Sage Journals: Discover world-class research

Abstract

Objective

To conduct a comprehensive health systems policy analysis of the Sindh Telemedicine and Telehealth Act 2021 by examining its contextual drivers, governance and stakeholder dynamics, implementation barriers and facilitators, and policy content, and by comparing it with telemedicine policies in neighboring low- and middle-income countries (LMICs).

Methods

Our study applied Walt and Gilson's policy triangle to examine context, content, process, and actors. A desk review of relevant policy documents from Sindh and other LMICs (India, Bangladesh, and Nepal) was conducted, followed by in-depth interviews with 28 stakeholders (July–October 2023) until data saturation was reached. Participants were recruited using purposive and snowball sampling strategies. Thematic analysis was done using Qualitative Data Analysis Software (QSR NVivo v12) to identify barriers and facilitators to policy implementation.

Result

The contextual drivers behind the formulation of the Act included the coronavirus disease 2019 pandemic, limited healthcare access, and the growth of telehealth providers in private sector. The Act provides a regulatory framework for healthcare providers registration and training requirements, guidelines for patient consent, emergency care, and data privacy. However, it lacks clarity on the cost of telemedicine services and measures for cross-border telemedicine. Stakeholder analysis showed government bodies hold the highest power in telemedicine policymaking. Telemedicine service providers and healthcare providers expressed support for the Act but were excluded from policymaking process. Service users also had minimal involvement in the policymaking process. Policy implementation varies, facing financial and technological barriers, while strategic financial planning and public–private partnerships, identified as facilitators in overcoming these challenges.

Limitations

The study may be subject to limitations, including potential selection bias while identifying stakeholders and the constraints of desk review in capturing details.

Conclusion

The Act is an important step towards addressing healthcare disparities, with its success contingent on overcoming implementation barriers through inclusive and strategic policymaking and investment in digital infrastructure.

Keywords

Telehealth policy digital health health systems policy analysis governance Pakistan

Introduction

Telemedicine has the potential to completely transform the way healthcare is delivered,¹ especially in low- and middle-income countries (LMICs), where access to healthcare services is often constrained by geographical and health system barriers. The coronavirus disease 2019 (COVID-19) pandemic triggered a boom in the digital health landscape, increasing the adoption of digital technologies within health services, particularly in telemedicine, bringing about innovations in healthcare delivery models in both high-income countries and LMICs.² In 2024, there were over 116 million users of online doctor consultations worldwide, up from around 57 million in 2019.³ While telemedicine promises to provide more convenient and cost-effective access to physicians compared to traditional approaches,³ the adoption of this technological change in LMICs may be constrained by a less favorable policy and regulatory environment.²

In Pakistan, where 61.2% of the population resides in rural areas,⁴ health systems face constraints due to inadequate healthcare infrastructure, a dual burden of communicable and non-communicable diseases, and a shortage of healthcare workforce relative to globally recommended standards, with only 1.1 medical doctors per 1000 population⁵ and 0.5 nurses per 1000 population as of 2019.⁶ Numerous tele-health initiatives have been introduced to address these health system gaps. The Aga Khan Development Network Digital Health Program leverages information and communication technologies to connect health care institutions and health care providers within and across Afghanistan, Kyrgyz Republic, Pakistan, and Tajikistan.⁷ Telehealth clinics, such as those established by Commission on Science and Technology for Sustainable Development in the South (COMSATS) and Sehat Kahani, offer access to quality healthcare for underserved populations. Additionally, platforms like doctHERs and Oladoc enable patients to book appointments and connect with doctors online. These initiatives are primarily led by the private sector but often operate in silos due to a lack of governance, which allows their implementation without following recommended standards or ensuring these are interoperable with other systems.⁸ In addition, research had highlighted the urgent need for a telemedicine policy to encourage acceptance and effective utilization across the country.⁹

In 2019, a draft for the National Telemedicine Policy was formulated in the wake of the COVID-19 pandemic, without it being finalized.¹⁰ In 2022, the National Digital Health Framework for Pakistan 2022–2030 was established, marking a crucial step towards the digitization of the country's healthcare infrastructure.¹¹ Leveraging the health programing, policymaking and legislative autonomy granted to the provinces by the 18th constitutional amendment, Sindh became the first among Pakistani provinces to formulate a legislation for telemedicine, enacting the Sindh Telemedicine and Telehealth Act 2021.¹² From here on, we use the term “Act” to refer to the Sindh Telemedicine and Telehealth Act 2021. This Act was a significant step in formally recognizing telemedicine within the province.

A conducive policy environment supporting integration of telemedicine into the health systems promises to address major health system challenges of access and quality of service delivery in Pakistan and other LMICs. The aim of this study was to conduct a comprehensive policy analysis of the Sindh Telemedicine and Telehealth Act 2021. Specifically, the study examined the contextual factors influencing telemedicine in Sindh, conducted a stakeholder analysis, identified key barriers and facilitators to implementation and conducted a content analysis of the Act alongside a comparative review of telemedicine policies in neighboring LMICs including India, Bangladesh, and Nepal to identify gaps and similarities to Act.

Methodology

Study design

The study employed a qualitative case study design to conduct policy analysis of the Sindh Telemedicine and Telehealth Act 2021.

Conceptual framework

For this study, we used the Walt and Gilson policy triangle framework for policy analysis,¹³ providing a structured approach to analyzing telemedicine law in Sindh. This framework is renowned for its comprehensive perspective on policy analysis and is particularly pertinent for examining the complex nature of telemedicine policy. It presents a simplified approach to a complex set of interrelationships among contextual factors, policy content, policy processes, and the roles of various actors. Figure 1 illustrates the adaptation of this framework in accordance with telemedicine policy analysis, also highlighting key research questions framed according to the various elements in the framework.

