WT/GC/W/866  
S/C/W/426  
 
24 February 2023  
(23-1320) Page: 1/6 
General Council  
Council for Trade in Services  Original: English  
 
ROLE OF TELEMEDICINE SERVICES IN RESPONSE TO THE PANDEMIC  
COMMUNICATION FROM INDIA  
The following communication, dated 23 February  2023, is being circulated at the request of the 
delegation of India.  
 
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1  INTRODUCTION  
1.1.   The COVID -19 pandemic represented an unprecedented disruption to the global economy and 
world trade. In the run -up to the Twelfth Session of the Ministerial Conference, WTO Members 
worked towards formulating a multilateral response to COVID -19 to guide the WTO 's work to render 
the multilateral trading system more resilient and better prepared for futures crises. This culminated 
in the 'Ministerial Declaration on the WTO Response to the COVID -19 Pandemic and Preparedness 
for Future Pandemics ' adopted by the membership on 17 June 2022 (WT/MIN(22)/31).  
1.2.  The Declaration calls on relevant WTO bodies to continue or initiate work to analyze lessons 
learned and challenges experienced during the COVID -19 pandemic. These deliberations would serve 
to build  effective understanding of potential solutions in case of future pandemics. Inter alia , the 
membership underlined the importance of facilitating trade in services, including health services and 
ICT services, during COVID -19 and future pandemics. Further, while taking into consideration 
Members ' public health policies and experiences during the COVID -19, the Members acknowledged 
the relevance of further cooperation including on interoperability and mutual recognition of digital 
health applications .1  
1.3.  At the global level, COVID -19 pandemic presented a unique situation where surpluses and 
shortages of health -related resources existed simultaneously as the pandemic came in waves, 
affecting different regions of the world at different times. At the domestic leve l, the COVID -19 
pandemic overwhelmed the capacity of domestic healthcare systems. Social distancing measures 
made in -person consultations on medical issues challenging. This spurred the adoption of 
telemedicine services, that is, the provision of health ca re services through the use of information 
and communication technologies.  
2   DEFINITION, NATURE AND BENEFITS OF TELEMEDICINE  
2.1.   The World Health Organization2  has adopted the following broad description for telemedicine 
- "The delivery of health care services, where distance is a critical factor, by all health care 
professionals using information and communication technologies for the exchange of valid 
informa tion for diagnosis, treatment and prevention of disease and injuries, research and evaluation, 
and for the continuing education of health care providers, all in the interests of advancing the health 
of individuals and their communities ". Telemedicine can i nclude a broad range of services including 
(a) teleconsultation between the health provider and patient, (b) tele -expertise between two health 
providers, (c) telemonitoring when the health provider remotely monitors the patients ' data 
(d) tele-assistance w hen a health professional remotely guides a medical procedure and 
 
1 https://docs.wto.org/dol2fe/Pages/SS/directdoc.aspx?filename=q:/WT/MIN22/31.pdf  
2 https://apps.who.int/iris/bitstream/handle/10665/44497/9789241564144_eng.pdf  WT/GC/W/866 • S/C/W /426 
 
