Vikrant Kanwar PGDHA, MHA1, Shivani Chaudhary MSc2, Anuj Kumar Sharma BSc2

1 Department of Hospital Administration, All India Institute of Medical Sciences, Bilaspur, Himachal Pradesh, India
2 Department of Nursing, All India Institute of Medical Sciences, Bilaspur, Himachal Pradesh, India


Introduction: The COVID-19 pandemic, with mandatory social distancing and lockdown, has shown the success of telemedicine in reducing geographical and time obstacles. This has stimulated its ingress into mainstream healthcare services as the safest means of interaction between doctor and patient during the pandemic. There are several barriers that need to be addressed in order to spread these digital services. Aim: This study explores the challenges to adopting telemedicine and its status in remote districts of Himachal Pradesh, India. Methods: A mixed-method approach was used to identify challenges found in remote healthcare facilities. A survey was conducted using a 20-item checklist to capture information regarding infrastructure, telemedicine equipment, manpower and demography of the area. During telephone interviews, questionnaires were used to evaluate the status of acceptance of telemedicine and challenges to its implementation in the remote State of Himachal Pradesh, India. Results: The study identifies the challenges as lack of awareness (75.9%), level of education of patient (44.8%) having primary education, age of the patient (17.2%), technically challenged staff (30%), followed by resistance to change (80%) and high workload with manpower shortage (60%). Conclusion: While there are other barriers, this study provides policymakers with insights into the current perceived challenges to telemedicine implementation, which they can address to increase the penetration of telehealth services, particularly in rural areas.

Keywords: digital health; rural; telemedicine; challenges; COVID-19; India

Kanwar V, et al. J Int Soc Telemed eHealth 2023;11:e3(1-5)
Copyright:© The Authors 2023
Open access, published under Creative Commons Attribution 4.0 BY International Licence


India has a diverse geography comprising high Himalayan mountains, deserts, extensive plateaus, and wide plains, with a population of more than 1.38 billion. Approximately 65% of the population live in rural areas.1 Most are economically debilitated and geographically and politically marginalised. The Indian rural health care system is a three-tier system comprising sub-centres, primary health centres and community health centres.2 Lack of awareness, limited access, shortages of manpower, low affordability and poor accountability are the major hurdles to healthcare delivery in rural India.3

To increase accessibility, availability and affordability of primary, secondary and tertiary healthcare services, the Ayushman Bharat Programme (PM-JAY) was launched in India in 2018. It has two components: Health and Wellness Centres, and the National Health Protection Scheme. The Health and Wellness Centres were expected to deliver a comprehensive primary health care package. Telemedicine was one of the components for the delivery of this service. The vision of PM-JAY is to achieve Sustainable Development Goal 3.8, ensuring financial protection against catastrophic health expenditure and access to affordable and quality healthcare for all.4

As a part of the Government’s commitment to sustainable development goals and to ensure inclusive growth, NITI Aayog (a Government public policy think tank) launched the Aspirational District Programme with an aim of transforming underdeveloped districts across the country quickly and effectively. The programme focuses on five main themes which have a direct bearing on the quality of life and economic productivity of citizens: health and nutrition; education; agriculture and water resources; financial inclusion and skills development; and basic infrastructure.5

The National Health Policy envisaged the creation of a digital technology health system in India. As a result, the National Digital Health Mission was launched by the National Health Authority. It is a complete digital ecosystem comprising four key features: health ID, personal health records, Digi-Doctor and a health facility registry.6 In order to create an online platform enabling interoperability within the digital ecosystem, the Ayushman Bharat Digital Mission was introduced in 2021 to connect the digital health solutions of hospitals across the country with each other. It had four key components: health ID, health records, healthcare facilities and professionals’ registry.4