Figure 1.

Model for health policy analysis for telemedicine.

In addition, a Political, Economic, Social, Technological, Legal, and Environmental (PESTLE) analysis was conducted to understand the multifaceted contextual factors that shaped the landscape of telemedicine in Sindh.

Study setting

Sindh is the second-largest province in Pakistan, with a population of 55.7 million, approximately 46.03% of which resides in rural areas.¹⁴ A 38% of the population lives below the poverty line of $3.65.¹⁵ Sindh's public sector health infrastructure comprises 8 teaching hospitals, 16 district headquarters hospitals, 18 major hospitals, 50 Taluka hospitals, 128 Rural Health Centers, 793 basic health units, and 1378 dispensaries.¹⁶ Despite having over 14,000 doctors, 2000 nurses, and 12,000 paramedics, the province faces significant challenges in healthcare access. Many rural health facilities are ill-equipped, understaffed, and underutilized, leading to disparities in healthcare access and quality.¹⁷ This study was conducted from July to October 2023.

Sampling strategy and study participants

The study utilized purposive and snowball sampling methods to carefully select participants with direct or indirect involvement and experience in telemedicine services. Purposive sampling was used to ensure representation across key stakeholder groups involved in telemedicine policy and implementation, while snowball sampling supported identification of additional relevant informants. We acknowledge that snowball sampling may introduce network bias and limit diversity of perspectives; however, this risk was mitigated by initiating recruitment across diverse institutions and sectors like policymakers, telemedicine service providers, healthcare providers and service users. Similar mixed sampling approaches have been commonly used in qualitative digital health research in LMIC settings to access diverse stakeholder perspectives.¹⁸

A total of 28 participants were selected to provide a comprehensive understanding of the policy. The sample size was determined by the point of data saturation, meaning the interviews continued until additional conversations no longer provided new or relevant information. No participants who were approached declined participation or withdrew from the study. The respondent groups included 9 provincial government officials from the Health Department, Sindh Healthcare Commission (SHCC), Planning and Development Department, and Population Welfare Department. Additionally, the study engaged 7 patients, 8 healthcare providers, and 4 telemedicine service providers, see Table 1.

Table 1.

Study Participants and Inclusion Criteria.

Stakeholder Group	Total Number	Inclusion Criteria
1. Provincial Government Officials	9	Minimum 1 year in their role
− Health Department
− Healthcare Commission
− Planning and Development Department
− Population Welfare Department
2. Community members/Patients	7	Have utilized telemedicine for their healthcare need
3. Healthcare providers	8	At least six months of delivering healthcare through telemedicine
4.Telemedicine Service Providers	4	Providing telemedicine services for the past two years
Total	28

Data collection and analysis

In-depth interviews were conducted in either Urdu or English using an interview guide (see Supplemental file 1) developed on the basis of the conceptual framework, which was piloted and refined prior to data collection. The interviews were conducted by a female member of the research team, who held postgraduate qualification in public health and health systems research and was working as a health systems researcher at the time of the study. Participants were approached via telephone and were informed about the purpose of the study and the researcher's role prior to providing consent. The interviews ranged from 30 to 45 min and were carried out either face-to-face or virtually. Repeat interviews were not conducted, and no non-participants were present during the interviews. Audio recordings of the interviews were made with the verbal consent of the participants and field notes were taken during the interviews to capture non-verbal cues. Literature search and desk review of policy documents of the Act and neighboring LMICs (India, Bangladesh, and Nepal) were conducted. Additionally, any publicly available information on the Act from provincial health department and annual reports from telemedicine providers like Sehat Kahani were also reviewed. Data was analyzed using thematic analysis to extract insights on the barriers, facilitators, and prospects of telemedicine with the help of NVivo software version 12. Initial coding was conducted by the lead author, with regular discussions among the research team to refine and validate themes. To minimize potential interviewer bias, the interview guide was applied consistently across participants, and probing was guided by the conceptual framework rather than individual assumptions. Interview transcripts were not returned to participants for comment or correction. This qualitative study is reported in accordance with the Consolidated Criteria for Reporting Qualitative Research checklist (see Supplemental file 2)

Results

Themes were derived inductively from the data and organized deductively using the Walt and Gilson policy triangle framework. Using this framework, thematic analysis identified four overarching themes that structure the results presented in this section. These included: (1) Contextual factors influencing the development and implementation of telemedicine policy in Sindh; (2) stakeholder roles, power dynamics, and positioning within telemedicine policymaking; (3) implementation barriers and facilitators affecting the operationalization of the Sindh Telemedicine and Telehealth Act 2021; and (4) strengths and gaps within the policy content, informed by analysis of the Act and comparative review of telemedicine policies in neighboring LMICs. These themes are presented sequentially in Sections “Contextual factors” to “Comparative analysis of Sindh Telemedicine and Telehealth Act 2021 with implemented telemedicine policies of India, Bangladesh, and Nepal.”

Contextual factors

The Act was developed to standardize the use of digital technologies to make healthcare more accessible, particularly in remote and underserved areas. Its implementation is shaped by various factors, including political priorities, economic conditions, social acceptance, technological infrastructure, legal frameworks, and environmental considerations as shown in Table 2.

Table 2.

Political, Economic, Social, Technological, Legal, and Environmental (PESTLE) Analysis of the Contextual Factors for Sindh Telemedicine and Telehealth Act 2021.

