Analysis

The use of technology in healthcare has expanded rapidly as smartphones and digital devices have become more accessible to the general public. Telemedicine in particular has enabled better healthcare service and capacity in primary healthcare, in a country where the healthcare workforce is inadequate and unevenly distributed, leading to disparities in health access and outcomes. As COVID-19 spread throughout the globe, while we saw communications technologies minimizing the barriers of restricted travel and social distancing, they also became critical for ensuring the wellbeing of large swathes of the population. A primary healthcare system is the first line of defense for the healthcare system and fields the health concerns of most of the population. With the spread of COVID-19, it became imperative to rapidly increase primary healthcare capacity through telemedicine to help continue essential health services while also addressing the rising infections. A surge of teleconsultations was seen in established platforms. Apps such as Practo sometimes saw an over 100% rise in teleconsultations week by week, a trend that was observed across the world. COVID-19 had created a void of primary care access that everyone rushed to fill.

To better understand the resulting telemedicine landscape, Swasti Health Catalyst conducted a landscape study on the available COVID-19 helplines across the country. The study covered helplines with a range of target beneficiaries, including COVID-19 positive individuals, the general public, pregnant and lactating women, senior citizens, low-income individuals, and other vulnerable groups. The helplines were also diverse in terms of services offered:  Some were focused on mental health, and others designed to help supply food and medications. As the results from the study took shape, they raised key questions: Are telemedicine services truly building capacity for primary care? Are they an effective channel to provide critical information in a crisis situation? What can we learn from the way telemedicine was deployed during the initial phase of the pandemic?

While analyzing the case stories of these helplines, recurrent themes emerged, which are described below.

1. Unmet Expectation with Government-run COVID-19 helplines There are approximately 54 COVID-19 helplines run by governments at the center, states, and union territories, but these often failed to meet the information needs of the public. Most reports in March and April were from the 1075 Central Helpline toll-free number. Due to the large volume of calls, when citizens tried calling the helpline, it was often busy or left unanswered. Complaints flooded in over social media. One Twitter user called the helpline after testing positive for COVID-19 and found the number was invalid. Another user mentioned that when they called the national helpline (1075), they were redirected to the state helpline, but later the state helpline number was unresponsive. Another person reported that the central helpline provided around six other numbers to call, and when none of these worked, the help desk operator suggested googling for assistance. There were similar anecdotes on the state helplines. In mid-May, a video circulated in Delhi of Dharmendra Bharadwaj, who said that the hospital where his mother had been admitted for COVID-19 asked him to move her to another hospital. He tried calling the central helplines and Delhi-based helplines for assistance but received no answer. A report of a patient with ear abscess and breathlessness being denied help by the 104 Arogya Sahayavani helpline in Karnataka was another of many stories shared widely where teleconsultation support fell short. Although the helplines were dedicated for specific states and even communities, their teams were overwhelmed by the scale and suddenness of the demand and lacked adequate time to pilot and test the services and weed out glitches and kinks in the processes.
2.  COVID-19’s impact on mental health It has been reported that the pandemic has exacerbated existing mental health conditions. The data from multiple helplines suggest that the most frequent calls were regarding mental health, including concerns about the pandemic and its socioeconomic aftermath, anxiety over contracting the illness, adjusting to quarantine life, the anticipation of vaccine arrivals, fear of losing jobs, managing stress related to work and postponement of exams, anxiety regarding children’s education and concerns about worker migration. When Karnataka launched helpline 104, a 24*7 toll-free number, catering to callers with COVID-19 symptoms or general queries, 70% of the helpline queries were from citizens who were “anxious“ about COVID-19. Counselors with different helplines gave patients and caregivers tips on how to feel engaged despite the lockdown. Specific groups were also at higher risk of mental health challenges: Helplines received distress calls from people in the LGBTQ community who were quarantined with toxic families and lacked the freedom to seek external support, as well as from those facing domestic abuse, with victims having no alternative besides staying quarantined with the perpetrators.
3. Challenges in COVID-19 risk assessment through mobile phones While technology poses significant advantages in allowing access to care, it is not without its limitations. When outreach workers from Swasti called community members to check if they had symptoms suggestive of COVID-19, many members preferred not to share their health details over the phone. There was a sense of fear and stigma with these symptoms, and uncertainty of what would happen if they reported them. This experience mirrored that of the HIV epidemic, in which many people distanced themselves, from individuals who were rumored to be infected with Covid-19, and isolated them from community resources.
   
   At the same time, the inability to assess temperature, blood pressure, and oxygen saturation over the phone made it difficult for primary care providers to assess the COVID-19 risk among community members and forced them to undertake community field visits. There were some aspects of primary health care that could not be replaced by technology, and one of these was the outreach and field workers who reach out to the most vulnerable populations.

Conclusion

The challenges and nuances outlined above, including the technological problems, the diversity of community member queries, and the limitations of risk assessment are solvable, and in many cases have been solved. Enabling organizations, entities, and agencies working on telecare solutions to coordinate and learn from each other will serve both them and the targeted communities by ensuring that efforts are not duplicated, patients' needs are met and resources are utilized optimally. These lessons and the infrastructure created will both support the system through the pandemic, but also strengthen existing primary care avenues that serve communities, pandemic or not.

Nilakshi Biswas is a Technical Specialist working on research at Swasti Health Catalyst. Savinitha Prakash is a Medical Officer and Technical Specialist at Swasti.