The restrictions imposed during the COVID-19 pandemic caused a higher rate of unemployment in the rural population, resulting in economic devastation. Decreased mobility hampered access to primary healthcare facilities in remote areas. Until the advent of COVID-19, the growth of telemedicine had been slow. Social distancing norms and the country-wide lockdown accelerated its popularity and accessibility. The Ministry of Health and Family Welfare, along with NITI Ayog issued the first practice guidelines for telemedicine in India.7

The two major telemedicine interfaces used were eSanjeevani and Piramal Swasthya. The Government of India introduced its telemedicine service, eSanjeevani, as part of its ‘Digital India’ initiative on 9 August, 2020. During the COVID-19 pandemic, physicians have used videoconferencing to diagnose and treat patients in geographically diverse locations. This digital platform currently permits two types of telemedicine services, Doctor to Doctor (eSanjeevani) and Patient-to-Doctor (eSanjeevani OPD).8 These services are part of the larger government initiative to connect larger hospitals to smaller health centres in remote areas. Piramal Swasthya is an initiative under the Piramal Foundation that endeavours to make primary health care available and accessible to vulnerable populations.9

Although a number of telemedicine initiatives have been launched within India, its adoption as a means of mainstream healthcare provision has been slow. Technology barriers and lack of computer literacy have remained major hurdles to implementing telemedicine globally.10 The challenges of implementing telemedicine in India at the policy level, resources level and at the socio-culture level have been evaluated.11 Perceived risk was conceived as another barrier to telemedicine adoption.12,13 In this study, we focused on the challenges faced by remote healthcare centres with pre-existing telemedicine services. The objective was to evaluate the current scenario and challenges faced by the telemedicine facilities in remote villages of Northern India. Additional objectives were to find out the primary pitfalls to the accessibility of telemedicine and to find a resolution as there was a lack of documented evidence.


The State of Himachal Pradesh is divided into districts, subdivisions, blocks and tehsils (local administrative divisions) of healthcare institutions. Kihar and Tissa of the district Chamba are two of the remotest blocks of the State. A field survey was conducted in 12 healthcare facilities in Kihar and Tissa, where telemedicine had already been set up. A 20-item survey checklist was developed to gather information from the respective Block medical officers of Kihar and Tissa regarding the infrastructure, telemedicine equipment, manpower of the healthcare facilities that were equipped with telemedicine, and the demography of the area these facilities were catering to.

In order to explore the challenges faced by the healthcare providers and patients, we conducted a telephonic survey of healthcare providers and patients using open-ended questionnaires with five questions to explore the challenges they faced. Surveys were conducted at the convenience of the participants after explaining the purpose of the survey, and verbal consent was taken. Each telephone call lasted for 10-15 minutes. Validation of participant’s responses was ensured by reading back the summary at the end of the survey. The participants from the 12 participating healthcare facilities included in the survey were enrolled using simple random sampling. The simple random number generator available in SPSS v23.0 was employed for randomisation. The survey data were analysed, and non-thematic, direct inferences were drawn. Most of the data gathered in this study pertained to telemedicine infrastructure, equipment and logistics available at the participating facilities. Furthermore, all the data gathered from the healthcare provider and patient telephone surveys were de-identified and anonymised before further analysis. Hence, no ethical clearance was sought for this study.


The field survey of facilities revealed that the majority of the health facilities are equipped with one or other type of telemedicine setup like eSanjeevani and Piramal Swasthya (under NHM). (Table 1) Examples of telemedicine facilities are shown in figure 1.

Table 1. Survey results for infrastructure, telemedicine equipment, manpower of health facilities providing telemedicine.

Figure1aFigure1b Figure1c
Figure 1: Telemedicine set up in healthcare facilities.