Factor	Effect	Supporting Quote
Political
Shifting government priorities and inconsistent commitment	Challenges in deploying sustainable health initiatives.	"Commitment—regulatory policy whether on national or provincial level needs to have commitment from the top tier then comes implementation and the response of the end user.” (government official #3).
Resistance to change	Slowed down the adoption of telemedicine policies and regulations, protecting vested interests.	“The dominance of traditional healthcare lobbies and their resistance to change have slowed down the adoption of telemedicine policies and regulations, protecting their vested interests.” (telemedicine service providers #4)
Economic
Telemedicine as a cost-effective alternative	Mitigates financial burdens associated with travel and potential loss of wages for patients.	“They sometimes come in too late because the cost of travel and treatment is something they try to avoid until it is absolutely necessary. We needed a system that makes basic healthcare more affordable and accessible.” (healthcare provider #8).
Economic disparities in healthcare access	Telemedicine may exacerbate existing inequalities if not implemented equitably.	“The private sector is rapidly adopting telemedicine, but we need government support to ensure that these services are affordable and accessible to the most vulnerable populations in Sindh.” (healthcare provider #2)
Financial sustainability of telemedicine services	Ensuring long-term funding and reimbursement models for telemedicine providers is crucial.	“Telemedicine has the potential to revolutionize healthcare in Sindh, but we need to develop sustainable business models that incentivize providers to offer these services in underserved areas.” (telemedicine service provider #2)
Socio-cultural context
Socio-cultural resistance and lack of awareness	Hesitation to adopt telemedicine due to cultural norms, particularly among women in rural areas.	"The issue is awareness. Our rural outreach showed, they are reluctant to use it because of cultural norms, especially women.” (telemedicine service provider #1)
Gender disparities in healthcare access	Telemedicine bridges gender gaps in healthcare access, but only if women are empowered to use it.	“Many women in our village are not comfortable using technology or speaking to male doctors. We need female telemedicine providers and culturally sensitive training to encourage women to utilize these services” (telemedicine service provider #1)
Traditional beliefs and practices	Integrating telemedicine with traditional healing practices can enhance its acceptance and effectiveness.	“Telemedicine should not replace traditional medicine but complement it. By incorporating local healers and traditional practices into telemedicine platforms, we can build trust and provide holistic care.” (healthcare provider #5)
Community engagement and trust-building	Building trust between healthcare providers and communities is essential for the successful adoption of telemedicine.	“We need to involve community leaders, religious figures, and local influencers in promoting telemedicine. Their endorsement can help overcome skepticism and encourage people to embrace this new way of accessing healthcare.” (government official #6)
Technological infrastructure
Telemedicine infrastructure and platforms for overcoming geographic inaccessibility	Enables remote consultations and the virtual delivery of healthcare services overcoming geographic inaccessibility	“We've seen a surge in users from rural areas. They tell us that getting to a government facility is a day's journey, and even then, the care is unpredictable. Our platform offers them a reliable alternative.” (telemedicine provider #3)
Digital divide	Limited access to technology and lack of awareness hindered full utilization of telemedicine.	“As part of the government's initiative to improve healthcare access, we are aware that socio-economic factors play a huge role. We have started awareness campaigns to bridge this gap. The disparity between urban and rural, rich, and poor, is significant when it comes to health outcomes. We are working towards more equitable health policies, but change is slow due to budgetary constraints and competing priorities.” (government official #9).
Lack of reliable internet connectivity and infrastructure	Hinders the reach and effectiveness of telemedicine, particularly in rural and remote areas.	“In villages, the internet is usually sporadic. When it does work, it is too slow for video consultations. We need better connectivity.” (healthcare provider #7)
Infrastructure challenges	Poor connectivity can negatively affect patient experiences,	“My telemedicine experience was frustrating. The connection was poor, and I felt like the doctor could not properly assess my condition. I would rather wait for an in-person appointment.” (patient #2)
Legal and regulatory framework
No prior national regulatory framework and standardization	Provided a regulatory framework for telehealth practices in Sindh.	“There was a shortage of human capital so with telemedicine, we benefited very much.” (government official #1).
Legislative development	Set a precedent for other regions, encouraging the adoption of similar telehealth policies.	“I think the Sindh Government has done well to create a legislative framework for the telemedicine initiatives in the province, and I think others should also learn from it” (government official #5).
Environmental challenges
Poor healthcare infrastructure	Lack of basic amenities like electricity and clean water can disrupt telemedicine services and compromise hygiene.	"We have a telemedicine kiosk, but frequent power outages make it unreliable. We need a sustainable solution to ensure uninterrupted access to healthcare”. (healthcare provider # 4)
Geographical inaccessibility	Limited access to healthcare facilities in remote areas hinders timely care and increases health risks.	“In some places in Sindh, the healthcare facilities are so sparse, it is hard to imagine how people survive. I've visited districts where the nearest hospital is over many kilometers away, with no proper roads to get there. In emergencies, people have lost their lives just trying to reach a doctor.” (Healthcare provider #4)

The stakeholders analysis

The implementation of Act relies on the collaborative efforts of various stakeholders, each bringing unique strengths and influence. We presented stakeholders’ sources of power, power, and their positions in Table 3. Our analysis did not identify any opponent groups through document reviews or stakeholder interviews.

Table 3.

Stakeholder Analysis for Sindh Telehealth and Telemedicine Act 2021.

Stakeholder Group	Source of Power	Power^a	Position
MoNHSRC	National health authority	High	Moderate support
Sindh Health Department	Authority in policy formulation	High	Moderate support
Sindh Health Care Commission	Regulatory authority	High	High support
Planning and Development Department	Integration with development plans	High	Moderate support
Population Welfare Department	Policy support	High	Moderate support
PTA	Telecommunication regulation	Moderate	Moderate support
Telemedicine Service Providers	Technical and operational expertise	Moderate	High support
Healthcare Providers	Service delivery	Moderate	Moderate support
Patients	Feedback and service usage	Minimal	Moderate support
Academic and Research Institutions	Evidence-based research	Moderate	Moderate support
WHO Country Office	Engaging health ministry, provide leadership and guidance	High	High support
Global Health Agencies/Donors	International funding, and technical assistance for health projects.	High	High support

PTA: Pakistan Telecommunication Authority; MoNHSRC: Ministry of National Health Services, Regulations and Coordination; WHO: World Health Organization.

