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The Promise of Teleconsultation in the Era of Pandemic: A Case from Bangladesh

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Introduction

COVID-19 pandemic has affected almost every country in the world. In Bangladesh, the first cases were reported on March 8, 2020 and at the end of year 2020 there were 508,099 cases and 7,428 deaths.1 After World Health Organization (WHO) declared a global pandemic on March 11, 2020, the Government of Bangladesh (GoB) closed all offices, schools, and businesses; local and international travel was severely restricted to reduce community transmission. Health care services in general and COVID-19-specific conditions were also negatively affected by these restrictions.

Bangladesh is a country with serious shortage of trained health care providers.1 The shortage affects both the quality of care and access to care.2 Given the high penetration of mobile phones in the country,3 in 2016 the GoB established a teleconsultation service, Shastho Batayon (24 h a day, 7 days a week) at only 4 cents (USD) for a 5 min call.4,5 Through Shastho Batayon, patients around the country could seek health information, clinical consultation, and prescriptions from qualified physicians. Despite the establishment of the service, the actual use of teleconsultation service has been low and prone to a digital bias favoring male, educated, and urban callers (unpublished report). There is also an expressed preference by the community for face-to-face consultations from trusted health care providers.6,7

The delivery of healthcare in a pandemic is complicated. On one hand, one wants to ensure that those in need of care receive it. On the other hand, one does not want services to be overwhelmed by unnecessary attendance, and there is also a well-founded concern that in pandemic situations, health care settings may become amplifiers of infection in the community.8,9 In nonpandemic circumstances, the provision of teleconsultation services offering health advice is regarded as an important add-on strategy for increasing access to health services for isolated and hard-to-reach populations.

In a pandemic, under “lockdown” conditions, healthcare services are, by fiat, hard to reach for everyone. The use of teleconsultation has been proposed as a mechanism for providing improved access to health care while simultaneously reducing the risk of transmission at the point-of-care, and providing appropriate triage. However, as teleconsultation emerges as an alternative to face-to-face medical visits during the COVID-19 pandemic, there are ethical and legal issues that should be taken into consideration.10 A national framework for evaluation and regulation of telehealth services is essential to protect the privacy and security of health-related data.11,12

In this article, we discuss the use of the national teleconsultation services in Bangladesh and the potential for this kind of services in other low- and middle-income countries (LMICs) to address the health needs of a population during any pandemic or other health emergency.

Relevant Changes During the Pandemic

During COVID-19 pandemic, common to many countries, the GoB took steps to reduce interpersonal contact and the spread of the virus. A lockdown was introduced, businesses and schools were closed, and public transport was curtailed. This had the dual effect of heightening anxiety in the population and placing the livelihoods of the millions of already poor people at the very margins. In this context, Shastho Batayon service was actively engaged to communicate information about COVID-19 symptoms, prevention messages, and referral.

During the early stages of the outbreak, the Ministry of Health and Family Welfare (MOH&FW) removed the service charges on calls to the Shastho Batayon service making it free for all callers and this service was widely publicized through traditional media channels and on social media platforms by the government. The number of doctors deployed per day increased from 21 in prepandemic to 73 during the pandemic to deal with the increased number of doctor’s consultation (Table 1). To assess the relevant changes during the pandemic, we conducted secondary analysis of service data from Shastho Batayon from January to April 2020.

Table 1. Description of Shasthyo Batayon Services from January to April 2020 and Changes Made During Pandemic in March 2020 in Bangladesh
SERVICES AND LOGISTICS JANUARY FEBRUARY MARCH APRIL
Teleconsultation √ √ √ √
Screening for COVID 19 based on national guidelines — — √ √
Call charge (4 cents/5 min) √ √ Toll free Toll free
Doctor’s deployment (daily) 21 21 73 73
Calls for doctor’s consultation 16,820 17,437 60,811 125,660

Results

In March 2020, the Shastho Batayon service experienced greater call volumes compared with the former toll-based service (data not shown).5 With increased concerns about potential disease transmission from face-to-face health consultation, Shastho Batayon filled an important niche for information and health care support during the pandemic. The calls received by Shastho Batayon can be categorized into calls for (1) doctor’s consultation, (2) ambulance services, (3) health information, (4) COVID-19-related automated information, and (5) other calls (complaints and information related to hospital services or Shastho Batayon services).