Most of the facilities with the Piramal Swasthya set up were manned by trained personnel. However, none of the facilities with the eSanjeevani platform were manned by Community Health Officers (CHOs). The facilities with e-Sanjeevani setups were not catering to patients at all; although the equipment was sufficient and of the latest version, it was not being used and was lying idle. The facilities with less physical outpatient department activity were providing fewer teleconsults and vice versa. The number of teleconsultations at Piramal facilities was very much less  (2-3/day) than physical consultations (50 – 100 /day). The conversion rate could be increased. No formal training was ever given to the provider staff at these facilities. There was no Information, Education and Communication (IEC) in the community regarding the availability of the services. Most of the facilities were deficient in diagnostic and emergency care services leading to low trust in the health facility. This acts as a barrier to accepting telemedicine.  

Thirty-nine people were interviewed, of whom 10 were telemedicine staff and 29 were patients. Barriers to telemedicine reported by the patients were lack of awareness of the existing telemedicine services until recently (75.9%), lack of Digital understanding and literacy (55.2%) and poor network connection (82.8%) which they felt impelled them to prefer physical in person consultation over telemedicine services at the facility. (Table 2) Difficult terrain and the distance they have to walk to access to the facility were also identified as barriers to adoption (51.7%).

Table 2: Demographic profile of the patients (n=29) and perceived challenges faced by patients at health facilities providing telemedicine.

The majority of the staff reported a lack of adequate telemedicine training (70%), resistance to change, lack of a positive attitude towards telemedicine (80%) and a high workload (60%). Technical Shortage of human resources and low education levels and digital literacy of the local population and technical  issues like network connectivity (80%), were the major reasons for the underutilisation of telemedicine services in their area. (Table 3)

Table 3: Demographic profile of the providers (n=10) and perceived challenges faced at health facilities providing telemedicine.


Even though telemedicine facilities were available in these centres, telemedicine was less commonly used than the conventional in person doctor patient consultation. Lack of awareness among rural population and reluctance of the staff are the major hindrances to standard delivery of telemedicine services in rural and remote areas.

Strong IEC and media publicity regarding availability of services  may  be conducted  through local health Administrative authorities, to increase the awareness, penetration  and the acceptance of  telemedicine services  at local level. A citizen centric communication approach is required for better adoption at as an informed choice. Merely imposing the programme thorugh a top-down approach is a less effective strategy. Involvement of Panchayati Raj Institutions (PRI) - a form of governance at village level, local bodies, and NGOs is highly recommended to take things forward. The PRIs may be involved for community engagement. The local provider staff must be encouraged to see telemedicine medicine as complementary to the care there are providing.

While there are other barriers, this study provides policymakers with insights into the current perceived challenges to telemedicine implementation, which they can address to increase penetration of telehealth services, particularly in rural areas.

Limitations of study
The main limitation of this study is that only two blocks of the district were examined. Further studies on challenges based on objective assessment using telemedicine are needed, especially in rural areas and in different States of the country. Further implementation research is highly needed, to corroborate the evidence of adoption and acceptance among providers and users in rural areas.

Corresponding author:
Vikrant Kanwar
Department of Hospital Administration
All India Institute of Medical Sciences Bilaspur
Himachal Pradesh-174001
Phone: +91-9418457251

Conflict of interest. The authors declare no conflicts of interest.

Authors’ contributions: Vikrant Kanwar - Resources, data collection, conceptualisation, methodology, supervision, validation, writing review and editing. Shivani Chaudhary- Data curation, formal analysis, writing original draft, project administration, data collection. Anuj Sharma – Data collection and formal analysis.

Funding: This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Ethics approval and consent to participate: The majority of the data gathered in this study pertained to telemedicine infrastructure, equipment and logistics available at the participating facilities. Further, all the data gathered from the healthcare provider and patient telephone surveys were identified and anonymised before further analysis. Hence, no ethical clearance was required for this study.

Acknowledgement: We acknowledge the contribution of District Administration Chamba, Block Medical Officer, Kihar and Tissa for their help and support during the survey visit. Also, we thank the respondents
of the survey for their valuable input.



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Kanwar V, et al. J Int Soc Telemed eHealth 2023;11:e3