Stakeholder power was assessed based on perceived influence over policy formulation and implementation, decision-making authority, and control over regulatory or financial resources, drawing on interview data and document review.

The Ministry of National Health Services, Regulations and Coordination (MoNHSRC) and Sindh Health Department hold substantial power and authority in telemedicine policy. They are central to policy formulation and implementation but demonstrated only moderate support for the Act. The SHCC ensures compliance with health standards through its significant regulatory power and expertise, thereby influencing the quality and standards of telehealth services, thus being highly supportive of this Act.

The Planning and Development Department and the Population Welfare Department play supportive roles by integrating health policies with broader developmental goals and providing policy support for population health management. Both departments demonstrated moderate support and are pivotal in aligning telehealth policies with overall development strategies.

The Pakistan Telecommunication Authority (PTA) plays a crucial role in regulating telecommunication infrastructure, ensuring robust connectivity and data security with a moderate power level. Telemedicine Service Providers and Healthcare Providers are vital for operationalizing the Act, advocating for resources, and delivering healthcare services. Despite their slightly lower power their roles are essential and were found to be highly and moderately supportive, respectively.

Patients, as primary beneficiaries, provide valuable feedback essential for continuous service improvement, although their individual power is minimal and were moderately supportive. Academic and research institutions hold influence through evidence-based research, shaping policy with critical insights. The World Health Organization (WHO) Country Office and Global Health Agencies and donors offer essential funding and technical assistance for health projects, also reflecting high support.

Implementation barriers and facilitators of the Sindh telemedicine and telehealth act 2021

The implementation of Act encountered several challenges and opportunities on ground, particularly in rural areas. Tables 4 and 5 provide detailed overviews of the specific barriers and facilitators identified during the implementation process.

Table 4.

Implementation Barriers.

Barrier	Effect	Quotes
Financial constraints	Hinders the development and expansion of telemedicine services.	“If it was implemented at earlier time when inflation was low only then it would have been cost-efficient and we would have expanded it more but right now, we are under a budget constraint due to dollar fluctuation” (government official #2).
Technological and infrastructural barriers	Limits access to telemedicine services, particularly in rural areas.	“Major challenges include not having a phone, high rates, expensive phone packages, lack of bandwidth, or no signal which we are trying our level best to solve” (government official #8).
Technological and infrastructural barriers	Reduced accessibility and utilization of telemedicine services.	“The payment process was online which could be problematic for some patients who may not be tech-savvy” (patient #1).
Socio-cultural barriers	Limited adoption and acceptance of telemedicine.	“There are specific challenges, especially in the case of female patients…they are reluctant to appear on camera” (healthcare provider #4).

Table 5.

Implementation Facilitators.

Facilitator	Effect	Quotes
Strategic financial reallocation	Enables sustainable long-term planning for telemedicine implementation.	"Make KPI for each district … this will help us to know how many users have availed the telemedicine facility so financial reallocation can be done” (government official #1).
PPPs	Broadens adoption and infrastructure development and service outreach by pooling strengths from multiple sectors	"Infrastructure development, PPP with active stakeholders” (government official #6).
Standardization and harmonization of telemedicine	Ensured consistent quality and user experience.	"There should be more work on the standardization of how telemedicine is operating across the province” (telemedicine service provider #2).
Educational initiatives and community engagement	Increased understanding and trust in telemedicine services.	"We visit their organization and give them training regarding the service facility” (telemedicine service provider #1).

KPI: key performance indicator; PPP: public-private partnership.

Content analysis of the Sindh telemedicine and telehealth act 2021

The Act aims to enhance healthcare delivery through telemedicine platforms, focusing on accessibility, quality, and security. The Act provides a comprehensive framework for remote healthcare services, addressing the shortage of healthcare professionals and promoting equitable healthcare access across Sindh. Table 6 summarizes the key components of the Act and its implications.

Table 6.

Key Components of “Sindh Telemedicine and Telehealth Act 2021.”

Component	Description	Implications
Objectives	Improve healthcare access, especially in remote areas, by utilizing telemedicine platforms.	Reduces geographical barriers, enhances healthcare delivery, and ensures that quality healthcare is accessible to all residents of Sindh.
Registration and training	Mandatory registration and training for medical practitioners and healthcare service organizations (HCSOs).	Ensures practitioners are well-equipped to deliver high-quality care via digital platforms, maintaining professional standards.
Patient consent and privacy	Requires explicit patient consent before telemedicine consultations and mandates robust data protection measures.	Protects patient rights and confidentiality, builds trust in telemedicine services, and aligns with international data protection standards.
Modes of telemedicine	Allows consultations via video, audio, text, or email, with the choice of mode determined by clinical needs.	Enhances the flexibility, convenience, and effectiveness of telehealth services, allowing tailored approaches to patient care.
Professional judgment	Practitioners must use professional judgment to determine the suitability of telemedicine consultations versus in-person visits.	Ensures the quality of care is maintained and that patients receive the most appropriate form of consultation based on their medical condition.
Data security and confidentiality	Mandates stringent data security measures to protect patient information, with severe penalties for breaches	Builds trust in telemedicine services by safeguarding patient information and ensuring compliance with data protection standards.
Healthcare services delivery	Defines the scope of services deliverable via telemedicine, including consultations, follow-ups, health education, and counseling.	Provides a clear framework for comprehensive healthcare delivery, ensuring continuous and holistic patient care.
Emergency situations	Recognizes limitations of telemedicine in emergencies, emphasizing the need for in-person care but allowing initial guidance and support.	Balances the use of telemedicine with the necessity of in-person consultations in critical situations, ensuring patient safety.
Regulatory provisions	Allows the government to create rules for implementation, override conflicting laws, and address difficulties in enforcing the act.	Ensures the act remains adaptable and effective, providing flexibility to address evolving healthcare needs and challenges.

