Digital Health In India: Can Esanjeevani Overcome Its Shortcomings To Complement Ayushman Bharat?

By Dr. Biswanath Ghosh Dastidar

A 29-year-old woman from Dahilamau, Uttar Pradesh, was suffering from severe breathlessness and palpitation. Her doctors advised her to undergo a life-saving heart valve replacement surgery at an expense of over Rs. 2.5 lakh. Her husband, a street vendor, struggled to arrange such a large sum but ultimately relied on the Ayushman Bharat insurance scheme to cover her surgery. She returned home a healthy woman. 

In north Gujarat’s Morbi district, a 12-year-old boy visited an Ayushman Bharat Health and Wellness Centre (AB-HWC) with constipation, where the community health officer prescribed a laxative. The next day, the community health officer logged onto the eSanjeevani – the free national telemedicine service – to enter the patient’s details for a consultation in his name, even though he had not returned to the health centre that day. 

In the Kuktar sub-centre in Maharashtra, the  medical officer-in-charge admitted to being able to prescribe appropriate medications to a majority of patients who visit for a consultation, but confided that there is a necessity to divert them to a tele-referral on the eSanjeevani website in order to meet daily referral targets set by the authorities.

The above stories, all available in the public domain, are testament to the markedly different fates of two of India’s most important healthcare initiatives launched with the common goal of expediting the provision of universal health coverage (UHC) to all citizens as per sustainable development goals (SDG) 2030.

Ayushman Bharat vs eSanjeevini

The Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (PM-JAY), launched in 2018, is the largest health insurance scheme in the world which provides a health cover of Rs. 5 lakh per family per year for secondary and tertiary care hospitalization, financed in collaboration between central and state governments. Over 12 crore poor and vulnerable families (approximately 55 crore beneficiaries), accounting for about 40% of the Indian population, can access cashless treatment at pre-designated government and private hospitals. Beneficiaries create an Ayushman ID card, which is also available via an app, to receive this treatment.

As of January 2024, over 30 crore Ayushman cards were created and facilitated around 6.2 crore free hospital admissions under this scheme, saving beneficiaries over Rs 1.25 lakh crore in out-of-pocket expenses. Users downloaded the Ayushman Bharat app more than 52 lakh times since its launch in September 2023.

Interestingly, the government of West Bengal launched the Swasthya Sathi scheme in 2016, predating this scheme and providing cashless secondary and tertiary care coverage of up to Rs 5 lakh per annum per family. This flagship scheme has covered over 2.4 crore families with over 85 lakh hospitalizations financed up to November 2024. 

In sharp contrast, state and national reports indicate that the eSanjeevani is facing significant challenges.

The eSanjeevani operates on a ‘Hub and Spoke’ model, where a health worker first provides a basic consultation to a patient at a primary health centre or sub-centre (‘Spoke’). If necessary, the health worker then initiates a web-based video or audio call to seek further advice from a specialist physician based at a medical college or district hospital (‘Hub’).

Although a resounding success on paper with over 276 million teleconsultations provided till August 2024, our recent Lancet paper has flagged important problems in the triage and tele-referral systems within the eSanjeevani platform which result in inappropriate and sub-optimal referrals, many of which do not lead to any patient benefit at all. 

An analysis of six months of consultations on eSanjeevani revealed that patients placed 65.6% of consultation requests to doctors outside their specialization. This often necessitates doctors returning patients to the referring primary health centre by generating a prescription that states, “Wrongly addressed call—this case is not related to my specialisation.”

Moreover, many patients submit requests for relatively simple complaints that a qualified general practitioner (GP) could and should have addressed. GPs are supposed to be part of the referral chain, according to the intended design of eSanjeevani. However, they seem to be completely absent from this platform. 

Inadequate Notes, Ineffective Care

Furthermore, over 90% of all referral requests are not video or audio call based, but simply comprise of very sparse written notes about the patient’s complaints from which it is difficult to provide any medico-legally safe and responsible advice, thus forcing the doctor to return the patient to the health-worker by generating a prescription that simply says ‘Inadequate case details’, and asks the health-worker to call back with more written details, or preferably, an audio or video call so that the doctor may derive a short medical history and make the bare minimum examination that a tele-referral platform allows before prescribing treatment. 

