assistants (ASHA workers or others) could help in addressing this need, they being aware of such details about the individuals. ● The dependency of villagers on these non-qualified practitioners is greater in tribal villages, especially those where mostly tribal languages are spoken ● Having the same set of Doctor(s) for the revisit cases and assigning of General Practitioners and even specialists (for some of the common treatment areas) at village or community level can be further useful in building that connect of villagers and communities with the remote doctors in the Telemedicine model, besides the benefit of providing better healthcare services ● People are mostly using indigenous treatment options like ayurveda, home remedies for regular health issues ● In villages people prefer to go to government doctors rather to go for a private practitioner. Even for medicines they look for getting the medicines from the government hospitals rather than pharmacy shops for reasons attributable to affordability as well as availability ● A good penetration of internet connectivity could be seen in the villages where trials were done. However, when it comes to doing a video-based consultation using the telemedicine app, challenges were observed with respect to availability of good internet speed. Not all places were having good internet speed, hence there need to be designated places identified with good internet connectivity. ● Execution of any such model on a larger scale within the government framework and with government staff and personnel looks to have potential challenges with respect to availability of bandwidth and resources, and effective sustenance of the efforts. It may be worthwhile exploring options for executing this model in a social entrepreneurship model

Assisted Telemedicine for Rural Healthcare Ecosystem P a g e | 31 Conclusion

This Project on “Assisted Telemedicine for Rural Healthcare Ecosystem” and its field trials enabled ground level learnings and a validation of the challenges being faced by rural citizens of states like Jharkhand with respect to accessibility, availability and affordability of primary healthcare services. For addressing these gaps in rural healthcare, while telemedicine and tele- consultations in the current form are not useful for, this project helped validate the potential of “assisted-telemedicine” model vis-à-vis rural regions of Jharkhand and possibly all other states as well. Both the need as well as the potential of the proposed solution were studied and validated. While the “assisted-telemedicine” model had limitations in arranging for Covid-19 specific consultations, this offers a lot of hope for addressing the outlined gaps during normal times, and for helping patients from the villages - especially the children, women, elderly and vulnerable ones - get the required guidance from doctors and qualified practitioners, without having to take pains of travelling to hospitals during illness or taking any risks with respect to exposure to the pandemic. However this assisted-telemedicine model also needs to be extended to cover the supply and availability of medicines in the rural regions without which its impact will be very limited. There is a good potential of executing this “extended” assisted-telemedicine based model on a larger scale across districts and states while giving appropriate consideration to the execution model, budgetary estimates, commercial feasibility, comprehensiveness of services, involvement of local communities, affordability of consultations and medicines and so on. Beside all other factors any such initiative will also have to be supported with a robust, secure and user-friendly technology platform designed for scalability in a bottom-up manner.

Scope for Enhancements and Future work

Towards effective and large scale implementation of assisted tele-consultation based model for rural regions the following studies and projects are recommended for future work: ● Detailed study and analysis for possibility of extending the tele-consultation model to cover facilitating the availability of prescribed medicines as well using Government and non-Government supply chains, including e-pharmacy options while looking at cost and affordability aspects as well ● Feasibility analysis for running a telemedicine based primary health consultations in a social entrepreneurship mode with some initial support from government or non-

Assisted Telemedicine for Rural Healthcare Ecosystem P a g e | 32 government agencies and funds covering all aspects including tele-consultation assistants, availability of doctors and medicines, tabs and internet connectivity ● Study and analysis of most common ailments reported by the rural populations and analyzing suitability of Tele-consultation based approach for each of those ● Exploring hardware and software options for facilitating easier entry of details into the tele-consultation app especially on Doctors’ end ● Identifying and exploring integration of medical devices of highest utility into the tele- consultation hardware and software setup towards improving the efficacy of the tele- consultations ● Exploring feasibility and options for extending this tele-consultation based model for secondary care, follow-ups, emergencies and critical-care-at-home scenarios

Summary

Regular tele-consultation platforms provisioned for patients on one end and physicians on the other, pose several challenges for those below the digital divide in our society, especially in the rural regions. Seeing the immense potential of the tele-consultation model and seeing the gaps in rural healthcare ecosystem a need was felt for focused efforts towards designing of new models and applications for telemedicine which can be more suited for the rural ecosystem and citizens, while applying the principles of design thinking towards a “bottom-up” approach.

With the background, this project was conceptualized around “Assisted Telemedicine” model and the objectives of the project were broadly defined as analyzing, developing and doing pilot runs of an “Assisted Telemedicine” model towards designing a blue-print of a Telemedicine platform for catering to the rural healthcare needs during Covid-19. E-Health Research Centre (IIIT-Bangalore) in collaboration with PHIA Foundation and Patharitech Private Ltd did the field work and trials of assisted-teleconsultation model in Maheshpur village (Angada Block, Ranchi district), Kurmul Village (Kamdara Block, Gumla district) and Ganker Village (Karra Block, Khunti district) in Jharkhand. As a part of this project a skeletal web-based “Assisted-Telemedicine” software application was customized and fine-tuned for usage in the rural healthcare ecosystem, with ASHA workers (and other health-workers) serving as the tele-assistants on the patient end and with Doctors providing tele-consultation from the other end from a physically different location. The software was fine-tuned incrementally based on the observations, inputs and learnings from the field trial and the need and fitment of the model explored and outlined as a part of this project. The use-cases for Covid-19 had to be adjusted considering the challenges observed due to the need for social-distancing from any Covid-19 suspected cases, and also a lower incidence rate of

Assisted Telemedicine for Rural Healthcare Ecosystem P a g e | 33 Covid-19 in the rural regions of Jharkhand. However the assisted-telemedicine model does show a lot of potential for usage and adoption for assisting non-Covid patients avoid hospital visits for consultations during and beyond Covid-19 pandemic. The relevance and need for this kind of model is further underlined due to increasing incidence of non-communicable diseases and a strong need for ensuring greater care for health of women, children and elderly point in the rural regions of states like Jharkhand. With the limited availability of healthcare services in the proximity and public transport facilities in most of the regions, and a dire need for ensuring affordability of primary healthcare this model does hold a lot of promise. However this model also needs to be extended to cover the supply and availability of medicines in the rural regions without which its impact will be very limited. There is a good potential of executing this “extended” telemedicine based model on a larger scale across districts and states while giving appropriate consideration to the execution model, budgetary estimates, commercial feasibility, comprehensiveness of services, involvement of local communities, affordability of consultations and medicines and so on. Beside all other factors any such initiative will also have to be supported with a robust, secure and user-friendly technology platform designed for scalability in a bottom-up manner.

Annexure

Source Code: Source-code for the customized tele-medicine application created for this project have been kept at: https://drive.google.com/drive/folders/17l-ua0V88ltJL2fIx_evhyzzVereSsJ9?usp=sharing

Contact Details: For any queries, request for access to source code or any additional details needed regarding the project or its outcomes a mail should be sent to the following email-ids with the subject-line mentioning of “Assisted Telemedicine for Rural Healthcare Project”: [email protected], [email protected]

End of Report FigureFigure SEQ SEQFigure Figure \* ARABIC \* ARABIC 16: ASHA 17: registered worker registering people waiting patinet's for consultationname for consultation

Assisted Telemedicine for Rural Healthcare Ecosystem P a g e | 34