Comparative analysis of Sindh telemedicine and Telehealth Act 2021 with implemented telemedicine policies of India, Bangladesh, and Nepal

The Telehealth Act of Sindh is comprehensively designed; however, there are a few domains where the Act is lacking compared to those in India,¹⁹ Bangladesh,²⁰ and Nepal.²¹ For instance, the Sindh policy does not address the use or standardization of technology platforms for telemedicine, which is crucial for ensuring interoperability and consistency across different telemedicine services. In contrast, India, Bangladesh, and Nepal have established standards for technology platforms, facilitating a more integrated and efficient telehealth ecosystem.^22–24 These interoperability frameworks enable secure data exchange, continuity of care, and integration with national health information systems.

Moreover, the Act does not cover regulations or guidelines for cross-border telemedicine, which could facilitate international consultations and collaborations. Nepal have incorporated guidelines for cross-border telemedicine, thus expanding the reach and scope of telehealth services beyond its national borders. Additionally, there is no provision or guideline regarding the cost of telemedicine services in the Sindh Act. Clear guidelines on the cost of services are important for ensuring affordability and transparency for patients. India, Bangladesh, and Nepal have recognized the need of preventing arbitrary pricing and ensuring affordability of telemedicine in making telemedicine accessible to a wider population. To address this need, they included cost-related provisions in their telemedicine policies. Table 7 provides a comparative analysis of the telemedicine policies implemented in India, Bangladesh, and Nepal with that of Sindh, highlighting these key gaps.

Table 7.

Comparative Analysis of Sindh Telemedicine and Telehealth Act 2021 with Implemented Telemedicine Policies of India, Bangladesh, and Nepal.

Clinical, Legal and Operational Domains	Sindh	India	Bangladesh	Nepal
Definition of telemedicine	✓	✓	✓	✓
Scope/purpose of telemedicine	✓	✓	✓	✓
Guidelines for emergency care	✓	✓	✓	✓
Qualifications of healthcare worker	✓	✓	✓	✓
Patient identification	✓	✓	✓	✓
Drug prescription	✓	✓	✓	✓
Technology platforms	Χ	✓	✓	✓
Standardized treatment guidelines	✓	✓	✓	✓
Medium of information exchange	✓	✓	✓	✓
Data safety and privacy	✓	✓	✓	✓
Cross-border telemedicine	X	X	X	✓
Patient consent	✓	✓	✓	✓
Tools for telemedicine	✓	✓	✓	✓
Cost of service	X	✓	✓	✓
Training in telemedicine	✓	✓	✓	✓
Digital health interoperability	X	✓	✓	✓

Discussion

Telemedicine is a transformative digital health intervention that offers flexible, patient-centric care delivery models. The COVID-19 pandemic accelerated its adoption globally, emphasizing the urgent need for effective telehealth policies in LMICs such as Pakistan.²⁵ The Sindh Telemedicine and Telehealth Act 2021 is a commendable step toward formalizing telehealth services, addressing key healthcare delivery challenges in Sindh's predominantly rural population. However, for its full potential to be realized, several enhancements to the policy and its implementation must be considered. The expansion of telemedicine initiatives hinges on overcoming barriers such as funding challenges, limited technological infrastructure in remote areas where such programs are most needed, and socio-cultural resistance as also reported in one of the studies.²⁶

The content and comparison analysis of the Act shows that Sindh Telemedicine and Telehealth Act 2021 covers important aspects for regulating telemedicine practice by addressing critical areas such as patient consent, data security, and professional judgment in remote consultations. However, significant gaps remain when compared to telehealth policies in neighboring countries like India,¹⁹ Bangladesh,²⁰ and Nepal.²¹ These gaps include the lack of standardized technology platforms to ensure interoperability, absence of clear cost regulations to ensure affordability and equitable pricing, and the omission of provisions for cross-border telemedicine consultations. In contrast, India has operationalized a national digital health architecture through the Ayushman Bharat Digital Mission to enable interoperability across health information systems,²² Nepal has placed interoperability at the center of its digital health agenda by adopting OpenHIE as a reference framework for standardized health information exchange,²⁴ and Bangladesh has implemented interoperability mechanisms linking sector-specific information systems with the national DHIS2 platform to support integrated data sharing and health system decision-making.²³ Addressing these gaps by incorporating lessons from neighboring countries could enhance the policy's robustness and adaptability to evolving healthcare needs. For instance, India's telemedicine guidelines provide detailed guidelines on doctor-patient consultation in specific scenarios and for different medical conditions, that may ensure consistency in service delivery if followed. Similarly, Bangladesh has articulated clear categorization of medicines for different situations while Nepal specifically mentions cost for services and cross-border telemedicine. Careful consideration for these components would not only enhance the effectiveness of the Act but also ensure its successful implementation.

From stakeholder analysis we identified that effective implementation of the Act requires active engagement and commitment from various stakeholders. Provincial governments must lead implementation efforts by allocating resources strategically to ensure policy compliance. SHCC should be the lead regulator overseeing the policy implementation. SHCC should establish monitoring and evaluation mechanisms to track telehealth performance, assess compliance with standards, and identify areas for improvement. Through structured licensure processes, SHCC should ensure that only qualified and accredited healthcare providers are authorized to offer telemedicine services, maintaining professional integrity and patient safety. Quality of care monitoring should be implemented by setting benchmarks, conducting regular assessments, and ensuring that telehealth services align with established clinical and ethical standards. A feedback mechanism should be developed to allow patients and providers to report concerns, ensuring continuous service improvement and timely policy adjustments.