Many of these simple patient complaints should have been easily addressed at the ‘Spoke’ itself by a health-worker or by a qualified GP.Health workers or qualified GPs should have easily addressed many of these simple patient complaints directly at the ‘Spoke’. None of the above ‘prescriptions’ provide any real benefit to the patient who has often travelled a fair distance to reach a primary health-centre or sub-centre for a consultation. All of these prescriptions are counted as valid ‘consultations’ while assessing the success of the system.

Why, then, do health-workers make such slipshod and inadequate referral requests, many of which simply consist of a mere word or two in its entirety such as ‘pain’ or ‘headache’? One explanation is clearly lack of training in appropriate triage and referral, as we have pointed out in our paper. Another worrying possibility is that health-workers may be logging into the system, often in the complete absence of a patient and  even after having already provided adequate advice or treatment to them previously, simply in order to meet referral targets assigned to them by authorities in order to boost eSanjeevani statistics. 

This creates problems by disillusioning and dissatisfying patients with the system, leading to a reported drop in patient footfall in the media. This, in turn, completes the vicious chicken-and-egg cycle of assigning forced targets for implementation. Indeed, in our study we found that only around one fifth of eSanjeevani referrals lead to useful and appropriate prescriptions, if the doctor abides by ethical and safe prescribing guidelines. 

These problems have also been reported at state and national levels. Analysis of data from over 60 million eSanjeevani consultations nationally by MIT revealed numerous problems such as lack of screening tools, incorrect OPD recommendations, limited application of SOPs, and inaccurate recording of patient symptoms. A Jharkhand based study pointed out problems of over-referrals, inadequately trained staff and digital infrastructure. In fact, as early as 2013, problems such as inadequate training and improper use of human resources were reported from the pilot state telemedicine project in Karnataka. 

Prevention Over Cure: Transforming Telehealth for Early Action

This is a lost opportunity of mammoth proportions. Preventive healthcare or primary interventions are easier to implement, more cost-effective to achieve and known to result in good health outcomes. In most cases, it is in such situations that patients opt for a teleconsultation. If appropriately addressed early, in many cases it would prevent future escalation to in person treatment or other interventions and surgeries at great expense to the national exchequer via insurance schemes such as the Ayushman Bharat. 

This is especially relevant in a country like India, where the government allocates only around 1.8% of the GDP to health, one of the lowest proportions globally. Individuals bear almost 62.6% of total health expenditure through out-of-pocket payments, one of the highest levels worldwide. Reports also highlight that healthcare costs drive a significant portion of the population into poverty.

India is experiencing an increasing burden of non-communicable and lifestyle diseases such as diabetes, obesity, cancer, and cardiovascular diseases as part of an ongoing epidemiological shift. These diseases are projected to cost the nation approximately 2.3 trillion US dollars by 2030, an amount 1.5 times India’s GDP and around 30 times its total annual health expenditure. All of these lend themselves well to initial screening and preventive or primary intervention through tele-consultations. 

It is commendable to enable crores of poor Indians to avail of quality healthcare when they need it urgently by means of providing government financed health insurance through programs such as the Ayushman Bharat PM-JAY or Swasthya Sathi. It would be even better to put in the difficult and tedious legwork to improve the processes, training and technology linked to eSanjeevani; and ensure better implementation, quality assessment and control to transform it into a platform that can provide early advice to our citizens, thereby preventing the need for expensive and often invasive treatment later. 

Dr Biswanath Ghosh Dastidar is presently Research Director at GD Institute for Fertility Research, and Assistant Professor at the Center of Excellence (COE) in Assisted Reproductive Technology (ART) at IPGMER & SSKM Hospital, Kolkata. 

Also read:

• Error 404: Privacy Not Found in Ayushman Bharat Digital Mission’s PMJAY Dashboard
• Govt telemedicine platform eSanjeevani alloted Rs 100 crore
• Health IDs to be based on KYC, data localisation required: What is the new Health Data Management Policy?

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