Introduction
The rapid expansion of telemedicine in India over the past two decades, accelerated by the COVID-19 pandemic, demonstrates how information and communication technologies (ICTs) can transform access to care. Telemedicine—using digital tools to exchange medical information, diagnose, treat, and monitor patients remotely—has evolved from satellite-based links in the 1990s to a large, mixed ecosystem of public, private, and PPP models. This article synthesizes lessons from a scoping review of large-scale telemedicine initiatives launched between 2000 and 2023 in India, with a focus on model types, scale, outputs, and the evidence base for impact.
What counts as telemedicine, and why it matters in India
India’s telemedicine landscape spans patient-to-provider and provider-to-provider interactions, delivered in real time (synchronous) or via deferred (asynchronous) modes. The World Health Organization framework helps categorize services by the delivery model and channel, from hospital-based networks to mobile apps and basic messaging. Understanding these typologies is crucial for evaluating reach, cost, and outcomes, especially in a country with vast geographic and socio-economic diversity.
Model types and scale: public, private, and PPP dynamics
Across 75 large-scale services that used specialized software, private sector providers led the majority (about 64%), with public and PPP models comprising the rest. Nearly half of the services operated in a patient-to-provider mode, while provider-to-provider and hybrid models were also common. A strong emphasis on real-time consultations (roughly 69%) demonstrates a preference for immediate clinical engagement, though mixed synchronous-asynchronous offerings were also important.
Scale varied widely. The public sector’s flagship eSanjeevani platform achieved unprecedented reach, with millions of registered providers and tens of millions of patients served, spanning 31 states and union territories. In PPP and private sectors, networks of hospitals and technology providers expanded access across many districts and states, with some services reporting millions of consultations and substantial geographic footprints. Yet reporting on active providers, geographic reach, and patient load often lacked standardization, complicating cross-service comparisons.
Evidence on effectiveness, costs, and value
Evidence on effectiveness emerged from 32 of 75 large-scale services, drawn from 84 peer‑reviewed articles. Across analytic designs, findings were mixed. Some telemedicine initiatives improved patient engagement, adherence, or condition-specific outcomes (for example, pediatric HIV care and diabetes management in select centers), while others showed limited or no population-level impact on health outcomes or service coverage. Importantly, no randomized trials were identified among the analytic studies, underscoring the challenges of evaluating telemedicine in real-world, large-scale settings.
Cost data were common, spanning patient costs, time savings, and system-level expenditures. A subset of studies conducted formal cost analyses or cost-effectiveness assessments, but methods varied, and comparability was limited. This fragmentation highlights the need for standardized costing frameworks to inform policy and scale. Despite methodological gaps, many programs reported substantial savings in travel time and costs, which are critical for rural and underserved populations.
Design, implementation, and governance lessons
Several factors appear pivotal to scalable telemedicine in India:
- Strong public investment paired with private and PPP capabilities can rapidly expand reach (eSanjeevani as a case in point).
- Hybrid models that blend provider-to-provider and patient-to-provider interactions can address both access and specialist input needs.
- Use of specialized software helps integrate telemedicine with electronic medical records, enabling data tracking, quality monitoring, and oversight, though reliance on non-specialized tools persists for user convenience.
- Clear regulatory and licensing provisions, plus affordable or nominal user fees in public/PPP settings, shape sustainability and equity.
- Data privacy, security, and workforce protection (e.g., separating work from personal device use) must keep pace with rapid scale.
Equity, access, and future directions
While high-profile platforms show scale, the literature indicates gaps in equitable access—particularly for women and those in low‑mobile-ownership settings. Continued emphasis on digital literacy, affordable devices, and inclusive design will be essential. Moreover, rigorous, standardized evaluations of health outcomes, user experience, and cost-effectiveness are needed to guide investments and improve care quality in India’s diverse landscape.
Conclusion
India’s two-decade journey in telemedicine reveals a path toward broader health access through scalable technology, with significant public and private sector learning. The main takeaways are: scale is achievable with coordinated governance; diverse models help meet different care needs; and robust, standardized evaluations are essential to demonstrate value and guide responsible scale in health systems across low- and middle-income settings.