Similarly, the Pakistan Medical and Dental Council (PMDC) should be responsible for overseeing professional standards in telemedicine. PMDC should regulate medical practitioners engaged in telehealth by ensuring they adhere to ethical guidelines, maintain patient confidentiality, and uphold professional integrity in virtual consultations. PMDC should also provide continuous guidance on ethical considerations and ensure that healthcare professionals receive adequate training on telemedicine best practices.

If we see the barriers and facilitators for the implementation of Act, the role of the private sector cannot be overstated. This finding aligns with international experiences demonstrating the effectiveness of public–private collaboration in telehealth scale-up.²⁷ Public–private partnerships can play a pivotal role in expanding the use of telehealth in at least two distinct ways. Firstly, the government-operated facilities in remote and rural districts could be contracted out to private telemedicine suppliers. Secondly, broadband providers should work on expanding access and mobile connectivity in rural areas while also focusing on development of scalable telemedicine platforms. The private sector's role is indispensable in enhancing service delivery, and their participation can be incentivized through tax benefits and grants. Investments in reliable internet infrastructure, complemented by the establishment of telemedicine kiosks with power backups, are essential to mitigate infrastructural challenges. Culturally sensitive awareness campaigns, engaging local leaders and influencers, can help build trust and promote telemedicine adoption, especially among women who face privacy concerns. Comprehensive training programs for healthcare professionals and digital literacy initiatives for communities can further ensure effective utilization of telehealth services.

An additional socio-economic barrier affecting telemedicine adoption in Sindh relates to the prevalence of informal, cash-based financial practices. Telemedicine models that rely primarily on digital payments may inadvertently exclude unbanked and underbanked populations, particularly low-income households and rural users with limited access to formal banking systems, mobile wallets, or digital literacy. In the absence of explicit policy guidance on alternative or hybrid payment mechanisms such as cash-based options, telemedicine risks reinforcing existing inequities in healthcare access. Addressing financial inclusion within telemedicine policy design is therefore critical to ensuring equitable uptake and sustainable scale-up.

This mirrors the approach taken in other countries, where public-private partnerships have been key to successful telehealth implementation. For example, the successful implementation of Technology-enabled Remote Healthcare in India showed that e-health in a public-private partnership (PPP) mode in a developing country is eminently doable.²⁸ Similarly, Aga Khan University (AKU)'s tele-ICU project enabled doctors across Pakistan treating patients in ICUs and HDUs to receive 24/7, free-of-cost consultations from AKU consultants. This initiative was launched in collaboration with the Government of Pakistan, as well as the Governments of Sindh, Punjab, and Khyber Pakhtunkhwa.²⁹

Active participation from all stakeholders is also critical for the successful implementation of the policy. Communities and patients, as end-users, should be actively engaged through feedback mechanisms. Clear metrics are needed to assess the policy's impact. Key performance indicators (KPIs) should evaluate improvements in healthcare access, patient satisfaction, and cost reduction for patients and providers. Regular evaluations and feedback loops will allow for continuous improvement, ensuring the policy remains responsive to emerging needs and challenges.

The policy should incorporate rigorous training for healthcare professionals in telehealth services, including periodic re-examinations. It must establish standards and regulations to ensure patient privacy and data security are upheld and are meeting the Health Insurance Portability and Accountability Act privacy rules. Additionally, the policy should facilitate partnerships between the public and private sectors to enhance service delivery. Addressing licensing and reimbursement issues is essential, as is integrating telehealth for emergency response strategies. Furthermore, regulations should be implemented for various telehealth platforms, including pricing structures, to ensure transparency, fairness and standardization in service delivery.

We conducted policy analysis of the Sindh Telemedicine and Telehealth Act 2021, which included reviewing the policy context, content, process, and stakeholders. The study highlights the status of telemedicine policy in Sindh and the challenges encountered by stakeholders as well as the barriers and enablers for the adoption of telemedicine policy across the province. We hope our findings will provide a roadmap for other provinces on how to strategically integrate telemedicine into their healthcare systems, thus improving service access and delivery, and ensuring enhanced healthcare accessibility for all.

Study strengths and limitations

The study's strength lies in its multi-method case study approach, incorporating desk review and in-depth interviews with diverse stakeholders for a comprehensive analysis of Telehealth Act in Sindh. This approach, using Walt and Gilson's policy triangle, provides an in-depth understanding of policy factors and implementation barriers and facilitators affecting telehealth platforms. However, the study faces limitations, including potential selection bias while identifying stakeholders and the constraints of desk review in capturing detailed policy implementation realities. Future research should aim for broader stakeholder engagement and empirical analyses of telemedicine implementation, with longitudinal studies to understand the adoption dynamics over time in Sindh.

Conclusion

The Sindh Telemedicine and Telehealth Act 2021 represents a significant legislative step toward formalizing telemedicine within Pakistan's healthcare landscape. This study demonstrates that while the Act provides a necessary regulatory foundation, its effectiveness is contingent on implementation factors such as governance arrangements, technical readiness, and socio-economic context. The analysis identifies critical gaps related to interoperability, pricing regulation, cross-border care, and financial inclusion, while also highlighting the enabling role of strategic public–private partnerships, workforce training, and digital infrastructure investment. By drawing on lessons from neighboring countries and situating these findings within a health systems policy framework, the study offers practical insights to strengthen telemedicine governance in Sindh and provides a transferable reference for other provinces and comparable LMIC settings.