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  (e) tele-education for health care providers. Mobile health (mHealth) is closely linked to 
telemedicine. It covers health practice through mobile devices such as mobile phones, patient 
monit oring devices and other wireless devices and health -related applications ( 'apps').3 
2.2.  The benefits of telemedicine include lowering the cost of health services, enhancing access 
where there is unavailability or undersupply of health services, early identifi cation and prevention of 
diseases leading to a reduction in health expenditure and transfer of know -how and technology.  
3   ADOPTION OF TELE -MEDICINE DURING COVID -19 - EXPERIENCE FROM DIFFERENT 
COUNTRIES  
3.1.   The COVID -19 pandemic catalysed the rapid adoption of digital solutions and advanced 
technology tools in healthcare within the national boundaries. In recent years, countries have 
undertaken various measures to facilitate this adoption. Some examples are as under:  
i.  India - The government launched the e -Sanjee vani4, a national telemedicine platform, 
in November 2019, which provided an integrated telemedicine solution for 
'doctor -to-doctor ' consultations. The pandemic outbreak witnessed two important 
developments. India notified the telemedicine practice guidelines in March 2020 which 
provided comprehensive guidelines for tele -health -care delivery in India. Further, 
e-Sanjeevani evolved to a  direct care module 'e-Sanjeevani outpatient department 
(OPD) ' to facilitate 'doctor -to-patient ' consultations. This web -based platform 
integrates registration, queue management, generation of e -prescriptions, short 
message service, and e -mail notification s. So far, e -Sanjeevani has crossed an 
astounding milestone by clocking 100 million teleconsultations .5 This platform has 
facilitated healthcare access across the country especially rural and isolated 
communities. It is designed for scale and low -cost upt ake by health providers and 
patients.  
Further, the government launched the COVID -19 Vaccine Intelligence Network 
(CoWIN)6, a state -of-the-art digital solution for one of the world 's largest COVID -19 
vaccination programmes. It is a scalable, inclusive, and  open platform for universal 
vaccination. The citizen -centric solution facilitates registration and booking of 
appointments for vaccination, regular reminders and communication, provision of 
vaccination certificates for citizens and helps programme manager s and vaccinators to 
create and manage sessions, develop reports and monitor progress. India offered the 
technological prowess of the Co -WIN platform as a Digital Public Infrastructure (DPI) 
freely to all countries in the fight against COVID -19. India has so far achieved the 
historic milestone of 2.2 billion doses of vaccinations.  
India also launched the Aarogya Setu app, aimed at COVID -19 contact tracing, 
self-assessment and informing the citizens about the best practices/relevant advisories 
pertaining to  the containment of COVID -19. This open source app is a readily available 
package for developers.  
ii. Brazil - The government launched the 'Coronavírus SUS ' app. If the app -facilitated 
diagnosis indicates a likely infection, patients are referred to the neares t healthcare 
facility for testing, improving the effectiveness of the traditional healthcare setting. 
The app also provides evidence -based insights as to the spread of a pandemic, 
reducing the prevalence of fake news and associated panic. The combination o f 
prevention, triage and information in one app helped reduce demands on the public 
healthcare system .7 
iii. Germany – Reimbursement is a key challenge for many new digital health solutions, 
whose importance and value have been highlighted and expanded by the current 
COVID -19 pandemic. Germany 's new Digital Healthcare Act (Digitale -Versorgung -
 
3 'Cross -border telemedicine – practices and challenges ', Ose Paper No. 44, Sherihane Be nsemmane and 
Rita Baeten, October 2019.  
4 https://esanjeevani.in . 
5 https://pib.gov.in/PressReleasePage.aspx?PRID=1899855 .  
6 https://www.cowin.gov.in . 
7 The worldwide impact of telemedicine during COVID -19: current evidence and recommendations for 
the future ', Stefano Ombani and others, January 2022 . WT/GC/W/866 • S/C/W/426  
 
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  Gesetz or DVG) entitles all individuals covered by statutory health insurance to 
reimbursement for certain digital health applications (i.e. insurers will pay for their 
use).8 
iv. Kenya - To ensure that effective health -related information can be transmitted to and 
from rural areas, Kenya fast -tracked the issuance of an operating licence to a company 
to extend the availability of WiFi to remote locations.  
v. South Africa - Before  COVID -19, telemedicine use was limited in South Africa, partly 
because of the restrictive 'General Ethical Guidelines for Good Practice in 
Telemedicine '. The Government allowed temporary relaxation of the guidelines for the 
duration of the pandemic, allow ing telemedicine to be practiced 'without an established 
practitioner -patient relationship '.9 
vi. United States - The Federal Communications Commission (FCC) adopted a 
USD200 million telehealth programme to support healthcare providers to purchase 
telecommuni cations, broadband connectivity and devices necessary for providing 
telehealth services. The FCC also launched a Connected Care Pilot Program to provide 
up to US D100 million worth of support from the Universal Service Fund (USF) to help 
defray healthcare p roviders ' costs of providing connected care services and to help 
assess how the USF can be used in the long term to support telehealth .10 
4  CROSS BORDER TRADE IN TELEMEDICINE SERVICES  
4.1.   As can be seen in the Chart below, the bulk of health/medical services tr ade takes place 
through Mode 2 (consumption abroad) and Mode 3 (commercial presence) with Mode 1 (cross border 
without movement of service supplier and consumer) and 4 (movement of natural persons) 
accounting for a small proportion. Given the pandemic situ ation, Mode 2 and Mode 4 that requires 
movement of people are likely to be largely paralysed. Mode 3 may not be helpful on account of 
global contraction in FDI during such crisis, its dependence on Mode 4 and the initial time needed to 
set up commercial pr esence. Cross -border trade in medical services (Mode 1) is thus most suitable 
mode in pandemic like situations. This will not only expand trade of health services during and after 
the pandemic, but also allow countries to benefit from the positive spill ov ers of building crucial 
digital infrastructure . 
  