The total calls for doctor’s consultation increased significantly after the pandemic started (Table 1). Prepandemic, the teleconsultation service received <20,000 calls per month. In March 2020, when the first cases of COVID-19 were confirmed, Shastho Batayon received 60,811 calls for doctor’s consultation followed by 125,660 calls in April, 2020. The doctor’s consultation for primary care during the pandemic has increased for all conditions: 1.5 times for diarrhea, 6.3 times for enteric fever, 2.6 times for skin disease, 6 times for generalized weakness, 6.8 times for joint or back pain, 3.5 times for peptic ulcer, and 2.7 times for obstetrics and gynecological problems (Fig. 1).

Fig. 1.

Fig. 1. Distribution of patients by provisional diagnosis during January–April 2020.

Beyond the calls for primary healthcare the doctors deployed by Shastho Batayon, screened the patients with influenza-like illness (ILI) or COVID-19 symptoms based on a national guideline to categorize them as (1) common cold (mild risk), (2) suspected COVID (moderate risk), and (3) high-risk COVID. The patients at moderate and high risk COVID-19 were provided management or referral.

Before the pandemic, the ILI calls were around 1,500–2,000 per month. In 2020, calls related to ILI increased 3-fold in March and 11-fold in April (Fig. 2). As a percentage of total calls, ILI calls represented 8.2%, 11%, 11.1%, and 17.6% of calls in January, February, March, and April, respectively (Fig. 2). This showed that Shastho Batayon was able to provide an increasingly important service for suspected or potential COVID-19 cases.

Fig. 2.

Fig. 2. Distribution of patients based on scoring system for clinical diagnosis of COVID-19.

Discussion and Lessons Learned

This analysis shows data from the national teleconsultation services during the pandemic and prepandemic period, in Bangladesh. The number of calls during the pandemic and lockdown period have increased, which indicates that people consider teleconsultation service as an alternative to face-to-face consultation for primary health services and health information. This increased volume of calls may be attributed to the need for pandemic-related care services such as ILI, health information for preventive measures,13 anxiety and panic disorders related to the pandemic,14 and for the toll-free feature of the service.15 Data indicate that proportion of calls for ILI increased and at the same time, doctors’ consultations for all other cases also increased.

Although the increase in the number of calls for general health and COVID-19-related information and services shows that the context of COVID-19 has created a niche for teleconsultation services, it is important to have a monitoring system in place to ensure accountability and quality of services.16 Furthermore, although Shastho Batayon identified high-risk COVID-19 cases and provided referral advice, there are additional opportunities for pandemic control. For instance, with some effort, the moderate and high-risk cases could be followed up for contact tracing above and below the nodal case. Once identified as a COVID-19 case in the community, additional resources could be mobilized to support home quarantine. The ILI cases could also be used to identify potential outbreak hotspots.

Our experience showed that for an LMIC such as Bangladesh the use of teleconsultation services has the potential to address some critical needs for health care in future, such as:

  • health information: teleconsultation can provide accurate information during the pandemic;

  • doctor’s consultation: as face-to-face consultation becomes difficult due to pandemic control measures;

  • protect frontline healthcare providers from exposure to life-threatening communicable diseases; and

  • support COVID-19 case identification, initiate timely measures for management, such as quarantine, testing, and referral.

Authors’ Contributions

F.K., S.R., and N.U.A. conceptualized and designed this case study. F.K. drafted the article. F.K., S.R., N.U.A., M.H.R., S.S.R., S.P.S., S.A.C., R.C., and D.D.R. reviewed and provided intellectual input into the article. All authors accept final responsibility for the article.

Acknowledgments

We thank Synesis IT team and MIS, DGHS team.

Disclosure Statement

No competing financial interests exist.

Funding Information

There is no specific funding for this study. Partial salary of F.K. and S.R. was supported by the Swedish International Development Cooperation Agency (Sida). D.D.R. was funded by core donors who provide unrestricted support to icddrb for its operations and research; current donors providing unrestricted support include the Governments of Bangladesh, Canada, Sweden, and the United Kingdom. We gratefully include our core donors for their support and commitment to icddrb research efforts.

References



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