Supplemental Material

sj-docx-1-dhj-10.1177_20552076261430096 - Supplemental material for Making policy to bridge gaps in health care access in Sindh, Pakistan: An analysis of the Sindh telemedicine and telehealth act 2021

Supplemental material, sj-docx-1-dhj-10.1177_20552076261430096 for Making policy to bridge gaps in health care access in Sindh, Pakistan: An analysis of the Sindh telemedicine and telehealth act 2021 by Samrah Jawed, Hasan N Tahir, Mustafa Hassan, Lorena Guerrero-Torres, Sara S Khurram and Shifa S Habib in DIGITAL HEALTH

Supplemental Material

sj-docx-2-dhj-10.1177_20552076261430096 - Supplemental material for Making policy to bridge gaps in health care access in Sindh, Pakistan: An analysis of the Sindh telemedicine and telehealth act 2021

Supplemental material, sj-docx-2-dhj-10.1177_20552076261430096 for Making policy to bridge gaps in health care access in Sindh, Pakistan: An analysis of the Sindh telemedicine and telehealth act 2021 by Samrah Jawed, Hasan N Tahir, Mustafa Hassan, Lorena Guerrero-Torres, Sara S Khurram and Shifa S Habib in DIGITAL HEALTH

Footnotes

Acknowledgements

The authors gratefully acknowledge the time and valuable insights shared by all stakeholder participants in this study.

ORCID iDs

Samrah Jawed

Mustafa Hassan

Lorena Guerrero-Torres

Shifa S Habib

Ethics approval

Ethical approval for this study was obtained from the Ethical Review Committee at the Aga Khan University, Karachi (ERC # 2023-8997-26440).

Consent to participate

All participants provided informed verbal consent prior to the interviews. Confidentiality and anonymity of all participants were strictly maintained. The study was conducted in accordance with the principles of the Declaration of Helsinki

Consent for publication

Not applicable.

Authors’ contributions

SJ: Conceptualization, methodology, formal analysis, investigation, writing – original draft preparation, and writing—review & editing.

HNT: Literature review, data analysis support, and writing—review & editing.

MH: Writing—review & editing and technical review of the manuscript.

LGT: Methodology, technical input and validation, and writing—review & editing.

SSK: Contribution to discussion, and writing—review & editing.

SSH: Conceptualization, methodology, supervision, data interpretation, writing—review & editing, and overall study oversight as senior author

Funding

The authors received no financial support for the research, authorship, and/or publication of this article: This work received financial support from the Alliance for Health Policy and Systems Research (Alliance). The Alliance is able to conduct its work thanks to the commitment and support from a variety of funders. These include our long-term support from the Swedish International Development Cooperation Agency (Sida) and the Norwegian Agency for Development Cooperation (Norad), as well as designated funding for specific projects within our current priorities. For the full list of Alliance donors, please visit .

Alliance for Health Policy and Systems Research

Declaration of conflicting interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Availability of data and materials

The data analyzed during the current study consist of anonymized interview transcripts and field notes from 28 stakeholders. This data is not publicly available due to participant confidentiality and ethical restrictions. However, they are available from the corresponding author upon reasonable request, subject to approval from the Aga Khan University Ethical Review Committee.

Supplemental material

Supplemental material for this article is available online.

References

Jin

Kim

Miller

, et al. Telemedicine: current impact on the future. Cureus 2020; 12(8): e9891. DOI: 10.7759/cureus.9891

Zhang

Zaman

. Adoption mechanism of telemedicine in underdeveloped country. Health Informatics J 2020 Jun; 26: 1088–1103.

Dorsey

Topol

. Telemedicine 2020 and the next decade. Lancet 2020 Mar 14; 395: 59.

ANNOUNCEMENT OF RESULTS OF 7 TH POPULATION AND HOUSING CENSUS-2023 [Internet]. Available from: https://www.pbs.gov.pk/sites/default/files/population/2023/Press%20Release.pdf

Physicians (per 1,000 people) - Pakistan | Data [Internet]. data.worldbank.org. Available from: https://data.worldbank.org/indicator/SH.MED.PHYS.ZS?locations=PK

Nurses and midwives (per 1,000 people) – Pakistan | Data [Internet]. data.worldbank.org. Available from: https://data.worldbank.org/indicator/SH.MED.NUMW.P3?locations=PK

Health

. Digital Health Beyond Borders 2023 [Internet]. Akdndhrc.com. 2023 [cited 2025 Mar 19]. Available from: https://ar-2023.akdndhrc.com/index.html

Tahir

Habib

Jabeen

, et al. Protocol of digital decision support system (DDSS) embedded within a tele-primary healthcare platform in Pakistan: an assessment of usability, acceptability, effectiveness and perceived quality of care in a resource-constrained setting. BMJ open 2024 Sep 1; 14: e082167.

Bilal

Qamar

Siddiqui

, et al. Digital health and telemedicine in Pakistan: improving maternal healthcare. Annals of Medicine and Surgery 2022 Sep; 1: 81.

10.

National Health Services, Regulations & Coordination (NHSRC), Pakistan. Policy for Telemedicine in Pakistan [Internet]. Islamabad: Government of Pakistan; [cited 2025 Mar 19]. Available from: https://nhsrc.gov.pk/SiteImage/Misc/files/FinalPolicy%20for%20Telemedicine%20in%20Pakistan%20(1)(1).pdf.

11.

National Digital Health Framework Pakistan 2022-2030.PDF [Internet]. National Digital Health Framework Pakistan 2022-2030.pdf | HPSIU PHKH. [cited 2023 Mar 7]. Available from: https://phkh.nhsrc.pk/sites/default/files/2022-06/National%20Digital%20Health%20Framework%20Pakistan%202022-30.pdf

12.

The Sindh Telemedicine and Telehealth Act, 2021 [Internet] Available from https://sindhlaws.gov.pk/setup/publications_SindhCode/PUB-NEW-23-000066.pdf

13.

Walt

Gilson

. Reforming the health sector in developing countries: the central role of policy analysis. Health Policy Plan 1994 Dec 1; 9: 353–370.

14.