Source: WTO estimates based on TISMOS Database .11  
4.2.  Examples of countries engaging in cross -border supply of health services (Mode 1), that is, 
cross border telemedicine services including tele diagnostic, surveillance, and consultation are 
 
8 Ibid. 
9 Ibid. 
10 How WTO Members have used trade measures to expedite access to C OVID -19 critical medical goods 
and services ', Information Note, WTO Secretariat, September 2020.  
11 Trade Therapy: Deepening cooperation to strengthen pandemic defences, WTO Publication . 
WT/GC/W/866 • S/C/W /426 
 
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  services being provided by US hospitals in many Gulf countries and some countries in Central 
America, telepathology services by Indian doctors to hospitals in Nepal and Bangladesh, 
teleradiology services by Indian radiologists to US hospitals and tele diagnostic services by hospitals 
in China to patients in Chinese Taipei ; Macau, China; and some South East Asian countries .12 
  
 
Source: WTO Estimates based on TISMOS Database .13  
4.3.  As per WTO estimates, global trade in medical services fell in 2020 with trade through Mode 2 
and Mode 4 falling sharply, trade through Mode 3 remaining resilient and trade through Mode 1 
(cross border supply) soaring by 14%. Cross -border trade in telemedicine services, though has 
gathered momentum, remains underdeveloped.  
5  CHALLENGES WITH TRADE IN TELEMEDICINE SERVICES  
5.1.  Growth of international tel emedicine remains a challenge given the wide regulatory diversity 
and differing national capabilities. Some of the major challenges include:  
i. Digital capability - Digital capability in terms of accessibility and affordability of 
connectivity, digital techno logies, digital identity system, digital payment system, and 
digital skilling are building blocks of digital transformation in the healthcare sector 
including telemedicine. Digital transformation of health provides the foundation for 
national use of teleme dicine which would eventually translate into international 
telemedicine. As per ITU statistics for 2022, 34% of the world 's population does not 
use internet. While internet usage in the developed countries is 90%, it is only 20% in 
the LDCs. About 23% of t he population in LDCs has no access to a mobile broadband 
network and even when they do, it is typically at relatively low download speeds and 
high cost .14 Lack of digital skills is another challenge that prevents adoption of 
telemedicine by health provide rs and patients. The availability of a clear/trusted 
framework for digital payment systems for the provision of telemedicine services is 
also important and is often underdeveloped in such countries. In India 's recent 
submission (WT/GC/W/863), the role of D PI in addressing the digital divide and 
promoting e -commerce has been outlined.  
ii. Regulations and guidelines - Telemedicine services often face geographic regulations, 
such as requiring the health professional to reside in the jurisdiction of the patient. 
Easing 'territorial ' restrictions on telemedicine, with appropriate regulatory oversight, 
even on a provisional basis can be useful especially to deal with a global health crisis. 
A pre -existing relationship between the patient and the health professional i s a 
 
12 ADBI Working Paper 668, Trade in Hea lth Services and Sustainable Development, Rupa Chanda, 
2017. 
13 Trade Therapy: Deepening cooperation to strengthen pandemic defences, WTO Publication . 
14 UNCTAD COVID -19 and e -commerce -A Global review . 
WT/GC/W/866 • S/C/W/426  
 