Pakistan Bureau of Statistics. Sindh Census Data 2023 [Internet]. Islamabad: Government of Pakistan; 2023 [cited 2025 Mar 19]. Available from: https://www.pbs.gov.pk/sites/default/files/population/2023/material/sindh_census_data.pdf.

15.

World Bank. Poverty & Equity Brief: Pakistan [Internet]. Washington, DC: World Bank Group. 2023 [cited 2025 Mar 19]. Available from: https://databankfiles.worldbank.org/public/ddpext_download/poverty/987B9C90-CB9F-4D93-AE8C-750588BF00QA/current/Global_POVEQ_PAK.pdf

16.

Sindh Bureau of Statistics. Health Profile of Sindh (District-wise) 01.01.2022 [Internet]. Karachi, Pakistan: Bureau of Statistics, Planning & Development Department, Government of Sindh. 2022 [cited 2025 Mar 19]. Available from: https://sbos.sindh.gov.pk/files/SBOS/Health/Health%20Profile%2001.01.2022.pdf

17.

Health Department, Government of Sindh. Introduction [Internet]. Government of Sindh; c2026 [cited 2025 Mar 19]. Available from: http://sindhhealth.gov.pk/Introduction

18.

Mahmoud

Jaramillo

Barteit

. Telemedicine in low-and middle-income countries during the COVID-19 pandemic: a scoping review. Front Public Health 2022 Jun 22; 10: 914423.

19.

Ministry of Health and Family Welfare (MoHFW), Government of India. Telemedicine Practice Guidelines [Internet]. New Delhi, India: MoHFW. 2020 [cited 2025 Mar 19]. Available from: https://www.mohfw.gov.in/pdf/Telemedicine.pdf

20.

Bangladesh Medical & Dental Council. Telemedicine Guidelines [Internet]. Dhaka, Bangladesh: Bangladesh Medical & Dental Council. July 2020 [cited 2026 Mar 19]. Available from: https://www.bmdc.org.bd/docs/BMDC_Telemedicine_Guidelines_July2020.pdf

21.

Nepal Medical Council. Telemedicine Guidelines for Registered Medical Practitioners in Nepal [Internet]. Kathmandu, Nepal: Nepal Medical Council. May 2020 [cited 2026 Jan 26]. Available from: https://nmc.org.np/files/4/Telemedicine%20guidelines%20for%20registered%20medical%20practitioners%20in%20nepal.pdf

22.

National Health Authority (NHA). Ayushman Bharat Digital Mission (ABDM). Government of India; 2023 [cited 2025 Mar 19]. Available from: https://abdm.gov.in

23.

Creating a New Digital Health System in Bangladesh by Building Interoperability between the Country’s Family Planning Service Statistics System and the DHIS2 — MEASURE Evaluation [Internet]. Measureevaluation.org. 2020 [cited 2026 Jan 26]. Available from: https://www.measureevaluation.org/resources/publications/fs-20-433.html

24.

Health and Population Sector Programme (GHPC) / Government of Nepal & BMZ. Nepal Digital Health Strategy. 2023 [cited 2025 Mar 19]. Available from: https://health.bmz.de/wp-content/uploads/dlm_download/GHPC_NEPAL_DIGI_FINAL_WEB__.pdf

25.

Aboye

Simegn

Aerts

. Assessment of the barriers and enablers of the use of mHealth systems in sub-saharan Africa according to the perceptions of patients, physicians, and health care executives in Ethiopia: qualitative study. J Med Internet Res 2024 Mar 27; 26: e50337.

26.

Alam

Malik

, et al. Is telemedicine our cup of tea? A nationwide cross-sectional survey regarding doctors’ experience and perceptions. Pak J Med Sci 2021 Sep; 37: 1319.

27.

Digital Health Transformation through Private Sector Engagement | Center for Global Digital Health Innovation [Internet]. Center for Global Digital Health Innovation. 2025. Available from: https://publichealth.jhu.edu/center-for-global-digital-health-innovation/digital-health-transformation-through-private-sector-engagement

28.

Ganapathy

Das

Reddy

, et al. Digital health care in public private partnership mode. Telemedicine and e-Health 2021 Dec 1; 27: 1363–1371.

29.

Aga Khan University. About Tele-ICU [Internet]. Karachi: Aga Khan University. [cited 2025 Jan 24]. Available from: https://www.aku.edu/tele-icu/Pages/about.aspx

Making policy to bridge gaps in health care access in Sindh,Pakistan: An analysis of the Sindh telemedicine and telehealth act 2021

Abstract

Objective

Methods

Result

Limitations

Conclusion

Keywords

Introduction

Methodology

Study design

Conceptual framework

Study setting

Sampling strategy and study participants

Data collection and analysis

Results

Contextual factors

The stakeholders analysis

Implementation barriers and facilitators of the Sindh telemedicine and telehealth act 2021

Content analysis of the Sindh telemedicine and telehealth act 2021

Comparative analysis of Sindh telemedicine and Telehealth Act 2021 with implemented telemedicine policies of India, Bangladesh, and Nepal

Discussion

Study strengths and limitations

Conclusion

Supplemental Material

sj-docx-1-dhj-10.1177_20552076261430096 - Supplemental material for Making policy to bridge gaps in health care access in Sindh, Pakistan: An analysis of the Sindh telemedicine and telehealth act 2021

Supplemental Material

sj-docx-2-dhj-10.1177_20552076261430096 - Supplemental material for Making policy to bridge gaps in health care access in Sindh, Pakistan: An analysis of the Sindh telemedicine and telehealth act 2021

Footnotes

Acknowledgements

ORCID iDs

Ethics approval

Consent to participate

Consent for publication

Authors’ contributions

Funding

Declaration of conflicting interests

Availability of data and materials

Supplemental material

References