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  precondition which some countries relaxed in the C OVID  times .15 The pandemic 
presented situations such as nationals/persons stranded in a country not being able to 
procure their regular medicines as prescriptions of doctors of their home country were 
not being recognized by the local pharmacists, while there was shortage of local 
doctors to seek treatment. For viability of international telemedicine, country -level 
regulations/guidelines need to be put in place. Arrangements for cooperation on 
harmonisin g national guidelines or formulating standardised international guidelines 
for the delivery of cross -border telemedicine needs to be explored.  
iii. Reimbursement under insurance schemes - The non -portability of health insurance 
coverage prevents people from see king often less expensive treatment abroad. Web 
or app -based medical appointments and consultations are typically not covered by 
medical insurance programs, despite some countries changing these regulations in 
response to the COVID -19 pandemic to facilitat e remote diagnosis .16 Such 
re-imbursement schemes need to be introduced for cross border telemedicine.  
iv. Interoperability of digital applications/systems – Interoperability of health -related 
digital applications which requires integration of systems with dif ferent standards, 
though costly and complex, could enhance the adoption of digital health applications 
and the compatibility of health care systems .17 
v. Health provider licensure/registration requirements - The need for recognition of 
doctor 's qualification and license to practice is among the most challenging aspects of 
an international telemedicine program. Hospitals need to be qualified and registered 
in the foreign jurisdiction as a 'health services establishment ' before their doctors can 
provide telemedi cine services into that jurisdiction .18 Expedited conclusion of mutual 
recognition agreements, creation of an international registry of recogni zed health 
establishments/providers and temporary relaxation of recognition norms could be 
explored to address em ergent pandemic like situations.  
vi. Professional liability provisions - Liability for the services provided is raised as an issue 
for providers involved in cross -border tele -expertise. Professional liability provisions 
vary between medical specialties and bet ween countries. It is unclear to the 
tele-experts and the requesting providers as to who is liable for the services provided. 
Some telemedicine providers define the responsibilities of each party in their contracts. 
However, these contracts may not be comp atible with the legal requirements in the 
countries involved .19 
vii. Quality and continuum of care – In case of remote healthcare delivery, challenges 
associated with ensuring quality and continuum of care could be faced. Adequate 
coordination may be required between telemedicine providers and health 
establishments, to ensure hospital care when needed.  
6   OPPORTUNITIES FOR TRADE IN TELEMEDICINE SERVICES  
6.1.   Telemedicine has showcased tremendous growth in recent years. This growth is bound to get 
a fillip wi th the emergence and adoption of new technologies such as AI, Internet of things and 
machine learning. The global telemedicine market was USD41.6 billion in 2019. It is projected to 
grow from USD79.8 billion in 2020 to USD396.8 billion in 2027 at a CAGR of  25.8% during 
2020-2027.20 Addressing digital capability and regulatory challenges will be key to achieving the 
potential of cross -border supply of telemedicine services.  
 
15 Trade in services in the context of COVID -19, Informat ion Note, WTO  Secretariat, May 2020 . 
16 Health services trade and the COVID -19 pandemic, Ian Gillson and Karen Muramatsu, World Bank 
Group, May 2020 . 
17 International Trade in Health Services under GATS, Chantal Blouin, Nick Drager, Richard Smith, World 
Bank Publication, 2006 . 
18 Cross -border telemedicine – practices and challenges ', Ose Paper No. 44, Sherihane Bensemmane 
and Rita Baeten, October 2019.  
19 Ibid. 
20 https://www.fortunebusinessinsights.com/industry -reports/telemedicine -market -101067 . WT/GC/W/866 • S/C/W /426 
 
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  6.2.  Cross border telemedicine provides immense opportunities for timely and affordable 
consultations, interventions and diagnostics especially when long waiting periods and high cost exist 
for such services in the home country.  
7  CONCLUSION  
7.1.   Telemedicine can help address global health equity problems, thus accelerating the 
achievement of United Nations Sustainable Development Goal 3 (Good health and well -being), which 
is part of the 2030 Agenda. Telemedicine complements the physical healthcare systems and its use 
across borders can help enhance access, reduce costs and relieve the healthcare syst ems around 
the world strained with constraints including shortages of doctors in pandemic like situations.  
7.2.  Deliberation on lessons learnt and sharing of best practices and experiences by the membership 
can help build effective solutions for bridging the di vide in digital capabilities and addressing 
regulatory barriers that prevent the expansion of cross -border supply of telemedicine services. 
International collaboration between the membership is needed to facilitate reliable and sustained 
cross-border suppl y of telemedicine services as a credible tool to deal with future pandemics. We 
propose that Members organi ze dedicated discussion in the Council for Trade in Services along with 
a Workshop/Seminar to share information, experiences and views on this matter . 
8  QUESTIONS FOR DISCUSSION  
i. What are Members ' experiences regarding adoption of telemedicine services 
domestically and supply of cross -border telemedicine services?  
ii. What are the challenges and opportunities for expanding telemedicine services? What 
steps ar e Members taking to address these challenges and harness these 
opportunities? For instance, what domestic programs, policies or regulations have 
been or are being put in place? What trade facilitating measures have Members taken 
to promote cross -border tra de in telemedicine services?  
iii. What role can Digital Public Infrastructures (DPIs) play in facilitating technology 
transfer and promoting digital delivery of health services? How can Members with rich 
experience in the use and development of DPIs support oth er Members in their 
adoption and use?  
iv. How can WTO Members move forward in pursuance of WT/MIN(22)/31 and agree on 
the next steps to enable use of cross -border supply of telemedicine services in dealing 
with future pandemics?  
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